Pharmacy Facts, Number 94 Page 2 of 3

Number 94 August 15, 2016

of 3 www.mass.gov/masshealth/pharmacy • Editor: Vic Vangel • Contributors: Paul Jeffrey, Kim Lenz, James Monahan, Nancy Schiff •

MHDL Update Kovaltry (antihemophilic factor, recombinant) Below are certain updates to the MassHealth Drug List (MHDL). See the MHDL for a complete listing of mebendazole – PA updates. Odefsey (emtricitabine/rilpivirine/tenofovir 1. Additions alafenamide) a. As of July 1, 2016, the following newly Otiprio (ciprofloxacin otic suspension)^ marketed drug has been added to the MHDL. Portrazza (necitumumab) – PA Epclusa (sofosbuvir/velpatasvir) – PA Quillichew ER (methylphenidate extended-release chewable tablet) – PA < b. Effective August 29, 2016, the following 3 years and PA > 60 units/month newly marketed drugs have been added to the MHDL. Seebri (glycopyrrolate inhalation powder) – PA > 1 inhaler/month Adzenys XR-ODT (amphetamine extended-release orally disintegrating Sernivo (betamethasone dipropionate tablet) – PA spray) – PA Belbuca (buprenorphine buccal film) – PA Spritam (levetiracetam tablet for oral suspension) – PA Bendeka (bendamustine) Taltz (ixekizumab) – PA Descovy (emtricitabine/tenofovir alafenamide) Ultravate (halobetasol lotion) – PA Dyanavel XR (amphetamine extended- Uptravi (selexipag) – PA release oral suspension) – PA Utibron (indacaterol/glycopyrrolate) – PA Dyloject (diclofenac injection) – PA Viberzi (eluxadoline) – PA Evomela (melphalan injection) Vivlodex (meloxicam capsule) – PA Fluad (influenza virus vaccine, Vraylar (cariprazine) – PA adjuvanted)1 – PA < 65 years Xeljanz XR (tofacitinib extended-release) Humulin R (insulin regular prefilled – PA syringe) – PA 2. Changes in Prior Authorization Status Idelvion (factor IX recombinant, albumin a. Effective August 29, 2016, the following fusion protein) vaccine will no longer require prior Imlygic (talimogene laherparepvec)^ – PA authorization (PA) for males ages 16 to < 27 Kanuma (sebelipase alfa) – PA years. [Type text]

Gardasil 9 (human papillomavirus 9-valent 5. MassHealth Over-the-Counter Drug List vaccine)1 – PA < 9 years and PA ≥ 27 Effective August 29, 2016, the following product years will be added to the MassHealth Over-the- b. Effective August 29, 2016, the following Counter Drug List as covered within the quantity limit. bowel preparation agent will no longer require PA. budesonide nasal spray ≤ 1 inhaler/month Golytely packet (polyethylene glycol- electrolyte solution) 6. Updated MassHealth Non-Drug Product List c. Effective August 29, 2016, the following Effective August 29, 2016, the following device fibric acid derivatives will no longer require has been added to the MassHealth Non-Drug Product List requiring PA. PA. Hymovis (hyaluronate modified) – PA fenofibrate capsule 43 mg Lipofen (fenofibrate capsule 50 mg) 7. MassHealth Brand Name Preferred Over Trilipix # (fenofibric acid capsule 45 mg Generic Drug List and 135 mg) The MassHealth Brand Name Preferred Over d. Effective August 29, 2016, the following otic Generic Drug List identifies the brand name drugs, including any applicable PA antibiotic will no longer require PA. requirements, that MassHealth prefers over Ciprodex (ciprofloxacin/dexamethasone) their generic equivalents because the net cost of the brand name drugs adjusted for rebates is e. Effective August 29, 2016, the following lower than the net cost of the generic intranasal corticosteroid will require PA for equivalents. Preferring lower-cost brand name all quantities. drugs allows MassHealth the ability to provide medications at the lowest possible costs. This flunisolide nasal spray – PA list may be updated often and is subject to change at any time.

3. MassHealth Supplemental Rebate/Preferred 8. MassHealth Pharmacy-Covered Professional Drug List Services List a. As of July 1, 2016, for the PCC and FFS This is a list of professional services that plans, and as of August 1, 2016, for the MassHealth pays for through the Pharmacy MCO plans, the following hepatitis antiviral Online Processing System (POPS). single agents have been added to the MassHealth Supplemental 9. Controlled Substances Management Rebate/Preferred Drug List. Program (CSMP): Criteria for Member Enrollment Daklinza (daclatasvir) PD – PA The MassHealth agency has established a PD Sovaldi (sofosbuvir) – PA Controlled Substance Management Program b. As of July 1, 2016, for the PCC and FFS (CSMP) for MassHealth members who over- utilize or improperly utilize prescribed drugs. plans, and as of August 1, 2016, for the Members in the Controlled Substance MCO plans, the following hepatitis antiviral Management Program are restricted to combination agent has been removed from obtaining prescribed drugs only from the the MassHealth Supplemental provider that the MassHealth agency designates as the member’s primary pharmacy. Rebate/Preferred Drug List. These criteria were previously documented in Viekira Pak (ombitasvir/paritaprevir/ the MassHealth Pharmacy regulation (130 CMR ritonavir/dasabuvir) – PA 406.000), but going forward will appear in the MassHealth Drug List. 4. [Type text]

PA Prior authorization is required. The prescriber Brand Name Drugs Currently Included in This must obtain PA for the drug in order for the List pharmacy to receive payment. Note: PA applies to both the brand-name and the FDA “A”-rated generic Adderall XR (amphetamine salts extended- equivalent of listed product. release) - PA < 3 years and PA > 60 units/month # This designates a brand-name drug with FDA “A”- Asacol HD (mesalamine high dose delayed- rated generic equivalents. PA is required for the brand, unless a particular form of that drug (for release) example, tablet, capsule, or liquid) does not have Baraclude (entecavir tablet) - PA > 30 units/ an FDA “A”-rated generic equivalent. month ^ This drug is available through the health care professional who administers the drug. MassHealth Copaxone (glatiramer 20 mg) does not pay for this drug to be dispensed through Diastat (diazepam rectal gel) - PA > 5 kits (10 a retail pharmacy. syringes/month) Focalin XR (dexmethylphenidate extended- MassHealth Brand Name Preferred Over release) - PA < 3 years and PA > 60 units/month Generic Drug List Gleevec (imatinib) In general, MassHealth strongly advocates the use of generic drugs. However, in some circumstances, Mepron (atovaquone) generic drugs may cost more than their brand-name Pulmicort (budesonide inhalation suspension) equivalents. For this reason, MassHealth is implementing a policy allowing MassHealth to prefer Valcyte (valganciclovir tablet) selected brand-name drugs over generic drugs Xeloda (capecitabine) when the net cost of the brand-name drug adjusted for rebates is lower than the net cost of the generic Xenazine (tetrabenazine) - PA equivalent. These preferred brand-name drugs are When submitting a claim for one of these brand- listed on the MassHealth Brand Name Preferred name drugs, an entry of “9” (“Substitution Allowed Over Generic Drug List. By Prescriber but Plan Requests Brand”) should be Please note that MassHealth may still require PA made in the DAW field (NCPDP-408-D8). for clinical reasons. Drugs that require additional PA Claims for these drugs will be paid at requirements are noted with “PA” on this list. a. the Estimated Acquisition Cost, plus the This list may be updated often and is subject to appropriate Dispensing Fee as listed in 114.3 change at any time. When changes are made to the CMR 31.06 or in successor regulations; or list, pharmacy providers will be notified via Pharmacy Facts. In the next column, we name the b. the Usual and Customary Charge. drugs currently on this list. SMAC (State Maximum Allowable Cost) or FUL (Federal Upper Limit) will not be used. If a pharmacy attempts to bill a generic equivalent for a drug on this list, the claim will deny with instructions to bill for the brand name.

Please direct any questions or comments (or to be taken off of this fax distribution) to Victor Moquin of Xerox at 617-423-9830.