To: HealthPartners Clinics and Contract Medical Group Providers HealthPartners Pharmacies and Contract Pharmacies
From: Terry Crowson MD, Associate Medical Director Chair, HealthPartners Pharmacy and Therapeutics Committee
Prepared by: Pete Marshall PharmD, HealthPartners Pharmacy Services 952-967-5807, 952-853-8700 fax, [email protected]
Date: July 1, 2010
Subject: HealthPartners Quarterly Drug Formulary Update, July 2010
These updates apply to both the commercial Drug Formulary (Preferred Drug List) and to the HealthPartners Medicare (Part D) Drug Formulary. Additions are effective July 1 2010.
Formulary Additions Dalfampridine (Ampyra), with prior authorization, for patients with EDSS Disability scores >= 5 and <= 7, and walking speeds of 8 - 45 seconds on a 25-foot walk test. Treatment for patients meeting these criteria will be approved for one month. Patients responding after one month will be approved for an additional 6 months. A positive response is defined as a 25% improvement in walking speed, or an improvement in functional impairment and activities of daily living. Patients responding after 6 months will be approved for one year, then annually for patients who continue to have a positive response. Ampyra will have a quantity limit of 2 tablets per day (per FDA dosing guidelines). Ampyra is a specialty medication, and must be obtained from Walgreens Specialty.
Liraglutide (Victoza), with prior authorization, for patients with an inadequate response to maximum dose exenatide (Byetta) within the previous 3 months. Patients also must have previous therapy with a first-line medication (metformin or a sulfonylurea).
Tadalafil (Adcirca), with “PAH” prior authorization. Adcirca is reserved: 1. per FDA-approved indications (pulmonary arterial hypertension WHO Group I). Patients with other WHO Group classifications will be reviewed for medical necessity. 2. Mean pulmonary artery pressure >= 25mmHg per right heart catheterization 3. Acute vasodilator testing has been done 4. Combination use requires documentation of medical necessity (including response to single- drug therapy, and rationale for adding a medication) Adcirca is a PDE-5 inhibitor, approved for pulmonary arterial hypertension. It is preferred by HealthPartners over sildenafil (Revatio). Adcirca is a specialty medication, and must be obtained from Caremark.
HealthPartners Quarterly Update, July 2010, page 2 of 2
Treprostinil (Tyvaso), with “PAH” prior authorization criteria. Tyvaso is an inhaled “prostanoid” for pulmonary arterial hypertension. Tyvaso is a specialty medication, and must be obtained from Caremark when billed as a pharmacy claim.
Deletions Sildenafil (Revatio). Tadalafil (Adcirca) will be preferred over Revatio. Adcirca has a longer half-life and a dosing advantage, and is less costly. Dates of Changes • For the Commercial Drug Formulary, Revatio will be deleted starting September 1 2010. Additional notices will be sent to providers. Members currently using Revatio will be grandfathered (allowed to continue therapy), and will be encouraged to use Adcirca. • For the Medicare Drug Formulary, changes are are pending CMS approval. Revatio is a non-formulary specialty medication, second-line to Adcirca, with “PAH” coverage criteira, and must be obtained from Caremark.
Formulary Changes Ambrisentan (Letairis). Prior authorization criteria have been updated per “PAH” criteria. Letairis is a specialty medication, and must be obtained from Caremark.
Bosentan (Tracleer). Prior authorization criteria have been updated per “PAH” criteria. Tracleer is a specialty medication, and must be obtained from Caremark.
Iloprost (Ventavis), with “PAH” prior authorization criteria. Ventavis is an inhaled “prostanoid” for pulmonary arterial hypertension. Ventavis is a specialty medication, and must be obtained from Caremark when billed as a pharmacy claim.
Oxycodone ER (OxyContin) quantity limit will decrease, from #180 per prescription to #120 per month. This quantity limit will more closely match industry standards to help reduce misuse. Dates of Changes • For the Commercial Drug Formulary, the new quantity limit will be effective starting September 1 2010. Additional notices will be sent to affected providers and members. • For the Medicare Drug Formulary, changes are are pending CMS approval.
Formulary Information and Requests Formulary Information is available at HealthPartners.com/ Provider/ Pharmacy Services. Pharmacy Customer Service is available to providers (physicians and pharmacies) from 8AM - 6PM CST, Monday through Friday. After hours calls are answered by our Pharmacy Benefit Manager. • Fax - 952-853-8700 or 1-888-883-5434. Telephone - 952-883-5813 or 1-800-492-7259. • Mail - HealthPartners Pharmacy Services, 8170 33rd Avenue S, PO Box 1309, Mpls, MN 55440.