July 1 pharmacy and formulary changes

At the January and March 2018 Pharmacy and Therapeutics (P&T) Committee meetings, 47 changes were approved and will be in effect beginning July 1, 2018.

Notifying members

About 41,000 members will be impacted by the July 1 formulary changes, 98% of whom are affected by the five changes listed below. For each change, members will receive letters outlining the change and what their next step should be.

Removal of OTC coverage

Removal of over-the-counter (OTC) or equivalent coverage: If an OTC drug option exists, members will be encouraged to purchase it themselves in order to save money. Drugs with an OTC equivalent will be moved to tier 3 and will be a higher cost if purchased using their pharmacy benefits.

Specifically, protein pump inhibitors (used for GERD, acid reflux, etc), nasal steroids such as Flonase® and Rhinocort® and histamine H2-receptor antagonists/H2 blockers (ulcer preventative) will move to a non-preferred brand tier (T3). This allows members to continue utilizing pharmacy benefit coverage; however; the T3 copay may be higher than the OTC price.

Fluoxetine tablets removed from formulary

Fluoxetine, an anti-anxiety drug, capsules are available at a significantly lower cost than tablets; therefore, tablets are being removed from the formulary. Michigan law allows pharmacists to automatically substitute the capsules in place of the tablets, so member disruption is anticipated to be minimal.

Site-of-service changes

As result of significant cost savings on the previous site-of-service drug injection programs at Priority Health, additional drug injectables will have site-of-service (SOS) requirements starting July 1. We're implementing changes to SOS on drugs for the following types of conditions currently purchased through Accredo (specialty pharmacy): enzyme deficiencies, pulmonary hypertension, alpha 1 deficiency, hereditary angioedema, and certain autoimmune diseases.

Starting July 1, when Priority Health receives a claim for one of the drugs, our pharmacy team will contact the provider's office to determine what the best SOS for continuing the member's treatment moving forward. This SOS change will impact roughly 100 members, and the goal is to have all members transitioned to a preferred SOS by October 1, 2018.

Advair and Breo removal from formulary

Advair® and Breo®, asthma and COPD inhalant medications, will be removed from the formulary due to rising costs for these branded drugs. Dulera®, Symbicort® and AirDuo® (authorized generic) are covered alternatives that are available at a lower cost.

Targadox removal from formulary

Targadox™ is a name-brand acne drug that's more costly than its generic alternative, doxycycline monohydrate. Approximately 65 members will need to transition to a lower-cost alternative such as doxycycline monohydrate.

More details

For a full list of all pharmacy and formulary changes, see Provider Center > Drugs > Formulary updates.