Priority Health - Commercial and Medicare Formulary Updates for January 1, 2021

November 9, 2020

Commercial formulary updates effective Jan. 1, 2021

In January and July of each year, the Priority Health Pharmacy and Therapeutics committee makes changes to the commercial formulary to ensure our members have access to safe, effective and affordable drugs. 

In 2020, we’ve made more than 66 enhancements, including 46 new drugs and changing 20 current drugs. 

Effective Jan. 1, 2021, 16 changes will go into effect that will either remove a drug from the formulary, increase the tier the drug is in, or add step therapy or prior authorization. These changes will impact 773 members.

Visit the provider manual for a list of changes


Rx formulary nomenclature update

Also effective Jan. 1, aligning with current formulary management practices, the commercial formularies will be updated to reflect tier categories based on drug cost vs. drug type, such as generic vs. specialty. The formulary will be categorized Tier 1 – Tier 5, based on price of the drug.


Medicare formulary changes

Effective Jan. 1, 2021, 212 drugs will be changed on the Medicare formulary, impacting 5,435 members (1,770 for formulary removal, 3,665 due to tier change).

Five drugs have been added in addition to the 52 new drugs that have been added since Jan. 1, 2020. The majority of changes are drugs for acute use, or for a single strength particular drug.


Visit the provider manual for a list of changes


How we’re communicating to our members
Commercial members impacted by changes will receive a letter advising them of how their drug coverage will be changing and what steps they can take prior to Jan. 1, 2021. The letters also include a list of alternative medications that may be options for them. 

Medicare members who are impacted by a drug removal will receive a letter with covered alternatives and steps they need to take prior to Jan. 1.


What do providers need to do?

You may proactively reach out to your patients whose drug is being removed from the formulary, with an alternative treatment or prescription.  Our members may also reach out to you to ask about alternative treatment options. 


Learn more
Our November 19th Virtual Office Advisory webinar will cover these changes. Join us to ask questions and learn more.