Preferred Drug List 2013 Standard Formulary (3 ... - Express Scripts

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DEVELOPMENT OF THE DRUG FORMULARY The Drug Formulary is the cornerstone of drug therapy quality assurance and cost containment efforts. The Drug Formulary process has been successfully used by hospitals and managed care organizations to provide comprehensive, cost-effective pharmacy services. This Drug Formulary document was developed by the Express Scripts’ Pharmacy and Therapeutics Committee (P&T Committee). Arise Health Plan delegates this responsibility to ESI. The ESI P&T committee is comprised of physicians from various medical specialties and pharmacists. Medications are reviewed for safety, effectiveness, and cost. Then, the Committee selects the drugs considered to offer the greatest value in each category. Formulary development and maintenance is a dynamic process. The P&T Committee will regularly review new and existing medications to ensure the Formulary remains responsive to the needs of our members and providers. DRUG FORMULARY MEDICATIONS The Drug Formulary is a listing of medications marketed at the time of the Formulary printing, and intended for use by the health plan physicians and pharmacy providers. Unless exceptions are noted, all forms (tablet, capsule, liquid, topical) and strengths of a drug product are included in the Formulary and will be covered by the plan. The Drug Formulary applies to prescription medications dispensed to outpatients by participating pharmacies. The Formulary does not apply to inpatient medications or to most medications administered in a physician’s office. Non-Prescription Medication (OTC) Policy Over-the-counter (OTC) products are typically not covered, but some are listed for informational purposes. (When available, non-prescription products may be less costly to the patient than a covered product.) Also, if a prescription product is available in the identical strength, dosage form, and active ingredient(s) as an OTC product, the prescription product will not be covered. In these instances, physicians and pharmacists should refer members to the OTC equivalent product. If the member or physician insists on the prescription equivalent product, the member must pay the entire cost of the prescription. Generic Drug Policy If a member requests the brand name product in place of its generic equivalent, the patient must pay the applicable copay plus the cost difference between the brand name and generic drug. Prescriptions for Non-Formulary Medications Providers are requested to comply with the Drug Formulary when prescribing medications for plan members. If a pharmacist receives a prescription for a non-Formulary medication, the pharmacist may attempt to contact the physician to request a change to a Formulary product.
Prior Authorization Process If a patient requires a medication that is subject to prior authorization, the provider should direct such inquiries to: Express Scripts, Inc. Drug Prior Authorization Department Fax: 800-357-9577 Tel: 800-417-8164 If a provider wishes to request that a new or existing medication be added to the Drug Formulary, a letter indicating the significant advantages of the drug product over current formulary medications, along with supporting medical literature, should be mailed to the following address. Thank you. Arise Health Plan Formulary Department 421 Lawrence Drive, Suite 100 DePere, WI 54115
Page 1: Preferred Drug List 2013 Standard F
Page 5 and 6: DRUG NAME 2.1.5 PENICILLINS amox tr
Page 7 and 8: DRUG NAME 1 2 3 SUGGESTED PREFFERED
Page 15 and 16: TIER DRUG NAME 1 2 3 primidone X SU
Page 23 and 24: TIER DRUG NAME 1 2 3 ACTONEL ST X A
Page 25 and 26: TIER DRUG NAME 1 2 3 SUGGESTED PREF
Page 35 and 36: DRUG NAME 16.1.3 URINARY ANESTHETIC
Page 39 and 40: AVALIDE 4.5.4.2 AVANDAMET 8.1.3 AVA
Page 41 and 42: donepezil hcl 5.9.3 DORYX 2.1.7 dor
Page 43 and 44: KAPVAY 5.9.6 kariva 13.7 kelnor 1
Page 45 and 46: ONGLYZA 8.1.5.2 ONSOLIS 5.1.1.1 OPA
Page 47 and 48: SUPREP 9.6 SURESTEP 18.1 SURE‐T 1

Preferred Drug List 2013 Standard Formulary (3 ... - Express Scripts

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