Provider Update: Q2 Formulary Changes
Date: 05/01/19
Oregon Health Plan
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 second quarter 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 July 1, 2019.
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.
Oregon Health Plan Pharmacy Services Anouncements
GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AGONISTS: EDUCATE FOR ADHERENCE
Analysis of Glucagon-like peptide-1 (GLP-1) receptor agonist claims show that members have a high rate of discontinuation and interrupted fills indicating low adherence. GLP-1 receptor agonists affect glucose control in several different ways for the treatment of type 2 diabetes mellitus. These include enhancing glucose-dependent insulin secretion, slowing gastric emptying and reduction of post prandial glucagon. GLP-1 receptor agonists are noted to be associated with greater adverse events than oral agents and this frequently leads to their discontinuation. Adverse effects are predominantly gastrointestinal and the effects most commonly reported are nausea, vomiting and diarrhea which in trials have been shown to occur consistently in 10-50% of individuals. These side effects commonly decrease with continued therapy but can also be reduced by dose titration. Educating patients on the likely side effects they will experience when starting a GLP-1 receptor agonist and that they commonly diminish with continued use can help to keep members to stay on therapy.
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. 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. 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.
PRIOR AUTHORIZATION CHANGES TO SPECIALIZED MEDICATIONS GIVEN IN OFFICE
See the table below for all HCPC codes affected by changes in the first quarter of 2019. These codes now require prior authorization for coverage.
Brand (Generic Name) | Description | HCPC Code |
|---|---|---|
PRIOR AUTHORIZATION REQUIRED - Effective 1/1/2019 | ||
Akynzeo (fosnetupitant-palonosetron) | Injection, fosnetupitant 235 mg and palonosetron 0.25 mg | J1454 |
Aliqopa (copanlisib) | Injection, copanlisib, 1 mg | J9057 |
Aristada Initio (aripiprazole lauroxil) | Injection, aripiprazole lauroxil (Aristada Initio), 1 mg | C9035 |
Besponsa (Inotuzumab ozogamicin) | Injection, inotuzumab ozogamicin, 0.1 mg | J9229 |
bortezomib, not otherwise specified | Injection, bortezomib, not otherwise specified, 0.1 mg | J9044 |
Brineura (cerliponase alfa) | Injection, cerliponase alfa, 1 mg | J0567 |
Cinvanti, Emend (aprepitant) | Injection, aprepitant, 1 mg | J0185 |
Crysvita (burosumab-twza) | Injection, burosumab-twza, 1 mg | J0584 |
Durolane (hyaluronic acid) | Hyaluronan or derivative, Durolane, for intra-articular injection, 1 mg | J7318 |
Fasenra (benralizumab) | Injection, benralizumab, 1 mg | J0517 |
Fibryga (human fibrinogen concentrate) | Injection, human fibrinogen concentrate (Fibryga), 1 mg | J7177 |
Haegarda (C-1 esterase inhibitor, human) | Injection, C-1 esterase inhibitor (human), (Haegarda), 10 units | J0599 |
Hemlibra (emicizumab-kxwh) | Injection, emicizumab-kxwh, 0.5 mg | J7170 |
Ilumya (tildrakizumab) | Injection, tildrakizumab, 1 mg | J3245 |
Imfinzi (durvalumab) | Injection, durvalumab, 10 mg | J9173 |
Ixifi (infliximab-qbtx) | Injection, infliximab-qbtx, biosimilar, (Ixifi), 10 mg | Q5109 |
Kymriah (tisagenlecleucel) | Tisagenlecleucel, up to 600 million CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose | Q2042 |
Lutathera (LUTETIUM LU 177 DOTATATE THER 1 MCI) | Lutetium Lu 177, dotatate, therapeutic, 1 mCi | A9513 |
Luxturna (Voretigene neparvovec-rzyl) | Injection, voretigene neparvovec-rzyl, 1 billion vector genomes | J3398 |
Mepsevii (Vestronidase alfa-vjbk) | Injection, vestronidase alfa-vjbk, 1 mg | J3397 |
Mvasi (bevacizumab-awwb) | Injection, bevacizumab-awwb, biosimilar, (Mvasi), 10 mg | Q5107 |
Onpattro (patisiran) | Injection, patisiran, 0.1 mg | C9036 |
Perseris (risperidone) | Injection, risperidone (Perseris), 0.5 mg | C9037 |
Poteligeo (mogamulizumab-kpkc) | Injection, mogamulizumab-kpkc, 1 mg | C9038 |
Radicava (edaravone) | Injection, edaravone, 1 mg | J1301 |
Rebinyn (factor IX) | Injection Factor IX, (antihemophilic factor, recombinant), glycopegylated, (Rebinyn), 1 IU | J7203 |
Rituxan Hycela (rituximab/hyaluronidase) | Injection, rituximab 10 mg and hyaluronidase | J9311 |
Rituxan (rituximab) | Injection, rituximab, 10 mg | J9312 |
Tremfya (guselkumab) | Injection, guselkumab, 1 mg | J1628 |
Triptodur (triptorelin, extended-release) | Injection, triptorelin, extended-release, 3.75 mg | J3316 |
Trivisc (sodium hyaluronate) | Hyaluronan or derivative, Trivisc, for intra-articular injection, 1 mg | J7329 |
Trogarzo (ibalizumab-uiyk) | Injection, ibalizumab-uiyk, 10 mg | J1746 |
Udenyca (pegfilgrastim-cbqv) | Injection, pegfilgrastim-cbqv, biosimilar, (Udenyca), 0.5 mg | Q5111 |
Unclassified drug or biological used for ESRD on dialysis | J3591 | |
Varubi (rolapitant) | Injection, rolapitant, 0.5 mg | J2797 |
Vyxeos (liposomal daunorubicin-cytarabine) | Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine | J9153 |
Zilretta (Triamcinolone acetonide, preservative-free) | Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg | J3304 |
PRIOR AUTHORIZATION REQUIRED - Effective 6/1/2019 | ||
Adasuve (Loxapine) | Loxapine for inhalation, 1 mg | J2062 |
Dexycu (dexamethasone) | Injection, dexamethasone 9%, intraocular, 1 mcg | J1095 |
Zemdri (plazomicin) | Injection, plazomicin, 5 mg | C9039 |
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 second quarter meeting April 12, 2019. All coverage guidelines will go into effect on July 1, 2019 and will become available to view in their entirety at trilliumohp.com/providers/helpful-links/clinical-payment-policies by the end of June.
UPDATED COVERAGE GUIDELINES – Clinically Significant Change(s) | |
|---|---|
CP.PHAR.105 Bosutinib (Bosulif) | CP.PHAR.273 Vismodegib (Erivedge) |
CP.PHAR.107.Regorafenib (Stivarga) | CP.PHAR.294 Osimertinib (Tagrisso) |
CP.PHAR.108 Omacetaxine (Synribo) | CP.PHAR.298 Afatinib (Gilotrif) |
CP.PHAR.112 Ponatinib (Iclusig) | CP.PHAR.308 Elotuzumab (Empliciti) |
CP.PHAR.128 Erenumab-aaoe (Aimovig) | CP.PHAR.316 Cabazitaxel (Jevtana) |
CP.PHAR.129 Ventoclax (Venclexta) | CP.PHAR.319 Ipilimumab (Yervoy) |
CP.PHAR.176 Paclitaxel protein-bound (Abraxane) | CP.PHAR.336 Dupilumab (Dupixent) |
CP.PHAR.342 Brigatinib (Alunbrig) | |
CP.PHAR.180 Eltrombopag (Promacta) | CP.PHAR.344 Midostaurin (Rydapt) |
CP.PHAR.228 Trastuzumab, Biosimilars, Trastuzumab-Hyaluronidase | CP.PHAR.349 Ceritinib (Zykadia) |
CP.PHAR.360 Olaparib (Lynparza) | |
CP.PHAR.229 Ado-Trastuzumab (Kadycla) | CP.PHAR.361 Tisagenlecleucel (Kymriah) |
CP.PHAR.232 OnabotulinumtoxinA (Botox) | CP.PHAR.362 Axicabtagene ciloleucel (Yescarta) |
CP.PHAR.235 Atezolizumab (Tecentriq) | |
CP.PHAR.237 Epoetin alfa (Epogen, Procrit), Epoetin alfa-epbx (Retacrit) | CP.PHAR.369 Alectinib (Alecensa) |
CP.PHAR.403 Fremanezumab-vfrm (Ajovy) | |
CP.PHAR.241 Abatacept (Orencia) | CP.PHAR.404 Galcanezumab-gnlm (Emgality) |
CP.PHAR.242 Adalimumab (Humira) | CP.PHAR.60 Capecitabeine (Xeloda) |
CP.PHAR.243 Alemtuzumab (Lemtrada) | CP.PHAR.64 Topotecan (Hycamtin) |
CP.PHAR.245 Apremilast (Otezla) | CP.PHAR.65 Imatinib (Gleevec) |
CP.PHAR.247 Certolizumab (Cimzia) | CP.PHAR.68 Gefitinib (Iressa) |
CP.PHAR.250 Etanercept (Enbrel) | CP.PHAR.71 Lenalidomide (Revlimid) |
CP.PHAR.253 Golimumab (Simponi, Simponi Aria) | CP.PHAR.72 Dasatinib (Sprycel) |
CP.PHAR.74 Erlotinib (Tarceva) | |
CP.PHAR.254 Infliximab (Remicade, Renflexis, Inflectra) | CP.PHAR.76 Nilotinib (Tasigna) |
CP.PHAR.78 Thalidomide (Thalomid) | |
CP.PHAR.257 Ixekizumab (Taltz) | CP.PHAR.90 Crizotinib (Xalkori) |
CP.PHAR.258 Mitoxantrone (Novantrone) | CP.PHAR.97 Eculizumab (Soliris) |
CP.PHAR.259 Natalizumab (Tysabri) | CP.PMN.138 Age Limit Override (Codeine, Tramadol, Hydrocodone) |
CP.PHAR.260 Rituximab (Rituxan, Truxima, Rituxan Hycela) | |
CP.PMN.86 Oxymetazoline (Rhofade) | |
CP.PHAR.261 Secukinumab (Cosentyx) | TCHP.PHAR.181 Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors |
CP.PHAR.264 Ustekinumab (Stelara) | |
CP.PHAR.267 Tofacitinib (Xeljanz, Xeljanz XR) | TCHP.PHAR.184 Growth Hormones |
UPDATED COVERAGE GUIDELINES – No Clinically Significant Change(s) | |
|---|---|
CP.PHAR.106 Enzalutamide (Xtandi) | CP.PHAR.337 Telotristat Ethyl (Xermelo) |
CP.PHAR.116 Pomalidomide (Pomalyst) | CP.PHAR.339 Durvalumab (Imfinzi) |
CP.PHAR.120 Sipuleucel-T (Provenge) | CP.PHAR.343 Edaravone (Radicava) |
CP.PHAR.127 Encorafenib (Braftovi) | CP.PHAR.346 Sarilumab (Kevzara) |
CP.PHAR.152 Laronidase (Aldurazyme) | CP.PHAR.364 Guselkumab (Tremfya) |
CP.PHAR.153 Eliflustat (Cerdelga) | CP.PHAR.374 Vestronidase alfa-vjbk (Mepsevii) |
CP.PHAR.154 Imiglucerase (Cerezyme) | CP.PHAR.375 Brodalumab (Siliq) |
CP.PHAR.155 Cysteamine oral (Cystagon, Procysbi) | CP.PHAR.376 Apalutamide (Erleada) |
CP.PHAR.378 Ibalizumab-uiyk (Trogarzo) | |
CP.PHAR.156 Idursulfase (Elaprase) | CP.PHAR.380 Cobimetinib (Cotellic) |
CP.PHAR.157 Taliglucerase Alfa (Elelyso) | CP.PHAR.386 Tildrakizumab-asmn (Ilumya) |
CP.PHAR.158 Agalsidase Beta (Fabrazyme) | CP.PHAR.406 Lorlatinib (Lorbrena) |
CP.PHAR.159 Sebelipase Alfa (Kanuma) | CP.PHAR.43 Saprpterin Dihydrochloride (Kuvan) |
CP.PHAR.160 Alglucosidase Alfa (Lumizyme) | CP.PHAR.50 Binimetinib (Mektovi) |
CP.PHAR.161 Galsulfase (Naglazyme) | CP.PHAR.58 Denosumab (Prolia, Xgeva) |
CP.PHAR.162 Elosulfase Alfa (Vimizim) | CP.PHAR.69 Sorafenib (Nexavar) |
CP.PHAR.163 Velaglucerase Alfa (VPRIV) | CP.PHAR.72 Dasatinib (Sprycel) |
CP.PHAR.164 Miglustat (Zavesca) | CP.PHAR.73 Sunitinib (Sutent) |
CP.PHAR.227.Pertuzumab (Perjeta) | CP.PHAR.75 Bexarotene (Targretin) |
CP.PHAR.230 AbobotulinumtoxinA (Dysport) | CP.PHAR.77 Temozolomide (Temodar) |
CP.PHAR.231 IncobotulinumtoxinA (Xeomin) | CP.PHAR.84 Abiraterone (Zytiga, Yonsa) |
CP.PHAR.233 RimabotulinumtoxinB (Myobloc) | CP.PMN.113 Safinamide (Xadago) |
CP.PHAR.239 Dabrafenib (Tafinlar) | CP.PMN.117 Naproxen and Esomeprazole (Vimovo) | |
CP.PHAR.240 Trametinib (Mekinist) | ||
CP.PHAR.244 Anakinra (Kineret) | CP.PMN.118 Netarsudil (Rhopressa) | |
CP.PHAR.246 Canakinumab (Ilaris) | CP.PMN.119 Ozenoxacin (Xepi) | |
CP.PHAR.248 Dalfampridine (Ampyra) | CP.PMN.120 Ibuprofen and Famotidine (Duexis) | |
CP.PHAR.249 Dimethyl Fumarate (Tecfidera) | CP.PMN.126 Toremifene (Fareston) | |
CP.PHAR.251 Fingolimod (Gilenya) | CP.PMN.127 Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) | |
CP.PHAR.252 Glatiramer Acetate (Copaxone, Glatopa) | ||
CP.PMN.128 Dutasteride (Avodart, Jalyn) | ||
CP.PHAR.255 Interferon Beta-1a (Avonex, Rebif) | CP.PMN.130 Cysteamine ophthalmic (Cystaran) | |
CP.PHAR.256 Interferon Beta-1b (Betaseron, Extavia) | CP.PMN.136 Mecamylamine (Vecamyl) | |
CP.PMN.183 GLP-1 Receptor Agonists | ||
CP.PHAR.260 Rituximab (Rituxan, Truxima, Rituxan Hycela) | CP.PMN.42 Sodium Oxybate (Xyrem) | |
CP.PMN.48 Cyclosprine ophthalmic emulsion (Restasis) | ||
CP.PHAR.262 Teriflunomide (Aubagio) | ||
CP.PHAR.263 Tocilizumab (Actemra) | CP.PMN.53 No Coverage Criteria / Off-Label Use | |
CP.PHAR.265 Vedolizumab (Entyvio) | ||
CP.PHAR.266 Rilonacept (Arcalyst) | CP.PMN.58 Propranolol (Hemangeol) | |
CP.PHAR.271 Peginterferon Beta-1a (Plegridy) | TCHP.PHAR.1807 Pregabalin (Lyrica) | |
CP.PHAR.272 Sonidegib (Odomzo) | TCHP.PHAR.1811 Palivizumab (Synagis) | |
CP.PHAR.335 Ocrelizumab (Ocrevus) | TCHP.PHAR.185 Drugs for Constipation | |
NEW COVERAGE GUIDELINES | ||
CP.PHAR.135 Baricitinib (Olumiant) | CP.PMN.132 Tadalafil BPH – ED (Cialis) | |
CP.PHAR.236 Darbepoetin Alfa (Aranesp) | CP.PMN.168 Ospemifene (Osphena) | |
CP.PHAR.238 Methoxy polyethylene glycol-epoetin beta (Mircera) | CP.PMN.192 Brimonidine (Mirvaso) | |
CP.PMN.193 Hydroxyurea (Siklos) | ||
CP.PHAR.411 Amifampridine (Firdapse) | CP.PMN.195 Revefenacin (Yupelri) | |
CP.PHAR.412 Gilteritinib (Xospata) | CP.PMN.196 Rifamycin (Aemcolo) | |
CP.PHAR.413 Glasdegib (Daurismo) | CP.PMN.198 Overactive Bladder Agents | |
CP.PHAR.414 Larotrectinib (Vitrakvi) | CP.PMN.61 ACEI and ARB Duplicate Therapy | |
CP.PHAR.415 Ravulizumab-cwvz (Ultomiris) | TCHP.PHAR.1903 Buprenorphine-naloxone (Suboxone, Bunavail, Zubsolv) | |
CP.PHAR.416 Caplacizumab-yhdp (Cablivi) | ||
CP.PMN.122 Celecoxib (Celebrex) | TCHP.PHAR.190 4 Dexmethylphenidate ER (Focalin XR) | |
CP.PMN.125 Milnacipran (Savella) | ||
CP.PMN.13 Dose Optimization |
| |
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 formulary.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.
Trillium Oregon Health Plan Preferred Drug List changes
Brand Name | Generic Name | Comments |
|---|---|---|
Aspercreme with Lidocaine | Lidocaine 4% cream | Brand product added to PDL with limit of one package per month. Effective now |
Cimzia | Cetolizumab | Product removed from PDL; preferred options are Enbrel and Humira. Effective 7/1/19. Current utilizers will be grandfathered for 1 year. |
Lomotil | Diphenoxylate-Atropine | Quantity limit of 8 tablets (20-0.2mg) per day added. Effective 7/1/19 |
Pancreaze | Pancrelipase (Amylase-Lipase-Protease) | 10850 U-2600 U-6200 U strength added to PDL. Effective 7/1/19 |
Pifeltro | Doravirine | Added to PDL with effective date 6/1/19 |
Tamiflu | Oseltamivir | Increased the quantity limit per fill to 14 capsules. Effective now. |
Zetia | Ezetimibe | Added generic to PDL, no prior authorization required. Effective date 5/1/19 |
- | Cholecalciferol Drops | 5000 Unit/ML (1000 Unit/0.2ML) and 400 Unit/0.028ML (Per Drop) products added to PDL. Effective date 7/1/19 |