Microsoft word - prescription drug coverage updates 01-2009.doc

Community Health Systems
(Facilities that were formerly Triad, updates effective January 2009)
Prescription Drug Coverage Updates

Below is the list of drugs impacted by changes effective January 2009.
Initial Prior Authorization:
Prior Authorization is a process that requires the prescribing physician to provide information prior to the
pharmacy dispensing the prescription.
Drug Class
Concerta, Daytrana, Focalin, Focalin XR, Metadate, Methylin, Ritalin, Ritalin LA, Amphetamines PA, Adderall, Adderall XR, Desoxyn, Dexedrine, Dextrostat, Vyvanse Aciphex, Nexium, Prilosec, Omeprazole, Prevacid, Protonix, Pantoprazole, Zegerid Depo-testerone, Testopel pellets, Methyltestosteone. Fluoxymesterone, Delatestryl, Testosterone cypionate, Androgel, Androderm, Testim, Striant, topical ointment, topical cream, and powder for compounding. Topical Tretinoin, Differin, Tazorac, Atralin, Avita, Retin-A, Tretin-X, Ziana
Proton Pump Inhibitors are covered for ages under 18 and over if Prior Authorization criteria is met.

Quantity Limit:
If the requested quantity is less than the limit below, prescription claim will process at the point of sale.
No action is required from the participant.
Drug Class
Quantity Limit
(tablets, capsules, or units)
4 tablet/25 days at retail; 12 tablets/75 days at mail Monthly dose- 1 tablet/25 days at retail; 3 tablets/75 days at mail # 20 tablets/25 days at retail # 20 tablets/25 days at mail # 150 tablets/25 days at retail # 450 tablets/75 days at mail Limitations are subject to updates. Please contact Caremark Customer Care at 1-888-771- 7268 for updates on specific drug coverage. Updated 1-20-2009 Quantity Limit with a post quantity limit prior authorization:
Initial Quantity limit, followed by a Prior Authorization if initial quantity is exceeded.
Drug Class
Initial Quantity Limit

Anzemet Inj 5 mL /15 days Aloxi 5 mL /15 days Aloxi Tabs 6 / 15 days Kytril Soln 30 mL / 15 days Kytril Inj = 1 mL / 15 days Zofran 24 mg tabs = 1 tablets/ 15 days Zofran 4 mg, ODT 9 tablets/ 15 days Zofran 8 mg tablets/ODT tabs - 9 tablets/ 15 days Zofran Soln 100 mL / 15 days Zofran 2 mg/mL inj 10 mL /15 days Zofran 32 mg/50 mL IV = 50 mL /15 days Emend 40mg 3 tables/ 6 months Emend 80 mg 2 tablets/15 days Emend 125 mg 1 tablet/ 15 days Emend 115 mg inj 1 vial/15 days (quantity limit is the same for both retail and mail) Imitrex,Maxalt, Relpax, Zomig Axert 12 tablets/ 25 days Frova 9 tablets/ 25 days Imitrex tablets 9 tablets/ 25 days Imitrex Inject syringe 4 syringes (2 kits)/ 25 days Imitrex Inject vials 5 vials / 25 days Imitrex nasal spray 6 doses (1 box) / 25 days Maxalt 12 tablets/ 25 days Maxalt-MLT 12 tablets/ 25 days Migranal Nasal Spray 1 kit (8 units)/ 25 days Relpax 12 / 25 days Treximet 9 / 25 days Zomig 6 / 25 days Zomig ZMT 6 / 25 days Zomig Nasal spray 6 / 25 days Tamiflu 75 & 45 mg capsules - 10 units Tamiflu 30 mg capsules- 20 units Tamiflu solution- 75 ml (1 fill every 180 days) 2 X 3ml unit/ 25 days at retail 6 X 3ml unit/ 75 days at mail 360 tablets/75 days at mail (all strengths combined) 360 tablets/75 days at mail (all strengths combined) Limitations are subject to updates. Please contact Caremark Customer Care at 1-888-771- 7268 for updates on specific drug coverage. Updated 1-20-2009
Quantity Limit with a post quantity limit prior authorization (continued):
Drug Class
Initial Quantity Limit

10 patches/25 days at retail 30 patches/75 days at mail 10 dosing units/365 days at retail and mail 20 dosing units/365 days at retail and mail Step Edit with a post step edit prior authorization
Drug Class
Over-the-Counter (OTC) Drugs

As the table below indicates, your prescription drug program does not cover prescription drugs in certain
categories that have OTC alternatives. This program helps to lessen the rising cost of medical insurance
to CHS and you—and encourages employees to save money by purchasing a less costly OTC drug
alternative, when available. OTC medications do not require a prescription. Please review your
enrollment guide for additional information.
Some Drugs with OTC Alternatives are NOT Covered
NOT covered under
medications may not be covered due to other factors subject to ageand/or authorization requirements ranitidine syrup1 ranitidine tablets1 Zantac syrup3 Zantac tablets1 discuss OTC alternatives with your doctor or your physician regarding any medication changes. Non-Drowsy Allergy Loratadine tablets Tavist ND tablets Zyrtec tablets/syrup 1Not Covered | 2Covered through age 6 | 3Covered for ages under 18 | 4Covered for ages under 18 and over if Prior Authorization criteria is met Limitations are subject to updates. Please contact Caremark Customer Care at 1-888-771- 7268 for updates on specific drug coverage. Updated 1-20-2009

Source: http://www.lutheranhealth.net/pdfs/team_members/Prescription%20Drug%20Coverage%20Updates.pdf