Changes to the HealthChoice Pharmacy Benefit

Plan Changes for 2013

There are no major changes to the pharmacy program for 2013. See the HealthChoice Select Medication List for changes.

Members can fill prescriptions for up to a 90-day supply at all HealthChoice Network Pharmacies at the same cost. The HealthChoice Pharmacy Network includes both independent and national chain pharmacies. Members also have the option to use mail service.

To view the list of preferred medications, see the HealthChoice Select Medication List or contact Express Scripts toll-free at 1-800-903-8113. TDD users call toll-free 1-800-825-1230.

The chart below provides a summary of the pharmacy benefits for 2013:

Network Pharmacy Benefits for Pre-Medicare Members
Medication Type	Up to a 30-day supply of any medication	Up to a 90-day supply of any medication
Generic	You pay cost of drug up to a maximum copay of $10.	You pay cost of drug up to a maximum copay of $25.
Preferred brand-name	If cost of drug is $60 or less, you pay maximum copay of $15 or cost of drug, if less. If cost of drug is more than $60, you pay 25% of cost up to a maximum copay of $30.	If cost of drug is $120 or less, you pay maximum copay of $30 or cost of drug, if less. If cost of drug is more than $120, you pay 25% of cost up to a maximum copay of $60.
Non-preferred brand-name	If cost of drug is $60 or less, you pay maximum copay of $30 or cost of drug, if less. If cost of drug is more than $60, you pay 50% of cost up to a maximum copay of $60.	If cost of drug is $120 or less, you pay maximum copay of $60 or cost of drug, if less. If cost of drug is more than $120, you pay 50% of cost up to a maximum copay of $120.
Specialty Specialty medications are covered for a 30-day supply when ordered through Accredo Health. Copays are as follows: Preferred drug: $60 copay Non-Preferred drug: $120 copay
*Note:* All plan provisions apply. Only costs for Preferred medications purchased at Network Pharmacies apply to the annual $2,500 out-of-pocket limit. Some medications are subject to prior authorization and/or quantity limitations. If you choose a brand-name medication when a generic is available, you are responsible for the difference in the cost in addition to the copay.

Plan Changes for 2011

Pharmacy Lifetime Maximum

The $2 million lifetime limit on Pharmacy Benefits was eliminated as of January 1, 2011.

New Step Therapy Program

Effective January 1, 2011, for non-Medicare members, there is a new Step Therapy Program for Intranasal Steroids directed at brand-name Intranasal Steroids that do not have a generic available. The generic medications, fluticasone and flunisolide, will continue to be covered as Preferred and not require a prior authorization. The prior authorization criteria for the single-sourced brand-name drugs will require use and failure of one of the generic medications in this category. The more commonly utilized examples of these drugs are Nasonex and Nasacort AQ.

Tobacco Cessation Program

Effective January 1, 2011, the tobacco cessation program is available for all members.

Medicare Coverage Limit

In accordance with CMS guidelines, the pharmacy initial coverage limit for Medicare members changed to $2,530. The annual deductible will remain at $310.

Plan Changes for 2010

Tobacco Cessation Program

- As of July 1, 2010, HealthChoice offers non-Medicare members lower copays for two 90-day courses of certain prescription tobacco cessation medications per year. The products are listed below and are available for $5 per fill:
  - Chantix 0.5mg & 1mg tablets
  - Buproban 150mg SA tablets
  - Bupropion HCL SR 150mg tablets
  - Nicotrol 10mg cartridge
  - Nicotrol NS 20mg/m nasal spray
- HealthChoice has also partnered with the Tobacco Settlement Endowment Trust (TSET) and Free and Clear to provide members with two 8-week courses of over-the-counter nicotine replacement therapy products and up to five one-on-one telephone coaching sessions at no charge to HealthChoice members.
- To take advantage of these benefits, contact the OKLAHOMA TOBACCO HELPLINE toll-free 1-800-QUIT-NOW (1-800-784-8669) and identify yourself as a HealthChoice member. Members living outside of Oklahoma call toll-free 1-866-QUIT-4-LIFE (1-866-784-8454).

New Prior Authorization Programs

- As of November 2010, Pharmacy Prior Authorization programs require all non-Medicare members to obtain a prior authorization for access to certain prescription medications used in the treatment of Narcolepsy, Multiple Sclerosis, and Rheumatoid Arthritis as well as select oncology/chemotherapy drugs. See Pharmacy Prior Authorizations, Quantity Limits, Specialty Medications and Step Therapy for Non-Medicare Members for more information regarding the medications included in the programs.

2010 Generic Releases

New generic medications are available for the brand-name medications listed below. If your medication is changing from Preferred status to non-Preferred status, please discuss the Preferred alternative with your physician. If your physician feels that it is in your best medical interest to continue taking any form of a non-Preferred medication, have your physician request a Prior Authorization review by calling the Medco Prior Authorization Line toll-free at 1-800-753-2851 or TDD 1-800-825-1230, Monday through Friday 7 a.m. to 8 p.m. CST.

BRAND-NAME MEDICATIONS	GENERIC MEDICATIONS	TREATMENT	LAUNCH DATE
Accolate	zafirlukast tablets 10 & 20mg	Asthma	Nov-10
Aceon Tablets	perindopril	High blood pressure	Apr-10
Aldara 5% Cream	imiquimod	External genital & perianal warts	Mar-10
Alphagan P Ophth Soln. 0.15%	brimonidine tartrate	Glaucoma	Feb-10
Ambien CR 6.25mg tablets	zolpidem tartrate extended-release 6.25mg tablets	Insomnia	Oct-10
Ambien CR 12.5mg tablets	zolpidem tartrate extended-release 12.5mg tablets	Insomnia	Dec-10
Amerge	naratriptan	Severe migraine headaches	Jul-10
Aricept	donepezil hci 5 & 10mg	Alzheimer’s disease	Nov-10
Arimidex	anastrozole	Breast cancer	Jun-10
Astelin Spray	azelastine HCL	Seasonal allergic rhinitis	Jun-10
Augmentin XR	amoxicillin/clavulanate/potassium	Various bacterial infections	May-10
Cardizem LA	diltiazem hydrochloride extended release tablets	Hypertension	Mar-10
Cozaar	losartan potassium	Hypertension	Apr-10
Diastat-Acudial 12.5-15-20mg	diazepam	Seizures	Oct-10
Differin Cream	adapalene 0.1%	Acne	Jul-10
Differin Gel	adapalene 0.1%	Acne	May-10
Effexor XR	venlafaxine hydrochloride	Depression / anxiety	Jul-10
Evoclin	clindamycin foam	Acne	Apr-10
Exelon 1.5mg, 3mg, 4.5mg, 6mg	rivastigmine tartrate	Dementia	Jul-10
Flomax	tamsulosin hydrochloride	Benign prostatic hyperplasia	Mar-10
Hyzaar	losartan / hydrochloro	Hypertension	Apr-10
Loprox Shampoo 1%	ciclopirox 1%	Seborrheic dermatitis	Mar-10
Lovenox	enoxaparin injection	Blood clot prevention	Jul-10
Methylin Oral Solution	methylphenidate oral solution	ADHD	Jul-10
Mirapex 0.75mg	pramipexole dihydrochloride	Parkinson’s disease	Oct-10
Mirapex all strengths (except 0.75mg)	pramipexole dihydrochloride	Parkinson’s disease	Jan-10
Opana tablets	oxymorphone immediate-release tablets	Moderate-severe pain	Sep-10
Pepcid Suspension	famotidine	GERD	Jun-10
Phenytek 200 & 300mg	phenytoin 200 & 300mg	Epilepsy	Jan-10
Ponstel 250mg capsules	metfenamic acid	Decreases inflammation (swelling) and uterine contractions	Dec-10
Prevacid Solu Tabs	pramipexole dihydrochloride	Parkinson’s Disease	Oct-10
Prozac Weekly	fluoxetine delayed-release capsules	Depression	Mar-10
Sanctura	trospium	Urinary incontinence	Aug-10
Skelaxin 800mg	metaxalone	Muscle spasms	Apr-10
Tarka 2/180, 2/240, 4/240	trandolapril/verapamil	Hypertension	Jul-10
Tofranil – PM	imipramine	Adult depression	Apr-10
Trileptal Suspension 300mg/5ml	oxcarbazepine	Epilepsy	Jan-10
Venlafaxine HCL ER	venlafaxine HCL	Depression	May-10
Yasmin	drospirenone and ethinyl estradiol	Contraception	Jun-10
Zegerid 40mg	omeprazole 40mg	Acid reflux	Jul-10

Please Note: The anticipated “generic” launch dates listed above are subject to change based on new or ongoing legal issues between the brand and generic manufacturers.

Last Modified on 03/13/2013