Formulary Updates

We are continuously reviewing new drug products as they become available in the marketplace and updating our formulary. The following drug products were reviewed and acted upon by the CDPHP Pharmacy and Therapeutics Committee on April 10, 2013. Review the full CDPHP Clinical Formulary, which includes tier status, prior authorization requirements and quantity limits for select drugs.

Also see Medicare RX.

You can review the archives as well.

Legend

• PA Prior Authorization required
• # Excluded for new starts only
• QL Quantity limit of # 12 tablets per 30 days (cumulative by class)

Drug	New Tier / Formulary Status	Previous Tier / Formulary Status
atorvastatin tablets (generic for Lipitor)	1	2
Axiron topical solution (testosterone)	3, #	3
Cometriq capsules (cabozantinib)	3, PA	New to Market
Eliquis tablets (apixaban)	3	New to Market
Fortesta topical gel (testosterone)	3, #	3
Fulyzaq tablets (crofelemer)	3, PA	New to Market
Gattex injection (teduglutide)	3, PA	New to Market
Jetrea injection (ocriplasmin)	Medical Benefit	New to Market
Juxtapid capsules (lomitapide)	3, PA	New to Market
Kynamro injection (mipomersen)	3, PA	New to Market
Picato external gel (ingenol)	3, PA	New to Market
Provenge intravenous suspension (sipuleucel-T)	Medical Benefit, PA	Not covered
rizatriptan benzoate tablets (generic for Maxalt)	1, QL	2, QL
Singulair chewable tablets, oral tablets, packets (montelukast)	Excluded	3, excluded for new starts only

The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with CDPHP. These trademarked brand names are included here for informational purposes only and are not intended to imply or suggest any affiliation between CDPHP and such third-party pharmaceutical companies.