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Egtrust.org


January 2016
Medications Requiring Prior Authorization for Medical Necessity
Below is a list of medicines by drug class that will not be covered without a prior authorization for medical necessity. If you continue
using one of these drugs without prior approval for medical necessity, you may be required to pay the full cost.
If you are currently using one of the drugs requiring prior authorization for medical necessity, ask your doctor to choose one of the generic or brand formulary options listed below. Category *
Drugs Requiring Prior
Formulary Options
Drug Class
Authorization for
Medical Necessity 1
Allergic Reaction (Anaphylaxis)
AUVI-Q, EPIPEN, EPIPEN JR Treatment *
Allergies *
flunisolide spray, fluticasone spray, triamcinolone spray, NASONEX Nasal Steroids / Combinations
QNASL RHINOCORT AQUA VERAMYST ZETONNA flunisolide spray, fluticasone spray, triamcinolone spray or NASONEX WITH
azelastine spray
or olopatadine spray
Allergies *
azelastine, cromolyn sodium, PATADAY, PATANOL Ophthalmic
Anti-infectives, Antivirals *
valganciclovir Cytomegalovirus Agents
Anti-infectives, Antivirals *
Hepatitis C Agents
Anti-infectives, Antivirals *
acyclovir, valacyclovir Herpes Agents
Antiobesity Agents *
BELVIQ, CONTRAVE, SAXENDA Newer Agents
Asthma *
Beta Agonists, Short-Acting
Asthma *
ASMANEX, FLOVENT, PULMICORT FLEXHALER, QVAR Steroid Inhalants
Asthma * or Chronic Obstructive SYMBICORT
Pulmonary Disease (COPD) *
Steroid / Beta Agonist
Combinations

Attention Deficit Hyperactivity
amphetamine-dextroamphetamine mixed salts, Disorder Agents *
amphetamine-dextroamphetamine mixed salts ext-rel, guanfacine ext-rel, methylphenidate, methylphenidate ext-rel, DAYTRANA, QUILLIVANT XR, STRATTERA, VYVANSE fenofibrate, fenofibric acid Antilipemics *
Fibrates


Category *
Drugs Requiring Prior
Formulary Options
Drug Class
Authorization for
Medical Necessity 1
atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, CRESTOR, SIMCOR, Antilipemics *
HMG-CoA Reductase Inhibitors
(HMGs or Statins) / Combinations LIPTRUZET
Chronic Obstructive Pulmonary
Disease (COPD) *
Depression *
duloxetine, venlafaxine, venlafaxine ext-rel, KHEDEZLA, PRISTIQ Antidepressants, Selective
Norepinephrine Reuptake

Inhibitors (SNRIs)
Depression *
trazodone Antidepressants, Miscellaneous
Depression *, Schizophrenia *
aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, LATUDA, Antipsychotics, Atypicals
fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil soln, imiquimod, PICATO, ZYCLARA Actinic Keratosis *
metronidazole, sulfacetamide-sulfur, FINACEA, SOOLANTRA Rosacea *
clobetasol spray clobetasol foam Skin Inflammation and Hives *
desoximetasone, fluocinonide Diabetes *
metformin, metformin ext-rel Biguanides
Diabetes *
JANUVIA, TRADJENTA Dipeptidyl Peptidase-4
(DPP-4) Inhibitors
Diabetes *
JANUMET, JANUMET XR, JENTADUETO Dipeptidyl Peptidase-4
(DPP-4) Inhibitor Combinations
Diabetes *
TRULICITY, VICTOZA Injectable Incretin Mimetics


Category *
Drugs Requiring Prior
Formulary Options
Drug Class
Authorization for
Medical Necessity 1
Diabetes *
Insulins
HUMALOG MIX 50/50 NOVOLOG MIX 70/30 HUMALOG MIX 75/25 NOVOLOG MIX 70/30 NOTE: Humulin R U-500 concentrate will not be subject to prior authorization and will continue to be covered. Diabetes *
pioglitazone Insulin Sensitizers
Diabetes *
FARXIGA, JARDIANCE Sodium-Glucose
Co-transporter 2 (SGLT2)
Inhibitors

Diabetes *
Co-transporter 2 (SGLT2)
Inhibitor / Biguanide
Combinations

Diabetes *
ACCU-CHEK STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3 Supplies 3, 4
BREEZE 2 STRIPS AND KITS CONTOUR NEXT STRIPS AND KITS CONTOUR STRIPS AND KITS FREESTYLE STRIPS AND KITS All other test strips that are not ONETOUCH Erectile Dysfunction *
Phosphodiesterase Inhibitors
Gastrointestinal Agents *
Irritable Bowel Disease -
Constipation Predominant

Gastrointestinal Agents *
Opioid-induced Constipation
Gastrointestinal Agents *
lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, Proton Pump Inhibitors (PPIs)
DEXILANT, NEXIUM Glaucoma *
latanoprost, travoprost, TRAVATAN Z, ZIOPTAN Prostaglandin Analogs
Growth Hormones *
HUMATROPE, NORDITROPIN OMNITROPE SAIZEN Hematologic *
clopidogrel, BRILINTA, EFFIENT Platelet Aggregation Inhibitors


Category *
Drugs Requiring Prior
Formulary Options
Drug Class
Authorization for
Medical Necessity 1
High Blood Pressure *
candesartan, eprosartan, irbesartan, losartan, telmisartan, valsartan, BENICAR Angiotensin II Receptor
Antagonists
High Blood Pressure *
Angiotensin II Receptor
Antagonist / Diuretic
hydrochlorothiazide, BENICAR HCT High Blood Pressure *
amlodipine-telmisartan, amlodipine-valsartan, AZOR Angiotensin II Receptor
Antagonist / Calcium Channel

Blocker Combinations
High Blood Pressure *
Angiotensin II Receptor
Antagonist / Calcium Channel
Blocker / Diuretic Combinations

High Blood Pressure *
amlodipine Calcium Channel Blockers
diltiazem ext-rel (except generic of Cardizem LA) CARDIZEM LA (includes generic Cardizem LA) Matzim LA Inflammatory Bowel Disease
balsalazide, budesonide capsule, sulfasalazine, sulfasalazine delayed-rel, APRISO, (IBD), Ulcerative Colitis *
LIALDA, PENTASA, UCERIS Kidney Disease *
calcium acetate, PHOSLYRA, RENVELA, VELPHORO Phosphate Binders
Multiple Sclerosis Agents *
AUBAGIO, BETASERON, COPAXONE, GILENYA, REBIF, TECFIDERA Musculoskeletal Agents *
cyclobenzaprine Opioid Dependence Agents *
buprenorphine-naloxone sublingual tablet, SUBOXONE FILM Osteoarthritis *
GEL-ONE, HYALGAN, SUPARTZ Overactive Bladder /
oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, Incontinence *
GELNIQUE, MYRBETRIQ, VESICARE Urinary Antispasmodics
Pain and Inflammation *
dexamethasone, methylprednisolone, prednisone Pain and Inflammation *
celecoxib; diclofenac sodium, meloxicam or naproxen WITH lansoprazole,
Nonsteroidal Anti-inflammatory
omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT or Drugs (NSAIDs) / Combinations
diclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN celecoxib, diclofenac sodium, meloxicam, naproxen


Category *
Drugs Requiring Prior
Formulary Options
Drug Class
Authorization for
Medical Necessity 1
Prostate Condition *
finasteride or AVODART WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin or
Benign Prostatic Hyperplasia
Agents / Combinations
Sleep *
eszopiclone, zolpidem, zolpidem ext-rel, SILENOR Hypnotics, Non-benzodiazepines LUNESTA
Testosterone Replacement *
testosterone gel 1% 5 ANDRODERM, AXIRON Androgens
ANDROGEL FORTESTA Transplant *
tacrolimus Immunosuppressants,
Calcineurin Inhibitors

Category *
Formulary Options
Drug Class
New-to-Market Agents 1
New-to-market products and new variations of products already in the marketplace will not be added to the formulary until the product has been evaluated, determined to be clinically appropriate and cost-ef ective, and approved by the CVS/caremark® Pharmacy and Therapeutics Committee (or other appropriate reviewing body). Specialty
As new specialty products launch, all existing products in the class will be re-evaluated to determine appropriate formulary placement and potentially excluded, added back to formulary or not listed. Hepatitis C *
As new Hepatitis C products launch, all existing products in the class will be re-evaluated to determine appropriate formulary placement and potentially excluded, added back to formulary or not listed. The listed formulary options are subject to change.


List of Drugs Requiring Prior Authorization for Medical Necessity
fluorouracil cream 0.5% ACCU-CHEK STRIPS AND KITS 4 FREESTYLE STRIPS AND KITS 4 HUMALOG MIX 50/50 HUMALOG MIX 75/25 testosterone gel 1% 5 BREEZE 2 STRIPS AND KITS 4 CARDIZEM LA (includes generic Cardizem LA) clobetasol spray CONTOUR NEXT STRIPS AND KITS 4 CONTOUR STRIPS AND KITS 4 Matzim LA There may be additional drugs subject to prior authorization or other plan design restrictions. Please consult your plan for further information. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. This is not an all-inclusive list of available drug options. Log in to www.caremark.com to check coverage and copay information for a specific drug. Discuss this information with your doctor or health care provider. This information is
not a substitute for medical advice or treatment. Talk to your doctor or health care provider about this information and any health-related questions you have. CVS/caremark assumes no
liability whatsoever for the information provided or for any diagnosis or treatment made as a result of this information. This list is subject to change. Subject to applicable laws and regulations. * This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. 1 If your doctor believes you have a specific clinical need for one of these products, he or she should contact the Prior Authorization department toll-free at: 1-855-240-0536. 2 Listing includes Relion Insulin products. 3 A OneTouch blood glucose meter will be provided at no charge by the manufacturer to those individuals currently using a meter other than OneTouch. For more information on how to obtain a blood glucose meter, call toll-free: 1-800-588-4456. Members must have CVS/caremark Mail Service Pharmacy™ benefits to qualify. 4 OneTouch brand test strips are the only preferred options.
5 Listing reflects the authorized generics for Testim and Vogelxo.
Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information.
This document contains confidential and proprietary information of CVS/caremark and cannot be reproduced, distributed or printed without written permission from CVS/caremark.
CVS/caremark may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not af iliated with CVS/caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the doctor.
2015 CVS/caremark. All rights reserved. 106-25923b 010116 www.caremark.com
Document date: September 30, 2015

Source: http://www.egtrust.org/wp-content/uploads/2015/06/Medications-Requiring-Prior-Authorization-01-2016.pdf

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