Q;A C900-t4 5\ --P4G J, oo4 jd1J)'5 STATE HEALTH BENEFIT PLAN JULY 1 , 2 004 - JUNE 3 0 , 2005 PHARMACY BENEFIT COMPARISON ~ ~ GEORGIA DEPARTMENT OF COMMUNITY HEALTH ~ II NEW PPO & INDEMNITY OPTIONS: PPO BASIC PPO PREMIER PPO CHOICE BASIC PPO CHOI CE PREMIER INDEMN ITY BASIC INDEMNITY PREMI ER HMO OPTIONS: BLUECHOICE CIGNA KAI SER PERMANENTE U N ITEDHEALTHCARE ., II IMPORTANT ENROLLMENT INFORMATION r If you do not submit your choice by May 14, 2004 and you are participating in the Current PPO, PPO Choice or Indemnity Options, your coverage will default to the New PPO Basic, New PPO Choice Basic or New Indemnity Basic Option. Failure to respond will not allow you to retain your current level of pharmacy coverage. '-- - 1. Review yom 2003-2004 coverage. 2. Determine the 2004-2005 benefit option that best fits your needs and budget. 3. Submit your 2004-2005 benefit elections using www.statehealth.org for agencies that do not participate in the State Flexible Benefit Program (FBP) offered by the Georgia Me rit System and www.gabenefits.org for agencies participating in the State FBP or via paper bv Mav 14. 2004. 4.You can go online to www.dch.state.ga.us and follow the pharmacy links to the Express Choice tool to calculate your estimated out-of-pocket costs for the Basic and Premier Plan Options. IMPORTANT MESSAGE FROM THE STATE HEALTH BENEFIT PLAN (SHBP) You have heard in the media how medical and pharmacy costs contilrne to i11crease. Our pharmacy costs are increasing at rates higher than the national average because, as a group, SliBP members use a high number of prescription medications. SHBP and Express Scripts (our pharmacy benefit manager) want to help you manage your prescription expenses. Our goal is to provide you with quality pharmacy benefits at a reasonable cost to you and the Plan. Effective July 1, 2004, the current PPO, PPO Choice and Indemnity Options will no longer be available. The New PPO, PPO Choice and 11ldemnity Options are: PPO Basic PPO Choice Basic Indemnity Basic PJ;>O Premier PPO Choice Premier Indemnity Premier OVERVIEW OF MY PHARMACY BENEFIT OPTIONS What Are the Differences Between the Basic and Premier Pharmacy Options? There are three differences between the Basic and Premier prescription benefits. The Basic Preferred Drug List (PDL) is not as extensive as the Premier Drug List; The co-payments are different (see Pharmacy Benefit Comparison Chart); and There are no Maximum Out-of-Pocket (MOP) limits for the Basic pharmacy options (see Pharmacy Benefit Cornparison Chart). During Open Enrollment, you can select the health be nefit coverage best suited for you and your family. Before making your choice, review the PPO, PPO Choice and Inde mnity Option Overviews and the Pharmacy Benefit Comparison Chart. PLAN PROVISIONS FOR THE BASIC AND PREMIER OPTIONS New Progressive Drug Management Program (PDMP) - This program has been designed to assist your doctor in finding the most appropriate drug treatment for you and your family.The first step in the program is usually a proven less e,xpensive treatment known to be safe and effective for most people. U the drug does not work for you, your doctor may progress to another drug.A Prior Authorization may be required as the next step in the program to obtain the drug that is best suited for you . Progressive Drng Management belps to ensure that you are receiving the most appropriate and costeffective drug for your condition.The PDMP is in effect for the following therapeutic categories:ACE Inhibitors, Brand NSAlD, Elidel/Protopic and Glucophage XR.Note:This list is subject to change during the Plan year. Note: If you should go to t he pharmacy and are told that your prescription cannot be filled because a prior authorization is required, please have your doctor call Express Scripts, lnc.'s (ESI's) prior authorization unit w ith your clinical information.The prior authorization process is a telephonic process where your doctor can give your clinical information over the phone for review. Uthe information provided by your doctor does not meet the criteria for the drug requested, you Hre entitled to appeal. Your physician will need to fax a written request to ESI's appeals unit that should include your medical history and all previously used drugs to treat your particular condition. HEALTH MAINTl!NANCE ORGANIZATIONS (HMOs) Generic co-payments are different from the PPO and Indemnity Options No Maximum Out-of-Pocket (MOP) limit feature Maintenance Drngs may be obtained for up to a 90-day supply of your prcscription(s) for two (2) co-payments. Note: (Kaiser: one co-payment per 30-day supply) Contact respective HMO for further Plan provisions ALL PLA~ O1'TI 0NS Re1nember: No co-payments for drugs that are covered by SHBP will be changed or overridden on an individual basis. The SHBP defines Maintenance Drugs as medications for specified chronic conditions where you may obtain up to a 90-day supply of your prescription(s) at one time for three (3) co-payments.Your co-payments are based on supplies of up to 30 days as this is the industry standard. However, some drugs are limited to a standard other than the 30-day supply for one co-payment. Note:This applies only to the PPO Basic, PPO Premier, PPO Choice Basic, PPO Choice Premier, Indemnity Basic and Indemnity Premier Options. In addition, many drugs listed as non-preferred have a generic or preferred brand-name drug alternative. Preferred drug alternatives are therapeutically equivalent while being more cost effective. If the drug cost is less than the co-payment, you do not pay the co-payment but the lesser of,which is the actual cost of the drug. For example, if the preferred drug cost is $18.23, and the preferred drug co-payment is $25.00, you will only pay $18.23. PHARMACY BENEFIT COMPARISON CHART ',...,.., -:~ -, -.-, -..11:f"" -, ,l . , i;_ - _I . - ' I PLAN T ,YPE , I - -, -"-' . _ - - __j PPOBasic - Basic $10 $25 PPO Choice Basic (see page 4 for abbreviated PDL) $40 Does not apply Indemnity Basic Basic S10 $25 $40 Does not apply (see page 4 for abbreviated POL) PPO Premier - Premier Sl5 PPO Choice Premier (see page 5 for abbreviated PDL) $25 20% of cost; $450 per minimum $40 - member/ maximum Sl 00 S1,300 family Indemnity Premier Premier $15 (see page 5 for abbreviated POL) $25 20% of cost; $450 per minimum $40 - member/ maximum $100 $1 ,300 family HMOs- BlueChoice CIGNA United.Healthcare Kaiser Permanente HMO Drug Lists $10 $25 $40 (see telephone numbers below) Kaiser Drug List (see telephone number below) I Kaiser : Eckerd's Facility Drugs $10 $16 Kaiser Facility $25 Eckerd 's Drugs $3 1 Does not apply Does not apply Does nm apply Note: Please:: contact each HMO regarding pharmacy lists - IllueChoice: (800) 464-1367; CIGNA: (800) 564-7642; Kaiser Permanente: (800) 611-1811 ; UniteclHealthcare: (866) 527-9599. BASTC A '\0 PltE\.lll':R DRUG LISTS The pharmacy drug lists are created, revie wed and continually updated by a team of health care professionals, including physicians and pharmacists. A medication becomes a preferred drug bas<.:d first on safety, then efficacy and last on cost-effectiveness. Your doctor can use the list associated w ith your chosen option to select mc.:dications for your healthcare needs, while helping you maximize your prescription drug benefit.The choice of medications is strictly between you and your doctor. Preferred Drug Lists for SHBP members arc subject to d1ange. Prior to p urchasing your medication(s) you may view the drug lists at www.clch.state.ga. us or contact Express Scripts by phone at (877) 650-9342 or TDD (800) 842-5754 to get the most current status on any covered cl.rug. Included in this brochure is an abbreviated version of the two drug lists for comparison. Use these lists to help you determine what your co-payments will be and to evaluate which cl.rug benefit will best meet your needs. GEORGIA BASIC PREFERRED DRUG LIST (ABBREVIATED) PA - prior authorization re9uired QLL - quantity or therapy limits exist EFFECTIVE JULY 1, 2004 f0R STATE HEALTH BENEFIT PLAN - PPO AND INDEMN ITY H EALTH PLANS All generics are considered preferred drugs (examples listed in each category). If at any time during the Plan year a brand has a generic equivalent become available, that brand will automatically b<:: moved to the non-preferred status. .\ l.l.F.RGY/ RESPTRATORY ADVAIR DISKUS albuterol generic ALLEGRA, -D CO M B IVENT FLOVENT ROTADISK FORADIL INTAL ipratropiL11n generic PROVENTIL 1-IFA QVAR SEREVENT DISKUS SINGULAIR A:-il"l -L',FECTIVES acyclovir generic amoxicillin generic amoxicillin/clavulanic generic ampicillin generic AUGMENnN ES AUGMENTIN XR AVELOX, ABC PACK cefuroxime generic cephalexin generic CIPRO DIFLUCAN doxycycline generic erythromycin generic ketoconazole generic nitrofurnatoi n generic penic illin generic SPORANOX TEQUIN tetracycline generic timethoprim generic tmp/smx generic ZITHROMAX Al/ rONO/IUC & C:-iS AMB IEN amitriptyline generic CELEXA CONCERTA ciextroamphetamine generic EFFEXOR, -XR fluoxetine generic IMITREX LEXAPRO METADATE CD m~thylpl~enidate seneric rrnrtazapme generic paroxeti ne generic PAXIL CR REMERON soltab SONATA ST RATTERA temazepam generic trazodone generic WELLBUTRIN SR ZOMIG, -ZMT GASTROINTST1l\A_L ASACOL cimetici ine generic fa motidine generic nizatidine generic omeprazole generic PENTASA PREVACI D PREVPAC ranitidine generic sulfasalazine generic C.\HDIOVASCI 11.Alt ADVICOR atenolol generic AVALI DE AVAPRO bisoprolol generic bisoprolol w/hclZ generic chlorthaliclone generic c lonidine generic COR EG CRESTOR diltiazem, er generic DIOVAN, HCT enalapril generic enak1pri l w/hctz generic gemfibrozil generic nydrochloroihiazide generic INNOPRAN XL LIPITOR l isinopril generic lisinopril w/hctz generic LOTENSIN HCT LOTREL lovastatin generic metoprolof tartrate generic moexipril generic NIASPAN nifedipine er generic NORVASC propranolol generic terzosin generic verapamn generic verapamil, xr generic ZAROXO LYN ZETIA EAR - 1 \ 0 S .' f H RO AT ASTELIN FLONASE NASONEX llllO l.()GICAT. DETROL, -LA oxybL1lynin generic AVODART EDEX FLOMAX VIAGRA MUSCUI.OS K EUffAI. diclofenac sodium generic ibuprofen generic indomethacin generic nabumetone generic naproxen generic VIOXX chol ine mag trisa licylate generi c d iflunisal generic salsalate generic E:-.DOCRlNE ACTONEL ACTOS AVANDAMET AVANDIA D IDRONEL EVISTA FORTEO FOSAMAX glipizide generic glyburide generic f-lUMALOC HUMULIN LANTUS metformin generic NOVOLIN NOVOI.OG PRANDIN PRECOSE STARLIX tolazamide generic tolbutamide generic OHSTETRICAI./ GY:\ECO I.OGICAI. ESCLIM estracliol generic FEMHRT medroxyprogesterone generic O RTHO ORTHO EVRA PREMARIN PREMPt-IASE PREMPRO TRI-CYCLEN LO YASMIN ALTERNATIVE PRODUCT LISTING FOR NON-PREFERRED BRANDS NON-PRCFERRED BRAND SELECTED ALlERNATIVE BRA'Ill~ Accolate ... . ....... . .. . . . . .. .. . .. . . Singulair AccupriI . .. . . . . . . . ...... . . . . ... . . . . lisinopril Aciphex ... .. .. . ...... .... omeprazole, Prevacid Act1vel la . . ... . . .. . . FemHRT, Prempro, Premphase Altace . .. . . .. .. .. . . .. . . . .. .. ....... lisinopril Atacand ... .. . . ... . .. . . ... ... . Avapro, Diovan Biaxin, -XL ... ... ..... . . erythromycin, Zithromax Clarinex . . ... .. . . .. . . . . .... . ... ... .. Allergra Cozaar. . ... .. . ... . . ...... . . . . : Avapro, Diovan Hyzaar ... . ... . .. . . , .. . ... Avahde, D 1ovan HCT Maxalt, -MLT . ... . . . ..... .. . lmi trex, Zom ig, -ZMT Mabie .. .... ..... . .. . . ... . . .. . generic NSAIDs Nexium . . .. . . .. , . .. , .. . . . omeprazole, Prevacid Plencii l .. . . . . . . . . . ...... . . . ni tedipine, Norvasc Protonix .... . . . . . . .. ..... . omeprazole, Prevacid Pulmicort ... . . . . .. . . . . . ... .... . Flovent, QVAR Sular . . . . . . . . . ... . ..... nifed ipine, Norvasc Zocor . . .. . . . .. .. .. . ... lovastatin, Crestor, Lipitor Zoloft . . .... ftuoxetine, paroxetine, Lexapro, Paxil CR Zyrtec. . . . ...... . ....... .. ... .. . .... . Allegra ( For Prior Authorizations (PA), Quantity Level Limits (QLL) or any questions rcg;irding specific coverage rules or co-payment i.tlformation for drugs not Usted on this document, please contact Express Scripts, Inc. at 1-877-650-9342. f'cbruary I 8, 2004 This list is subject to cb(mse al the discretion of tin l}eJ}(/r/menl ofCo1111111111ity f/e(l/tb. GEORGIA PREMIER PREFERRED DRUG LIST (ABBREVIATED) PA - prior authorization re9uired QLL - quantity or therapy hmits exist EFFECTIVE JULY 1, 2004 FOR STATE HEALTH BENEFIT PLANS - PPO AND INDEMNITY HEALTH PLANS All generics are considered preferred drugs (examples listed in each category). If at any time during the Plan year a brand has a generic equivalent become available, that brand w ill automatically be moved to the non-preferred status. A I. LERGY / R E S P I R A T O R Y ADVAIR D ISKUS QLL albuterol generic Q LL ALLEGRA, -D Q LL COMBIVENT QLL crornolyn sodium generic FLOVENT, - ROTADISK Q LL FORADIL QLL ipratropi um generic MAXAIR AUTOHALER Q LL metapro terenol generic QLL PROVENTIL I-IFA QLL PU LMICORT RESPS Q LL SI N G U LAIR TI LADE QLL ZYRTEC Q LL ANTI-INFECTIVES acyclovir generic amoxic il l in generi c arnoxicill in/c lavulanic generic ampicillin generic AUGMENTIN ER AUGMENTIN XR QLL AVELOX cefuroxirne generi c C EFZI L cephalexin generic CIPRO CIPRO XR Q LL D IFLUCAN lSOMG QLL D IFLUCAN PA cloxycyc li n~ generi ~ erythromyc1 n generic GANTRISIN PEDIATRIC gri seofulv in generic l