2014 Open Enrollment Frequently Asked Questions (FAQs)
Affordable Care Act (ACA)/Preventative Care
- Will the preventive medication list be available online?
- Yes. The approved ACA Preventive medications list and the CDHP Preventive medications list are posted to the SHP website.
- Do I have to meet certain criteria to have the preventive care medications covered at 100%?
- Yes, all medications will require a prescription and there are certain criteria you must meet, which are included on the list available on the Plan's website.
- Why is preventive care covered at 100% under the Enhanced 80/20 Plan and the Consumer-Directed Health Plan (CDHP) but not the Traditional 70/30 Plan?
- The Traditional 70/30 Plan is a "grandfathered health plan" under the Patient Protection and Affordable Care Act (the Affordable Care Act or ACA). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when the ACA law was enacted. Being a grandfathered health plan means that a member's plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing.
The Enhanced 80/20 Plan has been updated with numerous incentives and credits and includes 100% coverage for non-hospital ACA preventive services; however, it remains a grandfathered plan under the ACA.
The CDHP is a brand new option and therefore is subject to the Affordable Care Act, which means ACA preventive care must be covered at 100%.
- Which plans cover the Affordable Care Act (ACA) preventive medications at 100%?
- The Enhanced 80/20 Plan and the Consumer-Directed Health Plan (CDHP).
- How are medications selected for the ACA Preventive Medication list?
- The State Health Plan, in consultation with Express Scripts, the prescription benefit manager for the Plan, has developed a list of medications and criteria (i.e., gender and age) to support preventive medication requirements based on the recommendations of the U.S. Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention (CDC) to be covered under the pharmacy benefit.
- Can I receive free over-the-counter (OTC) nicotine replacement medications with a prescription?
- Members must contact QuitlineNC for smoking cessation counseling in order to obtain generic OTC nicotine patches and gum at no charge. There are also limits to quantities received per year.
- Are all prescription oral contraceptives covered at 100%?
- No, only generic oral contraceptives are covered at 100%. All brand oral contraceptives will be subject to the applicable copay.
- Are there limits on the colonoscopy preparation coverage?
- Yes, all brand and generic prescription colonoscopy preparations will be covered for men and women ages 49-76 years; however, there is a limit to 2 covered preps per year.
- What other coverage is included in the hormonal contraceptive category?
- Select brands of transdermal (e.g. Ortho Evra), intravaginal (e.g. Nuvaring) and injectable (e.g. Depo-subQ Provera) hormonal contraceptives will be covered at 100% since these dosage forms are available as brand only.
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