If you continue using one of these drugs without prior approval for medical necessity, you may be required to pay the full cost. THE THREE BIG PBMS (phar-macy benefit managers), Express Scripts, CVS Caremark, and OptumRx, released their 2020 exclusion lists in the fourth quarter of 2019. to the CVS Caremark® National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review and approval. Examples of excluded agents include mupirocin cream, Acanya, Finacea Gel, and fluocinonide cream 0.1%. This article represents PHSI’s analysis of publicly available information regarding the three PBMs’ formulary exclusion lists for 2020.

PBMs exclude products because of clinical, financial, and humanistic reasons. Of those 246 exclusions, 169 (69%) were for brands that have covered generic equivalents. h�b```��f!��1�0����X���[ �/��_�!G��3�2:� �����u�;j'�c��`� }��q$�G�dR�8����4�Gz5n�:˔$�F;t�y���4 ESI will exclude an additional 35 drugs, 13 (37%) of which are multisource brands. 1552 0 obj <>stream 888-258-0780 (Option 2) for questions Drug Lists Drug Safety Alerts Medicare Part D Any Willing Provider Request Pharmacy Pre-Enrollment Questionnaire Pharmacy Enrollment Self Service Emergency Response Mail Service Numbers, Forms and Information Notice of RI OHIC BULLETIN 2020-03. LIs�ѲLk+؇|x�o�i1�����������.�?L\^�V\ ��XW�O�fAY>�g�P=�/LYɯ����j�R3'=�X�eR M�������o_.��Q� ��c��I)�g��>ǩ�bZ�������/�EULn��b�=�҆��Q��i0OJ�SY Exclusion Drug List. It’s that time of year again, PHSI’s annual review of the PBM formulary exclusion list updates! endstream endobj startxref Generics Only Preventive Drug List. Drugs with Quantity Limits and Prior Authorization Requirements. 2020 Advanced Control Specialty Preferred Drug List. The new 2020 exclusions, as researched by PHSI, are as follows:Excluded multisource brands with available generics are as follows:During the review, PHSI made the following observations:Each of the major PBMs has taken a different approach to managing drug spend in 2020 and formulary exclusions continue to play a major role. ); requests for use of such medications outside of their listed criteria will be reviewed for medical necessity. CVS Caremark® Formulary Exclusions for PEBTF and non-Medicare Eligible REHP Members Below is a list of medicines by drug class that will not be covered without a prior authorization for medical necessity. %PDF-1.5 %���� Don Dietz, R.Ph. Formularies subject to change. Qw E��}�4?�\Ę�L����4F6�|k��0�LU��* �Ůw�����poK2���AL�쇋j1��t���{ �(S6 Readers are encouraged to assess the lists for themselves. h޼Wmo�6�+�>d�N�m@M�(�AMG�_[]��;Ғ%���Z4i�x:>�%��0 CVS Caremark added 100 new exclusions; 32 of those 100 exclusions (32%) were for brands with available generics. endstream endobj 1512 0 obj <>/Metadata 40 0 R/Pages 1509 0 R/StructTreeRoot 47 0 R/Type/Catalog>> endobj 1513 0 obj <>/MediaBox[0 0 612 792]/Parent 1509 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 1514 0 obj <>stream %%EOF October 2019 CVS Caremark® Formulary Exclusions for PEBTF and non-Medicare Eligible REHP Members Below is a list of medicines by drug class that will not be covered without a prior authorization for medical necessity. They are making value judgments and have decided covering these products is no longer warranted. CVS focused heavily on the dermatological category for 2020 exclusions, with an additional 19 dermatology agents being added to the exclusion list. Specialty As new specialty products launch, all existing products in the class will be re-evaluated to determine appropriate formulary placement and potentially excluded, added back to formulary or not listed. If you continue using one of these drugs without prior approval for medical necessity, you may be required to pay the full cost. Ann Johnson, Pharm.D. Certain medications on the list are covered if utilization management criteria are met (i.e., Step Therapy, Prior Authorization, Quantity Limits, etc.

If there is no generic available, there may be more than one brand name medicine to treat a condition. 1511 0 obj <> endobj Based on PHSI’s calculations, OptumRx leads the way with 246 new formulary exclusions. 2020 Formulary Exclusion Lists — Why All the Changes? CVS is making a strong push to exclude high cost dietary supplement agents. 2019-20 Plan Year (Plan year starting Sept. 1, 2019 - Aug. 31, 2020) ... 2020 CVS/Caremark Formulary. Express Scripts (ESI), CVS Caremark, and OptumRx have published their formulary exclusion lists for 2020. Preferred Drug List: The CVS Caremark® Performance/Preferred Drug List is a guide within select therapeutic categories for clients, plan members, and health care providers. January 2019 CVS Caremark® Formulary Exclusions for PEBTF and non-Medicare Eligible REHP Members Below is a list of medicines by drug class that will not be covered without a prior authorization for medical necessity. 0