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Preferred Drug List Updates

2024 Meridian Medicaid Plan Preferred Drug List Updates

This is an update to the Meridian Medicaid Plan (Meridian) Preferred Drug List.

Coverage of the medications listed below has changed, effective January 15, 2025, for all members. Please reference the table for changes.

Note: Active prior authorizations for the medication(s) listed will not be affected.

If you have any questions, please call the pharmacy help desk at 855-580-1688.

Impacted MedicationChangePreferred Agents or New Limits
KETOROLACQuantity Limit20 tablets every 30 days

This is an update to the Meridian Medicaid Plan (Meridian) Preferred Drug List.

Coverage of the medications listed below has changed, effective December 1, 2024, for all members. Please reference the table for changes.

Note: Active prior authorizations for the medication(s) listed will not be affected.

If you have any questions, please call the pharmacy help desk at 855-580-1688.

Impacted MedicationChangePreferred Agents or New Limits
AMLADEX TABCoverage ChangeRemoved from Preferred Drug list

This is an update to the Meridian Medicaid Plan (Meridian) Preferred Drug List.

Coverage of the medications listed below has changed, effective December 1, 2024, for all members. Please reference the table for changes.

Note: Active prior authorizations for the medication(s) listed will not be affected.

If you have any questions, please call the pharmacy help desk at 855-580-1688.

Impacted MedicationChangePreferred Agents or New Limits
DERMACINRX FOLIFLEX CAPLETCoverage ChangeRemoved from Preferred Drug list
DERMACINRX VITRAMYN CAPLETCoverage ChangeRemoved from Preferred Drug list
DERMACINRX VITRANOL CAPLETCoverage ChangeRemoved from Preferred Drug list
DERMACINRX VITREXATE CAPLETCoverage ChangeRemoved from Preferred Drug list
All Multivitamins and VitaminsNew LimitsVitamins are limited to $300 per claim
Multivitamins are limited to $450 per claim

This is an update to the Meridian Medicaid Plan (Meridian) Preferred Drug List.

Coverage of the medications listed below has changed, effective November 11, 2024, for all members. Please reference the table for changes.

Note: Active prior authorizations for the medication(s) listed will not be affected.

If you have any questions, please call the pharmacy help desk at 855-580-1688.

Click here to view impacted medications.

This is an update to the Meridian Medicaid Plan (Meridian) Preferred Drug List.

Coverage of the medications listed below has changed, effective November 1, 2024, for all members. Please reference the table for changes.

Note: Active prior authorizations for the medication(s) listed will not be affected.

If you have any questions, please call the pharmacy help desk at 855-580-1688.

Impacted MedicationChangeNew Limits
Alprazolam Conc 1 MG/MLNew Limits10 mL per day
Amiloride HCl Tab 5 MGNew Limits12 per day
Amiodarone HCl Tab 100 MGNew Limits4 per day
Amiodarone HCl Tab 200 MGNew Limits4 per day
Amiodarone HCl Tab 400 MGNew Limits4 per day
Amlodipine Besylate-Benazepril HCl Cap 2.5-10 MGNew Limits2 per day
Amlodipine Besylate-Benazepril HCl Cap 5-10 MGNew Limits2 per day
Amlodipine Besylate-Benazepril HCl Cap 5-20 MGNew Limits2 per day
Amlodipine Besylate-Benazepril HCl Cap 5-40 MGNew Limits2 per day
Amlodipine Besylate-Benazepril HCl Cap 10-40 MGNew Limits1 per day
Amlodipine Besylate-Benazepril HCl Cap 10-20 MGNew Limits1 per day
Ampicillin Cap 500 MGNew Limits4 per day
Umeclidinium-Vilanterol Aero Powd BA 62.5-25 MCG/INHNew Limits2 blisters per day
Atazanavir Sulfate Cap 150 MG (Base Equiv)New Limits1 per day
Atazanavir Sulfate Cap 300 MG (Base Equiv)New Limits1 per day
Atazanavir Sulfate Cap 200 MG (Base Equiv)New Limits2 per day
Benazepril HCl Tab 5 MGNew Limits2 per day
Benazepril HCl Tab 10 MGNew Limits2 per day
Benazepril HCl Tab 20 MGNew Limits2 per day
Benazepril HCl Tab 40 MGNew Limits2 per day
Bictegravir-Emtricitabine-Tenofovir AF Tab 50-200-25 MGNew Limits1 per day
Bictegravir-Emtricitabine-Tenofovir AF Tab 30-120-15 MGNew Limits1 per day
Buspirone HCl Tab 5 MGNew Limits3 per day
Buspirone HCl Tab 7.5 MGNew Limits3 per day
Buspirone HCl Tab 10 MGNew Limits6 per day
Buspirone HCl Tab 15 MGNew Limits4 per day
Buspirone HCl Tab 30 MGNew Limits3 per day
Captopril Tab 12.5 MGNew Limits3 per day
Captopril Tab 25 MGNew Limits3 per day
Captopril Tab 50 MGNew Limits3 per day
Captopril Tab 100 MGNew Limits3 per day
Chlorthalidone Tab 50 MGNew Limits4 per day
Chlorthalidone Tab 25 MGNew Limits4 per day
Clarithromycin For Susp 125 MG/5MLNew Limits280 mL per fill
Clarithromycin For Susp 250 MG/5MLNew Limits280 mL per fill
Clindamycin Phosphate Swab 1%New Limits2 per day
Emtricitabine-Rilpivirine-Tenofovir DF Tab 200-25-300 MGNew Limits1 per day
Cromolyn Sodium Soln Nebu 20 MG/2MLNew Limits8 mL per day
Doravirine-Lamivudine-Tenofovir DF Tab 100-300-300 MGNew Limits1 per day
Medroxyprogesterone Acetate Susp Pref Syr 104 MG/0.65MLNew Limits1 mL per 84 days
Diclofenac Potassium Tab 50 MGNew Limits4 per day
Diclofenac Sodium Tab Delayed Release 25 MGNew Limits4 per day
Diclofenac Sodium Tab Delayed Release 50 MGNew Limits4 per day
Diclofenac Sodium Tab Delayed Release 75 MGNew Limits2 per day
Diclofenac Sodium Tab ER 24HR 100 MGNew Limits2 per day
Diflunisal Tab 500 MGNew Limits3 per day
Dimethyl Fumarate Capsule Delayed Release 120 MGNew Limits2 per day
Dimethyl Fumarate Capsule Delayed Release 240 MGNew Limits2 per day
Dolutegravir Sodium-Lamivudine Tab 50-300 MG (Base Eq)New Limits1 per day
Emtricitabine Caps 200 MGNew Limits1 per day
Etodolac Cap 200 MGNew Limits4 per day
Etodolac Cap 300 MGNew Limits4 per day
Etodolac Tab 400 MGNew Limits3 per day
Etodolac Tab 500 MGNew Limits2 per day
Etodolac Tab SR 24HR 400 MGNew Limits1 per day
Etodolac Tab SR 24HR 500 MGNew Limits1 per day
Etodolac Tab SR 24HR 600 MGNew Limits1 per day
Ezetimibe Tab 10 MGNew Limits1 per day
Dapagliflozin Propanediol Tab 5 MG (Base Equivalent)New Limits1 per day
Dapagliflozin Propanediol Tab 10 MG (Base Equivalent)New Limits1 per day
Flurbiprofen Tab 100 MGNew Limits3 per day
Glipizide Tab SR 24HR 2.5 MGNew Limits3 per day
Glipizide Tab SR 24HR 5 MGNew Limits3 per day
Glipizide Tab SR 24HR 10 MGNew Limits2 per day
Glipizide-Metformin HCl Tab 2.5-250 MGNew Limits3 per day
Glipizide-Metformin HCl Tab 2.5-500 MGNew Limits3 per day
Glipizide-Metformin HCl Tab 5-500 MGNew Limits4 per day
Glyburide-Metformin Tab 1.25-250 MGNew Limits3 per day
Glyburide-Metformin Tab 2.5-500 MGNew Limits3 per day
Glyburide-Metformin Tab 5-500 MGNew Limits4 per day
Hydroxyzine HCl Tab 10 MGNew Limits8 per day
Hydroxyzine HCl Tab 25 MGNew Limits8 per day
Hydroxyzine HCl Tab 50 MGNew Limits8 per day
Hydroxyzine Pamoate Cap 25 MGNew Limits8 per day
Hydroxyzine Pamoate Cap 50 MGNew Limits8 per day
Hydroxyzine Pamoate Cap 100 MGNew Limits4 per day
Indomethacin Cap 25 MGNew Limits6 per day
Indomethacin Cap 50 MGNew Limits4 per day
Indomethacin Cap CR 75 MGNew Limits2 per day
Indomethacin Suppos 50 MGNew Limits4 per day
Canagliflozin Tab 100 MGNew Limits1 per day
Canagliflozin Tab 300 MGNew Limits1 per day
Itraconazole Cap 100 MGNew Limits6 per day
Fosamprenavir Calcium Tab 700 MG (Base Equiv)New Limits4 per day
Lisinopril Tab 2.5 MGNew Limits2 per day
Lisinopril Tab 5 MGNew Limits2 per day
Lisinopril Tab 10 MGNew Limits2 per day
Lisinopril Tab 20 MGNew Limits2 per day
Lisinopril Tab 30 MGNew Limits2 per day
Lisinopril Tab 40 MGNew Limits2 per day
Lisinopril & Hydrochlorothiazide Tab 10-12.5 MGNew Limits2 per day
Lisinopril & Hydrochlorothiazide Tab 20-12.5 MGNew Limits2 per day
Lisinopril & Hydrochlorothiazide Tab 20-25 MGNew Limits2 per day
Miglitol Tab 25 MGNew Limits3 per day
Miglitol Tab 50 MGNew Limits3 per day
Miglitol Tab 100 MGNew Limits3 per day
Nabumetone Tab 500 MGNew Limits4 per day
Nabumetone Tab 750 MGNew Limits3 per day
Nevirapine Tab 200 MGNew Limits2 per day
Nevirapine Susp 50 MG/5MLNew Limits40 mL per day
Nevirapine Tab ER 24HR 100 MGNew Limits4 per day
Nevirapine Tab ER 24HR 400 MGNew Limits1 per day
Oxazepam Cap 10 MGNew Limits4 per day
Oxazepam Cap 15 MGNew Limits4 per day
Oxazepam Cap 30 MGNew Limits4 per day
Darunavir Tab 600 MGNew Limits2 per day
Darunavir Tab 800 MGNew Limits1 per day
Propafenone HCl Tab 150 MGNew Limits4 per day
Propafenone HCl Tab 225 MGNew Limits3 per day
Propafenone HCl Tab 300 MGNew Limits3 per day
Pyridostigmine Bromide Tab CR 180 MGNew Limits2 per day
Quetiapine Fumarate Tab SR 24HR 50 MGNew Limits3 per day
Quetiapine Fumarate Tab SR 24HR 150 MGNew Limits3 per day
Quetiapine Fumarate Tab SR 24HR 200 MGNew Limits3 per day
Quetiapine Fumarate Tab SR 24HR 300 MGNew Limits4 per day
Quetiapine Fumarate Tab SR 24HR 400 MGNew Limits3 per day
Sofosbuvir-Velpatasvir Tab 400-100 MGNew Limits1 per day
Tiotropium Bromide Monohydrate Inhal Cap 18 MCG (Base Equiv)New Limits1 per day
Tiotropium Bromide Monohydrate Inhal Aerosol 2.5 MCG/ACTNew Limits0.134 g per day
Sulindac Tab 150 MGNew Limits2 per day
Sulindac Tab 200 MGNew Limits2 per day
Efavirenz-Lamivudine-Tenofovir DF Tab 400-300-300 MGNew Limits1 per day
Terbutaline Sulfate Tab 2.5 MGNew Limits6 per day
Terbutaline Sulfate Tab 5 MGNew Limits3 per day
Dolutegravir Sodium Tab 25 MG (Base Equiv)New Limits2 per day
Dolutegravir Sodium Tab 50 MG (Base Equiv)New Limits2 per day
Dolutegravir Sodium Tab for Oral Susp 5 MG (Base Equiv)New Limits6 per day
Tobramycin Nebu Soln 300 MG/5MLNew Limits10 mL per day
Verapamil HCl Cap ER 24HR 300 MGNew Limits1 per day
Verapamil HCl Cap ER 24HR 360 MGNew Limits1 per day
Zonisamide Cap 25 MGNew Limits4 per day
Zonisamide Cap 50 MGNew Limits4 per day
Zonisamide Cap 100 MGNew Limits6 per day

This is an update to the Meridian Medicaid Plan (Meridian) Preferred Drug List.

Coverage of the medications listed below has changed, effective September 17, 2024, for all members. Please eference the table for changes.

Note: Active prior authorizations for the medication(s) listed will not be affected.

If you have any questions, please call the pharmacy help desk at 855-580-1688.

Impacted MedicationChangePreferred Agents or New Limits
Trulicity Soln Pen-injector 0.75 MG/0.5ML
Trulicity Soln Pen-injector 1.5 MG/0.5ML
Trulicity Soln Pen-injector 3 MG/0.5ML
Trulicity Soln Pen-injector 4.5 MG/0.5ML
Byetta Soln Pen-injector 5 MCG/0.02ML
Byetta Soln Pen-injector 10 MCG/0.04ML
Bydureon Extended Release Susp Auto-Injector 2 MG/0.85ML
Victoza Soln Pen-injector 18 MG/3ML (6 MG/ML)
Adlyxin Soln Pen-injector 20 MCG/0.2ML (100 MCG/ML)
Adlyxin Pen-inj Starter Kit 10 MCG/0.2ML & 20 MCG/0.2ML
Rybelsus Tab 3 MG
Rybelsus Tab 7 MG
Rybelsus Tab 14 MG
Ozempic Soln Pen-inj 0.25 or 0.5 MG/DOSE (2 MG/1.5ML)
Ozempic Soln Pen-inj 1 MG/DOSE (2 MG/1.5ML)
Ozempic Soln Pen-inj 0.25 or 0.5 MG/DOSE (2 MG/3ML)
Ozempic Soln Pen-inj 1 MG/DOSE (4 MG/3ML)
Ozempic Soln Pen-inj 2 MG/DOSE (8 MG/3ML)
Mounjaro Soln Pen-injector 2.5 MG/0.5ML
Mounjaro Soln Pen-injector 5 MG/0.5ML
Mounjaro Soln Pen-injector 7.5 MG/0.5ML
Mounjaro Soln Pen-injector 10 MG/0.5ML
Mounjaro Soln Pen-injector 12.5 MG/0.5ML
Mounjaro Soln Pen-injector 15 MG/0.5ML
Saxenda (Weight Management) Soln Pen-Injector 6 MG/ML
Wegovy (Weight Mngmt) Soln Auto-Injector 0.25 MG/0.5ML
Wegovy (Weight Mngmt) Soln Auto-Injector 0.5 MG/0.5ML
Wegovy (Weight Mngmt) Soln Auto-Injector 1 MG/0.5ML
Wegovy (Weight Mngmt) Soln Auto-Injector 1.7 MG/0.75ML
Wegovy (Weight Mngmt) Soln Auto-Injector 2.4 MG/0.75ML
Zepbound (Weight Mngmt) Soln Auto-Injector 2.5 MG/0.5ML
Zepbound (Weight Mngmt) Soln Auto-Injector 5 MG/0.5ML
Zepbound (Weight Mngmt) Soln Auto-Injector 7.5 MG/0.5ML
Zepbound (Weight Mngmt) Soln Auto-Injector 10 MG/0.5ML
Zepbound (Weight Mngmt) Soln Auto-Injector 12.5 MG/0.5ML
Zepbound (Weight Mngmt) Soln Auto-Injector 15 MG/0.5ML

 

New Limits

Restricted to one medication (GLP-1 receptor agonists) per month

This is an update to the Meridian Medicaid Plan (Meridian) Preferred Drug List.

Coverage of the medications listed below has changed, 09/20/24, for all members. Please eference the table for changes.

Note: Active prior authorizations for the medication(s) listed will not be affected.

If you have any questions, please call the pharmacy help desk at 855-580-1688.

Impacted MedicationChangePreferred Agents or New Limits

Alprazolam Tab 0.25 MG

New Limits

4 Daily

Alprazolam Tab 0.5 MG

New Limits

4 Daily

Alprazolam Tab 1 MG

New Limits

4 Daily

Atazanavir Sulfate Cap 200 MG (Base Equiv

New Limits

2 Daily

Atazanavir Sulfate Cap 300 MG (Base Equiv

New Limits

2 Daily

Atazanavir Sulfate Oral Powder Packet 50 MG (Base Equiv)

New Limits

6 Daily

Balsalazide Disodium Cap 750 MG

New Limits

9 Daily

Bicalutamide Tab 50 MG

New Limits

3 Daily

Butalbital-Acetaminophen-Caffeine Cap 50-325-40 MG

New Limits

6 Daily

Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG

New Limits

6 Daily

Butalbital-Aspirin-Caffeine Cap 50-325-40 MG

New Limits

6 Daily

Chlordiazepoxide HCl Cap 10 MG

New Limits

4 Daily

Chlordiazepoxide HCl Cap 25 MG

New Limits

4 Daily

Chlordiazepoxide HCl Cap 5 MG

New Limits

4 Daily

Chloroquine Phosphate Tab 250 MG

New Limits

2 Daily

Citalopram Hydrobromide Tab 10 MG (Base Equiv)

New Limits

4 Daily

Citalopram Hydrobromide Tab 20 MG (Base Equiv)

New Limits

2 Daily

Citalopram Hydrobromide Tab 10 MG (Base Equiv)

New Limits

1 Daily

Clopidogrel Bisulfate Tab 75 MG (Base Equiv)

New Limits

1 Daily

Clorazepate Dipotassium Tab 15 MG

New Limits

6 Daily

Clorazepate Dipotassium Tab 3.75 MG

New Limits

6 Daily

Clorazepate Dipotassium Tab 7.5 MG

New Limits

6 Daily

Clozapine Tab 100 MG

New Limits

9 Daily

Clozapine Tab 200 MG

New Limits

3 Daily

Clozapine Tab 25 MG

New Limits

3 Daily

Clozapine Tab 50 MG

New Limits

3 Daily

Conjugated Estrogen-Medroxyprogest Acetate Tab 0.3-1.5 MG

New Limits

1 Daily

Conjugated Estrogen-Medroxyprogest Acetate Tab 0.45-1.5 MG

New Limits

1 Daily

Cyclobenzaprine HCl Tab 10 MG

New Limits

3 Daily

Cyclobenzaprine HCl Tab 5 MG

New Limits

3 Daily

Cyclobenzaprine HCl Tab 7.5 MG

New Limits

4 Daily

Darunavir-Cobic-Emtricitab-Tenofov AF Tab 800-150-200-10 MG

New Limits

1 Daily

Desipramine HCl Tab 25 MG

New Limits

2 Daily

Diltiazem HCl Tab 30 MG

New Limits

4 Daily

Diltiazem HCl Tab 60 MG

New Limits

4 Daily

Diltiazem HCl Tab 90 MG

New Limits

4 Daily

Efavirenz Cap 200 MG

New Limits

1 Daily

Efavirenz Cap 50 MG

New Limits

2 Daily

Efavirenz Cap 600 MG

New Limits

1 Daily

Efavirenz-Emtricitabine-Tenofovir DF Tab 600-200-300 MG

New Limits

1 Daily

Efavirenz-Lamivudine-Tenofovir DF Tab 600-300-300 MG

New Limits

1 Daily

Elvitegrav-Cobic-Emtricitab-Tenofov AF Tab 150-150-200-10 MG

New Limits

1 Daily

Empagliflozin Tab 10 MG

New Limits

1 Daily

Empagliflozin Tab 25 MG

New Limits

1 Daily

Emtricitabine Caps 200 MG

New Limits

1 Daily

Emtricitabine-Rilpivirine-Tenofovir AF Tab 200-25-25 MG

New Limits

1 Daily

Enalapril Maleate & Hydrochlorothiazide Tab 10-25 MG

New Limits

2 Daily

Enalapril Maleate & Hydrochlorothiazide Tab 5-12.5 MG

New Limits

2 Daily

Enalapril Maleate Tab 10 MG

New Limits

2 Daily

Enalapril Maleate Tab 2.5 MG

New Limits

2 Daily

Enalapril Maleate Tab 20 MG

New Limits

2 Daily

Enalapril Maleate Tab 5 MG

New Limits

2 Daily

Estradiol & Norethindrone Acetate Tab 0.5-0.1 MG

New Limits

1 Daily

Estradiol & Norethindrone Acetate Tab 1-0.5 MG

New Limits

1 Daily

Estrogens, Conjugated Tab 0.3 MG

New Limits

1 Daily

Estrogens, Conjugated Tab 0.45 MG

New Limits

1 Daily

Estrogens, Conjugated Tab 0.625 MG

New Limits

1 Daily

Estrogens, Conjugated Tab 0.9 MG

New Limits

1 Daily

Estrogens, Conjugated Tab 1.25 MG

New Limits

1 Daily

Etravirine Tab 100 MG

New Limits

4 Daily

Etravirine Tab 200 MG

New Limits

2 Daily

Etravirine Tab 67 MG

New Limits

4 Daily

Fenofibrate Micronized Cap 134 MG

New Limits

1 Daily

Fenofibrate Micronized Cap 200 MG

New Limits

1 Daily

Fenofibrate Micronized Cap 67 MG

New Limits

2 Daily

Fenofibrate Tab 160 MG

New Limits

1 Daily

Fenofibrate Tab 54 MG

New Limits

3 Daily

Finasteride Tab 5 MG

New Limits

1 Daily

Fluvoxamine Maleate Tab 100 MG

New Limits

3 Daily

Fluvoxamine Maleate Tab 25 MG

New Limits

2 Daily

Fluvoxamine Maleate Tab 50 MG

New Limits

2 Daily

Fosamprenavir Calcium Tab 700 MG (Base Equiv)

New Limits

4 Daily

Fosinopril Sodium & Hydrochlorothiazide Tab 10-12.5 MG

New Limits

2 Daily

Fosinopril Sodium & Hydrochlorothiazide Tab 20-12.5 MG

New Limits

4 Daily

Fosinopril Sodium Tab 10 MG

New Limits

1 Daily

Fosinopril Sodium Tab 20 MG

New Limits

2 Daily

Fosinopril Sodium Tab 40 MG

New Limits

2 Daily

Gabapentin Cap 300 MG

New Limits

9 Daily

Gemfibrozil Tab 600 MG

New Limits

2 Daily

Glecaprevir-Pibrentasvir Tab 100-40 MG

New Limits

3 Daily

Glimepiride Tab 1 MG

New Limits

4 Daily

Glimepiride Tab 2 MG

New Limits

4 Daily

Glimepiride Tab 4 MG

New Limits

2 Daily

Glycopyrrolate Tab 1 MG

New Limits

4 Daily

Glycopyrrolate Tab 2 MG

New Limits

4 Daily

Haloperidol Tab 0.5 MG

New Limits

3 Daily

Haloperidol Tab 1 MG

New Limits

3 Daily

Haloperidol Tab 10 MG

New Limits

3 Daily

Hyoscyamine Sulfate Tab SR 12HR 0.375 MG

New Limits

4 Daily

Irbesartan Tab 150 MG

New Limits

1 Daily

Irbesartan Tab 300 MG

New Limits

1 Daily

Irbesartan Tab 75 MG

New Limits

1 Daily

Irbesartan-Hydrochlorothiazide Tab 150-12.5 MG

New Limits

1 Daily

Irbesartan-Hydrochlorothiazide Tab 300-12.5 MG

New Limits

1 Daily

Isosorbide Mononitrate Tab 10 MG

New Limits

3 Daily

Isosorbide Mononitrate Tab 20 MG

New Limits

3 Daily

Isosorbide Mononitrate Tab ER 24HR 120 MG

New Limits

1 Daily

Isosorbide Mononitrate Tab ER 24HR 30 MG

New Limits

1 Daily

Isosorbide Mononitrate Tab ER 24HR 60 MG

New Limits

1 Daily

Labetalol HCl Tab 100 MG

New Limits

3 Daily

Labetalol HCl Tab 200 MG

New Limits

6 Daily

Labetalol HCl Tab 300 MG

New Limits

8 Daily

Lamivudine Tab 150 MG

New Limits

2 Daily

Lamivudine Tab 300 MG

New Limits

1 Daily

Lamivudine-Zidovudine Tab 150-300 MG

New Limits

2 Daily

Levetiracetam Tab 250 MG

New Limits

4 Daily

Levetiracetam Tab 500 MG

New Limits

6 Daily

Levetiracetam Tab 750 MG

New Limits

4 Daily

Levofloxacin Tab 250 MG

New Limits

1 Daily

Levofloxacin Tab 500 MG

New Limits

1 Daily

Levofloxacin Tab 750 MG

New Limits

1 Daily

Linagliptin Tab 5 MG

New Limits

1 Daily

Lopinavir-Ritonavir Tab 100-25 MG

New Limits

4 Daily

Lopinavir-Ritonavir Tab 200-50 MG

New Limits

6 Daily

Losartan Potassium & Hydrochlorothiazide Tab 100-12.5 MG

New Limits

2 Daily

Losartan Potassium & Hydrochlorothiazide Tab 100-25 MG

New Limits

2 Daily

Losartan Potassium & Hydrochlorothiazide Tab 50-12.5 MG

New Limits

2 Daily

Losartan Potassium 100 MG

New Limits

2 Daily

Losartan Potassium 25 MG

New Limits

2 Daily

Losartan Potassium 50 MG

New Limits

2 Daily

Metformin HCl Tab 1000 MG

New Limits

2 Daily

Metformin HCl Tab 500 MG

New Limits

5 Daily

Metformin HCl Tab 850 MG

New Limits

3 Daily

Metformin HCl Tab ER 24HR 500 MG

New Limits

4 Daily

Metformin HCl Tab ER 24HR 750 MG

New Limits

2 Daily

Metoprolol & Hydrochlorothiazide Tab 100-25 MG

New Limits

2 Daily

Metoprolol & Hydrochlorothiazide Tab 100-50 MG

New Limits

2 Daily

Metoprolol & Hydrochlorothiazide Tab 50-25 MG

New Limits

2 Daily

Metoprolol Tartrate Tab 100 MG

New Limits

4.5 Daily

Metoprolol Tartrate Tab 25 MG

New Limits

4 Daily

Metoprolol Tartrate Tab 50 MG

New Limits

4 Daily

Multiple Vitamins w/ Minerals Tab

New Limits

1

Nadolol Tab 20 MG

New Limits

2 Daily

Nadolol Tab 40 MG

New Limits

2 Daily

Nadolol Tab 80 MG

New Limits

4 Daily

Nateglinide Tab 120 MG

New Limits

3 Daily

Nateglinide Tab 60 MG

New Limits

3 Daily

Nelfinavir Mesylate Tab 250 MG

New Limits

9 Daily

Nelfinavir Mesylate Tab 625 MG

New Limits

4 Daily

Nevirapine Tab 200 MG

New Limits

2 Daily

Nevirapine Tab ER 24HR 100 MG

New Limits

3 Daily

Nevirapine Tab SR 2 4 DailyHR 4 Daily00 MG

New Limits

1 Daily

Nifedipine Cap 10 MG

New Limits

4 Daily

Nystatin Tab 500000 Unit

New Limits

6 Daily

Olanzapine Tab 10 MG

New Limits

2 Daily

Olanzapine Tab 15 MG

New Limits

2 Daily

Olanzapine Tab 2.5 MG

New Limits

4 Daily

Olanzapine Tab 20 MG

New Limits

2 Daily

Olanzapine Tab 5 MG

New Limits

4 Daily

Olanzapine Tab 7.5 MG

New Limits

2 Daily

Oxybutynin Chloride Tab 5 MG

New Limits

4 Daily

Oxybutynin Chloride Tab ER 2 4 DailyHR 15 MG

New Limits

2 Daily

Oxybutynin Chloride Tab ER 2 4 DailyHR 10 MG

New Limits

2 Daily

Oxybutynin Chloride Tab ER 2 4 DailyHR 5 MG

New Limits

2 Daily

Paroxetine HCl Tab 10 MG

New Limits

6 Daily

Paroxetine HCl Tab 20 MG

New Limits

3 Daily

Paroxetine HCl Tab 30 MG

New Limits

2 Daily

Paroxetine HCl Tab 4 Daily0 MG

New Limits

2 Daily

Perphenazine Tab 16 MG

New Limits

4 Daily

Perphenazine Tab 2 MG

New Limits

4 Daily

Perphenazine Tab 4 Daily MG

New Limits

4 Daily

Perphenazine Tab 8 MG

New Limits

4 Daily

Perphenazine-Amitriptyline Tab 2-10 MG

New Limits

4 Daily

Perphenazine-Amitriptyline Tab 2-25 MG

New Limits

4 Daily

Perphenazine-Amitriptyline Tab 4 Daily-10 MG

New Limits

4 Daily

Perphenazine-Amitriptyline Tab 4 Daily-25 MG

New Limits

4 Daily

Perphenazine-Amitriptyline Tab 4 Daily-50 MG

New Limits

4 Daily

Pilocarpine HCl Tab 5 MG

New Limits

6 Daily

Pramipexole Dihydrochloride Tab 0.125 MG

New Limits

3 Daily

Pramipexole Dihydrochloride Tab 0.25 MG

New Limits

3 Daily

Pramipexole Dihydrochloride Tab 0.5 MG

New Limits

3 Daily

Pramipexole Dihydrochloride Tab 0.75 MG

New Limits

3 Daily

Pramipexole Dihydrochloride Tab 1 MG

New Limits

3 Daily

Pramipexole Dihydrochloride Tab 1.5 MG

New Limits

3 Daily

Prenatal Vit w/ DSS-Fe Fumarate-FA Tab 29-1 MG

New Limits

1 Daily

Prenatal Vit w/ Iron Carbonyl-FA Tab 29-1 MG

New Limits

1 Daily

Quetiapine Fumarate Tab 100 MG

New Limits

4 Daily

Quetiapine Fumarate Tab 150 MG

New Limits

4 Daily

Quetiapine Fumarate Tab 200 MG

New Limits

4 Daily

Quetiapine Fumarate Tab 25 MG

New Limits

4 Daily

Quetiapine Fumarate Tab 300 MG

New Limits

2 Daily

Quetiapine Fumarate Tab 4 Daily00 MG

New Limits

2 Daily

Quetiapine Fumarate Tab 50 MG

New Limits

4 Daily

Quinapril HCl Tab 10 MG

New Limits

2 Daily

Quinapril HCl Tab 20 MG

New Limits

2 Daily

Quinapril HCl Tab 4 Daily0 MG

New Limits

2 Daily

Quinapril HCl Tab 5 MG

New Limits

2 Daily

Quinapril-Hydrochlorothiazide Tab 10-12.5 MG

New Limits

3 Daily

Quinapril-Hydrochlorothiazide Tab 20-12.5 MG

New Limits

4 Daily

Quinapril-Hydrochlorothiazide Tab 20-25 MG

New Limits

2 Daily

Raltegravir Potassium Chew Tab 100 MG (Base Equiv)

New Limits

6 Daily

Raltegravir Potassium Chew Tab 25 MG (Base Equiv)

New Limits

12 Daily

Raltegravir Potassium Packet For Susp 100 MG (Base Equiv)

New Limits

2 Daily

Raltegravir Potassium Tab 4 Daily00 MG (Base Equiv)

New Limits

2 Daily

Raltegravir Potassium Tab 600 MG (Base Equiv)

New Limits

2 Daily

Ramipril Cap 1.25 MG

New Limits

2 Daily

Ramipril Cap 10 MG

New Limits

2 Daily

Ramipril Cap 2.5 MG

New Limits

2 Daily

Ramipril Cap 5 MG

New Limits

2 Daily

Risperidone Tab 0.25 MG

New Limits

4 Daily

Risperidone Tab 0.5 MG

New Limits

4 Daily

Risperidone Tab 1 MG

New Limits

4 Daily

Risperidone Tab 2 MG

New Limits

4 Daily

Risperidone Tab 3 MG

New Limits

4 Daily

Risperidone Tab 4 Daily MG

New Limits

4 Daily

Ritonavir Tab 100 MG

New Limits

12 Daily

Saquinavir Mesylate Tab 500 MG

New Limits

4 Daily

Sertraline HCl Tab 100 MG

New Limits

4 Daily

Sertraline HCl Tab 25 MG

New Limits

4 Daily

Sertraline HCl Tab 50 MG

New Limits

4 Daily

Sotalol HCl Tab 120 MG

New Limits

4 Daily

Sotalol HCl Tab 160 MG

New Limits

2 Daily

Sotalol HCl Tab 80 MG

New Limits

2 Daily

Sucralfate Tab 1 GM

New Limits

4 Daily

Tamsulosin HCl Cap 0. 4 Daily MG

New Limits

2 Daily

Temozolomide Cap 180 MG

New Limits

2 Daily

Temozolomide Cap 250 MG

New Limits

2 Daily

Tenofovir Disoproxil Fumarate Tab 150 MG

New Limits

1 Daily

Tenofovir Disoproxil Fumarate Tab 200 MG

New Limits

1 Daily

Tenofovir Disoproxil Fumarate Tab 250 MG

New Limits

1 Daily

Tenofovir Disoproxil Fumarate Tab 300 MG

New Limits

1 Daily

Terbinafine HCl Tab 250 MG

New Limits

1 Daily

Thioridazine HCl Tab 10 MG

New Limits

4 Daily

Thioridazine HCl Tab 100 MG

New Limits

8 Daily

Thioridazine HCl Tab 25 MG

New Limits

4 Daily

Thioridazine HCl Tab 50 MG

New Limits

4 Daily

Thiothixene Cap 1 MG

New Limits

3 Daily

Thiothixene Cap 10 MG

New Limits

6 Daily

Thiothixene Cap 2 MG

New Limits

3 Daily

Thiothixene Cap 5 MG

New Limits

3 Daily

Ticagrelor Tab 60 MG

New Limits

2 Daily

Ticagrelor Tab 90 MG

New Limits

2 Daily

Topiramate Tab 100 MG

New Limits

4 Daily

Topiramate Tab 200 MG

New Limits

2 Daily

Topiramate Tab 25 MG

New Limits

6 Daily

Topiramate Tab 50 MG

New Limits

6 Daily

Torsemide Tab 10 MG

New Limits

1 Daily

Torsemide Tab 100 MG

New Limits

1 Daily

Torsemide Tab 5 MG

New Limits

1 Daily

Trandolapril Tab 1 MG

New Limits

1 Daily

Trandolapril Tab 2 MG

New Limits

1 Daily

Trandolapril Tab 4 Daily MG

New Limits

2 Daily

Trazodone HCl Tab 300 MG

New Limits

2 Daily

Triamterene & Hydrochlorothiazide Cap 37.5-25 MG

New Limits

1 Daily

Triamterene & Hydrochlorothiazide Tab 37.5-25 MG

New Limits

1 Daily

Triamterene & Hydrochlorothiazide Tab 75-50 MG

New Limits

1 Daily

Trifluoperazine HCl Tab 1 MG

New Limits

3 Daily

Trifluoperazine HCl Tab 10 MG

New Limits

3 Daily

Trifluoperazine HCl Tab 2 MG

New Limits

3 Daily

Trifluoperazine HCl Tab 5 MG

New Limits

3 Daily

Ursodiol Cap 300 MG

New Limits

3 Daily

Valacyclovir HCl Tab 500 MG

New Limits

2 Daily

Valganciclovir HCl Tab 4 Daily50 MG

New Limits

4 Daily

Valsartan Tab 160 MG

New Limits

2 Daily

Valsartan Tab 320 MG

New Limits

1 Daily

Valsartan Tab 4 Daily0 MG

New Limits

2 Daily

Valsartan Tab 80 MG

New Limits

2 Daily

Vancomycin HCl Cap 125 MG (Base Equivalent)

New Limits

4 Daily

Vancomycin HCl Cap 250 MG (Base Equivalent)

New Limits

8 Daily

Varenicline Tartrate Tab 0.5 MG (Base Equiv)

New Limits

2 Daily

Varenicline Tartrate Tab 1 MG (Base Equiv)

New Limits

2 Daily

Verapamil HCl Tab 120 MG

New Limits

3 Daily

Verapamil HCl Tab 4 Daily0 MG

New Limits

3 Daily

Verapamil HCl Tab 80 MG

New Limits

3 Daily

Zidovudine Cap 100 MG

New Limits

6 Daily

Zidovudine Cap 300 MG

New Limits

2 Daily

This is an update to the Meridian Medicaid Plan (Meridian) Preferred Drug List.

Coverage of the medications listed below has changed, 09/20/24, for all members. Please eference the table for changes.

Note: Active prior authorizations for the medication(s) listed will not be affected.

If you have any questions, please call the pharmacy help desk at 855-580-1688.

Impacted MedicationChangeNew Quantity Limit per fill

Amoxicillin & K Clavulanate Tab 250-125 MG

New Limits

30

Amoxicillin & K Clavulanate Tab 500-125 MG

New Limits

42

Amoxicillin & K Clavulanate Tab 875-125 MG

New Limits

30

Amoxicillin & K Clavulanate Chew Tab 200-28.5 MG

New Limits

30

Amoxicillin & K Clavulanate Chew Tab 400-57 MG

New Limits

30

Azithromycin Tab 600 MG

New Limits

30

Cefdinir Cap 300 MG

New Limits

28

Cefuroxime Axetil Tab 250 MG

New Limits

20

Cefuroxime Axetil Tab 500 MG

New Limits

56

Ciprofloxacin HCl Tab 100 MG (Base Equiv)

New Limits

6

Clarithromycin Tab 250 MG

New Limits

28

Clarithromycin Tab 500 MG

New Limits

28

Clarithromycin Tab ER 24HR 500 MG

New Limits

14

Nicotine TD Patch 24 HR Kit 21-14-7 MG/24HR

New Limits

56

Azithromycin Powd Pack for Susp 1 GM

New Limits

2

This is an important message from Meridian Medicaid Plan (Meridian).

Meridian would like to inform you that the coverage of the medications listed below has changed, effective August 15, 2024, for all members. Please reference the table for information regarding medication changes.

Please note: Active prior authorizations for this medication will not be affected. If you have questions, please call the pharmacy help desk at 855-580-1688.

Impacted MedicationChangePreferred Agents or New Limits

AZO HORMONAL HEALTH CYCLE CARE & COMFORT

Coverage Change

Removed from Preferred Drug List

CORVITA

Coverage Change

Removed from Preferred Drug List

DERMACINRX MULTITAM

Coverage Change

Removed from Preferred Drug List

FOLITIN-Z

Coverage Change

Removed from Preferred Drug List

HYLAZINC

Coverage Change

Removed from Preferred Drug List

KEYLOSA

Coverage Change

Removed from Preferred Drug List

K-PAX IMMUNE SUPPORT FORMULA PROFESSIONAL STRENGTH

Coverage Change

Removed from Preferred Drug List

LYSIPLEX PLUS

Coverage Change

Removed from Preferred Drug List

NICADAN

Coverage Change

Removed from Preferred Drug List

NICAZEL

Coverage Change

Removed from Preferred Drug List

ONEVITE

Coverage Change

Removed from Preferred Drug List

PHYTOMULTI

Coverage Change

Removed from Preferred Drug List

PROFOLA

Coverage Change

Removed from Preferred Drug List

STROVITE ONE

Coverage Change

Removed from Preferred Drug List

THRIVITE 19

Coverage Change

Removed from Preferred Drug List

Tm-Daily (multivitamins)

Coverage Change

Removed from Preferred Drug List

VENEXA FE

Coverage Change

Removed from Preferred Drug List

VENTRIXYL

Coverage Change

Removed from Preferred Drug List

VITEYES OPTIC NERVE SUPPORT

Coverage Change

Removed from Preferred Drug List

VITRAMYN

Coverage Change

Removed from Preferred Drug List

VITRANOL FE

Coverage Change

Removed from Preferred Drug List

VITREXATE FE

Coverage Change

Removed from Preferred Drug List

VITREXYL/IRON

Coverage Change

Removed from Preferred Drug List

This is an important message from Meridian Medicaid Plan (Meridian).

Meridian would like to inform you that the coverage of the medications listed below has changed, effective August 15, 2024, for all members. Please reference the table for information regarding medication changes.

Please note: Active prior authorizations for this medication will not be affected. If you have questions, please call the pharmacy help desk at 855-580-1688.

Impacted MedicationChangePreferred Agents or New Limits

ADVOCATE ALCOHOL PREP PADS

Coverage Change

Removed from Preferred Drug List

ALCOH-GLOVE CONTOURED WIPE

Coverage Change

Removed from Preferred Drug List

COMFORT TOUCH ALCOHOL PREP PADS

Coverage Change

Removed from Preferred Drug List

EASY COMFORT ALCOHOL PADS

Coverage Change

Removed from Preferred Drug List

GLOBAL ALCOHOL PREP EASEPADS

Coverage Change

Removed from Preferred Drug List

PHARMACIST CHOICE ALCOHOL PRED PADS

Coverage Change

Removed from Preferred Drug List

PRO COMFORT ALCOHOL PADS

Coverage Change

Removed from Preferred Drug List

PURE COMFORT ALCOHOL PREPPADS

Coverage Change

Removed from Preferred Drug List

SAPS CARE ALCOHOL PREP PADS

Coverage Change

Removed from Preferred Drug List

SAPS HEALTH ALCOHOL PREPPADS

Coverage Change

Removed from Preferred Drug List

SAPS HEALTH CARE ALCOHOLPREP PADS

Coverage Change

Removed from Preferred Drug List

TRUE COMFORT ALCOHOL PREP PADS

Coverage Change

Removed from Preferred Drug List

This is an important message from Meridian Medicaid Plan (Meridian).

Meridian would like to inform you that the coverage of the medications listed below has changed, effective August 15, 2024, for all members. Please reference the table for information regarding medication changes.

Please note: Active prior authorizations for this medication will not be affected. If you have questions, please call the pharmacy help desk at 855-580-1688.

Impacted MedicationChangePreferred Agents or New Limits

Ob Complete

Coverage Change

Removed from Preferred Drug List

Pnv-Select

Coverage Change

Removed from Preferred Drug List

Prenatryl

Coverage Change

Removed from Preferred Drug List

This is an important message from Meridian Medicaid Plan (Meridian).

Meridian would like to inform you that the coverage of the medications listed below has changed, effective August 15, 2024, for all members. Please reference the table for information regarding medication changes.

Please note: Active prior authorizations for this medication will not be affected. If you have questions, please call the pharmacy help desk at 855-580-1688.

Impacted MedicationChangePreferred Agents or New Limits

ACCU-CHEK FASTCLIX LANCETS

Coverage Change

Removed from Preferred Drug List

ACCU-CHEK SAFE-T-PRO LANCETS

Coverage Change

Removed from Preferred Drug List

ACCU-CHEK SOFTCLIX LANCETS

Coverage Change

Removed from Preferred Drug List

ACTI-LANCE LANCETS 28G

Coverage Change

Removed from Preferred Drug List

ACTI-LANCE LITE SAFETY LANCETS 28G

Coverage Change

Removed from Preferred Drug List

ACTI-LANCE SPECIAL SAFETY LANCETS 17G

Coverage Change

Removed from Preferred Drug List

ACTI-LANCE UNIVERSAL SAFETY LANCETS 23G

Coverage Change

Removed from Preferred Drug List

ADVOCATE LANCETS

Coverage Change

Removed from Preferred Drug List

ADVOCATE SAFETY LANCETS 26G

Coverage Change

Removed from Preferred Drug List

AGAMATRIX ULTRA-THIN LANCETS 33G

Coverage Change

Removed from Preferred Drug List

AIMSCO TWIST LANCETS 33G

Coverage Change

Removed from Preferred Drug List

ASSURE COMFORT LANCETS ULTRA THIN 28G

Coverage Change

Removed from Preferred Drug List

ASSURE HAEMOLANCE PLUS HIGH FLOW 18G

Coverage Change

Removed from Preferred Drug List

ASSURE HAEMOLANCE PLUS LOW FLOW 25G

Coverage Change

Removed from Preferred Drug List

ASSURE LANCE LANCETS 21G

Coverage Change

Removed from Preferred Drug List

ASSURE LANCE PLUS SAFETYLANCETS 25G

Coverage Change

Removed from Preferred Drug List

AURORA LANCET SUPER THIN30G

Coverage Change

Removed from Preferred Drug List

AURORA LANCET THIN 23G

Coverage Change

Removed from Preferred Drug List

BD MICROTAINER LANCETS

Coverage Change

Removed from Preferred Drug List

CAREONE LANCET SUPER THIN/30G

Coverage Change

Removed from Preferred Drug List

CARESENS LANCETS

Coverage Change

Removed from Preferred Drug List

CARETOUCH TWIST LANCETS 28G

Coverage Change

Removed from Preferred Drug List

CARETOUCH TWIST LANCETS 30G

Coverage Change

Removed from Preferred Drug List

CARETOUCH TWIST LANCETS 33G

Coverage Change

Removed from Preferred Drug List

CLEANLET LANCETS 28G

Coverage Change

Removed from Preferred Drug List

CLEVER CHEK LANCETS ULTRATHIN 30G

Coverage Change

Removed from Preferred Drug List

CLEVER CHOICE COMFORT EZLANCETS 21G

Coverage Change

Removed from Preferred Drug List

COAGUCHEK LANCETS

Coverage Change

Removed from Preferred Drug List

COMFORT ASSURED LANCETS SUPER THIN 28G

Coverage Change

Removed from Preferred Drug List

COMFORT TOUCH LANCETS ULTRA THIN 31G

Coverage Change

Removed from Preferred Drug List

COMFORT TOUCH PLUS SAFETY LANCETS PRESSURE ACTIVATED 28G

Coverage Change

Removed from Preferred Drug List

CVS LANCETS 21G

Coverage Change

Removed from Preferred Drug List

CVS LANCETS MICRO-THIN 33G

Coverage Change

Removed from Preferred Drug List

CVS LANCETS ORIGINAL

Coverage Change

Removed from Preferred Drug List

CVS LANCETS THIN 26G

Coverage Change

Removed from Preferred Drug List

CVS LANCETS ULTRA-THIN 30G

Coverage Change

Removed from Preferred Drug List

CVS ULTRA THIN LANCETS

Coverage Change

Removed from Preferred Drug List

DIATHRIVE LANCETS ULTRA THIN 30G

Coverage Change

Removed from Preferred Drug List

DROPLET LANCETS ULTRA THIN 30G

Coverage Change

Removed from Preferred Drug List

DRUG MART LANCETS THIN

Coverage Change

Removed from Preferred Drug List

DRUG MART ON-THE-GO LANCETS GENTLE 30G

Coverage Change

Removed from Preferred Drug List

DRUG MART UNILET LANCETS SUPER THIN 30G

Coverage Change

Removed from Preferred Drug List

DRUG MART UNILET LANCETS ULTRA THIN 28G

Coverage Change

Removed from Preferred Drug List

EASY COMFORT LANCETS 30G/PULL TOP

Coverage Change

Removed from Preferred Drug List

EASY COMFORT LANCETS 30G/THIN TOP

Coverage Change

Removed from Preferred Drug List

EASY COMFORT LANCETS TWIST TOP

Coverage Change

Removed from Preferred Drug List

EASY TOUCH LANCETS 21G/PRESSURE ACTIVATED

Coverage Change

Removed from Preferred Drug List

EASY TOUCH LANCETS 23G/PRESSURE ACTIVATED

Coverage Change

Removed from Preferred Drug List

EASY TOUCH LANCETS 28G/PRESSURE ACTIVATED

Coverage Change

Removed from Preferred Drug List

EASY TOUCH LANCETS 28G/PULL-TOP

Coverage Change

Removed from Preferred Drug List

EASY TOUCH LANCETS 30G/BUTTON-ACTIVATED

Coverage Change

Removed from Preferred Drug List

EASY TOUCH LANCETS 30G/TWIST

Coverage Change

Removed from Preferred Drug List

EASY TOUCH LANCETS 32G/TWIST

Coverage Change

Removed from Preferred Drug List

EASY TOUCH LANCETS 33G/TWIST

Coverage Change

Removed from Preferred Drug List

EASY TOUCH SAFETY LANCETS 26G/PRESSURE ACTIVATED

Coverage Change

Removed from Preferred Drug List

EASY TOUCH SAFETY LANCETS 28G/BUTTON ACTIVATED

Coverage Change

Removed from Preferred Drug List

EMBRACE LANCETS ULTRA THIN 30G

Coverage Change

Removed from Preferred Drug List

EMBRACE PRESSURE ACTIVATED SAFETY LANCET/28G

Coverage Change

Removed from Preferred Drug List

EQL SUPER THIN LANCETS 30G

Coverage Change

Removed from Preferred Drug List

E-Z JECT LANCETS 21G

Coverage Change

Removed from Preferred Drug List

E-ZJECT LANCETS MICRO-THIN 33G

Coverage Change

Removed from Preferred Drug List

EZ-LETS LANCETS 26G SUPER-SOFT

Coverage Change

Removed from Preferred Drug List

EZ-LETS LANCETS 30G

Coverage Change

Removed from Preferred Drug List

FIFTY50 SAFETY SEAL LANCETS 30G

Coverage Change

Removed from Preferred Drug List

FIFTY50 UNILET LANCETS 33G

Coverage Change

Removed from Preferred Drug List

FINE 30

Coverage Change

Removed from Preferred Drug List

FINGERSTIX LANCETS

Coverage Change

Removed from Preferred Drug List

FORA LANCETS

Coverage Change

Removed from Preferred Drug List

FREDS PHARMACY UNILET LANCETS ULTRA THIN 28G

Coverage Change

Removed from Preferred Drug List

FREESTYLE LANCETS

Coverage Change

Removed from Preferred Drug List

FREESTYLE UNISTICK II LANCETS

Coverage Change

Removed from Preferred Drug List

GENTLE-LET GP LANCETS

Coverage Change

Removed from Preferred Drug List

GENTLE-LET LANCETS GENERAL PURPOSE STYLE/FINE POINT

Coverage Change

Removed from Preferred Drug List

GENTLE-LET LANCETS GENERAL PURPOSE STYLE/MEDIUM POINT

Coverage Change

Removed from Preferred Drug List

GENTLE-LET LANCETS SAFETY STYLE/FINE POINT

Coverage Change

Removed from Preferred Drug List

GENTLE-LET LANCETS SAFETY STYLE/MEDIUM POINT

Coverage Change

Removed from Preferred Drug List

GLOBAL INJECT EASE LANCETS 28G

Coverage Change

Removed from Preferred Drug List

GLUCOCOM LANCETS 30G

Coverage Change

Removed from Preferred Drug List

GNP LANCETS 21G

Coverage Change

Removed from Preferred Drug List

GNP LANCETS THIN 26G

Coverage Change

Removed from Preferred Drug List

GNP STERILE LANCETS 28G

Coverage Change

Removed from Preferred Drug List

GNP STERILE LANCETS 33G

Coverage Change

Removed from Preferred Drug List

GOJJI STERILE LANCETS 30G

Coverage Change

Removed from Preferred Drug List

GOODSENSE COLOR LANCETS MICRO-THIN 33G UNIVERSAL

Coverage Change

Removed from Preferred Drug List

GOODSENSE LANCETS MICRO-THIN 33G UNIVERSAL

Coverage Change

Removed from Preferred Drug List

GOODSENSE LANCETS ULTRA-THIN 26G UNIVERSAL

Coverage Change

Removed from Preferred Drug List

GOODSENSE LANCETS ULTRA-THIN 30G UNIVERSAL

Coverage Change

Removed from Preferred Drug List

HAEMOLANCE LOW FLOW LANCETS

Coverage Change

Removed from Preferred Drug List

HAEMOLANCE PLUS

Coverage Change

Removed from Preferred Drug List

HAEMOLANCE PLUS LOW FLOW

Coverage Change

Removed from Preferred Drug List

HAEMOLANCE PLUS PEDIATRIC FLOW

Coverage Change

Removed from Preferred Drug List

H-E-B INCONTROL LANCETS MICRO THIN 33G

Coverage Change

Removed from Preferred Drug List

H-E-B INCONTROL LANCETS SUPER THIN 30G

Coverage Change

Removed from Preferred Drug List

H-E-B INCONTROL LANCETS ULTRA THIN 28G

Coverage Change

Removed from Preferred Drug List

HY-VEE LANCETS

Coverage Change

Removed from Preferred Drug List

KINNEY THIN LANCETS

Coverage Change

Removed from Preferred Drug List

KROGER HEALTHPRO TWIST LANCETS/26G

Coverage Change

Removed from Preferred Drug List

KROGER LANCETS SUPER THIN

Coverage Change

Removed from Preferred Drug List

KROGER LANCETS THIN

Coverage Change

Removed from Preferred Drug List

KROGER LANCETS THIN 26G

Coverage Change

Removed from Preferred Drug List

LANCETS 30G

Coverage Change

Removed from Preferred Drug List

LANCETS 30G TWIST TOP

Coverage Change

Removed from Preferred Drug List

LANCETS 33G EXTRA FINE

Coverage Change

Removed from Preferred Drug List

LANCETS MICRO THIN 33G

Coverage Change

Removed from Preferred Drug List

LANCETS SUPER THIN 28G

Coverage Change

Removed from Preferred Drug List

LANCETS THIN

Coverage Change

Removed from Preferred Drug List

LANCETS ULTRA THIN

Coverage Change

Removed from Preferred Drug List

LITE TOUCH LANCETS

Coverage Change

Removed from Preferred Drug List

LONGS LANCETS STANDARD

Coverage Change

Removed from Preferred Drug List

LONGS LANCETS ULTRA THIN

Coverage Change

Removed from Preferred Drug List

MEDICHOICE PRE-SET SAFETY LANCET MEDIUM FLOW

Coverage Change

Removed from Preferred Drug List

MEDICHOICE PRE-SET SAFETY LANCET MODERATE FLOW

Coverage Change

Removed from Preferred Drug List

MEDICHOICE SAFETY LANCETEXTRA

Coverage Change

Removed from Preferred Drug List

MEDLANCE PLUS EXTRA LANCETS 21G

Coverage Change

Removed from Preferred Drug List

MEDLANCE PLUS LANCETS

Coverage Change

Removed from Preferred Drug List

MEDLANCE PLUS LITE LANCETS 25G

Coverage Change

Removed from Preferred Drug List

MEDLANCE PLUS SPECIAL LANCETS 0.8MM

Coverage Change

Removed from Preferred Drug List

MEDLANCE PLUS SUPERLITE 30G/COMFORT MAX

Coverage Change

Removed from Preferred Drug List

MEDLANCE PLUS UNIVERSAL LANCETS 21G

Coverage Change

Removed from Preferred Drug List

MEDLANCE/UNIVERSAL

Coverage Change

Removed from Preferred Drug List

MEIJER LANCETS

Coverage Change

Removed from Preferred Drug List

MEIJER LANCETS THIN

Coverage Change

Removed from Preferred Drug List

MEIJER LANCETS UNIVERSAL21G

Coverage Change

Removed from Preferred Drug List

MEIJER LANCETS UNIVERSAL33G

Coverage Change

Removed from Preferred Drug List

MEIJER SUPER THIN LANCETS

Coverage Change

Removed from Preferred Drug List

MICROLET LANCETS

Coverage Change

Removed from Preferred Drug List

MM TWIST LANCETS

Coverage Change

Removed from Preferred Drug List

MONOLET LANCETS

Coverage Change

Removed from Preferred Drug List

MONOLETTOR SAFETY LANCETS

Coverage Change

Removed from Preferred Drug List

MPD SAFETY LANCET 30G/1.8MM

Coverage Change

Removed from Preferred Drug List

MPD SAFETY LANCETS 23G/1.8MM

Coverage Change

Removed from Preferred Drug List

MYGLUCOHEALTH MGH SOFTLANCE LANCETS 30G

Coverage Change

Removed from Preferred Drug List

NOVA SAFETY LANCETS 28G

Coverage Change

Removed from Preferred Drug List

NOVA SUREFLEX LANCETS

Coverage Change

Removed from Preferred Drug List

PERFECT PRESSURE ACTIVATED SAFETY LANCETS 28G

Coverage Change

Removed from Preferred Drug List

PHARMACIST CHOICE ULTRA THIN LANCETS

Coverage Change

Removed from Preferred Drug List

PHARMACIST CHOICE ULTRA THIN LANCETS 30G

Coverage Change

Removed from Preferred Drug List

PHARMACIST CHOICE ULTRA THIN LANCETS 33G

Coverage Change

Removed from Preferred Drug List

PHARMACY COUNTER LANCETS

Coverage Change

Removed from Preferred Drug List

PIP LANCETS/28G

Coverage Change

Removed from Preferred Drug List

PIP LANCETS/30G

Coverage Change

Removed from Preferred Drug List

PRECISION THINS GP LANCET

Coverage Change

Removed from Preferred Drug List

PREFERRED PLUS LANCETS COLORED 21G

Coverage Change

Removed from Preferred Drug List

PREFERRED PLUS LANCETS SUPER THIN 30G

Coverage Change

Removed from Preferred Drug List

PREFERRED PLUS LANCETS THIN 26G

Coverage Change

Removed from Preferred Drug List

PRO COMFORT LANCETS 31G

Coverage Change

Removed from Preferred Drug List

PRODIGY PRESSURE ACTIVATED SAFETY LANCETS

Coverage Change

Removed from Preferred Drug List

PRODIGY SAFETY LANCETS

Coverage Change

Removed from Preferred Drug List

PSS SELECT GP LANCETS

Coverage Change

Removed from Preferred Drug List

PURE COMFORT LANCETS 30G

Coverage Change

Removed from Preferred Drug List

PX LANCETS MICROTHIN 33G

Coverage Change

Removed from Preferred Drug List

PX LANCETS ULTRA THIN

Coverage Change

Removed from Preferred Drug List

PX LANCETS ULTRA THIN 28G

Coverage Change

Removed from Preferred Drug List

QC UNILET LANCETS 33G/MICRO THIN

Coverage Change

Removed from Preferred Drug List

RA E-ZJECT LANCETS 28G

Coverage Change

Removed from Preferred Drug List

RA E-ZJECT LANCETS THIN 26G

Coverage Change

Removed from Preferred Drug List

READYLANCE SAFETY LANCETS/23G/1.8MM

Coverage Change

Removed from Preferred Drug List

READYLANCE SAFETY LANCETS/28G/1.8MM

Coverage Change

Removed from Preferred Drug List

REALITY TRIGGER LANCETS

Coverage Change

Removed from Preferred Drug List

RELION LANCETS THIN 26G

Coverage Change

Removed from Preferred Drug List

RELION LANCETS ULTRA-THIN30G

Coverage Change

Removed from Preferred Drug List

RELION ULTRA THIN PLUS LANCETS 33G

Coverage Change

Removed from Preferred Drug List

RIGHTEST GL300 LANCETS

Coverage Change

Removed from Preferred Drug List

SAFE-T-LANCE LOW FLOW 25G

Coverage Change

Removed from Preferred Drug List

SAFE-T-LANCE NORMAL FLOW21G

Coverage Change

Removed from Preferred Drug List

SAFE-T-LANCE PLUS SAFETYLANCET HIGH FLOW

Coverage Change

Removed from Preferred Drug List

SAFE-T-LANCE PLUS SAFETYLANCET LOW FLOW

Coverage Change

Removed from Preferred Drug List

SAFETY LANCETS

Coverage Change

Removed from Preferred Drug List

SAFETY LANCETS 23G

Coverage Change

Removed from Preferred Drug List

SAFETY LANCETS 28G

Coverage Change

Removed from Preferred Drug List

SAFETY LANCETS/PRESSURE ACTIVATED/28G

Coverage Change

Removed from Preferred Drug List

SAPS HEALTH PLUS TWIST TOP LANCETS 30G

Coverage Change

Removed from Preferred Drug List

SB LANCETS THIN

Coverage Change

Removed from Preferred Drug List

SB LANCETS ULTRA THIN

Coverage Change

Removed from Preferred Drug List

SHOPKO UNILET LANCETS SUPER THIN 30G

Coverage Change

Removed from Preferred Drug List

SM MICRO THIN LANCETS 33G

Coverage Change

Removed from Preferred Drug List

SMART SENSE SUPER THIN LANCETS UNIVERSAL 30G

Coverage Change

Removed from Preferred Drug List

SMART SENSE THIN LANCETSUNIVERSAL 26G

Coverage Change

Removed from Preferred Drug List

SMARTEST LANCETS 28G

Coverage Change

Removed from Preferred Drug List

SOLUS V2 TWIST LANCETS 30G

Coverage Change

Removed from Preferred Drug List

STERILANCE TL

Coverage Change

Removed from Preferred Drug List

SUPER THIN LANCETS

Coverage Change

Removed from Preferred Drug List

SURE COMFORT LANCETS 18G

Coverage Change

Removed from Preferred Drug List

SURE COMFORT LANCETS 23G

Coverage Change

Removed from Preferred Drug List

SURE COMFORT LANCETS 28G

Coverage Change

Removed from Preferred Drug List

SURELITE LANCETS

Coverage Change

Removed from Preferred Drug List

TECHLITE AST LANCETS

Coverage Change

Removed from Preferred Drug List

TECHLITE LANCETS

Coverage Change

Removed from Preferred Drug List

TGT LANCET MICRO THIN 33G

Coverage Change

Removed from Preferred Drug List

TRAVEL LANCETS ADVANCED 28G

Coverage Change

Removed from Preferred Drug List

TRUE COMFORT TWIST TOP LANCETS 30G

Coverage Change

Removed from Preferred Drug List

TRUEPLUS LANCETS 28G

Coverage Change

Removed from Preferred Drug List

TRUEPLUS LANCETS 28G SUPER THIN

Coverage Change

Removed from Preferred Drug List

TRUEPLUS LANCETS 30G

Coverage Change

Removed from Preferred Drug List

TRUEPLUS LANCETS 30G ULTRA THIN

Coverage Change

Removed from Preferred Drug List

TRUEPLUS LANCETS 33G MICRO THIN

Coverage Change

Removed from Preferred Drug List

TRUEPLUS SAFETY LANCETS 28G

Coverage Change

Removed from Preferred Drug List

ULTILET CLASSIC LANCETS

Coverage Change

Removed from Preferred Drug List

ULTILET LANCETS 33G

Coverage Change

Removed from Preferred Drug List

ULTILET SAFETY LANCETS 21G X 2.2MM

Coverage Change

Removed from Preferred Drug List

ULTILET SAFETY LANCETS 23G

Coverage Change

Removed from Preferred Drug List

ULTRA-THIN II AUTO LANCET

Coverage Change

Removed from Preferred Drug List

ULTRA-THIN II LANCETS 30G

Coverage Change

Removed from Preferred Drug List

UNILET COMFORTOUCH LANCET

Coverage Change

Removed from Preferred Drug List

UNILET EXCELITE

Coverage Change

Removed from Preferred Drug List

UNILET EXCELITE II

Coverage Change

Removed from Preferred Drug List

UNILET G.P. LANCET

Coverage Change

Removed from Preferred Drug List

UNILET G.P. SUPERLITE LANCET

Coverage Change

Removed from Preferred Drug List

UNILET GP 28 ULTRA THIN

Coverage Change

Removed from Preferred Drug List

UNILET LANCETS MICRO-THIN33G

Coverage Change

Removed from Preferred Drug List

UNILET LANCETS ULTRA-THIN 28G

Coverage Change

Removed from Preferred Drug List

UNILET SUPERLITE LANCET

Coverage Change

Removed from Preferred Drug List

UNISTIK 3 GENTLE

Coverage Change

Removed from Preferred Drug List

UNISTIK PRO SAFETY LANCET 21G

Coverage Change

Removed from Preferred Drug List

UNISTIK PRO SAFETY LANCET 28G

Coverage Change

Removed from Preferred Drug List

UNISTIK SAFETY LANCETS 28G

Coverage Change

Removed from Preferred Drug List

UNISTIK SAFETY LANCETS 30G

Coverage Change

Removed from Preferred Drug List

UNISTIK TOUCH SAFETY LANCETS 21G

Coverage Change

Removed from Preferred Drug List

UNISTIK TOUCH SAFETY LANCETS 23G

Coverage Change

Removed from Preferred Drug List

UNIVERSAL 1 LANCETS THIN26G

Coverage Change

Removed from Preferred Drug List

UNIVERSAL 1 LANCETS/33G/MICRO-THIN

Coverage Change

Removed from Preferred Drug List

VALUE PLUS LANCETS STANDARD 21G

Coverage Change

Removed from Preferred Drug List

VALUE PLUS LANCETS THIN 26G

Coverage Change

Removed from Preferred Drug List

VERIFINE SAFETY LANCET MINI 21G X 2.4MM

Coverage Change

Removed from Preferred Drug List

VERIFINE SAFETY LANCET MINI 28G X 1.8MM

Coverage Change

Removed from Preferred Drug List

VERIFINE UNIVERSAL LANCETS 28G

Coverage Change

Removed from Preferred Drug List

VERIFINE UNIVERSAL LANCETS 33G

Coverage Change

Removed from Preferred Drug List

VIDA MIA UNILET LANCETS SUPER THIN 30G

Coverage Change

Removed from Preferred Drug List

VIDA MIA UNILET LANCETS ULTRA THIN 28G

Coverage Change

Removed from Preferred Drug List

VIVAGUARD LANCETS

Coverage Change

Removed from Preferred Drug List

WALGREENS ADVANCED TRAVEL LANCETS 28G

Coverage Change

Removed from Preferred Drug List

WALGREENS COMFORT ASSURED LANCETS MICRO THIN/33G

Coverage Change

Removed from Preferred Drug List

WALGREENS COMFORT ASSURED LANCETS MICRO THIN/28G

Coverage Change

Removed from Preferred Drug List

ZEVRX TWIST TOP LANCETS 30G

Coverage Change

Removed from Preferred Drug List

This is an important message from Meridian Medicaid Plan (Meridian).

Meridian would like to inform you that the coverage of the medications listed below has changed, effective August 1, 2024, for all members. Please reference the table for information regarding medication changes.

Please note: Active prior authorizations for this medication will not be affected. If you have questions, please call the pharmacy help desk at 855-580-1688.

Impacted MedicationChangePreferred Agents or New Limits

Trulicity

Coverage Change

Preferred with Diabetes Diagnosis

Victoza

Coverage Change

Preferred with Diabetes Diagnosis

This is an important message from Meridian Medicaid Plan (Meridian).

Meridian would like to inform you that the coverage of the medications listed below has changed, effective June 1, 2024, for all members. Please reference the table for information regarding medication changes.

Impacted MedicationChange

Symbicort Inhaler

Increase quantity limit to 2 inhalers per month

Please note: Active prior authorizations for this medication will not be affected.

If you have questions, please call the pharmacy help desk at 855-580-1688.

This is an important message from Meridian Medicaid Plan (Meridian).

This change has been postponed until further notice.

Meridian would like to inform you that the coverage of the medications listed below has changed, effective 2/1/2024, for all members. Please reference the table for information regarding medication changes.

Impacted MedicationChangeNew Limits

ADHD, Immediate Release

New Limits

Restricted to two medications per month

Antidepressants

New Limits

Restricted to two medications per month

Atypical Antipsychotics

New Limits

Restricted to one medication per month

Benzodiazepines

New Limits

Restricted to two medications per month

Muscle Relaxants

New Limits

Restricted to one medication per month

Opioid Max Fill

New Limits

Restricted to two fills per month

Sedative Hypnotics

New Limits

Restricted to one medication per month

ADHD, Long Acting

New Limits

Restricted to one medication per month

Antidepressants, Tricyclic

New Limits

Restricted to one medication per month

Please note: Active prior authorizations for this medication will not be affected.

If you have questions, please call the pharmacy help desk at 855-580-1688.

This is an important message from Meridian Medicaid Plan (Meridian).

This change has been postponed until further notice.

Meridian would like to inform you that the coverage of the medications listed below has changed, effective 6/15/2024, for all members. Please reference the table for information regarding medication changes.

Impacted MedicationChangeNew Limits

WELLFOLA

New Status

Non-Preferred

Please note: Active prior authorizations for this medication will not be affected.

If you have questions, please call the pharmacy help desk at 855-580-1688.

This is an important message from Meridian Medicaid Plan (Meridian).

This change has been postponed until further notice.

Meridian would like to inform you that the coverage of the medications listed below has changed, effective 4/15/2024, for all members. Please reference the table for information regarding medication changes.

Impacted MedicationChangeNew Limits

UL COMF BODY MIS MASSAGER

Supplemental Benefit Coverage

Removed from Coverage

Please note: Active prior authorizations for this medication will not be affected.

If you have questions, please call the pharmacy help desk at 855-580-1688.

2023 Meridian Medicaid Plan Preferred Drug List Updates

Meridian would like to inform you that the coverage of the medications listed below has changed, effective January 1, 2024, for all members. Please reference the table for information about medication changes.

Impacted MedicationChangeNew Limits

ADHD, Immediate Release

New Limits

Restricted to two medications per month

Antidepressants

New Limits

Restricted to two medications per month

Atypical Antipsychotics

New Limits

Restricted to one medication per month

Benzodiazepines

New Limits

Restricted to two medications per month

Muscle Relaxants

New Limits

Restricted to one medication per month

Opioid Max Fill

New Limits

Restricted to two fills per month

Sedative Hypnotics

New Limits

Restricted to one medication per month

ADHD, Long Acting

New Limits

Restricted to one medication per month

Antidepressants, Tricyclic

New Limits

Restricted to one medication per month

Please note: Active prior authorizations for this medication will not be affected. If you have questions, please call the pharmacy help desk at 855-580-1688.

This is an important message from Meridian Medicaid Plan (Meridian).

Meridian would like to inform you that the coverage of the medications listed below has changed, effective 10/01/2023, for all members. Please reference the table for information regarding medication changes.

Impacted MedicationChangePreferred Agents

AUVI-Q (Auto-Injector)

PREFERRED

NA

ORSERDU (Tabs)

PREFERRED

NA

ENDARI (Pack)

PREFERRED

NA

Please note: Active prior authorizations for this medication will not be affected.

If you have questions, please call the pharmacy help desk at 855-580-1688.

This is an important message from Meridian Medicaid Plan (Meridian).

Meridian would like to inform you that the coverage of the medications listed below has changed, effective November 1, 2023, for all members. Please reference the table for information regarding medication changes*.

For questions, please call the pharmacy help desk at 855-580-1688.

Impacted MedicationChangePreferred Agents
Product NameNDC

Keyfolic

Removal from preferred drug list

ONE-DAILY MULTI-VITAMIN/MINERALS

57896053110

Folamax

Removal from preferred drug list

ONE-DAILY MULTI-VITAMIN/MINERALS

57896053120

Nicazel Forte

Removal from preferred drug list

PX ADVANCED FORMULA MULTIVITAMINS/LYCOPENE

41415007977

 

ONE-DAILY MULTI-VITAMIN/MINERALS

57896053130

ONE-DAILY MULTI-VITAMIN/MINERALS

57896053101

KP VISION FORMULA

00179803212

KP MENS DAILY FORMULA

00179804712

*Not a complete list.

This is an important message from Meridian Medicaid Plan (Meridian).

Meridian would like to inform you that the coverage of the medications listed below has changed, effective October 15, 2023, for all members. Please reference the table for information regarding medication changes.

Impacted MedicationChange

Albuterol Sulfate Syrup

Non-Preferred

Please note: Active prior authorizations for this medication will not be affected.

If you have questions, please call the pharmacy help desk at 855-580-1688.

This is an important message from Meridian Medicaid Plan (Meridian).

Meridian would like to inform you that the coverage of the medications listed below has changed, effective October 15th, 2023, for all members. Please reference the table for information regarding medication changes.

Impacted MedicationChangeAlternative

Mirena, CPT code J7298

Not covered under pharmacy benefit

Covered under medical benefit

Liletta, CPT code J7297

Not covered under pharmacy benefit

Covered under medical benefit

Skyla, CPT code J7301

Not covered under pharmacy benefit

Covered under medical benefit

Kyleena, CPT code J7296

Not covered under pharmacy benefit

Covered under medical benefit

Paragard, Intrauterine copper CPT code J7300

Not covered under pharmacy benefit

Covered under medical benefit

Please note: Active prior authorizations for this medication will not be affected.

If you have questions, please call the pharmacy help desk at 855-580-1688.

This is an important message from Meridian Medicaid Plan (Meridian).

Meridian would like to inform you that the coverage of the medications listed below has changed, effective 07/01/2023, for all members. Please reference the table for information regarding medication changes.

Impacted MedicationChange as of 07/01/2023Preferred Agents

ALBUTEROL SULFATE

NON-PREFERRED

NA

SUNLENCA (TBPK, SOLN)

PREFERRED WITH PA

NA

EMGALITY (SOAJ, SOSY)

PREFERRED WITH PA

NA

LURASIDONE HYDROCHLORIDE (TABS)

PREFERRED

NA

MAVYRET (PACK, TABS)

PREFERRED

NA

SOFOSBUVIR/VELPATASVIR

PREFERRED

NA

Please note: Active prior authorizations for this medication will not be affected.

If you have questions, please call the pharmacy help desk at 855-580-1688.

This is an important message from Meridian Medicaid Plan (Meridian).

Meridian would like to inform you that the coverage of the medications listed below has changed, effective 07/01/2023, for all members. Please reference the table for information regarding medication changes.

Impacted MedicationChangePreferred Agents

Invega Hafyera

New Age Limit: Minimum age of 18 years

NA

Invega Trinza

New Age Limit: Minimum age of 18 years

NA

Invega Sustenna

New Age Limit: Minimum age of 18 years

NA

Please note: Active prior authorizations for this medication will not be affected.

If you have questions, please call the pharmacy help desk at 855-580-1688.

This is an important message from Meridian Medicaid Plan (Meridian).

Meridian would like to inform you that the coverage of the medications listed below has changed, effective 05/15/2023, for all members. Please reference the table for information regarding medication changes.

Impacted MedicationChangePreferred Agents

Aripiprazole IM For ER Susp Prefilled Syringe 300 MG

New Age Limit: Minimum age of 18 years

NA

Aripiprazole IM For ER Susp Prefilled Syringe 400 MG

New Age Limit: Minimum age of 18 years

NA

Aripiprazole IM For Extended Release Susp 300 MG

New Age Limit: Minimum age of 18 years

NA

Aripiprazole IM For Extended Release Susp 400 MG

New Age Limit: Minimum age of 18 years

NA

Please note: Active prior authorizations for this medication will not be affected.

If you have questions, please call the pharmacy help desk at 855-580-1688.

This is an important message from Meridian Medicaid Plan (Meridian).

Meridian would like to inform you that the coverage of the medications listed below has changed, effective 04/01/2023, for all members. Please reference the table for information regarding medication changes.

Impacted MedicationChangePreferred Agents

AUSTEDO PATIENT TITRATION KIT (TBPK)

PREFERRED WITH PA

NA

AUSTEDO (TABS)

PREFERRED WITH PA

NA

INGREZZA (CAPS)

PREFERRED WITH PA

NA

INGREZZA (CPPK)

PREFERRED WITH PA

NA

BERINERT

PREFERRED WITH PA

NA

Please note: Active prior authorizations for this medication will not be affected.

If you have questions, please call the pharmacy help desk at 855-580-1688.

This is an important message from Meridian Medicaid Plan (Meridian).

Meridian would like to inform you that the coverage of the medications listed below has changed, effective 05/01/2023, for all members. Please reference the table for information regarding medication changes.

Impacted MedicationChangePreferred Agents/New Limits

Opioids

Initial fill limit will be a maximum of 5 days' supply

New Limits

Benzodiazepines

Initial fill limit will be a maximum of 14 days' supply

New Limits

Please note: Active prior authorizations for this medication will not be affected.

If you have questions, please call the pharmacy help desk at 855-580-1688.

Meridian would like to inform you that the coverage of the medications listed below has changed for all members. Please reference the table for medication changes.

Impacted MedicationChangePreferred Agents

Enbrel

Preferred with Prior Authorization after 02/01/2023

NA

Tamiflu Brand

Non-preferred after 03/01/2023

NA

Please note: Active prior authorizations for this medication will not be affected.

If you have questions, please call the pharmacy help desk at 855-580-1688.

Meridian would like to inform you that the coverage of the medications listed below has changed, effective April 1, 2023, for all members.

Impacted MedicationChangePreferred Agents/New Limits

TRULICITY

New Quantity Limit

0.072 mL/day

Please note: Active prior authorizations for this medication will not be affected.

If you have questions, please call the pharmacy help desk at 855-580-1688.

2022 Meridian Medicaid Plan Preferred Drug List Updates

Meridian would like to inform you that the coverage of the medications listed below is changing, effective January 1, 2023, for all members.

Impacted MedicationChangePreferred Agents/New Limits

VICTOZA

New Quantity Limit

0.3 mL/day

TRULICITY

New Quantity Limit

0.5 mL/day

Please note: Active prior authorizations for this medication will not be affected.

If you have questions, please call the pharmacy help desk at 855-580-1688.

Meridian would like to inform you that the coverage of the medications listed below is changing, effective October 1, 2022, for all members.

Impacted MedicationChangePreferred Agents

INVEGA HAFYERA

Preferred with prior authorization after 10/1/22

NA

DYANAVEL XR

Preferred with prior authorization after 10/1/22

NA

DAYTRANA

Non Preferred after 10/1/22

NA

JORNAY PM

Preferred with prior authorization after 10/1/22

NA

MODAFINIL

Preferred after 10/1/22

NA

Please note: Active prior authorizations for this medication will not be affected.

If you have questions, please call the pharmacy help desk at 855-580-1688.

Meridian would like to inform you that the coverage of the medications listed below is changing, effective July 1, 2022, for all members.

Impacted MedicationChangePreferred Agents

APRETUDE

Preferred after 7/1/22

NA

CARGLUMIC ACID

Preferred with prior authorization after 7/1/22

NA

KERENDIA (except NDC: 50419054170)

Preferred with prior authorization after 7/1/22

NA

LIVTENCITY

Preferred with prior authorization after 7/1/22

NA

Please note: Active prior authorizations for this medication will not be affected.

If you have questions, please call the pharmacy help desk at 855-580-1688.

The grid below provides details of an upcoming negative formulary change(s) that may affect your patients. This change(s) will become effective 30 days from date of this notice.

For the most up-to-date information regarding formulary coverage and medication management, please visit our website and select the “2022 Formulary”.

MedicationCurrent Formulary StateFuture State/Utilization Management
OZOBAX 5 MG/5 ML SOLUTIONCoveredNot Covered
ADVOCATE INS 0.3 ML 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
ADVOCATE INS 0.5 ML 30GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
ADVOCATE INS 0.5 ML 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
ADVOCATE INS 1 ML 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
ADVOCATE PEN NEEDLE 4MM 33GTier 4 - SupplementalTier 3 - Non-Preferred
ADVOCATE PEN NEEDLES 5MM 31GTier 4 - SupplementalTier 3 - Non-Preferred
ADVOCATE PEN NEEDLES 8MM 31GTier 4 - SupplementalTier 3 - Non-Preferred
BD INS SYR 0.3 ML 8MMX31G(1/2)Tier 4 - SupplementalTier 3 - Non-Preferred
BD INS SYR UF 0.3ML 12.7MMX30GTier 4 - SupplementalTier 3 - Non-Preferred
BD INS SYR UF 0.5ML 12.7MMX30GTier 4 - SupplementalTier 3 - Non-Preferred
BD INS SYRN UF 1 ML 12.7MMX30GTier 4 - SupplementalTier 3 - Non-Preferred
BD INS SYRNG 0.3 ML 29GX12.7MMTier 4 - SupplementalTier 3 - Non-Preferred
BD INS SYRNG 0.5 ML 29GX12.7MMTier 4 - SupplementalTier 3 - Non-Preferred
BD INS SYRNG UF 0.3 ML 8MMX31GTier 4 - SupplementalTier 3 - Non-Preferred
BD INS SYRNG UF 0.5 ML 8MMX31GTier 4 - SupplementalTier 3 - Non-Preferred
BD INSULIN SYR 0.5 ML 28GX1/2""Tier 4 - SupplementalTier 3 - Non-Preferred
BD INSULIN SYR 1 ML 25GX1""Tier 4 - SupplementalTier 3 - Non-Preferred
BD INSULIN SYR 1 ML 25GX5/8""Tier 4 - SupplementalTier 3 - Non-Preferred
BD INSULIN SYR 1 ML 27GX12.7MMTier 4 - SupplementalTier 3 - Non-Preferred
BD INSULIN SYR 1 ML 27GX5/8""Tier 4 - SupplementalTier 3 - Non-Preferred
BD INSULIN SYR 1 ML 28GX1/2""Tier 4 - SupplementalTier 3 - Non-Preferred
BD INSULIN SYR 1 ML 29GX12.7MMTier 4 - SupplementalTier 3 - Non-Preferred
BD INSULIN SYR UF 1 ML 8MMX31GTier 4 - SupplementalTier 3 - Non-Preferred
BD NANO 2 GEN PEN NDL 32GX4MMTier 4 - SupplementalTier 3 - Non-Preferred
BD SAFETGLD INS 0.3 ML 8MMX31GTier 4 - SupplementalTier 3 - Non-Preferred
BD SAFETGLD INS 0.3ML 13MMX29GTier 4 - SupplementalTier 3 - Non-Preferred
BD SAFETGLD INS 0.5ML 13MMX29GTier 4 - SupplementalTier 3 - Non-Preferred
BD SAFETYGLD INS 1 ML 13MMX29GTier 4 - SupplementalTier 3 - Non-Preferred
BD UF MICRO PEN NEEDLE 6MMX32GTier 4 - SupplementalTier 3 - Non-Preferred
BD UF MINI PEN NEEDLE 5MMX31GTier 4 - SupplementalTier 3 - Non-Preferred
BD UF NANO PEN NEEDLE 4MMX32GTier 4 - SupplementalTier 3 - Non-Preferred
BD UF ORIG PEN NDL 12.7MMX29GTier 4 - SupplementalTier 3 - Non-Preferred
BD UF SHORT PEN NEEDLE 8MMX31GTier 4 - SupplementalTier 3 - Non-Preferred
BD VEO INS 0.3ML 6MMX31G (1/2)Tier 4 - SupplementalTier 3 - Non-Preferred
BD VEO INS SYRING 1 ML 6MMX31GTier 4 - SupplementalTier 3 - Non-Preferred
BD VEO INS SYRN 0.3 ML 6MMX31GTier 4 - SupplementalTier 3 - Non-Preferred
BD VEO INS SYRN 0.5 ML 6MMX31GTier 4 - SupplementalTier 3 - Non-Preferred
CAREFINE PEN NEEDLE 5MM 32GTier 4 - SupplementalTier 3 - Non-Preferred
CAREFINE PEN NEEDLE 6MM 31GTier 4 - SupplementalTier 3 - Non-Preferred
CAREFINE PEN NEEDLE 8MM 30GTier 4 - SupplementalTier 3 - Non-Preferred
COMFORT EZ PEN NEEDLES 4MM 32GTier 4 - SupplementalTier 3 - Non-Preferred
COMFORT EZ PEN NEEDLES 5MM 31GTier 4 - SupplementalTier 3 - Non-Preferred
COMFORT EZ PEN NEEDLES 8MM 31GTier 4 - SupplementalTier 3 - Non-Preferred
DROPLET PEN NEEDLE 31GX1/4""Tier 4 - SupplementalTier 3 - Non-Preferred
DROPLET PEN NEEDLE 31GX3/16""Tier 4 - SupplementalTier 3 - Non-Preferred
DROPLET PEN NEEDLE 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
DROPLET PEN NEEDLE 32GX5/32""Tier 4 - SupplementalTier 3 - Non-Preferred
EASY COMFORT PEN NDL 33G 4MMTier 4 - SupplementalTier 3 - Non-Preferred
EASY COMFORT PEN NDL 33G 5MMTier 4 - SupplementalTier 3 - Non-Preferred
EASY COMFORT PEN NDL 33G 6MMTier 4 - SupplementalTier 3 - Non-Preferred
EASY GLIDE INS 0.5 ML 31GX6MMTier 4 - SupplementalTier 3 - Non-Preferred
EASY GLIDE INS 1 ML 31GX6MMTier 4 - SupplementalTier 3 - Non-Preferred
EASY TOUCH INSULIN SYR 0.3 MLTier 4 - SupplementalTier 3 - Non-Preferred
EASY TOUCH INSULIN SYR 0.5 MLTier 4 - SupplementalTier 3 - Non-Preferred
EASY TOUCH INSULIN SYR 1 MLTier 4 - SupplementalTier 3 - Non-Preferred
EASY TOUCH PEN NEEDLE 29GX1/2""Tier 4 - SupplementalTier 3 - Non-Preferred
EASY TOUCH PEN NEEDLE 31GX1/4""Tier 4 - SupplementalTier 3 - Non-Preferred
EASY TOUCH PEN NEEDLE 31GX3/16Tier 4 - SupplementalTier 3 - Non-Preferred
EASY TOUCH PEN NEEDLE 31GX5/16Tier 4 - SupplementalTier 3 - Non-Preferred
EASY TOUCH PEN NEEDLE 32GX1/4""Tier 4 - SupplementalTier 3 - Non-Preferred
EASY TOUCH PEN NEEDLE 32GX3/16Tier 4 - SupplementalTier 3 - Non-Preferred
EASY-TOUCH INS 1 ML 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
GS PEN NEEDLE 31G X 8MMTier 4 - SupplementalTier 3 - Non-Preferred
HEALTHWISE PEN NEEDLE 31G 8MMTier 4 - SupplementalTier 3 - Non-Preferred
HM ULTICARE PEN NEEDLE 4MM 32GTier 4 - SupplementalTier 3 - Non-Preferred
HM ULTICARE PEN NEEDLE 6MM 31GTier 4 - SupplementalTier 3 - Non-Preferred
HM ULTICARE PEN NEEDLE 8MM 31GTier 4 - SupplementalTier 3 - Non-Preferred
INSULIN 1 ML SYRINGETier 4 - SupplementalTier 3 - Non-Preferred
INSULIN 1/2 ML SYRINGETier 4 - SupplementalTier 3 - Non-Preferred
INSULIN 3/10 ML SYRINGETier 4 - SupplementalTier 3 - Non-Preferred
INSULIN SYRIN 0.3 ML 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
INSULIN SYRIN 0.5 ML 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
INSULIN SYRINGE 1 ML 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
LITE TOUCH 31GX1/4"" PEN NEEDLETier 4 - SupplementalTier 3 - Non-Preferred
MINI ULTRA-THIN II PEN NDL 31GTier 4 - SupplementalTier 3 - Non-Preferred
MONOJECT INSUL SYR U100 1 MLTier 4 - SupplementalTier 3 - Non-Preferred
MONOJECT INSULIN SYR 1 MLTier 4 - SupplementalTier 3 - Non-Preferred
MONOJECT INSULIN SYR U-100Tier 4 - SupplementalTier 3 - Non-Preferred
MS PEN NEEDLE 6MM 31GTier 4 - SupplementalTier 3 - Non-Preferred
NOVOFINE 32G NEEDLESTier 4 - SupplementalTier 3 - Non-Preferred
PEN NEEDLE 30G X 5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
PEN NEEDLE 31G X 1/4""Tier 4 - SupplementalTier 3 - Non-Preferred
PEN NEEDLE 31G X 3/16""Tier 4 - SupplementalTier 3 - Non-Preferred
PEN NEEDLE 31G X 5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
PEN NEEDLE 32G X 5/32""Tier 4 - SupplementalTier 3 - Non-Preferred
PEN NEEDLES 12MM 29GTier 4 - SupplementalTier 3 - Non-Preferred
PEN NEEDLES 8MM 31GTier 4 - SupplementalTier 3 - Non-Preferred
PENTIPS PEN NEEDLE 31GX3/16""Tier 4 - SupplementalTier 3 - Non-Preferred
PENTIPS PEN NEEDLE 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
PENTIPS PEN NEEDLE 32GX5/32""Tier 4 - SupplementalTier 3 - Non-Preferred
PENTIPS PEN NEEDLE 6MM 31GTier 4 - SupplementalTier 3 - Non-Preferred
PRO COMFORT 0.5 ML 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
PRO COMFORT PEN NDL 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
PRO COMFORT PEN NDL 32G X 1/4""Tier 4 - SupplementalTier 3 - Non-Preferred
PRO COMFORT PEN NDL 4MM 32GTier 4 - SupplementalTier 3 - Non-Preferred
RELION INS SYR 0.5 ML 29GX1/2""Tier 4 - SupplementalTier 3 - Non-Preferred
RELION INS SYR 1 ML 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
RELION MINI PEN 31G X 1/4"" NDLTier 4 - SupplementalTier 3 - Non-Preferred
RELION PEN NEEDLES 32GX5/32""Tier 4 - SupplementalTier 3 - Non-Preferred
RELION SYRING 0.3 ML 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
RELION SYRING 0.5 ML 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
SURE COMFORT 0.3 ML SYRINGETier 4 - SupplementalTier 3 - Non-Preferred
SURE COMFORT 0.5 ML SYRINGETier 4 - SupplementalTier 3 - Non-Preferred
SURE COMFORT 1 ML SYRINGETier 4 - SupplementalTier 3 - Non-Preferred
SURE COMFORT 3/10 ML SYRINGETier 4 - SupplementalTier 3 - Non-Preferred
SURE COMFORT 30G PEN NEEDLETier 4 - SupplementalTier 3 - Non-Preferred
SURE COMFORT 31G PEN NEEDLETier 4 - SupplementalTier 3 - Non-Preferred
SURE COMFORT PEN NDL 29GX1/2""Tier 4 - SupplementalTier 3 - Non-Preferred
SURE COMFORT PEN NDL 31GX3/16""Tier 4 - SupplementalTier 3 - Non-Preferred
SURE COMFORT PEN NDL 32GX1/4""Tier 4 - SupplementalTier 3 - Non-Preferred
SURE COMFORT PEN NDL 32GX5/32""Tier 4 - SupplementalTier 3 - Non-Preferred
TECHLITE 0.3 ML 31GX6MM (1/2)Tier 4 - SupplementalTier 3 - Non-Preferred
TECHLITE 0.5 ML 31GX8MM (1/2)Tier 4 - SupplementalTier 3 - Non-Preferred
TECHLITE INS SYR 1 ML 30GX12MMTier 4 - SupplementalTier 3 - Non-Preferred
TECHLITE INS SYR 1 ML 30GX8MMTier 4 - SupplementalTier 3 - Non-Preferred
TECHLITE INS SYR 1 ML 31GX6MMTier 4 - SupplementalTier 3 - Non-Preferred
TECHLITE INS SYR 1 ML 31GX8MMTier 4 - SupplementalTier 3 - Non-Preferred
TECHLITE PEN NEEDLE 29GX1/2""Tier 4 - SupplementalTier 3 - Non-Preferred
TECHLITE PEN NEEDLE 31GX1/4""Tier 4 - SupplementalTier 3 - Non-Preferred
TECHLITE PEN NEEDLE 31GX3/16""Tier 4 - SupplementalTier 3 - Non-Preferred
TECHLITE PEN NEEDLE 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
TECHLITE PEN NEEDLE 32GX1/4""Tier 4 - SupplementalTier 3 - Non-Preferred
TECHLITE PEN NEEDLE 32GX5/32""Tier 4 - SupplementalTier 3 - Non-Preferred
TODAY''S HLTH PN NEEDLE 6MM 31GTier 4 - SupplementalTier 3 - Non-Preferred
TRUE COMFORT 0.5 ML 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
ULTCARE INS SYR 1 ML 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE INS 0.3 ML 30GX1/2""Tier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE INS 0.5 ML 30GX1/2""Tier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE INS SYR 1 ML 28GX1/2""Tier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE INS SYR 1 ML 29GX1/2""Tier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE INS SYR 1 ML 30GX1/2""Tier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE PEN NDL 12.7 MM 29GTier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE PEN NEEDLE 31GX3/16""Tier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE PEN NEEDLE 4MM 32GTier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE PEN NEEDLE 6MM 31GTier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE PEN NEEDLE 8MM 31GTier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE PEN NEEDLES 12MM 29GTier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE PEN NEEDLES 4MM 32GTier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE PEN NEEDLES 6MM 31GTier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE PEN NEEDLES 6MM 32GTier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE PEN NEEDLES 8MM 31GTier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE SYR 0.3 ML 30GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE SYR 0.3 ML 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE SYR 0.5 ML 29GX1/2""Tier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE SYR 0.5 ML 30GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE SYR 0.5 ML 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE SYR 1 ML 30GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE SYR 1 ML 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE SYRIN 0.3 ML 29GX1/2""Tier 4 - SupplementalTier 3 - Non-Preferred
ULTICARE SYRIN 0.5 ML 28GX1/2""Tier 4 - SupplementalTier 3 - Non-Preferred
ULTRA-THIN II PEN NDL 31GX5/16Tier 4 - SupplementalTier 3 - Non-Preferred
UNIFINE PENTIPS 12MM 29GTier 4 - SupplementalTier 3 - Non-Preferred
UNIFINE PENTIPS 31GX3/16""Tier 4 - SupplementalTier 3 - Non-Preferred
UNIFINE PENTIPS 32GX5/32""Tier 4 - SupplementalTier 3 - Non-Preferred
UNIFINE PENTIPS 6MM 31GTier 4 - SupplementalTier 3 - Non-Preferred
UNIFINE PENTIPS 8MM 31GTier 4 - SupplementalTier 3 - Non-Preferred
UNIFINE PENTIPS PLUS 31GX1/4""Tier 4 - SupplementalTier 3 - Non-Preferred
UNIFINE PENTIPS PLUS 31GX3/16""Tier 4 - SupplementalTier 3 - Non-Preferred
UNIFINE PENTIPS PLUS 31GX5/16""Tier 4 - SupplementalTier 3 - Non-Preferred
UNIFINE PENTIPS PLUS 32GX5/32""Tier 4 - SupplementalTier 3 - Non-Preferred
YOURX ULTICARE PEN NDL 4MM 32GTier 4 - SupplementalTier 3 - Non-Preferred
YOURX ULTICARE PEN NDL 6MM 31GTier 4 - SupplementalTier 3 - Non-Preferred

If you have questions, please call the pharmacy help desk at 855-580-1688.

The grid below provides details of an upcoming negative formulary change(s) that may affect your patients. This change(s) will become effective 30 days from date of this notice.

For the most up-to-date information regarding formulary coverage and medication management, please visit our website and select the “2022 Formulary”.

MedicationCurrent Formulary StateFuture State/Utilization Management
ADVAIR HFA 115-21 MCG INHALERNo Quantity Limit12 Grams (1 inhaler) per 30 days
ADVAIR HFA 115-21 MCG INHALERNo Quantity Limit8 Grams (1 inhaler) per 30 days
ADVAIR HFA 230-21 MCG INHALERNo Quantity Limit12 Grams (1 inhaler) per 30 days
ADVAIR HFA 230-21 MCG INHALERNo Quantity Limit8 Grams (1 inhaler) per 30 days
ADVAIR HFA 45-21 MCG INHALERNo Quantity Limit12 Grams (1 inhaler) per 30 days
ADVAIR HFA 45-21 MCG INHALERNo Quantity Limit8 Grams (1 inhaler) per 30 days
AIRDUO DIGIHALER 113-14 MCGNo Quantity Limit1 EA (1 inhaler) per 30 Days
AIRDUO DIGIHALER 232-14 MCGNo Quantity Limit1 EA (1 inhaler) per 30 Days
AIRDUO DIGIHALER 55-14 MCGNo Quantity Limit1 EA (1 inhaler) per 30 Days
AIRDUO RESPICLICK 113-14 MCGNo Quantity Limit1 EA (1 inhaler) per 30 Days
AIRDUO RESPICLICK 232-14 MCGNo Quantity Limit1 EA (1 inhaler) per 30 Days
AIRDUO RESPICLICK 55-14 MCGNo Quantity Limit1 EA (1 inhaler) per 30 Days
ARMONAIR DIGIHALER 113 MCGNo Quantity Limit1 EA (1 inhaler) per 30 Days
ARMONAIR DIGIHALER 232 MCGNo Quantity Limit1 EA (1 inhaler) per 30 Days
ARMONAIR DIGIHALER 55 MCGNo Quantity Limit1 EA (1 inhaler) per 30 Days
BREO ELLIPTA 100-25 MCG INHNo Quantity Limit1 EA (1 inhaler) per 30 Days
BREO ELLIPTA 200-25 MCG INHNo Quantity Limit1 EA (1 inhaler) per 30 Days
FLOVENT 100 MCG DISKUSNo Quantity Limit1 EA (1 inhaler) per 30 Days
FLOVENT 250 MCG DISKUSNo Quantity Limit1 EA (1 inhaler) per 30 Days
FLOVENT 50 MCG DISKUSNo Quantity Limit1 EA (1 inhaler) per 30 Days
FLUTICASONE-SALMETEROL 113-14No Quantity Limit1 EA (1 inhaler) per 30 Days
FLUTICASONE-SALMETEROL 232-14No Quantity Limit1 EA (1 inhaler) per 30 Days
FLUTICASONE-SALMETEROL 55-14No Quantity Limit1 EA per 30 Days
PULMICORT 180 MCG FLEXHALERNo Quantity Limit1 EA per 30 Days
PULMICORT 90 MCG FLEXHALERNo Quantity Limit1 EA per 30 Days
TRELEGY ELLIPTA 100-62.5-25No Quantity Limit1 EA per 30 Days
TRELEGY ELLIPTA 200-62.5-25No Quantity Limit1 EA per 30 Days

If you have questions, please call the pharmacy help desk at 855-580-1688.

Meridian would like to inform you that the coverage of the medications listed below is changing on April 15, 2022 for all members. Please reference the table below for information regarding medication changes and alternative preferred agents.

Meridian would like to work with you to help transition the impacted members onto a preferred formulary alternative. If a member requires continued therapy for a medication that has been changed, please submit a prior authorization with appropriate clinical documentation.

Impacted MedicationMedication ChangePreferred Agents
FLUTICASONE PROPIONATE/SALMETEROLNon-preferred after 4/15/22ADVAIR DISKUS®
ADVAIR HFA®
AIRDUO DIGIHALER 55/14®
AIRDUO DIGIHALER 113/14®
AIRDUO DIGIHALER 232/14®
AIRDUO RESPICLICK 55/14®
AIRDUO RESPICLICK 113/14®
AIRDUO RESPICLICK 232/14®
ADVAIR DISKUS ADVAIR HFAPreferred after 4/15/22NA
WIXELA INHUBNon-preferred after 4/15/22ADVAIR DISKUS®
ADVAIR HFA®
AIRDUO DIGIHALER 55/14®
AIRDUO DIGIHALER 113/14®
AIRDUO DIGIHALER 232/14®
AIRDUO RESPICLICK 55/14®
AIRDUO RESPICLICK 113/14®
AIRDUO RESPICLICK 232/14®
AIRDUO DIGIHALER 55/14
AIRDUO DIGIHALER 113/14
AIRDUO DIGIHALER 232/14
Preferred after 4/15/22NA
AIRDUO RESPICLICK 55/14
AIRDUO RESPICLICK 113/14
AIRDUO RESPICLICK 232/14
Preferred after 4/15/22NA
ANORO ELLIPTAPreferred after 4/15/22NA
BEVESPI AEROSPHERENon-preferred after 4/15/22Anoro Elipta ®
INCRUSE ELLIPTAPreferred after 4/15/22NA
SPIRIVA RESPIMATPreferred after 4/15/22NA
MYFEMBREEPreferred after 4/15/22NA
QULIPTAPreferred after 4/15/22NA
APO-VARENICLINENon-preferred after 4/15/22Varinecline

Note: Active prior authorizations for this medication will not be affected.

If you have questions, please call the pharmacy help desk at 855-580-1688.

Note: This notice replaces the previous notice dated 2/15/21

2021 Meridian Medicaid Plan Preferred Drug List Updates

The grid below provides details of an upcoming negative formulary change(s) that may affect your patients. This change(s) became effective on 10/08/2021.

MedicationCurrent Formulatory State

FLUOXETINE HCL 10 MG CAPSULE

30 tablets per 30 days, up to a 90 day supply

FLUOXETINE HCL 10 MG TABLET

30 tablets per 30 days, up to a 90 day supply

FLUOXETINE HCL 20 MG CAPSULE

30 tablets per 30 days, up to a 90 day supply

FLUOXETINE HCL 20 MG TABLET

30 tablets per 30 days, up to a 90 day supply

FLUOXETINE HCL 40 MG CAPSULE

30 tablets per 30 days, up to a 90 day supply

If you have questions, please call the pharmacy help desk at 855-580-1688.

The grid below provides details of an upcoming negative formulary change(s) that may affect your patients. This change(s) will become effective 30 days from date of this notice.

MedicationCurrent Formulary StateFuture State/Utilization Management
3-DAY VAGINAL CREAMCoveredNot Covered
CHLORPROPAMIDE 100 MG TABLETCoveredNot Covered
CHLORPROPAMIDE 250 MG TABLETCoveredNot Covered
CLOTRIMAZOLE-3 2% CREAMCoveredNot Covered
CVS CLOTRIMAZOLE-3 2% CREAMCoveredNot Covered
MICONAZOLE 2% VAGINAL CREAMCoveredNot Covered
MICONAZOLE 3 COMBO PACKCoveredNot Covered
MICONAZOLE 7 100 MG VAG SUPPCoveredNot Covered
MICONAZOLE 7 CREAMCoveredNot Covered
QC MICONAZOLE-7 CREAMCoveredNot Covered
SM 3-DAY VAGINAL CREAMCoveredNot Covered
SM MICONAZOLE 2% VAGINAL CREAMCoveredNot Covered
SM MICONAZOLE 7 100 MG VAG SUPCoveredNot Covered
SM MICONAZOLE 7 CREAMCoveredNot Covered

If you have questions, please call the pharmacy help desk at 855-580-1688.

The grid below provides details of an upcoming negative formulary change(s) that may affect your patients. This change(s) will become effective 30 days from date of this notice.

MedicationCurrent Formulary StateFuture State/Utilization Management
GAVISCON 80-14.2 MG TAB CHEWCoveredNot Covered

If you have questions, please call the pharmacy help desk at 855-580-1688.

The grid below provides details of an upcoming negative formulary change(s) that may affect your patients. This change(s) will become effective 30 days from date of this notice.

MedicationCurrent Formulary StateFuture State/Utilization Management
Microgestin 21 1-20 TabletPreferredPreferred; Limited to 30 tablets per 30 days; Limited to members between the ages of 10 and 55
Kurvelo-28 TabletPreferred; Limited to 30 tablets per 30 daysPreferred; Limited to 30 tablets per 30 days; Limited to members between the ages of 10 and 55
Westab Plus TabletPreferredPreferred; Limited to members between the ages of 10 and 55

If you have questions, please call the pharmacy help desk at 855-580-1688.

The grid below shows recent formulary changes that may affect your patients.

Illinois Medicaid
MedicationDate of ChangePrevious Formulatory StateCurrent State/Utilization Management
Medication Additions
Vyfemla 0.4mg-0.035mg Tablet2/26/2021Not FormulatoryPreferred
Vyfemla 0.4-0.035mg Chew Tablet2/26/2021Not FormulatoryPreferred
Utilization Criteria Updates
SPS 15 GM/60mL Suspension
SPS 30GM/120mG Enema Susp
2/26/2021PreferredNot-Preferred; PA required
Medication Deletions
Emend 40mg Capsule2/19/2021Not-Preferred; Specialty; PA requiredNot Formulary
Humira 10mg/0.2mL Syringe
Humira 20mg/0.4mL Syringe
2/19/2021Not-Preferred; Specialty; PA requiredNot Formulary

If you have questions, please call the pharmacy help desk at 855-580-1688.

The grid below shows recent formulary changes that may affect your patients.

Illinois Medicaid
MedicationDate of ChangePrevious Formulatory StateCurrent State/Utilization Management
Medication Additions
Reditrex 10mg/0.4mL Syringe
Reditrex 12.5mg/0.5mL Syringe
Reditrex 15mg/0.6mL Syringe
Reditrex 17.5mg/0.7mL Syringe
Reditrex 20mg/0.8mL Syringe
Reditrex 22.5mg/0.9mL Syringe
Reditrex 25mg/mL Syringe
Reditrex 7.5mg/0.3mL Syringe
1/29/2021Non-FormularyNon-preferred; PA required
Lyleq 0.35mg Tablet1/29/2021Non-FormulatoryPreferred
Tri-Nymyo 28 Tablet1/29/2021Non-FormulatoryPreferred
Twirla 120/30mcg/day Patch1/29/2021Non-FormulatoryPreferred
Lubiprostone 8mcg Capsule Lubiprostone 24mcg Capsule1/29/2021Non-FormulatoryPreferred
Abiraterone 500mg Tablet1/21/2021Non-FormulatoryPreferred
Utilization Criteria Updates
Azithromycin 250mg Tablet
Zithromax 250mg Tablet
1/15/2021Limited to 6 tablets per 5 days; Limited to 1 treatment every 30 daysLimited to 60 tablets per 180 days
Azithromycin 500mg Tablet
Zithromax 500mg Tablet
1/15/2021Limited to 3 tablets per fillLimited to 60 tablets per 180 days

If you have questions, please call the pharmacy help desk at 855-580-1688.

The grid below shows recent formulary changes that may affect your patients.

Illinois Medicaid
MedicationDate of ChangePrevious Formulatory StateCurrent State/Utilization Management
Medication Additions
Lyllana 0.025mg patch
Lyllana 0.0375mg patch
Lyllana 0.075mg patch
Lyllana 0.1mg patch
12/23/2020Not FormularyPreferred
Retacrit 20,000 Unit/mL Vial
Retacrit 20,000 Unit/2mL Vial
12/23/2020Not FormulatoryNot Preferred; Prior Authorization Required
Dificid 40 mg/mL Suspension1/1/2021Not FormulatoryNot Preferred; Prior Authorization Required
Nitazoxanide 500 mg Tablet 1/1/2021Not FormulatoryNot Preferred; Prior Authorization Required
Astrazeneca COVID-19 Vaccine
Moderna COVID-19 Vaccine
Pfizer COVID-19 Vaccine
1/1/2021Not FormulatorySupplemental Coverage
Utilization Criteria Updates
Accu-Chek Test Strips
Accutrend Test Strips
Advocate Test Strips
Assure Test Strips
Clever Choice Test Strips
Contour Test Strips
Easy Test Strips
Easymax Test Strips
Element Test Strips
Embrace Test Strips
Evencare Test Strips
Fora Test Strips
Freestyle Test Strips
Glucocard Test Strips
Optium Test Strips
Precision Test Strips
Truetrack Test Strips
True Matrix Test Strips
Unistrip Test Strip
Wavesense Test Strip
12/10/2020Limited to 300 Test strips per 90 daysLimited to 360 Test strips per 90 days

If you have questions, please call the pharmacy help desk at 855-580-1688.

2020 Meridian Medicaid Plan Preferred Drug List Updates

The grid below shows recent formulary changes that may affect your patients.

Illinois Medicaid
MedicationDate of ChangePrevious Formulatory StateCurrent State/Utilization Management
Medication Additions
ALKINDI SPRINKLE 0.5 MG CAP11/3/2020Not FormularyNot preferred; PA Required
ALKINDI SPRINKLE 1 MG CAPSULE11/3/2020Not FormularyNot preferred; PA Required
ALKINDI SPRINKLE 2 MG CAPSULE11/3/2020Not FormularyNot preferred; PA Required
ALKINDI SPRINKLE 5 MG CAPSULE11/3/2020Not FormularyNot preferred; PA Required
TOLVAPTAN 15 MG TABLET11/3/2020Not FormularyNot preferred; PA Required
TOLVAPTAN 15 MG TABLET11/3/2020Not FormularyNot preferred; PA Required
EPCLUSA 200 MG-50 MG TABLET11/1-/2020Not FormularyNot preferred; PA Required

If you have questions, please call the pharmacy help desk at 855-580-1688.

The grid below shows recent formulary changes that may affect your patients.

Illinois Medicaid
MedicationDate of ChangePrevious Formulatory StateCurrent State/Utilization Management
Medication Additions
KLOR-CON 10 MEQ TABLET10/15/2020Covered; Addition of NDCs requiredCovered
KLOR-CON M20 TABLET10/15/2020Covered; Addition of NDCs requiredCovered
Medication Deletions
EMBEDA ER 20-0.8 MG CAPSULE10/21/2020Preferred; Prior authorization required; limited to 30 ea per 30 daysNot Covered
EEMBEDA ER 30-1.2 MG CAPSULE10/21/2020Preferred; Prior authorization required; limited to 30 ea per 30 daysNot Covered
EEMBEDA ER 50-2 MG CAPSULE 10/21/2020Preferred; Prior authorization required; limited to 30 ea per 30 daysNot Covered
EEMBEDA ER 60-2.4 MG CAPSULE10/21/2020Preferred; Prior authorization required; limited to 30 ea per 30 daysNot Covered
EEMBEDA ER 80-3.2 MG CAPSULE10/21/2020Preferred; Prior authorization required; limited to 30 ea per 30 daysNot Covered
EMBEDA ER 100-4 MG CAPSULE10/21/2020Preferred; Prior authorization required; limited to 30 ea per 30 daysNot Covered
TANZEUM 30 MG PEN INJECT10/21/2020Non-preferred; Prior authorization requiredNot Covered

If you have questions, please call the pharmacy help desk at 855-580-1688.

The grid below shows recent formulary changes that may affect your patients.

Illinois Medicaid
MedicationDate of ChangePrevious Formulatory StateCurrent State/Utilization Management
Medication Additions
Magnesium Citrate Solution9/11/2020Not CoveredPreferred
Hyperrho S-D 1,500 Unit Syringe9/24/2020Not CoveredPreferred; Limited to 2 ea per 270 days
Hyperrho S-D 250 Unit Syringe9/24/2020Not CoveredPreferred; Limited to 2 ea per 270 days
Micrhogam Ultra-Filtd Plus Syringe9/24/2020Not CoveredPreferred; Limited to 2 ea per 270 days
RHOGAM ULTRA-FILTERED PLUS SYR9/24/2020Not CoveredPreferred; Limited to 2 ea per 270 days
RHOPHYLAC 300 MC G/2 ML SYRINGE9/24/2020Not CoveredPreferred; Limited to 4 mL per 270 days
WINRHO SDF 1,500 UNIT VIAL9/24/2020Not CoveredPreferred; Limited to 2.6 mL per 270 days
WINRHO SDF 15,000 UNIT VIAL9/24/2020Not CoveredPreferred; Limited to 26 mL per 270 days
WINRHO SDF 2,500 UNIT VIAL9/24/2020Not CoveredPreferred; Limited to 4.4 mL per 270 days
WINRHO SDF 5,000 UNIT VIAL9/24/2020Not CoveredPreferred; Limited to 8.8 mL per 270 days
Utilization Criteria Updates
Aciphex DR 20 MG Tablet9/11/2020Non PreferredNon preferred; Limited to 30 ea per 30 days, 6 fills per 365 days
Aciphex Sprinkle DR 10 MG Capsule9/11/2020Non PreferredNon preferred; Limited to 30 ea per 30 days, 6 fills per 365 days
Aciphex Sprinkle DR 5 MG Capsule9/11/2020Non PreferredNon preferred; Limited to 30 ea per 30 days, 6 fills per 365 days
Dexilant DR 60 MG Capsule9/11/2020Non PreferredNon preferred; Limited to 30 ea per 30 days, 6 fills per 365 days
Esomeprazole DR 10 MG Packet9/11/2020Non PreferredNon preferred; Limited to 30 ea per 30 days, 6 fills per 365 days
Esomeprazole DR 20 MG Packet9/11/2020Non PreferredNon preferred; Limited to 30 ea per 30 days, 6 fills per 365 days
Esomeprazole DR 24.65 MG Capsule9/11/2020Non PreferredNon preferred; Limited to 30 ea per 30 days, 6 fills per 365 days
Esomeprazole DR 40 MG Packet9/11/2020Non PreferredNon preferred; Limited to 30 ea per 30 days, 6 fills per 365 days
Esomeprazole DR 49.3 MG Capsule9/11/2020Non PreferredNon preferred; Limited to 30 ea per 30 days, 6 fills per 365 days
Esomeprazole Mag DR 20 MG Capsule9/11/2020Non PreferredNon preferred; Limited to 30 ea per 30 days, 6 fills per 365 days
Esomeprazole Mag DR 40 MG CAP9/11/2020Non PreferredNon preferred; Limited to 30 ea per 30 days, 6 fills per 365 days
Prevacid 15 MG Solutab9/11/2020Non PreferredNon preferred; Limited to 30 ea per 30 days, 6 fills per 365 days
Prevacid 30 MG Solutab9/11/2020Non PreferredNon preferred; Limited to 30 ea per 30 days, 6 fills per 365 days
Rabeprazole Sod DR 20 MG Tablet9/11/2020Non PreferredNon preferred; Limited to 30 ea per 30 days, 6 fills per 365 days
Dexilant DR 30 MG Capsule9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Dexilant DR 60 MG C apsule9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Lansoprazole ODT 15 MG Tablet9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Lansoprazole ODT 30 MG Tablet9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Nexium DR 10 MG Packet9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Nexium DR 2.5 MG Packet 9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Nexium DR 20 MG Capsule9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Nexium DR 20 MG Packet9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Nexium DR 40 MG C apsule9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Nexium DR 40 MG Packet9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Nexium DR 5 MG Packet9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Omeprazole DR 10 MG Capsule9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Omeprazole DR 20 MG Capsule9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Omeprazole DR 40 MG Capsule9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Pantoprazole Sod DR 20 MG Tablet9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Pantoprazole Sod DR 40 MG Tablet9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Protonix 40 MG Suspension9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Protonix DR 20 MG Tablet9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Protonix DR 40 MG Tablet9/11/2020Non PreferredNon preferred; Limited to 60 ea per 30 days, 6 fills per 365 days
Prilosec DR 10 MG Suspension9/11/2020Non PreferredNon preferred; Limited to 120 ea per 30 days, 6 fills per 365 days
Prilosec DR 2.5 MG Suspension9/11/2020Non PreferredNon preferred; Limited to 120 ea per 30 days, 6 fills per 365 days

If you have questions, please call the pharmacy help desk at 855-580-1688.

The grid below shows recent formulary changes that may affect your patients.

Illinois Medicaid
MedicationDate of ChangePrevious Formulatory StateCurrent State/Utilization Management
Medication Additions
Desvenlafaxine Succinate ER 50mg Tablet
Desvenlafaxine Succinate ER 100mg Tablet
8/4/2020Non-FormulatoryNon-Preferred; Prior Authorization Required
Sumatriptan 6mg/0.5mL Cartridge8/4/2020Non-FormulatoryPreferred
Prizopak II 2.5%-2.5% Cream Kit
Aprizo Pak II 2.5%-2.5% Cream
8/4/2020Non-FormulatoryNon-Preferred; Prior Authorization Required
Ortikos ER 6mg, 9mg Capsule8/4/2020Non-FormulatoryNon-Preferred; Prior Authorization Required
Enbrel 25mg/0.5mL Vial8/11/2020Non-FormulatoryNon-Preferred; Prior Authorization Required
Afluria Quad 2020-2021 Vial8/11/2020Non-FormulatoryPreferred; 1 shot per 180 days
Afluria Quad 2020-2021 (3YR UP)8/11/2020Non-FormulatoryPreferred; Min age 3; 1 shot per 180 days
Afluria Quad 2020-2021 (6-35MO)8/11/2020Non-FormulatoryPreferred; Min age 3; 1 shot per 180 days
Fluad 2020-2021 Syringe8/11/2020Non-FormulatoryPreferred; Min age 65; 1 shot per 180 days
Fluad Quad 2020-2021 Syringe8/11/2020Non-FormulatoryPreferred; Min age 65; 1 shot per 180 days
Fluarix Quad 2020-2021 Syringe8/11/2020Non-FormulatoryPreferred; 1 shot per 180 days
Flucelvax Quad 2020-2021 Syringe8/11/2020Non-FormulatoryPreferred; Min age 4; 1 shot per 180 days
Flucelvax Quad 2020-2021 Vial8/11/2020Non-FormulatoryPreferred; Min age 4; 1 shot per 180 days
Flulaval Quad 2020-2021 Syringe8/11/2020Non-FormulatoryPreferred; 1 shot per 180 days
Flumist Quad Nasal 2020-2021 Vaccine8/11/2020Non-FormulatoryPreferred; Min age 2 & Max age 49; 1 shot per 180 days
Fluzone High-Dose Quad 2020-20218/11/2020Non-FormulatoryPreferred; Min age 65; 1 shot per 180 days
Fluzone Quad 2020-2021 Syringe8/11/2020Non-FormulatoryPreferred; 1 shot per 180 days
Fluzone Quad 2020-2021 Vial8/11/2020Non-FormulatoryPreferred; 1 shot per 180 days
Deferasirox 90mg Granule
Deferasirox 180mg Granule
Deferasirox 360mg Granule
8/25/2020Non-FormulatoryNon-preferred; Prior Authorization Required
Desvenlafaxine Succinate ER 50mg Tablet
Desvenlafaxine Succinate ER 100mg Tablet
8/4/2020Non-FormulatoryNon-preferred; Prior Authorization Required
Sumatriptan 6mg/0.5mL Cartridge8/4/2020Non-FormulatoryPreferred
Prizopak II 2.5%-2.5% Cream Kit
Aprizo Pak II 2.5%-2.5% Cream
8/4/2020Non-FormulatoryNon-Preferred; Prior Authorization Required
Ortikos ER 6mg, 9mg Capsule8/4/2020Non-FormulatoryNon-Preferred; Prior Authorization Required
Enbrel 25mg/0.5mL Vial8/11/2020Non-FormulatoryPreferred; Prior Authorization Required
Afluria Quad 2020-2021 Vial8/11/2020Non-FormulatoryPreferred; 1 shot per 180 days
Afluria Quad 2020-2021 (3YR UP)8/11/2020Non-FormulatoryPreferred; Min age 3; 1 shot per 180 days
Afluria Quad 2020-2021 (6-35MO)8/11/2020Non-FormulatoryPreferred; Max age 3; 1 shot per 180 days
Fluad 2020-2021 Syringe8/11/2020Non-FormulatoryPreferred; Min age 65; 1 shot per 180 days
Fluad Quad 2020-2021 Syringe8/11/2020Non-FormulatoryPreferred; Min age 65; 1 shot per 180 days
Fluarix Quad 2020-2021 Syringe8/11/2020Non-FormulatoryPreferred; 1 shot per 180 days
Flucelvax Quad 2020-2021 Syringe8/11/2020Non-FormulatoryPreferred; Min age 4; 1 shot per 180 days
Flucelvax Quad 2020-2021 Vial8/11/2020Non-FormulatoryPreferred; Min age 4; 1 shot per 180 days
Flulaval Quad 2020-2021 Syringe8/11/2020Non-FormulatoryPreferred; 1 shot per 180 days
Flumist Quad Nasal 20202021 Vaccine8/11/2020Non-FormulatoryPreferred; Min age 2 & Max age 49; 1 shot per 180 days
Fluzone High-Dose Quad 2020-20218/11/2020Non-FormulatoryPreferred; Min age 65; 1 shot per 180 days
Fluzone Quad 2020-2021 Syringe8/11/2020Non-FormulatoryPreferred; 1 shot per 180 days
Fluzone Quad 2020-2021 Vial8/11/2020Non-FormulatoryPreferred; 1 shot per 180 days
Deferasirox 90mg Granule
Deferasirox 180mg Granule
Deferasirox 360mg Granule
8/25/2020Non-FormulatoryNon-preferred; Prior Authorization Required
Utilization Criteria Updates
Ubrelvy 50mg Tablet
Ubrelvy 100mg Tablet
7/31/2020Non-Preferred; Prior Authorization RequiredNon-Preferred; Prior Authorization Required; Quantity limit 10 tablets per 30 days
Nurtec ODT 75mg Tablet7/31/2020Non-Preferred; Prior Authorization RequiredNon-Preferred; Prior Authorization Required; Quantity limit 10 tablets per 30 days

If you have questions, please call the pharmacy help desk at 855-580-1688.

2019 Meridian Medicaid Plan Preferred Drug List Updates

MeridianRx, MeridianHealth’s pharmacy benefit manager, is providing this notice to inform you of upcoming formulary changes that may affect your patients.

7/15/2019 MeridianHealth’s Illinois Medicaid formulary is changing to a different preferred brand of test strips and meters. MeridianHealth will be converting to only OneTouch branded test strips and meters. All other test strips and meters are being removed from the formulary. Lancets and other diabetic supplies are not affected by this update.

To ensure members continue receiving coverage for their diabetes testing supplies, please provide a new script to your members for OneTouch test strips and meter. Members can obtain the new meter by any of the following methods:

  1. Calling 1-800-789-7022 and providing order code: 738WEL001
  2. Visiting www.OneTouch.orderpoints.com and inputting order code: 738WEL001
  3. Visiting provider offices who were stocked with new meters (at your request)
  4. Visiting their pharmacy with new prescription

If you would like for your office to receive OneTouch meters to give to qualifying members, please call 1-866-732-5941 or contact LifeScan_support@theacsadvantage.com to arrange a delivery to your office.

If you have any questions, please call our Pharmacy Help Desk at 855-580-1688.

MeridianRx, Meridian Health’s pharmacy benefit manager, is providing this notice to inform you of upcoming formulary changes that may affect your patients.

Effective June 1, Meridian Health’s Illinois Medicaid formulary may require approved prior authorizations for Medicaid members who are prescribed anticonvulsant medications without the diagnosis of epilepsy or a seizure disorder on record. Current patients receiving anticonvulsant medications without one of these diagnoses will need approved prior authorizations on file by June 1 in order to continue coverage of these medications. Pharmacies can submit patient diagnosis codes upon claim billing. For instructions on how to bill claims with a diagnosis code, please reference our payer sheet at www.meridianrx.com.

If any of your patients receive anticonvulsant medications and do not have one of the aforementioned diagnoses, please review our formulary for covered alternatives or submit a prior authorization with supporting documentation demonstrating intolerance to these alternative medications. For up to date formulary coverage please visit our website at www.mhplan.com (URL: https://corp.mhplan.com/en/provider/illinois/meridianhealthplan/pharmacy/pharmacybenefits/formulary/).

To submit a prior authorization for your patient(s), please visit our website at www.meridianrx.com and select “Submit Prior Authorization.”

If you have any questions, please call our Pharmacy Help Desk at 855-580-1688.

Please review the formulary changes below effective April 1, 2019.

The specialty indicator was removed from the antiretroviral class of medications in February 2018. Members are now able to fill their covered antiretroviral prescriptions at their local innetwork retail pharmacies.

Effective April 1st the following changes will be reflected on the Illinois Medicaid Formulary:

Drug RemovalsCovered Formulary AlternativeFormulary Alternative Criteria
Humalog 100U/mL vialAdmelog 100U/mL vialQuantity limit; 60mL (6 vials) per 30 days
Humalog 100U/mL cartridgeAdmelog Solostar 100U/mLQuantity limit; 60mL (4 boxes) per 30 days
Humalog 100U/mL cartridgeBasaglar 100U/mL KwikpenQuantity limit; 60mL (4 boxes) per 30 days
Humalog 100U/mL KwikpenVentolin HFA 90 mcg inhalerQuantity limit: 2 inhalers per month
Humalog 200U/mL Kwikpen
Lantus 100U/mL vial
Proair HFA 90mcg inhaler
Proair Respiclick inhaler
Albuterol Sulfate HFA 90 mcg inhalerQuantity limit: 2 inhalers per month

For questions or assistance with finding an in-network pharmacy, you can contact our Pharmacy Help Desk at 855-580-1688.