CP.PCH.32

Dapsone (Aczone Gel)

1/1/2027

Per August SDC, removed Clindagel from Appendix B.

CP.PCH.42

Deutetrabenazine (Austedo, Austedo XR)

1/1/2027

Retired, replaced by CP.CPA.370 and CP.PHAR.341

CP.PHAR.103

Immune Globulins

1/1/2027

Per August SDC, added HIM and ICHRA line of business; updated Appendix G with revised language for Tennessee; for Nebraska HIM line of business, added allowance of bypassing the exclusion of PANDAS in section III per state regulations.

CP.PHAR.341

Deutetrabenazine (Austedo, Austedo XR)

1/1/2027

Per August SDC, added HIM/ICHRA lines of business.

CP.PMN.143

Isotretinoin (Claravis Absorica Absorica LD Myorisan Zenatane Amnesteem)

1/1/2027

Per August SDC, removed Clindagel from Appendix B.

CP.PMN.295

Semaglutide (Wegovy)

1/1/2027

Per August SDC: updated redirection to preferred GLP-1 receptor agonist therapies from “failure of three of the following” to “failure of all of the following” for members with concurrent T2DM.

CP.PMN.298

Tirzepatide (Zepbound)

1/1/2027

Per August SDC: updated redirection to preferred GLP-1 receptor agonist therapies from “failure of three of the following” to “failure of all of the following” for members with concurrent T2DM.

CP.PMN.58

Propranolol (Hemangeol)

1/1/2027

Per August SDC, added HIM line of business.

HIM.PA.09

Insulin glargine (Basaglar, Lantus, Rezvoglar, Toujeo)

1/1/2027

Per August SDC: for Focused plans, added statement that Lantus, Toujeo, and unbranded Toujeo do not require prior authorization and added redirection to them as preferred products.

HIM.PA.153

Inhaled asthma and COPD agents

1/1/2027

Per August SDC: for Focused plans, added statement that Asmanex HFA, Asmanex Twisthaler, Tudorza Pressair, and Bevespi Aerosphere do not require prior authorization and added redirection to them as preferred products.

HIM.PA.161

Human Growth Hormone (Somapacitan, Somatrogon, Somatropin, Lonapegsomatropin-tcgd)

1/1/2027

Per August SDC, removed Humatrope as a preferred drug.

HIM.PA.168

Corticotropin (H.P. Acthar, Purified Cortrophin Gel)

1/1/2027

Per August SDC, removed ICHRA line of business, for Focused plans, added redirection of Acthar to Purified Cortrophin Gel.

HIM.PA.169

Berotralstat (Orladeyo)

1/1/2027

Per August SDC, added redirection to Haegarda for Focused plans only.

HIM.PA.171

Insulin detemir (Levemir) 08.18.26_SDC

1/1/2027

Retired per August SDC.

HIM.PA.172

Lanadelumab-fylo (Takhzyro)

1/1/2027

Per August SDC, added redirection to Haegarda for Focused plans only.

HIM.PA.173

Palbociclib (Ibrance)

1/1/2027

Per August SDC: for breast cancer, removed redirection to Kisqali.

HIM.PA.178

Immune Globulins_08.18.26 SDC

1/1/2027

Retired per August SDC.

HIM.PA.180

Insulin Icodec-abae (Awiqli)

1/1/2027

Per August SDC: for Focused plans, added redirection to Lantus, Toujeo, and unbranded Toujeo.

HIM.PA.58

DPP-4 inhibitors

1/1/2027

Per August SDC: added brand Januvia, Janumet, and Janumet XR to policy with redirection to generic; added ICHRA line of business.

HIM.PA.71

Topical Acne Treatment

1/1/2027

Per August SDC, removed Clindagel from Appendix B.

HIM.PA.87

Testosterone (Androderm)

1/1/2027

Retired per August SDC.

HIM.PA.91

SGLT2 inhibitors

1/1/2027

Per August SDC: added brand Farxiga and Xigduo XR to criteria with redirection to generic; added ICHRA line of business.

HIM.PA.SP60

Biologic and Non-biologic DMARDs

1/1/2027

Per August SDC: for CD, PsO, PsA, and UC, removed redirection to Stelara as agent is not preferred; removed step through criteria for initiating therapy for Stelara; added redirection to Imuldosa as agent is preferred).