STAT Bulletin. Drug Therapy Guideline Updates. May 11, 2012 Volume: 18 Issue: 12

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1 STAT Bulletin May 11, 2012 Volume: 18 Issue: 12 To: All primary care physicians and specialists Contracts Affected: All Lines of Business Drug Therapy Guideline Updates Why you re receiving this Stat What you need to know What you need to do The attached drug therapy guidelines updates are effective June 15, These updates are a result of the annual guideline review and new drug evaluations performed quarterly by our Pharmacy and Therapeutics Committee, or as a result of new medications entering the market. Updated Drug Therapy Guidelines will be available online as of May 15, 2012, at bcbswny.com. Select I m a Provider > Tools and Resources > Pharmacy Services. If you do not have access to the internet, paper copies are available upon request after May 15 by calling Provider Service at or

2 New Guidelines (please refer to individual guidelines for details) Abbreviated Criteria additions: o Dificid o Ferriprox o Xarelto o Korlym (preauthorization required) Prostaglandin Analogs o ZioptanTM and Travatan Z will require preauthorization starting June 15, o Implementation date has changed to June 15, 2012 (formerly slated for July 1, 2012). o Zioptan added to this policy based on recent FDA-approval. Zelboraf Xalkori Adcetris Jakafi Eylea Kalydeco Erivedge Inlyta Dermatologic Agents Smoking Cessation Linagliptin Step Therapy Drug Therapy Current Guidelines with Summary of Review Outcomes Abbreviated Criteria Afinitor Angiotensin Receptor Blockers (ARBs) Antifungal Agents Anti-Influenza Agents Appetite Suppressants and Weight Loss Agents Arcalyst Vimovo removed from policy; Dificid, Ferriprox, Xarelto, Korlym added; Cambia criteria altered; Krystexxa approval duration extended Addition of coverage criteria for pancreatic neuroendocrine tumors, breast cancer, lung cancer, and Waldenstrom s macroglobulinemia; warnings added Avapro, Avalide, Teveten 600mg removed from targeted therapies (generics available) Penlac removed from policy - prior authorization no longer required Dosing table updated; contraindications for Relenza added Age requirements added; Suprenza added to policy

3 Drug Therapy Avastin Benlysta Celebrex Egrifta Erbitux Fentanyl Gilenya Growth Stimulating Hormones Herceptin Hereditary Angioedema (HAE) Agents Immune Globulins Increlex Incretin Mimetics Intranasal Steroids Istodax Jevtana Kineret Kuvan Lucentis Macugen Metastatic breast cancer indication removed Requirement for therapy initiation by a rheumatologist added for coverage Duration of authorization expanded Lazanda, Subsys, Abstral added to policy; criteria altered to reflect FDA-approved indications (for the treatment of cancer-related pain only for patients who are new to therapy) Approval duration extended; AV block risk for ECG monitoring added Additional indications added to Omnitrope ; warnings added; required documentation outlined in criteria Warnings added; approval duration extended for adjuvant therapy Firazyr added to policy Criteria added for inability to mount an immune response; extended coverage duration Bydureon added to policy Qnasl and Zetonna added to policy Addition of criteria for peripheral T-cell lymphoma J code added Removed specific diagnostic criteria; extended authorization duration; added coverage criteria for branch retinal vein occlusion, central retinal vein occlusion Removed specific diagnostic criteria; extended authorization duration; added coverage criteria for branch retinal vein occlusion, central retinal vein occlusion

4 Drug Therapy Makena Multiple Sclerosis (MS) Self-Injectable Agents Myelodysplastic Syndrome (MDS) Therapy Neumega Nexavar Off-Label Drug Use Osteoporosis Agents Proton Pump Inhibitors (PPIs) Provenge Qutenza Remicade Renin Inhibitors Restasis Revlimid Rituxan Sedative Hypnotics Sensipar Simponi Soliris Updated FDA information added Betaseron became a targeted agent for new starts, Rebif moved to preferred agent status for new starts Coverage exclusion added for patients receiving myeloablative chemotherapy Clarification that provider must demonstrate why established alternatives cannot be used Coverage duration extended Generics no longer targeted; Nexium remains preferred agent along with generics Q code added; formatting change J code added Pediatric Crohn s criteria added; revision of Crohn s and Ulcerative Colitis criteria; black box warning added; revision of psoriasis criteria Defined chart documentation to be supplied; added renewal authorization criteria Dosage adjustment information added; baseline platelet and absolute neutrophil count values added to Non-Hodgkin s Lymphoma criteria for coverage Intermezzo added to policy Guideline removed - prior authorization no longer required Specialist criteria added; concurrent/past medication trials and other criteria outlined for each diagnosis Criteria for atypical hemolytic uremic syndrome (ahus) added

5 Drug Therapy Solodyn Somavert Stelara Symlin Synagis Triptans Tysabri Urinary Agents Votrient Xenazine Xolair Policy includes generic minocycline ER formulations; criteria for prior meds required altered; approval duration extended; language regarding automatic approvals removed Coverage duration extended Coverage renewal criteria altered Alsuma added to policy; coverage duration extended Anturol /Gelnique 3% added to policy Addition of coverage criteria for thyroid carcinoma

6 Medicaid / Family Health Plus Formulary Updates Travatan, Travatan-Z will be removed from the Medicaid/Family Health Plus Formulary effective June 15, Extavia will be removed from the Medicaid/Family Health Plus Formulary effective June 15, Auto-Pay ICD-9 Codes for Selected Medical Benefit Medications Some medical benefit medications will automatically pay when billed with the following diagnoses: Medication (J code) Auto-pay ICD-9 codes Arzerra (J9302) 204.1, , , Avastin (J9035, C9257) Rituxan (J9310) Lupron, Lupron Depot, Eligard (J1950, J9217, J9218) 185 IVIg (J1459, J1557, J1561, J1566, J1568, J1569, J1572, J1599) 446.1, , , , , , , , ( ), ( ), ( ), ( ), ( ), ( ), ( ), ( ), ( ), ( ), ( ), ( ), Dacogen, Vidaza (J0894, J9025) ( ), , , Botox, Myobloc, Dysport, Xeomin (J0585, J0586, J0587, J0588) 333.6, 333.7, , , , , , , 334.1, 340, 341, 341.0, 341.1, ( ), 341.8, 341.9, ( ), 343 ( ), ( ), 344.1, 344.2, ( ), 351.8, 378, ( ) and ( ), , 530.0, 564.6, 565.0, 723.5, 854, ( ), ( ), 952 ( )and ( )

7 Medical Benefit Reference Guide As a reference guide, the following list of medications require preauthorization when administered by a health care professional. Drug Code Drug Code Drug Code Actemra J3262 Gamunex J1561 Prolia J0897 Actimmune J9216 Gamunex-C J1561 Provenge Q2043 Adcetris J9999 H.P. Acthar Gel J0800 Qutenza J7335 Adcetris C9287 Halaven J9179 Reclast J3488 Amevive J0215 Herceptin J9355 Remicade J1745 Arzerra J9302 Hizentra J1559 Remodulin J3285 Avastin C9257 Istodax J9315 Rituxan J9310 Avastin J9035 IVIg NOS J1599 Simponi J3590 Benlysta J0490 IVIg Powder J1566 Soliris J1300 Berinert J0597 Jevtana J9043 Stelara J3357 Boniva J1740 Kalbitor J1290 Synagis Botox J0585 Krystexxa J2507 Torisel J9330 Cimzia J0718 Lucentis J2778 Tysabri J2323 Cinryze J0598 Lupron Depot J1950 Vectibix J9303 Dacogen J0894 Lupron J9218 Veletri J1325 Dysport J0586 Macugen J2503 Ventavis Q4074 Eligard J9217 Makena J1725 Vidaza J9025 Erbitux J9055 Mozobil J2562 Vivaglobin J1562 *Eylea Q2046 Myobloc J0587 Xeomin J0588 Flebogamma J1572 Nplate J2796 Xgeva J0897 Flolan J1325 Octagam J1568 Xolair J2357 Gammagard J1569 Orencia J0129 Yervoy J9228 Gammaplex J1557 Privigen J1459 *New as of June 15, 2012