Jan.1, 2021 Commercial and Medicare formulary changes

10/27/2020

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

In 2020, we’ve made more than 66 enhancements, including 46 new drugs and changing 20 current drugs.

Effective Jan. 1, 2021, 16 changes will go into effect that will either remove a drug from the formulary, increase the tier the drug is in, or add step therapy or prior authorization. These changes will impact 773 members.

Commercial formulary changes impacting 50+ members

Drug Common use Change type Preferred alternatives Anticipated severity Members impacted
Betamethasone Dipropionate ointment Dermatitis, eczema, psoriasis Tier increase (1 to 2) betamethasone dipropionate 0.05% cream or lotion Medium 404
Amitiza Constipation, irritable bowel syndrome Tier increase, add step therapy Motegrity, Linzess,or Trulance High 136
Calcipotriene ointment Psoriasis Tier increase (1 to 2) Calcipotriene cream Medium 99

Commercial formulary changes impacting 1-50 members

Drug Common use Change type Preferred alternatives Anticipated severity Members impacted
Desoximethasone 0.25% ointment Atopic dermatitis, poison ivy, pemphigus, urticaria, keloids Tier increase (1 to 2) Desoximethasone 0.25% cream Med 45
Albendazole Neurocysticercosis, hydatid cyst disease Tier increase (2 to 4) N/A acute use only Low 34
Cequa Dry eye, conjunctivitus Remove from formulary Restasis, Xiidra Low 32
Calcipotriene/Betamethasone ointment and suspension Psoriasis Tier increase (1 to 5) calcipotriene ointment/solution/cream and betamethasone ointment High-med 7
Alinia Treatment of infectious diarrhea due to susceptible organisms Tier increase (2 to 3) dapsone, metronidazole Low 6
Taclonex Psoriasis Tier increase calcipotriene ointment/solution/cream and betamethasone ointment Med 4
Apokyn Parkinson's disease Remove from formulary Kynmobi Med 2
Metformin suspension Diabetes Remove from formulary Metformin tablet Med 2
Soltamox Breast cancer treatment or prevention Remove from formulary Tamoxifen tablet Low 1
Targretin Cutaneous T-cell lymphoma, mycosis fungoides Remove from formulary tazarotene 0.1% cream Low 1

Rx formulary nomenclature update

Also effective Jan. 1, aligning with current formulary management practices, the commercial formularies will be updated to reflect tier categories based on drug cost vs. drug type, such as generic vs. specialty. The formulary will be categorized Tier 1 – Tier 5, based on price of the drug. See definitions below.

Drug tiers definition list

Medicare formulary changes

Effective Jan. 1, 2021, 212 drugs will be changed on the Medicare formulary, impacting 5,435 members (1,770 for formulary removal, 3,665 due to tier change).

Five drugs have been added in addition to the 52 new drugs that have been added since Jan. 1, 2020. The majority of changes are drugs for acute use, or for a single strength particular drug.

Tier increases impacting more than 50 members

Drug Change type Preferred alternative Members impacted
Risperidon Increase tier from 1 to 2 N/A 833
Esomeprazole Increase tier from 2 to 4 (also available OTC) omeprazole 810
Diphenoxylate/Atropine Increase tier from 2 to 4 loperamide

424

Venlafaxine ER 75mg tablet; Increase tier from 2 to 4 Venlafaxine ER 75mg capsule 410
Mesalamine DR 1.2gm and 800mg Increase tier from 3 to 4 Mesalamine DR 400mg 206
Memantine ER capsule and memantine oral solution Increase tier from 2 to 3/tier 2 to 4 Memantine IR tablets 196
Olanzapine 2.5mg tablet Increase tier from 1 to 2 N/A 178
Buprenorphine HCL Increase tier from 2 to 3

 Hydrocodone-acetaminophen, hydromorphone

115
Darifenacin Hydrobromide Increase tier from 2 to 4  oxybutynin 93
Potassium Chloride 10% solution Increase tier from 2 to 4  Potassium chloride ER tablet or capsule 79
Sumatriptan 6mg/0.5ml injection Increase tier from 2 to 4  Sumatriptan tablet 56

Tier increases impacting fewer than 50 members

Drug  Change type Anticipated members impacted
Fluvastatin IR and ER Increase tier from 2 to 4 38
Budesonide Increase tier from 2 to 4 27
Memantine HCL titration Increase tier from 2 to 4 26
Promethegan Increase tier from 2 to 4 22
Propafenone ER Increase tier from 2 to 4 21
Desmopressin Acetate Increase tier from 2 to 4 10
Dexmethylphenidate ;Increase tier from 2 to 4 10
Dexmethylphenidate ER Increase tier from 2 to 4 10
Fluphenazine HCL Increase tier from 1 to 2 7
Sertraline Increase tier from 1 to 2 7
Saphris Increase tier from 4 to 5 7
Oxymorphone Increase tier from 2 to 4 7
Veltassa Increase tier from 3 to 4 6
Citalopram Increase tier from 1 to 2 6
Bromfenac Increase tier from 2 to 4 6

Formulary removals affecting greater than 30 members

Drug Member count Covered alternatives
Fluoxetine tablets 446 Fluoxetine capsules
Mupirocin 2% cream 167 Mupirocin 2% ointment
Prolensa 143 Dexamethasone or ketorolac ophthalmic solution
Cefpodoxime Proxetil 114 Cefadroxil 500 capsule
Diclofenac ER 114 Naproxen tablet, diclofenac immediate release
Cephalexin tablets and 750mg capsules 77 Cephalexin 250mg and 500mg capsules
Paroxetine ER 72 Paroxetine immediate release tablet
OMEPRAZOLE/SODIUM BICARB 61 Omeprazole DR 20mg capsule
INVELTYS 43 Dexamethasone or ketorolac ophthalmic solution
PENTASA 40 Mesalamine

How we’re communicating to our members

Members impacted by changes to either the commercial or Medicare formulary will receive a letter advising them of how their drug coverage will be changing and what steps they can take prior to Jan. 1, 2020. The letters also include a list of alternative medications that may be options for them.

Learn more

Our Nov. 13, 2019 Virtual Office Advisory webinar will cover commercial and Medicare formulary changes coming Jan. 1, 2021. Register for the webinar so you can learn more or ask questions.