Download Advantage Choice

January 2016 Advantage Choice Pharmacy Benefit Updates
Drug Name
Current Formulary
Status
January 2016 Formulary Status
Clinical Summary
Oral Medications
Alosetron
Tier 1 with PA
Specialty with PA
Bunavail
Not Covered
Tier 3 with PA
Tier 1
Not Covered
Doxycycline Monohydrate 75mg
capsule
Alosetron is used for the treatment of diarrhea-predominant irritable bowel syndrome in
women. The preferred formulary alternatives are loperamide, dicyclomine, and
hyoscyamine.
Bunavail is used for the treatment of opioid dependence. A prior authorization will
promote appropriate use.
Doxycycline is an antibiotic used for the treatment of bacterial infections such as
urinary tract infections and acne. The preferred formulary alternatives include
doxycycline hyclate tablets, doxycycline hyclate capsules, and doxycycline
monohydrate tablets.
Hydrocodone/Acetaminophen
5mg/300mg
Vicodin 5mg/300mg
Hydrocodone/Acetaminophen
7.5mg/300mg
Tier 1
Not Covered
Vicodin ES 7.5mg/300mg
These medications are used for the treatment of pain. The preferred formulary
alternatives are hydrocodone/acetaminophen 5mg/325mg,
hydrocodone/acetaminophen 7.5mg/325mg, and hydrocodone/acetaminophen
10mg/325mg.
Hydrocodone/Acetaminophen
10mg/300mg
Vicodin HP 10mg/300mg
Xifaxan 550mg
Tier 3 with PA
Specialty with PA
Xifaxan 550mg tablets are used for the treatment of hepatic encephalopathy and
diarrhea predominate irritable bowel syndrome. The preferred formulary alternatives
are lactulose for hepatic encephalopathy and loperamide, dicyclomine, and
hyoscyamine for diarrhea predominate irritable bowel syndrome.
Not Covered
Hydrocortisone-iodoquinol cream is a topical product used to treatment inflammatory
skin conditions. The preferred formulary alternatives are hydrocortisone 2.5% cream,
fluocinolone cream, and fluticasone cream.
Topical Medications
Dermazene
Hydrocortisone-Iodoquinol 1%-1%
cream
Tier 1
Tier 1
Confidential
January 2016 Advantage Choice Pharmacy Benefit Updates
Drug Name
Current Formulary
Status
January 2016 Formulary Status
Clinical Summary
Topical Medications
Fluticasone propionate 0.05%
lotion
Tier 1
Not Covered
Fluticasone propionate lotion is a topical corticosteroid used to treat inflammatory skin
conditions. The preferred formulary alternatives are fluticasone cream and fluticasone
ointment.
Hydrocortisone butyrate 0.1% lipid
cream
Tier 1
Not Covered
Hydrocortisone butyrate 0.1% lipid cream is a topical corticosteroid used to treat
inflammatory skin conditions. Formulary alternatives include hydrocortisone 2.5%
cream, hydrocortisone 2.5% ointment, and hydrocortisone 2.5% lotion.
Bydureon (pen/vial)
Tier 2
Tier 3
Bydureon is used for the treatment of type 2 diabetes. The preferred formulary
alternatives in this class are Trulicity and Victoza.
Trulicity
Tier 3
Tier 2
Trulicity is used for the treatment of type 2 diabetes.
Durezol
Tier 3
Tier 2
Simbrinza
Tier 3
Tier 2
Bimatoprost 0.03%
Tier 1
Tier 1 with ST
Arnuity Ellipta
Tier 3 with ST
Tier 2
Arnuity Ellipta is used for the treatment of asthma.
Incruse Ellipta
Tier 3 with ST
Tier 2
Incruse Ellipta is used for the treatment of COPD.
Tier 2
Tier 3 with ST
Not Covered
Tier 2
Tier 2
Tier 3 with ST
Tudorza Pressair is used for the treatment of COPD. The step therapy will require
prior use of Incruse Ellipta or Spiriva.
Tier 3 with ST
Tier 3 with PA
Xopenex HFA is used for the treatment of asthma and COPD. A prior authorization with
promote appropriate use. The preferred formulary alternative is Ventolin HFA.
Specialty with PA and QL
Specialty with QL
Covered with a PA
Not Covered
Diabetes Medications
Ophthalmic Medications
Durezol is indicated for the treatment of inflammation and pain associated with eye
surgery.
Simbrinza is used for the treatment of elevated eye pressure in patients with openangle glaucoma or ocular hypertension.
Bimatoprost is used for the treatment of elevated eye pressure in patients with openangle glaucoma or ocular hypertension.
Inhaled Medications
Qvar
Symbicort
Tudorza Pressair
Xopenex HFA
Qvar is used for the treatment of asthma. The step therapy will require prior use of
Asmanex, Flovent HFA, or Arnuity Ellipta.
Symbicort is used for the treatment of asthma and COPD.
Injectable Medications
Plegridy
Plegridy is used for the treatment of multiple sclerosis.
Compounded Medications
Compounded Medications
Certain components of compounded products will no longer be covered and will be
considered benefit exclusions.
Confidential