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 Sept. 20, 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.

AFSTYLA
(antihemophilia factor-recombinant single chain)

• Commonly used for:

  Hemophilia

• 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

  Est. annual cost: $82,000

• Effective date

  11/01/2016

BEVESPI AEROSPHERE
(glycopyrrolate formoterol fumarate)

• Commonly used for:

  COPD

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred brand

  Medicare: Tier 4

• What changed/notes

  QL - one inhaler per 30 days for commercial, individual and Medicare

  AL - minimum of 40 years for commercial, individual and Medicare

  Est. annual cost: $4,500

• Effective date

  11/01/2016

FYCOMPA SUSPENSION
(perampanel)

• Commonly used for:

  Seizures

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred brand

  Medicare: Tier 4

• What changed/notes

  QL - 680mls per month applies to commercial and individual, 180 mls per month applies to Medicare

  AL - up to 24 months applies to Commercial and Individual

  Est. annual cost: $27,000

• Effective date

  11/01/2016

Hyaluronates and derivatives

• Commonly used for:

  Osteoarthritis of the knee

• Formulary (ACA-compliant plans)

  Commercial group/individual: NF

  Medicare: No change

• What changed/notes

  Coverage removed from commercial and individual formularies

  Est. annual cost: Varies

• Effective date

  1/01/2017

JENTADUETO XR
(linagliptin/metformin)

• Commonly used for:

  Diabetic

• Formulary (ACA-compliant plans)

  Commercial group/individual: Preferred brand

  Medicare: Tier 3

• What changed/notes

  QL - 1 tablet per day

  Est. annual cost: $4,800

• Effective date

  11/01/2016

OCALIVA
(obeticholic acid)

• Commonly used for:

  Primary biliary cholantitis

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-preferred specialty

  Medicare: Tier 5

• What changed/notes

  PA

  QL - 30 tablets per 30 days

  Est. annual cost: $82,000

• Effective date

  11/01/2016

PROBUPHINE
(buprenorphine implant)

• Commonly used for:

  Opioid dependence

• Formulary (ACA-compliant plans)

  Commercial group/individual: Excluded

  Medicare: Part B

• What changed/notes

  Excluded

  Est. annual cost: $11,000

• Effective date

  11/01/2016

Opioid management

• Commonly used for:

  Opioid dependence

• Formulary (ACA-compliant plans)

  Commercial group/individual: No change

  Medicare: No change

• What changed/notes

  Limited commercial and individual member fills to 30 days

  Est. annual cost: Varies

• Effective date

  09/01/2016

TECENTRIQ
(atexolizumab)

• Commonly used for:

  Urothelial carcinoma

• Formulary (ACA-compliant plans)

  Commercial group/individual: Preferred specialty - Medical benefit

  Medicare: Tier 5

• What changed/notes

  PA required for commercial and individual

  B/D for Medicare

  Est. cost: $41,000/3 months

• Effective date

  11/01/2016

VONVENDI
(van Willebrand factor [recombinant])

• Commonly used for:

  Bleeding

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-pref. specialty

  Medicare: Part B

• What changed/notes

  QL - 31 days per dispensing

  Est. cost: $8,400/event

• Effective date

  11/01/2016

XIIDRA
(lifitegrast ophthalmic solution)

• Commonly used for:

  Dry eye

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-pref. brand

  Medicare: Tier 4

• What changed/notes

  QL - 60 single-use containers per 30 days

  Est. annual cost: $6,100

• Effective date

  11/01/2016

ZINBRYTA
(daclizumab)

• Commonly used for:

  Multiple sclerosis

• Formulary (ACA-compliant plans)

  Commercial group/individual: Non-pref. specialty

  Medicare: Tier 5

• What changed/notes

  ST (commercial, individual) - Must try two of the following: Avonex, Gilenya or Tecfidera

PA (Medicare)

QL - Limit of one 150mcg/ML syringe every 30 days

Commercial & individual member prescriptions must be filled at Specialty pharmacy

Not covered in combination with other immunomodulatory drugs

Est. annual cost: $98,000

• Effective date

  11/01/2016

The P&T Committee reviewed the medical criteria for 52 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:

DAKLINZA EPCLUSA Epoetin agents: ARANESP, EPOGEN, PROCRIT - Medicaid HARVONI HUMIRA

KEYTRUDA Oral Oncology agents (Medicaid) OPDIVO SOVALDI STELARA

TECHNIVIE VIEKIRA PAK XTANDI ZEPATIER ZYTIGA

No changes were made to the following prior authorization requirements:

ANZEMET ARANESP BANZEL BELEODAQ DALIRESP DALVANCE ENBREL ENTRESTO ENTYVIO EPOGEN/PROCRIT (Medicare) ERBITUX FORTEO

GRANISETRON Inhalation solutions used with a nebulizer IRESSA KALYDECO KINERET MEKINIST NEUPOGEN ORENCIA ORKAMBI PROCRIT REMICADE RITUXAN

SAMSCA SIVEXTRO SUPPRELIN LA SYLVANT SYNAGIX TAFINLAR Temozolomide (TEMODAR) VECTIBIX XENICAL XOLAIR ZORBTIVE ZYDELIG