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Medications to be excluded from the Select Drug Program® Formulary

May 25, 2017

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The Independence Pharmacy and Therapeutics Committee periodically reviews the Select Drug Program Formulary to ensure the selection of clinically safe, clinically effective, and economically advantageous medications for our members. Effective July 1, 2017, based on a recent review, Independence will no longer cover the following five medications under the pharmacy benefit:

DrugComponentsReason for exclusion
Duexis®Ibuprofen 800 mg/famotidine 26.6 mg tabletCombination of ibuprofen and famotidine; no advantage over the individual components.
Glumetza®Metformin modified, extended release 500 mg, 1000 mg tabletExtended release formulation of metformin; other extended release products are available.
Vimovo®Naproxen 375 mg/ esomeprazole 20 mg tablet

Naproxen 500 mg/ esomeprazole 20 mg tablet
Combination of naproxen and esomeprazole; no advantage over the individual components; esomeprazole 20 mg is available over the counter.
Yosprala®Omeprazole 40 mg/aspirin 81 mg tablet

Omeprazole 40 mg/aspirin 325 mg tablet
Combination of aspirin and omeprazole; no advantage over the individual components.
Zegerid® capsulesOmeprazole 40 mg/sodium bicarbonate 1100 mgCombination of omeprazole and sodium bicarbonate offers no advantage over omeprazole alone or other proton pump inhibitors.

As part of the review, it was determined that these medications no longer meet the medical necessity criteria, as defined in the member benefit book, and are not eligible for a medical necessity formulary exception review. Members who currently take these medications will be sent a letter advising them to contact their physician to discuss alternatives and to obtain a new prescription for medications covered under their prescription drug benefit.

If you have any questions, please call Customer Service at 1-800-ASK-BLUE.

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