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Changes to the HealthChoice Pharmacy Benefit

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.

Brand-Name Medication

Generic Medication

Treatment

Effective Date
Adderall XR amphetamine/dextroamphetamine mixed salts 5mg, 10mg, 20mg,25mg, and 30mg capsules Attention Deficit Disorder 04/02/09
Ambien CR zolpidem controlled release Insomnia 03/09
Casodex bicalutamide Prostate Cancer 04/09
CellCept mycophenolate mofetil 500mg tablets and 250mg capsules Prevent transplant rejection 05/04/09
Cytomel liothyronine sodium Underactive thyroid 04/14/09
Depakote Sprinkles divalproex sodium Seizure Disorder 01/29/09
Depakote ER 250/500mg divalproex sodium extended release Seizure Disorder 01/30/09
Imitrex Nasal Spray sumatriptan nasal spray Migraine or cluster headaches 03/18/09
Keppra 1000mg levetiracetam tablets 1000mg Epilepsy 01/20/09
Keppra Solution levetiracetam solution Epilepsy 01/20/09
Tegretol XR carbamazepine extended release tablets neuralgia 04/03/09
Tobradex Suspension Ophthalmic tobramycin sulfate Intraocular Infection Following Surgery 01/20/09
Topamax topiramate Migraine Headache 04/09
Urso 250 and
Urso Forte
Ursodiol 250mg and 500mg tablets Cirrhosis 05/14/09

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.

Brand-Name Medication Generic Medication Treatment Effective Date
Activella
 
estradiol/norethindrone acetate Menopause 04/17/08
Altace Capsules ramipril High blood pressure 05/08
Cosopt dorzolamide and timolol ophthalmic solution Glaucoma 10/28/08
Diamox Sequels acetazolamide Glaucoma 12/25/08
Imitrex Injection sumatriptan succinate injection Migraine Headache 11/06/08
Fosamax alendronate sodium Osteoporosis 02/06/08
Keppra levetiracetam tablets 250mg, 500mg & 750mg Epilepsy 11/04/08
Miacalcin Spray calcitonin-salmon spray Osteoporosis 12/10/08
Paxil  CR paroxetine extended release Depression/anxiety 05/14/08
Precose acarbose tablets Type 2 diabetes 05/07/08
Prilosec 40mg Delayed -Release Capsules omeprazole 40mg delayed – release capsules GERD 06/02/08
Protonix pantoprazole Acid reflux 01/30/08
Pulmicort Respules budesonide inhalation solution Asthma 12/15/08
Requip ropinirole HCL Restless leg syndrome and Parkinson’s disease 05/05/08
Risperdal risperidone Schizophrenia and bipolar 06/29/08
Sonata zaleplon insomnia 05/05/08
Trusopt dorzolamide and timolol ophthalmic solution Glaucoma 10/28/08
Vivactil 5mg & 10mg protriptyline Depression 10/01/08
Wellbutrin XL 150mg Bupropion hydrochloride extended release 150mg Depression and / or tobacco cessation 05/30/08

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

Non-Preferred Medications Effective Date
Actonel and Actonel with Calcium 03/01/2008
Lexapro 01/01/2008
Lunesta, Rozerem, and Sonata 04/01/2008



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