AMANTADINE ER OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED RELEASE PRIOR CLAIM FOR AMANTADINE HCL IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS. 1
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 2 MG FYCOMPA 4 MG FYCOMPA 6 MG FYCOMPA 8 MG OXTELLAR XR 150 MG,EXTENDED RELEASE OXTELLAR XR 300 MG,EXTENDED RELEASE OXTELLAR XR 600 MG,EXTENDED RELEASE TROKENDI XR 200 MG CAPSULE, EXTENDED RELEASE VIMPAT 10 MG/ML ORAL SOLUTION VIMPAT 100 MG VIMPAT 150 MG VIMPAT 200 MG VIMPAT 200 MG/20 ML INTRAVENOUS SOLUTION VIMPAT 50 MG PRIOR CLAIM FOR GENERIC ANTICONVULSANT AGENT (CARBAMAZEPINE, DIVALPROEX SODIUM, GABAPENTIN, LAMOTRIGINE, LEVETIRACETAM, OXCARBAZEPINE, TIAGABINE, TOPIRAMATE, VALPROIC ACID, OR ZONISAMIDE), WITHIN THE PAST 120 DAYS. 2
ANTIDEPRESSANTS TRINTELLIX 10 MG TRINTELLIX 20 MG TRINTELLIX 5 MG VIIBRYD 10 MG (7)-20 MG (23) S IN A DOSE PACK VIIBRYD 10 MG VIIBRYD 20 MG PRIOR CLAIM FOR FORMULARY VERSION OF PAROXETINE, FLUOXETINE, SERTRALINE, DULOXETINE, CITALOPRAM, MIRTAZAPINE, ESCITALOPRAM, OR BUPROPION WITHIN THE PAST 120 DAYS. 3
ANTIDIABETIC AGENTS - MISCELLANEOUS GLYXAMBI 10 MG-5 MG GLYXAMBI 25 MG-5 MG INVOKAMET 150 MG-1,000 MG INVOKAMET 150 MG-500 MG INVOKAMET 50 MG-1,000 MG INVOKAMET 50 MG-500 MG INVOKAMET XR 150 MG-1,000 MG, EXTENDED RELEASE INVOKAMET XR 150 MG-500 MG, EXTENDED RELEASE INVOKAMET XR 50 MG-1,000 MG, EXTENDED RELEASE INVOKAMET XR 50 MG-500 MG, EXTENDED RELEASE INVOKANA 100 MG INVOKANA 300 MG JARDIANCE 10 MG JARDIANCE 25 MG SYNJARDY 12.5 MG-1,000 MG SYNJARDY 12.5 MG-500 MG SYNJARDY 5 MG-1,000 MG SYNJARDY 5 MG-500 MG SYNJARDY XR 10 MG-1,000 MG, EXTENDED RELEASE SYNJARDY XR 12.5 MG-1,000 MG, EXTENDED RELEASE SYNJARDY XR 25 MG-1,000 MG, EXTENDED RELEASE SYNJARDY XR 5 MG-1,000 MG, EXTENDED RELEASE PRIOR CLAIM FOR METFORMIN, METFORMIN ER, A SULFONYLUREA AGENT (GLYBURIDE, GLIPIZIDE, GLIMEPIRIDE, TOLAZAMIDE), PIOGLITAZONE, OR COMBINATION OF A SULFONYLUREA-METFORMIN WITHIN THE PAST 120 DAYS. 4
ANTI-INFLAMMATORY AGENTS - GI DIPENTUM 250 MG CAPSULE PRIOR CLAIM FOR ANY 1 OF THE FOLLOWING: BALSALAZIDE, APRISO, DELZICOL, MESALAMINE DR 800 MG TAB, OR FORMULARY MESALAMINE 1.2 G DR TAB WITHIN THE PAST 120 DAYS. 5
ANTIPSYCHOTIC AGENTS aripiprazole 10 mg disintegrating tablet aripiprazole 15 mg disintegrating tablet clozapine 100 mg disintegrating tablet clozapine 12.5 mg disintegrating tablet clozapine 150 mg disintegrating tablet clozapine 200 mg disintegrating tablet clozapine 25 mg disintegrating tablet FANAPT 1 MG FANAPT 10 MG FANAPT 12 MG FANAPT 1MG(2)-2 MG(2)-4MG(2)-6 MG(2) S IN A DOSE PACK FANAPT 2 MG FANAPT 4 MG FANAPT 6 MG FANAPT 8 MG SAPHRIS (BLACK CHERRY) 10 MG SUBLINGUAL SAPHRIS (BLACK CHERRY) 5 MG SUBLINGUAL SAPHRIS 10 MG SUBLINGUAL SAPHRIS 2.5 MG SUBLINGUAL SAPHRIS 5 MG SUBLINGUAL VERSACLOZ 50 MG/ML ORAL SUSPENSION VRAYLAR 1.5 MG (1)-3 MG (6) CAPSULES IN A DOSE PACK VRAYLAR 1.5 MG CAPSULE VRAYLAR 3 MG CAPSULE VRAYLAR 4.5 MG CAPSULE VRAYLAR 6 MG CAPSULE PRIOR CLAIM FOR FORMULARY VERSIONS OF ANY TWO ORAL ANTIPSYCHOTICS: RISPERIDONE, CLOZAPINE, OLANZAPINE, IMMEDIATE RELEASE QUETIAPINE FUMARATE, ZIPRASIDONE, ARIPIPRAZOLE WITHIN THE PAST 365 DAYS. 6
ANTIPSYCHOTIC AGENTS II REXULTI 0.25 MG REXULTI 0.5 MG REXULTI 1 MG REXULTI 2 MG REXULTI 3 MG REXULTI 4 MG PRIOR CLAIM FOR TWO (2) OF THE FOLLOWING FORMULARY ORAL VERSIONS OF ATYPICAL ANTIPSYCHOTICS (RISPERIDONE, CLOZAPINE, OLANZAPINE, QUETIAPINE, ARIPIPRAZOLE OR ZIPRASIDONE) OR SSRI (CITALOPRAM, ESCITALOPRAM, FLUOXETINE, PAROXETINE OR SERTRALINE) OR SNRI (DESVENLAFAXINE, DULOXETINE OR VENLAFAXINE) WITHIN THE PAST 365 DAYS 7
B VERSUS D ADMINISTRATIVE STEP CYCLOPHOSPHAMIDE 25 MG CAPSULE CYCLOPHOSPHAMIDE 50 MG CAPSULE methotrexate sodium 2.5 mg tablet XATMEP 2.5 MG/ML ORAL SOLUTION IN ORDER TO ASSIST IN A PART B VS. D PAYMENT DETERMINATION, A PRIOR CLAIM SEEN FOR A RHEUMATOID ARTHRITIS, PSORIASIS OR ACTIVE POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS DRUG WITHIN THE PAST 120 DAYS WILL QUALIFY FOR PART D PAYMENT. ALL OTHER INDICATIONS WILL HAVE A PART B VS. D PAYMENT DETERMINATION MADE THROUGH THE FORMULARY EXCEPTION PROCESS PRIOR TO THE APPROVAL OF THE DRUG. 8
ELUXADOLINE VIBERZI 100 MG VIBERZI 75 MG PRIOR CLAIM FOR DICYCLOMINE AND XIFAXAN 550MG WITHIN THE PAST 365 DAYS. 9
FIDAXOMICIN DIFICID 200 MG PRIOR CLAIM FOR ORAL VANCOMYCIN IN THE PAST 120 DAYS. 10
INSULIN/GLP-1 ANALOG SOLIQUA 100/33 100 UNIT-33 MCG/ML SUBCUTANEOUS INSULIN PEN XULTOPHY 100/3.6 100 UNIT-3.6 MG/ML (3 ML) SUBCUTANEOUS INSULIN PEN PRIOR CLAIM FOR 2 OF THE FOLLOWING (ONE FROM EACH GROUP): A) VICTOZA, LANTUS, TOUJEO, OR OZEMPIC AND B) METFORMIN, METFORMIN ER, SULFONYLUREA AGENT (GLYBURIDE, GLIPIZIDE, GLIMEPIRIDE, TOLAZAMIDE), COMBO SULFONYLUREA- METFORMIN, OR PIOGLITAZONE IN PAST 365 DAYS. 11
NOVEL ORAL ANTICOAGULANTS PRADAXA 110 MG CAPSULE PRADAXA 150 MG CAPSULE PRADAXA 75 MG CAPSULE PRIOR CLAIM FOR ELIQUIS AND XARELTO IN THE PAST 365 DAYS. 12
OPHTHALMIC ANTIHISTAMINES - NO OTC ALREX 0.2 % EYE DROPS,SUSPENSION PRIOR CLAIM FOR FEDERAL LEGEND LEVOCETIRIZINE, CROMOLYN SODIUM, EPINASTINE, OR FORMULARY OLOPATADINE EYE DROPS WITHIN THE PAST 120 DAYS. 13
RENIN ANGIOTENSIN SYSTEM INHIBITORS TEKTURNA 150 MG TEKTURNA 300 MG TEKTURNA HCT 150 MG-12.5 MG TEKTURNA HCT 150 MG-25 MG TEKTURNA HCT 300 MG-12.5 MG TEKTURNA HCT 300 MG-25 MG PRIOR CLAIM FOR AN ANGIOTENSIN CONVERTING ENZYME INHIBITOR (ACE INHIBITOR), OR ACE INHIBITOR COMBINATION OR A GENERIC ANGIOTENSIN RECEPTOR BLOCKER (ARB), OR GENERIC ARB COMBINATION WITHIN THE PAST 120 DAYS. 14
SPRITAM SPRITAM 1,000 MG FOR ORAL SUSPENSION SPRITAM 250 MG FOR ORAL SUSPENSION SPRITAM 500 MG FOR ORAL SUSPENSION SPRITAM 750 MG FOR ORAL SUSPENSION PRIOR CLAIM FOR LEVETIRACETAM SOLUTION IN THE PAST 120 DAYS 15
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INDEX ALREX 0.2 % EYE DROPS,SUSPENSION... 13 APTIOM 200 MG...2 APTIOM 400 MG...2 APTIOM 600 MG...2 APTIOM 800 MG...2 aripiprazole 10 mg disintegrating tablet... 6 aripiprazole 15 mg disintegrating tablet... 6 BANZEL 200 MG...2 BANZEL 40 MG/ML ORAL SUSPENSION... 2 BANZEL 400 MG...2 clozapine 100 mg disintegrating tablet...6 clozapine 12.5 mg disintegrating tablet...6 clozapine 150 mg disintegrating tablet...6 clozapine 200 mg disintegrating tablet...6 clozapine 25 mg disintegrating tablet... 6 CYCLOPHOSPHAMIDE 25 MG CAPSULE...8 CYCLOPHOSPHAMIDE 50 MG CAPSULE...8 DIFICID 200 MG... 10 DIPENTUM 250 MG CAPSULE... 5 FANAPT 1 MG... 6 FANAPT 10 MG... 6 FANAPT 12 MG... 6 FANAPT 1MG(2)-2 MG(2)-4MG(2)-6 MG(2) S IN A DOSE PACK... 6 FANAPT 2 MG... 6 FANAPT 4 MG... 6 FANAPT 6 MG... 6 FANAPT 8 MG... 6 FYCOMPA 0.5 MG/ML ORAL SUSPENSION... 2 FYCOMPA 10 MG...2 FYCOMPA 12 MG...2 FYCOMPA 2 MG... 2 FYCOMPA 4 MG... 2 FYCOMPA 6 MG... 2 FYCOMPA 8 MG... 2 GLYXAMBI 10 MG-5 MG...4 GLYXAMBI 25 MG-5 MG...4 INVOKAMET 150 MG-1,000 MG... 4 INVOKAMET 150 MG-500 MG... 4 INVOKAMET 50 MG-1,000 MG... 4 INVOKAMET 50 MG-500 MG... 4 INVOKAMET XR 150 MG-1,000 MG, EXTENDED RELEASE... 4 INVOKAMET XR 150 MG-500 MG, EXTENDED RELEASE... 4 INVOKAMET XR 50 MG-1,000 MG, EXTENDED RELEASE... 4 INVOKAMET XR 50 MG-500 MG, EXTENDED RELEASE... 4 INVOKANA 100 MG...4 INVOKANA 300 MG...4 JARDIANCE 10 MG... 4 JARDIANCE 25 MG... 4 methotrexate sodium 2.5 mg tablet... 8 OSMOLEX ER 129 MG, EXTENDED RELEASE... 1 OSMOLEX ER 193 MG, EXTENDED RELEASE... 1 OSMOLEX ER 258 MG, EXTENDED RELEASE... 1 OXTELLAR XR 150 MG,EXTENDED RELEASE... 2 OXTELLAR XR 300 MG,EXTENDED RELEASE... 2 OXTELLAR XR 600 MG,EXTENDED RELEASE... 2 PRADAXA 110 MG CAPSULE... 12 PRADAXA 150 MG CAPSULE... 12 PRADAXA 75 MG CAPSULE... 12 REXULTI 0.25 MG...7 REXULTI 0.5 MG...7 REXULTI 1 MG... 7 REXULTI 2 MG... 7 REXULTI 3 MG... 7 REXULTI 4 MG... 7 SAPHRIS (BLACK CHERRY) 10 MG SUBLINGUAL...6 SAPHRIS (BLACK CHERRY) 5 MG SUBLINGUAL...6 17
SAPHRIS 10 MG SUBLINGUAL... 6 SAPHRIS 2.5 MG SUBLINGUAL... 6 SAPHRIS 5 MG SUBLINGUAL... 6 SOLIQUA 100/33 100 UNIT-33 MCG/ML SUBCUTANEOUS INSULIN PEN...11 SPRITAM 1,000 MG FOR ORAL SUSPENSION...15 SPRITAM 250 MG FOR ORAL SUSPENSION...15 SPRITAM 500 MG FOR ORAL SUSPENSION...15 SPRITAM 750 MG FOR ORAL SUSPENSION...15 SYNJARDY 12.5 MG-1,000 MG... 4 SYNJARDY 12.5 MG-500 MG... 4 SYNJARDY 5 MG-1,000 MG... 4 SYNJARDY 5 MG-500 MG...4 SYNJARDY XR 10 MG-1,000 MG, EXTENDED RELEASE... 4 SYNJARDY XR 12.5 MG-1,000 MG, EXTENDED RELEASE... 4 SYNJARDY XR 25 MG-1,000 MG, EXTENDED RELEASE... 4 SYNJARDY XR 5 MG-1,000 MG, EXTENDED RELEASE... 4 TEKTURNA 150 MG... 14 TEKTURNA 300 MG... 14 TEKTURNA HCT 150 MG-12.5 MG... 14 TEKTURNA HCT 150 MG-25 MG... 14 TEKTURNA HCT 300 MG-12.5 MG... 14 TEKTURNA HCT 300 MG-25 MG... 14 TRINTELLIX 10 MG... 3 TRINTELLIX 20 MG... 3 TRINTELLIX 5 MG... 3 TROKENDI XR 200 MG CAPSULE, EXTENDED RELEASE... 2 VERSACLOZ 50 MG/ML ORAL SUSPENSION... 6 VIBERZI 100 MG...9 VIBERZI 75 MG... 9 VIIBRYD 10 MG (7)-20 MG (23) S IN A DOSE PACK... 3 VIIBRYD 10 MG... 3 VIIBRYD 20 MG... 3 VIIBRYD 40 MG... 3 VIMPAT 10 MG/ML ORAL SOLUTION... 2 VIMPAT 100 MG... 2 VIMPAT 150 MG... 2 VIMPAT 200 MG... 2 VIMPAT 200 MG/20 ML INTRAVENOUS SOLUTION...2 VIMPAT 50 MG...2 VRAYLAR 1.5 MG (1)-3 MG (6) CAPSULES IN A DOSE PACK...6 VRAYLAR 1.5 MG CAPSULE... 6 VRAYLAR 3 MG CAPSULE... 6 VRAYLAR 4.5 MG CAPSULE... 6 VRAYLAR 6 MG CAPSULE... 6 XATMEP 2.5 MG/ML ORAL SOLUTION... 8 XULTOPHY 100/3.6 100 UNIT-3.6 MG/ML (3 ML) SUBCUTANEOUS INSULIN PEN...11 18