| Therapeutic Class | Drug | Formulary designations | Comments | Effective date |
|---|
| Commercial | Medicaid | Medicare |
|---|
| CNS |
Ambien CR (zolpidem CR) |
Non-preferred (T3) |
** |
** |
Removed from commercial preferred formulary (grandfathered); Requires ST (zolpidem or zaleplon) |
1-1-2011 |
| Endocrine |
Apidra (insulin glulisine) |
Non-preferred (T3) |
** |
** |
Removed from commercial preferred formulary (grandfathered) |
1-1-2011 |
| Cardiovascular |
Benicar (olmesartan) |
Preferred brand (T2) |
** |
** |
Added to commercial preferred formulary; Requires ST (one generic ACE inhibitor or ARB) |
11-1-2010 |
| Cardiovascular |
Benicar HCT (olmesartan/HCTZ) |
Preferred brand (T2) |
** |
** |
Added to commercial preferred formulary; Requires ST (one generic ACE inhibitor or ARB) |
11-1-2010 |
| Analgesics |
Cambia (diclofenac oral solution) |
Non-preferred brand (T3) |
Non-formulary |
T3 |
Added to commercial preferred formulary; Requires ST (one generic ACE inhibitor or ARB) |
11-1-2010 |
| Dermatology |
Epiduo (adapalene/benzoyl peroxide) |
Preferred brand (T2) |
** |
** |
Added to commercial preferred formulary; Requires ST (generic adapalene) |
11-1-2010 |
| Neurology |
Fanatrex (gabapentin oral suspension) |
Non-preferred brand (T3) |
Not covered (bill First Health) |
T3 |
Requires ST (generic gabapentin) |
11-1-2010 |
| Musculoskeletal |
Fosamax Plus D (alendronate/ cholecalciferol) |
Non-preferred brand (T3) |
** |
** |
Removed from commercial preferred formulary (grandfathered) |
1-1-2011 |
| Musculoskeletal |
Fosamax Oral Solution (alendronate) |
Non-preferred brand (T3) |
** |
** |
Removed from commercial preferred formulary (grandfathered) |
1-1-2011 |
| Immunology |
Hizentra (immune globulin) |
Preferred specialty (T4)* |
Formulary* |
T4 B vs. D |
Requires PA |
11-1-2010 |
| Genitourinary |
Jalyn (dutaseride/tamsulosin) |
Non-preferred brand (T3) |
Non-formulary |
T3 |
Requires ST (generic finasteride AND generic tamsulosin) |
11-1-2010 |
| Antineoplastic |
Jevtana (carbazitaxel) |
Non-preferred specialty (T5)* |
Formulary* |
T4 B vs. D |
Requires PA |
11-1-2010 |
| Cardiovascular |
LETAIRIS (ambrisentan) |
Non-preferred brand (T3) |
** |
** |
Removed from commercial preferred formulary (grandfathered) |
1-1-2011 |
| Metabolic |
Lumizyme (alglucosidase alfa) |
Preferred specialty (T4)* |
Formulary* |
T4 B vs. D |
Limited distribution |
11-1-2010 |
| Hematologic |
Lysteda (tranexamic acid) |
Non-preferred brand (T3) |
Formulary |
T3 |
Requires ST (1 generic NSAID and 1 generic oral contraceptive) |
11-1-2010 |
| Neurology |
Mirapex ER (pramipexole ER) |
Non-preferred brand (T3) |
Non-formulary |
T3 |
Requires ST (generic pramipexole) |
11-1-2010 |
| Hormones |
Natazia (estradiol valerate and estradiol valerate/ dienogest) |
Non-preferred brand (T3) |
Formulary |
T3 |
Female gender restriction; Requires ST (one preferred oral contraceptive) |
11-1-2010 |
| Psychotropic |
Oleptro (trazodone ER) |
Non-preferred brand (T3) |
Not covered (bill First Health) |
T3 |
Requires ST (generic trazodone) |
11-1-2010 |
| Respiratory |
Omnaris (ciclesonide) |
Preferred brand (T2) |
** |
** |
Added to commercial preferred formulary with ST (flunisolide or fluticase first) |
11-1-2010 |
| Anti-infective |
Oravig (miconazole) |
Non-preferred brand (T3) |
Formulary |
T3 |
Requires ST (clotrimazole troches or nystatin suspension) |
11-1-2010 |
| Musculoskeletal |
Prolia (denosumab) |
Preferred specialty (T4)* |
Formulary* |
T4 B vs. D |
Requires PA |
11-1-2010 |
| Antineoplastic |
Provenge (sipuleucel-T) |
Non-preferred Specialty (T5)* |
Formulary* |
T4 B vs. D |
Requires PA |
11-1-2010 |
| Respiratory |
Rhinocort Aqua (budesonide) |
Non-preferred brand (T3) |
** |
** |
Removed from commercial preferred formulary (grandfathered) |
1-1-2011 |
| Biologic |
Soliris (eculizumab) |
Preferred specialty (T4)* |
Formulary* |
T4 B vs. D |
Requires PA |
11-1-2010 |
| Neurology |
Stavzor (valproic acid) |
Non-preferred brand (T3) |
Not covered (bill First Health) |
T3 |
Requires ST (generic valproic acid) |
11-1-2010 |
| Dermatologic |
Xiaflex (collagenase clostridium histolyticum) |
Preferred specialty (T4)* |
Formulary* |
T4 B vs. D |
Requires PA |
11-1-2010 |
| Ophthalmic |
Zymaxid (gatifloxacin OP) |
Non-preferred brand (T3) |
Non-formulary |
T3 |
Requires ST (Zymar or Vigamox) |
11-1-2010 |
