P&T/Formulary Committee s (1Q18) 1Q2018 Marketplace Standard (HIEx) Additions and/or Revisions effective: April 1, 2018 Deletions effective: April 1, 2018 for NEW member prescriptions; July 1, 2018 for EXISTING member prescriptions Elevate Formulary Updates to Elevate Plans (Bronze HDHP/Standard, Silver Select/Standard & Gold Select/Standard) P&T/Formulary Committee s 1Q 2018 (Effective April 1, 2018) Marketplace Standard Formulary Committee s HIV Biktarvy Drug ImmunomodulaƟng Biologics bictegravir/ emtricitabine/ tenofovir alafenamide N/A C=2 N/A A=QL CHANGE Biktarvy to Preferred Brand Tier (Tier 2). ADD QL on Biktarvy as follows: 1 tablet per day Actemra tocilizumab SC 4 S=4 PA CHANGE PA guideline on Actemra SC. Cimzia certolizumab 4 S=4 PA CHANGE PA guideline on Cimzia. Cosentyx secukinumab 4 S=4 PA CHANGE PA guideline on Cosentyx. Enbrel etanercept 4 S=4 PA CHANGE PA guideline on Enbrel. Humira adalimumab 4 S=4 PA CHANGE PA guideline on Humira. Kevzara sarilumab 4 S=4 PA CHANGE PA guideline on Kevzara Kineret anakinra 4 S=4 PA CHANGE PA guideline on Kineret. Orencia abatacept SC 4 S=4 PA CHANGE PA guideline on Orencia SC. Otezla apremilast 4 S=4 PA CHANGE PA guideline on Otezla. Siliq brodalumab 4 S=4 PA CHANGE PA guideline on Siliq. Simponi 50mg/0.5ml golimumab SC 50mg/0.5ml 4 S=4 PA CHANGE PA guideline on Simponi SC. Simponi 100mg/ml golimumab SC 100mg/ml 4 S=4 PA CHANGE PA guideline on Simponi SC. Stelara ustekinumab 4 S=4 PA CHANGE PA guideline on Stelara. Taltz ixekizumab 4 S=4 PA CHANGE PA guideline on Taltz. Tremfya guselkumab 4 S=4 PA CHANGE PA guideline on Trmfya. Xeljanz tofacitinib 4 S=4 PA CHANGE PA guideline on Xelijanz. Xeljanz XR tofacitinib extended release 4 S=4 PA CHANGE PA guideline on Xelijanz XR. ImmunomodulaƟng Biologics (NSA) Actemra tocilizumab IV 4 S=4 PA^ ^ CHANGE PA (NSA) guideline on Actemra IV. Entyvio vedolizumab 4 S=4 PA^ ^ CHANGE PA (NSA) guideline on Entyvio. Inflectra infliximab dyyb 4 S=4 PA^ ^ CHANGE PA (NSA) guideline on Inflectra. Orencia abatacept IV 4 S=4 PA^ ^ CHANGE PA (NSA) guideline on Orencia IV. Remicade infliximab 4 S=4 PA^ ^ CHANGE PA (NSA) guideline on Remicade. Renflexis infliximab abda 4 S=4 PA^ ^ CHANGE PA (NSA) guideline on Renflexis. Rituxan rituximab 4 S=4 PA^ ^ CHANGE PA (NSA) guideline on Rituxan.
Simponi Aria golimumab IV 4 S=4 PA^ ^ CHANGE PA (NSA) guideline on Simponi Aria. Hemophilia Hemlibra emicizumab 4 S=4 PA* CHANGE interim PA to final PA guideline on Hemlibra.
Drug Oncology Oral Calquence acalabrutinib 4 S=4 PA* CHANGE PA guideline on Calquence. Alunbrig brigatinib 4 S=4 PA CHANGE PA guideline on Alunbrig. Zelboraf vemurafenib 4 S=4 PA, QL Alecensa alectinib 4 S=4 PA, QL Sutent sunitinib 4 S=4 PA, QL MAINTAIN QL on Zelboraf. CHANGE PA guideline on Zelboraf. MAINTAIN QL on Alecensa. CHANGE PA guideline on Alecensa. MAINTAIN QL on Sutent. CHANGE PA guideline on Sutent. Cabometyx cabozantinib tablet 4 S=4 PA CHANGE PA guideline on Cabometyx. Bosulif bosutinib 4 S=4 PA, QL, QL Lynparza olaparib 4 S=4 PA, QL CHANGE PA guideline on Bosulif. CHANGE QL on Bosulif as follows: CHANGE PA guideline on Lynparza. MAINTAIN QL on Lynparza. Gilotrif afatinib 4 S=4 PA CHANGE PA guideline on Gilotif. Gleostine lomustine 4 S=4 none A=PA ADD PA guideline on Gleostine. Prevymis letermovir, oral 4 S=4 PA* CHANGE interim PA guideline on Prevymis to final PA Oncology Non Oral, NSA Faslodex fulvestrant 4 S=4 PA^ ^ CHANGE PA (NSA) guideline on Faslodex. Adcetris brentuximab 4 S=4 PA^ ^ CHANGE PA (NSA) guideline on Adcentris. Gazyva obinutuzumab 4 S=4 PA^ ^ CHANGE PA (NSA) guideline on Gazyva Avastin bevacizumab 4 S=4 PA^ ^ CHANGE PA (NSA) guideline on Avastin Opdivo nivolumab 4 S=4 PA^ ^ CHANGE PA (NSA) guideline on Opdivo Perjeta pertuzumab 4 S=4 PA^ ^ CHANGE PA (NSA) guideline on Perjeta Xgeva denosumab 4 S=4 PA^ ^ CHANGE PA (NSA) guideline on Xgeva Prevymis letermovir, IV 4 S=4 PA^* ^ Orphan Diseases Mepsevii vestronidase alfa vjbk 4 S=4 PA^* ^ Luxturna voretigene neparvovec 4 S=4 PA^* ^ Infectious Disease CHANGE interim PA (NSA) guideline on Prevymis IV to final PA (NSA) guideline CHANGE interim PA (NSA) guideline on Mepsevii to final PA (NSA) CHANGE interim PA (NSA) guideline on Luxturna to final PA (NSA) ADD QL on Solosec as follows : 1 single dose oral packet per 30 days. Solosec secnidazole 3 S=3 none A=QL, ST ADD ST on Solosec as follows: Trial two of the following agents: oral metronidazole, oral tinidazole, oral clindamycin; metronidazole gel (0.75%), clindamycin cream (2%) in the previous 365 days. ADD QL on Cleocin: 3 intravaginal ovules (1 box) per 30 days Cleocin Clindamycin, intravaginal 3 S=3 none A=QL, ST ADD ST on Cleocin: Trial two of the following agents: oral metronidazole, oral tinidazole, oral clindamycin; metronidazole gel (0.75%), clindamycin cream (2%) in the previous 365 days. Ximino minocycline ER cap 3 S=3 none A=QL, ST, AGE ADD QL on Ximino as follows: 1 ER capsule daily. ADD ST on Ximino as follows: Trial of generic IR Minocycline tablets or generic IR Minocycline capsules in the previous 120 days. Allergy Odactra house dust mite allergen 3 C=2 PA* ADD AGE on Ximino as follows: 12 years of CHANGE Odactra to Preferred Brand (Tier 2) CHANGE interim PA guideline on Odactra to final PA Ragwitek ragweed pollen allergen 2 S=2 PA CHANGE PA guideline on Ragwitek. Grastek timothy grass pollen allergen 2 S=2 PA CHANGE PA guideline on Grastek.
Oralair Drug mixed grass pollen allergen 2 3= (100/300IR tablet) S=2 S=3 (100/300IR tablet) PA CHANGE PA guideline on Oralair. ADD QL on Xhance as follows: 32 ml (2 inhalation devices) per 30 days. Xhance fluticasone propionate 3 S=3 none A=QL, ST ADD ST on Xhance as follows: Trial of 2 of the following inhaled nasal corticosteriods: mometasone, fluticasone propionate/furoate, flunisolide, beclomethasone (Qnasl) in the previous 365 days. Non Oral NSAIDs Sprix ketorolac 3 S=3 QL A=ST MAINTAIN QL on Sprix. ADD ST on Spri as follows: Trial 1 generic NSAID in the previous 120 days. Indocin indomethacin suppositories 2 C=3 none A=PA GNRH agonists CHANGE Indocin to Non Preferred Brand Tier (Tier 3). ADD PA guideline on Indocin. Triptodur triptorelin 4 S=4 PA^ ^ CHANGE PA (NSA) guideline on Triptodur. Supprelin LA histrelin 4 S=4 none A=PA^ ADD PA (NSA) guideline on Supprelin LA. Lupon Depot Ped leuprolide 4 S=4 none A=PA^ ADD PA (NSA) guideline on Lupron Depot Ped Misc Drugs Oral Tracleer bosentan 4 S=4 PA CHANGE PA guideline on Tracleer. Adempas riociguat 4 S=4 PA CHANGE PA guideline on Adempas. Sensipar cinacalcet 3 S=3 none A=QL ADD QL on Sensipar as follows: 30 mg: 2 tablets per day 60 mg: 2 tablets per day 90 mg: 4 tablets per day ADD QL on Lyrica CR as follows: 82.5 mg, 165 mg: 3 tablets per day, 330 mg: 2 tablets per day Lyrica CR pregabalin 3 S=3 PA D=PA A=QL, ST ADD ST on Lyrica CR as follows: Trial of 2 of the following: gabapentin, tricyclic antidepressants (amitripyline, nortriptyline/notriptyline solution, desipramine, doxepin capsules/solution, imipramine, maprotilene), duloxetine, venlafaxine,valproic acid / divalproex in the previous 365 days. Flolipid simvastatin suspension 3 S=3 QL,ST Silenor doxepin 2 S=2 QL, ST Misc Drugs Non Oral D=QL,ST A=PA C=ST DELETE PA on Lyrica CR. DELETE QL and ST on Flolipid. ADD PA guideline on Flolipid. MAINTAIN QL on Silenor. CHANGE ST on Silenor as follows: a trial of one of the following: zolpidem IR, zaleplon, eszopiclone, doxepin 10 mg/ml solution, or doxepin 10 mg capsule in the previous 120 days. Parsabiv etelcalcetide 4 S=4 PA*^ ^ Fasenra benralizumab 4 S=4 PA*^ ^ CHANGE interim PA (NSA) guideline on Parsabiv to final PA (NSA) CHANGE interim PA (NSA) guideline on Fasenra to final PA (NSA) Nucala mepolizumab 4 S=4 PA^ ^ CHANGE PA (NSA) guideline on Nucala. Cinqair reslizumab 4 S=4 PA^ ^ CHANGE PA (NSA) guideline on Cinqair Durolane hyaluronic acid NC^ S=NC^ PA*^ ^ Impoyz clobetasol 0.025% cream 3 S=3 none A=ST Rx Cough Codeine and Hydrocodone Tuzistra XR codeine/ chlorpheniramine 3 S=3 AGE, QL, ST Codeine/ Phenylephrine/ Promethazine Codeine/ Phenylephrine/ Promethazine C=AGE S=ST, QL 1 S=1 AGE C=AGE Promethazine/ Codeine Promethazine/ Codeine 1 S=1 AGE C=AGE CHANGE interim PA (NSA) guideline on Durolane to final PA (NSA) ADD ST on Impoyz as follows: trial of a topical corticosteroid in the previous 120 days. CHANGE AGE RESTRICTION on Tuzistra XR as follows: greater than 18 years of MAINTAIN QL and ST on Tuzistra XR CHANGE AGE RESTRICTION on Codeine/Phenylephrine/ Promethazine as follows: greater than 18 years of CHANGE AGE RESTRICTION on Promethazine/Codeine as follows: greater than 18 years of FlowTuss, Obredon hydrocodone, guaifenesin 3 S=3 ST, QL Hycofenix hydrocodone, pseudoephedrine, guaifenesin 3 S=3 ST, QL A=AGE S=ST, QL A=AGE S=ST, QL ADD AGE RESTRICTION on FlowTuss, Obredon as follows: greater than 18 years of MAINTAIN ST and QL on FlowTuss, Obredon. ADD AGE RESTRICTION on Hycofenix as follows: greater than 18 years of MAINTAIN ST and QL on Hycofenix.
Drug Vituz hydrocodone, chlorpheniramine 3 S=3 none A=AGE ADD AGE RESTRICTION on Vituz as follows: greater than 18 years of age required. Tussionex hydrocodone, chlorpheniramine ER 12H suspension 1 S=1 none A=AGE ADD AGE RESTRICTION on Tussionex as follows: greater than 18 years of Tussicaps hydrocodone, chlorpheniramine ER CAP 3 S=3 none A=AGE ADD AGE RESTRICTION on Tussicaps as follows: greater than 18 years of Zutripro hydrocodone, chlorpheniramine, pseudophedrine 1 S=1 none A=AGE ADD AGE RESTRICTION on Zutripro as follows: greater than 18 years of Tussigon (tablet), Hydromet (syrup) 1Q18 Clean up hydrocodone/homatropine 1 S=1 none A=AGE ADD AGE RESTRICTION on Tussigon, Hydromet as follows: greater than 18 years of Cialis tadalafil (2.5, 5 mg) 3 S=3 PA, QL Cialis tadalafil (10, 20 mg) 3 S=3 PA, QL D=PA A=ST MAINTAIN QL on Cialis 2.5, 5 mg CHANGE PA guideline on Cialis 2.5, 5 mg MAINTAIN QL on Cialis 10, 20 mg DELETE PA on Cialis 10, 20 mg ADD ST on Cialis 10, 20 mg as follows: Trial of sildenafil (Viagra) in the previous 120 days. Xigduo XR dapagliflozin/metformin 3 S=3 ST, QL S=ST C=QL CHANGE QL on Xigduo XR as follows: 2.5/1000mg, 5/1000mg: 2 tablets per day; 5/500mg, 10/500 mg, 10/1000 mg: 1 tablet per day Gamunex C IVIG (40G, GPID=37322) NC^ S=NC^ none A=PA ADD PA guideline on Gamunex C (40 Gram) Vemlidy tenofovir alafenamide 4 S=4 QL 1Q18 Exclusions A=ST MAINTAIN QL on Vemlidy ADD ST on Vemlidy as follows: Trial of tenofovir 300 mg (Viread) in the previous 120 days Fenortho, Profeno, Nalfon fenoprofen 200, 400, 600 mg 2 C=3 None None CHANGE Fenortho, Profeno, Nalfon to Non Preferred Brands (Tier 3) doxycyline doxycline DR 200 mg 1 S=1 ST,QL 1Q18 IR initiatives C=QL S=ST CHANGE QL on doxycycline DR 200 as follows: 1 tablet per day. MAINTAIN ST on doxycycline DR 200mg Uptravi selexipag 4 S=4 PA CHANGE PA guideline on Uptravi. Austedo deutetrabenazine 4 S=4 PA CHANGE PA guideline on Austedo. Ingrezza valbenazine 4 S=4 PA CHANGE PA guideline on Ingrezza. Negative Changes from 4Q17 (Approved at P&T 4Q17) MISC Non Oral (IV, SC) 4Q17 Carryover Benlysta IV belimumab 4 S=4 none A=PA^ ADD PA (NSA) guideline on Benlysta IV ADHD 4Q17 Carryover Cotempla XR ODT methylphenidate ER 3 S=3 ST A=QL C=ST CHANGE ST on Cotempla XR ODT as follows: Trial of methylphenidate IR, long acting formulation of methylphenidate (ER, LA, CD), or generic/multisource mixed amphetamine salts (Adderall IR/XR) in the previous 120 days. MISC Agents 4Q17 Carryover Duzallo allopurinol/ lesinurad 3 S=3 none A=ST, QL ADD QL on Cotempla XR ODT as follows: 8.6 mg, 17.3 mg: 1 tablet per day; 25.9 mg: 2 tablets per day ADD ST on Duzallo as follows: Trial of allopurinol or Uloric (feuxostat) in the previous 120 days. ADD QL on Duzallo as follows: 1 tablet per day. Zurampic lesinurad 2 C=3 ST, QL S=ST, QL CHANGE Zurampic to Non Preferred Brands (Tier 3) Carospir spironolactone oral suspension 3 S=3 none A=ST, QL ADD ST on Carospir as follows: Trial of spironolactone tablets in the previous 120 days. ADD QL on Carospir as follows: 600 ml per 30 days Glycopyrrolate Glycopyrrolate 1.5 mg 1 S=1 none A=ST, QL Chlorzoxazone Chlorzoxazone 250, 375, 750 mg 1 S=1 none A=ST, QL Taytulla ethnityl estradiol/ noethindrone/fe 3 S=3 none A=ST ADD ST on Glycopyrrolate 1.5 mg tablets as follows: Trial of glycopyrrolate 1 mg or 2 mg tablets in the previous 120 days. ADD QL on Glycopyrrolate 1.5 mg tablets as follows: 3 tablets per day. ADD ST on Chlorzoxazone 250, 375, 750 mg tablets as follows: trial of chlorozoxane 500 mg tablets in the previous 120 days. ADD QL on Chlorzoxazone 250, 375, 750 mg tablets as follows: 4 tablets per day. ADD ST to Taytulla as follows: trial of two generic contraceptives in the previous 365 days. Renagel sevelamer HCL 2 C=3 none none CHANGE Renagel to Non Preferred Brands (Tier 3)
Drug Zodex/Locort/ ZonaCort/Dexpack 1Q18 Additional Item dexamethasone 1.5 mg blister pack (misc pack sizes) 3 S=3 None C=ST Forteo teriparatide SC 2 S=2 QL C=QL CHANGE ST on Zodex/Locort/Zonacort/Dexpack (dexamethasone 1.5 mg tablet taper packs) as follows: trial of dexamethasone 1.5 mg tablets required. CHANGE QL on Forteo as follows: Limited 2.4mL per 28 days with a max duration of 728 days per lifetime COMMERCIAL LEGEND Formulary s Utilization Management (UM) s C = Change A = Add UM S = Sustain D = Delete UM NC^ = Not covered; Non C = Change UM Formulary if covered E = Exclude drug from formulary S = Sustain/maintain Multiple actions view cell for details