New Products for January - Tier 1A Pharmacy Riders

Coventry Health Care is pleased to announce the addition of three new pharmacy riders for groups of all sizes as of January 1, 2011. These riders include a unique feature on Tier 1, a list of select medications covered for a $3.00 copayment. In recent years, many of our members have taken advantage of $3.00 and $4.00 generic programs in local pharmacies. Our pharmacy riders have always had a "lesser of" feature that ensures our members will always pay the lesser amount of the cost of the medication or the copayment. However, when using these generic programs in local pharmacies, many members are not presenting their cards. The result has been an apparent drop-off in compliance rates for maintenance medications for many of our members, including those in disease management programs, when we know that is not the case.

In response, we have designed several pilot riders that cover many of the same medications offered in the programs at local pharmacies for a copayment of $3.00. Our hope is that members will realize the savings they have come to expect through the generic programs, and capitalize on them by taking it one more step. The 1-2-3 mail order program also applies to these select medications, meaning that members can receive a 90-day supply of drugs like simvastatin for just one $3.00 copayment. We look forward to hearing your feedback on this program.

Under PPACA, for plan years beginning on or after September 23, 2010, employers and carriers share a requirement to notify members about expanded dependent eligibility and the special enrollment right that must be provided for dependents who were previously ineligible due to age. To meet our obligation under this rule, Coventry Health Care will be sending an informational flyer to all subscribers who renewed in October or November, as well as those who will renew in December and January, by the middle of December. As required, this special enrollment notice states that members who were ineligible due to age may be added as groups renew. 

As mentioned in our May edition of this newsletter, when determining pricing for any plan design, underwriters evaluate specific features of the plan, including deductibles, and assign a utilization credit based on the assumed impact of the deductible on utilization patterns. As employers have begun providing Health Reimbursement Arrangements (HRAs) toward some portion of the deductible, the funding has mitigated the effect of the deductible on utilization patterns resulting in higher health care usage than assumed in pricing.

In response to this, underwriting guidelines have been revised to raise the responsibility required from members to the greater of $500 or 50% of the deductible value. If Coventry Consumer Choice is not selected as the HRA administrator, we expect our broker partners to understand the implications of an HRA design outside these guidelines. Our underwriters will need to evaluate the proposed plan design and determine whether rates that have been proposed by us are appropriate with the additional level of funding by the employer. Also, Coventry Health Care has had a long-standing policy against the pairing of any of our benefit designs with gap policies. In an effort to reinforce this position, we are working to have appropriate language added to our underwriting caveats for all group sizes. Thank you for your adherence to these policies.

Personal Health Accounts - Behavioral Health Claims Payment

One of the most popular features of choosing Coventry Consumer Choice as the administrator of personal health accounts is the integrated claims cross-over. Members have come to appreciate the convenience of not having to file claims for medical and pharmacy benefits since that claim data is provided by Coventry Health Care in an electronic file to Coventry Consumer Choice. As a point of clarification, behavioral health and substance abuse claims are processed by MHNet. Though MHNet is a subsidiary company of Coventry Health Care, Inc. (Coventry), as is Coventry Consumer Choice, the computer systems are not the same.

Since acquiring MHNet, Coventry has worked to move them to a shared computer system. We anticipate the change to be some time in the second quarter of 2011. Until then, behavioral health and substance abuse claims should be treated in the same manner as they have always been treated. Members should file a claim for reimbursement out of their HRA or FSA. Claim forms are available on www.southernhealth.com by going to the Health Care Solutions tab from the main page. Members should click the link for "Our Products" on the left side of the page, and then click Coventry Consumer Choice.