May 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 May 15, 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 July 1, 2018

BIKTARVY® (bictegravir/emtricitabine/tenofovir)

• Added to formularies
• HIV
• Traditional and Optimized formularies: Preferred specialty
• Medicare: Tier 5
• QL: 1 tablet per day
• Est. cost: $3,000/month

CIMDUO™ (lamivudine/tenofovir disoproxil fumarate)

• Added to formularies
• HIV
• Traditional and Optimized formularies: Preferred specialty
• Medicare: Tier 5
• QL: 1 tablet per day
• Est. cost: $34/tablet

ERLEADA™ (apalutamide)

• Added to formularies
• Prostate cancer
• Traditional and Optimized formularies: Preferred specialty
• Medicare: Tier 5
• PA required for all LOB
• QL for Traditional and Optimized #56/14 days. Limited to 14 days per fill
• QL for Medicare #120/30 days
• Requires fill at Specialty pharmacy for Traditional and Optimized
• Est. cost: $157,000/year

FIRVANQ™ (vancomycin)

• Added to formularies
• C. difficile infection
• Traditional and Optimized formularies: Preferred brand
• Medicare: Not covered
• Est. cost: $128/fill

FREESTYLE LIBRE FLASH (flash glucose monitoring system)

• Added to formularies
• Diabetes
• Traditional and Optimized formularies: Preferred brand
• Medicare: Part B DME
• QL for Traditional and Optimized of #3 sensors/30 day and #1 receiver/Year
• Est. cost: $63

LONHALA™ MAGNAIR™ (glycopyrrolate)

• Not added to formularies
• COPDTraditional and Optimized formularies: Non-formulary
• Medicare: Non-formulary
• Est. cost: $15,000/year

UTATHERA® (lutetium Lu 177 dotatate)

• Added to formularies
• Gastroenteropancreatic Neuroendocine Tumors
• Traditional and Optimized formularies: Medical benefit- preferred specialty
• Medicare: Part B medical
• PA required for Traditional and Optimized
• Est. cost: $228,000/year

MAKENA® (hydroxyprogesteron) SC

• Added to formularies
• Preterm labor
• Traditional and Optimized formularies: Medical benefit- preferred specialty
• Medicare: Non formulary
• PA required for Traditional and Optimized
• Est. cost: $803/dose

OZEMPIC® (semaglutide)

• Added to formularies
• Diabetes
• Traditional and Optimized formularies: non preferred brand
• Medicare: Tier 4
• ST – for Traditional and Medicare
• PA for Optimized
• Est. cost: $8,800/year

PLIAGLIS (lidocaine/ tetracaine)

• Not added to formulary
• Local anesthesia
• Traditional and Optimized formularies: non formulary
• Medicare: non formulary
• Est. cost: $247/30grams

RHOPRESSA® (netarsudil ophthalmic solution)

• Not added to Traditional, Optimized, or Medicare formulary
• Increased intraocular pressure
• Traditional and Optimized formularies: non formulary
• Medicare: non formulary
• Est. cost: $6,600/year

SINUVA™ (mometasone furoate)

• Not added to Traditional or Optimized formulary
• Nasal polyps
• Traditional and Optimized formularies: non formulary
• Medicare: Part B medical
• Est. cost: $1,300/year

SYMDEKO™ (tezacaftor/ivacaftor and ivacaftor tablets)

• Added to formularies
• Cystic fibrosis
• Traditional and Optimized formularies: preferred specialty
• Medicare: Tier 5
• PA required for all Medicare, Optimized and Traditional
• Requires fill at Specialty pharmacy for Traditional and Optimized
• Est. cost: $323,000/dose

SYMFI™ (efavirenz/lamivudine/tenofovir disoproxil fumate)

• Added to formularies
• HIV
• Traditional and Optimized formularies: Preferred specialty
• Medicare: Tier 5
• QL: 1 tablet per day
• Est. cost: $54/tablet

SYMFI™ LO (efavirenz/lamivudin/tenofovir disoproxil fumate) 

• Added to formularies
• HIV
• Traditional and Optimized formularies: Preferred specialty
• Medicare: Tier 5
• QL: 1 tablet per day
• Est. cost: $54/tablet

TROGARZO™ (ibalizumab-uiyk)

• Added to formularies
• HIV
• Traditional and Optimized formularies: Preferred specialty
• Medicare: Tier 5
• PA required for all Medicare, Optimized and Traditional
• Est. cost: $104,500/year

ZYPITAMAG™ (pitavastatin)

• Not added to formularies
• Hyperlipidemia
• Traditional and Optimized formularies: non formulary
• Medicare: non formulary
• Est. cost: $7.75/tablet

Prior authorization requirements for the following drugs were updated (see priorityhealth.com for the revised forms):

Commercial = Includes both the Traditional and Optimized formularies

ARYMO® ER

• Commercial: What is considered ‘failure’ on step therapy medications is now defined.
• Updated morphine equivalent dose chart.

BLINCYTO®

• Medicare: Removal of requirement that B cell precursor acute lymphoblastic leukemia diagnosis must be either Philadelphia chromosome positive or negative. In addition, if acute lymphoblastic leukemia is in first or second remission it must have MRD greater than or equal to 0.1%
• Commercial and Medicaid: Patient must now have diagnosis of Philadelphia chromosome-negative relapsed or refractory B-cell acute lymphoblastic leukemia which has an MRD of greater than or equal to 0.1% if in first or second remission, or Philadelphia chromosome-positive acute lymphoblastic leukemia that is refractory or patient is intolerant to TKI

CRESEMBA®

• Commercial: New Form

EMBEDA®

• Commercial: What is considered ‘failure’ on step therapy medications is now defined.
• Updated morphine equivalent dose chart.

HYSINGLA™ ER

• Commercial: Must trial and fail Oxycontin and indicate reason for failure.

LENVIMA®

• Commercial and Medicare: Added new drug strengths to form

LUCENTIS®

• Commercial and Medicaid: Additional language added stating that amount covered will be limited to the dosing as published on the FDA-approved label.

miglustat

• Commercial: New Form

NOXAFIL®

• Commercial: New Form

NUCYNTA® ER

• Commercial Optimized: What is considered ‘failure’ on step therapy medications is now defined.

• Updated morphine equivalent dose chart.

RUBRACA®

• Commercial: Add diagnosis of Recurrent ovarian cancer with a complete or partial response to platinum-based chemotherapy

SPORANOX®

• Commercial: New form

SUBLOCADE™

• Commercial: New Form as discussed at March P&T meeting

TAGRISSO™

• Medicare and Commercial: For EGFR mutation-positive non-small cell lung cancer, office must submit documentation of EDFR exon 19 deletion or exon 21 L858R mutation

TARGRETIN®

• Commercial: Addition of Targretin 1% gel to form
• Removal of AIDS- related Kaposi’s sarcoma, lymphomatoid papulosis , and moderate to severe chronic plaque type psoriasis as approved diagnoses.
• Medicare: Addition of Targretin 1% gel to form

XTAMPZA™ ER

• Commercial: What is considered ‘failure’ on step therapy medications is now defined.
• Updated morphine equivalent dose chart.

XTANDI

• Commercial and Medicaid: Xtandi will not be authorized in combination with Zytiga or Erleada

XYREM®

• Commercial: Must be prescribed by board certified sleep specialist or neurologist
• Medications used prior to request must have documented therapeutic trial and patient must have continued to have persistent sleepiness that significantly impairs the ability to function or poses a danger to them and others.
• Office must fax MSLT plus polysomnogram results and they must meet requirements from International Classification of Sleep Disorders for a diagnosis of narcolepsy.
• Patient must not drink alcohol when using Xyrem
• For continuation, patient must meet precertification requirements, be adsent of unacceptable toxicities, and have a response to therapy with a reduction in daytime sleepiness or reduced frequency of cataplexy attacks.

ZOHYDRO® ER

• Commercial: What is considered ‘failure’ on step therapy medications is now defined.
• Updated morphine equivalent dose chart.

ZYTIGA®

• Commercial and Medicaid: Zytiga will not be authorized in combination with Xtandi or Erleada

Changes to the formularies effective July 1, 2018

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

adapalene 0.1% cream

• Remove Age Limit

adapalene 0.3%

• Added as Preferred Brand

AFLURIA

• Update age edits covered 5 years and up

AFLURIA QUADRIVALENT

• Update age edits covered 18 years and up

ANALPRAM HC® Lotion 2.5%

• Added as Preferred Brand

BEXSERO

• Update age edits covered for ages 18-25

• clindamycin/tretinoin

• Added as Preferred Brand

CRESEMBA®

• PA Added

• Add QL of #60/30 days, 3 months per 365 days

cromolyn sodium 4% eye drops

• Move to generic tier

diclofenac 1% solution

• Remove from Step Therapy from Optimized

DIFFERIN 0.1% CREAM

• Remove Age Limit

DUAC®

• Added as Preferred Brand

ENGERIX-B 10mcg/0.5 mL (Pediatric)

• Update age edits covered up to age 19

ENGERIX-B 20mcg/1ml

• Update age edits covered ages 20 and up

erythromycin/benzoyl peroxide

• Move to Preferred Brand

FLUBLOK QUADRIVALENT

• Update age edits 18 years and up

FLULAVAL QUADRIVALENT

• Update age edits covered 6 months and up

FLUVIRIN

• Update age edits covered 4 years and up

FLUZONE QUADRIVALENT (0.25ml) PEDIATRIC

• Update age edits covered 6-35 months

FLUZONE QUADRIVALENT 5ml multi-dose vial only

• Update age edits covered 6 months and up

FLUZONE INTRADERMAL QUADRIVALENT 

• Update age edits covered 18 years – 64 years

Havrix 1440 ELISA/mL

• Update age edits covered 19 years old and up

hydrocortisone/pramoxine 2.5%/1% cream

•  Added as Preferred Brand 

miglustat

• Add as Non-Preferred Brand

• Add with PA

MOXEZA® (moxifloxacin)

• Move to Non-Preferred Brand

NOXAFIL® 100mg

• Add PA

• Add QL of #180/30 days, 3 months per 365 days

NOXAFIL® 40mg/ml

• Add PA

• Add QL of #450ml/30 days, 3 months per 365 days

OTOVEL (cipro/fluocinolone) ear drops

• Add Age limit of 6 months to 17 years

prednisolone sodium phosphate 1% eye drop

• Move to generic tier

RECOMBIVAX HB 5mcg/0.5ml (pediatric/adolescent)

• Update age edits covered up to age 19

RECOMBIVAX HB 10mcg/ml

• Update age edits covered ages 20 and up

SIMBRINZA® (brimonidine 0.2% and brinzolamide 1%)

• Move to Preferred Brand Tier

SPORANOX® 100mg

• Removed from Formulary

SPORANOX® 10mg/ml

• Moved to Preferred Specialty

PA added

• QL of 600mls/30 days and 3 months/365 days

SYNERA®

• Removed from Formulary

TAZORAC® (SSB only)

• Update step therapy – must first try tazarotene 0.1% cream

TRUMENBA

• Update age edits covered 18-25 years of age

vancomycin

• Removed from Formulary

Vaqta 50 unit (1 mL)

• Update age edits covered 19 years and up

XIIDRA™ (lifitegrast)

• Moved to Preferred Brand

ZAVESCA®

• Removed from Formulary

Changes to the formularies effective January 1, 2019

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

Ammonium lactate (all)

• Removed from formulary

AQUORAL®

• Removed from formulary

benzoyl peroxide 5% and 10% wash

• Removed from formulary

bimatoprost 0.03% ophthalmic solution

• Move to Preferred Brand

BLEPHAMIDE®

• Move to Non-Preferred Brand

BP 5% and 10% gel (benzoyl peroxide)

• Removed from Formulary

BP 5.5% Gel (benzoyl peroxide)

• Removed from Formulary

BP Wash (brand and generics)

• Removed from Formulary

BPO 4% gel, 8% gel, 4% creamy wash, 8% creamy wash, 10% wash, 5% wash

• Removed from Formulary

bromfenac 0.09% eye drops

• Move to Preferred Brand

BROMSITE™

• Removed from Formulary for Optimized only

clindamycin/benzoyl peroxide

• Move to Preferred Brand

CORTIFOAM® 10% foam

• Move to Non-Preferred Brand

• ST added – Must first try hydrocortisone 100mg enema.

dapsone 5% gel

• Move to Non-Preferred Brand

erythromycin/benzoyl peroxide

• Move to Non-Preferred Brand

FLUOROPLEX® 1% cream (fluorouracil)

• Move to Preferred Specialty

fluorouracil 0.5% cream

• Move to Non-Preferred Specialty

GELCLAIR®

• Removed from Formulary

GERI-HYDROLOAC™ (all)

• Removed from Formulary

hydrocortisone acetate 30 mg supp generics and brands (includes HEMMOREX-HC™ 30mg supp & PROCTOCORT® 30mg supp)

• Move to Non-Preferred Brand

hydrocortisone butyrate 0.1% lotion

• Removed from Formulary

hydrocortisone 1% cream generics and brands (includes Proctocort 1% cream, Procto-Pak 1% cream)

• Removed from Formulary

itraconazole 100mg

• Move to Preferred Brand

• Add QL of #120/30 days and 3 months per 365 days

LACRISERT® (hydroxypropyl cellulose)

• Move to Preferred Specialty

lidocaine/hydrocortisone (includes kits, cream)

• Removed from Formulary

lidocaine/hydrocortisone/aloe generics and brands

• Removed from Formulary

LOTEMAX® 0.5% eye drops

• Must first try 1 generic ophthalmic steroid

LOTEMAX® 0.5% gel drops

• Must first try 1 generic ophthalmic steroid

LOTEMAX® 0.5% ointment

• Must first try FML SOP ointment

LUMIGAN® 0.01%

• Must first try 1 generic prostaglandin analog (e.g., latanoprost, bimatoprost 0.03%)

• Applies to Optimized only

metronidazole benzoate powder

• Removed from Formulary

MUGARD™

• Removed from Formulary

Naphcon-A

• Removed from Formulary

NORITATE® (metronidazole 1% cream)

• Removed from Formulary

OraMagic® Rx

• Removed from Formulary

ORAVIG® (miconazole buccal tablet)

• Move to Preferred Specialty

• ST added - must first try clotrimazole troche AND oral fluconazole

OVACE® PLUS (SSB)

• Removed from Formulary

OVACE® PLUS WASH 10% gel (SSB)

• Removed from Formulary

PANOXYL®; PANOXYL®-4 (benzoyl peroxide)

• Removed from Formulary

pramoxine 1% foam

• Removed from Formulary

PROCTOFOAM® 1% (pramoxine)

• Removed from Formulary

PROLENSA® (bromfenac 0.07%)

• Removed from Formulary for Optimized only

RECTIV® (nitroglycerin) ointment

• Removed from Formulary

selenium sulfide 2.3% shampoo

• Removed from Formulary

timolol maleate 0.5% (new generic ISTALOL®) daily drop

• Move to Non-Preferred Brand

timolol maleate gel forming solution 0.25% and 0.5%

• Move to Preferred Brand

TRAVATAN Z®

• ST added - must first try 1 generic prostaglandin analog (e.g., latanoprost, bimatoprost 0.03%)

• Applies to Optimized only

tretinoin microsphere

• Move to Preferred Brand

TRUMENBA

• Update age edits covered 18-25 years of age