Avonex Pen Interferon beta-1a Added as alternative dosing formulation for the treatment of multiple sclerosis. Prior Korlym Mifepristone 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 Pulmicort Inhaler Budesonide inhalation maintenance treatment of asthma. Symbicort Budesonide/formoterol maintenance treatment of asthma. Step therapy Cimzia Certolizumab pegol treatment rheumatoid arthritis and Crohn s disease. Prior authorization required. Available through Forteo Teriparatide treatment of osteoporosis. Prior Ranexa Ranolazine treatment of chronic angina. Step therapy Penlac Solution 8%* Ciclopirox Added as an alternative agent for treatment of mild to moderate onychomycosis of fingernails and toenails. Desenex Powder 2%* Miconazole topical powder treatment of tinea pedis, tinea corporis, tinea cruris, and tinea versicolor. Aclovate Cream and Ointment 0.05%* Alclometasone topical cream Temovate Gel and Cream 0.5%* Clobetasol topical gel and cream Derma-Smooth Oil/FS* Fluocinolone acetonide topical oil Locoid Solution, Cream, and Ointment 0.1%* Hydrocortisone butyrate topical solution, cream, and ointment Dermatop Cream and Prednicarbate topical cream 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* Sulfacetamide Sodium 10% Metipranolol Ophthalmic Dexamethasone sodium phosphate Fluorometholone Naphazoline HCl Naphazoline-Glycerin treatment of conjunctivitis, corneal ulcer and other superficial infections. 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 1 of 5
Vasoclear A Ophthalmic Naphazoline/Zinc sulfate Sol* 6/1/2012 7/1/2012 Visine-AC Ophthalmic Sol* Tetrahydrozoline/Zinc sulfate Muro 128 Ophthalmic Sol Sodium chloride hypertonic 5%* Victrelis Boceprevir 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%* Amcinonide topical cream Desonide topical lotion Desoximetasone topical cream and gel Desoximetasone topical cream Diflorasone topical cream Westcort Ointment 0.2%* Hydrocortisone valerate topical ointment Betoptic-S Ophthalmic Susp 0.25%* Azopt Opthalmic Susp 1%* Betaxolol HCl Brinzolamide Viread Oral Powder and 150, 200, and 250 mg tablets Tenofovir 6/1/2012 7/1/2012 Prezista Darunavir 6/1/2012 7/1/2012 Jakafi Ruxolitinib 6/1/2012 7/1/2012 Inlyta Axitinib 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. temporary relief of corneal edema. An alternative agent is available on the PDL including Incivek. Current users will be including desonide ointment and cream, alclometasone, fluocinolone, hydrocortisone, and triamcinolone. including betamethasone, fluocinolone, fluticasone cream, hydrocortisone acetate, hydrocortisone butyrate, mometasone, and triamcinolone. including timolol, levobunolol, carteolol, and metipranolol. including dorzolamide and dorzolamide/timolol. Added as alternative dosing formulations for the treatment of HIV infection in combination with other anti-retroviral agents. Added as alternative dosing formulations for the treatment of HIV infection in combination with other anti-retroviral agents. treatment of intermediate or high-risk myelofibrosis, including primary myelofibrosis, post-polycythemia vera myelofibrosis, and post-essential thrombocythemia myelofibrosis. Prior treatment of advanced renal cell cancer after failure of 1 prior systemic therapy. Prior authorization required. Available through * Only Generics are covered Page 2 of 5
6/1/2012 7/1/2012 Erivedge Vismodegib Added as an alternative agent for treatment of metastatic basal cell carcinoma or in patients with locally advanced basal cell carcinoma that has recurred following surgery or who are not candidates for surgery or radiation. Prior authorization 6/1/2012 7/1/2012 Kalydeco Ivacaftor 6/1/2012 7/1/2012 Berinert C1 Inhibitor, Human treatment of cystic fibrosis (CF) in patients who have a G551D mutation in the CFTR gene. Prior authorization required. Available through treatment of acute abdominal or facial attacks of hereditary angioedema. Available through 6/1/2012 7/1/2012 Lipitor* Atorvastatin Added as an alternative agent as an adjunct to diet for the treatment of hypercholesterolemia or hyperlipoproteinemia. Step therapy 6/1/2012 7/1/2012 Xyzal* tablet Levocetirizine tablet treatment of allergic rhinitis. Step therapy 6/1/2012 7/1/2012 Nucynta ER Tapentadol ER treatment of chronic, moderate to severe pain that requires continuous, around-theclock opioid analgesia for an extended time period. Step therapy 6/1/2012 7/1/2012 Janumet XR Metformin/Sitagliptin treatment of type 2 diabetes mellitus. Step therapy 6/1/2012 7/1/2012 Xarelto Rivaroxaban Added as an alternative agent for deep venous thrombosis (DVT) prophylaxis in patients undergoing knee or hip replacement surgery and stroke and systemic embolism prophylaxis in patients with nonvalvular atrial fibrillation. Prior authorization required. 6/1/2012 7/1/2012 Abilify Aripiprazole Modification Step therapy 6/1/2012 7/1/2012 Seroquel XR Quetiapine ER including risperidone, olanzapine, ziprasidone, and quetiapine (immediate release formulation). Current users will be 6/1/2012 7/1/2012 Crestor Rosuvastatin including simvastatin, pravastatin, lovastatin, and atorvastatin. Current users will not be 6/1/2012 7/1/2012 Zovirax Ointment Acyclovir Alternative formulations and agents are available on the PDL including acyclovir tablet and valacyclovir tablet. Current prescriptions for the tablet formulation will be allowed to finish current therapy. 6/1/2012 7/1/2012 Allegra tablet* Fexofenadine tablet Alternatives agents are available on the PDL including loratadine, cetirizine, and levocetirizine. Current users will be Pegasys Proclick Peginterferon alfa-2a Androderm 2 mg and 4 mg patches Testosterone patch Firazyr Icatibant Added as an alternative dosing formulation for the treatment of chronic hepatitis C infection. Prior authorization required. Available through treatment of hypogonadism (primary or hypogonadotropic types). Prior authorization required. treatment of acute attacks of hereditary angioedema (HAE) in adults 18 years of age and older. Available through specialty * Only Generics are covered Page 3 of 5
Onfi Clobazam Added as an alternative agent for adjunctive treatment of seizures associated with Lennox-Gastaut syndrome in patients 2 years of age or older. Step therapy Xalkori Crizotinib Zelboraf Vemurafenib treatment of patients with locally advanced or metastatic non-small cell lung cancer that is anaplastic lymphoma kinase positive. Prior authorization required. Available through treatment of patients with unresectable or metastatic melanoma with BRAF V600E mutation. Prior authorization required. Available through Wellbutrin XL 150 mg and 300 mg* Bupropion ext release treatment of major depressive disorder and seasonal affective disorder. Uroxatral* Alfuzosin ER Accu-Chek Aviva Plus Test Strips Invega Sustenna Paliperidone inj Modification Risperdal Consta Risperidone inj Modification Carafate* Suspension Sucralfate Modification Suboxone Buprenorphine/naloxone Modification Subutex* Buprenorphine Modification Androgel 1% Testosterone gel Prozac 20 mg tablets Fluoxetine 20 mg tablets Suboxone tablets Buprenorphine/naloxone 2/1/2012 2/1/2012 Incivek Telaprevir 12/1/2011 1/1/2012 Androgel 1.62% Testosterone gel 12/1/2011 1/1/2012 Creon 3000 unit Pancrelipase 12/1/2011 1/1/2012 Lupron Depot 6- Month Leuprolide acetate treatment of benign prostatic hyperplasia. Added as an alternative test strip for blood glucose testing for patients with diabetes mellitus. Prior authorization required. Current users will be Prior authorization required. Current users will be Age edit Prior authorization required for patients aged 10 years of age up to 65 years of age. Current users will be Quantity limit remains the same (3 tabs per day 24 mg) for the initial 3 months of Alternative formulations are available on the PDL including Androgel 1.62% and Androderm. Current users will not be Alternative formulations of fluoxetine are available on the PDL including fluoxetine 10 and 20 mg capsules. Current users will not be grandfathered, and expected to transition to the capsule formulation. An alternative formulation is available on the PDL including Suboxone sublingual film. Current prescriptions for the tablet formulation will be allowed to finish current therapy. treatment of chronic hepatitis C infection (genotype 1) in adults with compensated liver disease. Prior authorization is treatment of hypogonadism (primary or hypogonadotropic types). Prior authorization is required. Added as an alternative dosage formulation for the treatment of pancreatic insufficiency. Added as an alternative dosing formulation for the treatment of advanced prostate cancer. Prior authorization is required. Available through * Only Generics are covered Page 4 of 5
12/1/2011 1/1/2012 Sylatron Peginterferon alfa-2b adjuvant treatment of malignant melanoma with microscopic or gross nodal involvement within 84 days of definitive surgical resection including complete lymphadenectomy. Prior authorization is 12/1/2011 1/1/2012 Edurant Rilpivirine 12/1/2011 1/1/2012 Complera Emtricitabine/Rilpivirine/ Tenofovir 12/1/2011 1/1/2012 Victrelis Boceprevir 12/1/2011 1/1/2012 Potiga Exogabine treatment of antiretroviral treatment-naive adults with human immunodeficiency virus (HIV) infection in combination with other antiretroviral agents. treatment of human immunodeficiency virus (HIV) infection in antiretroviral treatment-naive adults. treatment of chronic hepatitis C infection (genotype 1) in adults with compensated liver disease. Prior authorization is adjunctive treatment of partial-onset seizures in patients aged 18 years and older. Step therapy 12/1/2011 1/1/2012 Zytiga Abiraterone treatment of metastatic castration-resistant prostate cancer in combination with prednisone in patients who have received prior chemotherapy containing docetaxel. Prior authorization is required. Available through 12/1/2011 1/1/2012 Mepron Atovaquone Modification Prior authorization is required. 12/1/2011 1/1/2012 Celexa* 40 mg Citalopram Modification Quantity limit changed to 1 tablet per day. Current users of greater than 40 mg will be 12/1/2011 1/1/2012 Gabitril Tiagabine Modification Minimum age edit implemented to reflect FDA approved age limitations. Prior authorization required for patients less than the FDA approved age limitations. Age edit modification only applies to new starts. Step therapy remains for patients above the age edit. 12/1/2011 1/1/2012 Vimpat Lacosamide Modification Minimum age edit implemented to reflect FDA approved age limitations. Prior authorization required for patients less than the FDA approved age limitations. Age edit modification only applies to new starts. Step therapy remains for patients above the age edit. 12/1/2011 1/1/2012 Keppra* tablet Levetiracetam Modification Step therapy removed. 12/1/2011 1/1/2012 Keppra* solution Levetiracetam Modification Step therapy removed. Maximum age edit of 10 years of age Patients 10 years of age and greater require prior authorization. 12/1/2011 1/1/2012 Trileptal* tablet Oxcarbazepine Modification Step therapy removed. 12/1/2011 1/1/2012 Trileptal* suspension Oxcarbazepine Modification Step therapy removed. Maximum age edit of 10 years of age Patients 10 years of age and greater require prior authorization. 10/14/2011 10/14/2011 Vyvanse Lisdexamfetamine treatment of attention-deficit hyperactivity disorder (ADHD). Age edit * Only Generics are covered Page 5 of 5