May 2010 Pharmacy Passages

Pharmacy Passages: Your Source for Information About Changes to the Innoviant Preferred Products List

May 2010

Innoviant's Business Committee meets monthly to evaluate product status (tier placements) and new prescription products approved by the Food and Drug Administration (FDA). The committee makes decisions based on information and recommendations from Prescription Solutions^® National Pharmacy & Therapeutics (NP&T) Committee, which is comprised of independent physician providers, affiliated plan physicians and pharmacists.

Change Summary Table

The following table is an at-a-glance summary of decisions made at April committee meetings. Details about products and decisions are further outlined in the "review details" section of this newsletter. All changes are effective July 1, 2010 unless otherwise noted.


Table Key	Δ Change	• No Change	+ Addition	- Deletion


Tier 3 (Nonpreferred)	Tier 2 (Preferred)	Prior Authorization (PA)
Δ Aldurazyme*	+ Norvir Tablet (eff. 5-1-10)	+ Aldurazyme*
Δ Amevive*	Δ Gelnique (eff. 6-1-10)	+ Amevive*
Δ Apokyn*	Δ Rapaflo (eff. 6-1-10)	+ Apokyn*
Δ Atuss DS	Δ Saphris (eff. 5-1-10)	+ Carimune Nanofiltered*
Δ Brovex PSE		+ Copegus (eff. 8-1-10)
Δ Carimune Nanofiltered*	DACON	+ Fabrazyme*
+ Cayston	+ Mirapex ER (eff. 5-1-10)	+ Flebogamma*
Δ Copegus (eff. 8-1-10)		+ Forteo
Δ Emla Kit	*Specialty Pharmacy (SPP)	+ Gamastan S/D*
Δ Fabrazyme*	+ Istodax (eff. 5-1-10)	+ Gammagard Liquid*
Δ Flebogamma*	+ Revatio injection	+ Gammadard S/D*
Δ Flomax	+ Zyprexa Relprevv	+ Gamunex*
Δ Forteo	+ VPRIV	+ Isotodax* eff. 5-1-10
Δ Gamastan S/D*	+ Xiaflex	+ Kineret
Δ Gammagard Liquid*		+ Neumega
Δ Gammagard S/D*	Quantity Limit (QL)	+ Octagam*
Δ Gamunex*	- Pegasys / Kit (eff. 6-1-10)	+ Orencia*
+ Istodax* eff. 5-1-10	+ Zyprexa Relprevv*	+ Rebetol (eff. 8-1-10)
+ Mirapex ER		+ Remicade*
Δ Neumega	NDC Block	+ Revatio injection*
Δ Octagam*	+ hydrochlorothiazide 12.5 mg tablet	+ Ribapak (eff. 8-1-10)
Δ Orencia*	+ hydrochlorothiazide 12.5 mg tablet	+ ribavirin
Δ Promacta		- Saphris (eff. 5-1-10)
Δ Rebetol (eff. 8-1-10)		+ Symlin
+ Revatio injection*		+ Vivaglobulin*
ΔRibapak (eff. 8-1-10)		+ VPRIV*
Δ Symlin
Δ Valtrex
Δ Vivaglobulin*
+ VPRIV*
+ Xiaflex*
+ Zyprexa Relprevv*

Review Details

The NP&T Committee performs evidence-based clinical reviews of new products, line extensions, therapy classes, formulary placements, generic alternatives and clinical programs. Tier placement and utilization management edits promote safe, cost-effective use of products. Detailed information about the "Change Summary Table" is provided below.


	Table Key



	*Plan Design* Open = all generics at tier-1 and all brands at tier-2 (or all medications at tier-1) Select = generics at tier-1, preferred brands at tier-2 and nonpreferred brands at tier-3 Closed = generics at tier-1 and preferred brands at tier-2 (nonpreferred products are not covered or may require authorization for coverage)

	*PPL Status:* G = Generic PB= Preferred brand N = Nonpreferred brand		*Copay Tier:* 1 = Generic 2 = Brand/Preferred brand 3 = Nonpreferred brand 0 = Not covered/other



	New Specialty Medications Please note: If your plan includes the specialty pharamcy program (SPP), your members may get specialty products from Prescription Solutions^® Specialty Pharmacy for your plan's applicable copay. If your plan does not include the SPP, your members may get self-injectable specialty medications from retail pharmacies or specialty products may be covered under the medical plan. Specialty Program medications are limited to a 30 day supply.



*Istodax (romidepsin)* for injection** Indicated for treatment of cutaneous T-cell lymphoma (CTCL) in patients who have received at least one prior systemic therapy. Specialty Pharmacy Program (SPP) only Prior Authorization	N	2	3	0

*Revatio (sildenafil)* injection** A phosphodiesterase 5 (PDE5) inhibitor indicated for the treatment of pulmonary arterial hypertension (WHO Group I) to improve exercise ability and delay clinical worsening. Line extension (new dose form) Specialty Pharmacy Program (SPP) only Prior Authorization	N	2	3	0

VPRIV (velaglucerase alfa) for injection Indicated for long-term enzyme replacement therapy (ERT) for pediatric and adult patients with type 1 Gaucher disease. Specialty Pharmacy Program (SPP) only Prior Authorization	N	2	3	0

Xiaflex (collagenase clostridium histolyticum) for injection, for intralesional use Indicated for the treatment of adult patients with Dupuytren's contracture with a palpable cord. Specialty Pharmacy Program (SPP) only	N	2	3	0

Zyprexa Relprevv (olanzapine) for extended release injectable suspension A long-acting atypical antipsychotic for intramuscular injection indicated for the treatment of schizophrenia. Line extension (new dose form) Specialty Pharmacy Program (SPP) only Quantity Limit	N	2	3	0



	New Medications (non specialty)



Cayston (aztreonam for inhalation solution) Indicated to improve respiratory symptoms in cystic fibrosis (CF) patients with Pseudomonas aeruginosa.	N	2	3	0



Mirapex ER (pramipexole dihydrochloride extended-release) tablets A non-ergot dopamine agonist indicated for the treatment of the signs and symptoms of Parkinson’s disease. Line extension (new dose form) DACON edit (effective 5-1-10)	N	2	3	0



Norvir (ritonavir) tablet An HIV protease inhibitor used in combination of other antiretroviral agents for the treatment of HIV-1 infection. Line extension (new dose form) Added to preferred status (effective 5-1-10)	PB	2	2	2



	Preferred Products List (PPL) Updates



Atuss DS (chlorpheniramine/ psuedoephedrine/dextromethorphan) Used for the temporary relief of nasal congestion and cough associated with respiratory tract infections and related conditions by tenacious mucus and/or mucous plugs and congestion. Moved to nonpreferred status. Generic equivalent available	N	2	3	0



Brovex PSE (brompheniramine/pseudoephedrine) Used for the temporary relief of symptoms associated with seasonal and perennial allergic rhinitis and vasomotor rhinitis, including nasal congestion. Moved to nonpreferred status. Generic equivalent available.	N	2	3	0



*Copegus (ribavrin)* tablets** Used in combination with PEGASYS (peginterferon alfa-2a) for the treatment of adults with chronic hepatitis C virus infection who have compensated liver disease and have not been previously treated with interferon alpha Moved to nonpreferred status(effective 8-1-10). Generic equivalent available. Added to Prior Authorization program (effective 8-1-10)	N	2	3	0



Emla Kit (lidocaine 2.5%, prilocaine 2.5%) Used as a topical anesthetic for use on normal intact skin for local analgesia or genital mucous membranes for superficial minor surgery and as pretreatment for infiltration anesthesia. Moved to nonpreferred status. Generic equivalent available.	N	2	3	0



*Flomax (tamsulosin hydrochloride)* Capsules** Used for the treatment of the signs and symptoms of benign prostatic hyperplasia (BPH) Moved to nonpreferred status. Generic equivalent available. DACON edit	N	2	3	0



Forteo (teriparatide [rDNA origin] injection) for subcutaneous use A recombinant human parathyroid hormone analog indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture, and to increase bone mass in men with primary or hypogonadal osteoporosis at high risk for fracture, and for the treatment of men and women with osteoporosis associated with sustained systemic glucocorticoid therapy at high risk for fracture. Moved to nonpreferred status Added to Prior Authorization program Quantity Limit	N	2	3	0



Gelnique (oxybutynin chloride) gel for topical use Used for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency. Added to preferred status (effective 6-1-10) Quantity Limit	PB	2	2	2



Neumega (oprelvekin) Used for the prevention of severe thrombocytopenia and reduce the need for platelet transfusions following myelosuppressive chemotherapy in adult patients with nonmyeloid malignancies who are at high risk of severe thrombocytopenia. Moved to nonpreferred status Added to Prior Authorization program Specialty Pharmacy Program (option)	N	2	3	0



*Promacta (eltrombopag)* tablets** A thrombopoietin receptor agonist used for the treatment of thrombocytopenia in patients with chronic immune (idiopathic) thrombocytopenic purpura who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy. Moved to nonpreferred status Prior Authorization program	N	2	3	0



Rapaflo (silodosin) capsules Used for the treatment of the signs and syptoms of benign prostatic hyperplasia (BPH). Added to preferred status (effective 6-1-10) DACON edit	PB	2	2	2


*Rebetol (ribavirin)* capsules and solution** Used in combination with interferon alfa-2b (pegylated and nonpegylated) for the treatment of Chronic Hepatitis C (CHC) in patients 3 years of age and older with compensated liver disease. Moved to nonpreferred status (effective 8-1-10). Generic alternative available Added to Prior Authorization program (effective 8-1-10)	N	2	3	0



RibaPak (ribavirin) tablets Used in combination with peginterferon alfa-2a for the treatment of adults with chronic hepatitis C virus infection who have compensated liver disease and have not been previously treated with interferon alpha. Moved to nonpreferred status (effective 8-1-10). Generic alternative available. Added to Prior Authorization program (effective 8-1-10)	N	2	3	0


*Saphris (asenapine)* sublingual tablets** An atypical antipsychotic indicated for the acute treatment of schizophrenia in adults, and for the acute treatment of manic or mixed episodes associated with bipolar I disorder in adults. Added to preferred status (effective 5-1-10) Removed from Prior Authorization program (effective 5-1-10) DACON edit	PB	2	2	2


Symlin (pramlintide acetate) injection Type 2 diabetes, Used as an adjunct treatment in patients with Type 2 diabetes who have failed to achieve desired glucose control despite optimal insulin therapy, with or without a concurrent sulfonylurea agent and/or metformin, and as an adjunct treatment in patients with Type 1 diabetes who have failed to acheive glucose control despite optimal insulin therapy. Moved to nonpreferred status Added to Prior Authorization program	N	2	3	0



	Utilization Management Program: Prior Authorization (non-Specialty or Specialty Pharmacy Program option medications)



Saphris Removed from Prior Authorization Program (effective 5-1-10)	PB	2	2	2



*Forteo, Kineret, Neumega, Symlin* Added to Prior Authorization Program (Current utilizers will be grandfathered for continued use without PA ) Specialty Pharmacy Program option applies to products with asterisk (*)	N	2	3	0


ribavirin tablets Added to Prior Authorization (effective 8-1-10) (Current utilizers will be grandfathered for continued use without PA )	G	1	1	1




Copegus, Rebetol (tabs and solution), RibaPak Added to Prior Authorization (effective 8-1-10) (Current utilizers will be grandfathered for continued use without PA )	N	2	3	0



	Utilization Management Program: Quantity LImits



Pegasys, Pegasys Kit Quantity Limit removed (effective 6-1-10) Prior Authorization Specialty Pharmacy Program option	PB	2	2	2



	Specialty Pharmacy Program — SPP only medications added to Prior Authorization



Remicade Prior Authorization added, effective 7/1/10 (current utilizers grandfathered for continued use without PA)	PB	2	2	2



Aldurazyme, Amevive, Apokyn, Carimune Nanofiltered, Fabrazyme, Flebogamma, Gamastan S/D, Gammagard Liquid, Gammagard S/D, Gamunex, Istodax (5/1/10), Octagam, Orencia, Revatio injection, Vivaglobulin, VPRIV Prior Authorization added, effective 7/1/10 (current utilizers grandfathered for continued use without PA)	N	2	3	0



	Specialty Pharmacy Program — SPP only medications with status change



Aldurazyme, Amevive, Apokyn, Carimune Nanofiltered, Fabrazyme, Flebogamma, Gamastan S/D, Gammagard Liquid, Gammagard S/D, Gamunex, Octagam, Orencia, Vivaglobulin Products moving to nonpreferred status (current utilizers grandfathered for continued use at preferred status)	N	2	3	0


	Special Announcement: New NDC Block — Hydrochlorothiazide (HCTZ) 12.5 mg tablets



	Hydrochlorothiazide 12.5 mg is a diuretic supplied in more than one dosage form (capsules and tablets) achieving similar clinical results. Because significant cost differences exist between the capsules and tablets, we have selected HCTZ 12.5 mg capsule for coverage and will block HCTZ 12.5 mg in tablet form, effective July 1, 2010.


	Special Announcement: Name change for Kapidex



	Effective in late April, preferred brand Kapidex (dexlansoprazole) had a name change to Dexilant. Takeda Pharmaceuticals explained that Kapidex, a proton pump inhibitor medication made by them for the treatment of acid reflux disease, would undergo the name change to avoid confusion with similarly named products such as AstraZeneca’s prostate cancer drug Casodex (bicalutamide) and Actavis’ painkiller Kadian (morphine sulfate). The chemical composition and formulation of the product will remain unchanged. Effective May 1, 2010 Innoviant brochures containing references to Kapidex are updated to reflect the name change to Dexilant.


	Special Announcement: Update on Valtrex tier change



	An antiviral used in the treatment of shingles (herpes zoster) and for the treatment or suppression of genital herpes. The March 1 edition of Pharmacy passages reported that Valtrex would be moving to nonpreferred status, effective May 1 due to the introduction of a new generic equivalent. The effective date has been changed to July 1, 2010 due to a market shortage of generic product which is expected to be resolved by mid-June.