Pharmacy and Therapeutics Update

Transcription

1 Pharmacy and Therapeutics Update Summer 2017 Highlights of recent drug policy revisions, as well as any new drug policies approved by Prevea360 Health Plan s Medical Policy Committee, are shown below. NOTE: All changes to the policies may not be reflected in the written highlights below. It is encouraged all prescribers review the current policies. ALL DRUGS that have written Prevea360 Health Plan policies MUST BE PRIOR AUTHORIZED by sending requests to Navitus, unless otherwise noted in the policy. Please note that most drugs require specialists to prescribe and request authorization. We encourage all prescribers to review the current policies. Policies regarding medications may be found on prevea360.com by searching drug policies. Please note that the name of the drug (either brand or generic name) must be spelled completely and correctly when using the search bar. New Drug Policies LUMIGAN (bimatoprost ophthalmic 0.03 percent) PA9934 LUMIGAN requires prior authorization through Navitus and is considered medically appropriate when the patient has failed (at least a one-month trial) taking latanoprost and Travatan Z. LUMIGAN requires prior authorization through Navitus and must be prescribed by or in consultation with ophthalmology or optometry specialists.

2 WELCHOL (colesevelam) PA9935 WELCHOL requires prior authorization through Navitus and is considered medically appropriate when the patient has a clinical diagnosis of familial hypercholesterolemia; and failed (at least a one-month trial) with cholestyramine or colestipol. WELCHOL requires prior authorization through Navitus and must be prescribed by or in consultation with a cardiology specialist. PIROXICAM CAPSULES PA9936 PIROXICAM CAPSULES requires prior authorization through Navitus and is considered medically appropriate when the patient has a clinical diagnosis of a spondylo-arthropathy and has failed (at least a one-month trial of) meloxicam. PIROXICAM CAPSULES requires prior authorization through Navitus and must be prescribed by or in consultation with rheumatology specialists. STIVARGA (regorafenib) PA9937 STIVARGA requires prior authorization through Navitus and is considered medically appropriate when the patient has a clinical diagnosis of locally advanced, unresectable, or metastatic GI stromal tumor or metastatic colorectal cancer. STIVARGA requires prior authorization through Navitus and must be prescribed by or in consultation with oncology specialists. CHANGES TO DRUG POLICY NUVIGIL (armodafanil) PA9876 Refractory Attention Deficit Hyperactivity Disorder (ADHD) in patients who have failed one formulary stimulant is now a covered indication. NUVIGIL requires prior authorization through Navitus. PERJETA (pertuzumab) MP9438 Must be prescribed by, or in consultation with, an oncologist or hematologist with prior authorization through Navitus. Also added NCCN categories for off label uses in oncology, and authorization duration limits. ABILIFY MAINTENA (aripiprazole) MP9456 Must be prescribed by or in consultation with a psychiatrist with prior authorization through Navitus. Addition of initial and renewal authorization duration limits. PROMACTA (eltrombopag) PA9867 Addition of initial and renewal authorization duration limits. TRINTELLIX (Vortioxetine) PA9902 Must be prescribed by, or in consultation with, a psychiatrist with prior authorization through Navitus. 2

3 RITUXAN (rituximab) PA9847 Effective September 1, 2017, RITUXAN will require prior authorization through Navitus and is restricted to rheumatology, transplant, hematology, neurology or oncology specialists. Additional indications RITUXAN is covered for, include chronic graft versus host disease, neurolyelitis optica, post transplant lumphoproliferative disorder, thrombotic thrombocytopenic purpura, immune or idiopathic thrombocytopenic purpura, and autoimmune hemolytic anemia. Also added NCCN categories for off label uses in oncology and authorization duration limits. REMICADE (infliximab) INFLECTRA (infliximab-dyyb) MP9231 REMICADE is restricted to dermatology, rheumatology and gastroenterology specialists with prior authorization through Navitus. Prior authorization is required for all prescribers. Please review the policy. GAZYVA (obinutuzumab) MP9451 GAZYVA is restricted to oncology specialists with prior authorization through Navitus. Also added NCCN categories for off label uses in oncology, and authorization duration limits. CIMZIA (certolizumab pegol) PA9875 CIMZIA requires prior authorization through Navitus and is restricted to rheumatology and gastroenterology specialists. A failed trial of HUMIRA and ENBREL is required for patients with early severe rheumatoid arthritis, a diagnosis of rheumatoid arthritis longer than three years, active psoriatic arthritis and active ankylosing spondylitis. A failed trial of HUMIRA is required for patients with moderate to severe Crohn s disease. Also added language that CIMZIA may not be prescribed in combination with other biologic DMARDs, in patients with tuberculosis or other serious infections, or in those patients without a tuberculin skin test to evaluate for latent tuberculosis prior to initiating. Please review the policy. SIMPONI and SIMPONI ARIA (golimumab) PA9874 SIMPONI requires prior authorization through Navitus and is restricted to rheumatology or gastroenterology specialists. Requires failed trials (at least one month each) of Humira and Enbrel for Rheumatoid Arthritis, Peripheral Ankylosing Spondylitis and Psoriatic Arthritis. Requires failed trial of Humira for Ulcerative Colitis. SIMPONI ARIA does not require prior authorization. Please review the policy. ENBREL (etanercept) PA9716 Added quantity limits and specialty pharmacy requirement statement, and additional criteria language for those with moderate to severe plaque psoriasis. Please review the policy. 3

4 ORENCIA (abatacept) SQ FORMULATION PA9846 ORENCIA SQ must be prescribed by rheumatology specialists with prior authorization through Navitus. Added language that it may not be prescribed in combination with other biologic DMARDs, in patients with tuberculosis or other serious infections, or in those patients without a tuberculin skin test to evaluate for latent tuberculosis prior to initiating. Please review the policy. ORENCIA (abatacept) IV FORMULATION MP9457 ORENCIA IV must be prescribed by rheumatology specialists with prior authorization through Navitus. Clarified language surrounding failure of prior therapy, and added language that it may not be prescribed in combination with other biologic DMARDs, in patients with tuberculosis or other serious infections, or in those patients without a tuberculin skin test to evaluate for latent tuberculosis prior to initiating. Please review the policy. ACTEMRA (tocilizumab) IV FORMULATION MP9405 Clarified language surrounding failure of prior therapy, and Added language that it may not be prescribed in combination with other biologic DMARDs, in patients with tuberculosis or other serious infections, or in those patients without a tuberculin skin test to evaluate for latent tuberculosis prior to initiating. Please review the policy. XELJANZ (tofacitinib) PA9897 Clarified language surrounding failure of prior therapy. HUMIRA (adalimumab) PA9822 Panuveitis is now a covered indication for HUMIRA. HUMRIA must be prescribed by rheumatology (RA, JIA, psoriatic arthritis, reactive arthritis, ankylosing spondylitis, or panuveitis), gastroenterology (Crohn s Disease and Ulcerative Colitis), dermatology (plaque psoriasis), or ophthomology (panuveitis) specialists with prior authorization through Navitus. Also added language to criteria for plaque psoriasis, Crohn s Disease, and panuveitis. Please review the policy. LEMTRADA (alemtuzumab) MP9468 LEMTRADA patients must have a negative HIV lab result and patients and providers must be enrolled in the LEMTRADA REMS program. LEMTRADA requires prior authorization through Navitus and must be prescribed by a neurology specialist. GILENYA (fingolimod) PA9922 Added requirement of discontinuation of current disease modifying therapy before initiating. 4

5 TYSABRI (natalizumab) PA9854 TYSABRI must be prescribed by a neurology (for relapsing, remitting multiple sclerosis) or gastroenterology (for moderate to severe Crohn s Disease) specialists with prior authorization through Navitus. Please review the policy. LYRICA (pregabalin) PA9845 Changed dose titration requirements for gabapentin, removed requirement of amitriptyline trial, added requirement of duloxetine trial. ZINBRYTA (daclizumab) PA9930 ZINBRYTA requires prior authorization through Navitus and must be prescribed either in consultation with or by a neurology specialist. ZINBRYTA is contraindicated for patients with preexisting hepatic disease or hepatic impairment. The patient must also fulfill the ZINBRYTA REMS program requirements. FORMULARY CHANGES The following are formulary changes as a result of Pharmacy and Therapeutic Committee activity. Other changes to the formularies may be found by going to prevea360.com. Choose the Recent Formulary Changes for the selected formulary. Class Reviews Mesalamines Change Asacol HD, mesalamine DR and Delzicol from PB to NC. Change Apriso from NPB to PB. Keep Lialda at PB. (January 1, 2018) LAMAs Change Spiriva from PB to NC. Keep Incruse PB. (January 1, 2018) with QL. LAMA/LABAs Change Anoro from NC to preferred brand. Keep Stiolto to PB. Members who require a non-formulary agent may be presented as medical exceptions via the exception to coverage process. (January 1, 2018) with QL. 5

6 Constipation Change Linzess from NPB with PA to PB with PA (SS through an OTC product). Change Movantik from NC to PB with PA (SS through an OTC product). Change Relistor from PB with PA to NC. Change Amitiza from NC to NPB with PA for Exchange LOB if required for benchmarks. (January 1, 2018). Opioid Dependency Change Bunavail and Zubsolv from NC to PB. Change buprenorphine/naloxone tabs from NPG to NC (NDC block). Keep Suboxone film at PB. (January 1, 2018). All changes noted below will have the following effective date: Commercial new starts (May 1, 2017) providing a 90-day transition period for current users beginning May 1, PPIs Formulary agents: omeprazole caps and pantoprazole (PG), and First Omeprazole and Lansoprazole Suspensions (PB). Change lansoprazole and rabeprazole from PG to NC. Change Prevacid Solutab from PB to NC. Change Dexilant from NPB with ST to NC. All other products in this class to remain at their current tier. ACEs Formulary agents: Lisinopril, benazepril, lisinopril/hctz, enalapril/hctz will remain as PG, Epaned (enalapril solution) will remain at NPB with a PA. Change the following from PG to NC: Captopril, enalapril, fosinopril, moexipril, perindopril, quinapril, ramipril, trandolapril, benazepril/hctz, captopril/hctz, fosinopril/hctz, moexipril/hctz, quinapril/hctz. ARBs Formulary agents: Losartan, irbesartan, losartan/hctz and valsartan/hctz will remain at PG. Valsartan will be NPG with a PA. Change valsartan from PG to non-pg with PA. Change irbesartan from PG to NC. Change candesartan, telmisartan, and candesartan/hctz from PB to NC. 6

7 Change Edarbi and Edarbyclor from NPB with ST to NC. Topical Steroids Unless otherwise noted, all other agents will remain at their current tier. Change from PG to NC: Betamethasone dip 0.05 percent ointment, Fluocinonide 0.05 percent cream, Fluocinonide 0.01 percent cream, Fluocinonide 0.05 percent ointment, Diflorasone ointment, Prednicarbate cream and ointment, Pramosone cream and ointment. Change from PB to NC: Desoximetasone 0.05 percent cream, Flurandrenolide. Change from PB with PA to NC: Clobetasol 0.05 percent cream and ointment, Clobetasol foam. Change from NPB to NC: Verdeso, Taclonex. Change from PB with PA to PB (no authorization required): Clobetasol E 0.05 percent cream, Clobetasol 0.05 percent solution. Ophthalmic Prostaglandins Lumigan will change from PB to NPB with PA. Criteria: Must be prescribed by ophthalmology or optometry, and failure of latanoprost and Travatan Z. Latanoprost (PG) and Travatan Z (PB) will remain formulary alternatives. Triptans Zolmitriptan tabs and ODT tabs will change from PB to NC. All other formulary alternatives will remain unchanged, including rizatriptan tabs and ODT tabs, sumatriptan nasal, tabs, and injection at PG, naratriptan at PB, and Alsuma injection, Sumavel Dosepro, and Zomig nasal (NPB). Bile Acid Sequestrants Welchol will change from PB to NPB with PA. Criteria: Prescribed by preventive cardiology, diagnosis of familial hypercholesterolemia and failed either cholestyramine or colestipol. H2 Blockers Cimetidine tabs and solution will change from PG to NC. Fluoxetine Tablets will change from PG to NC. Capsules and solution will remain at PG. Intranasal antihistamines Olopatadine will change from PB to NC. 7

8 NSAIDs Naproxen sodium 550 mg tab (Anaprox) will change from PB to NC. Piroxicam caps will change from PB to PB with PA. Criteria: Prescribed by rheumatology, treatment for spondylarthropathies and failure of meloxicam. Abbreviations: EGFR : Epidermal growth factor GIST: gastrointestinal stromal tumor HCTZ: hydrochlorothiazide KRAS: V-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog mcrc: Metastatic colorectal cancer LABA: Long acting beta agonist LAMA: Long acting muscarinic antagonist LOB: Line of business NC: Not covered NPB: Non-preferred brand NPG: Non-preferred generic OTC: Over-the-counter PA: Prior authorization PB: Preferred brand PG: Preferred generic QL: Quantity limit SS: Single step ST: Step therapy VEGF: Vascular endothelial growth factor XOI: Xanthine oxidase inhibitor 8