Products & Programs PharmacyHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingJune 6, 2023

Quarterly Pharmacy Formulary Changes Effective May 1, 2023

Quarterly pharmacy formulary change notice

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, 2023

No 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