January 2018 P & T Updates

Transcription

1 January 2018 P & T Updates Commercial Triple Tier 4th Tier Applicable Traditional BEVYXXA 3 No 2 BOSULIF 3 2 * Indicates prior authorization (PA) or step (ST) Depending on your specific benefits and in which state you reside, some drugs on this list may have no cost sharing. Detailed s Onetime 42 day fill, 1 tablet 100 mg tablet: 3 tablets, mg & 500 mg tablet: 1 tablet per day, 30 day supply Alternatives enoxaparin, fondaparinux, heparin CALQUENCE capsules, 30 No 1 tablet ELIQUIS 2 No 2 No 2.5 mg tablet: 2 tablets 5 mg tablet: 4 tablets allopurinol, probenecid, Uloric* warfarin, Xarelto, ENTRESTO 2 No 2 2 tablets benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril, quinapril, trandolapril, ramipril, losartan, irbesartan, valsartan NITYR 3 2 No No No Nityr* OZEMPIC 2 No 2 PRADAXA 3 No mg/0.5 mg Pen: 0.06 ml 1 mg Pen: 0.11 ml 2 capsules warfarin, Eliquis*, Xarelto* SUTENT 3 2 TANZEUM 2 No 2, new No 1 capsule, ml Initial: 1 ml per 28 days Maintenance: 1 ml per 56 days metformin, Ozempic*, Victoza* sulfasalazine, Enbrel*, Humira*

2 Commercial (cont.) Triple Tier 4th Tier Applicable Traditional XARELTO 2 No 2 No Detailed s 10 mg & 20 mg tablet: 1 tablet per day 15 mg tablet: 2 tablets Alternatives warfarin, Eliquis, * Shingrix is now available for $0 cost sharing when administered at a pharmacy or at your physicians office. Coverage is limited to one course of (2 vaccines) per lifetime for members greater than or equal to 50 years of age. * Starting April 1, 2018, all prescriptions for adults for a total morphine equivalent dose (MED) of will require prior authorization from GHP or an override from the dispensing pharmacist. All prescriptions for a MED of 120 or greater will require prior authorization from GHP. CHIP Tier BEVYXXA 2 BOSULIF 10 CALQUENCE 0 Detailed s Onetime 42 day fill, 1 tablet 100 mg tablet: 3 tablets per day, mg & 500 mg tablet: 1 tablet, 30 day supply 2 capsules, 30 day * Indicates prior authorization (PA) or step (ST) Alternatives enoxaparin, fondaparinux, heparin 1 tablet allopurinol, probenecid, Uloric* ELIQUIS 2 No 2.5 mg tablet: 2 tablets 5 mg tablet: 4 tablets warfarin, Xarelto, ENTRESTO 2 2 tablets benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril, quinapril, trandolapril, ramipril, losartan, irbesartan, valsartan NITYR 2 No No Nityr* OZEMPIC 2 PRADAXA 2 SUTENT 0 TANZEUM 2, new 0.25 mg/0.5 mg Pen: 0.06 ml 1 mg Pen: 0.11 ml 2 capsules warfarin, Eliquis*, Xarelto* 1 capsule, 28 day ml metformin, Ozempic*, Victoza* Initial: 1 ml per 28 days Maintenance: 1 ml per 56 days Enbrel*, Humira* XARELTO 2 No 10 mg & 20 mg tablet: 1 tablet 15 mg tablet: 2 tablets warfarin, Eliquis,

3 GHP Family GHP Family Tier Detailed s Alternative(s) BEVYXXA Brand 1 tablet daily Enoxaparin, Fondaparinux, Heparin, Xarelto, Eliquis, CALQUENCE Brand 2 capsules daily 1 tablet daily allopurinol, probenecid ELIQUIS Brand No 2.5 mg: 2 tablets daily, 5 mg: 4 tablets warfarin, Xarelto daily NITYR Brand No No Nityr OZEMPIC Brand No 0.25 mg 0.5 mg: 1.5 ml per 28 days, 1 mg: 3 ml per 28 days PENTAZOCINE 50 MG / NALOXONE 0.5 MG Generic No 3 tablets daily buprenorphine patch PRADAXA Brand 2 capsules daily warfarin, Eliquis, Xarelto TANZEUM Brand (new metformin, Ozempic*, 4 pens per 28 days Victoza* ) XARELTO Brand No 1 syringe per 56 days * Indicates prior authorization (PA) or step (ST) 10 mg, 20 mg: 1 tablet daily, 15 mg: 2 tablets daily Enbrel*, Humira*, Stelara* warfarin, Eliquis

4 Geisinger Gold * Indicates prior authorization (PA) or step (ST) BEVYXXA $0 Deductible Brand CALQUENCE Specialty Brand MYLOTARG Specialty OZEMPIC RENFLEXIS Brand RITUXAN HYCELA Specialty VYXEOS Specialty Standard Detailed s 1 tablet ; 42 day supply max limit 120 capsules per 30 days 1 tablet Alternative(s) enoxaparin, fondaparinux, heparin Imbruvica*, Velcade*, Revlimid* allopurinol, probenecid, Uloric*, Zurampic* daunorubicin, cytarabine 0.25 mg syr: 1.5 ml every 28 day; 1 mg syr: 3 ml every 28 days 1400 mg vial: 4 vials per 28 days; 1600 mg vial 1 vial per 28 days, Tanzeum* sulfasalazine, Humira*. Enbrel*, Orencia* Rituxan* sulfasalazine, Humira*, Enbrel*, Stelara* daunorubicin, cytarabine

5 Marketplace Tier BEVYXXA 4 BOSULIF 0 CALQUENCE 0 Detailed s Onetime 42 day fill, 1 tablet 100 mg tablet: 3 tablets, 30 day supply 400 mg & 500 mg tablet: 1 tablet, 30 day 2 capsules, 30 Alternatives enoxaparin, fondaparinux, heparin 1 tablet allopurinol, probenecid, Uloric* ELIQUIS 3 No 2.5 mg tablet: 2 tablets 5 mg tablet: 4 tablets warfarin, Xarelto, ENTRESTO 3 2 tablets benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril, quinapril, trandolapril, ramipril, losartan, irbesartan, valsartan NITYR 5 No No Nityr* OZEMPIC 3 PRADAXA 4 SUTENT 0 TANZEUM 3, new XARELTO 3 No 0.25 mg/0.5 mg Pen: 0.06 ml 1 mg Pen: 0.11 ml per day 2 capsules warfarin, Eliquis*, Xarelto* 1 capsule, ml metformin, Ozempic*, Victoza* Initial: 1 ml per 28 days Maintenance: 1 ml per 56 days 10 mg & 20 mg tablet: 1 tablet 15 mg tablet: 2 tablets * Indicates prior authorization (PA) or step (ST) Enbrel*, Humira* warfarin, Eliquis, * Shingrix is now available for $0 cost sharing when administered at a pharmacy or at your physicians office. Coverage is limited to one course of (2 vaccines) per lifetime for members greater than or equal to 50 years of age. * Starting April 1, 2018, all prescriptions for adults for a total morphine equivalent dose (MED) of will require prior authorization from GHP or an override from the dispensing pharmacist. All prescriptions for a MED of 120 or greater will require prior authorization from GHP.