ELEVATE. Formulary Updates to Elevate Plans (Bronze HDHP/Standard, Silver Select/Standard & Gold Select/Standard)

Transcription

1 ELEVATE Formulary Updates to Elevate Plans (Bronze HDHP/Standard, Silver Select/Standard & Gold Select/Standard) P&T/Formulary Committee Actions 4Q 2017 (Effective January 1, 2018) Marketplace Standard P&T/Formulary Committee Actions (4Q17) 4Q2017 Marketplace Standard (HIEx) Additions and/or Revisions effective: January 1, 2018 Deletions effective: January 1, 2018 for NEW member prescriptions; April 1, 2018 for EXISTING member prescriptions Formulary Committee Actions Brand Name Oncology Oral Drug Generic Name Current Formulary Status Action Prescribing Guideline Actions Nerlynx neratinib 4 S=4 PA* C=PA Notes CHANGE interim PA guideline on Nerlynx to final PA guideline. Idhifa enasidenib 4 S=4 PA* C=PA CHANGE interim PA guideline on Idhifa to final PA guideline. Imbruvica ibrutinib 4 S=4 PA C=PA CHANGE PA guideline on Imbruvica. MAINTAIN QL on Lynparza as follows: Lynparza olaparib 4 S=4 PA, QL 16 capsules per day for 50mg capsule. C=PA 4 capsules per day for 100mg and 150mg tablets. Verzenio abemaciclib 4 S=4 PA*, QL C=PA CHANGE PA guideline on Lynparza. MAINTAIN QL on Verzenio as follows: 2 tablets per day. CHANGE PA guideline on Verzenio. Oncology NSA Vyxeos daunorubicin/ CHANGE interim PA (NSA) guideline on Vyxeos to final PA 4 S=4 PA^* C=PA^ cytarabine liposomal Besponsa inotuzumab ozogamicin 4 S=4 PA^* C=PA^ CHANGE interim PA (NSA) guideline on Besponsa to final PA Opdivo nivolumab 4 S=4 PA^ C=PA^ CHANGE PA (NSA) guideline on Opdivo. Vectibix panitumumab 4 S=4 PA^ C=PA^ CHANGE PA (NSA) guideline on Vectibix. Faslodex fulvestrant 4 S=4 PA^ C=PA^ CHANGE PA (NSA) guideline on Faslodex. Mylotarg gemtuzumab ozogamicin 4 S=4 PA^* C=PA^ CHANGE interim PA (NSA) guideline on Mylotarg to final PA

2 Aliqopa copanlisib 4 S=4 PA^* C=PA^ CHANGE interim PA (NSA) guideline on AliqoPA guideline to final PA (NSA)guideline. Keytruda pembrolizumab 4 S=4 PA^ C=PA^ CHANGE PA (NSA) guideline on Keytruda. Immunomodulators Actemra IV tocilizumab 4 S=4 PA^ C=PA^ CHANGE PA (NSA) guideline on Actemra IV. Renflexis infliximab abda 4 S=4 PA^* C=PA^ CHANGE interim PA (NSA) guideline on Renflexis to final PA Simponi Aria golimumab 4 S=4 PA^ C=PA^ CHANGE PA (NSA) guideline on Simponi Aria. Stelara ustekinumab SC 4 S=4 PA C=PA CHANGE PA guideline on Stelara. Orphan Diseases Kalydeco ivacaftor 4 S=4 PA C=PA CHANGE PA guideline on Kalydeco. Nityr nitisinone 4 S=4 PA* C=PA CHANGE interim PA guideline on Nityr to final PA guideline.

3 Orfadin nitisinone 4 S=4 PA C=PA CHANGE PA guideline on Orfadin. Triptodur triptorellin 4 S=4 PA^* CHANGE interim PA (NSA) guideline on Triptodur to final PA C=PA^ Endari L glutamine 4 S=4 PA* C=PA CHANGE interim PA guideline on Endari to final PA guideline. Neurology Austedo deutetrabenazine 4 S=4 PA C=PA CHANGE PA guideline on Austedo. Gocovri amantadine ER 3 S=3 CHANGE interim PA guideline on Gocovri to final PA guideline. PA* C=PA Soliris eculizumab 4 S=4 PA^ C=PA^ CHANGE PA (NSA) guideline on Soliris. Respiratory Conditions CHANGE Trelegy Ellipta to Preferred Brand Tier (Tier 2). Trelegy Ellipta fluticasone furoate, umeclidinium, vilanterol 3 C=2 ST, QL D=ST MAINTAIN QL on Trelegy Ellipta as follows: Limited to 1 inhaler per 30 days. ArmonAir RespiClick fluticasone propionate 3 S=3 none A=ST, QL Gastrointestinal DELETE ST on Trelegy Ellipta. ADD ST on ArmonAir RespiClick as follows: Trial of 2 of the following: Arnuity Ellipta, Flovent Diskus, Flovent HfA, or Qvar within the past 365 days. ADD QL on ArmonAir RespiClick as follows: Limited to one inhaler per 30 days. CHANGE QL on Nexium 40 mg capsule/packet as follows: 2 capsules or packet per day. Nexium esomeprazole trihydrate 1 S=1 QL,ST C=QL D=ST MAINTAIN QL on Nexium 20 mg capsule, 2.5 mg/5 mg/10 mg packet as follows: 1 capsule or packet per day. Infectious Disease Baxdela delafloxacin PO 3 S=3 PA* C=PA DELETE ST on Nexium. CHANGE interim PA guideline on Baxdela oral tablets to final PA guideline. DELETE PA guideline on Sivextro. Sivextro tedizolid 2 S=2 PA D=PA A=ST, QL ADD ST on Sivextro as follows: Trial of Linezolid 600 mg tablets in the past 120 days. ADD QL on Sivextro as follows: 1 tablet per day for a duration of 6 days. Emverm mebendazole 2 S=2 PA C=PA CHANGE PA guideline on Emverm. Albenza albendazole 3 C=2 none none CHANGE Albenza to Preferred Brand Tier (Tier 2). Phosphate Binders Velphoro sucroferric oxyhydroxide 500 mg chewable tab Pulmonary Arterial Hypertension (PAH) 3 C=2 none none CHANGE Velphoro to Preferred Brand Tier (Tier 2).

4 Orenitram treprostinil 4 S=4 PA C=PA CHANGE PA guideline on Orenitram. Vitamins Xyzbac, Mebolic MULTIVIT34/FOLIC ADD PA guideline on Xyzbac and Mebolic. 1 S=1 none A=PA AC/NADH/COQ10 CAR T Cell Therapies Kymriah tisagenlecleucel 4 S = 4 PA^* C = PA^ CHANGE interim PA (NSA) guideline on Kymriah to final PA Yescarta axicabtagene ciloleucel 4 S = 4 none A = PA^ ADD PA (NSA) guideline on Yescarta. Diabetes ADD QL on Fiasp as follows: Vial: 40mL (4 vials) per 28 days; Pen: Fiasp insulin aspart 30mL (10 pens) per 28 days. 3 S=3 none A=QL,ST (niacinamide) ADD ST on Fiasp as follows: Trial of Humalog in the past 120 days required. Zoster Vaccine MAINTAIN Shingrix as NOT COVERED (NON FORMULARY if covered). Shingrix Varicella Zoster GE/AS01/PF NC^ S = NC^ none A= QL, Age (EHB) ADD QL to Shingrix as follows: Limit to 2 doses per 365 days. ADD AGE EDIT to Shingrix as follows: Age 50 years of age Hepatitis C Mavyret glecaprevir/ CHANGE PA guideline on Mavyret. pibrentasvir Daklinza daclatasvir CHANGE PA guideline on Daklinza. Technivie ombitasvir, CHANGE PA guideline on Technivie. paritaprevir/ritonavir Olysio simeprevir CHANGE PA guideline on Olysio. Sovaldi sofosbuvir CHANGE PA guideline on Sovaldi. ombitasvir, CHANGE PA guideline on Viekira PA guideline/viekira XR. Viekira Pak/Viekira XR paritaprevir/ritonavir, dasabuvir Zepatier elbasvir/grazoprevir CHANGE PA guideline on ZePA guideline. COMMERCIAL LEGEND Formulary Actions Utilization Management (UM) Actions C = Change A = Add UM AGE = Age restriction PA = Prior Authorization S = Sustain D = Delete UM QL = Quantity Limit PA* = Interim Prior Authorization

5 NC^ = Not covered; Non Formulary if covered C = Change UM E = Exclude drug from formulary S = Sustain/maintain Multiple actions view cell for details ST = Step Therapy CU = Concurrent Use edit PA^ = Prior Authorization if covered PA^* = Interim Prior Authorization if covered