| Analgesic |
Conzip (tramadol extended-release) |
Commercial: Non-preferred brand
Medicaid: Non-formulary
Medicare: Non-formulary |
ST Required: trial and failure with generic tramadol tablets QL: 1 capsule daily Note: No CMS labeler code |
03/01/2012 |
| Antineoplastic |
Erwinaze (asparaginase Erwinia chrysanthemi) |
Commercial: Non-preferred specialty*
Medicaid: Medical benefit
Medicare: B/D |
PA required |
03/01/2012 |
| Anesthetic |
Exparel (bupivacaine liposome) |
Commercial: Medical benefit
Medicaid: Medical benefit
Medicare: B/D |
|
03/01/2012 |
Ophthalmic/
Biologic |
Eylea (aflibercept) |
Commercial: Non-preferred specialty*
Medicaid: Medical benefit
Medicare: B/D |
PA required PA - Medicare |
03/01/2012 |
| Toxicology |
Ferriprox (deferiprone) |
Commercial: Preferred specialty
Medicaid: Formulary
Medicare: T4 |
Commercial/Medicaid: Must be ordered from a network specialty pharmacy |
03/01/2012 |
| Antineoplastic |
Jakafi (ruxolitinib) |
Commercial: Preferred specialty
Medicaid: Formulary
Medicare: T4 |
PA required Limited distribution drug |
03/01/2012 |
| Antidiabetic/ Cardiovascular |
Juvisync (sitagliptin/simvastatin) |
Commercial: Preferred brand
Medicaid: Formulary
Medicare: T2 |
ST required: trial with metformin (90 days within the last 120 days) QL: 1 tablet daily |
03/01/2012 |
| Analgesic |
Lazanda (fentanyl nasal spray) |
Commercial: Non-preferred specialty*
Medicaid: Non-formulary
Medicare: Non-formulary |
PA required Note: No CMS labeler code |
03/01/2012 |
| Musculoskeletal |
Lorzone (chlorzoxazone) |
Commercial: Non-preferred brand
Medicaid: Non-formulary
Medicare: Non-formulary |
ST required: trial and failure with generic chlorzoxazone QL: 4 tablets daily Note: No CMS labeler code; high risk medication |
03/01/2012 |
| Cardiovascular |
Tekamlo (aliskiren/amlodipine) |
Commercial: Preferred brand
Medicaid: Formulary
Medicare: T2 |
ST updated: trial and failure with ARB (no concurrent use) |
03/01/2012 |
| Cardiovascular |
Tekturna (aliskiren) |
Commercial: Preferred brand
Medicaid: Formulary
Medicare: T2 |
ST updated: trial and failure with ARB (no concurrent use) |
03/01/2012 |
| Cardiovascular |
Tekturna HCT (aliskiren/HCTZ) |
Commercial: Preferred brand
Medicaid: Formulary
Medicare: T2 |
ST updated: trial and failure with ARB (no concurrent use) |
03/01/2012 |
| Cardiovascular |
Valturna (aliskiren/valsartan) |
Commercial: Not covered
Medicaid: Not covered
Medicare: Non-formulary pending CMS |
Removed from formulary |
04/01/2012 |
