2017, 2018 pharmacy benefit changes

Pharmacy costs continue to rise and represent a disproportionate percentage of the overall increase in medical trend. That’s why we're making formulary and pharmacy network changes designed to offer practical and cost-effective solutions for members and employers.

Encourage your patients to use the Cost Estimator tool (available to members logged in to their Priority Health accounts on this website) to know their costs based on their health plan. And please prescribe covered medications when available to save them out-of-pocket costs.

New: Medicaid narrow pharmacy network as of December 1

Effective Dec. 1, 2017, the Medicaid product pharmacy benefit will be managed under a narrow network through Express Scripts, Inc. (ESI). See the Oct. 13 article for more information.

New: Formulary changes for commercial members effective January 1

These changes will help employers reduce their costs while continuing to provide their employees drug coverage, and offer members ways to keep out-of-pocket pharmacy costs down. Many drugs will change benefit coverage: they may be removed from the formulary, moved to a higher tier, require step therapy or now require prior authorization. 

Commercial large group members 

Members with commercial large group benefits will receive letters mid-November announcing the changes and suggesting they speak to their doctor about options for going forward.

The Approved Drug List tool will be updated with these formulary changes by Dec. 31, 2017. 

Commercial small group members 

The new drug list, called the optimized formulary, will be standard for all small employer groups as of Jan. 1, 2018. 

Optimized formulary changes are currently live in the Approved Drug List tool.

Members will receive letters mid to late-November suggesting they look up their prescriptions using our online Approved Drug List and speak to their doctors about options for going forward.