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 March 15, 2016.

Medicare Part D formulary changes: These 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.

ADDYI
(fibanserin)

• Commonly used for:

  HSDD

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-pref. specialty

  Medicare: Excluded

• What changed/notes

  QL: 30 tablets every 30 days

  Sexual Dysfunction rider required

  Est. annual cost: $9,600

• Effective date

  05/01/2016

ADYNOVATE
(antihemophilic factor [recombinant] PE Glycated)

• Commonly used for:

  Hemophilia

• Formulary (ACA-compliant plans)

  Commercial group/individual: Pref. specialty

  Medicare: Part B

• What changed/notes

  Must be ordered from approved in-network hemophilia specialty pharmacy

  Est. annual cost: varies

• Effective date

  05/01/2016

ALECENSA
(alectinib)

• Commonly used for:

  Cancer

• Formulary (ACA-compliant plans)

  Commercial group/individual: Pref. specialty

  Medicare: Tier 5

• What changed/notes

  PA required for commercial and individual; limited to 14 days per fill

  Est. annual cost: $148,000

• Effective date

  05/01/2016

BELBUCA
(buprenorphine buccal film)

• Commonly used for:

  Severe pain

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-pref. brand

  Medicare: Tier 5

• What changed/notes

  QL: 60 film strips every 30 days

  ST: must first try methadone and morphine sulfate

  Est. annual cost: $3,000 - $7,500

• Effective date

  05/01/2016

COAGADEX
(coagulation factor X)

• Commonly used for:

  Hemophilia

• Formulary (ACA-compliant plans)

  Commercial group/individual: Pref. specialty

  Medicare: Part B

• What changed/notes

  Must be ordered from approved in-network hemophilia specialty pharmacy

  Est. annual cost: Varies

• Effective date

  05/01/2016

ENSTILAR
(calcipotriene/ betamethasone)

• Commonly used for:

  Plaque psoriasis

• Formulary (ACA-compliant plans)

  Commercial group/individual: NF

  Medicare: Tier 5

• What changed/notes

  Not covered for commercial and individual plans

  Est. annual cost: $5,800 every 4 weeks

• Effective date

  05/01/2016

KANUMA
(sebelipase alfa)

• Commonly used for:

  Enzyme deficiency

• Formulary (ACA-compliant plans)

  Commercial group/individual: Pref. specialty, medical benefit

  Medicare: Tier 5

• What changed/notes

  Covered under medical benefit

  Est. annual cost: Varies

• Effective date

  05/01/2016

NARCAN nasal spray
(naloxone)

• Commonly used for:

  Opioid overdose

• Formulary (ACA-compliant plans)

  Commercial group/individual: NF

  Medicare: Tier 3

• What changed/notes

  Not covered for commercial and individual plans

  Medicare QL: 2 doses every 30 days

  Est. annual cost: $1,500

• Effective date

  05/01/2016

PRALUENT
(alirocumab)

• Commonly used for:

  Cholesterol

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-pref. specialty

  Medicare: Tier 5

• What changed/notes

  PA required

  Must be ordered from network specialty pharmacy

  Est. annual cost: $14,560

• Effective date

  05/01/2016

PORTRAZZA
(necitumumab)

• Commonly used for:

  Cancer

• Formulary (ACA-compliant plans)

  Commercial group/individual: NF

  Medicare: Tier 5

• What changed/notes

  Not added to commercial/individual formulary

  Medicare: PA for B/D

  Est. annual cost: $136,500

• Effective date

  05/01/2016

REPATHA
(evolocumab)

• Commonly used for:

  Cholesterol

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-pref. specialty

  Medicare: Tier 5

• What changed/notes

  PA required

  Must be ordered from network specialty pharmacy

  Est. annual cost: $19,000

• Effective date

  05/01/2016

UPTRAVI
(selexipag)

• Commonly used for:

  Pulmonary artery hypertension

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-pref. specialty

  Medicare: Tier 5

• What changed/notes

  PA required

  Must be ordered from network specialty pharmacy

  Est. annual cost: $112,000 - $174,000

• Effective date

  05/01/2016

VALTRESSA
(patiromer)

• Commonly used for:

  Hyperkalemia

• Formulary (ACA-compliant plans)

  Commercial group/individual: Pref. brand

  Medicare: Tier 3

• What changed/notes

  QL: 30 packets each fill

  Est. annual cost: $7,100

• Effective date

  05/01/2016

VITATRUE
(prenatal MVI/DHA)

• Commonly used for:

  Prenatal vitamin

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-pref. brand

  Medicare: Not covered

• What changed/notes

  Not covered under Medicare

  Est. annual cost: $1,200

• Effective date

  05/01/2016

VIVLODEX
(meloxicam)

• Commonly used for:

  Arthritis pain

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-pref. brand

  Medicare: NF

• What changed/notes

  PA required

  Est. annual cost: $7,100

• Effective date

  05/01/2016

ZYKADIA
(ceritinib)

• Commonly used for:

  Cancer

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-pref. specialty

  Medicare: Tier 5

• What changed/notes

  Moved to non-pref. specialty

  Est. annual cost: $162,000

• Effective date

  07/01/2016

The P&T Committee reviewed the medical criteria for 30 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:

ARZERRA COSENTYX (Commercial, Medicaid) DAKLINZA (Commercial, Medicare) DALVANCE

KEYTRUDA (Commercial, Medicaid) OPDIVO (Commercial, Medicaid) TAFINLAR (Commercial, Medicare) XYREM (Commercial)

No changes were made to the following prior authorization requirements:

ARALAST BENLYSTA BLINCYTO CIMZIA Dispense as written (DAW) DUOPA GLASSIA HUMIRA HYSINGLA IBRANCE Intravenous Immunoglobulin

KRYSTEXXA LYNPARZA MODANIFIL PROLASTIN PROVIGIL SIMPONI SOLIRIS TYSABRI XELJANZ XGEVA ZEMAIR

Note: For the precertification requirements for medications requiring prior approval, visit the Drug authorizations forms page and click on the applicable prior authorization form.