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OPM has issued its annual “call letter” to FEHB carriers, urging them to continue cost-sharing initiatives involving prescription drugs, wellness programs and preventive care, although with a new emphasis in some cases.

The letter kicks off the annual process of negotiating plan terms and premium rates that are announced each fall in advance of an open season for the following calendar year. Areas of emphasis for 2021 include that carriers:


* Limit the cost-sharing for “observation care”—short-term treatment and tests to help doctors decide whether a patient needs in-patient admission—to the maximum charged for the same period of in-patient care.

* Review and potentially eliminate “low-value care” which it defined as care, including with prescription drugs, that is “provided in an inefficient manner, that is clinically inappropriate, or for which there are safer, more cost-effective alternatives.”

* Promote the use of “biosimilars,” which are less expensive than brand-name products but are considered interchangeable.

* Continue to emphasize tobacco cessation benefits, including making clear that those benefits extend to e-cigarettes and similar products, and continue to offer financial incentives for using wellness programs through lowered copayments or debit cards usable for certain medically related purposes.

* Continue to limit prescriptions of opioids and provide access to alternative pain treatments and treatments for overuse and addiction.

OPM also encouraged, but did not require, carriers to limit prescription drug coinsurance costs, in which the patient pays a percentage of the cost of the drug.

It said that as carriers have moved to coinsurance from copayments—a flat amount per prescription—”there is concern that some FEHB members may not be able to afford their medication costs and that the amount of their cost share is less transparent.”


OPM further said it is looking for ways to address “surprise billing”—unexpected additional costs to enrollees for out-of-network care.

That most commonly occurs in emergency or urgent care settings where the patient does not have an opportunity to select a provider but also can occur when out-of-network providers are involved in a patient’s care at an in-network facility, it said.

It did not impose policies for 2021 but said that by 2022 carriers will be expected to ensure that listings for in-network hospitals in their provider search tools include information on the availability of in-network providers there.

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