Samaritan Choice Plans F O R M U L A R Y List of Covered Drugs for 2016
TABLE OF CONTENTS INTRODUCTION... 15 The Samaritan Health Plans Operations (SHPO)... 15 Pharmacy and Therapeutics (P & T) Committee... 15 Notice... 15 Lost or Stolen Medications... 16 Preface... 16 Product Selection Criteria... 16 Co-Pay Tiers... 16 Medication Exception... 16 PRIOR AUTHORIZATION... 16 QUANTITY LIMITATIONS (QL)... 19 STEP THERAPY (ST)... 23 FORMULARY... 24 *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*... 24 *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor***... 24 *Amphetamine Mixtures***... 24 *Amphetamines***... 24 *Stimulants - Misc.***... 24 *Aminoglycosides*... 25 *Aminoglycosides***... 25 *Analgesics - Anti-Inflammatory*... 25 *Anti-Tnf-Alpha - Monoclonal Antibodies***... 26 *Anti-Tnf-Alpha - Monoclonoal Antibodies***... 26 *Cyclooxygenase 2 (Cox-2) Inhibitors***... 26 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)***... 26 *Pyrimidine Synthesis Inhibitors***... 27 *Soluble Tumor Necrosis Factor Receptor Agents***... 27 *Analgesics - Nonnarcotic*... 28 *Analgesics-Sedatives***... 28 *Salicylates***... 28 *Analgesics - Opioid*... 31 *Codeine Combinations***... 31 *Hydrocodone Combinations***... 32 *Opioid Agonists***... 32 *Opioid Combinations***... 33 *Opioid Partial Agonists***... 33 1
*Tramadol Combinations***... 33 *Androgens-Anabolic*... 34 *Androgens***... 34 *Anorectal Agents*... 34 *Intrarectal Steroids***... 34 *Rectal Anesthetic/Steroids***... 34 *Rectal Steroids***... 34 *Anthelmintics*... 35 *Anthelmintics***... 35 *Antianginal Agents*... 35 *Antianginals-Other***... 35 *Nitrates***... 35 *Antianxiety Agents*... 36 *Antianxiety Agents - Misc.***... 36 *Benzodiazepines***... 36 *Antiarrhythmics*... 36 *Antiarrhythmics Type I-A***... 36 *Antiarrhythmics Type I-B***... 37 *Antiarrhythmics Type I-C***... 37 *Antiarrhythmics Type Iii***... 37 *Antiasthmatic And Bronchodilator Agents*... 37 *Adrenergic Combinations***... 37 *Beta Adrenergics***... 37 *Bronchodilators - Anticholinergics***... 38 *Leukotriene Receptor Antagonists***... 38 *Steroid Inhalants***... 38 *Xanthines***... 39 *Anticoagulants*... 39 *Coumarin Anticoagulants***... 39 *Direct Factor Xa Inhibitors***... 39 *Low Molecular Weight Heparins***... 39 *Thrombin Inhibitors - Selective Direct & Reversible***... 40 *Anticonvulsants*... 40 *Anticonvulsants - Benzodiazepines***... 40 *Anticonvulsants - Misc.***... 40 *Gaba Modulators***... 41 *Hydantoins***... 41 *Succinimides***... 41 2
*Valproic Acid***... 41 *Antidepressants*... 42 *Alpha-2 Receptor Antagonists (Tetracyclics)***... 42 *Antidepressants - Misc.***... 42 *Modified Cyclics***... 42 *Monoamine Oxidase Inhibitors (Maois)***... 42 *Selective Serotonin Reuptake Inhibitors (Ssris)***... 43 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)***... 43 *Ssris-Nutritional Supplement Combinations***... 43 *Tricyclic Agents***... 43 *Antidiabetics*... 44 *Alpha-Glucosidase Inhibitors***... 44 *Antidiabetic - Amylin Analogs***... 44 *Biguanides***... 44 *Diabetic Other***... 44 *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors***... 44 *Human Insulin***... 44 *Incretin Mimetic Agents (Glp-1 Receptor Agonists)***... 46 *Meglitinide Analogues***... 46 *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors***... 47 *Sulfonylurea-Biguanide Combinations***... 47 *Sulfonylureas***... 47 *Thiazolidinedione-Biguanide Combinations***... 47 *Thiazolidinediones***... 47 *Antidiarrheals*... 47 *Antiperistaltic Agents***... 47 *Antidotes*... 48 *Antidotes - Chelating Agents***... 48 *Opioid Antagonists***... 48 *Antiemetics*... 48 *5-Ht3 Receptor Antagonists***... 48 *Antiemetics - Anticholinergic***... 48 *Antifungals*... 48 *Antifungals***... 48 *Imidazoles***... 49 *Triazoles***... 49 *Antihistamines*... 49 *Antihistamines - Ethanolamines***... 49 3
*Antihistamines - Non-Sedating***... 49 *Antihistamines - Phenothiazines***... 49 *Antihistamines - Piperidines***... 50 *Antihyperlipidemics*... 50 *Antihyperlipidemics - Misc.***... 50 *Bile Acid Sequestrants***... 50 *Fibric Acid Derivatives***... 50 *Hmg Coa Reductase Inhibitors***... 50 *Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib Comb***... 51 *Intestinal Cholesterol Absorption Inhibitors***... 51 *Nicotinic Acid Derivatives***... 51 *Antihypertensives*... 51 *Ace Inhibitor & Calcium Channel Blocker Combinations***... 51 *Ace Inhibitors & Thiazide/Thiazide-Like***... 51 *Ace Inhibitors***... 52 *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like***... 52 *Angiotensin Ii Receptor Antagonists***... 52 *Antiadrenergics - Centrally Acting***... 53 *Antiadrenergics - Peripherally Acting***... 53 *Beta Blocker & Diuretic Combinations***... 53 *Vasodilators***... 53 *Anti-Infective Agents - Misc.*... 54 *Anti-Infective Agents - Misc.***... 54 *Anti-Infective Misc. - Combinations***... 54 *Ketolides***... 54 *Lincosamides***... 54 *Oxazolidinones***... 54 *Antimalarials*... 55 *Antimalarial Combinations***... 55 *Antimalarials***... 55 *Antimyasthenic Agents*... 55 *Antimyasthenic Agents***... 55 *Antimyasthenic/Cholinergic Agents***... 55 *Antimyasthenic/Cholinergic Agents*... 55 *Antimycobacterial Agents*... 55 *Antimycobacterial Agents***... 55 *Antineoplastics And Adjunctive Therapies*... 56 *Alkylating Agents***... 56 4
*Antiadrenals***... 56 *Antiandrogens***... 56 *Antiestrogens***... 56 *Antimetabolites***... 56 *Antineoplastic - Autologous Cellular Immunotherapy***... 57 *Antineoplastic - Histone Deacetylase Inhibitors***... 57 *Antineoplastic - Monoclonal Antibodies***... 57 *Antineoplastic - Mtor Kinase Inhibitors***... 57 *Antineoplastic - Multikinase Inhibitors***... 57 *Antineoplastic - Proteasome Inhibitors***... 58 *Antineoplastic - Tyrosine Kinase Inhibitors***... 58 *Antineoplastic Antibiotics***... 58 *Antineoplastic -Antibody For Radiopharmaceutical Therapy***... 58 *Antineoplastic Enzymes***... 58 *Antineoplastics - Photoactivated Agents***... 59 *Antineoplastics Misc.***... 59 *Aromatase Inhibitors***... 59 *Cardiac Protective Agents***... 59 *Chemotherapy Adjuncts - Keratinocyte Growth Factors***... 59 *Estrogens-Antineoplastic***... 59 *Folic Acid Antagonists Rescue Agents***... 59 *Imidazotetrazines***... 60 *Lhrh Analogs***... 60 *Mitotic Inhibitors***... 60 *Nitrogen Mustards***... 60 *Nitrosoureas***... 61 *Progestins-Antineoplastic***... 61 *Selective Retinoid X Receptor Agonists***... 61 *Topoisomerase I Inhibitors***... 61 *Urinary Tract Protective Agents***... 61 *Antiparkinson Agents*... 61 *Antiparkinson Anticholinergics***... 61 *Antiparkinson Dopaminergics***... 61 *Antiparkinson Monoamine Oxidase Inhibitors***... 62 *Levodopa Combinations***... 62 *Nonergoline Dopamine Receptor Agonists***... 62 *Peripheral Comt Inhibitors***... 62 *Antipsychotics/Antimanic Agents*... 62 5
*Antimanic Agents***... 62 *Antipsychotics - Misc.***... 63 *Benzisoxazoles***... 63 *Butyrophenones***... 63 *Dibenzodiazepines***... 63 *Dibenzothiazepines***... 63 *Dibenzoxazepines***... 63 *Dihydroindolones***... 63 *Phenothiazines***... 63 *Quinolinone Derivatives***... 64 *Thienbenzodiazepines***... 64 *Thioxanthenes***... 64 *Antivirals*... 64 *Antiretroviral Combinations***... 64 *Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)***... 65 *Antiretrovirals - Fusion Inhibitors***... 65 *Antiretrovirals - Integrase Inhibitors***... 65 *Antiretrovirals - Protease Inhibitors***... 65 *Antiretrovirals - Rti-Non-Nucleoside Analogues***... 66 *Antiretrovirals - Rti-Nucleoside Analogues-Purines***... 66 *Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines***... 66 *Antiretrovirals - Rti-Nucleoside Analogues-Thymidines***... 67 *Antiretrovirals - Rti-Nucleotide Analogues***... 67 *Cmv Agents***... 67 *Hepatitis B Agents***... 67 *Hepatitis C Agents***... 67 *Herpes Agents - Purine Analogues***... 68 *Herpes Agents - Thymidine Analogues***... 68 *Influenza Agents***... 68 *Neuraminidase Inhibitors***... 69 *Rsv Agents - Nucleoside Analogues***... 69 *Assorted Classes*... 69 *Cyclosporine Analogs***... 69 *Immune Globulin Immunosuppressants***... 69 *Inosine Monophosphate Dehydrogenase Inhibitors***... 69 *Macrolide Immunosuppressants***... 69 *Monoclonal Antibodies***... 70 *Potassium Removing Resins***... 70 6
*Purine Analogs***... 70 *Beta Blockers*... 70 *Alpha-Beta Blockers***... 70 *Beta Blockers Cardio-Selective***... 70 *Beta Blockers Non-Selective***... 70 *Biologicals Misc*... 71 *Allergenic Extracts***... 71 *Calcium Channel Blockers*... 72 *Calcium Channel Blockers***... 72 *Cardiotonics*... 73 *Cardiac Glycosides***... 73 *Cardiovascular Agents - Misc.*... 74 *Calcium Channel Blocker & Hmg Coa Reductase Inhibit Comb***... 74 *Peripheral Vasodilators***... 74 *Prostaglandin Vasodilators***... 74 *Pulmonary Hypertension - Endothelin Receptor Antagonists***... 74 *Pulmonary Hypertension - Phosphodiesterase Inhibitors***... 74 *Cephalosporins*... 74 *Cephalosporins - 1St Generation***... 74 *Cephalosporins - 2Nd Generation***... 75 *Cephalosporins - 3Rd Generation***... 75 *Contraceptives*... 75 *Biphasic Contraceptives - Oral***... 75 *Combination Contraceptives - Oral***... 76 *Combination Contraceptives - Transdermal***... 81 *Combination Contraceptives - Vaginal***... 81 *Continuous Contraceptives - Oral***... 81 *Emergency Contraceptives***... 81 *Extended-Cycle Contraceptives - Oral***... 81 *Progestin Contraceptives - Injectable***... 82 *Progestin Contraceptives - Oral***... 82 *Triphasic Contraceptives - Oral***... 83 *Corticosteroids*... 84 *Glucocorticosteroids***... 84 *Mineralocorticoids***... 85 *Cough/Cold/Allergy*... 85 *Antitussive - Nonnarcotic***... 85 *Antitussive - Opioid***... 85 7
*Antitussive-Expectorant***... 85 *Antitussive-Expectorants-Decongestant***... 86 *Decongestant & Antihistamine***... 86 *Decongestant W/ Expectorant***... 90 *Misc. Respiratory Inhalants***... 90 *Non-Narc Antitussive-Antihistamine***... 90 *Non-Narc Antitussive-Decongestant-Antihistamine***... 90 *Opioid Antitussive-Antihistamine***... 90 *Opioid Antitussive-Decongestant***... 90 *Opioid Antitussive-Decongestant-Antihistamine***... 90 *Dermatologicals*... 90 *Acne Antibiotics***... 91 *Acne Combinations***... 91 *Acne Products***... 91 *Antibiotics - Topical***... 92 *Antifungals - Topical Combinations***... 92 *Antifungals - Topical***... 92 *Anti-Inflammatory Agents - Topical***... 93 *Anti-Inflammatory Combinations - Topical***... 93 *Antineoplastic Antimetabolites - Topical***... 93 *Antipruritics - Topical***... 93 *Antipsoriatics - Systemic***... 93 *Antipsoriatics***... 93 *Antiseborrheic Products***... 93 *Antivirals - Topical***... 93 *Burn Products***... 93 *Corticosteroids - Topical***... 94 *Imidazole-Related Antifungals - Topical***... 95 *Immunomodulators Imidazoquinolinamines - Topical***... 96 *Local Anesthetics - Topical***... 96 *Macrolide Immunosuppressants - Topical***... 96 *Misc. Topical Combinations***... 96 *Rosacea Agents***... 96 *Scabicides & Pediculicides***... 96 *Topical Anesthetic Combinations***... 96 *Wound Care - Growth Factor Agents***... 97 *Diagnostic Products*... 97 *Diagnostic Tests***... 97 8
*Digestive Aids*... 104 *Digestive Enzymes***... 104 *Diuretics*... 105 *Carbonic Anhydrase Inhibitors***... 105 *Diuretic Combinations***... 105 *Loop Diuretics***... 105 *Potassium Sparing Diuretics***... 105 *Thiazides And Thiazide-Like Diuretics***... 105 *Endocrine And Metabolic Agents - Misc.*... 106 *Bisphosphonates***... 106 *Calcitonins***... 106 *Carnitine Replenisher - Agents***... 106 *Dopamine Receptor Agonists***... 106 *Growth Hormones***... 106 *Hyperparathyroid Treatment - Vitamin D Analogs***... 107 *Lhrh/Gnrh Agonist Analog Pituitary Suppressants***... 107 *Parathyroid Hormone And Derivatives***... 107 *Selective Estrogen Receptor Modulators (Serms)***... 107 *Vasopressin***... 108 *Estrogens*... 108 *Estrogen & Androgen***... 108 *Estrogen & Progestin***... 108 *Estrogens***... 109 *Fluoroquinolones*... 110 *Fluoroquinolones***... 110 *Gastrointestinal Agents - Misc.*... 110 *Gallstone Solubilizing Agents***... 110 *Gastrointestinal Antiallergy Agents***... 110 *Gastrointestinal Chloride Channel Activators***... 110 *Gastrointestinal Stimulants***... 110 *Inflammatory Bowel Agents***... 110 *Intestinal Acidifiers***... 111 *Phosphate Binder Agents***... 111 *Tumor Necrosis Factor Alpha Blockers***... 111 *Genitourinary Agents - Miscellaneous*... 111 *5-Alpha Reductase Inhibitors***... 111 *Alpha 1-Adrenoceptor Antagonists***... 111 *Citrates***... 111 9
*Interstitial Cystitis Agents***... 112 *Urinary Analgesics***... 112 *Gout Agents*... 112 *Gout Agent Combinations***... 112 *Gout Agents***... 112 *Uricosurics***... 112 *Hematological Agents - Misc.*... 112 *Hematorheologic Agents***... 112 *Phosphodiesterase Iii Inhibitors***... 112 *Platelet Aggregation Inhibitor Combinations***... 112 *Platelet Aggregation Inhibitors***... 112 *Quinazoline Agents***... 112 *Thienopyridine Derivatives***... 112 *Hematopoietic Agents*... 112 *Cobalamins***... 112 *Erythropoiesis-Stimulating Agents (Esas)***... 113 *Erythropoietins***... 113 *Folic Acid/Folate Combinations***... 113 *Folic Acid/Folates***... 114 *Granulocyte Colony-Stimulating Factors (G-Csf)***... 114 *Granulocyte/Macrophage Colony-Stimulating Factor(Gm-Csf)***... 114 *Hepatitis C Agent - Combinations***... 114 *Hepatitis C Agent - Combinations***... 114 *Hypnotics*... 114 *Barbiturate Hypnotics***... 114 *Benzodiazepine Hypnotics***... 114 *Non-Benzodiazepine - Gaba-Receptor Modulators***... 114 *Selective Melatonin Receptor Agonists***... 115 *Laxatives*... 115 *Bowel Evacuant Combinations***... 115 *Laxatives - Miscellaneous***... 115 *Saline Laxative Mixtures***... 115 *Lysosomal Acid Lipase (Lal) Deficiency - Agents***... 115 *Lysosomal Acid Lipase (Lal) Deficiency - Agents***... 115 *Macrolides*... 115 *Azithromycin***... 116 *Clarithromycin***... 116 *Erythromycins***... 116 10
*Medical Devices*... 116 *Glucose Monitoring Test Supplies***... 116 *Needles & Syringes***... 126 *Spacer/Aerosol-Holding Chambers & Supplies***... 139 *Migraine Products*... 140 *Ergot Combinations***... 140 *Migraine Combinations***... 140 *Migraine Products***... 140 *Selective Serotonin Agonists 5-Ht(1)***... 140 *Minerals & Electrolytes*... 141 *Fluoride***... 141 *Phosphate***... 141 *Potassium Combinations***... 141 *Potassium***... 142 *Mouth/Throat/Dental Agents*... 143 *Anesthetics Topical Oral***... 143 *Anti-Infectives - Throat***... 143 *Antiseptics - Mouth/Throat***... 143 *Fluoride Dental Products***... 143 *Periodontal Anti-Infectives***... 143 *Saliva Stimulants***... 143 *Steroids - Mouth/Throat***... 143 *Multivitamins*... 143 *Ped Multi Vitamins W/Fl & Fe***... 143 *Ped Mv W/ Fluoride***... 143 *Ped Vitamins Acd Fluoride & Iron***... 144 *Ped Vitamins Acd W/ Fluoride***... 144 *Prenatal Mv & Min W/Fe-Fa***... 144 *Prenatal Mv & Min W/Fe-Fa-Ca-Omega 3 Fish Oil***... 148 *Prenatal Mv & Min W/Fe-Fa-Dha***... 149 *Prenatal Vitamins***... 150 *Musculoskeletal Therapy Agents*... 150 *Central Muscle Relaxants***... 150 *Direct Muscle Relaxants***... 150 *Muscle Relaxant Combinations***... 150 *Nasal Agents - Systemic And Topical*... 150 *Nasal Agents Misc. - Combinations***... 150 *Nasal Anticholinergics***... 150 11
*Nasal Antihistamines***... 150 *Nasal Steroids***... 151 *Systemic Decongestants***... 151 *Ophthalmic Agents*... 152 *Beta-Blockers - Ophthalmic Combinations***... 152 *Beta-Blockers - Ophthalmic***... 152 *Cycloplegic Mydriatics***... 153 *Miotics - Direct Acting***... 153 *Ophthalmic Antiallergic***... 153 *Ophthalmic Antibiotics***... 153 *Ophthalmic Anti-Infective Combinations***... 154 *Ophthalmic Antivirals***... 154 *Ophthalmic Carbonic Anhydrase Inhibitors***... 154 *Ophthalmic Local Anesthetics***... 154 *Ophthalmic Nonsteroidal Anti-Inflammatory Agents***... 155 *Ophthalmic Selective Alpha Adrenergic Agonists***... 155 *Ophthalmic Steroid Combinations***... 155 *Ophthalmic Steroids***... 155 *Ophthalmic Sulfonamides***... 156 *Prostaglandins - Ophthalmic***... 156 *Otic Agents*... 156 *Otic Analgesic Combinations***... 156 *Otic Anti-Infectives***... 156 *Otic Steroid-Anti-Infective Combinations***... 156 *Otic Steroids***... 156 *Passive Immunizing Agents*... 156 *Antiviral Monoclonal Antibodies***... 156 *Pcsk9 Inhibitors***... 156 *Pcsk9 Inhibitors***... 156 *Penicillins*... 157 *Aminopenicillins***... 157 *Natural Penicillins***... 157 *Penicillin Combinations***... 157 *Penicillinase-Resistant Penicillins***... 157 *Potassium Removing Agents***... 157 *Potassium Removing Agents***... 157 *Progestins*... 157 *Progestins***... 157 12
*Psychotherapeutic And Neurological Agents - Misc.*... 158 *Alcohol Deterrents***... 158 *Cholinomimetics - Ache Inhibitors***... 158 *Multiple Sclerosis Agents - Interferons***... 158 *Multiple Sclerosis Agents - Nrf2 Pathway Activators***... 159 *Multiple Sclerosis Agents***... 159 *N-Methyl-D-Aspartate (Nmda) Receptor Antagonists***... 159 *Psychotherapeutic And Neurological Agents - Misc.***... 159 *Smoking Deterrents***... 159 *Sphingosine 1-Phosphate (S1p) Receptor Modulators***... 162 *Pulmonary Hypertension - Prostacyclin Receptor Agonist***... 162 *Pulmonary Hypertension - Prostacyclin Receptor Agonist***... 162 *Serotonin Modulators***... 162 *Serotonin Modulators***... 163 *Tetracyclines*... 163 *Tetracycline Combinations***... 163 *Tetracyclines***... 163 *Thyroid Agents*... 163 *Antithyroid Agents***... 163 *Thyroid Hormones***... 163 *Ulcer Drugs*... 164 *Anticholinergic Combinations***... 164 *Antispasmodics***... 164 *Belladonna Alkaloids***... 164 *H-2 Antagonists***... 165 *Misc. Anti-Ulcer***... 165 *Proton Pump Inhibitors***... 165 *Quaternary Anticholinergics***... 166 *Ulcer Anti-Infective W/ Proton Pump Inhibitors***... 166 *Ulcer Drugs - Prostaglandins***... 166 *Urinary Anti-Infectives*... 166 *Urinary Anti-Infectives***... 166 *Urinary Antispasmodics*... 166 *Urinary Antispasmodic - Antimuscarinic (Anticholinergic)***... 166 *Urinary Antispasmodic - Antimuscarinics (Antichol)***(New)... 167 *Urinary Antispasmodics - Cholinergic Agonists***... 167 *Urinary Antispasmodics - Cholinergic Agonists*** (New)... 167 *Urinary Antispasmodics - Direct Muscle Relaxants***... 167 13
*Urinary Antispasmodics - Direct Muscle Relaxants*** (New)... 167 *Vaccines*... 167 *Viral Vaccines***... 167 *Vaginal Products*... 169 *Imidazole-Related Antifungals***... 169 *Vaginal Anti-Infectives***... 169 *Vaginal Estrogens***... 169 *Vasopressors*... 169 *Anaphylaxis Therapy Agents***... 169 *Vasopressors***... 170 *Vitamins*... 170 *Vitamin B-3***... 170 *Vitamin D***... 170 *Vitamin K***... 170 14
LEGEND PA: ST: QL: PRIOR AUTHORIZATION IS REQUIRED STEP THERAPY QUANTITY LIMIT INTRODUCTION Samaritan Health Plan Operations is pleased to provide the 2016 Samaritan Choice Plan (SCP) Formulary as a reference and informational tool for physicians, pharmacists and patients. The SCP Formulary is designed to assist practitioners in selecting clinically appropriate and cost-effective products for their patients. The Samaritan Health Plans Operations (SHPO) Pharmacy and Therapeutics (P & T) Committee The SHPO P&T Committee has reviewed all the medications listed on the formulary. Medications found to be clinically appropriate and cost effective have been selected as an option for SCP members. If a physician deems an unlisted product to be medically necessary, the physician may request coverage through the medical exception process. Notice This formulary is not intended to be a substitute for a medical provider s knowledge expertise, skill or judgment. SCP assumes no responsibility for the actions or omissions of any medical provider based upon the information herein. The medical provider should always consult the drug manufacturer s product insert for detailed information. The medications listed on this formulary are subject to change pursuant to the formulary management activities of SHPO and the Plan s Provisions. The presence of a medication on this formulary does not guarantee that you as a plan member will be prescribed that drug by your primary care physician or contracting provider for a particular medical condition. These medications may be subject to Prior Authorization. As new generics become available the corresponding brand name drug may no longer be considered a preferred agent. Branded Generics and Generics: All prescription medications enter the market place as brand name medications and when patents expire, other firms get FDA approval to market generic alternatives to the brand. There are two types of alternatives which are as follows: Generic- A generic alternative to a patented medication. An example of a generic is Levothyroxine. These medications are found on Tier 2 of the formulary. Branded Generic- A generic alternatives that a pharmaceuticals firm has branded. Branded Generics may cost more than the truly generic version. An example of Branded Generic is Synthroid, which is the original brand medication of generic Levothyroxine. These medications are found on Tier 2 and Tier 3 of the formulary book with printing the generic name twice. SCP covers both brand name drugs and generic drugs. Generic drugs are approved by the FDA as having the same active ingredient as the brand name drug. Generally, when a generic version of a drug is available SCP will require that the generic be used by members unless it is medically necessary for a member to use the brand version of a drug. SCP uses a formulary, that lists the covered prescription medications. Some covered medications may have additional requirements or limits on coverage. These requirements may include: Prior Authorization: SCP requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from SCP before you fill your prescriptions. Quantity Limits: For certain drugs, SCP limits the amount of the drug that is covered. Manage drug limit means quantity limit. Step Therapy: In some cases, SCP requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B. 15
You can find out more about additional requirements or limits on covered medication by contacting our Customer Service Department or you physician. Drugs may have been added or removed from the list after this formulary was published. For the most current listings, please contact us at (541) 768-5207 or1-800-832-4580. Lost or Stolen Medications The SCP policy for lost or stolen medications is that they are not covered unless the medication is emergent and a police report has been filed. Narcotic medications will never be filled early due to being lost or stolen. Please call Customer Service at (541) 768-4550 or (800) 832-4580 if you have any other questions regarding a member with this situation. Preface The SCP Formulary is a listing of preferred drug products eligible for reimbursement by SCP. All medications are listed organized by therapeutic class and appropriate Tier. Brand names are listed to assist in product recognition. Unless noted, all applicable dosage forms and strengths are generally covered. Extended release formulations (e.g., ext-rel, SR) are not considered formulary drugs unless specified. SCP will not cover prescription drugs when prescribed for experimental or investigational uses. Product Selection Criteria The SHPO P&T Committee is composed of physicians, pharmacists and health professionals. The primary goal of the Committee is to maintain and evaluate the SCP formulary based upon an objective analysis of the safety, efficacy, indications, adverse events, compliance, contraindications and cost-effectiveness of each drug. When a new drug is considered for formulary inclusion, it will be reviewed relative to similar drugs currently included in the SCP Formulary. Co-Pay Tiers The level of prescription drug coverage is determined through a five-tier system. The tiers are as follows: Tier 1: Therapeutic Tier specific therapeutic medications. Tier 2: Preferred Generic Tier Generic drugs provide the same high quality medicine and therapeutic benefits found in brand-name medications without the brand-name price. Tier 3: Preferred Tier Preferred Brand Name drugs provide high quality, effective and affordable prescription benefits to SCP members. Tier 4: Non-Preferred Tier Tier 5: Specialty Tier. Specialty medications as defined by the SHPO P&T Committee (generally very high cost, unique therapies). Medication Exception Exceptions are made in two rare circumstances: 1. There is a documented reaction to a component of the generic not present in the branded product. Usually this is a dye, filler, or preservative. 2. There is objective evidence of therapeutic failure after adjustment of dosage and/or timing of doses, and assurance of patient compliance. An example would be failure obtain/maintain therapeutic drug levels after dosage adjustments. If a medication is not on the formulary but is medically necessary you may request a formulary exception by faxing a completed medication exception form to SCP at 1-844-611-3831. PRIOR AUTHORIZATION Drugs indicated with "PA" require Prior Authorization for coverage, this includes some generic versions. Please call Customer Service at (541) 768-5207 or 1-888-435-2396 or fax completed PA form to1-844-611-3831 to request prior authorization (PA) for the following medications. This list is subject to change. Abilify TABLET 10 MG ORAL Abilify TABLET 15 MG ORAL Abilify TABLET 2 MG ORAL Abilify TABLET 20 MG ORAL Abilify TABLET 30 MG ORAL Abilify TABLET 5 MG ORAL Apidra SoloStar 100 UNIT/ML SUBCUTANEOUS* Aranesp (Albumin Free) 100 MCG/0.5ML INJECTION 16 Aranesp (Albumin Free) 150 MCG/0.3ML INJECTION Aranesp (Albumin Free) 200 MCG/0.4ML INJECTION Aranesp (Albumin Free) 25 MCG/0.42ML INJECTION Aranesp (Albumin Free) 300 MCG/0.6ML INJECTION Aranesp (Albumin Free) 40 MCG/0.4ML INJECTION Aranesp (Albumin Free) 500 MCG/ML INJECTION Aranesp (Albumin Free) 60 MCG/0.3ML INJECTION Aranesp (Albumin Free) SOLUTION 10 MCG/0.4ML INJECTION
Aranesp (Albumin Free) SOLUTION 100 MCG/ML INJECTION Aranesp (Albumin Free) SOLUTION 150 MCG/0.75ML INJECTION Aranesp (Albumin Free) SOLUTION 200 MCG/ML INJECTION Aranesp (Albumin Free) SOLUTION 25 MCG/ML INJECTION Aranesp (Albumin Free) SOLUTION 300 MCG/ML INJECTION Aranesp (Albumin Free) SOLUTION 40 MCG/ML INJECTION Aranesp (Albumin Free) SOLUTION 60 MCG/ML INJECTION ARIPiprazole TABLET 10 MG ORAL ARIPiprazole TABLET 15 MG ORAL ARIPiprazole TABLET 2 MG ORAL ARIPiprazole TABLET 20 MG ORAL ARIPiprazole TABLET 30 MG ORAL ARIPiprazole TABLET 5 MG ORAL Epogen SOLUTION 10000 UNIT/ML INJECTION Epogen SOLUTION 2000 UNIT/ML INJECTION Epogen SOLUTION 20000 UNIT/ML INJECTION Epogen SOLUTION 3000 UNIT/ML INJECTION Epogen SOLUTION 4000 UNIT/ML INJECTION Genotropin MiniQuick SOLUTION RECONSTITUTED 0.2 MG SUBCUTANEOUS* Genotropin MiniQuick SOLUTION RECONSTITUTED 0.4 MG SUBCUTANEOUS* Genotropin MiniQuick SOLUTION RECONSTITUTED 0.6 MG SUBCUTANEOUS* Genotropin MiniQuick SOLUTION RECONSTITUTED 0.8 MG SUBCUTANEOUS* Genotropin MiniQuick SOLUTION RECONSTITUTED 1 MG SUBCUTANEOUS* Genotropin MiniQuick SOLUTION RECONSTITUTED 1.2 MG SUBCUTANEOUS* Genotropin MiniQuick SOLUTION RECONSTITUTED 1.4 MG SUBCUTANEOUS* Genotropin MiniQuick SOLUTION RECONSTITUTED 1.6 MG SUBCUTANEOUS* Genotropin MiniQuick SOLUTION RECONSTITUTED 1.8 MG SUBCUTANEOUS* Genotropin MiniQuick SOLUTION RECONSTITUTED 2 MG SUBCUTANEOUS* Genotropin SOLUTION RECONSTITUTED 12 MG SUBCUTANEOUS* Genotropin SOLUTION RECONSTITUTED 5 MG SUBCUTANEOUS* Gilenya CAPSULE 0.5 MG ORAL Grastek TABLET SUBLINGUAL 2800 BAU SUBLINGUAL Harvoni TABLET 90-400 MG ORAL HumaLOG KwikPen 100 UNIT/ML SUBCUTANEOUS* HumaLOG Mix 50/50 KwikPen (50-50) 100 UNIT/ML SUBCUTANEOUS* HumaLOG Mix 75/25 KwikPen (75-25) 100 UNIT/ML SUBCUTANEOUS* Humatrope SOLUTION RECONSTITUTED 12 MG INJECTION Humatrope SOLUTION RECONSTITUTED 24 MG INJECTION Humatrope SOLUTION RECONSTITUTED 5 MG INJECTION Humatrope SOLUTION RECONSTITUTED 6 MG INJECTION Humira 10 MG/0.2ML SUBCUTANEOUS* Humira 20 MG/0.4ML SUBCUTANEOUS* Humira 40 MG/0.8ML SUBCUTANEOUS* Humira Pediatric Crohns Start 40 MG/0.8ML SUBCUTANEOUS* 17 Humira Pen 40 MG/0.8ML SUBCUTANEOUS* Humira Pen-Crohns Starter 40 MG/0.8ML SUBCUTANEOUS* Humira Pen-Psoriasis Starter 40 MG/0.8ML SUBCUTANEOUS* HumuLIN 70/30 KwikPen (70-30) 100 UNIT/ML SUBCUTANEOUS* HumuLIN 70/30 Pen (70-30) 100 UNIT/ML SUBCUTANEOUS* HumuLIN N KwikPen 100 UNIT/ML SUBCUTANEOUS* HumuLIN N Pen 100 UNIT/ML SUBCUTANEOUS* Intron A SOLUTION 10000000 UNIT/ML INJECTION Intron A SOLUTION 6000000 UNIT/ML INJECTION Intron A SOLUTION RECONSTITUTED 10000000 UNIT INJECTION Intron A SOLUTION RECONSTITUTED 18000000 UNIT INJECTION Intron A SOLUTION RECONSTITUTED 50000000 UNIT INJECTION Kadian CAPSULE EXTENDED RELEASE 24 HOUR 100 MG ORAL Kadian CAPSULE EXTENDED RELEASE 24 HOUR 20 MG ORAL Kadian CAPSULE EXTENDED RELEASE 24 HOUR 30 MG ORAL Kadian CAPSULE EXTENDED RELEASE 24 HOUR 50 MG ORAL Kadian CAPSULE EXTENDED RELEASE 24 HOUR 60 MG ORAL Kadian CAPSULE EXTENDED RELEASE 24 HOUR 80 MG ORAL Lantus SoloStar 100 UNIT/ML SUBCUTANEOUS* Leukine SOLUTION RECONSTITUTED 250 MCG INTRAVENOUS* Levemir FlexPen 100 UNIT/ML SUBCUTANEOUS* Levemir FlexTouch 100 UNIT/ML SUBCUTANEOUS* Linezolid SOLUTION 2 MG/ML INTRAVENOUS* Linezolid SUSPENSION RECONSTITUTED 100 MG/5ML ORAL Linezolid TABLET 600 MG ORAL Lyrica CAPSULE 100 MG ORAL Lyrica CAPSULE 150 MG ORAL Lyrica CAPSULE 200 MG ORAL Lyrica CAPSULE 225 MG ORAL Lyrica CAPSULE 25 MG ORAL Lyrica CAPSULE 300 MG ORAL Lyrica CAPSULE 50 MG ORAL Lyrica CAPSULE 75 MG ORAL Moderiba 1200 Dose Pack TABLET 600 MG ORAL Moderiba 200 & 400 MG ORAL Moderiba 400 & 600 MG ORAL Moderiba 800 Dose Pack TABLET 400 MG ORAL Moderiba TABLET 200 MG ORAL Morphine Sulfate ER CAPSULE EXTENDED RELEASE 24 HOUR 100 MG ORAL Morphine Sulfate ER CAPSULE EXTENDED RELEASE 24 HOUR 20 MG ORAL Morphine Sulfate ER CAPSULE EXTENDED RELEASE 24 HOUR 30 MG ORAL Morphine Sulfate ER CAPSULE EXTENDED RELEASE 24 HOUR 50 MG ORAL Morphine Sulfate ER CAPSULE EXTENDED RELEASE 24 HOUR 60 MG ORAL Morphine Sulfate ER CAPSULE EXTENDED RELEASE 24 HOUR 80 MG ORAL Neupogen SOLUTION 300 MCG/ML INJECTION Neupogen SOLUTION 480 MCG/1.6ML INJECTION Norditropin FlexPro SOLUTION 10 MG/1.5ML SUBCUTANEOUS*
Norditropin FlexPro SOLUTION 15 MG/1.5ML SUBCUTANEOUS* Norditropin FlexPro SOLUTION 5 MG/1.5ML SUBCUTANEOUS* NovoLOG FlexPen 100 UNIT/ML SUBCUTANEOUS* NovoLOG Mix 70/30 FlexPen (70-30) 100 UNIT/ML SUBCUTANEOUS* NovoLOG PenFill 100 UNIT/ML SUBCUTANEOUS* Nutropin AQ NuSpin 10 SOLUTION 10 MG/2ML SUBCUTANEOUS* Nutropin AQ NuSpin 20 SOLUTION 20 MG/2ML SUBCUTANEOUS* Nutropin AQ NuSpin 5 SOLUTION 5 MG/2ML SUBCUTANEOUS* Nutropin AQ Pen SOLUTION 10 MG/2ML SUBCUTANEOUS* Nutropin AQ Pen SOLUTION 20 MG/2ML SUBCUTANEOUS* Omnitrope SOLUTION 10 MG/1.5ML SUBCUTANEOUS* Omnitrope SOLUTION 5 MG/1.5ML SUBCUTANEOUS* Omnitrope SOLUTION RECONSTITUTED 5.8 MG SUBCUTANEOUS* Praluent 150 MG/ML SUBCUTANEOUS* Praluent 150 MG/ML SUBCUTANEOUS* Praluent 75 MG/ML SUBCUTANEOUS* Praluent 75 MG/ML SUBCUTANEOUS* Procrit SOLUTION 10000 UNIT/ML INJECTION Procrit SOLUTION 2000 UNIT/ML INJECTION Procrit SOLUTION 20000 UNIT/ML INJECTION Procrit SOLUTION 3000 UNIT/ML INJECTION Procrit SOLUTION 4000 UNIT/ML INJECTION Procrit SOLUTION 40000 UNIT/ML INJECTION Ranexa TABLET EXTENDED RELEASE 12 HR* 1000 MG ORAL Ranexa TABLET EXTENDED RELEASE 12 HR* 500 MG ORAL Remicade SOLUTION RECONSTITUTED 100 MG INTRAVENOUS* Revatio SOLUTION 10 MG/12.5ML INTRAVENOUS* Revatio SUSPENSION RECONSTITUTED 10 MG/ML ORAL Revatio TABLET 20 MG ORAL Ribasphere CAPSULE 200 MG ORAL Ribasphere RibaPak TABLET 200 & 400 MG ORAL Ribasphere RibaPak TABLET 400 & 600 MG ORAL Ribasphere RibaPak TABLET 400 MG ORAL Ribasphere RibaPak TABLET 600 MG ORAL Ribasphere TABLET 200 MG ORAL Ribasphere TABLET 400 MG ORAL Ribasphere TABLET 600 MG ORAL RibaTab 400 & 600 MG ORAL RibaTab TABLET 400 MG ORAL RibaTab TABLET 600 MG ORAL Ribavirin CAPSULE 200 MG ORAL Ribavirin TABLET 200 MG ORAL Saizen Click.Easy SOLUTION RECONSTITUTED 8.8 MG INJECTION Saizen SOLUTION RECONSTITUTED 5 MG INJECTION Saizen SOLUTION RECONSTITUTED 8.8 MG INJECTION Serostim SOLUTION RECONSTITUTED 4 MG SUBCUTANEOUS* Serostim SOLUTION RECONSTITUTED 5 MG SUBCUTANEOUS* Serostim SOLUTION RECONSTITUTED 6 MG SUBCUTANEOUS* Sildenafil Citrate SOLUTION 10 MG/12.5ML INTRAVENOUS* Sildenafil Citrate TABLET 20 MG ORAL Sovaldi TABLET 400 MG ORAL SymlinPen 120 2700 MCG/2.7ML SUBCUTANEOUS* SymlinPen 60 1500 MCG/1.5ML SUBCUTANEOUS* Synagis SOLUTION 100 MG/ML INTRAMUSCULAR* Synagis SOLUTION 50 MG/0.5ML INTRAMUSCULAR* Tecfidera CAPSULE DELAYED RELEASE 120 MG ORAL Tecfidera CAPSULE DELAYED RELEASE 240 MG ORAL Terbinafine HCl TABLET 250 MG ORAL Virazole SOLUTION RECONSTITUTED 6 GM INHALATION Zetia TABLET 10 MG ORAL Zorbtive SOLUTION RECONSTITUTED 8.8 MG SUBCUTANEOUS* Zyvox SOLUTION 2 MG/ML INTRAVENOUS* Zyvox TABLET 600 MG ORAL 18
QUANTITY LIMITATIONS (QL) Drugs with QL will have the limitations noted in the column to the right of the drug name. Once the QL has been exceeded a PA will be required. Managed drug limitations are subject to change. Product Actonel TABLET 35 MG ORAL Advair Diskus AEROSOL POWDER, BREATH ACTIVATED 100-50 MCG/DOSE INHALATION Advair Diskus AEROSOL POWDER, BREATH ACTIVATED 250-50 MCG/DOSE INHALATION Advair Diskus AEROSOL POWDER, BREATH ACTIVATED 500-50 MCG/DOSE INHALATION Advair HFA AEROSOL 115-21 MCG/ACT INHALATION Advair HFA AEROSOL 230-21 MCG/ACT INHALATION Advair HFA AEROSOL 45-21 MCG/ACT INHALATION Albuterol Sulfate NEBULIZATION SOLUTION (2.5 MG/3ML) 0.083% INHALATION Albuterol Sulfate NEBULIZATION SOLUTION (5 MG/ML) 0.5% INHALATION Albuterol Sulfate NEBULIZATION SOLUTION 0.63 MG/3ML INHALATION Albuterol Sulfate NEBULIZATION SOLUTION 1.25 MG/3ML INHALATION Alendronate Sodium TABLET 10 MG ORAL Alendronate Sodium TABLET 35 MG ORAL Alendronate Sodium TABLET 40 MG ORAL Alendronate Sodium TABLET 5 MG ORAL Alendronate Sodium TABLET 70 MG ORAL Almotriptan Malate TABLET 12.5 MG ORAL Almotriptan Malate TABLET 6.25 MG ORAL Asmanex 120 Metered Doses AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH INHALATION Asmanex 14 Metered Doses AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH INHALATION Asmanex 30 Metered Doses AEROSOL POWDER, BREATH ACTIVATED 110 MCG/INH INHALATION Asmanex 30 Metered Doses AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH INHALATION Asmanex 60 Metered Doses AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH INHALATION Asmanex 7 Metered Doses AEROSOL POWDER, BREATH ACTIVATED 110 MCG/INH INHALATION Asmanex HFA AEROSOL 100 MCG/ACT INHALATION Asmanex HFA AEROSOL 200 MCG/ACT INHALATION Atrovent HFA AEROSOL, SOLUTION 17 MCG/ACT INHALATION Axert TABLET 12.5 MG ORAL Axert TABLET 6.25 MG ORAL Budesonide SUSPENSION 0.25 MG/2ML INHALATION Budesonide SUSPENSION 0.5 MG/2ML INHALATION Budesonide SUSPENSION 1 MG/2ML INHALATION Combivent Respimat AEROSOL, SOLUTION 20-100 MCG/ACT INHALATION Daytrana PATCH 10 MG/9HR TRANSDERMAL Daytrana PATCH 15 MG/9HR TRANSDERMAL Daytrana PATCH 20 MG/9HR TRANSDERMAL Daytrana PATCH 30 MG/9HR TRANSDERMAL Dihydroergotamine Mesylate SOLUTION 4 MG/ML NASAL Dulera AEROSOL 100-5 MCG/ACT INHALATION Dulera AEROSOL 200-5 MCG/ACT INHALATION Endocet TABLET 10-325 MG ORAL Endocet TABLET 2.5-325 MG ORAL Endocet TABLET 5-325 MG ORAL Quantity Limit QL(4 EA per 28 days) QL(1 EA per 30 days) QL(1 EA per 30 days) QL(1 EA per 30 days) QL(1 GM per 30 days) QL(1 GM per 30 days) QL(1 GM per 30 days) QL(180 VIAL per 30 days) QL(180 VIAL per 30 days) QL(180 VIAL per 30 days) QL(180 VIAL per 30 days) QL(30 EA per 30 days) QL(8 EA per 28 days) QL(30 EA per 30 days) QL(30 EA per 30 days) QL(4 EA per 28 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(2 EA per 30 days) QL(2 EA per 30 days) QL(2 EA per 30 days) QL(2 EA per 30 days) QL(2 EA per 30 days) QL(2 EA per 30 days) QL(2 GM per 30 days) QL(2 GM per 30 days) QL(2 INH per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(120 VIAL per 30 days) QL(60 VIAL per 30 days) QL(30 VIAL per 30 days) QL(4 GM per 30 days) QL(30 EA per 30 days) QL(30 EA per 30 days) QL(30 EA per 30 days) QL(30 EA per 30 days) QL(12 ML per 30 days) QL(1 GM per 30 days) QL(1 GM per 30 days) QL(360 EA per 30 days) QL(360 EA per 30 days) QL(360 EA per 30 days) 19
Product Endocet TABLET 7.5-325 MG ORAL Enoxaparin Sodium SOLUTION 100 MG/ML SUBCUTANEOUS* Enoxaparin Sodium SOLUTION 120 MG/0.8ML SUBCUTANEOUS* Enoxaparin Sodium SOLUTION 150 MG/ML SUBCUTANEOUS* Enoxaparin Sodium SOLUTION 30 MG/0.3ML SUBCUTANEOUS* Enoxaparin Sodium SOLUTION 300 MG/3ML INJECTION Enoxaparin Sodium SOLUTION 40 MG/0.4ML SUBCUTANEOUS* Enoxaparin Sodium SOLUTION 60 MG/0.6ML SUBCUTANEOUS* Enoxaparin Sodium SOLUTION 80 MG/0.8ML SUBCUTANEOUS* FentaNYL PATCH 72 HR 100 MCG/HR TRANSDERMAL FentaNYL PATCH 72 HR 12 MCG/HR TRANSDERMAL FentaNYL PATCH 72 HR 25 MCG/HR TRANSDERMAL FentaNYL PATCH 72 HR 50 MCG/HR TRANSDERMAL FentaNYL PATCH 72 HR 75 MCG/HR TRANSDERMAL Flovent HFA AEROSOL 110 MCG/ACT INHALATION Flovent HFA AEROSOL 220 MCG/ACT INHALATION Flovent HFA AEROSOL 44 MCG/ACT INHALATION Foradil Aerolizer CAPSULE 12 MCG INHALATION Frova TABLET 2.5 MG ORAL GaviLyte-G SOLUTION RECONSTITUTED 236 GM ORAL GaviLyte-N with Flavor Pack SOLUTION RECONSTITUTED 420 GM ORAL Golytely SOLUTION RECONSTITUTED 236 GM ORAL Ibandronate Sodium TABLET 150 MG ORAL Ipratropium-Albuterol SOLUTION 0.5-2.5 (3) MG/3ML INHALATION Lansoprazole CAPSULE DELAYED RELEASE 15 MG ORAL Lansoprazole CAPSULE DELAYED RELEASE 30 MG ORAL Migranal SOLUTION 4 MG/ML NASAL Modafinil TABLET 100 MG ORAL Modafinil TABLET 200 MG ORAL MoviPrep SOLUTION RECONSTITUTED 100 GM ORAL Naratriptan HCl TABLET 1 MG ORAL Naratriptan HCl TABLET 2.5 MG ORAL Omeprazole CAPSULE DELAYED RELEASE 10 MG ORAL Omeprazole CAPSULE DELAYED RELEASE 20 MG ORAL Omeprazole CAPSULE DELAYED RELEASE 40 MG ORAL Ondansetron HCl SOLUTION 4 MG/5ML ORAL Ondansetron HCl TABLET 4 MG ORAL Ondansetron HCl TABLET 8 MG ORAL Ondansetron TABLET DISPERSIBLE 4 MG ORAL Ondansetron TABLET DISPERSIBLE 8 MG ORAL OxyCODONE HCl CAPSULE 5 MG ORAL OxyCODONE HCl ER 10 MG ORAL OxyCODONE HCl ER 15 MG ORAL OxyCODONE HCl ER 20 MG ORAL OxyCODONE HCl ER 30 MG ORAL OxyCODONE HCl ER 40 MG ORAL OxyCODONE HCl ER 60 MG ORAL OxyCODONE HCl ER 80 MG ORAL OxyCODONE HCl SOLUTION 5 MG/5ML ORAL OxyCODONE HCl TABLET 10 MG ORAL OxyCODONE HCl TABLET 15 MG ORAL OxyCODONE HCl TABLET 30 MG ORAL OxyCODONE HCl TABLET 5 MG ORAL Quantity Limit QL(360 EA per 30 days) QL(14 ML per 7 days) QL(14 ML per 7 days) QL(14 ML per 7 days) QL(4.2 ML per 7 days) QL(14 ML per 7 days) QL(5.6 ML per 7 days) QL(8.4 ML per 7 days) QL(11.2 ML per 7 days) QL(10 EA per 30 days) QL(10 EA per 30 days) QL(10 EA per 30 days) QL(10 EA per 30 days) QL(10 EA per 30 days) QL(24 GM per 30 days) QL(24 GM per 30 days) QL(22 GM per 30 days) QL(60 EA per 30 days) QL(12 EA per 30 days) QL(236 ML per 30 days) QL(420 ML per 30 days) QL(236 ML per 30 days) QL(1 EA per 30 days) QL(180 VIAL per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) QL(12 ML per 30 days) QL(30 EA per 30 days) QL(30 EA per 30 days) QL(100 EA per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) QL(600 ML per 30 days) QL(180 EA per 30 days) QL(90 EA per 30 days) QL(180 EA per 30 days) QL(90 EA per 30 days) QL(360 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(500 ML per 30 days) QL(360 EA per 30 days) QL(360 EA per 30 days) QL(360 EA per 30 days) QL(360 EA per 30 days) 20
Product Oxycodone-Acetaminophen TABLET 10-325 MG ORAL Oxycodone-Acetaminophen TABLET 2.5-325 MG ORAL Oxycodone-Acetaminophen TABLET 5-325 MG ORAL Oxycodone-Acetaminophen TABLET 7.5-325 MG ORAL OxyCONTIN 10 MG ORAL OxyCONTIN 15 MG ORAL OxyCONTIN 20 MG ORAL OxyCONTIN 30 MG ORAL OxyCONTIN 40 MG ORAL OxyCONTIN 60 MG ORAL OxyCONTIN 80 MG ORAL Pantoprazole Sodium TABLET DELAYED RELEASE 20 MG ORAL Pantoprazole Sodium TABLET DELAYED RELEASE 40 MG ORAL PEG 3350-KCl-Na Bicarb-NaCl SOLUTION RECONSTITUTED 420 GM ORAL PEG-3350/Electrolytes SOLUTION RECONSTITUTED 236 GM ORAL Prevacid SoluTab TABLET DISPERSIBLE 15 MG ORAL Prevacid SoluTab TABLET DISPERSIBLE 30 MG ORAL Primlev TABLET 10-300 MG ORAL Primlev TABLET 5-300 MG ORAL Primlev TABLET 7.5-300 MG ORAL ProAir HFA AEROSOL, SOLUTION 108 (90 Base) MCG/ACT INHALATION Proventil HFA AEROSOL, SOLUTION 108 (90 Base) MCG/ACT INHALATION Provigil TABLET 100 MG ORAL Provigil TABLET 200 MG ORAL Pulmicort Flexhaler AEROSOL POWDER, BREATH ACTIVATED 180 MCG/ACT INHALATION Pulmicort Flexhaler AEROSOL POWDER, BREATH ACTIVATED 90 MCG/ACT INHALATION Qvar AEROSOL, SOLUTION 40 MCG/ACT INHALATION Qvar AEROSOL, SOLUTION 80 MCG/ACT INHALATION Relpax TABLET 20 MG ORAL Relpax TABLET 40 MG ORAL Risedronate Sodium TABLET 150 MG ORAL Risedronate Sodium TABLET 35 MG ORAL Rizatriptan Benzoate TABLET 10 MG ORAL Rizatriptan Benzoate TABLET 5 MG ORAL Rizatriptan Benzoate TABLET DISPERSIBLE 10 MG ORAL Rizatriptan Benzoate TABLET DISPERSIBLE 5 MG ORAL Roxicet TABLET 5-325 MG ORAL Serevent Diskus AEROSOL POWDER, BREATH ACTIVATED 50 MCG/DOSE INHALATION Spiriva HandiHaler CAPSULE 18 MCG INHALATION Suboxone FILM 12-3 MG SUBLINGUAL Suboxone FILM 2-0.5 MG SUBLINGUAL Suboxone FILM 4-1 MG SUBLINGUAL Suboxone FILM 8-2 MG SUBLINGUAL SUMAtriptan Succinate TABLET 100 MG ORAL SUMAtriptan Succinate TABLET 25 MG ORAL SUMAtriptan Succinate TABLET 50 MG ORAL Symbicort AEROSOL 160-4.5 MCG/ACT INHALATION Symbicort AEROSOL 80-4.5 MCG/ACT INHALATION Terbinafine HCl TABLET 250 MG ORAL TriLyte SOLUTION RECONSTITUTED 420 GM ORAL Ventolin HFA AEROSOL, SOLUTION 108 (90 Base) MCG/ACT INHALATION Xarelto TABLET 10 MG ORAL Xarelto TABLET 15 MG ORAL Quantity Limit QL(360 EA per 30 days) QL(360 EA per 30 days) QL(360 EA per 30 days) QL(360 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) QL(420 ML per 30 days) QL(236 ML per 30 days) QL(60 EA per 30 days) QL(60 EA per 30 days) QL(360 EA per 30 days) QL(360 EA per 30 days) QL(360 EA per 30 days) QL(2 INH per 30 days) QL(2 INH per 30 days) QL(30 EA per 30 days) QL(30 EA per 30 days) QL(1 INH per 30 days) QL(1 INH per 30 days) QL(8.7 GM per 30 days) QL(17.4 GM per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(1 EA per 30 days) QL(4 EA per 28 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(360 EA per 30 days) QL(60 EA per 30 days) QL(30 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(90 EA per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(10.2 GM per 30 days) QL(10.2 GM per 30 days) QL(90 EA per 365 days) QL(420 ML per 30 days) QL(2 INH per 30 days) QL(34 EA per 34 days) QL(34 EA per 34 days) 21
Product Xarelto TABLET 20 MG ORAL Xopenex HFA AEROSOL 45 MCG/ACT INHALATION ZOLMitriptan TABLET 2.5 MG ORAL ZOLMitriptan TABLET 5 MG ORAL ZOLMitriptan TABLET DISPERSIBLE 2.5 MG ORAL ZOLMitriptan TABLET DISPERSIBLE 5 MG ORAL Zolpidem Tartrate ER TABLET EXTENDEDRELEASE* 12.5 MG ORAL Zolpidem Tartrate ER TABLET EXTENDEDRELEASE* 6.25 MG ORAL Zolpidem Tartrate TABLET 10 MG ORAL Zolpidem Tartrate TABLET 5 MG ORAL Zomig ZMT TABLET DISPERSIBLE 2.5 MG ORAL Zomig ZMT TABLET DISPERSIBLE 5 MG ORAL Zostavax SOLUTION RECONSTITUTED 19400 UNT/0.65ML SUBCUTANEOUS* Quantity Limit QL(34 EA per 34 days) QL(2 INH per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(30 EA per 30 days) QL(30 EA per 30 days) QL(30 EA per 30 days) QL(30 EA per 30 days) QL(12 EA per 30 days) QL(12 EA per 30 days) QL(1 EA per 365 days) 22
STEP THERAPY (ST) The following products have step therapy limitations. This list is subject to change. Product AndroGel 25 MG/2.5GM (1%) TRANSDERMAL AndroGel 25 MG/2.5GM (1%) TRANSDERMAL AndroGel 40.5 MG/2.5GM (1.62%) TRANSDERMAL AndroGel 40.5 MG/2.5GM (1.62%) TRANSDERMAL AndroGel 50 MG/5GM (1%) TRANSDERMAL AndroGel 50 MG/5GM (1%) TRANSDERMAL AndroGel Pump 12.5 MG/ACT (1%) TRANSDERMAL AndroGel Pump 12.5 MG/ACT (1%) TRANSDERMAL Dexilant CAPSULE DELAYED RELEASE 30 MG ORAL Dexilant CAPSULE DELAYED RELEASE 30 MG ORAL Dexilant CAPSULE DELAYED RELEASE 60 MG ORAL Dexilant CAPSULE DELAYED RELEASE 60 MG ORAL Lansoprazole CAPSULE DELAYED RELEASE 15 MG ORAL Lansoprazole CAPSULE DELAYED RELEASE 15 MG ORAL Lansoprazole CAPSULE DELAYED RELEASE 30 MG ORAL Lansoprazole CAPSULE DELAYED RELEASE 30 MG ORAL Omeprazole CAPSULE DELAYED RELEASE 20 MG ORAL Omeprazole CAPSULE DELAYED RELEASE 20 MG ORAL Omeprazole CAPSULE DELAYED RELEASE 40 MG ORAL Omeprazole CAPSULE DELAYED RELEASE 40 MG ORAL Pantoprazole Sodium TABLET DELAYED RELEASE 20 MG ORAL Pantoprazole Sodium TABLET DELAYED RELEASE 20 MG ORAL Pantoprazole Sodium TABLET DELAYED RELEASE 40 MG ORAL Pantoprazole Sodium TABLET DELAYED RELEASE 40 MG ORAL Prevacid SoluTab TABLET DISPERSIBLE 15 MG ORAL Prevacid SoluTab TABLET DISPERSIBLE 15 MG ORAL Prevacid SoluTab TABLET DISPERSIBLE 30 MG ORAL Prevacid SoluTab TABLET DISPERSIBLE 30 MG ORAL RABEprazole Sodium TABLET DELAYED RELEASE 20 MG ORAL RABEprazole Sodium TABLET DELAYED RELEASE 20 MG ORAL Testim 50 MG/5GM (1%) TRANSDERMAL Testim 50 MG/5GM (1%) TRANSDERMAL Testosterone 12.5 MG/ACT (1%) TRANSDERMAL Testosterone 12.5 MG/ACT (1%) TRANSDERMAL Testosterone 25 MG/2.5GM (1%) TRANSDERMAL Testosterone 25 MG/2.5GM (1%) TRANSDERMAL Testosterone 50 MG/5GM (1%) TRANSDERMAL Testosterone 50 MG/5GM (1%) TRANSDERMAL Testosterone Cypionate SOLUTION 100 MG/ML INTRAMUSCULAR* Testosterone Cypionate SOLUTION 100 MG/ML INTRAMUSCULAR* Testosterone Cypionate SOLUTION 200 MG/ML INTRAMUSCULAR* Testosterone Cypionate SOLUTION 200 MG/ML INTRAMUSCULAR* Testosterone Enanthate SOLUTION 200 MG/ML INTRAMUSCULAR* Testosterone Enanthate SOLUTION 200 MG/ML INTRAMUSCULAR* Vogelxo 50 MG/5GM (1%) TRANSDERMAL Vogelxo 50 MG/5GM (1%) TRANSDERMAL Vogelxo Pump 12.5 MG/ACT (1%) TRANSDERMAL Vogelxo Pump 12.5 MG/ACT (1%) TRANSDERMAL ST Group Topical testosterone Topical testosterone Topical testosterone Topical testosterone Topical testosterone Topical testosterone Topical testosterone Topical testosterone Dexilant Dexilant Dexilant Dexilant Dexilant Dexilant Dexilant Dexilant Dexilant Dexilant Dexilant Dexilant Dexilant Dexilant Dexilant Dexilant Dexilant Dexilant Dexilant Dexilant Dexilant Dexilant Topical testosterone Topical testosterone Topical testosterone Topical testosterone Topical testosterone Topical testosterone Topical testosterone Topical testosterone Topical testosterone Topical testosterone Topical testosterone Topical testosterone Topical testosterone Topical testosterone Topical testosterone Topical testosterone Topical testosterone Topical testosterone 23
FORMULARY lowercase italics = Generic drugs UPPERCASE BOLD = Brand name drugs Drug Status Notes *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg dextroamphetamine sulfate oral tablet 10 mg, 5 mg VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG *Stimulants - Misc.*** CONCERTA ORAL TABLET EXTENDEDRELEASE* 18 MG, 27 MG, 36 MG, 54 MG Status NC = Not Covered NF = Non-Formulary = Tier 1 = Tier 2 = Tier 3 = Tier 4 T5 = Tier 5 Notes PA = Prior Authorization Required PANS = PA for New Starts QL = Quantity Limit ST = Step Therapy Required STNS = Step Therapy Required For New Starts 24
DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, 30 MG/9HR dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG METADATE CD ORAL CAPSULE EXTENDED RELEASE* 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG METADATE ER ORAL TABLET EXTENDEDRELEASE* 20 MG methylphenidate hcl er (cd) oral capsule extended release* 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg methylphenidate hcl er oral tablet extended release 24 hr* 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extendedrelease* 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg QL (30 EA per 30 days) modafinil oral tablet 100 mg, 200 mg QL (30 EA per 30 days) PROVIGIL ORAL TABLET 100 MG, 200 MG RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 30 MG, 40 MG *Aminoglycosides* *Aminoglycosides*** neomycin sulfate oral tablet 500 mg *Analgesics - Anti-Inflammatory* QL (30 EA per 30 days) 25
*Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS* 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS* 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS* 40 MG/0.8ML HUMIRA SUBCUTANEOUS* 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS* 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS* 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS* 40 MG/0.8ML HUMIRA SUBCUTANEOUS* 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, 50 MG celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release 24 hr* 100 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg etodolac er oral tablet extended release 24 hr* 400 mg, 500 mg, 600 mg T5 T5 T5 T5 T5 T5 T5 T5 T5 T5 PA PA PA PA PA PA PA PA PA PA 26