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WELL SENSE HEALTH PLAN DRUG LIST (Effective )

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WELL SENSE HEALTH PLAN DRUG LIST (Effective ) WELL SENSE HEALTH PLAN DRUG LIST (Effective 12/12/2013 ) Below is a list of prescription drugs covered by Well Sense Health Plan (Plan). Covered devices are listed on the OTC formulary (drug list) at wellsense.org. The list is subject to change. If a drug is not on the list, it may still be available. All newly approved drugs require prior approval from Well Sense before they can be covered, and members may be required to try the generic version of a drug before the brand drug will be covered. Excluded drugs are outlined in the Member Handbook. Questions? Please contact Well Sense Health Plan at: 1-877-957-1300 Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants ZENZEDI TAB 2.5MG Brand 2 ZENZEDI TAB 5MG generic 1 PREF QL 90/30 PA DEXTROAMPHET TAB 5MG generic 1 PREF QL 90/30 PA ZENZEDI TAB 7.5MG Brand 2 ZENZEDI TAB 10MG generic 1 PREF QL 180/30 PA DEXTROAMPHET TAB 10MG generic 1 PREF QL 180/30 PA PROCENTRA SOL 5MG/5ML generic 1 DEXTROAMPHET SOL 5MG/5ML generic 1 DEXTROAMPHET CAP 5MG ER generic 1 PREF QL 60/30 PA DEXEDRINE CAP 5MG CR Brand 2 NON-PREF ST QL 60/30 DEXTROAMPHET CAP 10MG ER generic 1 PREF QL 150/30 PA DEXEDRINE CAP 10MG CR Brand 2 NON-PREF ST QL 150/30 DEXTROAMPHET CAP 15MG ER generic 1 PREF QL 120/30 PA DEXEDRINE CAP 15MG CR Brand 2 NON-PREF ST QL 120/30 VYVANSE CAP 20MG Brand 2 PREF QL 30/30 PA VYVANSE CAP 30MG Brand 2 PREF QL 30/30 PA VYVANSE CAP 40MG Brand 2 PREF QL 30/30 PA VYVANSE CAP 50MG Brand 2 PREF QL 30/30 PA VYVANSE CAP 60MG Brand 2 PREF QL 30/30 PA VYVANSE CAP 70MG Brand 2 PREF QL 30/30 PA METHAMPHETAM TAB 5MG generic 1 PREF PA DESOXYN TAB 5MG Brand 2 NON-PREF ST AMPHETAMINE TAB 5MG generic 1 PREF QL 90/30 PA KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 1 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO ADDERALL TAB 5MG Brand 2 NON-PREF ST QL 90/30 ADDERALL TAB 7.5MG Brand 2 NON-PREF ST QL 90/30 AMPHETAMINE TAB 7.5MG generic 1 PREF QL 90/30 PA AMPHETAMINE TAB 10MG generic 1 PREF QL 90/30 PA ADDERALL TAB 10MG Brand 2 NON-PREF ST QL 90/30 AMPHETAMINE TAB 12.5MG generic 1 PREF QL 90/30 PA ADDERALL TAB 12.5MG Brand 2 NON-PREF ST QL 90/30 AMPHETAMINE TAB 15MG generic 1 PREF QL 90/30 PA ADDERALL TAB 15MG Brand 2 NON-PREF ST QL 90/30 AMPHETAMINE TAB 20MG generic 1 PREF QL 90/30 PA ADDERALL TAB 20MG Brand 2 NON-PREF ST QL 90/30 AMPHETAMINE TAB 30MG generic 1 PREF QL 90/30 PA ADDERALL TAB 30MG Brand 2 NON-PREF ST QL 90/30 AMPHETAMINE CAP 5MG ER generic 1 NON-PREF ST QL 60/30 ADDERALL XR CAP 5MG Brand 2 PREF QL 60/30 PA AMPHETAMINE CAP 10MG ER generic 1 NON-PREF ST QL 60/30 ADDERALL XR CAP 10MG Brand 2 PREF QL 60/30 PA AMPHETAMINE CAP 15MG ER generic 1 NON-PREF ST QL 60/30 ADDERALL XR CAP 15MG Brand 2 PREF QL 60/30 PA ADDERALL XR CAP 20MG Brand 2 PREF QL 60/30 PA AMPHETAMINE CAP 20MG ER generic 1 NON-PREF ST QL 60/30 AMPHETAMINE CAP 25MG ER generic 1 NON-PREF ST QL 60/30 ADDERALL XR CAP 25MG Brand 2 PREF QL 60/30 PA AMPHETAMINE CAP 30MG ER generic 1 NON-PREF ST QL 60/30 ADDERALL XR CAP 30MG Brand 2 PREF QL 60/30 PA BENZPHETAMIN TAB 50MG generic 1 PA DIDREX TAB 50MG Brand 2 GR DIETHYLPROP TAB 25MG generic 1 PA DIETHYLPROP TAB 75MG ER generic 1 PA PHENDIMETRAZ TAB 35MG generic 1 PA BONTRIL PDM TAB 35MG Brand 2 GR PHENDIMETRAZ CAP 105MG ER generic 1 PA KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 2 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO PHENTERMINE CAP 15MG generic 1 PA PHENTERMINE CAP 30MG generic 1 PA PHENTERMINE CAP 37.5MG generic 1 PA ADIPEX-P CAP 37.5MG Brand 2 GR PHENTERMINE TAB 37.5MG generic 1 PA ADIPEX-P TAB 37.5MG Brand 2 GR XENICAL CAP 120MG Brand 2 PA CAFFEINE CIT INJ 60MG/3ML generic 1 CAFCIT INJ 60MG/3ML Brand 2 GR CAFFEINE CIT SOL 20MG/ML generic 1 CAFFEINE CIT SOL 60MG/3ML generic 1 CAFCIT SOL 60MG/3ML Brand 2 GR CAFFEINE/SOD INJ BENZOATE Brand 2 DOXAPRAM HCL INJ 20MG/ML generic 1 DOPRAM INJ 20MG/ML Brand 2 GR KAPVAY MIS 0.1&0.2 Brand 2 CLONIDINE TAB 0.1MG ER generic 1 KAPVAY TAB 0.1 MG Brand 2 GR INTUNIV TAB 1MG Brand 2 NON-PREF ST QL 30/30 INTUNIV TAB 2MG Brand 2 NON-PREF ST QL 30/30 INTUNIV TAB 3MG Brand 2 NON-PREF ST QL 30/30 INTUNIV TAB 4MG Brand 2 NON-PREF ST QL 30/30 STRATTERA CAP 10MG Brand 2 NON-PREF ST QL 60/30 STRATTERA CAP 18MG Brand 2 NON-PREF ST QL 60/30 STRATTERA CAP 25MG Brand 2 NON-PREF ST QL 60/30 STRATTERA CAP 40MG Brand 2 NON-PREF ST QL 60/30 STRATTERA CAP 60MG Brand 2 NON-PREF ST QL 60/30 STRATTERA CAP 80MG Brand 2 NON-PREF ST QL 60/30 STRATTERA CAP 100MG Brand 2 NON-PREF ST QL 60/30 NUVIGIL TAB 50MG Brand 2 QL 60/30 PA NUVIGIL TAB 150MG Brand 2 QL 30/30 PA NUVIGIL TAB 250MG Brand 2 QL 30/30 PA KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 3 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO FOCALIN TAB 2.5MG Brand 2 NON-PREF ST QL 60/30 DEXMETHYLPH TAB 2.5MG generic 1 PREF QL 60/30 PA DEXMETHYLPH TAB 5MG generic 1 FOCALIN TAB 5MG Brand 2 NON-PREF ST QL 60/30 DEXMETHYLPH TAB 10MG generic 1 FOCALIN TAB 10MG Brand 2 FOCALIN XR CAP 5MG Brand 2 FOCALIN XR CAP 10MG Brand 2 PREF QL 30/30 PA FOCALIN XR CAP 15MG Brand 2 PREF QL 30/30 PA FOCALIN XR CAP 20MG Brand 2 PREF QL 30/30 PA FOCALIN XR CAP 25MG Brand 2 PREF QL 30/30 PA FOCALIN XR CAP 30MG Brand 2 PREF QL 30/30 PA FOCALIN XR CAP 35MG Brand 2 PREF QL 30/30 PA FOCALIN XR CAP 40MG Brand 2 PREF QL 30/30 PA DAYTRANA DIS 10MG/9HR Brand 2 NON-PREF ST QL 30/30 DAYTRANA DIS 15MG/9HR Brand 2 NON-PREF ST QL 30/30 DAYTRANA DIS 20MG/9HR Brand 2 NON-PREF ST QL 30/30 DAYTRANA DIS 30MG/9HR Brand 2 NON-PREF ST QL 30/30 METADATE CD CAP 10MG Brand 2 NON-PREF ST QL 60/30 METHYLPHENID CAP 10MG generic 1 NON-PREF ST QL 60/30 METHYLPHENID CAP 20MG generic 1 NON-PREF ST QL 60/30 METADATE CD CAP 20MG Brand 2 NON-PREF ST QL 60/30 METHYLPHENID CAP 30MG generic 1 NON-PREF ST QL 60/30 METADATE CD CAP 30MG Brand 2 NON-PREF ST QL 60/30 METHYLPHENID CAP 40MG generic 1 NON-PREF ST QL 60/30 METADATE CD CAP 40MG Brand 2 NON-PREF ST QL 60/30 METHYLPHENID CAP 50MG generic 1 NON-PREF ST QL 60/30 METADATE CD CAP 50MG Brand 2 NON-PREF ST QL 60/30 METHYLPHENID CAP 60MG generic 1 NON-PREF ST QL 60/30 METADATE CD CAP 60MG Brand 2 NON-PREF ST QL 60/30 RITALIN TAB 5MG Brand 2 NON-PREF ST QL 90/30 METHYLPHENID TAB 5MG generic 1 PREF QL 90/30 PA KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 4 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170. Group Drug Name Brand/ Generic Tier PDL Status ST QL QL Amt/Day PA Specialty MO METHYLPHENID TAB 10MG generic 1 PREF QL 90/30 PA RITALIN TAB 10MG Brand 2 NON-PREF ST QL 90/30 METHYLPHENID TAB 20MG generic 1 PREF QL 90/30 PA RITALIN TAB 20MG Brand 2 NON-PREF ST QL 90/30 METHYLPHENID TAB 10MG ER generic 1 PREF QL 60/30 PA METADATE TAB 20MG ER generic 1 PREF QL 60/30 PA RITALIN TAB 20MG SR Brand 2 NON-PREF ST QL 60/30 METHYLPHENID TAB 18MG ER generic 1 PREF QL 30/30 CONCERTA TAB 18MG Brand 2 GR METHYLPHENID TAB 27MG ER generic 1 PREF QL 30/30 CONCERTA TAB 27MG Brand 2 GR METHYLPHENID TAB 36MG ER generic 1 PREF QL 60/30 CONCERTA TAB 36MG Brand 2 GR CONCERTA TAB 54MG Brand 2 GR METHYLPHENID TAB 54MG ER generic 1 PREF QL 30/30 METHYLIN CHW 2.5MG generic 1 PREF QL 90/30 PA METHYLIN CHW 5MG generic 1 PREF QL 90/30 PA METHYLIN CHW 10MG generic 1 PREF QL 180/30 PA QUILLIVANT SUS XR Brand 2 NON-PREF ST QL 240/30 METHYLIN SOL 5MG/5ML Brand 2 GR METHYLIN SOL 10MG/5ML Brand 2 GR RITALIN LA CAP 10MG Brand 2 METHYLPHENID CAP 20MG ER generic 1 NON-PREF ST QL 60/30 RITALIN LA CAP 20MG Brand 2 NON-PREF ST QL 30/30 METHYLPHENID CAP 30MG ER generic 1 NON-PREF ST QL 60/30 RITALIN LA CAP 30MG Brand 2 NON-PREF ST QL 30/30 METHYLPHENID CAP 40MG ER generic 1 NON-PREF ST QL 60/30 RITALIN LA CAP 40MG Brand 2 NON-PREF ST QL 30/30 MODAFINIL TAB 100MG generic 1 QL 30/30 PA PROVIGIL TAB 100MG Brand 2 GR MODAFINIL TAB 200MG generic 1 QL 30/30 PA PROVIGIL TAB 200MG Brand 2 GR KEY: GR=Generic Use required; PA=Prior Authorization required; ST=Step Therapy required; SP=Restricted to Orchard specialty Page 5 of 294 pharmacy: 1-877-437-9012; MO= 90days supply allowed at Retail-90 pharmacies or Orchard Mail Order Pharmacy: 1-866-909-5170.
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