NOTICE OF PROPOSED ADDITIONS TO THE ALASKACARE DEFINED BENEFIT RETIREE HEALTH PLAN
The Department of Administration, Division of Retirement and Benefits, is working with the Retiree Health Plan Advisory Board (RHPAB) to review the following proposed updates to the AlaskaCare Defined Benefit Retiree Health Plan, effective January 1, 2022:
- Addition of preventive care coverage
- Addition of prior authorization for specialty medications
- Executive Summary—Preventive Care Services
- Executive Summary—Specialty Medication Prior Authorization
- Information Flyer—Retiree Plan Proposals 2022
- Detailed Draft Proposal—Preventive Care Services
- Detailed Draft Proposal Attachments A, C-F – Preventive Care Services
- Detailed Draft Proposal Attachment B – Preventive Care Services
- Detailed Draft Proposal—Specialty Medication Prior Authorization
Have questions? Review the Frequently Asked Questions.
You may comment on the proposed updates by submitting written comments:
- By Mail: State of Alaska Department of Administration
Division of Retirement and Benefits
PO Box 110203
Juneau AK 99811-0203
- By Email: firstname.lastname@example.org
All comments must be received no later than 4:30 p.m. on September 3, 2021. Comments received after that date will be provided to the board through the standard procedures.
If you are a person with a disability who needs a special accommodation in order to participate in this process, please contact the Division at email@example.com or (907) 465-4460 no later than August 16, 2021 to ensure that any necessary accommodation can be provided.
Preventive Care Frequently Asked Questions
- Does the AlaskaCare Retiree plan include preventive service coverage?
- What preventive services will be covered?
- What is the cost for preventive services?
- Will the Plan cover colorectal cancer screenings, like colonoscopies or an at-home stool test?
- How does the Plan determine which preventive services are covered?
- Are there any vaccines included in the preventive coverage?
- Are shingles vaccinations covered?
- Will the new preventive care coverage include Silver Sneakers?
Preventive care was not part of the original benefits covered by the AlaskaCare Retiree plan when it was created in 1975. Effective January 1, 2022, the Division of Retirement and Benefits is expanding preventive care coverage to the Retiree Defined Benefit health plan.
Proposed preventive care coverage includes, but is not limited to vaccinations, wellness visits, colorectal cancer screenings, mammograms, pap smears, prostate cancer screenings, and lung cancer screenings. Like other health plans, services covered by the Plan are based on those recommended by the US Preventive Services Task Force (USPSTF) and other governmental advisory groups, and may include additional services as outlined in the Third-Party Administrator’s guidelines. These guidelines will change over time as they are updated to reflect the most current research and evidence.
After January 1, 2022, when you visit an in-network provider for preventive services, your AlaskaCare plan will pay 100% coinsurance and your deductible will not apply.
For preventive care received from out-of-network providers, you will first have to meet the $150 deductible, and then the plan would pay 80% coinsurance (up to the recognized charge) for covered services. Your AlaskaCare out-of-pocket maximum will not apply to preventive care services received from out-of-network providers. If you do not have access to an Aetna network provider in your area, you may contact Aetna to pre-certify use of an out-of-network provider, and those services will be paid as though they were received in-network.
Many retiree plan members have other health coverage, such as Medicare, or additional coverage through their spouse. The AlaskaCare plan will continue to coordinate with other plans the way it does today when determining payment for covered services.
Yes, colorectal cancer screenings including colonoscopies and at-home stool tests (such as Cologuard) will be covered in accordance with the standards outlined by the US Preventive Task Force and current clinical guidelines and frequency limitations outlined by the Third-Party Administrator’s (currently Aetna) clinical policy bulletins.
In alignment with the Plan booklet, Section 3.3.1 Medically Necessary Services and Supplies, and mainstream commercial health insurance practices, the Plan will utilize the current Third-Party Administrator’s (currently Aetna) clinical coverage standards for purposes of determining coverage of preventive services under the Plan. These standards must include, at a minimum, those services with an “A” or “B” recommendation by the USPTF but may include additional services or screenings. Clinical coverage standards regarding preventive care are subject to change and are updated periodically based the most current clinical evidence.
Yes. Common vaccines included in the proposed preventive care coverage are hepatitis A & B, HPV, influenza (flu shot), measles-mumps-rubella (MMR), meningitis, pneumococcal (pneumonia shot), tetanus, diphtheria, pertussis, polio, chickenpox, rabies and shingles.
Beginning January 1st, 2019, all retirees have access to the shingles vaccine, which is covered by AlaskaCare when administered at a pharmacy. The addition of preventive care services means effective January 1, 2022 you can also receive the shingles vaccine at your doctor’s office.
No, Silver Sneakers is only available to people who are covered by a participating Medicare Advantage or Medicare Supplement Insurance plan. The Division is working to evaluate if any similar programs could be offered to retirees in the future.
Specialty Medication Prior Authorization Frequently Asked Questions
- What is prior authorization?
- Ensures the therapy meets FDA guidelines for the condition being treated.
- Ensures providers follow nationally recognized care criteria when prescribing medication.
- Requires the prescriber to provide documentation in support of the clinical criteria specific to that medication prior to the medication being dispensed.
- What is a specialty medication?
- High Priced: can cost more than $1,000 for a 30-day supply.
- Complex: drug imitates compounds found in the body or is part of a specialty drug class.
- High-Touch: special shipping or handling requirements like refrigeration, special steps to follow as you take it, needs a pharmacist or doctor to measure how well it works for you.
- How will I know if my drug is a specialty medication?
- Will I be notified if my prescription needs a prior authorization?
- How long does the prior-authorization process take?
- Will my provider be able to help me with prior authorizations?
- Why would a prescription need a prior authorization?
- They’re only approved for, and effective in, treating specific illnesses.
- They may be inappropriately prescribed for conditions for which effectiveness has not been demonstrated.
- They may have dispensing and prescribing requirements specific to a patient’s age, gender, other medication usage, or clinical condition.
- What are the benefits of prior authorization?
- How long is a prior authorization good for?
- Why are you adding prior authorizations for specialty medications?
- Is my drug coverage changing?
- What are the qualifications of the persons reviewing the specialty medications?
- U.S. Food and Drug Administration (FDA) approved indications
- Manufacturer’s package labeling instructions
- Well-accepted and/or published clinical recommendations (ex: American Hospital Formulary Service Drug Information; DRUGDEX; National Comprehensive Cancer Network Drugs and Biologics Compendium; Clinical Pharmacology; major peer reviewed medical journals such as the American Journal of Medicine)
- Is the specialty medication Prior Authorization program a step-therapy program?
- Is there an appeal process for specialty prior authorizations?
Prior authorization is a pre-approval process guided by rigorous clinical standards for intensive, high-cost medical procedures. Prior authorization for specialty medications:
Prior authorization for specialty drugs is a pharmacy management process that reviews certain medications against clinical, evidence-based standards including those established by the FDA to promote safe and effective use of those medications.
A specialty medication has at least one of the following characteristics:
Only about 1% of covered prescriptions are specialty medications. You can review the OptumRx Specialty Pharmacy Drug List to see if any of your current medications are specialty drugs that may require a prior authorization. Please note this list may change over time and may be updated prior to January 1, 2022. If your drug appears on this list, you do not currently need to obtain a prior authorization prior to filling your prescription. This list is for informational purposes only. If this proposal is adopted, and if any of your medications require a prior authorization after January 1, 2022, you will receive a notification letter with detailed information 60 days in advance.
Yes. Members will receive a notification letter 60 days in advance of January 1, 2022 advising their medication requires prior authorization review. Once you have an approved prior authorization in place, when it nears expiration, OptumRx will proactively initiate outreach to your prescriber to obtain the information necessary to extend or renew the authorization.
Providers may submit prior authorization requests electronically, over the phone, or by mail. The prior authorization process is designed with expediency in mind. Most prior authorizations are completed within 72 hours. Physicians can use an electronic platform called Pre-Check my script for real-time information and authorizations.
Yes. This is common in health plans and physicians are already familiar with the prior authorization process. Providers may submit prior authorization requests electronically, over the phone, or by mail.
Some medications should be reviewed for coverage because:
Benefits of prior authorization include ensuring the right drug is dispensed at the right time and safety and efficacy standards are adhered to. Members may experience improved quality care when evidence-based criteria are reviewed to promote appropriate use of certain specialty medications.
Prior authorization approvals are typically valid for 3-36 months, depending on the medication. OptumRx identifies approved prior authorizations for prescriptions expiring within 30 days and will proactively reach out to the prescriber to request any information needed to extend the prior authorization.
Specialty medications are a relatively new type of treatment that has grown substantially over the last few years. In 2020, specialty medications accounted for about 1% of all prescriptions covered by the AlaskaCare retiree plan but cost $110 million in covered plan expenses. A single prescription can cost as much as $160K or more annually.
Similar to how the Plan requires precertification for certain intensive, complex, and high-cost medical services, prior authorization is a common tool used by pharmacy plans to ensure appropriate use.
Growth of specialty medication is expected to continue as new medications are developed and the conditions they are used to treat expand. Implementing a prior authorization process for the medications ensures that they are being used for indications approved by the FDA and align with guidelines established by national clinical specialist groups.
There is no change to coverage for prescription medications that are prescribed under the terms outlined in the Plan booklet. The plan will continue to cover medically necessary and clinically appropriate prescription drugs. There is no change to member copayments which will remain $8 for brand medications, $4 for generic medications, and $0 for medications filled through mail order
At OptumRx, prior authorization criteria are reviewed and approved by the OptumRx Pharmacy & Therapeutics (P&T) Committee. The P&T Committee is an independent, multi-specialty and nationally represented group of physicians and pharmacists. The P&T Committee evaluates medications based on scientific evidence to find their place in therapy. Quarterly meetings are held to evaluate, review, and make clinical recommendations. Industry, clinical, and company standards govern the P&T Committee’s review, consideration, and recommendation processes. The committee considers:
Based on this information, the P&T Committee evaluates whether a drug has a unique therapeutic benefit, comparable safety and efficacy, or whether risk of harm outweighs the benefits. The P&T Committee complies with national quality standards including those provided by the Centers for Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), and the Utilization Review Accreditation Commission (URAC®). After thorough clinical review of prior authorization guidelines is complete, the P&T Committee approves the utilization management criteria.
No. Prior Authorizations are not step therapy. Step therapy is focused on cost and, has not been implemented in the retiree plan. Prior authorization focuses on clinical indicators, and ensures that a prescription drug is medically necessary, appropriately prescribed, and meets FDA and other clinical guidelines for the condition being treated.
The AlaskaCare Retiree Pharmacy Plan provides members with the right to appeal the pharmacy claims and prior authorizations that have been denied by the pharmacy claims administrator, OptumRx. If a claim or prior authorizations is denied, in whole or in part, your letter from OptumRx will explain the reason for the denial. Please refer to your Retiree Insurance Information Booklet located at AlaskaCare.gov for coverage information and if necessary, call OptumRx toll-free at (855) 409-6999 for further clarification. For additional inforation, read the Pharmacy Plan Appeal Brochure.
Defined Benefit Retiree Health Plan: 2022 Benefit Expansion Frequently Asked Questions
- Is my health plan changing?
- When will any changes take effect?
- Will the addition of preventive care coverage increase the insurance premiums?
- How is this new benefit aligned with preventive care provisions in the Affordable Care Act (ACA)? For instance, if the ACA is changed or no longer offered, does that impact the continued availability of this benefit under our Plan?
The Division of Retirement and Benefit has been working with the Retiree Health Plan Advisory Board to review proposed updates to the AlaskaCare Defined Benefit Retiree Health Plan (Plan). These updates will add modern coverage provisions to the Plan, including highly desired coverage for preventive care service and prior authorizations for specialty medications.
The Plan Administrator (the Commissioner of Administration) has adopted the proposed updates, and the Plan will be changed to include the expanded coverage beginning on January 1, 2022.
The proposed changes will take effect on January 1, 2022. This means that the expanded coverage will apply to any dates of service on or after January 1, 2022.
No, the Retiree Plan monthly premiums for 2022 are not changing.
As a retiree-only plan, the Plan is exempt from the ACA provisions mandating coverage for preventive care. Though the additional benefits offered do align with the ACA’s preventive care provisions, these provisions do not impact the retiree plan.
In alignment with the Plan booklet, Section 3.3.1 Medically Necessary Services and Supplies, and mainstream commercial health insurance practices, the Plan will utilize the current Third-Party Administrator’s (TPA) clinical coverage standards for purposes of determining coverage of preventive services under the Plan.