Affordable Care Act

VDH Affordable Care Act Implementation Weekly Update


2017 Insurance Carriers
Please see the list below for plans that VDH will support.

Insurance Company Plan Name Comments
Aetna Aetna Leap Basic (Bronze) The Provider list includes, but is not limited to, the following provider sites: Carilion, UVA, VCU, Centra. Please check to see if your provider is on the plan.

 

Genvoya is not listed on this plan’s formulary. Your medical provider must request a coverage exception from the insurance plan if you are prescribed this medication.

 

Descovy, Odefsey, Truvada and Stribild require a prior authorization.

 

Mail order is managed by Aetna Specialty Pharmacy (the current exception for VA ADAP is still in place).

Aetna Leap Basic Bon Secours (Bronze)
Aetna Leap Basic Coastal VA HP (Bronze)
Aetna Leap Basic Gateway Health (Bronze)
Aetna Leap Basic Roanoke Valley (Bronze)
Aetna Leap Diabetes (Silver)
Aetna Leap Diabetes Coastal VA HP (Silver)
Aetna Leap Diabetes Gateway Health (Silver)
Aetna Leap Diabetes Roanoke Valley (Silver)
Aetna Leap Everyday (Silver)
Aetna Leap Everyday Coastal VA HP (Silver)
Aetna Leap Everyday Gateway Health (Silver)
Aetna Leap Everyday Plus (Silver)
Aetna Leap Everyday Plus Coastal VA HP (Silver)
Aetna Leap Everyday Plus Gateway Health (Silver)
Aetna Leap Everyday Plus Roanoke Valley (Silver)
Aetna Leap Everyday Roanoke Valley (Silver)
Aetna Leap Healthy Minds (Silver)
Aetna Leap Healthy Minds Coastal VA HP (Silver)
Aetna Leap Healthy Minds Gateway Health (Silver)
Aetna Leap Healthy Minds Roanoke Valley (Silver)
Aetna Leap Diabetes Gold Gateway Health
Aetna Leap Diabetes Bon Secours (Silver)
Aetna Leap Everyday Bon Secours (Silver)
Aetna Leap Everyday Plus Bon Secours (Silver)
Aetna Leap Healthy Minds Bon Secours (Silver)
Aetna Leap Diabetes Gold Bon Secours
Aetna Leap Catastrophic
Aetna Leap Catastrophic Bon Secours
Aetna Leap Catastrophic Coastal VA HP
Aetna Leap Catastrophic Gateway Health
Aetna Leap Catastrophic Roanoke Valley
CareFirst BlueChoice HMO Silver $3500 The Provider list includes, but is not limited to, the following provider sites: INOVA, Mary Washington Healthcare.   Please check to see if your provider is on the plan.

 

Genvoya, Descovy and Odefsey are not listed on this plan’s formulary. Your medical provider must request a coverage exception from the insurance plan if you are prescribed this medication.

 

Fuzeon requires a prior authorization.

 

Mail order is managed by CVS Caremark and OncosourceRx.

HealthyBlue HMO Gold $1000
BlueChoice HMO HSA Silver $1500
BlueChoice Plus Silver $2500
BlueChoice HMO Young Adult Catastrophic $7,150
HealthyBlue PPO Gold $1000
BluePreferred HSA Silver $2000
Healthkeepers(Anthem) Bronze X 6200 HSA The Provider list includes, but is not limited to, the following provider sites: Carilion, VCU, EVMS, ID Assoc. of Hampton Roads, Selma Medical, Mary Washington Healthcare, Centra, UVA.  Please check to see if your provider is on the plan.

 

Atripla, Complera, Genvoya, Descovy, Odefsey, Prezcobix, Lexiva, Lamivudine oral solution and 100mg tabs, and Viramune 400mg XR are not listed on the formulary. Your medical provider must request a coverage exception from the insurance plan if you are prescribed these medications.

 

Specialty mail order is managed by Accredo and coordinates medication coverage with Ramsell. Some HIV medications qualify as specialty medications.  Mail order is managed by Express Scripts which declines to coordinate medication coverage with Ramsell.  Express Scripts will have to be notified after the third refill at a retail pharmacy that mail order will not be used.  If this step is not completed, prescriptions will not be covered until Express Scripts is notified.

Bronze X 5900
Bronze X 5150
Bronze X 4500
Bronze X 4900 HSA
Silver X 3500
Silver X 2800
Silver X 2300
Bronze X 5750 HSA
Gold X 1300
Bronze X 6350
Silver X 5000
Bronze X POS 4500
Silver X POS 2300
Bronze X POS 5750 HSA
Catastrophic X 7150
Innovation Health Innovation Health Leap Catastrophic The Provider list includes, but is not limited to, the following provider sites: INOVA, Mary Washington Healthcare.  Please check to see if your provider is on the plan.

 

Genvoya is not listed on this plan’s formulary. Your medical provider must request a coverage exception from the insurance plan if you are prescribed these medications.

 

Descovy, Odefsey, Truvada and Stribild require a prior authorization.

 

Mail order is managed by Aetna Specialty Pharmacy (the current exception for VA ADAP is still in place)

Innovation Health Leap Bronze
Innovation Health Leap Silver Basic
Innovation Health Leap Silver Diabetes
Innovation Health Leap Silver Healthy Minds
Innovation Health Leap Silver Plus
Innovation Health Leap Gold Diabetes
Kaiser Gold 0/20/Dental/Ped Dental Coverage limited to Kaiser facilities and physicians.   You would have to choose an “In-Network” provider. Please check to see if your provider is on the plan.

 

Genvoya, Descovy and Odefsey are not listed on this plan’s formulary. Your medical provider must request a coverage exception from the insurance plan if you are prescribed this medication.

 

Mail order is managed by Kaiser Permanente.

Gold 1000/20/Dental/Ped Dental
Silver 1800/30/DentalPed Dental
Silver 2800/30/Dental/Ped Dental
Silver 2750/20%HSA/Dental/Ped Dental
Bronze 5000/50/Dental/Ped Dental
Bronze 6200/20%/HSA/Dental/Ped Dental
Platinum 0/20/Dental/Ped Dental
Bronze 6500/50/Dental/Ped Dental
STD Silver 3500/30Dental/Ped Dental
Silver 6000/30/Dental/Ped Dental
Optima OptimaFit Gold 1000 M The Provider list includes, but is not limited to, the following provider sites: Carilion, EVMS

Please check to see if your provider is on the plan.

 

Complera (components available) is not listed on this plan’s formulary. Your medical provider must request a coverage exception from the insurance plan if you are prescribed these medications.

 

Mail order is managed by Proprium.

OptimaFit Silver 4000 20 M
OptimaFit Silver 2600 25 20 M
OptimaFit Bronze 6850 30 M
OptimaFit Gold 1000 M Select
OptimaFit Bronze 6850 30 M Select
Piedmont HMO Gold Preferred 950/30/50 HMO The Provider list includes, but is not limited to, the following provider sites: Centra

Please check to see if your provider is on the plan.

 

Descovy and Odefsey are not listed on the formulary. Your medical provider must request a coverage exception from the insurance plan if you are prescribed these medications.

 

Mail order is managed by CVS Caremark.     Piedmont also offers “walk-in” 90-day supplies through some of its retail participating pharmacies – all CVS pharmacies, all K-Mart pharmacies, all Medicine Shoppe pharmacies, and a few individual pharmacies.

Gold Preferred 1200/25/50 HMO
Silver Preferred 3200/35/60 HMO
Silver Preferred 3800/40/65
Silver Basic 2500 HMO
Bronze 5250 HMO
Bronze 6200 HMO
Catastrophic 7150 HMO
Bronze HSA 5000 HMO
Bronze HSA 6000 HMO
Silver Standard 3500/30/65 HMO
Bronze Standard 6650 HMO
Piedmont PPO Gold Preferred 950/35/60 The Provider list includes, but is not limited to, the following provider sites: Centra

Please check to see if your provider is on the plan.

 

Descovy and Odefsey are not listed on the formulary. Your medical provider must request a coverage exception from the insurance plan if you are prescribed these medications.

 

Mail order is managed by CVS Caremark.     Piedmont also offers “walk-in” 90-day supplies through some of its retail participating pharmacies – all CVS pharmacies, all K-Mart pharmacies, all Medicine Shoppe pharmacies, and a few individual pharmacies.

Gold Preferred 1250/35/50
Silver Preferred 2900/40/60
Silver Preferred 3800/40/60
Bronze 5250
Bronze 6200
Bronze HSA 5000
Bronze HSA 6000
Silver Basic 2450
Silver Standard 3500/30/65
Bronze Standard 6650
Catastrophic 7150
United Healthcare UHC Compass HSA Silver 2800 The Provider list includes, but is not limited to, the following provider sites: INOVA, Mary Washington Healthcare, VCU.   Please check to see if your provider is on the plan.

 

Selzentry requires a prior authorization.

 

Specialty Mail-order is managed by Briova.

UHC Compass HSA Bronze 6550
UHC Compass Gold 1000
UHC Compass Silver 5200
UHC Compass Bronze 7100

 

 

Medication Exception Request

When a drug is not covered by an ACA insurance company’s published formulary, the provider must complete a Medication Exception request through the insurance company providing all required information. The ACA provides for expedited review (within 24 hours) in exigent circumstances, which is when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee’s life, health, or the ability to regain maximum function, or when an enrollee is undergoing a current course of treatment using a non-formulary drug.

As part of the request for an expedited review based on exigent circumstances, the prescribing physician or other prescriber should support the request by including an oral or written statement that:
1. An exigency exists and the basis for the exigency (that is, the harm that could reasonably come to the enrollee if the requested drug were not provided within the timeframes specified by the issuer’s standard drug exceptions process), and
2. A justification supporting the need for the non-formulary drug to treat the enrollee’s condition, including a statement that all covered formulary drugs on any tier will be or have been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

If the Medication Exception request is denied, the provider must file an appeal within 24 hours and follow up with the insurance company.  VDH requests in all cases where a drug exception has been denied that the Bureau of Insurance Ombudsman be contacted:
• By Toll free phone at: (877) 310-6560, select option 1
• By fax at: (804) 371-9944
• By letter at: Office of the Managed Care Ombudsman, Bureau of Insurance, P.O. Box 1157, Richmond, Virginia 23218
• By email: ombudsman@scc.virginia.gov

Medication Exception and Prior Authorization Guidance