PHC P & T ADDITIONS, CHANGES & DELETIONS: P & T COMMITTEE MEETING January 16, 2020

Key to Restriction Abbreviations: NC = Not covered (carved out to state, medical benefit or other reason for non-pharmacy benefit) DL = Dollar limit QL = Quantity Limit C1 = Code 1 Restriction FL = Fill limit (eg, # of Rx’s allowed) NF = Non-Formulary, TAR required STE = Step Therapy Requirement AL = Age Limit

Specific limitations (eg, specific age or fill limit) are included in the PHC Formulary Search Tool. Brand names are shown in parentheses for reference only; generic substitution is required. Drug Class Formulary Action Restrictions Effective Date Miscellaneous Agents Potassium effervescent tablet Addition None 04/01/2020 (Effer-K® ) 10 MEQ & 20 MEQ

Estradiol/ Norethindrone (Femhrt® Addition None 04/01/2020 Low Dose) 0.5 mg/2.5 mcg

Cimetidine 200 mg (Tagamet®) Addition None 04/01/2020

prescription tablet

Chlordiazepoxide (Librium®) 25 mg Changed quantity QL: 120 capsules per fill 04/01/2020

capsules limit

Asthma AL: ≤ 5 years QL: 1 packet daily Montelukast granules (Singulair®) Code 1: For the treatment Addition 04/01/2020 4 mg oral packet of asthma or allergic rhinitis in children unable to chew and swallow chewable montelukast.

Fluticasone propionate HFA (Flovent HFA®) 44 mcg, & 110 Removed age limit None 03/01/2020

mcg

STE: Prior claim for other Fluticasone propionate HFA Changed Step Edit formulary ICS within last 03/01/2020 (Flovent HFA®) 220 mcg 180 days.

Formulary update, continued

Drug Class Formulary Action Restrictions Effective Date Cardiovascular Disease – Hypertension

Enalapril (Epaned®) 1 mg/ml AL: ≤ 12 years

oral solution Code 1: For pediatric use when child is unable to Lisinopril (Qbrelis®) 1 mg/ml oral swallow tablets or when solution Addition 04/01/2020 tube administration is required. ® Amlodipine (Katerzia ) 1 mg/ml oral solution

Antiemesis/Antivertigo

QL: 4 per day FL: 30 day supply

Dronabinol (Marinol®) 2.5 mg & STE: Prior fill for Addition ondansetron (Zofran), OR 04/01/2020

5 mg capsules megestrol (Megace) suspension within the past 120 days.

AL: ≥ 18 years QL: 2 tablets per day Doxylamine/Pyridoxine (Bonjesta®) 20 mg/20 mg tablet Addition FL: 2 fills per year 04/01/2020

C1: Restricted for pregnancy.

Granisetron HCL (Kytril®) 1 mg Changed Quantity QL: 30 tablets per fill 04/01/2020 tablets Limit

QL: 18 ml per prescription Aprepitant (Cinvanti®) 130 mg/18 C1: Limited to the ml vial Addition 04/01/2020 prevention of nausea caused by chemotherapy.

Formulary update, continued

Drug Class Formulary Action Restrictions Effective Date Automatic Nervous System Disorders AL: ≥ 18 years Donepezil HCL (Aricept®) 23 Addition 04/01/2020

mg tablet QL: 1 per day

Dermatology – Miscellaneous AL: ≥ 18 years Lidocaine (Lidoderm®) 5% Addition QL: 30 patches per 30 04/01/2020

patch days

QL: 120 g per fill 04/01/2020 Lidocaine (OTC, Aspercreme®) Addition

4% cream FL: 1 fill per 30 days

Eye – General Disorders Proparacaine HCL 0.5% Addition None 04/01/2020

ophthalmic drops Olopatadine (Pataday®) 0.2% Addition QL: 2.5 ml per 25 days 04/01/2020 ophthalmic drops Olopatadine (Patanol®) 0.1% QL: 5 ml per 25 days 04/01/2020 ophthalmic drops

® Removed Step Edit QL: 6 ml per 25 days

Azelastine (Optivar ) 0.05% 04/01/2020

® QL: 5 ml per 25 days

Epinastine (Elestat ) 0.05% 04/01/2020

Eye – Glaucoma QL: 2.5 ml per 28 days STE: Prior claims for both Netarsudil/Latanoprost a formulary ophthalmic Addition 04/01/2020 0.02%/0.005% (Rocklatan®) prostaglandin analog and beta-blocker in the past 180 days.

Gout and Related Diseases QL: 1 tablet per day Febuxostat (Uloric®) 40 & 80 mg STE: Prior fill for allopurinol tablets Addition 04/01/2020 with minimum 30 day trial in the last 120 days.

® Colchicine (Mitigare ) 0.6 mg QL: 45 capsules per 30 capsules Addition days 04/01/2020

Formulary update, continued

Drug Class Formulary Action Restrictions Effective Date Infectious Disease Bacterial

QL: 40 capsules per fill or up to 4 capsules per day. FL: 2 fills per 365 days C1: Limited to treatment Vancomycin 125mg capsules Addition 04/01/2020 for members with Clostridium Difficile Infection (C. Diff) or Staph aureus Enterocolitis.

Inflammatory Disease (Rheumatology) and Lower Gastrointestinal – Bowel Inflammatory Disorders

Lidocaine anorectal QL: 120 gm per fill (Anecream5®, RectiCare®, Addition 04/01/2020 ® FL: ≤ 1fill in 30 days

LMX 5 ) 5% cream

Budesonide (Entocort® EC) QL: 3 capsules per day 3mg oral capsules Addition FL: Cumulative 90 day 04/01/2020 supply filled in prior 12 months. Budesonide (Uceris®) QL: 2 cans per fill or up 2 mg/actuation Rectal Foam Addition to 4.8 gm per day 04/01/2020 FL: 6 fills per 365 days Mesalamine (Canasa®) Rectal QL: 1 suppository per Suppository 1000 mg Addition day up to a total of 42 04/01/2020 suppositories per fill General Therapeutic Class Review – Other Drugs AL: ≥ 18 years Octreotide or derivative QL: 3 ml per day (Sandostatin®) ampules, Addition Provider Restriction: 04/01/2020 syringes and vials Endocrine, GI, or Hematology/Oncology Specialist Glucagon PFS & auto-injector (Gvoke Hypopen®, Gvoke PFS®) Addition 04/01/2020 0.5 mg, 1 mg QL: 2 Glucagon intranasal powder Addition 04/01/2020 (Baqsimi®) Reviews to follow PHC Perative® oral liquid (enteral Revised Formulary Enteral Nutritional 04/01/2020 formula) Status Products Policy.

Niacin powder 100gm Non-benefit product 04/01/2020 Formulary update, continued

Drug Class Formulary Action Restrictions Effective Date Seizure Disorder AL: ≥ 12yrs QL: 4 units per 30 days Midazolam (Nayzilam®) 5mg/0.1ml nasal solution C1: Limited to members Addition with epilepsy maintained 04/01/2020 (package size = 2 units) on antiepileptic agents but requiring occasional STAT treatment for break-through seizures. AL: ≥ 2yrs QL: 6 tablets per day Felbamate (Felbatol®) 400mg & STE: Prior fills of 2 Addition 04/01/2020 600mg tablets formulary AEDs in the past 180 days and prescribed by a neurologist

AL: ≥ 4yrs Perampanel (Fycompa®) 2mg, QL: 1 tablet per day 4mg, 6mg, 8mg, 10mg, & 12mg STE: Prior fills of 2 tablets Addition formulary AEDs in the 04/01/2020 past 180 days and prescribed by a neurologist

Clobazam (Onfi®) 10mg & 20mg Removed Step Edit QL: 2 tablets per day 04/01/2020 tablets Smoking Cessation Bupropion HCL (Zyban®) 150 mg extended release 12 hr Removed quantity limit QL: 2 tablets per day 04/01/2020

tablets Added to Formulary, Prior Authorization (TAR) required. Tofacitinib (Xeljanz®, Added criteria for: 04/01/2020 ®

Xeljanz XR ) Psoriatic Arthritis and Ulcerative Colitis Octreotide LAR depot 04/01/2020 (Sandostatin® LAR depot) Deferasirox (Exjade®) 125, 250, 04/01/2020 500 mg tablet for suspension Formulary, PA (see criteria) Vigabatrin (Sabril®) 500mg 04/01/2020 packet; 500mg tab

Criteria Additions, Updates:

Criteria specifics are included in the PHC Formulary Search Tool (available on 04/01/20), and in the P & T Changes Prior Auth Criteria document for Jan 16, 2020.

The following products have been ADDED to PHC’s TAR (Prior Auth) Criteria:

Abatacept (Orencia®) 50 mg, Abatacept (Orencia®) 250 mg Abatacept (Orencia Clicklect®) 87.5 mg, & 125 mg prefilled IV vials 125 mg/ml auto injector pen syringes

Brivaracetam (Briviact®) 10 mg, Brolucizumab-dbll (Beovu®) 6 Brivaracetam (Briviact®) 10 25 mg, 50 mg, 75 mg, 100 mg mg/0.05 mL intraocular mg/ml oral solution tablet solution

Elexacaftor/tezacaftor/Ivacaftor Deferasirox (Jadenu®, Jadenu Elagolix (Orilissa®) 150 mg, (Trikafta®) 100 mg/50 mg/75 Sprinkles®) 90 mg , 180 mg, 200 mg tablets mg & 150 mg combination 360 mg tablet or sprinkle sachet tablet pack

Eslicarbazepine (Aptiom®) 200 Felbamate (Felbatol®) 600 Ertapenem (Invanz®) 1 g vial mg, 400 mg, 600 mg, 800 mg mg/5 ml oral suspension tablet

Lacosamide (Vimpat®) 10 Infliximab-DYYB (Inflectra®) Infliximab-ABDA (Renflexis®) mg/ml oral solution 100 mg IV vial 100 mg IV vial

Lanreotide (Somatuline®) 60 Midazolam 5 mg/ml, 10 mg/2 Perampanel (Fycompa®) 0.5 mg/0.2 ml, 90 mg/0.3 ml, & 120 ml, 25 mg/5 ml, 50 mg/10 ml mg/ml oral suspension mg/0.5 ml depot vial

Stiripentol (Diacomit®) 250 mg, Semaglutide (Rybelsus®) 3 mg, Vedolizumab (Entyvio®) 300 500 mg capsule; 250 mg, 500 7 mg, 14 mg tablet mg IV vial mg packet

Vigabatrin (Sabril) 500 mg Vigabatrin (Vigadrone®) 500 mg packet packet & tablet

The following products have REVISED or UPDATED TAR Criteria:

Alcaftadine Bepotastine Colesevelam (Welchol) Alosetron (Lotronex®) (Lastacaft®) 0.25% (Bepreve®) 1.5% 625 mg tablet & 3.75 0.5 mg & 1 mg tablet

ophthalmic solution ophthalmic solution gm powder

Crisaborole Fentanyl patches 50 Infliximab (Eucrisa®) 2% Eluxadoline (Viberzi®) mcg, 75 mcg, 100 mcg (Remicade®) 100 mg ointment 75 mg & 100 mg tablet (Duragesic®) IV vial

Olopatadine Nintedanib (OFEV®) (Pazeo®) 0.7% Rifaximin (Xifaxan®) Ustekinumab 100 mg & 150 mg Ophthalmic solution 550 mg tablet (Stelara®) 130 mg/26 ml capsule IV vial

Ustekinumab (Stelara®) 45 Ustekinumab (Stelara®) 45 mg/0.5 ml, & 90 mg/1 ml syringe mg/0.5ml SQ vial

The following products have ARCHIVED TAR Criteria

Anakinra (Kineret®) 100 mg/0.67 ml syringe

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