Download Just the Facts... - Excellus BlueCross BlueShield

Just the Facts...
A nonprofit independent licensee of the BlueCross BlueShield Association
Excellus BlueCross BlueShield, Utica Region
Volume 10.12
The newsletter for Medical Office and Facility Staff
Inside this Issue
Clarification: Radiology Codes
that Require Prior Authorization,
p. 2
Decreasing your Wait Time
When Calling Provider Service,
p. 2
Recent Product Updates, p. 3
After-hours Requirements, p.4
2005 Benefit Updates for
Medicare Blue PPO, p. 4
Updated Clinical Guidelines are
on our Web site, p. 5
December 2004
Reminder-Medical Management Changes Effective
January 1, 2005
We would like to remind you that, effective January 1, 2005, the medical
management guidelines for HMO, point-of-service and governmentsponsored safety net products will be changing.
Please be sure to review the new medical management guidelines, which
were included in the November edition of Just the Facts, as well as in a
recent provider bulletin.
If you have any questions about these requirements, please contact your
local Provider Service department.
FLRx-Changes and Updates for 2005
QM Purpose, p. 5
Coding Corner-Correct use of
BH CPT Codes 90801 and 90808,
p. 5
Helping Patients with Chronic
Conditions through HM
Programs, p. 6
We have included a new FLRx Prescribing Tip Sheet, which describes
upcoming changes in the 2005 medication guide, as well as a complete
copy of the 2005 3-Tier Medication Guide of Commonly Prescribed Drugs
in this newsletter. For additional information, please visit us on the Web at
www.excellusbcbs.com or contact your Provider Relations
Representative.
Reminder-FHP and MMC
Approvals, p. 7
Reminder-CAQH-Credentialed
Providers Need to Supply
Contract/Payment Info, p. 7
Reminder-Correct Suffix for
BluePreferred and BluePoint
Members, p. 7
Medical Policy/Protocol Update,
p. 8
Provider Call Flow Chart
FLRx Tip Sheet (Nov. 2004)
2005 3-Tier Medication Guide
www.excellusbcbs.com
Save the Date: Eating Disorders Conference in
February
As a reminder, Excellus BlueCross BlueShield, in conjunction with our
Caring for Communities program, is sponsoring the first annual New York
State Eating Disorders Initiative Conference. The conference is being
held at the OnCenter Complex in Syracuse on February 24 and 25, 2005.
The conference represents a partnership with many organizations and
individuals, among them Clear Channel Communications, New York State
Sen. John DeFrancisco and Ophelia’s Place, a nonprofit organization in
Liverpool that provides support to individuals with eating disorders, their
friends and their families.
Please join us for workshops and training sessions, including discussions
held by eating disorder experts. If you would like more information about
the eating disorders conference, please go to www.opheliasplace.org.
Clarification: Radiology Codes that Require Prior Authorization
Last April, we revised our prior authorization requirements regarding which radiology CPT procedure
codes require prior authorization. We sent a provider bulletin to physicians, imaging facilities and
chiropractors that included a list of codes. (See Provider Bulletin No. 2004-06.)
Our recent provider bulletin (#2004-17) regarding changes to our managed care medical management
guidelines effective January 1, 2005, did not include specific codes or anatomical body areas for CT,
MRA, MRI or PET scans. We have not, however, changed the CT, MRA, MRI or PET scan codes that
require prior authorization. Please continue to use the same list provided with the April
communication.
Choosing the Right Option When Calling Provider Service can Decrease
your Wait Time
Our Provider Service Department has been experiencing an
increase in the number of callers choosing option 1 once they’ve
entered the claim information queue. Choosing option 1 transfers
callers to the PPO claim unit. As you are probably aware, the
PPO claim queue is not automated, so callers are sent directly to
a provider service representative. The problem is that many
callers are choosing option 1 regardless of whether or not they
have a PPO claim issue, hoping that the representative can either
help them or transfer them to the appropriate area. This is
causing tremendous delays within Provider Service.
At this time, our representatives are trained to handle certain types of inquiries. For example, the
representatives who are able to help you with PPO questions are not the same representatives who
can help you with indemnity questions. Therefore, when a caller chooses the PPO option when the
issue is not with a PPO claim, the representative can only transfer him/her to the appropriate service
area. When this happens, the call is placed at the end of the queue. This actually increases the
caller’s wait time.
In order to decrease wait time, please be sure the telephone prompt you choose corresponds to the
product within which the member is enrolled. Once you choose option 1 to enter the claim information
queue, you will have two options, 1) PPO claims, and 2) all other claims. Your prefix list can help you
decide which option to choose. For example, you would choose option 1 for PPO claims if the prefix is
ZFA or ZFG. You can find an updated prefix list, which includes the prefix and product type, in the
October 2004 edition of Just the Facts. Additionally, please note that calls for Medicare Blue PPO
(ZFM) should be directed to the managed care queue rather than the PPO queue.
To help you better understand the options when calling Provider Service, we’ve included an updated
Provider Call Flow Chart in this newsletter.
Page 2
December 2004
Recent Product Updates
Medicare Blue PPO
We now have approval to market Medicare Blue PPO in the following counties: Broome, Cayuga,
Chemung, Chenango, Clinton, Delaware, Essex, Franklin, Fulton, Hamilton, Herkimer, Jefferson, Lewis,
Madison, Montgomery, Oneida, Onondaga, Oswego, Otsego, Schuyler, St. Lawrence, Steuben and
Tioga. We anticipate approval in other counties in 2005. It’s important to remember that Medicare Blue
PPO participating providers may provide services to any Medicare Blue PPO member even if you are not
located in one of the approved counties.
The member ID card has the words “Medicare Blue PPO” on it. The prefix is ZFM. You should collect
copays at the time of service and submit claims directly to Excellus BCBS. You do not need to bill
Medicare first. Primary payment is made by Excellus BCBS.
For additional information, please refer to the September edition of Just the Facts, or call your local
Provider Service.
FourFront
As you may recall, we recently introduced a new product called “FourFront.” FourFront is an innovative,
consumer-driven health care plan that encourages members to take good care of themselves while
making wise, cost-conscious decisions. Because FourFront is based on our EPO product, members
have access to our BluePPO network, including BlueCard.
The name FourFront hints at the unique benefit design, which follows the “rule of four” for the first four
diagnostic office visits and first $400 of diagnostic lab and X-ray.
Diagnostic Office Visits
•
The first four diagnostic office visits are covered at a low office copay.
•
Preventive care is covered in full or with a low office copay; it is not included in the first four visits,
and is never subject to deductible or coinsurance.
•
The fifth and subsequent diagnostic office visit is subject to coinsurance and deductible.
Diagnostic Lab and X-ray
•
The first $400 of diagnostic lab and X-ray services are covered in full.
•
After the allowance is used, coinsurance and deductible applies.
Providers should always collect at least the office copay at the time of service (the remittance will
indicate if the visit is subject to deductible or coinsurance). Providers can identify members by their ID
card, which has the name “FourFront” on it. The prefix is ZFF.
For additional information, please refer to the August edition of Just the Facts, Provider Bulletin No.
2004-12, or call your local Provider Service.
BluePPO HSA
Effective January 1, 2005, Excellus BCBS will be introducing a new version of our BluePPO product.
BluePPO HSA is a high-deductible health plan that can be combined with a health savings account
(HSA). Members will utilize the BluePPO network, including BlueCard. Additionally, both the prefix (ZFA)
and the prior authorization requirements will be the same as BluePPO; however, the ID card will say
“HSA." Please note that the HSA indicator on the ID card tells you that the member is in a high
deductible PPO plan. The member may or may not have an actual HSA account.
For additional information, please refer to the October edition of Just the Facts, or call your local Provider
Service.
December 2004
Page 3
After-hours Coverage Requirements
In order to provide members with access to care 24 hours a day,
seven days a week, Excellus BlueCross BlueShield has made a
determination of what constitutes acceptable versus unacceptable
methods of after-hours coverage for managed care PCPs and
specialists. (For behavioral health providers, acceptable methods
differ from those for other providers. A listing of acceptable behavioral
health after-hours methods of contact can be found in the November
edition of Just the Facts.)
Members must be able to:
•
•
Reach the practitioner or a person with the ability to patch the call through to the practitioner (i.e.,
answering service); or
Reach an answering machine with instructions on how to contact the practitioner or his/her backup
(i.e., message with number for home, cell phone or beeper).
Unacceptable means of after-hours coverage include the following:
• An answering machine with instructions on how to contact the practitioner, but no live voice at the
contact phone number;
• An answering machine with instructions to go to or to call the emergency room;
• An answering machine that recommends calling during business hours;
• An answering machine with no instructions;
• No answer;
• A busy signal three times within 30 minutes.
PCPs and physician specialists, please be sure that you are compliant with one of the
acceptable methods of after-hours contact.
2005 Benefit Updates Planned for Medicare Blue PPO
Pending approval from CMS, we are planning some enhancements to our Medicare Blue PPO
product options during 2005. These are based on feedback from informational meetings we’ve hosted
for the Medicare-eligible population, as well as from current members.
Among the changes we plan to make are:
• An unlimited $10 generic drug benefit with discounts on brand drugs for Plan Two
• Fixed copays rather than coinsurance for Plan Two
• Lower copays for Plan Three
• A flexible fitness benefit where members will be reimbursed up to $40 per month (depending on
the plan) for a variety of fitness and/or qualified weight management programs
• Round-the-clock access to a “personal health coach” – a registered nurse, respiratory therapist or
dietician who can answer members questions about medications they are taking, health food
choices and other health-related topics.
Look for further information in future issues of this newsletter.
Page 4
December 2004
Updated Clinical Guidelines are Available on our Web site
We’ve recently updated the following clinical guidelines:
•
Prenatal Care
•
Anticoagulation Principles
•
Asthma
They are available on our Web site at www.excellusbcbs.com,
along with many other clinical practice guidelines and materials.
Click on For Providers, then on Patient Care. Select Clinical
Practice Guidelines from the menu on the left. Scroll down to the
guideline you need.
To have a paper copy of guidelines or other materials mailed to you, please contact our Quality
Management Department at (315) 671-7140.
QM Purpose to Improve Quality of Life
The purpose of our Quality Management Program is to support our mission by contributing to, and
being recognized for, improving the quality of life in the communities we serve. The program works in
partnership with our members, our participating physicians and other health care practitioners, as well
as with community agencies, to improve quality of care and services delivered to our members.
Evaluation of our success is the ability to measurably improve the health and satisfaction of the
population we serve.
If you would like a copy of our QM Program Description or most recent program evaluation, please
contact the Quality Management Department at (315) 671-7140.
CODING CORNER
Correct use of Behavioral Health CPT Codes 90801 and 90808
Our Behavioral Health Department has noticed that some behavioral health practitioners occasionally
bill 90801, psychiatric diagnostic interview examination, more than once for an initial assessment of
the same patient. While components of a diagnostic interview may be part of all therapy sessions,
practitioners should use procedure code 90801 for only the initial diagnostic examination.
The same provider can rebill 90801 for the same patient only after a 12-month break in treatment. The
exception to this is for child psychiatrists who see children and adolescents. We recognize that the
initial assessment of these patients is more time-consuming. Therefore, child psychiatrists may use
90801 for a maximum of two sessions, where necessary, for initial assessment of a child or
adolescent.
CPT procedure code 90808 is for an extended face-to-face contact (75-80 minutes). This amount of
time is not necessary for routine care and should only be used in unusual circumstances. The clinical
record should reflect the exceptional nature of this extended visit, with specific clinical justification.
Excellus BCBS behavioral health staff members review these CPT codes for utilization and make
appropriate adjustments when needed.
December 2004
Page 5
Helping Patients with Chronic Conditions through Health Management
Programs
Excellus BlueCross BlueShield is committed to helping patients
with chronic conditions through our health management (HM)
programs. We have developed HM programs for the following
chronic diseases: asthma, coronary artery disease, diabetes,
and depression.
We have designed our integrated, population-based health
management programs to help members with the above chronic
conditions become more proactive when managing their
conditions.
The programs use a systematic approach to improving the
health care of people with these chronic diseases. We have
established evidence-based guidelines for each of these chronic
diseases in order to provide information and direction for managing the disease. The goal of each
disease-specific program is to enhance the primary care physician’s ability to provide excellent care to
his/her patients with the disease.
Member Education
One of the prime components of each health management program is member education. Members
benefit from educational programs such as mailed and telephoned reminders specific to their chronic
disease. Information regarding standards of care is routinely distributed through these targeted
reminders and also through other educational tools and newsletters. Periodic reminders to obtain
screening services recommended for optimal health management, per evidence-based clinical
guidelines, are also sent to members.
Practitioner Support
Support for practitioners is available through various tools designed to assist practitioners with their
patient communications and management. Information explaining the function and purpose of the
support tools, how to contact the Plan for patient referrals into the program as well as answers to
other questions, is included in materials distributed to practitioners.
Physician CME programs may also be provided at various times throughout the year. Evidence-based
clinical guidelines that provide standards of care from which the programs are based can also be
accessed through the Web site (www.excellusbcbs.com). Most of the clinical guidelines also include
useful tools and patient education sheets. The patient sheets are also available in Spanish.
Physicians are encouraged to browse the Web site as a source of clinical care and health
management program information.
Please call us
Health management programs are free to members and participating health care practitioners.
Please contact us at 1 (877) 586-1990 with any questions, concerns, or patient referrals. Our goal is
to provide health care practitioners and their patients with a quality and comprehensive approach to
managing chronic disease.
Page 6
December 2004
Reminder: Family Health Plus and Medicaid Managed Care Approvals
We have been introducing Family Health Plus (FHP) and HMOBlue
Option (Medicaid managed care) on a county-by-county basis since
2000. We currently have membership in the following counties: Oneida,
Onondaga, Oswego and Herkimer. Additionally, we have FHP members
in Clinton, Essex and Franklin counties.
Pending approval, we will continue to introduce Family Health Plus and
HMOBlue Option on a county-by-county basis throughout 2005. Please
remember that, with our seamless network, you may see FHP and
HMOBlue Option members from the active counties regardless of whether or not your specific county
is enrolling members.
Reminder: CAQH-Credentialed Providers Still Need to Supply
Contract/Payment Info
If you are a participating provider using the Council for Affordable Quality Healthcare’s (CAQH)
universal credentialing data source, please remember that you still need to inform Excellus BlueCross
BlueShield directly, in writing, of any changes in your practice such as address, telephone number, or
tax ID. We need this information for directories and/or claims processing systems (separate from
CAQH, which is strictly for credentialing and recredentialing). As a convenience, you may use the
Provider Information Update form, available on our Web site. You may also contact your Provider
Relations Representative for a copy. Addresses and fax numbers for returning the completed form are
listed at the end of the form.
Reminder: Please use Correct Suffix for BluePreferred and BluePoint
(POS) Members
Since discontinuing the old claim system for local PPO and POS products in Central New York (CNY)
and CNY Southern Tier, we have found that some providers are still submitting with the old member
ID suffix. We have noticed this specifically with claims for members with prefixes SYU or ONC.
Providers in the Utica region may also see members with the prefixes SYU or ONC.
We would like to remind you that the suffix for BluePreferred and BluePoint (POS) subscribers is “00."
Suffixes for dependents would be "01, 02, etc." Please ask your patients for their ID card and use the
appropriate suffix.
As always, it is extremely important to check the member’s ID card, as it contains vital information that
can help to process claims more efficiently.
December 2004
Page 7
Important Addition to Medical Policy Update Section
Beginning with this issue of Just the Facts, we are including a brief description of Medicare coverage when
significant differences exist for high volume/high profile Health Plan medical policies and medical policies
maintained by the Centers for Medicare & Medicaid Services (CMS) for determining coverage under Medicare.
Please note that the absence of a comparison with CMS coverage determinations does not necessarily
constitute an agreement in coverage between CMS and the Health Plan.
Medical Policy/Protocol Update
To ensure that the development of corporate medical policies occurs through an open, collaborative process,
we encourage our participating practitioners to become actively involved in medical policy development. Each
month, draft policies are posted in the Provider section of our Web site (www.excellusbcbs.com) for
participating practitioners’ review and comment. Click on For Providers, then select the Patient Care button
along the top, and then View Our Medical Policies. At the bottom of the menu on the left side is a short list
under Medical Policies. Click on Preview & Comment on Draft Policies. The following policies are tentatively
scheduled to be available for comment in December 2004:
•
•
•
•
•
•
•
Allergy Immunotherapy
Biochemical Markers for Bone Turnover
Cardiac Bioimpedance
H Pylori Testing
HPV Testing
Preconception and Prenatal Genetic Testing/Counseling and Preimplantation Genetic Diagnosis
Wireless Endoscopy
Corporate medical policies are used as a guide. Coverage decisions are made on a case-by-case basis and in
accordance with the member's contract. While a technology or service may be medically necessary, payment
of benefits is subject to the member's eligibility on the date the service is rendered and the benefit/exclusion
provisions of the member's contract. Before rendering care, providers should verify the member's eligibility
and coverage by calling the Provider Service Department of your local plan.
The following new and updated medical policies have been reviewed and approved by the Corporate Medical
Policy Committee, including practitioner representatives from Excellus BlueCross BlueShield, Central New
York Region, Central New York Southern Tier Region, Utica Region, and Rochester Region.
Complete detailed policies are available on our Web site at www.excellusbcbs.com. Click on the
Patient Care menu option, then on View Our Medical Policies. Questions regarding medical policies may
be directed to your Provider Relations representative or to the Provider Service Department of your local health
plan.
Medical policies are also located on the Web site for Excellus BlueCross BlueShield members at
www.excellusbcbs.com. To access our policies, members need to click on For Members, followed by Health
and Wellness, then Research Health Conditions and lastly View our Medical Policies.
Policies and protocols referenced in this newsletter are written for commercial contracts only. A brief
description of CMS coverage has been provided for particular Excellus BlueCross BlueShield medical policies
that differ from CMS. Please refer to CMS for medical policies pertaining to Senior contracts. Web sites for
review of CMS policies are:
•
•
www.cms.hhs.gov/mcd/indexes.asp for the Medicare Manual
http://www.umd.nycpic.com/lmrp.html for local Upstate New York Medicare policies.
Please note: Although medical policies are effective on the date they are approved by the Medical Policy
Committee, updates to the claims processing systems may not occur for up to 90 days in order to allow you to
update your billing systems accordingly.
NEW POLICIES recently approved by Corporate Medical Policy Committee
There were no new policies this reporting period.
CURRENT POLICIES recently updated by Corporate Medical Policy Committee
Excimer Laser for the Treatment of Psoriasis treats only specific areas of the body with a concentrated
narrow beam of ultraviolet light. Excimer laser for psoriasis has not been proven to be effective in improving
clinical outcomes and is considered investigational. There have been no studies to provide comparative
outcomes or assessment of long-term outcomes of this treatment.
Positron Emission Tomography (PET) for Non-Oncologic Conditions (considered a high profile policy; we
are highlighting where the Excellus BlueCross BlueShield policy differs from CMS) is an imaging technology
that can reveal both anatomical and metabolic information in various tissue sites. PET is considered medically
appropriate as a diagnostic tool for several conditions/disorders, as outlined in the policy. Research on the
current update focused on its use in Alzheimer’s disease/dementia. Based upon our review and analysis, the
use of a PET scan has not been proven effective in improving patient outcomes (even in subsets) and is
considered investigational as a diagnostic tool for Alzheimer’s disease. CMS recently published a Decision
Memorandum regarding FDG-PET in the diagnosis and treatment of mild cognitive impairment (MCI) and early
dementia in elderly patients, which states the following: evidence is adequate to conclude that a FDG-PET
scan is reasonable and necessary in patients with documented cognitive decline of at least six months and a
recently-established diagnosis of dementia who meet diagnostic criteria for both Alzheimer’s disease (AD) and
fronto-temporal dementia (FDD), who have been evaluated for specific alternate neurodegenerative diseases
or causative factors, and for whom the cause of the clinical symptoms remains uncertain. CMS has also
determined that the evidence is not adequate to conclude that FDG-PET is reasonable and necessary for the
diagnosis of patients with mild cognitive impairment (MCI) or early dementia in clinical circumstances other
than that specified above, absent safeguards that would be present in formal, protocol-driven clinical
investigations. CMS would cover PET for these patients in a setting of a clinical trial that met specific criteria
set by CMS.
Pulmonary Rehabilitation (considered a high profile policy; we are highlighting where the Excellus BlueCross
BlueShield policy differs from CMS) is an individualized, multidisciplinary therapeutic program to improve the
quality of life and functional capacity of patients with chronic lung disease. Pulmonary rehabilitation is medically
appropriate for COPD patients with the following characteristics:
•
•
•
•
undergoing lung transplantation or lung volume reduction surgery; or
have moderate COPD and multiple exacerbations; or
have severe COPD; and
do not have a short life expectancy or a condition that would prohibit safe participation in the program; have
the mental stability, motivation and physical mobility to attend sessions and complete the program; and
require a medically-comprehensive, supervised pulmonary exercise program.
The local CMS policy addressing Pulmonary Rehabilitation states that, while there is no benefit category for
payments to be made for these services, Medicare does recognize that there are components of the programs
that are reimbursable when medically necessary.
Signal-averaged Electrocardiogram (SAECG) and T-Wave Alternans (TWA) have been evaluated as
technologies that stratify patient risk for fatal ventricular arrhythmias. SAECG is a modification of a
conventional ECG recording in which the signals are first amplified, then filtered, and finally averaged with the
assistance of computer software. TWA is a beat to beat measurement of the magnitude and morphology of
the ECG measurement of repolarization in the ST segment and T-wave. Based upon our criteria and
assessment of peer-reviewed literature, neither signal-averaged electrocardiography nor T-Wave Alternans
improve patient outcomes and, therefore, are considered not medically necessary for risk stratification
regarding ventricular arrhythmia in patients following acute myocardial infarction. The evidence demonstrates
that SAECG and TWA have little clinical value in selecting patients who are at high risk for an arrhythmic
event. Evidence is also lacking to demonstrate that the information could be used to alter treatment strategy
and improve health outcomes.
CURRENT POLICIES recently updated with minimal changes
The following policies only required minimal changes (e.g., updating of references, changing language to meet
legal needs). The coverage intent of the policies was not altered. These policies were recently approved
for updating by the Health Plan Medical Directors and are available on our Web site:
•
•
•
•
Intervertebral Disc Decompression techniques
Photodynamic Therapy for Malignant Conditions
Transendoscopic Therapies for Gastroesophageal Reflux Disease (GERD)
Home Automatic External Defibrillators (AED) and Wearable Defibrillator (WCD) Vests
NEW PROTOCOLS recently approved by Corporate Protocol Committee
The Oximetry and Oximeters for Home Use protocol provides coverage criteria for the use of short-term,
home-based oximetry (e.g., overnight oximetry) and for the use of home oximeters for long-term, continuous
monitoring.
CURRENT PROTOCOLS recently updated by Corporate Protocol Committee
Enteral Nutrition formulas consist of nutritional liquids administered by mouth or enterally. This protocol
provides coverage information for conditions as required by the New York Insurance Law mandate.
External Insulin Pumps are utilized by diabetic patients for continuous insulin infusion. These pumps contain
an insulin-filled syringe connected to a catheter that is inserted into a patient’s subcutaneous tissue. External
insulin pumps are considered medically appropriate when specific criteria are met as outlined within the
medical protocol. The criteria for coverage have been expanded with our recent review. Our medical protocol
mirrors the regional CMS coverage criteria related to external insulin pumps.
Hospital Beds provide the positioning required for a patient with certain medical condition(s). Hospital beds
are considered durable medical equipment and are medically appropriate when:
•
•
•
The patient's condition requires positioning of the body (such as the head or foot of bed elevated to
alleviate pain, promote good body alignment, prevent contractures, avoid respiratory infections) in ways not
possible in an ordinary bed; or
The patient's condition requires a bed height different than an ordinary bed to permit transfers from bed to
chair or bed to standing; or
The patient's condition requires special attachments that cannot be fixed and used on an ordinary bed.
The Respiratory Therapy Devices protocol provides definitions and the medical appropriateness of various
devices (e.g., nebulizers, peak flow meters) used in the treatment of respiratory conditions.
165 Court Street
Rochester, NY 14647
A nonprofit independent licensee of the BlueCross BlueShield Association
Prescribing
Tip Sheet
November 2004
Prescription Drug Medication Guide Changes for 2005
Excellus BlueCross BlueShield is committed to effectively managing prescription drug
benefit costs and providing our members with affordable access to prescription drugs. One
way we do this is by having our medication guides reflect the latest in clinical developments,
effectiveness, quality and value.
Our Pharmacy and Therapeutics Committee, which is made up of practicing community
physicians and clinical pharmacists, regularly reviews the drugs on the 3-Tier list. Its most
recent evaluation has resulted in changes of tier classifications for a small number of
medications effective January 1, 2005. A summary of those changes is printed on the
reverse.
PRESCRIBING GUIDELINES
♦ For new prescriptions: please refer to reclassifications effective January 1, 2005 when
considering prescription options.
♦ For patients with a 3-Tier benefit: Patients on medications that are being reclassified will
continue to have coverage and will pay the applicable lower or higher copayment/
coinsurance amount based on reclassification effective January 1, 2005. If you decide to
prescribe a Tier 3 medication the medication will be covered, but at the higher copayment/
coinsurance cost.
♦ For patients with a closed formulary benefit: Medications that are being reclassified as nonformulary generally will not be covered under the benefit. If you decide to prescribe a nonformulary medication, authorization will be required for coverage.
♦ This is not a benefit change or a mandate. Patients are not required to change
medications.
Patients whose medications are being reclassified from Tier 2 (lower copayment/
coinsurance) to Tier 3 (higher copayment/coinsurance) and from formulary (covered) to nonformulary (generally not covered) will be notified later this fall.
Summary of Formulary Reclassifications
Effective January 1, 2005
for Prescribers
3-Tier Medication Guide Reclassifications:
Drugs Reclassified from Tier 3 to Tier 2
Reclassification Decreases member Co-Payment/Coinsurance Amount
Therapeutic Class
Asthma
Cardiovascular/Heart: Diuretics
Growth Hormone
Intranasal Steroids/Antihistamines/Misc.
Migraine
Stomach: Inflammatory Bowel
Drug Reclassified to Tier 2
Foradil
Zaroxolyn
Norditropin
Astelin
Amerge
Dipentum
Drugs Reclassified from Tier 2 to Tier 3
Reclassification Increases member Co-Payment/Coinsurance Amount
Therapeutic Class
Antipsychotics
Men’s Health: Erectile Dysfunction
Mental Health: Antidepressants
Thyroid
Women’s Health: Oral Contraceptives
Drug Reclassified to Tier 3
NEW STARTS ONLY: AbilifyV, ZyprexaV
Viagra
Paxil 20mg, 30mg
Synthroid
Levlen, Levlite, Modicon, Ortho-Cept, OrthoCyclen, Ortho Micron, Ortho-Novum, Tri-Levlen,
Triphasil
Generic now available
V Tier 2 for select prescribers/diagnoses
Formulary Guide Reclassifications:
Drugs Reclassified from Non-Formulary to Formulary
Drugs classified as Formulary are generally covered under the benefit
Therapeutic Class
Drug Reclassified
Allergy
Astelin
Asthma
Foradil
Cardiovascular/Heart: Diuretics
Zaroxolyn
Growth Hormone
Norditropin
Migraine
Amerge
Stomach: Inflammatory Bowel
Dipentum
Drugs Reclassified from Formulary to Non-Formulary
Drugs classified as Non-Formulary are generally not covered under the benefit
Therapeutic Class
Mental Health: Antidepressants
Thyroid
Women’s Health: Oral Contraceptives
Generic now available
9.1.04
Drug Reclassified
Paxil 30mg, 40mg
NEW STARTS ONLY: Synthroid
Cylessa, Levlen, Levlite, Modicon, Ortho-Cept,
Ortho-Cyclen, Ortho Micron, Ortho-Novum,
Tri-Levlen, Trinorinyl, Triphasil
2005: 3-Tier Medication Guide of Commonly Prescribed Drugs
The designation of drugs in the following categories is for reference only and is not a clinical comparison.
Drug placement does not establish clinical comparability of products in individual situations.
This list provides examples within categories and is not comprehensive.
A nonprofit independent licensee of the BlueCross BlueShield Association
DRUG CLASS
Tier 1
Tier 2
Tier 3
ALLERGY
Antihistamines (oral)
Antihistamine/Decongestant
Combinations
Intranasal: Steroids/
Antihistamines/
Miscellaneous
ALZHEIMER’S
ARTHRITIS*
ASTHMA
Inhaled Beta Agonists/
Inhaled Respiratory Agents
Inhaled Steroids
Leukotriene Inhibitors
Respiratory Drugs (oral)
ATTENTION DEFICIT
DISORDER
BLOOD
Anticoagulants
Antiplatelet
Anemia*
CANCER
CARDIOVASCULAR / HEART
ACE Inhibitors
(high blood pressure)
Angiotensin II Receptor
Blockers (high blood pressure)
Antiarrhythmics
(for normal heart rhythm)
Antihyperlipidemics
(high cholesterol)
Antihypertensive
Combinations
(high blood pressure)
Beta Blockers
(high blood pressure)
Calcium Channel Blockers
Diuretics
(highest member co-payment)
Drugs listed CAPITALIZED IN BOLD/ITALICS are considered
NON-FORMULARY under the closed formulary benefit
(lowest member co-payment)
clemastine, cyproheptadine,
diphenhydramine, hydroxyzine
R-Tanna
No drugs listed at this time
Allegra, CLARINEX, Zyrtec
No drugs listed at this time
ALLEGRA-D, OPTIMINE, RYNATAN SA, SEMPREX-D, TRINALIN,
ZYRTEC-D
flunisolide, ipratropium nasal
spray
Astelin, Beconase AQ, Flonase,
Nasonex, Rhinocort AQ
ATROVENT NASAL SPRAY, NASACORT, NASACORT AQ,
NASAREL, NASALIDE, TRI-NASAL, VANCENASE, VANCENASE AQ,
VANCENASE DS
No drugs listed at this time
Aricept
COGNEX, EXELON,
azathioprine, cyclophosphamide,
gold, hydroxychloroquine,
methotrexate, penicillamine,
sulfasalazine
No drugs listed at this time
Arava, Enbrel§, Humira§, Kineret§, RHEUMATREX
albuterol, cromolyn sodium,
metaproterenol solution
No drugs listed at this time
Atrovent Inhaler, Combivent, Intal,
Foradil, Pulmozyme, Serevent
Azmacort, Beclovent, Flovent,
Pulmicort
Singulair (Tier 2 if asthmatic)
No drugs listed at this time
Advair, MAXAIR, MAXAIR AUTOHALER, PROVENTIL, PROVENTIL
HFA, Spiriva, TILADE, TORNALATE, VENTOLIN, XOPENOX
Advair, AEROBID, AEROBID M, QVAR, VANCERIL, VANCERIL DS
No drugs listed at this time
ADDERALL, Adderall XR, Concerta, DEXEDRINE,
DEXEDRINE SPANSULES, DEXTROSTAT, FOCALIN,
METADATE CD, RITALIN, RITALIN LA, Strattera
heparin, warfarin
dipyridamole
No drugs listed at this time
Coumadin
Agrylin, Plavix
Epogen§, Neupogen, Procrit§
ARIXTRA, FRAGMIN, INNOHEP,
methotrexate, tamoxifen
All brands are Tier 2
No drugs listed at this time
benazepril, captopril, enalapril,
fosinopril, lisinoprilp, moexepril
Altace
No drugs listed at this time
Avapro\, Diovan
§, ACEON§, CAPOTEN§, LOTENSIN§, MAVIK,
§, PRINIVIL§, UNIVASC§, VASOTEC§, ZESTRIL§
ATACAND, BENICAR, COZAAR§, MICARDIS, TEVETEN
amiodarone, digoxin,
disopyramide, mexiletine,
procainamide, quinidine, sotalol
cholestyramine, clofibrate,
(20mg only)
gemfibrozil, lovastatinp
Betapace AF, Lanoxin, Rythmol,
Tonocard
Betapace, CORDARONE, MEXITIL, NORPACE CR, PROCAN,
Procanbid, PRONESTYL, QUINIDEX, QUINIGLUTE, TAMBOCOR,
No drugs listed at this time
albuterol, metaproterenol,
theophylline
dextroamphetamine, methylin,
methylin ER, methylphenidate
benazepril/HCTZ,
bisoprolol/HCTZ, captopril/HCTZ,
enalapril/HCTZ,
fosinopril/HCTZ, lisinopril/HCTZ,
quinapril/HCTZ
(25mg only)
acebutolol, atenololp
,
bisoprolol, labetolol, metoprolol,
nadolol, propranolol, propranolol
solution, pindolol, timolol
diltiazem, diltiazem-XR,
nicardipine, nifedipine,
Taztia XT, verapamil,
verapamil (SR)
amiloride, furosemide,
(25mg only)
hydrochlorothiazidep
,
indapamide, spironolactone,
triamterene/hydrochlorothiazide
ACCOLATE
Namenda, Reminyl
§
ALUPENT, BRETHINE, PROVENTIL SA, T-PHYL, THEO-DUR,
UNIPHYL, VOLMAX
AGGRENOX,
Lovenox
Pletal, TICLID, TRENTAL
Aranesp§
ACCUPRIL
MONOPRIL
TIKOSYN
§, ADVICOR, CADUET§, COLESTID, CRESTOR§\,
§, LESCOL XL§, MEVACOR§, PRAVIGARD, QUESTRAN,
Lipitor\, Lofibra, Niaspan,
Pravachol\, Tricor, Vytorin,
Zocor\, Zetia
ALTOCOR
LESCOL
Welchol
§, ATACAND HCT, BENICAR HCT, CADUET§,
§, HYZAAR§, LEXXEL, LOPRESSOR HCT,
LOTENSIN HCT§, LOTREL, MICARDIS HCT, MONOPRIL HCT§,
PRINZIDE§, TARKA, TECZEM, TENORETIC, TEVETEN HCT,
UNIRETIC§, VASERETIC§, ZESTORETIC§, ZIAC
Avalide, Diovan HCT
ACCURETIC
CAPOZIDE
Coreg, Toprol XL 25mg, 50mg\,
100mg, 200mg
CORGARD, Inderal LA, INNOPRAN XL, KERLONE, LEVATOL,
LOPRESSOR, SECTRAL, TENORMIN, TRANDATE, VISKEN,
ZEBETA
Norvasc: (Tier 2 if age 55 or older
ADALAT CC, CALAN, CALAN SR, CARDENE, CARDENE SR ,
CARDIZEM, CARDIZEM CD, CARDIZEM LA , COVERA, COVERA HS,
§
and on concurrent ACE/ARB therapy
or on nitrate therapy)
§, PLENDIL§,
§, TIAZAC, VERELAN, VERELAN PM
DILACOR XR, DYNACIRC, DYNACIRC CR
PROCARDIA XL, SULAR
Zaroxolyn
ALDACTONE, BUMEX, DEMADEX, DYAZIDE, DYRENIUM,
§, LOZOL, MAXZIDE
HYDRODIURIL, HYGROTON, INSPRA
1
Co-payment/Coinsurance for each tier is based on the specific rider chosen by the employer group.
The majority of benefits include additional member payment when a brand drug is used and a generic equivalent is available.
ƒ
Brand drugs not listed are considered Tier 3. All compounds are considered Tier 3.
§ = Requires Prior Authorization
\ = Half Tablet opportunity: Certain strength tablets may be split to obtain lower dosage and reduce member out-of-pocket cost
ƒ
ƒ
* = Select self-injectable medications within this drug class are available through national specialty pharmacies CuraScript Pharmacy and Priority Healthcare
p
V
= Generic Trial opportunity: For select doses of these medications member copayment is waived for a two-week trial prescription
= Tier 2 for select prescribers/diagnoses
B-1462y5 10/6/04
List Subject to Change
DRUG CLASS
Tier 1
Tier 2
Tier 3
(highest member co-payment)
Drugs listed CAPITALIZED IN BOLD/ITALICS are considered
NON-FORMULARY under the closed formulary benefit
(lowest member co-payment)
Nitrates (angina)
Numerous generics
No drugs listed at this time
Potassium Supplements
CENTRAL NERVOUS
SYSTEM
COUGH / COLD
Antitussives and
Expectorants
potassium chloride generics
pemoline
Urocit-K
No drugs listed at this time
benzonatate, guiafenesin
products, hydrocodone products
No drugs listed at this time
AMIBID LA, DURATUSS G, HUMABID LA,
Antitussive Combinations
gauifenesin/codeine,
hydrocodone/homatropine,
promethazine/codeine
No drugs listed at this time
GENESIN DM, GUAITUSS AC, HISTUSSIN, HISTUSSIN HC,
HYCODAN, HYCOTUSS, PHENERGAN W/CODEINE,
RONDEC-DM
No drugs listed at this time
No drugs listed at this time
benzoyl peroxide, clindamycin,
erythromycin,
erythromycin/benzoyl peroxide,
isotretinoin, sulfacetamide,
tretinoin products, tetracycline
bacitracin/polymyxin,
erythromycin, gentamycin,
mupirocin ointment, neo/poly,
tobramycin
ketoconazole cream,
ketoconazole shampoo,
mycostatin,
triamcinolone/nystatin,
betamethasone/clotrimazole
betamethasone, clobetasol,
dexamethasone, fluocinolone,
fluocinonide, hydrocortisone,
triamcinolone
selenium sulfide
No drugs listed at this time
ENBREL§, RAPTIVA§, SORIATANE
Accutane, A/T/S, AVITA, AZELEX, BenzaClin,
Benzamycin, CLEOCIN T, DESQUAM E, Differin, EMGEL,
DEPONIT, IMDUR, ISMO, MONOKET, NITREK, NITRODISK,
NITRO-DUR, TRANSDERM-NITRO
K-DUR, K-LYTE, K-TAB, MICRO-K, SLOW K
CYLERT,
Desoxyn, DEXEDRINE, DEXEDRINE SPANSULES,
Provigil§, Xyrem§
Tussionex
DERMATOLOGY
Psoriasis Products*
Topical/Oral Acne Products
Topical Antibiotics
Topical/Combination
Antifungals
Topical/ Oral Steroids
Topicals: Psoriasis/Eczema
DIABETES
Blood Glucose Supplies
Insulin
FINACEA, FINEVIN, KLARON, METROCREAM, METROGEL,
NOVACET, RETIN-A, SULFACET-R, T-STAT
Bactroban cream
BACTROBAN OINTMENT, EMGEL, NORITATE, SILVADENE
No drugs listed at this time
EXELDERM, LOPROX, LOTRIMIN, LOTRISONE, MENTAX,
MYCELEX, MYCOLOG II, NAFTIN, NIZORAL CREAM,
NIZORAL SHAMPOO, OXISTAT, SPECTAZOLE
Capex Shampoo, Florinef
ACLOVATE, CLODERM, CORDRAN, Cordran Tape, Cutivate,
CYCLOCORT, DECADRON, DESOWEN, DIPROLENE/AF, ELOCON,
FLORONE/E, HALOG/E, LOCOID, MEDROL DOSE PACK, PANDEL,
PSORCON/E, TEMOVATE, TOPICORT, ULTRAVATE, UTICORT
Dovonex, Drithocreme
CAPITROL,
Elidel, Protopic, Selsun, Tazorac
Diabetic benefit and/or DME benefit applies: Preferred Meters are: Accu-check Active, Accu-check Advantage,
Accu-check Compact, Accu-check Complete, One Touch Sure Step, One Touch Ultra (All meters are paid through DME Benefit)
DIABETIC BENEFIT APPLIES FOR ALL INSULINS
If Diabetic benefit DOES NOT apply please refer to the following tier classifications:
No drugs listed at this time
Oral Hypoglycemics
Humalog, Humulin, Lantus,
No drugs listed at this time
Novolin, Novolog
DIABETIC BENEFIT APPLIES FOR ALL ORAL HYPOGYLCEMICS
If Diabetic benefit DOES NOT apply, please refer to the following tier classifications:
EAR
ENTERAL FORMULAS
EYE
Ophthalmic Antiallergics
Ophthalmic Antiinfectives
Ophthalmic
Anti-Inflammatory
Ophthalmic Antivirals
Ophthalmic Combinations
glipizide, glipizide ER, glyburide,
glyburide/metformin, metformin,
metformin XR
Numerous generics
Cipro HC and Floxin Otic
AURULGAN, CERUMENEX, CORTISPORIN, PEDIOTIC, VOSOL,
VOSOL HC
No drugs listed at this time
PKU Formulas§
All branded enteral products§
cromolyn sodium
Optivar, Zaditor, Acular,
Acular PF
No drugs listed at this time
ALAMAST, ALOCRIL, ALOMIDE, ALREX, EMADINE, LIVOSTIN,
OPTICROM, PATANOL
bacitracin, bac/poly/neo,
ciprofloxacin, neosporin,
ofloxacin, polysporin, erythro,
gent, sodium sulfacetamide,
TMP/pol, tobra
dexameth, dexa/neo,
fluorometholone, flurbiprofen,
prednisolone
No drugs listed at this time
neomycin, neomycin/polymixin,
dexamethasone sodium
phosphate solution
Actos, Amaryl, Avandia, Glyset,
Prandin, Precose, Starlix
Avandamet, DIABETA, GLUCOPHAGE, GLUCOPHAGE XR,
GLUCOTROL, GLUCOTROL XL, GLUCOVANCE, GLYNASE,
Metaglip, MICRONASE
CHIBROXIN, CILOXAN, OCUFLOX, QUIXIN,
VigamoxV,
ZymarV
Lotemax, Voltaren, PredForte
FML FORTE, OCUFEN, VEXOL
Vira A, Viroptic
FML-S, Poly-Pred
No drugs listed at this time
HMS, PRED-G, TobradexV
2
Co-payment/Coinsurance for each tier is based on the specific rider chosen by the employer group.
The majority of benefits include additional member payment when a brand drug is used and a generic equivalent is available.
ƒ
Brand drugs not listed are considered Tier 3. All compounds are considered Tier 3.
§ = Requires Prior Authorization
\ = Half Tablet opportunity: Certain strength tablets may be split to obtain lower dosage and reduce member out-of-pocket cost
ƒ
ƒ
* = Select self-injectable medications within this drug class are available through national specialty pharmacies CuraScript Pharmacy and Priority Healthcare
p
V
= Generic Trial opportunity: For select doses of these medications member copayment is waived for a two-week trial prescription
= Tier 2 for select prescribers/diagnoses
B-1462y5 10/6/04
List Subject to Change
DRUG CLASS
Tier 1
Tier 2
Tier 3
Glaucoma
GOUT
GROWTH HORMONES*
carbachol, carteolol, dipivefrin,
levobunolol, pilocarpine, timolol,
timolol XE
allopurinol, colchicine,
colchicine/probenecid,
probenecid, sulfinpyrazone
No drugs listed at this time
(highest member co-payment)
Drugs listed CAPITALIZED IN BOLD/ITALICS are considered
NON-FORMULARY under the closed formulary benefit
(lowest member co-payment)
Alphagan P, Lumigan, Trusopt,
Xalatan
AZOPT, BETAGAN, BETIMOL, BETOPTIC, BETOPTIC-S, COSOPT,
IOPIDINE, OCUPRESS, OPTIPRANOLOL, PILOPINE GEL, PROPINE,
RESCULA, TIMOPTIC, TIMOPTIC XE, TRAVATAN
No drugs listed at this time
ZYLOPRIM
§, HUMATROPE§, SAIZEN§, SEROSTIM§,
§, TEV-TROPIN§, ZORBTIVE§
Infergen§, Intron-A, REBETOL§, Rebetron§, Roferon A
HEPATITIS*
HIV
ribavirin§
Nutropin§, Nutropin AQ§,
Norditropin§, Protropin§
Copegus§, Pegasys§, §PegIntron
No drugs listed at this time
All brands are Tier 2
No drugs listed at this time
IMMUNE SYSTEM
azathioprine, cyclosporine
Cellcept, Neoral, Prograf,
Rapamune, Sandimmune,
Sandostatin
IMURAN
All brands when prescribed for
patients under age 11
Augmentin, AUGMENTIN XR, Avelox, Biaxin, CECLOR CD,
CEDAX, CEFTIN, Cefzil, Cipro, CIPRO XR, CLEOCIN,
DYNABAC§, Floxin, Ketek, Levaquin, LORABID, Macrobid,
MAXAQUIN, MONUROL, NOROXIN, OMNICEF, PCE, PENETRAX,
Spectracef, SUPRAX, Tequin, Tobi, TROVAN, VANTIN,
Vancocin, XIFAXAN, Zagam, Zithromax, Zyvox§
Griseofulvin Suspension, Lamisil§
Hepsera, Valtrex
Diflucan, PENLAC§, Sporanox§, Vfend
INFECTIONS: BACTERIAL, FUNGAL, VIRAL
amoxicillin,
Antibiotics
amoxicillin/clavulanate, ampicillin,
dicloxacillin, cefaclor, cefadroxil,
cefuroxime tablets, cephalexin,
ciprofloxacin, doxycycline,
erythromycins, ofloxacin,
penicillin
fluconazole, griseofulvin, nystatin
Antifungal Drugs (Oral)
Antiviral Drugs
MALARIA
MEN’S HEALTH
BPH Agents (prostate)
acyclovir, amantadine,
gancyclovir, rimantadine
chloroquine, hydroxychloroquine,
quinine
doxazosin, prazocin, terazosin
GENOTROPIN
SOMAVERT
Lariam
Relenza§,
Tamiflu, VALCYTE, ZOVIRAX
Daraprim, Fansidar, MALARONE, Plaquenil
Flomax (Tier 2 after failure to Tier 1
AVODART, CARDURA, HYTRIN,
CYTOVENE, DENAVIR, FAMVIR, FLUMADINE,
SYMMETREL,
Proscar, UROXATRAL
options)
Erectile Dysfunction
Hormones
Oral Androgens
MENTAL HEALTH
Antidepressants
yohimbine
testosterone
No drugs listed at this time
None
Android, Depo-Testosterone
Casodex, Eulexin
amitriptyline, amoxipine,
desipramine, doxepin,
(20 mg only)
, imipramine,
fluoxetinep
mirtazapine, nortriptyline,
paroxetine, trazodone
buproprion, buproprion SR,
nefazodone
Celexa 40mg\, Paxil suspension,
Zoloft 100mg\
Caverject, Cialis, Edex, Levitra, Muse, Viagra
Androgel, TESTIM, TESTODERM
No drugs listed at this time
ANDRODERM,
CELEXA 10MG, 20MG\, DESYREL, ELAVIL, LEXAPRO\,
LUVOX,
Nardil, PAMELOR, Parnate, PAXIL, PAXIL CR,
§, PROZAC WEEKLY§, Remeron, SARAFEM§,
SINEQUAN, SURMONTIL, SYMBYAX, TOFRANIL,
ZOLOFT 25MG, 50MG\
CYMBALTA§, SYMBYAX, WELLBUTRIN,
PROZAC
Effexor, Effexor XR: Tier 2 only if
prescribed by a psychiatrist or failure
of SSRI.
WELLBUTRIN SR
Welllbutrin XL: Tier 2 only if
prescribed by a psychiatrist, patient
under age 13, or failure of SSRI.
Antipsychosis
Sedatives/Hypnotics/
Anxiety
MIGRAINE
MULTIPLE SCLEROSIS*
OSTEOPOROSIS
clozapine, haloperidol,
trifluoperazine, thioridazine
Geodon, Risperdal, Seroquel
benzodiazepines (alprazolam,
clonazepam, diazepam,
triazolam), hydroxyzine
ergotamine,
isometheptene/dichlor/APAP
Ambien (only if over age 65)
ATIVAN, BUSPAR, SERAX, SONATA, VALIUM, XANAX
Amerge, Depakote ER, Maxalt,
Maxalt MLT, Migranal,
Imitrex 100mg & 50mg tablets,
Imitrex nasal spray and injection
AXERT, FROVA, IMITREX 25MG TABLETS, RELPAX, ZOMIG,
ZOMIG INTRANASAL, ZOMIG ZMT
No drugs listed at this time
Betaseron, Copaxone
Actonel, Actonel Weekly, Evista,
Fosamax, Fosamax Weekly
No drugs listed at this time
CLOZARIL, HALDOL, MELLARIL, NAVANE, PROLIXIN, STELAZINE,
THORAZINE, TRILAFON
Abilify, Zyprexa (Tier 2 when prescribed by a
psychiatrist and failure to Tier 2 options)
Avonex, Rebif
DIDRONEL,
Forteo,
SKELID,
Miacalcin Nasal
3
Co-payment/Coinsurance for each tier is based on the specific rider chosen by the employer group.
The majority of benefits include additional member payment when a brand drug is used and a generic equivalent is available.
ƒ
Brand drugs not listed are considered Tier 3. All compounds are considered Tier 3.
§ = Requires Prior Authorization
\ = Half Tablet opportunity: Certain strength tablets may be split to obtain lower dosage and reduce member out-of-pocket cost
ƒ
ƒ
* = Select self-injectable medications within this drug class are available through national specialty pharmacies CuraScript Pharmacy and Priority Healthcare
p
V
= Generic Trial opportunity: For select doses of these medications member copayment is waived for a two-week trial prescription
= Tier 2 for select prescribers/diagnoses
B-1462y5 10/6/04
List Subject to Change
DRUG CLASS
Tier 1
Tier 2
Tier 3
(lowest member co-payment)
PAIN / INFLAMMATION
Muscle Relaxants
NSAIDs
Pain Relievers (narcotic)
PARKINSON’S
SEIZURE / PAIN
SMOKING DETERRENTS
STOMACH / INTESTINAL
Antiemetics
baclofen, methocarbamol,
carisoprodol, cyclobenzaprine
diclofenac, fenoprofen,
flurbiprofen, ibuprofen,
indomethacin, ketoprofen,
nabumetone, naproxen, naproxen
sodium, oxaprozin, piroxicam,
salsalate, sulindac, tolmetin
No drugs listed at this time
acetaminophen/codeine,
acetaminophen/propoxyphene,
hydrocodone combinations,
methadone, morphine,
oxycodone SR
amantadine, anticholinergics,
benztropine, bromocriptine,
carbidopa/levodopa, selegiline
carbamazepine, clonazepam,
phenytoin, valproic acid
(highest member co-payment)
None
NORFLEX, SKELAXIN, ZANAFLEX
No drugs listed at this time
Step Therapy applies:
ARTHROTEC, CATAFLAM, DAYPRO, EC-NAPROSYN,
LODINE XL, MOBIC, NAPRELAN, ORUVAIL, PONSTEL,
RELAFEN, TORADOL, VOLTAREN XR
No drugs listed at this time
Step Therapy applies:
Bextra\, Celebrex
DuragesicV, OxycontinV
AVINA, AVINZA, KADIAN, MS CONTIN, MSIR, NORCO,
ORAMORPH SR, OXYIR, ULTRAM, ZYDONE
(Tier 2 for chronic, intractable pain
with letter of medical necessity)
Comtan, Permax, Requip
APOKYN, COGENTIN, DOPAR, ELDEPRYL, LARODOPA,
LODOSYN, MIRAPEX, PARLODEL, SINEMET CR, STALEVO,
TASMAR
Depakote, Dilantin, Felbatol,
Gabitril, Keppra, Klonopin,
Neurontin, Tegretol XR, Trileptal,
Zarontin
No drugs listed at this time
No drugs listed at this time
buproprion SR
No drugs listed at this time
NICOTROL INHALER, NICOTROL SPRAY, ZYBAN
meclizine, prochlorperazine,
Zofran
ALOXI, ANZEMET, EMEND,
TRANSDERM-SC
bethanechol, clidinium products,
dicyclomine, hyoscyamine,
oxybutyninp
pancrealipase
No drugs listed at this time
DETROL,
LamictalV , TopamaxV, ZonegranV
(for nausea)
Antispasmotic Drugs
Digestants
Inflammatory Bowel
Irritable Bowel Syndrome
Ulcer/Heartburn
sulfasalazine,
hydrocortisone enema
No drugs listed at this time
cimetidine, famotidine, ranitidine
No drugs listed at this time
omeprazole§, Prilosec OTCp
Kytril, MARINOL,
Detrol LA, DITROPAN, DITROPAN XL, LEVSIN,
§
LEVSINEX, OXYTROL PATCH, SANCTURA , URECHOLINE,
URISPAS
Cotazym, Cotazym S, Creon,
Kutrase, Pancrease, Pancrease
MT, Ultrase MT, Viokase, Zymase
Asacol, Canasa, Cortenema,
Dipentum, Pentasa, Rowasa enema
No drugs listed at this time
No drugs listed at this time
No drugs listed at this time
Prevacid, Protonix
No drugs listed at this time
AZULFIDINE (ENTERIC COATED),
Colazal, Entocort EC
Lotronex§, Zelnorm§
AXID, PEPCID, TAGAMET, ZANTAC
Helidac, Prevpac,TRITEC
ACIPHEX§ NEXIUM§, PREVACID NAPRAPAK§, PRILOSEC§,
§
THYROID
WEIGHT MANAGEMENT
metoclopramide, sucralfate
levothyroxine, levoxyl, levothroid,
PTU
diethylpropion
RAPINEX
CARAFATE
Cytotec
Cytomel, Tapazole
ARMOUR THYROID, SYNTHROID, THYROLAR, UNITHROID
No drugs listed at this time
ADIPEX-P, ADIPOST, BONTRIL-SR, DIDREX,
Meridia§,
phentermine, Xenical§
WOMEN’S HEALTH
Fertility Drugs*
clomiphene citrate
No drugs listed at this time
Bravelle§, Clomid, Crinone, Fertinex§, Follistim§,
Gonal-F§, Humegon§, Metrodin§, Ovidrel§,
Pergonal§, Repronex§
estradiol, medroxyprogesterone
Estratest, Estratest HS, Premarin,
Premphase, Prempro, Prometrium
Climara, Climara Pro
Ortho Evra, Ortho-Tri-Cyclen LO,
Yasmin
ACTIVELLA, CENESTIN, ENJUVIA, ESTRACE, ESTRATAB,
FEMHRT, MENEST, OGEN, ORTHO-PREFEST
Note: Not all prescription drug
benefits provide coverage
Hormones
Oral
Transdermal
Oral Contraceptives
estradiol patch
Alora, Combipatch, ESTRADERM, VIVELLE/DOT
ALESSE, BREVICON, CYLESSA, DEMULEN, DESOGEN,
Apri, Aviane, Camila, Cryselle,
ESTROSTEP, ESTROSTEP FE, LEVLEN, LEVLITE, LOESTRIN,
Enpresse, Jolivette, Kariva,
Note: Not all prescription drug
LOESTRIN FE, LO-OVRAL, MIRCETTE, MODICON, NORDETTE,
Lessina, Levora, Low-Ogestrel,
benefits provide coverage
NORINYL, NOR QD, NUVARING, ORTHO-CEPT, ORTHOCYCLEN, ORTHO MICRON, ORTHO-NOVUM, ORTHO TRIMicrogestin FE, Necon, Nelova,
CYCLEN, OVCON, OVRAL, PREVIFEM, TRI-LEVLEN,
Nora B, Nortrel, Ogestrel, Portia,
TRINORINYL, TRIPHASIL
Sprintec, Tri-Nessa, Tri-Previfem,
Tri-Sprintec, Trivora, Zovia
Miscellaneous Tier 2 agents: DDAVP tablets, Diamox Sequels, Elmiron, Epipen, Epipen Jr., Evoxac, Glucagen, Mestinon, Metrogel Vaginal, Metrolotion,
Phoslo, Premarin Vaginal, Pulmozyme, Renagel, Rilutek, Salagen, Stimate, Synarel
4
Co-payment/Coinsurance for each tier is based on the specific rider chosen by the employer group.
The majority of benefits include additional member payment when a brand drug is used and a generic equivalent is available.
ƒ
Brand drugs not listed are considered Tier 3. All compounds are considered Tier 3.
§ = Requires Prior Authorization
\ = Half Tablet opportunity: Certain strength tablets may be split to obtain lower dosage and reduce member out-of-pocket cost
ƒ
ƒ
* = Select self-injectable medications within this drug class are available through national specialty pharmacies CuraScript Pharmacy and Priority Healthcare
p
V
= Generic Trial opportunity: For select doses of these medications member copayment is waived for a two-week trial prescription
= Tier 2 for select prescribers/diagnoses
B-1462y5 10/6/04
List Subject to Change
Utica Business Park, 12 Rhoads Drive
Utica, New York 13502-6398
PRSRT STD
U.S. POSTAGE
PAID
ROCHESTER, NY
Permit No. 201