Prescription Drug Change Effective April 2014

Effective April 1, 2014, the Express Scripts Prescription Drug Coverage for members will no longer cover a select list of 48 medications (listed in the table below).

Express Scripts’ national formulary offers access to more than 4,000 safe and effective medications to treat every condition for which drug therapy is available, based upon guidance from an independent group of expert health professionals. However, drug choices in some categories are larger than ever with many products costing more with no additional health benefit.

If you are currently filling a prescription for one of the 48 medications no longer covered under the plan, you and your physician were sent letters by Express Scripts. A list of other covered alternative medications was included with these letters to provide your physician the opportunity to prescribe a different medication that is covered by your plan. If your physician does not prescribe one of the covered alternatives, when you next attempt to fill your prescription, you will be required to pay the full cost (with no discount) at the pharmacy, and will not be able to be reimbursed by the plan for any part of its cost.

You should consult with your physician regarding appropriate alternative medication for you.

Appeal Process

You have the right to appeal a denied claim. Your physician should contact the coverage review team at 1.800.753.2851 to initiate the formulary exception process.

Here is an overview on how the process works:
A coverage review representative reviews the formulary exception. Criteria for exceptions are based on: clinical recommendations, treatment guidelines, and evidence-based literature.

  •  If the exception is approved, you and your physician are notified.
  • If the exception is denied, the exception information is sent to a pharmacist for review.

After the pharmacist reviews the exception, three outcomes can occur:

  • If the exception is approved, Express Scripts notifies you and your physician.
  • If Express Scripts requires more information, a representative will contact your physician.
  • If the exception is denied, Express Scripts notifies you and your physician.

Should a denial occur, the reason(s) for the denial will be included in the communication from Express Scripts. Information regarding appeal rights is also provided along with the necessary steps to make such a request.

If an exception is granted you still need to pay the plan’s non-preferred drug copayment.

Drug Class Excluded Medications Covered Alternative
ANTINEOPLASTIC/
IMMUNOSUPPRESSANT
Biologics – Injectable Tumor
Necrosis Factor Antagonists
and Other Drugs for
Inflammatory Conditions
Cimzia, Simponi,
Stelara, Xeljanz
Enbril, Humira
AUTONOMIC & CENTRAL
NERVOUS SYSTEM
Interferon Beta Medications for
Multiple Sclerosis
Betaseron Avonex, Extavia,
Rebif
Long-Acting Opioid
Oral Analgesics
Avinza, Exalgo,
Kadian
morphine sulfate ER,
oxymorphone ER, Nucynta ER,
Opana ER, Oxycontin
CARDIOVASCULAR
Angiotensin II Receptor Antagonists
+ Diuretic Combinations
Edarbi/Edarbyclor,
Micardis/Micardis HCT,
Teveten/Teveten HCT
candesartan/hydrochlorothiazide (HCTZ),
irbesartan/HCTZ, losartan/HCTZ,
valsartan/HCTZ, Benicar/HCT
DIABETES
Blood Glucose Meters & Strips
Abbott (Freestyle, Precision),
Bayer (Breeze, Contour),
Nipro (TRUEtrack, TRUEtest),
Roche (Accu-Chek)
LifeScan (OneTouch)
Dipeptidyl Peptidase-IV Inhibitors
& Combos
Jentadueto, Kazano,
Nesina, Tradjenta
Janumet, Janumet XR,
Januvia, Kombiglyze,
Onglyza
Incretin Mimetics
(Glucagon-Like Peptide-1 Agonists)
Victoza Bydureon, Byetta
Insulins NovolinApidra, NovoLog HumulinHumalog
EAR/NOSE
Nasal Steroids
Beconase AQ, Omnaris,
Rhinocort Aqua, Veramyst,
Zetonna
flunisolide,
fluticasone propionate,
triamcinolone acetonide,
Nasonex, Qnasl
ENDOCRINE (OTHER)
Androgen Drugs
(Topical Testosterone Products)
Foresta, Testim Androgel, Axiron
Growth Hormones Nutropin/Nutropin AQ,
Omnitrope, Saizen,
Tev-Tropin
Genotropin,
Humatrope,
Norditropin
IMMUNOLOGICAL
Interferons
PegIntron Pegasys
OBSTETRICAL & GYNECOLOGICAL
Ovulatory Stimulants (Follitropins)
Bravelle, Follistim AQ Gonal-f
OPHTHALMIC
Antiglaucoma Drugs
(Ophthalmic Prostaglandins)
Zioptan latanoprost, travoprost,
Lumigan, Travatan Z
RESPIRATORY
Epinephrine Auto-Injector Systems
Auvi-Q EpiPen, EpiPen Jr
Pulmonary Anti-Inflammatory Inhalers Alvesco, Flovent Diskus/HFA Asmanex, Pulmicor Flexhaler,
QVAR
Pulmonary Anti-Inflammatory/
Beta Agonist Combination Inhalers
Advair Diskus/HFA, Breo Ellipta Dulera, Symbicort
Beta-2 Adrenergics
(Short-Acting Inhalers)
Maxair Autohaler, Proventil HFA,
Xopenex HFA
Proair HFA, Ventolin HFA
UROLOGICAL
Erectile Dysfunction Oral Agents
Levitra, Staxyn Cialis, Viagra