UnitedHealthcare Community Plan PDL Modifications

Transcription

1 Lialda Mesalamine Apriso Mesalamine treatment of ulcerative colitis. treatment of ulcerative colitis. Afinitor Disperz Everolimus treatment of subependymal giant cell astrocytoma (SEGA) with tuberous sclerosis complect (TSC). Prior authorization required. Available through 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 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 through Cometriq Cabozantinib of progressive, metastatic medullary thyroid cancer. Prior authorization required. Available through Stivarga Cystaran solution 0.44% Gattex Regorafenib Cysteamine Teduglutide 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 of corneal cysteine crystal accumulation in patients with cystinosis. Prior authorization required. Available through specialty pharmacy. of short bowel syndrome in patients who are dependent on parenteral support. Prior * Only Generics are covered Page 1 of 5

2 Juxtapid Lomitapide of homozygous familial hypercholesterolemia (HoFH). Prior authorization required. Available through 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 Norditropin Apixaban 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 Added as an alternative agent for stroke prophylaxis and systemic embolism prophylaxis in patients with nonvalvular atrial fibrillation. Prior authorization required. treatment of growth failure due to growth hormone deficiency. Prior authorization required. Available through specialty pharmacy. treatment of attention-deficit hyperactivity disorder (ADHD). Added as alternative insulin formulations for the treatment of type 1 and type 2 diabetes mellitus. AccuNeb 0.63 mg/3 ml and 1.25 mg/3 ml* Albuterol 0.63 mg/3 ml and 1.25 mg/3 ml* 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. Omnitrope Cimzia Hecoria* Combivent Respimat Somatropin Certolizumab pegol Tacrolimus Ipratropium/albuterol inhaler Alternative formulations are available on the PDL including Tev-Tropin and Norditropin. Current users will not be grandfathered. including Enbrel and Humira. Current users will not be grandfathered. Added as alternative formulation for the treatment of heart, kidney, and liver transplant rejection prophylaxis. Added as alternative formulation to for the treatment of chronic obstructive pulmonary disease (COPD). * Only Generics are covered Page 2 of 5

3 Detrol* Tolterodine Sanctura* Duoneb* Plan B One Step* Trospium Ipratropium/albuterol solution for inhalation Levonorgestrel 1.5 mg tab of an overactive bladder with symptoms of urinary frequency, urinary urgency, or urgerelated urinary incontinence. Step therapy of an overactive bladder with symptoms of urinary frequency, urinary urgency, or urgerelated urinary incontinence. Step therapy 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 Modification Step therapy removed. Peg-Intron Peginterferon alfa-2b Bayer (BREEZE 2, CONTOUR and ASCENSIA ) Test Strips 3/1/2013 4/1/2013 Isentress Chewable Raltegravir chewable tablet 3/1/2013 4/1/2013 Lyrica Solution Pregabalin oral solution 3/1/2013 4/1/2013 Xtandi Enzalutamide 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 grandfathered 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. metastatic castration-resistant prostate cancer in patients who have received prior chemotherapy containing docetaxel. Prior 3/1/2013 4/1/2013 Stribild Cobicistat/elvitegravir/ emtricitabine/tenofovir of HIV infection in antiretroviral naïve adults. 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 Modification 3/1/2013 4/1/2013 Adderall XR Amphet/d-amphet salts XR Modification 3/1/2013 4/1/2013 Strattera Atomoxetine Modification 3/1/2013 4/1/2013 Dexedrine* Dextroamphetamine Modification 3/1/2013 4/1/2013 Dextrostat* Dextroamphetamine Modification 3/1/2013 4/1/2013 Dexedrine Spansule* Dextroamphetamine ER Modification 3/1/2013 4/1/2013 Intuniv Guanfacine Modification 3/1/2013 4/1/2013 Ritalin* Methylphenidate Modification 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 grandfathered. *Only Generics are covered 3/1/2013 4/1/2013 Concerta* Methylphenidate ER Modification 3/1/2013 4/1/2013 Metadate ER* Methylphenidate SR Modification 3/1/2013 4/1/2013 Ritalin SR* Methylphenidate SR Modification 3/1/2013 4/1/2013 Vyvanse Lisdexamfetamine Modification * Only Generics are covered Page 3 of 5

4 3/1/2013 4/1/2013 Adcirca Tadalafil 3/1/2013 4/1/2013 Pristiq Desvenlafaxine Avonex Pen Interferon beta-1a Korlym Pulmicort Inhaler Symbicort Cimzia Penlac Solution 8%* Desenex Powder 2%* Aclovate Cream and Ointment 0.05%* Temovate Gel and Cream 0.5%* Derma-Smooth Oil/FS* Locoid Solution, Cream, and Ointment 0.1%* Dermatop Cream and Ointment 0.1%* Bleph 10 Ophthalmic Ointment* Optipranolol Ophthalmic Sol 0.3%* Dexasol Ophthalmic Sol 0.1%* FML Forte Opthalmic Sus 0.25%* Vasoclear Ophthalmic Sol 0.02%* Clear Eyes Redness Relief* Mifepristone Budesonide inhalation Budesonide/formoterol Certolizumab pegol Ciclopirox Miconazole topical powder Alclometasone topical cream Clobetasol topical gel and cream Fluocinolone acetonide topical oil Hydrocortisone butyrate topical solution, cream, Prednicarbate topical cream Sulfacetamide Sodium 10% Metipranolol Ophthalmic Dexamethasone sodium phosphate Fluorometholone Naphazoline HCl Naphazoline-Glycerin including sildenafil citrate 20 mg tablet, Letairis, and Tracleer. Current users will be grandfathered. including venlafaxine, venlafaxine ER capsules, fluoxetine, sertraline, paroxetine, and citalopram. Current users will be grandfathered. treatment of multiple sclerosis. Prior Added as alternative agent to control hyperglycemia secondary to hypercortisolism in adult patients with endogenous Cushing's syndrome who have type 2 diabetes mellitus or glucose intolerance and have failed surgery or are not candidates for surgery. Prior Added as an alternative agent for the maintenance treatment of asthma. Added as an alternative agent for the maintenance treatment of asthma. Step therapy rheumatoid arthritis and Crohn s disease. Prior Added as an alternative agent for treatment of mild to moderate onychomycosis of fingernails and toenails. treatment of tinea pedis, tinea corporis, tinea cruris, and tinea versicolor. of atopic dermatitis. of conjunctivitis, corneal ulcer and other superficial infections. Added as an alternative agent for the reduction of elevated intraocular pressure (IOP) in patients with open angle glaucoma or ocular hypertension. treatment of allergic conjunctivitis and allergic marginal corneal ulcer. treatment of allergic conjunctivitis, ocular burns or trauma due to corneal injury, thermal or penetration trauma, giant papillary conjunctivitis (GPC), keratitis, postoperative ocular inflammation, vernal keratoconjunctivitis, and chronic anterior uveitis. * Only Generics are covered Page 4 of 5

5 Vasoclear A Ophthalmic Naphazoline/Zinc sulfate Sol* Visine-AC Ophthalmic Sol* Tetrahydrozoline/Zinc sulfate Muro 128 Ophthalmic Sol 5%* Victrelis Cyclocort 0.1% Cream* Lokara Lotion 0.5%* Topicort Cream and Gel 0.05%* Topicort Cream and Ointment 0.25%* Apexicon Cream and Ointment 0.05%* Westcort Ointment 0.2%* Sodium chloride hypertonic Boceprevir Amcinonide topical cream Desonide topical lotion Desoximetasone topical cream and gel Desoximetasone topical cream Diflorasone topical cream and ointment Hydrocortisone valerate topical ointment Added as an alternative agent for the relief of redness of the eye due to minor irritations or relief of burning and irritation due to dryness of the eye or discomfort due to minor irritations. relief of corneal edema. An alternative agent is available on the PDL including Incivek. Current users will be grandfathered. including desonide ointment and cream, alclometasone, fluocinolone, hydrocortisone, and triamcinolone. including betamethasone, fluocinolone, fluticasone cream, hydrocortisone acetate, hydrocortisone butyrate, mometasone, and triamcinolone. * Only Generics are covered Page 5 of 5