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2008 Georgia Product Portfolio Maintenance and Review (PPMR)

2008 Georgia Product Portfolio Maintenance and Review (PPMR). October 2008 . Agenda. Annual Product Portfolio Maintenance and Review (PPMR) Urgent Care Pharmacy Changes Intermediate Level Mental Health Preventive Care PPO mammography benefits. Background.

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2008 Georgia Product Portfolio Maintenance and Review (PPMR)

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  1. 2008 Georgia Product Portfolio Maintenance and Review (PPMR) October 2008

  2. Agenda • Annual Product Portfolio Maintenance and Review (PPMR) • Urgent Care • Pharmacy Changes • Intermediate Level Mental Health • Preventive Care • PPO mammography benefits

  3. Background • Annual process; 1st time for Georgia • Starting with 01/01/09 new sales and upon each group’s renewal • Flyers highlighting changes will be included in each group’s renewal package • Will apply to all existing local fully insured plans, ASO, MPA and groups with non-standard benefits EXCEPT: managed indemnity plans 1-41 and legacy HDHP plans 9005SX-9809SX • Will not apply to new Blue Essential and Lumenos plans • Due to BCBSA ID Card Mandates, member ID cards will have a different look after 11/08/08

  4. Urgent Care • In-network: $60 co pay • Out-of-network: $60 co pay, subject to deductible and coinsurance • Provider must bill with Place of Service 20 • Co-pay displayed on ID card

  5. Urgent Care Centers Online • Go to www.bcbsga.com • Click on “Members” then “Find a Doctor” • Click on the “Locate Georgia Providers” link • Choose the network • Select a Plan from the drop down box • Select Provider Type “Hospitals, Facilities, Services and Equipment” • Select a Specialty Category “Clinics, Urgent Care Centers” • Complete the search criteria and click “View Results” • Click “Printer Friendly” for hardcopy

  6. Pharmacy • Language changes include: • Generic is generally on Tier 1 but may also be on Tier 2 or Tier 3 • Brand is generally on Tier 2 but may also be on Tier 1, Tier 2 or Tier 3 • Non-Preferred = Tier 3 • Mail Order Generic = Mail Order Tier 1 • Mail Order Brand = Mail Order Tier 2 • Limit day supply 30 days vs. 34 days* • Mandatory Generic (PTD)* *Only existing groups with these current pharmacy benefits will be impacted at the group’s renewal

  7. Anthem Tiered Drug List Online • Go towww.bcbsga.com • Under Learn More, click “Pharmacy” • Click on “HMO/POS members” or “PPO members” (you will be re-directed to the NextRx website) • Select “Print Drug List” in the upper left corner for a PDF of the Anthem Tiered Drug List • Or, use the search tools to search for a specific drug on the list

  8. Specialty RX • Pharmacies within the specialty pharmacy network must be utilized • PrecisionRx Specialty Solutions is a BCBSGa affiliated specialty pharmacy within the network • Prior to renewal, members will need to transition their current specialty prescription(s) • Letters will be sent to members currently using specialty medications 30 days prior to the change

  9. One-on-one service and support from a personal care coordinator. Proactive phone calls to schedule timely refills. 24/7 access to a registered nurse or pharmacist for urgent drug questions. Coordination between them and their providers. Drugs delivered in temperature-moderating packaging directly to any location specified. Educational support on what to expect from treatment, drug interactions and side effect management. Specialty RX Network Services • Members may be responsible for a greater cost share if a participating specialty pharmacy provider is not used

  10. Specialty RX List Online • Go to www.bcbsga.com • Click on “Members” • Under Learn More, click “Pharmacy” • On the Pharmacy Program page, click on the “Specialty Pharmacy Program – Drug List” link • Scroll down the disclaimer and click on the “Specialty Pharmacy Program – Drug List” link

  11. The Half Tablet Program • Limited to Lipitor, Cozarr, Diovan • Appropriate customers have physician write new prescription for double the dose and half the amount • Using tablet splitter member takes ½ a tablet per day • Not for individuals with limited vision, poor manual dexterity or those who become confused easily

  12. New Member ID Card • Effective 11/8/08 • ID card will now read RX and co pay amounts • New Urgent Care co-pay will display

  13. Mental Health Partial Hospitalization Program and Intensive Outpatient Program • Benefit is expanded to 10 visits for both intermediate level Mental Health programs • Partial Hospitalization Program (PHP) • Intensive Outpatient Program (IOP) • Applies to all plans • Already available in the new PPO plans that launched 11/15/07

  14. Other PPMR Changes • Adopting Enterprise Preventive Care list • PPO mammography benefit mirrors HMO benefits by allowing annual screening for any age: • “Benefits will be provided for one mammogram and one pap smear tissue examination per year, or more often when ordered by a Physician” • See the Agent/Broker site for side by side grids

  15. Groups Without PPMR Changes • If a Large Group renewal was released prior to 10/15/08 PPMR benefit changes AND Specialty Pharmacy network changes will NOT be applied 01/01/09 unless specifically requested • PPMR benefit changes AND Specialty Pharmacy network changes WILL be applied at 2010 renewal

  16. Summary • Urgent Care • Pharmacy Changes • Intermediate Level Mental Health • Preventive Care • PPO mammography benefits

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