HMSA Pharmacy Newsletter February

Transcription

1 HMSA s HMSA Pharmacy Newsletter February 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 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 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. 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 FORMULARY ADDITIONS 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 818 Keeaumoku St. P.O. Box 860 Honolulu, HI Phone: (808) Branch offi ces located on Hawaii, Kauai and Maui Internet address: Provider E-Library: PM

2 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 PCN 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 IVIG Carimune, Flebogamma, Gamimune N, Gammagard S/D, Gammar PI.V., Gamunex, Iveegam EN, Panglobulin, Polygam S/D, Venoglobulin-S 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 Lupron Milrinone Pegasys Pegintron Raptiva Rebetron Remicade Synagis Velcade Xolair Zevalin

3 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, 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 For existing HHIN users, please call on Oahu or (800) 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 The old NDC begins with 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 9 tablets per 30 days Zomig nasal spray 6 sprays per 30 days Precertification is required when a physician wishes to prescribe quantities exceeding the limits. 3

4 RISPERDAL NDC CLARIFICATION In November, 2005, a change made in First DataBank affected the NDC numbers for Risperdal. The NDC ending in 28 (NDC ) 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, 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 4

5 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 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 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 on Oahu or 1 (800) from the Neighbor Islands HMSA Membership Connection (touch-tone eligibility verification) on Oahu at or 1 (800) from the Neighbor Islands The HMSA Plan for QUEST Members Provider Services at on Oahu or 1 (800) from the Neighbor Islands 5

6 Members with questions or concerns regarding their HMSA drug plans may call an HMSA Customer Service representative at the following numbers: Oahu Kauai Hilo Maui, Lanai, Molokai Kona QUEST members who have questions or concerns may call QUEST Member Services at on Oahu or 1 (800) from the Neighbor Islands. 6