MedicaidJune 25, 2025
Quarterly pharmacy formulary change notice
The formulary changes listed in the table below were reviewed and approved at our first quarter 2025 Pharmacy and Therapeutics Committee meeting.
Effective August 1, 2025, the changes outlined below apply to all members of Anthem. Don’t forget to read the footnotes at the bottom of the tables.
EFFECTIVE FOR ALL PATIENTS ON AUGUST 1, 2025
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Therapeutic class | Drug | Revised status | Potential alternatives | |
GLUCOSE BLOOD TEST STRIP | GNP TRUE METRIX SELF MONITORING BLOOD GLUCOSE TEST STRIPS
| NON-PREFERRED | RELION TRUE METRIX BLOOD GLUCOSE TEST STRIPS TRUE METRIX BLOOD GLUCOSE TEST STRIP | |
INJECTION DEVICE** | AUTOJECT 2 DEVICE INJECT EASE DEVICE | PREFERRED | N/A | |
UM EDITS – EFFECTIVE FOR ALL MEMBERS NO LATER THAN AUGUST 1, 2025
| ||||
ACNE PRODUCTS | ACANYA 1.2-2.5% GEL | ADD QL 50 GRAMS PER 30 DAYS | ||
ALTERNATIVE MEDICINE
| MELATONIN OTC 1 MG MELATONIN OTC 2.5 MG MELATONIN OTC 3 MG MELATONIN OTC 5 MG MELATONIN OTC 10 MG MELATONIN OTC 12 MG MELATONIN OTC 2.5 MG/10 ML MELATONIN OTC 1 MG/4 ML MELATONIN OTC 5 MG/15 ML MELATONIN OTC 1 MG/ML MELATONIN OTC 3 MG/0.9 ML MELATONIN OTC 10 MG/ML MELATONIN ER OTC 1 MG, 3 MG, 5 MG, 10 MG MELATONIN OTC 3.5 MG/2 ML MELATONIN OTC 5 MG/ML | REMOVE QL ON TABLETS / CAPSULES / CHEWABLE / SUBLINGUAL TABLET / ORALLY DISINTEGRATING TABLET AND SOLUTION | ||
ANALGESICS |
JOURNAVX 50 MG TABLET
| ADD QL 15 TABLETS PER 7 DAYS; MAX OF 2 FILLS PER 30 DAYS | ||
ANALGESICS - ANTI-INFLAMMATORY* | AVTOZMA 80 MG, 200 MG, & 400 MG VIAL FOR INTRAVENOUS INFUSION AVTOZMA 162 MG/0.9 ML PREFILLED AUTOINJECTOR AVTOZMA 162 MG/0.9 ML PREFILLED SYRINGE | ADD PA | ||
ANALGESICS - ANTI-INFLAMMATORY* | AVTOZMA 162 MG/0.9 ML PREFILLED AUTOINJECTOR AVTOZMA 162 MG/0.9 ML PREFILLED SYRINGE | ADD QL 4 SYRINGES / AUTOINJECTORS PER 28 DAYS | ||
ANAPHYLAXIS THERAPY AGENTS | NEFFY 1 MG NASAL SPRAY
| 1 CARTON (2 SINGLE-DOSE NASAL SPRAYS) PER FILL; 4 FILLS PER CALENDAR YEAR | ||
ANDROGENS | AZMIRO 200MG/ML INJECTION | ADD PA | ||
ANTIANXIETY AGENTS | ALPRAZOLAM (XANAX) XR 0.5 MG TABLET LORAZEPAM (ATIVAN) 0.5 MG TABLET | UPDATE DOSE OP 12 TABLETS PER DAY | ||
ANTIANXIETY AGENTS | ALPRAZOLAM (XANAX) XR 1 MG TABLET LOREEV XR (LORAZEPAM ER) 1 MG CAPSULE | UPDATE DOSE OP 6 CAPSULES / TABLETS PER DAY | ||
ANTIANXIETY AGENTS | LOREEV XR 1.5 MG CAPSULE
| UPDATE DOSE OP 4 CAPSULES PER DAY | ||
ANTICONVULSANTS* | TOPIRAMATE SPRINKLE 50 MG CAPSULE | ADD QL 8 CAPSULES PER DAY | ||
ANTICONVULSANTS
| CARBAMAZEPINE 200 MG CHEWABLE | ADD QL 8 TABLETS PER DAY | ||
ANTICONVULSANTS | GABARONE 100 MG TABLET GABARONE 400 MG TABLET | ADD PA AND QL 6 TABLETS PER DAY | ||
ANTIDEPRESSANTS | BUPROPION 150 MG XL TABLET | UPDATE QL 3 TABLETS PER DAY | ||
ANTIFUNGALS | TERBINAFINE 250 MG TABLET | REMOVE QL | ||
ANTIHYPERTENSIVES | ACCUPRIL 5 MG TABLET | UPDATE QL 16 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | ACCUPRIL 10 MG TABLET | UPDATE QL 8 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | ACCURETIC 10-12.5 MG TABLET | UPDATE QL 4 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | ALTACE 1.25 MG CAPSULE | UPDATE QL 16 CAPSULES PER DAY | ||
ANTIHYPERTENSIVES | ALTACE 2.5 MG CAPSULE | UPDATE QL 8 CAPSULES PER DAY | ||
ANTIHYPERTENSIVES | CAPTOPRIL 12.5 MG TABLET | UPDATE QL 24 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | CAPTOPRIL 25 MG TABLET | UPDATE QL 12 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | FOSINOPRIL 10 MG TABLET | UPDATE QL 8 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | FOSINOPRIL/HCTZ 10-12.5 MG TABLET | UPDATE QL 4 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | BENAZEPRIL 5 MG TABLET | UPDATE QL 16 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | BENAZEPRIL 10 MG TABLET | UPDATE QL 8 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | BENAZEPRIL/HCTZ 5-6.25 MG TABLET | UPDATE QL 4 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | AMLODIPINE/BENAZEPRIL 2.5-10 MG CAPSULE | UPDATE QL 4 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | MOEXIPRIL 7.5 MG TABLET | UPDATE QL 8 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | PERINDOPRIL 2 MG TABLET | UPDATE QL 8 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | PERINDOPRIL 4 MG TABLET | UPDATE QL 4 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | PRESTALIA 3.5-2.5 MG TABLET | UPDATE QL 4 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | PRESTALIA 7-5 MG TABLET | UPDATE QL 2 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | TRANDOLAPRIL 1 MG TABLET | UPDATE QL 8 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | TRANDOLAPRIL 2 MG TABLET | UPDATE QL 4 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | ENALAPRIL 2.5 MG TABLET | UPDATE QL 16 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | ENALAPRIL 5 MG TABLET | UPDATE QL 8 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | LISINOP/HCTZ 10-12.5 MG TABLET | UPDATE QL 4 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | LISINOPRIL 2.5 MG TABLET | UPDATE QL 32 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | LISINOPRIL 5 MG TABLET | UPDATE QL 16 TABLETS PER DAY | ||
ANTIHYPERTENSIVES | LISINOPRIL 10 MG TABLET | UPDATE QL 8 TABLETS PER DAY | ||
ANTI-INFECTIVE AGENTS - MISC. | ALINIA 100 MG/5 ML SUSPENSION | ADD QL 180 ML (3 BOTTLE) PER FILL; 1 FILL PER 30 DAYS | ||
ANTI-INFECTIVE AGENTS - MISC. | ALINIA 500 MG TABLET | ADD QL 6 TABLETS PER FILL; 1 FILL PER 30 DAYS | ||
ANTI-INFECTIVE AGENTS - MISC. | METRONIDAZOLE 125 MG TABLET | ADD PA | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | GRAFAPEX 1 GM INJECTION GRAFAPEX 5 GM INJECTION | ADD PA | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | OPDIVO QVANTIG INJECTION | ADD PA | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PIQRAY 250 MG DOSE TABLET PIQRAY 300 MG DOSE TABLET | UPDATE QL 56 TABLETS PER 28 DAYS | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BOSULIF 100 MG CAPSULE BOSULIF 100 MG TABLET | UPDATE QL 6 TABLETS / CAPSULES PER DAY | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DATROWAY 100MG INJECTION | ADD PA | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* | NILOTINIB D-TARTRATE 50 MG CAPSULE NILOTINIB D-TARTRATE 150 MG CAPSULE NILOTINIB D-TARTRATE 200 MG CAPSULE | ADD QL 4 CAPSULES PER DAY | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | GOMEKLI 1 MG CAPSULE GOMEKLI 2 MG CAPSULE GOMEKLI 1 MG TABLET FOR ORAL SUSPENSION | ADD PA AND QL 1 MG: 8 CAPSULES / TABLETS PER DAY 2MG: 4 CAPSULES PER DAY | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ROMVIMZA 14 MG CAPSULE ROMVIMZA 20 MG CAPSULE ROMVIMZA 30 MG CAPSULE | ADD PA AND QL 1 CARTON (8 CAPSULES) PER 28 DAYS | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* | ENSACOVE 25 MG CAPSULE ENSACOVE 100 MG CAPSULE | ADD PA AND QL 2 CAPSULES PER DAY | ||
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* | UNLOXCYT INJECTION | ADD PA | ||
ANTIPARKINSON AND RELATED THERAPY AGENTS | ONAPGO 98 MG/20 ML (4.9 MG/ML) SUBCUTANEOUS SOLUTION | ADD PA AND QL 1 VIAL (20 ML) PER DAY | ||
ANTIPARKINSON AND RELATED THERAPY AGENTS | DHIVY 25-100 MG TABLET | ADD QL 8 TABLETS PER DAY | ||
ANTIPSORIATICS | WEZLANA 45/0.5 ML AUTOINJECTOR WEZLANA 90MG ML AUTOINJECTOR | ADD QL 1 AUTOINJECTOR PER 84 DAYS (12 WEEKS) | ||
ANTIPSORIATICS | STEQEYMA 45/0.5 ML INJECTION STEQEYMA 90MG ML INJECTION | ADD PA AND QL 1 SYRINGE PER 84 DAYS (12 WEEKS) | ||
ANTIPSORIATICS | STEQEYMA 130/26ML INJECTION
| ADD PA AND DOSING 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) | ||
ANTIPSORIATICS | VTAMA 1% CREAM | ADD ST | ||
ANTIPSORIATICS | VECTICAL 3 MCG/GM OINTMENT | ADD ST | ||
ANTIPSORIATICS | SORILUX 0.005% AEROSAL | ADD ST | ||
ANTIPSYCHOTICS / ANTIMANIC AGENTS | OPIPZA ORAL FILM 2 MG OPIPZA ORAL FILM 5 MG, 10 MG
| ADD QL 2 MG: 1 FILM PER DAY 5 MG,10 MG: 3 FILMS PER DAY | ||
ANTIPSYCHOTICS / ANTIMANIC AGENTS | LITHIUM CARBONATE 150 MG CAPSULES | UPDATE QL 12 CAPSULES PER DAY | ||
ANTIPSYCHOTICS / ANTIMANIC AGENTS | LITHIUM CARBONATE 300 MG CAPSULES LITHIUM CARBONATE 300 MG TABLETS | UPDATE QL 6 CAPSULES / TABLETS PER DAY | ||
CARDIOVASCULAR AGENTS - MISC. | CIALIS 2.5 MG TABLET | ADD QL 1 TABLET PER DAY | ||
CARDIOVASCULAR AGENTS - MISC. | CIALIS 5 MG TABLET | ADD QL 1 TABLET PER DAY | ||
CEPHALOSPORINS | CEFTRIAXONE 1 GM INJECTION CEFTRIAXONE 2 GM INJECTION CEFTRIAXONE 10 GM INJECTION CEFTRIAXONE 100 GM INJECTION CEFTRIAXONE 250 MG INJECTION CEFTRIAXONE 500 GM INJECTION | REMOVE QL | ||
CORTICOSTEROIDS | ORAPRED ODT 10 MG TABLET | UPDATE QL 6 TABLETS PER DAY | ||
CORTICOSTEROIDS | ORAPRED ODT 15 MG TABLET | UPDATE QL 4 TABLET PER DAY | ||
CORTICOSTEROIDS - TOPICAL | DUOBRII LOTION | ADD ST | ||
CYSTIC FIBROSIS AGENTS |
ALYFTREK 4-20-50 MG TABLET ALYFTREK 10-50-125 MG TABLET
| ADD PA AND QL 4-20-50 MG TABLET-3 TABLETS PER DAY 10-50-125 MG TABLET- 2 TABLETS PER DAY | ||
DIABETIC SUPPLIES | GUARDIAN CONNECT TRANSMITTER GUARDIAN LINK 3 TRANSMITTER EVERSENSE E3 TRANSMITTER EVERSENSE 365 TRANSMITTER | ADD QL 1 TRANSMITTER PER YEAR | ||
DIABETIC SUPPLIES | GUARDIAN REAL-TIME REPLACEMENT RECEIVER/MONITOR
| ADD QL 1 RECEIVER PER YEAR | ||
DIABETIC SUPPLIES | ENLITE SENSOR | ADD QL 5 SENSORS PER 30 DAYS | ||
DIABETIC SUPPLIES | EVERSENSE E3 SENSOR | ADD QL 2 SENSORS PER YEAR | ||
DIABETIC SUPPLIES | EVERSENSE 365 SENSOR | ADD QL 1 SENSOR PER YEAR | ||
DIABETIC SUPPLIES | FREESTYLE LIBRE 2 PLUS | ADD QL 2 SENSORS PER 30 DAYS | ||
DIABETIC SUPPLIES | TEMPO WELCOME KIT | ADD QL 1 KIT PER FILL; ONE TIME FILL ONLY | ||
ENDOCRINE AND METABOLIC AGENTS - MISC.* | OSPOMYV 60 MG/1 ML PREFILLED SYRINGE STOBOCLO 60 MG/ML PREFILLED SYRINGE | ADD PA AND QL 60 MG (1 PREFILLED SYRINGE) EVERY 6 MONTHS | ||
ENDOCRINE AND METABOLIC AGENTS - MISC.* | OSENVELT 120 MG/1.7 ML VIAL XBRYK 120 MG/1.7 ML VIAL | ADD PA AND QL 1 VIAL PER 28 DAYS | ||
ENDOCRINE AND METABOLIC AGENTS - MISC. | TRYNGOLZA (OLEZARSEN) 80 MG/0.8 ML | ADD PA AND QL 1 AUTOINJECTOR PER MONTH | ||
ENDOCRINE AND METABOLIC AGENTS - MISC. | CRENESSITY 25 MG, 50 MG, OR 100 MG CAPSULE CRENESSITY 50 MG/ML SOLUTION (30 ML) BOTTLE | ADD PA AND QL CAPSULE: 2 CAPSULES PER DAY SOLUTION: 4 ML PER DAY | ||
ESTROGENS | ESTROGEL 0.06% GEL | UPDATE QL 37.5MG GRAMS PER 30 DAYS | ||
IMMUNOMODULATING AGENTS - SYSTEMIC | NEMLUVIO 30 MG INJECTION | UPDATE QL 1 PEN PER 56 DAYS* | ||
INFLAMMATORY BOWEL AGENTS*
| OMVOH 100 MG/ML PREFILLED PEN/SYRINGE OMVOH 200 MG/2 ML + 100 MG/ML PREFILLED PEN/SYRINGE | UPDATE QL 2 PENS / SYRINGES [1 CARTON] PER 28 DAYS (4 WEEKS) | ||
INFLAMMATORY BOWEL AGENTS | OMVOH 300 MG/15 ML SINGLE-DOSE VIAL | UPDATE QL 9 VIALS TOTAL TO LAST 12 WEEKS | ||
INSULIN* | MERILOG U-100 INJECTION MERILOG SOLOSTAR U-100 INJECTION | ADD QL 30 ML PER 30 DAYS | ||
LAXATIVES - MISCELLANEOUS | LACTULOSE SOLUTION 10 GM/ 15 ML | REMOVE QL | ||
NEUROMUSCULAR AGENTS | EVRYSDI 5 MG TABLETS | ADD PA AND QL 1 TABLET PER DAY | ||
NON-BARBITURATE HYPNOTICS | IGALMI 120 MCG SUBLINGUAL FILM IGALMI 180 MCG SUBLINGUAL FILM | UPDATE QL 1 FILM PER DAY
| ||
OPHTHALMIC IMMUNOMODULATORS | VEVYE 0.1% DROPS | UPDATE QL 2 ML (1 BOTTLE) PER 30 DAYS | ||
OPHTHALMICS- MISC. | MIEBO 1.3 GM/ML DROPS | UPDATE QL 3 ML (1 BOTTLE) PER 30 DAYS | ||
ROSACEA AGENTS* | RHOFADE 1% 30 GRAM TUBE, 30 GRAM PUMP | ADD QL 30 GRAMS PER 30 DAYS | ||
ROSACEA AGENTS* | RHOFADE 1% 60 GRAM TUBE, 60 GRAMM PUMP | ADD QL 60 GRAMS PER 30 DAYS | ||
SALICYLATES | DOLOBID 250 MG TABLET | ADD QL 3 TABLETS PER DAY | ||
SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS | DALIRESP 500 MCG TABLET DALIRESP 250 MCG TABLET | ADD STEP THERAPY | ||
SULFONYLUREAS | GLIPIZIDE ER 2.5 MG TABLET GLIPIZIDE ER 5 MG TABLET GLIPIZIDE ER 10 MG TABLET GLIMEPIRIDE 1 MG TABLET GLIMEPIRIDE 2 MG TABLET GLIMEPIRIDE 4 MG TABLET GLIPIZIDE 5 MG TABLET GLIPIZIDE 10 MG TABLET GLYBURIDE 1.25 MG TABLET GLYBURIDE 2.5 MG TABLET GLYBURIDE 5 MG TABLET GLYBURIDE MICRONIZED 1.5 MG TABLET GLYBURIDE MICRONIZED 3 MG TABLET GLYBURIDE MICRONIZED 6 MG TABLET | REMOVE ST | ||
VAGINAL ESTROGENS | VAGIFEM 10 MCG TABLET | ADD QL 18 TABLETS PER 28 DAYS | ||
* 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 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 Anthem patient cannot be converted to a formulary alternative, contact Provider Services at 800‑450‑8753 and follow the voice prompts for pharmacy prior authorization. The Preferred Drug List is also 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 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-085751-25
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