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Michigan Department of Community Health PO Box 30752 Lansing MI 48909

March 5, 2010

Dear Beneficiary:

This letter applies only to Medicaid beneficiaries in the household who are age 21 and older and are in a health plan.

Starting April 1, 2010, Medicaid will pay for some medicines instead of your health plan. Your pharmacy knows what medicines Medicaid will pay for and what medicines your health plan will pay for.

When you go to your pharmacy to get more medicine you will need to show both your green mihealth card and your health plan card.

Starting April 1, 2010, you will have a co-pay if you need one of the medicines on the list that came with this letter. You will have a co-pay even if your health plan did not have a co-pay for the same medicine.

Your co-pay will be $1.00 for generic medicines or $3.00 for brand name medicines. Your pharmacy can tell you if your medicine is a generic or a brand medicine.

Your pharmacy can tell you how much your co-pay will be. You can call the First Health Beneficiary Help Line toll-free at 1-877-681-7540 to ask about co-pays.

Some medicines on the list may need to be approved by Medicaid. They will need to be approved before your pharmacy can give you the medicine. If your medicine needs to get approved by Medicaid, your doctor will get that approval.

If you have questions about this letter, you can:

• Call Member Services at your health plan, • Call First Health Services Beneficiary Help Line toll-free at 1-877-681-7540, • Call the Medicaid Beneficiary Help Line toll-free at 1-800-642-3195, or • Ask your pharmacy.

Medicaid is making this change because of the rebate law found in Section 1927 of the Social Security Act (Payment for Covered Outpatient ).

If your co-pays or Medicaid approval for your medicines (also called prior authorization) have changed because of the drug rebate law, you do not have a right to a hearing.

CAPITOL COMMONS BUILDING • 400 SOUTH PINE • LANSING, MICHIGAN 48909-7979 B 10-02 www.michigan.gov • 1-800-642-3195

B 10-02 March 5, 2010 Page 2

If you think your co-pays or Medicaid approval for your medicines (also called prior authorization) have changed for a reason other than the drug rebate law, you may request a hearing. Hearing requests must be made in writing to the State Office of Administrative Hearings and Rules within 90 calendar days of the date of this notice. The written hearing request must be signed by you or an authorized person and include you or your authorized person’s name, address, and telephone number.

If you have the right to a hearing, you can call the Beneficiary Help Line toll-free at 1-800-642-3195 to get a “Request for Hearing” form. The written request or the form must be mailed to:

State Office of Administrative Hearings and Rules for the Michigan Department of Community Health P.O. Box 30763 Lansing, Michigan 48909

You may call the State Office of Administrative Hearings and Rules (SOAHR) toll-free at 1-877-833-0870, if you have questions about hearings.

Sincerely,

Stephen Fitton, Director Medical Services Administration

Michigan Department of Community Health List of medicines that Medicaid will pay for instead of your health plan starting April 1, 2010 NAMES

40 WINKS AMPHET RESIN/ BUSPAR COMPOZ ACABAMATE DEXTROAMPHETAMINE HCL CONCERTA ACETAMINOPHN/DP-HYDRAM AMPHET SULF/ COPROBATE HCL/NIA DEXTROAMPHETAMINE BUTABARBITAL NA/M-AMPHT HCL CYLERT ADAPIN AMPHET SULF/D-AMPHET/ BUTABARBITAL SODIUM CYMBALTA ADDERALL M-AMPHT BUTA-KAY DALMANE ADDERALL XR SALT COMBO DALPRO AID TO SLEEP AMPHETAMINE SULFATE BUTALIX DARO AID TO SLEEP AMYTAL SODIUM BUTATRAN DAS W/ ANAFRANIL BUTISOL SODIUM DAYTRANA ANITSPASMATIC CAL GLUCONATE/NIA/NIAC/PB DEANOL ALPRAZOLAM ER ANTISPASMODIC CALM-AID DECONIL ALPRAZOLAM INTENSOL APLENZIN CALMIUM DEPACON ALPRAZOLAM XR A-POXIDE DEPAKENE ALTERRA CARBAMAZEPINE XR DEPAKOTE AMBIEN AQUACHLORAL CARBATROL DEPAKOTE ER AMBIEN CR ARMODAFINIL DEPAKOTE SPRINKLE AMBIEN PAK ASENDIN CDP DEPA-SYRUP AMITID ASPIRIN/ACETAMINOPHEN/ PYRIL CEBERCLON DEPROIC AMITRIP HCL/ ATIVAN CELEXA HCL HCL HCL CELONTIN DESOXYN AMITRIPTYLINE HCL ATRETOL CENTRUM ST. JOHN'S WORT DESOXYN GRADUMET AMITRIPTYLINE W/ AVENTYL HCL CEREBYX SUCCINATE PERPHENAZINE B.B.S. CHAMOMILE FLOWERS DESYREL AMITRIPTYLINE/ BANZEL CHLOR POX 10 DEXAMPEX CHLORDIAZEPOXIDE BARBASED CHLOR POX 25 DEXEDRINE AMITRIPTYLINE- BARBITA CHLOR POX 5 HCL CHLORDIAZEPOXIDE BELLADONNA W/ HYDRATE DEXMETHYLPHENIDATE HCL AMITRIPTYLINE-PERPHENAZINE BELLASTAL CHLORDIAZEPOXIDE DEXTROAMPHETAMINE SULFATE AMMONIA BENACTYZINE CHLORDIAZEPOXIDE HCL DEXTROAMPHETAMINE- AMMONIA AROMATIC HCL/ AMPHETAMINE AMMONIUM/SODIUM/POTASSIUM BET-R-REST CIBALITH-S DEXTROSTAT DIASTAT AMOBARBITAL SODIUM BUDEPRION SR CITALOPRAM HBR DIASTAT ACUDIAL AMOBARBITAL BUDEPRION XL CITALOPRAM HYDROBROMIDE SODIUM/SECOBARB NA HBR HCL DIAZEPAM/SOYBEAN OIL AMOPLY BUPROPION HCL DILANTIN BUPROPION HCL SR DIPOTASSIUM DILANTIN-125 AMPHET ASP/AMPHET/D-AMPHET BUPROPION XL COHIDRATE DIPHEN BUSODIUM COLSPAN DI-PHEN

3/5/2010 Page 1 of 4 This list may change as new are added to the groups of medications that Medicaid will pay for instead of your health plan. Your pharmacy or the First Health Beneficiary Help Line (toll-free at 1-877-681-7540) can tell you which medicine has a $1.00 or a $3.00 co-pay and if any medicines were added to the list. Michigan Department of Community Health List of medicines that Medicaid will pay for instead of your health plan starting April 1, 2010 MEDICATION NAMES DIPHENHYDRAMINE HCL IMAVATE LITHANE DIPHENLHYDANTOIN SODIUM HCL CARBONATE DIPHENTIN ETHOSUXIMIDE IMIPRAMINE PAMOATE DIPHENTOIN ETHOTOIN NO.40 LITHOBID DIPHENYLAN SODIUM ETHYL /HERBAL DRUGS LITHONATE DIPHENYLHYDANTOIN SODIUM ETNOFRIL JANIMINE LITHOTABS DITAN ETRAFON 2-10 J-TRAN LORANTOIN DI-TRAN ETRAFON 2-25 K PH,MBDB/YELLOW JASMINE DIVALPROEX SODIUM ETRAFON A 4-10 KENRAX LORAZEPAM INTENSOL DIVALPROEX SODIUM ER ETRAFON FORTE 4-25 KENVIL LORAZEPAM/DEXTROSE 5%- DIZAC E-VILL 10 KEPPRA WATER DON-A-SPAS E-VILL 100 KEPPRA XR LORAZEPAM/NORMAL SALINE DONNAPINE E-VILL 25 KIRA ST. JOHN'S WORT LORAZEPAM-D5W DONNATAL E-VILL 50 KLONOPIN LORAZEPAM-NS DOPRAM E-VILL 75 LACOSAMIDE L- DORAL FAST SLEEP LAMICTAL LUDIOMIL DORMALIN LAMICTAL (BLUE) LUMINAL DOXAPRAM HCL FELBATOL LAMICTAL (GREEN) LUMINAL SODIUM HCL FELSULES LAMICTAL (ORANGE) LUNESTA SUCCINATE FERNDEX LAMICTAL ODT LUVOX DOXYSOM HCL LAMICTAL ODT (BLUE) LUVOX CR D-TRAN HCL LAMICTAL ODT (GREEN) LYDIA E. PINKHAM HCL MALEATE LAMICTAL ODT (ORANGE) LYDIA PINKHAM HERBAL D-VAL FOCALIN LAMICTAL XR LYRICA EASY SLEEP FOCALIN XR LAMICTAL XR (BLUE) HCL EDLUAR FORTY WINKS LAMICTAL XR (GREEN) MARPLAN EFFEXOR FOSPHENYTOIN SODIUM LAMICTAL XR (ORANGE) MB-TAB EFFEXOR XR LAMOTRIGINE MEBARAL ELAVIL GABARONE LANABARB NO.1 MEDI-SLEEP EMITRIP GABITRIL LANABARB NO.2 MEPHENYTOIN EMSAM GEN-XENE LARGON MEPHOBARBITAL ENDEP LEVETIRACETAM MEPROBAMATE ENOVIL LEXAPRO MEPROBAN-400 EPITOL HALCION LIBACA MEPROMATE EQUANIL HCA SLEEP-EX LIBRITABS MESANTOIN EQUETRO LIBRIUM METADATE CD OXALATE HM SLEEPING LIMBITROL METADATE ER ESKALITH HM ST. JOHNS WORT LIMBITROL DS HCL ESKALITH CR H-TRAN LIPOXIDE HCL HYOSOPHEN LIQUADD ICN-AZEPOX LISDEXAMFETAMINE DIMESYLATE METHOXAMINE HCL

3/5/2010 Page 2 of 4 This list may change as new medications are added to the groups of medications that Medicaid will pay for instead of your health plan. Your pharmacy or the First Health Beneficiary Help Line (toll-free at 1-877-681-7540) can tell you which medicine has a $1.00 or a $3.00 co-pay and if any medicines were added to the list. Michigan Department of Community Health List of medicines that Medicaid will pay for instead of your health plan starting April 1, 2010 MEDICATION NAMES METHOXYPHENAMINE HCL HCL PHENSUXIMIDE RESTFULLY SLEEP METHSUXIMIDE NUVIGIL PHENURONE RESTORIL METHYLIN NYTOL PHENYLTOIN SODIUM RITALIN METHYLIN ER PHENYTEK RITALIN LA OXCARBAZEPINE PHENYTEX EXTENDED RITALIN-SR METHYLPHENIDATE ER OXYDESS RO-AZEPAM METHYLPHENIDATE HCL OXYDESS II PHENYTOIN PROMPT RO-POXIDE METHYLPHENIDATE SR PAMELOR PHENYTOIN PROMPT SODIUM ROZEREM PARADIONE PHENYTOIN SOD PROMPT RUFINAMIDE HCL PHENYTOIN SODIUM SABRIL MILES NERVINE PARAMETHADIONE PHENYTOIN SODIUM EXTENDED SARAFEM MILTOWN PARNATE PHENYTOIN SODIUM, EXTENDED HCL PHENYTOIN SODIUM INJECTION SECOBARBITAL SODIUM MITRAN PAROXETINE MESYLATE PHENYTOIN SODIUM/ SECONAL SODIUM MODAFINIL PAX 400 PHENOBARBITAL SEDABAMATE MOVANA PAXIL PLACIDYL M-TRAN PAXIL CR POXI SELFEMRA MURCIL PAXIPAM SERAX MYPROIC ACID PEECE PRECEDEX SEREEN MYSOLINE PEGANONE SERENITAS NARDIL PEMOLINE HCL HCL PRISTIQ SERZONE NEMBUTAL PENTOBARBITAL SODIUM PROBATE SIMPLE NERVOUS CONDITIONS NEMBUTAL SODIUM PENTOBARBITAL PROCENTRA SIMPLY SLEEP NEURATE-400 SODIUM/CARBROMAL HCL SINEQUAN NEURONTIN PERPHENAZINE/AMITRIPTYLINE PROSOM SK-AMITRIPTYLINE NEUROVAL HCL HCL SK-BAMATE NIGHT TIME SLEEP AID PERPHENAZINE-AMITRIPTYLINE PROVIGIL SK- NIGHT-TIME PER-TRIP PROZAC SK-LYGEN NIGHT-TIME SLEEP PEXEVA PROZAC WEEKLY SK-PHENOBARBITAL NIGHTTIME SLEEP AID PHENACEMIDE PYRILAMINE MALEATE SK-PRAMINE NIGHT-TIME SLEEP AID SULFATE Q.E.L SLEEP AID NIGHTTIME SLEEP GEL PHENOBARB SOD/BUTAB NA/AP- Q-BAM 400 SLEEP-AID NIKETHAMIDE BARB Q-PAM SLEEP CAPS NIRAVAM PHENOBARB/BUTAB QUANTERRA EMOTIONAL SLEEP EASY NITE TIME SLEEP AID NA/SECOBARB SLEEP FORMULA NITETIME SLEEP AID PHENOBARB/HYOSCY// SLEEP II NITETIME SLEEP-AID SCOP RAPIFLUX SLEEP SAFE NOCTEC PHENOBARBITAL RE-LIVE SLEEP SERENE NORFRANIL PHENOBARBITAL SODIUM REMERON SLEEP TABLET NORPRAMIN PHENOBARBITAL/ REST SIMPLY SLEEP TABS

3/5/2010 Page 3 of 4 This list may change as new medications are added to the groups of medications that Medicaid will pay for instead of your health plan. Your pharmacy or the First Health Beneficiary Help Line (toll-free at 1-877-681-7540) can tell you which medicine has a $1.00 or a $3.00 co-pay and if any medicines were added to the list. Michigan Department of Community Health List of medicines that Medicaid will pay for instead of your health plan starting April 1, 2010 MEDICATION NAMES SLEEPTABS STERASOLINE TRIAVIL 25-2 VALUSOM SLEEP-ETTES D STRATTERA TRIAVIL 25-4 VANATRIP SLEEP-EZE 3 SURMONTIL TRIAVIL 4-10 VANSPAR SLEEPGELS TRIAVIL 4-25 VASOXYL SLEEPINAL TEGA-DONNA TRIAVIL 4-50 HCL SLEEPING TEGRETOL VENLAFAXINE HCL ER SLEEPING TABLET TEGRETOL XR TRIDIONE VERSED SLEEPWELL 2-NITE TRILEPTAL VIGABATRIN SOLFOTON HCL TRIMETHADIONE VIMPAT SOMINEX TOFRANIL MALEATE VIVACTIL SOMINEX MAX STRENGTH TOFRANIL-PM TRYPTOMINE VYVANSE SOMNICAPS TOPAMAX TRYPTOPHAN WAL-SOM SOMNISED TRYPTO-SOM WELLBUTRIN SOMNITAB TRANCOPAL TUINAL WELLBUTRIN SR SOMNITABS FORMULA II TRANMEP TWILITE WELLBUTRIN XL SOMNOTE TRANQUIL TYBAMATE XANAX SONATA TRANQUIL-EZE ULTRA SLEEP XANAX XR SPANTRAN TRANXENE SD ULTRA-SLEEP X-O'SPAZ SPASMACAPS TRANXENE T-TAB UNISOM SPASMOLIN TRANXENE-T UNISOM SLEEP AID ZARONTIN SPAZ-10 SULFATE UNISOM SLEEPMELTS ZETRAN SPAZ-5 HCL VALINE/CA CARBONATE/MAG/VAL ZOLOFT ST. JOHN'S WORT TRIAVIL 10-2 VALIUM TARTRATE STABANIL TRIAVIL 2-10 VALPROATE SODIUM ZONEGRAN STAVZOR TRIAVIL 2-25 VALPROIC ACID ZONISAMIDE

3/5/2010 Page 4 of 4 This list may change as new medications are added to the groups of medications that Medicaid will pay for instead of your health plan. Your pharmacy or the First Health Beneficiary Help Line (toll-free at 1-877-681-7540) can tell you which medicine has a $1.00 or a $3.00 co-pay and if any medicines were added to the list.