Fidelis Care Healthier Life and Medicaid Formulary 07/01/2021 v2 INTRODUCTION ...................................................................................................................................................................................................... 4 NOTICE OF NONDISCRIMINATION ....................................................................................................................................................................... 4 PREFACE................................................................................................................................................................................................................. 7 PHARMACY AND THERAPEUTICS COMMITTEE ................................................................................................................................................. 7 DRUG LIST PRODUCT DESCRIPTIONS ................................................................................................................................................................ 7 GENERIC SUBSTITUTION ...................................................................................................................................................................................... 8 NON-COVERED MEDICATIONS ............................................................................................................................................................................. 8 NON-PREFERRED REQUEST ................................................................................................................................................................................ 8 QUANTITY LIMITATIONS ........................................................................................................................................................................................ 9 SPECIALTY DRUGS .............................................................................................................................................................................................. 12 PRIOR AUTHORIZATION ...................................................................................................................................................................................... 12 STEP THERAPY .................................................................................................................................................................................................... 14 ONCOLOGY AND SUPPORTIVE CARE ............................................................................................................................................................... 14 APPEALS INFORMATION/PROCESS .................................................................................................................................................................. 15 EDITOR................................................................................................................................................................................................................... 15 NOTICE................................................................................................................................................................................................................... 15 LEGEND ................................................................................................................................................................................................................. 15 ANALGESICS......................................................................................................................................................................................................... 16 ANALGESICS, OTHER ................................................................................................................................................................................ 16 NSAIDs......................................................................................................................................................................................................... 16 NSAIDs, TOPICAL ....................................................................................................................................................................................... 16 COX-2 INHIBITORS ..................................................................................................................................................................................... 16 GOUT ........................................................................................................................................................................................................... 16 OPIOID ANALGESICS ................................................................................................................................................................................. 16 NON-OPIOID ANALGESICS ........................................................................................................................................................................ 17 ANTI-INFECTIVES ................................................................................................................................................................................................. 17 ANTIBACTERIALS ....................................................................................................................................................................................... 17 ANTIFUNGALS ............................................................................................................................................................................................ 18 ANTIMALARIALS ......................................................................................................................................................................................... 18 ANTIRETROVIRAL AGENTS ...................................................................................................................................................................... 18 ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 20 ANTIVIRALS................................................................................................................................................................................................. 20 MISCELLANEOUS ....................................................................................................................................................................................... 20 ANTINEOPLASTIC AGENTS ................................................................................................................................................................................ 21 ALKYLATING AGENTS ............................................................................................................................................................................... 21 ANTIMETABOLITES .................................................................................................................................................................................... 21 HORMONAL ANTINEOPLASTIC AGENTS ................................................................................................................................................. 21 KINASE INHIBITORS ................................................................................................................................................................................... 21 KINASE INHIBITORS FOR CML ................................................................................................................................................................. 22 MULTIPLE MYELOMA ................................................................................................................................................................................. 22 MISCELLANEOUS ....................................................................................................................................................................................... 22 CARDIOVASCULAR .............................................................................................................................................................................................. 22 ACE INHIBITORS ........................................................................................................................................................................................ 22 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 22 ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 22 ADRENOLYTICS, CENTRAL ....................................................................................................................................................................... 23 ADRENOLYTICS, CENTRAL/DIURETIC COMBINATION .......................................................................................................................... 23 ALDOSTERONE RECEPTOR ANTAGONISTS .........................................................................................................................................