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: May 1, 2015 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 and New York Commercial plans. Exclusions: New Jersey Plans and Products: This policy does not apply to New Jersey Commercial plans. However, drugs included in this policy may still require precertification through another policy. Refer to the Member's certificate of coverage and/or member specific benefit document for additional information. 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 Isotretinoin (generic for Accutane), Amnesteem, Claravis, Myorisan, Sotret Abstral fentanyl citrate (generic Actiq), Lazanda, Subsys Acanya clindamycin 1%/benzoyl peroxide 5% gel (generic Benzaclin) Acticlate Doxycycline hyclate (generic Vibramycin, Vibra-Tabs) Actiq Fentanyl citrate lozenges (generic for Actiq) Active-Pac/Gaba 300 gabapentin (generic Neurontin) Actos (brand only) pioglitazone (generic Actos) Acuvail Ketorolac Adazin cream OTC capsaicin & OTC benzocaine cream & OTC methyl salicylate cream & lidocaine cream Adderall (brand only) amphetamine/dextroamphetamine immediate-release (generic Adderall) Adoxa Doxycycline (generic for Monodox, Vibramycin) Adrenaclick EpiPen, EpiPen Jr. Afrezza Humalog (vials and pens), Humulin R Akynzeo dolasetron (generic Anzemet), granisetron (generic Kytril), ondansetron (generic Zofran), Emend Alsuma sumatriptan injection Altoprev Lovastatin (generic Mevacor) Amlodipine/atorvastatin Amlodipine (generic Norvasc) plus atorvastatin (Lipitor), Norvasc plus Lipitor amphetamine/dextroamphetamine Adderall XR extended-release (generic Adderall XR) Amrix/cyclobenzaprine extended release Cyclobenzaprine HCL(generic for Flexeril) 2

3 Amturnide Analpram Advanced Kit Androgel Antara 30 mg & 90 mg strengths only Antara 43 mg, 130 mg Aplenzin Apop 10% gel Aqua Glycolilc HC Aricept (23 mg only) Arimidex (brand only) Arnuity Ellipta Asacol HD AsmalPred AsmalPred Plus Asmanex HFA Astagraf XL Astelin (brand only) Astepro Atelvia Ativan (brand only) Atralin Augmentin XR / Amoxicillin-Clavulanate ER Auralgan 5.5%/1.4% Auvi-Q Avar (sulfacetamide sodium/sulfur) 9.5-5%, 10-2% Avelox tablet (Brand Only) Avinza (Brand Only) Axiron Azor Beconase AQ Belsomra Benzaclin jar (brand only) Benzaclin Kit (1%-5%) Benzaclin Pump Benzefoam, Benzefoam Ultra Bepreve betamethasone valerate foam (generic Luxiq) Beyaz Binosto Brisdelle Bromday budesonide nasal spray (generic Rhinocort Aqua) Bunavail Film Amlodipine + Tekturna HCT (or individual components taken concomitantly) Hydrocortisone acetate/pramoxine HCl, Analpram HC Testim fenofibrate 54 mg, 160 mg (generic Lofibra) Buproprion XL (generic for Wellbutrin XL) Sulfacetamide lotion, solution, suspension Hydrocortisone 2.5% (generic Hytone) donepezil 10mg (generic for Aricept 10mg) anastrozole (generic Arimidex) Asmanex TwistHaler, Alvesco, QVAR, Flovent Apriso, Lialda Prednisolone sodium phosphate (generic Orapred) prednisolone sodium phosphate (generic Orapred) Asmanex TwistHaler, Alvesco, QVAR tacrolimus (generic Prograf), Prograf Azelastine nasal spray (generic Astelin) azelastine (generic Astelin) Actonel lorazepam (generic Ativan) tretinoin (generic Retin-A) Amoxicillin/clavulanate potassium (generic for Augmentin) Antipyrine/benzocaine solution 5.4%/1.4% (generic Auralgan) EpiPen, EpiPen Jr. sulfacetamide sodium/sulfur moxifloxacin tablets (generic Avelox) orphine sulfate extended-release tablet (generic MS Contin), morphine sulfate extended-release capsule (generic Avinza) Testim Amlodipine (generic Norvasc) plus Benicar, Norvasc plus Benicar Qnasl eszopiclone (generic Lunesta), zaleplon (generic Sonata), zolpidem (generic Ambien) clindamycin 1%/benzoyl peroxide 5% gel (generic Benzaclin) Clindamycin Phosphate + OTC Benzoyl Peroxide clindamycin 1%/benzoyl peroxide 5% gel (generic Benzaclin) OTC Benzoyl peroxide azelastine (generic for Optivar) AND Lastacaft betamethasone lotion (generic Valisone Yaz + folic acid Alendronate (generic Fosamax) paroxetine (generic Paxil), Paxil Bromfenac (generic Xibrom), ketorolac (generic Acular) Two of the following: fluticasone (generic Flonase), flunisolide (generic Nasarel), OTC - Nasacort Zubsolv 3

4 buprenorphine/naloxone (generic Suboxone) butalbital/acetaminophen/caffeine/codei ne 50mg/300mg/40mg/30mg (generic Fioricet with Codeine) Caduet and Generic Caduet (atorvastatin/amlodipine) Cambia Celexa (brand only) Cenestin Centany AT Kit choline fenofibrate (generic Trilipix) Ciclodan Combination Package Ciclodan Kit Clarinex / desloratidine Clarinex-D Zubsolv butalbital/acetaminophen/caffeine/codeine 50 mg/325 mg/40 mg/30 mg (generic Fioricet with Codeine) Amlodipine (generic Norvasc) + atorvastatin (generic for Lipitor) diclofenac potassium, diclofenac sodium citalopram (generic Celexa) Must try Both: Enjuvia, Premarin mupirocin ointment Fenofibrate 54 mg, 160 mg (generic Lofibra) Ciclopirox (generic for Loprox), Loprox Ciclopirox nail lacquer Levocetirizine (generic for Xyzal) Levocetirizine (generic for Xyzal) + OTC pseudoephedrine Clindamycin gel, solution, lotion or swabs Clindamycin gel 1% (generic Cleocin-T) Clindacin Pac Clindagel Clindamycin 1%/benzoyl peroxide 5% Must try both: clindamycin solution (generic Cleocin T) (generic BenzaClin) gel plus OTC benzoyl peroxide and clindamycin 1.2%/benzoyl peroxide 5% (generic Duac) Clobeta Clobetasol 0.05% + OTC coal tar Clobetasol shampoo (generic Clobex Clobetasol (generic Temovate), Temovate 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 of Colcrys West-Ward) Colchicine Tablet (manufacturer of Colcrys Prasco) Comfort Pac Tizanadine Tizanadine (generic for Zanaflex) ConZip tramadol immediate-release (generic Ultram), tramadol extended-release (generic Ultram ER) Coreg CR carvedilol (generic for Coreg), Coreg Cosentyx Trial and failure of both: Humira and Stelara Cosopt PF Dorzolamide/timolol (generic Cosopt) Cymbalta (brand only) duloxetine (generic Cymbalta) Daytrana Two of the following: Brand or generic: Adderall XR, Concerta, Metadate CD or Vyvanse. (note brand and generic will count as 1 alternative med) Delos Lotion OTC benzoyl peroxide Delos Cleanser OTC benzoyl peroxide Delzicol Apriso, Lialda Denavir Must try two: acyclovir capsule/tablet (generic Zovirax), famciclovir tablet (generic Famvir), valacyclovir tablet (generic Valtrex), OTC Abreva Dermasorb AF 3-0.5% kit clioquinol/hydrocortisone 3-0.5% (Ala-Quin) 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) 4

5 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 extendedrelease (generic Ditropan XL), Ditropan, Ditropan XL, Toviaz, Oxytrol OTC Detrol LA oxybutynin (generic Ditropan), oxybutynin extendedrelease (generic Ditropan XL), Ditropan, Ditropan XL, Toviaz, Oxytrol OTC dexmethlyphenidate extended-release TWO of the following: Brand or generic: Adderall XR, capsule (generic Focalin XR) Concerta, Metadate CD or Vyvanse. (note brand and generic will count as 1 alternative med) Diovan HCT (brand only) valsartan/hydrochlorothiazide (generic Diovan HCT) Disalcid salsalate donepezil 23 mg (generic Aricept 23 mg) donepezil 5, 10 mg (generic Aricept), Aricept 5 & 10mg Doryx /doxycycline hyclate delayed Doxycycline (generic for Monodox, Vibramycin) release tablet Doxycycline 75 mg capsule (generic doxycycline hyclate (generic Morgidox, Vibramycin), Monodox) doxycycline monohydrate 50 mg or 100 mg (generic Monodox) Doxycycline Delayed-Release Capsule Oracea 40 mg Doxycycline monohydrate 150mg Doxycycline (generic for Monodox, Vibramycin) capsule (generic for Adoxa) Duac, Duac CS clindamycin/benzoyl peroxide (generic for Benzaclin), Benzaclin Duexis Ibuprofen (generic Motrin) plus OTC famotidine (generic Pepcid AC) Duopa carbidopa/levodopa (generic Sinemet) Duragesic (Brand Only) fentanyl transdermal patch (generic Duragesic) Dymista fluticasone (generic for Flonase) + azelastine (generic for Astelin) or Astepro Ecoza econazole (generic Spectrazole) Effexor XR (brand only) venlafaxine extended-release capsule (generic Effexor XR) Elestat Azelastine (generic for Optivar) AND Lastacaft Emadine Azelastine (generic for Optivar) AND Lastacraft Embeda morphine sulfate extended-release (generic MS Contin), Opana ER, Oxycontin, Nucynta ER, Zohydro ER Enablex Oxytrol OTC, oxybutynin, oxybutynin extended-release, Ditropan, Ditropan XL, Toviaz Entocort EC (brand only) budesonide (generic Entocort EC) Epinephrine Pen Injection 0.15mg and EpiPen, EpiPen Jr. 0.3 mg (generic Adrenaclick) Ertaczo Must Try Two: ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral) Estradiol TD twice weekly patch (generic Vivelle-Dot Vivelle-Dot) Evekeo Evista (Brand Only) Evotaz amphetamine/dextroamphetamine immediate-release (generic Adderall), dextroamphetamine immediaterelease (generic Dexedrine) raloxifene (generic Evista) Reyataz + Tybost 5

6 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) Fentora Fibricor 35 mg, 105 mg Fioricet with Codeine capsule 50 mg/300 mg/40 mg/30 mg Fioricet with Codeine 50 mg/325 mg/40 mg/30 mg (Brand Only) Flector Flomax (brand only) Flo-Pred fluocinonide 0.1% cream (generic Vanos) Fluorac cream Fluorouracil 0.5% Cream Focalin XR Forfivo XL Fortesta Genadur Kit Generess FE Genotropin and Genotropin MiniQuick Geodon (brand only) Giazo Glycate Glyxambi Gralise 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) Fentanyl citrate lozenges (generic for Actiq), Lazanda, Subsys butalbital/acetaminophen/caffeine/codeine 50 mg/325 mg/40 mg/30 mg (generic Fioricet with Codeine butalbital/acetaminophen/caffeine/codeine phosphate 50 mg/325 mg/40 mg/30 mg (generic Fioricet with Codeine) Voltaren Gel tamsulosin (generic Flomax) Prednisolone sodium phosphate (generic for Orapred) fluocinonide cream (generic Lidex) fluorouracil 5% cream (Efudex) + diclofenac 3% gel (Solaraze) Carac Two of the following: Brand or generic: Adderall XR, Concerta, Metadate CD or Vyvanse. (note brand and generic will count as 1 alternative med) 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 Two of the following: 1 )Nutropin, Nutropin AQ, or Nutropin AQ NuSpin, 2) Saizen ziprasidone (generic Geodon) balsalazide (generic for Colazal) glycopyrrolate (generic Robinul) Nesina, Onglyza or Tradjenta + Invokana or Jardiance Gabapentin (generic Neurontin) 6

7 Granix Neupogen Helidac Pylera Hemangeol Oral solution Propranolol tablet, propranolol oral solution Horizant Gabapentin (generic Neurontin) Humatrope Two of the following: 1) Nutropin, Nutropin AQ, or Nutropin AQ NuSpin, 2) Saizen 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) Incruse Ellipta Spiriva HandiHaler, Tudorza Intuniv guanfacine (generic Tenex), Tenex Jalyn Avodart (requires precertification if <46 y.o. or female) + tamsulosin Kadian Morphine sulfate sustained action Kapvay clonidine immediate release tablets (generic for Catapres) 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) 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) Lidopin 3.25% cream Lidocaine 3% cream 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, Microgestin Fe (branded generics for Loestrin Fe), Lo Loestrin FE, LoMedia Lorenza Pad 4%-1% Licocaine transdermal patch (generic Lidoderm) 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) Maxalt (brand only) rizatriptan (generic Maxalt) Maxalt-MLT (brand only) rizatriptan orally disintegrating tablet (generic Maxalt MLT) Menthocin Pad Lidocaine transdermal patch (generic Lidoderm) Mepron suspension (Brand Only) atovaquone suspension (generic Mepron) methylphenidate extended-release Brand Concerta tablet (generic Concerta) 7

8 methylphenidate extended-release Brand Metadate CD capsule (generic Metadate CD) Metrogel 1% metronidazole gel 0.75% (generic Metrogel) Metronidazole 1% gel (generic Metrogel metronidazole gel 0.75% (generic Metrogel), Metrogel 1%) 0.75% Metozolv ODT Metoclopramide (generic for Reglan) Micardis (Brand Only) telmisartan (generic Micardis) Micardis HCT (Brand Only) telmisartan/hydrochlorothiazide (generic Micardis HCT) Mircera Aranesp, Epogen, Procrit Mitigare Colcrys Minastrin 24 FE Gildess Fe, Junel Fe, Microgestin Fe (branded generics for Loestrin Fe), LoMedia Minocin 75mg only minocycline (generic Dynacin, Minocin) Mirapex ER Pramipexole (generic for Mirapex) Moderiba Tablet ribavirin (generic Copegus) Moderiba Pak ribavirin (generic Copegus) Momexin Combo Pkg Mometasone furoate cream + ammonium lactate Monodox (brand only) doxycycline hyclate (generic Vibramycin), doxycycline monohydrate (generic Monodox) Morgidox Kit / (Combo Pkg) Doxycycline (generic for Monodox, Vibramycin) Morphine sulfate Extended Release Morphine sulfate sustained-action tablet (generic MS (generic Kadian) Contin), MS Contin Movantik Amitiza Myrbetriq Oxytrol OTC, oxybutynin, oxybutynin extended-release, Ditropan, Ditropan XL, Toviaz Naftin 1% Must Try Two: ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral) Naftin 2% gel or cream Must try two: ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral) Naprelan Naproxen sodium Naprelan CR (Dose Card) Naproxen sodium Nasonex Two of the following: flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, Nasacort OTC Natroba (brand only) spinosad (generic Natroba) Neo-Synalar OTC Neosporin plus fluocinolone cream (generic Lidex), Lidex cream New-Synalar Kit OTC Neosporin plus fluocinolone cream (generic Lidex), Lidex cream Neuac 1.2%-5% Clindamycin-benzoyl peroxide (generic Benzaclin jar) Neuac 1.2%-5% kit Clindamycin-benzoyl peroxide (generic Benzaclin jar) Nexiclon XR Tablet clonidine immediate release tablets (generic for Catapres) Nexiclon XR Suspension clonidine immediate release tablets (generic for Catapres) Nicazeldoxy 30 kit (Doxycycline plus MVI) doxycycline (generic Monodox, Vibramycin) Nitroglycerin Spray (generic Nitromist, Nitrostat Nitrolingual) Nitrolingual Pump Spray Nitromist, Nitrostat Norditropin, Norditropin NordiFlex, Two of the following: 1) Nutropin, Nutropin AQ, or Norditropin FlexPro Nutropin AQ NuSpin, 2) Saizen Noritate metronidazole 0.75% cream (generic Metrocream) Noxafil tablets Noxafil Suspension Nuvessa Metronidazole 0.75% vaginal gel (generic Metrogel- Vaginal) Nystatin/triamcinolone (generic nystatin cream (generic Mycostatin) + triamcinolone Mycolog II) cream 0.1% cream (generic Kenalog) 8

9 Nystatin/triamcinolone (generic Mycolog II) ointment Obredon solution Oleptro Olux Olux - CP Olux-E Omeclamox-Pak Omnaris Omnitrope Onexton % Onmel Optivar (brand only) Orbivan Ortho Evra (Brand Only) Otic Care Otrexup Ovace Plus 9.8% lotion Oxistat Lotion Oxycodone ER 12 HR Tablet Oxytrol Pacnex HP Pacnex LP Pain Relief Patch 5-1% Pataday Patanol Pazeo PCP 100 Kit Pediaderm AF Pediaderm TA Pedipirox-4 Pennsaid Drops Pennsaid 2% Pentasa Percocet (brand only) Pexeva Plavix (brand only) Plegridy Pen & Prefilled Syringe Plexion % cream, liquid, lotion Plexion Cloth 9.8%-4.8% pads nystatin ointment (generic Mycostatin) + triamcinolone 0.1% ointment (generic Kenalog) guaifenesin/codeine solution (Cheratussin) trazodone (generic for Desyrel) clobetasol 0.05% gel (generic Temovate), clobetasol 0.05% solution (generic Temovate) Clobetasol propionate foam clobetasol 0.05% gel (generic Temovate), clobetasol 0.05% solution (generic Temovate) Omepraxole (Prilosec) & clarithromycin (Biaxin) & amoxicillin (Amoxil) Two of the following: flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, Nasacort OTC Two of the following: 1) Nutropin, Nutropin AQ, or Nutropin AQ NuSpin, 2) Saizen clindamycin topical solution (generic Cleocin T) + OTC benzoyl peroxide or clindamycin-benzoyl peroxide (generic Duac) 1.2%-5% Itraconazole (generic for Sporanox), Sporanox azelastine (generic for Optivar) AND Lastacaft butalbital/acetaminophen/caffeine (generic for Fioricet) norelgestromin/ethinyl estradiol topical patch, Xulane (generic Ortho Evra) Antipyrine/benzocaine solution Must try both: methotrexate tablets, Rasuvo sulfacetamide sodium Must try two: ciclopirox (generic Loprox), econazole (generic Spectazole), ketoconazole (generic Nizoral) Oxycontin Oxytrol OTC, oxybutynin, oxybutynin extended-release, Ditropan, Ditropan XL, Toviaz OTC benzoyl peroxide OTC benzoyl peroxide lidocaine patch (generic Lidoderm) Azelastine (generic for Optivar) AND, Lastacaft Azelastine (generic for Optivar) AND, Lastacaft Trial and Failure of Both: azelastine (generic Optivar), Lastacaft metoclopramide (generic Reglan) + OTC magnesium citrate + OTC Miralax, + OTC bisacodyl + OTC Cerelyte 50 nystatin cream triamcinolone 0.1% cream Ciclopirox (generic Penlac) Voltaren Gel Voltaren Gel Apriso, Lialda acetaminophen/ oxycodone (generic Percocet) paroxetine (generic Paxil), paroxetine extended-release (generic Paxil CR), Paxil, Paxil CR clopidogrel (generic Plavix) Must Try 2 of the following: Avonex, Copaxone, Betaseron, Tecfidera sulfacetamide sodium/sulfur sulfacetamide sodium/sulfur 9

10 Pramosone E Hydrocortisone/pramoxine (generic Pramosone) Prevpac Omeclamox-Pak Prezcobix Prezista + Tybost Procort Hydrocortisone/pramoxine (generic Analpram E) Prolensa bromfenac ophthalmic solution (generic Xibrom) Prolida Pad 4%-1% Lidocaine transdermal patch (generic Lidoderm) Promiseb Complete Kit Promiseb Provigil (Brand and Generic) Nuvigil Prozac (brand only) fluoxetine (generic Prozac) Qnasl Two of the following: 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 Two of the following: Brand or generic: Adderall XR, Concerta, Metadate CD or Vyvanse. (note brand and generic will count as 1 alternative med) Rayos prednisone Relyyks pad Lidocaine transdermal patch (generic Lidoderm) Requip XL Ropinirole (Generic for Requip) Retin-A Micro (brand and generic) tretinoin (generic Retin-A), Retin-A Retin-A Micro Pump (brand and generic) tretinoin (generic Retin-A), Retin-A Revatio sildenafil (generic Revatio) Revatio 10 mg/ml Sildenafil tablet (generic Revatio) Rexaphenac 1% cream Voltaren Gel Rhinocort Aqua Two of the following: flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, Nasacort OTC Riax benzoyl peroxide Ribapak ribavirin (generic for Copegus, Rebetol) Risperdal (brand only) risperidone (generic Risperdal) Ritalin LA (brand and generic) Two of the following: Brand or generic: Adderall XR, Concerta, Metadate CD or Vyvanse. (note brand and generic will count as 1 alternative med) Ropinirole extended release (Requip XL) Ropinirole (generic Requip) 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 (generic Ryzolt) Tramadol IR (generic for Ultram), tramadol ER (generic for Ultram ER) Safyral Yasmin + folic acid 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 Sancuso Granisetron (generic for Kytril) Savaysa warfarin (generic Coumadin), Pradaxa, Xarelto, Eliquis Seroquel (brand only) quetiapine (generic Seroquel) Silenor doxepin Silvera Pain Relief Pad OTC capsaicin & lidocaine (generic Lidoderm) Simbrinza 1-0.2% brimonidine (generic Alphagan) plus Azopt Singulair Chewable Tablet (brand only) Montelukast chewable tablet (generic Singulair) 10

11 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%-4.5% Sodium sulfacetamide /sulfur kit (generic Sumadan Kit Soltamox Tamoxifen (generic for Nolvadex), Nolvadex Soma 250mg / carisoprodol 250mg Carisprodol 350mg (generic for Soma) Soolantra Metronidazole 0.75% cream (generic Metrocream), Finacia Sorilux (calcipotriene) calcipotriene (Dovonex) Sotylize sotalol (generic Betapace) Spiriva Respimat Spiriva-HandiHaler, Tudorza SSS 10-4 Sulfacetamide sodium/sulfur Striverdi Respimat Foradil, Serevent Diskus Suboxone film, tablets Zubsolv 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 Suprax Chewable Tablets Suprax Oral Suspension Symbicort Two of the following: Advair Diskus OR Advair HFA, Breo Ellipta, Dulera Synalar Fluocinolone (generic Synalar) Synalar Kit Fluocinolone (generic Synalar) Synalar TS Fluocinolone (generic Synalar) Synvexia TC 4-1% Lidocaine cream Taclonex Ointment (Brand Only) betamethasone/calcipotriene ointment (generic Taclonex) Tekamlo Amlodipine plus Tekturna Terbinex Terbinafine (generic for Lamisil) testosterone topical gel (generic Testim) Testim testosterone topical gel (generic Testim Volgelxo) Testosterone topical gel (manufacturer Androderm, Testim of Perrigo Israel) Tobi Nebs Bethkis Tobradex ST Tobramycin/dexamethasone ophthalmic drops (generic for Tobradex) Tobramycin nebulized solution Bethkis Tolterodine (generic Detrol) Oxytrol OTC, oxybutynin, oxybutynin extended-release, Ditropan, Ditropan XL, Toviaz Topicort Spray desoximetasone (generic Topicort) Tramadol extended-release (generic ryzolt) tramadol (generic Ultram), tramadol extended-release (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) 11

12 Tribenzor amlodipine plus hydrochlorothiazide plus Benicar (or) Benicar HCT plus amlodipine (or) Azor plus hydrochlorothiazide Tricor/Fenofibrate 48mg and 145mg (generic Tricor) Fenofibrate 54mg, 160m (generic Tricor), Antara, Lipofen Triglide Trilipix Trokendi XR topiramate (generic Topamax), Topamax Trulicity Must try two: Byetta, Bydureon, Tanzeum, Victoza 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% Utopic (urea) 41% urea 40% (generic Carmol 40) Valium (brand only) diazepam (generic Valium) Valtrex (brand only) valacyclovir (generic Valtrex) Valturna mg, mg Tablet Diovan + Tekturna Vanos fluocinonide cream (generic Lidex) Velma % pad OTC menthol patch & OTC methyl salicylate patch & licocaine patch (generic Lidoderm) Veltin Clindamycin gel + tretinoin gel Venlafaxine ER tablet venlafaxine extended-release capsule (Effexor XR) Veramyst Two of the following: flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, Nasacort OTC Verdeso desonide lotion (generic Desowen), Desowen Vesicare Oxytrol OTC, oxybutynin, oxybutynin extended-release, Ditropan, Ditropan XL, Toviaz Vexa % Lidocaine transdermal Patch (generic Lidoderm) 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) Virasal (brand only) Salicylic acid OTC Vitekta Tivicay, Isentress Vituz Hydrodocone-Chlorpheniramine (10-8MG/5ML) Vogelxo Testim Vusion Must Try Both: nystatin Cream (generic Mycostatin), OTC miconazole cream Wellbutrin SR (brand only) bupropion sustained-release (generic Wellbutrin SR) Wellbutrin XL (brand only) bupropion extended-release (generic Wellbutrin XL) Xanax (brand only) alprazolam (generic Xanax) Xanax XR (brand only) alprazolam extended-release (generic Xanax XR) Xartemis XR 7.5/325 mg oxycodone/acetaminophen (generic Percocet) Xerese Zovirax 5% cream + OTC hydrocortisone 1% cream Xigduo XR Invokana, Invokamet Xodol 10/300 (brand and generic) hydrocodone/acetaminophen 10/325 mg (generic Norco) Xodol 5/300 (brand and generic) hydrocodone/acetaminophen 5/325 mg (generic Norco) Xodol 7.5/300 (brand and generic) hydrocodone/acetaminophen 7.5/325 mg (generic Norco) 12

13 Xopenex Nebules Zenzedi Ziana Zipsor 25mg Zoloft (brand only) Zolvit Zonatuss Zorvolex Zovirax Cream Zuplenz Zutripro (Brand Only) Zyclara Zyprexa (brand only) Zyprexa Zydis (brand only) Albuterol nebulized solution dextroamphetamine (generic Dexedrine) Clindamycin gel + tretinoin gel Diclofenac potassium or diclofenac sodium sertraline (generic Zoloft) acetaminophen with hydrocodone solution 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). 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 05/01/2015 Action/Description Revised list of medications requiring precertification through the pharmacy benefit manager (PBM): 13

14 o Added Cosentyx, Fentanyl transdermal patch (37.5, 62.5 and 87.5 mcg/hr strengths only), Lorenza Pad 4%-1%, Menthocin Pad, Nuvessa,Otrexup, Pazeo, Prolida Pad 4%-1%, Rosula and Sotylize, o Removed Ferric Citrate and Harvoni o Updated formulary alternatives for budesonide nasal spray (generic Rhinocort Aqua) and Generess FE o Updated drug dosage listings for Xodol (brand and generic) Archived previous policy version PHARMACY T2 14