AlaskaCare Health Plans TPA Transition Guide

Intent to Award Contract Medical Third-Party Administrator—Aetna

October, 17 2019

The Department of Administration intends to award Aetna the Medical Third-Party Administrator, Benefit Manager services contract for the State of Alaska employee and retiree medical plans. A 10-day protest period will follow before the contract is awarded.

  • Medical, vision, and audio services are currently provided by Aetna.
  • This is a competitive bidding process.
  • The new Aetna contract will take effect January 1, 2020.
  • The contract is for an initial 5-year term with 5 years of optional renewal periods.
  • The estimated annual cost of the contract is around $21 million.
  • The selected bidder will process an estimated 2 million claims annually for nearly 90,000 policies.

Background
The State of Alaska provides health insurance, including medical insurance, through the AlaskaCare plans to certain state employees, retirees, and their dependents, including persons vested in the Public Employee Retirement System (PERS), Teachers Retirement System (TRS), and Judicial Retirement System (JRS).

The AlaskaCare health plans provide medical, dental, vision, audio, and long-term care benefits for an estimated 90,000 policies with an annual combined spend of over $700 million. The plans are self-insured, meaning the state is responsible for paying the claims incurred, and are managed in the Division of Retirement and Benefits (Division). The Division hires contractors, or Third-Party Administrators, to administer the benefits including adjudicating claims, developing a network of providers, establishing the systems necessary to process claims, providing a call center for members, and other activities necessary to carry out the functions of a health plan.

Resources

Copies of the Request for Proposals and the official notice of intent to award are available at here.

Frequently Asked Questions

What is a Third-Party Administrator/Medical Benefit Manager?

A Third-Party Administrator, or Medical Benefit Manager, is a company the Division hires to process AlaskaCare Medical claims. Today, these claims are processed by Aetna and they will continue to process them through the current benefit year and as the new contract takes effect on January 1, 2020.

How will members be impacted?

Members will receive announcements regarding the new contract, but because the current vendor, Aetna, will continue to process claims under the new contract, members will not experience a change in service. Employees who make new plan elections during the November 6 – November 27, 2019 medical open enrollment may receive new ID cards to reflect their new elections.

Why was this contract put out for bid?

Periodically the Division competitively bids these contracts through a Request For Proposal (RFP). This also gives the Division an opportunity to seek better service at lower cost for members and the plan.

Is the Medical Benefit Manager changing?

Periodically the Division competitively bids TPA contracts through a Request for Proposal (RFP). This gives the Division an opportunity to seek better service at lower cost for members and the plan. In this case, Aetna is the current medical benefit manager, and will continue to be the medical benefit manager when the new contract takes effect.

How was Aetna selected?

The Division conducted a competitive procurement that evaluated vendors based on a combination of competitive pricing, customer service, organizational capacity, and overall cost. This procurement mirrors the process used for both the recently issued pharmacy and dental benefit claims administrator. Evaluators included members of the retiree health plan advisory board and the health benefit evaluation committee. More information including the proposal materials are available online.

What’s different about this procurement process?

The Division is using a “best value” type process that provides additional time prior to awarding the contract to clarify contract terms and conditions with the top ranked bidder and ensure all expectations of the State and the bidder are aligned.

Historically the contract terms have been for no more than 5 years, which has resulted in frequent vendor turnover and transitions which are disruptive for the membership and the Division staff. Per the RFP, the initial contract term for this contract will be 5 years with up to 5 years of renewals, increasing the prospective contract term length to 10 years.

When will the new TPA contract take effect?

The Aetna contract will take effect January 1, 2020.

Are benefits changing due to the new contract?

No. Benefits are outlined in the AlaskaCare retiree or employee insurance information booklets. The Medical Third-Party Administrator processes claims in accordance with the appropriate AlaskaCare booklet.

Does this impact both retirees and active employees?

Yes. Aetna will process medical insurance claims for all AlaskaCare employees, retirees, and their covered dependents.

Will members receive a new Medical Insurance Card?

Members will not receive a new ID card due to the new medical TPA contract. However, employees who make new plan elections during the November 6 – November 27, 2019 medical benefit open enrollment period may receive new ID cards to reflect their new elections.

Who can I contact if I have more questions?
You can contact:
  • Aetna at (855) 784-8646
  • AlaskaCare – Plan Administrator at
    • Toll Free (800) 821-2251
    • In Juneau (907) 465-4460
    • TDD (907) 465-2805
    • Fax (907) 465-3086
    • Email doa.drb.mscc@alaska.gov

Dental Third-Party Administrator—Delta Dental of Alaska (MODA)

August 7, 2019

The Department of Administration intends to award Delta Dental of Alaska the Dental Third-Party Administrator, Benefit Manager services contract for the State of Alaska employee and retiree dental plans. A 10-day protest period will follow before the contract is awarded.

  • These services are currently provided by Delta Dental of Alaska (MODA).
  • The new Delta Dental of Alaska contract will take effect January 1st, 2020.
  • The contract was competitively bid via a Request for Proposals issued in October 2018.
  • The contract is for an initial 5-year term with an additional 5-year optional renewal period.

Background

The State of Alaska provides health insurance, including dental insurance, through the AlaskaCare plans to certain state employees, retirees, and their dependents, including persons vested in the Public Employee Retirement System (PERS), Teachers Retirement System (TRS), and Judicial Retirement System (JRS).

The AlaskaCare dental plans provide insurance for an estimated 71,000 covered lives and have a combined annual spend of around $37 million. The plans are self-insured, meaning the state is responsible for paying the claims incurred, and are managed in the Division of Retirement and Benefits. The Division hires contractors to administer the benefits including adjudicating claims, developing a network of providers, establishing the systems necessary to process claims, providing a call center for members, and other activities necessary to carry out the functions of a health plan.

Resources

Copies of the Request for Proposals and the official notice of intent to award are available here.

Frequently Asked Questions

What is a Third-Party Administrator?

A Third-Party Administrator (TPA) is a company the Division hires to process claims for the AlaskaCare health plans, including dental plans. Today, dental claims are processed by Delta Dental of Alaska (MODA) and they will continue to process them through the end of the current contract term (December 31, 2019) and continue with the start of the new contract on January 1, 2020.

Is the Dental Benefit Manager changing?

Periodically the Division competitively bids TPA contracts through a Request for Proposal (RFP). This gives the Division an opportunity to seek better service at lower cost for members and the plan. In this case, Delta Dental of Alaska (MODA) is the current dental benefit manager and will continue to be the dental benefit manager when the new contract takes effect.

I've seen the Dental Benefit Manager refered to as Delta Dental of Alaska (MODA) and Delta Dental of Alaska, are they the same?

Yes, Delta Dental of Alaska (MODA) is rebranding and is in the process of changing their name to Delta Dental of Alaska.

Are my benefits changing due to the new contract?

No. Your benefits are outlined in the AlaskaCare retiree or employee insurance information booklets. The dental Third-Party Administrator processes your claims in accordance with the appropriate booklet.

When will the new TPA contract take effect?

The Delta Dental of Alaska contract will take effect January 1, 2020.

How will members be impacted?

Delta Dental of Alaska (MODA) is the current claims administrator, so the impact will be minimal. You will continue to receive the same great service as you do today.

Does this impact both retirees and active employees?

Yes. Delta Dental of Alaska will process dental insurance claims for retirees and their dependents covered under the AlaskaCare DVA plan, and for employees and their dependents covered under the economy and standard AlaskaCare dental plans.

Will I receive a new Dental Insurance Card?

Members may receive new ID cards prior to the January 1, 2020 implementation date. If new cards will be issued, more information will be provided in advance to members.

What is the retiree DVA Plan?

Upon retirement, AlaskaCare retiree beneficiaries may opt to participate in a voluntary Dental, Vision, and Audio (DVA) plan to provide coverage for themselves and their eligible dependents. Unlike the medical and pharmacy plans, the DVA plan benefits are funded entirely by member-paid premiums.

Does this include dental insurance for employees as well?

Yes. This contract will also process dental insurance claims for employees covered under the economy and standard AlaskaCare dental plans.

Who can I contact if I have more questions?
  • Delta Dental of Alaska: (855) 718-1768
  • AlaskaCare Plan Administrator:
    • Toll Free: (800) 821-2251
    • In Juneau: (907) 465-4460
    • TDD: (907) 465-2805
    • Fax: (907) 465-3086
    • doa.drb.mscc@alaska.gov

New Pharmacy Benefit Manager – OptumRx

Background

On January 1, 2019, AlaskaCare changed its pharmacy benefit manager (PBM) to OptumRx. OptumRx now manages the pharmacy benefit for all our members, including retail, mail order and specialty prescription drugs, claims processing, and prior authorization requests for prescription medications.

Frequently Asked Questions

General

How do I contact OptumRx?

OptumRx’s pharmacy health care advisors are ready to answer your questions. Call them toll-free at (855) 409-6999 24 hours a day, 7 days a week, 365 days a year.

You can also access OptumRx online through a member portal. To create your individual account, go to Optumrx.com or download the OptumRx mobile app.

Will I receive a new member ID card?

Yes. OptumRx mailed new ID cards prior to going live on January 1, 2019. This pharmacy benefit card will be an addition to the Aetna card you use for medical services. Medicare-eligible retirees and dependents will receive a separate, individual ID card for their non-Medicare-eligible covered family members. If you did not receive your new ID card, please contact OptumRx at (855) 409-6999.

What if I need to fill a prescription after January 1, 2019, and have not yet received my new ID card?

You can go to OptumRx.com to register on the online member portal or download the mobile app to view and print a temporary copy of your ID card. You can also call OptumRx at (855) 409-6999 for assistance.

With OptumRx, can I continue to go to the same pharmacy?

You will have access to the OptumRx home delivery pharmacy or thousands of retail pharmacies—including all large national chains—and many local pharmacies. To find a network pharmacy in your area, use the online pharmacy locator tool, or go to OptumRx.com to register in the online member portal or download the mobile app to access the pharmacy locator tool. You can also call OptumRx at (855) 409-6999 for assistance.

How will I fill a prescription at a retail pharmacy?

To fill a prescription after January 1, 2019, just present your OptumRx ID card at the pharmacy counter. If you use a network pharmacy, your insurance information will be entered, and you will pay your share of the cost.

If you use a pharmacy that is not part of the network, you will need to pay the pharmacy up front and submit a Direct Member Reimbursement request to OptumRx for reimbursement. You can find the Direct Member Reimbursement form for employees here and for retirees here.

What if my prescriptions have expired?

You will need to obtain a new prescription from your doctor, and either bring the written prescription with you to the pharmacy or have your doctor send the prescription to OptumRx’s Home Delivery pharmacy. Instructions on how to have your doctor send new prescriptions to OptumRx’s Home Delivery pharmacy were included in the Welcome Kit you received at the end of November along with your ID card. You can call OptumRx at (855) 409-6999 if you would like to have OptumRx assist you in contacting your doctor to obtain a new prescription for home delivery.

What if I am taking a controlled substance?

If you are taking a controlled substance, you may need to obtain a prior authorization in order to continue use of your medication. Please contact OptumRx at (855) 409-6999 to determine if you will need a prior authorization for your controlled substance. OptumRx can assist you with contacting your doctor to initiate the prior authorization process.

If you are taking a controlled substance and would like to have it delivered to your home from OptumRx’s Home Delivery pharmacy, your doctor must send a new prescription to OptumRx. Instructions on how to have your doctor send new prescriptions to OptumRx’s Home Delivery pharmacy will be included in the Welcome Kit you will receive at the end of November along with your ID card. You can also contact OptumRx at (855) 409-6999 and they can assist in contacting your doctor for a new prescription.

Will I be able to see my pharmacy benefit information online?

Yes. After the plan moves to OptumRx, you will be able to access your prescription and home delivery information online at OptumRx.com or through the mobile app.

How do I file a paper claim?

After January 1, 2019, OptumRx will process paper claims (also known as Direct Member Reimbursement requests) for prescriptions paid out-of-pocket at a non-participating pharmacy. A paper claim form will be included in the Welcome Kit from OptumRx and will also be available online. Please call OptumRx if you need assistance completing the form. Submit a completed form to OptumRx using the address listed on the form. If you have paper claims for prescriptions filled prior to January 1, please forward to Aetna for processing.

Will OptumRx force me to change my prescription?

No. All your medications will continue to be covered under your AlaskaCare health plan. If you are a member of the Employee Health Plan or the Defined Contribution Retiree Health Plan, there could be changes to the amount you pay for your prescriptions due to classification of brand name drugs as preferred or non-preferred, or you may have to obtain prior authorization for certain medications. If you will be impacted by changes to classification of brand name drugs or new prior authorization requirements, you will receive a letter in early December indicating the impacted medications, what the changes are, and instructions on the next steps you can take.

I am a member of the Defined Benefit retiree health plan. Will the coverage of compound medication change when OptumRx becomes the new Pharmacy Benefit Manager?

No. OptumRx will process claims according to the AlaskaCare plan document. Compounds will continue to be covered under the Defined Benefit Retiree Health plan.

Coverage of compounds differs for the active employee and defined contribution retiree health plans. The AlaskaCare Employee Health Plan and AlaskaCare DCR Benefit Plan only cover compound drugs if:

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

OptumRx maintains a National Compound Credentialing Program (NCCP) to ensure the best compounded medication quality and effectiveness for the patients who need personalized medications. If you are receiving your compounded medications through a pharmacy outside of Alaska, you must fill your prescription at a pharmacy which has been credentialed with the OptumRx National Compound Credentialing Program (NCCP). Using an NCCP pharmacy ensures that you will not be charged up front for your prescription (and required to submit your own claim for reimbursement), you will not be charged for molding or other non-covered charges, and you will not be charged for shipping if the pharmacy mails your compounded medication to you. You can find a list of NCCP credentialed pharmacies here. You can also call OptumRx at (855) 409-6999 (TTY 711) to get help locating NCCP-credentialed pharmacies.

I received a letter from OptumRx asking me to confirm my enrollment in the AlaskaCare Retiree Medicare Prescription Drug Plan within 30 days. The bottom of the letter has this document code: S8841_19_EXH-5_AKC. What should I do next?

You received this letter because the Centers for Medicare & Medicaid Services (CMS or Medicare) indicated that you have alternative prescription drug coverage under another plan that may be receiving subsidies from Medicare for providing that coverage. We encourage members to confirm enrollment in the AlaskaCare Retiree Medicare Prescription Drug Plan by calling OptumRx at (855) 235-1405. If you do not confirm your enrollment, or choose not to participate in the AlaskaCare Retiree Medicare Prescription Drug Plan, you will be placed into the opt-out prescription drug program. This is highly discouraged, as it will result in higher costs for you and for the health plan. Please see section 1.2.2 of the AlaskaCare Retiree Insurance Information Booklet for more information on the opt-out benefit.

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Mail Order

Will I need to submit a new prescription to OptumRx Home Delivery Service?

On January 1, 2019, most home delivery prescriptions with remaining refills were automatically transferred to OptumRx from Aetna mail order delivery. Members will have to set up their account and, if applicable, enter a payment option to pay the charges before their medication ships. Prescriptions for certain medications did not transfer, for example, controlled substances and expired prescriptions. In these cases, you’ll need a new prescription from your doctor.

Can I refill my mail order/home delivery prescription automatically with OptumRx?

Yes, Hassle-Free Fill is the OptumRx automatic refill program for mail order/home delivery prescriptions. When you sign up for Hassle-Free Fill, OptumRx will:

  • call to notify you that your medication will ship soon (unless you cancel within three business days of the refill notice),
  • deliver your medication to the address on file with no shipping charge for standard delivery, and
  • bill your credit card for any copayment, coinsurance or amount due.
How do I enroll in Hassle-Free Fill?

Log in to your online account, set up a payment method, and select which medications you want to fill automatically. You can also call OptumRx at (855) 409-6999 and they can help you enroll in Hassle-Free Fill.

How does OptumRx home delivery work?

Order up to a three-month supply of qualifying medications you take regularly. Submit your order by phone, mail, online or through the mobile app.

OptumRx fills your order, mails it to you and lets you know when to expect your delivery. You can track your delivery through the online member portal or mobile app.

How do I order my prescriptions from OptumRx home delivery?

There are four ways to place a home delivery order:

  • Online. Sign in at the website on the back of your member ID card or open the mobile app.
  • ePrescription. Your doctor can send an electronic prescription to OptumRx.
  • Phone. Call the toll-free number on the back of your member ID card.
  • Mail. Download a form from alaskacare.gov. Then complete and mail it to OptumRx with your prescription.
Once I place a mail order/home delivery order, how quickly will I get my medication?

New prescription orders are delivered by standard U.S. mail and arrive about 10 business days from the date OptumRx receives the order. Refills normally arrive within 7 business days.

Will medications be sent express mail?

OptumRx ships medication through the U.S. Postal Service, with the exception of expedited shipping for medications that require special handling. You can upgrade to express or overnight shipping at your own expense.

I was using Aetna’s mail order/home delivery. How can I make sure my medication transitioned to OptumRx?

On January 1, 2019, most home delivery prescriptions with remaining refills were automatically transferred from Aetna mail order delivery to OptumRx Home Delivery. Prescriptions for certain medications did not transfer, such as controlled substances and expired prescriptions. In these cases, you’ll need a new prescription from your doctor.

Will my billing information also transfer to OptumRx?

No. We know how important it is to keep personal information safe. Before we can ship your first home delivery order, you must set up your credit card or billing preference with OptumRx. You can set up these preferences via the online member portal, mobile app, or by calling OptumRx at (855) 409-6999.

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Specialty Pharmacy

Who is BriovaRx®?

BriovaRx is the OptumRx specialty pharmacy. Their patient care coordinators and pharmacists are highly trained to understand your specialty medication needs. BriovaRx will replace the Aetna specialty pharmacy, Costco, and Diplomat options that were previously treated as “mail order” for purposes of member copay. Members may still use these other specialty pharmacies, but retail copay charges will apply.

How will I receive my specialty medication from BriovaRx?

OptumRx will ship your medication wherever you need it when it is ready to be refilled—in safe, temperature-controlled, and tested packaging—and shipping is at no cost to you.

Will my specialty medication automatically transfer to BriovaRx?

If you are covered under the AlaskaCare employee plan, then yes, open refills of your specialty prescription will automatically transfer from Aetna Specialty Pharmacy to BriovaRx, OptumRx’s specialty pharmacy.

Similarly, if you are NOT eligible for Medicare and are enrolled in one of the AlaskaCare retiree plans, your prescriptions will be automatically transferred.

However, if you are Medicare-eligible and are enrolled in one of the AlaskaCare retiree plans, your specialty medication will not automatically transfer to the OptumRx specialty pharmacy. Per Medicare regulations, we are restricted from transferring prescriptions from your current specialty pharmacy, including the Aetna Specialty Pharmacy.

However, you are encouraged to have your specialty medication transferred to BriovaRx after January 1, 2019. Call a BriovaRx representative at 1-855-4BRIOVA to enroll. You can also register online at briovarx.com/newpatient. BriovaRx representatives will contact your doctor and take care of everything else.

What if I don’t transfer my specialty medication to BriovaRx?

BriovaRx is the only specialty pharmacy that is considered a mail-order pharmacy by AlaskaCare. If you do not transfer your specialty prescription to BriovaRx, the plan will continue to cover your specialty medication. However, the pharmacy will be considered a retail pharmacy and you will be responsible to pay the retail prescriptions copayment as outlined in your health plan. If the specialty pharmacy you are using is out-of-network, you will be required to pay for the medication up front and submit for reimbursement.

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Prior Authorization

Will I need to get a new prior authorization if I just received one through Aetna?

In most cases, if your drug was previously approved under AlaskaCare by Aetna through a date after December 31, 2018, that approval will be transmitted to OptumRx to continue coverage of the drug through the date specified.

If you are a Medicare-eligible retiree, there are some medications for which you will need a new prior authorization. You will receive a letter indicating if prior authorization is needed for your medication for coverage under Medicare Part D. If your medication is not approved for prior authorization under Medicare Part D, then it will be covered under the enhanced wrap benefits.

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