HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsApril 4, 2025
Quarterly pharmacy formulary change notice
The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus and Family Access to Medical Insurance Security Plan (FAMIS) (CHIP) members. These changes were reviewed and approved at the fourth quarter 2024 pharmacy and therapeutics committee meeting.
Effective May 1, 2025, formulary changes, non‑formulary changes, and preapproval requirements will apply. Remember to read the footnotes at the end of the table.
UM EDITS — EFFECTIVE FOR ALL MEMBERS NO LATER THAN MAY 1, 2025 | ||
ANDROGENS* | UNDECATREX CAPSULES | ADD PA AND QL 200 MG: 4 CAPSULES PER DAY 100 AND 150 MG: 2 CAPSULES PER DAY |
ANTIANXIETY AGENTS | ALPRAZOLAM 0.25 MG TABLET ALPRAZOLAM 0.5 MG TABLET ALPRAZOLAM 1 MG TABLET ALPRAZOLAM 2 MG TABLET LORAZEPAM 0.5 MG TABLET | UPDATE QL 4 TABLETS PER DAY |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BORUZU 3.5MG/1.4ML INJECTION | ADD PA |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ITOVEBI 3MG TABLET ITOVEBI 9MG TABLET | ADD PA AND QL 3MG: 2 TABLETS PER DAY 9 MG: 1 TABLET PER DAY |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TECENTRIQ HYBREZA INJECTION | ADD PA |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TRUQAP 160MG TABLET TRUQAP 200MG TABLET TRUQAP 160MG THERAPY PACK TRUQAP 200MG THERAPY PACK | ADD QL 6 TABLETS PER 28 DAYS OR 1 CARTON (64 TABLETS) PER 28 DAYS |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | XALKORI 20MG CAPSULE | UPDATE QL 8 CAPSULES PER DAY |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | XALKORI 50MG CAPSULE | UPDATE QL 4 CAPSULES PER DAY |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | XALKORI 150MG CAPSULE | UPDATE QL 6 CAPSULES PER DAY |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LYTGOBI THERAPY PACK 4 MG (12 MG DAILY DOSE) | ADD QL 35 TABLETS PER 7 DAYS (1 CARTON PER 7 DAYS) |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LYTGOBI THERAPY PACK 4 MG (16 MG DAILY DOSE) | ADD QL 28 TABLETS PER 7 DAYS (1 CARTON PER 7 DAYS)
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ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LYTGOBI THERAPY PACK 4 MG (20 MG DAILY DOSE) | ADD QL 21 TABLETS PER 7 DAYS (1 CARTON PER 7 DAYS) |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ROZLYTREK PAK 50MG | UPDATE QL 12 PACKETS PER DAY |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BIZENGRI 375MG/18.75 ML INJECTION | ADD PA AND QL 4 VIALS PER 28 DAYS |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IMKELDI 80MG/ML SOLUTION | ADD PA AND QL 10 MLS PER DAY |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DANZITEN 71MG TABLET DANZITEN 95MG TABLET | ADD PA AND QL 4 TABLETS PER DAY |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | REVUFORJ 110 MG TABLETS REVUFORJ 160 MG TABLETS | ADD PA AND QL 110 MG 4 TABLETS PER DAY 160 MG 2 TABLETS PER DAY |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* | REVUFORJ 25MG TABLET | ADD QL 6 TABLETS PER DAY |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ZIIHERA 300MG INJECTION | ADD PA |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VYLOY 100MG INJECTION | ADD PA |
ANTIPARKINSON AND RELATED THERAPY AGENTS | CREXONT 35‑140MG CAPSULE | ADD QL 15 CAPSULES PER DAY |
ANTIPARKINSON AND RELATED THERAPY AGENTS | CREXONT 52.5‑210MG CAPSULE | ADD QL 10 CAPSULES PER DAY |
ANTIPARKINSON AND RELATED THERAPY AGENTS | CREXONT 70‑280MG CAPSULE | ADD QL 7 CAPSULES PER DAY |
ANTIPARKINSON AND RELATED THERAPY AGENTS | CREXONT 87.5‑350MG CAPSULE | ADD QL 6 CAPSULES PER DAY |
ANTIPARKINSON AND RELATED THERAPY AGENTS | VYALEV 12‑240MG INJECTION | ADD PA AND QL 42 VIALS (4200 ML) (6 CARTONS) PER 28 DAYS |
ANTIVIRALS | PREVYMIS 20MG PAK PREVYMIS 120MG PAK | ADD QL 810 PACKETS PER YEAR |
CARDIOVASCULAR AGENTS ‑ MISC. | ATTRUBY 356MG PAK | ADD PA AND QL 4 TABLETS PER DAY (1 PACK OF 112 TABLETS PER 28 DAYS) |
DERMATOLOGICALS | EMROSI 40MG CAPSULE | ADD PA AND QL 1 CAPSULE PER DAY |
DERMATOLOGICALS | MONDOXYNE NL 100MG CAPSULE | ADD STEP THERAPY |
ENDOCRINE AND METABOLIC AGENTS ‑ MISC.* | BYNFEZIA 2,500 MCG/ML PEN | ADD QL 1 PEN PER 14 DAYS |
HEMATOLOGICAL AGENTS ‑ MISC.* | BKEMV 300 MG/30ML INJECTION EPYSQLI 300 MG/30 ML INJECTION | ADD PA AND QL 8 VIALS PER 28 DAYS |
HEMATOLOGICAL AGENTS ‑ MISC. | FIBRYGA 1GM INJECTION | ADD PA |
MEDICAL DEVICES AND SUPPLIES | RELIZORB CARTRIDGE | UPDATE QL 6 CARTRIDGES PER DAY |
MEDICAL DEVICES AND SUPPLIES | CEQUR SIMPLICITY PATCH | ADD QL 8 PATCHES PER 32 DAYS |
MEDICAL DEVICES AND SUPPLIES | OMNIPOD GO KIT 20UNIT/DAY OMNIPOD GO KIT 40UNIT/DAY OMNIPOD GO KIT 25UNIT/DAY OMNIPOD GO KIT 15UNIT/DAY OMNIPOD GO KIT 35UNIT/DAY OMNIPOD GO KIT 10UNIT/DAY OMNIPOD GO KIT 30UNIT/DAY | ADD QL 10 PODS PER 30 DAYS |
MEDICAL DEVICES AND SUPPLIES | V‑GO 40 KIT V‑GO 20 KIT V‑GO 30 KIT | ADD QL 30 PUMPS PER 30 DAYS |
MULTIVITAMINS | TRI‑VI‑ FLOR /TRI‑VI‑ FLORO SUSPENSION, QUFLORA GUMMY, MULTI‑ VIT‑FL CHEWABLE, POLY‑VI‑ FLOR CHEWABLE/ SUSPENSION, POLY‑ VI‑FLOR /IRON CHEWABLE/ SUSPENSION, QUFLORA PED CHEWABLE/SOLUTION, QUFLORA FE CHEWABLE/ LIQUID, FLORAFOL /FLORAFOL PED CHEWABLE, FLORAFOL FE SOLUTION, DAVIMET /FLUORIDE CHEWABLE, FLORIVA LIQUID/ CHEWABLE, FLORIVA PLUS SOLUTION | ADD STEP THERAPY |
* EDIT WILL BE IMPLEMENTED WHEN THE MEDICATION IS AVAILABLE ON THE MARKET
What action do I need to take?
Please review these changes and work with your patients to transition them to formulary alternatives. If you determine formulary alternatives are not clinically appropriate for specific patients, you will need to obtain preapproval 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 preapproval. You can find the searchable formulary on our provider website at https://providers.anthem.com/virginia-provider/home > Eligibility & Pharmacy > Pharmacy Information > FAMIS Formulary.
If you have any questions about this communication, 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-081034-25
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