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HMSA’s
HMSA Pharmacy Newsletter
February 2006
www.HMSA.com/portal/provider
CDC HEALTH ALERT - USE OF ANTIVIRALS FOR INFLUENZA
The U.S. Centers for Disease Control and Prevention (CDC) issued a Health Alert on January 14,
2006 regarding the use of antivirals for the treatment of influenza. For the 2005-2006 season,
influenza A (H3N2) viruses isolated from 120 patients in 23 states have been tested at CDC and 109
(91 percent) found to be resistant to amantadine and rimantadine. However, all influenza viruses
found across the U.S. screened for antiviral resistance at CDC as of January 14 demonstrated
susceptibility to the neuraminidase inhibitors – oseltamivir and zanamivir.
On the basis of these results, CDC is providing an interim recommendation that neither amantadine
(Symmetrel) nor rimantadine (Flumadine) be used for the treatment or prophylaxis of influenza for
the remainder of the 2005-2006 influenza season. During this period, oseltamivir (Tamiflu) and
zanamivir (Relenza) should be selected if an antiviral medication is used for the treatment of
influenza, or oseltamivir (Tamiflu) should be prescribed for chemoprophylaxis of influenza.
CDC recommends that neuraminidase inhibitors (oseltamivir and zanamivir) be used as treatment for
any person experiencing a potentially life-threatening influenza-related illness and for persons at high
risk for serious complications from influenza. Annual influenza vaccination remains the primary
means of preventing morbidity and mortality associated with influenza.
FORMULARY ADDITIONS
New Generics
Remember to check here for
information on newly available
generics.
Generic name
azithromcycin
clindamycin, vaginal
cream
glimepiride
glipizide/metformin
halobetasol
leflunomide
ribavirin
Brand name
equivalent
Zithromax
Cleocin,
vaginal cream
Amaryl
Metaglip
Ultravate
Arava
Copegus
The drugs listed below will have the status of
PREFERRED for the Select plan, TIER 2 for HMSA’s
65C Plus Prescription Drug Coverage and FORMULARY
for The HMSA Plan for QUEST Members:
• cefdinir (Omnicef) – effective April 1, 2006
• fenofibrate (Lofibra) – effective January 1, 2006
• valganciclovir (Valcyte) – effective April 1, 2006
Inside this Issue
New BIN and PCN numbers .............................2
Patient Location Code.......................................2
QUEST injectables............................................2
Drug updates.....................................................3
Reminders.........................................................4
Formulary update ..............................................5
Contact information ...........................................5
Hawaii Medical Service Association
Phone: (808) 948-5110
Internet address:
818 Keeaumoku St.
Branch offices
www.HMSA.com
P.O. Box 860
located on
Hawaii, Kauai and Maui
Provider E-Library:
PM06-002
Honolulu, HI 96808-0860
www.HMSA.com/portal/provider/
NEW BIN AND PCN NUMBERS
A unique BIN and Process Control Number (PCN) has been assigned to HMSA’s 65C Plus Prescription
Drug Coverage. The BIN and PCN numbers remain the same for HMSA private business plans and for
QUEST plans. The appropriate numbers are listed on the table below.
BIN
012353
600428
PCN
03400000
00810000
600428
01180000
Line of Business
HMSA’s 65C Plus Prescription Drug Coverage
HMSA private business plans; 65C Plus members who do not
have HMSA’s 65C Plus Prescription Drug Coverage
The HMSA Plan for QUEST Members
PATIENT LOCATION CODE - HMSA’S 65C PLUS PRESCRIPTION DRUG
COVERAGE
As of January 1, 2006, pharmacies have been required to enter a patient location code for claims submitted
for HMSA’s 65C Plus Prescription Drug Coverage plan. Remember to submit “00” in the appropriate field
to indicate that the prescription is being filled at a retail pharmacy. Codes to be submitted for other
pharmacy types are “03” for home infusion therapy and “05” for pharmacies of long-term care facilities.
PRECERTIFICATION REQUIRED FOR QUEST INJECTABLES
The injectables listed below require precertification and have been processing incorrectly at
point-of-sale. A correction has been made to HMSA’s drug claims processor; therefore,
effective February 1, 2006, these drugs will deny at point-of-sale if a precertification has
not been approved for QUEST members.
Actimmune
Amevive
Amino acids – Aminosyn, Clinimix,
Freamine, Hepatamine, Procalamine,
Trophamine
Amrinone
Avastin
Byetta
Dobutamine
Dopamine
Erbitux
Forteo
Growth Hormone – Genotropin, Humatrope,
Norditropin, Nutropin AQ, Nutropin Depot,
Protropin, Saizen, Serostim
Intralipids
IVIG – Carimune, Flebogamma, Gamimune N,
Gammagard S/D, Gammar PI.V., Gamunex, Iveegam EN,
Panglobulin, Polygam S/D, Venoglobulin-S
Lupron
Milrinone
Pegasys
Pegintron
Raptiva
Rebetron
Remicade
Synagis
Velcade
Xolair
Zevalin
HMSA Pharmacy Newsletter
February 2006
MEDICATION THERAPY MANAGEMENT PROGRAM – COMING SOON!
The Medication Therapy Management Program (MTMP) for HMSA’s 65C Plus Prescription Drug
Coverage Plan will be coming soon. We will be recruiting a provider network starting in February in
preparation for a program launch date of May 1, 2006. Please look for upcoming mailings and
informational sessions on this new and exciting program.
HHIN DIAL-UP ACCESS TO BE DISCONTINUED
Effective May 1, 2006, the Hawaii Healthcare Information Network (HHIN) will no
longer be accessible through direct dial-up connections. If you are currently an
HHIN dial-up user, we urge you to convert to HHIN Internet service prior to May
1.
If you are not currently an HHIN subscriber, we encourage you to sign up for free
HHIN Internet service. With HHIN, you can quickly and efficiently obtain
eligibility, claims, TAD and benefit information online. In addition, you can enter
referral information and access HMSA's Provider E-Library and other references.
To start HHIN Internet service, please contact HHIN's support staff at 948-5387. For existing HHIN users,
please call 949-6446 on Oahu or (800) 760-4672 from the Neighbor Islands.
DRUG UPDATES___________________________________
LOFIBRA (fenofibrate) ADDED TO FORMULARY
On January 1, 2006, Lofibra (fenofibrate) was added to the HMSA Formulary
as a PREFERRED drug for Select plan members, TIER 2 for 65C Plus
Prescription Drug Coverage and as a FORMULARY drug for QUEST plan
members. Lofibra is available in 67, 134 and 200 MG micronized capsules as
well as 54 and 160 MG micro-coated tablets. The most commonly prescribed
fenofibrate in the formulary has been Tricor, which is classified as an OTHER
BRAND drug for the Select Plan and NON-FORMULARY for the QUEST plan.
Lofibra is approved by the FDA as therapeutically equivalent to and has the
same safety profile as Tricor, and will result in a lower copayment for
SELECT Plan members.
NEW NDC FOR MIRCETTE
A change in manufacturer for Mircette, a PREFERRED brand oral contraceptive for HMSA private business
and QUEST members, has resulted in a new NDC number. Pharmacies should be aware that there are
currently two different NDCs for Mircette that are considered Preferred. The new NDC begins with
51285. The old NDC begins with 00052. HMSA’s drug claims processor has been updated to process
Mircette claims correctly according to plan benefits.
TRIPTAN QUANTITY LIMIT CHANGES EFFECTIVE JANUARY 1, 2006
• Maxalt, Maxalt MLT
• Zomig nasal spray
9 tablets per 30 days
6 sprays per 30 days
Precertification is required when a physician wishes to prescribe quantities exceeding the limits.
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HMSA Pharmacy Newsletter
February 2006
RISPERDAL NDC CLARIFICATION
In November, 2005, a change made in First DataBank affected the NDC numbers for Risperdal. The
NDC ending in “28” (NDC 50458-0315-28) is now a non-unit dose and the NDC ending in “30” is now a
unit dose NDC.
Providers should be aware that if there are multiple NDCs for a drug and any of the NDCs are classified
as unit dose drugs, those drugs may deny as an exclusion for private business and The HMSA Plan for
QUEST Members as applicable.
LEVEMIR
Although Levemir (insulin detemir) is used to treat diabetes, it is not be classified at the same benefit
level as other insulins for the Select, 65C Plus Prescription Drug Coverage plan and QUEST plans.
Levemir will be a benefit for drug riders that currently cover insulin. It is classified as OTHER BRAND for
private business plans, TIER 3 for HMSA’s 65C Plus Prescription Drug Coverage plan, GENERIC for
Choice and Non-Formulary plans and NON-FORMULARY for QUEST.
The expected launch for Levemir is late March or early April, 2006. Levemir will be available in two
forms: FlexPen and vial.
REMINDERS____________________________________
SEASONALE DAY SUPPLY
The day supply for Seasonale should be submitted as 91. Currently, some
pharmacies are submitting claims at point-of-sale for a 90-day supply. An update
was made to HMSA’s drug claims processor to ensure claims submitted for a 91
day supply will not deny and return a maximum of 3 copayments.
NIASPAN EXCLUSIONS
In the last newsletter, we notified pharmacies that Niaspan was no longer a benefit of the Medicare
Discount Drug Card (MDDC) program. This exclusion also applies to HMSA’s 65C Plus Prescription
Drug Coverage plan.
FIXED DIFFERENTIAL FOR OTHER BRAND DRUGS
Effective January 1, 2006, a fixed “differential” of $35 per 30 days for OTHER BRAND drugs was
implemented for all Select plans except Federal Plan 87 (00F), Hawaii Employer-Union Health Benefits
Trust Fund (00S) and coverage codes 395 and 396.
Having the fixed differential in place gives the members predictability when purchasing OTHER BRAND
drugs. The member’s out-of-pocket cost will be equal to their PREFERRED brand copayment plus the fixed
differential of $35 per 30 days.
Copayments may vary between 2005 and 2006 for the same members as a result of the fixed differential
implementation. Previously, the differential was calculated as the average eligible charge of generics and
preferred drug products within the same therapeutic class for a given OTHER BRAND drug product.
Effective January 1, 2006, the fixed differential of $35 is the difference between the average eligible charge
of OTHER BRAND name drugs and the average eligible charge of GENERIC and PREFERRED drugs covered by
the association. This $35 is applied to all drugs classified as OTHER BRAND and is the amount the member
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HMSA Pharmacy Newsletter
February 2006
is responsible for in addition to the member’s PREFERRED brand copayment. For dual membership claims
(HMSA commercial plan as the primary and secondary plan), if the member receives an OTHER BRAND
drug, the secondary plan will coordinate benefits. However, in many cases, the member will still be
responsible for the $35 fixed differential.
HMSA’S 65C PLUS PRESCRIPTION DRUG COVERAGE INFORMATION
AVAILABLE ONLINE
Helpful information on HMSA’s new CMS-approved plan is available online in the Pharmacy Handbook
section of the Provider E-Library.
ARGUS PAYER SHEETS ONLINE
New Argus NCPDP Request Information Only Payer Sheets for all lines of business are now available
online in the Pharmacy Handbook section of the Provider E-Library.
MEDICARE PRESCRIPTION DRUG COVERAGE NOTICE
The Centers for Medicare & Medicaid Services (CMS) requires that a notice be made available to enrollees
instructing them on how to contact their Part D plan to obtain a coverage determination or ask for a
formulary or tier exception if the enrollee disagrees with the information provided by the pharmacist. A
printable copy of the notice is available in the 65C Plus Prescription Drug Coverage section of the online
Pharmacy Handbook.
HMSA FORMULARY UPDATE
Enclosed is the HMSA Formulary update. Please include it with your formulary reference material. The
formulary is available on the Hawaii Healthcare Information Network (HHIN) and on the Internet at
www.HMSA.com/portal/provider. Formulary changes referred to in this newsletter will not be reflected
in the online formulary until the effective date of the changes.
Updated condition codes, including 65C Plus Prescription Drug Coverage, will also be available online on
April 1 in the Formulary section of the E-Library. A printable version is also available in the same section.
CONTACT INFORMATION
Questions or comments regarding the HMSA Drug Formulary revisions may be directed to:
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. Other questions should be
directed to the applicable phone number below:
• HMSA Provider Teleservice Representatives at 948-6330 on Oahu or 1 (800) 790-4672 from the
Neighbor Islands
• HMSA Membership Connection (touch-tone eligibility verification) on Oahu at 948-6244 or 1
(800) 552-8507 from the Neighbor Islands
• The HMSA Plan for QUEST Members Provider Services at 948-6486 on Oahu or 1 (800) 440-0640
from the Neighbor Islands
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HMSA Pharmacy Newsletter
February 2006
Members with questions or concerns regarding their HMSA drug plans may call an HMSA Customer
Service representative at the following numbers:
Oahu
948-6111
Kauai
245-3393
Hilo
935-5441
Maui, Lanai, Molokai
871-6295
Kona
329-5291
QUEST members who have questions or concerns may call QUEST Member Services at 948-6486 on
Oahu or 1 (800) 440-0640 from the Neighbor Islands.
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