HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsSeptember 1, 2020
Quarterly pharmacy formulary change notice
The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus members (including those enrolled in FAMIS [the CHIP program] and Medallion [the Medicaid program]) and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) members. These changes were reviewed and approved at the fourth quarter pharmacy and therapeutics committee meeting.
Effective August 1, 2020, formulary changes, non-formulary changes and prior authorization (PA) requirements will apply. Remember to read the footnotes at the end of the table.
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Effective for all members on August 1, 2020 |
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Therapeutic class |
Medication |
Formulary status change |
Potential alternatives (preferred products) |
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Continuous Blood Glucose System |
DEXCOM GLUCOSE AND FREESTYLE LIBRE SYSTEM SENSOR TRANSMITTER RECEIVER |
Preferred with PA under the pharmacy benefit |
n/A |
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Edits effective August 1, 2020 No changes in preferred/nonpreferred status revision or addition to UM edit only |
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Therapeutic class |
Medication |
Formulary status change |
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ACNE PRODUCTS |
AKLIEF CRE 0.005% |
ADD PA ADD QL 1 pump per 30 days |
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AMZEEQ AER 4% |
ADD PA ADD QL 30 GRAMS PER 30 DAYS |
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ABSORICA LD CAP 8MG ABSORICA LD CAP 16MG ABSORICA LD CAP 24MG ABSORICA LD CAP 32MG |
ADD PA add ql 30 day supply per fill |
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ADENOSINE TRIPHOSPHATE-CITRATE LYASE (ACL) INHIBITORS |
NEXLETOL TAB 180MG |
ADD PA ADD QL 1 TABLET PER DAY |
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AGENTS FOR CONSTIPATION |
IBSRELA TAB 50 MG* |
add pa add ql 2 TABLETS per day |
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AGENTS FOR CONSTIPATION |
PIZENSY* |
add pa; add ql 20 grams per day |
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ALS AGENTS |
EXSERVAN 50 MG FILM* |
add st add pa add ql 4 films per day |
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ANTICONVULSANTS - BENZODIAZEPINES |
VALTOCO SPR 5MG |
ADD PA ADD QL 10 CARTONS PER 30 DAYS |
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ANTIDIABETIC COMBINATIONS |
TRIJARDY XR TAB 5-2.5-1000MG TRIJARDY XR TAB 12.5-2.5-1000MG |
ADD ST ADD QL 2 TABLETS PER DAY |
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TRIJARDY XR TAB 10-5-1000MG TRIJARDY XR TAB 25-5-1000MG |
ADD ST ADD QL 1 TABLET PER DAY |
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ANTIHYPERLIPIDEMICS |
NEXLIZET TAB 180MG* |
add pa Add ql 1 tablet per day |
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ANTIMETABOLITES |
REDITREX INJ* |
add pa add ql 4 auto-injectors per 28 days |
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ANTINEOPLASTIC - ANTIBODIES |
PADCEV INJ 20MG ENHERTU INJ 100MG |
add pa |
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ANTINEOPLASTIC ENZYME INHIBITORS |
AYVAKIT TAB 100MG |
ADD PA ADD QL 1 tablet per day |
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TAZVERIK TAB 200MG |
ADD PA ADD QL 8 tablets per day |
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ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS |
KAPVAY TAB 0.1 MG |
ADD QL 4 tablets per DAY |
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BONE DENSITY REGULATORS |
BONSITY INJ 620MCG/2.48ML* |
add pa add ql 1 pen per 28 days |
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CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG |
VYEPTI INJ 100MG/ML |
add pa ADD ST ADD QL 1 vial per 3 months |
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NURTEC CHW 75MG ODT |
ADD ST ADD QL 15 tablets per 30 days |
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DIBENZAPINES |
SECUADO DIS 3.8MG |
ADD QL 1 patch per day |
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FERTILITY REGULATORS |
NOVAREL INJ 5000UNIT PREGNYL INJ 10000UNT |
add pa |
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GLUCOCORTICOSTEROIDS |
HEMADY TAB 20MG* |
add pa add ql 2 tablets per day |
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HEMATOPOIETIC GROWTH FACTORS |
ZIEXTENZO INJ 6/0.6ML |
add pa add ql 2 syringes |
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REBLOZYL INJ 25MG REBLOZYL INJ 75MG |
add pa |
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UDENYCA INJ 6MG/.6ML |
add st add pa |
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NEULASTA INJ 6MG/0.6M |
add pa |
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OTIC COMBINATIONS |
CORTISPORIN SUS -TC OTIC |
add st |
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PLEUROMUTILINS |
XENLETA TAB 600MG |
add pa add ql 10 tablets per fill; 1 fill per 30 days |
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PROTECTIVES AGAINST UV RADIATION |
SCENESSE IMP 16MG |
add pa add ql 1 implant per 2 months |
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SOMATOSTATIC AGENTS |
BYNFEZIA PEN 2500MCG/ML |
add pa add ql 1 pen per 14 days |
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TARGETED IMMUNE MODULATORS |
AVSOLA 100MG VIAL* |
add pa |
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ABRILADA 10 MG/0.2 ML, 20 MG/0.4 ML PREFILLED SYRINGE |
add pa add ql 2 pens/syringes per 28 days |
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ABRILADA 40MG/0.8 ML PREFILLED PEN/SYRINGE |
add pa add ql 2 syringes per 28 days |
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* Medication will be added to the formulary when it is available on the market.
What action do I need to take?
Please review these changes and work with your Anthem HealthKeepers Plus patients 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 PA to continue coverage beyond the applicable effective date.
What if I need assistance?
We recognize the unique aspects of patient 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 PA. 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 Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.
AVA-NU-0279
PUBLICATIONS: September 2020 Anthem Provider News - Virginia
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Visit https://providernews.anthem.com/virginia/articles/quarterly-pharmacy-formulary-change-notice-6-5656
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