PLANS AND BENEFITS
2025 Product Guide for Providers is now available
We have a number of product changes taking effect on Jan. 1, 2025. To inform you about these updates taking effect across lines of business—commercial group, individual and Medicare—we’ve created a 2025 Product Guide for Providers.
Highlights include:
- HMA, a new TPA product for employer groups
- PriorityIntegra, a new narrow network plan for employer groups
- Optional riders for employer groups, including Musculoskeletal Centers of Excellence, virtual physical therapy with Sword® and Carrot Fertility®
- Reminders about MyPriority narrow networks
- PriorityMedicare updates,
including a new wellness line and changes to supplemental benefits
These product updates were previously shared at our October VOA, which is now available on-demand.
Thank you for serving our members in 2024, and we look forward to another great year of partnership in 2025.
INCENTIVE PROGRAMS
Here’s a look at our 2025 Disease Burden Management Program
We’ve used data from our 2024 Disease Burden Management Program (DBM) and feedback collected from our ACN partners and providers to build our 2025 DBM Program. Here’s a look at what’s coming.
What’s new for 2025 DBM?
In 2025, we’re adding two new incentives to the program.
- The Clinical Suspecting Incentive
- This incentive offers ACNs $2,500 per line of business if they can demonstrate the use of clinical suspecting for their eligible ACA and Medicare Advantage patients.
- The Coding Accuracy Incentive
- This incentive offers ACNs $0.50 PMPM if they achieve a coding accuracy score of 95% or greater in the documentation they submit for their eligible Medicare Advantage patients.
What’s staying the same?
All administrative details, requirements and incentives from the 2024 DBM program will carry over into 2025.
Want an in-depth review of 2025 DBM?
Check out our 2025 DBM webinar, located on the DBM webpage (behind login) and keep an eye out for the 2025 DBM Program manual, which will be released in December at the same time as our final PCP Incentive Program (PIP) manual.
PHARMACY
Commercial, individual and Medicare formulary changes coming Jan. 1, 2025
In January and July of each year, the Priority Health Pharmacy and Therapeutics committee makes changes to the commercial, individual and Medicare formularies to align with industry and regulatory changes and to ensure our members have access to safe and effective drugs.
The following drug coverage and mail-order pharmacy changes will take effect for our commercial, individual and Medicare members.
Mail order pharmacy supply change impacting new starts effective Dec. 1, 2024
To support medication adherence for current patients amongst ongoing GLP-1 supply concerns, Express Scripts has informed us they’ll no longer accept prescriptions for new start GLP-1 medications beginning Dec. 1, 2024. After December 1, patients with a new GLP-1 prescription or those who haven’t filled a GLP-1 medication through Express Scripts in the last 180 days will be directed to an in-network retail pharmacy.
Commercial and individual formulary changes effective Jan. 1, 2025
These changes will either add or remove a drug from the formulary, change the tier a drug is in or change prior authorization requirements for a drug.
Formulary additions, coverage expansion and tier changes
Drug name | Common use | What's changing | |
|---|---|---|---|
Additions to the preventive drug list | |||
ella® | Prevents pregnancy after unprotected sex or contraceptive failure. | Adding to the preventive drug list for optimized formularies only. This medication will be available at $0 for members. | |
Metformin, 850 mg tablet |
| Adding to the preventive drug list for ages 35 – 70 years for optimized formularies only. Medication will be available at $0 for members. | |
Additions to formulary | |||
Insulin degludec (unbranded) | Helps lower blood sugar in people with either type 1 or type 2 diabetes. | Adding to commercial and individual formularies at tier 2 with step therapy requirements, including a trial of Lantus®. | |
MIEBO™ | Treats the signs and symptoms of dry eye disease. | Adding to commercial and individual formularies at tier 2. | |
Tyenne® | Treats adults with moderately to severely active rheumatoid arthritis (RA). | Adding to commercial and individual formularies at tier 4 with prior authorization requirements. Tyenne is the biosimilar to Actemra. | |
Coverage expansion | |||
Osphena® | Treats moderate to severe vaginal dryness and/or moderate to severe painful intercourse. | Expanding coverage to include genitourinary conditions outside of the Oral Sexual Dysfunction rider. Osphena will remain on commercial and individual formularies at tier 2 with prior authorization requirements. | |
Tier changes | |||
Mavyret | Treats chronic hepatitis C virus infection (HCV) in adults and children over 3 years of age. | Moving to tier 1 on our commercial formulary and to tier 1b on our individual formulary. | |
Ribavirin (generic), 200 mg oral capsule or tablet | Works in conjunction with other medications to treat hepatitis C. | Moving to tier 1 on our commercial formulary and to tier 1b on our individual formulary. | |
Soliqua® | Treats type 2 diabetes in adults. | Moving to tier 2 on our individual formulary. | |
Formulary removals
Drug name | Common use | What's changing | Formulary alternatives |
|---|---|---|---|
Removals from the pre-deductible Chronic Conditions Drug List | |||
Mounjaro® | Improves blood sugar in people with type 2 diabetes. | The member will be required to meet their annual deductible before Mounjaro is available at the tier 2 copay. | Mounjaro remains on commercial and individual formularies at tier 2. |
Trulicity® | Improves blood sugar in people with type 2 diabetes. | The member will be required to meet their annual deductible before Trulicity is available at the tier 2 copay. | Trulicity remains on commercial and individual formularies at tier 2. |
Removals from formulary | |||
Actemra® | Treats adults with moderately to severely active rheumatoid arthritis (RA). | Removal of both intravenous and subcutaneous forms of the brand name, Actemra, from commercial and individual formularies. | Its biosimilar, Tyenne, will be added to commercial and individual formularies at tier 4. |
Levemir® | Lowers blood sugar in children and adults with type 1 or type 2 diabetes. | All Levemir products, including vials, FlexPen® and FlexTouch, will be discontinued by the manufacturer by the end of 2024 and will no longer be on commercial or individual formularies. | Lantus® is on commercial formulary at tier 1, optimized formulary at tier 1b and individual formulary at tier 2. The generic insulin, degludec, is on commercial and individual formularies at tier 2 with step therapy requirements. |
Neulasta®, Neulasta OnPro® | Prevents neutropenia in people who are receiving certain cancer treatments. | Removal of the originator Neulasta product from formulary for the pharmacy benefit only. Neulasta and Neulasta OnPro will remain covered under the medical benefit. | Biosimilar pegfilgrastim products, Nyvepria and Fulphila, are on commercial and individual formularies at tier 4. |
Tresiba® | Improves glycemic control in patients with diabetes who are 1 year and older. | Removal of Tresiba from the individual formulary only. | Insulin degludec (unbranded Tresiba) is on individual formulary at tier 2. |
Step therapy changes | |||
Xultophy® | Improves blood sugar in people with type 2 diabetes. | For commercial formulary, Xultophy will drop from tier 2 to tier 3, with a new step therapy requirement which includes a trial of Soliqua. For individual formulary, Xultophy will remain at tier 3 with step therapy requirements which include a trial of Xultophy. | Soliqua will remain on commercial and individual formularies at tier 2. |
Quantity limit changes | |||
Austedo® | Treats involuntary movements caused by tardive dyskinesia or Huntington's disease. | Addition of quantity limits due to higher strengths becoming available. | Austedo remains on formulary at tier 5. |
SaveOn SP drug changes effective Jan. 1, 2025
The SaveOn SP Program offers our members copay assistance through manufacturers’ discounts and pharmacy coupons so they can save money on their specialty medications. The following drugs were added or removed from our SaveOn SP drug list.
Drug name | Common use |
|---|---|
Additions to the SaveOn SP drug list | |
Acthar® | Treats certain chronic or acute, inflammatory or autoimmune conditions. |
Actimmune® | Treats chronic granulomatous disease. |
Adalimumab-adbm | Treats and prevents the progression of moderate to severe rheumatoid arthritis and ankylosing spondylitis. |
Adbry® | Treats atopic dermatitis in adults and some children. |
Dupixent® | Treats a variety of conditions by reducing inflammation and targeting the immune system. |
Enspryng® | Treats patients aged 12 or older with neuromyelitis optica spectrum disorders (NMOSD). |
Imbruvica® | Treats adults with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL). |
Ixinity | Treats or prevent bleeding in people with hemophilia B. |
Kineret® | Treats moderate to severe active rheumatoid arthritis (RA). |
Lupkynis® | Treats lupus nephritis in adults in conjunction with other medications. |
Myalept® | Treats complications caused by leptin deficiency in people who have lipodystrophy. |
Nyvepria™ | Treats neutropenia (low white blood cells) caused by cancer medicines. |
Ojemda™ | Treats glioma, a type of brain tumor, in patients 6 months and older. |
Opfolda® | Treats late-onset Pompe disease in adults. |
Orserdu® | Treats metastatic, estrogen receptor-positive breast cancer. |
Plegridy® | Treats multiple sclerosis (MS). |
Pyrukynd® | Treats hemolytic anemia in adults with pyruvate kinase. |
Simlandi® | Treats moderate to severe Crohn's disease (CD) in adults and children 6 years of age and older. |
Simponi® | Treats moderately to severely active ulcerative colitis (UC) when certain other UC medicines haven’t worked well. |
Sohonos® | Treats a certain rare genetic problem (fibrodysplasia ossificans progressiva-FOP). |
Somatuline®Depot | Treats gastrointestinal and pancreatic neuroendocrine tumors (GEPNETs) that have spread or cannot be removed by surgery. |
Sotyktu | Treats adults with moderate-to-severe plaque psoriasis. |
Tavneos® | Treats adults with severe active ANCA-Associated Vasculitis. |
Tyenne | Treats adults with moderately to severely active rheumatoid arthritis. |
Vosevi® | Treats chronic hepatitis C in adults. |
Voydeya™ | Treats the breakdown of red blood cells that takes place outside of blood vessels. |
Xolremdi® | Treats WHIM syndrome (warts, hypogammaglobulinemia, infections and myelokathexis). |
Xphozah® | Treats serum phosphorus in adults with chronic kidney disease (CKD) on dialysis. |
Zeposia® | Treats ulcerative colitis (UC) and certain forms of multiple sclerosis (MS). |
Removals from the SaveOn SP drug list | |
Actemra | |
Adempas® | |
Neulasta | |
Opsumit® | |
Orenitram | |
UPTRAVI® | |
Medicare formulary changes effective Jan. 1, 2025
In consideration of Inflation Reduction Act (IRA) requirements and the implementation of the Medicare Prescription Payment Plan (M3P), we’ve made changes to our 2025 Medicare Part D formulary that will either add or remove a drug from the formulary, change the tier a drug is in and/or change prior authorization requirements for a drug. To see the changes, please review our Medicare Part D formulary changes document.
How we’re communicating to impacted patients
For many of these drug changes, impacted patients will receive a letter advising them of what’s changing, what steps they can take prior to Jan. 1, 2025, and what alternative medications are available to them.
What can you do?
You’ll receive a list of impacted patients from your Provider Strategy and Solutions Consultant. If your patients contact you with questions, please work with them to determine the best treatment options.
Learn more
If you have questions or are interested in learning more about our 2025 formulary changes, please join us on November 21 for our formulary changes Virtual Office Advisory.
Can’t make it?
All webinars are recorded and posted to our website within a week of the event, so you can watch at your convenience.
New Medicare Prescription Payment Plan coming Jan. 1, 2025
In alignment with Inflation Reduction Act (IRA) requirements the new Medicare Prescription Payment Plan (M3P) launches on Jan. 1, 2025.
What’s M3P?
The Centers for Medicare and Medicaid Services’ (CMS) Medicare Prescription Payment Plan is a new program that allows anyone with a Medicare drug plan, or a Medicare health plan with drug coverage, to pay monthly installments directly to their health plan for their covered prescription drugs, rather than paying their Part D cost share at the pharmacy.
M3P is a voluntary program and free to your Medicare patients, meaning they won’t be charged any interest or fees for participating.
Will M3P save your patients money on their prescription drugs?
While M3P won’t discount the out-of-pocket costs of your patients’ prescription drugs, it can help them better manage costs by spreading the payments out over the course of the calendar year, rather than paying their Part D cost share upfront. Note: Your patients’ monthly payments could vary each month depending on new prescriptions and how many months are left in the calendar year. Because of this, they may not know their exact bill ahead of time.
Is M3P right for all your Medicare patients?
No. M3P is most beneficial for your patients being treated with high-cost, specialty drugs. It may not be helpful if they meet any of the following criteria:
- They’re included in the Medicare Extra Help program
- They qualify for a Medicare Savings Program
- They get help paying for their drugs from other organizations, like a State Pharmaceutical Assistance Program (SPAP) or other health coverage
- Their yearly drug costs are low
- Their drug costs are the same each month
- They sign up for the payment option late in the calendar year (after September)
Will this change how you write prescriptions?
No. Your patients will still get their medications from their pharmacy.
How do patients sign up?
For more information on M3P, including how to enroll, refer your patients to our M3P member webpage.