9/8/2023
•
Posted by Provider Relations
Fidelis Care has made changes to our Child Health Plus (CHP) 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
|
|
Rykindo
|
Add with PA
|
10/01/2023
|
|
Uzedys
|
Add with PA
|
10/01/2023
|
Part II: Formulary Removals & PA/ST/QL Additions
|
Drug
|
Action
|
Formulary Alternatives
|
Effective Date
|
|
Hydrocodone-Homatropine Solution
|
Remove from formulary
|
- Benzonatate
- Dextromethorphan Polistirex ext-rel sup
- Dextromethorphan/Guaifenesin
|
09/01/2023
|
|
Promethazine-Phenylephrine-Codeine Syrup
|
Remove from formulary
|
- Benzonatate
- Dextromethorphan Polistirex ext-rel sup
- Dextromethorphan/Guaifenesin
|
09/01/2023
|
|
Promethazine- Dextromethorphan Syrup
|
Remove from formulary
|
- Benzonatate
- Dextromethorphan Polistirex ext-rel sup
- Dextromethorphan/Guaifenesin
|
09/01/2023
|
|
Pseudoephedrine- Brompheniramine - Dextromethorphan Syrup
|
Remove from formulary
|
- Benzonatate
- Dextromethorphan Polistirex ext-rel sup
- Dextromethorphan/Guaifenesin
|
09/01/2023
|
|
Ammonium Lactate
|
Remove from formulary
|
|
10/01/2023
|
|
Urea
|
Remove from formulary
|
|
10/01/2023
|