Currentblue cross blue shield - louisianaPolicy N/A

BARIATRIC SURGERY SERVICES & PHARMACY PLAN YEAR AMENDMENT

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Amendment to the Health Plan for State of Louisiana Employees and Retirees that updates coverage, cost sharing, prior authorization, and pharmacy formulary arrangements for bariatric surgery services and the 2023 pharmacy plan year; affects plan participants under the listed Louisiana plan options.

Policy Summary

Payerblue cross blue shield - louisiana

PolicyBARIATRIC SURGERY SERVICES & PHARMACY PLAN YEAR AMENDMENT

Policy CodePolicy N/A

Change TypeCoverage and formulary updates (reformatting of Schedule of BenefitsPBM correction)

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionObtain prior authorization before performing bariatric surgery services; benefits will not be payable without it.

SourceLink

POLICY UPDATE CHANGES

The Schedule of Benefits for bariatric surgery services was reformatted and updated for the 2023 plan year, specifying facility, professional, and pre/postoperative service cost-sharing and network restrictions.

Pharmacy plan year corrected to identify CVS Caremark as the Pharmacy Benefit Manager and adoption of a 4-tier formulary for 2023.

$2,500facility copayment (network)

90%-10%professional services coinsurance (network)

80%-20%pre/postoperative services coinsurance (network)

4-tierformulary design

Requiredprior authorization requirement

Bariatric Surgery and Pharmacy Coverage

Bariatric surgery and pharmacy coverage

Bariatric surgery services coverage and cost sharing by plan option and network status:

Facility services (network): Network providers: $2,500.00 copayment; subject to plan year deductible, if applicable.

Facility services (non-network): Non-network providers: Not Covered for specified plan tiers.

Professional services (network): Network providers: 90% - 10% coinsurance for specified plan tiers.

Professional services (non-network): Non-network providers: Not Covered for specified plan tiers.

Preoperative and postoperative medical services (network): Network providers: 80% - 20% coinsurance for specified plan tiers.

Preoperative and postoperative medical services (non-network): Non-network providers: Not Covered for specified plan tiers.

Prior Authorization: No benefits will be payable unless prior authorization is obtained; note indicates prior authorization requirement and that it is not applicable for Medicare primary where specified.

Age/Time Restrictions: Age and/or time restrictions apply to bariatric surgery services as indicated in the Schedule of Benefits.

Authorization and Provider Requirements

Prior Authorization

Prior Authorization Required for Bariatric Surgery

Prior authorization is required for all bariatric surgery services; no benefits will be payable unless prior authorization is obtained. This requirement applies including plan participants with Medicare as the primary plan (prior authorization not applicable for Medicare primary in the footnote context).

No benefits will be payable unless prior authorization is obtained.
Footnote indicates pre-authorization required; not applicable for Medicare primary (document includes both statements).

Pharmacy Benefit Manager and Formulary

CVS Caremark Formulary — 2023

Formulary nameCVS Caremark Formulary

Plan year PBMOGB's Pharmacy Benefit Manager for the 2023 Plan year is CVS Caremark

Plan design4-tier plan design

Review frequencyFormulary is reviewed at least quarterly to re-assess drug tiers

Member requirementYou must use drugs on the Formulary to qualify for pharmacy benefits under the Plan

Policy Summary

Payerblue cross blue shield - louisiana

PolicyBARIATRIC SURGERY SERVICES & PHARMACY PLAN YEAR AMENDMENT

Policy CodePolicy N/A

Change TypeCoverage and formulary updates (reformatting of Schedule of BenefitsPBM correction)

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionObtain prior authorization before performing bariatric surgery services; benefits will not be payable without it.

SourceLink

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