e a 1, 2017 guide ahnj 4.1.17... · after 12 weeks of gestation in women who are at high risk for...

Select Drug Program® FormularyeFFective aPril 1, 2017

www.amerihealthnj.com

1

Dear Valued 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 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 approved 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.

Non-preferred brand drugs listed in the formulary are available at the highest level of cost-sharing (i.e., the highest cost to you). A non-preferred brand drug is displayed next to the equivalent generic drug that is available at the lowest level of cost-sharing (i.e., the lowest cost to you). For example: ciprofloxacin is the generic drug available at the lowest level of cost-sharing; Cipro® is the non-preferred brand available at the highest level of cost-sharing. In most cases when brand drugs have a generic equivalent, the brand version is considered non-preferred.

• Covered generic drugs not listed are formulary and are available at the lowest level of cost-sharing. • Covered brand drugs not listed are non-preferred and are available at the highest level of cost-sharing.

Certain preventive medications, as described in the Patient Protection and Affordable Care Act (PPACA) and detailed by the U.S. Preventive Services Task Force, 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) low-dose aspirin (81 mg) when used either for the primary prevention of cardiovascular disease and colorectal cancer in adults aged 50 to 59 years or as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia, 2) breast cancer chemotherapy prevention for members 35 years of age and older, 3) fluoride supplementation for children 6 months to 60 months, 4) prescription bowel prep medications indicated for colonoscopy screenings, for adults ages 50-75, 5) folic acid supplementation for women planning or capable of pregnancy, 6) iron supplementation for children ages 6 to 12 months who are at increased risk for iron deficiency anemia, 7) tobacco interventions for adults who use tobacco products, 8) vitamin D supplementation for ages 65 and over to prevent falls, and 9) contraceptives as mandated by the Women’s Preventive Services provision.

1

2

Dear Valued Physician:

This is a listing of formulary drugs to be considered for your patient, a Select 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.

Sincerely,

AmeriHealth

2

5PA = Prior authorization must be requested by the physician.LDD = Limited Distribution Drug at Briova

QL = Quantity limits apply.

1. ANTIBIOTICS & OTHER DRUGS USED FOR INFECTION

BRAND Formulary Tier GENERIC Formulary

TierGeneric

AvailableAdditional

RequirementsActiclate 3 PAAdoxa 3 doxycycline monohydrate 1 Yes PA

Ancobon 3 flucytosine 1 YesAralen 3 chloroquine phosphate 1 YesAtripla 2

Augmentin 3 amoxicillin/clavulanate 1 Yes

Augmentin XR 3 amoxicillin/clavulanate extended- release 1 Yes

Avelox 3 moxifloxacin hcl 1 YesBactrim,

Bactrim DS 3 sulfamethoxazole/tmp 1 Yes

Baraclude 3 entecavir 1 YesBiaxin 3 clarithromycin 1 Yes

Biaxin XL 3 clarithromycin SR 1 YesCedax 3 ceftibuten 1 YesCeftin 3 cefuroxime axetil 1 YesCipro 3 ciprofloxacin tabs 1 Yes

Cipro oral suspension 3 ciprofloxacin susp. 1 Yes

Cipro XR 3 ciprofloxacin ER tabs 1 YesCleocin 3 clindamycin 1 Yes

Combivir 3 lamivudine/zidovudine 1 YesComplera 2Cresemba 3 QL, PACrixivan 2Daklinza 3 PADiflucan 3 fluconazole 1 Yes

Doryx 50 mg and 200 mg dr

tablet3 doxycycline hyclate 50 mg and

200 mg dr tablet 1 Yes PA

Edurant 2E.E.S., EryPed 3 erythromycin ethylsuccinate 1 Yes

Emtriva 2Epclusa 3 PAEpivir 3 lamivudine 1 Yes

Epzicom 3 abacavir sulfate/lamivudine 1 YesEry-Tab 3 erythromycin delayed release 1 Yes

Erythrocin 3 erythromycin stearate 1 YesFactive 3 PAFamvir 3 famciclovir 1 Yes

6



TierGeneric

AvailableAdditional

RequirementsFlagyl 3 metronidazole 1 Yes

Flumadine 3 rimantadine 1 YesFuzeon 3

Grifulvin V 3 griseofulvin microsize 1 YesGris-PEG 3 griseofulvin ultramicrosize 1 YesHarvoni 2 PAHepsera 3 adefovir dipivoxil 1 YesHiprex 3 methenamine hippurate 1 Yes

Impavido 3 QLInvirase 2Isentress 2Kaletra 2

Kalydeco 3 PA, LDDKeflex 3 cephalexin 1 Yes

Lamisil Tabs 3 terbinafine tabs 1 YesLevaquin 3 levofloxacin 1 YesLexiva 2

Macrodantin 3 nitrofurantoin macrocrystals 1 YesMalarone 3 atovaquone/proguanil 1 YesMepron 3 atovaquone 1 YesMinocin 3 minocycline caps 1 Yes PA

Monodox 3 doxycycline monohydrate 1 Yes PAMoxatag 3 amoxicillin ER 1 Yes

Myambutol 3 ethambutol 1 YesMycobutin 3 rifabutin 1 Yes

Norvir 2Noxafil 3 QL, PAOlysio 3 PAOnmel 3 PAOracea 3 doxycycline ir-dr 1 Yes PA

Orkambi 3 PA, LDDPegasys 3

Peg-Intron 3Plaquenil 3 hydroxychloroquine 1 YesPrezista 2

Qualaquin 3 quinine sulfate 1 Yes PARetrovir 3 zidovudine 1 YesReyataz 2Ribapak 3 moderiba 1 Yes

PA = Prior authorization must be requested by the physician.LDD = Limited Distribution Drug at Briova


7



TierGeneric

AvailableAdditional

RequirementsRifadin 3 rifampin 1 Yes

Selzentry 2Sivextro 3 QL, PASovaldi 2 PA

Sporanox 3 itraconazole 1 YesStribild 2

Stromectol 3 ivermectin 1 YesSuprax Susp 100 mg/5 ml, 200 mg/5 ml

3 cefixime susp 100 mg/5 ml, 200 mg/5 ml 1 Yes

Sustiva 2Tamiflu 3 QL

Targadox 3 PATechnivie 3 PATindamax 3 tinidazole 1 Yes

Tobi 3 tobramycin 1 Yes LDDTriumeq 2Trizivir 3 abacavir/lamivudine/zidovudine 1 YesTruvada 2Valcyte 3 valganciclovir 1 YesValtrex 3 valacyclovir tab 1 Yes PA

Vancocin 3 vancomycin 1 YesVfend 3 voriconazole 1 Yes

Vibramycin 3 doxycycline hyclate 1 Yes PAVidex EC 3 didanosine 1 Yes

Viekira Pak 3 PAViramune 3 nevirapine 1 Yes

Viramune XR 3 nevirapine XR 1 YesViread 2

Xifaxan 200 mg 3 QL

Xifaxan 550 mg 3 PA

Zepatier 3 PAZerit 3 stavudine 1 Yes

Ziagen 3 abacavir sulfate 1 YesZinbryta 3 PA

Zithromax 3 azithromycin 1 YesZmax 3 PA

Zovirax 3 acyclovir 1 Yes



8



TierGeneric

AvailableAdditional

RequirementsZyvox 3 linezolid 1 Yes PA

amoxicillin 1 Yesampicillin 1 Yescefaclor 1 Yes

cefaclor ER 1 Yescefadroxil 1 Yescefdinir 1 Yes

clotrimazole troches 1 Yesdapsone 1 Yes

demeclocycline 1 Yesdicloxacillin 1 Yes

erythromycin susp w/sulfa 1 Yesisoniazid 1 Yes

ketoconazole tabs 1 Yesmebendazole 1 Yesmefloquine 1 Yes

minocycline tabs 1 Yesmoderiba 1 Yesnystatin 1 Yesofloxacin 1 Yes

penicillin VK 1 Yesprimaquine phosphate 1 Yes

tetracycline 1 Yes



9

2. CANCER & ORGAN TRANSPLANT DRUGS


TierGeneric

AvailableAdditional

RequirementsAlecensa 3 PAArimidex 3 anastrazole 1 YesAromasin 3 exemestane 1 Yes

Cabometyx 3 PACasodex 3 bicalutamide 1 YesCellcept 3 mycophenolate 1 YesCotellic 3 PA, LDDCytoxan 3 cyclophosphamide 1 Yes

Danocrine 3 danazol 1 YesDeltasone 3 prednisone 1 Yes

Emcyt 3Eulexin 3 flutamide 1 YesFarydak 3 PA, LDDFemara 3 letrozole 1 YesGilotrif 3 PAGleevec 3 imatinib mesylate 1 Yes PAHydrea 3 hydroxyurea 1 YesIbrance 3 PA, LDD

Imbruvica 3 PAImuran 3 azathioprine 1 Yes

Lenvima 3 PA, LDDLeukeran 2Lonsurf 3 PA

Lynparza 3 PALysodren 3Matulane 2Megace 3 megestrol 1 YesMyfortic 3 mycophenolic acid 1 Yes

Nilandron 3 nilutamide 1 YesNinlaro 3 PAOdomzo 3 PAPrograf 3 tacrolimus 1 YesProtopic 3 tacrolimus 1 Yes

Purinethol 3 mercaptopurine 1 YesRapamune

1 mg/ml Sol 2

Rapamune tab 3 sirolimus 1 YesRheumatrex, Trexall tab 3 methotrexate 1 Yes



10

2. CANCER & ORGAN TRANSPLANT DRUGS


TierGeneric

AvailableAdditional

RequirementsSandimmune,

Neoral 3 cyclosporine 1 Yes

Tabloid 3 thioguanine 1 YesTagrisso 3 PA

Targretin cap 3 bexarotene 1 YesTemodar 3 temozolomide 1 Yes PAValchlor 3 PA

Venclexta 3 PAVePesid 3 etoposide 1 YesXeloda 3 capecitabine 1 YesZydelig 3 PAZykadia 3 PA, LDD

leucovorin calcium 1 Yeslomustine 1 Yes

megestrol acetate 1 Yestamoxifen 1 Yes

temozolomide 1 Yes PA



11

3. PAIN, NERVOUS SYSTEM, & PSYCH


TierGeneric

AvailableAdditional

RequirementsAbilify 3 aripiprazole 1 Yes PAActiq 3 fentanyl citrate OTFC 1 Yes QL, PA

Adasuve 3 PA

Adderall 3amphetamine aspartate/

amphetamine sulfate/ dextroamphetamine

1 Yes QL, PA

Adderall XR 3amphetamine aspartate/

amphetamine sulfate/ dextroamphetamine ER

1 Yes QL

Adzenys XR-ODT 3 QL

Alsuma 3 sumatriptan succinate 1 Yes QL, PAAmbien 3 zolpidem tartrate 1 Yes QL, PA

Ambien CR 3 zolpidem tartrate controlled release 1 Yes QL, PA

Amerge 3 naratriptan 1 Yes QL, PAAnafranil 3 clomipramine HCl 1 YesAnsaid 3 flurbiprofen 1 Yes

Aptensio XR 3 QLAricept 3 donepezil hydrochloride 1 YesAtivan 3 lorazepam 1 Yes PA

Avinza 30 mg, 45 mg, 60 mg,

75 mg3 morphine sulfate ER 1 Yes QL

Avinza 90 mg, 120 mg 3 morphine sulfate ER 1 Yes QL, PA

Avonex 2 QLAxert 3 almotriptan maleate 1 Yes QL, PA

Azilect 2Belbuca 3 QL, PA

Belsomra 3 QL, PABelviq 3 PA

Betaseron 2 QLBrintellix 3 PABriviact 3 PABunavail 3 QL, PABuspar 3 buspirone 1 YesButrans 3 QL, PACafergot 3 ergotamine tartrate/caffeine 1 YesCampral 3 acamprosate 1 YesCataflam 3 diclofenac potassium 1 Yes



12



TierGeneric

AvailableAdditional

RequirementsCelexa 3 citalopram 1 Yes

Celontin 2Chantix 3 QLClinoril 3 sulindac 1 YesClozaril 3 clozapine 1 YesComtan 3 entacapone 1 YesConcerta 3 methylphenidate 1 Yes QL, PA

Contrave ER 3 PAConzip 3 tramadol hcl er 1 Yes QL, PA

Copaxone 2 glatopa 1 Yes QL, LDDCymbalta 3 duloxetine 1 YesDantrium 3 dantrolene 1 YesDaypro 3 oxaprozin 1 YesDemerol 3 meperidine HCl 1 Yes QL

Depakene 3 valproic acid 1 YesDepakote 3 divalproex sodium 1 Yes

Depakote ER 3 divalproex sodium ER 1 YesDepakote

Sprinkle Caps 3 divalproex sprinkle cap 1 Yes

Desoxyn 3 methamphetamine 1 Yes QL, PADesyrel 3 trazodone 1 Yes

Dexedrine 3 dextroamphetamine sulfate 1 Yes QL, PADiastat 3 diazepam rectal gel 1 Yes

Diastat AcuDial 3 diazepam rectal gel 1 YesDilantin

chewable tablets 2 phenytoin chewable tablets 1 Yes

Dilaudid 1 mg/ml liquid 3 hydromorphone 1 mg/ml liquid 1 Yes QL

Dilaudid 2 mg 3 hydromorphone HCl 1 Yes QLDilaudid 4 mg,

8 mg 3 hydromorphone HCl 1 Yes QL, PA

Dolobid 3 diflunisal 1 YesDolophine 3 methadone 1 Yes PA

Doral 3 quazepam 1 Yes QL, PADuragesic

12 mcg 3 fentanyl transdermal 1 Yes QL

Duragesic 25 mcg, 50 mcg, 75 mcg, 100 mcg

3 fentanyl transdermal 1 Yes QL, PA

Dyanavel XR 3 QLEffexor 3 venlafaxine 1 Yes



13



TierGeneric

AvailableAdditional

RequirementsEffexor XR 3 venlafaxine ER 1 Yes PA

Eldepryl 3 selegiline HCl 1 YesEmbeda 3 QL, PA

Esgic 3 butalbital/apap/caffeine 1 YesEsgic Plus 3 butalbital/apap/caffeine, zebutal 1 YesEskalith 3 lithium carbonate 1 Yes

Eskalith CR, Lithobid 3 lithium carbonate SR 1 Yes

Evekeo 3 QL, PAEvzio 3 QL, PAExalgo 3 hydromorphone ER 1 Yes QL, PAExelon 3 rivastigmine 1 YesFazaclo 3 clozapine ODT 1 YesFelbatol 3 felbamate 1 YesFeldene 3 piroxicam 1 YesFetzima 3 PAFioricet 3 butalbital/apap/caffeine 1 Yes

Fioricet with codeine 3 butalbital/apap/caffeine/codeine 1 Yes QL

Fiorinal with codeine 3 butalbital/aspirin/caffeine/codeine 1 Yes QL

Focalin 3 dexmethylphenidate hcl 1 Yes QLFocalin XR 3 dexmethylphenidate hcl xr 1 Yes QL, PA

Frova 3 frovatriptan succinate 3 Yes QLGabitril 3 tiagabine hcl 1 YesGeodon 3 ziprasidone 1 YesHalcion 3 triazolam 1 Yes QL, PAHetlioz 3 QL, PA

Horizant 3 PAHycet 3 hydrocodone/apap 1 Yes QL

Hysingla 3 QL, PAIbudone 3 ibuprofen/oxycodone HCl 1 Yes QLImitrex 3 sumatriptan 1 Yes QL, PA

Intermezzo 1.75 mg, 3.5 mg 3 zolpidem tartrate 1 Yes QL, PA

Intuniv 3 guanfacine ER 1 Yes QL, PAInvega 3 paliperidone er 1 YesIrenka 3 duloxetine hcl 1 YesKadian

10 mg, 20 mg, 30 mg, 40 mg

3 morphine extended release 1 Yes QL



14



TierGeneric

AvailableAdditional

RequirementsKadian

50 mg, 60 mg, 80 mg, 100 mg

3 morphine extended release 1 Yes QL, PA

Kadian 200 mg 3 QL, PAKapvay 3 clonidine HCl ER 1 Yes QL, PAKeppra 3 levetiracetam 1 Yes PA

Keppra XR 3 levetiracetam ER 1 Yes PAKhedezla 3 desvenlafaxine ER 1 Yes PAKlonopin 3 clonazepam 1 YesLamictal 3 lamotrigine 1 Yes PA

Lamictal ODT 3 lamotrigine ODT 1 Yes PALamictal XR 3 lamotrigine 1 Yes PA

Lazanda 3 PALexapro 3 escitalopram 1 Yes PA

Lodine XL 3 etodolac 1 YesLodosyn 3 carbidopa 1 YesLortab 3 hydrocodone/acetaminophen elixir 1 Yes QL

Loxitane 3 loxapine 1 YesLunesta 3 eszopiclone 1 Yes QL, PA

Luvox CR 3 fluvoxamine 1 YesMaxalt,

Maxalt-MLT 3 rizatriptan benzoate 1 Yes QL, PA

Mestinon 3 pyridostigmine 1 YesMetadate CD 3 methylphenidate hcl 1 Yes QL, PA

Methylin Chewable Tabs 3 methylphenidate hcl chewable

tabs 1 Yes QL

Midrin 3 isometheptene/ dichloralphenazone/apap 1 Yes

Migranal 3 dihydroergotamine 1 Yes QL, PAMirapex 3 pramipexole 1 Yes

Mirapex ER 3 pramipexole er 1 YesMoban 3 molindone hcl 1 Yes

MS Contin 15 mg, 30 mg 3 morphine sulfate, extended release 1 Yes QL

MS Contin 60 mg, 100 mg,

200 mg3 morphine sulfate, extended release 1 Yes QL, PA

MSIR 3 morphine sulfate 1 Yes QLMysoline 3 primidone 1 Yes

Nalfon 3 fenoprofen calcium 1 YesNamenda 3 memantine hcl 1 Yes



15



TierGeneric

AvailableAdditional

RequirementsNarcan 4 mg/

actuation spray 3 QL, PA

Nardil 3 phenelzine 1 YesNeurontin 3 gabapentin 1 YesNeurontin solution 3 gabapentin solution 1 Yes

Norpramin 3 desipramine 1 YesNucynta 50 mg,

75 mg QL

Nucynta 100 mg QL, PANucynta ER

50 mg, 100 mg QL

Nucynta ER 150 mg, 200 mg,

250 mgQL, PA

Nuplazid 3 PANuvigil 3 armodafinil 1 Yes PA

Onzetra Xsail 3 QL, PAOpana 5 mg 3 oxymorphone 1 Yes QLOpana 10 mg 3 oxymorphone 1 Yes QL, PA

Opana ER 5 mg, 7.5 mg, 10 mg, 15 mg

3 oxymorphone 1 Yes QL

Opana ER 20 mg, 30 mg,

40 mg3 oxymorphone 1 Yes QL, PA

Orap 3 pimozide 1 YesOrudis 3 ketoprofen 1 YesOxaydo 3 QL, PA

Oxycontin 10 mg, 15 mg,

20 mg3 oxycodone ER 1 Yes QL

Oxycontin 30 mg, 40 mg, 60 mg, 80 mg

3 oxycodone ER 1 Yes QL, PA

OxyIR 3 oxycodone 1 Yes QLPamelor 3 nortriptyline 1 YesParcopa 3 carbidopa/levodopa ODT 1 YesParlodel 3 bromocriptine mesylate 1 YesParnate 3 tranycypromine sulfate 1 YesPaxil 3 paroxetine 1 Yes

Paxil CR 3 paroxetine HCl ext-release 1 Yes



16



TierGeneric

AvailableAdditional

RequirementsPercocet, Roxicet 3 oxycodone/acetaminophen,

endocet 1 Yes QL, PA

Percodan 3 oxycodone/aspirin 1 Yes QLPhenytek 3 phenytoin sodium 1 YesPlegridy 2 QL

Prostigmin 2Provigil 3 modafinil 1 Yes PA

Prozac 3 fluoxetine 1 Yes QL (Weekly only), PA

Qudexy XR 3 topiramate ER 1 YesQuillichew ER 20 mg, 30 mg,

40 mg3 QL

Razadyne 3 galantamine 1 YesRazadyne ER 3 galantamine ER 1 Yes

Regimex 3 PARelpax 3 QL, PA

Remeron 3 mirtazapine 1 YesRemeron SolTab 3 mirtazapine rapid dissolve tabs 1 Yes

Requip 3 ropinirole 1 YesRequip XL 3 ropinirole EL 1 Yes

Restoril 3 temazepam 1 Yes QL, PARexulti 3 PARilutek 3 riluzole 1 Yes

Risperdal, Risperdal M-Tab 3 risperidone 1 Yes

Ritalin LA 20 mg, 30 mg,

40 mg3 methylphenidate ER 1 Yes QL, PA

Ritalin SR 3 methylphenidate SR 1 Yes QLRobaxin 3 methocarbamol 1 Yes

Roxicodone 15 mg 3 oxycodone 1 Yes QL

Roxicodone 30 mg 3 oxycodone 1 Yes QL, PA

Rozerem 3 QLRyzolt 3 tramadol ER 1 Yes QLSaphris 3 PASaxenda 3 PASeroquel 3 quetiapine fumarate 1 Yes

Seroquel XR 2



17



TierGeneric

AvailableAdditional

RequirementsSinemet 3 carbidopa/levodopa 1 Yes

Sinemet CR 3 carbidopa/levodopa CR 1 YesSonata 3 zaleplon 1 Yes QL, PAStalevo 3 carbidopa/levodopa/entacapone 1 YesStrattera 2 QL

Suboxone Sublingual Film 1 QL

Sylatron 3 PASymbyax 3 olanzapine/fluoxetine hcl 1 Yes

Synalgos-DC 3 dihydrocodeine/aspirin/caffeine 1 YesTasmar 3 tolcapone 1 Yes

Tecfidera 2 LDDTegretol 3 carbamazepine 1 Yes

Tegretol XR 3 carbamazepine XR 1 YesTofranil 3 imipramine 1 YesTopamax 3 topiramate 1 YesTopamax Sprinkle Capsules

3 topiramate sprinkle cap 1 Yes

Tranxene T 3 clorazepate dipotassium 1 YesTrezix 3 dihydrocodein-acetaminoph-caff 1 Yes QL

Trileptal 3 oxcarbazepine 1 YesUltracet 3 tramadol/acetaminophen 1 Yes QLUltram 3 tramadol 1 Yes QL

Ultram ER 3 tramadol ER 1 Yes QLValium 3 diazepam 1 Yes PA

Vicodin ES 3 hydrocodone/acetaminophen ES 1 Yes QLVicoprofen 3 hydrocodone/ibuprofen 1 Yes QL

Voltaren XR 3 diclofenac sodium 1 YesVoltaren XR

Gel 3 diclofenac sodium gel 1 Yes

Vraylar 3 PAVyvanse 2 QL

Wellbutrin 3 bupropion 1 YesWellbutrin SR 3 bupropion SR 1 YesWellbutrin XL 3 bupropion XR 1 Yes PA

Xanax 3 alprazolam 1 Yes PAXanax XR 3 alprazolam ER 1 Yes

Xartemis XR 3 QL, PAXenazine 3 tetrabenazine 1 Yes PA



18



TierGeneric

AvailableAdditional

RequirementsXodol, Norco,

Maxidone, Lortab, Lorcet,

Lorcet Plus, Zydone

3 hydrocodone/acetaminophen 1 Yes QL

Xtampza ER 3 QL, PAZarontin 3 ethosuximide 1 YesZecuity 3 QL, PA

Zembrace Symtouch 3 QL, PA

Zenzedi 2 mg, 7.5 mg, 15 mg, 20 mg, 30 mg

3 QL

Zenzedi 5 mg, 10 mg 3 dextroamphetamine 1 Yes QL

Zohydro ER 3 QL, PAZoloft 3 sertraline 1 Yes PA

Zomig, Zomig ZMT 3 zolmitriptan 1 Yes QL, PA

Zomig Nasal Spray 3 QL, PA

Zonegran 3 zonsinamide 1 YesZubsolv 3 QL, PAZyban 3 bupropion 1 Yes QL

Zyprexa 3 olanzapine 1 YesZyprexa Zydis 3 olanzapine ODT 1 Yes

acetaminophen/butalbital 1 Yesacetaminophen/codeine 1 Yes QL

acetazolamide 1 Yesamantadine 1 Yesamitriptyline 1 Yesamoxapine 1 Yes

aspirin with codeine 1 Yes QLbenztropine 1 Yes

buprenorphine 1 Yes QL, PAbuprenorphine hcl/naloxone hcl 1 Yes QL, PA

butorphanol tartrate nasal 1 Yes QLchlordiazepoxide 1 Yes

chlorpromazine HCl 1 Yesclonidine HCL ER 1 Yes QL, PA

codeine tabs, 30 mg/5 ml solution 1 Yes QLdesvenlafaxine ER 1 Yes



19



TierGeneric

AvailableAdditional

Requirementsdiflunisal 1 Yes

dihydroergotamine mesylate 1 Yes QLdoxepin 1 Yesduraxin 1 Yes

estazolam 1 Yes QLfentanyl citrate OTFC 1 Yes QL, PA

fluphenazine 1 Yesflurazepam 1 Yes QLfluvoxamine 1 Yeshaloperidol 1 Yes

hydromorphone ER 1 Yes PAketoprofen 1 Yesketorolac 1 Yes

maprotiline 1 Yesmeclofenamate 1 Yesmeprobamate 1 Yes

methadone 1 Yes PAmigergot 1 Yesmodafinil 1 Yes PA

nabumetone 1 Yesnefazodone 1 Yes

nicotine gum, inhalers, lozenges, patches 1 Yes QL

oxazepam 1 Yesoxycodone-ibuprofen 1 Yes QL

pentazocine-acetaminophen 1 Yespentazocine-naloxone 1 Yes

perphenazine 1 Yesphenytoin 1 Yessulindac 1 Yes

thioridazine 1 Yesthiothixene 1 Yes

tolmetin sodium 1 Yestrianex 3 Yes

trifluoperazine 1 Yestrihexyphenidyl 1 Yestrimipramine 1 Yes

vicodin, vicodin es, vicodin hp 1 Yes QLzgesic 1 Yes



20

4. HEART, BLOOD PRESSURE, & CHOLESTEROL


TierGeneric

AvailableAdditional

RequirementsAccupril 3 quinapril HCl 1 YesAccuretic 3 quinapril/HCTZ 1 Yes

Aceon 3 perindopril 1 YesAdalat CC 3 nifedipine ER 1 Yes

Adcirca 3 PAAdempas 3 PAAdvate 2 PA

Adynovate 3 PAAfstyla 3 PA

Aggrenox 3 aspirin-dipyridamole er 1 YesAgrylin 3 anagrelide 1 Yes

Aldactazide 3 spironolactone/HCTZ 1 YesAldactone 3 spironolactone 1 YesAlphanate 3 PA

Alphanine SD 3 PAAlprolix 3 PA, LDDAltace 3 ramipril 1 Yes

Amturnide 3 PAAntara 3 fenofibrate 1 YesArixtra 3 fondaparinux 1 YesAtacand 3 candesartan 1 Yes PA

Atacand HCT 3 candesartan/hydrochlorothiazide 1 Yes PAAvalide 3 irbesartan/hydrochlorothiazide 1 Yes PAAvapro 3 irbesartan 1 Yes PAAzor 3 amlodipine besylate/olmesartan 1 Yes

Bebulin 3 PABeneFIX 2 PABenicar 3 olmesartan medoxomil 1 Yes

Benicar HCT 3 olmesartan/hctz 1 YesBetapace AF 3 sotalol HCl 1 Yes

Bystolic 2Caduet 3 atorvastatin/amlodipine 1 YesCalan 3 verapamil HCl 1 Yes

Calan SR 3 verapamil HCl ER 1 YesCardizem 3 diltiazem HCl 1 Yes

Cardizem CD 3 diltiazem HCl CD 1 YesCardizem LA 3 diltiazem HCl LA 1 YesCardizem SR 3 diltiazem HCl SR 1 Yes

Cardura 3 doxazosin mesylate 1 Yes



21



TierGeneric

AvailableAdditional

RequirementsCartia XT 1 diltiazem HCl ER 1 Yes

Catapres tablets 3 clonidine 1 YesCatapres-TTS 3 clonidine patch 1 Yes

Coagadex 3 PAColestid 3 colestipol HCl 1 Yes

Cordarone 3 amiodarone HCl 1 YesCoreg 3 carvedilol 1 Yes

Corgard 3 nadolol 1 YesCorifact 3 PACorlanor 3 PACorzide 3 nadolol-bendroflume thiazide 1 Yes

Coumadin 2 warfarin 1 YesCozaar 3 losartan 1 Yes PACrestor 3 rosuvastatin 1 Yes PA

Demadex 3 torsemide 1 YesDiamox Sequels 3 acetazolamide ER 1 Yes

Dibenzyline 3 phenoxybenzamine hcl 1 Yes PADilacor XR 3 diltiazem HCl ER 1 Yes

Dilt-CD 1 diltiazem HCl CD 1 YesDiltzac ER 1 diltiazem HCl ER 1 Yes

Diovan 3 valsartan 1 Yes PADiovan HCT 3 valsartan/hydrochlorothiazide 1 Yes PA

Durlaza 3 PADutoprol 3 metoprolol succinate/hctz 25-12.5 mg 1 YesDyazide 3 triamterene/HCTZ 1 YesEdarbi 3 PA

Edarbyclor 3 PAEdecrin 3 ethacrynic acidEliquis 2Eloctate 3 PAEntresto 3 QL, PAExforge 3 amlodipine/valsartan 1 Yes PA

Exforge HCT 3 amlodipine/valsartan/HCTZ 1 Yes PAFeiba 3 PA

Fenoglide 3 fenofibrate 1 YesFibricor 3 fenofibric acid 1 Yes

Helixate FS 2 PAHemofil M 3 PAHumate-P 2 PA



22



TierGeneric

AvailableAdditional

RequirementsHyzaar 3 losartan-HCTZ 1 Yes PAImdur 3 isosorbide mononitrate ER 1 Yes

Inderal LA 3 propranolol ER 1 Yes PAInspra 3 eplerenone 1 YesIsordil

Titradose Tabs 3 isosorbide dinitrate 1 Yes

Ixinity 3 PA, LDDJantoven 1 warfarin 1 YesJuxtapid 3 PA

Koate-DVI 3 PAKogenate FS 2 PA

Kynamro 3 PALanoxin 3 digoxin 1 Yes

Lasix 3 furosemide 1 YesLescol 3 fluvastatin sodium 1 YesLetairis 2 PALipitor 3 atorvastatin 1 Yes PALipofen 3 fenofibrate 1 YesLiptruzet 2

Livalo 3 PALofibra 3 fenofibrate 1 YesLopid 3 gemfibrozil 1 Yes

Lopressor HCT 3 metoprolol tartrate/HCT 1 YesLotensin 3 benazepril 1 Yes

Lotrel 3 amlodipine/benazepril 1 YesLovaza 3 omega-3 acid ethyl esters 1 Yes

Lovenox 3 enoxaparin 1 YesMavik 3 trandolapril 1 Yes

Maxzide 3 triamterene/HCTZ 1 YesMevacor 3 lovastatin 1 YesMicardis 3 telmisartan 1 Yes PA

Micardis HCT 3 telmisartan/hydrochlorothiazide 1 Yes PAMicrozide 3 hydrochlorothiazide 1 YesMinipress 3 prazosin 1 Yes

Monoclate-P 3 PAMononine 2 PA

Multaq 2Niaspan 3 niacin ER 1 Yes

Nifedical XL 1 nifedipine ER 1 YesNitro-Bid 2



23



TierGeneric

AvailableAdditional

RequirementsNitro-Dur 3 nitroglycerin patches 1 YesNitromist 3 nitroglycerin spray 1 Yes

Nitrostat SL 3 nitroglycerin sub 0.3 mg, 0.4 mg, 0.6 mg 1 Yes

Norpace 3 disopyramide 1 YesNorthera 3 PANorvasc 3 amlodipine 1 Yes

Novoeight 3 PANovoseven RT 3 PA

Nuwiq 3 PAObizur 3 PA

Opsumit 3 PAOrenitram 3 PAPacerone 1 amiodarone HCl 1 YesPersantine 3 dipyridamole 1 Yes

Plavix 3 clopidogrel 1 YesPletal 3 cilostazol 1 Yes

Praluent 2 PA, LDDPravachol 3 pravastatin 1 YesPrevalite 1 cholestyramine light 1 YesPrinivil 3 lisinopril 1 Yes

Procardia 3 nifedipine 1 YesProcardia XL 3 nifedipine ER 1 Yes

Procrit 2Profilnine 3 PAQuestran 3 cholestyramine 1 Yes

Questran Light 3 cholestyramine light 1 YesRecombinate 2 PA

Repatha 3 PARevatio 3 sildenafil citrate 1 Yes PARiastap 3 PARixubis 3 PARythmol 3 propafenone 1 Yes

Rythmol SR 3 propafenone SR 1 YesSamsca 3 PA, LDDSectral 3 acebutolol 1 YesSular 3 nisoldipine ER 1 YesTarka 3 trandolapril/verapamil ER 1 Yes

Taztia XT 1 diltiazem HCl ER 1 YesTekamlo 3 PA



24



TierGeneric

AvailableAdditional

RequirementsTekturna/

Tekturna HCT 3 PA

Tenex 3 guanfacine 1 YesTenoretic 3 atenolol/chlorthalidone 1 Yes PATenormin 3 atenolol 1 Yes PATeveten 3 eprosartan 1 Yes PA

Teveten HCT 3 PATiazac 3 diltiazem HCl ER 1 Yes

Tikosyn 3 dofetilide 1 YesToprol XL 3 metoprolol succinate 1 YesTracleer 2 PA, LDDTrandate 3 labetalol HCl 1 YesTretten 3 PA, LDD

Tribenzor 3 olmesartan/amlodipine/hctz 1 YesTricor 3 fenofibrate nanocrystallized 1 Yes

Trilipix 3 fenofibric acid 1 YesTwynsta 3 telmisartan-amlodipine 1 Yes PATyvaso 3 PAUniretic 3 moexipril/HCTZ 1 YesUnivasc 3 moexipril 1 YesUptravi 3 PAVascepa 3Vaseretic 3 enalapril/HCTZ 1 YesVasotec 3 enalapril 1 YesVecamyl 1 PAVentavis 3 PA

Verelan ER, PM 3 verapamil HCl ER 1 Yes

Vonvendi 3 PAVytorin 2Wilate 3 PAXarelto 2Xyntha 2 PA

Yosprala 3 PAZaroxolyn 3 metolazone 1 Yes

Zebeta 3 bisoprolol 1 YesZestoretic 3 lisinopril/HCTZ 1 Yes

Zestril 3 lisinopril 1 YesZetia 2Ziac 3 bisoprolol/HCTZ 1 Yes



25



TierGeneric

AvailableAdditional

RequirementsZocor 3 simvastatin 1 Yes

acetazolamide 1 Yesamiloride 1 Yes

amiloride/HCTZ 1 Yesaminocaproic acid 1 Yesbenazepril/HCTZ 1 Yes

betaxolol 1 Yesbumetanide 1 Yescaptopril 1 Yes

captopril/HCTZ 1 Yeschlorothiazide 1 Yeschlorthalidone 1 Yes

digoxin solution 1 Yesfelodipine ER 1 Yes

flecainide 1 Yesfosinopril 1 Yes

fosinopril/HCTZ 1 Yeshydralazine 1 Yesindapamide 1 Yes

isosorbide dinitrate ER 1 Yesisosorbide mononitrate 1 Yes

isradipine 1 Yeslisinopril/HCTZ 1 Yes

methyldopa 1 Yesmetoprolol tartrate 1 Yes

mexiletine HCl 1 Yesminoxidil 1 Yes

nicardipine 1 Yesnimodipine 1 Yes

nitroglycerin ER 1 Yesnitroglycerin SL 1 Yespentoxifylline ER 1 Yes

pindolol ER 1 Yespropranolol/HCTZ 1 Yes

propranolol solution 1 Yessildenafil citrate 1 Yes PAticlopidine HCl 1 Yes

timolol 1 Yes



26

5. SKIN MEDICATIONS


TierGeneric

AvailableAdditional

RequirementsAbsorica 3 isotretinoin 1 Yes PAAcanya 3 PAAczone 3 PAAldara 3 imiquimod cream 1 YesAtralin 3 tretinoin 1 Yes PAAurstat 3 MB hydrogel 1 YesAzelex 3 PA

Bactroban cream 3 mupirocin cream 1 Yes

Bactroban ointment 3 mupirocin ointment 1 Yes

Benzaclin 3 clindamycin-benzoyl peroxide gel 1 Yes PABenzaclin

Pump 3 clindamycin-benzoyl peroxide gel w/pump 1 Yes PA

Benzamycin gel 3 benzoyl peroxide/erythromycin 1 Yes PABenzamycinpak 3 PA

Capex 3 PACarac 3 fluorouracil cream 1 Yes PA

Ciclodan 0.77% cream 3 ciclopirox 0.77% cream 1 Yes PA

Ciclodan 8% solution 3 ciclopirox 8% solution 1 Yes PA

Cleocin T 3 clindamycin 1 Yes PAClindagel 3 PAClobex 3 clobetasol propionate 1 Yes PA

Cloderm 3 clocortolone pivalate 1 Yes PACondylox 3 podofilox soln 1 YesCordran 3 flurandrenolide 1 Yes PA

Cosentyx 3 PA, LDDCutivate 3 fluticasone propionate 1 Yes PA

Cyclocort 3 amcinonide 1 YesDenavir 3 QLDerma-

Smoothe FS 3 fluocinolone acetonide 1 Yes PA

Dermatop 3 prednicarbate ointment 1 YesDesonate 3 PADesowen 3 PA

Differin 0.1% cream, gel 3 adapalene cream, gel 1 Yes PA

Differin 0.3% gel 3 adapalene 0.3% gel 1 Yes PA



27

5. SKIN MEDICATIONS


TierGeneric

AvailableAdditional

RequirementsDifferin 0.1%

lotion 3 adapalene 0.1% lotion 1 Yes

Diprolene, Diprolene AF 3 betamethasone dipropionate 1 Yes

Dovonex cream 3 calcipotriene cream 1 YesDrithrocreme

HP 3 anthralin 1 Yes

Duac 3 clindamycin/benzoyl peroxide 1 Yes PAEcoza 3 PA

Efudex cream 3 fluorouracil cream 1 YesElimite 3 permethrin 1 YesElocon 3 mometasone cream 1 Yes

Emla cream 3 prilocaine/lidocaine 1 YesEnstilar 3 PAEpiduo 2Ertaczo 3 PAErygel 3 erythromycin gel 1 YesEvoclin 3 clindamycin phosphate 1 Yes PA

Exelderm 3 PAExtina 3 PAHalog 3 PAJublia 3 PA

Kenalog Spray 3 triamcinolone acetonide 1 Yes PAKerydin 3 PAKlaron 3 sodium sulfacetamide suspension 1 Yes

Lidoderm 3 lidocaine 1 Yes PALocoid 3 hydrocortisone butyrate 0.1% 1 YesLocoid

Lipocream 3 hydrocortisone butyrate/emoll 1 Yes PA

Loprox 3 ciclopirox cream, gel, shampoo, suspension 1 Yes PA

Lotrisone 3 betamethasone/clotrimazole 1 YesLuxiq 3 betamethasone valerate 1 Yes PALuzu 3 PA

MetroCream 3 metronidazole cream 1 YesMetrogel 3 metronidazole topical gel 1 Yes

Metrolotion 3 metronidazole lotion 1 YesNaftin 3 naftifine hcl 1 Yes

Natroba 3 spinosad 1 YesNizoral

shampoo 3 ketoconazole shampoo 1 Yes



28

5. SKIN MEDICATIONS


TierGeneric

AvailableAdditional

RequirementsOlux [E] 3 PAOnexton 3 PAOvide 3 malathion lotion 1 YesOxistat 3 oxiconazole nitrate 3 Yes PA

Oxsoralen lotion 1% 2

Oxsoralen Ultra 3 methoxsalen 1 YesPandel 3 PAPenlac 3 ciclopirox solution 1 Yes PA

Proctofoam HC 2Psorcon 3 diflorasone diacetate 1 Yes PA

Retin-A, Avita 3 tretinoin 1 Yes PARetin-A Micro 3 tretinoin gel 1 Yes PA

Sernivo 3 PASilvadene 3 silver sulfadiazine 1 YesSoritane 3 acitretin 1 Yes

Sulfamylon 3 mafenide acetate 1 Yes

Synalar 3 fluocinolone acetonide cream, soln 1 Yes PA

Taclonex 3 calcipotriene-betamethasone dp 1 Yes PATaltz

Autoinjector 3 PA

Targretin gel 2 PATazorac 2

Temovate 3 clobetasol cream, ointment, solution 1 Yes

Topicort 3 desoximetasone cream, gel, ointment 1 Yes PA

Ultravate 3 halobetasol propionate 1 Yes PAVanos 3 fluocinonide 1 Yes PA

Vectical 3 calcitriol ointment 1 YesVeltin 3 clindamycin phos-tretinoin 1 Yes PAVusion 3 fluocinonide 1 Yes PA

Westcort 3 hydrocortisone valerate 0.2% 1 YesXolegel 3 PA

Xylocaine 3 lidocaine solution 1 YesZiana 3 PA

Zonalon 3 doxepin hcl 1 YesZovirax cream 2Zovirax oint 3 acyclovir 1 Yes



29

5. SKIN MEDICATIONS


TierGeneric

AvailableAdditional

Requirementsalclometasone cream, ointment 1 Yes

apexicon E 3 Yesbenzoyl peroxide/urea cream 1 Yes

clodan 3 Yesdiflorasone diacetate 1 Yes

econazole 1 Yeserythromycin solution 1 Yeserythromycin swabs 1 Yes

fluocinonide cream, gel, ointment 1 Yesgentamicin topical cream,

ointment 1 Yes

hydrocortisone 2.5% 1 Yeshydrocortisone/lidocaine HCl 1 Yes

ketoconazole cream 1 Yesnaftifine hcl cream 1% 1 Yes

nystatin/triamcinolone cream, ointment 1 Yes

triamcinolone cream, ointment 1 Yes



30

6. EAR, NOSE, THROAT MEDICATIONS


TierGeneric

AvailableAdditional

RequirementsAstelin 3 azelastine 1 YesAstepro 3 azelastine 1 Yes

Atrovent nasal spray 3 ipratropium 1 Yes

Bactroban nasal oint 2

Beconase AQ 3 PACetraxal 3 ciprofloxacin 1 YesCiprodex 2

Cortisporin Otic 3 neomycin/polymyxin/

hydrocortisone 1 Yes

Dermotic 3 fluocinolone acetonide oil 1 YesDymista 3 PAEvoxac 3 cevimeline hcl 1 YesFlonase 3 fluticasone propionate nasal susp 1 Yes PANasonex 3 mometasone furoate 1 Yes PAOmnaris 3 PAPatanase 3 olopatadine 1 Yes

Qnasl 3 PARhinocort AQ 3 budesonide 1 Yes PA

Salagen 3 pilocarpine HCl 1 YesTrioxin 3 myoxin 1 Yes

Veramyst 3 PAVosol HC 3 acetasol HC, acetic acid HC otic 1 YesZetonna 3 PA

aero otic HC 1 Yesaurodex otic 1 Yes

benzotic, benzocaine/antipyrine 1 Yescortane B otic drops 1 Yes

flunisolide 1 Yesofloxacin otic 1 Yes

oticin otic 1 Yes



31

7. DIABETES, THYROID, STEROIDS, & OTHER MISCELLANEOUS HORMONES


TierGeneric

AvailableAdditional

RequirementsActos 3 pioglitazone 1 Yes

Afrezza 3 PAAmaryl 3 glimepiride 1 Yes

Androderm patch 3 PA

Androgel 1% 3 testosterone 1% 1 Yes PAAndrogel

1.62% Packet, Pump

2 PA

Apidra Solostar 3 PAAxiron 3 PA

Basaglar 3 PABd Insulin

Syringe Micro- Fine

2 QL

Breeze 2 Test Strips 2 QL

Bydureon 2Byetta 2

Contour Next Test Strips 2 QL

Contour Test Strips 2 QL

Cortef 3 hydrocortisone 1 YesCytomel 3 liothyronine 1 YesDDAVP 3 desmopressin acetate 1 Yes

Decadron 3 dexamethasone 1 YesDiabeta 3 glyburide 1 YesDuetact 3 pioglitazone/glimepiride 1 YesFarxiga 3 PA

First Testosterone 3 PA

Fortamet 3 metformin ER 1 Yes PAFortesta 3 testosterone 1 Yes PAFreestyle InsuLinx

Test Strips2 QL

Freestyle Lite Test Strips 2 QL

Freestyle Test Strips 2 QL

Genotropin 3 PA



32



TierGeneric

AvailableAdditional

RequirementsGlucophage 3 metformin 1 Yes

Glucophage XR 3 metformin ER 1 YesGlucotrol 3 glipizide 1 Yes

Glucotrol XL 3 glipizide ER 1 YesGlucovance 3 metformin/glyburide 1 Yes

Glumetza ER tablet 3 metformin hcl er 3 Yes PA

Glynase 3 glyburide micronized 1 YesGlyset 3 miglitol 1 Yes

Glyxambi 3Hectorol 3 doxercalciferol 1 YesHumalog 3 PA

Humatrope 3 PAHumulin 3 PAIncrelex 3 PA, LDD

Invokamet 2Invokana 2Janumet 2 PA

Janumet XR 2 PAJanuvia 2 PA

Jardiance 2Jentadueto

tablet 3 PA

Jentadueto XR 3 PAKazano tablet 3 alogliptin benz/metformin hcl 1 Yes PAKeynote Strips 3 QL, PA

Kombiglyze XR 2 PA

Korlym tablet 3 PALantus 2

Levemir 2Levoxyl,

Synthroid, Unithroid

3 levothyroxine 1 Yes

Medrol 3 methylprednisolone 1 YesMicronase 3 glyburide 1 YesMyalept 3 PANatesto 3 PANatpara 3 PA

Nesina tablet 3 alogliptin benzoate 1 Yes PANorditropin 2 PA



33



TierGeneric

AvailableAdditional

RequirementsNovolin 2Novolog 2

Novolog mix 2Nutropin AQ 2 PA

Onglyza 2 PAOseni 3 alogliptin benz/pioglitazone 1 Yes PA

Oxandrin 3 oxandrolone 1 YesPediapred, Orapred,

Orapred ODT3 prednisolone sodium phosphate 1 Yes

Prandimet 3 repaglinide-metformin 1 YesPrandin 3 repaglinide 1 Yes

Precision XTRA Test

Strips2 QL

Precose 3 acarbose 1 YesPrelone 3 prednisolone syrup 1 YesRayos 3 PA

Rocaltrol capsules 3 calcitriol capsules 1 Yes

Saizen 3 PASensipar 2Serostim 3 PA, LDDSignifor 3 PAStarlix 3 nateglinide 1 Yes

Striant buccal system 3 PA

Symlin 2 PASynjardy 2Tanzeum 3 PATapazole 3 methimazole 1 Yes

Testim Gel 3 testosterone 1 Yes PAToujeo Solostar 2Tradjenta tablet 3 PA

Tresiba 2Trulicity 3 PAVictoza 2Vogelxo 3 testosterone 1 Yes PA

Xigduo XR 3 PAZemplar 3 paricalcitol 1 Yes

Zomacton 3 PA



34



TierGeneric

AvailableAdditional

Requirementsdanazol 1 Yes

fludrocortisone acetate 1 Yespropylthiouracil 1 Yes

tolbutamide 1 Yes



35

8. STOMACH, ULCER, & BOWEL MEDS


TierGeneric

AvailableAdditional

RequirementsAciphex 3 rabeprazole 1 Yes QL, PAAciphex Sprinkle 3 QL, PA

Actigall 3 ursodiol 1 YesAmitiza 3 PA

Anusol-HC Cream 3 hydrocortisone cream 1 Yes

Asacol HD 3 mesalamine dr 800 mg 1 YesAzulfidine 3 sulfasalazine 1 Yes

Bentyl 3 dicyclomine 1 YesCanasa supp 2Carafate susp 2Carafate tabs 3 sucralfate tabs 1 Yes

Cholbam 3 PAColazal 3 balsalazide 1 YesColocort 3 hydrocortisone retention enema 1 Yes

Compazine suppository 3 prochlorperazine suppository 1 Yes

Creon 2Cytotec 3 misoprostol 1 YesDelzicol 2Dexilant 3 QL, PADiclegis 3 PADuexis 3 PAEmend 3 QL

Entocort EC 3 budesonide 1 YesEsomeprazole

Strontium 3 QL, PA

Gastrocrom 3 cromolyn sodium solution 1 YesLialda 2Linzess 2Lomotil 3 diphenoxylate HCl/atropine 1 YesMarinol 3 dronabinol 1 Yes

Metozolv ODT 3 metoclopramide odt 1 YesMovantik 2Nexium 3 esomeprazole 1 Yes QL, PANulytely 3 PEG 3350 & electrolytes 1 Yes QLPentasa 2

Pepcid tabs, suspension 3 famotidine 40 mg tab, suspension 1 Yes

Phenergan 3 promethazine 1 YesPA = Prior authorization must be requested by the physician.LDD = Limited Distribution Drug at Briova


36

8. STOMACH, ULCER, & BOWEL MEDS


TierGeneric

AvailableAdditional

RequirementsPrevacid, Prevacid SoluTab

3 lansoprazole tabs, ODT 1 Yes QL, PA

Prilosec caps 3 omeprazole 1 Yes QL, PAPrilosec

suspension 3 omeprazole suspension 1 Yes QL, PA

Protonix 3 pantoprazole 1 Yes QL, PAReglan 3 metoclopramide 1 YesRelistor 3 PARowasa 3 mesalamine rectal susp 1 YesTagamet 3 cimetidine 1 Yes

Tigan 3 trimethobenzamide 1 YesViberzi 3 PAVimovo 3 PAZantac 3 ranitidine 300 mg 1 YesZegerid 3 omeprazole-sodium bicarbonate 3 Yes QL, PA

Zegerid packet 3 omeprazole-sodium bicarbonate packet 3 Yes QL, PA

Zenpep 2Zofran 3 ondansetron HCl 1 Yes

chlordiazepoxide/clidinium 1 Yesgranisetron 1 Yes

lactulose soln 1 Yesnizatidine solution 1 Yes

pancrelipase EC/SA 1 YesPEG 3350 & electrolytes 1 Yes QL

prochlorperazine tabs 1 Yes



37

9. BONE, JOINT, & MUSCLE


TierGeneric

AvailableAdditional

RequirementsActemra SC 3 QL, PA

Actonel 3 risedronate 1 Yes QLAmrix 3 PA

Anaprox 3 naproxen sodium 1 YesAnaprox DS 3 naproxen sodium 1 Yes PA

Ansaid 3 flurbiprofen 1 YesArava 3 leflunomide 1 Yes

Arthrotec 3 diclofenac/misoprostol 1 Yes PAAtelvia 3 risedronate dr 1 Yes QLBinosto 3 QLBoniva 3 ibandronate 1 Yes QL

Cataflam 3 diclofenac potassium 1 YesCelebrex 3 celecoxib 1 Yes PACimzia 2 PAColcrys 3 colchicine 1 Yes PA

Cuprimine 3 PADantrium 3 dantrolene 1 YesDaypro 3 oxaprozin 1 Yes PA

EC-Naprosyn 3 naproxen sodium 1 Yes PAEnbrel 3 PAEvista 3 raloxifene hcl 1 Yes

Feldene 3 piroxicam 1 YesFexmid 3 cyclobenzaprine 1 Yes

Flector Patch 3 QL, PAFosamax 3 alendronate 1 Yes QL

Fosamax Plus D 3 QLHumira 2 PA, LDDKineret 3 PALorzone 3 PALotronex 3 alosetron hcl 1 Yes

Miacalcin 3 calcitonin-salmon (rDNA origin) nasal spray 1 Yes

Mitigare 3 colchicine 1 Yes PAMobic 3 meloxicam 1 Yes PANalfon 3 fenoprofen calcium 1 Yes

Naprelan 3 naproxen sodium CR 3 Yes PANaprosyn 3 naproxen sodium 1 Yes PAOrencia 3 PAOtezla 3 PA

Otrexup 3 PA



38

9. BONE, JOINT, & MUSCLE


TierGeneric

AvailableAdditional

RequirementsParafon Forte 3 chlorzoxazone 1 Yes

Pennsaid 3 diclofenac sodium 3 Yes PARasuvo 3 PARobaxin 3 methocarbamol 1 YesSimponi 2 PA, LDDSkelaxin 3 metaxalone 3 Yes PASolaraze 3 diclofenac 1 Yes PA

Soma 3 carisoprodol 1 Yes PAStelara 2 PAUloric 3 PAViibryd 3 PA

Voltaren Gel 3 diclofenac sodium 1 YesVoltaren XR 3 diclofenac sodium ER 1 Yes PA

Xeljanz 3 PAZanaflex 3 tizanidine 1 Yes PAZipsor 3 QL, PA

Zurampic 200 mg 3 PA

Zyloprim 3 allopurinol 1 Yesbaclofen 1 Yes

colchicine/probenecid 1 Yescyclobenzaprine 1 Yes

diflunisal 1 Yesetidronate disodium 1 Yes

etodolac 1 Yesibuprofen 1 Yes

indomethacin 1 Yesindomethacin SR 1 Yes

ketoprofen 1 Yesketoprofen SR 1 Yes

ketorolac 1 Yesmeclofenamate 1 Yes

nabumetone 1 Yesnaproxen sodium SA 1 Yes

orphenadrine ER 1 Yesprobenecid 1 Yes

sulindac 1 Yestolmetin 1 Yes



39

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.


TierGeneric

AvailableAdditional

RequirementsAddyi 3 PA

Aygestin 3 norethindrone acetate 1 YesBeyaz 3 drospire/eth/estra/levomefol 1 Yes PA

Bravelle 2 QLCenestin 2

Cleocin vaginal 3 clindamycin cream 1 YesClimara patch 3 estradiol transdermal 1 YesDepo SubqQ

Provera 3 QL

Depo-Provera 3 medroxyprogesterone QLDesogen 3 apri 1 YesDiflucan 3 fluconazole 150 mg 1 YesEstrace 3 estradiol 1 YesEstring 2

Estrostep FE 3 norethindrone acetate/ethinyl estradiol/ferrous fumarate 1 Yes

Evista 3 raloxifene 1 YesFemcon FE 3 ethinyl estradiol/norethindrone 1 YesFemHRT 3 norethindrone ethinyl estradiol 1 Yes

Follistim AQ 2 QLGeneress FE 3 noreth-ethinyl estradiol/iron 1 YesLoseasonique 3 amethia lo/camrese lo 1 Yes

Lo Loestrin FE 2Menopur 2Metrogel vaginal 3 metronidazole vaginal gel 1 Yes

Minastrin 24 FE 3 PA

Natazia 2Nuvaring 2 QL

Ogen 3 estropipate 1 YesOrtho All-flex

diaphragm 3 QL

Ortho Evra 3 Xulane 1 Yes QLOrtho Micronor/

Nor QD 3 camila 1 Yes

Ortho Novum 3 necon/cyclafem/alyacen 1 YesOrtho Tri- Cyclen Lo 3 tri-lo-sprintec 1 Yes



40

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.


TierGeneric

AvailableAdditional

RequirementsPlan B One-Step 3 levonorgestrel/my way/next dose 1 Yes QL

Premarin 2Premarin

vaginal cream 2

Premphase 2Prempro 2

Prometrium 3 progesterone, micronized 1 YesProvera 3 medroxyprogesterone acetate 1 YesSafyral 3 PA

Seasonique 3 amethia 1 YesSerophene 3 clomiphene citrate 1 YesTerazol 3 3 terconazole cream 1 Yes

Tri-norinyl 3 aranelle 1 YesVagifem 3 yuvafem 1 Yes

Vandazole 3 metronidazole 1 YesVivelle Dot 3 estradiol 1 Yes

Yasmin 3 ethinyl estradiol/drospirenone 1 Yes

YAZ 3 Gianvi, ethinyl estradiol/ drospirenone 1 Yes

altavera/portia/levora 28/chateal/ marlissa/kurvelo 1 Yes

amethyst 1 Yesaviane 1 Yes

desogestrel/ethinyl estradiol 1 Yeslevonorgestrel/ethinyl estradiol 1 Yes

lomedia 24 Fe 1 Yesnorethindrone 1 Yes

norethindrone/ethinyl estradiol 1 Yesnorethindrone/ethinyl estradiol,

Fe 1 Yes

norethindrone/mestranol 1 Yesnorgestimate/ethinyl estradiol 1 Yes

norgestrel/ethinyl estradiol 1 Yes



41

11. EYE MEDICATIONS


TierGeneric

AvailableAdditional

RequirementsAcular/Acular LS 3 ketorolac opth soln 1 Yes

Alcaine 3 proparacaine 1 YesAlphagan P 3 brimonidine tartrate 1 Yes

Alrex 2Azopt 2

Besivance 2Betagan 3 levobunolol 1 YesBetimol 2

Betoptic S 2Bleph 10 3 sulfacetamide 1 Yes

Blephamide S.O.P. ointment 2

Ciloxan Sol. 3 ciprofloxacin 1 YesCosopt 3 dorzolamide-timolol 1 Yes

Cyclogyl 3 cyclopentolate HCl 1 YesDiamox Sequels 3 acetazolamide ER 1 Yes

Elestat 3 epinastine HCl 1 YesFml 3 fluorometholone 1 Yes

Gentak 3 gentamicin ophth 1 YesIopidine 3 apraclonidine 1 Yes

Isopto Atropine 3 atropine sulfate 1 YesIsopto

Carbachol 3% 3 carbachol 3% 1 Yes

Isopto Carpine 3 pilocarpine 1 YesIstalol Drops 2

Lotemax 2Lumigan 2

Maxitrol 3 neomycin/polymyxin B/ dexamethasone 1 Yes

Mydriacyl 3 tropicamide 1 YesNeosporin soln 3 polymyxin B/neo/gramicidin 1 Yes

Ocufen 3 flurbiprofen 1 YesOcuflox 3 ofloxacin 1 Yes

Omnipred 3 prednisolone 1 YesOptivar 3 azelastine HCL drops 1 YesPatanol 3 olopatadine hcl 1 Yes

Phospholine Iodide 2

Pilopine HS gel 2Polysporin 3 bacitracin/polymyxin B ophth oint 1 Yes



42

11. EYE MEDICATIONS


TierGeneric

AvailableAdditional

RequirementsPolytrim 3 trimethoprim sulfate/polymyxin B 1 Yes

Pred-Forte 3 prednisolone acetate 1 YesRescula 3 PARestasis 2 QLTimoptic 3 timolol ophth 1 Yes

Timoptic XE 3 timolol XE 1 YesTobradex 3 tobramycin-dexamethasone 1 YesTobrex 3 tobramycin 1 Yes

Travatan Z 2Trusopt 3 dorzolamide HCl 2% 1 Yes

Vasocidin oint 3 prednisolone/sodium sulfacetamide 1 Yes

Vexol 2Vigamox 2Viroptic 3 trifluridine 1 YesVoltaren 3 diclofenac sodium 1 YesXalatan 3 latanoprost 1 YesXiidra 3 PA

Zioptan 3 PAZymaxid 3 gatifloxacin 1 Yes

acetazolamide 1 Yesbacitracin ophth 1 Yes

betaxolol 1 Yesbimatoprost 1 Yes

carteolol 1 Yescromolyn ophth 1 Yes

dexamethasone ophth 1 Yeserythromycin 1 Yes

methazolamide 1 Yespolymyxin B/neo/bacitracin 1 Yes

prednisolone sodium phosphate 1 Yes



43

12. ALLERGY, COUGH & COLD, LUNG MEDS


TierGeneric

AvailableAdditional

RequirementsAccolate 3 zafirlukast 1 YesAdcirca 3 PA

AdrenaClick 3 PAAdvair Diskus 3 PAAdvair HFA 3 PA

Aerospan 3 PAAlvesco 3 PA

Anoro Ellipta 3 PAArnuity Ellipta 3 PA

Asmanex 2Astelin Nasal

Spray 3 azelastine nasal spray 1 Yes

Atrovent HFA 2Bevespi

aerosphere 3 PA

Breo Ellipta 3 PABromfed DM 1

Cheratussin AC 1Cheratussin DAC 1

Clarinex 3 desloratadine 1 YesCombivent Respimat 2

Dulera 2Duoneb 3 ipratropium-albuterol 1 Yes

Elixophyllin Elixir 3 theophylline elixir 1 Yes

EpiPen 2EpiPen Jr. 2

Esbriet 3 PA, LDDFlovent Diskus 3 PAFlovent HFA 3 PA

Grastek 3 PAGuiatuss AC 3 guaifenesin/codeine 1 YesHycofenix 3 QLHydromet 1

Iophen C-NR 1Kitabis Pak 3 tobramycin/nebulizer 1 Yes LDD

Obredon 3 QLOfev 3 PA

Oralair 3 PA, LDD



44



TierGeneric

AvailableAdditional

RequirementsProair HFA 2

Proair RespiClick 2

Proventil HFA 3 PAPulmicort Flexhaler 3 PA

Pulmicort Respules 3 budesonide 1 Yes

Pulmozyme 2Qvar 2

Ragwitek 3 PASerevent Diskus 2

Singulair 3 montelukast sodium 1 YesSpiriva 2Stiolto

Respimat 3 PA

Symbicort 2Tessalon Perles 3 benzonatate 1 Yes

Theo-24 2Theochron 1 theophylline extended release 1 Yes

Thiola 3 PATracleer 2 PA

Tussionex 3 hydrocodone-chlorpheniramine susp 1 Yes QLTuzistra XR 3 QL

Utibron Neohaler 3 PA

Ventolin HFA 3 PAVistaril 3 hydroxyzine pamoate 1 YesVituz 3 QL

VoSpire ER 3 albuterol sulfate er 1 YesXopenex 3 levalbuterol 1 Yes

Xopenex HFA 3 levalbuterol aer 1 Yes PAXyzal 3 levocetirizine dihydrochloride 1 Yes

Zutripro 3 hydrocod-cpm-pseudoephedrine 1 Yes QLacetylcysteine 1 Yes

albuterol sulfate soln, syrup, tab 1 Yesaminophylline tabs 1 Yes

carbinoxamine 1 Yesclemastine 1 Yes

cromolyn inhalation soln 1 YesPA = Prior authorization must be requested by the physician.LDD = Limited Distribution Drug at Briova


45



TierGeneric

AvailableAdditional

Requirementscyproheptadine 1 Yes

flunisolide 1 Yesguaifenesin/hydrocodone 1 Yes

guaifenesin/pseudoephedrine/ codeine 1 Yes

hydrocodone/homatropine syrup 1 Yeshydroxyzine HCl 1 Yes

ipratropium inhalation soln 1 Yesmetaproterenol tabs, syrup, inh

soln 1 Yes

phenylephrine/cpm/hydrocodone 1 Yespromethazine 1 Yes

promethazine/codeine 1 Yes QLpromethazine/dextromethorphan 1 Yes

promethazine/phenylephrine 1 Yespromethazine/phenylephrine/

codeine 1 Yes

pseudoephedrine/ chlorpheniramine/codeine 1 Yes

terbutaline sulfate tabs 1 Yes



46

13. URINARY & PROSTATE MEDS


TierGeneric

AvailableAdditional

RequirementsAvodart 3 dutasteride 1 YesCardura 3 doxazosin mesylate 1 Yes

Caverject 2 QL, PACialis 2 QL, PADetrol 3 tolterodine tartrate 1 Yes

Detrol LA 3 tolterodine tartrate LA 1 YesDitropan 3 oxybutynin 1 Yes

Ditropan XL 3 oxybutynin ER 1 YesEdex 3 QL, PA

Elmiron 3 PAEnablex 3 darifenacin er 1 YesFlomax 3 tamsulosin 1 YesJalyn 3 dutasteride/tamsulosin hcl 1 Yes

Levitra 3 QL, PAMuse 2 QL, PA

Myrbetriq 2Proscar 3 finasteride 1 YesRapaflo 2

Sanctura XR 3 trospium chloride 1 YesStaxyn 3 QL, PAStendra 3 QL, PA

Urecholine 3 bethanechol 1 YesUrocit-K 3 potassium citrate 1 YesUroxatral 3 alfuzosin 1 YesVESIcare 2

Viagra 2 QL, PAflavoxate 1 Yesterazosin 1 Yes



47

14. VITAMINS & ELECTROLYTES


TierGeneric

AvailableAdditional

RequirementsCalciferol 3 ergocalciferol 1 Yes

Icar 3 iron, carbonyl 15 mg 1 YesK-Tab 3 potassium chloride 1 Yes

Klor-Con 1 potassium chloride 1 YesMephyton 2Nascobal 3 PA

Tri-Vi-Flor, Poly-Vi-Flor

with and without iron

3 multivitamin with fluoride drops, tabs 1 Yes

fluoride 1 Yespotassium bicarbonate/potassium

citrate effervescent 1 Yes

sodium fluoride drops 1 Yes



48PA = Prior authorization must be requested by the physician.


15. DIAGNOSTICS & MISCELLANEOUS AGENTS


TierGeneric

AvailableAdditional

RequirementsCerdelga 3 PA, LDDChemet 2

Ferriprox 100 mg/ml

solution3 PA

Idelvion 3 PAJadenu 3 PA, LDD

Keveyis 3 PANovarel 3 chorionic gonadotropin 1 YesOcaliva 3 PAPhosLo 3 calcium acetate 1 YesPregnyl 3 chorionic gonadotropin 1 Yes

Proamatine 3 midodrine HCl 1 YesRenvela 3 sevelamer carbonate 1 Yes

Repronex 3 QLStrensiq 3 PASyprine 3 PAXuriden 3 PAZavesca 2 PA

49

PROCEDURES THAT SUPPORT SAFE PRESCRIBING

AmeriHealth utilizes an independent pharmacy benefits management (PBM) company, FutureScripts, to manage the administration of its 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. AmeriHealth 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 approved 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 evaluation may include a review of potential drug-drug interactions or contraindications, appropriate dosing and length of therapy, and utilization of other drug therapies, if necessary.

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.

50

AbilifyAbsorica™Abstral®

Acanya®

Aciphex®

Actemra® SCActiclate™Actiq®

Aczone®

Adasuve®

Adcirca™Adderall®

Addyi®

Adempas®

Adipex-P®

Adoxa®

Adrenaclick®

Advair®

Advate®

Adynovate®

Adzenys™ XR-ODTAerospan™Afinitor®

Afrezza®

Afstyla® Alecensa®

Alodox®

Alphanate®

Alphanine® SDAlprolix™Alsuma®

Altabax™Alvesco®

Ambien®

Ambien CR®

Amerge®

Amitiza® Ampyra™Amturnide™Anaprox® DSAndroderm®

Androgel®

Anoro™Ellipta™Apidra®

Apidra® SoloSTAR®

armodafinil Arnuity Ellipta®

Arthrotec®

Atacand® (HCT)Ativan®

Atralin®

Aubagio®

Auvi-Q®

Avapro®/Avalide®

Avidoxy™Avinza® 120mgAvita®

Axert®

Axiron®

Azelex®

Basaglar®

Bebulin®

Beconase AQ®

Belbuca™ 300mcg, 450mcg, 600mcg, 750mcg, 900mcg

Belsomra®

Belviq®

BeneFIX®

Benzaclin®

Benzamycin®

Benzamycinpak®

Bevespi aerosphere™ Beyaz® Bosulif ®

brand prenatal vitaminsBreo™ Ellipta™Brintellix®

Briviact® Bunavail™buprenorphinebuprenorphine/naloxoneButrans™ 15mcg/hr and

20mcg/hr patch Cabometyx™Capex®

Caprelsa®

Carac® Carbaglu®

Caverject®

Cayston™Celebrex®

Cerdelga™Cholbam® Cialis®

Ciclodan®

Cimzia®

Cleocin T®

Clindagel®

Clobex®

Cloderm®

Coagadex® Colcrys®

Cometriq™Concerta®

Contrave ER®

Conzip™Cordran® Corifact®

Corlanor®

Cosentyx™Cotellic™ Cozaar®/Hyzaar®

Cresemba®

Crestor® Cuprimine®

Cutivate®

Cystaran™Daklinza™ Daypro®

Daytrana™Dermasorb™ HC, TADesonate®

Desowen®

Desoxyn®

Dexedrine®

Dexilant™Diabetic test strips*Dibenzyline®

Diclegis®

diclofenac gelDifferin® Cream/GelDilaudid® 4mg, 8mgDiovan® (HCT)Dolophine®

Doral®

Doryx® DRDuac®

Duexis® Duragesic® 25mcg, 50mcg, 75mcg, 100mcgDurlaza®

Dymista®

EC-Naprosyn® Ecoza™Edarbi™Edarbyclor™Edex®

Edluar™Effexor XR® Elmiron® Eloctate™Embeda®

Enbrel®

Enstilar® 0.005-.064 foam Entresto™Epclusa®

Ertaczo®

Erivedge™

Esbriet®

esomeprazoleeszopiclone 3mgEvekeo™Evoclin® foamEvzio™Exalgo™Exelderm® Exforge® (HCT)Exjade®

Extavia®

Extina® Factive®

Fanapt™Farxiga™Farydak®

Feiba®

fentanyl citrate-OTFCfentanyl transdermal 25mcg, 37.5mcg, 50mcg, 62.5mcg,

75mcg, 87.5mcg, 100mcg

Fentora®

Ferriprox®

Fetzima™Firazyr®

First Testosterone®

Flector® patchFlonase®

Flovent®

Focalin® XR 5mg, 10mg, 15mg, 20mg, 30mg, 40mg

Fortamet® Forteo™Fortesta™Frova®

Fulyzaq™Gattex®

Genotropin®

Gilenya®

Gilotrif ™Gleevec®

Glumetza™Gralise™Grastek®

Halcion®

Halog® Harvoni™Helixate® FSHemofil® MHetlioz™

Prior authorization applies to all formulations of specific drugs, including but not limited to, tablet, capsule, and oral suspension.*

51

Horizant™Humalog®

Humate-P®

Humatrope®

Humira®

Humulin®

HYCAMTIN® capsuleshydromorphone 4mg, 8mghydromorphone ERHysingla™Ibrance®

Iclusig™Idelvion® imatinib mesylateImbruvica™Imitrex®

Impavido® Increlex®

Inderal® LAInlynta®

Intermezzo®

1.75mg, 3.5mgIntuniv™Invega™Ixinity® Jadenu™Jakafi™Janumet®

Janumet XR®

Januvia®

Jentadueto™Jublia®

Juxtapid™Kadian® 50mg, 60mg,

80mg,100mg, 200mgKalydeco™Kapvay®

Kazano®

Kenalog™ Keppra®

Kerydin™Keveyis™Khedezla®

Kineret®

Koate®-DVIKogenate® FSKombiglyze® XR Korlym™Kynamro®

Lamictal® (ODT)Latuda®

Lazanda®

Lenvima™Letairis®

Levitra®

Lexapro®

Lidoderm® linezolidLipitor®

Livalo®

Locoid® lipocreamLonsurf ®

Loprox® Lorzone®

Lunesta®

Luxiq®

Luzu®

Lynparza™Lyrica®

Maxalt® (MLT)Mekinist®

Metadate® CDmetformin er methadoneMicardis® (HCT)Migranal®

Minastrin® FE Minocin®

Mitigare® Mobic®

modafinilmometasone furoate Monoclate-P®

Monodox®

Mononine®

morphine sulfate 30mg IRmorphine sulfate ER 50mg, 60mg, 80mg,

90mg, 100mg,120mg, 200mg

MS Contin® 60mg, 100mg, 200mgMUSE®

Myalept™Naprelan®

Naprosyn®

Narcan® 4mg/actuation spray

Nascobal® Nasonex®

Natesto™Natpara®

Nesina®

Nexavar®

Nexium®

Ninlaro® Norditropin®

Northera™Novoeight®

Novoseven® RTNoxafil®

Nucynta® 100mg

Nucynta ER® 150mg, 200mg, 250mgNuedexta™Nuplazid™ Nutropin® (AQ)Nuvigil®

Nuwiq® ObizurOcaliva™ Odomzo®

Ofev®

Olux®[E] Olysio™omeprazole/sodium

bicarbonate Omnaris®

Omnitrope®

Onexton™Onglyza® Onmel™Onzetra Xsail™ Opana® 10mgOpana ER® 20mg,

30mg, 40mgOpsumit®

Oracea®

Oralair®

Orencia® SQOrenitram™Orkambi™ Oseni®

Otezla™Otrexup™Oxaydo™Oxistat® oxycodone ER 30mg, 40mg, 60mg, 80mgoxycodone IR 30mgOxycontin 30mg, 40mg, 60mg, 80mgoxymorphone 10mgPandel® Penlac®

Pennsaid®

Percocet®

Picato®

Pomalyst®

Praluent®

Prevacid®

Prilosec®

Pristiq™ Procysbi®

Profilnine®

Protonix®

Proventil® HFAProvigil®

Prozac®

Psorcon® Pulmicort Flexhaler® Qnasl™Qualaquin®

Quillichew ER™ 20mg, 30mg, 40mg

quinine sulfateQysmia™Ragwitek™Rasuvo™Ravicti™Rayos® Rebetol®

Rebif ®

Recombinate™Regimex®

ReliOn®

Relistor® Relpax® Repatha™ Rescula®

Restoril®

Retin-A® (Micro)Revatio™Revlimid®

Rexulti® Rhinocort Aqua®

Riastap® Ritalin® LA 20mg,

30mg, 40mg Rixubis™Roxicodone 30mgSafyral® Saizen®

Samsca™Saphris®

Saxenda®

Sernivo™ Serostim®

Signifor®

sildenafilSilenor®

Simponi™Sirturo™Sivextro™Skelaxin®

Solaraze® GelSolodyn®

Sonata®

Sovaldi™Sprycel®

Staxyn™Stelara® Stendra™Stiolto Respimat™

52

*All brand prenatal vitamins require prior authorization* All diabetic test strips require prior authorization except for the following: Breeze® 2, Contour®,

Contour® Next, Freestyle®, Freestyle InsuLinx®, Freestyle Lite®, and Precision XTRA®

* Compound products with total cost equal to or greater than $75 per prescription

Stivarga®

Strensiq™ Striant®

Subsys®

Sumavel™Suprenza ODT™Sutent®

Sylatron™Symlin®

Synalar® Syprine® Taclonex®

Taclonex Scalp®

SuspensionTafinlar®

Tagrisso™ Taltz Autoinjector® Tamiflu® Tanzeum™Tarceva®

Targadox™Targretin® GelTasigna®

Technivie™ Tekamlo™Tekturna® (HCT)Temodar® OraltemozolomideTenoretic®

Tenormin®

Testim®

testosterone gelTeveten® (HCT)Thalomid®

Thiola®

Topicort® Toviaz™Tracleer® Tradjenta™Tretten®

Treximet™Twynsta®

Tykerb®

Tyvaso®

Uloric®

Ultravate® Uptravi®

Utibron™ Neohaler Valchlor™Valium®

Valtrex™Vanos™Vecamyl™Veltin™Venclexta® Ventavis®

Ventolin® HFAVeramyst™Viagra®

Viberzi™

Vibramycin®

Viekira Pak™Viibryd®

Vimovo®

Vogelxo®

Voltaren-XR®

Vonvendi Votrient™Vraylar™ Vusion® Wellbutrin® XLWilate®

Xalkori®

Xanax®

Xartemis® XR Xeljanz®

Xenazine™Xenical®

Xifaxan® Xigduo XR™Xiidra™Xolegel®

Xopenex HFA®

Xtampza™ ER Xtandi®

Xuriden™ Xyntha®

Xyrem®

Yosprala™ Zavesca®

Zecuity®

Zegerid®

Zelboraf ®

Zembrace Symtouch™ Zepatier™ Zetonna™Ziana®

Zinbryta™ Zioptan™Zipsor™Zmax™Zohydro™ ERZolinza®

Zoloft® Zolpidem 10mgZolpidem CR 12.5mgZolpidem SL 3.5mgZolpimist™Zomacton™ Zomig® (ZMT)Zorbtive™Zubsolv®

Zurampic®

Zydelig®

Zykadia™Zytiga™Zyvox®

53

Age limits The 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 5 and older, such as zafirlukast. 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 limit, call FutureScripts at the number on the back of your ID card or see the plan website at https://www.amerihealthnj.com/html/members/index.html.

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.

• Quantity Over Time: This quantity limit is based on dosing guidelines over a rolling time period. For example, if a drug has a quantity limit over a 30-day time period and a member went to the pharmacy on January 1, 2017, for one of these medications, the computer system would have looked back 30 days to December 2, 2016, to see how much medication was dispensed. The purpose of these limits is to help keep excessive quantities from being dispensed. Examples of quantity limits over time are

◦ Nuvaring® = 1 ring per 28 days

◦ Ibandronate 150mg (Boniva®) 150mg = 1 tablet per 30 day ◦ Amerge® (nine 2.5mg tablets per 30 days), Imitrex® (eighteen 50mg tablets per 30 days), Maxalt®

(twelve 10mg tablets per 30 days), Migranal® (eight 4mg nasal spray units per 30 days), and Zomig® (nine 5mg tablets per 30 days);

◦ Diabetic supplies such as blood glucose test strips (#200 strips per 30 days) and lancets (#200 lancets per 30 days)

• Maximum daily dose: This quantity limit is based on maximum number of units of the drug allowed per day. For example, if a member went to a pharmacy for one of these medications, the computer system will ensure that the amount of medication being requested per day does not exceed the maximum daily dose. Examples of maximum daily dose quantity limits are:

◦ sedative hypnotic drugs, such as Sonata® (1 capsule per day) and Ambien® (1 tablet per day) ◦ oral narcotic drugs, such as OxyContin® (3 tablets per day), Percocet® (6 tablets per day), and

Percodan® (6 tablets per day). ◦ proton pump inhibitor drugs, such as Nexium® (1 capsule per day) and Protonix (1 tablet per day)

• Refill too soon: This limit is in place to encourage appropriate utilization and minimize stockpiling of prescription medications. Based on this edit, a member is able to receive a refill of a prescription after 75% utilization. However, if the same prescription is refilled every month at the 75% utilization point, an excess supply will be accumulated. The plan will “look back” over a period of 180 days and calculate the total day supply that has been dispensed.

• Therapeutic drug class: This limit is a day supply limit that applies to some classes of drugs, such as narcotics (i.e., short-acting and long-acting products). If a member uses more than one drug within the

54

same class, he or she may be unsafely duplicating drugs and would be affected by the total day supply limit 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.

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 as requested after the expiration date, a new request for a prior authorization needs 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 or requires prior authorization, call FutureScripts at the phone number on the back of your ID card or see the plan website at https://www.amerihealthnj.com/html/members/index.html.

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 either no out-of-pocket co-pay or the appropriate percentage cost-sharing as defined by the member’s benefit.

2. 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 request will either be approved or denied.

4. If approved, the remainder of the prescription may 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 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.

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.

55

• 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.

Exceptions for non-preferred drugs (specific to Select Drug Program members only) Providers may request consideration for preferred coverage of a covered non-preferred medication when all formulary alternatives have been exhausted or there are contraindications to using the formulary alternatives. The provider should complete the non-preferred request form, providing detail to support the exception for the non-preferred medication, and fax the request to 1-888-671-5285. If the non-preferred exception request is approved, the drug will be paid at the appropriate preferred 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 or not, the member may always obtain benefits for the covered non-preferred drug at the appropriate non-preferred level of cost-sharing. Out-of-pocket expenses for non-preferred drugs are higher than for preferred 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 and the member must provide consent.

4/17AHNJ

AmeriHealth Select Drug Program Formulary offered by: AmeriHealth HMO, Inc.

AmeriHealth Insurance Company of New Jersey

www.amerihealthnj.com

e a 1, 2017 guide ahnj 4.1.17... · after 12 weeks of gestation in women who are at high risk for...

Documents