Blog

Individuals – Need to Know

Viewing posts from the Individuals – Need to Know category

Blue Shield of CA Switching to CVS for Pharmacy Management

Blue Shield recently notified policyholders of the upcoming change to their pharmacy network benefits. The details in full are outlined below. Please review, and contact Allpointe if you have questions about how this may affect your pharmacy coverage. The change will take effect January 1, 2017 regardless of when your plan renews.

 

Blue Shield has entered into an agreement with CVS Health to support manufacturer rebate and pharmacy network contracting for the outpatient pharmacy benefit, which has been approved by the Department of Managed Health Care.

CVS Health will manage Blue Shield’s national retail pharmacy network, and become our exclusive mail order pharmacy for Commercial and Medicare plans and our specialty pharmacy for Commercial plans, starting January 1, 2017.

This new agreement will enable us to leverage CVS Health’s purchasing power and reduce pharmacy costs. It will allow us to offer more competitive pharmacy products while continuing in our commitment to provide access and convenience for our members.

Who is affected?
The new pharmacy network changes will apply to all Blue Shield lines of business:

  • Commercial
    Premier, Core, Small Business, Individual and Family Plans (IFP) and Self-Funded/Administrative Services Only (ASO)
  • Medicare
    Individual and Group Medicare Advantage and Prescription Drug plans

Pharmacy network changes that will affect how our members access their benefits at the retail, mail order and specialty pharmacy will become effective January 1, 2017. Impacted members will be notified 60 days in advance of these changes by mail and telephone.

What are the pharmacy network changes?
There are three areas that will be affected by these changes. The member impact for most of these changes are relatively minimal and are as follows:

  • Retail pharmacy
    CVS Health will support Blue Shield’s retail network contracts. The Blue Shield network retail pharmacies will be nearly unchanged and will continue to include all key chains such as CVS, Walgreens, Rite-Aid, Costco and many others. The vast majority of our members will continue to have the same convenient access to network pharmacies near where they live and work. In fact, the network pharmacies with preferred cost-sharing will expand to include additional national retail pharmacies. Please refer to the 2017 Medicare Pharmacy Directories for more information.
  • Mail order pharmacy
    Blue Shield will transition from current mail order pharmacy, PrimeMail, to CVS Health mail order pharmacy.
  • Specialty pharmacy
    Currently, Blue Shield’s commercial specialty network includes two vendors, CVS/Caremark and Walgreens Specialty, with the majority of specialty prescriptions filled by CVS/Caremark. With the agreement, CVS/Caremark will become our exclusive specialty pharmacy for Commercial plans. Members shall continue to have the convenient access to pick up their specialty medications at a local retail CVS pharmacy. Medicare plans will continue to have an open specialty pharmacy network, which includes Walgreens Specialty and CVS/Caremark.

Transition plan
Blue Shield Pharmacy Services has been working with CVS Health to develop an implementation plan that ensures a smooth transition. As part of the plan, members who may be affected by these changes will be notified 60 days in advance of the January 1effective date.

  • For retail
    Letters will be sent to impacted members, which will provide information on up to four network pharmacies (two based on the member’s address on file and two based on the terming pharmacies address).
  • For specialty and mail order
    Letters will be sent to impacted members. Members will also receive CVS Health Welcome Kits.
  • Active specialty and mail order prescriptions
    For prescriptions that have active, remaining refills, Blue Shield will work with PrimeMail (mail order) and Walgreens Specialty (for specialty drugs) to transfer members’ remaining refill prescriptions to CVS/Caremark. Member payment information, such as credit card details, will not be transferred. Members will need to register with CVS/Caremark to provide this information. CVS will conduct a call campaign to these members to assist with registration.
  • Non-transferable drugs
    Some selected drugs are not eligible for transfer, such as Schedule 2 prescriptions. Since Federal law doesn’t allow refills for Schedule 2 prescription drugs, members using such drugs will have to visit their provider to get new prescriptions for each fill, even when using mail order.

Blue Shield of CA and Sutter Health: Negotiating a new contract

From Blue Shield today:

Blue Shield and Sutter Health are engaged in contract negotiations
Blue Shield of California and Sutter Health are engaged in discussions on rates and terms for a new network contract (HMO/PPO and in some cases, Group Medicare Advantage). The current contract is set to expire at the end of this year and without a new deal, Sutter Health would no longer be a Blue Shield in-network provider starting January 1, 2017.

We are working diligently in good faith to complete a new contract that is fair and sustainably affordable for our customers. If the network relationship terminates, Blue Shield will ensure that members have continued access to care in their area, including continuity of care for those who qualify to continue in their current course of treatment with a Sutter Health provider.

What are the lines of business affected by the negotiations?
The contracts being negotiated apply to all Blue Shield plan types, including HMO, PPO, EPO, POS-HMO Tier, POS-PPO Tier and Group Medicare Advantage.

  • Individual and Family Plans: Grandfathered and Non-Grandfathered Plans (on and off exchange)
  • Medicare: Group Medicare Advantage Prescription Drug (GMAPD) plans
  • Small Business (1-100 employees)
  • Fully Funded Large Employers (101+ employees)
  • Self-Funded/ASO Large Employers (101+ employees)
  • Self-Funded/Shared Advantage (101+ employees)
  • CalPERS
  • FEP
  • FEHBP

Sutter Health providers are located in Northern and Central California (see listing of counties below). In addition, Sutter Health has surgery centers in San Diego County.

Sutter Health Counties
Alameda Marin San Joaquin Santa Cruz Sutter
Amador Merced San Luis Obispo Shasta Yolo
Contra Costa Placer San Mateo Solano
Del Norte Sacramento Santa Barbara Sonoma
Lake San Francisco Santa Clara Stanislaus

The contracts currently being negotiated include the following Sutter Health hospitals:

  • Alta Bates Medical Center Herrick Campus
  • Alta Bates Summit Medical Center Alta Bates Campus
  • California Pacific Medical Center – California Campus*
  • California Pacific Medical Center – Pacific Campus*
  • California Pacific Medical Center – St Luke’s Campus*
  • California Pacific Medical Center Davies Campus*
  • Eden Medical Center
  • Memorial Hospital Medical Center
  • Memorial Hospital of Los Banos
  • Menlo Park Surgical Hospital
  • Mills Peninsula Health Center
  • Mills Peninsula Medical Center
  • Novato Community Hospital
  • Sutter Amador Hospital
  • Sutter Auburn Faith Hospital
  • Sutter Center for Psychiatry
  • Sutter Coast Hospital
  • Sutter Davis Hospital
  • Sutter Delta Medical Center
  • Sutter Lakeside Hospital
  • Sutter Maternity and Surgery Center of Santa Cruz
  • Sutter Medical Center of Santa Rosa
  • Sutter Medical Center, Sacramento
  • Sutter Roseville Medical Center
  • Sutter Solano Medical Center
  • Sutter Surgical Hospital North Valley
  • Sutter Tracy Community Hospital

    *Includes Medicare Advantage

In the event of a termination with Sutter and in accordance with DMHC regulations, Blue Shield of California would notify HMO members assigned to a Sutter Health Primary Care Provider (PCP) 60-days in advance of a potential termination with Sutter Health. PPO members with an out-of-network benefit could receive services from a Sutter-affiliated provider, but the out-of-pocket costs will be at the non-preferred benefit level.

Our commitment to affordably priced health coverage
Blue Shield continues its provider contract discussions with Sutter Health in hopes that new agreements will soon be reached. We appreciate your patience while we work to secure the best possible outcome for our customers and members. Our goal is to provide our members with access to quality health care at an affordable price.

Emergency services
Blue Shield of California members who need emergency services should call 911 or seek care at the nearest emergency room. Blue Shield will provide the full emergency care level of benefits for these services.

Oscar is coming to San Francisco

Oscar is coming in 2017. No, not that Oscar.

A new health insurance carrier will offer plans both on- and off-exchange, in San Francisco, San Mateo, and Santa Clara counties. A little surprising it took this long, considering they are Google-funded, and we’ve heard them described as “great software – with health insurance attached.”

It appears their Bay Area rates and network will be middle-of-the-pack (current word is no Sutter Health/PAMF, though that could change). Will their customer service and user experience be enough to consider Oscar as a viable choice? Stay tuned.

Obama administration looks to curb use of short-term health plans

It is nice to know the President is reading my blog.

How else to explain today’s news that the administration is looking to curb the use of short-term plans to three months or less? Ok, I admit, maybe it was a low-level staffer at Health and Human Services who originally saw How to save $1,000 in health premiums over the next 4 months and they forwarded that up the chain of command. Still, I appreciate the implied compliment, Mr. President.

CNBC and Kaiser Health News both report today on the administration’s move to limit the maximum length of short-term plans to 3 months, without an option for renewal.

While the reasons cited are sound (only the healthiest people can obtain short-term coverage, and pulling healthy people from the overall insurance pool does ultimately raise the rates for others), short-term plans are often a last-resort option and fill a very specific need in the market.

We have clients who missed the open enrollment deadline. Their fault? Sure. But shouldn’t they be able to buy some coverage to protect them against catastrophic health expenses until the next open enrollment period?

Even more concerning, we are seeing cases of clients whose former employer screwed up in one way or another, e.g., the employer failed to pay premiums on the group health plan, employee coverage was canceled retroactively, and the employees didn’t find out until more than 60 days beyond the cancellation date. Note: 60 days happens to be the window to buy new minimum coverage following a qualifying event. Their fault? No way, but their only recourse would be to hire an attorney and hope for the best. But wouldn’t it be helpful if they could buy a short-term plan to cover the gap until they could get covered again?

You can learn more about short-term plans and whether they are right for you or someone you know, right here.

What we love/hate in 2016…about Blue Shield of CA

This is part of a series of posts to help clients understand the differences between the carriers and plans, and to make the best plan choice for their family in 2016. Maybe “like” and “dislike” are better categories, but what is the Internet for, if not strong opinions?

Blue Shield of California is one of just two remaining carriers that will offer PPO plans in every county in California in 2016. So, what do we love (and hate) about them?

Read More

What we love/hate in 2016 – individual and family health insurance

I wanted to put together a compiled resource to help clients distinguish between their insurance carrier choices in 2016. This seemed like a quick, fun way to summarize a lot of the highlights (and lowlights) that we see with the different carriers. The opinions here come from our personal experience, feedback from clients, news articles and other independent sources, and analyzing the information that comes directly from the carriers. We will hit all of the major carriers as well as some ancillary products and topics. Check back here frequently as the links below will go live as new posts are added for each carrier/topic.

Let us know if you agree/disagree in the comments!

Read More

LiveHealth Online – will everyone start using tele-health in 2016?

No, probably not everyone. But we love the idea, and expect many clients to test-drive this option in the next 12 months. Anthem Blue Cross has launched LiveHealth Online – an opportunity to access a doctor via secure app on your phone, tablet or computer. 24/7. For $49 or less. And you don’t have to be an Anthem subscriber to use it.

The immediate access off-hours is a terrific feature – especially if you need a prescription. Think: away on a ski trip, and knocked out with a terrible cold at 9pm on a Saturday night. Emergency room? Ugh.

Read More

How to save $1,000 in health premiums over the next 4 months

This isn’t a strategy for everyone. If you feel bad for the insurance companies, you can stop reading now. And if you have any significant health issues, this won’t work for you, either. But, if you:

  • Have had minimum essential coverage from January 1 through October 31 of this year
  • Are healthy, with no (or minimal) foreseen health expenses for the next few months
  • Are willing to take a few minutes to understand the rules and exceptions around:
    • Open enrollment
    • Guarantee-issue health insurance
    • Individual mandate to purchase minimum essential coverage
  • Would prefer to pay the lowest possible health premium, without subjecting yourself to financial risk or tax penalty

…then this could be for you.

Read More