Commercial and Medicare formulary updates effective Jan. 1, 2022
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 formulary changes effective Jan. 1, 2022
This year we’ve made more than 100 enhancements to the commercial formulary, including 58 new drugs along with changes to 45 current drugs.
Effective Jan. 1, 2022, 24 drug 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 1,129 members.
| Drug | Common use | Change type | Covered alternatives | Anticipated impact | Member impact | |
|---|---|---|---|---|---|---|
| Alogliptin* (o) | Diabetes | Tier increase (2 to 3) | Januvia/Janumet/Janumet XR | Medium | 184 | |
| Restasis (o) | Dry eye | Tier increase (2 to 4) Optimized formulary only | Xiidra | High | 171 | |
| Imvexxy | Dysparenuria | Add Prior Authorization | Estradiol (oral, topical, transdermal) | High | 170 | |
| Steglatro* (o) | Diabetes | Tier increase (2 to 3) | Januvia/Janumet/Janumet XR | Medium | 117 | |
| Vraylar* | Bipolar Disorder/schizophrenia | Tier increase (4 to 5) | Latuda/aripiprazole,/olanzapine/quetiapine | Medium | 117 | |
| Tradjenta | Diabetes | Tier increase (2 to 3) and Add Step Therapy | Januvia/Janumet/Janumet XR | Low | 78 | |
| Tazarotene 0.1% cream | Psoriasis/Acne | Tier increase (1 (1b) to 2) | Topical betamethasone dipropionate/topical Clobetasol/topical fluocinolone/ topical triamcinolone/topical fluocinonide, and Differin 0.1% Gel. | Medium | 70 | |
| Motegrity | Irritable Bowel Syndrome (IBS-C) | Tier increase (2 to 3) and Add Step Therapy | Linzess and Trulance | Medium | 65 | |
| Bevespi | COPD | Tier increase (2 to 3) and Add Step Therapy | Anoro or Stiolto | Medium | 29 | |
| Rexulti* | Schizophrenia, Major Depression | Tier increase (4 to 5) | Latuda/aripiprazole/olanzapine/quetiapine | High | 19 | |
| Nitrofurantoin (suspension only) | Bacterial infection | Tier increase (2 to 4) | Amoxicillin suspension/Bactrim suspension/nitrofurantoin capsules | Low | 18 | |
| Pramipexole ER | Parkinson's disease | Tier increase (1(1b) to 3) | Immediate Release pramipexole/ropinerole Extended Release & Immediate Release | High | 18 | |
| Alogliptin/metformin* (o) | Diabetes | Tier increase (2 to 3) | Januvia/Janumet/Janumet XR | Medium | 14 | |
| Desonide 0.05% lotion (t) | Skin Conditions (itching/swelling/redness) | Tier increase (1 to 2) | betamethasone valerate external lotion 0.1%/triamcinolone acetonide external cream 0.025% desonide external cream or ointment 0.05% | Low | 14 | |
| Tazorac 0.05% cream | Psoriasis | Tier increase (2 to 3) | Topical betamethasone dipropionate/ topical clobetasol/ topical fluocinolone/ topical triamcinolone/ topical fluocinonide/ calcipotriene cream or solution | Medium | 13 | |
| Fabior (t) | Acne | Formulary removal | tazarotene foam/tazarotene cream | Low | 8 | |
| Testosterone 1.62% topical gel packets | Hormone replacement | Formulary removal | Testosterone 1.62% pump/ transdermal 1% gel packets/ testosterone cypionate intramuscular solution | Medium | 5 | |
| Analpram – HC lotion | Hemorrhoids | Formulary removal | Hydrocortisone/pramoxine cream | Low | 3 | |
| Banzel | Epilepsy | Tier increase (4 to 5) | Rufinamide (generic Banzel) | High | 3 | |
| Caplyta* | Schizophrenia | Tier increase (4 to 5) | Latuda/aripiprazole/olanzapine/quetiapine | High | 3 | |
| Fanapt* | Schizophrenia | Tier increase (4 to 5) | Latuda/aripiprazole/olanzapine/quetiapine | High | 3 | |
| Natroba | Lice, Scabies | Formulary removal | Spinosad (generic Natroba) | Low | 3 | |
| Segluromet* (o) | Diabetes | Tier increase (2 to 3) | Januvia/Janumet/Janumet XR | Low | 3 | |
| Exelderm/Sulconazole | Fungal/yeast infections | Formulary removal | ketoconazole/ciclopirox/econazole | Low | 1 |
* Current members exempt from new step therapy requirement
(o) Applies to Optimized formulary only
(<>) Sexual dysfunction rider required
(t) Applies to Traditional formulary only
Medicare formulary changes effective Jan. 1, 2022
Throughout the year we’ve lowered drug tiers, added drugs to the formulary and removed prior authorization or step therapy requirements, positively impacting about 10,000 Medicare members.
Effective Jan. 1, 2022, 100 drug changes will go into effect that will increase tiers or remove drugs from the formulary. About 1,500 members will be impacted by formulary removals and 11,800 members impacted by tier increases.
| Drug | Common use | Change type | Covered alternatives | Anticipated impact | Member impact |
|---|---|---|---|---|---|
| Orphenadrine ER | Muscle relaxant | Formulary removal | Cyclobenzaprine, baclofen, tizanidine | Medium | 490 |
| Amitiza | Constipation | Formulary removal | Linzess, lactulose | Medium | 200 |
| Chlorzoxazone | Muscle relaxant | Formulary removal | Cyclobenzaprine, baclofen, tizanidine | Low | 190 |
| Cholestyramine 4g powder | Cholesterol, non-statin | Formulary removal | Cholestyramine packets, colesevelam tablet, ezetimibe | Low | 100 |
| Bydureon pen | Diabetes | Formulary removal | Trulicity | Low | 90 |
| Metoprolol 37.5mg, 75 mg | High blood pressure | Formulary removal | Metoprolol 25 mg, 50 mg, 100 mg, atenolol, bisoprolol | Low | 90 |
| Novolin products | Diabetes, insulin | Formulary removal | Humulin products | Low | N/A, grandfathering |
| Alprazolam ER/XR | Anxiety | Formulary removal | Alprazolam, lorazepam, clonazepam | Low | 42 |
| Envarsus XR | Immunosuppressant, transplant | Formulary removal | Tacrolimus, cyclosporine | Low | 29 |
| Zarxio | Cancer supportive care | Formulary removal | Nyvestym, Nyvepria, Fulphila | Low | 16 |
| Ropinirole | Parkinson’s disease | Tier increase | None | Medium | 2,000 |
| Quetiapine 25mg | Bipolar disorder | Tier increase | None | Medium | 1,010 |
| Pramipexole | Parkinson’s disease | Tier increase | None | Medium | 1,700 |
| Carbidopa/levodopa 10/100, 25/100 | Parkinson’s disease | Tier increase | None | Medium | 1,500 |
| Clindamycin 150mg | Antibiotic | Tier increase | None | Low | 520 |
| Topiramate 25mg and 50mg | Migraine or seizure | Tier increase | Lamotrigine | Low | 1,270 |
| Levetiracetam 250mg and 500mg | Seizure | Tier increase | Lamotrigine | Medium | 400 |
| Mirtazapine 7.5mg | Depression | Tier increase | Citalopram, fluoxetine, paroxetine, sertraline | Low | 200 |
| Venlafaxine ER 37.5mg | Depression | Tier increase | Citalopram, fluoxetine, paroxetine, sertraline | Low | 900 |
| Nicotrol | Smoking cessation | Tier increase | Bupropion ER | Low | 115 |
Medicare formulary removals, less than 15 members
- Apokyn
- Bidil
- Bupropion 450mg HCL ER
- Calcitrol
- Daptomycin solution
- Daytrana patch
- Desvenlafaxine ER 24h
- Doxycycline hyclate
- Epifoam
- Fulphila
- Gelnique gel
- Glucagon kit
- Granix
- Hydrocortisone butyrate
- Imiquimod pump
- Ketoprofen
- Kristalose
- Lactulose
- Lotamax SM
- Maxidex
- Micafungin
- Nuvaring
- Opium tincture
- Pred Mild 0.12% suspension
- Prevalite powder
- Risedronate 30mg
- Temazepam 22.5mg capsules
- Topiramate ER 200mg
- Triamcinolone 0.05% ointment
- Velphoro chewable
- Zipsor capsules
Medicare tier increases, less than 50 members
- Albedazole 200mg
- Bethanechol 5mg
- Colistimethate
- Dicyclomine solution
- Fluoxetine solution
- Flurazepam capsules
- Furosemide solution
- Ibuprofen solution
- Metoclopramide solution
- Miglitol
- Nicotrol NS
- Propranolol solution
- Seroquel 25mg
- Sirolimus
- Zonisamide capsules
How we’re communicating to members
Members impacted by changes will receive a letter advising them of their drug coverage changes and what steps they can take prior to Jan. 1, 2022. The letters also include a list of alternative medications that may be options for them.
What do providers need to do?
You can proactively reach out to your patients whose drug is impacted by these changes with an alternative treatment or prescription. Our members may also reach out to you to ask about alternative treatment options.
Learn more
These changes will be reviewed at our December 9 Virtual Office Advisory. Join us to ask questions and learn more.