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Formulary Changes

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Multi Tier Formulary Changes
effective October 1, 2012
Prescription Drug Change Alternatives That Cost You Less
Erivedge
(vismodegib)
Tier 2, subject to prior authorization and quantity limits; must be obtained through a specialty pharmacy  
Inlyta
(axitinib)
Tier 3, subject to prior authorization and quantity limits; must be obtained through a specialty pharmacy  
Oxecta
(oxycodone IR)
Tier 3, subject to prior authorization oxycodone IR
Rectiv
(nitroglycerin 0.4%)
Tier 3, subject to quantity limits  
Zioptan
(tafluprost)
Tier 3, subject to step therapy and quantity limits latanoprost
Kalydeco
(ivacaftor)
Tier 2, subject to prior authorization and quantity limits; must be obtained through a specialty pharmacy  
Blood Glucose Test Strips and Meters Roche Blood Glucose Test Strips as well as any other brand of Blood Glucose Test Strips not listed in our preferred Blood Glucose Test Strip listing will require prior authorization. Specific criteria, including medical records documenting that you cannot use our preferred products, must be sent in by your physician for review. If approved, you will be responsible for a Tier 3 copay for the strips and you must obtain the corresponding meter through your DME benefit. Bayer and Abbott Blood Glucose Meters and Test Strips
  Bayer Blood Glucose Test Strips (Breeze 2, Contour) will now be Tier 2, effective October 1, 2012. You may obtain a corresponding Blood Glucose Meter (Breeze 2, Contour, Contour USB, or Contour Link) for free, at your pharmacy with a prescription from your physician.  
  Abbott FreeStyle Blood Glucose Test Strips (FreeStyle Lite, FreeStyle InsuLinx, Precision Xtra) have been and will remain Tier 2. You may obtain a corresponding Blood Glucose Meter (FreeStyle Lite, FreeStyle Freedom Lite, FreeStyle InsuLinx, Precision Xtra) for free, at your pharmacy with a prescription from your physician.  

 

New Medications Covered Under the Medical Benefit

Perjeta (pertuzumab)

Perjeta is a new medication used in the treatment of metastatic breast cancer. It requires a prior authorization; see below for additional information.

Please refer to complete utilization management policies for full prior authorization criteria, step therapy criteria, quantity limits, as well as any additional information and restrictions.

New Pharmacy Prior Authorization/Step Therapy Criteria
Korlym (mifepristone) Prior Authorization

Korlym is a medication for treatment of adult patients with hyperglycemia secondary to Cushing’s syndrome. This is not a first line therapy; it is considered after failure of surgery. This medication must be requested by an endocrinologist; a number of clinical criteria must be met for coverage. Female patients taking this medication must have obtained a negative pregnancy test within 14 days of the start of the medication and a non-hormonal method of contraception must be used for the duration of treatment unless the patient has had a surgical sterilization. When approved, this medication must be obtained through a specialty pharmacy.

Perjeta (pertuzumab) Prior Authorization

Perjeta is a medication for the treatment of metastatic breast cancer; it must be given in conjunction with 2 other medications. It has been shown to work only in people with HER2-positive breast cancer. A prior authorization for coverage must be prescribed by an oncologist. In addition to specified clinical criteria which must be met, this medication should be used in patients who have not received prior anti-HER2 therapy or chemotherapy for metastatic disease. When approved, this medication is covered under the medical benefit.

V-Go Insulin Delivery Device Prior Authorization

The V-Go is a new disposable delivery device for insulin in adult patients with type 2 diabetes. This should be used for members who are already receiving insulin and are stabilized on a dose; the device delivers a fixed rate which cannot be varied. The prescribing physician must submit a prior authorization with specified information including your current insulin regimen.

Please refer to complete utilization management policies for full prior authorization criteria, step therapy criteria, quantity limits, as well as any additional information and restrictions.

Revised Pharmacy Prior Authorization/Step Therapy Criteria
Afinitor (everolimus) Prior Authorization Criteria

Afinitor now has an additional indication for treatment of renal angiomyolipoma and tuberous sclerosis complex not requiring immediate surgery. An oncologist must request prior authorization for this medication; in addition, specific medical records must be submitted for review. When approved, this medication must be obtained through our specialty pharmacy.

ARB/ARB HCTZ Combinations Step Therapy (ARB-angiotensin receptor blocker, a med for blood pressure)

With the addition of another generic ARB (angiotensin II receptor blocker) to the marketplace, our step therapy has been revised. As of 10-1-12, all previously issued prior authorizations for Benicar (olmesartan) and Benicar HCT (olmesartan/hctz) will be discontinued. Members will need to meet step therapy criteria to obtain Benicar, Benicar HCT. The 1st step medications are irbesartan, irbesartan/hctz, losartan, losartan/hctz, valsartan, valsartan/hctz, and eprosartan. Please see complete policy for additional information.

Blood Glucose Test Strip Prior Authorization

Bayer and FreeStyle meters/strips will now be our preferred products in this category. Please see listing above for products covered. Members may receive a free preferred Bayer or FreeStyle meter by presenting a prescription at a retail pharmacy. To obtain any blood glucose meter/strips other than our preferred products, your physician must submit a prior authorization. The auth request must document the use of both of our preferred products in addition to a documented reason that neither of these products can be used. If a non-preferred product is approved, the meter must be obtained through the member’s DME benefit; the non-preferred strips will be subject to tier 3.

Oral Contraceptive Prior Authorization Health Care Reform

BCNEPA has developed a standard list of covered contraceptives based on the recommendations of the FDA Birth Control Guide, which includes at least one product from each contraceptive method that could be covered under the pharmacy benefit. The products listed as covered will incur a "zero-cost share" , i.e. no copay, when filled by members covered under the Health Care Reform (HCR) mandate (upon a group’s renewal date). Those medications not listed as covered under HCR will be covered, however, you will be responsible for a copay and if a generic equivalent is available, an ancillary buy-up fee will be added to the copay. For consideration of a zero-cost share for these non-covered medications, the physician must submit a prior authorization with medical records documenting that certain criteria has been met. If you purchase a non-covered medication before a prior authorization has been submitted and approved, you will be responsible for the copay and the ancillary buyup fee. Please see complete policy for additional information.

Gabapentin/Lyrica Prior Authorization/Step Therapy Criteria

Horizant (gabapentin enacarbil) has a new indication for the treatment of postherpetic neuralgia (PHN). The prescribing physician must submit a prior authorization documenting specified criteria for consideration of coverage for this medication. Please see complete policy for additional information.

Nasal Corticosteroids Step Therapy

Two new nasal corticosteroid products have been added to the 2nd step of our Nasal Corticosteroid Step Therapy: Qnasl (beclomethasone) and Zetonna (ciclesonide). Two first step products (flunisolide, fluticasone or Nasonex) must be given a trial before a 2nd step medication will be covered. Please see complete policy for additional information.

Votrient Prior Authorization

Votrient is now approved for a new indication: treatment of advanced soft tissue sarcoma in patients who have received prior chemotherapy. An oncologist must submit a prior authorization request documenting specified criteria for consideration of coverage for this medication. Please see complete policy for additional information. When approved, this medication must be obtained through our specialty pharmacy.