March 2018 P & T Updates

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March 2018 P & T Updates Commercial Triple Tier 4th Tier Applicable Traditional Prior Auth AURYXIA 3 2 12 tablets per BAXDELA TABLETS 3 2 2 tablets per Depending on your specific benefits and in which state you reside, some drugs on this list may have no cost sharing. 100 mg tablets: 4 tablets per 12.5 mg tablets: 2 tablets per Alternatives calcium acetate, Eliphos, sevelamer carbonate, lanthanum carbonate ciprofloxacin, clindamycin, doxycycline, levofloxacin, linezolid, minocycline, moxifloxacin, ofloxacin, sulfamethoxazole/tmp BIKTARVY 2 2 1 tablet per Odefsey, Triumeq CHANTIX 0 0 COSENTYX 3 2 COTEMPLA XR ODT ENDARI 3 2 GENOTROPIN HUMATROPE IMBRUVICA 3 2 Starter Pack: 1 pack per 180 s Maintenance Pack, 0.5 mg, & 1 mg tablets: 2 tablets per Initial Fill: 6 syringes per 28 s Subsequent Fills: 2 syringes per 28 s 8.6 & 17.3 mg tablets: 1 tablet per 25.9 mg tablets: 2 tablets per 6 packets per, 30 bupropion, nicotine gum, nicotine lozenges, nicotine patches atomoxetine, dexmethylphenidate, dextroamphetamine tablets, dextroamphetamine ER capsules, dextroamphetamine/amphe tamine combination, guanfacine ER, methylphenidate, methylphenidate ER hydroxyurea rditropin rditropin 1 capsule/tablet per, 28 supply per fill

Commercial (cont.) Triple Tier 4th Tier Applicable Traditional Prior Auth JULUCA 2 2 1 tablet per NORDITROPIN NUTROPIN AQ OMNITROPE SAIZEN SEROSTIM TRELEGY ELLIPTA ZOMACTON ZORBTIVE ZYKADIA 3 2 8.6 & 17.3 mg tablets: 1 tablet per 25.9 mg tablets: 2 tablets per Alternatives Odefsey, Edurant, Tivicay, Trimeq atomoxetine, dexmethylphenidate, dextroamphetamine tablets, dextroamphetamine ER capsules, dextroamphetamine/amphe tamine combination, guanfacine ER, methylphenidate, methylphenidate ER rditropin rditropin 1 tablet per metformin, Glyxambi*, Jardiance*, Invokana*, Synjardy*, Invokamet*, Tradjenta*, Jentadueto* rditropin rditropin 1 tablet per Movantik, Amitiza Depending on your specific benefits and in which state you reside, some drugs on this list may have no cost sharing. Incruse Ellipta, Spiriva, Serevent, Striverdi Respimat, Arnuity Ellipta, Pulmicort Flexhaler, Flovent, Asmanex, Breo Ellipta, Advair, Anoro Ellipta, Stiolto Respimat rditropin rditropin 3 capsules per, 30 Beginning 6/1/18 members being newly started on Enbrel therapy for the treatment of plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis will require medical record documentation of therapeutic failure on, intolerance to, or contraindication to Cosentyx* and.

CHIP Tier Prior Auth Alternatives AURYXIA 2 12 tablets per BAXDELA TABLETS 2 2 tablets per 100 mg tablets: 4 tablets per 12.5 mg tablets: 2 tablets per BIKTARVY 2 1 tablet per calcium acetate, Eliphos, sevelamer carbonate, lanthanum carbonate ciprofloxacin, clindamycin, doxycycline, levofloxacin, linezolid, minocycline, moxifloxacin, ofloxacin, sulfamethoxazole/tmp Odefsey, Triumeq CHANTIX 0 COSENTYX 2 Starter Pack: 1 pack per 180 s Maintenance Pack, 0.5 mg, & 1 mg tablets: 2 tablets per Initial Fill: 6 syringes per 28 s Subsequent Fills: 2 syringes per 28 s bupropion, nicotine gum, nicotine lozenges, nicotine patches COTEMPLA XRODT 8.6 & 17.3 mg tablets: 1 tablet per 25.9 mg tablets: 2 tablets per dextroamphetamine tablets, dextroamphetamine ER capsules, dextroamphetamine/amphetamine combination, guanfacine ER, ER ENDARI 2 GENOTROPIN HUMATROPE IMBRUVICA 0 6 packets per, 30 hydroxyurea rditropin rditropin 1 capsule/tablet per, 28 JULUCA 2 1 tablet per Odefsey, Edurant, Tivicay, Trimeq 8.6 & 17.3 mg tablets: 1 tablet per 25.9 mg tablets: 2 tablets per dextroamphetamine tablets, dextroamphetamine ER capsules, dextroamphetamine/amphetamine combination, guanfacine ER, ER

CHIP (cont.) Tier NORDITROPIN NUTROPIN AQ OMNITROPE SAIZEN SEROSTIM TRELEGY ELLIPTA ZOMACTON ZORBTIVE Prior Auth Alternatives rditropin rditropin 1 tablet per metformin, Glyxambi*, Jardiance*, Invokana*, Synjardy*, Invokamet*, Tradjenta*, Jentadueto* rditropin rditropin 1 tablet per Movantik, Amitiza ZYKADIA 0 Incruse Ellipta, Spiriva, Serevent, Striverdi Respimat, Arnuity Ellipta, Pulmicort Flexhaler, Flovent, Asmanex, Breo Ellipta, Advair, Anoro Ellipta, Stiolto Respimat rditropin rditropin 3 capsules per, 30 Beginning 6/1/18 members being newly started on Enbrel therapy for the treatment of plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis will require medical record documentation of therapeutic failure on, intolerance to, or contraindication to Cosentyx* and.

GHP Family GHP Family Tier Prior Auth AURYXIA Brand 12 tablets daily BAXDELA Brand two tablets daily 100 mg 4 tablets daily, 12.5 mg 2 tablets daily BIKTARVY Brand one tablet daily BUPRENORPHINE SL TABLETS (EFFECTIVE MAY 1, 2018 BUPRENORPHINE/NALOX ONE SL TABLETS (EFFECTIVE MAY 1, 2018) Generic Alternative(s) calcium acetate, Eliphos, lanthanum carbonate, sevelamer carbonate, Fosrenol powder packets ciprofloxacin tabs, clindamycin caps, doxycycline cap/tabs, levofloxacin tabs, linezolid tabs, minocycline cap/tabs, ofloxacin tabs, TMPSMX, Sivextro* e Odefsey, Triumeq buprenorphine/naloxone SL tablets, Suboxone Film* Generic Suboxone Film* CHANTIX Brand COSENTYX Brand 1 fill per 180 s (starter pack), 2 tablets daily (0.5 mg tablets, 1 mg tablets) One injection (150 mg or 300 mg) every 4 weeks OTC nicotine replacement, Bupropion SR, XL COTEMPLA XRODT 8.6 mg, 17.3 mg 1 tablet daily, 25.9 mg 2 tablets daily dextroamphetamine, dextroamphetamine ER, dextroamphetamineamphetamine, dextroamphetamineamphetamine ER, guanfacine ER, methylphenidate, methylphenidate ER/LA/CD ENDARI FLONASE ALLERGY RELIEF OTC FLONASE SENSIMST OTC IVERMECTIN Generic 6 packets daily hydroxyurea 15.8 ml per 30 s 15.8 ml per 30 s JULUCA Brand one tablet daily Fluticasone, Triamcinolone, Flunisolide Fluticasone, Triamcinolone, Flunisolide Odefsey, Edurant, Tivicay, Triumeq one tablet daily dextroamphetamine, dextroamphetamine ER, dextroamphetamineamphetamine, dextroamphetamineamphetamine ER, guanfacine ER, methylphenidate, methylphenidate ER/LA/CD

GHP Family (cont.) GHP Family Tier Prior Auth Alternative(s) OMEGA3 ETHYL ESTERS Generic 4 capsules daily Fenofibrate, Gemfibrozil, Atorvastatin, Rosuvastatin metformin Glyxambi*, Invokamet*, Invokana*, one tablet daily Jardiance*, Jentadueto*, Synjardy*, Tradjenta* SENSIPAR Brand calcitriol, paricalcitol one tablet daily Amitiza*, Movantik* TRELEGY ELLIPTA 60 blisters per 30 s LAMA: Spiriva LABA: Serevent, Striverdi ICS: Arnuity Ellipta, Flovent* ICS/LABA: Breo Ellipta, Advair* LAMA/LABA: Anoro Ellipta, Stiolto

Geisinger Gold $0 Deductible AURYXIA Specialty BAXDELA Specialty BIKTARVY Specialty COSENTYX Specialty COTEMPLA XRODT ENDARI Specialty JULUCA Specialty TRELEGY ELLIPTA Standard Prior Auth 12 tablets per 2 tablets per Alternative(s) calcium acetate, sevelamer carbonate, lanthanum carbonate Trimethoprim/sulfamethoxazole, ciprofloxacin, clindamycin, doxycycline, levofloxacin, linezolid, daptomycin, vancomycin, Sivextro* 30 tablets per 30 s 180 packets per 30 s 30 tablets per 30 s Odefsey, Triumeq CR, methylphenidate SR, dexmethylphenidate, dexmethylphenidate ER, dextroamphetamine, amphetamine/dextroamphetamine, amphetamine/dextroamphetamine SR combination Hydroxyurea, Droxia Odefsey, Edurant, Tivicay, Triumeq CR, methylphenidate SR, dexmethylphenidate, dexmethylphenidate ER, dextroamphetamine, amphetamine/dextroamphetamine, amphetamine/dextroamphetamine SR combination metformin, Glyxambi*, Invokana*, Invokamet*, Jardiance*, Synjardy*, Tradjenta, Januvia, Janumet Movantik, Amitiza Brand Preferred TRISENOX Specialty VABOMERE 2 blisters per Incruse Ellipta, Spiriva, Serevent, Striverdi, Arnuity Ellipta, Pulmicort, Flovent, Asmanex, Breo Ellipta, Advair, Anoro Ellipta, Stiolto Sulfamethoxazole/TMP, ciprofloxacin, levofloxacin, imipenem/cilastin, doripenem, Invanz, tobramycin, Avycaz*

Marketplace Tier Prior Auth AURYXIA 5 12 tablets per BAXDELA TABLETS 5 2 tablets per 100 mg tablets: 4 tablets per 12.5 mg tablets: 2 tablets per BIKTARVY 3 1 tablet per CHANTIX 0 COSENTYX 3 COTEMPLA XR ODT Starter Pack: 1 pack per 180 s Maintenance Pack, 0.5 mg, & 1 mg tablets: 2 tablets per Initial Fill: 6 syringes per 28 s Subsequent Fills: 2 syringes per 28 s 8.6 & 17.3 mg tablets: 1 tablet per 25.9 mg tablets: 2 tablets per Alternatives calcium acetate, Eliphos, sevelamer carbonate, lanthanum carbonate ciprofloxacin, clindamycin, doxycycline, levofloxacin, linezolid, minocycline, moxifloxacin, ofloxacin, sulfamethoxazole/tmp Odefsey, Triumeq bupropion, nicotine gum, nicotine lozenges, nicotine patches dextroamphetamine tablets, dextroamphetamine ER capsules, dextroamphetamine/amphetamine combination, guanfacine ER, ER ENDARI 5 6 packets per, 30 hydroxyurea GENOTROPIN 5 rditropin HUMATROPE 5 rditropin IMBRUVICA 0 1 capsule/tablet per, 28 JULUCA 3 1 tablet per Odefsey, Edurant, Tivicay, Trimeq 8.6 & 17.3 mg tablets: 1 tablet dextroamphetamine tablets, dextroamphetamine ER capsules, per dextroamphetamine/amphetamine 25.9 mg tablets: 2 tablets per combination, guanfacine ER, ER NORDITROPIN 5 NUTROPIN AQ 5 rditropin OMNITROPE 5 rditropin 1 tablet per metformin, Glyxambi*, Jardiance*, Invokana*, Synjardy*, Invokamet*, Tradjenta*, Jentadueto* SAIZEN 5 rditropin SEROSTIM 5 rditropin 1 tablet per Movantik, Amitiza

Marketplace (cont.) Tier Prior Auth TRELEGY ELLIPTA Alternatives Incruse Ellipta, Spiriva, Serevent, Striverdi Respimat, Arnuity Ellipta, Pulmicort Flexhaler, Flovent, Asmanex, Breo Ellipta, Advair, Anoro Ellipta, Stiolto Respimat ZOMACTON 5 rditropin ZORBTIVE 5 rditropin ZYKADIA 0 3 capsules per, 30 Beginning 6/1/18 members being newly started on Enbrel therapy for the treatment of plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis will require medical record documentation of therapeutic failure on, intolerance to, or contraindication to Cosentyx* and.

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