Pharmacy Policy Bulletin

General Non-Formulary Request Criteria – Delaware – National Select Formulary
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, coverage of a targeted NSF contraceptive may be approved if a member meets one (1) 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 (1) alternative listed in the Contraceptive category in Table 1 below.

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

When a benefit, coverage of an antibiotic, anti-viral, or anti-fungal may be approved if a member meets the following criteria (A. and B.):

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

B. The member has tried and failed one (1) 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, coverage of a combination product may be approved if a member meets the following criteria (A. and B.):

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

B. The member has tried and failed two (2) alternative products, if available, from the corresponding category listed in the last column of Table 1 below with one (1) being in the same specific class as at least one (1) ingredient in the requested combination product

IV. All Other Targeted Medications

When a benefit, coverage of a targeted medication may be approved if a member meets all of the following criteria (A. and B.):

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

B. The member meets one (1) of the following criteria (1. or 2.):

1. The member has tried and failed all the alternative products, if available, listed in the last column in the corresponding category in Table 1 below.

2. 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
Anticoagulants	Pradaxa Savaysa	Eliquis Xarelto
Beta Interferons	Extavia	Avonex Betaseron Plegridy Rebif
Biologics- Injectable TNF	Cimzia Simponi	*See products required in policy J-558
Biologics- Other	Kineret Orencia Siliq Taltz Olumiant	*See products required in policy J-558
Blood Glucose Monitors and Test Strips	Accu-Chek Breeze Contour Truetrack True Metrix + All Others not listed as preferred	One Touch Ultra One Touch Verio Freestyle Precision Xtra
Bowel Evacuants	Osmoprep	Clenpiq Prepopik Suprep
Chorionic Gonadotropins	Pregnyl Chorionic gonadotropin	Novarel Ovidrel
Colchicine Products	colchicine capsules	Colcrys Mitigare colchicine tablets
Colony Stimulating Factors- Filgrastim Products	Granix Neupogen	Nivestym Zarxio
Direct-Acting Antivirals for Hepatitis C	Mavyret Sovaldi ledipasvir-sofosbuvir [Brand] sofosbuvir-velpatasvir [Brand]	*See products required in policy J-820
DPP4 Inhibitors	Alogliptin Alogliptin-Metformin Alogliptin-Pioglitazone Kazano Kombiglyze XR Nesina Onglyza	Januvia Janumet, Janumet XR Jentadueto, Jentadueto XR Trajenta
Epinephrine Auto-Injector System	Epinephrine auto-injector (non-Mylan) Auvi-Q	Epinephrine auto-injector (Mylan) Epipen/Epipen Jr.
Erythroid Stimulants	Aranesp Epogen Mircera	Procrit Retacrit
Estrogen Transdermal	Estrogel	Divigel estradiol patch
Estrogen Modifiers for Vaginal Symptoms	Femring	Estring Premarin
Estrogen/Progestin Combination Patches	Climara Pro	Combipatch
Factor VIII Recombinant Products	Nuwiq Recombinate Xyntha, Xyntha Solofuse	Advate Adynovate Afstyla Eloctate Jivi Kogenate FS Kovaltry Novoeight Esperoct
Follitropins	Follistim AQ	Gonal-F
Glucagon-Like Peptide-1 Agonists	Adlyxin Bydureon Byetta	Trulicy Victoza Ozempic
Growth Hormones	Omnitrope Saizen Nutropin Zomacton Humatrope	Genotropin Norditropin
Helicobacter pylori	Pylera Helidac	lansoprazole-amoxicillin-clarithromcyin Talicia
Hyaluronic Acid Derivatives**	Gel-One Gelsyn Genvisc Hyalgan Hymovis Supartz Synvisc Triluron Visco-3 Sodium Hyaluronate 1% Syringe [Brand] Trivisc	Euflexxa Monovisc Orthovisc
Inflammatory Bowel	Dipentum	Apriso Pentasa
Inhaled LAMA/LABA	Duaklir Pressair	Anoro Ellipta Bevespi Aerosphere Stiolto Respimat
Inhaled Long-Acting Muscarinic	Tudorza Pressair	Incruse Ellipta Spiriva Spiriva Respimat
Insulin Other - Human	Humulin R	Novolin R
Insulin Other- NPH	Humulin N	Novolin N
Insulin Other -Combo	Humulin	Novolin
Insulin Rapid Acting	Humalog Insulin Lispro Admelog Apidra Insulin Aspart	Novolog Fiasp
Long Acting Beta Agonist Inhalers	Striverdi Respimat	Serevent Diskus
Narcotic Analgesics- Oral	Embeda Oxycodone HCl ER Oxycontin	Hysingla ER Nucynta ER Xtampza ER
Nasal Steroids	Beconase Omnaris Zetonna	fluticasone propionate QNASL
Novel Psychotropics	Seroquel XR	aripiprazole Latuda quetiapine ER
Ophthalmic Anti-Allergy	Alocril Alomide	Alrex Bepreve Pazeo
Ophthalmic Anti-Inflammatory	FML Forte FML S.O.P Maxidex Pred Mild	Lotemax/Lotemax SM Dexamethasone Inveltys
Ophthalmic NSAIDs	Acuvail Nevanac	Ilevro Prolensa
Ophthalmic Prostaglandins	Xelpros	Lumigan Travatan Z Zioptan
Other Ophthalmic Drugs for Glaucoma	Timoptic	Alphagan P Combigan
Otic Antibiotic	Cetraxal Ciprofloxacin-fluocinolone [Brand]	Ciprodex Otovel
Pancreatic Enzymes- EC	Pancreaze DR Pertyze DR	Creon Zenpep
PCSK9 Inhibitors	Praluent	Repatha
Potassium Binders	Veltassa	Lokelma
PPIs	Aciphex Protonix suspension Prilosec DR suspension Zegerid Rabeprazole [Brand] esomeprazole strontium 49.3 mg [brand]	Nexium Rx packet omeprazole pantoprazole
Pulmonary Anti-Inflammatory/Beta-agonist	budesonidep-formoterol [Brand]	Symbicort Advair HFA Breo Ellipta Dulera
Short Acting Inhaled Bronchodilators	Albuterol Sulfate [Brand] Proventil Levalbuterol Xopenex HFA Proair Digihaler	Proair HFA/Respiclick Ventolin
Somatostatin Analogs	Signifor LAR Sandostatin LAR	Somatuline
Topical Actinic Keratosis	Fluorouracil [Brand] Zyclara Imiquimod [Brand] Carac	Picato
Miscellaneous Categories	Emflaza	prednisone
	Evzio naloxone auto-injector	Naloxone HCL Narcan
	Glumetza	Metformin ER (generic to Glucophage XR)
	Gocovri ER	Amantadine HCL
	Lyrica CR	Gralise Lyrica
	Xadago	Rasagiline selegiline
	Atripla [new starts only] Delstrigo [new starts only] Stribild [new starts only] Complera [new starts only]	Biktarvy Genvoya Odefsey Symfi/Symfi Lo
	Topicort Spray Verdeso	Desonide desoximtasone
	Fenoprofen calcium capsules [Brand] Fenortho Nalfon Zorvolex Relafen DS Tivorbex Vivlodex Zipsor indomethacin 20 mg capsules ketorolac nasal spray	Diclofenac Meloxicam Indomethacin Naprelan CR
	Diclofenac epolamine [Brand] Pennsaid	Flector
	Berinert	Ruconest
	Cortifoam	Uceris (foam) hydrocortisone
	Noctiva	desmopressin Nocdurna
	Siklos Oxbryta	Droxia hydroxyurea
	Lucemyra	clonidine
	luliconazole [Brand]	Luzu ciclopirox
	Butrans	Belbuca Buprenorphine patch
	Kapspargo Sprinkle	Bystolic Metoprolol succinate
	minocycline ER capsules [brand] Ximino	Minocycline ER tablets [generic]
	Pifeltro [new starts only]	efavirenz
	Tolsura	itraconazole
	Apadaz Benzphydrocodone-Acetaminophen [Brand]	hydrocodone w/ acetaminophen
	clocortolone pivalate [Brand]	betamethasone valerate fluocinolone acetonide triamcinolone acetonide
	Prezcobix [new starts only]	Prezista Kaletra
	Prolia Evenity	alendronate Tymlos Forteo
	lidocaine-tetracaine [Brand]	lidocaine cream lidocaine/prilocaine cream
	Dutoprol	metoprolol tartrate/hydrochlorothiazide metoprolol succinate ER
	Kisqali [new starts only] Kisqali Femara Co-Pack [new starts only] Piqray [new starts only]	Ibrance Verzenio
	topiramate er [Brand]	topiramate Qudexy XR
	Ingrezza	tetrabenazine Austedo
	Aspirin-Omeprazole DR [Brand] Yosprala	aspirin omeprazole esomeprazole magnesium lansoprazole pantoprazole sodium rabeprazole sodium
	Xpovio [new starts only]	Pomalyst Revlimid Thalomid
	Katerzia 1 Mg/ML Suspension	amlodipine besylate
	Inrebic [new starts only]	Jakafi
	Drizalma Sprinkle	Fetzima venlafaxine ER desvenlafaxine ER duloxetine
	Ozobax	baclofen tizanidine
	Veltin	Onexton
	Doxycycline IR-DR [brand]	doxycycline Oracea
	Altoprev Ezallor simvastatin suspension [Brand]	Livalo Lovastatin Atorvastatin simvastatin rosuvastatin
	Lazanda Fentora Fentanyl citrate buccal tabs [Brand] Subsys	Fentanyl Citrate
	Akynzeo Emend solution	aprepitant Varubi
	Epaned Qbrelis	enalapril lisinopril
	Mulpleta	Doptelet
	Sitavig	acyclovir valacyclovir famciclovir
	Sulconazole Nitrate	ciclopirox econazole nitrate ketoconazole naftifine hcl oxiconazole nitrate
	calcipotriene 0.005% foam [Brand]	calcipotriene calcitriol
	amphetamine ER suspension	dextroamphetamine sulfate ER dextroamphetamine-amphet ER Dyanavel XR Mydayis Quillichew ER Quillivant XR Vyvanse
	Jatenzo	testosterone (topical, generic) Androderm
	Palforzia	*see criteria in policy J-246.
	Clindagel Clindamycin phosphate gel [brand]	clindamycin phosphate gel erythromycin gel Amzeeq
	Doral	estazolam lorazepam
	Korlym	ketoconazole Lysodren Signifor
	Procysbi	Cystagon
	Tavalisse	Doptelet Promacta Nplate
	Zelapar	rasagaline selegiline
	Isturisa	Signifor
	Qinlock [New starts only]	imatinib Stivarga Sutent
	Fintepla	Diacomit Epidiolex

**Must be a covered benefit.

V. An exception to some or all of the criteria above may be granted for select members and/or circumstances based on state and/or federal regulations.

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