Pharmacy News October 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 October 1, 2016 (unless otherwise noted) Brand Name (generic name if available)
Therapeutic Class
Description of Change
Additional Comments
Accu-Chek
Diabetic Supplies
Move from Tier 2 to Tier 3
Effective 9/1/16
Crestor
Cholesterol Lowering Medications
Move from Tier 1 to Tier 3
Effective 8/5/16 generic equivalent now available
Impavido
Anti-Parasitic Medications
Add to Tier 2
None
Nilandron
Anticancer Medications
Move from Tier 2 to Tier 3
Effective 9/1/16 – generic equivalent now available
Renvela
Kidney Medications
Add to Tier 2
None
Tegretol-XR
Anticonvulsants
Move from Tier 2 to Tier 3
Effective 9/1/16 – generic equivalent now available
Velphoro
Kidney Medications
Add to Tier 2
None
Vivelle-Dot
Hormone Replacement
Move from Tier 2 to Tier 3
Voltaren
Anti-inflammatory Medications
Move from Tier 2 to Tier 3
Effective 9/1/16 – generic equivalent now available Effective 9/1/16 – 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.
Generic Plus Drug Guide Updates – Effective October 1, 2016 (unless otherwise noted) Brand Name (generic name if available)
Therapeutic Class
Description of Change
Additional Comments
Accu-Chek
Diabetic Supplies
Move from Tier 2 to Tier 3
Effective 9/1/16
BENZONATATE 150 mg capsule
Cough Medications
Move from Tier 2 to Tier 3
Effective 7/21/16
Desloratadine orally disintegrating tablets
Antihistamines
Add to Tier 2
Effective 5/19/16
Estropipate tablets
Hormone Replacement
Move from Tier 2 to Tier 3
Effective 5/26/16
Fluoxetine (PMDD) capsule
Miscellaneous Products
Move from Tier 2 to Tier 3
Effective 5/30/16
Impavido
Antiparasitic Medications
Add to Tier 2
None
Lidocaine HCl Laryngotracheal 4% solution
Pain Relievers
Move from Tier 2 to Tier 3
Effective 5/30/16
Lindane 1% lotion
Anti-Parasitics
Move from Tier 2 to Tier 3
Effective 5/9/16
Nilandron
Anticancer Medications
Move from Tier 2 to Tier 3
Effective 9/1/16 – generic equivalent now available
Nizatidine oral solution, 15mg/mL
Ulcer Drugs
Add to Tier 2
Effective 5/24/16
Nuvaring
Birth Control Medications
Add to Tier 2
None
Pain Relievers
Move from Tier 2 to Tier 3
Effective 5/12/16
Pain Relievers
Move from Tier 2 to Tier 3
Effective 6/29/16
Tolazamide 250 mg tablets
Antidiabetic Medications
Move from Tier 2 to Tier 3
Effective 5/30/16
Zamicet 10-325 mg15 mL solution
Pain Relievers
Move from Tier 2 to Tier 3
Effective 5/30/16 – generic equivalent now available
Orphenadrine/Aspirin/Caffeine 25-385-30 mg tablets OXYCODONE/IBUPROFEN 5-400 mg tablet
For a complete listing of generic and preferred brand alternatives, please refer to the Generics Plus Drug Guide located in the Pharmacy section of the Blue Cross website, AlabamaBlue.com/pharmacy. 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 October 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
Ocalvia
PA/DL
Selective Serotonin Inverse Agonist (SSIA)
PA/DL
Strensiq
PA/DL
HCN
PA/DL
Coverage Criteria and Changes NEW – Coverage will be allowed for the treatment of Primary Biliary Cholangitis (PBC) for patients with an inadequate response to ursodeoxycholic acid (UDCA). If approved, the quantity limits are 1 tablet per day. NEW – Coverage will be allowed for the treatment of hallucinations and delusions associated with Parkinson’s disease psychosis for patients who have previously tried clozapine or quetiapine. If approved, the quantity limits are 2 tablets per day. NEW – Coverage will be allowed for the treatment of perinatal/infantile and juvenile-onset hypophosphatasia (HPP). If approved, this product is subject to quantity limits. REVISED – Policy updated to allow the use in patients with inappropriate sinus tachycardia (IST) who are symptomatic.
Hepatitis C 1 Generation
st
PA/DL
Hepatitis C 2 Generation
nd
PA/DL
Multiple Sclerosis
ST/DL
Neprilysin Inhibitors
PA/DL
Doxycycline/Minocycline
ST
PCSK-9
PA/DL
Gattex
PA
Glucose Test Strip
ST
REVISED – Policy updated to allow the combination of Sovaldi and Olysio to treat genotype 1 or 4 for patients who are not candidates for Harvoni. Hepatitis B infection is no longer a restriction for the use of Daklinza, Olysio or Sovaldi. REVISED – Addition of Epclusa as a target drug. REVISED – Addition of Zinbryta as a target drug with a quantity limit of 1 injection per month. REVISED – Policy updated to require that a patient is currently not on another ACE inhibitor or ARB, or the patient will be discontinuing the current ACE inhibitor or ARB. REVISED – Addition of Doryx 120 mg. REVISED – Addition of Repatha 420mg/3.5 mL with a quantity limit of 1 per 30 days. REVISED – Policy updated to clarify the requirement to remove polyps applies only to those with evidence of polyps as seen on the colonoscopy. REVISED – Policy updated to remove Roche as a preferred product.
New or Revised Dispensing Limits Brand Name (generic if available) Adderall Adderall Adderall XR Afrezza Bevespi Aerosphere Butorphanol nasal spray Byvalson Celexa Celexa solution Concerta Cymbalta Dexedrine Effexor Emend suspension Evekeo Fluvoxamine Focalin Focalin XR Intuniv Jentadueto XR Kaletra solution Kapvay Lexapro Lexapro solution Luvox CR Maprotiline Metadate CD Methylin chewable Methylin solution Oleptro Paxil Paxil CR Pexeva Prozac Prozac solution Prozac weekly Qullivant XR
Strength
Dispensing Limit per month
New or Revised
5, 7.5, 10, 12.5, 15, & 30 mg 20 mg 5, 10, 15, 20, 25, & 30 mg
60 tablets 90 tablets 30 capsules 1,800 cartridges 1 inhaler 87.5 mL 30 tablets 30 tablets 600 mL 30 tablets 60 capsules 90, 120, or 120 capsules 90 tablets 6 kits 90 or 180 tablets 30, 30, or 90 tablets 60 tablets 30 capsules 30 tablets 60 or 30 tablets 480 mL 120 tablets 30 tablets 600 mL 60 capsules 90 tablets 30 capsules 90, 90, or 180 tablets 450 or 900 mL 45 or 30 tablets 30, 30, 60, or 30 tablets 30, 60, or 60 tablets 30, 30, 60, or 30 tablets 30, 120, or 60 capsules 600 mL 4 capsules/28 days 360 mL
New New Revised New New New New New New Revised Revised New New New New New New Revised New New Revised New New New New New Revised New New New New New New New New New New
9/4.8 mcg 10 mg/mL 5-80 mg 10, 20, & 40 mg 10 mg/5 mL 18, 27, & 54 mg 60 mg 5, 10, & 15 mg 25, 37.5, 50, 75, & 100 mg 125 mg/5 mL 5 mg, 10 mg 25, 50, & 100 mg 2.5, 5, & 10 mg 5, 10, 15, & 20 mg 1, 2, 3, & 4 mg 2.5/1000 mg, 5/1000 mg 20 mg/mL 0.1 mg 5, 10, & 20 mg 5 mg/5 mL 100 mg, 150 mg 25, 50, & 75 mg 10, 20, 30, 40, & 50 mg 2.5, 5, & 10 mg 5 mg/mL, 10 mg/mL 150 mg, 300 mg 10, 20, 30, & 40 mg 12.5, 25, & 37.5 mg 10, 20, 30, & 40 mg 10, 20, & 40 mg 20 mg/5 mL 90 mg 25 mg/mL
Relenza Remeron (mirtazapine) Remeron SolTab Rescula Reyataz packet Ritalin Ritalin LA Ritalin SR Selzentry Strattera Tamiflu Tamiflu suspension Tivicay Truvada Venlafaxine ER Viekira XR Viibryd Viibryd Starter Kit Wellbutrin Wellbutrin XL Xtampza ER Zenzedi Zenzedi Zoloft Zoloft solution
5 mg 7.5, 15, 30, & 45 mg 7.5, 15, 30, & 45 mg 0.15% 50 mg 5, 10, & 20 mg 10, 20, 30, 40, & 60 mg 20 mg 300 mg 60 mg 30, 45, & 75 mg 6 mg/mL, 12 mg/mL 10 mg, 25 mg 100, 133, & 167 mg 75 mg 10, 20, & 40 mg 10, 20, & 40 mg 75 mg 150 mg 9, 13.5, 18, 27, & 36 mg 2.5, 5, 7.5, 15, & 20 mg 10 mg, 30 mg 25, 50, & 100 mg 20 mg/mL
40 blisters/120 days 30 tablets 30 tablets 5 mL 240 packets 90 tablets 30 capsules 90 tablets 120 tablets 30 capsules 20 capsules/120 days 360 mL, 150 mL/120 days 60 tablets 30 tablets 90 tablets 90 tablets 30 tablets 1 kit per 180 days 60 tablets 30 tablets 60 tablets 90 tablets 180 or 60 tablets 30, 30, or 60 tablets 300 mL
Revised New New New Revised New Revised New Revised Revised Revised Revised New Revised Revised New New New Revised Revised New New New New New
Clinical Program Updates – Effective October 1, 2016 New or revised physician-administered (medical) drug programs Policy Name
Type of Policy
Antiemetic
Medical PA
Immune Globulin
Medical PA
Infusible Biologics
Medical PA
IV Multiple Sclerosis (MS)
Medical PA
Coverage Criteria and Changes
REVISED – Effective 10/1/16, Emend IV is added to this policy and requires precertification through AIM/Oncology Select prior to administration. The policy criteria will consider this agent appropriate for patients receiving a moderate-to high-risk emetogenic chemotherapy regimen within FDA labeled dosing. REVISED – Effective 10/1/16, added Idiopathic Thrombocytopenic Purpura (ITP) as the new FDA approved indication for Flebogamma 10% DIF; added Nplate, Promacta, and splenectomy as acceptable prior therapies for treatment of ITP; added criteria to allow approval of immune globulin for use prior to surgery (i.e. thymectomy) for myasthenia gravis crisis; added Zinbryta as acceptable prior therapy for treatment of remitting relapsing multiple sclerosis; added Xeljanz to the list of prerequisites for treatment of rheumatoid arthritis. REVISED – Effective 10/1/16, the policy is reformatted replacing list of drugspecific FDA labeled indications within the policy with generalized wording, ‘FDA labeled indication for the requested agent’. Requirements for Stelara 90 mg have been added. Removed Prime Standard grandfathering statements as they duplicated current continuation of therapy process. REVISED – Effective 8/1/16, new requirement stating physician buy and bill is excluded for Lemtrada and must be obtained through an in-network medical specialty pharmacy; enhanced definitions of different forms of MS and characterizations of the disease in the Clinical Rationale section; criteria updated to require use of at least 3 disease modifying agents (DMAs) for
Rituxan Non-Oncologic Uses
Medical PA
Synagis
Medical PA
Xolair
Medical PA
relapsing remitting forms of MS prior to Lemtrada; added requirement for Tysabri that patient has not previously received Lemtrada; shortened length of approval for Lemtrada to 3 months and added lifetime maximum coverage of Lemtrada to 8 doses; added renewal criteria for Lemtrada to verify that patient has not been treated with Lemtrada within the last year and patient is enrolled in the Lemtrada REMS Program; added renewal criteria stating patients receiving Tysabri or Lemtrada may not have received additional DMAs since initiating therapy. REVISED – Effective 10/1/16, removed Prime Standard grandfathering statements as they duplicated current continuation of therapy process; added azathioprine as an acceptable conventional agent for treatment of Rheumatoid Arthritis; added Xeljanz XR and Taltz to the list of agents that should not be used concomitantly with Rituxan; added splenectomy as acceptable first line therapy for patients with chronic idiopathic thrombocytopenic purpura; clarified that patients requesting rituximab for systemic lupus erythematosus (SLE) have to have active disease; added antiSm antibodies as one of the acceptable diagnostic criteria for SLE; added language to allow approval of “another FDA approved diagnosis” if rituximab was to receive a new indication mid-cycle; added requirement in the renewal criteria that the patient will not receive rituximab in combination with another biologic immunomodulator, Xeljanz, Xeljanz XR and Otezla (This requirement is also included in the initial criteria); clarified length of approval for both initial and renewal criteria is up to 12 months (as certain indications require less than 12 months of therapy). REVISED – Effective 10/1/16, added an allowance for infants with hemodynamically-significant congenital heart disease with lesions that were adequately corrected by surgery but still require medication for congenital heart disease when prescribed/consulted with a pediatric cardiologist. REVISED – Effective 8/1/16, Xolair policy updated to include separate criteria for patients < 12 years old.
