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®
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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)
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Commercial group and individual ACA plans: Change from T3 to NF
Glumetza® (metformin ER modified release)
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Commercial group and individual ACA plans: Change from T3 to NF
Invega® (paliperidone)
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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®
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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®
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Commercial group and individual ACA plans: Add QL effective 5/1/2017
mometasone furoate
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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™
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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®
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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®
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Commercial group and individual ACA plans: Change from T3 to NF; GF
Tresiba®
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Commercial group and individual ACA plans: Change from T3 to NF; GF
Vraylar™
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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
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Commercial group and individual ACA plans: NF
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Commercial group and individual ACA plans: No change
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Grandfathered through 12/31/2017
Aczone®
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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%
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Commercial group plans: Change from T1 to NF
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Commercial individual ACA plans: No change for 0.1% (NF); change from T1 to NF for 0.3%
adapalene 0.1% cream
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Commercial group plans: Change from T1 to T3
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Commercial individual ACA plans: No change (NF)
Aldurazyme® (larondase), for mucopolysaccharidosis I (MPS I)
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Commercial group plans: PA added
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Commercial individual ACA plans: No change
amlodipine besylate/ atorvastatin
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Commercial group plans: Change from T1 to T3
Amnesteem® (isotretinoin), for acne
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Commercial group plans: T2, PA required
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Medicare: No change
- Grandfathered through 12/31/2017
Androgel® and Androgel® Pump
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Commercial group and individual ACA plans: Change from T2 to NF
aplisol
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Commercial group and individual ACA plans: Change from T3 to medical benefit
Arymo ER™ (morphine sulfate ER tablet), for severe pain
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Commercial group and individual ACA plans: Non-preferred brand
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Medicare: NF
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ST for commercial/individual: Most first try two of the following: morphine sulfate ER, methadone, fentanyl patch, and Oxycontin (or Oxycontin ER)
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Est. cost: $7,500 annually
Axiron®
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Commercial and individual ACA plans: Change from T2 to NF
Azelex®
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Commercial group and individual ACA plans: Add ST with generic topical metronidazole or adapalene
Bavencio™ (avelumad), oncology
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Commercial group and individual ACA plans: Medical benefit, preferred specialty; PA
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Medicare: Tier 5, PA for B/D
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Est. cost: $188,000 annually
Betoptic S®
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Commercial group and individual ACA plans: Change from T2 to T3
Bromsite® (bromfenac ophthalmic solution), for ocular inflammation and pain
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Commercial group and individual ACA plans: Non-preferred brand
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Medicare: Tier 3
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Est. cost: $300/course of treatment
Candin®
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Commercial group and individual ACA plans: Change from T3 to medical benefit
Cerezyme® (imglucerase), for Gaucher's disease
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Commercial group and individual ACA plans: PA added
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Medicare: No change
-
Est. cost: N/A
Claravis™ (isotretinoin), for acne
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Commercial group and individual ACA plans: T2, PA required
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Medicare: No change
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Grandfathered through 12/31/2017
clindamycin/tretinoin
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Commercial group and individual ACA plans: Change from T1 to NF
coenzyme Q10
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Commercial group plans: Change from T2 to NF
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Commercial individual ACA plans: No change
Cuprimine®
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Commercial group and individual ACA plans: Change from T2 to NF
Depen® Titrateable Tablets
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Commercial group and individual ACA plans: Change from T3 to T4
Differin® 0.1% gel OTC
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Commercial group and individual ACA plans: Change from NF to T3
Dyrenium®
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Commercial group and individual ACA plans: Change from T3 to NF, GF
Edecrin®
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Commercial group and individual ACA plans: change from T3 to NF, non-GF, letter sent to members
Elaprase® (idursulfase), for mucopolysaccharidosis II (Hunter syndrome)
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Commercial group and individual: PA added
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Medicare: No change
Eleyso® (taliglucerase), for Gaucher's disease
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Commercial group and individual ACA plans: PA added
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Medicare: No change
Epiduo®, Epiduo® Forte
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Commercial group and individual ACA plans: Add ST, must first try adapalene and benzoyl peroxide in combination
ethacrynic acid
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Commercial group and individual ACA plans: change from T1 to NF, non-GF
Eucrisa™ (crisaorole), for atopic dermatitis
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Commercial group and individual ACA plans: Non-preferred brand; ST (must first try Elidel or tacrolimus ointment)
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Medicare: NF
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Est. cost: $8,400 yearly
fluvastatin and fluvastatin ER
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Commercial group and individual ACA plans: Change from T1 to T3
Fortesta®
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Commercial group and individual ACA plans: Change from T3 to NF
Kisqali™ (ribociclib), oncology
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Commercial group and individual ACA plans: Preferred specialty, PA, QL of 63 per 28 days
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Medicare: Tier 5, PA
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Est. cost: $171,000 yearly
Lemtrada® (alemtuzumab), for Multiple Sclerosis
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Commercial group and individual ACA plans: Removing coverage, adding Ocrevus™
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Medicare: No change
Myorisan™ (isotretinoin), for acne
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Commercial group and individual ACA plans: T2, PA required
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Medicare: No change
-
Grandfathered through 12/31/2017
Naglazyme® (galsufase), for mucopolysaccharidosis VI (Maroteaux-Lamy syndrome)
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Commercial group and individual ACA plans: PA added
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Medicare: No change
Ocrevus™ (ocrelizumab IV infusion), for Multiple Sclerosis
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Commercial group and individual ACA plans: Medical benefit, preferred specialty, PA
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Medicare: Part B, PA
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Est. cost: $78,000 yearly
olmesartan medoxomil
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Commercial group and individual ACA plans: Change from T1 to T3
olmesartan medoxomil/ amlodipine
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Commercial group and individual ACA plans: Change from T1 to T3
olopatadine
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Commercial group and individual ACA plans: Change from T1 to T3
Phenadoz®
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Commercial group and individual ACA plans: Added to formulary, T3
Promethegan™
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Commercial group and individual ACA plans: Change from T1 to T3
Revlimid®
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Commercial group and individual ACA plans: Added PA, GF
Rhofade™ (oxymetazoline hydrochloride), for persistent facial erythema
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Commercial group and individual ACA plans: Non-preferred brand; AL, min. 18 years; QL, 1 pkg./month
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Medicare: Tier 4; AL, min. 18 years; QL, 1 pkg./month
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Est. cost: $6,800 yearly
Saphris®
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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®
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Commercial group and individual ACA plans: Change from T2 to T3
Syprine®
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Commercial group and individual ACA plans: Add PA
Tanzeum®
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Commercial group plans: Add ST through preferred brand
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Commercial individual ACA plans: No change
Tazorac®
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Commercial group and individual ACA plans: Add ST, must first try one generic topical retinoid (adapalene or tretinoin)
Testim®
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Commercial group and individual ACA plans: Change from T3 to NF
Thalomid®
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Commercial group and individual ACA plans: Added PA, GF
trandolapril/ verapamil
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Commercial group and individual ACA plans: Change from T1 to T3
tretinoin microsphere (generic Retin-A® Micro)
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Commercial group and individual ACA plans: Add ST with generic topical retinoid (adapalene or tretinoin). Age limit remains.
Trulance™ (placanatide), for gastrointestinal use
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Commercial group and individual ACA plans: Non-preferred brand; ST, must first try amitiza and Linzess; QL, 1 tablet/day
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Medicare: NF
-
Est. cost: $4,700 yearly
Trulicity®
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Commercial group plans: Change from T3 to T2
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Commercial individual ACA plans: Change from T3 to T2, PA remains in place
Veltin®
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Commercial group and individual ACA plans: Change from T4 to T3
Viagra®
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Commercial group plans: Change from T2 to T3, add ST through preferred brand
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Commercial individual ACA plans: No change, not covered
Victoza®
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Commercial group plans: change from T2 to T3, add ST through preferred brand
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Commercial individual ACA plans: Change from T2 to T3, PA remains in place
Vpriv® (velaglucerase alfa), for Gaucher's disease
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Commercial group and individual ACA plans: PA added
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Medicare: No change
-
Est. cost: N/A
Vyvanse® chewable (lisdexamfetamine), for ADHD and binge-eating disorder
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Commercial group and individual ACA plans: Preferred brand; AL, min. 6 years; QL, 1 tablet/day
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Medicare: Tier 4; AL, min. 6 years; QL, 1 tablet/day
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Est. cost: $4,000 yearly
Welchol™
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Commercial group and individual ACA plans: ST added, must first try cholestyramine or colestipol
Xermelo™ (telotristat ethyl), for Carcinoid syndrome diarrhea
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Commercial group and individual ACA plans: Preferred specialty; PA
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Medicare: Tier 5; PA
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Est. cost: $80,000 yearly
Xultophy® (insulin degludec/liraglutide), for diabetes
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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
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Medicare: Tier 4; QL, 15ml per 30 days; not to be used with basal insulin and/or GLP-1
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Est. cost: $14,000 yearly
Zenatane™ (isotretinoin), for acne
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Commercial group and individual ACA plans: T2, PA required
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Medicare: No change
-
Grandfathered through 12/31/2017
Ziana®
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Commercial group and individual ACA plans: Change from T3 to NF
Zyflo®
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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® |
Key
ALL CAPS = Brand names
lower case = generic names
AL = Age limit
B/D = Coverage varies under Medicare Part B (hospitalization) vs. Part D (prescription) benefits
FF = "Free first fill" drug will be provided at zero cost-sharing the first time you fill it
HI = Home infusion drug
LA = Limited availability (available only at certain pharmacies)
NF = Non-formulary (not on Approved Drug List)
PA = Prior authorization from Priority Health is needed
QL = Quantity limits apply
ST = Step therapy (trying other drugs first) is required