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Update & Revision for Drugs Added to Medicaid, CHIP Formularies

Date: June 21, 2024

Attention: All Providers

Effective dates: June 6; June 12, 2024 for ESOMEPRAZOLE MAG DR 20 MG C

Call to action: This is an update to communication that was previously posted on June 18, 2024.

Texas Children’s Health Plan would like to inform providers that the Vendor Drug Program added the new drugs to the table available below, effective June 6; June 12, 2024 for ESOMEPRAZOLE MAG DR 20 MG C.

Background:
Vendor Drug Program (VDP) added new NDCs to the Medicaid and CHIP formularies that require additional and revised information for MCO manual addition to formulary.

National Drug CodeDrug NamePDL Status
62135099260ZIPRASIDONE HCL 40 MG CAPSULEPDL (preferred)
62135099160ZIPRASIDONE HCL 20 MG CAPSULEPDL (preferred)
62135099360ZIPRASIDONE HCL 60 MG CAPSULEPDL (preferred)
62135099460ZIPRASIDONE HCL 80 MG CAPSULEPDL (preferred)
62135004190FOSINOPRIL SODIUM 10 MG TABPDL (preferred)
69097099205DILTIAZEM 24H ER(LA) 120 MG TBNPD (non-preferred)
69097099305DILTIAZEM 24H ER(LA) 180 MG TBNPD (non-preferred)
69097099405DILTIAZEM 24H ER(LA) 240 MG TBNPD (non-preferred)
59651008314DIMETHYL FUMARATE DR 120 MG CPPDL (preferred)
62135072620DOXYCYCLINE MONO 100 MG TABLETNPD (non-preferred)
65862074860LACOSAMIDE 100 MG TABLETPDL (preferred)
65862075060LACOSAMIDE 200 MG TABLETPDL (preferred)
27241022230VENLAFAXINE HCL ER 75 MG TABNPD (non-preferred)
27241022130VENLAFAXINE HCL ER 37.5 MG TABNPD (non-preferred)
27241022330VENLAFAXINE HCL ER 150 MG TABNPD (non-preferred)
27241022430VENLAFAXINE HCL ER 225 MG TABNPD (non-preferred)
70710162601BALSALAZIDE DISODIUM 750 MGNPD (non-preferred)
68682013350CLINDAMYC-BNZ PEROX 1.2-3.7NPD (non-preferred)
32263601CREON DR 24,000 UNIT CAPSULEPDL (preferred)
43386028101DIAZEPAM 20 MG RECTAL GEL SPDL (preferred)
69238160608DIHYDROERGOTAMINE 4 MG/ML SNPD (non-preferred)
69097099205DILTIAZEM 24H ER(LA) 120 MG TBNPD (non-preferred)
69097099305DILTIAZEM 24H ER(LA) 180 MG TBNPD (non-preferred)
69097099405DILTIAZEM 24H ER(LA) 240 MG TBNPD (non-preferred)
59651008314DIMETHYL FUMARATE DR 120 MG CPPDL (preferred)
62135072620DOXYCYCLINE MONO 100 MG TABLETNPD (non-preferred)
70069081430ESOMEPRAZOLE MAG DR 20 MG CNAP (No Auto PA)
70069081490ESOMEPRAZOLE MAG DR 20 MG CNAP (No Auto PA)
70069081410ESOMEPRAZOLE MAG DR 20 MG CNAP (No Auto PA)
70069081590ESOMEPRAZOLE MAG DR 40 MG CNAP (No Auto PA)
70069081530ESOMEPRAZOLE MAG DR 40 MG CNAP (No Auto PA)
70069081510ESOMEPRAZOLE MAG DR 40 MG CNAP (No Auto PA)
43547029503FEBUXOSTAT 40 MG TABLETNPD (non-preferred)
23155086003FLUCYTOSINE 250 MG CAPSULENAP (No Auto PA)
23155086101FLUCYTOSINE 500 MG CAPSULENAP (No Auto PA)
23155086103FLUCYTOSINE 500 MG CAPSULENAP (No Auto PA)
66993079297FLUTICASONE PROP 250 MCG DISNPD (non-preferred)
62135004190FOSINOPRIL SODIUM 10 MG TABPDL (preferred)
65862074860LACOSAMIDE 100 MG TABLETPDL (preferred)
65862075060LACOSAMIDE 200 MG TABLETPDL (preferred)
173090442NUCALA 40 MG/0.4 ML SYRINGENPD (non-preferred)
72786010202OXBRYTA 300 MG TABLETPDL (preferred)
72786010203OXBRYTA 300 MG TABLETPDL (preferred)
43547065510TRANYLCYPROMINE SULF 10 MGNPD (non-preferred)
23155085825VANCOMYCIN HCL 125 MG CAPSUNPD (non-preferred)
23155085878VANCOMYCIN HCL 125 MG CAPSUNPD (non-preferred)
23155085978VANCOMYCIN HCL 250 MG CAPSUNPD (non-preferred)
23155085925VANCOMYCIN HCL 250 MG CAPSUNPD (non-preferred)
27241022330VENLAFAXINE HCL ER 150 MG TABNPD (non-preferred)
27241022430VENLAFAXINE HCL ER 225 MG TABNPD (non-preferred)
27241022130VENLAFAXINE HCL ER 37.5 MG TABNPD (non-preferred)
27241022230VENLAFAXINE HCL ER 75 MG TABNPD (non-preferred)
62135099160ZIPRASIDONE HCL 20 MG CAPSULEPDL (preferred)
62135099260ZIPRASIDONE HCL 40 MG CAPSULEPDL (preferred)
62135099360ZIPRASIDONE HCL 60 MG CAPSULEPDL (preferred)
62135099460ZIPRASIDONE HCL 80 MG CAPSULEPDL (preferred)

Next step for Providers: Providers should make note of the status for the drugs listed and share this communication with their staff.

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.

For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.