ABRIDGED STANDARD FORMULARY
The following is a list of the most commonly prescribed brand medications. It represents an abbreviated version of the drug list (formulary) that is at the core of your prescription drug benefit plan. The list is not all-inclusive and does not guarantee coverage. In addition to drugs on this list, the majority of generic medications are covered under your plan and you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. The Elixir Pharmacy & Therapeutics (P&T) committee is responsible for the development and maintenance of the formulary. The committee is comprised of independent practicing physicians and pharmacists from a wide variety of medical specialties. The formulary is reviewed and updated as new drugs or new prescribing information becomes available. Factors which affect decisions regarding the formulary include safe use, clinical efficacy, and therapeutic need. Only after those factors are assessed is cost considered. Compliance with the formulary is important for improving quality of care and restraining health care costs. Search complete formulary drug information at elixirsolutions.com.
PLEASE NOTE: Preferred brand drugs may move to non-preferred status if a generic version becomes available during the year. Any medication approved to enter the market will not be covered until reviewed by the Elixir P&T committee. The list may be subject to change. Not all drugs listed are covered by all prescription-drug benefit programs. For specific questions about your coverage, please call the phone number printed on your member ID card or visit elixirsolutions.com
ACNE PRODUCTS AKLIEF [NP] AMZEEQ [NP] EPIDUO EPIDUO FORTE ACTINIC KERATOSIS PICATO [NP] ALLERGENIC EXTRACTS GRASTEK [NP] ODACTRA [NP] RAGWITEK [NP] AMINOGLYCOSIDE INHALANTS KITABIS [SP]
AMYOTROPHIC LATERAL SCLEROSIS
TIGLUTIK [SP] ANDROGENS JATENZO [NP] NATESTO [NP] XYOSTED [NP] ANTIBIOTICS BAXDELA [NP] NUZYRA [SP] XENLETA [SP] ANTICONVULSANTS BRIVIACT [NP] FYCOMPA [NP] NAYZILAM [NP] SPRITAM [NP] VIMPAT [NP] ANTIDEPRESSANTS FETZIMA [NP] SAVELLA TRINTELLIX VIIBRYD [NP] ANTIDIABETIC - BIGUANIDES RIOMET ER [NP]
ANTIDIABETIC - DIPEPTIDYL PEPTIDASE-4 INHIBITORS (DPP-4) & COMBINATIONS
JANUMET JANUMET XR JANUVIA JENTADUETO ONGLYZA TRADJENTA ANTIDIABETIC - GLP-1 COMBINATION SOLIQUA XULTOPHY
ANTIDIABETIC - GLUCAGON-LIKE PEPTIDE-1 AGONISTS (GLP-1) OZEMPIC RYBELSUS TRULICITY VICTOZA ANTIDIABETIC - HYPOGLYCEMIA BAQSIMI GLUCAGEN GLUCAGON GVOKE ANTIDIABETIC - INSULIN FIASP HUMULIN R U-500 LANTUS LEVEMIR NOVOLIN NOVOLIN70/30 NOVOLOG TOUJEO TRESIBA ANTIDIABETIC - SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT-2) INHIBITOR & COMBINATIONS
FARXIGA INVOKAMET INVOKAMET XR INVOKANA SYNJARDY [NP] SYNJARDY XR [NP] TRIJARDY XR [NP] XIGDUO XR ANTIFUNGAL AGENTS JUBLIA NAFTIN 2% GEL ANTIHYPERLIPIDEMICS LIPOFEN LIVALO PRALUENT REPATHA VASCEPA WELCHOL ZYPITAMAG ANTI-INFECTIVE AGENTS XIFAXAN ANTIPARKINSON ADJUVANTS NOURIANZ [SP] ANTIPARKINSON DOPAMINERGICS NEUPRO [NP] ANTIPSYCHOTICS - INJECTABLE ABILIFY MAINTENA PERSERIS ANTIPSYCHOTICS - ORAL REXULTI SAPHRIS [NP] VRAYLAR [NP] ANTIRETROVIRALS DESCOVY [NP] ANTIRHEUMATIC OTREXUP [NP] RASUVO [NP] ANTIVIRALS (HEP C) EPCLUSA [SP] HARVONI [SP] LEDIP-SOFOSB [SP] MAVYRET [SP] SOFOS/VELPAT [SP] VOSEVI [SP]
ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) DYANAVEL [NP] JORNAY [NP] MYDAYIS [NP] QUILLICHEW [NP] QUILLIVANT [NP] VYVANSE BIOLOGIC INJECTABLE DUPIXENT [SP]
BONE DENSITY REGULATORS
PROLIA [SP] CARDIOVASCULAR - AGENT BRILINTA CORLANOR CARDIOVASCULAR - AGENT COMBINATIONS BIDIL [NP] ENTRESTO CARDIOVASCULAR - ANTIARRHYTHMICS MULTAQ CARDIOVASCULAR - ANTICOAGULANTS ELIQUIS PRADAXA XARELTO
CARDIOVASCULAR - BETA BLOCKERS CARDIO-SELECTIVE
BYSTOLIC
CARDIOVASCULAR - BETA BLOCKERS NON-SELECTIVE
HEMANGEOL [NP]
CARDIOVASCULAR - CALCIUM CHANNEL BLOCKERS
KATERZIA [NP]
CARDIOVASCULAR - PULMONARY ARTERIAL HYPERTENSION (PAH)
ADEMPAS [SP] OPSUMIT [SP] ORENITRAM [SP] UPTRAVI [SP] CONTRACEPTIVES - ORAL BEYAZ LO LOESTRIN NATAZIA SAFYRAL YASMIN YAZ CONTRACEPTIVES - VAGINAL ANNOVERA [NP] CORTICOSTEROIDS - TOPICAL DUOBRII ENSTILAR [NP] HALOG [NP] CORTICOTROPIN ACTHAR [SP] DIABETIC SUPPLIES
BD PEN NEEDLES & SYRINGES OMNIPOD [NP]
V-GO [NP]
DIABETIC SUPPLIES BLOOD GLUCOSE METERS & TEST STRIPS
FREESTYLE ONETOUCH
PRECISION
DIABETIC SUPPLIES CONTINOUS BLOOD GLUCOSE METERS & TEST STRIPS
DEXCOM G6 FREESTYLE LIBRE 1 & 2
DIGESTIVE ENZYMES CREON ZENPEP ENDOMETRIOSIS ORILISSA [SP] ESTROGEN COMBINATIONS BIJUVA [NP] ESTROGENS DUAVEE ESTROGEL [NP] PREMARIN
PREMARIN VAGINAL CREAM PREMPHASE
PREMPRO
FERTILITY REGULATORS
FOLLISTIM AQ [SP]
GASTROINTESTINAL - ANTIEMETIC NEUROKININ-1 RECEPTOR ANTAGONISTS
VARUBI
GASTROINTESTINAL - BOWEL PREP AGENTS
CLENPIQ SUPREP
GASTROINTESTINAL - IRRITABLE BOWEL SYNDROME & OPIOID INDUCED CONSTIPATION AGENTS (IBS - OICA)
LINZESS MOVANTIK [NP] SYMPROIC [NP] ZELNORM [NP]
GASTROINTESTINAL - IRRITABLE BOWEL SYNDROME (IBS) AGENTS
VIBERZI [NP]
GASTROINTESTINAL - PROTON PUMP INHIBITORS
DEXILANT
GASTROINTESTINAL - ULCERATIVE COLITIS AGENTS UCERIS [NP] GOUT AGENTS MITIGARE GRANULOCYTE COLONY-STIMULATING FACTORS (G-CSF) PROCRIT [SP] ZARXIO [SP] ZIEXTENZO [SP] GROWTH HORMONE GENOTROPIN [SP] OMNITROPE [SP] HYALURONICS EUFLEXXA [SP] SYNVISC [SP] SYNVISC ONE [SP]
ABRIDGED STANDARD FORMULARY
Continued
Elixir • 2021 Standard Formulary | 2
[NP] = Non-Preferred [SP] = Specialty [SP]* = All specialty brand drugs
HYPERKALEMIA LOKELMA [NP] INFLAMMATORY CONDITIONS COSENTYX [SP] ENBREL [SP] HUMIRA [SP] OTEZLA [SP] RINVOQ [SP] SKYRIZI [SP] STELARA [SP] XELJANZ [SP] INSOMNIA BELSOMRA DAYVIGO METABOLIC MODIFIERS RAYALDEE [NP] MIGRAINE - CGRP ANTAGONISTS AIMOVIG EMGALITY NURTEC ODT UBRELVY
MIGRAINE - SELECTIVE SEROTONIN AGONISTS 5-HT(1)
TOSYMRA
MIGRAINE - SEROTONIN AGONISTS
REYVOW ZEMBRACE [NP] MOVEMENT DISORDERS AUSTEDO [SP] MULTIPLE SCLEROSIS AUBAGIO [SP] AVONEX [SP] BAFIRATEM [SP] BETASERON [SP] COPAXONE 40MG [SP] GILENYA [SP] MAYZENT [SP] PLEGRIDY [SP] VUMERITY [SP] ZEPOSIA [SP] NARCOLEPSY SUNOSI XYREM [SP] XYWAV [SP] NASAL STEROIDS DYMISTA [NP] OMNARIS [NP] QNASL XHANCE [NP] ZETONNA [NP] NOCTURNAL POLYURIA NOCDURNA [NP] ONCOLOGY IBRANCE [SP] RUXIENCE [SP] TRAZIMERA [SP] ZIRABEV [SP] ONCOLOGY MYLERAN [SP] ONCOLOGY - GNRH AGONISTS ELIGARD [SP] ONCOLOGY - ANTIANDROGENS ERLEADA [SP] XTANDI [SP] ZYTIGA [SP]
ONCOLOGY - ENZYME INHIBITORS
KISQALI [SP]
ONCOLOGY - TYROSINE KINASE INHIBITORS SPRYCEL [SP] OPHTHALMICS - CYCLOSPORINE RESTASIS XIIDRA OPHTHALMICS - ADRENERGIC AGENTS ALPHAGAN COMBIGAN OPHTHALMICS - ALLERGIC CONJUNCTIVITIS PAZEO OPHTHALMICS - ANTIGLAUCOMA RHOPRESSA ROCKLATAN OPHTHALMICS - CARBONIC ANHYDRASE INHIBITORS AZOPT COSOPT PF [NP] SIMBRINZA OPHTHALMICS - CORTICOSTEROIDS FOR POST-OPERATIVE PAIN
DUREZOL INVELTYS [NP]
OPHTHALMICS - NSAIDS POST- OPERATIVE PAIN ILEVRO OPHTHALMICS - PROSTAGLANDINS LUMIGAN ZIOPTAN [NP] OPHTHALMICS - STEROIDS BROMSITE OPIOID ABUSE ZUBSOLV
OPIOID AGONISTS - EXTENDED RELEASE BELBUCA XTAMPZA OPIOID ANTAGONISTS NARCAN OSTEOPOROSIS TERIPARATIDE [SP] TYMLOS [SP] OTIC COMBINATIONS CIPRODEX OTOVEL [NP]
PHOSPHATE BINDER AGENTS
AURYXIA [NP] VELPHORO PRENATAL VITAMINS CITRANATAL PROGESTINS MAKENA RESPIRATORY - INHALED CORTICOSTEROIDS ALVESCO [NP] ARNUITY ASMANEX FLOVENT PULMICORT QVAR REDIHALER RESPIRATORY - CHRONIC OBSTRUCTIVE PULMONARY DISEASE
DALIRESP LONHALA [NP] YUPELRI [NP]
RESPIRATORY- INHALED CORTICOSTERIOD/LONG ACTING BETA-2 AGONIST
ADVAIR BREO SYMBICORT
RESPIRATORY - LONG ACTING BETA-2 AGONIST
SEREVENT
RESPIRATORY - LONG ACTING MUSCARINIC ANTAGONIST
INCRUSE SPIRIVA
RESPIRATORY - LONG ACTING MUSCARINIC ANTAGONIST/ LONG ACTING BETA-2 AGONIST
ANORO BREZTRI STIOLTO TRELEGY
RESPIRATORY - SHORT ACTING BETA-2 AGONIST/SHORT ACTING MUSCARINIC ANTAGONIST
COMBIVENT
RESPIRATORY - SHORT ACTING BETA-2 AGONIST PROAIR RESPICLICK VENTOLIN RESPIRATORY - SEVERE ASTHMA AGENTS FASENRA [SP] NUCALA [SP] ROSACEA AGENTS FINACEA FOAM [NP] RHOFADE [NP] ZILIXI [NP]
SICKLE CELL ANEMIA
DROXIA TOPICAL AGENTS EUCRISA FLECTOR [NP] QBREXZA [NP] UTERINE FIBROIDS ORIAHNN [SP] URINARY ANTISPASMODIC MYRBETRIQ VAGINAL ESTROGENS IMVEXXY [NP]
WEIGHT LOSS AGENTS
CONTRAVE SAXENDA
EXCLUDED MEDICATIONS WITH COVERED ALTERNATIVES
THERAPEUTIC CATEGORY FORMULARY ALTERNATIVE FORMULARY EXCLUSION
ANALGESICS
Anti-Inflammatory Injectable Caldolor[NP], ketorolac Anjeso
Nonsteroidal Anti-inflammatory Drugs (NSAIDs) diclofenac, indomethacin, meloxicam Indocin, Tivorbex, Vivlodex, Zipsor, Zorvolex
Opioid Agonists - Extended Release Belbuca, Xtampza Arymo ER, Butrans, Embeda, Exalgo, Hysingla ER,
Kadian, Nucynta ER, Opana ER, Oxycontin, oxycodone ER
Opioid Agonists - Immediate Release oxycodone Nucynta, Oxaydo
Opioid Combinations generic hydrocodone/acetaminophen Apadaz
ANAPHYLAXIS AGENTS
Allergic Reactions epinephrine auto-injector Auvi-Q 0.15mg, Auvi-Q 0.3mg
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT
Opioid Abuse Zubsolv Bunavail, buprenorphine/naloxone, Suboxone Film
Opioid Antagonists Narcan, Naloxone Evzio
ANTIBIOTICS
Antiprotozoals, Miscellaneous metronidazole Solosec
ANTICONVULSANTS
Anticonvulsants, Miscellaneous pregabalin Lyrica CR
ANTIHISTAMINE
Antihistamine Non-Sedating diphenhydramine injection Quzyttir
ANTIPARKINSON AGENTS
Parkinson disease[SP]* Apokyn, Inbrija, Nourianz Kynmobi
ANTIPSYCHOTICS/ANTIMANIC AGENTS
Antipsychotics Oral aripiprazole, olanzapine, quetiapine, Rexulti,
Saphris[NP], Vraylar[NP], ziprasidone Caplyta
ANTIPYSCHOTICS/ANTIMANIC AGENTS
Antipyshcotics Oral aripiprazole, olanzapine, quetiapine, Rexulti,
Saphris [NP], Vraylar [NP], ziprasidone Caplyta
ANTIVIRALS
Hepatitis C [SP]* Epclusa, Harvoni, Mavyret, Vosevi Daklinza, Olysio, Sovaldi, Technivie, Viekira, Zepatier
AUTONOMIC & CENTRAL NERVOUS SYSTEM
Movement Disorders [SP]* Austedo Ingrezza2
Transmucosal Fentanyl Analgesics fentanyl lozenge Abstral, Fentora, Lazanda, Subsys
CONTRACEPTIVES
Oral Contraceptives Beyaz, Lo Loestrin, Natazia, Safyral, Yasmin, Yaz generic Beyaz1, generic Safyral1, generic Yasmin1,
generic Yaz1
Topical Contraceptives Xulane [NP] Twirla
DERMATOLOGY
Acne (Antibiotics) minocycline ER tablets minocycline ER capsules, Minolira, Seysara, Ximino
Acne (Oral Agents) Claravis, Myorisan, Zenatane Absorica, Absorica LD
Acne (Topical Agents) clindamycin phosphate, Epiduo Forte Gel, Epiduo Acanya, Aczone, adapal/ben P gel, Atralin, Arazlo,
Clindagel, Onexton, Retin-A, Tazorac, Tretin-X, Ziana
Actinic Keratosis fluorouracil 5% cream, imiquimod 5% cream, Picato[NP] Aldara, Ameluz, Carac, Tolak, Zyclara
Antifungals - Body ciclopirox, luliconazole Luzu
Transdermal Anti-Inflammatory Agents Diclofenac 1.3% patch[NP], Flector patch [NP] Licart patch
DIABETES
Biguanides metformin (generic Glucophage or
generic Glucophage XR) Fortamet, Generic Fortamet, Glumetza, Generic Glumetza Blood Glucose Meters & Test Strips Abbott (Freestyle, Precision), Lifescan (Onetouch) Ascencia (Breeze, Contour), Roche (Accu-Chek),
all other test strips that are not Abbott (Freestyle, Precision) or Lifescan (Onetouch) brand
EXCLUDED MEDICATIONS WITH COVERED ALTERNATIVES Continued
Elixir • 2021 Standard Formulary | 4
[NP] = Non-Preferred [SP] = Specialty [SP]* = All specialty brand drugs
THERAPEUTIC CATEGORY FORMULARY ALTERNATIVE FORMULARY EXCLUSION
Continuous Blood Glucose Monitors Dexcom G6, FreeStyle Libre 1 & 2 All other continuous blood glucose products that
are not Freestyle Libre 1 & 2 or Dexcom G6
Glucagon-Like Peptide-1 Agonists (GLP-1) Ozempic, Rybelsus, Trulicity, Victoza Adlyxin, Bydureon, Byetta, Tanzeum
Long-Acting Insulin Lantus, Levemir, Novolin, Toujeo, Tresiba Basaglar, Humulin
Pen Needles & Syringes BD Products All Pen Needles and Syringes besides BD products
Rapid Acting Insulin Novolin, Novolog Afrezza, Apidra, Humalog, Humulin, Lyumjev
Sodium-Glucose Co-transporter 2 (SGLT-2)
Inhibitor & Combinations Farxiga, Invokamet, Invokamet XR, Invokana, Jardiance[NP], Synjardy[NP], Synjardy XR[NP], Trijardy XR[NP], Xigduo
Glyxambi, Qtern, Segluromet, Steglatro, Steglujan
ENDOCRINE AND METABOLIC AGENTS
Bile Acid Sequestrants Welchol colesevalam
Gonadotropin Releasing Hormone Agonists[SP]* Eligard Lupron2
Osteoporosis[SP]* Teriparatide, Tymlos Forteo
Topical Testosterone Products generic testosterones Androderm, Axiron, Fortesta, Testim, Vogelxo
GASTROINTESTINAL
Anti-Inflammatory/Anti-Ulcer Agents famotidine + ibuprofen or omeprazole + naproxen Duexis, Vimovo
Corticosteroid/Crohn’s disease budesonide tab Ortikos
HEMATOLOGICAL
Hereditary Angioedema[SP]* Firazyr icatibant
IMMUNE GLOBULIN
IVIG[SP]* Gammagard, Gammaplex, Octagam, Panzyga, Privigen Asceniv
MIGRAINE PRODUCTS
CGRP Medications Aimovig, Emgality Ajovy
ONCOLOGY
Corticosteroid/Multiple Myeloma dexamethasone Hemady
OPHTHALMIC AGENTS
Ophthalmic Adrenergic Agents Alphagan, brimonidine tartrate, Combigan, Timoptic
Ocudose[NP]2 Betimol, Betoptic-S, Istalol, Timoptic, Timoptic-XE
Ophthalmic Allergic Conjunctivitis olopatadine, Pazeo Alrex, Bepreve, Elestat, Lastacaft, Pataday, Patanol,
Zerviate
Ophthalmic Carbonic Anhydrase Inhibitors Azopt, Cosopt PF[NP]2, Simbrinza Cosopt, Trusopt
Ophthalmic NSAIDS Bromsite, Ilevro Acular, Acuvail, Nevanac, Prolensa
Ophthalmic Prostaglandins Lumigan, travoprost Travatan, Vyzulta, Xalatan, Xelpros
Ophthalmic Steroids Durezol Emu, Inveltys[NP] Blephamide, Dexameth, Flarex, FML, FML Forte,
FML Liquifilm, Lotemax, Maxidex, Maxitrol, Pred Forte, Pred Mild, Pred-G, Pred-G S.O.P., Pred Sod Phos, Tobradex, Zylet
OTIC AGENTS
Otic combinations Ciprodex cipro/dexa
RESPIRATORY
Long-Acting Beta-2 Agonists Serevent, Striverdi[NP] Arcapta
Long Acting Beta-2 Agonist/Inhaled Corticosteriod Advair, Breo Ellipta, Symbicort Airduo Digihaler, budesonide-formoterol,
fluticasone/salmeterol, Wixela Long Acting Beta-2 Agonist/Long Acting
Muscarinic Antagonist Anoro Ellipta, Stiolto Duaklir
Inhaled Corticosteriod Arnuity Ellipta, Asmanex, Flovent ArmonAir Digihaler
Short Acting Beta-2 Agonist Levalbuterol, ProAir Respiclick, Ventolin ProAir Digihaler, Xopenex
SLEEP DISORDER INSOMNIA AGENTS
Benzodiazepine Hypnotics temazepam, triazolam Doral, Halcion, quazepam, Restoril
Non-Benzodiazepine Hypnotics Belsomra, Dayvigo, doxepin, eszopiclone,
EXCLUDED MEDICATIONS WITH COVERED ALTERNATIVES Continued
UROLOGICAL
Urinary Antispasmodic Myrbetriq, oxybutynin, tolterodine, trospium Enablex, Toviaz, Vesicare
WEIGHT LOSS
STEP THERAPIES
Elixir • 2021 Standard Formulary | 6
[NP] = Non-Preferred [SP] = Specialty [SP]* = All specialty brand drugs
ANALGESICS/ANTI-INFLAMMATORY: BIOLOGIC IMMUNOMODULATORS[SP]*2
Ankylosing
Spondylitis Crohn's Disease Juvenile Idiopathic Arthritis Plaque Psoriasis Psoriatic Arthritis Rheumatoid Arthritis Ulcerative Colitis PRIMARY
TREATMENT[SP]* Enbrel Humira Humira Stelara Enbrel Humira Enbrel Humira
Otezla Skyrizi Stelara Enbrel Humira Otezla Stelara Enbrel Humira Rinvoq Humira Stelara SECONDARY
TREATMENT[SP]* Cosentyx Cimzia Actemra Orencia Cosentyx** Cosentyx Kevzara Simponi Xeljanz TERTIARY
TREATMENT† [SP]* Cimzia Simponi
Taltz Cimzia Ilumya Siliq Taltz Tremfya Cimzia Orencia Simponi Taltz Tremfya Actemra Cimzia Kineret Olumiant Orencia Simponi Xeljanz † Tertiary Treatment requires the trial and failure of all Primary and Secondary products
**Try and fail Humira only
THERAPEUTIC CATEGORY PRIMARY TREATMENT SECONDARY TREATMENT
ANTIBIOTICS
Aminoglycoside Inhalants[SP]*2 Kitabis Pak, tobramycin neb Bethkis, Tobi Neb, Tobi Podhaler
Topical Antibiotics mupirocin Xepi[NP]
ANTI-INFLAMMATORY
Tumor-Necrosis Factor-alpha (infusion)[SP]*2 Avsola Inflectra, Remicade, Reneflexis
ANTINEOPLASTIC
CD4/6 Inhibitors[SP]*2 Ibrance, Kisqali Verzenio
ANTIVIRALS
Antiretrovirals generic Symfi, generic Symfi Lo Atripla[NP]
DERMATOLOGY
Antifungals Jublia Kerydin[NP]
DIABETES
Dipeptidyl Peptidase-4 Inhibitors (DPP-4)
& Combinations Janumet, Janumet XR, Januvia, Jentadueto, Tradjenta alogliptin[NP], alogliptin/pioglitazone[NP], Kazano[NP], Kombiglyze[NP], Nesina[NP], Onglyza, Oseni[NP]
ENDOCRINE AND METABOLIC AGENTS
Growth Hormone[SP]*2 Genotropin, Omnitrope Humatrope Norditropin, Nutropin AQ, Saizen, Serostim,
Zomacton, Zorbtive
Hyperkalemia Lokelma[NP] Veltassa[NP]
Testosterone (injectable) testosterone cypionate, testosterone enanthate Xyosted[NP]
Vasopressin Analogs Nocdurna[NP] Noctiva[NP]
GASTROINTESTINAL
Bowel Prep Agents Clenpiq, Suprep Moviprep[NP], Osmoprep[NP], Plenvu[NP],
Prepopik[NP] Irritable Bowel Syndrome & Opioid Induced
Constipation Agents Linzess, Movantik[NP], Symproic[NP], Zelnorm[NP] Amitiza[NP], Motegrity[NP], Relistor[NP], Trulance[NP]
Ulcerative Colitis Agents balsalazide, mesalamine, sulfasalazine Apriso[NP], Asacol HD[NP], Azulfidine[NP], Canasa[NP]
Delzicol[NP], Dipentum[NP], Giazo[NP], Lialda[NP], Pentasa[NP], Uceris Tablet[NP], Uceris Foam[NP]
Travelers Diarrhea azithromycin, ciprofloxacin Aemcolo[NP]
HEMATOLOGICAL AGENTS
STEP THERAPIES Continued
About Elixir | elixirsolutions.com
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THERAPEUTIC CATEGORY PRIMARY TREATMENT SECONDARY TREATMENT
HEMATOPOIETIC AGENTS
Erythropoiesis-Stimulating Agents[SP]* Retacrit Aranesp, Epogen, Procrit
Granulocyte Colony-Stimulating Factors (G-CSF)[SP]*2 Zarxio Granix, Neupogen, Nivestym
Hematopoietic Agents[SP]*2 Ziextenzo Fulphila, Neulasta, Udenyca
Thrombopoietin Receptor Agonists[SP]*2 Mulpleta Doptelet
MIGRAINE
Acute Migraine (Oral) generic triptan Nurtec ODT, Reyvow, Ubrelvy
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS – MISC.
Amyotrophic Lateral Sclerosis (ALS)[SP]* Rilutek Tiglutik
Antidementia Agents donepezil, memantine (immediate release) Namenda XR[NP], Namzaric[NP]
Multiple Sclerosis[SP]*2,3 Aubagio, Avonex, Bafiertam, Betaseron, Copaxone
40mg, dimethyl fumarate, Gilenya,
glatiramer 20mg and 40mg, Plegridy, Vumerity, Zeposia
Copaxone 20mg, Extavia, Kesimpta, Lemtrada, Ocrevus, Rebif, Tecfidera, Tysabri
RESPIRATORY
Short Acting Beta-2 Agonist ProAir Respiclick, Ventolin albuterol sulfate HFA inhaler[NP], Proventil[NP]
[NP] = Non-Preferred [SP] = Specialty [SP]* = All specialty brand drugs | Brand drugs = Capitalized Generic drugs = lower case 1 Generic YASMIN and YAZ are commonly marketed as Gianvi, Loryna, Ocella, Syeda, Vestura, or Zarah
2 Managed by prior authorization to assess indication 3 Requires trial and failure of only one primary treatment
