The purpose of this page is to provide information about changes to the HealthChoice Select Medication List and changes to the pharmacy benefit. 

Pharmacy Out-of-Pocket Maximum for Non-Medicare Members

Only copays for Preferred medications purchased at Network pharmacies apply to the out-of-pocket calendar year maximum.  Non-Preferred medications, medications purchased at non-Network pharmacies, and brand/generic cost differences do not apply to your pharmacy deductible or out-of-pocket maximum, and are never paid at 100% even if you have met your out-of-pocket maximum.

Cough/Cold Medications and Antihistamines Are No Longer Covered

Effective January 1, 2009, HealthChoice no longer covers most cough/cold medications and antihistamines, including non-sedating antihistamines. This change has been made because there are many equivalent or alternative versions of these medications available over-the-counter.

Some examples of non-sedating antihistamines are:

• Allegra

• Allegra-D

• Claritin

• Claritin-D

• Clarinex

• fexofenadine hcl (generic for Allegra)

• Xyzal

• Zyrtec

• Zyrtec-D

Reminder: Over-the-counter medications are specifically excluded under the plan.

EXCEPTIONS

The cough/cold Medications covered by the Plan are:

• ipratropium (generic for Atrovent Nasal Spray)

• hydrocodone/homatropine (generic for Hycodan)

• benzonate (generic for Tessalon Perle)

• hydrocodone/homatropine (generic for Tussigon)

Antihistamine Nasal Sprays Restored

Effective April 8, 2009, the following antihistamine nasal sprays were restored by the plan at the non-Preferred copay:

• azelastine (Astepro Nasal Spray)

• azelastine (Astelin Nasal Spray)

• olopatadine (Patanase Nasal Spray)

Please note: if you choose a brand-name medication when a generic is available, you will be responsible for the brand-generic cost difference as well as the applicable copay.

As new cough/cold medications or antihistamines become available, they will not be covered by the plan.
 

Specialty Medication Copay Benefit Change
HealthChoice Medicare Supplement Plans With Part D are Exempt

As a reminder, the copay for specialty medications changed on January 1, 2009, to one copay for each 30-day fill.  Also, if you choose a brand-name specialty medication when a generic is available, you will be responsible for the brand-generic cost difference, plus the applicable copay.

2009 New Generic Releases

New generic medications have or will soon become available for the brand-name medications listed below.  If your medication is changing from Preferred status to non-Preferred status, please discuss the preferred alternative with your physician.  If your physician feels that it is in your best medical interest to continue taking any form of a non-Preferred medication, have your physician request a Prior Authorization Form by calling toll-free1-800-753-2851 or TDD 1-800-759-1089, Monday through Friday 7 a.m. to 8 p.m. CST.

Please Note: The anticipated “generic” launch dates listed above are subject to change based on new or ongoing legal issues between the brand and generic manufacturers.

New Triptan (Migraine Medication) Step Therapy Program Non-Medicare Members Only

Effective July 1, 2009, the brand-name triptan medications listed below, used to treat migraine or cluster headaches, will become non-Preferred. Sumatriptan, the generic for Imitrex, will be the only Preferred medication. Neither Imitrex nor sumatriptan will require a prior authorization. However, if you choose to take the brand-name Imitrex, you will be responsible for paying your copay plus the cost difference between the brand-name and the generic.

A Prior Authorization will be required for brand-name triptans, other than Imitrex, and will only be approved if you have tried and are unable to tolerate sumatriptan. Your doctor should contact Medco toll-free at 1-800-753-2851 for a Prior Authorization review. If a prior authorization is approved, you will pay the higher, non-Preferred copay. However, if it is not approved, you will be responsible for the entire cost of the medication.

Non-Preferred Triptans

• Amerge
• Axert
• Frova
• Maxalt
• Maxalt-MLT
• Relpax
• Treximet
• Zomig
• Zomig-ZMT

2008 New Generic Releases

New generic medications have or will soon become available for the brand-name medications listed below.  If your medication is changing from Preferred status to non-Preferred status, please discuss the preferred alternative with your physician.  If your physician feels that it is in your best medical interest to continue taking any form of a non-Preferred medication, have your physician request a Prior Authorization Form by calling toll-free1-800-753-2851 or TDD 1-800-759-1089, Monday through Friday 7 a.m. to 8 p.m. CST.

2008 Benefit Change for Tobacco Cessation Products

Effective January 1, 2008, HealthChoice will cover two courses of 90 treatment days of tobacco cessation medications per calendar year.  This benefit change does not require a prior authorization and is available to all HealthChoice members and dependents at least 18 years old.  Only FDA approved tobacco cessation medications that require a prescription are eligible under your plan.

2008 Specialty Pharmacy Program for HealthChoice Members
(Does Not Apply to Medicare Part D Members)

Certain specialty medications (usually high cost medications which are typically injected), will only be covered if they are obtained from Medco’s specialty care pharmacy, Accredo Health Group, (Accredo).  Previously these specialty medications may have been obtained from a retail pharmacy and/or other specialty pharmacy providers.  If a member does not utilize Accredo for their specialty medication(s) after January 1, 2008, the member will be responsible for the full cost of the medication(s).

2008 Prior Authorization Required for Certain Non-Preferred Medications