State & FederalHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsAugust 1, 2020

Quarterly pharmacy formulary change notice

The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) members.

Effective July 1, 2020, formulary changes, non-formulary changes and prior authorization requirements will apply.

Effective for all members on July 1, 2020
Therapeutic class	Medication	Formulary status change	Potential alternatives (preferred products)
ADHD AGENTS	DYANAVEL XR 2.5 MG/ML SUSPENSION	NON-PREFERRED	Vyvanse capsules/chewable tablet Adderall XR capsules Dextroamphetamine tablet
ADHD AGENTS	QUILLIVANT XR 25 MG/5 ML SUSPENSION QUILLICHEW ER 40 MG CHEW TABLET QUILLICHEW ER 20 MG CHEW TABLET QUILLICHEW ER 30 MG CHEW TABLET	NON-PREFERRED	Focalin XR capsules Daytrana transdermal patch Concerta tablet methylphenidate IR capsules/tablet
ANDROGENS	ANDROGEL 1.62%(1.25G) GEL PACKET	NON-PREFERRED WITH PA	testosterone pump (genric androgel) PA required
ANTIDIABETIC COMBINATIONS	INVOKAMET 50-500 MG TABLET INVOKAMET 50-1,000 MG TABLET INVOKAMET 150-500 MG TABLET INVOKAMET 150-1,000 MG TABLET XIGDUO XR 2.5 MG-1,000 MG TAB XIGDUO XR 5 MG-500 MG TABLET XIGDUO XR 5 MG-1,000 MG TABLET XIGDUO XR 10 MG-500 MG TABLET XIGDUO XR 10 MG-1,000 MG TAB	PREFERRED WITH MIN AGE LIMIT OF 18 YEARS AND OLDER	N/A
INSULIN	HUMALOG JR HUMALOG MIX 50/50 HUMALOG 100/ML VIAL	PREFERRED	N/A
INSULIN	INSULIN LISPRO KWIKPEN ADMELOG SOLOSTAR	NON-PREFERRED	HUMALOG KWIK INJ 100/ML
INSULIN	NOVOLIN N FLEXPEN	NON-PREFERRED	HUMULIN N KWIKPEN
INSULIN	NOVOLIN 70/30 FLEXPEN	NON-PREFERRED	HUMULIN 70/30 KWIKPEN
URINARY ANTISPASMODICS	SOLIFENACIN 5 MG TABLET SOLIFENACIN 10 MG TABLET	PREFERRED	N/A
URINARY ANTISPASMODICS	VESICARE 5 MG TABLET VESICARE 10 MG TABLET	NON-PREFERRED	SOLIFENACIN 5 MG TABLET SOLIFENACIN 10 MG TABLET

Edits effective July 1, 2020 No changes in preferred/nonpreferred status revision or addition to UM edit only
Therapeutic class	Medication	Formulary status change
ALLERGENIC EXTRACTS	PALFORZIA CAPSULES	PA REQUIRED
ANALGESICS - ANTI-INFLAMMATORY	OLUMIANT 1 MG TABLET OLUMIANT 2 MG TABLET	ADD QTY LIMIT 30 PER 30 DAYS
ANALGESICS - ANTI-INFLAMMATORY	OTEZLA 30 MG TABLET	ADD QTY LIMIT 60 PER 30 DAYS
ANTIRHEUMATIC ANTIMETABOLITES	OTREXUP INJECTIONS RASUVO INJECTIONS	ADD QTY LIMIT 4 PER 28 DAYS
HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS	WAKIX 4.45MG TABLET WAKIX 17.8MG TABLET	PA REQUIRED
INTERLEUKIN-1 RECEPTOR ANTAGONIST	KINERET INJ	ADD QTY LIMIT 30 PER 30 DAYS
MIGRAINE PRODUCTS	REYVOW TABLET UBRELVY TABLET	PA REQUIRED

What action do I need to take?

Please review these changes and work with your Anthem HealthKeepers Plus 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 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 1-800-901-0020 (Anthem HealthKeepers Plus members) or 1-855-323-4687 (Anthem CCC Plus members) and follow the voice prompts for pharmacy prior authorization. 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 our Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.

AVA-NU-0266-20

PUBLICATIONS: August 2020 Anthem Provider News - Virginia

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Quarterly pharmacy formulary change notice

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