Formulary updates, July 2017

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 July 17, 2017.

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.

Drugs added effective Sept. 1, 2017

AlunbrigÔäó (brigatinib)

  • Oncology
  • Commercial group and individual: Non-Preferred Specialty
  • Medicare: T5
  • PA, all plans; QL 14-day supply per fill for commercial
  • Must be ordered from Accredo specialty pharmacy
  • Est. cost: $208, 000 annually

AustedoÔäó (deutetrabenazine)

  • HuntingtonÔÇÖs disease chorea
  • Commercial group and individual: Preferred Specialty
  • Medicare: T5
  • PA; QL- 6mg limited to 8/day, 9mg limited to 5/day,  12mg limited to 4/day
  • Est. cost: $142,000 annually

AirDuoÔäó Respiclick (fluticasone propionate and salmeterol)

  • Asthma
  • Commercial group and individual: NF, use generic
  • Medicare: NF, use generic 
  • Est. cost: $4,100 annually

BrineuraÔäó (cerliponase)

  • Batten Disease (specific subset)
  • Commercial group and individual: Medical Benefit - Preferred Specialty
  • Medicare: T5
  • PA; B/D 
  • Est. cost: $842,000 annually

Dupixent® (dupilumad)

  • Atopic Dermatitis
  • Commercial group and individual: Preferred Specialty
  • Medicare: T5
  • PA; QL 3 syringes the first month and then 2 syringes every 28 days
  • Must be ordered from a specialty pharmacy
  • Est. cost: $44,000 annually

fluticasone propionate/salmeterol

  • Authorized generic for AirDuoÔäó Respiclick
  • Asthma
  • Commercial group and individual: Generic
  • Medicare: T2
  • Est. cost: $1,350 annually

ImfinziÔäó (durvalumab)

  • Urothelial carcinoma
  • Commercial group and individual: Medical Benefit - Preferred Specialty
  • Medicare: T5
  • PA; B/D 
  • Est. cost: $174,000 annually

IngrezzaÔäó (valbenazine)

  • Tardive Dyskinesia
  • Commercial group and individual: Non-Preferred Specialty
  • Medicare: T5
  • PA; QL 2 caps per day
  • Est. cost: $152,000 annually

RydaptÔäó (midostaurin)

  • Oncology
  • Commercial group and individual: Preferred Specialty
  • Medicare: T5
  • PA; QL embedded in PA
  • Est. cost: $459,000 annually

TymlosÔäó (abaloparatide)

  • Osteoporosis
  • Commercial group and individual: Preferred Specialty
  • Medicare: T5
  • PA; QL 1 pen per 30 days
  • Est. cost: $23,000 annually

ZejulaÔäó (niraparib)

  • Oncology
  • Commercial group and individual: Preferred Specialty
  • Medicare: T5
  • PA, all plans
  • QL for commercial plans, 3/day limited to 14 day supply
  • Est. cost: $212,000 annually

Other changes effective Sept. 1, 2017

ACTEMRA® PA criteria reviewed, updates made
ADCIRCA® PA criteria reviewed, no changes made
AFINITOR® PA criteria reviewed, no changes made
alogliptin PA criteria reviewed, no changes made
alprazolam ODT Move from T1 to T2 for commercial
AMRIX® Removed from commercial formulary
APAP/Caffeine/dihydrocodeine 325/30/16mg Removed from commercial formulary
APLENZIN® Removed from commercial formulary
APTIOM PA criteria reviewed, updates made
aripiprazole ODT Move from T1 to T3 for commercial
armodafinil Move from T1 to T3 for commercial
armodafinil PA criteria reviewed, updates made
ARZERRA® PA criteria reviewed, updates made
AVEED® PA criteria reviewed, updates made
AVONEX® PA criteria reviewed, no changes made
AZILECT® Updated ST requirements for commercial plans
BANZEL® Move from T2 to T4 for commercial; PA criteria reviewed, updates made
BELSOMRA® Updated ST requirements for commercial plans
BENLYSTA® PA criteria reviewed, updates made
BOSULIF® PA criteria reviewed, no changes made
botulinum PA criteria reviewed, updates made
BRISDELLE® Removed from commercial formulary
BRIVIACT® PA criteria reviewed, updates made
BUPHENYL® PA criteria reviewed, no changes made
CAPRELSA® PA criteria reviewed, no changes made
carbamazepine ER Updated ST requirements for commercial plans
carbamazepine ER Move from T1 to T2 for commercial
carbidopa Move from T1 to T3 for commercial
carisoprodol, carisoprodol/aspirin Removed from commercial formulary
CAYSTON® PA criteria reviewed, no changes made
CHOLBAM® PA criteria reviewed, no changes made
CIMZIA® PA criteria reviewed, updates made
CINQAIR® PA criteria reviewed, no changes made
CLARAVISÔäó PA criteria reviewed, no changes made
clozapine ODT Move from T1 to T3 for commercial
COMETRIQ® PA criteria reviewed, no changes made
COSENTYX® PA criteria reviewed, updates made
COTELLIC® PA criteria reviewed, no changes made
CYRAMZA® PA criteria reviewed, no changes made
DARAPRIM® PA criteria reviewed, no changes made
DEPEN® PA criteria reviewed, updates made
desipramine Move from T1 to T2 for commercial
DESOXYN® (methamphetamine) Removed from commercial formulary
desvenlafaxine ER (generic PRISTIQ┬« and generic KHEDEZLAÔäó) Updated ST requirements for commercial plans
DPP-4 (2 forms) PA criteria reviewed, no changes made
dronabinol PA criteria reviewed, no changes made
EMEND® PA criteria reviewed, no changes made
EMSAM® Updated ST requirements for commercial plans
ENBREL® PA criteria reviewed, updates made
EQUETRO® Updated ST requirements for commercial plans
ERIVEDGE® PA criteria reviewed, no changes made
ERWINAZE® PA criteria reviewed, updates made
felbamate Move from T1 to T2 for commercial plans
FETZIMAÔäó Updated ST requirements for commercial plans
FIRAZYR® PA criteria reviewed, updates made
FLOLAN® PA criteria reviewed, no changes made
fluoxetine DR Commercial plans: Updated ST requirements and moved from T1 to T2
fluvoxamine ER Move from T1 to T3 for commercial plans
FORFIVO® XL Removed from commercial formulary
FORTEO® PA criteria reviewed, updates made
FYCOMPAÔäó Updated ST requirements for commercial plans
GATTEX® PA criteria reviewed, no changes made
GILENYA® PA criteria reviewed, no changes made
GLATOPA® PA criteria reviewed, no changes made
GLEEVEC® PA criteria reviewed, no changes made
GLP-1 (2 forms) PA criteria reviewed, no changes made
GRALISE® PA criteria reviewed, updates made, removed from individual commercial formulary
HARVONI® PA criteria reviewed, no changes made
HUMIRA® PA criteria reviewed, updates made
ICLUSIG® PA criteria reviewed, no changes made
ILARIS® PA criteria reviewed, updates made
IMBRUVICA® PA criteria reviewed, updates made
imipramine pamoate capsule Commercial plans: Move from T1 to T3, updated ST requirements
IMPAVIDO® PA criteria reviewed, no changes made
INLYTA® PA criteria reviewed, no changes made
INTERMEZZO® Removed from commercial formulary
IVIG PA criteria reviewed, updates made
JAKAFI® PA criteria reviewed, no changes made
KALYDECOÔäó PA criteria reviewed, updates made
KEYTRUDA® PA criteria reviewed, updates made
KHEDEZLAÔäó Updated step therapy requirements for commercial plans
lamotrigine ER Move from T1 to T3 for commercial, updated ST requirements for commercial plans
lamotrigine ODT Move from T1 to T3 for commercial
LENVIMA® PA criteria reviewed, updates made
LETAIRIS® PA criteria reviewed, no changes made
LYRICA® Commercial plans: Move from T2 to T3, updated ST requirements
MATULANE® PA criteria reviewed, no changes made
memantine titration pack Move from T1 to T2 for commercial
meprobamate Removed from commercial formulary
MESTINON® TIMESPAN (pyridostigmine bromide ER) Removed from commercial formulary
Narcan nasal spray Add to the commercial formulary
NATPARA® PA criteria reviewed, no changes made
NEXAVAR® PA criteria reviewed, no changes made
NICOTROL® Nasal Spray Move from T2 to T3 for commercial
NPLATE® PA criteria reviewed, updates made
NUCALA® PA criteria reviewed, no changes made
NUPLAZID® PA criteria reviewed, no changes made
octreotide PA criteria reviewed, no changes made
olanzapine ODT Move from T1 to T2 for commercial
olopatadine 0.1% solution Move from T1 to T2 for commercial
ONFI® Move from T2 to T3 for commercial
ORFADIN® PA criteria reviewed, no changes made
OTEZLA® PA criteria reviewed, updates made
OXTELLARÔäó PA criteria reviewed, updates made; updated ST requirements for commercial
paliperidone ER Commercial plans: Updated ST requirements, moved from T1 to T3
paroxetine ER Commercial plans: Updated ST requirements, moved from T1 to T2
PROLIA® PA criteria reviewed, updates made
protriptyline Move from T1 to T2 for commercial
PROVENGE® PA criteria reviewed, updates made
QUDEXY® XR Removed from commercial formulary
quetiapine ER Commercial plans: Move from T1 to T3, updated ST requirements
QUFLORA/FEÔäó Removed from commercial formulary
rasagiline Commercial plans: Move from T1 to T3, updated ST requirements 
RAVICTI® PA criteria reviewed, updates made
REPATHA® PA criteria reviewed, no changes made
REVLIMID® PA criteria reviewed, no changes made
risperidone ODT Move from T1 to T2 for commercial
rivastigmine transdermal Move from T1 to T3 for commercial
ropinerole ER Updated ST requirements for commercial plans
ROZEREM® Updated ST requirements for commercial plans
RYTARYÔäó Removed from commercial formulary
SABRIL® PA criteria reviewed, updates made
SAVELLA® Updated ST requirements for commercial plans
SAVELLA® titration pack Updated ST requirements for commercial plans
SGLT-2 (2 forms) PA criteria reviewed, no changes made
SIGNIFOR® PA criteria reviewed, no changes made
sildenafil (REVATIO®) PA criteria reviewed, no changes made
SIMPONI® PA criteria reviewed, updates made
SKELAXIN┬« (metaxolone)
Removed from commercial formulary
SOLIRIS® PA criteria reviewed, updates made
SOMA® (carisoprodol) Removed from commercial formulary
SOMA® COMPOUND (carisoprodol/aspirin) Removed from commercial formulary
SOMA┬« COMPOUND w/ CODEINE (carisoprodol/aspirin/codeine)
Removed from commercial formulary
SPRYCEL® PA criteria reviewed, no changes made
STELARA® PA criteria reviewed, updates made
STIVARGA® PA criteria reviewed, no changes made
STIVARGA® PA criteria reviewed, updates made
STRATTERA® Move from T2 to T3 for commercial
SUTENT® PA criteria reviewed, no changes made
SYLATRONÔäó PA criteria reviewed, no changes made
SYMBYAX® (olanzapine/fluoxetine) Removed from commercial formulary
TARCEVA® PA criteria reviewed, no changes made
TARGRETIN® PA criteria reviewed, no changes made
TASIGNA® PA criteria reviewed, no changes made
TECENTRIQÔäó PA criteria reviewed, updates made
TECFIDERA® PA criteria reviewed, no changes made
temozolomide (TEMODAR®) PA criteria reviewed, no changes made
TESTOPEL® PA criteria reviewed, updates made
tetrabenazine PA criteria reviewed, updates made
THALOMID® PA criteria reviewed, no changes made
THIOLA® PA criteria reviewed, updates made
tiagabine Move from T1 to T3 for commercial
topiramate ER spinkle caps Commercial plans: Move from T1 to T3, updated ST requirements
topiramate sprinkle caps Updated ST requirements for commercial plans
TRACLEER® PA criteria reviewed, no changes made
tretinoin (generic VESANOID®) PA criteria reviewed, no changes made
TRINTELLIX Updated ST requirements for commercial plans
TROKENDIÔäó XR Removed from commercial formulary
TYKERB® PA criteria reviewed, no changes made
UNITUXIN® PA criteria reviewed, no changes made
VANATOLÔäó LQ Removed from commercial formulary
VASCEPA® PA criteria reviewed, updates made
VELETRI® PA criteria reviewed, no changes made
VENCLEXTAÔäó PA criteria reviewed, no changes made
VENTAVIS® PA criteria reviewed, no changes made
VIIBRYD Updated ST requirements for commercial plans
VIMPAT Move from T2 to T3 for commercial
VOTRIENT® PA criteria reviewed, no changes made
XALKORI® PA criteria reviewed, no changes made
XARELTO® PA criteria reviewed, no changes made
Xatmep with age limit 9 years Add to the commercial formulary
XENAZINE® Removed from commercial formulary
XGEVA® PA criteria reviewed, updates made
XIAFLEX® PA criteria reviewed, updates made
XTANDI® PA criteria reviewed, no changes made
YERVOY® PA criteria reviewed, no changes made
ZELBORAF® PA criteria reviewed, no changes made
ZOLINZA® PA criteria reviewed, no changes made
ZYTIGA PA criteria reviewed, no changes made