DRUG COVERAGE CRITERIA NEW AND THERAPEUTIC EQUIVALENT MEDICATIONS

Transcription

1 UnitedHealthcare Oxford Clinical Policy DRUG COVERAGE CRITERIA NEW AND THERAPEUTIC EQUIVALENT MEDICATIONS Policy Number: PHARMACY T2 Effective Date: April 1, 2018 Table of Contents Page INSTRUCTIONS FOR USE... 1 CONDITIONS OF COVERAGE... 1 COVERAGE RATIONALE... 2 DEFINITIONS REFERENCES POLICY HISTORY/REVISION INFORMATION Related Policies None INSTRUCTIONS FOR USE This Clinical Policy provides assistance in interpreting Oxford benefit plans. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify its policies as necessary. This Clinical Policy is provided for informational purposes. It does not constitute medical advice. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. When deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific benefit plan document [e.g., Certificate of Coverage (COC), Schedule of Benefits (SOB), and/or Summary Plan Description (SPD)] may differ greatly from the standard benefit plan upon which this Clinical Policy is based. In the event of a conflict, the member specific benefit plan document supersedes this Clinical Policy. All reviewers must first identify member eligibility, any federal or state regulatory requirements, and the member specific benefit plan coverage prior to use of this Clinical Policy. Other Policies may apply. UnitedHealthcare may also use tools developed by third parties, such as the MCG Care Guidelines, to assist us in administering health benefits. The MCG Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. CONDITIONS OF COVERAGE This policy applies to Connecticut, New Jersey, and New York Commercial plans. Exclusion Connecticut Plans and Products Effective January 1, 2012, as groups enroll or renew, insurers cannot require an individual to use an alternative brand name prescription drug or over-the-counter drug before using the brand name prescription drug that was prescribed by a licensed physician for pain management. Insurers can, however, first require the individual to try a therapeutically equivalent generic drug before approving the brand name prescription drug that was prescribed by the physician. Limitations Quantity Duration (QD) and Quantity Level Limitations (QLL) Quantity duration (QD) and quantity level limitations (QLL) may be in place for certain medications. For information regarding QD or QLL supply limits, refer to the following documents on UnitedHealthcareOnline.com > Tools & Resources > Pharmacy Resources >Clinical Programs > Supply Limits: QD Supply Limits (defines the maximum quantity of medication that can be covered in a specified time period) QLL Supply Limits (defines the maximum quantity of medication that is covered for one prescription or copayment) Notes: Not all Oxford Members have a pharmacy benefit. Drug Coverage Criteria - New and Therapeutic Equivalent Medications Page 1 of 18

2 For coverage of outpatient prescription drugs and specific exclusions, exceptions, and dispensing limitations, refer to the member's pharmacy plan, if applicable. Oxford's Pharmacy Benefit Manager (PBM) provides a nationwide network of participating pharmacies that dispense prescription medications on a retail level. Commercial groups with outpatient prescription drug coverage will have their pharmacy benefit administered by the PBM. COVERAGE RATIONALE This policy provides information and criteria relevant to medications for which certain types of prescription drug benefit exclusions may apply. In accordance with Oxford's prescription drug riders, certain medications are excluded from coverage. The rationale for such exclusions varies, and therefore coverage may be provided in certain clinical scenarios. There are two types of exclusions addressed in this policy: Exclude at Launch: In an effort to enhance the affordability and value of prescription drug riders, and as part of our Prescription Drug List (PDL) management, Oxford will proactively identify and help manage the cost of low value medications being introduced into the market. The Exclude at Launch program delays coverage until a full evaluation can be completed for new medications that may offer little to no additional health care value. Our PDL Management Committee will review each Exclude at Launch medication to determine its tier placement or benefit coverage. Same Active Ingredient: Oxford may exclude coverage for a medication, unless it is medically necessary for the member, if it includes the same active ingredient (or a modified version of an active ingredient) and is therapeutically equivalent to a covered prescription medication. Oxford's definition of therapeutic equivalence refers to medications that produce the same therapeutic outcome and adverse event profile. The following table provides a list of prescription medications for which one or both of the above exclusions apply. Precertification through the Pharmacy Benefit Manager (PBM) is required for all listed medications. Coverage will be provided only when the member has exhibited intolerance (that is, sensitivity, drug allergy, adverse effect) to, or experienced a therapeutic failure with at least one of the covered formulary alternatives noted below (except where noted). *Select medications have these additional requirements: Submission of medical records documenting history of trial and failure, inadequate response, or intolerance to the therapeutically equivalent covered medications as documented (document date and duration of trial); and Prescriber attests to the following: The information provided is true and accurate to the best of their knowledge and they understand that a routine audit may be performed and medical information may be requested as necessary to verify the accuracy of the information provided. **Select medications have these additional requirements: Submission of medical records documenting history of trial and failure, inadequate response, or intolerance to the Therapeutically Equivalent covered medications as documented (document date and duration of trial); and Care provider must give an explanation of potential rationale for how the excluded medication will work if stating the patient failed on the covered Therapeutically Equivalent product which has the same active ingredient (e.g., the member had an adverse reaction to an inactive ingredient in the alternative product); and Prescriber attests to the following: The information provided is true and accurate to the best of their knowledge and they understand that a routine audit may be performed and medical information may be requested as necessary to verify the accuracy of the information provided. ***Select medications have this additional requirement: Care provider must give an explanation of potential rationale for how the excluded medication will work if stating the patient failed on the covered Therapeutically Equivalent product which has the same active ingredient (e.g., the member had an adverse reaction to an inactive ingredient in the alternative product). Reauthorization Criteria for All Medications Requested medication will be approved based on both of the following: Documentation of positive clinical response; and Member is currently on medication as documented in claims history (evidence of claims in past 120 days) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Page 2 of 18

3 **Abilify Absorica Abstral **Acanya Acetaminophen/Caffeine/ Dihydrocodeine Bitartrate 325/30/16 mg Aciphex (brand only) Aciphex Sprinkle Acticlate Actiq Actos (brand only) Acuvail Adderall (brand only) Adoxa Adrenaclick Adynovate Adzenys XR - ODT Airduo RespiClick Aktipak Gel Allzital Alogliptin (Nesina authorized generic) Alogliptin/Metformin (Kazano authorized generic) Alogliptin/Pioglitazone (Oseni authorized generic) Altoprev **Ambien (brand only) **Ambien CR (brand and generic) ***Amphetamine/Dextroamphetamine Extended-Release (generic Adderall XR) Amrix/Cyclobenzaprine Extended Release Amturnide Anafranil (brand only) Analpram Advanced Kit Androgel Antara Anusol HC Suppository (brand only) Must try: aripiprazole (generic Abilify) And one of the following: Olanzapine (generic Zyprexa), quetiapine (generic Seroquel), risperidone (generic Risperdal), ziprasidone (generic Geodon) Must try two: Amnesteem, Claravis, Myorisan, Zenatane Must try both: Fentanyl citrate (generic Actiq), Lazanda Clindamycin 1.2%/benzoyl peroxide 5% gel (generic Duac), clindamycin solution + OTC benzoyl peroxide Acetaminophen/codeine (Tylenol with codeine), Trezix All of the following: Omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic Aciphex), Dexilant All of the following: Omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic Aciphex), Dexilant Doxycycline hyclate (generic Vibramycin, Vibra-Tabs), doxycycline monohydrate (generic Monodox) Must try both: Fentanyl citrate (generic Actiq), Lazanda Pioglitazone (generic Actos) Ketorolac ophthalmic solution (generic Acular, Acular LS) Amphetamine/dextroamphetamine immediate-release (generic Adderall) Doxycycline hyclate (generic Vibramycin, Vibra-Tab), doxycycline monohydrate 50 or 100mg (generic Monodox) Epinephrine (EpiPen or EpiPen Jr. authorized generic) Kogenate FS, Kovaltry, Novoeight, Nuwiq Must try two (brand or generic): Adderall XR, Concerta, methylphenidate extended release (generic Metadate CD ), methylphenidate extended release (generic Ritalin LA) or Vyvanse (Note: Brand and generic will count as 1 alternative med.) Must try two: Fluticasone/salmeterol powder for inhalation (generic AirDuo Respiclick), Advair Diskus/HFA, Breo Ellipta, Symbicort Erythromycin/benzoyl peroxide 3/5% (generic Benzamycin) Butalbital/acetaminophen 50mg/325mg (generic Phenrilin) Nesina Kazano Oseni Lovastatin (generic Mevacor) Must try two: Zolpidem, zalepelon, eszopiclone Must try two: Zolpidem, zalepelon, eszopiclone Adderall XR Cyclobenzaprine HCL (generic Flexeril), Flexeril Amlodipine + Tekturna HCT (or individual components taken concomitantly) Clomipramine (generic Anafranil) Hydrocortisone acetate/pramoxine HCl (generic for Analpram HC) Minimum 4 week trial of Testim Hydrocortisone cream (generic Anusol-HC), hydrocortisone suppository (generic Anusol-HC) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Page 3 of 18

4 Aptensio XR Aqua Glycolilc HC Aricept (23mg only) Arimidex (brand only) ArmonAir RespiClick **Asacol HD Astagraf XL Astelin (brand only) Astepro Atelvia **Ativan (brand only) Atralin Augmentin (brand only) Augmentin ES-600 (brand only) Augmentin XR/Amoxicillin-Clavulanate ER **Auvi-Q Avar Foam (9.5%-5%, 10-2%), Avar, Avar LS Avelox Tablet (brand only) Avodart (brand only) Avita 0.025% Cream, Gel Axert (brand only) Axiron Azilect (brand only) **Azor Baraclude Tablets (brand only) Beconase AQ Benicar (brand only) Benicar HCT (brand only) Benzaclin Jar (brand only) Benzaclin Kit (1%-5%) Benzaclin Pump Benzefoam, Benzefoam Ultra Bepreve Betamethasone Valerate Foam (generic Luxiq) Betapace (brand only) Bexarotene Caps (generic Targretin) Beyaz Bevyxxa Must try two: Adderall XR, Concerta, methylphenidate extendedrelease capsule (generic Metadate CD ), methylphenidate extendedrelease (generic Ritalin LA) or Vyvanse (Note: Brand and generic will count as 1 alternative med) Hydrocortisone 2.5% (generic Hytone) Donepezil 10mg (generic for Aricept 10mg) Anastrozole (generic Arimidex) Must try two: Alvesco, Asmanex (HFA or Twisthaler), Flovent, QVAR Apriso, Lialda Tacrolimus (generic Prograf) Azelastine nasal spray (generic Astelin) Azelastine (generic Astelin) Risedronate (generic Actonel), Actonel Must try: Lorazepam (generic Ativan) And one of the following: Alprazolam (generic Xanax), clonazepam (generic Klonopin), diazepam (generic Valium) Tretinoin cream (generic Retin-A) Amoxicillin/clavulanic acid (generic Augmentin) Amoxicillin/clavulanic acid (generic Augmentin) Amoxicillin/clavulanate potassium (generic Augmentin) Epinephrine auto-injector (EpiPen, EpiPen Jr. authorized generic) Sulfacetamide sodium/sulfur 10-5% Moxifloxacin tablets (generic Avelox) Dutasteride (generic Avodart), finasteride (generic Proscar) Must try both: OTC Differin gel, tretinoin cream (generic Retin-A) Almotriptan (generic Axert), naratriptan (generic Amerge), rizatriptan (generic Maxalt), sumatriptan (generic Imitrex) Minimum 4 week trial of Testim Rasagiline (generic Azilect) Must try both: Amlodipine (generic Norvasc) plus olmesartan (generic Benicar), amlodipine plus valsartan (generic Exforge) Entecavir tablet (generic Baraclude) Must try two: Flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, Nasacort OTC Olmesartan (generic Benicar) Olmesartan HCT (generic Benicar HCT) Clindamycin 1%/benzoyl peroxide 5% gel (generic Benzaclin) Clindamycin 1.2% /benzoyl peroxide 5% gel (generic Duac), clindamycin solution + OTC benzoyl peroxide Clindamycin 1.2% /benzoyl peroxide 5% gel (generic Duac), clindamycin solution + OTC benzoyl peroxide OTC Benzoyl peroxide Azelastine (generic for Optivar) and Lastacaft Betamethasone lotion (generic Valisone) Sotalol (generic Betapace) Targretin capsules Drospirenone/ethinyl estradiol (generic Yaz) or Yaz + Folic Acid Enoxaparin (generic Lovenox), heparin Drug Coverage Criteria - New and Therapeutic Equivalent Medications Page 4 of 18

5 Bimatoprost 0.03% (generic Lumigan) Lumigan 0.01% Binosto Brisdelle Bromsite Budesonide Nasal Spray (generic Rhinocort Aqua) Bunavail Film Butalbital/Acetaminophen/Caffeine/ Codeine 50mg/300mg/40mg/30mg (generic Fioricet with Codeine 300 mg stregnth) Byvalson Caduet and Generic Caduet (Atorvastatin/Amlodipine) Cambia Capecitabine (generic Xeloda) Cardizem (brand only) Cardizem CD (brand only) Cardizem LA (brand only) Carospir Suspension Celebrex (brand only) Cellcept (brand only) Cenestin Centany AT Kit Clenpiq Chlorzoxazone 250 mg Choline Fenofibrate (generic Trilipix) Ciclodan Combination Package Ciclodan Kit Clarifoam EF (brand only) Clarinex/Desloratidine Clarinex-D Clindacin Pac Clindagel Clindamycin 1%/Benzoyl Peroxide 5% (generic Benzaclin) Gel Clobetasol Shampoo (generic Clobex Shampoo) Clobex Lotion Clobex Shampoo Clodan 0.05% Clodan 0.05% Kit Colazal (brand only) Alendronate (generic for Fosamax), Fosamax Estradiol (generic Estrace), paroxetine (generic Paxil), paroxetine extended-release (generic Paxil CR), Enjuvia, Premarin Bromfenac ophthalmic solution (generic Bromday, Xibrom) Must try two: Flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, Nasacort OTC Zubsolv Butalbital/acetaminophen/caffeine/codeine 50mg/325mg/40mg/30mg (generic Fioricet with codeine 325 mg stregnth) Valsartan (generic Diovan) plus Bystolic Amlodipine (generic Norvasc) + atorvastatin (generic for Lipitor) Diclofenac tablets (generic Voltaren, Cataflam), Xeloda Diltiazem (generic Cardizem) Diltiazem extended-release (generic Cardizem CD) Diltiazem extended-release (generic Cardizem LA) Spironolactone tablet (generic Aldactone) Celecoxib (generic Celebrex) Mycophenolate (generic Cellcept) Must try both: Enjuvia, Premarin Mupirocin ointment (generic Bactroban), PEG-3350/electrolytes, Gavilyte-C (generic Colyte 240/22.74 g), PEG- 3350/electrolytes, Gavilyte-G (generic Golytely 236/22.7 g), PEG- 3350/NaCl/NaBicarbonate/KCl, Gavilyte-N, Trilyte (generic Nulytely), Prepopik Chlorzoxazone 500 mg (generic Parafon Forte DSC) Ciclopirox (generic Loprox), Ciclopirox nail lacquer (generic Penlac) Sulfacetamide sodium/sulfur 10-5% (generic Clarifoam EF) Levocetirizine (generic for Xyzal), Xyzal Levocetirizine (generic for Xyzal), Xyzal (+ OTC pseudoephedrine) Clindamycin gel 1% (generic for Cleocin-T), clindamycin solution, clindamycin lotion Clindamycin gel 1% (generic for Cleocin-T), clindamycin solution, clindamycin lotion Clindamycin 1.2% /benzoyl peroxide 5% gel (generic Duac), clindamycin solution + OTC benzoyl peroxide Clobetasol (generic Temovate), Temovate Clobetasol 0.05% gel (generic Temovate), clobetasol 0.05% solution (generic Temovate) Clobetasol (generic Temovate), Temovate Clobetasol (generic Temovate) lotion, Temovate lotion Clobetasol (generic Temovate) lotion, Temovate lotion Balsalazide (generic Colazal) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Page 5 of 18

6 Colchicine Capsule (manufacturer of West-Ward) Colchicine Tablet (manufacturer of Prasco) Colcrys Comfort Pac Tizanadine Conzip Cordran Cream (brand only) Cordran Lotion (brand only) Coreg CR Cosopt PF Cotempla XR-ODT Crestor Cuprimine **Cymbalta Daxbia Daytrana **Delzicol Denavir Mitigare Mitigare Mitigare Tizanadine (generic for Zanaflex) Tramadol (generic Ultram), tramadol ER (generic for Ultram ER), Ultram, Ultram ER Flurandrenolide 0.05% cream (generic Cordran cream) Flurandrenolide 0.05% lotion (generic Cordran) Carvedilol (generic for Coreg), Coreg Dorzolamide/timolol(generic Cosopt), Cosopt Must try two: Adderall XR, Concerta, methylphenidate extendedrelease capsule (generic Metadate CD, Ritalin LA), or Vyvanse Rosuvastatin (generic Crestor) Depen Must try both: duloxetine (generic Cymbalta), venlafaxine ER (generic Effexor XR) Cephalexin (generic Keflex) Must try two: Adderall XR, Concerta, methylphenidate extendedrelease capsule (generic Metadate CD ), methylphenidate extendedrelease (generic Ritalin LA) or Vyvanse (Note: Brand and generic will count as 1 alternative med.) Apriso, Lialda Dermasorb XM 39% Kit Urea 40% (generic Carmol 40) Desloratadine (generic Clarinex) Desvenlafaxine ER Detrol Detrol LA Dexmethylphenidate Extended-Release Capsule (generic Focalin XR) Must try two: Acyclovir capsule/tablet (generic Zovirax), famciclovir tablet (generic Famvir), valacyclovir tablet (generic Valtrex), OTC Abreva Levocetirizine (generic for Xyzal), Xyzal Venlafaxine extended-release capsule (generic Effexor XR) Oxybutynin (generic Ditropan), oxybutynin extended-release (generic Ditropan XL), Ditropan, Ditropan XL, Toviaz, Oxytrol OTC Oxybutynin (generic Ditropan), oxybutynin extended-release (generic Ditropan XL), Ditropan, Ditropan XL, Toviaz, Oxytrol OTC Must try two: Adderall XR, Concerta, methylphenidate extendedrelease capsule (generic Metadate CD), methlyphenidate extendedrelease (generic Ritalin LA) or Vyvanse (Note: Brand and generic will count as 1 alternative med.) D.H.E. 45 (brand only) Dihydroergotamine (generic D.H.E. 45) Dibenzyline (brand only) Diclofenac 1% Topical Gel (generic Voltaren) **Diovan (brand only) **Diovan HCT (brand only) Disalcid Donepezil 23mg (generic Aricept 23mg) Doryx/Doxycycline Hyclate Delayed Release Tablet Phenoxybenzamine (generic Dibenzyline) Voltaren gel Must try: Valsartan (generic Diovan) And one of the following: Losartan (generic Cozaar), telmisartan (generic Micardis), irbesartan (generic Avapro) Must try: Valsartan/HCTZ (generic Diovan HCT) And one of the following: Losartan/HCTZ (generic Hyzaar), telmisartan/hctz (generic Micardis HCT), irbesartan/hctz (generic Avalide) Salsalate (generic Disalcid) Donepezil 10mg (generic Aricept 10mg) Doxycycline hyclate (generic Morgidox, Vibramycin), doxycycline monohydrate 50mg or 100mg (generic Monodox) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Page 6 of 18

7 Doxycycline 75mg Capsule (generic Monodox) Doxycycline Delayed-Release Capsule 40mg (Oracea authorized generic) Doxycycline Monohydrate 150mg Capsule (generic for Adoxa) Duac, Duac CS **Duragesic (brand only) Dutoprol Duzallo Dyanavel XR **Dymista Ecoza Edluar Doxycycline hyclate (generic Morgidox, Vibramycin), doxycycline monohydrate 50mg or 100mg (generic Monodox) Must try two: Doxycycline hyclate (generic Morgidox, Vibramycin), doxycycline monohydrate 50 mg and 100 mg (generic Monodox), Oracea Doxycycline hyclate (generic Vibramycin, Vibra-Tab), doxycycline monohydrate 50 or 100mg (generic Monodox) Clindamycin 1.2% /benzoyl peroxide 5% gel (generic Duac) Fentanyl transdermal patch 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr (generic Duragesic) Metoprolol (generic Toprol-XL) plus hydrochlorothiazide Allopurinol (generic Zyloprim) plus Zurampic Must try two (brand or generic): Adderall XR, Concerta, methylphenidate extended-release (generic Metadate CD), methylphenidate extended-release (generic Ritalin LA) or Vyvanse (Note: Brand and generic will count as 1 alternative med.) Fluticasone (generic for Flonase) + azelastine (generic for Astelin) Must try two: Econazole (generic Spectazole), ketoconazole (generic Nizoral), terbinafine (generic Lamisil) Must try two: Zolpidem (generic Ambien), zalepelon (generic Sonata), eszopiclone (generic Lunesta) E.E.S. 400 (brand only) Erythromycin ethylsuccinate (generic E.E.S. 400) Elestat Emadine Emflaza Enablex Entocort EC (brand only) Envarsus XR Epiduo Epiduo Forte Epinephrine Pen Injection 0.15mg and 0.3mg (generic Adrenaclick) EpiPen/EpiPen Jr. (brand only) Epzicom (brand only) Ertaczo Estradiol (generic Estrace Cream 0.01%) Estradiol TD Twice Weekly Patch (generic Vivelle-Dot) Evekeo Evista (brand only) Exelon Patch (brand only) Exforge Azelastine (generic for Optivar) and Lastacaft Azelastine (generic for Optivar) and Lastacraft Prednisone Oxytrol OTC, oxybutynin, oxybutynin extended-release, Ditropan, Ditropan XL, Toviaz Budesonide (generic Entocort EC) Tacrolimus (generic Prograf) Must try both: OTC benzoyl peroxide PLUS OTC Differin gel; OTC benzoyl peroxide PLUS tretinoin cream (generic Retin-A) Must try both: tretinoin (generic Retin-A) + OTC Benzoyl Peroxide, OTC Differin + OTC Benzoyl Peroxide Epinephrine (EpiPen or EpiPen Jr. authorized generic) Epinephrine auto-injector (EpiPen, EpiPen Jr. authorized generic) Abacavir/lamivudine (generic Epzicom) Must try two: Ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral) Estrace Cream Vivelle-Dot Amphetamine/dextroamphetamine immediate-release (generic Adderall), dextroamphetamine immediate-release (generic Dexedrine) Raloxifene (generic Evista) Rivastigmine transdermal patch (generic Exelon), rivastigmine capsules (generic Exelon) Amlodipine/valsartan (generic Exforge), Amlodipine (generic Norvasc) + losartan (generic Cozaar), Amlodipine (generic Norvasc) + telmisartan (generic Micardis), Amlodipine (generic Norvasc) + olmesartan, Amlodipine (generic Norvasc) + valsartan (generic Diovan) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Page 7 of 18

8 Exforge HCT Fabior Falessa Kit Femara (brand only) Fenofibrate 43mg, 130mg (generic Antara) Capsule Fenofibrate 48mg, 145mg (generic Tricor) Fenofibrate 50mg, 150mg (generic Lipofen) Capsule Fenoglide Fentanyl Transdermal Patch (37.5, 62.5 and 87.5 Mcg/Hr strengths only) Fentora Fiasp Fibricor 35mg, 105mg Fioricet with Codeine 50mg/325mg/40mg/30mg (brand only) Fioricet with Codeine Capsule 50mg/300mg/40mg/30mg Flector Flomax (brand only) Flo-Pred Fluoxetine 60 mg Tablet Fluoxetine Tablets (generic Sarafem) Flowtuss Floxin 0.3% Otic (brand only) Fluocinonide 0.1% Cream (generic Vanos) Fluticasone/Salmeterol Focalin XR Fortesta Gelnique Genadur Kit Generess FE Genotropin and Genotropin Miniquick Geodon (brand only) Gialax Kit Giazo Glatopa (Glatiramer generic Copaxone) Gleevec (brand only) Amlodipine (generic Norvasc) + losartan/hydrochlorothiazide (generic Hyzaar), Amlodipine (generic Norvasc) + valsartan/hydrochlorothiazide (generic Diovan HCT), Amlodipine (generic Norvasc) + olmesartan HCT Amlodipine (generic Norvasc) + telmisartan/hydrochlorothiazide (generic Micardis HCT) Tazorac gel Levonorgestrel/ethinyl estradiol (generic Alesse, Levlite) [branded generics (Aubra, Aviane, Lessina, Lutera, Orsythia, Sronyx, Falmina)] plus Folic Acid Letrozole (generic Femara) Fentanyl transdermal patch (12.5, 25, 50, 75, 100 mcg/hr only) (generic Duragesic) Must try two: Fentanyl citrate (generic Actiq), Lazanda Humalog Butalbital/acetaminophen/caffeine/codeine phosphate 50mg/325mg/40mg/30mg (generic Fioricet with codeine) Butalbital/acetaminophen/caffeine/codeine 50mg/325mg/40mg/30mg (generic Fioricet with codeine) Voltaren Gel Tamsulosin (generic Flomax) Prednisolone sodium phosphate (generic Orapred, Pedipred, Prelone), Orapred, Pedipred, Prelone Fluoxetine capsules (generic Prozac) Fluoxetine capsules (generic Prozac) Guaifenesin/codeine solution (Cheratussin) Ofloxacin 0.3% otic solution (generic Floxin Otic, Ocuflox) Fluocinonide cream (generic Lidex) Advair Diskus/HFA, Breo Ellipta, Symbicort Must try two: Adderall XR, Concerta, methylphenidate extendedrelease capsule (generic Metadate CD), methylphenidate extendedrelease (generic Ritalin LA) or Vyvanse (Note: Brand and generic will count as 1 alternative med.) Testim, Androderm Oxytrol OTC, oxybutynin (generic Ditropan), oxybutynin extendedrelease (generic Ditropan XL), Ditropan, Ditropan XL, Toviaz Genadur Gildess FE, Junel FE, Larin FE, Microgestin FE (generic for Loestrin FE), Loestrin FE, Lo Loestrin FE, LoMedia Nutropin, Nutropin AQ, or Nutropin AQ NuSpin Ziprasidone (generic Geodon) PEG-3350 (generic Miralax) Balsalazide (generic for Colazal), Colazal Must try two: Avonex, Copaxone (brand only), Betaseron, Tecfidera Imatinib (generic Gleevec) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Page 8 of 18

9 Gocovri Gonitro Gralise Granix Helidac Helixate FS Hemangeol Oral Solution Horizant Humatrope Hycofenix Ilevro Imitrex Injection (brand only) Imitrex Tablets (brand only) Impoyz Imuran (brand only) Inderal LA (brand only) Intermezzo Intrarosa **Intuniv (brand only) Invega (brand only) Irenka Ixinity Jalyn Juluca Kapvay Karbinal ER Kenalog Spray (brand only) Amantadine immediate-release Nitroglycerin sublingual tablet (generic Nitrostat) Gabapentin (generic Neurontin) Zarxio Pylera Kogenate FS, Kovaltry, Novoeight, Nuwiq Propranolol tablet, propranolol oral solution Gabapentin (generic Neurontin) or ropinirole (generic Requip )or pramipexole (generic Mirapex) Nutropin, Nutropin AQ, or Nutropin AQ NuSpin Guaifenesin/codeine solution (Cheratussin) Bromfenac ophthalmic solution (generic Bromday, Xibrom) Sumatriptan injection or tablets (generic Imitrex) Sumatriptan injection or tablets (generic Imitrex) Betamethasone dipropionate augmented 0.05% cream (generic Diprolene AF) and fluocinonide 0.05% cream (generic Lidex cream) Azathioprine (generic Imuran) Propranolol extended-release capsule (generic Inderal LA) Must try two: Zolpidem (generic Ambien), zalepelon (generic Sonata), eszopiclone (generic Lunesta) Osphena Guanfacine extended-release (generic Intuniv) Paliperidone (generic Invega) Duloxetine (generic Cymbalta) BeneFIX, Rixubis Dutasteride (generic Avodart) + tamsulosin (generic Flomax) Edurant + Tivicay Keralac 47% Cream Urea 40% Keralyt Scalp Kit Guanfacine extended-release (generic Intuniv) Carbinoxamine tablets (generic Palgic) Triamcinolone spray (generic Kenalog) Salicylic acid shampoo, salicylic acid gel Ketocon Ketoconzaole 2% + hydrocortisone 1% Ketodan Combination Package Khedezla Kitabis Pak **Lantus, **Lantus Solostar Lescol XL (brand only) Levalbuterol Nebs (generic Xopenex Nebs) **Lexapro Librax (brand only) Lidoderm Ketoconazole cream, shampoo or foam (generic Nixoral) Venlafaxine extended-release capsule (generic Effexor XR) Bethkis Must try both: Basaglar, Levemir Must try three: Atorvastatin (generic Lipitor), fluvastatin (generic Lescol), lovastatin (generic Mevacor), pravastatin (generic Pravachol), simvastatin (generic Zocor) Albuterol nebulized solution (generic Proventil Inhalation Solution) Must try: escitalopram (generic Lexapro) And one of the following: paroxetine (generic Paxil), sertraline (generic Zoloft), fluoxetine (generic Prozac), citalopram (generic Celexa) Chlordiazepoxide/clidinium (generic Librax) Lidocaine transdermal patch (generic Lidoderm) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Page 9 of 18

10 **Lipitor (brand only) Lipofen Locoid Lipocream Locoid Lotion LoCort Lodosyn (brand only) Lofibra 54mg, 160mg (brand only) Lofibra 67, 134, 200mg Lo Minastrin FE Loprox 0.77% Cream Loprox Shampoo (brand only) Loprox (suspension) Lorzone Lotemax Gel Lotronex (brand only) Lovaza (brand only) **Lunesta (brand only) Luxiq Foam Luzu Lyrica CR Maxalt (brand only) Maxalt-Mlt (brand only) Mepron Suspension (brand only) Mesalamine (generic Lialda) Metadate CD (brand only) ***Methylphenidate Extended-Release Tablet (generic Concerta) Metoprolol 37.5, 75mg Metoprolol Extended-Release/ Hydrochlorothiazide (Dutoprol authorized generic) Metrogel 0.75% Vaginal (brand only) Metrogel 1% Metronidazole 1% Gel (generic Metrogel 1%) Metozolv ODT Micardis (brand only) Micardis HCT (brand only) Micort-HC 2.5% Cream Migranal (brand only) Must try: Atorvastatin (generic for Lipitor) And one of the following: Crestor, pravastatin (generic Pravachol), simvastatin (generic Zocor), lovastatin (generic Mevacor) Hydrocortisone butyrate (generic Locoid) Hydrocortisone butyrate (generic Locoid) Dexamethasone tablets Carbidopa (generic Lodosyn) Gildess Fe, Junel Fe, Larin FE, Microgestin Fe (branded generics for Loestrin Fe), Loestrin FE, Lo Loestrin FE, LoMedia Ciclopirox 0.77% cream (generic Loprox) Ciclopirox shampoo (generic Loprox Shampoo) Ciclopirox 0.77% suspension (generic Loprox) Chlorzoxazone (generic Parafon Forte DSC) Lotemax Ointment/Suspension Alosetron (generic Lotronex) Must try both: Omega-3-acid ethyl esters (generic Lovaza), Vascepa Must try two: Zolpidem (generic Ambien), zalepelon(generic Sonata), eszopiclone (generic Lunesta) Betamethasone lotion (generic Valisone) Must try two: Ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral) Gabapentin (generic Neurontin), duloxetine (generic Cymbalta), tricyclic antidepressant (e.g. amitriptyline), Lyrica Rizatriptan (generic Maxalt) Rizatriptan orally disintegrating tablet (generic Maxalt MLT) Atovaquone suspension (generic Mepron) Lialda (brand) Must try two (brand or generic): Adderall XR, Concerta, methylphenidate extended-release (generic Metadate CD), methylphenidate extended-release (generic Ritalin LA) or Vyvanse (Note: Brand and generic will count as 1 alternative med) Brand Concerta Metoprolol (25, 50, 100mg strengths) (generic Lopressor) Metoprolol (generic Toprol-XL) plus hydrochlorothiazide Metronidazole 0.75% vaginal gel (generic Metrogel-Vaginal) Metronidazole gel 0.75% (generic Metrogel) Metronidazole gel 0.75% (generic Metrogel) Metoclopramide (generic for Reglan), Reglan Telmisartan (generic Micardis) Telmisartan/hydrochlorothiazide (generic Micardis HCT) Hydrocortisone 2.5% cream Dihydroergotamine nasal spray (generic Migranal) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Page 10 of 18

11 Minastrin 24 FE Minocin 50mg, 75mg and 100mg Minocycline Tablet (generic Dynacin) Mirapex ER Moderiba Pak Moderiba Tablet Monodox (brand only) Morgidox Kit (combo package) MorphaBond ER Motofen Mydayis Myfortic (brand only) *Myrbetriq Naftin 1% & 2% Gel or Cream Namenda XR Namzaric Naprelan Nasonex Natesto Natroba (brand only) Neoral (brand only) Neo-Synalar Neo-Synalar Kit Nevirapine Extended-Release Neupogen Nicazeldoxy 30 Kit (Doxycycline Plus MVI) Nitroglycerin Spray (generic Nitrolingual) Nitrolingual Pump Spray Nityr Noctiva Norditropin, Norditropin Nordiflex, Norditropin Flexpro Noritate Nuvessa Nuvigil (brand) Nystatin/Triamcinolone (generic Mycolog II) Cream and Ointment Oleptro Gildess Fe, Junel Fe, Larin FE, Microgestin Fe (branded generics for Loestrin Fe), LoMedia Minocycline capsule (generic Minocin) Minocycline immediate-release capsules (generic Minocin) Pramipexole (generic for Mirapex), Mirapex Ribavirin (generic Copegus) Ribavirin (generic Copegus) Doxycycline hyclate (generic Vibramycin), doxycycline monohydrate 50 or 100mg (generic Monodox) Doxycycline hyclate (generic Vibramycin), doxycycline monohydrate 50 or 100mg (generic Monodox) Fentanyl transdermal patch 12, 25, 50, 75, 100 mcg/hr (generic Duragesic), morphine sulfate extended-release tablet (generic MS Contin), Nucynta ER, Xtampza ER Diphenoxylate/atropine (generic Lomotil) Must try two: Adderall XR, Concerta, methylphenidate extendedrelease capsule (generic Metadate CD, Ritalin LA), or Vyvanse Mycophenolate delayed-release (generic Myfortic) Must try: Toviaz And one of the following: Oxytrol OTC, oxybutynin (generic Ditropan), oxybutynin extended-release (generic Ditropan XL) Must try two: Ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral) Memantine immediate-release (generic Namenda) Donepezil (generic Aricept) plus memantine (generic Namenda) Naproxen sodium Two of the following: Flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, Nasacort OTC Androderm, Testim Spinosad (generic Natroba) Cyclosporine modified (generic Neoral) OTC Triple Antibiotic Ointment plus fluocinolone 0.025% cream (generic Synalar) OTC Neosporin plus fluocinolone cream (generic Lidex), Lidex cream Nevirapine (generic Viramune) Zarxio Doxycycline hyclate (generic Vibramycin, Vibra-Tab), doxycycline monohydrate 50 or 100mg (generic Monodox) Nitroglycerin spray (generic Nitromist), Nitromist, Nitrostat Nitroglycerin spray (generic Nitromist), Nitromist, Nitrostat Orfadin Desmopressin nasal spray (generic DDAVP) Nutropin, Nutropin AQ, or Nutropin AQ NuSpin Metronidazole 0.75% cream (generic Metrocream), metronidazole-.75% gel (generic Metrogel) Metronidazole 0.75% vaginal gel (generic Metrogel-Vaginal) Modafinil (generic Provigil) Nystatin cream or ointment (generic Mycostatin) + triamcinolone 0.1% cream or ointment (generic Kenalog) Trazodone (generic for Desyrel) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Page 11 of 18

12 Olux Olux-E Omeclamox-Pak Omnaris Omnitrope Onexton % Onmel Onzetra Xsail Opana ER Optivar (brand only) Ortho Evra (brand only) Ortho Tri-Cyclen Lo (brand only) Otovel Otrexup Ovace Plus 9.8% Lotion Ovace Plus Foam Oxaydo Oxistat Lotion Ozempic Parlodel Pataday Patanol Pazeo PCP 100 Kit Pediaderm AF Pediaderm TA Pedipirox-4 Penlac Nail Lacquer (brand only) **Pennsaid 1.5% Drops **Pennsaid 2% **Pentasa **Percocet (brand only) Plavix (brand only) Clobetasol 0.05% gel (generic Temovate), clobetasol 0.05% solution (generic Temovate) Clobetasol 0.05% gel (generic Temovate), clobetasol 0.05% solution (generic Temovate) Omepraxole (Prilosec) & clarithromycin (Biaxin) & amoxicillin (Amoxil) Must try two: Flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, Nasacort OTC Nutropin, Nutropin AQ, or Nutropin AQ NuSpin Clindamycin topical solution (generic Cleocin T) + OTC benzoyl peroxide or clindamycin-benzoyl peroxide (generic Duac) 1.2%-5% Itraconazole (generic for Sporanox), Sporanox Sumatriptan nasal spray (generic Imitrex) Must try three: Morphine sulfate extended-release tablet (generic MS Contin), Nucynta ER, Xtampza ER Azelastine (generic for Optivar) AND Lastacaft Norelgestromin/ethinyl estradiol topical patch, Xulane (generic Ortho Evra) Norgestimate/ethinyl estradiol, Tri-Lo-Estarylla, Tri-Lo-Marzia, Tri-Lo- Sprintec, Trinesa (generic for Ortho Tri-Cyclen Lo) Ofloxacin 0.3% solution (generic Floxin, Ocuflox), Ciprodex Must try both: Methotrexate tablets, Rasuvo Sulfacetamide sodium 10% lotion, gel Sulfacetamide sodium 10% lotion, gel Oxycodone immediate-release (generic Oxy IR) Must try two: Clopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral) Adlyxin, Bydureon, Tanzeum, Trulicity, Victoza Bromocriptine (generic Parlodel) Must try all of the following: Azelastine (generic for Optivar), Lastacaft, olopatadine (generic Patanol) Azelastine (generic for Optivar) and Lastacaft Azelastine (generic for Optivar) and Lastacaft Metoclopramide (generic Reglan) + OTC magnesium citrate + OTC Miralax, + OTC bisacodyl + OTC Cerelyte 50 Nystatin cream (generic Mycostatin) Triamcinolone 0.1% cream (generic Aristocort) Ciclopirox (generic Penlac) Ciclopirox 8% solution (generic Penlac Nail Lacquer) Voltaren Gel Voltaren Gel Apriso, Lialda Acetaminophen/oxycodone (generic Percocet) Clopidogrel (generic Plavix) Plexion % Cream, Liquid, Lotion Sulfacetamide sodium/sulfur 10-5% Plexion Cloth 9.8%-4.8% Pads Sulfacetamide sodium/sulfur 10-5% Pramosone E Prescription Emollients/Moisturizers Prestalia Prevpac Hydrocortisone/pramoxine (generic Pramosone) OTC Aquaphor, OTC Eucerin, OTC Lubriderm, OTC White Petroleum Perindopril (generic Aceon) plus amlodipine (generic Norvasc) Omeclamox-Pak Drug Coverage Criteria - New and Therapeutic Equivalent Medications Page 12 of 18

13 Prevymis Prilosec Suspension Pristiq (brand only) Valganciclovir (generic Valcyte) All of the following: Omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic Aciphex), Dexilant, Prevacid Solu-Tab, Nexium Suspension Desvenlafaxine extended-release tablet (generic Pristiq) Procort Hydrocortisone/pramoxine (generic Analpram E) Proctocort (brand only) Prodrin (brand only) Prograf Capsules (brand only) Prolensa Promiseb Complete Kit Protonix (brand only) Protonix Granules for Suspension Protopic Provigil (brand only) **Prozac Prozac Weekly (brand only) Qnasl Qtern Quartette Quillichew ER Quillivant XR Rapamune Tablets (brand only) Rayaldee **Rayos Rebinyn Requip XL Restasis Multidose Retin-A gel Retin-A Cream (brand only) Retin-A Micro (brand and generic) Retin-A Micro Pump (brand and generic) Revatio Rexaphenac 1% Cream Hydrocortisone 1% cream (generic Proctocort), hydrocortisone 30mg suppository (generic Proctocort) Isometheptene/caffeine/acetaminophen 65/20/325mg (generic Prodrin) Tacrolimus (generic Prograf) Bromfenac ophthalmic solution (generic Bromday, Xibrom) Promiseb All of the following: Omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic Aciphex), Dexilant All of the following: Omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic Aciphex), Dexilant, Prevacid Solu-Tab, Nexium Suspension Tacrolimus ointment (generic Protopic) Modafinil (generic Provigil) Must try: fluoxetine (generic Prozac) And one of the following: paroxetine (generic Paxil), sertraline (generic Zoloft), citalopram (generic Celexa), escitalopram (generic Lexapro) Fluoxetine capsules (generic Prozac) Must try two: Flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, Nasacort OTC Farxiga plus Onglyza Introvale, Jolessa, Quasense (generics for Seasonale); Amethia, Camrese, Daysee (generic for Seasonique); Amethia Lo, Camrese Lo (generic for LoSeasonique) Must try two (brand or generic): Adderall XR, Concerta, methylphenidate extended-release (generic Metadate CD), methylphenidate extended-release (generic Ritalin LA) or Vyvanse (Note: Brand and generic will count as 1 alternative med) Must try two (brand or generic): Adderall XR, Concerta, methylphenidate extended-release (generic Metadate CD), methylphenidate extended-release (generic Ritalin LA) or Vyvanse (Note: Brand and generic will count as 1 alternative med.) Sirolimus (generic Rapamune) Calcitriol (generic Rocaltrol) Prednisone Benefix, Rixubis Ropinirole (generic for Requip), Requip Restasis (single use vials) Must try both: OTC Differin gel, tretinoin cream (generic Retin-A) Must try both: OTC Differin gel, tretinoin cream (generic Retin-A) Tretinoin cream (generic Retin-A), Tretinoin cream (generic Retin-A), Sildenafil (generic Revatio) Voltaren Gel Drug Coverage Criteria - New and Therapeutic Equivalent Medications Page 13 of 18

14 Rhinocort Aqua Ribapak Risperdal (brand only) Ritalin LA (brand only) Ropinirole Extended Release (Requip XL) Rosadan Kit Cream Rosadan Kit Gel Must try two: Flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, Nasacort OTC Ribavirin (generic for Copegus, Rebetol) Risperidone (generic Risperdal) Must try two: Adderall XR, Concerta, methylphenidate extendedrelease capsule (generic Metadate CD), methylphenidate extendedrelease (generic Ritalin LA) or Vyvanse (Note: Brand and generic will count as 1 alternative med.) Ropinirole (generic Requip), Requip Metronidazole cream (Metrocream), metronidazole 0.75% gel Metronidazole gel 0.75% (Metrogel), metronidazole 0.75% lotion Rosula Sodium sulfacetamide/sulfur 10-5% Rytary Ryvent Tablet Tramadol Extended Release (generic Ryzolt) Safyral Saizen Sanctura (brand and generic) Sanctura XR (brand and generic) Sancuso Sandimmune Capsules (brand only) Sandostatin (brand only) Sarafem Tablets Seroquel XR (brand only) Sernivo Spray Seroquel (brand only) Silenor Simbrinza 1-0.2% Singulair Chewable Tablet (brand only) Singulair Tablet (brand only) Sitavig Skelaxin (brand only) Sodium Sulfacetamide/Sulfur 9-4.5% Kit (Generic Sumadan Kit) Solodyn Solosec Soltamox Soma 250mg/Carisoprodol 250mg Sorilux (Calcipotriene) Spritam Carbidopa/levodopa extended release tablet (generic Sinemet CR), carbidopa/levodopa (generic Sinemet) Carbinoxamine tablets (generic Palgic) Tramadol (generic for Ultram), tramadol ER (generic for Ultram ER) Drospirenone/ethinyl estradiol (generic Yasmin), Yasmin + folic acid Nutropin, Nutropin AQ, or Nutropin AQ NuSpin Oxytrol OTC, oxybutynin, oxybutynin extended-release, Ditropan, Ditropan XL, Toviaz Oxytrol OTC, oxybutynin, oxybutynin extended-release, Ditropan, Ditropan XL, Toviaz Granisetron (generic for Kytril) Cyclosporine (generic Sandimmune) Octreotide (generic Sandostatin) Fluoxetine capsules (generic Prozac) Quetiapine extended-release (generic Seroquel XR) Betamethasone lotion (generic Diprosone) Quetiapine (generic Seroquel) Doxepin (generic Sinequan); zolpidem (generic Ambien), zaleplon (generic Sonata) Brimonidine (generic Alphagan) or Alphagan plus Azopt Montelukast chewable tablet (generic Singulair) Montelukast (generic Singulair) Acyclovir tablets (Zovirax), acyclovir ointment (Zovirax ointment), Zovirax cream, Zovirax tablets Metaxolone (generic for Skelaxin) Sodium sulfacetamide/sulfur 10-5% Must try two: minocycline immediate-release capsules (generic Minocin) And either doxycycline hyclate (generic Vibramycin, Vibra- Tab) or doxycycline monohydrate (generic Monodox), Clindamycin capsules (generic Cleocin), clindamycin cream (generic Cleocin, Clindesse), metronidazole tablets (generic Flagyl), metronidazole vaginal gel (Metrogel-Vaginal), tinidazole (generic Tindamax) Tamoxifen (generic for Nolvadex), Nolvadex Carisprodol 350mg (generic for Soma) Calcipotriene (Dovonex), Dovonex Levetiracetam tablets, oral solution (generic Keppra) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Page 14 of 18

15 SSS 10-4 Sulfacetamide sodium/sulfur 10-5% Staxyn Steglatro Steglujan Stiolto Respimat Strattera (brand only) Subsys Post Levitra Invokana, Jardiance, Farxiga SGLT-2 inhibitor (i.e., Invokana, Jardiance, Farxiga) plus DPP-4 inhibitor (i.e., Januvia, Nesina, Onglyza, Tradjenta) Must try both: Anoro Ellipta, Utibron NeoHaler Atomoxetine (generic Strattera) Must try both: Fentanyl citrate (generic Actiq), Lazanda (Prior Authorization required) Sumadan Sulfacetammide sodium/sulfur 10-5% Sumadan Cleanser (brand only) Sulfacetammide sodium/sulfur 10-5% Sumadan Xlt Kit Sulfacetamide sodium/sulfur 10-5% Sumavel DosePro Sumatriptan injection (generic Imitrex) Sumaxin CP Sulfacetammide sodium/sulfur 10-5% Sumaxin TS Sulfacetamide sodium/sulfur 10-5% Symproic Synalar 0.01% Solution (brand only) Synalar 0.025% Cream, Ointment (brand only) Synalar Kit Synalar TS Taclonex Ointment (brand only) Targadox Tasmar (brand only) Taytulla Tekamlo Tenoretic (brand only) Tenormin (brand only) Terbinex Testosterone Topical Gel (authorized generic for Testim) Testosterone Topical Gel (generic Volgelxo) Testosterone Topical Gel (manufacturer of Perrigo Israel) Tirosint Tivorbex Tobi Nebs Tobradex ST Tobramycin Nebulized Solution Tolak 4% Cream Tolterodine (generic Detrol) Topicort Spray Toujeo Solostar Linzess, Movantik Fluocinolone 0.01% solution (generic Synalar) Fluocinolone 0.025% cream, ointment (generic Synalar) Fluocinolone (generic Synalar) Fluocinolone (generic Synalar) Betamethasone/calcipotriene ointment (generic Taclonex) Doxycycline hyclate capsules (generic Vibramycin, Vibra-Tab), doxycycline monohydrate (generic Monodox) Tolcapone (generic Tasmar) Blisovi FE, Gildess FE, Junel FE, Larin FE, Microgestin FE, Norethindrone/Ethinyl Estradiol/Ferrous Fumarate, Tarina FE (generics Loestrin FE), Blisovi 24 FE, Gildess 24 FE, Junel 24 FE, Larin 24 FE, LoMedia 24 FE, Microgestin FE (generic Loestrin 24 FE) Amlodipine (generic Norvasc) or Norvasc + Tekturna Atenolol/chlorthalidone (generic Tenoretic) Atenolol (generic Tenormin) Terbinafine (generic for Lamisil) Minimum 4 week trial of Testim Testim, Androderm Androderm, Testim Levothyroxine, Synthroid Indomethacin capsule (generic Indocin) Bethkis Tobramycin/dexamethasone ophthalmic drops (generic for Tobradex), Tobradex Bethkis Fluorouracil 5% cream (generic Efudex) Oxytrol OTC, oxybutynin, oxybutynin extended-release, Ditropan, Ditropan XL, Toviaz Desoximetasone (generic Topicort), Topicort Levemir Drug Coverage Criteria - New and Therapeutic Equivalent Medications Page 15 of 18

16 Tramadol Extended-Release (generic Ryzolt) Trelegy Ellipta Tretinoin Gel (generic Retin-A) Tretin-X Cream Tretin-X Kit **Treximet Trezix Trianex Tribenzor Tricor/Fenofibrate 48mg and 145mg (generic Tricor) Triglide Trilipix Tuzistra XR Twynsta Ultravate X Combination Package Umecta Emulsion, Foam, Suspension Urea 40% Umecta Kit (nail film pen/film suspension) Umecta PD Urea 40% Uramaxin GT 45% Urea 40% Uramaxin GT Kit Urea 40% Urevaz 44% Cream Tramadol (generic Ultram), tramadol extended-release (generic Ultram ER) Flovent plus Anoro Ellipta Must try both: OTC Differin gel, tretinoin cream (generic Retin-A) Tretinoin cream (generic Retin-A), OTC Differin Tretinoin cream (generic Retin-A), OTC Differin Must try both: Sumatriptan (generic Imitrex) + naproxen (generic Naprosyn), rizatriptan (generic Maxalt) + naproxen Acetaminophen/codeine (Tylenol with codeine) Triamcinolone ointment Amlodipine (generic Norvasc) + HCTZ + olmesartan OR olesartan HCT +amlodipine (generic Norvasc) Fenofibrate 54mg, 160m (generic Tricor) Hydrocodone polistirex/chlorpheniramine polistirex (generic Tussionex Pennkinetic), Z-Tuss Telmisartan (generic Micardis) + amlodipine (generic Norvasc) or Norvasc Halobetasol (generic for Ultravate) plus ammonium lactate (generic for Lac-Hydrin), Ultravate plus Lac-Hydrin Urea 40% emulsion (Umecta) + hyaluronate gel 0.2% (Hylira) Urea 40% cream Utopic (Urea) 41% Urea 40% Vagifem (brand only) Valcyte (brand only) **Valium (brand only) **Valtrex (brand only) Vanos Vaseretic (brand only) Vasotec (brand only) Veltin Venlafaxine ER Tablet Veramyst Verdeso Versacloz *Vesicare Vicodin 5/300mg Vicodin ES 7.5/300mg Vicodin HP 10/300mg Vigamox (brand only) Estradiol vaginal tablet (Yuvafem (generic Vagifem)) Valganciclovir (generic Valcyte) Diazepam (generic Valium) Valacyclovir (generic Valtrex) Fluocinonide cream (generic Lidex) Enalapril/hydrochlorothiazide (generic Vaseretic) Enalapril (generic Vasotec) Clindamycin gel, solution or lotion (generic Cleocin) + tretinoin cream Venlafaxine extended-release capsule (Effexor XR) Must try two: Flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, Nasacort OTC Desonide lotion (generic Desowen), Desowen Clozapine (generic Clozaril), clozapine orally disinegrating tablet (generic Fazaclo) Must try: Toviaz And one of the following: Oxytrol OTC, oxybutynin (generic Ditropan), oxybutynin extended-release (generic Ditropan XL) Hydrocodone/acetaminophen 5/325mg (generic Norco) Hydrocodone/acetaminophen 7.5/325mg (generic Norco) Hydrocodone/acetaminophen 10/325mg (generic Norco) Moxifloxacin ophthalmic solution (generic Viagamox) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Page 16 of 18

17 Viramune (brand only) Viramune XR 400mg (brand only) Viread (brand only) Vituz Vivlodex Vogelxo Vusion Vytone Vytorin (brand only) Vyzulta Wellbutrin (brand only) **Wellbutrin SR **Wellbutrin XL *Xanax (brand only) **Xanax XR (brand only) Xartemis XR 7.5/325mg Xenazine (brand only) Xerese Xhance Ximino Xodol 10/300 (brand and generic) Xodol 5/300 (brand and generic) Xodol 7.5/300 (brand and generic) Xopenex Nebules Xultophy Zecuity 6.5mg/4 Hr Patch Zembrace SymTouch Zenzedi Zestoretic (brand only) Zestril (brand only) Zetia (brand only) Ziana Zipsor 25mg Zodex 6 & 12-Day Pack **Zoloft Zomacton Zonacort Zonatuss Nevirapine (generic Viramune) Nevirapine (generic Viramune) Tenofovir (generic Viread) Hydrodocone-Chlorpheniramine (10-8MG/5ML) Meloxicam (generic Mobic) Minimum 4 week trial of Testim Must try both: Nystatin cream (generic Mycostatin), OTC miconazole cream Iodoquinol/hydrocortisone 1% cream, Dermazene cream Simvastatin/ezetimibe (generic Vytorin) Latanoprost (Xalatan), Lumigan, Travatan Z Bupropion (generic Wellbutrin) Bupropion extended-release (generic Wellbutrin SR) Bupropion extended-release (generic Wellbutrin XL)(trial must be in 2014 or later) Must try: Alprazolam (generic Xanax) And one of the following: Clonazepam (generic Klonopin), diazepam (generic Valium), lorazepam (generic Ativan) Must try: Alprazolam (generic Xanax) And one of the following: Clonazepam (generic Klonopin), diazepam (generic Valium), lorazepam (generic Ativan) Oxycodone/acetaminophen (generic Percocet) Tetrabenazine (generic Xenazine) Acyclovir capsule/tablet (generic Zovirax), famciclovir tablet (generic Famvir), valacyclovir tablet (generic Valtrex), OTC Abreva Fluticasone (generic Flonase) Minocycline immediate-release capsules (generic Minocin) Hydrocodone/acetaminophen 10/325mg (generic Norco) Hydrocodone/acetaminophen 5/325mg (generic Norco) Hydrocodone/acetaminophen 7.5/325mg (generic Norco) Albuterol nebulized solution (generic Proventil Inhalation Solution) Soliqua Sumatriptan injection, nasal spray, tablets (generic Imitrex) Sumatriptan injection, (generic Imitrex) Dextroamphetamine (generic Dexedrine) Lisinopril/hydrochlorothiazide (generic Zestoretic) Lisinopril (generic Zestril) Ezetimibe tablet (generic Zetia) Clindamycin gel, solution or lotion (generic Cleocin) + tretinoin cream Diclofenac potassium (generic Cataflam) or diclofenac sodium (generic Voltaren) Dexamethasone Must try: sertraline (generic Zoloft) And one of the following: paroxetine (generic Paxil), fluoxetine (generic Prozac), citalopram (generic Celexa), escitalopram (generic Lexapro) Nutropin, Nutropin AQ, Nutropin AQ NuSpin Dexamethasone Benzonatate (generic Tessalon Perles) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Page 17 of 18