AHCCCS Pharmacy and Therapeutics Committee Recommendations 19 May 2020

AHCCCS Pharmacy and Therapeutics Committee Recommendations 19 May 2020

Committee Recommendations PDL Recommendation Key: Products currently preferred and remaining preferred are listed in Black Products currently new, not previously reviewed or nonpreferred and recommended to be preferred are listed in Blue Products currently new, not previously reviewed or preferred and recommended to be non- preferred are listed in Red Products currently included on the AHCCCS approved drug list are noted with an asterisk (*) Classes where grandfathering is recommended will have a notation on the preferred recommendations page Reaching across Arizona to provide comprehensive quality health care for those in need 2

P&T Public Class Vote: Analgesics, Narcotics Long Reaching across Arizona to provide comprehensive quality health care for those in need 3

Analgesics, Narcotics Long PDL Recommendations (preferred products): Butrans* Embeda* † fentanyl transdermal (not including the 37.5mg, 62.5mg & 87.5 strengths)* morphine ER tablet* tramadol ER (generic Ultram ER)* Xtampza ER* No Changes Brand is preferred over generic † Voluntarily stopped sale and distribution in October 2019 Reaching across Arizona to provide comprehensive quality health care for those in need 4

P&T Public Class Vote: Antibiotics, Inhaled Reaching across Arizona to provide comprehensive quality health care for those in need 5

Antibiotics, Inhaled PDL Recommendations (preferred products): Bethkis* Kitabis Pak* No Changes Reaching across Arizona to provide comprehensive quality health care for those in need 6

P&T Public Class Vote: Anticoagulants Reaching across Arizona to provide comprehensive quality health care for those in need 7

Anticoagulants PDL Recommendations (preferred products): Oral Agents o o o o Eliquis*, Eliquis Dose Pack* Pradaxa* Xarelto*, Xarelto Dose Pack* warfarin* Injectable Agents o o enoxaparin syringe*, enoxaparin syringe* (AG) enoxaparin vial* (AG) No Changes Reaching across Arizona to provide comprehensive quality health care for those in need 8

P&T Public Class Vote: Antimigraine Agents, Other Reaching across Arizona to provide comprehensive quality health care for those in need 9

Antimigraine Agents, Other PDL Recommendations (preferred products): Ajovy Emgality Syringe 120mg* Emgality Pen* PDL Recommendations (non-preferred products): Aimovig* Emgality Syringe 100mg Nurtec ODT Reyvow Ubrelvy Vyepti Grandparenting – No Reaching across Arizona to provide comprehensive quality health care for those in need 10

P&T Public Class Vote: Antipsychotics, Oral Atypical Reaching across Arizona to provide comprehensive quality health care for those in need 11

Antipsychotics, Oral Atypical PDL Recommendations (preferred products): Oral Agents o aripiprazole tablet* o clozapine ODT*, clozapine ODT* (AG), clozapine tablet* o Latuda* o olanzapine ODT*, olanzapine tablet* o quetiapine tablet* o risperdone ODT*, risperidone solution*, risperidone tablet* o ziprasidone capsule* No Changes Reaching across Arizona to provide comprehensive quality health care for those in need 12

P&T Public Class Vote: Antipsychotics, Atypical Long-Acting Injectable Reaching across Arizona to provide comprehensive quality health care for those in need 13

Antipsychotics, Atypical Long-Acting Injectable PDL Recommendations (preferred products): Long-Acting Injectable Agents o o o o o o Abilify Maintena* Aristada* Aristada Initio* Invega Sustenna* Invega Trinza* Risperdal Consta* No Changes Reaching across Arizona to provide comprehensive quality health care for those in need 14

P&T Public Class Vote: COPD Agents Reaching across Arizona to provide comprehensive quality health care for those in need 15

COPD Agents PDL Recommendations (preferred products): Antimuscarinics - ShortActing Atrovent* o ipratropium nebulizer* o Antimuscarinics - LongActing Beta Agonist/Antimuscarinic Combination - Long-Acting Bevespi Aerosphere* o Stiolto Respimat* o No Changes Spiriva HandiHaler* o Tudorza Pressair o Beta Agonist/Antimuscarinic Combination - Short-Acting o ipratropium/albuterol Reaching across Arizona to provide comprehensive quality health care for those in need nebulizer* 16

P&T Public Class Vote: Cytokine and CAM Antagonists Reaching across Arizona to provide comprehensive quality health care for those in need 17

Cytokine and CAM Antagonists PDL Recommendations (preferred products): Xeljanz (immediate release) with PA Enbrel Kit*, Enbrel Syringe*, Enbrel Pen*, Enbrel Mini Cartridge* with PA Humira Kit*, Humira Pen Kit* with PA Otezla* with PA No Changes Reaching across Arizona to provide comprehensive quality health care for those in need 18

P&T Public Class Vote: Epinephrine, Self-Injected Reaching across Arizona to provide comprehensive quality health care for those in need 19

Epinephrine, Self-Injected PDL Recommendations (preferred products): epinephrine 0.15mg (generic EpiPen Jr.)* epinephrine 0.3mg (generic EpiPen)* PDL Recommendations (products moving to nonpreferred products): Symjepi Grandparenting - No Reaching across Arizona to provide comprehensive quality health care for those in need 20

P&T Public Class Vote: Glucocorticoids, Inhaled Reaching across Arizona to provide comprehensive quality health care for those in need 21

Glucocorticoids, Inhaled PDL Recommendations (preferred products): Single Agent Products o o o o o o PDL Recommendations (products moving to nonpreferred): Single Agent Products Asmanex* o Pulmicort 0.25, 0.5 mg budesonide 1 mg respules* Respules* Flovent HFA* Flovent Diskus Pulmicort Flexhaler* budesonide 0.25 and 0.5 mg Respules Grandparenting - No Combination Products Advair Diskus* o Advair HFA* o Dulera* o Symbicort* Brand is preferred over generic o Reaching across Arizona to provide comprehensive quality health care for those in need 22

P&T Public Class Vote: Growth Hormone Reaching across Arizona to provide comprehensive quality health care for those in need 23

Growth Hormone PDL Recommendations (preferred products): Genotropin Cartridge*, Genotropin Disp Syringe* Norditropin Pen* No Changes Reaching across Arizona to provide comprehensive quality health care for those in need 24

P&T Public Class Vote: Hepatitis C Agents Direct Acting Reaching across Arizona to provide comprehensive quality health care for those in need 25

Hepatitis C Agents (Direct Acting) PDL Recommendations (preferred products): o Mavyret* o sofosbuvir/velpatasvir (AG)* No Changes Reaching across Arizona to provide comprehensive quality health care for those in need 26

P&T Public Class Vote: Hypoglycemics, Incretin Mimetics/Enhancers Reaching across Arizona to provide comprehensive quality health care for those in need 27

Hypoglycemics, Incretin Mimetics/Enhancers PDL Recommendations (preferred products): Amylin Analogues o Symlin Pens* Dipeptidyl Peptidase-4 Enzyme Inhibitors (DPP-4s) o Glyxambi* o Janumet* o Janumet XR* o Januvia* o Jentadueto* o Kombiglyze XR* o Onglyza* o Tradjenta* Glucagon-Like Peptide-1 Receptor Agonists (GLP-1s) o Bydureon Pens*, Bydureon Vials (discontinued) o Byetta Pens* o Victoza* No Changes Reaching across Arizona to provide comprehensive quality health care for those in need 28

P&T Public Class Vote: Hypoglycemics, Insulin and Related Agents Reaching across Arizona to provide comprehensive quality health care for those in need 29

Hypoglycemics, Insulin and Related Agents PDL Recommendations (preferred products): o o o Humalog Cartridge, Humalog Pens*, Humalog Junior Kwikpen, Humalog Vials* Novolog Cartridge*, Novolog Pens*, Novolog Vials* Regular Insulins o Humulin R*, Humulin Pen OTC Humulin 500 Pens*, Humulin 500 Vials* Intermediate-Acting Insulins o Humulin N* Long-Acting Insulins o Rapid-Acting Insulins o o Rapid/Intermediate-Acting Combination Insulins o o Lantus Vial* Lantus Solostar Pen* Levemir Pens*, Levemir Vials* Humalog Mix Pens*, Humalog Mix Vials* Novolog Mix Vials* Regular/Intermediate-Acting Combination Insulins Humulin Pen 70/30 Pen OTC, Humulin 70/30 Vials* PDL Recommendations (nonpreferred products): o Lispro Junior Kwikpen o Lispro Protamine Mix Kwikpen o Novolin 70/30 Vial OTC o Grandparenting - No Reaching across Arizona to provide comprehensive quality health care for those in need 30

P&T Public Class Vote: Opioid Dependence Treatments Reaching across Arizona to provide comprehensive quality health care for those in need 31

Opioid Dependence Treatments PDL Recommendations (preferred products): Buprenorphine/Naloxone Products buprenorphine/naloxone sublingual tablet o Suboxone Film* o Buprenorphine Products buprenorphine sublingual tablet –PA required unless member is pregnant* o Sublocade subcutaneous – with PA (Statewide PA criteria to be developed) o Naloxone Products naloxone syringe*, naloxone vials* o Narcan Nasal* o Naltrexone Products naltrexone tablets* o Vivitrol* o Alpha Agonist Products o clonidine tablet* No Changes Reaching across Arizona to provide comprehensive quality health care for those in need 32 Brand is preferred over generic

P&T Public Class Vote: Pancreatic Enzymes Reaching across Arizona to provide comprehensive quality health care for those in need 33

Pancreatic Enzymes PDL Recommendations (preferred products): Creon* Zenpep* No Changes Reaching across Arizona to provide comprehensive quality health care for those in need 34

P&T Public Class Vote: Progestational Agents Reaching across Arizona to provide comprehensive quality health care for those in need 35

Progestational Agents PDL Recommendations (preferred products): Makena Auto Injector* Makena MDV* Makena SDV* No Changes Brand is preferred over generic Reaching across Arizona to provide comprehensive quality health care for those in need 36

P&T Public Class Vote: Stimulants and Related Agents Reaching across Arizona to provide comprehensive quality health care for those in need 37

Stimulants and Related Agents PDL Recommendations (preferred products): Adderall XR* amphetamine salt combination* Aptensio XR* atomoxetine, atomoxetine (AG)* clonidine ER* Concerta* Daytrana* Dexmethylphenidate*, dexmethylphenidate (AG)* dextroamphetamine tablet* Focalin XR* guanfacine ER* Methylin Solution* methylphenidate* methylphenidate CD*, methylphenidate CD (AG)* methylphenidate ER (generic Ritalin LA)* Ritalin LA 10mg capsule* Vyvanse Capsule*, Vyvanse Chewable Tablet* Brand is preferred over generic PDL Recommendations (products moving to nonpreferred): Dyanavel XR* Quillichew ER* Quillivant XR* Grandparenting - No Reaching across Arizona to provide comprehensive quality health care for those in need 38

New Drug Recommendations (Non-Supplemental) Adakveo - Nonpreferred Avyakit - Nonpreferred Nexletol - Nonpreferred Oxbryta - Nonpreferred Palforzia - Nonpreferred Reyvow - Nonpreferred Reaching across Arizona to provide comprehensive quality health care for those in need 39