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High Cost Medical Drug Policy

Friday February 28th, a letter was mailed to Health Alliance contracted providers in Illinois and other Midwestern states notifying them of a new policy governing reimbursement for high cost medical drugs administered in a medical setting. This policy will go into effect June 1, 2020.

Providers serving Health Alliance fully insured commercial group and individual members and many self-funded plans are subject to this policy. Providers are not subject to this policy if they are caring for members with Health Alliance Medicare plans or traditional Medicare.

This policy will allow us to ensure the same quality of care and continue offering competitive products by better managing expenses for very high cost drugs—the kind that must be administered by a healthcare professional, usually by injection or IV infusion, on a scheduled basis in physician offices, infusion centers or hospital outpatient settings. The policy does not include high cost medical drugs that must be administered in an inpatient, emergency or unscheduled situation.

Members will not be affected in any negative way. They may experience a positive impact with lower out-of-pocket costs if their coverage plan requires that they pay coinsurance when they receive these drugs. They will receive the same medications in the same way. The provider will simply arrange to order the drugs in advance.

Health Alliance’s list of high cost medical drugs and information on acquiring these medications can be found here

If you have questions, contact your provider relations specialist.

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