New regulations for non-grandfathered plans require coverage in full for certain preventive prescription drugs when obtained at an in-network pharmacy. These new requirements only apply to non-grandfathered plans with prescription drug coverage beginning:
- Sept. 1, 2011 for LifeWise individual health plans.*
- Aug. 1, 2011 for LifeWise portability health plans.*
- With plan years that begin on or after Oct. 1, 2010 for employer-sponsored health plans.
What preventive drugs are impacted?
This list outlines which preventive drugs are impacted as well as each drug’s specific requirements that must be met before they are covered.
Some of these drugs are over-the-counter drugs. How do I get these drugs covered?
Coverage for the specific over-the-counter drugs listed can be obtained two ways:
- You can take the product, your prescription from your doctor and your LifeWise member card to an in-network pharmacy. Ask the pharmacist to process your purchase and prescription, just like they would if they were filling a prescription. As long as you meet the requirements for coverage, it will be covered in full at point of sale.
- You can submit a prescription claim form, along with your receipt to LifeWise. Make sure to include the NDC (national drug code) number on the claim form or your claim will be denied. NDC numbers can be found on the outside of the over-the-counter drug’s box (under the bar code).
How can I find out more about my prescription drug coverage?
Go to the Pharmacy section of lifewisewa.com or log in to the secure member site.
How will I know if I have a non-grandfathered or grandfathered health plan?
- In general, a plan may be non-grandfathered if it is new or became effective after Mar. 23, 2010. If you were a LifeWise individual health plan member as of Mar. 23, 2010, and you have not made any changes to your plan since then, your plan is grandfathered.
- If you have an employer-sponsored health plan, you may wish to check with your benefits administrator about whether your plan is grandfathered.
More about grandfathering
* The Oregon Insurance Division has asked for clarification from the federal Department of Health and Human Services about the application of the “policy year” definition to Oregon’s fixed date individual products. Therefore, this date may be subject to change.
