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Formulary (List of Drugs)Effective Date: 04/01/2022 – 06/30/2022Member Services: 1-877-860-2837(TTY/TDD: 711)IL BCCHP RX Formulary20 Approved 09292020
WHEN YOU NEED TO CONTACTMEMBER SERVICESOur goal is to serve your health care needs through all of life’s changes. If you have anyquestions, our team stands ready to help.Call1-877-860-2837 (TTY/TDD: 711)We are open 24 hours a day, seven (7) days a week. The call is free.Websitewww.bcchpil.comWriteBlue Cross Community Health Plans c/o Member Services P.O. Box 3418 Scranton, PA 18505Member Services: 1-877-860-2837 TTY/TDD: 711 24/7 Nurseline: 1-888-343-2697i
What is the Blue Cross Community Health Plans (the “Plan”)drug list?The drug list (sometimes called a formulary) is a list showing the drugs that can be covered by the plan.The drugs listed will be covered as long as you: Have a medical need for themFill the medication orders at an in-network pharmacyFollow the other plan rulesFor more information on how to fill your medication orders, please review your Member Handbook.What will I pay?You do not pay for covered drugs.Can the drug list change?Yes, it can change. Coverage may change if: A new, less expensive generic drug becomes available New information about a drug shows it to be unsafe or less effectiveYou will be told in writing when the drug list does change.How do I use the drug list?There are two ways to find your drug in the list beginning on page 1.1. Category The list of covered drugs that begins on page 1 gives you information about the drugscovered by Blue Cross Community Health Plans. If you have trouble finding your drug in thelist, turn to the Index that begins at the back of this book. The first column of the chart has the name of the drug. Brand name drugs are capitalized(e.g., CIPRO) and generic drugs are listed in lower-case italics (e.g. ciprofloxacin).o The information in the “Necessary actions, restrictions, or limits on use” column tellsyou if Blue Cross Community Health Plans has any rules for covering your drug. The drugs are listed in categories, or groups, based on the type of medical conditions theytreat. (For example, drugs used to treat a heart condition are listed under CardiovascularAgents). If you know what your drug is used for, look for the group in the drug list. Then, look under that group for your drug.2. Alphabetical Listingii Look for your drug in the back of this book. Next to your drug, you will see the page number where you can find coverageinformation.Member Services: 1-877-860-2837 TTY/TDD: 711 www.bcchpil.com
What are generic drugs?A generic drug is approved by the Food and Drug Administration (FDA) as having the same activeingredient as the brand name drug, but often costs less. The plan covers both brand name drugs andgeneric drugs.Are there any limits on my coverage?Added conditions or limits on some covered drugs may include: Prior Authorization (PA): You or your doctor may need to get approval before you fill yourmedication orders. If you do not get approval, the plan may not cover the drug. Quantity Limits (QL): For certain drugs, the plan limits the amount that will be covered. Step Therapy (ST): In some cases, the plan requires you to first try certain drugs before anotherdrug can be covered. For example, if Drug A and Drug B both treat your medical condition, theplan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the planwill then cover Drug B. Age Limits (AL): Some drugs have limits based on the members age. This is a safety program toprevent harmful side effects. It follows age limits allowed by the FDA. Morphine Equivalent (ME) Dosing: ME dosing is a tool used to help prevent members fromtaking too much pain medication (opioids). This tool allows Blue Cross Community Health Plansto calculate the total daily dose of pain medications a member is taking no matter which opioidthey are prescribed. The current daily ME limit in Illinois is 120 mg per day. If you are taking adose above ME120, you will need to get prior authorization for Blue Cross Community HealthPlans to pay for the prescription(s). Specialty Pharmacy Split Fill Program (SF): Specialty drugs are certain prescription medicationsused to treat complex, chronic conditions like cancer, rheumatoid arthritis and multiplesclerosis. These drugs are an important part of many treatment plans. They can cause sideeffects which may lead to your doctor making changes to the dose or stopping the drugentirely. As you go through treatment, your doctor may make changes to the treatment planuntil the best dose is established for you. This may take a few months. The reason for theSpecialty Pharmacy Split Fill Program for members newly starting therapy is to: Prevent unnecessary prescriptions at inappropriate dosesMinimize waste of these drugsManage side effectsFor the first 2 to 3 months of your treatment, you will be able to receive a 14- or 15-day supplyof your prescription twice a month. Following the first 2 to 3 months of treatment and once theright dose has been established, you may start to receive a full 1-month supply for the rest ofyour therapy.Member Services: 1-877-860-2837 TTY/TDD: 711 24/7 Nurseline: 1-888-343-2697iii
You can find out if your drug has any added conditions or limits by looking at the list that begins onpage 1.You will find our contact information below, and the date we last updated the list on the back coverpage.Providers may submit coverage exception requests by fax (1-877-243-6930), phone1-800-285-9426 (TTY/TDD 711), or by website (MyPrime.com or CoverMyMeds.com). Providers mayfind forms on MyPrime.com.Does the plan pay for over-the-counter (OTC) drugs?Yes, the plan pays for certain OTC drugs with a valid medication order from your doctor, and you mayget those at no cost. Generic products are to be prescribed and given out when available. Theseproducts are to be filled at a plan network pharmacy and for quantities up to a 30-day supply.What if my drug is not on the drug list?Contact Member Services and ask if your drug is covered. If you learn that the plan does not cover yourdrug, you have two options: Talk to your doctor to decide if you should first try a different drug on our list before yourequest an exception. Ask Member Services about making an exception to cover your drug. Send in a statement fromyour doctor backing your request. We must decide within 24 hours of getting your doctor’sstatement.We usually only approve requests for exceptions if the other drugs included on our list or the addeduse limits would make your treatment less effective and/or would be harmful to your health.Which drug categories are not covered by the plan drug list?The following drug categories are not covered by your plan: Anorexia, weight loss, or weight gain drugs Bulk chemicals Cosmetic enhancing drugs Diagnostic agents Drug Efficacy Study Implementation(DESI) that are classified as ineffective Experimental and investigational drugs Erectile dysfunction drugs prescribed totreat impotence Fertility drugsivGeneral anesthetic drugsOver-the-counter products nototherwise included on the plan’s druglistSurgical supply/medical devicesMedications considered “unreasonable,unnecessary, and/or excessive”according to the standards of Medicaid,clinical practice guidelines, and FDAlabeling.Member Services: 1-877-860-2837 TTY/TDD: 711 www.bcchpil.com
For More InformationFor more details about your plan’s drug coverage, please review your Member Handbook and otherplan materials.If you have any questions, please call Member Services at: 1-877-860-2837 (TTY/TDD 711). We areavailable 24 hours a day, seven (7) days a week. The call is free.For Language AssistanceInterpreter ServicesWe can arrange for someone to help you speak with us in any language. These services are free. If yourdoctor does not speak your language, we can arrange for a translator to help you. Please call MemberServices at the number above.Hearing and Vision ProblemsFor our members with hearing problems, we offer TTY/TDD service free of charge. The line is open 24hours a day/seven day a week at 711.Other Languages and FormatsYou can get this document in Spanish, or speak with someone about this information in otherlanguages for free. Call 1-877-860-2837 (TTY/TDD: 711). The call is free. You can also call MemberServices, toll-free, to request this information in other alternative formats such as Braille, large printand other forms. Call Toll Free: 1-877-860-2837 (TTY/TDD: 711). We are available 24 hours a day, seven(7) days a week. The call is free.If any information in this Formulary (List of Drugs) is missing or inaccurate, please emailBCCHPFormulary@bcbsil.com. You can also call Member Services toll-free at: 1-877-860-2837,TTY/TDD 711. The call is free.Member Services: 1-877-860-2837 TTY/TDD: 711 24/7 Nurseline: 1-888-343-2697v
2022Drug NamePreferred Status Drug Status / RestrictionADHD / ANTI-NARCOLEPSY AGENTS : AMPHETAMINESADDERALL – amphetamine-dextroamphetamine tab 5 mgNPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)ADDERALL – amphetamine-dextroamphetamine tab 7.5 mgNPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)ADDERALL – amphetamine-dextroamphetamine tab 10 mgNPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)ADDERALL – amphetamine-dextroamphetamine tab 12.5 mgNPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)ADDERALL – amphetamine-dextroamphetamine tab 15 mgNPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)ADDERALL – amphetamine-dextroamphetamine tab 20 mgNPPA ( 5 yr & 19 yr),QL (90 tablets/30 days)ADDERALL – amphetamine-dextroamphetamine tab 30 mgNPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)ADDERALL XR – amphetamine-dextroamphetamine cap er 24hr5 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)ADDERALL XR – amphetamine-dextroamphetamine cap er 24hr10 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)ADDERALL XR – amphetamine-dextroamphetamine cap er 24hr15 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)ADDERALL XR – amphetamine-dextroamphetamine cap er 24hr20 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)ADDERALL XR – amphetamine-dextroamphetamine cap er 24hr25 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)ADDERALL XR – amphetamine-dextroamphetamine cap er 24hr30 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)ADZENYS XR-ODT – amphetamine tab extended releasedisintegrating 3.1 mgNPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)ADZENYS XR-ODT – amphetamine tab extended releasedisintegrating 6.3 mgNPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)ADZENYS XR-ODT – amphetamine tab extended releasedisintegrating 9.4 mgNPPA ( 5 yr & 19 yr),QL (30 tablets/30 days)ADZENYS XR-ODT – amphetamine tab extended releasedisintegrating 12.5 mgNPPA ( 5 yr & 19 yr),QL (30 tablets/30 days)ADZENYS XR-ODT – amphetamine tab extended releasedisintegrating 15.7 mgNPPA ( 5 yr & 19 yr),QL (30 tablets/30 days)ADZENYS XR-ODT – amphetamine tab extended releasedisintegrating 18.8 mgNPPA ( 5 yr & 19 yr),QL (30 tablets/30 days)amphetamine sulfate tab 5 mg (Evekeo)NPPA ( 5 yr & 19 yr),QL (90 tablets/30 days)P Preferred DrugAL Age LimitNP Non-Preferred DrugPA Prior AuthorizationSC Supplemental Coverage SF Split FillME Morphine EquivalentQL Quantity Limits90 90 days at mail orderSP Specialty DrugST Step TherapyEffective Date: April 20221
2022Drug NamePreferred Status Drug Status / RestrictionNPPA ( 5 yr & 19 yr), QL(180 tablets/30 days)amphetamine sulfate tab 10 mg (Evekeo)amphetamine-dextroamphetamine cap er 24hr 5 mg (Adderall xr)PPA ( 5 yr & 19 yr), QL(30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 10 mg (Adderallxr)PPA ( 5 yr & 19 yr), QL(30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 15 mg (Adderallxr)PPA ( 5 yr & 19 yr), QL(30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 20 mg (Adderallxr)PPA ( 5 yr & 19 yr), QL(30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 25 mg (Adderallxr)PPA ( 5 yr & 19 yr), QL(30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 30 mg (Adderallxr)PPA ( 5 yr & 19 yr), QL(30 capsules/30 days)amphetamine-dextroamphetamine tab 5 mg (Adderall)PPA ( 5 yr & 19 yr),QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 7.5 mg (Adderall)PPA ( 5 yr & 19 yr),QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 10 mg (Adderall)PPA ( 5 yr & 19 yr),QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 12.5 mg (Adderall)PPA ( 5 yr & 19 yr),QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 15 mg (Adderall)PPA ( 5 yr & 19 yr),QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 20 mg (Adderall)PPA ( 5 yr & 19 yr),QL (90 tablets/30 days)amphetamine-dextroamphetamine tab 30 mg (Adderall)PPA ( 5 yr & 19 yr),QL (60 tablets/30 days)DESOXYN – methamphetamine hcl tab 5 mgNPPA ( 5 yr & 19 yr), QL(150 patches/30 days)DEXEDRINE – dextroamphetamine sulfate cap er 24hr 5 mgNPPA ( 5 yr & 19 yr), QL(90 capsules/30 days)DEXEDRINE – dextroamphetamine sulfate cap er 24hr 10 mgNPPA ( 5 yr & 19 yr), QL(120 capsules/30 days)DEXEDRINE – dextroamphetamine sulfate cap er 24hr 15 mgNPPA ( 5 yr & 19 yr), QL(120 capsules/30 days)dextroamphetamine sulfate cap er 24hr 5 mg (Dexedrine)NPPA ( 5 yr & 19 yr), QL(90 capsules/30 days)dextroamphetamine sulfate cap er 24hr 10 mg (Dexedrine)NPPA ( 5 yr & 19 yr), QL(120 capsules/30 days)P Preferred DrugAL Age LimitNP Non-Preferred DrugPA Prior AuthorizationSC Supplemental Coverage SF Split FillME Morphine EquivalentQL Quantity Limits90 90 days at mail orderSP Specialty DrugST Step TherapyEffective Date: April 20222
2022Drug NamePreferred Status Drug Status / RestrictionNPPA ( 5 yr & 19 yr), QL(120 capsules/30 days)dextroamphetamine sulfate cap er 24hr 15 mg (Dexedrine)dextroamphetamine sulfate oral solution 5 mg/5mlNPPA ( 5 yr & 19 yr),QL (1800 mls/30 days)dextroamphetamine sulfate tab 5 mgNPPA ( 5 yr & 19 yr),QL (90 tablets/30 days)dextroamphetamine sulfate tab 10 mgNPPA ( 5 yr & 19 yr), QL(180 tablets/30 days)dextroamphetamine sulfate tab 15 mgNPPA ( 5 yr & 19 yr),QL (90 tablets/30 days)dextroamphetamine sulfate tab 20 mgNPPA ( 5 yr & 19 yr),QL (90 tablets/30 days)dextroamphetamine sulfate tab 30 mgNPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)DYANAVEL XR – amphetamine extended release susp 2.5 mg/mlNPPA ( 5 yr & 19 yr),QL (240 mls/30 days)EVEKEO – amphetamine sulfate tab 5 mgNPPA ( 5 yr & 19 yr),QL (90 tablets/30 days)EVEKEO – amphetamine sulfate tab 10 mgNPPA ( 5 yr & 19 yr), QL(180 tablets/30 days)EVEKEO ODT – amphetamine sulfate orally disintegrating tab5 mgNPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)EVEKEO ODT – amphetamine sulfate orally disintegrating tab10 mgNPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)EVEKEO ODT – amphetamine sulfate orally disintegrating tab15 mgNPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)EVEKEO ODT – amphetamine sulfate orally disintegrating tab20 mgNPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)methamphetamine hcl tab 5 mg (Desoxyn)NPPA ( 5 yr & 19 yr), QL(150 tablets/30 days)MYDAYIS – amphetamine-dextroamphetamine 3-bead cap er24hr 12.5 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)MYDAYIS – amphetamine-dextroamphetamine 3-bead cap er24hr 25 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)MYDAYIS – amphetamine-dextroamphetamine 3-bead cap er24hr 37.5 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)MYDAYIS – amphetamine-dextroamphetamine 3-bead cap er24hr 50 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)PPA ( 5 yr & 19 yr), QL(30 capsules/30 days)VYVANSE – lisdexamfetamine dimesylate cap 10 mgP Preferred DrugAL Age LimitNP Non-Preferred DrugPA Prior AuthorizationSC Supplemental Coverage SF Split FillME Morphine EquivalentQL Quantity Limits90 90 days at mail orderSP Specialty DrugST Step TherapyEffective Date: April 20223
2022Drug NameVYVANSE – lisdexamfetamine dimesylate cap 20 mgPreferred Status Drug Status / RestrictionPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)VYVANSE – lisdexamfetamine dimesylate cap 30 mgPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)VYVANSE – lisdexamfetamine dimesylate cap 40 mgPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)VYVANSE – lisdexamfetamine dimesylate cap 50 mgPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)VYVANSE – lisdexamfetamine dimesylate cap 60 mgPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)VYVANSE – lisdexamfetamine dimesylate cap 70 mgPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)VYVANSE – lisdexamfetamine dimesylate chew tab 10 mgPPA ( 5 yr & 19 yr),QL (30 tablets/30 days)VYVANSE – lisdexamfetamine dimesylate chew tab 20 mgPPA ( 5 yr & 19 yr),QL (30 tablets/30 days)VYVANSE – lisdexamfetamine dimesylate chew tab 30 mgPPA ( 5 yr & 19 yr),QL (30 tablets/30 days)VYVANSE – lisdexamfetamine dimesylate chew tab 40 mgPPA ( 5 yr & 19 yr),QL (30 tablets/30 days)VYVANSE – lisdexamfetamine dimesylate chew tab 50 mgPPA ( 5 yr & 19 yr),QL (30 tablets/30 days)VYVANSE – lisdexamfetamine dimesylate chew tab 60 mgPPA ( 5 yr & 19 yr),QL (30 tablets/30 days)ZENZEDI – dextroamphetamine sulfate tab 2.5 mgNPPA ( 5 yr & 19 yr),QL (90 tablets/30 days)ZENZEDI – dextroamphetamine sulfate tab 7.5 mgNPPA ( 5 yr & 19 yr),QL (90 tablets/30 days)ADHD / ANTI-NARCOLEPSY AGENTS : MISCatomoxetine hcl cap 10 mg (base equiv) (Strattera)NPPA ( 5 yr & 19 yr), QL(60 capsules/30 days)atomoxetine hcl cap 18 mg (base equiv) (Strattera)NPPA ( 5 yr & 19 yr), QL(60 capsules/30 days)atomoxetine hcl cap 25 mg (base equiv) (Strattera)NPPA ( 5 yr & 19 yr), QL(60 capsules/30 days)atomoxetine hcl cap 40 mg (base equiv) (Strattera)NPPA ( 5 yr & 19 yr), QL(60 capsules/30 days)atomoxetine hcl cap 60 mg (base equiv) (Strattera)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)atomoxetine hcl cap 80 mg (base equiv) (Strattera)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)P Preferred DrugAL Age LimitNP Non-Preferred DrugPA Prior AuthorizationSC Supplemental Coverage SF Split FillME Morphine EquivalentQL Quantity Limits90 90 days at mail orderSP Specialty DrugST Step TherapyEffective Date: April 20224
2022Drug Nameatomoxetine hcl cap 100 mg (base equiv) (Strattera)Preferred Status Drug Status / RestrictionNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)clonidine hcl tab er 12hr 0.1 mg (Kapvay)PQL (120 tablets/30 days), 90guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv)PQL (30 tablets/30 days), 90guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv)PQL (30 tablets/30 days), 90guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv)PQL (30 tablets/30 days), 90guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv)PQL (30 tablets/30 days), 90INTUNIV – guanfacine hcl tab er 24hr 1 mg (base equiv)NPPA ( 5 yr & 19 yr), QL(30 tablets/30 days), 90INTUNIV – guanfacine hcl tab er 24hr 2 mg (base equiv)NPPA ( 5 yr & 19 yr), QL(30 tablets/30 days), 90INTUNIV – guanfacine hcl tab er 24hr 3 mg (base equiv)NPPA ( 5 yr & 19 yr), QL(30 tablets/30 days), 90INTUNIV – guanfacine hcl tab er 24hr 4 mg (base equiv)NPPA ( 5 yr & 19 yr), QL(30 tablets/30 days), 90QELBREE – viloxazine hcl cap er 24hr 100 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)QELBREE – viloxazine hcl cap er 24hr 150 mgNPPA ( 5 yr & 19 yr), QL(60 capsules/30 days)QELBREE – viloxazine hcl cap er 24hr 200 mgNPPA ( 5 yr & 19 yr), QL(60 capsules/30 days)STRATTERA – atomoxetine hcl cap 10 mg (base equiv)NPPA ( 5 yr & 19 yr), QL(60 capsules/30 days)STRATTERA – atomoxetine hcl cap 18 mg (base equiv)NPPA ( 5 yr & 19 yr), QL(60 capsules/30 days)STRATTERA – atomoxetine hcl cap 25 mg (base equiv)NPPA ( 5 yr & 19 yr), QL(60 capsules/30 days)STRATTERA – atomoxetine hcl cap 40 mg (base equiv)NPPA ( 5 yr & 19 yr), QL(60 capsules/30 days)STRATTERA – atomoxetine hcl cap 60 mg (base equiv)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)STRATTERA – atomoxetine hcl cap 80 mg (base equiv)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)STRATTERA – atomoxetine hcl cap 100 mg (base equiv)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)SUNOSI – solriamfetol hcl tab 75 mg (base equiv)NPPA, QL (30 tablets/30 days)SUNOSI – solriamfetol hcl tab 150 mg (base equiv)NPPA, QL (30 tablets/30 days)WAKIX – pitolisant hcl tab 4.45 mg (base equivalent)NPPA, QL (60 tablets/30days), SPP Preferred DrugAL Age LimitNP Non-Preferred DrugPA Prior AuthorizationSC Supplemental Coverage SF Split FillME Morphine EquivalentQL Quantity Limits90 90 days at mail orderSP Specialty DrugST Step TherapyEffective Date: April 20225
2022Drug NamePreferred Status Drug Status / RestrictionNPPA, QL (60 tablets/30days), SPWAKIX – pitolisant hcl tab 17.8 mg (base equivalent)ADHD / ANTI-NARCOLEPSY AGENTS : STIMULANTSADHANSIA XR – methylphenidate hcl cap er 24hr 25 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)ADHANSIA XR – methylphenidate hcl cap er 24hr 35 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)ADHANSIA XR – methylphenidate hcl cap er 24hr 45 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)ADHANSIA XR – methylphenidate hcl cap er 24hr 55 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)ADHANSIA XR – methylphenidate hcl cap er 24hr 70 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)ADHANSIA XR – methylphenidate hcl cap er 24hr 85 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)APTENSIO XR – methylphenidate hcl cap er 24hr 10 mg (xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)APTENSIO XR – methylphenidate hcl cap er 24hr 15 mg (xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)APTENSIO XR – methylphenidate hcl cap er 24hr 20 mg (xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)APTENSIO XR – methylphenidate hcl cap er 24hr 30 mg (xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)APTENSIO XR – methylphenidate hcl cap er 24hr 40 mg (xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)APTENSIO XR – methylphenidate hcl cap er 24hr 50 mg (xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)APTENSIO XR – methylphenidate hcl cap er 24hr 60 mg (xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)armodafinil tab 50 mg (Nuvigil)NPPA, QL (30 tablets/30days), 90armodafinil tab 150 mg (Nuvigil)NPPA, QL (30 tablets/30days), 90armodafinil tab 200 mg (Nuvigil)NPPA, QL (30 tablets/30days), 90armodafinil tab 250 mg (Nuvigil)NPPA, QL (30 tablets/30days), 90AZSTARYS – serdexmethylphenidate-dexmethylphenidate cap26.1-5.2 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)AZSTARYS – serdexmethylphenidate-dexmethylphenidate cap39.2-7.8 mgNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)P Preferred DrugAL Age LimitNP Non-Preferred DrugPA Prior AuthorizationSC Supplemental Coverage SF Split FillME Morphine EquivalentQL Quantity Limits90 90 days at mail orderSP Specialty DrugST Step TherapyEffective Date: April 20226
2022Drug NameAZSTARYS – serdexmethylphenidate-dexmethylphenidate cap52.3-10.4 mgPreferred Status Drug Status / RestrictionNPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)CONCERTA – methylphenidate hcl tab er osmotic release (osm)18 mgPPA ( 5 yr & 19 yr),QL (30 tablets/30 days)CONCERTA – methylphenidate hcl tab er osmotic release (osm)27 mgPPA ( 5 yr & 19 yr),QL (30 tablets/30 days)CONCERTA – methylphenidate hcl tab er osmotic release (osm)36 mgPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)CONCERTA – methylphenidate hcl tab er osmotic release (osm)54 mgPPA ( 5 yr & 19 yr),QL (30 tablets/30 days)COTEMPLA XR-ODT – methylphenidate tab extended releasedisintegrating 8.6 mgNPPA ( 5 yr & 19 yr),QL (30 tablets/30 days)COTEMPLA XR-ODT – methylphenidate tab extended releasedisintegrating 17.3 mgNPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)COTEMPLA XR-ODT – methylphenidate tab extended releasedisintegrating 25.9 mgNPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)DAYTRANA – methylphenidate td patch 10 mg/9hrNPPA ( 5 yr & 19 yr), QL(30 patches/30 days)DAYTRANA – methylphenidate td patch 15 mg/9hrNPPA ( 5 yr & 19 yr), QL(30 patches/30 days)DAYTRANA – methylphenidate td patch 20 mg/9hrNPPA ( 5 yr & 19 yr), QL(30 patches/30 days)DAYTRANA – methylphenidate td patch 30 mg/9hrNPPA ( 5 yr & 19 yr), QL(30 patches/30 days)dexmethylphenidate hcl cap er 24 hr 5 mg (Focalin xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)dexmethylphenidate hcl cap er 24 hr 10 mg (Focalin xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)dexmethylphenidate hcl cap er 24 hr 15 mg (Focalin xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)dexmethylphenidate hcl cap er 24 hr 20 mg (Focalin xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)dexmethylphenidate hcl cap er 24 hr 25 mg (Focalin xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)dexmethylphenidate hcl cap er 24 hr 30 mg (Focalin xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)dexmethylphenidate hcl cap er 24 hr 35 mg (Focalin xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)dexmethylphenidate hcl cap er 24 hr 40 mg (Focalin xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)P Preferred DrugAL Age LimitNP Non-Preferred DrugPA Prior AuthorizationSC Supplemental Coverage SF Split FillME Morphine EquivalentQL Quantity Limits90 90 days at mail orderSP Specialty DrugST Step TherapyEffective Date: April 20227
2022Drug NamePreferred Status Drug Status / RestrictionPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)dexmethylphenidate hcl tab 2.5 mg (Focalin)dexmethylphenidate hcl tab 5 mg (Focalin)PPA ( 5 yr & 19 yr),QL (60 tablets/30 days)dexmethylphenidate hcl tab 10 mg (Focalin)PPA ( 5 yr & 19 yr),QL (60 tablets/30 days)FOCALIN – dexmethylphenidate hcl tab 2.5 mgNPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)FOCALIN – dexmethylphenidate hcl tab 5 mgNPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)FOCALIN – dexmethylphenidate hcl tab 10 mgNPPA ( 5 yr & 19 yr),QL (60 tablets/30 days)FOCALIN XR – dexmethylphenidate hcl cap er 24 hr 5 mgPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)FOCALIN XR – dexmethylphenidate hcl cap er 24 hr 10 mgPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)FOCALIN XR – dexmethylphenidate hcl cap er 24 hr 15 mgPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)FOCALIN XR – dexmethylphenidate hcl cap er 24 hr 20 mgPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)FOCALIN XR – dexmethylphenidate hcl cap er 24 hr 25 mgPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)FOCALIN XR – dexmethylphenidate hcl cap er 24 hr 30 mgPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)FOCALIN XR – dexmethylphenidate hcl cap er 24 hr 35 mgPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)FOCALIN XR – dexmethylphenidate hcl cap er 24 hr 40 mgPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)JORNAY PM – methylphenidate hcl cap delayed er 24hr 20 mg(pm)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)JORNAY PM – methylphenidate hcl cap delayed er 24hr 40 mg(pm)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)JORNAY PM – methylphenidate hcl cap delayed er 24hr 60 mg(pm)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)JORNAY PM – methylphenidate hcl cap delayed er 24hr 80 mg(pm)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)JORNAY PM – methylphenidate hcl cap delayed er 24hr 100 mg(pm)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)METHYLIN – methylphenidate hcl soln 5 mg/5mlNPPA ( 5 yr & 19 yr),QL (450 mls/30 days)P Preferred DrugAL Age LimitNP Non-Preferred DrugPA Prior AuthorizationSC Supplemental Coverage SF Split FillME Morphine EquivalentQL Quantity Limits90 90 days at mail orderSP Specialty DrugST Step TherapyEffective Date: April 20228
2022Drug NameMETHYLIN – methylphenidate hcl soln 10 mg/5mlPreferred Status Drug Status / RestrictionNPPA ( 5 yr & 19 yr),QL (900 mls/30 days)methylphenidate hcl cap er 10 mg (cd)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)methylphenidate hcl cap er 20 mg (cd)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)methylphenidate hcl cap er 30 mg (cd)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)methylphenidate hcl cap er 40 mg (cd)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)methylphenidate hcl cap er 50 mg (cd)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)methylphenidate hcl cap er 60 mg (cd)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)methylphenidate hcl cap er 24hr 10 mg (la) (Ritalin la)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)methylphenidate hcl cap er 24hr 20 mg (la) (Ritalin la)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)methylphenidate hcl cap er 24hr 30 mg (la) (Ritalin la)NPPA ( 5 yr & 19 yr), QL(60 capsules/30 days)methylphenidate hcl cap er 24hr 40 mg (la) (Ritalin la)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)methylphenidate hcl cap er 24hr 60 mg (la)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)methylphenidate hcl cap er 24hr 10 mg (xr) (Aptensio xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)methylphenidate hcl cap er 24hr 15 mg (xr) (Aptensio xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)methylphenidate hcl cap er 24hr 20 mg (xr) (Aptensio xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)methylphenidate hcl cap er 24hr 30 mg (xr) (Aptensio xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)methylphenidate hcl cap er 24hr 40 mg (xr) (Aptensio xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)methylphenidate hcl cap er 24hr 50 mg (xr) (Aptensio xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)methylphenidate hcl cap er 24hr 60 mg (xr) (Aptensio xr)NPPA ( 5 yr & 19 yr), QL(30 capsules/30 days)methylphenidate hcl chew tab 2.5 mgNPPA ( 5 yr & 19 yr),QL (90 tablets/30 days)P Preferred DrugAL Age LimitNP Non-Preferred DrugPA Prior AuthorizationSC Supplemental Coverage SF Split FillME Morphine EquivalentQL Quantity Limits90 90 days at mail orderSP Specialty DrugST Step TherapyEffective Date: April 20229
2022Drug NamePreferred Status Drug Status / RestrictionNPPA ( 5 yr & 19 yr),QL (90 tablets/30 days)methylphenidate hcl chew tab 5
The drug list (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. The drugs listed will be covered as long as you: Have a medical need for them Fill the medication orders at an in-network pharmacy Follow the other plan rules For more info
