Loading...Loading...November 15, 2022
Our pharmacy team updates our formulary (covered drug list) annually to reflect the safest, highest quality, most cost-effective prescription drugs and supplies available. Updates effective Jan. 1, 2023 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’ve mailed letters to employees directly affected by these updates to notify them of actions they can take to select the highest value medications.
Drug tier names have historically described 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 employees while containing costs for employers. Effective Jan. 1, 2023, tiers will no longer be categorized by type and may include both brand and generic drugs, depending on efficacy and value.
We continually track new products coming to market and study the research to determine if they meet the effectiveness and safety standards to be included in our formulary. Biologics—treatments made using large cells from living systems like microorganisms and cells from plants and animals—have been used in vaccines for more than 100 years. They’re now commonly used to treat conditions such as rheumatoid arthritis, psoriasis, Crohn’s disease, multiple sclerosis, diabetes, certain cancers, hemophilia and others.
New biologics usually carry brand names such as Humira or Remicade and are protected by patents for a certain number of years. They are expensive, costing between $10,000 and $30,000 a year. However, once a patent expires, competitors can begin creating biosimilars—products that perform the same function as the brand name at a 15% to 30% lower cost than their reference biologics. A recent American Journal of Managed Care study estimates the total savings from biosimilar adoption from 2021 to 2025 at between $38.4 billion and $124.5 billion.
Once adopted, biosimilars generally replace their reference biologic product on our formulary and we work closely with our members and their doctors to transition them to the biosimilar. For example, Remicade is a popular biologic that treats conditions such as Crohn’s disease, psoriatic arthritis, rheumatoid arthritis and more. The first biosimilars for infliximab were introduced in 2016 and we helped more than 90% of our members using Remicade transfer to infliximab. The result: savings of more than $2 million in three months with an anticipated $11 million in savings over a full year.
The cost of health care directly affects insurance premiums and employees’ out-of-pocket costs. When we can lower costs through use of biosimilars while maintaining quality of care, everyone benefits.
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. It is estimated approximately 600 members may be affected by this change. However, the change should also be fairly transparent to members. Just as with 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.
Effective Jan. 1, 2023, we’re transitioning coverage for continuous glucose monitors (CGMs) from our medical plans to pharmacy benefits. This shift will allow employees to obtain all their diabetes management supplies from one provider, saving them money and providing a more convenient member experience.
This coverage change is applicable to members on all group plans with integrated Regence pharmacy benefits. Self-funded groups with carved-out PBMs will not be impacted; CGMs will continue to be covered through their medical plans. Self-funded groups may also customize their choices to keep the CGM benefit on their medical plans.
Customer Service has mailed affected employees communications advising them of the cost savings and convenience of obtaining CGMs through their pharmacy, along with notifications about CGM coverage switching from their medical to pharmacy benefit.
Questions? Please contact your account representative.