Pharmacy and Therapeutics Committee Decisions June 17, 2016

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Claude Clark
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1 Pharmacy and Therapeutics Committee Decisions June 17, 2016 Type of Review New Medication Drug/Therapeutic Class Xuriden (uridine triacetate oral granules Wellstat Therapeutics Corporation) Xuriden (uridine triacetate oral granules Wellstat Therapeutics) ormulary Vistogard (uridine triacetate oral granules BTG International Inc.) P&T Decision 1. Maintain non-formulary status of Xuriden 1) Tony 2) Putter Vistogard (uridine triacetate oral granules BTG International) Uptravi (selexipag tablets Actelion ormulary 1. Change status to formulary with prior authorization 1) Tony 2) Erica

2 Pharmaceuticals US, Inc.) Uptravi tablets (selexipag - Actelion) lolan; Veletri IV infusion (epopropstenol GlaxoSmithKline; Actelion) Tyvaso inhalation solution (treprostinil United Therapeutics) Remodulin IV or subcutaneous infusion (treprostinil United Therapeutics) Orenitram ER tablet (treprostinil United Therapeutics) Ventavis inhalation solution (iloprost - Actelion) Alecensa (alectinib capsules Genentech) Alecensa (alectinib capsules Genentech) Zykadia (ceritinib capules Novartis) Xalkori (crizotinib capules - Pfizer) ormulary ormulary [PA] 1. Retain non-formulary status with attached criteria for coverage 2) Jamie 1. Retain non-formulary with formulary coverage criteria status of Alecensa 2. Retain non-formulary with formulary coverage review status of Zykadia 3. Retain current formulary status for the remaining drugs 1) Putter 2) Tony

3 Imbruvica (ibrutinib capsules Pharmacyclics/Janssen Biotech) Imbruvica (ibrutinib capsules Pharmacyclics/Janssen Biotech) Zydelig (idelalisib tablets - Gilead) Taltz (ixekizumab for subcutaneous injection Eli Lilly and Company) Enbrel (etanercept for SC injection - Amgen) Humira (adalimumab for SC injection - AbbVie) Simponi (golimumab for SC injection - Janssen) Stelara (ustekinumab for SC injection - Janssen) ormulary [PA] [PA] 1. Change Imbruvica from nonformulary to formulary with the attached prior authorization 2. Retain the current formulary. Hold until November P&T 1. Retain non-formulary status of Taltz and add attached CR criteria 2. Retain the current formulary Therapeutic Summary Class Review IV Remicade (infliximab recombinant for IV injection - Janssen) PO Otezla (apremilast tablets Celgene) Oral Antihistamines and Antihistamine-Decongestants ormulary 1) Tony 2) Erica 1. Move cetirizine chewable

4 ANTIHISTAMINES: cetirizine tablets (generics) cetirizine chewable tablets (generics) cetirizine syrup (generics) fexofenadine tablets (generics) fexofenadine oral suspension (generic) desloratadine tablets (generic) Clarinex (desloratadine syrup Schering-Plough) Clarinex Reditabs (desloratadine orally disintegrating tablets Schering-Plough) levocetirizine tablets (generic) Xyzal (levocetirizine tablets and oral solution UCB/sanofi-aventis, generics [tablets only]) loratadine tablets, chewable tablets, rapidly disintegrating tablets, and syrup (generics) ANTIHISTAMINE DECONGESTANTS: Rynatan (chlorpheniramine tannate/phenylephrine tannate tablets, chewable tablets, suspension Meda, generics) Allegra-D 12 Hour (fexofenadine/pseudoephedrine [60/120 mg] extended-release tablets OTC and Rx sanofi-aventis, generics [Rx only]) Allegra-D 24 Hour (fexofenadine/pseudoephedrine [180/240 mg] extended-release tablets OTC and Rx sanofi-aventis, generics) Clarinex-D 12-Hour (desloratadine/pseudoephedrine [2.5/120 mg] extended-release tablets Schering-Plough) Clarinex-D 24-Hour (desloratadine/pseudoephedrine [5/240 mg] extended-release tablets Schering-Plough) Zyrtec-D (cetirizine/pseudoephedrine extended-release tablets OTC McNeil, generics) Claritin-D 12-Hour and Claritin-D 24 Hour (loratadine/pseudoephedrine extended-release tablets OTC (PA) tablets (generics) to nonformulary with CR criteria 2. Retain all formulary status for oral antihistamine and antihistamine-decongestants. 2) Jamie

5 Schering-Plough, Alavert Allergy-Sinus Tab Wyeth Consumer Healthcare, other generics) Long-Acting Muscarinic Antagonist (LAMA) Inhalers umeclidinium inhalation powder (Incruse Ellipta - GlaxoSmithKline) Tiotropium bromide inhalation powder (Spiriva Handihaler - Boehringer Ingelheim Pharmaceuticals, Inc.) Tiotropium bromide inhalation spray (Spiriva Respimat - Boehringer Ingelheim Pharmaceuticals, Inc.) Aclidinium bromide inhalation powder (Tudorza Pressair - orest/almirall) Glycopyrrolate inhalation powder (Seebri Neohaler Novartis) LAMA/ LABA Combination Inhalers Anoro Ellipta (umeclidinium and vilanterol inhalation powder GlaxoSmithKline) Stiolto Respimat (tiotropium bromide and olodaterol inhalation spray Boehringer Ingelheim) Utibron Neohaler (indacaterol and glycopyrrolate inhalation powder Novartis) Long-Acting Inhaled Beta-Agonists ormulary ormulary ormulary 1. Add Incruse Ellipta to the formulary 2. Add Respimat to the formulary 3. Retain formulary status of all other long acting anticholinergic inhalers 2) Putter 1. Add Anoro Ellipta to formulary 2. Add ST criteria to Stiolto Respimat for trial and failure of Anoro Ellipta 1) Jamie 2) Erica

6 indacaterol inhalation powder (Arcapta Neohaler - Novartis) formoterol fumarate dinhalation powder (oradil Aerolizer - Merck) salmeterol xinafoate inhalation powder (Serevent Diskus - GlaxoSmithKline) olodaterol inhalation spray (Striverdi Respimat - Boehringer Ingelheim) Arformoterol nebulization solution (Brovana - Sunovion) (PA) (PA) 1. Add olodaterol inhalation spray (Striverdi Respimat) to formulary with prior authorization criteria. 2. Add prior authorization criteria to restrict the use of arformoterol nebulization solution (Brovana). 3. Move Serevent to nonformulary status 4. Require use of combination LABA/LAMA inhaler for members on LABA and LAMA single-entity. Short-Acting Inhaled Beta2-Agonists albuterol inhalation aerosol (ProAir HA Teva) albuterol inhalation powder (ProAir Respiclick Teva) albuterol inhalation aerosol (Proventil HA Merck) albuterol inhalation nebulizer solution (generics) albuterol oral syrup (generics) albuterol inhalation aerosol (Ventolin HA GlaxoSmithKline) ormulary 2) Putter 1. Add ProAir Respiclick to formulary 2. Move Ventolin HA to nonformulary 3. Retain current formulary status for all other short-acting inhaled beta2-agonists.

7 levalbuterol inhalation aerosol (Xopenex HA Sunovion) levalbuterol inhalation nebulizer solution (Xopenex - Akorn) Inhaled Corticosteroids (ICS) fluticasone furoate inhalation powder (Arnuity Ellipta - 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) Treatment of Idiopathic Pulmonary ibrosis ormulary Esbriet (pirfenidone capsules InterMune) Ofev (nintedinib-boehringer Ingelheim Pharmaceuticals) (NP) ormulary -NP -NP -NP 2) Tony 1. Add Arnuity Ellipta to formulary 2. Change lovent HA to formulary with prior authorization 3. Retain formulary status of all other inhaled corticosteroids 1) Putter 2) Jamie 1. Retain current formulary statuses for all medications for the treatment of idiopathic pulmonary fibrosis.

8 Pulmonary Anti-Inflammatory Beta2 Agonist Combo Inhalers Advair Diskus (fluticasone propionate and salmeterol inhalation powder GlaxoSmithKline) Advair HA (fluticasone propionate and salmeterol inhalation aerosol GlaxoSmithKline) Breo Ellipta (fluticasone furoate and vilanterol inhalation powder GlaxoSmithKline) Dulera (mometasone furoate and formoterol fumarate dihydrate inhalation aerosol Merck) Symbicort (budesonide and formoterol fumarate dihydrate inhalation aerosol AstraZeneca) ormulary (PA) (PA) (NP) (PA) 1) Tony 2) Putter 1. Alter PA criteria for all pulmonary anti-inflammatory Beta2 agonist combo inhalers to steer providers toward Advair Diskus 2. Change Breo Ellipta from formulary non-preferred to formulary with prior authorization 3. Change Dulera from nonformulary to formulary with prior authorization 4. Retain formulary status of all other medications Inhaled Antibiotics for Pseudomonas Infections in Cystic ibrosis tobramycin for inhalation solution (generics) ormulary 1) Jamie 2) Erica 1. Remove step therapy from aztreonam

9 aztreonam for inhalation solution (Cayston - Gilead Sciences) tobramycin inhalation powder (TOBI Podhaler - Novartis) [ST] 1) Tony 2) Putter tobramycin for inhalation solution (Bethkis - Cornerstone/Catalent) tobramycin inhalation solution (Kitabis TM Pak Catalent Pharma Solutions) Leukotriene Pathway Inhibitors montelukast oral tablet (generics) Brand-name montelukast (Singulair Merck Sharp & Dohme) montelukast granules (generics) montelukast chewable tablets (generics) zafirlukast (generics) zileuton extended-release tablet(zyflo CR - Cornerstone Therapeutics) zileuton oral tablet(zyflo - Cornerstone Therapeutics) Topical Immunomodulators Elidel (pimecrolimus 1% cream Valeant) Protopic (tacrolimus 0.03% and 0.1% ointment Astellas, generics) ormulary (NP) (PA) ormulary [ST] 1. Change Zyflo CR from formulary with prior authorization to non-formulary 2. Change zafirlukast from formulary non-preferred to formulary with prior authorization 3. Change montelukast granules from formulary to formulary with prior authorization criteria 1) Putter 2) Erica

10 1. Change generic tacrolimus ointment to formulary w/ step therapy Vitamin D Analogues Oral and Injectable calcitriol capsules (generics) calcitriol oral solution (generics) calcitriol injection (generics) doxercalciferol capsules (generics) doxercalciferol injection (generics) paricalcitol capsules and injection (generics) ormulary [medical] 1) Tony 2) Putter 1. Change calcitriol oral solution to formulary w/ PA criteria 2. Keep the current formulary Vitamin D Analogues Topical calcipotriene topical solution (generics) calcipotriene ointment (generics) calcipotriene cream (generics) calcipotriene/betamethasone dipropionate foam (generics) calcitriol ointment (generics) ormulary 2) Jamie 1. Calcipotriene ointment to formulary 2. Change calcipotriene cream from formulary to formulary with prior authorization

11 Benign Prostatic Hyperplasia Alfuzosin ER tablets (generics) Avodart (dutasteride capsules GlaxoSmithKline, generics) Cardura (doxazosin mesylate tablets Pfizer, generics) Cardura XL (doxazosin mesylate extended-release tablets Pfizer) doxazosin mesylate tablets (generics) dutasteride capsules (generics) dutasteride/tamsulosin capsules (generics) finasteride tablets (generics) lomax (tamsulosin tablets Boehringer Ingelheim) Hytrin (terazosin tablets Abbott) Jalyn (dutasteride/tamsulosin capsules GlaxoSmithKline, generics) Proscar (finasteride tablets Merck, generics) Rapaflo (silodosin capsules Watson) tamsulosin tablets generics terazosin tablets (generics) UroXatral (alfuzosin extended-release tablets Sanofi-Aventis) Bisphosphonates alendronate tablet (generics) alendronate effervescent tablet (Binosto Mission Pharmacal) alendronate plus cholecalciferol (osamax Plus D Merck) ibandronate tablets (generics) ibandronate injection (generics) risedronate (generics and Actonel Actavis) ormulary [PA] [QL] [PA] [QL] ormulary [ST] [medical] 1) Putter 2) Tony 1. Add prior authorization criteria with step therapy to dutasteride and dutasteride/tamsulosin 2. Add formulary coverage criteria to UroXatral 3. Retain the current formulary 2) Tony 1. Change ibandronate to formulary with step therapy 2. Change risedronate to formulary with step therapy 3. Change teriparatide (orteo) to

12 risedronate delayed-release (Atelvia Actavis) teriparatide pen injector (orteo) zoledronic acid injection (generics) [medical] formulary with the attached prior authorization criteria 4. Retain the current formulary Dipeptidyl-Peptidase-4 (DPP-4) Inhibitors Januvia (sitagliptin tablets Merck) Janumet (sitaglitin/metformin - Merck) Janumet XR (sitaglitin/metformin XR - Merck) alogliptin tablets (generics) alogliptin/metformin (generics) alogliptin/pioglitazone (generics) Nesina (alogliptin tablets Takeda) Oseni (alogliptin/pioglitazone - generics) Kazano (alogliptin/metformin - generics) Onglyza (saxagliptin tablets Bristol-Meyers Squibb) Kombiglyze (saxagliptin/metformin tablets - Astrazeneca) Tradjenta (linagliptin tablets Boehringer Ingelheim/Eli Lilly) Jentadueto (sitagliptin/metformin - Boehringer Ingeleheim) Juvisync (sitagliptin/simvastatin - generics) Glucagon-Like Peptide-1 (GLP-1) Agonists ormulary [PA] ormulary 1) Jamie 2) Erica 1. Change Januvia to nonformulary 2. Change alogliptin, alogliptin/metformin, and alogliptin/pioglitzasone to formulary with prior authorization 3. Retain the current formulary 1) Putter 2) Tony 1.Retain the current formulary

13 Byetta (exenatide injection Bristol-Myers Squibb) Bydureon VIAL (exenatide extended-release for injectable suspension Astra Zeneca) Bydureon PEN (exenatide extended-release for injectable suspension Astra Zeneca) Tanzeum (albiglutide for subcutaneous injection GlaxoSmithKline) Trulicity (dulaglutide for subcutaneous injection Eli Lilly) Victoza (liraglutide [rdna] injection NovoNordisk) Insulins (Basal) Lantus (insulin glargine injection sanofi-aventis) Lantus SOLOSTAR (insulin glargine injection sanofi-aventis) Levemir (insulin detemir injection Novo Nordisk) Levemir LEXPEN (insulin detemir injection Novo Nordisk) DISCONTINUED Levemir LEXTOUCH (insulin detemir injection Novo Nordisk) Toujeo SOLOSTAR (insulin glargine injection U-300 sanofiaventis) Tresiba LEXTOUCH U-100 (insulin degludec injection Novo Nordisk) Tresiba LEXTOUCH U-200 (insulin degludec injection Novo Nordisk) Insulins (Human Insulins) Afrezza (insulin human inhalation powder MannKind) Humulin R U-100 (insulin human [rdna origin] injection Eli Lilly) Humulin R U-500 (concentrated) [insulin human injection, USP [PA] [PA] [PA] [PA] ormulary * [PA] [PA] ormulary 2) Jamie 1. Change Levemir and Levemir lexpen to non-formulary 2. Add CR criteria to Levemir 3. Remove the prior authorization from Lantus Solostar Injection 2) Tony 1. Retain the current formulary

14 (rdna origin) Eli Lilly] Humulin N (human insulin [rdna origin] isophane suspension injection Eli Lilly) Humulin N Kwikpen (human insulin [rdna origin] isophane suspension injection Eli Lilly) Novolin R (insulin human [rdna origin] injection product line Novo Nordisk) Novolin N (insulin human [rdna origin] isophane suspension injection Novo Nordisk) Novolog Novolog lexpen Humalog Humalog Kwikpen Humalog Humalog Kwikpen Humulin Kwikpen Humulin Novolin [PA] [PA] [PA] [PA] [PA] 1) Jamie 2) Putter Insulins (Rapid-Acting Analogues) Apidra (insulin glulisine [rdna origin] injection - Aventis) Apidra SOLOSTAR (insulin glulisine [rdna origin] injection -Aventis) Humalog Cartridge (insulin lispro [rdna origin] injection - Eli Lilly) Humalog Vial (insulin lispro [rdna origin] injection - Eli Lilly) Humalog Kwikpen (insulin lispro [rdna origin] ormulary [PA] [PA] 1. Change Novolog cartridge from non-formulary to formulary 2. Retain the formulary status of all rapid-acting insulin analogues 2) Tony

15 injection - Eli Lilly) NovoLog Cartridge (insulin aspart [rdna origin] injection - Novo Nordisk) NovoLog Vial (insulin aspart [rdna origin] injection - Novo Nordisk) NovoLog lexpen (insulin aspart [rdna origin] injection - Novo Nordisk) MEGLITINIDES ormulary repaglinide/metformin (generics) repaglinide tablets (generics) nateglinide tablets (generics) [NP] [PA] 1. Change repaglinide/metformin to non-formulary 2. Change nateglinide to formulary with prior authorization 3. Retain the current formulary Oral Alpha-Glucosidase Inhibitors acarbose (generics) miglitol (Glyset Kabivitrum Inc) ormulary 1) Jamie 2) Erica 1. Retain current formulary status for all oral alpha glucosidase inhibiting agents.

16 Overactive Bladder Agents Enablex (darifenacin extended-release tablets Warner Chilcott) Gelnique (oxybutynin 3% and 10% gel Watson) Myrbetriq (mirabegron extended-release tablets Astellas Pharma Inc.) oxybutynin ER tablet (generics) oxybutynin tablet and syrup (generics) Oxytrol (oxybutynin transdermal system Watson) tolterodine tartrate tablets (generics) tolterodine tartrate extended-release capsules (generics) Toviaz (fesoterodine fumarate extended-release tablets Pfizer) Trospium chloride/extended-release capsules tablets Apotex/ Actavis Vesicare (solifenacin tablets Astellas Pharma) Phosphate Binders Auryxia TM (ferric citrate tablets Keryx Pharmaceuticals) osrenol (lanthanum carbonate oral powder Shire) osrenol (lanthanum carbonate chewable tablets Shire) sevelamer carbonate (generics) - DISCONTINUED Renagel (sevelamer hydrochloride tablets Genzyme) Renvela (sevelamer for oral suspension Genzyme) Renvela (sevelamer carbonate tablets Genzyme) ormulary [PA] [PA] ormulary 1) Putter 2) Jamie 1. Add step therapy to tolterodine IR/ER and trospium IR/ER requiring use of oxybutynin 2. Change Enablex, Vesicare and Toviaz to non-formulary 3. Retain the current formulary 1) Putter 2) Erica 1. Keep the current formulary To be reviewed at the P&T in November

17 Velphoro (sucroferric oxyhydroxide chewable tablet resenius Medical Care) Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors arxiga (dapagliflozin tablets - AstraZeneca/Bristol- Myers Squibb) Xigdeo (dapagliflozin/metformin IV) Invokana (canagliflozin tablets - Janssen) Invokamet (canagliflozin/metformin tablets - Janssen) Jardiance (empagliflozin tablets Boehringer Ingleheim/Eli Lilly) Glyxambi (empagliflozin/linagliptin - Boehringer Ingeleheim) ormulary 1. Retain the current formulary status of the SGLT-2 Inhibitors 2) Jamie Sulfonylureas chlorpropamide (generics) tolazamide (generics) tolbutamide (generics) glipizide (generics) glipizide/metformin (generics) glipizide XL/ER (generics) glimepiride (generics) glyburide (generics) glyburide/metformin (generics) ormulary 1. Change glipizide/metformin and glyburide/metformin from formulary to non- ormulary 2. Retain formulary status for all other medications 1) Tony 2) Erica

18 Thiazolidinediones (TZDs) Avandia (rosiglitazone tablets GlaxoSmithKline) Avandamet (rosiglitazone and metformin tablets GlaxoSmithKline) pioglitazone/metformin tablets (generics) Actoplus Met XR (pioglitazone and metformin extended release tablets - Takeda) pioglitazone tablets (generics) pioglitazone and glimepiride tablets (generics) ormulary [ST] [ST] [ST] 1. Change pioglitazone/metformin and Avandia to non-formulary 2. Retain the current formulary 1) Tony 2) Jamie

Select Inhaled Respiratory Agents

Select Inhaled Respiratory Agents Applies to all products administered or underwritten by Blue Cross and Blue Shield of Louisiana and its subsidiary, HMO Louisiana, Inc.(collectively referred to as the Company ), unless otherwise provided