Benefit rider

Sparrow Health System Employee Benefit Rider (current through 3/4/2014 Updated 2/19/2014 srk
Quantity Limit List
Category
Medication *
Quantity Limit
All products (e.g. albuterol, metaproterenol) 2 inhalers or bottles of solution / month Concerta all strengths except 36mg (preferred) Metadate CD all strengths (non-preferred) 68 capsules per month (prior notification required) Ritalin LA 20mg & 40mg (non-preferred) Strattera 10mg, 18mg, 25mg, 40mg (Preferred) Mobic 7.5mg & 15mg tabs (non-preferred) All products (e.g. beclomethasone, flunisolide) Clarinex 5mg & Clarinex D 24 hr (non-preferred) Sparrow Health System Employee Benefit Rider (current through 3/4/2014 Updated 2/19/2014 srk
Quantity Limit List
Category
Medication
Quantity Limit
Dexilant all strengths (non-preferred PA 1 Kit (2 syringes) / Rx; 2 fills per month 9 tablets (each strength) / Rx; 18 tablets month Selective Serotonin Receptor Agonist Imitrex Vials 5 vials (1 pack) per Rx; 10 vials/ per month disintegrating tabs Relpax 20mg & 40mg tablets 6 tablets per fill / 12 tablets per month (non-preferred)Luvox and fluvoxamine 50mg tab (non- preferred)Luvox and fluvoxamine 100mg tab (non-preferred)Luvox CR 100mg & 150mg Paxil 20mg, 30mg, & 40mg tablets (non- preferred)Paroxetine 20mg, 30mg, & 40mg tablets (preferred) Paxil CR 12.5mg, 25mg, & 37.5mg * Generic products are subject to quantity limits Sparrow Health System Employee Benefit Rider (current through 3/4/2014 Updated 2/19/2014 srk
Preferred Drug List
Category
Preferred
Non Preferred (Tier 3)
(Tier 1 or 2)
fluoxetine 10mg & 20mg
citalopram
sertraline
paroxetine
methylphenidate
Central Nervous System (CNS)
methylphenidate SR
Stimulants
amphetamine salts and Adderall XR
Strattera
Concerta (effective 6-1-05)
Nuvigil (not covered)Provigil (requires prior notification) Congestive Heart Failure Agents
Agents except BiDil
glimepiride
Diabetic Agents
Exubera (Prior notification approval required) Bydureon (Prior notification & step edit) fenofibrate generic products
HMG-CoA Reductase Agents
Pravachol
(Including combination products)
lovastatin
and the fenofibrate Agents
Lipitor 40mg & 80mg
Zocor(simvastatin) (effective 5-1-05)
Antara (step edit required generic fenofibrate) Lipitor 10mg & 20mg (step edit - simvastatin) Tricor (step edit requires generic fenofibrate) Trilipix (step edit requires generic fenofibrate) Sparrow Health System Employee Benefit Rider (current through 3/4/2014 Updated 2/19/2014 srk
Preferred Drug List
Category
Preferred
Non Preferred (Tier 3)
(Tier 1 or 2)
Inhaled Nasal Steroids
Fluticasone propionate
Flunisolide
Step edit requires use of generic product prior Beconase AQ (Step edit - use of generic product) Flonase (Step edit - use of generic product) Nasacort AQ (Step edit - use of generic product) Nasonex (Step edit - use of generic product) Rhinocoft Aqua (Step edit - use of generic product) Omnaris (Step edit - use of generic product) Veramyst (Step edit - use of generic product) Acetic Acid Agents (indomethacin capsule,
NSAID Agents
sulindac, diclofenac delayed release tablet, Fenemates (meclofenamate)
Oxicams (piroxicam)
Proprionic Acid Agents (flurbiprofen,
ibuprofen, naprosyn sodium tablet, fenoprofen,
Pyranocarboxylic Acid (etodolac tablet)
Misc (nabumetone)
inhalers {fluticasone or flunisolide} is use of one generic nasal steroid inhaler before using a brand name product) Leukotriene Receptor Antagonist (step
edit for class =use of nasal steroid inhaler OR other asthma medication within previous 12 months) Acyclovir
Antiviral Agents
Famvir- Step Edit - acyclovir first line therapy Valtrex - Step Edit - acyclovir first line therapy Hepatitis B Agents
(Tier 2 if patient had a 60 trial of Epivir within the previous 90 Sparrow Health System Employee Benefit Rider (current through 3/4/2014 Updated 2/19/2014 srk
Preferred Drug List
Category
Preferred
Non Preferred (Tier 3)
(Tier 1 or 2)
Flurazepam
Sedative Hypnotics - Non
Temazepam
Barbiturate
Triazolam
ibuprofen and oxycodone individually
metformin and glipizide
pravastatin and aspirin
Combination Products
Antispasmodic Agents
Ditropan & Ditropan XL
Detrol & Detrol LA
Bisphosphonates - alendronate
(Bone resorption suppression agents)
risedronate
Forteo (PA required)
Neuropathic Pain Agents (effective 9- Neurontin
(Tier 2 if patient has had a 60 day trial of Neurontin (gabapentin) Sparrow Health System Employee Benefit Rider (current through 3/4/2014 Updated 2/19/2014 srk
Preferred Drug List
Category
Preferred
Non Preferred (Tier 3)
(Tier 1 or 2)
Misc Agents
Alvesco HFA Inhaler / Alvesco Inhaler (step edit - trial of all formulary inhaled steroid asthma products) Astragraf XL (step edit = immediate release Dificid (Step edit - course of oral Vancomycin) Sparrow Health System Employee Benefit Rider (current through 3/4/2014 Updated 2/19/2014 srk
Sklice (step edit - use of Lindane or permethrin) Brand Name Products available at Accolate
the Generic Tier 1 ($7.00) Copay
Alphagan P 5mL botlle ONLY (Quantity limit of 2 bottles / copay) EpiPen and EpiPen Jr (Quantity limit of 2 pens / copay) Nexium (caps tier 1, susp tier 2)Novolin R, N and 70/30 Vials ONLY Excluded Products
Sparrow Health System Employee Benefit Rider (current through 3/4/2014 Updated 2/19/2014 srk
Differin products for members > 29 yrs of age. Tier 3 for all others Maxifed products / Maxiflu products / Maxiphen products Sparrow Health System Employee Benefit Rider (current through 3/4/2014 Updated 2/19/2014 srk
Protect Cardio / Protect CMB2/Ceramide/Protect Iron/ Protect Bone Ryzolt (tramadol preferred; Ultram ER tier 3) Sparrow Health System Employee Benefit Rider (current through 3/4/2014 Updated 2/19/2014 srk
Sparrow Health System Employee Benefit Rider (current through 3/4/2014 Updated 2/19/2014 srk
Benefit Exclusions
Compounded ProductsCosmetic Agents - Medications used for cosmetic purposes are not covered. (e.g. Propecia)Vitamins - OTC Vitamins are not covered - Prescription vitamins may be covered SPHN covers the following Over-the-Counter Medications ($5.00 Copay for a 28-34 days supply, depending on package size) Nicotine Patches, Lozenges, and Gum (quantity limit of 2 boxes per fill) OTC Prilosec and OTC omeprazole loratadine tablets and liquid Prior Notification Medications (all Specialty Pharmacy Medications require prior notification)
Medication
Information
Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to Plan. If approved, covered on Tier 3 Submit request to Plan. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 2 Not a covered beneft with the exception of oral liquids, which may be covered. Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 (requires tx with oral vanco first) Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered under Tier 3. Oral seligiline is preferred Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 3 Prior Authorization Required. Submit request to Plan Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3.
Submit request to MedImpact. If approved, covered under Tier 3. Submit request to MedImpact. If approved, covered under Tier 3. Submit request to MedImpact. If approved, covered under Tier 3. Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered under Tier 3. Submit request to MedImpact. If approved, covered under Tier 3. Submit request to MedImpact. If approved, covered under Tier 3. Submit request to MedImpact. If approved, covered under Tier 3. Sparrow Health System Employee Benefit Rider (current through 3/4/2014 Updated 2/19/2014 srk
Submit request to MedImpact. If approved, covered under Tier 3. Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered under Tier 3. Submit request to MedImpact. If approved, covered under Tier 3. Submit request to Plan. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered under Tier 3. Submit request to MedImpact. If approved, covered under Tier 3. Submit request to MedImpact. If approved, covered under Tier 3. Submit request to the Plan. If approved it is covered under the medical side.
Submit request to MedImpact. If approved, covered under Tier 3. Submit request to MedImpact. If approved covered on Tier 3. Need diagnosis verification Submit request to MedImpact. If approved, covered under Tier 3. Submit request to MedImpact. If approved, covered under Tier 3. Submit request to MedImpact. If approved, covered under Tier 3. Submit request to MedImpact. If approved, covered under Tier 3. Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered under Tier 3. Submit request to MedImpact. If approved, covered under Tier 3. Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact, include documentation showing superiority over other opioids. If approved, covered under Tier 3. Submit request to MedImpact, include documentation showing superiority over other opioids. If approved, covered under Tier 3. Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Sparrow Health System Employee Benefit Rider (current through 3/4/2014 Updated 2/19/2014 srk
Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to Plan. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 3 Submit request to MedImpact. If approved, covered on Tier 2 Submit request to MedImpact. If approved, covered on Tier 3 Sparrow Health System Employee Benefit Rider (current through 3/4/2014 Updated 2/19/2014 srk
Medication Extended Supply List
Please Note:
Generic dispensed when available. Brand name in most cases only listed for name recognition.
*Asterisked agents do not currently have a generic available.
I. 100 Units or 34 days supply, whichever is greater
Antidiabetic Agents
Cardiac Agents
Diuretics
Antihypertensives
Hydrochlorothiazide / Triamterene (eg.Dyazide/Maxzide) Estrogen and Hormone Therapy
Esterified Estrogens (eg. Estratab, Estrace, Ortho-est) Anti-inflamatory agents
H2 Blockers
Anti-Lipid Agents
Atorvastatin (Lipitor)Fluvastatine (Lescol)* Hyperuricemia/Gout agents
Lovastatin (Mevacor)Pravastatin (Pravachol) Potassium Chloride
(eg. Kay Ciel/Slow K/K Dur/ Micro K/Klotrix) Bronchodilators
Theophylline (eg. Theodur/Slo-bid)
II. 200 Units or 34 day supply, whichever is greater
Levothyroxine (eg. Levothroid/Synthroid)

Source: http://www.sparrow.org/upload/docs/Services/Physician/BenefitRider.pdf