Effective April 1, 2008, the Trustees amend the Prescription Drug Benefits as set out below in the new Section 5.9 of the Summary Plan Description of November 1, 2006.
Part V Open Access III Prescription Drug Benefits for Employees and Dependents is amended by deleting the text on Page 93 following the heading “The following classes of medications are covered but require the use of a front-line treatment or may be limited tin quantity or duration of treatment” and adding Section 5.9 and 5.10 as follows:
Section 5.9 Step Therapy
1. Step Therapy is a program designed especially for people who take prescription drugs regularly to treat ongoing medical conditions, such as arthritis and high blood pressure.
2. Step Therapies are developed under the guidance and direction of independent, doctors, pharmacists and other medical experts after review of the most current research on available drugs that have been clinically tested and approved by the FDA for safety and effectiveness.
Step Therapy medication is grouped into two categories:
• Front-Line Medications: It is recommended that you first try these drugs — they are usually generic medications, which have been proven safe and effective. You pay the lowest co-payment for these drugs.
• Back-Up Medications: These are brand-name medications, like those you see advertised on TV. It is recommended that you try these drugs only if a front-line medication doesn’t work for you.
The first time a patient submits a prescription for a drug that is classified as a Back-Up Medication, the pharmacist should inform the patient that their plan uses the Step Therapy program. This means that if the patient would rather not pay full price for the prescription drug, they must first try a Front-Line Medication.
To receive Front-Line Medication:
• If the physician prescribes a Back-Up Medication before the patient has tried a Front-Line Medication, the patient should ask the pharmacist to call the prescribing doctor and request a new prescription.
OR
• The patient should contact the prescribing doctor directly to get a new prescription.
Only a doctor can change a patient’s current prescription to a Front-Line Medication covered by the fund. The choice of drug should be a decision between the patient and the doctor.
If the patient starts taking a prescription drug regularly or is a new member of our plan, he or she may be informed by the pharmacy that the prescribed drug isn’t covered. If this should happen and the patient needs the medication right away, the patient can:
• Talk with the pharmacist about filling a small supply of the prescription right away. (The patient may have to pay full price for this quantity of the drug.)
• To ensure future medication will be covered by the plan, the patient should ask the prescribing doctor to write a new prescription for a Front-Line Medication. Only your physician can change the prescription to a Front-Line Medication.
Some of the medications included in the Step Therapy program are as follows:
• Acid/Peptic Medications
• Antidepressant Medications
• Cholesterol-Lowering
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
• COX-2 Medications (Newest type of non-steroidal anti-inflammatory (NSAIDS) to be approved by the FDA
• ACE Inhibitor Medications
• Antihistamines and Nasal Corticosteroids
• Topical Steroids
Each prescription is covered for a quantity of medication as prescribed by your Physician up to a 30-day supply. If you purchase maintenance drugs under the Maintenance Drug Program described in Section 5.5, you may obtain up to a 90-day supply.
Appeal Process
If the patient has already tried a generic medication covered in the Step Therapy program or is unable to take a medication due to an allergy, or the patient’s doctor decides for medical reasons that a brand name medication is need, the patient should contact the fund office for an override form. The fund’s pharmaceutical consultant will review this form and all information provided by the physician and notify Express Scripts should the drug be approved with the appropriate co-payment. If the override is not approved, the patient may have to pay full price for the drug.
Section 5.10 – Medications with Special Limitations
After review of the most current research, the following guidelines have been established for the fund by independent doctors, pharmacist and other medical experts.
• GI drugs (e.g., Prilosec, Prevacid, Pepcid etc) when such drugs have been prescribed for an individual in excess of one dose per day for more than eight weeks. Continued coverage of such dosage will be subject to review for medical necessity.
• Morphine-related medications after the covered individual has received the medication for 60 days. Coverage of such medication for a longer period of time is available only with Prior Authorization.
