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

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

Effective October 1, 2021

The FEP formulary includes the preferred drug list which is comprised of Tier 1, generics and Tier 2, preferred brand-name drugs. Also included in the formulary are Tier 3, non-preferred brand-name drugs, Tier 4, preferred specialty drugs and Tier 5, non-preferred specialty drugs.

Ask your physician if there is a generic drug available to treat your condition. If there is no generic drug available, ask your physician to prescribe a preferred brand-name drug.

The preferred brand-name drugs within our formulary are listed to identify medicines that are clinically appropriate and cost-effective.

Click on the category name in the Table of Contents below to go directly to that page

INTRODUCTION ........................................................................................................................................................................................................................5

PREFACE ................................................................................................................................................................................................................................... 5

MANAGED NOT COVERED DRUGS........................................................................................................................................................................................6

PRIOR APPROVAL ...................................................................................................................................................................................................................6

QUANTITY LIMITATIONS .........................................................................................................................................................................................................6

PHARMACY AND MEDICAL POLICY COMMITTEE................................................................................................................................................................6

PRODUCT SELECTION CRITERIA ..........................................................................................................................................................................................6

FORMULARY PRODUCT DESCRIPTIONS..............................................................................................................................................................................7

GENERIC SUBSTITUTION........................................................................................................................................................................................................7

DRUG EFFICACY STUDY IMPLEMENTATION DRUGS .........................................................................................................................................................8

EDITOR ......................................................................................................................................................................................................................................8

NOTICE ......................................................................................................................................................................................................................................8

LEGEND .....................................................................................................................................................................................................................................8

ANALGESICS ..........................................................................................................................................................................................................................10 ANALGESICS, OTHER..................................................................................................................................................................................................10 NSAIDs ........................................................................................................................................................................................................................... 10 NSAIDs, COMBINATIONS.............................................................................................................................................................................................10 NSAIDs, TOPICAL .........................................................................................................................................................................................................10 COX-2 INHIBITORS.......................................................................................................................................................................................................10 GOUT .............................................................................................................................................................................................................................10 OPIOID ANALGESICS...................................................................................................................................................................................................10 NON-OPIOID ANALGESICS .........................................................................................................................................................................................11 VISCOSUPPLEMENTS .................................................................................................................................................................................................11

ANTI-INFECTIVES ...................................................................................................................................................................................................................12 ANTIBACTERIALS ......................................................................................................................................................................................................... 12 ANTIFUNGALS ..............................................................................................................................................................................................................13 ANTIMALARIALS ........................................................................................................................................................................................................... 14 ANTIRETROVIRAL AGENTS ........................................................................................................................................................................................14 ANTITUBERCULAR AGENTS.......................................................................................................................................................................................15 ANTIVIRALS ..................................................................................................................................................................................................................15 MISCELLANEOUS ......................................................................................................................................................................................................... 16

ANTINEOPLASTIC AGENTS ..................................................................................................................................................................................................17 ALKYLATING AGENTS .................................................................................................................................................................................................17 ANTIMETABOLITES ...................................................................................................................................................................................................... 17 HORMONAL ANTINEOPLASTIC AGENTS ..................................................................................................................................................................17 IMMUNOMODULATORS ............................................................................................................................................................................................... 18 KINASE INHIBITORS ....................................................................................................................................................................................................18 MULTIPLE MYELOMA...................................................................................................................................................................................................19 TOPOISOMERASE INHIBITORS ..................................................................................................................................................................................19 MISCELLANEOUS ......................................................................................................................................................................................................... 20

CARDIOVASCULAR ................................................................................................................................................................................................................ 22 ACE INHIBITORS ..........................................................................................................................................................................................................22 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS..........................................................................................................................22 ACE INHIBITOR/DIURETIC COMBINATIONS..............................................................................................................................................................22 ADRENOLYTICS, CENTRAL ........................................................................................................................................................................................22

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ALDOSTERONE RECEPTOR ANTAGONISTS ............................................................................................................................................................23 ALPHA BLOCKERS.......................................................................................................................................................................................................23 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ............................................................................................................23 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ...........................................................................23 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS .........................................................23 ANTIARRHYTHMICS ..................................................................................................................................................................................................... 23 ANTILIPEMICS ..............................................................................................................................................................................................................24 BETA-BLOCKERS .........................................................................................................................................................................................................24 BETA-BLOCKER/DIURETIC COMBINATIONS ............................................................................................................................................................25 CALCIUM CHANNEL BLOCKERS ................................................................................................................................................................................25 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ..............................................................................................................................25 DIGITALIS GLYCOSIDES .............................................................................................................................................................................................25 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS .........................................................................................................................................25 DIURETICS ....................................................................................................................................................................................................................25 HEART FAILURE...........................................................................................................................................................................................................26 NITRATES ...................................................................................................................................................................................................................... 26 PULMONARY ARTERIAL HYPERTENSION ................................................................................................................................................................26 MISCELLANEOUS ......................................................................................................................................................................................................... 27

CENTRAL NERVOUS SYSTEM ..............................................................................................................................................................................................27 ANTIANXIETY ................................................................................................................................................................................................................ 27 ANTICONVULSANTS ....................................................................................................................................................................................................27 ANTIDEMENTIA............................................................................................................................................................................................................. 28 ANTIDEPRESSANTS ....................................................................................................................................................................................................28 ANTIPARKINSONIAN AGENTS ....................................................................................................................................................................................29 ANTIPSYCHOTICS ........................................................................................................................................................................................................ 30 ATTENTION DEFICIT HYPERACTIVITY DISORDER ..................................................................................................................................................31 FIBROMYALGIA ............................................................................................................................................................................................................31 HYPNOTICS ..................................................................................................................................................................................................................31 MIGRAINE ...................................................................................................................................................................................................................... 32 MOOD STABILIZERS ....................................................................................................................................................................................................33 MOVEMENT DISORDERS ............................................................................................................................................................................................33 MULTIPLE SCLEROSIS ................................................................................................................................................................................................33 MUSCULOSKELETAL THERAPY AGENTS .................................................................................................................................................................33 MYASTHENIA GRAVIS .................................................................................................................................................................................................33 NARCOLEPSY/CATAPLEXY ........................................................................................................................................................................................33 PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................................... 34 MISCELLANEOUS ......................................................................................................................................................................................................... 34

ENDOCRINE AND METABOLIC .............................................................................................................................................................................................35 ANDROGENS ................................................................................................................................................................................................................35 ANTIDIABETICS ............................................................................................................................................................................................................35 CALCIUM RECEPTOR ANTAGONISTS .......................................................................................................................................................................37 CALCIUM REGULATORS .............................................................................................................................................................................................37 CARNITINE DEFICIENCY AGENTS .............................................................................................................................................................................38 CONTRACEPTIVES ......................................................................................................................................................................................................38 ENDOMETRIOSIS .........................................................................................................................................................................................................39 ESTROGENS ................................................................................................................................................................................................................. 39 ESTROGEN/PROGESTINS ..........................................................................................................................................................................................40 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS...............................................................................................40 FERTILITY REGULATORS ...........................................................................................................................................................................................40 GAUCHER DISEASE.....................................................................................................................................................................................................41 GLUCOCORTICOIDS .................................................................................................................................................................................................... 41 GLUCOSE ELEVATING AGENTS.................................................................................................................................................................................41 HEREDITARY TYROSINEMIA TYPE 1 AGENTS.........................................................................................................................................................41 HUMAN GROWTH HORMONES ..................................................................................................................................................................................41 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ...................................................................................................................................41 INSULIN-LIKE GROWTH FACTOR-1 AGENTS............................................................................................................................................................41 PHENYLKETONURIA TREATMENT AGENTS.............................................................................................................................................................41 PHOSPHATE BINDER AGENTS...................................................................................................................................................................................41 POTASSIUM-REMOVING AGENTS .............................................................................................................................................................................42 PROGESTINS ................................................................................................................................................................................................................ 42 SELECTIVE ESTROGEN RECEPTOR MODULATORS...............................................................................................................................................42 THYROID AGENTS .......................................................................................................................................................................................................42 UREA CYCLE DISORDERS..........................................................................................................................................................................................42 UTERINE FIBROIDS .....................................................................................................................................................................................................42 VASOPRESSINS ...........................................................................................................................................................................................................42

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MISCELLANEOUS ......................................................................................................................................................................................................... 42

GASTROINTESTINAL .............................................................................................................................................................................................................43 ANTIDIARRHEALS ........................................................................................................................................................................................................43 ANTIEMETICS ...............................................................................................................................................................................................................43 ANTISPASMODICS .......................................................................................................................................................................................................44 CHOLELITHOLYTICS .................................................................................................................................................................................................... 44 H2 RECEPTOR ANTAGONISTS....................................................................................................................................................................................44 INFLAMMATORY BOWEL DISEASE ............................................................................................................................................................................44 IRRITABLE BOWEL SYNDROME.................................................................................................................................................................................45 LAXATIVES .................................................................................................................................................................................................................... 45 OPIOID-INDUCED CONSTIPATION .............................................................................................................................................................................45 PANCREATIC ENZYMES..............................................................................................................................................................................................45 PROSTAGLANDINS ......................................................................................................................................................................................................45 PROTON PUMP INHIBITORS.......................................................................................................................................................................................45 SALIVA STIMULANTS...................................................................................................................................................................................................45 STEROIDS, RECTAL.....................................................................................................................................................................................................45 ULCER THERAPY COMBINATIONS ............................................................................................................................................................................45 MISCELLANEOUS ......................................................................................................................................................................................................... 46

GENITOURINARY .................................................................................................................................................................................................................... 46 BENIGN PROSTATIC HYPERPLASIA..........................................................................................................................................................................46 URINARY ANTISPASMODICS......................................................................................................................................................................................46 VAGINAL ANTI-INFECTIVES ........................................................................................................................................................................................46 MISCELLANEOUS ......................................................................................................................................................................................................... 46

HEMATOLOGIC ....................................................................................................................................................................................................................... 47 ANTICOAGULANTS ......................................................................................................................................................................................................47 HEMATOPOIETIC GROWTH FACTORS......................................................................................................................................................................47 HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS..........................................................................................47 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS........................................................................................................................................48 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS..........................................................................................................................48 PLATELET AGGREGATION INHIBITORS....................................................................................................................................................................48 PLATELET SYNTHESIS INHIBITORS ..........................................................................................................................................................................48 SICKLE CELL DISEASE................................................................................................................................................................................................48 STEM CELL MOBILIZERS ............................................................................................................................................................................................49 THROMBOCYTOPENIA AGENTS ................................................................................................................................................................................49 MISCELLANEOUS ......................................................................................................................................................................................................... 49

IMMUNOLOGIC AGENTS .......................................................................................................................................................................................................49 ALLERGENIC EXTRACTS ............................................................................................................................................................................................49 AUTOIMMUNE AGENTS...............................................................................................................................................................................................49 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)...................................................................................................................................50 HEREDITARY ANGIOEDEMA AGENTS.......................................................................................................................................................................50 IMMUNE GLOBULINS ...................................................................................................................................................................................................50 IMMUNOMODULATORS ............................................................................................................................................................................................... 51 IMMUNOSUPPRESSANTS ...........................................................................................................................................................................................51

NUTRITIONAL/SUPPLEMENTS .............................................................................................................................................................................................51 ELECTROLYTES ........................................................................................................................................................................................................... 51 VITAMINS AND MINERALS ..........................................................................................................................................................................................51 MISCELLANEOUS ......................................................................................................................................................................................................... 52

RESPIRATORY ........................................................................................................................................................................................................................ 52 ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS.........................................................................................................................................................52 ANAPHYLAXIS TREATMENT AGENTS .......................................................................................................................................................................52 ANTICHOLINERGICS .................................................................................................................................................................................................... 52 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS .............................................................................................................................................52 ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS .........................................................................................................53 ANTIHISTAMINES, SEDATING.....................................................................................................................................................................................53 ANTITUSSIVES .............................................................................................................................................................................................................53 ANTITUSSIVE COMBINATIONS...................................................................................................................................................................................53 BETA AGONISTS ..........................................................................................................................................................................................................53 CYSTIC FIBROSIS ........................................................................................................................................................................................................53 LEUKOTRIENE MODULATORS ...................................................................................................................................................................................54 MAST CELL STABILIZERS ...........................................................................................................................................................................................54 NASAL ANTIHISTAMINES ............................................................................................................................................................................................54 NASAL STEROIDS/COMBINATIONS ...........................................................................................................................................................................54 PHOSPHODIESTERASE-4 INHIBITORS......................................................................................................................................................................54 PULMONARY FIBROSIS AGENTS...............................................................................................................................................................................54

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SEVERE ASTHMA AGENTS.........................................................................................................................................................................................54 STEROID/BETA AGONIST COMBINATIONS...............................................................................................................................................................54 STEROID INHALANTS ..................................................................................................................................................................................................54 XANTHINES ................................................................................................................................................................................................................... 55 MISCELLANEOUS ......................................................................................................................................................................................................... 55 TOPICAL ..................................................................................................................................................................................................................................55 DERMATOLOGY ...........................................................................................................................................................................................................55 MOUTH/THROAT/DENTAL AGENTS ...........................................................................................................................................................................59 OPHTHALMIC ................................................................................................................................................................................................................ 59 OTIC ............................................................................................................................................................................................................................... 61 WEBSITES ...............................................................................................................................................................................................................................63 2021 FEP MANAGED NOT COVERED DRUG LIST BASIC OPTION CHART .....................................................................................................................65 INDEX .......................................................................................................................................................................................................................................73

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The Retail and Mail Service Prescription Drug Program cannot refill a controlled substance until 80% of the prescription has been used. Call us at 1-800-624-5060 or visit our website if you have any questions about dispensing limits.

INTRODUCTION

FEP is pleased to provide the 2021 FEP 5 Tier Managed Rx Drug Formulary as a useful reference for drug product selection. The drugs on the FEP 5 Tier Managed Rx Drug Formulary have been reviewed by the FEP Pharmacy and Medical Policy Committee and FEP physicians and pharmacists and found appropriate for preferred status.

All the information in the FEP 5 Tier Managed Rx Drug Formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber.

National guidelines can be found on the National Guideline Clearinghouse site at on the websites listed under each therapeutic class and on the sites listed in the WEBSITES section of this publication.

PREFACE

The formulary is organized by sections, which refer to either a drug class or disease state. Unless exceptions are noted, generally all dosage forms and strengths of the drug cited are included in the formulary.

The FEP 5 Tier Managed Rx Drug Formulary is an open formulary, but FEP may impose restrictions or not reimburse for specific drug products or types of products. For example, drugs and supplies for weight loss are excluded from the pharmacy benefit. In addition, over-the-counter (OTC) products, with the exception of insulin and diabetes monitoring products, are generally not included in the pharmacy benefit. Some OTC products are listed in the formulary for informational purposes only.

The formulary is separated by Tiers in the following manner:

Basic Option Preferred Retail Pharmacy

Tier 1

Tier 2

Tier 3

generic drugs preferred brand- non-preferred brand-name

name drugs drugs and all compounded

medications

$10 copay for $55 copay for a 60% coinsurance*

a 0 to 30-day 0 to 30-day

supply

supply

$30 copay for $165 copay for

31 to 90-day 31 to 90-day

supply

supply

Basic Option Specialty

Drug Pharmacy Program

Tier 4

Tier 5

preferred

non-preferred

specialty drugs specialty drugs

$65 copay

$90 copay

Limit***: one 30- Limit***: one 30-

day supply fill at day supply fill at

retail

retail

$85 for a 0 to 30- $110 for a 0 to

day supply

30-day supply

Basic Option Retail Pharmacy (Med B Primary)

$10 copay $50 copay for a 50% coinsurance** for a 0 to 30- 0 to 30-day day supply supply

$30 copay for $150 copay for

31 to 90-day 31 to 90-day

supply

supply

Basic Option Mail

$20 copay $100 copay $125 copay

Pharmacy (Med B

Primary)

Basic Option Specialty

Drug Pharmacy Program

(Med B Primary)

$235 for 31 to $300 for 31 to 90-day supply 90-day supply

$60 copay

$80 copay

Limit***: one 30- Limit***: one 30-

day supply fill at day supply fill at

retail

retail

$80 for a 0 to 30- $100 for a 0 to

day supply

30-day supply

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