Updates to the EHP Prescription Drug Formulary-June 2017 The medications listed in the table below are being added to the EHP Prescription Drug Formulary. Drug Name Ocrevus Veltassa Dupixent Amnesteem Myorisan Zenatane Erythromycin 2% gel Adapalene 0.1% cream Formulary Tier* Tier-4 (specialty) Tier-4 (specialty) Tier-4 (specialty) Is Prior Authorization Required? Is this being added to the Step Therapy Program? Is there a quantity limit? 2 vials per 90 days & 4 vials (40 ml) per 365 days Limited based on instructions for use 26 syringes ages ages ages ages ages Is this medication considered a maintenance drug? Does this medication need refilled for a three month supply? per year
Adapalene 0.3% gel Metronidazole 1% gel Metronidazole 1% gel with pump Metronidazole 0.75% lotion Tretinoin 0.025% cream Tretinoin 0.05% cream Tretinoin 0.1% cream Tretinoin 0.01% gel Tretinoin 0.025% gel Tretinoin 0.05% gel Clindamycin 1% swab Clindamycin 1% solution Clindamycin 1% gel Clindamycin 1% lotion ages ages ages ages
Erythromycin 5mg/g ointment Erythromycin 2% solution Erythromycin pad 2% Sulfacetamide 10% lotion Sulfacetamide 10% Cleanser SSS cream sulfur 10-5%) AVAR cleanser sulfur 10-5%) Prascion cleanser sulfur 10-5%) Rosanil cleanser sulfur 10-5%) Sulfacleanse suspension sulfur 8-4%) SSS Foam sulfur 10-5%) Sensipar Alogliptin Tier-4 (specialty) -step through metformin; will be EHP s preferred DPP-IV inhibitor 1 tablet per day
Januvia Tanzeum Adlyxin Soliqua Generic epinephrine auto-injectors (made by Mylan) Lenvima Tier-2 brand) Tier-2 brand; starting June 1 st, Tier-2 brand; starting June 1 st, Tier-2 brand; starting June 1 st, Tier-4 (specialty) -step 1 tablet per through day metformin & alogliptin 4 pens per 30 days 6 ml (2 pens) per 30 days 15 ml (5 pens) per 30 days 4 pens per 30 days; 24 pens per 365 days Added to the split fill program; limited to 15 day supplies for the first two months of treatment
Restasis single-use vials Xiidra Tier-4 (specialty) Tier-4 (specialty) January 1 st, 2018) January 1 st, 60 singleuse vials per 30 days 60 singleuse vials 2018) per 30 days *Tier 4 specialty medications can only be obtained from a Cleveland Clinic pharmacy or from the CVS/caremark Specialty Mail Order Drug Program. The medications listed in the table below have been reviewed by the Employee Health Plan Pharmacy and Therapeutics Committee but are not being added to the EHP Prescription Drug Formulary.
Drug Name Rayaldee Formulary Tier* Is Prior Authorization Required? Is this being added to the Step Therapy Program? Is there a quantity limit? Is this medication considered a maintenance drug? Emflaza 1 st, Hectorol (generic only)* Hectorol (brand only) Zemplar (generic only)* Zemplar (brand only) Trulance Linzess Trokendi XR Qudexy XR * Lamisil (brand and * Tier-3 (nonformulary; starting Tier-3 (nonformulary; starting 1st, Tier-3 (nonformulary; starting 1 st, 1 tablet per day 1 tablet per day 1 st, 1 st, Does this medication need refilled for a three month supply?
Sporanox * Generic epinephrine auto-injectors (not made by Mylan) Auvi-Q Adrenaclick Epipen/Epipen Jr.(brand only) Zinplava Cycloset Bromocriptine 5 mg capsules Dutoprol Toprol XL 100 mg ER tablets (brand and Toprol XL 200 mg ER Tier-3 (nonformulary; starting under the Rx benefit -under the medical benefit
tablets (brand and Lopressor HCT 50/25 mg tablets (brand and Lopressor HCT 100/25 mg tablets (brand and Lopressor HCT 100/50 mg tablets (brand and Hydrochlorothiazide (HCTZ) 50 mg tablets (brand and Epaned Injectafer Lanoxin 62.5 mcg and 187.5 mcg tablets Meclofenamate Etodolac ER Naproxen DS Riomet
Amcinonide Ointment & Lotion Halog Ointment Zyflo IR, CR, & ER tablets Montelukast 4 mg packets Epiceram/Entty/ Ceracade/ Synerderm/ Emulsion SB Aggrenox (brand only) Viibryd Uloric Lysteda* Xultophy Restasis multidose formulations Biferarx tablets January 1 st, 2018) 1 tablet per day 1 tablet per 1 st, day 30 tablets per 30 days 5 pens (15 ml) per 30 days
Folic Acid/ B6/B12 Combination tablets FABB tablets 2.2-25-1 Feriva tablets 21/7 Ferralet 90 tablets Ferraplus 90 tablets Ferrex 150 Forte Plus capsules Ferrogels Forte capsules Folbee tablets Folgard Rx tablets 2.2 Folivane-PLS capsules Folplex 2.2 tablets Hematinic Plus tablets
Hematogen Forte Capsules Nephron FA tablets Poly-Iron Forte capsules 150 TL Gard Rx tablets Tretinoin Microsphere 0.04% gel Tretinoin Microsphere 0.04% gel with pump Tretinoin Microsphere 0.1% gel Tretinoin Microsphere 0.1% gel with pump clindamycinbenzoyl peroxide 1.2%- 5% gel clindamycinbenzoyl peroxide 1%- 5% gel clindamycinbenzoyl peroxide 1%-
5% gel with pump clindamycintretinoin 1.2-0.025% gel clindamycin 1 % foam akene-mycin 2% ointment erythromycinbenzoyl peroxide 3-5% gel Adapalene 0.3% gel with pump Adapalene 0.1% lotion Ovace plus lotion (sulfacetamide 9.8%) Ovace plus shampoo (sulfacetamide 10%) Ovace plus gel (sulfacetamide 10%) Ovace plus cream (sulfacetamide 10%) Ovace plus wash liquid (sulfacetamide 10%)
Ovace plus foam (sulfacetamide 9.8%) Plexion cream sulfur 9.8-4.8%) Avar-E emollient cream sulfur 10-5%) Avar-E LS cream sulfur 10-2%) Avar-E Green cream sulfur 10-5%) Plexion lotion sulfur 9.8-4.8%) Plexion cloths sulfur 9.8-4.8%) AVAR LS Pad sulfur 10-2%) AVAR Pad sulfur 9.5-5%) Rosula sulfur 10-5%) Sumaxin Pad sulfur 10-4%)
Sumaxin skin cleanser kit sulfur 10-4%) Plexion cleanser sulfur 9.8-4.8%) AVAR LS Cleanser sulfur 10-2%) Rosula liquid sulfur 10-4.5%) Sumaxin wash liquid sulfur 9-4%) AVAR LS Foam sulfur 10-2%) AVAR Foam sulfur 9.5-5%) *Due to the availability of preferred formulary alternatives, these generic medication formulations are considered non-preferred medications and are subject to a 50% member coinsurance with no monthly maximum out-of-pocket expense.