2012 Formulary Reference Guide
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FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page A 2012 Formulary Reference Guide A list of medications that may lower your patients’ costs Preferred Prescriptions® Rx Selections™ Express Scripts and Medco have come together as one company to manage the prescription benefits of your patients. FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page i TABLE OF CONTENTS INTRODUCTION . ii The Preferred Prescriptions/Rx Selections Formularies . ii Using this formulary book to help contain costs . iii Knowing how this formulary information is organized . iii Understanding the symbols used throughout this book . iv Considering preferred alternatives . iv Saving on out-of-pocket costs for patients . v Consulting your office when appropriate . v Getting answers to your questions . v THERAPEUTIC CHAPTER INDEX . .1 PREFERRED PRESCRIPTIONS/RX SELECTIONS FORMULARIES . .4 INDEX . .56 i FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page ii INTRODUCTION An independent committee of practicing physicians and a pharmacist has been established to help ensure that our formularies are medically sound and that they support your patients’ health. This committee—called the Pharmacy and Therapeutics Committee—reviews and evaluates medications on the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories. The Preferred Prescriptions/Rx Selections Formularies • Preferred Prescriptions—available with open and incentive formulary designs. • Rx Selections—available with closed and incentive formulary designs. In order to serve the diverse needs of patients and their plan sponsors, we make three options available in formulary design: 1. Open Formulary —Features uniform co-payments for medications that are preferred and nonpreferred brands, plus lower co-payments for generic drugs. 2. Incentive Formulary—Features different co-payments for medications that are on or off the formulary. In this type of formulary, the patient cost structure may be either a two-tier or three-tier design. In some cases, members may request a review of their non-preferred co-payment for special circumstances. Two-tier design Three-tier design • Tier 1: Generic drugs = • Tier 1: Generic drugs = Lowest patient costs* Lower patient costs • Tier 2: Preferred brand-name drugs = Midlevel patient costs • Tier 2: Brand-name drugs = • Tier 3: Nonpreferred brand-name drugs = Higher patient costs Highest patient costs *Some generics may not be in Tier 1. 3. Closed Formulary—Features the requirement that prescribed drugs must be on the formulary in order for the member to receive coverage. This is the most restrictive formulary. If a prescription is written for a medication that is not on the formulary, the patient will be responsible for the full cost. If special circumstances necessitate that the patient take the nonpreferred drug, prescribers may request a coverage review. If coverage is approved, the medication will be covered. If coverage is not approved, the patient will be responsible for the full cost of the medication. Policies for coverage vary by plan sponsor. If your patient requires a coverage review, please call 1 800 753-2851 from 8:00 a.m. to 9:00 p.m., eastern time, Monday through Friday. ii FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page iii USING THIS FORMULARY BOOK TO HELP CONTAIN COSTS Many employers and other benefit sponsors use our formularies to help manage the overall cost of providing prescription drug benefits for your patients. These formularies offer a wide range of outpatient medications from which to choose. We realize that these formularies may not include every drug from every manufacturer. However, choosing a preferred drug, when you feel it is appropriate, can help your patients gain access to the medications they need to stay healthy, at a cost that’s more affordable. KNOWING HOW THIS FORMULARY INFORMATION IS ORGANIZED The Preferred Prescriptions/Rx Selections Formularies are designed so that generic products are listed first in each drug category; corresponding brand-name versions for these generics are shown (in parentheses) for reference. The preferred brand-name products are listed next; likewise, corresponding generic names are shown (in parentheses) for reference. PLEASE NOTE: If a generic product is listed in the generics section and its referenced brand-name product is not listed in the preferred brand-name section, then only the generic product is on the formulary. If a brand-name product is listed in the preferred brand-name section and its referenced generic product is not listed in the generics section, then a generic version is not available. Here is an example: FORMULARY PRODUCTS DRUG NAME 3.9.3.3 MISCELLANEOUS ANTIPSYCHOTICS GENERICS Clozapine (Clozaril) Loxapine Succinate (Loxitane) Risperidone (Risperdal) Thiothixene (Navane) BRANDS Clozaril (Clozapine) Geodon (Ziprasidone HCl) Moban (Molindone HCl) Orap (Pimozide) Seroquel (Quetiapine Fumarate) Seroquel XR (Quetiapine Fumarate) Zyprexa (Olanzapine) Zyprexa Zydis (Olanzapine) • The generic version of Geodon is not available, since Ziprasidone HCl does not appear under GENERICS. • Only the generic version of Risperdal is on the formulary, since the brand-name does not appear under BRANDS. • Brand-name Clozaril and its generic version are on the formulary, since these drugs are referenced under both GENERICS and BRANDS. iii FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page iv UNDERSTANDING THE SYMBOLS USED THROUGHOUT THIS BOOK Throughout this book, you will see certain symbols that draw your attention to information that we would like you to consider before prescribing. Safety Consideration Symbols We have placed an indicator next to medications that may require special safety considerations. Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. CONSIDERING PREFERRED ALTERNATIVES We realize that you may not always be able to prescribe preferred drugs for your patients. However, by referring to this book before prescribing, you can help ensure that your patients take full advantage of coverage provided by their prescription drug plan. Possible preferred alternatives are listed for commonly prescribed nonpreferred drugs. Pharmacies cannot substitute a preferred brand-name drug without your approval. Therefore, a pharmacist may contact you to obtain authorization to dispense an alternative preferred product when a nonpreferred drug is prescribed. Again, since your patients can often benefit by paying less for alternative preferred products, we ask that you consider prescribing these preferred alternatives whenever possible. iv FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page v SAVINGONOUT-OF-POCKET COSTS FOR PATIENTS Your patients’ prescription drug plan determines the cost for generic, preferred brand-name, and nonpreferred brand-name drugs. Employers and other benefit providers often design prescription drug plans to encourage the use of generic and preferred brand-name drugs. For your patients, choosing nonpreferred drugs may mean paying higher out-of-pocket expenses (such as coinsurance, co-payments, and deductible amounts) or not receiving coverage at all. Patients may also pay less for generic drugs, or they may be asked to pay the cost difference between brand-name drugs and their generic equivalents, which are preferred by the plan. CONSULTING YOUR OFFICE WHEN APPROPRIATE When employers and other benefit sponsors design their prescription drug plans, they may choose to provide coverage only for certain medications or for particular uses, time periods, doses, or quantities (e.g., they may exclude coverage for medications for unapproved, unproven, or cosmetic indications, as well as over-the- counter medications). When coverage for medications is provided based on use or quantity, we may contact your office for additional information to determine whether coverage is available under the plan. Patients who are unsure whether these coverage rules apply for a particular medication can consult their prescription drug benefit manual or contact a Member Services representative to determine specific coverage requirements. GETTING ANSWERS TO YOUR QUESTIONS We maintain a national toll-free helpline exclusively for physicians and their staff. You or your office staff can call this phone number whenever you have a general question or don’t know the specific phone number you need. Just call 1 800 211-1456 from 8:00 a.m. to 8:00 p.m., eastern time, Monday through Friday, to reach our Physician Service Center. An experienced representative will answer your question or direct you to someone who can help you. If you know the specific phone number you want to reach, you may call that number directly. You can also access up-to-date information about the formularies administered by us in the “Physicians” section of our website at Express-Scripts.com. In addition, you can direct comments about the clinical content of the Preferred Prescriptions/Rx Selections Formularies to: Express Scripts Clinical Practices & Therapeutics Department of Medical Affairs 100 Parsons Pond Drive, MS F2-3 Franklin Lakes, NJ 07417 v FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A