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 = Prior Authorization QL = Quantity Limit ST = Step Therapy Drug Indication Formulary Action Effective Date Baxdela indicated in adults for the treatment of acute bacterial skin and skin structure infections (ABSSSI) caused by susceptible isolates, including Methicillin-Resistant Staphylococcus Aureus (MRSA). Benznidazole indicated in pediatric patients 2 to 12 years of age for the treatment of Chagas disease (American trypanosomiasis) caused by Trypanosoma cruzi. Fiasp Symproic to improve glycemic control in adults with diabetes. indicated for the treatment of opioidinduced constipation (OIC) in adult patients with chronic non-cancer pain. Formularies with Prior Authorization Endari To reduce the acute complications of sickle cell disease in adult and pediatric patients 5 years of age and older. Mylotarg Treatment of newly-diagnosed CD33- positive acute myeloid leukemia (AML) in adults and for the treatment of relapsed or refractory CD33-positive AML in adults and in pediatric patient s 2 years of age. Medicare January 2018 P&T Decisions Page 1
Nerlynx Kymriah The extended adjuvant treatment of adult patients with early-stage human epidermal growth factor receptor 2 (HER2) overexpressed/amplified (i.e., HER2 positive [HER2+]) breast cancer, to follow adjuvant Herceptin (trastuzumab intravenous infusion) based therapy. Patients up to 25 years of age with B-cell precursor acute lymphoblastic leukemia (ALL) that is refractory or two relapses. w/pa w/pa w/pa formularies with Prior Authorization. Yescarta Aliqopa Besponsa Calquence Shingrix Adult patients with relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy, including diffuse large B-cell lymphoma (DLBCL), primary mediastinal large B-cell lymphoma, highgrade B-cell lymphoma, and DLBCL arising from follicular lymphoma. or the treatment of adult patients with relapsed follicular lymphoma who have received at least two prior systemic therapies. This agent was granted accelerated approval and priority review as well as an Orphan Drug designation. indicated for the treatment of adults with relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL). The agent received priority review from the FDA, and was designated as a breakthrough therapy. It also was granted an orphan drug designation. Treatment of adult patients with mantle cell lymphoma who have received at least one prior therapy. Shingrix is indicated for the prevention of herpes zoster (shingles) in adults 50 years of age and older. Shingrix is not indicated for the prevention of primary varicella infection (chickenpox). w/pa w/pa w/pa formularies with Prior Authorization. Bevyxxa indicated for the prophylaxis of venous thromboembolism (VTE) in adult patients hospitalized for an acute medical illness who are at risk for thromboembolic January 2018 P&T Decisions Page 2
complications due to moderate or severe restricted mobility and other risk factors for VTE. New Generics Review All formulary changes noted are effective. Formulary coverage for each plan listed: Current Formulary Status/Proposed Formulary Status. F=Formulary NF=Non-Formulary DAPSONE 5% GEL First Generics for: ACZONE NOREPINEPHRINE 8 MG/250 ML-D5W First Generics for: NOREPINEPHRINE BITARTRATE-D5W UFS: F/F MSHO: F/F SPP: NF/NF CASPOFUNGIN ACETATE 70 MG VIAL First Generics for: CANCIDAS UFS: F/F MSHO: F/F SPP: NF/NF CARVEDILOL ER 10 MG CAPSULE CARVEDILOL ER 20 MG CAPSULE CARVEDILOL ER 40 MG CAPSULE CARVEDILOL ER 80 MG CAPSULE Generics for: COREG CR TESTOSTERONE 50 MG/5 GRAM GEL First Generics for: TESTIM UFS: NF/NF MSHO: NF/NF SPP: F/F IODOQUINOL-HYDROCORT-ALOE GEL First Generics for: ALCORTIN A UFS: F/F MSHO: F/F SPP: NF/NF OSELTAMIVIR 6 MG/ML SUSPENSION First Generics for: TAMIFLU FLUOXETINE HCL 60 MG TABLET First Generics for: FLUOXETINE HCL UFS: NF/F MSHO: NF/F SPP: NF/NF January 2018 P&T Decisions Page 3
TIMOLOL 0.5% EYE DROPS First Generics for: ISTALOL UFS: NF/F MSHO: NF/F SPP: NF/NF TIGECYCLINE 50 MG VIAL First Generics for: TYGACIL UFS: F/F MSHO: F/F SPP: NF/NF SILDENAFIL 100 MG TABLET SILDENAFIL 25 MG TABLET SILDENAFIL 50 MG TABLET First Generics for: VIAGRA New Indications Review All formulary changes noted are effective. Formulary coverage for each plan listed: Current Formulary Status/Proposed Formulary Status. F=Formulary, NF=Non-Formulary Vimpat (lacosamide tablets) Zelboraf (vemurafenib tablet) Alecensa (alectinib capsules) Auryxia (ferric citrate tablets) Adcetris (brentuximab vedotin injection) Sprycel (dasatinib tablets) Faslodex (fulvestrant injection) Tekturna (aliskiren tablets) UFS: F/F MSHO: F/F SPP: NF/NF Gazyva (obinutuzumab injection) January 2018 P&T Decisions Page 4
Sutent (sunitinib malate capsules) Tivicay (dolutegravir tablets) Triumeq (abacavir, dolutegravir, and lamivudine tablets) Isentress (raltegravir tablets) Taltz (ixekizumab injection) Repatha (evolocumab injection) Avastin (bevacizumab solution for intravenous [IV] infusion) UFS: F/F MSHO: F/F SPP: NF/NF Levo-T (levothyroxine sodium tablets) Nucala (mepolizumab injection, for subcutaneous [SC] use) Xeljanz (tofacitinib tablets) UFS: NF/NF MSHO: NF/NF SPP: F/F Xeljanz XR (tofacitinib extended-release tablets) Bosulif (bosutinib tablets) Cabometyx (cabozantinib tablets) Opdivo (nivolumab injection) Perjeta (pertuzumab injection, for intravenous [IV] use) January 2018 P&T Decisions Page 5
UFS: F/F MSHO: F/F SPP: NF/NF Procysbi (cysteamine bitartrate delayed-release capsules) Miscellaneous Previously Reviewed Items All formulary changes noted are effective. Formulary coverage for each plan listed: Current Formulary Status/Proposed Formulary Status. F=Formulary, NF=Non-Formulary FLOLIPID 20 MG/5 ML & 40 MG/5 ML (SIMVASTATIN) ORAL SUSP DUZALLO 200-200 MG & 200-300 MG (LESINURAD/ALLOPURINOL) TABLET CAROSPIR 25 MG/5 ML (SPIRONOLACTONE) SUSPENSION ZILRETTA 32 MG (TRIAMCINOLONE ACETONIDE) VIAL January 2018 P&T Decisions Page 6