2014 BlueChoice® HealthPlan Prescription Drug List Important Information About This List Copayments Pharmacy benefits cover prescription drugs at three levels. They are generic (tier 1), preferred (tier 2) and nonpreferred (tier 3). Generic drugs typically have the lowest copayment. This category includes most generic drugs and covered over-the-counter (OTC) drugs. Many members have a two-tier generic benefit: Generic drugs costing more than $15 have a low “Standard” generic copayment. Generic drugs that cost less than $15 and OTC drugs have the lowest “Value” generic copayment. Preferred drugs are generally brand drugs that have the middle copayment. Non-preferred drugs are brand drugs and occasionally, high-priced generic drugs, which have the highest copayment. We assign these levels based on cost, availability of a generic substitute and clinical value. Drugs may change levels at any time during the year without prior notice. These changes usually occur when new drugs become available. We do not cover specific “lifestyle” medications under the pharmacy benefit. Some examples of these types of drugs include those for: • • • •
The treatment of hair loss Erectile dysfunction Weight loss Skin pigmentation treatments
Members can get these types of drugs at a discounted price by presenting their prescription and member ID card at a network pharmacy. Quantity Limitations The BlueChoice® Pharmacy and Therapeutics Committee is made up of doctors and pharmacists. The Committee sets maximum-allowed amounts for certain prescription drugs. It bases the amounts on U.S. Food and Drug Administration (FDA) prescribing guidelines and available package sizes. As a result, we limit coverage for some drugs to a certain quantity within a certain period of time. In this drug list, you will see “QL” next to drugs with quantity limits. Prior Authorization Doctors must get prior authorization for certain drugs. This helps make sure the drugs are used according to their product labeling. We base the need for prior authorization on current FDA guidelines. We also base it on clinical decisions from the BlueChoice Pharmacy and Therapeutics Committee. Before a doctor prescribes a prior authorization drug, he or she should call Caremark at 800-294-5979. Caremark is an independent company that administers prescription drug benefits on behalf of BlueChoice. In this drug list, you will see “PA” next to drugs that require prior authorization. Medical Necessity Prior Authorization Some medications will not be covered without prior authorization for medical necessity (MN). Before a doctor prescribes an MN prior authorization drug, he or she should call Caremark at 800-294-5979. In this drug list, you will see “MN” next to drugs that require medical necessity prior authorization.
Step Therapy Some drugs require members to satisfy certain step therapy criteria before they can get the drug. Before a doctor prescribes a step therapy drug, he or she should call BlueChoice HealthPlan at 800-950-5387. We will decide if we can approve the drug based on the step therapy criteria for that drug. In this drug list, you will see “ST” next to drugs that have a step therapy requirement. Specialty Pharmaceuticals Specialty pharmaceuticals are drugs that treat complex or chronic medical conditions and that are usually very expensive. Some of these drugs are covered under the pharmacy benefit (oral and self-injectable drugs), and others are covered under the medical benefit. Specialty drugs are not included in this Prescription Drug List.* For information about specialty drugs, please see the Specialty Drug list. *One exception to this is Lovenox. Please see Lovenox in this PDL for more details.
Generic Available
Drug
ABILIFY
ABSTRAL
ACCOLATE
G
ACCU-CHEK kits and test strips
Formulary Status
Usage Guidelines
Limitations
NP
ST
Requires 30-day trial of clozapine, olanzapine, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days
NP
PA and QL apply. QL is maximum of 4 per day per month.
Indicated for the management of breakthrough cancer pain in patients with cancer who are already receiving and are tolerant of opioid therapy for their underlying persistent cancer pain
NP P
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
2
Effective 02/24/14
Generic Available
Formulary Status
ACCUNEB
G
NP
ACCUPRIL TABS
G
NP
ACCURETIC
G
NP
Drug
acetazolamide
Usage Guidelines
Limitations
Tier 1
ACIPHEX
NP
ACTIGALL
G
ST, PA, QL
Requires step thru generic lansoprazole, omeprazole, pantoprazole, rabeprazole, OTC PPI or Nexium. Max 8 wks therapy, then PA required for extension or twicedaily dose.
NP
ACTIQ
G
NP
ACTIVELLA
G
NP
PA and QL apply. QL is 120 lozenges per 31 days supply per fill.
Indicated for the management of breakthrough cancer pain in patients with cancer who are already receiving and are tolerant of opioid therapy for their underlying persistent cancer pain
ACTONEL (daily dose)
NP
QL
QL of 31 tabs per month
ACTONEL (weekly dose)
NP
QL
QL of 4 tabs per month
ACTONEL 75 mg (monthly dose)
NP
QL
QL of 2 tabs per month or 6 tabs per 90 days
QL
QL up to 62 caps per month
ACTOPLUS MET
G
NP NP
ACTOPLUS MET XR ACTOS
G
NP
ACULAR
G
NP
ADALAT CC
G
NP
ADDERALL XR
G
NP
NP
PA, QL
Coverage allows up to 14 days of therapy in 365 days. Requests for additional days of therapy for acne diagnoses require medical review.
ADVAIR DISKUS
P
QL
QL of 1 inhaler (60 caps) per month
ADVAIR HFA
P
QL
QL of 1 inhaler per month
ADOXA
G
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
3
Effective 02/24/14
Generic Available
Drug
ADVICOR
Formulary Status
Usage Guidelines
Limitations
MN
Alternatives that do not require PA for medical necessity are atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, Simcor
NP
ALAVERT OTC
G
Tier 1
OTC preparation available at Tier 1 copayment with prescription
ALAVERT-D OTC
G
Tier 1
OTC preparation available at Tier 1 copayment with prescription
albuterol inhalation solution, syrup, tabs
Tier 1
ALDACTAZIDE
G
NP
ALDACTONE
G
NP
ALLEGRA OTC
Tier 1
OTC preparation available at Tier 1 copayment with prescription
ALLEGRA-D OTC
Tier 1
OTC preparation available at Tier 1 copayment with prescription
ALPHAGAN P 0.1% ALTACE
P G
ALTOPREV
ALVESCO amantadine
NP
NP
MN
Alternatives that do not require PA for medical necessity are atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin
P
QL
QL of 2 units per month at retail or 6 units per 90 days by mail order
Tier 1
AMARYL
G
AMBIEN
G
NP
NP
MN, QL
Alternatives that do not require PA for medical necessity are zaleplon, zolpidem, zolpidem ext-rel. QL of 31 tabs per month at retail or 93 per 75 days by mail order.
AMBIEN CR
G
NP
MN, QL
Alternatives that do not require PA for medical necessity are zaleplon, zolpidem, zolpidem ext-rel. QL of 31 per month at retail or 93 per 75 days by mail order.
AMERGE
G
NP
QL
QL of 8 tabs per month, all strengths
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
4
Effective 02/24/14
Drug
Generic Available
Formulary Status
QL
P
PA
Coverage provided for male members who need replacement therapy in conditions associated with deficiency or absence of endogenous testosterone
NP
MN
If initial PA criteria is met (see Androderm, Axiron or Fortesta), MN applies to non-preferred options
ST
Requires 30-day trial of a generic fenofibrate before NP brand fenofibrate (Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, TriGlide, Trilipix)
MN
Alternatives that do not require PA for medical necessity are Novolin, Novolog
Tier 1
amiloride/ hydrochlorothiazide
Tier 1
amitriptyline
Tier 1
amoxicillin
Tier 1
ampicillin
Tier 1
ANAFRANIL
G
NP
ANAPROX
G
NP
ANDROGEL
ANTARA
G
NP
ANTIVERT
G
NP
ANUSOL HC
G
NP
APIDRA
NP
APRISO
P
APTIVUS
P
ARALEN
G
NP
ARTHROTEC
G
NP
ASACOL HD
Limitations QL of 31 doses, any strength/combination for 1-month supply, max 6 months therapy per year
AMNESTEEM
ANDRODERM
Usage Guidelines
P
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
5
Effective 02/24/14
Generic Available
Drug
ASMANEX
ASTELIN
G
ASTEPRO
ATACAND
G
Formulary Status
Usage Guidelines
Limitations
P
QL
QL varies by strength. Retail: Asmanex 7 – 2 inhalers; Asmanex 14 – 4 inhalers; Asmanex 30 – 2 inhalers (220mcg/inhaler) or Asmanex 30 – 1 inhaler (110mcg/inhaler); Asmanex 60 – 1 inhaler; Asmanex 120 – 1 inhaler at retail. Multiply each strength by 3 for mail order.
NP
QL
QL of 1 inhaler per month at retail or 3 units per 90 days by mail order
P
QL
QL of 1 inhaler per month at retail or 3 units per 90 days by mail order
MN
Alternatives that do not require PA for medical necessity are Benicar, Benicar HCT, candesartan, candesartan-HCT, Diovan, eprosartan, irbesartan, irbesartanHCT, losartan, losartan-HCT, valsartan-HCT
MN
Alternatives that do not require PA for medical necessity are Benicar, Benicar HCT, candesartan, candesartan-HCT, Diovan, eprosartan, irbesartan, irbesartanHCT, losartan, losartan-HCT, valsartan-HCT
QL
QL of 2 inhalers per month
MN
Alternatives that do not require PA for medical necessity are Benicar, Benicar HCT, candesartan, candesartan-HCT, Diovan, eprosartan, irbesartan, irbesartanHCT, losartan, losartan-HCT, valsartan-HCT
NP
ATACAND HCT
G
NP
ATIVAN
G
NP
ATRIPLA
P
ATROVENT INHAL SOLN
G
ATROVENT HFA
NP P
ATROVENT NASAL
G
NP
AUGMENTIN
G
NP
AUGMENTIN XR
G
NP
AVALIDE
G
NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
6
Effective 02/24/14
Drug
AVAPRO
Generic Available
G
Formulary Status
Usage Guidelines
Limitations
MN
Alternatives that do not require PA for medical necessity are Benicar, Benicar HCT, candesartan, candesartan-HCT, Diovan, eprosartan, irbesartan, irbesartanHCT, losartan, losartan-HCT, valsartan-HCT
NP
AVELOX
P
AVINZA
NP
QL
QL of 30 units at retail per month
AXERT
NP
QL
QL of 8 tabs per month, all strengths
PA
Coverage provided for male members who need replacement therapy in conditions associated with deficiency or absence of endogenous testosterone
MN
Alternatives that do not require PA for medical necessity are flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex
AXID
G
NP
AXIRON
P
AZOPT
P
AZOR
P
AZULFIDINE
G
NP
bacitracin ophthalmic ointment
Tier 1
baclofen
Tier 1
BACTROBAN
G
BACTROBAN NASAL
NP NP
BANZEL
P
BENICAR
P
BENICAR HCT
P
BENTYL
G
benztropine
NP Tier 1
BECONASE AQ
BETAGAN
NP
G
NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
7
Effective 02/24/14
Generic Available
Drug betamethasone dipropionate crm, gel, lotion, oint 0.05%
Formulary Status
Usage Guidelines
Limitations
Tier 1
BETAPACE
G
NP
BETAPACE AF
G
NP
BETIMOL
NP
BIAXIN
G
NP
BIAXIN XL
G
NP
BLEPH-10
G
NP
BLEPHAMIDE SOP
P
BONIVA
G
BREO ELLIPTA BREVICON
G
brimonidine 0.15%, 0.2%
NP
QL
150 mg tabs (QL of 1 tab per month)
NP
MN
Alternatives that do not require PA for medical necessity are Advair, Symbicort
PA, QL
Coverage provided for members who are confirmed to be receiving treatment for opioid dependence in a valid opioid-addiction treatment program
NP Tier 1
buprenorphine
Tier 1
buspirone
Tier 1
BUTRANS
NP
QL
QL of 4 patches per month
Tier 1
QL
QL of 2 units per month
QL
QL of 4 packets per month
butorphanol nasal spray BYDUREON
P
BYETTA
NP
CAFERGOT
NP
CALAN
G
NP
CALAN SR
G
NP
CAMBIA
NP
CANASA SUPPOSITORY
P
captopril
Tier 1
CARAFATE
G
NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
8
Effective 02/24/14
Generic Available
Formulary Status
CARDIZEM CD
G
NP
CARDIZEM LA
G
NP
CARDURA
G
NP
CATAPRES
G
NP
Drug
CAYSTON, inhalation
Usage Guidelines
Limitations
QL, PA, ST
Requires step thru generic DMARDs, NSAIDs, or GI drugs. QL of 62 of 100 mg or 31 of 200 mg per month. PA required for doses > 200 mg daily.
NP
cefdinir
Tier 1
CEFTIN
G
cefprozil
NP Tier 1
CELEBREX
NP
CELEXA
G
CENESTIN
NP NP
cetirizine OTC
Tier 1
OTC preparation available at Tier 1 copayment with prescription for OTC formulation
cetirizine-D OTC
Tier 1
OTC preparation available at Tier 1 copayment with prescription for OTC formulation
CHANTIX
P
chlorthalidone
Check member drug benefit for coverage of smoking cessation drugs. QL of 12 weeks per year.
QL
Tier 1
CIALIS
NP
See limitations
ciclopirox
Tier 1
cimetidine
Tier 1
CIPRO HC OTIC
Check member drug benefit for coverage of oral impotence drugs
P
CIPRO
G
ciprofloxacin ext-rel tabs CITRANATAL VITAMINS
NP Tier 1 P
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
9
Effective 02/24/14
Generic Available
Formulary Status
Usage Guidelines
CLARINEX
G
NP
ST
CLARITIN OTC
G
Tier 1
OTC preparation available at Tier 1 copayment with prescription
CLARITIN-D OTC
G
Tier 1
OTC preparation available at Tier 1 copayment with prescription
Tier 1
QL
QL of 31 doses, any strength/combination for 1-month supply, max 6 months therapy per year
ST
Requires 30-day trial of clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days
QL
QL of 60 tablets per month
QL
QL of 2 inhalers per month
QL
QL of 62 per month
Drug
CLARAVIS
CLEOCIN
G
CLEOCIN VAG SUPP
Requires 21-day trial of OTC nonsedating antihistamine in the last 12 months
NP NP
CLEOCIN T
G
NP
CLIMARA
G
NP
CLINORIL
G
NP
CLOZARIL
G
NP
COLAZAL
G
NP
COLCRYS
P
COLOCORT
Tier 1
COMBIGAN
P
COMBIVENT RESPIMAT
P
COMBIVIR
Limitations
G
COMPLERA
NP P
COMTAN
G
NP
CONCERTA
G
NP
CONDYLOX GEL
NP
CONDYLOX SOLN
G
NP
COPEGUS
G
NP
CORDARONE
G
NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
10
Effective 02/24/14
Generic Available
Formulary Status
COREG
G
NP
CORGARD
G
NP
CORTEF
G
NP
Drug
CORTIFOAM
Limitations
MN
Alternatives that do not require PA for medical necessity are Benicar, Benicar HCT, candesartan, candesartan-HCT, Diovan, eprosartan, irbesartan, irbesartanHCT, losartan, losartan-HCT, valsartan-HCT
MN
Alternative that does not require PA for medical necessity is atorvastatin
ST, QL
Requires 30-day trial of generic SSRI/SNRI in last 180 days. QLs per day (2 of 20 mg, 1 of 30 mg, 2 of 60 mg).
P
CORTISPORIN OTIC
G
NP
COSOPT
G
NP
COUMADIN
G
NP
COVERA HS
COZAAR
Usage Guidelines
NP
G
CREON
NP
P
CRESTOR
NP
CRIXIVAN
P
cromolyn inhalation, ophthalmic CYCLESSA
Tier 1 G
NP
cyclobenzaprine
Tier 1
cyclosporine
Tier 1
CYMBALTA
G
cyproheptadine
NP
Tier 1
CYTOTEC
G
NP
DANTRIUM
G
NP
dapsone
Tier 1
DAYPRO
G
NP
DDAVP SPRAY
G
NP
QL
QL of 2 bottles per month
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
11
Effective 02/24/14
Drug DEMADEX
Generic Available
Formulary Status
G
NP
demeclocycline
Usage Guidelines
Limitations
ST, QL
Requires 30-day trial of generic SNRI in last 180 days. QL of 31 per month.
MN
Alternatives that do not require PA for medical necessity are oxybutynin extrel, tolterodine, tolterodine ext rel, trospium, Gelnique, Vesicare
MN
Alternatives that do not require PA for medical necessity are oxybutynin extrel, tolterodine, tolterodine ext rel, trospium, Gelnique, Vesicare
QL
QL of 93 per month
Tier 1
DEPAKENE
G
NP
DEPAKOTE
G
NP
DEPAKOTE ER
G
NP
DEPAKOTE SPRINKLES
G
NP
DESOGEN
G
NP
DESVENLAFAXINE
NP
DETROL
G
DETROL LA
NP
NP
dexamethasone
Tier 1
dexamethasone sodium phosphate
Tier 1
dextroamphetamine
Tier 1
DEXILANT
NP
ST, PA, QL
diclofenac sodium delayedrel tabs
Tier 1
diclofenac sodium ophthalmic
Tier 1
dicloxacillin
Tier 1
DIFLUCAN TABS
G
NP
DILACOR XR
G
NP
DILANTIN 100 mg CAPS
G
NP
Requires step thru generic lansoprazole, omeprazole, pantoprazole, rabeprazole, OTC PPI or Nexium. Max 8 wks therapy, then PA required for extension or twicedaily dose.
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
12
Effective 02/24/14
Drug DILANTIN 125/5 SUSP
Generic Available
Formulary Status
G
NP
DILANTIN 30 mg CAPS
Usage Guidelines
Limitations
P
DILANTIN 50 mg CHEW
G
NP
DILAUDID
G
NP
DIOVAN
QL
QL of 180 tabs per month at retail
MN
Alternatives that do not require PA for medical necessity are Benicar, Benicar HCT, candesartan, candesartan-HCT, Diovan, eprosartan, irbesartan, irbesartanHCT, losartan, losartan-HCT, valsartan-HCT
MN
Alternatives that do not require PA for medical necessity are oxybutynin extrel, tolterodine, tolterodine ext rel, trospium, Gelnique, Vesicare
P
DIOVAN HCT
G
diphenhydramine
DITROPAN XL
NP
Tier 1
G
DORYX
NP
NP
DOVONEX
G
doxepin
PA, QL
Coverage allows up to 14 days of therapy in 365 days. Requests for additional days of therapy for acne diagnoses require medical review.
NP Tier 1
DUAC
G
DULERA
NP P
DUONEB
G
NP
DURAGESIC
G
NP
DUREZOL
QL
QL of 1 unit per month
QL
QL of 10 patches per month
MN
Alternatives that do not require PA for medical necessity are flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex
P
DYAZIDE
G
DYMISTA
NP
NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
13
Effective 02/24/14
Drug
Generic Available
EDARBI
Formulary Status
Usage Guidelines
Limitations
MN
Alternatives that do not require PA for medical necessity are Benicar, Benicar HCT, candesartan, candesartan-HCT, Diovan, eprosartan, irbesartan, irbesartanHCT, losartan, losartan-HCT, valsartan-HCT
MN
Alternatives that do not require PA for medical necessity are Benicar, Benicar HCT, candesartan, candesartan-HCT, Diovan, eprosartan, irbesartan, irbesartanHCT, losartan, losartan-HCT, valsartan-HCT
MN, QL
Alternatives that do not require PA for medical necessity are zaleplon, zolpidem, zolpidem ext-rel. QL of 31 per month at retail or 93 per 75 days by mail order.
QL
QL of (31 of 37.5 mg or 75 mg XR) or (31 of 150 mg XR) per month. For 225 mg dose, use (31 of 150 mg + 31 of 75 mg) = 1 copayment.
NP
EDARBYCLOR
NP
EDLUAR
NP
EDURANT
P
E.E.S.
G
NP
EFFEXOR XR
G
NP
EFUDEX
G
NP
ELIDEL CREAM
Coverage for 2 years of age and up. If less than 2 years old, call BlueChoice at 800-950-5387.
P
EMEND 40 mg
NP
QL
QL of 4 of 40 mg per month
EMEND 80 mg, 125 mg
NP
QL
QL of 2 of 80 mg or 125 mg per month
EMTRIVA
P
ENJUVIA TABS
P
EPIPEN
P
EPIPEN JR.
P
EPIVIR
G
EPZICOM
NP P
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
14
Effective 02/24/14
Generic Available
Drug ERY-TAB
Formulary Status
Usage Guidelines
Limitations
P
erythromycin
Tier 1
erythromycin stearate
Tier 1
erythromycin/sulfisoxazole suspension
Tier 1
ESTRACE TABS
G
NP Packaged as 90-day supply for 2 times the applicable copayment
ESTRING
NP
etodolac
Tier 1
etoposide
Tier 1
EVISTA
P
EXALGO
P
EXELON CAPS
G
NP
EXFORGE
P
EXFORGE HCT
P
FABIOR
PA, QL
NP
FAMVIR
G
FANAPT
Coverage provided for treatment of opioid-tolerant patients who require continuous, around-the-clock analgesia for an extended time frame. QL applies based on dosing.
ST
Requires 30-day trial of generic tretinoin product in the last 365 days
ST
Requires 30-day trial of clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days
ST
Requires 30-day trial of clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days
NP
NP
FAZACLO
G
NP
FELDENE
G
NP
FEMHRT 0.5/2.5
NP
FEMRING
NP
Packaged as 90-day supply for 2 times the applicable copayment
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
15
Effective 02/24/14
Drug
Generic Available
FENOGLIDE
FENTORA
Formulary Status
Usage Guidelines
Limitations Step thru 30-day trial of a generic fenofibrate before NP brand fenofibrate (Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, TriGlide, Trilipix)
NP
ST
NP
PA and QL apply. QL is 120 tabs per 31-day supply per fill.
Indicated for the management of breakthrough cancer pain in patients with cancer who are already receiving and are tolerant of opioid therapy for their underlying persistent cancer pain
fexofenadine OTC
Tier 1
OTC preparation available at Tier 1 copayment with prescription for OTC formulation
fexofenadine-D OTC
Tier 1
OTC preparation available at Tier 1 copayment with prescription for OTC formulation
NP
ST
Step thru 30-day trial of a generic fenofibrate before NP brand fenofibrate (Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, TriGlide, Trilipix)
Tier 1
PA
PA only for use in men under age 40
NP
MN, QL
Alternatives that do not require PA for medical necessity are flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex. QL of 1 inhaler per month.
FLOVENT DISKUS
P
QL
QL of 1 inhaler per month
FLOVENT HFA
P
QL
QL of 2 inhalers per month
Tier 1
QL
QL of 1 inhaler per month
FIBRICOR
G
finasteride 5 mg FIORICET
G
NP
FIORINAL
G
NP
FLAGYL
G
NP
FLAGYL ER
NP
fludrocortisone FLOMAX
Tier 1 G
FLONASE
G
flunisolide nasal
NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
16
Effective 02/24/14
Generic Available
Drug fluocinonide crm, gel, oint, soln 0.05%
Formulary Status
Usage Guidelines
Limitations
Tier 1
FLUOROPLEX
P
fluphenazine
Tier 1
FML OPHTH DROP
G
FORADIL AEROLIZER FORTAMET
FORTESTA
NP P
QL
QL of 1 inhaler (60 caps) per month
NP
MN
Alternatives that do not require PA for medical necessity are metformin, metformin ext-rel
P
PA
Coverage provided for male members who need replacement therapy in conditions associated with deficiency or absence of endogenous testosterone
FOSAMAX (daily dose)
G
NP
QL
QL of 31 tabs per month
FOSAMAX (weekly dose)
G
NP
QL
QL of 4 tabs per month
FOSAMAX PLUS D (weekly dose)
NP
QL
QL of 4 tabs per month
FREESTYLE TEST STRIPS
NP
MN
Alternatives that do not require PA for medical necessity are Accu-chek test strips and OneTouch test strips
FROVA
NP
QL
QL of 8 tabs per month
GELNIQUE
P
gentamicin ophthalmic, topical
GEODON
Tier 1
G
GIANVI
Requires 30-day trial of clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days
NP
Tier 1
GLUCAGON
P
GLUCOPHAGE
G
NP
GLUCOPHAGE XR
G
NP
GLUCOTROL
G
NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
17
Effective 02/24/14
Generic Available
Formulary Status
GLUCOTROL XL
G
NP
GLUCOVANCE
G
NP
Drug
GLUMETZA
Usage Guidelines
Limitations
MN
Alternatives that do not require PA for medical necessity are metformin, metformin ext-rel
NP
PA
Coverage requires that members have tried at least a 30-day supply of gabapentin immediate-release at a dose of 1800 mg daily without adequate response
Tier 1
QL, PA
QL of 4 tabs per month. Additional qtys require PA.
NP
QL, PA
QL of 30 ml per month. Additional qtys require PA.
NP
GOLYTELY
G
GRALISE
granisetron tabs GRANISOL ORAL SOLN GRIS-PEG
G
HALFLYTELY
NP
NP P
haloperidol
Tier 1
HELIDAC
P
HUMALOG (ALL FORMS)
NP
MN
Alternatives that do not require PA for medical necessity are Novolin, Novolog
HUMULIN (ALL FORMS except R U-500)
NP
MN
Alternatives that do not require PA for medical necessity are Novolin, Novolog
HUMULIN R U-500
P
hydralazine
Tier 1
HYDREA
G
NP
hydrochlorothiazide
Tier 1
hydrocortisone crm 2.5%
Tier 1
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
18
Effective 02/24/14
Drug
Generic Available
Formulary Status
Usage Guidelines
Limitations
HYZAAR
G
NP
MN
Alternatives that do not require PA for medical necessity are Benicar, Benicar HCT, candesartan, candesartan-HCT, Diovan, eprosartan, irbesartan, irbesartanHCT, losartan, losartan-HCT, valsartan-HCT
IMITREX INJECTION
G
NP
QL
QL of 3 kits or 5 vials per month
IMITREX NASAL
G
NP
QL
QL of 3 boxes (20 mg) or (5 mg) per month
IMITREX TABS
G
NP
QL
QL of 8 tabs per month, all strengths
IMURAN
G
NP
INDERAL LA
G
NP
MN, QL
Alternatives that do not require PA for medical necessity are zaleplon, zolpidem, zolpidem ext-rel. QL of 31 per month at retail or 93 per 75 days by mail order.
ST
Requires 30-day trial of clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days
MN
Alternatives that do not require PA for medical necessity are Janumet, Janumet XR, Januvia, Kombiglyze XR, Onglyza
INTELENCE
P
INTERMEZZO
NP
INVEGA
NP
INVIRASE
P
ISENTRESS
P
isoniazid
Tier 1
ISOPTO CARPINE
G
NP
ISORDIL
G
NP
JANUMET
P
JANUMET XR
P
JANUVIA
P
JENTADUETO
NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
19
Effective 02/24/14
Generic Available
Drug jinteli
Formulary Status
Usage Guidelines
Limitations
Tier 1
KALETRA
P
KAPVAY
G
KAZANO
NP
NP
KEFLEX
G
NP
KEPPRA
G
NP
KEPPRA XR
G
NP
ketoconazole tabs
Tier 1
ketoprofen
Tier 1
KLONOPIN
G
KOMBIGLYZE XR
QL
QL of 120 tablets per month
MN
Alternatives that do not require PA for medical necessity are Janumet, Janumet XR, Januvia, Kombiglyze XR, Onglyza
QL
QL of 93 tabs per year
NP P
labetalol
Tier 1
lactulose
Tier 1
LAMICTAL CHEW TABS
G
NP
LAMICTAL TABS
G
NP
LAMICTAL XR
G
NP
LAMISIL TABS
G
NP
LANOXIN
G
NP
lansoprazole delayed-rel OTC
Tier 1
QL
OTC preparation available at Tier 1 copayment with prescription. QL of 128 per month.
lansoprazole delayed-rel (Rx)
Tier 1
QL
Max 8 wks therapy, then PA required for extension or twice daily dose
ST
Requires 30-day trial of clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days
LANTUS (ALL FORMS) LASIX
P G
LATUDA
NP
NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
20
Effective 02/24/14
Drug
Generic Available
LAZANDA
LESCOL
G
LESCOL XL
Formulary Status
Usage Guidelines
Limitations
NP
PA and QL apply. Available via retail outlets only, QL is 8 bottles per 31 days supply per fill.
Indicated for the management of breakthrough cancer pain in patients with cancer who are already receiving and are tolerant of opioid therapy for their underlying persistent cancer pain
MN
Alternatives that do not require PA for medical necessity are atorvastatin, fluvastatin, lovastatin, pravastatin , simvastatin
MN
Alternatives that do not require PA for medical necessity are atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin
NP
NP
LEVAQUIN
G
NP
LEVEMIR
P
LEVITRA
NP
LEVORA
Tier 1
LEVOXYL
Tier 1
LEVSIN
G
NP
LEXAPRO
G
NP
LEXIVA
See limitations
Check member drug benefit for coverage of oral impotence drugs
P
lidocaine viscous
LIPITOR
Tier 1
G
NP
MN
Alternatives that do not require PA for medical necessity are atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin
LIPOFEN
NP
ST
Step thru 30-day trial of a generic fenofibrate before NP brand fenofibrate (Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, TriGlide, Trilipix)
LIPTRUZET
NP
MN
Alternative that does not require PA for medical necessity is atorvastatin
lithium carbonate
Tier 1
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
21
Effective 02/24/14
Drug LITHOBID
Generic Available
Formulary Status
G
NP
LIVALO
Usage Guidelines
Limitations
MN
Alternatives that do not require PA for medical necessity are atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin
ST
Step thru 30-day trial of a generic fenofibrate before NP brand fenofibrate (Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, TriGlide, Trilipix)
NP
LOFIBRA
G
NP
LOMOTIL
G
NP
loperamide
Tier 1
LOPID
G
NP
LOPRESSOR
G
NP
LOPROX GEL, LOTION
G
NP
loratadine OTC
Tier 1
OTC preparation available at Tier 1 copayment with prescription for OTC formulation
loratadine-D OTC
Tier 1
OTC preparation available at Tier 1 copayment with prescription for OTC formulation
LORTAB
G
NP
LOTEMAX
P
LOTENSIN
G
NP
LOTENSIN HCT
G
NP
LOTREL
G
NP
LOVAZA
NP
LOVENOX
G
LOW-OGESTREL
Coverage provided to members 18 years and older who have elevated triglycerides above 500 mg/dl and have failed on previous FDAapproved therapy to lower triglycerides along with diet
PA
Specialty
QL, PA
QL of maximum 35-day supply at retail pharmacy. Additional quantities require PA through preferred specialty pharmacy.
Tier 1
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
22
Effective 02/24/14
Generic Available
Drug
LUMIGAN
LUNESTA
Formulary Status
Usage Guidelines
Limitations
NP
MN
Alternatives that do not require PA for medical necessity are latanoprost, travoprost, Travatan Z, Zioptan
MN, QL
Alternatives that do not require PA for medical necessity are zaleplon, zolpidem, zolpidem ext-rel. QL of 31 per month at retail or 93 per 75 days by mail order.
NP
LURIDE
G
NP
LURIDE LOZI-TABS
G
NP
LYRICA
NP
MACRODANTIN
G
NP
MALARONE
G
NP
MAVIK
G
NP
MAXALT / MAXALT-MLT
G
NP
MAXITROL
G
NP
MAXZIDE
G
NP
MENEST
QL
QL for doses ≤ 200 mg, 90 caps per 30 days. QL for doses ≥ 225 mg, 60 caps per 30 days.
QL
QL of 8 tabs per month
NP
MESTINON 60 mg
G
NP
MESTINON SYRUP
P
MESTINON TIMESPAN
P
METADATE CD (10, 30, 40, 50, 60 mg)
G
NP
QL
QL up to 62 per month
METADATE CD 20 mg
G
NP
QL
QL up to 93 per month
METAGLIP
NP
methazolamide
Tier 1
methotrexate 2.5 mg, oral
Tier 1
methyldopa
Tier 1
METROGEL TOPICAL
G
NP
METROGEL VAG 0.75% GEL
G
NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
23
Effective 02/24/14
Generic Available
Drug
Formulary Status
Usage Guidelines
Limitations
MEVACOR
G
NP
MN
Alternatives that do not require PA for medical necessity are atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin
MIACALCIN SPRAY
G
NP
QL
QL of 2 units per month
MICRO-K
G
NP
MIGRANAL NASAL
G
NP
QL
QL of 8 units per month
MINIPRESS
G
NP
MINOCIN
G
NP
ST
Coverage requires that members be 12 years or older and must have tried at least 30 days of a generic immediate-release minocycline and a 30-day supply of one of these generics (doxycycline, erythromycin or tetracycline) within the previous 365 days
minocycline ext-rel
Tier 1
MIRAPEX
G
NP
MIRCETTE
G
NP
MODICON
G
NP
MONODOX
G
NP
PA, QL
morphine sulfate immediate release
Tier 1
QL
morphine suppository
Tier 1
QL
MOVIPREP
Coverage allows up to 14 days of therapy in 365 days. Requests for additional days of therapy for acne diagnoses require medical review. QL of 150 tabs per month
P
MS CONTIN
G
NP
MYAMBUTOL
G
NP
MYRBETRIQ
NP
MYFORTIC
G
NP
MYSOLINE
G
NP
QL
QL of 90 tabs per month
MN
Alternatives that do not require PA for medical necessity are oxybutynin extrel, tolterodine, tolterodine ext rel, trospium, Gelnique, Vesicare
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
24
Effective 02/24/14
Generic Available
Drug nabumetone
Formulary Status
Usage Guidelines
Limitations
NP
MN, QL
Alternatives that do not require PA for medical necessity are flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex. QL of 1 inhaler per month
P
QL
QL of 2 inhalers per month
MN
Alternatives that do not require PA for medical necessity are Janumet, Janumet XR, Januvia, Kombiglyze XR, Onglyza
PA, QL
QL of 31 caps or granule packets per month for up to max 8 weeks therapy, then PA required for extension or twice-daily dosing
Tier 1
NAMENDA
NP
NAPROSYN
G
NP
NARDIL
G
NP
NASACORT AQ
G
NASONEX NECON 10/11
NP
NEORAL
G
NP
NEOSPORIN
G
NP
NESINA
NP
NEURONTIN
G
NEXIUM
NP
P
NIASPAN
G
nicotine transdermal patches OTC
NP Check member drug benefit for coverage of smoking cessation drugs. OTC preparation available at Tier 1 copayment with prescription.
Tier 1
NIMOTOP
G
NP
NITRO-DUR
G
NP
nitroglycerin transdermal patches
Tier 1
NITROSTAT
NP
NORPRAMIN
G
NP
NORVASC
G
NP
NORVIR
P
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
25
Effective 02/24/14
Generic Available
Drug
Formulary Status
NOVOLIN (ALL FORMS)
P
NOVOLOG (ALL FORMS)
P
NOXAFIL
Usage Guidelines
Limitations
NP
NUVARING
Packaged as 90-day supply for 2 times the applicable copayment
P
PA, QL
PA req for treatment of narcolepsy, obstructive sleep disorder, shift work disorder or MS-related fatigue only
NP
MN
Alternative that does not require PA for medical necessity is trazodone
NP
MN
Alternative that does not require PA for medical necessity is clobetasol propionate foam 0.05%
NUVIGIL
NP
nystatin
Tier 1
OCUFLOX
G
ofloxacin otic
NP Tier 1
OLEPTRO
OLUX-E FOAM
G
omeprazole caps (Rx)
Tier 1
QL
QL of 31 caps per month for up to max 8 weeks therapy, then PA required for extension or twice-daily dosing
omeprazole OTC
Tier 1
QL
OTC preparation available at Tier 1 copayment with prescription. QL of 128 per month.
OMNARIS
MN, QL
Alternatives that do not require PA for medical necessity are flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex. QL of 1 unit per month
PA and QL apply. QL is 120 tabs per 31-day supply per fill.
Indicated for the management of breakthrough cancer pain in patients with cancer who are already receiving and are tolerant of opioid therapy for their underlying persistent cancer pain
NP
ONE TOUCH kits and test strips
P
ONGLYZA
P
ONSOLIS
NP
OPTIVAR
G
NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
26
Effective 02/24/14
Generic Available
Formulary Status
ORTHO-CEPT
G
NP
ORTHO-CYCLEN
G
NP
Drug
ORTHO EVRA
Limitations
MN
Alternatives that do not require PA for medical necessity are Janumet, Janumet XR, Januvia, Kombiglyze XR, Onglyza
QL
QL of 120 tabs per month
MN
Alternatives that do not require PA for medical necessity are oxybutynin extrel, tolterodine, tolterodine ext rel, trospium, Gelnique, Vesicare
QL
QL of 1 unit per month
QL
QL of 31 caps per month for up to max 8 weeks therapy, then PA required for extension or twice-daily dosing
P
ORTHO MICRONOR
G
NP
ORTHO TRI-CYCLEN
G
NP
ORTHO TRI-CYCLEN LO ORTHO-NOVUM
Usage Guidelines
P G
OSENI
NP
NP
OVIDE
G
NP
oxazepam
Tier 1
oxybutynin
Tier 1
OXYCONTIN
P
OXYTROL
NP
PAMELOR
G
PANCREAZE
NP P
PANRETIN
NP
PATANASE
NP
pantoprazole
Tier 1
PARLODEL
G
NP
PARNATE
G
NP
PAXIL
G
NP
PAXIL CR
G
NP
PCE
NP
penicillin VK
Tier 1
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
27
Effective 02/24/14
Generic Available
Formulary Status
PEPCID (Rx)
G
NP
PERCOCET
G
NP
PERIDEX
G
NP
Drug
perphenazine
Usage Guidelines
Limitations
Tier 1
PERSANTINE
G
phenobarbital
NP Tier 1
PHOSLO
G
pindolol
NP Tier 1
PLAQUENIL
G
NP
PLAVIX
G
NP
POLYTRIM
G
NP
potassium chloride ext-rel, liquid
Tier 1
PRADAXA
P
PRANDIN
G
Coverage provided to members who have non-valvular atrial fibrillation
MN
Alternatives that do not require PA for medical necessity are atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin
NP
PRAVACHOL
G
NP
PRECOSE
G
NP
PRED FORTE
G
NP
PRED MILD
PA
P
prednisolone acetate 1%
Tier 1
prednisone
Tier 1
PREFERAOB VITAMINS PRELONE
P G
NP
PREMARIN
P
PREMPHASE
P
PREMPRO
P
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
28
Effective 02/24/14
Generic Available
Drug
PREVACID (Rx)
G
PREVACID 24HR OTC PREZISTA
Formulary Status
Usage Guidelines
Limitations
NP
QL, PA, ST
Require step thru generic lansoprazole, omeprazole, pantoprazole, rabeprazole, OTC PPI or Nexium. Max 8 wks therapy, then PA required for extension or twicedaily dose.
Tier 1
QL
OTC preparation available at Tier 1 copayment with prescription. QL of 128 per month.
NP
ST, PA, QL
Require step thru generic lansoprazole, omeprazole, pantoprazole, rabeprazole, OTC PPI or Nexium. Max 8 wks therapy, then PA required for extension or twicedaily dose.
Tier 1
QL
OTC preparation available at Tier 1 copayment with prescription. QL of 128 per month.
NP
ST, QL
P
QL
QL of 2 inhalers per month
PA
PA only for use in men under age 40
P
PRILOSEC (Rx)
G
PRILOSEC OTC
PRISTIQ PROAIR HFA probenecid
Requires 30-day trial of generic SNRI in last 180 days. QL of 31 per month.
Tier 1
PROCARDIA XL
G
NP
prochlorperazine
Tier 1
promethazine
Tier 1
promethazine w/ codeine
Tier 1
promethazine w/ dextromethorphan
Tier 1
propranolol tabs
Tier 1
propylthiouracil
Tier 1
PROSCAR
G
NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
29
Effective 02/24/14
Generic Available
Drug
PROTONIX
G
PROTOPIC
Formulary Status
NP
Usage Guidelines
ST, PA, QL
NP
PROVERA
G
G
NP
PROZAC
G
NP
PROZAC WEEKLY
G
NP
ST, QL
Coverage requires members try and fail at least a 30-day trial of Nuvigil in the last 365 days and meet PA requirement for indications. QL of 60 per month.
QL of 4 per month at retail or 12 per 75 days by mail order QL
QL of 2 inhalers per month
QL
QL of 1 box per month
QL
QL of 360 ml per month
G
NP
PURINETHOL TABS
G
NP Tier 1
PYRIDIUM
G
QUILLIVANT XR
NP NP
QNASL
Alternatives that do not require PA for medical necessity are flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex. QL of 1 unit per month at retail or 3 units per 90 days by mail order.
NP
MN, QL
QL
QL of 42 caps/year. Additional qtys require PA.
QL
QL of 2 inhalers per month
QUALAQUIN
G
NP
QUESTRAN/QUESTRANLIGHT
G
NP
QVAR
QL of 2 inhalers per month
NP
PULMICORT RESPULES
pyrazinamide
QL
NP
PROVIGIL
PULMICORT FLEXHALER
Require step thru generic lansoprazole, omeprazole, pantoprazole, rabeprazole, OTC PPI or Nexium. Max 8 wks therapy, then PA required for extension or twicedaily dose. Coverage for 2 years of age and up for 0.03%, 16 years and up for 0.1%. Outside of these ages, call BlueChoice at 800-950-5387.
P
PROVENTIL HFA
Limitations
P
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
30
Effective 02/24/14
Generic Available
Drug
Formulary Status
ramipril
Tier 1
RAYOS
NP
RAZADYNE
G
NP
REGLAN TABS
G
NP
RELPAX
Usage Guidelines
P
REMERON
G
NP
REMERON SOLTAB
G
NP
RENAGEL
NP
RENVELA
P
REQUIP
G
NP
REQUIP XL
G
NP
RESCRIPTOR
Limitations
MN
Alternative that does not require PA for medical necessity is prednisone
QL
QL of 6 tabs per month, all strengths
P
RESTORIL
G
NP
QL
QL of 31 per month
RETIN-A CREAM, GEL
G
NP
ST
Coverage up to age 25 for acne. If over 25 yrs, PA required.
RETIN-A MICRO GEL
G
NP
ST
Coverage up to age 25 for acne. If over 25 yrs, PA required.
RETROVIR
G
NP
REYATAZ
P
RHINOCORT AQ
NP
ribasphere tabs & caps
Tier 1
ribavirin tabs & caps
Tier 1
RIFADIN
G
RIOMET
MN, QL
Alternatives that do not require PA for medical necessity are flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex. QL of 2 inhalers per month.
MN
Alternatives that do not require PA for medical necessity are metformin, metformin ext-rel
NP NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
31
Effective 02/24/14
Generic Available
Drug
Formulary Status
Usage Guidelines
Limitations Requires 30-day trial of clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days
RISPERDAL /RISPERDAL M
G
NP
RITALIN
G
NP
QL
RITALIN-SR
G
NP
QL
ROBAXIN
G
NP
ROCALTROL
G
NP
ROWASA ENEMA
G
NP
ROXICODONE
G
NP
QL
QL of 90 per month
P
QL
QL of 31 per month at retail or 93 per 75 days by mail order
PA, QL
QL of 2 patches per month, all strengths. Additional qtys require PA.
MN
Alternatives that do not require PA for medical necessity are oxybutynin extrel, tolterodine, tolterodine ext rel, trospium, Gelnique, Vesicare
MN
Alternatives that do not require PA for medical necessity are oxybutynin extrel, tolterodine, tolterodine ext rel, trospium, Gelnique, Vesicare
ROZEREM RYTHMOL
G
NP
RYTHMOL SR
G
NP
SANCUSO
NP
SANDIMMUNE
SANCTURA
G
G
SANCTURA XR
G
NP
NP
NP
SAPHRIS
NP
ST
Requires 30-day trial of clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days
SAVELLA
P
QL
QL of 62 caps per month
SEASONIQUE
G
selegiline tabs SELSUN
Packaged as 90-day supply for 2 times the applicable copayment
NP Tier 1
G
NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
32
Effective 02/24/14
Drug
Generic Available
Formulary Status
SELZENTRY
P
SENSIPAR
P
SEREVENT DISKUS
P
SEROQUEL
G
SEROQUEL XR
Usage Guidelines
QL
QL of 1 inhaler (60 caps) per month Requires 30-day trial of clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days
NP
P
SILENOR
NP
SILVADENE
Limitations
G
SIMCOR
MN, QL
Alternatives that do not require PA for medical necessity are zaleplon, zolpidem, zolpidem ext-rel. QL of 31 per month at retail or 93 per 75 days by mail order.
ST
Coverage requires that members be 12 years or older and must have tried at least 30 days of a generic immediate-release minocycline and a 30-day supply of one of these generics (doxycycline, erythromycin or tetracycline) within the previous 365 days
Coverage requires that members must have filled at least a 30-day supply in the previous 365 days, of generic zaleplon or zolpidem before filling a nonbenzodiazepine sedative/hypnotic agent. QL of 31 per month at retail or 93 per 75 days by mail order.
NP P
SINEMET
G
NP
SINEMET CR
G
NP
SINGULAIR
G
NP
SOLODYN
G
NP
SOMA
G
NP
SONATA
G
NP
MN, QL
SORIATANE CAPS
G
NP
PA
PA for treatment of severe psoriasis in adults
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
33
Effective 02/24/14
Generic Available
Drug SPIRIVA HANDIHALER SPORANOX CAPS
G
STAXYN STRATTERA
SUBOXONE sublingual film
SUBOXONE sublingual tabs
Formulary Status
Usage Guidelines
P
QL
QL of 1 inhaler (60 caps) per month
NP
QL
QL of 31 caps per month. Max 3 months therapy per year.
NP
See limitations
Check member drug benefit for coverage of oral impotence drugs
P
QL
SUBSYS
sulfamethoxazoletrimethoprim
QL of 62 per month
PA, QL
Coverage provided for members who are confirmed to be receiving treatment for opioid dependence in a valid opioid-addiction treatment program
NP
PA, QL
Coverage provided for members who are confirmed to be receiving treatment for opioid dependence in a valid opioid-addiction treatment program
NP
PA and QL apply. QL is 120 doses per 31 days supply per fill.
Indicated for the management of breakthrough cancer pain in patients with cancer who are already receiving and are tolerant of opioid therapy for their underlying persistent cancer pain
P
G
Limitations
Tier 1
SUMAVEL DOSEPRO
NP
ST, QL
Coverage requires that members must have filled 14 days of generic sumatriptan injection in the last 180 days. QL of 6 per month.
SUSTIVA
P
SYMBICORT
P
QL
QL of 2 inhalers per month
SYMLINPEN
NP
PA
PA required for use in type 1 or type 2 diabetics who have failed to achieve adequate glycemic control
QL
QL of 10 caps (1 blister pack) per year
SYNTHROID
G
NP
TAMIFLU
NP
tamoxifen
Tier 1
TAPAZOLE
G
NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
34
Effective 02/24/14
Drug
Generic Available
Formulary Status
TARKA
NP
TAZORAC
NP
TEGRETOL
G
NP
TEGRETOL XR
G
NP
Usage Guidelines
ST
TEKTURNA
NP
MN
TEKTURNA HCT
NP
MN
TEMOVATE
G
NP
TENORMIN
G
NP
terazosin
Tier 1
terbutaline
Tier 1
TESSALON
G
TESTIM
Requires 30-day trial of generic tretinoin product in the last 365 days
Alternatives that do not require PA for medical necessity are Benicar, Benicar HCT, candesartan, candesartan-HCT, Diovan, eprosartan, irbesartan, irbesartanHCT, losartan, losartan-HCT, valsartan-HCT Alternatives that do not require PA for medical necessity are Benicar, Benicar HCT, candesartan, candesartan-HCT, Diovan, eprosartan, irbesartan, irbesartanHCT, losartan, losartan-HCT, valsartan-HCT
NP NP
tetracycline
Limitations
MN
If initial PA criteria is met (see Androderm, Axiron or Fortesta), MN applies to non-preferred options
MN
Alternatives that do not require PA for medical necessity are Benicar, Benicar HCT, candesartan, candesartan-HCT, Diovan, eprosartan, irbesartan, irbesartanHCT, losartan, losartan-HCT, valsartan-HCT
Tier 1
TEVETEN
NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
35
Effective 02/24/14
Generic Available
Drug
TEVETEN HCT
Formulary Status
Usage Guidelines
Limitations
MN
Alternatives that do not require PA for medical necessity are Benicar, Benicar HCT, candesartan, candesartan-HCT, Diovan, eprosartan, irbesartan, irbesartanHCT, losartan, losartan-HCT, valsartan-HCT
MN
Alternatives that do not require PA for medical necessity are oxybutynin extrel, tolterodine, tolterodine ext rel. trospium, Gelnique, Vesicare
MN
Alternatives that do not require PA for medical necessity are Janumet, Janumet XR, Januvia, Kombiglyze XR, Onglyza
QL
QL of 9 tabs per month
NP
THEOCHRON
G
NP
theophylline ext-rel (12 hr)
Tier 1
thiothixene
Tier 1
TIMOPTIC
G
NP
TOBI, inhalation
NP
TOBRADEX ST
P
tobramycin-dexamethasone 0.3-0.1%
Tier 1
TOBREX
G
NP
TOFRANIL
G
NP
TOPAMAX
G
NP
TOPROL XL
G
NP
TOVIAZ
NP
TRADJENTA
NP
TRAVATAN Z
P
travoprost
Tier 1
trazodone
Tier 1
TREXIMET
NP
triamcinolone crm 0.5%
Tier 1
triamcinolone crm, lotion 0.025%
Tier 1
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
36
Effective 02/24/14
Generic Available
Drug
Formulary Status
triamcinolone crm, lotion, oint 0.1%
Tier 1
triamcinolone paste
Tier 1
TRIBENZOR
Usage Guidelines
Limitations
P
TRICOR
G
TRIGLIDE
NP
NP
trihexyphenidyl
ST
Coverage requires a 30-day trial of a generic fenofibrate before NP brand fenofibrate (Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, TriGlide, Trilipix)
ST
Coverage requires a 30-day trial of a generic fenofibrate before NP brand fenofibrate (Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, TriGlide, Trilipix)
ST
Coverage requires a 30-day trial of a generic fenofibrate before NP brand fenofibrate (Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, TriGlide, Trilipix)
Tier 1
TRILEPTAL
G
TRILIPIX
NP
NP
trimethoprim
Tier 1
TRI-NORINYL
G
TRIVORA
NP Tier 1
TRIZIVIR
G
P
TRUSOPT
G
NP
TRUVADA
P
TWYNSTA
NP
TYLENOL w/ CODEINE
G
NP
UNIRETIC
G
NP
ULTRAM
G
NP
QL
QL of 240 per month
ULTRAM ER
G
NP
QL
QL of 30 per month
URECHOLINE
G
NP
URSO
G
NP
VALCYTE
QL
NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
37
Effective 02/24/14
Generic Available
Formulary Status
VALIUM
G
NP
VALTREX
G
NP
VASERETIC
G
NP
VASOTEC
G
NP
Drug
Usage Guidelines
Limitations
QL
QL of 42 caps of 500 mg at a single fill, total limit of 84 caps per 25 days. For 1000 mg, 31 caps per 25 days.
venlafaxine
Tier 1
venlafaxine ext-rel
Tier 1
QL
QL of 31 of 37.5 mg, 75 mg, 150 mg. QL of 31 of 225 mg or use (31 of 150 mg + 31 of 75 mg) = 1 copayment.
P
QL
QL of 2 inhalers per month
VENTOLIN HFA
VERAMYST
NP
VESICARE
P
VFEND
G
VIAGRA
MN, QL
NP NP
VIBRAMYCIN
G
NP
VICODIN ES
G
NP
VICTOZA
P
VIDEX SOLN
P
VIDEX EC
G
VIGAMOX
Alternatives that do not require PA for medical necessity are flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex. QL of 1 inhaler per month.
See limitations
Check member drug benefit for coverage of oral impotence drugs
NP P
VIMOVO
NP
VIRACEPT
QL
QL of 62 tabs per month
P
VIRAMUNE
G
NP
VIRAMUNE XR
P
VIREAD
P
VIROPTIC
G
vitamin B-12 inj
NP Tier 1
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
38
Effective 02/24/14
Drug
Generic Available
VIVELLE-DOT VOSOL HC OTIC
Formulary Status
Usage Guidelines
Limitations
Alternative that does not require PA for medical necessity is atorvastatin. ST applies to 10/80 mg strength only: Requires 290-day supply within the previous 365 days.
P G
NP
VYTORIN
NP
MN, ST
VYVANSE
NP
QL
QL of 62 per month
WELCHOL
P
QL
QL of (31 of 150 mg) or (31 of 300 mg) per month. For 450 mg dose, use (31 of 300 mg + 31 of 150 mg) = 1 copayment.
ST
Coverage requires a trial of OTC nonsedating antihistamine for 21 days in the last 12 months
WELLBUTRIN
G
NP
WELLBUTRIN SR
G
NP
WELLBUTRIN XL
G
NP
XALATAN
G
NP
XANAX
G
NP
XYZAL
G
NP
YASMIN
G
NP
YAZ
G
NP
ZANTAC (Rx)
G
NP
ZARONTIN
G
NP
ZAROXOLYN
G
NP
ZEGERID
G
NP
ST, PA, QL
Coverage requires a trial of generic lansoprazole, omeprazole, pantoprazole, rabeprazole, OTC PPI or Nexium. Max 8 wks therapy, then PA required for extension or twicedaily dose.
ZEGERID OTC
G
Tier 1
QL
OTC preparation available at Tier 1 copayment with prescription. QL of 128 per month.
ZEMPLAR
G
NP
ZERIT
G
NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
39
Effective 02/24/14
Generic Available
Formulary Status
ZESTORETIC
G
NP
ZESTRIL
G
NP
Drug
ZETIA
Usage Guidelines
Limitations
MN
Alternatives that do not require PA for medical necessity are flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex
MN, ST
Alternatives that do not require PA for medical necessity are atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin. Zocor 80mg does not require MN prior auth, but does have a step therapy (ST) requirement. ST applies to 80 mg strength only: Requires 290-day supply within the previous 365 days.
QL, PA
QL on brand Zofran for 4 mg (9/month), 8 mg (6/month) and solution (50 ml/month). Additional qtys require PA.
Coverage requires that members must have filled at least a 30-day supply in the previous 365 days, of generic zaleplon or zolpidem before filling a nonbenzodiazepine sedative/hypnotic agent. QL of 31 per month at retail or 93 per 75 days by mail order.
NP
ZETONNA
NP
ZIAGEN
G
ZIOPTAN
P P
ZITHROMAX
ZOCOR
G
G
NP
NP
ZOFRAN
G
NP
ZOLOFT
G
NP
ZOLPIMIST
NP
MN, QL
ZOMIG NASAL
NP
QL
QL of 1 package (6 units) per month
QL
QL of 6 per month
QL
QL of 62 per month for 0.25 mg. QL of 124 for 0.5 mg and 0.75 mg.
ZOMIG/ZOMIG-ZMT
G
NP
ZONEGRAN
G
NP
ZORTRESS
NP
ZOVIA
Tier 1
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
40
Effective 02/24/14
Drug ZOVIRAX CAPS, OINT, SUSP, TABS
Generic Available
Formulary Status
G
NP
ZOVIRAX CREAM
Usage Guidelines
Limitations
NP
ZUBSOLV
NP
PA, QL
Coverage provided for members who are confirmed to be receiving treatment for opioid dependence in a valid opioid-addiction treatment program
ZUPLENZ
NP
QL, PA
QL of 10 per month. Additional qtys require PA.
ZYLET
P
ZYLOPRIM
G
NP
ZYMAXID
G
NP Requires 30-day trial of clozapine immediate release, clozapine orally disintegrating tabs (ODT), olanzapine, quetiapine, risperidone, ziprasidone or Seroquel XR in the last 365 days
ZYPREXA
G
NP
ZYRTEC OTC
G
Tier 1
OTC preparation available at Tier 1 copayment with prescription
ZYRTEC-D OTC
G
Tier 1
OTC preparation available at Tier 1 copayment with prescription
ZYVOX
NP
Legend Bold NP QL MN
Generic available at tier 1 Non-preferred available at tier 3 Quantity Limit Medical Necessity Prior Authorization
P ST PA
Preferred available at tier 2 Step Therapy Prior Authorization Required
41
Effective 02/24/14
