National Preferred Formulary January 2021 How to Use the Formulary The Formulary is a list of medications available to members under their pharmacy benefit. All drugs are listed by their generic names or most common proprietary (branded) name. Any drugs not found in this formulary listing or any formulary updates published by Express Scripts are considered non-formulary drugs and require prior authorization. All drugs are listed in each category in alphabetical order by generic or brand name. If the generic drug is FDA approved, it will appear italicized in the formulary listing. Covered brand drugs appear in CAPITALIZED font. Benefit Coverage and Limitations The Formulary applies only to outpatient drugs provided to members and does not apply to medications used in inpatient settings. If a member has any specific questions regarding their coverage, they should contact Wellfleet or Express Scripts at the phone numbers listed on their ID card. Excluded Agents Any drugs not listed in this print formulary are considered excluded from the drug benefit and are not covered. As new drugs become available, they will be considered for coverage under the Formulary. Non-Formulary and Step Therapy Exception Requests A member (or their appointed representative, prescribing physician, or authorized prescriber) may request a standard/non-urgent or expedited/urgent preservice/prior and current authorization for a drug that is subjected to utilization management tools such as step therapy. To initiate an exception request, contact 800-417-8164. Prior authorization guidelines will be made available to the member, member’s authorization representative, prescribing physician and other authorized prescriber upon request. PO Box 15369, Springfield, MA 01115 Copyright © 2019 Wellfleet Group, LLC. All rights reserved. www.wellfleetstudent.com i Table of Contents ANTI - INFECTIVES ........................................................................................................................................ 3 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ....................................................................... 22 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ........................................................................... 36 CARDIOVASCULAR, HYPERTENSION / LIPIDS ................................................................................... 65 DERMATOLOGICALS/TOPICAL THERAPY .......................................................................................... 85 DIAGNOSTICS / MISCELLANEOUS AGENTS ...................................................................................... 102 EAR, NOSE / THROAT MEDICATIONS .................................................................................................. 113 ENDOCRINE/DIABETES ............................................................................................................................ 115 GASTROENTEROLOGY ............................................................................................................................ 151 IMMUNOLOGY, VACCINES / BIOTECHNOLOGY .............................................................................. 161 MUSCULOSKELETAL / RHEUMATOLOGY ......................................................................................... 170 OBSTETRICS / GYNECOLOGY ................................................................................................................ 173 OPHTHALMOLOGY ................................................................................................................................... 185 RESPIRATORY AND ALLERGY .............................................................................................................. 191 UROLOGICALS ............................................................................................................................................ 202 VITAMINS, HEMATINICS / ELECTROLYTES ..................................................................................... 204 Index ................................................................................................................................................................ 224 1 List of Abbreviations ACA: Affordable Care Act. OTC: Over the Counter. An OTC drug is a non-prescription drug. PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. SP: Specialty ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. 2 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ANTI - INFECTIVES fluconazole in nacl 1 PA (iso-osm) ANTIFUNGAL AGENTS intravenous ABELCET 2 piggyback 100 INTRAVENOUS mg/50 ml, 200 SUSPENSION 5 mg/100 ml, 400 MG/ML mg/200 ml AMBISOME 2 fluconazole oral 1 INTRAVENOUS suspension for SUSPENSION FOR reconstitution 10 RECONSTITUTIO mg/ml, 40 mg/ml N 50 MG fluconazole oral 1 AMPHOTERICIN B 2 tablet 100 mg, 200 (BULK) POWDER mg, 50 mg amphotericin b 1 fluconazole oral 1 QL injection recon soln tablet 150 mg 50 mg FLUCYTOSINE 2 caspofungin 1 (BULK) POWDER intravenous recon 100 % soln 50 mg, 70 mg flucytosine oral 1 clotrimazole mucous 1 capsule 250 mg, 500 membrane troche 10 mg mg griseofulvin 1 CRESEMBA 2 PA microsize oral INTRAVENOUS suspension 125 mg/5 RECON SOLN 372 ml MG griseofulvin 1 CRESEMBA ORAL 2 PA microsize oral tablet CAPSULE 186 MG 500 mg ERAXIS(WATER 2 griseofulvin 1 DILUENT) ultramicrosize oral INTRAVENOUS tablet 125 mg, 250 RECON SOLN 100 mg MG, 50 MG ITRACONAZOLE 2 FLUCONAZOLE 2 (BULK) POWDER (BULK) POWDER itraconazole oral 1 QL 100 % capsule 100 mg itraconazole oral 1 solution 10 mg/ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 3 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits KETOCONAZOLE 2 posaconazole oral 1 PA (BULK) POWDER tablet,delayed release (dr/ec) 100 ketoconazole oral 1 mg tablet 200 mg TERBINAFINE 2 micafungin 1 (BULK) POWDER intravenous recon 100 % soln 100 mg, 50 mg terbinafine hcl oral 1 MICONAZOLE 2 tablet 250 mg (BULK) POWDER VORICONAZOLE 2 MYCAMINE 2 (BULK) POWDER INTRAVENOUS 100 % RECON SOLN 100 MG, 50 MG voriconazole 1 PA intravenous recon NOXAFIL 2 PA soln 200 mg INTRAVENOUS SOLUTION 300 voriconazole oral 1 PA MG/16.7 ML suspension for reconstitution 200 NOXAFIL ORAL 2 PA mg/5 ml (40 mg/ml) SUSPENSION 200 MG/5 ML (40 voriconazole oral 1 PA MG/ML) tablet 200 mg, 50 mg NYSTATIN 2 ANTIVIRALS (BULK) POWDER abacavir oral 1 SP 1 BILLION UNIT, 1 solution 20 mg/ml MILLION UNIT, 10 BILLION UNIT, 15 abacavir oral tablet 1 SP BILLION UNIT, 300 mg 150 MILLION abacavir-lamivudine 1 SP UNIT, 2 BILLION oral tablet 600-300 UNIT, 5 BILLION mg UNIT, 50 MILLION UNIT, 500 abacavir- 1 SP MILLION UNIT lamivudine- zidovudine oral nystatin oral 1 tablet 300-150-300 suspension 100,000 mg unit/ml ACYCLOVIR 2 nystatin oral tablet 1 (BULK) POWDER 500,000 unit 100 % acyclovir oral 1 capsule 200 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 4 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits acyclovir oral 1 cidofovir 1 suspension 200 mg/5 intravenous solution ml 75 mg/ml acyclovir oral tablet 1 CIMDUO ORAL 2 SP 400 mg, 800 mg TABLET 300-300 MG acyclovir sodium 1 intravenous recon CRIXIVAN ORAL 2 SP soln 1,000 mg, 500 CAPSULE 200 MG mg DESCOVY ORAL 2 SP acyclovir sodium 1 TABLET 200-25 intravenous solution MG 50 mg/ml didanosine oral 1 SP adefovir oral tablet 1 capsule,delayed 10 mg release(dr/ec) 250 mg, 400 mg AMANTADINE 2 HCL (BULK) DOVATO ORAL 2 SP POWDER TABLET 50-300 MG amantadine hcl oral 1 capsule 100 mg EDURANT ORAL 2 SP TABLET 25 MG amantadine hcl oral 1 solution 50 mg/5 ml efavirenz oral 1 SP capsule 200 mg, 50 amantadine hcl oral 1 mg tablet 100 mg efavirenz oral tablet 1 SP APTIVUS (WITH 2 SP 600 mg VITAMIN E) ORAL SOLUTION 100 efavirenz- 1 SP MG/ML emtricitabin-tenofov oral tablet 600-200- APTIVUS ORAL 2 SP 300 mg CAPSULE 250 MG efavirenz-lamivu- 1 SP atazanavir oral 1 SP tenofov disop oral capsule 150 mg, 200 tablet 400-300-300 mg, 300 mg mg, 600-300-300 mg BARACLUDE 2 emtricitabine oral 1 SP ORAL SOLUTION capsule 200 mg 0.05 MG/ML emtricitabine- 1 SP; ACA BIKTARVY ORAL 2 SP tenofovir (tdf) oral TABLET 50-200-25 tablet 200-300 mg MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 5 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits EMTRIVA ORAL 2 SP INTELENCE ORAL 2 SP SOLUTION 10 TABLET 100 MG, MG/ML 200 MG, 25 MG entecavir oral tablet 1 INVIRASE ORAL 2 SP 0.5 mg, 1 mg TABLET 500 MG EPCLUSA ORAL 2 PA; SP; QL ISENTRESS HD 2 SP TABLET 200-50 ORAL TABLET MG, 400-100 MG 600 MG EPIVIR HBV 2 ISENTRESS ORAL 2 SP ORAL SOLUTION POWDER IN 25 MG/5 ML (5 PACKET 100 MG MG/ML) ISENTRESS ORAL 2 SP famciclovir oral 1 QL TABLET 400 MG tablet 125 mg, 250 ISENTRESS ORAL 2 SP mg, 500 mg TABLET,CHEWAB fosamprenavir oral 1 SP LE