Microsoft word - bcnepa_formulary_update_4q.doc

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4th Quarter Update:
Highmark Medicare-Approved Formulary*

Enclosed is the 4th Quarter 2009 update to Highmark’s Medicare-Approved Select/Choice Formulary and
related pharmaceutical management procedures.
Highmark’s Medicare-Approved Select/Choice Formulary applies to all members enrolled in Highmark’s
Medicare Advantage FreedomBlueSM PPO product offered in partnership with Blue Cross of Northeastern
Pennsylvania® (BCNEPA) in the BCNEPA service area. The formulary also applies to all members
enrolled in Highmark’s Medicare Prescription Drug plan, BlueRxSM.
Highmark’s Medicare-Approved Select/Choice Formulary and related pharmaceutical management
procedures are updated on a quarterly basis, based on recommendations made by Highmark’s Pharmacy
and Therapeutics Committee and within the guidelines established by the Centers for Medicare and
Medicaid Services (CMS). On an ongoing basis, Highmark, in partnership with BCNEPA, will provide you
with quarterly updates regarding formulary changes. Please watch your mail for these important quarterly
updates.
The enclosed changes reflect the decisions made in September 2009 by Highmark’s Pharmacy and
Therapeutics Committee. These updates are effective on the dates noted throughout this document. As an
added convenience, you can search the Highmark Medicare-Approved Select/Choice Formulary online at
http://highmark.medicare-approvedformularies.com. This function allows you to search by the drug
name or therapeutic class. You can also find other helpful information regarding the prescription drug
program on Highmark’s online Provider Resource Center. Simply visit www.highmarkblueshield.com,
click on the Providers tab at right near the top of the page and then look under the Pharmacy/Formulary
Information link. (If you have access to Highmark’s NaviNet® system, simply click Resource Center at
left on the Plan Central welcome page to access the Pharmacy/Formulary Information link.) Additionally,
an electronic copy of the formulary for use with a portable handheld device can be downloaded free by visiting
www.epocrates.com.
If you have any questions regarding this Special Bulletin or Highmark’s Medicare-Approved
Select/Choice Formulary, please contact your Provider Relations representative.
*PLEASE NOTE: This formulary doesn’t apply to members enrolled in BCNEPA’s traditional Medicare products.
Highmark is a registered mark of Highmark Inc. Blue Shield and the Shield symbol are registered service marks of the Blue Cross and Blue Shield Association, an
association of independent Blue Cross and Blue Shield Plans. BlueRx and FreedomBlue are service marks of the Blue Cross and Blue Shield Association. Highmark
Senior Resources Inc., a subsidiary of Highmark Inc., has a contract with the Federal government to administer Medicare Prescription Drug Coverage in the states of
Pennsylvania and West Virginia. NaviNet is a registered trademark of NaviNet, Inc. NaviNet, Inc. is an independent company that provides a secure, Web-based
portal between providers and health care insurance plans.
(over, please)
Highmark Medicare-Approved Formulary Update
November 2009

Highmark Medicare-Approved Select/Choice Formulary
A.
Changes to the Highmark Medicare-Approved Select/Choice Formulary
The Highmark Pharmacy and Therapeutics Committee has reviewed the medications listed in the following
tables. As a reminder, the Highmark Medicare-Approved Select/Choice Formulary applies only to Highmark
BlueRxSM members and to members of Highmark’s Medicare Advantage FreedomBlueSM PPO product. For your
convenience, you can search the Highmark Medicare-Approved Select/Choice Formulary online at
http://highmark.medicare-approvedformularies.com.
Table 1: Products Added (All products added to the formulary effective immediately unless otherwise
noted)
Brand Name
Generic Name
Comments
A once-daily phosphodiesterase-5 (PDE-5) inhibitor for Pulmonary Arterial Hypertension (PAH). Colchicine is for the treatment of acute gout angiotensin receptor blocker-thiazide diuretic for the treatment of hypertension. A fully human monoclonal antibody that selectively blocks IL-1ß for the treatment of children and adults with cryopyrin-associated periodic syndrome (CAPS). A selective vasopressin V2-receptor antagonist indicated for the treatment of clinically significant hypervolemic and euvolemic hyponatremia. A prostacyclin analogue indicated to increase walk distance in patients with WHO Group I pulmonary arterial hypertension and NYHA Class III symptoms. A non-neurotoxic prescription product for treating head lice.
Table 2: Products Not Added*
Brand Name
Generic Name
Comments
Clindamycin and benzoyl peroxide topical preparations are on the formulary. Ciprofloxacin and ofloxacin ophthalmic solutions are on the formulary. Ketorolac injection is on the formulary. Ofloxacin otic solution is on the formulary. *Physicians may request coverage of these products using the Prescription Drug Medication Request Form, which can be found on Page 8 of the 2009 Highmark Drug Formulary book. You may also access the form online in Highmark’s Provider Resource Center; under Provider Forms, select Miscellaneous Forms, and select the link titled Request for Drug Coverage from Pharmaceutical Management Program. Changes to the Highmark Medicare-Approved Select/Choice Formulary (continued)
Table 2: Products Not Added* (continued)
Brand Name
Generic Name
Comments
An intravenous (IV) dihydropyridine calcium Multiple short-acting narcotic agonists are on the formulary. Maxalt ® and sumatriptan are on the formulary. Fibrinogen Concentrate indicated for the treatment of acute bleeding episodes in patients with congenital fibrinogen deficiency. An injectable agent for the treatment of adults with cervical dystonia to reduce the severity of abnormal head position and neck pain. An injectable agent indicated for the treatment of patients with persistent or recurrent cutaneous T-cell lymphoma (CTCL) whose malignant cells express the CD25 component of the IL-2 receptor. An injectable iron replacement product indicated for the treatment of iron deficiency anemia in adult patients with chronic kidney disease (CKD). Actos® and metformin are on the formulary. *Physicians may request coverage of these products using the Prescription Drug Medication Request Form, which can be found on Page 8 of the
2009 Highmark Drug Formulary book. You may also access the form online in Highmark’s Provider Resource Center; under Provider Forms,
select Miscellaneous Forms, and select the link titled Request for Drug Coverage from Pharmaceutical Management Program.

Table 3: Products to be Removed* From the Formulary (effective January 1, 2010)
Brand Name
Generic Name
Comments
Changes to the Highmark Medicare-Approved Select/Choice Formulary (continued)
Table 3: Products to be Removed* From the Formulary (effective January 1, 2010) (continued)
Fludara®
calcitonin (salmon) nasal spray Generic is on the formulary. *Physicians may request coverage of these products using the Prescription Drug Medication Request Form, which can be found on Page 8 of the
2009 Highmark Drug Formulary book. You may also access the form online in Highmark’s Provider Resource Center; under Provider Forms,
select Miscellaneous Forms, and select the link titled Request for Drug Coverage from Pharmaceutical Management Program.
B.
Updates to the Prior Authorization Program
Effective November 1, 2009, Adcirca™ (tadalafil) was added to Highmark’s Pulmonary Arterial Hypertension policy for Medicare Advantage and BlueRxSM members. When a benefit, tadalafil may be approved when all of the following criteria are met: 1. A diagnosis of pulmonary hypertension is substantiated by results from Doppler
echocardiography and/or direct measurement of pulmonary arterial pressure. Pulmonary arterial
hypertension is defined as a mean pulmonary arterial pressure of > or = 25 mmHg, with a pulmonary
capillary wedge pressure of < 15 mmHg AND
2. Tadalafil is to be prescribed under the supervision of a cardiologist or pulmonologist AND
3. Tadalafil is to be used for the treatment of pulmonary arterial hypertension (WHO Group I) to
increase exercise ability AND
4. Tadalafil may be used alone or in combination with calcium channel blockers, angiotensin
converting enzyme (ACE) inhibitors, diuretics, digoxin, and anticoagulants, but will not be covered
when used concomitantly with bosentan (Tracleer™), ambrisentan (Letairis™), sildenafil (Revatio™),
epoprostenol sodium (Flolan®), treprostinil sodium (Remodulin™, Tyvaso™), or iloprost (Ventavis®),
due to the lack of clinical data to support combination therapy with these agents.
Adcirca™ (tadalafil) (continued) As there is no established criterion or algorithm for the transitioning of patients from one PAH drug
product to another (e.g., sildenafil to bosentan), the use of two agents concomitantly may be authorized
for a period of up to one month to accommodate potential overlapping titration schedules when changing
therapy from one drug product to another. As stated in #4 above, coverage will not be provided for the
use of two agents (bosentan, ambrisentan, sildenafil, epoprostenol, iloprost, treprostinil) as maintenance
combination therapy for PAH.
Use of tadalafil for disease states outside of its FDA-approved indications will be denied based on the
lack of clinical data to support its effectiveness and safety in other conditions.

Duration of authorization: If approved, authorization may be granted for a period of up to one year.
2.
Onsolis™ (fentanyl buccal soluble film) Effective November 1, 2009, Onsolis™ (fentanyl buccal soluble film) was added to Highmark’s Oral Transmucosal Fentanyl Citrate Policy for Medicare Advantage and BlueRxSM members. When a benefit, oral transmucosal fentanyl citrate may be approved when the following criteria are met: For the management of breakthrough cancer pain in patients who are currently receiving and are tolerant to long-acting opioid therapy. Upon approval, coverage will be limited to 120 units total (Fentora or Actiq or Onsolis) per 25 days. If more units are required on a daily basis for the management of breakthrough cancer pain, an increase in the around-the-clock opioid dose for persistent pain should be considered.
Oral transmucosal fentanyl citrate should not be used for acute pain conditions, chronic pain conditions
which are not related to cancer, or in situations involving chronic pain in which the patient is not
receiving maintenance doses of long-acting opioid analgesics.
Duration of Authorization: If approved, authorization may be granted for a period of up to one year.

C.
Additions to Highmark’s Pharmaceutical Management Procedures
Additions to the Specialty Tier Copay Option Effective November 1, 2009, Firmagon® (degarelix) was added to the specialty tier copay program for
Medicare Advantage and BlueRxSM members.
Effective November 1, 2009, Adcirca™ (tadalafil) and Onsolis™ (fentanyl buccal soluble film) were added to
the specialty tier copay program with prior authorization criteria for Medicare Advantage and BlueRxSM
members.

D.
Specialty Drug Tier Program
Specialty drugs are very high-cost and unique drugs as defined by the Centers for Medicare & Medicaid Services. These drugs may incur a coinsurance based on their negotiated price. Because of this, the cost may vary slightly due to pricing changes in the drug. Drugs in the specialty tier apply to Highmark Medicare Advantage and BlueRx members. Please refer to the following list for products included in the Specialty Drug Tier program. Specialty Drug Tier Program (continued)
Table 4: Products Included in the Specialty Drug Tier Program
Specialty Drug Tier Program (continued)
Table 4: Products Included in the Specialty Drug Tier Program (continued)
ELAPRASE

Source: https://www.bcnepa.com/providers/freedomblue/BCNEPA_Formulary_Update_4Q.pdf