Loading...Loading...November 19, 2024
Our pharmacy team updates our covered drug list (formulary) throughout the year based on FDA approval of new drugs, new generics, changes in drug costs, and the latest clinical safety and efficacy information. Annually, our formulary and associated lists (e.g., Optimum Value Medication List and Drug Exclusions with Alternatives) are fully updated based on market and strategic objectives. Changes that will have a positive effect on members—such as removing a pre-authorization requirement—are generally implemented as soon as feasible throughout the year.
We’re planning fewer formulary changes in 2025 than in recent years. The 2025 updates include tier changes, formulary removals, and changes to the Optimum Value Medication List and Drug Exclusions with Alternatives. We’re mailing letters to members affected by the annual formulary updates that outline any changes relevant to their prescriptions and actions they can take.
- Some testosterone gel products, topical steroids and other low-utilized medications, such as anti-infective oral solutions, were moved to a higher tier because of their high cost relative to the availability of lower-cost generic and brand treatment options.
- Harvoni (ledipasvir/sofosbuvir) and Epclusa (sofosbuvir/velpatasvir), which are used for hepatitis C, were moved to a higher tier, but other guideline-recommended treatment options are available on lower tiers. Harvoni and Epclusa were removed from the CORE and QHP formularies.
- Spiriva HandiHaler (tiotropium) and brand Victoza injection were removed from formularies because generics are now available.
- Many medications have moved to a lower tier because their costs have decreased, including some oral antibiotics, oral contraceptives, medications used for pain, chronic medications used for hypertension, immunosuppressants used in transplant, and other topicals, including generic steroids.
- Eyedrops, including Alrex (loteprednol), Zylet (loteprednol/tobramycin), and Zerviate (cetirizine), were removed from the QHP formulary since there are many other treatment options available.
For Medicare Part D plans, cost-shares are changing from a copay to a coinsurance model for tier 3 and tier 4 drugs. This change will mean increased out-of-pocket costs for some members, depending on the benefit phase, total drug costs and calculations toward their max out-of-pocket. The new $2,000 out-of-pocket maximum set by Medicare will help manage the impact of this change. And members can take advantage of the new Medicare Prescription Payment Plan to even out their drug costs throughout the year.
- For diabetes-related medications, Semglee (insulin glargine) was removed from the formulary, and Lantus (insulin glargine) was added back onto it. Brand Victoza (liraglutide) was removed from the formulary since its generic is now available.
- More insulins are also available on the formulary, and all insulins are priced at $35 per month.
- Many generic medications used for chronic conditions, such as hypertension, cardiac conditions and depression, have moved to a lower tier.
- Intrauterine devices and more thyroid products have been added to the formulary.
- The estrogen products Prempro and Premarin and some thyroid products have moved to a higher tier.
- Many drugs covered under Medicare Part B, such as infused medications or medications with special administration requirements, were removed from the formulary.
Questions? Please contact your account representative.