New and Therapeutic Equivalent Medications

UnitedHealthcare Pharmacy

Clinical Pharmacy Programs

Program Number

2024 P 2121-33

Program

New and Therapeutic Equivalent Medications - Prior

Authorization

Medication/Therapeutic

Class

Select Medications

P&T Approval Date

5/2016 UM approval; 10/2016, 2/2017, 4/2017, 4/2018, 4/2019,

8/2019, 11/2019, 2/2020, 3/2020, 4/2020, 5/2020, 6/2020, 7/2020,

9/2020, 10/2020, 12/2020, 1/2021, 3/2021, 5/2021, 6/2021,

9/1/2021, 11/2021, 3/2022, 4/2022, 7/2022 (w/ 8/1/2022 effective

date), 6/2022 (w/ 9/1/2022 effective date), 11/2022, 3/2023,

6/2023, 12/2023, 3/2024

Effective Date

5/1/2024

1. Background:

UnitedHealthcare benefit documents define Therapeutically Equivalent as when

medications/products have essentially the same efficacy and adverse effect profile. This

determination is made by the UnitedHealthcare Pharmacy and Therapeutics (P&T)

Committee and is not intended to imply therapeutic equivalence as defined by the FDA

Orange Book.

Benefit plan designs include a prior authorization for certain prescription medications if

they are Therapeutically Equivalent, defined as similar outcomes and adverse events, to a

covered medication or an over-the-counter medication. Some states, including Oxford

plans due to state mandates, may require a prior authorization for these medications

which will require history of failure, contraindication or intolerance to another product(s)

or an over-the-counter medication. For additional information on coverage please see the

Physician PDL posted to UHCProvider.com.

2. Coverage Criteria

a, d

A. The following excluded medications may be approved based on the following criteria:

1. Approval Criteria

a. Submission of medical records documenting history of trial and failure,

inadequate response, or intolerance to the Therapeutically Equivalent covered

medications listed below. (Document date and duration of trial):

Excluded

Medication

Must try one unless otherwise noted

(up to a maximum of 5 alternatives)

Abilify

Tablets

Brand Only

MUST TRY: aripiprazole (generic Abilify)

AND ONE OF:

olanzapine (generic Zyprexa)

quetiapine (generic Seroquel)

risperidone (generic Risperdal)

ziprasidone (generic Geodon)

Januvia

Single Source

Brand

THREE MONTH TRIAL EACH OF BOTH

OF THE FOLLOWING

: Tradjenta and ONE

of the following: Nesina, Onglyza

Janumet/

Janumet XR

Single Source

Brand

THREE MONTH TRIAL EACH OF BOTH

OF THE FOLLOWING

: Kazano, or

Kombiglyze XR, AND

Jentadueto or Jentadueto XR

Myrbetriq

Single Source

Brand

MUST TRY ONE OF THE FOLLOWING:

solifenacin (generic Vesicare), trospium

(generic Sanctura), tolterodine (generic

Detrol),

AND ONE OF THE FOLLOWING:

Oxybutynin (generic Ditropan) or oxybutynin

extended-release (generic Ditropan XL)

Noritate

Single Source

Brand

MUST TRY ONE OF THE FOLLOWING:

metronidazole 0.75% cream (generic

Metrocream) or metronidazole 0.75% gel

(generic Metrogel)

Secuado

Single Source

Brand

Saphris

Symtuza

Single Source

Brand

Prezcobix plus Cimduo, Prezcobix plus

Descovy

Tresiba/Insulin Degludec

Single Source

Brand

MUST HAVE THREE MONTH TRIAL

BOTH: Lantus, Toujeo

Vesicare

Brand Only

MUST TRY ALL OF THE FOLLOWING:

solifenacin (generic Vesicare), trospium

(generic Sanctura), tolterodine (generic

Detrol), Oxytrol OTC,

AND ONE OF THE FOLLOWING:

Oxybutynin (generic Ditropan) or oxybutynin

extended-release (generic Ditropan XL)

Zovirax cream

Brand &

Generic

MUST TRY OTC Abreva

AND TWO OF THE FOLLOWING:

acyclovir capsule/tablet (generic Zovirax),

famciclovir tablet (generic Famvir),

valacyclovir tablet (generic Valtrex)

Authorization will be issued for 12 months.

B. The following excluded medications may be approved based on the following

criteria:

1. Approval Criteria

a. BOTH of the following:

(1) Submission of medical records documenting history of trial and failure,

inadequate response, or intolerance to the Therapeutically Equivalent covered

medications as listed below. (Document date and duration of trial)

Excluded

Medication

Must try one unless otherwise

noted (up to a maximum of 5

alternatives)

Acanya

Brand &

Generic

clindamycin 1.2% /benzoyl peroxide 5%

gel (generic Duac), clindamycin + OTC

benzoyl peroxide

Adapalene

0.1% pads

Single Source

Brand

OTC Differin gel, tretinoin cream

(generic Retin-A)

Albuterol HFA

[Ventolin HFA

Authorized

Generic (Prasco)]

Authorized

Generic

albuterol sulfate HFA (generic ProAir

HFA, Proventil HFA) [non-Prasco

products]

Ambien CR

Brand Only

Must try TWO (two week trial required):

zolpidem (generic Ambien), zaleplon

(generic Sonata), eszopiclone (generic

Lunesta)

Ambien

Brand Only

Must try TWO (two week trial required):

zolpidem (generic Ambien), zaleplon

(generic Sonata), eszopiclone (generic

Lunesta)

Aplenzin

Brand Only

bupropion extended-release (generic

Wellbutrin XL)

Ampyra

Brand Only

dalfampridine (generic Ampyra)

Asacol HD

Brand &

Generic

Lialda, Apriso

Ativan

Brand Only

MUST TRY: lorazepam (generic Ativan),

AND ONE OF: alprazolam (generic

Xanax), clonazepam (generic Klonopin),

diazepam (generic Valium)

Azor

Brand &

Generic

MUST TRY BOTH: amlodipine (generic

Norvasc) plus olmesartan (generic

Benicar), amlodipine /valsartan (generic

Exforge)

Basaglar

Single Source

Brand

Lantus, Toujeo

Celexa

Brand Only

citalopram (generic Celexa)

Clemastine fumarate syrup

Generic Only

OTC clemastine (generic Tavist)

Cymbalta

Brand Only

MUST TRY BOTH: duloxetine (generic

Cymbalta), venlafaxine ER (generic

Effexor XR)

Delzicol

Brand Only

Apriso, Lialda

Differin

Brand &

Generic

MUST TRY BOTH: OTC Differin gel,

tretinoin cream (generic Retin-A)

Diovan

Brand Only

MUST TRY: valsartan (generic Diovan),

AND ONE OF: losartan (generic Cozaar),

telmisartan (generic Micardis), irbesartan

(generic Avapro)

Diovan HCT

Brand Only

MUST TRY: valsartan/HCTZ (generic

Diovan HCT), AND ONE OF:

losartan/HCTZ (generic Hyzaar),

telmisartan/HCTZ (generic Micardis

HCT), irbesartan/HCTZ (generic Avalide)

Duexis

Brand &

Generic

ibuprofen (generic for Motrin) plus OTC

famotidine (generic for Pepcid AC)

Dymista

Brand &

Generic

fluticasone (generic for Flonase) plus

azelastine (generic for Astelin)

Duragesic

Brand Only

fentanyl transdermal patch (includes: 12

mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr,

100 mcg/hr (generic Duragesic))

Effexor XR

Brand Only

venlafaxine extended-release (generic

Effexor XR)

Forfivo XL

Brand &

Generic

bupropion extended-release (generic

Wellbutrin XL)

Gleevec

Brand Only

Imatinib (generic Gleevec)

Intuniv

Brand Only

guanfacine extended-release (generic

Intuniv)

Klonopin

Brand Only

MUST TRY: clonazepam (generic

Klonopin) AND ONE OF THE

FOLLOWING: alprazolam (generic

Xanax), diazepam (generic Valium),

lorazepam (generic Ativan)

Lexapro

Brand Only

MUST TRY: escitalopram (generic

Lexapro), AND ONE OF: paroxetine

(generic Paxil), sertraline (generic

Zoloft), fluoxetine (generic Prozac),

citalopram (generic Celexa)

Lipitor

Brand Only

MUST TRY: atorvastatin (generic for

Lipitor) AND ONE OF: pravastatin

(generic Pravachol), simvastatin (generic

Zocor), lovastatin (generic Mevacor),

rosuvastatin (generic Crestor)

Lunesta

Brand Only

Must try TWO (two week trial required):

zolpidem (generic Ambien), zaleplon

(generic Sonata), eszopiclone (generic

Lunesta)

Otrexup

Single Source

Brand

MUST TRY BOTH: Oral methotrexate

tablets, Rasuvo

Oxtellar XR

Single Source

Brand

oxcarbazepine, Trileptal

Pentasa

Brand and

Generic

Must try ALL of the following:

mesalamine delayed-release (generic

Delzicol),

mesalamine delayed-release (generic

Lialda),

Apriso

Percocet

Brand Only

oxycodone/ acetaminophen (generic

Percocet)

Pexeva

Brand Only

paroxetine (generic Paxil)

Proair RespiClick & HFA

Single Source

Brand

albuterol sulfate HFA (generic ProAir

HFA, Proventil HFA) [non-Prasco

products]

Prozac

Brand Only

MUST TRY: fluoxetine (generic Prozac)

AND ONE OF: paroxetine (generic

Paxil), sertraline (generic Zoloft),

citalopram (generic Celexa), escitalopram

(generic Lexapro)

Qudexy XR

Brand &

Generic

topiramate, Topamax

Rayos

Single Source

Brand

prednisone

Rebif & Rebif Rebidose

Single Source

Brand

MUST TRY TWO OF THE

FOLLOWING: Avonex, Betaseron,

Plegridy

Relafen

Brand Only

nabumetone (generic Relafen)

Relafen DS

Single Source

Brand

nabumetone (generic Relafen)

Semglee

Single Source

Brand

MUST HAVE THREE MONTH TRIAL

OF BOTH: Lantus, Toujeo

Sorilux

Single Source

Brand

calcipotriene (generic Dovonex)

Spritam

Single Source

Brand

levetiracetam immediate-release,

levetiracetam solution

Synthroid

Brand Only

levothyroxine (generic Synthroid)

Tecfidera

Brand Only

dimethyl fumarate (generic Tecfidera)

Tivorbex

Single Source

Brand

ibuprofen (generic Motrin), indomethacin

capsule (generic Indocin), meloxicam

(generic Mobic), naproxen (generic

Naprosyn)

Treximet

Brand &

Generic

MUST TRY BOTH: sumatriptan (generic

Imitrex) + naproxen rizatriptan (generic

Maxalt) + naproxen

Trokendi XR

Single Source

Brand

topiramate, Topamax

Ursodiol 200mg and 400mg

capsule

Multisource

Brand

without

Generic

ursodiol (generic Actigall)

Valium

Brand Only

diazepam (generic Valium)

Valtrex

Brand Only

valacyclovir (generic Valtrex)

Ventolin HFA

Single Source

Brand

albuterol sulfate HFA (generic ProAir

HFA, Proventil HFA) [non-Prasco

products]

Wellbutrin SR

Brand Only

bupropion extended-release (generic

Wellbutrin SR)

Wellbutrin

Brand Only

bupropion extended-release (generic

Wellbutrin XL)(trial must be in 2014 or

later)

Xanax

Brand Only

MUST TRY: alprazolam (generic Xanax)

AND ONE OF: clonazepam (generic

Klonopin), diazepam (generic Valium),

lorazepam (generic Ativan)

Xanax XR

Brand Only

MUST TRY: alprazolam (generic Xanax)

AND ONE OF: clonazepam (generic

Klonopin), diazepam (generic Valium),

lorazepam (generic Ativan)

Zoloft

Brand Only

MUST TRY: sertraline (generic Zoloft)

AND ONE OF: paroxetine (generic

Paxil), fluoxetine (generic Prozac),

citalopram (generic Celexa), escitalopram

(generic Lexapro)

-AND-

(2) Provider must give an explanation of potential rationale for how the excluded

medication will work if stating the patient failed on the covered

Therapeutically Equivalent product which has the same active ingredient- (eg,

the member had an adverse reaction to an inactive ingredient in the alternative

product)

Authorization will be issued for 12 months.

C. The following excluded medications may be approved based on the following criteria:

1. Approval Criteria

a. History of failure, contraindication or intolerance to one alternative (unless

otherwise specified below up to a maximum of 5 alternatives):

Excluded

Medication

Must try one unless otherwise noted

(up to a maximum of 5 alternatives)

Abilify MyCite

Single

Source

Brand

Use Medical Necessity criteria

Minnesota: See State Mandate Overview

Document

Abrilada

Single

Source

Brand

Adalimumab-adaz (unbranded Hyrimoz),

Amjevita, Cyltezo, Hadlima, Humira

Absorica (all strengths)

Brand Only

BOTH of the following:

(1) Must try two of the following:

(a) Topical retinoid or retinoid-like agent [e.g.,

Retin-A/Retin-A Micro (tretinoin)]

(b) oral antibiotic [e.g., Ery-Tab (erythromycin),

Minocin (minocycline)]

peroxide [e.g., Cleocin-T (clindamycin),

erythromycin, BenzaClin (benzoyl

peroxide/clindamycin), Benzamycin (benzoyl

peroxide/erythromycin)]

AND

(2) Must try two of the following oral

isotretinoin formulations (document duration of

trial):

(a) Claravis

(b) Myorisan

(d) Amnesteem

(e) isotretinoin 10mg, 20mg, 30mg, 40mg

Absorica LD

Single

Source

Brand

BOTH of the following:

(1) Must try two of the following:

(a) Topical retinoid or retinoid-like agent [e.g.,

Retin-A/Retin-A Micro (tretinoin)]

(b) oral antibiotic [e.g., Ery-Tab (erythromycin),

Minocin (minocycline)]

peroxide [e.g., Cleocin-T (clindamycin),

erythromycin, BenzaClin (benzoyl

peroxide/clindamycin), Benzamycin (benzoyl

peroxide/erythromycin)]

AND

(2) Must try two of the following oral

isotretinoin formulations (document duration of

trial):

(a) Claravis

(b) Myorisan

(d) Amnesteem

(e) isotretinoin 10mg, 20mg, 30mg, 40mg

Abstral

Single

Source

Brand

Must Try Both: fentanyl citrate lozenges

(generic Actiq), Lazanda

CT only: Must try fentanyl citrate (generic

Actiq)

MN, NV - Coverage of medications to treat

conditions associated with cancer may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Accrufer

Single

Source

Brand

OTC iron

Accupril

Brand Only

quinapril (generic Accupril)

Acetaminophen/ Caffeine/

Dihydrocodeine Bitartrate 325/30/16

Single

Source

Brand

acetaminophen/codeine

Aciphex

Brand Only

Must try all: omeprazole (generic Prilosec),

pantoprazole (generic Protonix), rabeprazole

(generic Aciphex), OTC Nexium, OTC

Prevacid, OTC Prilosec, OTC Zegerid

Aciphex Sprinkle

Single

Source

Brand

Must try all: omeprazole (generic Prilosec),

pantoprazole (generic Protonix), rabeprazole

(generic Aciphex), OTC Nexium, OTC

Prevacid, OTC Prilosec, OTC Zegerid

Actemra

Single

Source

Brand

Use Step Therapy

Acticlate

Single

Source

Brand

doxycycline hyclate (generic Vibramycin,

Vibra-Tab ), doxycycline monohydrate 50 or

100mg (generic Monodox)

Actigall

Brand Only

ursodiol (generic Actigall, generic Usro 250,

generic Urso Forte)

Actiq

Brand Only

Must Try Both: fentanyl citrate lozenges

(generic Actiq), Lazanda

CT only: Must try fentanyl citrate (generic

Actiq)

MN, NV - Coverage of medications to treat

conditions associated with cancer may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Actonel

Brand Only

Must try all: alendronate (generic Fosamax),

ibandronate (generic Boniva), risedronate

(generic Actonel)

Actos

Brand Only

pioglitazone (generic Actos)

In Florida, Maine, and Tennessee only,

medications prescribed for diabetes may be

approved based on both of the following: 1)

Provider attests use of this product is medically

necessary for the treatment of diabetes; and- 2)

If applicable, clinical characteristics exist that

preclude the use of the covered preferred

alternative(s) and use of the covered preferred

alternative(s) could result in worsening of

patient’s condition or inadequate treatment

(document alternatives and clinical information

related to worsening/inadequate treatment).

Acuvail

Single

Source

Brand

ketorolac ophthalmic solution (generic Acular,

Acular LS)

Aczone topical gel

Brand Only

dapsone topical gel (generic Aczone)

Adcirca

Brand Only

tadalafil tablets (generic Adcirca tablets)

Adderall

Brand Only

amphetamine/ dextroamphetamine immediate-

release (generic Adderall)

Adderall XR

Brand Only

amphetamine/dextroamphetamine extended-

release 24hr (generic Adderall XR)

Advair Diskus

Brand Only

Must try ALL: fluticasone propionate/salmeterol

(generic Advair Diskus), Breo Ellipta,

Symbicort

Adhansia XR

Single

Source

Brand

Must try TWO of the following:

amphetamine-dextroamphetamine extended-

release (generic Adderall XR),

dexmethylphenidate extended-release (generic

Focalin XR),

lisdexamfetamine (generic Vyvanse),

methylphenidate extended-release (generic

Concerta, Metadate CD, Metadate ER, Ritalin

LA)

Adlarity transdermal patch

Single

Source

Brand

Must try: donepezil tablet (generic Aricept)

AND one of the the following: galantamine

(Razadyne), memantine (generic Namenda),

rivastigmine transdermal patch (generic Exelon)

Admelog (All dosage forms)

Single

Source

Brand

Humalog vial, Humalog KwikPen

In Florida, Maine, and Tennessee only,

medications prescribed for diabetes may be

approved based on both of the following: 1)

Provider attests use of this product is medically

necessary for the treatment of diabetes; and- 2)

If applicable, clinical characteristics exist that

preclude the use of the covered preferred

alternative(s) and use of the covered preferred

alternative(s) could result in worsening of

patient’s condition or inadequate treatment

(document alternatives and clinical information

related to worsening/inadequate treatment).

Adoxa

Brand &

Generic

doxycycline hyclate (generic Vibramycin,

Vibra-Tab), doxycycline monohydrate 50 or

100mg (generic Monodox)

Adzenys XR

Single

Source

Brand

Must try TWO of the following:

amphetamine-dextroamphetamine extended-

release (generic Adderall XR),

dexmethylphenidate extended-release (generic

Focalin XR),

lisdexamfetamine (generic Vyvanse),

methylphenidate extended-release (generic

Concerta, Metadate CD, Metadate ER, Ritalin

LA)

Afinitor 2.5 mg, 5 mg, 7.5 mg, 10mg

tablet

Brand Only

everolimus (generic Afinitor)

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics

Afinitor Disperz

Brand Only

everolimus tablet for oral suspension (generic

Afinitor Disperz)

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics

Afrezza

Single

Source

Brand

Use Medical Necessity

Agrylin

Brand Only

anagrelide (generic Agrylin)

AirDuo Digihaler

Single

Source

Brand

Must try all: fluticasone/salmeterol (generic

AirDuo Respiclick), Advair Diskus/HFA, Breo

Ellipta, Symbicort

AirDuo Respiclick

Brand Only

Must try all: fluticasone/salmeterol (generic

AirDuo Respiclick), Advair Diskus/HFA, Breo

Ellipta, Symbicort

Ajovy

Single

Source

Brand

Use med nec or step therapy

Aldactone

Brand Only

spironolactone (generic Aldactone)

Alevicyn Antipruritic Gel

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Alevicyn Antipruritic Sg

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Alevicyn Dermal Spray

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Alinia tablets

Brand Only

nitazoxanide (generic Alinia)

Alkindi

Single

Source

Brand

dexamethasone tablet

Allegra (all dosage forms)

Legend

Medication

(Brand and

generic)

OTC Allegra (fexofenadine)

Allegra -D (all dosage forms)

Brand &

Generic

OTC Allegra D (fexofenadine-

pseudoephedrine)

Allopurinol 200mg

Single

Source

Brand

allopurinol 100 mg or 300 mg (generic

Zyloprim)

Allzital

Single

Source

Brand

butalbital/acetaminophen 50 mg/325 mg

(generic Phenrilin)

Alogliptin (Nesina Authorized Generic)

Authorized

Generic

Must try all: Nesina, Onglyza, Tradjenta

In Florida, Maine, and Tennessee only,

medications prescribed for diabetes may be

approved based on both of the following: 1)

Provider attests use of this product is medically

necessary for the treatment of diabetes; and- 2)

If applicable, clinical characteristics exist that

preclude the use of the covered preferred

alternative(s) and use of the covered preferred

alternative(s) could result in worsening of

patient’s condition or inadequate treatment

(document alternatives and clinical information

related to worsening/inadequate treatment).

Alogliptin/Metformin (Kazano

Authorized Generic)

Authorized

Generic

Must try all: Kazano, Jentadueto/Jentadueto XR,

Kombiglyze XR, Oseni

In Florida, Maine, and Tennessee only,

medications prescribed for diabetes may be

approved based on both of the following: 1)

Provider attests use of this product is medically

necessary for the treatment of diabetes; and- 2)

If applicable, clinical characteristics exist that

preclude the use of the covered preferred

alternative(s) and use of the covered preferred

alternative(s) could result in worsening of

patient’s condition or inadequate treatment

(document alternatives and clinical information

related to worsening/inadequate treatment).

Alogliptin/Pioglitazone (Oseni

Authorized Generic)

Authorized

Generic

Oseni

In Florida, Maine, and Tennessee only,

medications prescribed for diabetes may be

approved based on both of the following: 1)

Provider attests use of this product is medically

necessary for the treatment of diabetes; and- 2)

If applicable, clinical characteristics exist that

preclude the use of the covered preferred

alternative(s) and use of the covered preferred

alternative(s) could result in worsening of

patient’s condition or inadequate treatment

(document alternatives and clinical information

related to worsening/inadequate treatment).

Altace

Brand Only

ramipril (generic Altace)

Altoprev

Single

Source

Brand

Must try all: atorvastatin (generic Lipitor),

lovastatin (generic Mevacor), pravastatin

(generic Pravachol), simvastatin (generic

Zocor), rosuvastatin (generic Crestor)

Altreno

Single

Source

Brand

Mustr try all: OTC Differin gel, tretinoin cream

(generic Retin-A)

Alvesco

Single

Source

Brand

Must try all: Arnuity Ellipta, Flovent HFA,

Flovent Diskus, Pulmicort Flexhaler

Amaryl

Brand Only

glimepiride (generic Amaryl)

Amerge

Brand Only

naratriptan (generic Amerge)

Amicar

Brand Only

aminocaproic acid (generic Amicar)

Amitiza

Brand Only

Must try both: lubiprostone, Linzess

Amrix

Brand &

Generic

Must try cyclobenzaprine tablet (generic

Flexeril) and two of the following: carisoprodol

(Soma 350mg), methocarbamol (generic

Robaxin), chlorzoxazone (generic Parafon Forte

DSC), tizanidine (Zanaflex Tablets)

Anafranil

Brand Only

Must try all: clomipramine (generic Anafranil),

citalopram (generic Celexa), escitalopram

(generic Lexapro), fluoxetine capsules (generic

Prozac), fluvoxamine (generic Luvox),

paroxetine (generic Paxil), sertraline (generic

Zoloft)

AndroGel 1%

Brand &

Generic

Minimum 4 week trial of Testim

AndroGel 1.62%

Brand Only

Minimum 4 week trial of Testim

Antara

Single

Source

Brand

Must try ONE of the following:

1. fenofibrate 48mg, 54mg, 145mg, 160mg

tablet (generic Lofibra, Tricor, Triglide);

2. fenofibrate micronized capsule 43mg, 130mg

(generic Antara);

3. fenofibrate micronized capsule 67mg, 134mg,

200mg (generic Lofibra, Tricor)

Anusol HC Supp

Brand Only

hydrocortisone cream (generic Anusol-HC),

hydrocortisone suppository (generic Anusol-

HC)

Apadaz

Brand only

hydrocodone/acetaminophen (generic Norco)

Apidra (All dosage forms)

Single

Source

Brand

Use Step Therapy

Aptensio XR

Brand &

Generic

Must try TWO of the following:

amphetamine-dextroamphetamine extended-

release (generic Adderall XR),

dexmethylphenidate extended-release (generic

Focalin XR),

lisdexamfetamine (generic Vyvanse),

methylphenidate extended-release (generic

Concerta, Metadate CD, Metadate ER, Ritalin

LA)

Arava

Brand Only

leflunomide (generic Arava)

Arazlo

Single

Source

Brand

OTC Differin, tretinoin cream

Aricept 23 mg only

Brand Only

donepezil 10 mg (generic Aricept 10 mg)

Aricept 5 mg, 10 mg

Brand Only

donepezil (generic Aricept)

Arimidex

Brand Only

anastrozole (generic Arimidex)

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics

Arixtra

Brand Only

fondaparinux (generic Arixtra)

ArmonAir Digihaler

Single

Source

Brand

Must try all: Arnuity Ellipta, Flovent

Diskus/HFA, Pulmicort Flexhaler

ArmonAir RespiClick

Single

Source

Brand

Must try all: Arnuity Ellipta, Flovent HFA,

Flovent Diskus, Pulmicort Flexhaler

Aromasin

Brand Only

exemestane (generic Aromasin)

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Arthrotec

Brand Only

diclofenac/misoprostol (generic Arthrotec)

Asmanex HFA

Single

Source

Brand

Must try BOTH: Arnuity Ellipta, QVAR

RediHaler

Asmanex Twisthaler

Single

Source

Brand

Must try all: Arnuity Ellipta, Flovent HFA,

Flovent Diskus, Pulmicort Flexhaler

Astagraf XL

Single

Source

Brand

tacrolimus

Astepro

Brand &

Generic

azelastine nasal spray (generic Astelin)

Atacand

Brand Only

candesartan (generic Atacand)

Atacand HCT

Brand Only

candesartan/hydrochlorothiazide (generic

Atacand HCT)

Atelvia

Brand &

Generic

risedronate (generic Actonel)

Atopaderm

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Atopiclair

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Atralin

Brand &

Generic

Must try all: tretinoin cream (generic Retin-A)

OTC Differin gel

Atrapro Antipruritic Hydrogel

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Atrapro Cp

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Atrapro Dermal Spray

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Atripla

Brand Only

efavirenz/emtricitabine/tenofovir disoproxil

fumarate (generic Atripla), Symfi, Symfi Lo

Augmentin

Brand Only

amoxicillin/clavulanic acid (generic Augmentin)

Augmentin 125mg /5 mL

Single

Source

Brand

amoxicillin/clavulanic acid (generic Augmentin

250mg/5mL)

Augmentin ES-600

Brand Only

amoxicillin/clavulanic acid (generic Augmentin)

Augmentin XR (amoxicillin-

Clavulanate ER)

Brand &

Generic

amoxicillin/clavulanic acid (generic Augmentin)

Aurstat Anti-Itch Hydrogel

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Auryxia

Single

Source

Brand

Must try two: calcium acetate (generic PhosLo),

sevelamer (generic Renagel), Velphoro

Avalide

Brand Only

Must try all: irbesartan/hydrochlorothiazide

(generic Avalide),

candesartan/hydrochlorothiazide (generic

Atacand HCT) ), losartan-HCTZ (generic

Hyzaar), olmesartan-HCTZ (Benicar HCT),

valsartan-HCTZ (generic Diovan HCT),

telmisartan-HCTZ (generic Micardis HCT)

Avapro

Brand Only

Must try all: candesartan (generic Atacand),

eprosartan (generic Teveten), irbesartan (generic

Avapro), losartan (generic Cozaar), telmisartan

(generic Micardis), valsartan (generic Diovan),

Edarbi, olmesartan (generic Benicar)

Avar Foam (9.5%-5%, 10-2%)

Single

Source

Brand

sulfacetamide sodium/sulfur 10-5%

Avar, Avar LS

Single

Source

Brand

sulfacetamide sodium/sulfur 10-5%

Avelox tablet

Brand Only

moxifloxacin tablets (generic Avelox)

Avinza

Brand Only

Use med nec or step therapy

MN, NV - Coverage of medications to treat

conditions associated with cancer may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Avita 0.025%

Brand and

Generic

Must Try Both: OTC Differin gel, tretinoin

cream (generic Retin-A)

Avodart

Brand Only

Must try all: dutasteride (generic Avodart),

finasteride (generic Proscar)

Axid Solution

Brand &

Generic

Legend

Medication

OTC Axid (nizatidine)

Axiron

Brand &

Generic

Minimum 4 week trial of Testim

Azeschew

Single

Source

Brand

Brand and generic prenatal vitamins

Azesco

Single

Source

Brand

Brand and generic prenatal vitamins

Azilect

Brand Only

Use Step Therapy

Azopt (brand only)

Brand Only

Must try both: brinzolamide (generic Azopt),

dorzolamide (generic Trusopt)

Azstarys

Single

Source

Brand

amphetamine/ dextroamphetamine immediate-

release (generic Adderall), methylphenidate

extended-release capsules (generic Metadate

CD, Ritalin LA), Adderall XR, Concerta

Balcoltra

Brand Only

levonorgestrel 0.1 mg/ethinyl estradiol 0.02 mg

[Aubra, Aubra EQ, Aviane, Delyla, Falmina,

Larissia, Lessina, Lutera, Orsythia, Sronyx,

Vienva (generics for Alesse)]

DC, Oregon, Connecticut, California, Delaware,

Illinois, Maryland, Massachusetts, New Jersey,

New York, and West Virginia only: approve if

provider states medically necessary

Baraclude Tablets

Brand Only

entecavir tablet (generic Baraclude)

Beconase AQ

Single

Source

Brand

Must Try Three: flunisolide (generic Nasarel),

fluticasone (generic Flonase), Zetonna, Nasacort

OTC, Flonase OTC, Rhinocort OTC (flonase

OTC and fluticasone (generic Flonase) count as

one alternative) (flonase OTC and fluticasone

(generic Flonase) count as one alternative)

Belsomra

Single

Source

Brand

Use Step Therapy

Benadryl

Brand &

Generic

Legend

Medication

OTC Benadryl (diphenhydramine)

Benicar

Brand Only

Must try all: candesartan (generic Atacand),

eprosartan (generic Teveten), irbesartan (generic

Avapro), losartan (generic Cozaar), telmisartan

(generic Micardis), valsartan (generic Diovan),

Edarbi, olmesartan (generic Benicar)

Benicar HCT

Brand Only

Must try all: candesartan HCT (generic Atacand

HCT), irbesartan HCT (generic Avalide),

losartan HCT (generic Hyzaar), valsartan HCT

(generic Diovan HCT), Edarbyclor,

olmesartan/hydrochlorothiazide (generic Benicar

HCT)

Benzaclin jar & pump

Brand &

Generic

Must try Both: clindamycin 1.2% /benzoyl

peroxide 5% gel (generic Duac), clindamycin

solution + OTC benzoyl peroxide

Bepreve

Brand &

Generic

Must try all: azelastine (generic for Optivar),

olopatadine (generic Patanol), Lastacaft, OTC

Pataday, OTC Zaditor

Betapace

Brand Only

sotalol (generic Betapace)

Bethkis

Brand Only

tobramycin 300 mg /4 mL (generic Bethkis)

Beyaz

Brand &

Generic

drospirenone/ethinyl estradiol (generic Yaz) or

Yaz + Folic Acid

DC, Oregon, Connecticut, California, Delaware,

Illinois, Maryland, Massachusetts, New Jersey,

New York, and West Virginia only: approve if

provider states medically necessary

BiDil

Brand Only

isosorbide dinitrate/hydralazine (generic BiDil)

Binosto

Single

Source

Brand

Must try all: alendronate (generic for Fosamax),

ibandronate (generic Boniva)

Boniva tablet

Brand Only

ibandronate (generic Boniva)

Bonjesta

Single

Source

Brand

OTC doxylamine (Unisom) + pyridoxine

(Vitamin B6)

Brimonidine tartrate/timolol maleate

Generic

Only

brand Combigan

Brisdelle

Brand &

Generic

estradiol (generic Estrace), paroxetine (generic

Paxil), paroxetine extended-release (generic

Paxil CR), Premarin

Brompheniramine + pseudoephedrine +

dextromethorphan

Generic

Only

OTC brompheniramine/pseudoephedrine (e,g.

Rynex PSE) + OTC dextromethorphan (e.g.,

Robitussin, Delsym)

Bromsite

Single

Source

Brand

Must try all: bromfenac ophthalmic solution

(generic Bromday, Xibrom), diclofenac

ophthalmic solution (generic Voltaren),

ketorolac ophthalmic solution (generic Acular),

Nevanac

Bronchitol

Single

Source

Brand

Use Step Therapy

Bryhali

Single

Source

Brand

Use Step Therapy

Budesonide/ Formoterol (Symbicort

Authorized Generic)

Authorized

Generic

Symbicort

Bunavail Film

Single

Source

Brand

Zubsolv, buprenorphine/naloxone (tablet or

film)

Bupap (butalbital 50mg/300mg

acetaminophen)

Brand &

Generic

butalbital/acetaminophen 50 mg/325 mg

(generic Phrenilin)

Buphenyl

Brand Only

sodium phenylbutyrate (generic Buphenyl)

butalbital/acetaminophen capsule 50/300

generic

only

butalbital/acetaminophen 50/325 mg tablet

(generic Phrenilin)

Butrans

Brand Only

Use med nec or step therapy

MN, NV - Coverage of medications to treat

conditions associated with cancer may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Bystolic

Brand &

Generic

Must try all: atenolol (generic Tenormin),

bisoprolol (generic Zebeta), metoprolol (generic

Lopressor)

Caduet

Brand &

Generic

Must try all: amlodipine (generic Norvasc) +

atorvastatin (generic Lipitor), amlodipine

(generic Norvasc) + lovastatin (generic

Mevacor), amlodipine (generic Norvasc) +

pravastatin (generic Pravachol), amlodipine

(generic Norvasc) + simvastatin (generic Zocor),

amlodipine (generic Norvasc) + rosuvastatin

(generic Crestor)

Cambia

Single

Source

Brand

Must try all: diclofenac tablets (generic

Voltaren, Cataflam), ibuprofen (generic Motrin),

naproxen (generic Aleve)

Canasa

Brand Only

mesalamine suppository (generic Canasa)

Carac

Single

Source

Brand

fluorouracil 5% (generic Efudex), Fluoroplex

1% cream

Carafate tablet/suspension

Brand Only

sulcralfate (generic Carafate)

Carbaglu

Brand Only

carglumic tablets (generic Carbaglu)

carbinoxamine 6 mg

Generic

only

carbinoxamine tablets (generic Palgic)

Cardizem CD

Brand Only

diltiazem extended-release (generic Cardizem

CD)

Cardizem LA

Brand Only

diltiazem extended-release (generic Cardizem

LA)

Cardizem

Brand Only

diltiazem (generic Cardizem)

Carrasyn Hydrogel Wound Dressing

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Cataflam

Brand Only

diclofenac tablets (generic Cataflam, generic

Voltaren

Catapres-TTS

Brand Only

clonidine patch (generic Catapres-TTS)

Celebrex

Brand Only

Must try all: celecoxib (generic Celebrex),

ibuprofen (generic Motrin), meloxicam (generic

Mobic), naproxen (generic Naprosyn)

Cellcept

Brand Only

mycophenolate mofetil (generic Cellcept)

Centany AT Kit

Single

Source

Brand

mupirocin ointment (generic Bactroban)

Cequa

Single

Source

Brand

Must try all: Restasis (single use vials), Xiidra

Ceracade

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Chlorzoxazone 250 mg

Single

Source

Brand

chlorzoxazone 500 mg (generic Parafon Forte

DSC)

Cialis

Brand Only

Must try all: sildenafil (generic Viagra), tadalafil

(generic Cialis), and vardenafil (generic Levitra)

Ciclodan Combination Package

Brand &

Generic

ciclopirox (generic Loprox)

Ciclodan Kit

Brand &

Generic

ciclopirox nail lacquer (generic Penlac)

Cinryze

Single

Source

Brand

Haegarda, Takhzyro

Ciprodex

Brand Only

ciprofloxacin/dexamethasone otic (generic

Ciprodex)

Clarinex

Brand &

Generic

levocetirizine (generic for Xyzal)

Clarinex-D

Single

Source

Brand

levocetirizine (generic for Xyzal) + OTC

pseudoephedrine

Claritin (all dosage forms)

Brand &

Generic

OTC Claritin (loratadine)

Claritin D

Brand &

Generic

OTC Claritin-D (loratadine-pseudoephedrine)

Clemastine fumerate tab

Generic

Only

OTC clemastine (generic Tavist)

Cleocin Vaginal Supp

Single

Source

Brand

clindamycin vaginal cream (generic Cleocin)

Climara

Brand Only

estradiol transdermal patch (generic Climara)

Clindacin Pac

Single

Source

Brand

Must try all: clindamycin gel 1% (generic for

Cleocin-T), clindamycin solution, clindamycin

lotion

Clindagel

Brand &

Authorized

Generic

Must try all: clindamycin gel 1% (generic for

Cleocin-T), clindamycin solution, clindamycin

lotion

Clobex 0.05% spray

Brand Only

clobetasol 0.05% spray (generic Clobex spray)

Clobex Lotion

Brand &

Generic

clobetasol 0.05% gel (generic Temovate),

clobetasol 0.05% solution (generic Temovate)

Clobex Shampoo (including Clodan)

Brand &

Generic

clobetasol 0.05% gel (generic Temovate),

clobetasol 0.05% solution (generic Temovate)

Cloderm

Brand Only

Use med nec or step therapy

Colazal

Brand Only

balsalazide (generic Colazal)

Colchicine Capsule

Generic

Only

Mitigare

Colcrys tablet

Brand Only

Must try both: colchicine (generic Colcrys),

Mitigare

Comfort Pac Tizanidine

Single

Source

Brand

tizanadine tablets (generic Zanaflex)

Compounding Kits

All

Use prior authorization criteria

Concerta

Single

Source

Brand

methylphenidate extended-release osmotic

release (generic Concerta)

Conjupri

Single

Source

Brand

amlodipine (generic Norvasc)

Consensi

Single

Source

Brand

amlodipine (generic Norvasc) + celocoxib

(generic Celebrex)

ConZip

Single

Source

Brand &

Authorized

Generic

Must try all: tramadol (generic Ultram),

tramadol ER (generic for Ultram ER)

Cordran 0.025% cream

Single

Source

Brand

hydrocortisone valerate 0.2% cream (generic

Westcort cream), prednicarbate 0.1% cream

(generic Dermatop cream), fluticasone

propionate cream 0.05% (generic Cutivate

cream)

Cordran Lotion

Brand Only

Use step therapy

Coreg

Brand Only

carvedilol (generic Coreg)

Coreg CR

Brand &

Generic

carvedilol (generic for Coreg)

Cosopt PF

Brand and

Generic

dorzolamide/timolol (generic Cosopt)

Cotempla XR-ODT

Single

Source

Brand

Must try TWO of the following:

amphetamine-dextroamphetamine extended-

release (generic Adderall XR),

dexmethylphenidate extended-release (generic

Focalin XR),

lisdexamfetamine (generic Vyvanse),

methylphenidate extended-release (generic

Concerta, Metadate CD, Metadate ER, Ritalin

LA)

Cozaar

Brand Only

losartan (generic Cozaar)

Crestor

Brand only

Must try all: atorvastatin (generic Lipitor),

lovastatin (generic Mevacor), pravastatin

(generic Pravachol), simvastatin (generic

Zocor), rosuvastatin (generic Crestor)

Cyclosporine 0.05% ophthalmic

emulsion single dose vials (generic

Restasis SDV)

Generic

Only

OTC artificial tears, Restasis Single Use vials

Cytomel

Brand Only

liothyronine (generic Cytomel)

D.H.E. 45

Brand Only

dihydroergotamine (generic D.H.E. 45)

Darifenacin (generic Enablex)

Generic

Only

oxybutynin (generic Ditropan),

oxybutynin extended-release (generic Ditropan

XL),

solifenacin (generic Vesicare),

tolterodine (generic Detrol),

trospium (generic Sanctura),

Oxytrol OTC

Daxbia

Single

Source

Brand

cephalexin (generic Keflex)

Daytrana

Brand and

Generic

Must try TWO of the following:

amphetamine-dextroamphetamine extended-

release (generic Adderall XR),

dexmethylphenidate extended-release (generic

Focalin XR),

lisdexamfetamine (generic Vyvanse),

methylphenidate extended-release (generic

Concerta, Metadate CD, Metadate ER, Ritalin

LA)

Dayvigo

Single

Source

Brand

Use Step Therapy

DDAVP injection

Brand Only

desmopressin (generic DDAVP)

DDAVP tablets

Brand Only

desmopressin (generic DDAVP)

Decadron Elixer

Brand Only

dexamethasone elixer (generic Decadron)

Decadron tablets

Brand Only

dexamethasone tablets

Delstrigo

Single

Source

Brand

Symfi, Symfi Lo, Triumeq

Denavir

Brand and

Generic

Must Try Two: acyclovir capsule/tablet (generic

Zovirax), famciclovir tablet (generic Famvir),

valacyclovir tablet (generic Valtrex), OTC

Abreva

Dermasorb HC kit

Single

Source

Brand

hydrocortisone (generic Hytone)

Dermasorb TA

Single

Source

Brand

triamcinolone acetonide cream or ointment

(generic Kenalog)

Dermasorb XM 39% kit

Single

Source

Brand

urea 40%

Descovy

Single

Source

Brand

Use Medical Necessity or Step Therapy

Desoxyn

Brand Only

methamphetamine (generic Desoxyn)

Desvenlafaxine ER

Brand &

Generic

venlafaxine extended-release capsule (generic

Effexor XR)

Detrol

Brand Only

Must try one of: oxybutynin (generic Ditropan),

oxybutynin extended-release (generic Ditropan

XL), Oxytrol OTC and All of the following:

solifenacin (generic Vesicare), trospium (generic

Sanctura)

Detrol LA

Brand &

Generic

Must try one of: oxybutynin (generic Ditropan),

oxybutynin extended-release (generic Ditropan

XL), Oxytrol OTC and All of the following:

solifenacin (generic Vesicare), tolterodine

(generic Detrol), trospium (generic Sanctura)

Dexedrine (Brand Only)

Brand Only

dextroamphetamine extended-release (generic

Dexedrine)

Dexilant (dexlansoprazole)

Brand &

Generic

Must try all: omeprazole (generic Prilosec),

pantoprazole (generic Protonix), rabeprazole

(generic Aciphex)

Dhivy

Single

Source

Brand

carbidopa/levodopa (generic Sinemet)

Diab

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Diab F.D.G. Freeze-Dried

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Dibenzyline

Brand Only

phenoxybenzamine (generic Dibenzyline)

Diclegis

Brand &

Generic

OTC doxylamine (Unisom) + pyridoxine

(Vitamin B6)

diflorasone diacetate 0.05% ointment

(generic Psorcon)

Generic

Only

Must try all: clobetasol 0.05% ointment (generic

Temovate), halobetasol 0.05% ointment (generic

Ultravate)

Diflucan 100 mg, 150 mg, 200 mg

Brand Only

fluconazole (generic Diflucan)

Diflucan 50 mg

Brand Only

fluconazole (generic Diflucan)

Diflucan suspension

Brand Only

fluconazole (generic Diflucan)

Dilaudid

Brand Only

hydromorphone (generic Dilaudid)

Disalcid

Brand Only

salsalate (generic Disalcid)

Ditropan XL

Brand Only

oxybutynin extended-release tablet (generic

Ditropan XL)

Doral

Brand and

Generic

temazepam (generic Restoril)

Doryx/Doryx MPC

Brand &

Generic

doxycycline hyclate (generic Morgidox,

Vibramycin), doxycycline monohydrate 50 mg

or 100 mg (generic Monodox)

Dovonex

Brand Only

calcipotriene cream (generic Dovonex)

doxycycline 75mg capsule (generic

Monodox)

Generic

Only

doxycycline hyclate (generic Morgidox,

Vibramycin), doxycycline monohydrate 50 mg

or 100 mg (generic Monodox)

Duaklir

Single

Source

Brand

Must try all: Anoro Ellipta, Bevespi Aerosphere

Duexis

Brand &

Generic

ibuprofen (generic for Motrin) plus OTC

famotidine (generic for Pepcid AC)

Dulera

Single

Source

Brand

Use Step Therapy

duloxetine 40mg (Irenka)

Authorized

Generic

duloxetine (generic Cymbalta)

Duobrii

Single

Source

Brand

Must try all: Enstilar, Taclonex solution or

Tazorac + fluocinonide 0.05% gel/solution

(generic Lidex), desoximetasone 0.5% gel

(generic Topicort)

Duragesic

Brand Only

Use Step Therapy or medical necessity

MN, NV - Coverage of medications to treat

conditions associated with cancer may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Dutoprol

Brand &

Generic

metoprolol extended-release (generic Toprol-

XL) plus hydrochlorothiazide

Dvorah

Single

Source

Brand

acetaminophen/codeine

Dxevo-11 day pack

Single

Source

Brand

dexamethasone tablets

Dyanavel XR

Single

Source

Brand

Must try TWO of the following:

amphetamine-dextroamphetamine extended-

release (generic Adderall XR),

dexmethylphenidate extended-release (generic

Focalin XR),

lisdexamfetamine (generic Vyvanse),

methylphenidate extended-release (generic

Concerta, Metadate CD, Metadate ER, Ritalin

LA)

Dyrenium

Brand Only

triamterene capsules (generic Dyrenium)

E.E.S. 400

Brand Only

erythromycin ethylsuccinate (generic E.E.S.

400)

Ecoza

Single

Source

Brand

Must Try Two: econazole (generic Spectazole),

ketoconazole (generic Nizoral), terbinafine

(generic Lamisil)

Edarbi

Single

Source

Brand

Must try THREE: candesartan (generic

Atacand), irbesartan (generic Avapro), losartan

(generic Cozaar), olmesartan (generic Benicar),

telmisartan (generic Micardis), valsartan

(generic Diovan)

Edarbyclor

Single

Source

Brand

Must try THREE: candesartan HCT (generic

Atacand HCT), irbesartan HCT (generic

Avalide), losartan HCT (generic Hyzaar),

olmesartan HCT (Benicar HCT), valsartan HCT

(generic Diovan HCT)

Edecrin

Brand Only

ethacrynic acid tablets (generic Edecrin)

Edluar

Single

Source

Brand

Must Try Two: zolpidem (generic Ambien),

zaleplon (generic Sonata), eszopiclone (generic

Lunesta)

Effient

Brand Only

prasugrel (generic Effient)

Elepsia XR

Single

Source

Brand

levetiracetam (generic Keppra)

Eletone

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Eletone Twin pack

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Elidel

Brand Only

Use Step Therapy

Elyxyb oral solution

Single

Source

Brand

Must try all: celecoxib capsules (generic

Celebrex), OTC ibuprofen (generic Motrin),

OTC naproxen (Naprosyn)

Emadine

Single

Source

Brand

Must try all: azelastine (generic for Optivar),

olopatadine (generic Patanol), Lastacaft, OTC

Pataday, OTC Zaditor

Embeda

Single

Source

Brand

Use med nec or step therapy

Emend capsules

Brand Only

aprepitant capsules (generic Emend)

Emflaza

Single

Source

Brand

Use med nec or step therapy

Emulsion Sb

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Entadfi

Single

Source

Brand

finasteride (generic Proscar) plus tadalafil

(generic Cialis)

Entocort EC

Brand Only

budesonide (generic Entocort EC)

Entty

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Envarsus XR

Single

Source

Brand

Use Nonform guideline

Epiceram

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Epiduo

Brand and

Generic

Must Try Both: OTC benzoyl peroxide PLUS

OTC Differin Gel,

OTC benzoyl peroxide PLUS tretinoin cream

(generic Retin-A)

Epiduo Forte

Brand &

Generic

Must Try Both: tretinoin cream (generic Retin-

A) + OTC Benzoyl Peroxide, OTC Differin +

OTC Benzoyl Peroxide

EpiPen

Brand Only

Must try all: epinephrine auto injector (generic

EpiPen and EpiPen Jr.), Symjepi

EpiPen Jr

Brand Only

Must try all: epinephrine auto injector (generic

EpiPen and EpiPen Jr.), Symjepi

Epogen

Single

Source

Brand

Retacrit

Eprontia oral solution

Single

Source

Brand

topiramate IR (generic Topamax), topiramate

sprinkle (generic Topamax sprinkle)

Epsolay

Single

Source

Brand

Soolantra

Epzicom

Brand Only

abacavir/lamivudine (generic Epzicom)

Ertaczo

Single

Source

Brand

Must Try Two: ciclopirox (generic Loprox),

econazole (generic Spectazole), ketoconazole

(generic Nizoral)

Esbriet

Brand Only

pirfenidone (generic Esbriet)

Esomeprazole strontium

Single

Source

Brand

Legend

Medication

WY tried/failed only: omeprazole (generic

Prilosec), pantoprazole (generic Protonix) tablet,

rabeprazole (generic Aciphex) tablet

For all other states must try all: omeprazole

(generic Prilosec), pantoprazole (generic

Protonix) tablet, rabeprazole (generic Aciphex)

tablet

Esperoct

Single

Source

Brand

Use Step Therapy

Estrace

Brand Only

estradiol tablets (generic Estrace)

Estrace vaginal cream

Brand Only

estradiol vaginal cream (generic Estrace vaginal

cream)

Estrostep FE

Brand Only

norethindrone/ethinyl estradiol 1/20-1/30-1/35

[Tilia FE, Tri-Legest FE (generic Estrostep FE)]

DC, Oregon, Connecticut, California, Delaware,

Illinois, Maryland, Massachusetts, New Jersey,

New York, and West Virginia only: approve if

provider states medically necessary

Eulexin

Single

Source

Brand

flutamide (generic Eulexin)

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics

Evekeo

Brand Only

Must try all: amphetamine/dextroamphetamine

immediate-release (generic Adderall),

dextroamphetamine extended-release (generic

Dexedrine)

Evekeo ODT

Single

Source

Brand

Must try all: amphetamine/ dextroamphetamine

immediate-release (generic Adderall),

dextroamphetamine extended-release (generic

Dexedrine)

Evista

Brand Only

raloxifene (generic Evista)

Evoxac

Brand Only

cevimeline (generic Evoxac)

Evzio

Single

Source

Brand

naloxone (generic narcan); Narcan nasal spray

-OR-

if med nec = YES:: use medical necessity GL

Exalgo

Brand Only

Use med nec or step therapy

MN, NV - Coverage of medications to treat

conditions associated with cancer may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Exelon

Brand Only

Must try all: rivastigmine transdermal patch

(generic Exelon), rivastigmine capsules (generic

Exelon)

Exforge

Brand Only

Must try all: amlodipine/ valsartan (generic

Exforge), amlodipine (generic Norvasc) +

losartan (generic Cozaar), amlodipine (generic

Norvasc) + irbesartan (generic Avapro),

amlodipine (generic Norvasc) + telmisartan

(generic Micardis), amlodipine (generic

Norvasc) + candesartan (generic Atacand),

amlodipine (generic Norvasc) + eprosartan

(Teveten), amlodipine (generic Norvasc) +

Edarbi, amlodipine (generic Norvasc) +

valsartan (generic Diovan)

Exforge HCT

Generic

Only

Use non-Formulary Criteria.

T/F states only also allow trial and failaure of :

amlodipine (generic Norvasc) +

losartan/hydrochlorothiazide (generic Hyzaar),

amlodipine (generic Norvasc) +

valsartan/hydrochlorothiazide (generic Diovan

HCT), amlodipine (generic Norvasc) +

olmesartan HCT, amlodipine (generic Norvasc)

+ telmisartan/hydrochlorothiazide (generic

Micardis HCT)

Exjade

Brand Only

deferasirox (generic Exjade)

Exservan

Single

Source

Brand

riluzole (generic Rilutek)

Extavia

Single

Source

Brand

Use step therapy

Fabior

Single

Source

Brand

Must try all: tretinoin cream, Tazorac gel, OTC

Differin

Fareston

Brand Only

toremifene (generic Fareston)

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Farxiga

Single

Source

Brand

Use step therapy

Femara

Brand Only

letrozole (generic Femara)

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics

Femhrt

Brand Only

norethindrone/ethinyl estradiol 0.5 mg/2.5 mcg

[Fyavolv (generic Femhrt)]

Fenofibrate micronized capsule 30mg

and 90mg

Single

Source

Brand

Must try ONE of the following:

1. fenofibrate 48mg, 54mg, 145mg, 160mg

tablet (generic Lofibra, Tricor, Triglide);

2. fenofibrate micronized capsule 43mg, 130mg

(generic Antara);

3. fenofibrate micronized capsule 67mg, 134mg,

200mg (generic Lofibra, Tricor)

Fenofibric acid 35mg and 105mg

Generic

Only

Must try ONE of the following:

1. fenofibrate 48mg, 54mg, 145mg, 160mg

tablet (generic Lofibra, Tricor, Triglide);

2. fenofibrate micronized capsule 43mg, 130mg

(generic Antara);

3. fenofibrate micronized capsule 67mg, 134mg,

200mg (generic Lofibra, Tricor)

Fenoglide

Brand &

Generic

Must try ONE of the following:

1. fenofibrate 48mg, 54mg, 145mg, 160mg

tablet (generic Lofibra, Tricor, Triglide);

2. fenofibrate micronized capsule 43mg, 130mg

(generic Antara);

3. fenofibrate micronized capsule 67mg, 134mg,

200mg (generic Lofibra, Tricor)

Fenortho

Brand &

Generic

Must try all: ibuprofen (generic Motrin),

naproxen (generic Aleve, Naprosyn)

fentanyl transdermal patch (37.5, 62.5

and 87.5 mcg/hr strengths only)

Generic

Only

Use Step Therapy or medical necessity

MN, NV - Coverage of medications to treat

conditions associated with cancer may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Fentora

Single

Source

Brand

Must Try Both: fentanyl citrate lozenges

(generic Actiq), Lazanda

CT only: Must try fentanyl citrate (generic

Actiq)

MN, NV - Coverage of medications to treat

conditions associated with cancer may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Fexmid 7.5 mg

Brand &

Generic

cyclobenzaprine 5 mg, 10 mg (generic Flexeril)

Fiasp (All dosage forms)

Single

Source

Brand

Use step therapy

In Florida, Maine, and Tennessee only,

medications prescribed for diabetes may be

approved based on both of the following: 1)

Provider attests use of this product is medically

necessary for the treatment of diabetes; and- 2)

If applicable, clinical characteristics exist that

preclude the use of the covered preferred

alternative(s) and use of the covered preferred

alternative(s) could result in worsening of

patient’s condition or inadequate treatment

(document alternatives and clinical information

related to worsening/inadequate treatment).

Fibricor 35 mg, 105 mg

Multisource

Brand

Without

Generic

Must try ONE of the following:

1. fenofibrate 48mg, 54mg, 145mg, 160mg

tablet (generic Lofibra, Tricor, Triglide);

2. fenofibrate micronized capsule 43mg, 130mg

(generic Antara);

3. fenofibrate micronized capsule 67mg, 134mg,

200mg (generic Lofibra, Tricor)

Finacea

Brand Only

azelaic acid gel (generic Finacea)

Fioricet with Codeine 50 mg/325 mg/40

mg/30 mg

Brand Only

butalbital/acetaminophen/caffeine/codeine 50

mg/325 mg/40 mg/30 mg (generic Fioricet with

Codeine)

Fioricet with Codeine capsule

50mg/300mg/40 mg/30mg

Brand &

Generic

butalbital/acetaminophen/caffeine/codeine 50

mg/325 mg/40 mg/30 mg (generic Fioricet with

Codeine)

Firazyr

Brand Only

icatibant acetate (generic Firazyr)

Flomax

Brand Only

tamsulosin (generic Flomax)

Flovent Diskus

Single

Source

Brand

Must try BOTH: Arnuity Ellipta, QVAR

RediHaler

Flovent HFA

Multisource

Brand

Without

Generic

Must try BOTH: Arnuity Ellipta, QVAR

RediHaler

Floxin 0.3% Otic

Brand Only

ofloxacin 0.3% otic solution (generic Floxin

Otic, Ocuflox)

Fluorouracil 0.5% cream

Single

Source

Brand

fluorouracil 5% (generic Efudex), Fluoroplex

1% cream

Fluticasone furoate/Vilanterol Ellipta

Multisource

Brand

Without

Generic

Must try ALL: fluticasone propionate/salmeterol

(generic Advair Diskus), Advair HFA, Breo

Ellipta, Symbicort

Fluticasone propionate HFA

Multisource

Brand

Must try BOTH: Arnuity Ellipta, QVAR

RediHaler

Without

Generic

Fluticasone-salmeterol HFA

Multisource

Brand

Without

Generic

Must try ALL: fluticasone propionate/salmeterol

(generic Advair Diskus), Advair HFA, Breo

Ellipta, Symbicort

Focalin XR

Brand Only

Must try TWO of the following:

amphetamine-dextroamphetamine extended-

release (generic Adderall XR),

dexmethylphenidate extended-release (generic

Focalin XR),

lisdexamfetamine (generic Vyvanse),

methylphenidate extended-release (generic

Concerta, Metadate CD, Metadate ER, Ritalin

LA)

Fortamet

Brand &

Generic

Use Medical Necessity

Forteo

Brand and

Generic

Use Step Therapy

Fortesta

Single

Source

Brand

Four week trial of Testim

Fosrenol chewable tablets

Brand &

Generic

Use step therapy

Frova

Brand Only

Must try frovatriptan (Frova) plus two of the

following: almotriptan (Axert), eletriptan

(Relpax), naratriptan (generic Amerge),

rizatriptan (Maxalt/Maxalt MLT), sumatriptan

(Imitrex), zolmitriptan (Zomig)

Fulphila

Single

Source

Brand

Must try BOTH: Neulasta, Udenyca

Fylnetra

Single

Source

Brand

Must try BOTH: Neulasta, Udenyca

Gastrocrom

Brand Only

cromolyn oral concentrate (generic Gastrocrom)

Gelnique

Single

Source

Brand

Must try one of: oxybutynin (generic Ditropan),

oxybutynin extended-release (generic Ditropan

XL), Oxytrol OTC and All of the following:

solifenacin (generic Vesicare), tolterodine

(generic Detrol), trospium (generic Sanctura)

Gemtesa

Single

Source

Brand

Must try one of: oxybutynin (generic Ditropan),

oxybutynin extended-release (generic Ditropan

XL), Oxytrol OTC and All of the following:

solifenacin (generic Vesicare), tolterodine

(generic Detrol), trospium (generic Sanctura)

Genadur

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Genadur Kit

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Generess FE

Brand &

Generic

norethindrone/ethinyl estradiol 24 FE 1/0.02 mg

[Blisovi 24 FE, Junel 24 FE, Larin 24 FE,

LoMedia 24 FE, (branded generic Loestrin 24

FE)], and norethindone/ethinyl estradiol FE

1/0.02 mg [Blisovi FE, Junel FE, Larin FE,

Microgestin FE, Tarina FE (branded generic

Loestrin FE)

DC, Oregon, Connecticut, California, Delaware,

Illinois, Maryland, Massachusetts, New Jersey,

New York, and West Virginia only: approve if

provider states medically necessary

Genotropin and Genotropin MiniQuick

Single

Source

Brand

ONE of the following:

• Nutropin AQ; OR

• Nutropin AQ NuSpin

Geodon

Brand Only

Must try ziprasidone (generic Geodon) and two

of the following: olanzapine (generic Zyprexa),

quetiapine (generic Seroquel), risperidone

(generic Risperdal), aripiprazole tablets (generic

Abilify)

Minnesota: See State Mandate Overview

Document

Gialax kit

Single

Source

Brand

PEG-3350 (generic Miralax)

Giazo

Single

Source

Brand

Must try all: balsalazide (generic Colazal),

sulfasalazine (generic Azulfidine), Apriso

(brand)

Gilenya 0.5mg

Brand Only

fingolimod (generic Gilenya)

Gimoti

Single

Source

Brand

metoclopramide (generic Reglan)

GlucaGen Hypokit

Single

Source

Brand

Must try 2: glucagon (generic Glucagon

Emergency Kit), Baqsimi, Zegalogue

Glucagon Emergency Kit (Lilly)

Brand Only

Must try 2: glucagon (generic Glucagon

Emergency Kit), Baqsimi, Zegalogue

Glumetza

Brand &

Generic

Use Medical Necessity

Glycate

Brand Only

glycopyrrolate (generic Robinul)

Gocovri

Single

Source

Brand

amantadine IR (generic Symmetrel)

Gonitro

Single

Source

Brand

nitroglycerin sublingual tablet (generic

Nitrostat)

Gralise

Single

Source

Brand

gabapentin (generic Neurontin)

Granix

Single

Source

Brand

Zarxio

Halog 0.1% solution

Single

Source

Brand

Must try all: fluocinonide 0.05% gel/solution

(generic Lidex), desoximetasone 0.05% gel

(generic Topicort)

Halog cream

Brand Only

Use Step Therapy

Halog ointment

Single

Source

Brand

Use Step Therapy

Helidac

Single

Source

Brand

metronidazole (generic Flagyl) + tetracycline

(generic Sumycin) + OTC bismuth subsalicylate

or Omeclamox-Pak

Helixate FS

Single

Source

Brand

Use med nec or step therapy

Hemady

Single

Source

Brand

dexamethasone tablet

Hepsera

Brand Only

adefovir (generic Hepsera)

Hidex 6-day pack

Single

Source

Brand

dexamethasone

Histex

Legend

Medication

OTC triprolidine

Histex-AC Syrup

Single

Source

Brand

guaifenesin/codeine solution (cheratussin AC)

Horizant

Single

Source

Brand

gabapentin (generic Neurontin) or ropinirole

(generic Requip )or pramipexole (generic

Mirapex)

HPR

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

HPR Plus

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

HPR Plus Hydrogel

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

HPR Plus/MB Hydrogel

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Humalog Tempo Pen

Single

Source

Brand

Humalog KwikPen, Insulin Lispro KwikPen

(unbranded Humalog), Lyumjev KwikPen

In Florida, Maine, and Tennessee only, diabetes

medications may be approved based on both of

the following: 1) Provider attests use of this

product is medically necessary; and- 2) If

applicable, clinical characteristics exist that

preclude the use of the covered preferred

alternative(s) and use of the covered preferred

alternative(s) could result in worsening of

patient’s condition or inadequate treatment

(document alternatives and clinical information

related to worsening/inadequate treatment).

Humalog vial

Single

Source

Brand

insulin lispro vial (unbranded Humalog)

In Florida, Maine, and Tennessee only, diabetes

medications may be approved based on both of

the following: 1) Provider attests use of this

product is medically necessary; and- 2) If

applicable, clinical characteristics exist that

preclude the use of the covered preferred

alternative(s) and use of the covered preferred

alternative(s) could result in worsening of

patient’s condition or inadequate treatment

(document alternatives and clinical information

related to worsening/inadequate treatment).

Humatin

Brand Only

paromomycin (generic Humatin)

Humatrope

Single

Source

Brand

ONE of the following:

• Nutropin AQ; OR

• Nutropin AQ NuSpin

Hycodan

Single

Source

Brand

hydrocodone/homatropine 5/1.5 mg/5 mL

(generic Hycodan)

Hycofenix

Single

Source

Brand

guaifenesin/codeine solution (cheratussin AC)

Hydrocodone/ Guaifenesin Solution

2.5/200 mg/5 mL

Single

Source

Brand

guaifenesin/codeine solution (cheratussin AC)

hydrocortisone cream & lotion

Brand &

Generic

OTC hydrocortisone

Hylatopic Plus

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Hysingla extended-release

Brand Only

Use Medical Necessity

Hyzaar

Brand Only

Musts try all: candesartan HCT (generic

Atacand HCT), irbesartan HCT (generic

Avalide), losartan HCT (generic Hyzaar),

valsartan HCT (generic Diovan HCT),

Edarbyclor, olmesartan/hydrochlorothiazide

(generic Benicar HCT)

Ibsrela

Single

Source

Brand

Use Step Therapy

Icy Hot PM

Single

Source

Brand

OTC capsaicin patches

Ilevro

Single

Source

Brand

Must try all: bromfenac ophthalmic solution

(generic Bromday, Xibrom), diclofenac

ophthalmic solution (generic Voltaren),

ketorolac ophthalmic solution (generic Acular),

Nevanac

Ilumya

Single

Source

Brand

Use Medical Necessity criteria

Imbruvica 140mg and 280mg tablet

Single

Source

Brand

Imbruvica capsule

Imitrex (Injections & Tablets)

Brand Only

sumatriptan tablets or injection (generic Imitrex)

Imodium

Brand &

Generic

Legend

Medication

OTC Imodium (loperamide)

Impeklo 0.05% lotion

Single

Source

Brand

Must try all: betamethasone 0.05% augmented

gel (generic Diprolene), clobetasol propionate

0.05% gel (generic Temovate), clobetasol 0.05%

solution (generic Temovate)

Impoyz

Single

Source

Brand

Must try all: betamethasone dipropionate

augmented 0.05% cream (generic Diprolene

AF), fluocinonide 0.05% cream (generic Lidex

cream)

Imuran

Brand Only

azathioprine (generic Imuran)

Incruse Ellipta

Single

Source

Brand

Spiriva Respimat/HandiHaler

Inderal LA

Brand Only

propranolol extended-release capsule (generic

Inderal LA)

Inderal XL

Single

Source

Brand

Must try all: propranolol (generic Inderal),

propranolol extended-release (generic Inderal

LA)

Ingrezza

Single

Source

Brand

Use Step Therapy or medical necessity

Innopran XL

propranolol (generic Inderal), propranolol

extended-release (generic Inderal LA)

Inspra

Brand Only

eplerenone (generic Inspra)

Insulin Aspart

Single

Source

Brand

Use Step Therapy

Insulin Aspart Protamine/Insulin Aspart

Single

Source

Brand

Use Step Therapy

Insulin glargine vial, SoloStar (Lantus

vial/Lantus SoloStar Authorized Brand

Alternative)

Single

Source

Brand

Must try all: Lantus, Toujeo

In Florida, Maine, and Tennessee only,

medications prescribed for diabetes may be

approved based on both of the following: 1)

Provider attests use of this product is medically

necessary for the treatment of diabetes; and- 2)

If applicable, clinical characteristics exist that

preclude the use of the covered preferred

alternative(s) and use of the covered preferred

alternative(s) could result in worsening of

patient’s condition or inadequate treatment

(document alternatives and clinical information

related to worsening/inadequate treatment).

Insulin Lispro

Authorized

generic

(Single

Source

Brand)

Humalog vial or Humalog KwikPen

In Florida, Maine, and Tennessee only,

medications prescribed for diabetes may be

approved based on both of the following: 1)

Provider attests use of this product is medically

necessary for the treatment of diabetes; and- 2)

If applicable, clinical characteristics exist that

preclude the use of the covered preferred

alternative(s) and use of the covered preferred

alternative(s) could result in worsening of

patient’s condition or inadequate treatment

(document alternatives and clinical information

related to worsening/inadequate treatment).

Intermezzo

Brand &

Generic

Must Try Two: zolpidem (generic Ambien),

zalepelon(generic Sonata), eszopiclone (generic

Lunesta)

Invega

Brand Only

paliperidone (generic Invega)

Minnesota: See State Mandate Overview

Document

Invokamet

Single

Source

Brand

Use Step Therapy

Invokamet XR

Single

Source

Brand

Use Step Therapy

Invokana

Single

Source

Brand

Use Step Therapy

Isordil Titradose

Brand Only

isosorbide dinitrate (generic Isordil Titradose)

isosorbide dinitrate 40mg

Generic

Only

isosorbide dinitrate 2 x 20 mg (generic Isordil

Titradose)

Isotretinoin 25mg and 35mg (generic

Absorica)

Generic

Only

BOTH of the following:

(1) Must try two of the following:

(a) Topical retinoid or retinoid-like agent [e.g.,

Retin-A/Retin-A Micro (tretinoin)]

(b) oral antibiotic [e.g., Ery-Tab (erythromycin),

Minocin (minocycline)]

peroxide [e.g., Cleocin-T (clindamycin),

erythromycin, BenzaClin (benzoyl

peroxide/clindamycin), Benzamycin (benzoyl

peroxide/erythromycin)]

AND

(2) Must try two of the following oral

isotretinoin formulations (document duration of

trial):

(a) Claravis

(b) Myorisan

(d) Amnesteem

(e) isotretinoin 10mg, 20mg, 30mg, 40mg

Ixinity

Single

Source

Brand

Must try all: BeneFIX, Rixubis

Jadenu

Brand Only

deferasirox (generic Jadenu)

Jalyn

Brand &

Generic

dutasteride (generic Avodart) + tamsulosin

(generic Flomax)

Janumet

Single

Source

Brand

For NY Fully Insured, NJ Fully Insured, and CT

Fully Insured, Use separate excluded drug

criteria

For all ASO, Non-NY-Fully Insured, Non-NJ

Fully Insured, and Non-CT Fully Insured, Use

DPP4 Inhibitors - Step Therapy guideline

Janumet XR

Single

Source

Brand

For NY Fully Insured, NJ Fully Insured, and CT

Fully Insured, Use separate excluded drug

criteria

For all ASO, Non-NY-Fully Insured, Non-NJ

Fully Insured, and Non-CT Fully Insured, Use

DPP4 Inhibitors - Step Therapy guideline

Januvia

Single

Source

Brand

For NY Fully Insured, NJ Fully Insured, and CT

Fully Insured, Use separate excluded drug

criteria

For all ASO, Non-NY-Fully Insured, Non-NJ

Fully Insured, and Non-CT Fully Insured, Use

DPP4 Inhibitors - Step Therapy guideline

Jatenzo

Single

Source

Brand

Minimum 4 week trial of Testim

Javygtor

Brand Only

sapropterin (generic Kuvan)

Jornay PM

Single

Source

Brand

Must try all: Brand Adderall XR, Brand

Concerta, methylphenidate extended-release

capsule (generic Metadate CD or Ritalin LA)

(note trial of generic is acceptable)

Kadian

Brand Only

Use med nec or step therapy

MN, NV - Coverage of medications to treat

conditions associated with cancer may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Kapvay

Brand &

Generic

guanfacine extended-release (generic Intuniv)

Karbinal ER

Single

Source

Brand

carbinoxamine tablets (generic Palgic)

Katerzia suspension

Single

Source

Brand

Must try both: amlodipine (generic Norvasc),

Norliqva solution

Kenalog Spray

Brand Only

triamcinolone spray (generic Kenalog)

Kendall Amorphous Hydrogel Wound

Dressing

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Keralac 47% cream

Brand &

Generic

urea 40%

Keralyt Scalp Kit

Single

Source

Brand

salicylic acid shampoo, salicylic acid gel

Kerydin

Brand and

Generic

Use MedNec or Step Therapy

Ketodan Kit

Single

Source

Brand

ketoconazole cream (generic Nizoral)

ketoprofen (generic Orudis)

Generic

only

Use Step Therapy

ketoprofen extended-release (generic

Oruvail)

Generic

only

Use Step Therapy

Khedezla

Single

Source

Brand

venlafaxine extended-release capsule (generic

Effexor XR)

Kitabis Pak

Single

Source

Brand

tobramycin 300 mg /4 mL (generic Bethkis)

Kombiglyze XR

Brand Only

saxagliptin/metformin extended-release (generic

Kombiglyze XR)

Kuvan

Brand Only

sapropterin (generic Kuvan)

Lactic Acid with vitamin E (ammonium

lactate) OR Lactic Acid cream & lotion

(Lac Hydrin 12%)

Brand &

Generic

Legend

Medication

OTC Lac-Hydrin (ammonium lactate)

lactulose (generic Kristalose)

Generic

Only

lactulose oral solution

Lamictal XR (Lamotrigine ER)

Brand &

Generic

Use med nec or step therapy

Lanreotide

Single

Source

Brand

Somatuline Depot

Lansoprazole/amoxicillin/clarithromycin

therapy pack

Generic

Only

Omeclamox-Pak

Latuda

Brand Only

lurasidone (generic Latuda)

Minnesota: See State Mandate Overview

Document

Lescol XL

Brand Only

Use step therapy

Letairis

Brand Only

ambrisentan (generic Letairis)

Levemir (All dosage forms)

Single

Source

Brand

Use separate Levemir (insulin detemir) - All

Primary Review Types guideline

In Florida, Maine, and Tennessee only, diabetes

medications may be approved based on both of

the following: 1) Provider attests use of this

product is medically necessary; and- 2) If

applicable, clinical characteristics exist that

preclude the use of the covered preferred

alternative(s) and use of the covered preferred

alternative(s) could result in worsening of

patient’s condition or inadequate treatment

(document alternatives and clinical information

related to worsening/inadequate treatment).

Levitra

Brand Only

vardenafil (generic Levitra)

Lexette

Brand and

Authorized

generic

Must try all: betamethasone 0.05% augmented

gel (generic Diprolene), clobetasol propionate

0.05% gel (generic Temovate), clobetasol 0.05%

solution (generic Temovate)

Lexiva

Brand Only

fosamprenavir (generic Lexiva)

Lialda (mesalamine)

Brand Only

mesalamine delayed-release (generic Delzicol),

mesalamine delayed-release (generic Lialda),

Apriso

Librax

Brand Only

chlordiazepoxide/clidinium (generic Librax)

Licart

Single

Source

Brand

OTC Voltaren gel

Lidoderm

Brand Only

lidocaine transdermal patch (generic Lidoderm)

Lipofen

Brand &

Generic

Must try ONE of the following:

1. fenofibrate 48mg, 54mg, 145mg, 160mg

tablet (generic Lofibra, Tricor, Triglide);

2. fenofibrate micronized capsule 43mg, 130mg

(generic Antara);

3. fenofibrate micronized capsule 67mg, 134mg,

200mg (generic Lofibra, Tricor)

Livalo

Single

Source

Brand

For Oxford plans: Use Medical Necessity

For all other plans: Use Step Therapy

Locoid Lipocream

Brand &

Generic

hydrocortisone butyrate (generic Locoid) cream

ointment or solution

Locoid Lotion

Brand &

Generic

hydrocortisone butyrate (generic Locoid) cream

ointment or solution

Lodine

Brand Only

etodolac (generic Lodine)

Lodosyn

Brand Only

carbidopa (generic Lodosyn)

Loestrin 1.5/30

Brand Only

norethindrone/ethinyl estradiol 1.5 mg/30 mcg

[Aurovela, Hailey, Junel 1.5/30, Larin,

Microgestin (generic Loestrin 1.5/30)]

DC, Oregon, Connecticut, California, Delaware,

Illinois, Maryland, Massachusetts, New Jersey,

New York, and West Virginia only: approve if

provider states medically necessary

Loestrin 1/20

Brand Only

norethindrone/ethinyl estradiol 1 mg/20 mcg

[Aurovela, Junel 1/20, Larin, Microgestin

(generic Loestrin 1/20)]

DC, Oregon, Connecticut, California, Delaware,

Illinois, Maryland, Massachusetts, New Jersey,

New York, and West Virginia only: approve if

provider states medically necessary

Loestrin FE 1.5/30

Brand Only

norethindrone/ethinyl estradiol 1.5 mg/30 mcg

[Aurovela FE, Blisovi FE, Hailey FE, Junel FE,

Larin FE, Microgestin FE, (generic Loestrin FE

1.5/30)]

DC, Oregon, Connecticut, California, Delaware,

Illinois, Maryland, Massachusetts, New Jersey,

New York, and West Virginia only: approve if

provider states medically necessary

Loestrin FE 1/20

Brand Only

norethindrone/ethinyl estradiol [Aurovela FE,

Blisovi FE, Hailey FE, Junel FE, Larin FE,

Microgestin FE, Tarina FE (generics for

Loestrin FE 1/20)]

DC, Oregon, Connecticut, California, Delaware,

Illinois, Maryland, Massachusetts, New Jersey,

New York, and West Virginia only: approve if

provider states medically necessary

Lofena

Brand and

Generic

diclofenac tablets (generic Cataflam, generic

Voltaren)

Lonhala Magnair

Single

Source

Brand

Use Medical Necessity

Lonsurf

Single

Source

Brand

Stivarga

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics

Loprox 0.77% cream

Brand Only

ciclopirox 0.77% cream (generic Loprox)

Loprox 0.77% suspension

Brand Only

ciclopirox 0.77% suspension (generic Loprox)

Loprox Shampoo

Brand Only

ciclopirox shampoo (generic Loprox Shampoo)

Loreev XR

Single

Source

Brand

lorazepam (generic Ativan)

Lorzone

Brand and

Generic

Must try all: cyclobenzaprine HCL (generic

Flexeril), carisoprodol (Soma 350mg),

methocarbamol (generic Robaxin),

chlorzoxazone (generic Parafon Forte DSC),

tizanidine (Zanaflex Tablets)

Lotemax 0.5% ophthalmic suspension

Brand Only

loteprednol 0.5% ophthalmic suspension

(generic Lotemax)

Lotemax Gel

Brand &

Generic

loteprednol 0.5% suspension (generic Lotemax)

Lotrel

Brand Only

amlodipine/benazepril (generic Lotrel)

Lotrimin 1% cream & solution

Legend

Medication

OTC Lotrimin (clotrimazole)

Lotronex

Brand Only

alosetron (generic Lotronex)

Lovaza

Brand Only

Omega-3-acid ethyl esters (generic Lovaza)

Lovenox

Brand Only

enoxaparin (generic Lovenox)

Lumakras

Single

Source

Brand

Use Notification guideline

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics

Luxiq

Brand &

Generic

betamethasone lotion (generic Valisone)

Luzu

Brand &

Generic

Must Try Two: ciclopirox (generic Loprox),

econazole (generic Spectazole), ketoconazole

(generic Nizoral)

Lybalvi

Single

Source

Brand

Use Medical Necessity

Lymepak

Single

Source

Brand

Must try all: doxycycline hyclate 100 mg

(generic Morgidox, Vibramycin), doxycycline

monohydrate 100 mg (generic Monodox)

Lyrica CR

Single

Source

Brand

Use Step Therapy

Lyumjev Tempo Pen

Single

Source

Brand

Humalog KwikPen, Insulin Lispro KwikPen

(unbranded Humalog), Lyumjev KwikPen

In Florida, Maine, and Tennessee only, diabetes

medications may be approved based on both of

the following: 1) Provider attests use of this

product is medically necessary; and- 2) If

applicable, clinical characteristics exist that

preclude the use of the covered preferred

alternative(s) and use of the covered preferred

alternative(s) could result in worsening of

patient’s condition or inadequate treatment

(document alternatives and clinical information

related to worsening/inadequate treatment).

Lyvispah granules

Single

Source

Brand

Must try both: baclofen (generic Lioresal),

Ozobax

Maxalt

Brand Only

Must try rizatriptan (Maxalt/Maxalt MLT) plus

two of the following: almotriptan (Axert),

eletriptan (Relpax), frovatriptan (Frova),

naratriptan (generic Amerge), sumatriptan

(generic Imitrex), zolmitriptan (Zomig)

Maxalt- MLT

Brand Only

Must try rizatriptan (Maxalt/Maxalt MLT) plus

two of the following: almotriptan (Axert),

eletriptan (Relpax), frovatriptan (Frova),

naratriptan (generic Amerge), sumatriptan

(generic Imitrex), zolmitriptan (Zomig)

MB Hydrogel

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Meclizine (Antivert)

Brand &

Generic

Legend

Medication

OTC Meclizine

Mektovi

Single

Source

Brand

Use Step Therapy

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics

Mephyton

Brand Only

phytonadione (generic Mephyton)

Mepron Suspension

Generic

Only

atovaquone suspension (generic Mepron)

Mesalamine ER capsule (generic

Apriso)

Generic

Only

Apriso (brand)

Mestinon 60 mg tablet

Brand Only

pyridostigmine (generic Mestinon)

Mestinon Timespan

Brand Only

pyridostigmine extended-release tablet (generic

Mestinon Timespan)

Metadate CD

Brand Only

Must try two: Brand Adderall XR, Brand

Concerta, methylphenidate extended-release

capsule (generic Metadate CD or Ritalin LA)

(note trial of generic is acceptable )

Metformin 625mg

Generic

Only

metformin (generic Glucophage, generic

Glucophage XR)

In Florida, Maine, and Tennessee only,

medications prescribed for diabetes may be

approved based on both of the following: 1)

Provider attests use of this product is medically

necessary for the treatment of diabetes; and- 2)

If applicable, clinical characteristics exist that

preclude the use of the covered preferred

alternative(s) and use of the covered preferred

alternative(s) could result in worsening of

patient’s condition or inadequate treatment

(document alternatives and clinical information

related to worsening/inadequate treatment).

Methocarbamol 1000mg

Generic

Only

methocarbamol 500mg (generic Robaxin)

Methylphenidate extended-release tablet

Generic

Only

Must try TWO of the following:

amphetamine-dextroamphetamine extended-

release (generic Adderall XR),

dexmethylphenidate extended-release (generic

Focalin XR),

lisdexamfetamine (generic Vyvanse),

methylphenidate extended-release (generic

Concerta, Metadate CD, Metadate ER, Ritalin

LA)

Metoprolol 37.5, 75 mg

Generic

Only

(Single

Source

Brand)

metoprolol (25, 50, 100 mg strengths) (generic

Lopressor)

Metozolv ODT

Brand &

Generic

metoclopramide (generic Reglan)

Metrogel 0.75% Vaginal

Brand Only

metronidazole 0.75% vaginal gel (generic

Metrogel-Vaginal)

Metrogel 1%

Brand &

Generic

metronidazole gel 0.75% (generic Metrogel)

Micardis

Brand Only

Must try all: candesartan (generic Atacand),

eprosartan (generic Teveten), irbesartan (generic

Avapro), losartan (generic Cozaar), telmisartan

(generic Micardis), valsartan (generic Diovan),

Edarbi, olmesartan (generic Benicar)

Micardis HCT

Brand Only

Must try all: candesartan HCT (generic Atacand

HCT), irbesartan HCT (generic Avalide),

losartan HCT (generic Hyzaar), valsartan HCT

(generic Diovan HCT), Edarbyclor,

olmesartan/hydrochlorothiazide (generic Benicar

HCT)

Micort-HC 2.5% Cream

Brand

hydrocortisone 2.5% cream

Microcyn

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Migranal

Brand Only

dihydroergotamine nasal spray (generic

Migranal)

Millipred

Single

Source

Brand

prednisone tablet,

prednisolone tablet

Minastrin 24 FE

Brand Only

norethindrone/ethinyl estradiol FE 1/0.02 mg

[Blisovi FE, Junel FE, Larin FE, Microgestin

FE, Tarina FE (branded generics for Loestrin

FE)]

DC, Oregon, Connecticut, California, Delaware,

Illinois, Maryland, Massachusetts, New Jersey,

New York, and West Virginia only: approve if

provider states medically necessary

Minivelle

Brand Only

estradiol patch (generic Minivelle), Vivelle-Dot

Minocin 50mg, 75mg and 100mg

Brand Only

minocycline immediate release capsule (generic

Minocin)

minocycline tablet (Generic Dynacin)

Generic

Only

minocycline immediate release capsules (generic

Minocin)

Minolira

Single

Source

Brand

minocycline immediate-release capsules

(generic Minocin)

Mirapex ER

Brand &

Generic

pramipexole (generic for Mirapex)

Mircette

Brand Only

desogestrel/ethinyl estradiol [Azurette, Bekyree,

Kariva, Pimtrea, Simliya, Viorele, Volnea

(generic Mircette)]

DC, Oregon, Connecticut, California, Delaware,

Illinois, Maryland, Massachusetts, New Jersey,

New York, and West Virginia only: approve if

provider states medically necessary

Mobic

Brand Only

meloxicam (generic Mobic)

Moderiba Tablet and Pak

Generic

Only

ribavirin (generic for Copegus, Rebetol)

Monodox

Brand Only

doxycycline hyclate (generic Vibramycin,

Vibra-Tab), doxycycline monohydrate 50 or

100mg (generic Monodox)

Morgidox Kit

Single

Source

Brand

doxycycline hyclate (generic Vibramycin,

Vibra-Tab), doxycycline monohydrate 50 or

100mg (generic Monodox)

Motofen

Single

Source

Brand

diphenoxylate/atropine (generic Lomotil)

Motrin Suspension, Pedia-Profen

Brand &

Generic

Legend

Medication

OTC Motrin (ibuprofen)

Movantik

Single

Source

Brand

Symproic

MS Contin

Brand Only

Use Medical Necessity

Mycapssa

Single

Source

Brand

octreotide (generic Sandostatin)

Mydayis

Brand and

Generic

Must try TWO of the following:

amphetamine-dextroamphetamine extended-

release (generic Adderall XR),

dexmethylphenidate extended-release (generic

Focalin XR),

lisdexamfetamine (generic Vyvanse),

methylphenidate extended-release (generic

Concerta, Metadate CD, Metadate ER, Ritalin

LA)

Myfortic

Brand Only

mycophenolate sodium, delayed release (generic

Myfortic)

Naftin 1% & 2% Cream, Gel

Brand &

Generic

Must try all: ciclopirox (generic Loprox),

econazole (generic Spectazole), ketoconazole

(generic Nizoral)

Nalfon

Brand &

Generic

Must try all: ibuprofen (generic Motrin),

naproxen (generic Aleve, Naprosyn)

Nalocet/oxycodone-acetaminophen

2.5mg-300mg

Multisource

Brand

Without

Generic

oxycodone/acetaminophen (generic Percocet)

Namenda

Brand Only

memantine (generic Namenda)

Namenda XR

Brand Only

memantine immediate-release (generic

Namenda)

Namzaric

Single

Source

Brand

donepezil (generic Aricept) plus memantine

(generic Namenda)

Naprelan

Brand &

Generic

naproxen sodium (generic Naprosyn)

Naprosyn oral suspension

Brand &

Generic

Must try all: OTC Naproxen, OTC Ibuprofen

suspension

Naprosyn tablets

Brand Only

naproxen tablets (generic Naprosyn)

Nasonex

Brand &

Generic

Must Try Two: flunisolide (generic Nasarel),

fluticasone (generic Flonase), Zetonna, Nasacort

OTC, Flonase OTC, Rhinocort OTC (flonase

OTC and fluticasone (generic Flonase) count as

one alternative) (flonase OTC and fluticasone

(generic Flonase) count as one alternative)

Natesto

Single

Source

Brand

Four week trial of Testim

Natroba

Brand Only

spinosad (generic Natroba)

Neoral

Single

Source

Brand

cyclosporine modified (generic Neoral)

Neosalus

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Neosalus Cp

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Neo-Synalar

Single

Source

Brand

OTC Triple Antibiotic Ointment plus

fluocinolone 0.025% cream (generic Synalar)

Neo-Synalar Kit

Single

Source

Brand

OTC Triple Antibiotic Ointment plus

fluocinolone 0.025% cream (generic Synalar)

Neuac kit

Single

Source

Brand

Must try all: clindamycin 1.2% /benzoyl

peroxide 5% gel (generic Duac), clindamycin

solution + OTC benzoyl peroxide

Neupogen (Vial & Syringe)

Brand Only

1. For patients 12 years of age and younger -

Approve

2. For patients > 12 years of age - Must try

Zarxio

)

Nexavar

Brand Only

sorafenib (generic Nexavar)

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Nexiclon XR (clonidine extended-

release)

Multisource

Brand

Without

Generic

clonidine (generic Catapres)

Nexium Capsules

Brand &

Generic

Legend

Medication

Must try all: omeprazole (generic Prilosec),

pantoprazole (generic Protonix) tablet,

rabeprazole (generic Aciphex) tablet

Nextstellis

Single

Source

Brand

Must try all: Yaz, Yasmin

DC, Oregon, Connecticut, California, Delaware,

Illinois, Maryland, Massachusetts, New Jersey,

New York, and West Virginia only: approve if

provider states medically necessary

Niacor

Generic

Only

niacin extended-release (generic Niaspan) or

Niaspan

Brand Only

niacin extended-release (generic Niaspan)

Nicazeldoxy 30 kit (Doxycycline plus

MVI)

Single

Source

Brand

doxycycline hyclate (generic Vibramycin,

Vibra-Tab), doxycycline monohydrate 50 or

100mg (generic Monodox)

Nilandron

Brand &

Generic

bicalutamide (generic Casodex)

Nitisinone

Generic

Only

Orfadin

Nitrolingual

Brand &

Generic

nitroglycerin spray (generic Nitromist),

nitroglycerin sublingual tablet (generic

Nitrostat)

Nityr

Brand Only

Orfadin

Nivatopic Plus

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Nivestym

Single

Source

Brand

Zarxio

Norco

Brand Only

hydrocodone/acetaminophen (generic Norco)

Norgesic Forte

Brand &

Generic

OTC aspirin + cyclobenzaprine tablet (generic

Flexeril), chlorzoxazone (generic Parafon Forte

DSC) methocarbamol (generic Robaxin),

orphenadrine extended-release (generic

Norflex), or tizanidine (Zanaflex Tablets)

Northera

Brand Only

droxidopa (generic Northera)

Norvasc

Brand Only

amlodipine (generic Norvasc)

Norvir

Brand Only

ritonavir tablets (generic Norvir)

Novolin (includes Relion)

Single

Source

Brand

Use Step Therapy

Novolin 70/30 (Includes Novolin 70/30

Relion)

Single

Source

Brand

Use Step Therapy

Novolin N (Includes Novolin N Relion)

Single

Source

Brand

Use Step Therapy

Novolin R (Includes Novolin R Relion)

Single

Source

Brand

Use Step Therapy

Novolog (All dosage forms)

Single

Source

Brand

Use Step Therapy

Noxafil tablets

Brand Only

posaconazole tablets (generic Noxafil)

Nuvaring

Brand only

etonogestrel/ethinyl estradiol vaginal ring

(generic Nuvaring)

DC, Oregon, Connecticut, California, Delaware,

Illinois, Maryland, Massachusetts, New Jersey,

New York, and West Virginia only: approve if

provider states medically necessary

Nuvessa

Single

Source

Brand

metronidazole 0.75% vaginal gel (generic

Metrogel-Vaginal)

Nuvigil

Brand Only

armodafinil (generic Nuvigil)

nystatin/triamcinolone (generic Mycolog

II) cream and ointment

Generic

Only

nystatin cream or ointment (generic Mycostatin)

+ triamcinolone 0.1% cream or ointment

(generic Kenalog)

Nyvepria

Single

Source

Brand

Must try BOTH: Neulasta, Udenyca

Ogsiveo

Single

Source

Brand

Use Prior Authorization

Olux

Brand &

Generic

Must try all: betamethasone 0.05% augmented

gel (generic Diprolene), clobetasol propionate

0.05% gel (generic Temovate), clobetasol 0.05%

solution (generic Temovate)

Olux-E

Brand &

Generic

Must try all: betamethasone 0.05% augmented

gel (generic Diprolene), clobetasol propionate

0.05% gel (generic Temovate), clobetasol 0.05%

solution (generic Temovate)

Omnaris

Single

Source

Brand

Must Try Two: flunisolide (generic Nasarel),

fluticasone (generic Flonase), Zetonna, Nasacort

OTC, Flonase OTC, Rhinocort OTC (flonase

OTC and fluticasone (generic Flonase) count as

one alternative) (flonase OTC and fluticasone

(generic Flonase) count as one alternative)

Omnitrope

Single

Source

Brand

ONE of the following:

• Nutropin AQ; OR

• Nutropin AQ NuSpin

Onexton 1.2-3.75%

Brand and

Generic

clindamycin topical solution (generic Cleocin T)

+ OTC benzoyl peroxide or clindamycin-

benzoyl peroxide (generic Duac) 1.2%-5%

Ongentys

Single

Source

Brand

Must try all: carbidopa/levodopa (generic

Sinemet), entacapone (generic Comtan),

tolcapone (generic Tasmar)

Onglyza

Brand Only

saxagliptin (generic Onglyza)

Onmel

Single

Source

Brand

itraconazole (generic for Sporanox)

Onzetra Xsail

Single

Source

Brand

sumatriptan nasal spray (generic Imitrex)

Opana ER

Single

Source

Brand

use med nec

Optivar

Brand Only

Must Try All: azelastine (generic for Optivar),

olopatadine (generic Patanol), Lastacaft, OTC

Pataday, OTC Zaditor

Oracea

Brand and

Generic

Must Try Two: doxycycline hyclate 50 mg, 100

mg (generic Morgidox, Vibramycin),

doxycycline hyclate 20 mg (generic Periostat),

doxycycline monohydrate 50 mg, 100 mg

(generic Monodox)

Orladeyo

Single

Source

Brand

Use Medical Necessity

Orphengesic Forte

Brand &

Generic

OTC aspirin + cyclobenzaprine tablet (generic

Flexeril), chlorzoxazone (generic Parafon Forte

DSC) methocarbamol (generic Robaxin),

orphenadrine extended-release (generic

Norflex), or tizanidine (Zanaflex Tablets)

Ortho Tri-Cyclen Lo

Brand Only

norgestimate/ethinyl estradiol Lo 0.18-0.215-

0.25/0.025 mg [Tri-Lo-Estarylla, Tri-Lo-Marzia,

Tri-Lo-Sprintec, Trinessa Lo

(branded generics Ortho Tri-Cyclen Lo)]

DC, Oregon, Connecticut, California, Delaware,

Illinois, Maryland, Massachusetts, New Jersey,

New York, and West Virginia only: approve if

provider states medically necessary

Ortikos

Single

Source

Brand

budesonide extended-release (generic Entocort

EC)

Osmolex ER

Single

Source

Brand

amantadine immediate-release

OsmoPrep

Single

Source

Brand

polyethylene glycol powder (generic Glycolax),

PEG (generic Golytely), Sutab, Suprep

Otovel

Single

Source

Brand

ofloxacin 0.3% solution (generic Floxin,

Ocuflox), Ciprodex

Ovace Plus 9.8% lotion

Single

Source

Brand

sulfacetamide sodium 10% lotion, gel

Ovace Plus Foam

Single

Source

Brand

sulfacetamide sodium 10% lotion, gel

Oxaydo

Single

Source

Brand

oxycodone immediate-release (generic

Roxicodone)

Oxistat Lotion

Single

Source

Brand

Must Try Two: ciclopirox (generic Loprox),

econazole (generic Spectazole), ketoconazole

(generic Nizoral)

Oxycontin

Brand &

Generic

Use med nec or step therapy

MN, NV - Coverage of medications to treat

conditions associated with cancer may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Oxytrol

Brand &

Generic

Legend

Medication

Must try one of: oxybutynin (generic Ditropan),

oxybutynin extended-release (generic Ditropan

XL), Oxytrol OTC and All of the following:

solifenacin (generic Vesicare), tolterodine

(generic Detrol), trospium (generic Sanctura)

Pamelor

Brand Only

nortriptyline (generic Pamelor)

Panlor

Single

Source

Brand

acetaminophen/codeine

Parlodel

Brand only

bromocriptine (generic Parlodel)

Patanase

Brand Only

olopatadine 0.6% nasal spray (generic Patanase)

Paxil

Brand Only

paroxetine (generic Paxil)

Paxil CR

Brand Only

paroxetine extended-release (generic Paxil CR)

Pcp 100 Kit

Single

Source

Brand

metoclopramide (generic Reglan) + OTC

magnesium citrate + OTC Miralax, + OTC

bisacodyl + OTC Cerelyte 50

penicillamine (generic Cuprimine)

Generic

Only

penicillamine titratabs (generic Depen)

Penlac Nail Lacquer

Brand Only

ciclopirox 8% solution (generic Penlac Nail

Lacquer)

Pepcid Tablets

Brand &

Generic

Legend

Medication

OTC Pepcid AC (famotidine)

Pheburane

Single

Source

Brand

sodium phenylbutyrate (generic Buphenyl)

Phexxi gel

Single

Source

Brand

OTC spermicides

Pifeltro

Single

Source

Brand

Symfi, Symfi Lo, Triumeq

Plaquenil

Brand Only

hydroxychloroquine (generic Plaquenil)

Plavix

Brand Only

clopidogrel (generic Plavix)

Plexion 9.8-4.8% cream, liquid, lotion

Single

Source

Brand

sulfacetamide sodium/sulfur 10-5%

Plexion Cloth 9.8%-4.8% pads

Single

Source

Brand

sulfacetamide sodium/sulfur 10-5%

Ponvory

Single

Source

Brand

fingolimod (generic Gilenya)

PR Cream

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Praluent

Single

Source

Brand

Use Medical Necessity or Step Therapy

Pramosone E

Single

Source

Brand

hydrocortisone/pramoxine

Pravachol

Brand Only

pravastatin (generic Pravachol)

Pred Forte 1%

Brand Only

prednisolone 1% ophthalmic suspension

(generic Pred Forte)

prednisolone solution 5mg/5ml,

25mg/5ml, 20mg/5ml, 10mg/5ml

Generic

Only

prednisolone sodium phosphate 15mg/5mL

(generic Prelone)

Pregenna

Single

Source

Brand

Brand and generic prenatal vitamins

Prenara

Single

Source

Brand

Brand and generic prenatal vitamins

Prenatrix

Single

Source

Brand

Brand and generic prenatal vitamins

Prescription Benzoyl Preoxide Products-

multiple strengths and dosage forms (ex-

cleanser, cleansing pad, cream, creamy

wash, gel, etc.)

Brand &

Generic

(EPDL

OTC

Exclusion

list drug)

TWO OTC benzoyl peroxide formulations

Presera

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Prestalia

Single

Source

Brand

perindopril (generic Aceon) plus amlodipine

(generic Norvasc)

Prevacid Capsules

Brand &

Generic

Legend

Medication

Must try all: omeprazole (generic Prilosec),

pantoprazole (generic Protonix) tablet,

rabeprazole (generic Aciphex) tablet, Prevacid

24 hour

Prevacid Solutab

Brand Only

Use Step Therapy

Prezista

Brand Only

darunavir (generic Prezista)

Prilosec Capsules

Brand Only

Legend

Medication

Must try all: omeprazole (generic Prilosec),

pantoprazole (generic Protonix) tablet,

rabeprazole (generic Aciphex) tablet

Prilosec Suspension

Brand &

Generic

Must try all: omeprazole (generic Prilosec),

pantoprazole (generic Protonix), rabeprazole

(generic Aciphex), OTC Nexium, OTC

Prevacid, OTC Prilosec, OTC Zegerid

Primlev

Single

Source

Brand

oxycodone/acetaminophen (generic Percocet)

Pristiq

Brand Only

for BOB

Brand and

Generic for

EPDL

venlafaxine extended-release capsule (Effexor

XR)

ProAir Digihaler

Single

Source

Brand

albuterol sulfate HFA (generic ProAir HFA,

Proventil HFA)

Procardia XL

Brand Only

nifedipine extended-release tablet (generic

Procardia XL)

Procort

Single

Source

Brand

hydrocortisone acetate/pramoxine HCl

Procrit

Single

Source

Brand

Retacrit

Proctocort

Brand Only

hydrocortisone 1% cream (generic Proctocort),

hydrocortisone 30 mg suppository (generic

Proctocort)

Proglycem

Brand Only

diazoxide (generic Proglycem)

Prolate 10/300 mg

(oxycodone/acetaminophen) solution

Single

Source

Brand

oxycodone/acetaminophen (generic Percocet)

Prolate 5/300 mg

(oxycodone/acetaminophen) tablet

Single

Source

Brand

oxycodone/acetaminophen (generic Percocet)

Prolensa

Single

Source

Brand

Must try all: bromfenac ophthalmic solution

(generic Bromday, Xibrom), diclofenac

ophthalmic solution (generic Voltaren),

ketorolac ophthalmic solution (generic Acular),

Nevanac

Prometrium

Brand Only

progesterone (generic Prometrium)

Promiseb Complete Kit

Single

Source

Brand

Promiseb

Proscar

Brand Only

finasteride (generic Proscar)

Protonix

Brand Only

Must try all: omeprazole (generic Prilosec),

pantoprazole (generic Protonix), rabeprazole

(generic Aciphex), OTC Nexium, OTC

Prevacid, OTC Prilosec, OTC Zegerid

Protonix Granules for Suspension

Brand &

Generic

Must try all: omeprazole (generic Prilosec),

pantoprazole (generic Protonix), rabeprazole

(generic Aciphex), OTC Nexium, OTC

Prevacid, OTC Prilosec, OTC Zegerid

Protopic

Brand Only

Use step therapy

Proventil HFA

Brand Only

albuterol sulfate HFA (generic ProAir HFA,

Proventil HFA)

Provigil

Brand Only

modafinil

Prozac Weekly

Brand Only

fluoxetine capsules (generic Prozac)

Pruclair

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Prudoxin

Brand Only

betamethasone dipropionate cream 0.05%

(generic Diprosone), desoximetasone cream

0.05% (generic Topicort), fluocinonide cream

0.05% (generic Lidex), mometasone furoate

cream 0.1% (generic Elocon), triamcinolone

acetonide cream 0.5% (generic Aristocort)

Prumyx

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Pulmicort Flexhaler

Single

Source

Brand

Must try BOTH: Arnuity Ellipta, QVAR

RediHaler

Pulmicort inhalation suspension

Brand Only

budesonide inhalation suspension (generic

Pulmicort)

Pyridostigmine 30 mg

Single

Source

Brand

pyridostigmine 60 mg (generic Mestinon)

Qdolo

Single

Source

Brand

tramadol 50 mg (generic Ultram)

Qelbree

Single

Source

Brand

Use Medical Necessity

Qmiiz ODT

Single

Source

Brand

meloxicam (generic Mobic)

Qnasl

Single

Source

Brand

Must Try Two: flunisolide (generic Nasarel),

fluticasone (generic Flonase), Zetonna, Nasacort

OTC, Flonase OTC, Rhinocort OTC (flonase

OTC and fluticasone (generic Flonase) count as

one alternative) (flonase OTC and fluticasone

(generic Flonase) count as one alternative)

Qtern

Single

Source

Brand

Use Step Therapy

Quartette

Brand &

Generic

levonorgestrel/ethinyl estradiol 0.15/0.03 mg

[Introvale, Jolessa, , Quasense, Setlakin

(branded generic Seasonale)],

levonorgestrel/ethinyl estradiol [Amethia,

Ashlyna, Camrese, Daysee, (generic

Seasonique)], levonorgestrel/ethinyl estradiol

0.1 mg/20 mcg/10 mcg [Amethia Lo, Camrese

Lo, (generic LoSeasonique)]

DC, Oregon, Connecticut, California, Delaware,

Illinois, Maryland, Massachusetts, New Jersey,

New York, and West Virginia only: approve if

provider states medically necessary

Quillichew ER

Single

Source

Brand

Must try TWO of the following:

amphetamine-dextroamphetamine extended-

release (generic Adderall XR),

dexmethylphenidate extended-release (generic

Focalin XR),

lisdexamfetamine (generic Vyvanse),

methylphenidate extended-release (generic

Concerta, Metadate CD, Metadate ER, Ritalin

LA)

Quillivant XR

Single

Source

Brand

Must try TWO of the following:

amphetamine-dextroamphetamine extended-

release (generic Adderall XR),

dexmethylphenidate extended-release (generic

Focalin XR),

lisdexamfetamine (generic Vyvanse),

methylphenidate extended-release (generic

Concerta, Metadate CD, Metadate ER, Ritalin

LA)

Qulipta

Single

Source

Brand

Use Step Therapy or medical necessity

Quviviq

Single

Source

Brand

Use Step Therapy

QVAR RediHaler

Single

Source

Brand

Must try all: Arnuity Ellipta, Flovent HFA,

Flovent Diskus, Pulmicort Flexhaler

Rabeprazole delayed-release sprinkle

Single

Source

Brand

Must try all: omeprazole (generic Prilosec),

pantoprazole (generic Protonix), rabeprazole

(generic Aciphex), OTC Nexium, OTC

Prevacid, OTC Prilosec, OTC Zegerid

Radiagel

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

RadiaPlexRX

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Ranexa

Brand Only

ranolazine (generic Ranexa)

Rapaflo

Brand Only

silodosin (generic Rapaflo)

Rapamune Tablet

Brand Only

sirolimus (generic Rapamune)

Rayaldee

Single

Source

Brand

Must try all: calcitriol (generic Rocaltrol),

doxercalciferol (generic Hectorol), paricalcitol

(generic Zemplar)

Rebinyn

Single

Source

Brand

Benefix, Rixubis, Alprolix, Idelvion

Reditrex

Single

Source

Brand

methotrexate tablets, Rasuvo

Releuko

Single

Source

Brand

Zarxio

Relexxii/methylphenidate extended-

release 45 mg, 63 mg

Multisource

Brand

without

Generic

Must try TWO of the following:

amphetamine-dextroamphetamine extended-

release (generic Adderall XR),

dexmethylphenidate extended-release (generic

Focalin XR),

lisdexamfetamine (generic Vyvanse),

methylphenidate extended-release (generic

Concerta, Metadate CD, Metadate ER, Ritalin

LA)

Relexxii 72 mg

Brand and

Generic

Must try TWO of the following:

amphetamine-dextroamphetamine extended-

release (generic Adderall XR),

dexmethylphenidate extended-release (generic

Focalin XR),

lisdexamfetamine (generic Vyvanse),

methylphenidate extended-release (generic

Concerta, Metadate CD, Metadate ER, Ritalin

LA)

Relistor Tablet

Single

Source

Brand

Symproic

Relpax

Brand Only

Must try all: eletriptan (generic Relpax),

naratriptan (generic Amerge), rizatriptan

(generic Maxalt), sumatriptan (generic Imitrex),

zolmitriptan (generic Zomig)

Reltone

Single

Source

Brand

ursodiol (generic Actigall)

Remeron

Brand Only

mirtazapine (generic Remeron)

Remeron SolTab

Brand Only

mirtazapine (generic Remeron)

Renagel

Brand Only

sevelamer (generic Renagel)

Renvela

Brand Only

sevelamer tablets (generic Renvela)

Requip XL

Brand &

Generic

ropinirole (Requip)

Restasis MultiDose

Single

Source

Brand

Must try all: Restasis Single Use vials, Xiidra

Retin-A Cream

Brand Only

Must Try Both: OTC Differin gel, tretinoin

cream (generic Retin-A)

Retin-A Gel

Brand &

Generic

Must Try Both: OTC Differin gel, tretinoin

cream (generic Retin-A)

Retin-A Micro & Retin-A Micro Pump

Brand &

Generic

Must Try Both: OTC Differin gel, tretinoin

cream (generic Retin-A)

Revatio suspension

Brand Only

sildenafil (generic Revatio)

Revatio tablets

Brand Only

sildenafil (generic Revatio)

Rezvoglar KwikPen

Single

Source

Brand

Lantus, Toujeo

In Florida, Maine, and Tennessee only, diabetes

medications may be approved based on both of

the following: 1) Provider attests use of this

product is medically necessary; and- 2) If

applicable, clinical characteristics exist that

preclude the use of the covered preferred

alternative(s) and use of the covered preferred

alternative(s) could result in worsening of

patient’s condition or inadequate treatment

(document alternatives and clinical information

related to worsening/inadequate treatment).

Reyataz Capsules

Brand Only

atazanavir (generic Reyataz)

Ribasphere Ribapak

Generic

Only

ribavirin (generic for Copegus, Rebetol)

Rilutek (brand only)

Brand Only

riluzole (generic Rilutek)

Riomet

Brand Only

Must try all: metformin tablets (generic

Glucophage), metformin oral solution (generic

Riomet)

Risperdal

Brand Only

risperidone (generic Risperdal)

Minnesota: See State Mandate Overview

Document

Ritalin LA

Brand Only

Must try TWO of the following:

amphetamine-dextroamphetamine extended-

release (generic Adderall XR),

dexmethylphenidate extended-release (generic

Focalin XR),

lisdexamfetamine (generic Vyvanse),

methylphenidate extended-release (generic

Concerta, Metadate CD, Metadate ER, Ritalin

LA)

Ritalin tablets

Brand Only

methylphenidate tablets (generic Ritalin)

Robinul

Brand Only

glycopyrrolate tablet (generic Robinul)

Robinul Forte

Brand Only

glycopyrrolate tablet (generic Robinul Forte)

Rosadan Cream Kit

Single

Source

Brand

metronidazole cream (generic Metrocream),

metronidazole 0.75% gel (generic Metrogel)

Rosadan Gel Kit

Single

Source

Brand

metronidazole gel 0.75% (generic Metrogel),

metronidazole lotion (generic Metrolotion)

Rosula

Single

Source

Brand

sodium sulfacetamide/sulfur 10-5%

Roszet

Multisource

Brand

Without

Generic

ezetimibe (generic Zetia) plus rosuvastatin

(generic Crestor) or ezetimibe/simvastatin

(generic Vytorin)

Roxicodone

Brand Only

oxycodone immediate-release (generic

Roxicodone)

Roxybond

Single

Source

Brand

oxycodone immediate-release (generic

Roxicodone)

FL, MD and WV only: approve

Rozerem

Brand Only

Use Step Therapy

Ryaltris

Single

Source

Brand

olopatadine (generic Patanase) plus an over-the-

counter nasal steroid (e.g., Nasonex Allergy),

OR over-the-counter Astepro Allergy plus an

over-the-counter nasal steroid (e.g., Nasonex

Allergy)

Ryclora

Brand and

Generic

OTC chlorpheniramine (generic Chlor-

Trimeton)

Rytary

Single

Source

Brand

carbidopa/levodopa extended release tablet

(generic Sinemet CR), carbidopa/levodopa

(generic Sinemet)

Rythmol SR

Brand Only

propafenone extended-release capsules (generic

Rythmol)

Ryvent 6mg Tablet

Brand &

Generic

carbinoxamine tablets (generic Palgic)

Sabril powder pack

Brand Only

vigabatrin powder pack (generic Sabril)

Safyral

Brand &

Generic

drospirenone/ethinyl estradiol

(generic Yasmin), Yasmin + folic acid

DC, Oregon, Connecticut, California, Delaware,

Illinois, Maryland, Massachusetts, New Jersey,

New York, and West Virginia only: approve if

provider states medically necessary

Saizen

Single

Source

Brand

ONE of the following:

• Nutropin AQ; OR

• Nutropin AQ NuSpin

Sajazir

Generic

Only

Icatibant acetate (generic Firazyr)

Sancuso

Single

Source

Brand

granisetron (generic Kytril)

Sandimmune Capsule

Brand Only

cyclosporine (generic Sandimmune)

Sandostatin

Brand Only

octreotide (generic Sandostatin)

Saphris

Brand Only

asenapine (generic Saphris)

Sarafem

Brand &

Generic

fluoxetine capsules (generic Prozac);

Maryland only: approve

Seasonique

Brand Only

levonorgestrel/ethinyl estradiol [Introvale,

Jolessa, Quasense, Setlakin (generics for

Seasonale)], levonorgestrel/ethinyl estradiol

[Amethia, Ashlyna, Camrese, Daysee, Jaimiess,

Simpesse (generics for Seasonique)]

Segluromet

Single

Source

Brand

Use Step Therapy

Selenium sulfide-pyrithione zinc in urea

shampoo 2.3%

Brand &

Generic

selenium sulfide shampoo

Selrx

Single

Source

Brand

selenium sulfide shampoo (generic Selsun

shampoo), Selsun

Sensipar

Brand Only

Must try all: calcium acetate (generic PhosLo),

cinacalcet (generic Sensipar), sevelamer

(generic Renagel), Velphoro

Sernivo spray

Single

Source

Brand

betamethasone lotion (generic Del-Beta)

Seroquel

Brand Only

quetiapine (generic Seroquel)

Minnesota: See State Mandate Overview

Document

Seroquel XR

Brand Only

Must try all: olanzapine (generic Zyprexa),

quetiapine (generic Seroquel), risperidone

(generic Risperdal), ziprasidone (generic

Geodon), aripiprazole tablets (generic Abilify)

Minnesota: See State Mandate Overview

Document

Sertraline capsules 150 mg, 200 mg

Single

Source

Brand

sertraline tablets 25 mg, 50 mg, 100 mg (generic

Zoloft)

Sevenfact

Single

Source

Brand

Novoseven

Seysara

Single

Source

Brand

doxycycline hyclate (generic Vibramycin),

doxycycline monohydrate 50 mg and 100 mg

(generic Monodox), minocycline immediate-

release capsules (generic Minocin)

Siklos

Single

Source

Brand

hydroxyurea (generic Hydrea), Droxia

Silenor

Brand and

Generic

Must try all: doxepin (generic Sinequan),

zolpidem (generic Ambien), zaleplon (generic

Sonata)

Siliq

Single

Source

Brand

Use medical necessity

SilvaSorb

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Simbrinza 1-0.2%

Single

Source

Brand

brimonidine (generic Alphagan) plus Azopt

Singulair Chewable Tablet

Brand Only

montelukast chewable tablet (generic Singulair)

Singulair Tablet

Brand Only

montelukast tablet (generic Singulair)

Sitavig

Single

Source

Brand

Must try all: acyclovir capsule/tablet (generic

Zovirax), famciclovir tablet (generic Famvir),

valacyclovir tablet (generic Valtrex), OTC

Abreva

Skelaxin

Brand Only

Must try all: cyclobenzaprine tablet (generic

Flexeril), carisoprodol (Soma 350mg),

methocarbamol (generic Robaxin),

chlorzoxazone (generic Parafon Forte DSC),

tizanidine (Zanaflex Tablets), metaxalone

(generic Skelaxin)

Soaanz

Single

Source

Brand

torsemide (generic Demadex)

Sodium Oxybate

(manufactured by Amneal

Pharmaceuticals)

(Xyrem authorized generic)

Multisource

Brand

without

Generic

Must try THREE of the following:

armodafinil (generic Nuvigil),

modafinil (generic Provigil),

Lumryz,

Sodium Oxybate (Xyrem authorized generic

manufactured by Hikma Pharmaceuticals),

Sunosi,

Xywav

Sodium Sulfacetamide/Sulfur Kit

Generic

Only

sulfacetamide sodium/sulfur 10-5%

Sogroya

Single

Source

Brand

Must try BOTH of the following:

Ngenla,

Skytrofa

Solodyn

Brand &

Generic

Use med nec

for step therapy only: minocycline immediate-

release capsule (generic Minocin)

Soltamox

Single

Source

Brand

tamoxifen (generic Nolvadex)

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Soma 250 mg

Brand &

Generic

Must try all: cyclobenzaprine tablet (generic

Flexeril), carisoprodol (Soma 350mg),

methocarbamol (generic Robaxin),

chlorzoxazone (generic Parafon Forte DSC),

tizanidine (Zanaflex Tablets)

Soma 350 mg tablets

Brand Only

Must try all: cyclobenzaprine tablet (generic

Flexeril), carisoprodol (Soma 350mg),

methocarbamol (generic Robaxin),

chlorzoxazone (generic Parafon Forte DSC),

tizanidine (Zanaflex Tablets)

Soolantra

Generic

only

Brand Soolantra

Soriatane

Brand Only

acitretin (generic Soriatane)

Spectragel

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Sporanox

Brand Only

itraconazole (generic for Sporanox)

SSS 10-5

Single

Source

Brand

sulfacetamide sodium/sulfur 10-5%

Steglatro

Single

Source

Brand

Use Step Therapy

Steglujan

Single

Source

Brand

Use Step Therapy

Stimufend

Single

Source

Brand

Must try BOTH: Neulasta, Udenyca

Strattera

Brand Only

atomoxetine (generic Strattera)

Suboxone Film

Brand Only

Must try all: Zubsolv, buprenorphine/naloxone

(tablet or film)

Subsys

Single

Source

Brand

Must Try Both: fentanyl citrate lozenges

(generic Actiq), Lazanda

CT only: Must try fentanyl citrate (generic

Actiq)

MN, NV - Coverage of medications to treat

conditions associated with cancer may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Sumadan Kit

Brand &

Generic

sulfacetammide sodium/sulfur 10-5%

Sumadan Wash

Brand &

Generic

sulfacetammide sodium/sulfur 10-5%

Sumadan XLT Kit

Single

Source

Brand

sulfacetammide sodium/sulfur 10-5%

Sumaxin CP

Single

Source

Brand

sulfacetammide sodium/sulfur 10-5%

Sumaxin TS

Brand Only

sulfacetammide sodium/sulfur 10-5%

Sustiva capsules

Brand Only

efavirenz (generic Sustiva)

Sutent

Brand Only

sunitinib (generic Sutent)

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics

Synalar 0.01%

Brand Only

fluocinolone 0.01% solution (generic Synalar)

Synalar 0.025%

Brand Only

fluocinolone 0.025% cream, ointment (generic

Synalar)

Synalar Kit

Single

Source

Brand

fluocinolone (generic for Synalar)

Synalar TS

Single

Source

Brand

fluocinolone (generic for Synalar)

Syprine

Brand Only

trientine (generic Syprine)

Taclonex ointment

Brand &

Generic

Must try both: Enstilar foam, Taclonex

suspension

Taclonex Suspension

Generic

only BOB

Brand and

Generic

EPDL

Must try all: betamethasone (generic Diprosone)

+ calcipotriene (generic Dovonex), Enstilar

Talicia

Single

Source

Brand

amoxicillin (generic Amoxil) + omeprazole

(generic Prilosec) + rifabutin (generic

Mycobutin) OR Omeclamox

Taltz

Single

Source

Brand

Use Step Therapy or medical necessity

Tamiflu

Brand Only

oseltamivir capsules (generic Tamiflu)

Tamiflu Suspension

Brand Only

oseltamivir suspension (generic Tamiflu)

Tarceva

Brand Only

erlotinib (generic Tarceva)

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Targadox

Brand and

Generic

doxycycline hyclate (generic Vibramycin,

Vibra-Tab ), doxycycline monohydrate 50 or

100mg (generic Monodox)

Targretin capsule

Brand Only

bexarotene capsule (generic Targretin)

Targretin gel

Brand Only

bexarotene gel (generic Targretin)

Tarka

Brand Only

trandolapril/verapamil extended-release tablet

(generic Tarka)

Tascenso ODT

Single

Source

Brand

fingolimod (generic Gilenya)

Tasmar

Brand Only

for BOB

Generic

Only for

EPDL

tolcapone (generic Tasmar)

Taytulla

Single

Source

Brand

norethindrone/ethinyl estradiol 24 FE 1/0.02 mg

[Blisovi 24 FE, Junel 24 FE, Larin 24 FE,

LoMedia 24 FE, (branded generic Loestrin 24

FE)], and norethindone/ethinyl estradiol FE

1/0.02 mg [Blisovi FE, Junel FE, Larin FE,

Microgestin FE, Tarina FE (branded generic

Loestrin FE)]

DC, Oregon, Connecticut, California, Delaware,

Illinois, Maryland, Massachusetts, New Jersey,

New York, and West Virginia only: approve if

provider states medically necessary

Temixys

Single

Source

Brand

Cimduo

Temodar capsules

Brand Only

temozolomide (generic Temodar)

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Tenoretic

Brand Only

atenolol/chlorthalidone (generic Tenoretic)

Tenormin

Brand Only

atenolol (generic Tenormin)

testosterone topical gel (authorized

generic)

Authorized

Generic

Minimum 4 week trial of Testim

Testosterone topical gel (generic

Testim)

Generic

Only

Minimum 4 week trial of Testim

Tetravex gel

Single

Source

Brand

lidocaine 5% cream/ointment

Tev Tropin/Zomacton

Single

Source

Brand

ONE of the following:

• Nutropin AQ; OR

• Nutropin AQ NuSpin

Thalitone 15 mg

Single

Source

Brand

chlorthalidone (generic Hygronton)

Therahoney

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Thyquidity

Single

Source

Brand

Must try all: levothyroxine (generic Synthroid),

Tirosint-Sol

Tirosint capsules

Brand &

Generic

levothyroxine tablet (generic Synthroid)

Tlando capsule

Single

Source

Brand

Must try both: Androderm, Testim

Tobi Nebulized Solution

Brand &

Generic

tobramycin 300 mg /4 mL (generic Bethkis)

Tobradex ST

Single

Source

Brand

tobramycin/dexamethasone ophthalmic drops

(generic for Tobradex)

Tolak 4% cream

Single

Source

Brand

fluorouracil 5% cream (generic Efudex)

Tolsura

Single

Source

Brand

itraconazole capsule (generic Sporanox)

Topicort Spray

Single

Source

Brand

desoximetasone 0.05% gel (generic Topicort)

Topiramate ER

Generic

Only

topiramate (generic Topamax)

Toprol XL

Brand Only

metoprolol succinate extended-release tablet

(generic Toprol XL)

Tosymra

Single

Source

Brand

sumatriptan injection, nasal spray, tablets

(generic Imitrex)

Toviaz (fesoterodine)

Brand &

Generic

Must try one of: oxybutynin (generic Ditropan),

oxybutynin extended-release (generic Ditropan

XL), Oxytrol OTC and All of the following:

solifenacin (generic Vesicare), tolterodine

(generic Detrol), trospium (generic Sanctura)

Tramadol 100 mg

Generic

only

Use 2 of the tramadol 50 mg (generic Ultram)

Transderm Scop

Brand Only

scopolamine transdermal patch (generic

Transderm Scop)

Travatan Z

Brand &

Generic

latanoprost (generic Xalatan), Lumigan

Trezix

Brand and

Generic

acetaminophen/codeine

Trianex

Single

Source

Brand

Must try all: triamcinolone ointment (generic

Kenalog), fluocinolone 0.025% ointment

(generic Synalar)

Tribenzor

Brand &

Generic

Must try all: amlodipine (generic Norvasc) +

losartan/HCTZ (generic Hyzaar), amlodipine

(generic Norvasc) + irbesartan/HCTZ (generic

Avalide), amlodipine (generic Norvasc) +

valsartan/HCTZ (generic Diovan HCT),

amlodipine (generic Norvasc) +

candesartan/HCTZ (generic Atacand HCT),

amlodipine (generic Norvasc) + Edarbyclor,

amlodipine + olmesartan HCTZ (generic

Benicar HCT)

Tricor

Brand Only

Must try ONE of the following:

1. fenofibrate 48mg, 54mg, 145mg, 160mg

tablet (generic Lofibra, Tricor, Triglide);

2. fenofibrate micronized capsule 43mg, 130mg

(generic Antara);

3. fenofibrate micronized capsule 67mg, 134mg,

200mg (generic Lofibra, Tricor)

Trilipix

Brand Only

Must try ONE of the following:

1. fenofibrate 48mg, 54mg, 145mg, 160mg

tablet (generic Lofibra, Tricor, Triglide);

2. fenofibrate micronized capsule 43mg, 130mg

(generic Antara);

3. fenofibrate micronized capsule 67mg, 134mg,

200mg (generic Lofibra, Tricor)

Trinaz

Single

Source

Brand

Brand and generic prenatal vitamins

Tropazone

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Trospium chloride extended-release

(generic Sanctura ER)

Generic

Only

Must try one of: oxybutynin (generic Ditropan),

oxybutynin extended-release (generic Ditropan

XL), Oxytrol OTC and All of the following:

solifenacin (generic Vesicare), tolterodine

(generic Detrol), trospium (generic Sanctura)

Trudhesa

Single

Source

Brand

Must try one oral triptan [e.g.,almotriptan

(Axert), eletriptan (Relpax), rizatriptan

(Maxalt/Maxalt MLT), sumatriptan (Imitrex),

zolmitriptan (Zomig)] AND two nasal triptans

[i.e., sumatriptan (generic Imitrex), Zomig]

Trulance

Single

Source

Brand

Use Step Therapy or Prior Authorization

Medical Necessity

Tudorza Pressair

Single

Source

Brand

Spiriva Handihaler/Resipmat

Tuzistra XR

Single

Source

Brand

hydrocodone polistirex/chlorpheniramine

polistirex (generic Tussionex Pennkinetic), Z-

Tuss AC

Twirla

Single

Source

Brand

ethinyl estradiol/norelgestromin patch (generic

Ortho Evra)

DC, Oregon, Connecticut, California, Delaware,

Illinois, Maryland, Massachusetts, New Jersey,

New York, and West Virginia only: approve if

provider states medically necessary

Twyneo cream

Single

Source

Brand

OTC benzoyl peroxide + OTC Differin gel or

tretinoin cream (generic Retin A)

Twynsta

Brand &

Generic

telmisartan (generic Micardis) + amlodipine

(generic Norvasc)

Tykerb

Brand Only

lapatinib tablet (generic Tykerb)

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Uceris rectal foam

Brand Only

budesonide rectal foam (generic Uceris)

Uceris (budesonide) tablet

Generic

Only (Book

of Business

Exclusion)

Brand &

Generic

Essential

PDL Only

Uceris tablet

Uloric

Brand &

Generic

allopurinol (generic Zyloprim)

Ultram

Brand Only

tramadol (generic Ultram)

UltraSal-ER

Legend

Medication

OTC salicylic acid

Ultravate 0.05% lotion

Single

Source

Brand

Use Step Therapy

Umecta emulsion, foam, suspension

Brand &

Generic

urea 40%

Umecta Kit (nail film pen/ film

suspension)

Single

Source

Brand

urea 40% + hyaluronate gel 0.2% (Hylira)

Umecta PD

Single

Source

Brand

urea 40%

Uramaxin GT 45%

Single

Source

Brand

urea 40%

Uramaxin GT Kit

Single

Source

Brand

urea 40%

Urevaz 44% cream

Brand Only

urea 40% cream

Uroxatral

Brand Only

Must try all: alfuzosin (generic Uroxatral),

doxazosin (generic Cardura), terazosin (generic

Hytrin), tamsulosin (generic Flomax)

Urso 250

Brand Only

ursodiol (generic Actigall, generic Usro 250,

generic Urso Forte)

Urso Forte

Brand Only

ursodiol (generic Actigall, generic Usro 250,

generic Urso Forte)

Utopic (urea) 41%

Single

Source

Brand

urea 40%

Vacustim

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Vagifem

Brand Only

estradiol vaginal tablet (Yuvafem (generic

Vagifem))

Brand Only

valganciclovir (generic Valcyte)

Valcyte oral solution

Brand Only

valganciclovir oral solution (generic Valcyte)

Vanos

Brand &

Generic

fluocinonide 0.05% cream (generic Lidex)

Varubi

Single

Source

Brand

aprepitant capsule (generic Emend)

Vascepa 0.5g capsule

Single

Source

Brand

Use Medical Necessity

Vascepa 1g capsule

Brand Only

Use Medical Necessity

Vascepa 1g capsule

Generic

Only

Use Medical Necessity

Vascuderm

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Vascuderm Hydrogel Wound Dressing

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Vaseretic

Brand Only

enalapril/hydrochlorothiazide (generic

Vaseretic)

Vasotec

Brand Only

enalapril (generic Vasotec)

Vectical

Brand Only

calcitriol ointment (generic Vectical)

Veltin

Single

Source

Brand

clindamycin gel, solution or lotion (generic

Cleocin) + tretinoin cream (generic Retin-A)

Vemlidy

Single

Source

Brand

Use Medical Necessity

Venlafaxine besylate ER 112.5 mg

Single

Source

Brand

venlafaxine extended release (generic Effexor

XR)

Venlafaxine ER tablet

Brand &

Generic

venlafaxine extended-release capsule (Effexor

XR)

Veramyst

Single

Source

Brand

Must Try Two: flunisolide (generic Nasarel),

fluticasone (generic Flonase), Zetonna, Nasacort

OTC, Flonase OTC, Rhinocort OTC (flonase

OTC and fluticasone (generic Flonase) count as

one alternative) (flonase OTC and fluticasone

(generic Flonase) count as one alternative)

Verdeso

Single

Source

Brand

desonide lotion (generic Desowen)

Versacloz

Single

Source

Brand

Must try all: clozapine (generic Clozaril),

clozapine orally disinegrating tablet (generic

Fazaclo)

Minnesota: See State Mandate Overview

Document

Vesicare LS

Single

Source

Brand

Must try one of: oxybutynin (generic Ditropan),

oxybutynin extended-release (generic Ditropan

XL), Oxytrol OTC and All of the following:

solifenacin (generic Vesicare), tolterodine

(generic Detrol), trospium (generic Sanctura)

Viagra

Brand Only

Must try all: sildenafil (generic Viagra), tadalafil

(generic Cialis), and vardenafil (generic Levitra)

Vicodin 5/300 mg

Brand &

Generic

hydrocodone/acetaminophen 5/325 mg (generic

Norco)

Vicodin ES 7.5/300 mg

Brand &

Generic

hydrocodone/acetaminophen 7.5/325 mg

(generic Norco)

Vicodin HP 10/300 mg

Brand &

Generic

hydrocodone/acetaminophen 10/325 mg

(generic Norco)

Vigamox

Brand Only

moxifloxacin ophthalmic solution (generic

Vigamox)

Viibryd

Brand Only

vilazodone (generic Viibryd)

Vimovo

Brand &

Generic

Must try all: naproxen (generic Naprosyn) +

omeprazole (generic Prilosec), pantoprazole

(generic Protonix), rabeprazole (generic

Aciphex)

Viramune

Brand Only

nevirapine (generic Viramune)

Viramune XR

Brand&

Generic

nevirapine (generic Viramune)

Viread

Brand Only

tenofovir (generic Viread)

Vivelle-Dot

Brand only

estradiol TD twice weekly patch (generic

Vivelle-Dot)

Vivlodex

Brand &

Generic

meloxicam (generic Mobic)

Vogelxo

Single

Source

Brand

Minimum 4 week trial of Testim

Voltaren 1% gel

Brand &

Generic

OTC Voltaren Arthritis Pain 1% gel

Vosevi

Single

Source

Brand

Harvoni, Epclusa

Votrient

Brand Only

pazopanib (generic Votrient)

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics

Vuity 1.25% ophthalmic solution

Single

Source

Brand

Use Medical Necessity

Vumerity

Single

Source

Brand

Use Step Therapy or medical necessity

Vusion

Single

Source

Brand

Must Try Both: nystatin Cream (generic

Mycostatin), OTC miconazole cream

Vytorin

Brand Only

for BOB

Brand and

Generic for

EPDL

Must try all: simvastatin/ezetimibe (generic

Vytorin), ezetimibe plus atorvastatin (generic

Lipitor), ezetimibe plus lovastatin (generic

Mevacor), ezetimibe plus pravastatin (generic

Pravachol), ezetimibe plus simvastatin (generic

Zocor), ezetimibe plus rosuvastatin (generic

Crestor)

Vyvanse

Brand Only

lisdexamfetamine dimesylate (generic Vyvanse)

Vyzulta

Single

Source

Brand

use step therapy

Welchol

Brand Only

colesevelam (generic Welchol)

Wellbutrin

Brand Only

bupropion (generic Wellbutrin)

Winlevi

Single

Source

Brand

Use Medical Necessity

Wynzora

Single

Source

Brand

Must try all: betamethasone (generic Diprosone)

+ calcipotriene (generic Dovonex),

betamethasone/calcipotriene ointment (generic

Taclonex), Enstilar, Taclonex Suspension

Xadago

Single

Source

Brand

Must try all: selegiline (generic Eldepryl),

rasagiline (generic Azilect)

Xalatan (Brand Only)

Brand Only

latanoprost (generic Xalatan)

Xalkori

Single

Source

Brand

Use Nonform guideline

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Xartemis XR

Single

Source

Brand

oxycodone/acetaminophen (generic Percocet)

Xdemvy

Single

Source

Brand

Use Medical Necessity

Xeloda

Brand Only

capecitabine (generic Xeloda)

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics

Xenazine

Brand Only

tetrabenazine (generic Xenazine)

Xerese

Single

Source

Brand

Must try all: acyclovir capsule/tablet (generic

Zovirax), famciclovir tablet (generic Famvir),

valacyclovir tablet (generic Valtrex), OTC

Abreva

Xhance

Single

Source

Brand

fluticasone (generic Flonase)

Xifaxan

Single

Source

Brand

Use Medical Necessity

Xigduo XR

Single

Source

Brand

Use Step Threapy

Ximino

Single

Source

Brand

minocycline immediate-release capsules

(generic Minocin)

Xodol 10/300 mg

Brand &

Generic

hydrocodone/acetaminophen 10/325 mg

(generic Norco)

Xodol 5/300 mg

Brand &

Generic

hydrocodone/acetaminophen 5/325 mg (generic

Norco)

Xodol 7.5/300 mg

Brand &

Generic

hydrocodone/acetaminophen 7.5/325 mg

(generic Norco)

Xopenex Nebules

Multisource

Brand Only

albuterol nebulized solution (generic Proventil

Inhalation Solution)

Xultophy

Single

Source

Brand

Soliqua

In Florida, Maine, and Tennessee only,

medications prescribed for diabetes may be

approved based on both of the following: 1)

Provider attests use of this product is medically

necessary for the treatment of diabetes; and- 2)

If applicable, clinical characteristics exist that

preclude the use of the covered preferred

alternative(s) and use of the covered preferred

alternative(s) could result in worsening of

patient’s condition or inadequate treatment

(document alternatives and clinical information

related to worsening/inadequate treatment).

Xyntha

Single

Source

Brand

Use Medical Necessity

Xyosted

Single

Source

Brand

Use medical necessity

Xyrem

Multisource

Brand

Without

Generic

Use Prior Authorization or Medical Necessity

Yonsa

Single

Source

Brand

Use Step Therapy

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics

Yosprala

Single

Source

Brand

OTC Aspirin plus omeprazole (Prilosec) or

pantoprazole (Protonix)

Zalvit

Single

Source

Brand

Brand and generic prenatal vitamins

Zanabin Antipruritic Hydrogel

Single

Source

Brand

Must try all: OTC Aquaphor, OTC Eucerin,

OTC Lubriderm, OTC White Petroleum

Zantac Capsules/Tablets

Brand &

Generic

Legend

Medication

OTC Zantac (ranitidine)

Zavesca

Brand Only

miglustat (generic Zavesca)

Zcort

Single

Source

Brand

dexamethasone tablet

Zegerid capsule

(Brand and

generic)

Legend

Medication

Must try all: omeprazole (generic Prilosec),

pantoprazole (generic Protonix) tablet,

rabeprazole (generic Aciphex) tablet

Zegerid packet

Brand &

Generic

Use step therapy

Zembrace

Single

Source

Brand

sumatriptan injection (generic Imitrex)

Zenzedi

Single

Source

Brand (2.5

mg & 7.5

mg)

Brand &

Generic for

all other

strengths

Must try all: amphetamine/dextroamphetamine

immediate-release (generic Adderall),

dextroamphetamine extended-release (generic

Dexedrine)

Zerviate

Single

Source

Brand

Must try all: OTC ketotifen (Zaditor), OTC

olopatadine (Pataday), azelastine ophthalmic

solution (generic Optivar), olopatadine

ophthalmic solution (generic Patanol), Lastacaft

Zestoretic

Brand Only

lisinopril/hydrochlorothiazide (generic

Zestoretic)

Zestril

Brand Only

lisinopril (generic Zestril)

Zetia

Brand Only

ezetimibe tablet (generic Zetia)

Ziana

Brand &

Generic

clindamycin gel, solution or lotion (generic

Cleocin) + tretinoin cream (generic Retin-A)

Ziextenzo

Single

Source

Brand

Must try BOTH: Neulasta, Udenyca

Zipsor 25mg

Single

Source

Brand

oral diclofenac (generic Cataflam, Voltaren)

Zocor

Brand Only

simvastatin (generic Zocor)

Zofran tablets

Brand Only

ondansetron (generic Zofran)

Zohydro ER

Brand Only

Use Step Therapy or medical necessity

Zolpidem capsule

Single

Source

Brand

zolpidem tablet (generic Ambien, generic

Ambien CR)

Zomacton

Brand Only

ONE of the following:

• Nutropin AQ; OR

• Nutropin AQ NuSpin

Zomig nasal spray

Generic

Only

Must try all: sumatriptan nasal spray, brand

Zomig nasal spray

Zomig tablets

Brand Only

zolmitriptan tablets (generic Zomig)

Zomig ZMT

Brand Only

zolmitriptan orally disintegrating tablet (generic

Zomig)

Zonalon

Brand Only

for BOB

Generic

Only for

EPDL

doxepin cream

Zonatuss

Brand &

Generic

benzonatate (generic Tessalon Perles)

Zortress

Brand Only

everolimus (generic Zortress

Zorvolex

Single

Source

Brand

Must try all: diclofenac tablets (generic

Voltaren, Cataflam), ibuprofen (generic Motrin),

naproxen (generic Naprosyn)

Zovirax Ointment

Brand Only

Must try TWO of the following: oral acyclovir

(generic Zovirax), famciclovir (generic Famvir),

valacyclovir (generic Valtrex)

Zuplenz

Single

Source

Brand

ondansetron tablet (generic for Zofran),

ondansetron ODT (generic for Zofran ODT)

Zutripro

Brand Only

chlorpheniramine/hydrocodone/pseudoephedrine

(generic Zutripro)

Zyclara

Single

Source

Brand

imiquimod 5% cream (generic Aldara)

Zykadia

Single

Source

Brand

Use Nonform guideline

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics.

Zypitamag

Single

Source

Brand

Use Step Therapy

Zyprexa

Brand Only

olanzapine (generic Zyprexa)

Minnesota: See State Mandate Overview

Document

Zyprexa Zydis

Brand Only

olanzapine orally disintegrating tablet (generic

Zyprexa Zydis)

Minnesota: See State Mandate Overview

Document

Zyrtec (all dosage forms)

Brand &

Generic

Legend

Medication

OTC Zyrtec

Zytiga 250mg

Brand only

abiraterone 250mg (generic Zytiga)

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics

Zytiga 500mg

Brand &

Generic

Use 2 of the abiraterone 250mg (generic Zytiga)

AR, CT, CO, DE, IL, LA, MD, MN, NV -

Coverage of oncology medications may be

approved based on state mandates. See State

Mandate Overview Document for specifics

Zyvox

Brand Only

linezolid (generic Zyvox)

D. Copaxone Only

1. Copaxone will be approved based on ALL of the following:

a. Submission of medical records documenting history of trial and failure,

inadequate response, or intolerance to glatiramir acetate (generic Copaxone.

Mylan product only) Document date and duration of trial

-AND-

b. Submission of medical records documenting history of trial and failure,

inadequate response, or intolerance to Glatopa (Document date and duration of

trial)

-AND-

c. Provider must give an explanation of potential rationale for how the

excluded medication will work if stating the patient failed on the covered

Therapeutically Equivalent product which has the same active ingredient-

(eg, the member had an adverse reaction to an inactive ingredient in the

alternative product).

Authorization will be issued for 12 months.

E. Brand Truvada

1. Brand Truvada will be approved based on one of the following

a. All of the following:

(1) Member is taking brand Truvada 200/300 mg as effective antiretroviral

therapy for PrEP (Pre-exposure Prophylaxsis)

-AND-

(2) Brand Truvada 200/300 mg will be used as part of a comprehensive

prevention strategy including other prevention measures

-AND-

(3) Submission of medical records documenting a history of adverse event or

intolerance to prior use of generic Truvada (emtricitabine/tenofovir disoproxil

fumarate)

Authorization will be issued for zero copay for PreP with deductible bypass for

12 months.

-OR-

b. Submission of medical records documenting Truvada is not being used for PreP

and a history of adverse event or intolerance to prior use of generic Truvada

(emtricitabine/tenofovir disoproxil fumarate)

Authorization for Non-PreP indications will be issued for 12 months.

F. Levemir

1. Levemir will be approved based on one of the following:

a. Submission of medical records documenting history of a three month trial

resulting in a therapeutic failure, contraindication, or intolerance to both Lantus

and Toujeo

-OR-

b. Member is pregnant and has a history of trial and failure, contraindication, or

intolerance to insulin NPH

Authorization will be issued for 12 months.

State mandates may apply. Any federal regulatory requirements and the member specific benefit plan

coverage may also impact coverage criteria. Other policies and utilization management programs may

apply.

For Connecticut, Kentucky, and Mississippi business, only a 30 day trial will be required.

Coverage of oncology medications may be approved based on state mandates.

In Florida, Maine, and Tennessee only, medications prescribed for diabetes

may be approved

based on both of the following: 1) Provider attests use of this product is medically necessary for

the treatment of diabetes; and 2) If applicable, clinical characteristics exist that preclude the use

of the covered preferred alternative(s) and use of the covered preferred alternative(s) could result

in worsening of patient’s condition or inadequate treatment (document alternatives and clinical

information related to worsening/inadequate treatment).

Products listed as single source brands were not available generically at time of review and

publication. Products listed are current at the time of last review.

**Reauthorization criteria may be applied if initial review criteria is not met and member has a

previously approved PA on file for the same review type:

Requested medication will be approved based on both of the following: documentation of

positive clinical response and member is currently on medication as documented in claims

history (evidence of claims in past 120 days)

3. Additional Clinical Programs:

• Supply limits may also apply.

• Prior Authorization may also apply.

• Notwithstanding Coverage Criteria, UnitedHealthcare may approve initial and re-

authorization based solely on previous claim/medication history, diagnosis codes

(ICD-10) and/or claim logic. Use of automated approval and re-approval processes

varies by program and/or therapeutic class.

4. References:

N/A

Program

New and Therapeutic Equivalent Medications - Prior Authorization

Change Control

Date

Change

5/2016 AT UM

New program

10/2016

Added additional products to program. Added provider attestation

requirement

2/2017

Added Lantus and Auvi-Q. Added reauthorization criteria. Revised

formatting and added Connecticut, New Jersey and New York for

clarity.

4/2017

Added Lantus Solostar for clarification. Added state mandate reference

language.

4/2018

Annual Review. Administrative changes.

4/2019

Annual Review. Retitled document. Revised background section.

Removed provider attestation. Revised alternatives for Azor.

8/2019

Updated Delzicol, Vesicare, and Zovirax from Single Source Brands to

Brand & Generic.

11/2019

Added Aplenzin, Celexa, Effexor XR, Forfivo XL and Pexeva.

2/2020

Added Basaglar, Januvia, Janumet, Janumet XR and Tresiba. Removed

Lantus.

3/2020

Added Copaxone.

4/2020: 5/1/20

effective

Added Lantus. Removed Basaglar, Januvia, Januet, Janumet XR and

Tresiba due to change in effective date of exclusions.

4/2020: 6/1/20

effective

Added Copaxone to separate section Reformatted reauthorization

section.

5/2020: 7/1/20

effective

Added Noritate. Added Basaglar, Januvia, Janumet, Janumet XR and

Tresiba. Removed Lantus. Added Colcrys. Updated Dymista to brand

& generic. Updated background.

6/2020; 9/1/20

effective

Added Secuado.

7/2020; 10/1/20

effective

Revised criteria for Zovirax cream.

9/2020; 10/1/20

effective

Added Brand Truvada

10/2020; 1/1/21

effective

Added Tivorbex, brand Synthroid, Symtuza, Gleevec, Norditropin

Flexpro, Rayos, and Ampyra. Updated Forfivo XL to Brand & Generic

& Januvia, Janumet, and Janumet XR requirements.

12/2020; 1/1/21

effective

Removed Pennsaid.

1/1/2021; 3/1/21

effective

Added amphetamine/dextroamphetamine (generic Adderall XR) and

Focalin XR.

3/1/2021; 5/1/2021

effective

Added Otrexup, Relafen, Relafen DS, Semglee, and brand Tecfidera.

5/2021; 7/1/2021

effective

Added Adapalene 0.1% pads. Updated brand Focalin XR.

6/2021; 9/1/2021

effective

Added Oxtellar XR, Qudexy XR, Spritam, Trokendi XR, and Sorilux.

Removed reauthorization criteria for sections A and B.

9/1/2021, 12/1/2021

effective

Added Levemir. Updated note for Connecticut and Kentucky.

11/2021; 1/1/2022

effective

Added Ventolin HFA, Albuterol HFA, Rebif & Rebif Rebidose, Proair

RespiClick & HFA, methylphenidate extended-release tablet (generic

Concerta & methylphenidate extended-release tablet, and Klonopin.

3/2022, 5/1/2022

effective

Added Differin and Duexis. Updated Myrbetriq and Vesicare.

4/2022, 5/1/2022

effective

Added FL, ME, TN mandate language to diabetes drugs.

4/2022, 7/1/2022

effective

Updated oncology medications state mandate note.

7/2022, 8/1/2022

effective

Removed Norditropin Flexpro. Updated Rebif and Rebif Rebidose.

6/2022, 9/1/2022

effective

Added clemastine fumarate syrup.

11/2022, 1/1/2023

effective

Added criteria for existing excluded drugs into a new section within the

N&T guideline.

Added Vemlidy, Aczone 5% topical gel (brand only), Aczone 7.5%

topical gel (brand only), Alinia tablets (brand only), Auryxia, Dilaudid

(brand only), Firazyr (brand only), MS Contin (brand only), Nilandron

(brand and generic), Renagel (brand only), Welchol (brand only).

Removed dapsone gel (generic Aczone 5% and 7.5%), generic Firazyr,

generic Welchol.

Updated Hysingla ER, Colcrys.

3/2023, 5/1/2023

effective

Added Adlarity transdermal patch, Afinitor Disperz tablet for

suspension, Epsolay, Ibsrela, insulin glargine via/SoloStar, Katerzia

suspension, Lyvispah granules, metformin 625mg tablet, Nexiclon XR

and clonidine extended-release authorized brand alternative, Quviviq,

Releuko, Relexxii/methylphenidate extended-release 45mg and 63mg,

Relexxii 72mg, Robinul, Robinul Forte, Soaanz, Sutent, Tascenso ODT,

Tlando, Twyneo cream.

Revised criteria for Amitiza, Atripla, Colcrys tablet, Fiasp, Ponvory,

Vemlidy, Viibryd, Zortress.

Updated Pentasa to reflect brand and generic, Amitiza to reflect brand

only, Ambien CR to brand only, Aricept 23mg to brand only, Asacol

HD to brand and generic, Atripla to brand only, Butrans to brand only,

Lofibra 67mg/134mg/200mg to brand only, Minastrin 24 FE to brand

only, Namenda XR to brand only, Tricor to brand only, Nalocet to

include oxycodone/acetaminophen 2.5-300mg and reflect multisource

brand without generic. Updated Restasis SDV generic only to

cyclosporine 0.05% ophthalmic emulsion single dose vials generic only.

Updated state mandate note to include Mississippi.Updated diabetes

meds state mandate note for Florida, Maine, and Tennessee.

Removed Adrenaclick, Auvi-Q, Cordran cream, Cordran ointment,

Gvoke auto-injector/prefilled syringe, Gvoke kit, Mounjaro, Radicava

ORS, tramadol extended-release (generic Ryzolt), Trizivir, Verkazia

0.1% ophthalmic emulsion, Vijoice.

6/2023, 9/1/2023

effective date

Added allopurinol 200mg, Buphenyl, Entadfi, Esbriet, Fylnetra,

Gilenya, isotretinoin 25mg and 35mg, Javygtor, Lanreotide,

methocarbamol 1000mg, Pheburane, Ryaltris, Sajazir, Stimufend

Removed pantoprazole (Camber manufacturer)

Revised Absorica, Absorica LD, Amitiza

12/2023, 1/1/2024

effective date

Added Abrilada, Adderall XR, Advair Diskus, BiDil, Ciprodex,

Concerta, Edarbi, Edarbyclor, fenofibrate micronized capsule 30mg and

90mg, fenofibric acid 35mg and 105mg, Finacea, Flovent Diskus,

Flovent HFA, Humalog vial, Kombiglyze XR, nitisinone, Onglyza,

Prezista, Pulmicort Flexhaler, rabeprazole delayed-release sprinkle,

Targretin capsule, Targretin gel, topiramate ER (generic Trokendi XR),

Trezix, Uceris rectal foam, Xifaxan, Xyrem, Ziextenzo

Revised Antara, Asmanex HFA, Delzicol drug status, Fenoglide,

Fibricor, fluticasone furoate/vilanterol ellipta, fluticasone propionate

HFA, fluticasone propionate/salmeterol HFA, Fulphila, Fylnetra,

Humalog Tempo Pen, Jatenzo, Latuda, Lialda, Lipofen, Lyumjev

Tempo Pen, Neupogen, Nyvepria, Rezvoglar KwikPen, Saphris,

Stimufend, Tresiba, Vyvanse

Updated Androgel 1.62%, Apriso to generic, Daytrana, Denavir, Doral

to brand and generic, Enablex to generic, Fiasp to include diabetes

mandate, Kerydin drug status, Levemir to include diabetes mandate,

Lofena, Onexton, Prevpac to generic, Roszet drug status, Targadox,

Tricor, Trilipix, Zovirax ointment

Removed Aklief, amphetamine-dextroamphetamine XR, bexarotene

capsule, bexarotene gel, bimatoprost 0.03%, Elestat, fluticasone-

salmeterol (generic Advair Diskus), Lofibra, methylphenidate extended-

release (generic Concerta), QVAR RediHaler, Staxyn, Tavalisse,

Triglide, Wixela (generic Advair Diskus), Udenyca, Xopenex HFA

3/20/2024, 5/1/2024

effective date

Added Imbruvica 140mg and 280mg tablet, methylphenidate extended-

release tablet, Millipred, Ogsiveo, ursodiol 200mg and 400mg capsule,

Xdemvy, zolpidem capsule

Revised Adhansia XR, Adzenys XR-ODT, Aptensio XR, Cotempla

XR-ODT, Daytrana, Dyanavel XR, darifenacin, Evekeo (to brand only),

Focalin XR, Forteo (to brand and generic), Mydayis, Pentasa,

Quillichew ER, Quillivant XR, Relexxi 72mg, Relexxi/methylphenidate

extended-release 45mg and 63mg, Ritalin LA, Sodium Oxybate,

Sogroya, Trilipix (to brand only), Votrient

Removed fluoxetine 60mg tablet, Hemangeol, Skytrofa, Sohonos,

Sympazan

Update to Connecticut trial requirement from 60 days to 30 days.