Medicare Advantage Outreach and Education Bulletin Anthem BlueCross 2014 Coverage Changes for Diabetic Supplies for DME Effective January 1, 2014, all of our individual Medicare Advantage plans will only cover LifeScan, Inc., OneTouch or Roche Diagnostics, ACCU-CHEK diabetic glucometers and blood test strips. This benefit change is meant to help control outof-pocket expenses while not compromising on quality. Covered glucometers and blood test strips in 2014: LifeScan, Inc., OneTouch Roche Diagnostics, ACCU-CHEK A limit of 100 blood test strips per month We will not cover other brands and manufacturers, or more than 100 test strips per month unless an exception is received from the member s provider stating it s medically necessary. Members impacted by this change were notified in October through their Annual Notice of Change and Evidence of Coverage plan benefit materials. Additionally, an outbound call campaign was launched. What will you need to do? If your customers are currently using OneTouch or ACCU-CHEK blood test strips or glucometer products, no action is required on your part. Customers not using OneTouch or ACCU-CHEK blood test strips and glucometer products, will need to obtain a new prescription or an exception from their doctor for their supplies by January 1 st in order for these claims to be covered. If the customer has questions, direct the customer to call the health plan s customer service number found on the back of their ID card. Physicians may call the following numbers to request an exception to the quantity limits or continue coverage of non Lifescan, Inc., or Roche Diagnostics products: Phone numbers for Precert: Transition Period: 1. NY & CT Plans- 877-657-6115 2. All other Plans- 866-797-9884 FAX number for Precert: 3. NY & CT Plans- 800-464-5942 4. All other Plans- 800-959-1537
Our top priority is to ensure minimal disruption to our members who are impacted by these coverage changes. A transition period has been implemented to allow the member time to adjust to these changes. During the transition period, we will continue to cover the current brands for up to two fills during the first 90 days of the year (or the first 90 days of coverage for a new member). During this period, the member should talk with their doctor to decide what brand is medically appropriate for them. If a DME provider bills for non-covered brands or exceeds the quantity limit without having an exception on file once the transition period has expired, the DME provider will be liable for the charges, not the member, DME Providers will not be allowed to charge the member for those products unless they have a written agreement on file notifying the member that the product they chose is not covered and that they are 100% responsible for those charges. We recommend contacting the Precert number on the back of the member s ID card to confirm an exception is in place for plan permission to continue using the non LifeScan, Inc., and/or Roche Diagnostics blood test strips and glucometers once the transition period has expired. Diabetic Blood Test Strip Quantity Limits: Once the member has exceeded 1200/year blood test strips, provider claims will be rejected. Please refer back to page 1 What will you need to do? section and follow the instructions for the 4 th bullet. The member EOB will communicate a $0 member liability and no payment will be made to the DME Provider with the following reason: The plan allows for coverage of up to 100 Diabetic Test Strips per 30 days (1200/year) unless your doctor feels it is medically necessary for you to test more frequently. Your doctor must call the plan and order more. It is important that the DME provider work with the customer and/or physician to ensure that an exception be filed if needed. Once an exception is on file any charges that were denied can be resubmitted back to the health plan. HCFA Claim Form 1500/0805 Requirement: To ensure that members are using one of the two covered brands we request that DME Providers identify the National Drug Code (NDC) of the brand being used in section 24D on the claim form. As always, we reserve the right to conduct random audits to ensure compliance with the plan s benefit administration. Including the NDC on the claim form helps streamline the audit process, reducing the likelihood of requesting additional information from a DME Provider.
If a DME Provider does not include the NDC on the claim form, and we are unable to confirm an exception was given, allowing coverage for a non-covered brand during an audit, the DME Provider may be required to reimburse the health plan back for the benefits that were not covered. Medicare Advantage Plans included in this coverage change: CONTRACT # PBP PLAN NAME PLAN TYPE H0564 006 Blue Cross Senior Secure Plan I (HMO) CA-HMO H0564 047 Blue Cross Senior Secure Plan I (HMO) CA-HMO H0564 052 Blue Cross Senior Secure Plan II (HMO) CA-HMO H0564 054 Blue Cross Senior Secure Plan II (HMO) CA-HMO H1517 004 Anthem Medicare Preferred Core (PPO) MO-LPPO H1517 005 Anthem Medicare Preferred Core (PPO) MO-LPPO H1607 001 Anthem Medicare Preferred Standard (PPO) IN-LPPO H1849 015 Anthem Senior Advantage Value (HMO) KY-HMO H2836 001 Anthem MediBlue Preferred Standard (PPO) CT-LPPO H3342 001 Empire MediBlue Freedom III (PPO) NY-LPPO H3342 012 Empire MediBlue Freedom I (PPO) NY-LPPO H3342 013 Empire MediBlue Freedom II (PPO) NY-LPPO H3342 014 Empire MediBlue Freedom II (PPO) NY-LPPO H3370 001 Empire MediBlue Plus (HMO) NY-HMO H3370 002 Empire MediBlue Select (HMO) NY-HMO H3370 003 Empire MediBlue Plus (HMO) NY-HMO H3370 004 Empire MediBlue Plus (HMO) NY-HMO H3370 014 Empire MediBlue Plus (HMO) NY-HMO H3370 019 Empire MediBlue Essential (HMO) NY-HMO H3536 001 Anthem MediBlue Select (HMO) NH-HMO H3655 013 Anthem Senior Advantage Basic (HMO) OH-HMO H3655 030 Anthem Senior Advantage Plus (HMO) OH-HMO H4036 004 Anthem Medicare Preferred Core (PPO) WI-LPPO H4036 005 Anthem Medicare Preferred Standard (PPO) WI-LPPO H4036 007 Anthem Medicare Preferred Standard (PPO) WI-LPPO H4909 009 Anthem Medicare Preferred Core (PPO) VA-LPPO H4909 010 Anthem Medicare Preferred Core (PPO) VA-LPPO H5422 002 BlueValue Secure (HMO) GA-HMO H5422 006 BlueValue Basic (HMO) GA-HMO H5529 001 Anthem Medicare Preferred Standard (PPO) OH-LPPO H5529 004 Anthem Medicare Preferred Select (PPO) OH-LPPO H5530 001 Anthem Medicare Preferred Standard (PPO) KY-LPPO H5854 005 Anthem MediBlue Value (HMO) CT-HMO H6786 001 Anthem Medicare Preferred Premier (PPO) ME-LPPO H7728 001 Anthem Medicare Preferred Premier (PPO) NH - LPPO H8432 001 Anthem MediBlue Select (HMO) ME-HMO H8552 001 Anthem Medicare Preferred Standard (PPO) CA-LPPO H8552 002 Anthem Medicare Preferred Standard (PPO) CA-LPPO H8552 003 Anthem Medicare Preferred Standard (PPO) CA-LPPO H8552 006 Anthem Medicare Preferred Standard (PPO) CA-LPPO H8552 007 Anthem Medicare Preferred Standard (PPO) CA-LPPO
H8552 008 Anthem Medicare Preferred Standard (PPO) CA-LPPO H8552 009 Anthem Medicare Preferred Standard (PPO) CA-LPPO H8552 015 Anthem Medicare Preferred Standard (PPO) CA-LPPO H8552 017 Anthem Medicare Preferred Standard (PPO) CA-LPPO H8552 018 Anthem Medicare Preferred Standard (PPO) CA-LPPO H9525 001 Anthem MediBlue Select (HMO) WI-HMO H9525 002 Anthem MediBlue Select (HMO) WI-HMO H9886 001 Anthem MediBlue Select (HMO) MO-HMO H9947 001 Medicare Preferred Core (PPO) GA-LPPO H9954 001 Anthem MediBlue Select (HMO) IN-HMO R5941 007 Blue Medicare Access Classic (Regional PPO) OH-RPPO R5941 008 Blue Medicare Access Value (Regional PPO) OH-RPPO R5941 009 Blue Medicare Access Value (Regional PPO) IN&KY-RPPO To determine whether or not your customer is enrolled in one of our Individual Medicare Advantage plans versus an Employer or Union Sponsored plan, check the lower right front of the ID card which reflects the contract and PBP number (example: H1234-001) and/or plan name. Note: If the PBP (the last three digits of the contract-pbp number) is in the 800 series, that member is in an Employer or Union Sponsored plan and these changes do not apply to their plans. Please contact the plan s Provider Service Department listed on the back of the member s ID card if you have any questions about these coverage changes.
The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. For more information about the exception process, or the appeals policy, please see the plan s 2014 Evidence of Coverage located at www.anthem.com. Y0071_14_19281_I_002 01/30/2014 5 43031MUPENMUB_002 Anthem Blue Cross is the trade name of Blue Cross of California: Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross names and symbols are registered marks of the Blue Cross Association.