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INTEGRIS Formulary July 2017

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INTEGRIS Formulary July 2017 INTEGRIS Formulary July 2017 Foreword FORMULARY EXCLUDED THERAPEUTIC DRUG This document represents the efforts of the MedImpact Healthcare Systems THERAPEUTIC DRUGS CLASS Pharmacy and Therapeutics (P & T) and Formulary Committees to provide ALTERNATIVES physicians and pharmacists with a method to evaluate the safety, efficacy and cost- clindamycin/tretinoin, ACNE AGENTS, effectiveness of commercially available drug products. A structured approach to the VELTIN drug selection process is essential in ensuring continuing patient access to rational ZIANA TOPICAL drug therapies. The ultimate goal of the MedPerform Formulary is to provide a morphine sulfate ER process and framework to support the dynamic evolution of this document to guide tablets, oxycodone ANALGESICS, KADIAN prescribing decisions that reflect the most current clinical consensus associated ER, NUCYNTA, NARCOTICS with drug therapy decisions. NUCYNTA ER ANALGESICS, This is accomplished through the auspices of the MedImpact P & T and Formulary BELBUCA BUTRANS PATCH Committees. These committees meet quarterly and more often as warranted to NARCOTICS ensure clinical relevancy of the Formulary. To accommodate changes to this ABSTRAL, document, updates are made accessible as necessary. FENTORA, fentanyl citrate ANALGESICS, LAZANDA, lozenge NARCOTICS As you use this Formulary, you are encouraged to review the information and ONSOLIS, provide your input and comments to the MedImpact P & T and Formulary SUBSYS Committees. immediate-release GRALISE ANTICONVULSANTS The MedImpact P & T and Formulary Committees use the following criteria in the gabapentin evaluation of drug selection for the MedPerform Formulary: • Drug safety profile ACTIVE-PAC immediate-release • Drug efficacy gabapentin & KIT, • Comparison of relevant therapeutic benefits to current formulary agents of lidocaine/menthol SMARTRX similar use, and to minimize therapeutic duplication where possible topical, or ANTICONVULSANTS • GABA-V KIT, Cost-effectiveness relative to comparable therapies capsaicin/methyl SMART RX salicylate/menthol How to Use the Formulary GABA KIT The Formulary is a list of medications available to MedImpact members under their topical pharmacy benefit. All drugs are listed by their generic names and most common proprietary (branded) name. The Formulary may be accessed by using the index, immediate-release ANTICONVULSANTS either by generic or proprietary name (in capital letters) and by therapeutic drug gabapentin, (RESTLESS LEG HORIZANT category. In situations where an FDA approved generic equivalent is available, ropinirole, SYNDROME/POST brand names are listed for reference purposes only, and do not denote coverage pramipexole HERPETIC NEURALGIA) for the brand, unless specifically noted. Any drug not found in this Formulary listing, or any Formulary updates published by MedImpact shall be considered a FORFIVO XL bupropion ER ANTIDEPRESSANTS Non-Formulary drug. IRENKA duloxetine ANTIDEPRESSANTS desvenlafaxine All drugs are listed in each category in alphabetical order by generic name. Where succinate ER, KHEDEZLA ANTIDEPRESSANTS an FDA approved generic is available for the listed generic name, the generic name desvenlafaxine ER is bolded. (Ranbaxy) For certain agents within the Formulary, a recommended prescribing guideline may PEXEVA paroxetine ANTIDEPRESSANTS apply. These are denoted throughout the document using the following symbols: ZUPLENZ ondansetron ODT ANTIEMETIC AGENTS AGE Age Edit Coverage may depend on patient age NYATA nystatin topical ANTI-INFECTIVE CU Concurrent Coverage or lack thereof may depend upon Use Edit concurrent use of another drug DAXBIA cephalexin ANTI-INFECTIVE MD Physician Coverage may depend on prescribing physician’s ZIPSOR, ANTI-INFLAMMATORY Specialty Edit specialty or board certification diclofenac ZORVOLEX NON-STEROIDAL PA Prior Requires specific physician request process ANTI-INFLAMMATORY NAPRELAN naproxen Authorization NON-STEROIDAL ANTI-INFLAMMATORY VIVLODEX meloxicam QL Quantity Coverage may be limited to specific quantities NON-STEROIDAL Limit per prescription and/or time period ANTI-INFLAMMATORY ST Step Therapy Coverage may depend on previous use of another TIVORBEX indomethacin drug NON-STEROIDAL naproxen & Please refer to the prescribing guideline appendix within this document for details esomeprazole ANTI-INFLAMMATORY regarding specific agents. magnesium, VIMOVO NON-STEROIDAL lansoprazole, COMBINATION AGENTS Benefit Coverage and Limitations omeprazole, or This printed Formulary does not provide information regarding the specific coverage and limitations an individual member may be subject to. Many members pantoprazole ANTI-INFLAMMATORY have specific benefit inclusions, exclusions, copays, or a lack of coverage, which famotidine & are not reflected in the Formulary. DUEXIS NON-STEROIDAL ibuprofen COMBINATION AGENTS The Formulary applies only to outpatient drugs provided to members, and does not APTENSIO dextroamphetamine/ ATTENTION DEFICIT- apply to medications used in inpatient settings. If a member has any specific XR, questions regarding their coverage, they should contact their Plan Sponsor or amphetamine, HYPERACTIVITY ADZENYS XR MedImpact at (800) 788-2949. methylphenidate (ADHD)/NARCOLEPSY ODT Excluded Agents immediate-release ANTI-INFLAMMATORY RAYOS As new drugs become available, they will be considered for coverage under the prednisone STEROIDAL MedPerform Formulary. The plan administrator has the right to decide what drugs ZONACORT, dexamethasone ANTI-INFLAMMATORY are covered and to what extent, as well as the right to modify coverage including LOCORT 1.5mg tab STEROIDAL the exclusion of any prescription drugs. Please note that prescribing guidelines diphenoxylate/atropi such as Prior Authorization, Step Therapy, Quantity Limit, etc., may still apply to MOTOFEN ANTI-MOTILITY Formulary Therapeutic Alternatives. ne INTEGRIS Formulary – July 2017 iii INTEGRIS Formulary FORMULARY FORMULARY EXCLUDED THERAPEUTIC DRUG EXCLUDED THERAPEUTIC DRUG THERAPEUTIC THERAPEUTIC DRUGS CLASS DRUGS CLASS ALTERNATIVES ALTERNATIVES codeine/pseudoephe LEVITRA, HYCOFENIX ANTITUSSIVES DRUGS TO TREAT drine/guaifenesin sol STENDRA, VIAGRA IMPOTENCY ANTI-INFLAMMATORY STAXYN celecoxib & NON-STEROIDAL EMERGENCY epinephrine 0.3mg CAPXIB capsaicin/menthol CYCLOOXYGENASE-2 TREATMENT OF AUVI-Q or 0.15mg auto- topical patch (COX-2) SELECTIVE ALLERGIC REACTIONS injector INHIBITOR (TYPE 1) HUMIRA, ENBREL, VIEKIRA PAK, HARVONI, HEPATITIS C COSENTYX, DAKLINZA EPCLUSA STELARA, CIMZIA, HORMONAL XELJANZ/XR,OTEZ ESTROGEL DIVIGEL KEVZARA, DEFICIENCY LA, *SIMPONI AUTOIMMUNE DISEASE SIMPONI NATESTO, 100mg (*for 50mg, TALTZ TESTIM, ANDROGEL, HORMONAL diagnosis of VOGELXO, AXIRON DEFICIENCY ulcerative colitis FORTESTA only) GENOTROPI alendronate 70mg, BONE RESORPTION N, BINOSTO ibandronate INHIBITORS HUMATROPE aspirin (OTC), , NUTROPIN, DURLAZA CARDIOLOGY NUTROPIN OMNITROPE, clopidogrel GROWTH HORMONES AQ, NORDITROPIN YOSPRALA aspirin (OTC) CARDIOLOGY NUTROPIN GONITRO nitroglycerin CARDIOLOGY AQ NUSPIN, KELOCOTE, BEAU RX DERMATOLOGY SAIZEN, RECEDO ZOMACTON DERMAPAK amlodipine and tretinoin topical DERMATOLOGY PRESTALIA HYPERTENSION PLUS benazepril hcl APIDRA, ACCUCAINE lidocaine topical DERMATOLOGY APIDRA SOLOSTAR, PEDIPAK ciclopirox DERMATOLOGY HUMALOG INSULINS NOVOLOG, OTC EMOLLIENTS NOVOLOG (EUCERIN, FLEXPLEN SYNERDERM CETAPHIL, DERMATOLOGY LEVEMIR, VASELINE, BASAGLAR, LANTUS, TOUJEO INSULINS AQUAPHOR) TRESIBA URE-K, NOVOLIN HUMULIN INSULINS KERALAC, atorvastatin, UTOPIC, lovastatin, urea 40%, urea 50% DERMATOLOGY ALTOPREV, UREVAZ, pravastatin, LIPID IRREGULARITY LESCOL XL DERMASORB simvastatin, XM rosuvastatin diclofenac sodium DERMATOLOGY - PENNSAID fenofibrate/ 1% topical ANTIINFLAMMATORY ANTARA micronized/ LIPOTROPICS ADLYXIN, nanocrystallized BYDUREON, TRULICITY, balsalazide DIABETES LOWER BYETTA, VICTOZA DELZICOL, disodium, APRISO, GASTROINTESTINAL TANZEUM DIPENTUM LIALDA, PENTASA, TRULICITY, DISORDERS XULTOPHY, sulfasalazine VICTOZA, LANTUS, DIABETES SOLIQUA ONZETRA, TOUJEO ZEMBRACE sumatriptan MIGRAINE INVOKANA, SYMTOUCH, INVOKAMET, TREXIMET FARXIGA, INVOKAMET XR, DIABETES REBIF, GILENYA, XIGDUO XR JARDIANCE, PLEGRIDY, SYNJARDY, TECFIDERA, EXTAVIA MULTIPLE SCLEROSIS SYNJARDY XR AVONEX, GLUMETZA metformin ER DIABETES GLATOPA, NESINA, JENTADUETO, AUBAGIO KAZANO, JENTADUETO XR, Individual vitamin MULTIVITAMIN METHAVER OSENI, TRADJENTA, components PREPARATIONS DIABETES ONGLYZA, JANUVIA, Nasal triamcinolone, OMNARIS, KOMBIGLYZE JANUMET, flunisolide, ZETONNA, XR JANUMET XR fluticasone, NASAL ANTI- BECONASE ALL OTHER budesonide, INFLAMMATORY MANUFACTU AQ, ABBOTT mometasone, RERS OF DIABETIC SUPPLIES TICANASE (PRECISION AND QNASL DIABETIC (TEST STRIPS, NASAL ANTI- FREESTYLE azelastine & TEST STRIPS METERS) INFLAMMATORY/ANTI- BRAND) TICALAST fluticasone nasal AND HISTAMINE sprays METERS COMBINATION phentermine & QSYMIA OBESITY AGENTS topiramate 37012 MedPerform Medium Formulary – July 2017 iv INTEGRIS Formulary FORMULARY • EXCLUDED THERAPEUTIC DRUG A multi-source drug product manufactured by at least one (1) nationally THERAPEUTIC DRUGS CLASS marketed company. ALTERNATIVES • At least one (1) of the generic manufacturer’s products must have an latanoprost, “A” rating or the generic product has been determined to be travoprost, OPHTHALMIC unassociated with efficacy, safety or bioequivalency concerns by the ZIOPTAN LUMIGAN, GLAUCOMA MedImpact P & T Committee. TRAVATAN Z • Drug product will be approved for generic substitution by the NARCAN NASAL MedImpact P & T Committee. EVZIO
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