IMPORTANT CHANGES TO YOUR PRESCRIPTION BENEFITS EFFECTIVE JANUARY 1, 2016

Jan 9, 2019 | News

*IMPORTANT*

PLEASE READ EACH ITEM BELOW CAREFULLY TO SEE

HOW YOUR PRESCRIPTION BENEFITS WILL BE AFFECTED

The information in this SMM is different from the information you received in the Summary of Benefits and Coverage (SBC) which was mailed in September, 2015.

IMPORTANT CHANGES TO YOUR PRESCRIPTION BENEFITS

Effective JANUARY 1, 2016

*IMPORTANT*

PLEASE READ EACH ITEM BELOW CAREFULLY TO SEE

HOW YOUR PRESCRIPTION BENEFITS WILL BE AFFECTED

The information in this SMM is different from the information you received in the Summary of Benefits and Coverage (SBC) which was mailed in September, 2015.

At the September 2015 meeting, the Trustees of the Central Pennsylvania Teamsters Health & Welfare Fund (“Fund”) adopted the following changes to the Fund’s Prescription Benefits.  The changes below will be effective January 1, 2016.

  1. GPP FORMULARY ADOPTED:  As of January 1, 2016, your copayments for preferred and non-preferred brand name drugs and specialty drugs will be determined by the GPP Formulary. The new copayment description is included in the newsletter.  We will no longer use a negative formulary.  “GPP” is the Funds prescription drug pharmacy benefit manager, General Prescription Programs, Inc.

The Fund will provide benefits for ALL medically necessary Generic drugs, not just those Generic medications listed on the Formulary.  Unless subject to a specific exclusion or limitation, the Fund will provide benefits for medically necessary Brand Name drugs, even those not appearing on the Formulary.  However, you will be responsible for the Non-Preferred Brand copayment.

Your copayment will depend on whether you receive a Generic or Brand Preferred or Non-Preferred or Specialty medication.  Please see the Copayment Chart on Page XX.  These copayments differ between Plans and depend on the level of benefit selected.  Provided that other restrictions are not applicable, the Fund will provide benefits for Brand Name medications not appearing on the Formulary at the “Non-Preferred” or “Specialty” copayment level.

NOTE:  This Formulary may change in the future without advance notice to you upon the advice of the Fund’s pharmacy benefit manager.  Please call the Fund Office or check the Fund’s website: www.centralpateamsters.com to verify whether the prescription medication your doctor prescribes is on the GPP Formulary.  You will periodically receive a copy of the updated Formulary.

  1. STEP THERAPY:  The Trustees have expanded the Fund’s “Step Therapy” Program.  Effective January 1, 2016, under the “Step Therapy” Program, the Fund will not pay benefits for certain generic and brand name medications until you have first tried and failed a medication listed in Step I.  After you have tried and failed on a medication in Step I, the Fund will ONLY provide benefits for the medications listed in Step II if the Fund’s records (or documentation that you supply) show that you tried and failed on a Step I medication and your physician provides documentation demonstrating that the Step II medication is “medically necessary”.

IMPORTANT!  Please review the attached Step Therapy Chart carefully.  You may need to change medications effective January 1, 2016.  If your medication is not “grandfathered,” the Fund will notprovide benefits for the Step II medication after January 1, 2016 until you have documented that you have tried and failed on a Step I medication and your physician has demonstrated that it is “medically necessary” for you to have the Step II medication.

  1.  INSULIN DRUGS:  Effective January 1, 2016, the Fund will not provide benefits for any new prescriptions for insulin medications except NovolinR, Novolog, Levemir and Victoza.  If you are currently taking another insulin medication, you will be “grandfathered,” that is, the Fund will continue to provide benefits for this medication.
  1. ADVAIR and BREO EXCLUDED FROM COVERAGE:  Effective January 1, 2016, the Fund will not provide any benefits for ADVAIR or BREO. The Fund will provide benefits for the Asthma medications listed on the attached Formulary or other medically necessary asthma medications to which Fund restrictions or prohibitions do not apply.  Copayments will vary depending on the medication.  No patients will be “grandfathered” for these medications.  Therefore, if you currently use ADVAIR or BREO, it is essential that you speak with your physician now about moving to an alternative medication before January 1, 2016.
  1. SPECIALTY DRUGS DEFINED:  Effective January 1, 2016, any drug that costs $3,000 or more per script will be classified as “Specialty Drugs.”
  1. NEW COPAYMENT ADDED FOR SPECIALTY DRUGS:  Effective January 1, 2016, there will be a $150 copayment for any “Specialty Drug,” that is, for any drug that costs $3,000 or more per script.
  1. LIMITED COVERAGE OF NEW BRAND MEDICATIONS:  Effective January 1, 2016, the Fund will provide no benefits for new brand-name prescription drugs for the first 6 months after their initial public release.  After the initial six month period, these medications will be subject to any applicable plan rule (for example, copayment, pre-authorization, quantity limits, etc.).
  1. COMPOUND DRUGS EXCLUDED: Effective January 1, 2016, the Fund will provide no benefits for anycompound drugs.
  1. NEW RESTRICTIONS ON ZOHYDRO:  Effective January 1, 2016, the Fund will provide no benefits for Zohydro unless it has been submitted to GPP and approved pursuant to the Fund’s pre-authorization criteria.  The pre-authorization criteria include trying certain other medications listed in Step I under Narcotic Analgesics in the attached “Step Therapy” protocol.  In addition, the copayment for all Zohydro prescriptions will be $150 per script.
  1. PREAUTHORIZATION REQUIRED FOR PCSK9 (proprotein convertase subtilisin/kexin 9)  MEDICATIONS:  Effective January 1, 2016, the Fund will ONLY provide benefits for PCSK9 medication where that medication has been pre-authorized under the Fund’s criteria.  The medications will be considered for patients with diagnosed and documented homozygous familial hypercholesterolemia (HoFH),  who have no labeled contraindications to this therapy, where the therapy is prescribed by or in consultation with a cardiologist or lipid specialist, and who submit required documentation.
  1. HEPATITIS-C MEDICATIONS – PRE-AUTHORIZATION REQUIRED:  Effective January 1, 2016, the Fund will ONLY provide benefits where the medication has been pre-authorized under the Fund’s criteria, which include the patient’s Metavir score, as well as documentation of patient specific information related to their condition provided by the patient’s physician.
  1. LIMITS ON FDA “CLASS II” PAIN MEDICATIONS:  Effective January 1, 2016, the Fund will provide benefits fora maximum of  fifteen days (15) per script for medications classified as CLASS II medications by the U.S. Food and Drug Administration.
  1. NO BENEFITS FOR “REFORMULATED” MEDICATIONS:  Effective January 1, 2016, the Fund will notprovide any benefits for the medications in Column A.  The Fund will provide benefits for the medications in Column B.  This list is subject to modification.
COLUMN A COLUMN B
ATIVAN 0.5 MG TABLET LORAZEPAM 0.5 MG TABLET
ATIVAN 1 MG TABLET LORAZEPAM 1 MG TABLET
ATIVAN 2 MG TABLET LORAZEPAM 2 MG TABLET
COLAZAL 750 MG CAPSULE BALSALAZIDE DISODIUM 750 MG CAPSULE
DEXPAK 10 DAY 1.5 MG TABLET DEXAMETHASONE 1.5 MG TABLET
FORTAMET ER 1,000 MG TABLET METFORMIN ER 1,000 MG TABLET
GLUMETZA ER 1,000 MG TABLET METFORMIN ER 1,000 MG TABLET
NORITATE 1% CREAM METRONIZADOLE 1% GEL
VASOTEC 2.5 MG TABLET ENALAPRIL MALEATE 2.5 MG TABLET
VASOTEC 5 MG TABLET ENALAPRIL MALEATE 5 MG TABLET
VASOTEC 10 MG TABLET ENALAPRIL MALEATE 10 MG TABLET
VASOTEC 20 MG TABLET ENALAPRIL MALEATE 20 MG