Pharmacy Information and Preferred Drug List Changes - Third Quarter 2024
Date: 08/01/24
Appropriate Use of GLP-1 Agonists
GLP-1 agonists have become part of the standard of care in the treatment of Type II Diabetes. The American Diabetes Association (ADA) guidelines now recommends other medications (including GLP-1 agonists) with or without metformin based on glycemic needs, as appropriate initial therapy for individuals with type II diabetes with or at high risk for atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease. Inappropriate prescribing of drugs like Ozempic and Mounjaro for treatment of obesity alone has contributed to shortages of these products for patients with Type II diabetes.
We have noted, in recent months, many coverage requests for GLP-1 agonists (particularly Ozempic and Mounjaro) appear to be intended for use outside of the FDA-approved indications for the particular product. Trillium Community Health Plan in conjunction with Centene Pharmacy Solutions will be actively monitoring and reviewing PA requests to ensure these medications are used only per their FDA-approved indications. Requests for documentation to substantiate attestations made in the prior authorization (PA) request process may be required. It is also important to note that coverage of products with weight loss indications are not covered by Trillium Community Health Plan as pharmacologic treatment of obesity is an excluded benefit of the Oregon Health Plan.
Trillium Community Health Plan Preferred Drug List Changes
Trillium’s Preferred Drug List (PDL) is updated monthly and is available online. View this notice for a summary of the PDL changes made in the third quarter of 2024. For the most current preferred drug list, visit the Pharmacy section of our website.
Prior Authorization Changes to Specialized Medications Given in Office
View this notice for all HCPC codes. These codes now require prior authorization for coverage for Trillium Oregon Health Plan members.
Quarterly Update on Pharmacy Coverage Guidelines
The P&T Committee determines updates to coverage guidelines (criteria) based on quarterly, comprehensive reviews. Criteria serves as a reference for providers to use when prescribing pharmaceutical products for Trillium members with pharmacy coverage. 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.
View this notice for all the updated or new Trillium Community Health Plan coverage guidelines that were approved by P&T in the third quarter of 2024. All coverage guidelines will go into effect October 1, 2024 and will become available to view in their entirety at our website approximately 2 weeks prior to their implementation date.
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 Pharmacy section of the Trillium website.
For additional information on medication coverage guidelines, visit the Provider Resources section of Trillium’s website.
If you have questions regarding the information contained in this update, contact Trillium Provider Services through the Provider Resources section of the Trillium website or by telephone at 1-877-600-5472.