March 2017 P&T Updates Commercial Triple Tier 4th Tier Applicable Traditional Prior Auth DICLEGIS 3 No 2 No Yes EMVERM 2 No 2 Yes Yes Detailed s 4 tablets per day, 9 month supply per year Pinworms: 1 tablet Alternatives No nitroglycerin sublingual tablets, nitroglycerin transdermal nitroglycerin, Nitrostat, Nitro-Dur, Nitro-Bid LAMIVUDINE HBV 100 MG 2 No 2 No Yes 1 tablet per day PREZISTA 150 MG 2 No 2 No Yes 6 tablets per day PREZISTA 75 MG 2 No 2 No Yes 2 tablets per day RUBRACA 3 Yes 2 Yes Yes 4 tablets per day, 30 day supply per Lynparza* fill VEMLIDY 2 No 2 No Yes 1 tablet per day entecavir, adefovir, Intron-A, Pegasys, Epivir HBV (solution), Baraclude (solution), Viread No Yes Yes 1 tablet per day aspirin 81 mg, omeprazole,
CHIP Tier Prior Auth DICLEGIS 2 No Yes EMVERM 2 Yes Yes Detailed s 4 tablets per day, 9 month supply per year Pinworms: 1 tablet per fill tablets - Alternatives nitroglycerin sublingual tablets, nitroglycerin transdermal nitroglycerin, Nitrostat, Nitro-Dur, Nitro- Bid LAMIVUDINE HBV 100 MG 2 No Yes 1 tablet per day PREZISTA 150 MG 2 No Yes 6 tablets per day PREZISTA 75 MG 2 No Yes 2 tablets per day RUBRACA 2 Yes Yes 4 tablets per day, 30 day supply Lynparza* VEMLIDY 2 No Yes 1 tablet per day entecavir, adefovir, Intron- A, Pegasys, Epivir HBV (solution), Baraclude (solution), Viread aspirin 81 mg, omeprazole, - Yes Yes 1 tablet per day
GHP Family GHP Family Tier Prior Auth Detailed s Alternative(s) COLCHICINE 0.6 MG TABLET Generic No Yes 3 tablets daily allopurinol DICLEGIS TABLET Brand No Yes 4 tablets daily, 9 month duration DRYSOL SOLUTION Generic No No - DUTASTERIDE 0.5 MG CAPSULE Generic No No - finasteride EMVERM Brand Yes Yes Pinworms: 1 tablet nitroglycerin SL tabs, nitroglycerin SL spray, nitroglycerin ER caps, nitroglycerin transdermal patch LAMIVUDINE 100 MG TABLET Generic No Yes 1 tablet daily L-METHYLFOLATE 7.5 MG, 15 MG TABLET Generic No Yes 1 tablet daily folic acid PREZISTA 150 MG TABLET Brand No Yes 6 tablets daily PREZISTA 75 MG TABLETS Brand No Yes 2 tablets daily RUBRACA Brand Yes Yes 4 tablets daily Lynparza* VEMLIDY Brand No Yes one tablet daily Lamivudine HBV, Entecavir, Intron A, Pegasys, Baraclude, Viread^ Yes Yes one tablet daily omeprazole, aspirin 81 mg, aspirin 325 mg
Geisinger Gold $0 Deductible CUVITRU Specialty EMVERM Brand Preferred Standard Prior Auth Detailed s Yes - - Yes Yes 12 tablets in 30 days Alternative(s) Carimune*, Flebogamma*, Gammagard*, Gamunex*, Hizentra*, Hyqvia*, Octagam*, Privigen* - - - - - nitroglycerin SL tablets, nitroglycerin SL spray INFLECTRA Specialty Yes - - methotrexate, Enbrel*, Humira*, Remicade* RUBRACA Specialty VEMLIDY Brand Preferred Yes Yes 4 tablets/day No Yes 1 tablet/day Carboplatin, liposomal doxorubicin, paclitaxel, cisplatin, topotecan, docetaxel, gemcitabine, Avastin* lamivudine HBV, Viread, entecavir - - - - -
Marketplace Tier Prior Auth DICLEGIS 4 No Yes EMVERM 3 Yes Yes Detailed s 4 tablets per day, 9 month supply per year Pinworms: 1 tablet Alternatives nitroglycerin sublingual tablets, nitroglycerin transdermal nitroglycerin, Nitrostat, Nitro-Dur, Nitro-Bid LAMIVUDINE HBV 100 MG 3 No Yes 1 tablet per day PREZISTA 150 MG 3 No Yes 6 tablets per day PREZISTA 75 MG 3 No Yes 2 tablets per day RUBRACA 5 Yes Yes 4 tablets per day, 30 day supply Lynparza* VEMLIDY 3 No Yes 1 tablet per day entecavir, adefovir, Intron-A, Pegasys, Epivir HBV (solution), Baraclude (solution), Viread Yes Yes 1 tablet per day aspirin 81 mg, omeprazole,