The following changes will be effective on April 1, 2018, unless otherwise specified and apply to the following plans:
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1 The following changes will be effective on April 1, 2018, unless otherwise specified and apply to the following plans: Formulary Changes Individual and Family, Large/Small Groups (Commercial) Health Share of Oregon/Providence (Medicaid) Table Key: F = formulary, NF = non-formulary; PA = prior authorization; ST = step therapy; QL = quantity limit, N/A = not applicable (no changes); Negative change Drug Name(s) Commercial Formulary Status Medicaid Formulary Status Current Future Current Future Zolpidem Tartrate (Ambien ) Tablet F, QL (1 per F, QL (2 per F, QL (1 per F, QL (2 per Desmopressin Acetate (DDAVP) Solution N/A N/A F NF Ropinirole HCL (Requip XL) Tab ER 24H NF, QL NF NF, QL NF Topiramate (Trokendi XR) Cap ER 24H NF NF, PA NF NF, PA Valganciclovir HCL (Valcyte ) Soln Recon F, QL (18 ml per F, QL (36 ml per NF, QL (18 ml per NF, QL (36 ml per Valganciclovir HCL (Valcyte ) Tablet F, QL (2 tablets per F, QL (4 tablets per NF, QL (2 tablets per NF, QL (4 tablets per Ranibizumab (Lucentis ) Medical Medical, PA Medical Medical, PA aflibercept (Eylea ) Medical Medical, PA Medical Medical, PA pegaptanib (Macugen ) Medical Medical, PA Medical Medical, PA Herpes zoster vaccine (Shingrix ) Medical, PA, QL (2 Medical, QL (2 Medical, PA, QL (2 Medical, QL (2 Date Posted: 3/1/18 Page 1
2 Medical Policy Changes Coverage Criteria Changes Drug/Policy Name(s) Plans Affected Summary of Change Auryxia Added new criteria for new indication of iron deficiency anemia. Eligard, Lupron, Added Synarel and Supprelin LA to prior authorization policy and created step Lupaneta Pk therapy for different indications. Rituxan Criteria for refractory myasthenia gravis was developed to align with other agents (such as IVIG products) that are also used in this patient population. Short-acting insulins The new formulation of insulin aspart, Fiasp, was added to this policy. Medicaid Infusible Therapeutic Immunodulators (TIMs) Therapeutic Immunodulators Medicaid The criteria related to quantity exceptions was updated significantly to aid in operational impact of this policy and allow for dose escalation when appropriate clinically on case-by-case basis. Therapeutic Immunodulators (TIMs) - Commercial BPH Treatment- Rapaflo, Jalyn, Cialis Jalyn was removed from this policy and will remain non-formulary for all lines of business. The criteria were updated to reflect criteria for Cialis and Rapaflo separately. Date Posted: 3/1/18 Page 2
3 Drug/Policy Name(s) Plans Affected Summary of Change Injectable Anti-Cancer Medications New Formulation w/o Established Benefit Qudexy XR Tysabri Natroba Cinqair, Nucala Oral Anti-Cancer Medications Policy was updated to included guidance on billing Avastin for ophthalmic use. Additionally, the following requirement was added to the criteria section: For initial authorization: 1. Use must be for a FDA approved indication or indication supported by National Comprehensive Cancer Network guidelines with recommendation 2A or higher. Policy has been updated to include a new entity, Xhance (fluticasone nasal), as well as to include all strengths of Absorica. Clindesse was removed from this policy and will remain non-formulary. Trokendi XR is being added to this policy. This is an extended release formulation of topiramate and there is little evidence to support its use over formulary alternatives. The approval criteria diagnosis of Relapsing-Remitting Multiple Sclerosis (MS) was changed to Relapsing MS to align with FDA indication wording. In addition, added additional criteria that if patient has severe disease trial of other MS agents may be waived. Removed Medicaid from the policy as criteria requires trial of Ulesfia, which is non-formulary. Therefore, Natroba will be non-formulary only for Medicaid and require trial/failure of at least two formulary alternatives. Added new FDA approved indication, eosinophilic granulomatosis with polyangiitis (EGPA) for Nucala. Created approval criteria for EGPA based on clinical trial and treatment guidelines. The following requirement was added to the criteria section: For initial authorization: 1. Use must be for a FDA approved indication or indication supported by National Comprehensive Cancer Network guidelines with recommendation 2A or higher. This reflects information included in the position statement and operation policy and how the clinical staff currently reviews these requests. In addition, Targretin (bexarotene capsules and gel) was added to this policy and its separate policy will be retired. New Medical Policies Drug/Policy Name(s) Plans Affected Drug Name(s) Date Posted: 3/1/18 Page 3
4 Drug/Policy Name(s) Plans Affected Drug Name(s) Ophthalmic VEGF Ranibizumab Inhibitors (Lucentis ), aflibercept (Eylea ), and pegaptanib (Macugen ) Retired Medical Policies Drug/Policy Name(s) Plans Affected Comments Combined with Oral Anti- Targretin Cancer Medications policy New Drugs to Market Meropenem/vaborbactam (Vabomere ) Vial Delafloxacin Meglumine (Baxdela ) Vial and Oral Tablet o Vial Commercial: medical benefit Medicaid: medical benefit o Tablet: Commercial: Non-formulary Medicaid: Non-formulary Emicizumab-kxwh (Hemlibra ) Vial o Commercial: Formulary, Specialty, Prior Authorization o Medicaid: Formulary, Specialty, Prior Authorization Acalabrutinib (Calquence ) Capsule o Commercial: Formulary, Specialty, Prior Authorization o Medicaid: Formulary, Specialty, Prior Authorization Axicabtagene Ciloleucel (Yescarta ) Plastic bag Date Posted: 3/1/18 Page 4
5 , Prior Authorization, Quantity Limit (1 per, Prior Authorization, Quantity Limit (1 per Benralizumab (Fasenra ) syringe, Prior Authorization, Prior Authorization Benznidazole (Benznidazole ) Tablet o Commercial: Formulary, Specialty, Quantity Limit (2 claims/year), Restricted to Age 2-12 years o Medicaid: Formulary, Specialty, Quantity Limit (2 claims/year), Restricted to Age 2-12 years Etelcalcetide Hydrochloride (Parsabiv ) Vial Fluticasone Propionate (Xhance ) Nasal Spray o Commercial: Non-Formulary, Prior Authorization o Medicaid: Non-Formulary, Prior Authorization Insulin aspart (niacinamide) (Fiasp ) Vial and Insulin Pen o Commercial: Non-Formulary, Prior Authorization o Medicaid: Non-Formulary Factor IX (human) recombinant, pegylated (Rebinyn ) vial Date Posted: 3/1/18 Page 5
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