Products & Programs PharmacyMedicaidMarch 26, 2024

Quarterly pharmacy formulary change notice

Summary of change

The formulary changes listed in the table below were reviewed and approved at our fourth quarter 2023, Pharmacy and Therapeutics Committee meeting.

Effective May 1, 2024, the changes outlined below apply to all members of Anthem.

Don’t forget to read the footnotes at the bottom of the tables.

Therapeutic class	Drug	Revised status	Potential alternatives
COUGH AND COLD AGENTS**	BIO-DTUSS DMX LIQUID	PREFERRED	N/A
GROWTH HORMONES	HUMATROPE 6 MG INJECTION HUMATROPE 12 MG INJECTION HUMATROPE 24MG INJECTION	NON-PREFERRED WITH PA	ZOMACTON (PA REQUIRED)
IMMUNOMODULATING AGENTS – TOPICAL**	IMIQUIMOD 3.75% CREAM	PREFERRED WITH PA	N/A
INSULIN	ADMELOG 100U/ML INJECTION ADMELOG SOLOSTAR 100U/ML INJECTION	NON-PREFERRED WITH PA CURRENT UTILIZERS WILL BE GRANDFATHERED	INSULIN LISPRO HUMALOG 50/50 HUMALOG 75/25 VIAL INSULIN ASPART 70/30 VIAL HUMULIN N, R AND MIX NOVOLIN N, R AND MIX
INSULIN**	INSULIN GLARGINE 300/ML INJ INSULIN GLARGINE SOLOSTAR 300/ML INJ (TOUJEO)	PREFERRED	N/A
LOCAL ANESTHETICS - TOPICAL	RX LIDOCAINE 4% SOLUTION	NON-PREFERRED WITH ST	OTC LIDOCAINE SOLUTION AND LIQUID
LOCAL ANESTHETICS - TOPICAL	OTC LIDOCAINE SOLUTION/LIQUID	PREFERRED	N/A
OPIOID ANTAGONISTS**	OPVEE 2.7/0.1 MG NASAL SPRAY	PREFERRED	N/A
OPIOID ANTAGONISTS**	NALMEFENE 1 MG/ML INJECTION	PREFERRED	N/A
POTASSIUM REMOVING AGENTS**	LOKELMA 5GM PAK LOKELMA 10GM PAK	PREFERRED	N/A
SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS AND COMBINATIONS**	DAPAGLIFLOZIN 5MG TABLET DAPAGLIFLOZIN 10MG TABLET DAPAGLIFLOZIN-METFORMIN 5-1000 MG TABLET DAPAGLIFLOZIN-METFORMIN 10-1000 MG TABLET	PREFERRED WITH STEP THERAPY	N/A
URINARY ANTISPASMODIC**	OXYBUTYNIN 5MG/5ML SOLUTION	PREFERRED	N/A

UM EDITS – EFFECTIVE FOR ALL MEMBERS NO LATER THAN May 1, 2024 NO CHANGES IN PREFERRED/NON-PREFERRED STATUS REVISION OR ADDITION TO UM EDIT ONLY
AMINOGLYCOSIDES	HUMATIN 250MG CAPSULE	ADD PA
ANTIASTHMATIC AND BRONCHODILATOR AGENTS	AIRSUPRA 90-80MCG INHALER	ADD ST
ANTICONVULSANTS - MISC.	MOTPOLY XR 100Mg CAPSULE MOTPOLY XR 150Mg CAPSULE MOTPOLY XR 200Mg CAPSULE	ADD PA AND ql 100 MG: 1 CAPSULE PER DAY 150 MG AND 200 mg: 2 CAPSULES PER DAY
ANTIDEPRESSANT*	Exxua 18.2 MG TABLET Exxua 36.3 MG TABLET Exxua 54.5 MG TABLET Exxua 72.6 MG TABLET	ADD ST AND QL 1 TABLET PER DAY
ANTIEMETIC*	Focinvez 150 mg/50 ml injection	ADD QL 5 VIALS PER 30 DAYS
ANTIFUNGALS - TOPICAL	ALEVAZOL 1% OINTMENT	ADD QL 60 GM PER 30 DAYS
ANTIFUNGALS - TOPICAL	MICONAZOLE 2% SOLUTION	ADD QL 30 ML PER 30 DAYS
ANTIFUNGALS - TOPICAL	LOTRIMIN AF 2% AEROSAL	ADD QL 150 GM PER 30 DAYS
ANTI-INFECTIVE AGENTS - MISC.	LIKMEZ 500/5ML SUSPENSION	ADD PA
ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS	FRUZAQLA 1MG CAPSULE FRUZAQLA 5MG CAPSULE	ADD PA AND QL 1 MG: 84 CAPSULES PER 28 DAYS 5MG: 21 CAPSULES PER 28 DAYS
ANTINEOPLASTIC - ANTIBODIES	LOQTORZI 240/6ML INJECTION	ADD PA
ANTINEOPLASTIC ENZYME INHIBITORS	TRUQAP 160MG TABLET TRUQAP 200MG TABLET	ADD PA AND QL 64 CAPSULES PER 28 DAYS
ANTINEOPLASTIC ENZYME INHIBITORS	XALKORI 20MG CAPSULE XALKORI 200MG CAPSULE XALKORI 250MG CAPSULE	ADD QL 4 CAPSULES PER DAY
ANTINEOPLASTIC ENZYME INHIBITORS	XALKORI 50MG CAPSULE	ADD QL 2 CAPSULES PER DAY
ANTINEOPLASTIC ENZYME INHIBITORS	XALKORI 150MG CAPSULE	ADD QL 3 CAPSULES PER DAY
ANTINEOPLASTIC ENZYME INHIBITORS	BOSULIF 50MG CAPSULE	ADD QL 1 CAPSULE PER DAY
ANTINEOPLASTIC ENZYME INHIBITORS	BOSULIF 100MG CAPSULE/TABLET	ADD QL 4 TABLETS/CAPSULES PER DAY
ANTINEOPLASTIC ENZYME INHIBITORS	OGSIVEO 50MG TABLET	ADD PA ADD QL 6 TABLETS PER DAY
ANTINEOPLASTIC ENZYME INHIBITORS	ROZLYTREK 50MG PAK	ADD QL 8 PACKETS PER DAY
ANTINEOPLASTIC ENZYME INHIBITORS	AUGTYRO 40MG CAPSULE	ADD PA AND QL 8 CAPSULES PER DAY
ANTINEOPLASTIC ENZYME INHIBITORS	OJJAARA 100MG TABLET OJJAARA 150MG TABLET OJJAARA 200MG TABLET	ADD PA AND QL 1 TABLET PER DAY
ANTIPSORIATICS	BIMZELX 160MG/ML INJECTION	ADD PA AND QL 1 CARTON EVERY 8 WEEKS
ANTIPSORIATICS	COSENTYX 125/5ML INJECTION	ADD QL 3 VIALS EVERY 4 WEEKS
ANTIPSORIATICS	COSENTYX UNOready 300/2ML INJECTION	ADD QL 1 PEN/SYRINGE PER 28 DAYS
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES	YUFLYMA PSORIASIS STARTER PACK 80 MG/0.8 ML + 40 MG/0.4 ML PREFILLED AUTOINJECTOR YUFLYMA PSORIASIS STARTER PACK 40 MG/0.4 ML PREFILLED AUTOINJECTOR YUFLYMA CROHN’S DISEASE, PEDIATRIC CROHN’S DISEASE, ULCERATIVE COLITIS OR HIDRADENITIS SUPPURATIVA STARTER PACK 40 MG/0.4 ML PREFILLED AUTOINJECTOR YUFLYMA CROHN’S DISEASE, ULCERATIVE COLITIS OR HIDRADENITIS SUPPURATIVA STARTER PACK 80 MG/0.8 ML PREFILLED AUTOINJECTOR YUFLYMA PEDIATRIC CROHN’S DISEASE STARTER PACK 80 MG/0.8 ML + 40 MG/0.4 ML PREFILLED AUTOINJECTOR YUFLYMA PEDIATRIC CROHN’S DISEASE STARTER PACK 80 MG/0.8 ML PREFILLED AUTOINJECTOR	ADD QL 1 PACK (28 DAY SUPPLY); ONE TIME FILL
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES	YUFLYMA 80/0.8ML INJECTION AMJEVITA 40/0.4ML INJECTION AMJEVITA 80/0.8ML INJECTION	ADD QL 2 AUTOINJECTORS/ SYRINGES PER 28 DAYS
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES	AMJEVITA 20/0.2ML INJECTION	ADD QL 2 AUTOINJECTORS PER 28 DAYS
CARDIOVASCULAR SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITORS	INPEFA 200MG TABLET INPEFA 400MG TABLET	aDD ST
CHELATING AGENTS	TRIENTINE 500 MG CAPSULE	ADD QL 4 CAPSULES PER DAY
COLONY STIMULATING FACTORS*	Ryzneuta 20 mg/mL injection	add pa and ql 2 syringes per 28 days
COMPLEMENT INHIBITORS	EMPAVELI 1080 MG INJECTION	ADD QL 10 INJECTORS PER 30 DAYS
COMPLEMENT INHIBITORS	ZILBRYSQ 16.6 MG INJECTION ZILBRYSQ 23 MG INJECTION ZILBRYSQ 32.4 MG INJECTION	ADD PA AND ql 1 SYRINGE PER DAY
DIABETIC SUPPLIES	FREESTYLE LIBRe 3 READER	ADD QL 1 READER PER YEAR
DIABETIC SUPPLIES	GUARDIAN 4 SENSOR	ADD QL 5 SENSORS PER 30 DAYS
DIABETIC SUPPLIES	GUARDIAN 4 TRANSMITTER	ADD QL 1 TRANSMITTER PER YEAR
DIGESTIVE ENZYMES	ZENPEP 60000 UNIT CAPSULE	ADD QL 25 CAPSULES PER DAY
GENITOURINARY AGENTS - MISCELLANEOUS	RIVFLOZA 80/0.5ML INJECTION RIVFLOZA 128/0.8ml INJECTION RIVFLOZA 160MG/ML INJECTION	ADD PA AND QL 80/0.5ML: 2 VIALS PER MONTH 128/0.8 ML: 1 SYRINGE PER MONTH 160MG/ML: 1 SYRINGE PER MONTH
NEUROMUSCULAR BLOCKING AGENTS	DAXXIFY 100U INJECTION	ADD DOSING LIMIT Cervical Dystonia: 125 to 250 units as a divided dose among affected muscles as frequently as every 3 months
GLUCOCORTICOSTEROIDS	AGAMREE 40MG/ML SUSPENSION	ADD PA AND QL 7.5 ML PER DAY
HEMATOLOGICAL ENZYMES - MISC	ADZYNMA 500IU kit ADZYNMA 1500IU kit	ADD PA
HEMATOPOIETIC AGENTS	APHEXDA 62MG INJECTION	ADD PA
IMMUNOMODULATING AGENTS - TOPICAL	IMIQUIMOD 3.75% CREAM	REMOVE PA (GENERIC ONLY)
INFLAMMATORY BOWEL AGENTS	ENTYVIO 108/0.68 INJECTION	ADD QL 1 SYRINGE/PEN EVERY 2 WEEKS
INFLAMMATORY BOWEL AGENTS	OMVOh 100MG/ML INJECTION OMVOH 300/15ML INJECTION	ADD PA AND ql 100MG/ML: 2 PENS PER 28 DAYS 300/15ML: ADD QL 3 VIALS FOR A ONE TIME FILL
INFLAMMATORY BOWEL AGENTS	VELSIPITY TAB 2MG	ADD PA AND ql 1 TABLET PER DAY
INSULIN	FIASP PUMPCART U-100 INJECTION	ADD QL 30ML PER 30 DAYS
INSULIN	INSULIN GLARGINE SOLOSTAR U-300	ADD QL 13.5ML PER 30 DAYS
INSULIN	INSULIN GLARGINE MAX SOLOSTAR U-300	ADD QL 12ML PER 30 DAYS
INSULIN	GLARGIN YFGN 100U/ML INJECTION	ADD QL 30ML PER 30 DAYS
INSULIN	LEVEMIR FLEXPEN	ADD QL 30ML PER 30 DAYS
INTERLEUKIN-6 RECEPTOR INHIBITORS	TOFIDENCE 80 MG, 200 MG, & 400 MG VIAL	ADD DOSING LIMIT 8 MG/KG AS FREQUENTLY AS EVERY 4 WEEKS
LOCAL ANESTHETICS - TOPICAL	LIDOCAINE/PRILOCAINE 2.5-2.5% CREAM	ADD QL 30 GRAMS PER 30 DAYS
METABOLIC MODIFIERS	XPHOZAH 10MG TABLET* XPHOZAH 20MG TABLET XPHOZAH 30MG TABLET	ADD PA AND QL 2 TABLETS PER DAY
METABOLIC MODIFIERS	MYALEPT 11.3MG INJECTION	ADD QL 1 VIAL PER DAY
METABOLIC MODIFIERS	POMBILITI 105MG SOLUTION	ADD PA AND DOSING LIMIT 20 MG/KG EVERY 2 WEEKS
METABOLIC MODIFIERS	OPFOLDA 65MG CAPSULE	ADD PA AND QL 8 CAPSULES PER 28 DAYS
MINERALOCORTICOID RECEPTOR ANTAGONISTS	KERENDIA 10MG TABLET KERENDIA 20MG TABLET	ADD ST
MISC. ANTIVIRALS	LAGEVRIO 200MG CAPSULE	ADD QL 40 CAPSULES PER FILL; 1 FILL PER 90 DAYS
OPHTHALMIC AGENTS	IYUZEH 0.005% DROPS	UPDATE QL 30 UNITS PER 30 DAYS
OPHTHALMIC AGENTS	VABYSMO 6/0.05ML INJECTION	ADD DOSING LIMIT 6 MG PER EYE; EACH EYE MAY BE TREATED EVERY 4 WEEKS FOR 6 MONTHS
PROTON PUMP INHIBITORS	OMEPRAZOLE 20MG ODT TABLET	REMOVE QL 2 TABLETS PER DAY
PROTON PUMP INHIBITORS	VOQUEZNA 10MG TABLET	ADD PA AND QL 1 TABLET PER DAY
TARGETED IMMUNE MODULATORS*	ZYMFENTRA 120 MG/ML PREFILLED SYRINGE/PEN	ADD PA AND QL 1 SYRINGE/PEN EVERY 2 WEEKS
TARGETED IMMUNE MODULATORS*	WEZLANA 45 MG/0.5 ML VIAL/SINGLE-USE PREFILLED SYRINGE	ADD QL 1 VIAL/SYRINGE PER 84 DAYS
TARGETED IMMUNE MODULATORS*	WEZLANA 90 MG/1 ML SINGLE-USE PREFILLED SYRINGE	ADD QL 1 SYRINGE EVERY 84 DAYS
TARGETED IMMUNE MODULATORS*	WEZLANA 130 MG/26 ML (5 MG/ML) VIAL	ADD DOSING LIMIT BODY WEIGHT 55 KG OR LESS: 2 VIALS (8 WEEK SUPPLY, ONE TIME FILL) BODY WEIGHT MORE THAN 55KG TO 85 KG: 3 VIALS (8 WEEK SUPPLY, ONE TIME FILL) BODY WEIGHT MORE THAN 85 KG [MAX LIMIT]: 4 VIALS (8 WEEK SUPPLY, ONE TIME FILL)
THROMBOCYTOPENIA*	ALVAIZ 9MG TABLET ALVAIZ 18MG TABLET ALVAIZ 38MG TABLET ALVAIZ 54MG TABLET	ADD PA AND QL 9 MG AND 18 MG: 1 TABLET PER DAY 38 MG AND 54 MG: 1 TABLET PER DAY
VAGINAL ESTROGENS	ESTRING 2MG mis ESTRING 7.5/24HR mis	ADD QL 1 RING EVERY 90 DAYS

Please work with your Anthem patients to transition to formulary alternatives. If you determine preferred formulary alternatives are not clinically appropriate for specific patients, you must obtain prior authorization to continue coverage beyond the applicable effective dates.

We recognize the unique aspects of patients’ cases. If for medical reasons your Anthem patient cannot be converted to a formulary alternative, call Provider Services at 800-450-8753 and follow the voice prompts for pharmacy prior authorization. You can find the Preferred Drug List on our provider website at providers.anthem.com/new-york-provider/home.

If you need assistance with any other item, contact your local provider relationship management representative or call Provider Services at 800-450-8753.

Medicaid services provided by Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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PUBLICATIONS: May 2024 Provider Newsletter

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Provider News New York

Quarterly pharmacy formulary change notice

Summary of change

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