Ff-0712-sub

AMENDMENT 02-2012
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 Student Coverage
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. Services and
HNE is removing the following items or services from the Prior Approval list: Procedures that
• Continuous Positive Airway Pressure (CPAP) device Require Prior
• Self Monitoring of Oral Anticoagulant Therapy Approval
HNE no longer requires Prior Approval for these items. Limitations and
HNE provides reimbursement for eyeglasses and contact lenses following cataract Partial Exclusions
surgery. Reimbursement is limited to one pair per calendar year in which cataract surgery is performed, up to a limit of $250. Diagnostic Testing
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) Behavioral Health
HNE is removing the following service from the Prior Approval list: (Mental Health and
• Dialectical Behavior Therapy (DBT) Program Substance Abuse)
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.

Source: http://www.hnetalk.com/Member/wp-content/uploads/2012/06/ff-0712-sub.pdf