Prescription Drug Program Formulary (Prior Auth Required)

Prescription Drug Program Formulary
Effective January 1, 2015
www.MyIBXTPA.com
Dear Plan Member:
In an effort to continue our commitment to provide you with comprehensive prescription drug coverage, a
formulary feature is included in your prescription drug benefit. A formulary is a list of selected drugs that are
approved by the U.S. Food and Drug Administration (FDA) and reviewed by our Pharmacy and Therapeutics
Committee, a group of physicians and pharmacists from the area. These prescription drugs have been selected
for their reported medical effectiveness, safety, and value while providing you with the highest level of coverage
under your prescription drug benefits.
Our pharmacy benefits manager, FutureScripts®, an independent company, continuously monitors the
effectiveness and safety of drugs and drug prescribing patterns. Several procedures support safe prescribing
patterns for our prescription drug programs, such as:
• prior authorization;
• age and gender limits;
• quantity limits;
• 96-Hour Temporary Supply Program;
• coverage for medications not on the formulary.
These procedures are designed to optimize your prescription drug benefits by promoting appropriate utilization.
They are based on FDA guidelines, and the criteria are endorsed by our Pharmacy and Therapeutics Committee.
A detailed description of the procedures that support safe prescribing is included at the end of the formulary list.
Please note: Because prescription drug benefits vary by group, the inclusion of a drug in this formulary does
not imply coverage. This formulary was current at the time of printing and is subject to change. Please call
Customer Service at the number listed on the back of your ID card if you have any questions about your
prescription drug benefits. Please discuss any questions or concerns about your drug therapy with your
physician or pharmacist.
Brand drugs listed in the formulary with a “3” in the immediate column to the right are available at the highest
level of cost-sharing (i.e., the highest cost to you). It is displayed next to the equivalent formulary generic drug
that is available at the lowest level of cost-sharing (i.e., the lowest cost to you). For example: amoxicillin is
the formulary generic drug available at the lowest level of cost-sharing. Amoxil® is the non-formulary brand
available at the highest level of cost-sharing. In most cases when brand drugs have a generic equivalent, the
generic version is formulary and the brand version is non-formulary.
• Covered generic drugs not listed are formulary and are available at the lowest level of cost-sharing.
• Covered brand drugs not listed are non-formulary and are available at the highest level of cost-sharing.
Certain preventive medications, as described in the Patient Protection and Affordable Care Act (PPACA),
including generic products and those brand products that do not have a generic equivalent are covered without
cost-sharing with a doctor’s prescription when provided by a participating retail or mail-order pharmacy.
Coverage includes certain products within the following drug categories: (1) aspirin to prevent cardiovascular
disease for men age 45-79 and women age 55-79, (2) breast cancer chemotherapy prevention for women,
(3) fluoride supplementation for children 6 months thru 6 years, (4) folic acid supplementation for women
planning or capable of pregnancy, (5) iron supplementation for children ages 6 to 12 months who are at
increased risk for iron deficiency anemia, (6) tobacco interventions for adults who use tobacco products, and
(7) vitamin D supplementation for ages 65 and over to prevent falls. Contraceptives, mandated by the Women’s
Preventive Services provision of the PPACA, are covered at 100 percent when provided by a participating
provider for generic products and for those brand products that do not have a generic equivalent. Brand
contraceptive products with a generic equivalent are covered at the brand cost-sharing level for your plan.
1
Dear Valued Physician:
This is a listing of formulary drugs to be considered for your patient, a Prescription Drug Program participant.
Please refer to this formulary guide in order to choose a drug. Because prescription drug benefits vary by group,
the inclusion of a drug in this formulary does not imply coverage.
This formulary was current at the time of printing and is subject to change. Please understand that this
formulary is not intended as a substitute for your independent, professional judgment. Rather, it is offered as a
tool to help Plan members recognize formulary drugs. We hope that you will refer to the formulary as a guide to
prescribing formulary drugs.
2
1. ANTIBIOTICS & OTHER DRUGS USED FOR INFECTION
Adoxa
Ancobon
Aralen
Atripla
Augmentin
Formulary
Tier
3
3
3
2
3
Augmentin XR
3
Avelox
Bactrim,
Bactrim DS
Biaxin
Biaxin XL
Cedax
Ceftin
Cipro
Cipro oral
suspension
Cipro XR
Cleocin
Combivir
Complera
Crixivan
Diflucan
Doryx
EES, Eryped
Edurant
Emtriva
Epivir
Epzicom
Ery-Tab
Erythrocin
Factive
Famvir
Flagyl
Flumadine
Fuzeon
Grifulvin V
Gris-PEG
Hepsera
Hiprex
BRAND
GENERIC
doxycycline monohydrate
flucytosine
chloroquine phosphate
Formulary
Tier
1
1
1
Generic
Available
Yes
Yes
Yes
1
Yes
1
Yes
3
amoxicillin/clavulanate
amoxicillin/clavulanate extendedrelease
moxifloxacin hcl
1
Yes
3
sulfamethoxazole/tmp
1
Yes
3
3
3
3
3
clarithromycin
clarithromycin SR
ceftibuten
cefuroxime axetil
ciprofloxacin tabs
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
ciprofloxacin ER tabs
clindamycin
lamivudine/zidovudine
1
1
1
Yes
Yes
Yes
fluconazole
doxycycline
erythromycin ethylsuccinate
1
1
1
Yes
Yes
Yes
lamivudine
1
Yes
erythromycin delayed release
erythromycin stearate
1
1
Yes
Yes
Additional
Requirements
PA
2
3
3
3
2
2
3
3
3
2
2
3
2
3
3
3
3
3
3
2
3
3
3
3
PA = Prior authorization must be
requested by the physician.
PA
PA
famciclovir
metronidazole
rimantadine
1
1
1
Yes
Yes
Yes
griseofulvin microsize
griseofulvin ultramicrosize
adefovir dipivoxil
methenamine hippurate
1
1
1
1
Yes
Yes
Yes
Yes
3
QL = Quantity limits apply.
1. ANTIBIOTICS & OTHER DRUGS USED FOR INFECTION
BRAND
Invirase
Isentress
Kaletra
Keflex
Lamisil Tabs
Levaquin
Lexiva
Macrodantin
Malarone
Mepron
Minocin
Monodox
Myambutol
Mycobutin
Norvir
Noxafil
Olysio
Oracea
Peg-Intron
Pegasys
Plaquenil
Prezista
Qualaquin
Retrovir
Reyataz
Ribapak
Rifadin
Selzentry
Sivextro
Sovaldi
Sporanox
Stribild
Sustiva
Tamiflu
Tindamax
Tobi
Trizivir
Formulary
Tier
2
2
2
3
3
3
2
3
3
3
3
3
3
3
2
3
3
2
2
2
3
2
3
3
2
3
3
2
3
2
3
2
2
2
3
3
3
GENERIC
Formulary
Tier
Generic
Available
cephalexin
terbinafine tabs
levofloxacin
1
1
1
Yes
Yes
Yes
nitrofurantoin macrocrystals
atovaquone/proguanil
atovaquone
minocycline caps
doxycycline monohydrate
ethambutol
rifabutin
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Additional
Requirements
PA
PA
QL, PA
PA
PA
PA
hydroxychloroquine
1
Yes
quinine sulfate
zidovudine
1
1
Yes
Yes
PA
moderiba
rifampin
1
1
Yes
Yes
PA
QL, PA
PA
itraconazole
1
Yes
QL
tinidazole
tobramycin
abacavir/lamivudine/zidovudine
PA = Prior authorization must be
requested by the physician.
4
1
1
1
Yes
Yes
Yes
QL = Quantity limits apply.
1. ANTIBIOTICS & OTHER DRUGS USED FOR INFECTION
BRAND
Truvada
Valcyte tab
Valtrex
Vancocin
Vfend
Vibramycin
Victrelis
Videx EC
Viramune
Viramune XR
Viread
Xifaxan
Zerit
Ziagen
Zithromax
Zovirax
Formulary
Tier
2
2
3
3
3
3
2
3
3
3
2
2
3
3
3
3
PA = Prior authorization must be
requested by the physician.
GENERIC
Formulary
Tier
Generic
Available
valacyclovir tab
vancomycin
voriconazole
doxycycline hyclate
1
1
1
1
Yes
Yes
Yes
Yes
didanosine
nevirapine
nevirapine XR
1
1
1
Yes
Yes
Yes
stavudine
abacavir sulfate
azithromycin
acyclovir
amoxicillin
ampicillin
cefaclor
cefaclor ER
cefadroxil
cefdinir
clotrimazole troches
dapsone
demeclocycline
dicloxacillin
erythromycin susp w/sulfa
isoniazid
ketoconazole tabs
mebendazole
mefloquine
minocycline tabs
moderiba
nystatin
ofloxacin
penicillin VK
primaquine phosphate
quinine sulfate
tetracycline
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
5
Additional
Requirements
PA
PA
PA
PA
QL = Quantity limits apply.
2. CANCER & ORGAN TRANSPLANT DRUGS
BRAND
Alkeran
Arimidex
Aromasin
Casodex
Cellcept
Cytoxan
Danocrine
Deltasone
Emcyt
Eulexin
Fareston
Femara
Gilotrif
Gleevec
Hexalen
Hydrea
Imbruvica
Imuran
Leukeran
Lysodren
Matulane
Megace
Myfortic
Myleran
Prograf
Purinethol
Rapamune
1mg, 2mg tabs,
1mg/ml Sol
Rapamune
0.5mg tab
Rheumatrex,
Trexall tab
Sandimmune,
Neoral
Tabloid
Targretin cap
Targretin gel
Temodar
Formulary
Tier
2
3
3
3
3
3
3
3
2
3
2
3
3
2
2
3
3
3
2
2
2
3
3
2
3
3
GENERIC
Formulary
Tier
Generic
Available
anastrazole
exemestane
bicalutamide
mycophenolate
cyclophosphamide
danazol
prednisone
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
flutamide
1
Yes
letrozole
1
Yes
Additional
Requirements
PA
PA
hydroxyurea
1
Yes
PA
azathioprine
1
Yes
megestrol
mycophenolic acid
1
1
Yes
Yes
tacrolimus
mercaptopurine
1
1
Yes
Yes
3
sirolimus
1
Yes
3
methotrexate
1
Yes
3
cyclosporine
1
Yes
3
2
2
3
thioguanine
1
Yes
2
PA = Prior authorization must be
requested by the physician.
temozolomide
1
6
Yes
PA
PA
QL = Quantity limits apply.
2. CANCER & ORGAN TRANSPLANT DRUGS
BRAND
Valchlor
VePesid
Xeloda
Zykadia
Formulary
Tier
3
3
3
3
GENERIC
Formulary
Tier
Generic
Available
etoposide
capecitabine
1
1
Yes
Yes
PA
leucovorin calcium
lomustine
megestrol acetate
tamoxifen
temozolomide
PA = Prior authorization must be
requested by the physician.
Additional
Requirements
PA
7
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
PA
QL = Quantity limits apply.
3. PAIN, NERVOUS SYSTEM, & PSYCH
BRAND
Abilify
Abilify
Discmelt
Actiq
Adasuve
Formulary
Tier
2
GENERIC
Formulary
Tier
Generic
Available
Additional
Requirements
fentanyl citrate OTFC
1
Yes
QL, PA
PA
1
Yes
QL
3
Yes
1
1
Yes
Yes
QL, PA
(PA-Generic
Only)
QL, PA
QL, PA
2
3
3
1
Yes
QL, PA
3
3
3
3
3
3
amphetamine aspartate/
amphetamine sulfate/
dextroamphetamine
amphetamine aspartate/
amphetamine sulfate/
dextroamphetamine ER
sumatriptan succinate
zolpidem tartrate
zolpidem tartrate controlled
release
naratriptan
cyclobenzaprine
clomipramine HCl
flurbiprofen
donepezil hydrochloride
lorazepam
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
QL, PA
3
morphine sulfate ER
1
Yes
QL
3
2
2
3
2
3
3
3
3
3
3
2
3
3
3
3
3
morphine sulfate ER
1
Yes
QL, PA
QL
Adderall
3
Adderall XR
1
Alsuma
Ambien
3
3
Ambien CR
3
Amerge
Amrix
Anafranil
Ansaid
Aricept
Ativan
Avinza 30mg,
45mg, 60mg,
75mg, 90mg
Avinza 120mg
Avonex
Azilect
Belviq
Betaseron
Brintellix
Buspar
Cafergot
Campral
Cataflam
Celexa
Celontin
Clinoril
Clozaril
Comtan
Concerta
Conzip
PA = Prior authorization must be
requested by the physician.
PA
QL
PA
buspirone
ergotamine tartrate/caffeine
acamprosate
diclofenac potassium
citalopram
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
sulindac
clozapine
entacapone
methylphenidate
1
1
1
1
Yes
Yes
Yes
Yes
8
QL
QL, PA
QL = Quantity limits apply.
3. PAIN, NERVOUS SYSTEM, & PSYCH
BRAND
Copaxone
Cymbalta
Dantrium
Daypro
Demerol
Depakene
Depakote
Depakote ER
Depakote
Sprinkle Caps
Desoxyn
Desyrel
Diastat
Diastat AcuDial
Dilantin
chewable tablets Dilaudid 2mg
Dilaudid 4mg,
8mg
Dolobid
Dolophine
Doral
Duragesic
12mcg
Duragesic
25mcg, 50mcg,
75mcg, 100mcg
Effexor
Effexor XR
Eldepryl
Esgic
Esgic Plus
Eskalith
Eskalith CR,
Lithobid
Exalgo
Exelon
Evzio
Fazaclo
Felbatol
Feldene
Formulary
Tier
2
3
3
3
3
3
3
3
GENERIC
Formulary
Tier
Generic
Available
duloxetine
dantrolene
oxaprozin
meperidine HCl
valproic acid
divalproex sodium
divalproex sodium ER
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
3
divalproex sprinkle cap
1
Yes
3
3
3
3
methamphetamine
trazodone
diazepam rectal gel
diazepam rectal gel
1
1
1
1
Yes
Yes
Yes
Yes
2
phenytoin chewable tablets
1
Yes
3
hydromorphone HCl
1
Yes
QL
3
hydromorphone HCl
1
Yes
QL, PA
3
3
3
diflunisal
methadone
quazepam
1
1
1
Yes
Yes
Yes
PA
QL, PA
3
fentanyl transdermal
1
Yes
QL
3
fentanyl transdermal
1
Yes
QL, PA
3
3
3
3
3
3
venlafaxine
venlafaxine ER
selegiline HCl
butalbital/apap/caffeine
butalbital/apap/caffeine, zebutal
lithium carbonate
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
3
lithium carbonate SR
1
Yes
3
3
3
3
3
3
hydromorphone ER
rivastigmine
1
1
Yes
Yes
PA = Prior authorization must be
requested by the physician.
Additional
Requirements
QL
QL
QL
QL, PA
QL
clozapine ODT
felbamate
piroxicam
9
1
1
1
Yes
Yes
Yes
QL = Quantity limits apply.
3. PAIN, NERVOUS SYSTEM, & PSYCH
BRAND
Fetzima
Fioricet
Fioricet with
codeine
Fiorinal
Fiorinal with
codeine
Focalin
Focalin XR
15mg, 30mg,
40mg
Focalin XR
5mg, 10mg,
20mg, 25mg,
35mg
Gabitril
Geodon
Halcion
Hetlioz
Horizant
Hycet
Ibudone
Imitrex
Kadian 10mg,
20mg, 30mg,
40mg, 50mg
Kadian 60mg,
80mg, 100mg
Kadian 200mg
Kapvay
Keppra
Keppra XR
Khedezla
Klonopin
Lamictal
Lamictal XR
Lexapro
Lodine XL
Lodosyn
Lortab
Loxitane
Formulary
Tier
3
3
GENERIC
Formulary
Tier
Generic
Available
butalbital/apap/caffeine
1
Yes
3
butalbital/apap/caffeine/codeine
1
Yes
3
butalbital/aspirin/caffeine
1
Yes
3
butalbital/aspirin/caffeine/codeine
1
Yes
QL
3
dexmethylphenidate
1
Yes
QL
3
dexmethylphenidate hcl xr
1
Yes
QL
3
Additional
Requirements
PA
QL
QL
3
3
3
3
3
3
3
3
tiagabine hcl
ziprasidone
triazolam
1
1
1
Yes
Yes
Yes
hydrocodone/apap
ibuprofen/oxycodone HCl
sumatriptan
1
1
1
Yes
Yes
Yes
QL, PA
QL, PA
PA
QL
QL
QL, PA
3
morphine extended release
1
Yes
QL
3
morphine extended release
1
Yes
QL, PA
3
3
3
3
3
3
3
3
3
3
3
3
3
clonidine HCl ER
levetiracetam
levetiracetam
desvenlafaxine ER
clonazepam
lamotrigine
lamotrigine
escitalopram
etodolac
carbidopa
hydrocodone/acetaminophen elixir
loxapine
PA = Prior authorization must be
requested by the physician.
10
1
1
1
1
1
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
QL, PA
QL, PA
PA
QL
QL = Quantity limits apply.
3. PAIN, NERVOUS SYSTEM, & PSYCH
BRAND
Lunesta
Luvox CR
Maxalt,
Maxalt-MLT
Mestinon
Metadate CD
eszopiclone
fluvoxamine
Formulary
Tier
1
1
Generic
Available
Yes
Yes
Additional
Requirements
QL, PA
3
rizatriptan benzoate
1
Yes
QL, PA
3
3
pyridostigmine
methylphenidate hcl
isometheptene/
dichloralphenazone/apap
pramipexole
1
1
Yes
Yes
QL
1
Yes
1
Yes
Formulary
Tier
3
3
Midrin
3
Mirapex
Mirapex ER
MS Contin
15mg, 30mg
MS Contin
60mg, 100mg,
200mg
MSIR
Mysoline
Nalfon
Namenda
Naprelan
Naprosyn
Nardil
Neurontin
Neurontin
solution
Norpramin
Nucynta 50mg,
75mg
Nucynta 100mg
Nucynta ER
50mg, 100mg
Nucynta ER
150mg, 200mg,
250mg
Opana 5mg
Opana 10mg
Opana ER 5mg,
7.5mg, 10mg,
15mg
Opana ER
20mg, 30mg,
40mg
Orudis
3
2
GENERIC
3
morphine sulfate, extended release
1
Yes
QL
3
morphine sulfate, extended release
1
Yes
QL, PA
3
3
3
2
3
3
3
3
morphine sulfate
primidone
fenoprofen calcium
1
1
1
Yes
Yes
Yes
QL
naproxen sodium SA
naproxen
phenelzine
gabapentin
1
1
1
1
Yes
Yes
Yes
Yes
3
gabapentin solution
1
Yes
3
desipramine
1
Yes
QL
QL, PA
QL
QL, PA
3
3
oxymorphone
oxymorphone
1
1
Yes
Yes
QL
QL, PA
3
oxymorphone
1
Yes
QL
3
oxymorphone
1
Yes
QL, PA
3
ketoprofen
1
Yes
PA = Prior authorization must be
requested by the physician.
11
QL = Quantity limits apply.
3. PAIN, NERVOUS SYSTEM, & PSYCH
BRAND
Formulary
Tier
GENERIC
Formulary
Tier
Generic
Available
Additional
Requirements
3
oxycodone ER
1
Yes
QL
3
oxycodone ER
1
Yes
QL, PA
3
3
3
3
3
3
3
oxycodone
nortriptyline
carbidopa/levodopa ODT
bromocriptine mesylate
tranycypromine sulfate
paroxetine
paroxetine HCl ext-release
oxycodone/acetaminophen,
endocet
oxycodone/aspirin
phenytoin sodium
isometheptene/APAP/caffeine
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
QL
1
Yes
QL
1
1
1
Yes
Yes
Yes
QL
modafinil
1
Yes
PA
QL (Weekly
only)
Oxycontin
10mg, 15mg,
20mg
Oxycontin
30mg, 40mg,
60mg, 80mg
OxyIR
Pamelor
Parcopa
Parlodel
Parnate
Paxil
Paxil CR
Percocet,
Roxicet
Percodan
Phenytek
Prodrin
Prostigmin
Provigil
3
3
3
2
3
Prozac
3
fluoxetine
1
Yes
Qudexy XR
Razadyne
Razadyne ER
Relpax
Regimex
Remeron
Remeron SolTab
Requip
Requip XL
Restoril
Rilutek
Risperdal,
Risperdal M-Tab
Ritalin LA
Ritalin SR
Robaxin
Roxicodone
15mg
Roxicodone
30mg
3
3
3
2
3
3
3
3
3
3
3
topiramate ER
galantamine
galantamine ER
1
1
1
Yes
Yes
Yes
mirtazapine
mirtazapine rapid dissolve tabs
ropinirole
ropinirole EL
temazepam
riluzole
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
3
risperidone
1
Yes
3
3
3
methylphenidate ER
methylphenidate SR
methocarbamol
1
1
1
Yes
Yes
Yes
QL
QL
3
oxycodone
1
Yes
QL
3
oxycodone
1
Yes
QL, PA
3
QL
PA
PA = Prior authorization must be
requested by the physician.
12
QL, PA
QL = Quantity limits apply.
3. PAIN, NERVOUS SYSTEM, & PSYCH
BRAND
Rozerem
Ryzolt
Saphris
Seroquel
Seroquel XR
Sinemet
Sinemet CR
Soma
Sonata
Stalevo
Strattera
Suboxone
Sublingual
Film
Sylatron
Symbyax
Synalgos-DC
Tecfidera
Tegretol
Tegretol XR
Tofranil
Topamax
Topamax
Sprinkle
Capsules
Tranxene T
Trileptal
Ultracet
Ultram
Ultram ER
Valium
Vicodin ES
Vicoprofen
Voltaren XR
Vyvanse
Wellbutrin
Wellbutrin SR
Wellbutrin XR
Xanax
Xanax XR
Formulary
Tier
3
3
3
3
2
3
3
3
3
3
2
GENERIC
Formulary
Tier
Generic
Available
tramadol ER
1
Yes
Additional
Requirements
QL
PA
quetiapine fumarate
1
Yes
carbidopa/levodopa
carbidopa/levodopa CR
carisoprodol
zaleplon
carbidopa/levodopa/entacapone
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
QL, PA
QL
3
QL, PA
3
3
3
3
3
3
3
3
PA
olanzapine/fluoxetine hcl
dihydrocodeine/aspirin/caffeine
1
1
Yes
Yes
carbamazepine
carbamazepine XR
imipramine
topiramate
1
1
1
1
Yes
Yes
Yes
Yes
3
topiramate sprinkle cap
1
Yes
3
3
3
3
3
3
3
3
3
2
3
3
3
3
3
clorazepate dipotassium
oxcarbazepine
tramadol/acetaminophen
tramadol
tramadol ER
diazepam
hydrocodone/acetaminophen ES
hydrocodone/ibuprofen
diclofenac sodium
1
1
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
PA = Prior authorization must be
requested by the physician.
QL
QL
QL
QL
QL
QL
bupropion
bupropion SR
bupropion XR
alprazolam
alprazolam ER
13
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
QL = Quantity limits apply.
3. PAIN, NERVOUS SYSTEM, & PSYCH
BRAND
Xartemis XR
Xodol, Norco,
Maxidone,
Lortab, Lorcet,
Lorcet Plus,
Zydone
Zanaflex
Zarontin
Zenzedi 2mg,
7.5mg, 15mg,
20mg, 30mg
Zenzedi 5mg,
10mg
Zohydro ER
Zoloft
Zomig, Zomig
ZMT
Formulary
Tier
3
GENERIC
Formulary
Tier
Generic
Available
Additional
Requirements
QL
3
hydrocodone/acetaminophen
1
Yes
QL
3
3
tizanidine
ethosuximide
1
1
Yes
Yes
3
QL
dextroamphetamine
3
1
Yes
3
3
sertraline
1
Yes
3
zolmitriptan
1
Yes
QL
QL, PA
Zomig Nasal
Spray
3
Zonegran
3
Zubsolv
3
Zyban
3
bupropion
1
Yes
Zyprexa
Zyprexa Zydis
3
3
olanzapine
olanzapine ODT
acetaminophen/butalbital
acetaminophen/codeine
acetazolamide
amantadine
amitriptyline
amoxapine
aspirin with codeine
benztropine
buprenorphine
buprenorphine hcl/naloxone hcl
bupropion (generic Zyban)
butorphanol tartrate nasal
chlordiazepoxide
chlorpromazine HCl
choline magnesium trisalicylate
clonidine HCL ER
codeine tabs, 30mg/5ml solution
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
QL, PA
QL, PA
zonsinamide
1
Yes
PA
PA = Prior authorization must be
requested by the physician.
14
QL, PA
QL
QL
QL, PA
QL, PA
QL, PA
QL
QL
QL, PA
QL
QL = Quantity limits apply.
3. PAIN, NERVOUS SYSTEM, & PSYCH
BRAND
Formulary
Tier
GENERIC
desvenlafaxine ER
diflunisal
dihydroergotamine mesylate
doxepin
duraxin
estazolam
fentanyl citrate OTFC
fluphenazine
flurazepam
fluvoxamine
haloperidol
hydromorphone ER
ketoprofen
ketorolac
maprotiline
meclofenamate
meprobamate
methadone
migergot
modafinil
nabumetone
nefazodone
oxazepam
oxycodone-ibuprofen
pentazocine-acetaminophen
pentazocine-naloxone
perphenazine
phenobarbital
phenytoin
salsalate
sulindac
thioridazine
thiothixene
tolmetin sodium
trifluoperazine
trihexyphenidyl
trimipramine
vicodin, vicodin es, vicodin hp
zgesic
PA = Prior authorization must be
requested by the physician.
15
Formulary
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Generic
Available
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Additional
Requirements
QL
QL
QL, PA
QL
PA
PA
PA
QL
QL
QL = Quantity limits apply.
4. HEART, BLOOD PRESSURE, & CHOLESTEROL
Accupril
Accuretic
Aceon
Adalat CC
Adcirca
3
PA
Adempas
3
PA
Advate
Agrylin
Aldactazide
Aldactone
Altace
Alphanate
Alphanine SD
Alprolix
Amturnide
Antara
Arixtra
Atacand
Atacand HCT
Avalide
Avapro
Azor
Bebulin
BeneFIX
Benicar
Benicar HCT
Betapace AF
Bystolic
Caduet
Calan
Calan SR
Cardizem
Cardizem CD
Cardizem LA
Cardizem SR
Cardura
2
3
3
3
3
3
2
3
3
3
3
3
3
3
3
2
3
2
2
2
3
2
3
3
3
3
3
3
3
3
PA
GENERIC
quinapril HCl
quinapril/HCTZ
perindopril
nifedipine ER
anagrelide
spironolactone/HCTZ
spironolactone
ramipril
Formulary
Tier
1
1
1
1
Generic
Available
Yes
Yes
Yes
Yes
Formulary
Tier
3
3
3
3
BRAND
1
1
1
1
Additional
Requirements
Yes
Yes
Yes
Yes
PA
PA
PA
PA
fenofibrate
fondaparinux
candesartan
candesartan/hydrochlorothiazide
irbesartan/hydrochlorothiazide
irbesartan
PA = Prior authorization must be
requested by the physician.
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
PA
PA
PA
PA
PA
PA
sotalol HCl
1
Yes
atorvastatin/amlodipine
verapamil HCl
verapamil HCl ER
diltiazem HCl
diltiazem HCl CD
diltiazem HCl LA
diltiazem HCl SR
doxazosin mesylate
1
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
16
QL = Quantity limits apply.
4. HEART, BLOOD PRESSURE, & CHOLESTEROL
Formulary
Tier
Cartia XT
1
Catapres tablets
3
Catapres-TTS
3
Colestid
3
Cordarone
3
Coreg
3
Corgard
3
Corifact
3
Corzide
3
Coumadin
2
Cozaar
3
Crestor
2
Demadex
3
Diamox
3
Sequels
Dilacor XR
3
Dilt-CD
1
Diltzac ER
1
Diovan
3
Diovan HCT
3
Dyazide
3
Edarbi
3
Edarbyclor
3
Edecrin
2
Eloctate
3
Exforge/
3
Exforge HCT
Feiba
2
Fibricor
3
Helixate FS
2
Hemofil M
3
Humate-P
2
Hyzaar
3
Imdur
3
Inderal LA
3
Inspra
3
Isordil
3
Titradose Tabs
BRAND
PA = Prior authorization must be
requested by the physician.
GENERIC
diltiazem HCl ER
clonidine
clonidine patch
colestipol HCl
amiodarone HCl
carvedilol
nadolol
Formulary
Tier
1
1
1
1
1
1
1
Generic
Available
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Additional
Requirements
PA
nadolol-bendroflume thiazide
warfarin
losartan
1
1
1
Yes
Yes
Yes
torsemide
1
Yes
acetazolamide ER
1
Yes
diltiazem HCl ER
diltiazem HCl CD
diltiazem HCl ER
valsartan
valsartan/hydrochlorothiazide
triamterene/HCTZ
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
PA
PA
PA
PA
PA
PA
PA
PA
fenofibric acid
1
Yes
losartan-HCTZ
isosorbide mononitrate ER
propranolol ER
eplerenone
1
1
1
1
Yes
Yes
Yes
Yes
isosorbide dinitrate
1
Yes
17
PA
PA
PA
PA
QL = Quantity limits apply.
4. HEART, BLOOD PRESSURE, & CHOLESTEROL
Formulary
Tier
Jantoven
1
Juxtapid
3
Koate-DVI
3
Kogenate FS
2
Kynamro
3
Lanoxin
3
Lasix
3
Lescol
3
Letairis
3
Lipitor
3
Lipofen
3
Liptruzet
2
Livalo
3
Lofibra
3
Lopid
3
Lopressor HCT
3
Lotensin
3
Lotrel
3
Lovaza
3
Lovenox
3
Mavik
3
Maxzide
3
Mevacor
3
Micardis
3
Micardis HCT
3
Microzide
3
Minipress
3
Monoclate-P
3
Mononine
2
Multaq
2
Niaspan
3
Nifedical XL
1
Nitro-Bid
2
Nitro-Dur
3
Nitromist
3
Nitrostat SL
1
Norpace
3
Norvasc
3
Formulary
Tier
1
GENERIC
BRAND
warfarin
Generic
Available
Yes
Additional
Requirements
PA
PA
PA
PA
digoxin
furosemide
fluvastatin sodium
1
1
1
Yes
Yes
Yes
PA
atorvastatin
fenofibrate
1
1
Yes
Yes
PA
fenofibrate
gemfibrozil
metoprolol tartrate/HCT
benazepril
amlodipine/benazepril
omega-3 acid ethyl esters
enoxaparin
trandolapril
triamterene/HCTZ
lovastatin
telmisartan
telmisartan/hydrochlorothiazide
hydrochlorothiazide
prazosin
PA = Prior authorization must be
requested by the physician.
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
PA
PA
PA
PA
niacin ER
nifedipine ER
1
1
Yes
Yes
nitroglycerin patches
nitroglycerin spray
nitroglycerin SL
disopyramide
amlodipine
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
18
QL = Quantity limits apply.
4. HEART, BLOOD PRESSURE, & CHOLESTEROL
Formulary
Tier
Novoseven RT
2
Opsumit
3
Orenitram
3
Pacerone
1
Persantine
3
Plavix
3
Pletal
3
Pravachol
3
Prevalite
1
Prinivil
3
Procardia
3
Procardia XL
3
Procrit
2
Profilnine
3
Questran
3
Questran Light
3
Recombinate
2
Revatio
3
Rixubis
2
Rythmol
3
Rythmol SR
3
Samsca
3
Sectral
3
Sular
3
Tarka
3
Taztia XT
1
Tekamlo
3
Tekturna/
3
Tekturna HCT
Tenex
3
Tenoretic
3
Tenormin
3
Teveten
3
Teveten HCT
3
Tiazac
3
Toprol XL
3
Tracleer
2
Trandate
3
Tretten
3
BRAND
PA = Prior authorization must be
requested by the physician.
GENERIC
Formulary
Tier
Generic
Available
amiodarone HCl
dipyridamole
clopidogrel
cilostazol
pravastatin
cholestyramine light
lisinopril
nifedipine
nifedipine ER
1
1
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Additional
Requirements
PA
PA
PA
PA
cholestyramine
cholestyramine light
1
1
Yes
Yes
sildenafil citrate
1
Yes
propafenone
propafenone SR
1
1
Yes
Yes
PA
PA
PA
PA
acebutolol
nisoldipine ER
trandolapril/verapamil ER
diltiazem HCl ER
1
1
1
1
Yes
Yes
Yes
Yes
PA
PA
guanfacine
atenolol/chlorthalidone
atenolol
eprosartan
1
1
1
1
Yes
Yes
Yes
Yes
diltiazem HCl ER
metoprolol succinate
1
1
Yes
Yes
labetalol HCl
1
Yes
PA
PA
PA
19
QL = Quantity limits apply.
4. HEART, BLOOD PRESSURE, & CHOLESTEROL
BRAND
Tribenzor
Tricor
Trilipix
Twynsta
Tyvaso
Uniretic
Univasc
Vascepa
Vaseretic
Vasotec
Vecamyl
Ventavis
Verelan ER,
PM
Vytorin
Wilate
Xarelto
Xyntha
Zaroxolyn
Zebeta
Zestoretic
Zestril
Zetia
Ziac
Zocor
Formulary
Tier
2
3
3
3
3
3
3
2
3
3
1
3
3
2
2
2
2
3
3
3
3
2
3
3
PA = Prior authorization must be
requested by the physician.
GENERIC
Formulary
Tier
Generic
Available
fenofibrate nanocrystallized
fenofibric acid
telmisartan-amlodipine
1
1
1
Yes
Yes
Yes
moexipril/HCTZ
moexipril
1
1
Yes
Yes
enalapril/HCTZ
enalapril
1
1
Yes
Yes
Additional
Requirements
PA
PA
PA
PA
verapamil HCl ER
1
Yes
PA
PA
metolazone
bisoprolol
lisinopril/HCTZ
lisinopril
1
1
1
1
Yes
Yes
Yes
Yes
bisoprolol/HCTZ
simvastatin
acetazolamide
amiloride
amiloride/HCTZ
aminocaproic acid
benazepril/HCTZ
betaxolol
bumetanide
captopril
captopril/HCTZ
chlorothiazide
chlorthalidone
digoxin solution
felodipine ER
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
20
QL = Quantity limits apply.
4. HEART, BLOOD PRESSURE, & CHOLESTEROL
BRAND
Formulary
Tier
GENERIC
flecainide
fosinopril
fosinopril/HCTZ
hydralazine
indapamide
isosorbide dinitrate ER
isosorbide mononitrate
isradipine
lisinopril/HCTZ
methyldopa
metoprolol tartrate
mexiletine HCl
minoxidil
nicardipine
nimodipine
nitroglycerin ER
pentoxifylline ER
pindolol ER
propranolol/HCTZ
propranolol solution
sildenafil citrate
ticlopidine HCl
timolol
PA = Prior authorization must be
requested by the physician.
21
Formulary
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Generic
Available
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Additional
Requirements
PA
QL = Quantity limits apply.
5. SKIN MEDICATIONS
BRAND
Absorica
Acanya
Aldara
Avar-E LS
Bactroban
cream
Bactroban
ointment
Benzaclin
Benzamycin gel
Carmol scalp
lotion
Cleocin T
Clobex lotion,
shampoo
Clobex spray
Cloderm
Condylox
Cutivate
Cyclocort
Dermatop
Differin 1%
Differin 0.3% gel
Diprolene,
Diprolene AF
Dovonex cream
Drithrocreme
HP
Duac
Efudex cream
Elimite
Elocon
Emla cream
Epiduo
Erygel
Evoclin
Klaron
Lidoderm
Locoid
Locoid
Lipocream
isotretinoin
Formulary
Tier
1
Generic
Available
Yes
imiquimod cream
sulfacetamide sodium/sulfur
1
1
Yes
Yes
3
mupirocin cream
1
Yes
3
mupirocin ointment
1
Yes
3
3
clindamycin-benzoyl peroxide gel
benzoyl peroxide/erythromycin
1
1
Yes
Yes
3
sulfacetamide sodium/urea lotion
1
Yes
3
1
Yes
3
clindamycin
clobetasol propionate lotion,
shampoo
1
Yes
2
3
3
3
3
3
3
3
clocortolone pivalate
podofilox soln
fluticasone propionate
amcinonide
prednicarbate ointment
adapalene cream, gel
adapalene 0.3% gel
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
3
betamethasone dipropionate
1
Yes
3
calcipotriene cream
1
Yes
3
anthralin
1
Yes
3
3
3
3
3
2
3
3
3
3
3
clindamycin/benzoyl peroxide
fluorouracil cream
permethrin
mometasone cream
prilocaine/lidocaine
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
erythromycin gel
clindamycin phosphate
sodium sulfacetamide suspension
lidocaine
hydrocortisone butyrate 0.1%
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
3
hydrocortisone butyrate/emoll
1
Yes
Formulary
Tier
3
2
3
3
GENERIC
PA = Prior authorization must be
requested by the physician.
22
Additional
Requirements
PA
QL = Quantity limits apply.
5. SKIN MEDICATIONS
BRAND
Formulary
Tier
Loprox
3
Lotrisone
Luxiq
MetroCream
Metrogel
Metrolotion
Natroba
Nizoral
shampoo
Ovace Plus
Ovide
Oxsoralen
lotion 1%
Oxsoralen Ultra
Penlac
Proctofoam HC
Retin-A, Avita
Retin-A Micro
Silvadene
Soritane
Sulfamylon
3
3
2
3
3
3
3
3
Synalar
3
Taclonex
Targretin gel
Tazorac
3
2
2
Temovate
3
Topicort
3
Vanos
Vanoxide-HC
Vectical
Westcort
Xylocaine
Zovirax cream
Zovirax oint
3
3
3
3
3
2
3
GENERIC
Formulary
Tier
Generic
Available
1
Yes
3
3
3
3
3
3
ciclopirox cream, gel, shampoo,
suspension
betamethasone/clotrimazole
betamethasone valerate
metronidazole cream
metronidazole topical gel
metronidazole lotion
spinosad
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
3
ketoconazole shampoo
1
Yes
3
3
sulfacetamide sodium
malathion lotion
1
1
Yes
Yes
methoxsalen
ciclopirox solution
1
1
Yes
Yes
tretinoin
tretinoin gel
silver sulfadiazine
acitretin
mafenide acetate
fluocinolone acetonide cream,
soln
calcipotriene-betamethasone dp
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
1
Yes
1
Yes
1
Yes
Additional
Requirements
2
clobetasol cream, ointment,
solution
desoximetasone cream, gel,
ointment
fluocinonide
benzoyl peroxide/hydrocortisone
calcitriol ointment
hydrocortisone valerate 0.2%
lidocaine solution
1
Yes
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
acyclovir
alclometasone cream, ointment
benzoyl peroxide gel
1
1
1
Yes
Yes
Yes
PA = Prior authorization must be
requested by the physician.
23
PA
PA
PA
PA
QL = Quantity limits apply.
5. SKIN MEDICATIONS
BRAND
Formulary
Tier
GENERIC
benzoyl peroxide/urea cream
diflorasone diacetate
econazole
erythromycin solution
erythromycin swabs
fluocinonide cream, gel, ointment
gentamicin topical cream,
ointment
hydrocortisone 2.5%
hydrocortisone/lidocaine HCl
ketoconazole cream
nystatin/triamcinolone cream,
ointment
selenium sulfide
sodium sulfacetamide/sulfur
sulfacetamide sodium
triamcinolone cream, ointment
urea cream, ointment
PA = Prior authorization must be
requested by the physician.
24
Formulary
Tier
1
1
1
1
1
1
Generic
Available
Yes
Yes
Yes
Yes
Yes
Yes
1
Yes
1
1
1
Yes
Yes
Yes
1
Yes
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Additional
Requirements
QL = Quantity limits apply.
6. EAR, NOSE, THROAT MEDICATIONS
BRAND
Astelin
Astepro
Atrovent nasal
spray
Bactroban nasal
oint
Beconase AQ
Cetraxal
Ciprodex
Cortisporin
Otic
Dermotic
Evoxac
Flonase
Nasacort AQ
Nasonex
Omnaris
Qnasl
Rhinocort AQ
Salagen
Trioxin
Veramyst
Vosol HC
Zetonna
azelastine
azelastine
Formulary
Tier
1
1
Generic
Available
Yes
Yes
ipratropium
1
Yes
Formulary
Tier
3
3
GENERIC
3
Additional
Requirements
2
3
3
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
PA
ciprofloxacin
1
Yes
neomycin/polymyxin/
hydrocortisone
fluocinolone acetonide oil
cevimeline hcl
fluticasone propionate nasal susp
triamcinolone acetonide
1
Yes
1
1
1
1
Yes
Yes
Yes
Yes
budesonide
pilocarpine HCl
myoxin
1
1
1
Yes
Yes
Yes
PA
PA
PA
PA
PA
PA
PA
acetasol HC, acetic acid HC otic
1
Yes
PA
aero otic HC
aurodex otic
benzotic, benzocaine/antipyrine
cortane B otic drops
flunisolide
ofloxacin otic
oticin otic
PA = Prior authorization must be
requested by the physician.
25
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
QL = Quantity limits apply.
7. DIABETES, THYROID, STEROIDS, & OTHER MISCELLANEOUS HORMONES
BRAND
Actos
Amaryl
Androgel
Androderm
patch
Apidra Solostar
Ascenscia
Autodisc Test
Strips
Ascenscia
Breeze 2 Test
Strips
Ascensia
Contour Test
Strips
Ascenscia
Glucometer
Axiron
Bd Insulin
Syringe MicroFine
Bydureon
Byetta
Contour Next
Test Strips
Contour Test
Strips
Cortef
Cytomel
DDAVP
Decadron
Diabeta
Duetact
Farxiga
First
Testosterone
Fortamet
Fortesta
Freestyle Lite
Glucometer
Freestyle Lite
Test Strips
Formulary
Tier
3
3
2
Formulary
Tier
1
1
GENERIC
pioglitazone
glimepiride
Generic
Available
Yes
Yes
Additional
Requirements
PA
3
PA
3
PA
2
QL
2
QL
2
QL
2
QL
2
PA
2
QL
2
2
2
QL
2
QL
3
3
3
3
3
3
3
hydrocortisone
liothyronine
desmopressin acetate
dexamethasone
glyburide
pioglitazone/glimepiride
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
PA
3
3
3
PA
metformin ER
1
Yes
PA
2
QL
2
QL
PA = Prior authorization must be
requested by the physician.
26
QL = Quantity limits apply.
7. DIABETES, THYROID, STEROIDS, & OTHER MISCELLANEOUS HORMONES
Formulary
Tier
Freestyle Meter
2
Freestyle Test
2
Strips
Genotropin
3
Glucophage
3
Glucophage
3
XR
Glucotrol
3
Glucotrol XL
3
Glucovance
3
Glumetza ER
3
tablet
Glynase
3
Hectorol
3
Humalog
3
Humatrope
3
Humulin
3
Increlex
3
Janumet
2
Janumet XR
2
Januvia
2
Jentadueto
3
tablet
Kazano tablet
3
Keynote Strips
3
Kombiglyze
2
XR
Korlym tablet
3
Lantus
3
Levemir
2
Levoxyl,
Synthroid,
3
Unithroid
Medrol
3
Micronase
3
Myalept
3
Nesina tablet
3
Norditropin
2
Novolin
2
Novolog
2
BRAND
PA = Prior authorization must be
requested by the physician.
Formulary
Tier
GENERIC
Generic
Available
Additional
Requirements
QL
QL
PA
metformin
1
Yes
metformin ER
1
Yes
glipizide
glipizide ER
metformin/glyburide
1
1
1
Yes
Yes
Yes
PA
glyburide micronized
doxercalciferol
1
1
Yes
Yes
PA
PA
PA
PA
PA
PA
QL, PA
PA
PA
levothyroxine
1
Yes
methylprednisolone
glyburide
1
1
Yes
Yes
PA
PA
PA
27
QL = Quantity limits apply.
7. DIABETES, THYROID, STEROIDS, & OTHER MISCELLANEOUS HORMONES
BRAND
Novolog mix
Nutropin AQ
Onglyza
Oseni
Oxandrin
Pediapred,
Orapred
Prandin
Precision
XTRA
Glucometer
Precision
XTRA Test
Strips
Precose
Prelone
Rocaltrol
capsules
Saizen
Sensipar
Serostim
Signifor
Starlix
Striant buccal
system
Symlin
Tanzeum
Tapazole
Testim Gel
Tradjenta tablet
Victoza
Vogelxo
Zemplar
Formulary
Tier
Generic
Available
Formulary
Tier
2
3
2
3
3
oxandrolone
1
Yes
3
prednisolone sodium phosphate
1
Yes
3
repaglinide
1
Yes
GENERIC
Additional
Requirements
PA
PA
2
QL
2
QL
3
3
acarbose
prednisolone syrup
1
1
Yes
Yes
3
calcitriol capsules
1
Yes
3
2
3
3
3
PA
PA
PA
nateglinide
1
Yes
3
PA
2
3
3
3
3
2
3
3
PA
PA
PA = Prior authorization must be
requested by the physician.
methimazole
testosterone
1
1
Yes
Yes
testosterone
paricalcitol
danazol
fludrocortisone acetate
propylthiouracil
tolbutamide
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
28
PA
PA
PA
QL = Quantity limits apply.
8. STOMACH, ULCER, & BOWEL MEDS
BRAND
Aciphex
Aciphex
Sprinkle
Actigall
Analpram E Kit
Anusol-HC
Azulfidine
Bentyl
Canasa supp
Carafate susp
Carafate tabs
Colazal
Colocort
Compazine
suppository
Creon
Cytotec
Delzicol
Formulary
Tier
3
Formulary
Tier
1
GENERIC
rabeprazole
Generic
Available
Yes
3
Additional
Requirements
QL, PA
QL, PA
3
3
3
3
3
2
2
3
3
3
ursodiol
hydrocortisone/pramoxine kit
hydrocortisone
sulfasalazine
dicyclomine
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
sucralfate tabs
balsalazide
hydrocortisone retention enema
1
1
1
Yes
Yes
Yes
3
prochlorperazine suppository
1
Yes
2
3
2
misoprostol
1
Yes
Donnatal
3
phenobarb/hyoscyamine/atropine/
scopolamine
1
Yes
Emend
Entocort EC
Esomeprazole
Strontium
FirstLansoprazole
FirstOmeprazole
Gastrocrom
Kristalose
Levsin, Levbid
Lialda
Lomotil
Marinol
Nexium
Nulytely
Pentasa
3
3
QL
budesonide
1
Yes
3
QL, PA
3
QL, PA
3
omeprazole suspension
1
Yes
3
2
3
2
3
3
3
3
2
cromolyn sodium solution
1
Yes
hyoscyamine
1
Yes
diphenoxylate HCl/atropine
dronabinol
1
1
Yes
Yes
PA = Prior authorization must be
requested by the physician.
QL, PA
QL, PA
PEG 3350 & electrolytes
29
1
Yes
QL = Quantity limits apply.
8. STOMACH, ULCER, & BOWEL MEDS
BRAND
Formulary
Tier
GENERIC
Formulary
Tier
Generic
Available
Pepcid tabs,
suspension
Phenergan
Prevacid,
Prevacid
SoluTab
Prilosec caps
Prilosec
suspension
Proctofoam-HC
Protonix
Reglan
Rowasa
Tagamet
Tigan
Vimovo
Zantac
Zegerid
Zenpep
Zofran
3
famotidine 40mg tab, suspension
1
Yes
3
promethazine
1
Yes
3
lansoprazole tabs, ODT
1
Yes
QL, PA
3
omeprazole
1
Yes
QL, PA
3
omeprazole suspension
1
Yes
QL, PA
pantoprazole
metoclopramide
mesalamine rectal susp
cimetidine
trimethobenzamide
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
QL, PA
2
3
3
3
3
3
3
3
3
2
3
Additional
Requirements
PA
ranitidine 300mg
omeprazole-sodium bicarbonate
1
1
Yes
Yes
ondansetron HCl
chlordiazepoxide/clidinium
granisetron
lactulose soln
nizatidine solution
pancrelipase EC/SA
prochlorperazine tabs
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
PA = Prior authorization must be
requested by the physician.
30
QL, PA
QL = Quantity limits apply.
9. BONE, JOINT, & MUSCLE
BRAND
Actemra SC
Actonel 5mg,
30mg, 35mg
Actonel 150mg
Anaprox
Anaprox DS
Ansaid
Arava
Arthrotec
Atelvia
Binosto
Boniva
Cataflam
Celebrex
Colcrys
Dantrium
Daypro
Enbrel
Evista
Feldene
Fexmid
Flector Patch
Fosamax
Fosamax Plus D
Humira
Kineret
Formulary
Tier
3
Formulary
Tier
GENERIC
Generic
Available
2
QL
risedronate
naproxen sodium
naproxen sodium
flurbiprofen
leflunomide
diclofenac/misoprostol
3
3
3
3
3
3
3
3
3
3
2
2
3
3
2
3
3
3
3
3
3
2
3
Miacalcin
3
Mobic
Nalfon
Naprosyn
Orencia
Otezla
Otrexup
Parafon Forte
Pennsaid
Rasuvo
Robaxin
Simponi
Skelaxin
3
3
3
3
3
3
3
3
3
3
3
3
Additional
Requirements
QL, PA
ibandronate
diclofenac potassium
1
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
QL
QL
QL
QL
PA
dantrolene
oxaprozin
1
1
Yes
Yes
PA
raloxifene hcl
piroxicam
cyclobenzaprine
alendronate
calcitonin-salmon (rDNA origin)
nasal spray
meloxicam
fenoprofen calcium
naproxen
PA = Prior authorization must be
requested by the physician.
1
1
1
Yes
Yes
Yes
1
Yes
1
Yes
1
1
1
Yes
Yes
Yes
QL, PA
QL
QL
PA
PA
PA
PA
PA
chlorzoxazone
diclofenac sodium
1
1
Yes
Yes
PA
methocarbamol
1
Yes
PA
metaxalone
1
31
Yes
QL = Quantity limits apply.
9. BONE, JOINT, & MUSCLE
BRAND
Solaraze
Soma
Voltaren Gel
Voltaren XR
Xeljanz
Zanaflex
Zipsor
Zyloprim
Formulary
Tier
3
3
3
3
3
3
3
3
PA = Prior authorization must be
requested by the physician.
Formulary
Tier
1
1
GENERIC
diclofenac
carisoprodol
Generic
Available
Yes
Yes
Additional
Requirements
PA
diclofenac sodium ER
1
Yes
PA
tizanidine
1
Yes
QL, PA
allopurinol
baclofen
colchicine/probenecid
cyclobenzaprine
diflunisal
etidronate disodium
etodolac
ibuprofen
indomethacin
indomethacin SR
ketoprofen
ketoprofen SR
ketorolac
meclofenamate
nabumetone
naproxen sodium SA
orphenadrine ER
probenecid
sulindac
tolmetin
32
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
QL = Quantity limits apply.
10. FEMALE, HORMONE REPLACEMENT, & BIRTH CONTROL
The Injectable Fertility Agents in this section are covered only under certain benefits programs.
Please check your handbook to determine coverage.
Generic
Formulary
Formulary
Additional
BRAND
GENERIC
Available
Tier
Tier
Requirements
Yes
Aygestin
3
norethindrone acetate
1
Beyaz
2
Bravelle
2
QL
Cenestin
2
Yes
Cleocin vaginal
3
clindamycin cream
1
Yes
Climara patch
3
estradiol transdermal
1
Depo SubqQ
3
QL
Provera
Depo-Provera
3
medroxyprogesterone
QL
Yes
Desogen
3
apri
1
Yes
Diflucan
3
fluconazole 150mg
1
Yes
Eemt
3
covaryx/covaryx hs
1
Yes
Estrace
3
estradiol
1
Estring
2
norethindrone acetate/ethinyl
Yes
Estrostep FE
3
1
estradiol/ferrous fumarate
Yes
Evista
3
raloxifene
1
Yes
Femcon FE
3
ethinyl estradiol/norethindrone
1
First
progesterone
2
vaginal supps
Follistim AQ
2
QL
Generess FE
2
Yes
Loseasonique
3
amethia lo/camrese lo
1
Lo Loestrin FE
2
Menopur
2
Metrogel
Yes
3
metronidazole vaginal gel
1
vaginal
Minastrin 24
2
FE
Natazia
2
Nuvaring
2
QL
Yes
Ogen
3
estropipate
1
Ortho All-flex
3
QL
diaphragm
Yes
Ortho Evra
3
Xulane
1
QL
Ortho
Yes
Micronor/Nor
3
camila
1
QD
Yes
Ortho Novum
3
necon/cyclafem/alyacen
1
PA = Prior authorization must be
requested by the physician.
33
QL = Quantity limits apply.
10. FEMALE, HORMONE REPLACEMENT, & BIRTH CONTROL
The Injectable Fertility Agents in this section are covered only under certain benefits programs.
Please check your handbook to determine coverage.
Generic
Formulary
Formulary
Additional
BRAND
GENERIC
Available
Tier
Tier
Requirements
Ortho TriYes
2
tri-lo-sprintec
1
Cyclen Lo
Yes
Plan B One-Step
3
levonorgestrel/my way/next dose
1
QL
Premarin
2
Premarin
2
vaginal cream
Premphase
2
Prempro
2
Yes
Prometrium
2
progesterone, micronized
1
Yes
Provera
3
medroxyprogesterone acetate
1
Yes
Seasonique
3
amethia
1
Yes
Serophene
3
clomiphene citrate
1
Yes
Terazol 3
3
terconazole cream
1
Yes
Tri-norinyl
3
aranelle
1
Yes
Vandazole
3
metronidazole
1
Vivelle Dot
2
Yes
Yasmin
3
ethinyl estradiol/drospirenone
1
Gianvi, ethinyl estradiol/
Yes
YAZ
3
1
drospirenone
altavera/portia/levora 28/chateal/
Yes
1
marlissa/kurvelo
Yes
amethyst
1
Yes
aviane
1
Yes
desogestrel/ethinyl estradiol
1
esterified estrogens/
Yes
1
methyltestosterone
Yes
levonorgestrel/ethinyl estradiol
1
Yes
lomedia 24 Fe
1
Yes
norethindrone
1
Yes
norethindrone/ethinyl estradiol
1
norethindrone/ethinyl estradiol,
Yes
1
Fe
Yes
norethindrone/mestranol
1
Yes
norgestimate/ethinyl estradiol
1
Yes
norgestrel/ethinyl estradiol
1
PA = Prior authorization must be
requested by the physician.
34
QL = Quantity limits apply.
11. EYE MEDICATIONS
Formulary
Tier
Acular/Acular LS
3
Alcaine
3
Alphagan P
3
Alrex
2
Azopt
2
Besivance
2
Betagan
3
Betimol
2
Betoptic S
2
Bleph 10
3
Blephamide
2
Blephamide
2
S.O.P. ointment
Ciloxan Sol.
3
Cosopt
3
Cyclogyl
3
Diamox
3
Sequels
Elestat
3
Fml
3
Gentak
3
Iopidine
3
Isopto Atropine
3
Isopto
3
Carbachol 3%
Isopto Carpine
3
Isopto
3
Homatropine
Istalol Drops
2
Lotemax
2
Lumigan
2
BRAND
Maxitrol
3
Mydriacyl
Neosporin soln
Ocufen
Ocuflox
Omnipred
Optivar
Patanol
3
3
3
3
3
3
2
PA = Prior authorization must be
requested by the physician.
ketorolac opth soln
proparacaine
brimonidine tartrate
Formulary
Tier
1
1
1
Generic
Available
Yes
Yes
Yes
levobunolol
1
Yes
sulfacetamide
1
Yes
ciprofloxacin
dorzolamide-timolol
cyclopentolate HCl
1
1
1
Yes
Yes
Yes
acetazolamide ER
1
Yes
epinastine HCl
fluorometholone
gentamicin ophth
apraclonidine
atropine sulfate
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
carbachol 3%
1
Yes
pilocarpine
1
Yes
homatropine 5%
1
Yes
1
Yes
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
GENERIC
neomycin/polymyxin B/
dexamethasone
tropicamide
polymyxin B/neo/gramicidin
flurbiprofen
ofloxacin
prednisolone
azelastine HCL drops
35
Additional
Requirements
QL = Quantity limits apply.
11. EYE MEDICATIONS
BRAND
Formulary
Tier
Phospholine
Iodide
Pilopine HS gel
Polysporin
Polytrim
Pred-Forte
Timoptic
Timoptic XE
Tobradex
Tobrex
Travatan Z
Trusopt
2
2
3
3
3
3
3
3
3
2
3
Vasocidin oint
3
Vexol
Vigamox
Viroptic
Voltaren
Xalatan
Zioptan
Zymaxid
2
2
3
3
3
3
3
GENERIC
Formulary
Tier
Generic
Available
bacitracin/polymyxin B ophth oint
trimethoprim sulfate/polymyxin B
prednisolone acetate
timolol ophth
timolol XE
tobramycin-dexamethasone
tobramycin
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
dorzolamide HCl 2%
prednisolone/sodium
sulfacetamide
1
Yes
1
Yes
trifluridine
diclofenac sodium
latanoprost
1
1
1
Yes
Yes
Yes
Additional
Requirements
PA
gatifloxacin
acetazolamide
bacitracin ophth
betaxolol
carteolol
cromolyn ophth
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
dexamethasone ophth
1
Yes
erythromycin
1
Yes
methazolamide
1
Yes
polymyxin B/neo/bacitracin
1
Yes
prednisolone sodium phosphate
1
Yes
PA = Prior authorization must be
requested by the physician.
36
QL = Quantity limits apply.
12. ALLERGY, COUGH & COLD, LUNG MEDS
BRAND
Accolate
Adcirca
AdrenaClick
Advair Diskus
Advair HFA
Aerospan
Alvesco
Anoro Ellipta
Asmanex
Astelin Nasal
Spray
Atrovent HFA
Breo Ellipta
Bromfed DM
Cheratussin AC
Cheratussin
DAC
Clarinex
Combivent
Respimat
Dulera
Duoneb
Elixophyllin
Elixir
EpiPen
EpiPen Jr.
Flovent Diskus
Flovent HFA
Foradil
Grastek
Guiatuss AC
Hydromet
Iophen C-NR
Oralair
Proair HFA
Proventil HFA
Pulmicort
Flexhaler
Pulmicort
Respules
Pulmozyme
Qvar
Formulary
Tier
3
3
3
3
3
3
3
3
2
GENERIC
Formulary
Tier
1
3
azelastine nasal spray
zafirlukast
Generic
Available
Yes
Additional
Requirements
PA
PA
PA
PA
PA
PA
PA
1
Yes
2
3
1
1
PA
1
desloratadine
1
Yes
2
3
ipratropium-albuterol
1
Yes
3
theophylline elixir
1
Yes
3
2
2
2
3
3
2
3
3
1
1
3
2
3
PA
PA
PA
guaifenesin/codeine
1
Yes
PA
PA
3
3
PA
budesonide
1
Yes
2
2
PA = Prior authorization must be
requested by the physician.
37
QL = Quantity limits apply.
12. ALLERGY, COUGH & COLD, LUNG MEDS
BRAND
Ragwitek
Serevent
Diskus
Singulair
Spiriva
Symbicort
Tessalon Perles
Theo-24
Theochron
Tracleer
Formulary
Tier
3
GENERIC
Formulary
Tier
Generic
Available
montelukast sodium
1
Yes
benzonatate
1
Yes
theophylline extended release
1
Yes
Additional
Requirements
PA
2
3
2
2
3
2
1
2
Tussionex
3
Ventolin HFA
Vistaril
VoSpire ER
Xopenex
Xopenex HFA
Xyzal
Zutripro
3
3
3
3
3
3
3
PA
hydrocodone-chlorpheniramine
susp
1
Yes
PA
hydroxyzine pamoate
albuterol sulfate er
levalbuterol
1
1
1
Yes
Yes
Yes
PA
levocetirizine dihydrochloride
hydrocod-cpm-pseudoephedrine
acetylcysteine
albuterol sulfate soln, syrup, tab
aminophylline tabs
carbinoxamine
clemastine
cromolyn inhalation soln
cyproheptadine
flunisolide
guaifenesin/hydrocodone
guaifenesin/pseudoephedrine/
codeine
hydrocodone/homatropine syrup
hydroxyzine HCl
ipratropium inhalation soln
metaproterenol tabs, syrup, inh
soln
phenylephrine/cpm/hydrocodone
promethazine
promethazine/codeine
PA = Prior authorization must be
requested by the physician.
38
1
1
1
1
1
1
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
1
Yes
1
1
1
Yes
Yes
Yes
1
Yes
1
1
1
Yes
Yes
Yes
QL
QL = Quantity limits apply.
12. ALLERGY, COUGH & COLD, LUNG MEDS
BRAND
Formulary
Tier
GENERIC
promethazine/dextromethorphan
promethazine/phenylephrine
promethazine/phenylephrine/
codeine
pseudoephedrine/
chlorpheniramine/codeine
pseudoephedrine/guaifenesin
extended release
terbutaline sulfate tabs
PA = Prior authorization must be
requested by the physician.
39
Formulary
Tier
1
1
Generic
Available
Yes
Yes
1
Yes
1
Yes
1
Yes
1
Yes
Additional
Requirements
QL = Quantity limits apply.
13. URINARY & PROSTATE MEDS
Cardura
Cialis
Detrol
Detrol LA
Ditropan
Ditropan XL
Edex
Enablex
Flomax
Muse
Myrbetriq
Proscar
Formulary
Tier
3
2
3
3
3
3
3
2
3
2
2
3
Prosed-DS tab
3
Rapaflo
Sanctura XR
Stendra
Urecholine
Urocit-K
Uroxatral
VESIcare
Viagra
2
3
3
3
3
3
2
2
BRAND
GENERIC
doxazosin mesylate
Generic
Available
Yes
Additional
Requirements
QL, PA
tolterodine tartrate
tolterodine tartrate LA
oxybutynin
oxybutynin ER
1
1
1
1
Yes
Yes
Yes
Yes
QL, PA
tamsulosin
1
Yes
QL, PA
finasteride
methenamine/methylene blue/
benzoic acid/salicylic acid/
atropine
1
Yes
1
Yes
trospium chloride
1
Yes
QL, PA
bethanechol
potassium citrate
alfuzosin
1
1
1
Yes
Yes
Yes
QL, PA
flavoxate
phenazopyridine
terazosin
PA = Prior authorization must be
requested by the physician.
Formulary
Tier
1
40
1
1
1
Yes
Yes
Yes
QL = Quantity limits apply.
14. VITAMINS & ELECTROLYTES
BRAND
Calciferol
Icar
K-Tab
Klor-Con
Mephyton
Tri-Vi-Flor,
Poly-Vi-Flor
with and
without iron
Formulary
Tier
3
3
3
1
2
3
ergocalciferol
iron, carbonyl 15mg
potassium chloride
potassium chloride
Formulary
Tier
1
1
1
1
Generic
Available
Yes
Yes
Yes
Yes
multivitamin with fluoride drops,
tabs
1
Yes
fluoride
1
Yes
folic acid
1
Yes
Multigen
1
Yes
Multigen plus
1
Yes
potassium bicarbonate/potassium
citrate effervescent
1
Yes
sodium fluoride drops
1
Yes
GENERIC
PA = Prior authorization must be
requested by the physician.
41
Additional
Requirements
QL = Quantity limits apply.
15. DIAGNOSTICS & MISCELLANEOUS AGENTS
BRAND
Chemet
Novarel
PhosLo
Pregnyl
Proamatine
Renvela
Repronex
Zavesca
Formulary
Tier
2
3
3
3
3
3
3
2
PA = Prior authorization must be
requested by the physician.
GENERIC
Formulary
Tier
Generic
Available
Additional
Requirements
chorionic gonadotropin
calcium acetate
chorionic gonadotropin
midodrine HCl
sevelamer carbonate
1
1
1
1
1
Yes
Yes
Yes
Yes
Yes
PA
PA
QL
PA
42
QL = Quantity limits apply.
PROCEDURES THAT SUPPORT SAFE PRESCRIBING
Independence Administrators utilizes an independent pharmacy benefits management (PBM) company,
FutureScripts, to manage the administration of its commercial prescription drug programs. As our PBM,
FutureScripts is responsible for providing a network of participating pharmacies, administering pharmacy
benefits, and providing customer service to our members and providers.
Prior authorization
Prior authorization is a requirement that your physician obtain approval from your health plan for coverage
of, or payment for, prescription drugs. Independence Administrators requires prior authorization of certain
covered drugs to ensure that the drug prescribed is medically necessary and appropriate and is being prescribed
according to FDA guidelines. The approval criteria were developed and endorsed by the Pharmacy and
Therapeutics Committee, a group of physicians and pharmacists from the area.
Using these approved criteria, clinical pharmacists evaluate requests for these drugs based on clinical data,
information submitted by the member’s prescribing physician, and the member’s available prescription drug
therapy history. Their review includes a determination that there are no drug interactions or contraindications,
that dosing and length of therapy are appropriate, and that other drug therapies, if necessary, were utilized.
Without prior authorization, the member’s prescription will not be covered at the retail or mail-order
pharmacy. The prior authorization process may take up to two business days once complete information from
the prescribing physician has been received. Incomplete information will result in a delayed decision.
Prior authorization approvals for some drugs may be limited to 6 to 12 months. If the prior authorization for
a drug is limited to a certain time frame, an expiration date will be given at the time the approval is made. If
the physician wants a member to continue the drug therapy after the expiration date, a new prior authorization
request will need to be submitted and approved in order for coverage to continue.
43
Prior authorization applies to all formulations of specific drugs, including but not limited to, tablet,
capsule, and oral suspension.*
Absorica™
Abstral®
Aciphex®
Actemra® SC
Actiq®
Adasuve®
Adcirca™
Adempas®
Adipex-P®
Adoxa®
Adrenaclick®
Advair®
Advate®
Aerospan™
Afinitor®
Alodox®
Alphanate®
Alphanine® SD
Alprolix™
Alsuma®
Altabax™
Alvesco®
Ambien®
Ambien CR®
Amerge®
Ampyra™
Amturnide™
Androderm®
Androgel®
Anoro™Ellipta™
Apidra®
Apidra® SoloSTAR®
Atacand® (HCT)
Aubagio®
Auvi-Q®
Avapro®/Avalide®
Avidoxy™
Avinza® 120mg
Avita®
Axert®
Axiron®
Bebulin®
Beconase AQ®
Belviq®
BeneFIX®
Bosulif ®
Breo™ Ellipta™
Brintellix®
buprenorphine
buprenorphine/naloxone
bupropion
Caprelsa®
Carbaglu®
Caverject®
Cayston™
Celebrex®
Chantix®
Cialis®
Cimzia®
clonidine HCl ER
Cometriq™
Conzip™
Copegus®
Corifact®
Cozaar®/Hyzaar®
Cystaran™
Daytrana™
Dexilant™
Diabetic test strips*
Dilaudid® 4mg, 8mg
Diovan® (HCT)
Dolophine®
Doral®
Doryx® DR
Duragesic® 25mcg,
50mcg, 75mcg, 100mcg
Edarbi™
Edarbyclor™
Edex®
Edluar™
Eloctate™
Enbrel®
Erivedge™
Esomeprazole Strontium
eszopiclone 3mg
Exalgo™
Exforge® (HCT)
Exjade®
Extavia®
Factive®
Fanapt™
Farxiga™
Feiba®
fentanyl citrate-OTFC
fentanyl transdermal
25mcg, 50mcg,
75mcg, 100mcg
Fentora®
Ferriprox®
Fetzima™
Firazyr®
First Testosterone®
First® Lansoprazole
First® Omeprazole
Flector® patch
Flonase®
Flovent®
Forteo™
Fortesta™
Frova®
Fulyzaq™
Gattex®
Genotropin®
Gilenya®
Gilotrif™
Gleevec®
Glumetza™
Gralise™
Grastek®
Halcion®
Helixate® FS
Hemofil® M
Hetlioz™
Horizant™
Humalog®
Humate-P®
Humatrope®
Humira®
Humulin®
HYCAMTIN® capsules
hydromorphone 4mg, 8mg
hydromorphone ER
Iclusig™
Imbruvica™
Imitrex®
Increlex®
Inlynta®
Intermezzo®
Intuniv™
Invega™
Invokana™
Jakafi™
Jentadueto™
Juxtapid™
Kadian® 60mg, 80mg,
100mg, 200mg
Kalydeco™
Kapvay®
Kazano®
Khedezla®
Kineret®
Koate®-DVI
Kogenate® FS
Korlym™
Kynamro®
Lantus®
44
Latuda®
Lazanda®
Letairis®
Levitra®
Livalo®
Lunesta®
Lyrica®
Maxalt® (MLT)
Mekinist®
methadone
Micardis® (HCT)
Minocin®
modafinil
moderiba
Monoclate-P®
Monodox®
Mononine®
morphine sulfate 30mg IR
morphine sulfate ER
60mg, 80mg, 100mg,
120mg, 200mg
MS Contin® 60mg,
100mg, 200mg
MUSE®
Myalept™
Nasacort® AQ
Nasonex®
Nesina®
Nexavar®
Nexium®
Norditropin®
Novarel®
Novoseven® RT
Noxafil®
Nucynta ER® 150mg,
200mg, 250mg
Nucynta® 100mg
Nuedexta™
Nutropin® (AQ)
Nuvigil®
Olysio™
Omnaris®
Omnitrope®
Opana® 10mg
Opana ER® 20mg, 30mg,
40mg
Opsumit®
Oralair®
Orencia® SQ
Orenitram™
Oseni®
Otezla™
Otrexup™
oxycodone ER 30mg,
40mg, 60mg, 80mg
oxycodone IR 30mg
Oxycontin 30mg, 40mg,
60mg, 80mg
oxymorphone 10mg
Peg-Intron®
Pegasys® (ProClick)
Picato®
Pomalyst®
Pregnyl®
Prevacid®
Prilosec®
Pristiq™
Procysbi®
Profilnine®
Protonix®
Proventil® HFA
Provigil®
Pulmicort Flexhaler®
Qnasl™
Qualaquin®
quinine sulfate
Qysmia™
Ragwitek™
Rasuvo™
Ravicti™
Rebetol®
Rebif®
Recombinate™
Regimex®
ReliOn®
Rescula®
Restoril®
Retin-A® (Micro)
Revatio™
Revlimid®
Rhinocort Aqua®
RibaPak®
Ribasphere®
RibaTab®
Rixubis™
Roxicodone 30mg
Saizen®
Samsca™
Saphris®
Serostim®
Signifor®
sildenafil
Silenor®
Simponi™
Sirturo™
Sivextro™
Solodyn®
Sonata®
Sovaldi™
Sprycel®
Staxyn™
Stendra™
Stivarga®
Striant®
Suboxone® Sublingual
Film
Subsys®
Sumavel™
Suprenza ODT™
Sutent®
Sylatron™
Symlin®
Taclonex®
Taclonex Scalp®
Suspension
Tafinlar®
Tanzeum™
Tarceva®
Targretin® Gel
Tasigna®
Tekamlo™
Tekturna® (HCT)
Temodar® Oral
temozolomide
Testim®
testosterone gel
Tev-Tropin®
Teveten® (HCT)
Thalomid®
Toviaz™
Tradjenta™
Tretten®
Treximet™
Twynsta®
Tykerb®
Tyvaso®
Valchlor™
Vecamyl™
Ventavis®
Ventolin® HFA
Veramyst™
Viagra®
Vibramycin®
Victrelis™
Vimovo®
Vimpat™
Vogelxo®
Voltaren® Gel
Votrient™
Wilate®
Xalkori®
Xeljanz®
Xenazine™
Xenical®
Xopenex HFA®
Xtandi®
Xyntha®
Xyrem®
Zavesca®
Zegerid®
Zelboraf®
Zetonna™
Zioptan™
Zipsor™
Zmax™
Zohydro™ ER
Zolinza®
Zolpidem 10mg
Zolpidem CR 12.5mg
Zolpimist™
Zomig® (ZMT)
Zorbtive™
Zubsolv®
Zyban®
Zykadia™
Zytiga™
Zyvox®
* All diabetic test strips require prior authorization except the following: Autodisc®, Ascencia®, Breeze® 2,
Contour®, Contour® Next, Elite®, FreeStyle®, FreeStyle Lite®, Optium®, Optium EZ®, and Precision XTRA®
* Compound products containing any prescription bulk chemical
* Compound products with total ingredient cost equal to or greater than $150 per prescription
* nicotine patches, nicotine gums, nicotine lozenges, nicotine inhalers, nicotine sprays
45
Age and gender limits
The FDA has established specific procedures that govern prescription prescribing practices. These rules are
designed to prevent potential harm to patients and to ensure that the medication is being prescribed according to
FDA guidelines. For example, some drugs are approved by the FDA only for individuals age 14 and older, such
as ciprofloxacin, or prescribed only for females, such as prenatal vitamins. The pharmacist’s computer provides
up-to-date information about FDA rules. If the member’s prescription falls outside of the FDA guidelines, it
will not be covered until prior authorization is obtained. The prescribing physician may request consideration
for preapproval of restricted medications when medically necessary. The approval criteria for this review
were developed and endorsed by the Pharmacy and Therapeutics Committee. The member should contact
the prescribing physician to request that he or she initiate the preapproval process. To determine if a covered
prescription drug prescribed for you has an age or gender limit, call FutureScripts at 1-888-678-7013.
Quantity limits
Quantity limits are designed to allow a sufficient supply of medication based upon FDA-approved maximum
daily doses and length of therapy of a particular drug. We have several different types of quantity limits that are
explained in detail below.
• Rolling 30-day period
This quantity limit is based on dosing guidelines over a rolling 30-day period. For example, if a member went
to the pharmacy on January 1, 2015, for one of these medications, the computer system would have looked
back 30 days to December 1, 2014, to see how much medication was dispensed. The purpose of these limits is
to make certain that these drugs are being used appropriately and to guard against overuse or stockpiling.
Examples of quantity limits per rolling 30-day period are:
◦ Emend® (four 125mg capsules + eight 80mg capsules or four trifold packs [one 125mg capsule two
80mg capsules]); Boniva® (one 150mg tablet); Avonex® (one kit, four injections); Copaxone®
(30 vials); Fosamax Plus DTM (four tablets); and Rebif® (12 injections);
◦ migraine drugs, such as Amerge® (nine 2.5mg tablets), Imitrex® (18 50mg tablets), Maxalt® (12 10mg
tablets), Migranal® (eight 4mg nasal spray units), and Zomig® (nine 5mg tablets);
◦ sedative hypnotic drugs, such as Sonata® (30 capsules) and Ambien® (30 tablets);
◦ oral narcotic drugs, such as OxyContin® (90 units), Percocet® (180 units), and Percodan® (180 units).
• Refill too soon
With this quantity limit, if a member used less than 75 percent of the total day supply dispensed, the claim
will be rejected at the pharmacy. This will ensure that the drug is being taken in accordance with the
prescribed dose and frequency of administration.
• Therapeutic drug class
This quantity limit applies to some classes of drugs, such as narcotics (i.e., short-acting and long-acting). If
a member uses more than one drug within the same class, he or she may be unsafely duplicating drugs and
would be affected by the total quantity limits for a therapeutic drug class. Members will be able to obtain
only a 30-day total supply of any combination of drugs in the same therapeutic drug class each month.
If a physician requires that a member uses a drug therapy that exceeds any of the quantity limits described
above, the physician must request consideration for a quantity limit override. The member is required to contact
the prescribing physician to initiate a preapproval request for an override.
46
Some drugs may have a time period for quantity limit exceptions of 6 to 12 months. If the exception for a drug is
limited to a certain time frame, an expiration date will be given at the time the approval is made. If the physician
wants a member to continue the drug therapy that exceeds a quantity limit after the expiration date, a new request
for a quantity limit exception will need to be submitted and approved in order for coverage to continue.
To determine if a covered prescription drug prescribed for you has a quantity limit, call FutureScripts
at 1-888-678-7013.
96-Hour Temporary Supply Program
The 96-Hour Temporary Supply Program applies to the following covered drugs:
• most drugs that require prior authorization;
• drugs that are subject to age limits (pre-approval required for ages outside of recommended ranges);
• migraine drugs with quantity limits, such as Amerge®, Imitrex®, Maxalt®, Migranal®, and Zomig®
(preapproval of quantity override required for amounts over the quantity limits).
Under the 96-Hour Temporary Supply Program, if a member’s physician writes a prescription for a drug
that requires prior authorization, has an age limit, or exceeds the quantity limit for a medication, and prior
authorization has not been obtained by the physician, the following steps will occur:
1. The participating retail pharmacy will be instructed to release a 96-hour supply of the drug to the
member with no out-of-pocket cost-sharing (i.e., no cost to the member) at that time.*
2. By the next business day, FutureScripts will contact the member’s physician to request that he or she
submit the necessary documentation of medical necessity or medical appropriateness for review.
3. Once the completed medical documentation is received by FutureScripts, the review will be completed,
and the medication will be approved or denied.
4. If approved, the remainder of the prescription order will be filled, and the appropriate prescription drug
out-of-pocket cost-sharing will be applied.*
5. If denied, notification will be sent to both the physician and the member.
Obtaining a 96-hour temporary supply does not guarantee that the prior authorization/preapproval request will
be approved. Some drugs are not eligible for the 96-Hour Temporary Supply Program due to packaging or other
limitations such as Retin-A® (tube), Enbrel® (two-week injection kit), medroxyprogesterone acetate (monthly
injectable), and erectile dysfunction drugs. Additionally, certain drugs to treat hemophilia (antihemophilic
factors) are not usually purchased at the pharmacy and must be special-ordered; therefore, they are not eligible
under the 96-Hour Temporary Supply Program.
*Members with an integrated drug benefit (e.g., Comprehensive Major Medical and Major Medical) will pay the discounted cost of the 96-hour
supply as well as the remainder of the prescription order (if approved) at the time of purchase, and the medical claim for reimbursement will be
processed through standard procedures.
47
The process for requesting a prior authorization/preapproval or override is as follows:
• The physician prescribing the drug completes a prior authorization form or writes a letter of medical
necessity and submits it to FutureScripts by fax at 1-888-671-5285. The forms are available online at:
www.futurescripts.com/for_health_care_professionals/prior_authorization. The form must be completed
and submitted by the physician, not the member.
• FutureScripts will review the prior authorization request or letter of medical necessity. If a clinical
pharmacist cannot approve the request based on established criteria, a medical director will review
the document.
• A decision is made regarding the request.
• If approved, the prescribing physician will be notified of approval via fax or telephone, and the claims
system will be coded with the approval. The member may call the Customer Service phone number on
his or her ID card to determine if the prescription is approved.
• If denied, the prescribing physician will be notified via letter, fax, or telephone. The member is also
notified of all denied requests via letter. The appeals process will be detailed within the denial letters
sent to the member and physician.
Coverage for drugs not on the formulary (specific to Select Drug Program members only)
Providers may request consideration for formulary coverage of a covered non-formulary medication when all
formulary alternatives have been exhausted or there are contraindications to using the formulary alternatives.
The provider should complete the covered non-formulary appeal form, providing detail to support use of the
covered non-formulary medication, and fax the request to 1-888-671-5285. If the non-formulary exception
request is approved, the drug will be paid at the appropriate formulary level of cost-sharing. If the request is
denied, the member and provider will receive a denial letter with the appropriate appeals language. Whether an
appeal is filed, the member may always obtain benefits for the covered non-formulary drug at the appropriate
non-formulary level of cost-sharing. Out-of-pocket expenses for non-formulary drugs are higher than for
formulary drugs.
Appealing a decision
If a request for prior authorization/preapproval or exception results in a denial, the member, or physician on the
member’s behalf, may file an appeal. Both the member and his or her physician will receive written notification
of a denial, which will include the appropriate telephone number and address to direct an appeal. In all cases,
the physician needs to be involved in the appeals process to provide the required medical information for the
basis of the appeal.
Prescription drug program provider payment information
FutureScripts administers our prescription drug benefits and is responsible for providing a network of
participating pharmacies and processing pharmacy claims. FutureScripts also negotiates price discounts with
pharmaceutical manufacturers and provides drug utilization and quality reviews. Price discounts may include
rebates from a drug manufacturer based on the volume purchased. Independence Administrators anticipates that
it will pass along a high percentage of the expected rebates it receives from FutureScripts through reductions
in the overall cost of pharmacy benefits. Under most benefits plans, prescription drugs are subject to a member
cost-sharing.
48
FutureScripts® is an independent company that performs pharmacy benefits manager (PBM) services for Independence Administrators.
©2014 Independence Administrators. All rights reserved.
No part of this publication may be reproduced or distributed without the prior written permission of Independence Administrators.
Independence Administrators is an independent licensee of the Blue Cross and Blue Shield Association.
1/15
IAwPA

Download Report