drug coverage criteria – new and therapeutic equivalent medications

COVERAGE RATIONALEThis policy provides information and criteria relevant to medications for which certain types ofprescription drug benefit exclusions may apply.In accordance with Oxford's prescription drug riders, certain medications are excluded fromcoverage. The rationale for such exclusions varies, and therefore coverage may be provided incertain clinical scenarios.There are two types of exclusions addressed in this policy:Exclude at Launch: In an effort to enhance the affordability and value of prescriptiondrug riders, and as part of our Prescription Drug List (PDL) management, Oxford willproactively identify and help manage the cost of low value medications being introducedinto the market. The Exclude at Launch program delays coverage until a full evaluationcan be completed for new medications that may offer little to no additional health carevalue. Our PDL Management Committee will review each Exclude at Launch medicationto determine its tier placement or benefit coverage.Same Active Ingredient: Oxford may exclude coverage for a medication, unless it ismedically necessary for the member, if it includes the same active ingredient (or amodified version of an active ingredient) and is therapeutically equivalent to a coveredprescription medication. Oxford's definition of therapeutic equivalence refers tomedications that produce the same therapeutic outcome and adverse event profile.The following table provides a list of prescription medications for which one or both of the aboveexclusions apply. Precertification through the Pharmacy Benefit Manager (PBM) is requiredfor all listed medications. Coverage will be provided only when Member has exhibitedintolerance (that is, sensitivity, drug allergy, adverse effect) to, or experienced a therapeuticfailure with, the covered formulary alternative(s) noted below.Medication/DrugFormulary Alternative(s)Absoricaisotretinoin (generic Accutane), Amnesteem, Claravis,Myorisan, SotretAcuvailKetorolacAdoxa 150mg (Brand)Doxycycline 50 mg or 100mgAlsumasumatriptan injectionAltoprevLovastatin (generic Mevacor)AmrixCyclobenzaprine HCL(generic for Flexeril)AmturnideAmlodipine + Tekturna HCT (or individual components takenconcomitantly)Analpram Advanced KitHydrocortisone acetate/pramoxine HCl, Analpram HCAndrogelTestimAplenzinBuproprion XL (generic for Wellbutrin XL)Aqua Glycolilc HCHydrocortisone 2.5% (generic Hytone)Aricept (23 mg only)donepezil 10mg (generic for Aricept 10mg)Asacol HDAsacolAsmalPredPrednisolone sodium phosphate (generic Orapred)AsmalPred Plusprednisolone sodium phosphate (generic Orapred)Astelin (brand only)Azelastine nasal spray (generic Astelin), AsteproAtelviaActonelAugmentin XR / Amoxicillin-Clavulanate Amoxicillin/clavulanate potassium (generic for Augmentin)ERAuralgan 5.5%/1.4%Antipyrine/benzocaine solution – 5.4%/1.4% (genericAuralgan)Auvi-QEpiPen, EpiPen Jr.Drug Coverage Criteria - New and Therapeutic Equivalent Medications: Clinical Policy (Effective 04/01/2013)©1996-2013, Oxford Health Plans, LLC2