FLASH: P & T Changes and HCMD List Changes for December

Pharmacy Updates

January 14, 2025

All Plans

New Drug Review

• Cobenfy (xanomeline/trospium— Treatment of schizophrenia in adults
  • Formulary placement recommendations
    • Commercial—Non-Preferred Brand with PA and QL (#60/30 days)
    • Medicare—Non-Formulary

Commercial

Criteria Changes

• Dupixent
  • Added coverage criteria for COPD indication
• Zoryve
  • Added coverage criteria for atopic dermatitis
• Diabetes Medications
  • Added step through preferred GLP-1s to Victoza
• Polyarticular Juvenile Idiopathic Arthritis Immunomodulator Therapies
  • Added Cimzia to policy
• Ankylosing Spondylitis Immunomodulator Therapies
  • Added Bimzelx to policy
• Non-Radiographic Axial Spondyloarthritis Immunomodulator Therapies
  • Added Bimzelx to policy
• Psoriatic Arthritis Immunomodulator Therapies
  • Added Bimzelx to policy removed DMARD step
• Plaque Psoriasis Immunomodulator Therapies
  • Removed body surface area (BSA) requirement and updated step criteria

Formulary Changes—Commercial

Positive Changes (effective 1/1/2025)

Estradiol 0.01% cream – Down tier to Preventive

• New legislation requiring a vaginal estradiol product be covered without cost-share

Negative Changes (effective 2/1/2025)

Compounding kits and Wound dressings – Remove from formulary

• No member utilization
• Most products have over the counter equivalents

 Negative Changes (effective 4/1/2025)

BRAND Sprycel – Remove from formulary

• Equivalent generic product now available

Diclofenac 25mg immediate release products – Remove from formulary

• Rarely prescribed as most prefer delayed release formulations

Stelara Brand Removal (effective 4/1/2025)

• Several biosimilars have been approved by the FDA in the past several months and will launch in early 2025
  • Expect 6-8 products to launch within the first 3 months of 2025
  • These biosimilars have no clinically meaningful differences and share the same indications as Stelara
  • Several products will have interchangeability designation
• Policies Affected
  • Crohn’s Disease Immunomodulator Policy
  • Plaque Psoriasis Immunomodulator Policy
  • Psoriatic Arthritis Immunomodulator Policy
  • Remicade and Infliximab Biosimilars Policy
  • Tysabri Policy
  • Ulcerative Colitis Immunomodulator Policy

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 2025 and changes may be made:

• February Meeting: Oncology, Hematology, Infectious Disease.
• April Meeting: Rheumatology, Gastroenterology, Dermatology.
• June Meeting: Cardiology, Endocrinology, Pulmonology.
• August Meeting: Neurology, Psychiatry, Pain.
• 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.

The full list is available here: High Cost Medical Drugs List.

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.

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