January 1 Formulary Change for Express Scripts|Medco
Starting January 1, 2014, a group of 48 products will be removed from the Express Scripts Formulary and will no longer be covered. If one of the products you use is affected, you will receive a letter specific to that product in the mail that will include other formulary alternatives you can discuss with your physician.
If you purchase one of the affected medications after January 1, you will have to pay 100% of the full, non-discounted cost of the medication or product at the point of sale. In addition, a number of products will move from preferred to non-preferred status, meaning the drugs in this category will have a higher copay.
With the use of generic drugs increasing, the promotion of brand-name drugs by drug manufacturers is becoming more aggressive. The manufacturers of these products use copayment cards and coupons to promote their products, which drives up plan costs. In each case, the cost of these particular medications is significantly higher than other products in the group of medications used to treat the same illness.
The Formulary will continue to provide access to a broad list of medications. Only 1% of the 4,000+ currently covered products will be non-covered, anticipated to affect 2.6% of all current Express Scripts members, nationwide.
Pharmacists and physicians will also receive announcements and reminders before the formulary changes take effect letting them know the medications being removed from coverage and the alternatives available. After January 1, if you try to fill prescriptions for an excluded drug, claims payment will be rejected and pharmacists will receive messages suggesting covered alternatives. Additionally, your physician will receive a letter with prescription alternatives plus information on the coverage review process.
Express Scripts|Medco has Formulary Exception criteria which allow exceptions when medically necessary. Physicians may call or fax a clinical override request. Express Scripts Coverage Review & Determination team will review clinical criteria questions with the physician. If the criteria are not met, an Express Scripts|Medco pharmacist will review the case. The physician and member will be notified of the determination.
Even if you have received prior authorization for a medication, if it’s one of the medications being removed from the Formulary, it will no longer be covered beginning Jan. 1, 2014. You may ask your doctor to request a clinical exception to continue taking the medication. Your physician will need to request a Clinical Coverage Review. Where medically necessary, patients may be approved to stay on their current medications without disruption or financial impact.