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Notice - Pharmacy Medication Coverage Changes

Date: 03/06/17

There have been recent updates to the Preferred Drug List on medications that will no longer be covered. Members were mailed a letter informing them of this change as well.

Effective April 1, 2017, Coordinated Care will no longer be covering selected medications. Members were mailed a letter informing them of this change (please see below). If you have any questions or concerns, please contact the Coordinated Care Pharmacy Department at 1-877-644-4613 Ext. 69622.

Thank you for your cooperation and continuing to help us serve our members with high quality care.

Medication no Longer Covered

Preferred Alternate Medication

Wellbutrin Tablet XL (Valeant Brand)

Bupropion XL generic (except from Valeant)

Ciprodex Suspension 0.3-0.1%

Ofloxacin Otic Solution 0.3%

Pentasa Capsule 500mg

Delzicol

Cuprimine Capsule 250mg

Depen

Clindamycin Phosphate/Benzoyl Peroxide Gel 1-5%

Clindamycin Phosphate 1% Gel & Benzoyl Peroxide Gel 5%

Absorica 10mg, 20mg, & 40mg Capsules (brand)

Isotretinoin Capsule (generic)

Clindagel Gel 1%

Clindamycin Gel (generic)

Neupogen Injection

Zarxio (with PA restriction)

Bismatrol Suspension 262/15ml

Bismuth Subsalicylate Suspension 525mg/15ml

Kaopectate Suspension 262/15ml

Bismuth Subsalicylate Suspension 525mg/15ml

Pepto-Bismol Suspension 262/15 ml

Bismuth Subsalicylate Suspension 525mg/15ml

Sooth Suspension 262/15ml

Bismuth Subsalicylate Suspension 525mg/15ml

Stomach Relief Suspension 262/15 ml

Bismuth Subsalicylate Suspension 525mg/15ml