Date: October 3, 2017 To: Participating Providers From: YourCare Health Plan Provider Relations Subject: 2018 Formulary Changes 2018 Formulary-UM Changes What does this mean now, and for 2018? A number of formulary and use management program changes are being made for 1/1/18. These are described in the summary below, and with additional detail in the grid included in this communication. Members impacted by the changes will receive a communication in November 2017, as well as in the first quarter of 2018 (if there is a 4/1 impact). Prescribers are encouraged to use the preferred drug and formulary drugs now, and work with their patients to transition to formulary and preferred drugs prior to the impact dates. If you d like to request a list of your patients who fall into these categories, please contact us at 1.888.638.7149. If there are questions regarding these changes, please contact us at 1.888.638.7149. Change Summary Diabetes Medication Insulins: Basalgar, Levemir, and Treshiba going off formulary. Current users will need to transition by 4/1/18, or go through an exception request/review, and document why Lantus or Toujeo (the preferred drugs) can t be used as a replacement, or that diabetes is stable and A1C is <8.0. Insulins: Novo products (i.e. Novolog) going off formulary. Lilly products (i.e. Humalog) preferred. Impacts new starts, existing users will continue to get coverage into 2018, although transition of those members may be considered in 2018. Metformin ER: Going off formulary. Will require use/failure of non-er metformin for approval. Current users are grandfathered to 4/1/18 but will need to show clinical control (A1C < 8.0) and failure of non-er metformin in history for continued coverage post 4/1/18.
Proton Pump Inhibitors Esomeprazole: Going off formulary. Coverage approval will require trial/failure at maximum approved doses of 3 other generic PPIs. Current users will be required to document 3 previous trials of the other generic PPIs for coverage post 1/1/18. Branded Products: Non-Formulary. Coverage will require trial/failure at maximum doses of 3 generic PPI AND esomeprazole (4 total). Current users will be required to document this history for coverage post 1/1/18. Statins/Hypercholesterolemia/TG drugs Rosuvastatin: Going off formulary. Coverage will require use and intolerance/failure documentation to at least 2 of the preferred generic statins at maximum approved doses for at least 2 months with one of those being atorvastatin 80mg. Most current users will be able to continue into 2018 although some subgroups may be impacted after 4/1/18. Additional details will follow in 2018. Branded Statins: Non-Formulary. Coverage will require use and intolerance/failure documentation to at least 3 of the generic statins at maximum approved doses for at least a 2-month trial of each, with one of those being atorvastatin 80mg, as well as rosuvastatin at maximum doses. Current users will need to document this history, as well as documenting achieving target cholesterol control, for continued coverage after 1/1/18. Ezetimibe: Going off formulary. Coverage will require failure to achieve goals or intolerance to at least 3 of the generic statins at maximum doses, including atorvastatin 80mg, as above. Current users will be grandfathered until 4/1/18, but will need to demonstrate previous statin trials at maximum dose (i.e. atorvastatin at 80mg/day), and control of LDL/cholesterol on their ezetimibe regimen. Vascepa, Welchol and other Brands: Non-Formulary. Coverage will require documenting not achieving goal with maximum doses of at least 2 of the following: gemfibrozil and fenofibrate (for TG) and/or 3 generic statins and ezetimibe (as above), if for cholesterol control. Juxtapid: Going off formulary. Coverage will require prior use/trial of a PCSK9 drug. PCSK9: Policy update: will require lab documentation of non-smoking status prior to approval. Existing users will be required to provide documentation of non-smoking status for continued coverage after 4/1/18. Non-Opioid Pain Medication Lyrica: Adding additional coverage criteria, including diagnosis specific rules. New starts will require trial of at least 2 of the preferred products at full doses (i.e. gabapentin titrated to a minimum of
1800mg for at least 2 months, in addition to trials of duloxetine and/or tricyclics). Current users are not anticipated to be impacted, although certain use patterns may be identified, and those members may be subject to re-review in 2018. Gralise: Non-formulary. Coverage will be restricted to post-herpetic neuralgia and trial failure to at least 1800mg/day of gabapentin and Lyrica. Horizant: Non-formulary. Coverage will be restricted to post-herpetic neuralgia and restless leg syndrome, along with failure of either ropinirol or pramipexole, AND gabapentin at minimum dose of 1800mg (RLS) or for PHN - failure of gabapentin at a minimum 1800mg dose and Lyrica. Inhaled Steroid/Long Acting Beta Agonist Inhalers (ICI/LABA) Advair: Going off formulary. Coverage for new starts will require documentation of failure or intolerance to the 3 formulary ICI/LBA products, or justification as to why they could not be used (formulary products include Teva s fluticasone/salmeterol generic, Dulera, and Symbicort). Existing users will be allowed to continue on Advair, but certain subgroups (i.e. age criteria, lower dosage utilization) may be identified at a later date in 2018, to go through a continuation coverage review. (Teva's fluticasone/salmeterol is the generic for AirDuo, and has a lower concentration of the salmeterol compared to Symbicort and Advair, which may be clinically advantageous in lowering exposure to the long acting beta agonist.) ICI/LABA products: For non-formulary ICI/LABA product requests, step therapy will require a trial and documented intolerance or ineffectiveness of Teva s generic fluticasone/salmeterol, followed by Dulera or Symbicort, as coverage criteria for any breath activated ICS/LABA product. Some existing uses of these products may be identified at a later date in 2018 to go through a continuation coverage review.
YourCare 2018 Formulary-UM Changes Category Change Rationale Preferred Drug What this means Diabetes Insulins Remove Levemir, Basaglar, Tresiba from formulary Insulins Novo line of insulins becoming non-formulary Oral Proton Pump Inhibitors PPI Metformin ER remove from formulary add step therapy Stricter step therapy. Will need to try 3 generics at maximum doses before esomeprazole and 3 generics and esomeprazole before any branded product (i.e. Dexilant). Remove esomeprazole from formulary. Will require use of 3 formulary generics at max doses (the steps) to get non-formulary approval. Lower net cost for Lantus and Toujeo formulary products Lilly Insulins - lower net cost compared to Novo Cost: $136/Rx for ER vs $1.27/Rx metformin Maximize cost advantage of key generics High Cost ($90/Rx for esomeprazole vs <$15 for the 3 generics) Lantus, Toujeo Lilly Insulins (Humalog, Humulin, others) Metformin regular release Pantoprazole (<$4) Omeprazole (<$6) Lansoprazole (<$15) Pantoprazole (<$4) Omeprazole (<$6) Lansoprazole (<$15) Members will need to switch from Levmir, Basaglar, and Tresiba by 4/1/18, or document clinical control A1C<8 for continuation. No new starts on these starting 1/1/18. Existing users will be grandfathered until sometime in 2018. New starts as of 1/1/18 will require use of Lilly formulary products. Current users will need show diabetes control (A1C < 8) and use of formulary product in history to continue to get coverage post 4/1/18. No new start without step post 1/1/18. Branded products: would require coverage review under new steps for coverage post 1/1/18. Current users will be allowed up to 4/1/18 to document 3 formulary generics at max doses in order to get formulary coverage approval for esomeprazole after 4/1/18.
Category Change Rationale Preferred Drug What this means Statins Remove rosuvastatin (generic Crestor) from formulary: coverage will require 2 months each of trial/failure or intolerance to at least 2 of the preferred generic statins at maximum dose, one being atorvastatin 80mg. High Cost: $59/month generic vs 4 options under $10 simva ($1.27), lova ($3), atorvastatin ($6), Pravastin ($8) Statins Cholesterol/ TGs Branded Products Add Step Therapy for Statins: rosuvastatin requires 2 month each trial/failure, or intolerance to at least 2 of the preferred statins at max dose, one being atorvastatin 80mg. Branded products require documented trial/failure of 3 statins (including rosuvastatin - see formulary approval criteria above) at maximum dose for at least 2 months each. Add Step Therapy for branded and nonformulary products. (Add trial of gemfibrozil or fenofibrate to statin step above) Remove branded products from Formulary (Welchol, Vascepa, Juxtapid, others) (require statin steps and trial of ezetimibe prior to approval). High cost: (see above) Need to manage new/expensive brands and generics High cost: Vascepa: $233/Rx Welchol: $523/Rx Juxtipid: $30,000+/Rx simvastatin lovastatin atorvastatin (up to 80mg) pravastatin Statins, gemfibrozil fenofibrate niacin Formulary statins at max dose gemfibrozil fenofibrate niacin Require all brand users to go through new step for >1/1 coverage. For current generic users; evaluate history, LDL if possible. May require subgroup to go through step review by 4/1/18. Current brand users will need to go through re-review by 1/1/18 under new step rules for continued coverage. Will be added to review/documentation requirement per below. Current users will be required to demonstrate control of TG/cholesterol on current regimen and prior history of trials of the preferred drug for coverage post 4/1/18. Juxtapid: Requires use/failure of PCSK9.
Generics PCSK9 Remove ezetimibe (Zetia) from formulary Policy will be updated to require lab validation of non-smoking status High Cost: generic is $200-$250/Rx Statins as first line Current users will be grandfathered until 4/1/18, but will need to demonstrate previous statin trial at max dose (ie. Atorvastatin at 80mg), and control of LDL/cholesterol on ezetimibe regimen. Current users will be required to provide documentation by 4/1/18 for continued coverage. Category Change Rationale Preferred Drug What this means Pain Additional step therapy required and diagnosis specific edits for Lyrica and other branded gaba like products. Require trial of at least 2 of the preferred products at full doses (i.e. gabapentin 1800mg/day for at least 2 months, duloxetine, tricyclics, etc.) High Cost: Lyrica: $480/Rx, gabapentin= $9/Rx duloxetine: $16/Rx Add duloxetine and tricyclics, venflafaxine to step (need at least 2 of these), add indication specific rules. as appropriate). Asthma- COPD ICS/LABA ICS/LABA ICS/LABA Added authorized generic for AirDuo (same inged/lower strengths as in Advair) to formulary (2017) Remove Advair from formulary (1/1/18) Add Step Therapy to require initial trial of generic (fluticasone/salmeterol), followed by Dulera or Symbicort for any breath activated ICS/LABA product. Lower Cost, Lower LABA exposure Generic: $100 Advair: $370 Symbicort: $290 Highest Cost Option: promote lower cost/lower LABA product generic or lower cost brands. Cost. Lower strength/exposure to long acting beta agonist. fluticasone/salmete rol (generic of AirDuo by Teva) Dulera Symbicort fluticasone/salmete rol Symbicort, Dulera fluticasone/salmete rol Dulera Symbicort Grandfather existing users. New Starts impacted on 1/1. May identify target group to require rereview at some point in 2018. Gralise and Horizant: Coverage will be diagnosis specific and need trial of other drugs in history (including gabapentin and Lyrica Completed and available now. Grandfather existing users. May sub-identify intervention group (patient age, product strength) where a consideration of a change by a future date will be made. New starts will need to step through the generic, and then Dulera or Symbicort. Will impact formulary and nonformulary product requests.
Additional 2018 Formulary Changes Moving to non-preferred status in 2018 ACTOPLUS MET XR ANORO ELLIPTA AZASAN LEVEMIR/FLEXTOUCH PRED MILD BACTROBAN NASAL BASAGLAR KWIKPEN DUTOPROL RECOMBINATE SANDOSTATIN LAR/DEPOT E.E.S. GRANULES ELOCTATE ERYPED SUSPENSION TESTOPEL TREXALL ERY-TAB EC 500 MG TABLET HECTOROL VIAL KALBITOR NEUPOGEN VITAFOL-OB CAPLET Please share this important information with all practice locations or corporate offices. If you have additional questions on this bulletin, please contact our provider service department at 888.638.7149 or visit our website at yourcarehealthplan.com Thank you for your participation, and the care that you provide to our valued members.