Formulary Changes – Third Quarter 2022 - Medicaid, CHP, and HARP
5/31/2022
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Posted by Provider Relations
Fidelis Care has made changes to our Medicaid Managed Care, Child Health Plus (CHP), and HealthierLife (HARP) Formulary effective July 1, 2022. Some of the changes relate to quantity limitations, authorization requirements, as well as drugs being removed and added to the formulary.
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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Hydromorphone ER tablet
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Add with ST of a formulary long-acting agent
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07/01/2022
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Lidocaine 5% patch
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Add with QL of 90/25
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07/01/2022
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Moxifloxacin ophthalmic
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Add with QL of 6ml/25
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07/01/2022
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Norvir 100mg Powder
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Add; PA required for members 18 and over
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05/01/2022
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Omnipod 5
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Add with PA
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07/01/2022
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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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Memantine ER tablet
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Add QL of 30/25
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07/01/2022
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