Formulary search tool and updates

Stay up to date with your medicine. A formulary is a list of medicines we cover. It can help you manage your medicines. 

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See if your medicine has quantity limits, has age limits or needs prior authorization

Updates to the formulary

April 2024

Additions:

Dabigatran 110 mg Capsule (Quantity Level Limit)
Xolair 300 mg / 2 mL Prefilled Syringe (Prior Authorization)
Xolair 300 mg / 2 mL Pen (Prior Authorization)
Xolair 75 mg / 0.5 mL Pen (Prior Authorization)
Xolair 150 mg / mL (Prior Authorization)

Removals:

No updates

Other Updates:

No updates

March 2024

Additions:

Zenpep Capsule 60000 Unit

Removals:

No updates

Other Updates:

No updates

February 2024

Additions:

Adalimumab-Adaz Auto-Injector 40 mg/ 0.4 mL (Prior Authorization)
Adalimumab-Adaz Prefilled Syringe 40 mg/ 0.4 mL (Prior Authorization)
Adalimumab-Fkjp Auto-Injector Kit 40 mg/ 0.8 mL (Prior Authorization)
Adalimumab-Fkjp Prefilled Syringe Kit 20 mg/ 0.4 mL (Prior Authorization)
Adalimumab-Fkjp Prefilled Syringe Kit 40 mg/ 0.8 mL (Prior Authorization)
Aristada Initio Prefilled Syringe 675 mg/ 2.4 mL (Prior Authorization, Quantity Level Limit)
Dupixent Injection 100 mg/0.67 mL (Prior Authorization)
Dupixent Injection 200 mg (Prior Authorization)
Dupixent Injection 200 mg/1.14 mL (Prior Authorization)
Dupixent Injection 300 mg/2 mL (Prior Authorization)
Fesoterodine Fumarate Tablet Extended Release 24 Hour 4 mg (Step Therapy, Quantity Level Limit)
Fesoterodine Fumarate Tablet Extended Release 24 Hour 8 mg (Step Therapy, Quantity Level Limit)
Hadlima Auto-Injector 40 mg/0.4 mL (Prior Authorization)
Hadlima Auto-Injector 40 mg/0.8 mL (Prior Authorization)
Hadlima Prefilled Syringe 40 mg/0.4 mL (Prior Authorization)
Hadlima Prefilled Syringe 40 mg/0.8 mL (Prior Authorization)
Insulin Lispro Injection 100 Units/ mL
Insulin Lispro Injection Junior
Insulin Lispro Vial
Lurasidone Hydrochloride Tablet 120 mg (Quantity Level Limit, Age Limit)
Lurasidone Hydrochloride Tablet 20 mg (Quantity Level Limit, Age Limit)
Lurasidone Hydrochloride Tablet 40 mg (Quantity Level Limit, Age Limit)
Lurasidone Hydrochloride Tablet 60 mg (Quantity Level Limit, Age Limit)
Lurasidone Hydrochloride Tablet 80 mg (Quantity Level Limit, Age Limit)
Ondansetron Hydrochloride Oral Solution 4 mg/ 5 mL (Quantity Level Limit)
Orilissa Tablet 150 mg (Prior Authorization)
Orilissa Tablet 200 mg (Prior Authorization)
Rinvoq Tablet 15 mg Extended Release (Prior Authorization)
Rinvoq Tablet 30 mg Extended Release (Prior Authorization)
Rinvoq Tablet 45 mg Extended Release (Prior Authorization)
Teriparatide Pen Injector 620 mcg/2.48 mL (Prior Authorization, Quantity Level Limit)
Ubrelvy Tablet 100 mg (Step Therapy)
Ubrelvy Tablet 50 mg (Step Therapy)
Ultra-Fine U-100 (BD)
Ultra-Fine U-500 (BD)

Removals:

Admelog Pen Injector
Admelog Vial
Benzoyl Peroxide Liquid Wash 4%
Bromocriptine Mesylate Capsule 5 mg (Base Equivalent)
Bromocriptine Mesylate Tablet 2.5 mg (Base Equivalent)
Combipatch Dis 0.05/0.14 mg
Combipatch Dis 0.05/0.25 mg
Diflunisal Tablet
Glyburide Micronized Tablet 1.5 mg
Glyburide Micronized Tablet 3 mg
Glyburide Micronized Tablet 6 mg
Glyburide Tablet 1.25 mg
Glyburide Tablet 2.5 mg
Glyburide Tablet 5 mg
Glyburide-Metformin Tablet 1.25-250 mg
Glyburide-Metformin Tablet 2.5-500 mg
Glyburide-Metformin Tablet 5-500 mg
Humalog Vial 100 units /mL
Humalog Vial 100 units /mL
Humira Injection 10 mg /0.1 mL
Humira Injection 20 mg /0.2 mL
Humira Injection 40 mg/0.4 mL
Humira Kit 40 mg/0.8
Humira Pediatric Injection Crohns
Humira Pediatric Injection Crohns
Humira Pen Injection 40 mg /0.4 mL
Humira Pen Injection 40 mg /0.8 mL
Humira Pen Injection 80 mg /0.8 mL
Humira Pen Kit Psoriasis/Uveitis
Ins Aspart FlexPen 70/30
Insulin Aspart Protein Injection Flexpen
Insulin Syringe (Disposable) U-100 0.3 mL
Insulin Syringe (Disposable) U-100 1 mL
Insulin Syringe (Disposable) U-100 1/2 mL
Insulin Syringe/Needle U-100 0.3 mL 29 X 1/2"
Insulin Syringe/Needle U-100 0.3 mL 30 X 1/2"
Insulin Syringe/Needle U-100 0.3 mL 30 X 5/16"
Insulin Syringe/Needle U-100 0.3 mL 31 X 15/64"
Insulin Syringe/Needle U-100 0.3 mL 31 X 5/16"
Insulin Syringe/Needle U-100 1 mL 25 X 1"
Insulin Syringe/Needle U-100 1 mL 25 X 5/8"
Insulin Syringe/Needle U-100 1 mL 26 X 1/2"
Insulin Syringe/Needle U-100 1 mL 27 X 1/2"
Insulin Syringe/Needle U-100 1 mL 27 X 5/8"
Insulin Syringe/Needle U-100 1 mL 28 X 1/2"
Insulin Syringe/Needle U-100 1 mL 28 X 5/16"
Insulin Syringe/Needle U-100 1 mL 29 X 1/2"
Insulin Syringe/Needle U-100 1 mL 29 X 5/16"
Insulin Syringe/Needle U-100 1 mL 30 X 1/2"
Insulin Syringe/Needle U-100 1 mL 30 X 5/16"
Insulin Syringe/Needle U-100 1 mL 31 X 15/64"
Insulin Syringe/Needle U-100 1 mL 31 X 5/16"
Insulin Syringe/Needle U-100 1/2 mL 27 X 1/2"
Insulin Syringe/Needle U-100 1/2 mL 28 X 1/2"
Insulin Syringe/Needle U-100 1/2 mL 29 X 1/2"
Insulin Syringe/Needle U-100 1/2 mL 30 X 1/2"
Insulin Syringe/Needle U-100 1/2 mL 30 X 5/16"
Insulin Syringe/Needle U-100 1/2 mL 31 X 15/64"
Insulin Syringe/Needle U-100 1/2 mL 31 X 5/16"
Insulin Syringe/Needle U-100 2 mL 27.5 X 5/8"
Ketorolac Tromethamine Ophthalmic Solution 0.4%
Mesalamine Tablet Delayed Release 800 mg
Nayzilam
Novolog Mix Injection Flex ReliOn
Novolog Mix Vial 70/30
Salsalate Tablet 500 mg
Salsalate Tablet 750 mg
Tramadol Tablet 100mg
Viokace Tablet 10440 Units
Viokace Tablet 20880 Units

Other Updates:

*Sodium Phosphates - Enema*** (Quantity Level Limit)
Acarbose Tablet 100 mg (Quantity Level Limit)
Acarbose Tablet 25 mg (Quantity Level Limit)
Acarbose Tablet 50 mg (Quantity Level Limit)
Albuterol Sulfate Solution Nebulizer 0.083% (2.5 mg/3 mL) (Quantity Level Limit)
Albuterol Sulfate Solution Nebulizer 0.5% (5 mg/mL) (Quantity Level Limit)
Albuterol Sulfate Solution Nebulizer 0.63 mg/3 mL (Base Equivalent) (Quantity Level Limit)
Albuterol Sulfate Solution Nebulizer 1.25 mg/3 mL (Base Equivalent) (Quantity Level Limit)
Alfuzosin Hydrochloride Tablet Extended Release 24 Hour 10 mg (Quantity Level Limit)
Alogliptin-Pioglitazone Tablet 12.5-15 mg (Quantity Level Limit)
Alogliptin-Pioglitazone Tablet 12.5-45 mg (Quantity Level Limit)
Alprazolam Tablet Extended Release 24 Hour 0.5 mg (Quantity Level Limit)
Alprazolam Tablet Extended Release 24 Hour 1 mg (Quantity Level Limit)
Alprazolam Tablet Extended Release 24 Hour 2 mg (Quantity Level Limit)
Alprazolam Tablet Extended Release 24 Hour 3 mg (Quantity Level Limit)
Amlodipine Besylate-Benazepril Hydrochloride Capsule 10-20 mg (Quantity Level Limit)
Amlodipine Besylate-Benazepril Hydrochloride Capsule 10-40 mg (Quantity Level Limit)
Amlodipine Besylate-Benazepril Hydrochloride Capsule 2.5-10 mg (Quantity Level Limit)
Amlodipine Besylate-Benazepril Hydrochloride Capsule 5-10 mg (Quantity Level Limit)
Amlodipine Besylate-Benazepril Hydrochloride Capsule 5-20 mg (Quantity Level Limit)
Amlodipine Besylate-Benazepril Hydrochloride Capsule 5-40 mg (Quantity Level Limit)
Benazepril Hydrochloride Tablet 40 mg (Quantity Level Limit)
Bimatoprost Ophthalmic Solution 0.3% (Quantity Level Limit)
Buprenorphine Hydrochloride Sublingual Tablet 2 mg (Quantity Level Limit)
Buprenorphine Hydrochloride Sublingual Tablet 8 mg (Quantity Level Limit)
Buspirone Hydrochloride Tablet 10 mg (Quantity Level Limit)
Buspirone Hydrochloride Tablet 15 mg (Quantity Level Limit)
Buspirone Hydrochloride Tablet 5 mg (Quantity Level Limit)
Buspirone Hydrochloride Tablet 7.5 mg (Quantity Level Limit)
Candesartan Cilexetil Tablet 16 mg (Quantity Level Limit)
Candesartan Cilexetil Tablet 32 mg (Quantity Level Limit)
Candesartan Cilexetil Tablet 4 mg (Quantity Level Limit)
Candesartan Cilexetil Tablet 8 mg (Quantity Level Limit)
Candesartan Cilexetil-Hydrochlorothiazide Tablet 16-12.5 mg (Quantity Level Limit)
Candesartan Cilexetil-Hydrochlorothiazide Tablet 32-12.5 mg (Quantity Level Limit)
Candesartan Cilexetil-Hydrochlorothiazide Tablet 32-25 mg (Quantity Level Limit)
Cetirizine Hydrochloride Tablet 10 mg (Quantity Level Limit)
Cetirizine Hydrochloride Tablet 5 mg (Quantity Level Limit)
Chlorpheniramine Maleate Tablet Extended Release 12 mg (Quantity Level Limit)
Cimetidine Tab 800 mg (Quantity Level Limit)
Cimetidine Tablet 300 mg (Quantity Level Limit)
Cimetidine Tablet 400 mg (Quantity Level Limit)
Citalopram Hydrobromide Tablet 10 mg (Base Equivalent) (Quantity Level Limit)
Citalopram Hydrobromide Tablet 20 mg (Base Equivalent) (Quantity Level Limit)
Darunavir Tablet 600 mg (Quantity Level Limit)
Darunavir Tablet 800 mg (Quantity Level Limit)
Diltiazem Hydrochloride Capsule Extended Release 24 Hour 240 mg (Quantity Level Limit)
Diltiazem Hydrochloride Coated Beads Capsule Extended Release 24 Hour 120 mg (Quantity Level Limit)
Diltiazem Hydrochloride Extended Release Beads Capsule Extended Release 24 Hour 240 mg (Quantity Level Limit)
Doxazosin Mesylate Tablet 8 mg (Quantity Level Limit)
Duloxetine Hydrochloride Enteric Coated Pellets Capsule 60 mg (Base Equivalent) (Quantity Level Limit)
Enalapril Maleate & Hydrochlorothiazide Tablet 10-25 mg (Quantity Level Limit)
Enalapril Maleate & Hydrochlorothiazide Tablet 5-12.5 mg (Quantity Level Limit)
Enalapril Maleate Tablet 20 mg (Quantity Level Limit)
Esomeprazole Magnesium Capsule Delayed Release 40 mg (Quantity Level Limit)
Ezetimibe Tablet 10 mg (Quantity Level Limit)
Famotidine Tablet 10 mg (Quantity Level Limit)
Famotidine Tablet 40 mg (Quantity Level Limit)
Finasteride Tablet 5 mg (Quantity Level Limit)
Flavoxate Hydrochloride Tablet 100 mg (Quantity Level Limit)
Fluoxetine Hydrochloride Capsule 20 mg (Quantity Level Limit)
Fluvastatin Sodium Capsule 20 mg (Base Equivalent) (Quantity Level Limit)
Fluvoxamine Maleate Tablet 50 mg (Quantity Level Limit)
Fosinopril Sodium Tablet 40 mg (Quantity Level Limit)
Ibrutinib Tablet 420 mg (Quantity Level Limit)
Ibrutinib Tablet 560 mg (Quantity Level Limit)
Ipratropium-Albuterol Nebulizer Solution 0.5-2.5(3) mg/3 mL (Quantity Level Limit)
Irbesartan-Hydrochlorothiazide Tablet 300-12.5 mg (Quantity Level Limit)
Lansoprazole Capsule Delayed Release 30 mg (Quantity Level Limit)
Lisinopril & Hydrochlorothiazide Tablet 10-12.5 mg (Quantity Level Limit)
Lisinopril & Hydrochlorothiazide Tablet 20-25 mg (Quantity Level Limit)
Loratadine & Pseudoephedrine Tablet Extended Release 12 Hour 5-120 mg (Quantity Level Limit)
Loratadine & Pseudoephedrine Tablet Extended Release 24 Hour 10-240 mg (Quantity Level Limit)
Losartan Potassium & Hydrochlorothiazide Tablet 100-12.5 mg (Quantity Level Limit)
Losartan Potassium & Hydrochlorothiazide Tablet 100-25 mg (Quantity Level Limit)
Losartan Potassium & Hydrochlorothiazide Tablet 50-12.5 mg (Quantity Level Limit)
Losartan Potassium Tablet 100 mg (Quantity Level Limit)
Mesalamine Capsule Extended Release 24 Hour 0.375 GM (Quantity Level Limit)
Mirtazapine Orally Disintegrating Tablet 30 mg (Quantity Level Limit)
Mirtazapine Tablet 30 mg (Quantity Level Limit)
Mirtazapine Tablet 45 mg (Quantity Level Limit)
Montelukast Sodium Chewable Tablet 4 mg (Base Equivalent) (Quantity Level Limit)
Montelukast Sodium Chewable Tablet 5 mg (Base Equivalent) (Quantity Level Limit)
Montelukast Sodium Oral Granules Packet 4 mg (Base Equivalent) (Quantity Level Limit)
Montelukast Sodium Tablet 10 mg (Base Equivalent) (Quantity Level Limit)
Nelfinavir Mesylate Tablet 250 mg (Quantity Level Limit)
Nizatidine Capsule 150 mg (Quantity Level Limit)
Nizatidine Capsule 300 mg (Quantity Level Limit)
Omeprazole Capsule Delayed Release 40 mg (Quantity Level Limit)
Oxazepam Capsule 10 mg (Age Limit)
Oxazepam Capsule 15 mg (Age Limit)
Oxazepam Capsule 30 mg (Age Limit)
Oxybutynin Chloride Tablet Extended Release 24 Hour 10 mg (Quantity Level Limit)
Oxybutynin Chloride Tablet Extended Release 24 Hour 5 mg (Quantity Level Limit)
Oxymetazoline Hydrochloride Nasal Solution 0.05% (Quantity Level Limit)
Pantoprazole Sodium Enteric Coated Tablet 40 mg (Quantity Level Limit)
Paroxetine Hydrochloride Tablet 30 mg (Quantity Level Limit)
Paroxetine Hydrochloride Tablet 40 mg (Quantity Level Limit)
Polyethylene Glycol 3350 Oral Packet 17 GM (Quantity Level Limit)
Polyethylene Glycol 3350 Oral Powder 17 GM/Scoop (Quantity Level Limit)
Prazosin Hydrochloride Capsule 1 mg (Quantity Level Limit)
Prazosin Hydrochloride Capsule 2 mg (Quantity Level Limit)
Prazosin Hydrochloride Capsule 5 mg (Quantity Level Limit)
Quinapril Hydrochloride Tablet 40 mg (Quantity Level Limit)
Quinapril-Hydrochlorothiazide Tablet 20-12.5 mg (Quantity Level Limit)
Quinapril-Hydrochlorothiazide Tablet 20-25 mg (Quantity Level Limit)
Ramipril Capsule 10 mg (Quantity Level Limit)
Rosuvastatin Calcium Tablet 10 mg (Quantity Level Limit)
Rosuvastatin Calcium Tablet 20 mg (Quantity Level Limit)
Rosuvastatin Calcium Tablet 40 mg (Quantity Level Limit)
Rosuvastatin Calcium Tablet 5 mg (Quantity Level Limit)
Sertraline Hydrochloride Tablet 100 mg (Quantity Level Limit)
Sertraline Hydrochloride Tablet 25 mg (Quantity Level Limit)
Tamsulosin Hydrochloride Capsule 0.4 mg (Quantity Level Limit)
Terazosin Hydrochloride Capsule 2 mg (Base Equivalent) (Quantity Level Limit)
Terazosin Hydrochloride Capsule 5 mg (Base Equivalent) (Quantity Level Limit)
Tobramycin Nebulizer Solution 300 mg/5 mL (Quantity Level Limit)
Tolterodine Tartrate Tablet 1 mg (Quantity Level Limit)
Tolterodine Tartrate Tablet 2 mg (Quantity Level Limit)
Trandolapril Tablet 1 mg (Quantity Level Limit)
Trandolapril Tablet 2 mg (Quantity Level Limit)
Trandolapril Tablet 4 mg (Quantity Level Limit)
Valsartan Tablet 160 mg (Quantity Level Limit)
Valsartan Tablet 320 mg (Quantity Level Limit)
Valsartan Tablet 40 mg (Quantity Level Limit)
Valsartan Tablet 80 mg (Quantity Level Limit)
Zidovudine Syrup 10 mg/ mL (Quantity Level Limit)

January 2024

Additions:

Dexcom G7 Receiver (Prior Authorization, Quantity Level Limit)
Dexcom G7 Sensor (Prior Authorization, Quantity Level Limit)

Removals:

Benzoyl Peroxide Liquid Wash 0.04%

Other Updates:

None

December 2023

Additions:

None

Removals:

None

Other Updates:

None

November 2023

Additions:

Ciprofloxacin-Dexamethasone Otic Suspension 0.3-0.1% (Quantity Level Limit)
Dayvigo Tablet 10 mg (Prior Authorization, Quantity Level Limit)
Dayvigo Tablet 5 mg (Prior Authorization, Quantity Level Limit)
Gefitinib Tablet 250 mg (Prior Authorization, Quantity Level Limit)
Haegarda Injection 2000 unit (Prior Authorization)
Haegarda Injection 3000 unit (Prior Authorization)
Liqrev (Prior Authorization, Quantity Level Limit)
Phenylephrine-Mineral Oil-Petrolatum Rectal Ointment
Prezcobix Tablet 800-150 (Prior Authorization, Quantity Level Limit)
Takhzyro Injection 150 mg / mL (Prior Authorization, Quantity Level Limit)
Takhzyro Injection 300 / 2 mL (Prior Authorization, Quantity Level Limit)
Takhzyro Injection 300 / 2 mL (Prior Authorization, Quantity Level Limit)

Removals:

Proctofoam Aerosol Hydrocortisone 1%

Other Updates:

Abacavir Sulfate Solution 20 mg / mL (Base Equivalent) (Quantity Level Limit)
Abacavir Sulfate Tablet 300 mg (Base Equivalent) (Quantity Level Limit)
Abacavir Sulfate-Lamivudine Tablet 600-300 mg (Quantity Level Limit)
Abacavir Sulfate-Lamivudine-Zidovudine Tablet 300-150-300 mg (Quantity Level Limit)
Acarbose Tablet 100 mg (Quantity Level Limit)
Acarbose Tablet 25 mg (Quantity Level Limit)
Acarbose Tablet 50 mg (Quantity Level Limit)
Alogliptin Benzoate Tablet 12.5 mg (Base Equivalent) (Quantity Level Limit)
Alogliptin Benzoate Tablet 25 mg (Base Equivalent) (Quantity Level Limit)
Alogliptin Benzoate Tablet 6.25 mg (Base Equivalent) (Quantity Level Limit)
Alogliptin-Metformin Hydrochloride Tablet 12.5-1000 mg (Quantity Level Limit)
Alogliptin-Metformin Hydrochloride Tablet 12.5-500 mg (Quantity Level Limit)
Alogliptin-Pioglitazone Tablet 12.5-30 mg (Quantity Level Limit)
Alogliptin-Pioglitazone Tablet 25-15 mg (Quantity Level Limit)
Alogliptin-Pioglitazone Tablet 25-30 mg (Quantity Level Limit)
Alogliptin-Pioglitazone Tablet 25-45 mg (Quantity Level Limit)
Anastrozole Tablet 1 mg (Quantity Level Limit)
Atazanavir Sulfate Capsule 150 mg (Base Equivalent) (Quantity Level Limit)
Atazanavir Sulfate Capsule 200 mg (Base Equivalent) (Quantity Level Limit)
Atazanavir Sulfate Capsule 300 mg (Base Equivalent) (Quantity Level Limit)
Bicalutamide Tablet 50 mg (Quantity Level Limit)
Bisoprolol Fumarate Tablet 5 mg (Quantity Level Limit)
Carvedilol Tablet 12.5 mg (Quantity Level Limit)
Carvedilol Tablet 25 mg (Quantity Level Limit)
Carvedilol Tablet 3.125 mg (Quantity Level Limit)
Carvedilol Tablet 6.25 mg (Quantity Level Limit)
Complera Tablet (Quantity Level Limit)
Darunavir Oral Suspension 100 mg / mL (Quantity Level Limit)
Darunavir Tablet 150 mg (Quantity Level Limit)
Darunavir Tablet 75 mg (Quantity Level Limit)
Diazepam Rectal Gel 10 mg 2's (Quantity Level Limit)
Diazepam Rectal Gel 2.5 mg 2s (Quantity Level Limit)
Diazepam Rectal Gel 20 mg 2's (Quantity Level Limit)
Edurant Tablet 25 mg (Base Equivalent) (Quantity Level Limit)
Efavirenz Capsule 200 mg (Quantity Level Limit)
Efavirenz Capsule 50 mg (Quantity Level Limit)
Efavirenz Tablet 600 mg (Quantity Level Limit)
Efavirenz-Emtricitabine-Tenofovir Df Tablet 600-200-300 mg (Quantity Level Limit)
Ella Tablet 30 mg (Quantity Level Limit)
Emtricitabine Capsules 200 mg (Quantity Level Limit)
Emtricitabine Solution 10 mg / mL (Quantity Level Limit)
Erlotinib Hydrochloride Tablet 100 mg (Base Equivalent) (Quantity Level Limit)
Erlotinib Hydrochloride Tablet 150 mg (Base Equivalent) (Quantity Level Limit)
Erlotinib Hydrochloride Tablet 25 mg (Add Prior Authorization, Quantity Level Limit)
Estradiol & Norethindrone Acetate Tablet 0.5-0.1 mg (Quantity Level Limit)
Estradiol & Norethindrone Acetate Tablet 1-0.5 mg (Quantity Level Limit)
Etoposide Capsule 50 mg (Remove Prior Authorization)
Etravirine Tablet 100 mg (Quantity Level Limit)
Etravirine Tablet 200 mg (Quantity Level Limit)
Etravirine Tablet 25 mg (Quantity Level Limit)
Everolimus Tablet 10 mg (Quantity Level Limit)
Everolimus Tablet 2.5 mg (Quantity Level Limit)
Everolimus Tablet 5 mg (Quantity Level Limit)
Everolimus Tablet 7.5 mg (Quantity Level Limit)
Evotaz Tablet 300-150 (Quantity Level Limit)
Exemestane Tablet 25 mg (Quantity Level Limit)
Felodipine Tablet Extended Release 24-hour 10 mg (Quantity Level Limit)
Felodipine Tablet Extended Release 24-hour 2.5 mg (Quantity Level Limit)
Felodipine Tablet Extended Release 24-hour 5 mg (Quantity Level Limit)
Fluconazole Tablet 100 mg (Quantity Level Limit)
Fluconazole Tablet 200 mg (Quantity Level Limit)
Fluconazole Tablet 50 mg (Quantity Level Limit)
Fosamprenavir Calcium Suspension 50 mg / mL (Base Equivalent) (Quantity Level Limit)
Fosamprenavir Calcium Tablet 700 mg (Base Equivalent) (Quantity Level Limit)
Fuzeon (Quantity Level Limit)
Glipizide Tablet Extended Release 24-hour 10 mg (Quantity Level Limit)
Glipizide Tablet Extended Release 24-hour 2.5 mg (Quantity Level Limit)
Glipizide Tablet Extended Release 24-hour 5 mg (Quantity Level Limit)
Glipizide-Metformin Hydrochloride Tablet 2.5-250 mg (Quantity Level Limit)
Glipizide-Metformin Hydrochloride Tablet 2.5-500 mg (Quantity Level Limit)
Glipizide-Metformin Hydrochloride Tablet 5-500 mg (Quantity Level Limit)
Glyburide-Metformin Tablet 1.25-250 mg (Quantity Level Limit)
Glyburide-Metformin Tablet 2.5-500 mg (Quantity Level Limit)
Glyburide-Metformin Tablet 5-500 mg (Quantity Level Limit)
Imatinib Mesylate Tablet 100 mg (Base Equivalent) (Quantity Level Limit)
Imatinib Mesylate Tablet 400 mg (Base Equivalent) (Quantity Level Limit)
Imbruvica Tablet 420 mg (Add Prior Authorization, Quantity Level Limit)
Imbruvica Tablet 560 mg (Add Prior Authorization)
Isentress Chewable Tablet 100 mg (Base Equivalent) (Quantity Level Limit)
Isentress Chewable Tablet 25 mg (Base Equivalent) (Quantity Level Limit)
Isentress For Suspension 100 mg (Base Equivalent) (Quantity Level Limit)
Isentress Tablet 400 mg (Base Equivalent) (Quantity Level Limit)
Isosorbide Mononitrate Tablet Extended Release 24-hour 120 mg (Quantity Level Limit)
Isosorbide Mononitrate Tablet Extended Release 24-hour 30 mg (Quantity Level Limit)
Isosorbide Mononitrate Tablet Extended Release 24-hour 60 mg (Quantity Level Limit)
Itraconazole Capsule 100 mg (Quantity Level Limit)
Ketoconazole Tablet 200 mg (Quantity Level Limit)
Lamivudine Oral Solution 10 mg / mL (Quantity Level Limit)
Lamivudine Tablet 150 mg (Quantity Level Limit)
Lamivudine Tablet 300 mg (Quantity Level Limit)
Lamivudine-Zidovudine Tablet 150-300 mg (Quantity Level Limit)
Letrozole Tablet 2.5 mg (Quantity Level Limit)
Levothyroxine Sodium Tablet 100 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 112 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 125 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 137 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 150 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 175 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 200 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 25 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 300 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 50 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 75 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 88 mcg (Quantity Level Limit)
Lopinavir-Ritonavir Solution 400-100 mg / 5 mL (80-20 mg / mL) (Quantity Level Limit)
Lopinavir-Ritonavir Tablet 100-25 mg (Quantity Level Limit)
Lopinavir-Ritonavir Tablet 200-50 mg (Quantity Level Limit)
Mavyret Tablet 100-40 mg (Quantity Level Limit)
Metformin Hydrochloride Tablet Extended Release 24-hour 500 mg (Quantity Level Limit)
Metformin Hydrochloride Tablet Extended Release 24-hour 750 mg (Quantity Level Limit)
Methadone Hydrochloride Powder (Remove Prior Authorization)
Metoprolol Succinate Tablet Extended Release 24-hour 100 mg (Tartrate Equivalent) (Quantity Level Limit)
Metoprolol Succinate Tablet Extended Release 24-hour 200 mg (Tartrate Equivalent) (Quantity Level Limit)
Metoprolol Succinate Tablet Extended Release 24-hour 25 mg (Tartrate Equivalent) (Quantity Level Limit)
Metoprolol Succinate Tablet Extended Release 24-hour 50 mg (Tartrate Equivalent) (Quantity Level Limit)
Metronidazole Gel 1% (Remove Step Therapy)
Nateglinide Tablet 120 mg (Quantity Level Limit)
Nateglinide Tablet 60 mg (Quantity Level Limit)
Nayzilam Spray 5 mg (Remove Prior Authorization, Add Quantity Level Limit)
Nelfinavir Mesylate Tablet 250 mg (Quantity Level Limit)
Nelfinavir Mesylate Tablet 625 mg (Quantity Level Limit)
Nevirapine Susp 50 mg / 5 mL (Quantity Level Limit)
Nevirapine Tablet 200 mg (Quantity Level Limit)
Nevirapine Tablet Extended Release 24-hour 100 mg (Quantity Level Limit)
Nevirapine Tablet Extended Release 24-hour 400 mg (Quantity Level Limit)
Nifedipine Tablet Extended Release 24-hour 30 mg (Quantity Level Limit)
Nifedipine Tablet Extended Release 24-hour 60 mg (Quantity Level Limit)
Nifedipine Tablet Extended Release 24-hour 90 mg (Quantity Level Limit)
Nifedipine Tablet Extended Release 24-hour Osmotic Release 30 mg (Quantity Level Limit)
Nifedipine Tablet Extended Release 24-hour Osmotic Release 60 mg (Quantity Level Limit)
Nifedipine Tablet Extended Release 24-hour Osmotic Release 90 mg (Quantity Level Limit)
Norethindrone Acetate-Ethinyl Estradiol Tablet 0.5 mg - 2.5 mcg (Quantity Level Limit)
Norethindrone Acetate-Ethinyl Estradiol Tablet 1 mg - 5 mcg (Quantity Level Limit)
Norethindrone Tablet 0.35 mg (Quantity Level Limit)
Paricalcitol Capsule 1 mcg (Quantity Level Limit)
Paricalcitol Capsule 2 mcg (Quantity Level Limit)
Paricalcitol Capsule 4 mcg (Quantity Level Limit)
Progesterone Capsule 100 mg (Quantity Level Limit)
Progesterone Capsule 200 mg (Quantity Level Limit)
Propranolol Hydrochloride Capsule Extended Release 24-hour 60 mg (Quantity Level Limit)
Raloxifene Hydrochloride Tablet 60 mg (Quantity Level Limit)
Repaglinide Tablet 0.5 mg (Quantity Level Limit)
Repaglinide Tablet 1 mg (Quantity Level Limit)
Repaglinide Tablet 2 mg (Quantity Level Limit)
Ritonavir Tablet 100 mg (Quantity Level Limit)
Sprycel Tablet 20 mg (Quantity Level Limit)
Stavudine Capsule 15 mg (Quantity Level Limit)
Stavudine Capsule 20 mg (Quantity Level Limit)
Stavudine Capsule 30 mg (Quantity Level Limit)
Stavudine Capsule 40 mg (Quantity Level Limit)
Sunitinib Malate Capsule 50 mg (Base Equivalent) (Quantity Level Limit)
Tasigna Capsule 150 mg (Quantity Level Limit)
Tasigna Capsule 200 mg (Quantity Level Limit)
Tenofovir Disoproxil Fumarate Oral Powder 40 mg / GM (Quantity Level Limit)
Tenofovir Disoproxil Fumarate Tablet 150 mg (Quantity Level Limit)
Tenofovir Disoproxil Fumarate Tablet 200 mg (Quantity Level Limit)
Tenofovir Disoproxil Fumarate Tablet 250 mg (Quantity Level Limit)
Terbinafine Hydrochloride Tablet 250 mg (Quantity Level Limit)
Testosterone Transdermal Gel 25 mg / 2.5 GM (1%) (Quantity Level Limit)
Testosterone Transdermal Gel 50 mg / 5 GM (1%) (Quantity Level Limit)
Tipranavir Capsule 250 mg (Quantity Level Limit)
Tivicay 10 mg (Base Equivalent) (Quantity Level Limit)
Tobramycin Nebulizer Solution 300 mg / 5 mL (Quantity Level Limit)
Trelstar Mix Injection 11.25 mg (Remove Prior Authorization)
Trelstar Mix Injection 22.5 mg (Remove Prior Authorization)
Trelstar Mix Injection 3.75 mg (Remove Prior Authorization)
Triumeq Tablet (Quantity Level Limit)
Tybost Tablet 150 mg (Quantity Level Limit)
Valtoco Spray 10 mg (Quantity Level Limit)
Valtoco Spray 15 mg (Quantity Level Limit)
Valtoco Spray 20 mg (Quantity Level Limit)
Valtoco Spray 5 mg (Quantity Level Limit)
Varenicline Tablet 0.5 mg (Quantity Level Limit)
Varenicline Tablet 1 mg (Quantity Level Limit)
Verapamil Hydrochloride Capsule Extended Release 24-hour 120 mg (Quantity Level Limit)
Verapamil Hydrochloride Capsule Extended Release 24-hour 180 mg (Quantity Level Limit)
Zidovudine Capsule 100 mg (Quantity Level Limit)
Zidovudine Syrup 10 mg / ml (Quantity Level Limit)
Zidovudine Tablet 300 mg (Quantity Level Limit)

October 2023

Additions:

Humatrope Injection 6 mg (Prior Authorization)
Humatrope Injection 12 mg (Prior Authorization)
Humatrope Injection 24 mg (Prior Authorization)

Removals:

None

Other Updates:

None

September 2023

Additions:

Austedo Extended-Release Tablet Titration Kit (Prior Authorization, Quantity Level Limit)

Removals:

None

Other Updates:

None

August 2023

Additions:

* Prenatal WithFerrous Fumarate-Ferrous Polysaccharide-Folic Acid-Omega 3 Capsule 53.5-38-1 mg
Ascorbic Acid Chewable Tablet 250 mg
Ascorbic Acid Chewable Tablet 500 mg
Ascorbic Acid Tablet 1000 mg
Ascorbic Acid Tablet 250 mg
Ascorbic Acid Tablet 500 mg
Austedo Tablet Extended Release 24 hour 12 mg (Prior Authorization, Quantity Level Limit)
Austedo Tablet Extended Release 24 hour 24 mg (Prior Authorization, Quantity Level Limit)
Austedo Tablet Extended Release 24 hour 6 mg (Prior Authorization, Quantity Level Limit)
Biktarvy Tablet 30-120-15 mg (Prior Authorization, Quantity Level Limit)
Buprenorphine Hydrochloride Sublingual Tablet 2 mg (Base Equivalent) (Prior Authorization, Quantity Level Limit)
Buprenorphine Hydrochloride Sublingual Tablet 8 mg (Base Equivalent) (Prior Authorization, Quantity Level Limit)
Cholecalciferol Capsule 1.25 mg (50000 Unit)
Fluocinolone Acetonide Oil 0.01% (Body Oil) (Quantity Level Limit)
Ibandronate Sodium Intravenous Solution 3 mg/ 3 mL (Base Equivalent)
Mineral Oil
Nebivolol Hydrochloride Tablet 10 mg (Base Equivalent) (Quantity Level Limit)
Nebivolol Hydrochloride Tablet 2.5 mg (Base Equivalent) (Quantity Level Limit)
Nebivolol Hydrochloride Tablet 20 mg (Base Equivalent) (Quantity Level Limit)
Nebivolol Hydrochloride Tablet 5 mg (Base Equivalent) (Quantity Level Limit)
Nitroglycerin Capsule Extended Release 2.5 mg
Nonoxynol-9 Film 28% (Quantity Level Limit)
Novolin N Injection 100 Unit
Odefsey Tablet (Prior Authorization, Quantity Level Limit)
Pamidronate Disodium Intravenous Solution 3 mg/ mL
Pamidronate Disodium Intravenous Solution 6 mg/ mL
Pamidronate Disodium Intravenous Solution 9 mg/ mL
Tranexamic Acid Tablet 650 mg (Quantity Level Limit)

Removals:

*Alcohol Sheets***
*B-Complex W/ Minerals Liquid**
*Blood Glucose Calibration - Liquid - Low***
*Blood Glucose Calibration - Liquid - Normal***
*Calcium Alginate-Silver Pad 2" X 2"***
*Calcium Alginate-Silver Pad 4" X 4.75"***
*Calcium Carbonate-Vitamin D With Minerals Chewable Tablet 600 mg-400 Unit***
*Carboxymethylcellulose- Calcium Alginate-Silver Pad 2"X2"***
*Carboxymethylcellulose- Calcium Alginate-Silver Pad 4"X4.75"***
*Carboxymethylcellulose- Calcium Alginate-Silver Pad 4"X5"***
*Carboxymethylcellulose- Calcium Alginate-Silver Pad 6"X6"***
*Condoms - Male***
*Cream Base**
*Diapers & Supplies***
*Hearing Aid Batteries-Miscellaneous***
*Incontinence Supplies - Miscellaneous ***
*Incontinence Supplies Disposable - Miscellaneous ***
*Multiple Vitamin Liquid**
*Pediatric Multiple Vitamin Liquid**
*Pediatric Multiple Vitamin With Minerals & Vitamin C Drops 45 mg/ mL**
*Pediatric Multiple Vitamin With Minerals Oral Solution**
*Prenatal Vitamin With Docusate Sodium-Iron Carbonyl-Folic Acid Tab 90-1 mg***
*Prenatal Without A Vitamin With Ferrous Fumarate-Folic Acid Tablet Chewable 40-1 mg***
*Prenatal Without A With Ferrous Fumarate-Fe Poly-Folic Acid Capsule 85-1 mg***
*Sanitary Napkins & Tampons - Pads***
*Silver - Pad 12.5 cm X 12.5 cm***
*Silver - Pad 17.5 cm X 17.5 cm***
*Silver - Pad 2-3/8"X3-1/8"***
*Silver - Pad 3"X14"***
*Silver - Pad 4-3/4"X10"***
*Silver - Pad 7.5 cm X 7.5 cm***
*Silver Wound Dressings - Miscellaneous***
*Throat Lozenges - Lozenges**
*Wound Dressings - Pads***
Alogliptin-Pioglitazone Tablet 12.5-15 mg
Alogliptin-Pioglitazone Tablet 12.5-45 mg
Aluminum & Magnesium Hydroxide-Simethicone Chewable Tablet 200-200-25 mg
Aluminum Chloride Solution 20%
Aminocaproic Acid Tablet 500 mg
Aspirin Suppository 600 mg
Atazanavir Sulfate Oral Powder Packet 50 mg (Base Equivalent)
Benazepril & Hydrochlorothiazide Tablet 10-12.5 mg
Benazepril & Hydrochlorothiazide Tablet 20-12.5 mg
Benazepril & Hydrochlorothiazide Tablet 20-25 mg
Benazepril & Hydrochlorothiazide Tablet 5-6.25 mg
Benzoyl Peroxide Lotion 8%
Bethanechol Chloride (Bulk) Powder
Buprenorphine Hydrochloride-Naloxone Hydrochloride Sublingual Film 12-3 mg (Base Equivalent)
Buprenorphine Hydrochloride-Naloxone Hydrochloride Sublingual Film 2-0.5 mg (Base Equivalent)
Buprenorphine Hydrochloride-Naloxone Hydrochloride Sublingual Film 4-1 mg (Base Equivalent)
Buprenorphine Hydrochloride-Naloxone Hydrochloride Sublingual Film 8-2 mg (Base Equivalent)
Buprenorphine-Naloxone Buccal Film 2.1-0.3 mg (Base Equivalent)
Buprenorphine-Naloxone Buccal Film 4.2-0.7 mg (Base Equivalent)
Buprenorphine-Naloxone Buccal Film 6.3-1 mg (Base Equivalent)
Butalbital-Aspirin-Caffeine Tablet 50-325-40 mg
Caffeine Powder
Calcium & Phosphorus With Vitamin D Tablet 105 mg-81 mg-120 Unit
Calcium Carbonate-Magnesium Hydroxide Chewable Tablet 550-110 mg
Calcium Carbonate-Magnesium Hydroxide Suspension 400-135 mg / 5 mL
Calcium Carbonate-Vitamin D Tablet 600 mg-10 mcg (400 Unit)
Calcium Citrate-Vitamin D Tablet 200 mg-6.25 mcg(250 Unit) (Elemental Calcium)
Calcium Citrate-Vitamin D Tablet 315 mg-6.25 mcg(250 Unit) (Elemental Calcium)
Calcium Citrate-Vitamin D Tablet 315 mg-5 mcg (200 Unit) (Elemental Calcium)
Carboxymethylcellulose Sodium (Preservative-Free) Ophthalmic Solution 0.25%
Carboxymethylcellulose Sodium Ophthalmic Solution 1%
Carisoprodol With Aspirin & Codeine Tablet 200-325-16 mg
Cimetidine Hydrochloride Solution 300 mg /5 mL
Ciprofloxacin Hydrochloride Tablet 100 mg
Clemastine Fumarate Syrup 0.67 mg/ 5 mL (0.5 mg/ 5 mL Base Equivalent)
Coal Tar Shampoo 2%
Coal Tar Shampoo 2.5%
Corn Starch Topical Powder
Cyclophosphamide Tablet 25 mg
Cyclophosphamide Tablet 50 mg
Desmopressin Acetate Nasal Solution 0.01% (Refrigerated)
Dextromethorphan-Guaifenesin Liquid 30-200 mg/ 5 mL
Didanosine Delayed Release Capsule 200 mg
Didanosine Delayed Release Capsule 250 mg
Didanosine Delayed Release Capsule 400 mg
Diflunisal Powder
Diphenhydramine Hydrochloride Liquid 12.5 mg/ 5 mL
Diphenhydramine Hydrochloride Liquid 6.25 mg/ mL
Diphenhydramine-Acetaminophen Tablet 25-500 mg (Sleep)
Ergocalciferol Capsule 62.5 mcg (2500 Unit)
Esterified Estrogens Tab 2.5 mg
Etanercept For Subcutaneous Injection 25 mg
Fenoprofen Calcium Powder
Fluocinonide Ointment 0.05%
Flurazepam Hydrochloride Capsule 15 mg
Flurazepam Hydrochloride Capsule 30 mg
Fosinopril Sodium & Hydrochlorothiazide Tablet 10-12.5 mg
Fosinopril Sodium & Hydrochlorothiazide Tablet 20-12.5 mg
Gentamicin Sulfate Ophthalmic Ointment 0.3%
Glyburide Powder
Glycopyrrolate Injection 0.2 mg/ mL
Glycopyrrolate Injection 0.4 mg/ 2 mL (0.2 mg/ mL)
Glycopyrrolate Injection 1 mg/ 5 mL (0.2 mg/ mL)
Glycopyrrolate Injection 4 mg/20 mL (0.2 mg/ mL)
Guaifenesin-Codeine Liquid 200-10 mg/ 5 mL
Histrelin Acetate Implant Kit 50 mg
Hydrocortisone Acetate Suppository 30 mg
Hydrocortisone Powder
Indacaterol Maleate Inhalation Powder Capsule 75 mcg (Base Equivalent)
Indinavir Sulfate Capsule 400 mg
Insulin Syringe/Needle U-100 1/2 mL 30 X 3/8"
Interferon Alfa-2b For Injection 10000000 Unit
Interferon Alfa-2b For Injection 18000000 Unit
Interferon Alfa-2b For Injection 50000000 Unit
Irbesartan Tablet 150 mg
Irbesartan Tablet 300 mg
Irbesartan Tablet 75 mg
Ketoprofen Capsule 50 mg
Ketoprofen Capsule 75 mg
Lamivudine Oral Solution 5 mg/ mL (Hepatitis B virus)
Lamivudine-Tenofovir Disoproxil Fumarate Tablet 300-300 mg
Lidocaine-Hydrocortisone Acetate Cream 3-0.5%
Loperamide Hydrochloride Liquid 1 mg/ 5 mL (0.2 mg/ mL)
Loratadine Syrup 5 mg/ 5 mL
Magnesium Oxide Capsule 500 mg (Elemental mg)
Magnesium Oxide Tablet 250 mg (mg Supplement)
Magnesium Tablet 200 mg
Magnesium Tablet 400 mg
Maprotiline Hydrochloride Tablet 25 mg
Maprotiline Hydrochloride Tablet 50 mg
Maprotiline Hydrochloride Tablet 75 mg
Meloxicam Suspension 7.5 mg/ 5 mL
Methadone Hydrochloride Tablet For Oral Suspension 40 mg
Methyldopa & Hydrochlorothiazide Tablet 250-15 mg
Methyldopa & Hydrochlorothiazide Tablet 250-25 mg
Miconazole Nitrate Vaginal Applicator 100 mg & 2% Cream 9 GM Kit
Naltrexone For Intramuscular Extended Release Suspension 380 mg
Niacin Powder
Omeprazole (Bulk) Powder
Oxybutynin Chloride (Bulk) Powder
Oxycodone-Aspirin Tablet 4.8355-325 mg
Peginterferon Alfa-2b For Injection Kit 50 mcg /0.5 mL
Phenylephrine With Dm-Gg Liquid 10-15-300 mg/ 5 mL
Plerixafor Subcutaneous Injection 24 mg/ 1.2 mL (20 mg/ mL)
Potassium & Sodium Citrates With Citric Acid Syrup 550-500-334 mg/ 5 mL
Prednicarbate Ointment 0.1%
Propranolol & Hydrochlorothiazide Tablet 40-25 mg
Propranolol & Hydrochlorothiazide Tablet 80-25 mg
Pseudoephedrine-Brompheniramine-Codeine Liquid 10-1.33-6.33 mg/ 5 mL
Psyllium Powder Packet 58.6%
Rimantadine Hydrochloride Tablet 100 mg
Ritonavir Oral Solution 80 mg/ mL
Rosiglitazone Maleate Tablet 2 mg (Base Equivalent)
Rosiglitazone Maleate Tablet 4 mg (Base Equivalent)
Salicylic Acid Cream 6%
Saquinavir Mesylate Tablet 500 mg
Semaglutide Solution Pen-Injection 0.25 Or 0.5 mg/Dose (2 mg/ 1.5mL)
Semaglutide Solution Pen-Injection 1 mg/ Dose (2 mg/1.5 mL)
Silver Nitrate-Potassium Nitrate Applicator 75-25%
Simethicone Liquid 40 mg/ 0.6 mL
Sodium Chloride Solution Nebulizer 6%
Sodium Fluoride Solution 0.125 mg/ Drop Fluoride (0.275 mg/Drop Sodium Fluoride)
Sodium Fluoride Tablet 0.5 mg Fluoride (From 1.1 mg Sodium Fluoride)
Sodium Fluoride Tablet 1 mg Fluoride (From 2.2 mg Sodium Fluoride)
Sodium Fluoride-Potassium Nitrate Paste 1.1-5%
Stannous Fluoride Concentrated 0.63%
Sumatriptan Succinate Solution Prefilled Syringe 6 mg/0.5ml
Syringe/Needle (Disposable) 12 mL 20 X 1"
Syringe/Needle (Disposable) 12 mL 22 X 1"
Syringe/Needle (Disposable) 6 mL 20 X 1"
Syringe/Needle (Disposable) 6 mL 21 X 1-1/4"
Syringe/Needle (Disposable) 6 mL 22 X 1"
Syringe/Needle (Disposable) 6 mL 22 X 1-1/4"
Telmisartan Tablet 20 mg
Telmisartan Tablet 40 mg
Telmisartan Tablet 80 mg
Temsirolimus Solution For Intravenous Infusion 25 mg/ mL
Tipranavir Oral Solution 100 mg/ mL
Tolnaftate Aerosol Powder 1%
Zidovudine Intravenous Solution 10 mg/ mL

Other Updates:

Bisoprolol Fumarate Tablet 10 mg (Quantity Level Limit)
Desmopressin Acetate Nasal Spray Solution 0.01% (Quantity Level Limit)
Hydrocortisone Acetate Cream 1% (Quantity Level Limit)
Lisinopril & Hydrochlorothiazide Tablet 20-12.5 mg (Quantity Level Limit)
Oseltamivir Phosphate Capsule 30 mg (Quantity Level Limit)
Praziquantel Tablet 600 mg (Remove Prior Authorization)
Propranolol Hydrochloride Capsule Extended Release 24 hour 120 mg (Quantity Level Limit)
Propranolol Hydrochloride Capsule Extended Release 24 hour 160 mg (Quantity Level Limit)
Rosuvastatin Calcium Tablet 10 mg (Remove Step Therapy)
Rosuvastatin Calcium Tablet 20 mg (Remove Step Therapy)
Rosuvastatin Calcium Tablet 40 mg (Remove Step Therapy)
Rosuvastatin Calcium Tablet 5 mg (Remove Step Therapy)
Sildenafil Citrate Tablet 20 mg (Quantity Level Limit)

July 2023

Additions:

Kalydeco 13.4 mg (Prior Authorization)
Mekinist Solution 0.05 mg/ mL (Prior Authorization)
Tafinlar Tablet 10 mg (Prior Authorization)
Trikafta Packet 59.5 mg (Prior Authorization)
Trikafta Packet 75 mg (Prior Authorization)

Removals:

None

Other Updates:

None

June 2023

Additions:

None

Removals:

None

Other Updates:

None

May 2023

Additions:

Breztri Inhalation Aerosol 160-9-4.8 mcg / Actuation (Step Therapy, Quantity Level Limit)
Emgality Auto-Injector 120 mg / mL (Step Therapy, Quantity Level Limit)
Emgality Prefilled Syringe Pfs 120 mg / mL (Add Step Therapy, Quantity Level Limit)
Fexofenadine Hydrochloride Suspension 30 mg / mL (Quantity Level Limit)
Fluticasone-Salmeterol Inhalation Powder 250-50 mcg / Actuation (Add Quantity Level Limit)
Fluticasone-Salmeterol Inhalation Powder 500-50 mcg / Actuation (Add Quantity Level Limit)
Gilenya Capsule 0.25mg (Add Prior Authorization, Quantity Level Limit)
Salicylic Acid Liquid 17%
Trikafta Tablets (Add Prior Authorization)
Urea Cream 20%

Removals:

*Multiple Vitamins With Minerals Liquid**
*Omega-3 Fatty Acids Capsule 435 mg**
*Pediatric Multiple Vitamin With Minerals & Vitamin C Chewable Tablet**
*Pediatric Multiple Vitamins With Iron Drops 10 mg/mL**
*Prenatal Without A With/Ferrous Fumarate-Ferrous Polysaccharide-Folic Acid Capsule 130-92.4-1 mg**
*Prenatal Without A With/Ferrous Fumarate-Ferrous Polysaccharide -Folic Acid Capsule 20-20-1.25 mg**
Acetaminophen Elixir 160 mg/ 5 mL
Amiloride Hydrochloride Powder
Calcium Carbonate Powder
Capsaicin Cream 0.1%
Carboxymethylcellulose Sodium Ophthalmic Solution 0.25%
Chlorhexidine Gluconate Solution 20%
Cholecalciferol Capsule 400 Unit
Cholecalciferol Chewable Wafer 50000 Unit
Creon Capsule
Diphenhydramine Hydrochloride (Sleep) Tablet 50 mg
Elmiron Capsules
Ergocalciferol Tablet 400 Unit
Fluocinolone Acetonide Cream 0.01%
Fluocinonide Emulsified Base Cream 0.05%
Fluticasone Propionate Lotion 0.05%
Gentamicin Sulfate Powder
Heparin Sodium Injection 20,000 Units/ mL
Heparin Sodium Injection 5,000 Units/ 0.5 mL
Lidocaine Cream 4%
Lidocaine Hydrochloride Solution 4%
Mexiletine Hydrochloride Capsule 150 mg
Mexiletine Hydrochloride Capsule 200 mg
Mexiletine Hydrochloride Capsule 250 mg
Niacin Tablet 50 mg
Niacin Tablet 250 mg
Niacin Tablet Controlled Release 250 mg
Prenatal With Ferrous Fumarate-Folic Acid Tablet 28-0.8 mg & Docosahexaenoic Acid Capsule 200 mg Pack
Quinidine Sulfate Tablets 200 mg
Quinidine Sulfate Tablets 300 mg
Scalpicin Solution 1%
Sorbitol Rectal Solution 70%
Stiolto Inhalation Spray 2.5-2.5 mcg / Actuation
Triamcinolone Acetonide Ointment 0.05%

Other Updates:

Albendazole Tablet 200 mg (Add Prior Authorization, Remove Step Therapy)
Betamethasone Dipropionate Ointment 0.05% (Add Quantity Level Limit)
Enoxaparin Sodium Injection 100 mg / mL (Remove Quantity Level Limit)
Enoxaparin Sodium Injection 120 mg / 0.8 mL (Remove Quantity Level Limit)
Enoxaparin Sodium Injection 150 mg / mL (Remove Quantity Level Limit)
Enoxaparin Sodium Injection 30 mg / 0.3 mL (Remove Quantity Level Limit)
Enoxaparin Sodium Injection 40 mg / 0.4 mL (Remove Quantity Level Limit)
Enoxaparin Sodium Injection 60 mg / 0.6 mL (Remove Quantity Level Limit)
Enoxaparin Sodium Injection 80 mg / 0.8 mL (Remove Quantity Level Limit)
Enoxaparin Sodium Injection Solution 60 mg / 0.6 mL (Remove Quantity Level Limit)
Enoxaparin Sodium Injection Solution 80 mg / 0.8 mL (Remove Quantity Level Limit)
Fluconazole Tablet 150 mg (Add Quantity Level Limit)
Fluocinolone Acetonide Cream 0.025% (Add Quantity Level Limit)
Fluocinolone Acetonide Ointment 0.025% (Add Quantity Level Limit)
Fluticasone-Salmeterol Inhalation Powder 100-50 mcg / Actuation (Remove Age Limit)
Lidocaine Ointment 5% (Remove Prior Authorization)
Ozempic Pen-Injector
Trulicity Pen-Injector

April 2023

Additions:

None

Removals:

None

Other Updates:

Freestyle 14 Sensor Libre (Updated Quantity Level Limit)
Freestyle 14 Sensor Libre 2 (Updated Quantity Level Limit)
Freestyle 14 Sensor Libre 3 (Updated Quantity Level Limit)

March 2023

Additions:

Guaifenesin-Codeine Solution 100-6.33 mg/5 mL (Quantity Level Limit, Age Minimum)

Removals:

Doxycycline Capsule 150 mg
Fluocinolone Acetonide Powder
Hydrocortisone Acetate Powder
Hydrocortisone-Pramoxine-Chloroxylenol Lotion 10-10-1 mg/mL
Itraconazole Oral Solution 10 mg/mL
Metaproterenol Sulfate Powder
Triamcinolone Acetonide Powder

Other Updates:

Tobramycin Nebulizer Solution 300 mg/5 mL (Prior Authorization Required)

February 2023

Additions:

Atomoxetine Capsule 100 mg (Quantity Level Limit, Age Minimum)
Atomoxetine Capsule 10 mg (Quantity Level Limit, Age Minimum)
Atomoxetine Capsule 18 mg (Quantity Level Limit, Age Minimum)
Atomoxetine Capsule 25 mg (Quantity Level Limit, Age Minimum)
Atomoxetine Capsule 40 mg (Quantity Level Limit, Age Minimum)
Atomoxetine Capsule 60 mg (Quantity Level Limit, Age Minimum)
Atomoxetine Capsule 80 mg (Quantity Level Limit, Age Minimum)
Budesonide Tablet Extended-Release 9 mg
Buspirone Tablet 30 mg (Quantity Level Limit, Age Minimum)
Calcium Polycarbophil Tablet 625 mg
Carboxymethylcellulose-Glycerin-Polysorbate 80 Ophthalmic Solution 0.5-1-0.5%
Carboxymethylcellulose-Glycerin (Preservative Free) Ophthalmic Solution 0.5-0.9%
Carboxymethylcellulose-Glycerin (Preservative Free) Ophthalmic Solution 0.5-1%
Carboxymethylcellulose-Glycerin Ophthalmic Gel 1-0.9%
Carboxymethylcellulose-Glycerin Ophthalmic Solution 0.5-0.9%
Cyclosporine (Ophthalmic) Emulsion 0.05% (Prior Authorization Required, Quantity Level Limit)
Dabigatran Capsule 150 mg (Quantity Level Limit)
Dabigatran Capsule 75 mg (Quantity Level Limit)
Desvenlafaxine (P) Tablet 100 mg Extended Release (Quantity Level Limit)
Desvenlafaxine (P) Tablet 25 mg Extended Release (Quantity Level Limit)
Desvenlafaxine (P) Tablet 50 mg Extended Release (Quantity Level Limit)
Dificid Suspension (Prior Authorization Required)
Dificid Tablet 200 mg (Prior Authorization Required)
Esomeprazole Magnesium Capsule 40 mg Delayed Release (Quantity Level Limit)
Estradiol Vaginal Cream 0.1 mg/gm (Quantity Level Limit)
Ethacrynic Tablet Acid 25 mg
Fexofenadine Hydrochloride Tablet 180 mg (Quantity Level Limit)
Fexofenadine Hydrochloride Tablet 60 mg (Quantity Level Limit)
Fluocinolone Acetonide Oil Ear 0.01% (Quantity Level Limit)
Glucose Gel 40%
Glucose Gel 77.4%
Glycerin Suppository 1 gm
Glycerin-Hypromellose- Polyethylene Glycol 400 Ophthalmic Solution 0.2-0.2-1%
Hypromellose Ophthalmic Gel 0.3%
Imbruvica Tablet 140 mg (Prior Authorization Required, Quantity Level Limit)
Imbruvica Tablet 280 mg (Prior Authorization Required, Quantity Level Limit)
Invega Hafyera Injection 1092 mg (Prior Authorization Required, Quantity Level Limit)
Invega Hafyera Injection 1560 mg (Prior Authorization Required, Quantity Level Limit)
Lactobacillus Acidophilus-Pectin Capsule
Lactobacillus Capsule
Lactobacillus Tablet
Levonorgestrel-Ethinyl Estradiol (91-Day) Tablet 0.01/0.15/0.03 mg
Lidocaine 5% Rectal Cream (Quantity Level Limit)
Magnesium Citrate Solution
Miconazole Nitrate Vaginal Suppository 1200 mg & 2% Cream Kit
Naphazoline with Pheniramine Ophthalmic Solution 0.025-0.3%
Naphazoline with Pheniramine Ophthalmic Solution 0.027-0.315%
Norethindrone Acetate & Estradiol-Ferrous 24 Tablet 1/0.02 mg (Quantity Level Limit)
Phenylephrine Hydrochloride Tablet 10 mg
Phenylephrine-Dextromethorphan-Guaifenesin Liquid 10-18-200 mg/15 mL (Quantity Level Limit)
Phenylephrine-Dextromethorphan-Guaifenesin Liquid 2.5-5-100 mg/5 mL (Quantity Level Limit)
Phenylephrine-Brompheniramine- Dextromethorphan Liquid 2.5-1-5 mg/5 mL (Quantity Level Limit)
Polyethylene Glycol-Propylene Glycol Ophthalmic Solution 0.4-0.3%
Pramoxine Aerosol 1% Rectal (Quantity Level Limit)
Probiotic Product - Capsule
Pseudoephedrine- Brompheniramine- Dextromethorphan Syrup 30-2-10 mg/5 mL (Quantity Level Limit)
Pseudoephedrine- Dexchlorpheniramine -Chlophedianol Liquid 30-1-12.5 mg/5mL (Quantity Level Limit)
Pseudoephedrine Hydrochloride Tablet Extended Release 12-hour 120 mg
Quetiapine Tablet 150 mg Extended-Release (Quantity Level Limit, Age Minimum)
Quetiapine Tablet 200 mg Extended-Release (Quantity Level Limit, Age Minimum)
Quetiapine Tablet 300 mg Extended-Release (Quantity Level Limit, Age Minimum)
Quetiapine Tablet 400 mg Extended-Release (Quantity Level Limit, Age Minimum)
Quetiapine Tablet 50 mg Extended-Release (Quantity Level Limit, Age Minimum)
Rivastigmine Disc 13.3 mg/24 hour (Prior Authorization Required)
Rivastigmine Disc 4.6 mg/24 hour (Prior Authorization Required)
Rivastigmine Disc 9.5 mg/24 hour (Prior Authorization Required)
Saline Nasal Gel
Saline Nasal Solution 0.65%
Tetrahydrozoline Hydrochloride Ophthalmic Solution 0.05%
Tramadol Hydrochloride Tablet Extended Release 24-hour 100 mg (Prior Authorization Required, Quantity Level Limit, Age Minimum)
Tramadol Hydrochloride Tablet Extended Release 24-hour 200 mg (Prior Authorization Required, Quantity Level Limit, Age Minimum)
Tramadol Hydrochloride Tablet Extended Release 24-hour 300 mg (Prior Authorization Required, Quantity Level Limit, Age Minimum)
Vancomycin Capsule 125 mg (Quantity Level Limit)
Vancomycin Capsule 250 mg (Quantity Level Limit)
Xifaxan Tablet 550 mg (Prior Authorization Required)

Removals:

Alendronate Solution 70 mg/75 mL
Auryxia 210 mg Tablet
Benzocaine-Docusate Sodium Rectal Enema 20-283 mg
Bisacodyl Enema 10 mg/30 mL
Brimonidine Tartrate-Timolol Maleate Ophthalmic Solution 0.2-0.5%
Brinzolamide Ophthalmic Suspension 1%
Butalbital-Acetaminophen Tablet 50-325 mg
Butalbital-Acetaminophen-Caffeine with Codeine Capsule 50-300-40-30 mg
Butalbital-Acetaminophen-Caffeine with Codeine Capsule 50-325-40-30 mg
Butalbital-Aspirin-Caffeine with Codeine Capsule 50-325-40-30 mg
Butalbital-Aspirin-Caffeine Capsule 50-325-40 mg
Celontin Capsule 300 mg
Cequa
Coal Tar Shampoo 1%
Coal Tar Shampoo 10%
Colchicine Capsule 0.6 mg
Dermatological Products Miscellaneous - Cream
Dermatological Products Miscellaneous - Lotion
Dermazinc Cream
Desmopressin Spray Ref 0.01%
Diltiazem Extended-Release Capsule 120 mg/12 hour
Diphenoxylate with Atropine Liquid 2.5-0.025 mg/5 mL
Duloxetine Capsule 40 mg Delayed Release
Esbriet 267 mg Capsule
Estring
Ibrance Tablet 100 mg
Ibrance Tablet 125 mg
Ibrance Tablet 75 mg
Leukine Injection 250 mcg
Levofloxacin Ophthalmic Solution 0.5%
Lidocaine Solution 4%
Magnesium Hydroxide Suspension Concentrate 2400 mg/10 mL
Methylphenidate Capsule 20 mg Long Acting
Methylphenidate Capsule 30 mg Long Acting
Methylphenidate Capsule 40 mg Long Acting
Methylphenidate Capsule 60 mg Long Acting
Naproxen Tablet Enteric Coated 500 mg
Neomycin-Bacitracin-Polymyxin with Lidocaine Ointment 4%
Orencia Intravenous Injection 250 mg
Oxymorphone Hydrochloride Tablet Extended Release 12-hour 10 mg
Oxymorphone Hydrochloride Tablet Extended Release 12-hour 15 mg
Oxymorphone Hydrochloride Tablet Extended Release 12-hour 20 mg
Oxymorphone Hydrochloride Tablet Extended Release 12-hour 30 mg
Oxymorphone Hydrochloride Tablet Extended Release 12-hour 40 mg
Oxymorphone Hydrochloride Tablet Extended Release 12-hour 5 mg
Oxymorphone Hydrochloride Tablet Extended Release 12-hour 7.5 mg
Potassium-Sodium Citrates & Citric Acid Solution 550-500-334 mg/5 mL
Remicade Injection 100 mg
Sulfacetamide Sodium Ophthalmic Ointment 10%

Other Updates:

Azelastine Hydrochloride Ophthalmic Solution 0.05% (Remove Step Therapy)
Bacitracin Ophthalmic Ointment 500 unit/gm (Quantity Level Limit)
Bacitracin-Polymyxin B Ophthalmic Ointment (Quantity Level Limit)
Bacitracin-Polymyxin-Neomycin-Hydrocortisone Ophthalmic Ointment 1% (Quantity Level Limit)
Benzonatate Capsule 100 mg
Benzonatate Capsule 200 mg
Budesonide Capsule 3 mg Delayed Release (Remove Step Therapy)
Calcipotriene Cream 0.005%
Calcipotriene Ointment 0.005%
Calcipotriene Solution 0.005% (50 mcg/mL)
Carboxymethylcellulose Sodium Ophthalmic Gel 1%
Celecoxib Capsule 50 mg (Remove Step Therapy)
Celecoxib Capsule 100 mg (Remove Step Therapy)
Celecoxib Capsule 200 mg (Remove Step Therapy)
Celecoxib Capsule 400 mg (Remove Step Therapy)
Divalproex Tablet 250 mg Extended Release (Remove Prior Authorization)
Divalproex Tablet 500 mg Extended Release (Remove Prior Authorization)
Dorzolamide Hydrochloride-Timolol Maleate Ophthalmic Solution 22.3-6.8 mg/mL (Remove Step Therapy)
Duloxetine Capsule 20 mg Delayed Release (Quantity Level Limit)
Erythromycin Ophthalmic Ointment 5 mg/gm (Quantity Level Limit)
Fentanyl Oral Transmucosal Lozenge 1200 mcg (Added Prior Authorization)
Fentanyl Oral Transmucosal Lozenge 1600 mcg (Added Prior Authorization)
Fentanyl Oral Transmucosal Lozenge 200 mcg (Added Prior Authorization)
Fentanyl Oral Transmucosal Lozenge 400 mcg (Added Prior Authorization)
Fentanyl Oral Transmucosal Lozenge 600 mcg (Added Prior Authorization)
Fentanyl Oral Transmucosal Lozenge 800 mcg (Added Prior Authorization)
Gentamicin Sulfate Ophthalmic Ointment 0.3% (Quantity Level Limit)
Levonorgestrel Tablet 1.5 mg (Quantity Level Limit)
Tolterodine Tartrate Capsule Extended Release 24-hour 2 mg (Remove Step Therapy and Prior Authorization)
Tolterodine Tartrate Capsule Extended Release 24-hour 4 mg (Remove Step Therapy and Prior Authorization)
Tolterodine Tartrate Tablet 1 mg (Remove Step Therapy)
Tolterodine Tartrate Tablet 2 mg (Remove Step Therapy)
Trospium Chloride Tablet 20 mg (Remove Step Therapy)

January 2023

Additions:

None

Removals:

All Non OneTouch Delica and Delica Plus Lancets and Devices

Other Updates:

None

December 2022

Additions:

Benzoyl Peroxide Gel 2.5%

Removals:

Iodoquinol-Hydrocortisone Cream 1-1%

Other Updates:

Fingolimod Hydrochloride Capsule 0.5 mg (Base Equivalent)
Histex PD Drop 0.938 mg
Isotretinoin Capsule 10 mg
Isotretinoin Capsule 20 mg
Isotretinoin Capsule 30 mg
Isotretinoin Capsule 40 mg

November 2022

Additions:

Actimmune Injection 2 mu/0.5 (Prior Authorization Required)
Cromolyn Sodium Nasal Aerosol Solution 5.2 mg/Actuation (4%) (Added Quantity Level Limit)
Dextromethorphan Polistirex Extended-Release Suspension 30 mg/5 mL (Added Quantity Level Limit)
Dextromethorphan-Phenylephrine-Acetaminophen Capsule 10-5-325 mg (Added Quantity Level Limit)
Dimenhydrinate Tablet 50 mg (Added Quantity Level Limit)
Fexofenadine-Pseudoephedrine Tablet Extended Release 12-hour 60-120 mg (Added Quantity Level Limit)
Guaifenesin Tablet 200 mg
Guaifenesin Tablet 400 mg
Guaifenesin Tablet Extended Release 12-hour 1200 mg
Icosapent Capsule 0.5 gm (Prior Authorization Required, Quantity Level Limit)
Imbruvica Suspension 70 mg/mL (Prior Authorization Required, Quantity Level Limit)
Intron A Injection 10 mu (Prior Authorization Required)
Intron A Injection 18 mu (Prior Authorization Required)
Intron A Injection 50 mu (Prior Authorization Required)
Mineral Oil Heavy
Mineral Oil Light
Omeprazole Capsule Delayed Release 10 mg (Added Quantity Level Limit)
Orkambi Granules 75-94 mg (Prior Authorization Required)
Polyethylene Glycol-Propylene Glycol Preservative Free Ophthalmic Solution 0.4-0.3%
Polyvinyl Alcohol-Povidone Ophthalmic Solution 5-6 mg/mL (0.5-0.6%)
Pseudoephedrine Hydrochloride Tablet 30 mg
Pseudoephedrine-Guaifenesin Tablet Extended Release 12hr 60-600 mg
Refresh Ophthalmic Drops
Sodium Chloride Hypertonic Ophthalmic Ointment 5%
Sodium Fluoride Gel 1.1% (0.5% Fluoride)
White Petrolatum-Mineral Oil Ophthalmic Ointment

Removals:

Butalbital-Acetaminophen-Caffeine Capsule 50-300-40 mg
Butalbital-Acetaminophen-Caffeine Capsule 50-325-40 mg
Calcium Carbonate (Antacid) Chewable Tablet 420 mg
Dexamethasone Sodium Phosphate Preservative Free Injection 10 mg/mL
Dextromethorphan Hydrobromide Syrup 10 mg/5 mL
Divalproex Sodium Capsule Delayed Release Sprinkle 125 mg
Docusate Sodium Capsule 50 mg
Etodolac Tablet Extended Release 24-hour 400 mg
Etodolac Tablet Extended Release 24-hour 500 mg
Etodolac Tablet Extended Release 24-hour 600 mg
Fluphenazine Hydrochloride Oral Concentrate 5 mg/mL
Hepagam B Injection
Hycamtin Capsule 0.25 mg
Hycamtin Capsule 1 mg
Hyperhep B Injection
Ibuprofen-Diphenhydramine Citrate Tablet 200-38 mg
Iressa Tablet 250 mg
Lansoprazole Tablet Delayed Release Orally Disintegrating 15 mg
Lansoprazole Tablet Delayed Release Orally Disintegrating 30 mg
Levonorgestrel-Ethinyl Estradiol Tablet 0.1-0.02 mg (84) & Ethinyl Estradiol Tablet 0.01 mg (7)
Magnesium Oxide (Laxative) Tablet 500 mg
Magnesium Oxide Tablet 250 mg
Magnesium Oxide Tablet 420 mg
Menest Tablet 0.3 mg
Menest Tablet 0.625 mg
Menest Tablet 1.25 mg
Metamucil Powder Multihealth/Original
Mycophenolic Tablet 180mg Delayed Release
Mycophenolic Tablet 360mg Delayed Release
Nabi-Hb Injection
Nicotrol Inhaler 10 mg
Nicotrol Nasal Spray 4 x 10 mL
Nilutamide Tablet 150 mg
Nozin Nasal Kit Sanitize
Nozin Nasal Mis Sanitize
Olanzapine-Fluoxetine Hydrochloride Capsule 12-25 mg
Olanzapine-Fluoxetine Hydrochloride Capsule 12-50 mg
Olanzapine-Fluoxetine Hydrochloride Capsule 3-25 mg
Olanzapine-Fluoxetine Hydrochloride Capsule 6-25 mg
Olanzapine-Fluoxetine Hydrochloride Capsule 6-50 mg
Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 10 mg
Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 15 mg
Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 20 mg
Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 30 mg
Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 40 mg
Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 60 mg
Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 80 mg
Paroxetine Hydrochloride Oral Suspension 10 mg/5 mL (Base Equivalent)
Phenylephrine-Shark Liver Oil-Cocoa Butter Suppository 0.25-3-85.5%
Prednisolone Sodium Phosphate Orally Disintegrating Tablet 10 mg (Base Equivalent)
Prednisolone Sodium Phosphate Orally Disintegrating Tablet 15 mg (Base Equivalent)
Prednisolone Sodium Phosphate Orally Disintegrating Tablet 30 mg (Base Equivalent)
Prefest Tablet
Prilosec Powder 10 mg
Prilosec Powder 2.5 mg
Psyllium Powder 100%
Psyllium Powder 95%
Rufinamide Suspension 40 mg/mL
Sennosides Tablet 17.2 mg
Sodium Phosphates - Enema (Pediatric)
Somatuline Injection 120 mg/0.5 mL
Somatuline Injection 60 mg/0.2 mL
Somatuline Injection 90 mg/0.3 mL
Sucralfate Suspension 1 gm/10 mL
Zoladex Implant 10.8 mg
Zoladex Implant 3.6 mg
Zolinza Capsule 100 mg

Other Updates:

Aprepitant Capsule 125 mg (Added Quantity Level Limit)
Aprepitant Capsule 40 mg (Added Quantity Level Limit)
Artificial Tears Solution
Aspirin Suppository 300 mg
Atropine Sulfate Ophthalmic Ointment 1%
Codeine Sulfate Tablet 15 mg (Added Quantity Level Limit and Age Minimum)
Codeine Sulfate Tablet 60 mg (Added Quantity Level Limit and Age Minimum)
Dextromethorphan-Guaifenesin Tablet Extended Release 12-hour 60-1200 mg
Feverall Sup 325 mg
Hydromorphone Suppository 3 mg (Added Quantity Level Limit)
Lohist-Dextromethorphan Syrup 5-2-10 mg
Lubricant Drops Eye 0.6%
Lubricating Drops 0.5%
Tusnel C Syrup (Added Quantity Level Limit and Age Minimum)

October 2022

Additions:

None

Removals:

None

Other Updates:

Lenalidomide Capsule 2.5 mg
Lenalidomide Capsule 5 mg
Lenalidomide Capsule 10 mg
Lenalidomide Capsule 15 mg
Lenalidomide Capsule 20 mg
Lenalidomide Capsule 25 mg
Varenicline Tartrate Tablet 0.5 mg X 11 & Tablet 1 mg X 42 Pack

September 2022

Additions:

Phospho-Trin K500 Tablet

Removals:

Hypersal Nebulization Solution 3.5 %

Other Updates:

K-Phos Tablet 500 mg (Brand)

August 2022

Additions:

Bicillin L-A Suspension 2400000 Unit/4mL
Calamine Lotion (Quantity Level Limit)
Calamine-Zinc Oxide Lotion 8-8%
Doxycycline Monohydrate Tablet 100mg
Eplerenone Tablet 25 mg
Eplerenone Tablet 50 mg
Fenofibrate Tablet 145 mg
Fenofibrate Tablet 48 mg
Fluocinonide Cream 0.1%
Glucagon Emergency Solution Kit 1 mg/mL (Quantity Level Limit)
Hydrocortisone Acetate Ointment 1% (Quantity Level Limit)
Ivermectin Lotion 0.5% (Quantity Level Limit, Step Therapy)
Metronidazole Gel 1% (Quantity Level Limit, Step Therapy)
Olmesartan Medoxomil Tablet 20 mg (Quantity Level Limit)
Olmesartan Medoxomil Tablet 40 mg (Quantity Level Limit)
Olmesartan Medoxomil Tablet 5 mg (Quantity Level Limit)
Olopatadine Hydrochloride Ophthalmic Solution 0.2% (Over the Counter)
OneTouch Ultra 2 Kit with Device
OneTouch Verio Flex System Kit with Device
OneTouch Verio Reflect Kit with Device
Pataday Solution 0.7% Ophthalmic
Permethrin Liquid 1%
Selenium Sulfide Shampoo 1%
Symjepi Solution Prefilled Syringe 0.15 mg/0.3 mL (Quantity Level Limit)
Symjepi Solution Prefilled Syringe 0.3 mg/0.3 mL (Quantity Level Limit)
Tetrabenazine Tablet 12.5 mg (Prior Authorization Required, Quantity Level Limit)
Triamcinolone Acetonide Ointment 0.05% (Quantity Level Limit)
Triprolidine Hydrochloride Drops 0.938 mg/mL
Triprolidine Hydrochloride Liquid 0.625 mg/mL (Pediaclear PD Liquid)
Voriconazole Tablet 200 mg (Prior Authorization Required)
Voriconazole Tablet 50 mg (Prior Authorization Required)

Removals:

Adapalene Cream 0.1%
Amcinonide Ointment 0.1%
Amiodarone Hydrochloride Tablet 100 mg
Amiodarone Hydrochloride Tablet 400 mg
Amlodipine Besylate-Atorvastatin Calcium Tablet 10-10 mg
Amlodipine Besylate-Atorvastatin Calcium Tablet 10-20 mg
Amlodipine Besylate-Atorvastatin Calcium Tablet 10-40 mg
Amlodipine Besylate-Atorvastatin Calcium Tablet 10-80 mg
Amlodipine Besylate-Atorvastatin Calcium Tablet 2.5-10 mg
Amlodipine Besylate-Atorvastatin Calcium Tablet 2.5-20 mg
Amlodipine Besylate-Atorvastatin Calcium Tablet 2.5-40 mg
Amlodipine Besylate-Atorvastatin Calcium Tablet 5-10 mg
Amlodipine Besylate-Atorvastatin Calcium Tablet 5-20 mg
Amlodipine Besylate-Atorvastatin Calcium Tablet 5-40 mg
Amlodipine Besylate-Atorvastatin Calcium Tablet 5-80 mg
Amoxicillin & Potassium Clavulanate Tablet Extended Release 12-hour 1000-62.5 mg
Baraclude Solution 0.05 mg/mL
Benzoyl Peroxide Wash Liquid 2.5%
Capzasin-P Cream 0.035%
Carbinoxamine Maleate Solution 4 mg/5 mL
Carbinoxamine Maleate Tablet 4 mg
Cefaclor Capsule 250 mg
Cefaclor Capsule 500 mg
Cefpodoxime Proxetil For Suspension 100 mg/5 mL
Cefpodoxime Proxetil For Suspension 50 mg/5 mL
Clemastine Fumarate Tablet 12-Hour 1.34 mg
Colesevelam Hydrochloride Packet 3.75 gm
Diltiazem Hydrochloride Extended-Release Capsule Extended Release 12-Hour 60 mg
Diltiazem Hydrochloride Extended-Release Capsule Extended Release 12-Hour 90 mg
Diphenhydramine Dispersible Tablet 12.5 mg
Diphenhydramine Hydrochloride Tablet Chewable 12.5 mg
Doxycycline Monohydrate Capsule 150 mg
Erythromycin Ethylsuccinate for Suspension 200 mg/5 mL
Erythromycin Ethylsuccinate for Suspension 400 mg/5 mL
Fexofenadine Hydrochloride Childrens Suspension 30mg/5 mL
Flunisolide Nasal Spray 25 mcg/Actuation (0.025%)
Fluvastatin Sodium Tablet Extended Release 24-hour 80 mg (Base Equivalent)
Glucagen Hypokit Solution Reconstituted 1 mg
Isradipine Capsule 2.5 mg
Isradipine Capsule 5 mg
Lidocaine Hydrochloride Urethral/Mucosal Gel 2%
Lidocaine-Prilocaine Kit 2.5-2.5%
Memantine Hydrochloride Oral Solution 2 mg/mL
Memantine Hydrochloride Tablet 28 X 5 mg & 21 X 10 mg Titration Pack
Methazolamide Tablet 25 mg
Methazolamide Tablet 50 mg
Metronidazole Capsule 375 mg
Nicardipine Capsule 20 mg
Nicardipine Capsule 30 mg
Nitazoxanide Tablet 500 mg
OneTouch Kit Ultra Mini
OneTouch Solutions Starter Kit with Well Device
Perindopril Erbumine Tablet 2 mg
Perindopril Erbumine Tablet 4 mg
Perindopril Erbumine Tablet 8 mg
Propafenone Capsule Extended Release 12-Hour 325 mg
Propafenone Capsule Extended Release 12-Hour 425 mg
Propafenone Hydrochloride Extended-Release Capsule Extended Release 12-Hour 225 mg
Proxivol Gel 2%
Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4%
Rivastigmine Patch 24 Hour 13.3 mg/24 hour
Rivastigmine Patch 24 Hour 4.6 mg/24 hour
Rivastigmine Patch 24 Hour 9.5 mg/24 hour
Salicylic Acid Shampoo 6%
Santyl Ointment 250 unit/gm
Selenium Sulfide Shampoo 2.25%
Sulfacetamide Sodium Liquid Wash 10%
Vancomycin + Syrspen Sf Hydrochloride Oral Suspension 50 mg/mL (Compound Kit)
Vancomycin Hydrochloride for Intravenous Solution 1 gm (Base Equivalent)
Vancomycin Hydrochloride for Intravenous Solution 10 gm (Base Equivalent)
Vancomycin Hydrochloride for Intravenous Solution 5 gm (Base Equivalent)
Vancomycin Hydrochloride for Intravenous Solution 500 mg (Base Equivalent)
Vancomycin Hydrochloride Intravenous Solution 1250 mg/250 mL (Base Equivalent)
Vancomycin Hydrochloride Intravenous Solution 1750 mg/350 mL (Base Equivalent)
Vancomycin Hydrochloride Intravenous Solution 750 mg/150 mL (Base Equivalent)
Vemlidy Tablet 25 mg
Zafirlukast Tablet 10 mg
Zafirlukast Tablet 20 mg

Other Updates:

Acyclovir Capsule 200 mg (Removed Quantity Level Limit)
Acyclovir Tablet 400 mg (Removed Quantity Level Limit)
Acyclovir Tablet 800 mg (Removed Quantity Level Limit)
Austedo Tablet 12 mg (Added Quantity Level Limit)
Austedo Tablet 6 mg (Added Quantity Level Limit)
Austedo Tablet 9 mg (Added Quantity Level Limit)
Ceftriaxone Sodium for Injection 1 gm (Changed Quantity Level Limit)
Ceftriaxone Sodium for Injection 2 gm (Changed Quantity Level Limit)
Ceftriaxone Sodium for Injection 250 mg (Changed Quantity Level Limit)
Ceftriaxone Sodium for Injection 500 mg (Changed Quantity Level Limit)
Ezetimibe Tablet 10 mg (Removed Step Therapy)
Glucagon Emergency Kit 1 mg Injection (Changed Quantity Level Limit)
Gvoke Hypopen Solution Auto-Injector 0.5 mg/0.1 mL (Changed Quantity Level Limit)
Gvoke Hypopen Solution Auto-Injector 1 mg/0.2 mL (Changed Quantity Level Limit)
Gvoke PFS Solution Prefilled Syringe 0.5 mg/0.1 mL (Changed Quantity Level Limit)
Gvoke PFS Solution Prefilled Syringe 1 mg/0.2 mL (Changed Quantity Level Limit)
Olopatadine Hydrochloride Ophthalmic Solution 0.1% (Over the Counter) (Removed Step Therapy)
Omega-3-Acid Ethyl Esters Capsule 1 gm (Removed Step Therapy)
Valacyclovir Hydrochloride Tablet 1 gm (Removed Quantity Level Limit)
Valacyclovir Hydrochloride Tablet 500 mg (Removed Quantity Level Limit)

July 2022

Additions:

None

Removals:

None

Other Updates:

None

June 2022

Additions:

Epivir HBV Solution 5 mg/mL (Quantity Level Limit)
Gvoke Hypopen 1-Pack 0.5 mg/0.1 mL (Quantity Level Limit)
Gvoke PFS Prefilled Syringe Injection 1 mg/0.2 mL (Quantity Level Limit)
Lamivudine Tablet 100 mg (Quantity Level Limit)
Pregabalin Capsule 200 mg (Prior Authorization Required, Quantity Level Limit)

Removals:

None

Other Updates:

None

May 2022

Additions:

Ozempic (2 mg/Dose) 8 mg/3 mL (Quantity Level Limit, Step Therapy)
Triumeq PD Tablet 60-5-30 mg (Prior Authorization Required, Quantity Level Limit)

Removals:

None

Other Updates:

None

April 2022

Additions:

Descovy Tablet 120-15 mg (Prior Authorization Required, Quantity Level Limit)

Removals:

None

Other Updates:

None

March 2022

Additions:

Brimonidine Tartrate-Timolol Maleate Ophthalmic Solution 0.2-0.5% (Quantity Level Limit, Step Therapy)
Maraviroc Tablet 150 mg
Maraviroc Tablet 300 mg
Systane Gel Drop 0.4-0.3%

Removals:

Combigan Ophthalmic Solution 0.2-0.5%
Dry Eye Relief Drops 0.4-0.3%
Selzentry Tablet 150 mg
Selzentry Tablet 300 mg

Other Updates:

None

February 2022

Additions:

Dexcom G5 Mobile Receiver Kit (Prior Authorization Required, Quantity Level Limit)
Dexcom G5 Mobile Transmitter Kit (Prior Authorization Required, Quantity Level Limit)
Dexcom G5 Mobile/G4 Platinum Sensor Kit (Prior Authorization Required, Quantity Level Limit)
Dexcom G6 Receiver (Prior Authorization Required, Quantity Level Limit)
Dexcom G6 Sensor (Prior Authorization Required, Quantity Level Limit)
Dexcom G6 Transmitter (Prior Authorization Required, Quantity Level Limit)
Freestyle Libre 14 Day Reader Device (Prior Authorization Required, Quantity Level Limit)
Freestyle Libre 14 Day Sensor (Prior Authorization Required, Quantity Level Limit)
Freestyle Libre 2 Reader Device (Prior Authorization Required, Quantity Level Limit)
Freestyle Libre 2 Sensor (Prior Authorization Required, Quantity Level Limit)
Freestyle Libre Reader Device (Prior Authorization Required, Quantity Level Limit)
Freestyle Libre Sensor System (Prior Authorization Required, Quantity Level Limit)
Levocetirizine Tablet 5 mg (Quantity Level Limit)
Naloxone Nasal Liquid 4 mg/0.1 mL (generic)
Norditropin Flexpro Injection 10 mg/1.5 mL (Prior Authorization Required)
Norditropin Flexpro Injection 15 mg/1.5 mL (Prior Authorization Required)
Norditropin Flexpro Injection 30 mg/3 mL (Prior Authorization Required)
Norditropin Flexpro Injection 5 mg/1.5 mL (Prior Authorization Required)
Ziextenzo (Prior Authorization Required)

Removals:

Diphenhydramine Elixir 12.5 mg/5 mL
Estradiol Vaginal Cream 0.1 mg/gm
Felbamate Suspension 600 mg/5 mL
Felbamate Tablet 400 mg
Felbamate Tablet 600 mg
Megestrol Suspension 625 mg/5 mL
Omnitrope Injection 5.8 mg
Udenyca Injection 6 mg/0.6 mL

Other Updates:

Diphenhydramine Hydrochloride Liquid 12.5 mg/5 mL (Added Quantity Level Limit)
Eliquis Deep Vein Thrombosis/Pulmonary Embolism Starter Pack Tablet 5 mg (Removed Prior Authorization Required)
Eliquis Tablet 2.5 mg (Removed Prior Authorization Required)
Eliquis Tablet 5 mg (Removed Prior Authorization Required)
Promethazine Hydrochloride Syrup 6.25 mg/5 mL (Added Quantity Level Limit)
Xarelto 10 mg (Removed Prior Authorization Required)
Xarelto 15 mg (Removed Prior Authorization Required)
Xarelto 20 mg (Removed Prior Authorization Required)
Xarelto Starter Pack 15/20 mg (Removed Prior Authorization Required)

January 2022

Additions:

Etravirine Tablet 100 mg (Prior Authorization Required)
Etravirine Tablet 200 mg (Prior Authorization Required)
Gvoke Kit Solution 1 mg/0.2 mL (Quantity Level Limit)

Removals:

Intelence Tablet 100 mg
Intelence Tablet 200 mg

Other Updates:

None

December 2021

Additions:

Esomeprazole Tablet Delayed Release 20 mg
Everolimus Tablet 10 mg (Prior Authorization Required)
Insulin Glargine-YFGN Solution Vial 100 unit/mL
Insulin Glargine-YFGN Solution Pen-Injector 100 unit/mL
Lopinavir-Ritonavir Tablet 100-25 mg (Prior Authorization Required)
Lopinavir-Ritonavir Tablet 200-25 mg (Prior Authorization Required)
Mavyret Packet 50-20 mg (Prior Authorization Required)

Removals:

Afinitor Tablet 10 mg
Kaletra Tablet 100-25 mg
Kaletra Tablet 200-25 mg
Semglee Pen-Injector 100 unit/mL
Semglee Vial (Solution) 100 unit/mL

Other Updates:

None

November 2021

Additions:

None

Removals:

None

Other Updates:

None

October 2021

Additions:

Sunitinib Capsule 12.5 mg (Prior Authorization Required, Quantity Level Limit)
Sunitinib Capsule 25 mg (Prior Authorization Required, Quantity Level Limit)
Sunitinib Capsule 37.5 mg (Prior Authorization Required, Quantity Level Limit)
Sunitinib Capsule 50 mg (Prior Authorization Required, Quantity Level Limit)

Removals:

Sutent Capsule 12.5 mg (Brand)
Sutent Capsule 25 mg (Brand)
Sutent Capsule 37.5 mg (Brand)
Sutent Capsule 50 mg (Brand)

Other Updates:

None

September 2021

Additions:

None

Removals:

None

Other Updates:

None

August 2021

Additions:

Baqsimi Powder 3 mg/Dose (Quantity Level Limit)
Endari Powder 5 gm (Prior Authorization Required)
Inlyta Tablet 1 mg (Prior Authorization Required, Quantity Level Limit)
Inlyta Tablet 5 mg (Prior Authorization Required, Quantity Level Limit)
Nayzilam Spray 5 mg (Prior Authorization Required, Quantity Level Limit)
Pregabalin Capsule 100 mg (Prior Authorization Required, Quantity Level Limit)
Pregabalin Capsule 150 mg (Prior Authorization Required, Quantity Level Limit)
Pregabalin Capsule 225 mg (Prior Authorization Required, Quantity Level Limit)
Pregabalin Capsule 25 mg (Prior Authorization Required, Quantity Level Limit)
Pregabalin Capsule 300 mg (Prior Authorization Required, Quantity Level Limit)
Pregabalin Capsule 50 mg (Prior Authorization Required, Quantity Level Limit)
Pregabalin Capsule 75 mg (Prior Authorization Required, Quantity Level Limit)
Prolia Solution (Prior Authorization Required, Quantity Level Limit)
Semglee Injection 100-Unit Pen-Injector
Semglee Injection 100-Unit Vial Solution
Sofosbuvir-Velpatasvir Tablet 400-100 mg (Prior Authorization Required, Quantity Level Limit)

Removals:

Caffeine Citrate Powder
Ibrance Capsule 100 mg
Ibrance Capsule 125 mg
Ibrance Capsule 75 mg
Lidocaine-Hydrocortisone Acetate Cream 3-0.5%
Methoxsalen Rapid Capsule 10 mg
Nexavar Tablet 200 mg

Other Updates:

None

July 2021

Additions:

None

Removals:

None

Other Updates:

None

June 2021

Additions:

None

Removals:

Linzess Capsule 72 mcg
Linzess Capsule 145 mcg
Linzess Capsule 290 mcg

Other Updates:

Trulicity Injection 0.75 mg/0.5 mL (Added Quantity Level Limit)
Trulicity Injection 1.5 mg/0.5 mL (Added Quantity Level Limit)
Trulicity Injection 3 mg/0.5 mL (Added Quantity Level Limit)
Trulicity Injection 4.5 mg/0.5 mL (Added Quantity Level Limit)

May 2021

Additions:

None

Removals:

None

Other Updates:

None

April 2021

Additions:

Brinzolamide 1% Ophthalmic Suspension (Quantity Level Limit, Step Therapy)
Azopt 1% Ophthalmic Suspension

March 2021

Additions:

Bevespi Aerosphere 9-4.8 mcg (Quantity Level Limit)
Cequa Solution 0.09% Preservative Free (Prior Authorization Required)
Doxycycline Hyclate Capsule 100 mg
Doxycycline Hyclate Capsule 50 mg
Doxycycline Hyclate Tablet 100 mg
Esbriet Capsule 267 mg (Prior Authorization Required)
Esbriet Tablet 267 mg (Prior Authorization Required)
Esbriet Tablet 801 mg (Prior Authorization Required)
Fluticasone/Salmeterol Aerosol 100 mcg/50 mcg (Age Level Limit, Quantity Level Limit)
Hizentra Injection 1 gm/5 mL (Prior Authorization Required)
Hizentra Injection 2 gm/10 mL (Prior Authorization Required)
Hizentra Injection 2 gm/10 mL (Prior Authorization Required)
Hizentra Injection 4 gm/20 mL (Prior Authorization Required)
Hizentra Solution 20% (Prior Authorization Required)
Hizentra Vial 10 gm/50 mL (Prior Authorization Required)
Hizentra Vial 1 gm/5 mL (Prior Authorization Required)
Icosapent Capsule 1 gm (Prior Authorization Required, Quantity Level Limit)
Myleran Tablet 2 mg
Ocrevus Injection 300 mg/10 mL (Prior Authorization Required, Quantity Level Limit)
Potassium-Sodium Citrates & Citric Acid Solution 550-500-334 mg/5 mL
Privigen Injection 40 gm (Prior Authorization Required)
Rabeprazole Tablet 20 mg (Quantity Level Limit)
Sodium Citrate & Citric Acid Solution 500-334 mg/5 mL
Trulicity Injection 0.75 mg/0.5 mL (Step Therapy Required)
Trulicity Injection 1.5 mg/0.5 mL (Step Therapy Required)
Trulicity Injection 3 mg/0.5 mL (Step Therapy Required)
Trulicity Injection 4.5 mg/0.5 mL (Step Therapy Required)
Tukysa Tablet 150 mg (Prior Authorization Required)
Tukysa Tablet 50 mg (Prior Authorization Required)
Valtoco Liquid 15 mg (Quantity Level Limit)
Valtoco Liquid 20 mg (Quantity Level Limit)
Valtoco Spray 10 mg (Quantity Level Limit)
Valtoco Spray 5 mg (Quantity Level Limit)
Visco-3 Injection 25/2.5 mL (Prior Authorization Required)

Removals:

Anoro Ellipta Aerosolizer 62.5-25 mcg
Atrovent HFA Aerosol 17 mcg
Breo Ellipta Inhaler 100-25 mcg
Breo Ellipta Inhaler 200-25 mcg
Cefaclor for Suspension 125 mg/5 mL
Cefaclor for Suspension 250 mg/5 mL
Cefaclor for Suspension 375 mg/5 mL
Clarithromycin Tablet Extended Release 24-hour 500 mg
Combivent Aerosol 20 mcg-100 mcg
Diazepam Concentrate 5 mg/mL
Doxycycline Monohydrate Tablet 100 mg
Doxycycline Monohydrate Tablet 150 mg
Doxycycline Monohydrate Tablet 50 mg
Doxycycline Monohydrate Tablet 75 mg
Epogen Injection 10000 units/mL
Epogen Injection 2000 units/mL
Epogen Injection 20000 units/mL
Epogen Injection 3000 units/mL
Epogen Injection 4000 units/mL
Flebogamma Injection 10 gm/200 mL
Flebogamma Injection Dif 5%
Fulphila Injection 6 mg/0.6 mL
Hyalgan Injection 20 mg/2 mL
Hyoscyamine Drops 0.125 mg/mL
Janumet Tablet 50-1000 mg
Janumet Tablet 50-500 mg
Janumet Extended-Release Tablet 100-1000 mg
Janumet Extended-Release Tablet 50-1000 mg
Janumet Extended-Release Tablet 50-500 mg
Januvia Tablet 100 mg
Januvia Tablet 25 mg
Januvia Tablet 50 mg
Nivestym Injection 300 mcg/0.5 ml
Nivestym Injection 300 mcg
Nivestym Injection 480 mcg/0.8 ml
Nivestym Injection 480 mcg
Ofev Capsule 100 mg
Ofev Capsule 150 mg
Verzenio Tablet 100 mg
Verzenio Tablet 150 mg
Verzenio Tablet 200 mg
Verzenio Tablet 50 mg
Victoza Injection 18 mg/3 mL

Other Updates:

Albuterol Aerosol HFA (Added Quantity Level Limit)
Arnuity Ellipta Inhaler 100 mcg (Added Quantity Level Limit)
Arnuity Ellipta Inhaler 200 mcg (Added Quantity Level Limit)
Arnuity Ellipta Inhaler 50 mcg (Added Quantity Level Limit)
Azithromycin Suspension 100 mg/5 mL (Added Age Limit)
Azithromycin Suspension 200 mg/5 mL (Added Age Limit)
Cefadroxil Suspension 250 mg/5 mL (Added Age Limit)
Cefadroxil Suspension 500 mg/5 mL (Added Age Limit)
Cefdinir Suspension 125 mg/5 mL (Added Age Limit)
Cefdinir Suspension 250 mg/5 mL (Added Age Limit)
Cefpodoxime Proxetil Suspension 100 mg/5 mL (Added Age Limit)
Cefpodoxime Proxetil Suspension 50 mg/5 mL (Added Age Limit)
Cefprozil Suspension 125 mg/5 mL (Added Age Limit)
Cefprozil Suspension 250 mg/5 mL (Added Age Limit)
Cephalexin Suspension 125 mg/5 mL (Added Age Limit)
Cephalexin Suspension 250 mg/5 mL (Added Age Limit)
Clarithromycin Suspension 125 mg/5 mL (Added Age Limit)
Clarithromycin Suspension 250 mg/5 mL (Added Age Limit)
Extavia Injection 0.3 mg (Added Quantity Level Limit)
Gilenya Capsule 0.5 mg (Added Quantity Level Limit)
Glatiramer Injection 20 mg/mL (Added Quantity Level Limit)
Glatiramer Injection 40 mg/mL (Added Quantity Level Limit)
Juluca Tablet 50-25 mg (Added Prior Authorization)
Levalbuterol Aerosol 45 mcg/Actuation (Added Quantity Level Limit)
Levofloxacin Solution 25 mg/mL (Added Age Limit)
Neomycin-Polymyxin-Dexamethasone Ophthalmic Ointment 0.1% (Added Quantity Level Limit)
Ondansetron Tablet Dispersible 4 mg Oral (Added Quantity Level Limit)
Ondansetron Tablet Dispersible 8 mg Oral (Added Quantity Level Limit)
Phenylephrine Hydrochloride Ophthalmic Solution 2.5% (Added Quantity Level Limit)
Rebif Injection 22 mcg/0.5 mL (Added Quantity Level Limit)
Rebif Injection 44 mcg/0.5 mL (Added Quantity Level Limit)
Rebif Rebidose Injection 22 mcg/0.5 mL (Added Quantity Level Limit)
Rebif Rebidose Injection 44 mcg/0.5 mL (Added Quantity Level Limit)
Rebif Rebidose Injection Titration (Added Quantity Level Limit)
Rebif Titration Injection Pack (Added Quantity Level Limit)
Santyl Ointment 250 unit/gm (Added Quantity Level Limit)

February 2021

Additions:

None

Removals:

None

Other Updates:

None

January 2021

Additions:

Retacrit Injection 20000 units (Prior Authorization Required)

Removals:

None

Other Updates:

None

December 2020

Additions:

Trelegy Ellipta 200-62.5-25 mcg/Inhaler (Quality Level Limit, Step Therapy Required)

Removals:

None

Other Updates:

None

November 2020

Additions:

Dimethyl Fumarate Capsule 120 mg Delayed Release (Quantity Level Limit, Prior Authorization Required)
Dimethyl Fumarate Capsule 240 mg Delayed Release (Quantity Level Limit, Prior Authorization Required)
Dimethyl Fumarate Capsule Delayed Release Starter Pack 120 mg & 240 mg (Quantity Level Limit, Prior Authorization Required)
Emtricitabine Capsule 200 mg (Prior Authorization Required)

Removals:

Emtriva Capsule 200 mg
Tecfidera Capsule 120 mg Delayed Release
Tecfidera Capsule 240 mg Delayed Release
Tecfidera Capsule Delayed Release Starter Pack 120 mg & 240 mg

Other Updates:

None

October 2020

Additions:

Efavirenz-Lamivudine-Tenofovir Disoproxil Fumarate Tablet 400-300-300 mg
Efavirenz-Lamivudine-Tenofovir Disoproxil Fumarate Tablet 600-300-300 mg

Removals:

Symfi Lo Tablet 400-300-300 mg
Symfi Tablet 600-300-300 mg

Other Updates:

None

Septmeber 2020

Additions:

Abiraterone Tablet 250 mg (Prior Authorization Required)
Alecensa Capsule 150 mg (Prior Authorization Required)
Austedo Tablet 5 mg, 9 mg, 12 mg (Prior Authorization Required)
Budesonide Capsule 3 mg (Step Therapy Required, Quantity Level Limit)
Caprelsa Tablet 100 mg, 300 mg (Prior Authorization Required)
Cinacalcet Tablet 30 mg, 60 mg, 90 mg (Prior Authorization Required)
Cyclophosphamide Capsule 25 mg, 50 mg
Enbrel Injection 25 mg (Prior Authorization Required, Quantity Level Limit)
Erivedge Capsule 150 mg (Prior Authorization Required)
Gilotrif Tablet 20 mg, 30 mg, 40 mg (Prior Authorization Required)
Jakafi Tablet 5 mg, 10 mg, 15 mg, 20 mg, 25 mg (Prior Authorization Required)
Kalydeco Pak 25 mg, 50 mg, 75 mg (Prior Authorization Required)
Kalydeco Tablet 150 mg (Prior Authorization Required)
Lenvima Capsule 4 mg, 8 mg, 10 mg, 12 mg, 14 mg, 18 mg, 20 mg, 24 mg (Prior Authorization Required)
Linezolid Tablet 600 mg (Prior Authorization Required)
Mekinist Tablet 0.5 mg, 2 mg (Prior Authorization Required)
Ofev Capsule 100 mg, 150 mg (Prior Authorization Required)
Repatha Injection 140 mg/mL, 420 mg/3.5 mL (Prior Authorization Required)
Rydapt Capsule 25 mg (Prior Authorization Required)
Symdeko Tablet 50-75 mg, 100-150 mg (Prior Authorization Required)
Tafinlar Capsule 50 mg, 75 mg (Prior Authorization Required)
Venclexta Start Pack (Prior Authorization Required)
Venclexta Tablet 10 mg, 50 mg, 100 mg (Prior Authorization Required)
Xolair Injection 75 mg/0.5 mL, 150 mg/mL (Prior Authorization Required)
Zykadia Capsule 150 mg (Prior Authorization Required)

Removals:

None

Other Updates:

Soliris Injection 10 mg/mL (Prior Authorization Required)
Proton Pump Inhibitors (Quantity Level Limit)

August 2020

Additions:

Amitiza Capsule 8 mcg, 24 mcg (Prior Authorization Required, Quantity Level Limit)
Buprenorphine Weekly Patch 5 mcg, 7.5 mcg, 10 mcg, 15 mcg, 20 mcg (Prior Authorization Required, Quantity Level Limit)
Diclofenac Sodium Solution 1.5% (Step Therapy, Quantity Level Limit)
Ibrance Capsule 75 mg, 100 mg, 125 mg (Prior Authorization Required, Quantity Level Limit)
Lynparza Tablet 10 mg, 15 mg (Prior Authorization Required, Quantity Level Limit)
Omeprazole Over the Counter Tablet 20 mg (Generic)
Poly-Vi-Sol Solution 50 mg/mL
Solifenacin Succinate Tablet 5 mg, 10 mg (Step Therapy, Quantity Level Limit)
Symproic Tablet 0.2 mg (Prior Authorization Required, Quantity Level Limit)
Testosterone Transdermal Solution 30mg/Actuation (Prior Authorization Required, Quantity Level Limit)
Tivicay PD Tablet 5 mg (Diagnosis Confirmation Required, Age Limit)
Trelegy Ellipta (Step Therapy, Quantity Level Limit)
Tri-Vi-Sol Solution A/C/D

Removals:

Cimduo Tablet 300-300 mg
Fluocinolone Acetonide Solution 0.01%
Fluorouracil Cream 0.5%
Humulin 70/30
Humulin N
Humulin R
Kitabis Nebule Solution 300 mg/5 mL
Naproxen Sodium Tablet 275 mg
Nimodipine Capsule 30 mg
Prilosec Over the Counter Tablet 20 mg (Brand)
Targretin Gel 1%
Tolmetin Sodium Capsule 400 mg
Tolmetin Sodium Tablet 200 mg, 600 mg

Other Updates:

Adapalene Gel 0.1% (Removed Step Therapy from Prescription Product)
Athletes Foot (Miconazole Nitrate) Powder 2% (Quantity Level Limit)
Auryxia Tablet 210 mg (Step Therapy Required)
Betamethasone Dipropionate Augmented Cream 0.05% (Quantity Level Limit)
Betamethasone Dipropionate Cream 0.05% (Quantity Level Limit)
Betamethasone Dipropionate Lotion 0.05% (Quantity Level Limit)
Betamethasone Valerate Cream 0.1% (Quantity Level Limit)
Betamethasone Valerate Lotion 0.1% (Quantity Level Limit)
Betamethasone Valerate Ointment 0.1% (Quantity Level Limit)
Butenafine Hydrochloride Cream 1% (Quantity Level Limit)
Candesartan Cilexetil–Hydrochlorothiazide Tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg (Step Therapy Required)
Candesartan Cilexetil Tablet 4 mg, 8 mg, 16 mg, 32 mg (Step Therapy Required)
Ciclopirox Olamine Cream 0.77% (Quantity Level Limit)
Ciclopirox Olamine Suspension 0.77% (Quantity Level Limit)
Ciclopirox Shampoo 1% (Quantity Level Limit)
Ciclopirox Solution 8% (Quantity Level Limit)
Ciprofloxacin Hydrochloride Otic Solution 0.2% (Quantity Level Limit)
Clindamycin Phosphate Gel 1% (Quantity Level Limit)
Clindamycin Phosphate Lotion 1% (Quantity Level Limit)
Clindamycin Phosphate Solution 1% (Quantity Level Limit)
Clindamycin Phosphate Swab 1% (Quantity Level Limit)
Clotrimazole Cream 1% (Quantity Level Limit)
Clotrimazole Solution 1% (Quantity Level Limit)
Clotrimazole-Betamethasone Cream 1-0.05% (Quantity Level Limit)
Disulfiram Tablet 250 mg, 500 mg (Quantity Level Limit)
Ear Drops (Carbamide Peroxide) Otic Solution 6.5% (Quantity Level Limit)
Ery Pad (Erythromycin) 2% (Quantity Level Limit)
Erythromycin Gel 2% (Quantity Level Limit)
Erythromycin Solution 2% (Quantity Level Limit)
Flunisolide Nasal Solution 25 mcg/Actuation (Step Therapy Required)
Fluocinonide Cream 0.05% (Quantity Level Limit)
Fluocinonide Solution 0.05% (Quantity Level Limit)
Fluvastatin Sodium Capsule 20 mg, 40 mg (Step Therapy Required)
Hydrocortisone Cream 0.5%, 1%, 2.5% (Quantity Level Limit)
Hydrocortisone Lotion 1%, 2.5% (Quantity Level Limit)
Hydrocortisone Ointment 0.5%, 1%, 2.5% (Quantity Level Limit)
Hydrocortisone-Acetic Acid Otic Solution 1-2% (Quantity Level Limit)
Ketoconazole Cream 2% (Quantity Level Limit)
Ketoconazole Shampoo 2% (Quantity Level Limit)
Lidocaine Ointment 5% (Quantity Level Limit)
Linzess Capsule 72 mcg, 145 mcg, 290 mcg (Prior Authorization Required)
Liothyronine Sodium Tablet 25 mcg (Quantity Level Limit)
Miconazole Nitrate Aerosol Powder 2% (Quantity Level Limit)
Miconazole Nitrate Cream 2% (Quantity Level Limit)
Mometasone Furoate Cream 0.1% (Quantity Level Limit)
Mometasone Furoate Ointment 0.1% (Quantity Level Limit)
Mometasone Furoate Solution 0.1% (Quantity Level Limit)
Naltrexone Tablet 50mg (Quantity Level Limit)
Neomycin-Polymyxin-Hydrocortisone Otic Solution 1% (Quantity Level Limit)
Neomycin-Polymyxin-Hydrocortisone Otic Suspension 3.5 mg/mL-10000 unit/mL (Quantity Level Limit)
Nystatin Cream 100,000 units/gm (Quantity Level Limit)
Nystatin Ointment 100,000 units/gm (Quantity Level Limit)
Nystatin Powder 100,000 units/gm (Quantity Level Limit)
Ofloxacin Otic Solution 0.3% (Quantity Level Limit)
Permethrin Cream 5% (Quantity Level Limit)
Prednicarbate Ointment 0.1% (Quantity Level Limit)
Proton Pump Inhibitors (Quantity Level Limit)
Ropinirole Hydrochloride Extended-Release Tablet 2 mg, 4 mg, 8 mg, 6 mg, 12 mg (Step Therapy Required)
Scalp Relief Max Strength (Hydrocortisone 1%) Solution (Quantity Level Limit)
Stop Lice Maximum Strength (Pyrethrins-Piperonyl Butoxide) Liquid 0.33-4% (Quantity Level Limit)
Sulfacetamide Sodium (Acne) Lotion 10% (Quantity Level Limit)
Terbinafine Hydrochloride Cream 1% (Quantity Level Limit)
Testosterone Gel 1.62% (Prior Authorization Required, Quantity Level Limit)
Tolnaftate Cream 1% (Quantity Level Limit)
Triamcinolone Acetonide Cream 0.025%, 0.1%, 0.5% (Quantity Level Limit)
Triamcinolone Acetonide Lotion 0.0.25%, 0.1% (Quantity Level Limit)
Triamcinolone Acetonide Ointment 0.025%, 0.05% (Quantity Level Limit)

July 2020

Additions:

Gvoke PFS Pre Filled Syringe Injection 0.5 mg/0.1 mL (Quantity Level Limit)
HM Urinary Pain Relief (Phenazopyridine) Tablet 99.5 mg

June 2020

Additions:

Acne Medication Lotion (Benzoyl Peroxide) 10%
Alahist D Tablet
Atovaquone-Proguanil Tablet (Quantity Level Limit)
Claravis Capsule 10 mg, 20 mg, 30 mg, 40 mg (Step Therapy, Quantity Level Limit)
Dovato Tablet 50-300 mg (Diagnosis Confirmation Required, Quantity Level Limit)
Gvoke Hypopen Injection (Quantity Level Limit)
Isotretinoin Capsule 10 mg, 20 mg, 30 mg, 40 mg (Step Therapy, Quantity Level Limit)
Jock Itch/Athlete’s Foot Spray (Tolnaftate) Aerosol Powder 1% (Quantity Level Limit)
Phenazopyridine Tablet 95 mg
Primaquine Tablet 26.3 mg (Quantity Level Limit)
Tolnaftate Powder 1% (Quantity Level Limit)

Removals:

Clotrimazole Solution 1% - prescription (Removed Step Therapy)

May 2020

Additions:

Dexamethasone Concentrate Solution 1 mg/mL
Dexamethasone Vial 4 mg/mL, 10 mg/mL, 20 mg/5 mL, 120 mg/30 mL
Hydrocortisone Sodium Succinate PF Vials 100 mg, 250 mg, 500 mg, 1000 mg
Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4% (Quantity Level Limit)
Pyrimethamine Tablet 25 mg (Prior Authorization Required)

Removals:

Ala Scalp Lotion 2%
Daraprim Tablet 25 mg (Brand)

April 2020

Additions:

Aripiprazole Tablet 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg (Age Limit, Quantity Level Limit)
Budesonide-Formoterol Inhaler 80-4.5 mcg, 160-4.5 mcg (Quantity Level Limit)
Novolin R FlexPen 100 units/mL
Omeprazole Disintegrating Tablet 20 mg (Quantity Level Limit)
Orkambi Granules 100-125 mg, 200-125 mg (Prior Authorization Required)
Orkambi Tablet 100-125 mg, 200-125 mg (Prior Authorization Required)
Tramadol Tablet 100 mg (Quantity Level Limit)

Removals:

Carafate Suspension 1 gm/10 mL (Brand)

March 2020

Additions:

Mesalamine Capsule 0.375 gm
Penicillamine Tablet 250 mg (Prior Authorization Required, Quantity Level Limit)

Removals:

Apriso Capsule 0.375 gm (Brand)

Other Updates:

Prenatal Vitamin Tablet (Quantity Level Limit)

February 2020

Additions:

Bimatoprost Ophthalmic Solution 0.03% (Step Therapy Required)
Ethinyl Estradiol–Etonogestrel Ring 0.015 mg-0.12 mg (Quantity Level Limit)
Everolimus Tablet 2.5 mg, 5 mg, 7 mg (Prior Authorization Required)
Liletta Intrauterine Device 19.5 mcg/day

Removals:

Afinitor Tablet 2.5 mg, 5 mg, 7.5 mg (Brand)
Alprazolam Concentrate Solution 1 mg/mL
Chlorothiazide Tablet
Demeclocycline Tablet
Doxycycline Monohydrate Tablet 150 mg
First-Vanco Solution 25 mg/mL, 50 mg/mL
Homatropine Ophthalmic Solution 5%
Kyleena Intrauterine Device
Methyclothiazide Tablet 5 mg
Mirena Intrauterine Device
Nausea Relief Liquid
Nizatidine Solution 15 mg/mL
Nuvaring (Brand)
Phospholine Ophthalmic Solution 0.125%
Propantheline Capsule 15 mg
Rabeprazole Enteric Coated Capsule 20 mg
Ranitidine Capsule 150 mg, 300 mg
Skyla Intrauterine Device

Other Updates:

Atropine Ophthalmic Ointment 1% (Quantity Level Limit)
Atropine Ophthalmic Solution 1% (Quantity Level Limit)
Buspirone Tablet 5 mg, 7.5 mg, 10 mg, 15 mg (Age Limit)
Combigan Ophthalmic Solution 0.5/0.5% (Quantity Level Limit)
Diazepam Concentrate 5 mg/mL (Quantity Level Limit)
Diazepam Oral Solution (Quantity Level Limit)
Diazepam Tablet 2 mg, 5 mg, 10 mg (Quantity Level Limit)
Divalproex Extended-Release Tablet 250 mg, 500 mg (Prior Authorization Required)
Dorzolamide-Timolol Ophthalmic Solution 22.3-6.8% (Quantity Level Limit, Step Therapy Required)
Doxycycline Monohydrate Suspension 25 mg/5 mL (Age Limit)
Granisetron Tablet 1 mg (Step Therapy Required)
Hydroxyzine Pamoate Capsule 25 mg, 50 mg, 100 mg (Quantity Level Limit)
Hydroxyzine Tablet 50 mg (Quantity Level Limit)
Levofloxacin Ophthalmic Solution 0.5% (Quantity Level Limit)
Lorazepam Concentrate 2 mg/mL (Age Limit, Quantity Level Limit)
Memantine Tablet 5 mg, 10 mg (Quantity Level Limit)
Methazolamide Tablet 25 mg, 50 mg (Step Therapy Required)
Natacyn Ophthalmic Suspension 5% (Quantity Level Limit)
Tazarotene Cream 1% (Step Therapy Required)
Timolol Ophthalmic Gel Solution 0.25%, 0.5% (Quantity Level Limit)
Trifluridine Ophthalmic Solution 1% (Quantity Level Limit)

January 2020

Additions:

Buprenorphine-Naloxone Film 2-0.5 mg, 4-1 mg, 8-2 mg, 12-3 mg (Quantity Level Limit)

Removals:

Ventolin HFA Inhaler (Brand name)

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