pdl drug class review announcement january 07, 2020 ... · 7/20/2001 · dossiers and supplemental...

PDL Drug Class Review Announcement

January 07, 2020

Drug Classes to be reviewed:

Anti-Parkinson’s Agents; Antimigraine Agents - CGRP Inhibitors; Atypical Antipsychotics – Oral; Bile salts; Diabetes Management – Insulins; Glucagon, Self-Administered; Growth Hormones; Hemorrhoidal and Related Anorectal Agents; Immune Globulins; Intranasal Rhinitis Agents; Leukotriene Modifiers; Lipotropics – Statins, Statin Combinations, Other; Lithium Agents; Multiple Sclerosis Agents; Neurocognitive Disorder Agents; Ophthalmic Allergy Agents; Ophthalmic Anti-Inflammatory Agents; Ophthalmic Glaucoma Agents; Sedative/Hypnotics - Non-Benzodiazepine, Benzodiazepine; and Topical Steroids – Low, Medium, High, Very High Potency. These drug classes will be reviewed at the January 07, 2020 P&T Committee meeting from 1‐5pm. The location is 303 East 17th Avenue, Denver, CO 80203 11th Floor Conference Rooms. Dossiers and Supplemental Rebate offers are due to Magellan by December 20, 2019. Please provide your public comments to Jessica Czechowski, Clinical Account Manager ([email protected]) no later than January 3, 2020 to ensure they are included in the information supplied to the P&T Committee members. Please carbon copy Brittany Schock, PDL Pharmacist ([email protected]) on all clinical information and public comment submissions.

Anti-Parkinson’s Agents

Brand Name Generic Name

Dopa Decarboxylase Inhibitors

Duopa Carbidopa/Levodopa enteral suspension

Inbrija Levodopa capsule

Lodosyn Carbidopa tablet

Carbidopa tablet

Rytary ER Carbidopa/Levodopa capsule

Sinemet/Sinemet CR Carbidopa/Levodopa tablet

Carbidopa/Levodopa tablet, ER tablet, ODT

Stalevo Carbidopa/Levodopa/Entacapone tablet

Carbidopa/Levodopa/Entacapone tablet

Dopamine Agonists

Mirapex/Mirapex ER Pramipexole tablet, ER tablet

Pramipexole tablet, ER tablet

Neupro Rotigotine patch

Parlodel Bromocriptine capsule, tablet

Bromocriptine capsule, tablet

Requip/Requip XL Ropinirole tablet, ER tablet

Ropinirole tablet, ER tablet

MAO-B Inhibitors

Selegiline capsule, tablet

Azilect Rasagiline tablet

Rasagiline tablet

Zelpar Selegiline tablet

Xadago Safinamide tablet

Other Agents

Amantadine capsule, solution, tablet

Benztropine Mesylate tablet

Trihexyphenidyl elixir, tablet

Comtan Entacapone tablet

Entacapone tablet

Gocovri ER Amantadine capsule

Nourianz Istradefylline tablet

Osmolex ER Amantadine tablet

Tasmar Tolcapone tablet

Tolcapone tablet

Antimigraine Agents – CGRP Inhibitors


Aimovig Erenumab-aooe auto-injector, syringe

Ajovy Fremanezumab-vfrm syringe

Emgality Galcanezumab-gnlm syringe

Atypical Antipsychotics, Oral


Abilify/Abilify Mycite Aripiprizole tablet, Mycite Kit

Aripiprizole tablet, ODT, oral solution

Clozaril Clozapine tabs, ODT

Clozapine tabs, ODT

Fanapt Iloperidone tablet, pack

Fazaclo Clozapine ODT

Geodon Ziprasidone capsule

Ziprasidone capsule

Invega ER Paliperidone ER tablet

Paliperidone ER tablet

Latuda Lurasidone tablet

Nuplazid Pimavanserin capsule, tablet

Rexulti Brexpiprazole tablet

Risperdal Risperidone tablet, oral solution

Risperidone tablet, ODT, oral solution

Saphris Asenapine SL tablet

Seroquel/Seroquel XR Quetiapine tablet, ER tablet

Quetiapine tablet, ER tablet

Symbyax Olanzapine/fluoxetine capsule

Olanzapine/fluoxetine capsule

Versacloz Clozapine oral suspension

Vraylar Cariprazine capsule

Zyprexa/Zyprexa Zydis Olanzapine ODT, tablet

Olanzapine ODT, tablet

Bile Salts


Actigall Ursodiol capsule

Ursodiol capsule

Chenodal Chenodiol tablet

Cholbam Cholic acid capsule

Ocaliva Obeticholic Acid tablet

Urso/Urso Forte Ursodiol tablet

Ursodiol tablet

Diabetes Management - Insulins


Rapid-acting

Admelog Insulin lispro Solostar, vial

Afrezza Insulin regular cartridge, unit

Apidra Insulin glulisine Solostar, vial

Fiasp Insulin aspart FlexTouch, penfill, vial

Humalog/Humalog Jr. Insulin lispro cartridge, Kwikpen, vial

Insulin lispro pen

Novolog Insulin aspart cartridge, Flexpen, vial

Short-acting

Humulin R Regular insulin Kwikpen, vial

Novolin R Regular insulin Kwikpen, vial

Intermediate-acting

Humulin N Insulin NPH Kiwkpen, vial

Novolin N Insulin NPH vial

Long-acting

Basaglar Insulin glargine Kwikpen

Lantus Insulin glargine Solostar, vial

Levemir Insulin detemir Flextouch, vial

Toujeo/Toujeo Max Insulin glargine Solostar

Tresiba Insulin degludec Flextouch, vial

Insulin Mixtures

Humalog Mix 50/50 50% insulin lispro protamine/50% insulin lispro

Kwikpen, vial

Humalog Mix 75/25 75% insulin lispro protamine/25% insulin lispro

Kwikpen, vial

Humulin 70/30 70% insulin NPH/30% insulin regular Kwikpen, vial

Novolin 70/30 70% insulin NPH/30% insulin regular Flexpen, vial

Novolog Mix 70/30 70% insulin aspart protamine/30% insulin aspart

Flexpen, vial

Glucagon, Self-Administered


Baqsimi Glucagon spray

Glucagen Hypokit Glucagon kit

Glucagon Emergency Kit Glucagon kit

Gvoke Glucagon Hypopen, syringe

Growth Hormones


Genotropin Somatropin cartridge, Miniquick pen

Humatrope Somatropin cartridge, vial

Norditropin Somatropin Flexpro pen

Nutropin AQ Somatropin Nuspin injector

Omnitrope Somatropin cartridge, vial

Saizen Somatropin cartridge, vial

Serostim Somatropin vial

Zomacton Somatropin vial

Zorbtive Somatropin vial

Hemorrhoidal and Related Anorectal Agents


Lidocaine-Hydrocortisone 3%-0.5% cream/cream kit, 3%-1% cream/cream kit, 3%-2.5% gel/gel kit, 2%-2% cream kit

Analpram HC Hydrocortisone-Pramoxine 1%-1% cream, 2.5%-1% cream

Anucort-HC/Anusol-HC Hydrocortisone acetate 25 mg suppository

Hydrocortisone acetate 25 mg suppository

Anusol-HC Proctosol-HC Proctozone-HC Procto-Med HC

Hydrocortisone 2.5% cream

Colocort Cortenema

Hydrocortisone 100 mg/60 mL enema

Hydrocortisone 100 mg/60 mL enema

Cortifoam Hydrocortisone acetate 10% aerosol

Procort Hydrocortisone-Pramoxine 1.85%-1.15% cream

Proctocort Hydrocortisone acetate cream, 30 mg suppository

Hydrocortisone acetate cream, 30 mg suppository

Proctofoam-HC Hydrocortisone-Pramoxine 1%-1% foam

Procto-Pak Hydrocortisone 1% cream

Hydrocortisone 1% cream

Rectiv Nitroglycerin 0.4% ointment

Immune Globulins


Bivigam Immune Globulin IV solution

Carimune NF Immune Globulin IV powder vial

Cutaquig Immune Globulin-hipp SQ solution

Cuvitru Immune Globulin SQ solution

Flebogamma Dif Immune Globulin IV solution

Gammagard Immune Globulin SQ solution

Gammagard S/D Immune Globulin IV powder vial

Gammaked Immune Globulin IV/SQ solution

Gammaplex Immune Globulin IV solution

Gamunex-C Immune Globulin injection solution

Hizentra Immune Globulin SQ solution

Hyqvia Immune Globulin; Hyaluronidase SQ vial

Octagam Immune Globulin IV solution

Panzyga Immune Globulin-ifas IV solution

Privigen Immune Globulin IV solution

Xembify Immune Globulin-klhw SQ solution

Intranasal Rhinitis Agents Brand Name Generic Name

Budesonide (generic Rhinocort Aqua) spray OTC

Flunisolide (generic Nasarel) spray

Ipratropium (generic Atrovent) spray

Triamcinolone (generic Nasacort AQ) spray OTC

Astepro Azelastine 0.15% spray

Azelastine 0.1% (137 mcg), 0.15% spray

Beconase AQ Beclomethasone spray

Dymista Azelastine/Fluticasone spray

Flonase/Flonase Sensimist Fluticasone spray OTC

Fluticasone spray RX/OTC

Kenalog Triamcinolone

Nasonex Mometasone spray

Mometasone spray

Omnaris Ciclesonide spray

Patanase Olopatadine spray

Olopatadine spray

Qnasl/Qnasl Children’s Beclomethasone spray

Xhance Fluticasone spray

Zetonna Ciclesonide spray

Leukotriene Modifiers


Accolate Zafirlukast tablet

Zafirlukast tablet

Singulair Montelukast tablet, chewable tablet, granules

Montelukast tablet, chewable tablet, granules

Zyflo Zileuton ER tablet

Zileuton ER tablet

Lipotropics


Statins

Fluvastatin capsule

Lovastatin tablet

Altoprev Lovastatin ER tablet

Crestor Rosuvastatin tablet

Rosuvastatin tablet

Ezallor Rosuvasatin sprinkle capsules

Lescol XL Fluvastatin ER tablet

Fluvastatin ER tablet

Lipitor Atorvastatin tablet

Atorvastatin tablet

Livalo Pitavastatin tablet

Pravachol Pravastatin tablet

Pravastatin tablet

Zocor Simvastatin tablet

Simvastatin tablet

Zypitamag Pitavastatin tablet

Statin Combinations

Caduet Amlodipine/Atorvastatin tablet

Amlodipine/Atorvastatin tablet

Vytorin Ezetimibe/Simvastatin tablet

Ezetimibe/Simvastatin tablet

Other

Fenofibrate capsule, tablet

Antara Fenofibrate capsule

Colestid Colestipol granules, tablet

Colestipol granules, tablet

Fenoglide Fenofibrate tablet

Fenofibrate tablet

Fibricor Fenofibric Acid tablet

Fenofibric Acid tablet

Lipofen Fenofibrate capsule

Fenofibrate capsule

Lopid Gemfibrozil tablet

Gemfibrozil tablet

Lovaza Omega-3 Ethyl Esters

Omega-3 Ethyl Esters

Niaspan ER Niacin ER tablet

Niacin ER tablet

Prevalite Cholestyramine-Aspartame powder

Questran / Questran Light Cholestyramine-Sugar/Cholestyramine-Aspartame

powder

Cholestyramine-Sugar/Cholestyramine-Aspartame

(powder)

Tricor Fenofibrate tablet

Fenofibrate tablet

Triglide Fenofibrate tablet

Fenofibrate tablet

Trilipix Fenofibric Acid DR capsule

Fenofibric Acid DR capsule

Vascepa Icosapent ethyl capsule

Welchol Colesevelam packet, tablet

Colesevelam packet, tablet

Zetia Ezetemibe tablet

Ezetemibe tablet

Lithium Agents


Lithium carbonate capsule

Lithium citrate solution

Lithobid ER Lithium carbonate ER tablet

Lithium carbonate ER tablet

Multiple Sclerosis Agents


Ampyra Dalfampridine tablet

Dalfampridine tablet

Aubagio Teriflunomide tablet

Avonex Interferon Beta 1a PFS, kit

Betaseron Interferon Beta 1b vial, kit

Copaxone Glatiramer acetate syringe

Glatiramer acetate syringe

Extavia Interferon Beta 1b vial, kit

Gilenya Fingolimod capsule

Glatopa Glatiramer acetate syringe

Mavenclad Cladribine tablet

Mayzent Siponimod tablet

Plegridy Peginterferon Beta 1a syringe, pen

Rebif/Rebif Rebidose Interferon Beta 1a syringe

Tecfidera Dimethyl Fumarate capsule

Vumerity Diroximel DR capsule

Neurocognitive Disorder Agents


Rivastigmine capsule, oral solution

Aricept Donepezil tablet, ODT

Donepezil tablet, ODT

Exelon Rivastigmine patch

Rivastigmine patch

Namenda/Namenda XR Memantine IR tablet, ER capsule

Memantine tablet, oral solution, ER capsule

Namzaric Memantine/Donepezil ER capsule

Razadyne /Razadyne ER Galantamine IR tabs, ER caps

Galantamine IR tabs, oral solution, ER caps

Ophthalmic Allergy Agents


Azelastine (generic Optivar)

Cromolyn (generic Crolom, Opticrom)

Epinastine (generic Elestat)

Alaway (OTC) Ketotifen furmarate (OTC)

Ketotifen furmarate (OTC)

Alocril Nedocromil sodium

Alomide Lodoxamide tromethamine

Alrex Loteprednol

Bepreve Bepotastine besilate

Lastacaft Alcaftadine

Pataday (Rx) Olopatadine 0.2% (Rx)

Olopatadine 0.2% (Rx)

Patanol Olopatadine 0.1%

Olopatadine 0.1%

Pazeo Olopatadine 0.7%

Zaditor (OTC) Ketotifen fumarate (OTC)

Ketotifen fumarate (OTC)

Ophthalmic Anti-Inflammatory Agents


Bromfenac 0.09% drops

Dexamethasone drops

Diclofenac drops

Flurbiprofen drops

Acular/Acular LS Ketorolac drops

Ketorolac drops

Acuvail Ketorolac/PF drops

Bromsite Bromfenac 0.075% drops

Durezol Difluprednate drops

Flarex Fluorometholone Acetate drops

FML Forte/Liquifilm/S.O.P. Fluorometholone drops, ointment

Fluorometholone drops

Ilevro Nepafenac drops

Inveltys Loteprednol

Lotemax/Lotemax SM Loteprednol drops, gel, ointment

Loteprednol drops

Maxidex Dexamethasone drops

Nevanac Nepafenac droptainer

Omnipred Prednisolone Acetate drops

Pred Forte Prednisolone Acetate drops

Prednisolone Acetate drops

Pred Mild Prednisolone Acetate drops

Prolensa Bromfenac 0.07% drops

Ophthalmic Glaucoma Agents


Betaxolol 0.5%

Bimatoprost 0.03%

Brimonidine 0.2% (Generic Alphagan)

Carteolol 1%

Levobunolol 0.5%

Alphagan P Brimonidine 0.1%, 0.15%

Brimonidine 0.15%

Azopt Brinzolamide 1%

Betoptic S Betaxolol 0.25%

Combigan Brimonidine/Timolol 0.2%/0.5%

Cosopt/Cosopt PF Dorzolamide-Timolol 2%-0.5%/PF

Dorzolamide-Timolol 2%-0.5%/PF

Iopidine Apraclonidine 0.5%, 1%

Apraclonidine 0.5%

Isopto Carpine Pilocarpine 1%, 2%, 4%

Pilocarpine 1%, 2%, 4%

Istalol Timolol 0.5%

Timolol 0.5%

Lumigan Bimatoprost 0.1%

Phospholine Iodide Echothiophate 0.125%

Rhopressa Netarsudil 0.02%

Rocklatan Netarsudil 0.02%/Latanoprost 0.005%

Simbrinza Brinzolamide/Brimonidine 1%/0.2%

Timoptic Timolol 0.25%, 0.5%

Timolol 0.25%, 0.5%

Timoptic Ocudose Timolol PF 0.25%, 0.5%

Timoptic-XE Timolol GFS 0.25%, 0.5%

Timolol GFS 0.25%, 0.5%

Travatan Z Travoprost 0.004%

Trusopt Dorzolamide 2%

Dorzolamide 2%

Vyzulta Latanoprostene Bunod 0.024%

Xalatan Latanoprost 0.005%

Latanoprost 0.005%

Xelpros Latanoprost 0.005%

Zioptan Tafluprost 0.0015% PF

Sedative Hypnotics


Non-Benzodiazepine

Zaleplon capsule

Ambien/Ambien CR Zolpidem IR tablet, ER tablet

Zolpidem IR tablet, ER tablet

Belsomra Suvorexant tablet

Edluar Zolpidem SL tablet

Intermezzo Zolpidem SL tablet

Zolpidem SL tablet

Lunesta Eszopiclone tablet

Eszopiclone tablet

Rozerem Ramelteon tablet

Ramelteon tablet

Zolpimist Zolpidem oral solution/spray

Benzodiazepine

Estazolam tablet

Flurazepam capsule

Halcion Triazolam tablet

Triazolam tablet

Restoril Temazepam capsule

Temazepam capsule

Topical Steroids


Low Potency

Alclometasone 0.05% cream, 0.05% ointment)

Desonide 0.05% lotion, 0.05% ointment

Fluocinolone 0.01% cream

Hydrocortisone 2.5% cream 2.5% lotion, 1%, 2.5% ointment

Ala-Cort/Ala-Scalp Hydrocortisone 1% cream, 2% lotion

Hydrocortisone 1% cream, 2% lotion

Capex Fluocinolone (shampoo)

Derma-Smoothe-FS/ Scalp Fluocinolone 0.01% oil/ 0.01% scalp oil

Fluocinolone 0.01% oil/ 0.01% scalp oil

Desonate Desonide gel

Desowen Desonide 0.05% cream

Desonide 0.05% cream

Micort-HC Hydrocortisone 2.5% cream

Synalar Fluocinolone solution

Fluocinolone solution

Texacort Hydrocortisone 2.5% solution

Medium Potency

Betamethasone Dipropionate 0.05% cream, 0.05%

lotion

Betamethasone Valerate 0.1% cream, 0.1% lotion,

0.1% ointment

Fluocinonide-E 0.05% cream

Flurandrenolide 0.05% cream, 0.05% lotion, 0.05%

ointment

Hydrocortisone valerate 0.2% cream, 0.2% ointment

Triamcinolone 0.025%, 0.1% cream; 0.025%, 0.1%

lotion; 0.025%, 0.1% ointment

Beser Fluticasone 0.05% lotion

Fluticasone 0.05% lotion

Cloderm Clocortolone 0.1% cream, 0.1% cream pump

Clocortolone 0.1% cream, 0.1% cream pump

Cordran Flurandrenolide tape

Cutivate Fluticasone 0.05% cream, 0.05% lotion

Fluticasone 0.05% cream, 0.05%, lotion, 0.005%

ointment

Dermatop/Dermatop Emollient Prednicarbate 0.1% ointment, 0.1% emollient cream

Prednicarbate 0.1% ointment, 0.1% emollient cream

Elocon Mometasone 0.1% cream

Mometasone 0.1% cream, 0.1% ointment, 0.1%

solution)

Kenalog Triamcinolone 0.147 mg/g spray

Triamcinolone 0.147 mg/g spray

Locoid/Locoid Lipocream Hydrocortisone butyrate 0.1% cream, 0.1%

ointment, 0.1% lotion, 0.1% solution,

hydrocortisone-emollient 0.1% cream

Hydrocortisone butyrate 0.1% cream, 0.1%

ointment, 0.1% lotion, 0.1% solution,

hydrocortisone-emollient 0.1% cream

Luxiq Betamethasone 0.12% foam

Betamethasone 0.12% foam

Pandel Hydrocortisone probutate 0.1% cream

Psorcon Diflorasone 0.05% cream

Diflorasone 0.05% cream

Sernivo Betamethasone Dipropionate 0.05% spray

Synalar Fluocinolone 0.025% cream, 0.025% ointment

Fluocinolone 0.025% cream, 0.025% ointment

Synalar Kit Fluocinolone/emollient 0.025% cream, 0.025%

ointment

Synalar TS Kit Fluocinolone 0.01%/Skin Cleanser

Triderm Triamcinolone 0.1% cream

Triamcinolone 0.1% cream

High Potency

Amcinonide 0.1% cream, 0.1% lotion

Betamethasone Dipropionate 0.05% ointment

Betamethasone Dipr./propylene glycol, (aug.) 0.05%

cream

Diflorasone 0.05% ointment

Fluocinonide 0.05% cream, 0.05% gel, 0.05%

ointment, 0.05% solution

Triamcinolone 0.5% cream

Apexicon-E Diflorasone/emollient 0.05% cream

Halog Halcinonide 0.1% cream, 0.1% ointment

Halcinonide 0.1% cream, 0.1% ointment

Topicort Desoximetasone 0.05% cream, 0.05% gel; 0.05%,

0.25% ointment, spray

Desoximetasone 0.05% cream, 0.05% gel; 0.05%,

0.25% ointment, spray

Trianex Triamcinolone 0.5% ointment

Triderm Triamcinolone 0.5% cream

Triamcinolone 0.5% cream, 0.5% ointment

Very High Potency

Clobetasol emollient 0.05% cream

Bryhali Halobetasol 0.01% lotion

Clobex Clobetasol 0.05% lotion

Clobetasol 0.05% lotion, 0.05% gel

Clodan Clobetasol 0.05% cleanser kit

Diprolene Betamethasone/propylene glycol (aug.) 0.05%

ointment

Betamethasone/propylene glycol (aug.) 0.05%

ointment, 0.05% lotion, 0.05% gel

Lexette Halobetasol 0.05% foam

Halobetasol 0.05% foam

Olux/Olux-E Clobetasol 0.05% foam, 0.05% shampoo, 0.05%

spray; Clobetasol-emollient 0.05% foam

Clobetasol 0.05% foam, 0.05% shampoo, 0.05%

spray; Clobetasol-emollient 0.05% foam

Temovate Clobetasol 0.05% cream, 0.05% ointment

Clobetasol 0.05% cream, 0.05% ointment, 0.05%

solution

Topicort Desoximetasone 0.25% spray

Desoximetasone 0.25% spray

Tovet Clobetasol emollient 0.05% foam

Ultravate Halobetasol 0.05% cream, 0.05% lotion, 0.05%

ointment

Halobetasol 0.05% cream, 0.05% ointment

Ultravate X Halobetasol/Lactic Acid 0.05%-10% cream, 0.05%-

10% ointment

Vanos Fluocinonide 0.1% cream

Fluocinonide 0.1% cream

pdl drug class review announcement january 07, 2020 ... · 7/20/2001 · dossiers and supplemental...

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