PREFERRED NATIONAL DRUG FORMULARY

Effective January 1, 2010

Introduction
The Catalyst Rx Preferred National Drug Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals and members in the selection of cost-effective drug therapy. Catalyst Rx recognizes that drug therapy is an integral part of effective health management. The vast availability of medication options; however, warrants a reasonable program for drug selection and use. Catalyst Rx continually reviews new and existing medications to ensure the Drug Formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited, to: safety, efficacy and cost-effectiveness data, and comparison of relevant benefits of similar prescription or over-the counter (OTC) agents while minimizing potential duplications. The formulary is a continually reviewed and modified document that represents the prevailing clinical opinion of Catalyst Rx. This dynamic process does not allow this document to be completely accurate at all times. To accommodate regular changes, an updated electronic version of this formulary is available online at www.catalystrx.com. Catalyst Rx welcomes your input and feedback on the information provided in this document.

How to Read the Drug Formulary

All drugs are listed by their generic names and most common proprietary (branded) name. Specific drug listings may be accessed by using the index, either by generic (in lowercase) or proprietary name (in uppercase) and by therapeutic drug category. The brand names listed are for reference use only, and do not denote coverage, unless specifically noted. Any drug not found in this Drug Formulary listing, or any Drug Formulary updates published by Catalyst Rx, shall be considered a non-formulary drug.
Sample Listing: Tier PENICILLINS 1 1 1 1 1 2 2 2 2 3 Generic Name Reference Name amoxicilllin AMOXIL, TRIMOX AUGMENTIN, AUGMENTIN ES PRINCIPEN DYNAPEN VEETIDS AUGMENTIN SUSPENSION 125/31.25 AUGMENTIN XR BICILLIN LA BICILLIN CR MOXATAG amoxicillin, amoxicillin/clavulanate, penicillin v potassium Generic Status generic generic generic generic generic Preferred Alternatives/ Comments

amoxicillin/clavulanate ampicillin dicloxacillin penicillin v potassium amoxicillin/clavulanate amoxicillin/clavulanate er penicillin g benzathine penicillin g benzathine/penicillin g procaine amoxicillin er

Once the category or product is located, the following items can be viewed. Tier: This section identifies if the product is a Tier 1 product (i.e. typically generic), Tier 2 product (i.e. typically preferred brand), or Tier 3 product (i.e. typically non-preferred brand or non-formulary) on the Catalyst Rx 2010 Preferred National Drug Formulary. Generic products are considered to be Tier 1. Generic Name: This lists the generic name for the product (lowercase). Products are listed within the product index by both generic and brand name. Reference Name: This lists the brand name or common reference name for the product (UPPERCASE). Products are listed within the product index by both generic and brand name. Generic Status: If the word generic is listed, the product is available as a generic and the tier listing provided refers to the generic version. The generic listed within the Drug Name section is considered to be a Tier 1 product and the brand listed will cost significantly more and, depending on the plan design, may require a significantly higher or 100% member copayment or co-insurance. Preferred Alternatives/Comments: This field includes considerations for preferred Drug Formulary alternatives for non-preferred products or may include comments regarding preferred options or OTC product availability. For certain agents within the Drug Formulary, a recommended prescribing guideline may apply. Please refer to your specific benefit design for details.

Benefit Coverage and Limitations

This printed Formulary does not define benefit coverage and limitations. Many members have specific benefit inclusions, exclusions, copayments, or a lack of coverage, which are not reflected in the Catalyst Rx Preferred National Formulary. Members should contact their Plan Sponsor or the Catalyst Rx Customer Service Department at 1-888-869-4600 if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year. The following topics may or may not be applicable to individual members depending on member-specific benefit parameter. Tier Description The amount that plan participants pay when purchasing medications and the tier status of certain medications may vary depending on plan design and program. Three-tiered plan designs provide coverage of prescription drugs at different levels or tiers. Generally, generic drugs are available to plan participants at the lowest copayment (Tier 1). Brand-name drugs that are considered preferred (Tier 2) will cost plan participants more than generics, but less than non-preferred brands. Brand-name drugs that are considered non-preferred or non-formulary (Tier 3) will cost more than preferred brands. Prescribing Guidelines Prescribing guidelines may apply to select drugs on the Catalyst Rx Preferred National Formulary. Prescribing guidelines may vary by benefit design but may include: Prior Authorization Quantity Limit Step Therapy Age Edit Gender Edit Requires specific physician request process Coverage may be limited to specific quantities per prescription &/or time period Coverage may depend on previous use or trial of another drug Coverage may depend on patient age Coverage may depend on patient gender

Prior authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Catalyst Rx. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. A list of edits recommended by Catalyst Rx is available upon request. Members should contact their Plan
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Sponsor or the Catalyst Rx Customer Service Department at 1-888-869-4600 if they have questions regarding their specific coverage. Non-Formulary Agents Drugs not found on the Catalyst Rx Preferred National Drug Formulary, or any Preferred National Drug Formulary updates published by Catalyst Rx, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents may be requested by the health professional depending on specific coverage parameters. Review for non-formulary drug requests will require documentation of medical necessity. Generally, the following basic medical necessity guidelines are used in conducting a review: The patient has failed an appropriate trial of formulary or preferred agents. The use of preferred or formulary agent is contraindicated in the patient. The formulary drug or preferred agents are not suited for the present patient care need, and the drug selected is required for patient safety. If the request does not meet the established guidelines request, it will not be approved and alternative therapy may be recommended along with the proper course of alternative action. Common Drug Exclusions Due to benefit design parameters, some plan sponsors may choose to exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded coverages may include, but are not limited to: OTC medications or their equivalents unless otherwise specified in the Formulary listing. Smoking Cessation products (i.e. transdermal nicotine, nicotine gum, nicotine inhaler) Drug products used for cosmetic purposes Experimental drug products, or any drug product used in an experimental manner Replacement of lost or stolen medication Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA) Mandated Generic Substitution Catalyst Rx advocates the use of cost-effective generic drugs where FDA-labeled brand equivalent drugs are available. Generic products are listed in the Formulary and noted as generic wherever an FDA-approved generic drug product is available. If a member or physician requests a brand-name product in lieu of an approved generic, the member, based upon their coverage, will typically be required to pay the difference in cost between the brand and the generic drug. A physician can request coverage through the medication request process if he or she determines there is a documented medical need for the brand-drug equivalent. Select drug products are excluded from generic substitution due to unique dosage form, complex pharmacokinetics and pharmacodynamics (what the body does to the drugs and what a drug does to the body, respectively), narrow therapeutic efficacy and/or where the critical maintenance of the drug blood level is crucial to its efficacy and prevention of adverse effects. This mandated generic substitution process is not intended to supersede any federal, state or local statues or regulations of the dispensing or generic substitution of any prescription agents. The drug list below is continuously reviewed to reflect current clinical standards and practices. Products excluded for exclusion from the generic mandate are: Coumadin Dilantin Lanoxin Synthroid Tegretol/ XR Uniphyl Zarontin
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Medication Requests Procedure

Medication requests, questions or information regarding the medication requests, formulary status or other coverage may be requested. 1. The appropriate forms for medication review are available at www.catalystrx.com or by calling the Catalyst Rx Customer Service Department at 1-888-869-4600. 2. Completed Catalyst Rx Prior Authorization Forms should be faxed to 1-888-852-1832. 3. Alternatively, the prior authorization process can be initiated by contacting Catalyst Rx directly at 1-888-869-4600. The requesting provider will be provided written notification of Catalyst Rx review decisions. Non-approved requests may be appealed. The physician must provide information to support the appeal on the basis of medical necessity.

Contact Information
The Catalyst Rx Preferred National Drug Formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Catalyst Rx encourages your input and feedback on how we can assist in improving this document and the formulary management process. Please direct your communications to: Chairperson, Pharmacy & Therapeutics Committee Catalyst Rx 1650 Spring Gate Lane Las Vegas, NV 89134 In addition to the Catalyst Rx Preferred National Formulary booklet, other quick-reference guides are available on our Web site at www.catalystrx.com, including pocket-sized Preferred Drug Lists. Requests for additional formulary materials should include the type of formulary materials requested, the quantity of each and the physician and/or medical group name, address and telephone number. Please direct all requests to: Formulary Management Catalyst Rx 1650 Spring Gate Lane Las Vegas, NV 89134

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