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.
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|
Biologics – Injectable Tumor
Necrosis Factor Antagonists
and Other Drugs for
|AUTONOMIC & CENTRAL
Interferon Beta Medications for
|morphine sulfate ER,
oxymorphone ER, Nucynta ER,
Opana ER, Oxycontin
Angiotensin II Receptor Antagonists
+ Diuretic Combinations
Blood Glucose Meters & Strips
|Abbott (Freestyle, Precision),
Bayer (Breeze, Contour),
Nipro (TRUEtrack, TRUEtest),
|Dipeptidyl Peptidase-IV Inhibitors
|Janumet, Janumet XR,
(Glucagon-Like Peptide-1 Agonists)
|Beconase AQ, Omnaris,
Rhinocort Aqua, Veramyst,
(Topical Testosterone Products)
|Foresta, Testim||Androgel, Axiron|
|Growth Hormones||Nutropin/Nutropin AQ,
|OBSTETRICAL & GYNECOLOGICAL
Ovulatory Stimulants (Follitropins)
|Bravelle, Follistim AQ||Gonal-f|
Lumigan, Travatan Z
Epinephrine Auto-Injector Systems
|Auvi-Q||EpiPen, EpiPen Jr|
|Pulmonary Anti-Inflammatory Inhalers||Alvesco, Flovent Diskus/HFA||Asmanex, Pulmicor Flexhaler,
Beta Agonist Combination Inhalers
|Advair Diskus/HFA, Breo Ellipta||Dulera, Symbicort|
|Maxair Autohaler, Proventil HFA,
|Proair HFA, Ventolin HFA|
Erectile Dysfunction Oral Agents
|Levitra, Staxyn||Cialis, Viagra|