HMO and PPO Updates January 2014 - Commercial Results Triple Tier Formular y 4th Tier Applicable Traditiona l Authorizatio n Detailed s FABIOR FOAM 3 2 Yes BETHKIS 3 Yes 2 Yes Yes IMBRUVICA 3 Yes 2 Yes Yes 224 ml per 56 days 4 capsules per day FETZIMA 3 2 Yes Alternatives clindamycin phos/benzoyl peroxide, benzoyl peroxide microspheres, benzoyl peroxide & skin cleanser, benzoyl peroxide, salicylic acid, sulfacetamide sodium, tretinoin, erythromycin, adapalene Tobi Inhalation Solution*, Tobi Podhaler*, tobramycin inhalation solution* Revlimid* amitriptyline, amoxapine, bupropion, citalopram, clomipramine, desipramine, doxepin, duloxetine, escitalopram, fluoxetine, fluvoxamine, imipramine, maprotiline, mirtazapine, nefazodone, nortriptyline, paroxetine, sertraline, trazodone, venlafaxine STELARA SELF INJECTABLE 3 Yes 2 Yes Humira*, Enbrel* SUCRAID 3 Yes 2 Yes Yes One box per fill ne MIRVASO 3 2 Yes Yes One 30 gram tube per fill metronidazole cream/gel
HMO and PPO Updates January 2014 - Commercial Results Triple Tier Formular y 4th Tier Applicable Traditiona l Tazorac 3 2 Authorizatio n Yes, New Starts Only Detailed s VALCHLOR 3 Yes 2 Yes Alternatives lindamycin phos/benzoyl peroxide, benzoyl peroxide microspheres, benzoyl peroxide & skin cleanser, benzoyl peroxide, salicylic acid, sulfacetamide sodium, tretinoin, erythromycin, adapalene imiquimod, generic corticosteroids, Targretin 1% Gel*
CHIP Updates January 2014 - CHIP Results Tier Detailed s Alternatives FABIOR FOAM 2 Yes clindamycin phos/benzoyl peroxide, benzoyl peroxide microspheres, benzoyl peroxide & skin cleanser, benzoyl peroxide, salicylic acid, sulfacetamide sodium, tretinoin, erythromycin, adapalene BETHKIS 2 Yes Yes IMBRUVICA 2 Yes Yes 224 ml per 56 days 4 capsules per day Tobi Inhalation Solution*, Tobi Podhaler*, tobramycin inhalation solution* Revlimid* FETZIMA 2 Yes amitriptyline, amoxapine, bupropion, citalopram, clomipramine, desipramine, doxepin, duloxetine, escitalopram, fluoxetine, fluvoxamine, imipramine, maprotiline, mirtazapine, nefazodone, nortriptyline, paroxetine, sertraline, trazodone, venlafaxine STELARA *NEW INDICATION* 2 Yes Humira*, Enbrel* SUCRAID 2 Yes Yes One box per fill ne MIRVASO 2 Yes Yes One 30 gram tube per fill metronidazole cream/gel
CHIP Updates January 2014 - CHIP Results Tier Tazorac 2 Yes, New Starts Only Detailed s VALCHLOR 2 Yes Alternatives clindamycin phos/benzoyl peroxide, benzoyl peroxide microspheres, benzoyl peroxide & skin cleanser, benzoyl peroxide, salicylic acid, sulfacetamide sodium, tretinoin, erythromycin, adapalene imiquimod, generic corticosteroids, Targretin 1% Gel*
GHP Family Updates January 2014- GHP Family Results GHP Family Tier BETHKIS n n Yes Yes FABIOR FOAM n n Yes Quantit y Detailed s 224 ml per 56 days Alternative(s) Tobi inhalation solution*, Tobramycin inhalation solution* benzoyl peroxide, salicylic acid, clindamycin, clindamycin/benzoyl peroxide, erythromycin, erythromycin/benzoyl peroxide, sulfacetamide, tretinoin FETZIMA n n Yes 4 capsules per IMBRUVICA Brand Yes Yes day (1) 30 gram MIRVASO n n Yes Yes tube per fill SUCRAID n n Yes Yes 1 box per fill VALCHLOR n n Yes amoxapine, amitriptyline, bupropion, bupropion SR, bupropion XL, citalopram, desipramine, doxepin, duloxetine, escitalopram, fluoxetine, imipramine, mirtazapine, nortriptyline, paroxetine, paroxetine, ER, sertraline, venlafaxine, venlafaxine ER Revlimid metronidazole 0.75% cream, metronidazole 1% gel imiquimod, generic topical corticosteroids
GHP Family Updates January 2014- GHP Family Results GHP Family Tier Quantit y Detailed s Alternative(s) ADVAIR Yes - effective 3/3/2014 Dulera, Breo Ellipta ABILIFY (oral) Yes - effective 3/3/2014 Yes Tablets - 1 tablet per day, each strength clozapine, olanzapine, Solution - 900 quetiapine IR, risperidone, ml per 30 days ziprasidone STELARA (selfinjectable) Brand Yes Humira*, Enbrel*
Part D (GOLD) Updates January 2014 - Part D (Gold) Results BETHKIS FABIOR FOAM $0 Deductible Brand n Preferred Brand n Preferred Standard coinsurance Detailed s Alternative(s) TOBRAMYCIN INHALATION SOLUTION, TOBI INHALATION SOLUTION, TOBI PODHALER CLINDAMYCIN PHOS/BENZOYL PEROXIDE, CLINDAMYCIN PHOSPHATE, ERYTHROMYCIN/BENZOYL PEROXIDE, ADAPALENE, TRETINOIN, TAZORAC FETZIMA Brand n Preferred IMBRUVICA Speciality MIRVASO n VALCHLOR Speciality Yes CAPSULES/30 DAYS INCLUDING BUT NOT LIMITED TO: AMITRIPTYLINE, AMOXAPINE, BUPROPION, CITALOPRAM, DESIPRAMINE, DOXEPIN, DULOXETINE, ESCITALOPRAM, FLUOXETINE, FLUVOXAMINE, IMIPRAMINE, MAPROTILINE, MIRTAZAPINE, NEFAZODONE, NORTRIPTYLINE, PAROXETINE, SERTRALINE, VENLAFAXINE REVLIMID METRONIDAZOLE 0.75% CREAM, METRONIDAZOLE 1% GEL, METROGEL 1% IMIQUIMOD, GENERIC TOPICAL CORTICOSTEROIDS, TARGRETIN 1% GEL