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Metro Expansion End of Transition Updates

May 01, 2018

Download this info as a PDF

Key Highlights:

  • Usage of out-of-network Walgreens Pharmacy has decreased significantly from ~35% pre-transition to 9% as first week of April.
  • Over 4,000 members used transition benefits to get their medicines without disruption in coverage.
  • Benefit changes made for Medicaid:
    • PA removals (Examples: fluticasone nasal spray, Montelukast oral tablets, and injectable testosterone vials)
    • Formulary additions (Examples: rosuvastatin, finasteride, MVI/FL chewable with AR)


Staged Transition Plan

  • High cost and/or specialty drugs, low utilized NF drugs will need to go through the PA process (Examples: Lyrica, Vyvanse, sidenafil). Estimated PA volume is in the range of 20-25/day. (See Appendix for potential member impact at your clinic or system clinics.)
  • Lower cost drugs paid under transition will continue to be covered until 11/01/18. (Examples: Premarin, Diclofenac gel 1%, clobetasol 0.05% ointment) and 05/01/19 (Examples: minocycline, lansoprazole).


What do we need from you now?

  • Switch to CareOregon preferred formulary agents when it is clinically appropriate, examples: o Lantus vials àBasaglar pens
    • Topical testosterone à generic testosterone inj.
    • Partner with your clinic pharmacists (where available) to switch patients to CareOregon formulary agents and network pharmacies
  • Products that are not covered on CareOregon formulary:
    • cough and cold products
    • branded bowel prep.
    • Melatonin
    • Lidocaine patch or Lyrica used for non-FDA approved indications or “Below-The-Line” conditions


CareOregon Pharmacy Resources


Oregon Health Plan (OHP) Benefit:


Prioritized List: http://www.oregon.gov/OHA/HPA/CSI-HERC/Pages/Prioritized-List.aspx

Formulary Look up tool:

Formularies on CareOregon Website (PDFs)

Medicaid: http://www.careoregon.org/Providers/PharmacyHelpDesk/FormularylistAndUpdates.aspx

Medicare: http://www.careoregonadvantage.org/providers/rx-and-drug-information

Prior Authorization (PA) Look up:


Criteria and PA forms:

http://www.careoregon.org/Providers/ProviderFormsandPolicies.aspx

List of Injectable Drugs Requiring PA: 

http://www.careoregon.org/Providers/PharmacyHelpDesk/FormularylistAndUpdates.aspx

Pharmacy Contact information:


Customer Service: 503-416-4100 (M-F: 8:00 am – 5:00 pm)

Option 3 for provider, then option 2 for pharmacy staff, then option 1 for pharmacies or option 2 for providers

PA Fax: 503-416-8109

Injectable Drugs PA Fax: 503-416-4722

Appeals Fax: 503-416-1428 


DME No auth required: 

http://www.careoregon.org/Res/Documents/Providers/DME_HCPCS_Code_List.pdf


Appendix

Table 1. Top Impacted Products


* Drugs

#Mbrs

Alts or PA tips

VYVANSE

174

Generic Adderall IR or Generic Ritalin IR; generic ER products also require PA but preferred prior to Vyvanse

LYRICA

109

Alts: gabapentin, TCAs, duloxetine. Not covered for non-FDA approved indications or “Below-The-Line” conditions, such as fibromyalgia.

SILDENAFIL

58

Covered for PAH only; ED is excluded (do not submit PA)

TACROLIMUS TOPICAL

31

Most skin conditions not covered unless BSA 10%

HUMIRA PEN

25

PA required from specialist

BRAND EPI-PEN

25

Generic Epinephrine auto-injectors covered without PA

XIFAXAN

20

Covered for hepatic encephalopathy only.

OXYCONTIN

17

PA required.

PANCREATIC ENZYMES

17

Documented Pancreatic Insufficiency required

TESTOSTERON TOPICAL

14

Failure of injections required.

JARDIANCE

13

Alts: metformin, sulfonylureas, pioglitazone

STIOLTO

11

PA for COPD confirmation required

ALBENZA

10

Alt: Pin-X/Reese’s Pinworm

CALCIPOTRIEN

10

Most skin conditions not covered unless BSA 10%

NF METFORMIN

10

Alts: Metformin ER 500 and 750 mg tabs

MOMETASONE

10

Alts: triamcinolone

ESOMEPRA MAG

10

Alts: omeprazole and pantoprazole

LANTUS VIALS

232

Alt: Basaglar