FLASH: P&T Changes at April Meeting

Pharmacy Updates

April 15, 2025

All Plans

Dermatology

New Drug Reviews / Policies

• Ebglyss (lebrikizumab)—Treatment of moderate to severe atopic dermatitis in adults and pediatric patients ≥12 years of age weighing ≥40 kg whose disease is not adequately controlled with topical prescription therapies
  • Formulary placement recommendations
    • Commercial—Preferred Specialty Pharmacy with PA and MDL (4mL/28 days)
    • Medicare—Non-Formulary
  • Sofdra (sofpironium)—Treatment of primary axillary hyperhidrosis in adults and pediatric patients ≥9 years of age
    • Formulary placement recommendations
      • Commercial—Non-Preferred Brand with PA and MDL (4mL/28 days)
      • Medicare—Non-Formulary
    • Nemluvio (nemolizumab)—Treatment of moderate to severe atopic dermatitis in adults and pediatric patients ≥12 years of age AND Treatment of prurigo nodularis in adults
      • Formulary placement recommendations
        • Commercial—Non-Formulary
        • Medicare—Non-Formulary

Gastroenterology

New Drug Reviews / Policies

• Iqirvo (elafibranor)—Treatment of primary biliary cholangitis, in combination with ursodeoxycholic acid (UDCA), in adults who have had an inadequate response to UDCA
  • Formulary placement recommendations
    • Commercial—Non-Formulary
    • Medicare—Non-Formulary
  • Livdelzi (seladelpar)—Treatment of primary biliary cholangitis, in combination with ursodeoxycholic acid (UDCA), in adults who have had an inadequate response to UDCA
    • Formulary placement recommendations
      • Commercial—Non-Formulary
      • Medicare—Non-Formulary
    • Rezdiffra (resmetirom) policy
      • Remained Non-Formulary when presented at P&T last year
      • Now putting on formulary based on volume overturn rate and AASLD recommendations
      • Formulary placement recommendations
        • Commercial—Non-Preferred Specialty with PA and MDL of #30/30 days
        • Medicare—Non-Formulary (no change)

Commercial

Dermatology

Criteria Changes

• Spevigo
  • Added criteria for subQ formulation
• Livmarli
  • Updated age criteria based on FDA approval
• Vtama
  • Added criteria for atopic dermatitis

Gastroenterology

Criteria Changes

• Ocaliva
  • Added additional liver function criteria based on new boxed warning
• Tenapanor Products
  • Added trial with Velphoro

Brand Stelara Formulary Removal Update

Summary

• Covered biosimilars include: Wezlana (LW), Otulfi, Selarsdi, Yesintek, Steqeyma and Pyzchiva
• Cost difference (average)
  • Stelara: $25,912/script
  • Biosimilar: $5,274/script

Policies Affected (biosimilars replace mention of brand Stelara in criteria)

• Crohn’s Disease Immunomodulator Policy
  • Also added Omvoh and Tremfya since they are now FDA-approved for treatment of Crohn’s
• Plaque Psoriasis Immunomodulator Policy
• Psoriatic Arthritis Immunomodulator Policy
• Remicade and Infliximab Biosimilars Policy
• Tysabri Policy
• Ulcerative Colitis Immunomodulator Policy

Formulary Changes

• Positive Changes
  • Kesimpta and Vumerity
    • Downtier from Non-Preferred Specialty to Preferred Specialty
    • 31 members on Kesimpta
    • 17 members on Vumerity
  • Negative Changes
    • Altabax and Xepi topicals
      • Remove from formulary
      • No member utilization
      • Products have been discontinued

The P&T Committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes are generally 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:

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