HMO and PPO Updates September 2013- Commercial Results Triple Tier Formular y 4th Tier Applicable Traditiona l Quantit y Limit Alternatives SIRTURO 3 2 First fill: 56 tablets Subsequent fills: 24 tablets amoxicillin-clavulanic acid, clarithromycin, ethambutol, isoniazid, levofloxacin, pyrazinamide, rifampin, Avelox SUCLEAR 3 No 2 No No N/A Peg-3350 with electrolytes, Peg- 3350 with flavor packs, HalfLytely and Bisacodyl, GoLYTELY, MoviPrep, Prepopik OSPHENA 3 No 2 1 tablet per day Estring, Premarin Cream, Estrace Cream, Vagifem MEKINIST 3 2 tablets per 30 0.5 mg: 90 tablets per 30 e
HMO and PPO Updates September 2013- Commercial Results Triple Tier Formular y 4th Tier Applicable Traditiona l Quantit y Limit Alternatives INVOKANA 3 No 2 1 tablet per day chlorpropamide, glimepiride, glipizide IR, glipizide XL, glipizide-metformin, glyburide, glyburide micronized, metformin, pioglitazone, pioglitazoneglimepiride, pioglitazonemetformin, Januvia*, Janumet* DICLEGIS 3 No 2 4 tablets per day e LIPTRUZET 3 No 2 No N/A SIMBRINZA 3 No 2 No No N/A atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, Zetia brimonidine, dorzolamide, Azopt TECFIDERA 3 2 240 mg: 60 capsules per 30 120 mg: 14 capsules per 14 Starter Pack: 60 capsules per 30 Copaxone, Betaseron
HMO and PPO Updates September 2013- Commercial Results Triple Tier Traditiona 4th Tier Quantit Formular l Applicable y Limit Alternatives y EXJADE 3 2 No N/A e TAFINLAR 3 2 75 mg: 120 capsules per 30 50 mg: 120 capsules per 30 Zelboraf*
September 2013- CHIP Results Tier SIRTURO 3 Quantity Limit SUCLEAR 3 No No N/A First fill: 56 tablets Subsequent fills: 24 tablets OSPHENA 3 1 tablet per day 1 mg & 2 mg: 30 tablets per 30 0.5 mg: 90 tablets MEKINIST 3 per 30 Alternatives amoxicillin-clavulanic acid, clarithromycin, ethambutol, isoniazid, levofloxacin, pyrazinamide, rifampin, Avelox Peg-3350 with electrolytes, Peg-3350 with flavor packs, HalfLytely and Bisacodyl, GoLYTELY, MoviPrep, Prepopik Estring, Premarin Cream, Estrace Cream, Vagifem e INVOKANA 3 1 tablet per day chlorpropamide, glimepiride, glipizide IR, glipizide XL, glipizidemetformin, glyburide, glyburide micronized, metformin, pioglitazone, pioglitazone-glimepiride, pioglitazone-metformin, tolazamide, tolbutamide, Januvia*, Janumet* DICLEGIS 3 4 tablets per day e
September 2013- CHIP Results Tier Quantity Limit LIPTRUZET 3 No N/A SIMBRINZA 3 No No N/A Alternatives atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, Zetia brimonidine, dorzolamide, Azopt TECFIDERA 3 240 mg: 60 capsules per 30 120 mg: 14 capsules per 14 Starter Pack: 60 capsules per 30 Copaxone, Betaseron EXJADE 3 No N/A e TAFINLAR 3 75 mg: 120 capsules per 30 50 mg: 120 capsules per 30 Zelboraf*
GHP Family Member Updates September 2013- GHP Family Results GHP Family Tier Quantit y Limit Detailed Limits Alternative(s) SIRTURO 56 tablets for first fill, 24 tablets for subsequent fills. amoxicillin-clavulanic acid, clarithromycin, ethambutol, isoniazid, levofloxacin, pyrazinamide, rifampin, Zyvox (requires prior authorization) SUCLEAR PEG -3350 /na,sulf, bicarb, cl/kcl; polyethylene glycol 3350; sodium chlride, nahco3, kcl/peg OSPHENA 1 tabalet per day Premarin Cream MEKINIST Brand 1 mg and 2 mg tablets 30 tablets per 30, 0.5 mg 90 tablets per 30 glimepiride, glipizide, glipizide XL, glyburide, metformin, pioglitazone* INVOKANA 1 tablet daily *requires step therapy
GHP Family Member Updates September 2013- GHP Family Results DICLEGIS LIPTRUZET GHP Family Tier SIMBRINZA No Quantit y Limit Detailed Limits 4 tablets per day Alternative(s) atorvastatin, lovastatin, pravastatn, simvastatin, Zetia brimonidine, dorzolamide TECFIDERA TAFINLAR Brand 240 mg capsules - 60 capsules per 30, 120 mg capsules - 14 capsules per 7, starter pack - 60 capsules per 30 120 capsules per 30 Avonex*, Betaseron, Copaxone, Gilenya*, Rebif* Zelboraf*
GOLD Member Updates September 2013- Part D (Gold) Updates SIRTURO SUCLEAR OSPHENA $0 Deductible Brand Preferred MEKINIST Speciality Standard coinsurance No coinsurance 2013 No Quantity Limit g g 30 tablets per 30 ; 0.5mg: 90 tablets per 30 Alternative(s) Amoxicillin-clavulanic acid, clarithromycin, ethambutol, isoniazid, levofloxacin, pyrazinamide, rifampin, Avelox, Zyvox* - *prior authorization required Peg-3350 with Electrolytes, Peg-3350 with flavor packets, GoLYTELY, MoviPrep, OsmoPrep, Prepopik Premarin Cream, Estrace Cream, Estring, Vagifem Zelboraf* *prior authorization required
GOLD Member Updates September 2013- Part D (Gold) Updates $0 Deductible Standard 2013 Quantity Limit Alternative(s) INVOKANA DICLEGIS LIPTRUZET SIMBRINZA Brand Preferred Brand Preferred Brand Preferred coinsurance coinsurance coinsurance No No 1 tablet per day 4 tablets per day Generics : chlorpropamide, glimepiride, glipizide IR, glipizide XL, glipizidemetformin, glyburide, glyburide micronized, metformin, pioglitazone, pioglitazone-glimepiride, pioglitazone-metformin, tolazamide, tolbutamide. e atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, Crestor, Zetia brimonidine, dorzolamide, Azopt TECFIDERA TAFINLAR Speciality coinsurance 75mg and 50mg: 120 capsules per 30 Aubagio*, Avenox*, Betaseron, Copaxone, Tysabri* *prior authorization required Zelboraf* *prior authorization required