Presorted Standard U.S. POSTAGE PAID New York, NY Permit No. 3700 330 West 42nd Street New York, NY 10036-6977
SUMMER 2008
Your Key to the 1199SEIU Benefit Funds
New Prior Authorization Process for Certain Drugs Begins August 1, 2008 Back in October of last year, the 1199SEIU Benefit Funds instituted a “Step Therapy” program for the medication Nexium, requiring members to try the less-costly omeprazole before using Nexium. Due to the success of this program, we will now be extending step therapy to other medications, which became effective Friday, August 1, 2008. Under the 1199SEIU Benefit Fund’s Step Therapy policy, our members must first try established, lower-cost, clinically appropriate medications before moving on to other, more costly medications such as preferred brand names. Of course, if the medication is not effective in treating the member’s condition, you can request authorization for the higher-cost medication.
Refer to Participating Providers So Your 1199SEIU Patients Don’t Pay the Bill When you refer your 1199SEIU patients to a specialist or a facility, radiology, lab services, or any other ancillary services, be sure to refer them to an 1199SEIU participating provider. Referring within our network of credentialed providers helps our members get the high quality care they are entitled to with no out-of-pocket costs. For a complete list of participating specialists, lab and radiology providers, visit our website at www.1199SEIUBenefits.org. • For radiology services: Medfocus (888) 910-1199 • For diagnostic testing: Laboratory Corporation of America (LabCorp) (800) 788-9091 • Quest Diagnostics (800) 877-7530 • Bendiner and Schlesinger (877) 240-0349 • Centralized Lab Services (718) 786-2300
This means that 1199SEIU providers must follow a new authorization process when prescribing certain medications. (Please see a list of medications in the chart below). In addition to the medications listed below, certain cancer therapy, Pulmonary Arterial Hypertension (PAH) and miscellaneous hormone drugs will also be included in this Step Therapy policy. A Medco representative will be in contact with you to advise of the affected medications and provide further details. To arrange an authorization review, call Medco toll-free at (800) 417-1764, 8:00 am to 9:00 pm, Monday through Friday. You will also need to submit the necessary clinical documentation to Medco. If you fail to do so, your 1199SEIU members’ prescriptions may be rejected or they may be subject to expensive out-of-pocket costs. Medications Subject to Step Therapy Prior Authorization Rules Step Therapy Category
Preferred Brand
Non-Preferred Brand
Anemia • Aranesp *Note: Patients who have been taking Procrit or Epogen for less than 8 weeks will be permitted to remain on the Non-Preferred Brand for 8 weeks. Proper documentation is still required.
• Procrit • Epogen
Hepatitis C • Peg Intron *Note: All patients who are taking Pegasys prior to August 1, 2008, will be allowed to remain on the Non-Preferred Brand medication and be “grandfathered” into the system. Proper documentation is still required.
• Pegasys
Growth Hormone
• Genotropin • Saizen • Omnitrope • Accretropin
• Norditropin • Humatrope • Nutropin • Tev Tropin