Pharmacy and Therapeutics Committee formulary update

On November 17, 2009, 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 doesn't represent a comprehensive list of all drugs included on our approved drug list. Please visit priorityhealth.com for detailed information regarding drug coverage.

November P&T changes: At a glance

Alphabetized by drug name

Therapeutic Class	Drug	Change applies to			P&T recommendation	Effective Date
		Commercial	Medicaid	Medicare
Gastrointestinal	Aciphex (rabeprazole)	X	X		Modify ST (see table below)	1-1-2010
Infectious Disease	Cancidas (caspofungin)			X	Remove PA	1-1-2010
Cardiology	Effient (prasugrel)	X	X	X	Add to formulary	1-1-2010
Infectious Disease	Eraxis (anidulafungin)			X	Remove PA	1-1-2010
Neurology	Extavia (interferon beta-1b)	X		X	Add to formulary with ST (Copaxone or Rebif first)	1-1-2010
CNS	Fanapt (iloperidone)	X		X	Add to formulary with ST (one preferred atypical antipsychotic first)	1-1-2010
Immunology	Ilaris (canakinumab)	X*	X*	X*	Add to formulary with PA	1-1-2010
CNS	Intuniv (guanfacine)	X		X	Add to formulary with ST (generic guanfacine AND either Adderall XR or Concerta first)	1-1-2010
Gastrointestinal	Kapidex (dexlansoprazole)	X	X	X	Modify ST (see table below)	1-1-2010
Pain Management	Maxalt/MLT (rizatriptan)	X	X		Add ST (sumatriptan first)	1-1-2010
Infectious Disease	Mycamine (micafungin)			X	Remove PA	1-1-2010
Gastrointestinal	Nexium (esomeprazole)	X	X		Modify ST (see table below)	1-1-2010
Endocrine	Onglyza (saxagliptin)	X	X	X	Add to formulary with ST (metformin first)	1-1-2010
Pain Management	Onsolis (fentanyl buccal soluble film)	X		X	Add to formulary with PA	1-1-2010
Gastrointestinal	Prevacid SoluTab (lansoprazole)	X	X		Modify ST (see table below) Add to formulary Add to formulary with ST (one preferred atypical antipsychotic first) Add to formulary with PA/ST (Enbrel or Humira first) Change to generic T1 copay Add to formulary with PA Remove ST Modify ST (see table below) Add to formulary with ST (generic diclofenac first)	1-1-2010
Neurology	Sabril (vigabatrin)	X	X	X	Add to formulary	1-1-2010
CNS	Saphris (asenapine)	X		X	Add to formulary with ST (one preferred atypical antipsychotic first)	1-1-2010
Dermatology	Stelara (ustekinumab)	X*	X*	X*	Add to formulary with PA/ST (Enbrel or Humira first)	1-1-2010
Respiratory	Symbicort (budesonide/ formoterol)	X			Change to generic T1 copay	1-1-2010
Cardiology	Tyvaso (treprostinil)	X	X	X	Add to formulary with PA	1-1-2010
Infectious Disease	Valtrex (valacyclovir)	X	X	X	Remove ST	1-1-2010
Gastrointestinal	Zegerid (omeprazole/ sodium bicarbonate)	X	X		Modify ST (see table below)	1-1-2010
Pain Management	Zipsor (diclofenac potassium)	X	X	X	Add to formulary with ST (generic diclofenac first)	1-1-2010

PA = Prior Authorization
ST = Step Therapy
• Indicates the change applies to this formulary
* indicates drug is covered under the medical benefit
P = Preferred Brand
NP = Non-Preferred Brand
PS = Preferred Brand Specialty
NPS = Non-Preferred Brand Specialty
T1, T2, T3, T4 = Medicare Tier Designation

PPI step therapy

Step 1	Generics - covered with no ST/PA required - covered for twice-daily dosing with no PA required - all three generics/OTC must be tried prior to Step 2	Prilosec OTC/omeprazole Prevacid OTC/lansoprazole pantoprazole
Step 2	Preferred brand - covered after trial and failure of all three generics/OTC - covered for twice-daily dosing only with PA	Aciphex
Step 3	Non-preferred brands - covered after trial and failure of all three generics/OTC & Aciphex - covered for twice-daily dosing only with PA	Nexium Kapidex Prevacid Solutab Zegerid

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