UPMC for You Pharmacy and Therapeutics Committee Meeting July 27, 2010 meeting
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- Miles Stanley
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1 1. Call to order: The meeting was called to order at 7:10 a.m. UPMC for You Pharmacy and Therapeutics Committee Meeting July 27, 2010 meeting 2. Review of the minutes: The minutes of the April 6, 2010 meeting and fax vote were approved as amended by the Committee. 3. New Business: Medication Reviews Drug Class Contraceptive Sleep Aid Nitrate Antitussive Antifungal Enzyme Replacement Hypoglycemic Benign Prostatic Hypertrophy Agent Central Nervous System Agent Drug Name Natazia (estradiol valerate and estradiol valerate/dienogest) Silenor (doxepin) NitroMist (nitroglycerin) Zonatuss (benzonatate) Oravig (miconazole) Orbivan (acetaminophen/butalbital/caffeine) Oxycontin (oxycodone abuse resistant reformulation) Pancreaze (pancrelipase) Rybix ODT (tramadol) Vimovo (naproxen/esomeprazole) ActosPlus Met XR (pioglitazone/metformin) Jalyn (dutasteride/tamsulsin) Namenda XR (memantine) Formulary Coverage Recommendation with quantity limit with quantity limit with step therapy
2 Drug Class Drug Name Antiasthma Dulera (mometasone/formoterol) Immune Modulator Zyclara (imiquimod) Topical dermatologic Differin lotion (adapalene) Anesthetic Tetravisc Forte (tetracaine) Ophthalmic antibiotic Zymaxid (gatifloxacin) Sprix (ketorolac) Immune Suppressant Zortress (everolimus) Monoclonal Antibody Prolia (denosumab) Hyperammonemia Agent Carbaglu (carglumic acid) Immunological Agent Provenge (sipuleucel-t) All voted in favor to approve the recommendations noted above. Formulary Coverage Recommendation with quantity limit with prior authorization with prior authorization and quantity limit with prior authorization with prior authorization and quantity limit Medication Class Reviews Topical antibacterial products: Bactroban cream, Bactroban nasal ointment, Altabax ointment All voted in favor to approve the following product as must add status: Mupirocin ointment Dry mouth treatments: Evoxac, Pilocarpine tablets, Caphasol, Aquoral, Numoisyn lozenge, Numoisyn liquid, and Neutrasal Pegylated Interferons: Pegasys and PEG-Intron mtor Inhibitors: Rapamune and Zortress
3 New policies RX.PA. 140 Oral Diabetes step therapy RX.PA.141 Prolia RX.PA.142 IV Bisphosphonates RX.PA.143 Carbaglu RX.PA.144 Buphenyl RX.PA.144 Provenge RX.PA.146 Xifaxan RX.PA.147 Rapamune and Zortress RX.015 Prescribing Privileges of Non-Participating Providers 4. Updates: Policy Revisions RX.PA.037 Elidel and Protopic Updated to extend the approval and reauthorization period from 3 months to 1 year based on specialist feedback. RX.PA.054 LHRH agents Updated to include Synarel and new strength of Trelstar. RX.PA.065 Lucentis Updated to include new FDA approved indication for macular edema following retinal vein occlusion.
4 RX.PA.067 Oral Chemotherapeutic Agents Updated to include new indication for Tarceva for maintenance treatment of patients with locally advanced or metastatic non-small lung cancer (NSCLC) whose disease has not progressed after four cycles of platinum-based first-line chemotherapy. Updated to include new indication for Tasigna for adult patients with newly diagnosed Ph+ chronic phase CML. RX.PA.080 Suboxone and Subutex Updated initial coverage period from 3 months to 1 month, require documentation of buprenorphine positive drug screen, require initial substance abuse counseling by a licensed drug and alcohol or behavioral health provider, and allow less formal behavioral health counseling programs after 1 year of therapy. RX.PA.088 Glucocerebrosidase Replacement Enzymes Updated to include all types of Gaucher Disease instead of just Type 1 and 3. RX.PA.136 Lumizyme and Myozyme Updated to include criteria for Lumizyme. RX.PA.002 Pharmacy and Therapeutics Committee Structure Updated to include language to abstain from voting if conflict of interest and removed membership requirements. RX.007 Therapeutic Drug Utilization Review Updated to include the following drug utilization review (DURs): Coumadin DUR, Transitions Program, and Antipsychotic DUR. Also presented 2009 DUR report. RX.005 Quantity Limits The table below summarizes changes made to the Quantity Limit Policy: Drug Granisol solution (granisetron) Valcyte (valgancicilovir) Promacta (eltrombopag) Monophasic, biphasic, triphasic, and progestin only oral contraceptive tablets Extended cycle oral contraceptive tablets Depo-Provera (medroxyprogesterone) injection Nuvaring (etonogestrel/ethinyl estradiol) Cordran (flurandrenolide) Quantity Limit 90 ml per month 365 day supply per lifetime for CMV prophylaxis posttransplantation 25mg, 75mg: 30 tablets per 30 days 28 tablets per 28 days 91 tablets per 90 days 1 vial/syringe per 90 days 1 ring per 28 days 2 rolls of tape per month
5 Drug Quantity Limit Elidel (pimecrolimus) 6 months in a 12 month period Protopic (tacrolimus) 6 months in a 12 month period Victoza (liraglutide) 2 pens per month Actemra (tocilizumab) 800mg (40mL) per 28 days Ampyra (dalfampridine) 60 tablets per month Botox (onabotulinumtoxina) Four 100 Unit vials, Two 200 Unit vials Cayston (aztreonam inhalation solution) 84 vials per 56 days Copaxone (glatiramer acetate) 1 package of 30 vials per month Dysport (abobotulinumtoxina) Four 2,500 Unit vials, Two 5,000 Unit vials Forteo (teriparatide) 1 pen per 28 days, Maximum of 2 years per lifetime Myobloc (rimabotulinumtoxinb) Two 500 Unit vials Provenge (sipuleucel-t) 1 course per lifetime Qutenza (capsaicin patch) 4 patches per 90 days Rebif titration pack (interferon beta-1a) 1 package per lifetime TOBI (tobramycin) 56 vials per 56 days Xolair (omalizumab) 6 vials per 28 days Synarel (nafarelin) 5 bottles per 30 days Trelstar (triptorelin pamoate) 3.75 mg: 1 vial every 28 days, mg: 1 vial every 84 days, 22.5 mg: 1 vial every 168 days Zithromax (azithromycin) 500mg 4 tablets per month Xifaxan (rifaximin) 550 mg tablets: 60 tablets per 30 days Sporanox (itraconazole) 60 capsules per month Boniva (ibandronate) 1 vial per 90 days Prolia (denosumab) 2 vials per 365 days Rybix ODT (tramadol) 240 tablets per 30 days Ryzolt (tramadol) 30 tablets per 30 days Abilify (aripiprazole) 900 ml per 30 days Ambien CR (zolpidem) 1 tablet per day Edluar (zolpidem) 1 tablet per day Fanapt (iloperidone) Titration pack: 1 pack per year Invega Sustenna (paliperidone palmitate) 1 syringe/kit per 28 days (2 syringes per initial 28 days of therapy will be covered to allow for loading dose) Lexapro (escitalopram) Solution 20 ml per day Risperdal Consta (risperidone) 2 kits per 28 days Rozerem (ramelteon) 1 tablet per day Suboxone (buprenorphine/naloxone) 2/0.5 mg: 120 tablets per 30 days 8/2 mg: 90 tablets per 30 day Subutex (buprenorphine) 2 mg: 120 tablets per 30 days 8 mg: 90 tablets per 30 days Zyprexa Relprevv (olanzapine extended release injection) 210 mg and 300 mg: 2 kits per 28 days 405 mg: 1 kit per 28 days Provigil (modafinil) 100 mg: 30 tablets per 30 days 200mg : 60 tablets per 30 days Nuvigil (armodafinil) 30 tablets per 30 days
6 Definitions: Must add: Drug will be added to the formulary. : Drug may be added to the formulary or may be non-formulary. Other drugs already on the formulary are considered equally effective from a clinical standpoint. : Drug will be non-formulary. NOTE: All recommendations are subject to DPW approval and final decision determination by UPMC for You.
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Medications that require Step Therapy (ST) require trial and failure of preferred formulary agents prior to their authorization. If the prerequisite medications have been filled within the specified time
HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES. SEDATIVE HYPNOTIC AGENTS Generic Brand HICL GCN Exception/Other ZOLPIDEM
Generic Brand HICL GCN Exception/Other ZOLPIDEM AMBIEN 07842 GENERIC IS UNRESTRICTED TARTRATE AMBIEN CR EDLUAR INTERMEZZO ZOLPIMIST ESZOPICLONE LUNESTA 26791 GENERIC IS UNRESTRICTED RAMELTEON ROZEREM 33126
Michigan Department of Health & Human Services Quantity Limitations
Abstral (fentanyl) sl tab all strength Acetaminophen Actonel Actonel 35mg Adderall XR 5mg, 10mg, 15mg Advair Diskus Advair HFA Aero Chambers and Spacers Aerobid Aerobid M Albuterol HFA 90mcg Akynzeo Aldara
Rexulti (brexpiprazole)
Market DC Rexulti (brexpiprazole) Override(s) Approval Duration Prior Authorization 1 year Quantity Limit *Indiana see State Specific Mandates below *Maryland see State Specific Mandates below *Virginia
3 Tier Formulary Additions
3 Tier Formulary Additions Drug Name Tier Category Management ACCU-CHECK GUIDE ME GLUCOSE METER 3 Diabetic Supplies Step Therapy applies pyridostigmine bromide 60mg/5ml syrup 1 Antimyasthenic Agents New
5-ASA. Products Affected Dipentum 250 mg capsule. Details. Lialda 1.2 gram tablet,delayed release
5-ASA Dipentum 250 mg capsule Lialda 1.2 gram tablet,delayed release You are required to have previous therapy with balsalazide, Delzicol, Apriso, or Asacol HD before we will cover Lialda or Dipentum.
Step Therapy Criteria
Step Therapy Group ADCIRCA 1772-D ADCIRCA Coverage will be provided if the member has filled a prescription for sildenafil (at least a 30 day supply within the past 365 Step Therapy Group ANTIPSYCHOTICS
**CRITERIA UNDER CMS REVIEW**
**CRITERIA UNDER CMS REVIEW** ANTICONVULSANTS APTIOM TABLET 200 MG APTIOM TABLET 400 MG APTIOM TABLET 600 MG APTIOM TABLET 800 MG BANZEL SUSPENSION 40 MG/ML BANZEL TABLET 200 MG BANZEL TABLET 400 MG BRIVIACT
Pharmacy and Therapeutics (P&T) Committee Provider Update
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A Brief Overview of Psychiatric Pharmacotherapy. Joel V. Oberstar, M.D. Chief Executive Officer
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