2026 Formulary, Criteria and Policy Changes

• Exception to Rule (ETR) form: https://www.chpw.org/wp-content/uploads/content/provider-center/Exception_to_Rule_Request_form_508-1.pdf.

Effective 11/01/25

• Trulicity and Victoza/liraglutide: removed from indication of Type 2 Diabetes Mellitus (T2DM) with established cardiovascular (CV) disease or CV risk factors at risk for CV events.
  • Ozempic is the only medication for this indication.
• Ozempic: added new indication of T2DM with moderate to severe (F2 or F3) noncirrhotic metabolic dysfunction associated steatohepatitis (MASH).

Mounjaro: added new indication of T2DM with moderate to severe Obstructive Sleep Apnea (OSA) and obesity.

Effective 12/01/25

• Dupixent, Ebglyss, Adbry, Nemluvio: Atopic dermatitis reauthorization update.
  • Positive response to include reduction of BSA, or IGA 0 or 1, or decrease in EASI score.
  • Removed requirement of showing improvement of functional impairment (activities of daily living, skin infections, sleep disturbance).

66.27.00.AH Cytokine and CAM Antagonists: JAK Inhibitors

Opzelura – Atopic Dermatitis age requirement updated to 2 years of age or older.

Effective 01/01/26

• Dupixent – Asthma: Oral corticosteroid dependent asthma now requires to also have eosinophils of 150 cells/mm3 within 12 months.

66.27.00.AH Cytokine and CAM Antagonists: JAK Inhibitors

• Rinvoq, Opzelura, Cibinqo: Atopic dermatitis reauthorization update.
  • Positive response to include reduction of BSA, or IGA 0 or 1, or decrease in EASI score.
  • Removed requirement of showing improvement of functional impairment (activities of daily living, skin infections, sleep disturbance).

Androgenic Agents – Testosterone Replacement Therapy (23.10.00)

• Updated Testosterone cypionate 200mg/mL to allow 4 vials in 28 days.

Proton Pump Inhibitors (49.27.00)

• Added H. Pylori indication to allow 2 doses/day x 14 days.

Added ulcer prophylaxis post-bariatric surgery indication.

• Cabenuva
• Apretude
• Sunlenca (vial only, oral remains with MCOs)
• Yeztugo (vial only, oral remains with MCOs)
• Trogarzo
• Fuzeon
• Retrovir (vial only, oral remains with MCOs)
• Forzinity

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