FLASH: Upcoming changes to Commercial Drug Coverage Criteria

The following changes to drug coverage have been made as a result of the April P&T meeting for new starts to therapy^*:

Polyarticular Juvenile Idiopathic Arthritis (PJIA)

• Enbrel and Kineret: Change from triple step therapy (member must first try Humira, Actemra, and Orencia) to quadruple step therapy (member must first try Humira, Actemra, Orencia, and Xeljanz)

Rheumatoid Arthritis

• Xeljanz and Rinvoq: Change from Preferred formulary status with no step therapy to Preferred formulary status with a single step through a TNF-inhibitor (member must first try Cimzia, Humira, OR Simponi)

Behavioral Health – Brand Name Atypical Antipsychotics

• Bipolar disorder criteria: Change from a single step through quetiapine to double step therapy (member must first try two of the following: quetiapine, olanzapine, ziprasidone)

*Current utilizing members of the above therapies will not experience a disruption.

The P&T committee meets bimonthly and formulary changes and criteria changes can occur during the meetings.  Negative formulary changes are made effective on 1/1 and 7/1, while positive formulary changes are effective immediately to better serve our members and providers.  Drug coverage and policies in the following categories will be reviewed during the remainder of 2022 and potential changes may be made:

• June meeting: Cardiology, Endocrinology, Pulmonology
• August meeting: Neurology, Psychiatry, Pain
• October: Ophthalmology, Specialty