November 20, 2024
Notice of Changes to the 2025 Jefferson Health Plans Medicare Part D Formularies
Thank you for being a valued provider for members in one or more of our health plans: Health Partners Plans Medicaid, Health Partners Plans CHIP, Jefferson Health Plans Medicare Advantage, and/or Jefferson Health Plans Individual and Family Plans.
To help maintain high quality care while reducing health care expenditures to a sustainable level, we are implementing changes to our Medicare Part D formularies for the 2025 benefit year.
Below is a list of the highest utilized drugs that will be removed from the formulary or require prior authorization starting January 1, 2025.
|
Therapeutic Class |
Non-Formulary Drug |
Formulary Alternative(s) |
|
Insulins |
Insulin lispro (Humalog®, Admelog®, Lyumjev®, insulin lispro) |
Novolog®, Fiasp® |
|
Humulin®, Humulin® N, Humulin® U-100 |
Novolin®, Novolin® N, Novolin® R, Humulin® R U-500® |
|
|
Levemir®** |
Toujeo®, Tresiba® |
|
|
Respiratory, Long Acting Anticholingerics |
Spiriva®, Spiriva Respimat®, tiotropium bromide |
Incruse Ellipta |
|
Respiratory, Inhaled Corticosteroid/Beta Agonist Combinations |
Dulera® |
Advair HFA, Breo Ellipta, Breyna, budesonide-formoterol HFA, fluticasone-salmeterol, Wixela® Inhub |
|
Severe Asthma Agents |
Nucala |
Dupixent®*, Fasenra®*, Xolair®* |
|
Potassium Binders |
Veltassa® |
Lokelma® |
|
Alpha Adnergic Ophthalmic Agents |
Alphagan P® |
brimonidine tartrate |
|
Severe Hypoglycemia Rescue Agents |
Gvoke® |
Baqsimi®, Glucagon, Zegalogue® |
|
Long Acting Injectable Antipsychotics |
Abilify Maintena® |
Aristada®, Aristada Initio®, Abilify Asimtufii® |
|
Risperdal Consta® |
Risperidone ER microspheres |
|
|
Movement Disorder Agents |
Ingrezza® |
Austedo®*, Austedo XR®*, tetrabenazine* |
|
Anti-Migraine Agents |
Ajovy® |
Aimovig®*, Emgality®* |
|
Colonoscopy Preparations |
polyethylene glycol 3350, sodium sulfate, sodium chloride, potassium chloride, sodium ascorbate, ascorbic acid (generic Moviprep) |
Clenpiq®, GaviLyte-C, GaviLyte-G, sodium sulfate, potassium sulfate, and magnesium sulfate (generic Suprep), polyethylene glycol 3350-KCl-Na Bicarb-NaCl 420 gm |
|
Therapeutic Class |
Affected Drugs |
2025 Change |
|
GLP-1 Agonists |
Trulicity® Ozempic® Mounjaro® Rybelsus® |
Prior Authorization Required*** |
|
Part D Diabetic Supplies |
Alcohol swabs Insulin syringes Pen needles Gauze |
Prior Authorization Required**** |
*Prior authorization required
**Levemir is being discontinued by the manufactuer 12/31/2024
***Prior authorization does not apply to patients with pharmacy claims submitted with an ICD-10 diagnosis code of type 2 diabetes mellitus or to patients who have a history of an antidiabetic drug (excludes a history of GLP-1s and GIP/GLP-1s)
****Prior authorization does not apply to patients a history of insulin use
Please note, this is not an all inclusive listing of the formulary changes going into effect January 1, 2025. The formulary alternatives listed above can be used as a resource when prescribing medications for your Jefferson Health Plans Medicare patients. Please be aware that pharmacies will need new prescriptions for any alternatives prescribed.
For the most up-to-date information regarding Jefferson Health Plans’ Medicare formularies, please visit our online formulary at www.JeffersonHealthPlans.com/Medicare. For more information, call Jefferson Health Plans’ Pharmacy department at 215-991-4300 or our Provider Services Helpline at 1-888-991-9023 (Monday to Friday, 9 a.m. to 5:30 p.m.).
Thank you for your cooperation in improving the quality of care you deliver to your patients and our members.