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Express Scripts National Preferred Formulary July 2021

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National Preferred Formulary July 2021 How to Use the Formulary The Formulary is a list of medications available to members under their pharmacy benefit. All drugs are listed by their generic names or most common proprietary (branded) name. Any drugs not found in this formulary listing or any formulary updates published by Express Scripts are considered non-formulary drugs and require prior authorization. All drugs are listed in each category in alphabetical order by generic or brand name. If the generic drug is FDA approved, it will appear italicized in the formulary listing. Covered brand drugs appear in CAPITALIZED font. Benefit Coverage and Limitations The Formulary applies only to outpatient drugs provided to members and does not apply to medications used in inpatient settings. If a member has any specific questions regarding their coverage, they should contact Wellfleet or Express Scripts at the phone numbers listed on their ID card. Excluded Agents Any drugs not listed in this print formulary are considered excluded from the drug benefit and are not covered. As new drugs become available, they will be considered for coverage under the Formulary. Non-Formulary and Step Therapy Exception Requests A member (or their appointed representative, prescribing physician, or authorized prescriber) may request a standard/non-urgent or expedited/urgent preservice/prior and current authorization for a drug that is subjected to utilization management tools such as step therapy. To initiate an exception request, contact 800-417-8164. Prior authorization guidelines will be made available to the member, member’s authorization representative, prescribing physician and other authorized prescriber upon request. PO Box 15369, Springfield, MA 01115 Copyright © 2021 Wellfleet Group, LLC. All rights reserved. i Table of Contents ANTI - INFECTIVES ........................................................................................................................................ 3 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ....................................................................... 21 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ........................................................................... 34 CARDIOVASCULAR, HYPERTENSION / LIPIDS ................................................................................... 61 DERMATOLOGICALS/TOPICAL THERAPY .......................................................................................... 81 DIAGNOSTICS / MISCELLANEOUS AGENTS ........................................................................................ 96 EAR, NOSE / THROAT MEDICATIONS .................................................................................................. 107 ENDOCRINE/DIABETES ............................................................................................................................ 109 GASTROENTEROLOGY ............................................................................................................................ 143 IMMUNOLOGY, VACCINES / BIOTECHNOLOGY .............................................................................. 153 MUSCULOSKELETAL / RHEUMATOLOGY ......................................................................................... 161 OBSTETRICS / GYNECOLOGY ................................................................................................................ 164 OPHTHALMOLOGY ................................................................................................................................... 175 RESPIRATORY AND ALLERGY .............................................................................................................. 181 UROLOGICALS ............................................................................................................................................ 190 VITAMINS, HEMATINICS / ELECTROLYTES ..................................................................................... 193 Index ................................................................................................................................................................ 217 1 List of Abbreviations ACA: Affordable Care Act AGE: Age Edit OTC: Over the Counter. An OTC drug is a non-prescription drug. PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. SP: Specialty ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. 2 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ANTI - INFECTIVES fluconazole in nacl 1 PA (iso-osm) ANTIFUNGAL AGENTS intravenous ABELCET 2 piggyback 100 INTRAVENOUS mg/50 ml, 200 SUSPENSION 5 mg/100 ml, 400 MG/ML mg/200 ml AMBISOME 2 fluconazole oral 1 INTRAVENOUS suspension for SUSPENSION FOR reconstitution 10 RECONSTITUTIO mg/ml, 40 mg/ml N 50 MG fluconazole oral 1 AMPHOTERICIN B 2 tablet 100 mg, 200 (BULK) POWDER mg, 50 mg amphotericin b 1 fluconazole oral 1 QL injection recon soln tablet 150 mg 50 mg FLUCYTOSINE 2 caspofungin 1 (BULK) POWDER intravenous recon 100 % soln 50 mg, 70 mg flucytosine oral 1 clotrimazole mucous 1 capsule 250 mg, 500 membrane troche 10 mg mg griseofulvin 1 CRESEMBA 2 PA microsize oral INTRAVENOUS suspension 125 mg/5 RECON SOLN 372 ml MG griseofulvin 1 CRESEMBA ORAL 2 PA microsize oral tablet CAPSULE 186 MG 500 mg ERAXIS(WATER 2 griseofulvin 1 DILUENT) ultramicrosize oral INTRAVENOUS tablet 125 mg, 250 RECON SOLN 100 mg MG, 50 MG ITRACONAZOLE 2 FLUCONAZOLE 2 (BULK) POWDER (BULK) POWDER itraconazole oral 1 QL 100 % capsule 100 mg itraconazole oral 1 solution 10 mg/ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 3 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits KETOCONAZOLE 2 terbinafine hcl oral 1 (BULK) POWDER tablet 250 mg ketoconazole oral 1 VORICONAZOLE 2 tablet 200 mg (BULK) POWDER micafungin 1 100 % intravenous recon voriconazole 1 PA soln 100 mg, 50 mg intravenous recon soln 200 mg MICONAZOLE 2 (BULK) POWDER voriconazole oral 1 PA suspension for NOXAFIL 2 PA reconstitution 200 INTRAVENOUS mg/5 ml (40 mg/ml) SOLUTION 300 MG/16.7 ML voriconazole oral 1 PA tablet 200 mg, 50 mg NOXAFIL ORAL 2 PA SUSPENSION 200 ANTIVIRALS MG/5 ML (40 abacavir oral 1 SP MG/ML) solution 20 mg/ml NYSTATIN 2 abacavir oral tablet 1 SP (BULK) POWDER 300 mg 1 BILLION UNIT, 1 MILLION UNIT, 10 abacavir-lamivudine 1 SP BILLION UNIT, 15 oral tablet 600-300 BILLION UNIT, mg 150 MILLION abacavir- 1 SP UNIT, 2 BILLION lamivudine- UNIT, 5 BILLION zidovudine oral UNIT, 50 MILLION tablet 300-150-300 UNIT, 500 mg MILLION UNIT ACYCLOVIR 2 nystatin oral 1 (BULK) POWDER suspension 100,000 100 % unit/ml acyclovir oral 1 nystatin oral tablet 1 capsule 200 mg 500,000 unit acyclovir oral 1 posaconazole oral 1 PA suspension 200 mg/5 tablet,delayed ml release (dr/ec) 100 mg acyclovir oral tablet 1 400 mg, 800 mg TERBINAFINE 2 (BULK) POWDER 100 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 4 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits acyclovir sodium 1 DESCOVY ORAL 2 SP intravenous recon TABLET 200-25 soln 1,000 mg, 500 MG mg didanosine oral 1 SP acyclovir sodium 1 capsule,delayed intravenous solution release(dr/ec) 250 50 mg/ml mg, 400 mg adefovir oral tablet 1 DOVATO ORAL 2 SP 10 mg TABLET 50-300 AMANTADINE 2 MG HCL (BULK) EDURANT ORAL 2 SP POWDER TABLET 25 MG amantadine hcl oral 1 efavirenz oral 1 SP capsule 100 mg capsule 200 mg, 50 mg amantadine hcl oral 1 solution 50 mg/5 ml efavirenz oral tablet 1 SP 600 mg amantadine hcl oral 1 tablet 100 mg efavirenz- 1 SP emtricitabin-tenofov APTIVUS (WITH 2 SP oral tablet 600-200- VITAMIN E) ORAL 300 mg SOLUTION 100 MG/ML efavirenz-lamivu- 1 SP tenofov disop oral APTIVUS ORAL 2 SP tablet 400-300-300 CAPSULE 250 MG mg, 600-300-300 mg atazanavir oral 1 SP emtricitabine oral capsule 150 mg, 200 1 SP capsule 200 mg mg, 300 mg emtricitabine- BIKTARVY ORAL 2 SP 1 SP tenofovir (tdf) oral TABLET 50-200-25 tablet 100-150 mg, MG 133-200 mg, 167- cidofovir 1 250 mg intravenous solution emtricitabine- 75 mg/ml 1 ACA; SP tenofovir (tdf) oral CIMDUO ORAL 2 SP tablet 200-300 mg TABLET 300-300 MG EMTRIVA ORAL 2 SP SOLUTION 10 CRIXIVAN ORAL 2 SP MG/ML CAPSULE 200 MG entecavir oral tablet 1 0.5 mg, 1 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 5 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits EPCLUSA ORAL 2 PA; SP; QL ISENTRESS ORAL 2 SP TABLET 200-50 TABLET,CHEWAB MG, 400-100 MG LE 100 MG EPIVIR HBV 2 JULUCA ORAL 2 SP ORAL SOLUTION TABLET 50-25 MG 25 MG/5 ML (5 KALETRA ORAL 2 SP MG/ML) TABLET 100-25 famciclovir oral 1 QL MG, 200-50 MG tablet 125 mg, 250 lamivudine oral 1 SP mg, 500 mg solution 10 mg/ml fosamprenavir oral 1 SP lamivudine oral 1 tablet 700 mg tablet 100 mg foscarnet 1 lamivudine oral 1 SP intravenous
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