July 1, 2019 Premium Formulary Exclusions & Preferred Specialty Prior Authorization Requirements

Therapeutic Category Excluded Medications Preferred Alternatives

ALLERGIC REACTIONS

epinephrine injection made by Mylan, Auvi-Q (0.15mg, 0.3mg), Epi-Pen JR Anaphylaxis Treatment Epinephrine injection 0.15mg made by Impax(M), Epi- Pen 0.3mg

ANALGESICS

celecoxib, diflunisal, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, Non-Steroidal Anti- Cambia ketorolac, meclofenamate, Inflammatory Agents meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin

diclofenac, ibuprofen, Pain Sprix Nasal Spray meloxicam

ANTIBACTERIALS

Oral Antibiotics Doryx, Doryx MPC, Minolira doxycycline hyclate

(M) Co-branded product * Tier 3 preferred 1 Existing utilizers of these medications will be allowed to continue on therapy. Grandfathering will not be provided for any other excluded drugs. Therapeutic Category Excluded Medications Preferred Alternatives

ANTICONVULSANTS

Trokendi XR1 topiramate ER Seizure Disorders Oxtellar XR1 oxcarbazepine IR

ANTIMIGRAINES

amitriptyline, atenolol, divalproex sodium, nadolol, propranolol, CGRP agonists Ajovy timolol, topiramate, venlafaxine, Aimovig, Emgality

rizatriptan ODT, Serotonin Receptor Onzetra Xsail, Sumavel, Zembrace sumatriptan injection, Agonists Symtouch sumatriptan nasal spray, zolmitriptan ODT

ANTIPARKINSON AGENTS

Parkinson’s Disease Osmolex ER amantadine

ANTIVIRALS

Ledipasvir-Sofosbuvir (M), Sofosbuvir- Hepatitis-C drugs Epclusa, Harvoni, Mavyret Velpatasvir (M)

Please talk with your HIV drugs Atripla1 doctor about clinically appropriate options.

AUTONOMIC & CENTRAL NERVOUS SYSTEM

Interferon Beta Medications for Extavia1, Plegridy1 Avonex, Betaseron Multiple Sclerosis

hydromorphone HCl ER, morphine sulfate ER, Oral Long-Acting Arymo ER, Kadian, Nucynta ER, oxymorphone HCl ER, Opioid Analgesics Xtampza ER, Zohydro ER Embeda, Hysingla ER, OxyContin

codeine sulfate, hydromorphone HCl, Oral Short-Acting Nucynta morphine sulfate, Opioid Analgesics oxycodone HCl, oxymorphone HCl

Transmucosal Fentanyl Abstral, Fentora, Lazanda, Subsys fentanyl citrate lozenge Analgesics

CARDIOVASCULAR

Hypertension Kapspargo metoprolol ER

atorvastatin, fluvastatin, Cholesterol-Lowering lovastatin, pravastatin, Zypitamag Agents rosuvastatin, simvastatin, Livalo

CORTICOSTEROIDS

Oral Steroids Rayos prednisone

DERMATOLOGICAL AGENTS

Non-Steroidal Pennsaid diclofenac solution Anti-Inflammatory

adapalene, adapalene/ benzoyl peroxide, clindamycin gel/lotion/ Acanya, Aktipak, Clindagel solution, clindamycin/ Topical Acne Treatment Clindamycin phosphate 1% gel(M), benzoyl peroxide, Veltin erythromycin/benzoyl peroxide, tretinoin cream, Epiduo, Epiduo Forte, Onexton

Topical Anesthetics ZTlido lidocaine patch

Topical Antifungals Jublia terbinafine, Kerydin

metronidazole cream/gel/ Topical Antiinfective Noritate cream lotion, Soolantra

fluticasone ointment, Halog cream/ointment halobetasol cream/ ointment, triamcinolone Topical Corticosteroids betamethasone, Halobetasol foam (M), Lexette clobetasol, halobetasol cream/ointment

Topical Plaque Psoriasis Sorilux calcipotriene Treatment

DIABETES

Examples: Abbott (FreeStyle, Blood Glucose Meters, Precision), Arkray (Glucocard), Bayer Lifescan (One Touch Test Strips and Control (Breeze, Contour), Nipro (TRUEtest, products) Solutions TRUEtrack), Roche (Accu-Chek)

metformin HCl 24hr ER osmotic Blood Sugar Regulators metformin ER (generic release, metformin HCl 24hr ER Miscellaneous GLUCOPHAGE XR) modified release

Alogliptin(M), Alogliptin with Dipeptidyl Peptidase-4 Janumet, Janumet XR, metformin(M), Alogliptin with (DPP4) Inhibitors & Januvia, Jentadueto, pioglitazone(M), Kazano, Kombiglyze Combinations Jentadueto XR, Tradjenta XR, Nesina, Onglyza, Oseni

Basal insulin Basaglar, Levemir, Tresiba Lantus, Toujeo

Bydureon, Bydureon Glucagon-Like Peptide- Adlyxin, Tanzeum Bcise, Byetta, Ozempic, 1(GLP1) Agonists Trulicity, Victoza

Insulins Novolin Humulin

Rapid-acting insulin Admelog, Apidra, Fiasp, Novolog Humalog

Sodium-glucose Invokamet, Invokamet Farxiga, Segluromet, Steglatro, co-transporter (SGLT2) XR, Invokana, Jardiance, Xigduo XR Inhibitors Synjardy, Synjardy XR

SGLT2 and DPP4 Qtern, Steglujan Glyxambi Combinations

ENDOCRINE (OTHER)

Genotropin, Humatrope, Saizen, Norditropin, Nutropin, Growth Hormones Zomacton Omnitrope (M) Co-branded product * Tier 3 preferred 1 Existing utilizers of these medications will be allowed to continue on therapy. Grandfathering will not be provided for any other excluded drugs. Therapeutic Category Excluded Medications Preferred Alternatives

Infertility Bravelle, Follistim AQ Gonal-F

Nocturia Noctiva desmopressin, Nocdurna

GASTROINTESTINAL

diphenoxylate/atropine, Anti-Diarrheal Agents Motofen loperamide

granisetron solution/tablet, Antiemetics Sancuso patch ondansetron ODT

famotidine PLUS Anti-Inflammatory, Duexis, Vimovo ibuprofen, omeprazole Anti-Ulcer Agents PLUS naproxen Zorvolex ibuprofen, naproxen

Irritable Bowel Syndrome with Constipation/ Chronic Amitiza, Trulance Linzess Idiopathic Constipation (IBS-C/CIC)

Opioid-Induced Amitiza, Movantik, Relistor Symproic Constipation (OIC)

Inflammatory Bowel Delzicol, Dipentum balsalazide, Apriso Disease

Pancreatic Enzymes Pancreaze, Pertzye, Viokace Creon, Zenpep

esomeprazole magnesium delayed lansoprazole, omeprazole, Proton pump inhibitors release, omeprazole/ sodium pantoprazole bicarbonate cap/powder pak

HEMATOLOGICAL

Erythropoiesis-Stimulating Epogen Aranesp, Procrit, Retacrit Agents

Short-Acting Granulocyte- Colony Stimulating Factor Granix, Neupogen Nivestym, Zarxio (G-CSFs)

IMMUNOMODULATORS

Interleukin-17 (IL-17) Taltz1 Cosentyx*

JAK Inhibitor Olumiant1 Xeljanz, Xeljanz XR

OPHTHALMIC

latanoprost ophthalmic Antiglaucoma Drugs Rescula, Vyzulta, Zioptan solution, Lumigan, Travatan Z

Anti-Inflammatory Bromsite, Ilevro, Nevanac Prolensa

RESPIRATORY

COPD: Inhaled Seebri, Tudorza Incruse Ellipta, Spiriva Anticholinergics

COPD: Long-Acting Beta Agonist/Long-Acting Anoro Ellipta, Stiolto Bevespi, Utibron Muscarinic Agonist Respimat Combination inhalers

Cystic Fibrosis Kitabis Pak, TOBI Podhaler, Bethkis (inhaled tobramycin) Tobramycin Neb(M)

Alvesco, Armonair, Asmanex, Arnuity Ellipta, Flovent Pulmonary Anti- Asmanex HFA, QVAR, QVAR Diskus, Flovent HFA, Inflammatory Inhalers Redihaler Pulmicort Flexhaler

Pulmonary Anti- Advair Diskus, Advair Inflammatory , Long- AirDuo, Dulera HFA, Breo Ellipta, Acting Beta Agonist Symbicort Combination Inhalers

Short-Acting Beta-2 Levalbuterol Inhaler(M), Proventil ProAir HFA, ProAir Adrenergic Inhalers HFA, Xopenex HFA Respiclick Ventolin HFA

UROLOGICAL

Erectile Dysfunction Oral Stendra sildenafil Agents Excluded brand-name medications with generic equivalents

The brand-name medications below are excluded on the formulary. These brand-name medications have been identified as having available generic equivalents covered atTier 1 on the formulary. Speak with your pharmacist to have your excluded brand-name medication substituted with its generic equivalent. A generic medication contains the same active ingredient(s) as a brand-name medication. An active ingredient is what makes the medication work. For example, Liptor® and its generic both contain atorvastatin, which reduces the amount of bad cholesterol in the blood. Brand-name medications are often protected by a patent. When the patent ends, drug companies can apply to the U.S. Food and Drug Administration (FDA) to begin making generic versions of the medication.

Retin-A Micro Aciphex Celebrex Lialda Vytorin Gel 0.04%, 0.1%

Sabril Powder Acticlate Concerta Lidoderm Wellbutrin SR Pak

Sandostatin Aczone 5% Crestor Lipitor Wellbutrin XL Solution Injection

Adderall XR Cymbalta Lovaza Singulair Xanax

Alphagan P Cytomel Lunesta Staxyn Xanax XR 0.15%

Depo – Taclonex Ambien Testosterone Minastrin Yaz Ointment Injection

Dilantin Capsule Ambien CR Nasonex Tamiflu Capsule Zegerid 100mg

Dilantin Amrix Nexium Capsule Testim Zetia Chewable

Dilantin Androgel 1% Nitrostat TOBI Nebulizer Ziana Suspension

Tobradex Asacol HD Diovan Norco Zoloft Suspension

Ativan Diovan HCT Norvasc Topicort Spray Zomig

Axiron Duac Nuvigil Toprol XL Zomig ZMT Excluded brand-name medications with generic equivalents

Azor Duragesic Ortho Tri Cyclen Tribenzor

Ortho Tri Cyclen Benicar Effexor XR Vagifem Lo

Benicar HCT Fortamet Percocet Valium

Prevacid Zovirax oral, Benzaclin Fortesta Viagra Capsule ointment, suspension Benzamycin Glumetza Pristiq Vivelle-Dot

Beyaz Levitra Prozac Vogelxo

Pulmicort Carafate Lexapro Inhalation Voltaren Gel Suspension

Required Prior Authorization +

Therapeutic Class Non-Preferred Medications Preferred Medications

Lepidasvir- All other brands non-preferred with prior Sofosbuvir(M), Hepatitis C authorization Mavyret, Sofosbuvir- Velpatasvir(M), Vosevi

All other brands non-preferred with prior Avonex, Betaseron, Multiple Sclerosis authorization and Gilenya* Tier 3 with Copaxone, Tecfidera prior authorization

Cimzia, Humira, Otezla, All other brands non-preferred with Immunomodulators Simponi, Stelara, prior authorization Tremfya

+ All of the products listed above are currently subject to prior authorization. Preferred medications are required prior to new requests for non-preferred medication(s). Existing utilizers of non-preferred medication(s) within the therapeutic categories of Hepatitis C, Immunomodulators and Multiple Sclerosis will be eligible to remain on current therapy if compliance and efficacy of therapy are demonstrated. Exceptions will be granted for specific indications where the preferred agents do not have FDA-approval for use.

(M) Co-branded product

About this document: Where differences exist between this formulary and your benefit plan documents, the benefit plan documents rule. This may not be a complete list of medications, and not all medications listed may be covered by your plan. Please look at the benefit plan documents provided by your employer or plan sponsor for full details.

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