Health Care Reform Preventative Drug list

Transcription

1 Health Care Reform Preventative Drug list At Magellan Management, we are driven to helping our clients most effectively manage changes in the prescription drug environment. As part of the Patient Protection and Affordable Care Act (PPACA), non-grandfathered plans are required to cover select FDA-approved drug products related to preventive health services for Adults, Children and Women without a member having to pay a copayment or coinsurance or meet a deductible. As your pharmacy benefits manager, we will support coverage of specific products at $0 copay as prescription benefit plans become subject to the law. Magellan Management will also routinely update FDA-approved product lists to comply with the Preventive Health mandates, and require prescriptions for product coverage. To meet the needs and provide flexibility to our clients, we have created eight specific lists that address the preventive health requirements above. A plan decision is required for coverage under the pharmacy benefit for each of the lists noted below. The content of the list will be maintained by Magellan Management and will be continually reviewed and updated to ensure compliance with healthcare reform mandates. UPDATE: For plan years beginning on or after September 24, 2014 (January 1, 2015 for calendar year plans), non-grandfathered health plans are required to cover prescription medications designed to reduce the risk of breast cancer in women, without cost-sharing, subject to reasonable medical management. These required drugs have been added to the Preventive Health for Adults, Children and Women: Prescription and OTC Products list below. 1. Preventive Health for Adults, Children and Women: Prescription and OTC Products. Age edits apply Generic Name Covered Label Name or OTC aspirin chew tab 81 mg Aspirin Chew 81mg OTC aspirin tab 325 mg Aspirin Tab 325mg OTC aspirin tab 81 mg Aspirin Tab 81mg OTC aspirin tab delayed release 162 mg Halfprin Tab 162mg EC OTC aspirin tab delayed release 81 mg Adlt Asa Low Tab 81mg EC OTC aspirin tab delayed release 365 mg Adlt Asa Low Tab 265mg EC OTC cholecalciferol oral liquid 400 unit / ML Vitamin D OTC cholecalciferol cap 400 unit Vitamin D OTC cholecalciferol cap 1000 unit Vitamin D OTC cholecalciferol tab 400 unit Vitamin D OTC cholecalciferol cap 1000 unit Vitamin D OTC cholecalciferol chew tab 400 unit Vitamin D OTC cholecalciferol chew tab 1000 unit Vitamin D OTC ergocalciferol tab 400 unit Vitamin D OTC

2 Generic Name Covered Label Name or OTC ferrous sulfate elixir Ferrous Sulf Elx 220/5ml OTC ferrous sulfate soln Fer-In-Sol Drop 15mg/Ml OTC ferrous sulfate syrup Ferrous Sulf Syrup 300/5ml OTC folic acid cap 0.8 mg Fa-8 Cap 800mcg OTC folic acid tab 400 mcg Folic Acid Tab 400mcg OTC folic acid tab 800 mcg Fa-8 Tab 0.8mg OTC sodium fluoride chew tab Epiflur Chew 0.25mg F sodium fluoride solution Luride Drop 0.5mg/Ml Risk-Reducing Drugs for Breast Cancer Gender edits apply raloxifene hydrochloride 60mg Evista 60mg tamoxifen citrate 20mg Nolvadex 20mg Bowel Prep Products Quantity limit and age edits apply peg 3350/mannitol/sodium bicarbonate/citric Base, Pcca Rapid Dissolve Powd OTC Colyte with Flavor Packs Gavilyte-C Solution Gavilyte-G Solution Golytely Packet Peg 3350 Electrolyte Soln Peg-3350 and Electrolytes Soln peg 3350/sodium sulfate/sod chloride/kcl/ascorbate Moviprep Powder Packet Statins Age Edits atorvastatin calcium Atorvastatin 10 Mg Tablet atorvastatin calcium Atorvastatin 20 Mg Tablet lovastatin Lovastatin 10 Mg Tablet lovastatin Lovastatin 20 Mg Tablet lovastatin Lovastatin 40 Mg Tablet pravastatin sodium Pravastatin Sodium 10 Mg Tab pravastatin sodium Pravastatin Sodium 20 Mg Tab pravastatin sodium Pravastatin Sodium 40 Mg Tab pravastatin sodium Pravastatin Sodium 80 Mg Tab rosuvastatin calcium Rosuvastatin Calcium 5 Mg Tab rosuvastatin calcium Rosuvastatin Calcium 10 Mg Tab simvastatin Simvastatin 5 Mg Tablet simvastatin Simvastatin 10 Mg Tablet simvastatin Simvastatin 20 Mg Tablet simvastatin Simvastatin 40 Mg Tablet Magellan Management, LLC. All rights reserved_1117

3 2. Preventive Health for Women: Contraceptives* Prescription Contraceptive Products (*Required on or after August 1, 2012). Gender and Quantity Limits apply. Multi-source brands and select single source brands are not covered. Generic Name Covered Label Name Form Hormonal Contraceptives desogest-eth estrad & eth estrad /0.01 Kariva, Azurette, Viorele mg(21/5) desogest-ethin est / /0.15- Velivet Pak, Caziant Pak, Cesia Pak 0.025mg-mg desogestrel & ethinyl estradiol 0.15 mg-30 mcg Apri, Emoquette, Reclipsen, Solia drospirenone-ethinyl estradiol mg Gianvi mg, Loryna mg drospirenone-ethinyl estradiol mg Ocella mg, Syeda mg, Zarah ethynodiol diacetate & ethinyl estradiol 1 mg-35 mcg Kelnor 1/35, Zovia 1/35e ethynodiol diacetate & ethinyl estradiol 1 mg-50 mcg Zovia 1/50e levonorgestrel & ethinyl estradiol (91-day) Jolessa, Introvale, Quasense mg levonorgestrel & ethinyl estradiol 0.1 mg-20 mcg Lessina-28, Aviane, Orsythia, Lutera, Sronyx levonorgestrel & ethinyl estradiol 0.15 mg-30 mcg Portia-28, Altavera, Levora /30, Marlissa 0.15/30 levonorgestrel 0.75 mg Next Choice 0.75mg, Levonorgestrel 0.75 mg levonorgestrel 1.5 mg Next Choice 1.5mg, Levonorgestrel 1.5 mg levonorgestrel-eth estra / / Enpresse-28, Trivora-28, Myzilra 30mg-mcg levonorgestrel-ethinyl estradiol (continuous) Amethyst 90-20mcg mcg levonorg-eth est mg(84) & eth est 0.01mg(7) Camrese Lo, Amethia Lo, Levonorgestrel and Ethinyl Estradiol levonorg-eth est mg(84) & eth est 0.01mg(7) Camrese, Amethia norethindrone & ethinyl estradiol 0.4 mg-35 mcg Balziva, Philith , Zenchent, Briellyn norethindrone & ethinyl estradiol 0.5 mg-35 mcg Nortrel /35, Necon 0.5/35 norethindrone & ethinyl estradiol 1 mg-35 mcg Cyclafem 1/35, Alyacen 1/35, Nortrel 1/35, Necon 1/35 norethindrone & ethinyl estradiol-fe chew 0.4 mg-35 Zeosa Chw, Zenchent Fe Chw 0.4mg-35, Wymzya Fe mcg Chw 0.4mg-35 norethindrone & mestranol 1 mg-50 mcg Necon 1/50-28 norethindrone ace & ethinyl estradiol 1 mg-20 mcg Junel 1/20, Microgestin 1/20 norethindrone ace & ethinyl estradiol 1.5 mg-30 mcg Junel 1.5/30, Microgestin 1.5/30 norethindrone ace & ethinyl estradiol-fe 1 mg-20 mcg Junel Fe 1/20, Gildess Fe 1/20, Microgestin Fe 1/20 norethindrone ace & ethinyl estradiol-fe 1.5 mg-30 Junel Fe 1.5/30, Microgestin Fe1.5/30 mcg norethindrone ac-ethinyl estrad-fe 1-20/1-30/1-35 Tri-Legest Fe, Tilia Fe mg-mcg norethindrone 0.35 mg Errin 0.35mg, Camila 0.35mg, Nora-Be 0.35mg, Jolivette 0.35mg, Heather 0.35mg, Norethindrone 0.35mg norethindrone-eth estradiol / /1-35 mgmcg Cyclafem 7/7/7, Alyacen 7/7/7, Nortrel 7/7/7, Necon 7/7/7 norethindrone-eth estradiol /1-35 mg-mcg Necon 10/11-28 (10/11) norethindrone-eth estradiol /1-35/ mgmcg Aranelle, Leena norgestimate & ethinyl estradiol 0.25 mg-35 mcg Mononessa, Previfem, Sprintec Day, Norgestimate & Ethinyl Estradiol 0.25 Mg-35 Mcg norgestimate-eth estrad / / mg-mcg Tri-Sprintec, Tri-Previfem, Trinessa, Norgestimate/Ethinyl Estradiol norgestrel & ethinyl estradiol 0.3 mg-30 mcg Cryselle-28, Low-Ogestrel, Norgestrel/Ethinyl Estradiol norgestrel & ethinyl estradiol 0.5 mg-50 mcg Ogestrel uliprastal acetate 30 mg Ella Magellan Management, LLC. All rights reserved_1117

4 Generic Name Covered Label Name Form Cervical Caps Cervical CAP 22 MM Prentif MIS 22MM Cervical CAP 25 MM Prentif MIS 25MM Cervical CAP 28 MM Prentif MIS 28MM Cervical CAP 31 MM Prentif MIS 31MM *Cervical CAPS*** Prentif MIS FITTING Diaphragms *DIAPHRAGMS*** OMNIFLEX DPR Diaphragm Arc-Spring 65 Mm Ortho Flex pr 65mm Diaphragm Arc-Spring 70 Mm, 75Mm Ortho Flex Dpr 70mm, 75mm Diaphragm Arc-Spring 80 Mm Ortho Flex Dpr 80mm Diaphragm Coil Spring Kit 50 Mm Ortho Coil Dpr Kit 50 Kit Diaphragm Coil Spring Kit 100 Mm Ortho Coil Dpr Kit 100 Kit Diaphragm Coil Spring Kit 105 Mm Ortho Coil Dpr Kit 105 Kit Diaphragm Flat Spring Kit 55 Mm Ortho Flat Dpr Kit 55 Kit Diaphragm Flat Spring Kit 60 Mm, 65Mm Ortho Flat Dpr Kit 60, 65 Kit Diaphragm Flat Spring Kit 70 Mm, 75Mm Ortho Flat Dpr Kit 70, 75 Kit Diaphragm Flat Spring Kit 80 Mm, 85Mm Ortho Flat Dpr Kit 80, 85 Kit Diaphragm Flat Spring Kit 90 Mm, 95Mm Ortho Flat Dpr Kit Kit Diaphragm Wide Seal 60 Mm, 65Mm Wide-Seal Dpr Kit 60, 65 Kit Diaphragm Wide Seal 70 Mm, 75 Mm Wide-Seal Dpr Kit 70, 75 Kit Diaphragm Wide Seal 80 Mm, 85Mm Wide-Seal Dpr Kit Kit Diaphragm Wide Seal 90 Mm Wide-Seal Dpr Kit 90 Kit Other etonogestrel-ethinyl estradiol va ring Nuvaring Mis RG mg/24hr medroxyprogesterone acetate subc susp 104 INJ mg/0.65ml medroxyprogesterone acetate im susp 150 mg/ml Medroxypr Ac Inj 150mg/Ml INJ Magellan Management, LLC. All rights reserved_1117

5 3. Preventive Health for Women: Contraceptives OTCs: Condoms and Spermicides. Quantity Limits apply. Generic Name Covered Label Name Form Condoms *Condoms - Female*** FC FEMALE MIS CONDOM MISC *Condoms - Male*** Condoms Mis MISC Condoms Latex Lubricated Condoms-Prem Mis Lubricat MISC Condoms Non-Latex Non-Lubricated Condoms Non-Latex Non-Lubricated MISC Spermicides nonoxynol-9 film 28% VCF Vaginal Mis Contracp Film nonoxynol-9 foam 12.5% VCF Vaginal Aer Contracp Foam nonoxynol-9 gel 2% GYNOL II GEL 2% Gel nonoxynol-9 gel 3% GYNOL II GEL 3% X-STR Gel nonoxynol-9 gel 4% Conceptrol Gel 4% Gel nonoxynol-9 vaginal insert 150 mg Conceptrol Sup 150mg Insert nonoxynol mg Today Contraceptive Sponge Insert octoxynol gel 1% Ortho-Gynol Gel 1% Gel 4. Preventive Health for Women: Contraceptives Medical Drug Products: Implants and IUDs. Gender Edits and Quantity Limits apply. Generic Name Covered Label Name Form IUDS *IUDS*** PARAGARD IUD T380A IUD Releases approximately 14 mcg of levonorgestrel per MIRENA IUD SYSTEM IUD day over 5 years Releases approximately 6 mcg of levonorgestrel per SKYLA IUD 13.5MG IUD day over 3 years Implants etonogestrel subdermal implant 68 mg IMPLANON IMP 68MG 5. Preventive Health for Adults, and Children: Vaccines. These immunizations are covered under the medical component of the Plan. Gender Edits and Age Edits may apply. Generic Name Covered Label Name hepatitis a vaccine inj susp 1440 el unit/ml Havrix Adult hepatitis a vaccine inj susp 25 unit/0.5ml Vaqta Ped hepatitis a vaccine inj susp 50 unit/ml Vaqta Adult hepatitis a vaccine inj susp 720 el unit/0.5ml Havrix Ped hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml Recombivax Ped hepatitis b vaccine (recombinant) susp 10 mcg/ml Engerix B Adult hepatitis b vaccine (recombinant) susp 20 mcg/ml Recombivax Adult hepatitis b vaccine (recombinant) susp 40 mcg/ml Recombivax -dialysis hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml Engerix B ped human papillomavirus (hpv) bival (type 16, 18) recmb vac inj Cervarix human papillomavirus (hpv) quadrivalent recombinant vac inj Gardasil influenza virus vac split high-dose preservative free inj Fluzone HD influenza virus vaccine split inj Afluria, Flulaval, Afluria, Fluzone Split, Flushield influenza virus vaccine split intradermal inj 9 mcg/strain Fluzone ID influenza virus vaccine split preservative free inj Afluria PF, Fluzone/PED PF, Fluarix influenza virus vaccine types a & b surface antigen inj Fluvirin measles, mumps & rubella virus vaccines for inj MMR-II meningococcal Menactra, Menveo meningococcal vaccine a, c, y, and w-135 inj Menomune pneumococcal vaccine polyvalent inj 25 mcg/0.5ml Pneumovax Magellan Management, LLC. All rights reserved_1117

6 Generic Name Covered Label Name pneumococcal 13-Valent Conjugate Vaccine 0.5ml Prevnar 13 tet tox-diph-acell pertuss ad inj lf-lf-mcg/0.5ml Boostrix (Tdap) tet tox-diph-acell pertuss ad inj lf-lf-mcg/0.5ml Adacel (Tdap) tetanus toxoid adsorbed inj 5 lf Tetanus Toxoid tetanus-diphtheria toxoids (td) inj 5-2 lfu Decavac varicella virus vac live for subcutaneous inj 1350 pfu/0.5ml Varivax zoster vaccine live for inj unit/0.65ml Zostavax 6. Preventive Health for Adults: Smoking Cessation (Prescription and OTC). Age Edits and Quantity Limits apply. Covered Drug Name Nicotine TD 24 HR 7MG / 24HR Nicotine TD 24 HR 14MG / 24HR Nicotine TD 24 HR 21 MG / 24 HR Nicotine Polacrilex Gum 2 MG Nicotine Polacrilex Gum 4 MG Nicotine Polacrilex Lozenge 2 MG Nicotine Polacrilex Lozenge 4 MG Bupropion HCL (Smoking Deterrent) TAB SR 12 HR 150 MG Varenicline Tartrate TAB 0.5 MG (Base Equiv) Varenicline Tartrate TAB 1 MG (Base Equiv) Varenicline Tartrate TAB 0.5 MG X 11 & TAB 1 MG x 42 Pack Form 7. Preventive Health for Adults: Smoking Cessation (Prescription Only). Age Edits and Quantity Limits apply. Covered Drug Name Bupropion HCL (Smoking Deterrent) TAB SR 12 HR 150 MG Varenicline Tartrate TAB 0.5 MG (Base Equiv) Varenicline Tartrate TAB 1 MG (Base Equiv) Varenicline Tartrate TAB 0.5 MG X 11 & TAB 1 MG x 42 Pack Form 8. Preventive Health for Adults: Smoking Cessation (OTC Only). Age Edits and Quantity Limits apply. Covered Drug Name Nicotine TD 24 HR 7MG / 24HR Nicotine TD 24 HR 14MG / 24HR Nicotine TD 24 HR 21 MG / 24 HR Nicotine Polacrilex Gum 2 MG Nicotine Polacrilex Gum 4 MG Nicotine Polacrilex Lozenge 2 MG Nicotine Polacrilex Lozenge 4 MG Form Magellan Management, LLC. All rights reserved_1117