Pharmacy Policy Bulletin

General Non-Formulary Request Criteria – Delaware – NSF
Number: J-0752	Category: Formulary
Line(s) of Business: Commercial Healthcare Reform Medicare	Benefit(s): Not Applicable
Region(s): All Delaware New York Pennsylvania West Virginia	Additional Restriction(s): Formulary: NSF

I. Contraceptives

When a benefit, a targeted NSF contraceptive may be approved if a member meets one of the following criteria (A. or B.):

A. The prescribing physician indicates that the drug is medically necessary.

B. The member has tried and failed one alternative listed in the Contraceptive category in Table 1 below.

II. Antibiotics, Anti-virals, and Anti-fungals

When a benefit, an antibiotic, anti-viral, or anti-fungal may be approved if a member meets the following criteria:

A. The member has tried and failed one alternative with the same route of administration listed in the last column of Table 1 below for the corresponding antibiotic, anti-viral, or anti-fungal category.

III. Combination Medications

When a benefit, a combination product may be approved if a member meets the following criteria:

A. The member has tried and failed two alternative products, if available, from the corresponding category listed in the last column of Table 1 below with one being in the same specific class as at least one ingredient in the requested combination product

IV. All Other Targeted Medications

When a benefit, the requested medication will be approved if a member meets all of the following criteria (A. and B. or C.):

A. The medication must be used for a FDA approved indication.

B. For targeted medications listed in Table 1 below, the member must have tried and failed two alternative products, if available, listed in the last column in the corresponding category.

C. For targeted multisource brands NOT listed below, the member must have tried and failed the generic product.

Table 1. NSF Targeted Medications and Therapeutic Alternatives for Specific Therapeutic Categories

Category	Targeted Products	Alternative Products
Acne Combo w/ Antibiotics	Aktipak Veltin	Acanya Onexton
Acne - Oral	Doxycycline IR-DR	doxycycline Oracea
Biologics - Injectable TNF	Cimzia Simponi	*See products required in policy J-558
Biologics - Other	Kineret Orencia Siliq Taltz	*See products required in policy J-558
Blood Glucose Monitors and Test Stripts	Accu-Check Breeze Contour Freestyle Precision Truetrack True Metrix + All Others Except One Touch	One Touch Ultra One Touch Verio
Colchicine Products	Colchicine	Colcrys Mitigare
Contraceptives	Minastrin 24 FE	Lo Loestrin FE Natazia Nuvaring Taytulla Safyral
Direct-Acting Antivirals for Hepatitis C	Daklinzia Zepatier Olysio Sovaldi	*See products required in policy J-140
DPP4 Inhibitors	Alogliptin Alogliptin-Metformin Kazano Kombiglyze XR Nesina Onglyza	Januvia Janumet, Janumet XR Jentadueto, Jentadueto XR Tradjenta
Epinephrine Auto-Injector System	Epinephrine auto-injector (non-Mylan) Auvi-Q	Epinephrine auto-injector (Mylan) Epipen/Epipen Jr.
Erectile Dysfunction-Oral	Levitra Staxyn Stendra	Cialis sildenafil
Erythroid Stimulants	Aranesp Epogen Mircera	Procrit
Estrogen Transdermal	Estrogel	Divigel estradiol patch
Estrogen Modifiers for Vaginal Symptoms	Femring	Estring Premarin
Filgrastim Products	Neupogen	Granix Zarxio
Follitropins	Follistim AQ Bravelle	Gonal-F
Glucagon-Like Peptide-1 Agonists	Adlyxin Bydureon Byetta Tanzeum	Trulicity Victoza
GnRH Antagonists	Ganirelix Acetate	Cetrotide
Growth Hormones	Omnitrope Saizen Nutropin Zomacton	Genotrpoin Humatrope Norditropin
Hylauronic Acid Derivatives**	Gel-One Gelsyn Genvisc Hyalgan Hymovis Supartz Synvisc Visco-3	Euflexxa Monovisc Orthovisc
IBS-C and Chronic Constipation	Trulance	Amitiza Linzess
Inflammatory Bowel	Asacol Delzicol Dipentum Mesalamine DR	Apriso Pentasa
Insulin Other - Human	Humulin R	Novolin R
Insulin Other- NPH	Humulin N	Novolin N
Insulin Other -Combo	Humulin	Novolin
Insulin Rapid Acting	Humalog Admelog Apidra	Novolog
Narcotic Analgesics- Oral	buprenorphine patch Butrans Oxycodone HCl ER Oxycontin Opana ER	Hysingla ER Nucynta ER Xtampza ER
Nasal Steroids	Beconase Omnaris Zetonna	fluticasone propionate QNASL
Novel Psychotropics	Seroquel XR	Latuda quetiapine ER
Ophthalmic NSAIDs	Acuvail Nevanac	Ilevro Prolensa
Ophthalmic Prostaglandins	Zioptan	Lumigan Travatan Z
Osteoporosis- Parathyroid Hormone Agents	Forteo	Tymlos
Other Ophthalmic Drugs for Glaucoma	Timoptic Istalol	Alphagan P Combigan
Otic Antibiotic	Cetraxal	Ciprodex Otovel
Pancreatic Enzymes- EC	Pancreaze DR Pertyze DR Ultresa	Creon Zenpep
PCSK9 Inhibitors	Praulent	Repatha
Phosphate Binders	Fosrenol packet Renagel	Phoslyra Velphoro
PPIs	Aciphex Protonix suspension Prilosec DR suspension Zegerid	Nexium Rx packet omeprazole pantoprazole
Progesterones- Vaginal/Infertility	Endometrin Suppository	Crinone
Pulmonary Anti-Inflammatory	Alvesco	ArmonAir Arnuity Asmanex Flovent Pulmicort Inhaler Qvar
Short Acting Inhaled Bronchodilators	Proventil Levalbuterol Xopenex HFA	Proair Ventolin
Somatostatin Analogs	Signifor LAR Sandostatin LAR	Somatuline
Topical Actinic Keratosis	Fluorouracil Zyclara	Carac Picato
Topical Testosterone	Androgel 1% Vogelxo Testosterone Gel [Brand] Fortesta Natesto	Androgel 1.62% testosterone gel [generic]
Transmucosal Fentanyl Analgesics	Abstral Lazanda Fentora	Fentanyl Citrate Subsys
Weight Loss Products	Qsymia	Belviq/XR Contrave ER
Miscellaneous	Emflaza	prednisone
Miscellaneous	Endari	Glutament Glutasolve L-Glutamine
Miscellaneous	Evzio	Naloxone HCl Narcan
Miscellaneous	Glumetza	Metformin ER (generic to Glucophage XR)
Miscellaneous	Gocovri ER	Amantadine HCl
Miscellaneous	Lyrica CR	Gralise Lyrica

**Must be a covered benefit.

Drugs Products	All products not covered on the formulary due to being a targeted NSF Drug See Table 1 below
FDA-Approved Indications:	See individual product information