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Pharmacy Program Changes Coming in 2015

Coming in 2015: Updates to Our Pharmacy Formulary Program
On January 1, 2015, we will be updating our formulary program. We want to make you aware of these changes now so you can plan. We have already advised prescribers of the changes. Members who are directly affected will be notified directly on or before December 1, 2014.

We will be changing the coverage tier on some medications, adding dosing limits to others, and removing some medications from our formulary drug list. We've highlighted the changes below. Rest assured, members and prescribers will continue to have access to a variety of safe and effective medications at affordable prices.

Two Types of Plans Will Be Affected:

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

Medications That Will No Longer Be Covered
After carefully reviewing each drug's cost and covered alternatives, the medications in the chart below will no longer be covered. However, when medically necessary, your doctor or the person who prescribed the drug may request an exception to have these medications covered.

We previously communicated that ophthalmic prostaglandins (for glaucoma) including Lumigan, Travatan Z, Travatan, and Xalatan would no longer be covered as of 1/1/15. These medications will continue to be covered for our members in accordance with our Step Therapy program and there will be no change in coverage for members currently taking these medications.

Drug Class Non–Covered Medication or Supply
Insulin – basal Levemir
Topical testosterone Testim, Testosterone Authorized Generic Products

Ophthalmic anti-inflammatory

Ophthalmic antibiotics

Sedative hypnotics (sleep aids)


Compounded medications

Vexol, FML Forte

Moxeza, Vigamox, Zymar

Lunesta, Sonata

Cymbalta, Lexapro

Bulk chemical ingredients when used as part of a compounded medication

Medication with New Quality Care Dosing Limit
To ensure the quantity and dose of medication a member receives meets Federal Drug Administration, manufacturer, and clinical recommendations, we are adding a Quality Care Dosing limit to the following medications:

Medication Name Dosage Quality Care Dosing Limit
Insulin vials

Insulin pens/cartridges
All strengths

All strengths
4 vials per prescription

15 pens/cartridges per prescription

Medication That Will Be a Benefit Exclusion as It Is Now Available Over-the-Counter
The following medication will be excluded from our pharmacy coverage. We are making this change due to the over-the-counter availability of this medication, which can be purchased without a prescription. This change will apply to all commercial plans, group Medex plans with pharmacy benefits, and Managed Blue for Seniors.

Drug Class Medication Name
Proton pump inhibitors Nexium capsules (20mg strength only)

Medications That Will No Longer Be Available Through the Express Scripts Mail Service PharmacySM
The following medications will be covered only when purchased from a retail pharmacy in our network.

Drug Class Medication Name
Pain medication Conzip, Tramadol containing products and Tramadol combination products, Ultram, Ultram ER
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