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Ebenefit Highlights the Drugs Listed Below Will Require Prior Authorization Through Your GE Prescription Drug Benefits

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Ebenefit Highlights the Drugs Listed Below Will Require Prior Authorization Through Your GE Prescription Drug Benefits eBenefit Highlights The drugs listed below will require prior authorization through your GE Prescription Drug Benefits. Acne/Rosacea 1 1 • Absorica (isotretinoin) • Epiduo (adapalene/benzoyl peroxide) 1 • Acanya (clindamycin/benzoyl peroxide) • Fabior (tazarotene) 1 • Aczone (dapsone) • Inova (benzoyl peroxide/tocopherols) 1 • Akne-mycin (erythromycin) • Noritate (metronidazole) 1 • Atralin (tretinoin) • Onexton (clindamycin/benzoyl peroxide) 1 • Azelex (azelaic acid) • Tretin-X (tretinoin) 1 • Clindacin ETZ (clindamycin phosphate) • Vanoxide-HC (benzoyl peroxide/hydrocortisone) 1 • Clindacin PAC (clindamycin phosphate) • Veltin (clindamycin/tretinoin) 1 • Clindagel (clindamycin phosphate) • Ziana (clindamycin/tretinoin) 1 2 ADHD/Amphetamines/Stimulants 2 • Aptensio XR (methylphenidate) • Evekeo (amphetamine) 2 • Dyanavel XR (amphetamine extended release) • Intuniv (guanfacine) 2 3 Allergic Asthma/Asthma/COPD 3 • Aerospan (flunisolide) • Proventil HFA (albuterol) 3 • Alvesco (ciclesonide) • Symbicort (budesonide/formoterol) 3 • Cinqair (reslizumab) • Ventolin HFA (albuterol) 3 • Flunisolide nasal (flunisolide nasal) • Xolair (omalizumab) 3 • Incruse Ellipta (umeclidinium) • Xopenex HFA (levalbuterol) 3 • Nucala (mepolizumab) 3 4 Allergies Ophthalmic 4 • Lastacaft (alcaftadine) 4 5 Allergy/ Antihistamines/Nasal Corticosteroids 5 • Adrenaclick (epinephrine) • Omnaris (ciclesonide) 5 • Beconase AQ (beclomethasone) • Oralair (grass mixed pollens extract) 5 • Clarinex, Desloratadine (desloratadine) • Qnasl (beclomethasone) 5 • Clarinex-D (desloratadine/pseudoephedrine) • Ragwitek (ragweed pollen extract) 5 • Dymista (azelastine/fluticasone) • Veramyst (fluticasone) 5 • Grastek (timothy grass pollen extract) • Xyzal, Levocetirizine (levocetirizine) 5 • Nasonex (mometasone) • Zetonna (ciclesonide) 5 * Prior authorization applies after initial quantity limit Therapies covered by CVS/caremark Specialty Pharmacy may change or expand from time to time. This page contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with CVS Caremark. ©2016 CVS/caremark. All rights reserved 1 2016 04-20 6 Alzheimer’s Disease Therapy 6 • Aricept (donepezil) • Namenda XR (memantine ext-rel) 6 • Exelon (rivastigmine) • Namzaric (memantine ext-rel/donepezil) 6 • Exelon Patch (rivastigmine) • Razadyne (galantamine) 6 • Namenda (memantine) • Razadyne ER (galantamine ext-rel) 6 7 Anticoagulant Therapy 7 • Plavix (clopidogrel) 7 8 Anticonvulsants 8 • Banzel (rufinamide) • Onfi (clobazam) 8 • Briviact (brivaracetam) • Oxtellar XR (oxcarbazepine ext-rel) 8 • Celontin (methsuximide) • Spritam (levetiracetam) 8 • Lamictal ODT (lamotrigine) • Trokendi XR (topiramate ext-rel) 8 • Lamictal XR (lamotrigine ext-rel) 8 9 Antifungal 9 • Jublia (efinaconazole) • Kerydin (tavaborole) 9 10 Anti-Inflammatory Agents (Nonsteroidal) 10 • Arthrotec (diclofenac/misoprostol) • Tivorbex (indomethacin) 10 • Cambia (diclofenac) • Vivlodex (meloxicam) 10 • Celebrex (celecoxib) • Voltaren Gel 1% (diclofenac topical gel) 10 • Nalfon (fenoprofen) • Zipsor (diclofenac) 10 • Naprelan (naproxen ext-rel) • Zorvolex (diclofenac) 10 • Pennsaid (diflofenac) 10 11 Antipsychotics 11 • Abilify (aripiprazole) • Rexulti (brexpiprazole) 11 • Equetro (carbamazepine) • Vraylar (cariprazine) 11 12 Antiviral Agents (CMV) 12 • Valcyte (valacylclovir) 12 13 Antiviral Agents (Herpes) 13 • Sitavig (acyclovir) • Valtrex (valacylclovir) 13 * Prior authorization applies after initial quantity limit Therapies covered by CVS/caremark Specialty Pharmacy may change or expand from time to time. This page contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with CVS Caremark. ©2016 CVS/caremark. All rights reserved 2 2016 04-20 14 Appetite Suppressants 14 • Belviq (lorcaserin) • Phendimetrazine (phendimetrazine) 14 • Bontril, Bontril PDM (phendimetrazine) • Phentermine (phentermine) 14 • Contrave (bupropion SR/ naltrexone SR) • Qsymia (phentermine/topiramate) 14 • Didrex (benzphetamine) • Saxenda (liraglutide) 14 • Diethylpropion (diethylpropion) • Suprenza (phentermine) 14 15 Attention Deficit Hyperactivity Disorder • Adderall XR 15 (dextroamphetamine/amphetamine ext-rel) 15 16 Benign Prostatic Hyperplasia 16 • Avodart (dutasteride) • Jalyn (dutasteride/tamsulosin) 16 • Cardura XL (doxazosin ext-rel) • Rapaflo (silodosin) 16 17 Botulinum Toxin 17 • Botox (botulinum toxin type A) • Myobloc (botulinum toxin type B) 17 • Dysport (abobotulinumtoxinA) • Xeomin (incobotulinumtoxina) 17 18 CNS Stimulants/Narcolepsy 18 • Nuvigil (armodafinil) • Provigil (modafinil) 18 19 Compounded Medications $300 and over 19 • Various (various) 19 20 Corticosteroids 20 • Rayos (prednisone delayed release) 20 21 Cystic Fibrosis 21 • Bethkis (tobramycin) • Orkambi (lumacaftor/ivacaftor) 21 • Cayston (aztreonam lysinate) • Pulmozyme (dornase alfa) 21 • Kalydeco (ivacaftor) • Tobi Podhaler (tobramycin) 21 • Kitabis Pak (tobramycin inhalation solution) • TOBI, Tobramycin (tobramycin/sodium chloride) 21 22 Dermatologicals, Miscellaneous 22 • Apexicon E (diflorasone) • Efudex (fluorouracil) 22 • Avita (tretinoin) • Fluorouracil cream 0.5% (fluorouracil) 22 • Carac (fluorouracil) • Olux-E (clobetasol) 22 • Clobetasol spray (clobetasol) • Retin-A (tretinoin) 22 • Clobex Spray (clobetasol) • Retin-A Micro (tretinoin gel, microsphere) 22 * Prior authorization applies after initial quantity limit Therapies covered by CVS/caremark Specialty Pharmacy may change or expand from time to time. This page contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with CVS Caremark. ©2016 CVS/caremark. All rights reserved 3 2016 04-20 23 Diabetes 23 • Accu-Check Strips and Kits (test strips and kits) • Humalog Mix 50/50 (insulin Lispro) 23 • Actos (pioglitazone) • Humalog Mix 75/25 (insulin Lispro) • All other test strips that are not ONETOUCH 23 brand • Humulin 70/30 (insulin NPH/regular) 23 • Apidra (insulin glulisine) • Humulin N (insulin NPH) 23 • Breeze 2 Strips and Kits (test strips and kits) • Humulin R (insulin regular) 23 • Bydureon (exanatide) • Invokamet (canagliflozin/metformin) 23 • Byetta (exenatide) • Invokana (canagliflozin) • Contour Next Strips and Kits (test strips and 23 kits) • Kazano (alogliptin/metformin) 23 • Contour Strips and Kits (test strips and kits) • Kombiglyze XR (saxagliptin/metformin) 23 • Fortamet (metformin ext rel) • Nesina (alogliptin) 23 • Freestyle Strips/Kits (test strips and kits) • Onglyza (saxagliptin) 23 • Glumetza (metformin ext rel) • Oseni (alogliptin/pioglitizone) 23 • Humalog (insulin Lispro) • Riomet (metformin) 23 24 Enteral Nutritional Supplements 24 • Various Nutritional Products (various) 24 25 Erectile Dysfunction Agents 25 • Cialis (tadalafil) • Stendra (avanafil) 25 • Levitra (vardenafil) • Viagra (sildenafil) 25 • Staxyn (vardenafil) 25 26 Estrogen Combinations 26 • Angeliq (drospirenone/estradiol) • Prefest (estradiol/norgestimate) 26 • Climara Pro (estradiol/levonorgestrel) 26 27 Estrogens 27 • Alora (estradiol) • Menest (estrogens, esterified) 27 • Divigel (estradiol) • Menostar (estradiol) 27 • Elestrin (estradiol) • Minivelle (estradiol) 27 • Estrogel (estradiol) 27 28 Gastroinestinal Drugs, Miscellaneous 28 • Amitiza (lubiprostone) • Relistor (methylnaltrexone) 28 29 Glaucoma Agents 29 • Lumigan (bimatoprost) • Zioptan (tafluprost) 29 • Travatan Z (travoprost) 29 * Prior authorization applies after initial quantity limit Therapies covered by CVS/caremark Specialty Pharmacy may change or expand from time to time. This page contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with CVS Caremark. ©2016 CVS/caremark. All rights reserved 4 2016 04-20 30 Glucocorticoids 30 • Dexpak (dexamethasone) • Orapred ODT (prednisolone) 30 • Millipred (prednisolone) • Uceris (budesonide) 30 • Millipred DP (prednisolone) • Veripred 20 (prednisolone) 30 31 Gout Agents 31 • Krystexxa (pegloticase) • Uloric (febuxostat) 31 32 Growth Hormones 32 • Genotropin (somatropin) • Omnitrope (somatropin) 32 • Humatrope (somatropin) • Saizen (somatropin) 32 • Increlex (mecasermin) • Serostim (somatropin) 32 • Norditropin (somatropin) • Zomacton (somatropin) 32 • Nutropin AQ (somatropin) • Zorbtive (somatropin) 32 Hematopoietics, Erythroid Stimulants, Myeloid 33 Stimulants 33 • Aranesp (darbepoetin alfa) • Neulasta (pegfilgrastim) 33 • Epogen (epoetin alfa) • Neumega (oprelvekin) 33 • Granix (Tbo-filgrastim) • Neupogen (filgrastim) 33 • Leukine (sargramostim) • Omontys (peginesatide) • Mircera (methoxy polyethylene glycol-epoetin 33 beta) • Procrit (epoetin alfa) 33 • Mozobil (plerixafor) • Zarxio (filgrastim) 33 * Prior authorization applies after initial quantity limit Therapies covered by CVS/caremark Specialty Pharmacy may change or expand from time to time. This page contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with CVS Caremark. ©2016 CVS/caremark. All rights reserved 5 2016 04-20 Hemophilia, Von Willebrand Disease, and 34 Related Bleeding Disorders • Advate (antihemophilic factor, human, • Kogenate FS (antihemophilic factor, human, 34 recombinant) recombinant) 34 • Adynovate (pegylated recombinant factor VIII) • Kovaltry
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