Pharmacy Information and Preferred Drug List Changes 4th Quarter 2020
Date: 11/02/20
PRIOR AUTHORIZATION CHANGES TO SPECIALIZED MEDICATIONS GIVEN IN OFFICE
See the table below for all HCPC codes affected by changes in the fourth quarter of 2020. These codes now require prior authorization for coverage for Trillium Oregon Health Plan members.
Brand (Generic Name) | Description | HCPC Code |
Darzalex Faspro (daratumumab/hyaluronidase-fihj) | Injection Daratumumab 10mg and Hyaluronidase-fihj | C9062 |
Jelmyto (mitomycin) | Mitomycin Pyelocalyceal Instillation 1mg | C9064 |
Istodax (romidepsin) | Injection Romidepsin non-Lypohilized 1mg | C9065 |
Trodelvy (sacituzumab govitecan-hziy) | Injection Sacituzumab Govitecan-hziy 10mg | C9066 |
Monoferric (ferric derisomaltose) | Injection Ferric Derisomaltose 10mg | J1437 |
Zulresso (brexanolone) | Injection Brexanolone 1mg | J1632 |
Anjeso (meloxicam) | Injection Meloxicam 1mg | J1738 |
Vyepti (eptinezumab-jjmr) | Injection Eptinezumab-jjmr 1mg | J3032 |
Tepezza (teprotumumab-trbw) | Injection Teprotumumab-trbw 10mg | J3241 |
Durysta (bimatoprost) | Injection Bimatoprost Intracameral Implant 1mcg | J7351 |
Sarclisa (isatuximab-irfc) | Injection Isatuximab-irfc 10mg | J9227 |
Pemfexy (pemetrexed) | Injection Pemetrexed (Pemfexy) 10mg | J9304 |
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 fourth quarter of 2020. PDL revisions are as indicated beginning on page 5. Updated criteria and PDL can be accessed by going to the Provider Resources section on our website: www.trilliumohp.com/providers/resources.html. Changes will go into effect January 1, 2021.
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.
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 fourth quarter meeting October 15, 2020. All coverage guidelines will go into effect on January 1, 2021 and will become available to view in their entirety at https://www.trilliumohp.com/providers/resources/clinical-payment-policies2.html.
UPDATED COVERAGE GUIDELINES – Clinically Significant Change(s) | |||
CP.PHAR.11 Burosumab-twza (Crysvita) | CP.PHAR.359 Inotuzumab Ozogamicin (Besponsa) | ||
CP.PHAR.116 Pomalidomide (Pomalyst) | |||
CP.PHAR.119 Ramucirumab (Cyramza) | CP.PHAR.364 Guselkumab (Tremfya) | ||
CP.PHAR.121 Nivolumab (Opdivo) | CP.PHAR.385 Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) | ||
CP.PHAR.125 Palbociclib (Ibrance) | |||
CP.PHAR.129 Venetoclax (Venclexta) | CP.PHAR.387 Azacitidine (Vidaza) | ||
CP.PHAR.132 Nitisinone (Orfadin, Nityr) | CP.PHAR.390 Cholic Acid (Cholbam) | ||
CP.PHAR.136 Elagolix (Orilissa), elagolix-estradiol-norethindrone (Oriahnn) | CP.PHAR.391 Lanreotide (Somatuline Depot) | ||
CP.PHAR.395 Patisiran (Onpattro) | |||
CP.PHAR.137 Ivosidenib (Tibsovo) | CP.PHAR.409 Talazoparib (Talzenna) | ||
CP.PHAR.138 Lenvatinib (Lenvima) | CP.PHAR.421 Onasemnogeve abeparvovec (Zolgensma) | ||
CP.PHAR.140 Pegvaliase-pqpz (Palynziq) | |||
CP.PHAR.141 Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) | CP.PHAR.431 Selinexor (Xpovio) | ||
CP.PHAR.437 Thioguanine (Tabloid) | |||
CP.PHAR.151 Levoleucovorin (Fusilev, Khapzory) | CP.PHAR.439 Valrubicin (Valstar) | ||
CP.PHAR.452 Tazemetostat (Tazverik) | |||
CP.PHAR.201 Belatacept (Nulojix) | CP.PHAR.457 Givosiran (Givlaari) |
| |
CP.PHAR.232 OnabotulinumtoxinA (Botox) | CP.PHAR.458 Inebilizumab-cdon (Uplizna) |
| |
CP.PHAR.246 Canakinumab (Ilaris) | CP.PHAR.469 Belantamab mafodotin (Blenrep) |
| |
CP.PHAR.257 Ixekizumab (Taltz) | CP.PHAR.477 Risdiplam |
| |
CP.PHAR.260 Rituximab (Rituxan, Ruxience, Truxima, Rituxan Hycela) | CP.PHAR.479 Decitabine-Cedazuridine (Inqovi) | ||
CP.PHAR.58 Denosumab (Prolia Xgeva) | |||
CP.PHAR.261 Secukinumab (Cosentyx) | CP.PHAR.65 Imatinib (Gleevec) |
| |
CP.PHAR.304 Irinotecan Liposome (Onivyde) | CP.PHAR.71 Lenalidomide (Revlimid) |
| |
CP.PHAR.307 Bendamustine (Bendeka, Treanda) | CP.PHAR.78 Thalidomide (Thalomid) |
| |
CP.PHAR.79 Lapatinib (Tykerb) |
| ||
CP.PHAR.308 Elotuzumab (Empliciti) | CP.PHAR.89 Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) |
| |
CP.PHAR.309 Carfilzomib (Kyprolis) | |||
CP.PHAR.311 Belinostat (Beleodaq) | CP.PHAR.93 Bevacizumab (Avastin, Mvasi, Zirabev) | ||
CP.PHAR.313 Pralatrexate (Folotyn) | |||
CP.PHAR.314 Romidepsin (Istodax) | CP.PHAR.97 Eculizumab (Soliris) | ||
CP.PHAR.317 Cetuximab (Erbitux) | CP.PMN.116 L-glutamine (Endari) |
| |
CP.PHAR.318 Eribulin mesylate (Halaven) | CP.PMN.129 Pramlintide (Symlin) |
| |
CP.PHAR.319 Ipilimumab (Yervoy) | CP.PMN.164 Cannabidiol (Epidiolex) | ||
CP.PHAR.321 Panitumumab (Vectibix) | CP.PMN.181 Calcipotriene-Betamethasone Dipropionate Foam (Enstilar) |
| |
CP.PHAR.322 Pembrolizumab (Keytruda) |
| ||
CP.PHAR.325 Ziv-aflibercept (Zaltrap) | CP.PMN.182 Betamethasone dipropionate (Sernivo) |
| |
CP.PHAR.327 Nusinersen (Spinraza) | |||
CP.PHAR.332 Pasireotide (Signifor, Signifor LAR) | CP.PMN.209 Solriamfetol (Sunosi) | ||
CP.PMN.210 Acyclovir buccal tab (Sitavig) ophthalmic ointment (Avaclyr) | |||
CP.PHAR.334 Ribociclib (Kisqali, Kisqali Femara) | |||
CP.PMN.221 Pitolisant (Wakix) | |||
CP.PHAR.336 Dupilumab (Dupixent) | CP.PMN.42 Sodium Oxybate (Xyrem) | ||
CP.PHAR.350 Rucaparib (Rubraca) | CP.PMN.47 Rifaximin (Xifaxan) | ||
CP.PMN.53 Off-Label Use | |||
CP.PHAR.352 Daunorubicin-cytarabine (Vyxeos) | CP.PMN.86 Oxymetazoline (Rhofade, Upneeq) | ||
CP.PHAR.353 Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) | CP.PMN.90 Benznidazole | ||
TCHP.PHAR.2001 DPP-4 Inhibitors | |||
CP.PHAR.354 Testosterone (Testopel, Jatenzo) | TCHP.PHAR.2002 SGLT-2 Inhibitors | ||
CP.PHAR.355 Abemaciclib (Verzenio) |
| ||
CP.PHAR.358 Gemtuzumab (Mylotarg) | |||
NEW COVERAGE GUIDELINES | |||
CP.PHAR.472 Bresucabtagene autoleucel (Tecartus) | CP.PHAR.507 Lomustine (Gleostine) | ||
CP.PHAR.508 Tafasitamab-cxix (Monjuvi) | |||
CP.PHAR.477 Risdiplam (Evrysdi) | CP.PHAR.509 Triheptanoin (Dojolvi) | ||
CP.PHAR.484 Viltolarsen (Viltepso) | CP.PMN.246 Fenfluramine (Fintepla) | ||
CP.PHAR.488 Apomorphine (Apokyn, Kynmobi) | CP.PMN.247 Rivaroxaban (Xarelto) | ||
CP.PHAR.498 Burprenorphine (Brixadi) | CP.PMN.248 Ciprofloxacin-Dexamethasone (Ciprodex) | ||
CP.PHAR.499 Lonafarnib (Zokinvy) | |||
CP.PHAR.500 Lurbinectedin (Zepzelca) | CP.PMN.249 Ciprofloxacin-Fluocinolone (Otovel) | ||
CP.PHAR.501 Pertuzumab-trastuzumab-hyaluronidase-zzxf (Phesgo) | CP.PMN.250 Colesevelam (Welchol) | ||
CP.PMN.251 Lactic acid-citric acid-potassium bitartrate (Phexxi) | |||
CP.PHAR.502 Ripretinib (Qinlock) | |||
CP.PHAR.503 Sutimlimab | CP.PMN.252 Metoclopramide (Gimoti) | ||
CP.PHAR.504 Voclosporin | CP.PMN.253 Abametapir (Xeglyze) | ||
CP.PHAR.505 Continuous Insulin Delivery Systems (V-Go, Omnipod) | CP.PMN.254 Budesonide-glycopyrrolate-formoterol fumarate (Breztri Aerosphere) | ||
CP.PHAR.506 Antithymocyte Globulin (Atgam, Thymoglobulin) | CP.PMN.256 Nifurtimox (Lampit) | ||
| |||
UPDATED COVERAGE GUIDELINES – No Clinically Significant Change(s) | |||
CP.PHAR.130 Avatrombopag (Doptelet) | CP.PHAR.435 Darolutamide (Nubeqa) | ||
CP.PHAR.133 Idelalisib (Zydelig) | CP.PHAR.436 Pexidartinib (Turalio) | ||
CP.PHAR.134 Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) | CP.PHAR.438 Trientine (Syprine) | ||
CP.PHAR.441 Entrectinib (Rozlytrek) | |||
CP.PHAR.139 Mogamulizumab-kpkc (Poteligeo) | CP.PHAR.442 Fedratinib (Inrebic) | ||
CP.PHAR.142 Adefovir (Hepsera) | CP.PMN.13 Dose optimization | ||
CP.PHAR.143 Betaine (Cystadane) | CP.PMN.167 Neomycin-fluocinolone cream (Neo-Synalar) | ||
CP.PHAR.149 Baclofen (Gablofen, Lioresal, Ozobax) | |||
CP.PMN.17 Droxidopa (Northera) | |||
CP.PHAR.170 Degarelix (Firmagon) | CP.PMN.174 Perindopril-Amlodipine (Prestalia) | ||
CP.PHAR.171 Goserelin Acetate (Zoladex) | CP.PMN.176 Amlodipine-Atorvastatin (Caduet) | ||
CP.PHAR.172 Histrelin (Vantas, Supprelin LA) | CP.PMN.179 Megestrol Acetate Oral Suspension (Megace ES) | ||
CP.PHAR.174 Nafarelin (Synarel) | |||
CP.PHAR.175 Triptorelin pamoate (Trelstar, Triptodur) | CP.PMN.180 Halobetasol Propionate Lotion (Bryhali, Lexette, Ultravate) | ||
CP.PHAR.305 Obinutuzumab (Gazyva) | CP.PMN.184 Stiripentol (Diacomit) | ||
CP.PHAR.306 Ofatumumab (Arzerra) | CP.PMN.185 Baloxavir Marboxil (Xofluza) | ||
CP.PHAR.315 Vincristine Liposome (Marqibo) | CP.PMN.213 Ferric maltol (Accrufer) | ||
CP.PHAR.320 Necitumumab (Portrazza) | CP.PMN.215 Non-preferred blood glucose monitors and test strips | ||
CP.PHAR.324 Temsirolimus (Torisel) | |||
CP.PHAR.326 Olaratumab (Lartruvo) | CP.PMN.216 Diazepam nasal spray (Valtoco) | ||
CP.PHAR.328 Asfotase Alfa (Strensiq) | CP.PMN.226 Pancrelipase (Pertyze, Viokace, Zenpep) | ||
CP.PHAR.357 Copanlisib (Aliqopa) | |||
CP.PHAR.363 Enasidenib (Idhifa) | CP.PMN.54 Clobazam (Onfi, Sympazan) | ||
CP.PHAR.365 Neratinib (Nerlynx) | CP.PMN.59 Quantity Limit Override | ||
CP.PHAR.389 Pegvisomant (Somavert) | TCHP.PHAR.18000 Compounded Medications | ||
CP.PHAR.392 Pegademase Bovine (Adagen) | TCHP.PHAR.18001 Supplement Herbal and Vitamin Products | ||
CP.PHAR.393 Leucovorin Injection | |||
CP.PHAR.394 Migalastat (Galafold) | TCHP.PHAR.18002 Smoking Cessation Products | ||
CP.PHAR.397 Cemiplimab-rwlc (Libtayo) | |||
CP.PHAR.398 Moxetumomab pasudotox-tdfk (Lumoxiti) | TCHP.PHAR.18004 Atopic Dermatitis and Topical Antipsoriatics | ||
CP.PHAR.399 Dacomitinib (Vizimpro) | TCHP.PHAR.18006 Coenzyme Q-10 | ||
CP.PHAR.400 Duveli | TCHP.PHAR.1907 Gender Dysphoria | ||
| CP.PHAR.434 Bremelanotide (Vyleesi) | |||
Trillium Oregon Health Plan Preferred Drug List changes
Medication | Effective Date |
Additions | |
Arnuity Ellipta 50, 100 & 200 mcg/act | 1/1/2021 |
Removals | |
Asmanex HFA 100 & 200 mcg/act Removed from PDL. Current utilizers will be grandfathered for 5 years | 1/1/2021 |
Asmanex TwistHaler 110 & 220 mcg/act Removed from PDL. Current utilizers will be grandfathered for 5 years | 1/1/2021 |
Coverage Restriction Changes | |
Vivitrol (Naltrexone HCl) Injection No longer requires PA for coverage (Pharmacy & Medical benefit); QL of 1 per 28 days added | 10/22/2020 |
Key: PDL = preferred drug list; QL = quantity limit; PA = prior authorization | |
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 www.trilliumohp.com/providers/pharmacy.html.
For additional information on the drug classes and medication coverage guidelines reviewed by the P&T committee, visit the Provider Resources section on Trillium’s website at www.trilliumohp.com/providers/resources.html.
If you have questions regarding the information contained in this update, contact Trillium Provider Services through the Trillium provider website at trilliumohp.com or by telephone at 1-877-600-5472.