June 2019

Brand Drug Additions

Brand Name

Strength

Common Use

Clinical Edits

PDL Tier

Standard Formulary

Value Formulary

Performance Formulary

Advantage Formulary

Legacy Formulary

AFREZZA

8 UNIT(90)

Diabetes

PA

NC

NC

NC

NC

3

DIVIGEL

0.75/0.75G

Menopause symptoms

 

2

3

2

3

2

PROMACTA

12.5 MG

Hematologic disorders

PA

3

3

3

3

3

TIROSINT-SOL

13, 25, 50, 75, 88, 100, 112, 125, 137, 150, 175, 200 MCG/ML

Thyroid replacement

 

3

3

3

3

3

TREMFYA

100 MG/ML

Psoriasis

PA

3

3

3

3

3

AIMOVIG

70, 140 MG/ML

Migraine

PA 

2

2

2

2

2

BALVERSA

3, 4, 5 MG

Bladder cancer

PA

3

3

3

3

3

CABLIVI

11 MG

Hematologic disorders

PA

3

3

3

3

3

DEXCOM G6 SENSOR

 

Diabetes

PA, QL

2

2

2

2

2

DIACOMIT

250, 500 MG

Seizure disorders

 

3

3

3

3

3

DOVATO

50MG-300MG

HIV/AIDS

 

3

3

3

3

3

DXEVO

1.5 MG

Inflammatory conditions

 

NC

NC

NC

NC

3

FREESTYLE LIBRE 10 DAY SENSOR

 

Diabetes

PA, QL

2

2

2

2

2

FREESTYLE LIBRE 14 DAY SENSOR

 

Diabetes

PA, QL

2

2

2

2

2

INGREZZA INITIATION PACK

40 MG-80MG

Movement disorders

PA

3

3

3

3

3

LOTEMAX SM

0.0038%

Ocular pain and inflammation

 

2

3

2

3

2

MAVENCLAD

10 MG

Multiple sclerosis

PA

3

3

3

3

3

MAYZENT

0.25, 2 MG

Multiple sclerosis

PA

3

3

3

3

3

NIVESTYM

300, 480 MCG

Neutropenia (low white blood cells)

PA

3

3

3

3

3

PROGRAF

0.2, 1 MG

Prevent organ rejection after transplant

 

3

3

3

3

3

QMIIZ ODT

7.5, 15 MG

Rheumatoid artrtitis, osetoarthritis

ST

3

3

3

3

3

SKYRIZI

75MG/0.83

Psoriasis

PA

3

3

3

3

3

TUXARIN ER

8MG-54.3MG

Cough suppressant

QL

3

3

3

3

3

QMIIZ ODT

15 MG

NSAIDS, Cyclooxygenase inhibitor – type analgesics

ST

3

3

3

3

3

SKYRIZI

75MG/0.83

Antipsoriatic agents, systemic

PA

3

3

3

3

3

TUXARIN ER

8MG-54.3MG

Opioid antitussive – 1st generation antihistamine

QL

3

3

3

3

3

PA: Prior authorization
QL: Quantity limit
ST: Step therapy
T1/Tier 1: Generic
T2/Tier 2: Brand
T3/Tier 3: Non-preferred
NC: Not covered: This drug is not covered. However, if the covered alternative is not appropriate for the customer, there is a process where his/her provider can request approval of this drug.

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