March 2018 P & T Updates
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- Brendan Morgan
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1 March 2018 P & T Updates Commercial Triple Tier 4th Tier Applicable Traditional Prior Auth AURYXIA tablets per BAXDELA TABLETS tablets per Depending on your specific benefits and in which state you reside, some drugs on this list may have no cost sharing. 100 mg tablets: 4 tablets per 12.5 mg tablets: 2 tablets per Alternatives calcium acetate, Eliphos, sevelamer carbonate, lanthanum carbonate ciprofloxacin, clindamycin, doxycycline, levofloxacin, linezolid, minocycline, moxifloxacin, ofloxacin, sulfamethoxazole/tmp BIKTARVY tablet per Odefsey, Triumeq CHANTIX 0 0 COSENTYX 3 2 COTEMPLA XR ODT ENDARI 3 2 GENOTROPIN HUMATROPE IMBRUVICA 3 2 Starter Pack: 1 pack per 180 s Maintenance Pack, 0.5 mg, & 1 mg tablets: 2 tablets per Initial Fill: 6 syringes per 28 s Subsequent Fills: 2 syringes per 28 s 8.6 & 17.3 mg tablets: 1 tablet per 25.9 mg tablets: 2 tablets per 6 packets per, 30 bupropion, nicotine gum, nicotine lozenges, nicotine patches atomoxetine, dexmethylphenidate, dextroamphetamine tablets, dextroamphetamine ER capsules, dextroamphetamine/amphe tamine combination, guanfacine ER, methylphenidate, methylphenidate ER hydroxyurea rditropin rditropin 1 capsule/tablet per, 28 supply per fill
2 Commercial (cont.) Triple Tier 4th Tier Applicable Traditional Prior Auth JULUCA tablet per NORDITROPIN NUTROPIN AQ OMNITROPE SAIZEN SEROSTIM TRELEGY ELLIPTA ZOMACTON ZORBTIVE ZYKADIA & 17.3 mg tablets: 1 tablet per 25.9 mg tablets: 2 tablets per Alternatives Odefsey, Edurant, Tivicay, Trimeq atomoxetine, dexmethylphenidate, dextroamphetamine tablets, dextroamphetamine ER capsules, dextroamphetamine/amphe tamine combination, guanfacine ER, methylphenidate, methylphenidate ER rditropin rditropin 1 tablet per metformin, Glyxambi*, Jardiance*, Invokana*, Synjardy*, Invokamet*, Tradjenta*, Jentadueto* rditropin rditropin 1 tablet per Movantik, Amitiza Depending on your specific benefits and in which state you reside, some drugs on this list may have no cost sharing. Incruse Ellipta, Spiriva, Serevent, Striverdi Respimat, Arnuity Ellipta, Pulmicort Flexhaler, Flovent, Asmanex, Breo Ellipta, Advair, Anoro Ellipta, Stiolto Respimat rditropin rditropin 3 capsules per, 30 Beginning 6/1/18 members being newly started on Enbrel therapy for the treatment of plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis will require medical record documentation of therapeutic failure on, intolerance to, or contraindication to Cosentyx* and.
3 CHIP Tier Prior Auth Alternatives AURYXIA 2 12 tablets per BAXDELA TABLETS 2 2 tablets per 100 mg tablets: 4 tablets per 12.5 mg tablets: 2 tablets per BIKTARVY 2 1 tablet per calcium acetate, Eliphos, sevelamer carbonate, lanthanum carbonate ciprofloxacin, clindamycin, doxycycline, levofloxacin, linezolid, minocycline, moxifloxacin, ofloxacin, sulfamethoxazole/tmp Odefsey, Triumeq CHANTIX 0 COSENTYX 2 Starter Pack: 1 pack per 180 s Maintenance Pack, 0.5 mg, & 1 mg tablets: 2 tablets per Initial Fill: 6 syringes per 28 s Subsequent Fills: 2 syringes per 28 s bupropion, nicotine gum, nicotine lozenges, nicotine patches COTEMPLA XRODT 8.6 & 17.3 mg tablets: 1 tablet per 25.9 mg tablets: 2 tablets per dextroamphetamine tablets, dextroamphetamine ER capsules, dextroamphetamine/amphetamine combination, guanfacine ER, ER ENDARI 2 GENOTROPIN HUMATROPE IMBRUVICA 0 6 packets per, 30 hydroxyurea rditropin rditropin 1 capsule/tablet per, 28 JULUCA 2 1 tablet per Odefsey, Edurant, Tivicay, Trimeq 8.6 & 17.3 mg tablets: 1 tablet per 25.9 mg tablets: 2 tablets per dextroamphetamine tablets, dextroamphetamine ER capsules, dextroamphetamine/amphetamine combination, guanfacine ER, ER
4 CHIP (cont.) Tier NORDITROPIN NUTROPIN AQ OMNITROPE SAIZEN SEROSTIM TRELEGY ELLIPTA ZOMACTON ZORBTIVE Prior Auth Alternatives rditropin rditropin 1 tablet per metformin, Glyxambi*, Jardiance*, Invokana*, Synjardy*, Invokamet*, Tradjenta*, Jentadueto* rditropin rditropin 1 tablet per Movantik, Amitiza ZYKADIA 0 Incruse Ellipta, Spiriva, Serevent, Striverdi Respimat, Arnuity Ellipta, Pulmicort Flexhaler, Flovent, Asmanex, Breo Ellipta, Advair, Anoro Ellipta, Stiolto Respimat rditropin rditropin 3 capsules per, 30 Beginning 6/1/18 members being newly started on Enbrel therapy for the treatment of plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis will require medical record documentation of therapeutic failure on, intolerance to, or contraindication to Cosentyx* and.
5 GHP Family GHP Family Tier Prior Auth AURYXIA Brand 12 tablets daily BAXDELA Brand two tablets daily 100 mg 4 tablets daily, 12.5 mg 2 tablets daily BIKTARVY Brand one tablet daily BUPRENORPHINE SL TABLETS (EFFECTIVE MAY 1, 2018 BUPRENORPHINE/NALOX ONE SL TABLETS (EFFECTIVE MAY 1, 2018) Generic Alternative(s) calcium acetate, Eliphos, lanthanum carbonate, sevelamer carbonate, Fosrenol powder packets ciprofloxacin tabs, clindamycin caps, doxycycline cap/tabs, levofloxacin tabs, linezolid tabs, minocycline cap/tabs, ofloxacin tabs, TMPSMX, Sivextro* e Odefsey, Triumeq buprenorphine/naloxone SL tablets, Suboxone Film* Generic Suboxone Film* CHANTIX Brand COSENTYX Brand 1 fill per 180 s (starter pack), 2 tablets daily (0.5 mg tablets, 1 mg tablets) One injection (150 mg or 300 mg) every 4 weeks OTC nicotine replacement, Bupropion SR, XL COTEMPLA XRODT 8.6 mg, 17.3 mg 1 tablet daily, 25.9 mg 2 tablets daily dextroamphetamine, dextroamphetamine ER, dextroamphetamineamphetamine, dextroamphetamineamphetamine ER, guanfacine ER, methylphenidate, methylphenidate ER/LA/CD ENDARI FLONASE ALLERGY RELIEF OTC FLONASE SENSIMST OTC IVERMECTIN Generic 6 packets daily hydroxyurea 15.8 ml per 30 s 15.8 ml per 30 s JULUCA Brand one tablet daily Fluticasone, Triamcinolone, Flunisolide Fluticasone, Triamcinolone, Flunisolide Odefsey, Edurant, Tivicay, Triumeq one tablet daily dextroamphetamine, dextroamphetamine ER, dextroamphetamineamphetamine, dextroamphetamineamphetamine ER, guanfacine ER, methylphenidate, methylphenidate ER/LA/CD
6 GHP Family (cont.) GHP Family Tier Prior Auth Alternative(s) OMEGA3 ETHYL ESTERS Generic 4 capsules daily Fenofibrate, Gemfibrozil, Atorvastatin, Rosuvastatin metformin Glyxambi*, Invokamet*, Invokana*, one tablet daily Jardiance*, Jentadueto*, Synjardy*, Tradjenta* SENSIPAR Brand calcitriol, paricalcitol one tablet daily Amitiza*, Movantik* TRELEGY ELLIPTA 60 blisters per 30 s LAMA: Spiriva LABA: Serevent, Striverdi ICS: Arnuity Ellipta, Flovent* ICS/LABA: Breo Ellipta, Advair* LAMA/LABA: Anoro Ellipta, Stiolto
7 Geisinger Gold $0 Deductible AURYXIA Specialty BAXDELA Specialty BIKTARVY Specialty COSENTYX Specialty COTEMPLA XRODT ENDARI Specialty JULUCA Specialty TRELEGY ELLIPTA Standard Prior Auth 12 tablets per 2 tablets per Alternative(s) calcium acetate, sevelamer carbonate, lanthanum carbonate Trimethoprim/sulfamethoxazole, ciprofloxacin, clindamycin, doxycycline, levofloxacin, linezolid, daptomycin, vancomycin, Sivextro* 30 tablets per 30 s 180 packets per 30 s 30 tablets per 30 s Odefsey, Triumeq CR, methylphenidate SR, dexmethylphenidate, dexmethylphenidate ER, dextroamphetamine, amphetamine/dextroamphetamine, amphetamine/dextroamphetamine SR combination Hydroxyurea, Droxia Odefsey, Edurant, Tivicay, Triumeq CR, methylphenidate SR, dexmethylphenidate, dexmethylphenidate ER, dextroamphetamine, amphetamine/dextroamphetamine, amphetamine/dextroamphetamine SR combination metformin, Glyxambi*, Invokana*, Invokamet*, Jardiance*, Synjardy*, Tradjenta, Januvia, Janumet Movantik, Amitiza Brand Preferred TRISENOX Specialty VABOMERE 2 blisters per Incruse Ellipta, Spiriva, Serevent, Striverdi, Arnuity Ellipta, Pulmicort, Flovent, Asmanex, Breo Ellipta, Advair, Anoro Ellipta, Stiolto Sulfamethoxazole/TMP, ciprofloxacin, levofloxacin, imipenem/cilastin, doripenem, Invanz, tobramycin, Avycaz*
8 Marketplace Tier Prior Auth AURYXIA 5 12 tablets per BAXDELA TABLETS 5 2 tablets per 100 mg tablets: 4 tablets per 12.5 mg tablets: 2 tablets per BIKTARVY 3 1 tablet per CHANTIX 0 COSENTYX 3 COTEMPLA XR ODT Starter Pack: 1 pack per 180 s Maintenance Pack, 0.5 mg, & 1 mg tablets: 2 tablets per Initial Fill: 6 syringes per 28 s Subsequent Fills: 2 syringes per 28 s 8.6 & 17.3 mg tablets: 1 tablet per 25.9 mg tablets: 2 tablets per Alternatives calcium acetate, Eliphos, sevelamer carbonate, lanthanum carbonate ciprofloxacin, clindamycin, doxycycline, levofloxacin, linezolid, minocycline, moxifloxacin, ofloxacin, sulfamethoxazole/tmp Odefsey, Triumeq bupropion, nicotine gum, nicotine lozenges, nicotine patches dextroamphetamine tablets, dextroamphetamine ER capsules, dextroamphetamine/amphetamine combination, guanfacine ER, ER ENDARI 5 6 packets per, 30 hydroxyurea GENOTROPIN 5 rditropin HUMATROPE 5 rditropin IMBRUVICA 0 1 capsule/tablet per, 28 JULUCA 3 1 tablet per Odefsey, Edurant, Tivicay, Trimeq 8.6 & 17.3 mg tablets: 1 tablet dextroamphetamine tablets, dextroamphetamine ER capsules, per dextroamphetamine/amphetamine 25.9 mg tablets: 2 tablets per combination, guanfacine ER, ER NORDITROPIN 5 NUTROPIN AQ 5 rditropin OMNITROPE 5 rditropin 1 tablet per metformin, Glyxambi*, Jardiance*, Invokana*, Synjardy*, Invokamet*, Tradjenta*, Jentadueto* SAIZEN 5 rditropin SEROSTIM 5 rditropin 1 tablet per Movantik, Amitiza
9 Marketplace (cont.) Tier Prior Auth TRELEGY ELLIPTA Alternatives Incruse Ellipta, Spiriva, Serevent, Striverdi Respimat, Arnuity Ellipta, Pulmicort Flexhaler, Flovent, Asmanex, Breo Ellipta, Advair, Anoro Ellipta, Stiolto Respimat ZOMACTON 5 rditropin ZORBTIVE 5 rditropin ZYKADIA 0 3 capsules per, 30 Beginning 6/1/18 members being newly started on Enbrel therapy for the treatment of plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis will require medical record documentation of therapeutic failure on, intolerance to, or contraindication to Cosentyx* and.
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Tier 5 Formulary Step Therapy 2016 Updated: 05/24/2016 Effective: 06/01/2016 What is Step Therapy? Some prescription drugs require step therapy (ST). In some cases, the plan requires you to first try certain
TABLE OF CONTENTS (Click on a link below to view the section.)
Follow the links below to access the complete formularies for Plans: Health Plan Acne Allergy Allergic Anaphylactic Reaction Allergic Conjunctivitis Allergic Rhinitis Asthma Atopic Dermatitis Behavioral
Prescription benefit updates Large group
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A Visual Approach to Simplifying Respiratory Drug Regimens
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If you have questions about the Step Therapy Program, contact ClearScript Member Services at the number on the back of your ID Card.
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ALBUTEROL - SCORE{XE "ALBUTEROL - SCORE"}
Step Therapy ALBUTEROL - SCORE{XE "ALBUTEROL - SCORE"} Ventolin Hfa{XE "Ventolin Hfa"} Trial of ProAir Formulary ID# 00018097 Last Updated: 04/01/2018 1 ANTIDEPRESSANTS - SCORE{XE "ANTIDEPRESSANTS - SCORE"}
MedPerform High Preferred Drug List (PDL)
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Health Partners Medicare Special 2018 Formulary Changes
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December 2016 Formulary Updates
December 2016 Formulary Updates ABACAVIR/LAMIVUDINE AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 10-20MG QL AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 10-40MG QL AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 5-20MG QL AMLODIPINE/OLMESARTAN
Step Therapy Criteria
ADCIRCA ADCIRCA Coverage will be provided if the member has filled a prescription for sildenafil (at least a 30 day supply within the past 365 ) ELIDEL 76-F ELIDEL Coverage will be provided if the member
Step Therapy. Here s how it works: Move on to a Step 2 drug if necessary
Step Therapy Most medical conditions can be treated with several different drug options. There are many drugs that cost much less than others despite working the same way and being just as effective. The
AIRDUO RESPICLICK (fluticasone-salmeterol) aerosol DULERA (mometasone furoate and formoterol fumarate dihydrate) aerosol
DULERA (mometasone furoate and formoterol fumarate dihydrate) aerosol Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific
December 2016 Formulary Updates
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PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select Formulary April 1, 2018 Updates. Formulary Alternatives
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select April 1, 2018 Updates Drug Name adapalene-benzoyl-peroxide Gel 0.1-2.5% (Brand = Epiduo ) prasugrel hcl (Brand = Effient ) vigabatrin pak 500 mg (Brand
STRIVERDI RESPIMAT (olodaterol hcl) aerosol
STRIVERDI RESPIMAT (olodaterol hcl) aerosol Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy
Save on your drugs with HealthyRx
Save on your drugs with HealthyRx HealthyRx is a savings program offered through the UVa Hoo s Well program. It helps lower your costs on drugs for certain health conditions. Effective 4/1/17, you are
Clinical Policy: Roflumilast (Daliresp) Reference Number: CP.PMN.46 Effective Date: Last Review Date: 08.18
Clinical Policy: (Daliresp) Reference Number: CP.PMN.46 Effective Date: 11.01.11 Last Review Date: 08.18 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important
HMO and PPO Updates September Commercial Results
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ALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Farm Bureau Health Plans Date Effective: November 1, 2018.
ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID 18351, Version 15 1 ANTIDEPRESSANTS - SCORE Desvenlafaxine Er TB24 100MG, 50MG Emsam Fetzima Fetzima Titration Pack Trial of two of the following
AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details
AMANTADINE ER OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, EXTENDED RELEASE OSMOLEX ER 258 MG TABLET, PRIOR CLAIM FOR AMANTADINE HCL IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS.
reslizumab (Cinqair )
Applies to all products administered or underwritten by Blue Cross and Blue Shield of Louisiana and its subsidiary, HMO Louisiana, Inc.(collectively referred to as the Company ), unless otherwise provided
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SelectHealth Advantage 2018 Step Therapy Criteria Previous trial on at least ONE: Generic topical acne treatment
ACNE ADAPAL/BEN P GEL 0.1-2.5% AZELEX CRE 20% DAPSONE GEL 5% EPIDUO FORTE GEL 0.3-2.5% TRETINOIN GEL 0.04% TRETINOIN GEL 0.05% TRETINOIN GEL 0.1% ACTONEL ANTICONVULSANT ANTIDEPRESSION ANTIPSYCHOTIC ASTHMA
SelectHealth Advantage 2018 Step Therapy Criteria. Previous trial on at least ONE: Generic topical acne treatment. Previous trial on: alendronate
ACNE ACZONE ADAPAL/BEN P AZELEX DAPSONE EPIDUO EPIDUO FORTE TRETINOIN ACTONEL RISEDRON SOD RISEDRONATE SelectHealth Advantage Previous trial on at least ONE: Generic topical acne treatment alendronate
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select Formulary April 1, 2018 Updates. Formulary Alternatives
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select April 1, 2018 Updates Drug Name adapalene-benzoyl-peroxide Gel 0.1-2.5% (Brand = Epiduo ) prasugrel hcl (Brand = Effient ) vigabatrin pak 500 mg (Brand