The following formulary changes will be effective 07/01/2024 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 BRAND medications moving to NONPREFERED status
| Medication Name |
| Lorazepam Intensol (lorazepam concentrate) |
| Advair Diskus (fluticasone-salmaterol) |
| Advair HFA (fluticasone-salmaterol) |
| Xiidra (lifitegrast) |
List of medications (brand and generic, if applicable) moving to Fee-For-Service (carve out)
| Medication Name | Medication Name | These medications will be managed by Washington State Health Care Authority (HCA) Fee-For-Service. Please bill to Washington Medicaid. To initiate a prior authorization (if applicable), prescribers or pharmacies must call the HCA at 800-562-3022. |
| Lagevrio (molnupriavir) | Paxlovid (nirmatrelvir) | |
| Sandimmune (cyclosporine) | Cellcept (mycophenolate mofetil) | |
| Gengraf/Neoral (cyclosporine modified) | Myfortic (mycophenolate sodium) | |
| Prograf (tacrolimus) | Zortress (everolimus 0.25mg, 0.5mg, 0.75mg, 1mg) | |
| Astagraf XL (tacrolimus ER) | Rapamune (sirolimus) | |
| Envarsus XR (tacrolimus ER) | Rezurock (belumosudil) | |
| Nulojix (belatacept) | Wegovy (semaglutide) | |
| Simulect (basiliximab) |
Other HCA and CHPW Clinical Policy, Formulary and Criteria Updates (see table for effective dates)
| Policy | Summary of Update |
| New HCA Drug Policies
Effective 06/01/24 |
Neuromuscular Agents – Lupus Agents (99.40.20-1)
Sleep Disorder Agents (60.25.00.AA-1)
|
| Oral HIV Medications
Effective 06/01/24 |
All oral HIV medications are allowed to be filled with up to a 90-day supply. |
| Rezdiffra (resmetirom)
Effective 05/16/24 |
Rezdiffra (resmetirom) is preferred and requires prior authorization. New policy created with criteria requirements following labeling and compendia. |
