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Formulary Demonstration Project #03

Actimmune® (interferon gamma1b)

Acthar® Gel (repository corticotropin)

Actiq® (transmucosal fentanyl)

Addyi™ (flibanserin)

Afrezza®

Alpha1-Proteinase Inhibitors

Ampyra® (dalfampridine)

Anadrol® (oxymetholone)

Antiemetic Therapy

Antifungals, Topical

Antivirals, Topical

Apokyn®

(apomorphine)

Arcalyst™ (rilonacept)

Austedo™ (deutetrabenazine)

Baxdela™ (delafloxacin)

Benlysta® (belimumab)

Botulinum Therapy

Brineura® (cerliponase alfa)

Ceprotin® (protein C concentrate)

Chimeric Antigen Receptor T-Cell (CAR-T) & Advanced Cellular/Immune Effector Cell Therapy

Cholbam® (cholic acid)

Clotting Factors & Antithrombin

Compounded Medications

Controlled Substance Analgesic & Narcotic Antagonist Quantity Limitations

Corlanor® (ivabradine)

Cresemba® (isavuconazonium)

Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Modulators

Daraprim® (pyrimethamine)

Denosumab

Depen® (penicillamine & trientine hydrochloride)

Dimercaprol & Edetate Calcium Disodium

Dose Optimization

Duopa®

(carbidopa & levodopa enteral suspension)

Dupixent® (dupilumab)

Egrifta® (tesamorelin)

Emflaza™ (deflazacort)

Endometrin® (progesterone)

Entresto™ (sacubitril/valsartan)

Epinephrine

Erythropoiesis Stimulating Agents (ESA)

Evzio® (naloxone)

Gattex® (teduglutide)

Glycopyrrolate Inhalation Solution

Hepatitis C Therapy

Hereditary Angioedema (HAE) Therapy

Hetlioz® (tasimelteon)

HIV/AIDS

HMG-CoA Reductase Inhibitors (Statins)

Human Papillomavirus Vaccine

Idiopathic Pulmonary Fibrosis Therapy

Ilaris® (canakinumab)

Immune Globulin (IVIG)

Immunomodulators

Impavido® (miltefosine)

Increlex® (mecasermin)

Infertility Injectables

Ingrezza™ (valbenazine)

Insulin

glargine

Interferon Therapy

Interleukin (IL)-5 Antagonists: Mepolizumab

&

Reslizumab

Jakafi® (ruxolitinib)

Jetrea® (ocriplasmin)

Korlym® (mifepristone)

Krystexxa® (pegloticase)

Kuvan® (sapropterin)

Lesinurad

Luxturna™ (voretigene neparvovec)

Lysosomal Storage Disorders Therapy

Makena® (hydroxyprogesterone caproate Injection)

Medication Administration Site of Care

Modafinil/Armodafinil

Mozobil®

(plerixafor)

Multiple Sclerosis Therapy

Neulasta® (pegfilgrastim

Nplate® (romiplostim)

Ocaliva® (obeticholic acid)

Oncology Medications

Opioid Therapy

Oral Phosphodiesterase-5 (PDE5) Inhibitors

Otezla® (apremilast)

PCSK9

Inhibitors

Pharmacy

Prior Authorization

Promacta® (eltrombopag)

Pulmonary Hypertension (PH) Therapy

Radicava™ (edaravone)

Rituxan® (rituximab for Non-Oncology Indications)

Routine Immunizations

Sandostatin®, Sandostatin LAR ® Depot (octreotide)

Soliris® (eculizumab)

Somatropin

Spinraza™ (nusinersen)

Step

Therapy

Step Therapy Individual & Family Plan

Step Therapy – Legacy Prescription Drug Lists (Employer Group Plans

Step Therapy - Standard Prescription Drug Lists (Employer Group Plans)

Step Therapy – Value Prescription Drug Lists (Employer Group Plans)

Supprelin® LA (histrelin acetate subcutaneous implant)

Synagis® (palivizumab)

Testopel® (implantable hormone pellets)

Testosterone Therapy

Topical Alpha Adrenergic Agonists

Topical Doxepin

Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ocular Use

Vfend® voriconazole

Visco-supplementation

for Osteoarthritis

Xiaflex® (collagenase clostridium histolyticum)

Xolair® (omalizumab)

Zilretta® (triamcinolone acetonide extended-release injection)

Zyvox® (oxazolidinone) Antibiotics