1. Definitions


2. Additions to the Preferred Drug List


3. Changes to Preferred Drug List


4. Other Product Changes


5. Medications Reviewed but Not Added


6. Legal Disclaimer

The HealthPartners Pharmacy and Therapeutics Committee updates the preferred drug list every three months. This listing represents additions and changes implemented January 1, 2009 unless otherwise stated. All drug additions and changes are the same for the HealthPartners Medicare Drug Formulary unless otherwise stated in this Update.

This summary was written for health care providers and has been slightly modified for the general public.

Learn more about our HealthPartners preferred drug list, also available within the ePocrates database at no charge to users. The electronic ePocrates 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. Visit www.healthpartners.com/medicare for additional information.

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.

Quantity Limit: This term means that a limit has been set on the amount of medication you will receive each time you fill a prescription for that medication.

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 co-pay for generic medications. Members who choose to continue using brand-name medications when a generic is available may pay a higher amount. These brand medications will be deleted from the Medicare Formulary in 2009 pending CMS approval. Refer to the 2009 HealthPartners Medicare Formulary on our website to determine the current formulary status for these brands. Recent generics for preferred (formulary) products include:

Generic Update: Recently-available generics are listed below. Most members have a lower co-pay for generic medications.

• calcium acetate capsule (PhosLo)
• clobetasol foam (Olux)
• dorzolamide ophthalmic (Trusopt)
• dorzolamide/ timolol combination ophthalmic (Cosopt)
• fluorouracil 5% cream (Efudex)
• galantamine extended-release (Razadyne ER)
• levetiracetam regular release (Keppra)
• potassium chloride 8meq capsule (Micro-K equivalent)
• protriptyline tablet (Vivactil) Medicare Part D Formulary only
• sumatriptan injectable, nasal and tablets (Imitrex)
• tobramycin/dexamethasone combination ophthalmic suspension

ADDITIONS TO THE PREFERRED DRUG LIST (FORMULARY)

Cefixime tablets (Suprax)
Medication Category: Anti-Infectives / Antibacterials - 2009 Medicare Drug Formulary

Preferred Drug List Status: On the preferred drug list with a quantity limit

Cefixime is the only oral treatment recommended for gonorrhea. A quantity limit of 1 tablet has been added, to allow treatment per Center for Disease Control (CDC) guidelines, and to limit its use for other types of infections.

For more information, the April 2007 CDC gonorrhea guidelines are available at www.cdc.gov/std/treatment, and the prescribing information for Suprax is available at www.lupinpharmaceuticals.com.

Clindamycin swabs (Cleocin T)
Medication Category: Dermatologic Medications / Anti-Infectives (Skin and Mucous Membrane) - 2009 Medicare Drug Formulary

Preferred Drug List Status: On the preferred drug list without restrictions

The swab form of this topical antibiotic for acne is available generically. Most forms of topical clindamycin are available generically and included on the preferred drug list.

Dexmethylphenidate immediate release (Focalin)
Medication Category: Attention Deficit - Hyperactivity Disorder (ADHD) Drugs / Anorexigenics, Respiratory and Cerebral Stimulants - 2009 Medicare Drug Formulary

Preferred Drug List Status: On the preferred drug list without restrictions

The immediate-release dosage form of this attention deficit hyperactivity disorder (ADHD) medication is available generically. Focalin XR remains on the preferred drug list with step therapy (reserved for patients with an inadequate response to Concerta).

Insulin, Human Regular 500 units/mL (Humulin R U-500)
Medication Category: Diabetes Products / Antidiabetic Agents - 2009 Medicare Drug Formulary

Preferred Drug List Status: On the preferred drug list without restriction

This unique strength of regular human insulin is added for patients with high-dose insulin needs.

Norgestimate / Ethinyl Estradiol (Ortho Tri-Cyclen Lo)
Medication Category: Contraceptives / Contraceptives - 2009 Medicare Drug Formulary

Preferred Drug List Status: On the preferred drug list without restrictions

Ortho Tri-Cyclen Lo is a brand name low-dose tricyclic oral contraceptive.

Testosterone cypionate (Depo-Testosterone) and Testosterone enanthate injection

Medication Category: Endocrine Drugs / Androgens - 2009 Medicare Drug Formulary

Preferred Drug List Status: On the preferred drug list with prior approval

These injectable dosage forms of testosterone are added to the preferred drug list with prior approval and are reserved for male patients with documented testosterone deficiency. Both injectable formulations are available generically and are less costly than branded topical testosterone formulations. Topical testosterone (Androderm and Androgel) remains on formulary with the same prior authorization criteria as the injectable.

Topotecan (Hycamtin)
Medication Category: Cancer Drugs / Antineoplastic Agents - 2009 Medicare Drug Formulary

Preferred Drug List Status: On the preferred drug list without restrictions

Hycamtin is an oral cancer medication used for relapsed small cell lung cancer.

Torsemide (Demadex)
Medication Category: Cardiovascular Drugs / Diuretics - 2009 Medicare Drug Formulary

Preferred Drug List Status: On the preferred drug list without restrictions

Torsemide, a loop diuretic for congestive heart failure, is available generically.

PREFERRED DRUG LIST CHANGES

Azithromycin ophthalmic solution (AzaSite) will remain on the preferred drug list with a physician-edit and will be reserved for prescribing by ophthalmologists only (prescriptions written by ophthalmology will process automatically) starting on March 1. Other specialties, including optometry, can request prior approval if medically necessary. Prior approval reviews are based on diagnosis, other product(s) on the preferred drug list previously tried, and medical necessity.

For HealthPartners' Medicare Drug Formulary: The physician-edit will remain reserved for prescribing by both ophthalmology and optometry.

Budesonide (Entocort EC). Entocort EC, a medication used for treating Crohn's disease, will change from "on the preferred drug list with prior approval" to "on the preferred drug list with no restrictions".

Cinacalcet (Sensipar). Sensipar, a medication for hyperparathyroidism, will from "on the preferred drug list with prior approval" to "on the preferred drug list with no restrictions".

Duloxetine (Cymbalta). Step-therapy coverage criteria will be added for the new fibromyalgia indication, allowing its use after gabapentin. Step-therapy coverage criteria for depression, anxiety, and neuropathic pain remain unchanged. The following step criteria will now apply for the various Cymbalta uses:
1. Depression and anxiety: Reserved for patients who have first tried a generic SSRI antidepressant (such as citalopram, fluoxetine, paroxetine or sertraline) or generic bupropion or generic mirtazapine, or patients who are previously stable on Cymbalta.
2. Neuropathic pain: Reserved for patients who have first tried gabapentin.
3. Fibromyalgia: Reserved for patients who have first tried gabapentin. An accurate diagnosis of fibromyalgia using the American College of Rheumatology (ACR) or similar criteria is encouraged.

Gatifloxacin (Zymar) will remain on the preferred drug list with a physician-edit and will be reserved for prescribing by ophthalmologists only (prescriptions written by ophthalmology will process automatically) starting on March 1. Other specialties, including optometry, can request prior approval if medically necessary. Prior approval reviews are based on diagnosis, other product(s) on the preferred drug list previously tried, and medical necessity.

For HealthPartners' Medicare Drug Formulary: The physician-edit will remain reserved for prescribing by both ophthalmology and optometry.

Levofloxacin (IQuix) will remain on the preferred drug list with a physician-edit and will be reserved for prescribing by ophthalmologists only (prescriptions written by ophthalmology will process automatically) starting on March 1. Other specialties, including optometry, can request prior approval if medically necessary. Prior approval reviews are based on diagnosis, other product(s) on the preferred drug list previously tried, and medical necessity.

For HealthPartners' Medicare Drug Formulary: The physician-edit will remain reserved for prescribing by both ophthalmology and optometry.

Moxifloxacin (Vigamox) will remain on the preferred drug list with a physician-edit and will be reserved for prescribing by ophthalmologists only (prescriptions written by ophthalmology will process automatically) starting on March 1. Other specialties, including optometry, can request prior approval if medically necessary. Prior approval reviews are based on diagnosis, other product(s) on the preferred drug list previously tried, and medical necessity.

For HealthPartners' Medicare Drug Formulary: The physician-edit will remain reserved for prescribing by both ophthalmology and optometry.

OTHER PRODUCT CHANGES BLOOD GLUCOSE TEST STRIPS
Accu-Chek test strips. A quantity limit of 200 strips per month will be added, starting on March 1. Providers can request prior approval for higher quantities if medical necessary.

One Touch test strips. A quantity limit of 200 strips per month will be added, starting on March 1. Providers can request prior approval for higher quantities if medical necessary.

Non-Preferred Test strips (such as Ascencia, Freestyle, Precision, Prodigy, Nova Max and others). If a non-preferred test strip is approved for patient use under the exceptions process, a quantity limit of 200 strips per month will be applied, starting on March 1. Providers can request prior approval for higher quantities if medical necessary.

MEDICATIONS REVIEWED BUT NOT ADDED

Difluprednate (Durezol). Significant advantages of this ophthalmic steroid arent clear. Preferred drug list alternatives include fluoromethalone (FML), loteprednol (Alrex and Lotemax), and prednisolone ophthalmic. Unique situations and needs can be requested as an exception to the preferred drug list.

Granisetron patch (Sancuso). Significant advantages of this medication for chemotherapy-induced nausea have not been shown and the granisetron patch is more costly than current anti-nausea medications on the preferred drug list. A preferred drug list alternative is ondansetron oral tablet. Ondansetron injection given in a clinic setting is also an alternative. Unique situations and needs can be requested as an exception to the preferred drug list.

Levetiracetam extended release (Keppra XR). Significant advantages of this seizure medication have not been shown. Preferred drug list alternatives include Keppra regular release tablets which are now available generically and are less costly. Unique situations and needs can be requested as an exception to the preferred drug list.

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.