TABLE KEY

Tier 3

Brands for Generic

Δ Change
+ Addition
- Deletion / Not Covered

Δ Adderall (1-1-10)
Δ Azulfidine
Δ Azulfidine EN
Δ Bayer Autodisc (1-1-10)
Δ Bayer BREEZE 2 (1-1-10)
Δ Bayer CONTOUR (1-1-10)
Δ Bayer ELITE (1-1-10)
Δ Carbatrol
Δ Depakene
Δ Depakene Syrup
Δ Dextrostat (1-1-10)
Δ Dexedrine CR (1-1-10)
Δ Dilantin-125mg susp.
Δ Enbrel (1-1-10)
Δ Methylin chew (1-1-10)
Δ Methylin solution (1-1-10)

Δ Mysoline
+ Onglyza*
Δ Peg-Intron (1-1-10)
Δ Prograf
Δ Ritalin (1-1-10)
Δ Ritalin SR (1-1-10)
Δ Rowasa
Δ Rowasa Kit
Δ Tegretol XR**
Δ Topamax Sprinkle
Δ Viagra
Δ Xyrem
Δ Zarontin
Δ Zipsor
Δ Zonegran

- Bayer Autodisc (1-1-10)
- Bayer BREEZE 2 (1-1-10)
- Bayer CONTOUR (1-1-10)
- Bayer ELITE (1-1-10)
+ OneTouch (1-1-10)

KEY TO TIERS

DACON

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.)

*tier status pending full review
**200 and 400 mg

+ Onglyza
+ Ultram ER
+ Zipsor

QL

+ Acuvail
Δ Cialis (10mg, 20mg)
Δ Levitra
Δ Viagra

Tier 2

Not Covered

SPP

+ Acuvail
Δ Cimzia (1-1-10)
Δ OneTouch (1-1-10)

- Ilaris

+ Vimpat I.V.

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

Onglyza (saxagliptin)

Used as an adjuct to diet and exercise to improve control of blood sugar in patients with Type 2 diabetes mellitis.

• DACON edit applies
• In a limited category
  (antidiabetics)
• 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.

Ilaris (canakinumab) injection for subcutaneous use

An interleukin-1 blocker used for the treatment of children and adults with cryopyrin-associated periodic syndrome (CAPS).

Ilaris is not for self-administration and is not covered under the pharmacy benefit.

Not covered.

Not covered.

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

Zipsor (diclofenac potassium) liquid filled capsules

Used for the relief of mild to moderate acute pain in adults.

• DACON edit applies
• In a limited category
  (anti-inflammatory-nonsteroidal)

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.

Acuvail 0.45% (ketorloac tromethamine ophthalmic solution)

A nonsteroidal antiinflammatory agent used to treat pain and inflammation following cataract surgery.

• Quantity Limit applies
• In a limited category
  (ophthalmic - NSAIDS)

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.

Plan B^® One-Step (levonorgestrel 1.5mg tablet)

a single dose oral tablet used for emergency contraception.

• Quantity Limit applies
• Non-standard limited category
  (contraception)

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.

► DRUG CLASS REVIEW:
Erectile Dysfunction  
Comprehensive review of medications in a therapeutic 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

Cialis (tadalafil)

• Remains at preferred status
• Quantity Limit applies
  (changed to 6 tablets/month
  for the 10mg and 20mg tablets)
• Non-standard category
  (erectile dysfunction)

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.

Levitra (vardenafilt)

• Remains at nonpreferred status
• Quantity Limit applies
  (changed to 6 tablets/month)
• Non-standard category
  (erectile dysfunction)

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.

Viagra (sildenaf)

• Moved to nonpreferred status
• Quantity Limit applies
  (changed to 6 tablets/month)
• Non-standard category
  (erectile dysfunction)

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.

► DRUG CLASS REVIEW:
Anticonvulsants 
Comprehensive review of medications in a therapeutic 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

divalproex sodium, carbamazepine, gabapentin, ethosuximide, lamotrigine, levetiracetam,
oxcarbazepine, phenytoin, primidone, topiramate, valproic acid, valproate sodium syrup, zonisamide

• Listed items remain
  at generic status
• DACON edit may apply
  to some products

Generic copay.

Coverage is determined
by the plan sponsor's
chosen benefit design.

Generic copay.

Coverage is determined
by the plan sponsor's
chosen benefit design.

Generic copay.

Coverage is determined
by the plan sponsor's
chosen benefit design.

Banzel, Dilantin, Dilantin Infatab Chewable, Felbatol (tab and susp),
Gabitril, Lyrica, Phenytek, Tegretol XR 100mg, Trileptal susp.

• Listed items remain
  at preferred status
• DACON edit may apply
  to some products

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.

Carbatrol, Depakene, Depakene Syrup, Dilantin-125mg Suspension, Mysoline,
Tegretol XR 200mg and 400mg, Topamax Sprinkle, Zarontin (capsule and solution), Zonegran

• Listed items moving to
  nonpreferred status due to
  availability of generic equivalents
  or generic alternatives
• DACON edit may apply
  to some products

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.

Depakote DR, Depakote ER, Depakote Sprinkle, Keppra, Keppra XR, Lamictal, Neurontin,
Peganone, Stavzor, Tegretol (tab, chew, susp), Topamax, Trileptal, Vimpat

• Listed items remain
  at nonpreferred status
• DACON edit may apply
  to some products

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.

Vimpat I.V.

• Listed item added to Specialty Pharmacy Program (SPP)
  at nonpreferred status

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 medical benefit.

Coverage and pharmacy provider(s) determined by the benefit design selected by the plan sponsor.

If the customer has the SPP, this product may be obtained through our specialty pharmacy network at the third tier, nonpreferred brand copay or nonpreferred brand specialty copay.

If the customer does not have the SPP it may be considered under the medical benefit.

Coverage and pharmacy provider(s) determined by the benefit design selected by the plan sponsor.

Not covered.

► DRUG CLASS REVIEW:
Attention Deficit Hyperactivity Disorder (ADHD)  
Comprehensive review of medications in a therapeutic 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

amphetamine-dextroamphetamine salts tab, dextroamphetamine sulfate CR, Methylin tab, Methylin ER, methylphenidate / ER

• Listed items remain
  at generic status.
• DACON edit may apply
  to some items

Generic copay.

Coverage is determined
by the plan sponsor's
chosen benefit design.

Generic copay.

Coverage is determined
by the plan sponsor's
chosen benefit design.

Generic copay.

Coverage is determined
by the plan sponsor's
chosen benefit design.

Adderall, Dextrostat, Dexedrine CR, Methylin chew, Methylin solution, Ritalin, Ritalin SR

• Effective January 1, 2010:
  Listed items moving to nonpreferred status due to availability of generic equivalents or generic alternatives
• DACON edit may apply
  to some items

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.

► DRUG CLASS REVIEW:
Inflammatory Bowel
Disease Agents  
Comprehensive review of medications in a therapeutic 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

basalazide, mesalamine, sulfasalazine / DR

• Listed items remain
  at generic status

Generic copay.

Generic copay.

Generic copay.

Dipentum

• Listed item remains
  at preferred status

Brand copay.

Second tier,
preferred brand copay.

Second tier,
preferred brand copay.

Azulfidine, Azulfidine EN

• Listed items moving to nonpreferred status due to availability of generic equivalents or generic alternatives

Brand copay.

Third tier,
nonpreferred brand copay.

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

Bayer Autodisc^® Bayer BREEZE^® 2 Bayer CONTOUR^® Bayer ELITE^®

Blood Glucose testing strips by Bayer HealthCare.

• Quantity Limit applies
• Non-standard limited category (diabetic supplies)

Effective January 1, 2010:

• Removed from preferred status
• Removed from
  Brands for Generic 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.

Cimzia (certolizumab pegol)

A self-injectable TNF antagonist used in the treatment of rheumatoid arthritis and Crohn's disease.

• Prior Authorization applies
• Specialty Pharmacy Program (SPP)
• In a limited category
  (TNF antagonists)

Effective January 1, 2010:

• Added to preferred status

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) determined by the benefit design selected by the plan sponsor.

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) determined by the benefit design selected by the plan sponsor.

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) determined by the benefit design selected by the plan sponsor.

Enbrel (etanercept)

A self-injectable TNF antagonist used in the treatment of rheumatoid arthritis (RA), plaque psoriasis, psoriatic arthritis, ankylosing spondylitis (AS), and juvenile idiopathic arthritis (JIA).

• Quantity Limit applies
• Specialty Pharmacy Program (SPP)
• In a limited category
  (TNF antagonists)

Effective January 1, 2010:

• Moving to nonpreferred status

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) determined by the benefit design selected by the plan sponsor.

If the customer has the SPP, this product may be obtained through our specialty pharmacy at the third tier, nonpreferred brand copay 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) determined by the benefit design selected by the plan sponsor.

Not covered.

OneTouch^®

Blood Glucose testing strips by LifeScan.

• Quantity Limit applies
• Non-standard limited category (diabetic supplies)

Effective January 1, 2010:

• Added to preferred status
• Added to Brands for Generic 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.

Peg-Intron (peginterferon alfa-2b)

A self-injectable antiviral medication used in the treatment of chronic hepatitis C infection.

• Prior Authorization applies
• Specialty Pharmacy Program (SPP)
• In a limited category
  (Hepatitis C)

Effective January 1, 2010:

• Removed from preferred status (current utlizers will be grandfathered for continued access at Tier 2)

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) determined by the benefit design selected by the plan sponsor.

If the customer has the SPP, this product may be obtained through our specialty pharmacy at the third tier, nonpreferred brand copay 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) determined by the benefit design selected by the plan sponsor.

Not covered.

Xyrem (sodium oxybate) oral solution

Used in the treatment of narcolepsy.

• Removed from preferred status
• Prior Authorization applies
• 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.

► 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

Rowasa, Rowasa Kit (mesalamine enema)

Used in the treatment of mild to moderate distal ulcerative colitis.

• Removed from preferred status due to availability of generic equivalents
• In a limited category
  (gastrointestinal agents - misc.)

Brand copay.

Third tier,
nonpreferred brand copay.

Not covered.

Prograf (tacrolimus)

Used to prevent rejection in patients who have received kidney, liver or heart transplant.

• Removed from preferred status due to FDA approval of generic equivalent tacrolimus capsule

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

BRANDS FOR GENERIC: OneTouch^®

Added to Brands for Generic program effective January 1, 2009. Optional Program.

Generic copay.

Coverage is determined
by the plan sponsor's
chosen benefit design.

Generic copay.

Coverage is determined
by the plan sponsor's
chosen benefit design.

Generic copay.

Coverage is determined
by the plan sponsor's
chosen benefit design.

BRANDS FOR GENERIC: Bayer Autodisc^® Bayer BREEZE^® 2 Bayer CONTOUR^® Bayer ELITE^®

Removed from Brands for Generic program effective January 1, 2010. Optional 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.

DACON: Onglyza, Ultram ER, Zipsor

Listed items 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.

QUANTITY LIMITS: Cialis 10mg, 20mg

Quantity Limit is changing from 8 tablets per month to 6 tablets per month.

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: Levitra, Viagra

Quantity Limit is changing from 8 tablets per month to 6 tablets 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.

QUANTITY LIMITS: Acuvail

Listed items 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: Plan B^® One-Step

Listed items 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.