MedicaidJuly 10, 2024
Quarterly pharmacy formulary change notice
The formulary changes listed 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.
Don’t forget to read the footnotes at the bottom of the tables.
What is the impact of this change?
|
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) |
|
CONTRACEPTIVES** |
OPILL 0.075MG TABLET |
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 INEJCTION MIRCERA 120MCG INEJCTION MIRCERA 150MCG INEJCTION MIRCERA 200MCG INEJCTION |
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 1 GRAM PACKETS |
ADD QL 240 PACKETS PER 30 DAYS |
|
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. |
WAINUA 45/0.8ML INJECTION |
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 once the medication is on the market.
** This change will be implemented ASAP.
What actions do I need to take?
Please work with your 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.
What if I need assistance?
We recognize the unique aspects of patients’ cases. If for medical reasons your 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 https://providers.anthem.com/ny.
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.
NYBCBS-CD-061638-24
PUBLICATIONS: August 2024 Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/new-york/articles/quarterly-pharmacy-formulary-change-notice-20832
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