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July 1, 2021 Premium Formulary Exclusions & Preferred Specialty Prior Authorization Requirements

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July 1, 2021 Premium Formulary Exclusions & Preferred Specialty Prior Authorization Requirements July 1, 2021 Premium Formulary Exclusions & Preferred Specialty Prior Authorization Requirements Therapeutic Category Excluded Medications Preferred Alternatives ALLERGIC REACTIONS epinephrine injection (0.15mg, Anaphylaxis Treatment Auvi-Q (0.15mg, 0.3mg) 0.3mg) ANALGESICS celecoxib, diflunisal, etodolac, flurbiprofen, ibuprofen, indomethacin, ketoprofen, Cambia, Diclofenac Cap 35mg ketorolac, meclofenamate, (M), Zipsor, Zorvolex meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, Oral sulindac, tolmetin Non-Steroidal Anti- Qmiiz ODT meloxicam Inflammatory Agents Relafen DS nabumetone Ketorolac Nasal Spray (M), Sprix diclofenac, ibuprofen, Other Nasal Spray meloxicam Diclofenac Patch (M), Flector, Topical diclofenac gel/solution Licart, Pennsaid, Voltaren gel Opioid Apadaz, hydrocodone/acetaminophen, combinations Benzhydrocodone/acetaminophen oxycodone/acetaminophen hydromorphone HCl ER, Arymo ER, Kadian ER 200 mg, morphine sulfate ER, Oral Long- Nucynta ER, Oxycodone ER (M) oxymorphone HCl ER, Hysingla Acting ER, OxyContin, Xtampza ER Pain Opioid Analgesics Conzip, Tramadol ER 100mg, tramadol ER 200mg, 300mg cap (M) Oral Short- codeine sulfate, Acting hydromorphone HCl, morphine Nucynta Opioid sulfate, oxycodone HCl, Analgesics oxymorphone HCl 1 (M) Co-branded product 1 Existing utilizers of these medications will be allowed to continue on therapy. Continuation of therapy will not be provided for any other excluded drugs. 2 Existing utilizers of these medications will be allowed to continue on therapy with the diagnosis of HIV only. Continuation of therapy will not be provided for any other excluded drugs. Therapeutic Category Excluded Medications Preferred Alternatives ANALGESICS Transmucosal Abstral, Fentora, Fentanyl Citrate Pain Fentanyl Buccal Tab (M), fentanyl citrate lozenge Analgesics Lazanda, Subsys Norgesic Forte, Orphengesic Forte (M) orphenadrine tab, aspirin Skeletal Muscle Relaxants Ozobax baclofen ANTIBACTERIALS, ORAL Doryx 80mg, Doryx MPC, Doxycycline Hyclate DR Oral Antibiotics doxycycline, minocycline 80mg, Minolira ANTICONVULSANTS Lamictal ODT Kit lamotrigine ODT Seizure Disorders Oxtellar XR1 oxcarbazepine IR ANTIDEPRESSANTS Antidepressants Bupropion XL (M)1, Forfivo XL1 bupropion XL ANTIFUNGALS, ORAL Oral Antifungals Tolsura itraconazole cap ANTIHEMOPHILIACS Adynovate, Afstyla, Eloctate, Hemophilia A Esperoct 1 Jivi ANTIMIGRAINES amitriptyline, atenolol, divalproex sodium, nadolol, Ajovy propranolol, timolol, topiramate, CGRP Antagonists venlafaxine, Aimovig, Emgality Reyvow Nurtec ODT, Ubrelvy rizatriptan ODT, sumatriptan Serotonin Receptor Onzetra Xsail, Tosymra, Zembrace Symtouch injection, sumatriptan nasal Agonists spray, zolmitriptan ODT ANTIPARKINSON AGENTS Parkinson's Disease Gocovri, Osmolex ER amantadine ANTIPSYCHOTICS aripiprazole, asenipine, Atypical/Second Secuado1 olanzapine, quetiapine, Generation Antipsychotics quetiapine ER, risperidone ANTIVIRALS Ledipasvir-Sofosbuvir (M), Epclusa, Harvoni, Mavyret, Hepatitis-C drugs Sofosbuvir-Velpatasvir (M) Vosevi 2 (M) Co-branded product 1 Existing utilizers of these medications will be allowed to continue on therapy. Continuation of therapy will not be provided for any other excluded drugs. 2 Existing utilizers of these medications will be allowed to continue on therapy with the diagnosis of HIV only. Continuation of therapy will not be provided for any other excluded drugs. Therapeutic Category Excluded Medications Preferred Alternatives ANTIVIRALS Please talk with your doctor HIV drugs Descovy2, Temixys1 about clinically appropriate options. AUTONOMIC & CENTRAL NERVOUS SYSTEM Attention Deficit Disorder Adhansia XR methylphenidate ER, Vyvanse Interferon Beta Medications Extavia1, Plegridy1, Rebif 1, Avonex, Betaseron for Multiple Sclerosis Rebif Rebidose1 CARDIOVASCULAR atorvastatin, fluvastatin, Cholesterol-Lowering Livalo, Zypitamag lovastatin, pravastatin, Agents rosuvastatin, simvastatin Inderal XL , Innopran XL propranolol ER Hypertension Kapspargo metoprolol ER Katerzia amlodipine Hypertension with Consensi amlodipine, celecoxib Osteoarthritis CHEMOTHERAPY AGENTS Alkylating Agents Belrapzo, Bendamustine, Treanda Antiandrogens Erleada1, Yonsa1 HER-2 Inhibitors Herzuma, Ontruzant 1 Please talk to your doctor about Kinase Inhibitors Tabrecta clinically appropriate options. Methyltransferase Tazverik 1 Inhibitors Monoclonal Antibodies Ogivri, Truxima Miscellaneous Darzalex Faspro CONTRACEPTIVES Please talk to your doctor about Gel Phexxi clinically appropriate options. junel FE, larin FE, microgestin Lo Loestrin Oral FE, tarina FE 3 (M) Co-branded product 1 Existing utilizers of these medications will be allowed to continue on therapy. Continuation of therapy will not be provided for any other excluded drugs. 2 Existing utilizers of these medications will be allowed to continue on therapy with the diagnosis of HIV only. Continuation of therapy will not be provided for any other excluded drugs. Therapeutic Category Excluded Medications Preferred Alternatives CONTRACEPTIVES Camila, Incassia, Nora-Be, Oral Slynd norethindrone, Norlyda, Norlyroc levonorgestrel/ethinyl estradiol Patch Twirla combined generic oral contraceptive, Xulane etonogestrel-ethinyl estradiol Vaginal ring Annovera vaginal ring CORTICOSTEROIDS Hemady dexamethasone Oral Steroids Rayos prednisone DERMATOLOGICAL AGENTS adapalene, tretinoin cream/gel, Avita, Differin lotion Retin-A micro gel 0.06% and 0.08% adapalene, adapalene/benzoyl peroxide, clindamycin gel/lotion/solution, Aklief, Aktipak, Clindagel, Clindamycin phosphate clindamycin/benzoyl peroxide, Topical Acne Treatment 1% gel(M), Dapsone 7.5% (M), Veltin dapsone, erythromycin/benzoyl peroxide, tretinoin cream, Aczone 7.5%, Amzeeq, Epiduo Forte, Onexton Arazlo, Fabior, Tazorac tazarotene cream Topical anesthetics ZTlido lidocaine patch ciclopirox, tavaborole, Topical Antifungals Jublia terbinafine, Kerydin metronidazole cream/gel/lotion, Topical Antiinfectives Noritate cream Finacea, Soolantra ALA Scalp lotion hydrocortisone Apexicon E cream fluocinonide, betamethasone Derma-Smoothe/FS, Capex shampoo Topical Corticosteroids flucinolone acetonide scalp oil Cordran tape flurandrenolide 4 (M) Co-branded product 1 Existing utilizers of these medications will be allowed to continue on therapy. Continuation of therapy will not be provided for any other excluded drugs. 2 Existing utilizers of these medications will be allowed to continue on therapy with the diagnosis of HIV only. Continuation of therapy will not be provided for any other excluded drugs. Therapeutic Category Excluded Medications Preferred Alternatives DERMATOLOGICAL AGENTS betamethasone, clobetasol, Halobetasol foam(M), Lexette halobetasol cream/ointment betamethasone, mometasone, Halog ointment triamcinolone Impoyz cream clobetasol flurandrenolide, hydrocortisone Pandel cream valerate, triamcinolone Topical Corticosteroids acetonide Psorcon cream, Verdeso foam betamethasone, fluocinolone hydrocortisone valerate, Trianex oint 0.05% triamcinolone acetonide clobetasol proprionate, Ultravate lotion fluocinonide, halobetasol proprionate Topical Immune Response Imiquimod cream pump 3.75% (M), Zyclara Pump imiquimod Modifier Calcipotriene foam 0.005% (M), Sorilux calcipotriene clobetasol, fluocinonide, Topical Plaque Psoriasis Duobrii lotion halobetasol, tazorotene, Enstilar DIABETES Blood Glucose Meters, Examples: Abbott (FreeStyle, Precision), Ascencia (Contour, Contour Test Strips and Control Arkray(Glucocard), Lifescan (Onetouch), Trividia, Next) Solutions (TRUEtest, TRUEtrack), Roche (Accu-Chek) Continuous Glucose Freestyle Libre Dexcom Monitoring (CGM) Blood Sugar Regulators metformin HCl 24hr ER osmotic release, metformin metformin ER Miscellaneous HCl 24hr ER modified release Dipeptidyl Peptidase-4 Alogliptin(M), Alogliptin with metformin(M), Janumet, Janumet XR, Januvia, (DPP4) Inhibitors & Alogliptin with pioglitazone(M), Kazano, Jentadueto, Jentadueto XR, Combinations Kombiglyze XR, Nesina, Onglyza, Oseni Tradjenta Basal insulins Basaglar, Levemir, Semglee, Tresiba Lantus, Toujeo Bydureon, Bydureon BCise, Glucagon-Like Peptide- Adlyxin Byetta, Ozempic, Rybelsus, 1(GLP1) Agonists Trulicity, Victoza Insulins Novolin Humulin Admelog, Apidra, Fiasp, Insulin Aspart (M), Insulin Humalog, Lyumjev Rapid-acting insulins Lispro (M), Novolog 5 (M) Co-branded product 1 Existing utilizers of these medications will be allowed to continue on therapy. Continuation of therapy will not be provided for any other excluded drugs. 2 Existing utilizers of these medications will be allowed to continue on therapy with the diagnosis of HIV only. Continuation of therapy will not be provided for any other excluded drugs. Therapeutic Category Excluded Medications Preferred Alternatives DIABETES Sodium-glucose co- transporter (SGLT2) Invokana, Steglatro Farxiga, Jardiance Inhibitors - Single agent Sodium-glucose co- transporter (SGLT2) Synjardy, Synjardy XR, Xigduo Invokamet, Invokamet XR, Segluromet inhibitors - Combination XR agents SGLT2 and DPP4 QTERN, Steglujan Glyxambi, Trijardy XR Combinations ENDOCRINE (OTHER) Genotropin, Humatrope, Omnitrope, Saizen, Growth Hormones Norditropin, Nutropin Zomacton Gonal-F, Gonal-F RFF Follistim AQ Infertility Cetrotide ganirelix (made by Organon) Nocturia Noctiva desmopressin, Nocdurna testosterone, Androderm, Testosterone Replacement Aveed, Jatenzo, Natesto, Testopel Xyosted ENZYME DISORDERS Duchenne Muscular dexamethasone, Exondys 51, Vyondys 53 dystrophy (DMD) methylprednisolone, prednisone GASTROINTESTINAL diphenoxylate/atropine, Motofen
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