March 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 March 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.

Changes effective May 1, 2017

ADLYXIN (lixisenatide), for diabetes, Type 2

  • Commercial group and individual: Non-preferred brand, PA added for individual, ST for group
  • Medicare: Tier 4
  • Est. yearly cost: $8,024

BASAGLAR (glargine insulin), for diabetes

  • Commercial group and individual: NF
  • Medicare: Tier 4

CAYSTON (aztreonam), for cystic fibrosis

  • Commercial group and individual: Preferred specialty, PA added
  • Medicare: No change

EPANED (enalapril solution), for hypertension

  • Commercial group: Non-preferred brand, AL max. 9 years old
  • Commercial individual: NF
  • Medicare: NF
  • Est. yearly cost: $7,092

KYLEENA (levonorgestrel-releasing intrauterine system), a long-acting contraceptive

  • Commercial group and individual: Medical benefit
  • Medicare: Part B
  • Est. yearly cost: $1,030

RUBRACA (rucaparib), for ovarian cancer

  • Commercial group and individual: Preferred specialty, PA added
  • Medicare: T5
  • Est. yearly cost: $197,856

SOLIQUA (insulin glargine/lixisenatide), for diabetes, type 2

  • Commercial group and individual: Non-preferred brand, QL added. PA added for commercial individual.
  • Medicare: T4
  • Est. yearly cost: $10,973

SPINRAZA (nusinersen sodium), for spinal muscular atrophy (SMA)

  • Commercial group and individual: Medical benefit, preferred specialty. PA added.
  • Medicare: Part B
  • Est. cost, first year: $1,050. Est. annual maintenance cost: $450,000

SUBOXONE (buprenorphine/naloxone), for drug dependence

  • Commercial group and individual: No tier change, PA added for individual
  • Medicare: No change

VELCADE (bortezomib), oncology

  • Commercial group and individual: No tier change, PA added
  • Medicare: No change

ZINPLAVA (bezlotoxumab), to reduce CDI recurrences (not a treatment)

  • Commercial group and individual: NF
  • Medicare: Part B, PA added
  • Est. cost: $4,560 per dose

ZUBSOLV (buprenorphine/naloxone), for drug dependence

  • Commercial group and individual: No tier change, PA added for individual
  • Medicare: No change

Prior authorization requirements reviewed

The P&T Committee reviewed the medical criteria for 42 drugs on the Approved Drug List. Prior authorization requirements were updated for the following drugs. 

See each drug page for details:

No changes were made to the following prior authorization requirements: