March 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 March 20, 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 May 1, 2018

Admelog® (insulin lispro)

  • Added to the formularies
  • Type 1 and type 2 diabetes
  • Traditional and Optimized formularies: Non-preferred Brand
  • Medicare: NF
  • ST: must first try Humalog (Traditional and Optimized
  • AL: Covered up to age 21 (Optimized only)
  • Est. cost: Varies

Cinvanti™ (aprepitant injectable emulsion)

  • Added to the formularies
  • Nausea
  • Traditional and Optimized formularies: Medical benefit
  • Medicare: NF
  • Medicaid: Medical benefit
  • Est. cost: $300/vial

Idhifa® (enasidenib)

  • Added to the formularies
  • Acute myeloid leukemia
  • Traditional and Optimized formularies: Preferred Specialty, PA, QL (30/30 days)
  • Medicare: No change
  • Medicaid: N/A
  • Est. cost: $360,000/year

Luxturna™ (voretigene neparvovec)

  • Added to the formularies
  • Retinal dystrophy
  • Traditional formulary: Medical benefit, Preferred Specialty, PA, Gene Therapy Rider required
  • Optimized formulary: Not covered
  • Medicare: Part B
  • Medicaid: Not covered
  • Est. cost: $1,00,000/year

Mepsevii™ (vestonidase alfa-vjbk)

  • Added to the Medicare formulary
  • Mucopolysaccharidosis VII
  • Traditional and Optimized formularies: Not covered
  • Medicare: Part B
  • Medicaid: Not covered
  • Est. cost: $2 million/year

Mylotarg® (gemtuzumab ozogamicin)

  • Added to the formularies
  • Acute myeloid leukemia
  • Traditional and Optimized formularies: Medical benefit, Non-preferred Specialty, PA 
  • Medicare: T5, B/D
  • Medicaid: Medical benefit, PA
  • Est. cost: $30,000 to $108,000/treatment

Nerlynx® (neratinib)

  • Added to the formularies
  • Breast cancer
  • Traditional and Optimized formularies: Preferred Specialty, PA 
  • Medicare: No change
  • Medicaid: NF, carve out
  • Est. cost: $153,000/year

Noctiva™ (desmopressin)

  • Not added to the formularies
  • Nocturia
  • Est. cost: $5,400/year

Odactra™ (house dust mite allergen)

  • Added to the formularies
  • Allergic rhinitis
  • Traditional and Optimized formularies: Non-preferred Brand, AL (covered between ages 18-65 years)
  • Medicare: Part B
  • Medicaid: N/A
  • Est. cost: $3,600/year

Prevymis® (letemovir)

  • Added to the formularies
  • Prophylaxix of cytomegalovirus infection and disease
  • Traditional and Optimized formularies: Preferred Specialty, PA
  • Medicare: T5, PA
  • Medicaid: N/A
  • Est. cost: $23,000/100 days

Rebinyn® (GlycoPEGlylated, recombinant DNA-derived coagulation Factor IX concentrate)

  • Added to the formularies
  • Acute treatment for patients with Hemophilia B
  • Traditional and Optimized formularies: Non-preferred Specialty
  • Medicare: Part B
  • Medicaid: NF (carve out)
  • Must be filled at a participating hemophilia pharmacy
  • Medical policy 91569 will be updated to add this drug
  • Est. cost: $29,200/claim

Solosec™ (secnidazole)

  • Not added to the formularies
  • Bacteria vaginosis
  • Est. cost: $324/treatment

Steglatro™ (ertugliflozin)

  • Added to the formularies
  • Type 2 diabetes
  • Traditional formulary: Non-preferred Brand; ST (must first try Farxiga, Xigduo, Jardiance or Synjardy); QL (30/30 days)
  • Optimized formulary: Non-preferred Brand; PA; QL (30/30 days)
  • Medicare: T4; ST (must first try Jardiance, Synjardy, Farxiga or Xigduo XR); QL (30/30 days)
  • Medicaid: N/A
  • Est. cost: $4,000/year

Steglujan™ (ertugliflozin/sitagliptin)

  • Added to the formularies
  • Type 2 diabetes
  • Traditional formulary: Non-preferred Brand
  • Optimized formulary: Non-preferred Brand; PA; QL (30/30 days)
  • Medicare: T4; QL (30/30 days)
  • Medicaid: NF
  • Est. cost: $6,200/year

Segluromet™ (ertugliflozin/metformin)

  • Added to the formularies
  • Type 2 diabetes
  • Traditional formulary: Non-preferred Brand; ST (must first try Farxiga, Xigduo, Jardiance or Synjardy); QL (630/30 days)
  • Optimized formulary: Non-preferred Brand; PA; QL (30/30 days)
  • Medicare: T4; ST (must first try Jardiance, Synjardy, Farxiga or Xigduo XR); QL (60/30 days)
  • Medicaid: N/A
  • Est. cost: $3,200/year

Sublocade™ (buprenorphine ER injection)

  • Added to the formularies
  • Opioid Use Disorder
  • Traditional and Optimized formularies: Medical benefit, Preferred Specialty; PA
  • Medicare: Part B
  • Medicaid: Not covered
  • Est. cost: $24,000/year

Verzenio™ (abemaciclib)

  •  Added to the formularies
  • Breast cancer
  • Traditional and Optimized formularies: Preferred Specialty; PA
  • Medicare: No change
  • Medicaid: N/A
  • Est. cost: $169,000/year

Vyxeos® (daunorubicin liposomal/cytarabine liposomal)

  • Added to the formularies
  • Acute myeloid leukemia
  • Traditional and Optimized formularies: Medical benefit, Preferred Specialty, PA
  • Medicare: T5, B/D
  • Medicaid: Medical benefit; PA
  • Est. cost: $94,000/treatment

Changes to the formularies effective July 1, 2018

The P&T Committee reviewed the following medications and medical criteria changes are listed below. 

Commercial = Includes both the Traditional and Optimized formularies

Acthar®

  • No changes

Actimmune®

  • No changes

Afinitor®

  • No changes

Aldurazyme®

  • No changes

Alecensa®

  • No changes

Altoprev® (lovastatin ER tablet)

  • Commercial: Removed from the formularies

amlodipine/valsartan/HCTZ

  • Commercial: Tier change to generic

Antara® (fenofibrate 30mg and 90mg capsule)

  • Commercial: Removed from the formularies

Arnuity® Ellipta® (fluticasone furoate inhalation powder)

  • Traditional: Tier change to Generic
  • Optimized: Tier change to Preferred Brand

Aralast NP

  • No changes

Bavencio®

  • No changes

Benicar® (olmesartan/amlodipine)

  • Commercial: Remove ST

Benicar® HCT (olmesartan/HCTZ)

  • Commercial: Remove ST

Benlysta®

  • No changes

Bevespi Aerosphere® (formoterol fumarate and glycopyrrolate)

  • Commercial: Tier change to Preferred Brand

Breo™ Ellipta™ (fluticasone and vilanterol)

  • Commercial: Removed from the formularies

Brovana® (arformoterol tartrate)

  • Commercial: Tier change to Preferred Specialty

Blincyto®

  • Commercial: For diagnosis of Philadelphia chromosome-positive acute lymphoblastic leukemia, must first fail two tyrosine kinase inhibitors.
  • Medicare: Add diagnosis of Philadelphia chromosome–positive relapsed or refractory B cell precursor acute lymphoblastic leukemia.

Bosulif®

  • Commercial and Medicare: Separation of criteria based on whether diagnosis is chromosome-positive or negative.

Briviact®

  • No changes

Buphenyl®

  • No changes

Chemet® (succimer)

  • Commercial: Tier change to Preferred Specialty

Cimzia®

  • No changes

Cleocin® Ovule (clindamycin phosphate)

  • Commercial: Removed from the formularies

Clindesse® (clindamycin)

  • Commercial:  Add ST; requires trial with clindamycin 2% vaginal cream.

Depen®

  • No changes

dibenzyline capsule

  • Commercial: Removed from the formularies

diltiazem ER 12-hour capsule

  • Commercial: Tier change to Preferred Brand

diltiazem ER 24-hour capsule

  • Commercial: Tier change to Preferred Brand

diltiazem CD 24-hour ER capsule, 360mg

  • Commercial: Removed from the formularies

dronabinol

  • No changes

Entresto® (sacubitril/valsartan)

  • Commercial: Tier change to Preferred Brand

ezetimibe/simvastatin

  • Commercial: Remove ST

Flagyl ER 750mg

  • Commercial: Removed from the formularies

fenofibrate 50mg and 150mg capsules

  • Commercial: Removed from the formularies

Flovent®/Flovent® HFA (fluticasone)

  • Traditional: Tier change to Generic
  • Optimized: Tier change to Preferred Brand

Gilotrif®

  • Commercial and Medicare: Clarification of criteria for metastatic non-small-cell lung cancer.

Glassia

  • No changes

Humira®

  • No changes

Hysingla® ER

  • No changes

Ibrance®

  • No changes

Imbruvica®

  • Commercial: Add diagnosis of classic chronic graft vs. host disease, with significant criteria for approval.

Imfinzi®

  • Commercial and Medicaid: Add diagnosis of unreselectable stage III non-small-cell lung cancer.

Inderal® XL (propranolol capsule)

  • Commercial: Removed from the formularies

Inflectra® (infliximab-dyyp)

  • Commercial: Tier change to Medical benefit, Preferred Specialty; no change to PA

Innopran XL® (propranolol Hcl capsule)

  • Commercial: Removed from the formularies

IVIG

  • No changes

Kanuma®

  • No changes

Krystexxa®

  • No changes

Lartruvo™

  • No changes

levalbuterol tartrate HFA

  • Commercial: Tier change to Preferred Brand

Lynparza®

  • Commercial and Medicare: Add diagnosis of HER2-negative metastatic breast cancer.

metoprolol succinate ER/HCTZ tablet

  • Commercial: Removed from the formularies

modafinil

  • No changes

Multaq® (dronedarone tablet)

  • Commercial: Tier change to Non-preferred Brand

naloxone 0.4mg/mL vial

  • Commercial: Tier change to Generic; QL 2 vials/year

naloxone 1mg/mL syringe

  • Commercial: Tier change to Generic; QL 2 syringes/year

nicardipine HCl

  • Commercial: Tier change to Preferred Brand

nisoldipine ER

  • Commercial: Tier change to Preferred Brand

Nitro-Bid® (nitroglycerin)

  • Commercial: Tier change to Generic

Nuvessa™ (metronidazole vaginal gel 1.3%)

  • Commercial: Removed from the formularies

Nucala®

  • Commercial: Add diagnosis of Eosinophilic granulomatosis with polyangitis and criteria, clarification of criteria for diagnosis of severe eosinophilic asthma.

Nucynta® ER

  • Optimized: Created new drug-specific form.

olmesartan/amlodipine

  • Commercial: Tier change to Generic; remove ST

olmesartan/amlodipine/HCTZ

  • Commercial: Tier change to Generic; remove ST

omega-3-acid ethyl esters

  • Commercial: Remove PA

Opdivo®

  • Commercial and Medicaid: Add approved diagnoses of melanoma with lymph node involvement/metastatic disease after undergoing complete resection, as well as hepatocellular carcinoma previously treated with sorafenib (Nexavar®), (Child-Pugh Class A or B7 only).
  • Medicare: Add approved diagnosis of melanoma with lymph node involvement/metastatic disease after undergoing complete resection.

Orfadin®

  • No changes

Perforomist® (formoterol fumarate)

  • Commercial: Tier change to Preferred Specialty

phenoxybenzamine capsule

  • Commercial: Tier change to Preferred Specialty; PA added

Praluent®

  • No changes

Prolastin®

  • No changes

quinidine gluconate CR

  • Commercial: Tier change to Preferred Brand

Remicade® (infliximab)

  • Commercial: Excluded; removed from the formularies
  • Medicare: Add biosimilars Renflexis® and Inflectra® to Part B form, and Inflectra® only to Part D form.

Renflexis™ (infliximab abda)

  • Commercial: Medical benefit, tier change to Non-preferred Specialty. Add diagnosis of Eosinophilic granulomatosis with polyangitis and criteria, clarification of criteria for diagnosis of severe eosinophilic asthma.

Revlimid®

  • No changes

Rituxan™

  • Commercial and Medicaid: For diagnosis of follicular lymphoma, addition of criteria that Rituxan™ will be covered as single-agent maintenance therapy for patients achieving a complete or partial response to rituximab in combination with chemotherapy.

sildenafil 20mg tablet

  • Commercial: Tier change to Non-preferred Brand

Simponi®

  • No changes

Soliris®

  • Commercial: Add diagnosis of refractory generalized myasthenia gravis (MG) with criteria.

Stivarga®

  • Commercial: Removal of 90mg dosing criteria for plaque psoriasis and psoriatic arthritis.

Syprine®

  • Commercial: Removed from the formularies

Tarceva®

  • Commercial: For diagnosis of glioblastoma multiforme of brain, Tarceva® must now be used concomitantly with temozolamide and radiotherapy then as maintenance in combination with temozolomide.

Targretin®

  • Commercial and Medicare: Removal of diagnosis of non-small-cell lung cancer.

Tasigna®

  • No changes

telmisartan/HCTZ

  • Commercial: Tier change to Generic

temozolomide

  • Commercial: Removal of diagnosis of non-small-cell lung cancer.
  • Medicaid: Remove prior authorization form.

tetrabenazine

  • No changes

Thiola

  • No changes

tretinoin

  • No changes

Tribenzor®

  • Commercial: Remove ST

trientine 250mg capsule

  • Commercial: Tier change to Non-preferred Specialty; QL 5 capsules/day

Tysabri®

  • Commercial and Medicaid: For diagnosis of relapsing-remitting multiple sclerosis, add Glatopa® and glatiramer acetate to list of acceptable step therapy drugs.

Uptravi®

  • No changes

Veletri®

  • No changes

Vytorin® (ezetimibe/simvastatin)

  • Commercial: Remove ST for brand and generic

Xarelto®

  • No changes

Xeljanz®

  • Medicare: Add diagnosis of active psoriatic arthritis, update criteria to patient must have tried and failed one oral DMARD AND one injectable biologic DMARD. 

Xgeva®

  • No changes

Xyrem®

  • No changes

Zelboraf®

  • No changes

Zemaira

  • No changes

Zolinza®

  • No changes

Zytiga®

  • All plans: Add diagnosis of high-risk castration-sensitive prostate cancer and criteria.