2023 Formulary Changes - Washington State Local Health Insurance - CHPW

2023 Formulary Changes

The following formulary changes will be effective 4/1/23 for all CHPW Apple Health (Medicaid) members.  Please visit https://www.hca.wa.gov/billers-providers-partners/programs-and-services/apple-health-preferred-drug-list-pdl for more details or call CHPW Customer Service at 1-800-440-1561 Monday through Friday from 8am to 5pm.

List of medications moving to preferred status

Brand Name Generic Name Prior Authorization Status
Anoro Ellipta umeclidinium/vilanterol no prior authorization required
Dupixent dupilumab prior authorization required
Eucrisa crisaborole no prior authorization required
Qelbree viloxazine prior authorization required
Xiidra lifitegrast no prior authorization required


List of medications moving to nonpreferred status

Brand Name Generic Name Prior Authorization Status
Wakix pitolisant prior authorization required


HCA Clinical Policy Updates and Criteria Updates

Policy Name & Number Summary of Update
Dupixent Updated to preferred status and indications for age updates and approval duration
ADHD/Anti-Narcolepsy: Non-stimulants-viloxazine (61.35.40.AA_v1) New HCA policy.  SON review required for ages 0-5 and doses that exceed 400 mg per day for ages 6-17.  Max dose for adults is 600 mg/day
ADHD Stimulant Drugs Stimulant use for adults will require a diagnosis of ADHD.  This applies to both long and short acting stimulants.
Tyrosine Kinase Inhibitors 21.53.40-1 Added Exkivity (mobocertinib), Scemblix (asciminib), Jaypirca (pirtobrutinib) to policy.  Updated dosing for Lenvima (lenvatinib), Turalio (pexidartinib), Xalkori (crizotinib) and updated approval duration**
Antidiabetics-GLP-1 Agonists (27.17.00-1) Added Mounjaro (tirzepatide) to policy**
Testosterone 23.10.00-2 Added Kyzatrex & Tlando (testosterone undecanoate) to policy**
SUDs-Transmucosal Buprenorphine ( Expedited authorization code 85000000078 added for pharmacies to submit for non-pregnant members to receive buprenorphine while initiating a prior authorization**


** signifies an effective date of 3/1/23


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