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Pharmacy Changes, Effective January 1, 2014

Coming January 1, 2014: Updates to Pharmacy Formulary Program
With these changes, members and doctors will continue accessing a variety of safe, clinically effective medications at affordable prices.

Which Plans Will Be Affected?

  • Commercial plans with pharmacy benefits
  • Medex®' plans with the three-tier pharmacy benefit

Doctors and hospitals have already been advised of these changes. Members affected by any of these changes will be notified directly no later than December 1, 2013.

Medications Changing to Non-Covered Status
After careful consideration and cost evaluation of each drug's covered alternatives, the following medications will no longer be covered.

Drug Class Non–Covered Medication or Supply
Insulins Novolog, Novolin
Migraine Treatments Alsuma, Relpax, Zomig/ZMT (members currently using these medications will not be required to obtain a formulary exception for coverage)
H. Pylori Treatments Pylera, Helidac, PrevPac
Topical Steroids Clobex
Hyaluronic Acids/Joint Fluid Replacement Euflexxa, Hyalgan, Supartz
Glucose Testing Supplies-Testing Strips Precision X-tra (members currently using this medication will not be required to obtain a formulary exception for coverage and will be covered at Tier 3)

When medically necessary, a health care provider may request an exception to have these medications covered.

Medications Changing Tier Status
When we determine that a medication's clinical and financial value changes relative to alternative medications in its class, we change the medication's tier. Depending on the tier change, members may be required to pay more or less for these medications.

The medications below will change to the following tier levels:

Drug Class Medication Name Covered Tier Level as of January 1, 2014
Irritable Bowel Treatments Amitiza Tier 2
Hormone Replacement Therapy Premarin Tier 2
Women's contraceptives Nuvaring, Ortho-Evra, Depo-Provera-150, Medroxyprogesterone Tier 1

New Quality Care Dosing Limits
To monitor that the quantity and dose of medication that a member receives meets Federal Drug Administration, manufacturer, and clinical recommendations, we are adding the following Quality Care Dosing limits to the medication below:

Medication Name Dosage QCD limit
Epinephrine, Epi-pen, Auvi-Q All Strengths 2 injections per prescription

Medications requiring Prior Authorization–Effective January 1, 2014
The following medications will require a prior authorization

Drug Class Medication Name
Compounded Medications ketamine, gabapentin, diclofenac, ketoprofen, flurbiprofen, oral erectile dysfunction medications and oral pain/analgesic medications when included as part of a compounded medication
Weight Loss Belviq

New Step Therapy Policy-Effective January 1,2014

Drug Class Medication Name
Oral Medications for treatment of Prostate Cancer Step 1: Zytiga
Step 2: Xtandi (members currently using this medication will not be required to obtain a prior authorization for coverage)

Medications no longer covered when administered in a doctor's office or hospital setting*
The following medications will no longer be covered when administered in a doctor's office or hospital setting. They will only be covered if they are purchased through your pharmacy benefits.

Drug Class Medication Name
Hyaluronic Acids/Joint Fluid Replacement Euflexxa, Synvisc-One, Synvisc, Orthovisc, Supartz, Hyalgan, Gel-one

Coverage will no longer be available for the following medications when administered in a doctor's office or hospital setting. Coverage will only be available when purchased from a retail pharmacy in our specialty network.

Drug Class Medication Name
Fertility Regulator Ovidrel†
Antipsoriatic Stelara
Anti-TNF-alpha - Monoclonoal Antibodies Simponi
Bone Density Regulators Prolia, Xgeva
GnRH/LHRH Antagonists Cetrotide†
Growth Hormone Receptor Antagonist Somavert
Interleukin-1 Blockers Arcalyst
Interleukin-1beta Blockers Ilaris
Multiple Sclerosis Agent Extavia
Antineoplastic or Premalignant Lesion Agent – Topical Panretin

Have Questions?
If you have any questions, please contact your account executive.

 

 

*These changes do not impact Medex plans with a three tier pharmacy benefit
Purchase of this medication is only available when purchased through a network specialty fertility retail pharmacy.

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