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Blue Rx Preferred Formulary EFFECTIVE 10/01/2016 INTRODUCTION The Blue Rx Preferred formulary is a list of drugs covered under your pharmacy benefit and developed to serve as a guide for physicians, pharmacists, healthcare professionals and members in the selection of cost-effective drug therapy. Wellmark recognizes that drug therapy is an integral part of effective health management. The vast availability of drug options, however, warrants a reasonable program for drug selection and use. Wellmark continually reviews new and existing drugs to ensure the formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or overthe-counter (OTC) agents while minimizing potential duplications. The formulary is a continually reviewed and modified document that represents covered drugs under your pharmacy benefit. This dynamic process does not allow this document to be completely accurate at all times. To accommodate regular changes, an updated electronic version of this formulary is available online at www.Wellmark.com. Wellmark welcomes your input and feedback on the information provided in this document. FORMULARY OVERVIEW The Blue Rx Preferred formulary is continually changing to reflect new advances in drug treatment therapies and current practices of Wellmark providers. Due to the rapidly changing environment, this process ensures appropriate formulary review and tier placement. To continue to provide Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 sustainable pharmacy benefits and access to needed cost-effective treatments, concentrated evaluation and analysis of drug products in formularies is accomplished through this process. Wellmark has developed the Pharmacy and Therapeutics Committee (P&T) to ensure all drugs in the Blue Rx Preferred formulary and new drugs approved by the United States Food and Drug Administration (FDA) are reviewed by licensed physicians actively practicing medicine in Iowa and South Dakota. In addition, the process allows P&T members the opportunity to receive evidence-based clinical data and make clinical recommendations for formulary placement and utilization management. The entire Wellmark formulary is reviewed annually by P&T including all new drugs approved by the FDA. The P&T includes licensed physicians and pharmacists. These clinicians serve in an evaluation, education and advisory capacity to the Wellmark Pharmacy program specific to the coverage and limitations of drugs on the Wellmark formularies. Through review and discussion, P&T votes whether the drug or drug class is therapeutically unique, similar or inferior to existing treatment options. In addition, the P&T makes utilization management recommendations to Wellmark for consideration when there are therapeutically interchangeable alternatives. The P&T meets quarterly to evaluate drugs requested for addition to the Wellmark formularies, reviews existing drugs in the Wellmark formularies and establishes recommendations for utilization management. HOW TO READ THE FORMULARY All drugs are listed by their generic names and/or most common proprietary (brand) name. Specific drug listings may be accessed either by generic (in lowercase) or brand name (in uppercase) and by therapeutic drug tier. Any drug not found in this formulary listing, or any formulary updates published by Wellmark, shall be considered excluded from your benefit. Once the product is located, the following items can be viewed: Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 2 Drug Tier: Drugs are categorized within tiers on the formulary. Each tier is assigned a cost, which is determined by the member's pharmacy benefit plan. Specialty Drugs (SP-P): Specialty drugs are high-cost injectable, infused, oral or inhaled drugs for the ongoing treatment of a chronic condition. These drugs generally require close supervision and monitoring of the patient's drug therapy. Specialty drugs may be categorized within tiers on the formulary or as drugs covered under your medical benefit. • Specialty Drugs Preferred (SP-P): Drugs in this category will process with the preferred specialty drug cost-share. • Specialty Drugs Non-Preferred (SP-NP): Drugs in this category will process with the non-preferred specialty cost-share, and will have a higher cost share than preferred specialty drugs. Specialty pharmacies specialize in the delivery and clinical management of specialty drugs. Wellmark has two preferred specialty pharmacy providers: Caremark Specialty Pharmacy and Hy-Vee Pharmacy Solutions. You can find more information about their services at www.Wellmark.com. Drug Name: This lists the generic name for the product (lowercase) OR the brand name or common reference name for the product (UPPERCASE). Requirements/Limits: This lists Wellmark Pharmacy programs that may impact a particular drug or class of drugs and are described below: • Prior Authorization (PA): This indicates a drug requires prior authorization before it is covered under your benefit. Your health care provider will need to contact our Pharmacy program at 1-800- Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 3 600-8065. Hours of operation are Monday - Friday: 8 a.m. to 6 p.m. CST Prior authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Wellmark. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. A list of edits recommended by Wellmark is available upon request. Members should call Wellmark Customer Service at the number listed on the back of their ID card if they have questions regarding their specific coverage. • Medical Necessity Prior Authorization (MN-PA): This indicates a drug requires prior authorization before it is covered under your benefit. Your health care provider will need to contact our Pharmacy program at 1-800-600-8065. Hours of operation are Monday Friday: 8 a.m. to 6 p.m. CST The intent of formulary medical necessity prior authorization is to confirm the appropriate coverage of the target drugs when evidence is provided documenting a trial and failure of the preferred formulary alternatives or a clinical reason such as expected adverse reaction or contraindication that prevents the patient from trying the formulary alternatives. These criteria apply to all medications subject to formulary medical necessity not otherwise managed through drug specific criteria. Members should call Wellmark Customer Service at the number listed on the back of their ID card if they have questions regarding their specific coverage. • Quantity Limits (QL): Wellmark typically covers a 30-day supply for prescriptions per co-pay. Some drugs, however, have a quantity limit. Amounts over the specified quantity limits are not a covered benefit. Quantity limits are in place to ensure the drug is being used correctly and other treatments are not appropriate. Most people would not need to take these drugs more often than what Wellmark allows. No special steps are necessary by the physician or member to have these drugs covered as long as the drugs prescribed do not exceed quantity limits. A few drugs may also require prior authorization Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 (for example, Viagra). If you require one of these drugs in a larger quantity than is allowed, your physician may make a special request for coverage. Your physician may be asked to provide details about your medical condition and treatment plan. After reviewing the information, coverage will be evaluated based on medical necessity. Your benefits certificate, coverage manual, or policy has specific information about your plan's prior authorization requirements. • Preventive Drugs (PV): Preventive drugs are defined by the Internal Revenue Service. Preventive drugs are prescribed to prevent the occurrence of a disease or condition with risk factors such as high blood pressure, high cholesterol, diabetes, asthma, heart attack and stroke, or to prevent the recurrence of the disease or condition for individuals who have recovered. Preventive drugs do not include drugs used to treat an existing illness, injury or condition. For some pharmacy plans that require you to pay a certain amount before the plan coverage begins, preventive drugs may be covered before you reach that amount. To be sure, you should read your enrollment information to see how preventive drugs are covered specific to your plan. • Generic Available (GA): Indicates a generic equivalent is available for a brand name drug. In most cases, when you purchase a brand name drug that has an FDA-approved "A"-rated generic equivalent, Wellmark will pay only what it would have paid for the equivalent generic drug. You will be responsible for your payment obligation for the equivalent generic drug and any remaining cost difference up to the maximum allowed fee for the brand name drug HEALTH CARE REFORM PREVENTIVE DRUGS Preventive drugs with an "A" or "B" rating in the current recommendations of the United States Preventive Services Task Force (USPSTF) and immunizations as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention are not associated with any cost share for members on plans with this benefit. Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 5 A complete list of recommendations and guidelines related to preventive services can be found at Healthcare.gov. Recommended preventive items and services are subject to change and are subject to medical management. BENEFIT COVERAGE AND LIMITATIONS This printed formulary does not define benefit coverage and limitations. Many members have specific benefit inclusions, exclusions, copayments or a lack of coverage, which are not reflected in the Blue Rx Essentials formulary. Members should contact their Plan Sponsor or Wellmark Customer Service at the number on the back of their ID card if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year. The following topics may or may not be applicable depending on the parameters of your specific benefits. FORMULARY EXCEPTION PROCESS Drugs not included in this list shall be considered non-formulary and are NOT COVERED. In some instances, Wellmark will consider coverage exceptions. Coverage of non-formulary drugs may be requested by the health professional through an exception request for a non-formulary prescription drug (outlined below). Generally, the following guidelines must be documented in order for an exception to be granted: • All covered formulary drugs on any tier will be ineffective; OR • All covered formulary drugs on any tier have been ineffective; OR • All covered formulary drugs on any tier would not be as effective as the non-formulary drug; OR • All covered formulary drugs would have adverse effects COMMON DRUG EXCLUSIONS Due to benefit design parameters, some plan sponsors may choose to exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded drugs may include, but are not limited to: Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 6 • OTC drugs or their equivalents unless otherwise specified in the formulary listing. • Drug products used for cosmetic purposes • Experimental drug products, or any drug product used in an experimental manner • Replacement of a lost or stolen drug • Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA) GENERIC DRUG SUBSTITUTION In most cases, Wellmark promotes the use of equally effective generic drugs whenever possible. If a member or physician requests a brandname product when the prescription is filled and a generic equivalent is available, the member will typically be required to pay the difference in cost between the brand and the generic drug. When a brand-name drug becomes available as a generic, the brandname product may move to a higher tier. Members may be required to pay more for a prescription when a higher-tier brand-name product is dispensed. Members will not be responsible for the cost difference between brands and generics when choosing one of the products listed below: Coumadin Stavzor Cytomel Synthroid Depakene Tegretol/Tegretol XR Depakote/Depakote ER Theophylline products Dilantin Thyrolar Equetro Tirosint Lanoxin Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 7 LEGEND GA PA PV QL SP-P SP-NP lowercase UPPERCASE Generic Available Prior Authorization Preventive Medication Quantity Limit Specialty Preferred Specialty Non-Preferred Indicates generic availability Indicates brand availability CONTACT INFORMATION The Blue Rx formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Wellmark encourages your input and feedback on how we can assist in improving this document and the formulary management process. Please direct your communications to: Wellmark Blue Cross and Blue Shield 1331 Grand Avenue P.O. Box 9232 Des Moines, IA 50306 In addition to the Blue Rx formulary, other quick-reference guides are available on our web site at Wellmark.com. Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 8 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits ANALGESICS COX-II INHIBITORS CELEBREX celecoxib 4 1 GA; QL QL GOUT allopurinol colchicine colchicine/probenecid COLCRYS MITIGARE probenecid ULORIC ZURAMPIC ZYLOPRIM 1 1 1 4 4 1 2 4 4 GA GA PA; QL PA GA NON-OPIOID ANALGESICS acetaminophen/salicylamide/phenyltoloxamine BUPAP butalbital/acetaminophen butalbital/acetaminophen/caffeine butalbital/aspirin/caffeine EQUAGESIC ESGIC FIORICET FIORINAL LEVACET VANATOL LQ 1 4 1 1 1 4 4 4 4 4 4 GA GA GA NSAIDS ANAPROX ANAPROX DS choline/magnesium trisalicylates DAYPRO diclofenac potassium diclofenac sodium delayed-rel rel diflunisal EC-NAPROSYN etodolac Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 GA 4 GA 1 4 GA 1 1 diclofenac sodium ext1 1 4 GA 1 9 Wellmark Blue Rx Preferred Formulary Drug Name etodolac ext-rel FELDENE fenoprofen flurbiprofen ibuprofen INDOCIN SUPP INDOCIN SUSP indomethacin indomethacin ext-rel ketoprofen ketoprofen ext-rel ketorolac meclofenamate sodium mefenamic acid meloxicam MOBIC nabumetone NALFON NAPRELAN 375MG, 500MG NAPRELAN 750MG NAPROSYN naproxen naproxen delayed-rel naproxen sodium naproxen sodium ext-rel oxaprozin piroxicam PONSTEL salsalate SPRIX sulindac TIVORBEX tolmetin sodium ZIPSOR Drug Tier 1 4 1 1 1 3 2 1 1 1 1 1 1 1 1 4 1 4 4 4 4 1 1 1 1 1 1 4 1 4 1 4 1 4 Requirements/ Limits GA GA GA GA GA NSAIDS, COMBINATIONS ARTHROTEC diclofenac/misoprostol 4 1 GA NSAIDS, TOPICAL diclofenac gel 1% diclofenac sodium soln Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 4 10 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier FLECTOR PENNSAID REXAPHENAC VOLTAREN GEL 4 4 4 4 Requirements/ Limits GA OPIOID ANALGESICS ABSTRAL ACTIQ alfentanil injection butalbital/acetaminophen/caffeine/codeine butalbital/aspirin/caffeine/codeine butorphanol nasal spray BUTRANS CAPITAL W/CODEINE codeine codeine/acetaminophen CONZIP DEMEROL dihydrocodeine/acetaminophen/caffeine dihydrocodeine/aspirin/caffeine DILAUDID DOLOPHINE DURAGESIC EMBEDA EXALGO fentanyl transdermal 12mcg, 25mcg, 50mcg, 75mcg, 100mcg FENTANYL TRANSDERMAL 37.5MCG, 62.5MCG, 87.5MCG fentanyl transmucosal lozenge FENTORA FIORICET W/CODEINE FIORINAL W/CODEINE HYCET hydrocodone/acetaminophen hydrocodone/ibuprofen hydromorphone hydromorphone ext-rel HYDROMORPHONE SUPP HYSINGLA ER KADIAN 10MG, 20MG, 30MG, 50MG, 60MG, Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 4 1 1 1 1 4 1 1 1 4 4 1 1 4 4 4 4 4 PA PA; GA GA GA GA; QL QL GA; QL 1 QL 1 1 4 4 4 4 1 1 1 1 1 4 QL PA PA GA GA GA QL QL GA GA QL QL 11 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier 80MG, 100MG KADIAN 40MG, 200MG LAZANDA levorphanol LORTAB ELIXIR meperidine methadone METHADOSE CONCENTRATE morphine morphine ext-rel morphine ext-rel beads morphine supp 5mg, 10mg, 20mg MORPHINE SUPP 30MG MS CONTIN NORCO NUCYNTA NUCYNTA ER OPANA OPANA ER OXAYDO oxycodone oxycodone ext-rel oxycodone/acetaminophen oxycodone/aspirin oxycodone/ibuprofen OXYCONTIN oxymorphone oxymorphone ext-rel pentazocine/naloxone PERCOCET PRIMLEV REPREXAIN ROXICET SOLN ROXICODONE SUBSYS tramadol tramadol ext-rel caps 100mg, 200mg, 300mg TRAMADOL EXT-REL CAPS 150MG tramadol ext-rel tabs tramadol/acetaminophen TREZIX Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 4 4 1 4 1 1 4 1 1 4 1 1 4 4 4 4 4 4 4 1 2 1 1 1 2 1 1 1 4 4 4 4 4 4 1 4 4 1 1 4 Requirements/ Limits GA; QL QL GA QL QL GA; QL GA QL GA QL QL QL QL GA GA GA GA PA GA 12 Wellmark Blue Rx Preferred Formulary Drug Name TYLENOL W/CODEINE ULTRACET ULTRAM ULTRAM ER VICOPROFEN XARTEMIS XR ZOHYDRO ER Drug Tier 4 4 4 4 4 4 4 Requirements/ Limits GA GA GA GA GA QL QL ANTI-INFECTIVES AMINOGLYCOSIDES neomycin paromomycin 1 1 ANTIBACTERIALS, CEPHALOSPORINS 1ST GEN cefadroxil cephalexin KEFLEX 1 1 4 GA ANTIBACTERIALS, CEPHALOSPORINS, 2ND GEN cefaclor CEFACLOR ER cefprozil CEFTIN CEFTIN SUSP cefuroxime axetil 1 3 1 4 4 1 GA ANTIBACTERIALS, CEPHALOSPORINS, 3RD GEN CEDAX CAPS CEDAX SUSP 90MG/5ML CEDAX SUSP 180MG/5ML cefdinir cefditoren cefixime cefpodoxime ceftibuten ceftriaxone SUPRAX SUPRAX SUSP SUPRAX SUSP 500MG/5ML Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 4 4 1 3 1 1 1 1 3 4 3 GA GA GA 13 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin BIAXIN clarithromycin clarithromycin ext-rel DIFICID e.e.s. 400 ERYPED 200 ERYPED 400 erythromycin base erythromycin delayed-rel erythromycin ethylsuccinate erythromycin stearate ZITHROMAX ZMAX SUSP 1 4 1 1 4 4 4 2 1 1 1 1 4 4 GA GA GA ANTIBACTERIALS, FLUOROQUINOLONES AVELOX CIPRO CIPRO XR ciprofloxacin ciprofloxacin ext-rel ciprofloxacin oral susp FACTIVE LEVAQUIN levofloxacin levofloxacin oral soln moxifloxacin ofloxacin 4 4 4 1 1 1 4 4 1 1 1 1 GA GA GA GA ANTIBACTERIALS, KETOLIDES KETEK 4 ANTIBACTERIALS, PENICILLINS amoxicillin amoxicillin/clavulanate amoxicillin/clavulanate ext-rel ampicillin AUGMENTIN AUGMENTIN SUSP AUGMENTIN SUSP 125MG/5ML Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 1 1 1 4 4 4 GA GA 14 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier AUGMENTIN XR dicloxacillin penicillin vk Requirements/ Limits 4 1 1 GA 4 4 1 1 GA GA 4 1 4 1 1 PA; GA ANTIBACTERIALS, SULFONAMIDES BACTRIM BACTRIM DS SULFADIAZINE sulfamethoxazole/trimethoprim ANTIBACTERIALS, TETRACYCLINES ADOXA demeclocycline DORYX doxycycline hyclate doxycycline hyclate delayed-rel doxycycline monohydrate caps 50mg, 75mg, 100mg doxycycline monohydrate caps 150mg doxycycline monohydrate susp doxycycline monohydrate tabs MINOCIN minocycline minocycline ext-rel MONODOX SOLODYN tetracycline VIBRAMYCIN CAPS, SUSP VIBRAMYCIN SYRUP 1 1 1 1 4 1 1 4 4 1 4 3 PA PA PA PA GA PA GA PA GA ANTIFUNGALS ANCOBON BIO-STATIN clotrimazole troche CRESEMBA DIFLUCAN fluconazole flucytosine GRIS-PEG griseofulvin microsize griseofulvin ultramicrosize itraconazole Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 4 1 4 4 1 1 4 1 1 1 GA GA GA PA 15 Wellmark Blue Rx Preferred Formulary Drug Name ketoconazole tabs LAMISIL NOXAFIL nystatin oral ONMEL ORAVIG SPORANOX SPORANOX SOLN terbinafine VFEND voriconazole Drug Tier Requirements/ Limits 1 4 4 1 4 4 4 3 1 4 1 GA PA PA; GA PA GA ANTIMALARIALS ARALEN atovaquone/proguanil chloroquine COARTEM DARAPRIM MALARONE mefloquine PRIMAQUINE QUALAQUIN quinine sulfate 4 1 1 4 2 4 1 1 4 1 GA PV PV GA PV PV GA ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS TYBOST 2 ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir/lamivudine/zidovudine ATRIPLA COMBIVIR COMPLERA DESCOVY EPZICOM EVOTAZ GENVOYA lamivudine/zidovudine ODEFSEY PREZCOBIX STRIBILD TRIUMEQ TRIZIVIR Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 2 4 2 2 3 3 2 1 2 3 2 2 4 GA GA 16 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier TRUVADA Requirements/ Limits 2 ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY 2 ANTIRETROVIRALS, FUSION INHIBITORS FUZEON SP-P ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS ISENTRESS POWDER TIVICAY VITEKTA 2 3 2 2 ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS APTIVUS SOLN CRIXIVAN INVIRASE KALETRA LEXIVA LEXIVA SUSP NORVIR NORVIR SOLN PREZISTA SUSP PREZISTA TABS REYATAZ REYATAZ POWDER VIRACEPT 2 3 2 2 2 2 3 2 3 3 2 2 3 2 ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS NON-NUCLEOSIDE EDURANT INTELENCE nevirapine nevirapine ext-rel RESCRIPTOR SUSTIVA VIRAMUNE VIRAMUNE XR Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 2 2 1 1 2 2 4 4 GA GA 17 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS NUCLEOSIDE abacavir didanosine EMTRIVA EPIVIR lamivudine soln, tabs RETROVIR stavudine VIDEX EC VIDEX SOLN ZERIT ZIAGEN ZIAGEN SOLN zidovudine 1 1 2 4 1 4 1 4 3 4 4 2 1 GA GA GA GA GA ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS NUCLEOTIDE VIREAD VIREAD POWDER 2 3 ANTITUBERCULAR AGENTS cycloserine ethambutol isoniazid PASER GRANULES PRIFTIN pyrazinamide RIFADIN rifampin RIFATER SIRTURO TRECATOR 1 1 1 1 3 1 4 1 4 4 3 GA ANTIVIRALS, CMV AGENTS VALCYTE VALCYTE SOLN valganciclovir valganciclovir soln Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 4 1 1 GA GA 18 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS B adefovir dipivoxil BARACLUDE SOLN BARACLUDE TABS entecavir EPIVIR HBV EPIVIR HBV SOLN lamivudine tabs TYZEKA 1 4 4 1 4 3 1 SP-P GA GA ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS C COPEGUS DAKLINZA HARVONI OLYSIO REBETOL CAPS REBETOL SOLN ribavirin SOVALDI TECHNIVIE VIEKIRA PAK VIEKIRA XR ZEPATIER 4 SP-NP SP-P SP-NP 4 4 1 SP-P SP-NP SP-NP SP-NP SP-NP GA PA; QL PA; QL PA; QL GA PA; PA; PA; PA; PA; QL QL QL QL QL ANTIVIRALS, HERPES AGENTS acyclovir famciclovir FAMVIR SITAVIG valacyclovir VALTREX ZOVIRAX 1 1 4 4 1 4 4 GA GA GA ANTIVIRALS, INFLUENZA AGENTS FLUMADINE RELENZA rimantadine TAMIFLU 4 2 1 2 GA MISCELLANEOUS ALBENZA Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 3 19 Wellmark Blue Rx Preferred Formulary Drug Name ALINIA atovaquone BILTRICIDE CLEOCIN clindamycin caps, oral soln dapsone FLAGYL FLAGYL ER FURADANTIN SUSP IMPAVIDO ivermectin linezolid MACROBID MACRODANTIN MEPRON SUSP metronidazole MONUROL MYCOBUTIN NEBUPENT nitrofurantoin PRIMSOL rifabutin SIVEXTRO STROMECTOL TINDAMAX tinidazole trimethoprim VANCOCIN vancomycin caps vancomycin inj 500mg, 1000mg VANCOMYCIN INJECTION 750MG XIFAXAN ZYVOX SUSP Drug Tier 3 1 3 4 1 1 4 4 4 3 1 1 4 4 4 1 2 4 3 1 3 1 3 4 4 1 1 4 1 1 1 2 4 Requirements/ Limits GA GA GA GA GA GA GA GA GA GA GA ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN CYCLOPHOSPHAMIDE CAPS EMCYT GLEOSTINE 5MG GLEOSTINE 10MG, 40MG, 100MG Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 2 1 SP-P 2 4 20 Wellmark Blue Rx Preferred Formulary Drug Name HEXALEN LEUKERAN MYLERAN TEMODAR temozolomide VALCHLOR Drug Tier Requirements/ Limits 2 2 2 SP-NP SP-P 2 GA ANTIMETABOLITES capecitabine mercaptopurine methotrexate TABLOID TREXALL XELODA SP-P 1 1 2 4 SP-NP GA HORMONAL ANTINEOPLASTICS, ANTIANDROGENS bicalutamide flutamide NILANDRON nilutamide XTANDI ZYTIGA 1 1 4 1 SP-P SP-P GA HORMONAL ANTINEOPLASTICS, ANTIESTROGENS FARESTON SOLTAMOX tamoxifen 2 2 1 PA; PV HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS anastrozole ARIMIDEX AROMASIN exemestane FEMARA letrozole 1 4 4 1 4 1 GA GA GA HORMONAL ANTINEOPLASTICS, PROGESTINS megestrol acetate 1 IMMUNOMODULATORS POMALYST REVLIMID Blue Rx Preferred Formulary ©2016 Wellmark, Inc. SP-P SP-P 21 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier THALOMID SP-P Requirements/ Limits KINASE INHIBITORS AFINITOR AFINITOR DISPERZ ALECENSA BOSULIF CABOMETYX CAPRELSA COMETRIQ COTELLIC GILOTRIF GLEEVEC IBRANCE ICLUSIG imatinib mesylate IMBRUVICA INLYTA JAKAFI LENVIMA MEKINIST NEXAVAR SPRYCEL STIVARGA SUTENT TAFINLAR TAGRISSO TARCEVA TASIGNA TYKERB VOTRIENT XALKORI ZELBORAF ZYDELIG ZYKADIA SP-P SP-P SP-P SP-P SP-P 2 2 SP-P 2 SP-NP SP-P SP-P SP-P SP-P SP-P SP-P 2 SP-P SP-P SP-P SP-P SP-P SP-P SP-P SP-P SP-P SP-P SP-P SP-P SP-P 2 SP-P QL GA QL MISCELLANEOUS bexarotene DROXIA ERIVEDGE etoposide FARYDAK Blue Rx Preferred Formulary ©2016 Wellmark, Inc. SP-P 3 2 SP-P SP-P 22 Wellmark Blue Rx Preferred Formulary Drug Name HYDREA hydroxyurea leucovorin LONSURF LYNPARZA LYSODREN MATULANE NINLARO ODOMZO TARGRETIN CAPS TARGRETIN GEL tretinoin caps VENCLEXTA VISTOGARD ZOLINZA Drug Tier Requirements/ Limits 4 1 1 SP-P 2 2 2 SP-P SP-P SP-NP SP-P 1 SP-P SP-P SP-P GA GA TOPOISOMERASE INHIBITORS HYCAMTIN SP-P CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/benazepril LOTREL PRESTALIA TARKA trandolapril/verapamil 1 4 4 4 1 PV GA 1 1 1 1 1 4 1 1 4 PV PV PV PV PV GA PV PV GA 4 4 GA GA GA PV ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/hydrochlorothiazide captopril/hydrochlorothiazide enalapril/hydrochlorothiazide fosinopril/hydrochlorothiazide lisinopril/hydrochlorothiazide LOTENSIN HCT moexipril/hydrochlorothiazide quinapril/hydrochlorothiazide ZESTORETIC ACE INHIBITORS ACCUPRIL ALTACE Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 23 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier benazepril captopril enalapril EPANED fosinopril lisinopril LOTENSIN MAVIK moexipril perindopril PRINIVIL QBRELIS SOLN quinapril ramipril trandolapril VASOTEC ZESTRIL Requirements/ Limits 1 1 1 4 1 1 4 4 1 1 4 4 1 1 1 4 4 PV PV PV PV PV PV GA GA 4 4 1 1 1 4 GA GA PV PV PV GA 4 1 1 GA 4 1 1 1 GA PV PV GA GA PV PV GA ADRENOLYTICS, CENTRAL CATAPRES CATAPRES-TTS clonidine clonidine transdermal guanfacine TENEX ALDOSTERONE RECEPTOR ANTAGONISTS ALDACTONE eplerenone spironolactone ALPHA BLOCKERS CARDURA doxazosin prazosin terazosin ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/valsartan AZOR Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 4 PV 24 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier EXFORGE telmisartan/amlodipine TWYNSTA Requirements/ Limits 4 1 4 GA PV GA ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS amlodipine/valsartan/hydrochlorothiazide EXFORGE HCT TRIBENZOR 1 4 4 PV GA ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC COMBINATIONS ATACAND HCT AVALIDE BENICAR HCT candesartan/hydrochlorothiazide DIOVAN HCT EDARBYCLOR HYZAAR irbesartan/hydrochlorothiazide losartan/hydrochlorothiazide MICARDIS HCT telmisartan/hydrochlorothiazide valsartan/hydrochlorothiazide 4 4 4 1 4 4 4 1 1 4 1 1 GA GA PV GA GA PV PV GA PV PV ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND AVAPRO BENICAR candesartan COZAAR DIOVAN EDARBI eprosartan irbesartan losartan MICARDIS telmisartan valsartan Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 4 4 1 4 4 4 1 1 1 4 1 1 GA GA PV GA GA PV PV PV GA PV PV 25 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits ANTIARRHYTHMICS amiodarone BETAPACE disopyramide dofetilide flecainide mexiletine MULTAQ NORPACE NORPACE CR propafenone propafenone ext-rel quinidine gluconate quinidine sulfate quinidine sulfate ext-rel RYTHMOL RYTHMOL SR sotalol sotalol af TIKOSYN 1 4 1 1 1 1 3 4 3 1 1 1 1 1 4 4 1 1 4 PV GA PV PV GA PV PV GA GA PV PV GA ANTILIPEMICS, BILE ACID RESINS cholestyramine powder cholestyramine powder light COLESTID colestipol QUESTRAN QUESTRAN LIGHT WELCHOL 1 1 4 1 4 4 4 PV PV GA PV GA GA ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ZETIA 2 PV 4 1 1 1 4 1 4 PV PV PV GA PV GA ANTILIPEMICS, FIBRATES ANTARA fenofibrate caps, tabs fenofibric acid fenofibric acid delayed-rel FENOGLIDE gemfibrozil LIPOFEN Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 26 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier LOFIBRA TRICOR TRIGLIDE TRILIPIX 4 4 4 4 Requirements/ Limits GA GA GA ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS ALTOPREV atorvastatin CRESTOR fluvastatin fluvastatin ext-rel LESCOL XL LIPITOR LIVALO lovastatin MEVACOR PRAVACHOL pravastatin rosuvastatin simvastatin VYTORIN ZOCOR 4 1 4 1 1 4 4 2 1 4 4 1 1 1 4 4 PV GA PV GA GA PV PV GA GA PV PV PV GA ANTILIPEMICS, MISCELLANEOUS JUXTAPID KYNAMRO SP-P SP-P PA; QL PA; QL ANTILIPEMICS, NIACINS/COMBINATIONS ADVICOR niacin niacin ext-rel NIASPAN SIMCOR 4 4 1 4 4 PV GA ANTILIPEMICS, PCSK9 INHIBITORS PRALUENT REPATHA SP-NP SP-P MN-PA; QL PA; QL BETA-BLOCKER/DIURETIC COMBINATIONS atenolol/chlorthalidone Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 PV 27 Wellmark Blue Rx Preferred Formulary Drug Name bisoprolol/hydrochlorothiazide CORZIDE DUTOPROL LOPRESSOR HCT metoprolol/hydrochlorothiazide nadolol/bendroflumethiazide propranolol/hydrochlorothiazide ZIAC Drug Tier Requirements/ Limits 1 4 4 4 1 1 1 4 PV GA GA PV PV PV GA BETA-BLOCKERS acebutolol atenolol betaxolol bisoprolol BYSTOLIC carvedilol COREG COREG CR CORGARD HEMANGEOL INDERAL LA labetalol LEVATOL LOPRESSOR metoprolol succinate ext-rel metoprolol tartrate nadolol pindolol propranolol propranolol ext-rel SECTRAL TENORMIN timolol TOPROL-XL TRANDATE 1 1 1 1 4 1 4 4 4 4 4 1 4 4 1 1 1 1 1 1 4 4 1 4 4 PV PV PV PV PV GA GA GA PV GA PV PV PV PV PV PV GA GA PV GA GA CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine/atorvastatin CADUET 1 4 PV GA CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES ADALAT CC Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 GA 28 Wellmark Blue Rx Preferred Formulary Drug Name amlodipine felodipine ext-rel isradipine nicardipine nifedipine nifedipine ext-rel nimodipine nisoldipine ext-rel NYMALIZE PROCARDIA PROCARDIA XL Drug Tier Requirements/ Limits 1 1 1 1 1 1 1 1 4 4 4 PV PV PV PV PV PV PV GA GA CALCIUM CHANNEL BLOCKERS, NON DIHYDROPYRIDINES CALAN CALAN SR CARDIZEM CARDIZEM CD CARDIZEM LA 120MG CARDIZEM LA 180MG, 240MG, 300MG, 360MG, 420MG diltiazem diltiazem ext-rel verapamil verapamil ext-rel VERELAN VERELAN PM 4 4 4 4 4 GA GA GA GA 4 1 1 1 1 4 4 GA PV PV PV PV GA GA 1 4 4 GA DIGITALIS GLYCOSIDES digoxin LANOXIN 62.5MCG, 187.5MCG LANOXIN 125MCG, 250MCG DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS TEKTURNA TEKTURNA HCT 4 4 DIURETICS ALDACTAZIDE 25/25 ALDACTAZIDE 50/50 amiloride amiloride/hydrochlorothiazide bumetanide Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 4 1 1 1 GA PV 29 Wellmark Blue Rx Preferred Formulary Drug Name chlorothiazide chlorthalidone DEMADEX DIURIL DYAZIDE DYRENIUM EDECRIN ethacrynic acid furosemide FUROSEMIDE SOLN 8 MG/ML furosemide soln 10mg/ml hydrochlorothiazide indapamide LASIX MAXZIDE methyclothiazide metolazone MICROZIDE spironolactone/hydrochlorothiazide torsemide triamterene/hydrochlorothiazide Drug Tier Requirements/ Limits 1 1 4 3 4 3 4 1 1 4 1 1 1 4 4 1 1 4 1 1 1 PV PV GA GA GA PV PV GA GA PV GA PV PV MISCELLANEOUS clonidine/chlorthalidone CORLANOR DEMSER DIBENZYLINE hydralazine isoxsuprine 10mg isoxsuprine 20mg methyldopa methyldopa/hydrochlorothiazide midodrine minoxidil phenoxybenzamine RANEXA reserpine 4 4 2 4 1 1 4 1 1 1 1 1 3 1 GA PV PV PV PV PV NEPRILYSIN INHIBITOR/ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS ENTRESTO Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 3 PA; QL 30 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits NITRATE/VASODILATOR COMBINATIONS BIDIL 4 NITRATES, ORAL DILATRATE SR ISORDIL 5MG ISORDIL 40MG isosorbide dinitrate isosorbide dinitrate ext-rel isosorbide mononitrate isosorbide mononitrate ext-rel nitroglycerin caps 4 4 4 1 1 1 1 1 GA PV PV PV PV PV NITRATES, SUBLINGUAL/TRANSLINGUAL nitroglycerin lingual aerosol nitroglycerin lingual spray nitroglycerin sublingual NITROLINGUAL SPRAY NITROMIST NITROSTAT 1 1 1 4 4 4 PV GA GA GA NITRATES, TRANSDERMAL NITRO-BID NITRO-DUR 0.1MG, 0.2MG, 0.4MG, 0.6MG NITRO-DUR 0.3MG, 0.8MG nitroglycerin transdermal 3 4 4 1 GA PV PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR ANTAGONIST LETAIRIS OPSUMIT TRACLEER SP-P SP-P SP-P PA; QL PA; QL PA; QL PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE INHIBITOR ADCIRCA REVATIO INJ REVATIO SUSP REVATIO TABS sildenafil Blue Rx Preferred Formulary ©2016 Wellmark, Inc. SP-P SP-NP SP-NP SP-NP SP-P PA; PA; GA; PA; PA; GA; PA; QL QL QL QL QL 31 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits PULMONARY ARTERIAL HYPERTENSION, PROSTACYCLIN RECEPTOR AGONIST UPTRAVI SP-P PA; QL PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN VASODILATORS ORENITRAM TYVASO VENTAVIS SP-P SP-P SP-P PA PA; QL PA; QL PULMONARY ARTERIAL HYPERTENSION, SOLUBLE GUANYLATE CYCLASE STIMULATORS ADEMPAS SP-P PA; QL CENTRAL NERVOUS SYSTEM ANTIANXIETY, BENZODIAZEPINES alprazolam alprazolam ext-rel ALPRAZOLAM INTENSOL ATIVAN chlordiazepoxide clonazepam clorazepate diazepam KLONOPIN lorazepam NIRAVAM oxazepam VALIUM XANAX XANAX XR 1 1 1 4 1 1 1 1 4 1 4 1 4 4 4 GA PV GA GA GA GA GA ANTIANXIETY, MISCELLANEOUS ANAFRANIL buspirone clomipramine fluvoxamine fluvoxamine ext-rel meprobamate Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 1 1 1 1 1 GA PV PV PA; PV 32 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits ANTICONVULSANTS APTIOM BANZEL BRIVIACT carbamazepine carbamazepine ext-rel CARBATROL CELONTIN DEPAKENE DEPAKOTE DEPAKOTE ER DIASTAT diazepam gel DILANTIN 30MG DILANTIN 100MG DILANTIN CHEW 50MG DILANTIN-125 SUSP divalproex sodium divalproex sodium delayed-rel divalproex sodium ext-rel ethosuximide felbamate FELBATOL FYCOMPA gabapentin GABITRIL 2MG, 4MG GABITRIL 12MG, 16MG KEPPRA KEPPRA XR LAMICTAL LAMICTAL CHEW 2MG LAMICTAL CHEW 5MG, 25MG LAMICTAL ODT LAMICTAL XR lamotrigine lamotrigine ext-rel levetiracetam MYSOLINE NEURONTIN ONFI oxcarbazepine Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 2 4 1 1 4 2 4 4 4 4 1 4 4 4 4 1 1 1 1 1 4 4 1 4 4 4 4 4 4 4 4 4 1 1 1 4 4 4 1 PA; PV; QL PV PV GA PV GA GA GA GA GA GA GA PV PV PV PV PV GA GA GA GA GA GA GA GA PV PV PV GA GA PA; QL PV 33 Wellmark Blue Rx Preferred Formulary Drug Name OXTELLAR XR PEGANONE phenobarbital PHENYTEK phenytoin phenytoin sodium extended POTIGA primidone QUDEXY XR SABRIL POWDER SABRIL TABS STAVZOR TEGRETOL TEGRETOL-XR 100MG, 200MG, 400MG tiagabine TOPAMAX TOPAMAX SPRINKLE topiramate TRILEPTAL TROKENDI XR valproic acid VIMPAT ZARONTIN ZONEGRAN zonisamide Drug Tier 4 2 1 4 1 1 4 1 4 SP-P SP-P 4 4 4 1 4 4 1 4 4 1 2 4 4 1 Requirements/ Limits PV PV GA PV PV PV GA PA; QL QL GA GA PV GA GA PV GA PV PV GA GA PV ANTIDEMENTIA ARICEPT donepezil EXELON galantamine galantamine ext-rel memantine NAMENDA NAMENDA XR rivastigmine rivastigmine transdermal 4 1 4 1 1 1 4 4 1 1 GA GA GA ANTIDEPRESSANTS, MAOIS EMSAM MARPLAN NARDIL Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 3 2 4 GA 34 Wellmark Blue Rx Preferred Formulary Drug Name PARNATE phenelzine tranylcypromine Drug Tier 4 1 1 Requirements/ Limits GA PV PV ANTIDEPRESSANTS, MISCELLANEOUS APLENZIN bupropion bupropion delayed-rel bupropion ext-rel (12hr) bupropion ext-rel (24hr) chlordiazepoxide/amitriptyline FORFIVO XL maprotiline mirtazapine nefazodone OLEPTRO REMERON trazodone WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL 4 1 1 1 1 1 4 1 1 1 4 4 1 4 4 4 PV PV PV PV PV PV PV GA PV GA GA GA ANTIDEPRESSANTS, SNRIS CYMBALTA DESVENLAFAXINE ER 50MG, 100MG desvenlafaxine ext-rel 50mg, 100mg duloxetine EFFEXOR XR FETZIMA IRENKA KHEDEZLA PRISTIQ 50MG, 100MG venlafaxine venlafaxine ext-rel 4 4 1 1 4 4 4 4 4 1 1 GA PA; QL PA; PV; QL PV GA PA; QL PA; GA; QL PA; QL PV PV 4 1 1 1 1 1 GA PV PV PV PV PV ANTIDEPRESSANTS, SSRIS CELEXA citalopram escitalopram fluoxetine FLUOXETINE 60MG fluoxetine delayed-rel Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 35 Wellmark Blue Rx Preferred Formulary Drug Name LEXAPRO paroxetine paroxetine ext-rel PAXIL PAXIL CR PAXIL SUSP PEXEVA PROZAC PROZAC WEEKLY SARAFEM sertraline TRINTELLIX VIIBRYD ZOLOFT Drug Tier 4 1 1 4 4 4 4 4 4 4 1 4 4 4 Requirements/ Limits GA PV PV GA GA PA GA GA PV PA PA GA ANTIDEPRESSANTS, TCAS amitriptyline amoxapine desipramine doxepin imipramine hcl imipramine pamoate nortriptyline PAMELOR protriptyline SURMONTIL 25MG, 50MG SURMONTIL 100MG TOFRANIL trimipramine 1 1 1 1 1 1 1 4 1 4 4 4 1 PV PV PV PV PV PV PV GA PV GA GA PV ANTIPARKINSONIAN AGENTS amantadine AZILECT benztropine bromocriptine carbidopa carbidopa/levodopa carbidopa/levodopa ext-rel carbidopa/levodopa/entacapone COMTAN ELDEPRYL entacapone Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 2 1 1 1 1 1 1 4 4 1 GA GA 36 Wellmark Blue Rx Preferred Formulary Drug Name LODOSYN MIRAPEX MIRAPEX ER NEUPRO PARLODEL pramipexole pramipexole ext-rel REQUIP REQUIP XL ropinirole ropinirole ext-rel selegiline SINEMET SINEMET CR STALEVO TASMAR tolcapone trihexyphenidyl ZELAPAR Drug Tier 4 4 4 4 4 1 1 4 4 1 1 1 4 4 4 4 1 1 4 Requirements/ Limits GA GA PA; GA GA PA GA PA; GA PA GA GA GA GA ANTIPSYCHOTICS, ATYPICALS ABILIFY ABILIFY DISCMELT aripiprazole aripiprazole odt aripiprazole soln clozapine CLOZARIL FANAPT FAZACLO GEODON INVEGA LATUDA loxapine olanzapine olanzapine/fluoxetine paliperidone ext-rel quetiapine REXULTI RISPERDAL RISPERDAL-M TAB Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 4 1 1 1 1 4 4 4 4 4 4 1 1 1 1 1 4 4 4 GA GA PV PV GA QL GA GA GA PV PV PV PA; QL GA GA 37 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier risperidone SAPHRIS SEROQUEL SEROQUEL XR SYMBYAX VERSACLOZ VRAYLAR ziprasidone ZYPREXA ZYPREXA ZYDIS 1 4 4 4 4 4 4 1 4 4 Requirements/ Limits PV GA GA PA; QL PV GA GA ANTIPSYCHOTICS, MISCELLANEOUS chlorpromazine fluphenazine haloperidol ORAP perphenazine perphenazine/amitriptyline pimozide thioridazine thiothixene trifluoperazine 1 1 1 4 1 1 1 1 1 1 PV PV PV GA PV PV PV PV ATTENTION DEFICIT HYPERACTIVITY DISORDER ADDERALL ADDERALL XR amphetamine/dextroamphetamine amphetamine/dextroamphetamine ext-rel APTENSIO XR clonidine ext-rel CONCERTA DAYTRANA DEXEDRINE CR dexmethylphenidate dexmethylphenidate ext-rel dextroamphetamine 2.5mg, 7.5mg, 15mg, 20mg, 30mg dextroamphetamine 5mg, 10mg dextroamphetamine ext-rel 5mg, 10mg, 15mg dextroamphetamine soln FOCALIN FOCALIN XR 5MG, 10MG, 15MG, 20MG, Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 4 1 1 4 1 4 4 4 1 1 4 1 1 1 4 GA PA; GA PA PA PA PA; GA PA; QL PA; GA PA PA GA 38 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier 30MG, 40MG FOCALIN XR 25MG, 35MG guanfacine ext-rel INTUNIV KAPVAY METADATE CD methamphetamine tabs 5mg METHYLIN CHEW 2.5MG, 5MG, 10MG METHYLIN SOLN methylphenidate chew 2.5mg, 5mg, 10mg METHYLPHENIDATE ER 20MG, 30MG, 40MG methylphenidate ext-rel 18mg, 27mg, 36mg, 54mg methylphenidate ext-rel caps 10mg, 20mg, 30mg, 40mg, 50mg, 60mg methylphenidate ext-rel caps 20mg, 30mg, 40mg methylphenidate ext-rel tabs 10mg, 20mg methylphenidate soln methylphenidate tabs 5mg, 10mg, 20mg PROCENTRA QUILLIVANT XR RITALIN RITALIN LA 10MG, 60MG RITALIN LA 20MG, 30MG, 40MG STRATTERA VYVANSE 4 4 1 4 4 4 1 4 4 1 4 Requirements/ Limits PA; GA PA GA; QL PA; GA PA; GA GA GA PA; GA 1 PA 1 PA 1 1 1 1 4 4 4 4 4 2 3 PA PA GA PA; QL GA PA PA; GA PA; QL PA FIBROMYALGIA LYRICA SAVELLA 3 4 HUNTINGTON'S DISEASE AGENTS tetrabenazine XENAZINE SP-P SP-NP QL GA; QL HYPNOTICS, TRICYCLICS SILENOR 4 PA HYPNOTICS: BENZODIAZEPINES estazolam flurazepam Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 1 39 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier HALCION temazepam triazolam 4 1 1 Requirements/ Limits GA HYPNOTICS: NON-BENZODIAZEPINES AMBIEN AMBIEN CR BELSOMRA BUTISOL SODIUM EDLUAR eszopiclone HETLIOZ INTERMEZZO LUNESTA ROZEREM SECONAL SONATA zaleplon zolpidem zolpidem ext-rel zolpidem sublingual ZOLPIMIST 4 4 4 3 4 1 SP-P 4 4 4 3 4 1 1 1 1 4 GA PA; GA PA; QL PA PA PA; QL PA; GA PA; GA PA GA PA PA PA MIGRAINE, ERGOTAMINE DERIVATIVES CAFERGOT D.H.E. dihydroergotamine inj dihydroergotamine nasal spray ERGOMAR migergot supp MIGRANAL 4 4 1 1 4 1 4 GA QL GA; QL MIGRAINE, MISCELLANEOUS isometheptene/caffeine/acetaminophen isometheptene/dichloralphenazone/ acetaminophen PRODRIN 1 1 4 GA MIGRAINE, SELECTIVE SEROTONIN AGONIST/NSAID TREXIMET Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 PA; QL 40 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits MIGRAINE, SELECTIVE SEROTONIN AGONISTS almotriptan ALSUMA AMERGE AXERT FROVA frovatriptan IMITREX MAXALT MAXALT-MLT naratriptan RELPAX rizatriptan sumatriptan SUMAVEL DOSEPRO zolmitriptan ZOMIG ZOMIG NASAL SPRAY ZOMIG ZMT 1 4 4 4 4 1 4 4 4 1 4 1 1 4 1 4 4 4 PA; GA; GA; PA; GA; PA; GA; GA; GA; PA; PA; GA; PA; GA; QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL MISCELLANEOUS ergoloid mesylates GUANIDINE RILUTEK riluzole 1 3 4 1 GA MOOD STABILIZERS EQUETRO LITHIUM lithium carbonate lithium carbonate ext-rel LITHOBID 4 3 1 1 4 GA SP-P SP-P SP-P SP-P SP-P SP-P SP-NP QL QL QL QL QL QL QL MULTIPLE SCLEROSIS AMPYRA AUBAGIO AVONEX AVONEX PEN AVONEX PREFILLED SYG BETASERON COPAXONE 20 MG Blue Rx Preferred Formulary ©2016 Wellmark, Inc. PA; PA; PA; PA; PA; PA; GA; 41 Wellmark Blue Rx Preferred Formulary Drug Name COPAXONE 40 MG EXTAVIA GILENYA glatopa 20 mg PLEGRIDY REBIF TECFIDERA Drug Tier SP-NP SP-P SP-P SP-P SP-P SP-P SP-P Requirements/ Limits PA; PA; PA; PA; PA; PA; PA; QL QL QL QL QL QL QL MUSCULOSKELETAL THERAPY AGENTS AMRIX baclofen carisoprodol carisoprodol/aspirin carisoprodol/aspirin/codeine chlorzoxazone cyclobenzaprine DANTRIUM dantrolene FEXMID LORZONE metaxalone methocarbamol orphenadrine ext-rel orphenadrine/aspirin/caffeine PARAFON FORTE DSC ROBAXIN ROBAXIN-750 SKELAXIN SOMA tizanidine ZANAFLEX 4 1 1 1 1 1 1 4 1 4 4 1 1 1 1 4 4 4 4 4 1 4 GA GA GA GA GA GA GA GA MYASTHENIA GRAVIS MESTINON MESTINON SYRUP MESTINON TIMESPAN pyridostigmine pyridostigmine ext-rel 4 4 4 1 1 GA 1 1 PA; QL PA; QL GA NARCOLEPSY/CATAPLEXY armodafinil modafinil Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 42 Wellmark Blue Rx Preferred Formulary Drug Name NUVIGIL PROVIGIL XYREM Drug Tier Requirements/ Limits 4 4 2 PA; GA; QL PA; GA; QL PA; QL PSYCHOTHERAPEUTIC-MISC, ALCOHOL DETERRENTS acamprosate calcium ANTABUSE disulfiram 1 4 1 PV GA PV PSYCHOTHERAPEUTIC-MISC, OPIOID ANTAGONIST naltrexone 1 PV PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONIST/OPIOID ANTAGONIST COMBINATIONS buprenorphine/naloxone sublingual SUBOXONE ZUBSOLV 1 4 4 PV PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONISTS buprenorphine sublingual 1 PV PSYCHOTHERAPEUTIC-MISC, PSEUDOBULBAR AFFECT NUEDEXTA 4 PSYCHOTHERAPEUTIC-MISC, SMOKING DETERRENTS bupropion ext-rel CHANTIX NICOTROL INHALER NICOTROL NS ZYBAN 1 3 3 3 4 GA ENDOCRINE AND METABOLIC ANDROGENS ANADROL-50 ANDRODERM ANDROGEL 1% (25MG PAK) ANDROGEL 1% (50MG PAK) ANDROGEL 1% PUMP ANDROGEL 1.62% ANDROXY AXIRON Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 2 4 4 4 4 2 3 4 PA PA; GA PA PA; GA PA PA 43 Wellmark Blue Rx Preferred Formulary Drug Name DEPO-TESTOSTERONE 100MG/ML DEPO-TESTOSTERONE 200MG/ML FORTESTA OXANDRIN oxandrolone STRIANT TESTIM testosterone cypionate testosterone enanthate testosterone gel 1% testosterone gel 10mg/act VOGELXO Drug Tier Requirements/ Limits 4 4 4 4 1 4 4 1 1 2 2 4 GA GA PA; GA GA PA PA; GA PA PA PA; GA ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITOR acarbose GLYSET 1 4 PV 2 PV ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS glipizide/metformin GLUCOVANCE glyburide/metformin 1 4 1 PV GA PV 4 4 4 1 1 2 GA GA GA PV PV ANTIDIABETICS, BIGUANIDES FORTAMET GLUCOPHAGE GLUCOPHAGE XR metformin metformin ext-rel RIOMET ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR/BIGUANIDE COMBINATIONS JANUMET JANUMET XR JENTADUETO JENTADUETO XR KAZANO KOMBIGLYZE XR Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 2 2 2 2 4 4 PV PV PV PV MN-PA MN-PA 44 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR/INSULIN SENSITIZER COMBINATIONS OSENI 4 MN-PA ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA NESINA ONGLYZA TRADJENTA 2 4 4 2 PV MN-PA MN-PA PV ANTIDIABETICS, INCRETIN MIMETIC AGENTS BYDUREON BYETTA TANZEUM TRULICITY VICTOZA 2 3 4 4 2 PV; QL QL MN-PA; QL MN-PA; QL PV; QL ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION ACTOPLUS MET ACTOPLUS MET XR pioglitazone/metformin 4 4 1 GA PV ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBO pioglitazone/glimepiride 1 PV 4 4 1 GA 4 4 4 4 4 4 4 2 2 PA; QL MN-PA MN-PA MN-PA MN-PA MN-PA MN-PA PV PV ANTIDIABETICS, INSULIN SENSITIZERS ACTOS AVANDIA pioglitazone PV ANTIDIABETICS, INSULINS AFREZZA APIDRA HUMALOG HUMALOG MIX HUMULIN 70/30 HUMULIN N HUMULIN R HUMULIN R U-500 LANTUS Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 45 Wellmark Blue Rx Preferred Formulary Drug Name LEVEMIR NOVOLIN 70/30 NOVOLIN 70/30 RELION NOVOLIN N NOVOLIN N RELION NOVOLIN R NOVOLIN R RELION NOVOLOG NOVOLOG MIX Drug Tier Requirements/ Limits 2 2 2 2 2 2 2 2 2 PV PV PV PV PV PV PV PV PV 1 4 1 4 PV GA PV GA ANTIDIABETICS, MEGLITINIDE nateglinide PRANDIN repaglinide STARLIX ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATIONS repaglinide/metformin 1 ANTIDIABETICS, MISCELLANEOUS CYCLOSET 4 ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR/BIGUANIDE COMBINATIONS INVOKAMET INVOKAMET XR SYNJARDY XIGDUO XR 4 4 4 4 ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA INVOKANA JARDIANCE 4 3 4 ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR/DPP-4 INHIBITOR COMBINATIONS GLYXAMBI 4 ANTIDIABETICS, SULFONYLUREAS AMARYL Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 GA 46 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier chlorpropamide glimepiride glipizide glipizide ext-rel GLUCOTROL GLUCOTROL XL glyburide glyburide micronized tolazamide tolbutamide Requirements/ Limits 1 1 1 1 4 4 1 1 1 1 PV PV PV PV GA GA PV PV PV PV 3 MN-PA; QL 3 3 2 3 3 MN-PA; QL MN-PA; QL PV MN-PA; QL MN-PA; QL 3 3 2 2 2 2 MN-PA; QL MN-PA; QL PV PV; QL PV; QL PV 3 3 3 3 2 MN-PA; MN-PA; MN-PA; MN-PA; ANTIDIABETICS, SUPPLIES ACCU-CHEK BLOOD GLUCOSE TEST STRIPS ALL NON-PREFERRED BLOOD GLUCOSE TEST STRIPS ASCENSIA BLOOD GLUCOSE TEST STRIPS BLOOD KETONE TEST STRIPS BREEZE 2 BLOOD GLUCOSE TEST STRIPS CONTOUR BLOOD GLUCOSE TEST STRIPS CONTOUR NEXT BLOOD GLUCOSE TEST STRIPS FREESTYLE BLOOD GLUCOSE TEST STRIPS INSULIN SYRINGES LANCETS ONETOUCH BLOOD GLUCOSE TEST STRIPS PEN NEEDLES PRECISION XTRA BLOOD GLUCOSE TEST STRIPS SURE-TEST BLOOD GLUCOSE TEST STRIPS TRUETEST BLOOD GLUCOSE TEST STRIPS TRUETRACK BLOOD GLUCOSE TEST STRIPS URINE TEST STRIPS QL QL QL QL PV CALCIUM RECEPTOR ANTAGONISTS SENSIPAR SP-P CALCIUM REGULATORS, BISPHOSPHONATES ACTONEL alendronate 5mg, 10mg, 35mg, 70mg alendronate 40mg alendronate soln ATELVIA Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 1 1 4 4 GA PV GA 47 Wellmark Blue Rx Preferred Formulary Drug Name BONIVA TABS etidronate FOSAMAX FOSAMAX PLUS D ibandronate risedronate risedronate delayed-rel Drug Tier Requirements/ Limits 4 1 4 4 1 1 1 GA 1 4 4 PV GA PV PV PV CALCIUM REGULATORS, CALCITONINS calcitonin nasal spray FORTICAL MIACALCIN GA CALCIUM REGULATORS, PARATHYROID HORMONES FORTEO SP-P CONTRACEPTIVES, BIPHASIC azurette desogestrel/ethinyl estradiol kariva kimidess MIRCETTE NECON 10/11 pimtrea viorele 1 1 1 1 4 4 1 1 PV PV PV PV GA PV PV CONTRACEPTIVES, CONTINUOUS amethyst levonorgestrel/ethinyl estradiol 1 1 CONTRACEPTIVES, EMERGENCY CONTRACEPTION ELLA 4 CONTRACEPTIVES, EXTENDED CYCLE amethia amethia lo ashlyna camrese camrese lo daysee introvale jolessa Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 1 1 1 1 1 1 1 48 Wellmark Blue Rx Preferred Formulary Drug Name levonorgestrel/ethinyl estradiol LOSEASONIQUE QUARTETTE quasense SEASONIQUE setlakin Drug Tier 1 4 4 1 4 1 Requirements/ Limits GA GA CONTRACEPTIVES, FOUR PHASE NATAZIA 4 CONTRACEPTIVES, INJECTABLE DEPO-PROVERA DEPO-SUBQ PROVERA 104 medroxyprogesterone acetate 150mg/ml 4 4 1 GA CONTRACEPTIVES, MONOPHASIC altavera alyacen apri aubra aviane balziva BEYAZ BREVICON briellyn chateal cryselle cyclafem cyred dasetta delyla DESOGEN desogestrel/ethinyl estradiol drospirenone/ethinyl estradiol elinest emoquette enskyce estarylla FALESSA falmina FEMCON FE GENERESS FE Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 1 1 1 1 1 4 4 1 1 1 1 1 1 1 4 1 1 1 1 1 1 4 1 4 4 PV GA PV GA PV PV PV GA GA 49 Wellmark Blue Rx Preferred Formulary Drug Name gianvi gildagia gildess gildess fe gildess fe 24 juleber junel junel fe junel fe 24 kelnor kurvelo larin larin fe larin fe 24 layolis fe chew lessina levonorgestrel/ethinyl estradiol levora LO LOESTRIN LOESTRIN LOESTRIN FE lomedia fe 24 loryna low-ogestrel lutera marlissa microgestin microgestin fe microgestin fe 24 MINASTRIN FE 24 MODICON mono-linyah mononessa necon necon nikki norethindrone/ethinyl estradiol norethindrone/ethinyl estradiol fe norethindrone/ethinyl estradiol fe norethindrone/ethinyl estradiol fe chew norgestimate/ethinyl estradiol Blue Rx Preferred Formulary ©2016 Wellmark, Inc. Drug Tier 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 4 4 4 1 1 1 1 1 1 1 1 4 4 1 1 1 4 1 1 1 1 1 1 Requirements/ Limits PV PV PV PV PV PV PV GA GA PV PV GA PV PV 50 Wellmark Blue Rx Preferred Formulary Drug Name NORINYL nortrel ocella ogestrel orsythia ORTHO-CYCLEN ORTHO-NOVUM OVCON-35 philith pirmella portia previfem reclipsen SAFYRAL sprintec sronyx syeda tarina fe vestura vyfemla wera wymzya fe chew YASMIN YAZ zarah zenchent zenchent fe chew zovia Drug Tier 4 1 1 1 1 4 4 4 1 1 1 1 1 4 1 1 1 1 1 1 1 1 4 4 1 1 1 1 Requirements/ Limits GA GA GA GA PV PV PV GA GA PV CONTRACEPTIVES, PROGESTIN ONLY camila deblitane errin heather jencycla jolivette lyza NOR-QD nora-be norethindrone norlyroc Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 1 1 1 1 1 1 4 1 1 1 GA 51 Wellmark Blue Rx Preferred Formulary Drug Name ORTHO MICRONOR sharobel Drug Tier 4 1 Requirements/ Limits GA CONTRACEPTIVES, TRANSDERMAL xulane 1 CONTRACEPTIVES, TRIPHASIC alyacen aranelle caziant cyclafem CYCLESSA dasetta enpresse ESTROSTEP FE leena levonorgestrel/ethinyl estradiol myzilra necon norgestimate/ethinyl estradiol nortrel ORTHO TRI-CYCLEN ORTHO TRI-CYCLEN LO ORTHO-NOVUM 7/7/7 pirmella tilia fe tri-estaryll tri-legest fe tri-linyah tri-lo-sprintec TRI-NORINYL tri-previfem tri-sprintec trinessa trivora velivet 1 1 1 1 4 1 1 4 1 1 1 1 1 1 4 4 4 1 1 1 1 1 1 4 1 1 1 1 1 PV GA GA GA GA GA PV PV GA PV CONTRACEPTIVES, VAGINAL NUVARING 3 ENDOMETRIOSIS danazol Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 52 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits ESTROGEN/PROGESTIN, ORAL ACTIVELLA ANGELIQ estradiol/norethindrone ethinyl estradiol/norethindrone FEMHRT LOW DOSE JEVANTIQUE LO jinteli lopreeza mimvey mimvey lo PREFEST PREMPHASE PREMPRO 4 4 1 1 4 4 1 1 1 1 4 2 2 GA GA GA ESTROGEN/PROGESTIN, TRANSDERMAL CLIMARA PRO COMBIPATCH 3 3 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS DUAVEE 4 ESTROGENS, ORAL covaryx covaryx hs eemt eemt hs ENJUVIA esterified estrogens/methyltestosterone ESTRACE estradiol estropipate MENEST PREMARIN 1 1 1 1 4 1 4 1 1 4 2 GA ESTROGENS, TRANSDERMAL CLIMARA DIVIGEL ELESTRIN estradiol transdermal twice weekly Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 4 4 1 GA QL 53 Wellmark Blue Rx Preferred Formulary Drug Name estradiol transdermal weekly ESTROGEL EVAMIST MENOSTAR MINIVELLE VIVELLE-DOT Drug Tier 1 4 4 4 4 4 Requirements/ Limits QL GA; QL ESTROGENS, VAGINAL ESTRACE CREAM ESTRING FEMRING PREMARIN CREAM VAGIFEM 2 3 4 2 3 GLUCOCORTICOIDS CORTEF cortisone dexamethasone DEXAMETHASONE INTENSOL dexamethasone oral soln 0.5mg/5ml DEXPAK FLO-PRED fludrocortisone hydrocortisone KENALOG INJ MEDROL MEDROL 2MG methylprednisolone MILLIPRED ORAPRED ODT PEDIAPRED prednisolone sodium phosphate odt, soln prednisolone syrup prednisone PREDNISONE INTENSOL RAYOS VERIPRED 4 4 1 1 1 4 4 1 1 4 4 4 1 4 4 4 1 1 1 1 4 4 GA GA GA GA GLUCOSE ELEVATING AGENT GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 2 2 54 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits HUMAN GROWTH HORMONES GENOTROPIN HUMATROPE NORDITROPIN NUTROPIN AQ OMNITROPE SAIZEN SEROSTIM ZOMACTON ZORBTIVE SP-NP SP-NP SP-P SP-NP SP-NP SP-NP SP-NP SP-NP SP-NP PA PA PA PA PA PA PA PA PA HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol caps calcitriol soln doxercalciferol HECTOROL paricalcitol ROCALTROL ZEMPLAR 1 4 1 4 1 4 4 GA GA GA INSULIN-LIKE GROWTH FACTOR INCRELEX SP-P LYSOSOMAL STORAGE DISORDERS CERDELGA ZAVESCA SP-P SP-P MISCELLANEOUS cabergoline CARBAGLU CARNITOR CYSTADANE KORLYM levocarnitine methylergonovine octreotide ORFADIN ORFADIN SUSP RAVICTI SANDOSTATIN SOMAVERT Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 4 4 4 2 1 1 SP-P 3 3 SP-P SP-NP SP-P GA GA 55 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier STRENSIQ SYPRINE SP-P 3 Requirements/ Limits PHENYLKETONURIA TREATMENT AGENTS KUVAN SP-P PA PHOSPHATE BINDER AGENTS calcium acetate ELIPHOS FOSRENOL PHOSLO PHOSLYRA RENAGEL RENVELA VELPHORO 1 4 3 4 4 4 3 4 GA GA PROGESTINS, INJECTABLE progesterone 50mg/ml 1 PROGESTINS, ORAL AYGESTIN medroxyprogesterone acetate MEGACE ES megestrol susp norethindrone acetate progesterone micronized PROMETRIUM PROVERA 4 1 4 1 1 1 4 4 GA GA GA GA PROGESTINS, VAGINAL CRINONE GEL 4% 3 SELECTIVE ESTROGEN RECEPTOR MODULATOR EVISTA OSPHENA raloxifene 4 4 1 PA; GA PA; PV THYROID AGENTS, ANTITHYROID AGENTS iodine soln strong (lugol's) methimazole propylthiouracil SSKI Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 1 1 4 56 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits THYROID SUPPLEMENTS ARMOUR THYROID 15MG, 120MG, 180MG, 240MG, 300MG ARMOUR THYROID 30MG, 60MG, 90MG CYTOMEL levothyroxine levoxyl liothyronine NATURE THROID SYNTHROID thyroid tab THYROLAR TIROSINT unithroid WESTHROID WP THYROID 4 4 4 1 1 1 4 2 1 4 4 1 4 4 GA GA GA VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA 3 QL 4 1 4 GA VASOPRESSINS DDAVP desmopressin STIMATE GASTROINTESTINAL ANTIDIARRHEALS diphenoxylate/atropine LOMOTIL MOTOFEN opium tincture 1 4 4 1 GA ANTIEMETICS AKYNZEO ANZEMET CESAMET COMPAZINE dronabinol EMEND granisetron Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 2 2 4 1 2 1 GA 57 Wellmark Blue Rx Preferred Formulary Drug Name MARINOL metoclopramide METOZOLV ODT ondansetron ondansetron soln prochlorperazine prochlorperazine supp promethazine promethazine supp REGLAN SANCUSO TIGAN TRANSDERM-SCOP trimethobenzamide VARUBI ZOFRAN ZOFRAN SOLN ZUPLENZ Drug Tier 4 1 4 1 1 1 1 1 1 4 4 4 4 1 4 4 4 4 Requirements/ Limits GA GA QL GA PA; QL GA QL GA GA; QL ANTISPASMODICS ANASPAZ BELLADONNA/OPIUM SUPP BENTYL CANTIL chlordiazepoxide/clidinium CUVPOSA dicyclomine DONNATAL GASTRINEX NF glycopyrrolate hyoscyamine sulfate hyoscyamine sulfate ext-rel LEVBID LEVSIN LIBRAX methscopolamine propantheline ROBINUL ROBINUL FORTE SYMAX DUOTAB Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 1 4 2 1 3 1 4 4 1 1 1 4 4 4 1 1 4 4 4 GA GA GA GA GA GA GA 58 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits CHOLELITHOLYTICS ACTIGALL CHENODAL URSO 250 URSO FORTE ursodiol 4 2 4 4 1 GA GA GA H2-RECEPTOR ANTAGONISTS cimetidine famotidine nizatidine PEPCID ranitidine ZANTAC 1 1 1 4 1 4 GA GA INFLAMMATORY BOWEL DISEASE, ORAL AGENTS APRISO ASACOL HD AZULFIDINE AZULFIDINE EN-TABS balsalazide budesonide caps COLAZAL DELZICOL DIPENTUM ENTOCORT EC GIAZO LIALDA mesalamine delayed-rel PENTASA sulfasalazine sulfasalazine delayed-rel UCERIS 4 4 4 4 1 1 4 4 2 4 4 4 1 3 1 1 4 GA GA GA GA GA INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS CANASA CORTIFOAM hydrocortisone enema mesalamine enema SFROWASA UCERIS FOAM Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 2 4 1 1 4 4 59 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits IRRITABLE BOWEL SYNDROME WITH CONSTIPATION AMITIZA LINZESS 3 4 IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron LOTRONEX VIBERZI 1 4 4 GA LAXATIVES/STOOL SOFTENERS CASCARA SAGRADA COLYTE/FLAVOR PACKS GOLYTELY GOLYTELY KRISTALOSE lactulose MOVIPREP NULYTELY OSMOPREP peg 3350/electrolytes PREPOPIK SUPREP 2 4 4 4 1 1 2 4 2 1 4 2 GA GA PV GA PV PV PV MISCELLANEOUS BUPHENYL BUPHENYL POWDER CARAFATE CARAFATE SUSP cromolyn sodium 100mg/5ml ENTEREG GASTROCROM lactulose (encephalopathy) RECTIV SUCRAID sucralfate 4 4 4 4 1 3 4 1 4 2 1 GA GA GA OPIOID-INDUCED CONSTIPATION MOVANTIK RELISTOR Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 3 PA PA; QL 60 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits PANCREATIC ENZYMES CREON PANCREAZE PERTZYE VIOKACE ZENPEP ZENPEP 5000 UNIT 2 2 2 2 2 4 PROSTAGLANDINS CYTOTEC misoprostol 4 1 GA PROTON PUMP INHIBITORS (PPI) ACIPHEX ACIPHEX SPRINKLE DEXILANT esomeprazole lansoprazole NEXIUM NEXIUM GRANULES omeprazole pantoprazole PREVACID PREVACID SOLUTAB PRILOSEC PRILOSEC POWDER PROTONIX PROTONIX PAK rabeprazole 4 4 4 1 1 4 4 1 1 4 4 4 4 4 4 1 GA; PA; PA; PA; PA; GA; PA; GA; PA; GA; PA; GA; PA; QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL SALIVA STIMULANTS cevimeline EVOXAC pilocarpine SALAGEN 1 4 1 4 GA GA STEROIDS, RECTAL ANALPRAM-HC CREAM ANALPRAM-HC LOTION ANUSOL-HC EPIFOAM Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 4 4 3 GA GA 61 Wellmark Blue Rx Preferred Formulary Drug Name hydrocortisone acetate supp hydrocortisone cream hydrocortisone/pramoxine lidazone lidocaine/hydrocortisone LIDOCAINE/HYDROCORTISONE GEL PROCORT PROCTOCORT PROCTOFOAM HC Drug Tier Requirements/ Limits 1 1 1 1 1 1 3 4 3 GA ULCER THERAPY COMBINATION lansoprazole/amoxicillin/clarithromycin OMECLAMOX-PAK PREVPAC PYLERA 1 4 4 4 GA GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin AVODART CARDURA XL dutasteride dutasteride/tamsulosin finasteride FLOMAX JALYN PROSCAR RAPAFLO tamsulosin UROXATRAL 1 4 4 1 1 1 4 4 4 4 1 4 GA GA GA GA QL GA ERECTILE DYSFUNCTION, ALPROSTADIL AGENTS CAVERJECT EDEX MUSE 4 4 4 QL QL QL ERECTILE DYSFUNCTION, PHOSPHODIESTERASE INHIBITORS CIALIS LEVITRA STAXYN STENDRA Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 4 4 4 PA; PA; PA; PA; QL QL QL QL 62 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier VIAGRA 2 Requirements/ Limits PA; QL MISCELLANEOUS bethanechol CYSTAGON ELMIRON LITHOSTAT methenamine hippurate methenamine mandelate methenamine/hyoscyamine/methylene blue/ phenyl salicylate/benzoic acid methenamine/hyoscyamine/methylene blue/ phenyl salicylate/sodium bisphosphonate methenamine/hyoscyamine/methylene blue/ phenyl salicylate/sodium phosphate methenamine/hyoscyamine/methylene blue/ sodium phosphate ORACIT phenazopyridine potassium citrate potassium citrate/citric acid potassium citrate/sodium citrate/citric acid PROCYSBI PYRIDIUM RIMSO-50 SHOHLS SOLN MODIFIED sodium citrate/citric acid THIOLA UROCIT-K UROGESIC-BLUE UROQID #2 1 2 3 3 1 1 1 1 1 1 4 1 1 1 1 4 4 4 4 1 2 4 4 2 GA GA GA GA URINARY ANTISPASMODICS darifenacin ext-rel DETROL DETROL LA DITROPAN XL ENABLEX flavoxate GELNIQUE MYRBETRIQ oxybutynin Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 4 4 4 4 1 4 4 1 GA GA GA GA 63 Wellmark Blue Rx Preferred Formulary Drug Name oxybutynin ext-rel tolterodine tolterodine ext-rel TOVIAZ trospium trospium ext-rel VESICARE Drug Tier 1 1 1 4 1 1 4 Requirements/ Limits QL VAGINAL ANTI-INFECTIVES AVC CLEOCIN CREAM CLEOCIN SUPP clindamycin cream CLINDESSE GYNAZOLE-1 METROGEL-VAGINAL metronidazole gel 0.75% NUVESSA TERAZOL 3 TERAZOL 7 terconazole cream 0.4% terconazole cream 0.8% terconazole supp 4 4 3 1 4 4 4 1 4 4 4 1 1 1 GA GA GA GA PV HEMATOLOGIC ANTICOAGULANTS, INJECTABLE ARIXTRA enoxaparin fondaparinux FRAGMIN LOVENOX 4 1 1 2 4 GA 2 2 2 4 1 2 GA; PV PV PV MN-PA PV PV GA ANTICOAGULANTS, ORAL COUMADIN ELIQUIS PRADAXA SAVAYSA warfarin XARELTO Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 64 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits HEMATOPOIETIC GROWTH FACTORS ARANESP EPOGEN GRANIX LEUKINE NEULASTA NEUPOGEN PROCRIT ZARXIO SP-P SP-P SP-P SP-P SP-P SP-P SP-P SP-P HEMOSTATICS, SYSTEMIC AMICAR LYSTEDA tranexamic acid 4 4 1 GA SP-P PA HEREDITARY ANGIOEDEMA AGENTS FIRAZYR IDIOPATHIC THROMBOCYTOPENIC PURPURA PROMACTA SP-P PA; QL MISCELLANEOUS CHEMET cilostazol EXJADE FERRIPROX pentoxifylline 2 1 2 4 1 PLATELET AGGREGATION INHIBITORS AGGRENOX aspirin/dipyridamole ext-rel BRILINTA clopidogrel dipyridamole EFFIENT PLAVIX 4 1 3 1 1 3 4 GA PV PV GA PLATELET SYNTHESIS INHIBITORS anagrelide 1 IMMUNOLOGIC AGENTS Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 65 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits ALLERGENIC EXTRACTS GRASTEK ORALAIR RAGWITEK 4 4 4 PA; QL PA; QL PA; QL BIOLOGIC DISEASE-MODIFYING AGENTS ACTEMRA CIMZIA ENBREL HUMIRA KINERET ORENCIA SIMPONI SP-P SP-NP SP-P SP-P SP-P SP-P SP-NP PA; PA; PA; PA; PA; PA; PA; QL QL QL QL QL QL QL DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS) ARAVA DEPEN hydroxychloroquine leflunomide PLAQUENIL RHEUMATREX RIDAURA XELJANZ 4 2 1 1 4 2 2 SP-P GA GA PA; QL IMMUNOMODULATORS, INTERFERONS ACTIMMUNE PEGASYS PEGINTRON SYLATRON SP-P SP-P SP-P SP-P PA; QL PA; QL SP-P PA; QL IMMUNOMODULATORS, MISCELLANEOUS OTEZLA IMMUNOSUPPRESSANTS, ANTIMETABOLITES AZASAN azathioprine CELLCEPT IMURAN mycophenolate mofetil mycophenolate sodium delayed-rel MYFORTIC Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 1 2 4 1 1 4 GA GA PV PV GA 66 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS ASTAGRAF XL cyclosporine cyclosporine modified NEORAL PROGRAF SANDIMMUNE SANDIMMUNE SOLN tacrolimus 2 1 1 3 3 3 3 1 PV PV PV GA GA GA PV IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE RAPAMUNE SOLN RAPAMUNE TABS sirolimus ZORTRESS 2 4 1 SP-P PV GA PV 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV VACCINES ACTHIB ADACEL AFLURIA BEXSERO BOOSTRIX CERVARIX DAPTACEL DIPHTHERIA/TETANUS TOXOID ENGERIX-B FLUARIX FLUBLOK FLUCELVAX FLULAVAL FLUVIRIN FLUZONE GARDASIL HAVRIX HIBERIX INFANRIX IPOL INACTIVATED IPV KINRIX M-M-R II MENACTRA MENHIBRIX Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 67 Wellmark Blue Rx Preferred Formulary Drug Name MENOMUNE MENVEO PEDIARIX PEDVAX HIB PENTACEL PNEUMOVAX 23 PREVNAR 13 PROQUAD QUADRACEL RECOMBIVAX HB ROTARIX ROTATEQ TENIVAC TRUMENBA TWINRIX VAQTA VARIVAX ZOSTAVAX Drug Tier Requirements/ Limits 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV 2 2 2 2 2 2 PV PV PV PV PV PV MISCELLANEOUS DIAGNOSTIC PRODUCTS CHEMSTRIP COMBISTIX HEMA-COMBISTIX LABSTIX MULTISTIX URISTIX NUTRITIONAL / SUPPLEMENTS ELECTROLYTES, MISCELLANEOUS K-PHOS K-PHOS NEUTRAL K-PHOS NO 2 potassium/sodium phosphates 3 4 4 1 GA ELECTROLYTES, POTASSIUM EFFER-K K-TAB KLOR-CON M15 KLOR-CON/25 Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 4 1 4 GA 68 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier MICRO-K potassium potassium potassium potassium potassium 4 1 1 1 1 1 bicarbonate effervescent bicarbonate/chloride effervescent chloride ext-rel chloride powder chloride soln Requirements/ Limits GA ELECTROLYTES, POTASSIUM-REMOVING AGENTS sodium polystyrene sulfonate susp VELTASSA 1 SP-P VITAMINS AND MINERALS, FOLIC ACID / COMBINATIONS folic acid 1 VITAMINS AND MINERALS, MISCELLANEOUS ergocalciferol 50,000 IU MAGNEBIND 400 MEPHYTON 1 4 2 VITAMINS AND MINERALS, PRENATAL VITAMINS ACTIVE OB ATABEX EC BAL-CARE DHA C-NATE DHA CALCIUM PNV CITRANATAL CO-NATAL FA COMPLETE NATAL DHA COMPLETENATE CONCEPT DOTHELLE DHA DUET DHA elite-ob ENBRACE HR EXTRA-VIRT PLUS DHA FOCALGIN FOLCAL DHA FOLCAPS OMEGA 3 FOLET folinatal plus b FOLIVANE-OB HEMENATAL Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV 69 Wellmark Blue Rx Preferred Formulary Drug Name inatal advance inatal gt inatal ultra INFANATE BALANCE LEVOMEFOLATE DHA MACNATAL CN DHA MARNATAL-F multinatal plus MYNATAL MYNATE 90 PLUS NATACHEW NATALVIT NATELLE ONE NEEVO DHA NESTABS NEWGEN NEXA PLUS O-CAL PRENATAL OB COMPLETE OB COMPLETE GOLD OBSTETRIX PAIRE OB PNV OB+DHA PNV TABS 29-1 pnv-dha PNV-DHA+DOCUSATE PNV-OMEGA pnv-select PNV-TOTAL PNV-VP-U PR NATAL PREFERAOB PRENA1 PRENAISSANCE PRENATA prenatabs fa prenatabs rx PRENATAL PRENATAL 19 CHEW PRENATAL 19 TABS PRENATAL VITAMINS/FERROUS FUMARATE/ Blue Rx Preferred Formulary ©2016 Wellmark, Inc. Drug Tier 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Requirements/ Limits PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV 70 Wellmark Blue Rx Preferred Formulary Drug Name DOCUSATE PRENATE PREQUE 10 PRETAB PROVIDA PUREFE OB PLUS R-NATAL OB REDICHEW RX RELNATE DHA RULAVITE DHA SE-NATAL 19 SE-TAN DHA SELECT-OB TARON-BC TARON-C DHA TARON-PREX THRIVITE TL FOLATE TL-CARE DHA TL-SELECT TRI-TABS DHA triadvance TRICARE TRINATAL trinate TRISTART DHA TRIVEEN-DUO DHA TRIVEEN-PRX ULTIMATECARE ultra tabs VEMAVITE VENA-BAL DHA VINACAL B VINATE VIRT NATE VIRT-ADVANCE VIRT-C DHA VIRT-CARE ONE VIRT-PN VIRT-SELECT VIRT-VITE GT Blue Rx Preferred Formulary ©2016 Wellmark, Inc. Drug Tier 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Requirements/ Limits PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV PV 71 Wellmark Blue Rx Preferred Formulary Drug Name VIRTPREX VITA-PREN VITAFOL VITAMEDMD VITAPEARL VITATRUE VIVA DHA VOL-NATE VOL-TAB RX VP-CH VP-GGR-B6 PRENATAL VP-HEME VP-PNV-DHA ZATEAN Drug Tier Requirements/ Limits 2 2 2 2 2 2 2 2 2 2 2 2 2 2 PV PV PV PV PV PV PV PV PV PV PV PV PV PV 3 3 2 2 GA RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS ADRENACLICK epinephrine inj EPIPEN EPIPEN JR ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA COMBIVENT RESPIMAT ipratropium/albuterol nebulizer soln STIOLTO RESPIMAT 4 2 1 4 ANTICHOLINERGICS ATROVENT HFA ipratropium nebulizer soln SPIRIVA HANDIHALER SPIRIVA RESPIMAT TUDORZA PRESSAIR 2 1 2 3 4 ANTIHISTAMINE/DECONGESTANT COMBINATIONS CLARINEX-D 12 HOUR DECON-A promethazine/phenylephrine RELHIST RESCON-MX Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 4 1 4 4 72 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier SEMPREX-D 4 Requirements/ Limits ANTIHISTAMINES, LOW-SEDATING levocetirizine XYZAL 1 4 GA ANTIHISTAMINES, NONSEDATING CLARINEX CLARINEX SYRUP desloratadine 4 4 1 GA ANTIHISTAMINES, SEDATING brompheniramine carbinoxamine clemastine cyproheptadine hydroxyzine hcl hydroxyzine pamoate KARBINAL ER RESPA-BR VISTARIL 1 1 1 1 1 1 4 3 4 GA ANTITUSSIVE COMBINATIONS, NON-OPIOID CARBAPHEN DECON-G dextromethorphan/brompheniramine/ pseudoephedrine dextromethorphan/brompheniramine/ pseudoephedrine dextromethorphan/chlorpheniramine/ phenylephrine dextromethorphan/guaifenesin/phenylephrine EXACTUSS GILTUSS giltuss pediatric NEOTUSS PLUS NORTUSS-EX PEDIATEX TDM promethazine/dextromethorphan TGQ DM/BPM/PSE TGQ DM/CPM/PE TGQ DM/GFN/PSE Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 4 1 4 4 1 3 3 1 4 4 4 1 4 4 4 GA GA 73 Wellmark Blue Rx Preferred Formulary Drug Name TUSNEL Drug Tier Requirements/ Limits 4 ANTITUSSIVE COMBINATIONS, OPIOID FLOWTUSS GILTUSS PED-C HYCOFENIX hydrocodone polistirex/chlorpheniramine hydrocodone/chlorpheniramine/ pseudoephedrine hydrocodone/homatropine OBREDON promethazine/codeine promethazine/phenylephrine/codeine REZIRA SUTTAR-2 SUTTAR-SF TUSSICAPS TUSSIONEX TUZISTRA XR VITUZ ZUTRIPRO 4 4 4 1 1 1 4 1 1 4 4 4 4 4 4 4 4 GA GA GA GA ANTITUSSIVES benzonatate TESSALON PERLES ZONATUSS 1 4 4 GA GA BETA AGONISTS, INHALANTS, LONG ACTING ARCAPTA NEOHALER BROVANA FORADIL AEROLIZER PERFOROMIST SEREVENT DISKUS STRIVERDI RESPIMAT 4 2 2 2 2 3 PV PV PV PV BETA AGONISTS, INHALANTS, SHORT ACTING albuterol nebulizer soln levalbuterol nebulizer soln metaproterenol PROAIR HFA PROAIR RESPICLICK PROVENTIL HFA Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 1 1 1 1 2 74 Wellmark Blue Rx Preferred Formulary Drug Name VENTOLIN HFA XOPENEX HFA XOPENEX NEBULIZER Drug Tier Requirements/ Limits 2 4 4 MN-PA GA 1 1 1 4 GA BETA AGONISTS, ORAL AGENTS albuterol albuterol ext-rel terbutaline VOSPIRE ER CYSTIC FIBROSIS CAYSTON KALYDECO ORKAMBI PULMOZYME TOBI NEBULIZER tobramycin nebulizer soln 3 SP-P SP-P SP-P SP-NP SP-P PA; QL PA; QL GA DECONGESTANT/EXPECTORANT COMBINATIONS phenylephrine/guaifenesin 1 LEUKOTRIENE MODIFIERS ACCOLATE montelukast SINGULAIR zafirlukast ZYFLO ZYFLO CR 4 1 4 1 4 4 GA PV GA PV 1 PV MAST CELL STABILIZERS cromolyn sodium nebulizer soln MISCELLANEOUS acetylcysteine ATROVENT NASAL caffeine citrate dyphylline-guaifenesin HYPERSAL 3.5% HYPERSAL 7% ipratropium nasal spray NEBUSAL sodium chloride nebulizer soln Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 4 1 1 4 4 1 4 1 GA GA 75 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier XOLAIR SP-P Requirements/ Limits PA; QL NASAL ANTIHISTAMINE/STEROID COMBINATIONS DYMISTA 4 PA 4 1 1 4 GA 4 1 1 4 4 4 4 4 PA NASAL ANTIHISTAMINES ASTEPRO azelastine spray olopatadine spray PATANASE GA NASAL STEROIDS BECONASE AQ flunisolide spray mometasone spray NASONEX OMNARIS QNASL VERAMYST ZETONNA PA PA; GA PA PA PA PA PHOSPHODIESTERASE-4 INHIBITORS DALIRESP 4 PULMONARY FIBROSIS AGENTS ESBRIET OFEV SP-P SP-P PA; QL PA; QL 4 4 1 1 4 4 4 4 1 MN-PA MN-PA PV PV MN-PA MN-PA GA MN-PA PV 2 2 PV PV STEROID INHALANTS AEROSPAN ALVESCO ASMANEX budesonide nebulizer susp FLOVENT DISKUS FLOVENT HFA PULMICORT PULMICORT FLEXHALER QVAR STEROID/BETA AGONIST COMBINATIONS ADVAIR DISKUS ADVAIR HFA Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 76 Wellmark Blue Rx Preferred Formulary Drug Name BREO ELLIPTA DULERA SYMBICORT Drug Tier 4 2 4 Requirements/ Limits PA PV MN-PA TOPICAL DECONGESTANTS ADRENALIN TYZINE 3 4 XANTHINES ELIXOPHYLLIN LUFYLLIN THEO-24 theophylline ext-rel theophylline soln 4 3 1 1 1 TOPICAL DERMATOLOGY, ACNE: ORAL claravis myorisan zenatane 1 1 1 DERMATOLOGY, ACNE: TOPICAL ACANYA ACZONE adapalene ATRALIN AVAR AVAR LS AVAR LS CLEANSER AVAR-E LS AZELEX BENZACLIN BENZACLIN PUMP BENZAMYCIN BENZAMYCIN PAK BENZEFOAM BENZIQ benzoyl peroxide BPO CLEOCIN-T CLINDAGEL Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 4 1 4 4 4 4 4 4 4 4 4 4 4 4 1 1 4 4 PA; GA GA GA GA GA GA GA 77 Wellmark Blue Rx Preferred Formulary Drug Name clindamycin clindamycin/benzoyl peroxide clindamycin/tretinoin DIFFERIN DUAC GEL EPIDUO ERYGEL erythromycin gel, pads, soln erythromycin/benzoyl peroxide EVOCLIN KLARON NUOX PLEXION CLEANSER, CREAM, LOTION PLEXION PADS RETIN-A RIAX ROSULA sulfacetamide lotion sulfacetamide/sulfur SULFOAM SUMADAN WASH SUMAXIN TAZORAC TRETIN-X tretinoin VANOXIDE-HC VELTIN ZACLIR ZIANA Drug Tier 1 1 1 4 4 4 4 1 1 4 4 4 4 4 4 4 4 1 1 4 4 4 4 4 1 4 4 4 4 Requirements/ Limits PA GA GA GA GA GA GA PA; GA GA GA PA PA PA; GA DERMATOLOGY, ACTINIC KERATOSIS CARAC diclofenac gel 3% EFUDEX FLUOROPLEX fluorouracil cream 0.5% fluorouracil cream, drop, soln 5% fluorouracil drop, soln 2% LEVULAN KERASTICK METVIXIA PICATO Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 1 4 3 1 1 1 3 3 4 PA; GA PA GA PA PA PA 78 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier SOLARAZE ZYCLARA 4 4 Requirements/ Limits PA; GA PA DERMATOLOGY, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS CORTISPORIN CREAM 0.5% CORTISPORIN OINT 1% NEO-SYNALAR 4 4 4 DERMATOLOGY, ANTIBIOTICS ALTABAX BACTROBAN BACTROBAN NASAL CENTANY gentamicin mupirocin SILVADENE silver sulfadiazine 4 4 4 4 1 1 4 1 GA GA DERMATOLOGY, ANTIFUNGALS ciclopirox clotrimazole/betamethasone econazole ECOZA ERTACZO EXELDERM EXTINA HALOTIN ketoconazole LOPROX SHAMPOO LOTRISONE LUZU naftifine cream NAFTIN CREAM NAFTIN GEL NIZORAL nystatin topical nystatin/triamcinolone oxiconazole cream OXISTAT CREAM OXISTAT LOTION Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 1 1 4 4 4 4 1 1 4 4 4 1 4 4 4 1 1 1 4 4 GA GA GA GA GA GA 79 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier PENLAC VUSION 4 4 Requirements/ Limits GA DERMATOLOGY, ANTIPSORIATICS, INJECTABLE COSENTYX COSENTYX PEN SP-P SP-P PA; QL PA; QL DERMATOLOGY, ANTIPSORIATICS, ORAL acitretin methoxsalen 8-MOP OXSORALEN-ULTRA SORIATANE 1 1 4 4 4 GA GA DERMATOLOGY, ANTIPSORIATICS, TOPICAL calcipotriene calcitriol oint DOVONEX DRITHO-CREME HP SORILUX TACLONEX OINT TACLONEX SUSP VECTICAL ZITHRANOL ZITHRANOL-RR 1 1 4 4 4 4 4 4 4 4 GA GA GA DERMATOLOGY, ANTISEBORRHEICS OVACE PLUS CREAM, FOAM, LOTION OVACE PLUS SHAMPOO, WASH OVACE WASH selenium sulfide SELRX sulfacetamide gel, shampoo, wash 4 4 4 1 4 1 GA GA DERMATOLOGY, ANTISEPTICS/DISINFECTANTS triple dye soln 4 DERMATOLOGY, CORTICOSTEROID COMBINATIONS PRAMOSONE PRAMOSONE PRAMOSONE PRAMOSONE CREAM 1-1% CREAM 1-2.5% E LOTION Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 4 4 1 GA 80 Wellmark Blue Rx Preferred Formulary Drug Name PRAMOSONE OINT pramoxine/hydrocortisone 1-2.5% Drug Tier Requirements/ Limits 4 1 DERMATOLOGY, CORTICOSTEROIDS: HIGH POTENCY amcinonide cream, lotion 0.1% AMCINONIDE OINT 0.1% APEXICON E betamethasone dipropionate augmented cream, lotion 0.05% betamethasone dipropionate cream, lotion, oint 0.05% desoximetasone cream, oint 0.25% desoximetasone gel 0.05% diflorasone DIPROLENE DIPROLENE AF fluocinonide cream 0.1% fluocinonide cream, gel, oint, soln 0.05% fluocinonide-e cream 0.05% HALOG TOPICORT CREAM, OINT 0.25% TOPICORT GEL 0.05% TOPICORT SPRAY 0.25% triamcinolone cream, oint 0.5% VANOS 1 1 4 1 1 1 1 1 4 4 1 1 1 4 4 4 4 1 4 GA GA GA GA GA DERMATOLOGY, CORTICOSTEROIDS: LOW POTENCY ALA SCALP alclometasone CAPEX DERMA-SMOOTHE/FS BODY, SCALP DESONATE desonide cream, lotion, oint 0.05% DESOWEN CREAM, LOTION, OINT 0.05% fluocinolone acetonide cream, soln 0.01% fluocinolone acetonide oil body, scalp hydrocortisone cream, lotion, oint 2.5% hydrocortisone lotion 2% NUCORT SYNALAR TEXACORT VERDESO Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 1 4 4 4 1 4 1 1 1 1 3 4 4 4 GA GA GA GA 81 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits DERMATOLOGY, CORTICOSTEROIDS: MEDIUM POTENCY betamethasone valerate cream, lotion, oint 0.1% betamethasone valerate foam clocortolone cream 0.1% CLODERM CORDRAN CREAM, LOTION, OINT 0.05% CORDRAN TAPE CUTIVATE CREAM, LOTION 0.05% desoximetasone cream, oint 0.05% ELOCON CREAM, LOTION, OINT 0.1% fluocinolone acetonide cream, oint 0.025% fluticasone cream, lotion 0.05% fluticasone oint 0.005% hydrocortisone butyrate cream, oint, soln 0.1% hydrocortisone valerate cream, oint 0.2% KENALOG SPRAY LOCOID CREAM, OINT, SOLN 0.1% LOCOID LIPOCREAM 0.1% LOCOID LOTION 0.1% LUXIQ mometasone cream, oint, soln 0.1% PANDEL prednicarbate cream, oint 0.1% SYNALAR CREAM, OINT 0.025% TOPICORT CREAM, OINT 0.05% triamcinolone cream 0.1% triamcinolone cream, lotion, oint 0.1% triamcinolone cream, lotion, oint 0.025% triamcinolone spray TRIANEX 1 1 4 4 4 4 4 1 4 1 1 1 1 1 4 4 4 4 4 1 4 1 4 4 1 1 1 1 3 GA GA GA GA GA GA GA GA GA DERMATOLOGY, CORTICOSTEROIDS: VERY HIGH POTENCY betamethasone dipropionate augmented gel, oint 0.05% clobetasol cream, gel, lotion, oint, shampoo, soln, spray 0.05% clobetasol emollient cream 0.05% clobetasol foam CLOBEX LOTION, SHAMPOO, SPRAY 0.05% diflorasone oint 0.05% Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 1 1 1 4 1 GA 82 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier DIPROLENE OINT 0.05% halobetasol cream, oint 0.05% OLUX OLUX-E TEMOVATE CREAM, GEL, OINT, SOLN 0.05% TEMOVATE E CREAM 0.05% ULTRAVATE CREAM, OINT 0.05% ULTRAVATE LOTION 0.05% 4 1 4 4 4 4 4 4 Requirements/ Limits GA GA GA GA GA GA DERMATOLOGY, EMOLLIENTS CEM-UREA GORDONS UREA HYDRO 40 FOAM KERAFOAM KERALAC LATRIX XM RYNODERM UMECTA UMECTA NAIL FILM UMECTA PD URAMAXIN URAMAXIN FOAM urea cream urea emulsion urea foam urea gel urea lotion UREA NAIL urea nail gel 45% urea nail susp urea susp UTOPIC 4 4 4 4 4 4 4 4 4 4 4 3 1 1 1 1 1 4 1 1 1 4 GA GA GA GA DERMATOLOGY, IMMUNOMODULATORS ELIDEL PROTOPIC tacrolimus oint 4 4 1 GA DERMATOLOGY, LOCAL ANALGESIC lidocaine pad 5% LIDODERM Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 4 GA 83 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits DERMATOLOGY, LOCAL ANESTHETICS EMLA lidocaine oint 5% lidocaine soln 4% lidocaine/prilocaine 4 1 1 1 GA DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir oint ALDARA ARZOL SILVER NITRATE APPLICATORS CONDYLOX GEL CONDYLOX SOLN DENAVIR doxepin cream 5% imiquimod PANRETIN PODOCON 25 podofilox soln 0.5% PRUDOXIN CREAM 5% SALICYLIC ACID 26% salicylic acid soln 27.5% SANTYL silver nitrate applicators SILVER NITRATE OINT, SOLN 10% SILVER NITRATE SOLN 0.5%, 25%, 50% SULFAMYLON CREAM SULFAMYLON PAK TRI-CHLOR VEREGEN VIRASAL XERESE ZONALON CREAM 5% ZOVIRAX CREAM ZOVIRAX OINT 1 4 4 4 4 4 1 1 3 1 1 4 1 1 3 1 1 1 3 4 1 3 4 4 4 4 4 GA GA PA GA GA GA PA GA GA GA DERMATOLOGY, ROSACEA DOXYCYCLINE DELAYED-REL 40MG FINACEA METROCREAM METROGEL METROLOTION Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 4 4 4 4 PA GA GA GA 84 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier metronidazole cream, gel, lotion 0.75% metronidazole gel 1% MIRVASO NORITATE ORACEA Requirements/ Limits 1 1 4 4 4 PA DERMATOLOGY, SCABICIDES AND PEDICULICIDES ELIMITE EURAX lindane malathion NATROBA OVIDE permethrin SKLICE spinosad ULESFIA 4 3 1 1 4 4 1 4 4 3 GA GA GA DERMATOLOGY, WOUND CARE PRODUCTS REGRANEX 3 MOUTH/THROAT/DENTAL AGENTS, MISCELLANEOUS ARESTIN chlorhexidine gluconate DEBACTEROL PERIDEX triamcinolone dental paste viscous lidocaine 2 1 3 4 1 1 GA OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS BLEPHAMIDE BLEPHAMIDE S.O.P. MAXITROL neomycin/polymyxin b/bacitracin/ hydrocortisone neomycin/polymyxin b/dexamethasone neomycin/polymyxin b/hydrocortisone PRED-G PRED-G S.O.P sulfacetamide/prednisolone Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 3 3 4 GA 1 1 1 3 3 1 85 Wellmark Blue Rx Preferred Formulary Drug Name TOBRADEX OINT TOBRADEX ST TOBRADEX SUSP tobramycin/dexamethasone ZYLET Drug Tier Requirements/ Limits 3 4 4 1 3 GA OPHTHALMIC, ANTI-INFECTIVES AZASITE bacitracin bacitracin/polymyxin b BESIVANCE BETADINE OPHTHALMIC PREP BLEPH-10 CILOXAN OINT CILOXAN SOLN ciprofloxacin ophth erythromycin oint GARAMYCIN gatifloxacin gentamicin ophth levofloxacin soln MOXEZA neomycin/bacitracin/polymyxin b neomycin/polymyxin b/gramicidin OCUFLOX ofloxacin ophth polymyxin b/trimethoprim POLYTRIM sulfacetamide ophth tobramycin soln TOBREX OINT TOBREX SOLN VIGAMOX ZYMAXID 3 1 1 3 3 4 3 4 1 1 4 1 1 1 3 1 1 4 1 1 4 1 1 3 4 3 4 GA GA GA GA GA GA GA OPHTHALMIC, ANTI-INFLAMMATORY: NONSTEROIDAL ACULAR ACULAR LS ACUVAIL bromfenac diclofenac flurbiprofen soln Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 4 4 3 1 1 1 GA GA 86 Wellmark Blue Rx Preferred Formulary Drug Name ILEVRO ketorolac soln NEVANAC PROLENSA Drug Tier Requirements/ Limits 4 1 4 4 OPHTHALMIC, ANTI-INFLAMMATORY: STEROIDAL ALREX dexamethasone soln DUREZOL FLAREX fluorometholone FML FORTE FML LIQUIFILM FML OINT LOTEMAX MAXIDEX OMNIPRED PRED FORTE PRED MILD prednisolone acetate 1% PREDNISOLONE PHOSPHATE 1% VEXOL 3 1 3 3 1 4 4 3 3 3 3 3 3 1 1 3 GA GA GA OPHTHALMIC, ANTIALLERGICS ALOCRIL ALOMIDE azelastine BEPREVE cromolyn sodium ELESTAT EMADINE epinastine LASTACAFT olopatadine PATADAY PATANOL PAZEO 3 3 1 3 1 4 3 1 4 1 4 4 4 GA GA OPHTHALMIC, ANTIFUNGALS NATACYN Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 3 87 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits OPHTHALMIC, ANTIVIRAL trifluridine VIROPTIC ZIRGAN 1 4 4 GA OPHTHALMIC, BETA-BLOCKERS: NONSELECTIVE BETIMOL carteolol ISTALOL levobunolol metipranolol timolol gel soln timolol soln TIMOPTIC 0.25%, 0.5% TIMOPTIC OCUDOSE 0.25%, 0.5% TIMOPTIC-XE 2 1 3 1 1 1 1 4 4 4 GA GA OPHTHALMIC, BETA-BLOCKERS: SELECTIVE betaxolol soln BETOPTIC-S 1 2 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/BETA-BLOCKER COMBINATIONS COSOPT COSOPT PF dorzolamide/timolol 4 4 1 GA OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/SYMPATHOMIMETIC COMBINATIONS SIMBRINZA 4 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: ORAL acetazolamide acetazolamide ext-rel DIAMOX SEQUELS methazolamide 1 1 4 1 GA OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: TOPICAL AZOPT dorzolamide TRUSOPT Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 3 1 4 GA 88 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits OPHTHALMIC, IMMUNOMODULATOR RESTASIS 3 OPHTHALMIC, LOCAL ANESTHETIC AKTEN 3 OPHTHALMIC, MISCELLANEOUS CYSTARAN LACRISERT naphazoline phenylephrine proparacaine tetracaine 2 3 1 1 1 1 OPHTHALMIC, MYDRIATICS ATROPINE OINT atropine soln CYCLOGYL 0.5%, 1%, 2% CYCLOMYDRIL cyclopentolate homatropine ISOPTO HOMATROPINE 2% ISOPTO HOMATROPINE 5% ISOPTO HYOSCINE tropicamide 1 1 4 4 1 1 4 4 4 1 GA GA OPHTHALMIC, PARASYMPATHOMIMETICS ISOPTO CARBACHOL MIOCHOL-E pilocarpine soln 4 4 1 OPHTHALMIC, PROSTAGLANDINS bimatoprost latanoprost LUMIGAN TRAVATAN Z travoprost XALATAN ZIOPTAN Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 1 2 4 4 4 4 GA 89 Wellmark Blue Rx Preferred Formulary Drug Name Drug Tier Requirements/ Limits OPHTHALMIC, SYMPATHOMIMETIC/BETA-BLOCKER COMBINATIONS COMBIGAN 4 OPHTHALMIC, SYMPATHOMIMETICS ALPHAGAN P 0.1% ALPHAGAN P 0.15% apraclonidine brimonidine 0.15%, 0.2% IOPIDINE 0.5% IOPIDINE 1% PHOSPHOLINE IODIDE 4 4 1 1 4 3 3 GA GA OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS CIPRO HC CIPRODEX COLY-MYCIN S CORTISPORIN CORTISPORIN-TC hydrocortisone/acetic acid neomycin/polymyxin b/hydrocortisone soln neomycin/polymyxin b/hydrocortisone susp 3 3 3 4 3 1 1 1 GA OTIC, ANTI-INFECTIVES acetic acid acetic acid/aluminum acetate CETRAXAL ciprofloxacin otic ofloxacin otic 1 1 4 1 1 GA OTIC, MISCELLANEOUS antipyrine/benzocaine antipyrine/benzocaine/polycosanol CORTANE-B DERMOTIC fluocinolone acetonide oil 0.01% MYOXIN OTICIN HC DRO pramoxine/chloroxylenol pramoxine/hydrocortisone/chloroxylenol TREAGAN OTIC Blue Rx Preferred Formulary ©2016 Wellmark, Inc. 1 1 4 4 1 1 4 1 1 4 GA GA GA GA 90
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