2019 Benefit Updates

For Renewing Members

Renewing Medical Coverage

On Market plans purchased through the Federally- Facilitated Marketplace

Gold PPO 2000/10/20

  • Specialist copay: $45
  • $250 copay (deductible waived) for outpatient surgeries performed at a participating Ambulatory Surgical Facility
  • Outpatient surgeries performed at an Acute Care Hospital Facility charges subject to 10% coinsurance after meeting the deductible
  • 25% coinsurance after deductible for outpatient facility procedures for high tech imaging services
  • Added coverage for acupuncture and spinal manipulation services for chronic pain management
  • Change to Rx copayments and addition of a second tier of coverage for non-preferred generic drugs 
  • Formulary tier changes and authorization requirement changes were made to the prescription drug formulary. View the 2019 selectively closed formulary
  • See the 2019 certificate of coverage for more information

Silver PPO 5000/10/30

  • $250 copay (deductible waived) for outpatient surgeries performed at a participating Ambulatory Surgical Facility
  • Outpatient surgeries performed at an Acute Care Hospital Facility subject to 10% coinsurance after meeting the deductible
  • 25% coinsurance after deductible for outpatient facility procedures for high tech imaging services
  • Added coverage for acupuncture and spinal manipulation services for chronic pain management
  • Change to Rx copayments and addition of a second tier of coverage for non-preferred generic drugs
  • Formulary tier changes and authorization requirement changes were made to the prescription drug formulary. View the 2019 selectively closed formulary.
  • See the 2019 certificate of coverage for more information

Silver PPO 5000/10/30 CSR73

  • $200 copay (deductible waived) for outpatient surgeries performed at a participating Ambulatory Surgical Facility
  • Outpatient surgeries performed at an Acute Care Hospital Facility subject to 8% coinsurance after meeting the deductible
  • 18% coinsurance after deductible for outpatient facility procedures for high tech imaging services
  • Added coverage for acupuncture and spinal manipulation services for chronic pain management
  • Change to Rx copayments and addition of a second tier of coverage for non-preferred generic drugs
  • Formulary tier changes and authorization requirement changes were made to the prescription drug formulary. View the 2019 selectively closed formulary
  • See the 2019 certificate of coverage for more information

Silver PPO 5000/10/30 CSR87

  • $100 copay (deductible waived) for outpatient surgeries performed at a participating Ambulatory Surgical Facility
  • Outpatient surgeries performed at an Acute Care Hospital Facility subject to 5% coinsurance after meeting the deductible
  • 15% coinsurance after deductible for outpatient facility procedures for high tech imaging services
  • Added coverage for acupuncture and spinal manipulation services for chronic pain management
  • Change to Rx copayments and addition of a second tier of coverage for non-preferred generic drugs
  • Formulary tier changes and authorization requirement changes were made to the prescription drug formulary. View the 2019 selectively closed formulary
  • See the 2019 certificate of coverage for more information

Silver PPO 5000/10/30 CSR94

  • $50 copay (deductible waived) for outpatient surgeries performed at a participating Ambulatory Surgical Facility
  • Outpatient surgeries performed at an Acute Care Hospital Facility are covered in full after meeting the deductible
  • 10% coinsurance after deductible for outpatient facility procedures for high tech imaging services
  • Added coverage for acupuncture and spinal manipulation services for chronic pain management
  • Change to Rx copayments and addition of a second tier of coverage for non-preferred generic drugs
  • Formulary tier changes and authorization requirement changes were made to the prescription drug formulary. View the 2019 selectively closed formulary
  • See the 2019 certificate of coverage for more information

Bronze PPO 7350/0/60

  • $250 copay (deductible waived) for outpatient surgeries performed at a participating Ambulatory Surgical Facility
  • Outpatient surgeries performed at an Acute Care Hospital Facility charges are covered in full after the deductible is met
  • Added coverage for acupuncture and spinal manipulation services for chronic pain management
  • Formulary tier changes and authorization requirement changes were made to the prescription drug formulary. View the 2019 selectively closed formulary
  • See the 2019 certificate of coverage for more information

Off Market plans purchased directly through Capital BlueCross

Gold PPO 2000/10/20

  • Change specialist copayment to $45
  • $250 copay (deductible waived) for outpatient surgeries performed at a participating Ambulatory Surgical Facility
  • Outpatient surgeries performed at an Acute Care Hospital Facility charges subject to 10% coinsurance after meeting the deductible
  • 25% coinsurance after deductible for outpatient facility procedures for high tech imaging services
  • Added coverage for acupuncture and spinal manipulation services for chronic pain management
  • Change to Rx copayments and addition of a second tier of coverage for non-preferred generic drugs 
  • Formulary tier changes and authorization requirement changes were made to the prescription drug formulary. View the 2019 selectively closed formulary
  • See the 2019 certificate of coverage for more information

Silver CareConnect 3000/0/35

We will not be offering your current plan in 2019 and apologize for any inconvenience this may cause. We would like to support you in choosing a new plan and suggest that you consider either our Silver PPO 4950/10/30 plan or Gold PPO 2000/10/20 plan. While the benefits are different, they are competitively priced and offer a broader network than your current plan.

Silver PPO 4950/10/30

  • $250 copay (deductible waived) for outpatient surgeries performed at a participating Ambulatory Surgical Facility
  • Outpatient surgeries performed at an Acute Care Hospital Facility subject to 10% coinsurance after meeting the deductible
  • 25% coinsurance after deductible for outpatient facility procedures for high tech imaging services
  • Added coverage for acupuncture and spinal manipulation services for chronic pain management
  • Change to Rx copayments and addition of a second tier of coverage for non-preferred generic drugs 
  • Formulary tier changes and authorization requirement changes were made to the prescription drug formulary. View the 2019 selectively closed formulary
  • See the 2019 certificate of coverage for more information

Silver PPO 5000/10/30

  • $250 copay (deductible waived) for outpatient surgeries performed at a participating Ambulatory Surgical Facility
  • Outpatient surgeries performed at an Acute Care Hospital Facility subject to 10% coinsurance after meeting the deductible
  • 25% coinsurance after deductible for outpatient facility procedures for high tech imaging services
  • Added coverage for acupuncture and spinal manipulation services for chronic pain management
  • Change to Rx copayments and addition of a second tier of coverage for non-preferred generic drugs 
  • Formulary tier changes and authorization requirement changes were made to the prescription drug formulary. View the 2019 selectively closed formulary
  • See the 2019 certificate of coverage for more information

Bronze PPO 7350/0/60

  • $250 copay (deductible waived) for outpatient surgeries performed at a participating Ambulatory Surgical Facility
  • Outpatient surgeries performed at an Acute Care Hospital Facility services are covered in full after meeting the deductible
  • Added coverage for acupuncture and spinal manipulation services for chronic pain management
  • Formulary tier changes and authorization requirement changes were made to the prescription drug formulary. View the 2019 selectively closed formulary
  • See the 2019 certificate of coverage for more information

Bronze HMO 7350/0/60

  • $250 copay (deductible waived) for outpatient surgeries performed at a participating Ambulatory Surgical Facility
  • Outpatient surgeries performed at an Acute Care Hospital Facility services are covered in full after meeting the deductible
  • Added coverage for acupuncture and spinal manipulation services for chronic pain management
  • Formulary tier changes and authorization requirement changes were made to the prescription drug formulary. View the 2019 selectively closed formulary
  • See the 2019 certificate of coverage for more information

Catastrophic HMO 7900/0/75

  • Change In Network annual deductible to $7,900 individual/$15,800 family
  • Change In Network annual Maximum Out of Pocket to $7,900 individual/$15,800 family
  • Added coverage for acupuncture and spinal manipulation services for chronic pain management
  • Diagnostic lab test performed at an Independent clinical lab are covered in full after meeting the deductible
  • Mental Health care outpatient office visits are covered in full after meeting the deductible
  • Formulary tier changes and authorization requirement changes were made to the prescription drug formulary. View the 2019 selectively closed formulary
  • See the 2019 certificate of coverage for more information

Pharmacy Changes

Prescription Drug Updates

2019 Selectively Closed Formulary

Please read this document in its entirety as it provides important information about the list of prescription drugs in the Selectively Closed Formulary for 2019.
Each year we review and update the Selectively Closed Formulary* (list of drugs). As a result of our most recent review, changes for January 1, 2019 will include expanding the list of drugs needing prior authorization,* modifying quantity level limits* for certain drugs, and adding or removing drugs. Affected members and providers will be notified of the changes before they go into effect. Please visit capbluecross.com for a full listing of the 2019 Selectively Closed Formulary and other information about the prescription drug benefit.

What is changing

Some of the drug classes that have changes in the 2019 formulary include:†

  • Opioids (such as oxycodone or tramadol)
  • Muscle Relaxants (such as cyclobenzaprine or carisoprodol)
  • Topical Corticosteroids (such as betamethasone or clobetasol)

†This list does not represent all drug classes or all changes on the Selectively Closed Formulary. Please see the Selectively Closed Formulary at capbluecross.com to see the full list of drugs.

What should you do

We recommend taking the time to carefully review the 2019 Selectively Closed Formulary located on capbluecross.com to see if any drugs you currently take were changed. If a change applies to you, please contact your provider to discuss your care. To get a printed version of the formulary, call the number on the back of your member ID card. If you have any questions, please call CVS/caremarkTM member services at 800.585.5794.

Definitions of key terms in this document *

Formulary: A list of the most commonly prescribed drugs by therapeutic class.

Prior Authorization: This process helps ensure that certain drugs are prescribed appropriately and in keeping with Food and Drug Administration (FDA) guidelines. In-network providers are responsible for requesting prior authorization on your behalf. Medications requiring prior authorization will not be covered if authorization is not obtained before dispensing.

Quantity Level Limits: For certain drugs, the amount of the drugs covered by your plan during a certain time period is limited. This is to help promote use of selected medications and enhance patient safety.

Enrollment

Open Enrollment Timeline

Applications for coverage effective January 1, 2019 must be submitted November 1 – December 15, 2018.

Applications received after December 15, 2018 will fall into the Special Enrollment Period and must have a qualifying event to enroll.

Ready to Enroll or Make a Change

You can apply for medical, dental or vision plans if you live in our service area.

Visit our Individual and Family Plans to get started.

Enrollment Details

Current member

If you’re a current member and you would like to keep your current plan, you do not need to take any action. We will re-enroll you in your current plan. Review the renewal notice under the section titled, “Changes you’ll see to your plan in 2019” to see any changes to your plan details.

If you are a current CareConnect PPO member, your plan will no longer be offered in 2019. We would like to support you in choosing a new plan and suggest that you consider either our Silver PPO 4950/10/30 plan or Gold PPO 2000/10/20 plan. While the benefits are different, they are competitively priced and offer a broader network than your current plan.

Visit healthcare.gov to review your Marketplace application for any changes, including any changes to your financial help.

New Member

If you are a new member, you’ll receive a declaration page after you enroll. The page provides the effective date of coverage, covered members and expected premium amounts.

ID Cards

Renewing members who do not change plans will not receive a new ID card.

Renewing members who select and apply for a new plan will receive an ID card 7-10 business days after applying.

New members will receive ID cards within 7-10 business days after applying.

Billing

Invoices for January enrollment will be generated on December 10, 2018.

Payment Options

  • Credit Card/eCheck- Make payments by logging into your secure member account or by calling 877.889.7282. Select a single payment or setup recurring payment options.
  • Check It Out- Members will receive a notice when Check It Out is processed. Payment will be deducted from the selected account on the first day of each month.
  • Paper Bill- Invoices are mailed to the address on the enrollment application.
  • Bill Payer- Payments can be made through a financial institution’s bill payer program.


Visit the Welcome page for more information about your plan.