Provider Alert! Drugs Added to Medicaid, CHIP Formularies on June 6, 2024
Date: June 18, 2024
Attention: All Providers
Effective date: June 6, 2024
Call to action: 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, 2024.
| National Drug Code | Drug Name | PDL Status |
| 62135099260 | ZIPRASIDONE HCL 40 MG CAPSULE | PDL (preferred) |
| 62135099160 | ZIPRASIDONE HCL 20 MG CAPSULE | PDL (preferred) |
| 62135099360 | ZIPRASIDONE HCL 60 MG CAPSULE | PDL (preferred) |
| 62135099460 | ZIPRASIDONE HCL 80 MG CAPSULE | PDL (preferred) |
| 62135004190 | FOSINOPRIL SODIUM 10 MG TAB | PDL (preferred) |
| 69097099205 | DILTIAZEM 24H ER(LA) 120 MG TB | NPD (non-preferred) |
| 69097099305 | DILTIAZEM 24H ER(LA) 180 MG TB | NPD (non-preferred) |
| 69097099405 | DILTIAZEM 24H ER(LA) 240 MG TB | NPD (non-preferred) |
| 59651008314 | DIMETHYL FUMARATE DR 120 MG CP | PDL (preferred) |
| 62135072620 | DOXYCYCLINE MONO 100 MG TABLET | NPD (non-preferred) |
| 65862074860 | LACOSAMIDE 100 MG TABLET | PDL (preferred) |
| 65862075060 | LACOSAMIDE 200 MG TABLET | PDL (preferred) |
| 27241022230 | VENLAFAXINE HCL ER 75 MG TAB | NPD (non-preferred) |
| 27241022130 | VENLAFAXINE HCL ER 37.5 MG TAB | NPD (non-preferred) |
| 27241022330 | VENLAFAXINE HCL ER 150 MG TAB | NPD (non-preferred) |
| 27241022430 | VENLAFAXINE HCL ER 225 MG TAB | NPD (non-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.
