Pharmacy News July 2016 Drug Guide and Clinical Program Updates Prime Therapeutics® Pharmacy and Therapeutics (P & T) Committee in association with ...
Pharmacy News July 2016 Drug Guide and Clinical Program Updates Prime Therapeutics® Pharmacy and Therapeutics (P & T) Committee in association with Blue Cross and Blue Shield of Alabama’s Formulary Business Committee recently approved updates to the Drug Guides and made clinical program changes to select medications. All information is online at AlabamaBlue.com/pharmacy. The Prime Therapeutics P & T Committee ‐‐ consisting of doctors, pharmacists and other healthcare professionals ‐‐ advises and makes recommendations based on clinical appropriateness. The Blue Cross and Blue Shield of Alabama Formulary Business Committee makes final approval of these clinical recommendations before implementation. The following drugs may have coverage changes that affect what a member will be required to pay at the time of purchase. Members will receive a letter if they are negatively affected by a formulary change that is not a result of a new generic being available.
Prescription Drug Guide Updates – Effective July 1, 2016 (unless otherwise noted) Brand Name (generic name if available)
Therapeutic Class
Description of Change
Additional Comments
Actonel
Bisphosphonate Medication
Move from Tier 2 to Tier 3
Effective 6/9/15 generic equivalent now available
Effective 12/20/2015 Effective 5/27/15 generic equivalent now available None None None None None Effective 9/15/15 generic equivalent now available None None
Add to Tier 2 Move from Tier 2 to Tier 3
Xarelto
Anticoagulant Medication
Add to Tier 2
Zyvox
Antibiotic
Move from Tier 2 to Tier 3
Effective 11/24/15 generic equivalent now available None Effective 11/24/15 generic equivalent now available
The Prescription Drug Guide is updated quarterly. Please visit AlabamaBlue.com/pharmacy for the most up‐to‐date information. Note: Coverage is subject to each member’s specific benefits. Group‐specific policies will supersede these policies when applicable. Please refer to the member’s benefit plan.
Clinical Program Updates – Effective July 1, 2016 (unless otherwise noted) The following medication dispensing limits (DL), prior authorization (PA), predetermination (PD) and/or step therapy (ST) programs have been added or revised:
New or Revised Pharmacy PA or ST Programs Policy Name
Type of Policy
Hepatitis C 2nd Generation
PA
Hepatitis C Sovaldi/Daklinza
PA
HoFH
PA/DL
Oral PAH
PA/DL
PCSK9
PA/DL
Thrombopoeitin Receptor (ITP)
PA/DL
URAT1 Inhibitor
PA/DL
Topical Androgen
PA/QL
Atypical Antipsychotic
ST/DL
Coverage Criteria and Changes REVISED Addition of Zepatier (elbasvir/grazoprevir) as a target drug. Policy updated to align with the new AASLD treatment guidelines and includes the new FDA approved indications for Harvoni. This includes treatment recommendations for patients with decompensated cirrhosis and those who have had liver transplantation. REVISED Policy updated to align with the new AASLD treatment guidelines and includes the new FDA approved indications for Daklinza. This includes treatment recommendations for patients with chronic hepatitis C genotype 1 and those with decompensated cirrhosis and/or liver transplantation. REVISED – Policy updated with information from the American Heart Association scientific statement for HoFH treatment algorithm. Initial criteria: Added the requirement to try and fail a PCSK9 inhibitor (unless the patient has a medical reason preventing this) prior to adding Juxtapid/Kynamro. Renewal criteria: Added the requirement that the patient is still on the PCSK9 inhibitor (unless the patient has a medical reason preventing this) in order to continue on the requested agent. REVISED Policy updated to allow for any prostanoid to be started (instead of parenteral) as part of triple therapy unless there is a medical reason why the patient cannot be started on prostanoid therapy. In the Adcirca or Revatio/sildenafil module criteria added around diagnosis confirmation and add‐on therapy criteria. Updated list of concurrent medications not allowed (PDE5 inhibitors, Orenitram). REVISED Policy updated to allow use of PCSK9s with either Juxtapid or Kynamaro for patients with HoFH. This is based on treatment recommendations by the American Heart Associated (AHA). Removed the requirements that the patient must have been Zetia for at least 6 months prior to starting treatment with a PCSK9. REVISED Policy updated to allow an approval pathway for patients with ITP who have a platelet count of 30 x 109/L to