Formulary Updates: August 2020 P&T Committee Meeting

Brand Name

Generic Name

Prior Authorization (Y/N)

Valtoco^®

diazepam nasal spray

N

Ayvakit^TM

avapritinib

Y

Tazverik^®

tazemetostat

Y

Brand Name

Generic Name

Prior Authorization (Y/N)

Repatha^®

evolocumab

Y

Baqsimi^®

glucagon nasal powder

N

Dovato^®

dolutegravir and lamivudine

N

Soliqua^®

insulin glargine and lixisenatide injection

Y

Xultophy^®

insulin degludec and liraglutide injection

Y

Brand Name

Generic Name

Prior Authorization (Y/N)

Onglyza^®

saxagliptin

Y

Kombiglyze^® XR

saxagliptin and metformin

N

Omnipod DASH^®

insulin management system

Y

Brand Name

Generic Name

Prior Authorization (Y/N)

Ubrelvy^TM

ubrogepant

Y

Nurtec^TM ODT

rimegepant

Y

Revyow^®

lasmiditan

Y

Secuado^®

asenapine

Y

Caplyta^®

lumateperone

Y

Gloperba^®

colchicine oral solution

Y

Talicia^®

omeprazole magnesium, amoxicillin, and rifabutin

N

Zerviate^TM

cetirizine ophthalmic solution

Y

Jatenzo^®

testosterone undecanoate

Y

Riomet ER^TM

metformin HCL ER oral suspension

Y

Palforzia^® allergen powder

peanut (Arachis hypogaea) powder

Y

Brand Name

Generic Name

Prior Authorization (Y/N)

Fintepla^®

fenfluramine

Y

Tivicay^®

dolutegravir

N

Darzalex Faspro^TM

daratumumab-hyaluronidase-fihj

Y

Phesgo^TM

pertuzumab-trastuzumab-hyaluronidase-zzxf

Y

Rukobia^TM

fostemsavir tromethamine

N

Tabrecta^TM

capmatinib

Y

Zepzelca^TM

lurbinectedin

Y

Pemazyre^®

pemigatinib

Y

Retevmo^TM

selpercatinib

Y

Trodelvy^TM

sacituzumab govitecan-hziy

Y

Qinlock^TM

ripretinib

Y

Brand Name

Generic Name

Prior Authorization (Y/N)

Ortikos^TM

budesonide

n/a

Dayvigo^®

lemborexant

n/a

Zeposia^®

ozanimod

n/a

Evrysdi^TM

risdiplam

n/a

Licart^TM

diclofenac epolamine patch

n/a

Ferriprox^® Twice-A-Day

deferiprone

n/a

Dojolvi^TM

triheptanoin

n/a

Avsola^TM

infliximab-axxq

n/a

Twirla^®

levonorgestrel-ethinyl estradiol patch

n/a

Lyumjev^TM

insulin lispro-aabc

n/a

Oriahnn^TM

elagolix-estradiol-norethindrone

n/a

Fensolvi^®

leuprolide

n/a

Mycapssa^®

octreotide

n/a

Bynfezia Pen^TM

octreotide

n/a

Nexlizet^TM

bempedoic acid-ezetimibe

n/a

Breztri Aerosphere^TM

budesonide-glycopyrrolate-formoterol

n/a

Phexxi^TM

lactic acid-citric acid-potassium bitartrate gel

n/a

Kynmobi^TM

apomorphine

n/a

Zilxi^TM

minocycline micronized

n/a

Helidac^TM

metronidazole-tetracycline w/bismuth subsalicylate

n/a