May 2017 P&T Updates
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- George Miles
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1 May 2017 P&T Updates Commercial Triple Tier 4th Tier Applicable Traditional Prior Auth Alternatives 6 ml per AMPYRA tablets per day, 30 day BYDUREON vials per 28 days 5 mcg pen: 1.2 ml per 10 mcg pen: 2.4 ml per 30 mg: 2 tablets per day ISENTRESS 25 MG tablets per day - JADENU Exjade*, Ferriprox* KISQALI 3 2 Based on daily dose Ibrance* PATADAY *EFFECTIVE - olopatadine (generic Patanol) Renvela, calcium acetate, - Fosrenol RENVELA REVLIMID capsule per day, 28 day Xultophy*, Victoza*, 18 ml per Tanzeum*, Lantus*, Toujeo*, * TANZEUM pens per 28 days metformin Seizures: carbamazepine, divalproex, felbamate, valproic acid, topiramate IR, lamotrigine, levetiracetam, oxcarbazepine, phenytoin, zonisamide, gabapentin, tiagabine, phenobarbital Migraine: topiramate IR, propranolol, timolol, divalproex topiramate extended - release* TRULICITY ml per 28 days VICTOZA ml per metformin XULTOPHY ml per Victoza*, Tanzeum*, Lantus, Toujeo,
2 CHIP Tier Prior Auth Alternatives - 6 ml per AMPYRA 2 2 tablets per day, 30 day BYDUREON 2 4 vials per 28 days - 5 mcg pen: 1.2 ml per 10 mcg pen: 2.4 ml per - 30 mg: 2 tablets per day ISENTRESS 25 MG 2 6 tablets per day - JADENU 2 - Exjade*, Ferriprox* KISQALI 2 Based on daily dose Ibrance* PATADAY *EFFECTIVE - - olopatadine (generic Patanol) - - Renvela, calcium acetate, Fosrenol RENVELA REVLIMID 2 1 capsule per day, 28 day Xultophy*, Victoza*, Tanzeum*, Lantus*, - 18 ml per Toujeo*, * TANZEUM 2 4 pens per 28 days metformin 2 - Seizures: carbamazepine, divalproex, felbamate, valproic acid, topiramate IR, lamotrigine, levetiracetam, oxcarbazepine, phenytoin, zonisamide, gabapentin, tiagabine, phenobarbital Migraine: topiramate IR, propranolol, timolol, divalproex - - topiramate extended release* TRULICITY 2 2 ml per 28 days VICTOZA 2 9 ml per metformin XULTOPHY 2 15 ml per Victoza*, Tanzeum*, Lantus, Toujeo,
3 GHP Family JADENU GHP Family Tier Prior Auth Alternative(s) 6 ml per 6 mg, 30 mg - 2 tablets daily, 18 mg - 1 tablet daily - KISQALI Brand 600 mg daily dose: 63 tablets, 400 mg daily dose: 42 tablets, 200 mg daily dose: 21 tablets. Maximum of 28 day. Ibrance* (EFFECTIVE Renvela, calcium acetate, - 9/1/17) Fosrenol RENVELA Brand - calcium acetate, Fosrenol Victoza*, Tanzeum*, 18 ml per Xultopy*, Lantus, Toujeo, TANZEUM Brand 4 pens per 28 days metformin ER Generic - Topiramate IR TRULICITY 2 ml per 28 days VICTOZA Brand 9 ml per metformin XULTOPHY Brand 15 ml per Victoza*, Tanzeum*, Lantus, Toujeo,
4 Geisinger Gold $0 Deductible BAVENCIO Specialty Standard Prior Auth Alternative(s) Specialty 6mg and 30 mg tablets: 2 per day; 18 mg tablets: 1 per day JADENU Specialty KISQALI Specialty (EFFECTIVE 1/1/18) XULTOPHY tablets/28 days Brand Preferred ZINPLAVA Specialty - 15 ml every 30 days Deferoxamine*, Exjade*, Ferriprox* Ibrance* calcium acetate, Fosrenol, Renvela Lantus,, Toujeo,
5 Marketplace Tier Prior Auth Alternatives 6 ml per AMPYRA 3 2 tablets per day, 30 day BYDUREON 3 4 vials per 28 days Victoza*, Tanzeum* 5 mcg pen: 1.2 ml per 10 mcg pen: 2.4 ml per 30 mg: 2 tablets per day ISENTRESS 25 MG 3 6 tablets per day not applicable JADENU 5 - Exjade*, Ferriprox* KISQALI 5 Based on daily dose. Ibrance* PATADAY *EFFECTIVE - olopatadine (generic Patanol) - Renvela, calcium acetate, Fosrenol RENVELA REVLIMID 5 1 capsule per day, 28 day Xultophy*, Victoza*, Tanzeum*, 18 ml per Lantus*, Toujeo*, * TANZEUM 3 4 pens per 28 days metformin 2 - Seizures: carbamazepine, divalproex, felbamate, valproic acid, topiramate IR, lamotrigine, levetiracetam, oxcarbazepine, phenytoin, zonisamide, gabapentin, tiagabine, phenobarbital Migraine: topiramate IR, propranolol, timolol, divalproex - topiramare extended release* TRULICITY 3 2 ml per 28 days VICTOZA 3 9 ml per metformin XULTOPHY 3 15 ml per Victoza*, Tanzeum*, Lantus, Toujeo,
November 2018 P & T Updates
November 2018 P & T Updates Commercial Triple Tier 4th Tier Applicable Traditional Prior Auth AIMOVIG 3 2 Detailed s 70 mg per month: 2 ml per 60 days 140 mg per month: 2 ml per 30 days AJOVY 3 2 4.5 ml
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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, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED RELEASE PRIOR CLAIM FOR AMANTADINE HCL IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS. 1 ANTICONVULSANTS
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Effective: 11/01/2018 Updated 10/2018 ANTIDEPRESSANTS Sharp Health Plan (HMO) TRINTELLIX 10 MG TABLET TRINTELLIX 20 MG TABLET TRINTELLIX 5 MG TABLET VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK