March 2018 Pharmacy & Therapeutics Committee Decisions

Transcription

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: 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 = Authorization QL = Quantity Limit ST = Step Therapy Drug Indication Formulary Coverage For the treatment of nasal polyps in patients 18 years of age. Xhance Nasal Spray (fluticasone propionate) Action Effective Date Renflexis (infliximabadba) For the treatment of Crohn s disease (CD) in adult and pediatric patients; ulcerative colitis (UC) in adults, rheumatoid arthritis (RA) in adults (used in combination with methotrexate [MTX]); ankylosing spondylitis (AS); psoriatic arthritis (PsA), and plaque psoriasis. * * Added to Medicare formulary with Varubi (rolapitant hydrochloride) Vyzulta Ophth Solution (latanoprostene bunod) Indicated in combination with other antiemetic agents in adults for the prevention of delayed nausea and vomiting associated with initial and repeat courses of emetogenic cancer chemotherapy, including but not limited to, highly emetogenic chemotherapy (HEC) For the treatment of intraocular pressure (IOP) in patients with open-angle glaucoma (OAG). Added to Medicare formulary. March 2018 P&T Decisions Page 1

2 Ozempic (semaglutide) Prevymis (letermovir) Odactra (mite, d.farinaed. pteronyssinus) Fasenra (benralizumab) Mepsevii (vestronidase alfa-vjbk) Rebinyn (factor ix human rec, pegylated) In adjunct to diet and exercise to improve glycemic control in adults with type 2 DM. For prophylaxis of cytomegalovirus (CMV) infection and disease in adult CMV-seropositive recipients of an allogeneic hematopoietic stem cell transplant (HSCT). Odactra, a house dust mite (HDM) allergen extract, is indicated in patients 18 to 65 years of age as immunotherapy for the treatment of HDM-induced allergic rhinitis, with or without conjunctivitis (AR/C), confirmed by in vitro testing for immunoglobulin E (IgE) antibodies to HDM or a positive skin test to licensed HDM allergen extracts. An add-on maintenance treatment of patients with severe asthma aged 12 years who have an eosinophilic phenotype. An enzyme replacement therapy indicated in pediatric and adult patients for the treatment of Mucopolysaccharidosis VII (MPS VII, or Sly syndrome). The effect of Mepsevii on the central nervous system (CNS) manifestations of MPS VII has not been determined. A Factor IX recombinant product indicated for use in adults and children with hemophilia B for: 1) on-demand treatment and control of bleeding episodes and, 2) perioperative management of bleeding. Rebinyn is not indicated for routine prophylaxis in the treatment of patients with hemophilia B. Medicaid: F Exchange: F * * * Added to Medicare and Medicaid formularies. formularies (with a Authorization for Medicaid and Exchange). March 2018 P&T Decisions Page 2

3 Hemlibra (emicizumab- KXWH) Verzenio (abemaciclib) Protected Class A bispecific factor IXa and factor X- directed antibody indicated for routine prophylaxis to prevent or reduce the frequency of bleeding episodes in adult and pediatric patients with hemophilia A (congenital factor VIII deficiency) with factor VIII (FVIII) inhibitors. Indicated in combination with fulvestrant for the treatment of women with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)- negative advanced or metastatic breast cancer with disease progression following endocrine therapy; and as monotherapy for the treatment of adult patients with HR-positive, HER2-negative advanced or metastatic breast cancer with disease progression following endocrine therapy and prior chemotherapy in the metastatic setting. * Added to Medicaid and Exchange Added to Luxturna (voretigene neparvovec-ryzyl) For the treatment of patients with confirmed bi-allelic human retinal pigment epithelial 65 kda protein (RPE65) mutation-associated retinal dystrophy. Patients must have viable retinal cells as determined by the treating physician(s). * * * Triptodur (triptorelin pamoate) Sublocade (buprenorphine) For the treatment of pediatric patients 2 years and older with central precocious puberty. For the treatment of moderate to severe opioid use disorder (OUD) in patients who have initiated treatment with a transmucosal buprenorphine containing product. March 2018 P&T Decisions Page 3

4 Heplisav (hepatitis -B vaccine) Prevention of infection caused by all known subtypes of hepatitis B virus (HBV). Heplisav-B is approved for use in adults 18 years of age and older. Medicaid: F Exchange: F formularies. New Generics Review All formulary changes noted are effective 3/1/17. Formulary coverage for each plan listed: Current Formulary Status/Proposed Formulary Status. F=Formulary NF=Non-Formulary EFAVIRENZ 50 MG & 200 MG CAPSULE First Generic for SUSTIVA UFS: NF/NF MSHO: NF/NF SPP: NF/NF TENOFOVIR DISOP FUM 300 MG TB First Generic for VIREAD ATAZANAVIR SULFATE 150 MG, 200 MG & 300 MG CAP First Generic for REYATAZ UFS: NF/NF MSHO: NF/NF SPP: F/F ESTRADIOL 0.01% CREAM First Generic for ESTRACE UFS: NF/NF MSHO: NF/NF SPP: F/F REMIFENTANIL 1 MG, 2 MG & 5 MG VIAL First Generic for ULTIVA UFS: NF/NF MSHO: NF/NF SPP: F/F SUMATRIPTAN-NAPROXEN MG First Generic for TREXIMET EFAVIRENZ 600 MG TABLET First Generic for SUSTIVA TRIENTINE HCL 250 MG CAPSULE First Generic for SYPRINE March 2018 P&T Decisions Page 4

5 HYDROCORTISONE BUTYR 0.1% LOTN First Generic for LOCOID UFS: NF/F MSHO: NF/F SPP: NF/NF MEMANTINE HCL ER 7 MG, 14 MG, 21 MG & 28 MG CAPSULE First Generic for Namenda XR UFS: NF/F MSHO: NF/F SPP: NF/NF MINOCYCLINE ER 65 MG & 115 MG TABLET First Generic for SOLODYN PANLOR MG TABLET First Generic for APAP-CAFFEINE-DIHYDROCODEINE UFS: NF/NF MSHO: NF/NF SPP: NF/NF New Indications Review All formulary changes noted are effective 5/1/17. Formulary coverage for each plan listed: Current Formulary Status/Proposed Formulary Status. F=Formulary, NF=Non-Formulary Gilotrif (afatinib tablets) Trulance (plecanatide tablets) UFS: NF/NF MSHO: NF/NF SPP: NF/NF Zomacton (somatropin for injection, for subcutaneous use) UFS: NF/NF MSHO: NF/NF SPP: NF/NF Feraheme (ferumoxytol injection, for intravenous use) UFS: NF/NF MSHO: NF/NF SPP: NF/NF Zytiga (abiraterone acetate) Trisenox (arsenic trioxide injection) Xgeva (denosumab injection) March 2018 P&T Decisions Page 5

6 Fluarix Quadrivalent (influenza vaccine) Lynparza (olaparib tablets) Imfinzi (durvalumab injection, for intravenous use) Verzenio (abemaciclib tablets) Luzu (luliconazole cream, 1% for topical use) UFS: NF/NF MSHO: NF/NF SPP: NF/NF Norditropin (somatropin injection, for subcutaneous use) UFS: NF/NF MSHO: NF/NF SPP: NF/NF Miscellaneous Previously Reviewed Items All formulary changes noted are effective 5/1/17. F=Formulary, NF=Non-Formulary TRELEGY ELLIPTA (FLUTICASONE/UMECLIDIN/VILANTER) BLISTER PACK UFS: F MSHO: F SPP: F HIX: F XIMINO ER 45 MG, 90 MG & 135 MG (MINOCYCLINE HCL) CAPSULE ROMIDEPSIN 10 MG (ROMIDEPSIN) KIT IMPOYZ 0.025% (CLOBETASOL PROPIONATE) CREAM BORTEZOMIB 3.5 MG (BORTEZOMIB) VIAL UFS: F MSHO: F SPP: F HIX: F LYRICA CR 82.5 MG, 165 MG & 330 MG (PREGABALIN) TABLET QTERN 10 MG-5 MG (DAPAGLIFLOZIN/SAXAGLIPTIN HCL) TABLET March 2018 P&T Decisions Page 6

7 CINVANTI 130 MG/18 ML(APREPITANT) VIAL JULUCA MG (DOLUTEGRAVIR/RILPIVIRINE ) TABLET UFS: F MSHO: F SPP: F HIX: F VISCO-3 25 MG/2.5 ML (HYALURONATE SODIUM) SYRINGE ADMELOG 100 UNIT/ML (INSULIN LISPRO) VIAL & ADMELOG SOLOSTAR 100 UNIT/ML (INSULIN LISPRO) PEN CLENPIQ (SOD PICOSULF/MAG OX/CITRIC AC) SOLUTION March 2018 P&T Decisions Page 7