DRUG COVERAGE CRITERIA NEW AND THERAPEUTIC EQUIVALENT MEDICATIONS

Transcription

1 CLINICAL POLICY DRUG COVERAGE CRITERIA NEW AND THERAPEUTIC EQUIVALENT MEDICATIONS Policy Number: PHARMACY T2 Effective Date: January 1, 2016 Table of Contents CONDITIONS OF COVERAGE... COVERAGE RATIONALE.. DEFINITIONS... REFERENCES... POLICY HISTORY/REVISION INFORMATION... Page Related Policy: Prescription Drug Quantity Duration (QD) and Quantity Level Limitations (QLL) The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern CONDITIONS OF COVERAGE This policy applies to Connecticut, New Jersey and New York Commercial plans. Exclusions Connecticut Plans and Products: Effective January 1, 2012, as groups enroll or renew, insurers cannot require an individual to use an alternative brand name prescription drug or over-the-counter drug before using the brand name prescription drug that was prescribed by a licensed physician for pain management. Insurers can, however, first require the individual to try a therapeutically equivalent generic drug before approving the brand name prescription drug that was prescribed by the physician. Note: Not all Oxford Members have a pharmacy benefit. For coverage of outpatient prescription drugs and specific exclusions, exceptions, and dispensing limitations, refer to the Member's pharmacy plan, if applicable. Oxford's Pharmacy Benefit Manager (PBM) provides a nationwide network of participating pharmacies that dispense prescription medications on a retail level. Commercial groups with outpatient prescription drug coverage will have their pharmacy benefit administered by the PBM. For information regarding any quantity level limitations, refer to Prescription Drug Quantity Duration (QD) and Quantity Level Limitations (QLL). 1

2 COVERAGE RATIONALE This policy provides information and criteria relevant to medications for which certain types of prescription drug benefit exclusions may apply. In accordance with Oxford's prescription drug riders, certain medications are excluded from coverage. The rationale for such exclusions varies, and therefore coverage may be provided in certain clinical scenarios. There are two types of exclusions addressed in this policy: Exclude at Launch: In an effort to enhance the affordability and value of prescription drug riders, and as part of our Prescription Drug List (PDL) management, Oxford will proactively identify and help manage the cost of low value medications being introduced into the market. The Exclude at Launch program delays coverage until a full evaluation can be completed for new medications that may offer little to no additional health care value. Our PDL Management Committee will review each Exclude at Launch medication to determine its tier placement or benefit coverage. Same Active Ingredient: Oxford may exclude coverage for a medication, unless it is medically necessary for the member, if it includes the same active ingredient (or a modified version of an active ingredient) and is therapeutically equivalent to a covered prescription medication. Oxford's definition of therapeutic equivalence refers to medications that produce the same therapeutic outcome and adverse event profile. The following table provides a list of prescription medications for which one or both of the above exclusions apply. Precertification through the Pharmacy Benefit Manager (PBM) is required for all listed medications. Coverage will be provided only when Member has exhibited intolerance (that is, sensitivity, drug allergy, adverse effect) to, or experienced a therapeutic failure with at least ONE of the covered formulary alternatives noted below (EXCEPT where noted). Medication/Drug Absorica Abstral Acanya Acticlate Actiq Active-Pac/Gaba 300 Actos (brand only) Acuvail Adderall (brand only) Adoxa Adrenaclick Akynzeo Alsuma Altoprev Ambien (brand only) Ambien CR (brand and generic) amphetamine/dextroamphetamine extended-release (generic Adderall XR) Amrix/cyclobenzaprine extended release Amturnide Isotretinoin (generic for Accutane), Amnesteem, Claravis, Myorisan, Sotret, Zenatane fentanyl citrate (generic Actiq), Lazanda clindamycin 1%/benzoyl peroxide 5% gel (generic Benzaclin) Doxycycline hyclate (generic Vibramycin, Vibra-Tabs) Fentanyl citrate lozenges (generic for Actiq) gabapentin (generic Neurontin) pioglitazone (generic Actos) Ketorolac amphetamine/dextroamphetamine immediate-release (generic Adderall) Doxycycline (generic for Monodox, Vibramycin) EpiPen, EpiPen Jr. dolasetron (generic Anzemet), granisetron (generic Kytril), ondansetron (generic Zofran), Emend sumatriptan injection Lovastatin (generic Mevacor) Must try two: zolpidem, zalepelon, eszopiclone Must try two: zolpidem, zalepelon, eszopiclone Adderall XR Cyclobenzaprine HCL(generic for Flexeril) Amlodipine + Tekturna HCT (or individual components taken concomitantly) 2

3 Analpram Advanced Kit Hydrocortisone acetate/pramoxine HCl, Analpram HC Androgel Testim, Androderm Antara 30 mg & 90 mg strengths fenofibrate 54 mg, 160 mg (generic Lofibra) only Antara 43 mg, 130 mg Aplenzin Buproprion XL (generic for Wellbutrin XL) Apop 10% gel Sulfacetamide lotion, solution, suspension Aptensio XR Must try both: Concerta, Metadate CD Aqua Glycolilc HC Hydrocortisone 2.5% (generic Hytone) Aricept (23 mg only) donepezil 10mg (generic for Aricept 10mg) Arimidex (brand only) anastrozole (generic Arimidex) Asacol HD Apriso, Lialda AsmalPred Prednisolone sodium phosphate (generic Orapred) AsmalPred Plus prednisolone sodium phosphate (generic Orapred) Asmanex HFA Asmanex TwistHaler, Alvesco, QVAR Astagraf XL tacrolimus (generic Prograf), Prograf Astelin (brand only) Azelastine nasal spray (generic Astelin) Astepro azelastine (generic Astelin) Atelvia Actonel Ativan (brand only) lorazepam (generic Ativan) Atralin tretinoin (generic Retin-A) Augmentin XR / Amoxicillin- Amoxicillin/clavulanate potassium (generic for Augmentin) Clavulanate ER Auvi-Q EpiPen, EpiPen Jr. Avelox tablet (Brand Only) moxifloxacin tablets (generic Avelox) Avinza (Brand Only) orphine sulfate extended-release tablet (generic MS Contin), morphine sulfate extended-release capsule (generic Avinza) Axiron Testim Azor Amlodipine (generic Norvasc) plus Benicar, Norvasc plus Benicar Beconase AQ Must try two: flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, Nasacort OTC Benzaclin jar (brand only) clindamycin 1%/benzoyl peroxide 5% gel (generic Benzaclin) Benzaclin Kit (1%-5%) Clindamycin Phosphate + OTC Benzoyl Peroxide Benzaclin Pump clindamycin 1%/benzoyl peroxide 5% gel (generic Benzaclin) Benzefoam, Benzefoam Ultra OTC Benzoyl peroxide Bepreve azelastine (generic for Optivar) AND Lastacaft betamethasone valerate foam betamethasone lotion (generic Valisone (generic Luxiq) Beyaz Yaz + folic acid bimatoprost 0.03% (generic Lumigan) Lumigan 0.01% Binosto Alendronate (generic Fosamax) Brisdelle paroxetine (generic Paxil), Paxil Bromday Bromfenac (generic Xibrom), ketorolac (generic Acular) budesonide nasal spray (generic Rhinocort Aqua) Two of the following: fluticasone (generic Flonase), flunisolide (generic Nasarel), OTC - Nasacort Bunavail Film Zubsolv butalbital/acetaminophen/caffeine/c odeine 50mg/300mg/40mg/30mg butalbital/acetaminophen/caffeine/codeine 50 mg/325 mg/40 mg/30 mg (generic Fioricet with Codeine) (generic Fioricet with Codeine) 3

4 Caduet and Generic Caduet (atorvastatin/amlodipine) Amlodipine (generic Norvasc) + atorvastatin (generic for Lipitor) Cambia diclofenac potassium, diclofenac sodium capecitabine (generic Xeloda) Xeloda Celebrex (brand only) celecoxib (generic Celebrex) Celexa (brand only) citalopram (generic Celexa) Cenestin Must try both: Enjuvia, Premarin Centany AT Kit mupirocin ointment choline fenofibrate (generic Trilipix) Fenofibrate 54 mg, 160 mg (generic Lofibra) Ciclodan Combination Package Ciclopirox (generic for Loprox), Loprox Ciclodan Kit Ciclopirox nail lacquer Clarinex / desloratidine Levocetirizine (generic for Xyzal) Clarinex-D Levocetirizine (generic for Xyzal) + OTC pseudoephedrine Clindacin Pac Clindamycin gel, solution, lotion or swabs Clindagel Clindamycin gel 1% (generic Cleocin-T) Clindamycin 1%/benzoyl peroxide 5% (generic BenzaClin) gel Must try both: clindamycin solution (generic Cleocin T) plus OTC benzoyl peroxide and clindamycin 1.2%/benzoyl peroxide 5% (generic Duac) Clobeta Clobetasol 0.05% + OTC coal tar Clobetasol shampoo (generic Clobetasol (generic Temovate), Temovate Clobex shampoo) Clobex Lotion clobetasol 0.05% gel (generic Temovate), clobetasol 0.05% solution (generic Temovate) Clobex shampoo Generic clobetasol propionate solution or foam Clodan 0.05% Clobetasol (generic Temovate) lotion, Temovate lotion Clodan 0.05% kit Clobetasol (generic Temovate) lotion, Temovate lotion Cocet Plus Acetaminophen with codeine Colchicine Capsule (manufacturer Mitigare of West-Ward) Colchicine Tablet (manufacturer of Mitigare Prasco) Colcrys Mitigare Comfort Pac Tizanadine Tizanadine (generic for Zanaflex) ConZip tramadol immediate-release (generic Ultram), tramadol extended-release (generic Ultram ER) Coreg CR Corlanor Cosopt PF Culprimine Cymbalta (brand only) Daytrana Delos Lotion Delos Cleanser Delzicol Denavir carvedilol (generic for Coreg), Coreg benazepril (generic Lotensin), benazepril/hctz (generic Lotensin HCT), enalapril (generic Vasotec), enalapril/hctz (generic Vaseretic), irbesartan (generic Avapro), irbesartan/hctz (generic Avalide), lisinopril (generic Prinivil, Zestril), losartan (generic Cozaar), losartan/hctz (generic Hyzaar), ramipril (generic Altace), valsartan (generic Diovan), valsartan/hctz (generic Diovan HCT), Benicar, Benicar HCT Dorzolamide/timolol (generic Cosopt) Depen duloxetine (generic Cymbalta) Must try two: Brand or generic: Adderall XR, Concerta, Metadate CD or Vyvanse. (note brand and generic will count as 1 alternative med) OTC benzoyl peroxide OTC benzoyl peroxide Apriso, Lialda Must try two: acyclovir capsule/tablet (generic Zovirax), famciclovir tablet (generic Famvir), valacyclovir tablet (generic Valtrex), OTC Abreva 4

5 Dermasorb XM 39% kit urea 40% (generic Carmol 40) Desloratadine (generic Clarinex) Levocetirizine (generic Xyzal), OTC cetirizine (generic Zyrtec), OTC fexofenadine (generic Allegra), OTC loratadine (generic Claritin) Desonil cream/ointment (Kit) Desonide 0.05% cream, ointment Desvenlafaxine venlafaxine extended-release capsule (generic Effexor XR), Pristiq Desvenlafaxine ER venlafaxine extended-release (generic Effexor XR), Pristiq Detrol oxybutynin (generic Ditropan), oxybutynin extended-release (generic Ditropan XL), Ditropan, Ditropan XL, Toviaz, Oxytrol OTC Detrol LA oxybutynin (generic Ditropan), oxybutynin extended-release (generic Ditropan XL), Ditropan, Ditropan XL, Toviaz, Oxytrol OTC dexmethlyphenidate extendedrelease capsule (generic Focalin Metadate CD or Vyvanse. (note brand and generic will Must try two: Brand or generic: Adderall XR, Concerta, XR) count as 1 alternative med) Differin 0.3% gel adapalene gel (generic Differin gel), Differin 0.1% gel Diovan HCT (brand only) valsartan/hydrochlorothiazide (generic Diovan HCT) Disalcid salsalate donepezil 23 mg (generic Aricept 23 donepezil 5, 10 mg (generic Aricept), Aricept 5 & 10mg mg) Doryx /doxycycline hyclate delayed Doxycycline (generic for Monodox, Vibramycin) release tablet Doxycycline 75 mg capsule (generic Monodox) Doxycycline Delayed-Release Capsule 40 mg Doxycycline monohydrate 150mg capsule (generic for Adoxa) Duac, Duac CS Duexis Duopa Duragesic (Brand Only) Durlaza Dymista Ecoza Effexor XR (brand only) Elestat Emadine Embeda Enablex Entocort EC (brand only) Envarsus XR Epiduo Forte Epinephrine Pen Injection 0.15mg and 0.3 mg (generic Adrenaclick) Ertaczo doxycycline hyclate (generic Morgidox, Vibramycin), doxycycline monohydrate 50 mg or 100 mg (generic Monodox) Oracea Doxycycline (generic for Monodox, Vibramycin) clindamycin/benzoyl peroxide (generic for Benzaclin), Benzaclin Ibuprofen (generic Motrin) plus OTC famotidine (generic Pepcid AC) carbidopa/levodopa (generic Sinemet) fentanyl transdermal patch (generic Duragesic) OTC aspirin fluticasone (generic for Flonase) + azelastine (generic for Astelin) or Astepro econazole (generic Spectrazole) venlafaxine extended-release capsule (generic Effexor XR) Azelastine (generic for Optivar) AND Lastacaft Azelastine (generic for Optivar) AND Lastacraft morphine sulfate extended-release (generic MS Contin), Opana ER, Oxycontin, Nucynta ER, Zohydro ER Oxytrol OTC, oxybutynin, oxybutynin extended-release, Ditropan, Ditropan XL, Toviaz budesonide (generic Entocort EC) tacrolimus (generic Prograf), Hecoria Epiduo EpiPen, EpiPen Jr. Must try two: ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral) 5

6 Estradiol TD twice weekly patch (generic Vivelle-Dot) Evekeo Evista (Brand Only) Evzio Exalgo Exforge Exforge HCT Fabior Falessa Kit Femara (brand only) Fenofibrate 43 mg, 130 mg (generic Antara) capsule Fenofibrate 48mg, 145mg (generic Tricor) Fenofibrate 50 mg, 150 mg (generic Lipofen) capsule Fentanyl transdermal patch (37.5, 62.5 and 87.5 mcg/hr strengths only) Vivelle-Dot amphetamine/dextroamphetamine immediate-release (generic Adderall), dextroamphetamine immediate-release (generic Dexedrine) raloxifene (generic Evista) naloxone (generic Narcan) hydromorphone extended-release tablet (generic Exalgo) amlodipine (generic Norvasc) plus losartan (generic Cozaar), Benicar, Diovan, or telmisartan (generic Micardis) amlodipine (generic Norvasc) plus lisinopril/hydrochlorothiazide (generic Prinizide, Zestoretic), losartan/hydrochlorothiazide (generic Hyzaar), valsartan/hydrochlorothiazide (generic Diovan HCT), Benicar HCT, telmisartan/hydrochlorothiazide or telmisartan/hydrochlorothiazide (generic Micardis HCT) Tazorac gel levonorgestrel/ethinyl estradiol (generic Alesse, Levlite) [branded generics (Aubra, Aviane, Lessina, Lutera, Orsythia, Sronyx, Falmina)] plus Folic Acid letrozole (generic Femara) Fenofibrate 54mg, 160mg (generic Lofibra) Fentanyl transdermal patch (12.5, 25, 50, 75, 100 mcg/hr only) (generic Duragesic) Fentora Fentanyl citrate lozenges (generic for Actiq), Lazanda Fibricor 35 mg, 105 mg Finacea 15% Foam Finacea Gel 15% Fioricet with Codeine capsule 50 mg/300 mg/40 mg/30 mg butalbital/acetaminophen/caffeine/codeine 50 mg/325 mg/40 mg/30 mg (generic Fioricet with Codeine Fioricet with Codeine 50 mg/325 mg/40 mg/30 mg (Brand Only) butalbital/acetaminophen/caffeine/codeine phosphate 50 mg/325 mg/40 mg/30 mg (generic Fioricet with Codeine) Flector Voltaren Gel Flomax (brand only) tamsulosin (generic Flomax) Flo-Pred Prednisolone sodium phosphate (generic for Orapred) FlowTuss guaifenesin/codeine solution (Cheratussin) fluocinonide 0.1% cream (generic fluocinonide cream (generic Lidex) Vanos) Fluorouracil 0.5% Cream Carac Focalin XR Must try two: Brand or generic: Adderall XR, Concerta, Metadate CD or Vyvanse. (note brand and generic will count as 1 alternative med) Forfivo XL Fortesta Genadur Kit Generess FE Genotropin and Genotropin MiniQuick Bupropion (generic Wellbutrin), bupropion SR (Wellbutrin SR), buproprion XL (generic Wellbutrin XL), Wellbutrin, Wellbutrin SR, Wellbutrin XL Testim Genadur Gildess FE, Junel FE, Larin FE, Microgestin FE (generic for Loestrin FE), Loestrin FE, Lo Loestrin FE, LoMedia Nutropin, Nutropin AQ, or Nutropin AQ NuSpin 6

7 Geodon (brand only) ziprasidone (generic Geodon) Giazo balsalazide (generic for Colazal) Glatopa (Glatiramer generic Copaxone) Must try two: Avonex, Copaxone (brand only), Betaseron, Tecfidera Glycate glycopyrrolate (generic Robinul) Glyxambi Nesina, Onglyza or Tradjenta + Invokana or Jardiance Gralise Gabapentin (generic Neurontin) Granix Neupogen Helidac Pylera Hemangeol Oral solution Propranolol tablet, propranolol oral solution Histex-AC Syrup guaifenesin/codeine solution (Cheratussin) Horizant Gabapentin (generic Neurontin) Humatrope Nutropin, Nutropin AQ, or Nutropin AQ NuSpin Hycofenix guaifenesin/codeine solution (Cheratussin) Hysingla ER morphine sulfate extended-release (generic MS Contin), Opana ER, Oxycontin, Nucynta ER, Zohydro ER Ilevro Nevanac Imitrex tablets (brand only) sumatriptan injection and tablets (generic Imitrex) Imitrex injection (brand only) sumatriptan injection and tablets (generic Imitrex) Irenka duloxetine (generic Cymbalta) Ixinity BeneFIX, Rixubis Jalyn Avodart (requires precertification if <46 y.o. or female) + tamsulosin Kadian Morphine sulfate sustained action Kapvay clonidine immediate release tablets (generic for Catapres) Karbinal ER carbinoxamine tablets (generic Palgic) Keralac 47% cream urea 40% Keralyt Scalp Kit Salicylic acid shampoo, salicylic acid gel Ketocon ketoconzaole 2% + hydrocortisone 1% Ketodan Combination Package Ketoconazole cream, shampoo or foam (generic Nixoral) Keveyis acetazolamide (generic Diamox) Khedezia venlafaxine extended-release (generic Effexor XR), Pristiq Kitabis Pak Bethkis Levalbuterol nebs (generic Xopenex Albuterol (generic Proventil) nebs) Lexapro (brand only) escitalopram (generic Lexapro) Lidoderm lidocaine transdermal patch (generic Lidoderm) Lidorx lidocaine 2% gel Lipitor (brand only) Atorvastatin (generic Lipitor) Lipofen Liptruzet atorvastatin (generic Lipitor) plus Zetia Locoid Lipocream hydrocortisone butyrate (generic Locoid) Locoid Lotion hydrocortisone butyrate (generic Locoid) Lofibra 54 mg, 160 mg (Brand only) Lofibra 67, 134, 200 mg Lo Minastrin FE Gildess Fe, Junel Fe, Larin FE, Microgestin Fe (branded generics for Loestrin Fe), Loestrin FE, Lo Loestrin FE, LoMedia Lorzone Chlorzoxazone (generic Parafon Forte DSC) Lotemax Gel Lotemax Ointment/Suspension Lovaza (Brand Only) Must try both: omega-3-acid ethyl esters (generic Lovaza), Vascepa Luxiq foam betamethasone lotion (generic Valisone) Luzu Must try two: ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral) 7

8 Maxalt (brand only) Maxalt-MLT (brand only) Mepron suspension (Brand Only) methylphenidate extended-release tablet (generic Concerta) methylphenidate extended-release capsule (generic Metadate CD) Metrogel 1% Metronidazole 1% gel (generic Metrogel 1%) Metozolv ODT Micardis (Brand Only) Micardis HCT (Brand Only) Minastrin 24 FE Minocin Mirapex ER Moderiba Tablet Moderiba Pak Momexin Combo Pkg Monodox (brand only) Morgidox Kit / (Combo Pkg) Morphine sulfate Extended Release (generic Kadian) Myrbetriq Naftin 1% Naftin 2% gel or cream Namzaric Naprelan Naprelan CR (Dose Card) Nasonex Natesto Natroba (brand only) Neo-Synalar New-Synalar Kit Neuac 1.2%-5% Neuac 1.2%-5% kit Nexiclon XR Tablet Nexiclon XR Suspension Nicazeldoxy 30 kit (Doxycycline plus MVI) Nitroglycerin Spray (generic Nitrolingual) Nitrolingual Pump Spray Norditropin, Norditropin NordiFlex, Norditropin FlexPro Noritate rizatriptan (generic Maxalt) rizatriptan orally disintegrating tablet (generic Maxalt MLT) atovaquone suspension (generic Mepron) Brand Concerta Brand Metadate CD metronidazole gel 0.75% (generic Metrogel) metronidazole gel 0.75% (generic Metrogel), Metrogel 0.75% Metoclopramide (generic for Reglan) telmisartan (generic Micardis) telmisartan/hydrochlorothiazide (generic Micardis HCT) Gildess Fe, Junel Fe, Larin FE, Microgestin Fe (branded generics for Loestrin Fe), Loestrin FE, Lo Loestrin FE, LoMedia minocycline (generic Dynacin, Minocin) Pramipexole (generic for Mirapex) ribavirin (generic Copegus) ribavirin (generic Copegus) Mometasone furoate cream + ammonium lactate doxycycline hyclate (generic Vibramycin), doxycycline monohydrate (generic Monodox) Doxycycline (generic for Monodox, Vibramycin) Morphine sulfate sustained-action tablet (generic MS Contin), MS Contin Oxytrol OTC, oxybutynin, oxybutynin extended-release, Ditropan, Ditropan XL, Toviaz Must try two: ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral) Must try two: ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral) Donepezil (generic Aricept), Namenda ZXR Naproxen sodium Naproxen sodium Two of the following: flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, Nasacort OTC Androderm, Testim spinosad (generic Natroba) OTC Neosporin plus fluocinolone cream (generic Lidex), Lidex cream OTC Neosporin plus fluocinolone cream (generic Lidex), Lidex cream Clindamycin-benzoyl peroxide (generic Benzaclin jar) Clindamycin-benzoyl peroxide (generic Benzaclin jar) clonidine immediate release tablets (generic for Catapres) clonidine immediate release tablets (generic for Catapres) doxycycline (generic Monodox, Vibramycin) Nitromist, Nitrostat Nitromist, Nitrostat Nutropin, Nutropin AQ, or Nutropin AQ NuSpin metronidazole 0.75% cream (generic Metrocream) 8

9 Novoeight Advate, Helixate FS, Kogenate FS, Recombinate, Xyntha, Xyntha Solofuse Nuvessa Metronidazole 0.75% vaginal gel (generic Metrogel-Vaginal) Nystatin/triamcinolone (generic Mycolog II) cream nystatin cream (generic Mycostatin) + triamcinolone 0.1% cream (generic Kenalog) Nystatin/triamcinolone (generic Mycolog II) ointment nystatin ointment (generic Mycostatin) + triamcinolone 0.1% ointment (generic Kenalog) Obredon solution guaifenesin/codeine solution (Cheratussin) Oleptro trazodone (generic for Desyrel) Olux clobetasol 0.05% gel (generic Temovate), clobetasol 0.05% solution (generic Temovate) Olux - CP Clobetasol propionate foam Olux-E clobetasol 0.05% gel (generic Temovate), clobetasol 0.05% solution (generic Temovate) Omeclamox-Pak Omepraxole (Prilosec) & clarithromycin (Biaxin) & amoxicillin (Amoxil) Omnaris Must try two: flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, Nasacort OTC Omnitrope Nutropin, Nutropin AQ, or Nutropin AQ NuSpin Onexton % clindamycin topical solution (generic Cleocin T) + OTC benzoyl peroxide or clindamycin-benzoyl peroxide (generic Duac) 1.2%-5% Onmel Itraconazole (generic for Sporanox), Sporanox Optivar (brand only) azelastine (generic for Optivar) AND Lastacaft Orbivan butalbital/acetaminophen/caffeine (generic for Fioricet) Ortho Evra (Brand Only) norelgestromin/ethinyl estradiol topical patch, Xulane (generic Ortho Evra) Otrexup Must try both: methotrexate tablets, Rasuvo Ovace Plus 9.8% lotion sulfacetamide sodium Oxaydo Oxycodone immediate-release (generic Oxy IR) Oxistat Lotion Must try two: ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral) Oxytrol Oxytrol OTC, oxybutynin, oxybutynin extended-release, Ditropan, Ditropan XL, Toviaz Pacnex HP OTC benzoyl peroxide Pacnex LP OTC benzoyl peroxide Pataday Azelastine (generic for Optivar) AND, Lastacaft Patanol Azelastine (generic for Optivar) AND, Lastacaft Pazeo Trial and failure of both: azelastine (generic Optivar), Lastacaft PCP 100 Kit metoclopramide (generic Reglan) + OTC magnesium citrate + OTC Miralax, + OTC bisacodyl + OTC Cerelyte 50 Pediaderm AF nystatin cream Pediaderm TA triamcinolone 0.1% cream Pedipirox-4 Ciclopirox (generic Penlac) Pennsaid Drops Voltaren Gel Pennsaid 2% Voltaren Gel Pentasa Apriso, Lialda Percocet (brand only) acetaminophen/ oxycodone (generic Percocet) Pexeva paroxetine (generic Paxil), paroxetine extended-release (generic Paxil CR), Paxil, Paxil CR Plavix (brand only) clopidogrel (generic Plavix) Plegridy Pen & Prefilled Syringe Must try two: Avonex, Copaxone, Betaseron, Tecfidera Plexion % cream, liquid, sulfacetamide sodium/sulfur lotion 9

10 Plexion Cloth 9.8%-4.8% pads sulfacetamide sodium/sulfur Pramosone E Hydrocortisone/pramoxine (generic Pramosone) Prestalia perindopril (generic Aceon) plus amlodipine (generic Norvasc) Prevpac Omeclamox-Pak ProAir Respimat Ventolin HFA Procort Hydrocortisone/pramoxine (generic Analpram E) Prodrin (Brand only) isometheptene/ caffeine/ acetaminophen 65/20/325 mg (generic Prodrin) Prolensa bromfenac ophthalmic solution (generic Xibrom) Promiseb Complete Kit Promiseb Protopic tacrolimus ointment (generic Protopic) Provigil (Brand and Generic) Nuvigil Prozac (brand only) fluoxetine (generic Prozac) Prozena 4% patch lidocaine transdermal patch (generic Lidoderm) Qnasl Must try two: flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, Nasacort OTC Quartette Introvale, Jolessa, Quasense (generics for Seasonale); Amethia, Camrese, Daysee (generic for Seasonique); Amethia Lo, Camrese Lo (generic for LoSeasonique) Qudexy XR topiramate (generic Topamax), Topamax Quillivant XR Must try two: Brand or generic: Adderall XR, Concerta, Metadate CD or Vyvanse. (note brand and generic will count as 1 alternative med) Rayos prednisone Requip XL Ropinirole (Generic for Requip) Retin-A Micro (brand and generic) tretinoin (generic Retin-A), Retin-A Retin-A Micro Pump (brand and tretinoin (generic Retin-A), Retin-A generic) Revatio sildenafil (generic Revatio) Rexaphenac 1% cream Voltaren Gel Rexulti aripiprazole (generic Abilify), olanzapine (generic Zyprexa), quetiapine (generic Seroquel) Rhinocort Aqua Must try two: flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, Nasacort OTC Ribapak ribavirin (generic for Copegus, Rebetol) Risperdal (brand only) risperidone (generic Risperdal) Ritalin LA (brand and generic) Must try two: Brand or generic: Adderall XR, Concerta, Metadate CD or Vyvanse. (note brand and generic will count as 1 alternative med) Ropinirole extended release (Requip Ropinirole (generic Requip) XL) Rosadan Kit Cream Metronidazole cream (Metrocream) Rosadan Kit Gel Metronidazole gel 0.75% (Metrogel) Rosula sodium sulfacetamide/sulfur Rybix ODT tramadol Rytary carbidopa/levodopa extended release tablet (generic Sinemet CR), carbidopa/levodopa (generic Sinemet) Ryzolt / tramadol extended release Tramadol IR (generic for Ultram), tramadol ER (generic for (generic Ryzolt) Ultram ER) Safyral Yasmin + folic acid Saizen Nutropin, Nutropin AQ, or Nutropin AQ NuSpin Sanctura (brand and generic) Oxytrol OTC, oxybutynin, oxybutynin extended-release, Ditropan, Ditropan XL, Toviaz Sanctura XR (brand and generic) Oxytrol OTC, oxybutynin, oxybutynin extended-release, Ditropan, Ditropan XL, Toviaz 10

11 Sancuso Granisetron (generic for Kytril) Seroquel (brand only) quetiapine (generic Seroquel) Silenor doxepin Simbrinza 1-0.2% brimonidine (generic Alphagan) plus Azopt Singulair Chewable Tablet (brand Montelukast chewable tablet (generic Singulair) only) Singulair Tablet (brand only) Montelukast (generic Singulair) Sitavig acyclovir tablets (Zovirax), acyclovir ointment (Zovirax ointment), Zovirax tablets Skelaxin (brand only) chlorzoxazone (generic Parafon Forte DSC), cyclobenzaprine (generic Flexeril), metaxalone (generic Skelaxin), methocarbamol (generic Robaxin) Sodium Sulfacetamide/sulfur 9%- Sodium sulfacetamide /sulfur 4.5% kit (generic Sumadan Kit Soltamox Tamoxifen (generic for Nolvadex), Nolvadex Soma 250mg / carisoprodol 250mg Carisprodol 350mg (generic for Soma) Sorilux (calcipotriene) calcipotriene (Dovonex) Sotylize sotalol (generic Betapace) SSS 10-4 Sulfacetamide sodium/sulfur Stiolto Respimat Anoro Ellipta or (Striverdi Respimat + Incruse Ellipta, Spiriva or Tudorza Pressair) Subsys fentanyl citrate lozenges (generic Actiq), Lazanda Sumadan Sulfacetamide, sodium/sulfur (generic for Sulfatol) Sumadan Cleanser (brand only) sulfacetammide sodium/sulfur Sumadan XLT Kit sulfacetamide sodium/sulfur Sumaxin CP Sulfacetamide sodium/sulfur (generic Sulfatol) Sumaxin TS sulfacetamide sodium/sulfur Symbicort Must try two: Advair Diskus OR Advair HFA, Breo Ellipta, Dulera Synalar Fluocinolone (generic Synalar) Synalar Kit Fluocinolone (generic Synalar) Synalar TS Fluocinolone (generic Synalar) Taclonex Ointment (Brand Only) betamethasone/calcipotriene ointment (generic Taclonex) Targadox doxycycline hyclate capsules (generic Vibramycin) Technivie Sovaldi & ribavirin (generic Copegus) Tekamlo Amlodipine plus Tekturna Terbinex Terbinafine (generic for Lamisil) testosterone topical gel (generic Testim Testim) testosterone topical gel (generic Testim Volgelxo) Testosterone topical gel Androderm, Testim (manufacturer of Perrigo Israel) Tirosint levothyroxine, Synthroid Tivorbex indomethacin capsule (generic Indocin) Tobi Nebs Bethkis Tobradex ST Tobramycin/dexamethasone ophthalmic drops (generic for Tobradex) Tobramycin nebulized solution Bethkis Tolak 4% cream fluorouracil 5% cream (generic Efudex), Carac, Fluoroplex Tolterodine (generic Detrol) Oxytrol OTC, oxybutynin, oxybutynin extended-release, Ditropan, Ditropan XL, Toviaz Topicort Spray desoximetasone (generic Topicort) Toujeo Solo Must try both: Levemir, Lantus 11

12 Tramadol extended-release (generic tramadol (generic Ultram), tramadol extended-release ryzolt) (generic Ultram ER), Ultram, Ultram ER Tretin-X % cream tretinoin (generic Retin-A) Tretin-X 0.075% cream tretinoin (generic Retin-A), Retin-A Tretin-X Kit tretinoin (generic Retin-A) Treximet Sumatriptan plus naproxen Trezix Acetaminophen/codeine (Tylenol with Codeine) Trianex Triamcinolone ointment (generic Aristocort) Tribenzor amlodipine plus hydrochlorothiazide plus Benicar (or) Benicar HCT plus amlodipine (or) Azor plus hydrochlorothiazide Tricor/Fenofibrate 48mg and 145mg Fenofibrate 54mg, 160m (generic Tricor), Antara, Lipofen (generic Tricor) Triglide Trilipix Trokendi XR topiramate (generic Topamax), Topamax Tuzistra Xr Hydrodocone-Chlorpheniramine (10-8MG/5ML) Twynsta telmisartan (generic Micardis) + amlodipine Uceris foam Cortifoam Ultravate X Combination Package Halobetasol (generic for Ultravate) plus ammonium lactate (generic for Lac-Hydrin), Ultravate plus Lac-Hydrin Umecta emulsion, foam, suspension Urea 40% Umecta Kit (nail film pen/ film suspension) Urea 40% emulsion (Umecta) + hyaluronate gel 0.2% (Hylira) Umecta PD Urea 40% Uramaxin GT 45% Urea 40% emulsion Uramaxin GT Kit Urea 40% Urevaz 44% cream urea 40% cream Utopic (urea) 41% urea 40% (generic Carmol 40) Valium (brand only) diazepam (generic Valium) Valtrex (brand only) valacyclovir (generic Valtrex) Valturna mg, mg Diovan + Tekturna Tablet Vanos fluocinonide cream (generic Lidex) Varubi granisetron (generic Kytril), ondansetron (generic Zofran), Anzemet, Emend Veltin Clindamycin gel + tretinoin gel Venlafaxine ER tablet venlafaxine extended-release capsule (Effexor XR) Veramyst Must try two: flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, Nasacort OTC Verdeso desonide lotion (generic Desowen), Desowen Versacloz clozapine (generic Clozaril), clozapine orally disinegrating tablet (generic Fazaclo) Vesicare Oxytrol OTC, oxybutynin, oxybutynin extended-release, Ditropan, Ditropan XL, Toviaz Vicodin hydrocodone/acetaminophen 5/325 mg (generic Norco) Vicodin ES hydrocodone/acetaminophen 7.5/325 mg (generic Norco) Vicodin HP hydrocodone/acetaminophen 10/325 mg (generic Norco) Viekira Pak Sovaldi Viramune XR 400 mg (Brand Only) nevirapine extended-release (generic Viramune XR) Vituz Hydrodocone-Chlorpheniramine (10-8MG/5ML) Vogelxo Testim Vusion Must ty both: nystatin Cream (generic Mycostatin), OTC miconazole cream Vytone iodoquinol/ hydrocortisone 1% cream, Dermazene cream 12

13 Wellbutrin SR (brand only) Wellbutrin XL (brand only) Xanax (brand only) Xanax XR (brand only) Xartemis XR 7.5/325 mg Xerese Xodol 10/300 (brand and generic) Xodol 5/300 (brand and generic) Xodol 7.5/300 (brand and generic) Xopenex Nebules Zarxio Zecuity 6.5mg/4 hr patch Zenzedi Ziana Zipsor 25mg Zoloft (brand only) Zolvit Zomacton Zonatuss Zorvolex Zovirax Cream Zuplenz Zutripro (Brand Only) Zyclara Zyprexa (brand only) Zyprexa Zydis (brand only) bupropion sustained-release (generic Wellbutrin SR) bupropion extended-release (generic Wellbutrin XL) alprazolam (generic Xanax) alprazolam extended-release (generic Xanax XR) oxycodone/acetaminophen (generic Percocet) Zovirax 5% cream + OTC hydrocortisone 1% cream hydrocodone/acetaminophen 10/325 mg (generic Norco) hydrocodone/acetaminophen 5/325 mg (generic Norco) hydrocodone/acetaminophen 7.5/325 mg (generic Norco) Albuterol nebulized solution Neupogen sumatriptan injection, nasal spray, tablets (generic Imitrex), Sumavel dextroamphetamine (generic Dexedrine) Clindamycin gel + tretinoin gel Diclofenac potassium or diclofenac sodium sertraline (generic Zoloft) acetaminophen with hydrocodone solution Nutropin, Nutropin AQ, Nutropin AQ NuSpin Benzonatate diclofenac (generic Cataflam, Voltaren Must try two: acyclovir capsule/tablet (generic Zovirax), famciclovir tablet (generic Famvir), valacyclovir tablet (generic Valtrex), OTC Abreva ondansetron tablet (generic for Zofran), ondansetron ODT (generic for Zofran ODT) chlorpheniramine/hydrocodone/pseudoephedrine (generic Zutripro) Imiquimod 5% cream olanzapine (generic Zyprexa) olanzapine (generic Zyprexa), olanzapine orally disintegrating tablet (generic Zyprexa Zydis) DEFINITIONS For all of the definitions below, copayment/cost share will vary based on the members plan design. Refer to the Member's specific certificate of coverage, contract and/or prescription drug rider as applicable. Mail Order Pharmacy: A network pharmacy contracted to provide up to a 90-day supply of certain prescription medications (new or refill) by mail. Specialty Pharmacy: A network pharmacy contracted to provide coverage for specialty medications at an in network benefit level for members enrolled on NY and NJ LOBs. Retail Pharmacy: A network non-mail order pharmacy contracted to provide prescription medications (new or refill). Note: For members enrolled on NY LOBs new and renewing on or after 01/12/12, if a retail pharmacy has contracted with the PBM, in advance, for the same rates and terms and conditions as the mail order or specialty pharmacy, covered prescriptions will be available at the same co-payment or other reimbursement level that would apply to the mail-order or non-retail specialty pharmacies (should any of these pharmacies be available in the service area). 13

14 REFERENCES The foregoing Oxford policy has been adapted from an existing UnitedHealthcare Pharmacy Clinical Pharmacy Program that was researched, developed and approved by the UnitedHealth Group National Pharmacy & Therapeutics Committee 1. Oxford Commercial Certificates of Coverage, Health Benefit Plans and Pharmacy Benefit Riders. 2. Drug Facts and Comparisons. Lippincott Williams & Wilkins. 3. All applicable pharmaceutical manufacturer package inserts and prescribing information. 4. Connecticut Legislative Bulletin CT1117; Step Therapy for Pain Management. POLICY HISTORY/REVISION INFORMATION Date 01/01/2015 Action/Description Revised list of medications requiring precertification through the pharmacy benefit manager (PBM): o Added Ambien, (brand only), Ambien CR (brand and generic), capecitabine (generic Xeloda), Karbinal ER, Subsys, Tironsint and Varubi o Removed Arnuity Ellipta, Evotaz, Mitigare, Natpara, Oxycodone ER 12 HR Tablet, Scolantra and Xigduo XR o Updated formulary alternative for Abstral, Colchicine capsule (manufacturer of West-Ward), Colchicine tablet (manufacturer of Prasco), Fentora and Glatopa Archived previous policy version PHARMACY T2 14