January 2018 formulary update

From time to time, we add drugs to or remove them from Priority Health formularies and the Approved Drug List formulary lookup tool. We also may change their tier, which determines how much a member pays for a drug.

The Priority Health Pharmacy & Therapeutics (P&T) committee is a group of network physicians and pharmacists that help us make these changes based on scientific evidence we have of their value in helping people get well and stay healthy. Below is a summary of the pending changes made by the P&T committee on January 16, 2018.

Medicare Part D formulary changes will not be implemented until Priority Health receives CMS approval. For drugs covered by Medicare Part B, prescribers must follow WPS-Medicare local coverage determinations.

Jump down this page to see Changes to the formularies

Printable version of the P&T updates. 

New drugs reviewed/additions effective Mar. 1, 2018

Baxdela™ (delafloxacin)

  • Not added to the formularies
  • Acute bacterial skin infections, incl. MRSA
  • Traditional and Optimized formularies: NF
  • Medicare: Not covered
  • Est. cost: $4,500 for IV, $2,300 for tablet, per 14-day course

Benznidazole, 100mg tablets

  • Added to the formularies
  • Chagas disease
  • Traditional and Optimized formularies: Non-Preferred Brand
  • Medicare: NF
  • QL 60/lifetime
  • Est. cost: $860 per 60-day course

Benznidazole, 12.5mg tablets

  • Not added to the formularies

Calquence™ (acalabrutinib)

  • Added to the formularies
  • Oncology
  • Traditional and Optimized formularies: Non-preferred Specialty, QL 28 per 14 days
  • Medicare: Tier 5, QL 60 per 30 days
  • PA for all plans
  • Est. cost: $203,000 annually

Fasenra™ (benralizumab)

  • Added to the formularies
  • Severe asthma
  • Traditional and Optimized formularies: Medical benefit, Preferred Specialty
  • Medicare: Tier 5
  • PA for all plans
  • Est. cost: $39,900 annually

Fiasp® (insulin aspart recombinant)

  • Added to the formularies
  • Diabetes
  • Traditional and Optimized formularies: Non-preferred Brand
  • Medicare: Tier 4
  • ST for all plans; must first try Humalog®
  • Est. cost: $24,000 annually

Hemlibra® (emicizumab-kxwh)

  • Added to the formularies
  • Hemophilia
  • Traditional and Optimized formularies: Preferred Specialty
  • Medicare: Part B
  • PA for traditional and optimized formularies
  • Estimated cost: $1 million annually

Juluca (dolutegravir and rilpivirine)

  • Added to the formularies
  • HIV-1
  • Traditional and Optimized formularies: Preferred Specialty
  • Medicare: Tier 5
  • QL 1 tab daily
  • Estimated cost: $1,700 monthly

Kymriah™ (tisagenlecleucel)

  • Added to the formularies
  • Lymphoblastic leukemia
  • Traditional and Optimized formularies: Medical benefit, Preferred Specialty
  • Medicare: Part B
  • PA for optimized and traditional formularies
  • Gene Therapy Rider required (coming 7/2018)
  • Estimated cost: $570,000 annually

Parsabiv™ (etelcalcetide)

  • Added to the formularies
  • Secondary hypothyroidism in patients with chronic kidney disease
  • Traditional and Optimized formularies: Medical benefit, Non-preferred Specialty
  • Medicare: Part B, part of the ESRD bundle
  • PA for optimized and traditional formularies
  • Estimated cost: $30,100 annually

Qtern® (dapagliflozin and saxagliptin)

  • Added to the formularies
  • Type 2 diabetes
  • Traditional formulary: Non-preferred Brand
  • Optimized formulary: Non-preferred Brand, PA required
  • Medicare: Tier 4
  • QL 30 per 30 days
  • Estimated cost: $516 monthly

Symproic™ (naldemedine)

  • Added to the formularies
  • Opioid-induced constipation
  • Traditional and Optimized formularies: Non-preferred Brand
  • Medicare: Tier 4
  • ST with lactulose
  • QL 30 per 30 days
  • Estimated cost: $4,500 annually

Trelegy Ellipta (fluticasone furoate [FF], umeclidinium, vilanterol)

  • Added to commercial formularies
  • COPD
  • Traditional and Optimized formularies: Preferred Brand
  • Medicare: NF

Vabomere™ (meropenem/vaborbactam)

  • Added to the formularies
  • UTI
  • Traditional and Optimized formularies: Medical benefit, Non-preferred Specialty
  • Medicare: Part B
  • Almost exclusively an inpatient medication
  • Estimated cost: $16,600 per 14-day course

Varubi® (rolapitant)

  • Added to the formularies
  • Prophylaxis of chemo-induced nausea and vomiting
  • Traditional and Optimized formularies: Medical benefit
  • Medicare: Part B
  • Added as a medical benefit
  • Estimated cost: $16,600 per 14-day course

Vyzulta™ (latanoprostene bunod)

  • Not added to the formularies
  • Raised intraocular pressure
  • Estimated cost: $72 per unit

Vyzulta™ (latanoprostene bunod)

  • Not added to the formularies
  • Raised intraocular pressure
  • Traditional and Optimized formularies: NF
  • Medicare: NF
  • Estimated cost: $72 per unit

Yescarta™ (axicabtagene cioleucel)

  • Added to the formularies
  • B-cell lymphoma
  • Traditional and Optimized formularies: Medical benefit, Preferred Specialty
  • Medicare: Part B
  • PA required
  • Gene Therapy Rider required (coming 07/2018)
  • Estimated cost: $447,600 per unit

Xhance™ (fluticasone propionate)

  • Not added to the formularies
  • Nasal polyps
  • Estimated cost: $510 per bottle

Zilretta™ (triamcinolone)

  • Added to the Medicare formulary
  • Osteoarthritis pain
  • Traditional and Optimized formularies: NF
  • Medicare: Part B
  • Estimated cost: $570 per dose

Changes to the formularies effective March 1, 2018

The P&T Committee reviewed the following medications and medical criteria changes are listed below. Some changes will be effective July 1, 2018, if so noted.

Actemra®

  • Commercial and Medicaid: Add diagnosis of Cytokine Release Syndrome and criteria of a) patient is experiencing severe/life threatening T-cell induced reaction, b) the IV formulation of Actemra is being used for treatment, c) a maximum of 4 doses is requested.
  • Medicare: Change required diagnosis to "medically accepted indication" from rheumatoid/juvenile idiopathic arthritis; minor edits

Actoplusmet XR

  • Traditional and Optimized formularies: Preferred Brand, QL added 60 per 30 days effective July 1, 2018

Actretin® - No changes

Adcetris®

  • Commercial: Add diagnosis of CD30-expressing mycosis fungoides; add diagnosis of primary cutaneous anaplastic large cell lymphoma

Adempas®

  • Commercial: Added criteria requiring documentation of diagnosis
  • Medicaid: New Medicaid-specific form, added criteria requiring documentation of diagnosis
  • Medicare: Minor edits

Alecensa®

  • Commercial and Medicare: Added stipulation that diagnosis must be detected by an FDA-approved test, removed required trial with Xalkori┬«

Alogliptin

  • Traditional and Optimized formularies: QL added 30 per 30 days effective July 1, 2018

Amytriptyline

  • Medicare: Minor edits

Anadrol®-50

  • Traditional and Optimized formularies: Removed from formularies effective July 1, 2018

Android®

  • Traditional and Optimized formularies: Removed from formularies effective July 1, 2018

Aptiom®

  • Commercial: Minimum age lowered from 18 to 4

Aripiprazole

  • Medicare: Removed "autistic disorder" from approved indications

AuryxiaÔäó

  • Traditional and Optimized formularies: Changed ST to PA effective March 1, 2018

AustedoÔäó

  • Commercial: Add age requirement of 18 and older; add indication of tardive dyskinesia with criteria and initial approval length of 2 months (continuation requires separate authorization but is indefinite)

Berinert®

  • Commercial: Additional stipulation that patient's attacks must a) affect upper airways, b) involve face/neck/abdomen, or c) result in debilitation or dysfunction; added documentation requirement that Firazyr┬« was ineffective in controlling acute attacks; removed language stating step therapy with Firazyr┬« would be waived if patient had previously been maintained on Berinert; inclusion of Ruconest┬« in list of drugs not covered in combination with Berinert┬«
  • Medicare: Minor edits; age increased from 12 years or older to 18 or older for approval; inclusion of patient's weight

Boniva®

  • Commercial: Minor edits to language in precertification requirements

Botulinum toxin

  • Commercial: Criteria updated for patients with anal fissures, additional minor edits

Bravelle®

  • Traditional and Optimized formularies: Non-Preferred Brand tier change. ST added, must first try Gonal-F┬«, effective July 1, 2018.

Briviact®

  • Commercial: Removal of trial with second generic anti-seizure medication; removal of requirement that Briviact┬« be used as adjunctive therapy with generic anti-seizure medication

Budesonide (generic for Entocort®)

  • Traditional and Optimized formularies: Non-Preferred Brand. QL added, 90 per 30 days, effective July 1, 2018

Buprenorphine and naloxone

  • Medicare: Minor edits

CabometyxÔäó

  • Commercial: Removal of requirement that patient must have previously tried anti-angiogenic therapy (Avastin┬«, Sutent┬«, Nexavar┬«, etc.)

Chorionic gonadotropin

  • Medicare: Change "Cryptorchidism and hypogonadotropic hypogonadism" to "a medically accepted indication"

Cialis®

  • Medicare: Minor edits

Cinqair®

Commercial/Medicaid:

  • Criteria synced to better align with class agents (FasenraÔäó and Nucala┬«)
  • Updated cost information
  • Increased requirement for baseline peripheral blood eosinophil count from 300 to greater than 400 cells/mcl
  • Patient must be compliant on the following therapies for 3 months and continue use while on Cinqair┬«: a high dose inhaled corticosteroid, long-acting beta agonist, one additional asthma controller medication
  • Must have attestation of proper inhaler technique has been reviewed with patient Must have had greater than 3 asthma exacerbations in the previous year
  • Must be steroid-dependent or steroid refractory after trials with maintenance therapy
  • Must not currently use tobacco products
  • Must not use in combination with other monoclonal antibodies
  • Addition of continuation criteria which includes initiation criteria plus evidence that patient experienced clinical benefit from therapy with Cinqair┬«
  • Initial approval of 6 months, continuation approvals of 12 months per authorization

Climara Pro®

Traditional and Optimized formularies: Non-Preferred Brand tier change. ST added, must first try Combipatch® effective July 1, 2018.

Cotellic®

  • Medicare: Minor edits

Crinone®

  • Medicare: Change indication requirement from "secondary amenorrhea" to "a medically accepted indication"

Danazol

  • Traditional and Optimized formularies: Non-Preferred Brand tier change. QL added, 50mg and 100mg = 60 per 30 days, 200mg = 120 per 30 days, effective July 1, 2018.

Desmopressin

  • Traditional and Optimized formularies: Non-Preferred Brand tier change for 0.01% nasal spray effective July 1, 2018.
  • Traditional and Optimized formularies: QL added for 0.1mg tablet 180 per 30 days, effective July 1, 2018.

Digoxin

  • Medicare: Changed requirement to "a medically-accepted indication" (was either atrial fibrillation or heart failure only)

Doxercalciferol

  • Traditional and Optimized formularies: Non-Preferred Brand tier change effective July 1, 2018

Duetact

  • Traditional and Optimized formularies: Removed from formularies effective July 1, 2018

Esbreit®

  • Medicare: Minor edits

Etidronate disodium

  • Traditional and Optimized formularies: Non-Preferred Brand tier change. ST added, must first try alendronate. Effective July 1, 2018

Fabrazyme®

Commercial/Medicaid:

  • Approval length of 12 months
  • Requirement of documentation that confirms diagnosis
  • Prescriber must be nephrologist, cardiologist, specialist in metabolic disorders or genetics
  • Patient is either a classically affected male OR a female carrier or male with atypical presentations 
  • Addition of continuation criteria that confirms response to treatment/patient compliance/ continued efficacy

FenorthoÔäó

  • Traditional and Optimized formularies: Brand and generic removed from formularies effective July 1, 2018

Galzin®

  • Traditional and Optimized formularies: Removed from formularies effective July 1, 2018

Gazyva®

  • Commercial: New criteria for indication of follicular lymphoma: Must have previously untreated stage II bulky, III, or IV disease in those with at least a partial response to combination therapy AND must be used in combination with chemotherapy followed by obinutuzumab monotherapy

Glucagon emergency kit

  • Traditional and Optimized formularies: Preferred Brand, QL added 2 per 30 days effective July 1, 2018

Glucagen Hypokit

  • Traditional and Optimized formularies: Preferred Brand, QL added 2 per 30 days effective July 1, 2018

Glyxambi® (empagliflozin and linagliptin)

  • Traditional and Optimized formularies: Preferred Brand
  • Medicare: Tier 3
  • Tier changes March 1, 2018

Human growth hormone

  • Commercial group and MyPriority┬«: Language added for adult 12 month continuation: patient must have low IGF-1 but dose is being increased OR IGF-1 is within appropriate range for age and sex within the last 12 months

Imlygic®

  • Commercial/Medicaid: Criteria added - "must have disease recurrence after prior surgery"

Increlex®

  • Commercial/Medicaid: Documentation requirements added, including baseline height, history of lower than normal growth velocity

Ingrezza®

  • Commercial: Updated diagnosis "antipsychotic or dopamine receptor blocker-induced tardive"

Invokamet®

  • Traditional and Optimized formularies: QL added 50-1000mg, 150-500mg and 150-1000mg 60 per 30 days; 50-500mg, 12 per 30 days, effective July 1, 2018

Invokamet® XR

  • Traditional and Optimized formularies: QL added 50-1000mg, 150-500mg and 150-1000mg 60 per 30 days; 50-500mg, 12 per 30 days, effective July 1, 2018

Janumet®

  • Traditional and Optimized formularies: QL added 60 per 30 days, effective July 1, 2018

Janumet® XR

  • Traditional and Optimized formularies: QL added 60-100mg, 50-500mg 60 per 30 days; 100-1000mg 30 per 30 days, effective July 1, 2018

Jardiance®

  • Traditional and Optimized formularies: QL added 30 per 30 days effective July 1, 2018

Jentaduo®

  • Traditional and Optimized formularies: QL added 60 per 30 days effective July 1, 2018

Klor-Con® 25 mEq

  • Traditional and Optimized formularies: Removed from the formularies effective July 1, 2018

Kalbitor®

Commercial: 

  • Additional stipulation that patient's attacks must a) affect upper airways, b) involve face/neck/abdomen, or c) result in debilitation or dysfunction
  • Documentation requirement that Firazyr┬« was ineffective in controlling acute attacks
  • Remove language stating step therapy with Firazyr┬« would be waived if patient had previously been maintained on Kalbitor┬« for at least 6 months
  • Inclusion of Ruconest┬« in list of drugs with which Berinert┬« would not be covered in combination

Kalydeco®

  • Commercial: Now requires documentation of cystic fibrosis ICD-10 code in last 12 months, additional CFTR gene mutations added
  • MyPriority individual: Additional CFTR gene mutations added

Keytruda®

  • Medicare: Added indication of advanced gastric or gastroesophageal junction cancer

Lucentis®

Commercial/Medicaid:

  • Addition of step therapy requirement with Avastin┬« for diagnosis of diabetic retinopathy
  • Addition of diagnosis of myopic choroidal neovascularization with maximum of 1 injection per month for up to 3 months

Lynparza®

  • Commercial: Added diagnosis of recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer with requirement that patient must first have tried at least 2 platinum-based chemotherapy regimens with an objective response to the most recent
  • Medicare: Added diagnosis of recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer with requirement that patient must be in complete or partial response to platinum-based chemotherapy

Macugen®

  • Commercial/Medicaid: Added stipulation that Avastin┬« must be tried for 3 consecutive months with failure to effectively improve baseline visual acuity and/or reduce fluid
  • Patients currently receiving treatment with Macugen┬« who have a) demonstrated adequate response

Megaces® ES

  • Traditional and Optimized formularies: 625mg/5ml Non-Preferred brand tier change effective July 1, 2018

Mephyton®

  • Traditional and Optimized formularies: QL added 3 per 30 days effective July 1, 2018

MethitestÔäó

  • Traditional and Optimized formularies: 10mg tablet removed effective July 1, 2018

Methylergonovine

  • Traditional and Optimized formularies: 0.2mg tablet Non-Preferred Brand, QL added 28 per 365 days effective July 1, 2018

Methyltestosterone

  • Traditional and Optimized formularies: Non-Preferred Brand tier change, new auth form effective July 1, 2018

MibelasÔäó 24 Fe

  • 4x ferrous fumarate 75mg chewable tablet and 24x norethindrone acetate 1mg/ethinyl estradiol 20mcg chewable tablet 
  • Traditional and Optimized formularies: Preferred Brand tier change effective July 1, 2018

Millipred®

  • Traditional and Optimized formularies: Brand and generic removed effective July 1, 2018

Minocycline ER

  • Traditional and Optimized formularies: Preferred Brand tier change, added ST trial with minocycline IR, effective July 1, 2018

Myalept®

  • Commercial: Minor edits, added stipulation that request must not exceed maximum weight-based daily dosing per FDA-approved label
  • Medicare: Minor edits

Nalfon®

  • Traditional and Optimized formularies: Removed

Naprelan®

  • Traditional and Optimized formularies: Removed

Nascobal®

  • Traditional and Optimized formularies: Removed effective July 1, 2018

Nepupent®

  • Medicare: Minor edits

Nesina®

  • Traditional and Optimized formularies: QL added 30 per 30 days effective July 1, 2018

Novarel®

  • Traditional and Optimized formularies: Non-Preferred Brand tier change, ST added must first try Pregnyl┬«, effective July 1, 2018

Nucala®

  • Traditional and optimized formularies: Medical benefit, Non-preferred Specialty:
    • Criteria synced to better align with class agents (FasenraÔäó and Cinqair┬«)
    • Change indication to severe eosinophilic asthma
    • Remove requirement ÔÇśsputum eosinophil count of 3% or higher
    • Add patient must have been compliant on all of the following for at least 3 months and continue their use while on Nucala┬«: high-dose inhaled corticosteroid, long-acting beta agonist, and one additional asthma controller medication
    • Must have attestation of proper inhaler technique has been reviewed with patient
    • Must have had greater than 3 asthma exacerbations in the previous year
    • Must be steroid-dependent or steroid refractory after trials with maintenance therapy
    • Must not currently use tobacco products
    • Must not use in combination with other monoclonal antibodies
    • Addition of continuation criteria which includes initiation criteria plus evidence that patient experienced clinical benefit from therapy with Nucala┬«
  • Medicare: Remains NF
  • Medicaid: Changed to NF

OcrevusÔäó

  • MyPriority┬« only: Now requires documentation of multiple sclerosis ICD-10 code in last 12 months

Ofev®

  • Medicare: Minor edits

Onivyde® - No changes

Opdivo®

  • Commercial: New indication of hepatocellular carcinoma added, requires step therapy with Nexavar┬« (sorafenib)
  • Medicare: New indications added:
    • Hodgkin's lymphoma
    • Recurrent or metastatic squamous cell carcinoma of the head and neck
    • Locally advanced or metastatic urothelial carcinoma
    • Microsatellite instability-high or mismatch repair-deficient metastatic colorectal cancer
    • Hepatocellular carcinoma

Opsumit®

  • Commercial: New criteria - patient must have NYHA functional class II or greater symptoms prior to therapy initiation AND office must provide documentation to support diagnosis
  • Medicare: Minor edits

Orapred ODT®

  • Traditional and Optimized formularies: Removed

Oxandrolone

  • Optimized formulary: Non-Preferred Brand tier change effective July 1, 2018

Paricalcitol

  • Traditional and Optimized formularies: Preferred Brand tier change effective July 1, 2018

Phenobarbitol

  • Medicare: Minor edits

Pioglitazone and glimepiride

  • Traditional and Optimized formularies: Removed effective July 1, 2018

ProFeno®

  • Traditional and Optimized formularies: Generic and brand removed

Promethazine

  • Medicare: Edit to include language requiring patient to have an FDA-approved indication; removal of post-operative pain indication

Rajani

  • Drospirenone/Ethinyl Estradiol/Levomefolate and Levomefolate Calcium 3mg-0.02mg-0.451mg and 0.451mg tablet
  • Traditional and Optimized formularies: Preferred Brand tier change effective July 1, 2018

Ravicti®

  • Commercial: ST criteria added, patient must first try sodium phenylbutyrate

Relistor® (injection and tablet)

  • Commercial: Add Symproic┬« as an option to meet step therapy requirement

Remodulin®

  • Commercial and Medicaid: New criteria, patient must have a WHO functional class II or greater symptoms prior to therapy initiation AND office must provide documentation to support diagnosis

Risedronate sodium

  • Traditional and Optimized formularies: ST added, must first try Alendronate effective July 1, 2018

Risedronate sodium DR

  • Traditional and Optimized formularies: Preferred Brand tier change, ST added, must first try Alendronate effective July 1, 2018

Ruconest®

  • Commercial:
    • Additional stipulation that patientÔÇÖs attacks must a) affect upper airways, involveface/neck/abdomen, or result in debilitation or dysfunction
    • Requirement that office must provide documentation that Firazyr┬« was ineffective in controlling acute attacks
    • Remove language stating step therapy with Firazyr┬« would be waived if patient had previously been maintained on Ruconest┬« for at least 6 months
    • Remove requirement that patient must have failed one previous optimized prophylactic treatment
  • Medicare: Minor edits

SafyralÔäó

  • Traditional and Optimized formularies: ST added, must first try Beyaz or generic equivalent, effective July 1, 2018

Simponi®/Simponi Aria®

  • Commercial: Clarification that Simponi Aria┬« is covered for rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis specifically
  • Medicare:
    • Removed the required diagnosis of either ankylosing spondylitis, psoriatic arthritis, or rheumatoid arthritis, and replaced with "a medically accepted indication"
    • Added ulcerative colitis as an approved indication
    • Added "CMS coverage determination criteria" language

Solodyn®

  • Traditional and Optimized formularies: Removed effective July 1, 2018

Somavert®

  • Commercial:  New form

Sprycel®

Commercial:

  • Added Philadelphia chromosome-positive as indication of chronic myeloid leukemia
  • Changed requirement for BCR-ALB1 Gene Arrangement, Quantitative PCR to be completed every 3 months for 2 years once complete cytogenetic response has been obtained (previously required for 3 years)

Stimate®

  • Traditional and Optimized formularies: Non-Preferred Brand tier change effective July 1, 2018

Strensiq® - No changes

Striant®

  • Traditional and Optimized formularies: Removed
  • Medicare: Removed indication of hypogonadism in favor of  "a medically accepted indication"

 Suboxone┬« - No changes

SymlinPen® 120

  • Traditional and Optimized formularies: Non-Preferred Brand tier change effective July 1, 2018

SymlinPen┬« 60

  • Traditional and Optimized formularies: Non-Preferred Brand tier change, QL added 6ml per 30 days, effective July 1, 2018

Synjardy®

 

  • Traditional and Optimized formularies: QL added 60 per 30 days effective July 1, 2018

Synribo®

  • Medicare: Added language requiring medication be used for "a medically accepted indication"

Tagrisso® - No changes

Taltz®

  • Commercial: Add indication of psoriatic arthritis requiring step therapy with two of Cosentyx┬«, Enbrel┬«, Humira┬« or Stelara┬« for 3 months AND trial with one conventional DMARD for at least three months
  • Medicare: Add language requiring medication is used for "a medically accepted indication"; add step therapy requirement for psoriatic arthritis with Enbrel┬« or Humira┬«

Tasigna®

Commercial: 

  • Added MyPriority plans to form
  • Changed requirement for BCR-ALB1 Gene Arrangement, Quantitative PCR to be completed every 3 months for 2 years once complete cytogenetic response has been obtained (previously required for 3 years)

Testosterone topical pump

  • Traditional and Optimized formularies: QL added 60 per 30 days effective July 1, 2018

Testosterone topical solution

  • Traditional and Optimized formularies: QL added 180 per 30 days effective July 1, 2018

Testred® C-III

  • Traditional and Optimized formularies: Removed effective July 1, 2018

Trimipramine

  • Medicare: New form

Tysabri®

  • Commercial/Medicaid: Now requires documentation of multiple sclerosis ICD-10 code in last 12 months for MyPriority members

Tyvaso®

  • Commercial: Added requirement for documentation confirming diagnosis and WHO functional class III symptoms prior to initiation of drug
  • Medicare: Minor edits

Valchlor®

  • Medicare: Added language requiring medication be used for "a medically accepted indication"

Vascepa® - No changes

Xeljanz®/ Xeljanz® XR

  • Commercial/Medicare: Added diagnosis of active psoriatic arthritis

Xiaflex® - No changes

Xifaxan®

  • Medicare: Added language requiring medication be used for "a medically accepted indication"

Xigduo® XR

  • Traditional and Optimized formularies: QL added, 10-500mg and 10-1000mg 30 per 30 days, 5-500mg and 5-1000mg 60 per 30 days, effective July 1, 2018

XiminoÔäó

  • Traditional and Optimized formularies: Removed

Xolair®

  • Commercial/Medicaid ÔÇô criteria changed to better align with similar agents for severe asthma (FasenraÔäó, Cinqair┬«, Nucala┬«)
    • Added requirement that patient must have been compliant on all of the following for at least 3 months: High-dose inhaled corticosteroid, long-acting beta agonist, and one additional asthma controller medication
    • Compliant use of step therapy medications (above) must not be effective
    • Must be steroid-dependent or steroid refractory after trials with maintenance therapy
    • Must not use in combination with other monoclonal antibodies
    • Addition to continuation requirement: Patient must not currently use tobacco products, or use Xolair┬« in combination with other monoclonal antibodies
    • Sdditional minor edits

Yondelis®

  • Commercial/Medicaid: Updated approved diagnosis to "unresectable or metastatic leiomyosarcoma" and "unresectable or metastatic jiposarcoma"

Zelboraf®

  • Commercial: Added diagnosis of Erdheim-Chester Disease with BRAF V600 mutation with a) symptomatic disease or b) central nervous system involvement OR c) evidence of organ dysfunction or impending organ dysfunction
  • Medicare: Added diagnosis of Erdheim-Chester Disease with BRAF V600 mutation