CLINICAL POLICY
DRUG COVERAGE CRITERIA – NEW AND
THERAPEUTIC EQUIVALENT MEDICATIONS
Policy Number: PHARMACY 179.65 T2
Effective Date: December 1, 2014
Table of Contents
Page
CONDITIONS OF COVERAGE...................................
1
COVERAGE RATIONALE……………………………….. 2
DEFINITIONS……………………………………….…….. 11
REFERENCES............................................................. 11
POLICY HISTORY/REVISION INFORMATION............ 11
Related Policy:
Prescription Drug
Quantity Duration (QD)
and Quantity Level
Limitations (QLL)
The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's
contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage
enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written
notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term
Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.
Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the
Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there
are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between
any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of
Coverage will govern
CONDITIONS OF COVERAGE
This policy applies to Connecticut and New York Commercial plans.
Exclusions:
•
•
New Jersey Plans and Products: This policy does not apply to New Jersey Commercial
plans. However, drugs included in this policy may still require precertification through
another policy. Refer to the Member's certificate of coverage and/or member specific
benefit document for additional information.
Connecticut Plans and Products: Effective January 1, 2012, as groups enroll or renew,
insurers cannot require an individual to use an alternative brand name prescription drug
or over-the-counter drug before using the brand name prescription drug that was
prescribed by a licensed physician for pain management. Insurers can, however, first
require the individual to try a therapeutically equivalent generic drug before approving the
brand name prescription drug that was prescribed by the physician.
Note:
•
•
•
Not all Oxford Members have a pharmacy benefit.
For coverage of outpatient prescription drugs and specific exclusions, exceptions, and
dispensing limitations, refer to the Member's pharmacy plan, if applicable.
Oxford's Pharmacy Benefit Manager (PBM) provides a nationwide network of
participating pharmacies that dispense prescription medications on a retail level.
Commercial groups with outpatient prescription drug coverage will have their pharmacy
benefit administered by the PBM.
Drug Coverage Criteria - New and Therapeutic Equivalent Medications: Clinical Policy (Effective 12/01/2014)
©1996-2014, Oxford Health Plans, LLC
1
•
For information regarding any quantity level limitations, refer to Prescription Drug
Quantity Duration (QD) and Quantity Level Limitations (QLL). E
COVERAGE RATIONALE
This policy provides information and criteria relevant to medications for which certain types of
prescription drug benefit exclusions may apply.
In accordance with Oxford's prescription drug riders, certain medications are excluded from
coverage. The rationale for such exclusions varies, and therefore coverage may be provided in
certain clinical scenarios.
There are two types of exclusions addressed in this policy:
•
•
Exclude at Launch: In an effort to enhance the affordability and value of prescription
drug riders, and as part of our Prescription Drug List (PDL) management, Oxford will
proactively identify and help manage the cost of low value medications being introduced
into the market. The Exclude at Launch program delays coverage until a full evaluation
can be completed for new medications that may offer little to no additional health care
value. Our PDL Management Committee will review each Exclude at Launch medication
to determine its tier placement or benefit coverage.
Same Active Ingredient: Oxford may exclude coverage for a medication, unless it is
medically necessary for the member, if it includes the same active ingredient (or a
modified version of an active ingredient) and is therapeutically equivalent to a covered
prescription medication. Oxford's definition of therapeutic equivalence refers to
medications that produce the same therapeutic outcome and adverse event profile.
The following table provides a list of prescription medications for which one or both of the above
exclusions apply. Precertification through the Pharmacy Benefit Manager (PBM) is required
for all listed medications. Coverage will be provided only when Member has exhibited
intolerance (that is, sensitivity, drug allergy, adverse effect) to, or experienced a therapeutic
failure with at least ONE of the covered formulary alternatives noted below (EXCEPT where
noted).
Medication/Drug
Absorica
Abstral
Acanya
Aciphex Sprinkle
Acticlate
Actiq
Active-Pac/Gaba 300
Actos (brand only)
Acuvail
Adderall (brand only)
Adoxa
Adrenaclick
Alsuma
Altoprev
Amlodipine/atorvastatin
Formulary Alternative(s)
Isotretinoin (generic for Accutane), Amnesteem,
Claravis, Myorisan, Sotret
fentanyl citrate (generic Actiq), Lazanda, Onsolis,
Subsys
clindamycin 1%/benzoyl peroxide 5% gel (generic
Benzaclin)
rabeprazole
Doxycycline hyclate (generic Vibramycin, Vibra-Tabs)
Fentanyl citrate lozenges (generic for Actiq)
gabapentin (generic Neurontin)
pioglitazone (generic Actos)
Ketorolac
amphetamine/dextroamphetamine immediate-release
(generic Adderall)
Doxycycline (generic for Monodox, Vibramycin)
EpiPen, EpiPen Jr.
sumatriptan injection
Lovastatin (generic Mevacor)
Amlodipine (generic Norvasc) plus atorvastatin (Lipitor),
Norvasc plus Lipitor
Adderall XR
amphetamine/dextroamphetamine
extended-release (generic Adderall XR)
Amrix / cyclobenzaprine extended release Cyclobenzaprine HCL(generic for Flexeril)
Drug Coverage Criteria - New and Therapeutic Equivalent Medications: Clinical Policy (Effective 12/01/2014)
©1996-2014, Oxford Health Plans, LLC
2
Medication/Drug
Amturnide
Analpram Advanced Kit
Androgel
Antara 30 mg & 90 mg strengths only
Aplenzin
Apop 10% gel
Aqua Glycolilc HC
Aricept (23 mg only)
Arimidex (brand only)
Asacol HD
AsmalPred
AsmalPred Plus
Astagraf XL
Astelin (brand only)
Astepro
Atelvia
Ativan (brand only)
Augmentin XR / Amoxicillin-Clavulanate
ER
Auralgan 5.5%/1.4%
Auvi-Q
Avar (sulfacetamide sodium/sulfur) 9.55%, 10-2%
Axiron
Azor
Beconase AQ
Benzaclin jar (brand only)
Benzaclin Kit (1%-5%)
Benzaclin Pump
Benzefoam, Benzefoam Ultra
Bepreve
betamethasone valerate foam (generic
Luxiq)
Beyaz
Binosto
Brisdelle
Bromday
budesonide nasal spray (generic
Rhinocort Aqua)
Bunavail Film
buprenorphine/naloxone (generic
Suboxone)
butalbital/acetaminophen/caffeine/codeine
50mg/300mg/40mg/30mg (generic
Fioricet with Codeine)
Caduet and Generic Caduet
(atorvastatin/amlodipine)
Cambia
Celexa (brand only)
Formulary Alternative(s)
Amlodipine + Tekturna HCT (or individual components
taken concomitantly)
Hydrocortisone acetate/pramoxine HCl, Analpram HC
Testim
fenofibrate 54 mg, 160 mg (generic Tricor), fenofibrate
43mg, 130 mg (generic Antara), Antara Lipofen
Buproprion XL (generic for Wellbutrin XL)
Sulfacetamide lotion, solution, suspension
Hydrocortisone 2.5% (generic Hytone)
donepezil 10mg (generic for Aricept 10mg)
anastrozole (generic Arimidex)
Apriso, Lialda,
Prednisolone sodium phosphate (generic Orapred)
prednisolone sodium phosphate (generic Orapred)
tacrolimus (generic Prograf), Prograf
Azelastine nasal spray (generic Astelin)
azelastine (generic Astelin)
Actonel
lorazepam (generic Ativan)
Amoxicillin/clavulanate potassium (generic for
Augmentin)
Antipyrine/benzocaine solution – 5.4%/1.4% (generic
Auralgan)
EpiPen, EpiPen Jr.
sulfacetamide sodium/sulfur
Testim
Amlodipine (generic Norvasc) plus Benicar, Norvasc
plus Benicar
Qnasl
clindamycin 1%/benzoyl peroxide 5% gel (generic
Benzaclin)
Clindamycin Phosphate + OTC Benzoyl Peroxide
clindamycin 1%/benzoyl peroxide 5% gel (generic
Benzaclin)
OTC Benzoyl peroxide
azelastine (generic for Optivar) AND Lastacaft
betamethasone lotion (generic Valisone
Yaz + folic acid
Alendronate (generic Fosamax),
paroxetine (generic Paxil), Paxil
Bromfenac (generic Xibrom), ketorolac (generic Acular)
fluticasone (generic Flonase), flunisolide (generic
Nasarel), OTC - Nasacort
Zubsolv
Zubsolv
butalbital/acetaminophen/caffeine/codeine 50 mg/325
mg/40 mg/30 mg (generic Fioricet with Codeine)
Amlodipine (generic Norvasc) + atorvastatin (generic for
Lipitor)
diclofenac potassium , diclofenac sodium
citalopram (generic Celexa)
Drug Coverage Criteria - New and Therapeutic Equivalent Medications: Clinical Policy (Effective 12/01/2014)
©1996-2014, Oxford Health Plans, LLC
3
Medication/Drug
Centany AT Kit
Cerdelga
choline fenofibrate (generic Trilipix)
Ciclodan Combination Package
Ciclodan Kit
Clarinex / desloratidine
Clarinex-D
Clindacin Pac
Clindagel
Clindamycin 1.2%/benzoyl peroxide 5%
(generic Duac)
Clobeta
Clobetasol shampoo (generic Clobex
shampoo)
Clobex shampoo
Clodan 0.05%
Clodan 0.05% kit
Cocet Plus
Comfort Pac Tizanadine
ConZip
Coreg CR
Cosopt PF
Cymbalta (brand only)
Daytrana
Delos Lotion
Delos Cleanser
Delzicol
Dermasorb AF 3-0.5% kit
Dermasorb XM 39% kit
Desloratadine (generic Clarinex)
Desonil cream/ointment (Kit)
Desvenlafaxine
Desvenlafaxine ER
Detrol
Formulary Alternative(s)
mupirocin ointment
VPRIV hi (medical benefit)
fenofibrate 54 mg, 160 mg (generic Tricor), fenofibrate
43mg, 130 mg (generic Antara), Antara Lipofen
Ciclopirox (generic for Loprox), Loprox
Ciclopirox nail lacquer
Levocetirizine (generic for Xyzal)
Levocetirizine (generic for Xyzal) + OTC
pseudoephedrine
Clindamycin gel, solution, lotion or swabs
Clindamycin gel 1% (generic Cleocin-T)
Clindamycin 1%/benzoyl peroxide 5% gel (generic
Benzaclin),
Clobetasol 0.05% + OTC coal tar
Clobetasol (generic Temovate), Temovate
Generic clobetasol propionate solution or foam
Clobetasol (generic Temovate) lotion, Temovate lotion
Clobetasol (generic Temovate) lotion, Temovate lotion
Acetaminophen with codeine
Tizanadine (generic for Zanaflex)
tramadol immediate-release (generic Ultram), tramadol
extended-release (generic Ultram ER)
Carvedilol (generic for Coreg)
Dorzolamide/timolol (generic Cosopt)
duloxetine (generic Cymbalta)
Two of the following: Brand or generic: Adderall XR,
Concerta, Metadate CD or Vyvanse. (note brand and
generic will count as 1 alternative med)
OTC benzoyl peroxide
OTC benzoyl peroxide
Apriso, Lialda,
clioquinol/hydrocortisone 3-0.5% (Ala-Quin)
urea 40% (generic Carmol 40)
Levocetirizine (generic Xyzal), OTC cetirizine (generic
Zyrtec), OTC fexofenadine (generic Allegra), OTC
loratadine (generic Claritin)
Desonide 0.05% cream, ointment
venlafaxine extended-release capsule (generic Effexor
XR), Pristiq
venlafaxine extended-release (generic Effexor XR),
Pristiq
oxybutynin (generic Ditropan), oxybutynin extendedrelease (generic Ditropan XL), Ditropan, Ditropan XL,
Toviaz, Oxytrol OTC
Detrol IR
ALL of the following: Concerta (brand only) and
Metadate CD (brand only)
valsartan/hydrochlorothiazide (generic Diovan HCT)
salsalate
donepezil 5, 10 mg (generic Aricept), Aricept 5 & 10mg
Doxycycline (generic for Monodox, Vibramycin)
Detrol LA
dexmethlyphenidate extended-release
capsule (generic Focalin XR)
Diovan HCT (brand only)
Disalcid
donepezil 23 mg (generic Aricept 23 mg)
Doryx /doxycycline hyclate delayed
release tablet
Doxycycline monohydrate 150mg capsule Doxycycline (generic for Monodox, Vibramycin)
(generic for Adoxa)
Drug Coverage Criteria - New and Therapeutic Equivalent Medications: Clinical Policy (Effective 12/01/2014)
©1996-2014, Oxford Health Plans, LLC
4
Medication/Drug
Duac, Duac CS
Formulary Alternative(s)
clindamycin/benzoyl peroxide (generic for Benzaclin),
Benzaclin
Duexis
Ibuprofen (generic Motrin) plus OTC famotidine (generic
Pepcid AC)
Dymista
fluticasone (generic for Flonase) + azelastine (generic
for Astelin) or Astepro
Ecoza
econazole (generic Spectrazole)
Effexor XR (brand only)
venlafaxine extended-release capsule (generic Effexor
XR)
Elestat
Azelastine (generic for Optivar) AND Lastacaft
Emadine
Azelastine (generic for Optivar) AND Lastacraft
Enablex
Oxytrol OTC, oxybutynin, oxybutynin extended-release,
Ditropan, Ditropan XL, Toviaz
Entocort EC (brand only)
budesonide (generic Entocort EC)
Epaned
enalapril (generic Vasotec)
Epinephrine Pen Injection 0.15mg and 0.3 EpiPen, EpiPen Jr.
mg (generic Adrenaclick)
Esomeprazole Strontium
omeprazole (generic Prilosec), pantoprazole (generic
Protonix), Aciphex, Dexilant
Exforge
amlodipine (generic Norvasc) plus losartan (generic
Cozaar), Benicar, Diovan, or Micardis
Exforge HCT
amlodipine (generic Norvasc) plus
lisinopril/hydrochlorothiazide (generic Prinizide,
Zestoretic), losartan/hydrochlorothiazide (generic
Hyzaar), valsartan/hydrochlorothiazide (generic Diovan
HCT), Benicar HCT, telmisartan/hydrochlorothiazide or
Micardis HCT
Fabior
Tazorac gel
Falessa Kit
levonorgestrel/ethinyl estradiol (generic Alesse, Levlite)
[branded generics (Aubra, Aviane, Lessina, Lutera,
Orsythia, Sronyx, Falmina)] plus Folic Acid
Femara (brand only)
letrozole (generic Femara)
Fenofibrate 48mg, 145mg (generic Tricor) Fenofibrate 54mg, 160mg (generic Tricor, fenofibrate
43mg, 130 mg (generic Antara), Lipofen
Fentora
Fentanyl citrate lozenges (generic for Actiq), Abstral,
Onsolis
Ferric Citrate Tablet
Calcium acetate (generic Phoslo), Renvela
Fioricet with Codeine capsule 50 mg/300 butalbital/acetaminophen/caffeine/codeine 50 mg/325
mg/40 mg/30 mg
mg/40 mg/30 mg (generic Fioricet with Codeine
Flector
Voltaren Gel
Flomax (brand only)
tamsulosin (generic Flomax)
Flo-Pred
Prednisolone sodium phosphate (generic for Orapred)
fluocinonide 0.1% cream (generic Vanos) fluocinonide cream (generic Lidex)
Focalin XR
Two of the following: Brand or generic: Adderall XR,
Concerta, Metadate CD or Vyvanse. (note brand and
generic will count as 1 alternative med)
Forfivo XL
Bupropion (generic Wellbutrin), bupropion SR
(Wellbutrin SR), buproprion XL (generic Wellbutrin XL),
Wellbutrin, Wellbutrin SR, Wellbutrin XL
Fortesta
Testim
Genadur Kit
Genadur
Generess FE
Gildess FE, Junel FE, Larin FE, Microgestin FE (generic
for Loestrin FE), Loestrin FE, Lo Loestrin FE
Genotropin and Genotropin MiniQuick
Two of the following: 1 )Nutropin, Nutropin AQ, or
Nutropin AQ NuSpin, 2) Saizen
Geodon (brand only)
ziprasidone (generic Geodon)
Drug Coverage Criteria - New and Therapeutic Equivalent Medications: Clinical Policy (Effective 12/01/2014)
©1996-2014, Oxford Health Plans, LLC
5
Medication/Drug
Giazo
Glycate
Gralise
Helidac
Horizant
Humatrope
Ilevro
Imitrex tablets (brand only)
Imitrex injection (brand only)
Intuniv
Jalyn
Jardiance
Kadian
Kapvay
Keralac 47% cream
Keralyt Scalp Kit
Kerydin
Ketocon
Ketodan Combination Package
Khedezia
Levalbuterol nebs (generic Xopenex
nebs)
Lexapro (brand only)
Lidoderm
Lidorx
Lipitor (brand only)
Liptruzet
Locoid Lipocream,
Locoid Lotion
Lo Minastrin FE
Lorzone
Lotemax Gel
Luxiq foam
Maxalt (brand only)
Maxalt-MLT (brand only)
methylphenidate extended-release tablet
(generic Concerta)
methylphenidate extended-release
capsule (generic Metadate CD
Metrogel 1%
Metronidazole 1% gel (generic Metrogel
1%)
Metozolv ODT
Mitigare
Minastrin 24 FE
Minocin 75mg only
Formulary Alternative(s)
balsalazide (generic for Colazal)
glycopyrrolate (generic Robinul)
Gabapentin (generic Neurontin)
Pylera
Gabapentin (generic Neurontin)
Two of the following: 1) Nutropin, Nutropin AQ, or
Nutropin AQ NuSpin, 2) Saizen
Nevanac
sumatriptan injection and tablets (generic Imitrex)
sumatriptan injection and tablets (generic Imitrex)
guanfacine (generic Tenex), Tenex
Avodart (requires precertification if <46 y.o. or female) +
tamsulosin
Invokana
Morphine sulfate sustained action
clonidine immediate release tablets (generic for
Catapres)
urea 40%
Salicylic acid shampoo, salicylic acid gel
Ciclopirox (generic Penlac), itraconazole (generic
Sporanox), terbinafine (generic Lamisil)
ketoconzaole 2% + hydrocortisone 1%
Ketoconazole cream, shampoo or foam (generic
Nixoral)
venlafaxine extended-release (generic Effexor XR),
Pristiq
Albuterol (generic Proventil)
escitalopram (generic Lexapro)
lidocaine transdermal patch (generic Lidoderm)
lidocaine 2% gel
Atorvastatin (generic Lipitor)
atorvastatin (generic Lipitor) plus Zetia
hydrocortisone butyrate (generic Locoid)
hydrocortisone butyrate (generic Locoid)
Gildess Fe, Junel Fe, Microgestin Fe (branded generics
for Loestrin Fe), Lo Loestrin FE
Chlorzoxazone (generic Parafon Forte DSC)
Lotemax Ointment/Suspension
betamethasone lotion (generic Valisone)
rizatriptan (generic Maxalt)
rizatriptan orally disintegrating tablet (generic Maxalt
MLT)
Brand Concerta
Brand Metadate CD
metronidazole gel 0.75% (generic Metrogel)
metronidazole gel 0.75% (generic Metrogel), Metrogel
0.75%
Metoclopramide (generic for Reglan)
Colcrys
Gildess Fe, Junel Fe, Microgestin Fe (branded generics
for Loestrin Fe)
minocycline (generic Dynacin, Minocin)
Drug Coverage Criteria - New and Therapeutic Equivalent Medications: Clinical Policy (Effective 12/01/2014)
©1996-2014, Oxford Health Plans, LLC
6
Medication/Drug
Mirapex ER
Moderiba Tablet
Moderiba Pak
Momexin Combo Pkg
Monodox (brand only)
Formulary Alternative(s)
Pramipexole (generic for Mirapex)
ribavirin (generic Copegus)
ribavirin (generic Copegus)
Mometasone furoate cream + ammonium lactate
doxycycline hyclate (generic Vibramycin),
doxycycline monohydrate (generic Monodox)
Morgidox Kit / (Combo Pkg)
Doxycycline (generic for Monodox, Vibramycin)
Morphine sulfate Extended Release
Morphine sulfate sustained-action tablet (generic MS
(generic Kadian)
Contin), Avinza, MS Contin
Myrbetriq
Oxytrol OTC, oxybutynin, oxybutynin extended-release,
Ditropan, Ditropan XL, Toviaz
Naftin 2% gel
Naftin Cream, Naftin 1% Gel
Namenda XR
Namenda
Naprelan
Naproxen sodium
Naprelan CR (Dose Card)
Naproxen sodium
Nasonex
Two of the following: flunisolide (generic Nasarel),
fluticasone (generic Flonase), Zetonna, Nasacort OTC
Natroba (brand only)
spinosad (generic Natroba)
Neo-Synalar
OTC Neosporin plus fluocinolone cream (generic Lidex),
Lidex cream
New-Synalar Kit
OTC Neosporin plus fluocinolone cream (generic Lidex),
Lidex cream
Neuac 1.2%-5%
Clindamycin-benzoyl peroxide (generic Benzaclin jar)
Neuac 1.2%-5% kit
Clindamycin-benzoyl peroxide (generic Benzaclin jar)
Nexiclon XR Tablet
clonidine immediate release tablets (generic for
Catapres)
Nexiclon XR Suspension
clonidine immediate release tablets (generic for
Catapres)
Nicazeldoxy 30 kit (Doxycycline plus MVI) doxycycline (generic Monodox, Vibramycin)
Nitroglycerin Spray (generic Nitrolingual) Nitromist, Nitrostat
Nitrolingual Pump Spray
Nitromist, Nitrostat
Norditropin, Norditropin NordiFlex,
Two of the following: 1) Nutropin, Nutropin AQ, or
Norditropin FlexPro
Nutropin AQ NuSpin, 2) Saizen
Northera
Midodrine (generic Proamatine)
Noxafil tablets
Noxafil Suspension
Oleptro
trazodone (generic for Desyrel)
Olux - CP
Clobetasol propionate foam
Omeclamox-Pak
Omepraxole (Prilosec) & clarithromycin (Biaxin) &
amoxicillin (Amoxil)
Omnaris
Two of the following: flunisolide (generic Nasarel),
fluticasone (generic Flonase), Zetonna, Nasacort OTC
Omnitrope
Two of the following: 1) Nutropin, Nutropin AQ, or
Nutropin AQ NuSpin, 2) Saizen
Onmel
Itraconazole (generic for Sporanox), Sporanox
Optivar (brand only)
azelastine (generic for Optivar) AND Lastacaft
Orbivan
butalbital/acetaminophen/caffeine (generic for Fioricet)
Otic Care
Antipyrine/benzocaine solution
Ovace Plus 9.8% lotion
sulfacetamide sodium
Oxycodone ER 12 HR Tablet
Oxycontin
Oxytrol
Oxytrol OTC, oxybutynin, oxybutynin extended-release,
Ditropan, Ditropan XL, Toviaz
Pacnex HP
OTC benzoyl peroxide
Pacnex LP
OTC benzoyl peroxide
Pataday
Azelastine (generic for Optivar) AND, Lastacaft
Patanol
Azelastine (generic for Optivar) AND, Lastacaft
Drug Coverage Criteria - New and Therapeutic Equivalent Medications: Clinical Policy (Effective 12/01/2014)
©1996-2014, Oxford Health Plans, LLC
7
Medication/Drug
Pediaderm AF
Pediaderm TA
Pedipirox-4
Pennsaid Drops
Pennsaid 2%
Pentasa
Percocet (brand only)
Plavix (brand only)
Plegridy Pen & Prefilled Syringe
Formulary Alternative(s)
nystatin cream
triamcinolone 0.1% cream
Ciclopirox (generic Penlac)
Voltaren Gel
Voltaren Gel
Apriso, Lialda
acetaminophen/ oxycodone (generic Percocet)
clopidogrel (generic Plavix)
Must Try 2 of the following: Avonex, Copaxone,
Betaseron, Tecfidera
Plexion 9.8-4.8% cream, liquid, lotion
sulfacetamide sodium/sulfur
Plexion Cloth 9.8%-4.8% pads
sulfacetamide sodium/sulfur
Pramosone E
Hydrocortisone/pramoxine (generic Pramosone)
Prevpac
Omeclamox-Pak
Procort
Hydrocortisone/pramoxine (generic Analpram E)
Prolensa
bromfenac ophthalmic solution (generic Xibrom)
Promiseb Complete Kit
Promiseb
Provigil (Brand and Generic)
Nuvigil
Prozac (brand only)
fluoxetine (generic Prozac)
Purixan 20mg/ml
Mercaptopurine (generic Purinethol), Purinethol
Qnasl
Two of the following: flunisolide (generic Nasarel),
fluticasone (generic Flonase), Zetonna, Nasacort OTC
Quartette
Introvale, Jolessa, Quasense (generics for Seasonale);
Amethia, Camrese, Daysee (generic for Seasonique);
Amethia Lo, Camrese Lo (generic for LoSeasonique)
Qudexy XR
topiramate (generic Topamax), Topamax
Quillivant XR
Two of the following: Brand or generic: Adderall XR,
Concerta, Metadate CD or Vyvanse. (note brand and
generic will count as 1 alternative med)
Rayos
prednisone
Requip XL
Ropinirole (Generic for Requip)
Retin-A Micro (brand and generic)
tretinoin (generic Retin-A), Retin-A
Retin-A Micro Pump (brand and generic) tretinoin (generic Retin-A), Retin-A
Revatio
sildenafil (generic Revatio)
Revatio 10 mg/ml
Sildenafil tablet (generic Revatio)
Rhinocort Aqua
Two of the following: flunisolide (generic Nasarel),
fluticasone (generic Flonase), Zetonna, Nasacort OTC
Riax
benzoyl peroxide
Ribapak
ribavirin (generic for Copegus, Rebetol)
Risperdal (brand only)
risperidone (generic Risperdal)
Ritalin LA (brand and generic)
Two of the following: Brand or generic: Adderall XR,
Concerta, Metadate CD or Vyvanse. (note brand and
generic will count as 1 alternative med)
Ropinirole extended release (Requip XL) Ropinirole (generic Requip)
Rosadan Kit Cream
Metronidazole cream (Metrocream)
Rosadan Kit Gel
Metronidazole gel 0.75% (Metrogel)
Rybix ODT
tramadol
Ryzolt / tramadol extended release
Tramadol IR (generic for Ultram), tramadol ER (generic
(generic Ryzolt)
for Ultram ER)
Safyral
Yasmin + folic acid
Sanctura (brand and generic)
Oxytrol OTC, oxybutynin, oxybutynin extended-release,
Ditropan, Ditropan XL, Toviaz
Sanctura XR (brand and generic)
Oxytrol OTC, oxybutynin, oxybutynin extended-release,
Ditropan, Ditropan XL, Toviaz
Sancuso
Granisetron (generic for Kytril)
Drug Coverage Criteria - New and Therapeutic Equivalent Medications: Clinical Policy (Effective 12/01/2014)
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Medication/Drug
Selrx
Formulary Alternative(s)
selenium sulfide shampoo (generic Selsun shampoo),
Selsun
Seroquel (brand only)
quetiapine (generic Seroquel)
Silenor
doxepin
Simbrinza 1-0.2%
brimonidine (generic Alphagan) plus Azopt
Singulair Chewable Tablet (brand only)
Montelukast chewable tablet (generic Singulair)
Singulair Tablet (brand only)
Montelukast (generic Singulair)
Sitavig
acyclovir tablets (Zovirax), acyclovir ointment (Zovirax
ointment), Zovirax cream, Zovirax tablets
Skelaxin (brand only)
chlorzoxazone (generic Parafon Forte DSC),
cyclobenzaprine (generic Flexeril), metaxalone (generic
Skelaxin), methocarbamol (generic Robaxin)
Sodium Sulfacetamide/sulfur 9%-4.5% kit Sodium sulfacetamide /sulfur
(generic Sumadan Kit
Soltamox
Tamoxifen (generic for Nolvadex), Nolvadex
Soma 250mg / carisoprodol 250mg
Carisprodol 350mg (generic for Soma)
Sorilux (calcipotriene)
calcipotriene (Dovonex)
SSS 10-4
Sulfacetamide sodium/sulfur
Striverdi Respimat
Foradil, Serevent Diskus
Suboxone film, tablets
Zubsolv
Sumadan
Sulfacetamide, sodium/sulfur (generic for Sulfatol)
Sumadan Cleanser (brand only)
sulfacetammide sodium/sulfur
Sumadan XLT Kit
sulfacetamide sodium/sulfur
Sumaxin CP
Sulfacetamide sodium/sulfur (generic Sulfatol)
Sumaxin TS
sulfacetamide sodium/sulfur
Suprax Chewable Tablets
Suprax Oral Suspension
Symbicort
Two of the following: Advair Diskus OR Advair HFA,
Breo Ellipta, Dulera
Synalar
Fluocinolone (generic Synalar)
Synalar Kit
Fluocinolone (generic Synalar)
Synalar TS
Fluocinolone (generic Synalar)
Tekamlo
Amlodipine plus Tekturna
Terbinex
Terbinafine (generic for Lamisil)
testosterone topical gel (generic Testim) Testim
testosterone topical gel (generic Volgelxo) Testim
Tobi Nebs
Bethkis
Tobradex ST
Tobramycin/dexamethasone ophthalmic drops (generic
for Tobradex)
Tobramycin nebulized solution
Bethkis
Tolterodine (generic Detrol)
Oxytrol OTC, oxybutynin, oxybutynin extended-release,
Ditropan, Ditropan XL, Toviaz
Topicort Spray
desoximetasone (generic Topicort)
Tramadol extended-release (generic
tramadol (generic Ultram), tramadol extended-release
ryzolt)
(generic Ultram ER), Ultram, Ultram ER
Tretin-X 0.075% cream
tretinoin (generic Retin-A), Retin-A
Treximet
Sumatriptan plus naproxen
Trianex
Triamcinolone ointment (generic Aristocort)
Tribenzor
amlodipine plus hydrochlorothiazide plus Benicar (or)
Benicar HCT plus amlodipine (or) Azor plus
hydrochlorothiazide
Tricor/Fenofibrate 48mg and 145mg
Fenofibrate 54mg, 160m (generic Tricor), Antara,
(generic Tricor)
Lipofen
Trilipix
Fenofibrate, Antara, Lipofen
Triumeq
Epzicom plus Tivicay
Trokendi XR
topiramate (generic Topamax), Topamax
Drug Coverage Criteria - New and Therapeutic Equivalent Medications: Clinical Policy (Effective 12/01/2014)
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Medication/Drug
Twynsta
Ultravate X Combination Package
Formulary Alternative(s)
Micardis + amlodipine
Halobetasol (generic for Ultravate) plus ammonium
lactate (generic for Lac-Hydrin), Ultravate plus LacHydrin
Umecta emulsion, foam, suspension
Urea 40%
Umecta Kit (nail film pen/ film suspension) Urea 40% emulsion (Umecta) + hyaluronate gel 0.2%
(Hylira)
Umecta PD
Urea 40%
Uramaxin GT 45%
Urea 40% emulsion
Uramaxin GT Kit
Urea 40%
Utopic (urea) 41%
urea 40% (generic Carmol 40)
Valium (brand only)
diazepam (generic Valium)
Valsartan (generic Diovan)
Diovan
Valtrex (brand only)
valacyclovir (generic Valtrex)
Valturna 150-160mg, 300-320mg Tablet Diovan + Tekturna
Vanos
fluocinonide cream (generic Lidex)
Veltin
Clindamycin gel + tretinoin gel
Venlafaxine ER tablet
venlafaxine extended-release capsule (Effexor XR)
Veramyst
Two of the following: flunisolide (generic Nasarel),
fluticasone (generic Flonase), Zetonna, Nasacort OTC
Verdeso
desonide lotion (generic Desowen), Desowen
Vesicare
Oxytrol OTC, oxybutynin, oxybutynin extended-release,
Ditropan, Ditropan XL, Toviaz
Vexa 2-4-30%
Lidocaine transdermal Patch (generic Lidoderm)
Vicodin
hydrocodone/acetaminophen 5/325 mg (generic Norco)
Vicodin ES
hydrocodone/acetaminophen 7.5/325 mg (generic
Norco)
Vicodin HP
hydrocodone/acetaminophen 10/325 mg (generic
Norco)
Vimovo
Naproxen + omeprazole, pantoprazole tablet, Aciphex,
Dexilant
Virasal (brand only)
Salicylic acid OTC
Vituz
Hydrodocone-Chlorpheniramine (10-8MG/5ML)
Vogelxo
Testim
Wellbutrin SR (brand only)
bupropion sustained-release (generic Wellbutrin SR)
Wellbutrin XL (brand only)
bupropion extended-release (generic Wellbutrin XL)
Xanax (brand only)
alprazolam (generic Xanax)
Xanax XR (brand only)
alprazolam extended-release (generic Xanax XR)
Xartemis XR 7.5/325 mg
oxycodone/acetaminophen (generic Percocet)
Xerese
Zovirax 5% cream + OTC hydrocortisone 1% cream
Xodol 10/325 (brand and generic)
hydrocodone/acetaminophen 10/325 mg (generic
Norco)
Xodol 5/325 (brand and generic)
hydrocodone/acetaminophen 5/325 mg (generic Norco)
Xodol 7.5/325 (brand and generic)
hydrocodone/acetaminophen 7.5/325 mg (generic
Norco)
Xopenex Nebules
Albuterol nebulized solution
Zenzedi
dextroamphetamine (generic Dexedrine)
Ziana
Clindamycin gel + tretinoin gel
Zipsor 25mg
Diclofenac potassium or diclofenac sodium
Zoloft (brand only)
sertraline (generic Zoloft)
Zolvit
acetaminophen with hydrocodone solution
Zonatuss
Benzonatate
Zorvolex
diclofenac (generic Cataflam, Voltaren
Zovirax Ointment (brand only)
acyclovir ointment (generic Zovirax)
Drug Coverage Criteria - New and Therapeutic Equivalent Medications: Clinical Policy (Effective 12/01/2014)
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Medication/Drug
Zuplenz
Zyclara
Zyprexa (brand only)
Zyprexa Zydis (brand only)
Formulary Alternative(s)
ondansetron tablet (generic for Zofran) , ondansetron
ODT (generic for Zofran ODT)
Imiquimod 5% cream
olanzapine (generic Zyprexa)
olanzapine (generic Zyprexa), olanzapine orally
disintegrating
tablet (generic Zyprexa Zydis)
DEFINITIONS
For all of the definitions below, copayment/cost share will vary based on the members plan
design. Refer to the Member's specific certificate of coverage, contract and/or prescription drug
rider as applicable.
Mail Order Pharmacy: A network pharmacy contracted to provide up to a 90-day supply of
certain prescription medications (new or refill) by mail.
Specialty Pharmacy: A network pharmacy contracted to provide coverage for specialty
medications at an in network benefit level for members enrolled on NY and NJ LOBs.
Retail Pharmacy: A network non-mail order pharmacy contracted to provide prescription
medications (new or refill). Note: For members enrolled on NY LOBs new and renewing on or
after 01/12/12, if a retail pharmacy has contracted with the PBM, in advance, for the same rates
and terms and conditions as the mail order or specialty pharmacy, covered prescriptions will be
available at the same co-payment or other reimbursement level that would apply to the mail-order
or non-retail specialty pharmacies (should any of these pharmacies be available in the service
area).
REFERENCES
The foregoing Oxford policy has been adapted from an existing UnitedHealthcare Pharmacy
Clinical Pharmacy Program that was researched, developed and approved by the UnitedHealth
Group National Pharmacy & Therapeutics Committee.
1. Oxford Commercial Certificates of Coverage, Health Benefit Plans and Pharmacy Benefit
Riders.
2. Drug Facts and Comparisons. Lippincott Williams & Wilkins.
3. All applicable pharmaceutical manufacturer package inserts and prescribing information.
4. Connecticut Legislative Bulletin CT1117; Step Therapy for Pain Management.
POLICY HISTORY/REVISION INFORMATION
Date
•
12/01/2014
•
Action/Description
Revised conditions of coverage/exclusion language for NJ plan members
to indicate:
o This policy does not apply to New Jersey Commercial plans;
however, drugs included in this policy may still require
precertification through another policy (refer to the Member's
certificate of coverage and/or member specific benefit document for
additional information)
Revised list of medications requiring precertification through the
pharmacy benefit manager (PBM):
o Added Disalcid, Ferric Citrate tablet, Mitigare, Oxycodone ER 12HR
Tablet, Plegridy Pen & Prefilled Syringe, Provigil and Revatio
Drug Coverage Criteria - New and Therapeutic Equivalent Medications: Clinical Policy (Effective 12/01/2014)
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•
10mg/ml
o Removed Pertzye, Ultresa and Viokace
Archived previous policy version PHARMACY 179.64 T2
Drug Coverage Criteria - New and Therapeutic Equivalent Medications: Clinical Policy (Effective 12/01/2014)
©1996-2014, Oxford Health Plans, LLC
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