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M E M B E R A N D P H Y S I C I A N F O R M U L A R Y
We are pleased to introduce to you the Health New England (HNE) Member and Physician Formulary. It is designed to introduce members and physicians to HNE’s selection of Formulary Drugs. About the Formulary:
New Medications:
Health New England is committed to providing 1. HNE does not typically add brand name our members with access to safe and effective medications to its list of covered drugs for at medications. HNE covers most prescription drugs least six months after FDA approval. Once the and a small number of non-prescription drugs FDA approves a drug, HNE’s committee of and medical supplies. Covered prescription drugs physicians and pharmacists reviews the drug’s are divided into three tiers with different member safety, effectiveness and value. During this copayments. Together, the first two tiers described clinical review period, HNE does not cover below are known as the Health New England Formulary. If a covered medication is not in the 2. Your doctor or pharmacist can tell you if the Formulary, it is considered Brand/Non-Formulary FDA approved a drug within the last 6 months. (Tier 3). Members still have access to these To check the current formulary status of any medications, but at the highest copayment. Specific prescription drug, you can go to the HNE prescription drug copayments are listed on your Services at 413-787-4004 or 800-310-2835.
Generic Drugs (Tier 1):
Review request for newly approved drugs: If your
physician requests an FDA approved medication Administration (FDA), Generic Drugs (Tier 1) for a non-FDA approved disease state/condition, contain the same active ingredients as brand name your physician must submit at least 3 peer-reviewed drugs, are just as safe and effective, and usually cost journal articles or abstracts; a national or published less. In most cases, Massachusetts law requires and Clinical Guideline; and/or published information HNE encourages the dispensing of generic drugs whenever possible. You pay the lowest copayment for generic drugs.
Review process for quantity limitations, step
therapy or exceptions: Your physician may initiate
Brand/Formulary Drugs (Tier 2):
the review request by completing our Review Brand/Formulary Drugs (Tier 2) are marketed Request Form, which can be found on the HNE under a trademarked brand name, usually by one website at hne.com or call HNE Member Services at manufacturer, and usually do not have less costly generic equivalents. Brand/Formulary Drugs are selected based on a review of the relative safety, Over the Counter Medications:
effectiveness and cost of the many FDA-approved HNE now covers a number of over the counter drugs on the market. Your copayment for Brand/ (OTC) medications such as allergy and PPI Formulary Drugs is higher than for Generic Drugs, medications. HNE has opened up coverage of but lower than for Brand/Non-Formulary Drugs, these medications as a cost savings to our members. These medications will usually be covered at a Tier 1 copayment or less. Please refer to our formulary Brand/Non-Formulary Drugs (Tier 3):
Any brand name drug that HNE has not selected as
a Brand/Formulary Drug is a Brand/Non-Formulary What is compounding?
Drug (Tier 3). This category includes; any brand Compounding is the producing of a medication name drug that has a generic equivalent (Tier 1), using raw chemicals and ingredients that are or brand drugs that there are formulary generic customized to meet the specific needs of a patient and brand alternatives. You and your doctor may according to a doctor’s specifications.
decide that a Brand/Non-Formulary Drug is most appropriate for you. These medications are still covered, but at the highest copayment level.
1
What is the copay for compounded medications?
refills and does not apply to any initial orders) Copayments for compounds will vary based on Maintenance Medications and Retail:
ingredients. However, not all compounds are This is HNE’s Access 90 program. This program covered. For questions regarding coverage, please allows our members to receive up to a 90 day supply call HNE Member Services at 413-787-4004 or of a maintenance medication at participating retail pharmacies. A copayment will apply to each 30 day supply. The Access 90 program does not apply to Maintenance Medications at Mail Order:
prescriptions filled at HNE’s specialty vendor ICORE or if prohibited by law. For a list of participating pharmacies • Generally a maintenance drug can be described as visit hne.com or call HNE Member Services at a medication that is used for the treatment of a chronic condition (i.e. diabetes, asthma, arthritis and heart disease) taken to stabilize the illness or ICORE (Specialty Vendor)
symptoms of the illness AND that has been classified by FDB (industry standard classifier) Members being treated with specialty medications are required to use the specialty pharmacy to fill self-injectable and oral oncology medications, with the • Only maintenance medications with a maintenance exception of insulin products, in order to maximize the indicator will be available through mail order.
pharmacy benefit and minimize out of pocket expenses. When to use the WellDyneRx mail service
ICORE’s order forms are available on hne.com or can be prescription drug benefit (*if you have the mail order
faxed to your provider by calling HNE Member Services benefit):
• You have verified that your medication is a true PLEASE NOTE:
maintenance medication as defined by HNE.
Attention Deficit Disorder Medications that are classified • You have obtained at least 2 refills at Retail and have as a controlled substance (CII & CIII): can now be filled not had an adverse reaction.
for up to a 60-day supply at an In-Plan Retail Pharmacy (this is subject to the stores internal policy). One • To take advantage of lower copayments for your copayment applies for each 30-day supply. This applies generic and formulary maintenance medications. to the state of Massachusetts pharmacies only. All other states are subject to their own state laws and internal • To plan ahead when you are going on an extended vacation.
How to use the WellDyneRx mail service
prescription drug benefit:
• We recommend obtaining 2 prescriptions for new
maintenance medications. One to be used for a
preliminary 30-day supply to be filled by your
local
• Complete the mail order member profile and submit following directions on the form, or visit hne.com.
• For faster service you can order refills on line at hne.com as indicated on invoice received from mail order (this only applies to prescriptions with 2
How to Use the HNE Member and Physician Formulary
The Formulary is divided into three sections: Generic Questions:
Drugs (Tier 1), Brand/Formulary Drugs (Tier 2) and If you have any questions about your prescription Brand/Non-Formulary Drugs (Tier 3). Each section is drugs, please speak with your doctor. If you have questions about the Formulary or your coverage, please call the HNE Member Services Department To find out if a covered medication you are currently at 413-787-4004 or 1-800-310-2835, Monday taking is part of the Formulary, follow these simple steps: through Friday, 8am to 5pm, or visit our website at hne.com.
1. Look up the name of the medication you actually
Other Important Information:
2. If you find the medication listed under Generic
Also included in the Formulary is a description of Drugs (Tier 1), you pay the lowest copayment Health New England’s non-covered drugs, as well level. Please keep in mind that the Generic as drugs that might require prior authorization, step Drug (Tier 1) listing is representative only. There are hundreds of generic drug products available. If you think that your drug is available as a For reference, there is a list of common brand name generic, please contact your local pharmacist.
drugs with available generic equivalents. The brand name products on this list are covered as Brand/ 3. If you find the medication listed under Brand/
Non-Formulary Drugs (Tier 3) and the generic Formulary Drugs (Tier 2), there is usually no equivalents are covered as Generic Drugs (Tier 1).
available generic equivalent and you pay the Please note: You must be an eligible member with prescription drug coverage when the medication is 4. If you do not find the covered medication, then
dispensed. If you are not an eligible member with it is probably a Brand/Non-Formulary Drug prescription drug coverage, medications are not (Tier 3), which is not a part of the Formulary. You will pay the highest copayment for these drugs. Please consult your doctor to see if there are any formulary brand or generic alternatives Important Notes
NOTE: The contents of this Formulary are subject
Please be aware that once a generic equivalent to change at any time without member notification.
is available, a drug will move to Tier 3.
For the most up to date listing, visit hne.com.
Massachusetts state law requires pharmacists to dispense a generic equivalent unless otherwise The formulary is fully reviewed annually and as
necessary throughout the year.
What are the effects of not
switching to a generic?
• You pay a higher copay• If you choose to continue on the brand name drug, a new script from your physician will need to reflect “Dispense as written.” Contact your physician if interested in discussing alternatives.
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Tier 1 – Generic Drug Listing
Approved by the U.S. Food and Drug Administration (FDA), Generic Drugs (Tier 1) contain the same active ingredients as brand name drugs, are just as safe and effective, and usually cost less. In most cases, Massachusetts law requires and HNE encourages the dispensing of generic drugs whenever possible. You pay the lowest copayment for generic drugs.
This list is representative only. If you think that your drug is available as a generic product, please
contact your physician or local pharmacist.
4 This list is subject to change. ** Indicates a medication with a Prior Authorization, Step Therapy, or Limit please see pages 16-32.
Tier 1 – Generic Drug Listing (continued)
This list is subject to change. ** Indicates a medication with a Prior Authorization, Step Therapy, or Limit please see pages 16-32.
5
Tier 1 – Generic Drug Listing (continued)
6 This list is subject to change. ** Indicates a medication with a Prior Authorization, Step Therapy, or Limit please see pages 16-32.
Tier 1 – Generic Drug Listing (continued)
This list is subject to change. ** Indicates a medication with a Prior Authorization, Step Therapy, or Limit please see pages 16-32.
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Tier 2 – Brand/Formulary Drug Listing
Brand/Formulary Drugs (Tier 2) are marketed under a trademarked brand name, usually by one manufacturer, and do not have less costly generic equivalents. Brand/Formulary Drugs are selected based on a review of the relative safety, effectiveness and cost of the many FDA-approved drugs on the market. Your copayment for Brand/Formulary Drugs is higher than for Generic Drugs, but lower than for Brand/Non-Formulary Drugs, which are described below.
8 This list is subject to change. ** Indicates a medication with a Prior Authorization, Step Therapy, or Limit please see pages 16-32.
Tier 2 – Brand/Formulary Drugs Listing (continued)
This list is subject to change. ** Indicates a medication with a Prior Authorization, Step Therapy, or Limit please see pages 16-32.
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Tier 2 – Brand/Formulary Drugs Listing (continued)
(Roche/Lifescan products only)Thalomid 10 This list is subject to change. ** Indicates a medication with a Prior Authorization, Step Therapy, or Limit please see pages 16-32.
Tier 2 Brand/Formulary Drugs Listing (continued)
Topamax TorecanTransderm-Scop **TricorTrilisateTrisoralenTriViFlor/IronTrizivirTrusoptTruvadaTussionexUniretic VagifemValcyteValtrexVancerilVanceril DSVancocinVentolin RotocapViagra **VidexVidex ECViokaseVira-AViraceptViramuneVireadVytoneXalatanYoconZavescaZetia**ZiagenZmax suspensionZomig ** This list is subject to change. ** Indicates a medication with a Prior Authorization, Step Therapy, or Limit please see pages 16-32.
11
Tier 3 – Brand/Non-Formulary Drugs
This catagory includes; any brand name drug that has a generic equivalent, or brand drugs that there are formulary generic and brand alternatives. Please always consult with your doctor to discuss formulary alternatives.
12 This list is subject to change. ** Indicates a medication with a Prior Authorization, Step Therapy, or Limit please see pages 16-32.
Tier 3 – Brand/Non-Formulary Drugs (continued)
This list is subject to change. ** Indicates a medication with a Prior Authorization, Step Therapy, or Limit please see pages 16-32.
13
Tier 3 – Brand/Non-Formulary Drugs (continued)
14 This list is subject to change. ** Indicates a medication with a Prior Authorization, Step Therapy, or Limit please see pages 16-32.
Tier 3 – Brand/Non-Formulary Drugs (continued)
This list is subject to change. ** Indicates a medication with a Prior Authorization, Step Therapy, or Limit please see pages 16-32.
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This section lists medications that are excluded, require prior authorization, require step therapy or have quantity
limitations. These lists are subject to change.
Excluded Medications
The following brand medications and their generics are currently NOT covered by Health New England: Note: The shaded rows indicate medications that are allowed through mail order, due to their FDA maintenance
indicator. ** See quantity limitation list
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This list is subject to change.
Prior Authorizations (PA)
The following medications require HNE’s prior approval. For more information, please contact our Member Services
department at 1-800-310-2835 or 787-4004, or visit our website hne.com for the appropriate form. Completed forms
should be faxed to 800-550-9246. Only FDA maintenance indicator drugs are allowed through mail order.
Atralin (PA does not apply to ages 13-29) Differin (PA does not apply to ages 13-29) Note: The shaded rows indicate medications that are allowed through mail order, due to their FDA maintenance
indicator. ** See quantity limitation list
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This list is subject to change.
Prior Authorizations (PA) Continued
Retin-A (PA does not apply to ages 13-29) Retin-A Micro (PA does not apply to ages 13-29) Note: The shaded rows indicate medications that are allowed through mail order, due to their FDA maintenance
indicator. ** See quantity limitation list
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This list is subject to change.
Prior Authorizations (PA) Continued
tretinoin (PA does not apply to ages 13-29) Note: The shaded rows indicate medications that are allowed through mail order, due to their FDA maintenance
indicator. ** See quantity limitation list
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This list is subject to change.
Step Therapy
Step therapy is an approach to medication management. Step Therapy is a program designed exclusively for people
who have certain conditions—diabetes, high blood pressure, and high cholesterol. The HNE Step Therapy program
is all about value. Most simply, that means getting a tried-and-true medication that’s proven safe and effective for
your condition, and getting it at the lowest possible cost.
This program is designed to have your prescription drugs be more affordable. We will work with you and your physician to be certain that you are getting the appropriate drug for your condition. Claims for drugs listed in the Step Therapy column below will process only if you have had a prescription filled from the First Line and/or Second Line medications listed within the last 180 days. The use of samples does not satisfy the requirements of documented usage of a First or Second Line drug of medical necessity for a Step Therapy drug. If it is medically necessary for you to use a Step Therapy drug before trying a First and/or Second Line drug, then your doctor can contact HNE to request a pharmacy review. If you have any questions about the program or need any pharmacy forms, please contact our Member Services Department at 1-800-310-2835 or 413-787-4004, or visit our website at hne.com. Completed forms should be faxed to 413-233-2777.
Please Note: Some of these Step Therapies have 3 steps. You must try the First Line drug before HNE will cover the
Second Line drug. You must try the Second Line drug before HNE will cover the Step Therapy drug.
Allergy (eye)
Emadine
Optivar
Pataday
Patanol
Allergy (oral)
Clarinex
Allergy (oral w/
decongestant)
Allegra D
Clarinex D
Allergy (suspension)
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This list is subject to change.
Analgesic
Avinza
Kadian
MS Contin
Opana
Oxycontin
Angiotensin II
Receptor Antagonist
• Nephropathy in Type Benazapril/hydrochlorothiazide Blocker (ARB)
Atacand HCT
Benicar HCT
Diovan HCT
Micardis HCT
Teveten HCT
Anti-depressant
Cymbalta
Effexor XR
Pristiq
Prozac Weekly
Wellbutrin XL
Zoloft
Cardio-vascular
Altoprev
Pravachol
Pravigard
Lescol XL
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This list is subject to change.
AdvicorAltoprevCaduetCrestorFluvastatinLescol, Lescol XLLipitorLovastatinMevacorPravacholPravastatinPravigardSimcorSimvastatinVytorinZocor Constipation
Diabetes
Actos
ACTOplus met
Avandamet
Avandaryl
Avandia
Byetta
Duetact
Januvia
Janumet
Lyrica
carbamazepineDepakoteDilantinfelbatolGabitrilgabapentinLamictallamotrigneKeppraNeurontinTegretolTopamaxZonegran 22
This list is subject to change.
Hypnotics
Ambien
Ambien CR
Lunesta
Rozerem
Sonata
Zaleplon
Infertility
Bravelle
Follistim
Migraine
Amerge
Axert
Frova
Maxalt
Relpax
Zomig
Multiple Sclerosis
Avonex
Betaseron
Nasal Steroids
Beconase AQ
Flonase
Nasalide
Nasarel
Nasacort AQ
Rhinocort AQ
Veramyst
Osteoporosis
Actonel
Boniva
Fosamax
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This list is subject to change.
Overactive Bladder
Detrol
Detrol LA
Ditropan
Ditropan XL
Enablex
Oxytrol
Sanctura
Sanctura XR
Vesicare
Proton Pump
Inhibitors (PPI’s)
Nexium
Prevacid
Prilosec
Zegerid
Only FDA maintenance indicator drugs are allowed through mail order.
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This list is subject to change.
Quantity Limitations / Quantity-based Copayments
The following medications have quantity limitations or have quantity-based copayments (that is, one copayment
is charged for the quantity shown below). This is to ensure safe and appropriate use and to minimize potential
waste of expensive medications. If you have any questions or need any pharmacy forms, please contact our
Member Services Department at 1-800-310-2835 or 413-787-4004, or visit our website at hne.com. Completed
forms should be faxed to 413-233-2777. ONLY FDA maintenance indicator medications are allowed through
mail order.
HNE PHARMACY BENEFIT QUANTITY LIMITED DRUGS
*shaded Rx rows are maintenance medications Advair Diskus
1 diskus = 60 metered dose per 30 day period Advair HFA
1 inhaler (120 actuations) for 30 day period 30mg and 60mg = 60 tablets per 30 day period 180mg = 30 tablets per 30 day period Allegra-D-12 hour
Allegra-D-24 hour
Allegra ODT
Altoprev
Ambien, Ambien CR
amlodipine
2.5mg and 5mg = 45 tablets per 30 day period; 10mg = 30 tablets per 30 day period budeprion SR
buproban
This list is subject to change.
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*shaded Rx rows are maintenance medications 1mg, 2mg and 4mg = 30 tablets per 30 day period 8mg = 60 tablets per 30 day period Cardura XL
4mg and 8mg = 30 tablets per 30 day period Catapres TTS-1, 2, 3
Caverject
Celebrex
60 tablets per 30 day period
90 days only per 12 month period
citalopram
Clarinex
Clarinex D 12 hour
Clarinex D 24hr
Clarinex Reditabs
clozapine
14 day supply per fill the first year, copay applies each fill. After 1 year then 30 day supply per fill.
Clozaril
14 day supply for fill the first year, copay applies each fill. After 1 year then 30 day supply per fill.
Cymbalta
20mg = 60 capsules per 30 day period30mg and 60mg = 30 capsules per 30 day perod doxazosin
1mg, 2mg and 4mg = 30 tablets per 30 day period 8mg = 60 tablets 30 day period 26
This list is subject to change.
*shaded Rx rows are maintenance medications 25mg, 37.5mg, 50mg, 100mg = 60 tablets per 30 day period75mg = 90 tablets per 30 day period Effexor XR
37.5mg = 30 capsules per 30 day period 75mg = 90 capsules per 30 day period 150mg = 60 capsules per 30 day period 25mg = 8 syringes per 30 day period 50mg = 4 syringes per 30 day period Epipen, Epipen JR
fentanyl lozenge
fexofenadine
30mg and 60mg = 60 tablets per 30 day period 180mg = 30 tablets per 30 day period fluoxetine
10mg and 20mg = 90 capsules per 30 day period 40mg = 60 capsules per 30 day period fluvoxamine
25mg = 45 tablets per 30 day period 50mg = 60 tablets per 30 day period 100mg = 90 tablets per 30 day period Foradil Aerolizer
1 package (60 blisters) per 30 day period 100mg = 60 tablets per 30 day period400mg = 30 tablets per 30 day period Granisetron HCL
6 tablets per 30 day periodSolution = 1 bottle (30ml) per 30 day period 2 injections per 30 day period (after initial titration) Humira Starter Pack
1mg and 5mg = 30 capsules per 30 day period 2mg and 10mg = 60 capsules per 30 day period 27
This list is subject to change.
*shaded Rx rows are maintenance medications 1Kit (2 syringes) per 30 day period6 units per 30 day period12 tablets per 30 day period itraconazole
Ketorolac
6 tablets per 30 day period solution - 1 bottle (30ml) per 30 day period 90 day supply per 12 month period per member Lescol, Lescol XL
Lotronex
lovastatin
10mg and 20mg = 30 tablets per 30 day period40mg = 60 tablets per 30 day period 25mg = 45 tablets per 30 day period 50mg = 60 tablets per 30 day period 100mg = 90 tablets per 30 day period 225mg, 300mg = 30 capsules per 30 day periodAll other strengths = 90 capsules per 30 day period Maxalt, Maxalt MLT
meloxicam
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This list is subject to change.
*shaded Rx rows are maintenance medications 10mg, 20mg = 30 tablets per 30 day period40mg = 60 tablets per 30 day period Neulasta
Neupogen
Nexium, Nexium packet
Nicotine Patches
30 patches per 30 day period, 90 day supply per 12 month period Nicotrol Inhaler
168 units per rx, 90 day supply per 12 month period Nicotrol Nasal Spray
4 bottles per rx, 90 day supply per 12 month period 2.5mg and 5mg = 45 tablets per 30 day period10mg = 30 tablets per 30 day period omeprazole, OTC
10mg and 40mg = 30 capsules per 30 day period 20mg = 120 capsules per 30 day period Ortho-Evra
Oxycontin
Oxycodone HCL ER
paroxetine
10mg and 40mg = 45 tablets per 30 day period 20mg and 30mg = 60 tablets per 30 day period paroxetine CR
12.5mg = 30 tablets per 30 day period 25mg and 37.5mg = 60 tablets per 30 day period 10mg and 40mg = 45 tablets per 30 day period 20mg and 30mg = 60 tablets per 30 day period 12.mg = 30 tablets per 30 day period 25mg and 37.5mg = 60 tablets per 30 day period Perforomist
This list is subject to change.
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*shaded Rx rows are maintenance medications 10mg and 40mg = 45 tablets per 30 day period20mg and 30mg = 60 tablets per 30 day period Pravachol
pravastatin
Pravigard PAC
Prevacid
Prilosec
10mg and 40mg = 30 capsules per 30 day period 20mg = 60 capsules per 30 day period Prilosec OTC
Protonix
10mg and 20mg = 90 capsule per 30 day period 40mg = 60 capsules per 30 day period Prozac Weekly
Regranex
1 tube per 30 day period 3 tubes (90 day supply) per 12 month period 1 kit per 30 day period; 2 kits per 12 month period Revlimid
selfemra
Serevent Diskus
60 metered doses (1 diskus) per 30 day period sertraline
25mg and 50mg = 45 tablets per 30 day period100mg = 60 tablets per 30 day period simvastatin
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This list is subject to change.
*shaded Rx rows are maintenance medications Sporanox
Suboxone
2mg = 270 tablets per 30 day period 8mg = 90 tablets per 30 day period 2mg = 270 tablets per 30 day period8mg = 90 tablets per 30 day period Sumatriptan
1Kit (2 syringes) per 30 day period6 units per 30 day period12 tablets per 30 day period Symbicort
1 inhaler (120 acuations) per 30 day period 10 capsules per 30 day period20 capsules per 12 month periodLiquid = 3 bottles per 30 day period or 6 bottles per 12 month period terazosin
1mg and 5mg = 30 capsules 30 day period2 mg and 10mg = 60 capsules per 30 day period terbinafine
Transderm Scop
venlafaxine
25mg, 37.5mg, 50mg, 100mg = 60 tablets per 30 day period75mg = 90 tablets per 30 day period Wellbutrin SR
This list is subject to change.
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*shaded Rx rows are maintenance medications Wellbutrin XL
Zegerid, Zegerid packets
25mg and 50mg = 45 tablets per 30 day period 100mg = 60 tablets per 30 day period zolpidem
Zomig, Zomig ZMT
Zomig Nasal Spray
Zyrtec-D
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This list is subject to change.

Source: http://www.hne.com/HNE_pharmacy/ht/documents/7_09MembFormularyGuts.pdf