Coverage Review and Specialty Pharmacy Changes Beginning November 1, 2008
Coverage Review for New Users of Effexor XR® and Pristiq®
As of November 1, 2008, all new users of Effexor XR® and Pristiq® will be subject to a formulary coverage review , also called a step therapy program. A step therapy program encourages members to try less expensive, preferred medications before coverage is provided for non-preferred brand name medications.Coverage for Effexor XR® and Pristiq® will be provided if your provider documents that you have experienced failure or intolerance to one of the State Health Plan-preferred antidepressant medications.
Members will be responsible for the full cost of the Effexor XR® or Pristiq® prescription, if the provider does not receive approval during the coverage review. Providers may call Medco toll-free at 1-800-417-1764, from 8:00 a.m. to 9:00 p.m., Eastern Time, Monday through Friday, to request a review.
Please talk with your provider about possible alternatives to Effexor XR® and Pristiq®, including one of the many available generics. You can save money by using generic drugs instead of brand name drugs. Generic medications are always State Health Plan-preferred medications.
Members currently using these medications will not be subject to the prior authorization requirements.
Click here for frequently asked questions (FAQs), or call Medco Customer Service at 1-800-336-5933 for more information.
New Specialty Pharmacy Prior Authorization Programs
Also beginning November 1, 2008, the State Health Plan will implement pharmacy prior authorization programs for new users of the following specialty medications:
- Psoriasis Medications: Amevive® and Raptiva®
- Multiple Sclerosis Medications: Betaseron®, Rebif®, Avonex®, Copaxone®, and Tysabri®
- Immunomodulators: Thalomid® and Revlimid®
Members currently using these medications will not be subject to the prior authorization requirements. Program information is located on the Pharmacy Prior Authorization Policy Web page.
Members will be responsible for the full cost of these medications, if the provider does not receive approval during the coverage review. Providers may call Medco toll-free at 1-800-417-1764, from 8:00 a.m. to 9:00 p.m., Eastern Time, Monday through Friday, to request a review.
Click here for frequently asked questions (FAQs), or call Medco Customer service at 1-800-336-5933 for more information.
These specialty medications are available through Accredo Specialty Services. Members may contact Accredo at 1-800-803-2523 or visit our Specialty Care page for more information.