CareFirst Formulary 4Sep 01, 2020 · Federal Employees Health Benefits Program . List of Covered...

CareFirst Formulary 4Federal Employees Health Benefits Program List of Covered Drugs

2020PLEASE READ: this document contains information about the drugs we cover in this plan. This formulary is for members of the federal employees health benefits program.

For more recent information or other questions, please contact CareFirst Pharmacy Services at 800-241-3371 or visit carefirst.com/fedhmo.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). The Blue Cross® and Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

SUM5013-1S (12/20)

http://www.carefirst.com/fedhmo

CareFirst Formulary 4 12/01/2020

INTRODUCTION ...................................................................................................................................................................................................... 4 PREFACE ................................................................................................................................................................................................................. 4 PHARMACY AND THERAPEUTICS (P&T) COMMITTEE ...................................................................................................................................... 4 DRUG LIST PRODUCT DESCRIPTIONS ................................................................................................................................................................ 5 GENERIC SUBSTITUTION ...................................................................................................................................................................................... 5 SPECIALTY MEDICATIONS .................................................................................................................................................................................... 6 PLAN DESIGN.......................................................................................................................................................................................................... 6 PREVENTIVE SERVICES ........................................................................................................................................................................................ 7 LEGEND ................................................................................................................................................................................................................... 7 NOTICE ..................................................................................................................................................................................................................... 7 ANALGESICS........................................................................................................................................................................................................... 9

NSAIDs ........................................................................................................................................................................................................... 9 GOUT ............................................................................................................................................................................................................. 9 OPIOID ANALGESICS ................................................................................................................................................................................... 9

ANTI-INFECTIVES ................................................................................................................................................................................................. 10 ANTIBACTERIALS ....................................................................................................................................................................................... 11 ANTIFUNGALS ............................................................................................................................................................................................ 11 ANTIRETROVIRAL AGENTS ...................................................................................................................................................................... 12 ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 13 ANTIVIRALS................................................................................................................................................................................................. 13 MISCELLANEOUS ....................................................................................................................................................................................... 14

ANTINEOPLASTIC AGENTS ................................................................................................................................................................................ 15 ORAL HORMONAL ANTINEOPLASTIC AGENTS ...................................................................................................................................... 15 ORAL NON-HORMONAL ANTINEOPLASTIC AGENTS ............................................................................................................................. 15 MISCELLANEOUS ....................................................................................................................................................................................... 16

CARDIOVASCULAR .............................................................................................................................................................................................. 17 ACE INHIBITORS ........................................................................................................................................................................................ 17 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 17 ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 17 ADRENOLYTICS, CENTRAL ....................................................................................................................................................................... 17 ALDOSTERONE RECEPTOR ANTAGONISTS .......................................................................................................................................... 17 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ........................................................................................... 17 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ......................................................... 18 ANTIARRHYTHMICS ................................................................................................................................................................................... 18 ANTILIPEMICS............................................................................................................................................................................................. 18 BETA-BLOCKERS ....................................................................................................................................................................................... 19 BETA-BLOCKER/DIURETIC COMBINATIONS ........................................................................................................................................... 19 CALCIUM CHANNEL BLOCKERS .............................................................................................................................................................. 19 DIGITALIS GLYCOSIDES ............................................................................................................................................................................ 20 DIURETICS .................................................................................................................................................................................................. 20 HEART FAILURE ......................................................................................................................................................................................... 20 NITRATES .................................................................................................................................................................................................... 20 PULMONARY ARTERIAL HYPERTENSION .............................................................................................................................................. 21 MISCELLANEOUS ....................................................................................................................................................................................... 21

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CENTRAL NERVOUS SYSTEM ............................................................................................................................................................................ 21 ANTIANXIETY .............................................................................................................................................................................................. 21 ANTICONVULSANTS .................................................................................................................................................................................. 21 ANTIDEMENTIA ........................................................................................................................................................................................... 22 ANTIDEPRESSANTS .................................................................................................................................................................................. 22 ANTIPARKINSONIAN AGENTS .................................................................................................................................................................. 23 ANTIPSYCHOTICS ...................................................................................................................................................................................... 24 ATTENTION DEFICIT HYPERACTIVITY DISORDER ................................................................................................................................ 24 FIBROMYALGIA .......................................................................................................................................................................................... 24 HYPNOTICS ................................................................................................................................................................................................. 24 MIGRAINE .................................................................................................................................................................................................... 25 MOOD STABILIZERS .................................................................................................................................................................................. 25 MOVEMENT DISORDERS .......................................................................................................................................................................... 25 MULTIPLE SCLEROSIS AGENTS .............................................................................................................................................................. 25 MUSCULOSKELETAL THERAPY AGENTS ............................................................................................................................................... 25 MYASTHENIA GRAVIS ............................................................................................................................................................................... 26 NARCOLEPSY ............................................................................................................................................................................................. 26 PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................. 26 MISCELLANEOUS ....................................................................................................................................................................................... 26

ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 26 ACROMEGALY ............................................................................................................................................................................................ 26 ANDROGENS .............................................................................................................................................................................................. 26 ANTIDIABETICS .......................................................................................................................................................................................... 27 CALCIUM RECEPTOR ANTAGONISTS ..................................................................................................................................................... 29 CALCIUM REGULATORS ........................................................................................................................................................................... 29 CONTRACEPTIVES^ ................................................................................................................................................................................... 29 ENDOMETRIOSIS ....................................................................................................................................................................................... 30 ESTROGENS ............................................................................................................................................................................................... 30 ESTROGEN/PROGESTINS ......................................................................................................................................................................... 31 FERTILITY REGULATORS .......................................................................................................................................................................... 31 GAUCHER DISEASE ................................................................................................................................................................................... 31 GLUCOCORTICOIDS .................................................................................................................................................................................. 31 GLUCOSE ELEVATING AGENTS ............................................................................................................................................................... 31 HEREDITARY TYROSINEMIA TYPE 1 AGENTS ....................................................................................................................................... 31 HUMAN GROWTH HORMONES ................................................................................................................................................................. 31 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................. 32 PHOSPHATE BINDER AGENTS ................................................................................................................................................................. 32 POLYNEUROPATHY ................................................................................................................................................................................... 32 PROGESTINS .............................................................................................................................................................................................. 32 SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................. 32 THYROID AGENTS ..................................................................................................................................................................................... 32 UREA CYCLE DISORDERS ........................................................................................................................................................................ 32 VASOPRESSINS ......................................................................................................................................................................................... 32 MISCELLANEOUS ....................................................................................................................................................................................... 32

GASTROINTESTINAL ........................................................................................................................................................................................... 33 ANTIDIARRHEALS ...................................................................................................................................................................................... 33 ANTIEMETICS ............................................................................................................................................................................................. 33 ANTISPASMODICS ..................................................................................................................................................................................... 33 CHOLELITHOLYTICS .................................................................................................................................................................................. 33 H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................. 33 INFLAMMATORY BOWEL DISEASE .......................................................................................................................................................... 33 IRRITABLE BOWEL SYNDROME ............................................................................................................................................................... 34 LAXATIVES^ ................................................................................................................................................................................................. 34 OPIOID-INDUCED CONSTIPATION ........................................................................................................................................................... 34 PANCREATIC ENZYMES ............................................................................................................................................................................ 34 PROSTAGLANDINS .................................................................................................................................................................................... 34 PROTON PUMP INHIBITORS ..................................................................................................................................................................... 34 SALIVA STIMULANTS ................................................................................................................................................................................. 34 STEROIDS, RECTAL ................................................................................................................................................................................... 34 MISCELLANEOUS ....................................................................................................................................................................................... 34

GENITOURINARY .................................................................................................................................................................................................. 35 BENIGN PROSTATIC HYPERPLASIA ........................................................................................................................................................ 35 ERECTILE DYSFUNCTION ......................................................................................................................................................................... 35 URINARY ANTISPASMODICS .................................................................................................................................................................... 35 VAGINAL ANTI-INFECTIVES ...................................................................................................................................................................... 35

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MISCELLANEOUS ....................................................................................................................................................................................... 35 HEMATOLOGIC ..................................................................................................................................................................................................... 35

ANTICOAGULANTS .................................................................................................................................................................................... 35 HEMATOPOIETIC GROWTH FACTORS .................................................................................................................................................... 36 PLATELET AGGREGATION INHIBITORS .................................................................................................................................................. 36 PLATELET SYNTHESIS INHIBITORS ........................................................................................................................................................ 36 THROMBOCYTOPENIA AGENTS .............................................................................................................................................................. 36 MISCELLANEOUS ....................................................................................................................................................................................... 36

IMMUNOLOGIC AGENTS ...................................................................................................................................................................................... 36 ALLERGENIC EXTRACTS .......................................................................................................................................................................... 36 AUTOIMMUNE AGENTS ............................................................................................................................................................................. 36 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................. 37 HEREDITARY ANGIOEDEMA AGENTS ..................................................................................................................................................... 37 IMMUNOSUPPRESSANTS ......................................................................................................................................................................... 37

NUTRITIONAL/SUPPLEMENTS ............................................................................................................................................................................ 38 ELECTROLYTES ......................................................................................................................................................................................... 38 VITAMINS AND MINERALS ........................................................................................................................................................................ 38

RESPIRATORY ...................................................................................................................................................................................................... 38 ANAPHYLAXIS TREATMENT AGENTS...................................................................................................................................................... 38 ANTICHOLINERGICS .................................................................................................................................................................................. 39 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ............................................................................................................................ 39 ANTIHISTAMINES, SEDATING ................................................................................................................................................................... 39 ANTITUSSIVES............................................................................................................................................................................................ 39 ANTITUSSIVE COMBINATIONS ................................................................................................................................................................. 39 BETA AGONISTS ........................................................................................................................................................................................ 39 CYSTIC FIBROSIS ...................................................................................................................................................................................... 40 LEUKOTRIENE MODULATORS .................................................................................................................................................................. 40 NASAL ANTIHISTAMINES .......................................................................................................................................................................... 40 NASAL STEROIDS ...................................................................................................................................................................................... 40 PULMONARY FIBROSIS AGENTS ............................................................................................................................................................. 40 SEVERE ASTHMA AGENTS ....................................................................................................................................................................... 40 STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................. 40 STEROID INHALANTS ................................................................................................................................................................................ 40 XANTHINES ................................................................................................................................................................................................. 40 MISCELLANEOUS ....................................................................................................................................................................................... 40

TOPICAL ................................................................................................................................................................................................................ 41 DERMATOLOGY ......................................................................................................................................................................................... 41 MOUTH/THROAT/DENTAL AGENTS ......................................................................................................................................................... 43 OPHTHALMIC .............................................................................................................................................................................................. 43 OTIC ............................................................................................................................................................................................................. 45

WEBSITES ............................................................................................................................................................................................................. 46 INDEX ..................................................................................................................................................................................................................... 48

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INTRODUCTION We are pleased to provide the 2020 CareFirst Formulary 4 as a useful reference and informational tool. This document can assist practitioners in selecting clinically appropriate and cost-effective products for their patients. The drugs represented have been reviewed by a National Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The document is reflective of current medical practice as of the date of review. The information contained in this document and its appendices is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This document is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. All the information in the document is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information. National guidelines can be found on the National Guideline Clearinghouse site at https://www.ahrq.gov/gam/, on the websites listed under each therapeutic class and on the sites listed in the Websites section of this publication.

PREFACE The document is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Products are listed by generic name with brand name for reference only. Unless the cited drug is available as an injectable or an exception is specifically noted, generally, all applicable dosage forms and strengths of the drug cited are included in the document. Drugs represented in this document may have varying cost to the plan member based on the plan's benefit structure. Some prescription benefit plan designs may alter coverage of certain products or vary copay amounts based on the condition being treated. Generic medications typically are available at the lower cost, brand-name medications on the document will generally cost more than generics. Generics should be considered the first line of prescribing subject to applicable rules. Drugs are placed into tiers or levels of cost sharing by the plan member in the following manner: Tier 1: Preferred generic drugs. Tier 2: Preferred brand-name drugs. Tier 3: Preferred Specialty generic drugs. Tier 4: Preferred Specialty brand-name drugs.

PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The services of an independent National Pharmacy and Therapeutics Committee ("P&T Committee") are utilized to approve safe and clinically effective drug therapies. The P&T Committee is an external advisory body of clinical professionals from across the United States. The P&T Committee's voting members include physicians, pharmacists, a pharmacoeconomist and a medical ethicist, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. Voting members of the P&T Committee must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers.

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DRUG LIST PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms on the document are covered, examples are noted below. The general principles shown in the examples can usually be extended to other entries in the document. Any exceptions are noted. Listed products on the document generally include all strengths and all oral dosage forms of the cited product. escitalopram Lexapro Oral tablets, oral solution and all strengths of Lexapro would be included in this listing. Nasal sprays require a separate entry. sumatriptan nasal spray Imitrex Oral disintegrating tablets require a separate entry. prednisolone sodium phosphate orally disintegrating tabs Orapred ODT Injectable dosage forms require a separate entry. sumatriptan inj Imitrex When a strength or dosage form is specified, only the specified strength and dosage form is on the document. Other strengths/dosage forms, including injectable dosage forms of the reference product are not. gabapentin caps, tabs Neurontin The capsule and tablet formulations are listed on the document, but the oral solution is not. Extended-release and delayed-release products require their own entry. tofacitinib Xeljanz The immediate-release product listing of Xeljanz alone would not include the extended-release product Xeljanz XR. tofacitinib ext-rel Xeljanz XR A separate entry for Xeljanz XR confirms that the extended-release product is on the document. Dosage forms on the document will be consistent with the category and use where listed. nystatin The above nystatin entry listed in the TOPICAL/DERMATOLOGY section is limited to the topical dosage forms. From this entry the oral formulations cannot be assumed to be on the list unless there is an entry for this product in the ANTI-INFECTIVES section of the document.

GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. Boldface type indicates generic availability. However, not all strengths or dosage forms of the generic name in boldface type may be generically available. In most instances, a brand-name drug for which a generic product becomes available will become non-formulary, with the generic product covered in its place, upon release of the generic product to the market. However, the document is subject to state specific regulations and rules regarding generic substitution and mandatory generic rules apply where appropriate. Generic drugs are usually priced lower than their brand-name equivalents. Prescription generic drugs are:

• Approved by the U.S. Food and Drug Administration for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs.

• Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and extent compared to the brand-name drug (bioequivalence). Generics may be different from the brand in size, color and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug.

• Manufactured in the same strength and dosage form as the brand-name drugs.

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When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug (therapeutic equivalence).

SPECIALTY MEDICATIONS A new, rapidly growing category of drugs, specialty medications are the result of continued advances in drug development technology and design. They are created to target and treat complex chronic or genetic medical conditions and include bioengineered proteins, blood-derived products and complex molecules. The therapeutic categories listed below include products that are covered as part of the Specialty benefit.

Acromegaly Alpha-1 Antitrypsin Deficiency Amyloidosis Anemia Asthma Atopic Dermatitis Cardiac Disorders Coagulation Disorders Cryopyrin-Associated Periodic Syndromes Cystic Fibrosis Electrolyte Disorders Gastrointestinal Disorders-Other Gout Growth Hormone & Related Disorders Hematopoietics Hemophilia, Von Willebrand Disease & Related Bleeding Disorders Hepatitis C Hereditary Angioedema Hormonal Therapies Immune Deficiencies & Related Disorders Infectious Disease - Other Inflammatory Bowel Disease Iron Overload

Lysosomal Storage Disorders Mental Health Conditions Movement Disorders Multiple Sclerosis Neutropenia Oncology - Injectable Oncology - Oral/Topical Osteoporosis Paroxysmal Nocturnal Hemoglobinuria Phenylketonuria Pre-Term Birth Psoriasis Pulmonary Arterial Hypertension Pulmonary Disorders - Other Rare Disorders - Other Renal Disease Respiratory Syncytial Virus Rheumatoid Arthritis Seizure Disorders Sickle Cell Disease Sleep Disorders Systemic Lupus Erythematosus Thrombocytopenia Urea Cycle Disorders

Specialty Guideline Management (SGM)

SGM is our utilization management program that helps ensure appropriate utilization for specialty medications based on currently accepted evidence-based medicine guidelines. The utilization management program is available for therapeutic areas dispensed by our specialty pharmacies. SGM is designed to help ensure safety and efficacy while preventing off-guideline utilization. Medications which may be included in the SGM program are identified in the document as “SP” for your reference. For additional information, contact CareFirst Pharmacy Services at 800-241-3371 or CVS Specialty at 855-264-3237 for any questions about covered specialty drugs.

PLAN DESIGN The document represents a closed formulary plan design. Certain medications on the list are covered if utilization management criteria are met (i.e., Step Therapy, Prior Authorization, Quantity Limits, etc.); requests for use of such medications outside of their listed criteria will be reviewed for medical necessity. If a medication is not listed on the document, a formulary exception may be requested for coverage. Medical necessity or formulary exception requests will be reviewed based on drug-specific prior authorization criteria or standard non-formulary prescription request criteria.

Individual pharmacy benefit plans may impose restrictions or not reimburse some products.

Log in to www.carefirst.com/myaccount to check coverage.

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https://www.carefirst.com/myaccount

PREVENTIVE SERVICES The U.S. Department of Health and Human Services (HHS) has adopted Guidelines for Preventive Services under the Affordable Care Act (ACA). Under the ACA, some pharmacy benefit plans may provide a range of preventive services for $0 member cost share. These items may include:

• Aspirin to Prevent Cardiovascular Disease

• Bowel Preparations for Colorectal Cancer Screening

• Fluoride Supplementation in Children

• Folic Acid Supplementation for Women Expecting or Planning to be Pregnant

• Tobacco Use Counseling and Cessation Intervention

• Immunizations

• Medications for Risk Reduction of Primary Breast Cancer in Women

• Women's Health Preventive Services (i.e., birth control, emergency contraception)

• Statin Use for the Primary Prevention of Cardiovascular Disease in Adults Items that may be covered as preventive services under this formulary will not be specifically noted since final coverage is determined by the plan sponsor. For additional information regarding preventive services, please refer to https://www.hhs.gov or the CareFirst BCBS Preventive Drug List.

LEGEND

AL ^

Age Limit Items that may be covered as preventive services under this formulary

PA Prior Authorization PA, QL Quantity Limit is applied after Prior Authorization approval QL Quantity Limit QL, PA If Quantity Limit is exceeded, Prior Authorization may apply SP Specialty Drug ST Step Therapy ST, PA If Step Therapy requirements are not met, Prior Authorization may apply boldface Indicates generic availability; boldface may not apply to every strength or dosage form

under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for

clarification ext-rel Extended-release (also known as sustained-release), refer to the reference brand listed for

clarification

NOTICE This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. CareFirst does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by CareFirst. Please be advised that this document is updated periodically and changes may appear prior to their effective date to allow for client notification.

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https://www.hhs.gov/

https://www.hhs.gov/

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District

of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). The Blue Cross® and Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of

independent Blue Cross and Blue Shield Plans.

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ANALGESICS Practice guidelines of pain management are available at: https://www.asahq.org NSAIDs diclofenac potassium Tier 1 diclofenac sodium delayed-rel Tier 1 diclofenac sodium ext-rel Tier 1 diflunisal Tier 1 etodolac Tier 1 flurbiprofen Tier 1 ibuprofen Tier 1 ketoprofen 50 mg, 75 mg Tier 1 ketorolac Tier 1 ketorolac inj Tier 1 meloxicam Tier 1 nabumetone Tier 1 naproxen delayed-rel Tier 1 naproxen sodium tabs Tier 1 naproxen tabs Tier 1 oxaprozin Tier 1 piroxicam Tier 1 sulindac Tier 1 tolmetin Tier 1 GOUT allopurinol Tier 1 colchicine Tier 1 probenecid Tier 1 OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: https://www.asahq.org https://www.nccn.org Opioid guidelines in the management of chronic non-malignant pain are available at: https://www.asipp.org/ASIPP-Guidelines.html The quantity of opioid products prescribed (including those that are combined with acetaminophen, aspirin or ibuprofen) will be limited to up to 90 morphine milligram equivalents (MME) per day based on a 30-day supply. Members who are opioid-naïve will be required to use an immediate-release (IR) formulation before moving to an extended-release (ER) formulation and will be subject to quantity limit restrictions. QL, PA, † buprenorphine BELBUCA Tier 2 QL, PA, † buprenorphine transdermal Tier 1 QL, PA codeine sulfate Tier 1 LEGEND AL Age Limit ^ Items that may be covered as preventive services under this formulary PA Prior Authorization PA, QL Quantity Limit is applied after Prior Authorization approval QL Quantity Limit QL, PA If Quantity Limit is exceeded, Prior Authorization may apply SP Specialty Drug ST Step Therapy ST, PA If Step Therapy requirements are not met, Prior Authorization may apply boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification

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QL codeine/acetaminophen Tier 1 PA, QL fentanyl lozenge Tier 1 QL, PA, † fentanyl transdermal Tier 1 QL hydrocodone/acetaminophen Tier 1 QL, PA hydromorphone Tier 1 QL, PA methadone Tier 1 QL, PA morphine Tier 1 QL, PA, † morphine ext-rel Tier 1 QL, PA morphine supp Tier 1 QL, PA oxycodone Tier 1 QL oxycodone/acetaminophen Tier 1 QL oxycodone/acetaminophen soln Tier 1 QL, PA tramadol 50 mg Tier 1 QL, PA, † tramadol ext-rel tabs Tier 1 † Initial PA may apply to higher strengths ANTI-INFECTIVES Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: https://www.idsociety.org Hepatitis: CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/ Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at: https://www.aasld.org HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at: https://www.aidsinfo.nih.gov Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: https://professional.heart.org Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html International Travel: CDC recommendations for international travel are available at: https://wwwnc.cdc.gov/travel Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at: https://www.cdc.gov/pneumonia/management-prevention-guidelines.html Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: https://www.cdc.gov/std/treatment/default.htm

LEGEND AL Age Limit ^ Items that may be covered as preventive services under this formulary PA Prior Authorization PA, QL Quantity Limit is applied after Prior Authorization approval QL Quantity Limit QL, PA If Quantity Limit is exceeded, Prior Authorization may apply SP Specialty Drug ST Step Therapy ST, PA If Step Therapy requirements are not met, Prior Authorization may apply boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification

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ANTIBACTERIALS Cephalosporins First Generation cefadroxil Tier 1 cephalexin Tier 1 Second Generation cefprozil Tier 1 cefuroxime axetil Tier 1 Third Generation cefdinir Tier 1 cefpodoxime Tier 1 Erythromycins/Macrolides azithromycin Tier 1 clarithromycin Tier 1 clarithromycin ext-rel Tier 1 erythromycin delayed-rel Tier 1 erythromycin ethylsuccinate Tier 1 erythromycin stearate Tier 1 ERYTHROCIN Tier 2 PA fidaxomicin DIFICID Tier 2 Fluoroquinolones ciprofloxacin Tier 1 levofloxacin Tier 1 moxifloxacin Tier 1 Penicillins amoxicillin Tier 1 amoxicillin/clavulanate Tier 1 amoxicillin/clavulanate ext-rel Tier 1 ampicillin Tier 1 dicloxacillin Tier 1 penicillin VK Tier 1 Tetracyclines doxycycline hyclate caps Tier 1 doxycycline hyclate tabs 20 mg, 100

mg Tier 1

doxycycline monohydrate susp Tier 1 minocycline Tier 1 tetracycline Tier 1 ANTIFUNGALS clotrimazole troches Tier 1 fluconazole Tier 1


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griseofulvin microsize Tier 1 itraconazole Tier 1 nystatin Tier 1 terbinafine tabs Tier 1 voriconazole Tier 1 ANTIRETROVIRAL AGENTS Antiretroviral Combinations QL, PA abacavir/dolutegravir/lamivudine TRIUMEQ Tier 2 QL, PA abacavir/lamivudine Tier 1 QL, PA abacavir/lamivudine/zidovudine Tier 1 QL, PA atazanavir/cobicistat EVOTAZ Tier 2 QL, PA bictegravir/emtricitabine/

tenofovir alafenamide BIKTARVY Tier 2

QL, PA darunavir/cobicistat PREZCOBIX Tier 2 QL, PA darunavir/cobicistat/emtricitabine/

tenofovir alafenamide SYMTUZA Tier 2

QL, PA dolutegravir/lamivudine DOVATO Tier 2 QL, PA efavirenz/emtricitabine/

tenofovir disoproxil fumarate ATRIPLA Tier 2

QL, PA efavirenz/lamivudine/ tenofovir disoproxil fumarate

SYMFI Tier 2

QL, PA efavirenz/lamivudine/ tenofovir disoproxil fumarate

SYMFI LO Tier 2

QL, PA elvitegravir/cobicistat/emtricitabine/ tenofovir alafenamide

GENVOYA Tier 2

QL, PA emtricitabine/rilpivirine/tenofovir alafenamide

ODEFSEY Tier 2

QL, PA emtricitabine/tenofovir alafenamide DESCOVY Tier 2 QL, PA emtricitabine/tenofovir disoproxil

fumarate TRUVADA Tier 2

QL, PA lamivudine/tenofovir disoproxil fumarate CIMDUO Tier 2 QL, PA lamivudine/tenofovir disoproxil fumarate TEMIXYS Tier 2 QL, PA lamivudine/zidovudine Tier 1 Fusion Inhibitors QL, PA, SP enfuvirtide FUZEON Tier 4 Integrase Inhibitors QL, PA dolutegravir TIVICAY Tier 2 QL, PA raltegravir ISENTRESS Tier 2 QL, PA raltegravir ISENTRESS HD Tier 2 Non-nucleoside Reverse Transcriptase Inhibitors QL, PA efavirenz Tier 1 QL, PA etravirine INTELENCE Tier 2 QL, PA nevirapine Tier 1


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QL, PA nevirapine ext-rel Tier 1 QL, PA rilpivirine EDURANT Tier 2 Nucleoside Reverse Transcriptase Inhibitors QL, PA abacavir Tier 1 QL, PA didanosine delayed-rel 200 mg, 250

mg, 400 mg Tier 1

QL, PA emtricitabine EMTRIVA Tier 2 QL, PA lamivudine Tier 1 QL, PA stavudine Tier 1 QL, PA zidovudine Tier 1 Nucleotide Reverse Transcriptase Inhibitors QL, PA tenofovir disoproxil fumarate Tier 1 Protease Inhibitors QL, PA atazanavir Tier 1 QL, PA darunavir PREZISTA Tier 2 QL, PA fosamprenavir tabs Tier 1 QL, PA lopinavir/ritonavir Tier 1 KALETRA Tier 2 QL, PA ritonavir Tier 1 NORVIR Tier 2 ANTITUBERCULAR AGENTS capreomycin CAPASTAT SULFATE Tier 2 cycloserine Tier 1 ethambutol Tier 1 ethionamide TRECATOR Tier 2 isoniazid Tier 1 isoniazid/rifampin RIFAMATE Tier 2 isoniazid-rifampin w/pyrazinamide RIFATER Tier 2 pyrazinamide Tier 1 rifampin Tier 1 rifapentine PRIFTIN Tier 2 streptomycin sulfate inj Tier 1 ANTIVIRALS Cytomegalovirus Agents QL valganciclovir Tier 1 Hepatitis Agents Hepatitis B entecavir soln BARACLUDE Tier 2 entecavir tabs Tier 1 lamivudine tabs Tier 1 QL tenofovir alafenamide VEMLIDY Tier 2


13

Hepatitis C #, PA, SP, QL ledipasvir/sofosbuvir HARVONI Tier 4 PA, SP ribavirin Tier 3 #, PA, SP, QL sofosbuvir/velpatasvir EPCLUSA Tier 4 *, PA, SP, QL sofosbuvir/velpatasvir/voxilaprevir VOSEVI Tier 4 # HARVONI only for genotypes 1, 4, 5 and 6 EPCLUSA for genotypes 1, 2, 3, 4, 5, 6 * For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3). Herpes Agents acyclovir Tier 1 famciclovir Tier 1 valacyclovir Tier 1 Influenza Agents QL, PA oseltamivir Tier 1 MISCELLANEOUS atovaquone Tier 1 clindamycin Tier 1 dapsone Tier 1 ivermectin Tier 1 PA linezolid Tier 1 PA linezolid inj Tier 1 QL, PA mebendazole EMVERM Tier 2 metronidazole Tier 1 nitrofurantoin ext-rel Tier 1 nitrofurantoin macrocrystals Tier 1 QL, PA praziquantel Tier 1 rifabutin Tier 1 PA rifaximin 550 mg XIFAXAN Tier 2 sulfamethoxazole/trimethoprim Tier 1 sulfamethoxazole/trimethoprim DS Tier 1 tinidazole Tier 1 trimethoprim Tier 1 QL vancomycin Tier 1


14

ANTINEOPLASTIC AGENTS Clinical practice guidelines in oncology are available at: https://www.asco.org https://www.nccn.org Most oncology medications are eligible for coverage and some may require prior authorization. Please call the Customer Care phone number located on the prescription ID card for coverage determination. ORAL HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens PA, SP, QL abiraterone YONSA Tier 4 PA, SP, QL abiraterone 250 mg Tier 3 PA, SP, QL apalutamide ERLEADA Tier 4 bicalutamide Tier 1 PA, SP, QL darolutamide NUBEQA Tier 4 PA, SP, QL enzalutamide XTANDI Tier 4 flutamide Tier 1 nilutamide Tier 1 Antiestrogens/Selective Estrogen Receptor Modifiers PA fulvestrant Tier 1 tamoxifen Tier 1 toremifene Tier 1 Aromatase Inhibitors anastrozole Tier 1 exemestane Tier 1 letrozole Tier 1 Progestins megestrol acetate Tier 1 ORAL NON-HORMONAL ANTINEOPLASTIC AGENTS Alkylating Agents busulfan MYLERAN Tier 2 chlorambucil LEUKERAN Tier 2 cyclophosphamide caps Tier 1 estramustine EMCYT Tier 2 lomustine GLEOSTINE Tier 2 melphalan Tier 1 Antimetabolites PA, SP, QL capecitabine Tier 3 mercaptopurine Tier 1 thioguanine TABLOID Tier 2


15

Immunomodulators PA, SP, QL lenalidomide REVLIMID Tier 4 PA, SP, QL thalidomide THALOMID Tier 4 Kinase Inhibitors PA, SP, QL acalabrutinib CALQUENCE Tier 4 PA, SP, QL afatinib GILOTRIF Tier 4 PA, SP, QL bosutinib BOSULIF Tier 4 PA, SP, QL cabozantinib CABOMETYX Tier 4 PA, SP, QL dasatinib SPRYCEL Tier 4 PA, SP, QL duvelisib COPIKTRA Tier 4 PA, SP, QL erlotinib Tier 3 PA, SP, QL everolimus Tier 3 AFINITOR Tier 4 PA, SP, QL gefitinib IRESSA Tier 4 PA, SP, QL ibrutinib IMBRUVICA Tier 4 PA, SP, QL lapatinib TYKERB Tier 4 PA, SP, QL larotrectinib VITRAKVI Tier 4 PA, SP, QL midostaurin RYDAPT Tier 4 PA, SP, QL palbociclib IBRANCE Tier 4 PA, SP, QL pazopanib VOTRIENT Tier 4 PA, SP, QL ribociclib KISQALI Tier 4 PA, SP, QL ribociclib + letrozole KISQALI FEMARA CO-

PACK Tier 4

PA, SP, QL sunitinib SUTENT Tier 4 PA, SP, QL tucatinib TUKYSA Tier 4 PA, SP, QL vandetanib CAPRELSA Tier 4 Kinase Inhibitors for CML PA, SP, QL imatinib mesylate Tier 3 MISCELLANEOUS PA, SP bexarotene caps Tier 3 etoposide caps Tier 1 hydroxyurea Tier 1 mitotane LYSODREN Tier 2 PA, SP, QL niraparib ZEJULA Tier 4 PA, SP, QL olaparib LYNPARZA Tier 4 procarbazine MATULANE Tier 2 PA, SP, QL rucaparib RUBRACA Tier 4 PA, SP, QL sonidegib ODOMZO Tier 4 tretinoin caps Tier 1 SP, QL uridine triacetate VISTOGARD Tier 4 PA, SP, QL venetoclax VENCLEXTA Tier 4 PA, SP, QL vorinostat ZOLINZA Tier 4


16

CARDIOVASCULAR The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: https://www.acc.org https://professional.heart.org ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org https://www.acc.org https://professional.heart.org captopril Tier 1 enalapril Tier 1 lisinopril Tier 1 perindopril Tier 1 ramipril Tier 1 trandolapril Tier 1 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/benazepril Tier 1 ACE INHIBITOR/DIURETIC COMBINATIONS captopril/hydrochlorothiazide Tier 1 enalapril/hydrochlorothiazide Tier 1 lisinopril/hydrochlorothiazide Tier 1 ADRENOLYTICS, CENTRAL clonidine Tier 1 clonidine transdermal Tier 1 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone Tier 1 spironolactone Tier 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org irbesartan Tier 1 irbesartan/hydrochlorothiazide Tier 1 losartan Tier 1 LEGEND AL Age Limit ^ Items that may be covered as preventive services under this formulary PA Prior Authorization PA, QL Quantity Limit is applied after Prior Authorization approval QL Quantity Limit QL, PA If Quantity Limit is exceeded, Prior Authorization may apply SP Specialty Drug ST Step Therapy ST, PA If Step Therapy requirements are not met, Prior Authorization may apply boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification

17

losartan/hydrochlorothiazide Tier 1 olmesartan Tier 1 olmesartan/hydrochlorothiazide Tier 1 valsartan Tier 1 valsartan/hydrochlorothiazide Tier 1 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/olmesartan Tier 1 olmesartan/amlodipine/hydrochloroth

iazide Tier 1

ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: https://www.acc.org acebutolol Tier 1 amiodarone Tier 1 amiodarone - Pacerone Tier 1 disopyramide Tier 1 disopyramide ext-rel NORPACE CR Tier 2 PA, SP dofetilide Tier 3 flecainide Tier 1 ibutilide Tier 1 propafenone Tier 1 propafenone ext-rel Tier 1 sotalol Tier 1 ANTILIPEMICS The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol is available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625 Bile Acid Resins cholestyramine Tier 1 colestipol Tier 1 Cholesterol Absorption Inhibitors ezetimibe Tier 1 Fibrates fenofibrate Tier 1 fenofibrate caps 67 mg, 134 mg, 200

mg Tier 1

gemfibrozil Tier 1 HMG-CoA Reductase Inhibitors^ atorvastatin Tier 1


18

pravastatin Tier 1 rosuvastatin Tier 1 simvastatin Tier 1 Niacins niacin ext-rel Tier 1 Omega-3 Fatty Acids PA icosapent ethyl VASCEPA Tier 2 PCSK9 Inhibitors PA, QL alirocumab PRALUENT Tier 2 BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org atenolol Tier 1 bisoprolol Tier 1 carvedilol Tier 1 labetalol Tier 1 metoprolol 25 mg, 50 mg, 100 mg Tier 1 metoprolol ext-rel Tier 1 nadolol Tier 1 pindolol Tier 1 propranolol Tier 1 propranolol ext-rel Tier 1 BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org atenolol/chlorthalidone Tier 1 bisoprolol/hydrochlorothiazide Tier 1 metoprolol/hydrochlorothiazide Tier 1 propranolol/hydrochlorothiazide Tier 1 CALCIUM CHANNEL BLOCKERS Guidelines for the use of calcium channel blockers in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org Dihydropyridines amlodipine Tier 1 felodipine ext-rel Tier 1 isradipine Tier 1 LEGEND AL Age Limit ^ Items that may be covered as preventive services under this formulary PA Prior Authorization PA, QL Quantity Limit is applied after Prior Authorization approval QL Quantity Limit QL, PA If Quantity Limit is exceeded, Prior Authorization may apply SP Specialty Drug ST Step Therapy ST, PA If Step Therapy requirements are not met, Prior Authorization may apply boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification

19

nicardipine Tier 1 nifedipine ext-rel Tier 1 Nondihydropyridines diltiazem ext-rel Tier 1 diltiazem ext-rel Tier 1 CARDIZEM LA Tier 2 verapamil ext-rel Tier 1 DIGITALIS GLYCOSIDES digoxin Tier 1 LANOXIN Tier 2 digoxin ped elixir Tier 1 DIURETICS Loop Diuretics bumetanide Tier 1 furosemide Tier 1 torsemide Tier 1 Potassium-sparing Diuretics amiloride Tier 1 Thiazides and Thiazide-like Diuretics chlorthalidone Tier 1 hydrochlorothiazide Tier 1 indapamide Tier 1 metolazone Tier 1 Diuretic Combinations amiloride/hydrochlorothiazide Tier 1 spironolactone/hydrochlorothiazide Tier 1 triamterene/hydrochlorothiazide Tier 1 HEART FAILURE ivabradine CORLANOR Tier 2 sacubitril/valsartan ENTRESTO Tier 2 NITRATES Oral isosorbide dinitrate Tier 1 isosorbide mononitrate Tier 1 isosorbide mononitrate ext-rel Tier 1 Sublingual nitroglycerin sublingual Tier 1 Transdermal nitroglycerin transdermal Tier 1


20

PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists PA, SP, QL ambrisentan Tier 3 PA, SP, QL bosentan Tier 3 PA, SP, QL macitentan OPSUMIT Tier 4 Phosphodiesterase Inhibitors PA, SP, QL sildenafil Tier 3 Prostacyclin Receptor Agonists PA, SP, QL selexipag UPTRAVI Tier 4 Prostaglandin Vasodilators PA, SP treprostinil ext-rel ORENITRAM Tier 4 Soluble Guanylate Cyclase Stimulators PA, SP, QL riociguat ADEMPAS Tier 4 MISCELLANEOUS hydralazine Tier 1 methyldopa Tier 1 midodrine Tier 1 ranolazine ext-rel Tier 1 CENTRAL NERVOUS SYSTEM Practice guidelines for psychiatric disorders are available at: https://www.psychiatry.org ANTIANXIETY Benzodiazepines QL alprazolam Tier 1 QL alprazolam orally disintegrating tabs Tier 1 QL clorazepate Tier 1 QL diazepam Tier 1 QL lorazepam Tier 1 QL oxazepam Tier 1 Miscellaneous buspirone Tier 1 fluvoxamine Tier 1 ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: https://www.aan.com carbamazepine Tier 1 carbamazepine ext-rel Tier 1 LEGEND AL Age Limit ^ Items that may be covered as preventive services under this formulary PA Prior Authorization PA, QL Quantity Limit is applied after Prior Authorization approval QL Quantity Limit QL, PA If Quantity Limit is exceeded, Prior Authorization may apply SP Specialty Drug ST Step Therapy ST, PA If Step Therapy requirements are not met, Prior Authorization may apply boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification

21

PA clobazam Tier 1 QL clonazepam tabs Tier 1 divalproex sodium delayed-rel Tier 1 divalproex sodium ext-rel Tier 1 divalproex sodium sprinkle caps Tier 1 ethosuximide Tier 1 felbamate Tier 1 gabapentin caps, tabs Tier 1 lamotrigine Tier 1 lamotrigine ext-rel Tier 1 levetiracetam Tier 1 levetiracetam ext-rel Tier 1 oxcarbazepine Tier 1 phenobarbital Tier 1 phenytoin chewable tabs Tier 1 phenytoin sodium extended Tier 1 phenytoin susp Tier 1 primidone Tier 1 tiagabine Tier 1 topiramate Tier 1 topiramate sprinkle caps Tier 1 valproic acid Tier 1 PA, SP, QL vigabatrin Tier 3 zonisamide Tier 1 ANTIDEMENTIA Practice guidelines for the management of dementia are available at: https://www.aan.com donepezil Tier 1 donepezil orally disintegrating tabs Tier 1 galantamine Tier 1 galantamine ext-rel Tier 1 memantine Tier 1 rivastigmine Tier 1 rivastigmine transdermal Tier 1 ANTIDEPRESSANTS Although these agents are primarily indicated for depression, some of these are also approved for other indications, including bipolar disorder, obsessive-compulsive disorder, panic disorder and premenstrual dysphoric disorder. Guidelines for the evaluation and management of bipolar and depressive disorders are available at: https://www.psychiatry.org Monoamine Oxidase Inhibitors (MAOIs) phenelzine Tier 1 tranylcypromine Tier 1


22

Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram Tier 1 escitalopram Tier 1 fluoxetine Tier 1 paroxetine HCl ext-rel Tier 1 paroxetine HCl tabs Tier 1 sertraline Tier 1 Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) desvenlafaxine succinate ext-rel Tier 1 duloxetine delayed-rel Tier 1 venlafaxine Tier 1 venlafaxine ext-rel Tier 1 Tricyclic Antidepressants (TCAs) amitriptyline Tier 1 desipramine Tier 1 doxepin Tier 1 imipramine HCl Tier 1 nortriptyline Tier 1 Miscellaneous Agents bupropion Tier 1 bupropion ext-rel Tier 1 mirtazapine Tier 1 mirtazapine orally disintegrating tabs Tier 1 trazodone Tier 1 ANTIPARKINSONIAN AGENTS Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at: https://www.aan.com amantadine Tier 1 benztropine Tier 1 bromocriptine Tier 1 carbidopa/levodopa Tier 1 carbidopa/levodopa ext-rel Tier 1 carbidopa/levodopa orally

disintegrating tabs Tier 1

carbidopa/levodopa/entacapone Tier 1 entacapone Tier 1 pramipexole Tier 1 rasagiline mesylate Tier 1 ropinirole Tier 1 selegiline Tier 1 trihexyphenidyl Tier 1


23

ANTIPSYCHOTICS Atypicals aripiprazole Tier 1 clozapine Tier 1 clozapine orally disintegrating tabs Tier 1 olanzapine Tier 1 paliperidone ext-rel Tier 1 quetiapine Tier 1 risperidone Tier 1 risperidone orally disintegrating tabs Tier 1 ziprasidone Tier 1 Miscellaneous chlorpromazine Tier 1 fluphenazine Tier 1 haloperidol Tier 1 trifluoperazine Tier 1 ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the evaluation and management of attention deficit disorder are available at: https://www.aacap.org https://www.aap.org QL, PA amphetamine/

dextroamphetamine mixed salts Tier 1

QL, PA amphetamine/ dextroamphetamine mixed salts ext-rel

ADDERALL XR Tier 1

QL atomoxetine Tier 1 QL, PA dexmethylphenidate Tier 1 QL, PA dextroamphetamine Tier 1 QL, PA dextroamphetamine ext-rel Tier 1 QL, PA methylphenidate Tier 1 QL, PA methylphenidate ext-rel Tier 1 QL, PA methylphenidate ext-rel CONCERTA Tier 1 FIBROMYALGIA PA milnacipran SAVELLA Tier 2 HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia are available at: https://aasm.org Benzodiazepines QL temazepam Tier 1 Nonbenzodiazepines QL, PA zaleplon Tier 1 LEGEND AL Age Limit ^ Items that may be covered as preventive services under this formulary PA Prior Authorization PA, QL Quantity Limit is applied after Prior Authorization approval QL Quantity Limit QL, PA If Quantity Limit is exceeded, Prior Authorization may apply SP Specialty Drug ST Step Therapy ST, PA If Step Therapy requirements are not met, Prior Authorization may apply boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification

24

QL, PA zolpidem Tier 1 QL, PA zolpidem ext-rel Tier 1 MIGRAINE Guidelines for prevention and management of migraine headaches are available at: https://www.aan.com Monoclonal Antibodies ST, PA, QL erenumab-aooe AIMOVIG Tier 2 Selective Serotonin Agonists QL, PA naratriptan Tier 1 QL, PA rizatriptan Tier 1 QL, PA rizatriptan orally disintegrating tabs Tier 1 QL, PA sumatriptan Tier 1 QL, PA sumatriptan inj Tier 1 QL, PA sumatriptan nasal spray Tier 1 QL, PA zolmitriptan orally disintegrating tabs Tier 1 QL, PA zolmitriptan tabs Tier 1 MOOD STABILIZERS lithium carbonate Tier 1 lithium carbonate ext-rel tabs 300 mg,

450 mg Tier 1

MOVEMENT DISORDERS PA, SP, QL deutetrabenazine AUSTEDO Tier 4 PA, SP, QL tetrabenazine Tier 3 PA, SP, QL valbenazine INGREZZA Tier 4 MULTIPLE SCLEROSIS AGENTS Practice guidelines for multiple sclerosis are available at: https://www.aan.com PA, SP, QL dimethyl fumarate delayed-rel TECFIDERA Tier 4 PA, SP, QL diroximel fumarate delayed-rel VUMERITY Tier 4 PA, SP, QL fingolimod GILENYA Tier 4 PA, SP, QL glatiramer Tier 3 COPAXONE Tier 4 PA, SP, QL interferon beta-1a REBIF Tier 4 PA, SP, QL interferon beta-1b BETASERON Tier 4 PA, SP, QL siponimod MAYZENT Tier 4 PA, SP, QL teriflunomide AUBAGIO Tier 4 MUSCULOSKELETAL THERAPY AGENTS baclofen Tier 1 cyclobenzaprine 5 mg, 10 mg Tier 1 dantrolene Tier 1


25

methocarbamol Tier 1 tizanidine tabs Tier 1 MYASTHENIA GRAVIS pyridostigmine Tier 1 NARCOLEPSY PA armodafinil Tier 1 PA modafinil Tier 1 PSYCHOTHERAPEUTIC-MISCELLANEOUS Opioid Antagonists QL, PA naloxone nasal spray NARCAN Tier 2 naltrexone Tier 1 Partial Opioid Agonists PA buprenorphine Tier 1 Partial Opioid Agonist/Opioid Antagonist Combinations QL buprenorphine/naloxone sublingual

film Tier 1

QL buprenorphine/naloxone sublingual tabs

Tier 1

Smoking Deterrents Treating Tobacco Use and Dependence: 2008 Update-Clinical Practice Guideline is available at: https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html bupropion ext-rel Tier 1 varenicline CHANTIX Tier 2 MISCELLANEOUS riluzole Tier 1 ENDOCRINE AND METABOLIC ACROMEGALY PA, SP, QL octreotide acetate Tier 3 PA, SP, QL pegvisomant SOMAVERT Tier 4 ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: https://www.aace.com PA testosterone cypionate inj Tier 1 PA testosterone enanthate inj Tier 1 testosterone gel Tier 1 testosterone gel 25 mg/2.5 g Tier 1 LEGEND AL Age Limit ^ Items that may be covered as preventive services under this formulary PA Prior Authorization PA, QL Quantity Limit is applied after Prior Authorization approval QL Quantity Limit QL, PA If Quantity Limit is exceeded, Prior Authorization may apply SP Specialty Drug ST Step Therapy ST, PA If Step Therapy requirements are not met, Prior Authorization may apply boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification

26

ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: https://professional.diabetes.org Amylin Analogs ST, PA pramlintide SYMLINPEN Tier 2 Biguanides metformin Tier 1 † metformin ext-rel Tier 1 † Listing does not include generics for FORTAMET and GLUMETZA Biguanide/Sulfonylurea Combinations glipizide/metformin Tier 1 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors ST, PA sitagliptin JANUVIA Tier 2 Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations ST, PA sitagliptin/metformin JANUMET Tier 2 ST, PA sitagliptin/metformin ext-rel JANUMET XR Tier 2 Incretin Mimetic Agents ST, PA, QL dulaglutide TRULICITY Tier 2 ST, PA, QL liraglutide VICTOZA Tier 2 ST, PA, QL semaglutide OZEMPIC Tier 2 ST, PA semaglutide RYBELSUS Tier 2 Incretin Mimetic Agent/Insulin Combinations ST, PA lixisenatide/insulin glargine SOLIQUA Tier 2 Insulins insulin aspart FIASP Tier 2 insulin aspart NOVOLOG Tier 2 insulin aspart protamine 70%/insulin

aspart 30% NOVOLOG MIX 70/30 Tier 2

insulin detemir LEVEMIR Tier 2 insulin glargine BASAGLAR Tier 2 insulin human NOVOLIN R Tier 2 insulin human, concentrated HUMULIN R U-500 Tier 2 insulin isophane human NOVOLIN N Tier 2 insulin isophane human 70%/

regular 30% NOVOLIN 70/30 Tier 2

Insulin Sensitizers pioglitazone Tier 1 LEGEND AL Age Limit ^ Items that may be covered as preventive services under this formulary PA Prior Authorization PA, QL Quantity Limit is applied after Prior Authorization approval QL Quantity Limit QL, PA If Quantity Limit is exceeded, Prior Authorization may apply SP Specialty Drug ST Step Therapy ST, PA If Step Therapy requirements are not met, Prior Authorization may apply boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification

27

Insulin Sensitizer/Biguanide Combinations pioglitazone/metformin Tier 1 Insulin Sensitizer/Sulfonylurea Combinations pioglitazone/glimepiride Tier 1 Sodium Glucose Co-Transporter 2 (SGLT2) Inhibitors ST, PA dapagliflozin FARXIGA Tier 2 ST, PA empagliflozin JARDIANCE Tier 2 Sodium Glucose Co-Transporter 2 (SGLT2) Inhibitor/Biguanide Combinations ST, PA dapagliflozin/metformin ext-rel XIGDUO XR Tier 2 ST, PA empagliflozin/metformin SYNJARDY Tier 2 ST, PA empagliflozin/metformin ext-rel SYNJARDY XR Tier 2 Sodium Glucose Co-Transporter 2 (SGLT2) Inhibitor/Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations ST, PA empagliflozin/linagliptin GLYXAMBI Tier 2 Sodium Glucose Co-Transporter 2 (SGLT2) Inhibitor/Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations ST, PA empagliflozin/linagliptin/metformin ext-rel TRIJARDY XR Tier 2 Sulfonylureas glimepiride Tier 1 glipizide Tier 1 glipizide ext-rel Tier 1 Supplies* * An ACCU-CHEK blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a

meter other than ACCU-CHEK. For more information on how to obtain a blood glucose meter, call: 1-877-418-4746. QL blood glucose continuous monitoring

receivers, sensors, transmitters DEXCOM

CONTINUOUS GLUCOSE MONITORING SYSTEM

Tier 2

QL insulin infusion disposable pump V-GO INSULIN INFUSION PUMP

Tier 2

OTC insulin syringes, needles BD insulin syringes and needles

Tier 2

OTC, QL, PA test strips ACCU-CHEK AVIVA PLUS STRIPS

Tier 2

OTC, QL, PA test strips ACCU-CHEK COMPACT PLUS STRIPS

Tier 2

OTC, QL, PA test strips ACCU-CHEK GUIDE STRIPS

Tier 2

OTC, QL, PA test strips ACCU-CHEK SMARTVIEW STRIPS

Tier 2


28

CALCIUM RECEPTOR ANTAGONISTS PA, SP, QL cinacalcet Tier 3 CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at: https://www.aace.com https://www.nof.org Bisphosphonates alendronate Tier 1 ibandronate Tier 1 risedronate Tier 1 Parathyroid Hormones PA, SP, QL abaloparatide TYMLOS Tier 4 PA, SP, QL teriparatide FORTEO Tier 4 CONTRACEPTIVES^ EE = ethinyl estradiol Monophasic 20 mcg Estrogen drospirenone/EE 3/20 Tier 1 levonorgestrel/EE 0.1/20 - Lessina Tier 1 norethindrone acetate/EE 1/20 Tier 1 norethindrone acetate/EE 1/20 and

iron Tier 1

25 mcg Estrogen norethindrone acetate/EE 0.8/25 and

iron Tier 1

30 mcg Estrogen desogestrel/EE 0.15/30 - Apri Tier 1 drospirenone/EE 3/30 Tier 1 levonorgestrel/EE 0.15/30 - Levora Tier 1 norethindrone acetate/EE 1.5/30 Tier 1 norethindrone acetate/EE 1.5/30 and

iron Tier 1

norgestrel/EE 0.3/30 - Low-Ogestrel Tier 1 35 mcg Estrogen ethynodiol diacetate/EE 1/35 - Zovia

1/35 Tier 1

norethindrone/EE 0.5/35 Tier 1 norethindrone/EE 1/35 Tier 1 norgestimate/EE 0.25/35 Tier 1 LEGEND AL Age Limit ^ Items that may be covered as preventive services under this formulary PA Prior Authorization PA, QL Quantity Limit is applied after Prior Authorization approval QL Quantity Limit QL, PA If Quantity Limit is exceeded, Prior Authorization may apply SP Specialty Drug ST Step Therapy ST, PA If Step Therapy requirements are not met, Prior Authorization may apply boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification

29

50 mcg Estrogen ethynodiol diacetate/EE 1/50 Tier 1 Biphasic desogestrel/EE Tier 1 Triphasic desogestrel/EE Tier 1 levonorgestrel/EE - Trivora Tier 1 norethindrone/EE Tier 1 norgestimate/EE Tier 1 Extended Cycle levonorgestrel/EE 0.15/30 - Jolessa Tier 1 Progestin Only norethindrone Tier 1 Emergency Contraception ulipristal ELLA Tier 2 Injectable medroxyprogesterone acetate 150

mg/mL Tier 1

Transdermal norelgestromin/EE - Xulane Tier 1 Vaginal etonogestrel/EE ring Tier 1 ENDOMETRIOSIS danazol Tier 1 nafarelin SYNAREL Tier 2 ESTROGENS Guidelines of treatment and management of hormone therapy and menopause are available at: https://www.menopause.org https://www.aace.com/files/menopause.pdf Oral estradiol Tier 1 Transdermal estradiol Tier 1 Vaginal estradiol vaginal crm Tier 1 LEGEND AL Age Limit ^ Items that may be covered as preventive services under this formulary PA Prior Authorization PA, QL Quantity Limit is applied after Prior Authorization approval QL Quantity Limit QL, PA If Quantity Limit is exceeded, Prior Authorization may apply SP Specialty Drug ST Step Therapy ST, PA If Step Therapy requirements are not met, Prior Authorization may apply boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification

30

ESTROGEN/PROGESTINS Oral EE/norethindrone acetate Tier 1 EE/norethindrone acetate - Jinteli Tier 1 estradiol/norethindrone Tier 1 Transdermal estradiol/levonorgestrel CLIMARA PRO Tier 2 FERTILITY REGULATORS GNRH/LHRH Antagonists PA, SP cetrorelix CETROTIDE Tier 4 Ovulation Stimulants, Gonadotropins PA, SP choriogonadotropin alfa OVIDREL Tier 4 PA, SP, QL follitropin alfa GONAL-F Tier 4 GAUCHER DISEASE PA, SP, QL eliglustat CERDELGA Tier 4 GLUCOCORTICOIDS dexamethasone Tier 1 fludrocortisone Tier 1 hydrocortisone Tier 1 methylprednisolone Tier 1 MEDROL Tier 2 prednisolone sodium phosphate Tier 1 prednisolone sodium phosphate

orally disintegrating tabs Tier 1

prednisolone syrup Tier 1 prednisone Tier 1 GLUCOSE ELEVATING AGENTS glucagon, human recombinant GLUCAGEN HYPOKIT Tier 2 glucagon, human recombinant GLUCAGON

EMERGENCY KIT Tier 2

glucagon intranasal powder BAQSIMI Tier 2 glucagon subcutaneous soln GVOKE Tier 2 HEREDITARY TYROSINEMIA TYPE 1 AGENTS Metabolic Modifiers PA, SP nitisinone NITYR Tier 4 PA, SP nitisinone Tier 3 ORFADIN Tier 4 HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at: https://www.aace.com/publications/guidelines PA, SP somatropin HUMATROPE Tier 4 LEGEND AL Age Limit ^ Items that may be covered as preventive services under this formulary PA Prior Authorization PA, QL Quantity Limit is applied after Prior Authorization approval QL Quantity Limit QL, PA If Quantity Limit is exceeded, Prior Authorization may apply SP Specialty Drug ST Step Therapy ST, PA If Step Therapy requirements are not met, Prior Authorization may apply boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification

31

HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3) Tier 1 doxercalciferol Tier 1 paricalcitol Tier 1 PHOSPHATE BINDER AGENTS calcium acetate caps Tier 1 sevelamer carbonate Tier 1 POLYNEUROPATHY PA, SP, QL inotersen TEGSEDI Tier 4 PROGESTINS Oral medroxyprogesterone acetate Tier 1 norethindrone acetate Tier 1 progesterone, micronized Tier 1 Vaginal progesterone vaginal inserts ENDOMETRIN Tier 2 SELECTIVE ESTROGEN RECEPTOR MODULATORS ospemifene OSPHENA Tier 2 raloxifene Tier 1 THYROID AGENTS Antithyroid Agents methimazole Tier 1 propylthiouracil Tier 1 Thyroid Supplements levothyroxine Tier 1 levothyroxine - Levoxyl Tier 1 liothyronine Tier 1 UREA CYCLE DISORDERS PA, SP, QL sodium phenylbutyrate Tier 3 VASOPRESSINS desmopressin nasal spray Tier 1 desmopressin tabs Tier 1 MISCELLANEOUS cabergoline Tier 1 PA, SP cysteamine CYSTAGON Tier 4


32

GASTROINTESTINAL Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at: https://gi.org https://www.gastro.org ANTIDIARRHEALS diphenoxylate/atropine Tier 1 loperamide Tier 1 ANTIEMETICS QL, PA aprepitant caps Tier 1 dronabinol Tier 1 QL, PA granisetron Tier 1 meclizine Tier 1 metoclopramide Tier 1 QL, PA ondansetron Tier 1 QL, PA ondansetron orally disintegrating

tabs Tier 1

prochlorperazine Tier 1 promethazine Tier 1 trimethobenzamide Tier 1 ANTISPASMODICS dicyclomine Tier 1 hyoscyamine sulfate Tier 1 hyoscyamine sulfate ext-rel Tier 1 hyoscyamine sulfate ext-rel caps Tier 1 hyoscyamine sulfate orally

disintegrating tabs Tier 1

CHOLELITHOLYTICS ursodiol Tier 1 H2 RECEPTOR ANTAGONISTS cimetidine Tier 1 famotidine Tier 1 INFLAMMATORY BOWEL DISEASE Oral Agents balsalazide Tier 1 budesonide delayed-rel caps Tier 1 mesalamine delayed-rel Tier 1 mesalamine ext-rel caps Tier 1 sulfasalazine Tier 1 sulfasalazine delayed-rel Tier 1


33

Rectal Agents hydrocortisone enema Tier 1 mesalamine rectal susp Tier 1 IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation/Chronic Idiopathic Constipation linaclotide LINZESS Tier 2 plecanatide TRULANCE Tier 2 Irritable Bowel Syndrome with Diarrhea alosetron Tier 1 LAXATIVES^ lactulose soln Tier 1 peg 3350/electrolytes Tier 1 sodium sulfate/potassium

sulfate/magnesium sulfate SUPREP Tier 2

OPIOID-INDUCED CONSTIPATION naloxegol MOVANTIK Tier 2 PANCREATIC ENZYMES pancrelipase VIOKACE Tier 2 pancrelipase delayed-rel CREON Tier 2 PROSTAGLANDINS misoprostol Tier 1 PROTON PUMP INHIBITORS QL, PA lansoprazole Tier 1 QL, PA lansoprazole soluble tabs Tier 1 QL, PA omeprazole delayed-rel Tier 1 QL, PA omeprazole granules PRILOSEC Tier 2 QL, PA pantoprazole delayed-rel Tier 1 SALIVA STIMULANTS pilocarpine tabs Tier 1 STEROIDS, RECTAL hydrocortisone crm Tier 1 MISCELLANEOUS AL glycopyrrolate CUVPOSA Tier 2


34

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at: https://www.auanet.org/guidelines alfuzosin ext-rel Tier 1 doxazosin Tier 1 finasteride Tier 1 tamsulosin Tier 1 terazosin Tier 1 ERECTILE DYSFUNCTION QL sildenafil Tier 1 QL tadalafil Tier 1 QL vardenafil Tier 1 URINARY ANTISPASMODICS oxybutynin Tier 1 oxybutynin ext-rel Tier 1 tolterodine Tier 1 trospium Tier 1 VAGINAL ANTI-INFECTIVES clindamycin crm Tier 1 metronidazole Tier 1 terconazole Tier 1 MISCELLANEOUS bethanechol Tier 1 potassium citrate ext-rel Tier 1 HEMATOLOGIC ANTICOAGULANTS CHEST guidelines are available at: https://www.chestnet.org/Guidelines-and-Resources/CHEST-Guideline-Topic-Areas/Pulmonary-Vascular Injectable enoxaparin Tier 1 Oral rivaroxaban XARELTO Tier 2 warfarin Tier 1 Synthetic Heparinoid-like Agents fondaparinux Tier 1


35

HEMATOPOIETIC GROWTH FACTORS PA, SP darbepoetin alfa ARANESP Tier 4 PA, SP epoetin alfa-epbx RETACRIT Tier 4 PA, SP filgrastim-aafi NIVESTYM Tier 4 PA, SP, QL pegfilgrastim NEULASTA Tier 4 PA, SP, QL pegfilgrastim-cbqv UDENYCA Tier 4 PLATELET AGGREGATION INHIBITORS clopidogrel Tier 1 dipyridamole Tier 1 dipyridamole ext-rel/aspirin Tier 1 prasugrel Tier 1 ticagrelor BRILINTA Tier 2 PLATELET SYNTHESIS INHIBITORS anagrelide Tier 1 THROMBOCYTOPENIA AGENTS SP, QL lusutrombopag MULPLETA Tier 4 MISCELLANEOUS cilostazol Tier 1 IMMUNOLOGIC AGENTS ALLERGENIC EXTRACTS PA grass mixed pollen allergen extract ORALAIR Tier 2 AUTOIMMUNE AGENTS Ankylosing Spondylitis PA, SP, QL adalimumab HUMIRA Tier 4 PA, SP, QL etanercept ENBREL Tier 4 PA, SP, QL secukinumab COSENTYX Tier 4 Crohn's Disease PA, SP, QL adalimumab HUMIRA Tier 4 ##, PA, SP, QL ustekinumab subcutaneous STELARA Tier 4 ## After failure of HUMIRA Psoriasis PA, SP, QL adalimumab HUMIRA Tier 4 PA, SP, QL apremilast OTEZLA Tier 4 PA, SP, QL guselkumab TREMFYA Tier 4 PA, SP, QL risankizumab-rzaa SKYRIZI Tier 4 PA, SP, QL ustekinumab subcutaneous STELARA Tier 4


36

Psoriatic Arthritis PA, SP, QL adalimumab HUMIRA Tier 4 PA, SP, QL apremilast OTEZLA Tier 4 PA, SP, QL etanercept ENBREL Tier 4 PA, SP, QL secukinumab COSENTYX Tier 4 Rheumatoid Arthritis PA, SP, QL adalimumab HUMIRA Tier 4 PA, SP, QL etanercept ENBREL Tier 4 PA, SP, QL tofacitinib XELJANZ Tier 4 PA, SP, QL tofacitinib ext-rel XELJANZ XR Tier 4 PA, SP, QL upadacitinib RINVOQ Tier 4 Ulcerative Colitis PA, SP, QL adalimumab HUMIRA Tier 4 ##, PA, SP, QL tofacitinib XELJANZ Tier 4 ##, PA, SP, QL tofacitinib ext-rel XELJANZ XR Tier 4 ##, PA, SP, QL ustekinumab subcutaneous STELARA Tier 4 ## After failure of HUMIRA All Other Conditions PA, SP, QL adalimumab HUMIRA Tier 4 PA, SP, QL etanercept ENBREL Tier 4 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) Guidelines for the management of rheumatic diseases are available at: https://www.rheumatology.org hydroxychloroquine Tier 1 leflunomide Tier 1 methotrexate Tier 1 PA, SP, QL methotrexate RASUVO Tier 4 penicillamine Tier 1 HEREDITARY ANGIOEDEMA AGENTS PA, SP, QL C1 esterase inhibitor, recombinant RUCONEST Tier 4 PA, SP, QL icatibant FIRAZYR Tier 4 PA, SP, QL lanadelumab-flyo TAKHZYRO Tier 4 IMMUNOSUPPRESSANTS Antimetabolites azathioprine Tier 1 mycophenolate mofetil Tier 1 Calcineurin Inhibitors cyclosporine Tier 1


37

cyclosporine, modified Tier 1 tacrolimus Tier 1 Rapamycin Derivatives sirolimus Tier 1 NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Potassium potassium chloride ext-rel Tier 1 potassium chloride liquid Tier 1 VITAMINS AND MINERALS Folic Acid^ folic acid Tier 1 Prenatal Vitamins prenatal vitamin/minerals Tier 1 Miscellaneous cyanocobalamin inj Tier 1 ergocalciferol (D2) Tier 1 fluoride drops, tabs Tier 1 multivitamins/fluoride drops, tabs Tier 1 multivitamins/fluoride/iron drops,

tabs Tier 1

phytonadione Tier 1 vitamin ADC/fluoride drops Tier 1 vitamin ADC/fluoride/iron drops Tier 1 RESPIRATORY Guidelines to the management, prevention, or treatment of COPD and asthma are available at: https://www.aaaai.org https://ginasthma.org https://goldcopd.org https://www.nhlbi.nih.gov The Allergy Report and guidelines for allergy-related conditions are available at: https://www.aaaai.org ANAPHYLAXIS TREATMENT AGENTS QL, PA epinephrine EPIPEN Tier 2 QL, PA epinephrine Tier 1 EPIPEN JR Tier 2 QL, PA epinephrine SYMJEPI Tier 2 QL, PA epinephrine auto-injector Tier 1


38

ANTICHOLINERGICS QL ipratropium inhalation solution Tier 1 QL revefenacin inhalation solution YUPELRI Tier 2 QL umeclidinium INCRUSE ELLIPTA Tier 2 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting QL ipratropium/albuterol soln Tier 1 Long Acting QL glycopyrrolate/formoterol BEVESPI

AEROSPHERE Tier 2

QL umeclidinium/vilanterol ANORO ELLIPTA Tier 2 ANTIHISTAMINES, SEDATING cyproheptadine Tier 1 hydroxyzine HCl Tier 1 ANTITUSSIVES Clinical practice guidelines are available at: https://journal.chestnet.org/article/S0012-3692(15)52856-0/pdf benzonatate Tier 1 ANTITUSSIVE COMBINATIONS Opioid codeine/promethazine Tier 1 codeine/promethazine/phenylephrine Tier 1 hydrocodone/homatropine Tier 1 Non-opioid dextromethorphan/promethazine Tier 1 BETA AGONISTS Inhalants Short Acting QL albuterol inhalation soln Tier 1 QL albuterol sulfate, CFC-free aerosol Tier 1 QL levalbuterol nebulizer soln

concentrate Tier 1

Long Acting Hand-held Active Inhalation QL olodaterol, CFC-free aerosol STRIVERDI

RESPIMAT Tier 2

Nebulized Passive Inhalation QL formoterol inhalation soln PERFOROMIST Tier 2 LEGEND AL Age Limit ^ Items that may be covered as preventive services under this formulary PA Prior Authorization PA, QL Quantity Limit is applied after Prior Authorization approval QL Quantity Limit QL, PA If Quantity Limit is exceeded, Prior Authorization may apply SP Specialty Drug ST Step Therapy ST, PA If Step Therapy requirements are not met, Prior Authorization may apply boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification

39

CYSTIC FIBROSIS PA, SP, QL elexacaftor/tezacaftor/ivacaftor +

ivacaftor TRIKAFTA Tier 4

PA, SP, QL tezacaftor/ivacaftor + ivacaftor SYMDEKO Tier 4 PA, SP, QL tobramycin inhalation soln Tier 3 PA, SP, QL tobramycin inhalation soln BETHKIS Tier 4 LEUKOTRIENE MODULATORS montelukast Tier 1 NASAL ANTIHISTAMINES azelastine spray Tier 1 NASAL STEROIDS flunisolide spray Tier 1 fluticasone spray Tier 1 PULMONARY FIBROSIS AGENTS PA, SP, QL nintedanib OFEV Tier 4 PA, SP, QL pirfenidone ESBRIET Tier 4 SEVERE ASTHMA AGENTS PA, SP, QL benralizumab FASENRA Tier 4 PA, SP, QL dupilumab DUPIXENT Tier 4 PA, SP, QL mepolizumab NUCALA Tier 4 STEROID/BETA AGONIST COMBINATIONS QL budesonide/formoterol SYMBICORT Tier 2 QL fluticasone/salmeterol ADVAIR Tier 1 QL fluticasone/salmeterol, CFC-free aerosol ADVAIR HFA Tier 2 QL fluticasone/vilanterol BREO ELLIPTA Tier 2 STEROID INHALANTS QL beclomethasone breath-activated

aerosol QVAR REDIHALER Tier 2

QL, PA budesonide inh susp Tier 1 QL fluticasone furoate ARNUITY ELLIPTA Tier 2 QL fluticasone propionate FLOVENT DISKUS Tier 2 QL fluticasone propionate, CFC-free aerosol FLOVENT HFA Tier 2 XANTHINES theophylline ext-rel tabs Tier 1 MISCELLANEOUS ipratropium spray Tier 1


40

TOPICAL DERMATOLOGY Acne Guidelines for the care and treatment of acne vulgaris are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines Oral isotretinoin - Claravis Tier 1 Topical benzoyl peroxide crm, lotion Tier 1 QL, PA clindamycin gel, lotion, soln Tier 1 QL, PA erythromycin gel 2% Tier 1 QL, PA erythromycin soln Tier 1 erythromycin/benzoyl peroxide Tier 1 sulfacetamide lotion 10% Tier 1 PA tretinoin Tier 1 PA tretinoin - Avita Tier 1 Actinic Keratosis fluorouracil crm 4% TOLAK Tier 2 fluorouracil crm 5% Tier 1 fluorouracil soln 2%, 5% Tier 1 imiquimod crm Tier 1 Antibiotics gentamicin Tier 1 mupirocin oint Tier 1 silver sulfadiazine Tier 1 Antifungals QL, PA ciclopirox Tier 1 QL, PA clotrimazole Tier 1 QL, PA econazole Tier 1 QL, PA ketoconazole crm 2% Tier 1 QL, PA nystatin Tier 1 Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: https://www.aad.org Topical calcipotriene oint, soln 0.005% Tier 1 Antiseborrheics ketoconazole shampoo 2% Tier 1 selenium sulfide lotion 2.5% Tier 1 LEGEND AL Age Limit ^ Items that may be covered as preventive services under this formulary PA Prior Authorization PA, QL Quantity Limit is applied after Prior Authorization approval QL Quantity Limit QL, PA If Quantity Limit is exceeded, Prior Authorization may apply SP Specialty Drug ST Step Therapy ST, PA If Step Therapy requirements are not met, Prior Authorization may apply boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification

41

Atopic Dermatitis Guidelines for the treatment of atopic dermatitis are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines Injectable PA, SP, QL dupilumab DUPIXENT Tier 4 Topical pimecrolimus Tier 1 tacrolimus Tier 1 Corticosteroids Low Potency QL, PA alclometasone crm, oint 0.05% Tier 1 QL, PA desonide crm, lotion, oint 0.05% Tier 1 QL, PA fluocinolone acetonide soln 0.01% Tier 1 QL, PA hydrocortisone crm 2.5% Tier 1 Medium Potency QL, PA betamethasone valerate crm, lotion,

oint 0.1% Tier 1

QL, PA desoximetasone crm 0.05% Tier 1 QL, PA fluocinolone acetonide crm, oint

0.025% Tier 1

QL, PA fluticasone propionate crm 0.05%, oint 0.005%

Tier 1

QL, PA hydrocortisone butyrate crm, oint 0.1%

Tier 1

QL, PA hydrocortisone butyrate soln 0.1% Tier 1 QL, PA hydrocortisone valerate crm, oint

0.2% Tier 1

QL, PA mometasone crm, lotion, oint 0.1% Tier 1 QL, PA triamcinolone acetonide crm, lotion

0.025% Tier 1

QL, PA triamcinolone acetonide crm, lotion, oint 0.1%

Tier 1

High Potency QL, PA amcinonide crm, lotion, oint 0.1% Tier 1 QL, PA betamethasone dipropionate

augmented crm 0.05% Tier 1

QL, PA betamethasone dipropionate augmented lotion 0.05%

Tier 1

QL, PA betamethasone dipropionate crm, lotion, oint 0.05%

Tier 1

QL, PA desoximetasone crm, oint 0.25%, gel 0.05%

Tier 1


42

QL, PA fluocinonide crm, gel, oint 0.05% Tier 1 QL, PA fluocinonide soln 0.05% Tier 1 QL, PA triamcinolone acetonide crm 0.5% Tier 1 Very High Potency QL, PA betamethasone dipropionate

augmented gel, oint 0.05% Tier 1

QL, PA clobetasol propionate crm, gel, oint 0.05%

Tier 1

QL, PA clobetasol propionate foam 0.05% Tier 1 QL, PA clobetasol propionate lotion 0.05% Tier 1 QL, PA halobetasol propionate crm, oint

0.05% Tier 1

Emollients ammonium lactate 12% Tier 1 Local Anesthetics lidocaine/prilocaine crm Tier 1 Rosacea metronidazole crm 0.75% Tier 1 metronidazole gel 0.75% Tier 1 metronidazole lotion 0.75% Tier 1 Scabicides and Pediculicides malathion Tier 1 permethrin 5% Tier 1 MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral lidocaine viscous Tier 1 Protectants PA benzyl alcohol/carbomer 941/glycerin MUGARD Tier 2 Steroids - Mouth/Throat triamcinolone paste Tier 1 OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at: https://one.aao.org Antiallergics azelastine Tier 1 cromolyn sodium Tier 1


43

Antifungals natamycin NATACYN Tier 2 Anti-infectives bacitracin Tier 1 ciprofloxacin soln Tier 1 erythromycin Tier 1 gentamicin Tier 1 moxifloxacin Tier 1 neomycin/polymyxin B/gramicidin Tier 1 ofloxacin Tier 1 polymyxin B/bacitracin Tier 1 polymyxin B/trimethoprim Tier 1 sulfacetamide soln 10% Tier 1 tobramycin Tier 1 Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/

bacitracin/hydrocortisone oint Tier 1

neomycin/polymyxin B/ dexamethasone

Tier 1

neomycin/polymyxin B/ hydrocortisone susp

Tier 1

sulfacetamide/prednisolone phosphate

Tier 1

tobramycin/dexamethasone susp 0.3%/0.1%

Tier 1

Anti-inflammatories Nonsteroidal diclofenac sodium Tier 1 ketorolac 0.5% Tier 1 Steroidal dexamethasone sodium phosphate Tier 1 fluorometholone 0.1% susp Tier 1 fluorometholone oint FML S.O.P. Tier 2 loteprednol susp 0.5% Tier 1 prednisolone acetate 1% Tier 1 prednisolone phosphate 1% PREDNISOLONE

PHOSPHATE 1% Tier 2

Antivirals trifluridine Tier 1


44

Beta-blockers Nonselective timolol maleate Tier 1 timolol maleate gel Tier 1 Selective betaxolol solution Tier 1 Carbonic Anhydrase Inhibitors Topical dorzolamide Tier 1 Carbonic Anhydrase Inhibitor/Beta-blocker Combinations dorzolamide/timolol maleate Tier 1 Dry Eye Disease lifitegrast XIIDRA Tier 2 Prostaglandins latanoprost Tier 1 Sympathomimetics brimonidine 0.15% Tier 1 brimonidine 0.2% Tier 1 Sympathomimetic/Beta-blocker Combinations brimonidine/timolol COMBIGAN Tier 2 OTIC Clinical practice guidelines for the treatment of otitis media are available at: https://www.aap.org Anti-infectives acetic acid Tier 1 ofloxacin otic Tier 1 Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin

B/hydrocortisone Tier 1


45

WEBSITES Agency for Healthcare Research and Quality https://www.ahrq.gov Alzheimer's Association https://www.alz.org American Academy of Allergy, Asthma and Immunology https://www.aaaai.org American Academy of Child & Adolescent Psychiatry https://www.aacap.org American Academy of Dermatology https://www.aad.org American Academy of Neurology https://www.aan.com American Academy of Ophthalmology https://www.aao.org American Academy of Pediatrics https://www.aap.org American Association for the Study of Liver Disease https://www.aasld.org American Association of Clinical Endocrinologists https://www.aace.com American Association of Diabetes Educators https://www.diabeteseducator.org American Cancer Society https://www.cancer.org American College of Allergy, Asthma and Immunology https://www.acaai.org American College of Cardiology https://www.acc.org American College of Chest Physicians https://www.chestnet.org American College of Gastroenterology https://gi.org American College of Physicians https://www.acponline.org American College of Rheumatology https://www.rheumatology.org

American Congress of Obstetricians and Gynecologists https://www.acog.org American Diabetes Association http://www.diabetes.org American Gastroenterological Association https://www.gastro.org American Headache Society Committee for Headache Education https://americanheadachesociety.org American Heart Association https://professional.heart.org American Lung Association https://www.lung.org American Medical Association https://www.ama-assn.org American Psychiatric Association https://www.psychiatry.org American Society of Anesthesiologists https://www.asahq.org American Society of Clinical Oncology https://www.asco.org American Society of Interventional Pain Physicians https://www.asipp.org American Urological Association https://www.auanet.org Centers for Disease Control and Prevention https://www.cdc.gov Centers for Disease Control and Prevention Guideline topics: AIDS https://www.cdc.gov/hiv/default.html Centers for Disease Control and Prevention Guideline topics: Sexually Transmitted Diseases https://www.cdc.gov/std/treatment/default.htm CVS Caremark https://www.caremark.com The Food and Drug Administration https://www.fda.gov

46

Global Initiative for Asthma https://ginasthma.org Infectious Diseases Society of America https://www.idsociety.org Institute for Safe Medication Practices https://www.ismp.org Johns Hopkins AIDS Service https://www.thebody.com/content/art12096.html Juvenile Diabetes Research Foundation International https://www.jdrf.org MedWatch https://www.fda.gov/Safety/MedWatch/default.htm National Agricultural Library https://www.nal.usda.gov National Cancer Institute https://www.cancer.gov/about-cancer National Comprehensive Cancer Network https://www.nccn.org

National Foundation for Infectious Diseases http://www.nfid.org National Guideline Clearinghouse https://www.ahrq.gov National Heart, Lung and Blood Institute https://www.nhlbi.nih.gov National Institutes of Health https://www.nih.gov National Kidney Foundation https://www.kidney.org National Osteoporosis Foundation https://www.nof.org North American Menopause Society https://www.menopause.org United States Department of Health and Human Services https://www.hhs.gov World Health Organization https://www.who.int

47

INDEX

A abacavir, 13 abacavir/dolutegravir/lamivudine, 12 abacavir/lamivudine, 12 abacavir/lamivudine/zidovudine, 12 abaloparatide, 29 abiraterone, 15 abiraterone 250 mg, 15 acalabrutinib, 16 ACCU-CHEK AVIVA PLUS STRIPS, 28 ACCU-CHEK COMPACT PLUS STRIPS, 28 ACCU-CHEK GUIDE STRIPS, 28 ACCU-CHEK SMARTVIEW STRIPS, 28 acebutolol, 18 acetic acid, 45 acyclovir, 14 adalimumab, 36, 37 ADDERALL XR, 24 ADEMPAS, 21 ADVAIR, 40 ADVAIR HFA, 40 afatinib, 16 AFINITOR, 16 AIMOVIG, 25 albuterol inhalation soln, 39 albuterol sulfate, CFC-free aerosol, 39 alclometasone crm, oint 0.05%, 42 alendronate, 29 alfuzosin ext-rel, 35 alirocumab, 19 allopurinol, 9 alosetron, 34 alprazolam, 21 alprazolam orally disintegrating tabs, 21 amantadine, 23 ambrisentan, 21 amcinonide crm, lotion, oint 0.1%, 42 amiloride, 20 amiloride/hydrochlorothiazide, 20 amiodarone, 18 amiodarone - Pacerone, 18 amitriptyline, 23 amlodipine, 19 amlodipine/benazepril, 17 amlodipine/olmesartan, 18 ammonium lactate 12%, 43 amoxicillin, 11 amoxicillin/clavulanate, 11 amoxicillin/clavulanate ext-rel, 11 amphetamine/dextroamphetamine mixed salts, 24 amphetamine/dextroamphetamine mixed salts ext-rel, 24 ampicillin, 11 anagrelide, 36 anastrozole, 15 ANORO ELLIPTA, 39 apalutamide, 15 apremilast, 36, 37 aprepitant caps, 33 ARANESP, 36 aripiprazole, 24 armodafinil, 26 ARNUITY ELLIPTA, 40

atazanavir, 13 atazanavir/cobicistat, 12 atenolol, 19 atenolol/chlorthalidone, 19 atomoxetine, 24 atorvastatin, 18 atovaquone, 14 ATRIPLA, 12 AUBAGIO, 25 AUSTEDO, 25 azathioprine, 37 azelastine, 43 azelastine spray, 40 azithromycin, 11 B bacitracin, 44 baclofen, 25 balsalazide, 33 BAQSIMI, 31 BARACLUDE, 13 BASAGLAR, 27 BD insulin syringes and needles, 28 beclomethasone breath-activated aerosol, 40 BELBUCA, 9 benralizumab, 40 benzonatate, 39 benzoyl peroxide crm, lotion, 41 benztropine, 23 benzyl alcohol/carbomer 941/glycerin, 43 betamethasone dipropionate augmented crm 0.05%, 42 betamethasone dipropionate augmented gel, oint 0.05%, 43 betamethasone dipropionate augmented lotion 0.05%, 42 betamethasone dipropionate crm, lotion, oint 0.05%, 42 betamethasone valerate crm, lotion, oint 0.1%, 42 BETASERON, 25 betaxolol solution, 45 bethanechol, 35 BETHKIS, 40 BEVESPI AEROSPHERE, 39 bexarotene caps, 16 bicalutamide, 15 bictegravir/emtricitabine/tenofovir alafenamide, 12 BIKTARVY, 12 bisoprolol, 19 bisoprolol/hydrochlorothiazide, 19 blood glucose continuous monitoring receivers, sensors,

transmitters, 28 bosentan, 21 BOSULIF, 16 bosutinib, 16 BREO ELLIPTA, 40 BRILINTA, 36 brimonidine 0.15%, 45 brimonidine 0.2%, 45 brimonidine/timolol, 45 bromocriptine, 23 budesonide delayed-rel caps, 33 budesonide inh susp, 40 budesonide/formoterol, 40 bumetanide, 20 buprenorphine, 9, 26 buprenorphine transdermal, 9

48

buprenorphine/naloxone sublingual film, 26 buprenorphine/naloxone sublingual tabs, 26 bupropion, 23 bupropion ext-rel, 23, 26 buspirone, 21 busulfan, 15 C C1 esterase inhibitor, recombinant, 37 cabergoline, 32 CABOMETYX, 16 cabozantinib, 16 calcipotriene oint, soln 0.005%, 41 calcitriol (1,25-D3), 32 calcium acetate caps, 32 CALQUENCE, 16 CAPASTAT SULFATE, 13 capecitabine, 15 CAPRELSA, 16 capreomycin, 13 captopril, 17 captopril/hydrochlorothiazide, 17 carbamazepine, 21 carbamazepine ext-rel, 21 carbidopa/levodopa, 23 carbidopa/levodopa ext-rel, 23 carbidopa/levodopa orally disintegrating tabs, 23 carbidopa/levodopa/entacapone, 23 CARDIZEM LA, 20 carvedilol, 19 cefadroxil, 11 cefdinir, 11 cefpodoxime, 11 cefprozil, 11 cefuroxime axetil, 11 cephalexin, 11 CERDELGA, 31 cetrorelix, 31 CETROTIDE, 31 CHANTIX, 26 chlorambucil, 15 chlorpromazine, 24 chlorthalidone, 20 cholestyramine, 18 choriogonadotropin alfa, 31 ciclopirox, 41 cilostazol, 36 CIMDUO, 12 cimetidine, 33 cinacalcet, 29 ciprofloxacin, 11 ciprofloxacin soln, 44 citalopram, 23 clarithromycin, 11 clarithromycin ext-rel, 11 CLIMARA PRO, 31 clindamycin, 14 clindamycin crm, 35 clindamycin gel, lotion, soln, 41 clobazam, 22 clobetasol propionate crm, gel, oint 0.05%, 43 clobetasol propionate foam 0.05%, 43 clobetasol propionate lotion 0.05%, 43 clonazepam tabs, 22 clonidine, 17 clonidine transdermal, 17

clopidogrel, 36 clorazepate, 21 clotrimazole, 41 clotrimazole troches, 11 clozapine, 24 clozapine orally disintegrating tabs, 24 codeine sulfate, 9 codeine/acetaminophen, 10 codeine/promethazine, 39 codeine/promethazine/phenylephrine, 39 colchicine, 9 colestipol, 18 COMBIGAN, 45 CONCERTA, 24 COPAXONE, 25 COPIKTRA, 16 CORLANOR, 20 COSENTYX, 36, 37 CREON, 34 cromolyn sodium, 43 CUVPOSA, 34 cyanocobalamin inj, 38 cyclobenzaprine 5 mg, 10 mg, 25 cyclophosphamide caps, 15 cycloserine, 13 cyclosporine, 37 cyclosporine, modified, 38 cyproheptadine, 39 CYSTAGON, 32 cysteamine, 32 D danazol, 30 dantrolene, 25 dapagliflozin, 28 dapagliflozin/metformin ext-rel, 28 dapsone, 14 darbepoetin alfa, 36 darolutamide, 15 darunavir, 13 darunavir/cobicistat, 12 darunavir/cobicistat/emtricitabine/tenofovir alafenamide, 12 dasatinib, 16 DESCOVY, 12 desipramine, 23 desmopressin nasal spray, 32 desmopressin tabs, 32 desogestrel/EE, 30 desogestrel/EE 0.15/30 - Apri, 29 desonide crm, lotion, oint 0.05%, 42 desoximetasone crm 0.05%, 42 desoximetasone crm, oint 0.25%, gel 0.05%, 42 desvenlafaxine succinate ext-rel, 23 deutetrabenazine, 25 dexamethasone, 31 dexamethasone sodium phosphate, 44 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM,

28 dexmethylphenidate, 24 dextroamphetamine, 24 dextroamphetamine ext-rel, 24 dextromethorphan/promethazine, 39 diazepam, 21 diclofenac potassium, 9 diclofenac sodium, 44 diclofenac sodium delayed-rel, 9

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diclofenac sodium ext-rel, 9 dicloxacillin, 11 dicyclomine, 33 didanosine delayed-rel 200 mg, 250 mg, 400 mg, 13 DIFICID, 11 diflunisal, 9 digoxin, 20 digoxin ped elixir, 20 diltiazem ext-rel, 20 dimethyl fumarate delayed-rel, 25 diphenoxylate/atropine, 33 dipyridamole, 36 dipyridamole ext-rel/aspirin, 36 diroximel fumarate delayed-rel, 25 disopyramide, 18 disopyramide ext-rel, 18 divalproex sodium delayed-rel, 22 divalproex sodium ext-rel, 22 divalproex sodium sprinkle caps, 22 dofetilide, 18 dolutegravir, 12 dolutegravir/lamivudine, 12 donepezil, 22 donepezil orally disintegrating tabs, 22 dorzolamide, 45 dorzolamide/timolol maleate, 45 DOVATO, 12 doxazosin, 35 doxepin, 23 doxercalciferol, 32 doxycycline hyclate caps, 11 doxycycline hyclate tabs 20 mg, 100 mg, 11 doxycycline monohydrate susp, 11 dronabinol, 33 drospirenone/EE 3/20, 29 drospirenone/EE 3/30, 29 dulaglutide, 27 duloxetine delayed-rel, 23 dupilumab, 40, 42 DUPIXENT, 40, 42 duvelisib, 16 E econazole, 41 EDURANT, 13 EE/norethindrone acetate, 31 EE/norethindrone acetate - Jinteli, 31 efavirenz, 12 efavirenz/emtricitabine/tenofovir disoproxil fumarate, 12 efavirenz/lamivudine/tenofovir disoproxil fumarate, 12 elexacaftor/tezacaftor/ivacaftor + ivacaftor, 40 eliglustat, 31 ELLA, 30 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, 12 EMCYT, 15 empagliflozin, 28 empagliflozin/linagliptin, 28 empagliflozin/linagliptin/metformin ext-rel, 28 empagliflozin/metformin, 28 empagliflozin/metformin ext-rel, 28 emtricitabine, 13 emtricitabine/rilpivirine/tenofovir alafenamide, 12 emtricitabine/tenofovir alafenamide, 12 emtricitabine/tenofovir disoproxil fumarate, 12 EMTRIVA, 13 EMVERM, 14

enalapril, 17 enalapril/hydrochlorothiazide, 17 ENBREL, 36, 37 ENDOMETRIN, 32 enfuvirtide, 12 enoxaparin, 35 entacapone, 23 entecavir soln, 13 entecavir tabs, 13 ENTRESTO, 20 enzalutamide, 15 EPCLUSA, 14 epinephrine, 38 epinephrine auto-injector, 38 EPIPEN, 38 EPIPEN JR, 38 eplerenone, 17 epoetin alfa-epbx, 36 erenumab-aooe, 25 ergocalciferol (D2), 38 ERLEADA, 15 erlotinib, 16 ERYTHROCIN, 11 erythromycin, 44 erythromycin delayed-rel, 11 erythromycin ethylsuccinate, 11 erythromycin gel 2%, 41 erythromycin soln, 41 erythromycin stearate, 11 erythromycin/benzoyl peroxide, 41 ESBRIET, 40 escitalopram, 23 estradiol, 30 estradiol vaginal crm, 30 estradiol/levonorgestrel, 31 estradiol/norethindrone, 31 estramustine, 15 etanercept, 36, 37 ethambutol, 13 ethionamide, 13 ethosuximide, 22 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 29 ethynodiol diacetate/EE 1/50, 30 etodolac, 9 etonogestrel/EE ring, 30 etoposide caps, 16 etravirine, 12 everolimus, 16 EVOTAZ, 12 exemestane, 15 ezetimibe, 18 F famciclovir, 14 famotidine, 33 FARXIGA, 28 FASENRA, 40 felbamate, 22 felodipine ext-rel, 19 fenofibrate, 18 fenofibrate caps 67 mg, 134 mg, 200 mg, 18 fentanyl lozenge, 10 fentanyl transdermal, 10 FIASP, 27 fidaxomicin, 11 filgrastim-aafi, 36

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finasteride, 35 fingolimod, 25 FIRAZYR, 37 flecainide, 18 FLOVENT DISKUS, 40 FLOVENT HFA, 40 fluconazole, 11 fludrocortisone, 31 flunisolide spray, 40 fluocinolone acetonide crm, oint 0.025%, 42 fluocinolone acetonide soln 0.01%, 42 fluocinonide crm, gel, oint 0.05%, 43 fluocinonide soln 0.05%, 43 fluoride drops, tabs, 38 fluorometholone 0.1% susp, 44 fluorometholone oint, 44 fluorouracil crm 4%, 41 fluorouracil crm 5%, 41 fluorouracil soln 2%, 5%, 41 fluoxetine, 23 fluphenazine, 24 flurbiprofen, 9 flutamide, 15 fluticasone furoate, 40 fluticasone propionate, 40 fluticasone propionate crm 0.05%, oint 0.005%, 42 fluticasone propionate, CFC-free aerosol, 40 fluticasone spray, 40 fluticasone/salmeterol, 40 fluticasone/salmeterol, CFC-free aerosol, 40 fluticasone/vilanterol, 40 fluvoxamine, 21 FML S.O.P., 44 folic acid, 38 follitropin alfa, 31 fondaparinux, 35 formoterol inhalation soln, 39 FORTEO, 29 fosamprenavir tabs, 13 fulvestrant, 15 furosemide, 20 FUZEON, 12 G gabapentin caps, tabs, 22 galantamine, 22 galantamine ext-rel, 22 gefitinib, 16 gemfibrozil, 18 gentamicin, 41, 44 GENVOYA, 12 GILENYA, 25 GILOTRIF, 16 glatiramer, 25 GLEOSTINE, 15 glimepiride, 28 glipizide, 28 glipizide ext-rel, 28 glipizide/metformin, 27 GLUCAGEN HYPOKIT, 31 GLUCAGON EMERGENCY KIT, 31 glucagon intranasal powder, 31 glucagon subcutaneous soln, 31 glucagon, human recombinant, 31 glycopyrrolate, 34 glycopyrrolate/formoterol, 39

GLYXAMBI, 28 GONAL-F, 31 granisetron, 33 grass mixed pollen allergen extract, 36 griseofulvin microsize, 12 guselkumab, 36 GVOKE, 31 H halobetasol propionate crm, oint 0.05%, 43 haloperidol, 24 HARVONI, 14 HUMATROPE, 31 HUMIRA, 36, 37 HUMULIN R U-500, 27 hydralazine, 21 hydrochlorothiazide, 20 hydrocodone/acetaminophen, 10 hydrocodone/homatropine, 39 hydrocortisone, 31 hydrocortisone butyrate crm, oint 0.1%, 42 hydrocortisone butyrate soln 0.1%, 42 hydrocortisone crm, 34 hydrocortisone crm 2.5%, 42 hydrocortisone enema, 34 hydrocortisone valerate crm, oint 0.2%, 42 hydromorphone, 10 hydroxychloroquine, 37 hydroxyurea, 16 hydroxyzine HCl, 39 hyoscyamine sulfate, 33 hyoscyamine sulfate ext-rel, 33 hyoscyamine sulfate ext-rel caps, 33 hyoscyamine sulfate orally disintegrating tabs, 33 I ibandronate, 29 IBRANCE, 16 ibrutinib, 16 ibuprofen, 9 ibutilide, 18 icatibant, 37 icosapent ethyl, 19 imatinib mesylate, 16 IMBRUVICA, 16 imipramine HCl, 23 imiquimod crm, 41 INCRUSE ELLIPTA, 39 indapamide, 20 INGREZZA, 25 inotersen, 32 insulin aspart, 27 insulin aspart protamine 70%/insulin aspart 30%, 27 insulin detemir, 27 insulin glargine, 27 insulin human, 27 insulin human, concentrated, 27 insulin infusion disposable pump, 28 insulin isophane human, 27 insulin isophane human 70%/regular 30%, 27 insulin syringes, needles, 28 INTELENCE, 12 interferon beta-1a, 25 interferon beta-1b, 25 ipratropium inhalation solution, 39 ipratropium spray, 40 ipratropium/albuterol soln, 39

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irbesartan, 17 irbesartan/hydrochlorothiazide, 17 IRESSA, 16 ISENTRESS, 12 ISENTRESS HD, 12 isoniazid, 13 isoniazid/rifampin, 13 isoniazid-rifampin w/pyrazinamide, 13 isosorbide dinitrate, 20 isosorbide mononitrate, 20 isosorbide mononitrate ext-rel, 20 isotretinoin - Claravis, 41 isradipine, 19 itraconazole, 12 ivabradine, 20 ivermectin, 14 J JANUMET, 27 JANUMET XR, 27 JANUVIA, 27 JARDIANCE, 28 K KALETRA, 13 ketoconazole crm 2%, 41 ketoconazole shampoo 2%, 41 ketoprofen 50 mg, 75 mg, 9 ketorolac, 9 ketorolac 0.5%, 44 ketorolac inj, 9 KISQALI, 16 KISQALI FEMARA CO-PACK, 16 L labetalol, 19 lactulose soln, 34 lamivudine, 13 lamivudine tabs, 13 lamivudine/tenofovir disoproxil fumarate, 12 lamivudine/zidovudine, 12 lamotrigine, 22 lamotrigine ext-rel, 22 lanadelumab-flyo, 37 LANOXIN, 20 lansoprazole, 34 lansoprazole soluble tabs, 34 lapatinib, 16 larotrectinib, 16 latanoprost, 45 ledipasvir/sofosbuvir, 14 leflunomide, 37 lenalidomide, 16 letrozole, 15 LEUKERAN, 15 levalbuterol nebulizer soln concentrate, 39 LEVEMIR, 27 levetiracetam, 22 levetiracetam ext-rel, 22 levofloxacin, 11 levonorgestrel/EE - Trivora, 30 levonorgestrel/EE 0.1/20 - Lessina, 29 levonorgestrel/EE 0.15/30 - Jolessa, 30 levonorgestrel/EE 0.15/30 - Levora, 29 levothyroxine, 32 levothyroxine - Levoxyl, 32 lidocaine viscous, 43

lidocaine/prilocaine crm, 43 lifitegrast, 45 linaclotide, 34 linezolid, 14 linezolid inj, 14 LINZESS, 34 liothyronine, 32 liraglutide, 27 lisinopril, 17 lisinopril/hydrochlorothiazide, 17 lithium carbonate, 25 lithium carbonate ext-rel tabs 300 mg, 450 mg, 25 lixisenatide/insulin glargine, 27 lomustine, 15 loperamide, 33 lopinavir/ritonavir, 13 lorazepam, 21 losartan, 17 losartan/hydrochlorothiazide, 18 loteprednol susp 0.5%, 44 lusutrombopag, 36 LYNPARZA, 16 LYSODREN, 16 M macitentan, 21 malathion, 43 MATULANE, 16 MAYZENT, 25 mebendazole, 14 meclizine, 33 MEDROL, 31 medroxyprogesterone acetate, 32 medroxyprogesterone acetate 150 mg/mL, 30 megestrol acetate, 15 meloxicam, 9 melphalan, 15 memantine, 22 mepolizumab, 40 mercaptopurine, 15 mesalamine delayed-rel, 33 mesalamine ext-rel caps, 33 mesalamine rectal susp, 34 metformin, 27 metformin ext-rel, 27 methadone, 10 methimazole, 32 methocarbamol, 26 methotrexate, 37 methyldopa, 21 methylphenidate, 24 methylphenidate ext-rel, 24 methylprednisolone, 31 metoclopramide, 33 metolazone, 20 metoprolol 25 mg, 50 mg, 100 mg, 19 metoprolol ext-rel, 19 metoprolol/hydrochlorothiazide, 19 metronidazole, 14, 35 metronidazole crm 0.75%, 43 metronidazole gel 0.75%, 43 metronidazole lotion 0.75%, 43 midodrine, 21 midostaurin, 16 milnacipran, 24 minocycline, 11

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mirtazapine, 23 mirtazapine orally disintegrating tabs, 23 misoprostol, 34 mitotane, 16 modafinil, 26 mometasone crm, lotion, oint 0.1%, 42 montelukast, 40 morphine, 10 morphine ext-rel, 10 morphine supp, 10 MOVANTIK, 34 moxifloxacin, 11, 44 MUGARD, 43 MULPLETA, 36 multivitamins/fluoride drops, tabs, 38 multivitamins/fluoride/iron drops, tabs, 38 mupirocin oint, 41 mycophenolate mofetil, 37 MYLERAN, 15 N nabumetone, 9 nadolol, 19 nafarelin, 30 naloxegol, 34 naloxone nasal spray, 26 naltrexone, 26 naproxen delayed-rel, 9 naproxen sodium tabs, 9 naproxen tabs, 9 naratriptan, 25 NARCAN, 26 NATACYN, 44 natamycin, 44 neomycin/polymyxin B/bacitracin/hydrocortisone oint, 44 neomycin/polymyxin B/dexamethasone, 44 neomycin/polymyxin B/gramicidin, 44 neomycin/polymyxin B/hydrocortisone, 45 neomycin/polymyxin B/hydrocortisone susp, 44 NEULASTA, 36 nevirapine, 12 nevirapine ext-rel, 13 niacin ext-rel, 19 nicardipine, 20 nifedipine ext-rel, 20 nilutamide, 15 nintedanib, 40 niraparib, 16 nitisinone, 31 nitrofurantoin ext-rel, 14 nitrofurantoin macrocrystals, 14 nitroglycerin sublingual, 20 nitroglycerin transdermal, 20 NITYR, 31 NIVESTYM, 36 norelgestromin/EE - Xulane, 30 norethindrone, 30 norethindrone acetate, 32 norethindrone acetate/EE 0.8/25 and iron, 29 norethindrone acetate/EE 1.5/30, 29 norethindrone acetate/EE 1.5/30 and iron, 29 norethindrone acetate/EE 1/20, 29 norethindrone acetate/EE 1/20 and iron, 29 norethindrone/EE, 30 norethindrone/EE 0.5/35, 29 norethindrone/EE 1/35, 29

norgestimate/EE, 30 norgestimate/EE 0.25/35, 29 norgestrel/EE 0.3/30 - Low-Ogestrel, 29 NORPACE CR, 18 nortriptyline, 23 NORVIR, 13 NOVOLIN 70/30, 27 NOVOLIN N, 27 NOVOLIN R, 27 NOVOLOG, 27 NOVOLOG MIX 70/30, 27 NUBEQA, 15 NUCALA, 40 nystatin, 12, 41 O octreotide acetate, 26 ODEFSEY, 12 ODOMZO, 16 OFEV, 40 ofloxacin, 44 ofloxacin otic, 45 olanzapine, 24 olaparib, 16 olmesartan, 18 olmesartan/amlodipine/hydrochlorothiazide, 18 olmesartan/hydrochlorothiazide, 18 olodaterol, CFC-free aerosol, 39 omeprazole delayed-rel, 34 omeprazole granules, 34 ondansetron, 33 ondansetron orally disintegrating tabs, 33 OPSUMIT, 21 ORALAIR, 36 ORENITRAM, 21 ORFADIN, 31 oseltamivir, 14 ospemifene, 32 OSPHENA, 32 OTEZLA, 36, 37 OVIDREL, 31 oxaprozin, 9 oxazepam, 21 oxcarbazepine, 22 oxybutynin, 35 oxybutynin ext-rel, 35 oxycodone, 10 oxycodone/acetaminophen, 10 oxycodone/acetaminophen soln, 10 OZEMPIC, 27 P palbociclib, 16 paliperidone ext-rel, 24 pancrelipase, 34 pancrelipase delayed-rel, 34 pantoprazole delayed-rel, 34 paricalcitol, 32 paroxetine HCl ext-rel, 23 paroxetine HCl tabs, 23 pazopanib, 16 peg 3350/electrolytes, 34 pegfilgrastim, 36 pegfilgrastim-cbqv, 36 pegvisomant, 26 penicillamine, 37 penicillin VK, 11

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PERFOROMIST, 39 perindopril, 17 permethrin 5%, 43 phenelzine, 22 phenobarbital, 22 phenytoin chewable tabs, 22 phenytoin sodium extended, 22 phenytoin susp, 22 phytonadione, 38 pilocarpine tabs, 34 pimecrolimus, 42 pindolol, 19 pioglitazone, 27 pioglitazone/glimepiride, 28 pioglitazone/metformin, 28 pirfenidone, 40 piroxicam, 9 plecanatide, 34 polymyxin B/bacitracin, 44 polymyxin B/trimethoprim, 44 potassium chloride ext-rel, 38 potassium chloride liquid, 38 potassium citrate ext-rel, 35 PRALUENT, 19 pramipexole, 23 pramlintide, 27 prasugrel, 36 pravastatin, 19 praziquantel, 14 prednisolone acetate 1%, 44 prednisolone phosphate 1%, 44 PREDNISOLONE PHOSPHATE 1%, 44 prednisolone sodium phosphate, 31 prednisolone sodium phosphate orally disintegrating tabs,

31 prednisolone syrup, 31 prednisone, 31 prenatal vitamin/minerals, 38 PREZCOBIX, 12 PREZISTA, 13 PRIFTIN, 13 PRILOSEC, 34 primidone, 22 probenecid, 9 procarbazine, 16 prochlorperazine, 33 progesterone vaginal inserts, 32 progesterone, micronized, 32 promethazine, 33 propafenone, 18 propafenone ext-rel, 18 propranolol, 19 propranolol ext-rel, 19 propranolol/hydrochlorothiazide, 19 propylthiouracil, 32 pyrazinamide, 13 pyridostigmine, 26 Q quetiapine, 24 QVAR REDIHALER, 40 R raloxifene, 32 raltegravir, 12 ramipril, 17 ranolazine ext-rel, 21

rasagiline mesylate, 23 RASUVO, 37 REBIF, 25 RETACRIT, 36 revefenacin inhalation solution, 39 REVLIMID, 16 ribavirin, 14 ribociclib, 16 ribociclib + letrozole, 16 rifabutin, 14 RIFAMATE, 13 rifampin, 13 rifapentine, 13 RIFATER, 13 rifaximin 550 mg, 14 rilpivirine, 13 riluzole, 26 RINVOQ, 37 riociguat, 21 risankizumab-rzaa, 36 risedronate, 29 risperidone, 24 risperidone orally disintegrating tabs, 24 ritonavir, 13 rivaroxaban, 35 rivastigmine, 22 rivastigmine transdermal, 22 rizatriptan, 25 rizatriptan orally disintegrating tabs, 25 ropinirole, 23 rosuvastatin, 19 RUBRACA, 16 rucaparib, 16 RUCONEST, 37 RYBELSUS, 27 RYDAPT, 16 S sacubitril/valsartan, 20 SAVELLA, 24 secukinumab, 36, 37 selegiline, 23 selenium sulfide lotion 2.5%, 41 selexipag, 21 semaglutide, 27 sertraline, 23 sevelamer carbonate, 32 sildenafil, 21, 35 silver sulfadiazine, 41 simvastatin, 19 siponimod, 25 sirolimus, 38 sitagliptin, 27 sitagliptin/metformin, 27 sitagliptin/metformin ext-rel, 27 SKYRIZI, 36 sodium phenylbutyrate, 32 sodium sulfate/potassium sulfate/magnesium sulfate, 34 sofosbuvir/velpatasvir, 14 sofosbuvir/velpatasvir/voxilaprevir, 14 SOLIQUA, 27 somatropin, 31 SOMAVERT, 26 sonidegib, 16 sotalol, 18 spironolactone, 17

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spironolactone/hydrochlorothiazide, 20 SPRYCEL, 16 stavudine, 13 STELARA, 36, 37 streptomycin sulfate inj, 13 STRIVERDI RESPIMAT, 39 sulfacetamide lotion 10%, 41 sulfacetamide soln 10%, 44 sulfacetamide/prednisolone phosphate, 44 sulfamethoxazole/trimethoprim, 14 sulfamethoxazole/trimethoprim DS, 14 sulfasalazine, 33 sulfasalazine delayed-rel, 33 sulindac, 9 sumatriptan, 25 sumatriptan inj, 25 sumatriptan nasal spray, 25 sunitinib, 16 SUPREP, 34 SUTENT, 16 SYMBICORT, 40 SYMDEKO, 40 SYMFI, 12 SYMFI LO, 12 SYMJEPI, 38 SYMLINPEN, 27 SYMTUZA, 12 SYNAREL, 30 SYNJARDY, 28 SYNJARDY XR, 28 T TABLOID, 15 tacrolimus, 38, 42 tadalafil, 35 TAKHZYRO, 37 tamoxifen, 15 tamsulosin, 35 TECFIDERA, 25 TEGSEDI, 32 temazepam, 24 TEMIXYS, 12 tenofovir alafenamide, 13 tenofovir disoproxil fumarate, 13 terazosin, 35 terbinafine tabs, 12 terconazole, 35 teriflunomide, 25 teriparatide, 29 test strips, 28 testosterone cypionate inj, 26 testosterone enanthate inj, 26 testosterone gel, 26 testosterone gel 25 mg/2.5 g, 26 tetrabenazine, 25 tetracycline, 11 tezacaftor/ivacaftor + ivacaftor, 40 thalidomide, 16 THALOMID, 16 theophylline ext-rel tabs, 40 thioguanine, 15 tiagabine, 22 ticagrelor, 36 timolol maleate, 45 timolol maleate gel, 45 tinidazole, 14

TIVICAY, 12 tizanidine tabs, 26 tobramycin, 44 tobramycin inhalation soln, 40 tobramycin/dexamethasone susp 0.3%/0.1%, 44 tofacitinib, 37 tofacitinib ext-rel, 37 TOLAK, 41 tolmetin, 9 tolterodine, 35 topiramate, 22 topiramate sprinkle caps, 22 toremifene, 15 torsemide, 20 tramadol 50 mg, 10 tramadol ext-rel tabs, 10 trandolapril, 17 tranylcypromine, 22 trazodone, 23 TRECATOR, 13 TREMFYA, 36 treprostinil ext-rel, 21 tretinoin, 41 tretinoin - Avita, 41 tretinoin caps, 16 triamcinolone acetonide crm 0.5%, 43 triamcinolone acetonide crm, lotion 0.025%, 42 triamcinolone acetonide crm, lotion, oint 0.1%, 42 triamcinolone paste, 43 triamterene/hydrochlorothiazide, 20 trifluoperazine, 24 trifluridine, 44 trihexyphenidyl, 23 TRIJARDY XR, 28 TRIKAFTA, 40 trimethobenzamide, 33 trimethoprim, 14 TRIUMEQ, 12 trospium, 35 TRULANCE, 34 TRULICITY, 27 TRUVADA, 12 tucatinib, 16 TUKYSA, 16 TYKERB, 16 TYMLOS, 29 U UDENYCA, 36 ulipristal, 30 umeclidinium, 39 umeclidinium/vilanterol, 39 upadacitinib, 37 UPTRAVI, 21 uridine triacetate, 16 ursodiol, 33 ustekinumab subcutaneous, 36, 37 V valacyclovir, 14 valbenazine, 25 valganciclovir, 13 valproic acid, 22 valsartan, 18 valsartan/hydrochlorothiazide, 18 vancomycin, 14 vandetanib, 16

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vardenafil, 35 varenicline, 26 VASCEPA, 19 VEMLIDY, 13 VENCLEXTA, 16 venetoclax, 16 venlafaxine, 23 venlafaxine ext-rel, 23 verapamil ext-rel, 20 V-GO INSULIN INFUSION PUMP, 28 VICTOZA, 27 vigabatrin, 22 VIOKACE, 34 VISTOGARD, 16 vitamin ADC/fluoride drops, 38 vitamin ADC/fluoride/iron drops, 38 VITRAKVI, 16 voriconazole, 12 vorinostat, 16 VOSEVI, 14 VOTRIENT, 16 VUMERITY, 25 W warfarin, 35

X XARELTO, 35 XELJANZ, 37 XELJANZ XR, 37 XIFAXAN, 14 XIGDUO XR, 28 XIIDRA, 45 XTANDI, 15 Y YONSA, 15 YUPELRI, 39 Z zaleplon, 24 ZEJULA, 16 zidovudine, 13 ziprasidone, 24 ZOLINZA, 16 zolmitriptan orally disintegrating tabs, 25 zolmitriptan tabs, 25 zolpidem, 25 zolpidem ext-rel, 25 zonisamide, 22

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CareFirst Formulary 4Sep 01, 2020 · Federal Employees Health Benefits Program . List of Covered...

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Transcript of CareFirst Formulary 4Sep 01, 2020 · Federal Employees Health Benefits Program . List of Covered...