FEP® Blue Focus Formulary (907) - Caremark

1 1 FEP blue Focus Formulary (907) Effective April 1, 2023 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.

2 6 Formulary PRODUCT DESCRIPTIONS .. 6 GENERIC SUBSTITUTION .. 7 DRUG EFFICACY STUDY IMPLEMENTATION DRUGS .. 7 EDITOR .. 7 NOTICE .. 7 LEGEND .. 8 ANALGESICS .. 9 COX-2 9 GOUT .. 9 NSAIDs .. 9 NSAIDs, COMBINATIONS .. 9 NSAIDs, TOPICAL .. 9 OPIOID ANALGESICS .. 9 NON-OPIOID ANALGESICS .. 10 10 ANTI-INFECTIVES .. 10 11 ANTIFUNGALS .. 12 12 ANTIRETROVIRAL AGENTS .. 12 ANTITUBERCULAR 13 13 14 ANTINEOPLASTIC AGENTS .. 15 ALKYLATING 15 ANTIMETABOLITES .. 15 HORMONAL ANTINEOPLASTIC AGENTS .. 15 IMMUNOMODULATORS .. 16 KINASE 16 MULTIPLE MYELOMA .. 17 TOPOISOMERASE INHIBITORS .. 17 17 CARDIOVASCULAR .. 19 ACE INHIBITORS .. 19 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS .. 19 ACE INHIBITOR/DIURETIC COMBINATIONS .. 19 ADRENOLYTICS, CENTRAL .. 19 ALDOSTERONE RECEPTOR ANTAGONISTS.

3 19 2 ALPHA BLOCKERS .. 19 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS .. 20 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS .. 20 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS .. 20 ANTIARRHYTHMICS .. 20 ANTILIPEMICS .. 20 BETA-BLOCKERS .. 21 BETA-BLOCKER/DIURETIC COMBINATIONS .. 21 CALCIUM CHANNEL BLOCKERS .. 22 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS .. 22 DIGITALIS GLYCOSIDES .. 22 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS .. 22 DIURETICS .. 22 HEART 22 NITRATES .. 23 PULMONARY ARTERIAL HYPERTENSION .. 23 23 CENTRAL NERVOUS SYSTEM .. 23 ANTIANXIETY .. 23 ANTICONVULSANTS .. 24 ANTIDEMENTIA .. 24 ANTIDEPRESSANTS .. 25 ANTIPARKINSONIAN AGENTS .. 25 26 ATTENTION DEFICIT HYPERACTIVITY DISORDER .. 26 FIBROMYALGIA.

4 27 27 MIGRAINE .. 27 MOOD STABILIZERS .. 28 MOVEMENT 28 MULTIPLE SCLEROSIS .. 28 MUSCULOSKELETAL THERAPY AGENTS .. 28 MYASTHENIA 28 NARCOLEPSY/CATAPLEXY .. 28 PSYCHOTHERAPEUTIC-MISCELLANEOUS .. 29 29 ENDOCRINE AND METABOLIC .. 29 29 ANTIDIABETICS .. 30 ANTIOBESITY .. 32 CALCIUM RECEPTOR AGONISTS .. 32 CALCIUM REGULATORS .. 32 CARNITINE DEFICIENCY 33 CONTRACEPTIVES .. 33 ENDOMETRIOSIS .. 34 FERTILITY REGULATORS .. 34 GAUCHER DISEASE .. 34 GLUCOCORTICOIDS .. 34 GLUCOSE ELEVATING AGENTS .. 34 HEREDITARY TYROSINEMIA TYPE 1 AGENTS .. 35 HUMAN GROWTH HORMONES .. 35 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS .. 35 INSULIN-LIKE GROWTH FACTOR-1 AGENTS .. 35 MENOPAUSAL SYMPTOM 35 PHENYLKETONURIA TREATMENT AGENTS .. 36 PHOSPHATE BINDER 36 PROGESTINS .. 36 SELECTIVE ESTROGEN RECEPTOR MODULATORS.

5 36 THYROID AGENTS .. 36 UREA CYCLE 36 VASOPRESSINS .. 36 36 GASTROINTESTINAL .. 37 ANTIDIARRHEALS .. 37 37 3 ANTISPASMODICS .. 37 CHOLELITHOLYTICS .. 37 H2 RECEPTOR ANTAGONISTS .. 37 INFLAMMATORY BOWEL DISEASE .. 38 IRRITABLE BOWEL SYNDROME .. 38 LAXATIVES .. 38 OPIOID-INDUCED CONSTIPATION .. 38 PANCREATIC ENZYMES .. 38 PROSTAGLANDINS .. 38 PROTON PUMP 38 SALIVA STIMULANTS .. 38 STEROIDS, RECTAL .. 39 ULCER THERAPY 39 39 GENITOURINARY .. 39 BENIGN PROSTATIC HYPERPLASIA .. 39 URINARY ANTISPASMODICS .. 39 VAGINAL ANTI-INFECTIVES .. 39 39 HEMATOLOGIC .. 40 ANTICOAGULANTS .. 40 HEMATOPOIETIC GROWTH 40 HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS .. 40 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS .. 41 PLATELET AGGREGATION 41 PLATELET SYNTHESIS INHIBITORS .. 41 SICKLE CELL DISEASE.

6 41 STEM CELL MOBILIZERS .. 41 41 IMMUNOLOGIC AGENTS .. 41 ALLERGENIC EXTRACTS .. 41 AUTOIMMUNE AGENTS .. 41 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs).. 41 HEREDITARY ANGIOEDEMA AGENTS .. 42 IMMUNE GLOBULINS .. 42 IMMUNOMODULATORS .. 42 42 NUTRITIONAL/SUPPLEMENTS .. 43 43 VITAMINS AND MINERALS .. 43 RESPIRATORY .. 43 ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS .. 43 ANAPHYLAXIS TREATMENT AGENTS .. 43 ANTICHOLINERGICS .. 43 ANTICHOLINERGIC/BETA AGONIST 44 ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT 44 ANTIHISTAMINES, 44 ANTITUSSIVES .. 44 ANTITUSSIVE COMBINATIONS .. 44 BETA AGONISTS .. 44 CYSTIC FIBROSIS .. 44 LEUKOTRIENE MODULATORS .. 45 MAST CELL STABILIZERS .. 45 NASAL ANTIHISTAMINES .. 45 NASAL 45 PHOSPHODIESTERASE-4 INHIBITORS .. 45 PULMONARY FIBROSIS AGENTS .. 45 SEVERE ASTHMA 45 STEROID/BETA AGONIST COMBINATIONS.

7 45 STEROID INHALANTS .. 45 XANTHINES .. 45 46 46 DERMATOLOGY .. 46 4 MOUTH/THROAT/DENTAL 49 OPHTHALMIC .. 49 OTIC .. 51 WEBSITES .. 52 INDEX .. 54 5 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 if you have any questions about dispensing limits. INTRODUCTION FEP is pleased to provide the 2023 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.

8 National guidelines can be found on the National Guideline Clearinghouse site at , 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: Tier 1 Tier 2 Preferred generics Preferred brand-name, preferred generic 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.

9 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.

10 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. 6 PRODUCT SELECTION CRITERIA The FEP Pharmacy and Medical Policy Committee will consider 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.