HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsJuly 3, 2023
Quarterly Pharmacy Formulary Changes effective August 1, 2023
Please note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc.
The formulary changes listed in the table below apply to all FAMIS and Anthem HealthKeepers Plus members. These changes were reviewed and approved at the first quarter 2023 Pharmacy and Therapeutics Committee meeting.
Effective August 1, 2023, 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 August 1, 2023 | |||
Therapeutic class | Drug | Revised status | Potential alternatives |
OVER THE COUNTER AGENTS | (GENERIC) BROMPHENIRAMINE & PHENYLEPHRINE ELIXIR CAPSAICIN CREAM CHLORPHENIRAMINEIRAMINE & PHENYLEPHRINERINE LIQUID CHLORPHENIRAMINEIRAMINE & PHENYLEPHRINERINE TABLET CHLORPHENIRAMINEIRAMINE & PSEUDOEPHEDRINE TABLET CHLORPHENIRAMINEIRAMINE-DM LIQUID CHLORPHENIRAMINEIRAMINE-DM TABLET DEXBROMPHENIRAMINE-PHENYLEPHRINERINE TABLET DEXTROMETHORPHAN-GUAIFENESIN CAPSULE DEXTROMETHORPHAN-GUAIFENESIN LIQUID DEXTROMETHORPHAN-GUAIFENESIN TABLET DEXTROMETHORPHAN-GUAIFENESIN TABLET ER DIPHENHYDRAMINE-PHENYLEPHRINERINE LIQUID DIPHENHYDRAMINE-PHENYLEPHRINERINE SOLUTION DIPHENHYDRAMINE-PHENYLEPHRINERINE TABLET DIPHENHYDRAMINE-ZINC ACETATE CREAM DIPHENHYDRAMINE-ZINC ACETATE LIQUID DOCUSATE SODIUM ENEMA DOXYLAMINE-DM LIQUID DOXYLAMINE-PHENYLEPHRINERINE TABLET EPHEDRINE-GUAIFENESIN TABLET GUAIFENESIN TABLET ER LIDOCAINE (ANORECTAL) GEL LIDOCAINE (ANORECTAL) SUPP MENTHOL (TOPICAL ANALGESIC) GEL MENTHOL (TOPICAL ANALGESIC) LIQUID MENTHOL-METHYL SALICYLATE CREAM MENTHOL-METHYL SALICYLATE OINTMENT MENTHOL-METHYL SALICYLATE STICK OXYMETAZOLINE HCL SOLUTION PHENYLEPHRINERINE HCL SOLUTION PHENYLEPHRINERINE HCL TABLET PHENYLEPHRINERINE W/ DM-GUAIFENESIN LIQUID PHENYLEPHRINERINE W/ DM-GUAIFENESIN SYRUP PHENYLEPHRINERINE W/ DM-GUAIFENESIN TABLET PHENYLEPHRINERINE-BROMPHENIRAMINE-DM LIQUID PHENYLEPHRINERINE-CHLORPHENIRAMINE-DM LIQUID PHENYLEPHRINERINE-DM SOLUTION PHENYLEPHRINERINE-GUAIFENESIN LIQUID PHENYLEPHRINERINE-GUAIFENESIN TABLET PHENYLEPHRINERINE-IBUPROFEN TABLET PSEUDOEPHEDRINEED-BROMPHEN-DM SYRUP PSEUDOEPHEDRINEEDRINE HCL TABLET PSEUDOEPHEDRINEEDRINE W/ DM-GUAIFENESIN LIQUID PSEUDOEPHEDRINEEDRINE-DEXCHLORPHENIRAMINEIRAMINE-DEXTROMETHORPHAN LIQUID PSEUDOEPHEDRINEEDRINE-GUAIFENESIN SYRUP PSEUDOEPHEDRINEEDRINE-GUAIFENESIN TABLET PSEUDOEPHEDRINEEDRINE-GUAIFENESIN TABLET ER PSYLLIUM POWDER WHEAT DEXTRIN POWDER |
PREFERRED
PREFERRED
|
N/A
N/A |
OVER THE COUNTER AGENTS | BENADRYL ITCH GEL 2% COLACE CLEAR 50MG CAPSULE DOCUSATE MINI ENENMA 283MG ICY HOT PAD 5% ITCH ERASER SPRAY 2% KONSYL DAILY POW 100% LIDOCAINE CREAM 5% PHOS-NAK POWDER CONCENTRATE PROMETH VC 6.25-5/5 SYRUP ZOSTRIX HP CREAM 0.1% | NOT COVERED | GENERIC DOCUSATE SODIUM ENEMA MENTHOL GEL LIDOCAINE GEL |
UM edits – effective for all members no later than August 1, 2023 No changes in preferred/non-preferred status revision or addition to UM edit only | |||
ANTIASTHMATIC AND BRONCHODILATOR AGENTS | TEZSPIRE SOL 210MG | update QL 1 pen/syringe/vial per 28 days | |
ANTIASTHMATIC AND BRONCHODILATOR AGENTS | Airsupra inhaler | add pa and ql 3 inhalers per 30 days | |
ANTIASTHMATIC AND BRONCHODILATOR AGENTS | NUCALA 40MG/0.4 inj | add ql 40 mg (1 syringe) every 4 weeks | |
ANTIDIABETICS* | Brenzavvy 20 mg tablet | add ql 1 tablet per day | |
ANTIDIABETICS | Tempo Smart Button | 1 smart button every 8 months | |
ANTIDIABETICS | Tempo Refill Kit | 2 kits per 30 days | |
ANTI-INFECTIVE AGENTS - MISC. | nitrofurantoin monohydrate macrocrystals 100 mg capsule nitrofurantoin macrocrystals 25 mg, 50 mg, 100 mg capsule NITROFURANToin 25MG/5ML suspension FOSFOMYCIN 3GM powder Cleocin (clindamycin) 150 mg/mL injection Cleocin (clindamycin) 75 mg capsule Cleocin (clindamycin) 150 mg capsule Cleocin (clindamycin) 300 mg capsule | remove ql | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VIVIMUSTA 100/4ML inj | add pa | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CALQUENCE 100MG tablet CALQUENCE 100MG capsule | add ql 2 per day | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* | Adstiladrin INJ | add pa | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KRAZATI 200MG tablet | add pa and QL 6 tablets per day | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | JAYPIRCA 50MG tablet JAYPIRCA 100MG tablet | add pa and ql 50 mg: 1 tablet per day 100mg: 2 tablets per day | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LUNSUMIO 30MG/30 inj | add pa | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ORSERDU 86MG tablet ORSERDU 345MG tablet | add pa and ql 86 mg: 3 tablets per day 345 mg: 1 tablet per day | |
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TURALIO 125MG capsule | add ql 4 capsules per day | |
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES | Idacio 40 mg/0.8 mL prefilled pen/syringe | ADD QL 2 pens/syringes per 28 daysB | |
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES | Idacio Crohn’s Disease/Ulcerative Colitis starter pack 40 mg/0.8 mL prefilled pen Idacio Psoriasis starter pack 40 mg/0.8 mL prefilled pen | ADD QL 1 pack (28 day supply, one time fill) | |
ANTIVIRALS | SUNLENCA INJ | Add QL 2 VIALS EVERY 24 WEEKS | |
ANTIVIRALS | SUNLENCA 300MG TABLET
| ADD QL 1 PACK (4 TABLETS) PER FILL 1 PACK (5 TABLETS) PER FILL | |
COUGH/COLD/ALLERGY
| Dextromethorphan 15 mg capsules Dextromethorphan 30 mg/5 mL oral suspension Dextromethorphan 15 mg/5 mL oral solution/susp/syrup Dextromethorphan 12.5 mg/5 ml oral liquid Dextromethorphan 10 mg/5 ml oral liquid Dextromethorphan 7.5 mg/5 mL oral solution/susp/syrup Dextromethorphan 7.5 mg oral strip/chew tablet Dextromethorphan 5 mg lozenge Dextromethorphan/guaifenesin 20 mg/400 mg/5 mL Liquid Guaifenesin 200 mg Tablet Guaifenesin 400 mg Tablet Guaifenesin Er Tablet 600 mg Guaifenesin Er Tablet 1200 mg Guaifenesin 100 mg/5 mL liquid Guaifenesin 150 mg/15 mL liquid Guaifenesin 200 mg/5 mL liquid Dextromethorphan/guaifenesin syrup/solution Promethazine/Dextromethorphan Syrup Promethazine/Phenylephrine Syrup 6.25-5 mg/5 mL Pseudoephedrine Er tabLET 12 hour 120 mg Pseudoephedrine Er tabLET 24 hour 240 mg Pseudoephedrine 30 mg tablet Pseudoephedrine 60mg tablet Pseudoephedrine Oral Solution 15 mg/5 mL, 30 mg/5 mL | remove ql | |
DERMATOLOGICALS | NEXOBRID 8.8% GEL | ADD PA AND ql 440 GRAMS PER 2 DAYS | |
DERMATOLOGICALS | KLISYRI 1% OINTMENT
| UPDATE QL 5 packets per fill;1 fill per year | |
DERMATOLOGICALS
| ACITRETIN 25MG CAPSULE
| ADD QL 2 capsules per day | |
DERMATOLOGICALS
| ACITRETIN 10MG CAPSULE ACITRETIN 17.5MG CAPSULE | ADD QL 1 capsule per day | |
DIGESTIVE AIDS | SUCRAID 8500/ML oral solution
| update ql 360 mL per 30 days | |
DIGESTIVE AIDS | SUCRAID 17,000/2ML single use container
| udpate ql 360 mL per 30 days | |
ENDOCRINE AND METABOLIC AGENTS - MISC. | LAMZEDE 10MG INJ
| add pa | |
GASTROINTESTINAL AGENTS - MISC. | REBYOTA FECAL suspension
| add pa and ql One 150 mL dose, one time | |
GENITOURINARY AGENTS – MISC. | FILSPARI 200MG tablet FILSPARI 400MG tablet | add pa and ql 1 tablet per day | |
HEMATOLOGICAL AGENTS - MISC. | Soliris 300 mg/30 mL vial | add qL 8 vials per 28 days | |
HEMATOLOGICAL AGENTS - MISC.* | Jesduvroq tablet
| add pa and QL 1mg, 2mg, 4mg tablet: 1 per day 6mg tablet: 2 per day 8mg tablet: 3 per day | |
LAXATIVES | CLENPIQ SOLution | update ql 350 mL per 30 days | |
METABOLIC MODIFIERS* | Olpruya powder packet | add ql 1 KIT (90 DOSAGE ENVELOPES) PER 30 DAYS | |
MISCELLANEOUS THERAPEUTIC CLASSES | JOENJA 70MG tablet | add pa and ql 2 tablets per day | |
MISCELLANEOUS THERAPEUTIC CLASSES | VIJOICE 50MG tablet VIJOICE 125MG TABLET | Update QL 28 tablets per 28 days | |
MISCELLANEOUS THERAPEUTIC CLASSES | VIJOICE 250MG TABLET | ADD QL 56 TABLETS PER 28 DAYS | |
NEUROMUSCULAR AGENTS | SKYCLARYS 50MG CAPSULE | ADD Pa AND QL 3 capsules per day | |
NEUROMUSCULAR AGENTS | DAYBUE 200MG/ML SOLUTION
| ADD Pa AND QL 120 mL per day (60 mL twice daily) | |
OPHTHALMIC AGENTS | SYFOVRE 15/0.1ML INJ | ADD PA | |
PENICILLINS
| Amoxicillin 125 mg/5 mL, 200 mg/5 mL, 250 mg/5 mL, 400 mg/5 mL suspension Amoxicillin/clavulanate potassium 1,000 mg/62.5 mg 12HR tablet | REMOVE QL | |
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | BRIUMVI 150/6ML INJ
| ADD PA AND QL 3 VIALS EVERY 24 WEEKS | |
* 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 Anthem HealthKeepers Plus Provider Services at 800-901-0020.
VABCBS-CD-028367-23
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