Greg Nickell responds to Shirlee's questions re: health benefit changes for 2013

Greg Nickell to Shirlee Zerkel, Aug 30, 2012
Subject: RE: Health Benefits Changes for 2013

Dear Ms. Zerkel:

Comments to your questions are below.

1. Am I understanding this correctly that now there will be a difference for in and out of network providers?

Yes. In 2013, it impacts individuals enrolled in the Aetna plan who live in a county approved by Medicare to be an active Aetna PPO county. In Ohio, all counties are active Aetna PPO counties except Ashland.

a. How is this different from 2012?

For individuals living in an active PPO county, the annual $500 deductible is applied to all services for out-of-network providers except for preventive, urgent care, emergency room and emergency transport services. There is also a $40 out-of-network physician office visit copayment that applies after the $500 deductible is satisfied. Other out-of-network services that will be subject to the annual $500 deductible in 2013 include services such as allergy testing/treatment, outpatient laboratory, skilled nursing, home health care and podiatry.

Currently, there are in-network services such as inpatient hospital/mental health/alcohol/drug, physical/occupational/speech outpatient therapies, durable medical equipment, X-rays/radiology and chiropractic already subject to the annual $500 deductible. These are unchanged for 2013 as they will continue to be subject to the annual $500 deductible in 2013 for both in- and out-of-network services.

b. Will this also be true for providers who may read our x-rays and other tests?

For individuals living in an active PPO county, if you see an out-of-network provider you would be responsible for providers who interpret X-rays and other tests. If you see and in-network provider, that provider is responsible for seeing that all other subsequent provider activity be done by other in-network providers. In this instance, if any out-of-network providers subsequently deliver services, the in-network provider is responsible for the difference in costs and you will receive the in-network level of coverage.

2. Has STRS ever covered Tier 3 and 4 drugs 100%?

Yes. Currently, enrollees have a 50% coinsurance for Tier 3 drugs to a maximum of $100 at retail and $200 at home delivery and a 100% coinsurance for Tier 4 drugs. All Tier 3 drugs have either a generic available (most cases) or a therapeutically equivalent Tier 2 brand drug in the same drug class used for treating the same diagnosis. Tier 4 drugs are drugs such as those used to treat male baldness, erectile dysfunction, non-sedating antihistamines and over-the-counter allergy medications.

a. Does this mean that we will have to pay 100% for many drugs for very serious illnesses?

No. First, anyone currently taking or if their physician prescribes tier 3 drugs in 2013 has the right to appeal through their treating physician. Secondly, for certain individuals taking tier 3 drugs where there is often high sensitivity to change in drugs like multiple sclerosis will be grandfathered and will pay the brand copayment. Express Scripts is in the process of notifying anyone being impacted by these changes. The information will include the covered alternatives available under next year’s plan. The conservative estimate is that at least 75% of patients taking Tier 3 drugs will change their prescription to a generic or Tier 2 brand drug that reduces their copayment costs compared to this year.

b. Will Express Scripts now move many of our drugs to tier 3 and 4?

No. Only drugs that have generics or therapeutically equivalent covered preferred brand would become no longer covered. In 2013, there are less than 120 drugs moving from covered preferred to not covered.

People living in active Aetna PPO counties who have utilized out-of-network providers in the last 12 months and anyone currently filling prescriptions that will not be covered under the plan next year will receive mailings with specific details well in advance of Jan. 1 2013 and before this year’s open enrollment which begins Nov. 1.

Hopefully this answers your questions.

Sincerely,
Greg Nickell
Director, Health Care Services
State Teachers Retirement System of Ohio