Prescription Drug Program 2013

Transcription

1 Prescription Drug Program 2013

2 Habla Español or another language? For more information about alternative formats and interpreter services, call , toll free. These services are free to enrollees. Important contacts to know Website: bcbst.com Call Member Services: , toll free, Monday Friday, 8 a.m. to 6 p.m. ET; TDDT: (for hearing inpaired) Monday Friday, 8 a.m. to 6 p.m. ET covertn@bcbst.com Mail: BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN

3 Prescription Drug Program 2013 What do you want to do? Know the basics about my prescription drug benefit... 2 Understand generic drugs... 3 Find Participating Pharmacies... 4 Learn about home delivery retail network... 4 Find more information online... 5 Find out more about discounts on non-covered drugs... 5 Read important notice to Medicare-eligible individuals... 6 Find Drug Lists... 7 Keep a List of Medications...11 Learn how to appeal denials... Inside back cover Check for frequent updates on bcbst.com 1

4 CoverTN Prescription Drug Program CoverTN is an affordable health care plan designed to provide uninsured people with access to basic medical care. Your CoverTN Prescription Drug Program saves you money through the use of generic drugs and a network of pharmacies and mail order service. The CoverTN Drug Formulary includes many popular generics that have been approved by the U.S. Food and Drug Administration (FDA) as safe and effective. Some brand-name drugs are approved for certain drug classes - including some brand-name insulin and diabetic supplies * and the brand-name flu treatment drugs, Tamiflu and Relenza. However, for all other drug classes, only select generics are covered. For more information on generic drugs, see page 3. For a list of covered drugs, see pages to 7 to 9 of this booklet and check for updates throughout the year on bcbst.com. Covered prescription drugs are available through a network of retail chains, independent pharmacies and mail order service. See pages 4 to 5 for information 2 on where to purchase your prescription drugs. Prescription drug purchases made out of network are not covered. You will pay a copay for the drugs and supplies covered, subject to the calendar quarterly payment limits of your plan. A discount of up to 20% applies to all non-covered drugs and supplies. You will be required to pay 100 percent of the discounted price for the non-covered drugs and supplies. Please refer to your member handbook and schedule of benefits for details on your specific plan s limits and copays. *Diabetic supplies include: Blood glucose monitors (available free with a coupon) Test strips, and Needles, syringes, lancets and alcohol swabs.

5 Tips on Using Your Prescription Drug Benefits Once you understand how your benefits work, you can also become familiar with the drug choices that are available and appropriate for you. You can always get more information on the BlueCross BlueShield of Tennessee website, bcbst.com, but these tips can help you make the most of your prescription drug benefits: 1. Talk with your doctor. Doctors are your partners in achieving and maintaining better health, so discuss every aspect of the prescribed treatment, including the selection of drugs. The more you know, the better your choices. Show your doctor the list of drugs covered by your plan and discuss the options appropriate for you. 2. Ask for generic drugs. Your benefit plan covers many but not all generic drugs. Choosing generics will help you save money on your prescription drug costs. 3. Turn to your pharmacist. Your pharmacist can answer questions about drugs you are taking, help you avoid harmful drug interactions and help you select appropriate, lower-cost generics covered by your plan. 4. Use a network pharmacy. Prescription drug purchases made out of network are not covered. Network pharmacies fill your prescriptions and file the claims for you, making the process quicker and easier. Check bcbst.com for a list of network pharmacies. 5. Be a smart consumer. The prescription drug industry spends more than $2 billion each year to promote brand-name drugs, and those costs are passed along to consumers, insurance companies and businesses. So choose a drug based on its effectiveness, not its advertising slogan. Generic Drugs, Generic Equivalents and Generic Alternatives Know the Difference A generic drug is a copy of a brand-name drug that has the same dosage, safety, strength, quality performance, and intended use as a brand-name drug, as required by the FDA. A generic drug is also more affordable than a brand-name drug. A generic equivalent is made with the same active ingredients in the same dosage form as a brand-name product, and provides the same therapeutic effects as the brand-name drug. Not all brand-name drugs have generic equivalents, but many do. A generic alternative is a drug that may be used to treat the same condition as a brand-name drug. However, it may have a different chemical formula and ingredients. Talk to your doctor or pharmacist if you have questions about generic alternatives. Member ID Group No. RXBIN RXGRP BCTCOMM NETWORK: A Cover Tennessee Program LIMITED BENEFITS Plan A- Copayments: Office Visit $15 Inpatient $100 Outpatient $25 RX $10/$25 Your Member ID Card Carry your CoverTN member ID card with you at all times. You ll need to show it and have your membership number when you receive prescription medicine. The card shown is an example only. Depending on your plan choice (Plan A or Plan B), you may have different copays than shown here. 3

6 Participating Pharmacies The CoverTN Participating Pharmacy Network includes many retail pharmacy chains and independent pharmacies across the country. How do you find a Participating Pharmacy? Call Member Services , toll free, Monday through Friday, 8 a.m. to 6 p.m. Eastern Time, or Consult our website, bcbst.com. Network provider lists are frequently updated. At bcbst.com: Select Self Service Select Members Select Cover Tennessee Select Find a Doctor Select Begin Your Search! Enter your location in the Provider Box Enter your plan s Pharmacy Network (RX-04 for CoverTN) Click Search or use the drop down menus to further customize your search If you use a non-network pharmacy, you must pay all costs. If you are out of your service area and need to get a prescription, you can go to a participating pharmacy in our nationwide network. To fill your prescription, you may choose: Participating Network Pharmacy Present your CoverTN member ID card and your prescription. Your pharmacist will fill your prescription for covered drugs according to your doctor s directions up to a 30-day supply limit. Mail Order Mail order allows you the convenience of receiving more than a 30 day supply of covered drugs, delivered right to your door.* Your prescriptions will be delivered to you by mail in plain, tamper-resistant packaging. Every prescription is reviewed for possible drug interactions with other medications you may be taking and includes instructions for proper use. *Your physician will need to write your prescription for a 90-day supply. Specialty pharmacy medications are limited to a one-month supply. Pharmacy network may change. Visit bcbst.com for the most up-to-date information. 4 To use Mail Order, call and give the operator this information: Member ID number (on your member ID card) Name of the medications you ll need Shipping address Credit card number and expiration date Prescribing physician name and phone number Your doctor will be contacted, and if he or she authorizes the prescription, your medication will be mailed to you within 14 days. Refills are simple. You can request refills by phone at , 24 hours a day, seven days a week. To refill your prescription you ll need: Your prescription number Your five-digit zip code Your credit card number and expiration date. Plus90 Network Your prescription drug plan includes the Plus90 Network, so you can obtain up to a three-month* supply of medication. This network consists of small and large retail pharmacies that dispense prescription drugs to BlueCross members on the same terms as Mail Order. You can pick up the prescription at your local pharmacy or have it mailed to you at no extra charge. If you choose to use a retail pharmacy that is not part of the Plus90 Network, you are limited to a one-month supply. National Pharmacies in the Plus90 Network CVS Kmart Kroger Sam s Club Wal-Mart CVS, Kmart, Kroger, Sam s Club and Wal-Mart are all independent companies that offer prescription drug services for BlueCross BlueShield of Tennessee.

7 Find Help Online at bcbst.com You can visit bcbst.com for CoverTN information. Our website provides many tools to assist you. On bcbst.com, find: Online prescription drug search (compare drug costs, see your generic drug savings and learn more about the medications you take, their use and possible side effects) Drug Lists List of more than 400 brand-name drugs and their generic equivalents Alerts Online forms Participating Pharmacies Much more... Non-Covered Drugs If you buy a drug that is not on the list of covered drugs, or if you have reached your prescription drug calendar quarterly payment limit, you are responsible for the full discounted retail price. Present your CoverTN member ID card when you purchase these non-covered drugs online, at a network pharmacy or mail order service, and you will still receive up to a 20 percent discount. This discount is not the same as your copay for covered drugs. Use over-the-counter (OTC) medication to save money While OTC drugs are not covered by your CoverTN plan, you can buy some of the most popular and widely prescribed drugs on the market without a prescription. You ll pay much less for OTC medications than their prescription alternatives, yet they can have similar results. Note that your benefit plan may not cover prescription drugs that have OTC equivalents. Do not switch from a prescription drug to an OTC without the approval of your physician. Remember some newer medications may be more expensive while not necessarily more effective. Talk honestly with your doctor about the costs of all of your medications, as well as their side effects and how they are working for you and your health. Check for frequent updates on bcbst.com 5

8 Important Notice to Medicare-Eligible Individuals About Non-Creditable Prescription Drug Coverage The prescription drug coverage offered by CoverTN is, on average, for all plan participants, NOT expected to pay out as much as the standard Medicare Part D prescription coverage will pay. This is important, because for most people enrolling in Medicare, prescription drug coverage means you will get more assistance with drug costs. Consider Medicare prescription drug plan Because the coverage you have is, on average, for all plan participants, NOT expected to pay out as much as the standard Medicare prescription drug coverage will pay, you might want to consider enrolling in a Medicare prescription drug plan. Generally, after May 15, 2006, you were only able to join a Medicare prescription drug plan when you first became eligible for Medicare. You may still be able to do so between October 15 and December 7 of any year. If you didn t enroll in Medicare prescription drug coverage before May 15, 2006, or if you don t enroll when you are first eligible, and you change your mind later, you could pay more. Your premium will go up at least 1 percent per month for each month after your initial eligibility period (or May 15, 2006) that you did not have Medicare prescription drug coverage. Your current coverage pays for other health expenses, in addition to prescription drugs. You may still be eligible to receive all of your current health and prescription drug benefits if you choose to enroll in a Medicare prescription drug plan. Medicare prescription drug coverage information More detailed information about Medicare plans that offer prescription drug coverage will be available through the Medicare & You handbook from Medicare. You may also be contacted directly by Medicare-approved prescription drug plans. You ll get a copy of the handbook in the mail. You can also get more information about Medicare prescription drug plans from these places: Visit medicare.gov for personalized help. Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for the telephone number), Call MEDICARE ( ), toll free. TTY users should call For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information about this extra help is available from the Social Security Administration (SSA): Visit SSA online at socialsecurity.gov, or Call them at , toll free. TTY users should call , and/or Call our Member Services Department at , toll free. The hours are Monday through Friday, 8 a.m. to 6 p.m. Eastern Time. 6

9 Drug List We advise you to take the list on the following pages with you to all medical appointments and share it with your doctor to help coordinate your medication needs. You will pay a copay for the covered drugs and supplies until you reach your prescription drug calendar quarterly payment limit. You will be required to pay 100 percent of the discounted price for the drugs and supplies that are not covered or are beyond your quarterly limit. Note: This list will be updated throughout the year on bcbst.com. Drugs not on the updated list are not covered. Drug Benefits Appeals: CoverTN members or their physicians may appeal a denial of a drug or quantity limitation by faxing supportive documentation to CoverTN 2013 Formulary Effective 1/1/13 (Changes may be made to the list prior to 1/1/13.) ANTIBACTERIALS Antibiotics, Oral amoxicillin amoxicillin/potassium clavulanate azithromycin cefaclor cefdinir cefuroxime axetil cephalexin ciprofloxacin hcl clarithromycin clindamycin dicloxacillin sodium doxcycline hyclate erythromycin ethylsuccinate erythromycin/sulfisoxazole metronidazole penicillin V potassium suflamethoxazole/ trimethoprim tetracycline Antifungals, Oral fluconazole ketoconazole nystatin Urinary Anti-Infective and Analgesics nitrofurantoin macocrystals Phenazopyridine Plus Urogesic-Blue ANTIDEPRESSANTS Selective Serotonin Reuptake Inhibitors citalopram fluoxetine paroxetine sertraline Tricyclic Antidepressants amitriptyline doxepin trazodone Other Antidepressants Budeprion SR bupropion mirtazapine venlafaxine ANTI-INFECTIVE MEDICATIONS Anti-influenza Drugs amantadine rimantadine Relenza Tamiflu Antituberculosis Drugs isoniazid rifampin Antivirals acyclovir ribavirin AUTONOMIC AND CENTRAL NERVOUS SYSTEM MEDICATIONS Antianxiety Drugs alprazolam lorazepam buspirone Anticonvulsants and Mood Stabilizers carbamazepine clonazepam gabapentin lamotrigine levetiracetam lithium carbonate phenobarbital phenytoin sodium, extended valproic acid Attention Deficit Hyperactivity Disorder amphetamine/ dextroamphetamine mixed salts methylphenidate BLOOD MODIFIERS Antiplatelet Drugs heparin sodium warfarin sodium Blood Detoxicants sodium polystyrene sulfonate Potassium Supplements Klor-Con 10 potassium chloride Vitamins and Minerals, Therapeutic folic acid Hematinic Plus Prenatal Plus CARDIOVASCULAR MEDICATIONS ACE Inhibitors benazepril captopril enalapril fosinopril lisinopril moexipril quinapril ramipril trandolapril (List continued on page 8) Check for frequent updates on bcbst.com 7

10 CoverTN 2013 Formulary Effective 1/1/13 (Changes may be made to the list prior to 1/1/13.) ACE Inhibitor/Diuretic Combinations benazepril/ captopril/ enalapril/ fosinopril/ lisinopril/ moexipril/ quinapril/ Angiotensin II losartan Antiarrythmics amiodarone flecainide acetate propafenone Beta-Blockers atenolol carvedilol metoprolol metoprolol ext-rel propranolol Beta-Blocker/Diuretic Combinations atenolol/chlorthalidone bisoprolol/ metoprolol/ Calcium Channel Blockers amlodipine diltiazem hcl nifedipine ext-rel verapamil Cardiac Glycosides digoxin Centrally Acting Antihypertensives clonidine doxazosin hydralazine minoxidil terazosin Diuretics bumetanide furosemide indapamide spironolactone triamterene/ Hypolipoproteinemics gemfibrozil lovastatin pravastatin simvastatin Nitrates isosorbide dinitrate isosorbide mononitrate nitroglycerin DERMATOLOGICALS Antifungals, Topical ketoconazole nystatin Antifungal/Corticosteroid Combinations, Topical clotrimazole/ betamethasone nystatin/triamcinolone Corticosteroid, Topical triamcinolone acetonide cream DIABETES Diabetic Supplies** Bayer Contour/Breeze2 products (QL) Roche Accu-Chek products (QL) All brand syringes, needles, lancets, alcohol swabs (QL) Hypoglycemics, Oral glimepiride glipizide ext-rel glyburide metformin metformin ext-rel Insulins (vials only)** Lantus (QL) Levemir (QL) Novolin 70/30 (QL) Novolin N (QL) Novolin R (QL) Novolog (QL) Novolog Mix 70/30 (QL) ** These branded products have the generic copay. ENDOCRINE MEDICATIONS Corticosteroids dexamethasone methylprednisolone prednisone Thyroid Supplements levothyroxine sodium Levoxyl GASTROINTESTINAL MEDICATIONS Antiemetic metoclopramide Antihistamine cimetidine famotidine ranitidine Antihistamine/Antiemetic promethazine (oral) Antispasmodics dicyclomine hyoscyamine sulfate sucralfate Inflammatory Bowel Disease Agents sulfasalazine Proton Pump Inhibitors omeprazole GYNECOLOGICAL MEDICATIONS Contraceptives, Oral Alesse Apri Aranelle Aviane Balziva Camila Cesia Cryselle Enpresse Errin Jolivette Junel 1/20, 1.5/30 Kariva Leena Lessina Levora-28 Lutera Mononessa Necon Nora-BE Nortrel Ocella Ogestrel Portia Previfem 8

11 CoverTN 2013 Formulary Effective 1/1/13 (Changes may be made to the list prior to 1/1/13.) Reclipsen Solia Sprintec Sronyx Tilia FE Tri-Legest Trinessa Tri-Previfem Tri-Sprintec Trivora-28 Velivet Zenchent Zovia 1/35 Estrogens, Oral estradiol estropipate Progestins medroxyprogesterone acetate OPHTHALMIC MEDICATIONS Antibacterial Drugs bacitracin ciprofloxacin hcl erythromycin gentamicin sulfate neomycin/polymyxin B/ dexamethasone neomycin/polymyxin B/ gramicidin polymyxin B/trimethoprim sulfacetamide Antiglaucoma Drugs acetazolamide levobunolol timolol Anti-Inflammatory Drugs dexamethasone fluorometholone prednisolone acetate OSTEOPOROSIS MEDICATIONS Bisphosphonate alendronate OTIC MEDICATIONS Analgesic antipyrine/benzocaine Antibacterial neomycin/polymyxin B/ hydrocortisone Anti-Infective acetic acid Anti-Inflammatory acetic acid/ hydrocortisone UROLOGICAL MEDICATIONS Anticholinergic/ Antispasmodics oxybutynin MISCELLANEOUS Antihistamines hydroxyzine hcl hydroxyzine pamoate Anti-Inflammatories diclofenac sodium etodolac ibuprofen indomethacin meloxicam nabumetone naproxen naproxen sodium Antineoplastics hydroxyurea megestrol acetate mercaptopurine methotrexate tamoxifen citrate Gout allopurinol Methylxanthines dyphylline/guaifenesin theophylline anhydrous Skeletal Muscle Relaxants methocarbamol Vitamins calcitriol vitamin D This list is current as of September 1, 2012, and is subject to change without prior notice. Drug coverage may vary depending on the benefit plan. Check your Member Hanbook for special benefit information, and check bcbst.com for updates to the drug list. Drugs not on the updated list are not covered. Check for frequent updates on bcbst.com 9

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15 Drug Benefits Appeals CoverTN members or their physicians may appeal a denial of a drug benefit or a drug quantity limitation by faxing supportive documentation to Please read your member handbook for more information on your grievance rights. Requests for an exception to the non-covered brand name medication list, if based on a unique clinical justification, will be considered by the plan on a case-by-case basis. Fax requests with supportive documentation to

16 BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN bcbst.com Do you need help in these languages: (Arabic); (Bosnian); (Kurdish-Badinani); (Kurdish- Sorani); (Somali); Español (Spanish); (Vietnamese)? CoverTN language and member services are free at , Monday-Friday, 8 a.m. to 6 p.m. ET. For TDD/ TTY help call Federal and State laws protect your rights. They do not allow anyone to be treated in a different way because of: race, language, sex, age, color, birthplace, or disability. Need help? Call the Office of Non-Discrimination Compliance for free at or TTY: (877) BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association CVR-060 (9/12) Member