1. Definitions


2. Additions to the Preferred Drug List


3. Changes to the Preferred Drug List (Formulary)


4. Deletions from the Preferred Drug List


5. Legal Disclaimer

July 2010 Preferred Drug List (Formulary) Updates

The HealthPartners Pharmacy and Therapeutics Committee updates the preferred drug list every three months. This listing represents additions and changes implemented January 1, 2010 unless otherwise stated. All drug additions and changes are the same for the HealthPartners Medicare Drug Formulary unless otherwise stated in this Update.

This summary was written for health care providers and has been slightly modified for the general public.

Our HealthPartners preferred drug list information is available at www.healthpartners.com/formulary, and also within the ePocrates database at no charge to users. The electronic ePocrates database is downloaded from www.ePocrates.com. Providers and members are encouraged to use and share this information. The ePocrates drug information service is available for most handheld devices such as Palm Pilots.

The 2010 Medicare Drug Formulary is available at healthpartners.com/medicare-formulary/medicare.do. Visit medicare.healthpartners.com for additional information.

DEFINITIONS
The following terms have been used:

Age Limit: You'll see this term next to medications that are available to patients within a specific age group. Patients outside of this age group need to meet specific criteria before the medication will be approved.

Cost: All cost information reflects the average wholesale price (AWP). Costs to consumers may vary because of different strengths, forms, quantities and pharmacy benefits.

Physician-Edit: This term means that a medication is reserved for prescribing by certain physician specialists.

Prior Approval: This term means that specific criteria must be met before the medication will be approved. Typically, your provider submits these requests to HealthPartners.

Quantity Limit: This term means that a limit has been set on the amount of medication you will receive each time you fill a prescription for that medication.

Step Therapy: This term means that your doctor will need to prescribe one medication before trying another. Prior approval is needed if HealthPartners does not have a record of the first prescription.

ADDITIONS TO THE PREFERRED DRUG LIST Dalfampridine (Ampyra)

Medication Category: Multiple Sclerosis - PreferredRx and GenericsPlusRx Preferred Drug Lists
Miscellaneous Therapeutic Agents - 2010 Medicare Drug Formulary

Preferred Drug List Status: On the preferred drug list with prior approval

Ampyra will be reserved for patients with Expanded Disability Status Scale (EDSS) scores from five through seven, and walking speeds of 8 to 45 seconds on a 25-foot walk test. Initial approvals will be for one month. Patients with a positive response after one month will be approved for an additional six months. Patients who continue to respond after six months will be approved for one year, and will be approved each year thereafter for patients who continue to have a positive response. Ampyra will also have a quantity limit of two tablets per day which is based on FDA dosing guidelines.

Ampyra is a specialty medication and must be obtained from Walgreens Specialty.

Effective Date: PreferredRx & GenericsPlusRx Preferred Drug Lists - July 1, 2010
2010 Medicare Drug Formulary - July 1, 2010

Liraglutide (Victoza)

Medication Category: Diabetes - PreferredRx & GenericsPlusRx Preferred Drug Lists
Antidiabetic Agents - 2010 Medicare Drug Formulary

Preferred Drug List Status: On the preferred drug list with prior approval

Victoza will be reserved for patients with an inadequate response to maximum dose Byetta within the previous three months. Patients must also have previous use of a first medication, metformin OR a sulfonylurea.

Victoza is a once daily injection used to treat type 2 diabetes in adults.

Effective Date: PreferredRx & GenericsPlusRx Preferred Drug Lists July 1, 2010
2010 Medicare Drug Formulary July 1, 2010

Tadalafil (Adcirca)

Medication Category: Heart Health & Other - PreferredRx & GenericsPlusRx Preferred Drug Lists
Vasodilating Agents - 2010 Medicare Drug Formulary

Preferred Drug List Status: On the preferred drug list with prior approval

Adcirca is reserved for: (1) the FDA-approved indication of pulmonary arterial hypertension (PAH - high blood pressure in the arteries of the lungs) in World Health Organization (WHO) Group I; and (2) patients with an average pulmonary (lung) artery pressure higher than or equal to 25mmHg as measured by right heart catheterization, and (3) patients who have had vasodilator (widening of blood vessels) testing done.

Use with another PAH medication requires documentation of medical necessity, including previous response to single-drug therapy and reasons for adding a second medication. Patients in other WHO Groups will be reviewed for medical necessity.

Adcirca is an oral PDE-5 inhibitor used for the treatment of pulmonary arterial hypertension (PAH).

Adcirca is a specialty medication and must be obtained from Caremark.

Effective Date: PreferredRx & GenericsPlusRx Preferred Drug Lists - July 1, 2010
2010 Medicare Drug Formulary - July 1, 2010

Treprostinil (Tyvaso)

Medication Category: Heart Health & Other - PreferredRx & GenericsPlusRx Preferred Drug Lists
Vasodilating Agents - 2010 Medicare Drug Formulary

Preferred Drug List Status: On the preferred drug list with prior approval

Tyvaso is reserved for: (1) the FDA-approved indication of pulmonary arterial hypertension (PAH - high blood pressure in the arteries of the lungs) in World Health Organization (WHO) Group I; and (2) patients with an average pulmonary (lung) artery pressure higher than or equal to 25mmHg as measured by right heart catheterization, and (3) patients who have had vasodilator (widening of blood vessels) testing done.

Use with another PAH medication requires documentation of medical necessity, including previous response to single-drug therapy and reasons for adding a second medication. Patients in other WHO Groups will be reviewed for medical necessity.

Tyvaso is an inhaled "prostanoid" used for the treatment of pulmonary arterial hypertension (PAH).

Tyvaso is a specialty medication and must be obtained from Caremark when billed as a pharmacy claim.

Effective Date: PreferredRx & GenericsPlusRx Preferred Drug Lists - July 1, 2010
2010 Medicare Drug Formulary - July 1, 2010

CHANGES TO THE PREFERRED DRUG LIST (FORMULARY)

Ambrisentan (Letairis). Prior approval criteria is changed to the same as Adcirca and Tyvaso above and all other PAH drugs. Letairis is a specialty medication and must be obtained from Caremark.

Bosentan (Tracleer). Prior approval criteria is changed to the same as Adcirca and Tyvaso above and all other PAH drugs. Tracleer is a specialty medication and must be obtained from Caremark.

Iloprost (Ventavis). Prior approval criteria is changed to the same as Adcirca and Tyvaso above and all other PAH drugs. Ventavis is a specialty medication and must be obtained from Caremark when billed as a pharmacy claim.

Effective Date for PAH Drug Criteria Change: PreferredRx & GenericsPlusRx Preferred Drug Lists - July 1, 2010
2010 Medicare Drug Formulary - Pending CMS approval.

Oxycodone ER (OxyContin). The quantity limit will change from 180 tablets for each prescription to 120 tablets per month.

Effective Date for PAH Drug Criteria Change: PreferredRx & GenericsPlusRx Preferred Drug Lists - September 1, 2010
2010 Medicare Drug Formulary - Pending CMS approval.

DELETIONS FROM THE PREFERRED DRUG LIST (FORMULARY)

Sildenafil (Revatio).

Revatio will have them same prior approval criteria as all other PAH drugs and Adcirca will be preferred over Revatio.

Revatio is a non-formulary specialty medication that must be obtained from Caremark.

Effective Date: PreferredRx & GenericsPlusRx Preferred Drug Lists - September 1, 2010.
2010 Medicare Drug Formulary - Pending CMS approval.

LEGAL DISCLAIMER

The information regarding HealthPartners' preferred drug list and coverage criteria is regularly updated and is therefore subject to change without notice. HealthPartners reserves the right to make such changes without specific notice to members.

Various plan documents (including the Membership Contract or Summary Plan Description) determine governing contractual provisions, including exclusions, limitations and other coverage rules relating to specific health plans. The changes and the criteria described in this document apply to most, but not all, plans offered by HealthPartners. We strive to ensure that the contents of this site are correct and complete, but to verify benefits and preferred drug list contents, please check the applicable contract or SPD, or call HealthPartners Member Services at 952-883-5000. In the event of a conflict between specific plan documents and this general information, the plan documents will govern.

This document is derived from highly technical information used to educate medical personnel about changes to the HealthPartners preferred drug list. This document does not constitute medical advice.

These criteria in no way imply that any patient should not receive specific services based on the recommendation of a provider. The providers treating patients are responsible for medical advice and treatment of patients.

In those cases where interpretation of some or all of the parts of these criteria is required, HealthPartners medical personnel determine how the criteria, or specific parts of these criteria, apply to specific situations.

This information is not an offer of coverage, solicitation of coverage, summary of coverage or guarantee of coverage. All products and coverage criteria are subject to applicable laws and regulations. Coverage is contingent on all the applicable terms, conditions, limitations and exclusions of appropriate health plan documents.