Formulary Update, July 2021, Commercial

Drug Formulary Update, July 2021 Commercial Programs

Updates to the HealthPartners Commercial Formularies (PreferredRx and GenericsAdvantageRx) are listed below.

Please see www.healthpartners.com/formularies for details.

Updates are effective July 1, 2021.

Current Drug name New Status Comments Status Acebutolol NF F Adding a generic to formulary

Acyclovir/ benzyl alcohol NC Not an FDA-approved drug (Acyclovix)

Adalimumab (Humira) 80mg F-PA-QL-SP A new formulation Amlodipine/ olmesartan NF F Adding a generic to formulary Anakinra (Kineret) F-PA-QL-SP F-PA-QL-SP Updating criteria per new indication Belimumab (Benlysta) NF-PA-SP NF-PA-SP Updating criteria per new indication

Berotralstat (Orladeyo) F PA QL SP A new medication, added with standard hereditary angioedema criteria, including an inadequate response to Takhzyro, Betaxolol oral NF F Adding a generic to formulary Brinzolamide (Azopt) F NF A new generic is available and preferred

Budesonide/ formoterol F-PA F (generic Symbicort) Buprenorphine/ naloxone F-QL F-QL Updating the quantity limit, for the number of units per day Current update film 2-0.5mg 12 3 film 4-1mg 6 3 film 8-2mg 3 3 film 12-3mg 2 2 SL tablet 2-0.5mg 12 3 SL tablet 8-2mg 3 3

Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, SP = Specialty Drug, QL = Quantity Limit. ONC = Oncology medicine. A current formulary status is not shown for new medications. Formulary Update, page 2 of 4

Current Drug name New Status Comments Status

Cabotegravir (Vocabria) F

Calcipotriene solution NF-QL F-QL Candesartan NF F Adding a generic to formulary Carglumic acid (Carbaglu) F-PA-SP F-PA-SP Updating PA criteria

Ciclopirox/ triamcinolone NC not an FDA-approved drug (Trilociclo)

Clascoterone (Winlevi) cream NF PA

Clotrimazole/ NF F betamethasone cream

Cyclobenzap/ lido/ priloc/ NC not an FDA-approved medication glycer (Cyclopak)

Diclofenac (Venngel One) NF-PA Lower cost alternatives available Diclofenac 3% gel NF-PA NF A new generic is available and preferred Doxepin oral solution F-AGE F Removing elderly age limits for doxepin. Droxidopa (Northera) NF-PA-QL-SP NF-PA-QL-SP A new generic is available and preferred Edoxaban (Savaysa) NF NF-PA Adding standard PA criteria for this class Epoprostenol (Veletri) F-PA-SP NF-PA-SP A new generic is available and preferred

Erythromycin/ benzoyl NF F peroxide

Fluocinonide cream NF F Fluticasone (Ticanase) NF-PA NC not an FDA-approved drug Imiquimod (Zyclara) NC NF-PA A new generic is available and preferred Ivabradine (Corlanor) F-PA F-PA Updating criteria to include FDA-approved indications. Ivacaftor (Kalydeco) F-PA-SP F-PA-SP updating criteria Ixazomib (Ninlaro) F-PA-QL-SP F-PA-QL-SP Updating quantity limit. Lapatinib (Tykerb) F-PA-QL-SP NF-PA-QL-SP A new generic is available and preferred.

Levothyroxine (Thyquidity) NF-PA A new liquid thyroid product

Lidocaine/ epinephr/ NC Not an FDA approved Drug tetracaine (L.E.T) Lomitapide (Juxtapid) F-PA-SP F-PA-SP updating criteria

Lonafarnib (Zokinvy) F-PA-SP A new medication for progeria. Loteprednol (Lotemax) F NF A new generic is available and preferred Lubiprostone (Amitiza) F-QL NF-PA-QL A new generic is available and preferred

Mannitol (Bronchitol) NF-PA-QL-SP A new CF medication Mepolizumab (Nucala) F-PA-SP F-PA-SP Updating criteria per new indication.

Current Drug name New Status Comments Status

Methotrexate (Reditrex) F-PA

Metoclopramide (Gimoti) F-PA a new FDA-approval

Metoclopramide ODT NF F-PA Mycophenolate acid (generic NF F Adding a generic to formulary Myfortic) Naproxen (Naprelan CR) NF NF-PA A new generic is available and preferred Opicapone (Ongentys) NF-PA adding a new strength Ozempic (Ozempic) F QL adding a new strength Ponatinib (Iclusig) F-PA-SP-ONC- adding a new strength TD-QL Potassium sorbate/ NC not FDA-approved as a medication maltodextrin/ aloe vera/ mann (Oramagicrx) Povidone/ taurine/ zinc NC not FDA-approved as a medication gluconate/ peg-40 castor oil (Gelx) Ramelteon NF F-QL Adding a generic, with a standard quantity limit per FDA-labeling.

Relugolix (Orgovyx) F-PA, SP ONC standard oncology criteria Rifaximin (Xifaxan) F-PA F-PA updating criteria Rilonacept (Arcalyst) F-PA-SP F-PA-SP updating criteria per new indication

Setmelanotide (Imcivree) NF-PA-QL-SP a new medication for weight loss

Sodium sulfate/ potassium F Suprep has been added to the Generics- sulfate/ magnesium sulfate Advantage formulary (in February). Suprep is on- (Suprep) formulary for both PreferredRx and GenericsAdvantageRx.

Solifenacin (Vesicare LS) NF-PA a new suspension formulation Tasimelteon (Hetlioz) NF-PA-SP NF-PA-SP updating criteria per new indication Telmisartan/ NF F adding generic to formulary hydrochlorothiazide

Tepotinib (Tepmetko) F-PA-QL, SP A new oral oncology medication ONC Testosterone (testosterone) F-PA F-PA updating criteria Tezacaftor/ ivacaftor F-PA-SP F-PA-SP updating criteria per indication (Symdeko)

Tirbanibulin (Klisyri) NF-PA Preferred alternatives are available

Tofacitinib (Xeljanz) NF-PA-QL-SP A new dosage form

Triamazole NC not an FDA-approved drug Formulary Abbreviations: F = Formulary, NF = Non-Formulary, PA = Prior Authorization, ST = Step Therapy, SP = Specialty Drug, QL = Quantity Limit. ONC = Oncology medicine. A current formulary status is not shown for new medications. Formulary Update, page 4 of 4

Current Drug name New Status Comments Status

Umbralisib (Ukoniq) F-PA-QL, SP new oral oncology medication ONC

Ursodiol (Reltone) NF-PA Preferred alternatives are available

Vericiguat (Verquvo) F-PA A new medication for heart failure

Vibegron (Gemtesa) NF-PA Preferred alternatives are available.

Voclosporin (Lupkynis) NF-PA-QL, SP A new medication for lupus Zolmitriptan oral NF-QL F-QL Adding generic to formulary. Zolmitriptan nasal (Zomig) NF-QL NF-PA-QL A new generic is available and preferred.