September 2019

Brand Drug Additions

Brand Name Strength Common Use Clinical Edits Prescription Drug List Tier
Standard Formulary Value Formulary Performance Formulary Advantage Formulary Legacy Formulary
ADHANSIA XR 25, 35, 45, 55, 70, 85 MG ADD, ADHD   NC NC NC NC NC
DUOBRII 0.01-0.045 Psoriasis   NC NC NC NC 3
EGATEN 250MG Treatment of rare parasitic infection            
EMGALITY SYRINGE 100 MG/ML Prevention of migraine PA 2 3 2 3 2
EZALLOR SPRINKLE 5, 10, 20, 40 MG Cholesterol/lipid lowering ST NC NC NC NC 3
FENOFIBRATE NANOCRYSTALLIZED  160 MG Cholesterol/lipid lowering   NC NC NC NC NC
JORNAY PM 20, 40, 80, 100 MG ADD, ADHD   NC NC NC NC NC
KALYDECO 25 MG Cystic fibrosis   PA 3 3 3 3 3
NUCALA 100 MG/ML Eosinophilic asthma   3 3 3 3 3
PIQRAY 200, 250, 300 MG/DAY Breast cancer PA 3 3 3 3 3
QTERN 5 MG-5 MG Diabetes, type II QL 2 3 2 3 2
RUZURGI 10 MG Lambert-Eaton Myasthenic Syndrome (LEMS) PA 3 3 3 3 3
SKYRIZI 75 MG/0.83 Psoriasis PA 3 3 3 3 3
SYMDEKO 50 MG-75MG Cystic fibrosis   PA, QL 3 3 3 3 3
VYNDAQEL 20 MG Hereditary transthyretin-mediated amyloidosis PA, QL 3 3 3 3 3
ZYKADIA 150 MG Lung cancer   3 3 3 3 3

PA: Prior authorization
QL: Quantity limit
ST: Step therapy
T1/Tier 1: Generic
T2/Tier 2: Brand
T3/Tier 3: Non-preferred
NC: Not covered: This drug is not covered. However, if the covered alternative is not appropriate for the customer, there is a process where his/her provider can request approval of this drug.

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