HEALTH CARE CHANGES
-
Avoid costs for lab work and imaging services in Connecticut: Pay nothing when you see an in-network Preferred provider for outpatient lab work, diagnostic x-rays and/or high-cost imaging services like MRIs, CT and PET scans. For tests performed at Non-Preferred in-network labs or imaging centers, you'll pay 20% of the cost. If you are in the POS Plan, you'll pay 40% of the cost for out-of-network tests. To find a Preferred provider, visit www.Anthem.com/statect or www.welcometouhc.com/stateofct.
- Avoid costs for primary care physicians and certain specialists in Connecticut. Pay nothing when you see an in-network Preferred primary care physician (PCP) or specialist for one or more of ten medical specialties (including OB/GYN, cardiology, gastroenterology). The current $15 copay will be waived when you see a State of Connecticut "Preferred Provider." To find a Preferred Provider, visit www.Anthem.com/statect or www.oxhp.com/stateofct.
- The list of covered drugs - or "formulary" - for the prescription drug plan will change. If one or more of your current prescriptions will be affected by this change, you should have received a letter from CVS/Caremark in September with information on how to switch to a therapeutically equivalent drug.
- Prescription drug tiers for non-HEP drugs. The current generic drug copay will be split into two tiers: Preferred generic and Non-Preferred generic. New copays: Preferred generic: $5; Non-Preferred generic: $10; Preferred brand name: $25; Non-Preferred brand name: $40; no change to HEP copays.
- Emergency Room Copay for non-emergencies will cost $250. In certain circumstances, including actual emergencies or you're admitted to the hospital, your copay will be waived. Find the ER Copay Waiver Form here.
Be an Informed Consumer and Save!
Health care costs can vary from place to place in Connecticut, as they do in other states. This means smart health care shopping can help you pay less when you need care. Using high-value Anthem and United Healthcare/Oxford providers and facilities - those that offer higher quality care at lower costs - saves money for you and the State.
There are no changes to the Health Enhancement Program (HEP). HEP encourages you to take an active role in your health by getting age appropriate wellness exams and screenings. In exchange for doing so, HEP participants qualify for lower monthly premiums, reduced copays and don't pay an in-network deductible. There will be no changes to HEP, including copay amounts for drugs used to treat HEP targeted chronic conditions which include diabetes, asthma or COPD, heart disease/heart failure, hyperlipidemia (high cholesterol) or hypertension (high blood pressure). For more information on HEP, contact Care Management Solutions (CMSI) at 1-877-687-1448 or visit www.cthep.com.
Benefit Changes Effective October 1
Preferred Providers for Outpatient Lab Tests and Imaging
Anthem and United Healthcare/Oxford will have a Preferred designation for outpatient lab services and diagnostic imaging (e.g., blood work, urine tests, stool tests, x-rays, Mammograms, MRIs, CT scans) in Connecticut. You'll continue to pay nothing if you receive care at a Preferred lab! Otherwise, you'll pay 20% of the cost for Non-Preferred in-network services, or 40% of the cost for out-of-network services (POS Plan only).
Preferred Provider program will be beginning soon. Look for future communications with more details.
Cost for Covered Diagnostic Imaging and Lab Services
Preferred In-Network
Facility |
Non-Preferred In-Network
Facility |
Out-of-Network
Facility
(POS Plan only) |
$0 copay;
Plan pays 100% |
20% coinsurance;
Plan pays 80% |
40% coinsurance;
Plan pays 60% |
Preferred Provider Networks
Anthem and United Healthcare/Oxford will have a new designation for in-network providers. While you can still see any in-network primary care provider (PCP) or specialist and pay only a $15 copay, if you see a Preferred in-network provider, the copay will be waived - you'll pay nothing! Preferred in-network specialists are currently available for ten medical specialties:
- Allergy and immunology
- Cardiology
- Endocrinology
- Ear, nose and throat (ENT)
- Gastroenterology
- OB/GYN
- Ophthalmology
- Orthopedic surgery
- Rheumatology
- Urology
Your Doctor Might Already Be Preferred. If you already use an in-network PCP or specialist, there's a good chance your doctor is a Preferred provider. 70% of in-network PCPs and 60% of in-network specialists for the ten medical specialties noted above are considered Preferred.
How Much You Pay For In-Network Care
|
Preferred In-Network Provider |
Non-Preferred In-Network Provider |
| Available in Anthem's and United Healthcare/Oxford's Network |
Yes |
Yes |
| You Pay |
$0 copay; Plan pays 100% |
$15 copay |
| Preventive Care |
$0 copay; Plan pays 100% |
$0 copay; Plan pays 100% |
| Primary Care Providers (PCPs) |
Select list of in-network PCPs |
All in-network PCPs |
| Specialists |
Select list of in-network specialists in one of ten medical specialties |
All in-network specialists |
Finding a Preferred Provider
or Facility.
Prescription Drugs -- New Formulary, New Copays
Prescription drug costs are rapidly increasing. To help keep your prescription copays low, we're introducing the CVS/Caremark Standard Formulary or the "Covered Drug List." The formulary focuses on clinically effective, lower-cost alternatives to high-cost drugs.
In addition to the new formulary, the generic drug tier will split into two tiers: Preferred and Non-Preferred. Here's how much you will pay for your maintenance and non-maintenance prescriptions:
| Prescription Drug Tier |
Non-Maintenance Drugs
(30-day supply)
|
Maintenance Drugs
(90-day supply) |
| Tier 1
Preferred Generic |
$5 copay |
$5 copay |
| Tier 2
Non-Preferred Generic |
$10 copay |
$10 copay |
| Tier 3
Preferred Brand Name |
$25 copay |
$25 copay |
| Tier 4
Non-Preferred Brand Name |
$40 copay |
$40 copay |
No Change to Health Enhancement Program (HEP) Copays.
The copays for medications used to treat chronic conditions continue to be:
- Tier 1 (generic): $0 copay
- Tier 2 (Preferred brand name): $5 copay
- Tier 3 (Non-Preferred brand name): $12.50 copay.
Diabetes medications and supplies. You'll pay nothing for medications and supplies used to treat diabetes (Type 1 and Type 2).
Mandatory 90-day Supply for Maintenance Drugs. If
you or a covered family member takes a maintenance medication, you can only receive one 30-day fill at a
participating pharmacy. After this initial fill, you must
switch to a 90-day fill, available through:
- The CVS/Caremark mail-order pharmacy, or
- A pharmacy that participates in the State's
Maintenance Drug Network.
You can find a list of participating pharmacies on the Comptroller's website at
www.osc.ct.gov.
Physical and Occupation Therapy
Starting October 1, all physical and occupational therapy services are subject to medical necessity review - a determination indicating if your care is reasonable, necessary and/or appropriate based on your needs and condition. If you are seeing an in-network provider, it is the provider's responsibility to submit all necessary information during the medical necessity review process. Your co-pay will remain the same as it is today.
Where to Go When You Need Care
Knowing where to go when you need care can save you time and money. Use the information below as a starting point for determining the best place to go for your health care needs.
| Use This Health Care Option... |
...When You... |
And You'll Pay... |
| Primary Care Physician (PCP) |
Have a non-life-threatening medical concern or long term condition, or need a routine checkup |
$0 copay for Preferred in-network providers; $15 copay for Non-Preferred in-network providers |
Nurse Line
Anthem: 800-711-5947
United Healthcare/Oxford:
800-201-4911, option 4 |
Need medical guidance or information related to a symptom, treatment or surgery |
$0 |
| Walk-in Clinic |
Have a non-life-threatening minor ailment such as a cold, ear infections or sore throat |
$15 copay |
| Urgent Care |
Have a condition that is more than minor but not life-threatening (e.g., cuts or other superficial wounds, moderate burns sprains) |
$15 copay |
| Emergency Room |
Have a life-threatening concern such as shortness of breath, severe chest pain, severe wound or broken bone |
$250 copay; In certain circumstances, including actual emergencies or if you're admitted to the hospital, your copay will be waived |
