HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsFebruary 1, 2025
Quarterly pharmacy formulary change notice
The formulary changes listed in the table below were reviewed and approved at our Pharmacy and Therapeutics Committee meeting for the third quarter of 2024. Effective February 1, 2025, the changes outlined below apply to all Anthem HealthKeepers Plus members.
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Effective for all patients on February 1, 2025 | |||
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Therapeutic class |
Drug |
Revised status |
Potential alternatives |
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INSULIN |
INSULIN GLARGINE 100U/ML VIAL/PEN INSULIN GLARGINE-YFGN 100U/ML VIAL /PEN GLARGINE-YFGN 100U/ML VIAL/PEN |
PREFERRED |
N/A |
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INSULIN |
BASAGLAR KWIKPEN |
NON-PREFERRED |
INSULIN GLARGINE 100U/ML VIAL/PEN INSULIN GLARGINE-YFGN 100U/ML VIAL /PEN GLARGINE-YFGN 100U/ML VIAL/PEN LANTUS/LANTUS SOLOSTAR |
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INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) |
TRULICITY 0.75MG/0.5ML TRULICITY 1.5MG/0.5ML TRULICITY 3MG/0.5ML TRULICITY 4.5MG/0.5ML |
NON-PREFERRED |
OZEMPIC INJECTION LIRAGLUTIDE INJECTION (PA REQUIRED) |
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STIMULANTS - MISC. |
ARMODAFINIL 50MG TABLET ARMODAFINIL 150MG TABLET ARMODAFINIL 200MG TABLET ARMODAFINIL 250MG TABLET MODAFINIL 100MG TABLET MODAFINIL 200MG TABLET |
PREFERRED WITH PA |
N/A |
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UM edits – effective for all members no later than February 1, 2025 No changes in preferred/nonpreferred status revision or addition to UM edit only | ||
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ANALGESICS - OPIOID |
OXYCODONE/APAP 5/325 MG/5 ML SOLUTION |
UPDATE QL: 60 ML PER DAY |
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ANALGESICS - OPIOID |
APAP/CODEINE 120MG-12MG/5ML SUSPENSION OR ELIXIR |
UPDATE QL: 90 ML PER DAY* |
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ANTIASTHMATIC AND BRONCHODILATOR AGENTS |
OHTUVAYRE 3MG/2.5ML AMPULE |
ADD PA AND QL: 1 CARTON (60 AMPULES) PER 30 DAYS |
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ANTICONVULSANTS |
XCOPRI 25MG TABLET |
ADD QL: 1 TABLET PER DAY |
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ANTICONVULSANTS |
VIGADRONE 500MG TABLET |
ADD QL: 6 TABLETS PER DAY |
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ANTICONVULSANTS |
VIGAFYDE 100MG/ML ORAL SOLUTION |
ADD PA AND QL: 750 ML PER 30 DAYS |
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ANTICONVULSANTS |
VIGADRONE 500MG POWDER PACKET |
ADD QL: 6 PACKETS PER DAY |
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ANTICONVULSANTS |
XCOPRI 12.5MG TABLET |
ADD QL: 1 TABLET PER DAY |
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ANTIDEMENTIA AGENTS |
ZUNVEYL (BENZGALANTAMINE) 5 MG TABLET ZUNVEYL (BENZGALANTAMINE) 10 MG TABLET ZUNVEYL (BENZGALANTAMINE) 15 MG TABLET |
ADD QL: 2 TABLETS PER DAY
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ANTIDIABETICS |
ZITUVIMET XR 50-500MG TABLET ZITUVIMET XR 50-1000MG TABLET |
ADD QL: 2 TABLETS PER DAY |
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ANTIDIABETICS |
ZITUVIMET XR 100-1000MG TABLET |
ADD QL: 1 TABLET PER DAY |
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ANTIDOTES AND SPECIFIC ANTAGONISTS |
NALOXONE 0.4MG/ML INJECTION NALOXONE HCL 1MG/ML INJECTION NALOXONE INJECTION 2 MG/2 ML PREFILLED SYRINGE NALOXONE INJECTION 4 MG/10 ML VIAL |
ADD QL: 6 CARPUJECTS/ PREFILLED SYRINGES/ VIALS PER 3 MONTHS |
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ANTIDOTES AND SPECIFIC ANTAGONISTS |
ZURNAI (NALMEFENE)1.5 MG/0.5 ML INJECTION |
ADD QL: 6 AUTOINJECTORS PER 3 MONTHS |
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ANTIDOTES AND SPECIFIC ANTAGONISTS |
RIVIVE 3MG/0.1ML NASAL SPRAY REXTOVY 4 MG/0.25 ML NASAL SPRAY REZENOPY 10 MG/0.11 ML NASAL SPRAY |
ADD QL: 6 NASAL SPRAYS (3 CARTONS) PER 3 MONTHS |
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ANTIHYPERTENSIVES |
BENAZEPRIL 5MG TABLET
BENAZEPRIL 20MG TABLET ENALAPRIL 2.5MG TABLET ENALAPRIL 5MG TABLET ENALAPRIL 10MG TABLET ENALAPRIL/ HYDROCHLOROTHIAZIDE 5 MG/12.5 MG TABLET FOSINOPRIL 10 MG TABLET FOSINOPRIL 20 MG TABLET LISINOPRIL 2.5MG TABLET LISINOPRIL 5MG TABLET LISINOPRIL 10MG TABLET LISINOPRIL 20MG TABLET MOEXIPRIL 7.5MG TABLET QUINAPRIL 5MG TABLET QUINAPRIL 10MG TABLET QUINAPRIL 20MG TABLET |
UPDATE QL: 4 TABLETS PER DAY
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ANTIHYPERTENSIVES |
CAPTOPRIL 12.5MG TABLET CAPTOPRIL 25MG TABLET CAPTOPRIL 50MG TABLET |
UPDATE QL: 6 TABLETS PER DAY |
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ANTIHYPERTENSIVES |
RAMIPRIL 1.25MG CAPSULE RAMIPRIL 2.5MG CAPSULE RAMIPRIL 5MG CAPSULE |
UPDATE QL: 4 CAPSULES PER DAY |
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ANTIHYPERTENSIVES |
CATAPRES-TTS-1 (CLONIDINE) 0.1 MG TRANSDERMAL PATCH CATAPRES-TTS-2 (CLONIDINE) 0.2 MG TRANSDERMAL PATCH |
UPDATE QL: 12 PATCHES PER 28 DAYS |
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ANTIHYPERTENSIVES |
CLONIDINE 0.1MG TABLET CLONIDINE 0.2MG TABLET |
UPDATE QL: 6 TABLETS PER DAY |
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ANTIHYPERTENSIVES |
GUANFACINE 1MG TABLET |
UPDATE QL: 2 TABLETS PER DAY |
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ANTIHYPERTENSIVES |
METHYLDOPA 250MG TABLET |
UPDATE QL: 6 TABLETS PER DAY |
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ANTIHYPERTENSIVES |
AMLODIPINE/ BENAZEPRIL 2.5-10MG CAPSULE AMLODIPINE/ BENAZEPRIL 5-10MG CAPSULE AMLODIPINE/ BENAZEPRIL 5-20MG CAPSULE |
UPDATE QL: 2 CAPSULES PER DAY |
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ANTIHYPERTENSIVES |
LOTENSIN HCT (BENAZEPRIL/ HYDROCHLOROTHIAZIDE) 5 MG/6.25 MG TABLET LOTENSIN HCT (BENAZEPRIL/ HYDROCHLOROTHIAZIDE) 10 MG/12.5 MG TABLET ZESTORETIC (LISINOPRIL/ HYDROCHLOROTHIAZIDE) 10 MG/12.5 MG TABLET AZOR (AMLODIPINE/ OLMESARTAN) 5 MG/20 MG TABLET EXFORGE (AMLODIPINE/ VALSARTAN) 5 MG/160 MG TABLET HYZAAR (LOSARTAN/ HYDROCHLOROTHIAZIDE) 50 MG/12.5 MG TABLET BENICAR HCT (OLMESARTAN/ HYDROCHLOROTHIAZIDE) 20 MG/12.5 MG TABLET MICARDIS HCT (TELMISARTAN/ HYDROCHLOROTHIAZIDE) 40 MG/12.5 MG TABLET DIOVAN HCT (VALSARTAN/ HYDROCHLOROTHIAZIDE) 80 MG/12.5 MG, 160 MG/12.5 MG TABLET DIOVAN HCT (VALSARTAN/ HYDROCHLOROTHIAZIDE) 80 MG/12.5 MG, 160 MG/12.5 MG TABLET EXFORGE HCT (AMLODIPINE/ VALSARTAN/ HCTZ) 5 MG/160 MG/12.5 MG TABLET TRIBENZOR (AMLODIPINE/ OLMESARTAN/HCTZ) 5 MG/20 MG/12.5 MG TABLET TWYNSTA (AMLODIPINE/ TELMISARTAN) 5 MG/40 MG TABLET |
UPDATE QL: 2 TABLETS PER DAY
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ANTIHYPERLIPIDEMICS |
EZETIMIBE 10MG TABLET |
REMOVE STEP THERAPY |
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ANTIMYASTHENIC/ CHOLINERGIC AGENTS |
FIRDAPSE 10MG TABLET |
UPDATE QL: 10 TABLETS PER DAY |
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ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES |
AKEEGA 50/500MG TABLET AKEEGA 100/500 TABLET |
UPDATE QL: 2 TABLETS PER DAY |
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ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES |
TAFINLAR 10 MG TABLETS FOR ORAL SUSPENSION |
UPDATE QL: 30 TABLETS PER DAY |
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ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES |
PEMAZYRE 4.5MG TABLET PEMAZYRE 9MG TABLET |
UPDATE QL: 1 TABLET PER DAY |
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ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES |
RYTELO 47MG VIAL RYTELO 188MG VIAL |
ADD PA AND DOSING: 7.1 MG/KG PER 4 WEEKS |
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ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES |
LAZCLUZE 80MG TABLET LAZCLUZE 240MG TABLET |
ADD PA AND QL: 80 MG: 2 TABLETS PER DAY 240 MG: 1 TABLET PER DAY
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ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES |
VORANIGO 10MG TABLET VORANIGO 40MG TABLET |
ADD PA AND QL:
10MG: 2 TABLETS PER DAY 40 MG: 1 TABLET PER DAY |
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ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES |
TECELRA INJECTION |
ADD PA |
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ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES |
LYMPHIR INJECTION |
ADD PA |
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ANTIPSORIATICS |
TALTZ 20MG/0.5ML SYRINGE TALTZ 40MG/0.5ML SYRINGE |
ADD QL: 1 SYRINGE PER 28 DAYS |
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ANTIPSYCHOTICS/ ANTIMANIC AGENTS |
ERZOFRI 39 MG ER INJECTION ERZOFRI 78 MG ER INJECTION ERZOFRI 117 MG ER INJECTION ERZOFRI 156 MG ER INJECTION ERZOFRI 234 MG ER INJECTION |
ADD PA AND QL: 1 KIT EVERY 30 DAYS
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ANTIPSYCHOTICS/ ANTIMANIC AGENTS |
ERZOFRI 351 MG ER INJECTION |
ADD PA AND QL: 1 KIT, ONE TIME FILL |
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ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES |
SIMLANDI 40MG/0.4ML SYRINGE SIMLANDI 40/0.4ML 1 PEN KIT |
ADD QL: 2 AUTOINJECTORS/ SYRINGES PER 28 DAYS |
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ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES |
SIMLANDI 20MG/0.2ML SYRINGE |
ADD QL: 2 SYRINGES PER 28 DAYS |
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ANTIVIRALS |
EDURANT PED 2.5 MG TABLET FOR ORAL SUSPENSION |
ADD QL: 6 TABLETS PER DAY |
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ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS |
ONYDA XR 0.1MG/ML SUSPENSION |
ADD PA AND REMOVE QL: 4 ML PER DAY |
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ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS |
KAPVAY 0.1 MG TABLET |
REMOVE QL: 4 TABLETS PER DAY |
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ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS |
INTUNIV 1MG TABLET INTUNIV 2MG TABLET
INTUNIV 4MG TABLET |
REMOVE QL: 1 TABLET PER DAY |
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ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS |
STRATTERA (ATOMOXETINE) 10MG CAPSULE STRATTERA (ATOMOXETINE) 18MG CAPSULE STRATTERA (ATOMOXETINE) 25MG CAPSULE STRATTERA (ATOMOXETINE) 40MG CAPSULE |
REMOVE DOSE OP: 2 CAPSULES PER DAY
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ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS |
STRATTERA (ATOMOXETINE) 60MG CAPSULE STRATTERA (ATOMOXETINE) 80MG CAPSULE STRATTERA (ATOMOXETINE) 100MG CAPSULE |
REMOVE DOSE OP: 1 CAPSULE PER DAY
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ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS |
QELBREE (VILOXAZINE) 100MG CAPSULE |
REMOVE DOSE OP: 1 CAPSULE PER DAY |
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ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS |
QELBREE (VILOXAZINE) 150MG CAPSULE |
REMOVE DOSE OP: 2 CAPSULES PER DAY |
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ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS |
QELBREE (VILOXAZINE) 200MG CAPSULE |
REMOVE DOSE OP: 3 CAPSULES PER DAY |
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BENIGN PROSTATIC HYPERPLASIA AGENTS |
TEZRULY (TERAZOSIN) 1 MG/ML ORAL SOLUTION |
ADD PA AND QL: 20 ML PER DAY |
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BENIGN PROSTATIC HYPERTROPHY AGENTS |
CHEWTADZY 5MG CHEWABLE TABLET |
NEW PA AND QL: 1 TABLET PER DAY |
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BETA BLOCKERS |
NADOLOL 20MG TABLET NADOLOL 40MG TABLET |
UPDATE QL: 4 TABLETS PER DAY |
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BETA BLOCKERS |
PROPRANOLOL 10 MG TABLET PROPRANOLOL 20 MG TABLET PROPRANOLOL 40 MG TABLET PROPRANOLOL 60 MG TABLET |
UPDATE QL: 8 TABLETS PER DAY |
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BETA BLOCKERS
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COREG CR (CARVEDILOL ER) 10 MG CAPSULE COREG CR (CARVEDILOL ER) 20 MG CAPSULE INDERAL LA (PROPRANOLOL ER) 60 MG CAPSULE INDERAL LA (PROPRANOLOL ER) 80 MG CAPSULE INDERAL LA (PROPRANOLOL ER) 120 MG CAPSULE |
UPDATE QL: 4 CAPSULES PER DAY |
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BETA BLOCKERS
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COREG (CARVEDILOL) 3.125 MG TABLET COREG (CARVEDILOL) 6.25 MG TABLET COREG (CARVEDILOL) 12.5 MG TABLET |
UPDATE QL: 4 TABLETS PER DAY
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BETA BLOCKERS |
COREG CR (CARVEDILOL ER) 40 MG CAPSULE |
UPDATE QL: 2 CAPSULES PER DAY |
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BETA BLOCKERS |
LABETALOL 100 MG TABLET LABETALOL 200 MG TABLET |
UPDATE QL: 12 TABLETS PER DAY |
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BONE DENSITY REGULATORS |
JUBBONTI 60MG/ML INJECTION |
ADD PA AND QL: 60 MG (1 PREFILLED SYRINGE) EVERY 6 MONTHS |
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BONE DENSITY REGULATORS |
WYOST 120 MG/1.7 ML VIAL |
ADD PA AND QL: 1 VIAL PER 28 DAYS |
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CARDIOVASCULAR AGENTS MISC. - COMBINATIONS |
OPSYNVI TABLET |
ADD PA |
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CONTINUOUS GLUCOSE SYSTEM SUPPLIES
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FREESTYLE LIBRE 3 SENSOR PLUS |
ADD QL: 2 SENSORS PER 30 DAYS |
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CONTRACEPTIVES |
ENILLORING VAGINAL RING |
ADD QL: 1 RING PER 28 DAYS |
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COUGH/COLD/ALLERGY |
HYCODAN 5MG-1.5MG TABLET |
ADD QL: 30 TABLETS PER 5 DAYS; 2 FILLS PER 30 DAYS |
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COUGH/ COLD/ ALLERGY |
HYCODAN 5MG-1.5MG/5ML SYRUP/SOLUTION |
ADD QL: 150 ML PER 5 DAYS; 2 FILLS PER 30 DAYS |
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COUGH/ COLD/ ALLERGY |
TUZISTRA XR SUSPENSION |
ADD QL: 100 ML PER 5 DAYS; 2 FILLS PER 30 DAYS |
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COUGH/ COLD/ ALLERGY |
TUXARIN ER 54.3MG-8MG TABLET |
ADD QL: 10 TABLETS PER 5 DAYS; 2 FILLS PER 30 DAYS |
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COUGH/ COLD/ ALLERGY |
PROMETHAZINE/ CODEINE SYRUP |
UPDATE QL: 150 ML PER 5 DAYS; 2 FILLS PER 30 DAYS |
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COUGH/COLD/ALLERGY |
HYDROCODONE POLISTIREX/ CHLORPHENIRAMINE POLISTIREX 10MG-8MG/5ML SUSPENSION |
UPDATE QL:50 ML PER 5 DAYS; 2 FILLS PER 30 DAYS |
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COUGH/ COLD/ ALLERGY |
PROMETHAZINE AND PHENYLEPHRINE WITH CODEINE SYRUP |
UPDATE QL: 150 ML PER 5 DAYS; 2 FILLS PER 30 DAYS |
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COUGH/ COLD/ ALLERGY |
M-END PE LIQUID RYDEX LIQUID |
ADD QL: 450 ML PER 5 DAYS; 2 FILLS PER 30 DAYS |
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COUGH/ COLD/ ALLERGY |
POLY-TUSSIN AC LIQUID CAPCOF 5-2-10MG SYRUP MAR-COF BP (PSEUDOEPHEDRINE- BROMPHENIRAMINE- CODEINE) LIQUID |
ADD QL: 300 ML PER 5 DAYS; 2 FILLS PER 30 DAYS |
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COUGH/ COLD/ ALLERGY |
MAXI-TUSS CD LIQUID |
ADD QL: 150 ML PER 5 DAYS; 2 FILLS PER 30 DAYS |
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COUGH/ COLD/ ALLERGY |
HISTEX-AC SYPRUP |
ADD QL: 100 ML PER 5 DAYS; 2 FILLS PER 30 DAYS |
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COUGH/ COLD/ ALLERGY |
GUAIFENESIN- CODEINE SOLUTION |
UPDATE QL:300 ML PER 5 DAYS; 2 FILLS PER 30 DAYS |
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COUGH/ COLD/ ALLERGY |
TUSNEL C (PSEUDOEPHEDRINE- GUAIFENESIN WITH CODEINE) SYRUP TRIACIN C (PSEUDOEPHEDRINE- TRIPOLIDINE- CODEINE) SYRUP |
ADD QL: 200 ML PER 5 DAYS; 2 FILLS PER 30 DAYS |
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DERMATOLOGICALS |
ZORYVE (ROFLUMILAST) 0.15% CREAM |
ADD PA AND QL: 60 GM PER 30 DAYS |
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DERMATOLOGICALS |
ADBRY 300MG/2ML INJECTION |
ADD QL: 1 AUTOINJECTOR PER 28 DAYS |
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DERMATOLOGICALS |
TREMFYA 200MG/20ML INJECTION |
ADD QL: 3 VIALS TOTAL TO LAST 12 WEEKS |
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DERMATOLOGICALS |
TREMFYA 100MG/ML PEN/SYRINGE |
UPDATE QL: 1 PEN/SYRINGE PER 56 DAYS (8 WEEKS) |
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DERMATOLOGICALS |
TREMFYA 200MG/2ML PEN/SYRINGE |
ADD QL: 1 PEN/SYRINGE PER 28 DAYS(4 WEEKS) |
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DERMATOLOGICALS |
EBGLYSS 250MG/2ML INJECTION |
ADD PA AND QL: 1 PEN/SYRINGE PER 28 DAYS |
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DERMATOLOGICALS |
NEMLUVIO 30MG INJECTION |
ADD PA AND QL: 1 PEN PER 28 DAYS |
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DERMATOLOGICALS |
QBREXZA 2.4% PAD |
ADD PA |
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DERMATOLOGICALS |
SOFDRA 12.45% GEL |
ADD QL: 1 BOTTLE (40.2 ML) PER 30 DAYS |
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ENDOCRINE AND METABOLIC AGENTS - MISC. |
YORVIPATH 168MCG/0.56ML INJECTION YORVIPATH 294MCG/0.98ML INJECTION YORVIPATH 420MCG/1.4ML INJECTION |
ADD PA AND QL: 2 PREFILLED PENS (1 PACK) PER 28 DAYS
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ENDOCRINE AND METABOLIC AGENTS - MISC. |
XENPOZYME 4MG INJECTION |
ADD DOSING: 3 MG/KG EVERY 2 WEEKS |
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GASTROINTESTINAL AGENTS - MISC. |
LIVDELZI 10MG CAPSULE |
NEW PA AND QL: 1 CAPSULE PER DAY |
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HEMATOLOGICAL AGENTS - MISCELLANEOUS |
PIASKY 340MG/2ML INJECTION |
ADD PA AND QL: 3 VIALS PER 28 DAYS |
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HEMATOPOIETIC AGENTS
|
VAFSEO 150MG TABLET VAFSEO 300MG TABLET VAFSEO 450MG TABLET |
ADD PA AND QL: 150MG AND 450MG: 1 TABLET PER DAY 300MG: 2 TABLETS PER DAY |
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HEMATOPOIETIC AGENTS |
NYPOZI 300 MCG/0.5 ML INJECTION |
ADD PA |
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IMMUNOGLOBULINS |
YIMMUGO 100MG/ML INJECTION |
ADD PA |
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IMMUNOMODULATORS |
VYVGART HYTRULO SINGLE DOSE VIAL |
UPDATE QL: 4 VIALS PER 28 DAYS |
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IMMUNOSUPPRESSIVE AGENTS |
BENLYSTA 200 MG/ML PREFILLED SYRINGE OR AUTOINJECTOR |
ADD DOSING: 15 KG TO LESS THAN 40 KG: 2 INJECTIONS PER 28 DAYS
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INTERLEUKIN ANTAGONISTS
|
STELARA 5MG/ML INJECTION STELARA 45MG/0.5ML INJECTION STELARA 90MG/ML INJECTION |
ADD STEP THERAPY |
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INTERLEUKIN ANTAGONISTS |
SKYRIZI 600 MG/10 ML SINGLE-DOSE VIAL |
UPDATE QL: 6 VIALS TOTAL TO LAST 12 WEEKS |
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INTERLEUKIN ANTAGONISTS |
SKYRIZI 90MG/ML PEN |
UPDATE QL: 2 PREFILLED PENS PER 56 DAYS (8 WEEKS) |
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MISCELLANEOUS AGENTS |
NIKTIMVO INJECTION |
ADD PA |
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MISCELLANEOUS THERAPEUTIC AGENTS |
RYSTIGGO 280MG/2ML VIAL |
ADD QL: 840 MG OR 6 ML (3 VIALS) ONCE WEEKLY FOR 6 WEEKS (6 WEEKS = 1 CYCLE) |
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MISCELLANEOUS THERAPEUTIC AGENTS |
RYSTIGGO 420MG/3ML VIAL |
ADD QL: 3 ML (1 VIAL) ONCE WEEKLY FOR 6 WEEKS (6 WEEKS= 1 CYCLE) |
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MISCELLANEOUS THERAPEUTIC AGENTS |
RYSTIGGO 560MG/4ML VIAL |
ADD QL: 4 ML (1 VIAL) ONCE WEEKLY FOR 6 WEEKS (6 WEEKS = 1 CYCLE) |
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MISCELLANEOUS THERAPEUTIC AGENTS |
RYSTIGGO 840MG/6ML VIAL |
ADD QL: 6 ML (1 VIAL) ONCE WEEKLY FOR 6 WEEKS (6 WEEKS = 1 CYCLE) |
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MUSCULOSKELETAL THERAPY AGENTS |
BACLOFEN 15MG TABLET |
ADD QL: 3 TABLETS PER DAY |
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OPHTHALMIC AGENTS
|
PAVBLU 2MG INJECTION ENZEEVU 2MGINJECTION AHZANTIVE 2MG INJECTION YESAFILI 2MG INJECTION OPUVIZ 2MG INJECTION |
ADD PA AND DOSING DIABETIC MACULAR EDEMA, DIABETIC RETINOPATHY, NEOVASCULAR “WET” AGE-RELATED MACULAR DEGENERATION, RETINAL VEIN OCCLUSION: 2 MG PER EYE; EACH EYE MAY BE TREATED AS FREQUENTLY AS EVERY 4 WEEKS. RETINOPATHY OF PREMATURITY: 0.4 MG PER EYE; EACH EYE MAY BE TREATED AS FREQUENTLY AS EVERY 10 DAYS |
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PROTON PUMP INHIBITORS |
DEXILANT 30MG CAPSULE DEXILANT 60MG CAPSULE |
REMOVE QL: 1 CAPSULE PER DAY |
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PROTON PUMP INHIBITORS |
NEXIUM (ESOMEPRAZOLE) 20 MG TABLET/ CAPSULE OTC |
REMOVE QL: 2 CAPSULES/TABLETS PER DAY |
|
PROTON PUMP INHIBITORS |
NEXIUM 2.5MG GRANULES PACKET NEXIUM 5MG GRANULES PACKET NEXIUM 10MG GRANULES PACKET NEXIUM 20MG GRANULES PACKET NEXIUM 40MG GRANULES PACKET |
REMOVE QL: 1 PACKET PER DAY |
|
PROTON PUMP INHIBITORS |
NEXIUM (ESOMEPRAZOLE) 20 MG RX NEXIUM (ESOMEPRAZOLE) 40 MG RX PREVACID (LANSOPRAZOLE) RX 15 MG PREVACID (LANSOPRAZOLE) RX 30 MG PREVACID (LANSOPRAZOLE) ODT 15 MG PREVACID (LANSOPRAZOLE) ODT 30 MG PRILOSEC (OMEPRAZOLE) RX 10 MG PRILOSEC (OMEPRAZOLE) RX 20 MG
|
REMOVE QL: 1 CAPSULE/TABLET PER DAY |
|
PROTON PUMP INHIBITORS |
PRILOSEC OTC 20MG TABLET PREVACID 24 HR (LANSOPRAZOLE) 15 MG OTC OMEPRAZOLE 20 MG ODT |
REMOVE QL: 2 CAPSULES/TABLETS PER DAY |
|
PROTON PUMP INHIBITORS |
PRILOSEC 2.5MG POWDER PACKET PRILOSEC 10MG POWDER PACKET |
REMOVE QL: 1 PACKET PER DAY |
|
PROTON PUMP INHIBITORS |
PROTONIX 20MG TABLET PROTONIX 40MG TABLET |
REMOVE QL: 1 TABLET/PACKET OF GRANULES FOR SUSPENSION PER DAY |
|
PROTON PUMP INHIBITORS |
RABEPRAZOLE 20MG TABLET/CAPSULE RABEPRAZOLE 10MG TABLET/CAPSULE |
REMOVE QL: 1 TABLET/CAPSULE PER DAY |
|
PROTON PUMP INHIBITORS |
ZEGERID 20-1100MG CAPSULE OTC ZEGERID 20-1100MG CAPSULE RX ZEGERID 40-1100MG CAPSULE RX |
REMOVE QL: 1 CAPSULE PER DAY |
|
PROTON PUMP INHIBITORS |
ZEGERID 20-1680MG PACKET ZEGERID 40-1680MG PACKET |
REMOVE QL: 1 PACKET PER DAY |
|
PROTON PUMP INHIBITORS |
RABEPRAZOLE 5MG TABLET/CAPSULE |
REMOVE QL: 1 TABLET/CAPSULE PER DAY |
|
PROTON PUMP INHIBITORS |
ESOMEPRAZOLE STRONTIUM 49.3 MG CAPSULE |
REMOVE QL: 1 CAPSULE PER DAY |
|
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. |
AUSTEDO 6MG TABLET
|
UPDATE QL: 2 TABLETS PER DAY |
|
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. |
AUSTEDO XR 6MG TABLET AUSTEDO XR 12MG TABLET |
UPDATE QL:1 TABLET PER DAY |
|
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. |
AUSTEDO XR 18MG TABLET ER |
ADD QL: 1 TABLET PER DAY |
|
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. |
AUSTEDO XR 24MG TABLET |
UPDATE QL: 2 1 TABLETS PER DAY |
|
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. |
AUSTEDO XR 30MG TABLET ER AUSTEDO XR 36MG TABLET ER AUSTEDO XR 42MG TABLET ER AUSTEDO XR 48MG TABLET ER |
ADD QL: 1 TABLET PER DAY |
|
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. |
INGREZZA 40MG CAPSULE INGREZZA 60MG CAPSULE INGREZZA 80MG CAPSULE |
ADD QL: 1 CAPSULE PER DAY |
|
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. |
HORIZANT 300MG TABLET ER HORIZANT 600MG TABLET ER |
ADD ST
|
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PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. |
OCREVUS ZUNOVO 920 MG AND 23,000 UNITS/23 ML SINGLE-DOSE VIAL |
ADD PA AND QL: 1 VIAL PER 6 MONTHS |
|
VASOPRESSORS |
NEFFY 2MG/0.1ML NASAL SPRAY |
ADD QL: 1 CARTON (2 SINGLE-DOSE NASAL SPRAYS) PER FILL; 4 FILLS PER CALENDAR YEAR |
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 preferred formulary alternatives are not clinically appropriate for specific patients, you will need to obtain prior authorization (PA) to continue coverage beyond the applicable effective date.
What if I need assistance?
We recognize the unique aspects of patients’ cases. If for medical reasons your patient cannot be converted to a formulary alternative, call our Pharmacy department at 844‑396‑2330 and follow the voice prompts for pharmacy PA. You can find the Preferred Drug List on our provider website.
If you need assistance with any other item, reach out to your local provider relationship management representative or contact Provider Services 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.
VABCBS-CD-076347-25
PUBLICATIONS: February 2025 Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/virginia/articles/quarterly-pharmacy-formulary-change-notice-23807
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