P&T Committee formulary updates
On Nov. 16, 2010 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 16, 2010, P&T Changes: At a Glance
Alphabetized by drug name
| Therapeutic
Class |
Drug |
Formulary designations |
Comments |
Effective date |
| Commercial |
Medicaid |
Medicare |
| Oncology |
Arzerra (ofatumumab) |
Non-preferred
specialty (T5)* |
Formulary* |
T4 |
Requires PA |
1-1-2011 |
| Hormones |
Beyaz
(drospirenone/
ethinyl estradiol/
levomefolate) |
Non-preferred
(T3) |
Non-formulary |
T3 |
Requires ST (one generic
oral contraceptive);
Medicare does not
require ST |
1-1-2011 |
| Respiratory |
Dulera
(mometasone/
formotero 1) |
Generic (T1) |
Formulary |
T2 |
|
1-1-2011 |
| Analgesics |
Exalgo
(hydromorphone ER) |
T3 |
Formulary |
T3 |
Requires ST (morphine
sulfate ER) |
1-1-2011 |
| Oncology |
Firmagon
(degarelix) |
Non-preferred
specialty (T5)* |
Formulary |
|
Requires PA |
1-1-2011 |
| Neurology |
Gilenya
(fingolimod) |
Preferred
specialty (T4) |
Formulary |
T4 |
Requires PA |
1-1-2011 |
| Hematology |
Kalbitor
(ecallantide injection) |
Preferred
specialty (T4)* |
Formulary* |
T4 B v. D |
Age requirement ≥ 16
years
Covered only for
diagnosis of acute
attacks of hereditary
angioedema (HAE) |
1-1-2011 |
| Toxicology |
Relistor
(methylnaltrexone) |
Non-preferred
(T3)* |
Formulary* |
T3
B v. D |
Requires PA |
1-1-2011 |
| Psychotropic |
Silenor
(doxepin tablet) |
Non-preferred
brand (T3) |
Not covered
(bill First
Health) |
Non-formulary |
Requires ST (two of the
following: amitriptyline,
doxepin capsule,
mirtazapine or trazodone) |
1-1-2011 |
| Cardiology |
Tekamlo
(aliskirin/amlodipine) |
Preferred (T2) |
Formulary |
T2 |
Requires ST (concurrent
use with an ARB) |
1-1-2011 |
| Cardiology |
Tribenzor
(olmesartan/
amlodipine/HCTZ) |
Non-preferred
(T3) |
Non-formulary |
T3 |
Requires ST (generic
ACE or ARB) |
-1-1-2011 |
| Analgesics |
Vimovo
(esomeprazole/
naproxen) |
Non-preferred
(T3) |
Nonformulary |
T3 |
Requires ST (Prevacid
OTC/lansoprazole,
Prilosec OTC/omeprazole
and pantoprazole (step 1)
and AcipHex (step 2) |
1-1-2011 |
| Dermatology |
Qutenza
(capsaicin 8% patch) |
Non-preferred
specialty (T5)* |
Formulary* |
T4 |
Requires PA |
1-1-2011 |
| Musculoskeletal |
Xeomin
(botulinum toxin A) |
Preferred
specialty (T4)* |
Formulary* |
Medical
Benefit
(Part B) |
Requires PA
(same form as Botox) |
1-1-2011 |
| Gastrointestinal |
Zuplenz
(ondansetron film) |
Non-preferred
(T3) |
Non-formulary |
T3
B v. D |
Requires ST
(ondansetron)
QL of 20/30 days |
1-1-2011 |
PA= Prior Authorization
ST= Step Therapy
* = medical benefit
** = no change to formulary status
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