Employee Health PlanFrequently Asked Questions

  1. General Plan Questions
  2. Network Providers
  3. Recognized Charges
  4. Coordination of Benefits
  5. Medical Necessity
  6. Dental Plan
  7. Prescription Compound Medication

General Plan Questions

  • Why have I received two ID cards?

    To improve our network and customer service, AlaskaCare selected Aetna to administer all medical and pharmacy claims and Moda Health to administer all dental claims. In the past, these services had been provided by a single company. You should have received a medical ID card from Aetna and a dental ID card from Moda to use when visiting your health care provider or pharmacy.

  • My ID card hasn't arrived, what should I do?

    If your ID card hasn't arrived, you can view and print your Medical/Prescription ID card or download the mobile app that displays the ID card on your smartphone. Note: Aetna Navigator registration required.

    You can use your Social Security number to register or call the Aetna Concierge (855) 784-8646 for assistance.

  • Dental ID Card

    To print your Moda Health/Delta Dental of Alaska ID card or download the MyModa mobile app, register on the MyModa website or call Moda at (855) 718-1768.

  • How can I get a current copy of the Health Plan booklet showing all plan changes?

    A new plan booklet will be released on or after January 1, 2018, for the new benefit year.

  • Will I be taxed on my health benefits?

    The plan meets the criteria under Internal Revenue Code §125 and its accompanying Treasury Regulations, which govern cafeteria plans as offered under the Select Benefits Health Plan. This allows for premiums that are taken from your pay check to be deducted prior to taxes being calculated.

  • What if I have previously used Aetna Navigator?

    You may register using your SSN or Aetna ID number and the system will provide your previous user name. If you don't remember your old password, click, "I forgot my username and/or password." Then the system will walk you through your security questions to reset the password. If you don't recall the answer to your security question, click on the "Need Help?" option. Do not select "I need to register as a subscriber or dependent for another Aetna plan."

    The "Need Help?" option will provide an email and phone number for Technical Support. Technical Support has the ability to reset your entire profile, allowing you to create a new username and password.

Top of Page

Network Provider Questions

  • How do I find a network vision provider?

    Registering on the VSP website is the best way to find a network vision provider. Registering will allow you to:

    • Locate a network VSP doctor
    • Check claim history
    • View benefits
    • Learn about important aspects of eyecare

    If you choose not to register and search the VSP site as a guest, VSP cannot guarantee the doctors on the list will participate in your plan. In addition, VSP cannot guarantee all doctors on your plan will appear on the list.

  • What if my provider isn't in the network?

    If your current provider is not listed as an in-network provider, you can ask your physician to contact AlaskaCare for a participation application. If you would like the provider to receive an application, please complete a Provider Nomination form [PDF 37K]. However, until your current physician becomes a provider in the network, you may wish to consider changing to a network physician in order to better control your costs and avoid balance billing.

  • Do I have to change my provider?

    No. But seeking care from a network provider will protect you from balance billing by your provider.

    To determine if your medical provider is a network provider, contact the Aetna Concierge team at (855) 784-8646 or use the "Find a Doctor" button in the left column of this website.

    By ensuring you are using an in network provider, you can take advantage of the significant discounts we negotiate to help lower your out-of-pocket costs for medically necessary care. This can help you get the care you need at a lower price.

  • When I use an out-of-network provider, how much of the bill am I responsible for?

    If you use an out-of-network provider, you are responsible for the difference between the recognized charge and the amount charged by the provider in addition to other applicable charges such as deductibles, co-payments, co-insurance and non-covered charges.

  • What is balance billing?

    The AlaskaCare plans limit payment of covered services to the recognized charge. The recognized charge is the maximum amount the AlaskaCare plans will pay for a covered service. Aetna and Moda/Delta Dental, and their respective network providers (sometimes referred to as participating providers), agree to a set of discounted negotiated rates for services provided. The recognized charge for network providers is the negotiated rate. For an explanation of how the recognized charge is calculated for out-of-network providers, please see the recognized charge questions under the Network and Dental sections.

    An out-of-network provider has the right to bill you for the difference between the recognized charge and the actual charge. This is often referred to as balance billing. Network providers have agreed to accept, as payment in full, the negotiated charge. Therefore, you are not subject to balance billing when you use a network provider.

  • If I have a procedure or service at a network facility, can I be balance billed?

    You may find that not all providers at a "network" facility are part of the Aetna network. For example, if you have a surgical procedure performed at a network hospital, you may find that the hospital and surgeon are in the network, but the anesthesiologist is out-of-network. When you get your bill, you'll see that it reflects the negotiated network rates for your hospital and surgeon. The anesthesiologist, however, may charge what s/he chooses since s/he has no negotiated contract with Aetna. If the anesthesiologist claim exceeds the recognized charge, you may receive a bill for the balance.

  • How do I avoid receiving a balance bill?

    You may prevent balance billing by verifying all medical providers are in the Aetna network and making sure your AlaskaCare Plan covers the services you need. For example, if you're having x-rays, MRIs, CT scans, or PET scans, make sure both the imaging facility and the radiologist who will read your scan are in the network. If you're planning surgery, ask whether the anesthesiologists are in the network. If available, the facility should accommodate your request to use a network provider for your services.

    Similarly, for AlaskaCare covered dental services, you may prevent balance billing by verifying the provider is in the Moda/Delta Dental network.

  • What if there is no network provider available?

    If your provider is not a network provider, you may ask for an estimate of charges, the codes that will be used use for billing, and the provider's zip code. When you receive this information, contact the Aetna Concierge at (855) 784-8646 or Moda/Delta Dental at (855) 718-1768. A member of the Aetna Concierge or Moda Customer Service team can review the estimated charges and will advise you if the charges fall within the recognized charge for your area. If the estimated charges exceed the recognized charge, you may request that your provider accept that amount and not balance bill you, or you may request payment arrangements with their office.

    If your current provider is not listed as a network provider, you can ask your provider to contact Aetna at (800) 720-4009 or Moda at (855) 718-1768 for a participation application. Members are also encouraged to nominate their out-of-network providers to join the network. Contact the Aetna Concierge or Moda Customer Service to find out how.

    In some cases, unfortunately, there will not be a network provider for the service you need in your area. The Division, Aetna and Moda/Delta Dental are working diligently to improve network access, but please understand that we cannot force providers into the network.

  • Is there a "network" for durable medical equipment (DME)?

    Aetna does have a DME national provider listing on their DocFind website. To get the current listing, go to AlaskaCare.gov and select the Find a Doctor tool. In DocFind under the "Search by Location" tab, use the "Search for:" drop down menu to select Other (X-ray, Surg Ctrs; Med Equip, etc.) and the "Type:" drop down menu to select Durable Medical Equipment-National.

    For local DME providers, change the "Type:" to Durable Medical Equipment-Local and enter the appropriate zip code and plan.

Top of Page

Recognized Charges Questions

  • What is a recognized charge?

    A recognized charge is the maximum amount that AlaskaCare's Medical, Vision and Audio plans will pay for a covered service. The term recognized charge is sometimes referred to as the usual, customary and reasonable (UCR ) charge or the maximum allowed charge.

    An out-of-network provider has the right to bill you for the difference between the recognized charge and the actual charge. This is sometimes referred to as balance billing.

    When you use a network provider, you are not subject to balance billing for covered services. In other words, the provider has agreed to accept, as payment in full, the recognized charge for the service provided. You are only responsible for payment of other applicable charges such as deductibles, co-insurance, and/or non-covered charges.

    The recognized charge is the lesser of:

    • The amount the provider bills, or
    • The 90th percentile of the prevailing charge rate for the geographic area where the service is furnished. The 90th percentile of the prevailing charge rate means the charge that is at or below 90% for all of the charges reported for a service within a specific geographic area.
  • How is the recognized charge amount determined?

    The recognized charge for out-of-network providers is the 90th percentile of the prevailing charge rate for the geographic area where the service is furnished. The AlaskaCare plans establish the percentile (i.e., 90th percentile) to be applied to the prevailing charge rate; however, the prevailing charge rate is reported by FAIR Health, an independent not-for-profit corporation. FAIR Health collects charge data from claims received by insurance plans and health plan administrators across the country for charges billed by physicians, hospitals and other healthcare providers. Charges reported are the full fees that healthcare professionals report to insurers as part of the claims process—not the negotiated rates that apply when visiting a network provider. Charges reported are maintained by FAIR Health in its database which is comprised of billions of claims for billed medical procedures from across the United States. New charge data are continually added to the FAIR Health database.

  • How does the plan know that FAIR Health's information is reliable?

    FAIR Health has audit and validation programs in place to ensure the integrity of its data. Part of the validation process entails testing the data with statistical algorithms and examination by FAIR Health's in-house statistical and technology experts. A team of healthcare researchers from leading academic institutions advise FAIR Health on the best methods for analyzing its national claims data. FAIR Health is also advised by an independent Scientific Advisory Board of prominent researchers who review Fair Health's statistical methods and data. FAIR Health also seeks input from other stakeholders such as consumer and patient advocacy groups, healthcare providers, actuaries and federal officials.

  • How are the services identified in the FAIR Health database?

    Each specific service, procedure or supply in the FAIR Health database has a unique Current Procedural Terminology (CPT) code. CPT codes are numbers assigned to medical services and procedures. CPT codes are part of a uniform system of coding maintained by the American Medical Association and are used by providers, facilities and insurers. Each CPT code is unique. There are currently over 10,000 medical services and procedures classified by CPT code. Most CPT codes are very specific. For example, the CPT code for a 15-minute office visit is different from the CPT code for a 30-minute office visit.

  • How are the geographical areas determined?

    FAIR Health organizes its data by geozip—geographical area usually defined by the first three digits of the U.S. zip codes. Geozips may include areas defined by one three-digit zip code or a group of three-digit zip codes. Geozips generally do not include zip codes in different states. The State of Alaska is currently defined into three geozips:

    • 995—including Anchorage, Bethel, etc.
    • 996—including Homer, Kodiak, etc.
    • 997—including Fairbanks, Kotzebue, etc.
    • 998—including Juneau, Sitka, etc.
    • 999—including Ketchikan, Prince of Wales, Wrangell, etc.
  • What if there are not enough occurrences of a procedure in a particular geozip?

    If there are fewer than nine occurrences of a procedure in a geographic area, the plan uses FAIR Health's "derived charge data" instead. This data is based on the charges for comparable services, multiplied by a factor that takes into account the relative complexity of the service. If this information cannot be obtained locally, then national data is used.

  • What factors can affect the recognized charge?

    The following factors can affect the recognized charge:

    • Billing errors: when a provider makes a mistake on either the procedure code or zip code.
    • Multiple procedures: when a provider performs multiple surgical procedures during a single session. The standard practice in such cases is to bill 100% for the primary (largest) procedure, 50% for the secondary procedure and 25% for all others. However, incidental items that require little or no additional time should not have an additional fee.
    • Unbundling: when a provider shows separate codes on the bill for related or incidental services. For example, instead of being billed separately, related blood tests performed at the same time should be billed under a single General Health Panel code.
  • How can I make sure an out-of-network provider's rate will be within the recognized charge?

    You can verify whether an out-of-network provider's charges are within the recognized charge by calling the Aetna Concierge and providing the following information: (1) the procedure code, (2) the zip code where the service is to be performed, and (3) the projected cost. Aetna will use this information to estimate whether the proposed amount is within the recognized charge. Remember, if you use an Aetna network provider, those providers have already contracted with Aetna to offer discounted fees and those discounted fees are deemed to be within the recognized charge.

  • When I use an out-of-network provider, how much of the bill am I responsible for?

    If you use an out-of-network provider, you are responsible for the difference between the recognized charge and the amount charged by the provider in addition to other applicable charges such as deductibles, co-payments, co-insurance and non-covered charges.

  • What should I do if my out-of-network provider charges more than the recognized charge?

    If the out-of-network provider's claim exceeds the recognized charge, and you have already paid your out-of-network cost-sharing amount, wait for the provider to send you a bill, since the out-of-network provider may adjust their charges after reviewing the claim payment. If not, ask the out-of-network provider to:

    1. Consider reducing or waiving their fee to meet the recognized charge amount;
    2. Review the bill to ensure the correct procedure code and amount was used (and if not, submit a corrected bill to the plan);
    3. Confirm that the out-of-network provider charged their normal fee for the service, or if the out-of-network provider increased the charge due to unusual circumstances. If so, ask the out-of-network provider to either submit a corrected bill to the plan or provide a written explanation so you may file an appeal with the plan.
  • Is the recognized charges provision a change?

    No, the plan has always determined claims payment based upon the recognized charge. Prior to January 1, 2014, AlaskaCare plan documents referred to the recognized charge as the "usual, customary and reasonable (UCR) charge or the "maximum allowed charge."

  • As our claims administrator, what are Aetna's policies for claims reimbursement?

    Aetna's claim reimbursement policies address the appropriate billing of services, taking into account factors that are relevant to the cost of the service such as:

    • The duration and complexity of a service;
    • Whether multiple procedures are billed at the same time, but no additional overhead is required;
    • Whether an assistant surgeon is involved and necessary for the service;
    • Whether follow up care is included in the price of the service;
    • Whether there are any other characteristics that may modify or make a particular service unique; or
    • When a charge includes more than one claim line, whether any service described by a claim line is part of or incidental to the primary service provided.

    These claim reimbursement policies are based on:

    • Policies developed for Medicare;
    • Peer-reviewed, published medical journals;
    • Available studies on a particular topic;
    • Evidence-based consensus statements;
    • Expert opinions of health care professionals;
    • Guidelines from nationally recognized health care organizations.
  • How can I appeal a recognized charge determination for an out-of-network provider?

    You may appeal a recognized charge determination by providing additional information to indicate why the recognized charge was not correct, such as incorrect procedure codes, an incorrect zip code, etc. Information on appealing claim decisions is available in the AlaskaCare plan documents.

  • Where can I get more information about recognized charges?

    Specific plan language regarding recognized charges is available in the January 1, 2014, AlaskaCare Retiree Health Plan Amendment on pages 16 through 18 and in the AlaskaCare Employee Health Plan on pages 198 through 201.

  • How do I avoid recognized charge issues?

    See a network provider if one is available. When you see a network provider, the plan will pay based on the lesser of the billed amount or the provider's discounted fee amount.

Top of Page

Coordination of Benefits Questions

  • What is Coordination of Benefits?

    Coordination of Benefits (COB) is a method of ensuring that people covered by more than one medical plan will receive the benefits they are entitled to but not more than 100% of their covered expenses. The AlaskaCare health plans coordinate benefits with other group health care plans to which you or your covered dependents belong. Coordination of benefits can be very confusing, even for people who work at a physician's office.

    With COB, if you are covered by more than one health care plan, the plans work together to provide benefits. One plan is considered "primary" and pays your covered expenses first. The other plan is "secondary" and pays any remaining covered expenses up to 100%. In some cases, there may be a third or fourth plan, as well.

    It is important to remember that not all expenses are covered expenses.

  • Who sets COB rules?

    Most COB rules are set by the National Association of Insurance Commissioners (NAIC). Rules for coordinating with Medicare and Medicaid are set by federal and state law. Most plans follow the NAIC rules, but there is no requirement that they do so. The AlaskaCare health plans follow standard NAIC rules to ensure ease of coordination with other plans.

  • What are the rules?

    Here are examples of common COB situations and rules:

    If You Are Covered Under… Here's How the Plans Pay
    Active employee plan and retiree plan Primary: Active employee plan
    Secondary: Retiree plan
    Retiree plan and as dependent under another person's plan through active employment Primary: Retiree plan
    Secondary: Other person's plan
    Retiree plan and Medicare-eligible Primary: Medicare
    Secondary: Retiree plan
    Two retiree plans Primary: Plan in force the longest
    Secondary: Other plan
    Retiree plan, as dependent under another person's plan through active employment, and Medicare-eligible Primary: Other person's plan
    Secondary: Medicare
    Third: Retiree plan
    Active employee plan, retiree plan, as dependent under another person's plan through active employment, and Medicare-eligible Primary: Active employee plan
    Secondary: Other person's plan
    Third: Medicare
    Fourth: Retiree plan

    If your dependent children are covered under more than one plan, in most cases, the plan of the parent whose birthday falls earlier in the year (not the oldest) is primary. If both parents have the same birthday, the plan that has covered the children longer is primary. If the parents are separated or divorced, here's how the plans pay:

    • Primary: plan of the parent whom the court has established as financially responsible for the child's health care (the claims administrator must be informed of the court decree)
    • Secondary: plan of the parent with custody of the child
    • Pays third: plan of the spouse of the parent with custody of the child
    • Pays fourth: plan of the parent who does not have custody of the child
  • What if none of the rules describe my situation?

    If none of the above rules applies, the plan that has covered the patient the longest is primary.

  • How do the plans coordinate if my AlaskaCare plan is secondary?

    When an AlaskaCare plan is secondary, the amount the plan pays after the deductible is met is figured by subtracting the benefits payable by the other plan from 100% of expenses covered by the AlaskaCare plan on that claim.

    Example:

    • You obtain a filling from a network dentist who charges $200.
    • Both your dental plans pay 80% for class II (restorative) services.
    • You have met your deductibles for the year.
      • Primary plan pays: $160 (80% of $200)
      • Secondary plan pays: $40 (20% of $200)
      • Total paid: $200
  • Will the coverage from two AlaskaCare plans always pay 100% of what the provider charges?

    No, you may receive a balance bill if you use an out-of-network provider. In this case, the plan will pay up to the recognized charge for this service in your area. For more information on how recognized charges are calculated, see the Recognized Charges FAQ

    Example:

    • You obtain a filling from an out-of-network dentist who charges $250 for a filling.
    • The recognized charge for this service in Alaska is $150.
    • Both your plans pay 80% for class II (restorative) services.
    • You have met your deductibles for the year.
      • Primary plan pays: $120 (80% of $150)
      • Secondary plan pays: $30 (20% of $150)
      • Total paid: $150
      • Potential balance bill amount: $100 ($250 - $150)

    You may also receive a balance bill if one of your plans has a lower coinsurance rate (the percentage of the cost you pay for covered expenses once you meet any deductible) or excludes coverage for the service.

    Example:

    • You obtain a filling from a network dentist who charges $200.
    • Both your dental plans pay 80% for class II (restorative) services.
    • You have met your deductibles for the year.
      • Primary plan pays: $160 (80% of $200)
      • Secondary plan pays: $20 (10% of $200)
      • Total paid: $180
      • Potential balance bill amount: $20 ($200 - $180)
  • Are there other benefits to being covered by more than one plan?

    If you are covered under two AlaskaCare plans, the annual maximum that the plan pays will double. For example, under the Alaska care retiree dental plan, the annual $2,000 individual maximum would double to $4,000.

  • Do frequency limits double?

    No, the maximum frequency of services per year is not increased due to having other coverage. For example, if you have two plans that each cover a single vision exam each year, the plans coordinate to pay up to 100% of the single vision exam. They do not pay for two vision exams in a year.

  • How do the AlaskaCare plans coordinate with Medicare?

    If you are covered under AlaskaCare and eligible for Medicare, Medicare is your primary coverage. This means that the AlaskaCare plan reduces your benefits by the amount you are eligible to receive from Medicare Parts A and B, regardless of whether you actually enroll in Medicare.

    It's your responsibility to enroll in Medicare Parts A and B as soon as you become eligible and to pay applicable Medicare Part B premiums.

  • I am covered under the AlaskaCare Employee Health Plan. Is there anything my spouse should consider when making elections to a State employee union health trust?

    The AlaskaCare Employee Health Plan will only pay 30% of the covered charges for your dependents if your spouse, qualified same-sex partner or child(ren) are covered by a state employee health trust and that coverage:

    • Has been waived,
    • Pays less than 70% of covered expenses, or
    • Has an individual out-of-pocket maximum (including deductible) of more than $3,500.

    This applies to any dependent covered by the AlaskaCare Employee Health Plan whether the plan pays as primary or secondary.

    Example:

    • You incur covered expenses of $1,000. Your spouse elected limited coverage under a union health trust that pays 20% coinsurance, so your AlaskaCare Employee Health Plan will pay 30% after the deductible.
      • Spouse's plan pays: $200 (20% of $1,000)
      • AlaskaCare plan pays: $300 (30% of $1,000)
      • Total paid: $500
      • Potential balance bill amount: $500 ($1,000 - $500)
  • Am I required to enroll in Medicare Parts A and B?

    You are not required to enroll in Medicare Parts A and B, but the AlaskaCare Retiree Health Plan will estimate the portion that Medicare would have covered and pay third (after spouse's plan and Medicare).

  • Do I have to pay a premium for Medicare?

    For many people, Medicare Part A is premium-free. However, if you are not eligible for premium-free Part A, you may submit a copy of the denial letter from Social Security to the Third-Party Administrator. The claim administrator will document your file to reflect that the estimation of Medicare coverage will not occur for an expense that would have been covered under Medicare Part A. All coordination rules, including estimating Medicare benefits, would continue to apply to Part B expenses, even if you do not enroll.

    You do need to pay a monthly premium for Medicare Part B. For additional information, visit Medicare.gov.

  • What if I am only enrolled in Medicare Part B, and/or enrolled in Medicare Part A on a premium-paying basis?

    In this limited situation, standard Medicare coordination of benefits provisions do not apply. The plans will pay as follows:

    • Primary: Medicare
    • Secondary: Your spouse's active employee plan
    • Pays third: Your retiree plan

Top of Page

Medical Necessity Questions

  • What is "medical necessity?"

    Medical necessity is one factor the AlaskaCare health plans consider in determining whether to provide coverage for a service or supply. The AlaskaCare health plans do not pay for services or supplies that are not medically necessary, such as cosmetic procedures.

    The AlaskaCare medical plans use Aetna's current Medical and Pharmacy Clinical Policy Bulletins to determine medical necessity. You may access the bulletins at: Aetna.com/cpb.

    Determinations of medical necessity for dental procedures are made by Moda Health.

  • How does Aetna determine if a service or supply is medically necessary?

    Aetna's clinical policy bulletins are based on:

    • Reports in published, peer-reviewed medical literature
    • Studies on a particular topic
    • Evidence-based consensus statements
    • Expert opinions of health care professionals
    • Guidelines published by nationally recognized health care organizations that include supporting scientific data
  • Are there any limitations as to what kinds of services and supplies can be considered medically necessary?

    Under the AlaskaCare plans, services or supplies are never considered medically necessary if they:

    • Do not require the technical skills of health care professionals who are acting within the scope of their license;
    • Are provided mainly for the personal comfort or convenience of you, your family, anyone who cares for you, a health care provider, or a health care facility;
    • Are provided only because you are in the hospital on a day when you could safely and adequately be diagnosed or treated elsewhere; or
    • Are provided only because of where you are receiving the service or supply, if it can be provided in a doctor's or dentist's office or other less costly place.
  • If a service or supply fits the definition of medical necessity, is it always covered by the plan?

    No, not all medically necessary services or supplies are covered by a health plan. For example, a medically necessary service or supply is not covered by the AlaskaCare plans when:

    • It is specifically excluded; or
    • The duration of the medically necessary service reaches a plan limitation (for example, some benefits are limited to a certain number of days or visits).
  • Shouldn't medical necessity be defined by the plan document, and not the Third-Party Administrator?

    The number of medically necessary procedures and unique circumstances of their application are virtually limitless. Thus, it is simply not feasible to produce a plan document that can account for every scenario.

    Determinations of medical necessity are part of the claims processing function. Because AlaskaCare contracts with a Third-Party Administrator (TPA) to perform this function, it is the TPA who makes determinations of medical necessity as part of the claims processing function. This is not new. Prior TPAs also made medical necessity determinations as part of the claims processing function for the AlaskaCare plans. What is new is the publication of the data used by the TPA to make medical necessity determinations. This information is now available to AlaskaCare plan members through Aetna's contract with the State.

    The clinical policy bulletins provided by Aetna set guidelines that are transparent to members and their physicians, and clearly show the medical evidence relied upon to make the determination. The evidence basis of the policy bulletins are reviewed regularly and the bulletins are updated as necessary.

  • If my doctor recommended the treatment, isn't that enough to support medical necessity?

    The National Institute of Health estimates that nearly 30% of all medical procedures or services performed in the United States are either unnecessary and provide no benefit to the patient, or even worse, are harmful. Aetna's clinical policy bulletins rely on medical evidence to make decisions about coverage that are weighed against clinically accepted standards of medical practice.

    We encourage you to have your doctor review the clinical policy bulletins used to guide coverage decisions related to medical necessity. After your provider completes this review, and if they disagree, your provider may request a pre-determination of coverage and present additional medical evidence for consideration during the pre-determination review.

    To review your doctor's recommended treatment plan, and verify whether the services or supplies fit the definition of medical necessity, contact Moda Health at (855) 718-1768 for services covered under the dental plan, or contact the Aetna Concierge at (855) 784-8646 for services covered under the medical plan.

    If there continues to be a difference in opinion, you or your provider are encouraged to appeal the coverage decision.

  • What can I do if a claim is denied because the Third-Party Administrator determined my service is not medically necessary?

    If a claim is denied based on a medical necessity, you may request an explanation of the scientific or clinical judgment for the determination, free of charge.

    If you believe it's warranted, you may also initiate a written appeal to the plan. The AlaskaCare Employee Health Plan booklet and the AlaskaCare Retiree Health Plan amendment describe the process and timeline required for submitting an appeal. These plan booklets and an informational brochure on the appeals process are available at AlaskaCare.gov.

    Effective January 1, 2014, the appeals process used by AlaskaCare was enhanced to allow for the use of Independent Review Organizations (IRO) at level two for clinical appeals. Use of an IRO allows for an impartial review by a third-party medical expert when there is disagreement regarding medical necessity.

Top of Page

Dental Plan Questions

  • Why is nitrous oxide no longer covered by my dental plan?

    After talking to our members, we have added coverage for nitrous oxide to the dental plan. This change is retroactive to January 1, 2014. Denied claims were automatically reprocessed. If you have had a claim for nitrous oxide denied and have not received a revised Explanation of Benefits, please contact Moda/Delta Dental at (855) 718-1768.

  • Why are cleanings limited to once every six months?

    Some of our members have advised us of scheduling challenges when making appointments, especially for those members that have to travel to see a dentist. To address this issue, we have changed the frequency for exams and cleanings from once every six months, to twice per benefit year.

  • What if my health condition makes more frequent cleanings necessary?

    Recognizing that some members may need more frequent cleanings, we have increased the frequency limits in some cases. Your dental professional can contact Moda/Delta Dental to determine if cleanings in excess of the following limits can be approved.

    • Two cleanings per year, under normal circumstances.
    • Up to three cleanings per year for pregnancy.
    • Up to four cleanings per year for diabetes or periodontal disease.

    Additional cleanings are available when dentally or medically necessary with Moda/Delta Dental of Alaska prior approval.

Top of Page

Prescription Compound Medication Questions

  • What are compounded medications?

    Compounding medications is the product of a licensed pharmacist or physician that combines, mixes, or alters the ingredients of one or more drugs or products to create another drug or product. More information about compounding is available at fda.gov.

    Unlike commercial medications, compounded medications are not FDA-approved, which means the FDA does not verify the safety or effectiveness of compounded drugs (source: Compounding and the FDA, Frequently Asked Questions). Compound medications may contain both FDA-approved and non-FDA approved ingredients.

    In Alaska, the State Pharmacy Board provides oversight and has established guidelines.

  • When are compounded medications used?

    Compounded medications may be necessary when a patient requires a medication that is not available in the strength, dosage, or form required. Specific examples include:

    • For preparation of a medication that has been withdrawn from the marketplace due to economic concerns, NOT safety;
    • For those patients that cannot or have trouble swallowing and require a concentrated liquid or a rectal suppository;
    • For those patients who have sensitivity to dyes, preservatives, or fillers in commercial products and require allergy-free medications;
    • For children who require liquid medications.
  • Are compounded medications covered?

    Coverage of compound medications differs between the AlaskaCare Employee Health Plan and the AlaskaCare Retiree Health Plan.

    • AlaskaCare Employee Health Plan:

      The AlaskaCare Employee Health Plan only covers medically necessary, legend drugs prescribed by a physician and dispensed by a pharmacy. Legend drugs are medicines which must by law be labeled, “Caution: Federal Law prohibits dispensing without a prescription.”

      Compound drugs are only covered if: the product contains at least one prescription ingredient; the active ingredient(s) is approved by the FDA for medicinal use in the United States; the product is not a copy of a commercially available FDA approved drug; and the safety and effectiveness for the intended use is supported by FDA approval, or adequate medical and scientific evidence in the medical literature.

      If you are prescribed a compound medication made with an excluded ingredient, such as a bulk chemical or non-FDA approved bioidentical hormone, please speak with your healthcare provider to see if there is a commercially available, FDA approved medication that is appropriate for you.

      For additional information, please refer your health care provider to the Aetna policy on compounding.

      For more information in bioidentical compounds click here.

    • AlaskaCare Retiree Health Plan:

      The AlaskaCare Retiree Health Plan covers medically necessary compound medications, including those which contain bulk chemicals. Members are encouraged to review the information about compound medications below and to talk with their doctor.

  • Why are bulk chemical compounds excluded in the employee plan?

    Bulk chemical products are not regulated or approved by the FDA, nor is there clinical evidence available to support effectiveness or safety.

    The FDA states, “Compounded drugs are not FDA-approved. This means that FDA does not verify the safety, or effectiveness of compounded drugs. Consumers and health professionals rely on the drug approval process to ensure that drugs are safe and effective and made in accordance with Federal quality standards. Compounded drugs also lack an FDA finding of manufacturing quality before such drugs are marketed.

    There can be health risks associated with compounded drugs that do not meet federal quality standards. Compounded drugs made using poor quality practices may be sub- or super potent, contaminated, or otherwise adulterated. Additional health risks include the possibility that patients will use ineffective compounded drugs instead of FDA-approved drugs that have been shown to be safe and effective.”

  • Why are compounds made with non-FDA approved bioidentical hormones excluded in the employee plan?

    Bioidentical hormones do not have to be custom compounded. There are many well-tested, FDA approved hormone therapies. The misconception that custom-compounded hormone therapy is safer or more effective than FDA-approved bioidentical hormones is not supported by any large-scale, well designed studies. Also, the lack of FDA oversight for compounded hormones generates additional risks regarding the purity and safety of custom compounded bioidentical hormones over FDA approved bioidenticals which are held to rigorous purity and potency standards.

    Additionally, when the FDA approves a drug, the drug company must report on any side effects they are told about, and warnings must be included with the drug at the time it is picked up from the pharmacy. Pharmacies that compound hormones do not have to report drug side effects to the FDA, or warn patients of any potential adverse effects.

    Below is some recent literature on the topic of compounded bioidentical hormones:

    • The 2017 Position Statement from the American Association of Clinical Endocrinologists states under Bioidentical Hormones, “The most recent version of the AACE/ACE [American Association of Clinical Endocrinologists/American College of Endocrinology] menopause guidelines cautioned against the use of bioidentical hormone replacement, noting that there is no evidence to support superior safety with these products and that there is often lack of consistency in the content of compounded products, leading to either less or greater amounts of biologically active hormone being received (Table 3). Authorities have noted that there are no controlled trials which support claims for better efficacy, and most importantly, safety concerns (37).”
    • The October 2017 information from the FDA includes the statement, “Don’t believe false claims that compounded ‘bio-identical’ hormones are safer and more effective than FDA-approved Menopause Hormone Therapy drugs. Compounded ‘bio-identical’ Menopause Hormones are not FDA approved and may carry additional risks.”
    • The 2017 North American Menopause Society position statement states in part, “Compounded bioidentical HT presents safety concerns such as minimal government regulation and monitoring, overdosing or underdosing, presence of impurities or lack of sterility, lack of scientific efficacy and safety data, and lack of a label outlining risks.”
  • What can I do if I have a medical reason that the commercially available, FDA approved medication is not appropriate for me?

    A few consumers may need custom-compounded products to avoid allergies to certain ingredients or to provide dosages or mixtures that are not available commercially. In these instance, your provider can contact Aetna and request a Medical Exception. For an exception to be approved, the compound product must meet all four of the below criteria:

    • contain at least one prescription ingredient
    • the prescription ingredient is approved by the FDA for medical use in the United States
    • the compounded product is not a copy of commercially available FDA approved drug products, and
    • the safety and effectiveness of use for the prescribed indication is supported by FDA approval or adequate medical and scientific evidence in the medical literature.

    For additional information on how to request an exception, call the Aetna Concierge at (855) 784-8646.

Top of Page