Products & Programs PharmacyMedicaidFebruary 20, 2024

Quarterly pharmacy change notice

The formulary changes listed in the table below were reviewed and approved at our third quarter 2024, Pharmacy and Therapeutics Committee meeting.

Effective February 1, 2024, the changes outlined below apply to all Anthem members. <Remember to read the footnotes at the end of the table.>

EFFECTIVE FOR ALL PATIENTS ON FEBRUARY 1, 2024
Therapeutic class	Drug	Revised status	Potential alternatives
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES**	YUSIMRY 40MG/0.8ML PEN	PREFERRED WITH PA	N/A
GOUT AGENTS**	COLCHICINE CAPSULES/TABLETS	PREFERRED	N/A
HEMATOPOIETIC AGENTS**	INFED 50MG/ML INJECTION	PREFERRED WITH PA	N/A
INSULINS	LANTUS VIAL/PEN	PREFERRED	N/A
INSULINS	SEMGLEE VIAL/PEN INSULIN GLARGINE-YFGN VIAL/PEN	NON-PREFERRED	LANTUS
MONOCLONAL ANTIBODIES**	BEYFORTUS 50MG/0.5ML INJECTION BEYFORTUS 100MG/ML INJECTION	PREFERRED (Please note this is medical benefit only)	N/A
OPIOID DEPENDENCE AGENTS**	BRIXADI WEEKLY/MONTHLY INJECTION	NON-PDL	N/A
UM EDITS – EFFECTIVE FOR ALL MEMBERS NO LATER THAN FEBRUARY 1, 2024 No changes in Preferred/Non-Preferred status revision or addition to UM edit only
ANDROGENS	KYZATREX 200 MG CAPSULE	UPDATE QL 4 CAPSULES PER DAY
ANTIASTHMATIC AND BRONCHODILATOR AGENTS	BREO ELLIPTA 50 MCG/25 MCG	ADD QL 1 INHALER PER 30 DAYS
ANTIDEMENTIA AGENTS	NAMZARIC (MEMANTINE EXTENDED RELEASE/DONEPEZIL) TITRATION PACK	ADD 1 PACK PER FILL, ONE TIME FILL
ANTIDEPRESSANTS*	ZURZUVAE (ZURANOLONE) 20 MG, 25 MG, 30 MG CAPSULE	ADD PA AND QL ZURZUVAE 20MG, 25 MG (28 CAPSULES PER FILL; 1 FILL PER YEAR) 30 MG CAPSULE (14 CAPSULES PER DAY)
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	COLUMVI 10 mg/10 ml vial columvi 2.5 mg vial	ADD PA
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	vanflyta 17.7 mg TABLET VANFLYTA 26.5 mg tablet	add ql 2 tablets per day
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	lumakras 320 mg tablet	add ql 3 TABLETS PER DAY
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	talzenna 0.1 mg CAPSULE TALZENNA 0.35 mg capsule	add ql 1 capsule per day
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	akeega 50 mg/500mg TABLET AKEEGA 100 mg/500mg tablet	add pa and ql 1 tablet per day
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	elrexfio (elranatamab-bcmm) vials	add pa
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	talvey (Talquetamab-tgvs) vials	Add PA
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES	cyltezo crohn’s diseaSe, Ulcerative colitis starter package 40 mg/0.8 ml pens cyltezo psoriasis starter package 40mg/0.8 ml pens	add ql 1 pack (28 day supply, one time fill)
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES	hadlima 40 mg/0.4 ml autoinjector hadlima 40 mg/0.4 ml prefilled syringe	add ql 2 autoinjectors per 28 days 2 syringes per 28 days
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES	hyrimoz crohn’s disease starter package 80 mg/0.8 ml pen hyrimoz crohn’s disease starter package 80 mg/0.8 ml and 40 mg/0.4 ml pens hyrimoz plaque psoriasis starter package 80 mg/0.8 ml and 40 mg/0.4 ml pens hyrimoz pediatric crohn’s disease starter pack 80 mg/0.8 ml prefilled syringe hyrimoz pediatric crohn’s disease starter pack 80 mg/0.8 ml and 40 mg/0.4 ml prefilled syringe	add ql 1 pack (28 day supply, one time fill)
CARDIOVASCULAR AGENTS MISC	lodoco (colchicine) 0.5 mg tablet	add pa and ST and ql 1 tablet per day
CARDIOVASCULAR AGENTS MISC	liqrev (sildenafil) 10 mg/ml oral suspension	add pa
CMV AGENTS	PREVYMIS (LETERMOVIR) 240 MG, 480 MG TABLETS PREVYMIS (LETERMOVIR) 240 MG/12 ML, 480 MG/24 ML VIALS	UPDATE QL 224 TABLETS PER YEAR UPDATE ql 200 VIALS PER YEAR
COMPLEMENT INHIBITORS	VEOPOZ 400 MG/2 ML VIAL	ADD PA AND DOSING LIMIT/ql 10 mg/kg, up to a maximum of 800 mg (2 vials), once weekly; MAXIMUM OF 2 VIALS ONCE WEEKLY
CONTRACEPTIVES	HALOETTE VAGINAL RING	ADD QL 1 RING PER 28 DAYS
CONTRACEPTIVES	AFTERPILL, CURAE, ECONTRA OS, HER STYLE EMERGENCY CONTRACEPTIVES 1.5 MG TABLETS	ADD QL 1 TABLET PER 30 DAYS
DIABETIC SUPPLIES	INSULIN INFUSION PUMP SUPPLIES	REMOVE QL 15 INFUSION SETS/RESERVOIRS PER 30 DAYS
DIURETICS	ALDACTAZIDE (SPIRONOLACTONE / HYDROCHLOROTHIAZIDE 25 MG/25 MG) ALDACTAZIDE (SPIRONOLACTONE / HYDROCHLOROTHIAZIDE 50 MG/50 MG)	REMOVE DO 8 TABLETS PER DAY REMOVE QL 4 TABLETS PER DAY
FIBRODYSPLASIA OSSIFICANS PROGRESSIVA (FOP) AGENTS	SOHONOS (PALOVAROTENE) 1 MG, 1.5 MG, 2.5 MG, 5 MG, 10 MG CAPSULES	ADD pA AND QL SOHONOS 1 MG (4 CAPSULES PER DAY) sOHONOS 1.5 MG (2 CAPSULES PER DAY) SOHONOS 2.5 MG, 5 MG (1 CAPSULE PER DAY) 10 MG (APPROVED FOR FLARE UP TREATMENT VIA OVERRIDE CRITERIA)
GASTROINTESTINAL AGENTS MISC	bylvay 200 mcg, 600 mcg, 400 mcg, 1200 mg pellets	update ql bylvay 200 mcg (36 pellets per day bylvay 600 mcg (12 pellets per day) bylvay 400 mcg (18 pellets per day) bylvay 1200 mcg (6 pellets per day)
GROWTH HORMONES	NGENLA 24 MG/1.2 ML pREFILLED PEN NGENLA 60 MG/1.2 ML PREFILLED PEN	ADD QL 4 PENS PER 28 DAYS
HEMATOLOGICAL AGENTS MISC	KALBITOR 10 MG VIAL	UPDATE QL UP TO 6 VIALS (60 MG) PER ATTACK (mAXIMUM 36 VIALS/30 DAYS)
HEMATOLOGICAL AGENTS MISC	ICATIBANT 30 MG PREFILLED SYRINGE	UPDATE QL UP TO 3 SYRINGES (90 MG) PER ATTACK (mAXIMUM 18 SYRINGES/30 DAYS)
HEMATOPOIETIC AGENTS	FERAHEME (FERUMOXYTOL) 510 MG/17 ML VIAL	UPDATE QL 1020 MG PER 6 DAYS
HEMATOPOIETIC AGENTS	FERRLECIT 62.5 MG/5 ML VIAL	UPDATE QL 1000 MG PER 8 WEEKS
HEMATOPOIETIC AGENTS	INJECTAFER (FERRIC CARBOXYMALTOSE) VIALS	UPDATE QL 1500 MG PER 7 DAYS
HEMATOPOIETIC AGENTS	MONOFERRIC (FERRIC DERISOMALTOSE) VIALS	UPDATE QL 1000 MG PER DAY
HEMATOPOIETIC AGENTS	VENOFER (IRON SUCROSE) VIALS	UPDATE QL 1000 MG PER 14 DAYS
HEMATOPOIETIC AGENTS	MIRCERA 120 MCG/0.3 ML SYRINGE	ADD QL 2 SYRINGES (0.6 ML) PER 28 DAYS
IMMUNOMODULATORS	RYSTIGGO 280 mg/2 ml vial	ADD PA AND DOSING LIMIT
IMMUNOMODULATORS	vyvgart hytrulo vial	add pa and ql 1 vial once weekly for 4 weeks (4 weeks=1 cycle)
INFLAMMATORY BOWEL AGENTS	rowasa (mesalamine rectal suspension enema) 4 gram/60 ml sfrowasa (MESALAMINE RECTAL SUSPENSION ENEMA) 4 gram/60 ml	add Ql 1680 ml per 28 days
KERATOLYTIC AGENTS	ycanth (cantharidin) 0.7% topical solution	add pa and ql 8 applicators per 12 weeks
LAXATIVES	suflave solution kit	add ql 2 kits per 30 days
MULTIPLE SCLEROSIS AGENTS*	tyruko 300mg/15 ml vial	add ql 1 vial per 28 days
OPHTHALMIC AGENTS	eylea hd 8 mg vial	add pa and dosing limit 8 mg per eye every 4 weeks for the first three doses; followed by 8 mg per eye; each eye may be treated as frequently as every 8 weeks
OPHTHALMIC ANTI-INFECTIVES	xdemvy (lotilaner) ophthalmic solution	add pa and ql 1 bottle per fill; 2 fills per year
OPHTHALMIC COMPLEMENT INHIBITORS	izervay 20 mg/ml Vial	add pa and dosing limit 0.1 ml (or 2 mg) per eye; each eye may be treated as frequently as every 28 days
OPHTHALMIC DRY EYE AGENTS*	vevye (cyclosporine) ophthalmic 0.1% solution	add pa and ql 6 ml per 30 days
OPHTHALMIC DRY EYE AGENTS	miebo (perfluorohexyloctane) opthalmic solution	add pa and ql 12 ml per 30 days
OPIOID ANALGESICS	buprenex 0.3 mg/ml injection	REMOVE QL 3 ml per day
OPIOID ANALGESICS	butorphanol 1 mg/ml injection butorphanol 2 mg/ml injection	remove ql 8 ml per day Fremove ql 4 ml per day
OPIOID ANALGESICS	Dilaudid (hydromorphone) injection 0.2 mg/mL, 1 mg/mL ampule/syringe, 0.5 mg/0.5 mL Syringe (including PF), 2 mg/mL injection (ampule, syringe, vial; including PF) (includes all injectable formulations including vials, syringes and ampules)	REMOVE ql 6 ml per day
OPIOID ANALGESICS	Dilaudid (hydromorphone) 4 mg/mL injection (ampule, syringe) (including PF) (includes all injectable formulations including vials, syringes and ampules)	REMOVE QL 2 ml per day
OPIOID ANALGESICS	Dilaudid-HP (hydromorphone) 10 mg/mL injection (includes all injectable formulations including vials, syringes and ampules)	REMOVE ql 1 injection per 30 days
OPIOID ANALGESICS	Demerol (meperidine) injection 100 mg/2mL, 100 mg/mL, 25 mg/mL, 75 mg/mL, 10 mg/mL, 50 mg/mL, 75 mg/1.5 mL (includes all injectable formulations including vials, syringes and ampules)	remove ql 4 ml per day
OPIOID ANALGESICS	Mitigo/Infumorph 200 mg/20 mL Mitigol/Infumorph 500mg/20mL	REMOVE QL 2 vials per month
OPIOID ANALGESICS	Morphine sulfate injection 10 mg/0.7 mL (includes all injectable formulations including vials, syringes and ampules)	remove ql 6 injections/pens per day
OPIOID ANALGESICS	Morphine sulfate injection 150 mg/30 mL (includes all injectable formulations including vials, syringes and ampules)	remove ql 1 vial (30 mL) per day
OPIOID ANALGESICS	Morphine sulfate injection 25 mg/mL (100 mg/4 mL, 250 mg/10 mL) (includes all injectable formulations including vials, syringes and ampules)	remove ql 4 ml per day
OPIOID ANALGESICS	Morphine sulfate injection 50 mg/mL (includes all injectable formulations including vials, syringes and ampules)	remove ql 2 ml per day
OPIOID ANALGESICS	Morphine sulfate injection (including Duramorph injection) 0.5 mg/1 mL, 1 mg/mL, 2 mg/mL (10 mg/5 mL), 4 mg/mL, 5 mg/mL, 8 mg/mL, 10 mg/mL (15 mg/1.5 mL) (includes all injectable formulations including vials, syringes and ampules)	remove ql 6 ml per day
OPIOID ANALGESICS	oxycodone 10 mg/0.5 ml injection	remove ql 2 ml per day
OPIOID DEPENDENCE AGENTS	Brixadi 8 mg/0.16 mL weekly injection Brixadi 16 mg/0.32 mL weekly injection Brixadi 24 mg/0.48 mL weekly injection Brixadi 32mg/0.64ml weekly injection Brixadi 64 mg/0.18 mL monthly injection Brixadi 96mg/0.27ml monthly injection Brixadi 128mg/0.36ml monthly injection	add ql 4 syringes per 28 days (weekly injection) 1 syringe every 28 days (Monthly injection)
OPIOID DEPENDENCE AGENTS	Suboxone (Buprenorphine/naloxone) 2 mg/0.5 mg sublingual film/tablet	update ql 16 films/tablets per day
OPIOID DEPENDENCE AGENTS	Suboxone (Buprenorphine/naloxone) 8 mg/2 mg sublingual film/tablet	update ql 4 films/tablets per day
OPIOID DEPENDENCE AGENTS	Suboxone (Buprenorphine/naloxone) 4 mg/1 mg sublingual film	update ql 8 films per day
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC	Austedo XR (deutetrabenazine) 6 mg, 12 mg, 24 mg tablets Austedo XR (deutetrabenazine) 6-24 mg titration kit	add Pa and ql 2 tablets per day 1 kit per fill, one time FILL
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC*	Ingrezza (valbenazine) 40-60 mg initiation pack	add ql 1 pack (28 day supply), one time fill
SEDATIVE HYPNOTIC AGENTS	zolpidem 7.5 mg capsule	add ql 1 capsule per day
SELECT NALOXONE AGENTS	nalmefene 2 mg/2 ml injection	add ql 10 vials (1 carton) per 5 months
SELECT NALOXONE AGENTS	naloxone 2 mg/ 2ml injection NALOXONE 4 MG/10 ML INJECTION	add ql 6 syringes/vials per 3 months
SELECT NALOXONE AGENTS	opvee (nalmefene) 2.7 mg/0.1 ml nasal spray	add ql 6 nasal sprays (3 cartons) per 3 months

* 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 Anthem 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 prior authorization (PA) to continue coverage beyond the applicable effective date.

What if I need assistance?

We recognize the unique aspects of patients’ cases. If for medical reasons your Anthem patient cannot be converted to a formulary alternative, call our Pharmacy department at 844-396-2330 and follow the voice prompts for pharmacy PA. You can find the Preferred Drug List on our provider website at https://mediproviders.anthem.com/nv.

If you need assistance with any other item, contact your local provider relationship management representative or call Provider Services at 844-396-2330.

Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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Quarterly pharmacy change notice

EFFECTIVE FOR ALL PATIENTS ON FEBRUARY 1, 2024

What action do I need to take?

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