At Elixir, whole member health is at the heart of our formulary strategy and drug management practices. As we prepare for the start of the new year, Elixir’s members will experience minimal disruption, with changes impacting less than 1% of members:
Positive Tier Change
Negative Tier Change
As Elixir’s clinical team carefully evaluated negative changes to minimize member impact while balancing formulary value, there are few changes worth highlighting:
Diabetes or weight loss agents? Ensuring appropriate utilization.
In May 2022, the FDA approved the highly anticipated type 2 Diabetes medication, Mounjaro™. However, Mounjaro is the eighth product in the crowded GLP-1 market basket. Previously, approved products like Ozempic®, Trulicity® and Victoza® are indicated for diabetes with the added labeling for reduction in cardiovascular events in this high-risk diabetes population.
The GLP-1 drug class is unique as these products are not only approved for diabetes but have separate approvals for weight loss. These products are marketed as Saxenda® and Wegovy®. Elixir has a benefit design that allows for exclusion of weight loss coverage, but drug utilization trend has shown diabetes approved GLP-1s are being used off-label for their weight loss benefit without a diabetes diagnosis.
With the launch of Mounjaro and the potential risk for off-label use of GLP-1s, the decision was made to add a prior authorization to this class of drugs to ensure a clinically appropriate diagnosis and treatment regimen. Members currently utilizing preferred products (Bydeuron®, Ozempic, Rybelsus®, Trulicity, and Victoza) will not see disruption.
Continued biosimilar access and surveillance of Humira biosimilar launches expected in 2023
Elixir takes a multifaceted approach when evaluating a biosimilar strategy. Our Pharmacy & Therapeutics (P&T) Committee in conjunction with our Value Committee ensures that all the FDA-approved indications of the reference product are included on the formulary, considers biosimilar interchangeability status, confirms that the biosimilar product is cost effective compared to the originator, and minimizes member disruption with strategy change. For 2023, the following biosimilars are included on both formularies:
- Avsola® (reference product: Remicade®)
- Retacrit® (reference product: Epogen®)
- Nivestym®/Zarxio® (reference product: Neupogen®)
- Fulphilia®/Ziextenzo® (reference product: Neulasta®)
Elixir is actively evaluating the strategic opportunity of multiple Humira biosimilars that will launch in 2023-2024. Ideally, expanded market competition with Humira biosimilars will help to drive down costs for reference products and competing biosimilars.
Non-Essential Drugs—Continued costs that flies under the radar for most PBMs
The non-essential drug (NED) program blocks the use of high cost and low clinical value FDA-approved drugs. Products are closely reviewed by our P&T Committee and if determined to have no clinical advantage over previously approved, more cost-effective products, the drug is added to the program with a clinically appropriate alternative.
For 2023, there is expanded management of 17 additional products. These products range from unique strengths of metformin, that can be up to 200 times the cost of existing generics, to new formulations of products like baclofen, that have generic products available. This program is continually reviewed and updated as new drugs are launched.
A focus on achieving whole health
Looking ahead, Elixir will always ensure a member-focused approach to our formulary and drug management practices. While new medication entrants may offer cost reduction to our plans and members, it is imperative that our members have a smooth transition with minimal disruption to their disease state management. It is this discipline that helps members achieve whole health for life, while ensuring our customers minimize unnecessary costs.