July 2013 formulary updates

On July 16, 2013, the Pharmacy and Therapeutics (P&T) Committee met and reviewed several drugs, policies, and prior authorization criteria. The following information summarizes the recommendations made at the P&T meeting. It does not represent a comprehensive list of all drugs included on our Approved Drug List. Please visit and click on Approved Drug List for detailed information regarding drug coverage.

Key:

PA = Prior authorization
QL = Quantity limits
T&F = Trial & failure
ST = Step therapy
B/D = Coverage varies under Medicare Part B vs. Part D
* = Medical benefit
** = No change to formulary status

Class Drug Formulary Notes Effective
date
Analgesic Celebrex (celecoxib)

Commercial: Preferred brand

Medicaid: Formulary

Medicare: T3

Commercial and Medicaid PA criteria modified

Diagnosis of acute pain is limited to 90 days of therapy

07/16/2013
Ophthalmic agent Cystaran (cysteamine)

Commercial: Preferred specialty

Medicaid: Formulary

Medicare: T4

Added to formulary

Limited distribution

QL: 60ml every 28 days

09/01/2013
Antiemetic Diclegis (doxylamine/pyridoxine)

Commercial: Not covered

Medicaid: Not covered

Medicare: Non-formulary

Not added to formulary 07/16/2013
Gastrointestinal agent Gattex (teduglutide)

Commercial: Non-preferred specialty

Medicaid: Non-formulary

Medicare: T4

PA required

Must be ordered from a network specialty pharmacy

09/01/2013
Antidiabetic agent Invokana (canagliflozin)

Commercial: Preferred brand

Medicaid: Formulary

Medicare: T2

Added to formulary

QL: 31 tablets every 31 days

09/01/2013
Antilipemic agent Liptruzet (atorvastatin/ezetimibe)

Commercial: Non-preferred brand

Medicaid: Non-formulary

Medicare: T3

ST required

Must try two of the following generic statins: atorvastatin, lovastatin, pravastatin, simvastatin

QL: 31 tablets every 31 days

09/01/2013
Alzheimers agent Namenda XR (memantine)

Commercial: Non-preferred brand

Medicaid: Non-formulary

Medicare: T3

Added to formulary 09/01/2013
Hormone modifier Osphena (ospemifene)

Commercial: Preferred brand

Medicaid: Not covered

Medicare: Excluded

PA required

Oral sexual dysfunction rider required

09/01/2013
Metabolic agent Procysbi (cysteamine)

Commercial: Not covered

Medicaid: Not covered

Medicare: T4

Limited distribution

ST required; must first try Cystagon

09/01/2013
Ophthalmic agent Prolensa (bromfenac)

Commercial: Non-preferred brand

Medicaid: Formulary

Medicare: T3

ST required

Must try two of the following generic ophthalmic NSAID's: bromfenac, diclofenac, flurbiprofen, and ketorolac

09/01/2013
Adrenal agent Signifor (pasireotide)

Commercial: Non-preferred specialty

Medicaid: Formulary

Medicare: T4

PA required

Must be ordered from a network specialty pharmacy

09/01/2013
Antiglaucoma agent Simbrinza (brimonidine/brinzolamide)

Commercial: Preferred brand

Medicaid: Formulary

Medicare: T2

Added to formulary 09/01/2013
Antituberculosis agent Sirturo (bedaquiline)

Commercial: Preferred specialty

Medicaid: Formulary

Medicare: T4

Added to formulary

Limited distribution

09/01/2013
Prenatal vitamin Tricare Prenatal Compleat

Commercial: Non-preferred brand

Medicaid: Non-formulary

Medicare: T3

Added to commercial and Medicare formularies

Must be female

09/01/2013
Antineoplastic agent Xofigo (Radium-223 dichloride)

Commercial: Non-preferred specialty*

Medicaid: Formulary*

Medicare: Part B

Covered for metastatic prostate cancer only (limited to 6 infusions) 09/01/2013
Antiandrogen Xtandi

Commercial: Non-preferred specialty

Medicaid: Formulary

Medicare: T4

Commercial and Medicaid  PA criteria modified

Added ST requirement to PA criteria: must first try Zytiga

07/16/2013

Reviewed without changes

The P&T Committee reviewed the prior authorization criteria for the following drugs on the Approved Drug List and no changes were made:

  • Adcirca
  • Buphenyl
  • Caprelsa
  • Dronabinol
  • Emend
  • Enteral nutrition
  • Erivedge
  • Flolan
  • Incivek
  • Jakafi
  • Letairis
  • Parenteral nutrition
  • Prolia
  • Promacta
  • Sildenafil
  • Simponi
  • Sylatron
  • Tracleer
  • Ventavis
  • Vibativ
  • Victrelis
  • Yervoy

Note: For the precertification requirements for medications requiring prior approval, visit the Drug authorizations forms page and click on the applicable prior authorization form.

Last modified: 7/31/2015
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