December 21, 2022

Congratulations to Josh Howard from Johnson Co SUD for winning November’s $25 Amazon gift card! 

Want to increase your chances of winning in January? 

Sign up for our weekly BC Buzz emails to get weekly updates on trainings, announcements, and more. The more trainings you attend, the more submissions you have in the monthly raffle!

On January 1, 2023, TML Health will be rolling out our newest cost-saving program SurgeryPlus^®. Through the SurgeryPlus Program, we’ve partnered with a network of the nation’s leading surgeons to deliver high quality care at an incredible value.  Surgery Plus providers have agreed to a “bundled” price that includes all the surgeon, anesthesia, and facility costs in one low rate. 

With these bundled prices and lower complication rates, the savings are so substantial that the Pool will waive member deductibles and coinsurance for our PPO members on Classic and Copay plans. Members on a High Deductible Health Plan can also save on their deductible, as they will only have to meet the federal minimum deductible as required by law.  

SurgeryPlus will help your employees by scheduling access to these surgeons and then covering the cost of travel, stay, AND THE SURGERY!

Surgery Plus coverage includes:

• Access to Network of Leading Surgeons
• Consultations & Appointments
•  Anesthesia
•  Procedure & Hospital Fees
• Substantial Savings

You can expect more information and resources in January to help your employees be informed about the new program including emails, postcards, and webinars!

**HMO Plans are not eligible for the Surgery Plus Program.

MDLive is increasing their charges to all carriers, including TML Health, on January 1, 2023.   

IF YOUR EMPLOYEE NEEDS GENERAL MEDICAL CARE FROM MDLIVE…

• And is on a Classic PPO, Copay PPO, or a HMO Plan - TML Health will absorb the increase in costs and the copay will remain $0.
• And is on a High Deductible Health Plan – The employee will see a copay increase of just $4. The employee will pay $48 until their deductible is met.

IF YOUR EMPLOYEE NEEDS BEHAVIORAL HEALTH CARE FROM MDLIVE…

• And is on a Copay PPO or HMO Plan – TML Health will absorb cost increases and the copay will remain $30.
• And is on a Classic PPO Plan – The employee will see a copay increase ranging from $75-$250 depending on the level of care provided.
• And is on a High Deductible Health Plan – The employee will see a copay increase ranging from $75-$250 depending on the level of care provided.

Navitus has informed us there has been an increase in misuse of high-cost diabetes drugs. Instead of their intended purpose, individuals have been using the drugs for weight loss, which is not covered by the Pool.

To ensure the safety of our members and appropriate use of such high-cost drugs, two new edits will be put into place in the Navitus pharmacy claims system:

• Restricted Diagnosis (RDX) Edit – As of November 1^st, prescribers will be required to include the primary diagnosis associated certain anti-diabetic drugs on the actual prescriptions. If there is no diagnosis included, or if the diagnosis is anything other than diabetes, the claim will reject. There is no workaround or override for this rejection as the only covered use for this medication is to treat diabetes.

• Metformin Step Edit – As of November 1^st, the pharmacy claims system will look back over the member’s pharmacy claim history for the previous use of Metformin, which is a first line therapy for diabetes. If there is no history of the use of Metformin, the claim will reject when certain anti-diabetic drugs are being prescribed for the first time. If members are already established on these other drugs, the claim will pay (as long as the RDX requirements are also met). 

Sincerely,

TML Health

TML Health Benefits Pool is a non-profit trust organization created by political subdivisions to provide group benefits services to participating political subdivisions and is not an insurance company. This contains proprietary and confidential information of TML Health. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.