Feb 1. Medicaid Formulary Changes

Effective Feb. 1, 2021, there will be changes to the Medicaid Common Formulary.

The Michigan Department of Health and Human Services (MDHHS) works with its health plan partners to create a list of drugs that all Medicaid health plans must cover. This list is called the Michigan Medicaid Managed Care Common Formulary. The formulary is reviewed each quarter by the Common Formulary Workgroup and the MDHHS Pharmacy Division. The next round of changes will go into effect on Feb. 1, 2021.

What's changing?

The Summary of Changes is published by the Pharmacy Division at MDHHS. These updates will be reflected on the Priority Health Medicaid Approved Drug List starting Feb.1.

Why are we making the change?

These formulary changes were decided on by the MDHHS Pharmacy Division and the Common Formulary Workgroup. Priority Health Medicaid, and all Michigan Medicaid plans must comply with these decisions per our MDHHS contract.

Impact to members

In total, 58 Priority Health Medicaid Members will be negatively impacted by these changes.

Drug type Members impacted Coverage details Drug alternatives
Relpax 20mg & 40mg tablets 36 members
  • Will remain covered but will move from PDL preferred to PDL non-preferred. This means this medication will now require prior authorization.
  • Members who are currently utilizing Relpax will be grandfathered for 1 year.
rizatriptan and sumatriptan tablets
Zomig 2.5mg & 5mg nasal spray 12 members
  • Will remain covered but will move from PDL preferred to PDL non-preferred. This means this medication will now require prior authorization.
  • Members who are currently utilizing Zomig nasal spray will be grandfathered for 1 year.
 Imitrex nasal spray
Capsaicin 0.025% cream 7 members
  • This drug will be removed from coverage.
  • Members who are currently utilizing capsaicin 0.025% cream will not be grandfathered.
 lidocaine cream or ointment
Flavoxate hcl 100mg tablets 3 members
  • Will remain covered but will move from PDL preferred to PDL non-preferred. This means this medication will now require prior authorization.
  • Members who are currently utilizing flavoxate hcl 100mg tablets will not be grandfathered.
 oxybutynin and Toviaz

How we're communicating to members

We're notifying members in writing of negative coverage changes, at least 10 days prior to the change.

What providers need to know

Providers who have patients using capsaicin 0.025 percent cream or flavoxate hcl 100mg tablets will need to take immediate action by either:

  1. Prescribing a new prescription for a preferred/covered product, or
  2. Pursuing a prior authorization so that the patient may continuing utilizing their current therapy

Providers who have patients utilizing Relpax tablets or Zomig nasal spray should know that their patients are grandfathered for one year. This means that Medicaid members who were using these drugs prior to Feb. 1 can continue filling until Jan. 31, 2022. Prior to Jan. 31, 2022, providers will need to switch their patients to a preferred product or get a prior authorization for continued coverage.