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.

Printable version of the P&T updates. 

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