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PARTICIPANTS OF THE FRESNO UNIFIED SCHOOL DISTRICT EMPLOYEE HEALTH CARE PLAN SUBJECT: EMPLOYEE HEALTH CARE PLAN AMENDMENT 2012-2
The Joint Health Management Board of the Fresno Unified School District has modified the Plan Document regarding
Prescription Drug coverage to amend two existing Step Therapy (PPI & Statin) criteria to ensure they meet the most current
clinical standards and practices.
Effective October 1, 2012, the following Step Therapy Regimen changes have been implemented:
PPI Step Therapy: Generic Omegrazole will now move to a step 1 agent while the brand-name drugs remain as a Statin Step Therapy: Generic Atorvastiatin will now be added as step 1 agent and Livalo will be added as a step 2
This notice defines changes to the FRESNO UNIFIED SCHOOL DISTRICT EMPLOYEE HEALTH CARE PLAN. .
The language set forth below replaces the Step Therapy provisions on pages 41 through 44 of the Plan Document dated
April 1, 2012:
Step Therapy for Over the Counter “OTC” Drugs
There are more and more drugs that can now be purchased OTC that previously required a Physician’s written prescription.
Two such drugs that now have OTC equivalents are:
Also known as Proton Pump Inhibitors (PPI): treats stomach-related conditions, including heartburn. (Brand-Name Prescription Drugs include: Aciphex, Nexium, Prevacid, or Protonix.) Non-Sedating Antihistamine: treats allergy symptoms. (Brand-Name Prescription Drugs include: Allegra, Allegra-D, Clarinex, Clarinex-D, Clarinex RediTab, Zyrtec and Zyrtec- D.)
The Plan will require: Step Therapy for Brand-Name Prescription Drugs prescribed for Proton Pump Inhibitors and Non-
Sedating Antihistamines in order to be covered by the Plan and to promote proper utilization of these medications. There
are certain exceptions.
How Do I Receive “OTC” Step Therapy?
You should discuss with your Physician your Step Therapy options. Generally, Step Therapy requires that the patient try
one of the OTC/Generic drugs listed above before a Brand-Name Prescription Drug will be authorized. Note: There are
certain medical conditions where the patient will not have to obtain Step Therapy in order to receive medication.
In order for the Plan to cover any of the Brand-Name Prescription Drugs noted above, you or your Physician must receive
PRIOR authorization/approval from EnvisionRx Options by calling the Help Desk to begin the prior authorization process:
Make sure you (or your Physician) have available: the name of your medication, the Physician’s name and phone number
(and fax number, if possible), and your member ID number.
Step Therapy For Brand Sleep Agents, Cholesterol/Statins, Antidepressants, and Biphosphonates
How Do I Receive Step Therapy for the Above Medications?
In step therapy, medications are grouped into categories.
1st Step – First Line medications: mostly generic medications proven safe, effective, and affordable. These medications should be tried first. 2nd Step – Second Line medications: mostly higher brand-name medications
Step therapy is a process to ensure you are receiving a cost effective therapy. Under this program, you will be required to
first try a recognized First Line medication (Step 1) before approval of a more costly and complex therapy is approved
(Step 2). If the Step 1 therapy does not provide you with the therapeutic benefit desired, your physician may write a
prescription for a Second Line medication. Generally, Second Line medications require the usage and failure of a First
Line medication before coverage is authorized. The Step Therapy approach to care is a way to provide you with savings
without compromising your quality of care.
What Medications have Step Therapy?
The following medications are subject to Step Therapy:
REQUIRED STEP THERAPY REGIMENS
If you’ve been prescribed
Criteria for Coverage and First Line Medications
Second Line Medication/Class
Must have tried and failed a generic agent prior to use Zolpimist
Must have tried and failed statin therapy prior to use of Altoprev
Must have tried and failed a generic product prior to coverage of a branded Antidepressant. Cymbalta
Must have tried and failed Alendronate prior to coverage of branded Boniva or Actonel. Boniva/Actonel
Note: The above medications requiring Step Therapy will be updated from time to time. You will be advised of future
changes prior to the implementation date.
What Should I do if I Take a Medication that is Part of the Step Therapy Program?
It’s easy – if your physician writes a new prescription for a medication that is part of the Step Therapy Program, he/she will
need to write you a prescription for a First Line medication. You may request that your pharmacist call the doctor for you
and ask him to change to a First Line medication; or have your physician submit a prior authorization request for your
current prescription before you can continue to receive coverage for the medication. A prior authorization is a request to
the physician to document why you cannot take a First Line medication and must use a Second Line medication. You or
your physician can begin the prior authorization process by contacting the EnvisionRx Options Help desk at (800) 361-
IMPORTANT: Always talk to your doctor before discontinuing or changing any medication. As your pharmacist or doctor
about First Line Medications and discuss the Step Therapy medications on your benefit plan.
Ask your Doctor to write a prescription for one of the over the counter or generic medications listed above, and you will only be charged a $10 Copayment. If you use a Brand-name drug and have received a Clinical Prior Authorization from EnvisionRx Options, your Copay will be $35 and the Plan will cover the remaining cost. If you use a Brand-name Drug and DO NOT receive EnvisionRx Options Clinical Prior Authorization, you will be responsible for the full cost of the drug and the Plan will NOT cover any portion of it.
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