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Formulary Changes – Third Quarter 2022 - Medicaid, CHP, and HARP
9/1/2022 • 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

Drug/Product

Action

Effective Date

Quetiapine ER

Remove ST

10/01/2022

Donepezil 23mg

Add with QL of #30/30

10/01/2022

Potassium Chloride ER 20EQ Tablet

Add with QL of #240/30

10/01/2022

Omeprazole/Sodium Bicarbonate Rx Capsule

Add with QL of #60/30

08/08/2022

 

 

 

Part II: Formulary Removals & PA/ST/QL Additions

Drug

Action

Formulary Alternatives

Effective Date

Lansoprazole 15mg Rx

Add QL of #120/30

  • N/A

10/01/2022

 

 

 

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