0 /I2 12 0 R %PDF-1.5 %���� Step Therapy is a limitation that requires you to try preferred medications before the plan will pay for another drug for the same medical condition that the doctor may have originally prescribed. /MediaBox [0.000 0.000 612.000 792.000] 3 0 obj /F3 10 0 R JANUMET, JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR JIVI [INJ] JULUCA junel 2020 Express Scripts National Preferred Formulary The following is a list of the most commonly prescribed drugs. >>

Find a coupon and save up to 80% on your prescription at … >>

There is no minimum or maximum number of agents that may be placed in a given cost share tier classification, though you may submit multiple quotes based on different condition sets (See NOTE above and UF BPA and UF VARR Quotes section below). /Length 1743 >> ���. 7 0 obj stream 6 0 obj ] /Producer (dompdf + CPDF) /I4 20 0 R topiramate (Topamax, Qudexy XR) felbamate (Felbatol) oxcarbazepine (Oxtellar XR, Trileptal) and barbiturates like phenobarbital; Some HIV medications, such as efavirenz, protease inhibitors, or antiviral boosters may also affect birth control effectiveness. /F1 8 0 R S. Trokendi XR* or Qudexy XR* (brand and authorized generic) will be approved based on one of the following criteria: 1. /F2 9 0 R >> 1 0 obj %PDF-1.3 /Pages 3 0 R >> << /Type /Catalog << /Filter /FlateDecode endobj /ModDate (D:20200916153239+00'00') >> << /Type /Page %%EOF

Failure of a trial of generic immediate release topiramate (at up to maximally indicated doses) unless contraindicated or clinically significant adverse effects are experienced; 4. Y�)"ǎ5�;z�g�23�`)Q�� ��"� @��x�Ii ��2�3�IG)�l�v0c�djae�.�ܠ��a�q�lf�m' n�g`T �Db`c�s�4��b�@~a�� ������� Q�.� classification (i.e., generic (Tier 1), formulary (Tier 2), or non-formulary (Tier 3) for each agent. x��Xێܸ|����6�K�ڗ� ��'����S�R��g�$0�ݢX�N�b�w��eI.��V$��f;Y&�����6�žU/>ݧ⳽�r��]�leqHnd���+�ˊ���a{�+�\fev�!��,������D&x��ow���ȶ{��wb�ne���C->�!i)����;�z�ǿ��?��?кe�r���]6/KE��첬5^�V� ���PG;1y3�D��S�A(1:}�P��j�ܚN���ʇF�+���3Cc�;��v�j1X��Q��j�!��r���c�*-l#zlQ�NT��@�O?5���l''Z�����Gg�L����*��ba#_��c��@/��f��.i=��qXV��Jp6�G�4S-DZ&�klC�>�!��?&�},�7'�̠��ZU��R��*��y+�Z,�Y�\�/�t+�%�mmg|��7��6�:��7�Lo�=jo�y��Q����UkTp(�J��j��h;宿H'���'�[(g�(����� �c�~݈g�P��_�/S�����׏�4�p6*HEJ

/Contents 7 0 R Both of the following: a. Studies have not been done to see if topiramate use could make it harder for women to get pregnant. [/PDF /Text /ImageC ]

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All drugs are listed by brand or generic name. h�bbd``b`� $V � @�]$6�] b��� �;�� "n�C �� b�\Q u� �B���9L��� .#���Fo �` D /Outlines 2 0 R

endstream endobj startxref endstream endobj 443 0 obj < History of an inadequate response to one of the following: (1) generic topiramate (2) Topamax -OR- 2. 442 0 obj <> endobj 2. endobj >> /CreationDate (D:20200916153239+00'00') /Count 2 /Kids [6 0 R SmartPA: Claims for topiramate extended-release capsule (generic Qudexy XR) will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for 90 out of the last 120 days of the requested agent and if the member has a history of MassHealth medical claims for epilepsy/seizures.† >>

It represents an abbreviated version of the drug list (formulary) that is at the core of your prescription plan. /Resources << Can it make it harder for me to get pregnant? /Font << Studies << /Type /Outlines /Count 0 >> /Title (Topiramate | MotherToBaby) History of ≥ 2 week trial of one of the following: (1) generic topiramate (2) Topamax -AND- b.

14 0 R 5 0 obj 460 0 obj <>/Filter/FlateDecode/ID[<8ABD548209B4CB4DBC7346180667C8CC><5BF76BBE7C199249A7D6489976FEB9A0>]/Index[442 41]/Info 441 0 R/Length 89/Prev 85165/Root 443 0 R/Size 483/Type/XRef/W[1 2 1]>>stream

• Any brand-name drug for which a generic drug becomes available will be designated as a non-preferred drug. ���9�t�c�� /XObject <<

When a generic version is available, mandatory generic substitution will apply. /MediaBox [0.000 0.000 612.000 792.000] endobj (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program.

<< In this case, use of a non-preferred product will result in

/I5 21 0 R Qudexy XR Oral, Topamax Oral, Topiragen Oral, Trokendi XR Oral All generic drug interactions for topiramate oral (lists will include brand and generic names): 42 serious drug interactions endobj 482 0 obj <>stream /I3 13 0 R Levonorgestrel is used to prevent pregnancy after unprotected sexual intercourse (sex without any method of birth control or with a birth control method that failed or was not used properly [e.g., a condom that slipped or broke or birth control pills that were not taken as … Dose does not exceed: a. endobj Age ≥ 2 years old for Qudexy XR, ≥ 6 years old for Trokendi XR; 3.

<< /Type /Pages

h�b```��,����(� Methylphenidate ER Adhansia XR Add QL of 30 units per 30 days 01/01/2020 11/13/2019 ... Topiramate ER Qudexy XR Add PA 10/01/2019 08/14/2019 ... Levonorgestrel Plan B Remove from ACA list (generic available) 07/01/2019 05/15/2019 Browse all medications on GoodRx beginning with the letter Q.

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