The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) members.

 

Effective July 1, 2020, formulary changes, non-formulary changes and prior authorization requirements will apply.

 

Effective for all members on July 1, 2020

Therapeutic class

Medication

Formulary status change

Potential alternatives

(preferred products)

ADHD AGENTS

DYANAVEL XR 2.5

MG/ML SUSPENSION

NON-PREFERRED

Vyvanse capsules/chewable tablet

Adderall XR capsules

Dextroamphetamine tablet

ADHD AGENTS

QUILLIVANT XR 25 MG/5

ML SUSPENSION

QUILLICHEW ER 40 MG

CHEW TABLET

QUILLICHEW ER 20 MG

CHEW TABLET

QUILLICHEW ER 30 MG

CHEW TABLET

NON-PREFERRED

Focalin XR capsules

Daytrana transdermal patch

Concerta tablet

methylphenidate IR capsules/tablet

ANDROGENS

ANDROGEL 1.62%(1.25G)
GEL PACKET

NON-PREFERRED WITH PA

testosterone pump (genric androgel)

PA required

ANTIDIABETIC COMBINATIONS

INVOKAMET 50-500 MG

TABLET

INVOKAMET 50-1,000

MG TABLET

INVOKAMET 150-500

MG TABLET

INVOKAMET 150-1,000

MG TABLET

XIGDUO XR 2.5

MG-1,000 MG TAB

XIGDUO XR 5 MG-500

MG TABLET

XIGDUO XR 5 MG-1,000

MG TABLET

XIGDUO XR 10 MG-500

MG TABLET

XIGDUO XR 10

MG-1,000 MG TAB

PREFERRED WITH MIN AGE LIMIT OF 18 YEARS AND OLDER

N/A

INSULIN

HUMALOG JR

HUMALOG MIX 50/50

HUMALOG 100/ML VIAL

PREFERRED

N/A

INSULIN

INSULIN LISPRO KWIKPEN

ADMELOG SOLOSTAR

NON-PREFERRED

HUMALOG KWIK INJ 100/ML

INSULIN

NOVOLIN N FLEXPEN

NON-PREFERRED

HUMULIN N KWIKPEN

INSULIN

NOVOLIN 70/30 FLEXPEN

NON-PREFERRED

HUMULIN 70/30 KWIKPEN

URINARY ANTISPASMODICS

SOLIFENACIN 5 MG TABLET

SOLIFENACIN 10 MG TABLET

PREFERRED

N/A

URINARY ANTISPASMODICS

VESICARE 5 MG TABLET VESICARE

10 MG TABLET

NON-PREFERRED

SOLIFENACIN 5 MG TABLET

SOLIFENACIN 10 MG TABLET

 


Edits effective July 1, 2020

No changes in preferred/nonpreferred status revision or addition to UM edit only

Therapeutic class

Medication

Formulary status change

ALLERGENIC EXTRACTS

PALFORZIA CAPSULES

PA REQUIRED

ANALGESICS - ANTI-INFLAMMATORY

OLUMIANT 1 MG TABLET

OLUMIANT 2 MG TABLET

ADD QTY LIMIT 30 PER 30 DAYS

ANALGESICS - ANTI-INFLAMMATORY

OTEZLA 30 MG TABLET

ADD QTY LIMIT 60 PER 30 DAYS

ANTIRHEUMATIC ANTIMETABOLITES

OTREXUP INJECTIONS

RASUVO INJECTIONS

ADD QTY LIMIT 4 PER 28 DAYS

HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS

WAKIX  4.45MG TABLET

WAKIX  17.8MG TABLET

PA REQUIRED

INTERLEUKIN-1 RECEPTOR ANTAGONIST

KINERET INJ

ADD QTY LIMIT 30 PER 30 DAYS

MIGRAINE PRODUCTS

REYVOW TABLET

UBRELVY  TABLET

PA REQUIRED

 

 What action do I need to take?

 

Please review these changes and work with your Anthem HealthKeepers Plus and/or Anthem CCC Plus patients to transition them to formulary alternatives. If you determine formulary alternatives are not clinically appropriate for specific patients, you will need to obtain prior authorization to continue coverage beyond the applicable effective date.

 

What if I need assistance?

 

We recognize the unique aspects of patients’ cases. If your patients cannot be converted to a formulary alternative, call our Pharmacy department at 1-800-901-0020 (Anthem HealthKeepers Plus members) or 1-855-323-4687 (Anthem CCC Plus members) and follow the voice prompts for pharmacy prior authorization. You can find the Preferred Drug List (formulary) on our provider website at https://mediproviders.anthem.com/va > Pharmacy > Medicaid Common Core Formulary > Common Core Preferred Drug List.

 

If you have any questions about this communication, call our Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.

 

AVA-NU-0266-20



Featured In:
August 2020 Anthem Provider News - Virginia