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Some of your patients may have received a letter that reflects incorrect premium, copay, and/or deductible amounts. Current information, as received from the Centers for Medicare & Medicaid Services (CMS), is properly contained in the claims system. Beneficiary service is not affected by the letter. Community Care Rx (CCRx) is sending a revised letter to all affected beneficiaries.

We appreciate your continued support.
 

Community Care Rx would like to thank all pharmacists who participated in the CCRx Medication Therapy Management program under the Medicare Drug Discount Card. The CCRx Medication Therapy Management program under the Medicare Drug Discount Card will officially terminate for all beneficiaries effective Feb. 6, 2006.  After this date, no beneficiaries will be eligible for MTM services under the CCRx Medicare Drug Discount Card program. Pharmacists who perform MTM services under the CCRx Medicare Drug Discount Card program after this date will not be eligible for payment.

In addition, please note that once a beneficiary becomes active under any Part D plan, through any company, then that beneficiary is no longer eligible to receive benefits under the Medicare Drug Discount Card, including MTM services under the CCRx Medicare Drug Discount Card MTM program.  Pharmacists who perform MTM services under the CCRx Medicare Drug Discount Card program to non-eligible beneficiaries will not be eligible for payment.  Pharmacists will only receive payment for MTM services delivered prior to Feb. 6, 2006 to eligible beneficiaries who continue to participate in the CCRx Medicare Drug Discount Card program (i.e., beneficiary is not enrolled in Medicare Part D).

Based on the revised list of Medicare’s Top 100 drugs and with the addition of Crestor, the CCRx formulary now includes 96 of the Top 100 drugs.

For the four drugs that are on the Medicare Top 100 drug list but do not appear on the CCRx formulary, there are therapeutic equivalents that are covered.  When sending a copy of our Request for Coverage of a Nonformulary Drug to a physician, please also suggest preferred formulary alternatives for consideration.  Following is a list of commonly prescribed non-formulary medications and their CCRx therapeutic formulary equivalent.

• Lexapro-use citalopram (tier 1)
  
  
  • All SSRIs are considered to have equivalent efficacy and safety in the treatment of depression if comparable doses are given.
    
    
  • Escitalopram (Lexapro) is the S-isomer of its racemic parent compound, citalopram (generic Celexa).  It has not been shown to have significant advantages compared to citalopram or other formulary SSRIs.
    
    
  • Other tier 1 options include fluoxetine (generic Prozac) and paroxetine (generic Paxil).  Zoloft is available as a tier 2 option. 
    
    
• Pravachol or Lescol-use lovastatin (tier 1) or Zocor (tier 2)
  
  
  • Similar LDL reductions are achieved when equipotent doses are administered.  Lipitor is approximately twice as potent as Zocor, which is twice as potent as lovastatin and Pravachol, which are twice as potent as Lescol.  For example, Pravachol 20 mg or Lescol 40 mg provide similar LDL-lowering effect compared to 20 mg Lovastatin or 10 mg Zocor.
    
    
  • Use lower doses of lovastatin or simvastatin for patients with severe renal impairment.
    
    
• Prevacid capsules and Aciphex-use omeprazole capsules (tier 1), Protonix (tier 2), Nexium (tier 2), or Prevacid Solutabs (tier 3, requires PA)
  
  
  • Omeprazole 10 and 20 mg capsules are available as a generic product and allow for the greatest cost savings for the patient.  Avoid conversion to omeprazole if the patient is taking cyclosporine.
    
    

  • PPIs are considered to be effective, well tolerated and clinically interchangeable at therapeutically equivalent doses.  Omeprazole 20 mg, Protonix 40 mg, and Nexium 20 mg provide similar effect compared to Aciphex 20 mg or Prevacid 15 mg.  Omeprazole 40 mg, Protonix 80 mg, and Nexium 40 mg provide similar effect compared to Aciphex 40 mg or Prevacid 30 mg.

  • Dosing 30-60 minutes before meals and avoidance of H2 antagonists and antacids is necessary for optimal effect.

  • For uncomplicated GERD and dyspepsia, consider initial or step down use of high-dose H2 antagonists as a more affordable alternative to PPIs (e.g., famotidine 40 mg BID or ranitidine 300 mg BID).  Adjust dose for renal dysfunction.
    

• Avapro, Benicar, Micardis, Tevetan-use Diovan or Cozaar (Tier 2)
  
  
  • ARBs should be reserved for patients for whom an ACE inhibitor is indicated, but not tolerated.
    
    
  • All ARBS are indicated for and considered comparably effective for the treatment of hypertension.
    
    
  • The formulary agents Cozaar and Diovan have a greater number of indications.  The nonformulary agents Micardis, Benicar, and Tevetan are only indicated for treating hypertension.
    
    
• Mobic:  use etodolac, nabumetone, or other formulary NSAIDs
  
  
  • Evaluation of patients receiving MOBIC reveals only a slight decrease in gastrointestinal events compared with traditional NSAIDs. Increased risk of GI toxicity exists with Mobic> 7.5mg
    
    
  • There is no convincing evidence that the risk of the severest adverse gastrointestinal events is lower with meloxicam than with other NSAIDs when given at equi-effective doses.
    
    
  • For patients with high gastrointestinal risk (e.g., elderly, chronic use of oral steroids, previous hospitalization for GI bleed or ulcer): consider non-NSAID therapy (e.g. acetaminophen, tramadol, opioid) or low-risk (e.g., etodolac, nabumetone, salsalate) or average-risk (e.g., ibuprofen, naproxen, sulindac) NSAIDs + omeprazole 20 mg daily.
    
    
  • Patients with cardiovascular risk factors such as a prior myocardial infarction, hypertension, or congestive heart failure:  Attempt traditional NSAIDs or non-NSAIDs first.  Celebrex (celecoxib) should not be prescribed for patients with cardiovascular disease and is associated with the same rate of clinically significant GI events as diclofenac and ibuprofen.  Celebrex 100 mg and 200 mg requires step therapy (previous trial of formulary NSAID). Celebrex 400 mg requires prior authorization.
    
    
• Travatan (travoprost)-use Lumigan or Xalatan (tier 2)

Pharmacists are taking advantage of the dynamic PA instituted by CCRx until further notice. Unfortunately, this is resulting in the dispensing of many expensive brand medications when an equally effective generic is available. This is significantly increasing cost liability.

Please dispense the generic equivalent or a generic therapeutic alternative whenever possible and therapeutically appropriate for the patient. OxyContin tablets and Duragesic patches are the two leading, costly medications pharmacists are dispensing using the dynamic PA when a less expensive, equally effective alternative is available.
 

Please remember the following medications are excluded by Medicare and not covered by CCRx.  Formulary exception requests will not be approved, and the dynamic PA cannot be used for:

• barbiturates and benzodiazepines
• vitamin and mineral products, e.g., folic acid (exception:  prenatal vitamin and fluoride preparations not excluded)
• drugs when used for symptomatic relief of cough/cold, cosmetic purposes, hair growth, fertility, anorexia, weight loss, or weight gain (except AIDS wasting or cachexia)
• nonprescription drugs and diabetes supplies (except syringes, needles, and gauze for administration of insulin)
• drugs for which coverage is available under Medicare Part B (e.g., nebulized medications administered in the patient’s home)

CCRx has removed the need for prior authorization for the following select agents. The PA forms for these medications are being removed from CCRx.net.

• Duragesic
• Gleevec
• Hectorol
• Hydromorphone
• MAOI
• Marinol
• Targretin
• Zyvox

Effective immediately, please discard any PA forms you may have for these medications. The claims for these medications will now adjudicate at the point of sale without a PA message.
 

CMS expects that Part D plans will require their pharmacies to maintain prescription records in their original format for the greater of three years or the period required by state law, and permit the records to be transferred to an electronic format that replicates the original prescription (such as a digitized image) for the remaining years of the 10-year Part D retention period.

This requirement for retention in original format applies only to prescription records; all other records that must be maintained for Medicare under Parts C and D should be retained in the format(s) required by either state law or the HIPAA Privacy Rule, if applicable, or at the plan’s discretion. CMS reserves the right to revisit this requirement in the future.
 

When processing claims for beneficiaries, the states should remain the payer of last resort. Pharmacies are encouraged to fill beneficiaries’ prescriptions using their Part D coverage first and should follow the steps outlined below to do so:

1. Check for enrollment of the beneficiary in a Part D plan by asking for a plan ID card or letter, submitting an E1 eligibility query, or calling Medicare’s dedicated pharmacy line at 866-835-7595.

2. If the individual is enrolled in a plan but is not being charged the correct dual eligible copayment amounts, contact the drug plan. If the situation is urgent, and you are unable to reach the plan, call Medicare’s dedicated pharmacy line for urgent caseworker assistance for the beneficiary.

3. If there is no evidence of a Part D plan enrollment, but there is clear evidence of both Medicare and Medicaid eligibility, then the pharmacist should bill the point-of-sale contractor for the claim.

4. Only when the pharmacist is unable to complete items 1-3 should the State Medicaid system be billed for a short-term, temporary period.