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September 2020 Drug List Change Notification

The following changes to criteria are effective September 22, 2020.

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

See the Find a Drug page for the current drug list.