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- Definitions
- Additions to the Preferred Drug Lists
- Line Extension Additions to the Preferred Drug Lists
- Line Extension Additions to the HealthPartners Medicare Formulary Only
- Changes to the Preferred Drug Lists
- Medications Reviewed but Not Added
- Deletions from the Preferred Drug List
- Legal Disclaimer
January 2008 Preferred Drug List Updates
The HealthPartners Pharmacy and Therapeutics Committee updates the preferred drug list every three months. This listing represents additions and changes implemented January 1, 2008 unless otherwise stated. All drug additions and changes are the same for the HealthPartners Medicare Formulary unless otherwise stated in this Update.
This summary was written for health care providers and has been slightly modified for the general public.
Our HealthPartners preferred drug list information is also available within the ePocrates database at no charge to users. This electronic database is downloaded from www.ePocrates.com. Providers and members are encouraged to use and share this information. The ePocrates drug information service is available for most handheld devices such as Palm Pilots.
DEFINITIONS
The following terms have been used:
Age Limit: You'll see this term next to medications that are available to patients within a specific age group. Patients outside of this age group need to meet specific criteria before the medication will be approved.
Cost: All cost information reflects the average wholesale price (AWP). Costs to consumers may vary because of different strengths, forms, quantities and pharmacy benefits.
Physician-Edit: This term means that a medication is reserved for prescribing by certain physician specialists.
Prior Approval: This term means that specific criteria must be met before the medication will be approved. Typically, your provider submits these requests to HealthPartners.
Step Therapy: This term means that your doctor will need to prescribe one medication before trying another. Prior approval is needed if HealthPartners does not have a record of the first prescription.
GENERIC UPDATE
Most members have a lower copay for generic medications. Members who choose to continue using brand-name medications when a generic is available may pay a higher amount for the brand.
Recent generics for products on the preferred drug list (formulary) include:- Ofloxacin otic (Floxin®), an antibiotic ear drop.
- Oxcarbazine (Trileptal®), a seizure medication.
News and Announcements: Cetirizine (Zyrtec®), a commonly-used allergy medication, is changing to a non-prescription over-the-counter (OTC) status, and should be available in pharmacies January 2008. OTC costs are expected to be less than $20 per month for several months, and then to decrease further. HealthPartners is planning to delete Zyrtec® from the preferred drug list when prescription forms are no longer available.
ADDITIONS TO THE PREFERRED DRUG LISTS
chlorhexidine gluconate 0.12% oral solution (Peridex®)
Medication Category: Miscellaneous Products / Dental and Oral Agents
Preferred Drug List Status: On the preferred drug list without restriction
Chlorhexidine gluconate is an oral rinse used to treat gingivitis, a condition in which the gums become red and swollen. Chlorhexidine gluconate is also used to control gum bleeding caused by gingivitis. This medication is available generically.For Medicare Part D: No change–this medication was already on the HealthPartners Medicare Formulary.
Corticotrophin gel (Acthar® HP injection)
Medication Category: Endocrine Drugs
Preferred Drug List Status: On the preferred drug list with prior approval
Acthar® HP is reserved for treating infantile spasms, and for prescribing by providers with expertise in treating this condition.
Acthar® HP will be considered a specialty medication and must be obtained from CuraScript.
For Medicare Part D: Acthar® HP injection will not be added to the HealthPartners Medicare Formulary, since it is being added for use in infants only.
demeclocycline (Declomycin®)
Medication Category: Endocrine Drugs / Hormonal Agents, Stimulant / Replacement / Modifying (Pituitary) for HealthPartners Medicare Formulary
Preferred Drug List Status: On the preferred drug list without restriction
Demeclocycline is used for treating diabetes insipidus.
ethacrynic acid (Edecrin®)
Medication Category: Cardiovascular Drugs / Cardiovascular Agents for HealthPartners Medicare Formulary
Preferred Drug List Status: On the preferred drug list without restriction
Edecrin® is a potent diuretic similar in action to furosemide.
felbamate (Felbatol®)
Medication Category: Anticonvulsants) / Anticonvulsants Agents for HealthPartners Medicare Formulary
Preferred Drug List Status: On the preferred drug list with prior approval
Felbatol® is restricted for: (1) new start patients who have tried and failed or have medical contraindications to other anticonvulsants on the preferred drug list; or (2) patients previously stable on this medication.
For Medicare Part D: No change–this medication was already on the HealthPartners Medicare Formulary with prior approval.
hydrocodone / ibuprofen (Vicoprofen®)
Medication Category: Pain Medications / Analgesics (Pain Medications) for HealthPartners Medicare Formulary
Preferred Drug List Status: On the preferred drug list without restriction
Hydrocodone / Ibuprofen combination product is a pain medication.
Iloprost (Ventavis®)
Medication Category: Respiratory Drugs & Cardiovascular Drugs / Respiratory Tract Agents & Cardiovascular Agents for HealthPartners Medicare Formulary
Preferred Drug List Status: On the preferred drug list with prior approval
Ventavis® is reserved for its FDA-approved indication, and for prescribing by providers with expertise treating pulmonary arterial hypertension (high blood pressure in the lungs).
For Medicare Part D: Ventavis® also has an operational prior approval for purposes of determining coverage under Part B or Part D. If Part D, then Ventavis® has the same restriction as above.
Ventavis® is considered a specialty drug and must be obtained from CuraScript.
Members with Part D coverage are encouraged to obtain Ventavis® from CuraScript.
pravastatin (Pravachol®)
Medication Category: Cholesterol Lowering Drugs / Cardiovascular Agents for HealthPartners Medicare Formulary
Preferred Drug List Status: On the preferred drug list without restriction
Pravastatin is used for treating high cholesterol and is similar to other cholesterol lowering statin medications such as simvastatin (Zocor®) and atorvastatin (Lipitor®).
maraviroc (Selzentry®)
Medication Category: Anti-Infectives / Antivirals for HealthPartners Medicare Formulary
Preferred Drug List Status: On the preferred drug list without restriction
Selzentry® is an HIV medication for treatment-experienced patients with only CCR5-tropic HIV-1, resistant to multiple antiretroviral agents.
raltegravir (Isentress®)
Medication Category: Anti-Infectives / Antivirals for HealthPartners Medicare Formulary
Preferred Drug List Status: On the preferred drug list without restriction
Isentress® is an HIV medication for treatment-experienced patients resistant to multiple antiretroviral agents.
LINE EXTENSION ADDITIONS TO THE PREFERRED DRUG LISTS
albuterol (AccuNeb®) 0.63mcg/3mL and 1.25mcg/3mL solution for nebulization. These strengths of generic albuterol neb solution are added to the preferred drugs list without restriction.
For Medicare Part D: These strengths are also added to the HealthPartners Medicare Formulary with prior approval only to determine coverage under Part B or Part D.
benzonatate 200mg (Tessalon®). This strength of generic benzonatate is added to the preferred drug list without restriction.
For Medicare Part D: No change–benzonatate is a CMS excluded drug (cough & cold) and is not included on the HealthPartners Medicare Formulary.
buspirone 30mg (Buspar®). This strength of generic buspirone is added to the preferred drug list without restriction.
ciprofloxacin ophthalmic solution (Ciloxan®). This ophthalmic solution dosage form of ciprofloxacin is available generically and is now added to the preferred drug list without restriction.
diltiazem 24-hour sustained release (Tiazac®). The diltiazem 24-hour sustained release generic equivalent for Tiazac® is now added to the preferred drug list without restriction.
fluoride 1.1% cream & gel, 0.2% oral rinse, 0.5mg & 1mg regular tablet dosage forms and strengths are added to the preferred drug list without restriction and are all available generically.
For Medicare Part D: No change–these fluoride products are already on the HealthPartners Medicare Formulary.
hydrocodone / acetaminophen 10mg-750mg (Maxidone®). This strength is added to the preferred drug list with a quantity limit of four grams of acetaminophen per day (5 tablets) and is available generically.
For Medicare Part D: No change–this strength was already on the HealthPartners Medicare Formulary.
ipratropium 0.06% nasal spray (Atrovent®). This strength of generic ipratropium nasal spray is added to the preferred drug list without restriction.
ketoconazole 2% shampoo (Nizoral®). This strength and dosage form of ketoconazole is added to the preferred drug list without restriction and is available generically.
urea 40% generic dosage forms. The cream, gel, emulsion, lotion and suspension dosage forms of 40% urea are all available generically and are added to the preferred drug list without restriction.
LINE EXTENSION ADDITIONS TO THE HEALTHPARTNERS MEDICARE FORMULARY ONLY
carvedilol sustained release (Coreg® CR) is added to the HealthPartners Medicare Formulary with step therapy. Coreg® CR is reserved for patients who have had an inadequate response to generic carvedilol regular release.
rosiglitazone / glimepiride (Avandaryl®) is added to the HealthPartners Medicare Formulary with step therapy. Avandaryl® is reserved for patients with Type II diabetes who have tried a sulfonylurea such as glimepiride, glipizide, or glyburide or a TZD such as Actos® or Avandia®.
CHANGES TO THE PREFERRED DRUG LISTS
epoetin (Procrit® and Epogen®) and darbepoetin (Aranesp®). Coverage policies were added. There have been several changes with these medications, including a Medicare NCD requirement for oncology that hemoglobin values must be less than 10 mg/ dL, several FDA Safety Warnings, and updated prescribing information.
Coverage policies will be added to be consistent with Medicare NCD requirements. Recommendations will be added for non-Medicare and non-oncology uses that are consistent with ASCO guidelines and prescribing information.
adefovir (Hepsera®), entecavir (Baraclude®), pegylated interferon (Peg-Intron®) and telbivudine (Tyzeka®). The physician-edit has been removed. All of these medications used for treating hepatitis are now available on the preferred drug list without restriction.
budesonide neb suspension (Pulmicort® Respules). The age limit has been removed from this medication. Pulmicort® Respules are now available on the preferred drug list without restriction.
For Medicare Part D: Criteria have been modified. Prior approval will remain for this medication only for purposes of determining coverage under Part B or Part D.
cilostazol (Pletal®). The step therapy edit has been removed. Cilostazol, which is available generically, is now available on the preferred drug list without restriction.
cyclosporine eye drops (Restasis®). The physician-edit has been removed. Restasis® is now available on the preferred drug list without restriction.
duloxetine (Cymbalta®). Prior approval criteria for neuropathic pain have been modified. The requirements for prior use of a tricyclic antidepressant (TCA) will be deleted.- for depression and anxiety, Cymbalta® is reserved as a step therapy medication, for patients who have an inadequate response to a formulary generic SSRI antidepressant medication or bupropion or mirtazapine. Cymbalta® is also available for patients who are previously stable on this medication.
- for diabetic peripheral neuropathic pain, Cymbalta® is reserved as a prior approval medication, for patients who have tried and failed gabapentin.
For Medicare Part D: No change – prior use of a tricyclic antidepressant is not required under the HealthPartners Medicare Formulary criteria for Cymbalta®.
itraconazole (Sporanox®). Prior approval criteria have been modified. When prescribed for onychomycosis, itraconazole is now reserved for patients with an inadequate response to treatment with terbinafine oral (Lamisil).
For Medicare Part D: The criteria change to first require terbinafine oral for the treatment of onychomycosis will be made pending approval from CMS in 2008. Please refer to the HealthPartners Medicare Formulary on the website to determine the current HealthPartners Medicare Formulary status in mid-2008.
lidocaine patch (Lidoderm®). Prior approval criteria for neuropathic pain have been modified. The requirements for prior use of a tricyclic antidepressant (TCA) will be deleted.- Lidoderm® is reserved for prescribing by providers who specialize in chronic pain management (claims from providers with this specialty code will process automatically, without needing prior approval).
- Lidoderm® is also available for other providers (not specializing in pain management):
- for neuropathic pain: Lidoderm® is available with prior approval for patients with an inadequate response to gabapentin.
- for post-herpetic neuralgia: Lidoderm® is available with prior approval (no restrictions, but must call for approval).
For Medicare Part D: No change – prior use of a tricyclic antidepressant is not required under the HealthPartners Medicare Formulary criteria for Lidoderm®.
ondansetron (Zofran®). Quantity limits have been removed. Ondansetron, available generically, is now on the preferred drug list without restriction.
pregabalin (Lyrica®). Prior approval criteria were modified. For neuropathic pain: The requirements for prior use of a tricyclic antidepressant (TCA) will be deleted. For fibromyalgia: New criteria have been added for treating fibromyalgia.- for diabetic peripheral neuropathic pain: reserved for patients who have tried and failed gabapentin.
- for post-herpetic neuralgia: Lyrica® is reserved for patients who have tried and failed gabapentin.
- for seizures (no restrictions, but must call for authorization).
- for fibromyalgia: Lyrica® is reserved for patients who have tried and failed gabapentin. Patients must be accurately diagnosed with fibromyalgia per ACR or similar criteria. American College of Rheumatology (ACR) criteria are available (www.rheumatology.org).
For Medicare Part D: No change – prior use of a tricyclic antidepressant is not required under the HealthPartners Medicare Formulary criteria for Lyrica®.
terbinafine oral (Lamisil®). Prior approval criteria have been removed. Terbinafine oral is now available generically and is on the preferred drug list without restriction.
tipranavir (Aptivus®). The physician-edit has been removed. Aptivus® is now available on the preferred drug list without restriction.
For Medicare Part D: No change – Aptivus® has never had a physician edit applied on the HealthPartners Medicare Formulary.
MEDICATIONS REVIEWED BUT NOT ADDED
azithromycin ophthalmic (AzaSite®). AzaSite® is an antibiotic eye drop. There are several other antibiotic eye drop medication options on the preferred drug list such as ciprofloxacin, ofloxacin, Vigamox® and Zymar®. AzaSite® can be requested as an exception for unique situations.
DELETIONS FROM THE PREFERRED DRUG LIST
Meperidine (Demerol®). Effectiveness is not unique, and meperidine has safety concerns, especially in the elderly and with chronic use.
Meperidine will not be covered for new patients as of March 1, 2008. Patients currently using meperidine will be grandfathered for 3 months to allow discussion of any changes. Additional communications will be sent to affected patients and their providers.
For Medicare Part D: Meperidine will be deleted from the HealthPartners Medicare Formulary in 2008 pending approval from CMS. Please refer to the HealthPartners Medicare Formulary on the website to determine the current HealthPartners Medicare Formulary status in mid-2008.
LEGAL DISCLAIMER
The information regarding HealthPartners' preferred drug list and coverage criteria is regularly updated and is therefore subject to change without notice. HealthPartners reserves the right to make such changes without specific notice to members.
Various plan documents (including the Membership Contract or Summary Plan Description) determine governing contractual provisions, including exclusions, limitations and other coverage rules relating to specific health plans. The changes and the criteria described in this document apply to most, but not all, plans offered by HealthPartners. We strive to ensure that the contents of this site are correct and complete, but to verify benefits and preferred drug list contents, please check the applicable contract or SPD, or call HealthPartners Member Services at 952-883-5000. In the event of a conflict between specific plan documents and this general information, the plan documents will govern.
This document is derived from highly technical information used to educate medical personnel about changes to the HealthPartners preferred drug list. This document does not constitute medical advice.
These criteria in no way imply that any patient should not receive specific services based on the recommendation of a provider. The providers treating patients are responsible for medical advice and treatment of patients.
In those cases where interpretation of some or all of the parts of these criteria is required, HealthPartners medical personnel determine how the criteria, or specific parts of these criteria, apply to specific situations.
This information is not an offer of coverage, solicitation of coverage, summary of coverage or guarantee of coverage. All products and coverage criteria are subject to applicable laws and regulations. Coverage is contingent on all the applicable terms, conditions, limitations and exclusions of appropriate health plan documents.
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