2025 Formulary, Criteria and Policy Changes

Effective 07/01/25

• Switched from column AH “Specialty Drug” to column AI “Limited Distribution” to guide which medications are allowed to be restricted to specialty pharmacy
• 29 medications removed from specialty pharmacy restrictions
  • Highest impact: Dupixent, Rinvoq, Cosentyx

90 Day Supply

• 75 medications moving to 90-day supply allowance
  • o Highest impact: quetiapine, budesonide/formoterol, fluticasone/salmeterol
• 36 medications removed from 90-day supply allowance

Highest impact: hydroxyzine, buspirone, liraglutide

Effective 07/01/25

• Selarsdi 45mg/0.5mL and 90mg/0.5mL syringe
• Steqeyma 45mg/0.5mL and 90mg/0.5mL syringe
• Yesintek 45mg/0.5mL and 130mg/26mL vial

Non-preferred ustekinumab biosimilars will require trial and failure of all preferred biosimilars.

Stelara must follow HCA policy Brands with Biosimilars or A-rated Generics Non-Clinical Policy No. 0001-2:

• Trial and failure of two preferred products in the same class/category
• Trial and failure of biosimilar, interchangeable biosimilar from at least 5 manufacturers

Effective 07/01/25

• MUST have Type 2 Diabetes Mellitus to be considered for coverage
• Added preferred GLP-1 agonists
• Cannot use alongside another GLP-1 agonist or DPP4 inhibitor
• Updated step therapy
  • Removed SGLT-2 inhibitors
  • Liraglutide must be tried and failed at maximum or highest tolerated dose
  • Continuous 90 days requirement
  • Liraglutide and metformin can be skipped for certain GLP-1 agonist and comorbid conditions

GLP-agonist will be restricted to 30-day supply

Effective 07/01/25

• For certain indications, step therapy updated to two preferred Cytokine/CAM due to Xeljanz, Otezla and preferred ustekinumab biosimilars (see above) moving to preferred
• Mayzent, Ponvory and Fingolimod no longer on any HCA policy
  • Non-preferred, must try and fail two preferred Multiple Sclerosis agents

62.40.50.AA Multiple Sclerosis Agents- natalizumab (Tysabri)

62.40.70.AA Multiple Sclerosis Agents- Ozanimod (Zeposia)

Tysabri and Zeposia separated out into its own policy

Effective 06/01/25

• Revised into four different policies
• Refined criteria for high-risk fracture
• Updated step therapy
  • Minimum duration for trial and failure

One bisphosphonate

Effective 06/01/25

• Acute and preventative combined into one policy
• Botox use will no longer be an exception (Botox use is now allowed)
• Combination CGRP prophylactic and acute therapies will no longer be an exception
• Candesartan, nortriptyline & duloxetine added as additional acceptable options for step therapy

Effective 06/01/25

• Verzenio, Ibrance, Kisqali, Kisqali/Femara
• Created Verzenio new policy and criteria indication for adjuvant therapy of early-stage (I-III) breast cancer

Created Verzenio, Ibrance, Kisqali new policy and criteria indication for systematic therapy of recurrent, advanced, or metastatic breast cancer

See right for effective dates

• Imaavy

Effective 05/08/25

• Qfitlia
• Vanrafia

Effective 04/09/25

• Epysqli

Effective 03/26/25

• Bkemv

• Brilinta
  • Ticagrelor available

Effective 05/13/25

• Januvia
  • Sitagliptin available

Effective 05/08/25

• Janumet
  • Sitagliptin/metformin available
• Janumet XR
  • Prefer non-XR formulation