Formulary updates, July 2016
From time to time, we add drugs to or remove them from Priority Health formularies. 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 list of the pending changes made by the P&T committee on July 19, 2016.
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.
ALLI
Commonly used for:Weight loss
Formulary (ACA-compliant plans)Commercial group/individual:
- Non-preferred brand
Medicare:
- NF
- Added for plans with Weight Loss Rider only
- ST with generic weight-loss drug
- Est. annual cost: N/A
01/01/2017
BELVIQ
Commonly used for:Weight loss
Formulary (ACA-compliant plans)Commercial group/individual:
- Non-preferred brand
Medicare:
- NF
- Added for plans with Weight Loss Rider only
- ST with generic weight-loss drug
- Est. annual cost: N/A
01/01/2017
benzphetamine
Commonly used for:Weight loss
Formulary (ACA-compliant plans)Commercial group/individual:
- Generic
Medicare:
- NF
- Added for plans with Weight Loss Rider only
- Est. annual cost: N/A
01/01/2017
BIVIACT
(brivaracetam)
Commonly used for:
Seizures
Formulary (ACA-compliant plans)Commercial group/individual:
- Non-preferred brand
Medicare:
- Tier 5
- ST with levetiracetam for commercial plans
- Age: Must be 16 or older
- QL 2 tablets daily or 10ml/daily for commercial plans
- Est. annual cost: $13,104
09/01/2016
CABOMETYX
(cabozantinib s-malate)
Commonly used for:
Renal cell carcinoma
Formulary (ACA-compliant plans)Commercial group/individual:
- Preferred specialty
Medicare:
- Tier 5
- PA
- Limited to 14 days per dispensing for commercial
- Est. annual cost: $198,000
09/01/2016
CINQAIR
(reslizumab)
- Commonly used for:
Eosinophilic asthma
- Formulary (ACA-compliant plans)
Commercial group/individual:
- Non-pref. specialty, medical benefit
Medicare:
- Part B
- What changed/notes
- PA
- Est. annual cost: $26,052
- Effective date
09/01/2016
CONTRAVE
- Commonly used for:
Weight loss
- Formulary (ACA-compliant plans)
Commercial group/individual:
- Non-pref. brand
Medicare:
- NF
- What changed/notes
- Added for plans with Weight Loss Rider only
- ST with generic weight-loss drug
- Est. annual cost: N/A
- Effective date
01/01/2017
DESCOVY
(emtricitabine (FTC) tenofovir alafenamide (TAF))
- Commonly used for:
HIV
- Formulary (ACA-compliant plans)
Commercial group/individual:
- Preferred specialty
Medicare:
- Tier 5
- What changed/notes
- QL: 1 tablet daily for commercial plans
- Est. annual cost: $21,116
- Effective date
09/01/2016
diethylpropion
- Commonly used for:
Weight loss
- Formulary (ACA-compliant plans)
Commercial group/individual:
- Generic
Medicare:
- NF
- What changed/notes
- QL: Once daily
- Added for plans with Weight Loss Rider only
- Est. annual cost: $N/A
- Effective date
01/01/2017
EPCLUSA
(sofosburvir/ velpatasvir))
- Commonly used for:
Hepatitis C
- Formulary (ACA-compliant plans)
Commercial group/individual:
- Preferred specialty
Medicare:
- Tier 5
- What changed/notes
- PA: Used for genotype 2, 3, 5 and 6 disease. Use Zepatier for genotypes 1 and 4 disease.
- Est. cost: $74,760/12 weeks
- Effective date
09/01/2016
EVOMELA
(melphalan)
- Commonly used for:
Multiple myeloma
- Formulary (ACA-compliant plans)
Commercial group/individual:
- Preferred specialty, medical benefit
Medicare:
- Tier 5
- What changed/notes
- Covered under medical benefit
- Est. cost: $300/vial
- Effective date
09/01/2016
IMBRUVICA
- Commonly used for:
Chronic lymphocyctic leukemia
- Formulary (ACA-compliant plans)
Commercial group/individual:
- Preferred specialty
Medicare:
- No change
- What changed/notes
- Tier change only
- Est. annual cost: N/A
- Effective date
09/01/2016
IMPAVIDO
(miltefosine)
- Commonly used for:
Leishmaniasis
- Formulary (ACA-compliant plans)
Commercial group/individual:
- Non-preferred brand
Medicare:
- Tier 5
- What changed/notes
- PA required
- Est. cost: $19,200/month
- Effective date
09/01/2016
NUPLAZID
(pimavanserin)
- Commonly used for:
Parkinson's disease psychosis
- Formulary (ACA-compliant plans)
Commercial group/individual:
- Preferred specialty
Medicare:
- Tier 5
- What changed/notes
- PA required
- Est. annual cost: $28,080
- Effective date
09/01/2016
ONZETRA XSAIL
(sumatriptan)
- Commonly used for:
Migraine
- Formulary (ACA-compliant plans)
Commercial group/individual:
- NF
Medicare:
- Tier 5
- What changed/notes
- ST for Medicare with sumatriptan nasal spray
- Est. cost: $2,242/month
- Effective date
09/01/2016
ORFADIN
(nitisinone)
- Commonly used for:
Hereditary tyrosinemia
- Formulary (ACA-compliant plans)
Commercial group/individual:
- Preferred specialty
Medicare:
- Tier 5
- What changed/notes
- PA: Commercial plans
- AL: On suspension, covered for up to 24 months
- Est. cost: $13,759-$39,234/month
- Effective date
09/01/2016
phendimetrazine tartrate
- Commonly used for:
Weight loss
- Formulary (ACA-compliant plans)
Commercial group/individual:
- Generic
Medicare:
- NF
- What changed/notes
- Added for plans with Weight Loss Rider only
- Est. annual cost: N/A
- Effective date
01/01/2017
phentermine
- Commonly used for:
Weight loss
- Formulary (ACA-compliant plans)
Commercial group/individual:
- Generic
Medicare:
- NF
- What changed/notes
- Added for plans with Weight Loss Rider only
- Est. annual cost: N/A
- Effective date
01/01/2017
QSYMIA
- Commonly used for:
Weight loss
- Formulary (ACA-compliant plans)
Commercial group/individual:
- Non-preferred brand
Medicare:
- NF
- What changed/notes
- Added for plans with Weight Loss Rider only
- Est. annual cost: N/A
- Effective date
01/01/2017
SERNIVO
(betamethasone dipropionate)
- Commonly used for:
Psoriasis
- Formulary (ACA-compliant plans)
Commercial group/individual:
- NF
Medicare:
- Tier 5
- What changed/notes
- ST: With betamethasone dipropionae cream, lotion or ointment
- Est. cost: $936/120g spray
- Effective date
09/01/2016
SOLVADI
- Commonly used for:
Hepatitis C
- Formulary (ACA-compliant plans)
Commercial group/individual:
- Non-preferred specialty
Medicare:
- No change
- What changed/notes
- PA: no change
- Tier change only
- Est. annual cost: N/A
- Effective date
09/01/2016
VENCLEXTA
(venetoclax)
- Commonly used for:
Chronic lymphocyctic leukemia
- Formulary (ACA-compliant plans)
Commercial group/individual:
- Non-preferred specialty
Medicare:
- Tier 4/Tier 5
- What changed/notes
- PA
- 10mg and 50mg are T4 for Medicare
- 100mg and starter packs are T5 for Medicare
- QL: 14 days per dispensing for commercial plans
- Est. annual cost: $137,661
- Effective date
09/01/2016
XTAMPZA ER
(oxycodone)
- Commonly used for:
Pain
- Formulary (ACA-compliant plans)
Commercial group/individual:
- Non-preferred brand
Medicare:
- NF
- What changed/notes
- ST: Must try first try OxyContin (or oxycodone ER), AND either methadone or fentanyl patch.
- Requested dose cannot exceed the previously trialed equivalent dose of OxyContin (or oxycodone ER).
- Est. cost: $242-$775/month
- Effective date
09/01/2016
The P&T Committee reviewed the medical criteria for 59 drugs on the Approved Drug List
Prior authorization requirements were updated for the following drugs were update. Go to the drug auth forms page for details:
ACTHAR BERINERT Botulinum toxin CINRYZE |
FIRAZYR Human Growth Hormone HYSINGLA ER KALBITOR |
NINLARO NUCALA OPDIVO ZOHYDRO ER |
No changes were made to the following prior authorization requirements:
ADCIRCA AFINITOR BOSULIF BUPHENYL CAPRELSA CHOLBAM COMETRIQ CYRAMZA dronabinol EMEND ERIVEDGE FLOLAN GATTEX GLEEVEC HARVONI ICLUSIG |
INLYTA JAKAFI LETAIRIS MATULANE NATPARA NEXAVAR REVLIMID SIGNIFOR sildenafil SPRYCEL STIVARGA SUTENT SYLATRON TARCEVA TARGRETIN TASIGNA |
temozolomide (TEMODAR) THALOMID TRACLEER TYKERB UNITUXIN VELETRI VENTAVIS VESANOID VOTRIENT XALKORI XTANDI YERVOY ZELBORAF ZOLINZA ZYTIGA |
Key:
AL = Age limit
B/D = Coverage varies under Medicare Part B (hospitalization) vs. Part D (prescription) benefits
FF = "Free first fill" drug will be provided at zero cost-sharing the first time
HI = Home infusion drug
LA = Limited availability (available only at certain pharmacies)
NF = Non-formulary (not on Approved Drug List)
PA = Prior authorization from Priority Health is needed
QL = Quantity limits apply
ST = Step therapy (trying other drugs first) is required