Formulary Changes – Third Quarter 2022 - Medicaid, CHP, and HARP
9/1/2022
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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. 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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Quetiapine ER
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Remove ST
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10/01/2022
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Donepezil 23mg
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Add with QL of #30/30
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10/01/2022
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Potassium Chloride ER 20EQ Tablet
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Add with QL of #240/30
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10/01/2022
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Omeprazole/Sodium Bicarbonate Rx Capsule
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Add with QL of #60/30
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08/08/2022
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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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Lansoprazole 15mg Rx
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Add QL of #120/30
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10/01/2022
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