UnitedHealthcare Community Plan PDL Modifications

Transcription

1 12/1/2013 1/1/2014 Mekinist Trametinib 12/1/2013 1/1/2014 Tafinlar Dabrafenib 12/1/2013 1/1/2014 Tudorza Pressair Aclidinium inhalation 12/1/2013 1/1/2014 Cystagon Cysteamine bitartrate 12/1/2013 1/1/2014 Imitrex 4 mg injection* Sumatriptan 4 mg injection 12/1/2013 1/1/2014 Lexapro* Escitalopram 12/1/2013 1/1/2014 Trilipix* Choline Fenofibrate capsules 12/1/2013 1/1/2014 Xtandi Enzalutamide 12/1/2013 1/1/2014 Zantac* Ranitidine 12/1/2013 1/1/ mg capsule 150 mg capsule 12/1/2013 1/1/ mg capsule 300 mg capsule 12/1/2013 1/1/ mg tablet 300 mg tablet 12/1/2013 1/1/2014 Tobi Nebulizer Solution Tobramycin Targretin capsule and 12/1/2013 1/1/2014 topical gel Bexarotene unresectable or metastatic malignant melanoma in patients with BRAF V600E or V600K mutations. Prior authorization required. Available unresectable or metastatic malignant melanoma in patients with BRAF V600E mutation. Prior Added as an alternative agent for the long-term maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema. nephropathic cystinosis. Added as an alternative formulation for treating migraine attacks with or without aura. major depression and generalized anxiety disorder. Added as an alternative formulation for treating hypertriglyceridemia. Step therapy applies. An alternative agent is available on the PDL including Zytiga. Current users will be An alternative formulation is available on the PDL including Ranitidine 150 mg tablet. Current users will not be Prior authorization required. Current cystic fibrosis users will be 12/1/2013 1/1/2014 Panretin Alitretinoin 12/1/2013 1/1/2014 Singulair* Montelukast Step therapy removed. Cyclessa* Desogestrel/ethinyl estradiol Added as an alternative formulation for routine contraception. Cayston Biaxin XL* Cataflam* tablet Voltaren XR* tablet Abilify Maintena Aztreonam Clarithromycin ER Diclofenac potassium Diclofenac sodium extended release Aripiprazole ER injection Added as an alternative agent for the management of pulmonary exacerbations in patients with cystic fibrosis. Prior authorization required. Available treatment of chronic bronchitis, community acquired pneumonia, upper respiratory tract infections, skin and skin structure infections, and H. pylori eradication. treatment of osteoarthritis, rheumatoid arthritis, and primary dysmenorrhea. treatment of osteoarthritis and rheumatoid arthritis. treatment of schizophrenia. Prior authorization required. * Only Generics are covered Page 1 of 5

2 Signifor (pasireotide) Pasireotide SC injection Cushing s syndrome caused by Cushing s disease. Prior Pomalyst Sirturo Pomalidomide Bedaquilline of multiple myeloma. Prior authorization required. Available Added as an alternative agent for use as a part of a combination regimen to treat pulmonary multidrug resistant tuberculosis infection when other regimens are not available. Prior authorization required. Onglyza Saxagliptin of type 2 diabetes mellitus. Step therapy applies. Kombiglyze Metformin/Saxagliptin of type 2 diabetes mellitus. Step therapy applies. Ravicti Glycerol Phenylbutyrate *Only Generics are covered of hyperammonemia in patients with urea cycle disorders. Prior authorization required. Available Buphenyl Oral Powder* Carbaglu *Only Generics are covered Pancreaze Sodium Phenylbutyrate oral powder Carglumic Acid Pancrelipase of hyperammonemia in patients with urea cycle disorders. Prior authorization required. of hyperammonemia in patients with N- acetylglutamate synthase deficiency. Prior including Creon and Zenpep. Current users will be OxyIR* 5mg Capsules PrevPac Lipitor* Invega Sustenna Risperdal Consta Lialda Apriso Oxycodone immediate release 5 mg capsules Amoxicillin/clarithromycin/ lansoprazole Atorvastatin Paliperidone injection Risperidone injection Mesalamine Mesalamine including oxycodone immediate release tablets. Current users will not be including the individual components of amoxicillin, clarithromycin, and lansoprazole or other preferred proton pump inhibitors such as omeprazole or pantoprazole. Step therapy removed. Remains a preferred product. treatment of ulcerative colitis. treatment of ulcerative colitis. * Only Generics are covered Page 2 of 5

3 Afinitor Disperz Everolimus Added as alternative dosing formulation for the treatment of subependymal giant cell astrocytoma (SEGA) with tuberous sclerosis complect (TSC). Prior authorization required. Available Bosulif Bosutinib of chronic phase, accelerated phase, or blast phase Philadelphia chromosome-positive chronic myelogenous leukemia (CML) with resistance or intolerance to prior therapy. Prior authorization required. Available Iclusig Ponatinib of chronic phase, accelerated phase, or blast phase chronic myelogenous leukemia (CML) that is resistant or intolerant to prior tyrosine kinase inhibitor therapy and for the treatment of Philadelphia chromosome-positive acute lymphocytic leukemia (ALL) that is resistant or intolerant to prior tyrosine kinase inhibitor therapy. Prior authorization required. Available Cometriq Cabozantinib of progressive, metastatic medullary thyroid cancer. Prior authorization required. Available Stivarga Regorafenib of metastatic colorectal cancer in patients who have previously received fluoropyrimidine, oxaliplatin, and irinotecan based chemotherapy; an anti-vegf therapy; and an anti-egfr therapy if KRAS wild type. Also for the treatment of locally advanced, unresectable or metastatic gastrointestinal stromal tumors (GIST) in patients who have previously received imatinib and sunitinib. Prior authorization required. Available Cystaran ophthalmic solution 0.44% Gattex Cysteamine Teduglutide of corneal cysteine crystal accumulation in patients with cystinosis. Prior authorization required. Available of short bowel syndrome in patients who are dependent on parenteral support. Prior Juxtapid Lomitapide of homozygous familial hypercholesterolemia (HoFH). Prior authorization required. Available * Only Generics are covered Page 3 of 5

4 Marinol* Aubagio Gilenya Dronabinol* Teriflunomide Fingolimod of chemotherapy-induced nausea/vomiting (CINV) that is refractory to conventional antiemetic agents and for use as an appetite stimulant in patients with anorexia due to AIDS. Prior authorization required. of relapsing forms of multiple sclerosis. Prior of relapsing forms of multiple sclerosis. Prior Eliquis Apixaban Added as an alternative agent for stroke prophylaxis and systemic embolism prophylaxis in patients with nonvalvular atrial fibrillation. Prior authorization required. Norditropin Somatropin Ritalin LA* Methylphenidate ER* Eli Lilly Insulin Vials: Humalog Insulin Lispro Humilin R Insulin Regluar Humulin N Insulin Isophane Humulin 70/30 Insulin Isophane/Regular Humalog Mix 75/25 Insulin Lispro Prot/Lispro Humalog Mix 50/50 Insulin Lispro Prot/Lispro AccuNeb 0.63 mg/3 ml and 1.25 mg/3 ml* Omnitrope Cimzia Hecoria* Combivent Respimat Detrol* Sanctura* Orap Albuterol 0.63 mg/3 ml and 1.25 mg/3 ml* treatment of growth failure due to growth hormone deficiency. Prior authorization required. Available treatment of attention-deficit hyperactivity disorder (ADHD). Added as alternative insulin formulations for the treatment of type 1 and type 2 diabetes mellitus. Added as alternative dosing formulations for the treatment of acute bronchospasm (eg, asthma) and bronchospasm prophylaxis. Age edit applies for members 8 years of age or older. Prior authorization is required for members 8 years of age or older. Alternative formulations are available on the Somatropin PDL including Tev-Tropin and Norditropin. Current users will not be Certolizumab pegol including Enbrel and Humira. Current users will not be Tacrolimus Added as alternative formulation for the treatment of heart, kidney, and liver transplant rejection prophylaxis. Ipratropium/albuterol inhaler Added as alternative formulation to for the treatment of chronic obstructive pulmonary disease (COPD). Tolterodine of an overactive bladder with symptoms of urinary frequency, urinary urgency, or urgerelated urinary incontinence. Step therapy applies. Trospium of an overactive bladder with symptoms of urinary frequency, urinary urgency, or urgerelated urinary incontinence. Step therapy applies. Pimozide of Tourette s Syndrome. * Only Generics are covered Page 4 of 5

5 Duoneb* Ipratropium/albuterol solution for inhalation Plan B One Step* Levonorgestrel 1.5 mg tab Added as alternative formulation to for the treatment of chronic obstructive pulmonary disease (COPD). Added as an alternative dosing formulation for postcoital contraception. Added as alternative blood glucose testing strips. Lifescan (OneTouch, Basic, Profile, SureStep, Ultra ) Test Strips Effexor XR capsules* Venlafaxine ER capsules Step therapy removed. Enablex Darifenacin Vesicare Peg-Intron Bayer (BREEZE 2, CONTOUR and ASCENSIA ) Test Strips Solifenacin Peginterferon alfa-2b 3/1/2013 4/1/2013 Isentress Chewable Raltegravir chewable tablet 3/1/2013 4/1/2013 Lyrica Solution Pregabalin oral solution including oxybutynin, oxybutynin ER, tolterodine, and trospium. Current users will not be including oxybutynin, oxybutynin ER, tolterodine, and trospium. Current users will not be including Pegasys (peginterferon alfa-2a). Current users will be able to complete their current regimens. Alternative diabetic blood glucose testing strips are available on the PDL including Roche (Accu- Chek Aviva, Aviva Plus, Active, Comfort Curve, Compact, SmartView) and Lifescan (OneTouch Basic, Profile, SureStep, Ultra, Verio ) test strips. Current users will not be Added as alternative dosing formulation for the treatment of HIV infection in combination with other antiretroviral agents. Added as alternative dosing formulation to for the treatment of diabetic neuropathy, fibromyalgia, partial seizures, postherpetic neuralgia, and pain associated with spinal cord injury. Prior authorization required. 3/1/2013 4/1/2013 Xtandi Enzalutamide Cobicistat/elvitegravir/ 3/1/2013 4/1/2013 Stribild emtricitabine/tenofovir 3/1/2013 4/1/2013 Entocort Budesonide 3/1/2013 4/1/2013 Rectiv Nitroglycerin rectal ointment 3/1/2013 4/1/2013 Adderall* Amphet/d-amphet salts 3/1/2013 4/1/2013 Adderall XR Amphet/d-amphet salts XR 3/1/2013 4/1/2013 Strattera Atomoxetine 3/1/2013 4/1/2013 Dexedrine* Dextroamphetamine 3/1/2013 4/1/2013 Dextrostat* Dextroamphetamine 3/1/2013 4/1/2013 Dexedrine Spansule* Dextroamphetamine ER 3/1/2013 4/1/2013 Intuniv Guanfacine 3/1/2013 4/1/2013 Ritalin* Methylphenidate 3/1/2013 4/1/2013 Concerta* Methylphenidate ER 3/1/2013 4/1/2013 Metadate ER* Methylphenidate SR 3/1/2013 4/1/2013 Ritalin SR* Methylphenidate SR 3/1/2013 4/1/2013 Vyvanse Lisdexamfetamine 3/1/2013 4/1/2013 Adcirca Tadalafil 3/1/2013 4/1/2013 Pristiq Desvenlafaxine metastatic castration-resistant prostate cancer in patients who have received prior chemotherapy containing docetaxel. Prior authorization required. Available of HIV infection in antiretroviral naïve adults. of Crohn s disease. Prior authorization required. of pain associated with anal fissures. Prior authorization required. Maximum age edit changed to 18 years of age. Prior authorization is required for patients 18 years of age and older. Age edit modification only applies to new starts. Current users will be *Only Generics are covered including sildenafil citrate 20 mg tablet, Letairis, and Tracleer. Current users will be including venlafaxine, venlafaxine ER capsules, fluoxetine, sertraline, paroxetine, and citalopram. Current users will be * Only Generics are covered Page 5 of 5