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Pharmacy and Therapeutics Committee Decisions
March 19, 2010
Drug/Therapeutic Class
P&T Decision
Bepreve® (bepotastine besilate ophthalmic solution) • Non-formulary
Medications
– Treatment of Allergic Conjunctivitis
Effient®
(prasugrel) – Platelet Aggregation Inhibitor • Formulary
Multaq®
(dronedarone) – Treatment of Arrhythmias • Non-formulary
Sabril® (vigabatrin) – Treatment of Seizures and
Formulary with Prior
Authorization
Samsca® (tolvaptan) – Treatment of Hyponatremia
Formulary with Prior
Authorization
Votrient® (pazopanib) – Treatment of Renal Cell
Formulary with Prior
Authorization
Therapeutic
Acne Vulgaris
Formulary: benzoyl peroxide,
Acanya® (benzoyl peroxide/clindamycin), Aczone® (dapsone), Avita® (tretinoin), Azelex® (azelaic peroxide/erythromycin), benzoyl peroxide, benzoyl peroxide/erythromycin, clindamycin topical, • Non-formulary: Acanya, Aczone,
peroxide/clindamycin), Epiduo® (adapalene/benzoyl peroxide), erythromycin topical, Retin-A® Micro (tretinoin), sulfacetamide, Tazorac® (tazarotene), tretinoin, Ziana® (clindamycin/tretinoin) Gel, Duac, Epiduo, Retin-A Micro, Tazorac, Ziana Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
Non-formulary: Janumet, Januvia,
Janumet® (sitagliptin phosphate/metformin), Januvia® (sitagliptin phosphate), Onglyza®
(saxagliptin)
Central Nervous System Stimulants
Formulary: amphetamine/
amphetamine/dextroamphetamine, amphetamine/ (methylphenidate ER), Daytrana® (methylphenidate dextroamphetamine, dextroamphetamine SR, Focalin® XR (dexmethylphenidate ER), Intuniv® (guanfacine ER), Metadate® CD (methylphenidate ER), Metadate® ER (methylphenidate ER), • Non-formulary: Daytrana,
methamphetamine, Methylin® (methylphenidate), methylphenidate, methylphenidate ER, Ritalin® LA (methylphenidate SR), Strattera® (atomoxetine), 720 Olive Way, Suite 300 Seattle WA 98101 | www.chpw.org | 1.800.440.1561 | 206.521.8833 Drug/Therapeutic Class
P&T Decision
Vyvanse® (lisdexamfetamine)
Fibromyalgia Agents
Formulary: Cymbalta (prior auth)
Cymbalta® (duloxetine), Lyrica® (pregabalin), • Non-formulary: Lyrica, Savella
Savella® (milnacipran)
Pulmonary Arterial Hypertension
Formulary: Adcirca (prior auth),
Adcirca® (tadalafil), Letairis® (ambrisentan), Revatio® (sildenafil citrate), Tracleer® (bosentan), Tyvaso® (treprostinil inhalation), Ventavis® • Non-formulary: Tyvaso, Ventavis
(iloprost inhalation)
Atypical Antipsychotics
Formulary: Abilify (step therapy 2nd
Abilify®/Abilify® Discmelt/Abilify® Solution (aripiprazole), Fanapt® (iloperidone), Geodon®
(ziprasidone), Invega® (paliperidone), risperidone, risperidone orally disintegrating, risperidone solution , Saphris® (asenapine), Seroquel® (quetiapine), Seroquel® XR (quetiapine extended- release), Symbyax® (olanzapine/fluoxetine), • Non-formulary: Abilify Discmelt,
Abilify Solution, Fanapt, Geodon, Invega, Saphris, Symbyax, Zyprexa Zydis Bowel Evacuants
Formulary: NuLytely, Nulytely
Colyte® with Flavor Packets, GoLytely®, Half- Lytely-Bisacodyl® with Flavor Packs, MoviPrep®, • Non-formulary: Colyte with Flavor
NuLytely®, Nulytely® with Flavor Packs, PEG- Bisacodyl with Flavor Packs, MoviPrep, TriLyte with Flavor Packs Leukotriene Pathway Inhibitors
Formulary: Singulair (step therapy)
Accolate® (zafirlukast), Singulair® (montelukast), • Non-formulary: Accolate, Zyflo CR
Zyflo® CR (zileuton extended-release)
Oral Hepatitis B Agents
Formulary: Baraclude, Epivir HBV,
Baraclude® (entecavir), Epivir® HBV (lamivudine), Hepsera® (adefovir dipivoxil), Tyzeka® • Non-formulary: Hepsera, Tyzeka
(telbivudine), Viread® (tenofovir)
Macrolide/Ketolide Antibiotics
Formulary: azithromycin,
azithromycin, clarithromycin, clarithromycin ER, erythromycin, Ketek®, PCE® Dispertab, Zmax® • Non-formulary: clarithromycin ER,
Multiple Sclerosis Drugs
Formulary: Avonex, Betaseron,
Avonex® (interferon beta-1a [IM]), Betaseron® (interferon beta-1b), Copaxone® (glatiramer
acetate), Extavia® (interferon beta-1b), Rebif®
(interferon beta-1a [SC])
Nasal Steroids
Formulary: fluticasone propionate
Beconase® AQ (beclomethasone), flunisolide, • Non-formulary: Beconase AQ,
(mometasone), Omnaris® (ciclesonide), Rhinocort® Aqua (budesonide), Veramyst® (fluticasone furoate) Copayment/Coinsurance for all pharmaceuticals & pharmaceutical classes above:
• Healthy Options, Basic Health Plus, Children’s Health Insurance Program, & General Assistance Unemployable = $0 • Basic Health Plan = $10 copay for formulary generic products; 50% coinsurance for formulary brand products 720 Olive Way, Suite 300 Seattle WA 98101 | www.chpw.org | 1.800.440.1561 | 206.521.8833
Prior Authorization Criteria for:
Abilify = trial of Seroquel or Seroquel XR first (step therapy; 2nd step); treatment of major depressive
disorder after trial of three antidepressants; treatment of irritability with autistic disorder after trial of risperidone or clinical concerns regarding use of risperidone first • Adcirca = FDA-approved indications and not currently taking nitrates
Cymbalta = Trial of a tricyclic antidepressant, gabapentin and an SSRI first for treatment of
fibromyalgia; trial of 2 formulary SSRIs and Effexor XR or 1 formulary SSRI and venlafaxine IR for treatment of depression; trial of gabapentin for the treatment of diabetic peripheral neuropathy • Letairis = FDA-approved indications after trial of Adcirca or Revatio first (step therapy) unless
contraindication to Adcirca or Revatio; diagnosis of World Health Organization (WHO) class IV symptoms • Revatio = FDA-approved indications and not currently taking nitrates
Sabril = Treatment of refractory complex seizures after trial of ≥ 4 other antiepileptic drugs and infantile
Samsca = FDA-approved indications
Seroquel/Seroquel XR = trial of risperidone first (step therapy; 1st step) in patients < 65 years of age;
treatment of major depressive disorder after trial of three antidepressants; bipolar depression or depressive episodes associated with bipolar disorder • Singulair = Covered for patients < 12 years of age; for non-asthmatic patients ≥ 12 years of age trial of
non-sedating antihistamine and nasal steroid first (step therapy); for asthmatic patients ≥ 12 years of age trial with an inhaled corticosteroid first (step therapy); interstitial cystitis if the patient has tried two alternative therapies for this condition • Tracleer = FDA-approved indications after trial of Adcirca or Revatio first (step therapy) unless
contraindication to Adcirca or Revatio; diagnosis of World Health Organization (WHO) class IV symptoms • Votrient = FDA-approved indications
Zyprexa = trial of Seroquel or Seroquel XR first (step therapy; 2nd step)
720 Olive Way, Suite 300 Seattle WA 98101 | www.chpw.org | 1.800.440.1561 | 206.521.8833

Source: http://www.chpw.org/assets/file/PTDecisions.pdf

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