Perspective sept 2005 web

Prime PerspectiveTM
Q U A R T E R L Y P H A R M A C Y N E W S L E T T E R F R O M P R I M E T H E R A P E U T I C S L L C
I S S U E N O . 2 4
S E P T E M B E R 2 0 0 5
W H AT ’ S I N S I D E
P A P E R C L A I M
P R O C E S S I N G R E M I N D E R
■ Ortho Evra Transdermal
Patches — One patch is applied
– Illinois . . . . . . . . . . . . . . . . . . 3 weekly for 3 weeks, then 1 week off.
– Kansas . . . . . . . . . . . . . . . . . 3 – Nebraska . . . . . . . . . . . . . . . 3 – Oklahoma . . . . . . . . . . . . . . 4 ■ Byetta Injection — This drug is
■ Eligibility Verification . . . . . . . . 4 with reject code 81 “claim too old”.
– PrimeNational . . . . . . . . . . . 6 – Illinois . . . . . . . . . . . . . . . . . . 6 F R O M T H E A U D I T O R S
– Kansas . . . . . . . . . . . . . . . . . 7 ■ Zmax Suspension — The correct
– Minnesota . . . . . . . . . . . . . . 7 – Nebraska . . . . . . . . . . . . . . . 8 – Texas . . . . . . . . . . . . . . . . . 10 – Wyoming . . . . . . . . . . . . . . 10 C O N T A C T C E N T E R
■ Rebif Injection — One package
H O L I D A Y H O U R S
Center at 800.821.4795.
7:00 a.m. to 6:00 p.m.
■ Pegasys Kit Injection — The
O N - C A L L A S S I S TA N C E I S AVA I L A B L E 2 4 H O U R S A D AY, 7 D AY S A W E E K .
O N T H E W E B www.primetherapeutics.com
Transforming Pharmacy
D U R P R O G R A M C H A N G E R E M I N D E R
N O W A V A I L A B L E : P R I M E ’ S N E W
P H A R M A C Y P R O V I D E R M A N U A L
Prime is enhancing its concurrent drug utilization review (DUR) program by adding a dose-limiting threshold to the The updated Prime Pharmacy Provider Manual was dose-check edit. This enhancement will be phased-in mailed with the September issue of Prime Perspective.
It includes information on the following topics: Dosage that exceeds the maximum daily dose for a drug will continue to be paid and receive the standard high-dose alert message. Daily dosages that exceed 250 percent of the maximum daily dose will now reject with code 88 (DUR). The standard high-dose alert will be returned with the rejected claim and include a supplemental message stating The rejected claim — with a “reason for service” code of HD (high-dose alert) — may be resubmitted after review and correction of the submitted quantity and/or days supply when appropriate. If, in the professional judgment of the pharmacist, the original quantity and days supply submitted New! are correct, the rejected claim may be resubmitted with at 800.858.0723.
PA code (00000000003) to override this DUR edit.
Note that these claims will reject for reason code 88 (DUR).
M A C L I S T U P D A T E S
The local message may contain other information such as “non-formulary” that may not be related to the reject reason.
Prime Therapeutics MAC List Updates
Your software vendor determines the format for receiving May 1 to August 1, 2005
DUR messages. Please check with your vendor for help A D D E D T O M A C L I S T
■ DELETED FROM MAC LIST
aluminum chloride soln, 20% (Drysol)
indomethacin extended-release caps, 75 mg (Indocin SR) lithium carbonate caps, 300 mg (Eskalith) lithium carbonate extended-release tabs, 300 mg (Lithobid) norgestrel/ethinyl estradiol tabs (Ogestrel) Prime Perspective provides you with formulary updates, new group announcements and benefit information each quarter.
We value your participation in our network and hope you find Prime Perspective a useful source of information. If you have questions or comments, please contact the newsletter editor, Julie Damman, by email at jdamman@ primetherapeutics.com
or call 651.286.4203 or 800.858.0723.
I L L I N O I S N E W S
K A N S A S N E W S
B L U E C R O S S A N D B L U E S H I E L D O F
B L U E C R O S S A N D B L U E S H I E L D O F
I L L I N O I S L A U N C H E S P R I M E S E L E C T
K A N S A S L A U N C H E S P R I M E S E L E C T
N E T W O R K O N O C T O B E R 1 , 2 0 0 5
N E T W O R K O N O C T O B E R 1 , 2 0 0 5
On October 1, 2005, Blue Cross and Blue Shield of On October 1, 2005, Blue Cross and Blue Shield of Kansas Illinois will begin using the Prime Select Network for will begin using the Prime Select Network for all groups as pharmacies within the state of Illinois.
a wrap around network outside the state of Kansas.
Pharmacies that are interested in participating in the Pharmacies that are interested in participating in the Prime Select Network may call the Prime Contact Center Prime Select Network may call the Prime Contact Center at 800.821.4795 to request a Pharmacy Participation
at 800.821.4795 to request a Pharmacy Participation
Agreement. No changes are required to process claims.
Agreement. No changes are required to process claims.
N E B R A S K A N E W S
P R E - A U T H O R I Z AT I O N C H A N G E S M A D E F O R N E B R A S K A G R O U P S
As reported in the June 2005 issue of Prime Perspective, Criteria and pre-authorization forms can be found at effective September 1, 2005, the Educators Health www.bcbsneprovider.com under Pharmacy Resources.
Alliance (EHA) group, which administers health care Pre-authorization forms can also be obtained via fax by calling benefits for teachers and administrators in Nebraska, will the Prime Contact Center at 800.821.4795.
implement the following changes to its drug benefit design: If the pre-authorization criteria are met, the prescribed
The COX-2 Inhibitor Pre-authorization (PA) program drug will still require the appropriate copay based on the
formulary status.
■ A Leukotriene Modifier PA program will be added ■ A Proton Pump Inhibitor PA program will be added Drug Name
Formulary Status
Accolate . . . . . . . . . . . . . . . . . . . . . Non-formulary Prior to implementation, a review of pharmacy and Singulair . . . . . . . . . . . . . . . . . . . . . Formulary medical claims data will be used to identify those who Celebrex, Mobic . . . . . . . . . . . . . . . Non-formulary meet clinically based criteria for all programs. Members Nexium, Prevacid, Prilosec . . . . . . Non-formulary who meet the criteria will automatically receive coverage of the appropriate drug at the pharmacy. Members who Members and physicians will receive notification of do not meet the criteria will have their claim rejected and information relating to the PA programs. at point-of-service with a reject code 75 (prior authoriza- Pharmacists with questions on system rejects tion required) and/or 76 (plan limitations exceeded). resulting from pre-authorization edits should In either case, Prime will send back the following message: STEP NOT MET PA REQ’D. The pharmacist and/or member should then contact the prescribing physician to determine if the physician wishes to submit a N O R T H D A K O T A N E W S
O K L A H O M A N E W S
B L U E C R O S S B L U E S H I E L D O F
B L U E C R O S S A N D B L U E S H I E L D
N O R T H D A K O T A M O V E S T O P R I M E
O F O K L A H O M A L A U N C H E S
N AT I O N A L N E T W O R K
P R I M E S E L E C T N E T W O R K O N
N O V E M B E R 1 , 2 0 0 5
On December 1, 2005, Blue Cross Blue Shield of North Dakota (BCBSND) will begin using the Prime National On November 1, 2005, Blue Cross and Blue Shield of Network for pharmacies located within the state of North Oklahoma will begin using the Prime Select Network Dakota. Participation in the Prime National Network for pharmacies outside the state of Oklahoma.
enables pharmacies to continue to adjudicate claims for members of BCBSND beginning December 1, 2005.
Pharmacies that are interested in participating in the Prime Select Network may call the Prime Contact Pharmacies that are interested in participating in the Center at 800.821.4795 to request a Pharmacy
Prime National Network may call the Prime Contact Participation Agreement. No changes are required to Center at 800.821.4795 to request a Pharmacy
Participation Agreement. No changes are required to P R I M E T O I M P L E M E N T A U T O M AT I O N
F O R E L I G I B I L I T Y V E R I F I C AT I O N
P R I M E P E R S P E C T I V E A V A I L A B L E
In early October 2005, Prime will begin using a touch-tone voice response system that will allow pharmacies to verify If you would you like to receive an electronic copy member eligibility for a number of Prime’s Blue Cross and Blue of Prime Perspective via email, please contact Shield clients. After a pharmacy has entered a member ID [email protected] and ask to
number on a telephone keypad, the system will check be added to our quarterly distribution list.
eligibility and provide information to the pharmacy, including member date of birth, gender and coverage dates. If a pharmacy needs assistance from a Pharmacy Service Agent, press 0 at any time to be transferred to an agent.
M E D I C AT I O N T H E R A P Y M A N A G E M E N T
O P P O R T U N I T Y I S C O M I N G !
Prime is working diligently to prepare for Medicare Part D. In order to provide the highest level of service to the Medicare beneficiaries, Prime will offer its Medication Therapy Management Program (MTMP) to all qualifying Medicare Part D members, with the goal of optimizing therapeutic outcomes for those members enrolled in the program.
One component of the MTMP will utilize the expertise of our network pharmacy providers to reduce the risk of potential adverse experiences and at the same time enhance member understanding through educational counseling. In exchange for this enhanced service to our Medicare Part D members, pharmacies will be compensated for each qualified pharmacist
intervention. The level of compensation will depend on the extent of intervention required
Watch for further information by early 2006, including an MTMP exhibit to the Prime Therapeutics Pharmacy Participation Agreement for those pharmacies that are participating providers in the Prime Standard Network for Medicare. The update will provide specific details about how you can participate in the program to help improve the pharmaceutical services for our members and your patients.
In exchange for this enhanced service for each qualified pharmacist intervention. Please forward this important news to your staff and pharmacists.
F O R M U L A R Y U P D A T E S
K E Y: B L U E T Y P E = F O R M U L A RY A G E N T S R E D T Y P E = N O N - F O R M U L A RY A G E N T S
PrimeNationalSM Formulary Additions
Blue Cross and Blue Shield of
Illinois Drug Formulary Additions
■ G E N E R I C P R O D U C T S A D D E D
Brand products (in parentheses) are non-formulary and listed
■ B R A N D P R O D U C T S A D D E D
for reference only
ceftriaxone for inj, 250 mg, 500 mg, 1 g, 2 g (ROCEPHIN) ARICEPT ODT (donepezil orally disintegrating tabs) ATROVENT HFA (ipratropium bromide inhaler) PEG 3350/KCl/Na Bicarb/NaCl for soln, 420 g – Trilyte (NULYTELY) B R A N D P R O D U C T S A D D E D
ARICEPT ODT (donepezil orally disintegrating tabs) ATROVENT HFA (ipratropium bromide inhaler) ENTOCORT EC (budesonide extended-release caps) LITHOBID (lithium carbonate extended-release tabs) UNIPHYL (theophylline extended-release tabs) PrimeNationalSM Formulary Deletions
Blue Cross and Blue Shield of
Illinois Drug Formulary Deletions
B R A N D P R O D U C T S R E M O V E D
Generics remain
■ B R A N D P R O D U C T R E M O V E D
COLYTE (PEG 3350/KCl/Na Bicarb/NaCl/Na Sulfate for soln, 240 g) Generic remains
OXYCONTIN (oxycodone extended-release tabs, 10 mg, ■ B R A N D P R O D U C T S R E M O V E D
ROCEPHIN (ceftriaxone for inj, 250 mg, 500 mg, 1 g, 2 g) Generics are not available
FANSIDAR (sulfadoxine/pyramethamine tabs) ■ A L L V E R S I O N S , B R A N D A N D / O R G E N E R I C ,
R E M O V E D F R O M F O R M U L A R Y
sulfisoxazole acetyl susp (GANTRISIN PEDIATRIC) ■ D I S C O N T I N U E D B R A N D P R O D U C T
■ D I S C O N T I N U E D B R A N D P R O D U C T S
The following discontinued brand product has been removed
The following discontinued brand products have been removed
from formulary; generic is not available
from formulary; generics are not available
PANCRELIPASE (amylase/lipase/protease tabs, PROCHLORPERAZINE rectal supp, 2.5 mg, 5 mg REBETRON (ribavirin caps & interferon alfa-2b inj) F O R M U L A R Y U P D A T E S c o n t i n u e d
K E Y: B L U E T Y P E = F O R M U L A RY A G E N T S R E D T Y P E = N O N - F O R M U L A RY A G E N T S
Blue Cross Blue Shield of
Blue Cross and Blue Shield of
Kansas National Formulary Changes
Minnesota Formulary Additions
Blue Cross and Blue Shield of Kansas uses the PrimeNational
■ G E N E R I C P R O D U C T S A D D E D
Formulary. Please refer to PrimeNational Additions and Deletions
Brand products (in parentheses) are non-formulary and listed
for reference only
ceftriaxone for inj, 250 mg, 500 mg, 1 g, 2 g (ROCEPHIN) Blue Cross and Blue Shield of
Kansas Select Formulary Additions
octreotide acetate inj, 0.05 mg/mL, 0.1 mg/mL, 0.5 mg/mL PEG 3350/KCl/Na Bicarb/NaCl for soln, 420 g – Trilyte (NULYTELY) ■ G E N E R I C P R O D U C T S A D D E D
Brand products (in parentheses) are non-formulary and listed
■ B R A N D P R O D U C T S A D D E D
for reference only
PEG 3350/KCl/Na Bicarb/NaCl for soln, 420 g – Trilyte (NULYTELY) ATROVENT HFA (ipratropium bromide inhaler) CLINDESSE (clindamycin vaginal crm, single dose) ■ B R A N D P R O D U C T S A D D E D
ENTOCORT EC (budesonide extended-release caps) ARICEPT ODT (donepezil orally disintegrating tabs) LITHOBID (lithium carbonate extended-release tabs) ATROVENT HFA (ipratropium bromide inhaler) ENTOCORT EC (budesonide extended-release caps) UNIPHYL (theophylline extended-release tabs) LITHOBID (lithium carbonate extended-release tabs) ZMAX (azithromycin extended-release microspheres for susp, UNIPHYL (theophylline extended-release tabs) Blue Cross and Blue Shield of
Blue Cross and Blue Shield of
Minnesota Formulary Deletions
Kansas Select Formulary Deletions
■ B R A N D P R O D U C T S R E M O V E D
Generics remain
■ B R A N D P R O D U C T S R E M O V E D
COLYTE (PEG 3350/KCl/Na Bicarb/NaCl/Na Sulfate for soln, 240 g) Generics remain
COLYTE (PEG 3350/KCl/Na Bicarb/NaCl/Na Sulfate for soln, OXYCONTIN (oxycodone extended-release tabs, 10 mg, 20 mg, OXYCONTIN (oxycodone extended-release tabs, 10 mg, ROCEPHIN (ceftriaxone for inj, 250 mg, 500 mg, 1 g, 2 g) ■ A L L V E R S I O N S , B R A N D A N D / O R G E N E R I C ,
■ A L L V E R S I O N S , B R A N D A N D / O R G E N E R I C ,
R E M O V E D F R O M F O R M U L A R Y
R E M O V E D F R O M F O R M U L A R Y
sulfisoxazole acetyl susp (GANTRISIN PEDIATRIC) ■ D I S C O N T I N U E D B R A N D P R O D U C T S
olanzapine orally disintegrating tabs (ZYPREXA ZYDIS) The following discontinued brand products have been removed
from formulary; generics are not available
■ D I S C O N T I N U E D B R A N D P R O D U C T S
The following discontinued brand products have been removed
PANCRELIPASE (amylase/lipase/protease tabs, from formulary; generics are not available
PROCHLORPERAZINE rectal supp, 2.5 mg, 5 mg PROCHLORPERAZINE rectal supp, 2.5 mg, 5 mg REBETRON (ribavirin caps & interferon alfa-2b inj) REBETRON (ribavirin caps & interferon alfa-2b inj) F O R M U L A R Y U P D A T E S c o n t i n u e d
K E Y: B L U E T Y P E = F O R M U L A RY A G E N T S R E D T Y P E = N O N - F O R M U L A RY A G E N T S
Blue Cross and Blue Shield of
Blue Cross and Blue Shield of
Nebraska Formulary Additions
New Mexico Pharmacy Benefit
Drug List Additions
■ G E N E R I C P R O D U C T S A D D E D
Brand products (in parentheses) are non-formulary and listed
■ B R A N D P R O D U C T S A D D E D
for reference only
ARICEPT ODT (donepezil orally disintegrating tabs) PEG 3350/KCl/Na Bicarb/NaCl for soln, 420 gm – Trilyte (NULYTELY) ATROVENT HFA (ipratropium bromide inhaler) B R A N D P R O D U C T S A D D E D
ENTOCORT EC (budesonide extended-release caps) ARICEPT ODT (donepezil orally disintegrating tabs) ATROVENT HFA (ipratropium bromide inhaler) ENTOCORT EC (budesonide extended-release caps) LITHOBID (lithium carbonate extended-release tabs) UNIPHYL (theophylline extended-release tabs) Blue Cross and Blue Shield of
New Mexico Pharmacy Benefit
ZMAX (azithromycin extended-release microspheres for susp, Drug List Deletions
■ B R A N D P R O D U C T S R E M O V E D –
effective October 1, 2005
Blue Cross and Blue Shield of
Generics remain
Nebraska Formulary Deletions
OXYCONTIN (oxycodone extended-release tabs, 10 mg, 20 mg, ■ B R A N D P R O D U C T S R E M O V E D
Generics remain
■ B R A N D P R O D U C T S R E M O V E D –
COLYTE (PEG 3350/KCl/Na Bicarb/NaCl/Na Sulfate for soln, effective April 1, 2006
Generics remain
OXYCONTIN (oxycodone extended-release tabs, 10 mg, ■ B R A N D P R O D U C T S R E M O V E D –
effective April 1, 2006
■ A L L V E R S I O N S , B R A N D A N D / O R G E N E R I C ,
Generics are not available
R E M O V E D F R O M F O R M U L A R Y
AUGMENTIN (amoxicillin/clavulanate for susp, chew tabs, tabs) CARDIZEM LA (diltiazem extended-release tabs 24 hr) ■ D I S C O N T I N U E D B R A N D P R O D U C T S
CLEOCIN PEDIATRIC (clindamycin palmitate for oral soln) The following discontinued brand products have been removed
from formulary; generics are not available
ERYPED (erythromycin ethylsuccinate for susp, chew tabs) PANCRELIPASE (amylase/lipase/protease tabs, GANTRISIN PEDIATRIC (sulfisoxazole acetyl susp) PROCHLORPERAZINE rectal supp, 2.5 mg, 5 mg REBETRON (ribavirin caps & interferon alfa-2b inj) PRO-BANTHINE (propantheline bromide tabs, 7.5 mg) F O R M U L A R Y U P D A T E S c o n t i n u e d
K E Y: B L U E T Y P E = F O R M U L A RY A G E N T S R E D T Y P E = N O N - F O R M U L A RY A G E N T S
Blue Cross Blue Shield of
North Dakota Formulary Deletions
■ B R A N D P R O D U C T S R E M O V E D
ZANTAC EFFERDOSE (ranitidine effervescent tabs) Generics remain
■ D I S C O N T I N U E D B R A N D P R O D U C T S
The following discontinued brand products will be removed
GRIFULVIN V (griseofulvin microsize oral susp) effective April 1, 2006; generics are not available
ENZYMAX (amylase/lipase/protease tabs, 0.75-0.35-3.75) ORAPRED (prednisolone sodium phosphate oral soln, 15 mg/5 mL) PANCRELIPASE (amylase/lipase/protease tabs, 60-16-60) ■ A L L V E R S I O N S , B R A N D A N D / O R G E N E R I C ,
R E M O V E D F R O M F O R M U L A R Y
Blue Cross Blue Shield of
North Dakota Formulary Additions
G E N E R I C P R O D U C T S A D D E D
Brand products (in parentheses) are non-formulary and listed
for reference only
■ D I S C O N T I N U E D B R A N D P R O D U C T S
The following discontinued brand products have been removed
from formulary; generics are not available
griseofulvin microsize oral susp (GRIFULVIN V) PROPRANOLOL INTENSOL (propranolol oral concentrate, G E N E R I C P R O D U C T S A D D E D
Brand products (in parentheses) are also on formulary
octreotide acetate inj, 0.05 mg/mL, 0.1 mg/mL, 0.5 mg/mL ■ D I S C O N T I N U E D G E N E R I C P R O D U C T S
The following discontinued generic product has been removed
B R A N D P R O D U C T S A D D E D
from formulary; brand remains
ARICEPT ODT (donepezil orally disintegrating tabs) CAMPRAL (acamprosate delayed-release tabs) FLOVENT HFA (fluticasone inhalation aerosol) ■ O T H E R A D D I T I O N S
VENTAVIS (iloprost inhalation soln) – Prior Approval Required
F O R M U L A R Y U P D A T E S c o n t i n u e d
K E Y: B L U E T Y P E = F O R M U L A RY A G E N T S R E D T Y P E = N O N - F O R M U L A RY A G E N T S
Blue Cross and Blue Shield of Texas
■ B R A N D P R O D U C T S R E M O V E D –
Preferred Drug Guide Additions
effective January 1, 2006
CARDIZEM LA (diltiazem extended-release tabs 24 hr) B R A N D P R O D U C T S A D D E D
CLEOCIN PEDIATRIC (clindamycin palmitate for oral soln) ARICEPT ODT (donepezil orally disintegrating tabs) ATROVENT HFA (ipratropium bromide inhaler) FANSIDAR (sulfadoxine/pyrimethamine tabs) K-PHOS MF (potassium & sodium acid phosphates tabs) K-PHOS NO. 2 (potassium & sodium acid phosphates tabs) PASER (aminosalicylic acid delayed-release granules) Blue Cross and Blue Shield of Texas
POLYCITRA-LC (potassium & sodium citrates/citric acid soln) Preferred Drug Guide Deletions
■ B R A N D P R O D U C T S R E M O V E D
Generics remain
AMINO-CERV (amino acids/urea vaginal crm) B & O SUPPRETTES (belladonna/opium supp) ■ D I S C O N T I N U E D B R A N D P R O D U C T S
CYSTOSPAZ-M (hyoscyamine extended-release caps) The following discontinued brand products will be removed
effective January 1, 2006; generics are not available
K-PHOS NEUTRAL (potassium phosphate monobasic/sodium ENZYMAX (amylase/lipase/protease tabs, 0.75-0.35-3.75) PANCRELIPASE (amylase/lipase/protease tabs, 60-16-60) POLYCITRA (potassium & sodium citrates/citric acid syrup) PROCHLORPERAZINE rectal supp, 2.5 mg, 5 mg POLYCITRA-K (potassium citrate/citric acid powder for soln, soln) NULEV (hyoscyamine sulfate orally disintegrating tabs) REBETRON (ribavirin caps & interferon alfa-2b inj) OXYCONTIN (oxycodone extended-release tabs, 10 mg, 20 mg, PYRIDIUM PLUS (phenazopyridine/butabarbital/hyoscyamine tabs) Blue Cross Blue Shield of
SHOHL’S SOLUTION MODIFIED (sodium citrate/citric acid soln) Wyoming Formulary Changes
Please refer to PrimeNational Additions and Deletions for updates C O R PORAT E O F F I C E
1020 DISCOVERY ROAD No.100 EAGAN, MN 55121
M A I L I N G A D D R E S S
P.O. BOX 64812 ST. PAUL, MN 55164-0812
PHONE 651.286.4000
FAX 651.286.4408
TOLL FREE 800.858.0723
WEB SITE www.primetherapeutics.com
P U B . N O . 2 0 0 0 P R I M E T H E R A P E U T I C S L L C 0 9 / 0 5

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