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Coming in 2016: Updates to Our Pharmacy Formulary Program

On January 1, 2016, we will be updating our formulary program. We want to make you aware of these changes now so you can plan accordingly, and keep your employees informed. We have already advised prescribers of the upcoming changes. All affected members will be notified directly on or before December 1, 2015.

Additionally, the coverage tier on some medications will be changing—adding dosing limits to some, and removing other medications from our formulary drug list. These changes are highlighted below. Rest assured, your employees and prescribers will continue to have access to a variety of affordable, safe, and effective medications.

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, an employee’s doctor, or the person who prescribed the drug, may request an exception to have these medications covered.
Drug Class Non-Covered Medication or Supply
Blood Glucose Meters & Test Strips Accu-Chek Tffest Strips
Bowel evacuant combinations CoLyte
**Erythroid stimulants Aranesp
**GnRH/Antagonists Ganirelix
Phosphate binders Auryxia
Topical actinic keratosis Picato, Solaraze, and Fluoroplex
Compounded Medications Several classes of compounded medications will not be covered. These include:
- Calcium Channel Blockers
- Lidocaine topical and combinations
- Gastrointestinal Chloride Channel Activators
- Fibromyalgia Agent - SNRIs
- Carnitine Replenisher - Agents
- Antianxiety Agents - Misc.
- Opioid Agonists
- Antihistamines - Non-Sedating
- 5-HT3 Receptor Antagonists
- Nonsteroidal Anti-inflammatory Agents (NSAIDs)
- Leukotriene Receptor Antagonists
- Triazoles
- Central Muscle Relaxants
- Cyclooxygenase 2 (COX-2) Inhibitors
- Hematorheologic Agents
- Selective Serotonin Agonists 5-HT(1)
** Members currently taking these medications will be allowed to continue to fill them until 7/1/16.

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

The medications in the table below will change tier levels:

Drug Class Medication Name Covered Tier Level as of January 1, 2016 under a 3 Tier Formulary Covered Tier Level as of January 1, 2016 under a 4 Tier Formulary
Unspecified drug category Eurax
Tier 3
Tier 3
Tier 3
Tier 2
Tier 4
Tier 4
Tier 4
Tier 3
Inhaled long acting muscarinic antagonists Tudorza Tier 2 Tier 3


Medication with New Quality Care Dosing Limit

To make sure that the quantity and dose of a medication administered to a member 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
Bydureon 2mg vial/pen 4 vials/pens
Byetta 5mcg
Farydak 10mg
6 capsules
Farxiga 5mg
30 tablets
Invokana 100mg
30 tablets
Invokamet 50/500mg, 50/1,000mg, 150/500mg, 150/1,000mg 60 tablets
Jardiance 10mg
30 tablets
Tanzeum 30mg
4 pens
Trulicity 0.75mg/5ml, 1.5mg/5ml pen 2 ml
Victoza 2 pak
Victoza 3 pak
Xifaxin 200mg
9 tablets
60 tablets


Medication Class That Will Be a Benefit Exclusion as there are Over-the-Counter options available

Effective January 1, 2017, all inhaled nasal steroids used to treat allergies, in the therapeutic class, will be excluded from our pharmacy benefit coverage. Formulary exceptions, including those previously approved, will no longer be available for this class of medications. This change applies to all commercial plans, group Medex® plans with pharmacy benefits, and Managed Blue for seniors plans. We are making this change due to the over-the-counter availability of several products in this class, which can be purchased without a prescription.


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