Provider Alert! 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 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) |
| 70710162601 | BALSALAZIDE DISODIUM 750 MG | NPD (non-preferred) |
| 68682013350 | CLINDAMYC-BNZ PEROX 1.2-3.7 | NPD (non-preferred) |
| 32263601 | CREON DR 24,000 UNIT CAPSULE | PDL (preferred) |
| 43386028101 | DIAZEPAM 20 MG RECTAL GEL S | PDL (preferred) |
| 69238160608 | DIHYDROERGOTAMINE 4 MG/ML S | NPD (non-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) |
| 70069081430 | ESOMEPRAZOLE MAG DR 20 MG C | NAP (No Auto PA) |
| 70069081490 | ESOMEPRAZOLE MAG DR 20 MG C | NAP (No Auto PA) |
| 70069081410 | ESOMEPRAZOLE MAG DR 20 MG C | NAP (No Auto PA) |
| 70069081590 | ESOMEPRAZOLE MAG DR 40 MG C | NAP (No Auto PA) |
| 70069081530 | ESOMEPRAZOLE MAG DR 40 MG C | NAP (No Auto PA) |
| 70069081510 | ESOMEPRAZOLE MAG DR 40 MG C | NAP (No Auto PA) |
| 43547029503 | FEBUXOSTAT 40 MG TABLET | NPD (non-preferred) |
| 23155086003 | FLUCYTOSINE 250 MG CAPSULE | NAP (No Auto PA) |
| 23155086101 | FLUCYTOSINE 500 MG CAPSULE | NAP (No Auto PA) |
| 23155086103 | FLUCYTOSINE 500 MG CAPSULE | NAP (No Auto PA) |
| 66993079297 | FLUTICASONE PROP 250 MCG DIS | NPD (non-preferred) |
| 62135004190 | FOSINOPRIL SODIUM 10 MG TAB | PDL (preferred) |
| 65862074860 | LACOSAMIDE 100 MG TABLET | PDL (preferred) |
| 65862075060 | LACOSAMIDE 200 MG TABLET | PDL (preferred) |
| 173090442 | NUCALA 40 MG/0.4 ML SYRINGE | NPD (non-preferred) |
| 72786010202 | OXBRYTA 300 MG TABLET | PDL (preferred) |
| 72786010203 | OXBRYTA 300 MG TABLET | PDL (preferred) |
| 43547065510 | TRANYLCYPROMINE SULF 10 MG | NPD (non-preferred) |
| 23155085825 | VANCOMYCIN HCL 125 MG CAPSU | NPD (non-preferred) |
| 23155085878 | VANCOMYCIN HCL 125 MG CAPSU | NPD (non-preferred) |
| 23155085978 | VANCOMYCIN HCL 250 MG CAPSU | NPD (non-preferred) |
| 23155085925 | VANCOMYCIN HCL 250 MG CAPSU | NPD (non-preferred) |
| 27241022330 | VENLAFAXINE HCL ER 150 MG TAB | NPD (non-preferred) |
| 27241022430 | VENLAFAXINE HCL ER 225 MG TAB | NPD (non-preferred) |
| 27241022130 | VENLAFAXINE HCL ER 37.5 MG TAB | NPD (non-preferred) |
| 27241022230 | VENLAFAXINE HCL ER 75 MG TAB | NPD (non-preferred) |
| 62135099160 | ZIPRASIDONE HCL 20 MG CAPSULE | PDL (preferred) |
| 62135099260 | ZIPRASIDONE HCL 40 MG CAPSULE | PDL (preferred) |
| 62135099360 | ZIPRASIDONE HCL 60 MG CAPSULE | PDL (preferred) |
| 62135099460 | ZIPRASIDONE HCL 80 MG CAPSULE | PDL (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.
