Products & Programs PharmacyMedicaidJune 18, 2024

Quarterly pharmacy formulary change notice

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

Effective August 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 August 1, 2024
Therapeutic class	Drug	Revised status	Potential alternatives
ANTIDIABETICS	JARDIANCE 25MG TABLET JARDIANCE 10MG TABLET SYNJARDY 5-500MG TABLET SYNJARDY 12.5-500MG TABLET SYNJARDY 5-1000MG TABLET SYNJARDY 12.5-1000MG TABLET SYNJARDY 5-1000MG TABLET XR SYNJARDY 12.5-1000MG TABLET XR SYNJARDY 10-1000MG TABLET XR SYNJARDY 25-1000MG TABLET XR	NON-PREFERRED WITH PA	DAPAGLIFLOZIN 5MG TABLET DAPAGLIFLOZIN 10MG TABLET DAPAGLIFLOZIN- METFORMIN 5-1000 MG TABLET DAPAGLIFLOZIN- METFORMIN 10-1000 MG TABLET (STEP REQUIRED)
ANTIPSYCHOTICS	LURASIDONE 20MG TABLETS LURASIDONE 40MG TABLETS LURASIDONE 60MG TABLETS LURASIDONE 80MG TABLETS LURASIDONE 120MG TABLETS	PREFERRED	N/A
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES	SIMLANDI 40/0.4ML INJECTION	PREFERRED WITH PA	N/A
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES	YUSIMRY 40/0.8ML INJECTION	NON-PREFERRED AND CURRENT UTILIZERS WILL BE GRANDFATHERED	SIMLANDI 40/0.4ML INJECTION (PA REQUIRED)
CONTRACEPTIVES**	OPILL 0.075MG TABLET	PREFERRED	N/A
OPIOID ANTAGONISTS	RIVIVE 3/0.1ML NASAL SPRAY	PREFERRED	N/A

UM edits – effective for all members no later than august 1, 2024 No changes in preferred/non-preferred status revision or addition to UM edit only
ACNE PRODUCTS*	CABTREO GEL	ADD PA AND ADD QL 50 GRAMS PER 30 DAYS
ANALGESICS	TRAMADOL 25MG TABLET	ADD PA AND ADD QL 16 TABLETS PER DAY
ANTHELMINTICS	STROMECTOL 3MG TABLET	REMOVE PA
ANTIASTHMATIC AND BRONCHODILATOR AGENTS	XOLAIR 75/0.5 ML PREFILLED SYRINGE/ AUTOINJECTOR	ADD QL 2 PREFILLED SYRINGES/ AUTOINJECTORS PER 28 DAYS
ANTIASTHMATIC AND BRONCHODILATOR AGENTS	XOLAIR 150 MG vial, 150 MG/ML PREFILLED SYRINGE/ AUTOINJECTOR	ADD QL 4 VIALS/ PREFILLED SYRINGES/ AUTOINJECTORS PER 28 DAYS
ANTIASTHMATIC AND BRONCHODILATOR AGENTS	XOLAIR 300 MG/2 ML PREFILLED SYRINGE/ AUTOINJECTOR	ADD QL 2 PREFILLED SYRINGES/ AUTOINJECTORS PER 28 DAYS
ANTIASTHMATIC AND BRONCHODILATOR AGENTS	BREYNA 80/4.5MCG INHALER	ADD QL 3 INHALERS PER 30 DAYS
ANTIDIABETICS	ZITUVIO 25MG TABLET ZITUVIO 50MG TABLET ZITUVIO 100MG TABLET	ADD QL 1 TABLET PER DAY
ANTIDIABETICS*	ZITUVIMET 50 MG/500 MG TABLET ZITUVIMET 50 MG/10000 MG TABLET	ADD QL 2 TABLETS PER DAY
ANTIFUNGALS	VORICONAZOLE 200MG INJECTION	ADD PA
ANTIFUNGALS	CRESEMBA 74.5MG CAPSULE	ADD QL 5 CAPSULES PER DAY
ANTIFUNGALS	VFEND 40MG/ML SUSPENSION	UPDATE QL 17.5 mL per day
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	AMTAGVI INJECTION	ADD PA
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*	IWILFIN 192MG TABLET	ADD PA AND ADD QL 8 TABLETS PER DAY
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*	PHYRAGO 20 MG TABLETS PHYRAGO 50 MG TABLETS PHYRAGO 70 MG TABLETS PHYRAGO 80 MG TABLETS PHYRAGO 100 MG TABLETS PHYRAGO 140 MG TABLETS	ADD PA AND QL 1 TABLET PER DAY
ANTIRHEUMATIC - ENZYME INHIBITORS	RINVOQ 45MG TABLET ER	UPDATE QL 1 TABLET PER DAY; 84 TABLETS TOTAL (12 WEEK SUPPLY)
ANTISEBORRHEIC PRODUCTS*	ZORYVE 0.3% FOAM	ADD PA AND ADD QL 60 GRAMS PER 30 DAYS
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES	YUFLYMA 20/0.2ML SYRINGE	ADD QL 2 SYRINGES PER 28 DAYS
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES	SIMLANDI 40/0.4ML KIT	ADD PA AND ADD QL 2 AUTOINJECTORS PER 28 DAYS
ANTIVIRAL TOPICAL*	Zelsuvmi 10.3% GEL	ADD PA AND ADD QL 2 CARTONS PER 12 WEEKS
CENTRAL MUSCLE RELAXANTS	OZOBAX DS 10MG/5ML SOLUTION	ADD QL 40 ML PER DAY
COMPLEMENT INHIBITORS*	FABHALTA 200MG CAPSULE	ADD PA AND ADD QL 2 CAPSULES PER DAY
CORTICOSTEROIDS	EOHILIA 2MG/10ML SUSPENSPION	ADD PA AND ADD QL 4 MG PER DAY (20 ML
HEMATOPOIETIC AGENTS	UDENYCA ONBODY 6/0.6ML INJECTION	ADD QL 2 INJECTORS/ KITS PER 28 DAYS
HEMATOPOIETIC AGENTS	MIRCERA 30MCG INJECTION MIRCERA 50MCG INJECTION MIRCERA 75MCG INJECTION MIRCERA 100MCG INJECTION MIRCERA 120MCG INJECTION MIRCERA 150MCG INJECTION MIRCERA 200MCG INJECTION	ADD ST
HEMATOPOIETIC AGENTS	JESDUVROQ 1MG TABLET JESDUVROQ 2MG TABLET JESDUVROQ 4MG TABLET JESDUVROQ 6MG TABLET JESDUVROQ 8MG TABLET	ADD ST
IMMUNOGLOBULINS	ALYGLO 5GM/50ML INJECTION ALYGLO 10/100ML INJECTION ALYGLO 20/200ML INJECTION	ADD PA
INFLAMMATORY BOWEL AGENTS	ZYMFENTRA 120MG/ML INJECTION	ADD ST
INFLAMMATORY BOWEL AGENTS	ENTYVIO 108/0.68 ML INJECTION	ADD ST
LAXATIVES	LACTULOSE 10GM/15 SOLUTON	ADD QL 1800 ML PER 30 DAYS
LAXATIVES*	KRISTALOSE 10 GM PAK SOLUTION KRISTALOSE 20 GM PAK SOLUTION	ADD ST AND ADD QL 2 PACKETS PER DAY
LAXATIVES	LACTULOSE 10 GM PAK	ADD ST
MISCELLANEOUS LIQUIDS	COTTONSEED OIL	REMOVE QL
OPHTHALMIC AGENTS	VUITY 1.25% SOLUTION	UPDATE QL 5 ML PER 30 DAYS
OPHTHALMIC AGENTS*	QLOSI 0.4% SOLUTION	ADD PA AND ADD QL 60 VIALS PER 30 DAYS
OPHTHALMIC AGENTS*	iDOSE TR 75MCG IMPLANT	ADD PA AND ADD QL 2 APPLICATORS (75 MCG) PER LIFETIME
POTASSIUM	POKONZA 10MEQ POWDER	ADD ST
POTASSIUM REMOVING AGENTS*	VELTASSA 1GRAM PACKETS	ADD QL 240 PACKETS PER 30 DAYS
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.	WAINUA 45/0.8MLINJECTION	ADD PA AND ADD QL 1 AUTOINJECTOR PER 28 DAYS
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.	SYMBYAX 12 MG-25 MG CAPSULE	ADD QL 1 CAPSULE PER DAY
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.	GRALISE 450MG TABLET GRALISE 750MG TABLET GRALISE 900MG TABLET	ADD QL 2 TABLETS PER DAY
TETRACYCLINES	TETRACYCLINE 250MG CAPSULE TETRACYCLINE 500MG CAPSULE TETRACYCLINE 500MG TABLET	ADD QL 4 CAPSULES/ TABLETS PER DAY
WOUND CARE PRODUCTS	FILSUVEZ 10% GEL	ADD PA

** this change will be implemented on ASAP.
* this change will be implemented once the medication is on the market.

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 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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