Commercial, individual and Medicare formulary changes coming Jan. 1, 2025

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

The following drug coverage and mail-order pharmacy changes will take effect for your Priority Health commercial, individual and Medicare patients.

Mail order pharmacy supply change impacting new start prescriptions effective Dec. 1, 2024

To support medication adherence for current patients amongst ongoing GLP-1 supply concerns, Express Scripts has informed us they’ll no longer accept prescriptions for new start GLP-1 medications beginning Dec. 1, 2024. After December 1, patients with a new GLP-1 prescription or those who haven’t filled a GLP-1 medication through Express Scripts in the last 180 days will be directed to an in-network retail pharmacy.

Commercial and individual changes effective Jan. 1, 2025

These changes will either add or remove a drug from the formulary, change the tier a drug is in or change prior authorization requirements for a drug.

Formulary additions, coverage expansion and tier changes

Drug name	Common use	What's changing
Additions to the preventive drug list
ella®	Prevents pregnancy after unprotected sex or contraceptive failure.	Adding to the preventive drug list for optimized formularies only. This medication will be available at $0 for members.
Metformin, 850 mg tablet	Prevents or delays the progression to diabetes in persons with prediabetes.	Adding to the preventive drug list for ages 35 – 70 years for optimized formularies only. Medication will be available at $0 for members.
Additions to formulary
Insulin degludec (unbranded)	Helps lower blood sugar in people with either type 1 or type 2 diabetes.	Adding to commercial and individual formularies at tier 2 with step therapy requirements, including a trial of Lantus®.
MIEBO™	Treats the signs and symptoms of dry eye disease.	Adding to commercial and individual formularies at tier 2.
Tyenne®	Treats adults with moderately to severely active rheumatoid arthritis (RA).	Adding to commercial and individual formularies at tier 4 with prior authorization requirements. Tyenne is the biosimilar to Actemra.
Coverage expansion
Osphena®	Treats moderate to severe vaginal dryness and/or moderate to severe painful intercourse.	Expanding coverage to include genitourinary conditions outside of the Oral Sexual Dysfunction rider. Osphena will remain on commercial and individual formularies at tier 2 with prior authorization requirements.
Tier changes
Mavyret	Treats chronic hepatitis C virus infection (HCV) in adults and children over 3 years of age.	Moving to tier 1 on our commercial formulary and to tier 1b on our individual formulary.
Ribavirin (generic), 200 mg oral capsule or tablet	Works in conjunction with other medications to treat hepatitis C.	Moving to tier 1 on our commercial formulary and to tier 1b on our individual formulary.
Soliqua®	Treats type 2 diabetes in adults.	Moving to tier 2 on our individual formulary.

Formulary removals

Drug name	Common use	What's changing	Formulary alternatives
Removals from the pre-deductible Chronic Conditions Drug List (CDL)
Mounjaro®	Improves blood sugar in people with type 2 diabetes.	The member will be required to meet their annual deductible before Mounjaro is available at the tier 2 copay.	Mounjaro remains on commercial and individual formularies at tier 2.
Trulicity®	Improves blood sugar in people with type 2 diabetes.	The member will be required to meet their annual deductible before Trulicity is available at the tier 2 copay.	Trulicity remains on commercial and individual formularies at tier 2.
Removals from formulary
Actemra®	Treats adults with moderately to severely active rheumatoid arthritis (RA).	Removal of both intravenous and subcutaneous forms of the brand name, Actemra, from commercial and individual formularies.	Its biosimilar, Tyenne, will be added to commercial and individual formularies at tier 4.
Levemir®	Lowers blood sugar in children and adults with type 1 or type 2 diabetes.	All Levemir products, including vials, FlexPen® and FlexTouch, will be discontinued by the manufacturer by the end of 2024 and will no longer be on commercial or individual formularies.	Lantus® is on commercial formulary at tier 1, optimized formulary at tier 1b and individual formulary at tier 2. The generic insulin, degludec, is on commercial and individual formularies at tier 2 with step therapy requirements.
Neulasta®, Neulasta OnPro®	Prevents neutropenia in people who are receiving certain cancer treatments.	Removal of the originator Neulasta product from formulary for the pharmacy benefit only. Neulasta and Neulasta OnPro will remain covered under the medical benefit.	Biosimilar pegfilgrastim products, Nyvepria and Fulphila, are on commercial and individual formularies at tier 4.
Tresiba®	Improves glycemic control in patients with diabetes who are 1 year and older.	Removal of Tresiba from the individual formulary only.	Insulin degludec (unbranded Tresiba) is on individual formulary at tier 2.
Step therapy changes
Xultophy®	Improves blood sugar in people with type 2 diabetes.	For commercial formulary, Xultophy will drop from tier 2 to tier 3, with a new step therapy requirement which includes a trial of Soliqua. For individual formulary, Xultophy will remain at tier 3 with step therapy requirements which include a trial of Xultophy.	Soliqua will remain on commercial and individual formularies at tier 2.
Quantity limits
Austedo®	Treats involuntary movements caused by tardive dyskinesia or Huntington's disease.	Addition of quantity limits due to higher strengths becoming available.	Austedo remains on formulary at tier 5.

SaveOn SP drug changes effective Jan. 1, 2025

The SaveOn SP Program offers our members copay assistance through manufacturers’ discounts and pharmacy coupons so they can save money on their specialty medications. The following drugs were added or removed from our SaveOn SP drug list.

Drug name	Common use
Additions to the SaveOn SP drug list
Acthar®	Treats certain chronic or acute, inflammatory or autoimmune conditions.
Actimmune®	Treats chronic granulomatous disease.
Adalimumab-adbm	Treats and prevents the progression of moderate to severe rheumatoid arthritis and ankylosing spondylitis.
Adbry®	Treats atopic dermatitis in adults and some children.
Dupixent®	Treats a variety of conditions by reducing inflammation and targeting the immune system.
Enspryng®	Treats patients aged 12 or older with neuromyelitis optica spectrum disorders (NMOSD).
Imbruvica®	Treats adults with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL).
Ixinity	Treats or prevent bleeding in people with hemophilia B.
Kineret®	Treats moderate to severe active rheumatoid arthritis (RA).
Lupkynis®	Treats lupus nephritis in adults in conjunction with other medications.
Myalept®	Treats complications caused by leptin deficiency in people who have lipodystrophy.
Nyvepria™	Treats neutropenia (low white blood cells) caused by cancer medicines.
Ojemda™	Treats glioma, a type of brain tumor, in patients 6 months and older.
Opfolda®	Treats late-onset Pompe disease in adults.
Orserdu®	Treats metastatic, estrogen receptor-positive breast cancer.
Plegridy®	Treats multiple sclerosis (MS).
Pyrukynd®	Treats hemolytic anemia in adults with pyruvate kinase.
Simlandi®	Treats moderate to severe Crohn's disease (CD) in adults and children 6 years of age and older.
Simponi®	Treats moderately to severely active ulcerative colitis (UC) when certain other UC medicines haven’t worked well.
Sohonos®	Treats a certain rare genetic problem (fibrodysplasia ossificans progressiva-FOP).
Somatuline® Depot	Treats gastrointestinal and pancreatic neuroendocrine tumors (GEP NETs) that have spread or cannot be removed by surgery.
Sotyktu	Treats adults with moderate-to-severe plaque psoriasis.
Tavneos®	Treats adults with severe active ANCA-Associated Vasculitis.
Tyenne	Treats adults with moderately to severely active rheumatoid arthritis.
Vosevi®	Treats chronic hepatitis C in adults.
Voydeya™	Treats the breakdown of red blood cells that takes place outside of blood vessels.
Xolremdi®	Treats WHIM syndrome (warts, hypogammaglobulinemia, infections and myelokathexis).
Xphozah®	Treats serum phosphorus in adults with chronic kidney disease (CKD) on dialysis.
Zeposia®	Treats ulcerative colitis (UC) and certain forms of multiple sclerosis (MS).
Removals from the SaveOn SP drug list
Actemra
Adempas®
Neulasta
Opsumit®
Orenitram
UPTRAVI®

Medicare formulary changes effective Jan. 1, 2025

In consideration of Inflation Reduction Act (IRA) requirements and the implementation of the Medicare Prescription Payment Plan (M3P), we’ve made changes to our 2025 Medicare Part D formulary that will either add or remove a drug from the formulary, change the tier a drug is in and/or change prior authorization requirements for a drug. To see the changes, please review our Medicare Part D formulary changes document.

How we’re communicating to impacted patients

For many of these drug changes, impacted patients will receive a letter advising them of what’s changing, what steps they can take prior to Jan. 1, 2025, and what alternative medications are available to them.

What can you do?

If your patients contact you with questions, please work with them to determine the best treatment options.

Learn more

If you have questions or are interested in learning more about our 2025 formulary changes, join us November 21 for our formulary changes Virtual Office Advisory.

Can’t make it? All webinars are recorded and posted to our website within a week of the event, so you can watch at your convenience. 