February 2025 Provider Newsletter

Contents

AdministrativeAnthem Blue Cross and Blue Shield | CommercialJanuary 16, 2025

Submitting authorization for NICU services facilitates accurate and timely claims processing

AdministrativeAnthem Blue Cross and Blue Shield | CommercialFebruary 1, 2025

Medical records needed for accurate payment of certain facility inpatient claims

AdministrativeAnthem Blue Cross and Blue Shield | CommercialAnthem Blue Cross and Blue Shield | Medicare AdvantageHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsFebruary 1, 2025

New Communication Center added to Availity Essentials

Education & TrainingHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsFebruary 1, 2025

Claims billing education: Medicaid secondary billing errors

Education & TrainingAnthem Blue Cross and Blue Shield | CommercialAnthem Blue Cross and Blue Shield | Medicare AdvantageHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsJanuary 1, 2025

Enhance billing and coding accuracy with new Payment Integrity training

Education & TrainingHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsJanuary 30, 2025

Important update: group billable status for FQHCs and RHCs

Federal Employee Program (FEP)Anthem Blue Cross and Blue Shield | CommercialFebruary 1, 2025

Corrected claim guidance for the Federal Employee Program®

Federal Employee Program (FEP)Anthem Blue Cross and Blue Shield | CommercialJanuary 14, 2025

Authorization for post‑acute care services for FEP members

PharmacyAnthem Blue Cross and Blue Shield | CommercialFebruary 1, 2025

Pharmacy information available on our provider website

PharmacyHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsFebruary 1, 2025

Quarterly pharmacy formulary change notice

PharmacyAnthem Blue Cross and Blue Shield | CommercialJanuary 27, 2025

Key formulary updates: effective January 1, 2025

PharmacyHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsJanuary 28, 2025

FAMIS formulary and Preferred Drug List update

PharmacyAnthem Blue Cross and Blue Shield | CommercialFebruary 1, 2025

Clinical Criteria updates for specialty pharmacy are available

PharmacyHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsJanuary 6, 2025

Prior authorization updates for medications billed under the medical benefit

Quality ManagementAnthem Blue Cross and Blue Shield | CommercialAnthem Blue Cross and Blue Shield | Medicare AdvantageFebruary 1, 2025

2025 Clinical Quality in Practice webinar series

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AdministrativeAnthem Blue Cross and Blue Shield | CommercialJanuary 16, 2025

Submitting authorization for NICU services facilitates accurate and timely claims processing

As a crucial part of our commitment to providing the highest quality care and ensuring accuracy and timelines in the processing of claims, please remember to obtain prior authorization for neonatal intensive care unit (NICU) services at the level you intend to provide services.

Obtaining prior authorization helps us:

  • Ensure timely and appropriate care for our smallest and most vulnerable patients.
  • Streamline the claims process, thereby reducing delays and potential denials.
  • Facilitate accurate and efficient billing, which saves time and resources for everyone involved.

Please ensure all nonemergent NICU services are prior authorized before the commencement of treatment and continue to provide updates concurrently. This proactive step is essential for maintaining smooth and efficient operations. Prior authorization is not required for emergent NICU services or NICU services provided in the first 48 hours following birth for vaginal delivery and 96 hours following birth for cesarian delivery.

Should you have any questions or need further assistance with the authorization process, please do not hesitate to contact Provider Services via the number on the back of our member ID card.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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AdministrativeAnthem Blue Cross and Blue Shield | CommercialFebruary 1, 2025

Medical records needed for accurate payment of certain facility inpatient claims

To help ensure inpatient claims are processed quickly and accurately, and consistent with our Claims Requiring Additional Documentation reimbursement policy, starting May 1, 2025, inpatient claims with billed charges over $100,000, reimbursed partly or fully based on a percentage of charges, must include the full medical record upon submission. There is no impact to a member's ability to receive care.

The claim and medical record may be reviewed prior to claim payment or audited after claim payment. If claims meeting the above criteria are received without medical records, the claim will not be eligible for reimbursement until submitted with the appropriate documentation.

To view the full reimbursement policy, please visit our website: anthem.com/provider

Submit medical records with initial claim filing

Facilities can proactively submit medical records digitally with the initial claim filing via our preferred clearinghouse, Availity Essentials (https://Availity.com), through the Claim Status application. For additional options on claim and medical record submission, consult the provider manual at anthem.com/provider.

If your facility is not already registered for Availity Essentials or the Medical Attachments application, complete registration at https://Availity.com. Registering for the application allows facilities to receive digital notifications if documentation is required to complete a claim.

Training resources on submitting medical records attachments are available on our Digital Solutions Learning Hub. Trainings that begin with Attachments in the title provide education on this topic.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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AdministrativeAnthem Blue Cross and Blue Shield | CommercialAnthem Blue Cross and Blue Shield | Medicare AdvantageHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsFebruary 1, 2025

New Communication Center added to Availity Essentials

In March, we will add new functionality to the provider enrollment and network management tool hosted on Availity Essentials to improve the correspondence experience. We will start posting letters related to your credentialing directly in the Communication Center and you will be able to download the correspondence as a PDF.

How will this help you:

  • Convenience — reduced time spent sorting through mailed documents
  • Faster access — no need to wait for mail service delivery
  • Ease of access — access your correspondence 24/7 digitally
  • Environmental benefits — saving paper and printing costs helps you and the planet

Before you begin

If your organization is not currently registered for Availity Essentials, the person in your organization designated as the Availity administrator should go to https://Availity.com and select Get Started. If you need assistance registering with Availity Essentials, visit https://www.availity.com/customer-support.

For organizations already using Availity Essentials, your administrator(s) will automatically be granted access to the provider enrollment tool.

Staff using the provider enrollment tool need to be granted the user role Provider Enrollment by an administrator. To find yours, go to My Account Dashboard >My Account > Organization(s) > Administrator Information.

At this time, Carelon Behavioral Health is out‑of-scope for this implementation.

Accessing the Communication Center

1. Log in to https://Availity.com.

2. Select your market.

3. Select Payer Spaces in the top menu.

4. Select the brand that corresponds to your market.

5. Accept the User Agreement (once every 365 days).

6. On the Applications tab, select Provider Enrollment and Network Management.

7. Select the Communication Center link under the My Communications option on the side menu.

8. Enter your TIN and NPI to access the letters.

Carelon Behavioral Health, Inc. is an independent company providing utilization management services on behalf of the health plan.

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 Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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Education & TrainingHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsFebruary 1, 2025

Claims billing education: Medicaid secondary billing errors

Please review your electronic claims submission procedures and ensure all claims are submitted with the correct Claims Filing Indicator Codes as outlined below. Accurate use of these codes is crucial for the correct adjudication and payment of claims.

We identified an issue with claims when Medicare or Commercial is the primary payer and Medicaid is secondary. Claims are processing incorrectly due to provider billing errors. According to the DMAS Technical Manual, the Claims Filing Indicator Code is a mandatory field.

For electronic claims submissions, consult the Commonwealth of Virginia’s encounter processing solution (EPS) claims submission rules, which include the following guidelines for 837 transactions. Adhering to these guidelines will prevent recoupments and claims processing errors.

Claims filing requirements:

  • Loop 2320 (Other Subscriber Information):
    • Is used to report payment/adjudication information.
    • Must be repeated for each payer involved (including MCO entities).
  • Loop 2330B: Identifies the Payer.
  • Loop 2430: Contains detailed adjudication/payment information.
  • SBR01 (Payer Responsibility Sequence Number):
    • Indicates the order of claim adjudication when multiple payers are involved.
    • Medicaid is always the payer of last resort:
      • P = Primary, S = Secondary, T = Tertiary
  • SBR09 (Filing Indicator Code):
    • Mandatory to specify the carrier type:
      • Example: “MB” for Medicare Part B
      • “MC” for Medicaid (including MCOs)
  • Loop 2430, SVD01 (Other Payer Primary Identifier):
    • Must match the value in Loop 2330B, NM109 (Other Payer Primary Identifier) for complete adjudication information.
  • Filing Indicator Requirements:
    • When Medicaid is the primary payer, use Indicator MC = Medicaid/MCO.
    • When Medicaid is the secondary payer, use: MA = Medicare A, MB = Medicare B, OF = Medicare D, or CI = Commercial Insurance.

Please refer to EPS Support | MES (virginia.gov) for further information.

Contact us

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop‑down. Then, select Chat with Payer and complete the pre‑chat form to start your chat.

For additional support, visit the Contact Us section of our provider website for the appropriate contact.

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.

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Education & TrainingAnthem Blue Cross and Blue Shield | CommercialAnthem Blue Cross and Blue Shield | Medicare AdvantageHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsJanuary 1, 2025

Enhance billing and coding accuracy with new Payment Integrity training

We’re excited to introduce two new Payment Integrity trainings available on our Digital Solutions Learning Hub:

  • Payment Integrity: Emergency Dept Evaluation and Management Services
  • Payment Integrity: Outpatient Evaluation and Management Services

With an initial focus on these two key educational initiatives, our purpose is to amplify your billing and coding accuracy.

More trainings will be announced throughout the year.

Discover what our Digital Solutions Learning Hub has to offer.

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 Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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Education & TrainingHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsJanuary 30, 2025

Important update: group billable status for FQHCs and RHCs

On April 1, 2025, the following updates on billing processes will apply to Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), based on their enrollment type in PRSS.

Claims from FQHCs and RHCs will be processed at the group level. Please ensure you comply with the following requirements when submitting claims. Claims that do not meet these new requirements may not be accepted.

When Medicaid is the primary payer:

  • Bill the rendering NPI when required to submit a CMS‑1500 claim form.
  • Place of Service (POS) codes:
    • FQHCs should bill using POS 50.
    • RHCs should bill using POS 72.

When Medicaid is the secondary payer:

  • If Commercial insurance is the primary payer, utilize the CMS‑1500 claim form with the Place of Service requirements above.
  • If Medicare is the primary payer, follow CMS guidelines for FQHC and RHC billing.

Enrollment and claims information:

  • FQHCs and RHCs are enrolled in PRSS under the enrollment type Facility/Organization and can bill for all services using their facility/organization NPI.
  • FQHCs and RHCs are not required to affiliate their practitioners in PRSS.
  • Ordering, Referring, and Prescribing (ORP) practitioners at FQHCs and RHCs must be enrolled with DMAS as participating providers.

Contact us

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop‑down. Then, select Chat with Payer and complete the pre‑chat form to start your chat.

For additional support, visit the Contact Us section of our provider website for the appropriate contact.

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.

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Federal Employee Program (FEP)Anthem Blue Cross and Blue Shield | CommercialFebruary 1, 2025

Corrected claim guidance for the Federal Employee Program®

Our digital first approach enables providers to submit EDI corrected claims through Availity Essentials or the electronic data interchange (EDI).

Corrected claim guidance

When submitting a corrected claim, include all previous information along with any corrections or additions.

To correct a claim billed to us in error, submit the entire claim as a void/cancel. A new claim may be required if we identify missing or incorrect information based on the guidelines in the Claims Submission section. Providers will receive written or electronic notification indicating the missing data.

The provider manual at https://tinyurl.com/ms4vanmh offers guidance on submitting corrected claims, helping to prevent issues with reimbursement.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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Federal Employee Program (FEP)Anthem Blue Cross and Blue Shield | CommercialJanuary 14, 2025

Authorization for post‑acute care services for FEP members

For services beginning on January 1, 2025, prior authorization requests for admission to or concurrent stay requests in an inpatient acute rehab facility (ARF) or long‑term acute care hospital (LTACH) will be handled by the FEP Case Management team to review for medical necessity and care coordination. This change impacts members of the Anthem Blue Cross and Blue Shield Federal Employee Program® (FEP®), including Federal Employee Health Benefit (FEHB) and Postal Service Health Benefit (PSHB), The FEP Case Management team may be contacted by phone at 800‑711-2225 for FEHB members or 833‑277-5220 for PSHB members. Clinical information should be faxed to 866‑862-4288.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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PharmacyAnthem Blue Cross and Blue Shield | CommercialFebruary 1, 2025

Pharmacy information available on our provider website

Visit the Drug List page on our website for more information about:

  • Copayment/coinsurance requirements and their applicable drug classes.
  • Drug lists and changes.
  • Prior authorization criteria.
  • Procedures for generic substitution.
  • Therapeutic interchange.
  • Step therapy or other management methods subject to prescribing decisions.
  • Any other requirements, restrictions, or limitations that apply to using certain drugs.

The commercial and exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October.

To locate the exchange, select Formulary and Pharmacy Information and scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.

Federal Employee Program pharmacy updates and other pharmacy‑related information may be accessed at fepblue.org > Pharmacy Benefits.

Please call provider services to request a copy of the pharmaceutical information available online if you do not have internet access.

Through our efforts, we are committed to reducing the administrative burden because we value you, our care provider partner.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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PharmacyHealthKeepers, 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.

Effective for all patients on February 1, 2025

Therapeutic class

Drug

Revised status

Potential alternatives

INSULIN

INSULIN GLARGINE 100U/ML VIAL/PEN

INSULIN GLARGINE-YFGN 100U/ML VIAL /PEN

GLARGINE-YFGN 100U/ML VIAL/PEN

PREFERRED

N/A

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

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)

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

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

ANALGESICS - OPIOID

OXYCODONE/APAP 5/325 MG/5 ML SOLUTION

UPDATE QL: 60 ML PER DAY

ANALGESICS - OPIOID

APAP/CODEINE 120MG-12MG/5ML SUSPENSION OR ELIXIR

UPDATE QL: 90 ML PER DAY*

ANTIASTHMATIC AND BRONCHODILATOR AGENTS

OHTUVAYRE 3MG/2.5ML AMPULE

ADD PA AND QL: 1 CARTON (60 AMPULES) PER 30 DAYS

ANTICONVULSANTS

XCOPRI 25MG TABLET

ADD QL: 1 TABLET PER DAY

ANTICONVULSANTS

VIGADRONE 500MG TABLET

ADD QL: 6 TABLETS PER DAY

ANTICONVULSANTS

VIGAFYDE 100MG/ML ORAL SOLUTION

ADD PA AND QL:

750 ML PER 30 DAYS

ANTICONVULSANTS

VIGADRONE 500MG POWDER PACKET

ADD QL: 6 PACKETS PER DAY

ANTICONVULSANTS

XCOPRI 12.5MG TABLET

ADD QL: 1 TABLET PER DAY

ANTIDEMENTIA AGENTS

ZUNVEYL (BENZGALANTAMINE)

5 MG TABLET

ZUNVEYL (BENZGALANTAMINE)

10 MG TABLET

ZUNVEYL (BENZGALANTAMINE)

15 MG TABLET

ADD QL: 2 TABLETS PER DAY

ANTIDIABETICS

ZITUVIMET XR 50-500MG TABLET

ZITUVIMET XR 50-1000MG TABLET

ADD QL: 2 TABLETS PER DAY

ANTIDIABETICS

ZITUVIMET XR 100-1000MG TABLET

ADD QL: 1 TABLET PER DAY

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

ANTIDOTES AND SPECIFIC ANTAGONISTS

ZURNAI (NALMEFENE)1.5 MG/0.5 ML INJECTION

ADD QL: 6 AUTOINJECTORS PER 3 MONTHS

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

ANTIHYPERTENSIVES

BENAZEPRIL 5MG TABLET
BENAZEPRIL 10MG 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

ANTIHYPERTENSIVES

CAPTOPRIL 12.5MG TABLET

CAPTOPRIL 25MG TABLET

CAPTOPRIL 50MG TABLET

UPDATE QL: 6 TABLETS PER DAY

ANTIHYPERTENSIVES

RAMIPRIL 1.25MG CAPSULE

RAMIPRIL 2.5MG CAPSULE

RAMIPRIL 5MG CAPSULE

UPDATE QL: 4 CAPSULES PER DAY

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

ANTIHYPERTENSIVES

CLONIDINE 0.1MG TABLET

CLONIDINE 0.2MG TABLET

UPDATE QL: 6 TABLETS PER DAY

ANTIHYPERTENSIVES

GUANFACINE 1MG TABLET

UPDATE QL: 2 TABLETS PER DAY

ANTIHYPERTENSIVES

METHYLDOPA 250MG TABLET

UPDATE QL: 6 TABLETS PER DAY

ANTIHYPERTENSIVES

AMLODIPINE/ BENAZEPRIL 2.5-10MG CAPSULE

AMLODIPINE/ BENAZEPRIL 5-10MG CAPSULE

AMLODIPINE/ BENAZEPRIL 5-20MG CAPSULE

UPDATE QL: 2 CAPSULES PER DAY

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

ANTIHYPERLIPIDEMICS

EZETIMIBE 10MG TABLET

REMOVE STEP THERAPY

ANTIMYASTHENIC/ CHOLINERGIC AGENTS

FIRDAPSE 10MG TABLET

UPDATE QL: 10 TABLETS PER DAY

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

AKEEGA 50/500MG TABLET

AKEEGA 100/500 TABLET

UPDATE QL: 2 TABLETS PER DAY

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

TAFINLAR 10 MG TABLETS FOR ORAL SUSPENSION

UPDATE QL: 30 TABLETS PER DAY

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

PEMAZYRE 4.5MG TABLET

PEMAZYRE 9MG TABLET

UPDATE QL: 1 TABLET PER DAY

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

RYTELO 47MG VIAL

RYTELO 188MG VIAL

ADD PA AND DOSING: 7.1 MG/KG PER 4 WEEKS

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

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

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

TECELRA INJECTION

ADD PA

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

LYMPHIR INJECTION

ADD PA

ANTIPSORIATICS

TALTZ 20MG/0.5ML SYRINGE

TALTZ 40MG/0.5ML SYRINGE

ADD QL: 1 SYRINGE PER 28 DAYS

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

ANTIPSYCHOTICS/

ANTIMANIC AGENTS

ERZOFRI 351 MG ER INJECTION

ADD PA AND QL: 1 KIT, ONE TIME FILL

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

ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES

SIMLANDI 20MG/0.2ML SYRINGE

ADD QL: 2 SYRINGES PER 28 DAYS

ANTIVIRALS

EDURANT PED 2.5 MG TABLET FOR ORAL SUSPENSION

ADD QL: 6 TABLETS PER DAY

ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS

ONYDA XR 0.1MG/ML SUSPENSION

ADD PA AND REMOVE QL: 4 ML PER DAY

ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS

KAPVAY 0.1 MG TABLET

REMOVE QL: 4 TABLETS PER DAY

ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS

INTUNIV 1MG TABLET

INTUNIV 2MG TABLET
INTUNIV 3MG TABLET

INTUNIV 4MG TABLET

REMOVE QL: 1 TABLET PER DAY

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

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

ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS

QELBREE (VILOXAZINE) 100MG CAPSULE

REMOVE DOSE OP: 1 CAPSULE PER DAY

ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS

QELBREE (VILOXAZINE) 150MG CAPSULE

REMOVE DOSE OP: 2 CAPSULES PER DAY

ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS

QELBREE (VILOXAZINE) 200MG CAPSULE

REMOVE DOSE OP: 3 CAPSULES PER DAY

BENIGN PROSTATIC HYPERPLASIA AGENTS

TEZRULY (TERAZOSIN) 1 MG/ML

ORAL SOLUTION

ADD PA AND QL: 20 ML PER DAY

BENIGN PROSTATIC HYPERTROPHY AGENTS

CHEWTADZY 5MG CHEWABLE TABLET

NEW PA AND QL: 1 TABLET PER DAY

BETA BLOCKERS

NADOLOL 20MG TABLET

NADOLOL 40MG TABLET

UPDATE QL: 4 TABLETS PER DAY

BETA BLOCKERS

PROPRANOLOL 10 MG TABLET

PROPRANOLOL 20 MG TABLET

PROPRANOLOL 40 MG TABLET

PROPRANOLOL 60 MG TABLET

UPDATE QL: 8 TABLETS PER DAY

BETA BLOCKERS

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

BETA BLOCKERS

COREG (CARVEDILOL) 3.125 MG TABLET

COREG (CARVEDILOL) 6.25 MG TABLET

COREG (CARVEDILOL) 12.5 MG TABLET

UPDATE QL: 4 TABLETS PER DAY

BETA BLOCKERS

COREG CR (CARVEDILOL ER) 40 MG CAPSULE

UPDATE QL: 2 CAPSULES PER DAY

BETA BLOCKERS

LABETALOL 100 MG TABLET

LABETALOL 200 MG TABLET

UPDATE QL: 12 TABLETS PER DAY

BONE DENSITY REGULATORS

JUBBONTI 60MG/ML INJECTION

ADD PA AND QL: 60 MG (1 PREFILLED SYRINGE) EVERY 6 MONTHS

BONE DENSITY REGULATORS

WYOST 120 MG/1.7 ML VIAL

ADD PA AND QL: 1 VIAL PER 28 DAYS

CARDIOVASCULAR AGENTS MISC. - COMBINATIONS

OPSYNVI TABLET

ADD PA

CONTINUOUS GLUCOSE SYSTEM SUPPLIES

FREESTYLE LIBRE 3 SENSOR PLUS

ADD QL: 2 SENSORS PER 30 DAYS

CONTRACEPTIVES

ENILLORING VAGINAL RING

ADD QL: 1 RING PER 28 DAYS

COUGH/COLD/ALLERGY

HYCODAN 5MG-1.5MG TABLET

ADD QL: 30 TABLETS PER 5 DAYS; 2 FILLS PER 30 DAYS

COUGH/ COLD/ ALLERGY

HYCODAN 5MG-1.5MG/5ML SYRUP/SOLUTION

ADD QL: 150 ML PER 5 DAYS; 2 FILLS PER 30 DAYS

COUGH/ COLD/ ALLERGY

TUZISTRA XR SUSPENSION

ADD QL: 100 ML PER 5 DAYS; 2 FILLS PER 30 DAYS

COUGH/ COLD/ ALLERGY

TUXARIN ER 54.3MG-8MG TABLET

ADD QL: 10 TABLETS PER 5 DAYS; 2 FILLS PER 30 DAYS

COUGH/ COLD/ ALLERGY

PROMETHAZINE/ CODEINE SYRUP

UPDATE QL: 150 ML PER 5 DAYS; 2 FILLS PER 30 DAYS

COUGH/COLD/ALLERGY

HYDROCODONE POLISTIREX/ CHLORPHENIRAMINE POLISTIREX 10MG-8MG/5ML SUSPENSION

UPDATE QL:50 ML PER 5 DAYS; 2 FILLS PER 30 DAYS

COUGH/ COLD/ ALLERGY

PROMETHAZINE AND PHENYLEPHRINE WITH CODEINE SYRUP

UPDATE QL: 150 ML PER 5 DAYS; 2 FILLS PER 30 DAYS

COUGH/ COLD/ ALLERGY

M-END PE LIQUID

RYDEX LIQUID

ADD QL: 450 ML PER 5 DAYS; 2 FILLS PER 30 DAYS

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

COUGH/ COLD/ ALLERGY

MAXI-TUSS CD LIQUID

ADD QL: 150 ML PER 5 DAYS; 2 FILLS PER 30 DAYS

COUGH/ COLD/ ALLERGY

HISTEX-AC SYPRUP

ADD QL: 100 ML PER 5 DAYS; 2 FILLS PER 30 DAYS

COUGH/ COLD/ ALLERGY

GUAIFENESIN- CODEINE SOLUTION

UPDATE QL:300 ML PER 5 DAYS; 2 FILLS PER 30 DAYS

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

DERMATOLOGICALS

ZORYVE (ROFLUMILAST) 0.15% CREAM

ADD PA AND QL: 60 GM PER 30 DAYS

DERMATOLOGICALS

ADBRY 300MG/2ML INJECTION

ADD QL: 1 AUTOINJECTOR PER 28 DAYS

DERMATOLOGICALS

TREMFYA 200MG/20ML INJECTION

ADD QL: 3 VIALS TOTAL TO LAST 12 WEEKS

DERMATOLOGICALS

TREMFYA 100MG/ML PEN/SYRINGE

UPDATE QL: 1 PEN/SYRINGE PER

56 DAYS (8 WEEKS)

DERMATOLOGICALS

TREMFYA 200MG/2ML PEN/SYRINGE

ADD QL: 1 PEN/SYRINGE PER

28 DAYS(4 WEEKS)

DERMATOLOGICALS

EBGLYSS 250MG/2ML INJECTION

ADD PA AND QL: 1 PEN/SYRINGE

PER 28 DAYS

DERMATOLOGICALS

NEMLUVIO 30MG INJECTION

ADD PA AND QL: 1 PEN PER 28 DAYS

DERMATOLOGICALS

QBREXZA 2.4% PAD

ADD PA

DERMATOLOGICALS

SOFDRA 12.45% GEL

ADD QL: 1 BOTTLE (40.2 ML) PER 30 DAYS

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

ENDOCRINE AND METABOLIC AGENTS - MISC.

XENPOZYME 4MG INJECTION

ADD DOSING: 3 MG/KG EVERY 2 WEEKS

GASTROINTESTINAL AGENTS - MISC.

LIVDELZI 10MG CAPSULE

NEW PA AND QL: 1 CAPSULE PER DAY

HEMATOLOGICAL AGENTS - MISCELLANEOUS

PIASKY 340MG/2ML INJECTION

ADD PA AND QL: 3 VIALS PER 28 DAYS

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

HEMATOPOIETIC AGENTS

NYPOZI 300 MCG/0.5 ML INJECTION

ADD PA

IMMUNOGLOBULINS

YIMMUGO 100MG/ML INJECTION

ADD PA

IMMUNOMODULATORS

VYVGART HYTRULO SINGLE DOSE VIAL

UPDATE QL: 4 VIALS PER 28 DAYS

IMMUNOSUPPRESSIVE AGENTS

BENLYSTA 200 MG/ML PREFILLED SYRINGE OR AUTOINJECTOR

ADD DOSING: 15 KG TO LESS THAN 40 KG: 2 INJECTIONS PER 28 DAYS
ADD QUANTITY LIMIT: 40 KG AND ABOVE: 4 INJECTIONS PER 28 DAYS

INTERLEUKIN ANTAGONISTS

STELARA 5MG/ML INJECTION

STELARA 45MG/0.5ML INJECTION

STELARA 90MG/ML INJECTION

ADD STEP THERAPY

INTERLEUKIN ANTAGONISTS

SKYRIZI 600 MG/10 ML SINGLE-DOSE VIAL

UPDATE QL: 6 VIALS TOTAL TO LAST 12 WEEKS

INTERLEUKIN ANTAGONISTS

SKYRIZI 90MG/ML PEN

UPDATE QL: 2 PREFILLED PENS PER 56 DAYS (8 WEEKS)

MISCELLANEOUS AGENTS

NIKTIMVO INJECTION

ADD PA

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)

MISCELLANEOUS THERAPEUTIC AGENTS

RYSTIGGO 420MG/3ML VIAL

ADD QL: 3 ML (1 VIAL) ONCE WEEKLY FOR 6 WEEKS (6 WEEKS= 1 CYCLE)

MISCELLANEOUS THERAPEUTIC AGENTS

RYSTIGGO 560MG/4ML VIAL

ADD QL: 4 ML (1 VIAL) ONCE WEEKLY FOR 6 WEEKS (6 WEEKS = 1 CYCLE)

MISCELLANEOUS THERAPEUTIC AGENTS

RYSTIGGO 840MG/6ML VIAL

ADD QL: 6 ML (1 VIAL) ONCE WEEKLY FOR 6 WEEKS (6 WEEKS = 1 CYCLE)

MUSCULOSKELETAL THERAPY AGENTS

BACLOFEN 15MG TABLET

ADD QL: 3 TABLETS PER DAY

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

PROTON PUMP INHIBITORS

DEXILANT 30MG CAPSULE

DEXILANT 60MG CAPSULE

REMOVE QL: 1 CAPSULE PER DAY

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
PRILOSEC (OMEPRAZOLE) RX 40 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

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

PharmacyAnthem Blue Cross and Blue Shield | CommercialJanuary 27, 2025

Key formulary updates: effective January 1, 2025

Effective with dates of service on and after January 1, 2025, and in accordance with the CarelonRx, Inc. pharmacy and therapeutics (P&T) process, we updated our drug lists that support commercial health plans. Updates include changes to drug tiers and the removal of medications from the formulary.

Please see the attachment here for more information.

CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the health plan.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CM-075572-24-CPN75351

ATTACHMENTS (available on web): Key formulary updates: effective January 1, 2025_Blue Cross Blue Shield (pdf - 0.19mb)

PharmacyHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsJanuary 28, 2025

FAMIS formulary and Preferred Drug List update

Effective December 1, 2024, HealthKeepers, Inc. will implement the Family Access to Medical Insurance Security Plan (FAMIS) formulary and Preferred Drug List (PDL) for Family Access to Medical Insurance Security Plan (FAMIS) members.

This formulary change, affecting our approximately 35,000 FAMIS members, will transition them from the current formulary to a generic‑based formulary, while continuing to ensure access to clinically effective and appropriate drug therapies. There will be no change to our Medicaid members not in FAMIS groups.

The new FAMIS‑specific formulary will be available on our website at https://providers.anthem.com/virginia‑provider/home.

Impacted members and their providers will be notified by letter if a change to their medication is necessary based on PDL changes. To allow time for adjustments, claims for current medications will not be rejected until March 1, 2025. Some medications will be grandfathered in, so no change will be necessary for members with prescriptions for those drugs.

Contact us

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop‑down. Then, select Chat with Payer and complete the pre‑chat form to start your chat.

For additional support, visit the Contact Us section of our provider website for the appropriate contact.

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-072641-24

PharmacyAnthem Blue Cross and Blue Shield | CommercialFebruary 1, 2025

Clinical Criteria updates for specialty pharmacy are available

The following Clinical Criteria will be effective for dates of service on and after May 1, 2025.

CC‑0272

Aucatzyl (obecabtagene autoleucel)

CC‑0148

Agents for Hemophilia B

CC‑0149

Select Clotting Agents for Bleeding Disorders

CC‑0065

Agents for Hemophilia A and von Willebrand Disease

CC‑0170

Uplizna (inebilizumab‑cdon)

CC‑0199

Empaveli (pegcetacoplan)

CC‑0041

Complement Inhibitors

CC‑0003

Immunoglobulins

CC‑0043

Monoclonal Antibodies to Interleukin‑5

CC‑0197

Jemperli (dostarlimab‑gxly)

CC‑0094

Pemetrexed (Alimta, Pemfexy, Pemrydi)

Anthem will manage prior authorization of these specialty pharmacy drugs. Drugs used for the treatment of oncology will still require prior authorization by Carelon Medical Benefits Management, Inc. This applies to members enrolled in PPO and HMO plans.

Access the clinical criteria document information for details.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

VABCBS-CM-075637-24

PharmacyHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsJanuary 6, 2025

Prior authorization updates for medications billed under the medical benefit

Effective for dates of service on or after March 1, 2025, the following medication codes will require prior authorization.

Please note that the inclusion of a National Drug Code (NDC) on your medical claim is necessary for claims processing.

Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below.

Clinical Criteria

HCPCS or CPT® code(s)

Drug name

CC‑0265

J0175

Kisunla (donanemab)

CC‑0041

J3590

Piasky (crovalimab‑akkz)

What if I need assistance?

If you have any questions about this communication or need assistance with any other item, contact your local provider relationship management representative or call Provider Services at 800‑901-0020.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

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-069905-24-CPN69799

Quality ManagementAnthem Blue Cross and Blue Shield | CommercialAnthem Blue Cross and Blue Shield | Medicare AdvantageFebruary 1, 2025

2025 Clinical Quality in Practice webinar series

We are excited to announce our 2025 Clinical Quality in Practice, a continuing education webinar series. This comprehensive series will cover a diverse range of critical topics designed to equip clinicians with the latest strategies and best practices in patient care.

The webinar series will explore essential areas, such as:

  • Clinical strategies to care for patients with diabetes.
  • Clinical strategies to care for patients with cardiovascular disease and hypertension.
  • Post acute care management.
  • Motivating patients to adhere to cancer prevention and screenings.
  • Clinical strategies to increase flu vaccinations.
  • Clinical strategies for screening and preventive care.
  • Enhancing coordination of care.

Participants will have the opportunity to engage with experienced practitioners and thought leaders, gaining valuable insights that can be immediately applied in clinical settings.

For a detailed schedule of live events and a full listing of available on‑demand webinars that you can start viewing now, visit our Engagement Hub. Don’t miss this chance to advance your clinical expertise and enhance patient outcomes.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

MULTI-BCBS-CRCM-075332-24-CPN74850