News
Lowest Net Cost Formulary Update Bulletin
August 14, 2024
These changes apply to all groups that have OptumRx as their PBM and use the Lowest Net Cost (LNC) Formulary. They do NOT apply to groups using any other formulary.
The majority of these changes include decisions that occurred as a result of our May 2024 Pharmacy and Therapeutics Committee (P&T) meeting. Members negatively impacted by one of these changes will be sent a letter in August.
FORMULARY UPDATES
Additions
These drugs will be added to the formulary effective Oct. 1, 2024.
| Product | Utilization Management Programs | Formulary Status |
|---|---|---|
| Adzynma | PA | Non-Preferred |
| Augtyro | PA | Non-Preferred |
| Bimzelx | PA/QL | Non-Preferred |
| Fabhalta | PA/QL | Non-Preferred |
| Fruzaqla | PA | Non-Preferred |
| Iwilfin | PA/QL | Non-Preferred |
| Ogsiveo | PA/QL | Non-Preferred |
| Truqap | PA/QL | Non-Preferred |
| Velsipity | PA/QL | Non-Preferred |
| Xphozah | PA/QL |
Moving to Nonformulary Status
The following drugs will move to nonformulary status effective Oct. 1, 2024. The products listed have alternatives available on the formulary, many times at a lower cost to the member. Note: some covered alternatives may require prior authorization (PA).
• CEPHALEXIN CAP 750MG
• CEPHALEXIN TAB 500MG
• DILTIAZEM CAP 120MG ER
• DILTIAZEM TAB 240MG ER
• DILTIAZEM TAB 300MG ER
• DILTIAZEM TAB 360MG ER
• DILTIAZEM ER TAB 180MG
• DILTIAZEM ER TAB 240MG
• DILTIAZEM ER TAB 300MG
• DILTIAZEM ER TAB 360MG
• DILTIAZEM ER TAB 420MG
• DOXYCYC MONO CAP 150MG
• DOXYCYCL HYC TAB 100MG DR
• DOXYCYCL HYC TAB 150MG DR
• DOXYCYCL HYC TAB 50MG DR
• DOXYCYCL HYC TAB 75MG DR
• HALOBETASOL AER 0.05%
• MATZIM LA TAB 180MG/24
• MATZIM LA TAB 240MG/24
• MATZIM LA TAB 300MG/24
• MATZIM LA TAB 360MG/24
• MATZIM LA TAB 420MG/24
• METRONIDAZOL CAP 375MG
• MINOCYCLINE TAB 100MG
• MINOCYCLINE TAB 50MG
• MINOCYCLINE TAB 75MG
• SAJAZIR INJ 30MG/3ML
• ZILEUTON ER TAB 600MG
• ZOLPIDEM TAR SUB 1.75MG
• ZOLPIDEM TAR SUB 3.5MG
Brand Adderall Update
Brand Adderall XR will be removed from the formulary effective Oct. 1, 2024. The brand version was previously added to the formulary due to a shortage of the generic (amphetamine-dextroamphetamine) product. The generic shortage has improved, allowing us the remove the brand from coverage once again.
Medical Benefit Only
These specialty drugs will only be eligible for coverage under the medical benefit: Casgevy, Loqtorzi, Lyfgenia, Opfolda, and Pombiliti.
DRUG MANAGEMENT PROGRAM UPDATES
Quantity Management
Beginning Oct. 1, 2024, the following products will have new quantity limits:
| DRUG | QUANTITY LIMIT |
|---|---|
| AIMOVIG INJ | 1 syringe per 28 days |
| AJOVY | 3 syringes per 84 days |
| EMGALITY INJ 120mg/ml | 1 syringe per 28 days |
| EMGALITY INJ 100MG/ML | 3 syringes per 28 days |