2026 Formulary, Criteria and Policy Changes

Effective 08/01/26

• Patients with active cancer treatment, hospice, palliative care or end-of-life care may bypass 120MME limit up to 200MME using EA code 85000000540
  • Exception: Methadone and transmucosal fentanyl (see below)

65.10.00.50 Methadone: Policy

• Severe chronic pain requires trial and failure of all generic long-acting opioids (regardless of preferred status) within the last 12 months unless contraindicated or not tolerated
• Active cancer treatment requires trial and failure of two preferred long-acting opioids within the last 12 months unless contraindicated or not tolerated
  • EA 85000000540 code does not bypass 120 MME limit for methadone. Opioid attention form will be required.

65.10.00.25 Transmucosal Fentanyl: Policy

• EA 85000000540 code does not bypass 120 MME limit for transmucosal fentanyl. Opioid attention form will be required.

67.70.10 Migraine Products – Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists

• Updated preferred/non-preferred products to match changes from 07/01/26 quarterly changes
• Initial approval duration updated to 12 months
• Acute treatment
  • Removed NSAID requirement
  • Updated to trial and failure of two preferred products

Effective 08/01/26

• Onureg and Tabloid for Acute Myeloid Leukemia
  • Note: Tabloid does not have a federal rebate

Effective 07/24/26

• Kisqali 200mg – 400mg
  • Added the indication: Adjuvant therapy of early stage (II-III) breast cancer with high risk of recurrence
• Updated in advance of HCA’s policy to follow FDA labeling

Effective 08/20/26

• Added indication: Chronic Rhinosinusitis with Nasal Polyps indication (CRSwNP)

Effective 10/01/26

• Policy based on HCA’s Medical Necessity Non-Clinical

Rexulti (brexpiprazole)

• Schizophrenia
• Adjunct to antdepressants in Major Depressive Disorder
• Agitation due to dementia from Alzheimers

Caplyta (lumateperone)

• Schizophrenia
• Adjunct to antdepressants in Major Depressive Disorder
• Depressive episodes associated with bipolar I or II disorder

See right for effective dates

• Techlite and Trueplus preferred
• All other brands non-preferred

Continuous Glucose Monitors (Effective 09/01/26)

• Patients with diagnosis of Type 1 Diabetes will bypass prior authorization

Xeljanz (effective 06/26/26)

• Generic tofacitinib available
• Brand Xeljanz requires trial and failure of:
  • Two preferred Cytokine/CAM
  • Generic tofacitinib (up to 5 manufacturers

since 07/01/26

• Lynavoy
• Lumvoa
• Trutakna
• Besremi

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