September 2019

Tier Changes

Brand Name Strength Common Use Tier Change Clinical Edits Prescription Drug List Tier
Standard Formulary Value Formulary Performance Formulary Advantage Formulary Legacy Formulary
ADVAIR DISKUS  100-50, 250-50, 500-50 MCG Asthma NEGATIVE ST DRT DRT DRT DRT 3
NORDITROPIN   Growth hormone deficiency syndromes POSITIVE PA 2 2 2 2 2
SIMPONI  50, 100 MG/ML Inflammatory conditions (rheumatoid arthritis, ankylosing spondylistis, psoriatic arthritis, ulcerative colitis) POSITIVE PA 3 3 3 3 3
TREMFYA  100 MG/ML Psoriasis POSITIVE PA 2 2 2 2 2
XELJANZ  5, 10 MG Inflammatory conditions (rheumatoid arthritis, psoriatic arthritis, ulcerative colitis) POSITIVE PA 2 2 2 2 2
XELJANZ XR  11 MG Inflammatory conditions (rheumatoid arthritis, psoriatic arthritis, ulcerative colitis) POSITIVE PA 2 2 2 2 2

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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