Updates to the Alberta Human Services Drug Benefit Supplement

Transcription

1 Updates to the Alberta Human Services Drug Benefit Supplement Effective June 1, 2016

2 Inquiries should be directed to: Pharmacy Services Alberta Blue Cross Street NW Edmonton AB T5J 3C5 Telephone Number: (780) (Edmonton) (403) (Calgary) (Toll Free) FAX Number: (780) (Toll Free) 109BWebsite: Hhttp://humanservices.alberta.ca/alberta-supports.html Administered by Alberta Blue Cross on behalf of Alberta Health. The Drug Benefit List (DBL) is a list of drugs for which coverage may be provided to program participants. The DBL is not intended to be, and must not be used as a diagnostic or prescribing tool. Inclusion of a drug on the DBL does not mean or imply that the drug is fit or effective for any specific purpose. Prescribing professionals must always use their professional judgment and should refer to product monographs and any applicable practice guidelines when prescribing drugs. The product monograph contains information that may be required for the safe and effective use of the product. Copies of the Alberta Drug Benefit List are available from Pharmacy Services, Alberta Blue Cross at the address shown above. Binder and contents: ( G.S.T.) Contents only: ( G.S.T.) A cheque or money order must accompany the request for copies. ABC 40211/81160 (R2016/06)

3 UPDATES TO THE ALBERTA HUMAN SERVICES DRUG BENEFIT SUPPLEMENT Table of Contents Special Authorization... 1 New Drug Product(s) Available by Special Authorization... 1 Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Special Authorization... 1 Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Step Therapy / Special Authorization... 1 Drug Product(s) with Changes to Criteria for Coverage... 1 Discontinued Listing(s)... 1 Part 3 Special Authorization EFFECTIVE JUNE 1, 2016

4 Special Authorization UPDATES TO THE ALBERTA HUMAN SERVICES DRUG BENEFIT SUPPLEMENT The following drug product(s) will be considered for coverage by special authorization for patients covered under Alberta Human Services. New Drug Product(s) Available by Special Authorization JARDIANCE 10 MG TABLET EMPAGLIFLOZIN BOE JARDIANCE 25 MG TABLET EMPAGLIFLOZIN BOE Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Special Authorization VAN-RIZATRIPTAN ODT 10 MG ORAL DISINTEGRATING TABLET RIZATRIPTAN BENZOATE VAN VAN-ZOLMITRIPTAN ODT 2.5 MG ORAL DISPERSIBLE TABLET ZOLMITRIPTAN VAN Additional Brand(s) and/or Strength(s) of Drug Products Available by Step Therapy / Special Authorization MED-SOLIFENACIN 5 MG TABLET SOLIFENACIN SUCCINATE GMP MED-SOLIFENACIN 10 MG TABLET SOLIFENACIN SUCCINATE GMP Drug Product(s) with Changes to Criteria for Coverage NEUPOGEN 0.3 MG / ML INJECTION FILGRASTIM AMG Discontinued Listing(s) Notification of discontinuation has been received from the manufacturers. The Alberta government-sponsored drug programs previously covered the following drug product(s). Effective June 1, 2016, the listed product(s) will no longer be a benefit and will not be considered for coverage by special authorization. A transition period will be applied and, as of July 1, 2016 claims will no longer pay for these product(s). RATIO-BISACODYL 10 MG RECTAL SUPPOSITORY BISACODYL RPH EFFECTIVE JUNE 1,

5 Special Authorization PART 3 Special Authorization

6 ALBERTA HUMAN SERVICES DRUG BENEFIT SUPPLEMENT UPDATE CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS EMPAGLIFLOZIN "The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process. First-Line Drug Product(s): Metformin Second-Line Drug Product(s): Sulfonylureas And where insulin is not an option As add-on therapy for the treatment of Type 2 diabetes in patients with intolerance to and/or inadequate glycemic control on: - a sufficient trial (i.e. a minimum of 6 months) of metformin, AND - a sulfonylurea, AND - for whom insulin is not an option. Or, for whom these products are contraindicated. Special authorization may be granted for 24 months. Note: If a claim for the Step therapy drug product is rejected, pharmacists can use their professional judgment to determine the appropriateness of using the intervention code(s) noted below to re-submit a claim. The pharmacist is responsible to document on the patient's record the rationale for using the second-line therapy drug. UP - First-line therapy ineffective UQ - First-line therapy not tolerated CA - Prior adverse reaction CB - Previous treatment failure CJ - Product is not effective" All requests for empagliflozin must be completed using the DPP-4/SGLT2 Inhibitors Special Authorization Request Form (ABC 60012). 10 MG ORAL TABLET JARDIANCE 25 MG ORAL TABLET JARDIANCE BOE BOE FILGRASTIM "In patients with non-myeloid malignancies, receiving myelosuppresive anti-neoplastic drugs with curative intent, to decrease the incidence of infection, as manifested by febrile neutropenia." "Following induction and consolidation treatment for acute myeloid leukemia, for the reduction in the duration of neutropenia, fever, antibiotic use and hospitalization." "In patients with a diagnosis of congenital, cyclic or idiopathic neutropenia, to increase neutrophil counts and to reduce the incidence and duration of infection." Please note for the first criterion: Coverage cannot be considered for palliative patients. All requests for filgrastim must be completed using the Filgrastim/Pegfilgrastim/Plerixafor Special Authorization Request Form (ABC 60013). 0.3 MG / ML INJECTION NEUPOGEN AMG The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. UNIT OF ISSUE - REFER TO PRICE POLICY 3. 1 EFFECTIVE JUNE 1, 2016

7 ALBERTA HUMAN SERVICES DRUG BENEFIT SUPPLEMENT UPDATE CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS RIZATRIPTAN BENZOATE "For the treatment of acute migraine attacks in patients where other standard therapy has failed. Special authorization may be granted for 24 months." Information is required regarding previous medications utilized and the patient's response to therapy. The following product(s) are eligible for auto-renewal. 10 MG (BASE) ORAL DISINTEGRATING TABLET ACT RIZATRIPTAN ODT APO-RIZATRIPTAN RPD MINT-RIZATRIPTAN ODT MYLAN-RIZATRIPTAN ODT NAT-RIZATRIPTAN ODT PMS-RIZATRIPTAN RDT RIZATRIPTAN ODT RIZATRIPTAN ODT SANDOZ RIZATRIPTAN ODT TEVA-RIZATRIPTAN ODT VAN-RIZATRIPTAN ODT MAXALT RPD APH APX MPI MYP NTP PMS SNS SIV SDZ TEV VAN MFC The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. PRODUCT IS NOT INTERCHANGEABLE 3. 2 EFFECTIVE JUNE 1, 2016

8 ALBERTA HUMAN SERVICES DRUG BENEFIT SUPPLEMENT UPDATE CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS SOLIFENACIN SUCCINATE The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process. FIRST-LINE DRUG PRODUCT(S): OXYBUTYNIN "For patients who are intolerant to oxybutynin. Special authorization may be granted for 24 months." Note: If a claim for the Step therapy drug product is rejected, pharmacists can use their professional judgment to determine the appropriateness of using the intervention code(s) noted below to re-submit a claim. The pharmacist is responsible to document on the patient's record the rationale for using the second-line therapy drug. UP - First-line therapy ineffective UQ - First-line therapy not tolerated 5 MG ORAL TABLET ACT SOLIFENACIN JAMP-SOLIFENACIN MED-SOLIFENACIN PMS-SOLIFENACIN RAN-SOLIFENACIN SANDOZ SOLIFENACIN TEVA-SOLIFENACIN VESICARE 10 MG ORAL TABLET ACT SOLIFENACIN JAMP-SOLIFENACIN MED-SOLIFENACIN PMS-SOLIFENACIN RAN-SOLIFENACIN SANDOZ SOLIFENACIN TEVA-SOLIFENACIN VESICARE APH JPC GMP PMS RAN SDZ TEV ASP APH JPC GMP PMS RAN SDZ TEV ASP ZOLMITRIPTAN "For the treatment of acute migraine attacks in patients where other standard therapy has failed. Special authorization may be granted for 24 months." Information is required regarding previous medications utilized and the patient's response to therapy. The following product(s) are eligible for auto-renewal. 2.5 MG ORAL DISPERSIBLE TABLET SEPTA-ZOLMITRIPTAN-ODT AG-ZOLMITRIPTAN ODT JAMP-ZOLMITRIPTAN ODT MINT-ZOLMITRIPTAN ODT MYLAN-ZOLMITRIPTAN ODT PMS-ZOLMITRIPTAN ODT SANDOZ ZOLMITRIPTAN ODT TEVA-ZOLMITRIPTAN OD VAN-ZOLMITRIPTAN ODT ZOMIG RAPIMELT SEP AGP JPC MPI MYP PMS SDZ TEV VAN AZC The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. UNIT OF ISSUE - REFER TO PRICE POLICY 3. 3 EFFECTIVE JUNE 1, 2016