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2021 EMPIRE PLAN FLEXIBLE FORMULARY DRUG LIST Administered by CVS Caremark®

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2021 EMPIRE PLAN FLEXIBLE FORMULARY DRUG LIST Administered by CVS Caremark® April 2021 2021 EMPIRE PLAN FLEXIBLE FORMULARY DRUG LIST Administered by CVS Caremark® The Empire Plan Flexible Formulary is a guide within select therapeutic categories for enrollees and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name drug to treat a condition. These preferred brand-name drugs are listed to help identify products that are clinically appropriate and cost-effective. This is not an all-inclusive list. This formulary includes a list of commonly prescribed covered drugs by therapeutic class, a Quick Reference Drug List with commonly prescribed covered drugs in alphabetic order, a listing of commonly prescribed non-preferred (Level 3) covered drugs and covered preferred drug alternatives, and a listing of excluded drugs along with covered alternatives. This list represents brand-name drugs in CAPS and generic drugs in lowercase italics. Generally generics are subject to a Level 1 copayment, or the lowest copayment; preferred brand drugs are subject to a Level 2 copayment, and non-preferred brand drugs are subject to a Level 3 copayment, or the highest copayment. Refer to your plan materials for specific information regarding copayment amounts. ENROLLEE HEALTH CARE PROVIDER Your benefit plan provides you with a prescription benefit program Your patient is covered under a prescription benefit plan administered administered by CVS Caremark. Ask your doctor to consider by CVS Caremark. As a way to help manage health care costs, prescribing, when medically appropriate, a preferred generic or a authorize generic substitution whenever possible. If you believe a preferred brand-name drug from this list. Take this list along when brand-name drug is necessary, consider prescribing a brand-name you or a covered family member sees a doctor. drug on this list. Please note: Please note: • You will be responsible for the full cost of non-formulary products • Generics should be considered the first line of prescribing. that are excluded from coverage unless a request for a • This drug list represents a summary of prescription coverage. medical exception is approved. New prescription drug products It is not all-inclusive and does not guarantee coverage. may be subject to exclusion upon release to the market. • The enrollee's prescription benefit plan may have a different • For specific information regarding your prescription benefit copay for specific products on the list. coverage and copay information, please visit • Unless specifically indicated, drug list products will include all https://www.empireplanrxprogram.com or dosage forms. call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 • Log in to https://www.empireplanrxprogram.com to check for the Empire Plan Prescription Drug Program. coverage and copay information for a specific medicine. • Any brand-name drug for which a generic drug becomes available will be designated as a non-preferred drug. When a generic version is available, mandatory generic substitution will apply. In this case, use of a non-preferred product will result in the member paying the applicable non-preferred copayment plus the difference in cost between the brand-name drug and the generic, not to exceed the full retail cost of the drug (Ancillary Charge). ANALGESICS § NSAIDs, TOPICAL § OPIOID ANALGESICS hydromorphone ext-rel § NON-OPIOID ANALGESICS diclofenac sodium gel 1% buprenorphine transdermal QL/PA butalbital-acetaminophen- § NSAIDs (generic VOLTAREN GEL) (generic BUTRANS) methadone QL/PA caffeine diclofenac sodium QL/PA morphine QL/PA butalbital-aspirin-caffeine § COX-2 INHIBITORS diflunisal codeine-acetaminophen QL morphine ext-rel QL/PA etodolac celecoxib (generic fentanyl citrate (generic morphine suppository QL/PA VISCOSUPPLEMENTS ibuprofen CELEBREX) FENTORA) PA/QL oxycodone QL/PA DUROLANE meloxicam fentanyl transdermal QL/PA oxycodone-acetaminophen GELSYN-3 § GOUT nabumetone fentanyl transmucosal QL/PA HYALGAN naproxen (except naproxen CR or allopurinol lozenge PA/QL tramadol QL/PA SUPARTZ FX naproxen suspension) colchicine tablet (generic hydrocodone ext-rel (generic tramadol ext-rel QL/PA naproxen sodium COLCRYS) ZOHYDRO ER) QL/PA BELBUCA QL/PA ANTI-INFECTIVES oxaprozin febuxostat (generic ULORIC) HYSINGLA ER QL/PA hydrocodone-acetaminophen ANTIBACTERIALS sulindac probenecid (except hydrocodone-acetaminophen NUCYNTA QL/PA § CEPHALOSPORINS COLCRYS tablet 7.5-300 mg or hydrocodone- NUCYNTA ER QL/PA § NSAIDs, COMBINATIONS cefadroxil acetaminophen tablet 10-300 mg) OXYCONTIN QL/PA diclofenac sodium- cefdinir QL/PA SUBSYS PA/QL misoprostol cefixime (generic SUPRAX) XTAMPZA ER QL/PA hydromorphone QL/PA Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit https://www.empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program. 1 cefprozil emtricitabine-tenofovir nitazoxanide (generic MISCELLANEOUS § ANGIOTENSIN II cefuroxime axetil disoproxil fumarate ALINIA) ERIVEDGE SGM RECEPTOR ANTAGONIST / cephalexin (generic TRUVADA) nitrofurantoin LYNPARZA SGM CALCIUM CHANNEL SUPRAX SUSPENSION 500 BIKTARVY nitrofurantoin ext-rel RUBRACA SGM BLOCKER COMBINATIONS MG/5 ML, TABLET CIMDUO pentamidine (generic ZEJULA SGM amlodipine-olmesartan DESCOVY NEBUPENT) (generic AZOR) § ERYTHROMYCINS / DOVATO praziquantel (generic CARDIOVASCULAR MACROLIDES EVOTAZ BILTRICIDE) QL/PA § ANGIOTENSIN II § ACE INHIBITORS azithromycin GENVOYA sulfamethoxazole- RECEPTOR ANTAGONIST / clarithromycin ODEFSEY trimethoprim benazepril CALCIUM CHANNEL clarithromycin ext-rel SYMTUZA tinidazole captopril BLOCKER / DIURETIC erythromycin delayed-rel TRIUMEQ trimethoprim enalapril COMBINATIONS erythromycin ethylsuccinate TRUVADA vancomycin fosinopril olmesartan-amlodipine- erythromycin stearate ALINIA SUSPENSION lisinopril hydrochlorothiazide § ANTITUBERCULAR DIFICID EMVERM perindopril (generic TRIBENZOR) AGENTS SIVEXTRO quinapril § FLUOROQUINOLONES ethambutol XIFAXAN 550 MG ramipril § ANTIARRHYTHMICS ciprofloxacin isoniazid trandolapril amiodarone levofloxacin pyrazinamide ANTINEOPLASTIC disopyramide § ACE INHIBITOR / CALCIUM moxifloxacin rifampin AGENTS dofetilide (generic TIKOSYN) CHANNEL BLOCKER PRIFTIN SGM § PENICILLINS Generally, single-source brand COMBINATIONS TRECATOR drugs (products for which a flecainide amoxicillin generic is not available) and amlodipine-benazepril propafenone amoxicillin-clavulanate ANTIVIRALS generic drugs indicated for the trandolapril-verapamil ext-rel propafenone ext-rel treatment of cancer are amoxicillin-clavulanate ext-rel § CYTOMEGALOVIRUS (generic TARKA) formulary. sotalol ampicillin AGENTS § ACE INHIBITOR / MULTAQ dicloxacillin valganciclovir (generic HORMONAL penicillin VK DIURETIC COMBINATIONS ANTILIPEMICS VALCYTE) ANTINEOPLASTIC AGENTS benazepril- § ANTIANDROGENS § BILE ACID RESINS § TETRACYCLINES HEPATITIS AGENTS hydrochlorothiazide cholestyramine doxycycline hyclate abiraterone (generic captopril-hydrochlorothiazide Generally, single-source brand colesevelam (generic minocycline drugs (products for which a ZYTIGA) SGM enalapril-hydrochlorothiazide generic is not available) and WELCHOL) tetracycline ERLEADA SGM fosinopril-hydrochlorothiazide generic drugs indicated for the colestipol XTANDI SGM VIBRAMYCIN SYRUP treatment of Hepatitis B and lisinopril-hydrochlorothiazide Hepatitis C are formulary. YONSA SGM quinapril-hydrochlorothiazide § CHOLESTEROL § ANTIFUNGALS § LUTEINIZING HORMONE- ABSORPTION INHIBITORS clotrimazole troches § HEPATITIS B AGENTS § ADRENOLYTICS, RELEASING HORMONE CENTRAL ezetimibe (generic ZETIA) fluconazole entecavir tablet (LHRH) AGONISTS griseofulvin ultramicrosize lamivudine tablet clonidine § FIBRATES itraconazole PA ELIGARD SGM clonidine transdermal BARACLUDE SOLUTION fenofibrate (except fenofibrate tablet LUPRON DEPOT SGM nystatin EPIVIR-HBV SOLUTION guanfacine 120 mg) terbinafine tablet PA VEMLIDY § KINASE INHIBITORS fenofibric acid delayed-rel voriconazole § ALDOSTERONE gemfibrozil imatinib mesylate SGM RECEPTOR ANTAGONISTS NOXAFIL INJECTION, § HEPATITIS C AGENTS ALECENSA SGM SUSPENSION ribavirin SGM eplerenone § HMG-CoA REDUCTASE ALUNBRIG SGM EPCLUSA SGM spironolactone INHIBITORS / § ANTIMALARIALS BOSULIF SGM HARVONI SGM COMBINATIONS atovaquone-proguanil CABOMETYX SGM § ANGIOTENSIN II SOVALDI SGM atorvastatin chloroquine ◊ IBRANCE SGM RECEPTOR ANTAGONISTS / VOSEVI , SGM ezetimibe-simvastatin mefloquine ICLUSIG SGM DIURETIC COMBINATIONS (generic VYTORIN) pyrimethamine (generic § HERPES AGENTS IRESSA SGM candesartan fluvastatin DARAPRIM) KISQALI SGM candesartan- acyclovir lovastatin COARTEM KISQALI FEMARA CO- hydrochlorothiazide famciclovir pravastatin PACK SGM irbesartan valacyclovir rosuvastatin (generic ANTIRETROVIRAL AGENTS RYDAPT SGM irbesartan- CRESTOR) Generally, single-source brand § INFLUENZA AGENTS SPRYCEL SGM hydrochlorothiazide drugs (products for which a simvastatin generic is not available) and oseltamivir (generic TASIGNA SGM losartan generic drugs indicated for the TAMIFLU) QL/PA VERZENIO SGM losartan-hydrochlorothiazide § NIACINS treatment of HIV and its VITRAKVI SGM olmesartan (generic RELENZA QL/PA niacin ext-rel opportunistic infections are BENICAR) formulary. § MISCELLANEOUS MULTIPLE MYELOMA olmesartan- § OMEGA-3 FATTY ACIDS § ANTIRETROVIRAL albendazole (generic IMMUNOMODULATORS hydrochlorothiazide COMBINATIONS icosapent ethyl (generic ALBENZA) QL/PA
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