PHARMACY AND THERAPEUTICS COMMITTEE August 2016 A meeting of the Health Partners Pharmacy and Therapeutics (P&T) Committee was held on August 23, 2016. The following are the recommendations for the drugs reviewed at the meeting by the Committee: Drug Name 2 way edit for 1 st generation oral antipsychotics to deny in the presence of another 1 st generation oral antipsychotic Apply to pimozide, chlorpromazine, fluphenazine, perphenazine trifluoperazine, thioridazine, haloperidol, loxapine, molindone, thiothixene, perphenazine/amitriptyline Lookback 6 day supply in the previous 14 days 2 way edit for 2 nd generation oral antipsychotics to deny in the presence of another 2 nd generation oral antipsychotic Apply to aripiprazole, Saphris, Rexulti, Vraylar, Fanapt, Latuda, olanzapine, Symbyax, paliperidone, quetiapine, Seroquel R, risperidone, ziprasidone Lookback 6 day supply in the previous 14 days Afinitor Allow 1 fill of Vivitrol per 28 day supply to pay at POS without a PA every 180 days Amitiza will be combined into new Constipation Agents Criteria Ampyra Apriso Apriso 4 capsules per day Apriso Pay 18 and older (deny under 18) Asacol HD Asacol HD 6 tablets per day
Asacol HD Pay 18 and older (deny under 18) Atypicals under 18 Avonex Canasa Canasa 1supp per day Canasa Pay 18 and older (deny under 18) Canasa, Rowasa Two way DUR. Lookback 6 d/s in previous 30 days. Caprelsa will be combined into new Oral Constipation Agents Copaxone Early Refills Elidel 1% cream First and Second Generation Antipsychotics see attachment Flolan/Veletri Forteo Fuzeon Gilenya HP Acthar Gel (new) Humulin R U 500 Humulin R U-500 Kwikpen (with ) Jakafi will be combined into new Oral Lialda Lialda 4 tablets per day Lialda Pay 18 and older (deny under 18) Lialda, Asacol HD, Delzicol, Pentasa, Apriso Two way DUR. Lookback 6 d/s in previous 30 days Linzess will be combined into new Constipation Agents Criteria Marinol Matulane will be combined into new Oral Megace ES Narcotics under 21 Nexavar
Nifedical/nifedipine ER/L quantity of 2 per day Oral Anticoagulant DUR with warfarin Change to 1 way edit: Warfarin 1 way edit with arelto, Pradaxa, Eliquis, Savaysa - Lookback 6 d/s in previous 30 days Oral Chemotherapy Agents: -Tykerb (lapatinib) -Jakafi (ruxolitinib) -Zelboraf (vemurafenib) -alkori (crizotinib) -Matulane (procarbazine) -Caprelsa (vandetanib) Oral Isotretinoin products Pay with 12 years and older (deny for under 12 for age and PA) Peg-Intron Procrit Promacta Pulmozyme Ranexa and Cimiza lookback of 6 day supply in the previous 75 days Rebif Age Limit for Symbicort and Dulera Saxenda 0.5ml per day Saxenda Include in one-way edit with Trulicity. Saxenda will deny and Trulicity will continue to pay. Lookback of 6 d/s in previous 28 days Saxenda Pay for 18 and older (deny under 18) Tacrolimus 0.1% ointment Pay with for 16 and older (deny for 15 and under and PA) Tacrolimus 0.3% ointment Pay with for 2 and older (deny for 1 and under and PA) Testosterone 1% gel packets 150ml/30days (5ml/day) Testosterone 1% gel packets Pay 18 and older (deny under 18) Testosterone 1% gel packets (with ) Grandfather Edit
200mg/ml 10ml/30days (0.33ml/day) 200mg/ml Pay 12 and older (deny under 12) 200mg/ml (with ) Testosterone enanthate 200mg/ml 5ml/30 days (0.166ml/day) Testosterone enanthate 200mg/ml - Pay 12 and older (deny under 12) Testosterone enanthate 200mg/ml (with ) Testosterone replacement Tobi Toujeo Solostar 300 units/ml - One-way edit against Lantus/Levemir (Toujeo will continue to pay) Lookback for 6 d/s in 45 days Toujeo Solostar Pay for 18 and older (deny under 18) Tysabri Tyvaso/Remodulin Ventavis Virtrate-K Vitamins for addition. We will add each generic product associated with these brand names. -Folcaps -Folivane-OB -Virt-Vite Forte -Folbic -Dialyvite Zinc -Completenate -Folplex -Prenatal-U -Trinate -Citranatal B-Calm -Prenatal 19 -Nephron FA -Prenatal MTR -Ferraplus 90 alkori will be combined into new Oral arelto
yrem Zelboraf will be combined into new Oral