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
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

BELVIQ

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
  • ST with generic weight-loss drug
  • Est. annual cost: N/A
Effective date

01/01/2017

benzphetamine

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

BIVIACT
(brivaracetam)

Commonly used for:

Seizures

Formulary (ACA-compliant plans)

Commercial group/individual:

  • Non-preferred brand

Medicare:

  • Tier 5
What changed/notes
  • 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
Effective date

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
What changed/notes
  • PA
  • Limited to 14 days per dispensing for commercial
  • Est. annual cost: $198,000
Effective date

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