PHARMACY AND THERAPEUTICS COMMITTEE 4 th Quarter 2017

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1 PHARMACY AND THERAPEUTICS COMMITTEE 4 th Quarter 2017 A meeting of the Health Partners Pharmacy and Therapeutics (P&T) Committee was held on September and December The following are the recommendations for the drugs reviewed at the meeting by the Committee: Drug Name Actemra Ampyra Antipsychotics Under Age 18 Atovaquone-proguanil Atovaquone-proguanil 62.5/25 mg 3/day, 250/100 mg 1/day Aubagio Aubagio 1/1 day Avonex B&O suppositories B&O suppositories 4/day Botox Briviact 2/day Bunavail mg film change to 1/day Buprenorphine 2 mg tablets 3/day Buprenorphine Products for Medication Assisted Treatment Buprenorphine tablets (with ) Buprenorphine-naloxone 2 mg tablets 3/day 6

2 Byetta Ciclopirox 8% - 6.6ml/30 Clonazepam ODT add Oxtellar R, Briviact, Aptiom to Step 1 drugs CNS stimulants Copaxone Dupixent Dupixent 8 ml/28 Dupixent 1 way edit (Dupixent will pay) with the following vaccines: BCG, MMR, Rotavirus, Varicella, Zoster, Yellow fever, Adenovirus, Cholera, Thphoid Duplication of narcotics Early refills Egrifta Enbrel Epclusa Forteo Fuzeon Fuzeon Gilenya Gleevec (will be combined into oral chemo agent criteria) H.P. Acthar Gel Harvoni Humira Hydroquinone 4% cream (microspheres) GCN Ingrezza Ingrezza - 2 way edit(both will deny) with MAOIs and Strong CYP3A4 inducers 6 Step Therapy from

3 Ingrezza 2/day Injectable antidiabetic agents Isentress 1 way edit (Isentress will pay) with Rifampin, Dolutegravir, Raltegravir, Elvitegravir Isentress HD Isentress HD 2/day Jadenu/Exjade Janumet/Janumet R Lamictal tab start kit (green) Lupron Depot Lyrica Makena Marinol Mavyret Mavyret Mavyret 1 way edit (Mavyret will pay) with Atazanavir, Rifampin, Bosentan, Eltrombopag, Etravirine, Lopinavir, Phenytoin, Saquinavir, Tipranavir, DArunavir, Ritonavir, Carbamazepine, St John s Wort, Efavirenz Mavyret 18 years and older (deny under 18) Mavyret 3/day Megace ES Methenamine hippurate Methenamine mandelate Methylpenidate IR & ER (oral) 3 years and older (deny under 3) Metoprolol/HCTZ Metoprolol/HCTZ Metoprolol/HCTZ 50/25 mg 2/day, 100/25 mg 2/day, 100/50 mg 1/day 6

4 Metronidazole 250 mg increase from 3/day to 4/day Modafinil agents Narcotics Analgesics 21 years and older Narcotics over 21 Narcotics under 21 years old Neulasta Neupogen Non-formulary Oral antidiabetic agents Oral Chemotherapy Oral chemotherapy agents Orencia Oxandrin Oxycontin Promacta Protopic (tacrolimus) ointment Pulmozyme Rebif Rizatripan ODT (CHIP) 9/30 Rizatriptan ODT Sabril Powder Packet under 2 years of age (deny 2 and older) Sabril Powder Packet (generic) Sabril Powder Packet (generic) 4 packets/day Serostim Sodium chloride 7% - extend lookback to 90 (step through Duoneb) Suboxone 2 mg-0.5 mg film 3/day; Suboxone 4 mg-1 mg film 2/day 6 Step Therapy

5 Suboxone and buprenorphine - Remove between individual strengths of Suboxone - Remove between individual strengths of buprenorphine Remove DUR between Suboxone and buprenorphine Suboxone films/tablets, buprenorphine tablets 18 years and older (deny under 18) Synagis Tacrolimus ointment 30 grams per fill, max 60 grams per 180 Tacrolimus ointment step through at least 1 topical steroid for a 6 day supply in past 180 Targetin gel Testosterone Tivicay 10 mg, 25 mg 2/1 day Tivicay 25 mg and 10 mg Tobramycin Tradjenta Tysabri Valcyte (valganciclovir) Victoza Vivitrol Vivitrol Vosevi 6 Step Therapy

6 Vosevi 1 way edit (Vosevi will pay) with with PPIs except 20mg omeprazole, dabigatran, rifampin, betrixaban, amiodarone, statins except pravastatin 40mg and under, St. John s Wort Vosevi 1/ day Vosevi 18 years and older (deny under 18) Will be combined into new Buprenorphine Products for Medication Assisted Treatment: - Suboxone - Buprenorphine Will be combined into the Oral Chemo Therapy Criteria: - Afinitor - Nexavar yrem Zubsolv mg tablet 2/day; Zubsolv mg tablet 1/ day; Zubsolv mg tablet 2/day; Zubsolv mg tablet 2/day Zyvox (linezolid) 6

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