Regence formulary changes effective July 1, 2016 for Pioneer Educators Health Trust
Eurax - Move to Tier 3. Topical medication used to treat scabies. Generic alternatives available. Ivermectin
tablets (generic), malathion topical (generic), permethrin topical (generic).
Tazorac- Move to Tier 3. Topical medication used for the treatment of acne. Generic alternatives
available. Topical generic antibiotics (e.g. clindamycin, erythromycin), topical generic retinoids (e.g. adapalene,
tretinoin).
Dymistra - Not medically necessary for new and existing utilizers. A nasal spray combination medication used to
treat nasal allergy symptoms.
The combination of fluticasone (a corticosteroid) and azelastine (an antihistamine) are available separately as
generics.
Gralise - Not medically necessary for new and existing utilizers. Medication is for extended-release gabapentin
used to treat nerve pain and some other conditions. Generic extended-release gabapentin is available with a new
prescription.
Non-FDA Approved Medications – Medications that can no longer be offered due to not being FDA approved.
These mediations have over the counter options available and thus prescriptions are no longer necessary. These
items include specialty toothpaste, hemorrhoid crème, certain acne medications, or prenatal vitamins, all of
which have options for OTC use.
Omega-3 fatty acids (Epanova, Lovaza, Omtryg, Vascepa) - Pre-authorization required for new and existing
utilizers. These medications are used to treat high cholesterol. These medications will be coverable only when
there is documentation of an intolerance or contraindication to an inactive ingredient in all generic/OTC
alternatives (called Omega-3 fatty acids).
High cost fenofibrates (Antara, Fenoglide, Lipofen, Triglide) - Pre-authorization required for new and existing
utilizers. These medications are used to treat high cholesterol. Generic alternatives available. Generic gemfibrozil
and less costly generic fenofibrates.
Noritate - Pre-authorization required for new and existing utilizers. Topical metronidazole used to treat rosacea,
a chronic inflammatory skin condition. Will be approvable only when there is documentation that both generic
metronidazole cream and metronidazole gel have been ineffective after at least one month of treatment, are not
tolerated, or are contraindicated. Generic metronidazole cream and metronidazole gel.
Amitiza - Pre-authorization required for new and existing utilizers. Used to treat various types of constipation.
Alternatives OTC’s available.
Psyllium powder (OTC Metamucil), methylcellulose (OTC Citrucel), polyethylene glycol (OTC Miralax), bisacodyl
(OTC Dulcolax), senna (OTC).
Pennsaid - Pre-authorization required for new and existing utilizers. Topical non-steroidal anti-inflammatory drug
(NSAID) used to treat osteoarthritis of the knee. Alternatives available: generic diclofenac 1.5% topical solution,
diclofenac topical gel (Voltaren), oral diclofenac (generic).
Xanax and Xanax/XR -Pre-authorization required for new and existing utilizers. This medication is used to treat
anxiety. These medications will be coverable only when there is documentation of an intolerance or
contraindication to an inactive ingredient in all generic alternatives. Generic alprazolam, generic alprazolam ER.
Oral Emend - Pre-authorization for new utilizers. Tier change to 3 for existing utilizers. Oral medication used for
chemotherapy-induced nausea and vomiting. Pre-authorization will require step therapy with Varubi, a similar
medication. Injectable Emend will remain at Tier 3 (non-preferred) and does not require pre-authorization.
Amrix - Not medically necessary for new and existing utilizers. This is extended-release cyclobenzaprine, which is
used to treat muscle spasms. Generic extended-release gabapentin is available with a new prescription.
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