2026 Formulary, Criteria and Policy Changes

Effective 04/01/26

• Ebglyss no longer require trial/failure Dupixent for atopic dermatitis
• Adbry and Nemluvio require trial/failure of two preferred products for atopic dermatitis

66.27.00.AE Cytokine and CAM Antagonists: IL-17 Inhibitors

• Taltz no longer require trial/failure of two preferred products

66.27.00.AG Cytokine and CAM Antagonists: T-Lymphocyte Inhibitors

• Orencia no longer require trial/failure of two preferred products

66.27.00.AH Cytokine and CAM Antagonists: Janus Associated Kinase (JAK) Inhibitors

• Rinvoq and Cibinqo require trial/failure of two preferred products for atopic dermatitis

Effective 02/01/26

• Dupixent – Asthma: Oral corticosteroid dependent asthma no longer requires to have eosinophils of 150 cells/mm3
  • Eosinophils requirement still applies to eosinophilic phenotype asthma.

Effective 04/01/26

39.38.00 Antihyperlipidemics – Adenosine Triphosphate-Citrate Lyase Inhibitors

• Nexletol (bempedoic acid), Nexlizet (bempedoic acid/ezetimibe)
  • Reduce the risk of myocardial infarction (MI) and coronary revascularization in patients who are unable to take statin therapy
  • Reduce LDL-C in adults with primary hyperlipidemia including heterozygous familial hypercholesterolemia (HeFH)

40.90.00 Cardiovascular Agents – Vasoactive Soluble Guanylate Cyclase Stimulators

• Verquvo (vericiguat)
  • Chronic Heart Failure with Reduced Ejection Fraction

Effective 02/01/26

21.53.20 Oncology Agents: BRAF Kinase Inhibitors – Oral

• Tafinlar (dabrafenib)
  • Anaplastic thyroid cancer
  • Low grade glioma
  • Melanoma adjuvant, unresectable, or metastatic
  • Non-small cell lung cancer, metastatic
  • Solid tumor, unresectable or metastatic
• Braftovi (encorafenib)
  • Colorectal cancer, metastatic
  • Melanoma adjuvant, unresectable, or metastatic
  • Non-small cell lung cancer, metastatic
• Zelboraf (vemurafenib)
  • Erdheim-Chester disease
  • Hairy cell leukemia, relapsed or refractory
  • Melanoma adjuvant, unresectable, or metastatic
• Ojemda (tovorafenib)
  • Low grade glioma

21.53.80 Oncology Agents: Phosphatidylinositol 3-Kinase (PI3K) Inhibitors – Oral

• Piqray (alpelisib)
  • Breast cancer, advanced or metastatic HR positive, HER2-negative, PIK3CA-mutated

• Copiktra (duvelisib)
  • Chronic lymphoid leukemia
  • Small lymphocytic lymphoma, relapsed or refractory
• Zydelig (idelalisib)
  • Chronic lymphoid leukemia

30.17.00 Endocrine and Metabolic Agents: Somatostatic Agents

• Lanreotide acetate: Somatuline depot
  • Acromegaly
  • Carcinoid syndrome
  • Well-differentiated neuroendocrine tumor, gastroenteropancreatic
• Octreotide acetate: Mycapssa, Sandostatin, Sandostatin LAR
  • Acromegaly
  • Carcinoid syndrome
  • Diarrhea, chemotherapy-induced, severe or persistent
  • Vasoactive intestinal peptide secreting tumor, associated diarrhea
• Pasireotide dispartate: Signifor, Signifor LAR
  • Acromegaly
  • Cushing’s Syndrome

66.27.00.AL Cytokine and CAM Antagonists: IL-36 Inhibitors

• Spevigo
  • Generalized Pustular Psoriasis (GPP) flares and maintenance

NC-0002: Medical Necessity

• 265 medications (Anoro Ellipta, Ammonium lactate, Zoryve, Doxylamine-pyridoxine, Auvelity, Cobenfy, etc.)
• Initial criteria:
  • Indication, age and dosing fall within one of the following:
    • FDA labeling
    • Compendia supported (Category A or B, Class 1 or 2a)
  • History of failure, contraindication or intolerance to ALL AHPDL preferred products that fall within ALL the following:
    • First line therapies supported in North American or World Health Organization guidelines
    • FDA approved therapies
    • Compendia supported therapies
  • Refill protected drugs (mental health, HIV, oncology, etc.) may bypass the history of failure IF already established on the medication AND did not start using samples/manufacture coupons

since 01/01/26

• Aqvesme
• Zycubo
• Loargys
• Yuviwel

Note: Updated list of carve outs can always be found at  Health Care Authority (HCA) website

effective 01/01/26

• For Apple Health Expansion (AHE)
  • HIV: Antivirals – Oral