Products & Programs PharmacyMedicaidJanuary 28, 2025

Quarterly pharmacy formulary change notice

Summary of change

The formulary changes in the table below were reviewed and approved at our Pharmacy and Therapeutics Committee meeting for the third quarter of 2024.

What this means to you

Effective February 1, 2025, the changes below apply to all members of the health plan. Don’t forget to read the footnotes at the bottom of the table.

Therapeutic class	Drug	Revised status	Potential alternatives
INSULIN	INSULIN GLARGINE 100 U/ML VIAL/ PEN INSULIN GLARGINE - YFGN 100U/ML VIAL /PEN GLARGINE - YFGN 100 U/ML VIAL/PEN	PREFERRED	N/A
INSULIN	BASAGLAR KWIKPEN	NON- PREFERRED	INSULIN GLARGINE 100U /ML VIAL/ PEN INSULIN GLARGINE -YFGN 100 U/ML VIAL /PEN GLARGINE-YFGN 100 U/ML VIAL/ PEN LANTUS/ LANTUS SOLOSTAR
INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)	TRULICITY 0.75 MG/ 0.5ML TRULICITY 1.5 MG/ 0.5ML TRULICITY 3 MG/ 0.5ML TRULICITY 4.5 MG /0.5ML	NON-PREFERRED	OZEMPIC INJECTION LIRAGLUTIDE INJECTION (PA REQUIRED)
STIMULANTS - MISC.	ARMODAFINIL 50MG TABLET ARMODAFINIL 150MG TABLET ARMODAFINIL 200MG TABLET ARMODAFINIL 250MG TABLET MODAFINIL 100MG TABLET MODAFINIL 200MG TABLET	PREFERRED WITH PA	N/A
UM edits — effective for all members no later than February 1, 2025 No changes in preferred/nonpreferred status revision or addition to UM edit only
ANALGESICS - OPIOID	OXYCODONE /APAP 5/325 MG/5 ML SOLUTION	UPDATE QL: 60 ML PER DAY
ANALGESICS - OPIOID	APAP/ CODEINE 120MG -12 MG/5ML SUSPENSION OR ELIXIR	UPDATE QL: 90 ML PER DAY
ANTIASTHMATIC AND BRONCHODILATOR AGENTS	OHTUVAYRE 3 MG/2.5 ML AMPULE	ADD PA AND QL: 1 CARTON (60 AMPULES) PER 30 DAYS
ANTICONVULSANTS	XCOPRI 25MG TABLET	ADD QL: 1 TABLET PER DAY
ANTICONVULSANTS	VIGADRONE 500MG TABLET	ADD QL: 6 TABLETS PER DAY
ANTICONVULSANTS	VIGAFYDE 100 MG/ML ORAL SOLUTION	ADD PA AND QL: 750 ML PER 30 DAYS
ANTICONVULSANTS	VIGADRONE 500MG POWDER PACKET	ADD QL: 6 PACKETS PER DAY
ANTICONVULSANTS	XCOPRI 12.5MG TABLET	ADD QL: 1 TABLET PER DAY
ANTIDEMENTIA AGENTS	ZUNVEYL (BENZGALANTAMINE) 5 MG TABLET ZUNVEYL (BENZGALANTAMINE) 10 MG TABLET ZUNVEYL (BENZGALANTAMINE) 15 MG TABLET	ADD QL: 2 TABLETS PER DAY
ANTIDIABETICS	ZITUVIMET XR 50-500MG TABLET ZITUVIMET XR 50-1000MG TABLET	ADD QL: 2 TABLETS PER DAY
ANTIDIABETICS	ZITUVIMET XR 100-1000MG TABLET	ADD QL: 1 TABLET PER DAY
ANTIDOTES AND SPECIFIC ANTAGONISTS	NALOXONE 0.4MG/ML INJECTION NALOXONE HCL 1MG/ML INJECTION NALOXONE INJECTION 2 MG/2 ML PREFILLED SYRINGE NALOXONE INJECTION 4 MG/10 ML VIAL	ADD QL: 6 CARPUJECTS / PREFILLED SYRINGES / VIALS PER 3 MONTHS
ANTIDOTES AND SPECIFIC ANTAGONISTS	ZURNAI (NALMEFENE)1.5 MG/0.5 ML INJECTION	ADD QL: 6 AUTOINJECTORS PER 3 MONTHS
ANTIDOTES AND SPECIFIC ANTAGONISTS	RIVIVE 3MG/0.1ML NASAL SPRAY REXTOVY 4 MG/0.25 ML NASAL SPRAY REZENOPY 10 MG/0.11 ML NASAL SPRAY	ADD QL: 6 NASAL SPRAYS (3 CARTONS) PER 3 MONTHS
ANTIHYPERTENSIVES	BENAZEPRIL 5MG TABLET BENAZEPRIL 10MG TABLET BENAZEPRIL 20MG TABLET ENALAPRIL 2.5MG TABLET ENALAPRIL 5MG TABLET ENALAPRIL 10MG TABLET ENALAPRIL / HYDROCHLORO THIAZIDE 5 MG/12.5 MG TABLET FOSINOPRIL 10 MG TABLET FOSINOPRIL 20 MG TABLET LISINOPRIL 2.5MG TABLET LISINOPRIL 5MG TABLET LISINOPRIL 10MG TABLET LISINOPRIL 20MG TABLET MOEXIPRIL 7.5MG TABLET QUINAPRIL 5MG TABLET QUINAPRIL 10MG TABLET QUINAPRIL 20MG TABLET	UPDATE QL: 4 TABLETS PER DAY
ANTIHYPERTENSIVES	CAPTOPRIL 12.5MG TABLET CAPTOPRIL 25MG TABLET CAPTOPRIL 50MG TABLET	UPDATE QL: 6 TABLETS PER DAY
ANTIHYPERTENSIVES	RAMIPRIL 1.25MG CAPSULE RAMIPRIL 2.5MG CAPSULE RAMIPRIL 5MG CAPSULE	UPDATE QL: 4 CAPSULES PER DAY
ANTIHYPERTENSIVES	CATAPRES -TTS-1 (CLONIDINE) 0.1 MG TRANSDERMAL PATCH CATAPRES -TTS-2 (CLONIDINE) 0.2 MG TRANSDERMAL PATCH	UPDATE QL: 12 PATCHES PER 28 DAYS
ANTIHYPERTENSIVES	CLONIDINE 0.1MG TABLET CLONIDINE 0.2MG TABLET	UPDATE QL: 6 TABLETS PER DAY
ANTIHYPERTENSIVES	GUANFACINE 1MG TABLET	UPDATE QL: 2 TABLETS PER DAY
ANTIHYPERTENSIVES	METHYLDOPA 250MG TABLET	UPDATE QL: 6 TABLETS PER DAY
ANTIHYPERTENSIVES	AMLODIPINE /BENAZEPRIL 2.5-10MG CAPSULE AMLODIPINE /BENAZEPRIL 5-10MG CAPSULE AMLODIPINE /BENAZEPRIL 5-20MG CAPSULE	UPDATE QL: 2 CAPSULES PER DAY
ANTIHYPERTENSIVES	LOTENSIN HCT (BENAZEPRIL / HYDROCHLORO THIAZIDE) 5 MG/ 6.25 MG TABLET LOTENSIN HCT (BENAZEPRIL / HYDROCHLORO THIAZIDE) 10 MG/12.5 MG TABLET ZESTORETIC (LISINOPRIL / HYDROCHLORO THIAZIDE) 10 MG/12.5 MG TABLET AZOR (AMLODIPINE / OLMESARTAN) 5 MG/20 MG TABLET EXFORGE (AMLODIPINE / VALSARTAN) 5 MG/160 MG TABLET HYZAAR (LOSARTAN / HYDROCHLORO THIAZIDE) 50 MG/12.5 MG TABLET BENICAR HCT (OLMESARTAN / HYDROCHLORO THIAZIDE) 20 MG/12.5 MG TABLET MICARDIS HCT (TELMISARTAN / HYDROCHLORO THIAZIDE) 40 MG /12.5 MG TABLET DIOVAN HCT (VALSARTAN / HYDROCHLORO THIAZIDE) 80 MG/12.5 MG, 160 MG /12.5 MG TABLET DIOVAN HCT (VALSARTAN / HYDROCHLORO THIAZIDE) 80 MG/12.5 MG, 160 MG/12.5 MG TABLET EXFORGE HCT (AMLODIPINE /VALSARTAN /HCTZ) 5 MG/160 MG/12.5 MG TABLET TRIBENZOR (AMLODIPINE /OLMESARTAN/ HCTZ) 5 MG/20 MG/12.5 MG TABLET TWYNSTA (AMLODIPINE/ TELMISARTAN) 5 MG/40 MG TABLET	UPDATE QL: 2 TABLETS PER DAY
ANTIHYPERLIPIDEMICS	EZETIMIBE 10MG TABLET	REMOVE STEP THERAPY
ANTIMYASTHENIC / CHOLINERGIC AGENTS	FIRDAPSE 10MG TABLET	UPDATE QL: 10 TABLETS PER DAY
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	AKEEGA 50/500MG TABLET AKEEGA 100/500 TABLET	UPDATE QL: 2 TABLETS PER DAY
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	TAFINLAR 10 MG TABLETS FOR ORAL SUSPENSION	UPDATE QL: 30 TABLETS PER DAY
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	PEMAZYRE 4.5MG TABLET PEMAZYRE 9MG TABLET	UPDATE QL: 1 TABLET PER DAY
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	RYTELO 47MG VIAL RYTELO 188MG VIAL	ADD PA AND DOSING: 7.1 MG/KG PER 4 WEEKS
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	LAZCLUZE 80MG TABLET LAZCLUZE 240MG TABLET	ADD PA AND QL: 80 MG: 2 TABLETS PER DAY 240 MG: 1 TABLET PER DAY
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	VORANIGO 10MG TABLET VORANIGO 40MG TABLET	ADD PA AND QL: 10MG: 2 TABLETS PER DAY 40 MG: 1 TABLET PER DAY
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	TECELRA INJECTION	ADD PA
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	LYMPHIR INJECTION	ADD PA
ANTIPSORIATICS	TALTZ 20MG/0.5ML SYRINGE TALTZ 40MG/0.5ML SYRINGE	ADD QL: 1 SYRINGE PER 28 DAYS
ANTIPSYCHOTICS/ ANTIMANIC AGENTS	ERZOFRI 39 MG ER INJECTION ERZOFRI 78 MG ER INJECTION ERZOFRI 117 MG ER INJECTION ERZOFRI 156 MG ER INJECTION ERZOFRI 234 MG ER INJECTION	ADD PA AND QL: 1 KIT EVERY 30 DAYS
ANTIPSYCHOTICS / ANTIMANIC AGENTS	ERZOFRI 351 MG ER INJECTION	ADD PA AND QL: 1 KIT, ONE TIME FILL
ANTI- TNF -ALPHA - MONOCLONAL ANTIBODIES	SIMLANDI 40MG /0.4ML SYRINGE SIMLANDI 40/0.4ML 1 PEN KIT	ADD QL: 2 AUTOINJECTORS / SYRINGES PER 28 DAYS
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES	SIMLANDI 20MG/0.2ML SYRINGE	ADD QL: 2 SYRINGES PER 28 DAYS
ANTIVIRALS	EDURANT PED 2.5 MG TABLET FOR ORAL SUSPENSION	ADD QL: 6 TABLETS PER DAY
ATTENTION -DEFICIT / HYPERACTIVITY DISORDER (ADHD) AGENTS	ONYDA XR 0.1MG/ML SUSPENSION	ADD PA AND REMOVE QL: 4 ML PER DAY
ATTENTION -DEFICIT / HYPERACTIVITY DISORDER (ADHD) AGENTS	KAPVAY 0.1 MG TABLET	REMOVE QL: 4 TABLETS PER DAY
ATTENTION -DEFICIT / HYPERACTIVITY DISORDER (ADHD) AGENTS	INTUNIV 1MG TABLET INTUNIV 2MG TABLET INTUNIV 3MG TABLET INTUNIV 4MG TABLET	REMOVE QL: 1 TABLET PER DAY
ATTENTION- DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS	STRATTERA (ATOMOXETINE) 10MG CAPSULE STRATTERA (ATOMOXETINE) 18MG CAPSULE STRATTERA (ATOMOXETINE) 25MG CAPSULE STRATTERA (ATOMOXETINE) 40MG CAPSULE	REMOVE DOSE OP: 2 CAPSULES PER DAY
ATTENTION -DEFICIT / HYPERACTIVITY DISORDER (ADHD) AGENTS	STRATTERA (ATOMOXETINE) 60MG CAPSULE STRATTERA (ATOMOXETINE) 80MG CAPSULE STRATTERA (ATOMOXETINE) 100MG CAPSULE	REMOVE DOSE OP: 1 CAPSULE PER DAY
ATTENTION -DEFICIT / HYPERACTIVITY DISORDER (ADHD) AGENTS	QELBREE (VILOXAZINE) 100MG CAPSULE	REMOVE DOSE OP: 1 CAPSULE PER DAY
ATTENTION -DEFICIT / HYPERACTIVITY DISORDER (ADHD) AGENTS	QELBREE (VILOXAZINE) 150MG CAPSULE	REMOVE DOSE OP: 2 CAPSULES PER DAY
ATTENTION -DEFICIT / HYPERACTIVITY DISORDER (ADHD) AGENTS	QELBREE (VILOXAZINE) 200MG CAPSULE	REMOVE DOSE OP: 3 CAPSULES PER DAY
BENIGN PROSTATIC HYPERPLASIA AGENTS	TEZRULY (TERAZOSIN) 1 MG/ML ORAL SOLUTION	ADD PA AND QL: 20 ML PER DAY
BENIGN PROSTATIC HYPERTROPHY AGENTS	CHEWTADZY 5MG CHEWABLE TABLET	NEW PA AND QL: 1 TABLET PER DAY
BETA BLOCKERS	NADOLOL 20MG TABLET NADOLOL 40MG TABLET	UPDATE QL: 4 TABLETS PER DAY
BETA BLOCKERS	PROPRANOLOL 10 MG TABLET PROPRANOLOL 20 MG TABLET PROPRANOLOL 40 MG TABLET PROPRANOLOL 60 MG TABLET	UPDATE QL: 8 TABLETS PER DAY
BETA BLOCKERS	COREG CR (CARVEDILOL ER) 10 MG CAPSULE COREG CR (CARVEDILOL ER) 20 MG CAPSULE INDERAL LA (PROPRANOLOL ER) 60 MG CAPSULE INDERAL LA (PROPRANOLOL ER) 80 MG CAPSULE INDERAL LA (PROPRANOLOL ER) 120 MG CAPSULE	UPDATE QL: 4 CAPSULES PER DAY
BETA BLOCKERS	COREG (CARVEDILOL) 3.125 MG TABLET COREG (CARVEDILOL) 6.25 MG TABLET COREG (CARVEDILOL) 12.5 MG TABLET	UPDATE QL: 4 TABLETS PER DAY
BETA BLOCKERS	COREG CR (CARVEDILOL ER) 40 MG CAPSULE	UPDATE QL: 2 CAPSULES PER DAY
BETA BLOCKERS	LABETALOL 100 MG TABLET LABETALOL 200 MG TABLET	UPDATE QL: 12 TABLETS PER DAY
BONE DENSITY REGULATORS	JUBBONTI 60 MG/ML INJECTION	ADD PA AND QL: 60 MG (1 PREFILLED SYRINGE) EVERY 6 MONTHS
BONE DENSITY REGULATORS	WYOST 120 MG/1.7 ML VIAL	ADD PA AND QL: 1 VIAL PER 28 DAYS
CARDIOVASCULAR AGENTS MISC. - COMBINATIONS	OPSYNVI TABLET	ADD PA
CONTINUOUS GLUCOSE SYSTEM SUPPLIES	FREESTYLE LIBRE 3 SENSOR PLUS	ADD QL: 2 SENSORS PER 30 DAYS
CONTRACEPTIVES	ENILLORING VAGINAL RING	ADD QL: 1 RING PER 28 DAYS
COUGH /COLD /ALLERGY	HYCODAN 5MG-1.5MG TABLET	ADD QL: 30 TABLETS PER 5 DAYS; 2 FILLS PER 30 DAYS
COUGH /COLD/ ALLERGY	HYCODAN 5MG-1.5MG/5ML SYRUP /SOLUTION	ADD QL: 150 ML PER 5 DAYS; 2 FILLS PER 30 DAYS
COUGH/ COLD/ ALLERGY	TUZISTRA XR SUSPENSION	ADD QL: 100 ML PER 5 DAYS; 2 FILLS PER 30 DAYS
COUGH /COLD/ ALLERGY	TUXARIN ER 54.3 MG- 8MG TABLET	ADD QL: 10 TABLETS PER 5 DAYS; 2 FILLS PER 30 DAYS
COUGH/ COLD/ ALLERGY	PROMETHAZINE / CODEINE SYRUP	UPDATE QL: 150 ML PER 5 DAYS; 2 FILLS PER 30 DAYS
COUGH /COLD/ ALLERGY	HYDROCODONE POLISTIREX / CHLORPHENIRAMINE POLISTIREX 10MG -8MG /5ML SUSPENSION	UPDATE QL:50 ML PER 5 DAYS; 2 FILLS PER 30 DAYS
COUGH/ COLD/ ALLERGY	PROMETHAZINE AND PHENYLEPHRINE WITH CODEINE SYRUP	UPDATE QL: 150 ML PER 5 DAYS; 2 FILLS PER 30 DAYS
COUGH /COLD/ ALLERGY	M-END PE LIQUID RYDEX LIQUID	ADD QL: 450 ML PER 5 DAYS; 2 FILLS PER 30 DAYS
COUGH /COLD /ALLERGY	POLY-TUSSIN AC LIQUID CAPCOF 5-2-10MG SYRUP MAR-COF BP (P SEUDO EPHEDRINE -BROMPH ENIRAMINE -CODEINE ) LIQUID	ADD QL: 300 ML PER 5 DAYS; 2 FILLS PER 30 DAYS
COUGH/ COLD/ ALLERGY	MAXI- TUSS CD LIQUID	ADD QL: 150 ML PER 5 DAYS; 2 FILLS PER 30 DAYS
COUGH/ COLD/ ALLERGY	HISTEX-AC SYPRUP	ADD QL: 100 ML PER 5 DAYS; 2 FILLS PER 30 DAYS
COUGH /COLD/ ALLERGY	GUAIFENESIN -CODEINE SOLUTION	UPDATE QL:300 ML PER 5 DAYS; 2 FILLS PER 30 DAYS
COUGH/ COLD/ ALLERGY	TUSNEL C (PSEUDO EPHEDRINE -GUAIFENESIN WITH CODEINE) SYRUP TRIACIN C (PSEUDO EPHEDRINE -TRIPOLIDINE-CODEINE) SYRUP	ADD QL: 200 ML PER 5 DAYS; 2 FILLS PER 30 DAYS
DERMATOLOGICALS	ZORYVE (ROFLUMILAST) 0.15% CREAM	ADD PA AND QL: 60 GM PER 30 DAYS
DERMATOLOGICALS	ADBRY 300MG/2ML INJECTION	ADD QL: 1 AUTOINJECTOR PER 28 DAYS
DERMATOLOGICALS	TREMFYA 200MG/20ML INJECTION	ADD QL: 3 VIALS TOTAL TO LAST 12 WEEKS
DERMATOLOGICALS	TREMFYA 100MG/ML PEN/SYRINGE	UPDATE QL: 1 PEN/SYRINGE PER 56 DAYS (8 WEEKS)
DERMATOLOGICALS	TREMFYA 200MG/2ML PEN/SYRINGE	ADD QL: 1 PEN/SYRINGE PER 28 DAYS(4 WEEKS)
DERMATOLOGICALS	EBGLYSS 250 MG/2ML INJECTION	ADD PA AND QL: 1 PEN/ SYRINGE PER 28 DAYS
DERMATOLOGICALS	NEMLUVIO 30 MG INJECTION	ADD PA AND QL: 1 PEN PER 28 DAYS
DERMATOLOGICALS	QBREXZA 2.4% PAD	ADD PA
DERMATOLOGICALS	SOFDRA 12.45% GEL	ADD QL: 1 BOTTLE (40.2 ML) PER 30 DAYS
ENDOCRINE AND METABOLIC AGENTS - MISC.	YORVIPATH 168MCG/ 0.56ML INJECTION YORVIPATH 294MCG /0.98ML INJECTION YORVIPATH 420MCG /1.4ML INJECTION	ADD PA AND QL: 2 PREFILLED PENS (1 PACK) PER 28 DAYS
ENDOCRINE AND METABOLIC AGENTS - MISC.	XENPOZYME 4MG INJECTION	ADD DOSING: 3 MG/KG EVERY 2 WEEKS
GASTROINTESTINAL AGENTS - MISC.	LIVDELZI 10MG CAPSULE	NEW PA AND QL: 1 CAPSULE PER DAY
HEMATOLOGICAL AGENTS - MISCELLANEOUS	PIASKY 340MG /2ML INJECTION	ADD PA AND QL: 3 VIALS PER 28 DAYS
HEMATOPOIETIC AGENTS	VAFSEO 150MG TABLET VAFSEO 300MG TABLET VAFSEO 450MG TABLET	ADD PA AND QL: 150MG AND 450MG: 1 TABLET PER DAY 300MG: 2 TABLETS PER DAY
HEMATOPOIETIC AGENTS	NYPOZI 300 MCG/ 0.5 ML INJECTION	ADD PA
IMMUNOGLOBULINS	YIMMUGO 100MG/ML INJECTION	ADD PA
IMMUNOMODULATORS	VYVGART HYTRULO SINGLE DOSE VIAL	UPDATE QL: 4 VIALS PER 28 DAYS
IMMUNO SUPPRESSIVE AGENTS	BENLYSTA 200 MG/ML PREFILLED SYRINGE OR AUTOINJECTOR	ADD DOSING: 15 KG TO LESS THAN 40 KG: 2 INJECTIONS PER 28 DAYS ADD QUANTITY LIMIT: 40 KG AND ABOVE: 4 INJECTIONS PER 28 DAYS
INTERLEUKIN ANTAGONISTS	STELARA 5MG/ML INJECTION STELARA 45MG/0.5ML INJECTION STELARA 90MG/ML INJECTION	ADD STEP THERAPY
INTERLEUKIN ANTAGONISTS	SKYRIZI 600 MG/10 ML SINGLE -DOSE VIAL	UPDATE QL: 6 VIALS TOTAL TO LAST 12 WEEKS
INTERLEUKIN ANTAGONISTS	SKYRIZI 90MG/ML PEN	UPDATE QL: 2 PREFILLED PENS PER 56 DAYS (8 WEEKS)
MISCELLANEOUS AGENTS	NIKTIMVO INJECTION	ADD PA
MISCELLANEOUS THERAPEUTIC AGENTS	RYSTIGGO 280MG/2ML VIAL	ADD QL: 840 MG OR 6 ML (3 VIALS) ONCE WEEKLY FOR 6 WEEKS (6 WEEKS = 1 CYCLE)
MISCELLANEOUS THERAPEUTIC AGENTS	RYSTIGGO 420MG/3ML VIAL	ADD QL: 3 ML (1 VIAL) ONCE WEEKLY FOR 6 WEEKS (6 WEEKS= 1 CYCLE)
MISCELLANEOUS THERAPEUTIC AGENTS	RYSTIGGO 560MG/4ML VIAL	ADD QL: 4 ML (1 VIAL) ONCE WEEKLY FOR 6 WEEKS (6 WEEKS = 1 CYCLE)
MISCELLANEOUS THERAPEUTIC AGENTS	RYSTIGGO 840MG/6ML VIAL	ADD QL: 6 ML (1 VIAL) ONCE WEEKLY FOR 6 WEEKS (6 WEEKS = 1 CYCLE)
MUSCULOSKELETAL THERAPY AGENTS	BACLOFEN 15MG TABLET	ADD QL: 3 TABLETS PER DAY
OPHTHALMIC AGENTS	PAVBLU 2MG INJECTION ENZEEVU 2MGINJECTION AHZANTIVE 2MG INJECTION YESAFILI 2MG INJECTION OPUVIZ 2MG INJECTION	ADD PA AND DOSING DIABETIC MACULAR EDEMA, DIABETIC RETINOPATHY, NEOVASCULAR “WET” AGE-RELATED MACULAR DEGENERATION, RETINAL VEIN OCCLUSION: 2 MG PER EYE; EACH EYE MAY BE TREATED AS FREQUENTLY AS EVERY 4 WEEKS. RETINOPATHY OF PREMATURITY: 0.4 MG PER EYE; EACH EYE MAY BE TREATED AS FREQUENTLY AS EVERY 10 DAYS
PROTON PUMP INHIBITORS	DEXILANT 30MG CAPSULE DEXILANT 60MG CAPSULE	REMOVE QL: 1 CAPSULE PER DAY
PROTON PUMP INHIBITORS	NEXIUM ( ESOMEPRAZOLE ) 20 MG TABLET/ CAPSULE OTC	REMOVE QL: 2 CAPSULES / TABLETS PER DAY
PROTON PUMP INHIBITORS	NEXIUM 2.5MG GRANULES PACKET NEXIUM 5MG GRANULES PACKET NEXIUM 10MG GRANULES PACKET NEXIUM 20MG GRANULES PACKET NEXIUM 40MG GRANULES PACKET	REMOVE QL: 1 PACKET PER DAY
PROTON PUMP INHIBITORS	NEXIUM (ESOMEPRAZOLE) 20 MG RX NEXIUM (ESOMEPRAZOLE) 40 MG RX PREVACID (LANSOPRAZOLE) RX 15 MG PREVACID (LANSOPRAZOLE) RX 30 MG PREVACID (LANSOPRAZOLE) ODT 15 MG PREVACID (LANSOPRAZOLE) ODT 30 MG PRILOSEC (OMEPRAZOLE) RX 10 MG PRILOSEC (OMEPRAZOLE) RX 20 MG PRILOSEC (OMEPRAZOLE) RX 40 MG	REMOVE QL: 1 CAPSULE/ TABLET PER DAY
PROTON PUMP INHIBITORS	PRILOSEC OTC 20MG TABLET PREVACID 24 HR (LANSOPRAZOLE) 15 MG OTC OMEPRAZOLE 20 MG ODT	REMOVE QL: 2 CAPSULES/TABLETS PER DAY
PROTON PUMP INHIBITORS	PRILOSEC 2.5MG POWDER PACKET PRILOSEC 10MG POWDER PACKET	REMOVE QL: 1 PACKET PER DAY
PROTON PUMP INHIBITORS	PROTONIX 20MG TABLET PROTONIX 40MG TABLET	REMOVE QL: 1 TABLET /PACKET OF GRANULES FOR SUSPENSION PER DAY
PROTON PUMP INHIBITORS	RABEPRAZOLE 20MG TABLET/ CAPSULE RABEPRAZOLE 10MG TABLET /CAPSULE	REMOVE QL: 1 TABLET/ CAPSULE PER DAY
PROTON PUMP INHIBITORS	ZEGERID 20- 1100MG CAPSULE OTC ZEGERID 20- 1100MG CAPSULE RX ZEGERID 40- 1100MG CAPSULE RX	REMOVE QL: 1 CAPSULE PER DAY
PROTON PUMP INHIBITORS	ZEGERID 20-1680MG PACKET ZEGERID 40-1680MG PACKET	REMOVE QL: 1 PACKET PER DAY
PROTON PUMP INHIBITORS	RABEPRAZOLE 5MG TABLET/ CAPSULE	REMOVE QL: 1 TABLET/ CAPSULE PER DAY
PROTON PUMP INHIBITORS	ESOMEPRAZOLE STRONTIUM 49.3 MG CAPSULE	REMOVE QL: 1 CAPSULE PER DAY
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.	AUSTEDO 6MG TABLET	UPDATE QL: 2 TABLETS PER DAY
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.	AUSTEDO XR 6MG TABLET AUSTEDO XR 12MG TABLET	UPDATE QL:1 TABLET PER DAY
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.	AUSTEDO XR 18MG TABLET ER	ADD QL: 1 TABLET PER DAY
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.	AUSTEDO XR 24MG TABLET	UPDATE QL: 1 TABLET PER DAY
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.	AUSTEDO XR 30MG TABLET ER AUSTEDO XR 36MG TABLET ER AUSTEDO XR 42MG TABLET ER AUSTEDO XR 48MG TABLET ER	ADD QL: 1 TABLET PER DAY
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.	INGREZZA 40MG CAPSULE INGREZZA 60MG CAPSULE INGREZZA 80MG CAPSULE	ADD QL: 1 CAPSULE PER DAY
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.	HORIZANT 300MG TABLET ER HORIZANT 600MG TABLET ER	ADD ST
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.	OCREVUS ZUNOVO 920 MG AND 23,000 UNITS/ 23 ML SINGLE- DOSE VIAL	ADD PA AND QL: 1 VIAL PER 6 MONTHS
VASOPRESSORS	NEFFY 2MG/ 0.1ML NASAL SPRAY	ADD QL: 1 CARTON (2 SINGLE- DOSE NASAL SPRAYS) PER FILL; 4 FILLS PER CALENDAR YEAR

What actions do I need to take?

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.

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, contact 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.

If you need assistance with any other item, reach out to your local provider relationship management representative or contact 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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