| Antineoplastic |
Caprelsa (vandetanib) |
Commercial: Preferred specialty
Medicaid: Formulary
Medicare: T4 |
PA required (all lines of business) |
09/01/2011 |
| Anticholinergic |
Cuvposa (glycopyrrolate oral solution) |
Commercial: Non-preferred brand
Medicaid: Formulary
Medicare: T3 |
|
09/01/2011 |
| Antineoplastic |
Docefrez (docetaxel) |
Commercial: Preferred specialty*
Medicaid: Formulary*
Medicare: Part B |
|
09/01/2011 |
| Toxicology |
Fusilev (levoleucovorin) |
Commercial: Preferred brand*
Medicaid: Formulary*
Medicare: Part B |
|
09/01/2011 |
| Contraceptive |
Generess Fe
(norethindrone/EE/ferris fumarate chewable) |
Commercial: Non-preferred brand
Medicaid: Non-formulary
Medicare: T3 |
Employer's plan rider determines contraceptive coverage. |
09/01/2011 |
| Neurological |
GRALISE (gabapentin) |
Commercial: Non-preferred brand
Medicaid: Non-formulary
Medicare: T3 |
ST required: T&F with generic gabapentin. |
After product launch |
| Neurological |
Horizant (gabapentin enacarbil ER) |
Commercial: Non-preferred brand
Medicaid: Formulary
Medicare: T3 |
ST required: T&F with generic gabapentin, and also with ropinirole or pramipexole. |
09/01/2011 |
| Antiviral |
Incivek (telapravir) |
Commercial: Preferred specialty
Medicaid: Formulary
Medicare: T4 |
1. PA required (all lines of business)
2. Obtain from preferred network specialty pharmacy |
09/01/2011 |
| Genitourinary (impotence) |
Staxyn (vardenafil ODT) |
Commercial: Preferred brand
Medicaid: Excluded
Medicare: Excluded |
1. Employer's plan rider determines sexual dysfunction treatment coverage.
2. QL: 6 tablets every 30 days |
09/01/2011 |
| Analgesic |
Sprix (ketorolac nasal spray) |
Commercial: Non-preferred brand
Medicaid: Non-formulary
Medicare: T3 |
1. ST required: T&F with generic ketorolac
2. QL: 5 bottles every 30 days |
09/01/2011 |
| Biologic (interferon) |
SYLATRON (peginterferon alfa-2b) |
Commercial: Preferred specialty
Medicaid: Formulary
Medicare: T4 |
1. PA required (all lines of business)
2. Obtain from preferred network specialty pharmacy |
09/01/2011 |
| Antidiabetic |
Tradjenta (linagliptin) |
Commercial: Non-preferred brand
Medicaid: Formulary
Medicare: T3 |
ST required: patient has documented trial and failure with metformin for 3 of the last 4 months. |
09/01/2011 |
| Antiviral |
Victrelis (bocepravir) |
Commercial: Preferred specialty
Medicaid: Formulary
Medicare: T4 |
1. PA required (all lines of business)
2. Obtain from preferred network specialty pharmacy |
09/01/2011 |
| Psychotropic |
Viibryd (vilazodone) |
Commercial: Non-preferred brand
Medicaid: Carve Out (bill to Magellan)
Medicare: T3 |
ST required: T&F with one generic antidepressant. |
09/01/2011 |
| Antiviral |
Viramune XR (nevirapine SR) |
Commercial: Preferred brand
Medicaid: Carve Out (bill to Magellan)
Medicare: T2 |
|
09/01/2011 |
| Antineoplastic |
Yervoy (ipilimumab) |
Commercial: Preferred specialty*
Medicaid: Formulary*
Medicare: T4, B/D |
PA required (all lines of business) |
09/01/2011 |
| Antiandrogen |
Zytiga (abiraterone) |
Commercial: Preferred specialty
Medicaid: Formulary
Medicare: T4 |
PA required (all lines of business) |
09/01/2011 |
