FEP 5 Tier Managed Rx Drug Formulary (807) Basic Option

1 1 FEP 5 Tier Managed Rx Drug Formulary (807) Basic Option Effective April 1, 2022 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.

2 7 DRUG EFFICACY STUDY IMPLEMENTATION DRUGS .. 8 EDITOR .. 8 NOTICE .. 8 LEGEND .. 8 ANALGESICS .. 10 ANALGESICS, OTHER .. 10 COX-2 INHIBITORS .. 10 GOUT .. 10 NSAIDs .. 10 NSAIDs, COMBINATIONS .. 10 NSAIDs, TOPICAL .. 10 OPIOID ANALGESICS .. 10 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 MULTIPLE MYELOMA .. 19 TOPOISOMERASE INHIBITORS .. 20 MISCELLANEOUS .. 20 CARDIOVASCULAR .. 22 ACE INHIBITORS .. 22 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS .. 22 ACE INHIBITOR/DIURETIC COMBINATIONS .. 22 ADRENOLYTICS, CENTRAL .. 22 2 ALDOSTERONE RECEPTOR ANTAGONISTS .. 22 ALPHA BLOCKERS .. 23 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS .. 23 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS.

3 23 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS .. 23 ANTIARRHYTHMICS .. 23 ANTILIPEMICS .. 23 BETA-BLOCKERS .. 24 BETA-BLOCKER/DIURETIC COMBINATIONS .. 25 CALCIUM CHANNEL BLOCKERS .. 25 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS .. 25 DIGITALIS GLYCOSIDES .. 25 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS .. 25 DIURETICS .. 25 HEART FAILURE .. 26 NITRATES .. 26 PULMONARY ARTERIAL HYPERTENSION .. 26 MISCELLANEOUS .. 27 CENTRAL NERVOUS SYSTEM .. 27 ANTIANXIETY .. 27 ANTICONVULSANTS .. 27 28 ANTIDEPRESSANTS .. 28 ANTIPARKINSONIAN AGENTS .. 30 ANTIPSYCHOTICS .. 30 ATTENTION DEFICIT HYPERACTIVITY DISORDER .. 31 FIBROMYALGIA .. 31 HYPNOTICS .. 32 MIGRAINE .. 32 MOOD STABILIZERS .. 33 MOVEMENT DISORDERS .. 33 MULTIPLE SCLEROSIS .. 33 MUSCULOSKELETAL THERAPY AGENTS .. 33 MYASTHENIA GRAVIS .. 33 NARCOLEPSY/CATAPLEXY .. 33 PSYCHOTHERAPEUTIC-MISCELLANEOUS .. 34 MISCELLANEOUS .. 34 ENDOCRINE AND METABOLIC .. 35 ANDROGENS .. 35 ANTIDIABETICS .. 35 CALCIUM RECEPTOR ANTAGONISTS.

4 37 CALCIUM REGULATORS .. 37 CARNITINE DEFICIENCY AGENTS .. 38 CONTRACEPTIVES .. 38 DIABETIC KIDNEY DISEASE .. 40 ENDOMETRIOSIS .. 40 ESTROGENS .. 40 ESTROGEN/PROGESTINS .. 40 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS .. 40 FERTILITY REGULATORS .. 41 GAUCHER DISEASE .. 41 GLUCOCORTICOIDS .. 41 GLUCOSE ELEVATING AGENTS .. 41 HEREDITARY TYROSINEMIA TYPE 1 AGENTS .. 41 HUMAN GROWTH HORMONES .. 41 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS .. 41 INSULIN-LIKE GROWTH FACTOR-1 AGENTS .. 42 PHENYLKETONURIA TREATMENT AGENTS .. 42 PHOSPHATE BINDER AGENTS .. 42 POTASSIUM-REMOVING AGENTS .. 42 PROGESTINS .. 42 SELECTIVE ESTROGEN RECEPTOR MODULATORS .. 42 THYROID AGENTS .. 42 UREA CYCLE DISORDERS .. 43 UTERINE FIBROIDS .. 43 3 VASOPRESSINS .. 43 MISCELLANEOUS .. 43 GASTROINTESTINAL .. 44 ANTIDIARRHEALS .. 44 ANTIEMETICS .. 44 ANTISPASMODICS .. 44 CHOLELITHOLYTICS .. 44 H2 RECEPTOR ANTAGONISTS .. 44 INFLAMMATORY BOWEL DISEASE .. 44 IRRITABLE BOWEL SYNDROME .. 45 LAXATIVES .. 45 OPIOID-INDUCED CONSTIPATION.

5 45 PANCREATIC ENZYMES .. 45 PROSTAGLANDINS .. 45 PROTON PUMP INHIBITORS .. 45 SALIVA STIMULANTS .. 46 STEROIDS, RECTAL .. 46 ULCER THERAPY COMBINATIONS .. 46 MISCELLANEOUS .. 46 GENITOURINARY .. 46 BENIGN PROSTATIC HYPERPLASIA .. 46 URINARY ANTISPASMODICS .. 46 VAGINAL ANTI-INFECTIVES .. 47 MISCELLANEOUS .. 47 HEMATOLOGIC .. 47 ANTICOAGULANTS .. 47 HEMATOPOIETIC GROWTH FACTORS .. 47 HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS .. 48 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS .. 48 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS .. 48 PLATELET AGGREGATION INHIBITORS .. 48 PLATELET SYNTHESIS INHIBITORS .. 49 SICKLE CELL DISEASE .. 49 STEM CELL MOBILIZERS .. 49 THROMBOCYTOPENIA AGENTS .. 49 MISCELLANEOUS .. 49 IMMUNOLOGIC AGENTS .. 49 ALLERGENIC EXTRACTS .. 49 AUTOIMMUNE AGENTS .. 49 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) .. 50 HEREDITARY ANGIOEDEMA AGENTS .. 50 IMMUNE GLOBULINS .. 50 IMMUNOMODULATORS .. 51 IMMUNOSUPPRESSANTS .. 51 NUTRITIONAL/SUPPLEMENTS.

6 52 ELECTROLYTES .. 52 VITAMINS AND MINERALS .. 52 MISCELLANEOUS .. 52 RESPIRATORY .. 52 ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS .. 52 ANAPHYLAXIS TREATMENT AGENTS .. 52 ANTICHOLINERGICS .. 52 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS .. 53 ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS .. 53 ANTIHISTAMINES, SEDATING .. 53 ANTITUSSIVES .. 53 ANTITUSSIVE COMBINATIONS .. 53 BETA AGONISTS .. 53 CYSTIC FIBROSIS .. 54 LEUKOTRIENE MODULATORS .. 54 MAST CELL STABILIZERS .. 54 NASAL ANTIHISTAMINES .. 54 NASAL STEROIDS/COMBINATIONS .. 54 PHOSPHODIESTERASE-4 54 4 PULMONARY FIBROSIS AGENTS .. 54 SEVERE ASTHMA AGENTS .. 54 STEROID/BETA AGONIST COMBINATIONS .. 54 STEROID INHALANTS .. 55 XANTHINES .. 55 MISCELLANEOUS .. 55 TOPICAL .. 55 DERMATOLOGY .. 55 MOUTH/THROAT/DENTAL AGENTS .. 59 OPHTHALMIC .. 59 OTIC .. 62 WEBSITES .. 63 2022 FEP Managed NOT COVERED DRUG LIST Basic Option CHART .. 65 INDEX .. 74 5 The Retail and Mail Service Prescription Drug Program cannot refill a controlled substance until 80% of the prescription has been used.

7 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 2022 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 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 .

8 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-name drugs non-preferred brand-name drugs and all compounded medications preferred specialty drugs non-preferred specialty drugs Basic Option Preferred Retail Pharmacy $10 copay for a 0 to 30-day supply $30 copay for 31 to 90-day supply $55 copay for a 0 to 30-day supply $165 copay for 31 to 90-day supply 60% coinsurance* $85 copay Limit**: one 30-day supply fill at retail $110 copay Limit**: one 30-day supply fill at retail Basic Option Specialty Drug Pharmacy Program $85 for a 0 to 30-day supply $235 for 31 to 90-day supply $110 for a 0 to 30-day supply $300 for 31 to 90-day supply Basic Option Retail Pharmacy (Med B Primary) $10 copay for a 0 to 30-day supply $30 copay for 31 to 90-day supply $50 copay for a 0 to 30-day supply $150 copay for 31 to 90-day supply 50% coinsurance** $80 copay Limit**.

9 One 30-day supply fill at retail $100 copay Limit**: one 30-day supply fill at retail Basic Option Mail Pharmacy (Med B Primary) $20 copay $100 copay $125 copay Basic Option Specialty Drug Pharmacy Program (Med B Primary) $80 for a 0 to 30-day supply $100 for a 0 to 30-day supply 6 $210 for 31 to 90-day supply $255 for 31 to 90-day supply * With a minimum payment of $75 for a 0 to 30-day supply ($210 for a 31 to 90-day supply) ** With a minimum payment of $60 for a 0 to 30-day supply ($175 for a 31 to 90-day supply) ** 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 indicate generic availability. All drugs that are preferred are noted in their respective tiers of the drug lists throughout this Formulary .

10 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 Select medications are not 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 before the INDEX in this document. Patients taking a Managed Not Covered medication 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.