MedicaidMarch 31, 2025
Quarterly pharmacy formulary change notice
The formulary changes listed below were reviewed and approved at our fourth quarter 2025, Pharmacy and Therapeutics Committee meeting.
Effective May 1, 2025, the changes outlined below apply to all members.
Note: Please remember to read the footnotes at the end of the table.
Therapeutic class | Drug | Revised status | Potential alternatives | |
ANTIASTHMATIC AND BRONCHODILATOR AGENTS | LEVALBUTEROL 0.31MG NEBULIZER LEVALBUTEROL 0.63MG NEBULIZER LEVALBUTEROL 1.25MG NEBULIZER | NON-PREFERRED | ALBUTEROL 0.63MG NEBULIZER ALBUTEROL 0.083% NEBULIZER ALBUTEROL 1.25MG NEBULIZER | |
ANTIASTHMATIC AND BRONCHODILATOR AGENTS | LEVALBUTEROL HFA 45MCG INHALER | NON- PREFERRED | ALBUTEROL HFA INHALER | |
UM EDITS – EFFECTIVE FOR ALL MEMBERS NO LATER THAN MAY 1, 2025 NO CHANGES IN PREFERRED/NON-PREFERRED STATUS REVISION OR ADDITION TO UM EDIT ONLY | ||||
ADHD /ANTI- NARCOLEPSY / ANTI-OBESITY/ ANOREXIANTS**
| WEGOVY 0.25MG INJECTION WEGOVY 0.5MG INJECTION WEGOVY 1MG INJECTION WEGOVY 1.7MG INJECTION WEGOVY 2.4MG INJECTION | ADD QL 1 PEN PER WEEK
| ||
ANALGESICS - ANTI-INFLAMMATORY* | ERELZI 25 MG VIAL | ADD QL 8 VIALS PER 28 DAYS | ||
ANALGESICS - ANTI-INFLAMMATORY* | ETICOVO 50 MG/ML PREFILLED SYRINGE /AUTO INJECTOR PEN |
ADD QL 4 SYRINGES/PENS PER 28 DAYS
| ||
ANALGESICS – OPIOID
| TRAMADOL 75MG TABLET
| ADD PA AND QL 5 TABLETS PER DAY | ||
ANDROGENS*
| UNDECATREX CAPSULES
| ADD PA AND QL 200 MG: 4 CAPSULES PER DAY 100 AND 150 MG: 2 CAPSULES PER DAY | ||
ANTIANXIETY AGENTS
| ALPRAZOLAM 0.25 MG TABLET ALPRAZOLAM 0.5 MG TABLET ALPRAZOLAM 1 MG TABLET ALPRAZOLAM 2 MG TABLET LORAZEPAM 0.5 MG TABLET |
UPDATE QL 4 TABLETS PER DAY
| ||
ANTICONVULSANTS | LYRICA 75MG CAPSULE | UPDATE QL 3 CAPSULES PER DAY | ||
ANTIDIABETICS | GLIMEPIRIDE 3MG TABLET | ADD PA AND QL 2 TABLETS PER DAY | ||
ANTIEMETICS | ONDANSETRON 16MG ODT | ADD QL 4 TABLETS PER 30 DAYS | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BORUZU 3.5MG/1.4ML INJECTION | ADD PA | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ITOVEBI 3MG TABLET ITOVEBI 9MG TABLET | ADD PA AND QL 3MG: 2 TABLETS PER DAY 9 MG: 1 TABLET PER DAY | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TECENTRIQ HYBREZA INJECTION | ADD PA | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TRUQAP 160MG TABLET TRUQAP 200MG TABLET TRUQAP 160MG THERAPY PACK TRUQAP 200MG THERAPY PACK | ADD QL 6 TABLETS PER 28 DAYS OR 1 CARTON (64 TABLETS) PER 28 DAYS | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | XALKORI 20MG CAPSULE | UPDATE QL 8 CAPSULES PER DAY | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | XALKORI 50MG CAPSULE | UPDATE QL 4 CAPSULES PER DAY | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | XALKORI 150MG CAPSULE | UPDATE QL 6 CAPSULES PER DAY | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LYTGOBI THERAPY PACK 4 MG (12 MG DAILY DOSE) | ADD QL 35 TABLETS PER 7 DAYS (1 CARTON PER 7 DAYS) | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LYTGOBI THERAPY PACK 4 MG (16 MG DAILY DOSE) | ADD QL 28 TABLETS PER 7 DAYS (1 CARTON PER 7 DAYS) | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LYTGOBI THERAPY PACK 4 MG (20 MG DAILY DOSE) | ADD QL 21 TABLETS PER 7 DAYS (1 CARTON PER 7 DAYS) | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ROZLYTREK PAK 50MG | UPDATE QL 12 PACKETS PER DAY | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BIZENGRI 375MG/18.75 ML INJECTION | ADD PA AND QL 4 VIALS PER 28 DAYS | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IMKELDI 80MG/ML SOLUTION | ADD PA AND QL 10 MLS PER DAY | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DANZITEN 71MG TABLET DANZITEN 95MG TABLET | ADD PA AND QL 4 TABLETS PER DAY | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | REVUFORJ 110 MG TABLETS REVUFORJ 160 MG TABLETS | ADD PA AND QL 110 MG 4 TABLETS PER DAY 160 MG 2 TABLETS PER DAY | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* | REVUFORJ 25MG TABLET | ADD QL 6 TABLETS PER DAY | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ZIIHERA 300MG INJECTION | ADD PA | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VYLOY 100MG INJECTION | ADD PA | ||
ANTIPARKINSON AND RELATED THERAPY AGENTS |
CREXONT 35-140MG CAPSULE |
ADD QL 15 CAPSULES PER DAY | ||
ANTIPARKINSON AND RELATED THERAPY AGENTS | CREXONT 52.5-210MG CAPSULE | ADD QL 10 CAPSULES PER DAY | ||
ANTIPARKINSON AND RELATED THERAPY AGENTS | CREXONT 70-280MG CAPSULE | ADD QL 7 CAPSULES PER DAY | ||
ANTIPARKINSON AND RELATED THERAPY AGENTS | CREXONT 87.5-350MG CAPSULE | ADD QL 6 CAPSULES PER DAY | ||
ANTIPARKINSON AND RELATED THERAPY AGENTS | VYALEV 12-240MG INJECTION
| ADD PA AND QL 42 VIALS (4200 ML) (6 CARTONS) PER 28 DAYS | ||
ANTIPSYCHOTICS /ANTIMANIC AGENTS | COBENFY 50-20MG CAPSULE | ADD ST AND QL 2 CAPSULES PER DAY
| ||
ANTIPSYCHOTICS /ANTIMANIC AGENTS | COBENFY STARTER PACK CAPSULE | ADD ST AND QL 1 PACK (28-DAY SUPPLY), ONE TIME FILL | ||
ANTI-TNF- ALPHA - MONOCLONAL ANTIBODIES | CYLTEZO 40/0.4ML INJECTION | ADD QL 2 PENS/SYRINGES PER 28 DAYS | ||
ANTI-TNF- ALPHA - MONOCLONAL ANTIBODIES | CYLTEZO STARTER KIT | ADD QL 1 PACK (28 DAY SUPPLY, ONE TIME FILL) | ||
ANTI-TNF- ALPHA - MONOCLONAL ANTIBODIES | HUMIRA STARTER KIT | ADD QL 1 PACK (28 DAY SUPPLY, ONE TIME FILL) | ||
ANTI-TNF- ALPHA - MONOCLONAL ANTIBODIES | SIMLANDI 80/0.8ML INJECTION | ADD QL 2 SYRINGES PER 28 DAY | ||
ANTI-TNF- ALPHA - MONOCLONAL ANTIBODIES* | IDACIO STARTER PACK UVEITIS STARTER PACK YUFLYMA STARTER PACK | ADD QL 1 PACK (28 DAY SUPPLY, ONE TIME FILL) | ||
ANTIVIRALS | PREVYMIS 20MG PAK PREVYMIS 120MG PAK | ADD QL 810 PACKETS PER YEAR | ||
CARDIOVASCULAR AGENTS - MISC. | ATTRUBY 356MG PAK | ADD PA AND QL 4 TABLETS PER DAY (1 PACK OF 112 TABLETS PER 28 DAYS) | ||
DERMATOLOGICALS | BIMZELX 160MG/ML (2 PACK) INJECTION | ADD QL 1 CARTON (2 X 160 MG/ML AUTOINJECTORS /SYRINGES) EVERY 8 WEEKS | ||
DERMATOLOGICALS | BIMZELX 160MG/ML (1 PACK) INJECTION | ADD QL 1 CARTON (1 X 160 MG/ML AUTOINJECTOR /SYRINGES) PER 28 DAYS | ||
DERMATOLOGICALS | BIMZELX 320MG/2ML INJECTION (1 PACK) | ADD QL 1 CARTON (1 X 320 MG/2 ML AUTOINJECTOR /SYRINGE) EVERY 8 WEEKS | ||
DERMATOLOGICALS | EMROSI 40MG CAPSULE | ADD PA AND QL 1 CAPSULE PER DAY | ||
DERMATOLOGICALS | MONDOXYNE NL 100MG CAPSULE | ADD STEP THERAPY | ||
DERMATOLOGICALS* | LEQSELVI 8 MG TABLET | ADD PA AND QL 2 TABLETS PER DAY | ||
ENDOCRINE AND METABOLIC AGENTS - MISC.* | BYNFEZIA 2,500 MCG/ML PEN | ADD QL 1 PEN PER 14 DAYS | ||
GASTROINTESTINAL AGENTS - MISC. | CIMZIA 200MG VIAL KIT | ADD QL 1 VIAL KIT (2 X 200 MG VIALS) 2 VIALS PER 28 DAYS | ||
GASTROINTESTINAL AGENTS - MISC. | CIMZIA 200MG/ML PREFILLED KIT | ADD QL 1 SYRINGE KIT (2 X 200 MG/ML SYRINGES) 2 SYRINGES PER 28 DAYS | ||
GASTROINTESTINAL AGENTS - MISC. | ZYMFENTRA 120MG/ML INJECTION | ADD QL 1 SYRINGE /PEN EVERY 2 WEEKS; 2 SYRINGES /PENS PER 28 DAYS | ||
GASTROINTESTINAL AGENTS - MISC. | ENTYVIO 108MG/0.68ML INJECTION | ADD QL 1 SYRINGE /PEN EVERY 2 WEEKS; 2 SYRINGES /PENS PER 28 DAYS | ||
GASTROINTESTINAL AGENTS - MISC. | OMVOH 100MG/ML INJECTION | ADD QL 2 PENS/ SYRINGES PER 28 DAYS (4 WEEKS) | ||
HEMATOLOGICAL AGENTS - MISC.* | BKEMV 300 MG/30ML INJECTION EPYSQLI 300 MG/30 ML INJECTION | ADD PA AND QL 8 VIALS PER 28 DAYS | ||
HEMATOLOGICAL AGENTS - MISC. | HYMPAVZI 150MG/ML INJECTION | ADD PA | ||
HEMATOLOGICAL AGENTS - MISC. | FIBRYGA 1GM INJECTION | ADD PA | ||
INTERLEUKIN ANTAGONISTS*
| IMULDOSA INJECTION PYZCHIVA INJECTION OTULFI INJECTION YESINTEK INJECTION | ADD STEP THERAPY
| ||
INTERLEUKIN ANTAGONISTS*
| IMULDOSA 130 MG/26 ML (5 MG/ML) VIAL PYZCHIVA 130 MG/26 ML (5 MG/ML) VIAL SELARSDI 130 MG/26 ML (5 MG/ML) VIAL OTULFI 130 MG/26 ML (5 MG/ML) VIAL
YESINTEK 130 MG/26 ML (5 MG/ML) VIAL | ADD DOSING: BODY WEIGHT 55 KG OR LESS: 2 VIALS (8 WEEK SUPPLY, ONE TIME FILL) | ||
INTERLEUKIN ANTAGONISTS*
| IMULDOSA 45 MG/0.5 ML INJECTION IMULDOSA 90 MG/1 ML INJECTION
PYZCHIVA 45 MG/0.5 ML INJECTION PYZCHIVA 90 MG/1 ML INJECTION
OTULFI 45 MG/0.5 ML INJECTION OTULFI 90 MG/1 ML INJECTION
YESINTEK 45 MG/0.5 ML INJECTION YESINTEK 90 MG/1 ML INJECTION
| ADD QL 1 SYRINGE PER 84 DAYS (12 WEEKS) | ||
INTERLEUKIN ANTAGONISTS* | SKYRIZI 90 MG/ML INJECTION | ADD QL 2 PREFILLED PENS SYRINGES PER 56 DAYS (8 WEEKS) | ||
INTERLEUKIN ANTAGONISTS
| WEZLANA 130/26ML INJECTION | ADD STEP THERAPY
| ||
LAXATIVES | LACTULOSE SOL 10GM/15 | UPDATE QL 3600 ML PER 30 DAYS | ||
MEDICAL DEVICES AND SUPPLIES | RELIZORB CARTRIDGE | UPDATE QL 6 CARTRIDGES PER DAY | ||
MEDICAL DEVICES AND SUPPLIES | CEQUR SIMPLICITY PATCH | ADD QL 8 PATCHES PER 32 DAYS | ||
MEDICAL DEVICES AND SUPPLIES
| OMNIPOD GO KIT 20UNIT/DAY OMNIPOD GO KIT 40UNIT/DAY OMNIPOD GO KIT 25UNIT/DAY OMNIPOD GO KIT 15UNIT/DAY OMNIPOD GO KIT 35UNIT/DAY OMNIPOD GO KIT 10UNIT/DAY OMNIPOD GO KIT 30UNIT/DAY | ADD QL 10 PODS PER 30 DAYS
| ||
MEDICAL DEVICES AND SUPPLIES
| V-GO 40 KIT V-GO 20 KIT V-GO 30 KIT | ADD QL 30 PUMPS PER 30 DAYS
| ||
MULTIVITAMINS
| TRI-VI- FLOR/ TRI-VI- FLORO SUSPENSION, QUFLORA GUMMY, MULTI- VIT-FL CHEWABLE, POLY-VI- FLOR CHEWABLE/ SUSPENSION, POLY- VI-FLOR /IRON CHEWABLE /SUSPENSION, QUFLORA PED CHEWABLE/ SOLUTION, QUFLORA FE CHEWABLE /LIQUID, FLORAFOL/ FLORAFOL PED CHEWABLE, FLORAFOL FE SOLUTION, DAVIMET/ FLUORIDE CHEWABLE, FLORIVA LIQUID/ CHEWABLE, FLORIVA PLUS SOLUTION | ADD STEP THERAPY
| ||
MUSCULOSKELETAL THERAPY AGENTS | CYCLOBENZAPRINE 5MG TABLET | UPDATE QL 6 TABLETS PER DAY | ||
NEUROMUSCULAR AGENTS | TEGLUTIK 50MG/10ML SUSPENSION | ADD PA AND QL 40 ML PER DAY | ||
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS – MISC
| MIPLYFFA 47MG CAPSULE MIPLYFFA 62MG CAPSULE MIPLYFFA 93MG CAPSULE MIPLYFFA 124MG CAPSULE | ADD PA AND QL 3 CAPSULES PER DAY | ||
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | ZEPOSIA STARTER KIT | ADD QL 1 PACK PER FILL, ONE TIME | ||
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | LUMRYZ STARTER PACK
| ADD QL 1 PACK (28 DAY SUPPLY), ONE TIME FILL | ||
RESPIRATORY AGENTS - MISC. | ZEMAIRA 4000MG INJECTION ZEMAIRA 5000MG INJECTION | ADD DOSING LIMIT 60 MG/KG ONCE PER WEEK | ||
* Edit will be implemented when the medication is available on the market.
** QL for Wegovy is limited to plans that allow coverage.
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 preapproval 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 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 at https://providers.anthem.com/ny
If you need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 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.
NYBCBS-CD-080581-25
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