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 per 90 days COLCHICINE CAPSULES Alternatives propranolol, propranolol ER, oral timolol, divalproex DR, atenolol, nadolol, Ajovy*, Emgality* propranolol, propranolol ER, oral timolol, divalproex DR, atenolol, nadolol, Aimovig*, Emgality* 1 No 1 No 3 capsules per day colchicine tablets COPIKTRA 3 2 2 tablets per day, 30 day DELSTRIGO 2 No 2 No 1 tablet per day Depending on your specific benefits and in which state you reside, some drugs on this list may have no cost sharing. Imbruvica*, Venclexta*, Zydelig* Complera, Odefsey, Atripla, Symfi, Symfi Lo DOPTELET 3 2 Platelet Count 40,000 to < 50,000 x 10 9 /L: 10 tablets per fill Platelet Count < 40,000 x 10 9 /L: 15 tablets per fill none EMGALITY 3 2 1 ml per 30 days EPIDIOLEX 3 No 2 No - FULPHILA 3 2 LYRICA CR - - - OLUMIANT 3 2 ORILISSA 3 2 1 dose per chemotherapy cycle 82.5 &165 mg: 3 tablets per day 330 mg: 2 tablets per day 1 tablet per day, 30 day 150 mg: 1 tablet per day, 30 day supply per fill 200 mg tablet: 2 tablets per day, 30 day propranolol, propranolol ER, oral timolol, divalproex DR, atenolol, nadolol, Aimovig*, Ajovy* felbamate, lamotrigine, topiramate, valproic acid, divalproex, clonazepam, zonisamide, levetiracetam Neupogen*, Neulasta* Diabetic Peripheral Neuropathy: duloxetine, Lyrica Postherpetic Neuralgia: gabapentin, Lyrica Humira* norethindrone acetate, danazol capsule, formulary oral NSAIDS, Synarel
Commercial (cont.) Triple Tier 4th Tier Applicable Traditional Prior Auth Detailed s Depending on your specific benefits and in which state you reside, some drugs on this list may have no cost sharing. Alternatives PALYNZIQ 3 2 2.5 mg/0.5 ml syringe: 0.15 ml per day 10 mg/0.5 ml syringe: 0.5 ml per day 20 mg/ml syringe: 2 ml per day Kuvan* PIFELTRO 2 No 2 No 2 tablets per day efavirenz, nevirapine, Edurant, Rescriptor, Intelence RETACRIT 3 2 No - Epogen*, Procrit*, Aranesp* SUBOXONE FILM 3 No 2 No 2/0.5 mg: 3 films per day 4/1 mg & 8/2 mg: 2 films per day 12/3 mg: 1 film per day SYMTUZA 2 No 2 No 1 tablet per day VIZIMPRO 3 2 1 tablet per day, 30 day buprenorphine, buprenorphine/naloxone Genvoya, Stribild, Complera, Odefsey, Triumeq, Biktarvy, Atripla, Symfi, Symfi Lo Gilotrif*, Iressa*, Tagrisso*, Tarceva* MANDATORY GENERIC Commercial plan members all members not on a Geisinger Gold, GHP Marketplace, GHP Family or GHP Kids plan will no longer be able to obtain brand name drugs when a generic is available without prior authorization. Ongoing therapy will not be disrupted and narrow therapeutic agents will remain available. HEPATITIS C CENTER OF EXCELLENCE Beginning on 1/1/19, members seeking treatment for hepatitis C virus (HCV) will be required to receive their hepatitis C antiviral medications (GHP pharmacy prior authorization required) from a Center of Excellence (COE) provider following an office appointment and recommendations.
CHIP Tier Prior Auth AIMOVIG 2 Detailed s 70 mg per month: 2 ml per 60 days 140 mg per month: 2 ml per 30 days AJOVY 2 4.5 ml per 90 days COLCHICINE CAPSULES Alternatives timolol, divalproex DR, divalproex ER, topiramate, amitriptyline, venlafaxine, atenolol, nadolol, Ajovy*, Emgality* timolol, divalproex DR, divalproex ER, topiramate, amitriptyline, venlafaxine, atenolol, nadolol, Aimovig*, Emgality* 2 No 3 capsules per day colchicine tablets COPIKTRA 0 2 tablets per day, 30 day DELSTRIGO 2 No 1 tablet per day DOPTELET 2 Platelet Count 40,000 to < 50,000 x 10 9 /L: 10 tablets per fill Platelet Count < 40,000 x 10 9 /L: 15 tablets per fill EMGALITY 2 1 ml per 30 days EPIDIOLEX 2 No - FULPHILA 2 LYRICA CR - OLUMIANT 2 1 dose per chemotherapy cycle 82.5 &165 mg: 3 tablets per day 330 mg: 2 tablets per day 1 tablet per day, 30 day Imbruvica*, Venclexta*, Zydelig* Complera, Odefsey, Atripla, Symfi, Symfi Lo none timolol, divalproex DR, divalproex ER, topiramate, amitriptyline, venlafaxine, atenolol, nadolol, Aimovig*, Ajovy* felbamate, lamotrigine, topiramate, valproic acid, divalproex, clonazepam, zonisamide, levetiracetam Neupogen*, Neulasta* Diabetic Peripheral Neuropathy: duloxetine, Lyrica Postherpetic Neuralgia: gabapentin, Lyrica Humira* ORILISSA 2 PALYNZIQ 2 150 mg: 1 tablet per day, 30 day 200 mg tablet: 2 tablets per day, 30 day 2.5 mg/0.5 ml syringe: 0.15 ml per day 10 mg/0.5 ml syringe: 0.5 ml per day 20 mg/ml syringe: 2 ml per day norethindrone acetate, danazol capsule, formulary oral NSAIDS, Synarel Kuvan*
CHIP (cont.) Tier Prior Auth Detailed s Alternatives PIFELTRO 2 No 2 tablets per day efavirenz, nevirapine, Edurant, Rescriptor, Intelence RETACRIT 2 No - Epogen*, Procrit*, Aranesp* SUBOXONE FILM 2 No 2/0.5 mg: 3 films per day 4/1 mg & 8/2 mg: 2 films per day 12/3 mg: 1 film per day SYMTUZA 2 No 1 tablet per day VIZIMPRO 0 HEPATITIS C CENTER OF EXCELLENCE 1 tablet per day, 30 day buprenorphine, buprenorphine/naloxone Genvoya, Stribild, Complera, Odefsey, Triumeq, Biktarvy, Atripla, Symfi, Symfi Lo Gilotrif*, Iressa*, Tagrisso*, Tarceva* Beginning on 1/1/19, members seeking treatment for hepatitis C virus (HCV) will be required to receive their hepatitis C antiviral medications (GHP pharmacy prior authorization required) from a Center of Excellence (COE) provider following an office appointment and recommendations.
GHP Family AJOVY GHP Family Tier Prior Auth Detailed s 4.5 ml per 90 days Alternative(s) propranolol, propranolol ER, timolol, divalproex DR, divalproex ER, topiramate ER*, topiramate, atenolol, nadolol BECONASE AQ Brand No - Mometasone COLCHICINE CAPSULES Generic No 3 capsules daily Colchicine tablets COPIKTRA Brand 60 tablets per 30 days Imbruvica*, Venclexta*, Rituxan IV*, Rituxan Hycela* DELSTRIGO Brand No 1 tablet daily Complera, Odefsey, Atripla, Symfi, Symfi Lo For platelet count 40,000 to <50,000 x 109/L 10 DOPTELET tablets per fill, for platelet count <40,000 x 109/L 15 tablets per fill. One fill per Rx. - EMGALITY 1 ml per 30 days EPIDIOLEX Brand No - propranolol, propranolol ER, timolol, divalproex DR, divalproex ER, topiramate ER*, topiramate, atenolol, nadolol felbamate, lamotrigine, topiramate, topiramate ER*, valproic acid, divalproex, clonazepam, zonisamide, levetiracetam, Banzel* One 6mg dose per FULPHILA Generic Neupogen*, Neulasta* chemotherapy cycle IRESSA Brand 30 tablets per 30 days Gilotrif*, Tarceva*, Vizimpro* 82.5 mg tablets,165 mg duloxetine, gabapentin, lidocaine tablets: 3 tablets daily; LYRICA CR patch* 330 mg tablets: 2 tablets Lyrica* daily OLUMIANT ORILISSA Brand 1 tablet daily 150 mg: 30 tablets per 30 days; 200 mg: 60 tablets per 30 days Cimzia*, Enbrel*, Humira*, Kineret*, Orencia* Medroxyprogesterone IM 150 mg/ml, norethindrone acetate, danazol capsule, celecoxib, choline magnesium salicylate, diclofenac, diflunisal, etodolac, etodolac extended release, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, meloxicam
GHP Family (cont.) GHP Family Tier Prior Auth Detailed s Alternative(s) PALYNZIQ Brand 2.5 mg/0.5 ml syringe: 0.15 ml per day; 10 mg/0.5 ml syringe: 0.5 ml per day; Kuvan* 20 mg/ml syringe: 2 ml per day PIFELTRO Brand No 2 tablets per day Efavirenz, Nevirapine Edurant, Rescriptor, Intelence RETACRIT Brand No - Epogen*, Procrit*, Aranesp* SUBOXONE FILM Brand No 2/0.5 mg 3 daily, 4/1 mg, 8/2 mg 2 daily, 12/3 mg 1 daily SYMTUZA Brand 1 tablet daily Buprenorphine SL tablets, Buprenorphine/Naloxone SL tablets Genvoya, Stribild, Complera, Odefsey, Triumeq, Biktarvy, Atripla, Symfi, Symfi Lo VIZIMPRO Brand 30 tablets per 30 days Gilotrif*, Tagrisso*, Tarceva*
Geisinger Gold AJOVY $0 Deductible Brand Preferred COPIKTRA Specialty DELSTRIGO Specialty DOPTELET Specialty EMGALITY EPIDIOLEX Brand Preferred Brand Preferred FULPHILA Specialty Standard Prior Auth Detailed s 1.5 ml/30 days 60 tablets/30 days No 1 tablet/day 40 mg/day dose (10 count pack) 10 tablets/30 days; 60 mg/day dose (15 count pack) 15 tablets/30 days 2 ml/30 days No - No - Alternative(s) metoprolol, propranolol, timolol, atenolol, nadolol, topiramate, divalproex, sodium valproate, amitriptyline*, venlafaxine Venclexta*, Imbruvica*, Zydelig*, Rituxan*, Aliqopa* Complera, Odefsey, Atripla, Symfi, Symfi Lo none metoprolol, propranolol, timolol, atenolol, nadolol, topiramate, divalproex, sodium valproate, amitriptyline*, venlafaxine Felbamate, lamotrigine, topiramate, topiramate ER*, clonazepam, levetiracetam, Banzel*, Lamictal, Onfi* Granix*, Neupogen*, Neulasta* LIBTAYO Specialty No - Cisplatin, Gilotrif*, Tarceva*, Tykerb*, Vectibix*, Erbitux, Keytruda*, Opdivo*, Yervoy* LYRICA CR Brand Preferred OLUMIANT Specialty ORILISSA Specialty 82.5 mg tablets: 3 tablets per day; 165 mg tablets: 3 tablets per day; 330 mg tablets: 2 tablets per day 1 tablet/day 150 mg: 30 tablets/30 days; 200 mg: 60 tablets/30 days Lyrica, duloxetine, gabapentin, lidocaine patch* azathioprine, cyclosporine, hydroxychloroquine, methotrexate, sulfasalazine, leflunomide, Depen, Ridaura, Humira*, Xeljanz* celecoxib, diclofenac, diflunisal, etodolac, fenoprofen, flurbiprofen, ibuprofen, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin, norethindrone acetate, danazol, Zoladex, Synarel, Lupron Depot
Geisinger Gold (cont.) $0 Deductible PALYNZIQ Specialty PIFELTRO Specialty POTELIGEO Specialty RETACRIT Brand Preferred SYMTUZA Specialty VIZIMPRO Specialty Standard Prior Auth Detailed s 2.5 mg syringe: 4.5 ml/30 days; 10 mg syringe: 15 ml/30 days; 20 mg syringe: 60 ml/30 days No 2 tablets/day Alternative(s) Kuvan* Efavirenz, Nevirapine,Rescriptor, Intelence, Edurant - Zolinza* 12 ml/28 days No 1 tablet/day 1 tablet/day Epogen*, Procrit*, Aranesp*, Mircera* Genvoya, Stribild, Complera, Odefsey, Triumeq, Biktarvy, Atripla, Symfi, Symfi Lo Gilotrif*, Iressa*, Tagrisso*, Tarceva*
Marketplace Tier Prior Auth AIMOVIG 5 Detailed s 70 mg per month: 2 ml per 60 days 140 mg per month: 2 ml per 30 days AJOVY 5 4.5 ml per 90 days COLCHICINE CAPSULES Alternatives timolol, divalproex DR, atenolol, nadolol, Ajovy*, Emgality* timolol, divalproex DR, atenolol, nadolol, Aimovig*, Emgality* 2 No 3 capsules per day colchicine tablets COPIKTRA 0 2 tablets per day, 30 day DELSTRIGO 3 No 1 tablet per day DOPTELET 5 Platelet Count 40,000 to < 50,000 x 10 9 /L: 10 tablets per fill Platelet Count < 40,000 x 10 9 /L: 15 tablets per fill EMGALITY 5 1 ml per 30 days EPIDIOLEX 4 No - FULPHILA 5 LYRICA CR - OLUMIANT 5 1 dose per chemotherapy cycle 82.5 &165 mg: 3 tablets per day 330 mg: 2 tablets per day 1 tablet per day, 30 day Imbruvica*, Venclexta*, Zydelig* Complera, Odefsey, Atripla, Symfi, Symfi Lo none timolol, divalproex DR, atenolol, nadolol, Aimovig*, Ajovy* felbamate, lamotrigine, topiramate, valproic acid, divalproex, clonazepam, zonisamide, levetiracetam Neupogen*, Neulasta* Diabetic Peripheral Neuropathy: duloxetine, Lyrica Postherpetic Neuralgia: gabapentin, Lyrica Humira* ORILISSA 5 150 mg: 1 tablet per day, 30 day 200 mg tablet: 2 tablets per day, 30 day supply per fill norethindrone acetate, danazol capsule, formulary oral NSAIDS, Synarel
Marketplace (cont.) Tier Prior Auth Detailed s Alternatives PALYNZIQ 5 2.5 mg/0.5 ml syringe: 0.15 ml per day 10 mg/0.5 ml syringe: 0.5 ml per day Kuvan* 20 mg/ml syringe: 2 ml per day PIFELTRO 3 No 2 tablets per day efavirenz, nevirapine, Edurant, Rescriptor, Intelence RETACRIT 5 No - Epogen*, Procrit*, Aranesp* SUBOXONE FILM 2 No 2/0.5 mg: 3 films per day 4/1 mg & 8/2 mg: 2 films per day 12/3 mg: 1 film per day buprenorphine, buprenorphine/naloxone SYMTUZA 3 No 1 tablet per day VIZIMPRO 0 HEPATITIS C CENTER OF EXCELLENCE 1 tablet per day, 30 day Genvoya, Stribild, Complera, Odefsey, Triumeq, Biktarvy, Atripla, Symfi, Symfi Lo Gilotrif*, Iressa*, Tagrisso*, Tarceva* Beginning on 1/1/19, members seeking treatment for hepatitis C virus (HCV) will be required to receive their hepatitis C antiviral medications (GHP pharmacy prior authorization required) from a Center of Excellence (COE) provider following an office appointment and recommendations.