HMO and PPO Updates November 2014 - Commercial Results Traditiona Triple Tier 4th Tier Prior Quantit l Applicable Authorization y Limit ANORO ELLIPTA 2 No 2 No No BYDUREON 3 No 2 INCRUSE ELLIPTA No Yes, for new starts only No Detailed Limits Alternatives metformin, acarbose, chlorpropamide, glimepiride, glipizide, glyburide, nateglanide, repaglinide, pioglitazone, tolazamide, tolbutamide, Janumet, Januvia*, Jardiance*, Tanzeum*, Victoza* Yes No Spiriva Handihaler, Spiriva Respimat INVOKAMET 3 No 2 Yes Yes 2 tablets per day JARDIANCE 2 No 2 Step Therapy No KARBINAL ER No Yes No LEVOCETIRIZINE 1 No 1 No No metformin, acarbose, chlorpropamide, glimepiride, glipizide, glyburide, nateglanide, repaglinide, pioglitazone, tolazamide, tolbutamide, Janumet, Januvia*, Jardiance* metformin, acarbose, chlorpropamide, glimepiride, glipizide, glyburide, nateglanide, repaglinide, pioglitazone, tolazamide, tolbutamide, Janumet, Januvia* levocetirizine, brompheniramine, carbinoxamine, chlorpheniramine, clemastine, cyproheptadine, desloratadine, dexchlorpheniramine, diphenhydramine, promethazine, tripelennamine
HMO and PPO Updates November 2014 - Commercial Results Triple Tier 4th Tier Applicable Traditiona l Prior Authorization Quantit y Limit NEULASTA 2 Yes 2 Yes Yes Detailed Limits One 6 mg dose per chemotherapy cycle Alternatives SIVEXTRO TABLETS 3 Yes 2 Yes Yes 6 tablets cephalexin, amoxicillin, penicillin V, sulfamethoxaole/trimethoprim, clindamycin, cefaclor, cefadroxil, cefdinir, cefpodoxime, cefprozil, cefuroxime, azithromycin, clarithromycin, erythromycin, amoxicillin/clavulanate, ciprofloxacin, levofloxacin TANZEUM 2 No 2 Step Therapy No metformin, acarbose, chlorpropamide, glimepiride, glipizide, glyburide, nateglanide, repaglinide, pioglitazone, tolazamide, tolbutamide, Janumet, Januvia*, Jardiance*, Victoza* TRIUMEQ 3 Yes 2 No No TUDORZA PRESSAIR 3 No 2 Step Therapy No Spiriva Handihaler, Spiriva Respimat *Indicates prior authorization (PA) or Step Therapy Required
CHIP Updates November 2014 - CHIP Results Prior Quantit Tier Authorization y Limit ANORO ELLIPTA 2 No No BYDUREON 2 INCRUSE ELLIPTA Detailed Limits Alternatives Yes, for new starts only No Tanzeum*, Victoza* - Yes No Spiriva Handihaler, Spiriva Respimat INVOKAMET 2 Yes Yes 2 tablets per day JARDIANCE 2 Step Therapy No KARBINAL ER - Yes No LEVOCETIRIZINE 1 No No NEULASTA 2 Yes Yes One 6 mg dose per chemotherapy cycle metformin, acarbose, chlorpropamide, glimepiride, glipizide, glyburide, nateglanide, repaglinide, pioglitazone, tolazamide, tolbutamide, Janumet, Januvia*, Jardiance* metformin, acarbose, chlorpropamide, glimepiride, glipizide, glyburide, nateglanide, repaglinide, pioglitazone, tolazamide, tolbutamide, Janumet, Januvia* levocetirizine, brompheniramine, carbinoxamine, chlorpheniramine, clemastine, cyproheptadine, desloratadine, dexchlorpheniramine, diphenhydramine, promethazine, tripelennamine SIVEXTRO 2 Yes Yes 6 tablets cephalexin, amoxicillin, penicillin V, sulfamethoxaole/trimethoprim, clindamycin, cefaclor, cefadroxil, cefdinir, cefpodoxime, cefprozil, cefuroxime, azithromycin, clarithromycin, erythromycin, amoxicillin/clavulanate, ciprofloxacin, levofloxacin TANZEUM 2 Step Therapy No Victoza*
CHIP Updates November 2014 - CHIP Results Prior Quantit Tier Detailed Limits Alternatives Authorization y Limit TRIUMEQ 2 No No TUDORZA PRESSAIR 2 Step Therapy No Spiriva Handihaler, Spiriva Respimat *Indicates prior authorization (PA) or Step Therapy Required
GHP Family Updates November 2014- GHP Family Results BYDUREON INCRUSE ELLIPTA GHP Family Tier Prior Authorization Quantity Limit Detailed Limits Yes (new starts only) Yes Alternative(s) 4 vials per 28 days Victoza*, Tanzeum* Yes No Spiriva INVOKAMET Yes Yes 2 tablets daily acarbose, glimpeiride, glipizide, glyburide, metformin, nateglinide, pioglitazone, repaglinide, Januvia*, Lantus, Novolin 70-30, Novolin N, Novolin R, Novolog, Novolog Mix JARDIANCE Brand Step Therapy No JUBLIA Yes Yes KARBINAL ER Yes No LEVOCETIRIZINE Generic No No NEULASTA Brand Yes Yes 1 bottle per fill One 6 mg dose per chemothera py cycle acarbose, glimpeiride, glipizide, glyburide, metformin, nateglinide, pioglitazone, repaglinide, Januvia*, Lantus, Novolin 70-30, Novolin N, Novolin R, Novolog, Novolog Mix fluconazole, griseovulvin, itraconazole*, terbinafine tabs cyproheptadine, diphenhydramine, levocetirizine, fexofenadine, loratadine, cetirizine cyproheptadine, diphenhydramine, fexofenadine, loratadine, cetirizine
GHP Family Updates November 2014- GHP Family Results GHP Family Tier Prior Authorization Quantity Limit Detailed Limits SIVEXTRO Brand Yes Yes 6 tablets TANZEUM Brand Step Therapy No TRIUMEQ No No *Indicates prior authorization (PA) or Step Therapy Required Alternative(s) clindamycin, cefaclor, cefuroxime, azithromycin, clarithromycin, erythromycin, amoxicillin, penicillin, ciprofloxacin, levofloxacin, smz-tmp, doxycyline acarbose, glimpeiride, glipizide, glyburide, metformin, nateglinide, pioglitazone, repaglinide, Januvia*, Lantus, Novolin 70-30, Novolin N, Novolin R, Novolog, Novolog Mix abacavir, didanosine, lamivudine/zidovudine, stavudine, zidovudine, Atripla, Complera, Crixivan Please Note: Effective 2/1/2015 GHP Family members will be limited to one emergency fill per medication every 180 days.
Part D (GOLD) Updates November 2014 - Part D (Gold) Results $0 Deductible Standard Prior Authorization Quantity Limit Detailed Limits Alternative(s) DALVANCE clindamycin, cefaclor, cefadroxil, cefazolin, cefdinir, cefepime, cefoxitin, ceftriaxone, cephalexin, azithromycin, clarithromycin, ery-tab, aztreonam, amoxicillin, amoxicillin/clav, dicloxacillin, nafcillin, ciprofloxacin, levofloxacin, Zyvox* INVOKAMET Brand Preferred coinsurance Yes 2 tablets per day acarabose, glimepiride, glipizide, glipizide/metformin, metformin, tolbutamide, tolazamide, nateglinide, pioglitazone, pioglitazone/metformin, repaglinide, Bydureon, Januvia,Janumet, Janumet XR, Lantus, Levemir, Novolin/Novolog insulins, Prandin, Victoza JARDIANCE JUBLIA KARBINAL ER Brand Preferred coinsurance Step Therapy No acarabose, glimepiride, glipizide, glipizide/metformin, metformin, tolbutamide, tolazamide, nateglinide, pioglitazone, pioglitazone/metformin, repaglinide, Bydureon, Januvia,Janumet, Janumet XR, Lantus, Levemir, Novolin/Novolog insulins, Prandin, Victoza ciclopirox, fluconazole, griseofulvin, itraconazole*, terbinafine (*prior authorization) desloratadine, levocetirizine
Part D (GOLD) Updates November 2014 - Part D (Gold) Results $0 Deductible KEYTRUDA Speciality Standard Prior Authorization Quantity Limit coinsurance Yes No Detailed Limits Alternative(s) dacarbazine, Abraxane*, Temodar, Mekinist*, Tafinlar*, Yervoy*, Zelboraf* (*prior authorization) SIVEXTRO Speciality SYLVANT Speciality coinsurance Yes Yes coinsurance Yes No One-time fill of a quantity of 6 tablets or 6 vials for a 6 day supply clindamycin, cefaclor, cefadroxil, cefazolin, cefdinir, cefepime, cefoxitin, ceftriaxone, cephalexin, azithromycin, clarithromycin, ery-tab, aztreonam, amoxicillin, amoxicillin/clav, dicloxacillin, nafcillin, ciprofloxacin, levofloxacin, Zyvox* Rituxan*, Actemra* (*prior authorization) TANZEUM acarabose, glimepiride, glipizide, glipizide/metformin, metformin, tolbutamide, tolazamide, nateglinide, pioglitazone, pioglitazone/metformin, repaglinide, Bydureon, Januvia,Janumet, Janumet XR, Lantus, Levemir, Novolin/Novolog insulins, Prandin, Victoza TRIUMEQ Speciality coinsurance No No *Indicates prior authorization (PA) or Step Therapy Required all oral generic and brand without a generic equivalent antiretroviral medications and protease inhibitors are covered