September 2009

	TABLE KEY	Tier 3	Prior Authorization	DACON
	Δ Change + Addition *(see "Review Details" section for a full definition of the products, changes and additions)*	+ Adcirca + Edluar + Effient (pending full review) Δ Risperdal M Δ Risperdal Solution	+ Adcirca + Afinitor + Multaq + Qualaquin	+ Cardura XL + Edluar + Effient + Lyrica + Adcirca

		Tier 2	SPP	Quantity Limits
		+ Afinitor + Coartem Δ Exforge HCT (10-01-09) + Multaq	+ Temodar (injection)	NONE

	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
	Adcirca (tadalafil)
	A phosphodiesterase 5 (PDE5) inhibitor used in the treatment of pulmonary arterial hypertension (PAH) to improve exercise ability. Prior Authorization applies DACON edit applies In a limited category (pulmonary arterial hypertension)	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.
	Afinitor (everolimus)
	An oral anticancer medication used to treat advanced renal cell carcinoma in patients who have failed treatment using first line agents. Prior Authorization applies In a limited category (antineoplastics)	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.
	Coartem (artemether-lumefantrine)
	A combination product used in the treatment of acute, uncomplicated malaria infections. Not in a limited category (antimalarial combinations)	Brand copay.	Second tier, preferred brand copay.	Second tier, preferred brand copay.
	Effient (prasugrel)
	A platelet inhibitor used for the reduction of thrombotic cardiovascular events (including stent thrombosis) in patients with acute coronary syndrome who are to be managed with percutaneous coronary intervention (PCI). DACON edit applies In a limited category (anti-platelet) Tier status is pending full P&T review.	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.
	Multaq (dronedarone)
	An antiarrhythmic drug used to reduce the risk of cardiovascular hospitalization in patients with atrial fibrillation or atrial flutter. Prior Authorization applies Not in a limited category (antiarrhythmics)	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.

	► 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
	Edluar (zolpidem tartrate sublingual tablets)
	Used for the short-term treatment of insomnia as characterized by difficulties with sleep initiation. DACON edit applies In a limited category (sedative hypnotics)	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.
	Temodar for injection (temozolamide)
	A new dose form of an alkylating anti-cancer agent used to treat adult patients with glioblastoma multiforme (GBM) or refractory anaplastic astrocytoma. Specialty Pharmacy Program (SPP) Not in a limited category (antineoplastics)	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 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 second-tier, preferred brand copay 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 second-tier, preferred brand copay 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.

	► 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
	Exforge HCT (amlodipine-valsartan-hydrochlorothiazide)
	a combination product used in the treatment of hypertension. Added to preferred status, effective October 1, 2009. DACON edit applies In a limited category (blood pressure -- combination)	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.

	► 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
	Risperdal Oral Solution, Risperdal M-Tab (risperidone)
	Atypical antipsychotics used in the treatment of schizophrenia, or for the short-term treatment for the manic or mixed episodes associated with Bipolar I disorder, or for the treatment of irritability associated with autistic disorder in children and adolescents. Removed from preferred status due to availability of generic equivalents. In a limited category (antipsychotic -- atypical)	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: Lyrica
	Added to the DACON program, effective November 1, 2009	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: Cardura XL
	Added to the DACON program, effective November 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.
	PRIOR AUTHORIZATION: Qualaquin (quinine sulfate)
	indicated only for the treatment of uncomplicated Plasmodium falciparum malaria. Qualaquin is not approved for the treatment of patients with severe or complicated P. falciparum malaria, or for the prevention of malaria. Qualaquin is not approved for the treatment or prevention of nocturnal leg cramps. Not in a limited category (antimalarials) Qualaquin is added to the Prior Authorization program, effective November 1, 2009.	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.