Review Details
The P&T committee performs evidence-based clinical reviews of new drugs, line extensions, drug classes, preferred products list (PPL) placements, generic alternatives and clinical programs. Tier placement and utilization management edits promote safe, cost-effective use of the product. Details relating to decisions outlined above are provided below. |
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► NEW
DRUGS
Review of new drugs recently
introduced to the market or
approved by the FDA. |
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Standard Plan
Tier 1 = all generics
Tier 2 = all brands
(OR Tier 1 = all medications)
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Select Plan
Tier 1 = all generics
Tier 2 = preferred brands
Tier 3 = nonpref. brands
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Closed Plan
Tier 1 = all generics
Tier 2 = preferred brands
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Vibativ (telavancin hcl) |
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An i.v. administered antibiotic used for the treatment of adult patients with complicated skin and skin structure infections caused by susceptible Gram-positive bacteria.
- Specialty Pharmacy Program (SPP)
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If the customer has the SPP, this product may be obtained through our specialty pharmacy at the brand copay or the preferred brand specialty copay.
If the customer does not have the SPP it may be considered under the medical benefit.
Coverage and pharmacy provider(s) determined by the benefit design selected by the plan sponsor. |
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If the customer has the SPP, this product may be obtained through our specialty pharmacy at the third tier, nonpreferred brand copay or nonpreferred brand specialty copay.
If the customer does not have the SPP it may be considered under the medical benefit.
Coverage and pharmacy provider(s) determined by the benefit design selected by the plan sponsor. |
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Not covered. |
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Votrient (pazopanib hcl) |
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Indicated for the treatment of patients with advanced renal cell carcinoma.
- Prior Authorization applies
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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Arzerra (ofatumumab) Injection for intravenous infusion |
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An antineoplastic monoclonal antibody used to treat patients with chronic lymphocytic leukemia (CLL) refractory to fludarabine and alemtuzumab.
- Specialty Pharmacy Program (SPP)
- Prior Authorization applies
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If the customer has the SPP, this product may be obtained through our specialty pharmacy at the brand copay or the preferred brand specialty copay.
If the customer does not have the SPP it may be considered under the medical benefit.
Coverage and pharmacy provider(s) determined by the benefit design selected by the plan sponsor. |
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If the customer has the SPP, this product may be obtained through our specialty pharmacy at the third tier, nonpreferred brand copay or nonpreferred brand specialty copay.
If the customer does not have the SPP it may be considered under the medical benefit.
Coverage and pharmacy provider(s) determined by the benefit design selected by the plan sponsor. |
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Not covered. |
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Dysport (abobotulinumtoxinA) for injection |
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A neuromuscular blocking agent used for the treatment of adult patients with cervical dystonia.
- Specialty Pharmacy Program (SPP)
- Prior Authorization applies
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If the customer has the SPP, this product may be obtained through our specialty pharmacy at the brand copay or the preferred brand specialty copay.
If the customer does not have the SPP it may be considered under the medical benefit.
Coverage and pharmacy provider(s) determined by the benefit design selected by the plan sponsor. |
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If the customer has the SPP, this product may be obtained through our specialty pharmacy at the third tier, nonpreferred brand copay or nonpreferred brand specialty copay.
If the customer does not have the SPP it may be considered under the medical benefit.
Coverage and pharmacy provider(s) determined by the benefit design selected by the plan sponsor. |
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Not covered. |
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Berinert [C1 Esterase Inhibitor (Human)] for I.V. |
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Used to treat acute abdominal or facial attacks of hereditary angioedema (HAE) in adult and adolescent patients.
- Specialty Pharmacy Program (SPP)
- Prior Authorization applies
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If the customer has the SPP, this product may be obtained through our specialty pharmacy at the brand copay or the preferred brand specialty copay.
If the customer does not have the SPP it may be considered under the medical benefit.
Coverage and pharmacy provider(s) determined by the benefit design selected by the plan sponsor. |
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If the customer has the SPP, this product may be obtained through our specialty pharmacy at the third tier, nonpreferred brand copay or nonpreferred brand specialty copay.
If the customer does not have the SPP it may be considered under the medical benefit.
Coverage and pharmacy provider(s) determined by the benefit design selected by the plan sponsor. |
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Not covered. |
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Ilaris (canakinumab) injection for subcutaneous use |
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An interleukin-1 blocker used for the treatment of children and adults with cryopyrin-associated periodic syndrome (CAPS).
Ilaris is added to the
Specialty Pharmacy Program effective January 1, 2010.
- Specialty Pharmacy Program (SPP)
- Quantity Limit applies
- Prior Authorization applies
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If the customer has the SPP, this product may be obtained through our specialty pharmacy at the brand copay or the preferred brand specialty copay.
If the customer does not have the SPP it may be considered under the medical benefit.
Coverage and pharmacy provider(s) determined by the benefit design selected by the plan sponsor. |
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If the customer has the SPP, this product may be obtained through our specialty pharmacy at the third tier, nonpreferred brand copay or nonpreferred brand specialty copay.
If the customer does not have the SPP it may be considered under the medical benefit.
Coverage and pharmacy provider(s) determined by the benefit design selected by the plan sponsor. |
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Not covered. |
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► LINE
EXTENSIONS
Review of new products containing an active medication already available in a different dose form (as a single agent or in combination with other medications.) |
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Standard Plan
Tier 1 = all generics
Tier 2 = all brands
(OR Tier 1 = all medications) |
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Select Plan
Tier 1 = all generics
Tier 2 = preferred brands
Tier 3 = nonpref. brands
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Closed Plan
Tier 1 = all generics
Tier 2 = preferred brands
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Metozolv ODT (metoclopramide hcl orally disintegrating tablet) |
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A dopamine receptor antagonist used for short-term symptomatic relief of gastroesophageal reflux in adults who have not responded to conventional therapy, and for relief of the symptoms of acute or recurrent diabetic gastroparesis in adults.
- Quantity Limit applies
- In a limited category
(Antiemetics)
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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Twynsta (telmisartan-amlodipine) |
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A combination of an angiotensin receptor blocker (ARB) and calcium channel blocker (CCB) used for the treatment of hypertension.
- DACON edit applies
- In a limited category
(blood pressure - combination)
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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Halonate Kit (halobetasol propionate ointment & ammonium lactate foam 12% kit) |
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Used for the relief of inflammation and itching associated with corticosteroid responsive dermatological conditions.
- In a limited category
(Dermatologicals-corticosteroid)
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Brand copay. |
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Third tier,
nonpreferred brand copay. |
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Not covered. |
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► PPL
UPDATES
Medications added to or removed from the PPL in order to provide the most cost-effective therapy in the category. |
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Standard Plan
Tier 1 = all generics
Tier 2 = all brands
(OR Tier 1 = all medications) |
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Select Plan
Tier 1 = all generics
Tier 2 = preferred brands
Tier 3 = nonpref. brands
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Closed Plan
Tier 1 = all generics
Tier 2 = preferred brands
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Ciprodex |
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A combination of an antibiotic and a steroid, topically applied to reduce inflammation and treat infections of the middle and outer ear.
Removed from preferred status because there are therapeutically equivalent products available at the generic copay. |
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Brand copay.
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Third tier,
nonpreferred brand copay.
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Not covered. |
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Cipro HC |
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A combination of an antibiotic and a steroid, topically applied to reduce inflammation and treat otitis externa (swimmer's ear).
Removed from preferred status because there are therapeutically equivalent products available at the generic copay. |
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Brand copay.
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Third tier,
nonpreferred brand copay.
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Not covered. |
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Onglyza (saxagliptin) |
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Used as an adjuct to diet and exercise to improve control of blood sugar in patients with Type 2 diabetes mellitis.
Added to preferred status,
effective February 1, 2010.
- DACON edit applies
- In a limited category
(Antidiabetics)
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Second tier,
preferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Second tier,
preferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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► GENERIC ALTERNATIVES
Review of products with FDA approved generic equivalents. |
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Standard Plan
Tier 1 = all generics
Tier 2 = all brands
(OR Tier 1 = all medications) |
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Select Plan
Tier 1 = all generics
Tier 2 = preferred brands
Tier 3 = nonpref. brands
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Closed Plan
Tier 1 = all generics
Tier 2 = preferred brands
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Aceon (perindopril erbumine) |
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An ACE inhibitor used in the treatment of hypertension and stable coronary artery disease.
Removed from preferred status because the equivalent product (perindopril) is available at the generic copay.
- In a limited category
(Blood Pressure-ACE Inhibitors)
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Brand copay. |
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Third tier,
nonpreferred brand copay. |
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Not covered. |
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Cortisporin ophthalmic suspension (neomycin/polymyxin/HC ophthalmic) |
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A combination antibacterial/steroid product.
Removed from preferred status because the equivalent product (neomycin/polymyxin/HC ophthalmic) is available at the generic copay.
- In a limited category
(Ophthalmic - Steorids)
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Brand copay. |
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Third tier,
nonpreferred brand copay. |
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Not covered. |
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Ticlid (ticlopidine hcl) |
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A platelet aggregation inhibitor used to reduce the risk of stroke in patients who have experienced stroke precursors, and in patients who have had a completed thrombotic stroke.
Removed from preferred status because the equivalent product (ticlopidine hcl) is available at the generic copay.
- DACON applies
- In a limited category
(Anti-Platelet)
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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► DRUG
CLASS REVIEW:
Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
Comprehensive review of medications in a therapeutic category. |
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Standard Plan
Tier 1 = all generics
Tier 2 = all brands
(OR Tier 1 = all medications) |
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Select Plan
Tier 1 = all generics
Tier 2 = preferred brands
Tier 3 = nonpref. brands
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Closed Plan
Tier 1 = all generics
Tier 2 = preferred brands
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See Clinical Programs-DACON.
Safety review of products in the category of NSAIDS. All products in the category will be subject to daily dose limits based on maximum FDA approved dose. See Clinical Programs-DACON for list of products subject to change, effective March 1, 2010. |
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► DRUG
CLASS REVIEW:
Atypical Antipsychotics
Comprehensive review of medications in a therapeutic category. |
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Standard Plan
Tier 1 = all generics
Tier 2 = all brands
(OR Tier 1 = all medications) |
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Select Plan
Tier 1 = all generics
Tier 2 = preferred brands
Tier 3 = nonpref. brands
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Closed Plan
Tier 1 = all generics
Tier 2 = preferred brands
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See Clinical Programs-DACON.
Review of products in the category of Atypical Antipsychotics. All products in category will be subject to daily limits based on maximum FDA approved dose. See Clinical Programs-DACON for list of products subject to change effective March 1, 2010. |
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► DRUG
CLASS REVIEW:
Conventional Antipsychotics
Comprehensive review of medications in a therapeutic category. |
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Standard Plan
Tier 1 = all generics
Tier 2 = all brands
(OR Tier 1 = all medications) |
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Select Plan
Tier 1 = all generics
Tier 2 = preferred brands
Tier 3 = nonpref. brands
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Closed Plan
Tier 1 = all generics
Tier 2 = preferred brands
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perphenazine, haloperidal, prochlorperazine, chlorpromazine, fluphenazine, loxapine, thioridazine, trifluoperazine |
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Listed products are available at generic copay. |
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Generic copay. |
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First tier, generic copay. |
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First tier, generic copay. |
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Orap, Moban, Navane 20mg |
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Listed products remain at preferred status. |
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Brand copay. |
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Second tier,
preferred brand copay. |
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Second tier,
preferred brand copay. |
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Haldol, Haldol Deconoate, Loxitane, Navane (2, 5, 10mg) |
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Listed products will be removed from preferred status due to availability of AB rated generic equivalent products.
Current utilizers of brand name products will be grandfathered for continued use at preferred status to avoid disruption in therapy.
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Brand copay. |
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Third tier,
nonpreferred brand copay. |
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Not covered. |
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► DRUG
CLASS REVIEW:
Cardiovascular Agents - Antiarrhythmics
Comprehensive review of medications in a therapeutic category. |
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Standard Plan
Tier 1 = all generics
Tier 2 = all brands
(OR Tier 1 = all medications) |
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Select Plan
Tier 1 = all generics
Tier 2 = preferred brands
Tier 3 = nonpref. brands
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Closed Plan
Tier 1 = all generics
Tier 2 = preferred brands
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amiodarone, disopyramide, flecainide, mexiletine, Pacerone 200mg,
propafenone,
quinadine gluconate CR / ER / SA, quinidine sulfate, sotalol |
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Listed products are available at generic copay. |
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Generic copay. |
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First tier, generic copay. |
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First tier, generic copay. |
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Norpace CR, Pacerone 100mg, 300mg, Quinidine Sulfate ER, Rythmol SR, Tikosyn |
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Listed products are available at preferred status. |
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Brand copay. |
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Second tier,
preferred brand copay. |
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Second tier,
preferred brand copay. |
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Cordarone, Norpace, Pacerone 400mg, Rythmol, Tambocor |
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Listed products will be removed from preferred status due to availability of AB rated generic equivalent products.
Current utilizers of brand name products will be grandfathered for continued use at preferred status to avoid disruption in therapy.
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Brand copay. |
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Third tier,
nonpreferred brand copay. |
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Not covered. |
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►
CLINICAL PROGRAMS
Review of medications for inclusion in DACON, prior authorization, quantity limits, specialty pharmacy, step therapy or other clinical programs. |
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Standard Plan
Tier 1 = all generics
Tier 2 = all brands
(OR Tier 1 = all medications) |
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Select Plan
Tier 1 = all generics
Tier 2 = preferred brands
Tier 3 = nonpref. brands
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Closed Plan
Tier 1 = all generics
Tier 2 = preferred brands
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DACON: Zemplar |
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Zemplar will not be added to the DACON program (effective January 1, 2010) as reported in the November edition of Pharmacy Passages. |
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Brand copay. |
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Second tier,
preferred brand copay. |
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Second tier,
preferred brand copay. |
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DACON for NSAIDS: choline magnesium trisalicylate, diclofenac potassium, diclofenac sodium DR, diclofenac sodium ER, diflunisal, etodolac,etodolac ER, fenoprofen calcium, flurbiprofen, ibuprofen, indomethacin, indomethacin CR, ketoprofen, ketoprofen SR, meclofenamate sodium, mefenamic acid, meloxicam, nabumetone, naproxen, naproxen DR,
naproxen sodium, naproxen sodium SR, oxaprozin, piroxicam, sulindac, tolmetin sodium
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Listed items will be added to the DACON program or have revisions to the current limit already in place, effective March 1, 2010. |
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Generic copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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First tier, generic copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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First tier, generic copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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DACON for NSAIDS: Anaprox, Anaprox DS, Cataflam, Celebrex, Clinoril, Daypro, EC-Naprosyn, Feldene,
Flector, Indocin, Indocin SR, Mobic, Nalfon, Naprelan, Naprosyn, Ponstel, Voltaren, Voltaren-XR |
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Listed items will be added to the DACON program or have revisions to the current limit already in place, effective March 1, 2010.
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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DACON for ATYPICAL ANTIPSYCHOTICS: clozapine, risperidone, risperidone M-tab |
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Listed items will be added to the DACON program or have revisions to the current limit already in place, effective March 1, 2010. |
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Generic copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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First tier, generic copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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First tier, generic copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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DACON for ATYPICAL ANTIPSYCHOTICS:
Abilify, Abilfy Discmelt, Clozaril, Fazaclo, Seroquel, Zyprexa, Zyprexa Zydis |
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Listed items will be added to the DACON program or have revisions to the current limit already in place, effective March 1, 2010. |
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Second tier,
preferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Second tier,
preferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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DACON for ATYPICAL ANTIPSYCHOTICS: Geodon, Invega, Risperdal, Risperdal M-tab |
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Listed items will be added to the DACON program or have revisions to the current limit already in place, effective March 1, 2010.
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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DACON: ticlopidine |
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Added to the DACON program or have revisions to the current limit already in place, effective March 1, 2010. |
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Generic copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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First tier, generic copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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First tier, generic copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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DACON: Symbyax, Ticlid, Twynsta |
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Listed items will be added to the DACON program or have revisions to the current limit already in place, effective March 1, 2010.
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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QUANTITY LIMITS: Solaraze |
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Listed item will be added to the Quantity Limit program.
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Second tier,
preferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Second tier,
preferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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QUANTITY LIMITS:
Invega Sustenna (SPP only), ketorolac tromethamine inj (SPP only), Metozolv ODT, Risperdal Consta (SPP only) |
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Listed item will be added to the Quantity Limit program. |
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Second tier,
preferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Second tier,
preferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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PRIOR AUTHORIZATION: Arzerra (SPP only), Berinert (SPP only), Dysport (SPP only), Ilaris (SPP only), Votrient |
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Listed items will be added to the Prior Authorization program. See New Drug Review for more detailed information on these products.
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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SPECIALTY PHARMACY PROGRAM: Abilify injection, Arzerra*, Berinert*, Dysport*, Ilaris, Vibativ* |
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Listed Item added to Specialty Pharmacy Program at nonpreferred status.
*See New Drug Review for more detailed information on these products.
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If the customer has the SPP, this product may be obtained through our specialty pharmacy at the brand copay or the preferred brand specialty copay.
If the customer does not have the SPP it may be considered under the medical benefit.
Coverage and pharmacy provider(s) determined by the benefit design selected by the plan sponsor. |
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If the customer has the SPP, this product may be obtained through our specialty pharmacy at the third tier, nonpreferred brand copay or nonpreferred brand specialty copay.
If the customer does not have the SPP it may be considered under the medical benefit.
Coverage and pharmacy provider(s) determined by the benefit design selected by the plan sponsor. |
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Not covered. |
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