Formulary changes coming July 1, 2023

In January and July of each year, the Priority Health Pharmacy and Therapeutics committee makes changes to the commercial and individual formularies to ensure our members have access to safe, effective and affordable drugs.

Commercial formulary changes effective Jul. 1, 2023

This year we’ve made more than 100 enhancements to the commercial formulary, including 51 new drugs added to the formulary and changes to 53 current drugs.

Effective Jul. 1, 2023, nine drug changes will go into effect that will either increase the drug tier, increase cost share or add prior authorization requirements. These changes will impact 22 members.

Continuous glucose monitor (CGM) changes

We’re also making changes to continuous glucose monitor (CGM) devices and supplies that will impact 1,302 members. Freestyle Libre and Dexcom G6 Continuous Glucose Monitoring (CGM) devices and supplies will require a confirmed pharmacy claim for insulin within the last six months prior to coverage, which will affect optimized and traditional formularies.

Pharmacy claims for other drugs, such as GLP-1, DPP-4, and SGLT2 medications, will not qualify in place of insulin. Coverage for the Dexcom G7 CGM devices and supplies (previously non-formulary) will be added to the traditional and optimized formularies with the same restrictions.

SaveOnSP

Additionally, 32 drug changes will go into effect that will either remove or add specialty drugs at the $0 out of pocket cost through the SaveOnSP (SOSP) program. These changes will impact 238 members. See approved language section for the tables detailing drug changes and specific member impact numbers.

Formulary changes impacting < 25 members

*Some members may experience a cost share increase with reduced drug tier due to unique plan designs.

Drug	Common use	Change type	Preferred alternatives	Anticipated member impact	Members impacted
Valganciclovir	Cytomegalovirus	Cost share increase due to plan design	N/A	Low	10
Menopur	Infertility	Tier increase 2 to 3	Gonal-F	Low	7
Alendronate Oral Solution	Osteoporosis	Tier increase 1 to 2	Alendronate tablets	Low	2
Fondaparinux	Deep vein thrombosis (DVT)	Tier increase 4 to 5	Enoxaparin, and Xarelto or Eliquis	Low	2
Ibrance	Chemotherapy	Tier increase 4 to 5	Verzenio and Kisgal	Low	1
Gleostine	Brain tumor	Add prior authorization and tier increase (3 to 5)	N/A	N/A	0
Sunosi	Narcolepsy and obstructive sleep apnea	Add smart prior authorization (Optimized only)	N/A	N/A	0
Pyrimethamine	Antimicrobial	Add prior authorization	N/A	N/A	0
Alprolix	Hemophilia	Add prior authorization	N/A	N/A	0

Continuous glucose monitor (CGM) changes impacting 100 + members

Device	Common use	Change type	Preferred alternatives	Anticipated member impact	Members impacted
Freestyle Libre	Continuous glucose monitor	Insulin prescription claim in the last six months required	One touch fingerstick glucose monitoring	High	1,175
Dexcom G6	Continuous glucose monitor	Insulin prescription claim in the last six months required	One touch fingerstick glucose monitoring	High	133

How we're communicating to members

Impacted members will receive a letter advising them of their drug coverage or continuous glucose monitor (CGM) changes and what steps they can take prior to July 1, 2023. If an alternative medication is available, those options will be listed.

SaveOnSP will send a letter to affected members enrolled in the program, advising them of added or removed specialty drugs prior to Jul. 1, 2023.

What do you need to do?

You can proactively reach out to your patients impacted by these changes by referring to the member impact list your provider performance specialist shared with you and offering alternative treatment options. Your patients may also reach out to you to discuss alternative medications or how to submit a proper diagnosis to us.

Learn more

These changes will be reviewed at our June 8 Virtual Office Advisory. Join us to ask questions and learn more.