For Participating Medical Practitioners 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 2005-2006 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 United States 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 2005-2006 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 QUEST injectables...2 New medication management program...2 HHIN dial-up discontinued...2 Drug updates...3 Reminders...3 Formulary update...4 Contact information...4 PM06-004
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; effective February 1, 2006, these drugs deny at point-of-sale if a pre-certification 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 MEDICATION THERAPY MANAGEMENT PROGRAM COMING SOON! The Medication Therapy Management (MTP) Program for HMSA s 65C Plus Prescription Drug Coverage Plan is coming soon. We will be recruiting a provider network shortly in preparation for a program launch date of May 1, 2006. Physicians with eligible patients will be receiving information on the program in April. 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 948-5387. For existing HHIN users, please call 949-6446 on Oahu or 1 (800) 760-4672 from the Neighbor Islands. DRUG UPDATES 2
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. TRIPTAN QUANTITY LIMIT CHANGES EFFECTIVE JANUARY 1, 2006 Maxalt, Maxalt MLT 9 tablets per 30 days Zomig nasal spray 6 sprays per 30 days Pre-certification is required when a physician wishes to prescribe quantities exceeding the limits. NDC CLARIFICATION 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 classified at the same benefit level as other insulins for the Select, 65C Plus Prescription Drug Coverage 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 2006. Levemir will be available in two forms: FlexPen and vial. REMINDERS NIASPAN EXCLUSIONS In the last newsletter, we notified providers 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. 3
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 members 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 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. HMSA FORMULARY UPDATE Enclosed is the HMSA Formulary update. Please include it with your formulary reference material. The formulary is available on HHIN and the Internet at www.hmsa.com/portal/provider. 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 96808-0860 4
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 948-6330 on Oahu or 1 (800) 790-4672 from the Neighbor Islands HMSA Membership Connection (touch-tone eligibility verification) on Oahu at 948-6244 or 1 (800) 552-8507 from the Neighbor Islands The HMSA Plan for QUEST Members Provider Services at 948-6486 on Oahu or 1 (800) 440-0640 from the Neighbor Islands Members with questions or concerns regarding their HMSA drug plans may call an HMSA Customer Service representative at the following numbers: Oahu 948-6111 Kauai 245-3393 Hilo 935-5441 Maui, Lanai, Molokai 871-6295 Kona 329-5291 QUEST members who have questions or concerns may call QUEST Member Services at 948-6486 on Oahu or 1 (800) 440-0640 from the Neighbor Islands. 5