Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and Indiana PathWays for AgingJune 6, 2023
Quarterly Pharmacy Formulary Changes Effective May 1, 2023
The preferred formulary changes detailed in the table below were applied to Anthem Blue Cross and Blue Shield (Anthem) members enrolled in Hoosier Healthwise, Hoosier Care Connect, and Healthy Indiana Plan (HIP), beginning May 1, 2023. Additionally, changes were applied to the non-preferred and prior authorization (PA) requirements of these formulary items effective May 1, 2023. These formulary changes were reviewed and approved at the fourth quarter 2022 Pharmacy and Therapeutics Committee meeting.
Effective for all patients on May 1, 2023 | |||
Therapeutic class | Medication | Formulary status change | Potential alternatives (preferred products) |
Antineoplastics and adjunctive therapies | TREXALL 5MG TABLET TREXALL 7.5MG TABLET TREXALL 10MG TABLET TREXALL 15MG TABLET | NON-PREFERRED WITH STEP THERAPY | METHOTREXATE 2.5MG TABLET |
Hematopoietic agents | INFED 50MG/ML INJECTION | NON-PREFERRED WITH PA | (PA REQUIRED) FERUMOXYTOL 510/17ML INJECTION |
** Proton pump inhibitors | (Rx) OMEPRAZOLE CAPSULE PANTOPRAZOLE TABLET PANTOPRAZOLE PACKET | PREFERRED | N/A |
UM edits — effective for all members no later than May 1, 2023No changes in preferred/non-preferred status revision or addition to UM edit only | |||
Antidiabetics | TZIELD 2MG/2ML INJECTION | ADD PA AND DOSING LIMITS | |
Antifungals | VIVJOA 150MG CAPSULE | ADD PA AND QL 18 CAPSULES (1 CARTON) PER YEAR | |
Anti-infectives | Azithromycin Penicillin Combinations Cephalosporins (3rd gen) Fluoroquinolones Clarithromycin Lincosamides Urinary Anti-infectives | REMOVE QL | |
Anti-infectives – throat | Nystatin 100,000 units/mL suspension | UPDATE QL 24 ML PER DAY | |
Antimetabolites* | Jylamvo 2 mg/ml Oral Solution | ADD PA | |
Antineoplastics and adjunctive therapies* | Lytgobi 12 mg, 16 mg, 20 mg carton | ADD PA AND QL 1 CARTON PER 7 DAYS | |
Antineoplastics and adjunctive therapies | TECVAYLI 30MG/3ML INJECTION TECVAYLI 153/1.7 INJECTION | ADD PA | |
Antineoplastics and adjunctive therapies* | Vegzelma 100 mg, 400 mg vial | ADD PA AND ql 1.25 mg per eye | |
Antineoplastics and adjunctive therapies | ELAHERE 5MG/ML INJECTION | ADD PA | |
Antineoplastics and adjunctive therapies | REZLIDHIA 150MG CAPSULE | Add QL 2 capsules per day | |
Anti-TNF-alpha –monoclonal antibodies | Hyrimoz 10 mg/0.2 mL prefilled syringe | ADD QL 2 SYRINGES PER 28 DAYS | |
Antivirals | FUZEON 90MG INJ | UPDATE QL: 2 VIALS PER DAY | |
Chelating agents | Cuvrior 300 mg TABLET | ADD PA AND QL 10 TABLETS PER DAY | |
Dermatologicals | Jublia 10% solution | ADD QL 8 ML PER 30 DAYS | |
Dermatologicals | Zyclara 2.5% cream (pump) Zyclara 3.75% cream (packets) Zyclara 3.75% cream (pump) | 1 PUMP OR 1 BOX (28 PACKETS) PER 28 DAYS; 56 DAYS OF TREATMENT PER YEAR | |
Dermatologicals | TOLNAFTATE 1% CREAM | UPDATE QL 30 GM PER 30 DAYS | |
Dermatologicals | FORMULA 7 RAPID GEL | ADD QL 28 GM PER 30 DAYS | |
Dermatologicals | FUNGIFOAM 1% AEROSOL | ADD QL 75 GM PER 30 DAYS | |
Diabetic supplies | OmniPod 5 Pod | ADD QL 15 PODS PER 30 DAYS | |
Diabetic supplies | Dexcom G7 Receiver | ADD QL 1 receiver per year | |
Diabetic supplies | Dexcom G7 Sensor | ADD QL 3 sensors/transmitters per 30 days | |
Diabetic supplies | Freestyle Libre 3 Sensor Freestyle Libre 14-day sensor | ADD QL 2 sensors per 28 days | |
Digestive aids | Sucraid 17,000 units/2 mL single-use ORAL SOLUTION | ADD QL 300 ML PER 30 DAYS | |
Diuretics | Furoscix 80 mg/10 mL KIT | ADD PA AND ql 6 KITS PER 30 DAYS | |
Endocrine and metabolic agents – misc. | PHEBURANE 483/GM ORAL PELLET | ADD QL 8 BOTTLES PER 30 DAYS | |
Estrogen combinations* | Bijuva 0.5mg/100mg capsule | add QL 1 capsule per day | |
Estrogens | ELESTRIN GEL 0.06% | update ql 52 GRAMS PER 30 DAYS | |
Estrogens | EVAMIST 1.53MG spray | UPDATE QL 16.2 ML PER 30 DAYS | |
Estrogens | ESTROGEL GEL | UPDATE QL 50 GRAMS PER 30 DAYS | |
Gastrointestinal agents – misc. | Skyrizi 180 mg/1.2 mL prefilled cartridge | ADD NEW QL 1 KIT PER 56 DAYS (8 WEEKS) | |
Gout agents | Zyloprim 100 mg TABLET | ADD QL 8 TABLETS PER DAY | |
Gout agents | Allopurinol 200 mg TABLET | ADD QL 4 TABLETS PER DAY | |
Gout agents | Zyloprim 300 mg TABLET | ADD QL 2 TABLETS PER DAY | |
Hematological agents –misc.* | Ultomiris 245 mg/3.5 mL prefilled cartridge | ADD QL 2 CARTONS PER WEEK | |
Insulins | Insulin Degludec/Insulin Degludec FlexTouch U-100 Insulin Glargine/Insulin Glargine SoloStar U-100* | ADD QL 30 ML PER 30 DAYS | |
Insulins | Insulin Degludec FlexTouch U-200 | ADD QL 18 ML PER 30 DAYS | |
Insulins* | Rezvoglar KwikPen U-100 | ADD QL 30 ML PER 30 DAYS | |
Musculoskeletal therapy agents | methocarbamol 1,000 mg TABLET | ADD QL 4 TABLETS PER DAY | |
Neuromuscular agents | RELYVRIO 3-1 GM PAK | ADD QL 7 PACKETS – 3 CARTONS ONCE, ONE-TIME FILL 56 PACKETS – 1 CARTON PER 28 DAYS | |
Ophthalmic agents | BEPREVE 1.5% DROPS | UPDATE QL 10 ML PER 30 DAYS | |
Proton pump inhibitors* | Konvomep SOLUTION | ADD QL 20 ML PER DAY | |
Respiratory agents – misc. | Pirfenidone 534 mg TABLET | ADD QL 3 TABLETS PER DAY | |
Respiratory agents – misc. | ORKAMBI 75-94 MG GRANULES | ADD QL 2 PACKETS PER DAY | |
Vaginal estrogens | ESTRACE VAGINAL CREAM 0.01% | ADD QL 42.5 GRAMS PER 30 DAYS | |
* This change will be implemented once the medication is on the market.
** This change will be implemented ASAP.
What action do I need to take?
Please review these changes and work with your patients to transition them to formulary alternatives. If you determine preferred formulary alternatives are not clinically appropriate for specific patients, you will need to obtain PA to continue coverage beyond the applicable effective date.
What if I need assistance?
We recognize the unique aspects of patient cases. If your patient cannot be converted to a formulary alternative for medical reasons, call our Pharmacy department at:
- 866-408-6132 for Hoosier Healthwise
- 844-533-1995 for HIP
- 844‑284‑1798 for Hoosier Care Connect
Follow the voice prompts for pharmacy PA. You can find the preferred drug lists on our provider website at anthem.com/inmedicaiddoc > Member Eligibility & Benefits > Pharmacy Benefits.
If you need assistance with any other item, contact your local Provider Relationship Management representative or call Provider Services at the appropriate number listed above.
Contact us
Availity* Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to availity.com and select the appropriate payer space tile from the drop-down.
Then, select Chat with Payer and complete the pre-chat form to start your chat.
For additional support, visit the Contact Us section at the bottom of our provider website for the appropriate contact.
* Availity, LLC is an independent company providing administrative support services on behalf of the health plan.
INBCBS-CD-022612-23
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