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Provider Resources

November 2019

Table of Contents

Employer Group and Individual and Family Plans Patient Assurance Program Offers $25 Insulin
Medication Highlights
Statin Misconceptions
CCUM Portal
Medicare Vaccination Coverage
New Generics Released in 2019
Pharmacy Benefit Manager (PBM) CHANGE for 2020
Quantity Limit/Day Supply Edit on Opioid Medications
Contact Network Health Pharmacy Department
Pharmacy Review
Preferred Drug List

Employer Group and Individual and Family Plans Patient Assurance Program Offers $25 Insulin

Network Health strives to increase accessibility and affordability of medications for our members. Beginning January 1, 2020, Network Health will introduce the Patient Assurance Program for members with insulin-dependent diabetes who have employer group or individual and family plan coverage—excluding certain self-insured groups and transitional grandmothered and grandfathered plans. Eligible members are automatically enrolled in the program, which offers preferred insulin for $25 for a 30-day supply or $75 for a 90-day supply.

Key Takeaways

  • Preferred insulin products for 2020 employer group plans include Basaglar, Novolog, Novolin (excluding the Relion brand available at WalMart pharmacies).
  • Preferred insulin products for 2020 individual and family plans are Lantus, Humalog, Humulin.
  • This benefit is available to members at either in-network retail pharmacies or through ESI mail order.
  • Eligible members are automatically enrolled in the program.
  • Copayment is reduced to $25 at point of sale for a 30-day supply or $75 for a 90-day supply, regardless of plan design.
  • No coupons, additional enrollments or forms required to participate
  • Most members will see a 40 percent—or more—reduction in out-of-pocket costs on preferred insulin products.

Pharmacy and Therapeutic Changes for July and September

  Comment Preferred Brand Non-Preferred Brand Preferred Specialty Non-Preferred Specialty
Cablivi PA1     M, C  
Elzonris PA     M C
Inbrija QLL2     M C
Krintafel PA   M, C    
Motegrity QLL3   M, C    
Balversa PA, QLL     M C
Diacomit ST4, QLL     M C
Evenity ST, QLL   M, C    
Mavenclad PA, QLL M C
Mayzent PA, QLL M C
Skyrizi PA, QLL C
Vyndaqel PA, QLL     M C


C indicates commercial preffered drug list (PDL) status
PA indicates that prior authorization is required
ST indicates that the medication is part of a step-therapy protocol
QL indicates a quantity limit
M indicates Medicare PDL status

Footnotes:
1. PA for Commercial only; 2. QLL for Commercial only; 3. QLL for Medicare only; 4. ST for Medicare only

Statin Misconceptions

Patients may be hesitant about taking statin medications due to misconceptions about this drug class. In some cases, patients may have experienced side effects from aStatin Misconceptions
Patients may be hesitant about taking statin medications due to misconceptions about this drug class. In some cases, patients may have experienced side effects from a certain statin or dose and are cautious about trying a different statin. Patients may be more willing to try statins if you suggest the “start low and go slow” approach. Consider starting a patient on a statin once or twice a week or prescribing at the lowest daily dose and working closely with the patient to get the dosage right.
Network Health has the following resources to combat common statin myths. Please share these freely with patients.

  1. Statins are all hype with little benefit
  2. Statins will cause diabetes
  3. Statins will cause muscle pain
  4. Statins aren't needed if cholesterol levels are okay
  5. Statins will cause dementia
  6. Other prescriptions used to lower cholesterol are as good or better than statins
  7. Over-the-counter products, like red yeast rice, are a better alternative to statins

CCUM Portal

Express Scripts Care Continuum (CCUM) is Network Health's vendor for medical drug prior authorization (PA). This partnership has been in place since May 1, 2019, and has streamlined the PA process, improving efficiency and turnaround time for all parties involved. As a reminder, CCUM is specific to medical drugs—which excludes anything self-administered or with an oncology use—and serves Medicare, employer group and individual and family plan business.

Medical drug requests can be submitted through the ExpressPAth portal located in the Network Health provider portal. For ExpressPAth navigation assistance, visit the tutorial page.

Network Health strives to make the PA process as easy and efficient as possible. If you have any feedback or suggestions for improvement, please feel free to reach out to Andy Wheaton, PharmD at 920-720-1612, awheaton@networkhealth.com or send a message through the provider portal to share your input.

Medicare Vaccination Coverage

Medicare vaccinations can fall under Part B or Part D coverage. See below for a breakdown of which part covers specific vaccines.

Medicare Part B covers these vaccines.

  • Hepatitis B vaccine for patients at high or intermediate risk
  • Influenza vaccine
  • Pneumococcal vaccine (e.g. Prevnar13 and Pneumovax 23)
  • Vaccines directly related to the treatment of an injury or direct exposure to a disease or condition (such as receiving a tetanus shot after suffering a puncture wound)

Medicare Part D covers these vaccines. These should be administered at the pharmacy so the patient can have the lowest cost.

  • Does not cover any vaccines already covered under Medicare Part B
  • Covers all other commercially available vaccines as long as it is deemed reasonable and necessary to prevent illness
  • Examples include Shingrix, tetanus boosters, which are not used for treatment, injury, or direct exposure to a disease

For additional questions related to reimbursement of vaccines, please visit this fact sheet.

New Generics Released in 2019

Several common generic medications were launched in 2019. Generics tend to be priced considerably lower than brand names and are on a lower tier of the patient’s pharmacy formulary. However, there may be significant cost variability depending on the manufacturer and retail pharmacy. An excellent resource for consumers to price out medications is GoodRx.com. Below is a list of common drugs with generic versions launched in 2019.

Brand Name
Generic Name Generic Launch Date
Rozerem Ramelteon 7/22/19
Lyrica Pregabalin 7/19/19
Vesicare Solifenacin 4/22/19

Proventil HFA
Proair HFA
Ventolin HFA

Albuterol HFA

4/4/19
1/17/19
1/15/19

Suboxone film

Buprenorphine-Naloxone sublingual film

2/19/19

Advair Diskus*

Fluticasone/salmeterol diskus or Wixela

2/8/19


*Ingredient cost for generic AirDuo RespiClick (fluticasone/salmeterol RespiClick) is significantly lower than generic Advair Diskus and may represent the best value for a patient who is willing to switch.

Pharmacy Benefit Manager (PBM) CHANGE for 2020

On January 1, 2020 Network Health will transition to Express Scripts (ESI) as the manager for formulary and PA requests. Currently, we use ESI for the Medicare line of business—those PA contact numbers remain the same. We will provide new contact information for PA requests for employer groups and individual and family plans. Formulary changes for 2020 will be included in the next issue of The Script. Please contact a Network Health pharmacist at 920-720-1287 if you have any questions about this change.

Quantity Limit/Day Supply Edit on Opioid Medications

All three Network Health formularies have a quantity limit or day supply edit on opioid medications. The quantity limits are based on the Food and Drug Administration (FDA) approved maximum day supply for each medication. If a patient is using more than that recommended dose, you must call for a PA, so the prescription can be filled in a timely manner.

Prescribing Tip
Mark the maximum number of tablets or capsules per day on the prescription. For example, a prescription can be written as one to two tablets every four to six hours as needed for pain. Dispense #30 can be entered two ways at the pharmacy. This example allows a three-day supply assuming two tablets are taken around the clock. If the prescription specifies a maximum of 6 tablets per day, the pharmacy enters a five-day supply.
Knowing the maximum number of doses per day is helpful for both the patient and the pharmacist. The patient knows how many pills to take per day and the pharmacist can more accurately consult with the patient. By writing the prescription this way, fewer prescriptions may be denied based on the clinical review edits that are in place for opioids. Be sure to check the Prescription Drug Monitoring Program website for prescriptions written by other providers and filled at multiple pharmacies.

Contact Network Health Pharmacy Department

A pharmacist at Network Health is always available to help your office staff with any pharmacy-related questions. The pharmacist contact information is listed below.

Pharmacy Review

If you have questions about the 2020 pharmacy prescription benefits for Network Health members, or questions about websites where members can obtain information on patient assistance programs to help cover cost of medications, please contact Gary Melis at gmelis@networkhealth.com or 920-720-1696. Gary is available for office visits to discuss any pharmacy-related topics with pharmacy staff. 

Preferred Drug List

Network Health’s most up-to-date Preferred Drug List can be found at networkhealth.com/look-up-medications. Currently, both the 2019 Preferred Drug List and the 2020 Preferred Drug List are available. To view drugs on the 2020 list, members can select 2020 HMO/POS/EPO (I get coverage through my employer) from the Choose a Plan dropdown.

If you are not a current subscriber to The Script and you would like to be added to the mailing list, please email us today. Current and archived issues of The Pulse, The Script and The Consult are available at networkhealth.com/provider-resources/news-and-announcements.

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November 2019
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Contact Network Health Pharmacy Department

A pharmacist at Network Health is always available to help your office staff with any pharmacy-related questions. They can be reached at  apeterso@networkhealth.com, bcoopman@networkhealth.comgmelis@networkhealth.com, awheaton@networkhealth.com or tregalia@networkhealth.com.

Pharmacy Review

If you have questions about the 2019 pharmacy prescription benefits for Network Health members, or questions about websites where members can obtain information on patient assistance programs to help cover cost of medications, please contact Gary Melis at gmelis@networkhealth.com or 920-720-1696. Gary is available for office visits to discuss any pharmacy-related topics with pharmacy staff.

Preferred Drug List

Network Health’s current Preferred Drug List is available from multiple electronic sources. It can be viewed and printed from networkhealth.com in the Prescription Benefit section.


THE SCRIPT is a publication of Network Health.

Editor: Gary Melis, RPh. gmelis@networkhealth.com
Co-Editor: Anna Peterson Sanders, Pharm.D. apeterso@networkhealth.com

The information herein is provided with the understanding that Network Health is not rendering pharmacy advice, medical advice or other professional services. If pharmacy advice, medical advice or other professional services are required, an appropriate professional should be consulted.


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