PRESCRIPTION DRUG LIST CHANGES
|
|
- Jody Tucker
- 6 years ago
- Views:
Transcription
1 PRESCRIPTION DRUG LIST CHANGES For Providers 2018 Changes are being made to Cigna s Prescription Drug List that may affect some of your patients. These changes are listed by drug list name and by effective date. Below is the list of medications that are changing coverage levels. If you have patients who continue to fill prescriptions for these medications on or after the date listed, they will be responsible for the full cost and will not receive coverage for these medications. We encourage you to speak with your affected patients to see if there are covered alternative medications that may work for them. Please note that the coverage status of medications under our Prescription Drug Lists are always subject to the cost-share requirements, exclusions and coverage limitations of particular benefit plans. STANDARD PRESCRIPTION DRUG LIST Drug(s) not covered in drug class^ January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor Parnate Tofranil Drug(s) covered in drug class nortriptyline tranylcypromine imipramine ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ER ATTENTION DEFICIT HYPERACTIVITY DISORDER Zyflo CR Desoxyn Dexedrine zileuton ER methamphetamine dextroamphetamine, dextroamphetamine ER BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablets CANCER Nilandron nilutamide DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba Novolin, Novolog Humalog, Humulin GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Anucort-HC, Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto- Pak, Proctosol-HC, Proctozone-HC Lotronex alosetron Marinol dronabinol omeprazole bicarbonate packets, omeprazole mg capsules Rowasa mesalamine enema Uceris tablet budesonide EC capsule UPDATED_10/27/2017
2 STANDARD PRESCRIPTION DRUG LIST (cont.) Drug(s) not covered in drug class^ Drug(s) covered in drug class January 1, 2018 GASTROINTESTINAL/HEARTBURN (cont) Zegerid omeprazole Zofran ondansetron Zofran ODT ondansetron ODT HORMONAL AGENTS DDAVP desmopressin Hectorol doxercalciferol capsule INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillinclavulanate Diflucan fluconazole E.E.S. 200, Eryped 400 erythromycin ethylsuccinate Mepron atovaquone Sporanox itraconazole Targadox Valcyte Vancocin Zovirax Avidoxy tablet, doxycycline hyclate, Morgidox capsule valganciclovir vancomycin capsule acyclovir MISCELLANEOUS Gralise, Horizant gabapentin PAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone D.H.E. 45, Migranal dihydroergotamine Imitrex, Sumavel DosePro Lorzone OxyContin Roxicodone Tivorbex Vanatol LQ Vivlodex Zomig Zorvolex sumatriptan chlorzoxazone Embeda, Hysingla ER, Xtampza ER oxycodone indomethacin PARKINSON'S DISEASE Lodosyn carbidopa Requip XL butalbital/acetaminophen/caffeine tabs or caps meloxicam sumatriptan, zolmitriptan diclofenac, diclofenac ER ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone Zyprexa Zyprexa Zydis olanzapine olanzapine ODT
3 STANDARD PRESCRIPTION DRUG LIST (cont.) Drug(s) not covered in drug class^ Drug(s) covered in drug class January 1, 2018 SKIN CONDITIONS Cutivate fluticasone cream Kenalog triamcinolone spray Locoid lotion hydrocortisone butyrate Luzu ketoconazole cream Soriatane acitretin Ziana clindamycin-tretinoin SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil Provigil modafinil Restoril temazepam URINARY TRACT CONDITIONS Detrol tolterodine Detrol LA tolterodine ER Ditropan XL oxybutynin ER Enablex darifenacin ER Gelnique darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER Non-preferred brand drug(s) Generic and/or preferred brand alternatives January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY Adderall XR dextroamphetamine-amphetamine ER DISORDER Focalin XR dexmethylphenidate ER SKIN CONDITIONS Ala-Scalp hydrocortisone Analpram HC lotion hydrocortisone-pramoxine Capex shampoo fluocinolone Cordran flurandrenolide Differin adapalene Metrogel metronidazole gel Naftin naftifine Nucort, Texacort hydrocortisone Drug(s) requiring prior authorization January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi HORMONAL AGENTS Androderm, Androgel, Striant, testosterone Additional information This medication will only be covered by your patient s plan if you request and Drug(s) with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your patient s plan only covers this ALZHEIMER'S DISEASE Namenda XR, Namzaric medication up to a certain amount over a ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, certain number of days. Larger amounts Pristiq will only be covered if you request and ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, nilutamide EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan
4 STANDARD PRESCRIPTION DRUG LIST (cont.) Drug(s) with quantity limits Additional information January 1, 2018 HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ Fanapt ANTI-PSYCHOTICS SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical SLEEP DISORDERS/SEDATIVES Hetlioz January 1, 2018 Step Therapy medications^^ Your patient s plan only covers this medication up to a certain amount over a certain number of days. Larger amounts will only be covered if you request and Generic and/or preferred brand alternatives ATTENTION DEFICIT HYPERACTIVITY Focalin XR dexmethylphenidate ER DISORDER SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide SKIN CONDITIONS Ala-Scalp hydrocortisone Capex shampoo fluocinolone Cordran flurandrenolide Nucort, Texacort hydrocortisone Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT mg Bystolic 10mg Tekturna 150mg Tekturna HCT mg Benicar HCT 40-25mg Bystolic 20mg Tekturna 300mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Tekturna HCT mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg
5 STANDARD PRESCRIPTION DRUG LIST (cont.) PERFORMANCE PRESCRIPTION DRUG LIST Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg Non-preferred brand drug(s) Generic and/or preferred brand alternatives January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Tresiba, Levemir GASTROINTESTINAL/HEARTBURN omeprazole bicarbonate packet, omeprazole 40mg-1100mg capsule, 20mg-1100mg INFECTIONS Eryped 400 erythromycin PAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Embeda, Hysingla ER, Xtampza ER Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps SKIN CONDITIONS Ala-Scalp hydrocortisone topical Capex shampoo fluocinolone scalp Cordran flurandrenolide topical Differin adapalene Kenalog spray triamcinolone spray Locoid lotion hydrocortisone butyrate Metrogel metronidazole gel Naftin naftifine Nucort, Texacort hydrocortisone Drug(s) requiring prior authorization Additional information January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar This medication will only be covered by GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi your patient s plan if you request and HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, testosterone, Vogelxo PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone Drug(s) with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone, Nasonex Your patient s plan only covers this ALZHEIMER'S DISEASE Namenda XR, Namzaric medication up to a certain amount over a ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, certain number of days. Larger amounts will only be covered if you request and Pristiq
6 PERFORMANCE PRESCRIPTION DRUG LIST (cont.) Drug(s) with quantity limits Additional information January 1, 2018 ASTHMA/COPD/RESPIRATORY Perforomist Your patient s plan only covers this BLOOD PRESSURE/HEART MEDICATIONS Ranexa medication up to a certain amount over a CANCER Fareston, Nilandron, nilutamide certain number of days. Larger amounts will only be covered if you request and DIABETES Jentadueto, Tradjenta EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle Dot, yuvafem INFECTIONS Zovirax MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, Zyclara SLEEP DISORDERS/SEDATIVES Hetlioz Step Therapy medications^^ Generic and/or Preferred Brand Alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole Orap pimozide SKIN CONDITIONS Locoid lotion hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zolpidem Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT mg Tekturna HCT mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg
7 PERFORMANCE PRESCRIPTION DRUG LIST (cont.) VALUE PRESCRIPTION DRUG LIST Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg Non-preferred brand drug(s) Generic and/or preferred brand alternatives January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta Stiolto Respimat Anoro Ellipta ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER DIABETES Apidra Humalog Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia Toujeo Basaglar, Tresiba, Levemir PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45 dihydroergotamine Imitrex sumatriptan OxyContin Embeda, Hysingla ER, Xtampza ER Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps Zomig nasal spray sumatriptan, zolmitriptan SKIN CONDITIONS Differin adapalene Metrogel metronidazole gel Naftin naftifine Drug(s) requiring prior authorization Additional information January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar This medication will only be covered by GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder your patient s plan if you request and packet, tripack, Sancuso, Varubi HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, testosterone, Vogelxo PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone
8 VALUE PRESCRIPTION DRUG LIST (cont.) Drug(s) with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone Your patient s plan only covers this ALZHEIMER'S DISEASE Namenda XR, Namzaric medication up to a certain amount over a ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan, Pristiq certain number of days. Larger amounts will only be covered if you request and ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, Nilandron, nilutamide DIABETES Jentadueto, Tradjenta EYE CONDITIONS bimatoprost, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem INFECTIONS Zovirax MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, Zyclara SLEEP DISORDERS/SEDATIVES Hetlioz Step Therapy medications^^ Generic and/or preferred brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole Orap pimozide SKIN CONDITIONS Locoid lotion hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor zolpidem, eszopiclone Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT mg Tekturna HCT mg
9 VALUE PRESCRIPTION DRUG LIST (cont.) Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg ADVANTAGE PRESCRIPTION DRUG LIST Non-preferred brand drug(s) Generic and/or preferred brand alternatives January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta Stiolto Respimat Anoro Ellipta ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia Toujeo Basaglar, Tresiba, Levemir PAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Embeda, Hysingla ER, Xtampza ER Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps SKIN CONDITIONS Differin adapalene Metrogel metronidazole gel Naftin naftifine Drug(s) requiring prior authorization Additional information January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar This medication will only be covered by GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi your patient s plan if you request and HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, Vogelxo, testosterone gel, Vogelxo PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone Drug(s) with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone Your patient s plan only covers this ALZHEIMER'S DISEASE Namenda XR, Namzaric medication up to a certain amount over a certain number of days. Larger amounts ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan, Pristiq will only be covered if you request and
10 ADVANTAGE PRESCRIPTION DRUG LIST(cont.) January 1, 2018 Drug(s) with quantity limits Additional information January 1, 2018 ASTHMA/COPD/RESPIRATORY Perforomist Your patient s plan only covers this BLOOD PRESSURE/HEART MEDICATIONS Ranexa medication up to a certain amount over a certain number of days. Larger amounts CANCER Fareston, Nilandron, nilutamide will only be covered if you request and DIABETES Jentadueto, Tradjenta EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS INFECTIONS MISCELLANEOUS OSTEOPOROSIS PRODUCTS PAIN RELIEF AND INFLAMMATORY DISEASE SCHIZOPHRENIA/ANTI-PSYCHOTICS SEIZURE DISORDERS SKIN CONDITIONS SLEEP DISORDERS/SEDATIVES ATTENTION DEFICIT HYPERACTIVITY DISORDER Step Therapy medications^^ Adderall XR Focalin XR Generic and/or preferred brand alternatives dextroamphetamine-amphetamine ER dexmethylphenidate ER DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole Orap pimozide SKIN CONDITIONS Locoid lotion hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zaleplon, zolpidem, zolpidem ER Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem Zovirax Nuedexta alendronate Daliresp, Mitigare Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv Gabitril, Potiga Denavir, Regranex, Santyl, Vectical, Zyclara Hetlioz Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT mg Tekturna HCT mg
11 ADVANTAGE PRESCRIPTION DRUG LIST (cont.) Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Non-preferred brand drug(s) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg LEGACY PRESCRIPTION DRUG LIST Generic and/or preferred brand alternatives January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER CANCER Nilandron nilutamide DIABETES Apidra Humalog, Novolog Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba GASTROINTESTINAL/HEARTBURN omeprazole bicarbonate packet, omeprazole 40mg-1100mg capsule, 20mg-1100 mg capsule INFECTIONS Eryped 400 erythromycin PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45 dihydroergotamine Imitrex sumatriptan OxyContin Embeda, Hysingla ER, Xtampza ER Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps SKIN CONDITIONS Ala-Scalp hydrocortisone Analpram HC hydrocortisone-pramoxine Capex shampoo fluocinolone Cordran flurandrenolide Differin adapalene Kenalog triamcinolone spray Locoid lotion hydrocortisone butyrate Metrogel metronidazole gel Naftin naftifine Nucort, Texacort hydrocortisone
12 LEGACY PRESCRIPTION DRUG LIST (cont.) Drug(s) requiring prior authorization Additional information January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar This medication will only be covered by GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi your patient s plan if you request and HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, testosterone, Vogelxo PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone Drug(s) with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone Your patient s plan only covers this ALZHEIMER'S DISEASE Namenda XR, Namzaric medication up to a certain amount over a ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, certain number of days. Larger amounts Pristiq will only be covered if you request and ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, Nilandron, nilutamide DIABETES Jentadueto, Tradjenta EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem INFECTIONS Zovirax MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, Zyclara SLEEP DISORDERS/SEDATIVES Hetlioz Step Therapy medications^^ Generic and/or preferred brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole Orap dexmethylphenidate ER pimozide SKIN CONDITIONS Locoid lotion hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zolpidem Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg
13 LEGACY PRESCRIPTION DRUG LIST (cont.) January 1, 2018 Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) ANXIETY/DEPRESSION/ Trintellix 5mg BIPOLAR DISORDER (cont) Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT mg Tekturna HCT mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) Drug(s) not covered in drug class^ Drug(s) covered in drug class January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor nortriptyline Parnate tranylcypromine Tofranil imipramine ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ER Zyflo CR zileuton ER ATTENTION DEFICIT HYPERACTIVITY Desoxyn methamphetamine DISORDER Dexedrine dextroamphetamine, dextroamphetamine ER BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol CANCER Nilandron nilutamide DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba Novolin, Novolog Humalog, Humulin
14 PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Drug(s) not covered in drug class^ Drug(s) covered in drug class January 1, 2018 GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto-Pak, Proctosol-HC, Proctozone-HC Marinol dronabinol omeprazole bicarbonate packet, 40mg- omeprazole 1100mg capsule, 20mg-1100mg Rowasa mesalamine enema Uceris tablet budesonide EC capsule Zegerid omeprazole Zofran ondansetron Zofran ODT ondansetron ODT HORMONAL AGENTS Cortrosyn cosyntropin DDAVP Hectorol desmopressin doxercalciferol INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillinclavulanate Diflucan fluconazole E.E.S. 200, Eryped 400 Mepron Sporanox Targadox Valcyte Vancocin Zovirax erythromycin atovaquone itraconazole Avidoxy, demeclocycline, doxycycline, doxycycline IR-DR, minocycline, minocycline ER, mondoxyne NL, Morgidox capsule, tetracycline valganciclovir vancomycin capsule acyclovir PAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone D.H.E. 45, Migranal dihydroergotamine Gralise, Horizant Imitrex, Sumavel DosePro Lorzone OxyContin Roxicodone Tivorbex Vanatol LQ gabapentin sumatriptan chlorzoxazone Embeda, Hysingla ER, Xtampza ER oxycodone indomethacin butalbital/acetaminophen/caffeine tabs or caps
15 PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) January 1, 2018 Non-preferred brand drug(s) Generic and/or preferred brand alternatives January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER SKIN CONDITIONS Ala-Scalp hydrocortisone Analpram HC lotion hydrocortisone-pramoxine Capex shampoo fluocinolone Cordran flurandrenolide Differin adapalene Metrogel metronidazole gel Naftin naftifine Nucort, Texacort hydrocortisone Drug(s) not covered in drug class^ Drug(s) requiring prior authorization January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi HORMONAL AGENTS Androderm, Androgel, Striant, Testopel, testosterone Drug(s) covered in drug class PAIN RELIEF AND INFLAMMATORY Vivlodex meloxicam DISEASE (cont) Zomig sumatriptan, zolmitriptan Zorvolex diclofenac, diclofenac ER PARKINSON'S DISEASE Lodosyn carbidopa Requip XL ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon capsule ziprasidone Zyprexa tablet olanzapine Zyprexa Zydis olanzapine ODT SKIN CONDITIONS Cutivate fluticasone Kenalog topical spray triamcinolone Locoid hydrocortisone Luzu ketoconazole Soriatane acitretin Ziana clindamycin-tretinoin SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil Provigil modafinil Restoril temazepam URINARY TRACT CONDITIONS Detrol tolterodine Detrol LA tolterodine ER Ditropan XL oxybutynin ER Enablex darifenacin ER Gelnique darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER Additional information This medication will only be covered by your patient s plan if you request and receive approval from Cigna.
16 PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Drug(s) with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your patient s plan only covers this ALZHEIMER'S DISEASE Namenda XR, Namzaric medication up to a certain amount over a certain number of days. Larger amounts ANXIETY/DEPRESSION/BIPOLAR DISORDER desvanlafaxine 25mg, 100mg, Marplan, will only be covered if you request and Pristiq ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, nilutamide EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical SLEEP DISORDERS/SEDATIVES Hetlioz Step Therapy medications^^ Generic and/or preferred brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide dexmethylphenidate ER SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zolpidem Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT mg Tekturna HCT mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg
17 PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg Drug(s) not covered in drug class^ Drug(s) covered in drug class January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor nortriptyline Parnate tranylcypromine Tofranil imipramine ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta Stiolto Respimat Anoro Ellipta Zyflo montelukast, zafirlukast, zileuton ER Zyflo CR zileuton ER ATTENTION DEFICIT HYPERACTIVITY Desoxyn methamphetamine DISORDER Dexedrine dextroamphetamine, dextroamphetamine ER BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablet CANCER Nilandron nilutamide DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba EYE CONDITIONS Alocril, Alomide cromolyn eye drops Bepreve, Emadine, Lastacaft, Pataday, azelastine, epinastine, olopatadine Patanol, Pazeo Elestat epinastine GASTROINTESTINAL/HEARTBURN Marinol dronabinol Rowasa mesalamine enema Zofran ondansetron Zofran ODT ondansetron ODT
18 VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Drug(s) not covered in drug class^ Drug(s) covered in drug class January 1, 2018 HORMONAL AGENTS DDAVP nasal spray, tablet desmopressin nasal spray, tablets Hectorol doxercalciferol INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate Diflucan fluconazole E.E.S. 200, Eryped 400 Mepron Sporanox Targadox Valcyte Vancocin Zovirax erythromycin atovaquone itraconazole doxycycline valganciclovir vancomycin capsule acyclovir PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine Imitrex OxyContin Roxicodone Vanatol LQ Zomig sumatriptan Embeda, Hysingla ER, Xtampza ER oxycodone PARKINSON'S DISEASE Lodosyn carbidopa Requip XL butalbital/acetaminophen/caffeine tabs or caps sumatriptan, zolmitriptan ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone SKIN CONDITIONS Zyprexa tablet Zyprexa Zydis Acanya, Atralin, Avita, Azelex, Differin, Epiduo, Epiduo Forte, Fabior, Onexton, Retin-A, Retin-A Micro, Tretin-X, Veltin Cutivate Dovonex, Sorilux Enstilar, Taclonex Soriatane olanzapine tablet olanzapine ODT Aczone, adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycinbenzoyl peroxide, clindamycin-tretinoin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, tretinoin, triamcinolone, Trianex, Triderm fluticasone calcipotriene calcipotriene-betamethasone DP acitretin
19 VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Drug(s) not covered in drug class^ Drug(s) covered in drug class January 1, 2018 SKIN CONDITIONS (cont) Tazorac adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Benzepro, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, triamcinolone, Trianex, Triderm Vectical calcitriol ointment SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil URINARY TRACT CONDITIONS Provigil Restoril Detrol, Detrol LA, Ditropan XL, Enablex, Gelnique Non-preferred brand drug(s) modafinil temazepam darifenacin ER, oxybutynin ER, tolterodine, tolterodine ER, trospium ER Generic and/or preferred brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Drug(s) requiring prior authorization January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi HORMONAL AGENTS Androderm, Androgel, Striant testosterone Additional information This medication will only be covered by your patient s plan if you request and Drug(s) with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your patient s plan only covers this ALZHEIMER'S DISEASE Namenda XR, Namzaric medication up to a certain amount over a certain number of days. Larger amounts ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan will only be covered if you request and ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER EYE CONDITIONS HORMONAL AGENTS MISCELLANEOUS OSTEOPOROSIS PRODUCTS PAIN RELIEF AND INFLAMMATORY DISEASE SCHIZOPHRENIA/ANTI-PSYCHOTICS SEIZURE DISORDERS SKIN CONDITIONS SLEEP DISORDERS/SEDATIVES Fareston, nilutamide bimatoprost eye drops, Cystaran, Zioptan Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem Nuedexta alendronate Daliresp, Mitigare Fanapt Gabitril, Potiga Denavir, Regranex, Santyl Hetlioz
20 VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Step Therapy medications^^ Generic and/or preferred brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide dexmethylphenidate ER SLEEP DISORDERS/SEDATIVES Silenor zolpidem, eszopiclone Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Trintellix 5mg Fetzima ER 80mg Trintellix 20mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Fycompa 4mg Fycompa 6mg Trokendi XR 25mg Trokendi XR 100mg Aptiom 800mg Fycompa 8mg Fycompa 12mg Trokendi XR 50mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) Drug(s) not covered in drug class^ January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor Parnate Tofranil Drug(s) covered in drug class nortriptyline tranylcypromine imipramine ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta ATTENTION DEFICIT HYPERACTIVITY DISORDER Stiolto Respimat Zyflo Zyflo CR Desoxyn Dexedrine Anoro Ellipta BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablet CANCER Nilandron nilutamide montelukast, zafirlukast, zileuton ER zileuton ER methamphetamine dextroamphetamine, dextroamphetamine ER
21 ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Drug(s) not covered in drug class^ Drug(s) covered in drug class January 1, 2018 DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba EYE CONDITIONS Alocril, Alomide cromolyn eye drops Bepreve, Emadine, Lastacaft, Pataday, azelastine, epinastine, olopatadine Patanol, Pazeo Elestat epinastine GASTROINTESTINAL/HEARTBURN Marinol dronabinol Rowasa mesalamine enema Zofran ondansetron Zofran ODT ondansetron ODT HORMONAL AGENTS Cortrosyn cosyntropin DDAVP desmopressin Hectorol doxercalciferol INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate Diflucan fluconazole E.E.S. 200, Eryped 400 erythromycin Mepron Sporanox Targadox Valcyte Vancocin Zovirax atovaquone itraconazole doxycycline valganciclovir vancomycin capsule acyclovir PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine Imitrex OxyContin Roxicodone Vanatol LQ Zomig sumatriptan Embeda, Hysingla ER, Xtampza ER oxycodone PARKINSON'S DISEASE Lodosyn carbidopa Requip XL butalbital/acetaminophen/caffeine tabs or caps sumatriptan, zolmitriptan ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone Zyprexa tablet Zyprexa Zydis olanzapine olanzapine ODT
22 ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Drug(s) not covered in drug class^ January 1, 2018 SKIN CONDITIONS Acanya, Atralin, Avita, Azelex, Differin, Epiduo, Epiduo Forte, Fabior, Onexton, Retin-A, Retin-A Micro, Tretin-X, Veltin Cutivate Dovonex, Sorilux Enstilar, Taclonex Soriatane Tazorac Vectical Drug(s) covered in drug class Aczone, adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycinbenzoyl peroxide, clindamycin-tretinoin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, tretinoin, triamcinolone, Trianex, Triderm fluticasone calcipotriene calcipotriene-betamethasone DP acitretin SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil Provigil Restoril adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, Benzepro, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, triamcinolone, Trianex, Triderm calcitriol modafinil temazepam URINARY TRACT CONDITIONS Detrol tolterodine Detrol LA Ditropan XL Enablex Gelnique Non-preferred brand drug(s) tolterodine ER oxybutynin ER darifenacin ER darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER Generic and/or preferred brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER
23 ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Drug(s) requiring prior authorization January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi HORMONAL AGENTS Androderm, Androgel, Striant, Testopel, testosterone Additional information This medication will only be covered by your patient s plan if you request and Drug(s) with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your patient s plan only covers this ALZHEIMER'S DISEASE Namenda XR, Namzaric medication up to a certain amount over a ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan certain number of days. Larger amounts ASTHMA/COPD/RESPIRATORY Perforomist will only be covered if you request and BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, nilutamide EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl SLEEP DISORDERS/SEDATIVES Hetlioz Step Therapy medications^^ Generic and/or preferred brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zaleplon, zolpidem, zolpidem ER Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 20mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg
24 ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 SEIZURE DISORDERS (cont) Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg CIGNA RX ESSENTIAL 5-TIER PRESCRIPTION DRUG LIST MEDICATION NOT COVERED^ GENERIC AND/OR PREFERRED BRAND ALTERNATIVES January 1, 2018 Adderall XR dextroamphetamine-amphetamine ER Azilect rasagiline mesylate Cimzia Humira (requires prior authorization), Enbrel (requires prior authorization), Remicade (requires prior authorization) Combivir lamivudine/zidovudine diclofenac sodium 1.5% topical solution diclofenac sodium 1% gel Emend capsules aprepitant capsules EpiPen and EpiPen Jr epinephrine auto-injectors Epivir lamivudine Fuzeon Talk with your doctor about switching to a covered alternative. Glatopa Copaxone (requires prior authorization) Gleevec imatinib mesylate (requires prior authorization) Invirase Talk with your doctor about switching to a covered alternative. Maxitrol eye drops neomycin/polymyxin/dexamethasone eye drops metformin hcl ER (generic Fortamet) metformin hcl ER (generic Glucophage XR) Natroba spinosad Nilandron nilutamide Nitrostat nitroglycerin sublingual tablets Orencia Actemra (requires prior authorization) Pennsaid 2% Pump diclofenac sodium 1% gel Rayos prednisone Rescriptor Talk with your doctor about switching to a covered alternative. Retrovir zidovudine Selzentry Talk with your doctor about switching to a covered alternative. Stelara Cosentyx (requires prior authorization) Tamiflu capsules oseltamivir phosphate capsules Tikosyn dofetilide Trianex triamcinolone ointment Trizivir abacavir/lamivudine/zidovudine Vagifem yuvafem
25 CIGNA RX ESSENTIAL 5-TIER PRESCRIPTION DRUG LIST (cont.) MEDICATION NOT COVERED^ GENERIC AND/OR PREFERRED BRAND ALTERNATIVES January 1, 2018 Valcyte 50mg/ml solution valganciclovir hcl 50mg/ml solution Videx EC Viracept Viramune Viramune XR Zebutal mg capsule Zerit Zetia Ziagen 20mg/ml oral solution Ziagen 300mg tablet EXCLUDED MEDICATION didanosine DR Talk with your doctor about switching to a covered alternative. nevirapine nevirapine ER butalbital/acetaminophen/caffeine mg capsule stavudine ezetimibe abacavir 20mg/ml oral solution abacavir 300mg tablet ADDITIONAL INFORMATION January 1, 2018 lidocaine hcl 3% lotion This medication is not approved by the U.S. Food and Drug Administration (FDA). Talk with your doctor. There may be alternative FDA-approved prescription medications or over-the-counter medicines (those that don t need a prescription) available to treat your condition. MEDICATION WITH QUANTITY LIMITS ADDITIONAL INFORMATION January 1, 2018 epinephrine auto-injectors Your plan only covers this medication up to a certain amount over a certain lidocaine 5% ointment number of days. Your plan will only cover larger amounts if your doctor requests and receives approval from Cigna. STEP THERAPY MEDICATION^^ GENERIC AND/OR PREFERRED BRAND ALTERNATIVES January 1, 2018 Saizen Humatrope (requires prior authorization) CIGNA RX PLUS PRESCRIPTION DRUG LIST MEDICATION NOT COVERED^ GENERIC AND/OR PREFERRED BRAND ALTERNATIVES January 1, 2018 Adderall XR dextroamphetamine-amphetamine ER Azilect rasagiline mesylate Benicar olmesartan medoxomil Benicar HCT olmesartan medoxomil/hydrochlorothiazide Combivir lamivudine/zidovudine Cordran 0.05% lotion flurandrenolide 0.05% lotion diclofenac sodium 1.5% topical solution diclofenac sodium 1% gel Doral quazepam Edecrin ethacrynic acid Emend capsules aprepitant capsules EpiPen and EpiPen Jr epinephrine auto-injectors Epivir lamivudine Glatopa Copaxone (requires prior authorization)
26 CIGNA RX PLUS PRESCRIPTION DRUG LIST (cont.) MEDICATION NOT COVERED^ GENERIC AND/OR PREFERRED BRAND ALTERNATIVES January 1, 2018 Gleevec imatinib mesylate (requires prior authorization) Invirase Maxitrol eye drops metformin hcl ER (generic Fortamet) Naftin 2% cream Natroba Nilandron Nitrostat Orencia Pennsaid 2% Pump Rayos Rescriptor Retrovir Selzentry Stelara Tamiflu capsules Tikosyn Trianex Trizivir Vagifem Valcyte 50mg/ml solution Videx EC Viracept Viramune Viramune XR Zebutal mg capsule Zerit Zetia Ziagen 300mg tablet EXCLUDED MEDICATION Talk with your doctor about switching to a covered alternative. neomycin/polymyxin/dexamethasone eye drops metformin hcl ER (generic Glucophage XR) naftifine hcl 2% cream spinosad nilutamide nitroglycerin sublingual tablets Actemra (requires prior authorization) diclofenac sodium 1% gel prednisone Talk with your doctor about switching to a covered alternative. zidovudine Talk with your doctor about switching to a covered alternative. Cosentyx (requires prior authorization) oseltamivir phosphate capsules dofetilide triamcinolone ointment abacavir/lamivudine/zidovudine yuvafem valganciclovir hcl 50mg/ml solution didanosine DR Talk with your doctor about switching to a covered alternative. nevirapine nevirapine ER butalbital/acetaminophen/caffeine mg capsule stavudine ezetimibe abacavir 300mg tablet ADDITIONAL INFORMATION January 1, 2018 Lidocaine hcl 3% lotion This medication is not approved by the U.S. Food and Drug Administration Novacort (FDA). Talk with your doctor. There may be alternative FDA-approved prescription medications or over-the-counter medicines (those that don t need a prescription) available to treat your condition.
27 CIGNA RX PLUS PRESCRIPTION DRUG LIST (cont.) MEDICATION WITH QUANTITY LIMITS ADDITIONAL INFORMATION January 1, 2018 Epinephrine auto-injectors Your plan only covers this medication up to a certain amount over a certain Lidocaine 5% ointment number of days. Your plan will only cover larger amounts if your doctor requests and receives approval from Cigna. STEP THERAPY MEDICATION^^ GENERIC AND/OR PREFERRED BRAND ALTERNATIVES January 1, 2018 Saizen Humatrope (requires prior authorization) CIGNA RX PLUS PRESCRIPTION DRUG LIST (FLORIDA ONLY) MEDICATION NOT COVERED^ GENERIC AND/OR PREFERRED BRAND ALTERNATIVES January 1, 2018 Adderall XR dextroamphetamine-amphetamine ER Azilect Benicar Benicar HCT Cimzia Cordran 0.05% lotion diclofenac sodium 1.5% topical solution Doral Edecrin Emend capsules EpiPen and EpiPen Jr Glatopa Gleevec Maxitrol eye drops metformin hcl ER (generic Fortamet) Naftin 2% cream Natroba Nilandron Nitrostat Orencia Pennsaid 2% Pump Rayos Simponi Stelara Tamiflu capsules Tikosyn Trianex rasagiline mesylate olmesartan medoxomil olmesartan medoxomil/hydrochlorothiazide Humira (requires prior authorization), Enbrel (requires prior authorization), Remicade (requires prior authorization) flurandrenolide 0.05% lotion diclofenac sodium 1% gel quazepam ethacrynic acid aprepitant capsules epinephrine auto-injectors Copaxone (requires prior authorization) imatinib mesylate (requires prior authorization) neomycin/polymyxin/dexamethasone eye drops metformin hcl ER (generic Glucophage XR) naftifine hcl 2% cream spinosad nilutamide nitroglycerin sublingual tablets Actemra (requires prior authorization) diclofenac sodium 1% gel prednisone Humira (requires prior authorization), Enbrel (requires prior authorization), Remicade (requires prior authorization) Cosentyx (requires prior authorization) oseltamivir phosphate capsules dofetilide triamcinolone ointment
CHANGES TO YOUR DRUG LIST
CHANGES TO YOUR DRUG LIST More generics and lower-cost brands to help you stay healthy and save money As your health partner, we want to help you get and stay healthy. That means making sure you have access
More informationPRESCRIPTION DRUG LIST CHANGES
PRESCRIPTION DRUG LIST CHANGES Cigna Pharmacy Management 2018 The medications listed below are changing coverage (or cost levels) on Cigna s Prescription Drug List. Changes are listed by drug list name
More informationCHANGES TO YOUR DRUG LIST
CHANGES TO YOUR DRUG LIST More generics and lower-cost brands to help you stay healthy and save money As your health partner, we want to help you get and stay healthy. That means making sure you have access
More information1/1/2018 FORMULARY CHANGES CIGNA COMMERCIAL CUSTOMERS
1/1/2018 FORMULARY CHANGES CIGNA COMMERCIAL CUSTOMERS Effective 1/1/18, Cigna is making changes to our formularies that may impact medication coverage for customers at your pharmacy. We have included a
More informationBLUE SHIELD OF CALIFORNIA MARCH 2016 STANDARD DRUG FORMULARY CHANGES
BLUE SHIELD OF CALIFORNIA MARCH 2016 STANDARD DRUG FORMULARY CHANGES Blue Shield is committed to covering safe, effective and affordable medications, so we regularly review and update our drug formularies.
More informationPRESCRIPTION DRUG LIST CHANGES
PRESCRIPTION DRUG LIST CHANGES For Providers 2018 Changes are being made to Cigna s Prescription Drug List that may affect some of your patients. These changes are listed by drug list name and by effective
More informationHigh-Cost Drug Exclusions
PHARMACY SERVICES High-Cost Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at
More informationPRESCRIPTION DRUG LIST CHANGES
PRESCRIPTION DRUG LIST CHANGES Cigna Pharmacy Management 2018 The medications listed below are changing coverage (or cost levels) on Cigna s Prescription Drug List. Changes are listed by drug list name
More informationPRESCRIPTION DRUG LIST CHANGES
PRESCRIPTION DRUG LIST CHANGES Cigna Pharmacy Management 2018 The medications listed below are changing coverage (or cost levels) on Cigna s Prescription Drug List. Changes are listed by drug list name
More informationHigh-Cost Drug Exclusions
Pharmacy Services High-Cost Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at
More information2015 Step Therapy Prior Authorization Medical Necessity Guidelines
Tufts Health Unify 2015 Step Therapy Prior Authorization Medical Necessity Guidelines Effective: 01/01/2015 Updated: 10/01/2015 Tufts Health Plan P.O. Box 9194 Watertown, MA 02471-9194 Phone: 855-393-3154
More informationALLERGIC CONJUNCTIVITIS AGENTS
2018 5 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: 18390 Last Updated: 04/2018 Effective Date: 05-01-2018 ALLERGIC CONJUNCTIVITIS AGENTS epinastine 0.05 % eye drops
More informationCigna Drug and Biologic Coverage Policy
Cigna and Biologic Coverage Policy Subject Quantity Limitations Table of Contents Coverage Policy... 1 General Background... 6 Coding/Billing Information... 11 References... 11 Effective Date...2/15/2018
More informationStep Therapy Criteria 2019
Step Therapy 2019 For information on obtaining an updated coverage determination or an exception to a coverage determination please call Freedom Health Member Services at 1-800-401-2740 or, for TTY/TDD
More information1/1/2019 FORMULARY CHANGES CIGNA COMMERCIAL CUSTOMERS
1/1/2019 FORMULARY CHANGES CIGNA COMMERCIAL CUSTOMERS Effective 1/1/19, Cigna is making changes to our formularies that may impact medication coverage for customers at your pharmacy. We have included a
More informationStep Therapy Requirements
An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 12/01/2017 Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/2014 1 ABILIFY Abilify 10 mg tablet
More informationANGIOTENSIN RECEPTOR BLOCKERS STEP THERAPY
South Country Health Alliance 2017 Step Therapy Formulary ID: 17431 Last Updated: 10/20/2017 Effective Date: 11-01-2017 ANGIOTENSIN RECEPTOR BLOCKERS STEP THERAPY BENICAR 20 MG BENICAR 40 MG BENICAR 5
More information2017 Formulary Changes Year to Date
2017 Formulary Changes Year to Date Health Choice Arizona may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, add prior authorization, quantity limits and/or
More information2017 Step Therapy Criteria
FRESENIUS TOTAL HEALTH 2017 Step Therapy Updated 07/01/2017. For more recent information or other questions, please contact Fresenius Total Health Customer Service at 1-855-598-6774 / TTY 1-844-209-9094.
More informationHigh-Cost Drug Exclusions
PHARMACY SERVICES High-Cost Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at
More informationQuarterly pharmacy formulary change notice
Provider Bulletin June 2017 The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus patients. These changes were reviewed and approved at the first quarter Pharmacy and Therapeutics
More informationCRITERIA Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication.
ADHD STIMULANTS ATOMOXETINE HCL, DEXEDRINE 10 MG TABLET, DEXEDRINE 5 MG TABLET, DEXMETHYLPHENIDATE HCL, DEXMETHYLPHENIDATE HCL ER, DEXTROAMPHETAMINE 10 MG TAB, DEXTROAMPHETAMINE 5 MG TAB, DEXTROAMPHETAMINE
More informationAlprazolam 0.25mg, 0.5mg, 1mg tablets
Presbyterian Senior Care (HMO) / Presbyterian MediCare PPO Quantity Limits Effective November 1, 2014 For the most recent list of drugs or other questions, please contact the Presbyterian Customer Service
More informationPRESCRIPTION DRUG PROGRAM FORMULARY UPDATES
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Generic Additions These generic drugs recently became available in the marketplace. When these generic drugs became available, we began covering them at the
More informationHealth Net Health Plan of Oregon, Inc. Oregon Drugs with a quantity limit Effective January 1, 2015 (Published December 15, 2014)
Health Net Health Plan of Oregon, Inc. Oregon Drugs with a quantity limit Effective January 1, 2015 (Published December 15, 2014) Abstral SL Actonel 35mg Limited to 4 s per month. Actonel 5,30mg adapalene
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Step Therapy Reference Number: HIM.PA.109 Effective Date: 08.01.17 Last Review Date: 05.18 Line of Business: Health Insurance Marketplace Revision Log See Important Reminder at the end
More informationALOGLIPTIN STEP. Details. Step Therapy Requirements Effective November 1, 2017
ALOGLIPTIN STEP alogliptin 12.5 mg tablet alogliptin 12.5 mg-metformin 1,000 mg tablet alogliptin 12.5 mg-metformin 500 mg tablet alogliptin 12.5 mg-pioglitazone 15 mg tablet alogliptin 12.5 mg-pioglitazone
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Step Therapy Reference Number: HIM.PA.109 Effective Date: 08.01.17 Last Review Date: 05.18 Line of Business: Health Insurance Marketplace Revision Log See Important Reminder at the end
More informationStep Therapy Medications
Step Therapy Medications Step Therapy (ST PA ) is an automated form of prior authorization. It encourages the use of therapies that should be tried first, before other treatments are covered, based on
More informationALOGLIPTIN STEP. Step Therapy Requirements Effective April 1, 2018
Step Therapy Requirements Effective April 1, 2018 ALOGLIPTIN STEP alogliptin 12.5 mg tablet alogliptin 12.5 mg-metformin 1,000 mg tablet alogliptin 12.5 mg-metformin 500 mg tablet alogliptin 12.5 mg-pioglitazone
More informationSmithRx Standard Formulary Step Therapy List
SmithRx Standard Formulary Step Therapy List Revised: January 27, 2017 The following medications require prior use of at least one other medication for coverage. Please note that any plan-specific customizations
More informationALOGLIPTIN STEP. Step Therapy Requirements Effective June 1, 2018
Step Therapy Requirements Effective June 1, 2018 ALOGLIPTIN STEP alogliptin 12.5 mg tablet alogliptin 12.5 mg-metformin 1,000 mg tablet alogliptin 12.5 mg-metformin 500 mg tablet alogliptin 12.5 mg-pioglitazone
More informationPrescription benefit updates Large group
Prescription benefit updates Large group Moda Health s prescription program is a pharmacy benefit that offers members a choice of safe effective medication treatments. The program also helps you save money
More informationQuarterly Pharmacy Formulary Change Notice
MEDICAID PROVIDER BULLETIN February 26, 2015 Quarterly Pharmacy Formulary Change Notice Summary of Change: The formulary changes listed in the table below were reviewed and approved at our September 24,
More informationAetna Better Health of Illinois Medicaid Formulary Updates
October 2017 o DOXYLAMINE SUCCINATE 25mg-QL o DULOXETINE CAP 40MG DR-QL o GUANFACIN ER TABS (all strengths)-ql o TOBRAMYCIN NEBU SOLUTION- PA August 2017 Aetna Better Health of Illinois Medicaid 2017 Formulary
More informationNeighborhood Medicaid Formulary Changes: June 2017
Neighborhood Medicaid Formulary Changes: June 2017 The following changes to the Neighborhood Medicaid Formulary were recently approved by the Pharmacy and Therapeutics (P&T) Committee. All changes were
More informationLABEL NAME CHANGE EFFECTIVE DATE ARCALYST 220 MG INJECTION
LABEL NAME CHANGE EFFECTIVE DATE ARCALYST 220 MG INJECTION Added Prior Authorization 7/1/17 CORLANOR 5 MG TABLET Added Prior Authorization 7/1/17 CORLANOR 7.5 MG TABLET Added Prior Authorization 7/1/17
More informationStep therapy Premium. Utilization management updates - January 1, Here s how it works:
Utilization management updates - January 1, 2019 Step therapy Premium Most medical conditions have many medication options. Although their clinical effectiveness may be the same, the cost can be very different.
More information2019 PacificSource Health Plans Step Therapy Criteria. Last Modified: 02/22/2019 (All criteria reviewed at least once per year)
2019 PacificSource Health Plans Step Therapy Criteria Last Modified: 02/22/2019 (All criteria reviewed at least once per year) Table of Contents ACTICLATE... 3 AMITIZA/LINZESS... 4 ANTIDIABETICS Farxiga,
More informationALLERGIC RHINITIS-NASAL
ALLERGIC RHINITIS-NASAL FLUNISOLIDE Patient needs to have paid claims for any one of the following Step 1 drugs: NasaCort OTC, fluticasone Rx, fluticasone OTC, Budesonide OTC. Prior to filling the Step
More informationAvoid paying too much for your prescriptions
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2017 Aetna Rx Step Program Medicine List Avoid paying too much for your prescriptions It s important to try to
More informationMercy Care Plan. Acyclovir Ointment. Products Affected. acyclovir ointment 5 % external Details. Criteria. Requires use of oral Acyclovir
Acyclovir Ointment Mercy Care Plan acyclovir ointment 5 % external Requires use of oral Acyclovir 1 Adcirca ADCIRCA TABLET 20 MG ORAL Requires use of Sildenafil 2 Albenza ALBENZA TABLET 200 MG ORAL Requires
More informationStep Therapy Requirements
An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 05/01/2018 Updated 4/2018 H0302_2_2014 CMS Accepted 05/05/2014 1 BETA-BLOCKERS BYSTOLIC 10 MG
More informationYour prescription benefit updates Formulary Updates - Effective January 1, 2019
Your prescription benefit updates Formulary Updates - Effective January 1, 2019 Medications are grouped by the conditions they treat. Each medication is placed in a tier that shows the amount you will
More informationJANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET BYDUREON BCISE 2 MG/0.
ANTI DIABETICS BYDUREON 2 MG SUBCUTANEOUS JANUVIA 25 MG TABLET EXTENDED RELEASE SUSPENSION JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET
More informationTry a Step 1 medication first
Premium step therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment
More informationAttention: Behavioral Health Providers, Pharmacists and Prescribers N.C. Medicaid and N.C. Health Choice Preferred Drug List Changes - UPDATE
Attention: Behavioral Health Providers, Pharmacists and Prescribers N.C. Medicaid and N.C. Health Choice Drug List Changes - UPDATE Note: This article was previously published in the December 2014 Medicaid
More informationDrug Formulary Update, January 2017 Commercial and State Programs
Drug Formulary Update, January 2017 Commercial and State Programs Updates to the HealthPartners Commercial and State Program Drug Formularies are listed below. Updates apply to all Commercial groups (PreferredRx,
More information2019 Step Therapy (ST) Criteria
2019 Step Therapy (ST) Criteria Some drugs require step therapy pre-approval. This means that your doctor must have you first try a different drug to treat your medical condition before we will cover a
More informationStep Therapy Program Precision Formulary
Step Therapy Program Precision Formulary Physician Guidelines Failure of previous steps in the Step Therapy Program: For most therapies, Magellan Rx Management will review the most recent 180 days of claim
More informationGranite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18
Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18 Granite Alliance requires step therapy for certain drugs. This means prior to receiving a drug with a step therapy
More informationSelectHealth Advantage 2018 Step Therapy Criteria Previous trial on at least ONE: Generic topical acne treatment
ACNE ADAPAL/BEN P GEL 0.1-2.5% AZELEX CRE 20% DAPSONE GEL 5% EPIDUO FORTE GEL 0.3-2.5% TRETINOIN GEL 0.04% TRETINOIN GEL 0.05% TRETINOIN GEL 0.1% ACTONEL ANTICONVULSANT ANTIDEPRESSION ANTIPSYCHOTIC ASTHMA
More informationStep Therapy Information... 4 Prior Authorization Information ACE Inhibitors and ACE Inhibitor Combinations...60 Acne Therapy...
Step Therapy Information... 4 Prior Authorization Information... 27 ACE Inhibitors and ACE Inhibitor Combinations...60 Acne Therapy...62 Acne Therapy Topical...64 Alcoholism Treatment Agents... 66 Analgesic
More informationAcyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria
Medications that require Step Therapy (ST) require trial and failure of preferred formulary agents prior to their authorization. If the prerequisite medications have been filled within the specified time
More informationTrue Health New Mexico List of Medications with Quantity Limits
True Health New Mexico List of Medications with Quantity Limits Specialty Medications Contact True Health New Mexico Pharmacy Services at 1-866- 341-8561 for quantity limits on specialty medications. Maximum
More informationSelectHealth Advantage 2018 Step Therapy Criteria. Previous trial on at least ONE: Generic topical acne treatment. Previous trial on: alendronate
ACNE ACZONE ADAPAL/BEN P AZELEX DAPSONE EPIDUO EPIDUO FORTE TRETINOIN ACTONEL RISEDRON SOD RISEDRONATE SelectHealth Advantage Previous trial on at least ONE: Generic topical acne treatment alendronate
More informationEffective for all members on August 1, 2017
August 2017 Pharmacy Formulary Change Notice BlueChoice HealthPlan Medicaid is here to help you stay on top of your health care. We want to tell you about some upcoming changes to your Preferred Drug List
More informationPharmacy Program Updates: Quarterly Pharmacy Changes Effective July 1, 2017
Pharmacy Program Updates: Quarterly Pharmacy Changes Effective July 1, 2017 DRUG LIST CHANGES Based on the availability of new prescription medications and Prime s National Pharmacy and Therapeutics Committee
More informationMercy Care ALBENDAZOLE. Products Affected. ALBENZA TABLET 200 MG ORAL Details. Criteria. Refer to PA Guideline for approval criteria
ALBENDAZOLE Mercy Care ALBENZA TABLET 200 MG ORAL Refer to PA Guideline for approval criteria 1 BRIMONIDINE-TIMOLOL COMBIGAN SOLUTION 0.2-0.5 % OPHTHALMIC Requires use of separate ingredients for at least
More informationADHD STIMULANTS-S(SHC)
Step Therapy Simply Health Care 2014 Formulary ID: 14406 Version: 14 Last Updated: 08/01/2014 ADHD STIMULANTS-S(SHC) Daytrana Focalin Xr Strattera Patient needs to have a paid claim for one Step 1 drug
More informationMedication and Dose 10/04/ /05/2016 Total % Change Since 10/2012 ABILIFY 10 MG TABLET $18.76 $ %
Table Comparing NADAC prices for select brand name prescription medications on October 4, 2012 and October 5, 2016 to show how much prices have gone up for these medications. These medications increased
More informationATYPICAL ANTIPSYCHOTICS
Step Therapy CareOregon 2018 Last Updated: 07/27/2018 ATYPICAL ANTIPSYCHOTICS Fanapt Fanapt Titration Pack Paliperidone Er Vraylar The following criteria applies to members who newly start on the drug:
More informationAN ACTIVE, DISCIPLINED APPROACH TO FORMULARY MANAGEMENT TO DRIVE BETTER PLAN AFFORDABILITY
Cigna Pharmacy Management AN ACTIVE, DISCIPLINED APPROACH TO FORMULARY MANAGEMENT TO DRIVE BETTER PLAN AFFORDABILITY Changes begin 1/1/17 As part of the effort to position our pharmacy plans for long-term
More informationAETNA BETTER HEALTH January 2017 Formulary Change(s)
AETNA BETTER HEALTH January 2017 Formulary Change(s) The following updates will be made to the Aetna Better Health of MI formulary on March 1, 2017 Drug Name, Strength, Dosage Form ALFUZOSIN HCL ER 10
More informationDrug Formulary Update, April 2017 Commercial and State Programs
Drug Formulary Update, April 2017 Commercial and State Programs Updates to the HealthPartners Commercial and State Program Drug Formularies are listed below. Updates apply to all Commercial groups (PreferredRx,
More informationADHD STIMULANTS - SCORE
Step Therapy Trillium 5 Tier Effective Date: 12/01/2017 Approval Date: 10/24/2017 ADHD STIMULANTS - SCORE Strattera Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant
More informationFORMULARY UPDATES TO DENVER HEALTH MEDICAID CHOICE (DHMC) AND CHILD HEALTH PLAN PLUS (CHP+) PLANS
FORMULARY UPDATES TO DENVER HEALTH MEDICAID CHOICE (DHMC) AND CHILD HEALTH PLAN PLUS (CHP+) PLANS DHMC/CHP+ may add or remove drugs from the formulary or make changes to restrictions on formulary drugs
More informationPremium Step Therapy. Here s how it works:
Premium Step Therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment
More informationCigna Drug and Biologic Coverage Policy
Cigna Drug and Biologic Coverage Policy Subject Step Therapy Individual and Family Plan Table of Contents Coverage Policy... 1 General Background... 5 References... 5 Effective Date... 3/15/2018 Next Review
More informationALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Health Choice Generations 1 Tier Gold Effective Date: 11/01/2018.
ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/2018 1 ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG Emsam
More informationALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Optima Tier Gold Formulary Date Effective: November 1, 2018.
ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID 18354, Version 15 1 ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG Emsam Fetzima Fetzima Titration Pack Trial of two of
More informationABILIFY INJ. Products Affected Step 2: ABILIFY MAINTENA PREFILLED SYRINGE 300 MG INTRAMUSCULAR ABILIFY MAINTENA PREFILLED SYRINGE 400 MG INTRAMUSCULAR
ABILIFY INJ ABILIFY MAINTENA PREFILLED SYRINGE 300 MG ABILIFY MAINTENA PREFILLED SYRINGE 400 MG ABILIFY MAINTENA SUSPENSION RECONSTITUTED ER 300 MG Claim will pay automatically for ABILIFY MAINTENA if
More informationANTICONVULSANTS. Details
ANTICONVULSANTS APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET APTIOM 800 MG TABLET BANZEL 200 MG TABLET BANZEL 40 MG/ML ORAL SUSPENSION BANZEL 400 MG TABLET FYCOMPA 0.5 MG/ML ORAL SUSPENSION
More informationStep Therapy Group Algorithm Steps
Step Therapy Group Algorithm Steps ACTONEL AMITIZA ANTICONVULSANT ANTIDEPRESSION Previous trial on alendronate Step 1: ALENDRONATE SODIUM Step 2: RISEDRONATE SODIUM, RISEDRONATE SODIUM DR Previous trial
More informationADHD STIMULANTS - SCORE
ADHD STIMULANTS - SCORE Step Therapy Strattera Patient needs to have a paid claim for two generic formulary ADHD stimulant medications. Formulary ID# 00017034 Last Updated: 08/01/2017 1 ALPHA GLUCOSIDASE
More informationFORMULARY UPDATES TO DENVER HEALTH MEDICAID CHOICE (DHMC) AND CHILD HEALTH PLAN PLUS (CHP+) PLANS
FORMULARY UPDATES TO DENVER HEALTH MEDICAID CHOICE (DHMC) AND CHILD HEALTH PLAN PLUS (CHP+) PLANS DHMC/CHP+ may add or remove drugs from the formulary or make changes to restrictions on formulary drugs
More informationTEST ANTICONVULSANT THERAPY. Products Affected. Step 2: Network Health Insurance Corporation NetworkCares Step Therapy Criteria Last Updated 11/2018
TEST Network Health Insurance Corporation NetworkCares Step Therapy Last Updated 11/2018 ANTICONVULSANT THERAPY Aptiom Banzel Briviact Celontin Dilantin 30 Mg Capsule Equetro Fycompa 0.5 Mg/ml Oral Susp
More informationANTICONVULSANTS. Details
ANTICONVULSANTS APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG BANZEL 200 MG BANZEL 40 MG/ML ORAL SUSPENSION BANZEL 400 MG FYCOMPA 0.5 MG/ML ORAL SUSPENSION FYCOMPA 10 MG FYCOMPA 12 MG FYCOMPA
More informationANTICONVULSANTS. Details
ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200 mg tablet Banzel 40 mg/ml oral suspension Banzel 400 mg tablet Fycompa 0.5 mg/ml oral suspension
More informationStep Therapy Criteria
Tier 5 Formulary Step Therapy 2016 Updated: 05/24/2016 Effective: 06/01/2016 What is Step Therapy? Some prescription drugs require step therapy (ST). In some cases, the plan requires you to first try certain
More informationStep Therapy Criteria (Criteria for Step Therapy-2 [ST-2] Drugs)
CareAdvantage CMC 2018 Formulary Supplement II (List of Covered Drugs) Step Therapy Criteria (Criteria for Step Therapy-2 [ST-2] Drugs) Formulary ID: 00018157 Formulary Version:11 19 CMS Approved: 08/21/2018
More informationStep Therapy Medications
Step Therapy Medications Step Therapy Group APTIOM Step-2: APTIOM 200 MG TABLET or APTIOM 400 MG TABLET or APTIOM 600 MG TABLET or APTIOM 800 MG TABLET Step 1 Drug(s): Oxcarbazepine immediate-release,
More informationANTICONVULSANTS. Details
ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200 mg tablet Banzel 40 mg/ml oral suspension Banzel 400 mg tablet Fycompa 0.5 mg/ml oral suspension
More informationNetwork Health Insurance Corporation Upcoming Negative Changes to the Medicare Part D Formulary
Requesting an Exception to the Formulary You can ask Network Health Insurance Corporation to make an exception to our coverage rules. Generally, we will only approve your request for an exception if alternative
More informationDrug Formulary Update, January 2018 Commercial and State Programs
Drug Formulary Update, January 2018 Commercial and State Programs Updates to the HealthPartners Commercial and State Program Drug Formularies are listed below. Updates apply to all Commercial groups (PreferredRx,
More informationStep Therapy Requirements. Effective: 12/01/2016
Effective: 12/01/2016 H2986_PD_049 Updated 11/2016 ALPHA 1-PROTEINASE INHIBITOR GLASSIA PRIOR CLAIM FOR ARALAST NP OR ZEMAIRA WITHIN THE PAST 120 DAYS. ANALGESICS, NARCOTICS KADIAN MORPHINE SULFATE ER
More informationExcluded Drug Name. Tablet Delayed Release. Lozenge on a Handle
Abilify Absorica Abstral Acanya Accolate Aciphex Aciphex Sprinkle Acticlate Actiq Actonel Actos Adapalene Adderall Adderall XR Adrenaclick Page 1 of 9 Sublingual Delayed Release Sprinkle Lozenge on a Handle
More informationPrescription Step Therapy Program
Prescription Step Therapy Program 04HQ3972 R11/17 Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company. HMO Louisiana, Inc. is a subsidiary of Blue Cross
More informationALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Farm Bureau Health Plans Date Effective: November 1, 2018.
ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID 18351, Version 15 1 ANTIDEPRESSANTS - SCORE Desvenlafaxine Er TB24 100MG, 50MG Emsam Fetzima Fetzima Titration Pack Trial of two of the following
More information2018 Step Therapy (ST) Criteria
2018 Step Therapy (ST) Criteria Some drugs require step therapy pre-approval. This means that your doctor must have you first try a different drug to treat your medical condition before we will cover a
More informationStep Therapy Requirements
Step Therapy Requirements Denver Health Medicare Choice (HMO SNP)/Medicare Select (HMO) Effective: 09/01/2017 Updated 08/2017 ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet
More informationFee-for-Service Pharmacy Provider Notice #216 ** March 2016 PDL Changes ** Existing Drug Classes
Fee-for-Service Pharmacy Provider Notice #216 ** March 2016 PDL Changes ** December 19, 2016 Please be advised that the Department for Medicaid Services (DMS) is making changes to the Kentucky Medicaid
More informationMarch 2018 P & T Updates
March 2018 P & T Updates Commercial Triple Tier 4th Tier Applicable Traditional Prior Auth AURYXIA 3 2 12 tablets per BAXDELA TABLETS 3 2 2 tablets per Depending on your specific benefits and in which
More informationPremium step therapy. Here s how it works:
Premium step therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment
More information