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. |
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► NEW
DRUGS
Review of new drugs recently
introduced to the market or
approved by the FDA. |
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Standard Plan
Tier 1 = all generics
Tier 2 = all brands
(OR Tier 1 = all medications)
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Select Plan
Tier 1 = all generics
Tier 2 = preferred brands
Tier 3 = nonpref. brands
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Closed Plan
Tier 1 = all generics
Tier 2 = preferred brands
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Caldolor (ibuprofen) Injection |
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An NSAID for intravenous use indicated in adults for the management of mild to moderate pain,management of moderate to severe pain as an adjunct to opioid analgesics, and for the reduction of fever.
Added to the Specialty Pharmacy Program (SPP).
- Quantity Limit applies
- Specialty Pharmacy Program
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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. |
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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. |
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Not covered. |
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Folotyn (pralatrexate injection for i.v.) |
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A folate analogue metabolic inhibitor used for the treatment of patients with relapsed or refractory peripheral T-cell lymphoma (PTCL).
Added to the Specialty Pharmacy Program (SPP).
- Specialty Pharmacy Program
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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. |
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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. |
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Not covered. |
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Intuniv (guanfacine) Extended Release Tablets |
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A selective alpha2A-adrenergic receptor agonist indicated for the treatment of Attention Deficit Hyperactivity Disorder (ADHD).
- DACON edit applies
- In a limited category
(ADHD)
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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Samsca (tolvaptan) |
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A selective vasopressin V2-receptor antagonist used for the treatment of clinically significant hypervolemic and euvolemic hyponatremia or less marked hyponatremia that is symptomatic and has resisted correction with fluid restriction, including patients with heart failure, cirrhosis, and Syndrome of Inappropriate Antidiuretic Hormone (SIADH).
- Prior Authorization applies
- DACON edit applies
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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Stelara (ustekinumab) Injection for subcutaneous use |
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For the treatment of adult patients (18 years or older) with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. Stelara is not self-injectable.
Added to the Specialty Pharmacy Program (SPP).
- Prior Authorization applies
- Quantity Limit applies
- Specialty Pharmacy Program
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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. |
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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. |
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Not covered. |
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Ulesfia (benzyl alcohol) Lotion |
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A pediculocide used in the topical treatment of head lice infestation in patients 6 months of age and older.
Nonpreferred status,
effective January 1, 2010.
- In a limited category
(pediculocides/scabicides)
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Brand copay. |
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Third tier,
nonpreferred brand copay. |
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Not covered. |
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► 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.) |
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Standard Plan
Tier 1 = all generics
Tier 2 = all brands
(OR Tier 1 = all medications) |
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Select Plan
Tier 1 = all generics
Tier 2 = preferred brands
Tier 3 = nonpref. brands
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Closed Plan
Tier 1 = all generics
Tier 2 = preferred brands
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Colcrys (colchicine USP) Tablets |
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Indicated for the treatment of gout flares and for Familial Mediterranean fever (FMF) in adults and children 4 years or older.
PLEASE NOTE: Colcrys is the only FDA approved colchicine product. Generic colchicine tablets, which have been available for several years, do not have FDA approval and will no longer be manufactured.
- DACON edit applies
- Not in a limited category
(Gout Agents)
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Second tier,
preferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Second tier,
preferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Terbinex kit (terbinafine hcl tablets and hydroxypropyl chitosan 1.0% solution) |
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Used in treatment of onychomycosis, a fungal infection of the of the toenail or fingernail.
- Optional Prior Authorization may apply (edits applied at market introduction September 26, 2009)
- In a limited non-standard category
(oral antifungals for treatment of onychomycosis)
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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Valturna (aliskiren/valsartan) |
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A combination of aliskiren (Tekturna), a direct renin inhibitor, and valsartan (Diovan), an angiotensin II receptor blocker (ARB), used in the treatment of hypertension.
- DACON edit applies
- In a limited category
(blood pressure--combination)
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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► GENERIC ALTERNATIVES
Review of products with FDA approved generic equivalents. |
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Standard Plan
Tier 1 = all generics
Tier 2 = all brands
(OR Tier 1 = all medications) |
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Select Plan
Tier 1 = all generics
Tier 2 = preferred brands
Tier 3 = nonpref. brands
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Closed Plan
Tier 1 = all generics
Tier 2 = preferred brands
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Elixophyllin 80 (theophylline elixir) |
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Used in the treatment of asthma and chronic obstructive pulmonary disease (COPD).
Moving to nonpreferred status due to the availability of equivalent product, theophylline elixir, at the generic copay.
- In a limited category
(Asthma-COPD)
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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Ocufen (flurbiprofen ophthalmic solution) |
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A topically applied NSAID used for the treatment of post-operative ocular inflammation.
Moving to nonpreferred status due to availability of a generic equivalent flurbiprofen ophthalmic solution.
- Quantity Limit applies
- In a limited category
(Ophthalmic-NSAIDS)
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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Ocuflox (ofloxacin ophthalmic solution) |
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A a topically applied fluoroquinolone antibiotic used in the treatment of bacterial infections of the eye.
Moving to nonpreferred status due to availability of a generic equivalent, ofloxacin ophthalmic solution.
- Quantity Limit applies
- In a limited category
(ophthalmic antibiotics)
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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Procentra (dextroamphetamine sulfate oral solution) |
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Used in the treatment of ADHD and narcolepsy.
Moving to nonpreferred status due to availability of equivalent product, Liquadd, at the generic copay.
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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► DRUG
CLASS REVIEW:
Proton Pump Inhibitors
Comprehensive review of medications in a therapeutic category. |
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Standard Plan
Tier 1 = all generics
Tier 2 = all brands
(OR Tier 1 = all medications) |
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Select Plan
Tier 1 = all generics
Tier 2 = preferred brands
Tier 3 = nonpref. brands
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Closed Plan
Tier 1 = all generics
Tier 2 = preferred brands
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Review of Proton Pump Inhibitors in the category of Gastrointestinal Agents-Anti-ulcer.
SPECIAL NOTE: Lansoprazole delayed release capsules, an FDA approved AB rated generic equivalent for Prevacid 15mg and 30mg capsules was released the week of November 9, 2010. Lansoprazole is available at the generic copay and Prevacid will be moved to non-preferred status, effective 2/1/2010. Prevacid 24HR was launched to the OTC market in mid-November. The OTC product is not covered through Innoviant's pharmacy benefit. |
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lansoprazole, omeprazole, pantoprazole |
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- Listed products are available at generic copay.
- DACON edit applies (edits added or revised for consistency within therapeutic category)
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Generic copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Generic copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Generic copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Kapidex. Nexium |
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- Kapidex added to preferred status.
- Nexium remains at preferred status.
- DACON edit applies (edits added or revised for consistency within therapeutic category)
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Second tier,
preferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Second tier,
preferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Aciphex, Prevacid, Prilosec, Protonix |
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- Prevacid removed from
preferred status.
- Aciphex, Prilosec, and Protonix remain at non-preferred status.
- DACON edit applies (edits added or revised for consistency within therapeutic category)
- Step Therapy applies for
Rx InStep participants
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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►
CLINICAL PROGRAMS
Review of medications for inclusion in DACON, prior authorization, quantity limits, specialty pharmacy, step therapy or other clinical programs. |
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Standard Plan
Tier 1 = all generics
Tier 2 = all brands
(OR Tier 1 = all medications) |
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Select Plan
Tier 1 = all generics
Tier 2 = preferred brands
Tier 3 = nonpref. brands
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Closed Plan
Tier 1 = all generics
Tier 2 = preferred brands
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DACON: colchicine, fenofibrate, fenobibrate micronized, fenofibric acid, gemfibrozil, mesalamine kit, Trezix |
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Listed items added to the DACON program effective February 1, 2010. |
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Generic copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Generic copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Generic copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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DACON: Apriso, Asacol, Asacol HD, Canasa, Lialda, Pentasa, Renvela (tab and Pak), Colcrys, Antara, Lofibra, Tricor, Trilipex |
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Listed items added to the DACON program effective February 1, 2010. |
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Second tier,
preferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Second tier,
preferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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DACON: Ventavis, Fenoglide, Fibricor, Lipofen, Lopid, Triglide, Intuniv, Panlor DC, Panlor SS, Rowasa Kit, Samsca, Valturna |
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Listed items added to the DACON program effective February 1, 2010.
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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DACON: Provigil 200mg |
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The DACON edit decreases from two tablets daily to one tablet daily, effective February 1, 2010.
The maximum approved dose for Provigil is 400mg daily, however there is no evidence that 400mg daily is more effective than 200mg daily. DACON edit override and Prior Authorization for doses over 200mg daily will now require documented trial and failure of the 200mg dose. The current DACON edit for Provigil 100mg is one tablet daily, which will remain unchanged.
- DACON edit applies
- Prior Authorization applies
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Second tier,
preferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Second tier,
preferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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DACON: ADHD Agents |
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A utilization management review for ADHD medications at November meetings resulted in a decision to add all agents in the therapeutic category to the DACON program, effective April 1, 2010. A complete list of medications affected by this change will be provided in a future issue of Pharmacy Passages. |
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PRIOR AUTHORIZATION: Samsca, Stelara (SPP only) |
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Listed items will be added to the Prior Authorization Program, effective February 1, 2010. See New Drug Review for more detailed information on these products.
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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QUANTITY LIMITS: mesalamine kit, diclofenac ophthalmic solution, flurbiprofen ophthalmic solution,
ciprofloxacin ophthalmic solution, ofloxacin ophthalmic drops |
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Listed items will be added to the Quantity Limits program or have revisions to the current quantity limit already in place, effective February 1, 2010.
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Generic copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Generic copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Generic copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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QUANTITY LIMITS: Copaxone, Rebif, Rebif Titration Pack, Helidac, Prevpac, Pylera, Retin A Micro Pump,
Alphagan P, Acular, Acular LS, Nevanac, Xibrom, Ciloxan ophthalmic ointment, Vigamox, Acanya |
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Listed items will be added to the Quantity Limits program or have revisions to the current quantity limit already in place, effective February 1, 2010.
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Second tier,
preferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Second tier,
preferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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QUANTITY LIMITS: Betaseron, Extavia, Ocufen, Voltaren ophthalmic solution, Besivance,
Ciloxan ophthalmic solution, Iquix, Ocuflox, Quixin, Zymar, Rowasa Kit |
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Listed items will be added to the Quantity Limits program or have revisions to the current quantity limit already in place, effective February 1, 2010.
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Brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Third tier,
nonpreferred brand copay.
Coverage is determined
by the plan sponsor's
chosen benefit design. |
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Not covered. |
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SPECIALTY PHARMACY PROGRAM: Caldolor, Folotyn, Stelara |
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Listed Item added to Specialty Pharmacy Program at nonpreferred status. See New Drug Review for more information on these products.
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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. |
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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. |
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Not covered. |
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