Products & Programs PharmacyHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsMarch 20, 2024

Quarterly pharmacy formulary change notice

The formulary changes listed in the table below apply to all FAMIS and Anthem HealthKeepers Plus members. These changes were reviewed and approved at the fourth-quarter 2023 meeting of our Pharmacy and Therapeutics Committee.

Effective May 1, 2024, formulary changes, non-formulary changes, and prior authorization requirements will apply. Remember to read the footnotes at the end of the table.

Effective for all patients on May 1, 2024
Therapeutic class	Drug	Revised status	Potential alternatives
COUGH AND COLD AGENTS**	BIO-DTUSS DMX LIQUID	PREFERRED	N/A
IMMUNOMODULATING AGENTS – TOPICAL**	IMIQUIMOD 3.75% CREAM	PREFERRED	N/A
LOCAL ANESTHETICS - TOPICAL	RX LIDOCAINE 4% SOLUTION	NON-PREFERRED WITH ST	OTC LIDOCAINE SOLUTION AND LIQUID
LOCAL ANESTHETICS - TOPICAL	OTC LIDOCAINE SOLUTION/LIQUID	PREFERRED	N/A
POTASSIUM REMOVING AGENTS**	LOKELMA 5GM PAK LOKELMA 10GM PAK	PREFERRED	N/A

UM edits — Effective for all members no later than May 1, 2024 No changes in preferred/non-preferred status revision or addition to UM edit only
ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS	FRUZAQLA 1MG CAPSULE FRUZAQLA 5MG CAPSULE	ADD PA AND QL 1 MG: 84 CAPSULES PER 28 DAYS 5MG: 21 CAPSULES PER 28 DAYS
ANTINEOPLASTIC - ANTIBODIES	LOQTORZI 240/6ML INJECTION	ADD PA
ANTINEOPLASTIC ENZYME INHIBITORS	TRUQAP 160MG TABLET TRUQAP 200MG TABLET	ADD PA AND QL 64 CAPSULES PER 28 DAYS
ANTINEOPLASTIC ENZYME INHIBITORS	XALKORI 20MG CAPSULE XALKORI 200MG CAPSULE XALKORI 250MG CAPSULE	ADD QL 4 CAPSULES PER DAY
ANTINEOPLASTIC ENZYME INHIBITORS	XALKORI 50MG CAPSULE	ADD QL 2 CAPSULES PER DAY
ANTINEOPLASTIC ENZYME INHIBITORS	XALKORI 150MG CAPSULE	ADD QL 3 CAPSULES PER DAY
ANTINEOPLASTIC ENZYME INHIBITORS	BOSULIF 50MG CAPSULE	ADD QL 1 CAPSULE PER DAY
ANTINEOPLASTIC ENZYME INHIBITORS	BOSULIF 100MG CAPSULE/TABLET	ADD QL 4 TABLETS/CAPSULES PER DAY
ANTINEOPLASTIC ENZYME INHIBITORS	OGSIVEO 50MG TABLET	ADD PA ADD QL 6 TABLETS PER DAY
ANTINEOPLASTIC ENZYME INHIBITORS	ROZLYTREK 50MG PAK	ADD QL 8 PACKETS PER DAY
ANTINEOPLASTIC ENZYME INHIBITORS	AUGTYRO 40MG CAPSULE	ADD PA AND QL 8 CAPSULES PER DAY
ANTINEOPLASTIC ENZYME INHIBITORS	OJJAARA 100MG TABLET OJJAARA 150MG TABLET OJJAARA 200MG TABLET	ADD PA AND QL 1 TABLET PER DAY
CHELATING AGENTS	TRIENTINE 500 MG CAPSULE	ADD QL 4 CAPSULES PER DAY
COLONY STIMULATING FACTORS*	Ryzneuta 20 mg/mL injection	add pa and ql 2 syringes per 28 days
COMPLEMENT INHIBITORS	EMPAVELI 1080 MG INJECTION	ADD QL 10 INJECTORS PER 30 DAYS
COMPLEMENT INHIBITORS	ZILBRYSQ 16.6 MG INJECTION ZILBRYSQ 23 MG INJECTION ZILBRYSQ 32.4 MG INJECTION	ADD PA AND ql 1 SYRINGE PER DAY
DIABETIC SUPPLIES	FREESTYLE LIBRe 3 READER	ADD QL 1 READER PER YEAR
DIABETIC SUPPLIES	GUARDIAN 4 SENSOR	ADD QL 5 SENSORS PER 30 DAYS
DIABETIC SUPPLIES	GUARDIAN 4 TRANSMITTER	ADD QL 1 TRANSMITTER PER YEAR
GENITOURINARY AGENTS - MISCELLANEOUS	RIVFLOZA 80/0.5ML INJECTION RIVFLOZA 128/0.8ml INJECTION RIVFLOZA 160MG/ML INJECTION	ADD PA AND QL 80/0.5ML: 2 VIALS PER MONTH 128/0.8 ML: 1 SYRINGE PER MONTH 160MG/ML: 1 SYRINGE PER MONTH
NEUROMUSCULAR BLOCKING AGENTS	DAXXIFY 100U INJECTION	ADD DOSING LIMIT Cervical Dystonia: 125 to 250 units as a divided dose among affected muscles as frequently as every 3 months
GLUCOCORTICOSTEROIDS	AGAMREE 40MG/ML SUSPENSION	ADD PA AND QL 7.5 ML PER DAY
HEMATOLOGICAL ENZYMES - MISC	ADZYNMA 500IU kit ADZYNMA 1500IU kit	ADD PA
HEMATOPOIETIC AGENTS	APHEXDA 62MG INJECTION	ADD PA
IMMUNOMODULATING AGENTS - TOPICAL	IMIQUIMOD 3.75% CREAM	REMOVE PA (GENERIC ONLY)
INTERLEUKIN-6 RECEPTOR INHIBITORS*	Tofidence 80 mg, 200 mg, & 400 mg vial	ADD DOSING LIMIT 8 mg/kg as frequently as every 4 weeks
LOCAL ANESTHETICS - TOPICAL	LIDOCAINE/PRILOCAINE 2.5-2.5% CREAM	ADD QL 30 GRAMS PER 30 DAYS
METABOLIC MODIFIERS	XPHOZAH 10mg tablet XPHOZAH 20MG TABLET XPHOZAH 30MG TABLET	ADD PA AND QL 2 TABLETS PER DAY
METABOLIC MODIFIERS	MYALEPT 11.3MG INJECTION	ADD QL 1 VIAL PER DAY
METABOLIC MODIFIERS	POMBILITI 105MG SOLUTION	ADD PA AND DOSING LIMIT 20 mg/kg every 2 weeks
METABOLIC MODIFIERS	OPFOLDA 65MG CAPSULE	ADD PA AND QL 8 CAPSULES PER 28 DAYS
MINERALOCORTICOID RECEPTOR ANTAGONISTS	KERENDIA 10MG TABLET KERENDIA 20MG TABLET	ADD ST
OPHTHALMIC AGENTS	IYUZEH 0.005% DROPS	UPDATE QL 30 units per 30 days
OPHTHALMIC AGENTS	VABYSMO 6/0.05ML INJECTION	ADD Dosing LIMIT 6 mg per eye; each eye may be treated every 4 weeks for 6 months
THROMBOCYTOPENIA*	Alvaiz 9MG tablet Alvaiz 18MG tablet Alvaiz 38MG tablet Alvaiz 54MG tablet	add pa and ql 9 mg and 18 mg: 1 tablet per day 38 mg and 54 mg: 1 tablet per day
VAGINAL ESTROGENS	ESTRING 2MG mis ESTRING 7.5/24HR mis	ADD QL 1 RING EVERY 90 DAYS

* This change will be implemented once the medication is on the market.

** This change will be implemented ASAP.

What action do I need to take?

Please review these changes and work with your Anthem HealthKeepers Plus patients to transition them to formulary alternatives. If you determine that 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 800-901-0020 and follow the voice prompts for pharmacy prior authorization. You can find the searchable formulary on our provider website at providers.anthem.com/va under Eligibility & Pharmacy > Pharmacy Information.

If you have any questions about this communication, call our Provider Services team at 800-901-0020.

HealthKeepers, Inc. is an independent licensee of the Blue Cross Blue Shield Association. Anthem HealthKeepers Plus, offered by HealthKeepers, Inc., is a health plan that contracts with the Virginia Department of Medical Assistance Services to provide Medicaid benefits to enrollees. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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Quarterly pharmacy formulary change notice

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