Dear Monroe County School Board member
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RE: Rx Benefit Updates for 2014 Dear Monroe County School Board member: EnvisionRxOptions and Monroe County School Board are always working together to find ways to provide better prescription coverage while managing the rising costs of prescription medications. This letter is to inform you that effective January 1, 2014 the following changes will be in place on your prescription drug benefit: 1) Copayment Structure Change 2) Formulary Updates 3) Additional Medications Requiring Prior Authorization 4) Additional Medications Quantity Limits 5) Step Therapy Addition 6) Compound Medication Update: Bulk Powders Buy-Up Plan Copays 30-Day Retail Copay Tier 1 Generic $10 Tier 2 Formulary Brand $35 90-Day Mail Order Tier 3 Non-Formulary Brand $50 Tier 1 Generic $20 Tier 2 Formulary Brand $70 Tier 3 Non-Formulary Brand $100 Core Plan Copays 30-Day Retail Copay Tier 1 Generic $15 Tier 2 Formulary Brand $45 90-Day Mail Order Tier 3 Non-Formulary Brand $65 Tier 1 Generic $30 Tier 2 Formulary Brand $90 Tier 3 Non-Formulary Brand $130 High Deductible Plan Copays 30-Day Retail Copay Tier 1 Generic $15 Tier 2 Formulary Brand $50 90-Day Mail Order Tier 3 Non-Formulary Brand $75 Tier 1 Generic $30 Tier 2 Formulary Brand $100 Tier 3 Non-Formulary Brand $150 - - - - - Formulary Updates - - - - What is a Formulary? Your prescription drug benefit features a formulary drug list. A formulary is a list of preferred medications organized into groups or “Tiers”. - Tier 1 are Generic drugs and are the first choice whenever possible. - Tier 2 drugs are a set of preferred brand-name drugs. - Tier 3 drugs are non-preferred brand-name drugs. For a full formulary listing please visit www.envisionrx.com. What are the changes? Brand drugs which now have a generic alternative available will be placed on the non-preferred brand tier, with the generic versions of those drugs are available on the generic tier. - These drugs, along with their preferred brand alternatives, are listed in Table 1 at the end of this letter. Several other brand drugs will be placed on the non-preferred brand tier. Therapeutic alternatives will be available on the generic and preferred tiers. - These drugs, along with their generic and preferred brand alternatives, are listed in Table 2 at the end of this letter. Please be aware that these changes in tier level may impact your copay/coinsurance and/or Dispense As Written penalties if you continue to receive the brand medication, depending on your Plan’s benefits. - - - - - Prior Authorization Updates - - - - What is a Prior Authorization? Your prescription drug benefit requires prior authorization for certain medications. A prior authorization is documentation of medical necessity from your prescribing physician; this is a procedure that helps manage the use of medications identified as high-dollar, high-risk, or having the potential for inappropriate use. PA requirements are established by licensed pharmacists and other medical experts, and only apply to specific covered medications. What are the changes? Several drugs are being added to the prior authorization list. The medications requiring a new Prior Authorization are in Table 3 at the end of this letter. What should I do if I need to take a medication that will require a prior authorization? You will need to submit a prior authorization in order to continue receiving the medication. You or your physician can begin the prior authorization process by contacting the EnvisionRxOptions Helpdesk at 1800-361-4542. We recommend that you contact your physician prior to January 1, 2014 in order to start the prior authorization process so that you may continue taking your medication without any disruption. Continued on next page… - - - - - Quantity Limit Updates - - - - What is a Quantity Limit? Your prescription drug benefit enforces quantity limits for certain medications. Quantity limits are clinical recommended limits put in place to help ensure safe utilization of medication. What are the changes? 2 Several drugs are being added to the quantity limit list. The medications requiring a new Quantity Limit are in Table 4 at the end of this letter. If you are taking one of these medications but the amount you take does not exceed the limit, you will not need to do anything as a result of this change. What should I do if I need to take a medication at a higher quantity than the new limits? If you are in need of a medication that requires a higher quantity than that which is listed on the attached quantity limit list, you will need to submit a letter of medical necessity. Your physician will need to submit a letter of medical necessity request for your current prescription and quantity stating that it is medically necessary for you to be on the exact dosage and quantity. A letter of medical necessity is a request that must be submitted annually. You or your physician can begin the letter of medical necessity process by contacting the EnvisionRxOptions Helpdesk at 1-800-361-4542. We recommend that you discuss your situation with your physician prior to January 1, 2014 so that you may continue taking your medication without disruption. - - - - Step Therapies Updates - - - - What is a step therapy? A step therapy program is designed specifically for patients with certain conditions that require taking medications regularly. It is the practice of beginning medication therapy for a medical condition with the most cost-effective medication and progressing to other more costly therapy(s) should the initial medication not provide adequate therapeutic benefit. How does the program work? In step therapy, medications are grouped into categories. 1st Step – First Line medications – mostly generic medications proven safe, effective, and affordable. These medications should be tried first. 2nd Step – Second Line medications – mostly higher costing brand name medications Step therapy is a process to ensure you are receiving a cost effective therapy. You will first try a recognized First Line medication (Step 1) before approval of a more costly and complex therapy is approved (Step 2). If the Step 1 therapy does not provide you with the therapeutic benefit desired, your physician may write a prescription for a Second Line medication. Generally, Second Line medications require the usage and failure of a First Line medication before coverage. The step therapy approach to care is a way to provide you with savings without compromising your quality of care. What are the changes? Several drugs are being added to the Step Therapy programs listed in Table 5 at the end of this letter. - The following Step Therapies have generic additions to the first line medications: Angiotensin Receptor Blocker and Proton Pump Inhibitors. - The following Step Therapies have generic additions to the second line medication: Insomnia Agents, Cholesterol/Statins and Proton Pump Inhibitors. What should I do if I will need to take a medication that is a step 2 on the step therapy? If you are in need of a medication that is a step 2 on the step therapy program, you will need to do one of the following: Have your physician to write you a prescription for a first line medication, or 3 You will need to submit a letter of medical necessity in order to recieve the second line medication. Have your physician submit a letter of medical necessity request for your current prescription and quantity stating that it is medically necessary for you to be on the exact dosage and quantity. A letter of medical necessity is a request that must be submitted annually. You or your physician can begin the letter of medical necessity process by contacting the EnvisionRxOptions Helpdesk at 1-800-361-4542. - - - - - Compound Medication Updates - - - - What is a Compound Medication? The FDA defines pharmacy compounding as “the practice in which a licensed pharmacist combines, mixes, or alters ingredients of a drug in response to a prescription to create a medication tailored to the medical needs of an individual patient”.1 Compounds are necessary to when a patient cannot be treated with an FDA-approved medication. 1http://www.fda.gov/drugs/GuidanceComplianceRegulatoryInformation/PharmacyCompounding/ What are the changes? Bulk powders/bulk chemicals will no longer be covered when submitted as ingredients in a compounded medication. Compounds containing commercially available prescription products (made from manufactured dosage forms such as tablets, capsules, liquids, etc.) will still continue to be covered under your benefit plan. Always talk to your doctor before discontinuing or changing any medication. If you have medical questions please contact your health care provider. We encourage you to work with your physician to determine which medication options are best for you. Should you have additional questions, please contact the EnvisionRxOptions Customer Service Help Desk at 1-800-361-4542. Our Help Desk is here to assist you with prescription questions 24 hours a day/ 7 days a week. Sincerely, EnvisionRxOptions on behalf of Monroe County School Board 4 Table 1: Brand Drugs with Generics Available Moving to Non-Preferred Status on the Envision Formulary Drug Name ALDARA® CREAM ANTARA® CAP 130MG ARTHROTEC® 50 TAB ARTHROTEC® 75 TAB Reason for Change Generic Now Available Generic Now Available Generic Now Available Generic Now Available BACTROBAN® CRE 2% CEENU® CAP 100MG CEENU® CAP 10MG CEENU® CAP 40MG COMTAN® TAB 200MG DIASTAT® GEL 12.5-20 DILANTIN® CHW 50MG EVOXAC® CAP 30MG GABITRIL® TAB 2MG GABITRIL® TAB 4MG GRIFULVIN V® TAB 500MG GRIS-PEG TAB® 125MG GRIS-PEG TAB® 250MG LAMICTAL XR® TAB 100MG LAMICTAL XR® TAB 200MG LAMICTAL XR® TAB 250MG LAMICTAL XR® TAB 25MG LAMICTAL XR® TAB 300MG LAMICTAL XR® TAB 50MG LYSTEDA® TAB 650MG METROGEL® GEL 1% MIACALCIN® SPR 200/ACT MIGRANAL® SPR 4MG/ML REVATIO® TAB 20MG RILUTEK® TAB 50MG SULFAMYLON® PAK 5% Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available SYNALGOS-DC® CAP TRICOR® TAB 145MG TRICOR® TAB 48MG TRILIPIX® CAP 135MG Generic Now Available Generic Now Available Generic Now Available Generic Now Available Formulary Alternative Imiquimod Cream Fenofibrate Micronized Cap 130 MG Diclofenac w/ Misoprostol Tab Delayed Release Diclofenac w/ Misoprostol Tab Delayed Release 75-0.2 MG Mupirocin Calcium Cream 2% Lomustine Cap 100 MG Lomustine Cap 10 MG Lomustine Cap 40 MG Entacapone Tab 200 MG Diazepam Rectal Gel 20 MG Phenytoin Chew Tab 50 MG Cevimeline HCl Cap 30 MG Tiagabine HCl Tab 2 MG Tiagabine HCl Tab 4 MG Griseofulvin Microsize Tab 500 MG Griseofulvin Ultramicrosize Tab 125 MG Griseofulvin Ultramicrosize Tab 250 MG Lamotrigine Tab SR 24HR 100 MG Lamotrigine Tab SR 24HR 200 MG Lamotrigine Tab SR 24HR 250 MG Lamotrigine Tab SR 24HR 25 MG Lamotrigine Tab SR 24HR 300 MG Lamotrigine Tab SR 24HR 50 MG Tranexamic Acid Tab 650 MG Metronidazole Gel 1% (60) Calcitonin Nasal Soln 200 Unit/ACT Dihydroergotamine Nasal Spray 4 MG/ML Sildenafil Citrate Tab 20 MG Riluzole Tab 50 MG Mafenide Acetate Packet For Topical Soln 5% (50 GM) Dihydrocodeine/Aspirin/Caffeine capsule Fenofibrate Tab 145 MG Fenofibrate Tab 48 MG Choline Fenofibrate Cap DR 135 MG TRILIPIX® CAP 45MG YAZ® TAB 3-0.02MG ZOMIG® TAB 2.5MG ZOMIG® TAB 5MG ZOMIG ZMT® TAB 2.5 MG ZOMIG ZMT® TAB 5MG Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Generic Now Available Choline Fenofibrate Cap DR 45 MG Gianvi, Loryna, Vestura Zolmitriptan Tab 2.5 MG Zolmitriptan Tab 5 MG Zolmitriptan Orally Disintegrating Tab 2.5 MG Zolmitriptan Orally Disintegrating Tab 5 MG ZOVIRAX® OIN 5% Generic Now Available Acyclovir Oint 5% 5 Table 2: Therapeutic Interchanges Moving to Non-Preferred Status on the Envision Formulary Affected Drug Androderm® Aranesp®® Asacol HD Betaseron® Gilenya® Halflytely® * Latuda® Pentasa® Proventil® Rebif® Saphris® Suboxone® Tablets Preferred Formulary Alternative Androgel®, Testim® Procrit® Sulfasalazine®, Apriso®, Lialda® Copaxone®, Avonex®, Tecfidera® Copaxone®, Avonex®, Tecfidera® Generic bowel preparation, Moviprep® Quetiapine®, olanzapine, ziprasidone, Abilify®, Seroquel® XR Sulfasalazine®, Apriso®, Lialda® Proair®, Ventolin® Copaxone®, Avonex®, Tecfidera® Quetiapine®, olanzapine, ziprasidone, Abilify®, Seroquel® XR Buprenorphine/naloxone tablets (generic Suboxone tablets), Suboxone® Film Table 3: Medications Subject to New Prior Authorization Requirements Drug Category STIMULANTS ANTI-NEOPLASTICS ANTI-SEIZURE Affected Drugs XYREM® ORAL SOLUTION SYNRIBO®, ICLUSIG®, TAFINLAR®, MEKINIST®, GILOTRIF®, ERWINAZE® FYCOMP® Table 4: Medications Subject to New Quantity Limit Requirements Drug OXYMORPHONE HYDROCHLORIDE 10 MG ER OXYMORPHONE HYDROCHLORIDE 20 MG ER OXYMORPHONE HYDROCHLORIDE 30 MG ER OXYMORPHONE HYDROCHLORIDE 40 MG ER OXYMORPHONE HYDROCHLORIDE 5 MG ER TOBI PODHALER® KIT OPANA® 15 MG ER OPANA® 7.5 MG ER ONSOLIS® BUCCAL FILM LAZANDA® NASAL SOLN ABSTRAL® SUBLINGUAL TABLET ACTIQ BUCCAL® LOLLIPOP COMBIVENT RESPIMAT® 20/100 METERED DOSE INHALER SUBSYS 0.1 MG/ACTUAT MUCOSAL SPRAY SUBSYS 0.2 MG/ACTUAT MUCOSAL SPRAY SUBSYS 0.4 MG/ACTUAT MUCOSAL SPRAY SUBSYS 0.6 MG/ACTUAT MUCOSAL SPRAY SUBSYS 0.8 MG/ACTUAT MUCOSAL SPRAY SUBOXONE® 12MG/3MG ORAL STRIP SUBOXONE® 4MG/1MG ORAL STRIP SUBOXONE® 8MG/2MG ORAL STRIP SUBOXONE® 2MG/0.5MG ORAL STRIP Quantity Limit Per 30 Days 60 TABLETS 60 TABLETS 60 TABLETS 120 TABLETS 60 TABLETS 224 CAPSULES 60 TABLETS 60 TABLETS 120 FILMS 30 UNITS 120 TABLETS 120 LOLLIPOPS 1 INHALER 360 UNITS 360 UNITS 360 UNITS 360 UNITS 360 UNITS 90 STRIPS 240 STRIPS 120 STRIPS 480 STRIPS 6 Table 5: Updated Step Therapy Medication Programs Step Therapy Angiotensin Receptor Blocker (ARB) Proton Pump Inhibitor (PPI) Insomnia Agents Cholesterol/Statin Medication List Edarbi, Micardis/HCT, Hyzaar, Cozaar, Avapro, Avalide, Atacand/HCT, Teveten/HCT, Benicar/HCT Nexium, Prilosec 40mg , Aciphex, Rabeprazole, Protonix, Prevacid, Zegerid, Dexilant Ambien, Ambien Cr, Zolpidem CR, Edluar, Zolpimist, Sonata, Lunesta Crestor 5 mg, Lipitor 10mg /20mg, Lescol/XL, Fluvastatin, Vytorin, Altoprev, Mevacor, Pravachol, Zocor, Livalo Criteria Must have tried and failed Losartan/HCT, Valsartan/HCT, or Irbesartan prior to use of a STEP 2 product Must have tried and failed Prilosec OTC, Omeprazole, Prevacid OTC, Lansoprazole or Pantoprazole prior to utilizing a STEP 2 PPI agent Must have tried and failed Zolpidem IR or Zaleplon prior to use of a STEP 2 agent Must have tried and failed Simvastatin, Pravastatin, Lovastatin, Atorvastatin prior to utilizing a STEP 2 agent End of Document 7
