MedicaidJune 27, 2023
Quarterly Pharmacy Formulary Changes effective August 1, 2023
Effective August 1, 2023, the changes outlined below apply to all Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) members.
EFFECTIVE FOR ALL PATIENTS ON AUGUST 1, 2023 | |||
Therapeutic class | Drug | Revised status | Potential alternatives |
ANTIDEPRESSANTS** | FLUOXETINE 10MG TABLET FLUOXETINE 20MG TABLET FLUOXETINE 60MG TABLET FLUVOXAMINE ER 100MG CAPSULE FLUVOXAMINE ER 150MG CAPSULE | PREFERRED | N/A |
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES | HUMIRA 10/0.1ML INJ | NON-PREFERRED | AMJEVITA INJ (PA REQUIRED) |
ORAL GLUCOCORTICOSTEROIDS | MILLIPRED 5MG | NON-PREFERRED | PREDNISOLONE ODT TABLET METHYLPREDNISOLONE TABLET PREDNISONE TABLET PREDNISOLONE SOLUTION PREDNISONE SOLUTION |
OVER THE COUNTER AGENTS | (GENERIC) BROMPHENIRAMINE & PHENYLEPHRINE ELIXIR CAPSAICIN CREAM CHLORPHENIRAMINEIRAMINE & PHENYLEPHRINERINE LIQUID CHLORPHENIRAMINEIRAMINE & PHENYLEPHRINERINE TABLET CHLORPHENIRAMINEIRAMINE & PSEUDOEPHEDRINE TABLET CHLORPHENIRAMINEIRAMINE-DM LIQUID CHLORPHENIRAMINEIRAMINE-DM TABLET DEXBROMPHENIRAMINE-PHENYLEPHRINERINE TABLET DEXTROMETHORPHAN-GUAIFENESIN CAPSULE DEXTROMETHORPHAN-GUAIFENESIN LIQUID DEXTROMETHORPHAN-GUAIFENESIN TABLET DEXTROMETHORPHAN-GUAIFENESIN TABLET ER DIPHENHYDRAMINE-PHENYLEPHRINERINE LIQUID DIPHENHYDRAMINE-PHENYLEPHRINERINE SOLUTION DIPHENHYDRAMINE-PHENYLEPHRINERINE TABLET DIPHENHYDRAMINE-ZINC ACETATE CREAM DIPHENHYDRAMINE-ZINC ACETATE LIQUID DOCUSATE SODIUM ENEMA DOXYLAMINE-DM LIQUID DOXYLAMINE-PHENYLEPHRINERINE TABLET EPHEDRINE-GUAIFENESIN TABLET GUAIFENESIN TABLET ER LIDOCAINE (ANORECTAL) GEL LIDOCAINE (ANORECTAL) SUPP MENTHOL (TOPICAL ANALGESIC) GEL MENTHOL (TOPICAL ANALGESIC) LIQUID MENTHOL-METHYL SALICYLATE CREAM MENTHOL-METHYL SALICYLATE OINTMENT MENTHOL-METHYL SALICYLATE STICK OXYMETAZOLINE HCL SOLUTION PHENYLEPHRINERINE HCL SOLUTION PHENYLEPHRINERINE HCL TABLET PHENYLEPHRINERINE W/ DM-GUAIFENESIN LIQUID PHENYLEPHRINERINE W/ DM-GUAIFENESIN SYRUP PHENYLEPHRINERINE W/ DM-GUAIFENESIN TABLET PHENYLEPHRINERINE-BROMPHENIRAMINE-DM LIQUID PHENYLEPHRINERINE-CHLORPHENIRAMINE-DM LIQUID PHENYLEPHRINERINE-DM SOLUTION PHENYLEPHRINERINE-GUAIFENESIN LIQUID PHENYLEPHRINERINE-GUAIFENESIN TABLET PHENYLEPHRINERINE-IBUPROFEN TABLET PSEUDOEPHEDRINEED-BROMPHEN-DM SYRUP PSEUDOEPHEDRINEEDRINE HCL TABLET PSEUDOEPHEDRINEEDRINE W/ DM-GUAIFENESIN LIQUID PSEUDOEPHEDRINEEDRINE-DEXCHLORPHENIRAMINEIRAMINE-DEXTROMETHORPHAN LIQUID PSEUDOEPHEDRINEEDRINE-GUAIFENESIN SYRUP PSEUDOEPHEDRINEEDRINE-GUAIFENESIN TABLET PSEUDOEPHEDRINEEDRINE-GUAIFENESIN TABLET ER PSYLLIUM POWDER WHEAT DEXTRIN POWDER |
PREFERRED
PREFERRED
PREFERRED |
N/A
N/A
N/A |
OVER THE COUNTER AGENTS | HYDROCODONE POLISTIREX-CHLORPHENIRAMINE POLISTIREX 10-8/5ML SUSPENSION ALLEGRA-D 24 HOUR TABLET BENADRYL ITCH GEL 2% CLARINEX-D 2.5-120 MG TABLET CLARITIN-D 5-120MG TABLET COLACE CLEAR 50MG CAPSULE DOCUSATE MINI ENENMA 283MG ICY HOT PAD 5% ITCH ERASER SPRAY 2% KONSYL DAILY POW 100% LIDOCAINE CREAM 5% PHOS-NAK POWDER CONCENTRATE PROMETH VC 6.25-5/5 SYRUP PROMETH VC/CODEINE SYRUP ZOSTRIX HP CREAM 0.1% | NOT COVERED | GENERIC OTC COUGH AND COLD AGENTS FEXOFENADINE- PSEUDOEPHEDRINE LORATADINE- PSEUDOEPHEDRINE XYZAL DOCUSATE SODIUM ENEMA MENTHOL GEL LIDOCAINE GEL |
PROTON PUMP INHIBITORS** | OMEPRAZOLE 10MG CAPSULE OMEPRAZOLE 20MG CAPSULE OMEPRAZOLE 40MG CAPSULE PANTOPRAZOLE 20MG TABLET PANTOPRAZOLE 40MG TABLET PANTOPRAZOLE 40MG ORAL PACKET | PREFERRED | N/A |
UM EDITS – EFFECTIVE FOR ALL MEMBERS NO LATER THAN August 1, 2023 No changes in Preferred/Non-Preferred status revision or addition to UM edit only | |||
ANTIASTHMATIC AND BRONCHODILATOR AGENTS | TEZSPIRE SOL 210MG | update QL 1 pen/syringe/vial per 28 days | |
ANTIASTHMATIC AND BRONCHODILATOR AGENTS | Airsupra inhaler | add pa and ql 3 inhalers per 30 days | |
ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ArmonAir Digihaler 30 mcg
| add ql 1 inhaler per 30 days | |
ANTIASTHMATIC AND BRONCHODILATOR AGENTS | NUCALA 40MG/0.4 inj | add ql 40 mg (1 syringe) every 4 weeks | |
ANTIDEPRESSANTS | DULOXETINE 20MG capsule | update ql 6 capsules per day | |
ANTIDEPRESSANTS | DULOXETINE 30MG capsule | update ql 4 capsule per day and change from DO to QL | |
ANTIDEPRESSANTS | VENLAFAXINE ER 37.5 tablet
| update ql 6 tablet/capsule per day and change from DO to QL | |
ANTIDEPRESSANTS | VENLAFAXINE ER 75MG tablet | update QL 3 tablet/capsule per day and change from DO to QL | |
ANTIDIABETICS* | Brenzavvy 20 mg tablet | add st AND ql 1 tablet per day | |
ANTIDIABETICS | LYUMJEV TEMPO INJ 100/ML INJ HUMALOG TEMPO INJ 100/ML INJ BASAGLAR TEMPO INJ | ADD ST | |
ANTIDIABETICS | Tempo Refill Kit | 2 kits per 30 days | |
ANTIDIABETICS | Tempo Smart Button | 1 smart button every 8 months | |
ANTIFUNGALS | POSACONAZOLE DR 100MG TABLET | UPDATE QL 93 tablets per 30 | |
ANTIFUNGALS | VIVJOA 150MG CAPSULE | UPDATE QL 18 capsules (1 carton) per 4 months | |
ANTIFUNGALS | VFEND 50MG TABLET | ADD QL 6 tablets per day
| |
ANTIFUNGALS | VFEND 200MG TABLET | ADD QL 2 tablets per day
| |
ANTIFUNGALS | VFEND 40MG/ML oral SUSPENSION | ADD QL 10 mL per day | |
ANTIFUNGALS | NOXAFIL PAK 300MG | remoVe QL | |
ANTIHYPERLIPIDEMICS | Ezetimibe/atorvastatin 10mg/20mg | add st and QL 1 per day | |
ANTIHYPERLIPIDEMICS
| Ezetimibe/atorvastatin 10mg/10mg Ezetimibe/atorvastatin 10mg/40mg Ezetimibe/atorvastatin 10mg/80mg | add ql 1 per day | |
ANTIHYPERLIPIDEMICS
| ATORVALIQ 20MG/5ML suspension | add st and ql 20 ml per day | |
ANTI-INFECTIVE AGENTS - MISC. | nitrofurantoin monohydrate macrocrystals 100 mg capsule nitrofurantoin macrocrystals 25 mg, 50 mg, 100 mg capsule NITROFURANToin 25MG/5ML suspension FOSFOMYCIN 3GM powder Cleocin (clindamycin) 150 mg/mL injection Cleocin (clindamycin) 75 mg capsule Cleocin (clindamycin) 150 mg capsule Cleocin (clindamycin) 300 mg capsule | remove ql | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VIVIMUSTA 100/4ML inj | add pa | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CALQUENCE 100MG tablet CALQUENCE 100MG capsule | add ql 2 per day | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* | Adstiladrin INJ | add pa | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KRAZATI 200MG tablet | add pa and QL 6 tablets per day | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | JAYPIRCA 50MG tablet JAYPIRCA 100MG tablet | add pa and ql 50 mg: 1 tablet per day 100mg: 2 tablets per day | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LUNSUMIO 30MG/30 inj | add pa | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ORSERDU 86MG tablet ORSERDU 345MG tablet | add pa and ql 86 mg: 3 tablets per day 345 mg: 1 tablet per day | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TURALIO 125MG capsule | add ql 4 capsules per day | |
ANTIPSYCHOTICS/ANTIMANIC AGENTS* | Rykindo ER InJ | add pa and QL 2 inj per 28 days | |
ANTIPSYCHOTICS/ANTIMANIC AGENTS | Abilify Mycite 2 mg, 5 mg, 10 mg, 15 mg tablet with sensor maintenace kit | add dose op 1 tablet per day | |
ANTIPSYCHOTICS/ANTIMANIC AGENTS | Abilify Mycite 20 mg, 30 mG tablet with sensor maintenace kit | add ql 1 tablet per day | |
ANTIPSYCHOTICS/ANTIMANIC AGENTS | Abilify Mycite 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg tablets with sensor and pod starter kit | add ql 2 kits per year | |
ANTIPSYCHOTICS/ANTIMANIC AGENTS | QUETIAPINE 200MG tablet | update ql to do 3 tablets per day | |
ANTIPSYCHOTICS/ANTIMANIC AGENTS | QUETIAPINE 150MG TABLET | ADD QL 5 tablets per day | |
ANTIPSYCHOTICS/ANTIMANIC AGENTS | FLUPHENAZINe 5MG tablet | update ql to do 4 tablets per day | |
ANTIPSYCHOTICS/ANTIMANIC AGENTS | CAPLYTA 10.5MG capsule CAPLYTA 21MG CAPSULE | ADD DO 1 PER DAY | |
ANTIPSYCHOTICS/ANTIMANIC AGENTS | HALOPERIDOL 2MG/ML ORAL CONCENTRATE SOLUTION | ADD QL 30 mL per day | |
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES | Idacio 40 mg/0.8 mL prefilled pen/syringe | ADD QL 2 pens/syringes per 28 daysB | |
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES | Idacio Crohn’s Disease/Ulcerative Colitis starter pack 40 mg/0.8 mL prefilled pen Idacio Psoriasis starter pack 40 mg/0.8 mL prefilled pen | ADD QL 1 pack (28 day supply, one time fill) | |
BARBITURATE HYPNOTICS
| Phenobarbital 15 mg
| update do 4 tablets per day | |
BARBITURATE HYPNOTICS
| Phenobarbital 16.2 mg
| update do 7 tablets per day | |
BARBITURATE HYPNOTICS
| Phenobarbital 30 mg
| update do 4 tablets per day | |
BARBITURATE HYPNOTICS
| Phenobarbital 32.4 mg
| update do 7 tablets per day | |
BARBITURATE HYPNOTICS
| Phenobarbital 60 mg
| update ql 4 tablets per day | |
BARBITURATE HYPNOTICS
| Phenobarbital 64.8 mg
| update ql 4 tablets per day | |
BARBITURATE HYPNOTICS
| Phenobarbital 97.2 mg
| update ql 4 tablets per day | |
BETA BLOCKERS | KAPSPARGO 25MG capsule | update QL 16 capsules per day and change from DO to QL | |
BETA BLOCKERS | KAPSPARGO 50MG capsule | update QL 8 capsules per day and change from DO to QL | |
BETA BLOCKERS | KAPSPARGO 100MG capsule | update QL 4 capsules per day and change from DO to QL | |
BETA BLOCKERS
| Metoprolol tartrate 25 mg tablet metoprolol succinate ER 25 mg | update QL 16 tablets per day and change from DO to QL | |
BETA BLOCKERS
| Metoprolol tartrate 37.5 mg tablet
| update QL 10 TABLETS PER DAY AND CHANGE FROM DO TO QL | |
BETA BLOCKERS
| metoprolol tartrate 50 mg tablet metoprolol succinate ER 50 mg tablet | update QL 8 TABLETS PER DAY AND CHANGE FROM DO TO QL | |
BETA BLOCKERS | Metoprolol tartrate 75 mg tablet | update QL 5 TABLETS PER DAY and CHANGE FROM DO TO QL | |
BETA BLOCKERS | metoprolol succinate ER 100 mg tablet | update QL 4 tablets per day and change from DO to QL | |
CARDIOVASCULAR AGENTS - MISC. | TADLIQ 20MG/5ML oral suspension | add pa and ql 10 ml per day | |
CEPHALOSPORINS | CEFDINIR 125/5ML suspension CEFDINIR 250/5ML suspension CEFDINIR 300MG CAPSULE SUPRAX 100MG CHW SUPRAX 200MG CHW SUPRAX 400MG CAPSULE CEFIXIME 100/5ML SUSPENSION CEFIXIME 200/5ML SUSPENSION SUPRAX 500/5ML SUSPENSION | remove ql | |
COUGH/COLD/ALLERGY
| Dextromethorphan 15 mg capsules Dextromethorphan 30 mg/5 mL oral suspension Dextromethorphan 15 mg/5 mL oral solution/susp/syrup Dextromethorphan 12.5 mg/5 ml oral liquid Dextromethorphan 10 mg/5 ml oral liquid Dextromethorphan 7.5 mg/5 mL oral solution/susp/syrup Dextromethorphan 7.5 mg oral strip/chew tablet Dextromethorphan 5 mg lozenge Dextromethorphan/guaifenesin 20 mg/400 mg/5 mL Liquid Guaifenesin 200 mg Tablet Guaifenesin 400 mg Tablet Guaifenesin Er Tablet 600 mg Guaifenesin Er Tablet 1200 mg Guaifenesin 100 mg/5 mL liquid Guaifenesin 150 mg/15 mL liquid Guaifenesin 200 mg/5 mL liquid Dextromethorphan/guaifenesin syrup/solution Promethazine/Dextromethorphan Syrup Promethazine/Phenylephrine Syrup 6.25-5 mg/5 mL Pseudoephedrine Er tabLET 12 hour 120 mg Pseudoephedrine Er tabLET 24 hour 240 mg Pseudoephedrine 30 mg tablet Pseudoephedrine 60mg tablet Pseudoephedrine Oral Solution 15 mg/5 mL, 30 mg/5 mL | remove ql | |
DERMATOLOGICALS | NEXOBRID 8.8% GEL | ADD PA AND ql 440 GRAMS PER 2 DAYS | |
DERMATOLOGICALS | KLISYRI 1% OINTMENT
| UPDATE QL 5 packets per fill;1 fill per year | |
DERMATOLOGICALS
| ACITRETIN 25MG CAPSULE
| ADD QL 2 capsules per day | |
DERMATOLOGICALS
| ACITRETIN 10MG CAPSULE ACITRETIN 17.5MG CAPSULE | ADD QL 1 capsule per day | |
DIGESTIVE AIDS | SUCRAID 8500/ML oral solution
| update ql 360 mL per 30 days | |
DIGESTIVE AIDS | SUCRAID 17,000/2ML single use container
| udpate ql 360 mL per 30 days | |
ENDOCRINE AND METABOLIC AGENTS - MISC. | LAMZEDE 10MG INJ | add pa | |
FLUOROQUINOLONES | Baxdela 450 mg tablet Moxifloxacin 400 mg tablet Cipro 100 mg, 250 mg, 500 mg, 750 mg tablet Cipro 10% (500 mg/5 mL, 100 mL bottle) oral suspension Cipro 5% (250 mg/5 mL, 100 mL bottle) oral suspension Levofloxacin 250 mg, 500 mg, 750 mg tablet Levofloxacin 25 mg/mL (100 mL, 200 mL, and 480 mL bottle) oral solution Ofloxacin 300 mg, 400 mg tablet | remove QL | |
GASTROINTESTINAL AGENTS - MISC. | REBYOTA FECAL suspension | add pa and ql One 150 mL dose, one time | |
GENITOURINARY AGENTS – MISC. | FILSPARI 200MG tablet FILSPARI 400MG tablet | add pa and ql 1 tablet per day | |
HEMATOLOGICAL AGENTS - MISC. | Soliris 300 mg/30 mL vial | add qL 8 vials per 28 days | |
HEMATOLOGICAL AGENTS - MISC.* | Jesduvroq tablet
| add pa and QL 1mg, 2mg, 4mg tablet: 1 per day 6mg tablet: 2 per day 8mg tablet: 3 per day | |
HEMATOLOGICAL AGENTS - MISC. | TAKHZYRO 300/2ML INJ TAKHZYRO 150MG/ML INJ | add QL 1 syringe/vial per 28 days | |
LAXATIVES | CLENPIQ SOLution | update ql 350 mL per 30 days | |
MACROLIDES | Zithromax tablets and Z-Pak 250 mg Zithromax tablets and Tri-Pak 500 mg Azithromycin 600 mg tablets Zithromax 1g powder packets Zithromax suspension 100 mg/5 mL (15 mL bottle) Zithromax suspension 200 mg/5 mL (15 mL bottle) Zithromax suspension 200 mg/5 mL (22.5 mL bottle) Zithromax suspension 200 mg/5 mL (30 mL bottle) Clarithromycin 250 mg, 500 mg Clarithromycin granules for suspension 125 mg/5 mL, 250 mg/5 mL | remove QL | |
METABOLIC MODIFIERS* | Olpruya powder packet | add ql 1 KIT (90 DOSAGE ENVELOPES) PER 30 DAYS | |
MISCELLANEOUS THERAPEUTIC CLASSES | JOENJA 70MG tablet | add pa and ql 2 tablets per day | |
MISCELLANEOUS THERAPEUTIC CLASSES | VIJOICE 50MG tablet VIJOICE 125MG TABLET | Update QL 28 tablets per 28 days | |
MISCELLANEOUS THERAPEUTIC CLASSES | VIJOICE 250MG TABLET | ADD QL 56 TABLETS PER 28 DAYS | |
NEUROMUSCULAR AGENTS | SKYCLARYS 50MG CAPSULE | ADD Pa AND QL 3 capsules per day | |
NEUROMUSCULAR AGENTS | DAYBUE 200MG/ML SOLUTION | ADD Pa AND QL 120 mL per day (60 mL twice daily) | |
OPHTHALMIC AGENTS | SYFOVRE 15/0.1ML INJ | ADD PA | |
OPHTHALMIC AGENTS | ALPHAGAN P SOL 0.1% ALPHAGAN P SOL 0.15% BRIMONIDINE SOL 0.2% | UPDATE QL 30 mL per 30 days | |
OPHTHALMIC AGENTS | TIMOLOL MAL SOL 0.25% OP TIMOPTIC SOL 0.5% OP | UPDATE QL 20 mL per 30 days | |
OPHTHALMIC AGENTS | TRAVATAN Z DROP 0.004% | UPDATE QL 10 mL per 30 days | |
OPHTHALMIC AGENTS | VYZULTA SOL 0.024% | Update QL 5 ml per 30 days | |
OPHTHALMIC AGENTS | LATANOPROST SOL 0.005% XELPROS EMU 0.005% | Update QL 5 mL per 30 days | |
PENICILLINS
| Amoxicillin 125 mg/5 mL, 200 mg/5 mL, 250 mg/5 mL, 400 mg/5 mL suspension Amoxicillin/clavulanate potassium 1,000 mg/62.5 mg 12HR tablet | REMOVE QL | |
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | TASCENSO ODT TAB 0.5MG
| ADD QL 1 TABLET PER DAY | |
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | BRIUMVI 150/6ML INJ | ADD PA AND QL 3 VIALS EVERY 24 WEEKS | |
VAGINAL AND RELATED PRODUCTS | XACIATO GEL 2% | ADD PA 1 applicator (5 GRAMS of gel containing 100 mg clindamycin) per fill, 1 fill per 30 days | |
* This change will be implemented once the medication is on the market.
** This change will be implemented as soon as possible.
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.
NVBCBS-CD-027979-23
ATTACHMENTS: Quarterly pharmacy formulary change notice (pdf - 0.32mb)
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