Performance Drug List Change Detail Report Effective (Standard Drug List Reflects Exclusions)

Transcription

1 This report highlights all changes (additions and deletions) to the CVS Caremark Performance Drug List. ADDITIONS: Brand Agents: Betaseron (interferon beta-1b) Central Nervous System/ Multiple Sclerosis Agents Betaseron is indicated for treatment of relapsing forms of multiple sclerosis to reduce the frequency of clinical exacerbations. To continue to provide additional treatment option for multiple sclerosis. Humulin R U-500 (insulin human) Viibryd (vilazodone) Central Nervous System/ Antidepressants, Selective Serotonin Reuptake Inhibitors (SSRIs) Humulin R U-500 is indicated as an adjunct to diet and exercise to improve glycemic control in adults and children with type 1 and type 2 diabetes mellitus. Viibryd is indicated for the treatment of major depressive disorder (MDD). To provide the only concentrated insulin therapy option as there are no equivalent alternatives. Humulin R U-500 is already on the Performance Drug List in the adjudication systems. Humulin R U-500 will be listed on the Performance Drug List document, effective 1/1/2012. To provide an additional option for the management of major depressive disorder. Xarelto (rivaroxaban) Hematologic/ Anticoagulants Xarelto is indicated for the prophylaxis of deep vein thrombosis (DVT) which may lead to pulmonary embolism (PE) in patients undergoing knee or hip replacement surgery. To provide an additional oral anticoagulant therapy option for prevention of DVT following knee or hip replacement surgery that does not require regular blood test monitoring or dietary restrictions. Last Revised: 09/27/2011 Pg. 1 of 13

2 DELETIONS: Brand Agents: Estraderm (estradiol transdermal) Estrogens, Transdermal Estraderm is indicated in: Treatment of moderate to severe vasomotor symptoms associated with the menopause. Treatment of moderate to severe symptoms of vulvar and vaginal atrophy associated with the menopause. Treatment of hypoestrogenism due to hypogonadism, castration, or primary ovarian failure. Prevention of postmenopausal osteoporosis. Estraderm (estradiol transdermal) is being discontinued by the manufacturer. Alternatives on the Performance Drug List include estradiol, Evamist (estradiol transdermal) and Vivelle-Dot (estradiol transdermal). Genotropin (somatropin) Human Growth Hormones Genotropin is indicated for: Pediatric: Treatment of children with growth failure due to growth hormone deficiency, Prader-Willi syndrome, Small for Gestational Age, Turner syndrome and Idiopathic Short Stature. Adult: Treatment of adults with Availability of other therapy options. An alternative on the Performance Drug List is Norditropin (somatropin). Last Revised: 09/27/2011 Pg. 2 of 13

3 either adult onset or childhood onset growth hormone deficiency. Nasacort AQ (triamcinolone acetonide spray) Respiratory/ Nasal Steroids Nasacort AQ is indicated for treatment of nasal symptoms of seasonal and perennial allergic rhinitis in adults and children 6 years of age and older. Nasacort AQ (triamcinolone acetonide spray) is being removed from the drug list due to the availability of an A -rated generic, triamcinolone acetonide spray. Rebif (interferon beta-1a) Central Nervous System/ Multiple Sclerosis Agents Rebif is indicated for the treatment of patients with relapsing forms of multiple sclerosis to decrease the frequency of clinical exacerbations and delay the accumulation of physical disability. Availability of other therapy options. Alternatives on the Performance Drug List include Avonex (interferon beta-1a), Betaseron (interferon beta- 1b) and Copaxone (glatiramer). Seasonique (levonorgestrel/ ethinyl estradiol 0.15 mg/30 mcg and ethinyl estradiol 10 mcg) Contraceptives, Extended Cycle Seasonique is indicated for use by women to prevent pregnancy. Seasonique (levonorgestrel/ethinyl estradiol 0.15 mg/30 mcg and ethinyl estradiol 10 mcg) is being removed from the drug list due to the availability of an A -rated generic, levonorgestrel/ethinyl estradiol 0.15 mg/30 mcg and ethinyl estradiol 10 mcg). Last Revised: 09/27/2011 Pg. 3 of 13

4 EXCLUSIONS: Brand Agents: Advicor (niacin extendedrelease/ lovastatin) Altoprev (lovastatin extendedrelease) Antilipemics/ Niacins/Combinations Antilipemics/ HMG-CoA Reductase Inhibitors Advicor is indicated for the treatment of primary hypercholesterolemia (heterozygous familial and nonfamilial) and mixed dyslipidemia (Frederickson types IIa and IIb) in: patients treated with lovastatin who require further TG-lowering or HDL-raising who may benefit from having niacin added to their regimen. patients treated with niacin who require further LDL-lowering who may benefit from having lovastatin added to their regimen. Altoprev is indicated for: Primary Prevention of Coronary Heart Disease In individuals without symptomatic cardiovascular disease, average to moderately elevated Total-C and LDL-C, and below average HDL-C to reduce the risk of: Myocardial infarction An alternative on the Prescribing Guide is Simcor (niacin extended-release/simvastatin). Alternatives on the Prescribing Guide are lovastatin, pravastatin, simvastatin, Crestor (rosuvastatin) and Lipitor (atorvastatin). Last Revised: 09/27/2011 Pg. 4 of 13

5 Unstable angina Coronary revascularization procedures Coronary Heart Disease To slow the progression of coronary atherosclerosis in patients with coronary heart disease as part of a treatment strategy to lower Total-C and LDL- C to target levels. Arthrotec (diclofenac sodium delayed-release/ Analgesics/ NSAIDs Hyperlipidemia As an adjunct to diet for the reduction of elevated Total-C, LDL-C, Apo B, and TG, and to increase HDL-C in patients with primary hypercholesterolemia (heterozygous familial and nonfamilial) and mixed dyslipidemia (Fredrickson types IIa and IIb) when the response to diet restricted in saturated fat and cholesterol and to other nonpharmacological measures alone has been inadequate. Arthrotec is indicated for treatment of the signs and symptoms of osteoarthritis or rheumatoid Alternatives on the Prescribing Guide are diclofenac w/misoprostol, meloxicam w/misoprostol, naproxen w/misoprostol, Celebrex (celecoxib) and Vimovo Last Revised: 09/27/2011 Pg. 5 of 13

6 misoprostol) arthritis in patients at high risk of developing NSAID-induced gastric and duodenal ulcers and their complications. (naproxen/esomeprazole delayed-release). Atacand (candesartan) Angiotensin II Receptor Antagonists/Diuretic Combinations Atacand is indicated for the treatment of: Hypertension in adults and children 1 to <17 years of age. Treatment of heart failure (NYHA class II-IV); Atacand reduces cardiovascular death and heart failure hospitalization. Alternatives on the Prescribing Guide are losartan, Benicar (olmesartan), Diovan (valsartan) and Micardis (telmisartan). Atacand HCT (candesartan/ hydrochlorothiazide) Angiotensin II Receptor Antagonists/Diuretic Combinations Atacand HCT is indicated for the treatment of hypertension. This fixed dose combination is not indicated for initial therapy. Alternatives on the Prescribing Guide are losartan/hydrochlorothiazide, Benicar HCT (olmesartan/hydrochlorothiazide), Diovan HCT (valsartan/hydrochlorothiazide) and Micardis HCT (telmisartan/hydrochlorothiazide). Axiron (testosterone transdermal solution) Androgens Axiron is indicated for replacement therapy in males for conditions associated with a deficiency or absence of endogenous testosterone: Primary hypogonadism (congenital or acquired). Hypogonadotropic Alternatives on the Prescribing Guide are Androderm (testosterone transdermal) and Androgel (testosterone gel). Last Revised: 09/27/2011 Pg. 6 of 13

7 hypogonadism (congenital or acquired). Beconase AQ (beclomethasone spray) Brevoxyl (benzoyl peroxide) Edarbi (azilsartan) Respiratory/ Nasal Steroids Topical/ Dermatology/Acne/Topical Angiotensin II Receptor Antagonists/Diuretic Combinations Beconase AQ nasal spray is indicated for the relief of the symptoms of seasonal or perennial allergic and nonallergic (vasomotor) rhinitis. Brevoxyl is indicated for use in the topical treatment of mild to moderate acne vulgaris. Edarbi is indicated for the treatment of hypertension, to lower blood pressure. Alternatives on the Prescribing Guide are flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex (mometasone spray) and Veramyst (fluticasone furoate spray). An alternative on the Prescribing Guide is benzoyl peroxide. Alternatives on the Prescribing Guide are losartan, Benicar (olmesartan), Diovan (valsartan) and Micardis (telmisartan). Flector (diclofenac epolamine transdermal) Fortamet (metformin extendedrelease) Analgesics/ NSAIDs, Topical Antidiabetics/Biguanides Flector is indicated for the topical treatment of acute pain due to minor strains, sprains, and contusions. Fortamet is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Alternatives on the Prescribing Guide are diclofenac, meloxicam and naproxen. An alternative on the Prescribing Guide is metformin extended-release. Fortesta (testosterone transdermal gel) Androgens Fortesta is indicated for replacement therapy in males for conditions associated with a deficiency or absence of Alternatives on the Prescribing Guide are Androderm (testosterone transdermal), Androgel (testosterone gel) and testosterone (buccal). Last Revised: 09/27/2011 Pg. 7 of 13

8 endogenous testosterone: Primary hypogonadism (congenital or acquired). Hypogonadotropic hypogonadism (congenital or acquired). Freestyle Kits and Test Strips Antidiabetics/Supplies Not Applicable. Alternatives on the Prescribing Guide are Accu-Chek Kits and Test Strips and OneTouch Kits and Test Strips. Glumetza (metformin extendedrelease) Antidiabetics/Biguanides Glumetza is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. An alternative on the Prescribing Guide is metformin extended-release. Humalog (insulin lispro) Humalog is indicated in the treatment of patients with diabetes mellitus for the control of hyperglycemia. An alternative on the Prescribing Guide is Novolog (insulin aspart). Humalog Mix 50/50 (insulin lispro protamine 50%/ insulin lispro 50%) Humalog Mix 75/25 (insulin lispro protamine 75%/ insulin lispro 25%) Humalog Mix is indicated in the treatment of patients with diabetes mellitus for the control of hyperglycemia. Humalog Mix is indicated in the treatment of patients with diabetes mellitus for the control of hyperglycemia. An alternative on the Prescribing Guide is Novolog Mix 70/30 (insulin aspart protamine 70%/insulin aspart 30%). An alternative on the Prescribing Guide is Novolog Mix 70/30 (insulin aspart protamine 70%/insulin aspart 30%). Last Revised: 09/27/2011 Pg. 8 of 13

9 Humulin R (insulin human) Humulin R is indicated in the treatment of patients with diabetes mellitus for the control of hyperglycemia. An alternative on the Prescribing Guide is Novolin R (insulin human). Humulin N (insulin isophane human) Humulin 70/30 (insulin isophane human 70%/ regular 30%) Humulin N is indicated in the treatment of patients with diabetes mellitus for the control of hyperglycemia. Humulin 70/30 is indicated in the treatment of patients with diabetes mellitus for the control of hyperglycemia. An alternative on the Prescribing Guide is Novolin N (insulin isophane human). An alternative on the Prescribing Guide is Novolin 70/30 (insulin isophane human 70%/regular 30%). Levitra (vardenafil) Genitourinary/ Erectile Dysfunction/ Phosphodiesterase Inhibitors Levitra is indicated for treatment of erectile dysfunction. Alternatives on the Prescribing Guide are Cialis (tadalafil) and Viagra (sildenafil). Livalo (pitavastatin) Antilipemics/HMG-CoA Reductase Inhibitors Livalo is indicated for patients with primary hyperlipidemia and mixed dyslipidemia as an adjunctive therapy to diet to reduce elevated total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), apolipoprotein B (Apo B), triglycerides (TG), and to increase high-density lipoprotein cholesterol (HDL-C). Alternatives on the Prescribing Guide are lovastatin, pravastatin, simvastatin, Crestor (rosuvastatin) and Lipitor (atorvastatin). Maxair Respiratory/ Maxair is indicated for the Alternatives on the Prescribing Guide are Proair HFA Last Revised: 09/27/2011 Pg. 9 of 13

10 (pirbuterol) Beta Agonists, Inhalants, Short Acting prevention and reversal of bronchospasm in patients 12 years of age and older with reversible bronchospasm including asthma. (albuterol sulfate, CFC-free aerosol), Proventil HFA (albuterol sulfate, CFC-free aerosol) and Ventolin HFA (albuterol sulfate, CFC-free aerosol). Neobenz Micro (benzoyl peroxide) Topical/ Dermatology/Acne/Topical Neobenz Micro is indicated for use in the topical treatment of mild to moderate acne vulgaris. An alternative on the Prescribing Guide is benzoyl peroxide. Oleptro (trazodone extendedrelease) Central Nervous System/ Antidepressants/Tricyclic Antidepressants (TCAs) Oleptro is indicated for the treatment of major depressive disorder. An alternative on the Prescribing Guide is trazodone. Olux-E (clobetasol propionate emulsion foam 0.05%) Omnaris (ciclesonide spray) Topical/ Dermatology/ Corticosteroids/ Very High Potency Respiratory/ Nasal Steroids Olux-E is indicated for the treatment of inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses in patients 12 years of age or older. Omnaris nasal spray is indicated for treatment of nasal symptoms associated with seasonal allergic rhinitis in adults and children 6 years of age and older and perennial allergic rhinitis in adults and adolescents 12 years of age and older. An alternative on the Prescribing Guide is clobetasol propionate foam 0.05%. Alternatives on the Prescribing Guide are flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex (mometasone spray) and Veramyst (fluticasone furoate spray). Last Revised: 09/27/2011 Pg. 10 of 13

11 Oxytrol (oxybutynin transdermal) Genitourinary/ Urinary Antispasmodics Oxytrol is indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency. Alternatives on the Prescribing Guide are oxybutynin extended-release, Detrol (tolterodine), Detrol LA (tolterodine extended-release), Enablex (darifenacin extended-release), Gelnique (oxybutynin gel) and Vesicare (solifenacin succinate). Rhinocort Aqua (budesonide spray) Respiratory/ Nasal Steroids Rhinocort Aqua nasal spray is indicated for the treatment of nasal symptoms of seasonal and perennial allergic rhinitis in adults and children six years of age and older. Alternatives on the Prescribing Guide are flunisolide spray, fluticasone spray, triamcinolone spray, Nasonex (mometasone spray) and Veramyst (fluticasone furoate spray). Riomet (metformin solution) Antidiabetics, Biguanides Riomet is indicated as an adjunct to diet and exercise to improve glycemic control in adults and children with type 2 diabetes mellitus. An alternative on the Prescribing Guide is metformin extended-release. Ryzolt (tramadol extendedrelease) Analgesics/ Non-narcotic Analgesics Ryzolt is indicated for the management of moderate to moderately severe chronic pain in adults who require around-theclock treatment of their pain for an extended period of time. An alternative is tramadol extended-release. Sanctura XR Genitourinary/ Sanctura XR is indicated for the Alternatives on the Prescribing Guide are oxybutynin Last Revised: 09/27/2011 Pg. 11 of 13

12 (trospium extendedrelease) Urinary Antispasmodics treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency. extended-release, Detrol (tolterodine), Detrol LA (tolterodine extended-release), Enablex (darifenacin extended-release), Gelnique (oxybutynin gel) and Vesicare (solifenacin succinate). Testim (testosterone transdermal gel) Androgens Testim is indicated for replacement therapy in males for conditions associated with a deficiency or absence of endogenous testosterone: Primary hypogonadism (congenital or acquired). Hypogonadotropic hypogonadism (congenital or acquired). Alternatives on the Prescribing Guide are Androderm (testosterone transdermal) and Androgel (testosterone gel). Teveten (eprosartan) Angiotensin II Receptor Antagonists/Diuretic Combinations Teveten is indicated for the treatment of hypertension. Alternatives on the Prescribing Guide are losartan, Benicar (olmesartan), Diovan (valsartan) and Micardis (telmisartan). Teveten HCT (eprosartan/ hydrochlorothiazide) Angiotensin II Receptor Antagonists/Diuretic Combinations Teveten HCT is indicated for the treatment of hypertension. Alternatives on the Prescribing Guide are losartan/hydrochlorothiazide, Benicar HCT (olmesartan/hydrochlorothiazide), Diovan HCT (valsartan/hydrochlorothiazide) and Micardis HCT (telmisartan/hydrochlorothiazide). Last Revised: 09/27/2011 Pg. 12 of 13

13 Toviaz (fesoterodine extended-release) Tradjenta (linagliptin) Xopenex HFA (levalbuterol tartrate, CFC-free aerosol) Genitourinary/ Urinary Antispasmodics Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Respiratory/ Beta Agonists/Inhalants/ Short Acting Toviaz is a muscarinic antagonist indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency. Tradjenta is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Xopenex HFA is indicated for the treatment of prevention of bronchospasm in adults, adolescents, and children 4 years of age and older with reversible obstructive airway disease. Alternatives on the Prescribing Guide are oxybutynin extended-release, Detrol (tolterodine), Detrol LA (tolterodine extended-release), Enablex (darifenacin extended-release), Gelnique (oxybutynin gel) and Vesicare (solifenacin succinate). Alternatives on the Prescribing Guide are Januvia (sitagliptin phosphate) and Onglyza (saxagliptin). Alternatives on the Prescribing Guide are Proair HFA (albuterol sulfate, CFC-free aerosol), Proventil HFA (albuterol sulfate, CFC-free aerosol) and Ventolin HFA (albuterol sulfate, CFC-free aerosol). Last Revised: 09/27/2011 Pg. 13 of 13