2010 Prior Authorization and Formulary Changes

We want to alert you to changes coming for prior authorization and the RegenceRx formulary regarding certain chemotherapy medications. In addition, there are changes to the formulary and prior authorization for Asuris TruAdvantage and Medicare Part D prescription drug plans.

bortezomib (Velcade^®)

cetuximab (Erbitux^®)

Prior authorization required for Asuris members

• Starting treatment with bortezomib (Velcade) or cetuximab (Erbitux) after February 1, 2010.
• Members treated with either of these medications before February 1, 2010 will not need prior authorization for coverage.
• Prior authorization criteria for bortezomib (Velcade) and cetuximab (Erbitux) and supporting scientific evidence are available in our medication coverage policies.

bevacizumab (Avastin^®)

pemetrexed (Alimta^®)

rituximab (Rituxan^®)

Prior authorization required for Asuris TruAdvantage members

• Brand-name chemotherapy will only be able to be covered if it is administered according to Centers for Medicare & Medicaid Services (CMS) guidance.
• Specifically, chemotherapy will only be able to be covered for conditions that are acknowledged in national compendia that are recognized by CMS, such as the National Comprehensive Cancer Network (NCCN). “Off-label” use of chemotherapy that is not recognized by national oncology treatment guidelines will not be eligible for coverage for Asuris TruAdvantage members and subject to prior authorization.

If you have questions or need additional information, please call Pharmacy Customer Service at 1-800-643-5918.

As part of the changes for our Asuris TruAdvantage +Rx Classic and Asuris TruAdvantage +Rx Enhanced products we are making the following changes to the Medicare Part D formulary and prior authorization requirements effective January 1:

• Approximately 75 medications have been removed from the formulary. These are either brands that have exact generic equivalents or brands with current formulary alternatives.
• Approximately 17 additional drugs will require prior authorization.

Members currently on any of these medications must switch to a formulary alternative or seek an exception for 2010. This provides an opportunity for members to request continued coverage of non-formulary medications when medically necessary and/or consider formulary options to lower his or her out-of-pocket expense.

Review our current formulary, transition policy, and prior authorization requirements for additional information.