Formulary search tool and updates

Stay up-to-date with your medicine. A formulary is a list of medicines we cover. We keep it up-to-date for you. And make it easy to manage your medicines and your loved ones’ medicines.

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January 2021

Additions:

Trelegy Aer Ellipta 200-62.5-25mcg
Retacrit Inj 20000u

Removals:

No updates

Other Updates:

No updates

December 2020

Additions:

No updates

Removals:

No updates

Other Updates:

No updates

November 2020

Additions:

DIMETHYL FUM CAP 120MG DR (Prior Authorization, Quantity Limit)
DIMETHYL FUM CAP 240MG DR (Prior Authorization, Quantity Limit)

Removals:

Tecfidera Cap 120mg DR
Tecfidera Cap 240mg DR

Other Updates:

No updates

October 2020

Additions:

Vancomycin Hcl Iv Soln 1250 Mg/250ml (Base Equivalent)
Vancomycin Hcl Iv Soln 1750 Mg/350ml (Base Equivalent)
Vancomycin Hcl Iv Soln 750 Mg/150ml (Base Equivalent)

Removals:

No updates

Other Updates:

No updates

September 2020

Additions:

Abiraterone Tab 250mg (Prior Authorization)
Alecensa Cap 150mg (Prior Authorization)
Austedo Tab 12mg (Prior Authorization)
Austedo Tab 6mg (Prior Authorization)
Austedo Tab 9mg (Prior Authorization)
Cyclophosph Cap 25mg (Prior Authorization)
Cyclophosph Cap 50mg (Prior Authorization)
Erivedge Cap 150mg (Prior Authorization)
Etanercept Subcutaneous Inj 25 Mg/0.5ml (Quantity Limit, Prior Authorization)
Gilotrif Tab 20mg (Prior Authorization)
Gilotrif Tab 30mg (Prior Authorization)
Gilotrif Tab 40mg (Prior Authorization)
Jakafi Tab 10mg (Prior Authorization)
Jakafi Tab 15mg (Prior Authorization)
Jakafi Tab 20mg (Prior Authorization)
Jakafi Tab 25mg (Prior Authorization)
Jakafi Tab 5mg (Prior Authorization)
Kalydeco Pak 25mg (Prior Authorization)
Kalydeco Pak 50mg (Prior Authorization)
Kalydeco Pak 75mg (Prior Authorization)
Kalydeco Tab 150mg (Prior Authorization)
Lenvima Cap 10 Mg (Prior Authorization)
Lenvima Cap 12mg (Prior Authorization)
Lenvima Cap 14 Mg (Prior Authorization)
Lenvima Cap 18 Mg (Prior Authorization)
Lenvima Cap 20 Mg (Prior Authorization)
Lenvima Cap 24 Mg (Prior Authorization)
Lenvima Cap 4mg (Prior Authorization)
Lenvima Cap 8 Mg (Prior Authorization)
Mekinist Tab 0.5mg (Prior Authorization)
Mekinist Tab 2mg (Prior Authorization)
Ofev Cap 100mg (Prior Authorization)
Ofev Cap 150mg (Prior Authorization)
Omeprazole Tab 20mg Dr
Repatha Inj 140mg/Ml (Prior Authorization)
Repatha Push Inj 420/3.5 (Prior Authorization)
Repatha Sure Inj 140mg/Ml (Prior Authorization)
Rydapt Cap 25mg (Prior Authorization)
Soliris Inj 10mg/Ml (Prior Authorization)
Symdeko Tab 100-150 (Prior Authorization)
Symdeko Tab 50-75mg (Prior Authorization)
Tafinlar Cap 50mg (Prior Authorization)
Tafinlar Cap 75mg (Prior Authorization)
Venclexta Tab 100mg (Prior Authorization)
Venclexta Tab 10mg (Prior Authorization)
Venclexta Tab 50mg (Prior Authorization)
Venclexta Tab Start Pk (Prior Authorization)
Xolair Inj 150mg/Ml (Prior Authorization)
Xolair Inj 75/0.5 (Prior Authorization)
Xolair Sol 150mg (Prior Authorization)
Zykadia Cap 150mg (Prior Authorization)

Removals:

Prilosec OTC Tab 20mg DR

Other Updates:

No updates

August 2020

Additions:

Diclofenac Sodium Soln 1.5% (Quantity Limit, Step Therapy)
Ibrance Cap 100mg (Quantity Limit, Prior Authorization)
Ibrance Cap 75mg (Quantity Limit, Prior Authorization)
Ibrance Tab 100mg (Quantity Limit, Prior Authorization)
Ibrance Tab 125mg (Quantity Limit, Prior Authorization)
Ibrance Tab 75mg (Quantity Limit, Prior Authorization)
Ibrance Cap 125mg (Quantity Limit, Prior Authorization)
Liothyronine Sodium Tab 25 Mcg (Quantity Limit)
Lubiprostone Cap 24 Mcg (Quantity Limit, Prior Authorization)
Lubiprostone Cap 8 Mcg (Quantity Limit, Prior Authorization)
Lynparza Tab 10 (Quantity Limit, Prior Authorization)
Lynparza Tab 15 (Quantity Limit, Prior Authorization)
Solifenacin Succinate Tab 10 Mg (Quantity Limit, Step Therapy)
Solifenacin Succinate Tab 5 Mg (Quantity Limit, Step Therapy)
Symproic Tab 0.2mg (Quantity Limit, Prior Authorization)
Testosterone Gel 1.62% (Quantity Limit, Prior Authorization)
Testosterone Td Soln 30 Mg/Act (Quantity Limit, Prior Authorization)
Tobramycin Nebu Soln 300 Mg/5ml (Quantity Limit, Prior Authorization)
Trelegy Aer Ellipta (Quantity Limit, Step Therapy)

Removals:

Aftera Tab 1.5mg
Econtra Ez Tab 1.5mg
Econtra Os Tab 1.5mg
Estradiol Td Patch Twice Weekly 0.025 Mg/24hr
Estradiol Td Patch Twice Weekly 0.0375 Mg/24hr
Estradiol Td Patch Twice Weekly 0.05 Mg/24hr
Estradiol Td Patch Twice Weekly 0.075 Mg/24hr
Estradiol Td Patch Twice Weekly 0.1 Mg/24hr
Estradiol Vg Vtb 10mcg
Fluocinolone Acetonide Solution 0.01%
Fluorouracil Cream 0.5%
Kitabis Nebu Soln 300 Mg/5ml
Levonorgestr Tab 1.5mg
My Choice Tab 1.5mg
My Way Tab 1.5mg
Naproxen Sodium Tab 275 Mg
New Day Tab 1.5mg
Nimodipine Cap 30 Mg
Opcicon Tab 1.5mg
Plan B Tab 1.5mg
React Tab 1.5mg
Take Action Tab 1.5mg
Targretin Gel 1%
Tolmetin Sodium Cap 400
Tolmetin Sodium Tab 200
Tolmetin Sodium Tab 600

Other Updates:

Betamethasone Dipropionate Augmented Cream 0.05% (Quantity Limit Added)
Betamethasone Dipropionate Cream 0.05% (Quantity Limit Added)
Betamethasone Dipropionate Lotion 0.05% (Quantity Limit Added)
Betamethasone Valerate Cream 0.1% (Quantity Limit Added)
Betamethasone Valerate Lotion 0.1% (Quantity Limit Added)
Betamethasone Valerate Oint 0.1% (Quantity Limit Added)
Butenafine Hcl Cream 1% (Quantity Limit Added)
Candesartan Cilexetil Tab 16 Mg (Step Therapy Added)
Candesartan Cilexetil Tab 32 Mg (Step Therapy Added)
Candesartan Cilexetil Tab 4 Mg (Step Therapy Added)
Candesartan Cilexetil Tab 8 Mg (Step Therapy Added)
Candesartan Cilexetil-Hydrochlorothiazide Tab 16-12.5 M (Step Therapy Added)
Candesartan Cilexetil-Hydrochlorothiazide Tab 32-12.5 M (Step Therapy Added)
Candesartan Cilexetil-Hydrochlorothiazide Tab 32-25 Mg (Step Therapy Added)
Carbamide Peroxide 6.5% Otic Soln (Quantity Limit Added)
Ciclopirox Olamine Cream 0.77% (Quantity Limit Added)
Ciclopirox Olamine Susp 0.77% (Quantity Limit Added)
Ciclopirox Shampoo 1% (Quantity Limit Added)
Ciclopirox Solution 8% (Quantity Limit Added)
Ciprofloxacin Hcl Otic Soln 0.2% (Base Equivalent) (Quantity Limit Added)
Clindamycin Phosphate Gel 1% (Quantity Limit Added)
Clindamycin Phosphate Lotion 1% (Quantity Limit Added)
Clindamycin Phosphate Soln 1% (Quantity Limit Added)
Clindamycin Phosphate Swab 1% (Quantity Limit Added)
Clotrimazole Cream 1% (Quantity Limit Added)
Clotrimazole Soln 1% (Quantity Limit Added)
Clotrimazole W/ Betamethasone Cream 1-0.05% (Quantity Limit Added)
Erythromycin Gel 2% (Quantity Limit Added)
Erythromycin Pads 2% (Quantity Limit Added)
Erythromycin Soln 2% (Quantity Limit Added)
Flunisolide Nasal Soln 25 Mcg/Act (0.025%) (Step Therapy Added)
Fluocinonide Cream 0.05% (Quantity Limit Added)
Fluocinonide Soln 0.05% (Quantity Limit Added)
Fluvastatin Sodium Cap 20 Mg (Step Therapy Added)
Fluvastatin Sodium Cap 40 Mg (Step Therapy Added)
Hydrocortisone Cream 0.5% (Quantity Limit Added)
Hydrocortisone Cream 1% (Quantity Limit Added)
Hydrocortisone Cream 2.5% (Quantity Limit Added)
Hydrocortisone Lotion 1% (Quantity Limit Added)
Hydrocortisone Lotion 2.5% (Quantity Limit Added)
Hydrocortisone Oint 0.5% (Quantity Limit Added)
Hydrocortisone Oint 1% (Quantity Limit Added)
Hydrocortisone Oint 2.5% (Quantity Limit Added)
Hydrocortisone Soln 1% (Quantity Limit Added)
Hydrocortisone W/ Acetic Acid Otic Soln 1-2% (Quantity Limit Added)
Ketoconazole Cream 2% (Quantity Limit Added)
Ketoconazole Shampoo 2% (Quantity Limit Added)
Lidocaine Oint 5% (Quantity Limit Updated)
Linaclotide Capsules 145 Mcg (Prior Authorization Added)
Linaclotide Capsules 290 Mcg (Prior Authorization Added)
Linaclotide Capsules 72 Mcg (Prior Authorization Added)
Miconazole Nitrate Aerosol Pow 2% (Quantity Limit Added)
Miconazole Nitrate Cream 2% (Quantity Limit Added)
Miconazole Nitrate Powder 2% (Quantity Limit Added)
Mometasone Furoate Cream 0.1% (Quantity Limit Added)
Mometasone Furoate Oint 0.1% (Quantity Limit Added)
Mometasone Furoate Solution 0.1% (Lotion) (Quantity Limit Added)
Neomycin-Polymyxin-Hc Otic Soln 1% (Quantity Limit Added)
Neomycin-Polymyxin-Hc Otic Susp 3.5 Mg/Ml-10000 Unit/Ml (Quantity Limit Added)
Nystatin Cream 100000 Unit/Gm (Quantity Limit Added)
Nystatin Oint 100000 Unit/Gm (Quantity Limit Added)
Nystatin Topical Powder 100000 Unit/Gm (Quantity Limit Added)
Ofloxacin Otic Soln 0.3% (Quantity Limit Added)
Permethrin Cream 5% (Quantity Limit Updated)
Permethrin Lotion 1% (Quantity Limit Updated)
Prednicarbate Oint 0.1% (Quantity Limit Added)
Pyrethrins-Piperonyl Butoxide Liq 0.33-4% (Quantity Limit Updated)
Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4% (Quantity Limit Updated)
Ropinirole Hydrochloride Tab Er 24hr 12 Mg (Step Therapy Added)
Ropinirole Hydrochloride Tab Er 24hr 2 Mg (Step Therapy Added)
Ropinirole Hydrochloride Tab Er 24hr 4 Mg (Step Therapy Added)
Ropinirole Hydrochloride Tab Er 24hr 6 Mg (Step Therapy Added)
Ropinirole Hydrochloride Tab Er 24hr 8 Mg (Step Therapy Added)
Sulfacetamide Sodium Lotion 10% (Acne) (Quantity Limit Added)
Terbinafine Hcl Cream 1% (Quantity Limit Added)
Tolnaftate Cream 1% (Quantity Limit Added)
Triamcinolone Acetonide Cream 0.025% (Quantity Limit Added)
Triamcinolone Acetonide Cream 0.1% (Quantity Limit Added)
Triamcinolone Acetonide Cream 0.5% (Quantity Limit Added)
Triamcinolone Acetonide Lotion 0.025% (Quantity Limit Added)
Triamcinolone Acetonide Lotion 0.1% (Quantity Limit Added)
Triamcinolone Acetonide Oint 0.025% (Quantity Limit Added)
Triamcinolone Acetonide Oint 0.5% (Quantity Limit Added)

July 2020

Additions:

Gvoke Pfs (Quantity Limit)

Removals:

Alli Cap 60mg
Videx Ec Cap 125mg
Videx Ped Pow 2gm
Videx Sol 4gm

June 2020

Additions:

Alahist D Tab
Atovaquone-Proguanil Tablets 250-100mg (Quantity Limit)
Atovaquone-Proguanil Tablets 62.5-25mg (Quantity Limit)
Benzoyl Peroxide Gel 2.5%
Benzoyl Peroxide Lotion 10%
Claravis Cap 10mg (Step Therapy, Quantity Limit)
Claravis Cap 20mg (Step Therapy, Quantity Limit)
Claravis Cap 30mg (Step Therapy, Quantity Limit)
Claravis Cap 40mg (Step Therapy)
Gvoke Hypopen Inj (Quantity Limit)
Isotretinoin Cap 10mg (Step Therapy, Quantity Limit)
Isotretinoin Cap 20mg (Step Therapy, Quantity Limit)
Isotretinoin Cap 30mg (Step Therapy, Quantity Limit)
Isotretinoin Cap 40mg (Step Therapy)
Phenazopyridine Tab 95 Mg
Primaquine Tablet 26.3 Mg (Quantity Limit)
Tolnaftate Aerosol 1% (Quantity Limit)
Tolnaftate Powder 1% (Quantity Limit)

Removals:

Myorisan Cap 10mg
Myorisan Cap 20mg
Myorisan Cap 30mg
Myorisan Cap 40mg
Zenatane Cap 10mg
Zenatane Cap 20mg
Zenatane Cap 30mg
Zenatane Cap 40mg

Other Updates:

Clotrimazole 1% solution (RX) (Step Therapy Removed)

May 2020

Additions:

Dexameth Pho Inj 20mg/5ml
Dexameth Pho Mdv 10mg/Ml
Dexameth Pho Via 120mg/30
Dexamethason Con 1mg/Ml
Dexamethason Via 10mg/Ml
Dexamethason Via 4mg/Ml
Hydrocortisone Sodium Succinate Pf For Inj 100 Mg
Hydrocortisone Sodium Succinate Pf For Inj 1000 Mg
Hydrocortisone Sodium Succinate Pf For Inj 250 Mg
Hydrocortisone Sodium Succinate Pf For Inj 500 Mg
Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4% (Quantity Limit)
Pyrimethamine Tab 25 Mg (Prior Authorization Required)

Removals:

Daraprim Tab 25 Mg
Sodium Chloride Flush Iv Soln 0.9%

April 2020

Additions:

Alcohol, Rubbing 70% (Quantity Limit)
Alcohol, Usp 70% (Quantity Limit)
Antiseptic Products Misc – Gel (Quantity Limit)
Antiseptic Products Misc - Solution
Budes/Formot Aer 160-4.5 (Quantity Limit)
Budes/Formot Aer 80-4.5 (Quantity Limit)
Ethyl Alcohol 60% Gel OTC (Quantity Limit)
Ethyl Alcohol 62% Foam OTC (Quantity Limit)
Ethyl Alcohol Gel 60% (Quantity Limit)
Ethyl Alcohol Gel 62% (Quantity Limit)
Ethyl Alcohol Gel 66.5% (Quantity Limit)
Ethyl Alcohol Gel 70% (Quantity Limit)
Ethyl Alcohol Liquid 62% (Quantity Limit)
Ethyl Alcohol Liquid 62% (Quantity Limit)
Ethyl Alcohol Liquid 70% (Quantity Limit)
Isopropyl Alcohol 70% Spray OTC (Quantity Limit)
Isopropyl Alcohol Spray 70% (Quantity Limit)
Novolin R Flexpen Inj 100 Unit
Omeprazole Tablet Delayed Release Disintegrating 20 Mg (Quantity Limit)
Orkambi Granules 100-125 Mg (Prior Authorization Required)
Orkambi Granules 200-125 Mg (Prior Authorization Required)
Orkambi Tab 100-125 Mg (Prior Authorization Required)
Orkambi Tab 200-125 Mg (Prior Authorization Required)
Tramadol Hcl Tab 100mg (Quantity Limit, Age Limit)

March 2020

Additions:

Gel-One Inj 30mg/3ml (Prior Authorization Required)
Hyalgan Inj 20mg/2ml (Prior Authorization Required)
Penicillamine Tab 250mg (Prior Authorization Required, Quantity Limit)

Removals:

Allevyn Ag Mis 6-3/4"
Allevyn Ag Pad 3"X3"
Allevyn Ag Pad 5"X5"
Allevyn Ag Pad 7"X7"
Arglaes Film Pad 3"X14"
Arglaes Film Pad 4.75"X10
Arglaes Pad Film
Artificial Dro 1% Tears
Fluoritab Dro 0.125mg
Johnsons Pow Baby
Maxorb Extra Pad Ag+
Prenata Chw 29-1mg
Prevident Sol Rinse
Restore Silv Pad 2"X2"
Restore Silv Pad 4"X4.75"
Tegaderm Ag Pad Alg 4x5
Tegaderm Ag Pad Alg 6x6
Tegaderm Ag Pad Alginate

February 2020

Additions:

Bimatoprost sol 0.03% (Step Therapy)

Removals:

Alprazolam Concentrate 1MG/ML Solution
Alprazolam ODT 0.25 MG
Alprazolam ODT 0.5 MG
Alprazolam ODT 1 MG
Alprazolam ODT 2 MG
Chlorothiazide Tabs 250 MG
Chlorothiazide Tabs 500 MG
Demeclocycline 150 MG Tablet
Demeclocycline 300 MG Tablet
Doxycycline Monohydrate Tab 150mg
Homatropine Opth Sol 5%
Kyleena
Meprobamate Tab 200 MG
Meprobamate Tab 400 MG
Methyclothiazide Tab 5MG
Mirena
Nausea Liquid Relief (fructose-dextrose-phosphoric acid)
Nizatidine Soln 15MG/ML
Phospholine (echothiophate iodide) opth solution 0.125%
Propantheline 15 MG CAP
Rabeprazole EC 20 MG Cap
Ranitidine Capsule 150 mg
Ranitidine Capsule 300 mg
Skyla

Other updates:

Atropine sul oin 1% op (Quantity Limit Added)
Atropine sul Sol 1% op (Quantity Limit Added)
Buspirone Tab 10mg (Age Limit Added)
Buspirone Tab 15mg (Age Limit Added)
Buspirone Tab 5mg (Age Limit Added)
Buspirone Tab 7.5mg (Age Limit Added)
Diazepam Oral Sol. (Quantity Limit Added)
Diazepam Tab 10 MG (Quantity Limit Added)
Diazepam Tab 2 MG (Quantity Limit Added)
Diazepam Tab 5 MG (Quantity Limit Added)
Divalproex ER 250 MG (Prior Authorization Added)
Divalproex ER 500 MG (Prior Authorization Added)
Dorzol/timol Sol 22.3-6.8 (Step Therapy Added)
Doxycycline monohydrate Susp 25mg/5ml (Age Limit Added)
Granisetron Tab 1mg (Step Therapy Added)
Hydroxyz hcl Syp 10mg/5ml (Quantity Limit Added)
Hydroxyz hcl Tab 50mg (Quantity Limit Added)
Hydroxyz pam Cap 100mg (Quantity Limit Added)
Hydroxyz pam Cap 25mg (Quantity Limit Added)
Hydroxyz pam Cap 50mg (Quantity Limit Added)
Ibandronate inj 3mg/3ml (Quantity Limit Added)
Levofloxacin Sol 0.5% (Quantity Limit Added)
Lorazepam Con 2mg/ml (Quantity Limit Added, Age Limit Added)
Memantine Tab hcl 10mg (Quantity Limit Added)
Memantine Tab hcl 5mg (Quantity Limit Added)
Methazolamide Tab 25 mg (Step Therapy Added)
Methazolamide Tab 50 mg (Step Therapy Added)
Natacyn Sus 5% op (Quantity Limit Added)
Tazarotene Cre 0.1% (Step Therapy Added)
Trifluridine Sol 1% op (Quantity Limit Added)

January 2020

No changes

December 2019

No changes

November 2019

Additions:

Heplisav Pfs 20 Mcg/0.5ml (Age Limit)
Methylergonovine 0.2 Mg Tab
Methylergonovine Inj 0.2 Mg/Ml
Penicillin G Procaine Im 600000iu/Ml
Rhopressa Soln 0.02%
Shingrix 50 Mcg/0.5ml (Age Limit)
Symlin Pen 60 Inj 1500mcg/1.5ml (Prior Authorization Required)
Thiamine Hcl Cap 50 Mg
Thiamine Hcl Elixir 2.25 Mg/5ml
Thiamine Hcl Tab 10 Mg
Thiamine Hcl Tab 100 Mg
Thiamine Hcl Tab 25 Mg
Thiamine Hcl Tab 250 Mg
Thiamine Hcl Tab 5 Mg
Thiamine Hcl Tab 50 Mg
Thiamine Hcl Tab 500 Mg
Thiamine Mononitrate Tab 100 Mg
Thiamine Mononitrate Tab 250 Mg
Thiamine Pyrophosphate Tab 20 Mg
Twinrix Pfs 720-20 Mcg/Ml (Age Limit)

October 2019

No changes

September 2019

Additions:

Ambrisentan Tab 10mg (Prior Authorization Required, Quantity Limit)
Ambrisentan Tab 5mg (Prior Authorization Required, Quantity Limit)
Bosentan Tab 125mg (Prior Authorization Required, Quantity Limit)
Bosentan Tab 62.5mg (Prior Authorization Required, Quantity Limit)
Febuxostat Tab 80mg (Step Therapy Required, Quantity Limit)
Febuxostat Tab 80mg (Step Therapy Required, Quantity Limit)

Removals:

Letairis Tab 10mg
Letairis Tab 5mg
Tracleer Tab 125mg
Tracleer Tab 62.5mg
Uloric Tab 40mg
Uloric Tab 80mg

August 2019

Additions:

Butenafine Hcl Cream 1%
Lidocaine Patch 4% (Quantity Limit)
Lorcaserin Hcl Tab Er 24hr 20mg (Prior Authorization Required, Quantity Limit)
Pegfilgrastim-Cbqv Soln Prefilled Syringe 6mg/0.6ml (Prior Authorization Required)
Pegfilgrastim-Jmdb Soln Prefilled Syringe 6mg/0.6ml (Prior Authorization Required)

Removals:

Butalbital-Acetaminophen-Caff W/ Cod Cap 50-300-40-30 Mg
Butalbital-Acetaminophen-Caffeine Cap 50-300-40 Mg
Butalbital-Acetaminophen-Caffeine Cap 50-325-40 Mg
Calcium Acetate (Phosphate Binder) Oral Soln 667 Mg/5ml
Ciclopirox Gel 0.77%
Clotrimazole W/ Betamethasone Lotion 1-0.05%
Colestipol Hcl Granule Packets 5 Gm
Colestipol Hcl Granules 5 Gm
Entecavir Oral Soln 0.05 Mg/Ml
Epinastine Hcl Ophth Soln 0.05%
Erythromycin Ethylsuccinate For Susp 200 Mg/5ml
Erythromycin Ethylsuccinate For Susp 400 Mg/5ml
Esterified Estrogens Tab 0.3 Mg
Esterified Estrogens Tab 0.625 Mg
Esterified Estrogens Tab 1.25 Mg
Estradiol Tab 1 Mg(15)/Estrad-Norgestimate Tab 1-0.09mg(15)
Etodolac Tab Er 24hr 400 Mg
Etodolac Tab Er 24hr 500 Mg
Etodolac Tab Er 24hr 600 Mg
Lindane Shampoo 1%
Moexipril Hcl Tab 15 Mg
Moexipril Hcl Tab 7.5 Mg
Olopatadine Hcl Ophth Soln 0.2%
Quinidine Gluconate Tab Er 324 Mg
Thyroid Tab 130 Mg
Vagifem Tab 10mcg

Other updates:

Anecream Cre 4% (Added Quantity Level Limit)
Armour Thyroid 180mg Tab (Quantity Level Limit)
Armour Thyroid 240mg Tab (Quantity Level Limit)
Armour Thyroid 300mg Tab (Quantity Level Limit)
Azelastine Hcl Ophth Soln 0.05% (Added Quantity Level Limit)
Betamethasone Dipropionate Oint 0.05% (Added Quantity Level Limit)
Calcipotriene Cream 0.005% (Added Prior Authorization Required, Quantity Limit)
Calcipotriene Oint 0.005% (Added Prior Authorization Required, Quantity Limit)
Calcipotriene Soln 0.005% (50 Mcg/Ml) (Added Prior Authorization Required, Quantity Limit)
Ciclopirox Olamine Cream 0.77% (Added Step Therapy)
Ciclopirox Olamine Susp 0.77% (Added Step Therapy)
Ciclopirox Shampoo 1% (Added Step Therapy)
Clotrimazole Soln 1% (Rx Only) (Added Step Therapy)
Estradiol Tab 10mcg (Quantity Level Limit)
Fluocinolone Acetonide Cream 0.025% (Added Quantity Level Limit)
Fluocinolone Acetonide Oint 0.025% (Added Quantity Level Limit)
Ketoconazole Cream 2% (Added Step Therapy, Quantity Limit)
Lc-4 Lidocne Cre 4% (Added Quantity Level Limit)
Lidocaine Cre 4% (Added Quantity Level Limit)
Lidocaine Hcl Gel 2% (Added Quantity Level Limit)
Lidocaine-Prilocaine Cream Kit 2.5-2.5%
Liothyronine Sodium Tab 5 Mcg (Added Quantity Level Limit)
Liothyronine Sodium Tab 50 Mcg (Added Quantity Level Limit)
Norethindrone Tab 0.35 Mg (Added Step Therapy)
Sertraline conc 20mg/mL (Added Age Limit)
Thyroid Tab 120 Mg (2 Grain) (Added Quantity Level Limit)
Thyroid Tab 15 Mg (1/4 Grain) (Added Quantity Level Limit)
Thyroid Tab 30 Mg (1/2 Grain) (Added Quantity Level Limit)
Thyroid Tab 60 Mg (1 Grain) (Added Quantity Level Limit)
Thyroid Tab 90 Mg (1 1/2 Grain) (Added Quantity Level Limit)

July 2019

Additions:

Mesalamine Cap 400mg (Quantity Limit)
Cefixime Cap 400mg (Quantity Limit)
Erlotinib Tab 25mg, 100mg, 150mg (Quantity Limit)

Removals:

Suprax Cap 400mg
Tarceva Tab 25mg, 100mg, 150mg

June 2019

Additions:

Docosanol Crm 10%
Insulin Lispro Pen Injector 100u/mL (Age Limit)
Insulin Lispro Sol 100u/mL

Removals:

Humalog Kwik Pen 100u/mL
Humalog Vial 100u/mL
Novolog Flex Pen 100u/mL
Novolog Sol 100u/mL

May 2019

Additions:

Nivestym Inj 300mcg (Prior Authorization Required)
Nivestym Inj 480mcg (Prior Authorization Required)
Erythromycin Sup 400/5mL
Sirolimus Sol 1mg/mL

Removals:

EryPed 400 Sus
Rapamune Sol 1mg/mL

April 2019

No changes

March 2019

Additions:

Albuterol Aer HFA (Quantity Level Limit)
Butalbital-Aspirin-Caffeine Tab 50-325-40mg (Quantity Level Limit)
Mesalamine Sup 1000mg
Methylpred Tab 4mg (Quantity Level Limit)
Nicotrol Inh
Nicotrol NS Spr 10mg/ml
Tolnaftate Cre 1%
Toremifene Tab 60mg
Vigabatrin Tab 500mg

Removals:

Canasa Suppository 1000mg
Fareston Tablet 60mg
Norethin Acet & Estrad-Fe (24)

Other updates:

Butalbital-Acetaminophen-Caffeine Cap 50-325-40mg (Decreased Quantity Level Limit)
Butalbital-Acetaminophen-Caffeine Tab 50-325-40mg (Decreased Quantity Level Limit)
Butalbital-Aspirin-Caffeine Cap 50-325-40mg (Decreased Quantity Level Limit)
Chantix (Removed Prior Authorization)

February 2019

Additions:

Arnuity Elpt 100mcg/Act
Arnuity Elpt 200mcg/Act
Arnuity Elpt 50mcg/Act
Calcipotrien Cre 0.005% (Quantity Level Limit)
Immune Globulin (Human) Iv Or Subcutaneous Soln 1 Gm/10ml (Prior Authorization Required)
Immune Globulin (Human) Iv Or Subcutaneous Soln 10 Gm/100ml (Prior Authorization Required)
Immune Globulin (Human) Iv Or Subcutaneous Soln 2.5 Gm/25ml (Prior Authorization Required)
Immune Globulin (Human) Iv Or Subcutaneous Soln 20 Gm/200ml (Prior Authorization Required)
Immune Globulin (Human) Iv Or Subcutaneous Soln 30 Gm/300ml (Prior Authorization Required)
Immune Globulin (Human) Iv Or Subcutaneous Soln 40 Gm/400ml (Prior Authorization Required)
Immune Globulin (Human) Iv Or Subcutaneous Soln 5 Gm/50ml
Immune Globulin (Human) Iv Soln 10 Gm/100ml (Prior Authorization Required)
Immune Globulin (Human) Iv Soln 20 Gm/200ml (Prior Authorization Required)
Immune Globulin (Human) Iv Soln 5 Gm/50ml (Prior Authorization Required)
Ozempic Inj (Quantity Level Limit, Step Therapy Required)
Ozempic Inj (Quantity Level Limit, Step Therapy Required)
Prenatal Mv & Min W/Fe Bisglyc-Fe Prot Succ-Fa-Ca-Omega 3 29-1-200-250mg Pack (Quantity Level Limit)
Prenatal Mv & Min W/Fe Fumarate-Fa-Dha 28-0.8-200mg Pack (Quantity Level Limit)
Prenatal Vit W/ Ferrous Fumarate-Folic Acid 27-0.8mg Tab (Quantity Level Limit)
Prenatal Vit W/ Ferrous Fumarate-Folic Acid 28-0.8mg Tab (Quantity Level Limit)
Prenatal Vit W/ Ferrous Fumarate-Folic Acid 29-1mg Tab (Quantity Level Limit)
Prenatal Without A Vit W/ Fe Fumarate-Folic Acid 29-1mg Chew Tab (Quantity Level Limit)
Prenatal Without A Vit W/ Fe Fum-Iron Polysacch Complex –Fa 130-92.4-1mg Cap (Quantity Level Limit)
Prenatal Without A Vit W/ Fe Fum-Iron Polysacch Complex –Fa 20-20-1.25mg Cap (Quantity Level Limit)
Segluromet 2.5-1000tab (Quantity Level Limit, Step Therapy Required)
Segluromet 2.5-500tab (Quantity Level Limit, Step Therapy Required)
Segluromet 7.5-1000 Tab (Quantity Level Limit, Step Therapy Required)
Segluromet 7.5-500 Tab (Quantity Level Limit, Step Therapy Required)
Steglatro 10mg Tab (Quantity Level Limit, Step Therapy Required)
Steglatro 5mg Tab (Quantity Level Limit, Step Therapy Required)
Victoza Inj (Quantity Level Limit, Step Therapy Required)
Eligard Kit 22.5mg (Prior Authorization Required)
Eligard Kit 30 Mg (Prior Authorization Required)
Eligard Kit 45 Mg (Prior Authorization Required)
Eligard Kit 7.5mg (Prior Authorization Required)
Leuprolide Acetate Kit 1mg/0.2ml (Prior Authorization Required)
Prenatal Vit W/ Docusate-Fe Fumarate-Folic Acid 29-1mg Tab (Quantity Level Limit)
Prenatal Vit W/ Fe Fum-Iron Polysacch Complex -Fa-Omega 3 53.5-38-1mg Cap (Quantity Level Limit)
Prenatal Vit W/ Ferrous Fumarate-Folic Acid 28-1mg Tab (Quantity Level Limit)
Prenatal Vit W/ Ferrous Fumarate-Folic Acid 29-1mg Chew Tab (Quantity Level Limit)
Prenatal Vit W/ Ferrous Fumarate-Folic Acid 60-1mg Tab (Quantity Level Limit)
Prenatal Vit W/ Iron Carbonyl-Folic Acid 29-1mg Tab (Quantity Level Limit)
Prenatal Without A Vit W/ Fe Fumarate-Folic Acid 106.5-1mg Cap (Quantity Level Limit)
Zoladex Imp 10.8mg (Prior Authorization Required)
Zoladex Imp 3.6mg (Prior Authorization Required)

Removals:

Alprazolam ODT
Cleocin Vag Ovu 100mg
Clorazepate Dipotassium Tab
Cortifoam Aer Rectal
Dihydroergotamine
Dulera Aer
Ergot/Caffen
Ergotamine
Fluticasone Propionate Aer Pow Ba 100 Mcg/Blister
Fluticasone Propionate Aer Pow Ba 250 Mcg/Blister
Fluticasone Propionate Aer Pow Ba 50 Mcg/Blister
Invokamet
Invokana Tab
Levonor/Ethi Tab Estradio
Lidocaine/Hc Kit 20x7gm
Lidocaine/Hc Kit 3%-1%
Meprobamate Tab
Miconazole 3 Sup 200mg
Neonatal Pls
Nitro-Bid 2% Packets
Penicillamine Cap 250 Mg
Pimecrolimus Cream 1%
Podofilox Gel 0.5%
Prenatal Mv & Min W/Fe Polysaccharide Complex-Fa-Dha 29-1mg & 250mg Pack
Prenatal Vit W/ Ferrous Fumarate-Folic Acid 65-1mg Tab
Prenatal Vit W/ Ferrous Fumarate-L Methylfolate-Folic Acid 27-0.6-0.4mg Tab
Prenatal Vit W/ Iron Polysaccharide Complex-Folic Acid 29-1 Chew Tab
Prenatal W/O Vit A W/ Fe Carbonyl-Fe Gluconate-Dss-Fa-Dha 27-1mg & 250mg Pack
Prenatal W/O Vit A W/ Fe Fumarate-Dss-Fa-Dha 27-1.25-300mg Cap
Prenatal Without A W/ Fe Fumarate-L Methylfolate-Fa-Dha 27-0.6-0.4-300mg Cap
Pulmicrt Flx
Qvar
Relenza Mis Diskhale
Synjardy
Terconazole Vaginal Suppos 80 Mg
Thalomid Cap
Triazolam Capsules
Tricare Tab Prenatal
Trimethobenzamide Hcl Cap 300 Mg
Trulicity Inj

January 2019

Additions:

None

Removals:

Ibalizumab-uiyk (Trogarzo) 200mg/1.33mL IV solution

December 2018

Additions:

Filgrastim-AAFI Soln Prefilled Syringe 300mcg/0.5ml (Prior Authorization Required)
Filgrastim-AAFI Soln Prefilled Syringe 480mcg/0.8ml (Prior Authorization Required)

Removals:

Tamiflu Caps

November 2018

Additions:

Abelcet Inj 5mg/ml (Prior Authorization required)
Acyclovir Na Inj 500mg (Prior Authorization required)
Acyclovir Na Inj 50mg/ml (Prior Authorization required)
Albendazole Tab 200mg
Ambisome Inj 50mg (Prior Authorization required)
Aminosyn 7% Inj /Lytes (Prior Authorization required)
Aminosyn II Inj 8.5/Lyte (Prior Authorization required)
Aminosyn II Inj 7% (Prior Authorization required)
Aminosyn II Inj 8.5% (Prior Authorization required)
Aminosyn M Inj 3.5% (Prior Authorization required)
Aminosyn-Rf Inj 5.2% (Prior Authorization required)
Ampicillin Inj 10gm (Prior Authorization required)
Ampicillin Inj 1gm (Prior Authorization required)
Ampicillin Inj 2gm (Prior Authorization required)
Amp-Sulbacta Inj 1.5gm (Prior Authorization required)
Amp-Sulbacta Inj 15gm (Prior Authorization required)
Amp-Sulbacta Inj 3gm (Prior Authorization required)
Ascor Sol 25000mg (Prior Authorization required)
Avelox Inj (Prior Authorization required)
Avycaz Inj 2-0.5gm (Prior Authorization required)
Azactam/Dex Inj 1gm (Prior Authorization required)
Azactam/Dex Inj 2gm (Prior Authorization required)
Bactocill Inj Dex 1gm (Prior Authorization required)
Bactocill Inj Dex 2gm (Prior Authorization required)
Baxdela Inj 300mg (Prior Authorization required)
Calcium Cl Inj 10% (Prior Authorization required)
Cancidas Inj 50mg (Prior Authorization required)
Cancidas Inj 70mg (Prior Authorization required)
Cefazln/NaCl Sol 3g/100ml (Prior Authorization required)
Cefazol/NaCl Inj 1gm/10ml (Prior Authorization required)
Cefazol/NaCl Sol 2gm/100 (Prior Authorization required)
Cefazol/NaCl Sol 2gm/10ml (Prior Authorization required)
Cefazol/NaCl Sol 2gm/50ml (Prior Authorization required)
Cefazolin Inj 1gm (Prior Authorization required)
Cefazolin Inj 1gm/10ml (Prior Authorization required)
Cefazolin Inj 1gm/50ml (Prior Authorization required)
Cefazolin Inj 2gm/20ml (Prior Authorization required)
Cefazolin Inj 2gm/50ml (Prior Authorization required)
Cefazolin Sol (Prior Authorization required)
Cefazoln Sod Sol 3gm/20ml (Prior Authorization required)
Cefepime Inj 1gm (Prior Authorization required)
Cefepime Inj 2gm (Prior Authorization required)
Cefoxitin Inj 1gm (Prior Authorization required)
Cefoxitin Inj 1gm (Prior Authorization required)
Cefoxitin Inj 2gm (Prior Authorization required)
Cefoxitin Inj 2gm (Prior Authorization required)
Ceftriaxone Inj 10gm (Prior Authorization required)
Ceftriaxone Inj 1gm (Prior Authorization required)
Ceftriaxone Inj 2gm (Prior Authorization required)
Cefuroxime Inj 1.5gm (Prior Authorization required)
Chloramphen Inj 1gm (Prior Authorization required)
Cidofovir Inj 75mg/ml (Prior Authorization required)
Ciprofloxacn Inj 200mg (Prior Authorization required)
Ciprofloxacn Inj 200mg (Prior Authorization required)
Ciprofloxacn Inj 400mg (Prior Authorization required)
Ciprofloxacn Inj 400mg (Prior Authorization required)
Claforan Inj 1gm (Prior Authorization required)
Claforan Inj 2gm (Prior Authorization required)
Cleocin Phos Inj 600/4ml (Prior Authorization required)
Cleocin Phos Inj 900/6ml (Prior Authorization required)
Cleocin/D5W Inj 300mg (Prior Authorization required)
Cleocin/D5W Inj 600mg (Prior Authorization required)
Cleocin/D5W Inj 900mg (Prior Authorization required)
Clindamycin Inj 300/2ml (Prior Authorization required)
Clindmyc/NaC Inj 300/50ml (Prior Authorization required)
Clindmyc/NaC Inj 600/50ml (Prior Authorization required)
Clindmyc/NaC Inj 900/50ml (Prior Authorization required)
Clinimix E Inj 2.75/D10 (Prior Authorization required)
Clinimix E Inj 2.75/D5W (Prior Authorization required)
Clinimix E Inj 4.25/D10 (Prior Authorization required)
Clinimix E Inj 4.25/D25 (Prior Authorization required)
Clinimix E Inj 4.25/D5W (Prior Authorization required)
Clinimix E Inj 5%/D15W (Prior Authorization required)
Clinimix E Inj 5%/D20W (Prior Authorization required)
Clinimix E Inj 5%/D25W (Prior Authorization required)
Clinimix Inj 2.75/D5W (Prior Authorization required)
Clinimix Inj 4.25/D10 (Prior Authorization required)
Clinimix Inj 4.25/D20W (Prior Authorization required)
Clinimix Inj 4.25/D25 (Prior Authorization required)
Clinimix Inj 4.25/D5W (Prior Authorization required)
Clinimix Inj 5%/D15W (Prior Authorization required)
Clinimix Inj 5%/D20W (Prior Authorization required)
Clinimix Inj 5%/D25W (Prior Authorization required)
Clinimix Sol 2.75% (Prior Authorization required)
Clinimix Sol 4.25% (Prior Authorization required)
Clinisol SF Inj 15% (Prior Authorization required)
Cresemba Inj 372mg (Prior Authorization required)
Cubicin Sol 500mg (Prior Authorization required)
Cupric Chlor Inj 0.4mg/ml (Prior Authorization required)
Cytogam Inj (Prior Authorization required)
Cytovene Inj 500mg (Prior Authorization required)
D10w/NaCl Inj 0.2%
D10W/NaCl Inj 0.225%
D10w/NaCl Inj 0.45%
D2.5w/NaCl Inj 0.45%
D5W/LR Inj
D5W/Lytes Inj #48
D5w/NaCl Inj 0.2%
D5W/NaCl Inj 0.225%
D5W/NaCl Inj 0.3%
D5w/NaCl Inj 0.33%
D5w/NaCl Inj 0.45%
D5w/NaCl Inj 0.9%
Dalvance Sol 500mg (Prior Authorization required)
Daptomycin Sol 350mg (Prior Authorization required)
Darzalex Sol (Prior Authorization required)
Dextrose Inj 10%
Dextrose Inj 20% (Prior Authorization required)
Dextrose Inj 25% (Prior Authorization required)
Dextrose Inj 30% (Prior Authorization required)
Dextrose Inj 40% (Prior Authorization required)
Dextrose Inj 5%
Dextrose Inj 50% (Prior Authorization required)
Dextrose Inj 70% (Prior Authorization required)
Docetaxel Inj (Prior Authorization required)
Doribax Inj 250mg (Prior Authorization required)
Doribax Inj 500mg (Prior Authorization required)
Doxorubicin Inj 2mg/ml (Prior Authorization required)
Doxy 100 Inj 100mg (Prior Authorization required)
Eraxis Inj 100mg (Prior Authorization required)
Eraxis Inj 50mg (Prior Authorization required)
Erythrocin Inj 500mg (Prior Authorization required)
Fluconazole/ Inj Dex 200 (Prior Authorization required)
Fluconazole/ Inj Dex 400 (Prior Authorization required)
Fluconazole/ Inj Nacl 100 (Prior Authorization required)
Fluconazole/ Inj Nacl 200 (Prior Authorization required)
Fluconazole/ Inj Nacl 400 (Prior Authorization required)
Fluticasone-Salmeterol Aer Powder Ba 113-14 Mcg/Act (Quantity Level Limit)
Fluticasone-Salmeterol Aer Powder Ba 232-14 Mcg/Act (Quantity Level Limit)
Fluticasone-Salmeterol Aer Powder Ba 55-14 Mcg/Act (Quantity Level Limit)
Fortaz Inj 1gm (Prior Authorization required)
Fortaz Inj 2gm (Prior Authorization required)
Foscavir Inj 24mg/ml (Prior Authorization required)
Freamine Hbc Inj 6.9% (Prior Authorization required)
Freamine III Inj 10% (Prior Authorization required)
Ganciclovir Inj 500/25 (Prior Authorization required)
Ganciclovir Inj 500mg (Prior Authorization required)
Gentam/NaCl Inj 0.9mg/ml (Prior Authorization required)
Gentam/NaCl Inj 1.4mg/ml (Prior Authorization required)
Gentam/NaCl Inj 100mg (Prior Authorization required)
Gentam/NaCl Inj 100mg (Prior Authorization required)
Gentam/NaCl Inj 60mg (Prior Authorization required)
Gentam/NaCl Inj 80mg (Prior Authorization required)
Gentam/NaCl Inj 80mg (Prior Authorization required)
Hepatamine Sol 8% (Prior Authorization required)
Herceptin Inj 150mg (Prior Authorization required)
Hyperlyte-Cr Inj
Infuvite Inj (Prior Authorization required)
Infuvite Inj Pediatri (Prior Authorization required)
Injectafer Inj 750/15ml (Prior Authorization required)
Intralipid Inj 20% (Prior Authorization required)
Intralipid Inj 30% (Prior Authorization required)
Invanz Inj 1gm (Prior Authorization required)
Ionosol-B/ Inj D5W
Ionosol-Mb Inj /D5W
Isolyte-P Inj /D5W
Isolyte-S Inj
Isolyte-S Inj Ph 7.4
Kabiven EMU (Prior Authorization required)
KCl/D5W/Lact Inj 20meq/L
KCl/D5W/Lact Inj 40meq/L
KCl/D5W/NaCl Inj .075/.45
KCl/D5W/NaCl Inj .15-.45%
KCl/D5W/NaCl Inj .15/.33%
KCl/D5W/NaCl Inj .224/.45
KCl/D5W/NaCl Inj 0.15/0.2
Kcl/D5W/Nacl Inj 0.15/0.2
KCl/D5W/NaCl Inj 0.15/0.9
KCl/D5W/NaCl Inj 0.3/0.45
KCl/D5W/NaCl Inj 0.3/0.9%
KCl/Lido/D5W Sol 20/100ml
KCl/Lidocain Inj NaCl
KCl/NaCl Inj 10/100ml
KCl/NaCl Inj 30/100ml
KCl/NaCl Inj 40/250ml
Lactated Rin Inj
Lartruvo Inj (Prior Authorization required)
L-Cysteine Inj 50mg/ml (Prior Authorization required)
Levoflox/D5W Inj 250/50ml (Prior Authorization required)
Levoflox/D5W Inj 500/100ml (Prior Authorization required)
Levoflox/D5W Inj 750/150ml (Prior Authorization required)
Levofloxacin Inj 25mg/ml (Prior Authorization required)
Linezolid Inj 2mg/ml (Prior Authorization required)
Liquilift Kit Trace (Prior Authorization required)
Maxipime Inj 1gm (Prior Authorization required)
Maxipime Inj 2gm (Prior Authorization required)
Merrem Inj 1gm (Prior Authorization required)
Merrem Inj 500mg (Prior Authorization required)
Metron/Nacl Inj 500mg (Prior Authorization required)
Metronidazol Inj 5mg/ml (Prior Authorization required)
Metronidazol Inj 5mg/ml (Prior Authorization required)
Minocin Inj 100mg (Prior Authorization required)
Moxifloxacin Inj (Prior Authorization required)
Multitrace-4 Inj (Prior Authorization required)
Multitrace-4 Inj Conc (Prior Authorization required)
Multitrace-4 Inj Neonatal (Prior Authorization required)
Multitrace-4 Inj Ped (Prior Authorization required)
Multitrace-5 Inj Conc (Prior Authorization required)
Multitrace-5 Inj Regular (Prior Authorization required)
Mycamine Inj 100mg (Prior Authorization required)
Mycamine Inj 50mg (Prior Authorization required)
Nafcillin Inj 10gm (Prior Authorization required)
Nafcillin Inj 1gm (Prior Authorization required)
Nafcillin Inj 1gm/50ml (Prior Authorization required)
Nafcillin Inj 2gm (Prior Authorization required)
Nafcillin Inj 2gm/100 (Prior Authorization required)
Nephramine Inj 5.4% (Prior Authorization required)
Norml Saline Inj Flush
Normosol -M Inj /D5W
Normosol -R Inj
Normosol -R Inj /D5W
Normosol-R Inj Ph 7.4
Noxafil Inj 300/16.7 (Prior Authorization required)
Nutrilyte Inj
Opdivo Inj (Prior Authorization required)
Oral Electrolyte Sol
Orbactiv Sol 400mg (Prior Authorization required)
Penicill Gk/ Inj Dex 1MU (Prior Authorization required)
Penicill Gk/ Inj Dex 2MU (Prior Authorization required)
Penicill Gk/ Inj Dex 3MU (Prior Authorization required)
Perikabiven EMU (Prior Authorization required)
Piper/Tazoba Inj 12-1.5gm (Prior Authorization required)
Plasma-Lyte Inj -148
Plasma-Lyte Inj -A
Plasma-Lyte Inj 56/D5W
Pot Chl/D5W Inj 20meq/L
Pot Chl/D5W Inj 40meq/L
Pot Chl/NaCl Inj 20meq/L
Pot Chl/NaCl Inj 20meq/L
Pot Chl/NaCl Inj 40meq/L
Potassium Ch Inj NaCl
Potassium Ch Inj NaCl
Prevymis Inj 240/12 (Prior Authorization required)
Prevymis Inj 480/24 (Prior Authorization required)
Primaxin IV Inj 250mg (Prior Authorization required)
Primaxin IV Inj 500mg (Prior Authorization required)
Procalamine Inj 3% (Prior Authorization required)
Proparacaine Sol 0.5% Op
Prosol Inj 20% (Prior Authorization required)
Rapivab Inj 200mg/20 (Prior Authorization required)
Retrovir Inj 10mg/ml (Prior Authorization required)
Rifadin Inj 600 mg (Prior Authorization required)
Ringers Inj
Rituxan Inj 500mg (Prior Authorization required)
Selenium Inj 40mcg/ml (Prior Authorization required)
Sensipar Tab
Sivextro Inj 200mg (Prior Authorization required)
Smoflipid EMU (Prior Authorization required)
SMZ-TMP Inj 400-80/5 (Prior Authorization required)
Sod Acetate Inj 2meq/ml (Prior Authorization required)
Sod Acetate Inj 4meq/ml (Prior Authorization required)
Sod Chloride Inj 0.45%
Sod Chloride Inj 0.9%
Sod Chloride Inj 23.4%
Sod Chloride Inj 3%
Sod Chloride Inj 5%
Sod Cit-Gent Inj 4%-320 (Prior Authorization required)
Steril Water Inj
Sterile Dilu Sol Flolan
Synercid Inj 500mg (Prior Authorization required)
Tazicef Inj 1gm (Prior Authorization required)
Tazicef Inj 1gm/50ml (Prior Authorization required)
Tazicef Inj 2gm (Prior Authorization required)
Teflaro Inj 400mg (Prior Authorization required)
Teflaro Inj 600mg (Prior Authorization required)
Trace Elem 4 Inj Ped (Prior Authorization required)
Trogarzo Inj 150mg/ml (Prior Authorization required)
Trophamine Inj 6% (Prior Authorization required)
Tygacil Inj 50mg (Prior Authorization required)
Vabomere Inj 2gm(1-1) (Prior Authorization required)
Vancomycin Inj 1000mg (Prior Authorization required)
Vancomycin Inj 100gm (Prior Authorization required)
Vancomycin Inj 10gm (Prior Authorization required)
Vancomycin Inj 1gm (Prior Authorization required)
Vancomycin Inj 500mg (Prior Authorization required)
Vancomycin Inj 500mg (Prior Authorization required)
Vancomycin Inj 5gm (Prior Authorization required)
Vancomycin Inj 750mg (Prior Authorization required)
Vancomycin Inj 750mg (Prior Authorization required)
Venofer Inj 20mg/ml (Prior Authorization required)
Vfend IV Inj 200mg (Prior Authorization required)
Vibativ Inj 250mg (Prior Authorization required)
Vibativ Inj 750mg (Prior Authorization required)
Vincristine Inj 1mg/ml (Prior Authorization required)
Zemdri Inj 500mg/10 (Prior Authorization required)
Zerbaxa Inj 1.5gm (Prior Authorization required)
Zinacef Inj 750mg (Prior Authorization required)
Zithromax Inj 500mg (Prior Authorization required)
Zosyn Inj 2-0.25gm (Prior Authorization required)
Zosyn Inj 3-0.375g (Prior Authorization required)
Zosyn Inj 36-4.5gm (Prior Authorization required)
Zosyn Inj 4-0.5gm (Prior Authorization required)
Zosyn Sol 2-0.25gm (Prior Authorization required)
Zosyn Sol 3-0.375g (Prior Authorization required)
Zosyn Sol 4-0.50gm (Prior Authorization required)
Zyvox Sol 2mg/ml (Prior Authorization required)
Zyvox Sol 2mg/ml (Prior Authorization required)

Removals:

Albenza Tab 200mg

October 2018

Additions:

Loratadine Chw 5mg Tab (Quantity Level Limit)
Prasugrel Tab 10mg (Quantity Level Limit)
Prasugrel Tab 5mg (Quantity Level Limit)
Tadalafil 20mg (PAH) (Quantity Level Limit)
Tazarotene Cre 0.1% (Quantity Level Limit)
Tizanidine HCl Tab 2mg (Quantity Level Limit)
Tizanidine HCl Tab 4mg (Quantity Level Limit)
Tymlos Pen 3120mcg (Prior Authorization Required, Quantity Level Limit)
Valganciclov Tab 450mg (Quantity Level Limit)

Removals:

Adcirca Tab 20mg

Other updates:

Ondansetron HCl Tab 4mg (Increased Quantity Level Limit)
Ondansetron HCl Tab 8mg (Increased Quantity Level Limit)

September 2018

Additions:

Humira Pen Kit CD/UC/HS Starter Kit 80mg/0.8ml (Prior Authorization Required, Quantity Level Limit)
Humira Pen 80mg/ml and 40mg/0.4ml Kit PS/UV Starter Kit (Prior Authorization Required, Quantity Level Limit)

August 2018

Additions:

Epoetin Alfa-Epbx Inj (Prior Authorization Required)
Hydroxyprogesterone Inj 250mg/ml
Ibuprofen Tab 100mg Jr
Omega-3-Acid Cap 1gm (Quantity Level Limit, Step Therapy Required)
Sevelamer Tab 800mg (Step Therapy Required)
Telmisartan Tab (Quantity Level Limit)
Tolterodine Cap ER (Quantity Level Limit, Step Therapy Required)
Verzenio Tab (Prior Authorization Required, Quantity Level Limit)

Removals:

Amlodipine-Valsartan-Hydrochlorothiazide
Benzonatate Cap 150mg
Betaxolol
Captopril Tab
Captopril-Hydrochlorothiazide
Chlorpropamide
Climara Pro Patch Weekly
Desipramine
Diltiazem CD Cap 360/24hr
Femring
Fenofibrate Tab 145mg
Fenofibrate Tab 48mg
Fenofibric Cap DR
Fenoprofen Tab 600mg
Lidocaine Cre 3%
Makena Oil 250mg/ml
Meclofenamate Sod Cap
Methyltestos Cap 10mg
Nadolol
Nisoldipine Tab ER
Ondansetron Sol 4mg/5ml
Oxaprozin Tab 600mg
Oxytrol Patch
Pindolol
Pioglitazone-Glimepiride
Pioglitazone-Metformin
Potassium/Sodium Citrates & Citric Acid
Premarin Tabs
Premarin Vag Cre 0.625mg
Prempro And Premphase Tabs
Protriptyline
Tolazamide
Tolbutamide 500mg Tab
Verapamil Extended Release 24 Hour Cap 200mg
Verapamil Extended Release 24 Hour Cap 300mg

Other updates:

Amlodipine Besylate Tab 2.5mg, 5mg (Increased Quantity Level Limit)
Baraclude Sol .05mg/ml (Added Quantity Level Limit)
Benazepril Tab 5mg, 10mg, 20mg (Quantity Level Limit Increased)
Benzonatate Cap 100mg, 200mg (Added Age Limit, Added Quantity Level Limit)
Bupropion SR (Removed Prior Authorization)
Clonidine-TTS Dis (Added Step Therapy)
Diclofenac Gel 1% (Removed Prior Authorization, Added Quantity Level Limit)
Diltiazem CD Capsule Extended Release 24 Hour 180mg (Increased Quantity Level Limit)
Diltiazem HCl ER Capsule Extended Release 24hr 180mg Oral (Increased Quantity Level Limit)
Diltiazem HCl ER Beads Capsule Extended Release 24 Hour 180mg (Increased Quantity Level Limit)
Elmiron Cap 100mg (Added Prior Authorization)
Enalapril Tab 2.5mg, 5mg, 10mg (Increased Quantity Level Limit)
Estradiol Vag Cre 0.01% (Added Prior Authorization)
Flunisolide Nasal Soln 25mcg/Act (0.025%) (Added Quantity Level Limit)
Fosinopril Tab 10mg, 20mg (Increased Quantity Level Limit)
Griseofulvin Sus 125/5ml (Added Step Therapy)
Griseofulvin Tab Micr 500mg (Added Step Therapy)
Griseofulvin Tab Ultr (Added Step Therapy)
Hydrocodone W/ Homatropine Syrup, Tablet (Added Age Limit, Added Quantity Level Limit)
Lidocaine 5% Ointment (Added Prior Authorization)
Lisinopril Tab 2.5mg, 5mg, 10mg, 20mg, 30mg (Increased Quantity Level Limit)
Losartan Potassium Tab 25mg, 50mg (Increased Quantity Level Limit)
Mometasone Furoate Nasal Susp 50mcg/ACT (Added Quantity Level Limit)
Oxybutynin ER 15mg Tablet (Increased Quantity Level Limit)
Oxybutynin IR 5mg Tablet (Increased Quantity Level Limit)
Oxybutynin Syrup (Added Quantity Level Limit)
Propranolol Cap 80mg ER (Decreased Quantity Level Limit)
Quinapril Tab 5mg, 10mg, 20mg (Increased Quantity Level Limit)
Ramipril Cap 1.25mg, 2.5mg, 5mg (Increased Quantity Level Limit)
Tolterodine Tab (Added Step Therapy)
Verapamil HCl ER Tablet Extended Release 120mg (Increased Quantity Level Limit)

July 2018

Additions:

Baclofen Tab 5 Mg (Quantity Level Limit)
Diphenhydramine Liq 6.25mg
Pediatric Multiple Vitamins W/ Iron Drops 11 Mg/Ml
Phytonadione Tab 5mg
Zenpep Cap 15000 Unit
Zenpep Cap 3000 Unit

Removals:

Mephyton Tab 5mg

June 2018

Additions:

Humira Pedia Inj Crohns Prefilled Syringe Kit 80mg/0.8ml & 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
Humira Pedia Inj Crohns Prefilled Syringe Kit 80mg/0.8ml (Prior Authorization Required, Quantity Level Limit)
Humira Pen-injector kit 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
Humira Prefilled Syringe Kit 10mg/0.1ml, 20mg/0.2ml, 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
Polyethylene Glycol 3350 Powder (Quantity Level Limit)
Praziqueantel Tab 600mg
Tasigna 50mg (Prior Authorization Required, Quantity Level Limit)
Zenpep 10000 Unit

Removals:

Biltricide Tab 600mg

May 2018

Additions:

Colchicine Cap 0.6mg (Quantity Level Limit)
Firvanq Sol 25mg/Ml; 50mg/Ml
Flovent Hfa 44mcg , 110mcg, 220mcg (Quantity Level Limit)
Imbruvica Cap 70mg (Quantity Level Limit)
Jardiance Tablet (Quantity Level Limit, Step Therapy Required)
Synjardy Tablet & Synjardy Xr 5mg/1000mg; 12.5mg/1000mg; 10mg/1000mg; 25mg/1000mg (Quantity Level Limit, Step Therapy Required)

Other updates:

Rosuvastatin Tablets (Remove Prior Authorization, Added Step Therapy)

April 2018

Additions:

Zenpep Cap 5000-17000-24000 UNIT; 25000-79000-105000 UNIT

March 2018

No formulary updates

February 2018

Additions:

Armodafanil 50, 150, 200, 250 mg tablets (Prior Authorization Required, Quantity Level Limit)
Estradiol Cre 0.01%
Janumet 50-1000 MG, 50-500 MG (Quantity Level Limit, Step Therapy Required)
Janumet XR ER 24HR 50-1000 MG, 50-500 MG, 00-1000 MG (Quantity Level Limit, Step Therapy Required)
Januvia 100 MG, 25 MG, 50 MG (Quantity Level Limit, Step Therapy Required)
Qvar Rediha Aer 40MCG, 80MCG (Quantity Level Limit)
Sprycel tablets, all strengths (Prior Authorization Required, Quantity Level Limit)
Tamiflu 30 mg, 45mg, 75mg (Quantity Level Limit)

Removals:

Betoptic-S susp 0.25%
Brimonidine 0.15% ophth soln
Cefaclor ER tablets 500 mg; Use Cefaclor IR
Cefixime Suspension, all strengths
Cephalexin tablets, all strengths; Use capsules
Ciloxan ointment 0.3%
Ciprofloxacin ER tablets, all strengths; Use ciprofloxacin IR
Estrace Cream 0.01%
FML Forte 0.25%
Fondaparinux, all strengths
Fragmin, all strengths
Gatifloxacin solution 0.5%
Jentadueto 2.5/1000 mg, 2.5/850 mg, 2.5/500 mg tablets
Jentadueto XR 2.5-1000 MG, 5-1000 MG
Modafinil tablets 100 MG, 200 MG
Morphine ER Capsule (generic Kadian), all strengths
Moxifloxacin Solution 0.5%
Neomycin/polymixin/HC Susp
Ofloxacin tablets, all strengths
Oxycodone 5mg CAPSULE, Use tablets
Oxycodone concentrated solution (20mg/mL)
Oxycontin, all strengths
Oxymorphone IR tablets, all strengths
Pen needles; Use BD brand
Pred Mild 0.12%
Suprax chew tablets, all strengths
Tobradex Ointment 0.3-0.1%
Tobradex ST Suspension 0.3-0.05%
Tobramycin/dexamethasone Suspension 0.3-0.1%
Tobrex Ointment 0.3%
Tradjenta 5mg

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