ProviderMatters

Formulary Update (June 2024)

Posted on June 4, 2024

Health New England’s formularies are located at healthnewengland.org. At the top of the page, use the “Find A Drug” tool.

 

Brand Name Generic Name GPI Commercial Formulary status
Aphexda MRX MOTIXAFORTIDE ACETATE 82502050102150 PA thru Magellan, T4
Daxxify MRX DAXIBOTULINUMTOXINA-LANM 90890045402140 PA thru Magellan, T4
Elrexfio MRX ELRANATAMAB-BCMM 213520281520** PA thru Magellan, T4
Eylea HD MRX AFLIBERCEPT INTRAVITREAL 86655010002080 PA thru Magellan, T4
FABHALTA  CAP 200MG IPTACOPAN HCL CAP 200 MG 85807535200130 Pa thru Optum, T3, QL 60 capsules/30 days
Izervay MRX AVACINCAPTAD PEGOL INTRAVITREAL 86456020102020 PA thru Magellan, T4
Mounjaro TIRZEPATIDE 2717308000D2** Pa thru Optum, T2, 4 pens per 28 days
Pombiliti MRX CIPAGLUCOSIDASE ALFA-ATGA 30907730052120 PA thru Magellan, T4
Talvey MRX TALQUETAMAB-TGVS 21352076802020 PA thru Magellan, T4
Tofidence MRX TOCILIZUMAB PA thru Magellan, T4
Tyruko MRX NATALIZUMAB PA thru Magellan, T4
Veopoz MRX POZELIMAB-BBFG 85805070152020 PA thru Magellan, T4
Vowst CAP FECAL MICROBIOTA SPORES, LIVE-BRPK CAPS 52522020100120 Not Covered, formulary alternatives available
Zoryve foam ROFLUMILAST FOAM 0.3% 90300045003920 Pa thru Optum, T3, QL-60 grams/30 days

 

If you have any questions about the information in this notice, please contact Health New England Provider Experience at (800) 842-4464, extension 5000. A representative is available Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m. You may also send an email to providerrelations@hne.com.

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