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2018 National Formulary - Southern Scripts, LLC

2018 National Formulary Effective 01/01/2018 The Formulary List is a guide providing tier designation for common medicines within select therapeutic categories. The Formulary List may not include all drugs covered by your prescription drug benefit. Generic medicines are available within many of the therapeutic categories listed, in addition to categories not listed, and should be considered as the first line of prescribing. For benefit coverage or restrictions please check your benefit plan document(s). This listing is revised periodically as new drugs and new prescribing information becomes available. It is recommended that you bring this list of medications when you or a covered family member sees a physician or other healthcare provider. Tier Definitions 1 Generics 2 Preferred Brands 3 Non-Preferred Brands (ST) Step Therapy (PA) Prior Authorization (SP) Specialty Drugs Major Drug Class Overview Non-Preferred and Excluded* Drugs With Preferred Options 2018 Preferred Non-Preferred / Excluded * Drug Class ANALGESICS EUFLEXXA, GEL-ONE, HYALGAN, MONOVISC, ORTHOVISC GELSYN-3, SUPARTZ FX, SYNVISC, SYNVISC-ONE ANTIARTHRITICS ABSTRAL, EMBEDA, KADIAN, ZOHYDRO ER fentanyl, fentanyl citrate, morphine sulfate er, oxycodone hcl, FENTORA, HYSINGLA ER, NUCYNTA ER, OXYCONTIN NARCOTICS ANTI-INFECTIVES REBETOL moderiba, ribapak, ribavirin, ribavirin ANTIVIRALS DAKLINZA*, EPCLUSA*, HARVONI*, SOVALDI*, TECHNIVIE*, VIEKIRA PAK* MAVYRET, ZEPATIER HEPATITIS C DOXYCYCLINE

2018 National Formulary Effective 01/01/2018 The Formulary List is a guide providing tier designation for common medicines within select therapeutic categories.

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Transcription of 2018 National Formulary - Southern Scripts, LLC

1 2018 National Formulary Effective 01/01/2018 The Formulary List is a guide providing tier designation for common medicines within select therapeutic categories. The Formulary List may not include all drugs covered by your prescription drug benefit. Generic medicines are available within many of the therapeutic categories listed, in addition to categories not listed, and should be considered as the first line of prescribing. For benefit coverage or restrictions please check your benefit plan document(s). This listing is revised periodically as new drugs and new prescribing information becomes available. It is recommended that you bring this list of medications when you or a covered family member sees a physician or other healthcare provider. Tier Definitions 1 Generics 2 Preferred Brands 3 Non-Preferred Brands (ST) Step Therapy (PA) Prior Authorization (SP) Specialty Drugs Major Drug Class Overview Non-Preferred and Excluded* Drugs With Preferred Options 2018 Preferred Non-Preferred / Excluded * Drug Class ANALGESICS EUFLEXXA, GEL-ONE, HYALGAN, MONOVISC, ORTHOVISC GELSYN-3, SUPARTZ FX, SYNVISC, SYNVISC-ONE ANTIARTHRITICS ABSTRAL, EMBEDA, KADIAN, ZOHYDRO ER fentanyl, fentanyl citrate, morphine sulfate er, oxycodone hcl, FENTORA, HYSINGLA ER, NUCYNTA ER, OXYCONTIN NARCOTICS ANTI-INFECTIVES REBETOL moderiba, ribapak, ribavirin, ribavirin ANTIVIRALS DAKLINZA*, EPCLUSA*, HARVONI*, SOVALDI*, TECHNIVIE*, VIEKIRA PAK* MAVYRET, ZEPATIER HEPATITIS C DOXYCYCLINE IR-DR ORACEA TETRACYCLINES CARDIAC BENICAR HCT, EDARBI, EDARBYCLOR candesartan-hydrochlorothiazid, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, valsartan-hydrochlorothiazide ANGIOTENSIN RECEPTOR BLOCKER PRADAXA clopidogrel, ELIQUIS, XARELTO ANTICOAGULANTS LIVALO, VYTORIN atorvastatin calcium, rosuvastatin calcium.

2 Simvastatin STATINS CNS ADDERALL XR dextroamphetamine-amphet er, dextroamphetamine-amphetamine ADHD PEXEVA, SARAFEM citalopram hbr, escitalopram oxalate, escitalopram oxalate, fluoxetine hcl, fluvoxamine maleate, paroxetine er, paroxetine hcl, sertraline hcl, trazodone hcl, VIIBRYD ANTIDEPRESSANTS FANAPT, INVEGA, REXULTI aripiprazole, olanzapine, olanzapine odt, quetiapine fumarate, quetiapine fumarate er, LATUDA, SAPHRIS ANTI-PSYCHOTIC ZOLPIMIST eszopiclone, zaleplon, zolpidem tartrate er, BELSOMRA, ROZEREM SLEEP DIABETES ALOGLIPTIN, KAZANO, KOMBIGLYZE XR, NESINA, ONGLYZA, OSENI JANUMET XR, JANUVIA, JENTADUETO, TRADJENTA DPP-4 BYDUREON PEN, BYETTA, TANZEUM TRULICITY, VICTOZA INCRETINS AFREZZA, APIDRA HUMALOG, HUMALOG MIX 50-50, HUMALOG MIX 75-25, HUMULIN 70-30, HUMULIN N, HUMULIN R, NOVOLIN 70-30, NOVOLIN N, NOVOLIN R, NOVOLOG, NOVOLOG FLEXPEN, NOVOLOG MIX 70-30 INSULIN BASAGLAR KWIKPEN U-100 LANTUS, LANTUS SOLOSTAR, LEVEMIR, TOUJEO SOLOSTAR, TRESIBA FLEXTOUCH U-200 INSULIN.

3 LONG ACTING GLUMETZA, RIOMET metformin hcl OTHER INVOKAMET, INVOKANA FARXIGA, JARDIANCE, SYNJARDY, XIGDUO XR SGLT-2 Preferred Non-Preferred / Excluded * Drug Class DIABETES ACCU-CHEK AVIVA CONNECT, ACCU-CHEK AVIVA PLUS, ADVOCATE BLOOD GLUCOSE MONITOR, ASCENSIA BREEZE 2, CONTOUR, EMBRACE, PRODIGY, TRUETEST TEST STRIPS, TRUETRACK SMART SYSTEM, UNISTRIP1 FREESTYLE TEST STRIPS, ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO TESTING ENDOCRINE ESTRING estradiol, DIVIGEL, PREMARIN ESTROGENS GANIRELIX ACETATE, PREGNYL CETROTIDE, NOVAREL GONADOTROPIN BRAVELLE clomiphene citrate, FOLLISTIM AQ, FOLLISTIM AQ, GONAL-F, MENOPUR OVULATORY STIMULANTS CRINONE, ENDOMETRIN PROGESTINS FORTESTA, NATESTO, STRIANT, TESTIM, VOGELXO ANDROGEL, AXIRON TESTOSTERONE GASTROINTESTINAL PANCREAZE, PERTZYE CREON, VIOKACE, ZENPEP DIGESTIVE ENZYMES DIPENTUM, LIALDA balsalazide disodium, AMITIZA, APRISO, ASACOL HD, DELZICOL, LINZESS, PENTASA OTHER DEXILANT, ZEGERID RX lansoprazole, omeprazole, pantoprazole sodium PROTON PUMP INHIBITORS GROWTH HORMONES GENOTROPIN, HUMATROPE, NUTROPIN AQ NUSPIN, OMNITROPE, SAIZEN, ZOMACTON, ZORBTIVE NORDITROPIN FLEXPRO HEMATOLOGY ARANESP, EPOGEN, MIRCERA PROCRIT MUSCULOSKELETAL ACTEMRA, CIMZIA, OTEZLA, REMICADE, SIMPONI, STELARA, TALTZ AUTOINJECTOR, TALTZ SYRINGE, XELJANZ COSENTYX 150MG, COSENTYX 300MG, ENBREL, ENTYVIO, HUMIRA, ORENCIA, SILIQ ANTI-INFLAMMATORY ** ** Trial of ONE First Line Product and ONE Second Line Product is Required before any Non-Preferred Products.

4 Required Second Line Required First Line Indication HUMIRA or ORENCIA HUMIRA or ORENCIA Rheumatoid Arthritis Juvenille Idiopathic Arthritis HUMIRA or ORENCIA HUMIRA or ORENCIA COSENTYX or HUMIRA or ORENCIA HUMIRA or ORENCIA Ankylosing Spondylitis Psoriatic Arthritis HUMIRA or ORENCIA HUMIRA or ORENCIA COSENTYX or SILIQ COSENTYX or HUMIRA Plaque Psoriasis ENBREL Pediatric Plaque Psoriasis ENTYVIO HUMIRA Crohn's Disease HUMIRA Pediatric Crohn's ENTYVIO HUMIRA Ulcerative Colitis HUMIRA Hidradentis Supperativa HUMIRA Uvelitis OPHTHALMIC COSOPT PF, SIMBRINZA, ZIOPTAN dorzolamide hcl, latanoprost, AZOPT, COMBIGAN, TRAVATAN Z GLAUCOMA ACUVAIL bromfenac sodium, diclofenac sodium, ketorolac tromethamine, ILEVRO, NEVANAC, PROLENSA NSAIDS Preferred Non-Preferred / Excluded * Drug Class OTIC CETRAXAL ciprofloxacin hcl MISCELLANEOUS RESPIRATORY DULERA, INCRUSE ELLIPTA ADVAIR DISKUS, ANORO ELLIPTA, BREO ELLIPTA, SPIRIVA, STIOLTO RESPIMAT, SYMBICORT, TUDORZA PRESSAIR ARCAPTA NEOHALER, FORADIL, PROVENTIL HFA, XOPENEX HFA PERFOROMIST, PROAIR HFA, SEREVENT DISKUS, VENTOLIN HFA BETA AGONISTS ALVESCO, ASMANEX ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR INHALED STEROIDS BECONASE AQ, NASONEX, OMNARIS, QNASL, ZETONNA flunisolide, DYMISTA NASAL STEROIDS TOPICAL ATRALIN, AVAGE, AZELEX, BENZACLIN, VELTIN adapalene, clindamycin phos-tretinoin, clindamycin-benzoyl peroxide, erythromycin, metronidazole, tretinoin, ACANYA, EPIDUO, FINACEA, TAZORAC ACNE ALDARA, FLUOROURACIL, ZYCLARA fluorouracil, imiquimod, PICATO MISCELLANEOUS UROLOGICAL ENABLEX, GELNIQUE, TOVIAZ oxybutynin chloride, tolterodine tartrate, MYRBETRIQ, VESICARE ANTISPASMODICS LEVITRA, STAXYN, STENDRA, VIAGRA sildenafil citrate, CIALIS ERECTILE DYSFUNCTION Please Note.

5 Drugs Marked with * are Excluded CARDIAC ACE INHIBITORS CAPSULE amlodipine besylate-benazepril 1 TABLET benazepril hcl 1 TABLET benazepril hcl-hctz 1 TABLET captopril 1 TABLET captopril/hydrochlorothiazide 1 TABLET enalapril maleate 1 TABLET fosinopril sodium 1 TABLET fosinopril-hydrochlorothiazide 1 TABLET lisinopril 1 TABLET lisinopril-hctz 1 TABLET moexipril hcl 1 TABLET moexipril-hydrochlorothiazide 1 TABLET perindopril erbumine 1 TABLET quinapril 1 TABLET quinapril-hydrochlorothiazide 1 CAPSULE ramipril 1 TABLET trandolapril 1 TABLET ACCUPRIL 3 CAPSULE ALTACE 3 SOLUTION, ORAL EPANED 3 TABLET LOTENSIN 3 TABLET MAVIK 3 TABLET PRINIVIL 3 SOLUTION, ORAL QBRELIS 3 TABLET,IMMED AND EXTEND REL BIPHASE 24HR TARKA 3 TABLET VASOTEC 3 TABLET ZESTRIL 3 ANTICOAGULANTS TABLET cilostazol 1 TABLET clopidogrel 1 TABLET dipyridamole 1 SYRINGE (ML) enoxaparin sodium SP 1 SYRINGE (ML) fondaparinux sodium SP 1 VIAL (ML) heparin sodium 1 TABLET jantoven 1 TABLET, EXTENDED RELEASE pentoxifylline 1 TABLET ticlopidine hcl 1 TABLET warfarin sodium 1 TABLET BRILINTA 2 TABLET COUMADIN 2 TABLET EFFIENT 2 TABLET ELIQUIS 2 SYRINGE (ML) FRAGMIN SP 2 TABLET MEPHYTON 2 TABLET XARELTO SP 2 CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR AGGRENOX 3 CAPSULE PRADAXA 3 ANTIARRHYTHMIC TABLET amiodarone hcl 1 SOLUTION, ORAL digoxin 1 TABLET digoxin 1 CAPSULE disopyramide phosphate 1 TABLET flecainide acetate 1 CAPSULE mexiletine hcl 1 TABLET pacerone 1 VIAL (ML) procainamide hcl 1 TABLET propafenone hcl 1 Printed Date:11/1/2017 Page 5 | 2018 National Formulary Data Last Updated:10/30/2017 B4G Participant.

6 N CARDIAC ANTIARRHYTHMIC VIAL (ML) quinidine gluconate 1 TABLET, EXTENDED RELEASE quinidine sulfate 1 TABLET quinidine sulfate 1 TABLET sorine 1 TABLET sotalol 1 TABLET sotalol af 1 TABLET MULTAQ 2 CAPSULE, EXTENDED RELEASE NORPACE CR 3 CAPSULE TIKOSYN SP 3 OTHER TABLET ENTRESTO 2 TABLET, EXTENDED RELEASE 12 HR RANEXA 2 TABLET VECAMYL 3 ANGIOTENSIN RECEPTOR BLOCKER TABLET candesartan cilexetil 1 TABLET candesartan-hydrochlorothiazid 1 TABLET eprosartan mesylate 1 TABLET irbesartan 1 TABLET irbesartan-hydrochlorothiazide 1 TABLET losartan potassium 1 TABLET losartan-hydrochlorothiazide 1 TABLET olmesartan medoxomil 1 TABLET olmesartan medoxomil 1 TABLET telmisartan 1 TABLET telmisartan-amlodipine 1 TABLET telmisartan-hydrochlorothiazid 1 TABLET valsartan 1 TABLET valsartan-hydrochlorothiazide 1 TABLET TEKAMLO 2 TABLET TEKTURNA 2 TABLET TEKTURNA HCT 2 TABLET ATACAND HCT 3 TABLET AZOR 3 TABLET BENICAR 3 TABLET BENICAR HCT 3 TABLET DIOVAN HCT 3 TABLET EDARBI 3 TABLET EDARBYCLOR 3 TABLET EXFORGE 3 TABLET EXFORGE HCT 3 TABLET TRIBENZOR 3 BETA BLOCKERS CAPSULE acebutolol hcl 1 TABLET atenolol 1 TABLET atenolol w/chlorthalidone 1 TABLET betaxolol hcl 1 TABLET bisoprolol fumarate 1 TABLET bisoprolol fumarate/hctz 1 TABLET carvedilol 1 TABLET labetalol hcl 1

7 TABLET metoprolol tartrate 1 TABLET nadolol 1 TABLET nadolol-bendroflumethiazide 1 TABLET pindolol 1 TABLET propranolol hcl 1 SOLUTION, ORAL propranolol hcl 1 TABLET propranolol hcl-hctz 1 Printed Date:11/1/2017 Page 6 | 2018 National Formulary Data Last Updated:10/30/2017 B4G Participant: N CARDIAC BETA BLOCKERS TABLET timolol maleate 1 TABLET BYSTOLIC 2 CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR COREG CR 2 TABLET LEVATOL 3 CALCIUM CHANNEL BLOCKERS TABLET, EXTENDED RELEASE afeditab cr 1 TABLET amlodipine besylate 1 CAPSULE, EXT RELEASE 24 HR cartia xt 1 CAPSULE, EXT RELEASE 24 HR diltiazem 24hr cd 1 CAPSULE, EXT RELEASE 24 HR diltiazem er 1 TABLET diltiazem hcl 1 TABLET, EXTENDED RELEASE 24 HR felodipine er 1 CAPSULE isradipine 1 CAPSULE nifedipine 1 TABLET, EXTENDED RELEASE nifedipine er 1 CAPSULE nimodipine 1 TABLET, EXTENDED RELEASE 24 HR nisoldipine 1 CAPSULE, EXTENDED RELEASE 24HR taztia xt 1 CAPSULE,24HR EXTENDED RELEASE PELLET CT verapamil er pm 1 TABLET verapamil hcl 1 DIURETICS TABLET acetazolamide 1 TABLET amiloride hcl 1 TABLET amiloride hcl w/hctz 1 TABLET bumetanide 1 TABLET chlorothiazide 1 TABLET eplerenone 1 SOLUTION.

8 ORAL furosemide 1 TABLET hydrochlorothiazide 1 TABLET indapamide 1 TABLET methazolamide 1 TABLET methyclothiazide 1 TABLET metolazone 1 TABLET spironolactone 1 TABLET spironolactone w/hctz 1 TABLET torsemide 1 TABLET triamterene w/hctz 1 CAPSULE DYRENIUM 3 OTHER ANTI-HYPERTENSIVES TABLET clonidine hcl 1 TABLET clorpres 1 TABLET doxazosin mesylate 1 TABLET guanfacine hcl 1 TABLET hydralazine hcl 1 TABLET methyldopa 1 TABLET methyldopa/hydrochlorothiazide 1 TABLET minoxidil 1 CAPSULE prazosin hcl 1 TABLET reserpine 1 CAPSULE terazosin hcl 1 TABLET BIDIL 3 TABLET, EXTENDED RELEASE 24 HR CARDURA XL 3 STATINS TABLET amlodipine-atorvastatin 1 TABLET atorvastatin calcium 1 POWDER IN PACKET (EA) cholestyramine 1 TABLET colestipol hcl 1 Printed Date:11/1/2017 Page 7 | 2018 National Formulary Data Last Updated:10/30/2017 B4G Participant: N CARDIAC STATINS TABLET fenofibrate 1 CAPSULE,DELAYED RELEASE (ENTERIC COATED) fenofibric acid 1 CAPSULE fluvastatin sodium 1 TABLET gemfibrozil 1 TABLET lovastatin 1 TABLET, EXTENDED RELEASE 24 HR niacin er 1 TABLET pravastatin sodium 1 POWDER IN PACKET (EA) prevalite 1 TABLET rosuvastatin calcium 1 TABLET simvastatin 1 CAPSULE JUXTAPID SP 2 CAPSULE LIPOFEN 2 PEN INJECTOR (ML) PRALUENT PEN SP 2 SYRINGE (ML) PRALUENT SYRINGE SP 2 PEN INJECTOR (ML) REPATHA SURECLICK SP 2 SYRINGE (ML) REPATHA SYRINGE SP 2 CAPSULE VASCEPA 2 TABLET WELCHOL 2 POWDER IN PACKET (EA) WELCHOL 2 TABLET, EXTENDED RELEASE 24 HR ALTOPREV 3 CAPSULE ANTARA 3 TABLET CRESTOR 3 TABLET FENOGLIDE 3 TABLET, EXTENDED RELEASE 24 HR LESCOL XL 3 TABLET LIVALO 3 CAPSULE LOVAZA 3 TABLET NIACOR 3 TABLET TRIGLIDE 3 TABLET VYTORIN 3 TABLET ZETIA 3 NITRATES TABLET isosorbide dinitrate 1 TABLET isosorbide mononitrate 1 OINTMENT (GRAM) nitro-bid 1 PATCH, TRANSDERMAL 24 HOURS nitroglycerin 1 AEROSOL, SPRAY (GRAM)

9 Nitroglycerin 1 CAPSULE, EXTENDED RELEASE DILATRATE-SR 2 PATCH, TRANSDERMAL 24 HOURS MINITRAN 3 PATCH, TRANSDERMAL 24 HOURS NITRO-DUR 3 TABLET, SUBLINGUAL NITROSTAT 3 ANALGESICS ANTIARTHRITICS SYRINGE (ML) GELSYN-3 SP 2 SYRINGE (ML) SUPARTZ FX SP 2 SYRINGE (ML) SYNVISC SP 2 SYRINGE (ML) SYNVISC-ONE SP 2 SYRINGE (ML) EUFLEXXA SP 3 SYRINGE (ML) GEL-ONE SP 3 SYRINGE (ML) GENVISC 850 SP 3 SYRINGE (ML) HYALGAN SP 3 SYRINGE (ML) HYMOVIS SP 3 SYRINGE (ML) MONOVISC 3 SYRINGE (ML) ORTHOVISC SP 3 HEADACHE CAPSULE apap/dichlphen/isometheptene 1 AEROSOL, SPRAY WITH PUMP (ML) dihydroergotamine mesylate SP 1 TABLET naratriptan hcl 1 Printed Date:11/1/2017 Page 8 | 2018 National Formulary Data Last Updated:10/30/2017 B4G Participant: N ANALGESICS HEADACHE TABLET rizatriptan 1 TABLET sumatriptan succinate 1 PEN INJECTOR (ML) sumatriptan succinate SP 1 SPRAY, NON-AEROSOL (EA) sumatriptan succinate SP 1 TABLET zolmitriptan 1 TABLET,DISINTEGRATING zolmitriptan odt 1 NEEDLE-FREE INJECTOR (ML) SUMAVEL DOSEPRO 2 TABLET TREXIMET 2 SPRAY, NON-AEROSOL (EA) ZOMIG 2 TABLET AXERT 3 TABLET CAFERGOT 3 TABLET, SUBLINGUAL ERGOMAR 3 TABLET FROVA 3 TABLET RELPAX 3 NARCOTIC ANTAGONISTS TABLET, SUBLINGUAL buprenorphine-naloxone 1 TABLET naltrexone hydrochloride 1 SPRAY, NON-AEROSOL (EA) NARCAN 2 FILM, MEDICATED (EA) SUBOXONE 2 SUSPENSION, EXTENDED RELEASE, RECONST.

10 VIVITROL SP 2 TABLET, SUBLINGUAL ZUBSOLV 2 NARCOTICS SOLUTION, ORAL acetaminophen w/codeine 1 TABLET acetaminophen w/codeine 1 TABLET, SUBLINGUAL buprenorphine hydrochloride 1 CAPSULE butalbital compound 1 CAPSULE butalbital compound w/codeine 1 TABLET butalbital/apap/caffeine 1 CAPSULE butalbital/caff/apap/codeine 1 TABLET codeine sulfate 1 TABLET, SOLUBLE diskets 1 PATCH, TRANSDERMAL 72 HOURS fentanyl 1 LOZENGE ON A HANDLE fentanyl citrate 1 TABLET hydrocodone bit-ibuprofen 1 TABLET hydrocodone w/acetaminophen 1 SOLUTION, ORAL hydrocodone w/acetaminophen 1 TABLET hydromorphone hcl 1 SOLUTION, ORAL meperidine hcl 1 SOLUTION, ORAL methadone hcl 1 SUPPOSITORY, RECTAL morphine sulfate 1 TABLET, EXTENDED RELEASE morphine sulfate er 1 SOLUTION, ORAL oxycodone hcl 1 TABLET oxycodone hcl-ibuprofen 1 TABLET oxycodone w/acetaminophen 1 TABLET oxycodone w/aspirin 1 TABLET oxymorphone hcl 1 PATCH, TRANSDERMAL WEEKLY BUTRANS 2 TABLET, EFFERVESCENT FENTORA 2 TABLET,ORAL ONLY,EXTENDED RELEASE 24 HR HYSINGLA ER 2 TABLET NUCYNTA 2 TABLET, EXTENDED RELEASE 12 HR NUCYNTA ER 2 TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR OXYCONTIN 2 TABLET, SUBLINGUAL ABSTRAL 3 SUSPENSION, ORAL (FINAL DOSE FORM) CAPITAL W/CODEINE 3 CAPSULE,ORAL ONLY, EXT.


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