September 2020 Drug List Change Notification

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