Not a year goes by without health plans adjusting their formularies to make way for new, improved medications, control costs and give patients better treatment options. These changes occur across many, if not all, plans and involve adding hundreds of medications to exclusions lists, moving medications to preferred lists and updating medications tiers.
The results of these changes can affect providers and their staff with an increase in PA volume in the following months. For patients, it can mean waiting longer for their prescriptions to get filled or having to pay more for out-of-pocket costs.
Drug formularies, also called drug lists, are a list of prescription drugs covered by a prescription drug plan or another insurance offering prescription drug benefits. Typically, a plan’s pharmacy and therapeutics (P&T) team reviews new and existing drugs based on safety, quality and cost-effectiveness. They also consider drug alternatives and reimbursement.
Health plans exclude drugs from their formularies for many reasons, including wanting patients to use a different drug in that therapeutic class, the drug being available over the counter, a new generic option or they have concerns about safety or effectiveness.
Below, we’ve compiled notable updates for a few of the nation’s largest prescription plans.
Need to submit a PA request for a patient on Medicare or Medicaid? Here's what you need to know about Medicare, Medicaid and the PA process.
Express Scripts National Preferred Formulary (NPF)
Beginning Jan. 1, 2022, the NPF will exclude 32 additional products, including five specialty drugs.
Notable additions to the plan’s exclusion list: Merck’s Zioptan, Allergan’s Durysta, and Sun Pharma’s Xelpros (glaucoma). Pfizer’s Nyvepria and Amgen’s Neulasta and Udenyca (cancer), and Alrex (loteprednol ophthalmic), Zerviate (allergic conjunctivitis), Otovel (ear infections).
No longer excluded: Calquence® (cancer), Inflectra (TNF-alpha inhibitor)
CVS Caremark Commercial
For 2022, CVS removed 20 drugs from its formulary and added four drugs back. Two drugs were added to Tier 1 strategy, which is expected to save an average of 31% per claim.
Notable additions to the plan’s exclusions list: Eliquis (blood thinner), Aimovig® (migraines). Truvada® (HIV) Atripla®, Complera® (Combination HIV) are being excluded for recently approved generic equivalents.
No longer excluded: Avonex®, Plegridy® (both MS) are being added back to the formulary.
United Healthcare Commercial
United Healthcare will exclude 50 drugs from its 2022 formulary with many of those being replaced by generic alternatives.
Notable additions to the plan’s exclusions list: Rebif/Rebif Rebidose (MS), Gemtessa (overactive bladder), Epiduo, Epiduo Forte (acne), Follistim AQ (Infertility). Tykerb (cancer) is being excluded for a recently approved generic equivalent.
No longer excluded: Xeloda (cancer), Carac (cancer – topical).
PA is unavoidable, but there are ways to save time
When health plans make yearly changes to their formulary lists, providers and care teams typically face an increase in PA requests. Time-saving tools like electronic PA (ePA) can help organize and manage PA for all medications and health plans, which helps the process work more efficiently.
PA requests submitted electronically receive determinations 35% faster than requests submitted by phone or fax. With an ePA solution like CoverMyMeds, providers can also get alerts on medications with new PA requirements following a formulary update, which can help patients get the medications they need faster.
To learn more about electronic PA and other trends affecting medication access, read the 2022 Medication Access Report.