We have recently updated our prior authorization list and coverage policies. These changes are effective for dates of service on or after May 15, 2024.
Summary of changes effective May 15, 2024
Change: Removed from formulary
- Afinitor 10mg tablet; consider generic
- Buphenyl powder; consider generic
- Carbaglu; consider generic
- Celontin; consider generic
- Cystadane powder; consider generic
- Farxiga; consider generic
- Gabitril tablet; consider generic
- Mozobil; consider generic
- Orfadin capsule; consider generic
- Sutent; consider generic
- Targretin 75mg capsule; consider generic
- Valcyte solution; consider generic
- Vandazole 0.75% vaginal gel; consider generic
- Zortress; consider generic
Change: Add Prior Authorization
- Prevymis tablet
Change: Update Quantity limit
- Dupixent 200mg/1.14 ml; update quantity limit to 2.28ml/28 days
In addition to the above changes, we have updated the formulary to include a number of new medications that have been released in the past year. For a complete formulary listing, please visit our Find a drug: Medicaid page.