NYSHIP has just announced some changes to the plan starting this January. Here are the highlights.

The less good news:

There will be a change in the bi-weekly premium rates: in other words, a change in the percentage of the insurance that the state pays for.

  • For individual coverage:
    • State share: 88% (down from 90%)
    • Employee share: 12& (up from 10%)
  • For family coverage:
    • State share: 73%  (down from 75%)
    • Employee share: 27% (up from 25%)
  • We will receive a letter of the new rate in late November/early December.

There will also be some increase in co-pays for the Prescription drug program:

  • 30 day supply from Pharmacy:
    • Level 1 or most generics: $5
    • Level 2 Preferred drugs: $25 (up from $15)
    • Level 3 non-preferred drugs: $45 (up from $40)
  • 31-90 supply through Mail Service pharmacy or special pharmacy:
    • Level 1: $5
    • Level 2: $50 (up from $20)
    • Level 3: $90 (up from $65)
  • It appears as well that there will be a slight increase to the start-up cost of getting onto the mail service pharmacy for certain maintenance medications: for these, at least two 30-day prescriptions must be filled using your benefits before a supply greater than 30 days will be covered. If you attempt to fill a prescription for a maintenance med for more than a 30-day supply through the Mail Service Pharmacy/Specialty Pharmacy, the last 180 days of your prescription history will be reviewed to determine whether at least 60 days worth of the drug has been previously dispensed.

….and now the good news!:

NYSHIP is now required to be ACA-Compliant: Because the plan was “grandfathered in” to the Federal Patient Protection and Affordable Care Act, it was not required to make the changes mandated by the act. Now that it has lost that status, it must “include all changes required by the Act, according to the Act’s timetable.” Here are some changes to take note of:

  • Free birth control: Generic oral contraceptive drug and devices or brand names without generic equivalents will be covered under the prescription drug program with no out-of-pocket costs.
  • Breast pump and breastfeeding support:  The plan will provide one double-electric breast pump after the birth of a child, as well as lactation support and counseling from a trained participating provider. To receive the maximum, paid-in-full benefit, you must purchase it from a contracted supplier:
  • Other enhanced women’s healthcare: The plan will provider an annual preventive care visit to obtain recommended preventive services, covered with no co-pay. These services include:
    • Screenings: mammography for breast cancer every 1-2 years starting at 40, depression, gonorrhea/chlamydia/syphilis/HIV, HPV DNA testing every 3 yrs for women over 30, gestation diabetes for women 24-28 wks pregnant or first visit for high risk of becoming diabetic
    • Counseling: women at high risk of breast cancer for chemoprevention, counseling and evaluation for genetic testing of women for BRCA breast cancer gene, counseling for sexually transmitted diseases
    • Screening and counseling for alcohol misuse, tobacco use, obesity, diet and nutrition in primary care setting
    • Annual HIV screening and counseling
    • Interpersonal and domestic violence screening/counseling
  • Immunizations at network pharmacies: Enrollees may receive the following preventive vaccines without copayment from a licensed pharmacist at pharmacies under CVS Caremark’s national vaccine network.
    • Flu shot
    • Pneumonia shot
    • Meningitis shot
    • Herpes Zoster–shingles (if 60 or older; also 55-59 subject to $5 Level 1 copay. Prescription required).

Maximum out-of-pocket limit: There is an annual maximum out-of-pocket limit for covered, in-network services. Your out-of-pocket costs, such ascopayments, for covered in-network services will not exceed the limit. For example, a $10 copayment fora doctor’s office visit will count toward your maximum out-of-pocket limit. Once you reach your limit (see below) the copayment will be waived. The total maximum out-of-pocket limit for 2015 is$6,600 for Individual coverage and $13,200 for Family coverage. It is split between the Prescription Drug Program and the Hospital, Medical/Surgical and Mental Health and Substance Abuse Programs, combined. Costs for dental and vision services do not count towards the limit.

Individual coverage:

  • $2,300 for the Prescription Drug Program
  • $4,300 for the Hospital, Medical and Mental Health/Substance Abuse Programs
Family coverage:
  • $4,600 – for the Prescription Drug Program
  • $8,600 – for the Hospital, Medical and Mental Health/Substance Abuse Program

Convenience care clinics: Convenience care clinics, or health care clinics located in retail stores, supermarkets, and pharmacies, will now be covered under the plan. Note that any visit to one of these clinics counts towards the 15 visits a year per person annual limit, excepting preventive care visits covered under the ACA. 

Licensed nurse practitioners: LPNs have been added to the list of covered providers. Note that any visit to one of these clinics counts towards the 15 visits a year per person annual limit, excepting preventive care visits covered under the ACA. 

Brand for Generic feature: When generic drugs first become available, they are often costlier to the plan than the brand name version. This feature allows the plan to place a brand-name drug on Level 1 (the lowest copayment level) and exclude the generic or put it on Level 3. These placements are for a limited time–6 months–and may be revised during the year.

Look in the mail for your new benefit card, reflecting changes in the prescription drug copayments, to arrive in the mail this month!

Find the full report of all the January 1st, 2015 changes here:

http://ebd.upsidedev.com/ebdonline/ebdonlinecenter/reports/14eprs/SEHP_Special_EPR_2014.pdf