Nebraska.edu

January 2015
Formulary Drug Removals
Below is a list of medicines by drug class that have been removed from your plan's formulary. This list is effective January 1, 2015. If you continue using one of the drugs listed below and identified as a Formulary Drug Removal after this date, you may be required to pay the full cost. If you are currently using one of the formulary drug removals, ask your doctor to choose one of the generic or brand formulary consideration options listed below. Bolded products represent formulary drug removals that are new for the 2015 plan year.
Category *
Formulary Drug
Formulary Options
Drug Class
Removals
Allergic Reaction
ADRENACLICK
AUVI-Q, EPIPEN, EPIPEN JR (Anaphylaxis) Treatment *
Allergies *
flunisolide spray, fluticasone spray, triamcinolone spray, NASONEX Nasal Steroids / Combinations OMNARIS
QNASL RHINOCORT AQUA VERAMYST ZETONNA flunisolide spray, fluticasone spray, triamcinolone spray, or NASONEX WITH azelastine spray or
PATANASE
Allergies *
azelastine, cromolyn sodium, PATADAY, PATANOL Ophthalmic
Anti-infectives, Antivirals *
acyclovir, valacyclovir Herpes Agents
Asthma *
PROVENTIL HFA
Beta Agonists, Short-Acting
Asthma *
AEROSPAN
ASMANEX, FLOVENT, PULMICORT FLEXHALER, QVAR Steroid Inhalants
Asthma * or Chronic
SYMBICORT
Obstructive Pulmonary
Disease (COPD) *
Steroid / Beta Agonist
Attention Deficit Hyperactivity ADDERALL XR
amphetamine-dextroamphetamine mixed salts ext-rel Disorder Agents
fenofibrate, fenofibric acid Antilipemics *
Fibrates
atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, CRESTOR, SIMCOR, VYTORIN Antilipemics *
HMG Co-A Reductase
Inhibitors (HMGs or Statins) /

Category *
Formulary Drug
Formulary Options
Drug Class
Removals
Chronic Obstructive
Pulmonary Disease (COPD) *
clobetasol propionate foam 0.05%, CLOBEX SPRAY Skin Inflammation and Hives * APEXICON E
desoximetasone, fluocinonide Diabetes *
metformin, metformin ext-rel Biguanides
Diabetes *
JANUVIA, TRADJENTA Dipeptidyl Peptidase-4
(DPP-4) Inhibitors
Diabetes *
JANUMET, JANUMET XR, JENTADUETO Dipeptidyl Peptidase-4
(DPP-4) Inhibitor Combinations OSENI
Diabetes*
BYDUREON, VICTOZA Injectable Incretin Mimetics
Diabetes *
Insulins
HUMALOG MIX 50/50 NOVOLOG MIX 70/30 HUMALOG MIX 75/25 NOVOLOG MIX 70/30 NOTE: Humulin R U-500 concentrate will not be subject to removal and will continue to be covered. Diabetes *
pioglitazone Insulin Sensitizers
Diabetes*
Sodium-Glucose
Co-Transporter-2 (SGLT2)
Inhibitors
Diabetes *
ACCU-CHEK STRIPS AND KITS
ONETOUCH ULTRA STRIPS AND KITS 1, ONETOUCH VERIO STRIPS AND KITS 1 Supplies 1
BREEZE 2 STRIPS AND KITS CONTOUR NEXT STRIPS AND KITS CONTOUR STRIPS AND KITS FREESTYLE STRIPS AND KITS 2 Al other test strips that are not
ONETOUCH brand
Erectile Dysfunction *
Phosphodiesterase Inhibitors
Gastrointestinal Agents *
lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT, Proton Pump Inhibitors (PPIs) PROTONIX
Glaucoma *
latanoprost, travoprost, TRAVATAN Z, ZIOPTAN Prostaglandin Analogs

Category *
Formulary Drug
Formulary Options
Drug Class
Removals
Growth Hormones *
HUMATROPE, NORDITROPIN OMNITROPE SAIZEN Hematologic *
clopidogrel, BRILINTA, EFFIENT Platelet Aggregation Inhibitors
High Blood Pressure *
candesartan, eprosartan, irbesartan, losartan, telmisartan, BENICAR, DIOVAN Angiotensin II Receptor
Antagonists
High Blood Pressure *
Angiotensin II Receptor
telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide, BENICAR HCT Antagonist / Diuretic
EDARBYCLOR TEVETEN HCT High Blood Pressure *
amlodipine Calcium Channel Blockers
Inflammatory Bowel Disease
balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA (IBD), Ulcerative Colitis *
Multiple Sclerosis Agents*
AVONEX, COPAXONE, EXTAVIA, GILENYA, TECFIDERA Musculoskeletal Agents*
cyclobenzaprine Opioid Dependence Agents *
buprenorphine-naloxone sublingual tablet, ZUBSOLV EUFLEXXA
GEL-ONE, HYALGAN, SUPARTZ ORTHOVISC
Overactive Bladder /
oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, Incontinence *
Urinary Antispasmodics
Pain and Inflammation *
dexamethasone, methylprednisolone, prednisone Pain and Inflammation *
CELEBREX; diclofenac, meloxicam, or naproxen WITH lansoprazole, omeprazole,
omeprazole/sodium bicarbonate, pantoprazole, DEXILANT, or NEXIUM inflammatory Drugs (NSAIDs) / VIMOVO
Combinations
diclofenac, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GEL PENNSAID
NAPRELAN
diclofenac, meloxicam, naproxen, CELEBREX Prostate Condition *
finasteride or AVODART WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin or RAPAFLO
Benign Prostatic Hyperplasia
Agents / Combinations
Sleep *
eszopiclone, zolpidem, zolpidem ext-rel Hypnotics,
Testosterone Replacement *
testosterone gel
ANDRODERM, AXIRON, FORTESTA Androgens
ANDROGEL
NATESTO
TESTIM
VOGELXO

Category *
Formulary Drug
Formulary Options
Drug Class
Removals
Transplant *
tacrolimus Calcineurin Inhibitors

Category *
Formulary Options
Drug Class
Hepatitis C Agents*
OLYSIO, SOVALDI and/or other Hepatitis C agents in the pipeline: Evaluation and identification of Drugs Requiring Prior Authorization for Medical Necessity will be made upon approval of the new Hepatitis C agents. New to Market Agents 2
New to market products and new variations of products already in the marketplace will be excluded from [or "will not be added to"] the formulary until the product has been evaluated, determined to be clinically appropriate and cost ef ective, and approved by the CVS/caremark Pharmacy and Therapeutics Committee (or other appropriate reviewing body). The listed formulary options are subject to change. List of Formulary Drug Removals - Carryover from 2014
HUMALOG MIX 50/50 HUMALOG MIX 75/25 BREEZE 2 STRIPS AND KITS CONTOUR NEXT STRIPS AND KITS CONTOUR STRIPS AND KITS FREESTYLE STRIPS AND KITS 2 List of Formulary Drug Removals - New for 2015
ACCU-CHEK STRIPS AND KITS +
PENNSAID
ADDERALL XR
EUFLEXXA
PROVENTIL HFA
ADRENACLICK
AEROSPAN
SYMBICORT
NAPRELAN
testosterone gel
APEXICON E
ORTHOVISC

+ Also includes all other test strips that are not ONETOUCH brand

This list represents brand products in CAPS, branded generics in upper- and lowercase, and generic products in lowercase italics. This is not an all-inclusive list of available drug options. Log in to www.caremark.com to check coverage and copay information for a specific drug. Discuss this information with your doctor or health care provider. This information is not a
substitute for medical advice or treatment. Talk to your doctor or health care provider about this information and any health-related questions you have. CVS/caremark assumes no
liability whatsoever for the information provided or for any diagnosis or treatment made as a result of this information. This list is subject to change. There may be additional plan restrictions. Please consult your plan for further information. Subject to applicable laws and regulations. * This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. 1 A OneTouch blood glucose meter will be provided at no charge by the manufacturer to those individuals currently using a meter other than OneTouch. For more information on how to obtain a blood glucose meter, call toll-free: 1-800-588-4456. Members must have CVS Caremark Mail Service Pharmacy benefits to qualify. 2 An exception process is in place for specific clinical circumstances that may require continued coverage for Freestyle diabetic test strips. If your doctor believes you have a specific clinical need for this product, he or she should fax an exception request toll-free to: 1-888-487-9257. Your plan may choose to provide an exception process for additional medications on this list and new to market agents.
Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information.
This document contains confidential and proprietary information of CVS/caremark and cannot be reproduced, distributed or printed without written permission from CVS/caremark. CVS/caremark may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not af iliated with CVS/caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the doctor.
2014 Caremark Rx, L.L.C. All rights reserved. 106-25923c 010115 www.caremark.com
Document date: July 31, 2014

Source: http://www.nebraska.edu/docs/benefits/formularyexclusion2013.pdf