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 |
Key:
AL = Age limit
B/D = Coverage varies under Medicare Part B (hospitalization) vs. Part D (prescription) benefits
FF = "Free first fill" drug will be provided at zero cost-sharing the first time
HI = Home infusion drug
LA = Limited availability (available only at certain pharmacies)
NF = Non-formulary (not on Approved Drug List)
PA = Prior authorization from Priority Health is needed
QL = Quantity limits apply
ST = Step therapy (trying other drugs first) is required