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2020 Welldyne Formulary.Pdf LEGEND TIER DESCRIPTION 1 Preferred Generics 2 Non-Preferred Generics 3 Preferred Brands 4 Non-Preferred Brands 5 Preferred Specialty 6 Non-Preferred Specialty TYPE DESCRIPTION There is a limit on the amount of this drug that is covered per QL Quantity Limit prescription, or within a specific time frame. You (or your physician) are required to get prior authorization before PA Prior Authorization you fill your prescription for this drug. Without prior approval, we may not cover this drug. In some cases, you may be required to first try certain drugs to treat ST Step Therapy your medical condition before we will cover another drug for that condition. This prescription drug may only be covered if you meet the minimum AL1 Age Limit or maximum age limit. LA Limited Access This prescription drug is limited to certain pharmacies. Specialty drugs are high-cost drugs used to treat complex or rare S Specialty Drug conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. PAGE 1 LAST UPDATED 01/2020 LIST OF COVERED PRESCRIPTION MEDICATIONS PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ADHD/ANTI-NARCOLEPSY /ANTI-OBESITY/ANOREXIANT AGENTS ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS ADDERALL 4 AL1 Up to 25 yrs old ADDERALL XR 4 AL1 Up to 25 yrs old QL 30 / 30 day(s) ADHANSIA XR 4 AL1 Up to 25 yrs old QL 30 / 30 Days ADIPEX-P 4 PA QL 300 / 30 day(s) ADZENYS ER 4 AL1 Up to 25 yrs old QL 30 / 30 Days ADZENYS XR-ODT 4 AL1 Up to 25 yrs old QL 300 / 30 day(s) AMPHETAMINE ER 4 AL1 Up to 25 yrs old QL 180 / 30 day(s) amphetamine sulfate 10 mg tab 1 AL1 Up to 25 yrs old QL 90 / 30 day(s) amphetamine sulfate 5 mg tab 1 AL1 Up to 25 yrs old amphetamine-dextroamphet er 1 AL1 Up to 25 yrs old amphetamine-dextroamphetamine 1 AL1 Up to 25 yrs old QL 30 / 30 Days APTENSIO XR 4 AL1 Up to 25 yrs old QL 30 / 30 Days armodafinil (150 mg tab, 200 mg tab, 250 mg tab) 1 PA QL 60 / 30 Days armodafinil 50 mg tab 1 PA QL 60 / 30 Days atomoxetine hcl (18 mg cap, 25 mg cap) 1 AL1 Up to 25 yrs old PAGE 2 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS atomoxetine hcl (40 mg cap, 60 mg cap, 80 mg cap, 100 mg QL 30 / 30 Days 1 cap) AL1 Up to 25 yrs old QL 90 / 30 Days atomoxetine hcl 10 mg cap 1 AL1 Up to 25 yrs old QL 60 / 30 Days BELVIQ 4 PA QL 30 / 30 Days BELVIQ XR 4 PA QL 90 / 30 Days BENZPHETAMINE HCL 25 MG TAB 3 PA QL 90 / 30 Days benzphetamine hcl 50 mg tab 1 PA BONTRIL PDM 4 CAFCIT 4 CAFFEINE 4 CAFFEINE ANHYDROUS 4 caffeine citrate 1 CAFFEINE CITRATED 4 CAFFEINE-SODIUM BENZOATE 3 clonidine hcl er 1 QL 120 / 30 Days CONCERTA (18 MG TAB ER, 27 MG TAB ER, 54 MG TAB QL 30 / 30 Days 4 ER) AL1 Up to 25 yrs old QL 60 / 30 Days CONCERTA 36 MG TAB ER 4 AL1 Up to 25 yrs old QL 120 / 30 Days CONTRAVE 4 PA COTEMPLA XR-ODT (17.3 MG TAB ER DISP, 25.9 MG TAB QL 60 / 30 Days 4 ER DISP) AL1 Up to 25 yrs old QL 30 / 30 Days COTEMPLA XR-ODT 8.6 MG TAB ER DISP 4 AL1 Up to 25 yrs old PAGE 3 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 Box / 30 Days DAYTRANA 3 AL1 Up to 25 yrs old PA DESOXYN 4 AL1 Up to 25 yrs old DEXEDRINE (5 MG CAP ER 24H, 10 MG CAP ER 24H, 15 MG AL1 Up to 25 yrs old CAP ER 24H) 4 QL 60 / 30 Days dexedrine (5 mg tab, 10 mg tab) 1 AL1 Up to 25 yrs old QL 90 / 30 Days dexmethylphenidate hcl (2.5 mg tab, 5 mg tab) 1 AL1 Up to 25 yrs old QL 60 / 30 Days dexmethylphenidate hcl 10 mg tab 1 AL1 Up to 25 yrs old QL 30 / 30 Days dexmethylphenidate hcl er 1 AL1 Up to 25 yrs old QL 60 / 30 Days dextroamphetamine sulfate (5 mg tab, 10 mg tab) 1 AL1 Up to 25 yrs old QL 1800 Milliliters / 30 dextroamphetamine sulfate 5 mg/5ml solution 1 Days AL1 Up to 25 yrs old dextroamphetamine sulfate er 1 AL1 Up to 25 yrs old QL 90 / 30 Days diethylpropion hcl 25 mg tab 1 PA DIETHYLPROPION HCL 25 MG TAB 4 QL 30 / 30 Days DIETHYLPROPION HCL ER 2 PA diethylpropion hcl er 1 PA QL 240 Milliliters / 30 Days DYANAVEL XR 4 AL1 Up to 25 yrs old QL 180 / 30 day(s) EVEKEO 10 MG TAB 3 AL1 Up to 25 yrs old PAGE 4 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 90 / 30 day(s) EVEKEO 5 MG TAB 3 AL1 Up to 25 yrs old EVEKEO ODT (ODT 5 MG TAB DISP, ODT 10 MG TAB DISP, QL 30 / 30 day(s) 4 ODT 15 MG TAB DISP) AL1 Up to 25 yrs old QL 90 / 30 day(s) EVEKEO ODT 20 MG TAB DISP 4 AL1 Up to 25 yrs old QL 90 / 30 Days FOCALIN (2.5 MG TAB, 5 MG TAB) 4 AL1 Up to 25 yrs old QL 60 / 30 Days FOCALIN 10 MG TAB 4 AL1 Up to 25 yrs old QL 30 / 30 Days FOCALIN XR 4 AL1 Up to 25 yrs old guanfacine hcl er 1 QL 30 / 30 Days INTUNIV 4 QL 30 / 30 Days KAPVAY 4 QL 120 / 30 Days QL 90 / 30 Days LOMAIRA 4 PA METADATE CD 4 QL 90 / 30 Days metadate er 1 AL1 Up to 25 yrs old PA methamphetamine hcl 1 AL1 Up to 25 yrs old METHYLIN (2.5 MG CHEW TAB, 5 MG CHEW TAB, 10 MG CHEW TAB) 4 QL 900 Milliliters / 30 Days METHYLIN 10 MG/5ML SOLUTION 4 AL1 Up to 25 yrs old QL 450 Milliliters / 30 Days METHYLIN 5 MG/5ML SOLUTION 4 AL1 Up to 25 yrs old methylphenidate hcl (2.5 mg chew tab, 5 mg chew tab, 5 mg QL 90 / 30 Days 1 tab, 10 mg tab, 20 mg tab) AL1 Up to 25 yrs old PAGE 5 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 180 / 30 Days methylphenidate hcl 10 mg chew tab 1 AL1 Up to 25 yrs old QL 900 Milliliters / 30 Days methylphenidate hcl 10 mg/5ml solution 1 AL1 Up to 25 yrs old QL 450 Milliliters / 30 Days methylphenidate hcl 5 mg/5ml solution 1 AL1 Up to 25 yrs old QL 30 / 30 Days methylphenidate hcl er (cd) 1 AL1 Up to 25 yrs old QL 90 / 30 Days methylphenidate hcl er (er 10 mg tab er, er 20 mg tab er) 1 AL1 Up to 25 yrs old METHYLPHENIDATE HCL ER (ER 18 MG TAB ER 24H, ER QL 30 / 30 Days 3 27 MG TAB ER 24H, ER 54 MG TAB ER 24H) AL1 Up to 25 yrs old methylphenidate hcl er (er 18 mg tab er, er 27 mg tab er, er 27 QL 30 / 30 Days 1 mg tab er 24h, er 54 mg tab er, er 54 mg tab er 24h) AL1 Up to 25 yrs old QL 60 / 30 Days methylphenidate hcl er (er 36 mg tab er, er 36 mg tab er 24h) 1 AL1 Up to 25 yrs old QL 30 / 30 Days methylphenidate hcl er (la) 1 AL1 Up to 25 yrs old METHYLPHENIDATE HCL ER 18 MG TAB ER 4 QL 60 / 30 Days METHYLPHENIDATE HCL ER 36 MG TAB ER 24H 3 AL1 Up to 25 yrs old QL 30 / 30 day(s) METHYLPHENIDATE HCL ER 72 MG TAB ER 3 AL1 Up to 25 yrs old QL 60 / 30 Days modafinil 1 PA QL 30 / 30 Days MYDAYIS 4 AL1 Up to 25 yrs old NUVIGIL (150 MG TAB, 200 MG TAB, 250 MG TAB) 4 QL 30 / 30 Days NUVIGIL 50 MG TAB 4 QL 60 / 30 Days PAGE 6 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 90 / 30 Days phendimetrazine tartrate 1 PA QL 30 / 30 Days PHENDIMETRAZINE TARTRATE ER 4 PA QL 30 / 30 Days phentermine hcl (15 mg cap, 30 mg cap, 37.5 mg cap) 1 PA phentermine hcl 37.5 mg tab 1 QL 30 / 30 Days QL 1800 Milliliters / 30 PROCENTRA 4 Days AL1 Up to 25 yrs old PROVIGIL 4 QL 60 / 30 Days QSYMIA (3.75-23 MG CAP ER 24H, 11.25-69 MG CAP ER QL 14 / 365 Days 4 24H) PA QL 30 / 30 Days QSYMIA (7.5-46 MG CAP ER 24H, 15-92 MG CAP ER 24H) 4 PA QL 30 / 30 Days QUILLICHEW ER (ER 20 MG, ER 40 MG) 3 AL1 Up to 25 yrs old QL 60 / 30 Days QUILLICHEW ER 30 MG CHER 3 AL1 Up to 25 yrs old QL 360 Milliliters / 30 Days QUILLIVANT XR 3 AL1 Up to 25 yrs old QL 90 / 30 Days REGIMEX 4 PA QL 30 / 30 day(s) RELEXXII 3 AL1 Up to 25 yrs old QL 90 / 30 Days RITALIN 4 AL1 Up to 25 yrs old RITALIN LA (10 MG CAP ER 24H, 20 MG CAP ER 24H, 30 MG QL 30 / 30 Days 4 CAP ER 24H, 40 MG CAP ER 24H) AL1 Up to 25 yrs old PAGE 7 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 30 / 30 Days RITALIN LA 60 MG CAP ER 24H 3 AL1 Up to 25 yrs old QL 1 Box / 30 Days SAXENDA 4 PA QL 60 / 30 Days STRATTERA (18 MG CAP, 25 MG CAP) 4 AL1 Up to 25 yrs old STRATTERA (40 MG CAP, 60 MG CAP, 80 MG CAP, 100 MG QL 30 / 30 Days 4 CAP) AL1 Up to 25 yrs old QL 90 / 30 Days STRATTERA 10 MG CAP 4 AL1 Up to 25 yrs old QL 30 / 30 day(s) SUNOSI (75 MG TAB, 150 MG TAB) 4 PA SUPRENZA 4 PA QL 30 / 30 Days VYVANSE 3 AL1 Up to 25 yrs old QL 60 / 30 day(s) PA WAKIX 17.8 MG TAB 6 AL1 At least 18 yrs old LA Limited Access S QL 60 / 30 day(s) PA WAKIX 4.45 MG TAB 4 AL1 At least 18 yrs old LA Limited Access S QL 90 / 30 Days XENICAL 4 PA ZENZEDI (2.5 MG TAB, 7.5 MG TAB, 15 MG TAB, 20 MG TAB, QL 60 / 30 Days 4 30 MG TAB) AL1 Up to 25 yrs old QL 60 / 30 Days zenzedi (5 mg tab, 10 mg tab) 1 AL1 Up to 25 yrs old PAGE 8 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANALGESIC/ANTI-INFLAMMATORY/MIGRAINE/GOUT AGENTS/ANESTHETICS ANALGESICS - ANTI-INFLAMMATORY PA ACTEMRA (80 MG/4ML SOLUTION, 200 MG/10ML LA Limited Access SOLUTION, 400 MG/20ML SOLUTION) 5 S QL 4 Syringes / 28 Days PA ACTEMRA 162 MG/0.9ML SOLN PRSYR 5 LA Limited Access S QL 4 / 28 day(s) PA ACTEMRA ACTPEN 5 LA Limited Access S ANAPROX DS 4 ANODYNE ILE 4 ARAVA 4 PA ARCALYST 5 LA Limited Access S ARTHROTEC 4 QL 120 / 30 Days CELEBREX (50 MG CAP, 100 MG CAP, 200 MG CAP) 4 QL 60 / 30 Days CELEBREX 400 MG CAP 4 QL 30 / 30 Days celecoxib (50 mg cap, 100 mg cap, 200 mg cap) 1 QL 60 / 30 Days QL 30 / 30 Days celecoxib 400 mg cap 1 ST DAYPRO 4 diclofenac potassium 1 diclofenac sodium (25 mg tab dr, 50 mg tab dr, 75 mg tab dr) 1 diclofenac sodium er 1 diclofenac-misoprostol 1 QL 120 / 30 Days PAGE 9 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DYLOJECT 4 EC-NAPROSYN 4 EC-NAPROXEN 4 QL 4 Syringes / 28 Days ENBREL (25 MG/0.5ML SOLN PRSYR, 50 MG/ML SOLN PA PRSYR) 5 S PA ENBREL 25 MG RECON SOLN 5 S QL 4 Syringes / 28 Days ENBREL MINI 5 PA S QL 4 Auto-Injectors / 28 Days ENBREL SURECLICK 5 PA S etodolac 1 etodolac er 1 FELDENE 4 FENOPROFEN CALCIUM POWDER 4 FENOPROFEN CALCIUM (200 MG CAP, 400 MG CAP) 4 ST fenoprofen calcium 600 mg tab 1 FENORTHO 4 ST FLURBIPROFEN POWDER
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