MedicaidMay 19, 2023
Quarterly Pharmacy Formulary Changes effective 5/1/2023 (Part II)
Quarterly pharmacy formulary change notice
The formulary changes listed in the table below were reviewed and approved at our fourth quarter 2022 Pharmacy and Therapeutics Committee meeting.
Effective May 1, 2023, the changes outlined below apply to all Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) members. Remember to read the footnotes at the end of the table.
Effective for all members on May 1, 2023 | ||||
Therapeutic class | Drug | Revised status | Potential alternatives | |
ANTIHISTAMINES** | (OTC) CHLOR-TRIMETON 12MG TABLET CR CHLOR-TRIMETON 4MG TABLET (OTC) XYZAL 5MG TABLET LEVOCETIRIZINE 5MG TABLET | PREFERRED | N/A | |
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 | |
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES | HUMIRA PEDIATRIC CROHNS INJECTION HUMIRA PEDIATRIC UC PEN KIT HUMIRA CD/UC/HS PEN HUMIRA CD/UC/HS PEN KIT HUMIRA PS/UV PEN HUMIRA PS/UV PEN KIT HUMIRA20/0.2ML INJECTION HUMIRA 40/0.4ML INJECTION HUMIRA 40/0.4ML PEN HUMIRA 40MG/0.8 KIT HUMIRA 80/0.8ML PEN | NON-PREFERRED WITH STEP THERAPY | (PA REQUIRED) AMJEVITA 20 MG SYRINGE AMJEVITA 40 MG SURECLICK PEN | |
ANTIVIRALS** | SUNLENCA 300MG TABLET SUNLENCA INJECTION | COVERED | N/A | |
HEMATOPOIETIC AGENTS | INFED 50MG/ML INJECTION | NON-PREFERRED WITH PA | (PA REQUIRED) FERUMOXYTOL 510/17ML INJECTION | |
UM edits – effective for all members no later than May1, 2023 No changes in preferred/non-preferred status revision or addition to UM edit only | ||||
ANTIDEPRESSANTS | Auvelity 45 mg/105 mg tablet | Add pa and ql 2 tablets per day | ||
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 - 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 | IMJUDO 25/1.25ml iNJECTION IMJUDO 300/15ML INJECTION | 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 | PEDMARK 12.5GM INJECTION | ADD PA | ||
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 PA AND QL 1 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% AEROSAL | 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) | ||
CYSTINOSIS AGENTS | CYSTAGON 50MG capsule CYSTAGON 150MG capsule PROCYSBI 25MG granules PROCYSBI 75MG granules PROCYSBI 300MG granules | ADD PA | ||
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 CARONS 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 3-1GM PAK | ADD PA AND 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 75-94MG 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 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.
NVBCBS-CD-024351-23
To view this article online:
Or scan this QR code with your phone