Updates on Existing Criteria
Preauthorization Criteria – Clinical Updates
- Ferriprox and Exjade & Jadenu – Combine policies to create “Chelating Agents”
- Histrelin – Update criteria to include required step through leuprolide formulations for Supprelin
- Leuprolide – Update to include requirements for Central Precocious Puberty, update coverage for Uterine Leiomyomata and add new drug Fensolvi
- Oncology Agents – remove Opdivo and Yervoy to create separate policies for each drug
- Orilissa – Remove stand-alone policy and combine with new drug Oriahnn to be “Elagolix”
- Sirturo – Update age restriction to 5 years and older and add prescriber restriction
- Targeted Immune Modulators – Update with separated preferred pharmacy/medical drugs and update requirements for non-preferred drugs
- Teptrotumumab – remove requirement of diagnosis to be made less than or equal to 9 months after symptom onset
Preauthorization Criteria – Clerical Updates
- Kynamro – rename Mipomersen
- Luxturna – rename Voretigene neparvovec
- Myalept – rename Metreleptin
Preferred Drug List (PDL) Changes
Formulary Additions
- Ajovy auto injector add Tier 3 with preauthorization
- Apokyn solution add Tier 3 with SP and preauthorization
- Asmanex HFA inhaler add Tier 2 with quantity limit
- Diazoxide suspension add Tier 1
- Dulera inhaler add Tier 3 with quantity limit and medical necessity preauthorization
- Dupixent Pen injector add Tier 3 with SP, quantity limit and preauthorization
- Econasil kit add Tier 3 with medical necessity preauthorization
- Ferriprox Twice-A-Day tablet add Tier 3 with limited access and preauthorization
- Fluopar kit add Tier 3 with medical necessity preauthorization
- Harvoni packet add Tier 3 with SP, quantity limit and medical necessity preauthorization
- Insulin Lispro Junior Kwikpen add Tier 3 medical necessity preauthorization
- Insulin Lispro pen injector add Tier 3 medical necessity preauthorization
- Insulin Lispro Prot & Lispro sus (75-25) pen injector add Tier 3 medical necessity preauthorization
- Kynmobi film add Tier 3 with SP, quantity limit and preauthorization
- Licart patch add Tier 3 with medical necessity preauthorization
- Lipritin II kig add Tier 3 with medical necessity preauthorization
- Lipritin pack add Tier 3 medical necessity preauthorization
- Metformin solution add Tier 1 with medical necessity preauthorization
- Mytesi tablet add Tier 3 with medical necessity preauthorization
- Novolin Flexpen (Relion) add Tier 3 with medical necessity preauthorization
- Novolin Flexpen add Tier 2
- Nuvakaan kit add Tier 3 with medical necessity preauthorization
- Nuvakaan-II kit add Tier 3 with medical necessity preauthorization
- Oriahnn capsule add Tier 3 with quantity limit and preauthorization
- Phexxi gel add Tier 3 with medical necessity preauthorization
- Prolate tablet add Tier 3 with medical necessity preauthorization
- Pyrimethamine tablet add Tier 1 with medical necessity preauthorization
- Qinlock tab add Tier 3 with SP, quantity limit and preauthorization
- Sirturo tablet add Tier 3 with preauthorization
- Sovaldi packet add Tier 3 with SP, quantity limit and medical necessity preauthorization
- Zeposia capsule add Tier 3 with SP, quantity limit and preauthorization
- Zilxi foam add Tier 3 with step therapy
Quantity Limit Updates
- Update quantity limit: Ketorolac tablets
Preauthorization Updates
- Add preauthorization:
- Apokyn solution
- Daraprim tablet (medical necessity)
- Jadenu Sprinkle Packet (medical necessity)
State Based Drug List (OR, ID, MT, WA) Changes
Formulary Additions
- Ajovy solution add Tier 3 with quantity limit and preauthorization
- Apokyn solution add Tier 4 with SP and preauthorization
- Asmanex HFA Inhaler add Tier 2 with quantity limit
- Diazoxide suspension add Tier 1
- Dupixent Pen injector add Tier 4 with SP, quantity limit and preauthorization
- Ferriprox Twice-A-Day tablet add Tier 4 with limited access and preauthorization
- Kynmobi film add Tier 4 with SP, quantity limit and preauthorization
- Oriahnn capsule add Tier 3 with quantity limit and preauthorization
- Pyrimethamine tablet add Tier 1 with medical necessity preauthorization
- Qinlock tablet add Tier 4 with SP, quantity limit and preauthorization
- Sirturo tablet add Tier 3 with preauthorization
- TDVAX add Tier 0 (ACA covered vaccine, restrictions apply)
- Zeposia capsule add Tier 4 with SP, quantity limit and preauthorization
Quantity Limit Update
- Update quantity limit: Ketorolac tablet
Tier Update
- Apokyn solution
Removed from Formulary
- Depen titratabs; consider penicillamine tabet
- Trianex ointment; consider triamcinolone ointment
Preauthorization Updates
- Add preauthorization: Apokyn solution
Removed from Formulary
- Daraprim tablet; consider atovaquone-proguanil tablet, mefloquine, hydroxychloroquine, chloroquine
- Proglycem suspension; consider diazoxide suspension