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VA Anthem Common Core Formulary

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VA Anthem Common Core Formulary VA Anthem Common Core Formulary Medicaid-Approved Drug List Effective August 1, 2021 Legend In each class, drugs are listed alphabetically by either brand name or generic name. Brand name drug: Uppercase in bold type Generic drug: Lowercase in plain type AL: Age Limit Restrictions DO: Dose Optimization Program GR: Gender Restriction OTC: Over the counter medication available with a prescription. (Prescribers please indicate OTC on the prescription) PA: Prior authorization is required. Prior authorization is the process of obtaining approval of benefits before certain prescriptions are filled. QL: Quantity limits; certain prescription medications have specific quantity limits per prescription or per month. SP: Specialty Pharmacy ST: Step therapy is required. You may need to use one medication before benefits for the use of another medication can be authorized. Drug Name Reference Notes *ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS*** clonidine hcl er oral tablet extended release Kapvay 12 hour guanfacine hcl er oral tablet extended Intuniv AL release 24 hour INTUNIV ORAL TABLET EXTENDED PA; AL RELEASE 24 HOUR KAPVAY ORAL TABLET EXTENDED PA RELEASE 12 HOUR *ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR*** atomoxetine hcl oral capsule Strattera AL; QL QELBREE ORAL CAPSULE EXTENDED PA; DO; QL RELEASE 24 HOUR 100 MG QELBREE ORAL CAPSULE EXTENDED PA; QL RELEASE 24 HOUR 150 MG, 200 MG STRATTERA ORAL CAPSULE PA; AL; QL *AMPHETAMINE MIXTURES*** ADDERALL ORAL TABLET PA; AL ADDERALL XR ORAL CAPSULE PA; AL EXTENDED RELEASE 24 HOUR amphetamine-dextroamphet er oral capsule Adderall XR PA; AL extended release 24 hour amphetamine-dextroamphetamine oral Adderall AL tablet MYDAYIS ORAL CAPSULE EXTENDED PA; AL RELEASE 24 HOUR *AMPHETAMINES*** ADZENYS ER ORAL SUSPENSION PA; AL EXTENDED RELEASE ADZENYS XR-ODT ORAL TABLET PA; AL EXTENDED RELEASE DISPERSIBLE amphetamine er oral suspension extended Adzenys ER release amphetamine sulfate oral tablet Evekeo PA; AL DESOXYN ORAL TABLET PA; AL 2 Drug Name Reference Notes DEXEDRINE ORAL CAPSULE EXTENDED PA; AL RELEASE 24 HOUR dextroamphetamine sulfate er oral capsule Dexedrine PA; AL extended release 24 hour dextroamphetamine sulfate oral solution ProCentra PA; AL dextroamphetamine sulfate oral tablet Zenzedi AL DYANAVEL XR ORAL SUSPENSION PA; AL EXTENDED RELEASE EVEKEO ODT ORAL TABLET PA DISPERSIBLE EVEKEO ORAL TABLET PA; AL methamphetamine hcl oral tablet Desoxyn PA; AL PROCENTRA ORAL SOLUTION PA; AL VYVANSE ORAL CAPSULE AL VYVANSE ORAL TABLET CHEWABLE AL ZENZEDI ORAL TABLET PA; AL *ANALEPTIC COMBINATIONS*** energy chews oral tablet chewable OTC *ANALEPTICS*** awake maximum strength oral tablet Vivarin OTC CAFCIT INTRAVENOUS SOLUTION caffeine citrate intravenous solution Cafcit caffeine citrate oral solution caffeine oral tablet Vivarin OTC cvs caffeine oral tablet Vivarin OTC DOPRAM INTRAVENOUS SOLUTION eq stay awake oral tablet Vivarin OTC eql stay awake max st oral tablet Vivarin OTC eql stay awake oral tablet Vivarin OTC gnp alert aid oral tablet Vivarin OTC hm stay awake oral tablet Vivarin OTC keep alert oral tablet Vivarin OTC sm stay awake oral tablet Vivarin OTC stay awake maximum strength oral tablet Vivarin OTC stay awake oral tablet Vivarin OTC VIVARIN ORAL TABLET OTC 3 Drug Name Reference Notes *DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS)*** SUNOSI ORAL TABLET PA *HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS*** WAKIX ORAL TABLET PA; SP *LIPASE INHIBITORS*** ALLI ORAL CAPSULE PA; OTC; QL *STIMULANTS - MISC.*** ADHANSIA XR ORAL CAPSULE PA EXTENDED RELEASE 24 HOUR APTENSIO XR ORAL CAPSULE PA; AL EXTENDED RELEASE 24 HOUR armodafinil oral tablet Nuvigil PA; AL CONCERTA ORAL TABLET EXTENDED AL RELEASE COTEMPLA XR-ODT ORAL TABLET PA EXTENDED RELEASE DISPERSIBLE DAYTRANA TRANSDERMAL PATCH AL dexmethylphenidate hcl er oral capsule Focalin XR PA; AL extended release 24 hour dexmethylphenidate hcl oral tablet Focalin PA; AL FOCALIN ORAL TABLET AL FOCALIN XR ORAL CAPSULE AL EXTENDED RELEASE 24 HOUR JORNAY PM ORAL CAPSULE EXTENDED PA RELEASE 24 HOUR METHYLIN ORAL SOLUTION PA; AL methylphenidate hcl er (cd) oral capsule PA; AL extended release methylphenidate hcl er (la) oral capsule Ritalin LA PA; AL extended release 24 hour methylphenidate hcl er (xr) oral capsule Aptensio XR PA; AL extended release 24 hour methylphenidate hcl er oral tablet extended PA; AL release 10 mg, 20 mg methylphenidate hcl er oral tablet extended Concerta PA; AL release 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extended PA; AL release 24 hour 4 Drug Name Reference Notes methylphenidate hcl er oral tablet extended Relexxii PA release 72 mg methylphenidate hcl oral solution Methylin PA; AL methylphenidate hcl oral tablet Ritalin AL methylphenidate hcl oral tablet chewable PA; AL modafinil oral tablet Provigil PA; AL NUVIGIL ORAL TABLET PA; AL PROVIGIL ORAL TABLET PA; AL QUILLICHEW ER ORAL TABLET PA CHEWABLE EXTENDED RELEASE QUILLIVANT XR ORAL SUSPENSION PA RECONSTITUTED ER RELEXXII ORAL TABLET EXTENDED RELEASE RITALIN LA ORAL CAPSULE EXTENDED PA; AL RELEASE 24 HOUR RITALIN ORAL TABLET PA; AL *ALLERGENIC EXTRACTS/BIOLOGICALS MISC* *ALLERGENIC EXTRACTS*** acacia subcutaneous solution acremonium subcutaneous solution alder subcutaneous solution alternaria subcutaneous solution american beech subcutaneous solution american cockroach subcutaneous solution american elm subcutaneous solution arizona cypress subcutaneous solution aspergillus fumigatus injection solution aureobasidium pullulans injection solution aureobasidium subcutaneous solution australian pine subcutaneous solution bahia subcutaneous solution bald cypress subcutaneous solution bayberry (wax myrtle) subcutaneous solution bermuda grass injection solution bermuda grass subcutaneous solution black willow subcutaneous solution 5 Drug Name Reference Notes botrytis injection solution botrytis subcutaneous solution brome subcutaneous solution california pepper tree subcutaneous solution candida albicans extract injection solution candida albicans extract subcutaneous solution cat hair extract injection solution cat hair extract subcutaneous solution cattle epithelium subcutaneous solution cedar elm subcutaneous solution cladosporium cladosporioides injection solution cladosporium cladosporioides intradermal solution cladosporium cladosporioides subcutaneous solution cladosporium sphaerospermum subcutaneous solution cocklebur subcutaneous solution corn pollen subcutaneous solution curvularia subcutaneous solution dandelion subcutaneous solution dog epithelium subcutaneous solution dog fennel subcutaneous solution drechslera subcutaneous solution eastern cottonwood subcutaneous solution epicoccum nigrum injection solution epicoccum subcutaneous solution fire ant subcutaneous solution fusarium subcutaneous solution german cockroach subcutaneous solution goldenrod subcutaneous solution grass pollen(k-o-r-t-swt vern) injection solution GRASTEK SUBLINGUAL TABLET PA; AL; QL SUBLINGUAL hackberry subcutaneous solution 6 Drug Name Reference Notes HONEY BEE VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED honey bee venom subcutaneous solution reconstituted horse epithelium subcutaneous solution johnson grass subcutaneous solution june grass pollen standardized subcutaneous solution kapok subcutaneous solution kochia subcutaneous solution lenscale subcutaneous solution meadow fescue grass pollen subcutaneous solution melaleuca subcutaneous solution mesquite subcutaneous solution mite (d. farinae) injection solution mite (d. farinae) subcutaneous solution mite (d. pteronyssinus) injection solution mite (d. pteronyssinus) subcutaneous solution mixed ragweed subcutaneous solution mixed vespid venom protein injection solution reconstituted mixed vespid venom protein subcutaneous solution reconstituted mountain cedar subcutaneous solution mouse epithelium subcutaneous solution mucor injection solution mucor intradermal solution mucor subcutaneous solution mugwort subcutaneous solution olive tree subcutaneous solution orchard grass pollen subcutaneous solution PALFORZIA (12 MG DAILY DOSE) ORAL PA; SP; QL PALFORZIA (120 MG DAILY DOSE) ORAL PA; SP; QL PALFORZIA (160 MG DAILY DOSE) ORAL PA; SP; QL PALFORZIA (20 MG DAILY DOSE) ORAL PA; SP; QL PALFORZIA (200 MG DAILY DOSE) ORAL PA; SP; QL PALFORZIA (240 MG DAILY DOSE) ORAL PA; SP; QL 7 Drug Name Reference Notes PALFORZIA (3 MG DAILY DOSE) ORAL PA; SP; QL PALFORZIA (300 MG MAINTENANCE) PA; SP; QL ORAL PACKET PALFORZIA (300 MG TITRATION) ORAL PA; SP; QL PACKET PALFORZIA (40 MG DAILY DOSE) ORAL PA; SP; QL PALFORZIA (6 MG DAILY DOSE) ORAL PA; SP; QL PALFORZIA (80 MG DAILY DOSE) ORAL PA; SP; QL PALFORZIA INITIAL ESCALATION ORAL PA; SP; QL penicillium notatum injection solution penicillium notatum subcutaneous solution perennial rye grass pollen injection solution phoma exigua subcutaneous solution privet subcutaneous solution queen palm subcutaneous solution rabbit epithelium subcutaneous solution RAGWITEK SUBLINGUAL TABLET PA; AL SUBLINGUAL red maple subcutaneous solution red mulberry subcutaneous solution red top grass pollen subcutaneous solution rhizopus subcutaneous solution rough marsh elder subcutaneous solution russian thistle subcutaneous solution saccharomyces cerevisiae injection solution saccharomyces cerevisiae subcutaneous solution shagbark hickory subcutaneous solution sheep sorrel subcutaneous solution short ragweed pollen ext subcutaneous solution spiny pigweed subcutaneous solution stemphylium subcutaneous solution sweet gum subcutaneous
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