FLASH: August P&T Committee Meeting Updates

Neurology

 New Drug Reviews/Policies

• Zilbrysq (zilucoplan)— Treatment of generalized myasthenia gravis (gMG) in adults who are anti-acetylcholine receptor (AChR) antibody positive
  • Formulary placements
    • Commercial—Non-Preferred Specialty Pharmacy with PA and MDL per package size
    • Medicare—Non-Formulary
  • Kisunla (donanemab)—Treatment of Alzheimer disease; to be initiated in patients with mild cognitive impairment or mild dementia stage of disease
    • Formulary placements
      • Commercial—Non-Formulary
      • Medicare—Non-Formulary (Part D)
    • Agamree (vamorolone)— Treatment of Duchenne muscular dystrophy (DMD) in patients 2 years of age or older
      • Note: Agamree and Duvyzat are covered since they are FDA approved (not on accelerated basis) and coverage is required by the State of IL.
      • Formulary placements
        • Commercial—Non-Preferred Specialty Pharmacy with PA and MDL (#300mL/30 days)
        • Medicare—Non-Formulary
      • Duvyzat (givinostat)— Treatment of Duchenne muscular dystrophy (DMD) in patients 6 years of age or older
        • Formulary placements
          • Commercial—Non-Preferred Specialty Pharmacy with PA and MDL (#280mL/30 days)
          • Medicare—Non-Formulary

Behavioral Health

 New Drug Reviews/Policies

• Zurzuvae (zuranolone)—Treatment of postpartum depression in adults
  • Formulary placements
    • Commercial—Non-Preferred Specialty Pharmacy with PA and MDL (#28 or 14 per 365 days)
    • Medicare—Tier 5, Rx Specialty with PA and MDL (#28 or 14 per 14 days)

Miscellaneous

 New Drug Reviews/Policies

• Tavneos (avacopan)—Adjunctive treatment of severe active antineutrophil cytoplasmic autoantibody-associated vasculitis (granulomatosis with polyangiitis and microscopic polyangiitis) in combination with standard therapy, including glucocorticoids, in adults.
  • Formulary placements
    • Commercial—Non-Preferred Specialty Pharmacy with PA and MDL (#180 per 30 days)
    • Medicare—Tier 5, Rx Specialty with PA and MDL (#180 per 30 days)
  • Ryplazim (plasminogen, human)—Treatment of patients with plasminogen deficiency type 1 (hypoplasminogenemia).
    • Formulary placements
      • Commercial—Non-Preferred Specialty Medical with PA
      • Medicare—Non-Formulary (part D)

Commercial

Neurology

 Criteria Changes

• Ingrezza (valbenazine)
  • Added criteria for chorea in Huntington’s
• Vyvgart (efgartigimod alfa)
  • Added criteria for CIDP, added Vyvgart Hytrulo HCPCS code

Miscellaneous

 Criteria Changes

• Diabetes Drug Therapies
  • Added exception for SOIL weight loss members to bypass GLP-1 criteria
• Growth Hormone
  • Moved Norditropin to preferred product
  • Added double step to Sogroya
  • Added applicable product to each indication
• Ulcerative Colitis Immunomodulator Therapies
  • Added Skyrizi to policy
• Preventive Vaccine
  • Added Capvaxive
  • Added RSV vaccines

Formulary Changes—Commercial

Positive Changes (effective immediately)

• Norditropin (somatropin)—Move from Non-Preferred Specialty tier to Preferred Specialty tier
  • Increase in utilization over the past few months
  • Adds an additional preferred tier option for members

Negative Changes (effective 1/1/2025)

• Relyvrio (sodium phenylbutyrate/taurursodiol)—Remove from formulary
  • Product discontinued by manufacturer based on lack of efficacy data from extension phase 3 PHOENIX clinical trial
  • No member impact
  • Other covered therapies include Radicava (PA required), riluzole
• Victoza (liraglutide)—Move from Preferred Brand tier to Non-Preferred Brand tier
  • ~180 members currently on Victoza (membership fluctuates due to ongoing supply shortages)
  • Other therapies at Preferred Brand tier include Ozempic, Rybelsus, Trulicity, Bydureon, Byetta, Mounjaro

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. Upcoming negative formulary and criteria changes can be found online at the following website: HealthAlliance.org/Documents/960/2022. Drug coverage and policies in the following categories will be reviewed during the remainder of 2024 and changes may be made:

• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Updates to High Cost Medical Drugs List

See the table below for changes to the High Cost Medical Drugs List with effective dates.

Note: Medications removed from the High Cost Medical Drugs List may still require prior authorization.

Note: This article/table only applies to our Health Alliance^TM branded Commercial plans. It does not apply to Health Alliance Northwest^TM branded plans.

Note: This article/table does not apply to any of our Medicare plans (no matter what their brand/name).