Physicians/Specialists
Facilities/Hospitals
Ancillary
Pharmacy

Publication Date

Publication Date: 
2016-04-25

We want to inform you about the following new pharmacy utilization management requirements that will be effective July 1, 2016.  Below is a high-level summary of the criteria and more details can be found online.

 

Pharmacy Benefit Changes

The following requirements will apply to all commercial members who have their pharmacy benefit coverage with us.  These changes will not apply to State Health Plan, Federal Employee Program, Medicare Part D members, or to any ASO employer groups that carve out their pharmacy benefits to another pharmacy benefits manager.

 

  • Angiotensin Receptor Blockers (ARBs) and Renin Inhibitors:
     
    • The following brand medications will continue to require step therapy and add a quantity limit: Amturnide, Atacand, Atacand HCT, Avalide, Avapro, Azor, Benicar, Benicar HCT, Cozaar, Diovan, Diovan HCT, Edarbi, Edarbyclor, Exforge, Exforge HCT, Hyzaar, Micardis, Micardis HCT, Tekamlo, Tekturna, Tekturna HCT, Tribenzor, and Twynsta.
    • The following generics will add a quantity limit: amlodipine-valsartan, amlodipine-valsartan-HCTZ, candesartan, candesartan-HCTZ, eprosartan mesylate, irbesartan, irbesartan-HCTZ, losartan, losartan-HCTZ, telmisartan, telmisartan-amlodipine, telmisartan-HCTZ, valsartan, and valsartan-HCTZ.  Existing authorizations in place will be honored unless they are for more than the new quantity limit.
  • Biologics:
     
    • Cimzia and Otezla will continue to require prior review, step therapy and have quantity limits. Program has been updated so that members can only receive a starter dose every six months.
    • Humira will continue to require prior review and have quantity limits. Program has been updated so that members can only receive a starter dose every six months. 
    • Kineret and Stelara will continue to require prior review, and both will have a quantity limit added. Existing authorizations in place will be honored unless they conflict with updated quantity limit requirements.
  • Celebrex: Prior review will continue to be required, and quantity limits will be added.  Existing authorizations in place will be honored unless they are for more than the new quantity limit.
  • Metastatic melanoma: Cotellic will be added to this program, requiring prior review
    and having a quantity limit.  Mekinist, Tafinlar and Zelboraf will continue to require prior review, and will have quantity limits added.  Existing authorizations in place will be honored unless they are for more than the new quantity limit.
  • Multiple Sclerosis Treatment: Ampyra, Betaseron, Copaxone, Glatopa, Plegridy, Rebif, and Tecfidera will continue to require prior review and have quantity limits added.  Aubagio, Avonex, Extavia, and Gilenya will continue to require prior review, step therapy and have quantity limits added.  Existing authorizations in place will be honored unless they are for more than the new quantity limit.
  • Niaspan: Brand and generic versions will have a quantity limit.
  • Overactive Bladder: Detrol, Detrol LA, Ditropan XL, Enablex, GeInique, Myrbetriq, Oxytrol, Sanctura, Sanctura XR, Toviaz, and Vesicare will require step therapy and have quantity limits.  Darifenacin, Oxybutynin, Oxybutynin HCI, Tolterodine, Tolterodine SR, Trospium, and Trospium ER will require quantity limits.  Existing authorizations in place will be honored.
  • Promacta: Will require prior review.
  • Provigil /Nuvigil: Criteria for this program has been updated.  Provigil will continue to require prior review, and the quantity limit has changed.  Nuvigil will continue to require prior review, step therapy, and have a quantity limit.  Existing authorizations in place will be honored unless they are for more than the new quantity limit.
  • Respiratory: Step therapy will be required for the following medications:  Aerospan, Alvesco, Arcapta Neohaler, Atrovent HFA, Foradil Aerolizer, Proair HFA and RespiClick, Proventil HFA, Pulmicort Flexhaler, QVAR, Seebri Neohaler, Stiolto Respimat, Striverdi Respimat, Tudorza Pressair, and Xopenex HFA.  Existing authorizations in place will be honored.
  • Somatostatin Analogues: Prior review will be required for octreotide, Sandostatin, Somavert, and Somatuline.  Existing authorizations in place will be honored.
  • Suboxone/ Buprenorphine: Continues to require prior review, step therapy, and quantity limits, but quantity limits have changed on some strengths of Bunavail, buprenorphine SL, buprenorphine/naloxone, Suboxone films, and Zubsolv.  Existing authorizations in place will be honored unless they conflict with updated quantity limit requirements.

 

These pharmacy utilization management changes are effective July 1, 2016.  If you have any questions, please contact us via the Provider Blue LineSM at 1.800.214.4844.