Pharmacy Information and Preferred Drug List Changes 3rd Quarter 2020
Date: 08/01/20
PRIOR AUTHORIZATION CHANGES TO SPECIALIZED MEDICATIONS GIVEN IN OFFICE
See the table below for all HCPC codes affected by changes in the 3rd quarter of 2020. These codes now require prior authorization for coverage for Trillium Oregon Health Plan members.
Brand (Generic Name) | Description | HCPC Code |
Adakveo (crizanlizumab-tmca) | Injection, crizanlizumab-tmca, 5 mg | J0791 |
Andexxa (Factor Xa recombinant, inactivated-zhzo) | Injection, coagulation Factor Xa (recombinant), inactivated-zhzo (Andexxa), 10 mg | J7169 |
Avsola (infliximab-axxq) | Injection, infliximab-axxq, biosimilar, (AVSOLA), 10 mg | Q5121 |
Enhertu (fam-trastuzumab deruxtecan-nxki) | Injection, fam-trastuzumab deruxtecan-nxki, 1 mg | J9358 |
Esperoct (Factor VIII recombinant glycopegylated-exei) | Injection, Factor VIII, antihemophilic factor (recombinant), (Esperoct), glycopegylated-exei, per IU | J7204 |
Evomela (melphalan hydrochloride) | Injection, melphalan (Evomela), 1 mg | J9246 |
Givlaari (givosiran) | Injection, givosiran, 0.5 mg | J0223 |
Infugem (gemcitabine hydrochloride) | Injection, gemcitabine hydrochloride, (Infugem), 100 mg | J9198 |
Kybella (deoxycholic acid) | Injection, deoxycholic acid, 1 mg | J0591 |
Padcev (enfortumab vedotin-ejfv) | Injection, enfortumab vedotin-ejfv, 0.25 mg | J9177 |
Reblozyl (luspatercept-aamt) | Injection, luspatercept-aamt, 0.25 mg | J0896 |
Ruxience (rituximab-pvvr) | Injection, rituximab-pvvr, biosimilar, (RUXIENCE), 10 mg | Q5119 |
Sinuva (mometasone furoate) | Mometasone furoate sinus implant, 10 mcg (Sinuva) | C9122 |
Tepezza (teprotumumab-trbw) | Injection, teprotumumab-trbw, 10 mg | C9061 |
Visco-3 (hyaluronate sodium) | Hyaluronan or derivative, Visco-3, for intra-articular injection, per dose | J7333 |
Vyepti (eptinezumab-jjmr) | IInjection, eptinezumab-jjmr, 1 mg | C9063 |
Vyondys 53 (golodirsen) | Injection, golodirsen, 10 mg | J1429 |
Xembify (immune globulin-klhw) | Injection, (xembify), 100 mg | J1558 |
Xenleta (lefamulin) | Injection, lefamulin, 1 mg | J0691 |
Ziextenzo (pegfilgrastim-bmez) | Injection, pegfilgrastim-bmez, biosimilar, (ZIEXTENZO), 0.5 mg | Q5120 |
Zolgensma (onasemnogene abeparvovec-xioi) | Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5x10^15 vector genomes | J3399 |
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 quarter of 2020. PDL revisions are as indicated at the end of this notice. Updated criteria can be accessed by going to the Provider Resources on our website: www.trilliumohp.com. Changes will go into effect October 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 review of clinical drug information and coverage guidelines, 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.
COVERAGE OF MAINTENANCE MEDICATIONS INCREASED TO 90 DAY FILLS
Effective July 1, 2020 members can fill up to a 90 day supply of maintenance medications at retail or mail order pharmacies. Maintenance medications are those that require regular daily use and are for treatment of conditions considered to be chronic or long-term. This includes medications used to treat high blood pressure, heart disease and diabetes. Maintenance medications that require prior authorization may also be filled for up to a 90 day supply but may require you to contact the health plan to adjust the approval day supply. Please note that not all drugs taken routinely for chronic conditions are classified as maintenance medications and are thus not subject to greater than 31 day supply fills. If you have any questions regarding which of your patient’s medications are eligible for up to 90 day supply fills please call our Provider Services team at 541-485-2155 and ask for Pharmacy.
BIOLOGICS: PREFERENCING OF BIOSIMILARS
Biosimilar agents are biological products that are highly similar to and have no clinically meaningful differences from an existing FDA approved reference product. The Biologics Price Competition and Innovation (BPCI) Act was passed in 2009 and allows an abbreviated licensure process to facilitate the innovation of more biologic products. This abbreviated approval pathway allows for biosimilar products to make it to market more quickly and with less cost; thus introducing more competition, more therapeutic options and potential savings. Here at Trillium Community Health Plan, the development and implementation of pharmacy clinical criteria that steer toward the use of biosimilar products where appropriate are ongoing. Using clear clinical guidance and sound reasoning we support use of biosimilar products in place of the reference products to help in our aim of delivering quality, cost effective health care services.
JARDIANCE USE TO BE RESTRICTED TO THOSE WITH CARDIAC DISEASE 10/1/2020
Effective October 1, 2020 Jardiance will be removed from Trillium Oregon Health Plans Preferred Drug List and will only be covered for those with cardiac disease (e.g., ASCVD or HF) per coverage guidelines. Coverage of those with identified cardiac disease will not be affected by this change. Trillium will be sending out letters to both members and prescribers who will be impacted. Steglatro and Segluromet will remain Trillium Oregon Health Plan’s preferred Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor. Steglatro prior authorizations will be entered for the members currently taking Jardiance who have not been identified as having cardiac disease. Please make sure the member has a prescription for Steglatro or your staff has submitted a prior authorization request for continued use of Jardiance prior to 10/1/2020 to avoid a lapse in care.
JANUVIA TO BE REMOVED FROM PREFERRED DRUG LIST 10/1/2020
Effective October 1, 2020 Januvia will be removed from the preferred drug list. Generic alogliptin is Trillium Oregon Health Plans preferred Dipeptidyl Peptidase-4 (DPP-4) Inhibitor and does not require prior authorization for coverage. Trillium will be sending out letters to both members and prescribers who will be impacted. Please make sure your patients on Januvia have a prescription for alogliptin or your staff has submitted a prior authorization request for continued use of Januvia prior to 10/1/2020 to avoid a lapse in care.
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 third quarter meeting July 16, 2020. All coverage guidelines will go into effect on October 1, 2020 and will become available to view in their entirety at: www.trilliumohp.com/providers/resources/clinical-payment-policies2.html by the end of September.
UPDATED COVERAGE GUIDELINES – Clinically Significant Change(s) | ||
CP.PHAR.103 Immune Globulins | CP.PHAR.360 Olaparib (Lynparza) | |
CP.PHAR.11 Burosumab-twza (Crysvita) | CP.PHAR.365 Neratinib (Nerlynx) | |
CP.PHAR.121 Nivolumab (Opdivo) | CP.PHAR.370 Emicizumab-kxwh (Hemlibra) | |
CP.PHAR.130 Avatrombopag (Doptelet) | CP.PHAR.379 Etelcalcetide (Parsabiv) | |
CP.PHAR.14 Hydroxyprogesterone caproate (Makena) | CP.PHAR.381 Mechlorethamine (Valchlor) | |
CP.PHAR.146 Deferoxamine (Desferal) | CP.PHAR.383 Trifluridine-tipiracil (Lonsurf) | |
CP.PHAR.150 Mecasermin (Increlex) | CP.PHAR.384 Lutetium Lu 177 dotatate (Lutathera) | |
CP.PHAR.168 Corticotropin (H.P. Acthar) | CP.PHAR.385 Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) | |
CP.PHAR.173 Leuprolide Acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi) | CP.PHAR.405 Inotersen (Tegsedi) | |
CP.PHAR.179 Romiplostim (Nplate) | CP.PHAR.408 Niraparib (Zejula) | |
CP.PHAR.180 Eltrombopag (Promacta) | CP.PHAR.422 Cladribine (Mavenclad) | |
CP.PHAR.210 Ivacaftor (Kalydeco) | CP.PHAR.423 Erdafitinib (Balversa) | |
CP.PHAR.212 Dornase alfa (Pulmozyme) | CP.PHAR.424 Fulvestrant (Faslodex Injection) | |
CP.PHAR.213 Lumacaftor-ivacaftor (Orkambi) | CP.PHAR.427 Siponimod (Mayzent) | |
CP.PHAR.215 Factor VIII | CP.PHAR.433 Polatuzumab vedotin-piiq (Polivy) | |
CP.PHAR.216 Factor VIII-von Willebrand (Alphanate, Humate-P, Vonvendi, Wilate) | CP.PHAR.440 Elexacaftor-ivacaftor-tezacaftor (Trikafta) | |
CP.PHAR.217 Anti-inhibitor Coagulant Complex (Feiba) | CP.PHAR.450 Luspatercept-aamt (Reblozyl) | |
CP.PHAR.218 Factor IX Human Recombinant | CP.PHAR.460 Monomethyl fumarate (Bafiertam) | |
CP.PHAR.221 Factor XIII Human (Corifact) | CP.PHAR.462 Ozanimod (Zeposia) | |
CP.PHAR.222 Factor XIIIa Recombinant (Tretten) | CP.PHAR.464 Selumetinib (Koselugo) | |
CP.PHAR.228 Trastuzumab Biosimilars Trastuzumab-Hyaluronidase | CP.PHAR.465 Teprotumumab (Tepezza) | |
CP.PHAR.243 Alemtuzumab (Lemtrada) | CP.PHAR.466 Valoctocogene Roxaparvovec | |
CP.PHAR.249 Dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity) | CP.PHAR.468 Aducanumab | |
CP.PHAR.251 Fingolimod (Gilenya) | CP.PHAR.475 Sacituzumab govitecan-hziy (Trodelvy) | |
CP.PHAR.252 Glatiramer (Copaxone, Glatopa) | CP.PHAR.476 Ubrogepant (Ubrelvy) | |
CP.PHAR.255 Interferon beta-1a (Avonex, Rebif) | CP.PHAR.478 Selpercatinib (Retevmo) | |
CP.PHAR.256 Interferon beta-1b (Betaseron, Extavia) | CP.PHAR.61 Cinacalcet (Sensipar) | |
CP.PHAR.258 Mitoxantrone (Novantrone) | CP.PHAR.81 Pazopanib (Votrient) | |
CP.PHAR.259 Natalizumab (Tysabri) | CP.PHAR.89 Peginterferon Alfa-2a,b (Pegasys, PegIntron, Sylatron) | |
CP.PHAR.260 Rituximab (Rituxan, Ruxience, Truxima, Rituxan Hycela) | CP.PHAR.93 Bevacizumab (Avastin, Mvasi, Zirabev) | |
CP.PHAR.262 Teriflunomide (Aubagio) | CP.PHAR.94 Alpha1-Proteinase Inhibitors | |
CP.PHAR.270 Paricalcitol Injection (Zemplar) | CP.PMN.132 Tadalafil BPH - ED (Cialis) | |
CP.PHAR.271 Peginterferon beta-1a (Plegridy) | CP.PMN.163 Sodium zirconium cyclosilicate (Lokelma) | |
CP.PHAR.295 Sargramostim (Leukine) | CP.PMN.198 Overactive Bladder Agents | |
CP.PHAR.297 Filgrastim (Neupogen, Zarxio, Granix, Nivestym) | CP.PMN.208 Halobetasol-Tazarotene (Duobrii) | |
CP.PHAR.302 Ixazomib (Ninlaro) | CP.PMN.44 Pyrimethamine (Daraprim) | |
CP.PHAR.303 Brentuximab (Adcetris) | CP.PMN.76 Calcifediol (Rayaldee) | |
CP.PHAR.310 Daratumumab, Daratumumab-Hyaluronidase-fihj (Darzalex, Darzalex Faspro) | TCHP.PHAR.1801 Hepatitis C Direct-Acting Antivirals | |
CP.PHAR.319 Ipilimumab (Yervoy) | TCHP.PHAR.1802 Acitretin (Soriatane) | |
CP.PHAR.322 Pembrolizumab (Keytruda) | TCHP.PHAR.184 Growth Hormones | |
CP.PHAR.335 Ocrelizumab (Ocrevus) | TCHP.PHAR.2002 Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors | |
UPDATED COVERAGE GUIDELINES – No Clinically Significant Change(s) | ||
CP.PHAR.109 Tesamorelin (Egrifta SV) | CP.PMN.146 Fluticasone-umeclidinium-vilanterol (Trelegy Ellipta) | |
CP.PHAR.145 Deferasirox (Exjade, Jadenu) | CP.PMN.147 Indacaterol-glycopyrrolate (Utibron Neohaler) | |
CP.PHAR.147 Deferiprone (Ferriprox) | CP.PMN.148 Tiotropium-olodaterol (Stiolto Respimat) | |
CP.PHAR.169 Vigabatrin (Sabril) | CP.PMN.149 Umeclidinium-vilanterol (Anoro Ellipta) | |
CP.PHAR.27 Tolvaptan (Jynarque, Samsca) | CP.PMN.152 Lofexidine (Lucemyra) | |
CP.PHAR.277 Cytomegalovirus Immune Globulin (Cytogam) | CP.PMN.155 lacosamide (Vimpat) | |
CP.PHAR.28 Immunization coverage | CP.PMN.156 Perampanel (Fycompa) | |
CP.PHAR.287 Obeticholic acid (Ocaliva) | CP.PMN.157 Rufinamide (Banzel) | |
CP.PHAR.296 Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) | CP.PMN.164 Cannabidiol (Epidiolex) | |
CP.PHAR.312 Blinatumomab (Blincyto) | CP.PMN.200 Aclidinium-formoterol (Duaklir Pressair) | |
CP.PHAR.323 Plerixafor (Mozobil) | CP.PMN.201 Arformoterol tartrate (Brovana) | |
CP.PHAR.338 Cerliponase alfa (Brineura) | CP.PMN.202 Benzyl alcohol (Ulesfia) | |
CP.PHAR.351 Daptomycin (Cubicin, Cubicin RF) | CP.PMN.203 Indacaterol (Arcapta Neohaler) | |
CP.PHAR.382 Panobinostat (Farydak) | CP.PMN.204 Olodaterol (Striverdi Respimat) | |
CP.PHAR.41 Enfuvirtide (Fuzeon) | CP.PMN.205 Patiromer (Veltassa) | |
CP.PHAR.425 Metreleptin (Myalept) | CP.PMN.207 Triclabendazole (Egaten) | |
CP.PHAR.430 Alpelisib (Piqray) | CP.PMN.211 Midazolam (Nayzilam) | |
CP.PHAR.431 Selinexor (Xpovio) | CP.PMN.229 Fluticasone-vilanterol (Breo Ellipta) | |
CP.PHAR.432 Tafamidis (Vyndaqel, Vyndamax) | CP.PMN.230 Mometasone-formoterol (Dulera) | |
CP.PHAR.82 Collagenase (Xiaflex) | CP.PMN.31 Fluticasone-salmeterol (Advair Diskus, Advair HFA) | |
CP.PHAR.83 Vorinostat (Zolinza) | CP.PMN.46 Roflumilast (Daliresp) | |
CP.PHAR.88 Belimumab (Benlysta) | TCHP.PHAR.18003 Sedatives | |
CP.PHAR.95 Thyrotropin alfa (Thyrogen) | TCHP.PHAR.1805 Lidocaine Transdermal (Lidoderm ZTlido) | |
CP.PMN.09 Lindane shampoo | TCHP.PHAR.1808 Lidocaine-Prilocaine (EMLA) | |
CP.PMN.139 Naloxone (Evzio) | TCHP.PHAR.1905 Request for Medically Necessary Drug Not on the PDL | |
CP.PMN.144 Epinephrine (Auvi-Q, Epipen, Epipen Jr) Quantity Limit | TCHP.PHAR.1906 Request for Medically Necessary Drug on the PDL | |
NEW COVERAGE GUIDELINES | ||
CP.PHAR.479 Cedazuridine-decitabine (ASTX-727) | CP.PHAR.494 Capmatinib (Tabrecta)* | |
CP.PHAR.480 Ferric Derisomaltose (Monoferric) | CP.PHAR.495 Mitomycin for Pyelocalyceal Solution (Jelmyto)* | |
CP.PHAR.481 Idecabtagene vicleucel (BB2121) | CP.PHAR.496 Pemigatinib (Pemazyre)* | |
CP.PHAR.482 Isatuximab-irfc (Sarclisa) | CP.PHAR.497 Tucatinib (Tukysa)* | |
CP.PHAR.483 Lisocabtagene maraleucel (JCAR017) | CP.PMN.234 EPSDT Benefit for Pediatric Members | |
CP.PHAR.484 Viltolarsen | CP.PMN.235 Emtricitabine/Tenofovir Alafenamide (Descovy) | |
CP.PHAR.485 Berotralstat | CP.PMN.236 Amisulpride (Barhemsys) | |
CP.PHAR.486 Bimatoprost Implant (Durysta) | CP.PMN.237 Bempedoic acid (Nexletol), bempedoic acid-ezetimibe (Nexlizet)* | |
CP.PHAR.487 Osilodrostat (Isturisa) | CP.PMN.238 Carbidopa-Levodopa ER Capsules (Rytary) | |
CP.PHAR.488 Apomorphine (Apokyn) | CP.PMN.240 Gabapentin ER (Gralise, Horizant) | |
CP.PHAR.489 Eptinezumab (Vyepti) | CP.PMN.245 Opicapone (Ongentys)* | |
CP.PHAR.490 Rimegepant (Nurtec ODT) | TCHP.PHAR.2005 Icosapent ethyl (Vascepa) | |
CP.PHAR.492 Teplizumab | TCHP.PHAR.2005 Interstitial Lung Disease Agents | |
CP.PHAR.493 Infusion Therapy Site of Care Optimization |
| |
TRILLIUM OREGON HEALTH PLAN PREFERRED DRUG LIST CHANGES
Medication | Effective Date |
Additions | |
Boric Acid Powder PA is required for compounding of 600mg capsules | 10/1/2020 |
Ceftriaxone Sodium | 10/1/2020 |
Cranberry Tablets QL 3/day | 10/1/2020 |
Doxycycline Hyclate Capsules 50mg and 100mg strength capsules added QL 2 per day; max 10 DS per fill; max 2 fills per year | 10/1/2020 |
Doxycycline Hyclate Tablets 20mg and 100mg strength tablets added QL 2 per day; max 10 DS per fill; max 2 fills per year | 10/1/2020 |
Famotidine 40 mg/5 mL susp QL 150ml per fill; max 2 fills per year | 10/1/2020 |
First Omeprazole 2 mg/ml susp QL 300ml per fill; max of 2 fills per year | 10/1/2020 |
Kyleena (levonorgestrel) IUD Added to mirror medical benefit | 7/1/2020 |
Liletta (levonorgestrel) IUD Added to mirror medical benefit | 7/1/2020 |
Mirena (levonorgestrel) IUD Added to mirror medical benefit | 7/1/2020 |
Nexplanon (etonogestrel) implant Added to mirror medical benefit | 7/1/2020 |
Paragard (copper) IUD Added to mirror medical benefit | 7/1/2020 |
Penicillin G Benzathine 600000 U/mL | 10/1/2020 |
Priftin (rifapentine) 150 mg tab QL 72 tabs per year | 10/1/2020 |
Skylea (levonorgestrel) IUD Added to mirror medical benefit | 7/1/2020 |
Valtoco (diazepam) PA required | 9/1/2020 |
Vitamin C EST requirement of concurrent iron | 10/1/2020 |
Zomacton (somatropin) PA required | 10/1/2020 |
Removals | |
Doxycycline Monohydrate Capsules 75mg and 150mg strength capsules removed | 10/1/2020 |
Doxycycline Monohydrate Tablets 75mg and 150mg strength tablets removed | 10/1/2020 |
Dulera (mometasone furoate-formoterol fumarate) | 10/1/2020 |
Esomeprazole Oral Packets | 10/1/2020 |
Januvia (sitagliptin) | 10/1/2020 |
Jardiance (empagliflozin) Member’s with identified cardiac disease will be grandfathered | 10/1/2020 |
Lansoprazole ODT Tablets | 10/1/2020 |
Sulfanilamide 15% cream | 10/1/2020 |
Wixela (fluticasone propionate-salmeterol xinafoate) | 10/1/2020 |
Coverage Restriction Changes | |
Humira (adalimumab) QL 2 per 28 days; PA still required | 10/1/2020 |
Key: PDL = preferred drug list; QL = quantity limit; DS = day supply; PA = prior authorization; EST = electronic step therapy | |
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 1-877-600-5472.