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 a plan-preferred 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 and the member does not otherwise meet the definition of stable ). 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. Coverage of the requested medication will be granted for FDA-approved or other supported uses (in accordance with corporate Offlabel use policy) and when all stated criteria are met. Coverage is granted indefinitely for the life of this policy once the step therapy criteria have been met, unless otherwise stated. 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 candesartan, candesartan/hctz, eprosartan 600mg, irbesartan, irbesartan/hctz, losartan, losartan/hctz, telmisartan, telmisartan/hctz, valsartan, valsartan/hctz Antipsychotics, 2 nd Generation For treatment of depression (adjunctive, where applicable) Abilify, Rexulti, Seroquel XR, aripiprazole, olanzapine (in combination with fluoxetine) Symbyax, Zyprexa/Zydis For all other FDAapproved indications Abilify, Fanapt, Geodon, Invega, Latuda, paliperidone, Rexulti, Risperdal/M-tab, Saphris, Seroquel, Seroquel XR, Symbyax, Vraylar, Zyprexa/Zydis olanzapine, quetiapine, risperidone, ziprasidone Page 1 of 9
BPH (alpha-antagonists) Flomax, Rapaflo, Uroxatral alfuzosin, doxazosin, tamsulosin, terazosin 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, Jornay PM, 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) Consensi Formularies 1, 2, 3/Exclusive, 4/AON For long-term treatment of hypertension and osteoarthritis in members with documented contraindication to the concurrent administration of amlodipine and celecoxib Non- Preferred Consensi Plan-Preferred (trial of TWO required) amlodipine and celecoxib (administered concurrently) Initial Coverage Duration: 3 months Renewal Criteria: May be renewed in 12-month increments when updated supporting documentation has been provided and the following criteria have been met: Documented existing contraindication to the administration of separate ingredients (amlodipine and celecoxib) concurrently AND Analgesic therapy is still indicated and blood pressure is closely monitored AND Documented sustained benefit of therapy. Page 2 of 9
Constipation Agents Formularies 1, 2, 4/AON Amitiza, Trulance Linzess 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 Coverage Duration: 12 months Renewal Criteria: May be renewed in 12-month increments in presence of sustained benefit of therapy Epinephrine Products Adrenaclick, Auvi-Q, EpiPen, EpiPen Jr, Symjepi Updated: 12/21/18 epinephrine auto-injector (generic Epipen), Epinephrine Auto- Injector (Authorized Generics for EpiPen Jr and Adrenaclick) 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 Page 3 of 9
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 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) Page 4 of 9
Select Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Topical Flector Patch, Pennsaid Solution, diclofenac diclofenac 1% topical gel (generic Voltaren gel) sodium 1.5% topical solution Coverage Duration: Flector- 30 days Pennsaid Solution, diclofenac sodium 1.5% topical solution- 12 months Renewal Criteria: Flector- up to two 30-day renewals may be available dependent on documentation showing continued presence of acute pain Pennsaid Solution, diclofenac sodium 1.5% topical solution- May be renewed in 12-month increments in the presence of sustained benefit of therapy Oral Qmiiz ODT, Vivlodex meloxicam Coverage Duration: 12 months Renewal Criteria: May be renewed in 12-month increments in the presence of sustained benefit of therapy Osteoporosis Agents Actonel, Atelvia, risedronate DR (generic Atelvia), Boniva, Fosamax, Fosamax Plus D, Binosto alendronate, ibandronate Pancreatic Enzymes Creon, Pancreaze, Pertzye Zenpep Prexxartan (valsartan oral solution) Prexxartan valsartan tablet Updated: 6/1/18 Prostaglandin Analogs Formularies 1, 2, 4/AON Rescula, Travatan Z, Vyzulta, Xalatan, Zioptan latanoprost, Lumigan, bimatoprost 0.03% (generic Lumigan) travoprost, Xelpros Page 5 of 9
Prostaglandin Analogs Rescula, Lumigan, Travatan Z, Vyzulta, Xalatan, Zioptan Proton Pump Inhibitors (PPIs) Aciphex, Dexilant, lansoprazole DR orally disintegrating tablet, Nexium, omeprazole/sodium bicarbonate, Prevacid, Prevacid Solutab, Prilosec, Protonix, Zegerid latanoprost, travoprost, bimatoprost 0.03% (generic Lumigan), Xelpros Updated: 11/8/18 lansoprazole, Nexium 24HR (OTC), pantoprazole, Prevacid 24HR (OTC), Prilosec OTC/omeprazole, rabeprazole, Zegerid OTC Rayos (prednisone delayed-release) Formulary 1, 2, 3/Exclusive, 4/AON Rayos generic corticosteroid Renin Inhibitors Tekamlo, Tekturna, Tekturna HCT Generic antihypertensive medications Rhopressa (netasurdil) Rhopressa Plan-Preferred (trial of TWO classes required) ONE plan-preferred Prostaglandin Analog AND ONE ophthalmic Beta Receptor Antagonist 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 Page 6 of 9
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 Sympazan (clobazam oral film) Sympazan clobazam Test Strips for Blood Glucose, Medical Accu-Chek, Contour, Freestyle, Precision, TRUEtrack, TRUEtest, etc One Touch products Testosterone Replacements Formularies 1, 2, 4/AON Topical Axiron, Bio-T-Gel, Fortesta, Natesto, Striant, Androgel, generic testosterone gel Testim, Testosterone Gel (brand), Vogelxo Injectable Xyosted testosterone cypionate, testosterone enanthate Testosterone Replacements Topical Androderm, Axiron, Bio-T-Gel, Fortesta, Androgel, generic testosterone gel Natesto, Striant, Testim, Testosterone Gel (brand), Vogelxo Injectable Xyosted testosterone cypionate, testosterone enanthate Updated 2/15/19 Page 7 of 9
Select Tetracyclines For treatment of moderate or severe acne vulgaris (adjunctive treatment, according to FDA-labeled use regarding age and indication) For all other FDAapproved indications Doryx, doxycycline DR tablet, immediate-release doxycycline, immediate-release minocycline minocycline extended-release, Minolira ER, Seysara, Solodyn, Ximino ER Initial Coverage Duration: 3 months Renewal Criteria: May be renewed ONE TIME for up to an additional 3 months when the following criteria have been met: Sustained benefit of therapy AND Prescriber documents rationale for continuing therapy beyond the initial 3-month period Total Coverage Duration: 6 months. Additional treatment courses can be approved, if clinically appropriate, when at least 6 months have passed since the previous treatment course was completed. Doryx, doxycycline DR tablet, immediate-release doxycycline, immediate-release minocycline Oracea Tiglutik (riluzole suspension) Tiglutik riluzole Topical Dermatologics Formularies 2, 3/Exclusive, 4/AON tretinoin microspheres, tazarotene cream, and all branded medications for acne/rosacea (including Acanya, Aczone, Altreno, 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) all generics except tretinoin microspheres and tazarotene cream Urinary Agents Formularies 1, 2, 4/AON Detrol, Detrol LA, Ditropan XL, Enablex, Gelnique, Oxytrol Myrbetriq, oxybutynin/oxybutynin ER, tolterodine/tolterodine ER, trospium/trospium ER, Toviaz, Vesicare Page 8 of 9
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 Updated: 11/118 Vimovo Plan-Preferred (trial of TWO required) Vimovo 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 Coverage Duration: 12 months Renewal Criteria: May be renewed in 12-month increments in presence of sustained benefit of therapy Yupelri Yupelri Spiriva, Spiriva Respimat, Tudorza 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. 2/15/19 Page 9 of 9