MedicaidSeptember 14, 2023
Quarterly pharmacy formulary changes effective November 1, 2023
The formulary changes listed in the table below were reviewed and approved at our second quarter 2023 Pharmacy and Therapeutics Committee meeting.
Effective November 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 patients on November 1, 2023 | |||
Therapeutic class | Drug | Revised status | Potential alternatives |
ANTIHISTAMINES** | CETIRIZINE 5MG CHEWABLE CETIRIZINE 10MG CHEWABLE CETIRIZINE HCL 10 MG CAPSULE CETIRIZINE 10MG TABLET CETIRIZINE 1MG/ML SOLUTION/SYRUP CETIRIZINE-PSEUDOEPHEDRINE 5-120MG TABLET | PREFERRED | N/A |
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES** | HADLIMA 40/0.4ML INJECTION HADLIMA 40/0.8ML INJECTION | PREFERRED WITH PA | N/A |
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES** | AMJEVITA 10MG SYRINGE | PREFERRED WITH PA | N/A |
HEMATOPOIETIC AGENTS** | UDENYCA 6MG/0.6 AUTOINJECTOR | PREFERRED WITH PA | N/A |
PRENATAL
| VITA-PAC CAPSULE | NOT COVERED | NESTAB TABLETS RX OTC PRENATALS |
SELECTIVE SEROTONIN REUPTAKE INHIBITORS | PAROXETINE 10MG/5ML | PREFERRED | N/A |
UM edits – Effective for all members no later than November 1, 2023 No changes in preferred/non-preferred status revision or addition to UM edit only. | |||
ALS AGENTS | QALSODY 100 MG/15 ML VIAL INTRATHECAL SOLUTION | ADD PA AND QL 1 VIAL EVERY 4 WEEKS | |
ANALGESICS - ANTI-INFLAMMATORY* | COMBOGESIC (ACETAMINOPHEN 325 MG- IBUPROFEN 97.5MG) TABLET | ADD ST AND QL 12 TABLETS PER DAY | |
ANALGESICS - ANTI-INFLAMMATORY | ADVIL DUAL ACTION (IBUPROFEN 125 MG /ACETAMINOPHEN 250 MG) TABLET | ADD QL 6 TABLETS PER DAY | |
ANALGESICS - ANTI-INFLAMMATORY | MELOXICAM 7.5MG/5ML ORAL SUSPENSION | ADD QL 10 ML PER DAY | |
ANTIANXIETY AGENTS | BUSPIRONE 5 MG, 7.5 MG, 10 MG, 15 MG TABLET | REMOVE QL 3 TABLETS PER DAY | |
ANTIANXIETY AGENTS | BUSPIRONE 30 MG TABLET | REMOVE QL 2 TABLETS PER DAY | |
ANTIANXIETY AGENTS | HYDROXYZINE HYDROCHLORIDE 10 MG, 25 MG TABLET | REMOVE QL 4 PER DAY | |
ANTIANXIETY AGENTS | HYDROXYZINE HYDROCHLORIDE 50 MG TABLET | REMOVE QL 8 TABLETS PER DAY | |
ANTIANXIETY AGENTS | HYDROXYZINE HYDROCHLORIDE 10 MG/5 ML SYRUP/SOLUTION | REMOVE QL 100 ML PER DAY | |
ANTIANXIETY AGENTS | MEPROBAMATE 200 MG AND 400 MG TABLET | REMOVE QL 4 TABLETS PER DAY | |
ANTI-CATAPLECTIC AGENTS |
LUMRYZ PKG 4.5GM, 6 GM, 7.5 GM AND 9 GM
| ADD PA AND QL LUMRYZ 4.5 G, 6 G, 7.5 G, 9 G (CARTON OF 7 PACKETS)- 4 CARTONS PER 28 DAYS | |
ANTIDEPRESSANTS | MIRTAZAPINE 7.5 MG, 15 MG MIRTAZAPINE 30 MG, 45 MG TABLET | REMOVE QL/DOSE OP 1 TABLET PER DAY | |
ANTIDEPRESSANTS | CITALOPRAM 30 MG CAPSULE | REMOVE QL/DOSE OP 1 CAPSULE PER DAY | |
ANTIDEPRESSANTS | CELEXA (CITALOPRAM) 10 MG, 20 MG TABLET | REMOVE QL/DOSE OP 1.5 TABLETS PER DAY | |
ANTIDEPRESSANTS | CITALOPRAM 10 MG/5 ML SOLUTION | REMOVE QL 20 ML PER DAY | |
ANTIDEPRESSANTS | FLUOXETINE (PROZAC) 40 MG CAPSULE | REMOVE QL 2 CAPSULES PER DAY | |
ANTIDEPRESSANTS | FLUOXETINE (PROZAC, SARAFEM) 20 MG TABLET/CAPSULE | REMOVE QL 4 TABLETS OR CAPSULES PER DAY | |
ANTIDEPRESSANTS | FLUOXETINE 20 MG/5 ML SOLUTION | REMOVE QL 20 ML PER DAY | |
ANTIDEPRESSANTS | FLUOXETINE WEEKLY DELAYED-RELEASE 90 MG CAPSULE | REMOVE QL 4 CAPSULES PER 28 DAYS | |
ANTIDEPRESSANTS | FLUVOXAMINE 100 MG TABLET | REMOVE QL 3 TABLETS PER DAY | |
ANTIDEPRESSANTS | PAROXETINE HYDROCHLORIDE/MESYLATE (PAXIL/PEXEVA) 30 MG TABLET | REMOVE QL 2 TABLETS PER DAY | |
ANTIDEPRESSANTS | PAXIL (PAROXETINE HYDROCHLORIDE) 10 MG/5 ML SUSPENSION | REMOVE QL 30 ML PER DAY | |
ANTIDEPRESSANTS | ZOLOFT (SERTRALINE) 20 MG/ ML SOLUTION | REMOVE QL 10 ML PER DAY | |
ANTIHYPERTENSIVES | GUANFACINE 1 MG AND 2 MG TABLET | REMOVE QL/ DOSE OP 1 TABLET PER DAY | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KISQALI (RIBOCICLIB) 200 MG TABLET | UPDATE QL 21 TABLETS PER 28 DAYS | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KISQALI (RIBOCICLIB) 400 MG TABLET | ADD QL 42 TABLETS PER 28 DAYS | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KISQALI (RIBOCICLIB) 600 MG TABLET | ADD QL 63 TABLETS PER 28 DAYS | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KISQALI FEMARA CO-PACK (RIBOCICLIB/LETROZOLE) 600 MG/2.5 MG TABLET | UPDATE QL 91 TABLETS PER 28 DAYS | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KISQALI FEMARA CO-PACK (RIBOCICLIB/LETROZOLE) 400 MG/2.5 MG TABLET | UPDATE QL 70 TABLETS PER 28 DAYS | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KISQALI FEMARA CO-PACK (RIBOCICLIB/LETROZOLE) 200 MG/2.5 MG TABLET | UPDATE QL 49 TABLETS PER 28 DAYS | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VERZENIO (ABEMACICLIB) 50 MG, 100 MG, 150 MG, 200 MG TABLET | UPDATE 56 TABLETS PER 28 DAYS | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MEKINIST (TRAMETINIB) 4.7 MG SOLUTION/BOTTLE | ADD QL 40 ML PER DAY | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ERLEADA (APALUTAMIDE) 240 MG TABLET | ADD QL 1 TABLET PER DAY | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TAFINLAR (DABRAFENIB) 10 MG TABLETS FOR ORAL SUSPENSION | ADD QL 15 TABLETS PER DAY | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ZYNYZ 500 MG/ 20 ML VIAL | ADD PA AND QL 500 MG EVERY 28 DAYS | |
BETA BLOCKERS | ACEBUTOLOL 200 MG CAPSULE | REMOVE QL 6 CAPSULES PER DAY | |
BETA BLOCKERS | ACEBUTOLOL 400 MG | REMOVE QL 3 CAPSULES PER DAY | |
BETA BLOCKERS | TENORMIN (ATENOLOL) 25 MG, 50 MG, 100 MG TABLET | REMOVE QL/DOSE OP 2 TABLETS PER DAY | |
BETA BLOCKERS | BETAXOLOL 10 MG TABLET | REMOVE DOSE OP 1 TABLET PER DAY | |
BETA BLOCKERS | TOPROL XL (METOPROLOL SUCCINATE ER) 25 MG | REMOVE QL 16 TABLETS PER DAY | |
BETA BLOCKERS | TOPROL XL (METOPROLOL SUCCINATE ER) 50 MG | REMOVE QL 8 TABLETS PER DAY | |
BETA BLOCKERS | TOPROL XL (METOPROLOL SUCCINATE ER) 100 MG | REMOVE QL 4 TABLETS PER DAY | |
BETA BLOCKERS | KAPSPARGO SPRINKLE (METOPROLOL SUCCINATE ER) 25 MG CAPSULE | REMOVE QL 16 CAPSULE PER DAY | |
BETA BLOCKERS | KAPSPARGO SPRINKLE (METOPROLOL SUCCINATE ER) 50 MG CAPSULE | REMOVE QL 8 CAPSULES PER DAY | |
BETA BLOCKERS | KAPSPARGO SPRINKLE (METOPROLOL SUCCINATE ER) 100 MG CAPSULE | REMOVE QL 4 CAPSULES PER DAY | |
BETA BLOCKERS | KAPSPARGO SPRINKLE (METOPROLOL SUCCINATE ER) 200 MG CAPSULE | REMOVE QL 2 CAPSULES PER DAY | |
BETA BLOCKERS | METOPROLOL TARTRATE 37.5 MG TABLET | REMOVE QL 10 TABLETS PER DAY | |
BETA BLOCKERS | METOPROLOL TARTRATE 75 MG TABLET | REMOVE 5 TABLETS PER DAY | |
DIURETICS | ALDACTONE (SPIRONOLACTONE) 25 MG, 50 MG TABLET | REMOVE QL 2 TABLETS PER DAY | |
DIURETICS | ALDACTONE (SPIRONOLACTONE) 100 MG | REMOVE QL 4 TABLETS PER DAY | |
DIURETICS | ALDACTAZIDE (SPIRONOLACTONE/HYDROCHLOROTHIAZIDE) 25 MG/25 MG | UPDATE DOSE OP TO QL 2 8 TABLETS PER DAY | |
DIURETICS | CAROSPIR (SPIRONOLACTONE ORAL SUSPENSION) 25 MG/5 ML | REMOVE QL 20 ML PER DAY | |
ENDOCRINE AND METABOLIC AGENTS - MISC. | SOGROYA (SOMAPACITAN-BECO) 15 MG/1.5 ML PREFILLED PEN | ADD QL 4 PENS PER 28 DAYS | |
GASTROINTESTINAL AGENTS - MISC. | VOWST (FECAL MICROBIOTA SPORES, LIVE - BRPK) | ADD PA AND QL 12 CAPSULES PER FILL: ONE TIME ONLY | |
HEMATOPOIETIC AGENTS | UDENCYA (PEGFILGRASTIM-CBQV) 6 MG/0.6 ML PREFILLED SYRINGE OR AUTOINJECTOR | ADD QL 2 SYRINGES OR AUTOINJECTORS PER 28 DAYS | |
MIGRAINE PRODUCTS* | RIZAFILM (RIZATRIPTAN) 10 MG ORAL FILM | ADD QL 6 FILMS PER 30 DAYS | |
MIGRAINE PRODUCTS | ELYXYB (CELECOXIB ORAL SOLUTION) 120 MG/4.8 ML (25 MG/ML) | ADD QL 9 BOTTLES (43.2 ML) PER 30 DAYS | |
MIGRAINE PRODUCTS | ZAVZPRET (ZAVEGEPANT) 10 MG NASAL SPRAY | ADD ST AND QL 1 SPRAY PER DAY: 8 SPRAYS (DEVICES) PER 30 DAYS | |
RESPIRATORY AGENTS - MISC. | KALYDECO (IVACAFTOR) 5.8 MG* AND 13.4 MG | ADD QL 2 PACKETS PER DAY | |
RESPIRATORY AGENTS - MISC. | TRIKAFTA (ELEXACAFTOR/TEZACAFTOR/IVACAFTOR 80 MG/40 MG/60 MG AND IVACAFTOR 59.5 MG) GRANULES AND TRIKAFTA (ELEXACAFTOR/TEZACAFTOR/IVACAFTOR 100 MG/50 MG/75 MG AND IVACAFTOR 75 MG) GRANULES | ADD QL 1 CARTON (56 PACKETS) PER 28 DAYS | |
URINARY ANTISPASMODICS | OXYBUTYNIN 2.5 MG TABLETS | ADD 3 TABLETS PER DAY | |
URINARY ANTISPASMODICS | OXYBUTYNIN 5 MG/5 ML SOLUTION | ADD 20 ML PER DAY | |
* 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, call Provider Relationship Management at 844-396-2330.
NVBCBS-CD-037127-23
PUBLICATIONS: October 2023 Provider Newsletter
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