Pharmacy

Pharmacy formulary and prior authorization changes for January 2025

November 21, 2024

Beginning January 2025, some drugs will experience a formulary drug list change. For more information, read about the formulary drug list changes.

How we’re notifying impacted members:

Members received a letter in the mail in November 2024 notifying them of the change.
Members’ providers were notified of the change in our October 2024 Provider News.

If you have any questions about these formulary and prior authorization changes, please contact your Premera representative or producer.

Also, beginning January 2025, the following drugs will require a new prior authorization:

Condition:

Drugs Requiring a New Prior Authorization:

Preferred Alternatives:

Asthma

Airsupra (albuterol-budesonide)
Brand Albuterol HFA
Brand Levalbuterol HFA
ProAir Respiclick (albuterol)
Ventolin HFA (albuterol)
Xopenex HFA (levalbuterol)

Generic albuterol HFA

Cancer

Avastin (bevacizumab)

Mvasi (bevacizumab-awwb)
Zirabev (bevacizumab-bvzr)

Herceptin (trastuzumab)
Herceptin Hylecta (trastuzumab-hyaluronidase-oysk)

Kanjinti (trastuzumab-anns)
Trazimera (trastuzumab-qyyp)

Rituxan (rituximab)

Ruxience (rituximab-pvvr)
Truxima (rituximab-abbs)

Fertility Support

Fyremadel (ganirelix)
Brand ganirelix
Generic ganirelix

Generic cetrorelix
Cetrotide (cetrorelix)

Inflammatory Diseases

Hyrimoz (adalimumab-adaz)

Adalimumab-adaz
Adalimumab-adbm
Adalimumab-ryvk
Cyltezo (adalimumab-adbm)
Humira (adalimumab) (AbbVie)*
Simlandi (adalimumab-ryvk)

Avsola (infliximab-axxq)

Inflectra (infliximab-dyyb)
Brand Infliximab
Remicade (infliximab)

Rare Diseases

Glassia (alpha1-proteinase inhibitor)

Aralast (alpha1-proteinase inhibitor)
Prolastin-C (alpha1-proteinase inhibitor)
Zemaira (alpha1-proteinase inhibitor)

Remodulin (treprostinil)

Generic treprostinil

Rystiggo (rozanolixizumab-noli)

Soliris (eculizumab)
Ultomiris (ravulizumab-cwvz)
Vyvgart (efgartigimod alfa-fcab)
Vyvgart Hytrulo (efgartigimod-hyaluronidase-qvfc)