July 2010 Pharmacy Passages

Pharmacy Passages: Your Source for Information About Changes to the Innoviant Preferred Products List

July 2010

Innoviant's Business Committee meets monthly to evaluate product status (tier placements) and new prescription products approved by the Food and Drug Administration (FDA). The committee makes decisions based on information and recommendations from Prescription Solutions^® National Pharmacy & Therapeutics (NP&T) Committee, which is comprised of independent physician providers, affiliated plan physicians and pharmacists.

Change Summary Table

The following table is an at-a-glance summary of decisions made at June committee meetings. Details about products and decisions are further outlined in the "review details" section of this newsletter. All changes are effective September 1, 2010 unless otherwise noted.


Table Key	Δ Change	• No Change	+ Addition	- Deletion


Tier 3 (Nonpreferred)	DACON	Quantity Limit (QL)
Δ Augmentin XR	+ Altace cap	+ Adapalene Gel
Δ Benzacllin	+ Altace tab	+ Benzaclin
Δ Bidil	+ Baraclude	+ Byetta
Δ Cinryze (SPP)	+ Bidil	+ Clindamycin phosphate-benzoyl peroxide gel
Δ Cordran	+ Clozapine 50 mg, 200 mg	+ Clindamycin phosphate-benzoyl peroxide gel
Δ Cordran SP	Δ Concerta 36 mg	+ Cordran
Δ Depo-Provera Contraceptive (SPP)	+ Dynacirc CR	+ Cordran SP
Δ Depo-Provera Contraceptive (SPP)	+ Felodipine	+ Diastat
Δ Duac CS	+ Lovaza	+ Differin Cream
Δ Fuzeon	+ Pexeva	+ Differin Gel
Δ Increlex	+ Plendil	+ Differin Lotion
Δ Monurol	+ Priftin	+ Duac CS
Δ Noxafil	+ Ramipril	+ EpiPen
Δ Priftin	+ Requip XL	+ EpiPen Jr
Δ Skelid	+ Rybix ODT	+ Finacea Gel
Δ Somavert	+ Valcyte tab	+ Finacea Plus
Δ Sporanox	+ Vfend	+ Fuzeon
Δ Terazol	+ Welchol tab	+ Kineret
Δ Ultravate Kit		+ Serostim
+ Valcyte Sol.	Prior Authorization (PA)	+ Twinject
Δ Valcyte tab	+ Zortress	+ Terazol
Δ Vfend		+ Ziana
Δ Xifaxan 200 mg	NDC Block	+ Zorbtive
+ Xifaxan 550 mg	- Hydrochlorothiazide 12.5 mg tab
ΔZiana	- Hydrochlorothiazide 12.5 mg tab
Δ Zithromax Susp
+ Zortress	*Specialty Pharmacy (SPP)
	Δ Cinryze
Tier 2 (Preferred)	Δ Depo-Provera Contraceptive
Δ Tev-Tropin

Tier 1
Δ Hydrochlorthiazide 12.5 mg tablet
Δ Hydrochlorthiazide 12.5 mg tablet

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.


	Table Key



	*Plan Design* Open = all generics at tier-1 and all brands at tier-2 (or all medications at tier-1) Select = generics at tier-1, preferred brands at tier-2 and nonpreferred brands at tier-3 Closed = generics at tier-1 and preferred brands at tier-2 (nonpreferred products are not covered or may require authorization for coverage)

	*PPL Status:* G = Generic PB= Preferred brand N = Nonpreferred brand		*Copay Tier:* 1 = Generic 2 = Brand/Preferred brand 3 = Nonpreferred brand 0 = Not covered/other


	New Specialty Medications Please note: If your plan includes the specialty pharmacy program (SPP), your members may get specialty products from Prescription Solutions® Specialty Pharmacy for your plan's applicable copay. If your plan does not include the SPP, your members may get self-injectable specialty medications from retail pharmacies or specialty products may be covered under the medical plan. Specialty Program medications limited to a 30 day supply.

No new medications added to Specialty Pharmacy Program at the June business meeting.



	New Medications (non specialty)



*Xifaxan (rifaximin)* 550 mg** Indicated for reduction in risk of overt hepatic encephalopathy (HE) recurrence in patients ≥ 18 years of age. Line extension (new strength and indication)	N	2	3	0



Valcyte (valganciclovir hcl for sol) An antivrial Used for used for the prevention of CMV (cytomegalovirus) disease in pediatric kidney and heart transplant patients at high risk. Line extension (new strength and dose form)	N	2	3	0



Zortress (everolimus) Used for the prophylaxis of organ rejection in adult patients at low to moderate immunologic risk receiving a kidney transplant. Prior Authorization	N	2	3	0



	Preferred Products List (PPL) Updates



*Augmentin XR (amoxicillin & K clavulanate SR 12 hr 1000-62.5 mg)* Tab** (oral antibiotic) Benzaclin (Benzoyl Peroxide / Clindamycin Phosphate) Gel (topical acne agent)* Terazol (terconazole) Cream and Supp (vaginal antifungal)* Ultravate (halobetasol prop. oint & ammonium lactate lot) Kit (topical dermatological) Zithromax (azithromycin) Susp.(oral antibiotic) Listed agents moved to nonpreferred status. Generic equivalents available * Benzaclin, Terazol, and their generic equivalents also added to Quantity Limits program	N	2	3	0



Bidil (isosorbide dinitrate-hydralazine hcl) Bidil is used for the treatment of heart failure as an adjunct to standard therapy in African Americans to improve survival, to prolong time to hospitalization for heart failure, and to improve patient-reported functional status. Moved to nonpreferred status. Current utilizers will be grandfathered for continued use at preferred status. Added to DACON program	N	2	3	0



Cordran, Cordran SP (flurandrenolide cream, lotion, tape) Topical corticosteroid used to treat itching, redness, dryness, inflammation, and discomfort of various skin conditions. Moved to nonpreferred status. Generic therapeutic alternatives are available. Added to Quantity Limits program	N	2	3	0



Duac CS Kit (benzoyl peroxide/clindamycin phosphate 1-5%, and cleanser lotion kit) Used for the topical treatment of acne Moved to nonpreferred status. Generic and preferred brand therapeutic alternatives are available. Added to Quantity Limits program	N	2	3	0



Fuzeon (enfuvertide for inj. kit) Used in combination with other antiretroviral agents for the treatment of HIV-1 infection in treatment-experienced patients. Moved to nonpreferred status. Current utilizers will be grandfathered for continued use at preferred status. Added to Quantity Limits program Prior Authorization Specialty Pharmacy Program	N	2	3	0



Increlex (mecasermin for inj) Used for the long-term treatment of growth failure in children with severe primary IGF-1 deficiency (Primary IGFD) or with growth hormone (GH) gene deletion who have developed neutralizing antibodies to GH. Moved to nonpreferred status. Current utilizers will be grandfathered for continued use at preferred status. Prior Authorization Specialty Pharmacy Program	N	2	3	0



Monurol (fosfomycin tromethamine) An antibiotic used to treat infections of the urinary tract Moved to nonpreferred status. Generic therapeutic alternatives are available.	N	2	3	0



Noxafil (posaconazole oral suspension) An antifungal used for the treatment of oropharyngeal candidiasis, and for the prophylaxis of invasive Aspergillus and Candida infections in patients, 13 years of age and older, who are at high risk of developing these infections due to being severely immunocompromised. Moved to nonpreferred status. Generic and preferred brand therapeutic alternatives are available. Prior Authorization	N	2	3	0



Priftin (rifapentine) Used in combination with one or more antituberculosis agents for the treatment of pulmonary tuberculosis infection. Moved to nonpreferred status. Generic and preferred brand therapeutic alternatives are available. Added to DACON program	N	2	3	0


Skelid (tiludronate disodium tablet) Used for treatment of patients with Paget's disease of bone who have a level of serum alkaline phosphatase (SAP) at least twice the upper limit of normal, or who are symptomatic, or who are at risk for future complications of their disease. Moved to nonpreferred status. Generic and preferred brand alternatives are available.	N	2	3	0


Somavert (pegvisomant for inj) A growth hormone antagonist used for the treatment of acromegaly in patients who have had an inadequate response to surgery and/or radiation therapy and/or other medical therapies, or for whom these therapies are not appropriate. Moved to nonpreferred status. Current utilizers will be grandfathered for continued use at preferred status. Prior Authorization program Specialty Pharamcy Program	N	2	3	0


*Sporanox (itraconazole)* Solution** An antifungal used for empiric therapy of febrile neutropenic patients with suspected fungal infections, and for the treatment of oropharyngeal and esophageal candidiasis. Moved to nonpreferred status. Generic and preferred brand alternatives are available. Prior Authorization (non-standard category-Oral Antifungals)	N	2	3	0


Tev-Tropin (somatropin for subcutaneous injection) Used only for the treatment of children who have growth failure due to an inadequate secretion of normal endogenous growth hormone. Moved to preferred status. Non-standard category - Growth Hormones Prior Authorization Program Specialty Pharmacy Program	PB	2	2	2


Valcyte (valganciclovir hcl tab) An antivrial used for the treatment of CMV retinitis in adult patients with acquired munodeficiency syndrome (AIDS), and for the prevention of CMV disease in adult kidney, heart, and kidney-pancreas transplant patients at high risk. Moved to nonpreferred status. Added to DACON Program	N	2	3	0


*Vfend (voriconazole) tablet and suspension* An antifungal agent used in the treatment of fungal infections including esophageal candidiasis, systemic candidiasis, and invasive aspergillosis. Moved to nonpreferred status. Generic and preferred brand therapeutic alternatives are available. Added to DACON Program	N	2	3	0


*Xifaxan (rifaximin)* 200 mg tab** An antibiotic used to treat traveler's diarrhea caused by bacteria. Moved to nonpreferred status. Generic therapeutic alternatives are available.	N	2	3	0


Ziana (clindamycin phosphate/tretinoin gel) Used for the topical treatment of acne. Moved to nonpreferred status. Generic and preferred brand therapeutic alternatives are available. Added to Quantity Limit Program	N	2	3	0



	Utilization Management Program: DACON (non-Specialty medications)



clozapine (50mg, 200mg tab) felodipine, ramipril Added to DACON program	G	1	1	1



Baraclude, Lovaza, Requip XL, Welchol tab Added to DACON program	PB	2	2	2



*Altace (tab and cap), Bidil, Concerta 36 mg, Dynacirc CR, Pexeva, Plendil, Priftin, Rybix ODT, Valcyte tab, Vfend** Added to DACON program *Concerta 36 mg daily dose edit is being revised from 2.5 per day to 2 per day	N	2	3	0



	Utilization Management Program: Prior Authorization (non-Specialty or Specialty Pharmacy Program option medications)



Zortress Added to Prior Authorization program.	N	2	3	0



	Utilization Management Program: Quantity LImits

adapalene gel, benzoyl peroxide/clindamycin phosphate gel, terconazole (cream and supp)

Added to Quantity Limits program.

Byetta, Diastat, Differin (Cream, Gel, Lotion), EpiPen, EpiPen Jr, Finacea Gel, Finacea Plus, Twinject

Added to Quantity Limits program.

Benzaclin, Cordran, Cordran SP, Duac CS, Kineret, Terazol (cream and supp), Serostim, Ziana, Zorbtive

Added to Quantity Limits program.



	Specialty Pharmacy Program — Tier status changes



Cinryze, Depo-Provera Contraceptive Moved to nonpreferred status	N	2	3	0


	Special Announcement: NDC Block - Hydrochlorothiazide (HCTZ) 12.5 mg tablet


A special announcement in the May 1 edition of Pharmacy Passages indicated that HCTZ 12.5 mg tablets would be added to the NDC block program due to significant cost differences between the tablet and capsule dose forms. This decision has been rescinded in favor of placing the tablets at tier 1 and applying a Maximum Allowable Cost (MAC) to claims for this product.