This is an Amendment to your Health New England, Inc. Explanation of Coverage (EOC). Please keep this Amendment with your EOC as it changes the terms of that EOC. Any language in the EOC that is inconsistent with the terms of this Amendment no longer applies. This Amendment is effective as of July 1, 2012, unless noted below.
Benefit, Program, Description or Requirement Out of Area
FOR HMO PLANS (for non-HMO plans with an out of network benefit, these
services are covered at the out of network benefit level): Dependents attending and residing at school outside of the HNE Service Area are covered for:
• Follow-up Visit After an ER or Urgent Care Visit
• Outpatient Short-term Rehabilitation Services
All services require Prior Approval by HNE.
HNE is removing the following items or services from the Prior Approval list:
• Continuous Positive Airway Pressure (CPAP) device
• Self Monitoring of Oral Anticoagulant Therapy
HNE no longer requires Prior Approval for these items.
HNE provides reimbursement for eyeglasses and contact lenses following cataract
surgery. Reimbursement is limited to one pair per calendar year in which cataract surgery is performed, up to a limit of $250.
Reminder: Effective January 1, 2011, HNE covers sleep studies done in the home. The sleep study copay will be waived for studies done in the home setting. If a sleep study is needed, please discuss the home sleep study option with your provider.
High Cost Imaging
HNE requires providers who provide the technical component of certain high cost imaging services to be accredited by one of three independent organizations. Providers who are not accredited will be considered Out-of-Plan providers. For the most current list of In-Plan providers, go to hne.com or contact HNE Member Services.
Benefit, Program, Description or Requirement Inpatient Care
Under the heading, What Is Not Covered, the bullet below is revised as follows:
• Blood or blood products, this includes the cost of donating blood for use
during surgery or medical procedures. Blood products do not include Antihemophilic Factor (Recombinant), e.g., factors VII and VIII. (sentence in italics added)
HNE is removing the following service from the Prior Approval list:
(Mental Health and
• Dialectical Behavior Therapy (DBT) Program
HNE no longer requires Prior Approval for this service.
Prescription Drug Coverage Note: Tier 1 – lowest copay; Tier 2 – mid copay level; Tier 3 – highest copay level Step Therapy: For HNE to cover the Step Therapy drugs listed here, you first must try one of the corresponding First Line drugs. If HNE has paid a claim for the First Line drug within the previous 180 days, then you are eligible for coverage of the Step Therapy drug. The use of samples does not satisfy the requirements of documented usage of a First Line drug or medical necessity for a Step Therapy drug.
If it is Medically Necessary for you to use a Step Therapy drug before trying a First Line drug, then your doctor can contact HNE to request a medical review. You must try: First Line Drug(s): Before HNE will Step Therapy Drug(s):
Note: Applies to new prescriptions only
You must try: First Line Drug(s): Step Therapy Drug(s): Before HNE will You must try: First Line Drug(s): Step Therapy Drug(s): Before HNE will
• Fortesta Gel® Note: Applies to new prescriptions only
Prescription Drug Coverage Note: Tier 1 – lowest copay; Tier 2 – mid copay level; Tier 3 – highest copay level Tier Assignments The following Prescription Drugs are changing Copay Tier Assignment Quantity Limit Additions
Starting 7/1/2012, HNE will add the following Quantity Limits to the drugs in Columns 1 and 3 below.
Medicijnlijst Onderstaande lijst is samengesteld in uitvoerig overleg met 3 verschillendehuisartsen, bedoeld voor een gezin die 3 jaar op reis ging. Geneesmiddel Hoeveelheid aan Indicaties Antibiotica: Amoxicilline 3x500mg NitroFurantoine: 4x 5mg 5 dagen Claritromycine capsules van 2 kuren 2x20 nierbekken onsteking,oppervlakkigeaderontsteking,andere infecties; mensen-endie
SECTION 1: IDENTIFICATION OF THE SUBSTANCE/MIXTURE AND OF THE COMPANY/UNDERTAKING1.2. Relevant identified uses of the substance or mixture and uses advised against1.3. Details of the supplier of the safety data sheetAgropharm LimitedBuckingham Place,Church Road, Penn,High WycombeBucksHP10 8LNTel: +44 (0) 1494 816575Factory: +44 (0)1952 740333Fax: +44 (0) 1494 [email protected]