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 Nov. 15, 2016.

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.

ACTEMRA (tocilizumab)

• Commonly used for:

  Rheumatoid arthritis

• Formulary (ACA-compliant plans)

  Commercial group/individual: Preferred specialty

  Medicare: Part B

• What changed/notes

  Must be filled at Hemophilia Centers of Excellence pharmacy for commercial and individual

• Effective date

  1/01/2017

AMITIZA (lubiprostone)

• Commonly used for:

  Irritable bowel with constipation, idiopathic constipation

• Formulary (ACA-compliant plans)

  Commercial group/individual: Preferred brand

  Medicare: No change

• What changed/notes

  Move to Preferred brand for commercial group and individual

• Effective date

  1/01/2017

ANORO
(umeclidinium bromide and vilanterol trifenatate)

• Commonly used for:

  COPD

• Formulary (ACA-compliant plans)

  Commercial group/individual: Preferred brand

  Medicare: No change

• What changed/notes

  Move to Preferred brand for commercial group and individual

• Effective date

  1/01/2017

APRISO
(mesalamine)

• Commonly used for:

  Crohn's / Ulcerative colitis

• Formulary (ACA-compliant plans)

  Commercial group/individual: Preferred brand

  Medicare: No change

• What changed/notes

  Tier change

• Effective date

  1/01/2017

ASACOL HD
(mesalamine)

• Commonly used for:

  Crohn's / Ulcerative colitis

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred brand

  Medicare: No change

• What changed/notes

  Tier change

  ST - Must first try Preferred brand for commercial group and individual

• Effective date

  1/01/2017

BAYER BREEZE/ CONTOUR

• Commonly used for:

  Diabetic blood glucose test strips

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred brand

  Medicare: Excluded

• What changed/notes

  ST: Must first try JJHCS, exclude pump users

• Effective date

  1/01/2017

BELVIQ XR
(lorcaserin hydrochloride)

• Commonly used for:

  Obesity

• Formulary (ACA-compliant plans)

  Commercial group: Non-preferred brand

  Commercial individual: Excluded

  Medicare: Excluded

• What changed/notes

  Covered only on the commercial group formulary with a weight -loss rider

  ST: Must first try a generic weight-loss drug

  Est. annual cost: $3,471

• Effective date

  1/01/2017

BYVALSON
(nebivolol HCI / valsartan)

• Commonly used for:

  Blood pressure

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred brand

  Medicare: Tier 3

• What changed/notes

  ST: Must first try a generic ACE or ARB

  Est. annual cost: $1,576

• Effective date

  1/01/2017

COSENTYX
(secukinumab)

• Commonly used for:

  Psoriasis/ PSA /ankylosing spondylitis

• Formulary (ACA-compliant plans)

  Commercial group/individual: Preferred specialty

  Medicare: No change

• What changed/notes

  For commercial group and individual:

  PA: Removing ST with Humira and Enbrel

  Tier change

• Effective date

  1/01/2017

DELZICOL
(mesalamine)

• Commonly used for:

  Chron's / Ulcerative colitis

• Formulary (ACA-compliant plans)

  Commercial group: Non-preferred brand

  Commercial individual: Preferred brand

  Medicare: No change

• What changed/notes

  Tier change

  ST: Must first try preferred brand

• Effective date

  1/01/2017

DUEXIS
(ibuprophen and famotidine)

• Commonly used for:

  Osteoarthritis/ rheumatoid arthritis with GI prophylaxis

• Formulary (ACA-compliant plans)

  Commercial group/individual: Excluded

  Medicare: No change

• What changed/notes

  Remove from commercial group and individual formularies

• Effective date

  1/01/2017

EXONDYS
(eteplirsen)

• Commonly used for:

  Muscular dystrophy

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-formulary

  Medicare: Non-formulary

• What changed/notes

  Requests will be reviewed through the medical necessity / exceptions process.

  Est. annual cost: $1,535,040

• Effective date

  1/01/2017

GONITRO
(nitroglycerin)

• Commonly used for:

  Angina

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-formulary

  Medicare: Tier 3

• What changed/notes

  Requests will be reviewed through the medical necessity / exceptions process.

  Est. annual cost: $9,411

• Effective date

  1/01/2017

hydroxyprogesterone caproate IM

• Commonly used for:

  Pre-term labor prophylaxis

• Formulary (ACA-compliant plans)

  Commercial group/individual: Preferred sprecialty - Medical benefit

  Medicare: T5

• What changed/notes

  PA: For commercial group and individual

  Est. annual cost: $1,167

• Effective date

  1/01/2017

INVOKAMET
(canagliflozin, metformin HCL)

• Commonly used for:

  Diabetes

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred brand

  Medicare: No change

• What changed/notes

  ST: Updated to include Jardiance/ Synjardy

  PA: Remains for individual

• Effective date

  1/01/2017

INVOKAMET XR
(canagliflozin, metformin extended release HCL)

• Commonly used for:

  Diabetes

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred brand

  Medicare: No change

• What changed/notes

  ST: for commercial group. Must first try Farxiga, Xigduo, Jardiance or Synjardy

  PA: Applies to individual

  Est. annual cost: $5,641

• Effective date

  1/01/2017

INVOKANA
(canagliflozin)

• Commonly used for:

  Diabetes

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred brand

  Medicare: No change

• What changed/notes

  ST: Updated to include Jardiance/ Synjardy

  PA: Remains for individual

• Effective date

  1/01/2017

JARDIANCE
(empagiflozin)

• Commonly used for:

  Diabetes

• Formulary (ACA-compliant plans)

  Commercial group/individual: Preferred brand

  Medicare: No change

• What changed/notes

  Tier change for commercial group and individual

  PA: Remains for individual

• Effective date

  1/01/2017

KAZANO
(alogliptin and metformin hydrochloride)

• Commonly used for:

  Diabetes

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred brand

  Medicare: No change

• What changed/notes

  ST: Must first try a preferred brand

  PA: Remains for individual

• Effective date

  1/01/2017

KRISTALOSE
(lactulose)

• Commonly used for:

  Constipation

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-formulary

  Medicare: No change

• What changed/notes

  Remove from commercial formularies

• Effective date

  1/01/2017

LETAIRIS
(ambrisentan)

• Commonly used for:

  Pulmonary arterial hypertension

• Formulary (ACA-compliant plans)

  Commercial group/individual: Preferred specialty

  Medicare: No change

• What changed/notes

  Move to Tier 4 for commercial group and individual formularies

• Effective date

  1/01/2017

LINZESS
(linaclotide)

• Commonly used for:

  IBS - constipatient, idiopathic constipation

• Formulary (ACA-compliant plans)

  Commercial group/individual: Preferred brand

  Medicare: No change

• What changed/notes

  Move to Preferred brand for commercial group and individual formularies

• Effective date

  1/01/2017

LOMAIRA
(phentermine hydrochloride)

• Commonly used for:

  Obesity

• Formulary (ACA-compliant plans)

  Commercial group: Non-preferred brand

  Commercial individual: Excluded

  Medicare: Excluded

• What changed/notes

  Covered only on the commercial group formulary with a Weight loss rider

  ST: Must first try a generic weight-loss drug

  Est. annual cost: $626

• Effective date

  1/01/2017

MAKENA
(hydroxyprogesterone caproate)

• Commonly used for:

  Pre-term labor prophylaxis

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred specialty - medical benefit

  Medicare: No change

• What changed/notes

  Tier change

  ST, PA: Use of generic hydroxyprogesterone prior to authorization

• Effective date

  1/01/2017

mesalamine tablets

• Commonly used for:

  Crohn's / Ulcerative colitis

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred brand

  Medicare: No change

• What changed/notes

  Tier change

  ST: Must first try preferred brand for commercial group & individual

• Effective date

  1/01/2017

NESINA
(alogliptin)

• Commonly used for:

  Diabetes

• Formulary (ACA-compliant plans)

  Commercial group: Non-preferred brand

  Commercial individual: Preferred brand

  Medicare: No change

• What changed/notes

  ST: Must first try a preferred brand

  PA: Remains for commercial individual

• Effective date

  1/01/2017

ONE TOUCH/ all Non-JJHCS test strips

• Commonly used for:

  Diabetic blood glucose test strips

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred brand

  Medicare: No change

• What changed/notes

  ST: Must first try JJHCS, exclude pump users

• Effective date

  1/01/2017

ONGLYZA
(saxagliptin)

• Commonly used for:

  Diabetes

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred brand

  Medicare: No change

• What changed/notes

  ST: Must first try a preferred brand

  PA: Remains for commercial individual

• Effective date

  1/01/2017

OPSUMIT
(macitentan)

• Commonly used for:

  Pulmonary hypertension

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred specialty

  Medicare: No change

• What changed/notes

  Tier change to non-preferred specialty for commercial group & individual formularies

• Effective date

  1/01/2017

OTEZLA
(apremilast)

• Commonly used for:

  Psoriasis and psoriatic arthritis

• Formulary (ACA-compliant plans)

  Commercial group/individual: Preferred specialty

  Medicare: No change

• What changed/notes

  For commercial group & individual: Tier change

  PA, removing ST with Humira and Enbrel

• Effective date

  1/01/2017

OTOVEL
(ciprofloxacin and fluocinolone acetonide)

• Commonly used for:

  Otitis media

• Formulary (ACA-compliant plans)

  Commercial group/individual: Preferred brand

  Medicare: Tier 3

• What changed/notes

  Added to formularies

  Est. cost: $198/month

• Effective date

  1/01/2017

PANCREAZE
(pancrelipase)

• Commonly used for:

  Pancreatic enzyme replacement

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred brand

  Medicare: No change

• What changed/notes

  Tier change

  ST: Must first try Creon for commercial group & individual

• Effective date

  1/01/2017

QBRELIS
(lisinopril oral solution)

• Commonly used for:

  Hypertension

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred brand

  Medicare: Not covered

• What changed/notes

  AL: Covered up to age 9 for commercial group & individual

  Est. annual cost: $7,110

• Effective date

  1/01/2017

REBIF
(interferon beta-1a)

• Commonly used for:

  Multiple sclerosis

• Formulary (ACA-compliant plans)

  Commercial group/individual: Preferred specialty

  Medicare: No change

• What changed/notes

  ST: Removed

• Effective date

  1/01/2017

RELISTOR
(methylnaltrexone bromide tablets)

• Commonly used for:

  Opioid-induced constipation

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred specialty

  Medicare: Tier 5

• What changed/notes

  PA

• Effective date

  1/01/2017

RELISTOR injection
(methylnaltrexone bromide)

• Commonly used for:

  Opioid-induced constipation

• Formulary (ACA-compliant plans)

  Commercial group: Non-preferred specialty

  Commercial individual: Non-preferred specialty

  Medicare: No change

• What changed/notes

  Tier change for commercial group and individual

  PA: Add requirement of Movantik trial

• Effective date

  1/01/2017

STELARA
(ustekinumab)

• Commonly used for:

  Psoriasis, psoriatic arthritis, Crohn's

• Formulary (ACA-compliant plans)

  Commercial group/individual: Preferred specialty

  Medicare: No change

• What changed/notes

  For commercial group & individual:

  ST removed with Humira and Enbrel

  Tier change

• Effective date

  1/01/2017

STIOLTO
(tiotropium bromide and olodaterol)

• Commonly used for:

  Asthma/COPD

• Formulary (ACA-compliant plans)

  Commercial group/individual: Preferred brand

  Medicare: No change

• What changed/notes

  For commercial group & individual:

  Tier change for commercial formularies

• Effective date

  1/01/2017

SYNJARDY
(empagliflozin and metformin hydrochloride)

• Commonly used for:

  Diabetes

• Formulary (ACA-compliant plans)

  Commercial group/individual: Preferred brand

  Medicare: No change

• What changed/notes

  Tier change

  PA: Remains for commercial individual

• Effective date

  1/01/2017

TRACLEER
(bosentan)

• Commonly used for:

  Pulmonary hypertension

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred specialty

  Medicare: No change

• What changed/notes

  Tier change

• Effective date

  1/01/2017

ULTRESA
(pancrelipase)

• Commonly used for:

  Pancreatic enzyme replacement

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred brand

  Medicare: No change

• What changed/notes

  Tier change

• Effective date

  1/01/2017

XELJANZ
(tofacitnib citrate)

• Commonly used for:

  Rheumatoid arthritis

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred brand

  Medicare: No change

• What changed/notes

  PA: For commercial group & individual

  ST: Must first try Creon

• Effective date

  1/01/2017

YOSPRALA
(aspirin and omeprazole)

• Commonly used for:

  Anti-platelet treatment with GI prophylaxis

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-formulary

  Medicare: Non-formulary

• What changed/notes

  Requests will be reviewed through the medical necessity/exceptions process

  Est. annual cost: $2,160

• Effective date

  1/01/2017

ZENPEP
(pancrelipase)

• Commonly used for:

  Pancreatic enzyme replacement

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred brand

  Medicare: No change

• What changed/notes

  Tier change

  ST: Must first try Creon for commercial group & individual

• Effective date

  1/01/2017

ZURAMPIC
(lesinurad)

• Commonly used for:

  Gout

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred brand

  Medicare: Tier 4

• What changed/notes

  ST: Must first try allopurinol 900mg /day for at least 6 months, or Uloric, if allopurinol contraindication or failure

  Est. annual cost: $5,040

• Effective date

  1/01/2017

The P&T Committee reviewed the medical criteria for 58 drugs on the Approved Drug List

Prior authorization requirements were updated for the following drugs were updated. Go to the drug auth forms page for details:

DPP-4 ENTRESTO ENTYVIO

MAKENA NUCALA ORKAMBI

STELARA TARCEVA

No changes were made to the following prior authorization requirements:

ABSTRAL ACTHAR ACTIMMUNE ADCETRIS AMPYRA ARZERRA AZATHIOPRINE BETHKIS CARBAGLU CHANTIX

EYLEA FENTANYL CITRATE FENTORA FIRAZYR GAZYVA GILOTRIF HETLIOZ HUMAN GROWTH HORMONE ILARIS IMIPRAMINE

JEVTANA KEVEYIS KEYTRUDA KITABIS LAZANDA LIDODERM LONSURF MARQUIBO NEULASTA NUEDEXTA

NULOJIX NUVIGIL ODOMZO ONDANSETRON ONSOLIS PERJETA PROVENGE PULMOZYME RELISTOR SABRIL

SEROQUEL SUBSYS TOBIPODHALER TOBRAMYCIN TORISEL VACCINES ZEVALIN ZUBSOLV ZYKADIA ZYVOX