Indication-based management
DRUG CLASS
EXCLUDED MEDICATIONS
PREFERRED ALTERNATIVES
Adalimumab Products for Inflammatory Conditions‡ ADALIMUMAB-AACF, IDACIO ADALIMUMAB-AATY, YUFLYMA ADALIMUMAB-BWWD
ADALIMUMAB-ADAZ ADALIMUMAB-ADBM (by Boehringer Ingelheim
& Quallent) SIMLANDI
ADALIMUMAB-FKJP, HULIO ADALIMUMAB-RYVK (by Teva)
ABRILADA AMJEVITA CYLTEZO HADLIMA HUMIRA HYRIMOZ YUSIMRY
Tocilizumab Products for Inflammatory Conditions‡
ACTEMRA SC, AVTOZMA SC
TYENNE SC**
Ustekinumab Products for Inflammatory Conditions‡ OTULFI SC, PYZCHIVA SC, SELARSDI SC, STARJEMZA SC, STELARA SC, STEQEYMA SC, USTEKINUMAB SC, USTEKINUMAB-AAUZ SC, USTEKINUMAB-AEKN SC, WEZLANA SC
IMULDOSA SC, USTEKINUMAB-TTWE SC (by Quallent), YESINTEK SC
Referenced excluded medications for Inflammatory Conditions‡ as indicated
KINERET, SILIQ
See below for Preferred Alternatives
DRUG CLASS
OTHER MEDICATIONS
PREFERRED ALTERNATIVES
Inflammatory Conditions‡
All other Brand Name medications for Inflammatory Conditions may require a trial of one or more Preferred medications as part of the Formulary exceptions process.
Preferred: ADALIMUMAB-ADAZ, ADALIMUMAB- ADBM (by Boehringer Ingelheim & Quallent), COSENTYX SC, ENBREL, ICOTYDE, IMULDOSA SC, OMVOH SC, OTEZLA, OTEZLA XR, RINVOQ ER, RINVOQ LQ, SIMLANDI, SKYRIZI SC, SOTYKTU, TALTZ, TREMFYA SC, tofacitinib, tofacitinib er, USTEKINUMAB-TTWE SC (by Quallent), VELSIPITY, YESINTEK SC, ZYMFENTRA Preferred for Non-Radiographic Axial Spondyloarthritis (nr-axSpA) only: CIMZIA, COSENTYX SC, TALTZ **Preferred after use of one Preferred Medication: CIMZIA (for Crohn’s Disease only), SIMPONI 100MG, TYENNE SC
‡ Please note that PDL and product placement for treatment of Inflammatory and Atopic Conditions in the Inflammatory and Atopic Conditions Care Value (IACCV) Program are subject to change throughout the year based upon changes in market dynamics, new indications for existing products, biosimilar and new product launches.
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