August 2009

	TABLE KEY	Tier 3	Tier 2	Quantity Limits
	Δ Change + Addition *(see "Review Details" section for a full definition of the products, changes and additions)*	+ Besivance Δ Betaseron (01-01-2010) Δ Golytely + Lamictal XR Kit + Lamictal XR tablet + Nucynta + Sarafem 15mg Δ Xalatan	Δ Lumigan Δ Rebif (01-01-2010)	+ Golytely + Lamictal XR Kit + Nucynta (08-01-2009)

				DACON
				+ Lamictal XR tablet + Sarafem 15mg

	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.

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
	Besivance (besifloxacin ophthalmic suspension)
	A quinolone antibiotic used to treat bacterial conjunctivitis. In a limited category (ophthalmic-antibiotics)	Brand copay.	Third tier, nonpreferred brand copay.	Not covered.
	Nucynta (tapentadol)
	An opioid analgesic used for the relief of moderate to severe acute pain in patients 18 years of age or older. In a limited category (analgesics and narcotics) Quantity Limit applies Effective August 1, 2009	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
	Lamictal XR (lamotrigine extended release tablet)
	Used as adjunctive treatment of partial onset seizures in patient aged 13 years or older. In a limited category (anticonvulsants) DACON edit applies for Lamictal XR tablets Quantity Limit applies for Lamictal XR Titration Kit	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.
	Sarafem 15mg (fluoxetine HCl tablet)
	Used to treat the mood and physical symptoms of Premenstrual Dysphoric Disorder (PMDD). 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
	Xalatan (latanoprost ophthalmic solution)
	Used to reduce intraocular pressure in patients with open-angle glaucoma or ocular hypertension. Removed from preferred status. In a limited category (ophthalmic--prostaglandins) 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.
	Lumigan (bimatoprost ophthalmic solution)
	Used to reduce intraocular pressure in patients with open-angle glaucoma or ocular hypertension. Added to preferred status. In a limited category (ophthalmic--prostaglandins) Quantity Limit 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.
	Betaseron (interferon beta 1-a)
	Used for the treatment of relapsing forms of multiple sclerosis to reduce the frequency of clinical exacerbations. Removed from preferred status effective January 1, 2010. Current utilizers will be grandfathered for continued use of Betaseron at preferred status. In a limited category (multiple sclerosis) Prior Authorization applies 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 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 third-tier, 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.
	Rebif (interferon beta-1a)
	Used to treat relapsing forms of MS to decrease the frequency of relapses and delay the occurrence of some of the physical disability that is common in people with MS. Added to preferred status effective January 1, 2010. In a limited category (multiple sclerosis) Prior Authorization applies Specialty Pharmacy Program (SPP)	If the customer has the SPP, this product may be obtained through our specialty pharmacy at the brand copay or 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 second-tier, preferred brand copay or 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 second-tier, preferred brand copay or 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.

	► 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
	Golytely (PEG-3350 and electrolytes for oral solution)
	Used for bowel cleansing prior to colonoscopy and barium enema X-ray examination. Removed from preferred status due to availability of generic equivalents Gavilyte G solution and PEG-3350 electrolyte solution. In a limited category (laxatives) 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.