CurrentExecutive Office of Health and Human ServicesPolicy N/A

Pharmacy & Therapeutics Committee — Formulary Recommendations / Coverage Criteria

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Quarterly Pharmacy & Therapeutics Committee meeting minutes documenting formulary reviews, product additions/removals, and recommendations affecting the preferred drug list (PDL) and prior authorization practices for the Executive Office of Health & Human Services; intended for prescribers, pharmacists, and internal payer staff.

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyPharmacy & Therapeutics Committee — Formulary Recommendations / Coverage Criteria

Policy CodePolicy N/A

Change TypeRoutine formulary recommendations and DUR referrals

Effective DateN/A

Next Review DateN/A

Key ActionDUR to review prior authorization diagnosis requirements for androgenic agents and consider adding diagnosis-based PA criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~14therapeutic categories reviewed

commonunanimous recommendations

2new specialty agents

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CurrentExecutive Office of Health and Human ServicesPolicy N/A

Pharmacy & Therapeutics Committee — Formulary Recommendations / Coverage Criteria

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Policy Summary

PayerExecutive Office of Health and Human Services

PolicyPharmacy & Therapeutics Committee — Formulary Recommendations / Coverage Criteria

Policy CodePolicy N/A

Change TypeRoutine formulary recommendations and DUR referrals

Effective DateN/A

Next Review DateN/A

Key ActionDUR to review prior authorization diagnosis requirements for androgenic agents and consider adding diagnosis-based PA criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~14therapeutic categories reviewed

commonunanimous recommendations

2new specialty agents

Formulary and Coverage Recommendations

Formulary Recommendations

Committee recommendations on formulary/PDL status and actions

Alzheimer's agents: Namenda oral solution discontinued; committee recommended no changes to the PDL.

Analgesics, Narcotic Long Acting: Reviewed safety communications (codeine and tramadol in children), new products (Arymo ER), new generic for Butrans, and market withdrawal of Opana ER; committee recommended no changes to preferred products.

Analgesics, Narcotic Short Acting: New product RoxyBand (oxycodone IR) reviewed; recommendations accepted.

Androgenic Agents: Recommendation to discontinue Axiron and its generics; committee noted there is not currently a diagnosis requirement on the prior authorization and referred this for DUR review.

Antiparkinson's Agents: New items Gocovri and Osmolex ER reviewed; committee accepted recommendations.

Benign Prostatic Hyperplasia (BPH) Agents: No changes to the class; recommendations accepted.

Bladder Relaxants: Updated indication for Myrbetriq and recommendation to remove Enablex from preferred list; recommendations accepted.

Cytokine and Calmodulin (CaM) Antagonists / Biologics: Updated indications and new formulations reviewed (Stelara, Taltz, Xeljanz/XR, Cimzia; Cyltezo, Enbrel Mini, Kevzara); two new products Ilumya and Olumiant noted; committee stated biosimilars should be considered safe and effective with substitutions made by the prescriber; motion to add Cosentyx failed and original motion passed.

Erythropoietins: New biosimilar Retacrit (for Epogen/Procrit) noted and Mircera approved for dialysis; recommendations approved with one abstention.

Ophthalmic Agents: Multiple ophthalmic subcategories reviewed (allergic conjunctivitis, antibiotics, antibiotic-steroid combinations, anti-inflammatory, immunomodulators, glaucoma); new products Rhopressa and Vyzulta noted; recommendations accepted.

Otic Agents: Antibiotics, anti-infectives/anesthetics, and anti-inflammatory otic agents reviewed; preferred products recommended (e.g., acetic acid, Dermotic) and approved.

Phosphate Binders: New generic lanthanum carbonate chewable (for Fosrenol) and new drug Axorerol reviewed; recommendations approved.

Stimulants & Related Agents: New formulations (Adzenys ER oral suspension) and product changes (addition of Vyvanse chewable tablets, discontinuation of dextroamphetamine ER capsules and Methlyn chewables) reviewed; committee requested potential PA modification to document prior duration of use and continuity of care.

Antihypertensives, Sympatholytics: Reviewed and recommendations accepted.

The committee minutes do not record broad class‑level exclusions but do document specific removals from preferred lists. For example, the committee recommended discontinuing Axiron and its generics from the androgenic agents category and recommended removal of Enablex from the bladder relaxants preferred list. These actions represent targeted formulary removals rather than a blanket class exclusion and were accepted by unanimous vote.

The minutes do not include explicit not medically necessary (NMN) determinations for individual drugs. Decisions recorded are limited to formulary placement and PDL recommendations (additions, removals, or status changes) voted on by the committee rather than statements declaring products NMN.

Prior Authorization, Documentation, and Provider-Facing Actions

Prior Authorization

Prior auth for androgenic agents lacks diagnosis requirement — referred to DUR

Committee identified that the prior authorization for androgenic agents (e.g., Axiron) currently does not include a diagnosis requirement and referred the issue to the DUR committee for review. No immediate PA policy change was recorded in the minutes.

Step Therapy

No step therapy requirements specified

The minutes document that no formal step therapy (step edits) were specified for the reviewed classes; committee discussion did not produce any step therapy requirements.

Committee requested potential PA modification for stimulants to capture prior duration of use, but this was not recorded as a step therapy edit.

Step Therapy and Stimulant Prior Use Considerations

Issue	Committee discussion / recommendation	Planned follow-up / action
Prior authorization modification for stimulants
Committee asked whether the prior authorization could be modified to document if the patient has been on the medication and the start date (duration of prior use) to support continuity of care
Refer to DUR for potential PA wording change to capture prior duration of use and continuity-of-care information; no formal policy change recorded in minutes (motion to accept recommendations approved)

Biosimilars and Related Notes

Note

Retacrit (biosimilar for Epogen/Procrit) noted and accepted

Retacrit (biosimilar for Epogen/Procrit) was noted as a new biosimilar and the committee accepted the recommendations regarding erythropoietins.

Policy Context and Committee Process

These are the quarterly Pharmacy & Therapeutics committee minutes summarizing routine class reviews and PDL recommendations. The committee conducts periodic reviews of approximately ~14 therapeutic classes, considers new approvals and generics, FDA safety communications, biosimilars, and utilization trends, and records motions to accept recommendations (commonly approved unanimously). Where issues were identified—such as lack of a diagnosis requirement on androgenic agent prior authorizations or potential modifications to stimulant prior authorization to capture prior duration of use—these were referred to DUR for follow‑up rather than immediately implemented as policy changes.

Key Definitions

inv-09: Biosimilar — definition and committee stance on biosimilars

DefinitionA biological product highly similar to an approved reference biologic; the minutes note biosimilars should be considered safe and effective with substitutions made by the prescriber.

Committee stanceBiosimilars should be considered safe and effective; substitutions should be made by the prescriber.

Example notedRetacrit identified as a biosimilar for Epogen and Procrit; committee accepted recommendations.

Implementation noteCommittee accepted biosimilar recommendations during formulary review with motions to approve related class recommendations.

Action for prescribersWhen substituting a biosimilar for a reference biologic, prescribers should document the substitution per usual prescribing practices.