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2004 Benefit Update winter 2004
2004 Benefit Update
Updates to Tufts Health Plan
Pharmacy BenefitJanuary 1, 2004
In an effort to continue to offer a pharmacy
benefit that is both clinically appropriate and
cost effective, we consistently review how we
cover prescription medications. By conducting
this review and monitoring the marketplace, we
realize that, on occasion, adjustments need to be
made to keep the benefit in line with current
trends. If you offer your employees prescription
drug coverage through Tufts Health Plan, the
following is a synopsis of the changes you will
experience with our pharmacy benefit effective
January 1, 2004.
Some New Generic Medications to Start
Out on Tier-2
Because of the increase in the cost of new
Benefit Changes for the New Year
The following benefit changes will be effective
on your groups renewal date that falls on or
after January 1, 2004.
Behavioral Health (Mental Health):
Acute Residential Treatment
IMPORTANT CLARIFICATION
The way we calculate the inpatient mental
health day limit will remain the same in 2004.
We had planned to begin to change the way
acute residential treatment accumulated toward
that limit, effective January 1, 2004. But due
to the timing of questions raised by the
Division of Insurance, we have decided to not
go forward with the change at this point.
As a result, there will be no acute residential
treatment benefit change, effective January 1,
2004. We apologize for any inconvenience this
may have caused.
Compounded Medications
Compounded medications will be covered if at
least one active ingredient requires a prescrip-
tion by law. Compounded medications will not
be covered if there are no active ingredients
that, by law, require a prescription.
Nutritional Counseling Now Unlimited
We have removed the eight visit limit from the
INSIDE...
Updates to
Tufts Health Plan
Pharmacy Benefit
January 1, 2004
1
Benefit Changes for
the New Year
1
Secure Horizons®,
Tufts Health Plan
for Seniors, Benefit
Update
3
Lower Copayments
for Choice Copay
Plans
4
New Weight Watchers
Discount in 2004
4
Helping Members
Understand Their Plan
4
(Continued on page 2)
(Continued on page 4) [2]
Updates to Tufts Health Plan Pharmacy BenefitJanuary 1, 2004
(Continued from page 1)
2004 Benefit Update
generic medications, as of January 1, 2004, Tufts Health Plan
will place some new, high-cost generics on Tier-2 of the 3-Tier
Pharmacy Copayment Program as these drugs come on the
market. These high-cost generic drugs will remain on Tier-2
until their price comes into alignment with the price of other
generic drugs. Please note, this will not affect the tier place-
ment or copayment levels of generic medications currently on
Tier-1 of our list of covered drugs.
Changes to the Drugs Requiring
Dispensing Limitations
In an effort to monitor safety and control the cost of prescrip-
tion drugs, we review national clinical guidelines for the drugs
we cover on an annual basis. Effective January 1, 2004, after
reviewing U.S. Food and Drug Administration (FDA) guide-
lines, we are making some changes (see chart on right).
Changes to the List of Non-Covered Drugs
Physicians often use an approach called "step therapy" to treat
their patients for certain diseases. Under step therapy, select
groups of drugs, called "first-line agents, are used initially.
Then, if the first-line agents fail to treat the patient, other
groups of drugs, called "second-line agents, are used.
Effective January 1, 2004, preferred drugs in second-
line drug classes will move to Tier-3 of our 3-Tier
Pharmacy Copayment Program, and the following
drugs in second-line drug classes will move to our List
of Non-Covered Drugs:
Atacand
Prevacid
Atacand HCT
Prilosec
Avalide
Sporanox (capsules only)
Avapro
Teveten
Genotropin
Teveten HCT
In addition, the growth hormone, Genotropin, will be
added to our List of Non-Covered Drugs, effective
January 1, 2004.
Drug Name
New Dispensing Limitation
Amerge
(1 mg and 2.5 mg tablets)
Anzemet
(50 mg and 100 mg
tablets)
Anzemet
(20 mg/ml and 12.5/0.625
injection)
Axert
(6.25 mg and 12.5 mg
tablets)
Frova (2.5 mg tablets)
Imitrex (injection, kit)
Imitrex (injection, vials)
Imitrex (5 mg nasal spray)
Imitrex
(20 mg nasal spray)
Imitrex
(25 mg, 50 mg, 100 mg
tablets)
Kytril (1 mg tablets)
Kytril
(1 mg/5 ml oral solution)
Kytril (1 mg/ml injection)
Maxalt and Maxalt MLT
(5 mg and 10 mg tablets)
Migranal
(4 mg/ml nasal spray)
Relpax
(20 mg and 40 mg tablets)
Zofran (24 mg tablets)
Zofran
(4 mg/5 ml oral solution)
Zofran (2 mg/ml injection)
Zofran/Zofran ODT
(4 mg and 8 mg tablets)
Zomig and Zomig ZMT
(2.5 mg tablets)
Zomig and Zomig ZMT
(5 mg tablets)
9 tabs/30 days
3 tabs/7 days
5 ml/7 days
6 tabs/30 days
9 tabs/30 days
4 injections (2 boxes)/30 days
4 injections/30 days
12 units/30 days
6 units/30 days
9 tabs/30 days
6 tabs/7 days
30 ml/7 days
1 ml/7 days
6 tabs/30 days
4 units/30 days
6 tabs/30 days
1 tab/7 days
90 ml/7 days
10 ml/7 days
9 tabs/7 days
6 tabs/30 days
3 tabs/30 days Secure Horizons®, Tufts Health Plan for Seniors,
Benefit Update
01810, 01812, 01899,
05501, 05544
01833
01834
01830, 01831, 01832,
01833, 01835
01840, 01841, 01842, 01843
01844
01845
Andover:
Georgetown:
Groveland:
Haverhill:
Lawrence:
Methuen:
North Andover:
Employer groups offering health care coverage to their
retirees will see changes to Secure Horizons benefits, copay-
ments, and service area in 2004. The change in service area
will take effect for all groups on January 1, 2004. The other
changes will take effect either on January 1, 2004, or on a
groups renewal date on or after January 1, 2004.
If you have any questions regarding this information,
contact Peter Stoner, Tufts Health Plan retiree product sales
manager, at (800) 442-0422, extension 9032.
Premium Increase
The Secure Horizons plan premium will increase by
approximately 7%.
Change in Service Area
Effective January 1, 2004, the following Massachusetts
zip codes will no longer be part of the Secure Horizons
service area:
Outpatient Procedure Coinsurance Maximums
In 2004, there will be 20% coinsurance, up to a maximum
of $50 per day, for outpatient procedures in a hospital or
ambulatory surgical center. Please note, all large bowel pre-
ventive screening procedures, such as colonoscopy and sig-
moidoscopy, will be covered in full.
Pharmacy Cost Increases
Tier-1, Tier-2, and Tier-3 retail and mail order copayments
charged for outpatient prescription drugs will increase.
Deductible Change for Hospitalization
The annual hospital deductible will increase from $125
to $200 in 2004. There will be a maximum deductible
out-of-pocket limit, so members will not pay more than one
deductible in 2004, even if they are admitted to the hospital
more than once. Please note, the deductible does not apply
to inpatient mental health care.
Copayment for PCP Visits Decreases
Specialist Visits Remain the Same
In 2004, the copayment for primary care physician (PCP)
office visits and specialist office visits will no longer be the
same. The copayment for PCP office visits will decrease from
$15 to $10 and the copayment for specialist office visits will
remain at $15. Please note, the specialist copayment applies
to outpatient mental health services and routine vision and
hearing exams, as well as specialty care.
Preventive Dental Services Discontinued for 2004
Preventive dental services, including oral exams, two clean-
ings per year and dental bitewing X-rays, will no longer be
covered in 2004.
Rx
Copayment
2003 Current
Effective January 1, 2004
RETAIL
Tier-1
Tier-2
Tier-3
MAIL
ORDER
Tier-1
Tier-2
Tier-3
$10 up to 30-day supply
$20 up to 30-day supply
$40 up to 30-day supply
$20 up to 90-day supply
$40 up to 90-day supply
$80 up to 90-day supply
$15 up to 30-day supply
$25 up to 30-day supply
$50 up to 30-day supply
$30 up to 90-day supply
$50 up to 90-day supply
$100 up to 90-day supply
[3] 2004 Benefit Update
nutritional counseling benefit for members. Members are now
covered for unlimited, medically necessary nutritional counseling
visits. For HMO members, and POS members seeking benefits
at the authorized level of benefits, primary care physician
authorization is required. For in-network level benefits, PPO
members must visit a contracting network provider. This change
does not automatically apply to self-insured employer groups.
Internet Pharmacies
If a PPO or POS member fills a prescription through an out-of-
network or u