November 2017 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 November 21, 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.

Additions to the formularies effective Jan. 1, 2018

Aliqopa™ (copanlisib)

  • For relapsed follicular lymphoma
  • Traditional and optimized formularies: Medical Benefit – Preferred Specialty
  • Medicare: Tier 5, BvsD
  • PA for Traditional and Optimized
  • Est. cost: $197,000 annually

Armonair Respiclick™ (fluticasone propionate)

  • Maintenance treatment of asthma
  • Traditional and optimized formularies: Non-Preferred Brand
  • Non-Preferred Brand
  • Medicare: Non-Formulary
  • ST for Optimized, Qvar and Pulmicort
  • Est. cost: $210 per month

Besponsa™ (inotuzumab ozogamicin)

  • For relapsed/refractory acute lymphoblastic leukemia
  • Traditional and optimized formularies: Medical Benefit – Preferred Specialty
  • Medicare: Tier 5, BvsD
  • PA for Traditional, Optimized and Medicaid
  • Est. cost: $512,000 annually

Bevyxxa® (betrixaban)

  • For venous thromboembolism
  • Traditional and optimized formularies: Non-Formulary
  • Medicare: Not covered
  • Est. cost: $756 per month

Duzallo™ (lesinurad & allopurinol)

  • For hyperuricemia associated with gout
  • Traditional and optimized formularies: Non-Preferred Brand
  • Medicare: Non-Formulary
  • ST for Traditional and Optimized - Must first try allopurinol 900mg/day for at least 6 months, or Uloric, if allopurinol contraindication or failure.
  • Est. cost: $371/month

Endari™ (L-glutamine)

  • For sickle cell disease
  • Traditional and optimized formularies: Excluded
  • Medicare: Non-Formulary
  • Nutritional supplements are excluded
  • Est. cost: $32,000 annually

Gocovri™ (amantadine)

  • For dyskinesia in patients with Parkinson’s disease
  • Traditional and optimized formularies: Non-formulary
  • Medicare:Non-formulary
  • Est. cost: $34,000 annually

Inflectra™ (infliximab-dyyb)

  • For autoimmune disorders (biosimilar to Remicade)
  • Traditional and optimized formularies: Medical Benefit - Preferred Specialty
  • Medicare: Tier 5 (no change)
  • PA for Traditional and Optimized

Mavyret™ (glecaprevir/pibrentasvir)

  • For chronic hepatitis C
  • Traditional and optimized formularies: Preferred Specialty
  • Medicare: Tier 5
  • PA
  • QL – limit of 84 tabs in 28 days
  • Est. cost: $32,000 annually

Mylotarg™ (gemtuzumab ozogamicin)

  • For acute myeloid leukemia
  • Traditional and optimized formularies: Not Reviewed
  • Medicare: Tier 5, BvsD
  • Awaiting NCCN recommendation for formulary review
  • Est. cost: $42,000 annually

Nityr™ (nitisone)

  • For hereditary tyrosinemia
  • Traditional and optimized formularies: Preferred Specialty
  • Medicare: Tier 5
  • PA for Traditional and Optimized
  • LA
  • Est. cost: $12,300 annually

Renflexis™ (infliximab-abda)

  • Autoimmune disorders (biosimilar to Remicade®)
  • Traditional and optimized formularies: Medical Benefit- Preferred Specialty
  • Medicare: Tier 5 (no change)
  • PA for Traditional and Optimized

Tremfya™ (guselkumab)

  • Plaque psoriasis
  • Traditional and optimized formularies: Non-Preferred Specialty
  • Medicare: Tier 5
  • PA for Traditional, Optimized and Medicare
  • QL of 1 syringe every 8 weeks for Traditional, Optimized and Medicare
  • Est. cost: $76,000

Trimpex (trimethoprim)

  • Acute otitis media
  • Traditional and optimized formularies: Non-formulary
  • Medicare: Non-Formulary
  • Est. cost: $60/day

Triptodur™ (triptorelin)

  • Central precocious puberty
  • Traditional and optimized formularies: Medical Benefit – Non-Preferred Specialty
  • Medicare: Part B
  • QL limit of 2 injections per year
  • Est. cost: $38,000

Verzenio™ (abemaciclib)

  • Breast cancer
  • Traditional and optimized formularies: Not reviewed
  • Medicare: Tier 5
  • PA for Medicare
  • Awaiting NCCN recommendation for formulary review
  • Est. cost: $169,000 annually

Vosevi™ (sofosbuvir/velpatasvir/voxilaprevir)

  • Chronic hepatitis C
  • Traditional and optimized formularies: Non-Preferred Specialty
  • Medicare: Non-formulary
  • PA for Traditional and Optimized
  • QL for Traditional and Optimized of 28 tablets per 28 days
  • Est. cost: $90,000 annually

Reviews and updates

The P&T Committee reviewed the medical criteria for 61 drugs on the Approved Drug List. 

Abstral® Medicare – clarification of opioid tolerance definition
Commercial – minor edits to existing language
Acthar® Medicare:
  • Inclusion of "adjunctive therapy for acute exacerbations" for patients with diagnosis of inflammatory disorder of musculoskeletal system
  • Removal of diagnosis of 'disorder of lipid metabolism'
Commercial: Minor edits
Actimmune® Medicare: Minor edits
Adcetris® Commercial/Medicaid: Inclusion of new requirement, "Adults with classical Hodgkin's Lymphoma at high risk of relapse or progression as post-auth-HSCT consolidation". Specification of autologous hematopoietic stem cell transplant or at least two prior multi-agent chemotherapy regimens in patients who are not auto-HSCT eligible
Aerospan™ Commercial: Remove ST effective 01/01/2018; remains at Non-Preferred Brand tier
Alvesco™ Commercial: Move from Preferred Brand to Non-Preferred Brand tier
Ampyra®

Medicare: Minor edits
Commercial/Medicaid:

  • Additional requirement for continuation - The patient meets all initial criteria
  • Additional requirement: Prescriber is a neurologist
  • Additional question: Does the patient have a spinal cord injury, myasthenia gravis, or demyelinating peripheral neuropathies (such as Guillain-Barre syndrome), Alzheimer's disease, or Lambery Eaton myasthenic syndrome?
Arzerra® Medicare: New form
Commercial/Medicaid: Clarification of precertification requirements, criteria for approval remains the same
Aveed™

Commercial: No changes
Medicare:

  • Addition of minimum 2 month trial with generic testosterone
  • Must have a serum total testosterone test result of 300 ng/dl or less on two different dates in the previous two months. Removal of differing criteria based on age.
  • Must be screened for prostate cancer before starting therapy and regularly while on therapy
Axiron® Medicare:
  • Addition of 'minimum 2 month' trial with generic testosterone
  • Must be screened for prostate cancer before starting therapy and regularly while on therapy
azathioprine Medicare: Diagnosis of polymyositis, remove diagnosis of Crohn's disease
Bupap® (butalbital 50mg/Apap 325mg tab) Removed from the commercial group and individual formularies. Not grandfathered for members currently on medication.
Cabometyx™ Commercial: Inclusion of MyPriority® plans
Medicare: Minor edits
Carbaglu®

Commercial: No changes
Medicare: Minor edits
Epiduo® Forte (adapalene 0.3% /benzoyl peroxide gel)
 Removed from the commercial group and individual formularies. Not grandfathered for members currently on medication.
eszopiclone Medicare: Minor edits
Eyelea®
 Reviewed, no changes
fentanyl citrate Commercial/Medicaid/Medicare: Minor edits
Fentora® Commercial/Medicare: Minor edits
Firazyr® Commercial: No changes
Medicare: Minor edits
Gazyva® Commercial: Additional criteria, must be used in combination with bendamustine (e.g., Bendeka™, Treanda®
Gilotrif® Commercial: Criteria added: Diagnosis of advanced squamous cell carcinoma of the head and neck after failure of platinum-based chemotherapy
Medicare: Minor edits
Hetlioz® Commercial: Minor edits
Medicare: Removal of criteria: 3) patient must be blind, 4) must first try melatonin or rozerem for 6 months, 5) must first try eszopiclone or zolpidem
human growth hormone Commercial group:
  • Criteria added for diagnosis of pre-transplant renal insufficiency: No evidence of active malignancy
  • Minor edits
MyPriority/Medicaid/Medicare: Minor edits
Ilaris® Commercial: Minor edits
Medicare:
  • Additional criteria: Diagnosis of periodic fever syndromes, diagnosis of systemic juvenile idiopathic arthritis
  • Removal of approval dosing and length language
imipramine Medicare: Removal of schizophrenia as an approved diagnosis
Jevtana®
 Reviewed, no changes
Keveyis® Reviewed, no changes
Medicare: New form
Keytruda® Commercial/Medicaid (new criteria/diagnosis specific criteria for each):
  • unresectable or metastatic melanoma
  • metastatic non-small cell lung cancer (NSCLC)
  • recurrent or metastatic squamous cell head and neck cancer
  • classic Hodgkin’s lymphoma
  • unresectable or metastatic microsatellite instability-high (MSI-H) or mismatch repair-deficient (dMMR)
  • advanced gastric or gastroesophageal junction adenocarcinoma
  • advanced urothelial carcinoma
Lazanda™ Commercial: Removal of criteria "patient is already receiving and is tolerant to opioid therapy for underlying persistent cancer pain"; removal of drug cost
lidocaine patch Commercial: Reviewed, no changes
Medicare: Inclusion of authorization length based on diagnosis
Lonsurf ® Commercial: Reviewed, no changes
Medicare: Minor edits
Marqibo® Commercial/Medicaid: Minor edits
Natesto®

 Removed from the commercial group and individual formularies. Not grandfathered for members currently on medication.
Nuedexta® Commercial: Updated list of drug interactions
Nulojix®

 Reviewed, no changes
Nuvigil® Medicare: Minor edits
Odomzo® Commercial: No changes
Medicare: New form
odansetron Medicare: Add approved diagnosis, Prevention of post-anesthesia shivering (PAS)
Opdivo® Commercial/Medicaid: Removal of BRAF targeted therapy requirement for BRAF-mutated disease
Orfadin® Removed from the Commercial group and individual formularies. Not grandfathered for members currently on medication.
Perjeta® Commercial/Medicaid:
  • First-line treatment of HER2-positive metastatic breast cancer
  • Neoadjuvant treatment of HER2-positive, locally advanced, inflammatory, or early stage breast cancer (must be used in combination with trastuzumab and docetaxel)
Primsol®  Removed from the commercial group and individual formularies. Not grandfathered for members currently on medication.
Provenge®
 Reviewed, no changes
Pulmozyme® Commercial: Reviewed, no changes
Medicaid:
  • Authorization limited to 12 months per approval
  • New criteria for continuation: Must provide FVC, must provide documentation showing stable disease, must provide documentation supporting decreased incidence of respiratory infections
Relistor® Commercial: Reviewed, no changes
Medicare: Must first try and be unresponsive to a minimum of 2 other laxative drugs
Remicade® Commercial/Medicaid: Moved from medical Preferred Specialty to medical Non-Preferred Specialty tier, will require use of biosimilar (Inflectra™ or Renflexis™) prior to approval
Sabril® Commercial: Inclusion of drug product vigabatrin to form
Seroquel XR® Medicare: Minor edits
smoking cessation products Commercial/Medicaid: Change in form title from "Chantix®" to "Smoking cessation products" and inclusion of generic nicotine patch/lozenge/gum, Nicotrol® inhaler/NS, and bupropion (Zyban®)
Stelara® Commercial: Minor edits
Medicare: Additional criteria for Crohn's diagnosis added
Subsys® Commercial/Medicare: Minor edit to "opioid tolerant" language
Testopel®
 Reviewed, no changes
Tobi® Commercial/Medicaid: Additional criteria, must have suspected or confirmed diagnosis of Pseudomonas aeruginosa lung infection

tobramycin /Kitabis™ /Bethkis®

 Commercial/Medicaid: Minor edits
Torisel® Medicare: Minor edits
Trintellix Commercial: ST requirement adjusted, QL added
Viibryd® Commercial: ST requirement adjusted
Vimpat® Commercial: Add edit limiting all strengths to a combined 400mg/day
Zevalin® Commercial/Medicaid:
  • New/additional requirement: Relapsed or refractory, low-grade or follicular B cell, non-Hodgkins lymphoma or rituximab-refractory B-cell NHL with platelet count >100,00/mm^3
  • New/additional requirement: Previously untreated follicular NHL in a patient who achieved a partial or complete response to first-line chemotherapy. Must be administered at least 6 weeks but no more than 12 weeks following the last dose of chemotherapy and platelet count >150,000/mm^3
Zubsolv®

Medicare:

  • Diagnosis of opioid dependence used for induction therapy in a patient dependent on heroin or other short-acting opioids
  • Indication that buprenorphine monotherapy is recommended for patients dependent on methadone or long-acting opioids
Zykadia™ 
 Commercial/Medicare: Minor edits
Zyvox®

Medicare: Form name change to Linezolid (Zyvox®)
MyPriority:

  • Addition of stipulation that longer courses of therapy may be approved if recommended by an infectious disease specialist
  • Removal of language stating safety/efficacy beyond 28 days is unstudied