HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsSeptember 16, 2024
Quarterly pharmacy formulary change notice
The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus members. These changes were reviewed and approved at the second quarter 2024 pharmacy and therapeutics committee meeting.
Effective October 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 OCTOBER 1, 2024 | |||
Therapeutic class | Drug | Revised status | Potential alternatives |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IMATINIB 100MG TABLET IMATINIB 400MG TABLET | PREFFERED WITH PA | N/A |
UM EDITS – EFFECTIVE FOR ALL MEMBERS NO LATER THAN NOVEMBER 1, 2024 | ||
ANTIBIOTICS* | PIVYA 185 MG TABLET | ADD PA AND QL |
ANTIHISTAMINES | HISTEX PD AND PDX 1.25MG/ML DROPS | ADD QL 10.67 ML PER DAY |
ANTIHISTAMINES | DEXBROMPHENIRAMINE MALEATE 2 MG TABLET | ADD QL 6 TABLETS PER DAY |
ANTIHISTAMINES | HISTEX 2.5MG/5ML SYRUP | ADD QL 20 ML PER DAY |
ANTIHISTAMINES | PEDIACLEAR 8 LIQUID | ADD QL 60 ML PER DAY |
ANTIHISTAMINES | AHIST 25MG TABLET | ADD QL 3 TABLETS PER DAY |
ANTIHYPERTENSIVES* | TRYVIO 12.5MG TABLET | ADD PA AND QL 1 TABLET PER DAY |
ANTIMALARIALS |
| ADD ST AND QL |
ANTIMALARIALS | PLAQUENIL 200MG TABLET | ADD ST AND QL 3 TABLETS PER DAY |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ANKTIVA 400MCG SOLUTION | ADD PA |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | OJEMDA 25MG/ML SUSPENSION | ADD PA AND QL |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | OJEMDA 100MG TABLET | ADD PA AND QL |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IMDELLTRA 1MG INJECTION | ADD PA |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | OGSIVEO 100MG TABLET | ADD QL 2 TABLETS PER DAY |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | RETEVMO 40MG CAPSULE | UPDATE QL 3 CAPSULES PER DAY |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* | TEVIMBRA 100MG/10 ML INJECTION | ADD PA |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | RETEVMO 40MG TABLET | ADD QL 2 TABLETS PER DAY |
CARDIOVASCULAR AGENTS - MISC. |
| ADD PA AND QL 1 KIT PER 3 WEEKS |
DERMATOLOGICALS | SKLICE 0.5% LOTION | ADD QL 120 GM PER 30 DAYS |
GASTROINTESTINAL AGENTS - MISC. | IQIRVO 80MG TABLET | ADD PA AND QL 1 TABLET PER DAY |
HEMATOLOGICAL AGENTS - MISC | VOYDEYA 50-100MG TABLET | ADD PA AND QL 6 TABLETS (THREE 50 MG TABLETS AND THREE 100 MG TABLETS) PER DAY |
HEMATOLOGICAL AGENTS - MISC | VOYDEYA 100MG TABLET | ADD PA AND QL 6 TABLETS PER DAY |
HEMATOLOGICAL AGENTS - MISC | VOYDEYA 50-100MG TABLET BLISTER CARD
| ADD QL 4 BLISTER CARDS (168 TABLETS [EIGHTY-FOUR 50 MG TABLETS AND EIGHT-FOUR 100MG TABLETS]) PER 28 DAYS |
HEMATOLOGICAL AGENTS – MISC* | VOYDEYA 100MG TABLET BLISTER CARD | 4 BLISTER CARDS (168 TABLETS) PER 28 DAYS |
HEMATOPOIETIC AGENTS | XOLREMDI 100MG CAPSULE | ADD PA AND QL 4 CAPSULES PER DAY |
IMMUNOSUPPRESSIVE AGENTS | CELLCEPT 200MG/ML ORAL SUSPENSION | ADD PA |
MIGRAINE PRODUCTS | ERGOMAR 2MG SUBLINGUAL TABLET | ADD ST AND QL 20 TABLETS PER 30 DAYS |
MISCELLANEOUS THERAPEUTIC CLASSES | VIJOICE 50MG AND VIJOICE 125MG TABLET | UPDATE QL 1 TABLET PER DAY |
MISCELLANEOUS THERAPEUTIC CLASSES | VIJOICE 250MG TABLET | UPDATE QL 2 TABLETS PER DAY |
MISCELLANEOUS THERAPEUTIC CLASSES | VIJOICE 50MG GRANULES PACKET | ADD QL 1 PACKET PER DAY |
NEUROMUSCULAR AGENTS | DUVYZAT 8.86MG SUSPENSION | ADD PA AND QL 12 ML PER DAY |
PRENATAL VITAMINS | ALIVE PREMIUM PRENATAL COMPLETE CHEW TABLET | ADD QL 2 CHEWABLES PER DAY |
PRENATAL VITAMINS | OBTREX DHA PAK | ADD QL 2 PER DAY (1 TABLET/1 SOFTGEL) |
PRENATAL VITAMINS | ONE A DAY PRENATAL ADVANCED COMPLETE MULTIVITAMIN/BRAIN SUPPLEMENT | ADD QL 2 PER DAY (1 TABLET/1 SOFTGEL) |
PRENATAL VITAMINS* | PRENATAL ESSENTIALS CAPSULE | ADD QL 5 CAPSULES PER DAY |
PRENATAL VITAMINS | VITAFUSION PRENATAL CHEWABLE TABLET | ADD QL 2 CHEWABLE TABLETS PER DAY |
TETRACYCLINES | NUZYRA 150MG TABLET | ADD QL 30 TABLETS PER FILL; 1 FILL PER 30 DAYS |
*This change will be implemented once the medication is on the market.
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 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 https://providers.anthem.com/va > Eligibility & Pharmacy > Pharmacy Information > Anthem HealthKeepers Plus Searchable Formulary.
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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