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.