July 2017 P&T Updates

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1 July 2017 P&T Updates Commercial Triple Tier 4th Tier Applicable Traditional Prior Auth Alternatives ALUNBRIG 3 2 DUPIXENT Pharmacy tablets per day, 30 day One-week auth for QL of 3 syringes per 28 Remainder of the 6 month auth duration, QL of 2 syringes per 28 Then, 2/28 Elidel*, topical prednisone, prednisolone EUCRISA 3 No 2 No - prednisolone, prednisone ISENTRESS HD 2 No 2 No 2 tablets per day - RILUZOLE 1 No 1 No No - none RYDAPT 3 2 STIVARGA 3 2 AML: 56 capsules per 21 SM: 112 capsules per tablets per 28 Systemic Mastocytosis: imatinib 1 No 1 No No - - No 1 tablet per day Amitiza, Linzess - XERMELO 3 2 ZEJULA tablets per day, 28 day 3 tablets per day, 30 day octreotide, Somatuline Depot*

2 CHIP Tier Prior Auth ALUNBRIG 2 DUPIXENT Pharmacy 2 6 tablets per day, 30 day One-week auth for QL of 3 syringes per 28 Remainder of the 6 month auth duration, QL of 2 syringes per 28 Alternatives Elidel*, prednisone, prednisolone Then, 2/28 topical EUCRISA 2 No - prednisolone, prednisone ISENTRESS HD 2 No 2 tablets per day - RILUZOLE 2 No No - none AML: 56 capsules per 21 RYDAPT 2 SM: 112 capsules per 28 Systemic Mastocytosis: imatinib STIVARGA 2 84 tablets per 28-2 No No tablet per day Amitiza, Linzess XERMELO 2 3 tablets per day, 28 day octreotide, Somatuline Depot* ZEJULA 2 3 tablets per day, 30 day

3 GHP Family GHP Family Tier Prior Auth Alternative(s) ALUNBRIG Brand 6 tablets daily Xalkori*, Alcensa*, Zykadia* ATOMOXETINE Generic No 10 mg, 100 mg, 40 mg, 60 mg, 80 mg one capsule daily, 18 mg two capsules daily, 25 mg three capsules daily DUPIXENT Brand 2 syringes per 28 EUCRISA Brand No - Methylphenidate, Methylphenidate ER, Amphetamine Salt Combo, Amphetamine- Dextroamphetamine, Amphetamine- Dextroamphetamine ER, Guanfacine ER tacroliumus ointment, Elidel* tacroliumus ointment, Elidel* FOSRENOL PACKETS Brand No No - Fosrenol Tablets, Renagel ISENTRESS HD Brand No two tablets daily Isentress Tablet, Isentress Chewable Tablet LINZESS Brand No - Amitiza* OCTREOTIDE Generic No No - e RILUZOLE Generic No No - e RYDAPT Brand AML - 56 capsules per 21, SM capsules per 28 imatinib* STIVARGA Brand 84 tablets per 28 e Generic No No - Elidel* one tablet daily Amitiza*, Linzess* XERMELO Brand three tablets daily octrotide ZEJULA Brand 3 tablets daily Beginning August 15th, any prescription for greater than a 7 day supply of opioids for anyone age 17 or younger will require prior authorization. Beginning September 15th, any prescription for a greater than 14 day supply of opioids for anyone age 18 and older will require prior authorization. Beginning September 15th, any high dose of opioids will require prior authorization. Beginning November 1, new opioid quantity limits will be effective. Please call for details.

4 Geisinger Gold $0 Deductible ALUNBRIG Specialty DUPIXENT Specialty EUCRISA Brand Preferred IMFINZI Specialty ISENTRESS HD Specialty RADICAVA Specialty RYDAPT Specialty Standard Prior Auth 6 tablets/day 8 ml in Alternative(s) clobetasol, halobetasol, clobetasol, halobetasol, Bavencio*, Keytruda*, Opdivo*, Tecentriq* No 2 tablets/day Isentress 2800 mls every capsules per 28 riluzole Imatinib Generic No - - alclometasone, clobetasol, desonide, diflorasone, fluocinolone, fluticasone, halobetasol, mometasone, XERMELO Specialty ZEJULA Specialty Amitiza, Linzess 3 tablets/day octreotide, Somatuline Depot 3 tablets/day

5 Marketplace Tier Prior Auth ALUNBRIG 5 DUPIXENT Pharmacy 5 6 tablets per day, 30 day One-week auth for QL of 3 syringes per 28 Remainder of the 6 month auth duration, QL of 2 syringes per 28 Alternatives Elidel*, topical prednisone, prednisolone Then, 2/28 EUCRISA 4 No - prednisolone, prednisone ISENTRESS HD 3 No 2 tablets per day - RILUZOLE 2 No No - none RYDAPT 5 AML: 56 capsules per 21 SM: 112 capsules per 28 Systemic Mastocytosis: imatinib STIVARGA 5 84 tablets per 28-2 No No tablet per day Amitiza, Linzess XERMELO 5 3 tablets per day, 28 day octreotide, Somatuline Depot* ZEJULA 5 3 tablets per day, 30 day

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