Provider Manual

November 2011 formulary updates

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
Biologic	Adcetris (brentuximab)	Commercial: Preferred specialty* Medicaid: Medical benefit Medicare: Part B	PA required	01/01/2012
Biologic	Anascorp (centruroides (scorpion))	Commercial: Preferred specialty* Medicaid: Medical benefit Medicare: T4, B/D		01/01/2012
Toxicology	Buprenorphine	Commercial: Generic Medicaid: Formulary Medicare: **	QL added to commercial and Medicaid (10 tablets)	01/01/2012
Genitourinary	Cialis 2.5 and 5 mg tablets (tadalafil)	Commercial: Non-preferred brand Medicaid: Not covered Medicare: T3 for BPH	BPH: 2.5 and 5 mg tablets covered only; QL; ST required: trial and failure with one generic alpha-1 adrenergic antagonist (tamsulosin or alfuzosin, minimum one month trial) AND one generic 5-alpha-reductase inhibitor (finasteride, minimum six month trial)	01/01/2012
Respiratory	Combivent Respimat (ipratropium/albuterol)	Commercial: Preferred brand Medicaid: Formulary Medicare: T2	Replaces current Combivent MDI	Launch of product
Gastrointestinal	Duexis (ibuprofen/famotidine)	Commercial: Non-preferred brand Medicaid: Non-formulary Medicare: Not covered	ST required: trial and failure with both ibuprofen and famotidine	01/01/2012
Cardiovascular	Firazyr (icatibant)	Commercial: Non-preferred specialty* Medicaid: Medical benefit Medicare: T4		01/01/2012
Insulin	Humalog (insulin lispro)	Commercial: Generic Medicaid: Medicare:		01/01/2012
Insulin	Humalog Mix (insulin lispro)	Commercial: Generic Medicaid: Medicare:		01/01/2012
Insulin	Humulin 50/50 (regular insulin; NPH)	Commercial: Generic Medicaid: Medicare:		01/01/2012
Insulin	Humulin 70/30 (regular insulin; NPH)	Commercial: Generic Medicaid: Medicare:		01/01/2012
Insulin	Humulin L (lente insulin)	Commercial: Generic Medicaid: Medicare:		01/01/2012
Insulin	Humulin R (regular insulin)	Commercial: Generic Medicaid: Medicare:		01/01/2012
Insulin	Humulin U (ultralente insulin)	Commercial: Generic Medicaid: Medicare:		01/01/2012
Insulin	Humulin N (isophane insulin (NPH))	Commercial: Generic Medicaid: Medicare:		01/01/2012
Ophthalmic	Lotemax Ointment (loteprednol)	Commercial: Non-preferred brand Medicaid: Non-formulary Medicare: T3		01/01/2012
Neurological	Nuedexta (dextromethorphan/quinidine)	Commercial: Non-preferred brand Medicaid: Non-formulary Medicare: **	PA required	11/15/2011
Insulin	Novolin 70/30 (lente insulin)	Commercial: Non-preferred brand Medicaid: Medicare:		01/01/2012
Insulin	Novolin L (lente insulin)	Commercial: Non-preferred brand Medicaid: Medicare:		01/01/2012
Insulin	Novolin N (isophane insulin (NPH))	Commercial: Non-preferred brand Medicaid: Medicare:		01/01/2012
Insulin	Novolin R (regular insulin)	Commercial: Non-preferred brand Medicaid: Medicare:		01/01/2012
Insulin	Novolog FlexPen (insulin aspart)	Commercial: Non-preferred brand Medicaid: Medicare:		01/01/2012
Insulin	Novolog Vial (insulin aspart)	Commercial: Non-preferred brand Medicaid: Medicare:		01/01/2012
Insulin	Novolog Mix 70/30 (insulin aspart)	Commercial: Non-preferred brand Medicaid: Medicare:		01/01/2012
Analgesic	Nucynta ER 12 Hour (tapentadol extended-release)	Commercial: Non-preferred brand Medicaid: Non-formulary Medicare: Non-formulary	QL	01/01/2012
Toxicology	Suboxone (buprenorphone/naloxone)	Commercial: Preferred brand Medicaid:Formulary Medicare: **	PA required	01/01/2012
Antineoplastic	Xalkori (crizotinib)	Commercial: Preferred brand Medicaid:Formulary Medicare: T4	PA required; limited distribution	01/01/2012
Antineoplastic	Zelboraf (vemurafenib)	Commercial: Preferred brand Medicaid:Formulary Medicare: T4	PA required	01/01/2012

Last modified: 2/3/2012

Provider Manual

November 2011 formulary updates

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