September 2018 Pharmacy & Therapeutics Committee Decisions

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1 UCare s Pharmacy and Therapeutics Committee (P&T) is a group of physicians and pharmacists that meet throughout the year to make changes to UCare (approved drug list). These changes are reviewed based on clinical evidence, safety, and therapeutic guidelines. All changes that are recommended by P&T for the Medicare are tentative until UCare receives final CMS approval. Key: Medicare: UCare for Seniors, EssentiaCare, Minnesota Senior Health Options & Connect + Medicare and Employer Group Medicaid: PMAP, MnCare, MSC+ & Connect Exchange: UCare Choices & Fairview Choices NF = Non-formulary PA = Prior Authorization QL = Quantity Limit ST = Step Therapy New Drug Reviews Drug Indication Formulary Coverage Akynzeo IV (fosnetupitant/palono setron) The prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of highly emetogenic cancer chemotherapy (HEC). Medicare: NF Medicaid: NF Exchange: NF *Covered under Medical benefit Action Not added to at this time. Effective Date N/A Doptelet (avatrombopag maleate) 20mg Tablet Thrombopoietin receptor agonist indicated for the treatment of thrombocytopenia in adult patients with chronic liver disease who are scheduled to undergo a procedure. Added to all Tavalisse (fostamatinib sodium) tablets For the treatment of thrombocytopenia in adult patients with chronic immune thrombocytopenia (ITP) who have had an insufficient response to a previous treatment. Medicare: NF Medicaid: NF Exchange: NF Not added to at this time. N/A Noctiva (desmopressin acetate) spray For the treatment of nocturia due to nocturnal polyuria in adults who awaken at least two times per night to void. Medicare: NF Medicaid: NF Exchange: NF Not added to at this time. N/A September 2018 P&T Decisions Page 1

2 Crysvita (burosumabtwza) For the treatment of X-linked hypophosphatemia (XLH) in adult and pediatric patients 1 year of age. Added to Jynarque (tolvaptan) To slow kidney disease function decline in adults at risk of rapidly-progressing autosomal dominant polycystic kidney disease (ADPKD). Added to Palynziq (pegvaliase- PQPZ) To reduce phenylalanine concentrations in adult patients with phenylketonuria (PKU) who have uncontrolled blood phenylalanine (greater than 600 umol/l) on existing management. Added to New Generics Review All formulary changes noted are effective 10/1/18. Formulary coverage for plan listed: current formulary status/proposed formulary Status. F=formulary NF=non-formulary COLESEVELAM 625 MG TABLET First Generic for WELCHOL UFS: NF/F MSHO: NF/F SPP: F/F BUPRENORP-NALOX 8-2 MG SL FILM First Generic for SUBOXONE ERTAPENEM 1 GRAM VIAL First Generic for INVANZ BUDESONIDE ER 9 MG TABLET First Generic for UCERIS UFS: F/F MSHO: F/F SPP: NF/NF HYDROXYPROGEST 250 MG/ML VIAL First Generic for MAKENA COLESEVELAM HCL 3.75 G PACKET First Generic for WELCHOL September 2018 P&T Decisions Page 2

3 UFS: NF/F MSHO: NF/F SPP: F/F DORZOLAMIDE-TIMOLOL 2%-0.5% First Generic for COSOPT PF UFS: NF/F MSHO: NF/F SPP: NF/NF DESOXIMETASONE 0.25% SPRAY First Generic for TOPICORT UFS: NF/F MSHO: NF/F SPP: NF/NF CLIND PH-BENZOYL PERO % First Generic for ACANYA UFS: NF/F MSHO: NF/F SPP: NF/NF New Indications Review All formulary changes noted are effective 10/1/18. Formulary coverage for each plan listed: Current formulary status/proposed formulary status. F=formulary, NF=non-formulary Truvada (emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg tablets) Arnuity Ellipta (fluticasone furoate inhalation powder) UFS: NF/NF MSHO: NF/NF SPP: NF/NF Prolia (denosumab injection for subcutaneous use) Cimzia (certolizumab pegol injection for subcutaneous use) UFS: NF/NF MSHO: NF/NF SPP: NF/NF Prograf (tacrolimus capsules) UFS: NF/NF MSHO: NF/NF SPP: NF/NF Xeljanz (tofacitinib tablets) UFS: NF/NF MSHO: NF/NF SPP: F/F Alimta (pemetrexed for injection for intravenous use) UFS: F/F MSHO: F/F SPP: NF/NF Mircera (methoxy polyethylene glycol-epoetin beta injection for intravenous or subcutaneous use) UFS: NF/NF MSHO: NF/NF SPP: NF/NF Rituxan (rituximab intravenous infusion) UFS: F/F MSHO: F/F SPP: NF/NF Venclexta (venetoclax tablets) Keytruda (pembrolizumab injection for intravenous use) September 2018 P&T Decisions Page 3

4 Tecentriq (atezolizumab injection) Avastin (bevacizumab solution for intravenous [IV] infusion) UFS: F/F MSHO: F/F SPP: NF/NF Cinryze (C1 esterase inhibitor [human] injection for intravenous use) UFS: F/F MSHO: F/F SPP: NF/NF Xeomin (incobotulinumtoxina injection for intramuscular or intraglandular use) UFS: NF/NF MSHO: NF/NF SPP: F/F Opdivo (nivolumab injection for intravenous use) Yervoy (ipilimumab injection for intravenous use) UFS: F/F MSHO: F/F SPP: NF/NF Xtandi (enzalutamide capsules) Signifor LAR (pasireotide injectable suspension for intramuscular use) Kisqali (ribociclib tablets) UFS: F/F MSHO: F/F SPP: NF/NF Zomacton (somatropin for injection, for subcutaneous use) UFS: NF/NF MSHO: NF/NF SPP: NF/NF HIX:NF/NF Intelence (etravirine tablets) Timoptic-XE (timolol maleate ophthalmic gel forming solution) UFS: NF/NF MSHO: NF/NF SPP: NF/NF HIX:NF/NF Lotemax (loteprednol etabonate ophthalmic gel) UFS: NF/NF MSHO: NF/NF SPP: F/F HIX:NF/NF Atripla (efavirenz, emtricitabine, and tenofovir disoproxil fumarate tablets) Granix (tbo-filgrastim injection for subcutaneous use) UFS: F/F MSHO: F/F SPP: NF/NF Nuvessa (metronidazole vaginal gel 1.3%) UFS: NF/NF MSHO: NF/NF SPP: NF/NF HIX:NF/NF September 2018 P&T Decisions Page 4

5 Orkambi (lumacaftor/ ivacaftor tablets) Kalydeco (ivacaftor tablets and oral granules) Lenvima (lenvatinib capsules) Opdivo (nivolumab injection for intravenous use) Miscellaneous Previously Reviewed Items All formulary changes noted are effective 10/1/18. F=formulary, NF=non-formulary DUROLANE 60 MG/3 ML (HYALURONATE SODIUM, STABILIZED) SYRINGE ZYPITAMAG 1 MG, 2MG & 4MG (PITAVASTATIN MAGNESIUM) TABLET BALCOLTRA (LEVONORGEST/ETH. ESTRADIOL/IRON) TABLET OSMOLEX ER 193 MG, 129MG & 258MG (AMANTADINE HCL) TABLET KEDRAB 150 UNIT/ML (RABIES IMMUNE GLOBULIN/PF) VIAL SYMFI MG & MG (EFAVIRENZ/LAMIVU/TENOFOV DISOP) TABLET UFS: F MSHO: F SPP: F HIX: F CIMDUO MG (LAMIVUDINE/TENOFOVIR DISOP FUM) TABLET UFS: F MSHO: F SPP: F HIX: F YONSA 125 MG (ABIRATERONE ACET,SUBMICRONIZED) TABLET *Protected Class Drug* UFS: F MSHO: F SPP: NF HIX: NF September 2018 P&T Decisions Page 5

6 September 2018 P&T Decisions Page 6

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