Updates to the Formulary Effective January 1, 2014

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Job Franklin
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1 Updates to the Formulary Effective January 1, 2014 The first part of this document highlights several important formulary changes for Please note that this is not a complete list of all changes. Contents Updates to the Formulary Effective January 1, Tier formulary structure... 2 Members pay lower drug copays at preferred pharmacies CMS high risk medications continue to require prior authorization... 3 New quantity limit restrictions for antipsychotics, amphetamines, benzodiazepines, and other drugs. 4 Highlighted Formulary Drug Tier Changes... 5 Prior Authorization Request Forms for Part D and Part B Drugs... 6 Pharmacy and Formulary Resources available on the Essence Provider Portal... 6 Medicare Part D Standard Benefit Coverage Phases for

2 5-Tier formulary structure In 2013 we introduced a new 5-tier formulary structure, and we continue to have the same 5-tier formulary structure for Tier 1 (preferred generic) includes a limited list of commonly used generics available to members at a reduced copay. It is similar to the Walmart $4 list. Tier 2 (non-preferred generic) includes almost all other generic drugs. Throughout the year first-time generics introduced to the market will be placed on Tier 2. Essence 2014 Formulary Structure Tier Number Tier 1 Tier 2 Tier 3 Tier 4 Tier Tier Name Preferred generic Non-preferred generic Preferred brand Non-preferred brand Specialty (cost > $600/month) Members pay lower drug copays at preferred pharmacies. We have continued our partnership with Schnucks as the preferred pharmacy. In St. Francois County, where there are no Schnucks stores, the preferred pharmacy is Pharmax. Essence members are free to use any network pharmacy to obtain their medicines; however, they will pay lower copays at preferred pharmacies. Members pay $0 copay on Tier 1 and Tier 2 generics at preferred pharmacies. Copays for Tier 3 drugs are $5 lower, and copays for Tier 4 drugs are $10 lower at preferred pharmacies compared to non-preferred pharmacies. The table below shows copays at preferred and non-preferred pharmacies for one specific Essence plan; other plans have different copays. Drug Category (Tier) Copay for a One Month Supply* at a preferred pharmacy Copay for a One Month Supply* at a non-preferred pharmacy Tier 1 (Preferred Generic) $0 $2 Tier 2 (Non-Preferred Generic) $0 $5 Tier 3 (Preferred Brand) $34 $39 Tier 4 (Non-Preferred Brand) $65 $75 Tier 5 (Specialty) 33% co-insurance 33% co-insurance *This table displays plan H copays. Other Essence plans may have different copays. 2

3 CMS high risk medications continue to require prior authorization (PA). Certain medications should be avoided or used with caution in the elderly population according to the American Geriatrics Society s updated Beers Criteria. These drugs are considered to have a high risk of side effects when used by geriatric patients, and risks generally outweigh benefits. Many formulary high risk medications have a prior authorization requirement when prescribed for patients 65 years and older. The PA requirement does not apply to patients 64 years and under. For more detailed information, please refer to the High Risk Medication Provider Reference on the provider portal. The PA criteria require that the prescriber document the information listed below. To facilitate the coverage determination process, please include this information on the coverage determination or redetermination request: 1. The indication for the continued use of the high risk medication with an explanation of the specific benefit established with the medication 2. How that benefit outweighs the potential risk 3. That there is an ongoing monitoring plan for the patient 4. That patient counseling has and will continue to take place outlining the risks and potential side effects of the medication. High risk meds that require prior authorization Hypoglycemics Glyburide and glyburide-metformin Tricyclic Antidepressants Amitriptyline, imipramine, doxepin, clomipramine, trimipramine, chlordiazepoxide-amitriptyline, perphenazine-amitriptyline Skeletal Muscle Relaxants Carisoprodol, chlorzoxazone, cyclobenzaprine ir and er, Lorzone, methocarbamol, orphenadrine ir and er, Parafon Forte DSC, Skelaxin, Soma, carisoprodol/aspirin, carisoprodol/aspirin/codeine, orphenadrine/aspirin/caffeine Nitrofurantoin Macrocrystalline and monohydrate forms Oral and Topical Estrogen-Containing Products Alora, Climara Pro, Combipatch, Divigel, Elestrin, estradiol-norethindrone acetate, estradiol tab, estradiol patch, Evamist, Menest, Menostar, Minivelle, Prefest, Premarin, Prempro, Vivelle-DOT First-Gen Antihistamines and Anticholinergics Hydroxyzine, benztropine, carbinoxamine, Cogentin, diphenhydramine inj, promethazine inj, trihexyphenidyl Digoxin dose >0.125mg/day (must have documented trial and failure of doses up to 0.125mg/day or documented indication for higher doses) 3

4 New quantity limit restrictions for antipsychotics, amphetamines, benzodiazepines, and other drugs. We continue to employ utilization management tools to improve patient safety. Effective on January 1 st 2014 we have added quantity limit restrictions on antipsychotics, amphetamines, benzodiazepines that did not already have limits in place, certain ophthalmics, and some other medications. Please review the table below for a list of drugs with new limits. Please note that this is not a complete list of all changes; refer to the online formulary for the most up-to-date information and for the specific limits for each drug. Antipsychotic drugs haloperidol tabs loxapine caps Abilify tabs, oral soln Abilify Discmelt Abilify Maintena inj Fanapt Geodon inj Invega tabs Invega Sustenna inj Latuda tabs olanzapine tabs, inj olanzapine odt tabs quetiapine tabs Risperdal Consta inj risperidone tabs, soln risperidone odt tabs Saphris Seroquel XR tabs ziprasidone caps clozapine tabs Fazaclo tabs Amphetamines amphetamine/dextroamphetamine dextroamphenatmine sulfate dextroamphetamine sulfate er methamphetamine procentra Vyvanse Ophthalmic Drugs Azasite Bromday ophth bromfenac ophth Restasis Tobradex ophth oint Benzodiazepines clonazepam clonazepam odt clorazepate dipotassium diazepam intensol diazepam tabs, soln ONFI (benzo for sz disorder) Other Drugs nitrofurantoin Rozerem Lidoderm Kadian bactroban nasal bactroban cream mupirocin oint Glucagon kit 4

5 Highlighted Formulary Drug Tier Changes We make changes to the formulary status of some drugs from one year to the next. This might be due to the availability or anticipated availability of a generic, significant cost changes, or other reasons. Generic versions of drugs that became available at the end of 2013 (after the 2014 formulary was approved by CMS) will process at the Tier 2 copay even though they might not display on the formulary until after February. Please review the information below for some important changes in Please note that this is not a complete list of all changes; refer to the online formulary for the most up-to-date information. Moved to lower cost-sharing tier: Non-preferred brand (T4) to preferred brand (T3) Creon Edarbi Edarbyclor Horizan Lialda Symbicort Moved to higher cost-sharing tier: Preferred brand (T3) to non-preferred brand (T4) Actonel Aranesp 25mcg, 40mcg, 60mcg Asacol HD Avelox Avelox ABC Pack Celebrex Cymbalta Diovan Hectorol caps and soln Niaspan Renvela Trilipix Brand name drugs removed from formulary because a generic is available Actos Atacand HCT Detrol Diovan HCT Duetact Maxalt Maxalt MLT Provigil Sanctura XR Singulair Suboxone tab Tricor Moved to higher cost-sharing tier: Lower tier to specialty (T5). Per CMS specifications, drugs are placed on T5 when the cost exceeds $600/month. Enoxaparin 150mg/ml Valcyte Aranesp 100mcg/0.5ml, 100mcg/ml Forteo Fondaparinux inj 10mg/0.8ml, 7.5mg/0.6ml Reyataz 200mg, 300mg Sensipar 60mg, 90mg Truvada Epzicom Baraclude tab Zyvox Atripla Mepron 5

6 Prior Authorization Request Forms for Part D and Part B Drugs We require different forms for Part D drug coverage determinations and Part B drug prior authorization requests. It is very important to use the correct forms in order to avoid delays in processing, as Part D and Part B forms are routed differently. In addition, we have specialized PA forms for many Part D and Part B drugs. The specialized forms guide you to provide all of the required medical information in order to facilitate processing of the request. They are available on the Essence provider portal under the Forms link. The Provider Quick Reference Guide, currently posted on the Provider Portal, lists all Part B drugs that require prior authorization. Pharmacy and Formulary Resources available on the Essence Provider Portal There are a number of pharmacy-related resources available on the provider portal, including: Access to the formulary, step therapy protocols, and prior authorization criteria for Part D drugs Quick Formulary Reference Guide (formulary status for commonly used classes of drugs) Tier 1 Generic Drugs by Therapeutic Category (complete list of Tier 1 drugs) High Risk Medication Reference Guide (list of HRM and alternatives) Zostavax Provider Reference Guide Stretching the Part D Benefit (highlights lower cost alternatives within therapeutic classes) Medication Therapy Management Program (program description) 6

7 Medicare Part D Standard Benefit Coverage Phases for 2014 Coverage Phase Initial Coverage Phase Member begins each new calendar year in this phase. Coverage Gap Phase, also called the Donut Hole Catastrophic Coverage Phase Who pays for prescription drugs in this phase? Member pays co-pay or co-insurance according to benefit plan. The health plan pays the rest. Member pays 72% coinsurance for generic drugs and 47.5% of the cost for brand name drugs (unless receiving low-income subsidy) NOTE: The full retail cost for brand name drugs will count towards the Out-of-Pocket threshold. Member pays the greater of a $2.55 co-pay for generics, $6.35 co-pay for brand names OR a 5% co-insurance for a one month supply. The health plan pays the rest. How long is a member in this phase? Until Total Drug Costs reach the Initial Coverage Limit Total Drug Costs = the amount that the member, others on his behalf, and the health plan paid for his Part D drugs Until the member or others on his behalf have paid amounts that reach the Out-of-Pocket Threshold, also called true out-of-pocket amount, or TrOOP. For 2014 the TrOOP is $4550. True out-of-pocket amount = amounts paid for copays and co-insurance plus any amounts paid by the member during the Coverage Gap No amounts paid by the health plan are applied towards the TrOOP. Until the first day of the next calendar year. 7

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RxBLUE (PDP) Formulary Changes

RxBLUE (PDP) Formulary Changes Updated 5/11 The following pages include additions, removals and deletions made to the RxBLUE (PDP) Drug Formulary since the publication of the RxBLUE (PDP) Comprehensive