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FEP 5 Tier Managed Rx Drug Formulary (807) Basic Option

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FEP 5 Tier Managed Rx Drug Formulary (807) Basic Option FEP 5 Tier Managed Rx Drug Formulary (807) Basic Option Effective July 1, 2021 The FEP formulary includes the preferred drug list which is comprised of Tier 1, generics and Tier 2, preferred brand-name drugs. Also included in the formulary are Tier 3, non-preferred brand-name drugs, Tier 4, preferred specialty drugs and Tier 5, non-preferred specialty drugs. Ask your physician if there is a generic drug available to treat your condition. If there is no generic drug available, ask your physician to prescribe a preferred brand-name drug. The preferred brand-name drugs within our formulary are listed to identify medicines that are clinically appropriate and cost-effective. Click on the category name in the Table of Contents below to go directly to that page INTRODUCTION ........................................................................................................................................................................................................................ 5 PREFACE ................................................................................................................................................................................................................................... 5 MANAGED NOT COVERED DRUGS ........................................................................................................................................................................................ 6 PRIOR APPROVAL ................................................................................................................................................................................................................... 6 QUANTITY LIMITATIONS ......................................................................................................................................................................................................... 6 PHARMACY AND MEDICAL POLICY COMMITTEE ................................................................................................................................................................ 6 PRODUCT SELECTION CRITERIA .......................................................................................................................................................................................... 6 FORMULARY PRODUCT DESCRIPTIONS .............................................................................................................................................................................. 7 GENERIC SUBSTITUTION ........................................................................................................................................................................................................ 7 DRUG EFFICACY STUDY IMPLEMENTATION DRUGS ......................................................................................................................................................... 8 EDITOR ...................................................................................................................................................................................................................................... 8 NOTICE ...................................................................................................................................................................................................................................... 8 LEGEND ..................................................................................................................................................................................................................................... 8 ANALGESICS .......................................................................................................................................................................................................................... 10 ANALGESICS, OTHER .................................................................................................................................................................................................. 10 NSAIDs ........................................................................................................................................................................................................................... 10 NSAIDs, COMBINATIONS ............................................................................................................................................................................................. 10 NSAIDs, TOPICAL ......................................................................................................................................................................................................... 10 COX-2 INHIBITORS ....................................................................................................................................................................................................... 10 GOUT ............................................................................................................................................................................................................................. 10 OPIOID ANALGESICS ................................................................................................................................................................................................... 10 NON-OPIOID ANALGESICS ......................................................................................................................................................................................... 11 VISCOSUPPLEMENTS ................................................................................................................................................................................................. 11 ANTI-INFECTIVES ................................................................................................................................................................................................................... 12 ANTIBACTERIALS ......................................................................................................................................................................................................... 12 ANTIFUNGALS .............................................................................................................................................................................................................. 13 ANTIMALARIALS ........................................................................................................................................................................................................... 14 ANTIRETROVIRAL AGENTS ........................................................................................................................................................................................ 14 ANTITUBERCULAR AGENTS ....................................................................................................................................................................................... 15 ANTIVIRALS .................................................................................................................................................................................................................. 15 MISCELLANEOUS ......................................................................................................................................................................................................... 16 ANTINEOPLASTIC AGENTS .................................................................................................................................................................................................. 17 ALKYLATING AGENTS ................................................................................................................................................................................................. 17 ANTIMETABOLITES ...................................................................................................................................................................................................... 17 HORMONAL ANTINEOPLASTIC AGENTS .................................................................................................................................................................. 17 IMMUNOMODULATORS ............................................................................................................................................................................................... 18 KINASE INHIBITORS .................................................................................................................................................................................................... 18 MULTIPLE MYELOMA ................................................................................................................................................................................................... 19 TOPOISOMERASE INHIBITORS .................................................................................................................................................................................. 19 MISCELLANEOUS ......................................................................................................................................................................................................... 20 CARDIOVASCULAR ...............................................................................................................................................................................................................
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