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CoverKids Preferred Drug List 07-571

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CoverKids Preferred Drug List 07-571 Powered By Docstoc
					2007
Preferred Drug List and
Pharmacy Program
                  Take Note

Use this page to list your medications and any
questions to ask your doctor or pharmacist.
Prescription Drugs I Take          Generic?
                                   Yes   No
____________________________

____________________________

____________________________

____________________________

____________________________

____________________________

____________________________

____________________________

____________________________

____________________________

Questions to ask:
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
Important Information
About Your Drug Plan
This booklet contains your 2007 Preferred Drug
List and other important information about the
prescription drugs covered by your pharmacy
plan. This drug list applies to members of
CoverKids and HealthyTNBabies. The list also
shows you which drugs are available at the
most affordable cost.
Every CoverKids member has a CoverKids
Member ID card. Every CoverKids
HealthyTNBabies member has a CoverKids
HealthyTNBabies Member ID card. Carry
your ID card with you at all times. You’ll need
to show it when you receive prescription
medicine. If you are a CoverTN member who
enrolled in CoverKids HealthyTNBabies when
you became pregnant, you MUST show your
CoverKids HealthyTNBabies ID card, and not
your CoverTN ID card, to receive prescription
medicine.




                                                  1
Check the Preferred Drug List
As a first step, check the Preferred Drug List on
pages 8 – 11 to see if it includes drugs that you
currently take. The Preferred Drug List includes
generic drugs and many popular brand-name
drugs. If a drug you take is not on this list, talk
with your doctor to see if one of the preferred
drugs would be just as effective for you.
Working with your doctor and pharmacist, you
can use the information in this brochure to help
make smart choices about the drugs you take
and the amount you pay.
It will help for you to become familiar with
these lists:
•   Preferred Drug List (PDL) – A convenient
    listing of the preferred brand drugs
    and generic medications that help save
    you money on your prescription costs.
    Depending on your drug plan and copay
    levels, your savings could be considerable.
•   Specialty Pharmacy Drug List (SRx) –
    Certain injectable, infusion and oral
    medications that require complex care,
    special handling, and education and
    monitoring during treatment use. Specialty
    Pharmacy drugs are either given by the
    doctor (as provider-administered) or taken
    in the home (as self-administered).
•   Prior Authorization List (PA) – Specific
    drugs that may need authorization from
    your benefit plan before they are dispensed
    by your pharmacy.
•   Quantity Limitations List (QL) – In keeping
    with standard medical practices, certain
    drugs have limits on the amount that can
    be purchased at one time.



2
Tips on Using Your
Prescription Drug Benefits
Once you understand how your drug benefits
work, you can also become familiar with the
drug choices that are available and appropriate
for you. More information is provided on the
bcbst.com Web site. Just go to the CoverKids
Member Web page. Following are tips that can
help you make the most of your prescription
drug benefits:
1. Talk with your doctor. Doctors are your
   partners in achieving and maintaining your
   good 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
   Preferred Drug List and discuss the options
   appropriate for you.
2. Ask for generic drugs. The U.S. Food
   and Drug Administration (FDA) requires
   generic drugs to have the same quality,
   strength and purity as brand-name drugs.
   Remember: You will pay less for generic
   drugs almost every time.
3. Turn to your pharmacist. Your pharmacist
   can answer questions about the drugs
   you are taking, help you avoid harmful
   drug interactions, and help you select
   appropriate, lower-cost generics and
   preferred brands whenever available.
4. Use a network pharmacy. 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. Just go to the
   CoverKids Member Web page to access
   information about your network pharmacies.



                                              3
5. Above all, be a smart consumer. The
   prescription drug industry spends more
   than $2 billion on advertising each year
   to promote their brands, and those costs
   are passed along to consumers, insurance
   companies, and businesses. So, choose a
   drug based on its effectiveness – not its
   advertising slogan.

It’s also important to remember that:
1. Some medications require prior
   authorization. (See page 16 for the list.)
   Network doctors are usually familiar with
   this list and know how to obtain prior
   authorization. However, you may want to
   show this list to your doctor – especially
   if you use an out-of-network doctor or a
   doctor outside Tennessee.
2. Some medications have quantity
   limitations. Benefits for most covered
   prescriptions are provided for up to a
   month’s supply. But some drugs are limited
   to a specific amount or dose. (See pages
   20-21 for the list.)
3. Quantities of less than a month’s
   supply. Coverage for prescription drugs
   commercially packaged or commonly
   dispensed in quantities less than a one-
   month supply will be subject to one copay,
   as long as the quantity does not exceed the
   FDA-approved dosage for four calendar
   weeks.




4
4. You can appeal denials. If you or your
   doctor disagree with a denial for a drug
   that requires prior authorization or has
   quantity limits, you have the right to appeal
   the decision. Please read your Member
   Handbook for more information.
5. Some types of medications are not
   covered by your plan. Please review the
   Limitations and Exclusions section of your
   Member Handbook so you will know what
   is not covered. An exclusion does not mean
   you cannot have a particular drug. It simply
   means that no benefits will be provided,
   and you will be responsible for the total
   cost of the drug.
6. You can visit bcbst.com for CoverKids
   information. With the multi-level approach
   to prescription copays from your health
   plan, you play an important role in
   managing your benefits costs. Visit
   bcbst.com and go to the CoverKids
   Member Web page for more information
   about drug benefits.




                                               5
What’s On the CoverKids Member Web page
Your prescription drug benefits from your
health plan include many useful tools to help
you get the most from your pharmacy benefits.
In addition to the information in this booklet,
you can visit the CoverKids Member Web page
on the bcbst.com Web site to find these easy-
to-use tools:
• Online prescription drug search (lets you
   compare drug costs, see your generic drug
   savings, and learn more about the medications
   you take, their use and possible side effects)
• Preferred Drug List
• Specialty Pharmacy Drug List
• Prior Authorization and Quantity Limitations Lists
• List of more than 400 brand-name drugs and
   their generic equivalents
• Prescription drug claim form for out-of-
   network claims
• Link to Caremark.com
Your prescription drug benefits also give you
access to Caremark.com – an innovative online
pharmacy center that lets you:
• Manage your prescriptions
• Look up drug coverage and pricing
• Locate a pharmacy
• Use a drug dictionary
• Check drug-to-drug interactions
• Shop the online drugstore
• Find online forms




6
Save an Average of 20 Percent on
Non-Covered Drugs
How Does the Discount Work?
If you buy a drug that is not on the list of
covered drugs, you are responsible for the full
discounted retail price. It’s easy to get your
discount. Here’s how:
• When you purchase these drugs at a
   participating retail pharmacy, present your
   Member ID card, or
• Present the special discount card.

It’s important to remember your savings may
vary by drug, and this discount is not part of
your prescription drug plan and is not insurance.

You can learn more about this program, print the
discount card and access the list of participating
retail pharmacies at bcbst.com. Just go to the
CoverKids Member Web page.




 Find Out More About Generics
 Important information about cost-saving
 generic drugs is included throughout this
 brochure. Special details for you and your
 doctor are on pages 23 and 25.                   7
2007 Preferred Drug List
Use Your Preferred Drug List
to Save Time and Money
The Preferred Drug List includes generic drugs
and many popular brand-name drugs. All
generics are covered in the 1st tier. Choosing
drugs from the Preferred Drug List may help save
you money on drug costs and copays. If you are
taking a brand-name drug on this list, the chart
will also show you generic alternatives for that
drug, if available. Your savings on generics could
be substantial. You’ll find important information
about generic drugs throughout this booklet.


Generic Equivalents and Generic Alternatives
Know the Difference
The U.S. Food and Drug Administration (FDA)
requires generics to have the same quality,
strength, purity and stability as brand-name
drugs.
Generic Equivalent: 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.
Generic Alternative: 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.




8
Brands on the                             Generic Alternatives
Preferred Drug List                       Always your lowest copay

Accolate
Actonel
Actonel with Calcium
ACTOplus met                               glipizide or glyburide plus metformin
Actos                                      glipizide, glyburide, metformin
Advair Diskus
Alkeran
Alphagan P                                 brimonidine 0.2%
Androgel
Asmanex
Astelin nasal
Atacand
Atacand HCT
Avandamet                                  glipizide or glyburide plus metformin
Avandia                                    glipizide, glyburide, metformin
Avinza                                     morphine ext-rel
Azopt
BD insulin syringes
Benicar
Benicar HCT
Betimol                                    levobunolol, metipranolol, timolol
                                           maleate solution
Cenestin                                   estradiol, estropipate
Cleocin ovules
Climara                                    estradiol patch
Clindesse                                  clindamycin vaginal cream,
                                           clotrimizole(OTC), terconazole
                                           miconazole(OTC)
Combivent
Copaxone
Coreg                                      metoprolol
Cozaar
Crestor                                    lovastatin, pravastatin,
                                           simvastatin
Cyclessa                                   Cesia, Velivet
Cymbalta                                   bupropion, mirtazapine
Depakote                                   carbamazepine, clonazepam,
                                           phenobarbital, phenytoin,
                                           primidone, valproic acid,
                                           zonisamide
Detrol                                     oxybutynin
Detrol LA                                  oxybutynin ext-rel

            PA = This drug requires prior authorization before purchase.
            OTC= An over-the-counter product (no prescription required).
                 OTCs are a non-covered benefit.
            QL = This drug has quantity limits on amount covered.
                                                                                9
 Brands on the                            Generic Alternatives
 Preferred Drug List                      Always your lowest copay
Duac                                      tretinoin (PA>31yrs)
Effexor XR                                bupropion ext-rel, venlafaxine
Epipen
Epipen Jr
Estrostep Fe                              Trivora
Flovent HFA
Fosamax
Fosamax Plus D
Glucagon
 emergency kit
Humulin
Hyzaar
Imitrex (QL)
Lantus
Leukeran
Levlite                                   Lessina, Sronyx
Lexapro                                   fluoxetine, paroxetine hcl,
                                          sertraline
LifeScan OneTouch Products:
 Basic/Profile
 FastTake
 SureStep
 Ultra
Maxalt (QL)
Maxalt-MLT (QL)
Miacalcin
Mircette                                  Kariva
Nasacort AQ                               flunisolide, fluticasone
Nasonex                                   flunisolide, fluticasone
Necon 10/11
Nexium                                    cimetidine, omeprazole, ranitidine
Niaspan                                   cholestyramine, gemfibrozil,
                                          niacin(OTC)
Noritate
Norvasc                                   diltiazem ext-rel, nifedipine ext-rel,
                                          verapamil ext-rel
Novolin
Novolog
Novolog Mix
NuvaRing
Paxil CR                                  fluoxetine, paroxetine hcl,
                                          sertraline
                 PA = This drug requires prior authorization before purchase.
                 OTC= An over-the-counter product (no prescription required).
                      OTCs are a non-covered benefit.
                 QL = This drug has quantity limits on amount covered.


10
 Brands on the                                 Generic Alternatives
 Preferred Drug List                           Always your lowest copay
Pegasys(QL)
Premarin                                      estradiol, estropipate
Premphase                                     estradiol plus
                                              medroxyprogesterone
Prempro                                       estradiol plus
                                              medroxyprogesterone
Prevacid                                      cimetidine, omeprazole, ranitidine
Pulmicort Respules
Rebif
Roche Diagnostic ACCU-CHEK
 Products:
 Active
 Aviva
 Comfort Curve
 Compact Test Drum
Serevent Diskus
Tricor                                        cholestyramine, gemfibrozil,
                                              niacin(OTC)
Toprol XL                                     metoprolol
Tri-Norinyl                                   Aranelle, Leena
Valtrex                                       acyclovir
Vivelle                                       estradiol patch
Vivelle-Dot                                   estradiol patch
Vytorin                                       lovastatin, pravastatin, simvastatin
Yasmin                                        Apri, Levora, Portia, Solia, Zovia
Xalatan                                       betaxolol, timolol maleate solution
Yaz                                           Apri, Levora, Portia, Solia, Zovia
Zomig (QL)
Zomig-ZMT (QL)
              PA = This drug requires prior authorization before purchase.
              OTC= An over-the-counter product (no prescription required).
                   OTCs are a non-covered benefit.
              QL = This drug has quantity limits on amount covered.




                       Generic Drugs
                     Safe. Effective. Affordable.
                                           Is your brand-name drug
                                           available as a generic? Check
                                           our Web site for a list of brand-
                                           name drugs with their generic
                                           equivalents.




                                                                             11
Non-Preferred Drugs and Alternatives
What If Your Drug is Not on the
Preferred Drug List?
If you are taking a brand drug that is not on the
Preferred Drug List, the chart below may help you
find lower-cost alternatives. Often, many different
drugs are available to treat the same problems.
The drugs indicated below may be alternatives,
but not chemical equivalents. Generic equivalents
are shown in bold print. Talk to your doctor
about which drugs are right for you.
                          Other Options You Can Choose
 Non-Preferred            Preferred                       Generic
 Brands                   Brands                          Drugs
 Always your              May have a                      Always your
 highest copay            reduced copay                   lowest copay
Accupril                                                  quinapril
Accuretic                                                 quinapril/hctz
Accutane                                                  Amnesteem,
                                                          Claravis, Sotret
AcipHex                   Nexium, Prevacid                cimetidine,
                                                          omeprazole, ranitidine
Adderall                                                  amphetamine/
                                                          dextroamphetamine
                                                          mixed salts,
                                                          methylphenidate
Allegra                                                   fexofenadine
Allegra-D                                                 fexofenadine plus
                                                          pseudoephedrine
Altace                                                    benazepril, enalapril,
                                                          lisinopril
Altoprev                                                  lovastatin
Amaryl                                                    glimepiride
Ambien (QL)                                               flurazepam,
                                                          temazepam
Ambien CR(QL)                                             flurazepam,
                                                          temazepam
Augmentin                                                 amoxicillin/
                                                          potassium-clavulanate
Augmentin ES 600                                          amoxicillin/
                                                          potassium-clavulanate
Avalide                   Atacand HCT,
                          Benicar HCT, Hyzaar
Avapro                    Atacand, Benicar,
                          Cozaar
Avelox                                                    ciprofloxacin tabs
Avonex
 Administration Pack
Azmacort             Flovent HFA
                PA = This drug requires prior authorization before purchase.
                OTC = An over-the-counter product (no prescription required).
                      OTCs are a non-covered benefit.
                QL = This drug has quantity limits on amount covered.
12              ST = Step therapy. Other selected drugs must be tried first.
                         Other Options You Can Choose
 Non-Preferred           Preferred        Generic
 Brands                  Brands           Drugs
 Always your             May have a       Always your
 highest copay           reduced copay    lowest copay
Bactroban                                 mupirocin
Betaseron                Copaxone, Rebif
Biaxin                                    clarithromycin
Biaxin XL                                 clarithromycin ext-rel
Boniva                   Actonel, Fosmax
ByettaST
Ceftin                                                    cefuroxime
Cefzil                                                    cefprozil
Celebrex (QL)                                             etodolac, ibuprofen,
                                                          naproxen
Celexa                                                    citalopram
Cipro                                                     ciprofloxacin tabs
Clarinex                                                  chlorpheniramine (OTC),
                                                          cyproheptadine,
                                                          diphenhydramine(OTC),
                                                          hydroxyzine,
                                                          loratadine (OTC),
                                                          fexofenadine
Concerta                                                  methylphenidate
Copegus                                                   ribavirin
Coumadin                                                  warfarin
Differin (PA>31 yrs)     Duac                             tretinoin (PA>31 yrs)
Diflucan (PA)                                              fluconazole (PA)
Diflucan 150mg (QL)                                        fluconazole 150mg (QL)
Diovan                   Atacand, Benicar,
                         Cozaar
Diovan HCT               Atacand HCT,
                         Benicar HCT, Hyzaar
Duragesic                                   fentanyl transdermal
Effexor                                     venlafaxine
Enbrel                                      methotrexate
Estratest               Premphase, Prempro estradiol plus
                                            medroxyprogesterone
Evista                  Actonel, Fosamax
FemHRT                  Cenestin, Premarin, estradiol
                        Prempro, Premphase
Flomax                                      doxazosin, finasteride,
                                            prazosin, terazosin
Flonase                                     fluticasone
Glucometer Elite strips ACCU-CHEK strips,
                        OneTouch strips
Glucophage                                  metformin
Glucophage XR                               metformin ext-rel
Glucotrol XL                                glipizide ext-rel
Glucovance                                  glyburide/metformin
Humalog Mix             Novolog Mix

                PA = This drug requires prior authorization before purchase.
                OTC = An over-the-counter product (no prescription required).
                      OTCs are a non-covered benefit.
                QL = This drug has quantity limits on amount covered.
                ST = Step therapy. Other selected drugs must be tried first.


                                                                                13
                           Other Options You Can Choose
 Non-Preferred             Preferred          Generic
 Brands                    Brands             Drugs
 Always your               May have a         Always your
 highest copay             reduced copay      lowest copay
Keppra                     Depakote, Dilantin carbamazepine,
                                              clonazepam,
                                              gabapentin,
                                              phenobarbital,
                                              phenytoin, primidone,
                                              valpronic acid
Ketek
Lamitical                  Depakote, Dilantin              carbamazepine,
                                                           clonazepam, gabapentin
Lescol                     Crestor, Vytorin                lovastatin, pravastatin,
                                                           simvastatin
Lescol XL                  Crestor, Vytorin                lovastatin, pravastatin,
                                                           simvastatin
Levaquin                                                   ciprofloxacin tabs
Lipitor                    Crestor, Vytorin                lovastatin, pravastatin,
                                                           simvastatin
Lotensin                                                   benazepril
Lotensin HCT                                               benazepril/hctz
Lotrel                                                     captopril, enalapril,
                                                           lisinopril, or quinapril
                                                           plus diltiazem,
                                                           nifedipine, or verapamil
Lovenox
Lunesta                                                    flurazepam, temazepam
Macrobid                                                   nitrofurantoin ext-rel
Micardis                   Atacand, Benicar,
                           Cozaar
Mobic                                                      meloxicam
Monopril                                                   fosinopril
Neurontin                                                  gabapentin
Nolvadex                                                   tamoxifen
Nor-QD                                                     Camila, Nora-Be
Omnicef                                                    cefaclor, cefuroxime,
                                                           cephalexin
Ortho Tri-Cyclen                                           TriNessa, Tri-Previfem,
                                                           Tri-Sprintec
OxyContin (QL)             Avinza                          oxycodone ext-rel
Patanol                                                    ketotifen, naphazoline
Paxil                                                      paroxetine hcl
Peg-Intron (QL)            Pegasys (QL)
Plavix                                                     dipyridamole, ticlopidine
Pravachol                                                  pravastatin
Precose
Prilosec                                                   omeprazole
Proscar                                                    finasteride
Protonix                   Nexium, Prevacid                cimetidine, omeprazole,
                                                           ranitidine
Proventil HFA                                              albuterol HFA
Prozac                                                     fluoxetine
Pulmicort Turbuhaler Flovent HFA
                  PA = This drug requires prior authorization before purchase.
                  OTC= An over-the-counter product (no prescription required).
                       OTCs are a non-covered benefit.
                  QL = This drug has quantity limits on amount covered.
14                ST = Step therapy. Other selected drugs must be tried first.
                            Other Options You Can Choose
 Non-Preferred              Preferred                  Generic
 Brands                     Brands                     Drugs
 Always your                May have a                 Always your
 highest copay              reduced copay              lowest copay
Rebetol (QL)                                          ribavirin (QL)
Relpax (QL)                Imitrex (QL), Maxalt (QL),
                           Maxalt-MLT (QL),
                           Zomig (QL),
                           Zomig-ZMT (QL)
Rhinocort Aqua             Nasacort AQ,               flunisolide, fluticasone
                           Nasonex
Risperdal                                             chlorpromazine,
                                                      haloperidol
Seroquel                                              chlorpromazine,
                                                      haloperidol
Singulair                  Accolate
Skelaxin                                              cyclobenzaprine,
                                                      methocarbamol
Starlix
Synthroid                                                  levothyroxine
Tamiflu (QL)                                                amantadine, rimantadine
Terazol                                                    terconazole
Tiazac                     Norvasc                         Taztia XT
Topamax                    Depakote, Dilantin              carbamazepine,
                                                           clonazepam,
                                                           gabapentin,
                                                           phenobarbital,
                                                           phenytoin, primidone,
                                                           valproic acid
Ultracet                                                   tramadol/
                                                           acetaminophen
Ultram                                                     tramadol
Wellbutrin SR                                              bupropion ext-rel
Wellbutrin XL                                              bupropion ext-rel
Zestoretic                                                 lisinopril/hctz
Zestril                                                    lisinopril
Zetia                                                      cholestyramine,
                                                           gemfibrozil, niacin (PA)
Zithromax                                                  azithromycin
Zocor                                                      simvastatin
Zofran                                                     ondansetron
Zoloft                                                     sertraline
Zyprexa                                                    chlorpromazine,
                                                           haloperidol
Zyrtec                                                     chlorpheniramine (OTC),
                                                           cyproheptadine,
                                                           diphenhydramine (OTC),
                                                           hydroxyzine,
                                                           fexofenadine,
                                                           loratadine (OTC)

                 PA = This drug requires prior authorization before purchase.
                 OTC= An over-the-counter product (no prescription required).
                      OTCs are a non-covered benefit.
                 QL = This drug has quantity limits on amount covered.
                 ST = Step therapy. Other selected drugs must be tried first.


                                                                                15
2007 Prior Authorization List
Drugs That Need Prior Authorization
To maximize your benefits, the drugs listed
below need authorization from your benefit plan
before they are dispensed by your pharmacy.
Your network physician is responsible for
contacting Caremark at 1-877-916-2271 to
obtain prior authorization when prescribing a
drug on this list. Ask your physician to make
the call at the same time the medication is
prescribed so that there will be no delay when
you go to the pharmacy.

adapalene (Differin) – PA required for members age 31
   or older
anabolic steroids
antifungal/onychomycosis drugs
erectile dysfunction drugs – PA for males 19-49 years of age
fluconazole (Diflucan) – except three doses x 150 mg / 30 days
growth hormones
itraconazole (Sporanox)
tegaserod (Zelnorm) – PA required for males
tretinoin (Avita, Retin-A) – PA required for members age
   31 or older

2007 Specialty Pharmacy Drug Lists
Specialty Pharmacy drugs are certain injectable,
infusion and oral medications that require
complex care, special handling, and education
and monitoring during treatment use. Specialty
Pharmacy drugs are either given by the doctor
(as provider-administered) or taken in the home
(as self-administered).

Some of these drugs also require prior
authorization (PA). See the list of provider-
administered and self-administered specialty
pharmacy medications below.

The physician may obtain approval and order
Specialty Pharmacy Products by calling one of
the Specialty Pharmacies. The member may

16
also order self-administered drugs from one of
these Specialty Pharmacies:

Caremark Specialty Rx:        1-866-295-2779;
             fax              1-866-295-2778

CuraScript Pharmacy:          1-888-773-7376;
              fax             1-888-773-7386

Accredo Health Group:         1-888-239-0725;
             fax              1-866-387-1003

Caremark, CuraScript, and Accredo are
independent companies serving CoverKids and
CoverKids HealthyTNBabies members.

The PA List and the Specialty Pharmacy
Products List are subject to change. Please visit
bcbst.com for the current lists. Just go to the
CoverKids Member Web page.

The Specialty Pharmacy Network vendors
are experts in specialty medications, and
have agreed to offer these high-cost drugs
at discounted rates. When your doctor writes
your prescription and faxes it to one of the
three specialty pharmacies, the pharmacy
ships the medications directly to your home
or other designated location. Plus, registered
pharmacists and nurse specialists are available
to answer any questions or concerns you may
have about your medication.

Please note that your copay will be higher if you
choose to purchase self-administered specialty
medications from another pharmacy instead
of one of the preferred vendors listed above.
Please check your Member Handbook for details
about your specific benefits.



                                               17
A. Provider-Administered
The following specialty pharmacy medications
are provider-administered, meaning that a
doctor or other health care professional orders
the drug and supplies its treatment in the
office or facility setting. Provider-administered
specialty medications are covered as a medical
benefit and not a prescription drug benefit.

Abraxane                    Neulasta
Aldurazyme                  Neumega
Alferon N                   Neupogen
Alimta                      NovoSeven
AmevivePA                   Orencia
Aralast                     Orthovisc
Aranesp                     Procrit
AvastinPA                   Prolastin
Botox                       Proleukin
Ceredase                    RemicadePA
Cerezyme                    RemodulinPA
Dacogen                     Risperdal Consta
Elaprase                    RituxanPA
Eligard IM                  Sandostatin LAR
Epogen                      Supartz
ErbituxPA                   SynagisPA
Euflexxa                     Synvisc
Fabrazyme                   Thyrogen
FlolanPA                    Trelstar
Herceptin                   Trisenox
Hyalgan                     TysabriPA
Immune Globulins            Vectibix
Intron A IV                 VelcadePA
Leukine                     Viadur Implant
Lupron Depot                Vidaza
Macugen                     Vistide
Mirena                      Visudyne
mitoxandrone (Novantrone)   Vitravene
Myobloc                     Vivitrol
Myochrysine                 Zemaira
Myozyme                     Zoladex
Naglazyme                   Zometa

PA = These drugs require prior authorization.
Your network physician or specialty pharmacy
vendor must call BlueCross BlueShield
of Tennessee at 1-800-924-7141 for prior
authorization. See prior authorization details on
page 16.



18
B. Self-Administered
The following specialty pharmacy medications
are self-administered, meaning that the doctor
would provide a prescription, but then you
would administer the drug to yourself – usually
by injection. Self-administered specialty
medications are covered as a prescription drug
benefit.

ActimmunePA                      Procrit
Anti-Hemophilic Factors          Pulmozyme
Apokyn                           RaptivaPA
Aranesp                          Rebif
Avonex                           RevatioPA
Betaseron                        RevlimidPA
Copaxone                         ribavirin (Copegus,
Enbrel                             Rebetol, Ribasphere)
Epogen                           Roferon A
Forteo                           Sensipar
Fuzeon                           Somavert
Gleevec                          SprycelPA
Growth HormonesPA                Stimate
Humira                           SutentPA
IncrelexPA                       Tarceva
Infergen                         TemodarPA
Intron A SQ                      ThalomidPA
Iressa                           TOBI
Kineret                          TracleerPA
Lupron SQ                        Ventavis
Neumega                          VivaglobinPA
Neupogen                         Xeloda
NexavarPA                        XolairPA
octreotide SQ (Sandostatin SQ)   ZavescaPA
Pegasys                          Zolinza
Peg-Intron

PA = These drugs require prior authorization.
Your network physician or specialty pharmacy
vendor must call Caremark at 1-877-916-2271
for prior authorization. See prior authorization
details on page 16.

The following drugs are not covered for the
CoverKids program:
 • Anti-obesity drugs
 • Cosmetic drugs
 • Infertility drugs


                                                          19
Drugs With Quantity Limits
The Quantity Limitations (QL) List at your health
plan contains drugs that have a quantity limit
per certain period of time. These limits are
in keeping with the manufacturer’s and the
U.S. Food and Drug Administration’s (FDA)
recommendations and accepted medical
practices. Prescriptions for drugs that have
quantity limitations cannot be filled by the
pharmacist for a greater amount than specified
by the limitation.

If an exception to the quantity limitation
is needed, your network physicians are
responsible for contacting Caremark at
1-877-916-2271 to obtain a quantity override
for drugs on the Quantity Limitations List. This
should be done when the physician prescribes
the medication so that the drug is ready when
the member arrives at the pharmacy. Not all
plans have quantity limitations, but most do.
The pharmacist cannot dispense a prescription
for drugs that have a quantity limitation greater
than the amount specified as the limit without
plan approval.

Members are encouraged to talk to their
physician if a problem occurs with the Quantity
Limitations program.




20
Amerge: 9 x 1 mg OR 2.5 mg tablets/30 days
Anzemet: 10 tablets/30 days
Arixtra: 14 days, then PA required
Axert: 6 x 6.25 mg OR 12.5 mg tablets/30 days
butorphanol nasal spray: 2 bottles (2.5 mL each)/30 days
Celebrex: 400 mg/day
Emend: 1 capsule (125 mg)/15 days; 2 capsules (80 mg)/
  15 days; 1 capsule (40mg)/15 days
Erectile dysfunction drugs: 8 units/30 days
fentanyl citrate (Actiq): 6 lozenges/30 days
Fentora: 8 tablets/30 days
fluconazole (Diflucan): 3 x 150 mg tablets/30 days
Fragmin: 14 days, then PA required
Frova: 9 tablets/30 days
Gleevec: 60 days, then PA required
Imitrex: 2 injections (one kit) OR 6 nasal sprays; 9 tablets
  (25 mg, 50 mg & 100 mg) /30 days
Infergen: 16 wks, then 2-log decrease in viral load
  required
Innohep: 14 days, then PA required
ketorolac (Toradol): 20 tablets OR 2 injections/30 days
Kytril: 20 tablets/30 days; 90 mL/30 days
Lovenox: 14 days, then PA required
Lyrica: 600 mg/day
Maxalt, Maxalt-MLT: 9 x 5 mg OR 10 mg tablets/30days
Migranal: 4 ampules/30 days
Noxafil: 6 days, then PA required
ondansetron (Zofran): 30 tabs x 4 mg OR 30 tabs x 8 mg
  OR 10 tabs x 24 mg OR 150 mL of 4 mg/5 mL
  solution/30 days
oxycodone ext-rel (OxyContin): 120 tabs/30 days (max
  320 mg/day)
Pegasys: 16 wks, then 2-log decrease in viral load required
Peg-Intron: 16 wks, then 2-log decrease in viral load
  required
Plan-B: one kit/Rx; 3 kits/365 days
Relenza: 20 units/365 days - one treatment
Relpax: 6 x 20 mg or 40 mg tablets/30 days
ribavirin (Copegus, Rebetol, Ribasphere): 16 wks, then
  2-log decrease in viral load required
Smoking Cessation products: 90-day treatment/year;2X
  90-day treatment/lifetime
Specialty Pharmacy products: limited to one month’s supply
Tamiflu: 10 capsules OR 75 ml/365 days - one treatment
Zomig, Zomig-ZMT: 6 x 2.5 mg OR 5 mg tablets/30 days
  OR one 6-pack nasal spray/30 days
Zyvox: 3 days, then PA required

Products available generically are listed first
with examples of brand names (if available) in
parentheses. If only the brand name is listed,
there is no generic available at the time this list
was developed.


                                                         21
For More Information
Your health plan is working hard to help you
save money whenever possible. If you have any
questions, call CoverKids Member Service at
1-866-325-8386. This is a free call. The hours
are Monday through Friday, 8 a.m. to 6 p.m.
Eastern Time.

Drug Benefits Appeals
CoverKids and CoverKids HealthyTNBabies
members or their physicians may appeal a
denial of a drug or quantity limitation by faxing
supportive documentation to 1-888-343-4232.
Please read your Member Handbook for more
information on your grievance rights.




 Questions About Generics?
 You may think that because generic drugs
 are lower in cost, they don’t provide
 the same benefits as their brand-name
 counterparts. But they do. Drugs sold in
 the United States are approved by the FDA
 whether they are brand-name or generic.
 The standards for quality are the same.
 Knowing the truth about generics can
 help you make smart decisions about the
 drugs you take and save money on your
 prescription costs.

22
             Generic Drug Request Form

Generic prescription drugs are proven to be
as safe and effective as more costly brand-
name drugs. Generic equivalents produce the
same effects in the body as their brand-name
counterparts because both contain the identical
active ingredients and are approved by the U.S.
Food and Drug Administration (FDA).
Yes, I want to help contain health care
costs by requesting a generic prescription
drug when available and appropriate.

________________________________________
Sign your name here                       Date
Talk with your doctor or pharmacist to see if
generic drugs are right for you.
Cut out this request card and give it to your
doctor to place in your medical file. It can
help you save money again and again.
How do you know that generic drugs are
safe and effective?
The Office of Generic Drugs, part of the U.S.
Food and Drug Administration’s Center for
Drug Evaluation and Research, is dedicated
to assuring that only safe, effective, high-
quality, and equivalent generic products are
approved for use by consumers and health
care professionals.
The American public can be confident that
when a generic drug product is approved, it
has met the rigorous standards established
by the FDA with respect to identity, strength,
quality, purity and potency.




   Excerpted from the U.S. Food and Drug Administration
   Web site welcome letter at www.fda.gov

                                                     23
     Notes




24
              Consistent labeling

  Assured quality                                  Rigorous
                                                   manufacturing
                                                   standards




   Purity check


             Same drug
                                    Performance evaluation

 FDA ensures that your generic drug is safe and
 effective. All generic drugs are put through a
 rigorous, multi-step approval process. From
 quality and performance to manufacturing
 and labeling, everything must meet FDA’s
 high standards. We make it tough to become
 a generic drug in America so it’s easy for you
 to feel confident. Visit www.fda.gov/cder/ or
 call 1-888-INFO-FDA to learn more.



                                    U.S. Food and Drug Administration

Generic Drugs: Safe. Effective. FDA Approved.
                                                                         21
  U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES                          25
 The Preferred Drug List, Specialty
   Pharmacy List, Prior Authorization
        and Quantity Limitations
 lists may be updated throughout the
 year. Call Member Service or visit the
     CoverKids Member Web page
     on the BlueCross BlueShield of
    Tennessee Web site at bcbst.com
         for current information.




                       bcbst.com

                    801 Pine Street
              Chattanooga, TN 37402

            BlueCross BlueShield of Tennessee, Inc.,
an Independent Licensee of the BlueCross BlueShield Association
  ® Registered marks of the BlueCross BlueShield Association,
    an Association of Independent BlueCross BlueShield Plans
     This document has been classified as public information

                       CKIDS-005 (3/07)

				
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