September 2017 formulary updates

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 September 19, 2017.

Medicare Part D formulary changes are not 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 Nov. 1, 2018

Benlysta® SC (belimumab)

  • For lupus
  • Commercial group: Preferred specialty, PA, QL
  • Commercial ACA-compatible individual: Preferred specialty, PA, QL
  • Medicare: N/A

Haegarda™ (C1 esterase inhibitor [human])

  • For hereditary angiodema
  • Commercial group: Preferred specialty, PA
  • Commercial ACA-compatible individual: Preferred specialty, PA
  • Medicare: T5, PA
  • Est. cost: $504,000 annually

Idhifa™ (enasidenib)

  • For cancer
  • Only reviewed for Medicare
  • PA, QL
  • Est. cost: $360,000 annually

Intrarosa™ (prasterone)

  • For dyspareunia
  • Commercial group: Non-preferred Brand, PA
  • Commercial ACA-compatible individual: Non-preferred Brand, PA
  • Medicare: Excluded
  • Requires OSD Rider
  • Est. cost: $2,700 annually

Jadenu® Sprinkle (deferasirox)

  • For iron toxicity/overload
  • Commercial group:  Preferred Specialty
  • Commercial ACA-compatible individual: Preferred Specialty
  • Medicare: T5

Kevzara® (sanilumab)

  • For rheumatoid arthritis
  • Commercial group: Non-preferred Specialty; PA, QL
  • Commercial ACA-compatible individual: Non-preferred Specialty; PA, QL
  • Medicare: T5; PA, QL
  • Est. cost: $46,800 annually

Nerlynx® (neratinib)

  • For cancer
  • Only reviewed for Medicare: T5; PA, QL of 6 per day
  • Est. cost: $154,000 annually

Radicava™ (edaravone)

  • For amyotrophic lateral sclerosis (ALS)
  • Commercial group: Non-preferred Specialty., Medical benefit; PA
  • Commercial ACA-compatible individual: Non-preferred Specialty, Medical benefit; PA
  • Medicare: T5; PA, B/D
  • Est. cost: $156,000 annually

Rituxan Hycela™ (rituximab/hyaluronidase)

  • For lymphoma and leukemia
  • Commercial group:  Preferred Specialty, Medical benefit
  • Commercial ACA-compatible individual: Preferred Specialty, Medical benefit
  • Medicare: T5, B/D
  • Est. cost: $8,000 annually

Siliq™ (brodalumab)

  • For plaque psoriasis
  • Commercial group: Non-preferred Specialty; PA, QL
  • Commercial ACA-compatible individual: Non-preferred Specialty; PA, QL
  • Medicare: T5; PA, QL
  • Est. cost: $54,600 annually

Vyxeos™ (daunorubicin liposomal/ cytarabiine liposomal)

  • For cancer
  • Only reviewed for Medicare: T5; B/D
  • Est. cost: $95,000 annually

Xadago® (safinamide)

  • For Parkinson's Disease
  • Commercial group: Non-preferred Brand; QL, ST
  • Commercial ACA-compatible individual: Non-formulary
  • Medicare: Non-formulary
  • Est. cost: $10,000 annually

Reviewed but not added to the formularies

Aktipak™ (benzoly peroxide, erythromycin)

Cotempla XR-ODT™ (methylphenidate)

Emflaza™ (deflazacort)

Morphabond ER™ (morphine sulfate)

Syndros™ (dronabinal)

Pending changes effective Nov. 1, 2017

Drug Notes
Abuse deterrent opioids New form; for commercial (non-PPACA) only
almotriptan Removed from the commercial individual formulary; moved to T3 for commercial group; ST added/updated
alosetron hydrochloride Moving to T3
Anzemet® No change
Aranesp® No change
armodafinil No change
Banzel® No change
Belbuca™ ST added/updated
Beleodaq® No change
Belladonna & opium Removed from the commercial group and individual formularies
Belladonna alkaloids & op 16.2mg; 60mg Removed from the commercial group and individual formularies
Bunavail™ ST added/updated for commercial group
buprenorphine-OUD Updated precertification requirements
bupenorphine patch Moving to T3; ST added/updated
Butalbital/ APAP/ caffeine ((50/30/40) Removed from the commercial group and individual formularies
Butalbital/ APAP/ caffeine/ codeine (50/300/40/30) Removed from the commercial group and individual formularies
butorphanol tartrate 10mg/mL nasal spray Moving to T2
Butrans® Removed from the commercial group and individual formularies
Cafergot® Removed from the commercial group and individual formularies
Cambia® Removed from the commercial group and individual formularies
chlordiazepoxide HCL/clidinium bromide Moving to T2
Cimetidine (300mg, 400mg and 800mg tablets & 300mg/ml solution) Removed from the commercial group and individual formularies
Cinryze® Add trial of Haegarda®
Colcrys® tablets Removed from the commercial group and individual formularies
Conzip® (tramadol ER capsule) Removed from the commercial group and individual formularies
chromolyn sodium Moving to T3
Cuvposa® Removed from the commercial individual formulary; moving to T3
Daklinza™ No change
Daliresp® No change
Dalvance® No change
Darifenacin Moving to T2
demeclocycline HCL Moving to T3
Dihydroergotamine (DHE) 4 mg/mL nasal spray Removed from the commercial group and individual formularies
Diclofenac/misoprostol Removed from the commercial group and individual formularies
Donnatal® Removed from the commercial group and individual formularies
Doryx® 150mg ST added/updated
doxycycline hyclate DR Moving to T3; ST added/updated
dronabinol Moving to T3
dutasteride/ tamsulosin HC, HY (Jalyn®) HC moving to T2; ST added/updatedfor HC, HY
eletriptan Moving to T2
Elmiron® Moving to T3
Enablex® Removed from the commercial individual formulary
Enbrel® No change
Entresto™ No change
Entyvio® No change
Epclusa® No change
Epoetin® / Procrit® No change
Erbitux® No change
ergotamine/ caffeine (generic Cafergot®) Moving to T3
Estrace® 0.1mg/ GM cream Moving to T2
Estring® Removed from the commercial individual formulary; moving to T3
etodolac ER, ketoprofen ER, tolmetin sodium, oxaprozin granisetron HCL Moving to T2
Exalgo® ST added/updated
famotidine (40mg) Removed from the commercial group and individual formularies
Femring® Moving to T3
fenoprofen Removed from the commercial individual formulary; moving to T3 for commercial group
fentanyl citrate Update dosing limit to 120 lozenges per 30 days
fentanyl 37.5, 62.5, 87.5 mcg/hr patch Removed from the commercial group and individual formularies
Forteo® No change
frovatriptan Removed from the commercial group and individual formularies
Gelnique® Removed from the commercial group and individual formularies
granisetron No change
hydromorphone ER Moving to T3; ST added/updated
Hyophen® Removed from the commercial group and individual formularies
Ibudone® hcd/ibuprofen 5mg/200mg tablet Removed from the commercial group and individual formularies
Immunosuppressive drugs No change
Inhalation solutions Add Levalbuterol and Perforomist
Iressa® No change
Isometheptene/ caffeine/ APAP Removed from the commercial group and individual formularies
isometheptene mucate, dichloralphenazone and acetaminophen 65/100/325 Moving to T2
Kadian® Removed from the commercial group and individual formularies
Kalbitor® No change
Kalydeco™ Medicare, no change
Kineret® Remove the following criteria: Patient does not have moderate to severe heart failure (or heart failure is adequately managed)
lanspprazole/ amoxicillin/ clarithromycin Moving to T3
Librax® Removed from the commercial group and individual formularies
Lidoderm® Add condition: Cancer-related neuropathy
Lithostat® Removed from the commercial group and individual formularies
Lortab® Removed from the commercial group and individual formularies
Lotronex® (alosetron) New form; moving to T3
Macrodantin® 50mg and 100mg capsules Removed from the commercial individual formulary
meclofenamate sodium Removed from the commercial individual formulary
mefenamic acid Removed from the commercial group and individual formularies
Mekinist® Update precertification requirements
Methergine® Moving to T3
methscopolamine bromide Moving to T2
methylergonovine Moving to T3
metoclopramide ODT Moving to T3; ST added/updated
Migeregot® rectal suppository Moving to T2
Migranal® (DHE) nasal spray Removed from the commercial group and individual formularies
minocycline HCL ER Moving to T2
Mitigare® colchicine 0.6mg Removed from the commercial group and individual formularies
Morgidox® 2X100mg Moving to T3
morphine ER capsule Removed from the commercial group and individual formularies
Myrbetriq® ST added/updated
Naprelan® 750mg Removed from the commercial group and individual formularies
naproxen sodium ER, CR Removed from the commercial group and individual formularies
Neupogen® No change
Nucynta®, Nucynta® ER ST added/updated
Ocaliva® No change
Opana® ER Removed from the commercial group and individual formularies
opium, opium tincture Removed from the commercial group and individual formularies
Opdivo® Add condition: Metastatic colorectal cancer (MSI-H or dMMR)
Orencia® Add psoriatic arthritis criteria
Orkambi® No change
Oxado® ST added/updated
oxycodone IR 5 mg capsule Removed from the commercial group and individual formularies
OxyContin® PPACA only: Moving to T2
oxymorphone ER, IR Moving to T2; ST added/updated
paregoric Removed from the commercial group and individual formularies
pentazocine/ naloxone Moving to T2; ST added/updated
Pepcid® 40mg Removed from the commercial group and individual formularies
Phenohytro™ Removed from the commercial group and individual formularies
Premarin® 0.625mg/ Gm Moving to T3; ST added/updated
ranitidine HCL capsules and syrup Removed from the commercial group and individual formularies
Rapaflo® Removed from the commercial individual formulary
Rasuvo® ST added/updated
Rayos® Removed from the commercial group and individual formularies
Remicade® Add precertification requirements to Hidradenitis Suppurativa (Medicaid)
Renagel® Moving to T3; ST added/updated
Renvela® Moving to T3; ST added/updated
Ridaura® Removed from the commercial group and individual formularies
Rituxan® No change
rospium chloride ER Moving to T2
Samsca™ No change
Sivextro® No change
Sovaldi® No change
Sprix® ketorolac nasal spray Removed from the commercial group and individual formularies
sulfadiazine Moving to T2
sumatriptan 4mg injectable products Removed from the commercial group and individual formularies
sumatriptan nasal spray, 20mg and 5mg Moving to T2
sumatriptan succinate 6mg/ 05.mL injection/kit/cartridge Moving to T2
Sumavel® Removed from the commercial group and individual formularies
Supprelin®, Sylvant® No change
Synagis® No change
Tafinlar® Updated precertification requirements
Technivie™ No change
Tivorbex® Removed from the commercial group and individual formularies
tobramycin Add Bethkis®, add diagnosis of pseudomonas aeruginosa lung infection
tramadol ER capsule Removed from the commercial group and individual formularies
Transderm®-SCOP Removed from the commercial individual formulary
Treximet® Removed from the commercial group and individual formularies
Vanatol® LQ Removed from the commercial group and individual formularies
Vectibix® Require documentation of wild-type RAS metastatic colorectal cancer, remove trial of fluoropyridimine-containing chemotherapy
Vesicare® ST added/updated
Viberzi™ New form; moving to T3
Viekira™ No change
Vimovo® Removed from the commercial individual formulary
Vivlodex® 5mg and 10mg capsules Removed from the commercial group and individual formularies
Zipsor® diclofenac pot. capsule Removed from the commercial group and individual formularies
zolmitriptan Moving to T2
Zorbtive® No change
Zorvolex® diclofenac capsule Removed from the commercial group and individual formularies
Zubsolv® ST added/updated
Zuplenz® Removed from the commercial individual formulary; moving to T2 for commercial group only; ST added/updated
Zydelig® No change