Medicare Part D November 2014 CHANGES TO HMSA S MEDICARE FORMULARY As part of HMSA s ongoing efforts to provide our members a sustainable and affordable health plan option, it s necessary to make adjustments to the HMSA Medicare Part D formulary. The changes, which will go into effect on January 1, 2015, are designed to encourage you and your patients to consider lower-cost alternative medications, as well as address quality and safety concerns that are associated with high-risk medications. New Preauthorization Medications Table 1 These medications will require preauthorization (PA) for HMSA Medicare Part D members. Table 1: Medicare Formulary New Preauthorization Effective January 1, 2015 Drug Name Drug Class Rationale/Criteria Banzel Anticonvulsants FDA approved indications/appropriate use Emend, 40 mg Antiemetics Part B vs. Part D determination ketoconazole, 200 mg Antifungals FDA approved indications/appropriate use methylprednisolone acetate, injection Glucocorticoids Part B vs. Part D determination methylprednisolone tablet, dose pack Glucocorticoids Part B vs. Part D determination methylprednisolone, sodium succinate, injection Glucocorticoids Part B vs. Part D determination Namenda XR Antidementia *Criteria under CMS review Namenda, solution Antidementia *Criteria under CMS review prednisolone, solution Glucocorticoids Part B vs. Part D determination prednisone tablet, dose pack, solution Glucocorticoids Part B vs. Part D determination Quinine Antimalarials FDA approved indications/appropriate use temazepam Hypnotics *Criteria under CMS review Versacloz Antipsychotics FDA approved indications/appropriate use Xyrem Narcolepsy/Cataplexy FDA approved indications/appropriate use * Pending CMS approval Hawai i Medical Service Association 818 Keeaumoku St. (808) 948-6330 P.O. Box 860 Honolulu, HI 96808-0860 hmsa.com hhin.hmsa.com Provider Resource Center hmsa.com/portal/provider An Independent Licensee of the Blue Cross and Blue Shield Association 1100-1074
2 Medicare Part D November 2014 Non-Formulary Medications Table 2 These medications will be removed from the Medicare Part D formulary because equally effective, safe, and lower-cost alternatives are available. This is not a comprehensive list of all drugs being removed. It s a listing of drugs being removed effective January 1, 2015, that may cause the most potential impact. Table 2: Medicare Formulary Non-Formulary Medications Effective January 1, 2015 Drug Name Drug Class Alternative Formulary Drug(s) Actonel, tablet Bisphosphonates alendronate, ibandronate amlodipine/atorvastatin Calcium Channel Blocker/Antilipemic Combinations amlodipine and atorvastatin separately AndroGel Androgens Testim Apidra Antidiabetics Novolog Avelox Fluoroquinolones ciprofloxacin, levofloxacin Bydureon Antidiabetics Victoza Byetta Antidiabetics Victoza candesartan Angiotensin II Receptor Antagonists losartan, irbesartan, valsartan Carac Dermatology fluorouracil, imiquimod Carafate (tablet, susp) Miscellaneous sucralfate tablet, famotidine, ranitidine Cimetidine H2-Receptor Antagonists famotidine, ranitidine Clobetasol Dermatology diflorasone, halobetasol, betamethasone dipropionate Coreg CR Beta-Blockers carvedilol desloratadine Antihistamines levocetirizine Detrol LA Urinary Antispasmodics tolterodine ER Estrace, vaginal cream Estrogens Premarin cream, Vagifem Evista Selective Estrogen Receptor Modulators raloxifene glyburide Antidiabetics glipizide, glimepiride glyburide/metformin Antidiabetics glipizide/metformin Humalog Antidiabetics Novolog Humalog Mix Antidiabetics Novolog Mix Kombiglyze Antidiabetics Janumet, Jentadueto lansoprazole Proton Pump Inhibitors omeprazole, pantoprazole Lipitor Antilipemics atorvastatin Lovaza Antilipemics omega-3-acid metronidazole, gel 1% Dermatology metronidazole, gel 0.75% mupirocin, cream 2% Dermatology mupirocin, ointment Onglyza Antidiabetics Januvia, Tradjenta Oxycontin Opioid Analgesics oxycodone, morphine ER pioglitazone/metformin Antidiabetics pioglitazone and metformin separately Progesterone, capsule Progestins medroxyprogesterone Proventil HFA Beta Agonists Proair HFA rabeprazole Proton Pump Inhibitors omeprazole, pantoprazole ranitidine, capsule H2-Receptor Antagonists ranitidine, tablet Rapaflo Benign Prostatic Hyperplasia tamsulosin, alfuzosin telmisartan Angiotestin II Receptor Antagonists losartan, irbesartan, valsartan triamcinolone, nasal spray Nasal Steroids fluticasone, flunisolide Ventolin HFA Beta Agonists Proair HFA Vytorin Antilipemics atorvastatin Zioptan Antiglaucoma latanoprost, Lumigan, Travatan Z zolpidem ER Hypnotics trazodone, Silenor, temazepam
3 Medicare Part D November 2014 New Quantity Limits Table 3 These medications will require a preauthorization for HMSA Medicare Part D members when the prescribed amounts exceed the quantity limit listed. Quantity limits are based on FDA prescribing maximum limits for safe and effective use. Patients using these medications in amounts lower than the amount listed won t need a PA. This is not a comprehensive list of all drugs with new quantity limits. It s a listing of drugs with new quantity limits effective January 1, 2015, that may cause the most potential impact. Please review the therapies of your patients whose current medications exceed the listed quantity limits to determine if their prescription strengths are appropriate. Table 3: Medicare Formulary New Quantity Limits Effective January 1, 2015 Drug Name Strength Rationale/Criteria Limit Drug Class Abilify, solution 1 mg/ml Amount: 900.0, Days: 30 Antipsychotics Abilify, tablet All Amount: 30.0, Days: 30 Antipsychotics alendronate, tablet 35 mg Amount: 4.0, Days: 28 Bisphosphonates 70 mg amlodipine/benazepril, capsule 2.5-10 mg Amount: 30.0, Days: 30 Ace Inhibitor Combinations 5-10 mg 5-20 mg 5-40 mg amlodipine, tablet 2.5 mg Amount: 45.0, Days: 30 Calcium Channel Blockers 5 mg atorvastatin, tablet All Amount: 30.0, Days: 30 Antilipemics Avodart, capsule 0.5 mg Amount: 30.0, Days: 30 Benign Prostatic Hyperplasia Azor, tablet 5-20 mg Amount: 30.0, Days: 30 5-40 mg 10-20 mg Benicar, tablet 5 mg Amount: 60.0, Days: 30 Angiotensin Receptor Antagonists 20 mg Amount: 30.0, Days: 30 Benicar HCT, tablet 20-12.5 mg Amount: 30, Days: 30 40-12.5 mg Celebrex, capsule All Amount: 60.0, Days: 30 NSAIDS citalopram, tablet 10 mg Amount: 45.0, Days: 30 20 mg 40 mg Amount: 30.0, Days: 30 clopidogrel, tablet 75 mg Amount: 30.0, Days: 30 Platelet Aggregation Inhibitors Crestor, tablet All Amount: 30.0, Days: 30 Antilipemics Diovan, tablet 40 mg Amount: 60.0, Days: 30 Angiotensin II Receptor Antagonists 80 mg 160 mg donepezil, tablet & ODT 5 mg Amount: 30.0, Days: 30 Antidementia doxazosin, tablet 1 mg Amount: 30.0, Days: 30 Alpha Blockers 2 mg 4 mg duloxetine, capsule All Amount: 60.0, Days: 30 escitalopram, solution 5 mg/5 ml Amount: 600.0, Days: 30
4 Medicare Part D November 2014 Drug Name Strength Rationale/Criteria Limit Drug Class escitalopram, tablet 5 mg Amount: 45.0, Days: 30 10 mg 20 mg Amount: 60.0, Days: 30 Exelon patch All Amount: 30.0, Days: 30 Antidementia Exforge, tablet 5-160 mg Amount: 30.0, Days: 30 5-320 mg 10-160 mg fluoxetine, capsule 10 mg Amount: 30.0, Days: 30 20 mg Amount: 120.0, Days: 30 galantamine, ER capsule 8 mg Amount: 30.0, Days: 30 Antidementia 16 mg galantamine, tablet 4 mg Amount: 180.0, Days: 30 Antidementia 8 mg Amount: 90.0, Days: 30 ibandronate, tablet 150 mg Amount: 1.0, Days: 30 Bisphosphonates Jalyn, capsule Amount: 30.0, Days: 30 Benign Prostatic Hyperplasia Latuda, tablet 20 mg Amount: 240.0, Days: 30 Antipsychotics 40 mg Amount: 30.0, Days: 30 120 mg 60 mg Amount: 60.0, Days: 30 80 mg losartan, tablet 25 mg Amount: 60.0, Days: 30 Angiotensin II Receptor Antagonists 50 mg losartan/hct, tablet 50-12.5 mg Amount: 30.0, Days: 30 100-12.5 mg lovastatin, tablet 10 mg Amount: 30.0, Days: 30 Antilipemics 20 mg Amount: 120.0, Days: 30 40 mg Amount: 60.0, Days: 30 metoprolol, ER tablet 25 mg Amount: 60.0, Days: 30 Beta-Blockers 50 mg 100 mg Amount: 45.0, Days: 30 Namenda, XR capsule 7 mg Amount: 30.0, Days: 30 Antidementia 14 mg Niacin, ER tablet 500 mg Amount: 90.0, Days: 30 Antilipemics olanzapine, tablet 2.5 mg Amount: 30.0, Days: 30 Antipsychotics 5 mg 7.5 mg 10 mg Amount: 60.0, Days: 30 15 mg 20 mg oxybutynin, ER tablet 5 mg Amount: 30.0, Days: 30 Urinary Antispasmodics 10 mg 15 mg Amount: 60.0, Days: 30
5 Medicare Part D November 2014 Drug Name Strength Rationale/Criteria Limit Drug Class paroxetine, tablet 10 mg Amount: 45.0, Days: 30 20 mg 40 mg 30 mg Amount: 60.0, Days: 30 Paxil, susp 10 mg/5ml Amount: 900.0, Days: 30 pravastatin, tablet All Amount: 30.0, Days: 30 Antilipemics Pristiq, tablet All Amount: 30.0, Days: 30 Prolia, solution 60 mg/ml Amount: 1.0, Days: 180 Miscellaneous quetiapine, tablet All Amount: 90.0, Days: 30 Antipsychotics Restasis 0.05% Amount: 64.0, Days: 30 Miscellaneous risperidone, solution 1 mg/ml Amount: 240.0, Days: 30 Antipsychotics risperidone, tablet 0.25 mg Amount: 90.0, Days: 30 Antipsychotics 0.5 mg 1 mg Amount: 60.0, Days: 30 2 mg 3 mg 4 mg Amount: 120.0, Days: 30 Sensipar, tablet 30 mg Amount: 120.0, Days: 30 Calcium Receptor Agonists 90 mg 60 mg Amount: 60.0, Days: 30 Seroquel, XR tablet 50 mg Amount: 120, Days: 30 Antipsychotics 150 mg Amount: 30.0, Days: 30 200 mg 300 mg Amount: 60.0, Days: 30 400 mg sertraline, tablet 25 mg Amount: 45.0, Days: 30 50 mg simvastatin, tablet All Amount: 30.0, Days: 30 Antilipemics tamsulosin, capsule 0.4 mg Amount: 60.0, Days: 30 Benign Prostatic Hyperplasia Tekturna, tablet 150 mg Amount: 30, Days: 30 Direct Renin Inhibitors/Combinations Tekturna, HCT tablet 150-12.5 mg Amount: 30.0, Days: 30 Direct Renin Inhibitors/Combinations 300-12.5 mg 150-25 mg Amount: 60.0, Days: 30 tolterodine, ER capsule All Amount: 30.0, Days: 30 Urinary Antispasmodics valsartan/hctz, tablet 80-12.5 mg Amount: 30.0, Days: 30 160-12.5 mg 160-25 mg venlafaxine, ER capsule 37.5 mg Amount: 30.0, Days: 30 75 mg 150 mg Amount: 60.0, Days: 30 ziprasidone, capsule 20 mg Amount: 60.0, Days: 30 Antipsychotics 40 mg 60 mg 80 mg Amount: 90.0, Days: 30
6 Medicare Part D November 2014 Tier Changes Table 4 Patients on these medications will pay a higher amount than they currently pay. Consider moving your patients who use these medications to a lower-cost alternative on the HMSA Medicare Part D formulary. This is not a comprehensive list of all drugs with tier changes. It s a listing of drugs with tier changes effective January 1, 2015, that may cause the most potential impact. Table 4: Medicare Formulary Tier Changes Effective January 1, 2015 Drug Name Drug Class 2014 Tier 2015 Tier Alternatives Abilify, tablet Antipsychotics 3 5 olanzapine, quetiapine, resperidone, ziprasidone Amitriptyline 1 4 citalopram, duloxetine, escitalopram fluoxetine, sertraline, venlafaxine Celebrex NSAIDS 2 4 Celecoxib (Pending FDA approval) Diovan Angiotensin II Receptor Antagonists 2 4 Valsartan Doxepin capsule, solution 1 4 citalopram, duloxetine, escitalopram fluoxetine, sertraline, venlafaxine Dulera Steroid/Beta-Agonist Combinations 2 4 Advair, Symbicort Estradiol tablet, patch Estrogens 1 4 Imipramine 1 4 citalopram, duloxetine, escitalopram fluoxetine, sertraline, venlafaxine Latuda, tablet Antipsychotics 3 5 olanzapine, quetiapine, resperidone, ziprasidone Megestrol acetate Hormonal Antineoplastic Agents 1 4 Namenda XR Antidementia 2 4 donepezil, Namenda solution Nasonex Nasal Steroids 2 4 fluticasone, flunisolide Nitrofurantoin Anti-Infectives 1 4 ciprofloxacin, sufamethoxazole/trimethoprim, trimethoprim Phenobarbital tablet, elixir, injectionection Anticonvulsants 1 4 carbamazepine, lamotrigine, topiramate Zolpidem Hypnotics 1 4 trazodone, Silenor, temazepam We understand that some patients may need to continue the use of certain medication for clinical reasons. We encourage you to discuss formulary options with your patients; in some cases, your patients may benefit from switching to an alternative medication. If needed, your patients can get one 30-day transition supply during the first 90 days of 2015 for new PA medications, non-formulary medications, and medications with new quantity limits. Medicare Formulary Preauthorization and Exception Requests To request a PA or an exception, please call or fax CVS/Caremark, HMSA s pharmacy benefits manager. Call TTY Fax Hours of Operation 1 (855) 479-3659 toll-free 1 (866) 236-1069 toll-free 1 (855) 633-7673 toll-free 24 hours a day, seven days a week Mail Medicare Coverage Determination and Appeals MC 109 P.O. Box 52000 Phoenix, AZ 85072-2000
7 Medicare Part D November 2014 General information about Changes to Akamai Advantage Part D (Drug) Hydrocodone Combination Products (HCPs) How is the new formulary structure different from CY2014 to CY2015? In CY2014, Akamai Advantage (AA) plans used a four-tier expanded drug formulary. - Tier 1: Generic - Tier 2: Preferred brand - Tier 3: Non-preferred brand - Tier 4: Specialty In CY2015, AA plans will use a five-tier standard drug formulary. - Tier 1: Preferred generic - Tier 2: Non-preferred generic - Tier 3: Preferred brand - Tier 4: Non-preferred brand - Tier 5: Specialty The Akamai Advantage prescription drug benefit includes four stages. The first stage is the annual deductible. - AA Complete and AA Standard have an annual deductible of $320, except for tier 1 drugs. - AA Complete Plus and AA Standard Plus have no deductible. The first dollar the member spends goes toward the cost of the prescription drugs. The second stage is the initial coverage stage. - The member stays in the initial coverage stage until the total drug costs (what the plan, the member, and others pay for the drugs) reach $2,960. Retail (30-day supply) Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Mail Order (90-day supply) Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Complete Complete Plus Standard Standard Plus $4.50 $4.00 $4.50 $4.00 $11.00 $10.00 $11.00 $10.00 $45.00 $40.00 $45.00 $45.00 $95.00 $75.00 $95.00 $95.00 25% 33% 25% 33% Complete Complete Plus Standard Standard Plus $4.50 $4.00 $4.50 $4.00 $22.00 $20.00 $22.00 $20.00 $90.00 $80.00 $90.00 $90.00 $190.00 $150.00 $190.00 $190.00 25% 33% 25% 33%
8 Medicare Part D November 2014 The third stage is the coverage gap. - The member stays in the coverage gap stage until the annual out-of-pocket drug costs reach $4,700. Not all plans have a coverage gap. Complete Complete Plus Standard Standard Plus No additional coverage gap Additional coverage gap for tier 1 drugs: $4.00 The fourth stage is the catastrophic stage. No additional coverage gap Member has to pay 45 percent of the drug cost for brand drugs. Member has to pay 65 percent of the drug costs for generic drugs. - The member moves to this stage after the yearly out-of-pocket drug costs reach $4,700. Additional coverage gap for tier 1 drugs: $4.00 Retail (30-day supply) All Akamai Advantage Plans Member Share The greater of 5 percent or $2.65 for generic drugs (including brand drugs treated as generic) and $6.60 for all other drugs Why do some drugs have restrictions? For certain prescription drugs, special rules restrict how and when HMSA pays for them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective way. These special rules also help control overall drug costs and keep members drug coverage more affordable. In general, these rules encourage members to get a drug that works for their medical condition and is safe and effective. Examples of rules include: - Restricting brand-name drugs when a generic version is available. - Getting the plan approval in advance. - Trying a different drug first. - Quantity limits. Why does HMSA restrict brand-name drugs when a generic version is available? Generally, a generic drug works the same as a brand-name drug and usually costs your patients less. When a generic version of a brand-name drug is available, HMSA usually won t cover the brand-name drug and network pharmacies will give the generic version. Why does HMSA require getting plan approval (prior authorization) in advance for certain drugs? The requirement for getting approval in advance helps guide appropriate use of certain drugs. For certain drugs, you or the member need to get approval from the plan before HMSA will agree to pay for the drug. This is called prior authorization. If approval isn t obtained, HMSA might not pay for the drug. Why does HMSA require trying a different drug (step therapy) first? This requirement encourages members to try less costly but just as effective drugs before HMSA covers another drug. For example, if drug A and drug B treat the same medical condition, the plan may require the member to try drug A first. If drug A doesn t work, the plan will then cover drug B. This requirement to try a different drug first is called step therapy. If you have documentation of your patient already trying the preferred drug or have clinical information that this would negatively affect the health and safety of your patient, please contact us for an exception. Why does HMSA require quantity limits? For certain drugs, HMSA limits the amount of the drug that members can have. For example, the plan might limit the number of refills, or how much of a drug can be dispensed at one time. If it s normally considered safe
9 Medicare Part D November 2014 to take only one pill per day of a certain drug, for example, HMSA may limit coverage to no more than one pill per day. What is HMSA s mail-order drug program? Generally, the drugs available through mail order are drugs that are taken on a regular basis for a chronic or long-term medical condition. The drugs available through HMSA s mail-order service are marked as mail-order (M) drugs in our drug list. HMSA s mail-order service requires you to order a 90-day supply. To get order forms and information about filling prescriptions by mail, members can call our mail-order pharmacy at 1 (855) 479-3659. This toll-free number is available 24 hours a day, seven days a week. TTY users, call 1 (866) 236-1069. If your patient uses a mail-order pharmacy that s not in the plan s network, the prescription won t be covered. Usually a mail-order pharmacy order will arrive in no more than 14 days. However, sometimes the mail order may be delayed. Your patient may get a temporary 30-day supply of the drug from a retail pharmacy in the event that the mail-order supply is delayed. HMSA s Akamai Advantage plans are governed by CMS rules that preempt state laws regarding mail order prescriptions. Did you know there are programs to help people pay for their drugs? Medicare provides Extra Help to pay prescription drug costs for people who have limited income and resources. Resources included in the analysis to determine eligibility for Extra Help include savings and stocks, not a member s home or car. If members qualify, they can get help paying for any Medicare drug plan s monthly premium, yearly deductible, and prescription copayments. This Extra Help also counts toward out-of-pocket costs. Members may be able to get Extra Help to pay for their prescription drug premiums and costs. To see if they qualify for Extra Help, members can call: - 1 (800) MEDICARE [1 (800) 633-4227]. TTY users, call 1 (877) 486-2048, 24 hours a day, seven days a week; - The Social Security Office at 1 (800) 772-1213, between 7 a.m. to 7 p.m., Monday through Friday. TTY users, call 1 (800) 325-0778; or - Med-QUEST (Hawaii s Medicaid program) at 587-3521 on Oahu or 1 (800) 316-8005 toll-free on the Neighbor Islands and U.S. Mainland. TTY users, call 692-7182 on Oahu or 1 (800) 603-1201 toll-free on the Neighbor Islands and U.S. Mainland. What is the Medicare Coverage Gap Discount Program? The Medicare Coverage Gap Discount Program provides manufacturer discounts on brand-name drugs to Part D enrollees who have reached the coverage gap and are not currently receiving Extra Help. What is a network pharmacy? A network pharmacy is a pharmacy that has a contract with the plan to provide members with covered prescription drugs. The term covered drugs means all of the Part D prescription drugs that are covered on HMSA s drug list. To find a network pharmacy, you can look in your Provider Directory, visit our website (hmsa.com/advantage), or call Customer Relations.