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Coming in 2017: Updates to Our Pharmacy Formulary Program

On January 1, 2017, we will be updating our formulary program. We have already advised prescribers of the upcoming changes. If your employees are affected by these changes, they will receive notification on or before December 1, 2016.


As part of the pharmacy updates, certain medications will be removed from our formulary, the coverage tier on some medications will change, and dosing limits will be applied to certain medications. In addition, all inhaled nasal steroids used to treat allergies, in the therapeutic class, will be excluded from our pharmacy benefit coverage. These changes are specified below.



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, we have removed the medications in the chart below from our formulary for the above-referenced plan types. However, when medically necessary, a member’s doctor or prescriber may request an exception to have these medications covered.

Drug Class Non-Covered Medication or Supply
Immune Modulating Drug* Cimzia, Entyvio, Orencia, Simponi, Simponi Aria
Inflammatory Bowel Agents Asacol, Delzicol, Mesalamine HD
Hepatits C* Sovaldi
Acne Combinations with Antibiotics Duac gel kit, Benzaclin gel and pump
Vitamins-Single Ingredient Nascobal
Angiotensin II Receptor Antagonists and Combinations Avapro, Avalide, Diovan, Diovan HCT, Exforge, Exforge HCT
HMG CoA Reductase Inhibitors (cholesterol) Crestor
Medications included as part of Compounded Medications Duloxetine capsules, irenka capsules, saltstable LO cream, salstable LS cream
Oral Contraceptives Minastrin FE Chewable
*Members currently taking these medications will be allowed to continue to take these medications. Members taking Orencia and/or Sovaldi will be affected by a tier change for these drugs to the highest tier.

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, members may be required to pay more or less for these medications. The medications in the table below will change tiers:

The medications in the table below will change tier levels:

Drug Class Medication Name Covered Tier Level as of January 1, 2017 under a 3 Tier Formulary Covered Tier Level as of January 1, 2017 under a 4 Tier Formulary
Topical Retinoic Acids tretinoin, tretinoin microsphere, adapalene Tier 2 Tier 2 (no change from 2016)
Syringes Ulticare, GNP Ultra Tier 2 Tier 2
Non Covered Generic Medications with approved Formulary Exception Avita, DermaWerx Surgical Plus Pak, Eletone, HPR Plus, Lidocaine/Hydrocortisone Gel and Cream kits, Salicylic Acid/Ceramide 6% kit Tier 3 Tier 4

 

Medication with New Quality Care Dosing Limit

To make sure that the quantity and dose of a medication meets the Federal Drug Administration, manufacturer, and clinical recommendations, we are adding a Quality Care Dosing Limit to the following medications:

Medication Name Quality Care Dosing Limit
Diclofenac 1.5% solution 150ml
Diclofenac 1% gel 500GM
Diclofenac 3% gel 100GM
Lidocaine 5% 35GM ointment 35GM (1 tube)
Lidocaine 5% 50GM ointment 50GM (1 tube)
Voltaren 1% gel 500GM
Breo-Ellipta 200/25mcg 28 pack 28 blisters
Breo-Ellipta 100/25mcg 28 pack 28 blisters
Climara-Pro patch 4 patches
Nucynta 50, 100, 150, 200mg 60 tabs
Pennsaid 2% pump 112 gm 1 bottle

 

Medication Class That Will Be a Benefit Exclusion

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 non-grandfathered 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.

 

If you have any questions about these changes, please contact your account executive.

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