Download - Kentucky Pharmacy and Therapeutics Committee meeting minutes · Testosterone cypionate injection, Testosterone enanthate injection . COMPARATOR PRODUCTS : (BRAND ONLY PRODUCTS) Androderm

Anthem BlueCross BlueShield Medicaid Kentucky Pharmacy and Therapeutics Committee meeting minutes

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Kentucky Pharmacy and Therapeutics Committee meeting minutes

December 16, 2015, 1 p.m. Attendees: Andrew Rudd, PharmD Robert Dinwiddie, PharmD Peter Thurman, MD

Ivy Sams, RN, BSN, CCM Setifah Jordan, PharmD Stephen Broudy, PharmD

David Crowley

1. Phosphate binders Review date 3Q15 Clinical review: Phosphate binders Reason for review: Category review PRODUCTS INCLUDED IN THE REVIEW: Renagel (sevelamer HCL tablets), Renvela (sevelamer carbonate), Fosrenol (lanthanum carbonate chewable tablet), Phoslyra (calcium acetate oral solution), Velphoro (sucroferric oxyhydroxide) and Auryxia (ferric citrate) COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Fosrenol, Renagel, Calcium Acetate (generic) and Eliphos RECOMMENDATION:

• Fosrenol, Renagel will move from preferred to nonpreferred • Velphoro will move from nonpreferred to preferred

2. Topical immunomodulators

Review date 3Q15 Clinical review: Topical immunomodulators Reason for review: Category review PRODUCTS INCLUDED IN THE REVIEW: Elidel (pimecrolimus cream) COMPARATOR PRODUCTS: generic Protopic and topical corticosteroids for atopic dermatitis CURRENT PREFERRED PRODUCTS: Elidel cream, Tacrolimus ointment RECOMMENDATION:

• Elidel will move from preferred to nonpreferred

3. Short-acting beta agonist (SABAs)

Review date 3Q15 Clinical review: Short-Acting Beta Agonist (SABAs) Reason for review: Category review PRODUCTS INCLUDED IN REVIEW: ProAir Respiclick dry powder inhaler (albuterol); ProAir HFA inhaler (albuterol), Proventil HFA inhaler (albuterol), Ventolin HFA inhaler (albuterol); Xopenex HFA (levalbuterol) COMPARATOR PRODUCTS: None


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CURRENT PREFERRED PRODUCTS: Proventil, Ventolin and ProAir RECOMMENDATION:

• ProAir HFA will move from preferred to nonpreferred • Proventil will move from preferred to nonpreferred

4. Testosterone replacement

Review date 3Q15 Clinical review: Testosterone replacement Reason for review: Formulary alignment category PRODUCTS INCLUDED IN REVIEW: Testosterone cypionate injection, Testosterone enanthate injection COMPARATOR PRODUCTS: (BRAND ONLY PRODUCTS) Androderm (testosterone patch); Androgel (testosterone gel); Aveed (testosterone undecanoate injection); Axiron (testosterone solution); Depo-Testosterone (testosterone cypionate) brand only products; First Testosterone (testosterone ointment); First Testosterone MC (testosterone cream); Fortesta (testosterone gel); Natesto (testosterone nasal gel); Striant (testosterone buccal tablet); Testim (testosterone gel); Testopel (testosterone pellet); Testosterone gel (brand only products); Testone CIK Kit (testosterone cypionate); Vogelxo (testosterone gel); METHYLTESTOSTERONE PRODUCTS (BRAND ONLY PRODUCTS) – Android (methyltestosterone capsule); Methitest (methyltestosterone tablet); Testred (methyltestosterone capsule) CURRENT PREFERRED PRODUCTS: Androgel 1% gel pump, Testim 1%, Androderm patch, testosterone 25 mg (1%) gel, testosterone 50 mg (1%) gel RECOMMENDATIONS:

• Testosterone cypionate injection and testosterone enanthate injection will move from nonpreferred to preferred

5. Hepatitis C

Review date 3Q15 Clinical review: Hepatitis C Reason for review: Category review PRODUCT INCLUDED IN REVIEW: Daklinza COMPARATOR PRODUCTS: Sovaldi, Harvoni, Viekira and Olysio CURRENT PREFERRED PRODUCTS: Harvoni and Sovaldi RECOMMENDATIONS:

• Daklinza will move from nonpreferred to preferred 6. Select cardiovascular agents

Review date 3Q15 Clinical review: Select cardiovascular agents Reason for review: New drug review PRODUCT INCLUDED IN REVIEW: Entresto


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COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: None RECOMMENDATIONS:

• Entresto will remain nonpreferred 7. Select cystic fibrosis agents

Review date 3Q15 Clinical review: Select cystic fibrosis agents Reason for review: New drug review PRODUCT INCLUDED IN REVIEW: Orkambi (ivacaftor/lumacaftor) COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: None RECOMMENDATIONS:

• Orkambi will remain nonpreferred 8. Select antihyperlipidemic agents

Review date 3Q15 VAC Clinical review: Select antihyperlipidemic agents Reason for review: Category review PRODUCTS INCLUDED IN REVIEW: Praluent and Repatha COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Simvastatin, Pravastatin, Atorvastatin and Lovastatin RECOMMENDATIONS:

• Praluent and Repatha will remain nonpreferred

9. Growth hormones

Review date 3Q15 VAC Clinical review: Growth hormones Reason for review: Category review PRODUCTS INCLUDED IN REVIEW: Humatrope, Norditropin, Omnitrope, Zomacton, Genotropin, Nutropin/AQ and Saizen COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Norditropin and Omnitrope RECOMMENDATIONS:

• Zomacton will move from nonpreferred to preferred • Nodritropin will move from preferred to nonpreferred • Omnitrope will move from preferred to nonpreferred • Saizen will remain nonpreferred • Genotropin will remain nonpreferred • Nurotpin/AQ will remain nonpreferred • Humatrope will remain nonpreferred


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10. Select antiemetic agents

Review date 3Q15 Clinical review: Select antiemetic agents Reason for review: Category review PRODUCTS INCLUDED IN REVIEW: Droperidol vial, Droperidol ampul, Granisteron injection, Ondansetron ODT Ondansetron solution, Ondansetron injection and tablet COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Ondansetron ODT, Ondansetron solution, Ondansetron injection, Ondansetron tablet and Granisetron injection RECOMMENDATIONS:

• Droperidol vial will move from preferred to nonpreferred • Droperidol ampul will move from preferred to nonpreferred • Granisetron injection will move from preferred to nonpreferred (grandfather current

utilizers) • Ondansetron solution will move from preferred to nonpreferred (grandfather current

utilizers) • Ondansetron injection will move from preferred to nonpreferred (grandfather current

utilizers) • Ondansetron tablet will move from preferred to nonpreferred (grandfather current

utilizers) 11. Select topical steroids (super potency) agents

Review date 3Q15 Clinical review: Select topical steroids Reason for review: Focus on super potency topical steroids PRODUCTS INCLUDED IN REVIEW: Clobetasol cream, Clobetasol gel, Clobetasol ointment, Clobetasol solution, Clobetasol Foam, Clobetasol lotion, Clobetasol shampoo, Halobetasol cream, Halobetasol ointment, Betamethasone dipropionate augmented ointment and Diflorasone ointment COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Cormax 0.05% solution, Clobetasol 0.05% gel, Clobetasol 0.05% cream, Clobetasol 0.05% ointment, Clobetasol 0.05% solution, Clobetasol emollient 0.05% cream RECOMMENDATIONS:

• Halobetasol cream will move to from preferred to nonpreferred • Halobetasol ointment will move from preferred to nonpreferred

12. Select transmucosal immediate release fentanyl agents

Review date 3Q15 Clinical review: Select transmucosal immediate release fentanyl agents


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Reason for review: Category review PRODUCTS INCLUDED IN REVIEW: Fentanyl citrate lozenge, Abstral, Fentora, Lazanda, MSB Actiq, Onsolis and Subsys COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Fentanyl citrate lozenge RECOMMENDATIONS:

• Fentanyl citrate lozenge will remain preferred

13. Select electrolyte agents

Review date 3Q15 Clinical review: Galzin Reason for review: Formulary alignment check PRODUCT INCLUDED IN REVIEW: Galzin COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: None (other zinc formulations preferred, none indicated for Wilson’s disease) RECOMMENDATIONS:

• Galzin will move from nonpreferred to preferred 14. Select gastrointestinal agents

Review date 3Q15 Clinical review: Select Gastrointestinal Agents Reason for review: Formulary alignment check PRODUCT INCLUDED IN REVIEW: Ipecac syrup COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: None RECOMMENDATIONS:

• Ipecac syrup will move from preferred to nonpreferred 15. Spacer devices

Review date 3Q15 Clinical review: Spacer devices Reason for review: Category review PRODUCTS INCLUDED IN REVIEW: (PRESCRIPTION) Microchamber, Microspacer for aerosol device, Vortex Holding Chamber, Aerotrach holding chamber, Breatherite MDI spacer, Breathrite valved MDI chamber, Breathrite valved MDI spacer, pocket chamber, Aerochamber Z-stat plus large, Aerochamber Z-stat plus W-flow, Aerochamber Z-stat plus-med, Aerochamber Z-stat plus-small, Ace aerosol cloud enhancer, Aerochamber plus flow-VU, Aerochamber plus W-flowsignal, Primeaire chamber, Riteflo spacer, Liteaire MDI chamber, Prochamber holding chamber,Vortex VHC ladybug toddler MS, Vortex VHC frog child mask Inspirachamber, Inspirachamber with mask-med, Inspirachamber with mask-small, Flexichamber, Aerochamber


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mini, Aerochamber MV hold chamber, Aerochamber Plus Flow-Vu, Aerochamber Plus Flow-Vu Large, Aerochamber Plus Flow-Vu Med, Aerochamber Plus Flow-Vu Small, E-Z spacer and Easivent holding chamber COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Microchamber, Microspacer for aerosol device, Vortex holding chamber, Breatherite MDI spacer, Breathrite valved MDI chamber, Breathrite valved MDI spacer, Pocket chamber, Aerochamber Z-Stat Plus, Aerochamber Plus Flow-VU, Aerochamber Plus W-Flowsignal, Riteflo spacer, Liteaire MDI chamber, Prochamber holding chamber, Aerochamber mini and Aerochamber MV hold chamber RECOMMENDATIONS:

• Vortex VHC Ladybug toddler mask will move from nonpreferred to preferred • Vortex VHC Frog child mask will move from nonpreferred to preferred • Inspirachamber will move from nonpreferred to preferred • Primeaire chamber will move from nonpreferred to preferred • Ace Aerosol Cloud Enhancer will move from nonpreferred to preferred • Aerotrach holding chamber will move from nonpreferred to preferred

16. Select antibiotic agents

Review date 3Q15 Clinical review: Select antibiotic agents Reason for review: Category review PRODUCT INCLUDED IN REVIEW: Minocycline ER 45 mg, Minocycline ER 90 mg, Minocycline ER 135 mg, Vancomycin vial, Ketek and Zyvox IV solution COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Minocycline capsule, Minocycline tablet, Doxycycline monohydrate capsule, tetracycline capsule, Vancomycin capsule and Levofloxacin RECOMMENDATIONS:

• Vancomycin vial will move from preferred to nonpreferred (grandfather current utilizers) • Ketek will move from preferred to nonpreferred • Zyvox IV solution will move from preferred to nonpreferred

17. Select third generation cephalosporin agents

Review date 3Q15 Clinical review: Select third generation cephalosporin agents Reason for review: Category review PRODUCT INCLUDED IN REVIEW: Ceftibuten suspension, Ceftibuten capsule and Spectracef dose pack COMPARATOR PRODUCTS: Cefdinir, Cefditoren, Cefixime, Suprax and Cedax CURRENT PREFERRED PRODUCTS: Cefdinir suspension and Cefdinir capsules RECOMMENDATIONS:

• Spectracef dose pack will move from preferred to nonpreferred


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18. Select antiviral agents

Review date 3Q15 Clinical review: Select antiviral agents Reason for review: Category review PRODUCT INCLUDED IN REVIEW: Virazole COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Virazole RECOMMENDATIONS:

• Virazole will move from preferred to nonpreferred 19. Select hepatitis C treatment agents

Review date 3Q15 Clinical review: Select hepatitis C treatment agents Reason for review: Formulary alignment check PRODUCT INCLUDED IN REVIEW: Moderiba COMPARATOR PRODUCTS: Ribasphere, Ribasphere Ribapak, Rebetol and Ribavirin CURRENT PREFERRED PRODUCTS: Ribavirin capsule, Ribavirin tablet, Ribasphere Ribapak, Moderiba and Ribasphere RECOMMENDATIONS:

• Moderiba will move from preferred to nonpreferred 20. Select antifungal agents

Review date 3Q15 Clinical review: Select antifungal agents Reason for review: Formulary alignment check PRODUCT INCLUDED IN REVIEW: Amphotericin B 50mg vial and Griseofulvin micro 500 mg tablet COMPARATOR PRODUCTS: Griseofulvin suspension and Griseofulvin Ultra CURRENT PREFERRED PRODUCTS: Griseofulvin suspension, Griseofulvin Ultra tablet, Nystatin suspension, Nystatin unit powder, Flucytosine capsule, Fluconazole tablet and Fluconazole suspension RECOMMENDATIONS:

• Amphotericin B 50mg vial will move from preferred to nonpreferred • Griseofluvin micro 500 mg tablet will move preferred to nonpreferred

21. Select antituberculosis agents

Review date 3Q15 Clinical review: Select antituberculosis agents Reason for review: Formulary alignment check


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PRODUCT INCLUDED IN REVIEW: Rifater COMPARATOR PRODUCTS: Rifampin, Isoniazid, Ethambutol, Pyrazinamide and Trecator CURRENT PREFERRED PRODUCTS: Rifampin, Isoniazid, Ethambutol, Rifabutin and Pyrazinamide RECOMMENDATIONS:

• Rifater will move from nonpreferred to preferred 22. Select anti-parkisonism agents

Review date 3Q15 Clinical review: Select anti-parkisonism agents Reason for review: Formulary alignment check PRODUCT INCLUDED IN REVIEW: Apokyn cartridge and Tasmar tablet COMPARATOR PRODUCTS: Carbidopa-Levodopa, Pramipexole, Carbidopa-Levodopa-Entacapone, Entacapone, Ropinirole, Rytary ER CURRENT PREFERRED PRODUCTS: Ropinirole, Pramipexole, Carbidopa-Levodopa, Selegiline, Carbidopa-Levodopa-Entacapone, Entacapone, Trihexyphenidyl RECOMMENDATIONS:

• Apokyn cartridge will move from preferred to nonpreferred 23. Select antihyperlipidemic agents

Review date 3Q15 Clinical review: Select antihyperlipidemic agents Reason for review: Formulary alignment check PRODUCT INCLUDED IN REVIEW: Kynamro COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: None RECOMMENDATIONS:

• Kynamro will move from preferred to nonpreferred 24. Select topical local anesthetic agents

Review date 3Q15 Clinical review: Select topical local anesthetic agents Reason for review: Formulary alignment check PRODUCT INCLUDED IN REVIEW: Lidocaine 5% patch COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: None RECOMMENDATIONS:

• Lidocaine 5% patch will move from nonpreferred to preferred


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25. Select antihyperglycemic agents

Review date 3Q15 Clinical review: Select antihyperglycemic agents Reason for review: Formulary alignment check PRODUCT INCLUDED IN REVIEW: Avandia, Avandamet, Repaglinide and Tolazamide COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Pioglitazone, Pioglitazone –Metformin and Pioglitazone-Glimepiride RECOMMENDATIONS:

• Avandia will remain nonpreferred • Avandamet will remain nonpreferred • Repaglinide will remain preferred • Tolazamide will remain nonpreferred

26. Select vasopressor hormone agents

Review date 3Q15 Clinical review: Select vasopressor hormone agents Reason for review: Category review PRODUCTS INCLUDED IN REVIEW: Desmopressin AC vial, Desmopressin AC ampul and Desmopressin vial COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Desmopressin Nasal solution/spray and Desmopressin tablet RECOMMENDATIONS:

• Desmopressin AC vial will move from preferred to nonpreferred (grandfather current utilizers)

• Desmopressin AC ampul will move from preferred to nonpreferred (grandfather current utilizers)

• Desmopressin vial will move from preferred to nonpreferred (grandfather current utilizers)

27. Select histamine H-2 receptor inhibitor agents

Review date 3Q15 Clinical review: Select histamine H-2 receptor inhibitor agents Reason for review: Category review PRODUCT INCLUDED IN REVIEW: Famotidine 20mg/2 ml vial COMPARATOR PRODUCTS: Ranitidine vial CURRENT PREFERRED PRODUCTS: None RECOMMENDATIONS:

• Famotidine 20mg/2 ml vial will remain preferred


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28. Select antihemophilic agents

Review date 3Q15 Clinical review: Select antihemophilic agents Reason for review: Category review PRODUCTS INCLUDED IN REVIEW: Novoseven Rt 1 Mg Vial, Novoseven Rt 2 Mg Vial, Novoseven Rt 5 Mg Vial, Novoseven Rt 8 Mg Vial, Humate-P 1; 200 Unit Vwf:Rco, Humate-P 600 Unit Vwf:Rco, Humate-P 2;400 Unit Vwf:Rco,Wilate 1;000-1;000 Unit Kit, Wilate 500-500 Unit Kit, Wilate 450-450 Unit Kit, Wilate 900-900 Unit Kit, Feiba Nf 1;000 Unit (Nominal), Feiba Nf 1;750-3;250 Unit Vial, Feiba Nf 2;500 Unit (Nominal), Feiba Nf 400-650 Unit Vial, Feiba Nf 500 Unit (Nominal), Hemofil M 1;000 Unit Nominal, Hemofil M 1;700 Unit Nominal, Hemofil M 500 Unit Nominal, Hemofil M 250 Unit Nominal, Koate-Dvi 250 Units Vial, Koate-Dvi 500 Units Vial, Koate-Dvi 1;000 Units Vial Monoclate-P 1;500 Units Kit, Monoclate-P 250 Unit Kit, Monoclate-P 500ahfu Kit Monoclate-P 1;000 Units Kit, Recombinate 1;241-1;800 Unit, Recombinate 1;801-2;400 Unit V, Recombinate 220-400 Unit Vial, Recombinate 401-800 Unit Vial, Recombinate 801-1;240 Unit Vl, Alphanate 250-100 Unit Vial, Alphanate 1;000-400 Unit Vial, Alphanate 500-200 Unit Vial, Alphanate 1;500-600 Unit Vial, Alphanate 2;000-800 Unit Vial, Eloctate 3;000 Unit Nomina, L Eloctate 250 Unit Nominal, Eloctate 500 Unit Nominal, Eloctate 750 Unit Nominal, Eloctate 1;000 Unit Nominal, Eloctate 1;500 Unit Nominal, Eloctate 2;000 Unit Nominal, Obizur 500 Unit Vial, Obizur 500 Unit Vial - 5 Vials, Obizur 500 Unit Vial -10 Vials, Novoeight 1;500 Unit Vial, Novoeight 2;000 Unit Vial, Novoeight 250 Unit Vial, Novoeight 500 Unit Vial, Novoeight 1;000 Unit Vial, Novoeight 3;000 Unit Vial, Xyntha 2;000 Unit Kit, Xyntha 250 Unit Kit, Xyntha 500 Unit Kit, Xyntha 1;000 Unit Kit, Xyntha 3;000 Unit Syringe Kit, Xyntha Solofuse 2;000 Unit Kit, Xyntha Solofuse 250 Unit Kit, Xyntha Solofuse 500 Unit Kit, Xyntha Solofuse 1;000 Unit Kit, Kogenate Fs 2;000 Unit Vial, Kogenate Fs 2;000 Unit-Bioset, Kogenate Fs 250 Unit Vial, Kogenate Fs 250 Unit Vl-Bioset, Kogenate Fs 500 Unit Vial, Kogenate Fs 500 Unit Vl-Bioset, Kogenate Fs 1;000 Unit-Bioset, Kogenate Fs 1;000 Units Vial, Kogenate Fs 3;000 Unit-Bioset, Kogenate Fs 3;000 Units Vial, Helixate Fs 2;000 Unit Vial, Helixate Fs 250 Unit Vial, Helixate Fs 500 Unit Vial, Helixate Fs 1;000 Unit Vial, Helixate Fs 3;000 Units Vial, Advate 3;601-4;800 Units Vial, Advate 1;201-1;800 Units Vial, Advate 1;801-2;400 Units Vial, Advate 200-400 Units Vial, Advate 401-800 Units Vial, Advate 801-1;200 Units Vial, Advate 2;401-3;600 Units Vial, Advate 200-400 Units Vial, Advate 401-800 Units Vial, Advate 801-1;200 Units Vial, Advate 1;201-1;800 Units Vial, Advate 1;801-2;400 Units Vial, Benefix 3;000 Unit Kit, Benefix 250 Unit Kit, Benefix 500 Unit Kit, Benefix 1;000 Unit Kit, Benefix 2;000 Unit Kit, Alphanine Sd 1;500 Units Vial, Alphanine Sd 500 Units Vial, Alphanine Sd 1;000 Units Vial, Mononine 1;000 Units Kit and Corifact kit COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Advate, Alphanate, AlphanineSD, Benfix, Corifact, Feiba NF, Helixate FS, Hemofil M, Humate-P, Kogenate FS, Novoseven RT, Recombinate, Xyntha and Xyntha Solufuse RECOMMENDATIONS:

• Novoseven RT will move from preferred to nonpreferred • Humate-P will move from preferred to nonpreferred


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• Wilate 1;000-1;000 unit kit will move from preferred to nonpreferred • Wilate 500-500 unit kit will move from preferred to nonpreferred • Feiba NF will move from preferred to nonpreferred • Hemofil M will move from preferred to nonpreferred • Koate-DVI will move from preferred to nonpreferred • Monoclate-P will move from preferred to nonpreferred • Recombinate will move from preferred to nonpreferred • Alphanate will move from preferred to nonpreferred • Xyntha will move from preferred to nonpreferred • Xyntha Solofuse Kogenate FS 2;000 unit vial will move from preferred to nonpreferred • Kogenate FS will move from preferred to nonpreferred • Helixate FS will move from preferred to nonpreferred • Advate will move from preferred to nonpreferred • Benefix will move from preferred to nonpreferred • Alphanine Sd 1;500 units vial will move from preferred to nonpreferred • Mononine 1;000 units kit will move from preferred to nonpreferred • Corifact kit will move from preferred to nonpreferred

29. Select heparins for IV line maintenance agents

Review date 3Q15 Clinical review: Select heparins for IV line maintenance agents Reason for review: Review heparin flush, heparin lock, normal saline flush PRODUCTS INCLUDED IN REVIEW: Heparin flush, heparin lock, normal saline flush COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Heparin lock RECOMMENDATIONS:

• Heparin lock will move from preferred to nonpreferred 30. Select hereditary angioedema agents

Review date 3Q15 Clinical review: Select hereditary angioedema agents Reason for review: Category review PRODUCTS INCLUDED IN REVIEW: Berinert, Cinryze and Firazyr COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Berinert RECOMMENDATIONS:

• Berinert will move from preferred to nonpreferred


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31. Select bone density regulator agents

Review date 3Q15 Clinical review: Select Reason for review: Formulary alignment review check PRODUCTS INCLUDED IN REVIEW: Xgeva and Zoledronic acid vial COMPARATOR PRODUCTS: Prolia, Forteo and Zometa CURRENT PREFERRED PRODUCTS: Forteo RECOMMENDATIONS:

• Zolendronic acid 4 mg vial will move from preferred to nonpreferred • Xgeva will remain nonpreferred

32. Select viscosupplement agents

Review date 3Q15 Clinical review: Select viscosupplement agents Reason for review: Category review PRODUCT INCLUDED IN REVIEW: Euflexxa, Gel-One, Hyalgan, Orthovisc, Supartz, Synvisc and Synvisc-One COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Euflexxa, Hyalgan, Orthovisc, Supartz, Synvisc and Synvisc –One RECOMMENDATIONS:

• Euflexxa will move from preferred to nonpreferred • Hyalgan will move from preferred to nonpreferred • Orthovisc will move from preferred to nonpreferred • Supartz will move from preferred to nonpreferred • Synvisc will move from preferred to nonpreferred • Synvisc –One will move from preferred to nonpreferred

33. Select topical anesthetics

Review date 3Q15 Clinical review: Select topical anesthetics Reason for review: Formulary alignment check PRODUCTS INCLUDED IN REVIEW: Lidocaine HCL 2% gel, Lidocaine HCL 2% jelly, Lidocaine HCL 4% solution and Lidocaine-Prilocaine cream COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Lidocaine 2% viscous solution, lidocaine 3% lotion and lidocaine- hydrocortisone cream RECOMMENDATIONS:

• Lidocaine HCL 2% gel will move from nonpreferred to preferred • Lidocaine HCL 2% jelly will move from nonpreferred to preferred • Lidocaine HCL 4% solution will move from nonpreferred to preferred


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• Lidocaine-prilocaine cream will move from preferred to nonpreferred

34. Select cough and cold products

Review date 3Q15 Clinical review: Select cough and cold products Reason for review: Formulary alignment check PRODUCT INCLUDED IN REVIEW: Cepacol sore throat lozenge, Chloraseptic sore throat spray, Chloraseptic Max lozenge, Cepastat 14.5 mg lozenge, sore throat lozenge, antiseptic sore throat spray, Pectin throat 2 mg drops and Pectin throat 2.8 mg drops COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Generic over-the-counter (OTC) sore throat lozenges RECOMMENDATIONS:

• Cepacol sore throat lozenge will move from preferred to nonpreferred • Chloraseptic sore throat spray will move from preferred to nonpreferred • Chloraseptic Max lozenge will move from preferred to nonpreferred • Cepastat 14.5 mg lozenge will move from preferred to nonpreferred • Sore throat lozenge will move from preferred to nonpreferred • Antiseptic sore throat spray will move from preferred to nonpreferred • Pectin throat 2 mg drops will move from nonpreferred to preferred • Pectin throat 2.8 mg drops will move from nonpreferred to preferred

35. Select antihistamines

Review date 3Q15 Clinical review: Select antihistamines Reason for review: Formulary alignment check PRODUCT INCLUDED IN REVIEW: Child's Claritin 5 mg tab chew and Claritin 5 mg Reditabs COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Child Allegra ODT, child Allegra suspension, Fexofenadine tablets, Loratadine tablets and Loratadine solution RECOMMENDATIONS:

• Child’s Claritin 5 mg chew tab will move from preferred to nonpreferred • Claritin 5 mg Reditabs will move from preferred to nonpreferred

36. Select therapy for acne

Review date 3Q15 Clinical review: Select therapy for acne Reason for review: Formulary alignment check PRODUCTS INCLUDED IN REVIEW: BP Wash 10% liquid, Sod sulfacetamide-sulfur cream, Sss 10-5 Cream, Sulfacetamide-Sulfur 10-5% cream, Virti-Sulf emollient cream, Benzac


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Ac wash 10% liquid, Benzefoam Ultra 9.8% foam, Benzepro 9.8% foam, benzoyl peroxide 9.8% foam, benzoyl peroxide powder, BPO 3% foaming cloths, BPO 6% foaming cloths, BPO 9% foaming cloths, CVS acne spot treatment 2.5% cream, Delos 3.5% lotion, Dual Action 3.5% cleanser-mask, Oc8 gel, On-the-spot 2.5% acne cream, Pacnex Hp 7% cleansing pads, Pacnex Lp 4.25% cleansing pads, Pacnex mx 4.25% cleanser, Panoxyl 10% acne cleansing bar, Pr benzoyl peroxide 7% wash, SE BPO 3% foaming cloths, SE BPO 6% foaming cloths, SE BPO 9% foaming cloths, Tl 4.25% BPO Mx Cleanser, Avar Cleanser, Prascion cleanser, Sod sulfacetamide-sulfur lotion, Sod sulfacetamide-sulfur suspension, Sod sulfacet-sulfur 10-5% cleanser, Sod sulfacet-sulfur suspension, sodium sulf-sulfur cleanser, sulfacetamide-sulfur 10-5% cleanser, Clindareach 1% kit, Noritate 1% cream, Adapalene 0.3% gel pump, Benzaclin gel 35g pump, Benzaclin gel 50g pump, SE BPO 7% wash, Pernox lemon scrub cleanser, Pernox regular scrub cleanser, Sebasorb lotion COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Tretinoin gel, Tretinoin cream, Clindamycin phosphate solution, benzoyl peroxide 5% wash, benzoyl peroxide gel, Erythromycin 2% gel, Erythromycin 2% solution RECOMMENDATIONS:

• BP Wash 10% liquid will move from nonpreferred to preferred • Sod sulfacetamide-sulfur cream will move from nonpreferred to preferred • Sss 10-5 cream will move from nonpreferred to preferred • Sulfacetamide-sulfur 10-5% cream will move from nonpreferred to preferred • Virti-sulf emollient cream will move from nonpreferred to preferred • Benzac Ac wash 10% liquid will move from preferred to nonpreferred • Benzefoam ultra 9.8% foam will move from preferred to nonpreferred • Benzepro 9.8% foam will move from preferred to nonpreferred • Benzoyl peroxide 9.8% foam will move from preferred to nonpreferred • Benzoyl peroxide powder will move from preferred to nonpreferred • Bpo 3% foaming cloths will move from preferred to nonpreferred • Bpo 6% foaming cloths will move from preferred to nonpreferred • Bpo 9% foaming cloths will move from preferred to nonpreferred • CVS acne spot treatment 2.5% cream will move from preferred to nonpreferred • Delos 3.5% lotion will move from preferred to nonpreferred • Dual action 3.5% cleanser-mask will move from preferred to nonpreferred • Oc8 gel will move from preferred to nonpreferred • On-the-spot 2.5% acne cream will move from preferred to nonpreferred • Pacnex Hp 7% cleansing pads will move from preferred to nonpreferred • Pacnex Lp 4.25% cleansing pads will move from preferred to nonpreferred • Pacnex Mx 4.25% cleanser will move from preferred to nonpreferred • Panoxyl 10% acne cleansing bar will move from preferred to nonpreferred • PR benzoyl peroxide 7% wash will move from preferred to nonpreferred • SE Bpo 3% foaming cloths will move from preferred to nonpreferred • SE Bpo 6% foaming cloths will move from preferred to nonpreferred • SE Bpo 9% foaming cloths will move from preferred to nonpreferred


January 2016 of 23

• Tl 4.25% Bpo Mx cleanser will move from preferred to nonpreferred • Avar cleanser will move from preferred to nonpreferred • Prascion cleanser will move from preferred to nonpreferred • Sod sulfacetamide-sulfur lotion will move from preferred to nonpreferred • Sod sulfacetamide-sulfur suspension will move from preferred to nonpreferred • Sod sulfacet-sulfur 10-5% cleanser will move from preferred to nonpreferred • Sod sulfacet-sulfur suspension will move from preferred to nonpreferred • Sodium sulf-sulfur cleanser will move from preferred to nonpreferred • Sulfacetamide-sulfur 10-5% cleanser will move from preferred to nonpreferred • Clindareach 1% kit will move from preferred to nonpreferred • Noritate 1% cream will move from preferred to nonpreferred • Adapalene 0.3% gel pump will move from preferred to nonpreferred • Benzaclin gel 35g pump will move from preferred to nonpreferred • Benzaclin gel 50g pump will move from preferred to nonpreferred • SE BPO 7% wash will move from preferred to nonpreferred • Pernox lemon scrub cleanser will move from preferred to nonpreferred • Pernox regular scrub cleanser will move from preferred to nonpreferred • Sebasorb lotion will move from preferred to nonpreferred

37. Select topical antibacterial/antispeptic agents

Review date 3Q15 Clinical review: Select topical anesthetics Reason for review: Formulary alignment check PRODUCT INCLUDED IN REVIEW: Centany 2% ointment, antiseptic solution, CVS Povidone-Iodine 10% solution, Eq first aid antiseptic solution Grx Dyne 10% Solution, HM Povidone-Iodine 10% solution, Peri-Wash 10% Concentrate, Povidone-Iodine 10% Prep Pad, Povidone-Iodine 10% Solution, QC povidone-iodine 10% solution, RA antiseptic 10% solution, RA antiseptic solution, SB Povidone-Iodine 10% solution, SM Povidone-Iodine 10% solution, first aid antibiotic ointment, Medi-First triple antibiotic, triple antibiotic ointment, Procomycin cream and Bactroban nasal 2% ointment COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Mupirocin 2% ointment, Isopropyl alcohol 70%, hydrogen peroxide 3% and (generic) triple antibiotic ointment RECOMMENDATIONS:

• Centany 2% ointment will move from preferred to nonpreferred • Antiseptic solution will move from preferred to nonpreferred • CVS povidone-iodine 10% solution will move from preferred to nonpreferred • EQ first aid antiseptic solution will move from preferred to nonpreferred • Grx dyne 10% solution will move from preferred to nonpreferred • HM povidone-iodine 10% solution will move from preferred to nonpreferred • Peri-wash 10% concentrate will move from preferred to nonpreferred • Povidone-iodine 10% prep pad will move from preferred to nonpreferred


January 2016 of 23

• Povidone-iodine 10% solution will move from preferred to nonpreferred • QC povidone-iodine 10% solution will move from preferred to nonpreferred • RA antiseptic 10% solution will move from preferred to nonpreferred • RA antiseptic solution will move from preferred to nonpreferred • SB povidone-iodine 10% solution will move from preferred to nonpreferred • SM povidone-iodine 10% solution will move from preferred to nonpreferred • First aid antibiotic ointment will move from preferred to nonpreferred • Medi-first triple antibiotic will move from preferred to nonpreferred • Triple antibiotic ointment will move from preferred to nonpreferred • Procomycin cream will move from preferred to nonpreferred • Bactroban nasal 2% ointment will move from nonpreferred to preferred

38. Select topical antifungals

Review date 3Q15 Clinical review: Select topical antifungals Reason for review: Formulary alignment check PRODUCT INCLUDED IN REVIEW: Tinactin 1% aerosol powder, Tinactin 1% deodorant spray powder, Lamisil At 1% cream, Aloe Vesta 2% antifungal ointment, Azolen 2% tincture, Critic-Aid Clear Af 2% ointment, Dermafungal 2% ointment, Desenex 2% spray liquid, Fungoid 2% tincture, Triple Paste Af 2% ointment, Fungi-Nail Toe & Foot ointment, Tinactin 1% liquid spray, Fungi Cure Intensive 1% spray, Undelenic tincture, Desenex Max 1% cream, EQ Terbinafine 1% cream, Lamisil 1% cream, Terbinafine HCL 1% cream, Undecylenic Acid Liquid and Mentax 1% cream COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Tinactin 1% powder, Tolnaftate 1% cream, Tolnaftate 1 % spray powder, Clotrimazole AF 1 % cream and Clotrimazole 1% solution RECOMMENDATIONS:

• Tinactin 1% aerosol powder will move from nonpreferred to preferred • Tinactin 1% deodorant spray powder will move from nonpreferred to preferred • Lamisil At 1% cream will move from nonpreferred to preferred • Aloe Vesta 2% antifungal ointment will move from preferred to nonpreferred • Azolen 2% tincture will move from preferred to nonpreferred • Critic-Aid Clear Af 2% ointment will move from preferred to nonpreferred • Dermafungal 2% ointment will move from preferred to nonpreferred • Desenex 2% spray liquid will move from preferred to nonpreferred • Fungoid 2% tincture will move from preferred to nonpreferred • Triple Paste Af 2% ointment will move from preferred to nonpreferred • Fungi-nail toe & foot ointment will move from preferred to nonpreferred • Tinactin 1% liquid spray will move from preferred to nonpreferred • Fungi cure intensive 1% spray will move from preferred to nonpreferred • Undelenic tincture will move from preferred to nonpreferred • Desenex Max 1% cream will move from preferred to nonpreferred


January 2016 of 23

• EQ Terbinafine 1% cream will move from preferred to nonpreferred • Lamisil 1% cream will move from preferred to nonpreferred • Terbinafine Hcl 1% cream will move from preferred to nonpreferred • Undecylenic acid liquid will move from preferred to nonpreferred • Mentax 1% cream will move from preferred to nonpreferred

39. Select keratolytics

Review date 3Q15 Clinical review: Select keratolytics Reason for review: Formulary alignment check PRODUCT INCLUDED IN REVIEW: X-Seb T Pearl shampoo and Sebex shampoo COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Salicylic acid 6% shampoo RECOMMENDATIONS:

• X-Seb T Pearl shampoo will move from nonpreferred to preferred • Sebex shampoo will move from nonpreferred to preferred

40. Select anti-inflammatory steroid combination products

Review date 3Q15 Clinical review: Select topical anti-inflammatory steroid combination products Reason for review: Formulary alignment check PRODUCT INCLUDED IN REVIEW: Hydrocortisone-pramoxine 2.5-1% cream COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Lidocaine-hydrocortisone 3-0.5% cream RECOMMENDATIONS:

• Hydrocortisone-pramoxine 2.5-1% cream will move from nonpreferred to preferred 41. Select topical antiparasitics

Review date 3Q15 Clinical review: Select topical antiparasitics Reason for review: Formulary alignment check PRODUCT INCLUDED IN REVIEW: Malathion 0.5% lotion COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: OTC products: lice killing shampoo, lice treatment permethrin, Permethrin 5% cream, Permethrin 1% lotion RECOMMENDATIONS:

• Malathion 0.5% lotion will move from nonpreferred to preferred


January 2016 of 23

42. Select miscellaneous dermatologicals

Review date 3Q15 Clinical review: Select miscellaneous dermatologicals Reason for review: Formulary alignment check PRODUCTS INCLUDED IN REVIEW: Calamine phenolated lotion, Sm Calamine phenolated lotion, diaper rash 10% ointment, GNP diaper rash 10% ointment, CVS menthol gel, SM pain relief gel, Nutraplus 10% cream, Nutraplus 10% lotion, Tl 45% urea lotion, ultra mide 25 lotion, urea 10% cream, urea 10% lotion, urea 20% cream, urea 40% lotion, urea 45% lotion, urea 45% nail gel, X-Viate 40% lotion, antiseptic skin cleanser 4% chlorhexidine 2% solution, antiseptic skin cleanser 4%, ammonium lactate 12% cream, ammonium lactate 12% lotion, Cerave hydrating cleanser, Cerave moisturizing cream, Cerave moisturizing lotion cerave Pm lotion, Cerave foaming facial cleanser, Cerave sunscreen lotion, Gordofilm solution, Aveeno clear complexion bar, Bensal Hp 3% ointment, Betasal shampoo, Calicylic crème, CVS acne spot treatment 2% cream, CVS fast clearing spot 2% gel, DHS sal 3% shampoo, Keralyt 3% gel, Keralyt scalp complete kit, oil-free 2% acne wash, Psoriasin 3% medicated wash, salicylic acid crystals salicylic acid Er 28.5% solution, salicylic acid powder, scalp relief liquid, Trans-Ver-Sal patch kit, Ultrasal-Er 28.5% solution, Virasal antiviral wart remove, Podocon-25 liquid, Salvax duo plus combo pack, Noble Formula S spray, liquid corn & callus remover, Pv liquid corn-callus remover carb-o-lac hp cream, carb-o-lac 5 cream, carb-o-sal5 cream, CVS foot softener ointment, Ra exfoliating moisturizer corn & callus remover, Salkera 6% foam, dandruff shampoo, Dermadrox 1.2% ointment, olive oil, sweet oil, Bodi lotion, Pretty Feet & Hands Cream, Ceta-Klenz Skin Cleanser, Cetaphil cleansing cleanser, Cetaphil cleansing lotion, Cetaphil daily facial cleanser, Cetaphil gentle skin cleanser, CVS gentle skin cleanser, SM skin cleanser, Pub calamine lotion, calamine powder, Desitin diaper rash 40% paste, diaper rash 40% paste, Peterson's ointment, Flanders buttocks ointment, Amerigel premium care lotion, Boudreauxs butt paste, Delazinc 25% ointment, Secura Extra Protective cream triple paste medicated ointment, zinc oxide paste, zinc oxide powder, Aspercreme Heat10% Gel, Bengay 2.5% Pain Relief Gel, Bengay 5% Cold Therapy Gel, Bengay 5% Zero Degrees Gel, Bengay Vanishing Scent GeL, Berri-Freez Gel,Berri-Freez Spray, Biofreeze 4% Gel, Icy Hot Naturals 7.5% Cream, Icy Hot Pain Relieving 2.5% Sombra Cool Therapy Gel, Zim's Max-Freeze 3.7% Gel, Z-Clinz Cleanser, Septi-Soft Conc Liquid Soap Lanaphilic With Urea 10% Ointment, Lanaphilic With Urea 20% Ointment, Hydrisinol Crème, Saratoga 1% Ointment, Spectro-Jel Jelly, Aloe Vesta 43% Protective Ointment, Americerin Moist Cream, Aquaphor 41% Healing Ointment, Aquaphor Ointment, Aquaphor W-Nat Heal Ointment, CVS Petroleum Jelly Cream, Dermaphor Ointment, Petrolatum Jelly, Aquaphilic Ointment, Kerodex 71 (Wet) Cream Ointment Base, Fluoroplex 1% Cream, Castellani Paint 1.5%,Castellani Paint Modified, Phenol Crystals, Phenol Liquid, Phenol Liquified, Amerigel Barrier Lotion, Sween 24 Cream, Baza Protect Cream, Condylox 0.5% Gel, CVS First Aid Ointment, Peleverus 0.9% Ointment, Peleverus Clear 0.9% Ointment Peleverus Gold Ointment, Geri Protect Barrier Ointment, Geri Protect Barrier Ointment, Zyclara 2.5% Cream Pump, Dandruff 1% Shampoo, Selsun Blue 1% Shampoo, Sorbolene Cream, Perishield Ointment, Periguard Ointment, Critic-Aid Clear Ointment, Resinol Ointment, Flexall 16% Gel, Polar Frost Gel, A+D Zinc Oxide Cream, Radigel Acemannan Hydrogel, Flexall 7% gel, Eucerin Calm Itch-Relief LotIon, Gold Bond Ultimate Healing cream, Gold Bond Ultimate 45% Ointment, Pentravan Plus Cream Base


January 2016 of 23

COMPARATOR PRODUCTS: None RECOMMENDATIONS: ITEMS MOVING FROM NONPREFERRED TO PREFERRED:

• Lidocaine HCl 2% gel • Calamine Phenolated lotion • SM Calamine Phenolated lotion • Diaper Rash 10% ointment • GNP diaper rash 10% • CVS menthol gel • SM pain relief gel • Nutraplus 10% cream • Nutraplus 10% lotion • Tl 45% Urea lotion • Ultra Mide 25 lotion • Urea 10% cream • Urea 10% lotion • Urea 20% cream • Urea 40% lotion • Urea 45% lotion • Urea 45% nail gel • X-Viate 40% lotion • Antiseptic Skin cleanser 4% • Chlorhexidine 2% solution • Antiseptic Skin cleanser 4% • Ammonium Lactate 12% cream • Ammonium Lactate 12% lotion • Cerave Hydrating cleanser • Cerave Moisturizing cream • Cerave Moisturizing lotion • Cerave Pm lotion • Cerave foaming facial cleanser • Cerave sunscreen lotion

ITEMS MOVING FROM PREFERRED TO NONPREFERRED: • Gordofilm Solution • Aveeno Clear Complexion Bar • Bensal Hp 3% Ointment • Betasal Shampoo • Calicylic Creme • CVS Acne Spot Trtmnt 2% Cream • CVS Fast Clearing Spot 2% Gel • DHS Sal 3% Shampoo • Keralyt 3% Gel


January 2016 of 23

• Keralyt Scalp Complete Kit • Oil-Free 2% Acne Wash • Psoriasin 3% Medicated Wash • Salicylic Acid Crystals • Salicylic Acid Er 28.5% Soln • Salicylic Acid Powder • Scalp Relief Liquid • Trans-Ver-Sal Patch Kit • Ultrasal-Er 28.5% Solution • Virasal Antiviral Wart Remover • Podocon-25 Liquid • Salvax Duo Plus Combo Pack • Noble Formula S Spray • Liquid Corn & Callus Remover • PV Liquid Corn-Callus Remover • Carb-O-Lac Hp Cream • Carb-O-Lac5 Cream • Carb-O-Sal5 Cream • Cvs Foot Softener Ointment • Ra Exfoliating Moisturizer • Corn & Callus Remover • Salkera 6% Foam • Dandruff Shampoo • Dermadrox 1.2% Ointment • Olive Oil • Sweet Oil • Bodi Lotion • Pretty Feet & Hands Cream • Ceta-Klenz Skin Cleanser • Cetaphil Cleansing Cleanser • Cetaphil Cleansing Lotion • Cetaphil Daily Facial Cleanser • Cetaphil Gentle Skin Cleanser • Cvs Gentle Skin Cleansr Lotion • Gentle Skin Cleanser • Sm Skin Cleanser • Pub Calamine Lotion • Calamine Powder • Desitin Diaper Rash 40% Paste • Diaper Rash 40% Paste • Peterson's Ointment • Flanders Buttocks Ointment


January 2016 of 23

• Amerigel Premium Care Lotion • Boudreauxs Butt Paste • Delazinc 25% Ointment • Secura Extra Protective Cream • Triple Paste Medicated Ointment • Zinc Oxide Paste • Zinc Oxide Powder • Aspercreme Heat 10% Gel • Bengay 2.5% Pain Relief Gel • Bengay 5% Cold Therapy Gel • Bengay 5% Zero Degrees Gel • Bengay Vanishing Scent Gel • Berri-Freez Gel • Berri-Freez Spray • Biofreeze 4% Gel • Icy Hot Naturals 7.5% Cream • Icy Hot Pain Relieving 2.5% • Sombra Cool Therapy Gel • Zim's Max-Freeze 3.7% Gel • Z-Clinz Cleanser • Septi-Soft Conc Liquid Soap • Lanaphilic With Urea 10% Ointment • Lanaphilic With Urea 20% Ointment • Hydrisinol Creme • Saratoga 1% Ointment • Spectro-Jelly • Aloe Vesta 43% Protective Ointment • Americerin Moist Cream • Aquaphor 41% Healing Ointment • Aquaphor Ointment • Aquaphor W-Nat Heal Ointment • Cvs Petroleum Jelly Cream • Dermaphor Ointment • Petrolatum Jelly • Aquaphilic Ointment • Kerodex 71 (Wet) Cream • Ointment Base • Fluoroplex 1% Cream • Castellani Paint 1.5% • Castellani Paint Modified • Phenol Crystals • Phenol Liquid


January 2016 of 23

• Phenol Liquified • Amerigel Barrier • Sween 24 Cream • Baza Protect Cream • Condylox 0.5% Gel • Cvs First Aid Ointment • Peleverus 0.9% Ointment • Peleverus Clear 0.9% Ointment • Peleverus Gold Ointment • Geri Protect Barrier Ointment • Zyclara 2.5% Cream Pump • Dandruff 1% Shampoo • Selsun Blue 1% Shampoo • Sorbolene Cream • Perishield Ointment • Periguard Ointment • Critic-Aid Clear Ointment • Resinol Ointment • Flexall 16% Gel • Polar Frost Gel • A+D Zinc Oxide Cream • Radigel Acemannan Hydrogel • Flexall 7% Gel • Eucerin Calm Itch-Relief Lotion • Gold Bond Ultimate Healing Cream • Gold Bond Ultimate 45% Ointment • Pentravan Plus Cream Base

43. Select miscellaneous otic preparations

Review date 3Q15 Clinical review: Select miscellaneous otic preparations Reason for review: Formulary alignment check PRODUCT INCLUDED IN REVIEW: Acetic acid 2% ear solution, Aero Otic Hc ear drops, Cortane-B Otic Drops, Exotic-Hc Ear Drop, Oto-End 10 Ear Drops,Otomax-Hc Ear Drops, Pramoxine-HC Otic Drops, Cortane-B Otic Drops, Treagan Otic Drops, Antipyrine-Benzocaine Otic Solution COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: Acetic acid/aluminum acetate drops RECOMMENDATIONS:

• Acetic acid 2% ear solution will move from nonpreferred to preferred • Aero otic HC ear drops will move from nonpreferred to preferred • Cortane-B otic drops will move from nonpreferred to preferred


January 2016 of 23

• Exotic-HC ear drops will move from nonpreferred to preferred • Oto-End 10 ear drops will move from nonpreferred to preferred • Otomax-Hc ear drops will move from nonpreferred to preferred • Pramoxine-HC otic drops will move from nonpreferred to preferred • Cortane-B otic drops will move from nonpreferred to preferred • Treagan otic drops will move from nonpreferred to preferred • Antipyrine-benzocaine otic solution will move from nonpreferred to preferred

44. Select topical dental agents

Review date 3Q15 Clinical review: Select topical dental agents Reason for review: Formulary alignment check PRODUCT INCLUDED IN REVIEW: Dentagel 1.1% gel, Fluoridex defense 1.1% gel, neutral sodium fluoride and SF 1.1% gel COMPARATOR PRODUCTS: None CURRENT PREFERRED PRODUCTS: SF 5000 Plus cream, Denta 5000 Plus cream and Periodmed dental rinse RECOMMENDATIONS:

• Dentagel 1.1% gel will move from nonpreferred to preferred • Fluoridex Defense 1.1% gel will move from nonpreferred to preferred • Neutral sodium fluoride will move from nonpreferred to preferred • SF 1.1% gel will move from nonpreferred to preferred