PDL Drug Class Review Announcement

July 9, 2019

Drug Classes to be reviewed:

Anticoagulants (Oral & Injectable), Anticonvulsants, Bone Resorption Suppression & Related Agents, Colony Stimulating Factors, Contraceptives, Diabetes Management Agents (Amylin, Biguanides, DPP-4 Inhibitors, GLP-1 Analogues, Hypoglycemic Combinations, Meglitinides, SGLT-2 Inhibitors, Thiazolidinediones), Erythropoiesis Stimulating Agents, GI Motility (Chronic), Newer HAE – Hereditary Angioedema Agents, Ophthalmic Immunomodulators, Overactive Bladder Agents, Prenatal Vitamins and Stimulants and other ADHD Agents.

These drug classes will be reviewed at the July 9th, 2019 P&T Committee meeting from 1‐5pm. The location is

303 East 17th Avenue, Denver, CO 80203 7th Floor Conference Rooms. Dossiers and Supplemental Rebate offers

are due to Magellan by May 31, 2019.

Please provide your public comments to Jessica Czechowski, Clinical Account Manager

(jlczechowski@magellanhealth.com) no later than July 4, 2019 to ensure they are included in the information

supplied to the P&T Committee members. Please carbon copy Brittany Schock, PDL Pharmacist

(Brittany.schock@state.co.us) on all clinical information and public comment submissions.

ANTICOAGULANTS- ORAL

Brand Name Generic Name

Bevyxxa Betrixaban

Coumadin Warfarin

Jantoven Warfarin

Warfarin

Eliquis Apixaban

Pradaxa Dabigatran

Savaysa Edoxaban

Xarelto Rivaroxaban

ANTICOAGULANTS- INJECTABLE

Brand Name Generic Name

Arixtra Fondaparinux

Fondaparinux

Fragmin Dalteparin

Lovenox Enoxaparin

Enoxaparin

ANTICONVULSANTS

Brand Name Generic Name

Aptiom Eslicarbaepine

Banzel Rufinamide

Briviact Brivaracetam

Carbatrol ER Carbamazepine ER

Carbamazepine ER

Celontin Methsuximide

Depakene Valproic Acid

Valproic Acid

Depakote DR, Depakote ER Divalproex Sodium

Divalproex Sodium

Diacomit Stiripentol

Dilantin Phenytoin

Epidiolex Cannabidiol (CBD)

Epitol Carbamazepine

Equetro Carbamazepine

Felbatol Felbamate

Felbamate

Fycompa Perampanel

Gabitril Tiagabine

Tiagabine

Keppra, Keppra XR Levetiracetam

Levetiracetam

Klonopin Clonazepam

Clonazepam

Lamictal, Lamictal XR Lamotrigine

Lamotrigine

Mysoline Primidone

Primidone

Onfi Clobazam

Clobazam

Oxtellar XR Oxcarbazepine

Peganone Ethotoin

Phenobarbital

Phenytek Phenytoin ER

Phenytoin ER

Potiga Ezogabine

Qudexy XR Topiramate ER

Topiramate ER

Roweepra XR Levetiracetam ER

Sabril Vigabatrin

Vigabatrin

Spritam Levetiracetam

Subvenite Lamotrigine

Sympazan Clobazam

Tegretol, Tegretol XR Carbamazepine

Carbamazepine

Topamax Topiramate

Topiramate

Trileptal Oxcarbazepine

Oxcarbazepine

Trokendi XR Topiramate

Vimpat Lacosamide

Zarontin Ethosuximide

Ethosuximide

Zonegran Zonisamide

Zonisamide

BONE RESORPTION SUPPRESSION & RELATED AGENTS

Brand Name Generic Name

Actonel Risedronate

Risedronate

Atelvia Risedronate

Binosto Alendronate

Boniva Ibandronate

Ibandronate

Calcitonin

Etidronate

Evista Raloxifene

Raloxifene

Forteo Teriparatide

Fosamax Alendronate

Alendronate

Fosamax Plus D Alendronate with D

Tymlos Abaloparatide

COLONY STIMULATING FACTORS

Brand Name Generic Name

Granix tbo-Flilgrastim

Fulphila** Pegfilgrastim-jmdb

Leukine Sargramostim

Neulasta Pegfilgrastim

Neupogen Filgrastim

Nivestym* Filgrastim-aafi

Udenyca** Pegfilgrastim-cbqv

Zarxio* Filgrastim-sndz

*biosimilar to Neupogen **biosimilar to Neulasta

CONTRACEPTIVES, Oral

Brand Name Generic Name

Altavera Levonorgestrel/Ethinyl Estradiol

Alyacen Norethindrone/Ethinyl Estradiol

Amethyst Levonorgestrel/Ethinyl Estradiol

Apri Desogestrel/Ethinyl Estradiol

Aranelle Norethindrone/Ethinyl Estradiol

Aubra Levonorgestrel/Ethinyl Estradiol

Aurovela/Aurovela Fe Norethindrone/Ethinyl Estradiol

Aviane Levonorgestrel/Ethinyl Estradiol

Azurette Desogestrel-Ethinyl Estradiol/Ethinyl Estradiol

Balcoltra Levonorgestrel/Ethinyl Estradiol/Iron

Balziva Norethindrone/Ethinyl Estradiol

Bekyree Desogestrel-Ethinyl Estradiol/Ethinyl Estradiol

Beyaz Dropirenone/Ethinyl Estradiol/Levonorgestrel

Blisovi Fe Norethindrone/Ethinyl Estradiol/Iron

Briellyn Norethindrone/Ethinyl Estradiol

Camila Norethindrone

Caziant Desogestrel/Ethinyl Estradiol

Chateal Levonorgestrel/Ethinyl Estradiol

Cryselle Norgestrel/Ethinyl Estradiol

Cyclafem Norethindrone/Ethinyl Estradiol

Cyclessa Desogestrel/Ethinyl Estradiol

Cyred Desogestrel/Ethinyl Estradiol

Dasetta Norethindrone/Ethinyl Estradiol

Deblitane Norethindrone

Desogestrel/Ethinyl Estradiol

Desogestrel-Ethinyl Estradiol/Ethinyl Estradiol

Drospirenone/Ethinyl Estradiol

Drospirenone/Ethinyl Estradiol/Levomethofolate

Elinest Norgestrel/Ethinyl Estradiol

Emoquette Desogestrel/Ethinyl Estradiol

Enpresse Levonorgestrel/Ethinyl Estradiol

Enskyce Desogestrel/Ethinyl Estradiol

Errin Norethindrone

Estarylla/Tri-Estarylla/Tri-Lo-Estarylla Norgestimate/Ethinyl Estradiol

Estrostep Fe Norethindrone/Ethinyl Estradiol/Iron

Ethynodiol/Ethinyl Estradiol

Falmina Levonorgestrel/Ethinyl Estradiol

Femynor/Tri Femynor Norgestimate/Ethinyl Estradiol

Generess Fe (chewable) Norethindrone/Ethinyl Estradiol/Iron

Gianvi Drospirenone/Ethinyl Estradiol

Gildagia Norethindrone/Ethinyl Estradiol

Hailey 24 Fe Norethindrone/Ethinyl Estradiol/Iron

Heather Norethindrone

Incassia Norethindrone

Isibloom Desogestrel/Ethinyl Estradiol

Jasmiel Drospirenone/Ethinyl Estradiol

Jencycla Norethindrone

Jolivette Norethindrone

Juleber Desogestrel/Ethinyl Estradiol

Junel/Junel Fe Norethindrone/Ethinyl Estradiol

Kaitlib Fe (chewable) Norethidrone/Ethinyl Estradiol

Kariva Desogestrel-Ethinyl Estradiol/Ethinyl Estradiol

Kelnor Ethynodiol/Ethinyl Estradiol

Kurvelo Levonorgestrel/Ethinyl Estradiol

Kimidess Desogestrel-Ethinyl Estradiol/Ethinyl Estradiol

Larin /Larin Fe Norethindrone/Ethinyl Estradiol

Larissa Levonorgestrel/Ethinyl Estradiol

Layolis Fe (chewable) Norethindrone/Ethinyl Estradiol/Iron

Leena Norethindrone/Ethinyl Estradiol

Lessina Levonorgestrel/Ethinyl Estradiol

Levonest Levonorgestrel/Ethinyl Estradiol

Levonorgestrel/Ethinyl Estradiol

Levora Levonorgestrel/Ethinyl Estradiol

Lillow Levonorgestrel/Ethinyl Estradiol

Lo Loestrin/Lo Loestrin Fe Norethindrone/Ethinyl Estradiol

Loestrin Norethindrone/Ethinyl Estradiol

Lomedia Fe Norethindrone/Ethinyl Estradiol/Iron

Loryna Drospirenone/Ethinyl Estradiol

Low-Ogestrel Norgestrel/Ethinyl Estradiol

Lutera Levonorgestrel/Ethinyl Estradiol

Lyza Norethindrone

Marlissa Levonorgestrel/Ethinyl Estradiol

Melodetta Fe (chewable) Norethindrone/Ethinyl Estradiol/Iron

Mibelas Fe (chewable) Norethindrone/Ethinyl Estradiol/Iron

Microgestin/Microgestin Fe Norethindrone/Ethinyl Estradiol

Mili/Tri-Mili Norgestimate/Ethinyl Estradiol

Minastrin Fe (chewable) Norethindrone/Ethinyl Estradiol/Iron

Mircette Desogestrel-Ethinyl Estradiol/Ethinyl Estradiol

Mono-Linyah Norgestimate/Ethinyl Estradiol

Mononessa Norgestimate/Ethinyl Estradiol

Myzilra Levonorgestrel/Ethinyl Estradiol

Natazia Dienogestrel/Estradiol Valerate

Necon Norethindrone/Ethinyl Estradiol

Nikki Drospirenone/Ethinyl Estradiol

Nora-Be Norethindrone

Norethindrone

Norethindrone/Ethinyl Estradiol

Norethindrone/Ethinyl Estradiol/Iron

Norgestimate/Ethinyl Estradiol

Norinyl/Tri-Norinyl Norethindrone/Ethinyl Estradiol

Norlyda Norethindrone

Nortrel Norethindrone/Ethinyl Estradiol

Ocella Drospirenone/Ethinyl Estradiol

Ogestrel Norgestrel/Ethinyl Estradiol

Orsythia Levonorgestrel/Ethinyl Estradiol

Ortho-Cyclen Norgestimate/Ethinyl Estradiol

Ortho-Micronor Norethindrone

Ortho-Novum Norethindrone/Ethinyl Estradiol

Ortho Tri-Cyclen/Ortho Tri-Cyclen Lo Norgestimate/Ethinyl Estradiol

Philith Norethindrone/Ethinyl Estradiol

Pimtrea Desogestrel-Ethinyl Estradiol/Ethinyl Estradiol

Pirmella Norethindrone/Ethinyl Estradiol

Portia Levonorgestrel/Ethinyl Estradiol

Previfem/Tri-Previfem Norgestimate/Ethinyl Estradiol

Rajani Drospirenone/Ethinyl Estradiol/Levomethofolate

Reclipsen Desogestrel/Ethinyl Estradiol

Safyral Drospirenone/Ethinyl Estradiol/Levomethofolate

Sharobel Norethindrone

Sprintec/Tri-Sprintec/Tri-Lo-Sprintec Norgestimate/Ethinyl Estradiol

Sronyx Levonorgestrel/Ethinyl Estradiol

Syeda Drospirenone/Ethinyl Estradiol

Tarina Fe Norethindrone/Ethinyl Estradiol/Iron

Taytulla Norethindrone/Ethinyl Estradiol/Iron

Tilia Fe Norethindrone/Ethinyl Estradiol/Iron

Tri-Legest Fe Norethindrone/Ethinyl Estradiol/Iron

Tri-Linyah Norgestimate/Ethinyl Estradiol

Tri-Lo-Marzia Norgestimate/Ethinyl Estradiol

Trinessa/Trinessa Lo Norgestimate/Ethinyl Estradiol

Trivora Levonorgestrel/Ethinyl Estradiol

Tulana Norethindrone

Tydemy Drospirenone/Ethinyl Estradiol/Levomethofolate

Velivet Desogestrel/Ethinyl Estradiol

Vienva Levonorgestrel/Ethinyl Estradiol

Viorele Desogestrel-Ethinyl Estradiol/Ethinyl Estradiol

Vyfemla Norethindrone/Ethinyl Estradiol

Vylibra/Tri-Vylibra Norgestimate/Ethinyl Estradiol

Wera Norethindrone/Ethinyl Estradiol

Wymzya Fe (chewable) Norethindrone/Ethinyl Estradiol/Iron

Yasmin/Yaz Drospirenone/Ethinyl Estradiol

Zarah Drospirenone/Ethinyl Estradiol

Zenchent Norethindrone/Ethinyl Estradiol

Zovia Ethynodiol/Ethinyl Estradiol

CONTRACEPTIVES, Extended Therapy

Brand Name Generic Name

Amethia/Amethia Lo Levonorgestrel/Ethinyl Estradiol/Ethinyl Estradiol

Ashlyna Levonorgestrel/Ethinyl Estradiol/Ethinyl Estradiol

Camrese/Camrese Lo Levonorgestrel/Ethinyl Estradiol/Ethinyl Estradiol

Daysee Levonorgestrel/Ethinyl Estradiol/Ethinyl Estradiol

Fayosim Levonorgestrel/Ethinyl Estradiol/Ethinyl Estradiol

Jolessa Levonorgestrel/Ethinyl Estradiol

Introvale Levonorgestrel/Ethinyl Estradiol

LoSeasonique Levonorgestrel/Ethinyl Estradiol/Ethinyl Estradiol

Levonorgestrel/Ethinyl Estradiol/Ethinyl Estradiol

Quartette Levonorgestrel/Ethinyl Estradiol/Ethinyl Estradiol

Quasense Levonorgestrel/Ethinyl Estradiol

Rivelsa Levonorgestrel/Ethinyl Estradiol/Ethinyl Estradiol

Seasonale Levonorgestrel/Ethinyl Estradiol

Levonorgestrel/Ethinyl Estradiol

Seasonique Levonorgestrel/Ethinyl Estradiol/Ethinyl Estradiol

Setlakin Levonorgestrel/Ethinyl Estradiol

DIABETES MANAGEMENT CLASSES: Amylin

Brand Name Generic Name

Symlin Pramlintide

DIABETES MANAGEMENT CLASSES: Biguanides

Brand Name Generic Name

Fortamet ER Metformin ER Osm-Tab

Metformin ER Osm-Tab

Glucophage/Glucophage XR Metformin

Metformin

Glumetza ER Metformin ER

Metformin ER

Riomet Metformin solution

DIABETES MANAGEMENT CLASSES: DPP-4 Inhibitors & Combinations

Brand Name Generic Name

Janumet/Janumet XR Sitagliptin/Metformin

Januvia Sitagliptin

Jentadueto/Jentadueto XR Linagliptin/Metformin

Kazano Alogliptin/Metformin

Alogliptin/Metformin

Kombiglyze Saxagliptin/Metformin

Nesina Alogliptin

Alogliptin

Onglyza Saxagliptin

Tradjenta Linagliptin

DIABETES MANAGEMENT CLASSES: GLP-1 Analogues Brand Name Generic Name

Adlyxin Lixisenatide

Bydureon/Bydureon BCISE Exenatide

Byetta Exenatide

Ozempic Semaglutide

Trulicity Dulaglutide

Victoza Liraglutide

DIABETES MANAGEMENT CLASSES: Hypoglycemic Combinations

Brand Name Generic Name

Actoplus Met Pioglitazone/ metformin

Pioglitazone/ metformin

Actoplus Met XR Pioglitazone/ metformin ER

Duetact Pioglitazone/ glimepiride

Pioglitazone/ glimepiride

Glipizide/ metformin

Glucovance Glyburide/ metformin

Glyburide/ metformin

Glyxambi Empagliflozin/ linagliptin

Oseni Alogliptin/ pioglitazone

Alogliptin/ pioglitazone

Qtern Dapagliflozin/Saxagliptin

Soliqua Lixisenatide/ insulin glargine

Steglujan Ertugliflozin/sitagliptin

Xultophy Liraglutide/insulin degludec

DIABETES MANAGEMENT CLASSES: Meglitinides & Combinations

Brand Name Generic Name

Prandin Repaglinide

Repaglinide

Repaglinide/ metformin

Starlix Nateglinide

Nateglinide

DIABETES MANAGEMENT CLASSES: SGLT-2 Inhibitors & Combinations

Brand Name Generic Name

Farxiga Dapagliflozin

Invokana Canagliflozin

Invokamet Canagliflozin/Metformin

Jardiance Empagliflozin

Segluromet Ertugliflozin/Metformin

Steglatro Ertugliflozin

Synjardy/Synjardy XR Empagliflozin/Metformin

Xigduo XR Dapagliflozin/Metformin

DIABETES MANAGEMENT CLASSES: Thiazolidinediones & Combinations

Brand Name Generic Name

Actos Pioglitazone

Pioglitazone

Actosplus Met/Actoplus Met XR Pioglitazone/Metformin

Pioglitazone/Metformin

Avandamet Rosiglitazone/Metformin

Avandia Rosiglitazone

ERYTHROPOIESIS STIMULATING AGENTS

Brand Name Generic Name

Aranesp Darbepoetin alfa

Epogen Epoetin alfa

Mircera Methoxy peg- epoetin beta

Procrit Epoetin alfa

Retacrit* Epoetin alfa-epbx

*biosimilar to Procrit

GI MOTILITY, CHRONIC

Brand Name Generic Name

Amitiza Lubiprostone

Linzess Linaclotide

Lotronex Alosetron

Alosetron

Motegrity Prucalopride

Movantik Naloxegol

Relistor Methylnaltrexone

Symproic Naldemedine

Trulance Plecanatide

Viberzi Eluxadoline

NEWER HAE – HEREDITARY ANGIOEDEMA AGENTS

Brand Name Generic Name

Berinert C1 Esterase Inhibitor

Cinryze C1 Esterase Inhibitor

Firazyr Icatibant

Haegarda C1 Esterase Inhibitor

Ruconest C1 Esterase Inhibitor, recombinant

Takhzyro Lanadelumab-flyo

OPHTHALMIC, IMMUNOMODULATORS

Brand Name Generic Name

Cequa Cyclosporine

Restasis Cyclosporine

Restasis Multidose Cyclosporine

Xiidra Lifitegrast

OVERACTIVE BLADDER AGENTS

Brand Name Generic Name

Flavoxate

Detrol/Detrol LA Tolterodine

Tolterodine

Ditropan/Ditropan XL Oxybutynin

Oxybutynin

Enablex Darifenacin

Darifenacin

Gelnique Oxybutynin gel

Myrbetriq Mirabegron

Oxytrol Oxybutynin patch

Toviaz Fesoterodine ER

Vesicare Solifenacin

Solifenacin

Trospium

PRENATAL VITAMINS

Brand Name Generic Name

Calcium-PNV PNV/Ca/Fe/FA/DHA

Citranatal/Citranatal Assure/Citranatal 90/

Citranatal DHA/Citranatal Harmony/

Citranatal Rx

Various formulations

C-Nate DHA PNV/FeF/FA/Omega 3

Complete Natal DHA PNV/Fe/FA

Completenate PNV/FeF/FA

Concept DHA/Concept OB Various Formulations

Elite OB PNV/Fe/FA

Enbrace HR PNV/Fe/Folate/DHA

Extra-Virt Plus DHA PNV/Fe/FA/DSS/DHA

Folivane-OB PNV/FeF/FA

M-Natal Plus PNV/Ca/Fe/FA

Marnatal-F PNV/Ca/Fe/FA

Nestabs/Nestabs ABC/Nestabs DHA Various Formulations

OB Complete Various Formulations

O-Cal Tablet Various Formulations

PNV/PNV OB+DHA/PNV-Select/PNV-VP-U/

PNV-DHA/PNV-Omega

Various Formulations

Prefera OB Various Formulations

Prenaissance Various Formulations

Prenatal Vitamin Plus Low Iron PNV/Ca/Fe/FA

Prenate/Prenate AM/Prenate DHA/Prenate

Elite/Prenate Enhance/Prenate Essential/

Prenate Mini/Prenate Pixie/ Prenate Plus/

Prenate Restore/ Prenate Star

Various Formulations

Preplus PNV/Ca/Fe/FA

Pretab PNV/Ca/Fe/FA

Primacare PNV/Fe/Folate/DHA

Provida DHA/Provida OB Various Formulations

PureFe Various Formulations

Select-OB Various Formulations

SE-Natal 19 Various Formulations

Taron/Taron-C/Taron-Prex Various Formulations

Thrivite Various Formulations

Tricare Prenatal Various Formulations

Trinatal Rx 1 PNV/Ca/Fe/FA

Tristart DHA PNV/Fe/Folate/DHA

Triveen-Duo DHA PNV/Fe/FA/Omega 3

Trust Natal DHA PNV/Fe/FA/Omega 3

Vinate DHA PNV/Fe/LMF

Virt-Advance/Virt-C DHA/Virt-Nate/Virt-PN

/Virt-Select/Virt-Vite

Various Formulations

Virtprex PNV/Fe/FA/DSS/DHA

Vitafol/Vitafol-Fe/Vitafol Nano/Vitafol-OB/

Vitafol-One/ Vitafol-Ultra

Various Formulations

VP-CH/VP-GGR/VP-Heme/VP-PNV Various Formulations

Zatean-PN/Zatean-PN Plus Various Formulations

Note: Ca – Calcium, DSS – Docusate Sodium, FA – Folic Acid Fe – Iron, FeF – Iron fumarate, FeG – Iron Gluconate, LMF – L-

methylfolate, PNV – prenatal vitamin

STIMULANTS and other ADHD Agents

Brand Name Generic Name

Adderall (tablet)/Adderall XR (capsule) Dextroamphetamine/amphetamine

Dextroamphetamine/amphetamine;

Dextroamphetamine/amphetamine ER

Adzenys ER (suspension) Amphetamine

Adzenys XR-ODT (OD tablet) Amphetamine ER

Aptensio XR (capsule) Methylphenidate ER

Clonidine ER

Concerta (tablet) Methylphenidate ER

Methylphenidate ER

Cotempla XR-ODT Methylphenidate

Daytrana (patch) Methylphenidate patch

Desoxyn (tablet) Methamphetamine

Methamphetamine

Dexedrine (capsule, tablet) Dextroamphetamine

Dextroamphetamine

Dyanavel XR (suspension) Amphetamine suspension ER

Evekeo (tablet) Amphetamine

Amphetamine

Focalin (tablet)/Focalin XR (capsule) Dexmethylphenidate

Dexmethylphenidate/Dexmethylphenidate ER

Intuniv (tablet) Guanfacine ER

Guanfacine ER

Metadate CD (capsule)/ Metadate ER

(tablet)

Methylphenidate ER

Methylphenidate CD/ER

Methylin (solution, tablet) Methylphenidate

Methylphenidate

Methylphenidate ER 72mg

Mydayis ER Dextroamphetamine/Amphetamine

Nuvigil (tablet) Armodafinil

Armodafinil

Procentra (solution) Dextroamphetamine solution

Dextroamphetamine solution

Provigil (tablet) Modafinil

Modafinil

Quillichew ER (chewable tablet) Methylphenidate ER

Quillivant XR (suspension) Methylphenidate ER

Relexxi ER Methylphenidate ER

Ritalin (tablet)/Ritalin LA (capsule)/Ritalin

SR (tablet)

Methylphenidate

Methylphenidate/Methylphenidate ER/LA

Strattera (capsule) Atomoxetine

Atomoxetine

Vyvanse (capsule, chewable tablet) Lisdexamfetamine

Zenzedi (tablet) Dextroamphetamine

Dextroamphetamine