The following formulary changes will be effective 04/01/25 for all CHPW Apple Health (Medicaid) members. Please visit Health Care Authority (HCA) website or CHPW Online Formulary 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 PREFERED status
| Medication name | ||
| Adalimumab-AATY | Adalimumab-ADAZ | Adalimumab-ADBM |
| Insulin glargine-YFGN | Clomipramine capsules | Cyltezo |
*For Humira/Adalimumab details, see below notice from the HCA
List of medications moving to NON-PREFERED status
| Medication name | ||
| Humira | Basaglar | Levemir |
| Amoxapine | Duavee | Veozah |
*For Humira/Adalimumab details, see below notice from the HCA
Other HCA and CHPW Clinical Policy, Formulary and Criteria Updates (see table for effective dates)
| Policy | Summary of Update |
| Updated Cytokine/CAM HCA Policy
Effective 04/01/25 |
66.27.00.AA CAM-TNF Inhibitors, 66.27.00.AB CAM- IL4/IL13/IL31 Inhibitors, 66.27.00.AC CAM- IL6 Inhibitors,
66.27.00.AD CAM-IL12/IL23 Inhibitors, 66.27.00.AE CAM-IL17 Inhibitors, 66.27.00.AF CAM- PDE-4 Inhibitors, 66.27.00.AG CAM-T-Lymphocyte Inhibitors, 66.27.00.AH CAM-JAK Inhibitors, 66.27.00.AI CAM- IL-1 Inhibitors, 66.27.00.AJ CAM- Integrin Receptor Antagonists, 66.27.00.AK CAM- S1-P Receptor Modulator
|
| Quantity Limits Implementation
Effective 04/01/25 |
Quantity limits from Apple Health Preferred Drug List (AHPDL) will be implemented. Exceeding quantity limits will require an authorization. Quantity limits may include the following:
|
| Fill Limit Implementation
Effective 04/01/25 |
Medications will be restricted to a certain number of fills (between one and five) within a thirty-day period. Claims exceeding this limit can be overridden at point-of-sale using Prior Authorization Type = 08 and entering 8888 for the Prior Authorization Number if one of the following reasons applies:
If the reject is not overridden by the pharmacy, prior authorization will be required. Prior authorization requests should be submitted via Express Scripts. Providers may use CoverMyMeds or call 1-844-605-8168 to speak with a prior authorization specialist. |
| Retired HCA Policies
Effective 02/14/25 |
HCA clinical policy 65.20.00.10 – SUD Opioid Partial Agonists Transmucosal Buprenorphine
|
| Updated Methadone HCA Policy
Effective 01/24/25 |
HCA clinical policy 65.10.00.50 – Methadone
|
| Medications Moving to Fee-For-Service (FFS) [Carve out] Updates
See right for effective dates |
Effective 02/26/25
Effective 02/18/25
Effective 01/28/25
Effective 01/03/25
|
Effective April 1, 2025 Washington Apple Health (Medicaid) will make a significant change to the preferred products in the Cytokine and CAM Antagonist drug class. Brand name Humira products will no longer be preferred. Select adalimumab biosimilars (see included list for specific products), Enbrel, Enbrel Sureclick and Spevigo will be the preferred products in this class.
This change will apply to all agency-contracted managed care organizations (MCOs) and the fee-for-service (FFS) program per the Apple Health PDL. For questions about the Apple Health PDL, please email [email protected].
Preferred adalimumab biosimilars
| Product ID | Label Name | Generic Name | Strength | Dosage Form |
| 72606002206 | ADALIMUMAB-AATY(CF) | ADALIMUMAB-AATY | 40MG/0.4ML | SYRINGEKIT |
| 72606004101 | ADALIMUMAB-AATY(CF) | ADALIMUMAB-AATY | 20MG/0.2ML | SYRINGEKIT |
| 72606002210 | ADALIMUMAB-AATY(CF) AUTOINJ(2) | ADALIMUMAB-AATY | 40MG/0.4ML | AUTOINJKIT |
| 72606002209 | ADALIMUMAB-AATY(CF) AUTOINJECT | ADALIMUMAB-AATY | 40MG/0.4ML | AUTOINJKIT |
| 72606004004 | ADALIMUMAB-AATY(CF) AUTOINJECT | ADALIMUMAB-AATY | 80MG/0.8ML | AUTOINJKIT |
| 61319.5%32764 | ADALIMUMAB-ADAZ(CF) | ADALIMUMAB-ADAZ | 40MG/0.4ML | SYRINGE |
| 61319.5%32720 | ADALIMUMAB-ADAZ(CF) PEN | ADALIMUMAB-ADAZ | 40MG/0.4ML | PEN INJCTR |
| 00597055580 | ADALIMUMAB-ADBM(CF) | ADALIMUMAB-ADBM | 20MG/0.4ML | SYRINGEKIT |
| 00597056520 | ADALIMUMAB-ADBM(CF) | ADALIMUMAB-ADBM | 40MG/0.4ML | SYRINGEKIT |
| 00597058589 | ADALIMUMAB-ADBM(CF) | ADALIMUMAB-ADBM | 10MG/0.2ML | SYRINGEKIT |
| 00597059520 | ADALIMUMAB-ADBM(CF) | ADALIMUMAB-ADBM | 40MG/0.8ML | SYRINGEKIT |
| 00597057550 | ADALIMUMAB-ADBM(CF) PEN | ADALIMUMAB-ADBM | 40MG/0.4ML | PEN IJ KIT |
| 00597054566 | ADALIMUMAB-ADBM(CF) PEN CROHNS | ADALIMUMAB-ADBM | 40MG/0.8ML | PEN IJ KIT |
| 00597057560 | ADALIMUMAB-ADBM(CF) PEN CROHNS | ADALIMUMAB-ADBM | 40MG/0.4ML | PEN IJ KIT |
| 00597054544 | ADALIMUMAB-ADBM(CF) PEN PS-UV | ADALIMUMAB-ADBM | 40MG/0.8ML | PEN IJ KIT |
| 00597057540 | ADALIMUMAB-ADBM(CF) PEN PS-UV | ADALIMUMAB-ADBM | 40MG/0.4ML | PEN IJ KIT |
| 00597054522 | ADALIMUMAB-ADBM(CF)PEN | ADALIMUMAB-ADBM | 40MG/0.8ML | PEN IJ KIT |
| 00597037082 | CYLTEZO(CF) | ADALIMUMAB-ADBM | 40MG/0.8ML | SYRINGEKIT |
| 00597040089 | CYLTEZO(CF) | ADALIMUMAB-ADBM | 10MG/0.2ML | SYRINGEKIT |
| 00597040580 | CYLTEZO(CF) | ADALIMUMAB-ADBM | 20MG/0.4ML | SYRINGEKIT |
| 00597048520 | CYLTEZO(CF) | ADALIMUMAB-ADBM | 40MG/0.4ML | SYRINGEKIT |
| 00597037597 | CYLTEZO(CF) PEN | ADALIMUMAB-ADBM | 40MG/0.8ML | PEN IJ KIT |
| 00597049550 | CYLTEZO(CF) PEN | ADALIMUMAB-ADBM | 40MG/0.4ML | PEN IJ KIT |
| 00597037516 | CYLTEZO(CF) PEN CROHN’S-UC-HS | ADALIMUMAB-ADBM | 40MG/0.8ML | PEN IJ KIT |
| 00597049560 | CYLTEZO(CF) PEN CROHN’S-UC-HS | ADALIMUMAB-ADBM | 40MG/0.4ML | PEN IJ KIT |
| 00597037523 | CYLTEZO(CF) PEN PSORIASIS-UV | ADALIMUMAB-ADBM | 40MG/0.8ML | PEN IJ KIT |
| 00597049540 | CYLTEZO(CF) PEN PSORIASIS-UV | ADALIMUMAB-ADBM | 40MG/0.4ML | PEN IJ KIT |
