FEP 5 Tier Rx Drug Formulary (607) Standard Option ...

FEP 5 Tier Rx Drug Formulary (607) Standard Option

Effective July 1, 2024

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

EXCLUDED 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

COX-2 INHIBITORS ....................................................................................................................................................................................................... 10

GOUT ............................................................................................................................................................................................................................. 10

NSAIDs........................................................................................................................................................................................................................... 10

NSAIDs, COMBINATIONS ............................................................................................................................................................................................. 10

NSAIDs, TOPICAL ......................................................................................................................................................................................................... 10

OPIOID ANALGESICS ................................................................................................................................................................................................... 10

NON-OPIOID ANALGESICS ......................................................................................................................................................................................... 11

VISCOSUPPLEMENTS ................................................................................................................................................................................................. 11

ANTI-INFECTIVES ................................................................................................................................................................................................................... 12

ANTIBACTERIALS ......................................................................................................................................................................................................... 12

ANTIFUNGALS .............................................................................................................................................................................................................. 13

ANTIMALARIALS ........................................................................................................................................................................................................... 14

ANTIRETROVIRAL AGENTS ........................................................................................................................................................................................ 14

ANTITUBERCULAR AGENTS ....................................................................................................................................................................................... 15

ANTIVIRALS .................................................................................................................................................................................................................. 15

MISCELLANEOUS ......................................................................................................................................................................................................... 16

ANTINEOPLASTIC AGENTS .................................................................................................................................................................................................. 17

ALKYLATING AGENTS ................................................................................................................................................................................................. 17

ANTIMETABOLITES ...................................................................................................................................................................................................... 17

HORMONAL ANTINEOPLASTIC AGENTS................................................................................................................................................................... 18

IMMUNOMODULATORS ............................................................................................................................................................................................... 18

KINASE INHIBITORS .................................................................................................................................................................................................... 19

MULTIPLE MYELOMA ................................................................................................................................................................................................... 20

TOPOISOMERASE INHIBITORS .................................................................................................................................................................................. 20

MISCELLANEOUS ......................................................................................................................................................................................................... 20

CARDIOVASCULAR ................................................................................................................................................................................................................ 22

ACE INHIBITORS .......................................................................................................................................................................................................... 22

ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS .......................................................................................................................... 23

ACE INHIBITOR/DIURETIC COMBINATIONS .............................................................................................................................................................. 23

ADRENOLYTICS, CENTRAL ........................................................................................................................................................................................ 23

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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 ........................................................................... 24

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ......................................................... 24

ANTIARRHYTHMICS ..................................................................................................................................................................................................... 24

ANTILIPEMICS .............................................................................................................................................................................................................. 24

BETA-BLOCKERS ......................................................................................................................................................................................................... 25

BETA-BLOCKER/DIURETIC COMBINATIONS............................................................................................................................................................. 25

CALCIUM CHANNEL BLOCKERS ................................................................................................................................................................................ 26

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS .............................................................................................................................. 26

DIGITALIS GLYCOSIDES ............................................................................................................................................................................................. 26

DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ......................................................................................................................................... 26

DIURETICS .................................................................................................................................................................................................................... 26

HEART FAILURE ........................................................................................................................................................................................................... 27

NITRATES...................................................................................................................................................................................................................... 27

PULMONARY ARTERIAL HYPERTENSION ................................................................................................................................................................ 27

MISCELLANEOUS ......................................................................................................................................................................................................... 28

CENTRAL NERVOUS SYSTEM .............................................................................................................................................................................................. 28

ANTIANXIETY ................................................................................................................................................................................................................ 28

ANTICONVULSANTS .................................................................................................................................................................................................... 28

ANTIDEMENTIA............................................................................................................................................................................................................. 29

ANTIDEPRESSANTS .................................................................................................................................................................................................... 29

ANTIPARKINSONIAN AGENTS .................................................................................................................................................................................... 30

ANTIPSYCHOTICS ........................................................................................................................................................................................................ 31

ATTENTION DEFICIT HYPERACTIVITY DISORDER .................................................................................................................................................. 32

FIBROMYALGIA ............................................................................................................................................................................................................ 32

HYPNOTICS .................................................................................................................................................................................................................. 33

MIGRAINE...................................................................................................................................................................................................................... 33

MOOD STABILIZERS .................................................................................................................................................................................................... 34

MOVEMENT DISORDERS ............................................................................................................................................................................................ 34

MULTIPLE SCLEROSIS ................................................................................................................................................................................................ 34

MUSCULOSKELETAL THERAPY AGENTS ................................................................................................................................................................. 34

MYASTHENIA GRAVIS ................................................................................................................................................................................................. 35

NARCOLEPSY/CATAPLEXY ........................................................................................................................................................................................ 35

PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................................... 35

MISCELLANEOUS ......................................................................................................................................................................................................... 35

ENDOCRINE AND METABOLIC ............................................................................................................................................................................................. 36

ANDROGENS ................................................................................................................................................................................................................ 36

ANTIDIABETICS ............................................................................................................................................................................................................ 37

ANTIOBESITY................................................................................................................................................................................................................ 40

CALCIUM RECEPTOR AGONISTS .............................................................................................................................................................................. 40

CALCIUM REGULATORS ............................................................................................................................................................................................. 40

CARNITINE DEFICIENCY AGENTS ............................................................................................................................................................................. 40

CONTRACEPTIVES ...................................................................................................................................................................................................... 41

DIABETIC KIDNEY DISEASE ........................................................................................................................................................................................ 42

ENDOMETRIOSIS ......................................................................................................................................................................................................... 42

FERTILITY REGULATORS ........................................................................................................................................................................................... 42

GAUCHER DISEASE ..................................................................................................................................................................................................... 43

GLUCOCORTICOIDS .................................................................................................................................................................................................... 43

GLUCOSE ELEVATING AGENTS................................................................................................................................................................................. 43

HEREDITARY TYROSINEMIA TYPE 1 AGENTS ......................................................................................................................................................... 43

HUMAN GROWTH HORMONES .................................................................................................................................................................................. 43

HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................................... 43

INSULIN-LIKE GROWTH FACTOR-1 AGENTS ............................................................................................................................................................ 44

MENOPAUSAL SYMPTOM AGENTS ........................................................................................................................................................................... 44

PHENYLKETONURIA TREATMENT AGENTS ............................................................................................................................................................. 44

PHOSPHATE BINDER AGENTS................................................................................................................................................................................... 44

POMPE DISEASE .......................................................................................................................................................................................................... 45

POTASSIUM-REMOVING AGENTS ............................................................................................................................................................................. 45

PROGESTINS ................................................................................................................................................................................................................ 45

SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................................... 45

THYROID AGENTS ....................................................................................................................................................................................................... 45

UREA CYCLE DISORDERS .......................................................................................................................................................................................... 45

UTERINE FIBROIDS...................................................................................................................................................................................................... 45

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VASOPRESSINS ........................................................................................................................................................................................................... 45

MISCELLANEOUS ......................................................................................................................................................................................................... 46

GASTROINTESTINAL ............................................................................................................................................................................................................. 47

ANTIDIARRHEALS ........................................................................................................................................................................................................ 47

ANTIEMETICS ............................................................................................................................................................................................................... 47

ANTISPASMODICS ....................................................................................................................................................................................................... 47

CHOLELITHOLYTICS .................................................................................................................................................................................................... 47

H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................................... 47

INFLAMMATORY BOWEL DISEASE ............................................................................................................................................................................ 47

IRRITABLE BOWEL SYNDROME ................................................................................................................................................................................. 48

LAXATIVES .................................................................................................................................................................................................................... 48

OPIOID-INDUCED CONSTIPATION ............................................................................................................................................................................. 48

PANCREATIC ENZYMES .............................................................................................................................................................................................. 48

PROSTAGLANDINS ...................................................................................................................................................................................................... 48

PROTON PUMP INHIBITORS ....................................................................................................................................................................................... 49

SALIVA STIMULANTS ................................................................................................................................................................................................... 49

STEROIDS, RECTAL ..................................................................................................................................................................................................... 49

ULCER THERAPY COMBINATIONS ............................................................................................................................................................................ 49

MISCELLANEOUS ......................................................................................................................................................................................................... 49

GENITOURINARY .................................................................................................................................................................................................................... 49

BENIGN PROSTATIC HYPERPLASIA .......................................................................................................................................................................... 49

URINARY ANTISPASMODICS ...................................................................................................................................................................................... 50

VAGINAL ANTI-INFECTIVES ........................................................................................................................................................................................ 50

MISCELLANEOUS ......................................................................................................................................................................................................... 50

HEMATOLOGIC ....................................................................................................................................................................................................................... 50

ANTICOAGULANTS ...................................................................................................................................................................................................... 50

HEMATOPOIETIC GROWTH FACTORS ...................................................................................................................................................................... 50

HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS .......................................................................................... 51

IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS ........................................................................................................................................ 52

PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS .......................................................................................................................... 52

PLATELET AGGREGATION INHIBITORS .................................................................................................................................................................... 52

PLATELET SYNTHESIS INHIBITORS .......................................................................................................................................................................... 52

SICKLE CELL DISEASE ................................................................................................................................................................................................ 52

THROMBOCYTOPENIA AGENTS ................................................................................................................................................................................ 52

MISCELLANEOUS ......................................................................................................................................................................................................... 52

IMMUNOLOGIC AGENTS ....................................................................................................................................................................................................... 53

ALLERGENIC EXTRACTS ............................................................................................................................................................................................ 53

AUTOIMMUNE AGENTS ............................................................................................................................................................................................... 53

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................................... 53

HEREDITARY ANGIOEDEMA AGENTS ....................................................................................................................................................................... 54

IMMUNE GLOBULINS ................................................................................................................................................................................................... 54

IMMUNOMODULATORS ............................................................................................................................................................................................... 54

IMMUNOSUPPRESSANTS ........................................................................................................................................................................................... 55

NUTRITIONAL/SUPPLEMENTS ............................................................................................................................................................................................. 55

ELECTROLYTES ........................................................................................................................................................................................................... 55

VITAMINS AND MINERALS .......................................................................................................................................................................................... 55

MISCELLANEOUS ......................................................................................................................................................................................................... 56

RESPIRATORY ........................................................................................................................................................................................................................ 56

ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS ......................................................................................................................................................... 56

ANAPHYLAXIS TREATMENT AGENTS ....................................................................................................................................................................... 56

ANTICHOLINERGICS .................................................................................................................................................................................................... 56

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ............................................................................................................................................. 56

ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS ......................................................................................................... 56

ANTIHISTAMINES, LOW SEDATING ........................................................................................................................................................................... 56

ANTIHISTAMINES, NONSEDATING ............................................................................................................................................................................. 57

ANTIHISTAMINES, SEDATING ..................................................................................................................................................................................... 57

ANTIHISTAMINE/DECONGESTANT COMBINATIONS ............................................................................................................................................... 57

ANTITUSSIVES ............................................................................................................................................................................................................. 57

ANTITUSSIVE COMBINATIONS ................................................................................................................................................................................... 57

BETA AGONISTS .......................................................................................................................................................................................................... 57

CYSTIC FIBROSIS ........................................................................................................................................................................................................ 57

LEUKOTRIENE MODULATORS ................................................................................................................................................................................... 58

MAST CELL STABILIZERS ........................................................................................................................................................................................... 58

NASAL ANTIHISTAMINES ............................................................................................................................................................................................ 58

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NASAL STEROIDS/COMBINATIONS ........................................................................................................................................................................... 58

PHOSPHODIESTERASE-4 INHIBITORS...................................................................................................................................................................... 58

PULMONARY FIBROSIS AGENTS ............................................................................................................................................................................... 58

SEVERE ASTHMA AGENTS ......................................................................................................................................................................................... 58

STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................................... 58

STEROID INHALANTS .................................................................................................................................................................................................. 59

XANTHINES ................................................................................................................................................................................................................... 59

MISCELLANEOUS ......................................................................................................................................................................................................... 59

TOPICAL .................................................................................................................................................................................................................................. 59

DERMATOLOGY ........................................................................................................................................................................................................... 59

MOUTH/THROAT/DENTAL AGENTS ........................................................................................................................................................................... 63

OPHTHALMIC ................................................................................................................................................................................................................ 63

OTIC ............................................................................................................................................................................................................................... 66

WEBSITES ............................................................................................................................................................................................................................... 67

2024 FEP EXCLUDED DRUG LIST STANDARD OPTION CHART ....................................................................................................................................... 69

INDEX ....................................................................................................................................................................................................................................... 76

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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 2024 FEP 5 Tier Rx Drug Formulary as a useful reference for drug product selection. The drugs on

the FEP 5 Tier 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 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, all

dosage forms and strengths of the drug cited are included in the formulary.

The FEP 5 Tier 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, certain drugs and supplies for hair removal and hair growth are excluded from the

pharmacy benefit. In addition, over-the-counter (OTC) products, with the exception of insulin and diabetes monitoring products,

are generally not included in the pharmacy benefit. Some OTC products are listed in the formulary for informational purposes

only.

The formulary is separated by Tiers in the following manner:

Tier 1

generic drugs

Tier 2

Tier 3

preferred brand- non-preferred brandname drugs

name drugs and all

compounded

medications

30% coinsurance 50% coinsurance

Tier 4

Tier 5

preferred specialty non-preferred

drugs

specialty drugs

Standard Option

Preferred Retail

Pharmacy

$7.50 copayment

for a 0 to 30-day

supply

($22.50 copayment

for a 31 to 90-day

supply)

Medicare Part B

Primary

$5 copayment for a

0 to 30-day supply

($15 copayment for a

31 to 90-day supply)

45% of average wholesale price plus any difference between our allowance and the billed amount

Standard Option

Non-Preferred

Retail Pharmacy

Standard Option

Mail Pharmacy

$15 copay

Medicare Part B

$10 copay

Standard Option

Specialty Drug

Pharmacy Program

$90 copay

30% coinsurance 30% coinsurance

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

supply fill at retail supply fill at retail

$125 copay

$65 for a 0 to 30day supply

$85 for a 0 to 30day supply

$185 for 31 to 90- $240 for 31 to 90day supply

day supply

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