Commercial and Medicare formulary changes coming Jan. 1, 2023

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

Commercial changes effective Jan. 1, 2023

In 2022, we made more than 100 enhancements to the formulary by adding drugs or changing coverage of existing drugs. In 2023, we'll add 16 drugs to the formulary or cover them more favorably. Starting Jan. 1, 2023, 21 drug changes impacting 1,992 members will go into effect. These changes will either remove a drug from the formulary or increase the tier the drug is in.

Drug Common Use Change Type Preferred Alternative(s)
Atomoxetine ADHD Tier increase 1(1b) to 2 Guanfacine/ Guanfacine ER
Duloxetine 40mg capsule Depression Tier increase 191b) to 2  Duloxetine (generic for Cymbalta)/ Venlafaxine (generic for Effexor)/ Venlafaxine ER (generic for Effexor XR)
 Colchicine capsule Gout Tier increase 2 to 3 Colchicine tablets/ Allopurinol

Click here to download the full list of changes

Chronic Condition Drug List Changes

For many years, we've supported optional coverage for select chronic medications, ahead of deductible, for a copay or no cost for individual market and select employer group plans. Beginning Jan. 1, 2023, we'll update the Chronic Condition List to align with IRS standards. Medication not identified by the IRS will be removed from pre-deductible coverage. Mostly very low-cost drugs are impacted, and members are unlikely to experience any change because the negotiated price is often less than the member's copay.

The IRS defines the following classes as allowable ahead of deductible:

  • Diabetes including insulin and other glucose lowering drugs
  • Blood glucose monitors and supplies
  • Inhaled corticosteroids (asthma/COPD)
  • ACE inhibitors (blood pressure)
  • Beta-blockers (blood pressure)
  • SSRIs (depression)
  • Statins (cholesterol)
  • Anti-resorptive drugs (osteoporosis)

For select brand name drugs, like diabetes medications and inhalers, we're strengthening the drug list to encourage use of preferred brand drugs available at the lowest cost. 

 Site-of-Service Update

We're adding 12 new drug codes to the site-of-service policy. Beginning Jan. 1, 2023, new starts to the following drugs will need to have their medication administered at the correct site of service for their plan. Members currently taking the medication will need to transition to the correct site of service by April 1, 2023. 

Drug Code Member Impact
Camcevi J1952 0
Eligard J9217 30
Fensolvi J1951 0
Lupron J9218 1
Lupron Depot

J1950

J9217

J3490

 47

Prolia

Xgeva

 J0897 54
Riabni Q5123 0
Rituxan J9312 0
Rituxan Hycela J9311 0
Ruxience Q5119 36
Truxima Q5115 24

Medicare changes effective Jan. 1, 2023

We've made the following enhancements to the Medicare formulary, positively impacting thousands pf our members: 

  • $0 three-month supply (90-day) at preferred retail pharmacies for tier 1 drugs
  • Movement of chronic condition HEDIS drugs to tier 1 (statins, blood pressure)
  • Diabetic supplies moving from tier 4 to tier 1 (see chart below)
  • Out-of-pocket insulin CAP at $35 for a month's supply in accordance with the Inflation Reduction Act
  • $0 vaccines for Part D beneficiaries in accordance with the Inflation Reduction Act

Diabetic supplies moving to tier 1

Drug: Insulin supplies:
  • Glipizide/Metformin
  • Pioglitazone
  • Repaglinide
  • Reli-On insulin syringe
  • Preferred Plus insulin syringe
  • Assure insulin syringe
  • Comfort Assist insulin syringe
  • Exel Comfort pen needle

Formulary Changes

The following drug changes take effect Jan. 1, 2023, and will either remove the drug from formulary or increase the tier the drug is in. 

Drug Common Use Change Type Preferred Alternative(s)
Vyvanse ADHD Removed Methylphenidate ER, dexmethylphenidate ER, amphetamine/ dextroamphetamine ER
ProAir Respiclick Asthma Removed Albuterol HFA, Ventolin HFA, levalbuterol HFA
Tudorza COPD Removed Spiriva, Incruse Ellipta

Click here to download the full list of changes

Pharmacy Network Update

The following pharmacies are moving from preferred to non-preferred: 

  • Parkwood (Wyoming, MI)
  • Family Health (Kalamazoo, MI)
  • East Ann Arbor (MI)
  • Safeway
  • HEB
  • Winn-Dixie

Members may continue using these pharmacies to fill their prescription drugs; however, their out-of-pocket costs may increase.