Download New EUTF drug plan Formulary additions

HMSA’s
pharmacy newsletter for participating medical practitioners
NEW GENERICS
July 2007
New EUTF drug plan
E
ffective July 1, 2007, drug coverage for approximately 114,000 participants
in the Hawaii Employer-Union Health Benefits Trust Fund (EUTF) will be
administered by either HMSA or National Medical Health Card (NMHC). The
administrator, HMSA or NMHC, will be determined by the medical plan the
participants choose.
Available generics
are listed following
their brand-name
equivalent
Ambien
zolpidem
Colestid
colestipol
Mavik
trandolapril
Norvasc
amlodipine
Uniretic
moexipril/hctz
Zofran
ondansetron

If you have questions
about information in
this Provider Update,
please call a Provider
Teleservice Representative at 948-6330
on Oahu or 1 (800)
790-4672 from the
Neighbor Islands.
Participants who choose the PPO medical plan or a supplemental plan
administered by HMSA will have their prescription benefits administered
by NMHC. Participants choosing either of the following two medical plans
administered by HMSA will retain HMSA prescription benefits with the
corresponding coverage code listed below:
•
EUTF HMO plan with drug coverage code 462
•
EUTF High Deductible Health Plan (HDHP) with drug coverage code 461.
This plan combines the medical and drug accumulators. A deductible must
be met before members can be charged their standard copayment. Members
must pay in full for the drugs dispensed until the deductible has been met and
members are eligible to pay the standard copayment.
Participants choosing NMHC for their drug benefits will receive new member ID
cards and information from NMHC.
Drug claims submitted after June 30, 2007 for a participant who chooses the PPO
medical plan or the supplemental plan administered by HMSA will deny. The drug
benefits for these plan participants will be administered by NMHC. In addition,
effective July 1, HMSA drug coverage codes 00S, 368 and 445 through 449 will
become obsolete for all EUTF members. Effective July 1, HMSA drug benefits are
only available as described above.
Members with questions regarding the new drug coverage should be directed to
contact NMHC at 1 (866) 533-6977.
Formulary additions
The drugs listed below will have the status of PREFERRED for the Select drug plan and
FORMULARY for The HMSA Plan for QUEST Members effective July 1, 2007:
Azilect (rasagiline)
Comtan (entacapone)
Stalevo (levodopal carbidopal entacapone)
PM07-016
Hawaii Medical Service Association
Phone: (808) 948-5110
Internet address:
818 Keeaumoku St.
Branch offices
www.HMSA.com
P.O. Box 860
located on
Provider Resource Center:
Honolulu, HI 96808-0860
Hawaii, Kauai and Maui
hhin.hmsa.com
w Pharmacy Newsletter
July 2007
Drug status changes
Effective July 1, 2007, the formulary status of a number of drugs will change, including some medications
with high utilization. The status is listed in the following tables and on the enclosed Formulary Update.
Colestid (colestipol)
Plan
Select
65C Plus Prescription
Drug Coverage
QUEST
Status
Other Brand
Tier 2 (no change)
Non-Formulary
Desogen (desogestrel-ethinyl estradiol)
Plan
Status
Select
Preferred oral contraceptive (no change)
Choice
Preferred oral contraceptive (no change)
65C Plus Prescription
Tier 2 (no change)
Drug Coverage
QUEST
Non-Formulary
Nor-Q-D (norethindrone)
Plan
Status
Select
Other Brand oral contraceptive
Choice
Other Brand oral contraceptive
65C Plus Prescription
Tier 2 (no change)
Drug Coverage
QUEST
Non-Formulary
Zofran (ondansetron)
Plan
Select
65C Plus Prescription
Drug Coverage
QUEST
Status
Other Brand
Tier 2 (no change)
Non-Formulary
Formulary Update
The HMSA Formulary Update is enclosed with this newsletter. The formulary is available through the Hawaii
Healthcare Information Network (HHIN) at hhin.hmsa.com by clicking on the link to the Provider Resource
Center. Formulary changes referred to in this newsletter will not be reflected in the online formulary until the
effective date of the changes.
Drug news & updates
Byetta
As of April 16, 2007, precertification for Byetta
(exenatide) is no longer required for private business
plans. Byetta remains a medical benefit.
Exubera age edit in place
Exubera (insulin human [rDNA origin]; inhalation
powder) was approved by the FDA in January 2006
for use by adults with diabetes mellitus for control of
hyperglycemia. An age edit was implemented on May
15, 2007. Claims submitted for members under the
age of 18 will deny at point-of-sale.
Prilosec OTC coupons
Program launched in April
HMSA has begun offering certain members
three manufacturer coupons, each good for
one 14-day supply of Prilosec OTC. The first
coupon was mailed during the week of April 23;
the second will be sent in July and the third and
final mailing will be in November.
Pharmacy Newsletter w July 2007
Qualaquin
According to First DataBank, the
status for Qualaquin was changed in
March 2007 from generic to brand and
is classified as Other Brand for HMSA
private business and Tier 1 for Medicare Part D plans. Qualaquin
is the only approved quinine sulfate drug available for treatment of
malaria. It is not approved for any other indication.
Oral contraceptives conversion continues
As part of the continuing effort to simplify the oral contraceptive
benefit design, effective July 1, 2007, Nor-Q-D will be classified
as Other Brand oral contraceptives for private business plans and
QUEST. Its generic will take its place as the Preferred oral contraceptive. While the similar conversion of Desogen will not be effective for private business plans until October 1, 2007, the benefit
change will be effective July 1, 2007 for QUEST plan members. A
summary of all the announced changes is listed in the Reminders
section of this newsletter.
Cymbalta - new indication added
Effective May 1, 2007, a new diagnosis for generalized anxiety disorder (GAD) was added for Cymbalta for The HMSA Plan for QUEST Members
and CCS plan participants. For your reference, the
list below contains all the diagnoses currently applicable to Cymbalta. The most up-to-date information is always available under Condition Codes in
the Pharmacy/Formulary section of the Provider
E-Library. (See the Reminders section of this newsletter for a recap
of condition codes for covered psychotropic drugs.)
Major depressive disorder, single episode (296.20-296.26)
Major depressive disorder, recurrent episode (296.30-296.36)
Psychogenic depressive psychosis (298.0)
General anxiety disorder (300.02)
Neurotic depression (300.4)
Acute reaction to major stress with depressive symptoms
(308.0)
Depressive states associated with stressful events (309.0-309.1)
Mixed adjustment reaction with depressive symptoms (309.4)
Depressive disorder, not elsewhere classified (311)
Benoquin and Oxsoralen
covered benefits
Effective July 1, 2007, HMSA will cover Benoquin (monobenzone) and Oxsoralen (methoxsalen) when used for the
treatment of vitiligo. Previously drugs
for this indication have been benefit
exclusions. Pharmacy claims must be
submitted with the ICD-9-CM code of
709.01 (vitiligo) for coverage. Claims
submitted without this diagnosis code
will deny at point-of-sale. These drugs
will process at Tier 3 for private business plans and Medicare Part D plans
and will be Formulary for QUEST.
MTM program continues
HMSA’s Medication Therapy Management (MTM) Program for eligible
members continues with medication
therapy reviews to help improve their
drug therapy outcomes.
To be eligible for services through
HMSA’s program, the member must
have an active HMSA Part D plan
(65C Plus Prescription Drug Coverage
or Medicare Rx Plan) and be determined as eligible for MTM services by
HMSA.
Please note that the EUTF members
whose drug coverage moves to NMHC
(see page 1) will no longer be eligible
for MTM services through HMSA.
w Pharmacy Newsletter
July 2007
Reminders
Transition to HFA inhalers
The transition from chlorofluorocarbon-based (CFC) metered-dose albuterol inhalers
to the environmentally friendly hydrofluoroalkane-based (HFA) albuterol inhalers will
continue on a more-frequent basis. Listed below is a summary of the Generic and Preferred
Brand drugs within the therapeutic class that are available during the transition from CFC
to HFA asthma inhalers.
Medication
Trade Name
Select
Med D plans
QUEST
albuterol
Proair HFA
Generic
Tier 1
Formulary
albuterol
Proventil HFA
Preferred
Tier 2
Formulary
albuterol
Ventolin HFA
Preferred
Tier 2
Formulary
levabuterol
Xopenex HFA
Generic
Tier 1
Formulary
Psychotropic drugs
In the December 2006 newsletter, we reported that psychotropic drugs are now covered by QUEST. Additions have been made to the formulary, and condition codes applicable to some psychotropic drugs have been
updated in the Provider E-Library and are listed under Benzodiazepines and Stimulants. Listed below for your
convenience are the medications currently covered along with their covered conditions and diagnosis codes.
benzodiazepines (BZD)
alprazolam
alprozalam, extended release
Ativan*
chlordiazepoxide
chlordiazepoxide/amitriptyline
clonazepam
clorazepate
diazepam
Klonopin
Librium*
Limbitrol DS*
lorazepam
oxazepam
Serax*
Tranxene*
Valium*
Xanax*
Restricted to treatment or prevention of:
Epilepsy without intractable (345.00)
Epilepsy with intractable (345.01)
Panic disorder (300.01)
Generalized anxiety disorder (300.02)
OCD (300.3)
ETOH withdrawal (291.81)
Bipolar agitation (296.40-296.46)
BZDs are NOT payable for insomnia.
*DAW 1 required for QUEST coverage
(continued)
July 2007
stimulants
(Respiratory and Cerebral):
Treatment of ADD or ADHD:
Adderal XR
Concerta
Daytrana
Desoxyn
Focalin
Focalin XR
Metadate CD
Metadate ER
Ritalin LA
Treatment of narcolepsy:
Provigil
Treatment of ADD, ADHD and narcolepsy:
amphetamine mixture
Adderall*
dextroamphetamine, sustained release
Dexedrine*
Dexedrine spansules*
methylphenidate
methylphenidate, sustained release
Ritalin*
Ritalin SR*
Pharmacy Newsletter w Restricted to treatment of attention deficit disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD).
ADD (314.00)
ADHD (314.01)
Restricted to treatment of narcolepsy.
Narcolepsy without cataplexy (347.00)
Narcolepsy with cataplexy (347.01)
Narcolepsy in conditions classified elsewhere without cataplexy
(347.10)
Narcolepsy in conditions classified elsewhere with cataplexy
(347.11)
See above for approved ADD, ADHD and narcolepsy ICD.9.CM
codes
*DAW 1 required for QUEST coverage
Contact information
Questions or comments regarding HMSA Drug Formulary revisions:
Kris Tsutomi, R.Ph., HMSA Pharmacy Management, P.O. Box 860, Honolulu, HI 96808-0860
For routine claims and eligibility questions, we encourage you to use HHIN or HMSA Membership Connection
(touch-tone eligibility verification) at 948-6244 (Oahu), 1 (800) 552-8507 (Neighbor Islands).
Other questions should be directed to:
HMSA Provider Teleservice at 948-6330 (Oahu), 1 (800) 790-4672 (Neighbor Islands)
QUEST Provider Services at 948-6486 (Oahu), 1 (800) 440-0640 (Neighbor Islands)