April 2024 Formulary Policy Updates

Inpefa™   (sotagliflozin)

Risk reduction of cardiovascular death, hospitalization for heart failure, and urgent heart failure visits in adults with heart failure, or type 2 diabetes mellitus, chronic kidney disease, and other cardiovascular risk factors

Miebo ™ (perfluorohexyloc-tane)

The treatment of dry eye disease

Columvi™ (glofitamab)

The treatment of adults with relapsed or refractory diffuse large B-cell lymphoma, not otherwise specified, or large B-cell lymphoma arising from follicular lymphoma, after 2 or more lines of systemic therapy

Rezzayo ™ (rezafungin)

The treatment of candidemia and invasive candidiasis in adults with limited or no alternative treatment options

Rystiggo® (rozanolixizumab-noli)

The treatment of generalized myasthenia gravis in adults who are anti-acetylcholine receptor or anti-muscle-specific tyrosine kinase antibody positive

Xdemvy™ (lotilaner}

The treatment of Demodex blepharitis

Ngenla™ (somatrogon-ghla}

The treatment of growth failure due to inadequate secretion of endogenous growth hormone in patients ages 3 to 17 years

Beyfortus™ (nirsevimab-alip)

The prevention of respiratory syncytial virus (RSV) infection in newborns and infants entering or during their first RSV season, and for children up to 24 months of age who remain vulnerable to severe RSV disease through their second RSV season

Xacduro® (durlobactam/ sulbactam}

The treatment of hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia caused by susceptible isolates of Acinetobacter baumannii-calcoaceticus complex in adults

Izervay™ (avacincaptad pegol)

The treatment of geographic atrophy (GA), due to age-related macular degeneration (AMD)

Elrexfio™ (elranatamab-bcmm }

The treatment of multiple myeloma in adults who are refractory to at least 1 proteasome inhibitor, 1 immunomodulatory agent, and 1 anti-CD38 antibody

Opvee® (nalmefene}

The emergency treatment of known or suspected opioid overdose induced by natural or synthetic opioids, as manifested by respiratory and/or central nervous system depression in patients ages 12 years and older

Airsupra™ (budesonide/ albuterol)

The as-needed treatment or prevention of bronchoconstriction, and the prevention of asthma exacerbations in patients aged 4 years and older

Veopoz™ (pozelimab)

The treatment of CD55-deficient protein-losing enteropathy (also known as CHAPLE syndrome)

Olpruva™ (sodium phenylbutyrate)

The treatment of urea cycle disorders

Vyvgart® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc)

The treatment of generalized myasthenia gravis in adults who are anti-acetylcholine receptor antibody positive

Idacio® (adalimumab-aacf)

The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, moderate to severe hidradenitis suppurativa (HS) in adults, ulcerative colitis, and plaque psoriasis in adults, the treatment of juvenile idiopathic arthritis in patients aged 2 years and older, and the treatment of Crohn's disease in patients aged 6 years and older (biosimilar of Humira)

Hulio® (adalimumab-fkjp)

The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, moderate to severe hidradenitis suppurativa (HS) in adults, Crohn's disease, ulcerative colitis, and plaque psoriasis in adults and the treatment of juvenile idiopathic arthritis in patients aged 2 years and older (biosimilar of Humira)

ADALIMU-FKJP (adalimumab-fkjp)

The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, moderate to severe hidradenitis suppurativa (HS) in adults, Crohn's disease, ulcerative colitis, and plaque psoriasis in adults and the treatment of juvenile idiopathic arthritis in patients aged 2 years and older (biosimilar of Humira)

Cyltezo™ (adalimumab-adbm)

The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, moderate to severe hidradenitis suppurativa (HS) in adults, Crohn's disease, ulcerative colitis, and plaque psoriasis in adults, non-infectious intermediate, posterior, and panuveitis in adults and the treatment of juvenile idiopathic arthritis in patients 2 years of age and older (biosimilar of Humira)

Suflave™ (polyethylene glycol 3350/ sodium sulfate/ potassium chloride/ magnesium sulfate/ sodium chloride)

Osmotic laxative indicated for cleansing of the colon in preparation for colonoscopy in adults.

Yusimry® ™ (adalimumab-aqvh)

The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, ulcerative colitis, plaque psoriasis in adults, the treatment of juvenile idiopathic arthritis in patients ages 2 years and older, and Crohn's disease in patients ages 6 and older (biosimilar of Humira)

Yuflyma® (adalimumab-aaty)

The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, ulcerative colitis, plaque psoriasis, and hidradenitis suppurativa in adults, the treatment of juvenile idiopathic arthritis in patients ages 2 years and older, and the treatment of Crohn's disease in patients ages 6 years and older (biosimilar of Humira)

Hadlima™ (adalimumab-bwwd)

The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, ulcerative colitis, plaque psoriasis, and hidradenitis suppur-ativa, non-infectious inter-mediate, pos-terior, and panuveitis in adults, the treat-ment of juvenile idio-pathic arthritis in patients ages 2 years and older, and the treatment of Crohn's disease in patients ages 6 years and older (biosimilar of Humira)

ADALIMU-ADAZ  (adalimumab-adaz)

The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, ulcerative colitis, plaque psoriasis in adults, the treatment of juvenile idiopathic arthritis in patients ages 2 years and older, and the treatment of Crohn's disease in patients ages 6 years and older (biosimilar of Humira)

Hyrimoz® ™ (adalimumab-adaz)

The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, ulcerative colitis, plaque psoriasis, and hidradenitis suppurativa in adults, the treatment of juvenile idiopathic arthritis in patients ages 2 years and older, and Crohn's disease in patients ages 6 and older (biosimilar of Humira)

Bevacizumab intravitreal (bevacizumab)

Used as an intravitreal injection to treat age-related macular degeneration (AMD) and non-AMD eye conditions (biosimilar of Avastin®)

Iyuzeh™ (Latanoprost)

The reduction of elevated intraocular pressure in patients with open-angle glaucoma or ocular hypertension

Sohonos™   (palovarotene)

For the reduction in the volume of new heterotopic ossification in females ages 8 years and older and in males ages 10 years and older with fibrodysplasia ossificans progressiva

Balfaxar® (prothrombin complex concentrate, human-lans)

The urgent reversal of acquired coagulation factor deficiency induced by Vitamin K antagonist (VKA, e.g., warfarin) therapy in adults with need for an urgent surgery/invasive procedure

Lodoco® (colchicine}

The risk reduction of myocardial infarction, stroke, coronary revascularization, and cardiovascular death in adults with established atherosclerotic disease or with multiple risk factors for cardiovascular disease

Rykindo® (risperidone extended release}

The treatment of schizophrenia, and as monotherapy or as adjunctive therapy to lithium or valproate for the maintenance treatment of bipolar I disorder, in adults

Altuviiio™ ([antihemophilic factor (recombinant), Fc-VWF-XTEN fusion protein-ehtl])

Use in adults and pediatrics with hemophilia A for routine prophylaxis to reduce the frequency of bleeding episodes, for on-demand treatment and control of bleeding episodes, and for perioperative management of bleeding

Adstiladrin® (nadofaragene firadenovec-vncg)

The treatment of adults with high-risk bacillus Calmette-Guérin (BCG)-unresponsive non-muscle invasive bladder cancer with carcinoma in situ with or without papillary tumors

Brenzavvy™ (bexagliflozin)

Use as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes

Litfulo™ (ritlecitinib)

The treatment of alopecia areata in patients aged 12 years and older

Vanflyta® (quizartinib)

The treatment of newly diagnosed acute myeloid leukemia in patients with the FLT3-ITD mutation, in combination with induction and consolidation chemotherapy, and as maintenance monotherapy following consolidation chemotherapy

Jesduvroq (daprodustat)

The treatment of anemia due to chronic kidney disease in adults who have been receiving dialysis for at least 4 months

Lantidra (donislecel-jujn)

The treatment of type 1 diabetes mellitus in adults who are unable to approach target glycated hemoglobin because of current repeated episodes of severe hypoglycemia despite intensive diabetes management and education

Ojjaara™ (momelotinib)

The treatment of intermediate or high-risk myelofibrosis (MF), including primary MF or secondary MF [post-polycythemia vera and post-essential thrombocythemia], in adults with anemia

Pombiliti™ (cipaglucosidase alfa-atga)

The treatment of late-onset Pompe disease (glycogen storage disease type II) in adults weighing 40 kg or more and who are not improving on their current enzyme replacement therapy, in combination with Opfolda (miglustat)

Velsipity™ (etrasimod)

The treatment of moderately to severely active ulcerative co

Bimzelx® (bimekizumab-bkzx)

The treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy

Omvoh IV infusion™ (mirikizumab)

The treatment of adults with moderate-to-severe ulcerative colitis

Omvoh SQ pen™ (mirikizumab)

The treatment of adults with moderate-to-severe ulcerative colitis

Akeega™ (niraparib/ abiraterone)

The treatment of deleterious or suspected deleterious BRCA mutated metastatic castrationresistant prostate cancer in adults

Brixadi® (buprenorphine)

The treatment of moderate-tosevere opioid use disorder in patients who have initiated treatment with a single dose of a transmucosal buprenorphine product or who are already being treated with buprenorphine

Pokonza™ (potassium chloride powder)

Indicated for the treatment and prophylaxis of hypokalemia with or without metabolic alkalosis, in patients for whom dietary management with potassium-rich foods or diuretic dose reduction is insufficient

Opfolda™ (miglustat)

The treatment of late-onset Pompe disease (glycogen storage disease type II) in adults weighing 40 kg or more and who are not improving on their current enzyme replacement therapy, in combination with Pombiliti (cipaglucosidase alfa)-atga

Motpoly XR™ (lacosamide extended release)

The treatment of partial-onset seizures in adults and pediatrics weighing at least 50 kg

Entyvio Pen® (vedolizumab)

The maintenance treatment of moderately-to-severely active ulcerative colitis in adults

 Likmez™ (metronidazole)

The treatment of trichomoniasis in adults, amebiasis in adults and pediatrics, and anaerobic bacterial infections in adults

Cosentyx IV Solution® (secukinumab)

The treatment of psoriatic arthritis in adults