November 2012 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
Neurological Aubagio
(teriflunomide)

Commercial: Non-preferred specialty

Medicaid: Formulary

Medicare: T4

PA required; must be ordered from a network specialty pharmacy 01/01/2013
Musculoskeletal Binosto
(alendronate)

Commercial: Non-preferred brand

Medicaid: Non-formulary

Medicare: T3

ST required: therapeutic trial with alendronate or ibandronate 01/01/2013
Antineoplastic Bosulif
(bosutinib)

Commercial: Non-preferred specialty

Medicaid: Formulary

Medicare: T4

ST required: therapeutic trial with one of Gleevec, Sprycel, or Tysigna 01/01/2013
Psychotropic Forfivo XL
(bupropion)

Commercial: Non-preferred brand

Medicaid: Carve-out

Medicare: T3

ST required: 14-day trial with generic bupropion 300 mg daily 01/01/2013
Urological Myrbetriq
(mirabegron)

Commercial: Non-preferred brand

Medicaid: Non-formulary

Medicare: T3

ST required: therapeutic trial with one of oxybutynin, oxybutynin ER, or trospium 01/01/2013
Gastrointestinal Prepopik
(sodium picosulfate; magnesium oxide; anhydrous citric acid)

Commercial: Non-preferred brand

Medicaid: Non-formulary

Medicare: T3

01/01/2013
Anorectic Qsymia
(phentermine; topiramate)

Commercial: Excluded

Medicaid: Excluded

Medicare: Excluded

Immediate
Adrenal agent Rayos
(prednisone)

Commercial: Non-preferred brand

Medicaid: Non-formulary

Medicare: T3

ST required: therapeutic trial with one generic oral corticosteroid 01/01/2013
Oncology Stivarga
(regorafenib)

Commercial: Non-preferred specialty

Medicaid: Formulary

Medicare: T4

PA required 01/01/2013
Antiretroviral Stribild
(elvitegravir; cobicistat; emtricitabine; tenofovir)

Commercial: Preferred specialty

Medicaid: Carve-out

Medicare: T4

01/01/2013
Pulmonary Surfaxin
(lucinactant)

Commercial: Medical benefit

Medicaid: Medical benefit

Medicare: Non-formulary

01/01/2013
Pulmonary Tudorza Pressair
(aclidinium bromide)

Commercial: Preferred brand

Medicaid: Formulary

Medicare: T2

01/01/2013
Device V-Go
(disposable insulin delivery device)

Commercial: Preferred brand

Medicaid: Formulary

Medicare: T2

Gastrointestinal Viokace
(pancrelipase)

Commercial: Non-preferred specialty

Medicaid: Non-formulary

Medicare: T3

01/01/2013
Oncology Xtandi
(enzalutamide)

Commercial: Non-preferred specialty

Medicaid: Formulary

Medicare: T4

PA required 01/01/2013
Oncology Zaltrap
(ziv-aflibercept)

Commercial: Non-preferred specialty
(medical benefit)

Medicaid: Medical benefit

Medicare: Part B

01/01/2013
Last modified: 5/28/2014
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