FLASH: June P&T Committee Meeting Updates

Cardiology

New Drug Reviews/Policies

• Inpefa (sotagliflozin)—Risk reduction of cardiovascular mortality, hospitalization for heart failure, and urgent heart failure visits in adults with heart failure or type 2 diabetes and other cardiovascular risk factors
  • Formulary placements
    • Commercial—Non-Formulary
    • Medicare—Non-Formulary
  • Wegovy (semaglutide) ­­for the risk reduction of major adverse cardiovascular events (cardiovascular death, nonfatal MI, nonfatal stroke) in adults with established cardiovascular disease and either obesity or overweight
    • NOTE: Wegovy will NOT be covered for weight loss except for members of these plans (with PA): State of Illinois (effective 7/1/24), FEHB and FirstHealth
    • Formulary placements
      • Commercial—Non-Preferred Brand with PA
      • Medicare—Non-Formulary

Endocrinology

New Drug Reviews/Policies

• Brenzavvy (bexagliflozin)—As an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus
  • Formulary placements
    • Commercial—Non-Preferred Brand with PA and MDL (#30/30)
    • Medicare—Non-Formulary
  • Lantidra (donislecel)—Treatment of type 1 diabetes mellitus, in conjunction with concomitant immunosuppression, in adults who are unable to approach target HbA1c because of current repeated episodes of severe hypoglycemia
    • Formulary placements
      • Commercial—Non-Formulary
      • Medicare—Non-Formulary
    • Sohonos (palovarotene)—Reduction in the volume of new heterotopic ossification in adults and pediatric patients with FOP
      • Formulary placements
        • Commercial—Non-Preferred Specialty Pharmacy with PA
        • Medicare—Non-Formulary

Pulmonology

New Drug Reviews/Policies

• Winrevair (sotatercept)—Treatment of PAH, WHO Group 1 to increase exercise capacity, improve WHO functional class, and reduce the risk of clinical worsening events in adults
• • Winrevair has been added to the Pulmonary Arterial Hypertension Products policy
  • Formulary placements
    • Commercial—Non-Preferred Specialty Pharmacy with PA
    • Medicare—Non-Formulary

Commercial

Cardiology

Criteria Changes

• Nexletol (bempedoic acid) /Nexlizet (bempedoic acid-ezetimibe)
  • Updated diagnosis language to align with package insert

Endocrinology

Criteria Changes

• Kerendia (finerenone)
  • Added step through SGLT-2 inhibitor given KDIGO update
• Imcivree (setmelanotide)
  • Updated verbiage around covered indications to align with package insert
  • Updated exclusion criteria
• Korlym (mifepristone)
  • Added step through generic product

Pulmonology

Criteria Changes

• Xolair (omalizumab)
  • Added criteria for IgE-mediated food allergy
  • Updated step for nasal polyps
• Dupixent (dupilumab)
  • Updated step for nasal polyps
  • Updated age/weight criteria for EoE
• Fasenra (benralizumab)
  • Updated age criteria
• Nucala (mepolizumab)
  • Updated step for nasal polyps
• Esbriet (pirfenidone) and Ofev (nintedanib esylate)
  • Added statement that coverage of brand Esbriet requires allergic reaction to the generic
• Synagis (palivizumab)
  • Added exclusion related to Beyfortus

Miscellaneous Policies

New Policy

• State of Illinois – Weight Loss Medications
  • State of IL coverage begins 7/1
  • Members can get first fill without PA
  • We’re partnering with Virta Health as well as our own health coaching
    • Coverage is discontinued for members who do not enroll in Virta program

Criteria Changes

• Xiaflex (collagenase clostridium histolyticum)
  • Removed step through pentoxifylline
• Crohn’s Disease Immunomodulator Therapies
  • Added section Coverage Criteria of Non-Preferred Products with Double Step-Edit (Entyvio IV or Sub-Q)
  • Added Entyvio FDA approved Crohn’s disease dosages
• Polyarticular Juvenile Idiopathic Arthritis Immunomodulator Therapies
  • Added coverage for Rinvoq

Formulary Changes—Commercial

Positive Changes (effective immediately)

• Airsupra (albuterol/budesonide) – Added to formulary
  • Preferred brand tier with MDL of #3 inhalers/30 days (each inhaler is a 10 day-supply)
  • Combo albuterol/budesonide (SABA/ICS) inhaler approved January 2023
  • Indicated for as-needed treatment or prevention of bronchoconstriction and to reduce the risk of exacerbations in adults with asthma
  • Combination of 2 commercially available products initially excluded from coverage
  • Clinical data:
    • Airsupra 160/180 mcg reduced the risk of a severe exacerbation by 26%
    • 4-6% decrease in severe exacerbations
  • Both the Global Initiative for Asthma (GINA) asthma guidelines and the National Heart, Lung, and Blood Institute (NHLBI)/National Asthma Education and Prevention Program (NAEPP) asthma guidelines contain recommendations for the use of an as-needed ICS plus concomitant LABA or concomitant albuterol instead of albuterol-only

Negative Changes (effective 7/1/2024)

• Lonhala Magnair (glycopyrrolate) – Removed from formulary
  • Product discontinued by manufacturer due to low utilization
  • No member impact
  • Other covered LAMAs or LAMA combinations include: Spiriva Handihaler/Respimat, Incruse Ellipta, Breztri Aerosphere, Trelegy Ellipta, Yupelri (PA required)

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:

• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

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