Identifying theMysteries Of PPOs
A Fearless Look Inside the Workings of the State’s Best Plans

Welcome to Part I of our ninth annual PPO survey. For this survey, eight PPOs in California diligently answered direct questions about their plans. Our readers, who are savvy health brokers, suggested many of the questions. We hope this information will help the professional agent or broker better serve sophisticated healthcare clients. We offer a special thanks to the insurance carriers that took the time to answer our lengthy questionnaire. We interpret their careful responses as a sure sign of their high level of commitment to the professional agent. Look for Part II in our April issue. We will be posting the survey on our Website at www.calbrokermag.com.

1. Is an Approval Procedure required for Getting a Specialist Referral or a Diagnostic Test or Treatment In-Network or Out-of-Network?

Aetna: There is a new high tech radiology pre-certification requirement for some customers.
Anthem Blue Cross: It is not required for PPO plans, but the member ends up paying more if they go out-of-network without getting an Out of Network approval.
Blue Shield: No, PPO plan members can generally self-refer to any doctor for care. They can choose to use in-network or out-of-network providers with claims reimbursement based on their benefit plan. Out-of-network services are usually subject to a higher deductible and co-payment amount.
Cigna: No referrals or approvals are required since the PPO benefit plan is an open-access program. Members are covered whether or not they get care from PPO network providers. Members who use services from an in-network provider may have reduced co-payments and lower out-of-pocket costs.
Guardian: No, Guardian has no required approval procedure required for getting a specialist referral or a Diagnostic test or treatment in-network or out-of-network
Health Net: There are no approval procedure requirements for visits to in-network or out-of-network specialists. A prior authorization list for diagnostic tests or treatments is included in the member’s evidence of coverage (EOC).
Kaiser Permanente: No, the PPO plan does not require a referral to see a specialist. Diagnostic tests are covered provided they are ordered by an insured’s doctor, are a covered benefit, and are deemed medically necessary.
UnitedHealthcare: To strengthen the patient-physician relationship, primary physicians are not required to request an authorization when they refer a patient to a network specialist for an office visit. Primary physici ans are very effective at ensuring that our enrolled individuals receive medically appropriate and necessary specialty care. In fact, practice pattern analysis shows that primary physician referrals to network specialists have been almost 100 percent effective and medically appropriate.

2. Are there any restrictions on Getting Second Opinions from an In-Network Provider or an Out-Of-Network Provider?

Aetna: A member who has the option of an out-of-network benefit can arrange their own second surgical opinion with a non-participating provider.
Anthem: No, not for the PPO.
Blue Shield: A member can get a second opinion from any in network or out-of-network provider. When an out-of-network provider is used, the member is responsible for any difference between Blue Shield of California’s payment and the billed amount.
Cigna: There are no restrictions. The PPO is an open access plan, allowing members to seek care in-network and out-of-network at any time. When accessing medical services, members may decide whether to use a network provider. By using a network provider, members have a lower out-of-pocket cost for each service.
Guardian: No, there are no restrictions on getting second opinions from an in-network provider or an out-of-network provider.
Kaiser Permanente: Second medical opinions are covered. Coverage is limited to charges for physician consultation and any additional X-rays, laboratory tests, and other diagnostic studies. Benefits will not be payable for X-ray, laboratory tests, or diagnostic studies that are repetitive of those obtained as part of the original medical opinion and/or for which Kaiser Permanente Insurance Company (KPIC) has paid benefits. For benefits to be payable, the second medical opinion must be rendered by a physician who agrees not to treat the covered person’s diagnosed condition. The physician offering the second medical opinion may not be affiliated with the physician offering the original medical opinion.
UnitedHealthcare: A second opinion is not mandatory under our plans. Our UnitedHealthcare Options PPO product is open access. Members may seek second opinions from any participating or non-participating physician. The member’s benefit level will vary depending on the physician’s participation status.

3. Where are Decisions Made About Specialist Referrals, Testing, Treatment, Surgery, and Hospitalization?

b Decisions regarding specialist referrals, testing, treatment, surgery, and hospitalization are made between the treating physician and the patient. Coverage determinations that require pre certification are made by Aetna’s medical management teams, which are regionally located.
Anthem: Members may see specialists without referrals. Our Utilization Management Department handles the review and approval for services that require pre-authorization.
Cigna: These decisions are made with a member’s physician in partnership with the member and the CIGNA nurse and physicians.
Health Net: Decisions regarding specialty referrals for testing, treatment, surgery, or hospitalization are made with the member, the member’s physician, Health Net’s Care Management team and, if the member chooses, Health Net’s Decision Power Health Coaches, who will provide additional information to help the member through the decision-making process.
Guardian: Plan members and their providers make decisions about what tests, treatments, or surgeries are performed. Guardian and our vendors make coverage decisions about whether the care or treatment is medically necessary and should be covered under our policy. We use a utilization management vendor for decisions related to surgeries and hospitalizations and other specialty vendors for prescriptions, behavior management, NICU admissions, and transplants.
Kaiser Permanente: In most cases, the insured does not need a referral to see a specialist. Decisions regarding testing, treatment, surgery, and hospitalization are made by the insured and their physician. The insured is required to get pre-certification for any hospitalization or certain special procedures as defined in the insured’s Certificate of Insurance. SHPS performs pre-certification to verify the medical necessity of a particular service or procedure that a physician has ordered for an insured.
UnitedHealthcare: The treating healthcare professional and the patient make decisions about providing specialist referrals, testing, treatment, surgery, and hospitalization. We determine whether such services are covered by referencing the member’s summary plan description.

4. Which Complementary Medical Disciplines are Covered Under the PPO or Will be Covered Under the PPO?

Aetna: Members get special rates on visits to acupuncturists, chiropractors, massage therapists, and nutritional counselors, which they pay directly to the participating provider. Participating providers and vendors in the alternative healthcare programs are solely responsible for their products and services. We have not credentialed or reviewed them. Members can save on over-the-counter vitamins and supplements, aromatherapy, foot care, and natural body-care products.
Anthem: Physical therapy, occupational therapy, chiropractic care, speech therapy, DME and acupressure/acupuncture are covered.
Blue Shield: The enhanced Blue Shield Website, blueshieldca.com, makes online health information available to all Californians. Blue Shield offers among the most comprehensive array of health education programs and materials in the industry and is one of the few health plans with prevention programs designed specifically for men, women, children and seniors. Alternative health and wellness services are available through credible providers that don’t cost employers more money. Blue Shield members living in California can get discounts of 25% or more on alternative services, such as acupuncture, chiropractic, and massage therapy; 20% off the published retail prices when using a participating California provider in the Discount Vision Program for routine eye exams, frames and lenses, photochromic lenses, tints, and coatings, and 15% for LASIK laser vision correction surgery through the TLCVision provider network in California.
Cigna: Complementary medical disciplines, such as acupuncture, massage therapy, and chiropractic care, may be covered if they meet CIGNA’s evidence-based medical necessity guidelines, which are accessible online. Members get generous discounts on a variety of health and wellness products and services including alternative therapies, such as massage, acupuncture and chiropractic care, plus discounts on laser vision correction, fitness club memberships, hearing care products and services, guided imagery mind body techniques, and vision care. Healthy Rewards also offers savings on herbals, vitamins, and non-prescription health and beauty products. CIGNA’s enhanced personal Web portal, myCIGNA.com, provides access to online provider directories, benefit and claim information, pharmacy services, and specific health information (including complementary medicine topics), among other things.
Guardian: Chiropractic, physical therapy, occupational therapy, speech therapy and acupuncture are covered when medically necessary.
Health Net: Complementary medical disciplines vary by each employer contract. If an employer chooses to offer complementary medicine, Health Net’s program offers direct referral to chiropractic and acupuncture care. However, all PPO members get discounts on chiropractic; acupuncture; relaxation and massage therapy; hearing aids and screenings; children’s health products; eye exams, frames, lenses, contacts and LASIK; fitness clubs; vitamins, herbs, and supplements; weight management; and many other services. Members can log onto www.healthnet.com to learn more about these discounts and how to access them.
Kaiser Permanente: The PPO plan does not offer coverage for any complementary and alternative medicine services. However, the insured can purchase the chiropractic/acupuncture rider. The rider offers a combined $1,000 or $2,000 benefit maximum and the insured pays coinsurance for services received.
UnitedHealthcare: American Chiropractic Network, a business segment of UnitedHealth Group, provides chiropractic benefits as well as discounts for the following complementary alternative medicine services to our enrolled individuals.
• Acupuncture
• Massage therapy
• Nutritional counseling
• Naturopathic medicine services (in states where naturopathic physicians are licensed).
UnitedHealthcare also offers employers an optional acupuncture benefit. Finally, through UnitedHealth Wellness programs, we provide discounts on products and services for nutrition, weight-management, fitness, stress management, and other wellness products and services.

5. Describe Your Coverage For Mammograms.

Aetna: Aetna considers annual mammography screening a medically necessary preventive service for women aged 40 and older. Annual screening is also considered a medically necessary preventive service for younger women who are judged to be at high risk by their primary care physician.
Anthem: Once a year routine mammograms are covered when ordered by a physician. There is no limit in frequency if medically necessary for “sick/medical conditions” when ordered by a physician.
Blue Shield: One annual mammography test is covered for screening and diagnostic purposes without illness or injury being present.
Cigna: Mammograms are covered annually for women age 40 and over or more frequently and at younger ages when medically indicated.
Guardian: This is covered under the CA mandate:
CA has mandated this benefit as follows:
1. 1 baseline mammogram for women age 35 to 39
2. 1 mammogram for women age 40 to 49 every two years or more frequently if recommended by a physician, nurse practitioners, or certified nurse midwives.
3. Annual mammogram for women age 50 and older.
Kaiser Permanente: Mammograms are covered as part of the adult preventive screenings benefits as follows:
• One baseline mammogram for women 35 to 39.
• One mammogram every two years or more frequently upon recommendation of a physician, for women 40 to 49.
• For women age 50 and older, one yearly mammogram.
UnitedHealthcare: UnitedHealthcare Options PPO provides coverage for mammograms as part of our standard outpatient surgery, diagnostic, and therapeutic services benefit. It is covered both as a preventive and diagnostic service.

6. Do You Cover PSA Tests For Non-Symptomatic Men? If So, at What Age?
Aetna: Yes, if a state has specific legislation, we will pay it in accordance with the law. There is no age limit unless it’s being paid under a specific benefit, like the trust benefit, which has a contractual limit.
Anthem: Yes, when ordered by a physician.
Blue Shield: Coverage includes, but is not limited to, prostate-specific antigen testing and digital rectal examinations, when medically necessary and consistent with good professional practice. There is no age limit for PSA testing when billed with a preventive-care diagnosis.
Cigna: It is covered based on the treating physician’s determination.
Guardian: If the preventive care rider is purchased, the age we start allowing is 50.
Health Net: Preventive care and diagnostic procedures for adults (age 17 and older) are covered at a physician’s direction. When medically indicated for men age 50 and above, test and procedures, including, but not limited to, prostate-specific antigen testing (PSA) and digital rectal examinations are covered.
Kaiser Permanente: The following prostate-specific antigen (PSA) tests are covered as part of the adult preventive screenings benefits, which are available at age 18: screening and diagnosis of prostate cancer, including but not limited to PSA testing and digital rectal examination when medically necessary and consistent with good professional practice. This coverage does not cover the surgical and other procedures known as radical prostatectomy, external beam radiation therapy, radiation seed implants, or combined hormonal therapy.
UnitedHealthcare: Network physicians are encouraged to follow the Guide to Clinical Preventive Services of the United States Preventive Services Task Force (USPSTF) as the basis for preventive care. We cover PSA tests regardless of age even though the USPSTF indicates this screening lacks clinical value.

7. Describe Your Drug Formulary. (Three Tier etc.) If it’s a Closed Formulary, What Happens if a Non-Formulary Drug is Needed?

Aetna: The formulary may be open or closed depending on the benefit plan. In plans with an open formulary, both formulary and non-formulary drugs are generally covered subject to applicable limitations and conditions. With a closed formulary, formulary and non-formulary drugs are generally covered except for drugs on the formulary exclusions list. Formulary exclusions provide less overall value than therapeutically equivalent formulary drugs. The member’s physician can request approval for coverage for a formulary exclusion.
Anthem: Non-formulary or non-preferred drugs that have a formulary or non-prescription equivalent are not covered unless the prescribing doctor indicates that the drug should be dispensed as written on the prescription.
Blue Shield: The Blue Shield three-tiered open formulary benefit allows members to get generic drugs at the lowest co-payment, brand-name drugs at a higher brand co-payment, and non-formulary drugs at the highest non-formulary co-payment. A drug prior authorization program is in place for selected drugs on the formulary and for non-formulary drugs to promote appropriate first-line therapy or to reserve use of certain medications with specialized uses or significant potential for misuse or overuse. The Pharmacy and Therapeutics Committee is responsible for establishing and providing oversight of the drug prior authorization policies and procedures and the maintenance of the Medication Policy Coverage Criteria. By encouraging the use of generic and brand formulary drugs, savings are realized by the employer, the member, and Blue Shield of California.
Cigna: We offer several kinds of formulary including open, closed, and tiered.
Guardian: The Guardian has contracted with Medco Health Solutions Inc. to manage the formulary, which is approved for safety and efficacy by independent medical professionals on the Pharmacy and Therapeutics Committee. Medco is a leader in the management of integrated prescription drug benefits. The company pioneered formulary management and continues to be a leader in the industry with innovative formulary compliance programs. The formulary consists of FDA-approved drugs that were selected based on their safety, efficacy, and cost. For three-tier plans, the plan may prefer some medications over others. These are called “preferred drugs,” and their co-payment is lower. The member’s co-payment depends on which drug the doctor prescribes for the member. The member may pay the lowest co-payment for generic drugs and a higher co-payment for preferred, brand name drugs. The highest co-payment for non-preferred, brand name drugs.
Health Net: The most common pharmacy-benefit structure is a three-tier plan, although a small number of employers have selected a closed formulary. When members with access to a closed formulary get a prescription for a non-formulary drug, coverage for the drug is not typically available unless it meets medical necessity guidelines.
Kaiser Permanente: The PPO plan has an open formulary, in which all FDA-approved drugs are covered for the insured with the exception of those listed in the Optional Prescription Drug Exclusions and Limitations. The insured pays a co-pay based on whether the drug is generic or brand.
UnitedHealthcare: Unlike a formulary, the prescription drug list does not imply any drug therapy recommendations. Rather, we assign prescription medications a co-payment tier based on an evaluation of clinical, economic, and pharmacoeconomic evidence. Unlike our competitors, some brand drugs are placed in Tier 1 and some generic drugs are placed in Tier 2 or Tier 3 based on the overall value (for example, the lowest net cost that they offer our clients). UnitedHealth Pharmaceutical Solutions’ (UHPS) offers a three-tier plan and an open benefit design. Tier 1 drugs represent the lowest co-payment option and include many generic drugs. Tier 2 drugs represent a middle co-payment option and include many brand name drugs. Tier 3 drugs represent the most costly drugs, often with Tier 1 or Tier 2 alternatives and have the highest co-pay option. A drug’s tier placement is subject to change when its value changes as a result of a patent expiration, new product introduction, or other important clinical, safety, or economic information. When a generic drug is more costly than the brand drug during six-month exclusivity arrangement this period, UHPS may place the generic in Tier 2 and move the generic to Tier 1 once the price decreases.