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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 medications requiring prior approval, visit the Drug authorizations forms page and click on the applicable form for precertification requirements. All forms will be posted by August 1, 2013.

Last modified: 5/28/2014
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