MedPerform Low Formulary July 2017 Foreword FORMULARY This document represents the efforts of the MedImpact Healthcare Systems EXCLUDED THERAPEUTIC THERAPEUTIC DRUG CLASS Pharmacy and Therapeutics (P & T) and Formulary Committees to provide DRUGS physicians and pharmacists with a method to evaluate the safety, efficacy and cost- ALTERNATIVES effectiveness of commercially available drug products. A structured approach to the clindamycin/tretinoin, VELTIN ACNE AGENTS, TOPICAL drug selection process is essential in ensuring continuing patient access to rational ZIANA 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 ER, ANALGESICS, prescribing decisions that reflect the most current clinical consensus associated KADIAN with drug therapy decisions. NUCYNTA, NUCYNTA NARCOTICS ER This is accomplished through the auspices of the MedImpact P & T and Formulary ANALGESICS, 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, ANALGESICS, LAZANDA, fentanyl citrate lozenge As you use this Formulary, you are encouraged to review the information and NARCOTICS provide your input and comments to the MedImpact P & T and Formulary ONSOLIS, Committees. SUBSYS 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 KIT, gabapentin & Comparison of relevant therapeutic benefits to current formulary agents of SMARTRX lidocaine/menthol topical, ANTICONVULSANTS similar use, and to minimize therapeutic duplication where possible GABA-V KIT, Cost-effectiveness relative to comparable therapies or capsaicin/methyl SMART RX salicylate/menthol topical GABA KIT How to Use the Formulary The Formulary is a list of medications available to MedImpact members under their ANTICONVULSANTS pharmacy benefit. All drugs are listed by their generic names and most common immediate-release (RESTLESS LEG proprietary (branded) name. The Formulary may be accessed by using the index, HORIZANT gabapentin, SYNDROME/POST either by generic or proprietary name (in capital letters) and by therapeutic drug ropinirole, pramipexole category. In situations where an FDA approved generic equivalent is available, HERPETIC NEURALGIA) brand names are listed for reference purposes only, and do not denote coverage FORFIVO XL bupropion ER ANTIDEPRESSANTS 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 IRENKA duloxetine ANTIDEPRESSANTS Non-Formulary drug. desvenlafaxine succinate KHEDEZLA ER, desvenlafaxine ER ANTIDEPRESSANTS All drugs are listed in each category in alphabetical order by generic name. Where an FDA approved generic is available for the listed generic name, the generic name (Ranbaxy) is bolded. PEXEVA paroxetine ANTIDEPRESSANTS For certain agents within the Formulary, a recommended prescribing guideline may ZUPLENZ ondansetron ODT ANTIEMETIC AGENTS apply. These are denoted throughout the document using the following symbols: NYATA nystatin topical ANTI-INFECTIVE AGE Age Edit Coverage may depend on patient age CU Concurrent Use Edit Coverage or lack thereof may depend upon DAXBIA cephalexin ANTI-INFECTIVE concurrent use of another drug MD Physician Specialty Edit Coverage may depend on prescribing ZIPSOR, ANTI-INFLAMMATORY diclofenac physician’s ZORVOLEX NON-STEROIDAL specialty or board certification PA Prior Authorization Requires specific physician request process QL Quantity Limit Coverage may be limited to specific quantities ANTI-INFLAMMATORY NAPRELAN naproxen per prescription and/or time period NON-STEROIDAL ST Step Therapy Coverage may depend on previous use of another drug ANTI-INFLAMMATORY VIVLODEX meloxicam Please refer to the prescribing guideline appendix within this document for details NON-STEROIDAL regarding specific agents. ANTI-INFLAMMATORY TIVORBEX indomethacin Benefit Coverage and Limitations NON-STEROIDAL This printed Formulary does not provide information regarding the specific coverage and limitations an individual member may be subject to. Many members naproxen & have specific benefit inclusions, exclusions, copays, or a lack of coverage, which esomeprazole ANTI-INFLAMMATORY are not reflected in the Formulary. magnesium, VIMOVO NON-STEROIDAL lansoprazole, The Formulary applies only to outpatient drugs provided to members, and does not COMBINATION AGENTS apply to medications used in inpatient settings. If a member has any specific omeprazole, or questions regarding their coverage, they should contact their Plan Sponsor or pantoprazole MedImpact at (800) 788-2949. ANTI-INFLAMMATORY DUEXIS famotidine & ibuprofen NON-STEROIDAL Excluded Agents COMBINATION AGENTS As new drugs become available, they will be considered for coverage under the ANTI-INFLAMMATORY MedPerform Formulary. The plan administrator has the right to decide what drugs are covered and to what extent, as well as the right to modify coverage including celecoxib & NON-STEROIDAL the exclusion of any prescription drugs. Please note that prescribing guidelines CAPXIB capsaicin/menthol topical CYCLOOXYGENASE-2 such as Prior Authorization, Step Therapy, Quantity Limit, etc., may still apply to patch (COX-2) SELECTIVE Formulary Therapeutic Alternatives. INHIBITOR immediate-release ANTI-INFLAMMATORY RAYOS prednisone STEROIDAL 37010 MedPerform Low Formulary – July 2017 i MedPerform LOW Formulary FORMULARY FORMULARY EXCLUDED THERAPEUTIC DRUG EXCLUDED THERAPEUTIC DRUG THERAPEUTIC THERAPEUTIC DRUGS CLASS DRUGS CLASS ALTERNATIVES ALTERNATIVES LEVITRA, DRUGS TO TREAT STENDRA, VIAGRA ZONACORT, dexamethasone ANTI-INFLAMMATORY IMPOTENCY STAXYN LOCORT 1.5mg tab STEROIDAL EMERGENCY diphenoxylate/atropi epinephrine 0.3mg MOTOFEN ANTI-MOTILITY TREATMENT OF ne AUVI-Q or 0.15mg auto- ALLERGIC REACTIONS codeine/pseudoephe injector HYCOFENIX ANTITUSSIVES (TYPE 1) drine/guaifenesin sol GENOTROPIN, APTENSIO XR, dextroamphetamine/ ATTENTION DEFICIT- HUMATROPE, ADZENYS XR amphetamine, HYPERACTIVITY NUTROPIN, ODT methylphenidate (ADHD)/NARCOLEPSY NUTROPIN AQ, OMNITROPE, GROWTH HORMONES HUMIRA, ENBREL, NUTROPIN AQ NORDITROPIN COSENTYX, NUSPIN, STELARA, CIMZIA, SAIZEN, XELJANZ/XR, KEVZARA, ZOMACTON OTEZLA, *SIMPONI AUTOIMMUNE DISEASE SIMPONI 50mg, VIEKIRA PAK, HARVONI, 100mg (*for HEPATITIS C TALTZ DAKLINZA EPCLUSA diagnosis of ESTROGEL DIVIGEL HORMONAL DEFICIENCY ulcerative colitis only) NATESTO, TESTIM, ANDROGEL, alendronate 70mg, BONE RESORPTION HORMONAL DEFICIENCY BINOSTO VOGELXO, AXIRON ibandronate INHIBITORS FORTESTA aspirin (OTC), amlodipine and DURLAZA CARDIOLOGY PRESTALIA HYPERTENSION clopidogrel benazepril hcl YOSPRALA aspirin (OTC) CARDIOLOGY APIDRA, GONITRO nitroglycerin CARDIOLOGY APIDRA SOLOSTAR, KELOCOTE, HUMALOG INSULINS BEAU RX DERMATOLOGY NOVOLOG, RECEDO NOVOLOG DERMAPAK tretinoin topical DERMATOLOGY FLEXPLEN PLUS LEVEMIR, ACCUCAINE lidocaine topical DERMATOLOGY BASAGLAR, LANTUS, TOUJEO INSULINS PEDIPAK ciclopirox DERMATOLOGY TRESIBA OTC EMOLLIENTS NOVOLIN HUMULIN INSULINS (EUCERIN, atorvastatin, lovastatin, SYNERDERM CETAPHIL, DERMATOLOGY ALTOPREV, pravastatin, LIPID IRREGULARITY VASELINE, LESCOL XL AQUAPHOR) simvastatin, URE-K, rosuvastatin KERALAC, fenofibrate/ UTOPIC, ANTARA micronized/ LIPOTROPICS urea 40%, urea 50% DERMATOLOGY UREVAZ, nanocrystallized DERMASORB balsalazide LOWER XM DELZICOL, disodium, APRISO, GASTROINTESTINAL diclofenac sodium DERMATOLOGY - DIPENTUM LIALDA, PENTASA, PENNSAID DISORDERS 1% topical ANTIINFLAMMATORY sulfasalazine ADLYXIN, ONZETRA, BYDUREON, TRULICITY, ZEMBRACE DIABETES sumatriptan MIGRAINE BYETTA, VICTOZA SYMTOUCH, TANZEUM TREXIMET TRULICITY, REBIF, GILENYA, XULTOPHY, VICTOZA, LANTUS, DIABETES PLEGRIDY, SOLIQUA TECFIDERA, TOUJEO EXTAVIA MULTIPLE SCLEROSIS INVOKANA, AVONEX, INVOKAMET,INVOK GLATOPA, FARXIGA, AMET XR, AUBAGIO DIABETES Individual vitamin MULTIVITAMIN XIGDUO XR JARDIANCE, METHAVER SYNJARDY, components PREPARATIONS SYNJARDY XR Nasal triamcinolone, GLUMETZA metformin ER DIABETES OMNARIS, flunisolide, ZETONNA, fluticasone, NASAL ANTI- NESINA, JENTADUETO, BECONASE AQ, budesonide, INFLAMMATORY KAZANO, JENTADUETO XR, TICANASE mometasone, OSENI, TRADJENTA, DIABETES QNASL ONGLYZA, JANUVIA, NASAL ANTI- Azelastine & KOMBIGLYZE JANUMET, INFLAMMATORY/ANTI- TICALAST fluticasone nasal XR JANUMET XR HISTAMINE sprays ALL OTHER COMBINATION MANUFACTUR ABBOTT phentermine & ERS OF (PRECISION AND DIABETIC SUPPLIES QSYMIA OBESITY AGENTS DIABETIC TEST FREESTYLE (TEST STRIPS, METERS) topiramate STRIPS AND BRAND) METERS 37010 MedPerform Low Formulary – July 2017 ii MedPerform LOW Formulary FORMULARY EXCLUDED THERAPEUTIC DRUG THERAPEUTIC DRUGS CLASS ALTERNATIVES latanoprost, travoprost, OPHTHALMIC ZIOPTAN LUMIGAN, GLAUCOMA TRAVATAN Z NARCAN NASAL OPIOID REVERSAL EVZIO SPRAY LASTACAFT, BEPREVE, PATADAY, OPHTHALMIC EMADINE, olopatadine ANTIHISTAMINES PAZEO ORAL/PHARYNGEAL ARESTIN N/A DISORDERS lipase/protease/amyl PANCREAZE, ase, CREON, PANCREATIC ENZYMES PERTZYE ZENPEP AIRDUO RESPICLICK AND AUTHORIZED ADVAIR, BREO GENERIC ELIPTA, RESPIRATORY ASTHMA FLUTICASONE/ SYMBICORT, SALMETEROL DULERA (55/14mcg, 113/14mcg, and 232/14mcg) UTIBRON, STIOLTO