July 2015 P & T Updates
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- Willis Blankenship
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1 Commercial Triple Tier 4th Tier Applicable Traditional CORLANOR tablets per day GLYXAMBI tablet per day Alternatives carvedilol, bisoprolol, metoprolol succinate, digoxin, hydralazine, isosorbide dinitrate, bumetanide, torsemide, enalapril, captopril, fosinopril, lisinopril, losartan, irbesartan, valsartan acarbose, metformin, nateglinide, pioglitazone, repaglinide, glimepiride, glipizide, glipizide/metformin, glyburide, glyburide/metformin, Janumet, Januvia*, Jardiance* (effective 10/1/15) 3 2 MOVANTIK tablet per day polyethylene glycol 3350, lactulose, metoclopramide, Amitiza VIEKIRA PAK capsule per day 2 cartridges per 28 days none pramipexole, ropinirole, ropinirole ER, bromocriptine, selegiline, amantadine, benztropine, trihexyphenidyl, Azilect
2 CHIP Tier July 2015 P & T Updates CORLANOR 2 2 tablets per day - GLYXAMBI 2 1 tablet per day (effective 10/1/15) - 2 MOVANTIK 2 1 tablet per day VIEKIRA PAK - 1 capsule per day Alternatives carvedilol, bisoprolol, metoprolol succinate, digoxin, hydralazine, isosorbide dinitrate, bumetanide, torsemide, enalapril, captopril, fosinopril, lisinopril, losartan, irbesartan, valsartan acarbose, metformin, nateglinide, pioglitazone, repaglinide, glimepiride, glipizide, glipizide/metformin, glyburide, glyburide/metformin, Janumet, Januvia*, Jardiance* polyethylene glycol 3350, lactulose, metoclopramide, Amitiza - 2 cartridges per 28 days none - 2 pramipexole, ropinirole, ropinirole ER, bromocriptine, selegiline, amantadine, benztropine, trihexyphenidyl, Azilect
3 GHP Family CORLANOR GHP Family Tier 2 tablets daily Alternative(s) carvedilol, bisoprolol, metoprolol, digoxin, hydralazine, isosorbide, bumetanide, torsemide, enalapril, captopril, fosinopril, lisinopril, candesartan, losartan One injection (150 mg or 300 mg) every 4 weeks, Stelara* GLYXAMBI (effective 10/1/15) MOVANTIK w/pa 1 tablet daily metformin, glyburide, glipizide, glipizide sustained-release, glimepiride, acarbose, repaglinide, Januvia*, pioglitazone, Lantus, vo rdisk insulins: volin N, volin R, volin 70/30, volog, volog 70/30 Tanzeum*, Victoza*, Jardiance* 1 tablet daily Viekira Pak Brand 2 packets per day 1 tablet daily 1 capsule daily 2 cartridges every 28 days bisacodyl, calcium polycarbophil, docusate, magnesium citrate, milk of magnesia, psyllium, sennosides/docusate, polyethylene glycol, lactulose, metoclopramide donepezil (5 mg, 10 mg), rivastigmine, Namenda amantadine, benztropine, bromocriptine, pramipexole, ropinirole, selegiline, trihexyphenidyl VIEKIRA PAK w/ PA Brand 112 tablets every 28 days
4 Geisinger Gold $0 Deductible Standard Alternative(s) AVYCAZ Sulfamethoxazole/trimethoprim, ampicillin/sulbactam, aztreonam, cefadroxil, cefazolin, cefepime, cefotaxime, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, ciprofloxacin, gentamicin, imipenem/cilastatin, levofloxacin, meropenem, Zerbaxa CORLANOR GLYXAMBI MOVANTIK Brand Brand Brand Specialty SIGNIFOR LAR Specialty VIEKIRA PAK Specialty 2 tablets per day 150 mg every 4 weeks: 1 syringe every 28 days; 300 mg every 4 weeks: 2 syringes every 28 days 1 tablet per day 1 tablet per day 1 capsule per day 2 cartridges per 28 days 1 kit per 28 days carvedilol, digoxin, furosemide, bumetanide, enalapril, fosinopril, lisinopril, losartan, bisoprolol, metoprolol succinate, hydralazine, isosorbide dinitrate, spironolactone, torsemide, captopril, candesartan, valsartan, Otezla*, Remicade*, Stelara* (* authorization metformin, glipizide, glipizide sustained-release, glimepiride, acarbose, Glyset, repaglinide, nateglinide, Januvia, Janumet, pioglitazone, Bydureon, Lantus, Victoza, Jardiance*, volin, volog Polyethylene glycol 3350, lactulose, Amitiza, Relistor* (* authorization donepezil,, Namenda amantadine, bromocriptine, carbidopa, carbidopa/levodopa ODT, carbidopa/levodopa tablet, carbidopa/levodopa ER tablet, carbdiopa/levodopa/entacapone, pramipexole, ropinirole, ropinirole ER, selegiline, tolcapone, Azilect octreotide, cabergoline, bromocriptine, Somatuline depot* Somavert (* authorization
5 Marketplace Tier July 2015 P & T Updates CORLANOR Specialty 2 tablets per day - GLYXAMBI Specialty 1 tablet per day (effective 10/1/15) - Specialty MOVANTIK Specialty 1 tablet per day - 1 capsule per day Alternatives carvedilol, bisoprolol, metoprolol succinate, digoxin, hydralazine, isosorbide dinitrate, spironolactone, furosemide, bumetanide, torsemide, enalapril, captopril, fosinopril, lisinopril, losartan, irbesartan, valsartan acarbose, metformin, nateglinide, pioglitazone, repaglinide, glimepiride, glipizide, glipizide/metformin, glyburide, glyburide/metformin, Janumet, Januvia*, Jardiance* polyethylene glycol 3350, lactulose, metoclopramide, Amitiza - 2 cartridges per 28 days none - VIEKIRA PAK 3 carbidopa/levodopa/entacapon e, pramipexole, ropinirole, ropinirole ER, bromocriptine, selegiline, amantadine, benztropine, trihexyphenidyl, Azilect
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