Formularies / 2027 MA-PD Parent Formulary
2027 MA-PD Parent Formulary
Parent locked HPMS-submittable
Details
HPMS submission status
EligibleEligible for HPMS submission.
Derived child formularies
- 2027 Client A Enhanced Formulary approved
Formulary items (8 drugs)
| Drug | RXCUI | Tier | PA | ST | QL | Covered | Effective |
|---|---|---|---|---|---|---|---|
| atorvastatin calcium 40 MG Oral Tablet | 617311 | 1 | — | — | — | Yes | 2027-01-01 |
| Eliquis 5 MG Oral Tablet | 1364447 | 3 | PA | — | — | Yes | 2027-01-01 |
| Entresto 49 MG / 51 MG Oral Tablet | 1656351 | 3 | PA | — | — | Yes | 2027-01-01 |
| Humira 40 MG in 0.8 ML Auto-Injector | 1655728 | 5 | PA | ST | 1 per 28 days | Yes | 2027-01-01 |
| Jardiance 10 MG Oral Tablet | 1545664 | 3 | PA | ST | — | Yes | 2027-01-01 |
| metFORMIN HCl 500 MG Oral Tablet | 861007 | 1 | — | — | — | Yes | 2027-01-01 |
| OZEMPIC 4 MG in 3 ML Pen Injector | 2398842 | 3 | PA | ST | 2 per 28 days | Yes | 2027-01-01 |
| TRELEGY ELLIPTA 100 MCG / 62.5 MCG / 25 MCG Dry Powder Inhaler, 30 Blisters | 1945048 | 3 | PA | — | — | Yes | 2027-01-01 |
Change history
| Change set | Requested by | Status | |
|---|---|---|---|
| Atorvastatin — move to Tier 2 and add Prior Authorization 2026-06-15 18:56 UTC | J. Rivera (Clinical Pharmacy) | in_review | Review → |
Submission artifacts
| Version | Generated | Hash | Status |
|---|---|---|---|
| No artifacts generated yet. | |||