FEP ® Blue Focus Formulary (907) Effective January 1, 2019 v2 The FEP formulary includes a preferred drug list which is comprised of Tier 1, generics and Tier 2, preferred brand-name drugs, preferred generic specialty drugs, and preferred brand-name 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 PRIOR APPROVAL .................................................................................................................................................................................................. 5 QUANTITY LIMITATIONS........................................................................................................................................................................................ 5 PHARMACY AND MEDICAL POLICY COMMITTEE .............................................................................................................................................. 5 PRODUCT SELECTION CRITERIA......................................................................................................................................................................... 6 FORMULARY PRODUCT DESCRIPTIONS ............................................................................................................................................................ 6 GENERIC SUBSTITUTION ...................................................................................................................................................................................... 7 DRUG EFFICACY STUDY IMPLEMENTATION DRUGS........................................................................................................................................ 7 EDITOR..................................................................................................................................................................................................................... 7 NOTICE..................................................................................................................................................................................................................... 7 LEGEND ................................................................................................................................................................................................................... 8 ANALGESICS........................................................................................................................................................................................................... 9 NSAIDs ........................................................................................................................................................................................................... 9 NSAIDs, COMBINATIONS ............................................................................................................................................................................. 9 NSAIDs, TOPICAL ......................................................................................................................................................................................... 9 COX-2 INHIBITORS ....................................................................................................................................................................................... 9 GOUT ............................................................................................................................................................................................................. 9 OPIOID ANALGESICS ................................................................................................................................................................................... 9 NON-OPIOID ANALGESICS........................................................................................................................................................................ 10 VISCOSUPPLEMENTS ............................................................................................................................................................................... 10 ANTI-INFECTIVES ................................................................................................................................................................................................. 10 ANTIBACTERIALS ....................................................................................................................................................................................... 11 ANTIFUNGALS ............................................................................................................................................................................................ 12 ANTIMALARIALS ......................................................................................................................................................................................... 12 ANTIRETROVIRAL AGENTS ...................................................................................................................................................................... 12 ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 14 ANTIVIRALS................................................................................................................................................................................................. 14 MISCELLANEOUS ....................................................................................................................................................................................... 14 ANTINEOPLASTIC AGENTS ................................................................................................................................................................................ 15 ALKYLATING AGENTS ............................................................................................................................................................................... 15 ANTIMETABOLITES .................................................................................................................................................................................... 15 HORMONAL ANTINEOPLASTIC AGENTS ................................................................................................................................................. 16 IMMUNOMODULATORS ............................................................................................................................................................................. 16 KINASE INHIBITORS ................................................................................................................................................................................... 16 TOPOISOMERASE INHIBITORS ................................................................................................................................................................ 17 MISCELLANEOUS ....................................................................................................................................................................................... 17 CARDIOVASCULAR .............................................................................................................................................................................................. 19 ACE INHIBITORS......................................................................................................................................................................................... 19 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 19 ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 19 ADRENOLYTICS, CENTRAL....................................................................................................................................................................... 20 ALDOSTERONE RECEPTOR ANTAGONISTS .......................................................................................................................................... 20 ALPHA BLOCKERS ..................................................................................................................................................................................... 20 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS........................................................................................... 20 1
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FEP® Blue Focus Formulary (907) Effective January 1, 2019 v2
The FEP formulary includes a preferred drug list which is comprised of Tier 1, generics and Tier 2, preferred brand-name drugs, preferred generic specialty drugs, and preferred brand-name 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
WEBSITES ............................................................................................................................................................................................................. 52 INDEX ..................................................................................................................................................................................................................... 54
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The Retail 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 2019 FEP Blue Focus Drug Formulary as a useful reference for drug product coverage. The drugs on the FEP Blue Focus 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 Blue Focus Formulary is provided as a reference for drug therapy coverage. 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 Blue Focus Formulary is a closed formulary that does not cover all FDA-approved drugs. Coverage consists of mainly generics, some preferred brands, and preferred specialty drugs.
The formulary is separated by Tiers in the following manner:
specialty, and preferred brand-name specialty FEP Blue Focus Preferred Retail Pharmacy
$5 copay for a 0 to 30-day supply $15 copay for a 31 to 90-day supply
40% coinsurance (up to $350 for a 0 to 30-day supply)***
FEP Blue Focus Specialty Drug Pharmacy Program***
40% coinsurance (up to $350 for a 0 to 30-day supply)
*** Specialty medications are limited to a 30-day supply. If a 31 to 90-day supply of a specialty drug has to be dispensed due to manufacturer packaging, you pay 40% of the Plan allowance (up to a $1,050 maximum) for each purchase. Drug products shown in boldface type indicate generic availability.
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-covered on the FEP Blue Focus 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 on the FEP Blue Focus Formulary. 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
When a new drug is considered for preferred status on the FEP Blue Focus Formulary, an attempt will be made to examine the drug relative to similar drugs currently preferred on the FEP Blue Focus Formulary. In addition, entire therapeutic classes are periodically reviewed. The class review process may result in a non-covered designation 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-covered designation in the FEP Blue Focus 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.
All the information in the FEP Blue Focus 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.
cefixime Suprax Chewable tablets, capsules and all strengths of Suprax suspension 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 Zovirax crm The cream dosage form of Zovirax is preferred. From this entry, the capsules, tablets, suspension 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.
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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:
• 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 Blue Focus 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 Blue Focus 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 Blue Focus Formulary is not a complete list of all covered medications. This FEP Blue Focus 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.
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. ST Step Therapy 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
QL hydromorphone Tier 1 QL hydromorphone ext-rel Tier 1 QL methadone Tier 1 QL morphine Tier 1 QL morphine ext-rel Tier 1 QL morphine supp Tier 1 QL oxycodone Tier 1 QL oxycodone concentrate 20 mg/mL Tier 1 QL oxycodone soln Tier 1 QL oxycodone/acetaminophen 5/325 Tier 1 QL oxymorphone Tier 1 QL tramadol Tier 1 QL tramadol ext-rel Tier 1 NON-OPIOID ANALGESICS QL butalbital/acetaminophen Tier 1 QL butalbital/acetaminophen/caffeine Tier 1 QL butalbital/aspirin/caffeine Tier 1 ziconotide PRIALT Tier 2 VISCOSUPPLEMENTS PA sodium hyaluronate GEL-ONE Tier 2 PA sodium hyaluronate GELSYN-3 Tier 2 PA sodium hyaluronate HYALGAN Tier 2 PA sodium hyaluronate SUPARTZ FX Tier 2 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/
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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 Second Generation cefaclor Tier 1 cefoxitin Tier 1 cefprozil Tier 1 cefuroxime axetil Tier 1 Third Generation cefdinir Tier 1 cefditoren Tier 1 cefixime susp 100 mg/5 mL,
mercaptopurine susp PURIXAN Tier 2 pemetrexed ALIMTA Tier 2 pentostatin NIPENT Tier 2 pralatrexate FOLOTYN Tier 2 rasburicase ELITEK Tier 2 thioguanine TABLOID Tier 2 HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens bicalutamide Tier 1 flutamide Tier 1 PA nilutamide Tier 1 PA abiraterone 250 mg Tier 2 PA abiraterone YONSA Tier 2 PA abiraterone 500 mg ZYTIGA 500 mg Tier 2 PA enzalutamide XTANDI Tier 2 Antiestrogens tamoxifen Tier 1 fulvestrant FASLODEX Tier 2 toremifene FARESTON Tier 2 Aromatase Inhibitors anastrozole Tier 1 exemestane Tier 1 letrozole Tier 1 Gonadotropin-Releasing Hormone (GnRH) Antagonists PA degarelix acetate FIRMAGON Tier 2 Luteinizing Hormone-Releasing Hormone (LHRH) Agonists PA leuprolide acetate Tier 2 PA goserelin acetate ZOLADEX Tier 2 PA histrelin acetate VANTAS Tier 2 PA leuprolide acetate ELIGARD Tier 2 PA leuprolide acetate LUPRON DEPOT Tier 2 PA triptorelin pamoate TRELSTAR Tier 2 PA triptorelin pamoate TRELSTAR DEPOT Tier 2 PA triptorelin pamoate TRELSTAR LA Tier 2 Progestins megestrol acetate Tier 1 IMMUNOMODULATORS PA pomalidomide POMALYST Tier 2 PA lenalidomide REVLIMID Tier 2 PA pembrolizumab KEYTRUDA Tier 2 thalidomide THALOMID Tier 2 KINASE INHIBITORS PA imatinib mesylate Tier 2 temsirolimus Tier 2 PA abemaciclib VERZENIO Tier 2 PA acalabrutinib CALQUENCE Tier 2 PA afatinib GILOTRIF Tier 2 PA alectinib ALECENSA Tier 2 PA axitinib INLYTA Tier 2
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PA bosutinib BOSULIF Tier 2 PA brigatinib ALUNBRIG Tier 2 PA cabozantinib CABOMETYX Tier 2 PA cabozantinib COMETRIQ Tier 2 PA ceritinib ZYKADIA Tier 2 PA cobimetinib COTELLIC Tier 2 PA crizotinib XALKORI Tier 2 PA dabrafenib TAFINLAR Tier 2 PA dasatinib SPRYCEL Tier 2 PA erlotinib TARCEVA Tier 2 PA everolimus AFINITOR Tier 2 PA everolimus tabs for oral suspension AFINITOR DISPERZ Tier 2 PA gefitinib IRESSA Tier 2 PA ibrutinib IMBRUVICA Tier 2 PA idelalisib ZYDELIG Tier 2 PA lapatinib TYKERB Tier 2 PA lenvatinib LENVIMA Tier 2 PA midostaurin RYDAPT Tier 2 PA neratinib NERLYNX Tier 2 PA nilotinib TASIGNA Tier 2 PA osimertinib TAGRISSO Tier 2 PA palbociclib IBRANCE Tier 2 PA pazopanib VOTRIENT Tier 2 PA ponatinib ICLUSIG Tier 2 PA regorafenib STIVARGA Tier 2 PA ribociclib KISQALI Tier 2 PA ribociclib + letrozole KISQALI FEMARA CO-PACK Tier 2 PA ruxolitinib JAKAFI Tier 2 PA sorafenib NEXAVAR Tier 2 PA sunitinib SUTENT Tier 2 PA trametinib MEKINIST Tier 2 PA vandetanib CAPRELSA Tier 2 PA vemurafenib ZELBORAF Tier 2 TOPOISOMERASE INHIBITORS topotecan inj Tier 2 topotecan HYCAMTIN Tier 2 MISCELLANEOUS hydroxyurea Tier 1 leucovorin calcium Tier 1 amifostine Tier 2 arsenic trioxide Tier 2 azacitidine Tier 2 PA bexarotene caps Tier 2 bleomycin sulfate Tier 2 carboplatin Tier 2 cisplatin Tier 2 dactinomycin Tier 2 daunorubicin Tier 2 decitabine Tier 2 dexrazoxane Tier 2 docetaxel Tier 2 doxorubicin Tier 2 doxorubicin liposomal Tier 2 epirubicin Tier 2 etoposide Tier 2
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idarubicin Tier 2 ifosfamide Tier 2 irinotecan Tier 2 levoleucovorin calcium Tier 2 mesna inj Tier 2 mitomycin Tier 2 mitoxantrone Tier 2 oxaliplatin Tier 2 paclitaxel Tier 2 PA romidepsin Tier 2 teniposide Tier 2 vinblastine Tier 2 vincristine Tier 2 vinorelbine Tier 2 PA ado-trastuzumab emtansine KADCYLA Tier 2 aldesleukin PROLEUKIN Tier 2 PA alemtuzumab CAMPATH Tier 2 asparaginase ELSPAR Tier 2 PA asparaginase Erwinia chrysanthemi ERWINAZE Tier 2 PA atezolizumab TECENTRIQ Tier 2 PA avelumab BAVENCIO Tier 2 BCG live vaccine THERACYS Tier 2 BCG live vaccine TICE BCG Tier 2 PA belinostat BELEODAQ Tier 2 PA bendamustine BENDEKA Tier 2 PA bevacizumab AVASTIN Tier 2 PA bexarotene gel TARGRETIN gel Tier 2 PA blinatumomab BLINCYTO Tier 2 PA brentuximab vedotin ADCETRIS Tier 2 PA cabazitaxel JEVTANA Tier 2 PA carfilzomib KYPROLIS Tier 2 PA cetuximab ERBITUX Tier 2 PA daratumumab DARZALEX Tier 2 doxorubicin ADRIAMYCIN Tier 2 PA durvalumab IMFINZI Tier 2 PA elotuzumab EMPLICITI Tier 2 PA enasidenib IDHIFA Tier 2 PA eribulin HALAVEN Tier 2 etoposide phosphate ETOPOPHOS Tier 2 PA gemtuzumab ozogamicin MYLOTARG Tier 2 glucarpidase VORAXAZE Tier 2 PA inotuzumab ozogamicin BESPONSA Tier 2 PA ipilimumab YERVOY Tier 2 PA ivosidenib TIBSOVO Tier 2 ixabepilone IXEMPRA Tier 2 PA ixazomib NINLARO Tier 2 mesna tabs 400 mg MESNEX Tier 2 methoxsalen inj UVADEX Tier 2 mitotane LYSODREN Tier 2 PA necitumumab PORTRAZZA Tier 2 nelarabine ARRANON Tier 2 PA niraparib ZEJULA Tier 2 PA nivolumab OPDIVO Tier 2 PA obinutuzumab GAZYVA Tier 2 PA ofatumumab ARZERRA Tier 2 PA olaparib LYNPARZA Tier 2 PA olaratumab LARTRUVO Tier 2
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PA omacetaxine mepesuccinate SYNRIBO Tier 2 paclitaxel protein-bound particles ABRAXANE Tier 2 PA panitumumab VECTIBIX Tier 2 PA panobinostat FARYDAK Tier 2 pegaspargase ONCASPAR Tier 2 PA pertuzumab PERJETA Tier 2 procarbazine MATULANE Tier 2 PA ramucirumab CYRAMZA Tier 2 PA rituximab RITUXAN Tier 2 PA rucaparib RUBRACA Tier 2 samarium sm 153 lexidronam QUADRAMET Tier 2 PA sonidegib ODOMZO Tier 2 PA talimogene laherparepvec IMLYGIC Tier 2 PA trastuzumab HERCEPTIN Tier 2 PA trifluridine/tipiracil LONSURF Tier 2 valrubicin VALSTAR Tier 2 PA venetoclax VENCLEXTA Tier 2 PA vincristine sulfate liposomal MARQIBO Tier 2 PA vismodegib ERIVEDGE Tier 2 PA vorinostat ZOLINZA Tier 2 PA ziv-aflibercept ZALTRAP Tier 2 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 enalapril Tier 1 fosinopril Tier 1 lisinopril Tier 1 perindopril Tier 1 quinapril Tier 1 ramipril Tier 1 trandolapril Tier 1 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS benazepril/amlodipine Tier 1 trandolapril/verapamil ext-rel Tier 1 ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/hydrochlorothiazide Tier 1 captopril/hydrochlorothiazide Tier 1 enalapril/hydrochlorothiazide Tier 1 fosinopril/hydrochlorothiazide Tier 1
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lisinopril/hydrochlorothiazide Tier 1 quinapril/hydrochlorothiazide Tier 1 ADRENOLYTICS, CENTRAL clonidine Tier 1 clonidine transdermal Tier 1 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone Tier 1 spironolactone Tier 1 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 prazosin Tier 1 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 olmesartan/hydrochlorothiazide Tier 1 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 amlodipine/telmisartan Tier 1 amlodipine/valsartan Tier 1 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS amlodipine/valsartan/
hydrochlorothiazide Tier 1
olmesartan/amlodipine/ hydrochlorothiazide
Tier 1
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 flecainide Tier 1 mexiletine Tier 1
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propafenone ext-rel Tier 1 quinidine gluconate ext-rel Tier 1 sotalol Tier 1 dofetilide Tier 2 disopyramide ext-rel NORPACE CR Tier 2 dronedarone MULTAQ Tier 2 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 colesevelam Tier 1 colestipol Tier 1 Cholesterol Absorption Inhibitors ezetimibe Tier 1 Fibrates fenofibrate Tier 1 fenofibric acid delayed-rel Tier 1 gemfibrozil Tier 1 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 2 Niacin niacin ext-rel Tier 1 Omega-3 Fatty Acids omega-3 acid ethyl esters Tier 1 PCSK9 Inhibitors PA evolocumab REPATHA Tier 2 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 atenolol Tier 1
ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the evaluation and management of attention deficit disorder are available at: http://www.aacap.org http://www.aap.org PA amphetamine/
dextroamphetamine mixed salts Tier 1
PA amphetamine/ dextroamphetamine mixed salts ext-rel
Tier 1
atomoxetine Tier 1 clonidine ext-rel Tier 1 PA dexmethylphenidate Tier 1 PA dexmethylphenidate ext-rel Tier 1 PA dextroamphetamine Tier 1 PA dextroamphetamine ext-rel Tier 1 PA dextroamphetamine soln Tier 1 guanfacine ext-rel Tier 1 PA methamphetamine Tier 1 PA methylphenidate Tier 1 PA methylphenidate ext-rel Tier 1 PA lisdexamfetamine VYVANSE Tier 2 FIBROMYALGIA QL pregabalin LYRICA Tier 2 HUNTINGTON'S DISEASE AGENTS PA tetrabenazine Tier 2 HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia in adults are available at: http://www.aasmnet.org Benzodiazepines QL estazolam Tier 1 QL flurazepam Tier 1 QL temazepam Tier 1 Nonbenzodiazepines QL eszopiclone Tier 1 QL zaleplon Tier 1 QL zolpidem Tier 1 QL zolpidem ext-rel Tier 1 PA tasimelteon HETLIOZ Tier 2 MIGRAINE Guidelines for prevention and management of migraine headaches are available at: http://www.aan.com Ergotamine Derivatives dihydroergotamine inj Tier 1 ergotamine/caffeine Tier 1 ergotamine/caffeine supp Tier 1 MIGERGOT Tier 1 Selective Serotonin Agonists QL almotriptan Tier 1 QL eletriptan Tier 1
QL buprenorphine/naloxone sublingual film SUBOXONE FILM Tier 2 QL buprenorphine/naloxone sublingual tabs ZUBSOLV Tier 2 Pseudobulbar Affect PA dextromethorphan/quinidine NUEDEXTA Tier 2 Smoking Deterrents Treating Tobacco Use and Dependence: 2008 Update-Clinical Practice Guideline is available at: http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html bupropion ext-rel Tier 1 OTC nicotine transdermal Tier 1 varenicline CHANTIX Tier 2 MISCELLANEOUS Amyotrophic Lateral Sclerosis riluzole Tier 1 PA edaravone RADICAVA Tier 2 Botulinum Toxins PA abobotulinumtoxinA DYSPORT Tier 2 PA incobotulinumtoxinA XEOMIN Tier 2 PA onabotulinumtoxinA BOTOX Tier 2 PA rimabotulinumtoxinB MYOBLOC Tier 2 Duchenne Muscular Dystrophy PA deflazacort EMFLAZA Tier 2 PA eteplirsen EXONDYS 51 Tier 2 Tardive Dyskinesia PA valbenazine INGREZZA Tier 2 ENDOCRINE AND METABOLIC ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: http://www.aace.com PA testosterone cypionate Tier 1 PA testosterone enanthate Tier 1 PA testosterone gel Tier 1 PA testosterone soln Tier 1 PA testosterone transdermal ANDRODERM Tier 2 PA testosterone undecanoate inj AVEED Tier 2 ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: http://professionals.diabetes.org Alpha-glucosidase Inhibitors acarbose Tier 1
OTIC Clinical practice guidelines for the treatment of otitis media are available at: http://www.aap.org Anti-infectives acetic acid Tier 1 ciprofloxacin otic Tier 1 ofloxacin otic Tier 1 Anti-infective/Anti-inflammatory Combinations acetic acid/hydrocortisone Tier 1 neomycin/polymyxin B/hydrocortisone Tier 1 ciprofloxacin/dexamethasone CIPRODEX Tier 2 ciprofloxacin/hydrocortisone CIPRO HC OTIC Tier 2 Miscellaneous fluocinolone acetonide Tier 1
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WEBSITES Agency for Healthcare Research and Quality http://www.ahrq.gov Alzheimer's Association http://www.alz.org American Academy of Allergy, Asthma and Immunology http://www.aaaai.org American Academy of Child & Adolescent Psychiatry http://www.aacap.org American Academy of Dermatology http://www.aad.org American Academy of Neurology http://www.aan.com American Academy of Ophthalmology http://www.aao.org American Academy of Pediatrics http://www.aap.org American Association for the Study of Liver Disease http://www.aasld.org American Association of Clinical Endocrinologists http://www.aace.com American Association of Diabetes Educators http://www.diabeteseducator.org American Cancer Society http://www.cancer.org American College of Allergy, Asthma and Immunology http://www.acaai.org American College of Cardiology http://www.acc.org American College of Chest Physicians http://www.chestnet.org American College of Gastroenterology http://gi.org American College of Physicians http://www.acponline.org American College of Rheumatology http://www.rheumatology.org
American Congress of Obstetricians and Gynecologists http://www.acog.org American Diabetes Association http://www.diabetes.org American Gastroenterological Association http://www.gastro.org American Headache Society Committee for Headache Education http://www.achenet.org American Heart Association http://www.myamericanheart.org American Lung Association http://www.lung.org American Medical Association http://www.ama-assn.org American Psychiatric Association http://www.psych.org American Society of Anesthesiologists http://www.asahq.org American Society of Clinical Oncology http://www.asco.org American Society of Interventional Pain Physicians http://www.asipp.org American Urological Association http://www.auanet.org Centers for Disease Control and Prevention http://www.cdc.gov Centers for Disease Control and Prevention Guideline topics: AIDS http://www.cdc.gov/hiv/default.html Centers for Disease Control and Prevention Guideline topics: Sexually Transmitted Diseases http://www.cdc.gov/std/treatment/default.htm CVS Caremark® https://www.caremark.com The Food and Drug Administration http://www.fda.gov Global Initiative for Asthma http://www.ginasthma.com
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Infectious Diseases Society of America http://www.idsociety.org Institute for Safe Medication Practices http://www.ismp.org Johns Hopkins AIDS Service http://www.thebody.com/content/art12096.html Juvenile Diabetes Research Foundation International http://jdrf.org MedWatch http://www.fda.gov/Safety/MedWatch/default.htm National Agricultural Library http://www.nal.usda.gov National Cancer Institute http://www.cancer.gov/cancertopics National Comprehensive Cancer Network http://www.nccn.org National Foundation for Infectious Diseases http://www.nfid.org
National Guideline Clearinghouse http://www.guideline.gov National Heart, Lung and Blood Institute http://www.nhlbi.nih.gov National Institutes of Health http://www.nih.gov National Kidney Foundation http://www.kidney.org National Osteoporosis Foundation http://www.nof.org North American Menopause Society http://www.menopause.org United States Department of Health and Human Services http://www.hhs.gov World Health Organization http://www.who.int