Prior Authorization

Highlights from 2021 Drug Formulary Updates

For providers and their staff, annual formulary changes mean prior authorization (PA) volume is likely to increase. Here, we’ve compiled some highlights of the 2021 changes.

Jenny RogersCoverMyMeds Editorial Team
December 29th, 2020
A pharmacist holding a prescription bottle explaining the label

It’s that time of year again: Many health plans have adjusted their drug formularies to give patients better therapy options while controlling costs. Across the board, plans have added hundreds of medications to their exclusions lists, moved several medications to their preferred lists and updated medication tiers.

For providers and their staff, these formulary changes mean prior authorization (PA) volume is likely to increase in the coming months. For patients, these changes may result in waiting longer than usual to get their prescriptions filled — or spending more money out-of-pocket for the medications they need.

Drug formularies are prescription lists that health insurers prefer (and will cover) based on greatest overall value. To decide what gets included in the formulary, a plan’s pharmacy and therapeutics (P&T) committee first reviews medications for efficacy and safety. They next consider drug alternatives and cost or reimbursement.

Plans exclude medications from a formulary for a variety of reasons, from safety concerns and quantity limits to the introduction of a new generic option.How Medicare Drug Plans Use Pharmacies, Formularies, & Common Coverage Rules Patients and providers rely on these formularies — alongside medical efficacy considerations — to make prescribing decisions that are both medically appropriate and cost-conscious.

While plans are dropping fewer drugs in 2021 than in 2020, these changes can create confusion and additional administrative work. Here, we’ve compiled notable updates for a few of the nation’s largest prescription plans.

Express Scripts National Preferred Formulary (NPF)

For 2021, Express Scripts added 70 new medications to their list of excluded drugs.

Notable additions to the plan’s exclusions list: Morphabond ER and Nucynta ER (long-acting opioid oral analgesics), Inderal XL and Innopran XL (beta blockers), Semglee (insulin), Pregenna and Trinaz (prenatal vitamins), Calquence (chronic lymphocytic leukemia), Travatan Z (glaucoma) and six inhalers, including Airduo Digihaler and ProAir HFA.

No longer excluded: Cetraxal, Embeda, Jatenzo, Ortho Tri-Cyclen and Ortho Tri-Cyclen Lo, Pancreaze, Protonix Suspension, Simvastatin Suspension and Taltz.

View Express Scripts' updated formulary

CVS Caremark Commercial

CVS added nearly 60 medications to their list of excluded drugs — and seven medications back to their formulary.

Notable additions to the plan’s exclusions list: Accu-Check’s Aviva Plus, Compact Plus, Guide and SmartView (diabetes test strips and kits), Adzenys ER and Adzenys XR-ODT (ADHD), NuvaRing (contraceptive), Bevespi Aerosphere (COPD), Differin lotion (acne), Amitiza (irritable bowel syndrome) and Tecfidera (multiple sclerosis).

No longer excluded: Euflexxa, Flarex, Lamictal, Norditropin, OneTouch Ultra and OneTouch Verio, and Toujeo.

View CVS Caremark’s updated formulary

United Healthcare Commercial

United Healthcare’s 2021 formulary updates include 27 new exclusions, while four medications not previously covered under most United Healthcare plans are now eligible for coverage.

Notable additions to the plan’s exclusions list: ProAir Digihaler (asthma), True Metrix and TRUEtrack test strips and meters (diabetes), Truvada (HIV), Tecfidera (multiple sclerosis), Inderal XL and Innopran XL (hypertension) and Forteo (osteoporosis)

No longer excluded: Abiraterone 250 MG (prostate cancer), Accu-Check Guide (diabetes test strips), Bafiertam (multiple sclerosis) and Ziextenzo (neutropenia).

View United Healthcare's updated formulary

You Can’t Avoid PA — But You Can Save Yourself Time

During this busy season, time-saving tools are more important than ever. With an electronic PA (ePA) solution, providers and their teams can submit, manage and organize their PA workload — regardless of medication or health plan — more efficiently. In fact, requests submitted electronically receive determinations 35 percent faster than requests submitted by phone and fax.Express Scripts data on file, 2019

Another benefit? An ePA solution like CoverMyMeds can alert providers to medications that have new PA requirements because of a formulary update.

Faster determinations, of course, mean patients get their medications faster. To learn more about an electronic solution, explore our ePA resources.

Jenny RogersCoverMyMeds Editorial Team
  1. 1. How Medicare Drug Plans Use Pharmacies, Formularies, & Common Coverage Rules
  2. 2. Express Scripts data on file, 2019

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