Premera Blue Cross Medicare Advantage Plans Pharmacy Policy Updates Most Part D-eligible drugs and drug policies are not effective and administered until Centers for Medicare and Medicaid Services approval is obtained. Please refer to the most current approved formulary document at premera.com/medicare-advantage/pharmacy-services/. Pharmacy policies are updated and available on the secure provider Medicare Advantage website at premera.com/wa/provider/medicare-advantage/; simply click on the Get Started button. You can find the Premera Medicare Advantage (MA) Formulary (List of Covered Drugs) at premera.com/medicare-advantage/pharmacy-services/. You can also check the Premera MA Formulary using Epocrates. The “Premera Medicare Advantage” formulary can be downloaded from epocrates.com onto a tablet or smartphone. To add the formulary to your device, log in to your Epocrates account, and select “Edit Formularies.” Select “Washington” and “Medicare Part D—MA.” Add “Premera Medicare Advantage” to “Formularies on My Device” and select “Done”. Premera Medicare Advantage plans have a different formulary than non-Medicare Advantage plans. There may also be differences in prior authorization criteria for Premera Medicare Advantage members and Premera members on non-Medicare Advantage plans. If you have questions on specific criteria, formulary alternatives, or prior authorization/exception processes, please contact Pharmacy Services at 877-216-3644. Effective March 1, 2015 (unless otherwise noted below) Class Reviews: Class Review- Glycopeptides The following medications were reviewed: Dalvance® (dalbavancin), Orbactive® (oritavancin), Vibativ® (telavancin), Sivextro® ( tedizolid) Dalbavancin and oritavancin provide additional options for treatment in patients at risk for non-adherence to daily outpatient parenteral antimicrobial therapy (OPAT) or in circumstances where access to healthcare may be challenging for the patient. Tedizolid was found to be non-inferior to linezolid in terms of percentage of responders. Formulary, tier 6 (specialty), with prior authorization Class Review- Hemophilia The following medications were reviewed: Rixubis® (factor IX human recombinant), Alprolix®
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(factor IX rec, FC fusion), Eloctate® (factor VIII rec, FC fusion protein) No restrictions for Part B benefit; non-formulary for Part D New Drugs and Combinations: Keytruda® (pembrolizumab) vial
Indication: Treatment in patients with unresectable or metastatic melanoma and disease progression following ipilimumab and, if BRAF V600 mutation positive, a BRAF inhibitor.
Prior authorization for Part B; non-formulary for Part D Entyvio® (vedolizumab) vial
Indications: Moderate to severe active ulcerative colitis (UC) and moderate to severe active Crohn’s disease (CD) for patients that have failed prior therapy with a tumor necrosis factor (TNF) blocker (e.g., Humira®, Remicade®) or systemic therapies (e.g., corticosteroids).
Formulary, tier 6 (specialty) with prior authorization Evzio® (naloxone) auto injector
Indication: Emergency treatment of known or suspected opioid overdose, as manifested by respiratory and/or central nervous system depression
Non-formulary Jublia® (efinaconazole) solution with applicator
Indication: Topical treatment of onychomycosis of the toenail(s) due to Trichophyton rubrum and Trichophyton mentagrophytes Formulary Alternatives: Terbinafine tablets
Non-formulary Clodan® (clobetasol) skin cleanser
Indication: Treatment of moderate to severe forms of scalp psoriasis in subjects 18 years of age and older Formulary Alternatives: Clobetasol propionate 0.05 percent shampoo
Non-formulary
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Triumeq® (abcavir/dolutegravir/lamivudine) oral tablet
Indication: Treatment of human immunodeficiency virus type 1 (HIV-1) infection
Formulary, tier 6 (specialty) Neo-Synalar® (neomycin/flucinolone/emol) cream
Indication: Treatment of corticosteroid-responsive dermatoses with secondary infection
Non-formulary New Strengths and Formulations: Hemangeol® (propranolol HCL) oral solution
Indication: Treatment of proliferating infantile hemangioma requiring systemic therapy Formulary Alternatives: Propranolol 20mg/5ml oral solution
Non-formulary Sitavig® (acyclovir) MA buccul tablet
Indications: Treatment of recurrent herpes labialis (cold sores) in immunocompetent adults Formulary Alternatives: Acyclovir tablets and capsules, Valacyclovir tablets, Famciclovir tablets
Non-formulary Karbinal® ER (carbinoxamine maleate) suspension Indications: Symptomatic treatment of: o Seasonal and perennial allergic rhinitis o Vasomotor rhinitis o Allergic conjunctivitis due to inhalant allergens and foods o Mild, uncomplicated allergic skin manifestations of urticaria and angioedema o Dermatographism o As therapy for anaphylactic reactions adjunctive to epinephrine and other standard measures after the acute manifestations have been controlled o Amelioration of the severity of allergic reactions to blood or plasma Non-formulary Atryn® (antithrombin III, human recomb) vial
Indication: Prevention of peri-operative and peri-partum thromboembolic events in hereditary antithrombin deficient patients
No restrictions for Part B benefit. Non-formulary for Part D Page | 3
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Bunavail® (buprenorphine/naloxone) film
Indication: Maintenance treatment of opioid dependence and should be used as part of a complete treatment plan to include counseling and psychosocial support Formulary Alternatives: Suboxone SL film and tablets
Non-formulary Neuac® (clindamycin/benzoyl/emol CMB94) gel
Indication: Topical treatment of inflammatory acne vulgaris Formulary Alternatives: Clindamycin phosphate and benzoyl peroxide gel, tretinoin
Non-formulary Ryanodex® (dantrolene)
Indication: Treatment of malignant hyperthermia in conjunction with appropriate supportive measures and the prevention of malignant hyperthermia in patients at high risk Formulary Alternatives: Dantrium
No restrictions for Part B benefit; non-formulary for Part D New Indications: Relistor® (methylnaltrexone bromide) vial/syringe/kit
New FDA-approved indication: Opioid-induced constipation (OIC) in adult patients with chronic non-cancer pain
Update policy with new indication and criteria Xtandi® (enzalutamide) oral capsule
Expanded FDA-approved indication: Patients with metastatic castration-resistant prostate cancer
Update policy with new indication and criteria Velcade® (bortezomib) vial
Expanded FDA-approved indication: Treatment of patients with mantel cell lymphoma
Update policy with new indication and criteria
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New Generic Medications First-time generics to market:
Megestrol acetate 800mg/20ml suspension o Formulary, Tier 2 (non-preferred generic) Mycophenolate mofetil (Cellcept®) 200mg/ml suspension o Non-formulary Prenatal vitamins without calcium NO5/Ferrous fumarate/folic acid (PNV-VP-U®) o Formulary, Tier 2 (non-preferred generic) Dexmethylphenidate HCL (Focalin XR) 5mg capsule o Non-formulary Ivermectin (Stromectol) 3mg tablet o Formulary, Tier 2 (non-preferred generic) Sirolimus (Rapamune®) 1mg and 2mg tablet o Non-formulary Morphine sulfate 10mg/ml and 8mg/ml isecure syringe o Non-formulary Fluorouracil (Carac®) 0.50% cream o Formulary, Tier 3 (preferred brand, not a true generic) Amlodipine/valsartan (Exforge®) 5mg-160mg, 10mg-160mg, 5mg-320mg, 10mg-320mg tablet o Non-formulary
Other Formulary and Policy Changes: Drug/Policy Name Urocit-K ER® (potassium citrate) 15 meq
Criteria Changes Add to formulary, tier 2 (non-preferred generic)
Add criteria for recently approved indication of atypical hemolytic uremic syndrome The following policies were retired effective Jan. 1, 2015: o Diovan o Hepatitis B, Hepatitis C o Noxafil o Zyvox o Baraclude, Tyzeka Soliris® (eculizumab)
Drug Safety Alert Key Issue: An FDA review of safety studies suggests a slightly increased risk of problems involving the heart and blood vessels supplying the brain among patients being treated with the asthma drug Xolair® (omalizumab) than in those not treated with Xolair. As a result, FDA has
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added information about these potential risks to the drug label. The review found no difference in cancer rates between patients being treated with Xolair and those not being treated with Xolair. However, due to limitations in the five-year study, the FDA can’t rule out a potential risk of cancer with Xolair, so this information was added to the warnings and precautions section of the drug label. Background: Xolair is an injectable medicine for patients 12 years of age and older with moderate to severe persistent allergic asthma whose asthma symptoms are not controlled by asthma medicines called inhaled corticosteroids. Recommendation: Patients taking Xolair should continue to take the medication as prescribed and discuss any questions or concerns with their healthcare professionals. Healthcare professionals and patients are encouraged to report adverse events or side effects related to the use of these products to the FDA's MedWatch Safety Information and Adverse Event Reporting Program
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