Pharmacy Department Date: November 7, 2014 November Pharmacy and Therapeutics Committee Formulary Decisions

Transcription

1 Interoffice Memo To: All MAPMG Providers From: Sheireen Huang, PharmD Regional Clinical Pharmacy Services Manager Pharmacy Co-Chair, Regional P&T Committee CC: Pharmacy Department Date: November 7, 2014 Re: Carol Forster, MD Physician Director, Pharmacy & Therapeutics/Medication Safety Physician Co-Chair, Regional P&T Committee November Pharmacy and Therapeutics Committee Formulary Decisions The chart below outlines KPMAS Virginia Medicaid and Maryland HealthChoice formulary decisions from the November 2014 KPMAS Regional Pharmacy & Therapeutics Committee meeting. Detailed evidence-based drug monographs used when evaluating these products are available by request. In addition, please see the attached for summary of tips on how to find formulary information online and the formulary review process. Please feel free to contact Sheireen Huang, PharmD and/or Carol Forster, MD via at and/or if there are any questions. Commercial, Medicare Part D (MPD) and Medicaid Formulary Decisions Entereg (Alvimopan) Entereg is now indicated to accelerate the time to upper and lower 12 mg capsules gastrointestinal recovery following any surgery that includes partial bowel resection with primary anastomosis. Previously it was only indicated in patients with colorectal disease undergoing surgery. Reviewed and voted to NOT ADD Entereg to the commercial, MD HealthChoice, and VA Medicaid Oralair (sweet vernal, orchard, perennial rye, timothy, and kentucky blue grass mixed pollens allergen extract) 300 IR sublingual tablets Ragwitek (short ragweed pollen allergen extract) 12 Amb a 1-unit sublingual tablet Ineligible for the Medicare Part D formulary coverage. Oralair is indicated to treat allergic rhinitis (hay fever) with or without conjunctivitis. Guidelines do not address the place in therapy for this first-in-class sublingual immunotherapy allergen extract product. Use is recommended after failure of pharmacotherapy and activity avoidance. Reviewed and voted to NOT ADD Oralair to the commercial, MD Maintain on Tier 4 of the MPD formulary. Ragwitek is indicated to treat short ragweed pollen induced allergic rhinitis (hay fever), with or without conjunctivitis. Guidelines do not address the place in therapy for this first-in-class sublingual immunotherapy allergen extract product. Use is recommended after failure of pharmacotherapy and activity avoidance. Reviewed and voted to NOT ADD Ragwitek to the commercial, MD HealthChoice, and VA Medicaid Maintain on Tier 4 of the MPD formulary.

2 Commercial, Medicare Part D (MPD) and Medicaid Formulary Decisions cont d Grastek (timothy grass pollen Grastek is indicated for the treatment of grass pollen-induced allergic allergen extract) rhinitis with or without conjunctivitis confirmed by positive skin test or in 2800 BAUs sublingual tablets vitro testing for pollen-specific IgE antibodies for Timothy grass or crossreactive grass pollens. Guidelines do not address the place in therapy for this first-in-class sublingual immunotherapy allergen extract product. Use is recommended after failure of pharmacotherapy and activity avoidance. Reviewed and voted to NOT ADD Grastek to the commercial, MD YF-VAX (yellow fever vaccine) 4.74 Log 10 plaque-forming units (PFU) per 0.5 ml injection Lumigan (bimatoprost) 0.01% ophthalmic solution Harvoni (ledipasvir/sofosbuvir) 90 mg/400 mg tablets Tamiflu (oseltamivir) 30 mg, 45 mg capsules Pancof PD (Phenylephrine/ chlorpheniramine/dihydrocodeine) 7.5 mg/2 mg/3 mg/5 ml oral solution Maintain on Tier 4 of the MPD formulary. YF-VAX is a live attenuated vaccine approved for use in children 9 months of age for active immunity against yellow fever virus. This is the only vaccine available for the prevention of yellow fever. Reviewed and voted to ADD YF-VAX to the commercial and VA Medicaid formularies; effective 12/2/2014. ADD YF-VAX to the MD HealthChoice formulary; effective 1/6/2015. Maintain on Tier 6 of the MPD formulary. Lumigan is an ophthalmic prostaglandin analog available as a brand only product with a projected generic release in Latanoprost (generic Xalatan) is the preferred formulary prostaglandin. Guidelines currently do not give preference to one prostaglandin analog over another. Drugs in this class are equally efficacious. Reviewed and voted to REMOVE Lumigan from the commercial, MD HealthChoice and VA Medicaid formularies; effective 1/6/2015. Maintain on Tier 3 of the MPD formulary. Harvoni is a new oral combination product indicated for the treatment of chronic hepatitis C (CHC) genotype (GT) 1 infection in adults. Harvoni quantity limits are recommended to verify adherence, assess tolerability and decrease inappropriate dispensing. Reviewed and voted to ADD quantity limits: o 14 day supply with zero refills for first two fills. o 28 day supply with zero refills for subsequent refills. Maintain Harvoni as non-formulary on the commercial, MD HealthChoice and VA Medicaid Maintain on Tier 5 of the MPD formulary. In October 2014, Tamiflu prescribing recommendations were updated to include a lower FDA-approved dose for renal impairment. Tamiflu 75 mg capsules and 6 mg/ml suspension are currently the only Tamiflu products on the formulary. Reviewed and voted to ADD Tamiflu 30 mg and 45 mg to the commercial and VA Medicaid formularies; effective 12/2/2014. ADD Tamiflu 30 mg and 45 mg to the MD HealthChoice formulary; effective 1/6/2015. Placed on the Preferred Brand Tier 3 of the MPD formulary; effective 12/2/2014. Antitussives class review recommendations were made during the October 3, 2014 P&T Formulary Drug Class Review Recommended and voted to REMOVE Pancof PD from the commercial, MD HealthChoice and VA Medicaid formularies; effective 12/2/2014. Ineligible for the Medicare Part D formulary coverage.

3 KPMAS List of Standard Compounds Ursodiol 50 mg/ml suspension Ursodiol 300 mg capsules are no longer available on formulary. Ursodiol 250 mg and 500 mg tablets are formulary. Ursodiol 50 mg/ml extemporaneous oral suspension prepared with formulary ursodiol tablets can replace the 60 mg/ml suspension previously prepared with ursodiol capsules. Reviewed and voted to ADD ursodiol 50 mg/ml to formulary and the KPMAS List of Standard Compounds; effective 12/2/2014. Prescribing Recommendations for Pradaxa (dabigatran) for Stroke/Systemic Embolism in Non-valvular Atrial Fibrillation and Venous Thromboembolism Update: Pneumococcal Vaccine 2014 Adult Immunization Schedule Acamprosate (generic Campral) 333 mg tablets Buprenorphine/naloxone (generic Suboxone) 2 mg/0.5 mg, 8 mg/2 mg sublingual tablets Chantix (varenicline) 0.5 mg, 1 mg tablets Chantix starting month pak (varenicline) 0.5 mg, 1 mg tablets Chantix continuing month pak (varenicline) 1 mg tablets Disulfiram (generic Antabuse) 250 mg tablets Prescribing Recommendations Reviewed and endorsed prescribing recommendations for Pradaxa (dabigatran) for Stroke/Systemic Embolism in Non-valvular Atrial Fibrillation and Venous Thromboembolism. Pradaxa is an oral direct thrombin inhibitor FDA- approved for two indications: o In October 2010, to reduce the risk of stroke or systemic embolism (S/SE) in patients with non-valvular atrial fibrillation (NVAF). o In April 2014, to treat acute venous thromboembolism (VTE) and reduce the risk of recurrent VTE. Reviewed and endorsed CDC Pneumococcal Vaccine 2014 Adult Immunization Schedule Update drug FAQ for Clinicians. In August 2014, the ACIP recommended the routine use of Prevnar 13 in addition to Pneumovax 23 in adults 65 years of age. Medicaid Formulary Decisions Carved out on the MD HealthChoice formulary; effective Maintain on Tier 2 of the MPD formulary. Carved out on the MD HealthChoice formulary; effective Maintain on Tier 2 of the MPD formulary. Carved out on the MD HealthChoice formulary; effective MAINTAIN as non-formulary on the commercial and VA Medicaid Maintain on Tier 4 of the MPD formulary. Carved out on the MD HealthChoice formulary; effective MAINTAIN as non-formulary on the commercial and VA Medicaid Maintain on Tier 4 of the MPD formulary. Carved out on the MD HealthChoice formulary; effective MAINTAIN as non-formulary on the commercial and VA Medicaid Maintain on Tier 4 of the MPD formulary. Carved out on the MD HealthChoice formulary; effective Maintain on Tier 2 of the MPD formulary.

4 Naloxone (generic Narcan) 0.4 mg/ml injection Naltrexone (generic ReVia) 50 mg tablets Nicotine transdermal system (generic Nicoderm CQ) 7 mg/24 hour, 14 mg/24 hour, 21 mg/24 hour patches Nicotine polacrilex (generic Nicorette) 2 mg, 4 mg gum Nicotine polacrilex (generic Nicorette) 2 mg, 4 mg lozenges Nicotrol Inhaler (nicotine) 10 mg/cartridge Nicotrol NS (nicotine) 10 mg/ml nasal spray Cyclophosphamide (generic Cytoxan) 25 mg, 50 mg capsules Beleodaq (Belinostat) 500 mg/30 ml injection Zydelig (Idelalisib) 100 mg, 150 mg tablets Anoro Ellipta (umeclidinium and vilanterol) aerosol powder breath activated inhalation 62.5 mcg/25 mcg per inhalation Medicaid Formulary Decisions cont d Carved out on the MD HealthChoice formulary; effective 10/1/2014. Maintain on Tier 2 of the MPD formulary. Carved out on the MD HealthChoice formulary; effective Maintain on Tier 2 of the MPD formulary. Carved out on the MD HealthChoice formulary; effective MAINTAIN as non-formulary on the commercial and VA Medicaid OTC products are exempt from the MPD formulary. Carved out on the MD HealthChoice formulary; effective MAINTAIN as non-formulary on the commercial and VA Medicaid OTC products are exempt from the MPD formulary. Carved out on the MD HealthChoice formulary; effective MAINTAIN as non-formulary on the commercial and VA Medicaid OTC products are exempt from the MPD formulary. Carved out on the MD HealthChoice formulary; effective Maintain on Tier 3 of the MPD formulary. Carved out on the MD HealthChoice formulary; effective MAINTAIN as non-formulary on the commercial and VA Medicaid Maintain on Tier 4 of the MPD formulary. Inter-regional MPD Pharmacy and Therapeutics (im-pact) Committee September 30, 2014 Meeting Drug Decisions CMS/Medicare Part D Formulary Review Accepted to Brand Tier 3; effective 9/16/14. Confirmed specialty Tier 5 status, Protected Class. Confirmed specialty Tier 5 status, Protected Class. Inter-regional MPD Pharmacy and Therapeutics (im-pact) Committee September 30, 2014 Meeting Decisions CMS/Medicare Part D Formulary Review Indicated for the long-term, once daily, maintenance treatment of airflow obstruction in patients with COPD, including chronic bronchitis and/or emphysema. Specialist review in progress, remains on the Non-Preferred Brand Tier 4

5 Inter-regional MPD Pharmacy and Therapeutics (im-pact) Committee September 30, 2014 & October 28, 2014 Meeting Decisions CMS/Medicare Part D Formulary Review Prior Authorization Clinical Prior Authorization Reviewed and approved the clinical prior authorization criteria for the following medications; effective Zohydro ER (hydrocodone) 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg extended release capsules o Covered Uses: All FDA-approved indications not otherwise excluded from Part D. o Exclusion Criteria: Use in patients who require opioid analgesia for a short period of time for as needed pain relief (prn). o Required Medical Information: Documentation of diagnosis and previous therapies. Transmucosal Immediate Release Fentanyl drugs o Affected drugs: Brand and generic Actiq, Fentora, Abstral, Lazanda, Onsolis, Subsys o Covered Uses: All FDA-approved indications not otherwise excluded from Part D. o Required Medical Information: Documentation of diagnosis of cancer pain. Sovaldi (sofosbuvir) 400 mg tablets o Covered Uses: All FDA-approved indications not otherwise excluded from Part D. o Required Medical Information: Must have chronic hepatitis C genotype 1, 2, 3, 4, 5, or 6 infection. Genotype determines length of approval. o Prescriber Restrictions: Healthcare prescribers specializing in treatment of hepatitis C Olysio (simeprevir) 150 mg capsules o Covered Uses: All FDA-approved indications not otherwise excluded from Part D. o Required Medical Information: Must have chronic hepatitis C genotype 1 or 4 infection. Q80K polymorphism is strongly recommended at baseline (confirmed by GenoSure NS3/4 resistance testing) o Prescriber Restrictions: Healthcare prescribers specializing in treatment of hepatitis C Harvoni (Ledipasvir/sofosbuvir) 90 mg/400 mg tablets o Covered Uses: All FDA-approved indications not otherwise excluded from Part D. o Required Medical Information: Must have chronic hepatitis C genotype 1, 3, or 6 infection o Prescriber Restrictions: Healthcare prescribers specializing in treatment of hepatitis C Conditional Prior Authorization Reviewed and approved the conditional prior authorizations (PAs) for certain MPD medications; effective Centers for Medicare & Medicaid Services (CMS) will only cover FDAapproved indications for these drugs starting Prescriptions with non-fda approved indications will not be covered and the patient will be charged member rate.

6 Inter-regional MPD Pharmacy and Therapeutics (im-pact) Committee cont d September 30, 2014 & October 28, 2014 Meeting Decisions CMS/Medicare Part D Formulary Review Prior Authorization Conditional Prior Authorization Conditional PAs will apply to the following drugs listed below: o Baclofen (Gaboflen/Lioresal) IT o Carisoprodol Products o Diclofenac (Flector) Patch o Lidocaine (Lidoderm) Patch o Transmucosal Immediate-release Fentanyl (TIRF) o Armodafinil (Nuvigil) o Modafinil (Provigil) o Tretinoin (Retin-A/Avita) o Tadalafil (Adcirca/Cialis) o Sildenafil (Revatio) o AbobotulinumtoxinA (Dysport) o OnabotulinumtoxinA (Botox) o IncobotulinmtoxinA (Xeomin) Conditional Prior Authorization Approved Criteria Questions National Part D 30 day supply limit for all schedule II opioid drugs o o Hydrocodone (Zohydro) Somatropin Products: Genotropin Humatrope Norditropin Nutropin Nutropin AQ Omnitrope Saizen Serostim Zorbtive Tev Tropin Reviewed and approved the following conditional prior authorization (PA) criteria questions: o Botulinum Toxin A Is this being used for a Cosmetic indication? o Baclofen Is this being used for severe spasticity resistant to oral treatment? o Armodafinil and Modafinil Is this being used for narcolepsy, obstructive sleep apnea (OSA), or shift work disorder (SWD)? o Somatropin Products Is this being used for an FDA approved indication? Not Cosmetic o Diclofenac Patch Is this being used for 90 days? o Lidocaine Patch Is this being used for nerve pain due to shingles or diabetic neuropathy? o Carisoprodol Products Is this being used for < 21 days? Inter-regional MPD Pharmacy and Therapeutics (im-pact) Committee October 28, 2014 Meeting Decisions National Part D 30 Day Supply Limit Reviewed and approved National Part D 30 day supply limit for all schedule II opioid drugs (including morphine and hydrocodone combination products); effective The implementation of the Medicare Part D Overutilization Monitoring System (OMS) indicate CMS' heightened awareness of opioid use and abuse.

7 Inter-regional MPD Pharmacy and Therapeutics (im-pact) Committee (Brand Tier 3 and Specialty Tier 5 Additions to Non-Preferred Brand Tier 4 of the MPD Formulary) Actos (pioglitazone) 15 mg tablets Amitiza (lubiprostone) 8 mcg, 24 mcg capsules Androgel (testosterone) 1% gel pump Bactroban (mupirocin) 2% cream Campral (acamprosate) 333 mg tablets Carimune nanofiltered (human immune globulin) 3 g, 6 g, 12 g injection Cyklokapron (tranexamic) 100 mg/ml injection Generic equivalent to Actos is available on formulary. Brand Actos will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Actos as non-formulary on the commercial, MD Lactulose, OTC Miralax, Metamucil, and Dulcolax are the preferred formulary alternatives. Amitiza will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Amitiza as non-formulary on the commercial, MD Generic Depo-Testosterone 200 mg/ml is the preferred formulary alternative. Brand Androgel will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Androgel as non-formulary on the commercial, MD Generic equivalent to Bactroban is available on formulary. Brand Bactroban will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Bactroban as non-formulary on the commercial, MD Generic equivalent to Campral is available on formulary. Brand Campral will be placed on Tier 4 of the MPD formulary; effective Carved out on the MD HealthChoice formulary; effective MAINTAIN brand Campral as non-formulary on the commercial and VA Medicaid Flebogamma DIF is the preferred formulary alternative. Carimune nanofiltered will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Carimune nanofiltered 3 g and 12 g as non-formulary on the commercial, MD REMOVE Carimune nanofiltered 6 g from the commercial, MD HealthChoice and VA Medicaid formularies; effective 1/6/2015. Generic equivalent to Cyklokapron is not available on formulary. Aminocaproic Acid is the preferred formulary alternative. Brand Cyklokapron will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Cyklokapron as non-formulary on the commercial, MD

8 Inter-regional MPD Pharmacy and Therapeutics (im-pact) Committee cont d (Brand Tier 3 and Specialty Tier 5 Additions to Non-Preferred Brand Tier 4 of the MPD Formulary) Dacogen (decutabube) 50 mg injection Doxil (doxorubicin liposomal) 2 mg/ml injection Epivir (lamivudine) 100 mg tablets FazaClo (clozapine) 25 mg, 100 mg oral dispersable tablet (ODT) GlucaGen Hypokit (glucagon) 1 mg injection kit Gris-peg (griseofulvin ultramicrosize) 125 mg, 250 mg tablets Metadate CD (methylphenidate) 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg capsules Myfortic (mycophenolate) 180 mg, 360 mg tablets Oxytrol DIS (oxybutynin) 3.9 mg/24 hour patch Generic equivalent to Dacogen is available on formulary. Brand Dacogen will be placed on Tier 4 of the MPD formulary; effective REMOVE brand Dacogen from the commercial, MD HealthChoice and VA Medicaid formularies; effective 1/6/2015. Generic equivalent to Doxil is available on formulary. Brand Doxil will be placed on Tier 4 of the MPD formulary; effective REMOVE brand Doxil from the commercial, MD HealthChoice and VA Medicaid formularies; effective 1/6/2015. Generic equivalent to Epivir is available on formulary. Brand Epivir will be placed on Tier 4 of the MPD formulary; effective REMOVE brand Epivir tablets from the commercial, MD HealthChoice and VA Medicaid formularies; effective 1/6/2015. Generic equivalent to Fazaclo tablet is available on formulary; ODT formulation is not available on formulary. Brand Fazaclo will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Fazaclo as non-formulary on the commercial and VA Medicaid Glucagon Emergency Kit 1 mg is the preferred formulary alternative. Brand GlucaGen Hypokit will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Glucagen hypokit as non-formulary on the commercial, MD Generic equivalent to Gris-peg is available on formulary. Brand Gris-peg will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Gris-peg as non-formulary on the commercial, MD Generic equivalent to Metadate CD is available on formulary. Brand Metadate CD will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Metadate CD as non-formulary on the commercial and VA Medicaid Generic equivalent to Myfortic is not available on formulary. Generic CellCept is the preferred formulary alternative. CellCept and Myfortic dosage forms should not be used interchangeably due to differences in absorption. Brand Myfortic will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Myfortic as non-formulary on the commercial, MD OTC Oxytrol For Women is the preferred formulary alternative. Brand Oxytrol DIS will be placed on Tier 4 of the MPD formulary; effective REMOVE brand Oxytrol DIS from the commercial, MD HealthChoice and VA Medicaid formularies; effective 1/6/2015.

9 Inter-regional MPD Pharmacy and Therapeutics (im-pact) Committee cont d (Brand Tier 3 and Specialty Tier 5 Additions to Non-Preferred Brand Tier 4 of the MPD Formulary) Prandin (repaglinide) 0.5 mg, 1 mg, 2 mg tablets Protonix (pantoprazole) 40 mg injection Rapamune (sirolimus) 0.5 mg, 1 mg, 2 mg tablets 1 mg/ml solution Singulair (montelukast) 4 mg, 5 mg chewable tablets 4 mg granules 10 mg tablets Stalevo (carbidopa-levodopaentacapone) 50 mg, 75 mg, 100 mg, 125 mg, 150 mg, 200 mg tablets Trileptal (oxcarbazepine) 300 mg/5 ml suspension Twinject (epinephrine) 0.15 mg, 0.3 mg injection Tybost (cobicistat) 150 mg tablets Urso (ursodiol) 250 mg tablets Generic equivalent to Prandin is not available on formulary. Clinical judgment should be used to determine an appropriate alternative. Brand Prandin will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Prandin as non-formulary on the commercial, MD Generic equivalent to Protonix is available on formulary. Brand Protonix will be placed on Tier 4 of the MPD formulary; effective REMOVE brand Protonix from the commercial, MD HealthChoice and VA Medicaid formularies; effective 1/6/2015. Generic equivalent to Rapamune is not available on formulary. Brand Rapamune will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Rapamune as non-formulary on the commercial, MD Generic equivalent to Singulair is available on formulary. Brand Singulair will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Singulair as non-formulary on the commercial, MD Generic equivalent to Stalevo is not available on formulary. Generic Sinemet PLUS generic Comtan is the preferred formulary alternative. Brand Stalevo will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Stalevo as non-formulary on the commercial, MD Generic equivalent to Trileptal suspension is available on formulary. Brand Trileptal will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Trileptal as non-formulary on the commercial and VA Medicaid Generic equivalent to Twinject is available on formulary. Brand Twinject will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Twinject as non-formulary on the commercial, MD Clinical judgment should be used to determine an appropriate alternative. Brand Tybost will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Tybost as non-formulary on the commercial, MD Generic equivalent to Urso is available on formulary. Brand Urso will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Urso as non-formulary on the commercial, MD

10 Inter-regional MPD Pharmacy and Therapeutics (im-pact) Committee cont d (Brand Tier 3 and Specialty Tier 5 Additions to Non-Preferred Brand Tier 4 of the MPD Formulary) Urso Forte (ursodiol) 500 mg tablets Venlafaxine ER (venlafaxine) 37.5 mg, 75 mg, 150 mg, 225 mg extended-release tablets Vfend (voriconazole) 200 mg injection Viramune (nevirapine) 200 mg tablets 50 mg/5 ml suspension Zinecard (dexrazoxane) 250 mg injection Zosyn (piperacillin/tazobactam) 2.25 g, g, 4.5 g injection 2.25 g, g, 4.5 g premix solution Zubsolv (buphrenorphine/naloxone) 1.4 mg/0.36 mg, 5.7 mg/1.4 mg sublingual tablets Naprosyn (naproxen) 125 mg/5ml suspension Generic equivalent to Urso Forte is available on formulary. Brand Urso Forte will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Urso Forte as non-formulary on the commercial, MD Generic equivalent to Venlafaxine ER capsule is available on formulary. Brand Venlafaxine ER will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Venlafaxine ER as non-formulary on the commercial and VA Medicaid Generic equivalent to Vfend is available on formulary. Brand Vfend will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Vfend as non-formulary on the commercial, MD Generic equivalent to Viramune is available on formulary. Brand Viramune will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Viramune as non-formulary on the commercial and VA Medicaid Generic equivalent to Zinecard is not available on formulary. Clinical judgment should be used to determine an appropriate alternative. Brand Zinecard will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Zinecard as non-formulary on the commercial, MD Generic equivalent to Zosyn is available on formulary. Brand Zosyn will be placed on Tier 4 of the MPD formulary; effective MAINTAIN brand Zosyn as non-formulary on the commercial, MD Buprenorphine/naloxone (generic Suboxone) is the preferred formulary alternative. Zubsolv will be placed on Tier 4 of the MPD formulary; effective MAINTAIN Zubsolv as non-formulary on the commercial and VA Medicaid Inter-regional MPD Pharmacy and Therapeutics (im-pact) Committee (Products Deleted from the MPD formulary) Naprosyn suspension has been discontinued by the manufacturer. Generic equivalent to Naprosyn is available on formulary. DELETE from the MPD formulary; effective MAINTAIN brand Naprosyn as non-formulary on the commercial, MD

11 Inter-regional MPD Pharmacy and Therapeutics (im-pact) Committee cont d (Products Deleted from the MPD formulary) Amevive (alefacept) 15 mg injection Onfi (clobazam) 5 mg tablets Ketorolac tomethamine (ketorolac) 0.4% ophthalmic solution Budeprion SR (bupropion) 100 mg, 150 mg tablets Crixivan (indinavir) 100 mg capsules Viracept (nelfinavir) 50 mg/g powder Osphena (ospemifene) 60 mg tablets Stavzor (valproic acid) 125 mg, 250 mg, 500 mg capsules Amevive has been discontinued by the manufacturer. Alternative biologics are available on formulary. DELETE from the MPD formulary; effective MAINTAIN Amevive as non-formulary on the commercial, MD Onfi has been discontinued by the manufacturer. Alternative benzodiazepines (e.g. clonazepam) are available on formulary. DELETE from the MPD formulary; effective MAINTAIN Onfi as non-formulary on the commercial and VA Medicaid Ketorolac 0.4% has been discontinued by the manufacturer. Ketorolac 0.5% is the preferred formulary alternative. DELETE from the MPD formulary; effective DELETE from the commercial, MD HealthChoice and VA Medicaid formularies; effective 1/6/2015. Budeprion has been discontinued by the manufacturer. Bupropion is the preferred formulary alternative. DELETE from the MPD formulary; effective MAINTAIN Budeprion as non-formulary on the commercial and VA Medicaid Crixivan has been discontinued by the manufacturer. Alternative protease inhibitors (e.g. Reyataz, Prezista) are available on formulary. DELETE from the MPD formulary; effective MAINTAIN Crixivan as non-formulary on the commercial and VA Medicaid Viracept has been discontinued by the manufacturer. Alternative protease inhibitors (e.g. Reyataz, Prezista) are available on formulary. DELETE from the MPD formulary; effective MAINTAIN Viracept as non-formulary on the commercial and VA Medicaid Osphena is excluded from the MPD formulary since its use is solely for sexual dysfunction; effective Topical estrogen cream is the preferred formulary alternative. Osphena has been excluded from MD HealthChoice and VA Medicaid Stavzor has been discontinued by the manufacturer. Alternative anticonvulsants are available on formulary. DELETE from the MPD formulary; effective MAINTAIN brand Stavzor as non-formulary on the commercial and VA Medicaid

12 Diastat (diazepam) 5 mg/10 mg, 12.5 mg/20 mg Acudial gel Inter-regional MPD Pharmacy and Therapeutics (im-pact) Committee (Brand Additions to Preferred Brand Tier 3 of the MPD Formulary) ADD Diastat Acudial Gel to Tier 3 of the MPD formulary; effective Inter-regional MPD Pharmacy and Therapeutics (im-pact) Committee cont d (Brand Additions to Preferred Brand Tier 3 of the MPD Formulary) Diastat (diazepam) 2.5 mg pediatric gel Effective dates represent implementation into the systems. ADD Diastat Pediatric Gel to Tier 3 of the MPD formulary; effective

13 Tips on how to find formulary information from the computer KAISER PERMANENTE Mid-Atlantic States Region Pharmacy & Therapeutics Committee On the Kaiser Permanente Intranet 1. Where can I find the drug formulary online? Click on Formulary link on KPHealthConnect home page (bottom right), or MAPMG Providers via intranet: Go to Network Providers: Go to 2. How can I find out if something is on the drug formulary and view the drug monograph for a drug on the formulary? MAPMG Providers To view the criteria for use, contraindications, adverse reactions, drug interactions, and dosing information, click on the Lexi-comp Interactive Version under Full MAS Drug Formulary. When you enter the site, a search screen appears in the upper left hand corner of your screen. Type in the first few letters or the entire drug name and select SEARCH. All drugs containing that information are listed in the SEARCH RESULTS box. If a drug is not on formulary or it is spelled incorrectly, "No occurrences found" will appear in the SEARCH RESULTS box. Formulary status of a particular drug can be found in HealthConnect in the Pharmacy column in the drug listing. Yes in this column means that particular product is formulary. Remember, there are sometimes many duplicative products for a single drug entity. In that event, scroll down the list to look for the product that is formulary. Network Providers Go to Click on comprehensive listing of formulary drugs Press (ctrl+f) and search for the particular drug of interest on the Find field appearing on the upper left corner of the screen. If the drug is spelled incorrectly or is not on the formulary the following message will appear The Item was not found 3. How can I receive a copy of the formulary? MAPMG Providers Go to You may print a copy of the formulary document Network Providers Go to Click on comprehensive listing of formulary drugs You may print a copy of the formulary document

14 You may also contact our Provider Relations Department at for a paper copy of our 4. How can I request an addition or deletion from the formulary? New drug entities remain Non-formulary until reviewed by the Regional P&T Committee. We will review any drug upon written request with supporting evidence to make an evidencebased decision. The Drug Formulary Addition and Deletion Request Form can be obtained via the internet for both MAPMG and Network Providers: MAPMG: Go to uest.pdf Network Providers: Go to Under section Request to review medications for addition/deletion to the formulary, click on download a form. The completed form can be 1. Faxed at , attention: P&T Committee co-chairs 2. Mailed to: Kaiser Permanente Regional Office, Pharmacy 3-West Attention: P&T Committee Co-Chairs, Drug Review 2101 East Jefferson Street Rockville, MD ed by contacting any of the P&T Committee Co-Chairs: Carol Forster, MD Sheireen Huang, PharmD Ashely Kim, PharmD

15 FORMULARY REVIEW PROCESS Applying evidence-based medicine, the Regional P&T Committee and its Consultants determine whether a medicine should be added to the drug formulary. The key points of this evidence-based review are highlighted; a full description of the formulary review process is available on within the Pharmacy Group.