Text Size:   A+ A- A   •   Text Only
Find     
Site Image

2010-11 New Tiers & Copayments
"Value Tier" for Prescription Medications
(ODS and Providence plans only)
 
"Value Tier" is a new pharmacy tier that gives ODS and Providence plan members a lower copayment for certain medications used for asthma, heart conditions, cholesterol, high blood pressure and diabetes.
 
With the addition of “Value Tier,” there are now four “tiers” (cost groups) for prescription medications: Value Tier, Generic Tier, Preferred Brand Tier, and Non-Preferred Brand Tier.
 
 
Why does the new “Value Tier” have a lower copayment for certain medications?
If you have asthma, a heart condition, high cholesterol, high blood pressure, or diabetes, taking certain medications can be an important part of staying healthy. Taken regularly, these medications improve your quality of life by making you feel better and help to prevent complications.
 
Since you may need to take these medications for a long time, the cost can add up. By making your copayment lower, the new “Value Tier” makes these medications more affordable and encourages you to keep taking them on schedule.
Which medications are on the “Value Tier”?
To find out which medications are included, click on your medical plan below for their “Value Tier" formulary. 
  • ODS 
  • Providence (page 87- 88)
If your medications are on the “Value Tier” formulary, then your copayment for these medications will be lower beginning on October 1, 2010.
What if your medication is noton the “Value Tier”?
If you are using a medication for asthma, a heart condition, high cholesterol, high blood pressure, or diabetes, and this medication is not covered on the new “Value Tier,” you may want to talk with your doctor about your medication choices.
  • You could print a copy of the “Value Tier” formulary and show it to your doctor during your next appointment. Perhaps there is another medication on the “Value Tier” that would work as well or better for you than the medication you are taking. If so, you will be able to save money on your prescriptions.
  • The medications on the “Value Tier” were chosen by doctors and pharmacists based on which medications have been shown to work best and be the safest for people with asthma, a heart condition, high cholesterol, high blood pressure, or diabetes.
  • By talking with your doctor about your medication choices, you can learn more about your condition and your treatment choices, and decide what’s best for you.
 

 
"Additional Cost Tier" Procedures
(ODS and Providence plans only)

The new "Additional Cost Tier" adds an additional $500 copayment for certain procedures
The "Additional Cost Tier" is a new cost tier that requires plan members to pay an additional $500 copayment (“copay”) for each of the following procedures:
  • outpatient upper endoscopy* (through September 30, 2011 -- moves to $100 copay effective October 1, 2011)
  • spine surgery for pain
  • knee arthroscopy
  • knee replacement
  • shoulder arthroscopy
  • hip replacement
The $500 copay for these “Additional Cost Tier” procedures must be paid in addition to a member’s plan deductible, regular copayment, or coinsurance. The additional $500 copay does not count toward the member’s yearly out-of-pocket maximum. 
 
*Patients diagnosed with Barrett's esophagus and esophageal stricture are exempt from the $500 copay for outpatient upper endoscopies.
Why is there a new additional copayment for these procedures?
For the procedures on the “Additional Cost Tier,” the additional copayment was added to encourage plan members to talk with their doctor and consider other choices before deciding whether or not to have the procedure.
 
For each procedure on the “Additional Cost Tier,” there are other possible treatment choices to consider that might be less invasive, safer, and work just as well or better, depending on the patient’s situation. A different treatment choice may also be more cost-effective than the “Additional Cost Tier” procedure.
What if one of these procedures has been recommended for you?
If one of the “Additional Cost Tier” procedures has been recommended for you, ask your doctor to explain why you need the procedure, what would happen if you decided not to have it, and what other treatment choices you could consider.
 
Your doctor can help you understand and compare the risks, benefits, and costs of the “Additional Cost Procedure” and your other treatment choices. You may also want to get a second opinion from another doctor.
 
If you and your doctor decide that one of the “additional Cost Tier” procedures is right for you, you will have to pay the $500 additional copayment when you have the procedure. There is only one exception: the additional $500 copay is not required if the procedure is related to ongoing evaluation or treatment of cancer.
 
For more information about the “Additional Cost Tier,” the procedures included on it, and tips on making informed medical decisions, visit your medical plan website:
  • ODS 
  • Providence 
 

 
Additional Copayment Tests/Services
(ODS and Providence plans only)
 
An additional $100 copayment for certain tests and services
An additional $100 copayment (or "copay") will be required for each of the following diagnostic tests and imaging services:
  • Sleep Studies
  • MRIs
  • CT scans
  • PET scans
  • Spinal Injections for Pain  (effective October 1, 2011)
  • Outpatient Upper Endoscopy (effective October 1, 2011)
This new $100 copay for these tests and services must be paid in addition to a member’s plan deductible, regular copayment, or coinsurance. The additional $100 copay does not count toward the member’s yearly out-of-pocket maximum. 
Why is there a new additional copayment for these tests and services?
For sleep studies, MRIs, CT scans, and PET scans, the “additional $100 copay” was added to encourage plan members to talk with their doctor and consider other choices before deciding whether or not to have the test or imaging service.
What if one of the tests and services with additional $100 copay has been recommended for you?
If a sleep study, MRI, CT scan, or PET scan has been recommended for you, ask your doctor to explain why you need it, what would happen if you decided not to have it, and what other choices you could consider.
 
Your doctor can help you understand and compare the risks, benefits, and costs of the test or service that’s been recommended with the other choices you may have. You may also want to get a second opinion from another doctor.
 
If you and your doctor decide that one of the diagnostic tests or imaging services with the additional $100 copay is right for you, then you will have to pay the $100 additional copayment when you get the test or service. There is only one exception: the additional $100 copay is not required if the test or imaging service is related to ongoing evaluation or treatment of cancer.
Note: Procedures and tests related to ongoing evaluation or treatment of cancer will not require either of the additional copayments.
 

 
New Tiers for Office Visits
(ODS and Providence plans only)
 
"Incentive Tier" is a new tier for office visits that gives ODS and Providence plan members a lower copayment for office visits related to care for asthma, heart conditions, high cholesterol, high blood pressure, and diabetes.
 
With the addition of “Incentive Tier,” there are now three “tiers” (cost groups) for office visits: Preventive, Incentive, and Primary/Specialist.
 
Why is there a new lower copayment for office visits for certain ongoing medical conditions?
If you have an ongoing medical condition such as asthma, a heart condition, high cholesterol, high blood pressure, or diabetes, then you know it’s especially important to look after your health. This includes making regular visits to your doctor. Staying on schedule with these visits helps make sure you are getting all the tests and other care you need to stay healthy. Seeing your doctor regularly helps prevent complications by finding problems at an early stage when treatment can be more effective.
 
By making your copayment lower for the office visits related to your ongoing medical condition, the new “Incentive Tier” makes these office visits more affordable and encourages you to stay on schedule with your regular medical care.
 
The new “Incentive Tier" applies onlyto office visits to an “in-network” provider
Beginning on October 1, 2010, your office visits for asthma, a heart condition, high cholesterol, high blood pressure, or diabetes will have a lower copayment (“Incentive Tier”) as long as your office visit is with an “in-network” provider.
 
If your office visit for one of these medical conditions is with an “out-of-network” provider, then you will not have the new lower copayment. (If you want to change from an out-of-network provider to an in-network provider, you can go to your medical plan’s website and use the provider directory to search for in-network providers.)
 
 

 
Additional Questions? Call (888) 4My-OEBB.
 
If you have additional questions about these changes, please call OEBB at (888) 469-6322.