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FEP 5 Tier Managed Rx Drug Formulary (807) Basic Option Effective August 1, 2018

The FEP formulary includes the preferred drug list which is comprised of Tier 1, generics and Tier 2, preferred brand-name drugs. Also included in the formulary are Tier 3, non-preferred brand-name drugs, Tier 4, preferred specialty drugs and Tier 5, non-preferred specialty drugs.

Ask your physician if there is a generic drug available to treat your condition. If there is no generic drug available, ask your physician to prescribe a preferred brand-name drug.

The preferred brand-name drugs within our formulary are listed to identify medicines that are clinically appropriate and cost-effective.

Click on the category name in the Table of Contents below to go directly to that page

INTRODUCTION....................................................................................................................................................................................................... 5 PREFACE ................................................................................................................................................................................................................. 5 MANAGED NOT COVERED DRUGS ...................................................................................................................................................................... 6 PRIOR APPROVAL .................................................................................................................................................................................................. 6 QUANTITY LIMITATIONS ........................................................................................................................................................................................ 6 PHARMACY AND MEDICAL POLICY COMMITTEE .............................................................................................................................................. 6 PRODUCT SELECTION CRITERIA......................................................................................................................................................................... 6 FORMULARY PRODUCT DESCRIPTIONS ............................................................................................................................................................ 7 GENERIC SUBSTITUTION ...................................................................................................................................................................................... 7 DRUG EFFICACY STUDY IMPLEMENTATION DRUGS ........................................................................................................................................ 8 EDITOR ..................................................................................................................................................................................................................... 8 NOTICE ..................................................................................................................................................................................................................... 8 LEGEND ................................................................................................................................................................................................................... 9 ANALGESICS......................................................................................................................................................................................................... 10

ANALGESICS, OTHER ................................................................................................................................................................................ 10 NSAIDs ......................................................................................................................................................................................................... 10 NSAIDs, COMBINATIONS ........................................................................................................................................................................... 10 NSAIDs, TOPICAL ....................................................................................................................................................................................... 10 COX-2 INHIBITORS ..................................................................................................................................................................................... 10 GOUT ........................................................................................................................................................................................................... 10 OPIOID ANALGESICS ................................................................................................................................................................................. 11 NON-OPIOID ANALGESICS ........................................................................................................................................................................ 11 VISCOSUPPLEMENTS ............................................................................................................................................................................... 11

ANTI-INFECTIVES ................................................................................................................................................................................................. 12 ANTIBACTERIALS ....................................................................................................................................................................................... 12 ANTIFUNGALS ............................................................................................................................................................................................ 13 ANTIMALARIALS ......................................................................................................................................................................................... 14 ANTIRETROVIRAL AGENTS ...................................................................................................................................................................... 14 ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 15 ANTIVIRALS................................................................................................................................................................................................. 15 MISCELLANEOUS ....................................................................................................................................................................................... 16

ANTINEOPLASTIC AGENTS ................................................................................................................................................................................ 17 ALKYLATING AGENTS ............................................................................................................................................................................... 17 ANTIMETABOLITES .................................................................................................................................................................................... 17 HORMONAL ANTINEOPLASTIC AGENTS ................................................................................................................................................. 17 IMMUNOMODULATORS ............................................................................................................................................................................. 18 KINASE INHIBITORS ................................................................................................................................................................................... 18 TOPOISOMERASE INHIBITORS ................................................................................................................................................................ 19 MISCELLANEOUS ....................................................................................................................................................................................... 19

CARDIOVASCULAR .............................................................................................................................................................................................. 21 ACE INHIBITORS......................................................................................................................................................................................... 21 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 21 ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 21 ADRENOLYTICS, CENTRAL ....................................................................................................................................................................... 21

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ALDOSTERONE RECEPTOR ANTAGONISTS .......................................................................................................................................... 21 ALPHA BLOCKERS ..................................................................................................................................................................................... 22 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ........................................................................................... 22 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ......................................................... 22 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ....................................... 22 ANTIARRHYTHMICS ................................................................................................................................................................................... 22 ANTILIPEMICS............................................................................................................................................................................................. 23 BETA-BLOCKERS ....................................................................................................................................................................................... 23 BETA-BLOCKER/ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS .................................................................................. 24 BETA-BLOCKER/DIURETIC COMBINATIONS ........................................................................................................................................... 24 CALCIUM CHANNEL BLOCKERS .............................................................................................................................................................. 24 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ............................................................................................................ 24 DIGITALIS GLYCOSIDES ............................................................................................................................................................................ 24 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ....................................................................................................................... 24 DIURETICS .................................................................................................................................................................................................. 24 HEART FAILURE ......................................................................................................................................................................................... 25 NITRATES .................................................................................................................................................................................................... 25 PULMONARY ARTERIAL HYPERTENSION .............................................................................................................................................. 25 MISCELLANEOUS ....................................................................................................................................................................................... 26

CENTRAL NERVOUS SYSTEM ............................................................................................................................................................................ 26 ANTIANXIETY .............................................................................................................................................................................................. 26 ANTICONVULSANTS .................................................................................................................................................................................. 26 ANTIDEMENTIA ........................................................................................................................................................................................... 27 ANTIDEPRESSANTS .................................................................................................................................................................................. 27 ANTIPARKINSONIAN AGENTS .................................................................................................................................................................. 28 ANTIPSYCHOTICS ...................................................................................................................................................................................... 29 ATTENTION DEFICIT HYPERACTIVITY DISORDER ................................................................................................................................ 30 FIBROMYALGIA........................................................................................................................................................................................... 30 HUNTINGTON'S DISEASE AGENTS .......................................................................................................................................................... 30 HYPNOTICS................................................................................................................................................................................................. 30 MIGRAINE .................................................................................................................................................................................................... 31 MOOD STABILIZERS .................................................................................................................................................................................. 31 MULTIPLE SCLEROSIS .............................................................................................................................................................................. 31 MUSCULOSKELETAL THERAPY AGENTS ............................................................................................................................................... 32 MYASTHENIA GRAVIS ............................................................................................................................................................................... 32 NARCOLEPSY/CATAPLEXY ....................................................................................................................................................................... 32 PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................. 32 MISCELLANEOUS ....................................................................................................................................................................................... 33

ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 33 ANDROGENS .............................................................................................................................................................................................. 33 ANTIDIABETICS .......................................................................................................................................................................................... 33 CALCIUM RECEPTOR ANTAGONISTS ..................................................................................................................................................... 35 CALCIUM REGULATORS ........................................................................................................................................................................... 35 CARNITINE DEFICIENCY AGENTS ........................................................................................................................................................... 36 CONTRACEPTIVES .................................................................................................................................................................................... 36 ENDOMETRIOSIS ....................................................................................................................................................................................... 37 ESTROGENS ............................................................................................................................................................................................... 37 ESTROGEN/PROGESTINS ......................................................................................................................................................................... 38 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS ............................................................................. 38 FERTILITY REGULATORS .......................................................................................................................................................................... 38 GAUCHER DISEASE ................................................................................................................................................................................... 38 GLUCOCORTICOIDS .................................................................................................................................................................................. 39 GLUCOSE ELEVATING AGENTS ............................................................................................................................................................... 39 HEREDITARY TYROSINEMIA TYPE 1 AGENTS ....................................................................................................................................... 39 HUMAN GROWTH HORMONES ................................................................................................................................................................. 39 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................. 39 INSULIN-LIKE GROWTH FACTOR-1 AGENTS .......................................................................................................................................... 39 PHENYLKETONURIA TREATMENT AGENTS ........................................................................................................................................... 39 PHOSPHATE BINDER AGENTS ................................................................................................................................................................. 39 PROGESTINS .............................................................................................................................................................................................. 40 SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................. 40 THYROID AGENTS ..................................................................................................................................................................................... 40 UREA CYCLE DISORDERS ........................................................................................................................................................................ 40 VASOPRESSINS ......................................................................................................................................................................................... 40 MISCELLANEOUS ....................................................................................................................................................................................... 40

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GASTROINTESTINAL ........................................................................................................................................................................................... 41 ANTIDIARRHEALS ...................................................................................................................................................................................... 41 ANTIEMETICS ............................................................................................................................................................................................. 41 ANTISPASMODICS ..................................................................................................................................................................................... 42 CHOLELITHOLYTICS .................................................................................................................................................................................. 42 H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................. 42 INFLAMMATORY BOWEL DISEASE .......................................................................................................................................................... 42 IRRITABLE BOWEL SYNDROME ............................................................................................................................................................... 42 LAXATIVES .................................................................................................................................................................................................. 42 OPIOID-INDUCED CONSTIPATION ........................................................................................................................................................... 43 PANCREATIC ENZYMES ............................................................................................................................................................................ 43 PROSTAGLANDINS .................................................................................................................................................................................... 43 PROTON PUMP INHIBITORS ..................................................................................................................................................................... 43 SALIVA STIMULANTS ................................................................................................................................................................................. 43 STEROIDS, RECTAL ................................................................................................................................................................................... 43 ULCER THERAPY COMBINATIONS .......................................................................................................................................................... 43 MISCELLANEOUS ....................................................................................................................................................................................... 43

GENITOURINARY .................................................................................................................................................................................................. 44 BENIGN PROSTATIC HYPERPLASIA ........................................................................................................................................................ 44 URINARY ANTISPASMODICS .................................................................................................................................................................... 44 VAGINAL ANTI-INFECTIVES ...................................................................................................................................................................... 44 MISCELLANEOUS ....................................................................................................................................................................................... 44

HEMATOLOGIC ..................................................................................................................................................................................................... 44 ANTICOAGULANTS .................................................................................................................................................................................... 44 HEMATOPOIETIC GROWTH FACTORS .................................................................................................................................................... 45 HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS ........................................................................ 45 HEREDITARY ANGIOEDEMA AGENTS ..................................................................................................................................................... 46 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS ...................................................................................................................... 46 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS ........................................................................................................ 46 PLATELET AGGREGATION INHIBITORS .................................................................................................................................................. 46 PLATELET SYNTHESIS INHIBITORS ........................................................................................................................................................ 46 STEM CELL MOBILIZERS ........................................................................................................................................................................... 46 MISCELLANEOUS ....................................................................................................................................................................................... 46

IMMUNOLOGIC AGENTS ...................................................................................................................................................................................... 47 ALLERGENIC EXTRACTS .......................................................................................................................................................................... 47 AUTOIMMUNE AGENTS ............................................................................................................................................................................. 47 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................. 47 IMMUNE GLOBULINS ................................................................................................................................................................................. 47 IMMUNOMODULATORS ............................................................................................................................................................................. 48 IMMUNOSUPPRESSANTS ......................................................................................................................................................................... 48

NUTRITIONAL/SUPPLEMENTS ............................................................................................................................................................................ 48 ELECTROLYTES ......................................................................................................................................................................................... 48 VITAMINS AND MINERALS ........................................................................................................................................................................ 49

RESPIRATORY ...................................................................................................................................................................................................... 49 ANAPHYLAXIS TREATMENT AGENTS ..................................................................................................................................................... 49 ANTICHOLINERGICS .................................................................................................................................................................................. 49 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ............................................................................................................................ 49 ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS ........................................................................................ 50 ANTIHISTAMINES, SEDATING ................................................................................................................................................................... 50 ANTITUSSIVES............................................................................................................................................................................................ 50 ANTITUSSIVE COMBINATIONS ................................................................................................................................................................. 50 BETA AGONISTS ........................................................................................................................................................................................ 50 CYSTIC FIBROSIS ...................................................................................................................................................................................... 51 LEUKOTRIENE MODULATORS .................................................................................................................................................................. 51 MAST CELL STABILIZERS ......................................................................................................................................................................... 51 NASAL ANTIHISTAMINES .......................................................................................................................................................................... 51 NASAL STEROIDS ...................................................................................................................................................................................... 51 PHOSPHODIESTERASE-4 INHIBITORS .................................................................................................................................................... 51 PULMONARY FIBROSIS AGENTS ............................................................................................................................................................. 51 STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................. 51 STEROID INHALANTS ................................................................................................................................................................................ 51 XANTHINES ................................................................................................................................................................................................. 52 MISCELLANEOUS ....................................................................................................................................................................................... 52

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TOPICAL ................................................................................................................................................................................................................ 52 DERMATOLOGY.......................................................................................................................................................................................... 52 MOUTH/THROAT/DENTAL AGENTS ......................................................................................................................................................... 56 OPHTHALMIC .............................................................................................................................................................................................. 56 OTIC ............................................................................................................................................................................................................. 58

WEBSITES ............................................................................................................................................................................................................. 60 MANAGED NOT COVERED DRUG LIST BASIC OPTION CHART ..................................................................................................................... 62 INDEX ..................................................................................................................................................................................................................... 65

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The Retail and Mail Service Prescription Drug Program cannot refill a controlled substance until 80% of the prescription has been used. Call us at 1-800-624-5060 or visit our website www.fepblue.org if you have any questions about dispensing limits.

INTRODUCTION

FEP is pleased to provide the 2018 FEP 5 Tier Managed Rx Drug Formulary as a useful reference for drug product selection. The drugs on the FEP 5 Tier Managed Rx Drug Formulary have been reviewed by the FEP Pharmacy and Medical Policy Committee and FEP physicians and pharmacists and found appropriate for preferred status.

All the information in the FEP 5 Tier Managed Rx Drug Formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber.

National guidelines can be found on the National Guideline Clearinghouse site at http://www.guideline.gov, on the websites listed under each therapeutic class and on the sites listed in the WEBSITES section of this publication.

PREFACE

The formulary is organized by sections, which refer to either a drug class or disease state. Unless exceptions are noted, generally all dosage forms and strengths of the drug cited are included in the formulary.

The FEP 5 Tier Managed Rx Drug Formulary is an open formulary, but FEP may impose restrictions or not reimburse for specific drug products or types of products. For example, drugs and supplies for weight loss are excluded from the pharmacy benefit. In addition, over-the-counter (OTC) products, with the exception of insulin and diabetes monitoring products, are generally not included in the pharmacy benefit. Some OTC products are listed in the formulary for informational purposes only.

The formulary is separated by Tiers in the following manner:

Tier 1 Tier 2 Tier 3 Tier 4 Tier 5

generic drugs

preferred brand products

non-preferred brand products and all compounded medications

preferred specialty products

non-preferred specialty products

Basic Option Retail Pharmacy

Up to $10

Up to $50 60% coinsurance* Up to $65 Limit***: one 30-day supply fill at retail

Up to $90 Limit***: one 30-day supply fill at retail

Basic Option Specialty Pharmacy

$55 for up to a 30-day supply $165 for up to a 90-day supply

$80 for up to a 30-day supply $240 for up to a 90-day supply

Basic Option Retail Pharmacy (Med B)

Up to $10

Up to $45 50% coinsurance** Up to $60 Limit***: one 30-day supply fill at retail

Up to $80 Limit***: one 30-day supply fill at retail

Basic Option Mail Pharmacy (Med B)

Up to $20

Up to $90 Up to $125

Basic Option Specialty Pharmacy (Med B)

$50 for up to a 30-day supply $140 for up to a 90-day supply

$70 for up to a 30-day supply $195 for up to a 90-day supply

* With a minimum payment of $75 up to a 30-day supply ($210 up to a 90-day supply) ** With a minimum payment of $60 up to a 30-day supply ($175 up to a 90-day supply)

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*** First fill of specialty medications is limited to a 30-day supply at retail. All subsequent fills must be through the Specialty Drug Pharmacy Program. A 90-day supply fill of a specialty medication may only be obtained through the Specialty Drug Pharmacy Program once a member has received three 30-day supply fills of that medication. Drug products shown in boldface type in Tier 2, Tier 3, Tier 4 and Tier 5 have generic versions.

All drugs that are preferred are noted in their respective tiers of the drug lists throughout this formulary. Drugs may be reviewed by the FEP Pharmacy and Medical Policy Committee and designated non-preferred. FEP may designate certain drugs as non-preferred, typically if the cost-effectiveness is less than other similar drugs.

MANAGED NOT COVERED DRUGS

Effective January 1, 2018, selected medications will no longer be covered on the Basic Option drug benefit plan. These medications known as Managed Not Covered drugs have available covered options in the same therapeutic class. For a full listing of these Managed Not Covered medications please see the MANAGED NOT COVERED DRUG LIST BASIC OPTION CHART located on page 62 before the INDEX in this document.

Patients taking a Managed Not Covered medication on or after January 1, 2018 should expect to pay the full cost of the prescription.

PRIOR APPROVAL

Prior approval (PA) is required for certain drugs before FEP will cover them. The prescribing physician may request PA by calling toll-free 1-877-727-3784. The list of prior approval medications is subject to change. For a current list of medications that require prior approval please see our Prior Approval web page.

QUANTITY LIMITATIONS

Quantity limitations (QL) have been established for some of the medications covered by FEP. Requests for quantities greater than allowed can be submitted to the Prior Approval program by the prescribing physician by calling toll-free 1-877-727-3784. The list of medications that have quantity limitations is subject to change. For a current list of medications with quantity limitations please see our Prior Approval web page.

PHARMACY AND MEDICAL POLICY COMMITTEE

The role of the FEP Pharmacy and Medical Policy Committee includes the evaluation of new medications, and making recommendations to FEP for their designation as preferred or non-preferred on the FEP 5 Tier Managed Rx Drug Formulary. The FEP Pharmacy and Medical Policy Committee is made up of physicians and pharmacists who are not employees or agents of, nor have financial interest in FEP.

PRODUCT SELECTION CRITERIA

The FEP Pharmacy and Medical Policy Committee will consider U.S. Food and Drug Administration (FDA) approved drugs for preferred status designation. The evaluation includes a literature review; expert opinion may also be sought. Formal reviews are prepared that typically address the following information:

Safety

Efficacy

Comparison studies

Drug interactions

Approved indications

Formulation and administration

Adverse effects

Contraindications

Pharmacokinetics

Patient compliance considerations

Medical outcome and pharmacoeconomic studies

https://www.caremark.com/wps/portal/WEBSUPPORT_FAQS?cms=CMS-PWCM-2034779https://www.caremark.com/wps/portal/WEBSUPPORT_FAQS?cms=CMS-PWCM-2034779

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When a new drug is considered for preferred status, an attempt will be made to examine the drug relative to similar drugs currently preferred. In addition, entire therapeutic classes are periodically reviewed. The class review process may result in a designation of non-preferred status to drug(s) in a particular therapeutic class, in an effort to continually promote the most clinically useful and cost-effective agents.

Drugs evaluated by the Pharmacy and Medical Policy Committee and not classified as preferred receive a non-preferred designation in the FEP 5 Tier Managed Rx Drug Formulary. This designation indicates the Pharmacy and Medical Policy Committee's belief that the drug offers no important clinical or cost advantage over comparable preferred drugs, or that there is currently insufficient information to determine its appropriate clinical role, or that questions remain regarding safety and effectiveness. In an open formulary environment, non-preferred drugs are covered under FEP's pharmacy benefit. However, there may be additional costs incurred by the patient to receive a non-preferred medication. Physicians are encouraged to prescribe preferred drugs.

All the information in the FEP 5 Tier Managed Rx Drug Formulary is provided as a reference for drug therapy selection. The final choice of a specific drug selection for an individual patient rests solely with the prescriber.

FORMULARY PRODUCT DESCRIPTIONS

To assist in understanding which specific strengths and dosage forms are preferred, examples are noted below. The general principles shown in the examples can usually be extended to other entries in the book. Any exceptions are noted.

Preferred products include all strengths and dosage forms of the cited brand-name product.

sevelamer carbonate Renvela Oral powder packets, tabs and all strengths of Renvela would be included in this listing. When a strength or dosage form is specified, only the specified strength and dosage form is preferred. Other strengths/dosage forms of the reference product are not.

acyclovir caps, susp, tabs Zovirax The capsules, suspension and tablets of Zovirax are preferred. From this entry, the cream and ointment cannot be assumed to be on the list unless there is a specific entry.

Extended-release and delayed-release products require their own entry.

sitagliptin/metformin Janumet The immediate-release product listing of Janumet alone would not include the extended-release product Janumet XR. sitagliptin/metformin ext-rel Janumet XR A separate entry for Janumet XR confirms that the extended-release product is on the formulary.

Dosage forms will be consistent with the category and use where listed.

neomycin/polymyxin B/hydrocortisone Cortisporin Since Cortisporin is listed only in the OTIC section, it is limited to the otic solution and suspension. From this entry, the topical cream cannot be assumed to be on the list unless there is an entry for this product in the DERMATOLOGY section of the formulary.

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 addition, boldface type may indicate that the brand name cited is a generic. Examples of the latter include Levoxyl and Trivora.

One way to reduce out-of-pocket cost is by requesting a generic drug. Generic drugs are usually priced lower than their brand-name equivalents. Prescription generic drugs are:

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Approved by the FDA 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 to the same extent as the brand-name drug. 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.

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.

DRUG EFFICACY STUDY IMPLEMENTATION DRUGS

Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Since 1962, all new drugs are required to be both safe and effective before they can be marketed. The legislation that resulted in this change also applies retroactively to all drugs approved as safe from 1938-1962. The Drug Efficacy Study Implementation (DESI) program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as "less than fully effective" while awaiting final administrative disposition. Also classified as DESI are many products listed as identical, similar, or related to actual DESI products.

EDITOR

Your comments and suggestions regarding this FEP 5 Tier Managed Rx Drug Formulary are encouraged. Your input is vital to this formulary's continued success. All responses will be reviewed and considered. Please send your comments to:

FEP Rx Drug Formulary - MC 145 P.O. Box 52115 Phoenix, AZ 85072-2115

NOTICE

The information contained in this FEP 5 Tier Managed Rx Drug Formulary and its appendices is provided by FEP, solely for the convenience of medical providers. FEP does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. The FEP 5 Tier Managed Rx Drug Formulary is not a complete list of all covered medications. This FEP 5 Tier Managed Rx Drug Formulary 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. FEP assumes 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.

The information contained in this document is proprietary. The information may not be copied in whole or in part without the written permission of FEP. 2018. All rights reserved.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with FEP.

If viewing this formulary via Internet, please be advised that the formulary is updated periodically and changes may appear prior to their effective date.

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LEGEND

Generic contraceptives are covered at no charge to the member

Medication is covered at no charge to the member

d DESI drug

OTC Over the counter

PA Prior Approval

QL Quantity Limitations - quantity allowed before prior approval is required. Quantity limits apply for both brands and generics.

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

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ANALGESICS

Practice guidelines of pain management are available at: http://www.asahq.org ANALGESICS, OTHER Treatment recommendations for osteoarthritis are available at: http://www.rheumatology.org

acetaminophen inj OFIRMEV Tier 3

NSAIDs

diclofenac sodium delayed-rel Tier 1

diclofenac sodium ext-rel Tier 1

diflunisal Tier 1

etodolac Tier 1

etodolac ext-rel Tier 1

fenoprofen Tier 1 NALFON Tier 3

flurbiprofen Tier 1

ibuprofen Tier 1

indomethacin Tier 1

indomethacin ext-rel Tier 1

ketoprofen Tier 1

ketoprofen ext-rel Tier 1

ketorolac Tier 1

meloxicam Tier 1 MOBIC Tier 3

nabumetone Tier 1

naproxen Tier 1

naproxen sodium Tier 1

naproxen sodium ext-rel Tier 1

oxaprozin Tier 1 DAYPRO Tier 3

piroxicam Tier 1

sulindac Tier 1

ibuprofen inj CALDOLOR Tier 2

indomethacin susp INDOCIN susp Tier 3

PA ketorolac tromethamine nasal spray SPRIX Tier 3

NSAIDs, COMBINATIONS

diclofenac sodium delayed-rel/ misoprostol

Tier 1

NSAIDs, TOPICAL

QL diclofenac sodium gel 1% Tier 1 VOLTAREN GEL Tier 3

diclofenac sodium soln Tier 1

COX-2 INHIBITORS

PA celecoxib Tier 1 CELEBREX Tier 3

GOUT

allopurinol Tier 1 ZYLOPRIM Tier 3

colchicine Tier 1 COLCRYS Tier 3

probenecid Tier 1

febuxostat ULORIC Tier 2

colchicine MITIGARE Tier 3

PA lesinurad ZURAMPIC Tier 3

PA lesinurad/allopurinol DUZALLO Tier 3

PA pegloticase KRYSTEXXA Tier 5

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OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: http://www.asahq.org http://www.nccn.org Opioid guidelines in the management of chronic non-malignant pain are available at: http://www.asipp.org/Guidelines.htm

QL butalbital/acetaminophen/caffeine/ codeine

Tier 1 FIORICET w/CODEINE Tier 3

QL butalbital/aspirin/caffeine/codeine Tier 1 FIORINAL w/CODEINE Tier 3

QL butorphanol nasal spray Tier 1

QL codeine/acetaminophen Tier 1 TYLENOL w/CODEINE Tier 3

QL fentanyl transdermal Tier 1 DURAGESIC Tier 3

PA fentanyl transmucosal lozenge Tier 1 ACTIQ Tier 3

QL hydrocodone/acetaminophen - Vicodin Tier 1

QL hydrocodone/ acetaminophen - Vicodin ES

Tier 1

QL hydromorphone Tier 1 DILAUDID Tier 3

QL hydromorphone ext-rel Tier 1 EXALGO Tier 3

QL methadone Tier 1

QL morphine Tier 1

QL morphine ext-rel Tier 1 KADIAN Tier 3

QL morphine ext-rel Tier 1 MS CONTIN Tier 3

QL morphine supp Tier 1

QL oxycodone Tier 1 ROXICODONE Tier 3

QL oxycodone concentrate 20 mg/mL Tier 1

QL oxycodone soln Tier 1

QL oxycodone/acetaminophen 5/325 Tier 1 PERCOCET Tier 3

QL oxymorphone Tier 1 OPANA Tier 3

QL tramadol Tier 1 ULTRAM Tier 3

QL tramadol ext-rel Tier 1 ULTRAM ER Tier 3

PA fentanyl citrate buccal FENTORA Tier 2

QL tapentadol NUCYNTA Tier 2

QL tapentadol ext-rel NUCYNTA ER Tier 2

QL buprenorphine transdermal BUTRANS Tier 3

PA fentanyl citrate nasal spray LAZANDA Tier 3

PA fentanyl sublingual spray SUBSYS Tier 3

PA fentanyl sublingual tablets ABSTRAL Tier 3

PA hydrocodone ext-rel caps ZOHYDRO ER Tier 3

PA hydrocodone ext-rel tabs HYSINGLA ER Tier 3

QL morphine ext-rel MORPHABOND Tier 3

QL morphine/naltrexone ext-rel EMBEDA Tier 3

QL oxycodone ext-rel OXYCONTIN Tier 3

QL oxycodone ext-rel XTAMPZA ER Tier 3

QL oxycodone/acetaminophen PRIMLEV Tier 3

NON-OPIOID ANALGESICS

QL butalbital/acetaminophen Tier 1

QL butalbital/acetaminophen/caffeine Tier 1 FIORICET Tier 3

QL butalbital/aspirin/caffeine Tier 1 FIORINAL Tier 3

ziconotide PRIALT Tier 4

VISCOSUPPLEMENTS

PA sodium hyaluronate GEL-ONE Tier 4

PA sodium hyaluronate GELSYN-3 Tier 4

PA sodium hyaluronate HYALGAN Tier 4

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PA sodium hyaluronate SUPARTZ FX Tier 4

PA high molecular weight hyaluronan ORTHOVISC Tier 5

PA hylan G-F 20 SYNVISC Tier 5

PA hylan G-F 20 SYNVISC-ONE Tier 5

PA sodium hyaluronate EUFLEXXA Tier 5

PA sodium hyaluronate MONOVISC Tier 5

ANTI-INFECTIVES

Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: http://www.idsociety.org Hepatitis: CDC recommendations on the treatment of hepatitis are available at: http://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: http://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: http://www.aidsinfo.nih.gov Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: http://www.myamericanheart.org Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: http://www.cdc.gov/ncidod/diseases/flu/fluvirus.htm International Travel: CDC recommendations for international travel are available at: http://www.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: http://www.cdc.gov/flu/ Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: http://www.cdc.gov/std/treatment/default.htm ANTIBACTERIALS Cephalosporins First Generation

cephalexin Tier 1 KEFLEX Tier 3

Second Generation

cefaclor Tier 1

cefoxitin Tier 1

cefprozil Tier 1

cefuroxime axetil Tier 1 CEFTIN Tier 3

Third Generation

cefdinir Tier 1

cefditoren Tier 1 SPECTRACEF Tier 3

cefotaxime Tier 1

cefpodoxime Tier 1

ceftazidime Tier 1

ceftriaxone Tier 1 ROCEPHIN Tier 3

cefixime SUPRAX Tier 2

13

Fourth Generation

cefepime Tier 1

Fifth Generation

ceftaroline fosamil TEFLARO Tier 2

Erythromycins/Macrolides

azithromycin Tier 1 ZITHROMAX Tier 3

clarithromycin Tier 1

clarithromycin ext-rel Tier 1

erythromycin delayed-rel Tier 1

erythromycin delayed-rel - Ery-tab Tier 1

erythromycin ethylsuccinate Tier 1 E.E.S. Tier 3

erythromycin ethylsuccinate Tier 1 ERYPED Tier 3

erythromycin stearate Tier 1

azithromycin ext-rel ZMAX Tier 2

fidaxomicin DIFICID Tier 2

erythromycin dispertabs PCE Tier 3

Fluoroquinolones

ciprofloxacin Tier 1 CIPRO Tier 3

ciprofloxacin ext-rel Tier 1

levofloxacin Tier 1 LEVAQUIN Tier 3

moxifloxacin Tier 1 AVELOX Tier 3

ofloxacin Tier 1

Penicillins

amoxicillin, except film-coated tabs Tier 1

amoxicillin/clavulanate Tier 1 AUGMENTIN Tier 3

amoxicillin/clavulanate ext-rel Tier 1 AUGMENTIN XR Tier 3

amoxicillin/clavulanate susp 600 mg Tier 1

ampicillin Tier 1

ampicillin sodium/sulbactam sodium Tier 1 UNASYN Tier 3

dicloxacillin Tier 1

penicillin VK Tier 1

piperacillin/tazobactam Tier 1 ZOSYN Tier 3

amoxicillin ext-rel MOXATAG Tier 3

Tetracyclines

doxycycline hyclate Tier 1 VIBRAMYCIN Tier 3

doxycycline monohydrate Tier 1

minocycline Tier 1 MINOCIN Tier 3

minocycline ext-rel Tier 1 SOLODYN Tier 3

tetracycline Tier 1

ANTIFUNGALS

clotrimazole troches Tier 1

fluconazole Tier 1 DIFLUCAN Tier 3

griseofulvin microsize Tier 1

griseofulvin ultramicrosize Tier 1 GRIS-PEG Tier 3

PA itraconazole caps Tier 1 SPORANOX caps Tier 3

PA ketoconazole tabs Tier 1

nystatin Tier 1

PA terbinafine tabs Tier 1 LAMISIL Tier 3

QL voriconazole Tier 1 VFEND Tier 3

amphotericin B lipid complex inj ABELCET Tier 2

amphotericin B liposome inj AMBISOME Tier 2

14

anidulafungin ERAXIS Tier 2

posaconazole NOXAFIL Tier 2

PA isavuconazonium CRESEMBA Tier 3

PA itraconazole oral soln SPORANOX oral soln Tier 3

micafungin MYCAMINE Tier 3

ANTIMALARIALS

atovaquone/proguanil Tier 1 MALARONE Tier 3

chloroquine Tier 1

mefloquine Tier 1

primaquine Tier 2

artemether/lumefantrine COARTEM Tier 2

PA pyrimethamine DARAPRIM Tier 2

ANTIRETROVIRAL AGENTS Antiretroviral Adjuvants

cobicistat TYBOST Tier 2

Antiretroviral Combinations

abacavir/lamivudine Tier 1 EPZICOM Tier 3

abacavir/lamivudine/zidovudine Tier 1 TRIZIVIR Tier 3

lamivudine/zidovudine Tier 1 COMBIVIR Tier 3

abacavir/dolutegravir/lamivudine TRIUMEQ Tier 2

atazanavir/cobicistat EVOTAZ Tier 2

darunavir/cobicistat PREZCOBIX Tier 2

efavirenz/emtricitabine/ tenofovir disoproxil fumarate

ATRIPLA Tier 2

elvitegravir/cobicistat/emtricitabine/ tenofovir alafenamide

GENVOYA Tier 2

elvitegravir/cobicistat/emtricitabine/ tenofovir disoproxil fumarate

STRIBILD Tier 2

emtricitabine/rilpivirine/ tenofovir alafenamide

ODEFSEY Tier 2

emtricitabine/rilpivirine/ tenofovir disoproxil fumarate

COMPLERA Tier 2

emtricitabine/tenofovir disoproxil fumarate TRUVADA Tier 2

emtricitabine/tenofovir alafenamide DESCOVY Tier 3

Chemokine Receptor Antagonists

maraviroc SELZENTRY Tier 2

Fusion Inhibitors

enfuvirtide FUZEON Tier 4

Integrase Inhibitors

dolutegravir TIVICAY Tier 2

raltegravir ISENTRESS Tier 2

Monoclonal Antibody

PA ibalizumab-uiyk TROGARZO Tier 5

Non-nucleoside Reverse Transcriptase Inhibitors

efavirenz Tier 1 SUSTIVA Tier 3

nevirapine ext-rel Tier 1 VIRAMUNE XR Tier 3

nevirapine tabs Tier 1 VIRAMUNE Tier 3

delavirdine RESCRIPTOR Tier 2

etravirine INTELENCE Tier 2

15

rilpivirine EDURANT Tier 2

nevirapine susp VIRAMUNE susp Tier 3

Nucleoside Reverse Transcriptase Inhibitors

abacavir Tier 1 ZIAGEN Tier 3

abacavir soln Tier 1 ZIAGEN soln Tier 3

didanosine delayed-rel Tier 1 VIDEX EC Tier 3

lamivudine Tier 1 EPIVIR Tier 3

stavudine Tier 1 ZERIT Tier 3

zidovudine Tier 1 RETROVIR Tier 3

didanosine soln VIDEX soln Tier 2

emtricitabine EMTRIVA Tier 2

stavudine soln ZERIT soln Tier 3

Nucleotide Reverse Transcriptase Inhibitors

tenofovir disoproxil fumarate VIREAD Tier 2

Protease Inhibitors

atazanavir caps Tier 1 REYATAZ Tier 3

fosamprenavir Tier 1 LEXIVA Tier 3

darunavir PREZISTA Tier 2

indinavir CRIXIVAN Tier 2

lopinavir/ritonavir KALETRA Tier 2

nelfinavir VIRACEPT Tier 2

ritonavir NORVIR Tier 2

saquinavir mesylate INVIRASE Tier 2

tipranavir APTIVUS Tier 2

ANTITUBERCULAR AGENTS

ethambutol Tier 1 MYAMBUTOL Tier 3

isoniazid Tier 1

pyrazinamide Tier 1

rifampin Tier 1 RIFADIN Tier 3

rifampin/isoniazid/pyrazinamide RIFATER Tier 2

rifapentine PRIFTIN Tier 2

bedaquiline SIRTURO Tier 3

ANTIVIRALS Cytomegalovirus Agents

cidofovir Tier 1 VISTIDE Tier 3

PA valganciclovir Tier 1 VALCYTE Tier 3

ganciclovir inj Tier 4 CYTOVENE inj Tier 5

cytomegalovirus immune globulin CYTOGAM Tier 4

PA letermovir PREVYMIS Tier 4

Hepatitis Agents Hepatitis B

lamivudine Tier 1 EPIVIR-HBV Tier 3

adefovir dipivoxil Tier 4 HEPSERA Tier 5

entecavir tabs Tier 4 BARACLUDE Tier 5

entecavir soln BARACLUDE soln Tier 4

telbivudine TYZEKA Tier 4

tenofovir alafenamide VEMLIDY Tier 4

Hepatitis C

PA ribavirin caps Tier 4 REBETOL Tier 4

PA ribavirin caps - Ribasphere Tier 4

16

PA ribavirin tabs Tier 4 COPEGUS Tier 5

PA glecaprevir/pibrentasvir MAVYRET Tier 4

PA ledipasvir/sofosbuvir HARVONI Tier 4

PA ribavirin oral soln REBETOL Tier 4

PA sofosbuvir SOVALDI Tier 4

PA sofosbuvir/velpatasvir EPCLUSA Tier 4

PA sofosbuvir/velpatasvir/voxilaprevir VOSEVI Tier 4

PA daclatasvir DAKLINZA Tier 5

PA dasabuvir/ombitasvir/paritaprevir/ ritonavir ext-rel

VIEKIRA XR Tier 5

PA elbasvir/grazoprevir ZEPATIER Tier 5

PA ombitasvir/paritaprevir/ritonavir TECHNIVIE Tier 5

PA ombitasvir/paritaprevir/ ritonavir with dasabuvir

VIEKIRA PAK Tier 5

PA simeprevir OLYSIO Tier 5

Herpes Agents

acyclovir caps, susp, tabs Tier 1 ZOVIRAX Tier 3

famciclovir Tier 1

valacyclovir Tier 1 VALTREX Tier 3

Influenza Agents

QL oseltamivir Tier 1 TAMIFLU Tier 3

rimantadine Tier 1 FLUMADINE Tier 3

QL zanamivir RELENZA Tier 2

Respiratory Syncytial Virus Agents

PA palivizumab SYNAGIS Tier 4

MISCELLANEOUS

atovaquone Tier 1 MEPRON Tier 3

aztreonam Tier 1 AZACTAM Tier 3

clindamycin Tier 1 CLEOCIN Tier 3

dapsone Tier 1

daptomycin 500 mg Tier 1 CUBICIN Tier 2

doripenem Tier 1

QL linezolid Tier 1 ZYVOX Tier 3

meropenem Tier 1 MERREM Tier 3

methenamine hippurate, prophylaxis Tier 1 HIPREX Tier 3

metronidazole tabs Tier 1 FLAGYL Tier 3

nitrofurantoin ext-rel Tier 1 MACROBID Tier 3

nitrofurantoin macrocrystals Tier 1 MACRODANTIN Tier 3

rifabutin Tier 1 MYCOBUTIN Tier 3

sulfamethoxazole/trimethoprim Tier 1

sulfamethoxazole/trimethoprim DS Tier 1

tigecycline Tier 1 TYGACIL Tier 3

tinidazole Tier 1 TINDAMAX Tier 3

trimethoprim Tier 1

vancomycin Tier 1 VANCOCIN Tier 3

ertapenem INVANZ Tier 2

imipenem/cilastatin PRIMAXIN Tier 2

miltefosine IMPAVIDO Tier 2

nitazoxanide ALINIA Tier 2

PA rifaximin XIFAXAN Tier 2

QL tedizolid SIVEXTRO Tier 2

secnidazole SOLOSEC Tier 3

telavancin VIBATIV Tier 3

17

ANTINEOPLASTIC AGENTS

Clinical practice guidelines in oncology are available at: http://www.asco.org http://www.nccn.org ALKYLATING AGENTS

busulfan Tier 1 BUSULFEX Tier 2

ifosfamide/mesna Tier 1

cyclophosphamide inj Tier 4

dacarbazine Tier 4

melphalan inj Tier 4 ALKERAN inj Tier 5

melphalan tabs Tier 4 ALKERAN tabs Tier 5

temozolomide Tier 4 TEMODAR Tier 5

thiotepa Tier 4

altretamine HEXALEN Tier 2

busulfan MYLERAN Tier 2

chlorambucil LEUKERAN Tier 2

carmustine BICNU Tier 4

cyclophosphamide caps CYCLOPHOSPHAMIDE CAPSULES Tier 4

mechlorethamine MUSTARGEN Tier 4

PA mechlorethamine gel VALCHLOR Tier 4

streptozocin ZANOSAR Tier 4

PA trabectedin YONDELIS Tier 4

PA bendamustine TREANDA Tier 5

ANTIMETABOLITES

mercaptopurine Tier 1

capecitabine Tier 4 XELODA Tier 5

cladribine Tier 4

clofarabine Tier 4 CLOLAR Tier 5

cytarabine Tier 4

floxuridine Tier 4

fludarabine Tier 4 FLUDARA Tier 4

fluorouracil inj Tier 4

gemcitabine Tier 4 GEMZAR Tier 5

thioguanine TABLOID Tier 2

fluorouracil inj ADRUCIL Tier 4

pemetrexed ALIMTA Tier 4

pentostatin NIPENT Tier 4

pralatrexate FOLOTYN Tier 4

rasburicase ELITEK Tier 4

mercaptopurine susp PURIXAN Tier 5

HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens

bicalutamide Tier 1 CASODEX Tier 3

flutamide Tier 1

PA nilutamide Tier 1 NILANDRON Tier 3

PA abiraterone ZYTIGA Tier 4

PA enzalutamide XTANDI Tier 4

PA abiraterone YONSA Tier 5

PA apalutamide ERLEADA Tier 5

Antiestrogens

tamoxifen Tier 1

toremifene FARESTON Tier 2

18

fulvestrant FASLODEX Tier 4

Aromatase Inhibitors

anastrozole Tier 1 ARIMIDEX Tier 3

exemestane Tier 1 AROMASIN Tier 3

letrozole Tier 1 FEMARA Tier 3

Gonadotropin-Releasing Hormone (GnRH) Antagonists

degarelix acetate FIRMAGON Tier 4

Luteinizing Hormone-Releasing Hormone (LHRH) Agonists

PA leuprolide acetate Tier 4

PA goserelin acetate ZOLADEX Tier 4

PA histrelin acetate VANTAS Tier 4

PA leuprolide acetate ELIGARD Tier 4

PA leuprolide acetate LUPRON DEPOT Tier 4

PA triptorelin pamoate TRELSTAR Tier 4

PA triptorelin pamoate TRELSTAR DEPOT Tier 4

PA triptorelin pamoate TRELSTAR LA Tier 4

Progestins

megestrol acetate Tier 1

IMMUNOMODULATORS

PA lenalidomide REVLIMID Tier 4

PA pembrolizumab KEYTRUDA Tier 4

thalidomide THALOMID Tier 4

PA pomalidomide POMALYST Tier 5

KINASE INHIBITORS

PA imatinib mesylate Tier 4 GLEEVEC Tier 5

PA abemaciclib VERZENIO Tier 4

PA acalabrutinib CALQUENCE Tier 4

PA afatinib GILOTRIF Tier 4

PA axitinib INLYTA Tier 4

PA bosutinib BOSULIF Tier 4

PA cabozantinib CABOMETYX Tier 4

PA cabozantinib COMETRIQ Tier 4

PA ceritinib ZYKADIA Tier 4

PA cobimetinib COTELLIC Tier 4

PA crizotinib XALKORI Tier 4

PA dabrafenib TAFINLAR Tier 4

PA dasatinib SPRYCEL Tier 4

PA erlotinib TARCEVA Tier 4

PA everolimus AFINITOR Tier 4

PA everolimus tabs for oral suspension AFINITOR DISPERZ Tier 4

PA ibrutinib IMBRUVICA Tier 4

PA idelalisib ZYDELIG Tier 4

PA lapatinib TYKERB Tier 4

PA lenvatinib LENVIMA Tier 4

PA midostaurin RYDAPT Tier 4

PA palbociclib IBRANCE Tier 4

PA pazopanib VOTRIENT Tier 4

PA ponatinib ICLUSIG Tier 4

PA regorafenib STIVARGA Tier 4

PA ribociclib KISQALI Tier 4

PA ribociclib + letrozole KISQALI FEMARA CO-PACK Tier 4

19

PA ruxolitinib JAKAFI Tier 4

PA sorafenib NEXAVAR Tier 4

PA sunitinib SUTENT Tier 4

temsirolimus TORISEL Tier 4

PA trametinib MEKINIST Tier 4

PA vandetanib CAPRELSA Tier 4

PA vemurafenib ZELBORAF Tier 4

PA alectinib ALECENSA Tier 5

PA binimetinib MEKTOVI Tier 5

PA brigatinib ALUNBRIG Tier 5

PA encorafenib BRAFTOVI Tier 5

PA gefitinib IRESSA Tier 5

PA neratinib NERLYNX Tier 5

PA nilotinib TASIGNA Tier 5

PA osimertinib TAGRISSO Tier 5

TOPOISOMERASE INHIBITORS

topotecan inj Tier 4 HYCAMTIN inj Tier 5

topotecan HYCAMTIN Tier 4

PA irinotecan liposome inj ONIVYDE Tier 5

MISCELLANEOUS

hydroxyurea Tier 1 HYDREA Tier 3

leucovorin calcium Tier 1

amifostine Tier 4 ETHYOL Tier 5

azacitidine Tier 4 VIDAZA Tier 5

PA bexarotene caps Tier 4 TARGRETIN caps Tier 5

bleomycin sulfate Tier 4

carboplatin Tier 4

cisplatin Tier 4

dactinomycin Tier 4 COSMEGEN Tier 5

daunorubicin Tier 4 CERUBIDINE Tier 5

decitabine Tier 4 DACOGEN Tier 5

dexrazoxane Tier 4 TOTECT Tier 5

dexrazoxane Tier 4 ZINECARD Tier 5

docetaxel Tier 4 TAXOTERE Tier 5

doxorubicin Tier 4

doxorubicin liposomal Tier 4 DOXIL Tier 5

epirubicin Tier 4

epirubicin Tier 4 ELLENCE Tier 5

etoposide Tier 4

idarubicin Tier 4 IDAMYCIN PFS Tier 5

ifosfamide Tier 4 IFEX Tier 5

irinotecan Tier 4 CAMPTOSAR Tier 5

levoleucovorin calcium Tier 4 FUSILEV Tier 4

mesna inj Tier 4 MESNEX inj Tier 5

mitomycin Tier 4

mitoxantrone Tier 4

oxaliplatin Tier 4

paclitaxel Tier 4

PA romidepsin Tier 4 ISTODAX Tier 5

teniposide Tier 4

vinblastine Tier 4

vincristine Tier 4

vinorelbine Tier 4 NAVELBINE Tier 5

mitotane LYSODREN Tier 2

PA ado-trastuzumab emtansine KADCYLA Tier 4

20

aldesleukin PROLEUKIN Tier 4

PA alemtuzumab CAMPATH Tier 4

arsenic trioxide TRISENOX Tier 4

asparaginase ELSPAR Tier 4

PA asparaginase Erwinia chrysanthemi ERWINAZE Tier 4

PA atezolizumab TECENTRIQ Tier 4

BCG live vaccine THERACYS Tier 4

BCG live vaccine TICE BCG Tier 4

PA belinostat BELEODAQ Tier 4

PA bendamustine BENDEKA Tier 4

PA bevacizumab AVASTIN Tier 4

PA bexarotene gel TARGRETIN gel Tier 4

PA blinatumomab BLINCYTO Tier 4

PA brentuximab vedotin ADCETRIS Tier 4

PA cabazitaxel JEVTANA Tier 4

PA cetuximab ERBITUX Tier 4

PA daratumumab DARZALEX Tier 4

doxorubicin ADRIAMYCIN Tier 4

PA elotuzumab EMPLICITI Tier 4

PA eribulin HALAVEN Tier 4

etoposide phosphate ETOPOPHOS Tier 4

glucarpidase VORAXAZE Tier 4

PA ipilimumab YERVOY Tier 4

ixabepilone IXEMPRA Tier 4

PA ixazomib NINLARO Tier 4

mesna tabs 400 mg MESNEX Tier 4

methoxsalen inj UVADEX Tier 4

PA necitumumab PORTRAZZA Tier 4

nelarabine ARRANON Tier 4

PA niraparib ZEJULA Tier 4

PA nivolumab OPDIVO Tier 4

PA obinutuzumab GAZYVA Tier 4

PA ofatumumab ARZERRA Tier 4

PA olaparib LYNPARZA Tier 4

PA olaratumab LARTRUVO Tier 4

PA omacetaxine mepesuccinate SYNRIBO Tier 4

paclitaxel protein-bound particles ABRAXANE Tier 4

PA panitumumab VECTIBIX Tier 4

pegaspargase ONCASPAR Tier 4

PA pertuzumab PERJETA Tier 4

procarbazine MATULANE Tier 4

PA rucaparib RUBRACA Tier 4

samarium sm 153 lexidronam QUADRAMET Tier 4

PA talimogene laherparepvec IMLYGIC Tier 4

PA trastuzumab HERCEPTIN Tier 4

valrubicin VALSTAR Tier 4

PA venetoclax VENCLEXTA Tier 4

PA vincristine sulfate liposomal MARQIBO Tier 4

PA vismodegib ERIVEDGE Tier 4

PA vorinostat ZOLINZA Tier 4

PA ziv-aflibercept ZALTRAP Tier 4

PA avelumab BAVENCIO Tier 5

PA bortezomib VELCADE Tier 5

PA carfilzomib KYPROLIS Tier 5

PA durvalumab IMFINZI Tier 5

PA enasidenib IDHIFA Tier 5

PA gemtuzumab ozogamicin MYLOTARG Tier 5

21

PA hydroxyurea SIKLOS Tier 5

PA inotuzumab ozogamicin BESPONSA Tier 5

PA melphalan EVOMELA Tier 5

PA panobinostat FARYDAK Tier 5

PA ramucirumab CYRAMZA Tier 5

PA rituximab RITUXAN Tier 5

PA sonidegib ODOMZO Tier 5

PA trifluridine/tipiracil LONSURF Tier 5

CARDIOVASCULAR

The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: http://www.acc.org http://www.heartfailureguideline.org http://www.myamericanheart.org ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 http://professional.diabetes.org http://www.acc.org http://www.myamericanheart.org

benazepril Tier 1 LOTENSIN Tier 3

enalapril Tier 1 VASOTEC Tier 3

fosinopril Tier 1

lisinopril Tier 1 PRINIVIL Tier 3

lisinopril Tier 1 ZESTRIL Tier 3

perindopril Tier 1

quinapril Tier 1 ACCUPRIL Tier 3

ramipril Tier 1 ALTACE Tier 3

trandolapril Tier 1

enalapril oral soln EPANED Tier 3

lisinopril oral soln QBRELIS Tier 3

ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

benazepril/amlodipine Tier 1 LOTREL Tier 3

trandolapril/verapamil ext-rel Tier 1 TARKA Tier 3

perindopril arginine/amlodipine PRESTALIA Tier 3

ACE INHIBITOR/DIURETIC COMBINATIONS

benazepril/hydrochlorothiazide Tier 1 LOTENSIN HCT Tier 3

captopril/hydrochlorothiazide Tier 1

enalapril/hydrochlorothiazide Tier 1 VASERETIC Tier 3

fosinopril/hydrochlorothiazide Tier 1

lisinopril/hydrochlorothiazide Tier 1 ZESTORETIC Tier 3

quinapril/hydrochlorothiazide Tier 1 ACCURETIC Tier 3

ADRENOLYTICS, CENTRAL

clonidine Tier 1 CATAPRES Tier 3

clonidine transdermal Tier 1 CATAPRES-TTS Tier 3

ALDOSTERONE RECEPTOR ANTAGONISTS

eplerenone Tier 1 INSPRA Tier 3

22

spironolactone Tier 1 ALDACTONE Tier 3

ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497

doxazosin Tier 1 CARDURA Tier 3

prazosin Tier 1 MINIPRESS Tier 3

terazosin Tier 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 http://professional.diabetes.org

candesartan Tier 1

candesartan/hydrochlorothiazide Tier 1

eprosartan Tier 1

irbesartan Tier 1

irbesartan/hydrochlorothiazide Tier 1

losartan Tier 1

losartan/hydrochlorothiazide Tier 1

olmesartan Tier 1 BENICAR Tier 3

olmesartan/hydrochlorothiazide Tier 1 BENICAR HCT Tier 3

telmisartan Tier 1

telmisartan/hydrochlorothiazide Tier 1

valsartan Tier 1

valsartan/hydrochlorothiazide Tier 1

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine/olmesartan Tier 1 AZOR Tier 3

amlodipine/telmisartan Tier 1 TWYNSTA Tier 3

amlodipine/valsartan Tier 1 EXFORGE Tier 3

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS

amlodipine/valsartan/ hydrochlorothiazide

Tier 1 EXFORGE HCT Tier 3

olmesartan/amlodipine/ hydrochlorothiazide

Tier 1 TRIBENZOR Tier 3

ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: http://www.acc.org

amiodarone Tier 1

disopyramide Tier 1 NORPACE Tier 3

flecainide Tier 1

mexiletine Tier 1

propafenone ext-rel Tier 1 RYTHMOL SR Tier 3

quinidine gluconate ext-rel Tier 1

sotalol Tier 1 BETAPACE Tier 3

dofetilide Tier 4 TIKOSYN Tier 5

disopyramide ext-rel NORPACE CR Tier 2

dronedarone MULTAQ Tier 2

23

ANTILIPEMICS The 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults is available at: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a Bile Acid Resins

cholestyramine pkt Tier 1 QUESTRAN/QUESTRAN LIGHT Tier 3

colesevelam tabs Tier 1 WELCHOL Tier 2

colestipol Tier 1 COLESTID Tier 3

colesevelam packets WELCHOL Tier 2

Cholesterol Absorption Inhibitors

ezetimibe Tier 1 ZETIA Tier 3

Fibrates

fenofibrate Tier 1 LIPOFEN Tier 3

fenofibrate Tier 1 TRICOR Tier 3

fenofibric acid delayed-rel Tier 1 TRILIPIX Tier 3

gemfibrozil Tier 1 LOPID Tier 3

fenofibrate ANTARA Tier 3

fenofibrate TRIGLIDE Tier 3

HMG-CoA Reductase Inhibitors/Combinations

, * atorvastatin Tier 1

, * fluvastatin Tier 1

, * fluvastatin ext-rel Tier 1

, * lovastatin Tier 1

, * pravastatin Tier 1

, * rosuvastatin Tier 1

, * simvastatin Tier 1

* Generic cholesterol-lowering statin drugs are covered at no charge to the member at a preferred retail pharmacy or for Standard Option members and for Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program. Microsomal Triglyceride Transfer Protein Inhibitors

PA lomitapide JUXTAPID Tier 4

Niacins

niacin ext-rel Tier 1 NIASPAN Tier 3

Omega-3 Fatty Acids

omega-3 acid ethyl esters Tier 1 LOVAZA Tier 3

icosapent ethyl VASCEPA Tier 3

PCSK9 Inhibitors

PA evolocumab REPATHA Tier 4

PA alirocumab PRALUENT Tier 5

Miscellaneous

PA mipomersen KYNAMRO Tier 4

BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 http://www.acc.org

acebutolol Tier 1

24

atenolol Tier 1 TENORMIN Tier 3

carvedilol Tier 1 COREG Tier 3

carvedilol phosphate ext-rel Tier 1 COREG CR Tier 3

esmolol Tier 1 BREVIBLOC Tier 3

metoprolol succinate ext-rel Tier 1 TOPROL-XL Tier 3

metoprolol tartrate Tier 1 LOPRESSOR Tier 3

pindolol Tier 1

propranolol Tier 1

propranolol ext-rel Tier 1 INDERAL LA Tier 3

nebivolol BYSTOLIC Tier 2

penbutolol LEVATOL Tier 3

propranolol ext-rel INNOPRAN XL Tier 3

BETA-BLOCKER/ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS

nebivolol/valsartan BYVALSON Tier 3

BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: http://jama.jamanetwork.com/article.aspx?articleid=1791497 http://www.acc.org

atenolol/chlorthalidone Tier 1

bisoprolol/hydrochlorothiazide Tier 1 ZIAC Tier 3

metoprolol/hydrochlorothiazide Tier 1 LOPRESSOR HCT Tier 3

metoprolol succinate ext-rel/ hydrochlorothiazide

DUTOPROL Tier 3

CALCIUM CHANNEL BLOCKERS Dihydropyridines

amlodipine Tier 1 NORVASC Tier 3

felodipine ext-rel Tier 1

nicardipine Tier 1

nifedipine ext-rel Tier 1 ADALAT CC Tier 3

nifedipine ext-rel Tier 1 PROCARDIA XL Tier 3

nimodipine Tier 1 NIMOTOP Tier 3

nisoldipine ext-rel Tier 1 SULAR Tier 3

Nondihydropyridines

diltiazem Tier 1 CARDIZEM Tier 3

diltiazem ext-rel Tier 1 CARDIZEM CD Tier 3

diltiazem ext-rel Tier 1 TIAZAC Tier 3

verapamil Tier 1 CALAN Tier 3

verapamil ext-rel Tier 1 CALAN SR Tier 3

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS

amlodipine/atorvastatin Tier 1

DIGITALIS GLYCOSIDES

digoxin Tier 1 LANOXIN Tier 2

DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS

aliskiren TEKTURNA Tier 2

aliskiren/hydrochlorothiazide TEKTURNA HCT Tier 2

DIURETICS Carbonic Anhydrase Inhibitors

acetazolamide Tier 1

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acetazolamide ext-rel Tier 1

methazolamide Tier 1

PA dichlorphenamide KEVEYIS Tier 3

Loop Diuretics

bumetanide Tier 1

ethacrynic acid Tier 1 EDECRIN Tier 3

furosemide Tier 1 LASIX Tier 3

torsemide Tier 1 DEMADEX Tier 3

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 ALDACTAZIDE Tier 3

triamterene/hydrochlorothiazide Tier 1 DYAZIDE Tier 3

triamterene/hydrochlorothiazide Tier 1 MAXZIDE Tier 3

triamterene/ hydrochlorothiazide 37.5/25

Tier 1 MAXZIDE-25 Tier 3

triamterene/hydrochlorothiazide 50/25 Tier 1

HEART FAILURE

isosorbide dinitrate/hydralazine BIDIL Tier 2

PA ivabradine CORLANOR Tier 3

PA sacubitril/valsartan ENTRESTO Tier 3

NITRATES Oral

isosorbide dinitrate oral Tier 1 ISORDIL Tier 3

isosorbide mononitrate Tier 1

isosorbide mononitrate ext-rel Tier 1

Sublingual/Translingual

nitroglycerin lingual spray Tier 1 NITROLINGUAL Tier 3

nitroglycerin sublingual Tier 1 NITROSTAT Tier 3

nitroglycerin sublingual aerosol NITROMIST Tier 3

nitroglycerin sublingual powder GONITRO Tier 3

Transdermal

nitroglycerin transdermal Tier 1

nitroglycerin transdermal Tier 1 NITRO-DUR Tier 3

nitroglycerin ointment NITRO-BID Tier 3

PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists

PA ambrisentan LETAIRIS Tier 4

PA bosentan TRACLEER Tier 4

PA macitentan OPSUMIT Tier 4

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Phosphodiesterase Inhibitors

PA sildenafil tabs Tier 4 REVATIO tabs Tier 5

PA sildenafil inj REVATIO inj Tier 5

PA sildenafil oral susp REVATIO susp Tier 5

PA tadalafil ADCIRCA Tier 5

Prostacyclin Receptor Agonists

PA selexipag UPTRAVI Tier 5

Prostaglandin Vasodilators

PA epoprostenol sodium Tier 4 FLOLAN Tier 5

PA iloprost VENTAVIS Tier 4

PA treprostinil ext-rel ORENITRAM Tier 4

PA epoprostenol VELETRI Tier 5

PA treprostinil REMODULIN Tier 5

PA treprostinil TYVASO Tier 5

Soluble Guanylate Cyclase Stimulators

PA riociguat ADEMPAS Tier 5

MISCELLANEOUS

hydralazine Tier 1

midodrine Tier 1

minoxidil Tier 1

ranolazine ext-rel RANEXA Tier 2

mecamylamine VECAMYL Tier 3

PA droxidopa NORTHERA Tier 5

CENTRAL NERVOUS SYSTEM

Practice guidelines for psychiatric disorders are available at: http://www.psych.org ANTIANXIETY Benzodiazepines

alprazolam Tier 1 XANAX Tier 3

alprazolam ext-rel Tier 1 XANAX XR Tier 3

chlordiazepoxide Tier 1

clonazepam tabs Tier 1 KLONOPIN Tier 3

clorazepate Tier 1 TRANXENE T-TAB Tier 3

diazepam Tier 1 VALIUM Tier 3

lorazepam Tier 1 ATIVAN Tier 3

oxazepam Tier 1

Miscellaneous

buspirone Tier 1

clomipramine Tier 1 ANAFRANIL Tier 3

fluvoxamine Tier 1

fluvoxamine ext-rel Tier 1

hydroxyzine HCl Tier 1

hydroxyzine pamoate Tier 1 VISTARIL Tier 3

ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: http://www.aan.com

carbamazepine Tier 1 TEGRETOL Tier 3

carbamazepine ext-rel Tier 1 CARBATROL Tier 3

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carbamazepine ext-rel Tier 1 TEGRETOL-XR Tier 3

diazepam rectal gel Tier 1 DIASTAT Tier 3

divalproex sodium delayed-rel Tier 1 DEPAKOTE Tier 3

divalproex sodium ext-rel Tier 1 DEPAKOTE ER Tier 3

divalproex sodium sprinkle caps Tier 1 DEPAKOTE SPRINKLE Tier 3

ethosuximide Tier 1 ZARONTIN Tier 3

felbamate Tier 1 FELBATOL Tier 3

QL gabapentin Tier 1 NEURONTIN Tier 3

lamotrigine Tier 1 LAMICTAL Tier 3

lamotrigine ext-rel Tier 1 LAMICTAL XR Tier 3

lamotrigine orally disintegrating tabs Tier 1 LAMICTAL ODT Tier 3

levetiracetam Tier 1 KEPPRA Tier 3

levetiracetam ext-rel Tier 1 KEPPRA XR Tier 3

oxcarbazepine Tier 1 TRILEPTAL Tier 3

phenobarbital Tier 1

phenytoin Tier 1 DILANTIN INFATABS Tier 3

phenytoin sodium extended Tier 1 DILANTIN Tier 3

primidone Tier 1 MYSOLINE Tier 3

tiagabine Tier 1 GABITRIL Tier 3

topiramate Tier 1 TOPAMAX Tier 3

topiramate ext-rel Tier 1 QUDEXY XR Tier 3

valproic acid Tier 1 DEPAKENE Tier 3

zonisamide Tier 1 ZONEGRAN Tier 3

PA vigabatrin powder Tier 4 SABRIL Tier 5

clobazam ONFI Tier 2

lacosamide VIMPAT Tier 2

rufinamide BANZEL Tier 2

brivaracetam BRIVIACT Tier 3

eslicarbazepine APTIOM Tier 3

levetiracetam tabs for oral suspension SPRITAM Tier 3

oxcarbazepine ext-rel OXTELLAR XR Tier 3

perampanel FYCOMPA Tier 3

topiramate ext-rel TROKENDI XR Tier 3

PA vigabatrin tabs SABRIL Tier 5

ANTIDEMENTIA Practice guidelines for the management of dementia are available at: http://www.aan.com

donepezil Tier 1 ARICEPT Tier 3

donepezil orally disintegrating tabs Tier 1

galantamine Tier 1 RAZADYNE Tier 3

galantamine ext-rel Tier 1 RAZADYNE ER Tier 3

memantine tabs Tier 1 NAMENDA tabs Tier 3

rivastigmine Tier 1

rivastigmine transdermal Tier 1 EXELON PATCH Tier 3

memantine soln NAMENDA soln Tier 2

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: http://www.psych.org Monoamine Oxidase Inhibitors (MAOIs)

phenelzine Tier 1 NARDIL Tier 3

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tranylcypromine Tier 1 PARNATE Tier 3

isocarboxazid MARPLAN Tier 3

selegiline transdermal EMSAM Tier 3

Selective Serotonin Reuptake Inhibitors (SSRIs)

citalopram Tier 1 CELEXA Tier 3

escitalopram Tier 1 LEXAPRO Tier 3

fluoxetine Tier 1 PROZAC Tier 3

fluoxetine Tier 1 SARAFEM Tier 3

fluoxetine delayed-rel Tier 1

paroxetine HCl Tier 1 PAXIL Tier 3

paroxetine HCl ext-rel Tier 1 PAXIL CR Tier 3

sertraline Tier 1 ZOLOFT Tier 3

paroxetine mesylate PEXEVA Tier 3

vilazodone VIIBRYD Tier 3

vortioxetine TRINTELLIX Tier 3

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

desvenlafaxine ext-rel Tier 1 KHEDEZLA Tier 3

desvenlafaxine ext-rel Tier 1 PRISTIQ Tier 3

duloxetine delayed-rel Tier 1 CYMBALTA Tier 3

venlafaxine Tier 1

venlafaxine ext-rel Tier 1 EFFEXOR XR Tier 3

venlafaxine ext-rel tabs Tier 1

levomilnacipran ext-rel FETZIMA Tier 3

Tricyclic Antidepressants (TCAs)

amitriptyline Tier 1

desipramine Tier 1 NORPRAMIN Tier 3

doxepin Tier 1

imipramine HCl Tier 1 TOFRANIL Tier 3

imipramine pamoate Tier 1

nortriptyline Tier 1 PAMELOR Tier 3

protriptyline Tier 1

Miscellaneous Agents

amitriptyline/perphenazine Tier 1

bupropion Tier 1