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 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 Medication | Change | Preferred Agents or New Limits |
|---|---|---|
| AMLADEX TAB | Coverage Change | Removed 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 Medication | Change | Preferred Agents or New Limits |
|---|---|---|
| DERMACINRX FOLIFLEX CAPLET | Coverage Change | Removed from Preferred Drug list |
| DERMACINRX VITRAMYN CAPLET | Coverage Change | Removed from Preferred Drug list |
| DERMACINRX VITRANOL CAPLET | Coverage Change | Removed from Preferred Drug list |
| DERMACINRX VITREXATE CAPLET | Coverage Change | Removed from Preferred Drug list |
| All Multivitamins and Vitamins | New Limits | Vitamins 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.
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 Medication | Change | New Limits |
|---|---|---|
| Alprazolam Conc 1 MG/ML | New Limits | 10 mL per day |
| Amiloride HCl Tab 5 MG | New Limits | 12 per day |
| Amiodarone HCl Tab 100 MG | New Limits | 4 per day |
| Amiodarone HCl Tab 200 MG | New Limits | 4 per day |
| Amiodarone HCl Tab 400 MG | New Limits | 4 per day |
| Amlodipine Besylate-Benazepril HCl Cap 2.5-10 MG | New Limits | 2 per day |
| Amlodipine Besylate-Benazepril HCl Cap 5-10 MG | New Limits | 2 per day |
| Amlodipine Besylate-Benazepril HCl Cap 5-20 MG | New Limits | 2 per day |
| Amlodipine Besylate-Benazepril HCl Cap 5-40 MG | New Limits | 2 per day |
| Amlodipine Besylate-Benazepril HCl Cap 10-40 MG | New Limits | 1 per day |
| Amlodipine Besylate-Benazepril HCl Cap 10-20 MG | New Limits | 1 per day |
| Ampicillin Cap 500 MG | New Limits | 4 per day |
| Umeclidinium-Vilanterol Aero Powd BA 62.5-25 MCG/INH | New Limits | 2 blisters per day |
| Atazanavir Sulfate Cap 150 MG (Base Equiv) | New Limits | 1 per day |
| Atazanavir Sulfate Cap 300 MG (Base Equiv) | New Limits | 1 per day |
| Atazanavir Sulfate Cap 200 MG (Base Equiv) | New Limits | 2 per day |
| Benazepril HCl Tab 5 MG | New Limits | 2 per day |
| Benazepril HCl Tab 10 MG | New Limits | 2 per day |
| Benazepril HCl Tab 20 MG | New Limits | 2 per day |
| Benazepril HCl Tab 40 MG | New Limits | 2 per day |
| Bictegravir-Emtricitabine-Tenofovir AF Tab 50-200-25 MG | New Limits | 1 per day |
| Bictegravir-Emtricitabine-Tenofovir AF Tab 30-120-15 MG | New Limits | 1 per day |
| Buspirone HCl Tab 5 MG | New Limits | 3 per day |
| Buspirone HCl Tab 7.5 MG | New Limits | 3 per day |
| Buspirone HCl Tab 10 MG | New Limits | 6 per day |
| Buspirone HCl Tab 15 MG | New Limits | 4 per day |
| Buspirone HCl Tab 30 MG | New Limits | 3 per day |
| Captopril Tab 12.5 MG | New Limits | 3 per day |
| Captopril Tab 25 MG | New Limits | 3 per day |
| Captopril Tab 50 MG | New Limits | 3 per day |
| Captopril Tab 100 MG | New Limits | 3 per day |
| Chlorthalidone Tab 50 MG | New Limits | 4 per day |
| Chlorthalidone Tab 25 MG | New Limits | 4 per day |
| Clarithromycin For Susp 125 MG/5ML | New Limits | 280 mL per fill |
| Clarithromycin For Susp 250 MG/5ML | New Limits | 280 mL per fill |
| Clindamycin Phosphate Swab 1% | New Limits | 2 per day |
| Emtricitabine-Rilpivirine-Tenofovir DF Tab 200-25-300 MG | New Limits | 1 per day |
| Cromolyn Sodium Soln Nebu 20 MG/2ML | New Limits | 8 mL per day |
| Doravirine-Lamivudine-Tenofovir DF Tab 100-300-300 MG | New Limits | 1 per day |
| Medroxyprogesterone Acetate Susp Pref Syr 104 MG/0.65ML | New Limits | 1 mL per 84 days |
| Diclofenac Potassium Tab 50 MG | New Limits | 4 per day |
| Diclofenac Sodium Tab Delayed Release 25 MG | New Limits | 4 per day |
| Diclofenac Sodium Tab Delayed Release 50 MG | New Limits | 4 per day |
| Diclofenac Sodium Tab Delayed Release 75 MG | New Limits | 2 per day |
| Diclofenac Sodium Tab ER 24HR 100 MG | New Limits | 2 per day |
| Diflunisal Tab 500 MG | New Limits | 3 per day |
| Dimethyl Fumarate Capsule Delayed Release 120 MG | New Limits | 2 per day |
| Dimethyl Fumarate Capsule Delayed Release 240 MG | New Limits | 2 per day |
| Dolutegravir Sodium-Lamivudine Tab 50-300 MG (Base Eq) | New Limits | 1 per day |
| Emtricitabine Caps 200 MG | New Limits | 1 per day |
| Etodolac Cap 200 MG | New Limits | 4 per day |
| Etodolac Cap 300 MG | New Limits | 4 per day |
| Etodolac Tab 400 MG | New Limits | 3 per day |
| Etodolac Tab 500 MG | New Limits | 2 per day |
| Etodolac Tab SR 24HR 400 MG | New Limits | 1 per day |
| Etodolac Tab SR 24HR 500 MG | New Limits | 1 per day |
| Etodolac Tab SR 24HR 600 MG | New Limits | 1 per day |
| Ezetimibe Tab 10 MG | New Limits | 1 per day |
| Dapagliflozin Propanediol Tab 5 MG (Base Equivalent) | New Limits | 1 per day |
| Dapagliflozin Propanediol Tab 10 MG (Base Equivalent) | New Limits | 1 per day |
| Flurbiprofen Tab 100 MG | New Limits | 3 per day |
| Glipizide Tab SR 24HR 2.5 MG | New Limits | 3 per day |
| Glipizide Tab SR 24HR 5 MG | New Limits | 3 per day |
| Glipizide Tab SR 24HR 10 MG | New Limits | 2 per day |
| Glipizide-Metformin HCl Tab 2.5-250 MG | New Limits | 3 per day |
| Glipizide-Metformin HCl Tab 2.5-500 MG | New Limits | 3 per day |
| Glipizide-Metformin HCl Tab 5-500 MG | New Limits | 4 per day |
| Glyburide-Metformin Tab 1.25-250 MG | New Limits | 3 per day |
| Glyburide-Metformin Tab 2.5-500 MG | New Limits | 3 per day |
| Glyburide-Metformin Tab 5-500 MG | New Limits | 4 per day |
| Hydroxyzine HCl Tab 10 MG | New Limits | 8 per day |
| Hydroxyzine HCl Tab 25 MG | New Limits | 8 per day |
| Hydroxyzine HCl Tab 50 MG | New Limits | 8 per day |
| Hydroxyzine Pamoate Cap 25 MG | New Limits | 8 per day |
| Hydroxyzine Pamoate Cap 50 MG | New Limits | 8 per day |
| Hydroxyzine Pamoate Cap 100 MG | New Limits | 4 per day |
| Indomethacin Cap 25 MG | New Limits | 6 per day |
| Indomethacin Cap 50 MG | New Limits | 4 per day |
| Indomethacin Cap CR 75 MG | New Limits | 2 per day |
| Indomethacin Suppos 50 MG | New Limits | 4 per day |
| Canagliflozin Tab 100 MG | New Limits | 1 per day |
| Canagliflozin Tab 300 MG | New Limits | 1 per day |
| Itraconazole Cap 100 MG | New Limits | 6 per day |
| Fosamprenavir Calcium Tab 700 MG (Base Equiv) | New Limits | 4 per day |
| Lisinopril Tab 2.5 MG | New Limits | 2 per day |
| Lisinopril Tab 5 MG | New Limits | 2 per day |
| Lisinopril Tab 10 MG | New Limits | 2 per day |
| Lisinopril Tab 20 MG | New Limits | 2 per day |
| Lisinopril Tab 30 MG | New Limits | 2 per day |
| Lisinopril Tab 40 MG | New Limits | 2 per day |
| Lisinopril & Hydrochlorothiazide Tab 10-12.5 MG | New Limits | 2 per day |
| Lisinopril & Hydrochlorothiazide Tab 20-12.5 MG | New Limits | 2 per day |
| Lisinopril & Hydrochlorothiazide Tab 20-25 MG | New Limits | 2 per day |
| Miglitol Tab 25 MG | New Limits | 3 per day |
| Miglitol Tab 50 MG | New Limits | 3 per day |
| Miglitol Tab 100 MG | New Limits | 3 per day |
| Nabumetone Tab 500 MG | New Limits | 4 per day |
| Nabumetone Tab 750 MG | New Limits | 3 per day |
| Nevirapine Tab 200 MG | New Limits | 2 per day |
| Nevirapine Susp 50 MG/5ML | New Limits | 40 mL per day |
| Nevirapine Tab ER 24HR 100 MG | New Limits | 4 per day |
| Nevirapine Tab ER 24HR 400 MG | New Limits | 1 per day |
| Oxazepam Cap 10 MG | New Limits | 4 per day |
| Oxazepam Cap 15 MG | New Limits | 4 per day |
| Oxazepam Cap 30 MG | New Limits | 4 per day |
| Darunavir Tab 600 MG | New Limits | 2 per day |
| Darunavir Tab 800 MG | New Limits | 1 per day |
| Propafenone HCl Tab 150 MG | New Limits | 4 per day |
| Propafenone HCl Tab 225 MG | New Limits | 3 per day |
| Propafenone HCl Tab 300 MG | New Limits | 3 per day |
| Pyridostigmine Bromide Tab CR 180 MG | New Limits | 2 per day |
| Quetiapine Fumarate Tab SR 24HR 50 MG | New Limits | 3 per day |
| Quetiapine Fumarate Tab SR 24HR 150 MG | New Limits | 3 per day |
| Quetiapine Fumarate Tab SR 24HR 200 MG | New Limits | 3 per day |
| Quetiapine Fumarate Tab SR 24HR 300 MG | New Limits | 4 per day |
| Quetiapine Fumarate Tab SR 24HR 400 MG | New Limits | 3 per day |
| Sofosbuvir-Velpatasvir Tab 400-100 MG | New Limits | 1 per day |
| Tiotropium Bromide Monohydrate Inhal Cap 18 MCG (Base Equiv) | New Limits | 1 per day |
| Tiotropium Bromide Monohydrate Inhal Aerosol 2.5 MCG/ACT | New Limits | 0.134 g per day |
| Sulindac Tab 150 MG | New Limits | 2 per day |
| Sulindac Tab 200 MG | New Limits | 2 per day |
| Efavirenz-Lamivudine-Tenofovir DF Tab 400-300-300 MG | New Limits | 1 per day |
| Terbutaline Sulfate Tab 2.5 MG | New Limits | 6 per day |
| Terbutaline Sulfate Tab 5 MG | New Limits | 3 per day |
| Dolutegravir Sodium Tab 25 MG (Base Equiv) | New Limits | 2 per day |
| Dolutegravir Sodium Tab 50 MG (Base Equiv) | New Limits | 2 per day |
| Dolutegravir Sodium Tab for Oral Susp 5 MG (Base Equiv) | New Limits | 6 per day |
| Tobramycin Nebu Soln 300 MG/5ML | New Limits | 10 mL per day |
| Verapamil HCl Cap ER 24HR 300 MG | New Limits | 1 per day |
| Verapamil HCl Cap ER 24HR 360 MG | New Limits | 1 per day |
| Zonisamide Cap 25 MG | New Limits | 4 per day |
| Zonisamide Cap 50 MG | New Limits | 4 per day |
| Zonisamide Cap 100 MG | New Limits | 6 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 Medication | Change | Preferred 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 Medication | Change | Preferred 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 Medication | Change | New 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 Medication | Change | Preferred 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 Medication | Change | Preferred 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 Medication | Change | Preferred 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 Medication | Change | Preferred 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 Medication | Change | Preferred 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 Medication | Change |
|---|---|
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 Medication | Change | New 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 Medication | Change | New 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 Medication | Change | New 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 Medication | Change | New 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 Medication | Change | Preferred 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 Medication | Change | Preferred Agents | |
|---|---|---|---|
| Product Name | NDC | ||
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 Medication | Change |
|---|---|
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 Medication | Change | Alternative |
|---|---|---|
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 Medication | Change as of 07/01/2023 | Preferred 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 Medication | Change | Preferred 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 Medication | Change | Preferred 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 Medication | Change | Preferred 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 Medication | Change | Preferred 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 Medication | Change | Preferred 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 Medication | Change | Preferred 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 Medication | Change | Preferred 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 Medication | Change | Preferred 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 Medication | Change | Preferred 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”.
| Medication | Current Formulary State | Future State/Utilization Management |
|---|---|---|
| OZOBAX 5 MG/5 ML SOLUTION | Covered | Not Covered |
| ADVOCATE INS 0.3 ML 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ADVOCATE INS 0.5 ML 30GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ADVOCATE INS 0.5 ML 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ADVOCATE INS 1 ML 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ADVOCATE PEN NEEDLE 4MM 33G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ADVOCATE PEN NEEDLES 5MM 31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ADVOCATE PEN NEEDLES 8MM 31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD INS SYR 0.3 ML 8MMX31G(1/2) | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD INS SYR UF 0.3ML 12.7MMX30G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD INS SYR UF 0.5ML 12.7MMX30G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD INS SYRN UF 1 ML 12.7MMX30G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD INS SYRNG 0.3 ML 29GX12.7MM | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD INS SYRNG 0.5 ML 29GX12.7MM | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD INS SYRNG UF 0.3 ML 8MMX31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD INS SYRNG UF 0.5 ML 8MMX31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD INSULIN SYR 0.5 ML 28GX1/2"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD INSULIN SYR 1 ML 25GX1"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD INSULIN SYR 1 ML 25GX5/8"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD INSULIN SYR 1 ML 27GX12.7MM | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD INSULIN SYR 1 ML 27GX5/8"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD INSULIN SYR 1 ML 28GX1/2"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD INSULIN SYR 1 ML 29GX12.7MM | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD INSULIN SYR UF 1 ML 8MMX31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD NANO 2 GEN PEN NDL 32GX4MM | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD SAFETGLD INS 0.3 ML 8MMX31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD SAFETGLD INS 0.3ML 13MMX29G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD SAFETGLD INS 0.5ML 13MMX29G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD SAFETYGLD INS 1 ML 13MMX29G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD UF MICRO PEN NEEDLE 6MMX32G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD UF MINI PEN NEEDLE 5MMX31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD UF NANO PEN NEEDLE 4MMX32G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD UF ORIG PEN NDL 12.7MMX29G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD UF SHORT PEN NEEDLE 8MMX31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD VEO INS 0.3ML 6MMX31G (1/2) | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD VEO INS SYRING 1 ML 6MMX31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD VEO INS SYRN 0.3 ML 6MMX31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| BD VEO INS SYRN 0.5 ML 6MMX31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| CAREFINE PEN NEEDLE 5MM 32G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| CAREFINE PEN NEEDLE 6MM 31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| CAREFINE PEN NEEDLE 8MM 30G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| COMFORT EZ PEN NEEDLES 4MM 32G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| COMFORT EZ PEN NEEDLES 5MM 31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| COMFORT EZ PEN NEEDLES 8MM 31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| DROPLET PEN NEEDLE 31GX1/4"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| DROPLET PEN NEEDLE 31GX3/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| DROPLET PEN NEEDLE 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| DROPLET PEN NEEDLE 32GX5/32"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| EASY COMFORT PEN NDL 33G 4MM | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| EASY COMFORT PEN NDL 33G 5MM | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| EASY COMFORT PEN NDL 33G 6MM | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| EASY GLIDE INS 0.5 ML 31GX6MM | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| EASY GLIDE INS 1 ML 31GX6MM | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| EASY TOUCH INSULIN SYR 0.3 ML | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| EASY TOUCH INSULIN SYR 0.5 ML | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| EASY TOUCH INSULIN SYR 1 ML | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| EASY TOUCH PEN NEEDLE 29GX1/2"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| EASY TOUCH PEN NEEDLE 31GX1/4"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| EASY TOUCH PEN NEEDLE 31GX3/16 | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| EASY TOUCH PEN NEEDLE 31GX5/16 | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| EASY TOUCH PEN NEEDLE 32GX1/4"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| EASY TOUCH PEN NEEDLE 32GX3/16 | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| EASY-TOUCH INS 1 ML 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| GS PEN NEEDLE 31G X 8MM | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| HEALTHWISE PEN NEEDLE 31G 8MM | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| HM ULTICARE PEN NEEDLE 4MM 32G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| HM ULTICARE PEN NEEDLE 6MM 31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| HM ULTICARE PEN NEEDLE 8MM 31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| INSULIN 1 ML SYRINGE | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| INSULIN 1/2 ML SYRINGE | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| INSULIN 3/10 ML SYRINGE | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| INSULIN SYRIN 0.3 ML 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| INSULIN SYRIN 0.5 ML 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| INSULIN SYRINGE 1 ML 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| LITE TOUCH 31GX1/4"" PEN NEEDLE | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| MINI ULTRA-THIN II PEN NDL 31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| MONOJECT INSUL SYR U100 1 ML | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| MONOJECT INSULIN SYR 1 ML | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| MONOJECT INSULIN SYR U-100 | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| MS PEN NEEDLE 6MM 31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| NOVOFINE 32G NEEDLES | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| PEN NEEDLE 30G X 5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| PEN NEEDLE 31G X 1/4"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| PEN NEEDLE 31G X 3/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| PEN NEEDLE 31G X 5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| PEN NEEDLE 32G X 5/32"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| PEN NEEDLES 12MM 29G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| PEN NEEDLES 8MM 31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| PENTIPS PEN NEEDLE 31GX3/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| PENTIPS PEN NEEDLE 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| PENTIPS PEN NEEDLE 32GX5/32"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| PENTIPS PEN NEEDLE 6MM 31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| PRO COMFORT 0.5 ML 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| PRO COMFORT PEN NDL 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| PRO COMFORT PEN NDL 32G X 1/4"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| PRO COMFORT PEN NDL 4MM 32G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| RELION INS SYR 0.5 ML 29GX1/2"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| RELION INS SYR 1 ML 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| RELION MINI PEN 31G X 1/4"" NDL | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| RELION PEN NEEDLES 32GX5/32"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| RELION SYRING 0.3 ML 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| RELION SYRING 0.5 ML 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| SURE COMFORT 0.3 ML SYRINGE | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| SURE COMFORT 0.5 ML SYRINGE | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| SURE COMFORT 1 ML SYRINGE | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| SURE COMFORT 3/10 ML SYRINGE | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| SURE COMFORT 30G PEN NEEDLE | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| SURE COMFORT 31G PEN NEEDLE | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| SURE COMFORT PEN NDL 29GX1/2"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| SURE COMFORT PEN NDL 31GX3/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| SURE COMFORT PEN NDL 32GX1/4"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| SURE COMFORT PEN NDL 32GX5/32"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| TECHLITE 0.3 ML 31GX6MM (1/2) | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| TECHLITE 0.5 ML 31GX8MM (1/2) | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| TECHLITE INS SYR 1 ML 30GX12MM | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| TECHLITE INS SYR 1 ML 30GX8MM | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| TECHLITE INS SYR 1 ML 31GX6MM | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| TECHLITE INS SYR 1 ML 31GX8MM | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| TECHLITE PEN NEEDLE 29GX1/2"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| TECHLITE PEN NEEDLE 31GX1/4"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| TECHLITE PEN NEEDLE 31GX3/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| TECHLITE PEN NEEDLE 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| TECHLITE PEN NEEDLE 32GX1/4"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| TECHLITE PEN NEEDLE 32GX5/32"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| TODAY''S HLTH PN NEEDLE 6MM 31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| TRUE COMFORT 0.5 ML 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTCARE INS SYR 1 ML 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE INS 0.3 ML 30GX1/2"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE INS 0.5 ML 30GX1/2"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE INS SYR 1 ML 28GX1/2"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE INS SYR 1 ML 29GX1/2"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE INS SYR 1 ML 30GX1/2"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE PEN NDL 12.7 MM 29G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE PEN NEEDLE 31GX3/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE PEN NEEDLE 4MM 32G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE PEN NEEDLE 6MM 31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE PEN NEEDLE 8MM 31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE PEN NEEDLES 12MM 29G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE PEN NEEDLES 4MM 32G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE PEN NEEDLES 6MM 31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE PEN NEEDLES 6MM 32G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE PEN NEEDLES 8MM 31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE SYR 0.3 ML 30GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE SYR 0.3 ML 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE SYR 0.5 ML 29GX1/2"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE SYR 0.5 ML 30GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE SYR 0.5 ML 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE SYR 1 ML 30GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE SYR 1 ML 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE SYRIN 0.3 ML 29GX1/2"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTICARE SYRIN 0.5 ML 28GX1/2"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| ULTRA-THIN II PEN NDL 31GX5/16 | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| UNIFINE PENTIPS 12MM 29G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| UNIFINE PENTIPS 31GX3/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| UNIFINE PENTIPS 32GX5/32"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| UNIFINE PENTIPS 6MM 31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| UNIFINE PENTIPS 8MM 31G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| UNIFINE PENTIPS PLUS 31GX1/4"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| UNIFINE PENTIPS PLUS 31GX3/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| UNIFINE PENTIPS PLUS 31GX5/16"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| UNIFINE PENTIPS PLUS 32GX5/32"" | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| YOURX ULTICARE PEN NDL 4MM 32G | Tier 4 - Supplemental | Tier 3 - Non-Preferred |
| YOURX ULTICARE PEN NDL 6MM 31G | Tier 4 - Supplemental | Tier 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”.
| Medication | Current Formulary State | Future State/Utilization Management |
|---|---|---|
| ADVAIR HFA 115-21 MCG INHALER | No Quantity Limit | 12 Grams (1 inhaler) per 30 days |
| ADVAIR HFA 115-21 MCG INHALER | No Quantity Limit | 8 Grams (1 inhaler) per 30 days |
| ADVAIR HFA 230-21 MCG INHALER | No Quantity Limit | 12 Grams (1 inhaler) per 30 days |
| ADVAIR HFA 230-21 MCG INHALER | No Quantity Limit | 8 Grams (1 inhaler) per 30 days |
| ADVAIR HFA 45-21 MCG INHALER | No Quantity Limit | 12 Grams (1 inhaler) per 30 days |
| ADVAIR HFA 45-21 MCG INHALER | No Quantity Limit | 8 Grams (1 inhaler) per 30 days |
| AIRDUO DIGIHALER 113-14 MCG | No Quantity Limit | 1 EA (1 inhaler) per 30 Days |
| AIRDUO DIGIHALER 232-14 MCG | No Quantity Limit | 1 EA (1 inhaler) per 30 Days |
| AIRDUO DIGIHALER 55-14 MCG | No Quantity Limit | 1 EA (1 inhaler) per 30 Days |
| AIRDUO RESPICLICK 113-14 MCG | No Quantity Limit | 1 EA (1 inhaler) per 30 Days |
| AIRDUO RESPICLICK 232-14 MCG | No Quantity Limit | 1 EA (1 inhaler) per 30 Days |
| AIRDUO RESPICLICK 55-14 MCG | No Quantity Limit | 1 EA (1 inhaler) per 30 Days |
| ARMONAIR DIGIHALER 113 MCG | No Quantity Limit | 1 EA (1 inhaler) per 30 Days |
| ARMONAIR DIGIHALER 232 MCG | No Quantity Limit | 1 EA (1 inhaler) per 30 Days |
| ARMONAIR DIGIHALER 55 MCG | No Quantity Limit | 1 EA (1 inhaler) per 30 Days |
| BREO ELLIPTA 100-25 MCG INH | No Quantity Limit | 1 EA (1 inhaler) per 30 Days |
| BREO ELLIPTA 200-25 MCG INH | No Quantity Limit | 1 EA (1 inhaler) per 30 Days |
| FLOVENT 100 MCG DISKUS | No Quantity Limit | 1 EA (1 inhaler) per 30 Days |
| FLOVENT 250 MCG DISKUS | No Quantity Limit | 1 EA (1 inhaler) per 30 Days |
| FLOVENT 50 MCG DISKUS | No Quantity Limit | 1 EA (1 inhaler) per 30 Days |
| FLUTICASONE-SALMETEROL 113-14 | No Quantity Limit | 1 EA (1 inhaler) per 30 Days |
| FLUTICASONE-SALMETEROL 232-14 | No Quantity Limit | 1 EA (1 inhaler) per 30 Days |
| FLUTICASONE-SALMETEROL 55-14 | No Quantity Limit | 1 EA per 30 Days |
| PULMICORT 180 MCG FLEXHALER | No Quantity Limit | 1 EA per 30 Days |
| PULMICORT 90 MCG FLEXHALER | No Quantity Limit | 1 EA per 30 Days |
| TRELEGY ELLIPTA 100-62.5-25 | No Quantity Limit | 1 EA per 30 Days |
| TRELEGY ELLIPTA 200-62.5-25 | No Quantity Limit | 1 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 Medication | Medication Change | Preferred Agents |
|---|---|---|
| FLUTICASONE PROPIONATE/SALMETEROL | Non-preferred after 4/15/22 | ADVAIR 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 HFA | Preferred after 4/15/22 | NA |
| WIXELA INHUB | Non-preferred after 4/15/22 | ADVAIR 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 4/15/22 | NA |
| AIRDUO RESPICLICK 55/14 AIRDUO RESPICLICK 113/14 AIRDUO RESPICLICK 232/14 | Preferred after 4/15/22 | NA |
| ANORO ELLIPTA | Preferred after 4/15/22 | NA |
| BEVESPI AEROSPHERE | Non-preferred after 4/15/22 | Anoro Elipta ® |
| INCRUSE ELLIPTA | Preferred after 4/15/22 | NA |
| SPIRIVA RESPIMAT | Preferred after 4/15/22 | NA |
| MYFEMBREE | Preferred after 4/15/22 | NA |
| QULIPTA | Preferred after 4/15/22 | NA |
| APO-VARENICLINE | Non-preferred after 4/15/22 | Varinecline |
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.
| Medication | Current 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.
| Medication | Current Formulary State | Future State/Utilization Management |
|---|---|---|
| 3-DAY VAGINAL CREAM | Covered | Not Covered |
| CHLORPROPAMIDE 100 MG TABLET | Covered | Not Covered |
| CHLORPROPAMIDE 250 MG TABLET | Covered | Not Covered |
| CLOTRIMAZOLE-3 2% CREAM | Covered | Not Covered |
| CVS CLOTRIMAZOLE-3 2% CREAM | Covered | Not Covered |
| MICONAZOLE 2% VAGINAL CREAM | Covered | Not Covered |
| MICONAZOLE 3 COMBO PACK | Covered | Not Covered |
| MICONAZOLE 7 100 MG VAG SUPP | Covered | Not Covered |
| MICONAZOLE 7 CREAM | Covered | Not Covered |
| QC MICONAZOLE-7 CREAM | Covered | Not Covered |
| SM 3-DAY VAGINAL CREAM | Covered | Not Covered |
| SM MICONAZOLE 2% VAGINAL CREAM | Covered | Not Covered |
| SM MICONAZOLE 7 100 MG VAG SUP | Covered | Not Covered |
| SM MICONAZOLE 7 CREAM | Covered | Not 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.
| Medication | Current Formulary State | Future State/Utilization Management |
|---|---|---|
| GAVISCON 80-14.2 MG TAB CHEW | Covered | Not 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.
| Medication | Current Formulary State | Future State/Utilization Management |
|---|---|---|
| Microgestin 21 1-20 Tablet | Preferred | Preferred; Limited to 30 tablets per 30 days; Limited to members between the ages of 10 and 55 |
| Kurvelo-28 Tablet | Preferred; Limited to 30 tablets per 30 days | Preferred; Limited to 30 tablets per 30 days; Limited to members between the ages of 10 and 55 |
| Westab Plus Tablet | Preferred | Preferred; 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 | |||
|---|---|---|---|
| Medication | Date of Change | Previous Formulatory State | Current State/Utilization Management |
| Medication Additions | |||
| Vyfemla 0.4mg-0.035mg Tablet | 2/26/2021 | Not Formulatory | Preferred |
| Vyfemla 0.4-0.035mg Chew Tablet | 2/26/2021 | Not Formulatory | Preferred |
| Utilization Criteria Updates | |||
| SPS 15 GM/60mL Suspension SPS 30GM/120mG Enema Susp | 2/26/2021 | Preferred | Not-Preferred; PA required |
| Medication Deletions | |||
| Emend 40mg Capsule | 2/19/2021 | Not-Preferred; Specialty; PA required | Not Formulary |
| Humira 10mg/0.2mL Syringe Humira 20mg/0.4mL Syringe | 2/19/2021 | Not-Preferred; Specialty; PA required | Not 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 | |||
|---|---|---|---|
| Medication | Date of Change | Previous Formulatory State | Current 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 | 1/29/2021 | Non-Formulary | Non-preferred; PA required |
| Lyleq 0.35mg Tablet | 1/29/2021 | Non-Formulatory | Preferred |
| Tri-Nymyo 28 Tablet | 1/29/2021 | Non-Formulatory | Preferred |
| Twirla 120/30mcg/day Patch | 1/29/2021 | Non-Formulatory | Preferred |
| Lubiprostone 8mcg Capsule Lubiprostone 24mcg Capsule | 1/29/2021 | Non-Formulatory | Preferred |
| Abiraterone 500mg Tablet | 1/21/2021 | Non-Formulatory | Preferred |
| Utilization Criteria Updates | |||
| Azithromycin 250mg Tablet Zithromax 250mg Tablet | 1/15/2021 | Limited to 6 tablets per 5 days; Limited to 1 treatment every 30 days | Limited to 60 tablets per 180 days |
| Azithromycin 500mg Tablet Zithromax 500mg Tablet | 1/15/2021 | Limited to 3 tablets per fill | Limited 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 | |||
|---|---|---|---|
| Medication | Date of Change | Previous Formulatory State | Current State/Utilization Management |
| Medication Additions | |||
| Lyllana 0.025mg patch Lyllana 0.0375mg patch Lyllana 0.075mg patch Lyllana 0.1mg patch | 12/23/2020 | Not Formulary | Preferred |
| Retacrit 20,000 Unit/mL Vial Retacrit 20,000 Unit/2mL Vial | 12/23/2020 | Not Formulatory | Not Preferred; Prior Authorization Required |
| Dificid 40 mg/mL Suspension | 1/1/2021 | Not Formulatory | Not Preferred; Prior Authorization Required |
| Nitazoxanide 500 mg Tablet | 1/1/2021 | Not Formulatory | Not Preferred; Prior Authorization Required |
| Astrazeneca COVID-19 Vaccine Moderna COVID-19 Vaccine Pfizer COVID-19 Vaccine | 1/1/2021 | Not Formulatory | Supplemental 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 | 12/10/2020 | Limited to 300 Test strips per 90 days | Limited 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 | |||
|---|---|---|---|
| Medication | Date of Change | Previous Formulatory State | Current State/Utilization Management |
| Medication Additions | |||
| ALKINDI SPRINKLE 0.5 MG CAP | 11/3/2020 | Not Formulary | Not preferred; PA Required |
| ALKINDI SPRINKLE 1 MG CAPSULE | 11/3/2020 | Not Formulary | Not preferred; PA Required |
| ALKINDI SPRINKLE 2 MG CAPSULE | 11/3/2020 | Not Formulary | Not preferred; PA Required |
| ALKINDI SPRINKLE 5 MG CAPSULE | 11/3/2020 | Not Formulary | Not preferred; PA Required |
| TOLVAPTAN 15 MG TABLET | 11/3/2020 | Not Formulary | Not preferred; PA Required |
| TOLVAPTAN 15 MG TABLET | 11/3/2020 | Not Formulary | Not preferred; PA Required |
| EPCLUSA 200 MG-50 MG TABLET | 11/1-/2020 | Not Formulary | Not 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 | |||
|---|---|---|---|
| Medication | Date of Change | Previous Formulatory State | Current State/Utilization Management |
| Medication Additions | |||
| KLOR-CON 10 MEQ TABLET | 10/15/2020 | Covered; Addition of NDCs required | Covered |
| KLOR-CON M20 TABLET | 10/15/2020 | Covered; Addition of NDCs required | Covered |
| Medication Deletions | |||
| EMBEDA ER 20-0.8 MG CAPSULE | 10/21/2020 | Preferred; Prior authorization required; limited to 30 ea per 30 days | Not Covered |
| EEMBEDA ER 30-1.2 MG CAPSULE | 10/21/2020 | Preferred; Prior authorization required; limited to 30 ea per 30 days | Not Covered |
| EEMBEDA ER 50-2 MG CAPSULE | 10/21/2020 | Preferred; Prior authorization required; limited to 30 ea per 30 days | Not Covered |
| EEMBEDA ER 60-2.4 MG CAPSULE | 10/21/2020 | Preferred; Prior authorization required; limited to 30 ea per 30 days | Not Covered |
| EEMBEDA ER 80-3.2 MG CAPSULE | 10/21/2020 | Preferred; Prior authorization required; limited to 30 ea per 30 days | Not Covered |
| EMBEDA ER 100-4 MG CAPSULE | 10/21/2020 | Preferred; Prior authorization required; limited to 30 ea per 30 days | Not Covered |
| TANZEUM 30 MG PEN INJECT | 10/21/2020 | Non-preferred; Prior authorization required | Not 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 | |||
|---|---|---|---|
| Medication | Date of Change | Previous Formulatory State | Current State/Utilization Management |
| Medication Additions | |||
| Magnesium Citrate Solution | 9/11/2020 | Not Covered | Preferred |
| Hyperrho S-D 1,500 Unit Syringe | 9/24/2020 | Not Covered | Preferred; Limited to 2 ea per 270 days |
| Hyperrho S-D 250 Unit Syringe | 9/24/2020 | Not Covered | Preferred; Limited to 2 ea per 270 days |
| Micrhogam Ultra-Filtd Plus Syringe | 9/24/2020 | Not Covered | Preferred; Limited to 2 ea per 270 days |
| RHOGAM ULTRA-FILTERED PLUS SYR | 9/24/2020 | Not Covered | Preferred; Limited to 2 ea per 270 days |
| RHOPHYLAC 300 MC G/2 ML SYRINGE | 9/24/2020 | Not Covered | Preferred; Limited to 4 mL per 270 days |
| WINRHO SDF 1,500 UNIT VIAL | 9/24/2020 | Not Covered | Preferred; Limited to 2.6 mL per 270 days |
| WINRHO SDF 15,000 UNIT VIAL | 9/24/2020 | Not Covered | Preferred; Limited to 26 mL per 270 days |
| WINRHO SDF 2,500 UNIT VIAL | 9/24/2020 | Not Covered | Preferred; Limited to 4.4 mL per 270 days |
| WINRHO SDF 5,000 UNIT VIAL | 9/24/2020 | Not Covered | Preferred; Limited to 8.8 mL per 270 days |
| Utilization Criteria Updates | |||
| Aciphex DR 20 MG Tablet | 9/11/2020 | Non Preferred | Non preferred; Limited to 30 ea per 30 days, 6 fills per 365 days |
| Aciphex Sprinkle DR 10 MG Capsule | 9/11/2020 | Non Preferred | Non preferred; Limited to 30 ea per 30 days, 6 fills per 365 days |
| Aciphex Sprinkle DR 5 MG Capsule | 9/11/2020 | Non Preferred | Non preferred; Limited to 30 ea per 30 days, 6 fills per 365 days |
| Dexilant DR 60 MG Capsule | 9/11/2020 | Non Preferred | Non preferred; Limited to 30 ea per 30 days, 6 fills per 365 days |
| Esomeprazole DR 10 MG Packet | 9/11/2020 | Non Preferred | Non preferred; Limited to 30 ea per 30 days, 6 fills per 365 days |
| Esomeprazole DR 20 MG Packet | 9/11/2020 | Non Preferred | Non preferred; Limited to 30 ea per 30 days, 6 fills per 365 days |
| Esomeprazole DR 24.65 MG Capsule | 9/11/2020 | Non Preferred | Non preferred; Limited to 30 ea per 30 days, 6 fills per 365 days |
| Esomeprazole DR 40 MG Packet | 9/11/2020 | Non Preferred | Non preferred; Limited to 30 ea per 30 days, 6 fills per 365 days |
| Esomeprazole DR 49.3 MG Capsule | 9/11/2020 | Non Preferred | Non preferred; Limited to 30 ea per 30 days, 6 fills per 365 days |
| Esomeprazole Mag DR 20 MG Capsule | 9/11/2020 | Non Preferred | Non preferred; Limited to 30 ea per 30 days, 6 fills per 365 days |
| Esomeprazole Mag DR 40 MG CAP | 9/11/2020 | Non Preferred | Non preferred; Limited to 30 ea per 30 days, 6 fills per 365 days |
| Prevacid 15 MG Solutab | 9/11/2020 | Non Preferred | Non preferred; Limited to 30 ea per 30 days, 6 fills per 365 days |
| Prevacid 30 MG Solutab | 9/11/2020 | Non Preferred | Non preferred; Limited to 30 ea per 30 days, 6 fills per 365 days |
| Rabeprazole Sod DR 20 MG Tablet | 9/11/2020 | Non Preferred | Non preferred; Limited to 30 ea per 30 days, 6 fills per 365 days |
| Dexilant DR 30 MG Capsule | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Dexilant DR 60 MG C apsule | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Lansoprazole ODT 15 MG Tablet | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Lansoprazole ODT 30 MG Tablet | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Nexium DR 10 MG Packet | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Nexium DR 2.5 MG Packet | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Nexium DR 20 MG Capsule | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Nexium DR 20 MG Packet | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Nexium DR 40 MG C apsule | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Nexium DR 40 MG Packet | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Nexium DR 5 MG Packet | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Omeprazole DR 10 MG Capsule | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Omeprazole DR 20 MG Capsule | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Omeprazole DR 40 MG Capsule | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Pantoprazole Sod DR 20 MG Tablet | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Pantoprazole Sod DR 40 MG Tablet | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Protonix 40 MG Suspension | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Protonix DR 20 MG Tablet | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Protonix DR 40 MG Tablet | 9/11/2020 | Non Preferred | Non preferred; Limited to 60 ea per 30 days, 6 fills per 365 days |
| Prilosec DR 10 MG Suspension | 9/11/2020 | Non Preferred | Non preferred; Limited to 120 ea per 30 days, 6 fills per 365 days |
| Prilosec DR 2.5 MG Suspension | 9/11/2020 | Non Preferred | Non 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 | |||
|---|---|---|---|
| Medication | Date of Change | Previous Formulatory State | Current State/Utilization Management |
| Medication Additions | |||
| Desvenlafaxine Succinate ER 50mg Tablet Desvenlafaxine Succinate ER 100mg Tablet | 8/4/2020 | Non-Formulatory | Non-Preferred; Prior Authorization Required |
| Sumatriptan 6mg/0.5mL Cartridge | 8/4/2020 | Non-Formulatory | Preferred |
| Prizopak II 2.5%-2.5% Cream Kit Aprizo Pak II 2.5%-2.5% Cream | 8/4/2020 | Non-Formulatory | Non-Preferred; Prior Authorization Required |
| Ortikos ER 6mg, 9mg Capsule | 8/4/2020 | Non-Formulatory | Non-Preferred; Prior Authorization Required |
| Enbrel 25mg/0.5mL Vial | 8/11/2020 | Non-Formulatory | Non-Preferred; Prior Authorization Required |
| Afluria Quad 2020-2021 Vial | 8/11/2020 | Non-Formulatory | Preferred; 1 shot per 180 days |
| Afluria Quad 2020-2021 (3YR UP) | 8/11/2020 | Non-Formulatory | Preferred; Min age 3; 1 shot per 180 days |
| Afluria Quad 2020-2021 (6-35MO) | 8/11/2020 | Non-Formulatory | Preferred; Min age 3; 1 shot per 180 days |
| Fluad 2020-2021 Syringe | 8/11/2020 | Non-Formulatory | Preferred; Min age 65; 1 shot per 180 days |
| Fluad Quad 2020-2021 Syringe | 8/11/2020 | Non-Formulatory | Preferred; Min age 65; 1 shot per 180 days |
| Fluarix Quad 2020-2021 Syringe | 8/11/2020 | Non-Formulatory | Preferred; 1 shot per 180 days |
| Flucelvax Quad 2020-2021 Syringe | 8/11/2020 | Non-Formulatory | Preferred; Min age 4; 1 shot per 180 days |
| Flucelvax Quad 2020-2021 Vial | 8/11/2020 | Non-Formulatory | Preferred; Min age 4; 1 shot per 180 days |
| Flulaval Quad 2020-2021 Syringe | 8/11/2020 | Non-Formulatory | Preferred; 1 shot per 180 days |
| Flumist Quad Nasal 2020-2021 Vaccine | 8/11/2020 | Non-Formulatory | Preferred; Min age 2 & Max age 49; 1 shot per 180 days |
| Fluzone High-Dose Quad 2020-2021 | 8/11/2020 | Non-Formulatory | Preferred; Min age 65; 1 shot per 180 days |
| Fluzone Quad 2020-2021 Syringe | 8/11/2020 | Non-Formulatory | Preferred; 1 shot per 180 days |
| Fluzone Quad 2020-2021 Vial | 8/11/2020 | Non-Formulatory | Preferred; 1 shot per 180 days |
| Deferasirox 90mg Granule Deferasirox 180mg Granule Deferasirox 360mg Granule | 8/25/2020 | Non-Formulatory | Non-preferred; Prior Authorization Required |
| Desvenlafaxine Succinate ER 50mg Tablet Desvenlafaxine Succinate ER 100mg Tablet | 8/4/2020 | Non-Formulatory | Non-preferred; Prior Authorization Required |
| Sumatriptan 6mg/0.5mL Cartridge | 8/4/2020 | Non-Formulatory | Preferred |
| Prizopak II 2.5%-2.5% Cream Kit Aprizo Pak II 2.5%-2.5% Cream | 8/4/2020 | Non-Formulatory | Non-Preferred; Prior Authorization Required |
| Ortikos ER 6mg, 9mg Capsule | 8/4/2020 | Non-Formulatory | Non-Preferred; Prior Authorization Required |
| Enbrel 25mg/0.5mL Vial | 8/11/2020 | Non-Formulatory | Preferred; Prior Authorization Required |
| Afluria Quad 2020-2021 Vial | 8/11/2020 | Non-Formulatory | Preferred; 1 shot per 180 days |
| Afluria Quad 2020-2021 (3YR UP) | 8/11/2020 | Non-Formulatory | Preferred; Min age 3; 1 shot per 180 days |
| Afluria Quad 2020-2021 (6-35MO) | 8/11/2020 | Non-Formulatory | Preferred; Max age 3; 1 shot per 180 days |
| Fluad 2020-2021 Syringe | 8/11/2020 | Non-Formulatory | Preferred; Min age 65; 1 shot per 180 days |
| Fluad Quad 2020-2021 Syringe | 8/11/2020 | Non-Formulatory | Preferred; Min age 65; 1 shot per 180 days |
| Fluarix Quad 2020-2021 Syringe | 8/11/2020 | Non-Formulatory | Preferred; 1 shot per 180 days |
| Flucelvax Quad 2020-2021 Syringe | 8/11/2020 | Non-Formulatory | Preferred; Min age 4; 1 shot per 180 days |
| Flucelvax Quad 2020-2021 Vial | 8/11/2020 | Non-Formulatory | Preferred; Min age 4; 1 shot per 180 days |
| Flulaval Quad 2020-2021 Syringe | 8/11/2020 | Non-Formulatory | Preferred; 1 shot per 180 days |
| Flumist Quad Nasal 20202021 Vaccine | 8/11/2020 | Non-Formulatory | Preferred; Min age 2 & Max age 49; 1 shot per 180 days |
| Fluzone High-Dose Quad 2020-2021 | 8/11/2020 | Non-Formulatory | Preferred; Min age 65; 1 shot per 180 days |
| Fluzone Quad 2020-2021 Syringe | 8/11/2020 | Non-Formulatory | Preferred; 1 shot per 180 days |
| Fluzone Quad 2020-2021 Vial | 8/11/2020 | Non-Formulatory | Preferred; 1 shot per 180 days |
| Deferasirox 90mg Granule Deferasirox 180mg Granule Deferasirox 360mg Granule | 8/25/2020 | Non-Formulatory | Non-preferred; Prior Authorization Required |
| Utilization Criteria Updates | |||
| Ubrelvy 50mg Tablet Ubrelvy 100mg Tablet | 7/31/2020 | Non-Preferred; Prior Authorization Required | Non-Preferred; Prior Authorization Required; Quantity limit 10 tablets per 30 days |
| Nurtec ODT 75mg Tablet | 7/31/2020 | Non-Preferred; Prior Authorization Required | Non-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:
- Calling 1-800-789-7022 and providing order code: 738WEL001
- Visiting www.OneTouch.orderpoints.com and inputting order code: 738WEL001
- Visiting provider offices who were stocked with new meters (at your request)
- 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 Removals | Covered Formulary Alternative | Formulary Alternative Criteria |
|---|---|---|
| Humalog 100U/mL vial | Admelog 100U/mL vial | Quantity limit; 60mL (6 vials) per 30 days |
| Humalog 100U/mL cartridge | Admelog Solostar 100U/mL | Quantity limit; 60mL (4 boxes) per 30 days |
| Humalog 100U/mL cartridge | Basaglar 100U/mL Kwikpen | Quantity limit; 60mL (4 boxes) per 30 days |
| Humalog 100U/mL Kwikpen | Ventolin HFA 90 mcg inhaler | Quantity 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 inhaler | Quantity 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.