The following formulary changes will be effective 01/01/25 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 | ||
| Albuterol HFA | Bethkis | Pantoprazole suspension pack |
| Tarceva | Epinephrine 1 mg/10mL vial | Paricalcitol capsule |
| Cystadrops 0.37% | Ergocalciferol 200 mcg/mL | Pilocarpine eye drops |
| Uptravi (vial & tablet) | Erythromycin 400 mg/5mL susp | Pyridoxine tablet |
| Zonisade | Extencilline vial | Rayaldee capsule |
| Acyclovir 200 mg/100 0.9% NaCl | Fenesin tablet | Reditrex syringe |
| Adapalene 0.1% Gel | Fenofibrate capsule | Ropinirole ER tablet |
| Aemcolo DR 194 MG tablet | Feraheme vial | Sandostatin LAR Depot |
| Alavert D-12 Allergy | Ferumoxytol vial | Sevelamer HCl tablet |
| Ampicillin-Sulbactam Vial | Fiasp pumpcart | Signifor LAR |
| Astepro allergy spray | Gallifrey tablet | Tascenso ODT |
| Azathioprine 75 mg, 100mg tablet | Galzin capsule | Tazarotene 0.1% foam |
| Azathioprine Sodium 100 mg vial | Imbruvica suspension | Tembexa |
| Baby D Drops 400 IU | Impavido capsule | Terbutaline sulfate vial |
| Benfotiamine capsule | Ivermectin cream | Testosterone cyp 1000mg/5mL |
| Budesonide 2mg rectal foam | Kionex suspension | Testosterone cyp 500mg/2.5mL |
| Captopril-HCTZ | Lactulose packet | Testosterone cyp 6000mg/30mL |
| Carbidopa-Levo ODT | Lanreotide syringe | Theo-24 ER capsule |
| Oxbryta tablet | Lantus (Solostar & vial) | Thiamine tablet |
| Cefazolin 2g/100mL D5W | Lazcluze tablet | Thiola EC tablet |
| Cefazolin 3g/100mL 0.9% NaCl | Levothyroxine vial | Timolol 0.5%/dorzolamide 2% |
| Cefixime suspension | Linezolid | Tobradex ST eye drop |
| Cefpodoxime tablet | Liothyronine vial | Tobramycin 300mg/4ml Ampule |
| Cefpodoxime suspension | Lyvispah granule pack | Torpenz tablet |
| Child Astepro spray | Marplan tablet | Triamterene capsule |
| Claforan vial | Methoxsalen | Trimazole 1% cream |
| Colestipol granule | Methylprednisolone AC 80mg/mL vial | Triptodur 22.5 mg |
| Corlanor oral solution | Metyrosine capsule | Ulesfia 5% lotion |
| Crinone gel | Micafungin vial | Valsartan solution |
| Dificid tablet | Monistat cream | Vancomycin vial |
| Dificid suspension | Monoferric vial | Vraylar capsule |
| Digoxin 62.5 mcg tablet | Moxatag ER 775 mg tablet | Zyvox 600 mg/300 mL D5W |
| Diltiazem 125mg/125ml D5W | Mytesi tablet | Teriflunomide tablet |
| Diltiazem 125mg/125ml 0.7% NaCl | Neostigmine vial | Testosterone 20.25/1.25 gel pump |
| Diltiazem 125mg/125ml 0.9% NaCl | Nephro vitamins | Telmisartan tablet |
| Doxercalciferol capsule | Nimodipine capsule | Telmisartan/HCTZ tablet |
| D-Penamine | Norvir softgel | Telmisartan/amlodipine tablet |
| Dramamine | Nymalize syringe | Nebivolol tablet |
| Zolmitriptan tablet | Onelax | Asmanex twisthaler |
| Oxbryta tablet | Otrexup auto-inj | Tolterodine ER capsule |
List of medications moving to NON-PREFERED status
| Medication name | ||
| Acticlate tablet | Euthyrox tablet | Nyamyc powder |
| Active Injection Kit D | Exelon patch | Nystop powder |
| Ala-Cort cream | Factive tablet | Oravig tablet |
| Albuterol sulfate ER tablet | Felbatol tablet & suspension | Oscimin tablet |
| Aloprim vial | Fexofenadine 60mg tablet | Pentasa 500mg capsule |
| Altacaine drops | Finacea foam & gel | Phenytek capsule |
| Alyq tablet | Firvanq solution | Phospholine iodine drops |
| Amabelz tablet | Focalin tablet | Prevalite powder |
| Amitiza capsule | Fruzaqla 1mg capsule | Pro-C-Dure kit |
| Amlodipine-Valsartan tablet | Fyavolv tablet | Procto-Med HC cream |
| Apriso capsule | Geodon vial | Proctosol-HC cream |
| Ascomp with Codeine capsule | Glydo jelly syringe | Proctozone-HC cream |
| Atripla tablet | Granisetron vial | Proglycem suspension |
| Avar cleanser | Homatropaire drop | Promethazine 50mg suppository |
| Avidoxy tablet | Humalog Kwikpen U-100 | Promethegan suppository |
| Avita cream | Humatin capsule | Protonix vial & suspension |
| Bexarotene gel | Imitrex nasal spray | Pulmosal vial |
| Bismuth-Metronidazole-Tetracycline kit | Impoyz cream | Ranolazine ER 1000mg tablet |
| Bloxiverz vial | Intelence 100mg and 200mg tablet | Rextovy nasal spray |
| Carafate suspension | Isordil Titradose tablet | Rosadan cream & gel |
| Cardene-NACL IV | Jinteli tablet | Roweepra tablet |
| Chantix | Kaletra tablet & solution | Salimez 6% cream |
| Chemet capsule | Keralyt shampoo | Scalacort 2% lotion |
| Ciclodan cream | Klor-con 8, 10 & 20 MEQ tablet | Selzentry 150mg & 300mg tablet |
| Cipro oral suspension | Lacrisert insert | Sensipar tablet |
| Constulose solution | Levo-T tablet | SSD 1% cream |
| Cyclogyl drops | Levoxyl tablet | Subvenite tablet |
| Delzicol capsule | Lialda tablet | Sucraid solution |
| Depakote DR 125mg sprinkle capsule | Lido-K 3% lotion | Sulfatrim solution |
| Depen 250mg titratab | Lidopin 3% cream | Sutent capsule |
| Depo-Testosterone Vial | Lido-sorb 3% lotion | Symax-SR 0.375mg tablet |
| Diclegis tablet | Lidozion 3% lotion | Targadox tablet |
| Digitek tablet | Lofena tablet | Teriparatide pen |
| Dilt-XR capsule | Lymepak tablet | Testim 1% gel |
| Diphen Elixer | MAS Care-Pak Kit | Testosterone 25mg (1%) and 50mg (1%) gel packet |
| Dodex vial | Mesalamine enema | Testosterone 50mg (1%) gel |
| Doubledex kit | Mestinon solution | Tiadylt capsule |
| Doxepin cream | Methylin solution | Toviaz tablet |
| Doxy 100 vial | Methylpred dosepack | Tracleer tab suspension |
| Ed-Spaz ODT | Metronidazole 375mg capsule | Triderm cream |
| Emgality 300mg/3mL syrgine | Mimvey tablet | Trileptal suspension |
| Emtriva capsule | Mondoxyne NL 100mg capsule | Tykerb tablet |
| Endocet tablet | Morgidox capsule | Uceris 9mg tablet |
| Enulose solution | Moxifloxacin tablet | Unitroid tablet |
| Epinephrine 0.15mg/0.3mL auto injector
(TEVA & A-S medication) |
Narcan nasal spray | Vivjoa capsule |
| Epinephrinesnap-EMS kit | Natroba suspension | Vyvanse chewable tablets |
| Esomeprazole magnesium DR 20mg capsule | Nebusal 3% vial | Yuvafem vaginal inserts |
| Estradiol Valerate 50mg/5mL vial | Nulev chewable tablet | Zavesca capsule |
| Eurax cream | Nuvessa gel | Ziondil lotion |
List of medications moving to PRIOR AUTHORIZATION (PA) required
| Medication Name | ||
| Amiodarone 150mg/3mL syringe | Droperidol vial | Salicylic acid 6% cream |
| Ampicillin injectables | Fluoroplex 1% cream | Salycim 6% cream |
| Anoro Ellipta inhaler | Foscavir bottle | Salicylic acid 6% foam |
| Betamethasone injectable | Hydroxyzine injectable | Salicylic acid 6% shampoo |
| Calcitonin-salmon nasal spray | Phexxi vaginal gel | Flolipid oral suspension |
| Cefazolin injectable | Methylcobalamin vial | Sulfamethoxazole-TMP vial |
| Cefepime injectable | Methylprednisolone injectable | Tetracaine 0.5% eye drops |
| Cefotaxime injectable | Infuvite pediatric vial | Tabloid 40mg tablet |
| Cefotetan injectable | Nicardipine injectable | Triamcinolone injectable |
| Cefoxitin injectable | Upneeq 0.1% eye drop | Tropicamide 0.5% eye drops |
| Ceftriaxone injectable | Phenylephrine eye drop | Urea 40% lotion |
| Cefuroxime injectable | Phenytoin injectable | Xuriden 2GM granule packet |
| Cyclopentolate eye drops | Podofilox 0.5% topical solution | |
| Dexonto 0.4% solution | Proparacaine 0.5% eye drop | |
List of medications moving to PRIOR AUTHORIZATION (PA) NOT required
| Medication Name | ||
| Amlodipine-Benazepril tablet | Felbamate tablet & suspension | Purixan 20mg/mL suspension |
| Avita 0.025% gel | Glycopyrrolate solution | Pyridostigmine 60mg/5mL solution |
| Azithromycin powder packet | Kesimpta 20mg/0.4mL pen | Tarpeyo DR 4mg capsule |
| Dexamethasone 0.5mg/5mL liquid | Olanzapine 10mg vial | Tigabine tablet |
List of medications (brand and generic, if applicable) moving to Fee-For-Service (carve out)
| 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.
|
|
| Tolvaptan | Pulmozyme | |
| Samsca | Trikafta | |
| Jynarque | Symdeko | |
| Imcivree | Orkambi | |
| Bronchitol | Kalydeco | |
List of medications (brand and generic, if applicable) moving away from Fee-For-Service to MCO coverage (carve in)
| Medication name | ||
| Lagevrio | Retrovir (vial for injection) | Sunlenca |
| Paxlovid | Cabenuva | Trogarzo |
| Fuzeon | Apretude | |
| APPLE HEALTH EXPANSION: Will include above therapies AND HIV ORAL AGENTS | ||
Other HCA and CHPW Clinical Policy, Formulary and Criteria Updates (see table for effective dates)
| Policy | Summary of Update |
| OTC Contraceptives | For OTC contraceptives that can be billed without prescription, the prescriber’s, pharmacy or pharmacist’s NPI should be used when submitting claims.
|
| Daily Contraceptives
(Including OTC Opill) |
See below table for Expedited Authorization (EA) code guide
· Claims submitted with an EA code will pay
|
| Brixadi weekly injection
Effective 10/1/24
|
· Brixadi weekly injections no longer have any quantity limits · The max fill limit is 4 fills per month |
| Buprenorphine sublingual tablets
Effective 10/21/24 |
Buprenorphine sublingual tablets moved to preferred status and no longer require prior authorization. Quantity is still restricted to 32mg per day. |
