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High Cost Medical Drug Provider Policy

Health Alliance has a responsibility to be a good steward of members’ and employers’ premium dollars. Starting June 1, 2020, Health Alliance is implementing a provider policy governing how Health Alliance contracted providers serving our fully insured commercial group and individual members and many Health Alliance self-funded plans must acquire high cost medical drugs prescribed for our members. This is not a member policy.

This policy will allow us to 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. 

If you have any questions, please contact your Client Consultant or