February 2024 Formulary Policy Updates

Inpefa™(sotagliflozin)

Risk reduction of cardiovascular death, hospitalization for heart failure, and urgent heart failure visits in adults with heart failure, or type 2 diabetes mellitus, chronic kidney disease, and other cardiovascular risk factors

Miebo™ (perfluorohexyloc-tane)

The treatment of dry eye disease

Columvi™ (glofitamab)

The treatment of adults with relapsed or refractory diffuse large B-cell lymphoma, not otherwise specified, or large B-cell lymphoma arising from follicular lymphoma, after 2 or more lines of systemic therapy

Rezzayo™ (rezafungin)

The treatment of candidemia and invasive candidiasis in adults with limited or no alternative treatment options

Rystiggo®(rozanolixizumab-noli)

The treatment of generalized myasthenia gravis in adults who are anti-acetylcholine receptor or anti-muscle-specific tyrosine kinase antibody positive

Xdemvy™ (lotilaner}

The treatment of Demodex blepharitis

Ngenla™ (somatrogon-ghla}

The treatment of growth failure due to inadequate secretion of endogenous growth hormone in patients ages 3 to 17 years

Beyfortus™ (nirsevimab-alip)

The prevention of respiratory syncytial virus (RSV) infection in newborns and infants entering or during their first RSV season, and for children up to 24 months of age who remain vulnerable to severe RSV disease through their second RSV season

Xacduro® (durlobactam/ sulbactam}

The treatment of hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia caused by susceptible isolates of Acinetobacter baumannii-calcoaceticus complex in adults

Izervay™ (avacincaptad pegol)

The treatment of geographic atrophy (GA), due to age-related macular degeneration (AMD)

Elrexfio™ (elranatamab-bcmm }

The treatment of multiple myeloma in adults who are refractory to at least 1 proteasome inhibitor, 1 immunomodulatory agent, and 1 anti-CD38 antibody

Opvee® (nalmefene}

The emergency treatment of known or suspected opioid overdose induced by natural or synthetic opioids, as manifested by respiratory and/or central nervous system depression in patients ages 12 years and older

Airsupra™ (budesonide/ albuterol)

The as-needed treatment or prevention of bronchoconstriction, and the prevention of asthma exacerbations in patients aged 4 years and older 

Veopoz™ (pozelimab)

The treatment of CD55-deficient protein-losing enteropathy (also known as CHAPLE syndrome)

Sohonos™ (palovarotene)

For the reduction in the volume of new heterotopic ossification in females ages 8 years and older and in males ages 10 years and older with fibrodysplasia ossificans progressiva

Balfaxar® (prothrombin complex concentrate, human-lans)

The urgent reversal of acquired coagulation factor deficiency induced by Vitamin K antagonist (VKA, e.g., warfarin) therapy in adults with need for an urgent surgery/invasive procedure

Olpruva™ (sodium phenylbutyrate)

The treatment of urea cycle disorders

Vyvgart® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc)

The treatment of generalized myasthenia gravis in adults who are anti-acetylcholine receptor antibody positive

Idacio® (adalimumab-aacf)

The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, moderate to severe hidradenitis suppurativa (HS) in adults, ulcerative colitis, and plaque psoriasis in adults, the treatment of juvenile idiopathic arthritis in patients aged 2 years and older, and the treatment of Crohn's disease in patients aged 6 years and older (biosimilar of Humira)

Hulio® (adalimumab-fkjp)

The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, moderate to severe hidradenitis suppurativa (HS) in adults, Crohn's disease, ulcerative colitis, and plaque psoriasis in adults and the treatment of juvenile idiopathic arthritis in patients aged 2 years and older (biosimilar of Humira)

ADALIMU-FKJP (adalimumab-fkjp)

The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, moderate to severe hidradenitis suppurativa (HS) in adults, Crohn's disease, ulcerative colitis, and plaque psoriasis in adults and the treatment of juvenile idiopathic arthritis in patients aged 2 years and older (biosimilar of Humira)

Cyltezo™ (adalimumab-adbm)

The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, moderate to severe hidradenitis suppurativa (HS) in adults, Crohn's disease, ulcerative colitis, and plaque psoriasis in adults, non-infectious intermediate, posterior, and panuveitis in adults and the treatment of juvenile idiopathic arthritis in patients 2 years of age and older (biosimilar of Humira)

Suflave™ (polyethylene glycol 3350/ sodium sulfate/ potassium chloride/ magnesium sulfate/ sodium chloride)

Osmotic laxative indicated for cleansing of the colon in preparation for 

colonoscopy in adults.

Yusimry® ™ (adalimumab-aqvh)

The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, ulcerative colitis, plaque psoriasis in adults, the treatment of juvenile idiopathic arthritis in patients ages 2 years and older, and Crohn's disease in patients ages 6 and older (biosimilar of Humira)

Yuflyma® (adalimumab-aaty)

The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, ulcerative colitis, plaque psoriasis, and hidradenitis suppurativa in adults, the treatment of juvenile idiopathic arthritis in patients ages 2 years and older, and the treatment of Crohn's disease in patients ages 6 years and older (biosimilar of Humira)

Hadlima™ (adalimumab-bwwd)

The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, ulcerative colitis, plaque psoriasis, and hidradenitis suppur-ativa, non-infectious inter-mediate, pos-terior, and panuveitis in adults, the treat-ment of juvenile idio-pathic arthritis in patients ages 2 years and older, and the treatment of Crohn's disease in patients ages 6 years and older (biosimilar of Humira)

ADALIMU-ADAZ  (adalimumab-adaz)

The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, ulcerative colitis, plaque psoriasis in adults, the treatment of juvenile idiopathic arthritis in patients ages 2 years and older, and the treatment of Crohn's disease in patients ages 6 years and older (biosimilar of Humira)

Hyrimoz® ™ (adalimumab-adaz)

The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, ulcerative colitis, plaque psoriasis, and hidradenitis suppurativa in adults, the treatment of juvenile idiopathic arthritis in patients ages 2 years and older, and Crohn's disease in patients ages 6 and older (biosimilar of Humira)

Bevacizumab intravitreal (bevacizumab)

Used as an intravitreal injection to treat age-related macular degeneration (AMD) and non-AMD eye conditions (biosimilar of Avastin®)

Iyuzeh™ (Latanoprost)

The reduction of elevated intraocular pressure in patients with open-angle glaucoma or ocular hypertension

Lodoco® (colchicine} 

The risk reduction of myocardial infarction, stroke, coronary revascularization, and cardiovascular death in adults with established atherosclerotic disease or with multiple risk factors for cardiovascular disease

Rykindo® (risperidone extended release}

The treatment of schizophrenia, and as monotherapy or as adjunctive therapy to lithium or valproate for the maintenance treatment of bipolar I disorder, in adults

Altuviiio™ ([antihemophilic factor (recombinant), Fc-VWF-XTEN fusion protein-ehtl])

Use in adults and pediatrics with hemophilia A for routine prophylaxis to reduce the frequency of bleeding episodes, for on-demand treatment and control of bleeding episodes, and for perioperative management of bleeding

Beyfortus*

Opvee

Krazati

Sunleca tablet 

Sunleca injection*

Sezaby*

Nexobrid*

Jaypirca

Aponvie*

Orserdu

Lunsumio*

Hyftor

Atorvaliq

Iheezo gel *

Zynz *

Idacio

Hulio

Adalimumab-FKJP

Cyltezo

Yusimry

Yuflyma

Hadlima

Iyuzeh

Tascenso ODT

Tlando

Amjevita

Filspari

Konvomep

Rezvoglar

Mozobil inj

Plerixafor inj

Tier 1

NYRX Medicaid Transition

Tier 2

Folotyn

Pralatrexate inj

Medical, Prior Authorization per Orphan Drug Policy

Medical, Prior Authorization per Orphan Drug Policy

Medical, Prior Authorization per Orphan Drug Policy

Onglyza

Saxagliptin

Brand and generic excluded

NYRX Medicaid Transition

Brand and generic excluded

Indocin

Indomethacin suppositories

Brand and generic excluded

NYRX Medicaid Transition

Brand and generic excluded

Kombiglyze

Saxagliptin- Metformin

Brand and generic excluded

NYRX Medicaid Transition

Brand and generic excluded

Spiriva handihaler

Tiotropium bromide inhalation

Brand Tier 2, generic non-formulary

NYRX Medicaid Transition

Brand Tier 2, generic non-formulary

Levemir, Levemir Flexpen and Levemir FlexTouch

Move Levemir, Levemir Flexpen and Levemir FlexTouch to excluded status

Basaglar, Lantus

Aemcolo

Move Aemcolo to excluded status

Xifaxan

adalimumab-adaz and Hyrimoz

ADD Prior Authorization (PA) to adalimumab-adaz and Hyrimoz 
(cordavis) consistent with Humira criteria. Tier 2

budesonide/formoterol fumarate (generic Symbicort)

MOVE budesonide/formoterol fumarate (generic Symbicort) to Preferred/Generic status (Tier 1)

Advair Diskus, Advair HFA, fluticasone furoate/vilanterol, and Symbicort

MOVE Advair Diskus, Advair HFA, fluticasone furoate/vilanterol, and Symbicort to Excluded status.

budesonide/formoterol fumarate (generic Symbicort), Wixela (generic Advair) , fluticasone-salmeterol (generic Advair), Breo Ellipta 

Flovent Diskus, Flovent HFA & Pulmicort Flexhaler

Move from Tier 2 to Tier 3

Saxenda and Wegovy

Remove 12 month per lifetime quantity limit. Add prior authorization under new Weight Loss Drugs policy.

Phentermine, benzphetamine, diethylpropion, Qsymia, Contrave are available with a 365-day lifetime limit.