| Respiratory |
ADVAIR (fluticasone/salmeterol) |
Commercial: Non-preferred brand
Medicaid: **
Medicare: ** |
Moving from preferred to non-preferred brand on commercial formulary |
07/01/2011 |
| Respiratory |
ADVAIR HFA (fluticasone/salmeterol) |
Commercial: Non-preferred brand
Medicaid: **
Medicare: ** |
Moving from preferred to non-preferred brand on commercial formulary |
07/01/2011 |
| Neurology |
ALSUMA (sumatriptan pen kit) |
Commercial: Non-preferred brand
Medicaid: Non-formulary
Medicare: Non-formulary |
|
03/01/2011 |
| Cardiovascular |
AMTURNIDE
(aliskiren/amlodipine/HCTZ) |
Commercial: Preferred brand
Medicaid: Formulary
Medicare: T2 |
Requires concurrent use of an angiotension receptor blocker (ARB) |
05/01/2011 |
| Musculoskeletal |
ATELVIA (alendronate ER) |
Commercial: Non-preferred brand
Medicaid: Non-formulary
Medicare: T3 |
Commercial requires ST: alendronate (step 1), Actonel (step 2) |
03/01/2011 |
| Ophthalmic |
BROMDAY (bromfenac) |
Commercial: Non-preferred brand
Medicaid: Non-formulary
Medicare: T3 |
Requires ST: 2 of the following: flurbiprofen sodium, diclofenac sodium, or Acular |
03/01/2011 |
| Analgesics |
BUTRANS (buprenorphine) |
Commercial: Non-preferred brand
Medicaid: Formulary
Medicare: T3 |
ST required: T&F with 2 of the following: extended-release morphine sulfate, methadone, fentanyl patch, and OxyContin |
05/01/2011 |
| Metabolic |
CARBAGLU (carglumic acid) |
Commercial: Preferred specialty
Medicaid: Formulary
Medicare: Excluded (no labeler contracts with CMS) |
Commercial must fill with preferred specialty pharmacy
Requires PA: covered only for diagnosis of hyperammonemia with N-acetyl glutamate deficiency |
03/01/2011 |
| Antidiabetic Agent |
CYCLOSET
(bromocriptine) |
Commercial: Non-preferred brand
Medicaid: Non-formulary
Medicare: T3 |
Not approved for use with insulin; must be used concurrently with a sulfonylurea |
03/01/2011 |
| Pituitary Hormones |
EGRIFTA
(tesamorelin) |
Commercial: Excluded
Medicaid: Not covered
Medicare: Excluded |
Tesamorelin is considered a cosmetic therapy by Priority Health and is not a covered benefit. |
Immediately |
| Respiratory |
FLOVENT HFA
(fluticasone) |
Commercial: Non-preferred brand
Medicaid: **
Medicare: ** |
Moving from preferred to non-preferred brand on commercial formulary |
07/01/2011 |
| Respiratory |
GLASSIA
(alpha-1-proteinase inhibitor) |
Commercial: Preferred specialty*
Medicaid: Formulary*
Medicare: T4, B/D |
PA required |
05/01/2011 |
| Antineoplastic |
HALAVEN
(eribulin mesylate) |
Commercial: Non-preferred specialty*
Medicaid: Formulary*
Medicare: T4, B/D |
|
03/01/2011 |
| Psychotropic
(ADHD) |
KAPVAY
(clonidine extended-release) |
Commercial:Non-preferred brand
Medicaid: Carve-out to Magellan
Medicare: T3 |
ST required: T&F with Adderall XR and Concerta |
05/01/2011 |
| Musculoskeletal |
KRYSTEXXA
(pegloticase) |
Commercial: Preferred specialty*
Medicaid: Formulary*
Medicare: T4, B/D |
PA required |
05/01/2011 |
| Antidiabetic agent |
KOMBIGLYZE XR
(saxagliptan/metformin) |
Commercial: Preferred brand
Medicaid: Formulary
Medicare: T2 |
QL: 31 tablets every 31 days (except 2.5-1000mg tablet QL of 62 tablets every 31 days) |
03/01/2011 |
| Ophthalmic |
LASTACAFT
(alcaftadine) |
Commercial:Non-preferred brand
Medicaid: Non-formulary
Medicare: T3 |
ST required: T&F with Alaway or Zaditor OTC |
05/01/2011 |
| Psychiatric |
LATUDA
(lurasidone) |
Commercial:Non-preferred brand
Medicaid: Carve out to Magellan
Medicare: T3 |
Subject to quantity limit of 1 tablet daily |
05/01/2011 |
| Contraceptive |
LOSEASONIQUE (levonorgestrel/ethinyl estradiol) |
Commercial: Preferred brand
Medicaid: **
Medicare: T2 |
Remove ST for commercial |
02/01/2011 |
| Contraceptive |
LYBREL (levonorgestrel/ethinyl estradiol) |
Commercial: Non-preferred brand
Medicaid: **
Medicare: ** |
Remove ST for commercial |
02/01/2011 |
| Ophthalmic |
MOXESA (moxifloxacin) |
Commercial: Preferred brand
Medicaid: Formulary
Medicare: T2 |
|
05/01/2011 |
| Contraceptive |
NATAZIA (estradiol valerate/dienogest) |
Commercial: Non-preferred brand
Medicaid: **
Medicare: ** |
Remove ST for commercial |
02/01/2011 |
| Dermatologic |
NATROBA (spinosad) |
Commercial: Non-preferred brand
Medicaid: Non-formulary
Medicare: Non-formulary (mfr. did not sign agreement with CMS) |
ST required: T&F with malathion or lindane |
05/01/2011 |
| Neurologic |
NUEDEXTA (dextromethorphan/quinidine) |
Commercial: Non-preferred brand
Medicaid: Formulary
Medicare: T3 |
ST required for commercial and Medicaid only: T&F with compounded dextromethorphan/quinidine available from PCAB-accredited pharmacies |
05/01/2011 |
| Contraceptive |
NUVARING (Etonogestrel/
Ethinyl estradiol) |
Commercial: Non-preferred brand
Medicaid: **
Medicare: ** |
Remove ST for commercial |
02/01/2011 |
| Contraceptive |
ORTHO EVRA (Norelgestromin/ethinyl estradiol) |
Commercial: Non-preferred brand
Medicaid: **
Medicare: ** |
Remove ST for commercial |
02/01/2011 |
| Contraceptive |
ORTHO TRI-CYCLEN LO
(norgestimate/ethinyl estradiol) |
Commercial: Preferred brand
Medicaid: **
Medicare: ** |
Remove ST for commercial |
02/01/2011 |
| Hematological |
PRADAXA
(dabigatran) |
Commercial: Preferred brand
Medicaid: Formulary
Medicare: T2 |
QL: 62 capsules every 31 days |
03/01/2011 |
| Analgesic |
RYBIX
(tramadol ODT) |
Commercial: Non-preferred brand
Medicaid: Non-formulary
Medicare: T3 |
ST required: T&F with tramadol |
05/01/2011 |
| Contraceptive |
SAFYRAL (ethinyl estradiol/ drosprenone/ metafolin) |
Commercial: Non-preferred brand
Medicaid: Non-formulary
Medicare: T3 |
|
05/1/2011 |
| Contraceptive |
SEASONIQUE
(levonorgestrel/ethinyl estradiol) |
Commercial: Preferred brand
Medicaid: **
Medicare: T2 |
Remove ST for commercial |
02/01/2011 |
| Gastrointestinal |
SUPREP BOWEL PREP (Magnesium Sulfate, Potassium Sulfate, Sodium Sulfate) |
Commercial: Non-preferred brand
Medicaid: Non-formulary
Medicare: T3 |
|
03/01/2011 |
| Infectious Disease |
TEFLARO (ceftaroline fosamil) |
Commercial: Non-preferred specialty*
Medicaid: Formulary*
Medicare: T3, B/D |
ST required (based on diagnosis): community-acquired bacterial pneumonia (CABP) requires T&F with ceftriaxone; acute bacterial skin and skin structure infection requires T&F with vancomycin |
05/01/2011 |
| Dermatologic |
XERESE (acyclovir/hydrocortisone) |
Commercial: Non-preferred brand
Medicaid: Formulary
Medicare: T3 |
ST required: T&F with topical acyclovir (Zovirax) and hydrocortisone |
05/01/2011 |
| Musculoskeletal |
XGEVA (denosumab) |
Commercial: Preferred specialty*
Medicaid: Formulary*
Medicare: Part B |
Requires PA: Covered for bone metastases with advanced breast or prostate cancer, other indications require ST with Zometa |
03/01/2011 |
| Psychotropic |
ZOLPIMIST (zolpidem oral spray) |
Commercial: Non-preferred brand
Medicaid: Formulary
Medicare: T3 |
ST required: T&F with zolpidem tablets |
05/01/2011 |
| Dermatologic |
ZYCLARA
(imiquimod cream) |
Commercial:
Non-preferred brand
Medicaid:
Non-formulary
Medicare: T3 |
ST required: T&F with imiquimod cream |
05/01/2011 |
