Provider Update: Q1 Formulary Changes
Date: 02/01/20
This update applies to Trillium Oregon Health Plan (OHP)
Oregon Health Plan Pharmacy Services ANNOUNCEMENTS
This update contains changes to the pharmacy services of Trillium Community Health Plan (Trillium) Oregon Health Plan members. Based on the recommendations of the Trillium Pharmacy and Therapeutics (P&T) Committee, the Trillium Oregon Health Plan medication coverage guidelines (criteria) and Preferred Drug List (PDL) has been revised for the third fourth of 2019. PDL revisions are as indicated beginning on page 6. Updated criteria can be accessed by going to the Provider Resources on our website: www.trilliumohp.com. Changes will go into effect January 1, 2020.
The Trillium Oregon Health Plan P&T Committee determines updates to criteria and the PDL based on quarterly, comprehensive reviews. Criteria and the PDL serves as a reference for providers to use when prescribing pharmaceutical products for Trillium members with pharmacy coverage. Medications newly approved by the FDA require prior-authorization until reviewed by P&T. Prior authorization (PA) does not guarantee payment. PA determination is based on multiple factors in conjunction to the criteria posted in drug coverage guidelines. These factors include but are not limited to: treatment of a funded vs non-funded condition as defined by the Oregon Prioritized List and applicable guidelines; prior trial and failure of agents on the PDL; comparative costs of available treatment options.
AVAILABLE SEATS ON THE PHARMACY AND THERAPEUTICS COMMITTEE
Seats are open on the combined Trillium Community Health Plan and Health Net of Oregon Pharmacy and Therapeutics (P&T) Committee. We are looking for community based practitioners representing various clinical specialties who adequately represent the membership of our health plans. Meetings are held once a quarter and are comprised of a remote review of clinical drug information and coverage guidelines, electronic vote and committee meetings. Individuals who are selected to join by the committee are eligible to receive an honorarium to compensate them for the time spent reviewing materials and attending meetings. If you are interested in learning more or attending a quarterly meeting please contact Susan Van Horn via email at: Susan.E.VanHorn@TrilliumCHP.com.
PEER TO PEERS AVAILABLE WITH A PHARMACIST
Trillium Oregon Health Plan pharmacists are available to discuss prior authorization denials and help you navigate treatment options for your patients. If you would like to speak to a pharmacist, please call our Provider Services team at 541-485-2155.
2020 PREFERRED DIABETIC TESTING SUPPLIES
No change has been made in Trillium Oregon Health Plans’ preferred glucose testing meters or testing supplies for the year 2020. The preferred meter and testing strips are Trividia Health products (True Metrix and True Metrix Air meters). Your patients can get a new or replacement meter at no cost by calling the manufacture fulfillment center at 1-866-788-9618 or at the pharmacy using the billing information below.
- BIN #: 015251
- PCN #: PRX2000
- Identification #: HB224289455
- Group Code #: TRUEPORT22
Preferred glucose blood test strips are True Metrix Blood Glucosetest Strips and True Metrix Self Monitoring Blood Glucose Strips. Test strips are restricted by quantity limits of 100 per 90 days for non-insulin users and 450 per 90 days for insulin users (paid claim for insulin in prior 180 days) without needing prior authorization.
QUARTERLY UPDATE ON PHARMACY COVERAGE GUIDELINES
See the table below for all the updated or new Trillium Oregon Health Plan coverage guidelines that were approved by P&T at our first quarter meeting January 10, 2020. All coverage guidelines will go into effect on April 1, 2020, unless otherwise noted, and will become available to view in their entirety at trilliumohp.com/providers/helpful-links/clinical-payment-policies by the end of March.
| UPDATED COVERAGE GUIDELINES – Clinically Significant Change(s) | |
|---|---|
| CP.PHAR.100 Axitinib (Inlyta) | CP.PHAR.408 Niraparib (Zejula) |
| CP.PHAR.103 Immune Globulins | CP.PHAR.412 Gilteritinib (Xospata) |
| CP.PHAR.106 Enzalutamide (Xtandi) | CP.PHAR.413 Glasdegib (Daurismo) |
| CP.PHAR.114 Teduglutide (Gattex) | CP.PHAR.414 Larotrectinib (Vitrakvi) |
| CP.PHAR.121 Nivolumab (Opdivo) | CP.PHAR.415 Ravulizumab-cwvz (Ultomiris) |
| CP.PHAR.123 Evolocumab (Repatha) | CP.PHAR.428 Romosozumab-aqqg (Evenity) |
| CP.PHAR.124 Alirocumab (Praluent) | CP.PHAR.434 Bremelanotide (Vyleesi) |
| CP.PHAR.138 Lenvatinib (Lenvima) | CP.PHAR.440 Elexacaftor-ivacaftor-tezacaftor (Trikafta) |
| CP.PHAR.177 Ecallantide (Kalbitor) | CP.PHAR.52 Interferon Gamma- 1b (Actimmune) |
| CP.PHAR.178 Icatibant (Firazyr) | CP.PHAR.58 Denosumab (Prolia Xgeva) |
| CP.PHAR.179 Romiplostim (Nplate) | CP.PHAR.59 Zoledronic Acid (Reclast, Zometa) |
| CP.PHAR.180 Eltrombopag (Promacta) | CP.PHAR.61 Cinacalcet (Sensipar) |
| CP.PHAR.184 Aflibercept (Eylea) | CP.PHAR.63 Everolimus (Afinitor, Afinitor Disperz, Zortress) |
| CP.PHAR.188 Teriparatide (Forteo) | CP.PHAR.84 Abiraterone (Zytiga, Yonsa) |
| CP.PHAR.189 Ibandronate injection (Boniva) | CP.PHAR.91 Vemurafenib (Zelboraf) |
| CP.PHAR.202 C1 Esterase Inhibitors (Berinert Cinryze Haegarda Ruconest) | CP.PHAR.97 Eculizumab (Soliris) |
| CP.PHAR.210 Ivacaftor (Kalydeco) | CP.PHAR.98 Ruxolitinib (Jakafi) |
| CP.PHAR.213 Lumacaftor-ivacaftor (Orkambi) | CP.PMN.100 Risedronate (Actonel, Atelvia) |
| CP.PHAR.233 RimabotulinumtoxinB (Myobloc) | CP.PMN.102 Rolapitant (Varubi) |
| CP.PHAR.235 Atezolizumab (Tecentriq) | CP.PMN.108 Latanoprostene Bunod (Vyzulta) |
| CP.PHAR.24 Fostamatinib (Tavalisse) | CP.PMN.113 Safinamide (Xadago) |
| CP.PHAR.257 Ixekizumab (Taltz) | CP.PMN.115 Delafloxacin (Baxdela) |
| CP.PHAR.264 Ustekinumab (Stelara) | CP.PMN.14 SGLT2 inhibitors |
| CP.PHAR.283 Lomitapide (Juxtapid) | CP.PMN.187 Icosapent ethyl (Vascepa) |
| CP.PHAR.284 Mipomersen (Kynamro) | CP.PMN.21 Becaplermin (Regranex) |
| CP.PHAR.301 Erwinia Asparaginase (Erwinaze) | CP.PMN.212 Bedaquiline (Sirturo) |
| CP.PHAR.322 Pembrolizumab (Keytruda) | CP.PMN.22 Brand Name Override |
| CP.PHAR.333 Avelumab (Bavencio) | CP.PMN.27 Linezolid (Zyvox) |
| CP.PHAR.345 Abaloparatide (Tymlos) | CP.PMN.62 Tedizolid (Sivextro) |
| CP.PHAR.360 Olaparib (Lynparza) | CP.PMN.67 Sacubitril-Valsartan (Entresto) |
| CP.PHAR.367 Letermovir (Prevymis) | CP.PMN.92 CNS Stimulants |
| CP.PHAR.376 Apalutamide (Erleada) | CP.PMN.94 Etidronate (Didronel) |
| CP.PHAR.377 Tezacaftor-Ivacaftor (Symdeko) | CP.PMN.95 Fluticasone propionate (Xhance) |
| CP.PHAR.396 Lanadelumab-fylo (Takhzyro) | CP.PMN.96 Ibandronate Oral (Boniva) |
| CP.PHAR.40 Octreotide (Sandostatin, Sandostatin LAR) | TCHP.PHAR.1814 Antifungals |
| CP.PHAR.403 Fremanezumab-vfrm (Ajovy) | |
| CP.PHAR.404 Galcanezumab-gnlm (Emgality) | |
| UPDATED COVERAGE GUIDELINES –No Clinically Significant Change(s) | |
| CP.PHAR.01 Omalizumab (Xolair) | CP.PHAR.361 Tisagenlecleucel (Kymriah) |
| CP.PHAR.101 Mifepristone (Korlym) | CP.PHAR.362 Axicabtagene ciloleucel (Yescarta) |
| CP.PHAR.111 Cabozantinib (Cabometyx, Cometriq) | CP.PHAR.366 Acalabrutinib (Calquence) |
| CP.PHAR.115 Pegloticase (Krystexxa) | CP.PHAR.368 Pemetrexed (Alimta) |
| CP.PHAR.119 Ramucirumab (Cyramza) | CP.PHAR.370 Emicizumab-kxwh (Hemlibra) |
| CP.PHAR.126 Ibrutinib (Imbruvica) | CP.PHAR.371 Triamcinolone ER Injection (Zilretta) |
| CP.PHAR.128 Erenumab-aaoe (Aimovig) | CP.PHAR.372 Voretigene neparvovec-rzyl (Luxturna) |
| CP.PHAR.14 Hydroxyprogesterone caproate (Makena) | CP.PHAR.373 Benralizumab (Fasenra) |
| CP.PHAR.165 Ferumoxytol (Feraheme) | CP.PHAR.388 Chloramphenicol |
| CP.PHAR.166 Ferric Gluconate (Ferrlecit) | CP.PHAR.401 Amikacin (Arikayce) |
| CP.PHAR.167 Iron Sucrose (Venofer) | CP.PHAR.402 Emapalumab-lzsg (Gamifant) |
| CP.PHAR.168 Corticotropin (H.P. Acthar) | CP.PHAR.405 Inotersen (Tegsedi) |
| CP.PHAR.181 Hemin (Panhematin) | CP.PHAR.407 Lusutrombopag (Mulpleta) |
| CP.PHAR.185 Pegaptanib (Macugen) | CP.PHAR.409 Talazoparib (Talzenna) |
| CP.PHAR.186 Ranibizumab (Lucentis) | CP.PHAR.410 Bortezomib (Velcade) |
| CP.PHAR.187 Verteporfin (Visudyne) | CP.PHAR.43 Sapropeterin (Kuvan) |
| CP.PHAR.190 Ambrisentan (Letairis) | CP.PHAR.80 Vandetanib (Caprelsa) |
| CP.PHAR.191 Bosentan (Tracleer) | CP.PHAR.94 Alpha1-Proteinase Inhibitors |
| CP.PHAR.192 Epoprostenol (Flolan, Veletri) | CP.PHAR.96 Naltrexone (Vivitrol) |
| CP.PHAR.193 Iloprost (Ventavis) | CP.PHAR.411 Amifampridine (Firdapse, Ruzurgi) |
| CP.PHAR.194 Macitentan (Opsumit) | CP.PMN.03 DPP-4 inhibitors |
| CP.PHAR.195 Riociguat (Adempas) | CP.PMN.04 Non-Calcium Phosphate Binders (Auryxia, Fosrenol, Renagel, Renvela, Velphoro) |
| CP.PHAR.196 Selexipag (Uptravi) | |
| CP.PHAR.197 Sildenafil (Revatio) | CP.PMN.05 Rifapentine (Priftin) |
| CP.PHAR.198 Tadalafil (Adcirca, Alyq) | CP.PMN.07 Levalbuterol (Xopenex) |
| CP.PHAR.199 Treprostinil (Orenitram, Remodulin, Tyvaso) | CP.PMN.19 Aprepitant (Cinvanti, Emend) |
| CP.PHAR.200 Mepolizumab (Nucala) | CP.PMN.20 Aspirin-dipyridamole (Aggrenox) |
| CP.PHAR.203 Cosyntropin (Cortrosyn) | CP.PMN.34 Ranolazine (Ranexa) |
| CP.PHAR.204 Trabectedin (Yondelis) | CP.PMN.45 Ondansetron (Zuplenz) |
| CP.PHAR.206 Carglumic acid (Carbaglu) | CP.PMN.52 Omega-3-Acid Ethyl Esters (Lovaza) |
| CP.PHAR.207 Glycerol phenylbutyrate (Ravicti) | CP.PMN.57 Febuxostat (Uloric) |
| CP.PHAR.208 Sodium phenylbutyrate (Buphenyl) | CP.PMN.70 Ivabradine (Corlanor) |
| CP.PHAR.209 Aztreonam (Cayston) | CP.PMN.72 Metformin ER (Glumetza, Fortamet) |
| CP.PHAR.211 Tobramycin | CP.PMN.74 Granisetron (Kytril, Sancuso, Sustol) |
| CP.PHAR.212 Dornase alfa (Pulmozyme) | CP.PMN.82 Buprenorphine (Subutex) |
| CP.PHAR.214 Desmopressin (DDAVP, Stimate, Nocdurna, Noctiva) | CP.PMN.89 Amantadine ER (Gocovri,Osmolex ER) |
| CP.PHAR.215 Factor VIII | CP.PMN.90 Benznidazole |
| CP.PHAR.216 Factor VIII-von Willebrand_Human (Alphanate, Humate-P, Wilate) | CP.PMN.93 Dextromethorphan-Quinidine (Nuedexta) |
| CP.PHAR.217 Anti-inhibitor Coagulant Complex (Feiba) | CP.PMN.97 Opioid Analgesics |
| CP.PHAR.218 Factor IX_Human Recombinant | CP.PMN.99 Prasterone (Intrarosa) |
| CP.PHAR.219 Factor IX Complex, Human (Bebulin, Profilnine) | CP.PMN.101 Rivastigmine (Exelon) |
| CP.PHAR.220 Factor VIIa Recombinant (NovoSeven RT) | CP.PMN.103 Secnidazole (Solosec) |
| CP.PHAR.221 Factor XIII Human (Corifact) | CP.PMN.121 Lisdexamfetamine (Vyvanse) |
| CP.PHAR.222 Factor XIIIa_Recombinant (Tretten) | CP.PMN.123 Colchicine (Colcrys) |
| CP.PHAR.223 Reslizumab (Cinqair) | CP.PMN.129 Pramlintide (Symlin) |
| CP.PHAR.224 Enoxaparin (Lovenox) | CP.PMN.141 Dolasetron (Anzemet) |
| CP.PHAR.225 Dalteparin (Fragmin) | CP.PMN.150 Lesinurad (Zurampic), Lesinurad-allopurinol (Duzallo) |
| CP.PHAR.226 Fondaparinux (Arixtra) | CP.PMN.151 QL of Blood Glucose Test Strips Not Receiving insulin |
| CP.PHAR.234 Ferric Carboxymaltose (Injectafer) | CP.PMN.158 Netupitant and Palonosetron (Akynzeo) |
| CP.PHAR.282 Parathyroid hormone (Natpara) | CP.PMN.159 Dronabinol (Marinol, Syndros) |
| CP.PHAR.288 Eteplirsen (Exondys 51) | CP.PMN.160 Nabilone (Cesamet) |
| CP.PHAR.289 Buprenorphine (Probuphine, Sublocade) | CP.PMN.183 GLP-1 receptor agonists |
| CP.PHAR.300 Bezlotoxumab (Zinplava) | CP.PMN.186 Cenegermin-bkbj (Oxervate) |
| CP.PHAR.327 Nusinersen (Spinraza) | CP.PMN.188 Omadacycline (Nuzyra) |
| CP.PHAR.329 Siltuximab (Sylvant) | CP.PMN.189 Sarecycline (Seysara) |
| CP.PHAR.330 Protein C Concentrate Human (Ceprotin) | CP.PMN.190 Segesterone-Ethinyl Estradiol (Annovera) |
| CP.PHAR.331 Deflazacort (Emflaza) | TCHP.PHAR.184 Growth Hormones |
| CP.PHAR.336 Dupilumab (Dupixent) | TCHP.PHAR.1903 Buprenorphine-naloxone (Suboxone, Bunavail, Zubsolv) |
| CP.PHAR.350 Rucaparib (Rubraca) | |
| NEW COVERAGE GUIDELINES | |
| CP.PHAR.441 Entrectinib (Rozlytrek) | CP.PMN.217 Istradefylline (Nourianz) |
| CP.PHAR.442 Fedratinib (Inrebic) | CP.PMN.218 Lasmiditan (Reyvow) |
| CP.PHAR.443 Upadacitinib (Rinvoq) | CP.PMN.219 Lefamulin (Xenleta) |
| CP.PHAR.444 Afamelanotide (Scenesse) | CP.PMN.220 Peanut allergen powder (Palforzia) |
| CP.PHAR.445 Brolucizumab (Beovu) | CP.PMN.221 Pitolisant (Wakix) |
| CP.PHAR.447 Mercaptopurine (Purixan) | CP.PMN.222 Pretomanid |
| CP.PHAR.449 Crizanlizumab-tmca (Adakveo) | CP.PMN.223 Rifabutin (Mycobutin), Rifabutin, omeprazole, amoxicillin (Talicia) |
| CP.PHAR.450 Luxpatercept-aamt (Reblozyl) | CP.PMN.225 Trifarotene (Aklief) |
| CP.PHAR.451 Voxelotor (Oxbryta) | CP.PMN.226 Pancrelipase (Pertyze, Viokace, Zenpep) |
| CP.PHAR.452 Tazemetostat | |
| CP.PHAR.453 Golodirsen (Vyondys 53) | |
| CP.PMN.216 Diazepam nasal spray (Valtoco) | |
Trillium Oregon Health Plan Preferred Drug List Changes
| Brand Name | Generic Name | Comments |
|---|---|---|
| Formulary Additions and Changes | ||
| - | Co-Q 10 | PA requirement added. Effective date 4/1/2020. All current utilizers to receive continued benefit x1 yr. |
| Aimovig | Erenumab | Added to PDL with PA required. Effective date 2/1/2020. |
| Aubagio | Teriflunomide | Added to PDL with PA required. Effective date 1/1/2020 |
| Cimzia | Certolizumab | Added to PDL with PA required. Effective date 1/1/2020 |
| Gilenya | Fingolimod | Added to PDL with PA required. Effective date 1/1/2020 |
| Kevzara | Sarilumab | Added to PDL with PA required. Effective date 1/1/2020 |
| Mayzent | Siponimod | Added to PDL with PA required. Effective date 3/1/2020. |
| Otezla | Apremilast | Added to PDL with PA required. Effective date 1/1/2020 |
| Ruzurgi | Amifampridine | Added to PDL with PA required. Effective date 3/1/2020. |
| Simponi | Golimumab | Added to PDL with PA required. Effective date 1/1/2020 |
| Taltz | Ixekizumab | Added to PDL with PA required. Effective date 1/1/2020 |
| Vyndamax/Vyndaqel | Tafamidis | Added to PDL with PA required. Effective date 3/1/2020. |
| Zofran | Ondansetron | Increased quantity limit to 4/day for preferred 4mg & 8 mg strengths. Effective date 2/17/2020. |
ADDITIONAL INFORMATION
For additional information regarding changes to the Trillium Preferred Drug List (PDL), contact Trillium by telephone at 1(877) 600-5472. For the most current version of the PDL, visit the Trillium website at trilliumohp.com.
For additional information on the drug classes and medication coverage guidelines reviewed by the P&T committee visit the Provider Resources on Trillium’s website at trilliumohp.com.
If you have questions regarding the information contained in this update, contact the Trillium Provider Services through the Trillium provider website at trilliumohp.com or by telephone at 877-600-5472.