Upcoming 2025 Medicare Advantage, Part D formulary changes may require prescribing alternative drugs

Changes to Blue Cross Blue Shield of Michigan and Blue Care Network’s 2025 drug formularies may require health care providers to prescribe alternative medications to some of our Medicare Plus Blue℠, BCN Advantage℠ or Prescription Blue℠ PDP individual plan members, starting Jan. 1, 2025.

To comply with federal government constraints and Part D redesign provisions expected in 2025, we’re adjusting our formulary and utilization management requirements. We collaborated with physicians and pharmacists to develop a comprehensive formulary strategy by considering safety, efficacy and cost.

As a result, some of the drugs currently on our formularies will be:

• Removed
• Moved to higher tiers
• Added to the list of drugs requiring prior authorization, step therapy or quantity limits

The upcoming formulary modifications are more significant compared to previous years, so health care providers may receive an increase in patient calls and may need to prescribe alternative medications. Nevertheless, the majority of current medications have suitable replacements that we’ll continue to cover. Our projections indicate that approximately two-thirds of our members won’t experience an increase in out-of-pocket costs.

We recently mailed letters explaining these changes to specific providers. These letters include a list of their patients who may be most affected by the formulary changes, as well as suggestions for suitable alternative prescriptions. To assist providers in advance, we posted our 2025 formularies on our website. Visit the Drug Lists for Medicare Members webpage. We’re also educating pharmacists about potential changes that can be directly managed at the pharmacy level.

We’ve also developed a Formulary Alternative Finder tool that’s available on our provider portal. Follow these steps:

1. Log in to our provider portal at availity.com.**
2. Click on Payer Spaces on the Availity menu bar.
3. Click on the BCBSM and BCN logo.
4. Click on Secure Provider Resources (Blue Cross and BCN) on the Resources tab.
5. Click on Pharmacy on the Member Care tab.
6. Select the Formulary Alternative Finder.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.