Formulary updates, May 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 May 16, 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

Fanapt®

  • Commercial group and individual ACA plans: ST criteria updated, must first try two of the following for 28 days: olanzapine, quetiapine (immediate or extended release), risperidone, ziprasidone, or aripiprazole; GF

Fortamet® (metformin ER OSM tablet)

  • Commercial group and individual ACA plans: Change from T3 to NF

Glumetza® (metformin ER modified release)

  • Commercial group and individual ACA plans: Change from T3 to NF

Invega® (paliperidone)

  • Commercial group and individual ACA plans: ST criteria updated, must first try two of the following for 28 days: olanzapine, quetiapine (immediate or extended release), risperidone, ziprasidone, or aripiprazole; GF

Latuda®

  • Commercial group and individual ACA plans: ST criteria updated, must first try two of the following for 28 days: olanzapine, quetiapine (immediate or extended release), risperidone, ziprasidone, or aripiprazole; GF

Linzess®

  • Commercial group and individual ACA plans: Add QL effective 5/1/2017

mometasone furoate

  • Commercial group and individual ACA plans: Change from T1 to T3; add ST, must first try one of fluticasone (Flonase) or flunisolide or triamcinolone acetonide (Nasacort AQ); GF

Rexulti™

  • Commercial group and individual ACA plans: ST criteria updated, must first try two of the following for 28 days: olanzapine, quetiapine (immediate or extended release), risperidone, ziprasidone, or aripiprazole; GF

Saphris®

  • Commercial group and individual ACA plans: ST criteria updated, must first try two of the following for 28 days: olanzapine, quetiapine (immediate or extended release), risperidone, ziprasidone, or aripiprazole; GF

Tirosint®

  • Commercial group and individual ACA plans: Change from T3 to NF; GF

Tresiba®

  • Commercial group and individual ACA plans: Change from T3 to NF; GF

Vraylar

  • Commercial group and individual ACA plans: ST criteria updated, must first try two of the following for 28 days: olanzapine, quetiapine (immediate or extended release), risperidone, ziprasidone, or aripiprazole; GF

Changes effective July 1, 2017

Absorica® (isotretinoin), for acne

  • Commercial group and individual ACA plans: NF

  • Commercial group and individual ACA plans: No change

  • Grandfathered through 12/31/2017

Aczone®

  • Commercial group and individual ACA plans: Add ST, must first use generic antibiotic/ benzoyl peroxide combination

adapalene 0.1% gel and lotion; adapalene 0.3%

  • Commercial group plans: Change from T1 to NF

  • Commercial individual ACA plans: No change for 0.1% (NF); change from T1 to NF for 0.3%

adapalene 0.1% cream

  • Commercial group plans: Change from T1 to T3

  • Commercial individual ACA plans: No change (NF)

Aldurazyme® (larondase), for mucopolysaccharidosis I (MPS I)

  • Commercial group plans: PA added

  • Commercial individual ACA plans: No change

amlodipine besylate/ atorvastatin

  • Commercial group plans: Change from T1 to T3

Amnesteem® (isotretinoin), for acne

  • Commercial group plans: T2, PA required

  • Medicare: No change

  • Grandfathered through 12/31/2017

Androgel® and Androgel® Pump

  • Commercial group and individual ACA plans: Change from T2 to NF

aplisol

  • Commercial group and individual ACA plans: Change from T3 to medical benefit

Arymo ER (morphine sulfate ER tablet), for severe pain

  • Commercial group and individual ACA plans: Non-preferred brand

  • Medicare: NF

  • ST for commercial/individual: Most first try two of the following: morphine sulfate ER, methadone, fentanyl patch, and Oxycontin (or Oxycontin ER)

  • Est. cost: $7,500 annually

Axiron®

  • Commercial and individual ACA plans: Change from T2 to NF

Azelex®

  • Commercial group and individual ACA plans: Add ST with generic topical metronidazole or adapalene

Bavencio (avelumad), oncology

  • Commercial group and individual ACA plans: Medical benefit, preferred specialty; PA

  • Medicare: Tier 5, PA for B/D

  • Est. cost: $188,000 annually

Betoptic S®

  • Commercial group and individual ACA plans: Change from T2 to T3

Bromsite® (bromfenac ophthalmic solution), for ocular inflammation and pain

  • Commercial group and individual ACA plans: Non-preferred brand

  • Medicare: Tier 3

  • Est. cost: $300/course of treatment

Candin®

  • Commercial group and individual ACA plans: Change from T3 to medical benefit

Cerezyme® (imglucerase), for Gaucher's disease

  • Commercial group and individual ACA plans: PA added

  • Medicare: No change

  • Est. cost: N/A

Claravis (isotretinoin), for acne

  • Commercial group and individual ACA plans: T2, PA required

  • Medicare: No change

  • Grandfathered through 12/31/2017

clindamycin/tretinoin

  • Commercial group and individual ACA plans: Change from T1 to NF

coenzyme Q10

  • Commercial group plans: Change from T2 to NF

  • Commercial individual ACA plans: No change

Cuprimine®

  • Commercial group and individual ACA plans: Change from T2 to NF

Depen® Titrateable Tablets

  • Commercial group and individual ACA plans: Change from T3 to T4

Differin® 0.1% gel OTC

  • Commercial group and individual ACA plans: Change from NF to T3

Dyrenium®

  • Commercial group and individual ACA plans: Change from T3 to NF, GF

Edecrin®

  • Commercial group and individual ACA plans: change from T3 to NF, non-GF, letter sent to members

Elaprase® (idursulfase), for mucopolysaccharidosis II (Hunter syndrome)

  • Commercial group and individual: PA added

  • Medicare: No change

Eleyso® (taliglucerase), for Gaucher's disease

  • Commercial group and individual ACA plans: PA added

  • Medicare: No change

Epiduo®, Epiduo® Forte

  • Commercial group and individual ACA plans: Add ST, must first try adapalene and benzoyl peroxide in combination

ethacrynic acid

  • Commercial group and individual ACA plans: change from T1 to NF, non-GF

Eucrisa (crisaorole), for atopic dermatitis

  • Commercial group and individual ACA plans: Non-preferred brand; ST (must first try Elidel or tacrolimus ointment)

  • Medicare: NF

  • Est. cost: $8,400 yearly

fluvastatin and fluvastatin ER

  • Commercial group and individual ACA plans: Change from T1 to T3

Fortesta®

  • Commercial group and individual ACA plans: Change from T3 to NF

Kisqali (ribociclib), oncology

  • Commercial group and individual ACA plans: Preferred specialty, PA, QL of 63 per 28 days

  • Medicare: Tier 5, PA

  • Est. cost: $171,000 yearly

Lemtrada® (alemtuzumab), for Multiple Sclerosis

  • Commercial group and individual ACA plans: Removing coverage, adding Ocrevus™

  • Medicare: No change

Myorisan (isotretinoin), for acne

  • Commercial group and individual ACA plans: T2, PA required

  • Medicare: No change

  • Grandfathered through 12/31/2017

Naglazyme® (galsufase), for mucopolysaccharidosis VI (Maroteaux-Lamy syndrome)

  • Commercial group and individual ACA plans: PA added

  • Medicare: No change

Ocrevus (ocrelizumab IV infusion), for Multiple Sclerosis

  • Commercial group and individual ACA plans: Medical benefit, preferred specialty, PA

  • Medicare: Part B, PA

  • Est. cost: $78,000 yearly

olmesartan medoxomil

  • Commercial group and individual ACA plans: Change from T1 to T3

olmesartan medoxomil/ amlodipine

  • Commercial group and individual ACA plans: Change from T1 to T3

olopatadine

  • Commercial group and individual ACA plans: Change from T1 to T3

Phenadoz®

  • Commercial group and individual ACA plans: Added to formulary, T3

Promethegan

  • Commercial group and individual ACA plans: Change from T1 to T3

Revlimid®

  • Commercial group and individual ACA plans: Added PA, GF

Rhofade (oxymetazoline hydrochloride), for persistent facial erythema

  • Commercial group and individual ACA plans: Non-preferred brand; AL, min. 18 years; QL, 1 pkg./month

  • Medicare: Tier 4; AL, min. 18 years; QL, 1 pkg./month

  • Est. cost: $6,800 yearly

Saphris®

  • Commercial group and individual ACA plans: ST criteria updated, must first try two of the following for 28 days: olanzapine, quetiapine (immediate or extended release), risperidone, ziprasidone, or aripiprazole; GF

Simbrinza®

  • Commercial group and individual ACA plans: Change from T2 to T3

Syprine®

  • Commercial group and individual ACA plans: Add PA

Tanzeum®

  • Commercial group plans: Add ST through preferred brand

  • Commercial individual ACA plans: No change

Tazorac®

  • Commercial group and individual ACA plans: Add ST, must first try one generic topical retinoid (adapalene or tretinoin)

Testim®

  • Commercial group and individual ACA plans: Change from T3 to NF

Thalomid®

  • Commercial group and individual ACA plans: Added PA, GF

trandolapril/ verapamil

  • Commercial group and individual ACA plans: Change from T1 to T3

tretinoin microsphere (generic Retin-A® Micro)

  • Commercial group and individual ACA plans: Add ST with generic topical retinoid (adapalene or tretinoin). Age limit remains.

Trulance (placanatide), for gastrointestinal use

  • Commercial group and individual ACA plans: Non-preferred brand; ST, must first try amitiza and Linzess; QL, 1 tablet/day

  • Medicare: NF

  • Est. cost: $4,700 yearly

Trulicity®

  • Commercial group plans: Change from T3 to T2

  • Commercial individual ACA plans: Change from T3 to T2, PA remains in place

Veltin®

  • Commercial group and individual ACA plans: Change from T4 to T3

Viagra®

  • Commercial group plans: Change from T2 to T3, add ST through preferred brand

  • Commercial individual ACA plans: No change, not covered

Victoza®

  • Commercial group plans: change from T2 to T3, add ST through preferred brand

  • Commercial individual ACA plans: Change from T2 to T3, PA remains in place

Vpriv® (velaglucerase alfa), for Gaucher's disease

  • Commercial group and individual ACA plans: PA added

  • Medicare: No change

  • Est. cost: N/A

Vyvanse® chewable (lisdexamfetamine), for ADHD and binge-eating disorder

  • Commercial group and individual ACA plans: Preferred brand; AL, min. 6 years; QL, 1 tablet/day

  • Medicare: Tier 4; AL, min. 6 years; QL, 1 tablet/day

  • Est. cost: $4,000 yearly

Welchol

  • Commercial group and individual ACA plans: ST added, must first try cholestyramine or colestipol

Xermelo (telotristat ethyl), for Carcinoid syndrome diarrhea

  • Commercial group and individual ACA plans: Preferred specialty; PA

  • Medicare: Tier 5; PA

  • Est. cost: $80,000 yearly

Xultophy® (insulin degludec/liraglutide), for diabetes

  • Commercial group and individual ACA plans: Non-preferred brand; QL, 15ml per 30 days; not to be used with basal insulin and/or GLP-1

  • Medicare: Tier 4; QL, 15ml per 30 days; not to be used with basal insulin and/or GLP-1

  • Est. cost: $14,000 yearly

Zenatane (isotretinoin), for acne

  • Commercial group and individual ACA plans: T2, PA required

  • Medicare: No change

  • Grandfathered through 12/31/2017

Ziana®

  • Commercial group and individual ACA plans: Change from T3 to NF

Zyflo®

  • Commercial group and individual ACA plans: Change from T3 to T5

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. 

Harvoni®

Keytruda®

Fabrazyme®

Ibrance®

Solvadi®

Vimizim®

No changes were made to the following prior authorization requirements:

Cosentyx®

Erwinaze®

Farydak™

Flector™

Juxtapid®

Kadcycla™

Korlym®

Kynamro™

Lenvima®

Lovaza®

Makena®

Nplate®

Orenitram®

Orkambi™

Osphena®

Otezla®

Pomalyst™

Prolia®

Promacta®

Ravicti®

Sancuso®

Seroquel XR™

Serostim®