June 2009

	TABLE KEY	Not Added	Tier 2	Tier 3
	Δ Change + Addition • No Action *(see "Review Details" section for a full definition of the products, changes and additions)*	• RiaSTAP • Vaprisol	+ Afinitor + Banzel (06/01/09) + Degarelix (SPP only) + Epiduo + Mozobil (SPP only) + Trilpix (06/01/09) + Uloric Δ Xopenex HFA	Δ Caduet Δ Celebrex (09/01/09) Δ Detrol Δ Detrol LA Δ Fenoglide Δ Focalin Δ Focalin XR + Gelnique Δ Geodon Capsule + Kapidex + Moxatag Δ Proventil HFA + Ryzolt Δ Straterra Δ Topamax tablet + Toviaz Δ Triglide + ZolpiMist

		Prior Authorization
		+ Mozobil

	KEY TO TIERS	Specialty Pharmacy	Rx Instep
	TIER 1 = All Generics (One-tier standard plans cover ALL medications at the tier 1 copayment.) TIER 2= Preferred Brands (Multi-tiered standard plans cover tier 2 and tier 3 brand medications at the tier 2 copayment.) TIER 3 = Nonpreferred Brands (Closed plans do not cover tier 3 medications)	+ Degarelix + Mozobil	+ Kapidex (PPI)

		DACON	Quantity Limits
		+ Ryzolt + Toviaz + Uloric + Venlafaxine ER	+ Gelnique Δ oxycodone ER Δ Oxycontin + Subutex + Suboxone + ZolpiMist



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.

	► NEW DRUGS Review of new drugs recently introduced to the market or approved by the FDA.	Standard Plan Tier 1 = all generics Tier 2 = all brands (OR Tier 1 = all medications)	Select Plan Tier 1 = all generics Tier 2 = preferred brands Tier 3 = nonpref. brands	Closed Plan Tier 1 = all generics Tier 2 = preferred brands
	Afinitor (everolimus)
	An oral anti-cancer medication used to treat advanced renal cell carcinoma in patients who have failed first line agents. Not in a limited category (antineoplastics)	Brand copay.	Second tier, preferred brand copay.	Second tier, preferred brand copay.
	Banzel (rufinamide)
	Indicated for adjunctive treatment of seizures associated with Lennox-Gastaut Syndrome (LGS) in adults and children 4 years and older. Added to preferred status, effective June 1, 2009. In a limited category (anticonvulsants)	Brand copay.	Second tier, preferred brand copay.	Second tier, preferred brand copay.
	Degarelix
	A subcutaneously administered injectable medication used to treat advanced prostate cancer. Not in a limited category (antineoplastics) Specialty Pharmacy Program (SPP)	If the customer has the SPP, this product may be obtained through our specialty pharmacy at the brand or brand specialty copay. If the customer does not have the SPP it may be considered under the medical benefit. Coverage and pharmacy provider(s) are determined by the plan sponsor's selected benefit design.	If the customer has the SPP, this product may be obtained through our specialty pharmacy at the preferred brand or 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) are determined by the plan sponsor's selected benefit design.	If the customer has the SPP, this product may be obtained through our specialty pharmacy at the preferred brand or 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) are determined by the plan sponsor's selected benefit design.
	Mozobil (plerixafor injection)
	A hematopoietic stem cell mobilizer indicated for use with granulocyte colony stimulating factor (G-CSF) to mobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in patients with non-Hodgkin's lymphoma and multiple myeloma. Not in a limited category (hematopoietic growth factors) Prior authorization required Specialty Pharmacy Program (SPP)	If the customer has the SPP, this product may be obtained through our specialty pharmacy at the brand or brand specialty copay. If the customer does not have the SPP it may be considered under the medical benefit. Coverage and pharmacy provider(s) are determined by the plan sponsor's selected benefit design.	If the customer has the SPP, this product may be obtained through our specialty pharmacy at the preferred brand or 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) are determined by the plan sponsor's selected benefit design.	If the customer has the SPP, this product may be obtained through our specialty pharmacy at the preferred brand or 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) are determined by the plan sponsor's selected benefit design.
	RiaSTAP™ (Fibrinogen Concentrate-Human)
	Indicated to treat acute bleeding episodes in patients with congenital fibrinogen deficiency, including afibrinogenemia and hypofibrinogenemia. Not added to the pharmacy benefit.	Not covered.	Not covered.	Not covered.
	Ryzolt (tramadol extended release tablets)
	A once-daily formulation of tramadol indicated for management of moderate to moderately severe chronic pain in adults who require around-the-clock treatment of pain for an extended period. In a limited category (analgesics and narcotics) DACON edit applies	Brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Third tier, nonpreferred brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Not covered.
	Uloric (febuxostat)
	Indicated for chronic management of hyperuricemia in patients with gout. Not in a limited category (gout agents) DACON edit applies	Brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Second tier, preferred brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Second tier, preferred brand copay. Coverage is determined by the plan sponsor's chosen benefit design.
	Vaprisol (conivaptan hcl injection)
	A therapy for managing euvolemic and hypervolemic hyponatremia in hospitalized patients. Not added to the pharmacy benefit.	Not covered.	Not covered.	Not covered.
	Toviaz (fesoterodine fumarate extended release tablets)
	A once-daily therapy used for treating overactive bladder (OAB) with symptoms of urge urinary incontinence, urgency and frequency. In a limited category (genitourinary agents) DACON edit applies	Brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Third tier, nonpreferred brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Not covered.

	► 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.)	Standard Plan Tier 1 = all generics Tier 2 = all brands (OR Tier 1 = all medications)	Select Plan Tier 1 = all generics Tier 2 = preferred brands Tier 3 = nonpref. brands	Closed Plan Tier 1 = all generics Tier 2 = preferred brands
	Gelnique (oxybutynin chloride) Gel 10%
	A once-daily, topically applied gel indicated to treat overactive bladder with symptoms of urge urinary incontinence, urgency and frequency. In a limited category (genitourinary agents) Quantity Limit applies	Brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Third tier, nonpreferred brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Not covered.
	Moxatag (amoxicillin extended release)
	A once-daily penicillin-class antibacterial indicated to treat tonsillitis and/or pharyngitis secondary to Streptococcus pyogenes (S. pyogenes) in adults and pediatric patients 12 years and older.	Brand copay.	Third tier, nonpreferred brand copay.	Not covered.
	Epiduo (adapalene and benzoyl peroxide) Gel 0.1%, 2.5%
	Indicated for topical treatment of acne vulgaris in patients 12 years and older. Not in a limited category (acne agents)	Brand copay.	Second tier, preferred brand copay.	Second tier, preferred brand copay.
	ZolpiMist (zolpidem oral spray)
	Indicated for short-term treatment of insomnia characterized by difficulties with sleep initiation. In a limited category (sedative hypnotics) Quantity Limit applies	Brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Third tier, nonpreferred brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Not covered.
	Kapidex (dexlansoprazole delayed release capsule)
	A proton pump inhibitor (PPI) indicated for healing all grades of erosive esophagitis (EE) for up to 8 weeks, maintaining healing of EE for up to 6 months and treating heartburn associated with symptomatic non-erosive gastroesophageal reflux disease (GERD) for 4 weeks. In a limited category (gastrointestinal agents-anti-ulcer) Rx InStep (PPIs)	Brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Third tier, nonpreferred brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Not covered.
	Trilipix (fenofibric acid)
	A delayed release capsule used as monotherapy or in combination with a statin to reduce triglycerides (TG) in patients with primary or mixed hyperlipidemia or hypertriglyeridemia. Added to preferred status, effective June 1, 2009. In a limited category (cholesterol loweing).	Brand copay.	Second tier, preferred brand copay.	Second tier, preferred brand copay.

	► DRUG CLASS REVIEW Comprehensive review of all medications in a therapeutic category.	Standard Plan Tier 1 = all generics Tier 2 = all brands (OR Tier 1 = all medications)	Select Plan Tier 1 = all generics Tier 2 = preferred brands Tier 3 = nonpref. brands	Closed Plan Tier 1 = all generics Tier 2 = preferred brands
	No changes from the May meetings

	► PPL UPDATES Medications added to or removed from the PPL to achieve the lowest net cost.	Standard Plan Tier 1 = all generics Tier 2 = all brands (OR Tier 1 = all medications)	Select Plan Tier 1 = all generics Tier 2 = preferred brands Tier 3 = nonpref. brands	Closed Plan Tier 1 = all generics Tier 2 = preferred brands
	Caduet (amlodipine besylate/atorvastatin calcium)
	A combined calcium channel blocker and statin medication used to treat patients with hypertension and elevated cholesterol. Removed from preferred status. In a limited category (cholesterol lowering) DACON edit applies	Brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Third tier, nonpreferred brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Not covered.
	Celebrex (celecoxib)
	A nonsteroidal anti-inflammatory drug (NSAID) used to treat acute pain, primary dysmenorrhea and various forms of arthritis. Removed from preferred status, effective September 1, 2009. In a limited category (NSAID) DACON edit applies Rx InStep (COX-II)	Brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Third tier, nonpreferred brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Not covered.
	Detrol (tolterodine tartrate tablet) and Detrol LA ( tolterodine tartrate extended release capsule)
	Used to treat overactive bladder. Removed from preferred status. In a limited category (genitourinary agents) DACON edit applies (Detrol LA only)	Brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Third tier, nonpreferred brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Not covered.
	Fenoglide (fenofibrate tablet)
	Used in the treatment of adults with hyperlipidemia. Removed from preferred status. In a limited category (cholesterol lowering)	Brand copay.	Third tier, nonpreferred brand copay.	Not covered.
	Focalin XR (dexmethylphenidate hcl extended release capsule)
	Used in the treatment of attention deficit and hyperactivity disorder (ADHD). Removed form preferred status. In a limited category (ADHD)	Brand copay.	Third tier, nonpreferred brand copay.	Not covered.
	Geodon Capsule (ziprasidone hcl)
	Used to treat schizophrenia and acute episodes of mania or mixed episodes of bipolar disorder. Removed from preferred status. Current utilizers will be grandfathered for continued use of Geodon at preferred status. In a limited category (antipsychotic-atypical).	Brand copay.	Third tier, nonpreferred brand copay.	Not covered.
	Proventil HFA (albuterol sulfate inhalation aerosol)
	Used to treat bronchospasm associated with asthma and to prevent exercise-induced bronchospasm. Removed from preferred status. In a limited category (asthma/COPD) Quantity Limit applies	Brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Third tier, nonpreferred brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Not covered.
	Strattera (atomoxetine HCl)
	A non-stimulant medicine used to treat attention-deficit and hyperactivity disorder (ADHD). Removed from preferred status. In a limited category (ADHD) DACON edit applies	Brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Third tier, nonpreferred brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Not covered.
	Triglide Tablets (fenofibrate)
	Used in the treatment of adults with hyperlipidemia. Removed from preferred status. In a limited category (cholesterol lowering)	Brand copay.	Third tier, nonpreferred brand copay.	Not covered.
	Xopenex HFA (levalbuterol tartrate inhalation aerosol)
	Used to treat or prevent brochospasm in patients with asthma. Added to preferred status. In a limited category (asthma/COPD)	Brand copay.	Second tier, preferred brand copay.	Second tier, preferred brand copay.

	► GENERIC ALTERNATIVES Review of products with FDA approved, AB rated generic equivalents.	Standard Plan Tier 1 = all generics Tier 2 = all brands (OR Tier 1 = all medications)	Select Plan Tier 1 = all generics Tier 2 = preferred brands Tier 3 = nonpref. brands	Closed Plan Tier 1 = all generics Tier 2 = preferred brands
	Focalin (dexmethylphenidate hcl)
	Used to treat attention deficit and hyperactivity disorder (ADHD). Removed form preferred status because the generic equivalent, dexmethylphenidate tablet, is available at the generic copay. In a limited category (ADHD)	Brand copay.	Third tier, nonpreferred brand copay.	Not covered.
	Topamax tablet (topiramate)
	Used as monotherapy or adjunctive therapy in treating seizure disorder and for prophylaxis of migraine headaches. Removed from preferred status because the generic equivalent, topiramate tablet, is available at the generic copay. In a limited category (Anticonvulsants)	Brand copay.	Third tier, nonpreferred brand copay.	Not covered.

	► CLINICAL PROGRAMS Review of medications for inclusion in DACON, prior authorization, quantity limits, specialty pharmacy, step therapy or other clinical programs.	Standard Plan Tier 1 = all generics Tier 2 = all brands (OR Tier 1 = all medications)	Select Plan Tier 1 = all generics Tier 2 = preferred brands Tier 3 = nonpref. brands	Closed Plan Tier 1 = all generics Tier 2 = preferred brands
	DACON: Venlafaxine ER tablet
	Will be added to the DACON program.	Brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Third tier, nonpreferred brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Not covered.
	QUANTITY LIMITS: Oxycontin (oxycodone ER tablet)
	The current quantity limit for Oxycontin and oxycodone ER tablets will change from 270 tablets per month to 120 tablets per month.	Oxcycodone ER tablet is available at the generic copay. Oxycontin is available at the brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Oxcycodone ER tablet is available at the first tier, generic copay. Oxycontin is available at the second tier, preferred brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Oxcycodone ER tablet is available at the first tier, generic copay. Oxycontin is available at the second tier, preferred brand copay. Coverage is determined by the plan sponsor's chosen benefit design.
	QUANTITY LIMITS: Suboxone, Subutex
	Will be added to the Quantity Limits program.	Brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Third tier, nonpreferred brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Not covered.

	June 2009



Innoviant's Business Committee meets monthly to evaluate product status (tier placements) and new prescription products approved by the Food and Drug Administration (FDA). Decisions made by the Innoviant Business Committee are based on information and recommendations provided by Prescription Solutions' National Pharmacy & Therapeutics Committee (NPTC). The P&T is comprised of independent physician providers, affiliated plan physicians and pharmacists. Change Summary Table The following table provides an at-a-glance summary of the decisions made at the May committee meetings. Details about the products and decisions are further outlined in the "review details" section of this newsletter. All changes are effective August 1, 2009 unless otherwise noted.