2024 Formulary Changes - Washington State Local Health Insurance - CHPW
Community Health Plan of Washington Apple Health Medicaid Plan Community Health Plan of Washington Apple Health Medicaid Plan

2024 Formulary Changes

The following formulary changes will be effective 04/01/24 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 

Medication Name Prior Authorization Required?
Austedo XR (deutetrabenazine ER) No


List of medications moving to NONPREFERRED status 

Medication Name Prior Authorization Required?
Vraylar (cariprazine) Yes


List of medications moving to Fee-For-Service (carve out); effective dates varied since prior update 01/01/24

Medication Name These medications will be managed by Washington State Health Care Authority (HCA) Fee-For-Service. To initiate a prior authorization, prescribers or pharmacies must call the HCA at 800-562-3022.
Zilbrysq (zilucoplan sodium)
Wainua (eplontersen sodium)
Casgevy (exagamglogene autotemcel)
Lyfgenia (lovotibeglogene autotemcel)
Rivfloza (nedosiran sodium)
Fabhalta (iptacopan hcl)


Other HCA and CHPW Clinical Policy, Formulary and Criteria Updates (see below for effective dates)

Policy Summary of Update
Tick-Borne Encephalitis Vaccine

Effective 01/01/24

Ticovac covered, no restrictions
Morphine Milligram Equivalent Conversion Factor

Effective 01/12/24

  • Tramadol MME conversion factor updated from 0.1 to 0.2.
  • Hydromorphone MME conversion factor updated from 4 to 5.
Long Acting Insulins

Effective 01/18/24

Due to insulin glargine market access challenges, the HCA has added the following to be preferred with no prior authorization:

  • Basaglar Kwikpen
  • Basaglar Tempo Pen
New HCA drug policies

Effective 02/01/24

  • Emflaza (deflazacort): Corticosteroids HCA policy 22.10.00.AA
  • Vascepa (icosapent ethyl): Antihyperlipidemics HCA policy 39.50.00.AA
Anti-Narcolepsy Updated (61.40.00-2)

Effective 02/01/24

  • Sunosi and Wakix added to the policy
  • Narcolepsy split into “Excessive Daytime Sleepiness” and “Cataplexy”
  • Sleep Deprivation indication removed
  • Shift Work Sleep Disorder reauthorization increased to 6 months

Effective 02/16/24

Brand name Vyvanse may be approved for 3 months at a time through prior authorization if reason for request is due to shortage of generic lisdexamfetamine.

Effective 03/01/24

Brixadi moved to preferred status with no prior authorization required. Brixadi is NOT restricted to specialty pharmacy.
Proton Pump Inhibitor (PPI) (49.27.00-2)

Effective 03/01/24

For long-term use of PPI for diagnosis of Barret’s esophagus, the requirement of “corresponding pathology report showing histological confirmation of intestinal metaplasia in esophageal biopsies” has been removed.
Multiple Sclerosis therapy

Effective 04/01/24

  • Ocrevus ( criteria updated to allow either “oligoclonal IgG bands in cerebral spinal fluid” OR “T2 lesions on brain or spinal cord imaging”
  • Mavenclad, Ponvory, Vumerity: requires step therapy with 2 preferred agents (dimethyl fumarate, Kesimpta, Copaxone, Avonex, or Betaseron), no other clinical criteria requirements needed.
Cytokine & CAM Antagonists (66.27.00)

Effective 04/01/24

  • Policy will now include biosimilars of Humira, Sotyktu, Bimzelx, Olumiant, Velsipity, & Omvoh to follow their respective indications.
  • Quantity limits updates:
    • Entyvio maintenance SQ dosing for CD/UC (216 mg per 28 days).
    • Rinvoq for CD/UC: 45mg daily x 8 weeks, then 30mg daily.
GLP 1 Agonist (27.17.00-1)

Effective dates noted on the right

Effective 12/20/23

  • Reauthorization criteria for “Patients with Type 2 diabetes and established cardiovascular disease or multiple cardiovascular risk factors who are at risk for major adverse cardiovascular events” updated to require documentation of HbA1c improvement from baseline

Effective 04/01/24

  • Dulaglutide will be updated to be covered for 10 years of age or older
  • Updated quantity limits for Byetta, Victoza and Adlyxin
Movement Disorders

Effective 04/01/24

  • Austedo: No prior authorization required
  • Austedo XR: Moving to preferred, no prior authorization required
  • Ingrezza: will require prior authorization with step therapy including trial of Austedo


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