Carolina Care Plan ® - A Medical Mutual of Ohio ® Company

2009 Prescription Information Benefit
Carolina Care Plan® Inc.


INTRODUCTION

Carolina Care Plan’s Preferred Drug List (PDL) is designed to provide a broad therapeutic list of preferred drugs for use in meeting the pharmacy needs of our members. It is intended to serve as a guide in selecting clinically and therapeutically appropriate medications in a cost-effective manner. Carolina Care Plan’s Preferred Drug List is not intended to take the place of physician’s judgement with regard to their patient’s pharmaceutical care. Each physician/practitioner must rely on his/her own best medical judgement in selecting appropriate pharmaceutical agents. The Preferred Drug List does not define coverage, which is determined by the member's prescription drug benefit plan. The designation of drug tiers is for benefit reference and information only. In and of itself, it is not a clinical comparison between drugs. Placement on the list does not establish clinical comparability of products in individual situations. The list provides examples of drugs but is not an exhaustive list of all drugs falling into each benefit category.

Carolina Care Plan®, Inc. and our Pharmacy Benefit Manager, Express Scripts Inc, develop and maintain a list of recommended medications for our members called a Preferred Drug List (PDL). Express Scripts recommends preferred drug list updates to Carolina Care Plan, after they evaluate the drugs to see, first, how effective and safe they are, then how affordable. Prescription drugs that meet these standards are included in your PDL. Periodic additions and modifications to the Preferred Drug List can be viewed at www.carolinacareplan.com.

Privacy and confidentiality are long standing principals in the way we, at Carolina Care, have conducted business over the years. So, in many respects the concepts are not new. The part that is new is that the federal government published rules and standards which everyone in the healthcare industry must follow to ensure uniformity regarding the Privacy of every members’ health information

The Privacy Regulation protects health information relating to past, present, or future physical or mental health of an individual. Any health information that can be directly linked or associated with an individual is referred to as “protected health information” or PHI for short. Protected health information can be in written, electronic or oral form. For more information please visit United States Department of Health & Human Services Website.

You can find more details bellow on the following topics:


Preferred Drug List Overview

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The Preferred Drug List is a listing of medications available at the time the drug list was printed and is intended for use by physicians.

A generic drug is defined as a prescription drug product that either:

  • is chemically equivalent to a brand name drug.
  • we identify as a Generic product.

The classification of a prescription drug product as a generic is determined by us and not by the manufac¬turer or pharmacy. We classify a prescription drug product as a generic based on commercially avail¬able data resources, such as FirstData Bank. Therefore, all products identified as a "generic" by the manufacturer or pharmacy may not be classified as a generic by us.

Also, the classification of a drug as a brand or generic may change from time to time, based on a variety of factors.

The Preferred Drug List applies only to prescription medications dispensed to outpatients at network pharmacies. The drug list does not include inpatient medications or medications obtained or administered in a physician's office.


Over The Counter (OTC) Medications

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Carolina Care Plan does not cover medications avail¬able over the counter (OTC) that do not require a prescription order or refill by federal or state law before being dispensed, or medications that are therapeutically equivalent to an over the counter drug.

A prescription drug will be considered to be equivalent to an OTC drug when:

  • it is available in the identical strength and dosage form as both a prescription and non prescription drug.
  • it is available in a higher strength as a non prescription drug.
  • prescription combination products contain ingredients that may be available separately as non prescription drugs.
  • the OTC drug is therapeutically equivalent to the prescription product.

In these cases, providers should refer the patient to the equivalent OTC product. In some instances, OTC medications are listed in the Preferred Drug List for reference purposes only. If the member or physi¬cian insists on the prescription equivalent product, the member will be required to pay the entire cost of the prescription. This is determined by the mem¬ber's prescription drug benefit plan.


Half-Tablet Program

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When clinically appropriate, CCP may require the use of the higher strength of a drug, when the tablets are scored and can be easily halved. CCP realizes there might be instances when the half-tablet program is not clinically appropriate. When this is the case, an override can be obtained by calling CCP’s Pharmacy Benefit Manager at 800-417-8164. Aceon 4mg, Celexa 20mg, Lexapro 10mg, mirtazapine 7.5mg, Paxil 10mg, Valtrex 500mg, and Zoloft 50mg tablets for inclusion on the Half Tablet Program; therefore, no coverage is provided without authorization. This list could change without notice.


Step Therapy Program

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CCP is committed to providing quality health care benefits while maximizing the use of valuable resources. In order for certain drugs to be covered without notification and approval, other clinically proven, "prerequisite therapy" medication(s) must be tried first. CCP realizes there might be instances when the step therapy program is not clinically appropriate. When this is the case, the prescribing physician, or their designee, must provide member clinical information to the Physician Notification Call Center by calling toll free 800-417-8164 or 877-853-5756 (fax).

Drugs in the therapeutic classes known as Angiotensin Converting Enzyme Inhibitors (ACEIs), Angiotensin II (A-II) Receptor Antagonists, Antidepressants, Bisphosphonates, Branded Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and COX-2 Inhibitors, Disease-Modifying Anti-Rheumatic Drugs (DMARDs), Growth Hormones, HMG-COA Reductase Inhibitors (HMGs),Oral Anti-fungals, Overactive Bladder Agents, Proton Pump Inhibitors (PPIs), Topical Immunomodulators, Advair, Avodart, Cymbalta, Effexor, Forteo, Janumet, Januvia, Lexapro, Seroquel, Singulair, Strattera, Symbicort, Topamax, Xopenex, and Zetia for inclusion in the Step Therapy Program.


Quantity Limit Program

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Most plan sponsors establish general parameters regarding day’s supply and quantity of a given drug that a patient may receive under their pharmacy benefit plan. The drug-specific limits will be referred to as the Quantity Limits (QL) Program. QL Program controls the quantity (number of units or tablets) or the number of prescriptions a member may receive for a specified drug. Based on the manufacturers’ administration and dosing guidelines, and the Food and Drug Administration’s (FDA) approval of those guidelines.


Generic Drug Policy

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Generic drugs are included on the Preferred Drug List even though they are not all listed in this book. Specific drugs, which have generic equivalents, may be covered at an established reimburse¬ment level and when appropriate, physicians should consider prescribing the generic form. If a brand is dispensed when a generic is available, the member will be responsible for the generic co-payment and ancillary charge. (Ancillary charge is the generic copay plus the difference in cost between the brand and generic.)

Note that if a brand name drug becomes available as a generic during the year, that brand name product may become non preferred. The member's copay¬ment is determined by their prescription drug bene¬fit plan. When generic substitution conflicts with state regulations or restrictions, the pharmacist must obtain approval from the prescriber to use the generic equivalent.


Self Administered Injectables

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Some members may have coverage for self adminis¬tered injectable medications through their pharmacy benefit plan. You will find these drugs included in the body of this document within the appropriate therapeutic categories. The preferred vendor for these self administered injectable medications is CuraScript Pharmacy. CuraScript Pharmacy can be reached toll free at 888-773-7376 (phone) or 888-773-7386 (fax). If a member receives one of these medications in the provider’s office, they may be responsible for their prescription copayment. The majority of members must pay a $75.00 copayment. RA drugs (Enbrel, Humira and Kineret) and MS drugs (Avonex, Betaseron, Copoxone, Rebif) must be filled at CuraScript Pharmacy.


Medications Requiring Notification

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Selected medications may require notification (N) to be eligible for coverage consistent with the member's benefit plan. These drugs are designated in the Preferred Drug List.

In order for a member to receive coverage for a medication requiring notification, the prescribing physician, or their designee, must provide member clinical information to the Physician Notification Call Center by calling toll free 800-417-8164 or 877-853-5756 (fax).

Medication

Summary of Criteria*

Actiq lozenges, fentanyl citrate, Fentora

Treatment of breakthrough cancer pain.

Angiotensin Converting Enzyme Inhibitors

(Aceon, Altace, Azor, Lexxel, Lotrel, Tarka, Tekturna)

Notification required if no history of trial using a generic angiotensin converting enzyme inhibitor (ACEI), ACEI /HCTZ combination, or ACEI /CCB combination within previous 180 days. (benazepril, benazepril/hctz,captopril, captopril/hctz, enalapril, enalapril/hctz, fosinopril, fosinopril /hctz, lisinopril, lisinopril/hctz, moexipril,/hctz, quinapril, quinaretic, trandolapril)

Angiotensin II (A-II) Receptor Antagonist

(Atacand, Atacand HCT, Avalide, Avapro, Benicar, Benicar HCT, Cozaar, Hyzaar, Diovan, Diovan HCT, Micardis, Micardis HCT, Teveten)

Notification required if no history of trial using a generic or brand name angiotensin converting enzyme inhibitor (ACEI), ACEI /HCTZ combination, or ACEI /CCB combination within previous 130 days.(Aceon, Aldoril, Altace, atenolol/chlorthalidone, benazepril, benazepril/hctz, bisoprolol fumarate/hctz, Capoten, Capozide, captopril, captopril/hctz, clonidine/chlorthalidone, Clorpres, Corzide, enalapril maleate, enalapril/hctz, fosinopril, Inderide, Lexxel, lisinopril, lisinopril/hctz, Lopressor HCT, Lotrel, moexipril hcl, Prinivil, Prinzide, propranolol/hctz, quinapril, quinaretic ,Tarka, Tenoretic, trandolapril , Uniretic, Univasc, Vaseretic, Vasotec, Zestoretic, Zestril, Ziac)

Antidepressants

(Cymbalta, Effexor /XR, Lexapro)

Notification required if no history of trial using generic antidepressant for 60 days, within previous 130 days. (bupropion, citalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline)

Bisphosphonates

(Actonel/with Calcium, Boniva, Fosamax/Soln/Plus-D)

Notification required if no history of trial using generic bisphosphonates within previous 180 days. (alendronate)

Branded NSAIDS & COX-2 Inhibitors

(Arthrotec, Celebrex, Ponstel)

Notification required if no history of trial using a generic non-steroidal anti-inflammatory (NSAID) within previous 180 days. (diclofenac potassium, diclofenac sodium, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meclofenamate, mefenamic acid, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tramadol, meloxicam)

Combination Beta Agonist/Corticosteroid Standard Inhaler PA

(Advair, Advair Diskus, Symbicort)

Notification required. Approved if member is using for asthma, reactive airway disease, COPD, Chronic Bronchitis, emphysema, post infectious cough

Crinone 8% gel, Prochieve 8% gel

No coverage unless the group’s prescription benefits allow coverage for fertility medications.

Disease-Modifying Antirheumatic Drugs

Enbrel injection, Humira injection, Kineret injection

Treatment of rheumatoid arthritis. Approved if patient has trial of using a disease-modifying antirheumatic drug (DMARD) within previous 180 days. (Arava, Azulfadine, gold sodium thiomalate, hydroxychloroquine, Imuran, methotrexate, MTX, Plaquenil, Rheumatrex, Solganal, sulfasalazine) MUST USE CURASCRIPT, NOT COVERED AT RETAIL.

Forteo

Approved for treatment of osteoporosis or severe ongoing bone loss (bone density T-score below –2.0) and for hypoparathyroidism if prescribed by an endocrinologist. Approved if trial of using Actonel, Evista, Fosamax, or Miacalcin within previous 180 days.

Fuzeon

Approved for patients who have been treated with, and were refractory to, a combination of at least two individual antiretroviral medications of one combination antiretroviral medication. (Zerit, Agenerase, Combivir, Crixivan, Epivir (not Epivir-HBV), Epzicom, Fortovase, Hivid, Norvir, Rescriptor, Retrovir, Sustiva, Trizivir, Truvada, Videx, Videx EC, Viracept, Viramune, Ziagen)

Growth Hormones

Genotropin, Tev-Tropin, Humatrope, Norditropin, Nutropin AQ, Nutropin Depot, Nutropin, Protropin, Saizen, Serostim, somatrem, somatropin, Iplex, Increlex

Children diagnosed with acquired growth hormone deficiency, Turner’s syndrome, Prader-Willi syndrome, Silver-Russell syndrome, congenital hypopituitarism, chronic renal insufficiency, AIDS wasting, HIV-associated failure to thrive, or who have undergone brain radiation.

Half-Tablet Program

(Aceon 4mg, Celexa 20mg, Lexapro 10mg, mirtazapine 7.5mg, Paxil 10mg, Valtrex 500mg, Zoloft 50mg)

No coverage unless patient is unable to cut the higher strength tablet in half to achieve proper dosing due to difficulties with dexterity, eyesight, etc. May also be authorized if patient’s dosing requires that this strength tablet be cut in half. Rationale is that while these drugs are manufactured in several strengths, all the tablets are scored (which allows them to be cut in half and still achieve proper dosing) and all strengths are priced virtually the same.

HMG-COA Reductase Inhibitors

(Lipitor, Lescol/XL, Caduet, Vytorin, Crestor, Altoprev, and Altocor)

Notification required if no history of trial using generic HMG-COA Reductase Inhibitors. within the previous 180 days. (lovastatin, simvastatin or pravastatin)

Inspra

Notification required if no history of trial using spironolactone or spironolactone/hctz. Authorized if patient is post myocardial infarction, or has been hospitalized for heart failure, and has already been started and stabilized on Inspra. Also approved for adverse reaction to spironolactone.

Janumet, Januvia

Notification required if no history of trial using Glucophage or metforin.

Lamisil tablets or Sporanox capsules

Must have a positive result for onychomycosis either by a KOH or laboratory culture of the nail fungus. Approval may be granted when prescribed by a dermatologist or podiatrist.

Lupron injection, Lupron Depot, Lupron Depot-Ped, Leuprolide acetate

Treatment of endometriosis, uterine leiomyomata (fibroids), menstrual disorder associated with excessive bleeding and pain, prostatic cancer, and central precocious puberty. Notification required for females 18 years old and above. No coverage for fertility treatment unless the group’s prescription benefits allow coverage for fertility medications.

Avodart, finesteride

Notification required if no history of trial using generic finesteride. (New starts only) Treatment of benign prostatic hyperplasia (BPH). Notification required for males less than 45 years old. No coverage for use by females.

Overactive Bladder Agents

(Detrol, LA, Ditropan XR, Oxytrol, Vesicare)

Notification required if no history of trial using generic oxybutynin/er

Peginterferons

Pegasys, PEG-Intron

Treatment of hepatitis C, chronic hepatitis B, renal cell carcinoma, chronic myelogeneous leukemia, other cancers, essential thrombocythemia. Patients with hepatitis will be evaluated by a pharmacist and/or physician on a case-by-case basis.

Proton Pump Inhibitors

(Aciphex, Nexium, Prevacid)

Treatment of gastric ulcers, erosive esophagitis, gastroesophageal reflux disease (GERD), and hypersecretory conditions. omeprazole 20mg is covered. Notification required if no history of trial using omeprazole within previous 180 days.

Provigil

Treatment of narcolepsy, idiopathic hypersomnia or excessive daytime sleepiness (e.g., may be due to sleep apnea, etc.), fatigue associated with multiple sclerosis (MS) or cerebral palsy. Not approved for ADD/ADHD, as adjunctive treatment of depression, or for fatigue or sleepiness associated with use of narcotic analgesics unless another CNS stimulant has been tried first. (Adderall, Adderall XR, amphetamine salts, Concerta, Cylert, Desoxyn, Dexedrine, Focalin, dextroamphetamine, Metadate CD, Metadate ER, methylphenidate, pemoline, Ritalin, Ritalin LA)

Raptiva

Treatment of chronic (> 1 year) plaque psoriasis with minimum body surface area involvement of > 15%, less if face and hands are affected. Patient must have previously tried systemic therapy.

Restasis

Treatment of keratoconjunctivitis sicca (KCS).

Atralin, Differin, Retin-A, Trentinoin

Treatment of medical skin conditions (i.e., acne vulgaris, actinic keratoses, precancerous skin lesion). Notification required for patients greater than 29 years old. No coverage for treatment of cosmetic skin conditions, e.g., wrinkles, hyper- or hypopigmentation, alopecia, melasma/cholasma, stretch marks, scars, etc.

Revatio

Treatment of pulmonary arterial hypertension (PAH).

Seroquel

Notification required if member is taking <100mg per day . Not approved for insomnia or headaches.

Singulair

Treatment of asthma or acute respiratory syncytial virus (RSV) bronchiolitis. No notification required if prescription history of patient using a beta-adrenergic agonist or an inhaled corticosteroid or inhaled cromolyn/ nedocromil. No coverage for treatment of allergic rhinitis, atopic dermatitis, or chronic urticaria.

Strattera

Treatment of attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD). Notification required if no history of trial using brand or generic central nervous system (CNS) stimulant within previous 180 days. (Adderall, Adderall XR, amphetamine salts, Concerta, Cylert, Desoxyn, Dexedrine, Focalin, dextroamphetamine, Metadate CD, Metadate ER, methylphenidate, pemoline, Ritalin, Ritalin LA)

Suboxone

Treatment of opioid dependence. Carolina Care Plan’s Medical Director will make the coverage determination.

Tazorac

Treatment of stable plaque psoriasis, mild to moderate acne vulgaris, basal cell carcinoma, congenital ichthyoses, keratosis pilaris, Darier’s disease (keratosis follicularis), discoid lupus erythematosus, keratoderma blennorrhagicum, perforans serpiginosa, or spiny keratoderma. No coverage for treatment of cosmetic skin conditions, e.g., wrinkles, hyper- or hypopigmentation, alopecia, melasma/cholasma, stretch marks, scars, etc.

Topamax

Notification required. Approved for seizures, bipolar disorder, migraine headache prevention. Not approved for weight loss.

Topical Immunomodulators

Elidel, Protopic

Treatment of anogenital lichen sclerosis, atopic blepharitis , atopic dermatitis (atopic eczema), bullous pemphigoid, chronic actinic dermatitis, chronic cutaneous graft-vs.-host disease (GVHD), contact allergic dermatitis, cutaneous lupus erythematosus, dermatomyositis, dyshidrotic palmar eczema, eczema, erosive or ulcerative mucosal (oral, vulvovaginal), erosive pustular dermatosis, lichen planus, orofacial or perineal Crohn’s disease, psoriasis, pyoderma gangrenosum, seborrhoeic dermatitis, severe uremic pruritus, steroid-induced rosacea, vitiligo, etc Notification required if no history of trial using a prescription strength topical corticosteroid. (Aclovate, Ala-Quin, alclometasone ointment, amcinonide, Aristocort, betamethasone dipropionate, betamethasone valerate, betamethasone/propylene glycol, clobetasol propionate, Clobex, Cloderm, Cordran, Cormax, Cutivate, Cyclocort, Derma-Smoothe/FS, desonide, Desowen, desoximetasone, diflorasone, Diprolene /AF, Elocon, Enzone, Epifoam, Florone, fluocinolone acetonide, fluocinonide, fluticasone propionate, Halog /-E, hydrocortisone, hydrocortisone butyrate, hydrocortisone valerate, hydrocortisone/clioquinol, hydrocortisone/iodoquinol, hydrocortisone/pramoxine, hydrocortisone/pramoxine, Hytone, Kenalog, Lidex, Locoid, Luxiq, mometasone, Pandel, Pramosone, Psorcon E, Synalar, Temovate, Topicort, triamcinolone acetonide, Ultravate, Vytone, Westcort)

Vfend

Treatment or prevention of other serious systemic fungal infections or invasive aspergillosis. Treatment of esophageal candidiasis after a trial of one other systemic agent. Patient started and stabilized on IV therapy and oral therapy is continuation of treatment.

Xolair

Treatment of moderate to severe persistent asthma for patients > 6 years of age. Treatment of seasonal or perennial allergic rhinitis for patients > 12 years of age.

Xopenex

Treatment of asthma. Notification required if no history of trial using albuterol-containing inhalation solution for nebulization within previous 180 days. (albuterol, Duoneb, Proventil, Ventolin)

Zavesca

Treatment of mild to moderate type 1 Gaucher disease. Carolina Care Plan’s Medical Director will make the coverage determination.

Zetia

Adjunctive therapy for reduction of elevated total cholesterol (total-C), low-density lipoprotein cholesterol (LDL-C) and apolipoprotein B (Apo-B). Members must have concurrent use of an HMG-CoA reductase inhibitor (Altocor, Crestor, Lescol, Lescol XL, Lipitor, lovastatin, Mevacor, Pravachol, or Zocor) within the past 180 days.

Zyvox

Patient must have been started in hospital, other inpatient facility, or as an outpatient on intravenous (IV) therapy and is now being changed to oral Zyvox. This is to allow continuation of therapy.

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