Formulary Changes – Fourth Quarter 2022 - Medicaid, CHP, and HARP
29.11.2022
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Posted by Provider Relations
Fidelis Care has made changes to our Medicaid Managed Care/HealtherLife (HARP) and Child Health Plus (CHP) Formularies. Some of the changes relate to quantity limitations, authorization requirements, as well as drugs being removed and added to the formulary. In addition, please refer to the Medicaid Managed Care/HealtherLife (HARP) OTC updates in accordance with the New York State Department of Health requirements.
Part I: Formulary Additions & PA/ST/QL Removals
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Drug/Product
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Action
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Effective Date
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Budesonide 32mcg/ACT OTC
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Increase QL to #16.86mL/25 days
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12/27/2022
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Cefixime Suspension
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Remove QL
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12/27/2022
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Dupixent
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Add with PA
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12/27/2022
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Epinephrine 0.15mg Injection
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Increase QL to #8pens/25 days
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12/27/2022
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Fluticasone Propionate OTC
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Increase QL to #32mL/25 days
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12/27/2022
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Granisetron 4mg/4mL injection
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Increase QL to #1mL/25 days
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12/27/2022
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Nebivolol
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Add with ST (two formulary selective Beta Blockers)
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12/27/2022
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Supprelin LA*
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Add with PA
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12/27/2022
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Triptodur*
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Add with PA
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12/27/2022
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Pulmicort Flexhaler*
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Add with QL 3 Inhalers /75 days
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12/27/2022
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* Change for CHP Only; Change will not affect NYM/HARP †Change for NYM/HARP Only; Change will not affect CHP
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Part II: Formulary Removals & PA/ST/QL Additions
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Drug
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Action
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Formulary Alternatives
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Effective Date
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Brimonidine 0.2%
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Add QL #10mL/25 days
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12/27/2022
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Butalbital-Aspirin-Caffeine capsule
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Add Max Daily Limit of 6 caps/day
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12/27/2022
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Combivent Respimat
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Add QL #2 inhalers (8g)/25 days
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12/27/2022
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HC Pramoxine 1-1%
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Add QL #30g/25 days
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12/27/2022
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Insulin Aspart Protamine/Aspart Pen
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Add QL #45mL/25 days
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12/27/2022
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Insulin Aspart Protamine/Aspart Vial
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Add QL #40mL/25 days
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12/27/2022
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Ipratropium Nasal Spray 0.03%
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Change QL to #30mL (1 bottle)/25 days
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12/27/2022
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Nystatin-Triamcinolone
cream/ointment
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Add QL #60g/25 days
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12/27/2022
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Ozempic
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Add QL #3/25 days
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12/27/2022
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Pioglitazone-Metformin 15-850mg
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Add QL #90 tabs/25 days
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12/27/2022
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Risperidone tablets and ODT
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Add Max Daily Dose Limit
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|
12/27/2022
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Rybelsus
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Add QL #30/25 days
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12/27/2022
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Trulicity
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Add QL #2/25 days
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12/27/2022
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Arnuity Ellipta*
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Removal from formulary
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Asmanex HFA
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12/27/2022
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Lupron Depot & Lupron Depot-PED*
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Removal from formulary
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Triptodur
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12/27/2022
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Creon†
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Remove from formulary
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Pancreaze
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12/27/2022
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Opsumit†
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Remove from formulary
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Traceleer
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12/27/2022
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* Change for CHP Only; Change will not affect NYM/HARP †Change for NYM/HARP Only; Change will not affect CHP
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PA- Prior Authorization | ST- Step Therapy | QL- Quantity Limit