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October 25, 2022

On Jan. 1, 2023, our formulary (covered drug list) will be refreshed to reflect current scientific findings and new medications on the market. Our pharmacy team updates our formulary annually to reflect the safest, highest quality, most cost-effective prescription drugs and supplies available.

The 2023 updates include:

• new quantity limits and pre-authorization requirements
• cost-share and tier changes
• changes to the Optimum Value and Drug Exclusions with Alternatives Lists
• removal of certain medications from our formulary

• exclusion of certain drugs, medical foods and over-the-counter medications

We’re mailing letters to members directly affected by these updates to notify them of actions they can take to select the highest value medications.

Currently, drug tier names generally describe the category of drugs found in each tier, such as generic, brand, and specialty. However, the market is moving toward basing formulary design on value and efficacy rather than drug category. This will allow for more flexibility in formulary design to provide the highest value medications for members while containing costs for employers.

Beginning with our 2023 formularies, tiers will no longer be categorized by type and may include both brand and generic drugs, depending on efficacy and value.

As more competition enters the biosimilar market, comparable, lower-cost products continue to emerge that help reduce overall drug spend while maintaining efficacy and quality. Beginning Jan. 1, 2023, Fulphila (pegfilgrastim-jmbd) will replace Udenyca (pegfilgrastim-cbgv) as the preferred product—both of which are biosimilars to the originator product Neulasta. On Jan. 1, 2023, the formulary will include two preferred pegfilgrastim products: Fulphila and Ziextenzo.

These products are used intermittently to support the production of white blood cells in patients receiving chemotherapy. Because they are prescribed intermittently, it is difficult to identify members currently receiving therapy for notification purposes. It is estimated approximately 600 members may be affected by this change. However, the change should also be fairly transparent to members. Just as in generic drugs, in the unlikely event the patient does not tolerate the preferred products, the provider may request pre-authorization for coverage of another product.

Providers were notified of this change in the October Provider newsletter. A reminder will be included in the December newsletter. Provider Relations will also support implementation through communications with prescribing providers.

Questions? Please contact your account representative.