| Respiratory |
Arcapta Neohaler (indacaterol) |
Commercial: Non-preferred brand
Medicaid: Non-formulary
Medicare: T3 |
Requires ST: trial and failure with Foradil or Serevent. |
11/01/2011 |
| Hematologic |
Brilinta (ticagrelor) |
Commercial: Preferred brand
Medicaid: Formulary
Medicare: T2 |
|
11/01/2011 |
| Psychtropic |
Citalopram |
Commercial: Generic
Medicaid: Formulary
Medicare: ** |
New QL added; dosages exceeding 40 mg per day not covered. |
12/01/2011 |
| Antiviral |
Complera (rilpivirine/TDF/FTC) |
Commercial: Preferred specialty
Medicaid: Carve out (bill to Magellan)Medicare: T4 |
Available from all network pharmacies |
11/01/2011 |
| Hematologic |
Corifact
(factor XIII concentrate (human)) |
Commercial: Preferred specialty*
Medicaid: Medical benefit
Medicare: Part B |
Members must place routine orders for their clotting factor from an approved, in-network hemophilia specialty pharmacy. |
11/01/2011 |
| Respiratory |
Daliresp (roflumilast) |
Commercial: Non-preferred brand
Medicaid: Non-formulary
Medicare: T3 |
PA Required |
11/01/2011 |
| Antiinfective |
Dificid (fidaxomicin) |
Commercial: Non-preferred specialty Medicaid: Conditional (brand)
Medicare: T4 |
Requires ST: 2 documented trials and clinical failure with vancomycin injection, used orally. Available from all network pharmacies. |
11/01/2011 |
| Biologic |
Nulojix (belatacept) |
Commercial: Non-preferred specialty* Medicaid: Non-formulary*
Medicare: T4, B/D |
PA Required |
11/01/2011 |
| Renal agent |
Phoslyra (calcium acetate oral solution) |
Commercial: Non-preferred brand
Medicaid: Non-formulary
Medicare: T3 |
ST Required: trial and failure with generic calcium acetate |
11/01/2011 |
| Genitourinary |
Rapaflo (silodosin) |
Commercial: Preferred brand
Medicaid: **
Medicare: ** |
|
01/01/2012 |
| Cough & cold |
Rezira (PSE/hydrocodone) |
Commercial: Excluded
Medicaid: Excluded
Medicare: Excluded |
|
11/01/2011 |
| Analgesic |
Voltaren Gel (diclofenac) |
Commercial: Non-preferred brand
Medicaid: Formulary
Medicare: ** |
Moving to non-preferred brand for commercial. Removing ST for commercial and Medicaid. |
01/01/2012 |
| Psychotropic |
Vyvanse (lisdexamfetamine) |
Commercial: Preferred brand
Medicaid: **
Medicare: ** |
ST removed for commercial formulary |
01/01/2012 |
| Hematologic |
Xarelto (rivaroxaban) |
Commercial: Preferred brand
Medicaid: Formulary
Medicare: T2 |
|
11/01/2011 |
| Cough & cold |
Zutripro (CPE/hydrocodone/PSE) |
Commercial: Excluded
Medicaid: Excluded
Medicare: Excluded |
|
11/01/2011 |
