Drug Therapy Guidelines

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1 Classes of medications may be targeted for preferred products when there are multiple entries into the market in the same therapeutic category. Coverage of any non-preferred medication can be granted when the following criteria are met: When requesting coverage of a brand medication for which an A/B rated generic is available, there is sufficient evidence that the use of the A/B rated generic equivalent has resulted in inadequate results AND At least one of the following is true: o The required plan-preferred medications have been tried (see tables below). o The plan-preferred medications are contraindicated or will likely cause an adverse reaction by or physical or mental harm to the member. o The plan-preferred medications are expected to be ineffective based on the known clinical history and conditions of the member and the member s prescription drug regimen. o The member has tried the plan-preferred medications or another prescription drug in the same pharmacologic class or with the same mechanism of action and such prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event. o The member is stable on the medication selected by their healthcare professional for the medical condition under consideration (where stable is defined as receiving the medication for an adequate period of time, have achieved optimal response, and continued favorable outcomes are expected UNLESS the medication was initially selected due to the availability of a drug sample or a coupon card). o The plan-preferred medication is not in the best interest of the member because it will likely cause a significant barrier to the member s adherence or to compliance with the member s plan of care, will likely worsen a comorbid condition of the member, or will likely decrease the member s ability to achieve or maintain reasonable functional ability in performing daily activities. Angiotensin Receptor Blockers (ARBs) Formularies 2, 3/Exclusive, 4/AON Atacand, Atacand HCT, Avapro, Avalide, Benicar, Benicar HCT, Cozaar, Diovan, Diovan HCT, Edarbi, Edarbyclor, Hyzaar, Micardis, Micardis HCT Antipsychotics, 2 nd Generation Abilify, Fanapt, Geodon, Invega, Latuda, paliperidone, Rexulti, Risperdal/M-tab, Saphris, Seroquel, Seroquel XR, Symbyax, Vraylar, Zyprexa/Zydis candesartan, candesartan/hctz, eprosartan 600mg, irbesartan, irbesartan/hctz, losartan, losartan/hctz, telmisartan, telmisartan/hctz, valsartan, valsartan/hctz olanzapine, quetiapine, risperidone, ziprasidone BPH (alpha-antagonists) Flomax, Rapaflo, Uroxatral alfuzosin, doxazosin, tamsulosin, terazosin Page 1 of 7

2 Beta Agonist Inhalers Proventil HFA, Ventolin HFA, Xopenex HFA ProAir HFA, ProAir Respiclick Calcipotriene Agents calcipotriene/betamethasone dipropionate combination, Enstilar, Taclonex calcipotriene CNS Stimulants Adzenys XR ODT, Aptensio XR, Cotempla XR, Dyanavel XR, Focalin XR, Mydayis ER, Quillichew ER, Vyvanse Plan-Preferred (trial of TWO classes required) Generic amphetamine products (dextroamphetamine, mixed amphetamine salts/er); generic methylphenidate products (dexmethylphenidate/er, methylphenidate/er/sr) Constipation Agents Amitiza, Trulance Linzess Updated: 6/21/17 Desvenlafaxine Desvenlafaxine fumarate ER, Desvenlafaxine ER, Khedezla, Pristiq desvenlafaxine succinate, duloxetine, venlafaxine ER capsules DPP-4 Inhibitors, Medical Alogliptin, Alogliptin-Metformin, Alogliptin-Pioglitazone, Kazano, Kombiglyze, Nesina, Onglyza, Oseni Janumet, Janumet XR, Januvia, Jentadueto, Tradjenta Duexis Duexis Plan-Preferred (trial of TWO required) famotidine and ibuprofen Updated: 6/21/17 Page 2 of 7

3 Epinephrine Products Adrenaclick, Auvi-Q, EpiPen, EpiPen Jr Epinephrine Auto-Injector (Authorized Generics for EpiPen, EpiPen Jr, or Adrenaclick) Extended-Release Antibiotics Doryx, doxycycline DR tablet, minocycline extended-release, Oracea, Solodyn immediate-release doxycycline, immediate-release minocycline Fenofibrates Antara, Fenofibrate 50mg capsule, Fenofibrate 150mg capsule, Fenoglide, Fibricor, Lipofen, Tricor, Triglide, Trilipix generic fenofibric acid, generic fenofibrate Inhaled Combinations Advair HFA/Diskus, AirDuo Respiclick, Breo Ellipta Dulera, fluticasone propionate/salmeterol, Symbicort Inhaled Corticosteroids Alvesco, ArmonAir, Arnuity, Flovent Asmanex, Pulmicort, Qvar Insulin, Medical Apidra, Fiasp, Fiasp FlexTouch, Novolin, Novolog, Admelog, Admelog Solostar Humulin, Humalog Insulin, Basal Formulary 1, Medical Levemir, Tresiba Lantus, Toujeo Page 3 of 7

4 Insulin, Basal Formularies 2, 3/Exclusive, 4/AON, Medical Levemir, Tresiba Basaglar, Lantus, Toujeo Intranasal Steroids Formulary 1 Beconase AQ, Omnaris, Qnasl, Zetonna Clarispray, Flonase Allergy Relief, Flonase Sensimist, fluticasone, Nasacort Allergy, Rhinocort Allergy Intranasal Steroids Formularies 2, 3/Exclusive, 4/AON Beconase AQ, mometasone, Nasonex, Omnaris, Qnasl, Zetonna Clarispray, Flonase Allergy Relief, Flonase Sensimist, fluticasone, Nasacort Allergy, Rhinocort Allergy Metformin ER, Medical Fortamet, Glumetza, metformin ER (generics other than Glucophage XR) metformin ER (generic for Glucophage XR specifically) Osteoporosis Agents Actonel, Atelvia, risedronate DR (generic Atelvia), Boniva, Fosamax, Fosamax Plus D, Binosto alendronate, ibandronate Pancreatic Enzymes Creon, Pancreaze, Pertzye Zenpep Updated: 6/21/17 Prexxartan (valsartan oral solution) Prexxartan Valsartan tablet Updated: 6/1/18 Page 4 of 7

5 Prostaglandin Analogs Rescula, Travatan Z, Vyzulta, Xalatan, Zioptan latanoprost, Lumigan, travoprost Updated: 2/1/18 Prostaglandin Analogs Rescula, Lumigan, Travatan Z, Vyzulta, Xalatan, Zioptan latanoprost, travoprost Updated: 2/1/18 Proton Pump Inhibitors (PPIs) Aciphex, Dexilant, esomeprazole magnesium, Esomeprazole strontium, Nexium, omeprazole/sodium bicarbonate, Prevacid, Prevacid Solutab, Prilosec, Protonix, Zegerid Updated: 8/2/17 lansoprazole, Nexium 24HR (OTC), pantoprazole, Prevacid 24HR (OTC), Prilosec OTC/omeprazole, Zegerid OTC Proton Pump Inhibitors (PPIs) Aciphex, Dexilant, esomeprazole magnesium, Esomeprazole strontium, Nexium, omeprazole/sodium bicarbonate, Prevacid, Prevacid Solutab, Prilosec, Protonix, rabeprazole, Zegerid Updated: 8/2/17 lansoprazole, Nexium 24HR (OTC), pantoprazole, Prevacid 24HR (OTC), Prilosec OTC/omeprazole, Zegerid OTC Renin Inhibitors Tekamlo, Tekturna, Tekturna HCT Generic antihypertensive medications Rayos (prednisone delayed-release) Formulary 1, 2, 3/Exclusive, 4/AON Rayos generic corticosteroid Rhopressa (netasurdil) Rhopressa Plan-Preferred (trial of TWO classes required) ONE plan-preferred Prostaglandin Analog AND ONE ophthalmic Beta Receptor Antagonist Updated: 6/1/18 Page 5 of 7

6 Selective Serotonin Reuptake Inhibitors (SSRIs) Celexa, Fluoxetine 60mg tablets, fluvoxamine ER, Lexapro, Luvox CR, Paxil, Pexeva, Prozac, Sarafem, Viibryd, Zoloft citalopram, escitalopram, fluoxetine (except 60mg), fluvoxamine, paroxetine, sertraline SGLT-2 Inhibitors Formularies 2, 3/Exclusive, 4/AON, Medical Farxiga, Segluromet, Steglatro, Xigduo XR Invokamet, Invokamet XR, Invokana, Jardiance, Synjardy, Synjardy XR Updated: 6/1/18 Statins Altoprev, Crestor, Flolipid, Lescol, Lescol XL, Lipitor, Livalo, Nikita, Pravachol, Zocor, Zypitamag fluvastatin, atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin Test Strips for Blood Glucose, Medical Accu-Chek, Contour, Freestyle, Precision, TRUEtrack, TRUEtest, etc One Touch products Testosterone Replacements Axiron, Bio-T-Gel, Fortesta, Natesto, Striant, Testim, Testosterone Gel (brand), Vogelxo Androgel, generic testosterone gel Testosterone Replacements Androderm, Axiron, Bio-T-Gel, Fortesta, Natesto, Striant, Testim, Testosterone Gel (brand), Vogelxo Androgel, generic testosterone gel Updated 5/1/18 Topical Dermatologics Formularies 2, 3/Exclusive, 4/AON tretinoin microspheres, tazarotene cream, and all branded medications for acne/rosacea (including Acanya, Aczone, Atralin, Avita, Azelex, Benzaclin, Benzamycin, Brevoxyl, Clindagel, Differin, Duac, Epiduo, Evoclin, Finacea, Metrogel, Mirvaso, Noritate, Plexion, Retin-A, Rhofade, Tazorac, Tretin-A, Veltin, Ziana, etc). Plan-Preferred (trial of TWO required) Updated: 9/29/17 all generics except tretinoin microspheres and tazarotene cream Page 6 of 7

7 Topical Non-Steroidal Anti-Inflammatory Drugs Flector Patch, Pennsaid Solution, diclofenac sodium 1.5% topical solution diclofenac 1% topical gel (generic Voltaren gel) Urinary Agents Detrol, Detrol LA, Ditropan XL, Enablex, Gelnique, Oxytrol Myrbetriq, oxybutynin/oxybutynin ER, tolterodine/tolterodine ER, trospium/trospium ER, Toviaz, Vesicare Urinary Agents Detrol, Detrol LA, Ditropan XL, Enablex, Gelnique, Myrbetriq, Oxytrol, Toviaz, Vesicare oxybutynin/oxybutynin ER, tolterodine/tolterodine ER, trospium/trospium ER Versacloz (clozapine oral suspension) Formulary 1, 2, 3/Exclusive, 4/AON Versacloz Clozapine tablet Vimovo Vimovo Plan-Preferred (trial of TWO required) ONE Non-steroidal Antiinflamatory Drug (NSAID) AND ONE plan-preferred Proton Pump Inhibitor (PPI) : lansoprazole, Nexium 24HR (OTC), pantoprazole, Prevacid 24HR (OTC), Prilosec OTC/omeprazole, Zegerid OTC Vivlodex Vivlodex meloxicam Updated: 4/3/17 The Plan fully expects that only appropriate and medically necessary services will be rendered. The Plan reserves the right to conduct pre-payment and post-payment reviews to assess the medical appropriateness of the above-referenced therapies. The preceding policy applies only to members for whom the above named pharmacy benefit medications are included on their covered formulary. Members with closed formulary benefits are subject to trying all appropriate formulary alternatives before a coverage exception for a non-formulary agent will be considered. Coverage under the Medical benefit may apply for diabetic drugs and supplies. The preceding policy is a guideline to allow for coverage of the pertinent medication/product, and is not meant to serve as a clinical practice guideline. 6/1/18 Page 7 of 7

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