EHIM Cares Custom Me Too Closed Formulary 26711 Northwestern Highway, Suite 400 :: Southfield, MI 48033-2154 :: 800-311-3446 :: 248-948-9900 :: www.ehimrx.com EHIM Cares Custom Formulary is a well-designed, evidenced- currently available and less costly therapies. This listing is based formulary that optimizes patient outcomes by ensuring revised periodically as new medications and new prescribing that patients receive the most effective and safe therapy. All information becomes available. If you are utilizing an Excluded medications are reviewed by EHIM Pharmacy & Therapeutics or Non-Preferred medication, you may want to speak with Committee for clinical efficacy, safety and cost savings for your physician to determine if there is an alternative therapy formulary consideration. that provides the same therapeutic efficacy, but is available at a lower cost to you. This document may be shared with your This list of medications is a guide which includes preferred physician to evaluate potential preferred therapy options. medications within select therapeutic classes that demonstrate the greatest value to you and your Employer. For additional benefit coverage information, please check Medications are excluded from formulary coverage if they your benefit plan documents or feel free to contact the EHIM fail to demonstrate a clinical or safety advantage over Pharmacy Call Center at 800-311-3446. Frequently Asked Questions About Generic Medications What is a generic drug? Are generics really the same as the brand name? A generic drug is a lower cost version of a brand-name Yes. Generic drugs have the same medicine as the brand- medication. They are just as safe and effective as the brand name, and the FDA will not approve them unless they are name, but they are more affordable. just as safe and effective as the brand-name drug. There are a few special medical conditions where a generic drug might How are generic drugs different from brand name drugs? have a small difference in how it works, but that is very rare. The biggest difference between a generic and brand name Do generic drugs cause more side effects than brand-name drug is the price. Most generics cost 70-90% less than the drugs? brand name version. Generic drugs may also have a different No. Brand-name drugs and a generic drug have the same shape, color or package. But these differences only affect rates of side effects. Each medication can affect each person how the medicine looks, not how it works. in a different way. If your medicine has side effects that you are worried about, call your doctor. • All MULTISOURCE medications (DAW) (brand name • Some medications may require an approved Prior medications that have an EXACT generic equivalent) are Authorization before being covered subject to the Non-Preferred copay (Not All MULTISOURCE medications are listed on this Formulary or may be covered) • Some medications may be applicable to a Quantity Limitation • All forms (oral, liquid, topical…) and dosages (DR, ER, LA, XR….) of the medications listed are classified as Non- • Not all medications on this formulary may be covered by Preferred your plan • This formulary is subject to change at any time without notice ehimrx.com EHIM Cares Custom Me Too Closed Formulary 26711 Northwestern Highway, Suite 400 :: Southfield, MI 48033-2154 :: 800-311-3446 :: 248-948-9900 :: www.ehimrx.com Non-Preferred medications are highlighted. Preferred generic medications are WHITE. Any medication in the 1st Tier can be interchanged for any of the medications in the 4th or 3rd Tier. This list is intended to be a guide. Not all medications listed on this formulary may be covered by your plan. derreferP-noN derreferP Excluded derreferP-noN derreferP Excluded yapoC yapoC yapoC yapoC Alzheimer’s/Dementia Analgesics/Narcotics Con’t Namenda XR donepezil Ryzolt (tramadol) tramadol/APAP (memantine) (Ultracet) Namzaric (donepezil/ memantine Synalgos memantine) (dihydrocodeine, APAP, Analgesics/Narcotics caffeine) Aleveer (capsaicin) Abstral (fentanyl) buprenorphine/naloxone Trezix (dihydrocodeine, SL (Suboxone) caffeine, APAP) Allzital (butalbital/ Embeda (morphine buprenorphine patch Troxyca ER acetaminophen) naltrexone) (Butrans) (oxycodone, Avinza (morphine) Fentora (fentanyl codeine naltrexone) buccal) Ultram ER (tramadol) Belbuca Hysingla ER codeine/APAP (buprenorphine) (hydrocodone) Xartemis XR Bunavail Lazanda (fentanyl) fentanyl patch (oxycodone/ (buprenorphine/ (Duragesic) acetaminophen) naloxone) Zydone (hydrocodone, Butrans Nucynta, Nucynta ER hydrocodone/APAP APAP) (buprenorphine) (tapentadol) (Lortab, Norco, Vicodin, Zubsolv etc) (buprenorphine/ Cassipa Obredon hydrocodone/ibuprofen naloxone) (buprenorphine/ (hydrocodone, (Vicoprofen) Androgens/Hypogonadism naloxone) guaifenesin) Xyosted (testosterone Androderm testosterone cypionate inj Conzip (tramadol) Onsolis (fentanyl hydromorphone enanthate) Injection (testosterone) buccal) (Dilaudid) Androgel Elenza (capsaicin) Opana ER hydromorphone XR (testosterone) (oxymorphone) (Exalgo) Android Flowtuss (hydrocodone, Oxycontin (oxycodone) levorphenol (Levo (methyltestosterone) guaifenesin) Dromoran) Androxy Hycofenix Subsys (fentanyl) methadone (fluoxymesterone) (hydrocodone, pse, Aveed (testosterone guaifenesin) undecanote) Hydrocodone Targiniq ER morphine Axiron (testosterone) Bitartrate, Guaifenesin (oxycodone/naloxone) Tablets Danocrine (danazol) Morphabond Viberzi (eluxadoline) morphine ER (MS Contin, Delatestryl (morphine sulfate) Oramorph) (testosterone Oxaydo (oxycodone) Vicodin (hydrocodone/ oxycodone (OxyIR) enanthate) Inj acetaminophen) Depo-Testosterone Oxecta (oxycodone IR) Zohydro ER oxycodone/APAP (testosterone cyp) Inj (hydrocodone) (Percocet) Halotestin Qroxin (capsaicin) oxycodone/ibuprofen (fluoxymesterone) (Combunox) Methitest Renovo (capsaicin) oxymorphone IR (Opana) (methyltestosterone) Roxybond (oxycodone) tramadol (Ultram) Methyltestosterone Oral Tablets (Testred) Rybix ODT (tramadol) ehimrx.com EHIM Cares Custom Me Too Closed Formulary 26711 Northwestern Highway, Suite 400 :: Southfield, MI 48033-2154 :: 800-311-3446 :: 248-948-9900 :: www.ehimrx.com Non-Preferred medications are highlighted. Preferred generic medications are WHITE. Any medication in the 1st Tier can be interchanged for any of the medications in the 4th or 3rd Tier. This list is intended to be a guide. Not all medications listed on this formulary may be covered by your plan. derreferP-noN derreferP derreferP-noN derreferP Excluded yapoC yapoC Excluded yapoC yapoC Androgens/Hypogonadism Con’t Anticoagulants Natesto (testosterone) Eliquis (apixaban) warfarin Nasal Pradaxa (dabigatran) Oxandrin Savaysa (edoxaban) (oxandrolone) Xarelto (rivaroxaban) Striant XR Anticonvulsants/Seizures (testosterone) Elepsia XR Aptiom carbamazepine Testim (testosterone) (levetiracetam) (eslicarbazepine) (Tegretol) Testoprel Gralise (gabapentin) Briviact (brivacetam) carbamazepine XR (testosterone) (Tegretol XR) Testred Horizant (gabapentin) Carbatrol clonazepam (Klonopin) (methyltestosterone) (carbamazepine) Virilon Keppra XR Diastat Rectal Delivery divalproex (Depakote) (methyltestosterone) (levetiracetam) System (diazepam) Vogelxo (testosterone) Lamictal XR Dilantin (phenytoin)* divalproex ER (Depakote Anti Arthritics (lamotrigine) ER) Cambia (diclofenac) Flector Patch celecoxib (Celebrex) Lyrica CR (pregabalin) Equetro ethosuximide (Zarontin) Packets (diclofenac) (carbamazepine) Consensi (amlodipine, Indocin (indomethacin) diclofenac (Cataflam, Onfi (clobazam) Felbatol (felbamate) felbamate (Felbatol) celecoxib) supp Voltaren, Voltaren XR) Oxtellar XR Fycompa (perampanel) gabapentin (Neurontin) Duexis (ibuprofen, Siprix Nasal Spray diclofenac/misoprostol (oxcarbazepine) famotidine) (ketorolac) (Arthrotec) Qudexy XR Gabitril (tiagabine) lacosamide (Vimpat) Durlaza (aspirin) diclofenac 1% topical (topiramate) (Voltaren Gel) Spritam Lyrica (pregabalin) lamotrigine (Lamictal) Licart (diclofenac) diclofenac 1.5% topical (levetiracetam) (Pennsaid) Stavzor (valproic acid) Mebaral lamotrigine XR (Lamictal Nalfon (fenoprofen) etodolac (Lodine, Lodine (mephobarbital) XR) XL) Tegretol XR Nayzilam Nasal levetiracetam (Keppra) Naprelan (naproxen) ibuprofen (Motrin) (carbamazepine) (midazolam) Nexcede (ketoprofen) indomethacin (Indocin) Trokendi XR Peganone (ethotoin) oxcarbazepine (Trileptal) Film (topiramate) Pennsaid Topical ketoprofen (Orudis, Phenytek (phenytoin)* phenobarbital Solution (diclofenac) Oruvail) Potiga (ezogabine) phenytoin (Dilantin) Prevacid NapraPac lidocaine topical primidone (Mysoline) (naproxen, (Lidoderm) rufinamide (Banzel) lansoprazole) tiagabine (Gabitril) Tivorbex meloxicam (Mobic) (indomethacin) topiramate (Topamax) Vimovo (naproxen nabumetone (Relafen) valproate, valproic acid esomeprazole) zonisamide (Zonegran) Vivlodex (meloxicam) naproxen (Naproxen) Zipsor (diclofenac) naproxen DS (Anaprox DS) Zorvolex (diclofenac) oxaprozin (Daypro) piroxicam (Feldene) sulindac (Clinoril) ehimrx.com EHIM Cares Custom Me Too Closed Formulary 26711 Northwestern Highway, Suite 400 :: Southfield, MI 48033-2154 :: 800-311-3446 :: 248-948-9900 :: www.ehimrx.com Non-Preferred medications are highlighted. Preferred generic medications are WHITE. Any medication in the 1st Tier can be interchanged for any of the medications in the 4th or 3rd Tier. This list is intended to be a guide. Not all medications listed on this formulary may be covered by your plan. derreferP-noN derreferP Excluded derreferP-noN derreferP Excluded yapoC yapoC yapoC yapoC Antidiabetics Antihypertensives/Angiotension