November 2009 Pharmacy Passages

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
	Bepreve (bepotastine besilate ophthalmic solution) 1.5%
	An antihistamine used for the treatment of itching associated with allergic conjunctivitis. Quantity Limit applies In a limited category (ophthalmic -- antiallergic)	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.
	Sabril (vigabatrin tablets and powder for oral solution)
	Indicated as monotherapy for pediatric patients 1 month to 2 years of age with infantile spasms (IS) for whom the potential benefits outweigh the potential risk of vision loss. Sabril is also indicated as adjunctive therapy for adult patients with refractory complex partial seizures (CPS) who have inadequately responded to several alternative treatments and for whom the potential benefits outweigh the risk of vision loss.Sabril is not indicated as a first-line therapy agent for CPS. Sabril will only be available through a limited number of specialty pharmacies as part of a program called SHARE^® (Support, Help, And Resources for Epilepsy). Prior Authorization applies DACON edit applies In a limited category (anticonvulsants)	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.
	Saphris (asenapine sublingual tablets)
	An atypical antipsychotic used in the acute treatment of schizophrenia in adults and the acute treatment of manic or mixed episodes associated with bipolar I disorder in adults.. Prior Authorization applies DACON edit applies In a limited category (atypical antipsychotics)	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.
	Tyvaso (treprostinil) Inhalation Solution
	Indicated to increase walk distance in patients with WHO Group I pulmonary arterial hypertension (PAH) and NYHA Class III symptoms. 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.

	► 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
	Benzefoam (benzoyl peroxide 5.3% emollient foam)
	Used in the topical treatment of mild to moderate acne vulgaris.	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.
	Embeda (morphine sulfate and naltrexone hydrochloride) Extended Release Capsules
	Used in the management of moderate to severe pain when a continuous, around the clock opioid analgesic is needed for an extended period of time. Quantity Limit applies In a limited category (analgesics and narcotics)	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.
	Extavia (interferon beta-1b for sc injection)
	Used in the treatment of relapsing forms of Multiple Sclerosis. Prior Authorization applies (effective at market introduction) Specialty Pharmacy Program (SPP) In a limited category (multiple sclerosis agents)	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.
	Fibricor (fenofibric acid tablets)
	Used to reduce triglyceride (TG) levels in patients with severe hypertriglyceridemia and to reduce elevated total cholesterol (TC) in patients with primary hyperlipidemia or mixed dyslipidemia. DACON edit applies In a limited category (cholesterol lowering)	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.
	Invega Sustenna (paliperidone palmitate extended release suspension for IM injection)
	Used in the acute and maintenance treatment of schizophrenia in adults. Specialty Pharmacy Program (SPP) In a limited category (atypical antipsychotics)	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 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.
	Onsolis (fentanyl buccal soluble film)
	An opioid analgesic indicated only for the management of breakthrough pain in patients with cancer, 18 years of age and older, who are already receiving and who are tolerant to opioid therapy for their underlying persistent cancer pain. Onsolis is available only through a restricted distribution program called the FOCUS Program and requires prescriber, pharmacy, and patient enrollment. Prior Authorization applies (effective 11/01/09) Quantity Limit applies (effective 11/01/09) In a limited category (analgesics and narcotics)	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
	Adderall XR (amphetamine-dextroamphetamine SR 24HR capsule)
	Used in the treatment of attention deficit hyperactivity disorder (ADHD.) Removed from preferred status. (Colicensed equivalent product, amphetamine ER capsule is available at preferred brand copay.) In a limited category (ADHD)	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. Added to preferred status. (From September meeting decisions / also reported in October issue of Pharmacy Passages) Prior Authorization applies Quantity Limit applies Specialty Pharmacy Program (SPP) In a limited category (TNF antagonists)	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). The October edition of Pharmacy Passages reported that Enbrel would be moved to nonpreferred status, effective January 1, 2010. That change is no longer scheduled to take place.Enbrel is remaining at preferred status. Quantity Limit applies Prior Authorization applies Specialty Pharmacy Program (SPP) In a limited category (TNF antagonists)	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.
	Relion blood glucose test strips
	Added to preferred status. Added to Brands for Generic program (generic copay). Quantity Limit applies Non-standard limited category (diabetic supplies)	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
	Catapres-TTS (clonidine)
	A topically applied patch used in the treatment of hypertension. Removed from preferred status due to availability of generic equivalent product, clonidine HCl TD patch. Quantity Limit applies In a limited category (blood pressure- other)	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.

	► 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: Relion blood glucose test strips
	Added to Brands for Generic program. 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.
	DACON: Adcirca, Adoxa Pak, Doryx 150mg tab, Fibricor, Keppra XR, Oracea, Sabril, Sabril Powder, Saphris, Solodyn, Tyvaso
	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.
	DACON: Ventavis, Zemplar
	Listed items 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: Revatio
	Listed item will undergo change in daily dose edit from 4.5 tabs daily to 3 tabs daily. Prior Authorization also 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.
	DACON: Ascomp/Codeine, Fiorinal/Codeine, Balacet 325, Darvocet A500, Darvocet N-100,Talacen, Capital/Codeine, Co-Gesic, Dolorex Forte, Lortab 2.5, Lortab 5, Margesic-H, Stagesic, Vanacet, Vicodin, Combunox, Darvocet N-50, Oxycod/APAP, Tylox, Roxicet, Endocet, Percocet, Endodan, Percodan, Fioricet/codeine, Phrenelin, Hycet, Zamicet, Lorcet, Lorcet Plus, Vicodin HP, Lortab, Magnacet, Maxidone, Vicodin ES, Norco, Perloxx, propoxyphene/APAP, APAP/codeine, Reprexain, Vicoprofen, Volpac, Talwin NX, Tylenol with Codeine # 3, Tylenol with Codeine # 4, Ultracet, Ultram, Ultram ER, Xodol, Zydone
	Listed items will be added to DACON program, effective February 1, 2010 as result of safety review for narcotic agents. Products limited to maximum safe daily dose based on content of narcotic component or acetaminophen. Edits apply to both brand products and generic equivalents if available. Not all generics listed.	Generic products Tier 1. Brand products subject to Brand copay. Coverage determined by the benefit design chosen by the plan sponsor.	Generic products Tier 1. Brand products subject to third tier, nonpreferred brand copay. Coverage determined by the benefit design chosen by the plan sponsor.	Generic products Tier 1. Brand products not covered. Coverage determined by the benefit design chosen by the plan sponsor.
	PRIOR AUTHORIZATION: Enbrel, Humira, Humira Kit, Humira Crohn's Disease Starter Kit, Humira Psoriasis Starter Kit, Ventavis
	Listed item added to PA program at preferred status. Quantity Limit or DACON may also apply. SPP may apply.	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.
	PRIOR AUTHORIZATION: Extavia, Onsolis, Sabril, Sabril Powder, Saphris, Tyvaso
	Listed items added to PA program at nonpreferred status. Extavia PA effective at market introduction, Onsolis PA effective November 1, 2009. All others effective January 1, 2010 Quantity Limit or DACON may also apply. SPP may apply.	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: Ultracet (tramadol / acetaminophen)
	Removed from Quantity Limit program effective February 1, 2010. Limit of 40 tablets per prescription will no longer apply. Added to DACON program with daily dose edit of 8 tablets daily.	Tramadol / acetaminophen generic copay. Ultracet, brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Tramadol / acetaminophen generic copay. Ultracet, third tier nonpreferred brand copay. Coverage is determined by the plan sponsor's chosen benefit design.	Tramadol / acetaminophen generic copay. Ultracet, not covered. Coverage is determined by the plan sponsor's chosen benefit design.
	QUANTITY LIMITS: Cimzia
	Added to Quantity Limits program at preferred status. Prior Authorization and SPP also apply.	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: Adoxa, Adoxa CK Kit, Adoxa TT Kit, Bepreve, Doryx 75mg tab, Doryx 100mg tab, Embeda, Simponi
	Listed items 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.
	RX IN STEP--PSORIASIS: Enbrel, Humira, Humira Kit, Humira Crohn's Disease Starter Kit, Humira Psoriasis Starter Kit
	In consideration of the growing number of agents in the TNF Antagonist therapy class, along with expanded indications for these agents, Innoviant will be discontinuing the Rx InStep program for psoriasis effective January 1, 2010. Enbrel and Humira are joining the Prior Authorization program and will require review for all indications. Quantity Limits for both agents will be adjusted to meet approved dosing for the specific indication being treated.	Prior Authorization for the listed medications will apply to members starting medication after December 31, 2009. Members who currently utilize these medications or members who have met the Rx InStep program requirements for use prior to January 1, 2010 will be grandfathered for continued use wihout Prior Authorization.
	SPECIALTY PHARMACY PROGRAM: Invega Sustenna
	Listed Item added to Specialty Pharmacy Program 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 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.

TABLE KEY	Tier 3	Quantity Limit
Δ Change + Addition - Deletion / Not Covered	Δ Adderall XR + Benzefoam + Bepreve Δ Catapres-TTS + Embeda + Extavia + Fibricor + Invega Sustenna (SPP only) + Onsolis + Sabril + Sabril powder + Saphris + Tyvaso	+ Adoxa + Adoxa CK Kit + Adoxa TT Kit + Bepreve + Cimzia + Doryx 75mg & 100mg + Embeda Δ Enbrel Δ Humira Crohn's Disease Starter Kit Δ Humira Kit Δ Humira Psoriasis Starter Kit + Onsolis (11/1/09) + Simponi - Ultracet (2/1/10)

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.)




	Tier 2	Prior Authorization
	Δ Cimzia Δ Relion Test Strips	+ Enbrel + Extavia (9/16/09) + Humira Crohn's Disease Starter Kit + Humira Kit + Humira Psoriasis Starter Kit + Onsolis (11/1/09) + Sabril + Sabril powder + Saphris + Tyvaso + Ventavis

SPP	Brands for Generic	Rx InStep
+ Extavia + Invega Sustenna	+ Relion Test Strips	- Humira Crohn's Disease Starter Kit - Humira Kit - Humira Psoriasis Starter Kit - Enbrel

DACON	DACON (effective 2/1/10)
+ Adcirca + Adoxa Pak + Doryx 150mg + Fibricor + Keppra XR + Oracea Δ Revatio + Sabril + Sabril powder + Saphris + Solodyn + Tyvaso + Ventavis + Zemplar	+ APAP/Codeine + Ascomp/Codeine + Balacet 325 + Capital/Codeine + Co-Gesic + Combunox + Darvocet A500 + Darvocet N-100 + Darvocet N-50 + Dolorex Forte + Endocet + Endodan + Fioricet/Codeine + Fiorinal/Codeine + Hycet + Lorcet + Lorcet Plus	+ Lortab + Lortab 2.5 + Lortab 5 + Magnacet + Margesic-H + Maxidone + Norco + Oxycod/APAP + Percocet + Percodan + Perloxx + Phrenilin + Propoxyphene/APAP + Reprexain + Roxicet + Stagesic + Talacen	+ Talwin NX + Tylenol/Codeine #3 + Tylenol/Codeine #4 + Tylox + Ultracet + Ultram + Ultram ER + Vanacet + Vicodin + Vicodin ES + Vicodin HP + Vicoprofen + Vopac + Xodol + Zamicet + Zydone