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Rx Utilization Management Changes Effective October 1, 2014

We want to inform you about the following new pharmacy utilization management requirements that will be effective October 1, 2014. Below is a high-level summary of the criteria, and more details can be found online. 

Medical Benefit Changes

The following requirements will apply to medical benefit coverage for commercial and State Health Plan members (does not apply to Federal Employee Program or Medicare Part D members):

  • Entyvio (vedolizumab)

Entyvio, a medication used to treat ulcerative colitis or Crohn’s disease, will require prior review for ALL users.

Pharmacy Benefit Changes

The following requirements will apply to pharmacy benefit coverage for all commercial members who have their pharmacy benefits with us. These changes will not apply to State Health Plan, Federal Employee Program, Medicare Part D members, or for any ASO employer groups that carve out their pharmacy benefits to another pharmacy benefits manager.

  •  Hetlioz (tasimelteon)

Hetlioz, a specialty medication used to treat patients with non-24-hour sleep-wake disorder, will require prior review for ALL users.

  •  Otezla (apremilast)

Otezla, a specialty medication used to treat psoriatic arthritis, will be added to the list of oral biologics that require prior review and quantity limit review. Additionally, Otezla is a nonpreferred medication, which means that before approval can be given, patients must first try two of the following preferred medications: Enbrel, Humira, Simponi, and Stelara. These requirements apply to ALL users.

  •  Oral Immunotherapy

There are three new medications to treat grass and ragweed-induced allergic rhinitis. All will require prior approval for ALL users:

  • Oralair (Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract)
  • Grastek (Timothy Grass Pollen Allergen Extract)
  • Ragwitek (Short Ragweed Pollen Allergen Extract)

 

  •   Actemra SubQ (tocilizumab)

Actemra SubQ, a specialty medication used to treat rheumatoid and polyarticular juvenile idiopathic arthritis, was previously considered for coverage under the patient’s medical benefit, but will now be considered for coverage under the patient’s pharmacy benefit.  It 

will continue to require prior review and quantity limit review for ALL users. Actemra is a nonpreferred medication, which means that before approval can be given, patients must first try two of the following preferred medications: Enbrel, Humira and Simponi.

 

These pharmacy utilization management changes are effective October 1, 2014. If you have any questions, please contact us via the Provider Blue LineSM at 1.800.214.4844.