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A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
2020 Small Group (1-50) UpdatesTHIS PRESENTATION AND THE INFORMATION CONTAINED WITHIN IT, IS BEING SHARED FOR INFORMATIONAL PURPOSES ONLY AND IS CURRENT AS OF AUGUST, 2019. IT IS SUBJECT TO CHANGE BASED ON SUBSEQUENT FEDERAL AND STATE LAWS, REGULATIONS AND GUIDANCE. IT DOES NOT CONSTITUTE LEGAL, COMPLIANCE, OR TAX ADVICE. IF YOU HAVE QUESTIONS, PLEASE CONTACT YOUR LEGAL, COMPLIANCE, OR TAX PROFESSIONALS.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
2020 Medical UpdatesNOTE: 2020 products are not considered final and are still pending regulatory approvals
Discontinuing Plans
• ALL Blue Essentials Access (applicable for Small Group only, network remains available in mid/large segments)
• ALL Blue Premier Access (SG only)
• Discontinuation notices drop 90 days in advance of renewal
• No changes to Blue Choice PPO plans
• New Blue Advantage HMO Plans• G9E5ADT• G9E3ADT• S9E5ADT• G9E1ADT• S9E1ADT• B9E1ADT
2020 Small Group Medical Changes
3
2020 Discontinuance Mapping
4
2019 Discontinuing Plan
2020 Mapped Plan
G601HMO G9E5ADT
G610HMO G9E3ADT
S611HMO S9E5ADT
S604HMO S643ADT
S602HMO S9E5ADT
S601HMO S643ADT
S603HMO S9E1ADT
B601HMO B660ADT
G630HMH G663ADT
S623HMH S9E5ADT
S621HMH S641ADT
S620HMH S643ADT
S622HMH S9E1ADT
B640HMH B660ADT
Blu
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Acc
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Blu
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Virtual Visits
5
Virtual Visits = PCP Copay
HSA plans = $44
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
2020 HSA Updates
Health Savings Accounts
7
All small group products are embedded.
Embedded - Individual based
Once an individual reaches Limit (deductible or OOP) benefits apply.
When family limit is reached, benefits apply even to those that have not met individual deductible or OOP.
Embedded plans have both an individual limit that one person on the plan can meet, but not exceed prior to receiving benefits, as well as a family limit.
Once the family limit (accumulated from all members of the family) is met, all members of the family are eligible for benefits.
2019 to 2020 IRS Guideline Changes
2019 IRS HSA Guidelines
HSA Embedded Minimum Deductible
Individual/Self Only
Family (2X’s)
2019 $2,700 $5,400
2020 $2,800 $5,600HSA Embedded Out-of-Pocket Maximum
Individual/Self Only
Family (2X’s)
2019 $6,750 $13,5002020 $6,900 $13,800
Non-HSA Out-of-Pocket Maximum
Individual/Self Only
Family (2X’s)
2019 $7,900 $15,800
2020 $8,150 $16,300
HSA Contributions
Individual, self-only is $3,550 Family coverage is $7,100 No change to catch up contribution limits for individuals
ages 55 and older
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
2020 Dental Updates
2020 Small Group Dental Changes
9
TypeCoinsurance (In-Network) Annual
Max
Ortho Lifetime
Max
Ded. In-Net. Implants
Class I Class II Class III Class IV
Contrib. 100% 100% 60% 50% $1,500 $1,500 $50 YesDTXHM27
TypeCoinsurance (In-Network) Annual
Max
Ortho Lifetime
Max
Ded. In-Net. Implants
Class I Class II Class III Class IV
Vol. 100% 100% 60% 50% $1,500 $1,500 $50 No
Contributory = 75% participation and 50% employee-only contribution
Voluntary = 25% participation and maximum of 50% contribution
2020 Small Group Dental Changes
10
TypeCoinsurance (In-Network) Annual
Max
Ortho Lifetime
Max
Ded. In-Net. Implants
Class I Class II Class III Class IV
Contrib. 100% 80% 50% 50% $1,000 $1,000 $50 NoDTXHM28
TypeCoinsurance (In-Network) Annual
Max
Ortho Lifetime
Max
Ded. In-Net. Implants
Class I Class II Class III Class IV
Vol. 100% 80% 50% 50% $1,000 $1,000 $50 No
!!! Diagnostic and Preventive services do NOT count toward the annual max !!!
Includes: Dental exams and cleanings (2x every 12 months); Bitewing, full mouth and panoramic X-rays (limits on how many and timeframes) and Fluoride treatments (up to age 19, 2x per plan year)
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
2020 Pharmacy Updates
2020: Pharmacy
Formulary Changes• Annual Drug List Review
• Adds, moves, removes eligibility, or included in utilization management programs
• bcbstx.com/member/prescription-drug-plan-information/drug-lists
2020 Preferred Pharmacies• Walgreens
• Walmart
• RETURNING! Sam’s Club
• Alberton's
• Brookshire
• HEB
• Health Mart Atlas
12
Locating Preferred Pharmacies
13
1. Log on to www.myprime.com2. Choose Pharmacy Network3. Search by ZIP Code or City4. Filter by Preferred Pharmacies
Blue Advantage = Preferred Network for HMO
Blue Choice = Preferred Choice Network
Out of State Preferred Pharmacy / MyPrime.com
14
2020: Pharmacy Updates
Specialty Pharmacy Program• Limited to a 30-day supply
• Self-administered meds are standardly covered under pharmacy benefit; physician administered meds are covered under medical benefit
• 50% out-of-network penalty if In-Network Specialty Pharmacy Network is NOT used (applies to PPO plans only)
Member Pay the Difference Penalty • IF a member chooses to use a brand name prescription versus the EXACT generic
equivalent the member will be required to pay copay or coinsurance PLUS the difference in cost
• Penalty applies to OPX (once OPX is satisfied, penalties will cease)
• Waiver Request (submitted by the Provider): • MPTD Penalty Waiver Form • FDA MedWatch Form
90-Day Delivery Options• Only available at preferred pharmacies (3x copay) or,
• Mail ordered through Alliance Rx Walgreens Prime (3x copay)
15
2020: Pharmacy Updates
Drug Coupons• Effective 1/1/20, or upon renewal, drug coupons used for brand name meds will
not count toward the annual deductible and OPX, IF the med has a generic equivalent
• If a brand med is required due to availability or medical requirements, the coupon WILL count toward the deductible and OPX
Out-of-Network Pharmacies (applies to PPO plans only)• Meds filled at an out-of-network pharmacy must be initially paid in full, by member
• Submit claim for out-of-network eligible reimbursement
16
2020: Pharmacy Drug List Exclusions
17
This is a list of the most common drugs being excluded in 2020. Members impacted will be mailed a letter with a link to the BCBSTX website where they can search for all the drug list changes
Drug Name* Generic Alternatives Brand Alternatives
RANEXAAntianginal Agents/Other
• nitroglycerin tablet• nitroglycerin transdermal
• NA
TROKENDI XRAnticonvulsants
• topiramate ER capsules• topiramate tablets
• N/A
REXULTIAntipsychotics
• aripiprazole• risperidone• ziprasidone
• N/A
XELJANZ XRBiologics: Rheumatoid & Other Arthritides
• N/A • ENBREL• HUMIRA• SIMPONI
SENSIPARCalcimimetic (Calcium Reducer)
• Generic equivalent available • N/A
*May not apply to all strengths/formulations.
2020: Pharmacy Drug List Exclusions
18
This is a list of the most common drugs being excluded in 2020. Members impacted will be mailed a letter with a link to the BCBSTX website where they can search for all the drug list changes
Drug Name* Generic Alternatives Brand Alternatives
TRADJENTAAnti-Diabetic
• N/A • JANUVIA• ONGLYZA
MINIVELLEEstrogens, TD
• Generic equivalent available
• N/A
COLCHICINEGout
• N/A • MITIGARE
ULORICGout
• allopurinol • MITIGARE
COLCRYSGout
• N/A • MITIGARE
OMNITROPEGrowth Hormones & Somatomedins
• N/A • NORDITROPIN
CIALISImpotence Agents
• Generic equivalent available
• N/A
COPAXONEMultiple Sclerosis
• glatiramer • N/A
*May not apply to all strengths/formulations.
2020: Pharmacy Drug List Exclusions
19
This is a list of the most common drugs being excluded in 2020. Members impacted will be mailed a letter with a link to the BCBSTX website where they can search for all the drug list changes
Drug Name* Generic Alternatives Brand Alternatives
METAXALONEMusculoskeletal Therapy Agents
• baclofen tablet• cyclobenzaprine hcl tablet• methocarbamol tablet
• N/A
CHLORZOXAZONEMusculoskeletal Therapy Agents
• cyclobenzaprine hcl tablet • N/A
AURYXIAPhosphate Binders
• OTC options available • N/A
SOOLANTRARosacea Agents
• N/A • SKLICE
FINACEARosacea Agents
• Generic equivalent available • N/A
SUBOXONESubstance Abuse
• Generic equivalent available • N/A
MUPIROCIN CREAMTopical Antibiotics
• mupirocin ointment • N/A
*May not apply to all strengths/formulations.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
2020 Behavioral Health Updates
• New Opioid / Substance Use Initiative• Risk Identification & Outreach + dedicated multi-disciplinary team to support
positive health outcomes
• Applied Behavior Analysis (ABA) / Autism• Leverages technology from the Cedar Group,
provides for improved consistency of ABA treatment by implementing an objective, evidence-based treatment decision support to guide authorization recommendations
• Behavioral Health Network Access• Improved user experience in identifying BH provider
specialties, including Medication Assisted Therapy (MAT) providers
• Advanced Analytics and Reporting• Continued focus on the cost of care for members and employers
2020: Enhanced Behavioral Health
21
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
2020 Blue Balance Funded
2020: Blue Balance Funded
Employer Size• 10-50
Participation Requirements• 75% employee participation
• Eligible employees w/valid waivers will be excluded from participation calculations
• 50% employee-only contribution
23
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Q4 Renewals
Renewal Timeframes
25
January Renewals
26
Release date dependent upon federal and state approvals of products AND rates
Paperwork due 30 days prior
Blue Advantage Network
• Covers all 254 Counties
• 8,626 Primary Care Physicians
• 28,815 Specialists
27
January Renewals
Blue Advantage Education
• FAQs
• Network comparison charts based on region• Austin• DFW• Houston• San Antonio/Valley• West Texas
• Myth Buster Videos
• Employee communications
• Electronic communication directly to employers renewing in January w/out a Blue Advantage plan (est. release date 9/16)
28
Blue Advantage Savings
29
$551G652CHC (2019)
$619 (+12%)G652CHC (2020)
$396 (-28%)G663ADT (2020)
Age 40 Q1 rates for rating area 8 (Dallas) are used for comparison. Rate increases vary by plan and area.*Membership as of 6/30/2019
Dual Options
30
$494G652CHC
(18 Members, 2019)
$572 (+16%)G652CHC
(18 Members, 2020)
$505 (+2%)G663ADT
(9 Members, 2020)G652CHC
(6 Members, 2020)P621CHC
(3 Members, 2020)
Age 40 Q1 rates for rating area 23 (Victoria) are used for comparison. Group of 18 – 9 moving to Blue Advantage; 3 on a Platinum Choice plan; 6 on a Gold Choice plan*Membership as of 6/30/2019
$572 (+16%)G652CHC
(6 Members, 2020)
$405 (-18%)G663ADT
(9 Members, 2020)
$673 (+36%)P621CHC
(3 Members, 2020)
Renewal Reminders
• Out-of-state employees and/or dependents –Blue Choice PPO is a must
• Employers can offer up to SIX benefit plans• 50% employer contribution is based upon the lowest plan offered
• Employee plan changes may be submitted with the BPA Amendment –OR – can be submitted later, if open enrollment has not occurred• Includes PCP selections:
• Family Practice• General Practice• Internal Medicine• Obstetrics & Gynecology (in some cases)
• Full BCBSTX portfolio is available in Section 5 of renewal exhibits
31
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Everything else, and….
Sales & Renewal Microsite
33
Sales & Renewal Microsite
• Paperwork deadlines
• Forms• BPA Amendment• Membership application
• Contact listing
• Most requested marketing materials:
• Blue365• Pediatric vision• Virtual visits
• Dental SBCs
• 2019 Benefit booklets
• 2020 information added as available
34
Sanitas Partnership
35
BCBS of Texas & Sanitas are forming a joint venture in TX in order to enhance care delivery in Dallas and Harris counties, opening 10 clinics by January 1, 2020.
Details: This offerings allows us to create a unique product & partnerships with providers to be competitive in a dynamic market. Benefits: Both Medical Management and Customer Service will be
onsite at select clinics.
Future expansion concepts are being consideration for 2021 and beyond.
New Payment Address
• Beginning with premium payments due in Oct., 2019
Fully Insured
Blue Balance Funded / ASO
36
Mailing Address Blue Cross and Blue Shield of TexasP. O. Box 650615 Dallas, TX 75265-0615
Overnight/Courier Address
Blue Cross and Blue Shield of TexasATTN: 6506151501 North Plano Rd., Suite 100Richardson, TX 75081
Mailing Address Blue Cross Blue Shield of TexasDept. 1134 (ASO)P.O. Box 121134Dallas, TX 75312-1134
Overnight/Courier Address
Blue Cross Blue Shield of <State>ASO BusinessBox 8911341501 North Plano Rd.Richardson, TX 75081
Ancillary
• Effective 1/1/20 Dearborn products will be re-branded as “Blue”• Life• Disability• Accident• Vision
37
Looking to the future…
• New technology
• One-bill capabilities
• Data sharing
Deductible and OPX Credits
Small Employers (1-50)
• Deductible credit = Yes
• OPX = No
Mid Market Employers (51-150)
• Deductible credit = Yes
• OPX = Yes, IF reporting is provided with OPX amounts
38