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Prescription Benefits Health & Security Plan Cultural Institutions Health & Security Plan New York Public Library Health & Security Plan by PO Box 8082 Wausau, WI 54402-8082 t 800.207.1561 f 715.841.5050 w www.innoviant.com welcome to innoviant prescription benefits Table of Contents Preferred Products...........................................................................1 Using the Preferred Products List.....................................................5 Retail Pharmacies and Retail 90 Rx . ..............................................6 Rx Instep—Step Therapy...............................................................12 Half Tab Rx—Tablet Splitting..........................................................14 Customer Service...........................................................................16 Prior Authorization..........................................................................17 Common Preferred Alternatives.....................................................19 Frequently Asked Questions...........................................................22 Quantity Limits on Medications.......................................................24 Mail Order Program........................................................................28 Wise Choice Rx by Innoviant..........................................................30 by For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (800) 207-1561, Fax: (715) 841-5050 www.innoviant.com Effective July 1, 2008 Preferred ProductS This Preferred Products List (PPL) includes our preferred products for many commonly prescribed medication categories. This is only a partial listing, and not all products on this list may be covered by your prescription benefits plan. Your specific benefit plan’s guidelines regarding quantity limits, step therapy, prior authorization, and generic usage will apply. If you have any questions about product status, or if the product you’re considering does not appear here, please call Innoviant ALLERGY (intranasal) PB Astelin G ipratropium G fluticasone PB Nasonex PB Veramyst common nonpreferred products in this class include • Nasacort AQ • Rhinocort Aqua • ALZHEIMER AGENTS Aricept/ODT Exelon/Patch Namenda Razadyne/ER PB PB PB PB ANALGESICS and NARCOTICS G all generic analgesics G all generic narcotics all generic narcotic and G analgesic combinations G QL acet/tramadol PB Avinza PB Dolophine G fentanyl TD QL PA fentanyl oral transmucosal G PB MSIR PB Opana ER PB OXY-IR PB QL Oxycontin PB Oxyfast G tramadol common nonpreferred products in this class include • Actiq • Fentora • ANTIANGINAL isosorbide dinitrate isosorbide mononitrate nitroglycerin Ranexa** G G G PB ANTIANXIETY alprazolam buspirone chlordiazepoxide clorazepate dipotassium diazepam lorazepam meprobamate oxazepam Tranxene SD G G G G G G G G PB at 800-207-1561. We’re available 24-hours a day, seven days a week, or visit our Web site at www.innoviant.com. The PPL is subject to change without notice. Our independent review committee (including physicians and pharmacists) considers new and existing prescription medications for inclusion on the PPL quarterly. The most current version of the PPL is available on our Web site at www.innoviant.com. ANTIBIOTICS G all generic antibiotics G amoxicillin G amox/clavulanate K PB Augmentin ES/XR PB Avelox G azithromycin G cefaclor G cefpodoxime G cephalexin PB Cipro HC (otic) PB Ciprodex (otic) G ciprofloxacin G clarithromycin/ER G clindamycin G doxycycline G erythromycin PB Levaquin G minocycline G nitrofurantoin G ofloxacin sol (otic) G penicillin V potassium G smz/tmp PB Xifaxin common nonpreferred products in this class include Biaxin XL • Cefzil • Omnicef • ANTICONVULSANTS acetazolamide carbamazepine Carbatrol Celontin Cerebyx clonazepam clorazepate dipotassium Depakene Depakote/ER Diastat Dilantin Felbatol gabapentin Gabitril Keppra Lamictal Lyrica Mebaral mephobarbital Mysoline oxcarbazepine Peganone G G PB PB ANTICONVULSANTS [continued] G phenobarbital G phenytoin G primidone PB Tegretol XR PB Topamax PB Tranxene/SD PB Zarontin PB Zonegran common nonpreferred products in this class include • Neurontin • Tegretol • Trileptal • ANTIDEPRESSANTS— BIPOLAR DISORDER Symbyax PB ANTIDEPRESSANTS—SNRI TYPE Cymbalta Effexor XR venlafaxine PB PB G ANTIDEPRESSANTS—SSRI TYPE G citalopram G fluoxetine capsules PB Lexapro G paroxetine G sertraline common nonpreferred products in this class include • Celexa • Paxil CR • Zoloft • ANTIDEPRESSANTS—OTHER PB G G all tricyclic generics G budeprion XL G bupropion/SR G mirtazapine G trazodone common nonpreferred products in this class include • Wellbutrin XL • G PB PB PB PB PB G PB ANTIEMETICS PB PB PB PB G PB G PB Column Guide G Generic medication G*Covered as generic if plan participates in the Brands for Generic Program PB Preferred brand medication QL Quantity limits may apply PA Prior authorization may be required STStep therapy may be required (Rx Instep Program) **Limitations may apply in the form of an electronic step edit or electronic prior authorization continued... G all generics PB QL Anzemet PB QL Emend G QL granisetron G QL ondansetron G meclizine (Rx only) PB Transderm-Scop common nonpreferred products in this class include • Kytril • Zofran • continued on next page... This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0038A p1/5 • 0608 Page 1 ANTIHISTAMINES Alavert G (Rx OTC Program) G brompheniramine cetirizine G (Rx OTC Program) G chlorpheniramine G clemastine G cyproheptadine G diphenhydramine G fexofenadine G hydroxyzine loratadine G (Rx OTC Program) common nonpreferred products in this class include • Allegra/D • Clarinex/D • Xyzal • ANTIPSYCHOTIC—ATYPICAL Abilify clozapine Geodon Risperdal Seroquel/XR Zyprexa PA PB PB PB PB ANTIVIRAL—GENERAL G acyclovir G amantadine PB Cytovene G famciclovir G rimantadine PB Valtrex common nonpreferred products in this class include • Famvir • ASTHMA / CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Accolate Advair Diskus/HFA albuterol Asmanex Atrovent Inhaler Azmacort Combivent cromolyn sodium Flovent HFA Foradil Intal ipratropium metaproterenol sulfate Perforomist ProAir HFA Proventil HFA Pulmicort PB ST PB QL G QL PB QL PB PB G PB QL PB G PB PB QL PB QL continued... COPD [continued] QVAR Serevent Diskus Singulair Spiriva Symbicort Tilade Ventolin HFA PB PB QL PB ST PB PB QL PB PB G PB PB G PB PB G PB PB PB BETA BLOCKERS BLOOD PRESSURE— ACE INHIBITORS PB Aceon G benazepril G captopril G enalapril G fosinopril G lisinopril G moexipril G quinapril G trandolapril common nonpreferred products in this class include • Accupril • Altace • Mavik • BLOOD PRESSURE— ANGIOTENSIN RECEPTOR BLOCKERS BLOOD PRESSURE— CALCIUM CHANNEL BLOCKERS G PB PB PB Avapro PB Benicar PB Diovan common nonpreferred products in this class include • Atacand • Cozaar • Micardis • Teveten • PB PB Adderall XR amphetamine salt combinations Concerta Daytrana dextroamphetamine sulfate Focalin/XR Metadate CD methylphenidate Ritalin LA/SR Strattera Vyvanse G all generics G atenolol G carvedilol G metoprolol/ER G propranolol common nonpreferred products in this class include • Toprol XL • Coreg • Coreg CR • PB G ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) QL G amlodipine G diltiazem G nifedipine PB Sular G verapamil common nonpreferred products in this class include • Norvasc • BLOOD PRESSURE— COMBINATION G all generics G amlodipine/benazepril PB Avalide PB Azor PB Benicar-HCT PB Diovan HCT PB Exforge PB Lotrel (5/40 and 10/40 only) PB Tekturna HCT** common nonpreferred products in this class include • Atacand HCT • Hyzaar • Lotrel 2.5/10, 5/10, 5/20, 10/20 • Micardis HCT • Teveten HCT • BLOOD PRESSURE—OTHER Tekturna** PB CHOLESTEROL LOWERING PB Advicor PB Antara PB Caduet G cholestyramine G colestipol PB Crestor PB Fenoglide G gemfibrozil PB Lipitor PB Lofibra G lovastatin PB Niaspan G pravastatin G simvastatin PB Triglide PB Vytorin PB Welchol PB Zetia common nonpreferred products in this class include • Lescol/XL• Pravachol • Simcor • Tricor • Zocor • CONTRACEPTIVES G all generics PB Nuvaring PB Ortho Evra PB Ortho Tri-Cyclen Lo PB Yasmin PB Yaz common nonpreferred products in this class include • Estrostep Fe • Mircette • ANTI-DIABETIC acetohexamide ActoPlus Met Actos Avandamet Avandaryl Avandia Byetta chlorpropamide Duetact Fortamet glimepiride glipizide/ER glipizide/metformin glyburide G PB PB PB PB PB PB ST G PB PB G G G G continued... continued on next page... This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0038A p2/5 • 0608 Page 2 ANTI-DIABETIC [continued] G glyburide micronized G glyburide/metformin PB Humalog cartridge PB Humalog pen G* PB Humalog vial PB Humulin cartridge PB Humulin pen G* PB Humulin vial PB Janumet PB Januvia PB Lantus OptiClik PB Lantus SoloSTAR PB Levemir PB Novolin cartridge PB Novolin innolet PB Novolin pen G* PB Novolin vial PB Novolog cartridge PB Novolog innolet PB Novolog pen G* PB Novolog vial PB Prandin PB Precose PB Symlin common nonpreferred products in this class include • Metaglip • Starlix • DIURETICS G all generics common nonpreferred products in this class include • Dyrenium • HORMONE REPLACEMENT THERAPY Activella Climara Pro estradiol Estratest/H.S. estrogens, esterified estropipate medroxyprogesterone Menest Premarin/Low Premphase Prempro/Low Prometrium Vagifem PB Asacol PB Canasa PB Creon PB Dipentum PB Entocort EC PB Lialda PB Pentasa PB Rowasa G sulfasalazine common nonpreferred products in this class include • Colazal • HEPATITIS AGENTS Copegus PEG-Intron Pegasys ribavirin G PB PA PB PA PB PA G PB G MUSCLE RELAXANTS (skeletal) G G all generics cyclobenzaprine Skelaxin PB PB PB PB PB IMMUNOSUPPRESSIVE AGENTS—TOPICAL Elidel Protopic cromolyn Elestat Optivar Pataday Patanol PB Detrol/LA G hyoscyamine G oxybutynin/ER PB Sanctura/XR PB Vesicare common nonpreferred products in this class include • Ditropan XL • Bravelle Menopur Novarel Repronex INFERTILITY PB all generics Ciloxan ointment ciprofloxacin solution Natacyn Ocuflox Vigamox all generics Alphagan P Alrex Azopt Betimol Betoptic S brimonidine Cosopt dipivefrin timolol Tobradex Trusopt PB PB (NON-STEROIDAL) G PB QL QL PB QL PB QL G QL PB G QL QL PB QL PB QL PB QL OPHTHALMIC— MISCELLANEOUS G PB PB QL PB PB PB G PB G G PB PB OPHTHALMIC— NSAIDS PB ANTI-INFLAMMATION all generics Celebrex PB PB OPHTHALMIC— ANTIBIOTICS PB (URINARY) PB G PB INCONTINENCE G G OPHTHALMIC— ANTIALLERGIC PB PB PA Genotropin PB PA Humatrope PB PA Norditropin PB PA Nutropin PB PA Omnitrope PB PA Protropin PB PA Serostim common nonpreferred products in this class include • Saizen • (ANTI-ULCER) GASTROINTESTINAL AGENTS— MISCELLANEOUS PB PB HORMONE GROWTH AGENTS GASTROINTESTINAL AGENTS G cimetidine G famotidine 40mg G omeprazole Prilosec OTC G (Rx OTC Program) PB Protonix Prevacid/SoluTab/ PB Oral Suspension G ranitidine 300mg tablets common nonpreferred products in this class include • Aciphex • Nexium • Prilosec • Zegerid MULTIPLE SCLEROSIS PB PA Betaseron PB PA Copaxone PB PA Rebif common nonpreferred products in this class include • Avonex • ST PB QL Acular/LS G diclofenac G QL flurbiprofen PB QL Nevanac common nonpreferred products in this class include • Voltaren • MIGRAINE PB QL Imitrex 50mg/100mg PB QL Imitrex Injection PB QL Imitrex Nasal Spray isometheptene/ G dichloralphenazone PB QL Relpax PB QL Zomig/ZMT/Nasal common nonpreferred products in this class include • Amerge • Axert • Frova • Midrin • Travatan/Z Xalatan OPHTHALMIC— PROSTAGLANDINS PB QL PB QL continued on next page... This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0038A p3/5 • 0608 Page 3 OSTEOPOROSIS PB QL Actonel PB QL Actonel w/ Calcium G QL alendronate PB QL Boniva PB Evista PB QL Forteo PB Menostar Patch PB Miacalcin common nonpreferred products in this class include • Fosamax • ANTI-PARKINSONS all generics Azilect Comtan Mirapex Neupro Requip Tasmar Aggrenox anagrelide cilostazol dipyridamole Plavix ticlopidine G PB PB PB PB PB PB ANTI-PLATELET PB G SEXUAL DYSFUNCTION—ORAL Cialis Viagra yohimbine PB QL PB QL G Levothroid levothyroxine Levoxyl Synthroid Unithroid THYROID G G G PB G TNF ANTAGONISTS PB Enbrel (ST for psoriasis) PB Humira (ST for psoriasis) common nonpreferred products in this class include • Kineret • TRANSDERMAL ANDROGENIC AGENTS Androderm Androgel PB PB G G PB G PROSTATE (enlarged) Avodart doxazosin finasteride Flomax terazosin PB G G PB G ANTI-PSORIATICS—TOPICAL all generics aclometasone amcinonide betamethasone clobetasol Cordran desonide desoximetasone diflorasone Dovenox fluocinolone fluocinonide halobetasol Halog mometasone prednicarbate Tazorac triamcinolone G G G G G PB G G G PB G G G PB G G PB G SEDATIVE HYPNOTICS PB Ambien CR G temazepam G triazolam G zolpidem common nonpreferred products in this class include Ambien • Lunesta • Rozerem • Sonata • end This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0038A p4/5 • 0608 Page 4 decide with your doctor Using the Preferred Products List Q Generics W hat is the Preferred Products List (PPL)? ANSWER The Innoviant PPL lists many of the commonly prescribed generic and brand products currently available under your prescription drug benefit. Included on the PPL Innoviant issues a PPL, similar to a drug formulary, to help you and your physician select the most cost effective prescription product(s) for you. Some medications are available as generics and brand names. Our list includes generics and preferred brands. This is only a partial listing, and not all products on this list may be covered by your prescription benefits plan. Your specific benefit plan’s guidelines regarding quantity limits, step therapy, prior authorization, and generic usage will apply. An independent review committee considers all Innoviant preferred products based on: • Clinical safety standards • Effectiveness • Cost Using the PPL Share the PPL with your doctor for help with choosing the right prescription product for you. Take the PPL with you to doctors’ visits. It’s a handy guide for selecting the most cost-effective medication for you. If you choose to obtain a brand name drug that has a generic equivalent, then you will be responsible for paying the difference in cost between the brand name drug and the generic drug in addition to the appropriate co-payment. Generics are the best value for most members. They are also FDA approved to be just as safe and effective as their brand name counterparts. This PPL lists the most common generic products in each medication class. Preferred brands are also listed for each class, when applicable. Updating the PPL Every three months our independent review committee (including physicians and pharmacists) considers new and existing prescription medications for addition to the Innoviant PPL. The most upto-date PPL can be found on our web site at www.innoviant.com or by calling customer service. For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Innoviant, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0038A p5/5 • 0608 Page 5 convenience close to home Retail Pharmacies and Q W hat can I expect from a pharmacy network? ANSWER A well-balanced pharmacy network should provide members with the convenience of broad access, while maintaining competitive discounts for brand and generic medications. Finding a Network Pharmacy Using Your ID Card Our national retail pharmacy network includes more than 58,000 chain and independent retail pharmacies, so you’re sure to find one close to home or work. You can use your prescription ID card at any network pharmacy. Just present your card to the pharmacy and they will enter your claim. The pharmacy will apply the benefit amount applicable to your plan for the prescription product purchased. If the charges are more than the benefit amount, the pharmacy will collect the balance from you. To help you find a participating pharmacy in your local area, we’ve included a listing of network chain stores on the following pages. To locate a specific pharmacy in our network, visit www.innoviant.com. Simply type in your ZIP Code to get a list of participating pharmacies, including their locations and phone numbers. For directions, click on the map icon. If you need help locating a pharmacy, contact Innoviant customer service at 877-559-2955. If you present your card at a non-participating pharmacy, or if other circumstances require a cash purchase, you must pay 100 percent of the retail price for your prescription. For reimbursement on your eligible prescriptions, submit a claim reimbursement form (available from your benefit manager or download one from our Web site, www.innoviant. com) and the prescription receipt directly to us. Your reimbursement amount is based on the participating pharmacy’s contracted rate less your co-payment, and will be subject to your benefit plan’s rules and restrictions. Program The Innoviant Retail 90 Rx program allows you to receive a threemonth supply of your medication at more than 48,000 participating retail pharmacies. Like a traditional mail-order service, you can avoid refilling a prescription every month while still having the opportunity to receive individualized counsel from a trained pharmacy professional in your neighborhood. Consult your member benefit booklet for your plan’s co-payment structure. Some medications may only be dispensed for the exact quantity as written by your physician—so have your physician prescribe a 90-day supply. Other drugs may have a dispensing limit controlled by law which may be less than 90 days and are not eligible for this program. For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0036C p1/6 • 1107 Page 6 convenience close to home National Retail Pharmacy Chain Listing A & P Pharmacy ABCO Desert Markets Access Health Member Pharmacies Acme Pharmacy Ahold USA AHS - St. John Pharmacy Albertsons Allina Community Pharmacy Allscripts Ambulatory Pharmaceutical Svcs American Drug Stores Anchor Pharmacy Appalachian Regional Health Assoc Wholesalers Groc Ntwk Astrup Drug Aurora Pharmacy B & R Stores Bakers Pharmacy Balls Four B Bartell Drugs Bashas’ United Drug Bel Air Pharmacy Bell Pharmacy Big A Drug Stores Big Bear/Harts Stores Biggs Pharmacy Clinic Pharmacy Administration Clinic Pharmacy of Marshfield Coborn’s Pharmacy Community Distributors Community Pharmacy Bi-Lo Bi-Mart BJ’s Pharmacy Brooks Pharmacy Brookshire Brothers Brookshire Grocery Brown & Cole Stores Continuing Care Rx Controlex Enterprises Costco Covenant Regional Services Cub Pharmacy CVS/Pharmacy D & W Food Centers Bruno’s Buehler Foods Cash Wise Pharmacy Care Pharmacies Carrs Pharmacy Centex Pharmacies Chronimed City Center Drug City Market (Kroger) CJM Cleveland Clinic Foundation Dahl’s Foods Dean Pharmacy Administration Department of Veterans Affairs Pharmacies Dierbergs Family Markets Dillon’s Pharmacy (Kroger) Discount Drug Mart Discount Emporium Doc’s Drugs Ltd Dominicks Drug Castle For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0036C p2/6 • 1107 Page 7 convenience close to home National Retail Pharmacy Chain Listing Drug Emporium Fairview Pharmacy Services Drug Town Family Fare Drug World Pharmacy Family Pharmacy Duane Reade Eagle Food Centers Pharmacy Eagle Pharmacy Familycare Network Familymeds Farm Fresh Pharmacies Giant Food Stores Giant Of Maryland Glass Gardens Golub Good Neighbor Pharmacy Provider Network Felpausch Pharmacy Greco Enterprises Econo Foods Fleming Companies Gristedes Em Dee Drug Food Circus Super Markets Group Health Associates Enloe Drugs Food City Pharmacy H E B Pharmacy Epic Pharmacy Network Fred Meyer (Kroger) Eckerd Drugs Erlanger Pharmacy Fred’s Eureka Drug Stores Fruth Fagen Pharmacy Family Pharmacare Center Denotes that the pharmacy participates in the Retail 90 Rx program. Many independent pharmacies also participate in the Retail 90 Rx program, and additional chains are joining monthly. For a complete and up-to-date listing, please call Innoviant customer service at 800-207-1561. Haggen Food & Pharmacy Hannaford Bros Happy Harry’s Discount Drug Frys Food And Drug (Kroger) Harmons Pharmacy Furrs Supermarkets Harps Food Stores G & A Medical Personnel Harris Teeter Pharmacy Gabler’s Drug Hartig Drug Gavin Herbert Health Mart Gentiva Health Svcs (Quantum) Healthpartners Pharmacy Genuardi’s (Safeway) Heartland Pharmacy Gerimed Pharmacy Henry Ford Med Ctr Pharmacy Giant Eagle Pharmacy Hi-School Pharmacy For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0036C p3/6 • 1107 Page 8 convenience close to home National Retail Pharmacy Chain Listing HIP Pharmacy Service of NY Homeland Stores Hy-Vee Food Stores IHC Health Services Ingles Markets Jewel-OSCO Jordan Drug K Mart Pharmacy Kelsey Seybold Pharmacy Kerr Drug Stores Kessel Pharmacy Keystone - Medicine Chest King Kullen Pharmacy King Soopers Pharmacy (Kroger) Kings Pharmacy Kinney Drugs Klingensmith’s Drug Stores Knight Drugs Kohll’s Pharmacy & Homecare Kopp Drug Kreisler Drug Kroger Pharmacy K-VA-T Food Stores Leader Drug Stores Lewis Drug Lewis Family Drug Longs Drug Store Louis & Clark Drugstores Lowe’s Marketplace Pharmacy M.K. Stores Major Value Member Pharmacies MAL Enterprises Marc Glassman Market Basket Marsh Drugs Maxor Pharmacy Maxi Drug Inc. Mays Drug Stores Mcauley Pharmacy McKesson Med-Fast Pharmacy Medic Drug Medicap Pharmacy Medicine Center Medicine Shoppe Mediserv Med-Rx Drug Med-X Drug Meijer Pharmacy Metro Group #64 Minyard Food Stores Morton Drug Mr Discount Drugs Mr Z’s Pharmacy Nash Finch Navarro Discount Pharmacy NCS Healthcare Neighborcare Pharmacy New Oakland Pharmacy Nob Hill Pharmacy Nortex Drug Distributors Northwest Health Ventures Nova Factor Oakwood Healthcare OK Health Care Authority-Tpl Omnicare Inc. For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0036C p4/6 • 1107 Page 9 convenience close to home National Retail Pharmacy Chain Listing Oncology Pharmacy Services OptionCare Osco Drug P & C Food Markets Pamida Park Nicollet Pharmacy Pathmark Stores Patient’s Pharmacy Pavilions Pharmacy Payless Drugs Perlmart/Shoprite Pediatric Services Of America Penn Traffic Peoples Pharmacy Pharma-Card Pharmacare Pharmacy Associates Pharmacy Express Services Pharmacy Plus Pharmacy Providers Of OK Pharmapoint Pharmacy Network Pharmerica Drug Systems Pinnacle Pharmacy Planned Parenthood Greater NNJ Price Chopper Pharmacy Price Cutter Pharmacy Primemed Pharmacy Services Priority Health Care Pharmacy Procare Pharmacy Professional Pharmacy Services Providence Pharmacy Publix Super Markets Denotes that the pharmacy participates in the Retail 90 Rx program. Many independent pharmacies also participate in the Retail 90 Rx program, and additional chains are joining monthly. For a complete and up-to-date listing, please call Innoviant customer service at 800-207-1561. QFC (Kroger) Quick Chek Pharmacy Dept Rainbow Food Group Raley’s Pharmacy Ralphs (Kroger) Randalls Reasor’s Ridley’s Food And Drug Rinderer’s Drug Stores Rite Aid Ritzman Pharmacy Rogers Pharmacy Ronci Family Discount Drugs Inc Ronetco Rosauers Supermarkets Rxd Pharmacy Safeway (Genuardi’s) Save Mart Pharmacy Sav-Mor Drug Stores Sav-On Drugs Schnucks Markets Scolari’s Food & Drug Scots Lo-Cost Pharmacy Seaway Food Town Sedano’s Pharmacy Sedell’s Pharmacy Shaws Supermerkets For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0036C p5/6 • 1107 Page 10 convenience close to home National Retail Pharmacy Chain Listing Shelby Shore Drugs Shelly’s Pharmacy Shop n Save Pharmacy Shopko Pharmacy Shoppers Pharmacy Shoprite Pharmacy Smiths Food & Drug Centers (Kroger) Smittys Pharmacy Snyder Drug Emporium Snyder’s Drug Store St Louis Connectcare Standard Drug Statscript Pharmacy Steele’s Pharmacy Stop & Shop Pharmacy Strategic Health Alliance/Caremax Sun Factors Sun Fresh Pharmacy Super D Drugs Super One Pharmacy Super Rx Pharmacy Supermarket Inv/ Harvest Foods Supervalu Pharmacy Target Pharmacy Thriftway Pharmacy Associates Thrifty-White Drug Tidyman’s Pharmacy Village Supermarkets Vollmer Pharmacy Von’s Pharmacy W P Malone Walgreens Tiffany-Davis Drug Wayne Drug Tom Thumb Weber & Judd Tom’s Mad Pricer Discount TOPS Markets TriNet Pharmacy (Truecare) Wegmans Food Market Weis Pharmacy Welcome Pharmacy Twin Knolls Pharmacy Wender & Roberts Ukrops Super Markets Westbury Pharmacy UMC Dept Of Pharmacy Services Wilkinson Pharmacy Union Prescription Center Winn-Dixie Stores United Pharmacy Woods Pharmacy United Supermarkets Unity Retail Pharmacy Yoke’s Pharmacy Zallie Supermarkets Univ Of Utah Health Network University Of Wisconsin USA/Super D Drug Value Center Vg’s Pharmacy For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0036C p6/6 • 1107 Page 11 a first step toward savings Rx InStep—Step Therapy Q of the use of a first step drug. W hat is Rx Instep? ANSWER Rx Instep is a step therapy program especially for people who take prescription drugs to treat certain ongoing medical conditions with safety, cost and most importantly, your health in mind. Controlling Rising Rx Costs Rx Instep Review Step therapy allows you and your family to receive affordable treatment and helps the plan contain the rising cost of prescription drug coverage. If you were prescribed a second step medication in the past and have not filled a prescription for it in four months or more, you will not be able to re-start that medication without first trying a first step drug. The program starts with generic drugs in the first step. Generics covered by your plan are proven to be effective in treating many medical conditions. You will have the lowest copayment for first step generics. More costly brand name drugs are usually covered in the second step, even though generics are proven to be effective in treating many medical conditions. These brand name drugs will have higher copayments. Always ask your doctor to prescribe a first step medication before a second step medication. You can provide your doctor with a copy of Rx Instep medications by printing a list from the DC 37 Web site. If treatment with a first step drug does not work well, you can be given a more costly second step drug. You will not need an approval to fill the new prescription at the pharmacy because Innoviant will have a record If you fill a prescription for a second step medication without trying a first step medication, your pharmacist will receive a message indicating that your plan has a step therapy program. The pharmacist will generally contact the physician to request a new prescription for a step one drug. If a physician is unavailable, you will be responsible for obtaining the new prescription. If you choose to get your written prescription filled as is, you will pay the full cost and the medication will not be covered by the plan. Psychotropic and Asthma Products To ensure continuity of your benefits for coverage of psychotropic and asthma products, as previously administered under the New York City PICA program, the same criteria have been maintained for use in review of these products.* Rx Instep Medications See the next page for a listing of Rx Instep medications. For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0051C p1/2 • 0608 Page 12 a first step toward savings Rx Instep Medications Category Rx Instep Review Not Required Rx Instep Review Required Hypertension (ACE) benazepril benazepril/hctz captopril captopril/hctz enalapril enalapril/hctz fosinopril fosinopril/hctz lisinopril lisinopril/hctz quinapril quinapril/hctz Aceon Altace Mavik Univasc Uniretic Hypertension (A2) Must try an ACE from ACE step therapy medications Aceon Altace benazepril benazepril/hctz captopril captopril/hctz enalapril enalapril/hctz fosinopril fosinopril/hctz lisinopril lisinopril/hctz Mavik Univasc Uniretic quinapril quinapril/hctz Atacand/HCT Avapro Avalide Benicar/HCT Cozaar Diovan/HCT Hyzaar Micardis/HCT Teveten Arthritis (DMARDS) azathioprine cyclosporin hydoxychloroquine gold compounds leflunomide methotrexate penicillamine sulfasalazine Enbrel Humira Kineret Orencia Remicade Dermatitis alclometasone amcinonide betamethasone diproprionate augmented butyrate clobetasol Cloderm desoximetasone diflorasone Florone-E flurandrenolide fluticasone halocinonide halobetasol hydrocortisone mometasone Pandel Elidel Protopic Attention Deficit Disorder amphetamine salt combinations dextroamphetamine methamphetamine methylphenidate/ER Strattera Asthma Beconase AQ Clarinex fexofenadine/D Flonase Flovent Intal Nasacort AQ Nasalide Nasarel Nasonex Rhinocort AQ Zyrtec/D Accolate Singulair Pain & Inflammation (COX-2/NSAIDS) diclofenac sodium/ potassium etodolac/ER fenoprofen flurbiprofen ibuprofen indomethacin ketoprofen ketorolac meclofenamate meloxicam nabumetone naproxen oxaprosin piroxicam sulindac tolmetin Arthrotec Celebrex Ponstel PPIs omeprazole Prevacid/SoluTab/Oral Suspension Depression (SSRI) citalopram fluoxetine fluvoxamine paroxetine Mental Health Abilify Clozaril Fazaclo Other Antidrepressants bupropion SR citalopram fluoxetine Aciphex Nexium Prilosec Protonix Zegerid sertraline Lexapro Paxil CR Pexeva Prozac/weekly Geodon Risperdal Seroquel Zyprexa Symbyax fluvoxamine paroxetine sertraline venlafaxine Cymbalta Effexor/XR Wellbutrin XL end This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0051C p2/2 • 0608 Page 13 saving money Half Tab Rx—Tablet Splitting Q Safe Tablet Splitting C an I split tablets prescribed by my doctor to save money? ANSWER In some cases, tablet splitting is a safe way to create savings for both you and your prescription benefit program. How Half Tab Rx Works Some medications cost about the same, regardless of dosage. For example, the 20mg and 40mg dosages of a popular medication used to treat high cholesterol both cost about $95.70 for a 30-day supply. When 40mg tablets are split, a 30-day supply of 20mg half tablets costs only $47.85. Splitting the 40mg tablets makes a 30-day supply of 20mg half tabs and effectively cuts the cost of your medication in half. Your co-pay will go twice as far with Half Tab Rx. See the following example: Savings Example Half Tab Rx Drug and Dosage Without 20mg* With 40mg* Because not all medications are safe to split, we’ve defined a list of drugs that are covered under the Half Tab Rx program. • Ambien • Diovan • Atacand • Lexapro • Avapro • Lipitor • Cozaar • Toprol XL • Crestor • benazepril (generic for Lotensin) • citalopram (generic for Celexa) • doxazosin (generic for Cardura) (30 tablets) (15 tablets split in half) 30 30 Cost to Plan $80.70 $40.35 • pravastatin (generic for Pravachol) Cost to You $15.00 $7.50 • quinapril (generic for Accupril) Days Supplied Annual Savings None Plan: $484.20 • fosinopril (generic for Monopril) • lisinopril (generic for Prinivil, Zestril) • paroxetine (generic for Paxil) • sertraline (generic for Zoloft) • simvastatin (generic for Zocor) You: $90.00 * Drug included in this savings example is a popular medication used to treat high cholesterol. Actual savings vary based on your plan design, but with Half Tab Rx, the savings are real. And helping your plan save money contributes to the overall cost management of your prescription benefits. This list is not intended to be a complete listing of all medications in tablet form that might be suitable for splitting and is subject to change without notice. continued For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0060C p1/2 • 061108 Page 14 To Split Or Not To Split? You are not required to split tablets to save money, but if you choose to participate, be sure to talk with your doctor before splitting any of your medications. If you and your doctor agree that tablet splitting is a safe way for you to save money, you will need: 1.A new prescription from your doctor for the new dosage of your medication. The prescription must clearly instruct you to take one-half tablet daily. 2.A tablet splitting device. Tablet splitters allow you to cut tablets more accurately and safely. You can purchase one for just a few dollars at a local pharmacy. For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0060C p2/2 • 061108 Page 15 answering your benefit questions Customer Service Q Easy-to-Use Web Site H ow can I learn more about my prescription benefits? ANSWER The best place to start is with Innoviant, your prescription benefits administrator. We’re Here to Help As your prescription benefits administrator, Innoviant is here to answer any pharmacy questions and help you save money on your prescription medications in the process. We are committed to you, and your well-being is important to us. Dedicated Customer Service We have dedicated customer service representatives available to help you with your questions and concerns. Just call us toll-free at 877-559-2955. We’re available 24hours a day, seven days a week. Our staff is friendly and knowledgeable and can provide real-time, immediate information directly to you. Most of our customer service representatives are certified pharmacy technicians (CPhT). This designation is a national, professional certification, which we encourage our customer service representatives to achieve. With this professional education and expertise, you receive better comprehensive customer service. The Innoviant Web site is easy to use and available 24 hours a day at www.innoviant.com. Simply click on the Members’ tab to explore areas of interest, such as: • Pharmacy Finder—a handy tool to quickly identify pharmacies in your area. • Essential forms—easy to download before your doctor visit. • My Health Zone—an interactive online educational tool. My Health Zone includes a variety of information you can personalize to encourage healthy lifestyle decisions for you and your family. A medical library, along with motivational tools and activities, is also available to help you manage areas such as nutrition, allergies and asthma. We welcome your questions, comments and suggestions to provide you with exceptional customer service! end For more information, contact us at 877-559-2955. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0093 p1/1 • 062007 Page 16 clinically sound medication use Prior Authorization Q Requesting a Prior Authorization W hy do I need a prior authorization for some medications? ANSWER Some medications must be authorized for coverage because they’re only approved or effective in treating specific illnesses or they cost more. Reviewing Medications At Innoviant, an independent review committee (including physicians and pharmacists) meets every three months to review medications and recommend prior authorization guidelines as needed. For each new and existing prescription product, they consider how the medication should be covered under the prescription benefit plan. These physicians and pharmacists will recommend when a medication needs prior authorization. Safe and Effective When making a recommendation, the review committee focuses on a medication’s proven safety, effectiveness and cost. The committee considers: • Food and Drug Administration (FDA) approved indications • Manufacturer’s package labeling instructions • Well-accepted or published clinical recommendations You, your pharmacist, or physician can start the prior authorization process by contacting your benefit plan office at (212) 815-1608. A benefit representative will provide you with the information needed to consider your request. Your benefit plan will inform you of the decision, and, if approved, will also notify Innoviant. The next page contains a partial listing of medications requiring prior authorization. Getting a Short-Term Supply If the medication you need requires prior authorization and you must start taking it right away, ask your doctor if a drug sample is available. If the prior authorization is approved, your pharmacist can then dispense your prescription. continued on next page... For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2008 Innoviant, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0094E p1/2 • 050608 Page 17 clinically sound medication use Prior Authorization List ** Acne Differin Accutane Retin-A Tazorac Antianginal Ranexa Antidepressant Emsam Antifungal Diflucan (if > 2 tablets) Nizoral Noxafil Penlac Sporanox (itraconazole) Vfend Chemotherapy Medication* Narcotic Analgesic CNS Medication* Actiq Fentora Fentanyl Anti-emetics Cesamet Growth Hormone Genotropin Humatrope Norditropin Nutropin/AQ Omnitrope Protropin Saizen Serostim Anti-hypertensive Tekturna Antineoplastic Immunosuppressant Tasigna Zolinza Clozaril (clozapine) Invega Seroquel 25mg CellCept Imuran Myfortic Neoral Prograf Rapamune Sandimmune Antiviral Obesity Fuzeon Bontril/SR Didrex Ionamin Meridia Tenuate Xenical Antipsychotic Antiviral Monoclonal Antibodies Synagis Pulmonary Arterial Hypertension Letairis Revatio Tracleer Sexual Dysfunction Yohimbine Cialis Levitra Viagra Somatostatic Somatuline * Contact your benefit plan office at (212) 815-1608 for more information. **Please note: this is a partial listing of medications requiring prior authorization. end For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2008 Innoviant, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0094E p2/2 • 050608 Page 18 cost saving choices Common Preferred Alternatives Q Generics First C an I save money with preferred alternative products? ANSWER Yes. Preferred alternative products offer you choice in deciding with your physician if lower cost medications are right for you. Preferred products have lower co-pays than nonpreferred products, and are often available as generics. Saving Money At Innoviant, we care about cost savings and know how important it is to keep your medication expenses down. That’s why we’ve developed a preferred alternatives list. If you see one of your medications in the nonpreferred brand column, consider asking your physician about a preferred generic or preferred brand alternative. A preferred alternative may be just as effective and save you money too. If you choose to obtain a brand name drug that has a generic equivalent, then you will be responsible for paying the difference in cost between the brand name drug and the generic drug in addition to the appropriate co-payment. This list shows common nonpreferred brand products and preferred alternatives, but is not intended to include all products. A current listing of our preferred products is available on our Web site, www.innoviant.com, or by calling us. This list is subject to change without notice. Nonpreferred BrandsPreferred GenericsPreferred Brands Accupril quinapril Aciphex omeprazole Allegra/D Alavert/D*, cetirizine*, fexofenadine, Ambien flurazepam, temazepam, triazolam, zolpidem Amerge Avonex Axert Benicar HCT Aceon, Altace Prevacid/SoluTab/Oral Suspension, Protonix Zyrtec/D Ambien CR Imitrex, Relpax, Zomig Betaseron, Copaxone, Rebif Imitrex, Relpax, Zomig Atacand/HCT, Avapro/Avalide, Diovan/HCT continued on next page... For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0095C p1/3 • 052808 Page 19 Preferred Alternatives Nonpreferred BrandsPreferred GenericsPreferred Brands Cefzil cefdinir, cefprozil, cefuroxime Celexa citalopram, fluoxetine capsules, Lexapro paroxetine, sertraline Clarinex/D Alavert/D*, cetirizine*, fexofenadine, Zyrtec/D Coreg/Coreg CR atenolol, carvedilol, metoprolol ER, propranolol Cozaar Avapro, Atacand, Diovan Frova Imitrex, Relpax, Zomig Hyzaar Atacand HCT, Avalide, Diovan HCT Kineret Enbrel, Humira Lotrel 2.5/10, 5/10, 5/20, 10/20 amlodipine/benazepril Atacand HCT, Avalide, Diovan HCT, Exforge Lunesta flurazepam, temazepam, triazolam, Ambien CR zolpidem Nasacort AQ fluticasone Astelin, Nasonex, Veramyst Nexium omeprazole Prevacid/SoluTab/Oral Suspension, Protonix Norvasc amlodipine, diltiazem, nifedipine, Sular verapamil Pravachol lovastatin, pravastatin, simvastatin Advicor, Crestor, Lipitor, Vytorin Prilosec omeprazole Prevacid/SoluTab/Oral Suspension, Protonix Omnicef cefdinir, cefprozil, cefuroxime Rhinocort Aqua fluticasone Astelin, Nasonex, Veramyst Rozerem flurazepam, temazepam, triazolam, Ambien CR zolpidem Sonata flurazepam, temazepam, triazolam, Ambien CR zolpidem Teveten Atacand, Avapro, Diovan Toprol XL atenolol, carvedilol, metoprolol ER, propranolol Tricor gemfibrozil Antara, Lofibra, Triglide Wellbutrin XL Budeprion XL 300mg, bupropion/SR Xyzal Alavert/D*, cetirizine*, fexofenadine, continued on next page... For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0095C p2/3 • 052808 Page 20 Preferred Alternatives Nonpreferred BrandsPreferred GenericsPreferred Brands Zocor Zoloft Zyrtec/D lovastatin, pravastatin, simvastatin Advicor, Crestor, Lipitor, Vytorin citalopram, fluoxetine capsules, Lexapro paroxetine, sertraline Alavert/D*, cetirizine*, fexofenadine, * Covered only if plan participates in the Rx OTC Program. ** Generic co-pay applies as part of the Brands for Generic Program. end For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0095C p3/3 • 052808 Page 21 Q A How do I fill a prescription? Frequently Asked Questions Show your written prescription and ID card at the pharmacy. Your ID card contains important benefit information needed to process your claim. Q. How many pharmacies are in the Innoviant network? A. Our network has more than 58,000 chain and independent pharmacies throughout the U.S., Puerto Rico, Guam and the Virgin islands. Q. How do I find a network pharmacy? A. Visit www.innoviant.com and use the pharmacy look-up feature. Enter a ZIP code close to home or work, and you’ll see a list of participating pharmacies, including locations and phone numbers. Or take a look at our Retail Pharmacy Network brochure. It has an alphabetical listing of many pharmacies in our retail network. The pharmacy listing may be included with your benefit information, and is also available through customer service. Q. What if my pharmacy is not in the Innoviant network? A. Any pharmacy may join the Innoviant network. Ask your local pharmacy to contact Innoviant customer service, and we will process their request to join our network. A new network pharmacy is usually setup within one business day. Q. What is a Preferred Products List? A. A Preferred Products List (PPL) includes commonly prescribed preferred brand and generic products. Using the PPL can save you money. Show it to your physician and together you can decide on the most effective prescription product for you. A PPL may be included in your new enrollment packet. Q. Are generic medications as effective as brand names? A. Yes, for most people. Generics are copies of brand name medications that have been fully tested and approved by the FDA. Generics have the same strength, purity, safety and quality as more expensive brand name drugs. Q. When can prescription(s)? I refill my A. Prescription refills authorized by your doctor may be refilled after you have used 70 percent of the medication. For example, if you’ve used 21 days of medication out of a 30-day prescription, or 63 days of medication out of a 90-day supply, you can refill the medication. For more information, contact us at 877-559-2955. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0096 p1/2 • 062007 Page 22 Q A Who should I call with question about my prescription benefits? Frequently Asked Questions Contact Innoviant customer service at 877-559-2955 or e-mail us at: RxQuestions@ innoviant.com Q. Which medications require prior authorization? A. Innoviant recommends a limited number of products for prior authorization. A listing may be included in your enrollment packet. For a current listing, visit www.innoviant.com or call customer service. Q. What if the medicine my doctor prescribes needs a prior authorization, but I need to start taking it right away? A. Ask your doctor if a drug sample is available. Or see if the pharmacist can fill a short-term supply (five days or less). You will still be responsible for the 30-day co-payment. If the prior authorization is approved, then your pharmacist can dispense the rest of your prescription. Q. How do I request permission to refill my medication early, such as before going on vacation? A. Contact Innoviant customer service to request an early refill authorization. Please note, the authorization will not exceed a one-month supply. Q. How do I request a prior authorization? A. You or your pharmacist may contact Innoviant customer service. A customer service representative will work with your doctor’s office and pharmacy to gather the information required. Q. How do I use the mail order program? A. If your plan offers mail order service, and you would like to start using the program, call us at 877-559-2955 to request a packet. Mail order information may be included in your enrollment packet, and it’s also available online at www.innoviant.com. You will need a new written prescription from your doctor for up to a 90-day supply. For more information, see the Mail Order Program page. Q. How long will it take for my medication to reach me through mail order? A. New mail order prescriptions will usually arrive within three weeks of placing an order. Refills usually arrive within two weeks. We recommend members order at least two weeks before medication is needed. For more information, contact us at 877-559-2955. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0096 p2/2 • 062007 Page 23 sensible dosing Quantity Limits on Medications Q Establishing Guidelines for Use W hy do some medications have quantity limits? ANSWER Quantity limits are in place to support appropriate dosing. They are based on solid recommendations from the FDA and other medical sources. Determining Quantity Limits Quantity limits are meant to minimize the risk of over-dosing and unwanted drug interactions. Quantity limit rules are based on: • Food and Drug Administration (FDA) approved indications • Manufacturer’s package labeling instructions • Well-accepted or published clinical recommendations An independent review committee (including physicians and pharmacists) meets every three months to review existing medications and new medications coming to market. For each prescription product, they consider how the medication should be covered under the prescription benefit plan. These physicians and pharmacists will recommend when a medication needs quantity limits. Currently, the committee recommends medications listed be limited to a defined quantity. This is only a partial listing and not all products may be covered by your prescription benefits plan. Your specific benefit plan’s guidelines regarding quantity limits will apply. Call Innoviant customer service for more information. Drug NameTherapy Class Limit Actiq (fentanyl oral transmucosal) Actonel 35mg Actonel 75mg Acular/Acular LS Advair Diskus/HFA Alocril Alomide Alrex Narcotic analgesic 6 units per day Osteoporosis Osteoporosis Ophthalmic NSAID Asthma inhaler Ophthalmic antiallergic Ophthalmic antiallergic Ophthalmic steroid 4 tablets per 28 days 2 tablets per 30 days 2 (10ml) bottles per month 1 device per month 3 (5ml) bottles per month 3 (10ml) bottles per month 3 (5ml) bottles per month continued on next page... For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2008 Innoviant, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0097D p1/4 • 062608 Page 24 sensible dosing Medications With Quantity Limits Drug NameTherapy Class Limit Altabax Amerge Anzemet Aranesp Asmanex Avonex Axert Azasite Blood glucose testing strips (all brands and generics) Boniva 150mg Cesamet Cialis 5mg, 10mg, 20 mg Cialis 2.5 mg Ciloxan ophthalmic ointment Diflucan (fluconazole) 150mg Elestat Emend 80mg, 125mg Emend (combo pack) 125mg-80mg Enbrel Epogen Estring Femring Fentora Foradil Forteo Fosamax 35mg, 70mg Fosamax D 70/2800, 70/5600 Frova Humira Imitrex 25mg, 50mg, 100mg Imitrex Injections Imitrex Nasal Spray Iquix Antibiotics–topical Acute migraine therapy Nausea and vomiting Hematopoietic agent Asthma inhaler Multiple sclerosis Acute migraine therapy Ophthalmic antibiotic Diabetic testing supplies 1 tube per month 9 tablets per month 1 tablet per month 28 day supply per dispense 3 devices per month 4 injections per month 9 tablets per month 1 (2.5ml) bottle per month 150 test strips per month Osteoporosis Nausea and vomiting Sexual dysfunction Sexual dysfunction Ophthalmic antibiotic Antifungal Ophthalmic antiallergic Nausea and vomiting Nausea and vomiting Anti-TNF agent Hematopoietic agent Hormone replacement therapy Hormone replacement therapy Narcotic analgesic Asthma medication Osteoporosis Osteoporosis Osteoporosis Acute migraine therapy Anti-TNF agent Acute migraine therapy Acute migraine therapy Acute migraine therapy Ophthalmic antibiotic 1 tablet per 30 days 20 capsules per month 8 tablets per month 30 tablets per month 1 tube (3.5gm) per month 2 tablets per month 2 (5ml) bottles per 30 days 3 capsules per month 1 pack per month 8 doses per month 28 day supply per dispense 1 device per 3 months (3 months) 1 device per 3 months (3 months) 6 units per day 60 capsules per month 24 months of therapy 4 tablets per 28 days 4 tablets per 28 days 9 tablets per month 1 package per 28 days 9 tablets per month 1 package per month 1 package per month 1 (5ml) bottle per month continued on next page... For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2008 Innoviant, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0097D p2/4 • 062608 Page 25 Medications With Quantity Limits Drug NameTherapy Class Limit Ketek Kytril (granisetron) Levitra Lidoderm Livostin Lumigan Lupron Depot 11.25, 22.5 Luveris Maxalt and Maxalt MLT Migranal Natacyn Neulasta Neupogen Nevanac Ocufen (flurbiprofen) Optivar Oxycontin Pataday Patanol Pegasys Pegasys kit ProAir HFA Procrit Proventil HFA Prozac Weekly Quixin Regenecare Wound Gel Relenza Relpax Restasis Revlimid Seasonale (Seasonique) Serevent Diskus Stadol NS (butorphanol) 20 dosage units per 30 days 2 tablets per month 8 tablets per month 1 box per month 2 (5ml) bottles per month 1 (2.5ml) bottle per month 1 unit per 90 days 14 vials per month 9 tablets per month 1 package per month 1 (15ml) bottle per month 28 day supply per dispense 28 day supply per dispense 2 (3ml) bottles per year 1 (2.5ml) bottle per month 2 (5ml) bottles per 30 days 270 tablets per month 2 (2.5ml) bottles per 30 days 2 (5ml) bottles per 30 days 4 vials per 28 days 1 kit per 28 days 2 devices per month 28 day supply per dispense 2 devices per month 4 capsules per month 1 (5ml) bottle per month 1 copay per package 1 treatment per year 9 tablets per month 2 per day 28 day supply per dispense 1 pkg per 91 days (3 copays) 1 device per month 4 (2.5ml) pumps per month Antibiotics Nausea and vomiting Sexual dysfunction Anesthetic patch Ophthalmic antiallergic Glaucoma Cancer Infertility Acute migraine therapy Acute migraine therapy Ophthalmic antibiotic Hematopoietic agent Hematopoietic agent Ophthalmic NSAID Ophthalmic NSAID Ophthalmic antiallergic Narcotic analgesic Ophthalmic antiallergic Ophthalmic antiallergic Hepatitis C Hepatitis C Asthma inhaler Hematopoietic agent Asthma inhaler SSRI antidepressant Ophthalmic antibiotic Wound care Influenza antiviral Acute migraine therapy Ophthalmic-other Cancer Contraception Asthma inhaler Narcotic analgesic nasal spray continued on next page... For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2008 Innoviant, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0097D p3/4 • 062608 Page 26 Medications With Quantity Limits Drug NameTherapy Class Limit Symbicort Tamiflu Toradol 10mg (ketorolac) Travatan/Z Ultracet (tramadol/acetaminophen) Ventolin HFA Veregen Viagra Vigamox Viroptic (trifluridine) Voltaren (diclofenec) ophthalmic solution Xalatan Xibrom solution Zofran (ondansetron) 2mg, 4mg, 8mg, 24mg Zofran (ondansetron) ODT 2mg, 4mg, 8mg Zofran (ondansetron) oral solution Zomig and Zomig ZMT 2.5mg, 5mg Zomig Nasal Spray Zymar Asthma inhaler Influenza antiviral COX-1 Inhibitor, NSAID Glaucoma Pain medication Asthma inhaler External genital warts Sexual dysfunction Ophthalmic antibiotic ophthalmic antiviral Ophthalmic NSAID 1 device per month 1 treatment per year 20 tablets per month 1 (2.5ml) bottle per month 40 tablets per month 2 devices per month 16 weeks per year 8 tablets per month 1 (3ml) bottle per month 1 (7.5ml) bottle per month 1 (5ml) bottle per month Glaucoma Ophthalmic NSAID Nausea and vomiting 1 (2.5ml) bottle per month 2 (5ml) bottles per year 18 tablets per month Nausea and vomiting 18 tablets per month Nausea and vomiting Acute migraine therapy Acute migraine therapy Ophthalmic antibiotic 200ml per month 9 tablets per month 1 pkg per month 1 (5ml) bottle per 15 days end For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2008 Innoviant, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0097D p4/4 • 062608 Page 27 convenient savings Mail Order Program Q W ho should consider the mail order program? ANSWER If you take prescription products on a long-term, regular basis, our mail order program may be just right for you. It’s easy, convenient and could save you money. Read on to learn more . . . Overview As part of your plan benefits, you and your eligible dependents have access to our mail service prescription program, Innoviant Rx. Through this program, you will receive quick, safe and reliable services including: • Postage-paid delivery right to your door Mail order is not recommended for short-term medications, such as antibiotics. These prescriptions should be filled at a participating retail pharmacy. Coverage varies from plan-to-plan. Please refer to your plan documents for information on your prescription co-payment amounts. • Registration by mail, fax or Web • Refills by mail, fax, Web or phone • E-mail notifications of order status • Multilingual pharmacists • TTY service for hearing impaired members Generics = Money Savings Be sure to ask your doctor to prescribe a generic equivalent when possible. If your choose to obtain a brand name drug that has a generic equivalent, then you will be responsible for paying the difference in cost between the brand name drug and the generic drug in addition to the appropriate co-payment. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be just as safe and effective. Choosing generic drugs can help you keep your out-of-pocket prescription costs under control. Covered Products Most prescription products taken on an ongoing basis that are covered under your present prescription plan, are also covered by the mail service program. Occasionally, you may receive prescriptions for non-covered medications, such as those available overthe-counter, or your physician may use the prescription pad to write down recommended non-prescription items. These items are not covered under the mail order program. For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0101B p1/2 • 062507 Page 28 Quantities Prescription Expiration Date Getting Started You can receive up to a 90-day supply when your physician prescribes a 90-day supply, and if allowable by law. Some medications may only be dispensed for the exact quantity as written by your physician, which may be less than 90 days (i.e. controlled substances and antidepressants). Prescriptions typically expire one year (but sometimes sooner) from the date they are written. After the expiration date you must obtain a new prescription from your doctor, even if the label shows refills remaining. If our mail order program is right for you, complete a registration/ order form and mail it to us, along with your prescription and copayment. For your convenience, a self-addressed envelope is included with the form. Extra mail order forms are available by calling customer service or online at www.innoviantrx.com. Prescription Delivery New Prescriptions For each new prescription, we recommend asking your doctor for a single 30-day prescription to be filled at a participating retail pharmacy. This gives you time to try the medicine to see if it works for you as your physician intended. If the medication is right for you, ask your physician for a 90-day prescription to be filled through Innoviant Rx mail service. New mail order prescriptions will usually arrive within three weeks of placing an order. Refills usually arrive within two weeks. We recommend members order at least two weeks before medication is needed. Customer Service If you have any questions or need a mail order form, call Innoviant Rx at 877-390-9200. We’re available to help you start using the mail order program. If you already have a prescription at a local pharmacy, you will need to ask your physician for a new 90day prescription for the mail service program. Innoviant Rx needs a written prescription on file. For more information, contact us at 800-207-1561. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0101B p2/2 • 062507 Page 29 saving money Wise Choice Rx by Innoviant Q Save Plan Expenses H ow can I use my prescription benefit plan’s features to pay less for my medications? ANSWER Wise Choice Rx analyzes your prescriptions and helps you use your plan’s built-in options to get the most out of each dollar you and your plan spend on medications. Personalized Benefit Consultation Wise Choice Rx is a unique service that helps you to identify and use the money saving options in your prescription benefits program. This service is available at no cost to you. When you contact us, a pharmacy benefit representative schedules a time for your personalized benefit consultation. Before your appointment, the representative reviews your medications and searches for ways you could pay less for them using your prescription benefits program. The representative shares this information with you during your consultation and helps you start using options that are right for you. The following options may be reviewed during your consultation depending on your plan’s benefit design: • Generics: Generic medications cost less without sacrificing quality. • Preferred Products: Medicines on the Preferred Products List cost less than other brand name products. •Mail Order Pharmacy Service: With mail order, you may save money and have up to a 90-day supply delivered right to your home. • Tablet Splitting: Innoviant has identified a list of medications that can be safely split to save money without decreasing effectiveness. • Rx OTC: Over-the-counter medication options are offered by Innoviant. These products are less expensive and may be covered by your program. Contacting Wise Choice Rx is also good for your prescription benefits program. The options reviewed during your personalized benefit consultation usually save both you and your plan money. By using your plan’s money saving features, you help manage the cost of your prescription coverage. Get Started with Wise Choice Rx To schedule your personalized benefit consultation, contact Wise Choice Rx by Innoviant at 877-809-6996. We’re available Monday through Friday, 7 a.m. to 6 p.m. CT. Information provided to you through the Wise Choice Rx program is intended to educate you about cost savings measures under your prescription benefits program. It is not intended to substitute for the professional medical advice, diagnosis, or treatment of a physician, pharmacist or other health care professional. Always seek the advice of your physician or other qualified health provider regarding any questions you may have about a medical condition or a prescription. If you think you have a medical emergency, call your doctor or 911 immediately. end For more information, contact us at 877-559-2955. We’re available 24-hours a day, seven days a week. Or visit us at www.innoviant.com This notice does not imply coverage. Plan booklets provide specific benefit and coverage limitations. All rights reserved. © 2007 Fiserv, Inc. Innoviant , P.O. Box 8082, Wausau WI 54402-8082 Phone: (877) 559-2955, Fax: (715) 841-5050 www.innoviant.com NV0119 p1/1 • 072007 Page 30
