The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus members (including those enrolled in FAMIS [the CHIP program] and Medallion [the Medicaid program]) and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) members. These changes were reviewed and approved at the fourth quarter pharmacy and therapeutics committee meeting.

 

Effective August 1, 2020, formulary changes, non-formulary changes and prior authorization (PA) requirements will apply. Remember to read the footnotes at the end of the table.

 

Effective for all members on August 1, 2020

Therapeutic class

Medication

Formulary status change

Potential alternatives

(preferred products)

Continuous Blood Glucose System

DEXCOM GLUCOSE AND

FREESTYLE LIBRE  SYSTEM

SENSOR

TRANSMITTER

RECEIVER

Preferred with PA under the pharmacy benefit

n/A

 

Edits effective August 1, 2020

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

Therapeutic class

Medication

Formulary status change

ACNE PRODUCTS

AKLIEF CRE 0.005%

ADD PA

ADD QL

1 pump per 30 days

AMZEEQ AER 4%

ADD PA

ADD QL

30 GRAMS PER 30 DAYS

ABSORICA LD CAP 8MG

ABSORICA LD CAP 16MG

ABSORICA LD CAP 24MG

ABSORICA LD CAP 32MG

ADD PA

add ql

30 day supply per fill

ADENOSINE TRIPHOSPHATE-CITRATE LYASE (ACL) INHIBITORS

NEXLETOL TAB 180MG

ADD PA

ADD QL

1 TABLET PER DAY

AGENTS FOR CONSTIPATION

IBSRELA TAB 50 MG*

add pa

add ql

2 TABLETS per day

AGENTS FOR CONSTIPATION

PIZENSY*

add pa; add ql

20 grams per day

ALS AGENTS

EXSERVAN 50 MG FILM*

add st

add pa

add ql

4 films per day

ANTICONVULSANTS - BENZODIAZEPINES

VALTOCO SPR 5MG

ADD PA

ADD QL

10 CARTONS PER 30 DAYS

ANTIDIABETIC COMBINATIONS

TRIJARDY XR  TAB 5-2.5-1000MG

TRIJARDY XR  TAB 12.5-2.5-1000MG

ADD ST

ADD QL

2 TABLETS PER DAY

TRIJARDY XR  TAB 10-5-1000MG

TRIJARDY XR  TAB 25-5-1000MG

ADD ST

ADD QL

1 TABLET PER DAY

ANTIHYPERLIPIDEMICS

NEXLIZET TAB 180MG*

add pa

Add ql

1 tablet per day

ANTIMETABOLITES

REDITREX INJ*

add pa

add ql

4 auto-injectors per 28 days

ANTINEOPLASTIC - ANTIBODIES

PADCEV INJ 20MG

ENHERTU INJ 100MG

add pa

ANTINEOPLASTIC ENZYME INHIBITORS

AYVAKIT TAB 100MG

ADD PA

ADD QL

1 tablet per day

TAZVERIK TAB 200MG

ADD PA

ADD QL

8 tablets per day

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS

KAPVAY TAB 0.1 MG

ADD QL

4 tablets per DAY

BONE DENSITY REGULATORS

BONSITY INJ 620MCG/2.48ML*

add pa

add ql

1 pen per 28 days

CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG

VYEPTI INJ 100MG/ML

add pa

ADD ST

ADD QL

1 vial per 3 months

NURTEC CHW 75MG ODT

ADD ST

ADD QL

15 tablets per 30 days

DIBENZAPINES

SECUADO DIS 3.8MG

ADD QL

1 patch per day

FERTILITY REGULATORS

NOVAREL INJ 5000UNIT
NOVAREL INJ 10000UNIT

PREGNYL INJ 10000UNT
OVIDREL INJ

add pa

GLUCOCORTICOSTEROIDS

HEMADY TAB 20MG*

add pa

add ql

2 tablets per day

HEMATOPOIETIC GROWTH FACTORS

ZIEXTENZO INJ 6/0.6ML

add pa

add ql

2 syringes

REBLOZYL INJ 25MG

REBLOZYL INJ 75MG

add pa

UDENYCA INJ 6MG/.6ML

add st

add pa

NEULASTA INJ 6MG/0.6M
FULPHILA INJ 6/0.6ML

add pa

OTIC COMBINATIONS

CORTISPORIN SUS -TC OTIC

add st

PLEUROMUTILINS

XENLETA TAB 600MG

add pa

add ql

10 tablets per fill;

1 fill per 30 days

PROTECTIVES AGAINST UV RADIATION

SCENESSE IMP 16MG

add pa

add ql

1 implant per 2 months

SOMATOSTATIC AGENTS

BYNFEZIA PEN 2500MCG/ML

add pa

add ql

1 pen per 14 days

TARGETED IMMUNE MODULATORS

AVSOLA 100MG VIAL*

add pa

ABRILADA 10 MG/0.2 ML, 20 MG/0.4 ML PREFILLED SYRINGE

add pa

add ql

2 pens/syringes per 28 days

ABRILADA 40MG/0.8 ML PREFILLED PEN/SYRINGE

add pa

add ql

2 syringes per 28 days

* Medication will be added to the formulary when it is available on the market.

 

 What action do I need to take?

 

Please review these changes and work with your Anthem HealthKeepers Plus patients 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 PA to continue coverage beyond the applicable effective date.


What if I need assistance?

 

We recognize the unique aspects of patient 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 PA. 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 Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.

 

AVA-NU-0279



Featured In:
September 2020 Anthem Provider News - Virginia