Pharmacy and Therapeutics Committee Decisions March 27, 2015

Transcription

1 Pharmacy and Therapeutics Committee Decisions March 27, 2015 Type of Review New Medications Drug/Therapeutic Class Olaparib (Lynparza - AstraZeneca) P&T Decision Recommended that Olaparib NOT be added to the formulary Cosentyx (secukinumab for SC injection- Novartis) Remicade (infliximab for intravenous- Janssen Biotech) Humira (adalimumab for SC injection AbbVie) Enbrel (etanercept for SC injection Immunex) Stelara (ustekinumab for SC injection Janssen Products) Otezla (apremilast tablets - Celgene) methotrexate tablets (multiple generics) [ST] Recommended that Cosentyx be added to the formulary with prior Authorization. Recommend changing Stelara criteria to denial request to plan required. Multiple Sclerosis Drugs peginterferon beta- 1a injection (Plegridy - Biogen Do not add Plegridy to the formulary. Retain formulary status of Extavia and move

2 Idec) fingolimod (Gilenya - Novartis) teriflunomide (Aubagio - Genzyme/Sanofi) glatiramer acetate injection (Copaxone - Teva) interferon beta-1a injection [IM] (Avonex - Biogen Idec) interferon beta-1a injection [SC] (Rebif - Serono) interferon beta-1b injection (Betaseron - Bayer; Extavia - Novartis) dimethyl fumarate (Tecfidera - Biogen Idec) natalizumab injection (Tysabri - Biogen Idec) mitaxantrone (generic) 1 1 Betaseron to Non-ormulary status. Members with current authorizations for Betaseron are recommended to be grandfathered through the end of their authorization. Insulin (Rapid-Acting and Other) insulin human [rdna origin] inhalation powder (Afrezza - Sanofi) insulin aspart (Novolog Novo Nordisk) insulin lispro Recommended that Afrezza not be added to the formulary. Non-formulary criteria will automatically deny Afrezza and require all requests to go through appeal with CHPW. 1 IV Products are not covered by pharmacy benefit but are usually covered by medical benefit

3 (Humalog - Eli Lilly) insulin glulisine (Apidra Sanofi Aventis) Coverage Criteria Reviews everolimus (Afinitor Novartis) Recommended to maintain Afinitor on the formulary with updated prior authorization criteria for expanded indication. Prior authorization will limit its use to DA approved indications as specified in the indication section With an Authorization of a year. Anticonvulsants carbamazepine carbamazepine extended-release capsule carbamazepine extended-release capsule (Equetro and Carbatrol Shire) carbamazepine extended-release tablet (generics, Tegretol XR Novartis) divalproex sodium divalproex sodium delayed-release divalproex sodium extended-release ethosuximide status for all anticonvulsants. Update PA criteria for Lyrica to include new DA indication.

4 ethotoin (Peganone Lunbeck Inc) ezogabine (Potiga GlaxoSmithKline) felbamate gabapentin (generics, Gralise Depomed Inc.) gabapentin solution lacosamide (Vimpat UCB Pharma) lamotrigine levetiracetam (generics, Keppra - UBC Pharma) levetiracetam extended-release (generics, Keppra XR -UBC Pharma) methsuximide (Celontin Pfizer) oxcarbazepine oxcarbazepine suspension phenytoin pregabalin (Lyrica Pfizer) primidone rufinamide (Banzel Eisai) - NP [PA ] tiagabine -

5 Therapeutic Class Review (Gabitril Cephalon) topiramate valproic acid valproic acid delayed-release (Stavzor Noven) vigabatrin (Sabril Lundbeck) NP [PA ] zonisamide ivacaftor (Kalydeco Vertex) Long-Acting Anticholinergic Inhalers umeclidinium inhalation powder (Incruse Ellipta - GlaxoSmithKline) Tiotropium bromide inhalation power (Spiriva Handihaler - Boehringer Ingelheim Pharmaceuticals, Inc. Aclidinium bromide inhalation powder (Tudorza Pressair - orest/almirall) Recommended to maintain Kalydeco on the formulary with updated prior authorization criteria for expanded indication. Prior authorization will limit its use to DA approved indications as specified in the indication Leave formulary as is with Incruse Ellipta as nonformulary. And work with network to look at approbate Tudorza Pressair utilization in members that will not mind twice daily dosing, or were Tudorza Pressair might be utilized. Revisit with new indications. Will add quantity limits to Spiriva and Tudorza. Inhaled Corticosteroids (ICS) fluticasone furoate inhalation powder (Arnuity Ellipta - Recommend retaining formulary status for all other inhaled corticosteroids. Recommended that Arnuity Ellipta not be added to the

6 GlaxoSmithKline) beclomethasone HA inhalation aerosol (QVAR Teva) budesonide inhalation suspension (generic) budesonide inhalation powder (Pulmicort lexhaler AstraZeneca) ciclesonide inhalation aerosol (Alvesco Sunovion) flunisolide HA inhalation aerosol (Aerospan Acton) fluticasone HA inhalation aerosol (lovent HA GlaxoSmithKline) fluticasone inhalation powder (lovent Diskus GlaxoSmithKline) mometasone HA inhalation aerosol (Asmanex HA - Merck) mometasone inhalation powder (Asmanex Twisthaler Merck) - NP - NP - NP formulary. Therapeutic Summary Class Review dexlansoprazole (Dexilant Takeda) esomeprazole magnesium delayed-release Proton Pump Inhibitors Add Prilosec Packets for Solution to the formulary. Coverage is recommended for members under 6 with prior authorization required for those older than 6. Retain formulary status of all other proton pump inhibitors.

7 esomeprazole magnesium delayed-release (Nexium 24HR OTC Pfizer) lansoprazole delayed-release lansoprazole delayed-release (Prevacid 24 HR OTC Novartis) lansoprazole delayed-release (Prevacid /Preva cid SoluTab Takeda) omeprazole delayed-release capsule omeprazole magnesium delayed-release tablet omeprazole/sodiu m bicarbonate (Zegerid OTC - Merck) omeprazole/sodiu m bicarbonate capsules/suspensi on (Zegerid

8 Santarus) pantoprazole sodium delayedrelease rabeprazole delayed-release (Aciphex Eisai) donepezil tablet & dispersible tablet galantamine tablet galantamine extendedrelease capsules memantine tablet/ extended-release tablet (Namenda/ XRP P orest Lab) rivastigmine tablet rivastigmine transdermal patch (ExelonP P patch Novartis) Antidementia Agents status for all antidementia agents. teriflunomide (Aubagio - Genzyme/Sanofi) Multiple Sclerosis Oral Agents status for all oral multiple sclerosis agents.

9 fingolimod (Gilenya - Novartis) dimethyl fumurate (Tecfidera - Biogen Idec) (PA) (PA) adefovir dipivoxil entecavir (Baraclude Bristol-Myers Squibb) lamivudine (generics, Epivir HBV GlaxoSmithKline) telbivudine (Tyzeka Novartis) tenofovir (Viread Gilead Sciences) Oral Hepatitis B Agents status for all oral hepatitis B agents. ciprofloxacin tablets ciprofloxacin oral suspension gemifloxacin tablets (active - Vansen Pharma) levofloxacin tablets moxifloxacin tablets norfloxacin tablets (Noroxin - Merck) ofloxacin tablets Oral Quinolones status for all oral quinolone antibiotics. baclofen tablet carisoprodol Skeletal Muscle Relaxants status for all skeletal muscle relaxants. Add Methocarbamol to the

10 chlorzoxazone cyclobenzaprine tablet cyclobenzaprine extended-release capsule dantrolene sodium capsule (generic) metaxalone methocarbamol tablet orphenadrine citrate tablet tizanidine formulary. Bile Acid Sequestrants and Other Dyslipidemia Treatment Medications cholestyramine oral suspension colestipol oral suspension & micronized tablets colesevelam tablets (Welchol Daiichi- Sankyo) ezetimbe (Zetia - Merck) niacin extended-release status for all bile acid sequestrants. ibric Acid Derivatives fenofibrate tablets fenofibrate capsules fenofibric acid capsules and tablets fenofibric acid capsules delayed release status for all fibric acid derivatives. Gemfibrozil will be moved to formulary Non-preferred, and existing users of Gemfibrozil will be grandfathered in for a year.

11 fenofibric acid tablets gemfibrozil tablets micronized fenofibrate capsules/tablets HMG-CoA Reductase Inhibitors atorvastatin Recommend to retain current formulary status for all HMG-CoA Reductase Inhibitors. fluvastatin fluvastatin extended-release (Lescol XL Novartis) lovastatin lovastatin extended-release (Altoprev Shionogi) pitavastatin (Livalo Kowa Pharmaceuticals) pravastatin rosuvastatin (Crestor AstraZeneca) simvastatin [ST]

12 atorvastatin/amlodi pine atorvastatin/ezetim be (Liptruzet Merck) lovastatin/niacin (Advicor AbbVie) simvastatin/ezetimi be (Vytorin Merck) simvastatin/niacin (Simcor AbbVie) simvastatin/sitaglip tin (Juvisync Merck) Bisphosphonates alendronate alendronate effervescent tablet (Binosto Mission Pharmacal) alendronate plus cholecalciferol (osamax Plus D Merck) ibandronate [ST] [ST} status for all bisphosphonates.

13 risedronate (generics and Actonel Actavis) risedronate delayed-release (Atelvia Actavis) ibandronate injection zoledronic acid injection [ST] * * Oral Nonsteroidal Anti-Inflammatory Drugs ibuprofen indomethacin status for all oral nonsteroidal antiinflammatory drugs. meloxicam naproxen piroxicam celecoxib diclofenac diflunisal (generic) etodolac

14 fenoprofen flurbiprofen ketoprofen ketorolac meclofenamate mefenamic acid nabumetone oxaprozin sulindac tolmetin Vimovo (Naproxen and esomeprazole) Loop Diuretics bumetanide ethacrynic acid (Edecrin - Valeant Pharmaceutical International, Inc.) furosemide torsemide Insulin (Basal) insulin detemir status for all loop diuretics. status for all basal insulins.

15 (Levemir Novo Nordisk) insulin detemir pen device (Levemir lextouch Novo Nordisk) insulin glargine (Lantus Sanofi Aventis) insulin glargine pen device (Lantus Solostar - Sanofi Aventis) Insulin (Rapid-Acting and Other) insulin aspart (Novolog Novo Nordisk) status for all rapid-acting and other insulins. insulin aspart pen device/cartridge (Novolog lexpen Novo Nordisk) 70% insulin aspart protamine suspension/30% insulin aspart (Novolog Mix 70/30 Novo Nordisk) insulin aspart protamine suspension/insulin aspart pen device (Novolog Mix 70/30 lexpen Novo Nordisk) insulin regular (Novolin R Novo Nordisk)

16 NPH insulin (Novolin N Novo Nordisk) 70% NPH/30% regular insulin (Novolin 70/30 NovoNordisk) insulin glulisine (Apidra Sanofi Aventis) insulin glulisine pen device (Apidra Solostar Sanofi Aventis) insulin lispro (Humalog - Eli Lilly) insulin lispro pen device (Humalog Kwikpen - Eli Lilly) 50% insulin lispro protamine suspension/ 50% insulin lispro (Humalog Mix 50/50 Eli Lilly) 50% insulin lispro protamine suspension/ 50% insulin lispro pen device (Humalog Mix 50/50 Kwikpen Eli Lilly) 75% insulin lispro protamine

17 suspension/ 25% insulin lispro (Humalog Mix 75/25 Eli Lilly) 75% insulin lispro protamine suspension/ 25% insulin lispro pen device (Humalog Mix 75/25 Kwikpen Eli Lilly) regular insulin (Humulin R- Eli Lily) insulin regular concentrate (Humulin R U-500 Eli Lilly) NPH insulin (Humulin N Eli Lily) NPH insulin pen device (Humulin N Kwikpen Eli Lily) 70% NPH/30% regular insulin pen (Humulin 70/30 Eli Lily) 70% NPH/30% regular insulin pen device (Humulin 70/30 Kwikpen Eli Lily) Dipeptidyl-Peptidase 4 (DPP-4) Inhibitors and Combinations status for all Dipeptidyl-

18 Alogliptin (Nesina Takeda) alogliptin/metformin (Kazano Takeda) alogliptin/pioglitazone (Oseni Takeda) linagliptin (Tradjenta Boehringer Ingelheim/Eli Lilly) linagliptin/metformin (Jentadueto Boehringer Ingelheim/Eli Lilly) saxagliptin (Onglyza Bristol Meyers Squibb) saxagliptin/metformin extended release (Kombiglyze XR Bristol Myers Squibb) sitagliptin (Januvia Merck) sitagliptin/metformin (Janumet Merck) sitagliptin/metformin extended release (Janumet XR Merck) Peptidase 4 (DPP-4) Inhibitors and Combinations. Come back in June with a full therapeutic class infomation, and with a recommendation based on rebates, ethicacy and cost

19 Meglitinide Agents repaglinide/metformin (Prandimet Novo Nordisk) nateglinide repaglinide status for all Meglitinide anti diabetic agents. Oral Alpha-Glucosidase Inhibitors acarbose status for all oral alpha glucosidase inhibiting agents. miglitol (Glyset Kabivitrum Inc) Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors arxiga TM (dapagliflozin tablets AstraZeneca/Bristo l Myers Squibb status for all Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors. Invokana TM (canagliflozin tablets Janssen) Sulfonylureas chlorpropamide tolazamide tolbutamide glipizide glipizide XL status for all sulfonylureas. With the exeption of Glyburide, and Glyburide micronized will be moved to ormulary Non-Preferred. And grandfather in existing users for a year

20 glimepiride glyburide glyburide micronized Thiazolidinediones (TZDs) pioglitazone [ST] status for all TZDs. pioglitazone/glimepiri de pioglitazone/metfor min rosiglitazone (Avandia GlaxoSmithKline) rosiglitazone/glimepir ide (Avandaryl GlaxoSmithKline) rosiglitazone/metfor min (Avandamet GlaxoSmithKline) Selective Serotonin Reuptake Inhibitors (SSRIs) and Related Agents vortioxetine (Brintellix Takeda) [ST] Change formulary status of paroxetine ER to ormulary Step Therapy, and grandfather in existing user for a year. paroxetine 7.5mg capsules (Brisdelle Noven Therapeutics) paroxetine mesylate (Pexeva Noven [ST] [ST] Retain formulary status of all other SSRIs.

21 Therapeutics) vilazodone (Viibryd Merck/Trovis Pharmaceuticals) celexa escitalopram fluoxetine fluvoxamine paroxetine paroxetine controlled release sertraline [ST] Serotonin and Norepinephrine Reuptake Inhibitors levomilnacipran extended release capsules (etzima orest) [ST] status for all serotonin and norepinephrine reuptake inhibitors. desvenlafaxine succinate extended release capsules [ST] (Pristiq Wyeth) desvenlafaxine succinate extended release [ST]

22 tablets (Khedezla Osmotica/Macoven ) duloxetine (Cymbalta Lily) venlafaxine immediate release venlafaxine extended release [ST] Pulmonary Arterial Hypertension Oral Agents Sildenafil (Revatio tablets) (PA ) status for all oral Pulmonary Arterial Hypertension agents Tadalafil (Adcirca tablets) Bosentan (Tracleer tablets) Riocigaut (Adempas tablets) (PA ) (PA ) Beta-3 Adrenergic Agonist; Overactive Bladder Agents darifenacin (Enablex Warner Chilcott) fesoterodine (Toviaz Pfizer) status of all overactive bladder agents. Maintain current therapeutic class Non-ormulary Criteria. mirabegron (Myrbetriq

23 Astellas Pharma Inc.) oxybutynin immediate release oxybutynin extendedrelease oxybutynin patch (Oxytrol Watson, OTC Actavis) oxybutynin topical gel (Gelnique Watson) solifenacin succinate extended release (Vesicare GlaxoSmithKline) tolterodine (generics; Detrol ; Detrol LA Pfizer) trospium immediate release (generics; Sanctura Allergan) trospium extended release (Sanctura XR Allergan) Anti-gout Therapy Class Summary Maintain current formulary status of all anti-gout agents. Allopurinol Probenecid

24 Colchicine (generic Prasco Laboratories) Colchicine (Colcrys Takeda) ebuxostat tablets (Uloric Takeda)