eBenefit Highlights The drugs listed below will require prior authorization through your GE Prescription Drug Benefits. Acne/Rosacea 1 1 • Absorica (isotretinoin) • Epiduo (adapalene/benzoyl peroxide) 1 • Acanya (clindamycin/benzoyl peroxide) • Fabior (tazarotene) 1 • Aczone (dapsone) • Inova (benzoyl peroxide/tocopherols) 1 • Akne-mycin (erythromycin) • Noritate (metronidazole) 1 • Atralin (tretinoin) • Onexton (clindamycin/benzoyl peroxide) 1 • Azelex (azelaic acid) • Tretin-X (tretinoin) 1 • Clindacin ETZ (clindamycin phosphate) • Vanoxide-HC (benzoyl peroxide/hydrocortisone) 1 • Clindacin PAC (clindamycin phosphate) • Veltin (clindamycin/tretinoin) 1 • Clindagel (clindamycin phosphate) • Ziana (clindamycin/tretinoin) 1 2 ADHD/Amphetamines/Stimulants 2 • Aptensio XR (methylphenidate) • Evekeo (amphetamine) 2 • Dyanavel XR (amphetamine extended release) • Intuniv (guanfacine) 2 3 Allergic Asthma/Asthma/COPD 3 • Aerospan (flunisolide) • Proventil HFA (albuterol) 3 • Alvesco (ciclesonide) • Symbicort (budesonide/formoterol) 3 • Cinqair (reslizumab) • Ventolin HFA (albuterol) 3 • Flunisolide nasal (flunisolide nasal) • Xolair (omalizumab) 3 • Incruse Ellipta (umeclidinium) • Xopenex HFA (levalbuterol) 3 • Nucala (mepolizumab) 3 4 Allergies Ophthalmic 4 • Lastacaft (alcaftadine) 4 5 Allergy/ Antihistamines/Nasal Corticosteroids 5 • Adrenaclick (epinephrine) • Omnaris (ciclesonide) 5 • Beconase AQ (beclomethasone) • Oralair (grass mixed pollens extract) 5 • Clarinex, Desloratadine (desloratadine) • Qnasl (beclomethasone) 5 • Clarinex-D (desloratadine/pseudoephedrine) • Ragwitek (ragweed pollen extract) 5 • Dymista (azelastine/fluticasone) • Veramyst (fluticasone) 5 • Grastek (timothy grass pollen extract) • Xyzal, Levocetirizine (levocetirizine) 5 • Nasonex (mometasone) • Zetonna (ciclesonide) 5 * Prior authorization applies after initial quantity limit Therapies covered by CVS/caremark Specialty Pharmacy may change or expand from time to time. This page contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with CVS Caremark. ©2016 CVS/caremark. All rights reserved 1 2016 04-20 6 Alzheimer’s Disease Therapy 6 • Aricept (donepezil) • Namenda XR (memantine ext-rel) 6 • Exelon (rivastigmine) • Namzaric (memantine ext-rel/donepezil) 6 • Exelon Patch (rivastigmine) • Razadyne (galantamine) 6 • Namenda (memantine) • Razadyne ER (galantamine ext-rel) 6 7 Anticoagulant Therapy 7 • Plavix (clopidogrel) 7 8 Anticonvulsants 8 • Banzel (rufinamide) • Onfi (clobazam) 8 • Briviact (brivaracetam) • Oxtellar XR (oxcarbazepine ext-rel) 8 • Celontin (methsuximide) • Spritam (levetiracetam) 8 • Lamictal ODT (lamotrigine) • Trokendi XR (topiramate ext-rel) 8 • Lamictal XR (lamotrigine ext-rel) 8 9 Antifungal 9 • Jublia (efinaconazole) • Kerydin (tavaborole) 9 10 Anti-Inflammatory Agents (Nonsteroidal) 10 • Arthrotec (diclofenac/misoprostol) • Tivorbex (indomethacin) 10 • Cambia (diclofenac) • Vivlodex (meloxicam) 10 • Celebrex (celecoxib) • Voltaren Gel 1% (diclofenac topical gel) 10 • Nalfon (fenoprofen) • Zipsor (diclofenac) 10 • Naprelan (naproxen ext-rel) • Zorvolex (diclofenac) 10 • Pennsaid (diflofenac) 10 11 Antipsychotics 11 • Abilify (aripiprazole) • Rexulti (brexpiprazole) 11 • Equetro (carbamazepine) • Vraylar (cariprazine) 11 12 Antiviral Agents (CMV) 12 • Valcyte (valacylclovir) 12 13 Antiviral Agents (Herpes) 13 • Sitavig (acyclovir) • Valtrex (valacylclovir) 13 * Prior authorization applies after initial quantity limit Therapies covered by CVS/caremark Specialty Pharmacy may change or expand from time to time. This page contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with CVS Caremark. ©2016 CVS/caremark. All rights reserved 2 2016 04-20 14 Appetite Suppressants 14 • Belviq (lorcaserin) • Phendimetrazine (phendimetrazine) 14 • Bontril, Bontril PDM (phendimetrazine) • Phentermine (phentermine) 14 • Contrave (bupropion SR/ naltrexone SR) • Qsymia (phentermine/topiramate) 14 • Didrex (benzphetamine) • Saxenda (liraglutide) 14 • Diethylpropion (diethylpropion) • Suprenza (phentermine) 14 15 Attention Deficit Hyperactivity Disorder • Adderall XR 15 (dextroamphetamine/amphetamine ext-rel) 15 16 Benign Prostatic Hyperplasia 16 • Avodart (dutasteride) • Jalyn (dutasteride/tamsulosin) 16 • Cardura XL (doxazosin ext-rel) • Rapaflo (silodosin) 16 17 Botulinum Toxin 17 • Botox (botulinum toxin type A) • Myobloc (botulinum toxin type B) 17 • Dysport (abobotulinumtoxinA) • Xeomin (incobotulinumtoxina) 17 18 CNS Stimulants/Narcolepsy 18 • Nuvigil (armodafinil) • Provigil (modafinil) 18 19 Compounded Medications $300 and over 19 • Various (various) 19 20 Corticosteroids 20 • Rayos (prednisone delayed release) 20 21 Cystic Fibrosis 21 • Bethkis (tobramycin) • Orkambi (lumacaftor/ivacaftor) 21 • Cayston (aztreonam lysinate) • Pulmozyme (dornase alfa) 21 • Kalydeco (ivacaftor) • Tobi Podhaler (tobramycin) 21 • Kitabis Pak (tobramycin inhalation solution) • TOBI, Tobramycin (tobramycin/sodium chloride) 21 22 Dermatologicals, Miscellaneous 22 • Apexicon E (diflorasone) • Efudex (fluorouracil) 22 • Avita (tretinoin) • Fluorouracil cream 0.5% (fluorouracil) 22 • Carac (fluorouracil) • Olux-E (clobetasol) 22 • Clobetasol spray (clobetasol) • Retin-A (tretinoin) 22 • Clobex Spray (clobetasol) • Retin-A Micro (tretinoin gel, microsphere) 22 * Prior authorization applies after initial quantity limit Therapies covered by CVS/caremark Specialty Pharmacy may change or expand from time to time. This page contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with CVS Caremark. ©2016 CVS/caremark. All rights reserved 3 2016 04-20 23 Diabetes 23 • Accu-Check Strips and Kits (test strips and kits) • Humalog Mix 50/50 (insulin Lispro) 23 • Actos (pioglitazone) • Humalog Mix 75/25 (insulin Lispro) • All other test strips that are not ONETOUCH 23 brand • Humulin 70/30 (insulin NPH/regular) 23 • Apidra (insulin glulisine) • Humulin N (insulin NPH) 23 • Breeze 2 Strips and Kits (test strips and kits) • Humulin R (insulin regular) 23 • Bydureon (exanatide) • Invokamet (canagliflozin/metformin) 23 • Byetta (exenatide) • Invokana (canagliflozin) • Contour Next Strips and Kits (test strips and 23 kits) • Kazano (alogliptin/metformin) 23 • Contour Strips and Kits (test strips and kits) • Kombiglyze XR (saxagliptin/metformin) 23 • Fortamet (metformin ext rel) • Nesina (alogliptin) 23 • Freestyle Strips/Kits (test strips and kits) • Onglyza (saxagliptin) 23 • Glumetza (metformin ext rel) • Oseni (alogliptin/pioglitizone) 23 • Humalog (insulin Lispro) • Riomet (metformin) 23 24 Enteral Nutritional Supplements 24 • Various Nutritional Products (various) 24 25 Erectile Dysfunction Agents 25 • Cialis (tadalafil) • Stendra (avanafil) 25 • Levitra (vardenafil) • Viagra (sildenafil) 25 • Staxyn (vardenafil) 25 26 Estrogen Combinations 26 • Angeliq (drospirenone/estradiol) • Prefest (estradiol/norgestimate) 26 • Climara Pro (estradiol/levonorgestrel) 26 27 Estrogens 27 • Alora (estradiol) • Menest (estrogens, esterified) 27 • Divigel (estradiol) • Menostar (estradiol) 27 • Elestrin (estradiol) • Minivelle (estradiol) 27 • Estrogel (estradiol) 27 28 Gastroinestinal Drugs, Miscellaneous 28 • Amitiza (lubiprostone) • Relistor (methylnaltrexone) 28 29 Glaucoma Agents 29 • Lumigan (bimatoprost) • Zioptan (tafluprost) 29 • Travatan Z (travoprost) 29 * Prior authorization applies after initial quantity limit Therapies covered by CVS/caremark Specialty Pharmacy may change or expand from time to time. This page contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with CVS Caremark. ©2016 CVS/caremark. All rights reserved 4 2016 04-20 30 Glucocorticoids 30 • Dexpak (dexamethasone) • Orapred ODT (prednisolone) 30 • Millipred (prednisolone) • Uceris (budesonide) 30 • Millipred DP (prednisolone) • Veripred 20 (prednisolone) 30 31 Gout Agents 31 • Krystexxa (pegloticase) • Uloric (febuxostat) 31 32 Growth Hormones 32 • Genotropin (somatropin) • Omnitrope (somatropin) 32 • Humatrope (somatropin) • Saizen (somatropin) 32 • Increlex (mecasermin) • Serostim (somatropin) 32 • Norditropin (somatropin) • Zomacton (somatropin) 32 • Nutropin AQ (somatropin) • Zorbtive (somatropin) 32 Hematopoietics, Erythroid Stimulants, Myeloid 33 Stimulants 33 • Aranesp (darbepoetin alfa) • Neulasta (pegfilgrastim) 33 • Epogen (epoetin alfa) • Neumega (oprelvekin) 33 • Granix (Tbo-filgrastim) • Neupogen (filgrastim) 33 • Leukine (sargramostim) • Omontys (peginesatide) • Mircera (methoxy polyethylene glycol-epoetin 33 beta) • Procrit (epoetin alfa) 33 • Mozobil (plerixafor) • Zarxio (filgrastim) 33 * Prior authorization applies after initial quantity limit Therapies covered by CVS/caremark Specialty Pharmacy may change or expand from time to time. This page contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with CVS Caremark. ©2016 CVS/caremark. All rights reserved 5 2016 04-20 Hemophilia, Von Willebrand Disease, and 34 Related Bleeding Disorders • Advate (antihemophilic factor, human, • Kogenate FS (antihemophilic factor, human, 34 recombinant) recombinant) 34 • Adynovate (pegylated recombinant factor VIII) • Kovaltry