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Minnesota Advantage Health Plan members who are diagnosed with Type I or Type II diabetes and have received a qualifying medical service or prescription drug are eligible for the enhanced benefits of Advantage Value for Diabetes. The following groups Advantage members are eligible:
Diabetes is a relatively common chronic disease that can be effectively managed with the right care at the right time. It increases your risk of serious and costly medical complications, including vision loss, nerve damage, kidney failure, cardiovascular disease (heart attacks and strokes), and other health problems. With timely and appropriate treatment, along with lifestyle changes, the risk of complications can be reduced for many people diagnosed with diabetes. By reducing financial barriers to high-value medical services and prescription drugs, Advantage Value for Diabetes encourages members to receive appropriate care to manage their diabetes to help prevent or delay the onset of complications. Consult with your doctor regarding the appropriate care for you.
Advantage Value for Diabetes pilot is open to Advantage Plan members whether active employee, dependent, early retiree, or former employee who has continued coverage (FEWD, COBRA).
If you receive an eligible medical services or prescription drug for diabetes, you will begin receiving discounts on certain medical and pharmacy out-of-pocket costs through your health plan or CVS Caremark. You will receive lower out-of-pocket costs through waived or reduced copays and coinsurance.
Copays: Eligible diabetes care or eligible prescription medication copays will be waived or reduced by the health care provider or pharmacist at the time of the appointment or prescription fill. Members should ask health care providers not to collect copays at the point of care for care that is primarily related to diabetes. Members should call their health plan administrator or CVS Caremark with additional questions.
Coinsurance: Members will be charged reduced coinsurance for certain services through the health plan billing process. The member should see the reduced coinsurance amount (compared to the SEGIP Minnesota Advantage Health Plan) in the explanation of benefits and amount due. Members should call their health plan administrator or CVS Caremark with additional questions.
Deductibles: Members will not be charged their SEGIP Minnesota Advantage Health Plan deductible for primarily diabetes-related care for eligible medical services or testing supplies. Members will be responsible for their Advantage Plan deductibles for services that are not included in the Advantage Value for Diabetes benefit. Members should call their health plan administrator or CVS Caremark with additional questions.
Once you qualify, you are automatically enrolled. Your do not need to take extra steps enroll to receive Advantage Value for Diabetes benefits. Eligible members will receive enhanced benefits from their health plan administrator and/or CVS Caremark once they have had an eligible medical service primarily for diabetes, and/or filled a prescription for a qualifying diabetes medication. After the claim for your eligible medical service has processed, your health plan administrator will send you a letter to inform you that you qualify for the benefit and are automatically enrolled. Review these resources to learn more:
Members and family members do not need to enroll to receive Advantage Value for Diabetes benefits. Eligible members/family members will receive enhanced benefits from their health plan administrator and/or CVS Caremark once they have had an eligible medical service primarily for diabetes, and/or filled a prescription for a qualifying diabetes medication. After the claim for your eligible medical service has processed, your health plan administrator will send you a letter informing you that you qualify for the benefit and that you are automatically enrolled.
To receive the most out-of-pocket costs and eligible services for Advantage Value for Diabetes benefit, members are recommended to review the following resources:
No, members are not eligible for reimbursement for care, services, or medications that was not primarily for the treatment and evaluation of diabetes mellitus (Type 1 or Type 2). Members must be filling a prescription for a qualifying diabetic medication or receiving eligible medical services primarily for diabetes mellitus to receive lower out-of-pocket costs.
All eligible medical services must be for primarily diabetes-related care through your primary care clinic or referred in-network provider (call your health plan to determine if you need a referral). All care not primarily related to diabetes will be covered under the standard Minnesota Advantage Health Plan benefits.
Eligible medical services received outside the service area are subject to the Advantage Value for Diabetes for their national network. Refer to the list of eligible medical services and out-of-pocket medical costs for Advantage Value-eligible members.
There are general diabetic care recommendations from recognized sources listed below, but it is best for members to speak directly to their primary care provider, to determine the best care for their condition.
The medical services listed above are eligible for enhanced coverage if they are primarily for diabetes treatment and management. Health care providers must bill your medical plan administrator (Blue Cross or HealthPartners) for these services with a leading diagnosis code of diabetes mellitus (Type 1 or Type 2) for you to receive a cost sharing discount.
For example, if you have been previously diagnosed with diabetes but have an office visit with your primary care physician principally for the examination and treatment of a sprained ankle, that visit may not qualify for a cost sharing discount. Eligibility for enhanced coverage will depend chiefly on how providers bill your medical plan administrator for these services and what diagnosis information they submit on the claim.Primary care and specialty care visits are considered office visits. Check with your health plan to determine if you need a referral.
Clinics who incorrectly charge a copay are responsible for providing the member a refund. Members may need to work with their health plan administrator and their clinic’s financial services or customer service representatives to receive a copay refund.
To avoid needing copay reimbursements, members should ask their clinic not to charge a copay for diabetes related visits until after the medical claim has been processed. The medical claim process will determine if a member copay is required and will notify the clinic regarding the member’s copay responsibility.
In cases where a clinic does charge a member a copay for an eligible service primarily for diabetes care, members should review their explanation of benefits from their health plan administrator. If the explanation of benefits lists no member copay amount, the member should call their clinic’s financial services customer service to request a copay refund.
The eligible medical service and prescription drug list was based on the generally accepted clinical guidelines of how to manage diabetes as outlined by the National Institutes of Health, the Centers for Disease Control, clinical experts, health plan administrators, and other state employer group programs.
CVS Caremark formulary medications for diabetes, hypertension, cholesterol, and depression drugs as well as diabetic testing supplies are covered under the Advantage Value for Diabetes benefit. Drugs must be purchased through CVS Caremark in-network pharmacies including retail, mail, and specialty. Refer to the list of eligible pharmacy services and out-of-pocket pharmacy costs for Advantage Value-eligible members.
Refer to the Advantage Value for Diabetes Eligible Drug List. The list includes all covered prescription medications and diabetic testing supplies for eligible Advantage Value for Diabetes members. Eligible medications and testing supplies must be purchased through a CVS Caremark in-network pharmacies including retail, mail, and specialty. The Advantage Value for Diabetes Eligible Drug List will be updated by CVS Caremark on a quarterly basis. Please call CVS Caremark, 844-345-3234 (toll free) with any medication questions.
Members should look up their prescription medications in the Advantage Value for Diabetes Eligible Drug List. Advantage Value for Diabetes eligible medications are listed. If your prescription medication is not on the eligible list, it is not covered under Advantage Value for Diabetes, but it may be covered under CVS Caremark’s standard Advantage Plan formulary. Members should call CVS Caremark, 844-345-3234 (toll free) with any medication questions.
CVS Caremark will apply a reduced or waived copay at the time of purchase for eligible prescription medications if the member has either 1) filled a prescription for a qualifying diabetes medication or 2) received medical care that was primarily for the treatment and evaluation of diabetes mellitus (Type 1 or Type 2) within the last year. Members who received medical care for diabetes but are not filling a qualifying diabetes medication, please note that it may take 1-2 months for CVS Caremark to receive this information and provide these members with reduced or waived copays for eligible medications.
Also, please note that there are some diabetes prescription medications listed in the Advantage Value for Diabetes Eligible Drug List that are not used to determine Advantage Value for Diabetes eligibility. Once a member has been determined Advantage Value for Diabetes medication eligible through either 1) having filled a qualifying diabetes medication (indicated by an asterisk in the antidiabetic drug class of the Advantage Value for Diabetes Eligible Drug List), or 2) having received medical care that was primarily for the treatment and evaluation of diabetes mellitus (Type 1 or Type 2) within the past year, members will have coverage for Advantage Value for Diabetes drugs that are not used to determine eligibility.
Members can check the Advantage Value for Diabetes Eligible Drug List to find what tier and general associated copay their drug will be. Members should call CVS Caremark Care toll-free at 1-844-345-3234 if they have any questions about the Advantage Value for Diabetes pharmacy benefits or prescription medications.
No, eligible Advantage Value for Diabetes prescription medications are not covered if they are administered by a medical professional in a hospital, outpatient, or physician’s office, or other location. Eligible diabetes, hypertension, cholesterol, and depression drugs are only covered when purchased through CVS Caremark in-network pharmacies including retail, mail, and specialty.
Check the pharmacy locator to see if your pharmacy is in CVS Caremark’s network for Advantage Value for Diabetes drugs as well as other retail prescription drugs.
You can call CVS Caremark by calling 1-844-345-3234 with pharmacy benefits questions.
Equipment and supplies you need to manage your diabetes are generally covered through both medical and pharmacy benefits. You save money when you buy supplies using pharmacies in the CVS Caremark network. Some diabetes equipment, indicated below, can only be purchased through the member’s medical health plan administrator (Blue Cross or HealthPartners). Call your medical plan to learn more about covered equipment (e.g. insulin pumps, continuous glucose monitors, etc.) and in-network medical equipment suppliers. Covered equipment and supplies include:
A list of eligible 0% coinsurance (when you use a pharmacy in the CVS Caremark network) supplies for testing diabetes can be found on the last page of the Advantage Value for Diabetes Eligible Drug list.
Purchase eligible testing supplies through a pharmacy in the CVS Caremark or by calling your medical plan to determine eligible equipment and supplies and suppliers. Diabetes equipment, such as continuous blood glucose monitors and insulin pumps, may only be purchased using the medical benefit plan administrator (Blue Cross or HealthPartners). Each medical plan administrator will have its own policy determining coverage of specific insulin pumps and glucose monitors. Diabetes equipment and supply brands as well as suppliers may vary by medical plan administrator. Call your medical plan administrator and ask for a list of covered insulin pumps or other equipment or supplies you need for your care. Your plan administrator may change the insulin pumps and glucose monitors it covers from year-to-year. A change could mean you have to switch brands to get the equipment paid for by insurance.
Members should call their health plan administrator (Blue Cross or HealthPartners) to see if their existing brand of diabetes equipment or testing supplies is covered through the medical benefit. Members should also ask their health plan administrator how to purchase their covered diabetes equipment and supplies.
Members and family members do not need to enroll. Eligible members/family members will receive enhanced benefits from their health plan administrator and/or CVS Caremark once they have had an eligible medical service primarily for diabetes, and/or filled a prescription for a qualifying diabetes medication.
No, there are no required member activities to keep this enhanced benefit. However, members will lose access to the enhanced prescription drug benefit of Advantage Value for Diabetes if they have not received a qualifying medical service for diabetes or filled a prescription for diabetes medication in more than a year. There are member eligibility requirements and benefits apply only to eligible medical, pharmacy, or diabetic supplies.
No, there are no HRA incentives in the Advantage Value for Diabetes benefit. Members benefit from reduced out-of-pocket costs for eligible medical services, prescription drugs, and testing supplies.
Your health information is private data. None of the information about your health status or claims which has been gathered by the Claims Administrator in order to adjudicate claims can be disseminated without your consent unless you are notified at the time of open or special enrollment [62D.145]
For more information, members should refer to the Medical Data Privacy information in the Minnesota Advantage Health Plan Summary of Benefits.
When you have a concern about a medical benefit, claim or other service, file a medical claim complaint or appeal with your health plan administrator (Blue Cross or HealthPartners). Follow the directions in the Minnesota Advantage Health Plan Summary of Benefits under the section for Disputing a claim, Section B Complaints and Appeals.
Health plan administrator contact information.
When members or family members have a concern about a pharmacy benefit, claim or other service, please call Caremark Customer Care toll-free at 1-844-345-3234. Customer Care Representatives will answer questions and resolve your concerns quickly.
Members or family members may also file a pharmacy appeal by following these directions.