Pharmacy and therapeutic updates effective April 1

Changes listed below are the result of decisions made by the Prominence Health Plan Pharmacy and Therapeutics Committee during the quarterly review.

These high-level changes impact the Commercial (Employer Group) formulary and prior authorization (PA) criteria. Additional authorization criteria may apply for each drug. These changes are not applicable to Prominence Health Plan’s Medicare Advantage formulary.

For more complete information, visit the health plan formulary. The formulary is updated monthly.

  • Tymlos (abaloparatide) has been added under Tier 5 (Specialty Tier) with PA criteria. PA criteria includes diagnosis of postmenopausal osteoporosis with high risk for fracture, trial of bisphosphonates, and trial of Prolia (denosumab) or Reclast (zoledronic acid).
  • Forteo (teriparatide) has been reviewed, and PA criteria has been revised to require trial of Tymlos (abaloparatide) in addition to trial of Prolia (denosumab) or Reclast (zoledronic acid) and trial of an oral bisphosphonate.
  • Haegarda (C1 esterase inhibitor) has been added under Tier 5 (Specialty Tier) with PA criteria. PA requires the appropriate indication.
  • Endari (L-glutamine) has been added to our formulary under Tier 5 (Specialty Tier) with PA criteria. PA criteria requires appropriate FDA-approved indication with physician attestation.
  • Bev xx (betrixaban) has been placed as non-formulary with PA criteria. PA criteria will require appropriate FDA-approved indication, low risk of bleeding, and trial of low molecular weight heparins.
  • Luxturna (voretigene) has been placed as non-formulary with PA criteria. Select authorization requirements include documentation of confirmed biallelic RPE-65 mutation via genetic testing, documentation of visual acuity of 20/60 or worse or visual field less than 20 degrees in any meridian in both eyes, attestation that patient has sufficient viable retinal cells.
  • Trelegy Ellipta (fluticasone/umeclidinium/vilanterol) has been added under Tier 3 (Preferred Brand Tier) with step therapy requirement with preferred combination agents. Approval will require trial, failure, or contraindication to a combination of Advair (fluticasone/ salmeterol) and Spiriva (tiotropium) or a combination of Breo (fluticasone/vilanterol), Dulera (mometasone/formoterol), and Stiolto (tiotropium/olodaterol).
  • Shingrix (zoster subunit vaccine) has been reviewed and added under Tier 1 (Essential Health Benefits Tier) for members at least the age of 50 years with a quantity limit of two injections per year.
  • Symproic (naldemedine) has been added under Tier 4 (Non-Preferred Brand Tier) with step therapy requirements. Coverage will require trial of Movantik (naloxegol).
  • Baxdela (delafloxacin) has been added under Tier 4 (Non-Preferred Brand Tier) with PA requirements. Authorization for coverage will require an initiation of therapy by an infectious disease (ID) specialist and a diagnosis of acute bacterial skin and skin structure infection (ABSSSI). Authorization will also require documentation of ABSSSI organism sensitivity to delafloxacin and resistance to one standard of care agent (e.g., PO Bactrim, levofloxacin, clindamycin, cephalexin, vancomycin). If sensitivity tests are unavailable, authorization will require trial of or contraindication to a gram-positive targeting, penicillin-based, fluoroquinolone-based, or cephalosporin-based agent.