Medical

Preferred/Non-Preferred classifications are subject to change during quarterly pharmaceutical review.

MEDCO Preferred Drug Step Therapy Program

Preferred Drug Step Therapy is a program that promotes generic and preferred brand medications as first line therapy. Therapeutically equivalent generic or preferred brands are required before non-preferred drugs unless the physician provides clinical support for the non-preferred drug. This program focuses on prescriptions written for the following medications:

• Prevacid
• Aciphex
• Zegerid
• Protonix
• Prilosec 40mg

• You lower your out-of-pocket cost by using the OTC, Generic or Preferred brand.
• Your physician must approve any change or provide clinical explanation for the non-preferred drug.

• Human Growth Hormones: Protropin, Humatrope, Geref, Genotropin, Norditropin, Nutropin, Saizen, Serostim
• Hormone Agents: Crinone 8%, Lupron, Factrel, Lutrepulse, Synarel
• Immune Globulins: Gamimune, Gammagard, Gammar-IV, Sandoglobulin, Venoglobulin
• Anti-Psoriasis: Raptiva
• Anti-Obesity Agents: Xenical, Meridia, Tenuate & generics, phentermine
• Asthma:Xoliar
• Respiratory Syncytial Virus (RSV) therapy:Synagis, RespiGam
• Cancer Therapy:Iressa, Gleevec, Tarceva
• Irritable Bowel Syndrome (IBS):Lotronex, Zelnorm
• Acromegaly:Somavert
• Interferons:Actimmune, Infergen, Roferon, Intron, Intron-A, Alferon, Rebetol, Rebetron, PEG-Intron, Pegasys
• Erythroid Stimulants:Epogen, Procrit, Aranesp
• Multiple Sclerosis Agents:Betaseron, Avonex, Rebif, Copaxone
• Myeloid Stimulants:Neupogen, Leukine, Neulasta
• Platelet Growth Factor:Neumega
• Immunomodulatory Agents:Thalomid
• Acne & other dermatologicals: Accutane, Retin-A, Avita for ages 36 and over

Medications requiring authorization to obtain additional supplies (Contact Medco Health to request a Smart Prior Authorization):

• Onychomycosis Therapy: Sporanox, Lamisil, Diflucan, fluconazole
• Anti-Virals:Acyclovir, Famvir, Valtrex, Zovirax
• Pain Management:Actiq
• Rheumatoid Arthritis:Humira, Enbrel

Medications requiring authorization based on drug history (Contact Medco Health to see if authorization is required):

• Pain Management:Actiq
• Antidepressant Therapy: Wellbutrin SR, bupropion SR
• Rheumatoid Arthritis:Enbrel, Humira, Kineret, Arava, Remicade
• Dermatological Agent:Elidel, Protopic

Medco also offers Health Management programs for certain participants, based on your prescription history. The Health Management programs are included as part of the UT SELECT prescription drug program and are available at no additional cost. The Health Management programs provide educational materials and expert knowledge about many chronic medical conditions including:

• Diabetes
• Hypertension
• Respiratory Disease

You may read additional information about pharmacy plan features and exclusions in the Medical Plan certificates available from your campus Benefits Office or online at www.utsystem.edu/benefits.

UT Medical Plans and Medicare

The University of Texas System urges all retired employees and dependents to enroll in Medicare Part B when they become eligible at age 65 or earlier if they are eligible due to a disability. As a Medicare-eligible individual, you and your Medicare-eligible dependents have the option of enrolling in Part A and refusing Part B coverage. If you are a retired employee or will soon become a retired employee or the dependent of a retired employee and are eligible for Medicare, you must have Medicare Part B to receive the maximum benefits available from a UT medical plan option.

In most instances, if you are eligible for Medicare and are working in a position for at least 20 hours per week, your UT medical plan will be primary, and Medicare will be secondary. Medicare may be primary for some Medicare-eligible active employees with certain medical conditions. Consult with your local Social Security Administration office to learn what illnesses qualify for Medicare coverage prior to turning age 65.

If you are retired and also eligible for Medicare, Medicare becomes your primary payer and pays your medical claims first. UT SELECT pays second. If you choose a doctor who accepts Medicare assignment, you will not be responsible for any difference between the billed charge and the Medicare allowed amount.

If you decline Part B, you will have to pay a higher premium if you ever re-apply for Medicare coverage later. In addition, without Medicare Part B, you become responsible for paying any share of your and your Medicare eligible dependents’ medical claims that Medicare Part B would have covered. As a retiree, if you or your Medicare eligible dependent have declined Medicare Part B, you will be required to pay the portion that Medicare Part B would have paid as primary insurer for Part B-covered items for yourself and any Medicare eligible dependents.

In order to assure that claims are correctly processed, you should contact Blue Cross and Blue Shield of Texas and report your or your dependent’s Medicare Health Insurance Claim (HIC) number and the effective dates of Medicare Parts A and B immediately upon enrollment.

If you or your dependents are enrolled in Medicare and your doctor accepts Medicare assignment:

• The doctor may be in or out of the UT SELECT Network
• For HMO Blue Texas, the doctor must be in the HMO Blue Texas network
• UT SELECT will pay 100% of benefits approved but not paid by Medicare (subject to UT SELECT plan limitations)
• No Deductibles
• No Copayments
• No Coinsurance
• When you or your dependents are an inpatient at a facility that accepts Medicare assignment, UT SELECT will pay the Medicare inpatient deductible, and the $100 per day Copay ($500 maximum) will not apply.

If your doctor does not accept Medicare assignment:

• Network and out-of-network benefits apply
• UT SELECT will coordinate with Medicare
• Deductibles may apply
• Copayments may apply
• Coinsurance may apply

¹All services are subject to HMO Blue referral and authorization requirements.
²The difference between BCBS Allowed and Billed Charges may be paid if that amount is in available COB Savings.
³A Provider who does not participate with Medicare may not bill more than the Medicare Limiting Charge (115% of MC Allowed).

Your Medical Plans and Medicare Part D

On January 1, 2006, Medicare beneficiaries will be eligible for a new Medicare-approved prescription drug benefit. The University of Texas System continues to offer your current prescription drug benefit. Enrollment in Medicare Part D will have a negative financial impact for most UT participants.

UT strongly urges you NOT to enroll in the Medicare Part D program.UT is committed to providing your prescription drug coverage in 2006 and beyond and to helping you make informed choices about your prescription drug benefit. For a relatively small amount of very low income retirees, enrolling in Medicare Part D plan may save them money if they also qualify for a “low income subsidy” provided as part of the Medicaid Part D Program. For more information about the low income subsidy visit www.socialsecurity.gov or call 1-800-772-1213.

If you choose to enroll in a Medicare plan, you will not be eligible to also have a policy that offers prescription drug coverage. You can keep your UT prescription policy only if you do not enroll in the Medicare Prescription Drug Coverage.

You may find additional information about the Medicare Part D program at www.cms.hhs.gov/medicarereform.