Q1 2018 Pharmacy & Therapeutics Committee TUESDAY, JANUARY 16, 2018, 5:30-7:00 PM Louisiana Healthcare Connections Jazz Vieux Executive Conference Room 8585 Archives Avenue, Suite 310 Baton Rouge, Louisiana 70809 Agenda I. Call to Order: Marcus Wallace, Senior Vice President and Amy Himel, Medical Director II. Introduction of New Members III. Meeting Procedures IV. Meeting Minutes Review (Vote Required) V. Old Business 1. Barriers to oral Abilify 2. Change cancer/palliative care exemptions 3. PMUR (Psychotropic Medication Utilization Review) process VI. New Business A. Therapeutic Class (Public Comment, Discussion, Vote Required) i. 31: Cardiotonics ii. 32: Antianginals iii. 33: Beta Blockers iv. 34: Calcium Channel Blockers v. 35: Antiarrhythmic Agents vi. 36: Antihypertensives vii. 37: Diuretics viii. 38: Vasopressors ix. 39: Antihyperlipidemic Agents x. 40: Cardiovascular Agents, Miscellaneous xi. 41: Antihistamines xii. 42: Nasal Agents, Systemic and Topical xiii. 43: Cough/Cold/Allergy xiv. 44: Antiasthmatic and Bronchodilator Agents xv. 45: Respiratory Agents, Miscellaneous xvi. 86: Ophthalmic Agents xvii. 87: Otic Agents B. New Drugs (Public Comment, Discussion, Vote Required) a. Review Types 1, 2, 3 and 5 i. RT1 – acalabrutinib (Calquence®) ii. RT1 – benznidazole iii. RT1 – latanoprostene bunod (Vyzulta TM ) iv. RT1 – letermovir (Prevymis TM ) v. RT1 – secnidazole (SolosecTM ) vi. RT2 – alectinib (Alecensa TM ) vii. RT2 – amantadine ER (GocovriTM) viii. RT2 – deutetrabenazine (Austedo TM) ix. RT2 – eculizumab (Soliris TM ) x. RT2 – fluticasone propionate (Xhance TM) xi. RT2 – vemurafenib (Zelboraf TM ) b. Review Type 4 Abbreviated Review i. RT4 – adalimumab-adbm (Cyltezo™) ii. RT4 – allopurinol/ lesinurad (Duzallo®) iii. RT4 – alpha-1-proteinase inhibitor (Prolastin®-C Liquid) iv. RT4 – amphetamine XR oral suspension (Adzenys ER™) ® v. RT4 – antihemophilic factor VIII, recombinant (Nuwiq ) vi. RT4 – aripiprazole with ingestible sensor and wearable sensor patch ® (Abilify Mycite ) vii. RT4 – atropine and pralidoxime chloride (DuoDote®) viii. RT4 – bosentan (Tracleer®) ix. RT4 – bosentan (Tracleer®) tablets for oral suspension x. RT4 – brentuximab vedotin (Adcetris®) xi. RT4 – budesonide/ formoterol (Symbicort®) xii. RT4 – buprenorphine (Sublocade™) xiii. RT4 – cariprazine (Vraylar™) xiv. RT4 – daptomycin (Cubicin®) xv. RT4 – dasatinib (Sprycel®) xvi. RT4 – etanercept (Enbrel® Mini) xvii. RT4 – exenatide, extended release (Bydureon® BciseTM) xviii. RT4 – fulvestrant (Faslodex®) xix. RT4 – gadoterate meglumine (Dotarem®) xx. RT4 – golimumab (Simponi Aria®) xxi. RT4 – herpes zoster vaccine (Shingrix®) xxii. RT4 – human rabies immune globulin (KedRABTM) xxiii. RT4 – hyaluronic acid for injection (Durolane®) xxiv. RT4 – immune globulin intravenous (human), 10% liquid (Privigen®) xxv. RT4 – influenza vaccine (Alfluria® Quadrivalent) xxvi. RT4 – insulin aspart (Fiasp®) xxvii. RT4 – lacosamide (Vimpat®) xxviii. RT4 – lanreotide acetate (Somatuline® Depot) xxix. RT4 – liraglutide (Victoza®) xxx. RT4 – meropenem/vaborbactam (VabomereTM) xxxi. RT4 – obinutuzumab (Gazyva®) xxxii. RT4 – onabotulinumtoxin A (Botox® Cosmetic) xxxiii. RT4 – oxybutynin (Oxytrol®) xxxiv. RT4 – peginterferon alfa 2a (Pegasys®) xxxv. RT4 – peramivir (Rapivab®) xxxvi. RT4 – pregabalin controlled release (Lyrica® CR) xxxvii. RT4 – rivaroxaban (Xarelto®) xxxviii. RT4 – rolapitant (Varubi®) xxxix. RT4 – triamcinolone acetonide injec suspension (ZilrettaTM) xl. RT4 – umeclidinium/vilanterol/fluticasone (Trelegy Ellipta®) xli. RT4 – ustekinumab (Stelara®) xlii. RT4 – valbenazine (IngrezzaTM) C. Guidelines (Public Comment, Discussion, Vote Required) a. Medicare i. MCPD.PA.XX acalabrutinib (Calquence®) ii. MCPD.PA.60 alectibin (Alecensa®) iii. MCPD.PA.XX amantadine ER (Gocovri®) iv. MCPD.PA.XX benznidazole v. MCPD.PA.XX deutetrabenazine (Austedo®) vi. MCPD.PA.XX fluticasone propionate (Xhance®) vii. MCPD.PA.XX latanoprostene Bunod (Vyzulta®) viii. MCPD.PA.XX letermovir (Prevymis®) ix. MCPD.PA.XX secnidazole (Solosec®) x. MCPD.PA.93 vemurafenib (Zelboraf®) b. New Guidelines i. CP.PHAR.366 Acalabrutinib (Calquence®) ii. CP.PHAR.367 Letermovir (Prevymis®) iii. CP.PHAR.368 Pemetrexed (Alimta®) iv. CP.PMN.89 Amantadine ER (Gocovri®) v. CP.PMN.90 Benzinadazole vi. CP.PMN.93 Dextromethorphan-Quinidine (Nuedexta®) vii. CP.PMN.95 Fluticasone Propionate (Xhance®) viii. CP.PMN.103 Secnidazole (Solosec®) ix. CP.PMN.108 Lantanoprostene Bunod (Vyzylta®) x. CP.PST.14 GLP-1 receptor agonists xi. CP.PST.18 DPP-4 inhibitors xii. CP.PST.19 SGLT2 inhibitors c. No Significant Clinical Change(s) xiii. CP.PHAR.14 Hydroxyprogesterone caproate (Makena®) xiv. CP.PHAR.115 Pegloticase (Krystexxa®) xv. CP.PHAR.165 Ferumoxytol (Feraheme®) xvi. CP.PHAR.166 Ferric Gluconate (Ferrlecit®) xvii. CP.PHAR.167 Iron Sucrose (Venofer®) xviii. CP.PHAR.177 Ecallantide (Kalbitor®) xix. CP.PHAR.178 Icatibant (Firazyr®) xx. CP.PHAR.179 Romiplostim (Nplate®) xxi. CP.PHAR.180 Eltrombopag (Promacta®) xxii. CP.PHAR.181 Hemin (Panhematin®) xxiii. CP.PHAR.192 Epoprostenol (Flolan®, Veletri®) xxiv. CP.PHAR.193 Iloprost (Ventavis®) xxv. CP.PHAR.194 Macitentan (Opsumit®) xxvi. CP.PHAR.195 Riociguat (Adempas®) xxvii. CP.PHAR.197 Sildenafil (Revatio®) xxviii. CP.PHAR.198 Tadalafil (Adcirca®) xxix. CP.PHAR.199 Treprostinil (Orenitram®, Remodulin®, Tyvaso®) xxx. CP.PHAR.210 Ivacaftor (Kalydeco®) xxxi. CP.PHAR.213 Lumacaftor-ivacaftor (Orkambi®) xxxii. CP.PHAR.214 Desmopressin (DDAVP®, Stimate®) xxxiii. CP.PHAR.215 Factor VIII xxxiv. CP.PHAR.216 Factor VIII-von Willebrand_Human xxxv. CP.PHAR.217 Anti-inhibitor Coagulant Complex (Feiba®) xxxvi. CP.PHAR.220 Factor VIIa Recombinant (NovoSeven® RT) xxxvii. CP.PHAR.221 Factor XIII Human (Corifact®) xxxviii. CP.PHAR.222 Factor XIIIa_Recombinant (Tretten®) xxxix. CP.PHAR.223 Reslizumab (Cinqair®) xl. CP.PHAR.234.Ferric Carboxymaltose (Injectafer®) xli. CP.PHAR.235 Atezolizumab (Tecentriq®) xlii. CP.PHAR.288 Eteplirsen (Exondys 51®) xliii. CP.PHAR.300 Bezlotoxumab (Zinplava®) xliv. CP.PHAR.301 Erwinia Asparaginase (Erwinaze®) xlv. CP.PHAR.329 Siluximab (Sylvant®) xlvi. CP.PHAR.330 Protein C Concentrate Human (Ceprotin®) xlvii. CP.PHAR.331 Deflazacort (Emflaza®) xlviii. CP.PHAR.336 Dupilumab (Dupixent®) xlix. CP.PHAR.341 Deutetrabenazine (Austedo®) l. CP.PHAR.350 Rucaparib (Rubraca®) li. CP.PHAR.40 Octreotide Acetate (Sandostatin®, Sandostatin LAR Depot®) lii. CP.PMN.05 rifapentine (Priftin®) liii. CP.PMN.07 Levalbuterol (Xopenex®) liv. CP.PMN.12 Clozapine orally disintegrating tablet (Fazaclo®) lv. CP.PMN.15 Asenapine (Saphris®) lvi. CP.PMN.20 Aspirin-dipyridamole (Aggrenox®) lvii. CP.PMN.21 Becaplermin (Regranex®) lviii. CP.PMN.29 Olanzapine ODT (Zyprexa Zydis®) lix. CP.PMN.30 Paliperidone (Invega®) lx. CP.PMN.32 Iloperidone (Fanapt®) lxi. CP.PMN.34 Ranolazine (Ranexa®) lxii. CP.PMN.50 Lurasidone (Latuda®) lxiii. CP.PMN.52 Omega-3-Acid Ethyl Esters (Lovaza®) lxiv. CP.PMN.64 Quetiapine ER (Seroquel XR®) lxv. CP.PMN.77 Ezetimibe-Simvastatin (Vytorin®) lxvi. CP.PMN.78 Ezetimibe (Zetia®) lxvii. CP.PMN.91 Cariprazine (Vraylar®) lxviii. CP.PMN.92 CNS Stimulants lxix. CP.PMN.94 Etidronate (Didronel®) lxx. CP.PMN.96 Ibandronate Oral (Boniva®) lxxi. CP.PMN.99 Prasterone (Intrarosa®) lxxii. CP.PMN.100 Risedronate (Actonel®, Atelvia®) lxxiii. CP.PMN.101 Rivastigmine (Exelon®) lxxiv. CP.PMN.105 Tavaborole (Kerydin®) lxxv. CP.PMN.106 Tiludronate (Skelid®) lxxvi. CP.PMN.107 Topical Immunomodulators lxxvii. CP.PMN.109 Suvorexant (Belsomra®) lxxviii. CP.PST.08 Mesalamine Oral Therapy lxxix. LA.PMN.68 Brexpiprazole (Rexulti®) lxxx. LA.PPA.12 Opioid Analgesics d. Significant Clinical Change(s) lxxxi. CP.PHAR.01 Omalizumab (Xolair®) lxxxii. CP.PHAR.100 Axitinib (Inlyta®) lxxxiii. CP.PHAR.101 Mifepristone (Korlym®) lxxxiv. CP.PHAR.111 Cabozantinib (Cabometyx®, Cometriq®) lxxxv. CP.PHAR.114 Teduglutide (Gattex®) lxxxvi. CP.PHAR.119 Ramucirumab (Cyramza®) lxxxvii. CP.PHAR.121 Nivolumab (Opdivo®) lxxxviii. CP.PHAR.125 Palbociclib (Ibrance®) lxxxix. CP.PHAR.168 Corticotropin (H.P. Acthar®) xc. CP.PHAR.184 Aflibercept (Eylea®) xci. CP.PHAR.185 Pegaptanib (Macugen®) xcii. CP.PHAR.186 Ranibizumab (Lucentis®) xciii. CP.PHAR.187 Verteporfin (Visudyne®) xciv. CP.PHAR.188 Teriparatide (Forteo®) xcv. CP.PHAR.189 Ibandronate injection (Boniva®) xcvi. CP.PHAR.190 Ambrisentan (Letairis®) xcvii. CP.PHAR.191 Bosentan (Tracleer®) xcviii. CP.PHAR.196 Selexipag (Uptravi®) xcix. CP.PHAR.200 Mepolizumab (Nucala®) c. CP.PHAR.202 C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®, Ruconest®) ci. CP.PHAR.203 Cosyntropin (Cortrosyn®) cii. CP.PHAR.204 Trabectedin (Yondelis®) ciii. CP.PHAR.206 Carglumic acid (Carbaglu®) civ. CP.PHAR.207 Glycerol phenylbutyrate (Ravicti®) cv. CP.PHAR.208 Sodium phenylbutyrate (Buphenyl®) cvi. CP.PHAR.209 Aztreonam (Cayston®) cvii. CP.PHAR.211 Tobramycin cviii. CP.PHAR.212 Dornase alfa (Pulmozyme®) cix. CP.PHAR.218 Factor IX_Human Recombinant cx. CP.PHAR.219 Factor IX Complex Human cxi. CP.PHAR.224 Enoxaparin (Lovenox®) cxii. CP.PHAR.225 Dalteparin (Fragmin®) cxiii. CP.PHAR.226 Fondaparinux (Arixtra®) cxiv. CP.PHAR.289 Buprenorphine Implant (Probuphine®) cxv. CP.PHAR.298 Afatinib (Gilotrif®) cxvi. CP.PHAR.327 Nusinersen (Spinraza®) cxvii. CP.PHAR.333 Avelumab (Bavencio®) cxviii. CP.PHAR.334 Ribociclib (Kisqali®, Kisqali Femara®) cxix. CP.PHAR.345 Abaloparatide (Tymlos®) cxx. CP.PHAR.43 Sapropterin (Kuvan®) cxxi. CP.PHAR.52 Interferon Gamma- 1b (Actimmune®) cxxii. CP.PHAR.59 Zoledronic Acid (Reclast®, Zometa®) cxxiii. CP.PHAR.61 Cinacalcet (Sensipar®) cxxiv. CP.PHAR.63 Everolimus (Afinitor®,