Δ Change

Review Details

The NP&T Committee performs evidence-based clinical reviews of new products, line extensions, therapy classes, formulary placements, generic alternatives and clinical programs. Tier placement and utilization management edits promote safe, cost-effective use of products. Detailed information about the "Change Summary Table" is provided below.

Copay Tier:
1 = Generic
2 = Brand/Preferred brand
3 = Nonpreferred brand
0 = Not covered/other

Hizentra, Immune Globulin Subcutaneous (Human), 20% Liquid

Indicated for the treatment of primary immunodeficiency.

• Specialty Pharmacy Program (SPP) only
• Prior Authorization

Differin (adapalene) Lotion, 0.1%

Used for the topical treatment of acne vulgaris in patients 12 years and older.

• Line extension (new dose form)
• Added to preferred status (effective 6-1-10)
• Non-standard item: Topical Retinoid Acne Products

Exalgo (hydromorphone HCl) Extended-Release Tablets

An opioid agonist indicated for once daily administration for the management of moderate to severe pain in opioid tolerant patients requiring continuous, around-the-clock opioid analgesia for an extended period of time.

• New dose form
• Quantity Limit (effective 6-1-10)
• DACON edit (effective 6-1-10)

Nitromist (nitroglycerin lingual aerosol 400 mcg spray)

Used for the acute relief of an attack or acute prophylaxis of angina pectoris due to coronary artery disease.

• New dose form

Pennsaid (diclofenac sodium topical solution)

A topically applied nonsteroidal anti-inflammatory drug (NSAID) used for the treatment of the signs and symptoms of osteoarthritis of the knee(s).

• New dose form

Qutenza (capsaicin) 8% patch

Indicated for the management of neuropathic pain associated with postherpetic neuralgia (pain after shingles).

• New dose form

Tirosint (levothyroxine sodium) Capsule

A synthetic levothyroxine product used as replacement or supplemental therapy in congenital or acquired hypothyroidism of any etiology, and for the treatment or prevention of various types of euthyroid goiters.

• New dose form

Triaz (benzoyl peroxide) Foaming Cloths

Used in the topical treatment of acne vulgaris.

• Moved to nonpreferred status

Zirgan (ganciclovir ophthalmic gel) 0.15%

A topical ophthalmic antiviral that is indicated for the treatment of acute herpetic keratitis (dendritic ulcers).

• New dose form
• Quantity Limit

Zyclara (imiquimod) Cream 3.75%

Topical treatment of clinically typical, visible or palpable actinic keratoses (AK) of the full face or balding scalp in immunocompetent adults.

• Line extension (new strength)
• Quantity Limit

Alahist DM (phenylephrine, brompheniramine, dextromethorphan)
Aldex DM (phenylephrine, pyrilamine, dextromethorphan)
Brovex PEB DM (phenylephrine, brompheniramine, dextromethorphan)
Brovex PSB DM (pseudoephedrine, brompheniramine, dextromethorphan)

Combination products used for the temporary relief of cough, cold or allergy symptoms.

• Moved to nonpreferred status. Generic equivalent available

Aldara (imiquimod) Cream 5%

Used for the topical treatment of actinic keratoses (AK) on the face or scalp in immunocompetent adults, for biopsy-confirmed, primary superficial basal cell carcinoma (sBCC) in immunocompetent adults, and for external genital and perianal warts/condyloma acuminata in patients 12 years old or older.

• Moved to nonpreferred status. Generic equivalent available.
• Quantity Limit added (also applies to generic equivalent product)

Analpram-E Kit (pramoxine 1%/hydrocortisone 2.5% cream with pramoxine 1% wipes kit)

A combination medication used to treat minor pain, itching, swelling, and discomfort caused by hemorrhoids and other problems of the anorectal area.

• Moved to nonpreferred status. Generic equivalent available.

Clarifoam EF(sodium sulfacetamide 10%, sulfur 5% foam)

Used for the topical control of acne vulgaris, acne rosacea and seborrheic dermatitis.

• Moved to nonpreferred status. Generic equivalent available.
  

Evoclin (clindamycin phosphate) Foam

Indicated for topical application in the treatment of acne vulgaris.

• Moved to nonpreferred status. Generic equivalent available.
• Quantity Limit added (also applies to generic equivalent product)

Skelaxin (metaxalone)

Used as an adjunct to rest, physical therapy and other measures for the symptomatic relief of acute painful musculoskeletal conditions.

• Moved to nonpreferred status. Generic equivalent available.

Lotronex (alosetron hcl)

A selective serotonin 5-HT3 antagonist indicated only for women with severe diarrhea-predominant irritable bowel syndrome with specific clinical features.

• Moved to nonpreferred status
• Added to Prior Authorization program
• Gender Edit added (coverage allowed for female members only)
  
• DACON edit

8-MOP (methoxsalen capsules)

A photochemotherapy agent (used in conjunction with UVA radiation) for the treatment of disabling psoriasis, idiopathic vitiligo, and cutaneous T-cell lymphoma (CTCL).

• Moved to nonpreferred status
• Added to Prior Authorization program
• Current utilizers will be grandfathered for continued use without PA or change in tier status.

Emend (aprepitant), Emend Pak

Used for the prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of moderately emetogenic and highly emetogenic chemotherapy.

• Moved to nonpreferred status
• Added to Prior Authorization program
• Quantity Limit Revised
• Current utilizers will be grandfathered for continued use without PA or change in tier status.

Exalgo

• Added to DACON program (effective 6-1-10)
  

Amnesteen, Claravis, Sotret

• Added to Prior Authorization program.Current utilizers grandfathered for continued use without PA.
  

Androderm, Androgel, Femara

• Added to Prior Authorization program.Current utilizers grandfathered for continued use without PA.
  

8-MOP, Accutane, Celebrex, Emend, Emend Pak, Ketek, Lotronex, Oxsoralen, Oxsoralen Ultra, Regranex, Striant, Testim

• Added to Prior Authorization program. Current utilizers grandfathered for continued use without PA.
  

butorphanol nasal spray

• Quantity Limit revised from 4 bottles per month to 3 bottles per month.
  

Emend, Emend Pak

• Quantity Limit for Emend is being revised from 3 capsules per month to the following:
  Emend 40 mg = 1 capsule per prescription
  Emend 80 mg = 2 capsules per prescription
  Emend 125 mg = 1 capsule per prescription
• Quantity Limit for Emend Pak is being revised from 1 pack per month to 1 pack per prescription
  

Aldara (imiquimod 5% cream), Evoclin, Exalgo, Zirgan, Zyclara

• Exalgo added to Quantity Limits program (effective 6-1-10)
• Aldara, Evoclin, Zirgan, Zyclara added to Quantity Limits program (effective 8-1-10)
• QL also applies to generic equivalent products, noted in parentheses
  

Valturna (aliskiren/valsartan)

• A combination product used for the treatment of hypertension.
• Electronic step edit added. Requires step 1 therapy with ACE inhibitor or ACE inhibitor combination, or ARB or ARB combination.

Delatestryl (testosterone enanthate inj), Depo-Testosterone (testosterone cypionate inj), Hizentra (effective 7/1/10)

• Prior Authorization added to Hizentra (effective 7-1-10)
• Prior Authorization added to Delatestryl and Depo-testosterone (effective 8-1-10)
• Current utilizers grandfathered for continued use without PA
• PA also applies to generic equivalent products, noted in parentheses
• Product may be available through the retail benefit depending on benefit design.

Depo-Testosterone (testosterone cypionate inj)

• Product moving to nonpreferred status (generic equivalent available)
• Product may be available through the retail benefit depending on benefit design.