July 2009

	TABLE KEY	Tier 3	DACON	Quantity Limits
	Δ Change + Addition *(see "Review Details" section for a full definition of the products, changes and additions)*	Δ Avandamet Δ Avandia Δ Aygestin + Exforge HCT + Nuvigil Δ Provera + Savella + Savella Titration Pack + Simponi	+ Bystolic (10mg & 20mg) + Coreg CR + Detrol + Exforge + Exforge HCT + Lotrel (5/40 & 10/40) + Lotronex + Lunesta + Nuvigil + Provigil + Rozerem + Savella + Uroxatral	+Aerobid + Aerobid-M + Alvesco + Azmacort + Catapres TTS + Flovent Diskus + Flovent HFA + Helidac + Prevacid NapraPAC + Pulmicort + QVAR + Regranex Δ Relenza + Savella Titration Pack + Soriatane CK + Spiriva Δ Tamiflu + Xopenex HFA + Xyrem

	KEY TO TIERS
	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.)

		Prior Authorization
		+ Nuvigil + Simponi

		Specialty Pharmacy
		+ Simponi

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
	Nuvigil (armodafini)
	A once-daily medication used to improve wakefulness in patients with excessive sleepiness associated with obstructive sleep apnea (OSA), shift work sleep disorder (SWD), and narcolepsy. In a limited category (stimulants-misc.) Prior authorization required 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.
	Savella (milnacipran HCl)
	Used for the management of fibromyalgia — a chronic condition characterized by widespread pain and tenderness. In a limited category (fibromyalgia Agents) DACON edit applies for Savella tablets Quantity Limit applies for Savella Titration Pack	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.
	Simponi (golimumab)
	Indicated for treatment of patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), or ankylosing spondylitis (AS). In a limited category (TNF Antagonists) 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 copay or the preferred brand specialty copay. If the customer does not have the SPP it may be considered under the pharmacy 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 nonpreferred brand or nonpreferred brand specialty copay. If the customer does not have the SPP it may be considered under the pharmacy benefit. Coverage and pharmacy provider(s) are determined by the plan sponsor's selected 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
	Exforge HCT (amlodipine-valsartan-hydrochlorthiazide)
	A combination product used to treat high blood pressure. In a limited category (blood pressure-combination) 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.

	► PPL UPDATES Medications added to or removed from the PPL in order to provide the most cost-effective therapy in the 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
	Avandamet (rosiglitazone maleate-metformin HCl)
	Used as an adjunct to diet and exercise to improve control of blood glucose in adults with type 2 diabetes when dual therapy is appropriate. Removed from preferred status. In a limited category (anti-diabetic) 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.
	Avandia (rosiglitazone maleate)
	Used as an adjunct to diet and exercise to improve control of blood glucose in adults with type 2 diabetes. Removed from preferred status. In a limited category (anti-diabetic) 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.

	► GENERIC ALTERNATIVES Review of products with FDA approved 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
	Aygestin (norethindrone acetate)
	A synthetic oral progestin used to treat the symptoms of hormone imbalance in females. Removed from preferred status due to availability of a generic equivalent. In a limited category (hormone replacement therapy)	Brand copay.	Third tier, nonpreferred brand copay.	Not covered.
	Provera (medroxyprogesterone acetate)
	An oral progestin used to treat the symptoms of hormone imbalance in females and as hormone replacement therapy in combination with an estrogen in post-menopausal women. Removed from preferred status due to availability of a generic equivalent. In a limited category (hormone replacement therapy)	Brand copay.	Third tier, nonpreferred brand copay.	Not covered.
	Cellcept (mycophenolate mofetil)
	Used for the prevention of organ rejection in patients receiving renal, cardiac or hepatic transplants. Remains at preferred status. Generic equivalent is available. Not in a limited category (immunosuppressive agents-oral)	Brand copay.	Second tier, preferred brand copay.	Second tier, preferred brand copay.

	► 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
	QUANTITY LIMITS: Azmacort, Catapres TTS, Flovent Diskus/HFA, Helidac, Pulmicort, Regranex, Soriatane CK, Spiriva, QVAR, Xopenex HFA, Xyrem
	Will be added to the quantity limits program.	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.
	QUANTITY LIMITS: Aerobid, Aerobid-M, Alvesco, Prevacid NapraPAC
	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.
	QUANTITY LIMITS: Relenza, Tamiflu
	Quantity limit will change from one treatment yearly to one treatment per month.	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.
	DACON: Exforge, Lotrel (5/40 and 10/40), Lotronex, Provigil
	Will be added to the DACON program.	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.
	DACON: Bystolic (10mg, 20mg), Coreg CR, Detrol, Lunesta, Rozerem, Uroxatral
	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.

	SPECIAL ANNOUNCEMENT: The scheduled August 1 quantity limit changes for Oxycontin and oxycodone ER tablets reported in the June edition of Pharmacy Passages (Clinical Programs, Quantity Limits) will be postponed to allow Innoviant's Clinical Department to further evaluate the impact on members currently utilizing these medications. We will continue to communicate updates in future editions of Pharmacy Passages.