Affordable Care Act

2018 Open Enrollment

November 1, 2017-December 15, 2017

 

VDH has contracted with an outside agency, Benalytics, to assist with enrolling clients. Clients will be contacted by Benalytics to enroll in a 2018 insurance plan and may reach out to them if there are any questions 1-855-483-4647.  Other providers and sites throughout the state will also be assisting clients in enrolling in marketplace plans.  For a full list of enrollment sites, please see below.

 

Important Information for All Agencies Assisting Clients with Insurance Plan Enrollment:

 

Client Letters

Insured

Uninsured

 

 

 

Important Information for Agencies Paying Premiums on Behalf of Clients:

If your agency is registered in e2Virginia user, you are required to submit client insurance and premium payment information through the ACA enrollment module in e2Virginia.com.  If your agency is not registered in e2Virginia, please complete a hard copy of the checklist above and fax to 804-864-8050.  If information is submitted via e2VA, do not submit by fax or mail; duplicates are NOT needed.

Important Resources for e2Virginia.com Users:

Open Enrollment Call Summaries:

Enrollment Sites…Coming Soon!

Enrollment Events

2018 Insurance Carrier Information

2018 Coverage Map

2018 Coverage by County

 

Please check to see if your doctor is in-network for the health insurance you choose. The doctor you see now for HIV medical care may not take the only health insurance that is available in your area. ADAP clients should still sign up for that plan if it is the only choice. ADAP clients can get medications through health insurance. VDH will work with the doctor you see to be sure you can receive HIV medical care. Please call VDH at (855) 362-0658 or your doctor if you have questions. 

CareFirst
Plans VDH Will Support: VDH will support all Marketplace health insurance plans for CareFirst.
Pharmacy: Mail order is managed by CVS Caremark and OncosourceRx.
Formulary:  Epzicom and Fuzeon 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.
Cigna
Plans VDH Will Support: VDH will support all Marketplace health insurance plans for Cigna.
Pharmacy: Please use retail pharmacies only. Mail order is not an option.
Formulary: Prezcobix, Prezista 800mg, Viracept and Selzentry 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.                                                                                                                       
Healthkeepers (Anthem)
Plans VDH Will Support:: VDH will support all Marketplace health insurance plans for Healthkeepers (Anthem).
Pharmacy: 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.
Formulary: Prezcobix, Atripla, Complera, Odefsey, Descovy, Epzicom, Viramune XL 400mg and Lexiva are not listed on the formulary. Your medical provider must request a coverage exception from the insurance plan if you are prescribed these medications.
Kaiser
Plans VDH Will Support:: VDH will support all Marketplace health insurance plans for Kaiser.
Pharmacy: Mail order is managed by Kaiser Permanente.
Formulary: Ziagen solution and Epzicom 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.
Optima
Plans VDH Will Support:: VDH will support all Marketplace health insurance plans for Optima except for OptimaFit Gold.
Pharmacy: Mail order is managed by Proprium.
Formulary: No formulary limitations. 
Piedmont
Plans VDH Will Support:: VDH will support all Marketplace health insurance plans for Piedmont.
Pharmacy: 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. 
Formulary: Epzicom is not listed on the formulary.  Your medical provider must request a coverage exception from the insurance plan if you are prescribed this medication.

 

Information prepared by the Virginia Department of Health, Division of Disease Prevention, on October 25, 2017 from publicly available sources. This information is subject to change. Insurance carriers are the official repository for information on their respective plans. Please check the publicly available information from the insurance carrier for the most current information.



 

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