Medical Mutual of Ohio Announces 2017 Pharmacy Plan Changes


Medical Mutual ACA Members Save Money with New 2017 High Performance Plus Formulary
(Applies to: Individual; Small Group)

Medical Mutual is moving all individual and small group ACA members to a custom closed formulary called the High Performance Plus formulary. This formulary provides members with a selection of high-quality drugs, carefully selected by a committee of physicians and pharmacists that encourages the use of generics and low cost brands. This saves the member money.

While the High Performance Plus formulary does exclude certain drugs from coverage that does not mean treatment for medical conditions for which those drugs might be used will not be available. Other lower cost alternatives will be included in the formulary. In the rare instance that none of the covered drugs is appropriate for the member and a non-formulary medication is required, the memberís physician or health provider can contact Express Scripts for a formulary exception.

A copy of the High Performance Plus formulary is available at and will soon be available on My Health Plan in the Prescription Drug Benefits tab.

The new High Performance Plus formulary will be made available to approximately 8,000 members enrolled in plans compliant with the Affordable Care Act (ACA) purchased on and off the exchange. The change goes into effect on January 1, 2017.

Minor Changes to the Basic/Basic Plus Formulary Effective January 1, 2017; Express Scripts to Notify Impacted Members of Non-ACA Plans
(Applies to: All non-ACA plans; excludes Medicare Advantage and Medicare Supplement)

To help ensure Medical Mutual offers our members a formulary that promotes safe, high-quality and cost-effective prescription medications, we are updating our Basic/Basic Plus formulary with Express Scripts. The brand-name medications included on the attached list will move from tier 2 (preferred brand-name drugs) to tier 3 (non-preferred brand-name drugs) or tier 4 (specialty) for groups with three- or four-tier benefit plans.

These changes impact non-ACA groups and members only. Groups that do not have at least a three-tier prescription benefit design are not affected by these changes.

As a reminder, formularies change on a regular basis. The updates occur for several reasons including:

  • New drugs are approved by the U.S. Food and Drug Administration and may be added to the formulary.
  • A generic equivalent of a drug becomes available and replaces the brand-name drug on the list. This usually makes the brand-name drug change tiers to non-preferred, increasing a memberís copay or coinsurance.
  • Drugs are taken off the formulary because they are not safe or donít work as well as other options.
The MMO Pharmacy Quality Committee of providers and internal clinicians supports the recommended changes from Express Scriptsí independent Pharmacy and Therapeutics Committee.

Member Notifications Planned
Express Scripts will send a letter to non-ACA members with a three- or four-tier prescription benefit design who have filled a prescription for one or more of the drugs moving to tier 3 or tier 4. The letter includes the names of alternative preferred formulary medications, if available. Using an alternative preferred formulary medication may help the member reduce his or her out-of-pocket costs.

Please talk to your groups about these upcoming changes. In addition, MMO will include a list of formulary changes on the provider eportal,, to ensure providers are aware of any updates to our preferred and non-preferred drugs.

If you have any questions, please contact BUA.