July 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 July 17, 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.
New drugs reviewed/additions effective September 1, 2018
AIMOVIG™ (erenumab-aooe)
- Migraine prevention
- PA required for Traditional, Optimized and Medicare
- Traditional and Optimized formularies: Non-preferred specialty
- Medicare: Tier 5
- Est. cost: $8,280/year
AKYNZEO® IV (Fosnetupitant and Palonosetron)
- Chemo-induced nausea and vomiting
- Added as Non-Preferred Medical benefit
- Added as Medical Benefit for Medicaid
- Traditional and Optimized formularies: Non-Preferred Specialty
- Medicare: Part B medical drug
- Est. cost: $510/vial
CRYSVITA® (burosumab-twza)
- X-linked hypophosphatemia
- Traditional and Optimized: Medical benefit- Preferred Specialty, PA required
- Medicare: Part B medical drug
- Est. cost: $106,000-$477,000/year
DEXYCU ™ (dexamethasone 9% intraocular suspension)
- Cataract surgery
- Traditional and Optimized commercial formularies: Not added
- Medicare: Part B medical drug
- Est. cost: $648/year
LUCEMYRA™ (lofexidine)
- Opioid detoxification
- Traditional and Optimized: Non-formulary
- Medicare: Non-formulary
- $4635/treatment
OSMOLEX ER™ (amantadine)
- Parkinson's disease and drug-induced extrapyramidal reactions in adult patients
- Traditional and Optimized : Non-formulary
- Medicare: Non-formulary
- Est. cost: $5400/year
TAVALISSE™ (fostamatinib disodium hexahydrate)
- Chronic idiopathic thrombocytopenic purpura (ITP)
- Traditional and Optimized : Non-formulary
- Medicare: Non-formulary
- Est. cost: $136,000/year
Prior authorization requirements for the following drugs were updated.
ADCIRCA® (tadalafil)
Traditional & Optimized: Added requirement: must first try sildenafil (generic Revatio®)
CINQAIR® (resilizumab)
Traditional & Optimized: Removed the requirement that a patient must be steroid-dependent or steroid-refractory. For continuation, remove requirement that patient must be compliant on an ICS/LABA plus one other asthma medication and replace with requirement that patient must be compliant on Cinqair®.
DARAPRIM® (pyrimethamine)
Medicaid only:
Initial authorization 6 weeks for toxoplasmosis and 3 months for pneumocystis. For continuation authorization may be required every 6 months for toxoplasmosis and every 3 months for pneumocystis.
Criteria for continuation added for toxoplasmosis prophylaxis:
- Patient remains symptomatic
- Patient not receiving antiretroviral therapy
- Patient has detectable HIV viral load
- Patient has maintained a CD4 could above 200 cells/microliter for less than six months
Criteria for continuation added for pneumocystis prophylaxis:
- CD4 count less than 200 cells/microliter
- Oropharyngeal candidiasis
- CD4 count percentage less than 14
- CD4 cell count between 200 and 250 cells/microliter if frequent monitoring is not possible
FANAPT® (iloperidone)
Traditional & Optimized: New form
FASENRA™ (benralizumab)
Traditional & Optimized: Removed the requirement that a patient must be steroid-dependent or steroid-refractory. For continuation, remove requirement that patient must be compliant on an ICS/LABA plus one other asthma medication and replace with requirement that patient must be compliant on Fasenra™.
HEXALEN® (altretamine
Traditional, Optimized, and Medicaid: New form
ILUVIEN® (fluocinolone acetonide implant)
Traditional, Optimized, and Medicaid: New form
MEKINIST® (trametinib)
Medicare: Added diagnosis of locally advanced or metastatic anaplastic thyroid carcinoma
Traditional & Optimized: Added diagnosis of locally advanced or metastatic anaplastic thyroid carcinoma. Must be used in combination with Tafinlar®.
NUCALA® (mepolizumab)
Traditional & Optimized: Removed the requirement that a patient must be steroid-dependent or steroid-refractory. For continuation, remove requirement that patient must be compliant on an ICS/LABA plus one other asthma medication and replace with requirement that patient must be compliant on Nucala®.
OZURDEX® (dexamethasone implant)
Traditional, Optimized, and Medicaid: New form
SABRIL® (vigabatrin)
Traditional & Optimized: For diagnosis of infantile spasms, patient must now be age 2 or younger.
SOLIRIS® (eculizumab)
Traditional, Optimized, and Medicaid: For diagnosis of refractory generalized myasthenia gravis, criteria no longer includes an inadequate response or contraindication to medications specified on form.
TAFINLAR® (dabrafenib)
Traditional & Optimized and Medicare: Diagnosis of locally advanced or metastatic anaplastic thyroid carcinoma added.
XELJANZ® (tofacitinib)
Traditional & Optimized: Diagnosis of Ulcerative Colitis added; patient must be 18 years old and has tried at least one systemic agent from list of medications on form.
XOLAIR® (omalizumab)
Traditional & Optimized: Removed the requirement that a patient must be steroid-dependent or steroid-refractory.
Changes to the formularies effective September 1, 2018
The P&T Committee reviewed the following medications and medical criteria changes are listed below.
DIBENZYLINE® (phenoxybenzamine)
Removed from formulary
Changes to the formularies effective January 1, 2019
The P&T Committee reviewed the following medications and medical criteria changes are listed below.
aripiprazole ODT 10mg, 15mg
Add age limit of 12 years and younger
caffeine citrate
Add age limit of 1 year and younger
carbamazepine ER tablet (except 400mg ER)
- Moved from Preferred Brand to Generic
- QL added, 100mg and 200mg of 60 tablets per 30 days
Carbamazepine ER 400mg
QL added, 120 tablets per 30 days
chlorpromazine 10mg, 25mg, 50mg, 100mg, 200mg
- Moved from Generic to Preferred Brand
- QL added, 180 tablets per 30 days
clomipramine 25mg, 50 mg, 75mg capsules
Moved from Generic to Preferred Brand
DAYTRANA® (methylphenidate) patch
Optimized: Non-formulary
Traditional: ST added. Must try one of the following: generic dexmethylphenidate HCL ER, methylphenidate HCL ER, methylphenidate HCL CD (generics of Focalin XR, Ritalin LA, and Metadate CD)
Dextroamphetamine sulfate ER
Moved from Generic to Preferred Brand
EDLUAR® (zolpidem tartrate)
Removed from formulary
FANAPT® (iloperidone)
- ST removed
- PA added
Fluphenazine 1mg, 2.5mg, 5mg and 10mg
- Moved from Generic to Preferred Brand
- QL added, 60 tablets per 30 days
HEXALEN® (altretamine)
- Moved from Non-Preferred Brand to Non-Preferred Specialty
- PA added
Imipramine pamoate 75mg, 100mg, 150mg
Moved from Generic to Preferred Brand
phenoxybenzamine
- Move from Non-Preferred Brand to Preferred Specialty
- PA added
ONFI® (clobazam) suspension
QL updated to 240ml per 30 days
quazepam
Removed from formulary
QUILLICHEW ER™ (methylphenidate hydrochloride)
- Optimized: Non-formulary
- Traditional: ST added, must try one of the following: generic dexmethylphenidate HCL ER, methylphenidate HCL ER, methylphenidate HCL CD (generics of Focalin XR, Ritalin LA, and Metadate CD)
QUILLIVANT XR® (methylephnidate hydrochloride)
- Optimized: Non-formulary
- Traditional: ST added, must try one of the following: generic dexmethylphenidate HCL ER, methylphenidate HCL ER, methylphenidate HCL CD (generics of Focalin XR, Ritalin LA, and Metadate CD)
SABRIL® (vigabatrin)
PA criteria updated
temazepam 7.5mg, 22.5mg
Removed from formulary
Tranylcypromine sulfate 10mg
Moved from Generic to Preferred Brand
vigabatrin powder packet
PA criteria updated