March 2017 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 the UCare formulary (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 formularies are tentative until UCare receives final CMS approval. Key: UFS: UCare for Seniors Medicare Formulary MSHO: Minnesota Senior Health Options/Special Needs Medicare Formulary SPP: State Public Programs or Medicaid HIX: Health Exchange Formulary EGWP: Employer Group Medicare Formulary T = Tier Level NF = Non-formulary Specialty: T5 UFS, T4 EGWP 4 Tier PA = Prior Authorization Non-Preferred Brand: T4 UFS, T3 EGWP 4 Tier QL = Quantity Limit Preferred Brand: T3 UFS, T2 EGWP 4 Tier ST = Step Therapy Brand: T2 EGWP 2 Tier, T2 Medicaid, T2 Exchange Non-Preferred generic: T2 UFS Preferred Generic: T1 UFS Generic: T1 EGWP 2 & 4 Tier, T1 Medicaid, T1 Exchange Drug Indication Formulary Action Effective Date Exondys Not added to Treatment of Duchenne muscular dystrophy (DMD) in patients who have a time - can be confirmed mutation of the DMD gene that obtained through is amenable to exon 51 skipping. Spinraza Rubraca Treatment of spinal muscular atrophy (SMA) in pediatric and adult patients. Indicated as monotherapy for the treatment of patients with deleterious BRCA mutation associated advanced ovarian cancer who have been treated with two or more chemotherapies. UFS & EGWP: F w/pa MSHO: F w/pa Medicaid: F w/pa Exchange: F w/pa Not added to time - can be obtained through Added to all formularies with PA. 4/1/2017 Ravaldee ER Treatment of secondary hyperparathyroidism in adults with stage 3 or 4 chronic kidney disease (CKD) and serum total 25-hydroxyvitamin D levels < Not added to time. March 2017 P&T Decisions Page 1

2 30 ng/ml. Vemlidy Zinplava Treatment of chronic HBV infection in adults with compensated liver disease. Indicated to reduce the recurrence of Clostridium difficile (C. difficile) infection (CDI) in patients 18 years of age who are receiving antibacterial drug treatment for CDI and are at a high-risk of CDI recurrence. UFS & EGWP: F MSHO: F Medicaid: F Exchange: F Added to all formularies. Will not be added to formularies at this time - can be obtained through 4/1/2017 Adlyxin Indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Will not be added to formularies at this time. New Generics Review All formulary changes noted are effective 4/1/17. Formulary coverage for each plan listed: Current Formulary Status/Proposed Formulary Status. OSELTAMIVIR PHOS 30 MG, 45 MG & 75 MG CAPSULE First Generics for: TAMIFLU UFS: F/F MSHO: F/F SPP: F/F HIX: F/F BIMATOPROST 0.03% EYELASH SOLN First Generics for: LATISSE UFS: NF/NF /NF SPP: NF/NF EZETIMIBE 10 MG TABLET First Generics for: ZETIA UFS: F/F MSHO: F/F SPP: F/F HIX: F/F NAFTIFINE HCL 1% CREAM First Generics for: NAFTIN (Obsolete) UFS: NA/F MSHO: NA/F SPP: NA/NF *Added to UFS and MSHO HIX: NA/NF March 2017 P&T Decisions Page 2

3 SODIUM NITROPRUSSIDE 50 MG/2ML First Generics for: NITROPRESS UFS: NF/NF /NF SPP: NF/NF APREPITANT 40 MG, 80 MG, 125 MG CAPSULE & MG PACK First Generics for: EMEND UFS: F/F MSHO: F/F SPP: NF/F HIX: NF/F *Added to SPP & HIX DEXMETHYLPHENIDATE ER 25 MG CP & 35 MG CP First Generics for: FOCALIN XR UFS: NF/F /F SPP: NF/F HIX: NF/F *Added to all formularies LOPINAVIR-RITONAVIR 80-20MG/ML First Generics for: KALETRA UFS: F/F MSHO: F/F SPP: F/F HIX: F/F RIBAVIRIN 6 GM INHALATION VIAL First Generics for: VIRAZOLE UFS: F/F MSHO: F/F SPP: NF/NF RASAGILINE MESYLATE 0.5 MG & 1 MG TAB First Generics for: AZILECT UFS: F/F MSHO: F/F SPP: NF/NF New Indications Review All formulary changes noted are effective 3/1/17. Formulary coverage for each plan listed: Current Formulary Status/Proposed Formulary Status. Adynovate (Antihemophilic Factor [recombinant], PEGylated lyophilized powder for intravenous injection) UFS: F/F MSHO: F/F SPP: F/F Lucentis (ranibizumab injection) UFS: F/F MSHO: F/F SPP: NF/NF March 2017 P&T Decisions Page 3

4 Revlimid (lenalidomide capsules) UFS: F/F MSHO: F/F SPP: F/F HIX: F/F Miscellaneous Previously Reviewed Items All formulary changes noted are effective 3/1/17. EPINEPHRINE 0.15 MG, 0.3 MG (EPINEPHRINE) AUTO-INJECTOR UFS: NF/F /F SPP: NF/F HIX: NF/F METOPROLOL ER-HCTZ MG, MG, MG (METOPROLOL SUCCINATE/HCTZ) TABLET UFS: NF/NF /NF SPP: NF/NF AUVI-Q 0.15 MG, 0.3 MG (EPINEPHRINE) AUTO-INJECTOR UFS: NF/NF /NF SPP: NF/NF Inflammatory Specialty Class Review P & T decisions made to this class from November March Medicaid formulary status and PA changes will be effective 5/1. PA changes and formulary additions for Health Exchange will also be effective 5/1, however, formulary removals, which will mirror the Medicaid changes, will not be effective until 1/1/18. Health Exchange Drug Current New Actemra (tocilizumab) IV and Sub Q F with PA F with updated PA Cimzia (certolizumab pegol) Cimzia powder and Syringe F with PA F with updated PA Enbrel (etanercept) F with PA and QL F with updated PA and QL Humira (adalimumab) F with PA and QL F with updated PA and QL Kineret (anakinra) F with PA F with updated PA Orencia (abatacept) F with PA F with updated PA Remicade (infliximab) F F Rituxan (rituximab) F F Simponi (golimumab) F with PA F with updated PA Xeljanz (tofacitinib) F with PA and QL F with updated PA and QL Taltz (ixekizumab) NF NF Cosentyx (secukinumab) F with PA F with updated PA Entyvio (vedolizumab) NF NF Stelara (ustekinumab) F with PA F with updated PA Otezla (Apremilast) NF F with PA and QL (60 per 30) Tysabri (natalizumab) F F with new PA March 2017 P&T Decisions Page 4

5 Medicaid Drug Current Change Actemra (tocilizumab) F with PA NF Cimzia (certolizumab pegol) NF NF Enbrel (etanercept) F with PA and QL F with updated PA and QL Humira (adalimumab) F with PA and QL F with updated PA and QL Kineret (anakinra) NF NF Orencia (abatacept) NF F with PA Remicade (infliximab) F NF Rituxan (rituximab) F NF Simponi (golimumab) NF NF Xeljanz (tofacitinib) NF F with PA and QL (60 per 30 (IR) or 30 per 30 (ER); match HIX)) Taltz (ixekizumab) NF NF Cosentyx (secukinumab) NF F with PA Entyvio (vedolizumab) F with PA NF Stelara (ustekinumab) NF F with PA Otezla (Apremilast) F with PA F with PA and QL (60 per 30) Tysabri (natalizumab) NF NF Medical Injectable Prior Authorization Criteria Review Adding all medically accepted conditions to PA Criteria where only FDA approved conditions were approvable previously. PA verbiage will be added for continuation of therapy if member is stabilized on drug. Epinephrine Auto-Injector Formulary Review Adding to all formularies. March 2017 P&T Decisions Page 5