November 2015 formulary updates

From time to time, we add drugs to or remove them from the approved drug list (formulary). 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 list of the pending changes made by the P&T committee on November 17, 2015.

Note: Changes to the Medicare formulary 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.

celecoxib
(generic CELEBREX)

  • Commonly used for:

    Pain

  • Formulary (ACA-compliant plans)

    Commercial group/individual: Generic

    Medicaid/Healthy MI: Formulary

    Medicare: 2015 formulary

  • What changed/notes

    For commercial and Medicaid, PA removed and ST added. Must first try one of the following: diclofenac potassium, diclofenac sodium, etodolac, meloxicam or nabumetone.

    QL: 2 capsules daily for 50, 100, and 200 mg strengths and 1 capsule daily for 400 mg

  • Effective date

    01/01/2016

DYLOJECT
(diclofenac sodium injection)

  • Commonly used for:

    Pain

  • Formulary (ACA-compliant plans)

    Commercial group/individual: Medical benefit

    Medicaid/Healthy MI: Medical benefit

    Medicare: Part B

  • What changed/notes

    Added under medical

    Est. annual cost: $4,536

  • Effective date

    01/01/2016

ENVARSUS XR
(tacrolimus)

  • Commonly used for:

    Kidney transplant

  • Formulary (ACA-compliant plans)

    Commercial group/individual: Non-preferred brand

    Medicaid/Healthy MI: NF

    Medicare: Tier 4

  • What changed/notes

    ST required: Must first try tacrolimus immediate-release

    PA required for Medicare

    Est. annual cost: $6,722

  • Effective date

    01/01/2016

FLOWTUSS
(guafenesin/hydrocodone)

  • Commonly used for:

    Cough and cold

  • Formulary (ACA-compliant plans)

    Commercial group/individual: Excluded

    Medicaid/Healthy MI: Excluded

    Medicare: Excluded

  • What changed/notes

    Excluded

    Est. cost: $598 per bottle

  • Effective date

    01/01/2016

HYCOFENIX
(guaifenesin/ hydrocodone/pseudoephedrine)

  • Commonly used for:

    Cough and cold

  • Formulary (ACA-compliant plans)

    Commercial group/individual: Excluded

    Medicaid/Healthy MI: Excluded

    Medicare: Excluded

  • What changed/notes

    Excluded

    Est. cost: $636 per bottle

  • Effective date

    01/01/2016

KEVEYIS
(dichlorphenamide)

  • Commonly used for:

    Periodic paralysis

  • Formulary (ACA-compliant plans)

    Commercial group/individual: Preferred specialty

    Medicaid/Healthy MI: Formulary

    Medicare: Tier 5

  • What changed/notes

    PA required

    Must be filled at preferred network specialty pharmacy

    Est. annual cost: $235,872

  • Effective date

    01/01/2016

LONSURF
(trifluridine/tipiracil)

  • Commonly used for:

    Metastatic colon cancer

  • Formulary (ACA-compliant plans)

    Commercial group/individual: Non-preferred specialty

    Medicaid/Healthy MI: NF

    Medicare: Tier 5

  • What changed/notes

    Est. annual cost: Up to $105,098

  • Effective date

    01/01/2016

ODOMZO
(sonidegib)

  • Commonly used for:

    Advanced basal cell carcinoma

  • Formulary (ACA-compliant plans)

    Commercial group/individual: Non-preferred specialty

    Medicaid/Healthy MI: Formulary

    Medicare: Tier 5

  • What changed/notes

    PA required

    QL: 1 capsule daily and 14 days per fill (does not to Medicare)

    Est. annual cost: $144,864

  • Effective date

    01/01/2016

OXECTA
(oxycodone)

  • Commonly used for:

    Pain

  • Formulary (ACA-compliant plans)

    Commercial group/individual: Non-pref. brand

    Medicaid/Healthy MI: Formulary

    Medicare: NF

  • What changed/notes

    PA removed for commercial and Medicaid

  • Effective date

    01/01/2016

SYNJARDY
(empagliflozin/metformin)

  • Commonly used for:

    Diabetes

  • Formulary (ACA-compliant plans)

    Commercial group/individual: Non-pref. brand

    Medicaid/Healthy MI: NF

    Medicare: NF

  • What changed/notes

    ST required: must first try Farxiga or Xigduo XR

    Est. annual cost: $4,939

  • Effective date

    01/01/2016

ZECUITY
(sumatripan)

  • Commonly used for:

    Migraine

  • Formulary (ACA-compliant plans)

    Commercial group/individual: Non-pref. brand

    Medicaid/Healthy MI: NF

    Medicare: NF

  • What changed/notes

    ST required: must first try two other sumatriptan formulations (tablets, nasal spray or subcutaneous injection)

    QL: 4 patches every 28 days

    AL: must be age 18 or older

    Est. annual cost: $16,646

  • Effective date

    01/01/2016

The P&T Committee reviewed the medical criteria for 54 drugs on the Approved Drug List.

Prior authorization requirements for the following drugs were updated:

Celecoxib (see above)

Cimzia

Enbrel

Fentanyl Citrate

Humira

Imipramine

Immune Globulin

Keytruda

Oxecta (see above)

Promacta

Remicade

No changes were made to the following prior authorization requirements:

Abstral

Acthar

Actimmune

Adcetris

Ampyra

Arzerra

Azathioprine

Bethkis

Carbaglu

Chantix

Eylea

Fentora

Firazyr

Gazyva

Gilotrif

Hetlioz

Human Growth Hormone

Ilaris

Jevtana

Lazanda

Lidoderm/lidocaine patch

Marqibo

Neudexta

Neulasta

Nulojix

Nuvigil

Ondansetron

Onsolis

Perjeta

Provenge

Pulmozyme

Relistor

Sabril

Stelara

Subsys

TobiPodhaler

Tobramycin

Torisel

Vaccines

Zevalin

Zubsolv

Zykadia

Zyvox

Note: For the precertification requirements for medications requiring prior approval, visit the Drug authorizations forms page and click on the applicable prior authorization form.