May 2017 P&T Updates Commercial Triple Tier 4th Tier Applicable Traditional Prior Auth Alternatives 6 ml per AMPYRA 3 2 2 tablets per day, 30 day BYDUREON 3 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 2 6 tablets per day - JADENU 3 2 - Exjade*, Ferriprox* KISQALI 3 2 Based on daily dose Ibrance* PATADAY *EFFECTIVE - olopatadine (generic Patanol) Renvela, calcium acetate, - Fosrenol RENVELA 3 2 - - REVLIMID 3 2 1 capsule per day, 28 day Xultophy*, Victoza*, 18 ml per Tanzeum*, Lantus*, Toujeo*, * TANZEUM 2 2 4 pens per 28 days metformin 1 1 - 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 3 2 2 ml per 28 days VICTOZA 2 2 9 ml per metformin XULTOPHY 2 2 15 ml per Victoza*, Tanzeum*, Lantus, Toujeo,
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 2 - - 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,
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,
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 - - - - - 63 tablets/28 days - - - - - - - Brand Preferred ZINPLAVA Specialty - 15 ml every 30 days Deferoxamine*, Exjade*, Ferriprox* Ibrance* calcium acetate, Fosrenol, Renvela Lantus,, Toujeo, - - - -
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 3 - - 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,