You can find the latest changes to the Medicaid PDL on the Florida Agency for Health Care Administration (AHCA) website. Just look for the document called “Changes Summary Report.”

December 2023

Additions:

• OneTouch delica plus 30g lancet
• OneTouch delica plus 33g lancet
• OneTouch delica plus lancing
• OneTouch delica safety lancing
• OneTouch ultra 2 kit with device
• OneTouch verio flex system kit with device
• OneTouch verio in vitro strip
• OneTouch verio reflect kit with device

Removals:

• N/A

Other Updates:

• N/A

November 2023

Additions:

• Dayvigo 5 mg tablet (Prior Authorization, Quantity Limit)
• Dayvigo 10 mg tablet (Prior Authorization, Quantity Limit)
• Haegarda 2000 unit injection (Prior Authorization)
• Haegarda 3000 unit injection (Prior Authorization)
• Takhzyro 300 mg per 2 mL injection (Prior Authorization, Quantity Limit)
• Takhzyro 150 mg per mL injection (Prior Authorization, Quantity Limit)
• Gefitinib 250 mg tablet (Prior Authorization, Quantity Limit)
• Liqrev 10 mg per mL suspension (Prior Authorization, Quantity Limit)
• Ciprofloxacin-Dexmethasone 0.3%/0.1% otic suspension (Quantity Limit)
• Goodsense 0.25-14-74.9% hemorrhoidal ointment
• Gnp 0.25-14-74.9% hemorrhoidal ointment

Removals:

• Cinryze 500 unit solution
• Proctofoam 1% rectal foam

Other Updates:

• Abacavir sulfate 20 mg per mL solution (Added Quantity Limit)
• Abacavir sulfate 300 mg tablet (Added Quantity Limit)
• Abacavir sulfate 600 mg/lamivudine 300 mg tablet (Added Quantity Limit)
• Abilify maintena 300 mg extended release injection (Added Prior Authorization)
• Abilify maintena 300 mg prefilled syringe (Added Prior Authorization)
• Abilify maintena 400 mg prefilled syringe (Added Prior Authorization)
• Acarbose 100 mg tablet (Added Quantity Limit)
• Acarbose 25 mg tablet (Added Quantity Limit)
• Acarbose 50 mg tablet (Added Quantity Limit)
• Alendronate sodium 10 mg tablet (Added Quantity Limit)
• Amabelz 0.5 mg/0.1 mg tablet (Added Quantity Limit)
• Amabelz 1 mg/0.5 mg tablet (Added Quantity Limit)
• Amlodipine besylate 10 mg tablet (Added Quantity Limit)
• Amlodipine besylate 2.5 mg tablet (Added Quantity Limit)
• Amlodipine besylate 5 mg tablet (Added Quantity Limit)
• Aripiprazole 10 mg tablet (Removed Prior Authorization)
• Aripiprazole 15 mg tablet (Removed Prior Authorization)
• Aripiprazole 2 mg tablet (Removed Prior Authorization)
• Aripiprazole 20 mg tablet (Removed Prior Authorization)
• Aripiprazole 30 mg tablet (Removed Prior Authorization)
• Aripiprazole 5 mg tablet (Removed Prior Authorization)
• Aristada 1064 mg per 3.9 mL prefilled syringe (Added Prior Authorization)
• Aristada 441 mg per 1.6 mL prefilled syringe (Added Prior Authorization)
• Aristada 662 mg per 2.4 mL prefilled syringe (Added Prior Authorization)
• Aristada 882 mg per 3.2 mL prefilled syringe (Added Prior Authorization)
• Armodafinil 150 mg tablet (Added Prior Authorization)
• Armodafinil 250 mg tablet (Added Prior Authorization)
• Armodafinil 50 mg tablet (Added Prior Authorization)
• Armour thyroid 180 mg tablet (Added Quantity Limit)
• Armour thyroid 240 mg tablet (Added Quantity Limit)
• Armour thyroid 300 mg tablet (Added Quantity Limit)
• Atazanavir sulfate 150 mg capsule (Added Quantity Limit)
• Atazanavir sulfate 200 mg capsule (Added Quantity Limit)
• Atazanavir sulfate 300 mg capsule (Added Quantity Limit)
• Bisoprolol fumarate 5 mg tablet (Added Quantity Limit)
• Capecitabine 150 mg tablet (Added Prior Authorization)
• Capecitabine 500 mg tablet (Added Prior Authorization)
• Carbamazepine 100 mg extended release capsule (Removed Prior Authorization)
• Carbamazepine 100 mg extended release tablet (Removed Prior Authorization)
• Carbamazepine 100 mg per 5 mL suspension (Removed Prior Authorization)
• Carbamazepine 200 mg extended release capsule (Removed Prior Authorization)
• Carbamazepine 200 mg extended release tablet (Removed Prior Authorization)
• Carbamazepine 200 mg tablet (Removed Prior Authorization)
• Carbamazepine 300 mg extended release capsule (Removed Prior Authorization)
• Carbamazepine 400 mg extended release tablet (Removed Prior Authorization)
• Cartia 120 mg extended release capsule (Added Quantity Limit)
• Cartia 180 mg extended release capsule (Added Quantity Limit)
• Cartia 240 mg extended release capsule (Added Quantity Limit)
• Carvedilol 12.5 mg tablet (Added Quantity Limit)
• Carvedilol 25 mg tablet (Added Quantity Limit)
• Carvedilol 3.125 mg tablet (Added Quantity Limit)
• Carvedilol 6.25 mg tablet (Added Quantity Limit)
• Ceftriaxone sodium 2 gm for injection (Added Quantity Limit)
• Ceftriaxone sodium 250 mg for injection (Added Quantity Limit)
• Ceftriaxone sodium 500 mg for injection (Added Quantity Limit)
• Chloroquine phosphate 250 mg tablet (Removed Prior Authorization)
• Chloroquine phosphate 500 mg tablet (Removed Prior Authorization)
• Ciclopirox olamine 0.77% cream (Added Step Therapy)
• Ciclopirox olamine 0.77% suspension (Added Step Therapy)
• Citalopram 10 mg per 5 mL solution (Changed Quantity Limit)
• Clindamycin phosphate 1% gel (Removed Step Therapy)
• Clindamycin phosphate 1% lotion (Removed Step Therapy)
• Clobetasol propionate 0.05% solution (Removed Step Therapy)
• Clonidine 0.1 mg per 24 hour weekly patch (Added Step Therapy)
• Clonidine 0.2 mg per 24 hour weekly patch (Added Step Therapy)
• Clonidine 0.3 mg per 24 hour weekly patch (Added Step Therapy)
• Clozapine 100 mg tablet (Removed Prior Authorization)
• Clozapine 200 mg tablet (Removed Prior Authorization)
• Clozapine 25 mg tablet (Removed Prior Authorization)
• Clozapine 50 mg tablet (Removed Prior Authorization)
• Cyclosporine 0.05 ophthalmic emulsion (Added Prior Authorization)
• Darunavir 100 mg per mL suspension (Added Quantity Limit)
• Darunavir 150 mg tablet (Added Quantity Limit)
• Darunavir 75 mg tablet (Added Quantity Limit)
• Descovy 120 mg/15 mg tablet (Added Quantity Limit)
• Desmopressin acetate 0.1 mg tablet (Added Quantity Limit)
• Desmopressin acetate 0.2 mg tablet (Added Quantity Limit)
• Diazepam 10 mg rectal gel (Changed Quantity Limit, Removed Age Limit)
• Diazepam 2.5 mg rectal gel (Changed Quantity Limit, Removed Age Limit)
• Diazepam 20 mg rectal gel (Changed Quantity Limit, Removed Age Limit)
• Diltiazem 120 mg extended release beads capsule (Added Quantity Limit)
• Diltiazem 120 mg extended release capsule (Added Quantity Limit)
• Diltiazem 120 mg extended release coated beads capsule (Added Quantity Limit)
• Diltiazem 120 mg tablet (Added Quantity Limit)
• Diltiazem 180 mg extended release beads capsule (Added Quantity Limit)
• Diltiazem 180 mg extended release capsule (Added Quantity Limit)
• Diltiazem 180 mg extended release coated beads capsule (Added Quantity Limit)
• Diltiazem 240 mg extended release beads capsule (Added Quantity Limit)
• Diltiazem 240 mg extended release capsule (Added Quantity Limit)
• Diltiazem 240 mg extended release coated beads capsule (Added Quantity Limit)
• Diltiazem 30 mg tablet (Added Quantity Limit)
• Diltiazem 300 mg extended release beads capsule (Added Quantity Limit)
• Diltiazem 360 mg extended release beads capsule (Added Quantity Limit)
• Diltiazem 420 mg extended release beads capsule (Added Quantity Limit)
• Diltiazem 60 mg tablet (Added Quantity Limit)
• Diltiazem 90 mg tablet (Added Quantity Limit)
• Dilt-xr 120 mg extended release capsule (Added Quantity Limit)
• Dilt-xr 180 mg extended release capsule (Added Quantity Limit)
• Dilt-xr 240 mg extended release capsule (Added Quantity Limit)
• Dimethyl fumarate 120 mg delayed release capsule (Added Prior Authorization)
• Dimethyl fumarate 240 mg delayed release capsule (Added Prior Authorization)
• Divalproex sodium 125 mg delayed release tablet (Removed Prior Authorization)
• Divalproex sodium 250 mg delayed release tablet (Removed Prior Authorization)
• Divalproex sodium 250 mg extended release tablet (Removed Prior Authorization)
• Divalproex sodium 500 mg delayed release tablet (Removed Prior Authorization)
• Divalproex sodium 500 mg extended release tablet (Removed Prior Authorization)
• Doxazosin mesylate 8 mg tablet (Changed Quantity Limit)
• Efavirenz 200 mg capsule (Added Quantity Limit)
• Efavirenz 50 mg capsule (Added Quantity Limit)
• Efavirenz 600 mg capsule (Added Quantity Limit)
• Efavirenz 600 mg/emtricitabine 200 mg/tenofovir 300 mg tablet (Added Quantity Limit)
• Ella 30 mg tablet (Changed Quantity Limit, Removed Age Limit)
• Emtricitabine 10 mg per mL solution (Added Quantity Limit)
• Emtricitabine 200 mg capsule (Added Quantity Limit)
• Entecavir 0.5 mg tablet (Added Quantity Limit)
• Entecavir 1 mg tablet (Added Quantity Limit)
• Epoprostenol sodium 0.5 mg injection (Added Prior Authorization)
• Epoprostenol sodium 1.5 mg injection (Added Prior Authorization)
• Estradiol 0.5 mg/norethindrone acetate 0.1 mg tablet (Added Quantity Limit)
• Estradiol 1 mg/norethindrone acetate 0.5 mg tablet (Added Quantity Limit)
• Ethosuximide 250 mg capsule (Removed Prior Authorization)
• Ethosuximide 250 mg per 5 mL solution (Removed Prior Authorization)
• Etravirine 100 mg tablet (Added Quantity Limit)
• Etravirine 200 mg tablet (Added Quantity Limit)
• Etravirine 25 mg tablet (Added Quantity Limit)
• Euthyrox 100 mcg tablet (Added Quantity Limit)
• Euthyrox 125 mcg tablet (Added Quantity Limit)
• Euthyrox 137 mcg tablet (Added Quantity Limit)
• Euthyrox 150 mcg tablet (Added Quantity Limit)
• Euthyrox 175 mcg tablet (Added Quantity Limit)
• Euthyrox 200 mcg tablet (Added Quantity Limit)
• Euthyrox 50 mcg tablet (Added Quantity Limit)
• Euthyrox 75 mcg tablet (Added Quantity Limit)
• Euthyrox 88 mcg tablet (Added Quantity Limit)
• Everolimus 10 mg tablet (Added Quantity Limit)
• Everolimus 2.5 mg tablet (Added Quantity Limit)
• Everolimus 5 mg tablet (Added Quantity Limit)
• Everolimus 7.5 mg tablet (Added Quantity Limit)
• Felodipine 10 mg extended release tablet (Added Quantity Limit)  
• Felodipine 2.5 mg extended release tablet (Added Quantity Limit)
• Felodipine 5 mg extended release tablet (Added Quantity Limit)  
• Fingolimod 0.5 mg capsule (Added Prior Authorization)
• Fluconazole 100 mg tablet (Added Quantity Limit)
• Fluconazole 200 mg tablet (Added Quantity Limit)
• Fluconazole 50 mg tablet (Added Quantity Limit)
• Fosamprenavir calcium 50 mg per mL suspension tablet (Added Quantity Limit)
• Fosamprenavir calcium 700 mg tablet (Added Quantity Limit)
• Fuzeon 90 mg reconstituted solution (Added Quantity Limit)
• Fyavolv 0.5 mg/2.5 mcg tablet (Added Quantity Limit)
• Fyavolv 1 mg/5 mcg tablet (Added Quantity Limit)
• Gabapentin 100 mg capsule (Removed Prior Authorization)
• Gabapentin 250 mg per 5 mL oral solution (Removed Prior Authorization)
• Gabapentin 300 mg capsule (Removed Prior Authorization)
• Gabapentin 400 mg capsule (Removed Prior Authorization)
• Gabapentin 600 mg tablet (Removed Prior Authorization)
• Gabapentin 800 mg tablet (Removed Prior Authorization)
• Glatiramer acetate 20 mg per mL prefilled syringe (Added Prior Authorization)
• Glipizide 10 mg extended release tablet (Added Quantity Limit)
• Glipizide 2.5 mg extended release tablet (Added Quantity Limit)
• Glipizide 2.5 mg/metformin 250 mg tablet (Added Quantity Limit)
• Glipizide 2.5 mg/metformin 500 mg tablet (Added Quantity Limit)
• Glipizide 5 mg extended release tablet (Added Quantity Limit)
• Glipizide 5 mg/metformin 500 mg tablet (Added Quantity Limit)
• Glyburide 1.25 mg/metformin 250 mg tablet (Added Quantity Limit)
• Glyburide 2.5 mg/metformin 500 mg tablet (Added Quantity Limit)
• Glyburide 5 mg/metformin 500 mg tablet (Added Quantity Limit)
• Griseofulvin microsize 125 mg per 5 mL suspension (Added Step Therapy)
• Haloperidol 0.5 mg tablet (Removed Prior Authorization)
• Haloperidol 1 mg tablet (Removed Prior Authorization)
• Haloperidol 10 mg tablet (Removed Prior Authorization)
• Haloperidol 2 mg tablet (Removed Prior Authorization)
• Haloperidol 20 mg tablet (Removed Prior Authorization)
• Haloperidol 5 mg tablet (Removed Prior Authorization)
• Haloperidol lactate 2 mg per mL concentrate (Removed Prior Authorization)
• Haloperidol lactate 5 mg per mL injection (Removed Prior Authorization)
• Hydroxychloroquine sulfate 200 mg tablet (Removed Prior Authorization)
• Hydroxyurea 200 mg capsule (Removed Prior Authorization)
• Hydroxyurea 300 mg capsule (Removed Prior Authorization)
• Hydroxyurea 400 mg capsule (Removed Prior Authorization)
• Hydroxyurea 500 mg capsule (Removed Prior Authorization, Removed Quantity Limit)
• Imatinib mesylate 100 mg tablet (Added Prior Authorization)
• Imatinib mesylate 400 mg tablet (Added Prior Authorization)
• Interferon beta-1a 30 mcg per 0.5 mL auto injector kit (Added Prior Authorization)
• Interferon beta-1a 30 mcg per 0.5 mL prefilled syringe kit (Added Prior Authorization)
• Interferon beta-1b 0.3 mg kit for injection (Added Prior Authorization)
• Invega hafyera 1092 mg per 3.5 mL injection (Added Prior Authorization)
• Invega hafyera 1560 mg per 5 mL injection (Added Prior Authorization)
• Invega sustenna 117 mg per 0.75 mL injection (Added Prior Authorization)
• Invega sustenna 156 mg per 1 mL injection (Added Prior Authorization)
• Invega sustenna 234 mg per 1.5 mL injection (Added Prior Authorization)
• Invega sustenna 39 mg per 0.25 mL injection (Added Prior Authorization)
• Invega sustenna 78 mg per 0.5 mL injection (Added Prior Authorization)
• Invega trinza 273 mg per 0.88 mL injection (Added Prior Authorization)
• Invega trinza 410 mg per 1.32 mL injection (Added Prior Authorization)
• Invega trinza 546 mg per 1.75 mL injection (Added Prior Authorization)
• Invega trinza 819 mg per 2.63 mL injection (Added Prior Authorization)
• Isentress 100 mg chewable tablet (Added Quantity Limit)
• Isentress 100 mg for suspension (Added Quantity Limit)
• Isentress 25 mg chewable tablet (Added Quantity Limit)
• Isentress 400 mg tablet (Added Quantity Limit)
• Isentress 600 mg tablet (Added Quantity Limit)
• Isosorbide mononitrate 120 mg extended release tablet (Added Quantity Limit)
• Isosorbide mononitrate 30 mg extended release tablet (Added Quantity Limit)
• Isosorbide mononitrate 60 mg extended release tablet (Added Quantity Limit)
• Itraconazole 100 mg capsule (Changed Quantity Limit)
• Jinteli 1 mg/5 mcg tablet (Added Quantity Limit)
• Ketoconazole 2% cream (Added Step Therapy)
• Ketoconazole 200 mg tablet (Changed Quantity Limit)
• Lamivudine 10 mg per mL solution (Added Quantity Limit)
• Lamivudine 100 mg tablet (Added Quantity Limit)
• Lamivudine 150 mg tablet (Added Quantity Limit) 
• Lamivudine 150 mg/zidovudine 300 mg tablet (Added Quantity Limit)
• Lamivudine 300 mg tablet (Added Quantity Limit)
• Lamotrigine 100 mg tablet (Removed Prior Authorization)
• Lamotrigine 150 mg tablet (Removed Prior Authorization)
• Lamotrigine 200 mg tablet (Removed Prior Authorization)
• Lamotrigine 25 mg chewable dispersible tablet (Removed Prior Authorization)
• Lamotrigine 25 mg tablet (Removed Prior Authorization)
• Lamotrigine 5 mg chewable dispersible tablet (Removed Prior Authorization)
• Lenalidomide 10 mg capsules (Added Prior Authorization)
• Lenalidomide 15 mg capsules (Added Prior Authorization)
• Lenalidomide 2.5 mg capsules (Added Prior Authorization)
• Lenalidomide 20 mg capsules (Added Prior Authorization)
• Lenalidomide 25 mg capsules (Added Prior Authorization)
• Lenalidomide 5 mg capsules (Added Prior Authorization)
• Levalbuterol tartate 45 mcg per actuation inhaler (Added Step Therapy)
• Levetiracetam 100 mg per mL oral solution (Removed Prior Authorization)
• Levetiracetam 1000 mg tablet (Removed Prior Authorization)
• Levetiracetam 250 mg tablet (Removed Prior Authorization)
• Levetiracetam 500 mg extended release tablet (Removed Prior Authorization)
• Levetiracetam 500 mg tablet (Removed Prior Authorization)
• Levetiracetam 750 mg extended release tablet (Removed Prior Authorization)
• Levetiracetam 750 mg tablet (Removed Prior Authorization)
• Levo-t 100 mcg tablet (Added Quantity Limit)
• Levo-t 125 mcg tablet (Added Quantity Limit)
• Levo-t 137 mcg tablet (Added Quantity Limit)
• Levo-t 150 mcg tablet (Added Quantity Limit)
• Levo-t 175 mcg tablet (Added Quantity Limit)
• Levo-t 200 mcg tablet (Added Quantity Limit)
• Levo-t 50 mcg tablet (Added Quantity Limit)
• Levo-t 75 mcg tablet (Added Quantity Limit)
• Levo-t 88 mcg tablet (Added Quantity Limit)
• Levothyroxine sodium 100 mcg tablet (Added Quantity Limit)
• Levothyroxine sodium 112 mcg tablet (Added Quantity Limit)
• Levothyroxine sodium 125 mcg tablet (Added Quantity Limit)
• Levothyroxine sodium 137 mcg tablet (Added Quantity Limit)
• Levothyroxine sodium 150 mcg tablet (Added Quantity Limit)
• Levothyroxine sodium 175 mcg tablet (Added Quantity Limit)
• Levothyroxine sodium 200 mcg tablet (Added Quantity Limit)
• Levothyroxine sodium 25 mcg tablet (Added Quantity Limit)
• Levothyroxine sodium 300 mcg tablet (Added Quantity Limit)
• Levothyroxine sodium 50 mcg tablet (Added Quantity Limit)
• Levothyroxine sodium 75 mcg tablet (Added Quantity Limit)
• Levothyroxine sodium 88 mcg tablet (Added Quantity Limit)
• Levoxyl 100 mcg tablet (Added Quantity Limit)
• Levoxyl 112 mcg tablet (Added Quantity Limit)
• Levoxyl 125 mcg tablet (Added Quantity Limit)
• Levoxyl 137 mcg tablet (Added Quantity Limit)
• Levoxyl 150 mcg tablet (Added Quantity Limit)
• Levoxyl 175 mcg tablet (Added Quantity Limit)
• Levoxyl 200 mcg tablet (Added Quantity Limit)
• Levoxyl 88 mcg tablet (Added Quantity Limit)
• Liothyronine sodium 5 mcg tablet (Added Quantity Limit)
• Liothyronine sodium 50 mcg tablet (Added Quantity Limit)
• Lisinopril 10 mg tablet (Added Quantity Limit)
• Lisinopril 2.5 mg tablet (Added Quantity Limit)
• Lisinopril 20 mg tablet (Added Quantity Limit)
• Lisinopril 30 mg tablet (Added Quantity Limit)
• Lisinopril 40 mg tablet (Added Quantity Limit)
• Lisinopril 5 mg tablet (Added Quantity Limit)
• Lopinavir 400 mg/ritonavir 100 mg per 5 mL solution (Added Quantity Limit)
• Loxapine succinate 10 mg capsule (Removed Prior Authorization)
• Loxapine succinate 25 mg capsule (Removed Prior Authorization)
• Loxapine succinate 5 mg capsule (Removed Prior Authorization)
• Loxapine succinate 50 mg capsule (Removed Prior Authorization)
• Malathion 0.5% lotion (Added Step Therapy)
• Mercaptopurine 50 mg tablet (Removed Prior Authorization, Removed Quantity Limit)
• Metformin 500 mg extended release tablet (Added Quantity Limit)
• Metformin 750 mg extended release tablet (Added Quantity Limit)
• Metoprolol succinate 100 mg extended release tablet (Added Quantity Limit)
• Metoprolol succinate 200 mg extended release tablet (Added Quantity Limit)
• Metoprolol succinate 25 mg extended release tablet (Added Quantity Limit)
• Metoprolol succinate 50 mg extended release tablet (Added Quantity Limit)
• Mimvey 1 mg/0.5 mg tablet (Added Quantity Limit)
• Naproxen 125 mg per 5 mL suspension (Added Step Therapy)
• Nateglinide 120 mg tablet (Added Quantity Limit)
• Nateglinide 60 mg tablet (Added Quantity Limit)
• Nelfinavir mesylate 250 mg tablet (Added Quantity Limit)
• Nelfinavir mesylate 625 mg tablet (Added Quantity Limit)
• Nevirapine 100 mg extended release tablet (Added Quantity Limit)
• Nevirapine 200 mg tablet (Added Quantity Limit)
• Nevirapine 400 mg extended release tablet (Added Quantity Limit)
• Nevirapine 50 mg per 5 mL suspension (Added Quantity Limit)
• Nifedipine 30 mg extended release tablet (Added Quantity Limit)
• Nifedipine 30 mg osmotic release tablet (Added Quantity Limit)
• Nifedipine 60 mg extended release tablet (Added Quantity Limit) 
• Nifedipine 60 mg osmotic release tablet (Added Quantity Limit)  
• Nifedipine 90 mg osmotic release tablet (Added Quantity Limit)  
• Norethindrone acetate 0.5 mg/ethinyl estradiol 2.5 mcg tablet (Added Quantity Limit)
• Norethindrone acetate 1 mg/ethinyl estradiol 5 mcg tablet (Added Quantity Limit)
• Norethindrone acetate 5 mg tablet (Added Step Therapy)
• Np thyroid 120 mg tablet (2 grain) (Added Quantity Limit)
• Np thyroid 15 mg tablet (1/4 grain) (Added Quantity Limit)
• Np thyroid 30 mg tablet (1/2 grain) (Added Quantity Limit)
• Np thyroid 60 mg tablet (1 grain) (Added Quantity Limit)
• Np thyroid 90 mg tablet (1 1/2 grain) (Added Quantity Limit)
• Octreotide acetate 100 mcg per mL injection (Added Prior Authorization)
• Octreotide acetate 100 mcg per mL prefilled syringe (Added Prior Authorization)
• Octreotide acetate 1000 mcg per mL injection (Added Prior Authorization)
• Octreotide acetate 200 mcg per mL injection (Added Prior Authorization)
• Octreotide acetate 50 mcg per mL injection (Added Prior Authorization)
• Octreotide acetate 50 mcg per mL prefilled syringe (Added Prior Authorization)
• Octreotide acetate 500 mcg per mL injection (Added Prior Authorization)
• Octreotide acetate 500 mcg per mL prefilled syringe (Added Prior Authorization)
• Olanzapine 10 mg orally disintegrating tablet (Removed Prior Authorization)
• Olanzapine 10 mg tablet (Removed Prior Authorization)
• Olanzapine 15 mg orally disintegrating tablet (Removed Prior Authorization)
• Olanzapine 15 mg tablet (Removed Prior Authorization)
• Olanzapine 2.5 mg tablet (Removed Prior Authorization)
• Olanzapine 20 mg orally disintegrating tablet (Removed Prior Authorization)
• Olanzapine 20 mg tablet (Removed Prior Authorization)
• Olanzapine 5 mg orally disintegrating tablet (Removed Prior Authorization)
• Olanzapine 5 mg tablet (Removed Prior Authorization)
• Olanzapine 7.5 mg tablet (Removed Prior Authorization)
• Oxcarbazepine 150 mg tablet (Removed Prior Authorization)
• Oxcarbazepine 300 mg per 5 mL suspension (Removed Prior Authorization)
• Oxcarbazepine 300 mg tablet (Removed Prior Authorization)
• Oxcarbazepine 600 mg tablet (Removed Prior Authorization)
• Paricalcitol 1 mcg capsule (Added Step Therapy, Added Quantity Limit)
• Paricalcitol 2 mcg capsule (Added Step Therapy, Added Quantity Limit)
• Paricalcitol 4 mcg capsule (Added Step Therapy, Added Quantity Limit)
• PazoPanib 200 mg tablet (Added Prior Authorization, Added Quantity Limit)
• Perphenazine 16 mg tablet (Removed Prior Authorization)
• Perphenazine 2 mg tablet (Removed Prior Authorization)
• Perphenazine 2 mg/amitriptyline 10 mg tablet (Removed Prior Authorization)
• Perphenazine 2 mg/amitriptyline 25 mg tablet (Removed Prior Authorization)
• Perphenazine 4 mg tablet (Removed Prior Authorization)
• Perphenazine 4 mg/amitriptyline 10 mg tablet (Removed Prior Authorization)
• Perphenazine 4 mg/amitriptyline 25 mg tablet (Removed Prior Authorization)
• Perphenazine 4 mg/amitriptyline 50 mg tablet (Removed Prior Authorization)
• Perphenazine 8 mg tablet (Removed Prior Authorization)
• Phenytoin 125 mg per 5 mL suspension (Removed Prior Authorization)
• Phenytoin 50 mg chewable tablet (Removed Prior Authorization)
• Phenytoin sodium 100 mg extended release capsule (Removed Prior Authorization)
• Phenytoin sodium 200 mg extended release capsule (Removed Prior Authorization)
• Phenytoin sodium 300 mg extended release capsule (Removed Prior Authorization)
• Pioglitazone 15 mg tablet (Added Quantity Limit)
• Pioglitazone 30 mg tablet (Added Quantity Limit)
• Pioglitazone 45 mg tablet (Added Quantity Limit)
• Primidone 250 mg tablet (Removed Prior Authorization)
• Primidone 50 mg tablet (Removed Prior Authorization)
• Prochlorperazine maleate 10 mg tablet (Removed Prior Authorization)
• Prochlorperazine maleate 5 mg tablet (Removed Prior Authorization)
• Progesterone 100 mg capsule (Added Quantity Limit)
• Progesterone 200 mg capsule (Added Quantity Limit)
• Propranolol 60 mg extended release capsule (Added Quantity Limit)
• Propranolol 80 mg extended release capsule (Added Quantity Limit)
• Quetiapine fumarate 100 mg tablet (Removed Prior Authorization)
• Quetiapine fumarate 150 mg extended release tablet (Removed Prior Authorization)
• Quetiapine fumarate 200 mg extended release tablet (Removed Prior Authorization)
• Quetiapine fumarate 200 mg tablet (Removed Prior Authorization)
• Quetiapine fumarate 25 mg tablet (Removed Prior Authorization)
• Quetiapine fumarate 300 mg extended release tablet (Removed Prior Authorization)
• Quetiapine fumarate 300 mg tablet (Removed Prior Authorization)
• Quetiapine fumarate 400 mg extended release tablet (Removed Prior Authorization)
• Quetiapine fumarate 400 mg tablet (Removed Prior Authorization)
• Quetiapine fumarate 50 mg extended release tablet (Removed Prior Authorization)
• Quetiapine fumarate 50 mg tablet (Removed Prior Authorization)
• Raloxifene 60 mg tablet (Added Quantity Limit)
• Ramelteon 8 mg tablet (Added Step Therapy)
• Ramipril 1.25 mg capsule (Removed Prior Authorization, Removed Quantity Limit)
• Ramipril 2.5 mg capsule (Removed Prior Authorization, Removed Quantity Limit)
• Ramipril 5 mg capsule (Removed Prior Authorization, Removed Quantity Limit)
• Repaglinide 0.5 mg tablet (Added Quantity Limit)
• Repaglinide 1 mg tablet (Added Quantity Limit)
• Repaglinide 2 mg tablet (Added Quantity Limit)
• Revlimid 10 mg capsule (Added Prior Authorization)
• Revlimid 15 mg capsule (Added Prior Authorization)
• Revlimid 2.5 mg capsule (Added Prior Authorization)
• Revlimid 20 mg capsule (Added Prior Authorization)
• Revlimid 25 mg capsule (Added Prior Authorization)
• Revlimid 5 mg capsule (Added Prior Authorization)
• Risperdal consta 12.5 mg extended release injection (Added Prior Authorization)
• Risperdal consta 25 mg extended release injection (Added Prior Authorization)
• Risperdal consta 37.5 mg extended release injection (Added Prior Authorization)
• Risperdal consta 50 mg extended release injection (Added Prior Authorization)
• Risperidone 0.25 mg orally disintegrating tablet (Removed Prior Authorization, Added Age Limit)
• Risperidone 0.25 mg tablet (Removed Prior Authorization)
• Risperidone 0.5 mg orally disintegrating tablet (Removed Prior Authorization)
• Risperidone 0.5 mg tablet (Removed Prior Authorization)
• Risperidone 1 mg orally disintegrating tablet (Removed Prior Authorization)
• Risperidone 1 mg per mL solution (Removed Prior Authorization)
• Risperidone 1 mg tablet (Removed Prior Authorization)
• Risperidone 2 mg orally disintegrating tablet (Removed Prior Authorization)
• Risperidone 2 mg tablet (Removed Prior Authorization)
• Risperidone 3 mg orally disintegrating tablet (Removed Prior Authorization)
• Risperidone 3 mg tablet (Removed Prior Authorization)
• Risperidone 4 mg orally disintegrating tablet (Removed Prior Authorization, Added Age Limit)
• Risperidone 4 mg tablet (Removed Prior Authorization)
• Ritonavir 100 mg tablet (Added Quantity Limit)
• Sevelamer carbonate 800 mg tablet (Added Step Therapy)
• Sodium chloride 10% nebulizer (Removed Prior Authorization)
• Sodium chloride 3% nebulizer (Removed Prior Authorization)
• Sodium chloride 7% nebulizer (Removed Prior Authorization)
• Spinosad 0.9% suspension (Added Step Therapy)
• Sprycel 20 mg tablet (Changed Quantity Limit)
• Sprycel 80 mg tablet (Changed Quantity Limit)
• Stavudine 15 mg capsule (Changed Quantity Limit)
• Stavudine 20 mg capsule (Changed Quantity Limit)
• Sunitinib malate 12.5 mg capsule (Added Prior Authorization)
• Sunitinib malate 25 mg capsule (Added Prior Authorization)
• Sunitinib malate 37.5 mg capsule (Added Prior Authorization)
• Sunitinib malate 50 mg capsule (Added Prior Authorization)
• Tacrolimus 0.03% ointment (Added Step Therapy)
• Tacrolimus 0.1% ointment (Added Step Therapy)
• Tadalafil 20 mg tablet (Removed Prior Authorization, Added Step Therapy, Added Quantity Limit)
• Taztia 120 mg extended release capsule (Added Quantity Limit)
• Taztia 180 mg extended release capsule (Added Quantity Limit)
• Taztia 240 mg extended release capsule (Added Quantity Limit)
• Taztia 300 mg extended release capsule (Added Quantity Limit)
• Taztia 360 mg extended release capsule (Added Quantity Limit)
• Tenofovir disoproxil fumarate 150 mg tablet (Added Quantity Limit)
• Tenofovir disoproxil fumarate 200 mg tablet (Added Quantity Limit)
• Tenofovir disoproxil fumarate 250 mg tablet (Added Quantity Limit)
• Tenofovir disoproxil fumarate 300 mg tablet (Added Quantity Limit)
• Tenofovir disoproxil fumarate 40 mg per gm oral powder (Added Quantity Limit)
• Teriflunomide 14 mg tablet (Added Prior Authorization)
• Teriflunomide 7 mg tablet (Added Prior Authorization)
• Testosterone 25 mg per 2.5 gm transdermal gel (Added Quantity Limit)
• Testosterone 50 mg per 5 gm transdermal gel (Added Quantity Limit)
• Testosterone cypionate 100 mg per mL injection (Added Prior Authorization)
• Testosterone cypionate 200 mg per mL injection (Added Prior Authorization)
• Testosterone enanthate 200 mg per mL injection (Added Prior Authorization)
• Thioridazine 10 mg tablet (Removed Prior Authorization)
• Thioridazine 100 mg tablet (Removed Prior Authorization)
• Thioridazine 25 mg tablet (Removed Prior Authorization)
• Thioridazine 50 mg tablet (Removed Prior Authorization)
• Thiothixene 1 mg capsule (Removed Prior Authorization)
• Thiothixene 10 mg capsule (Removed Prior Authorization)
• Thiothixene 2 mg capsule (Removed Prior Authorization)
• Thiothixene 5 mg capsule (Removed Prior Authorization)
• Thyroid 120 mg tablet (2 grain) (Added Quantity Limit)
• Thyroid 15 mg tablet (1/4 grain) (Added Quantity Limit)
• Thyroid 180 mg tablet (3 grain) (Added Quantity Limit)
• Thyroid 240 mg tablet (4 grain) (Added Quantity Limit)
• Thyroid 30 mg tablet (1/2 grain) (Added Quantity Limit)
• Thyroid 300 mg tablet (5 grain) (Added Quantity Limit)
• Thyroid 60 mg tablet (1 grain) (Added Quantity Limit)
• Thyroid 90 mg tablet (1 1/2 grain) (Added Quantity Limit)
• Tiadylt 120 mg extended release Capsule (Added Quantity Limit)
• Tiadylt 180 mg extended release Capsule (Added Quantity Limit)
• Tiadylt 240 mg extended release Capsule (Added Quantity Limit)
• Tiadylt 300 mg extended release Capsule (Added Quantity Limit)
• Tiadylt 360 mg extended release Capsule (Added Quantity Limit)
• Tiadylt 420 mg extended release Capsule (Added Quantity Limit)
• Tiagabine 12 mg tablet (Removed Prior Authorization)
• Tiagabine 16 mg tablet (Removed Prior Authorization)
• Tiagabine 2 mg tablet (Removed Prior Authorization)
• Tiagabine 4 mg tablet (Removed Prior Authorization)
• Timolol maleate 0.25% gel forming ophthalmic solution (Added Step Therapy)
• Timolol maleate 0.5% gel forming ophthalmic solution (Added Step Therapy)
• Tipranavir 250 mg capsule (Added Quantity Limit)
• Tivicay 10 mg tablet (Added Quantity Limit)
• Tivicay 25 mg tablet (Added Quantity Limit)
• Tivicay 50 mg tablet (Added Quantity Limit)
• Tobramycin 300 mg per 5 mL nebulizer solution (Changed Quantity Limit)
• Tretinoin 10 mg capsule (Added Prior Authorization)
• Trifluoperazine 1 mg tablet (Removed Prior Authorization)
• Trifluoperazine 10 mg tablet (Removed Prior Authorization)
• Trifluoperazine 2 mg tablet (Removed Prior Authorization)
• Trifluoperazine 5 mg tablet (Removed Prior Authorization)
• Unithroid 100 mcg tablet (Added Quantity Limit)
• Unithroid 112 mcg tablet (Added Quantity Limit)
• Unithroid 125 mcg tablet (Added Quantity Limit)
• Unithroid 137 mcg tablet (Added Quantity Limit)
• Unithroid 150 mcg tablet (Added Quantity Limit)
• Unithroid 175 mcg tablet (Added Quantity Limit)
• Unithroid 200 mcg tablet (Added Quantity Limit)
• Unithroid 50 mcg tablet (Added Quantity Limit)
• Unithroid 88 mcg tablet (Added Quantity Limit)
• Valganciclovir 450 mg tablet (Added Quantity Limit)
• Valsartan 160 mg tablet (Removed Prior Authorization)
• Valsartan 40 mg tablet (Removed Prior Authorization)
• Valsartan 80 mg tablet (Removed Prior Authorization)
• Valtoco 10 mg spray (Changed Quantity Limit)
• Valtoco 15 mg spray (Changed Quantity Limit)
• Valtoco 20 mg spray (Changed Quantity Limit)
• Valtoco 5 mg spray (Changed Quantity Limit)
• Varenicline 0.5 mg tablet (Removed Age Limit, Removed Quantity Limit)
• Varenicline 1 mg tablet (Removed Age Limit, Removed Quantity Limit)
• Verapamil 120 mg extended release capsule (Added Quantity Limit)
• Verapamil 120 mg extended release tablet (Added Quantity Limit) 
• Verapamil 120 mg tablet (Added Quantity Limit) 
• Verapamil 180 mg extended release capsule (Added Quantity Limit) 
• Verapamil 180 mg extended release tablet (Added Quantity Limit) 
• Verapamil 240 mg extended release capsule (Added Quantity Limit) 
• Verapamil 240 mg extended release tablet (Added Quantity Limit) 
• Verapamil 360 mg extended release capsule (Added Quantity Limit) 
• Verapamil 40 mg tablet (Added Quantity Limit)
• Verapamil 80 mg tablet (Added Quantity Limit) 
• Viokace 10440 unit/39150 unit tablet (Removed Prior Authorization)
• Viokace 20880 unit/78300 unit tablet (Removed Prior Authorization)
• Zenpep 10000 unit/32000 unit delayed release particles capsule (Removed Prior Authorization)
• Zenpep 15000 unit/47000 unit delayed release particles capsule (Removed Prior Authorization)
• Zenpep 20000 unit/63000 unit delayed release particles capsule (Removed Prior Authorization)
• Zenpep 25000 unit/79000 unit delayed release particles capsule (Removed Prior Authorization)
• Zenpep 3000 unit/10000 unit delayed release particles capsule (Removed Prior Authorization)
• Zenpep 40000 unit/126000 unit delayed release particles capsule (Removed Prior Authorization)
• Zenpep 5000 unit/24000 unit delayed release particles capsule (Removed Prior Authorization)
• Zidovudine 10 mg per mL syrup (Added Quantity Limit)
• Zidovudine 100 mg capsule (Added Quantity Limit)
• Zidovudine 300 mg tablet (Added Quantity Limit)
• Ziprasidone 20 mg capsule (Removed Prior Authorization)
• Ziprasidone 40 mg capsule (Removed Prior Authorization)
• Ziprasidone 60 mg capsule (Removed Prior Authorization)
• Ziprasidone 80 mg capsule (Removed Prior Authorization)
• Zolpidem tartrate 10 mg tablet (Removed Prior Authorization, Added Age Limit)
• Zolpidem tartrate 5 mg tablet (Added Age Limit)

October 2023

Additions:

• N/A

Removals:

• N/A

Other Updates:

• Abiraterone acetate 250 mg tablet (Added Diagnosis Exclusion)
• Alora patch twice weekly 0.05 mg per 24 hours (Added Diagnosis Exclusion)
• Alora patch twice weekly 0.075 mg per 24 hours (Added Diagnosis Exclusion)
• Alora patch twice weekly 0.1 mg per 24 hours (Added Diagnosis Exclusion)
• Amabelz 0.5 mg/0.1 mg tablet (Added Diagnosis Exclusion)
• Amabelz 1 mg/0.5 mg tablet (Added Diagnosis Exclusion)
• Anastrozole 1 mg tablet (Added Diagnosis Exclusion)
• Bicalutamide 50 mg tablet (Added Diagnosis Exclusion)
• Climara pro patch weekly 0.045 mg/0.015 mg per day (Added Diagnosis Exclusion)
• CombiPatch patch twice weekly 0.05 mg/0.14 mg per day (Added Diagnosis Exclusion)
• CombiPatch patch twice weekly 0.05 mg/0.25 mg per day (Added Diagnosis Exclusion)
• Danazol 100 mg capsule (Added Diagnosis Exclusion)
• Danazol 200 mg capsule (Added Diagnosis Exclusion)
• Danazol 50 mg capsule (Added Diagnosis Exclusion)
• Dotti patch twice weekly 0.025 mg per 24 hours (Added Diagnosis Exclusion)
• Dotti patch twice weekly 0.0375 mg per 24 hours (Added Diagnosis Exclusion)
• Dotti patch twice weekly 0.05 mg per 24 hours (Added Diagnosis Exclusion)
• Dotti patch twice weekly 0.075 mg per 24 hours (Added Diagnosis Exclusion)
• Dotti patch twice weekly 0.1 mg per 24 hours (Added Diagnosis Exclusion)
• Eligard 22.5 mg subcutaneous kit (Added Diagnosis Exclusion)
• Eligard 30 mg subcutaneous kit (Added Diagnosis Exclusion)
• Eligard 45 mg subcutaneous kit (Added Diagnosis Exclusion)
• Eligard 7.5 mg subcutaneous kit (Added Diagnosis Exclusion)
• Emcyt 140 mg capsule (Added Diagnosis Exclusion)
• Estradiol patch twice weekly 0.025 mg per 24 hours (Added Diagnosis Exclusion)
• Estradiol patch twice weekly 0.0375 mg per 24 hours (Added Diagnosis Exclusion)
• Estradiol patch twice weekly 0.05 mg per 24 hours (Added Diagnosis Exclusion)
• Estradiol patch twice weekly 0.075 mg per 24 hours (Added Diagnosis Exclusion)
• Estradiol patch twice weekly 0.1 mg per 24 hours (Added Diagnosis Exclusion)
• Estradiol patch weekly 0.025 mg per 24 hours (Added Diagnosis Exclusion)
• Estradiol patch weekly 0.0375 mg per 24 hours (Added Diagnosis Exclusion)
• Estradiol patch weekly 0.05 mg per 24 hours (Added Diagnosis Exclusion)
• Estradiol patch weekly 0.06 mg per 24 hours (Added Diagnosis Exclusion)
• Estradiol patch weekly 0.075 mg per 24 hours (Added Diagnosis Exclusion)
• Estradiol patch weekly 0.1 mg per 24 hours (Added Diagnosis Exclusion)
• Estradiol 0.5 mg tablet (Added Diagnosis Exclusion)
• Estradiol 1 mg tablet (Added Diagnosis Exclusion)
• Estradiol 2 mg tablet (Added Diagnosis Exclusion)
• Estradiol-Norethindrone 0.5 mg/0.1 mg tablet (Added Diagnosis Exclusion)
• Estradiol-Norethindrone 1 mg/0.5 mg tablet (Added Diagnosis Exclusion)
• Exemestane 25 mg tablet (Added Diagnosis Exclusion)
• Flutamide 125 mg capsule (Added Diagnosis Exclusion)
• Fyavolv 0.5 mg/2.5 mcg tablet (Added Diagnosis Exclusion)
• Fyavolv 1 mg/5 mcg tablet (Added Diagnosis Exclusion)
• Hydroxyprogesterone caproate 250 mg per mL intramuscular oil (Added Diagnosis Exclusion)
• Hydroxyprogesterone caproate 1.25 gm per 5 mL intramuscular solution (Added Diagnosis Exclusion)
• Jinteli 1 mg/5 mcg tablet (Added Diagnosis Exclusion)
• Letrozole 2.5 mg tablet (Added Diagnosis Exclusion)
• Leuprolide acetate 1 mg per 0.2mL injection (Added Diagnosis Exclusion)
• Lyllana patch twice weekly 0.025 mg per 24 hours (Added Diagnosis Exclusion)
• Lyllana patch twice weekly 0.0375 mg per 24 hours (Added Diagnosis Exclusion)
• Lyllana patch twice weekly 0.05 mg per 24 hours (Added Diagnosis Exclusion)
• Lyllana patch twice weekly 0.075 mg per 24 hours (Added Diagnosis Exclusion)
• Lyllana patch twice weekly 0.1 mg per 24 hours (Added Diagnosis Exclusion)
• Lysodren 500 mg tablet (Added Diagnosis Exclusion)
• Medroxyprogesterone acetate 10 mg tablet (Added Diagnosis Exclusion)
• Medroxyprogesterone acetate 2.5 mg tablet (Added Diagnosis Exclusion)
• Medroxyprogerterone acetate 5 mg tablet (Added Diagnosis Exclusion)
• Megestrol acetate 40 mg per mL oral suspension (Added Diagnosis Exclusion)
• Megestrol acetate 400 mg per 10 mL oral suspension (Added Diagnosis Exclusion)
• Megestrol acetate 20 mg tablet (Added Diagnosis Exclusion)
• Megestrol acetate 40 mg tablet (Added Diagnosis Exclusion)
• Mimvey 1mg/0.5 mg tablet (Added Diagnosis Exclusion)
• Norethindrone acetate 5 mg tablet (Added Diagnosis Exclusion)
• Oriahnn 300 mg/1-0.5 mg/300 mg therapy pack (Added Diagnosis Exclusion)
• Progesterone 100 mg capsule (Added Diagnosis Exclusion)
• Progesterone 200 mg capsule (Added Diagnosis Exclusion)
• Soltamox 10 mg per 5 L oral solution (Added Diagnosis Exclusion)
• Tamoxifen citrate 10 mg tablet (Added Diagnosis Exclusion)
• Tamoxifen citrate 20 mg tablet (Added Diagnosis Exclusion)
• Testosterone cypionate 100 mg per mL intramuscular solution (Added Diagnosis Exclusion)
• Testosterone cypionate 200 mg per mL intramuscular solution (Added Diagnosis Exclusion)
• Testosterone enanthate 200 mg per mL intramuscular solution (Added Diagnosis Exclusion)
• Testosterone 1.62 % transdermal gel (Added Diagnosis Exclusion)
• Testosterone 10 mg per actuation (2%) transdermal gel (Added Diagnosis Exclusion)
• Testosterone 12.5 mg per actuation (1%) transdermal gel (Added Diagnosis Exclusion)
• Testosterone 20.25 mg per actuation (1.62%) transdermal gel (Added Diagnosis Exclusion)
• Testosterone 25 mg per 2.5 gm (1%) transdermal gel (Added Diagnosis Exclusion)
• Testosterone 50 mg per 5 gm (1%) transdermal gel (Added Diagnosis Exclusion)
• Testosterone Solution 30 mg per actuation transdermal gel (Added Diagnosis Exclusion)
• Toremifene citrate 60 mg tablet (Added Diagnosis Exclusion)

September 2023

Additions:

• Austedo extended release titration kit (Prior Authorization, Quantity Limit)

Removals:

• N/A

Other Updates:

• N/A

August 2023

Additions:

• Ace aerosol cloud enhancer
• Adult aerosol mask
• Austedo extended release 24 mg tablet (Prior Authorization, Quantity Limit)
• Austedo extended release 12 mg tablet (Prior Authorization, Quantity Limit)
• Austedo extended release 6 mg tablet (Prior Authorization, Quantity Limit)
• Bd glucose 5 gm chewable tablet
• Ebase controller kit
• Filter air pp
• Gnp oral mineral oil
• Litetouch mask
• Melatonin 3 mg tablet
• Melatonin 5 mg tablet
• Melatonin maxmum strength 5 mg tablet
• Multivitamin infant/toddler oral solution
• Multivitamin with iron 11 mg per mL infant/toddler solution
• Nebivolol 10 mg tablet (Quantity Limit)
• Nebivolol 2.5 mg tablet (Quantity Limit)
• Nebivolol 20 mg tablet (Quantity Limit)
• Nebivolol 5 mg tablet (Quantity Limit)
• Niacin 100 mg tablet
• Niacin extended release 500 mg tablet
• Pari altera nebulizer handset
• Pari baby conversion kit
• Pari baby smart mask
• Pari erapid nebulizer handset
• Pari trek s combo kit
• Pflex
• Pharmacist choice mask wipes
• Qc castor oil
• Replacement filters
• Sidestream adult face mask
• Sidestream pediatric face mask
• Sm sweet oil
• Threshold imt
• Threshold pep device
• Tubing/wing tip
• Tyblume 0.1 mg/20 mg/0.02 mcg chewable tablet
• Vitamin a 250 mcg/vitamin c 10 mcg/vitamin d 50 mg per mL infant/toddler drops

Removals:

• 1^st base cream
• A thru z advantage tablet
• Abobotulinumtoxina 300 unit intramuscular injection
• Abobotulinumtoxina 500 unit intramuscular injection
• Acacia syrup
• Acamprosate calcium 333 mg delayed release tablet
• Acetylcysteine 200 mg per mL injection
• Activite 1 mg tablet
• Advance intuition control liquid normal in vitro
• Advate 1000 unit reconstituted intravenous solution
• Advate 1500 unit reconstituted intravenous solution
• Advate 2000 unit reconstituted intravenous solution
• Advate 250 unit reconstituted intravenous solution
• Advate 3000 unit reconstituted intravenous solution
• Advate 4000 unit reconstituted intravenous solution
• Advate 500 unit reconstituted intravenous solution
• Advocate control solution liquid low in vitro
• Adynovate 1000 unit reconstituted intravenous solution
• Adynovate 1500 unit reconstituted intravenous solution
• Adynovate 2000 unit reconstituted intravenous solution
• Adynovate 250 unit reconstituted intravenous solution
• Adynovate 3000 unit reconstituted intravenous solution
• Adynovate 500 unit reconstituted intravenous solution
• Adynovate 750 unit reconstituted intravenous solution
• Afstyla 1000 unit kit
• Afstyla 1500 unit kit
• Afstyla 2000 unit kit
• Afstyla 250 unit kit
• Afstyla 2500 unit kit
• Afstyla 3000 unit kit
• Afstyla 500 unit kit
• Agamatrix control solution normal in vitro
• Aloe vera 25 mg capsule
• Alphanate 1000 unit reconstituted intravenous solution
• Alphanate 1500 unit reconstituted intravenous solution
• Alphanate 2000 unit reconstituted intravenous solution
• Alphanate 250 unit reconstituted intravenous solution
• Alphanate 500 unit reconstituted intravenous solution
• Alphanine sd 1000 unit reconstituted intravenous solution
• Alphanine sd 1500 unit reconstituted intravenous solution
• Alphanine sd 500 unit reconstituted intravenous solution
• Alprolix 1000 unit reconstituted intravenous solution
• Alprolix 2000 unit reconstituted intravenous solution
• Alprolix 250 unit reconstituted intravenous solution
• Alprolix 3000 unit reconstituted intravenous solution
• Alprolix 4000 unit reconstituted intravenous solution
• Alprolix 500 unit reconstituted intravenous solution
• Altaderm cream
• Alteplase 2 mg for injection
• Amino acid 2.4%/dextrose 6.8%/lipid 3.5%/electrolyte 0.5% intravenous emulsion
• Amino acid 3.3%/dextrose 9.8%/lipid 3.9%/electrolyte 0.7% intravenous emulsion
• Aminocaproic acid 0.25 gm per mL oral solution
• Aminocaproic acid 1000 mg tablet
• Aminocaproic acid 250 mg per mL injection
• Aminocaproic acid 500 mg tablet
• Aminosyn 10% intravenous solution
• Aminosyn-pf 7% intravenous solution
• Amlodipine besylate/olmesartan medoxomil 10 mg/20 mg tablet
• Amlodipine besylate/olmesartan medoxomil 10 mg/40 mg tablet
• Amlodipine besylate/olmesartan medoxomil 5 mg/20 mg tablet
• Amlodipine besylate/olmesartan medoxomil 5 mg/40 mg tablet
• Antiinhibitor coagulant complex 1000 unit for intravenous solution
• Antiinhibitor coagulant complex 2500 unit for intravenous solution
• Antiinhibitor coagulant complex 500 unit for intravenous solution
• Apretude 600 mg extended release suspension
• Aquaphor healing balm baby stick
• Aralast np 500 mg injection
• Ascorbic acid 100 mg tablet
• Ascorbic acid 500 mg capsule
• Ascorbic acid 500 mg wafer
• Ascorbic acid 60 mg lozenge
• Ascorbic acid chewable 125 mg tablet
• Ascorbic acid extended release 1000 mg tablet
• Ascorbic acid extended release 1500 mg tablet
• Ascorbic acid extended release 500 mg capsule
• Ascorbic acid extended release 500 mg tablet
• Ascorbic acid oral powder
• Atovaquone 750 mg per 5 mL suspension
• Benazepril 10 mg/hydrochlorothiazide 12.5 mg tablet
• Benazepril 20 mg/hydrochlorothiazide 12.5 mg tablet
• Benazepril 20 mg/hydrochlorothiazide 25 mg tablet
• Benazepril 5 mg/hydrochlorothiazide 6.25 mg tablet
• Benefix 1000 unit kit
• Benefix 2000 unit kit
• Benefix 250 unit kit
• Benefix 3000 unit kit
• Benefix 500 unit kit
• Bioflavonoid chewable tablets
• Bioflavonoid extended release tablet
• Bss plus intraocular solution
• Bumetanide 0.25 mg per mL injection
• Bupivacaine 0.25% injection
• Bupivacaine 0.25%/epinephrine 1:200000 (pf) injection
• Bupivacaine 0.25%/epinephrine 1:200000 injection
• Bupivacaine 0.5% injection
• bupivacaine 0.5%/epinephrine 1:200000 (pf) injection
• bupivacaine 0.5%/epinephrine 1:200000 injection
• Bupivacaine preservative free 0.25% injection
• Bupivacaine preservative free 0.5% injection
• Bupivacaine preservative free 0.75% injection
• C complex extended release tablet
• C1 esterase inhibitor (human) 500 unit for intravenous injection kit
• Cabenuva 400 mg/600 mg suspension
• Cabenuva 600 mg/900 mg suspension
• Caffeine citrate 60 mg per 3 mL injection
• Calcium 250 mg/phosphorus 107 mg/vitamin d 500 unit chewable tablet
• Calcium 500 mg/vitamin c 10 mg/vitamin d 250 unit chewable tablet
• Calcium 500 mg/vitamin d 100 unit/vitamin k 40 mcg chewable tablet
• Calcium 500 mg/vitamin d 1000 unit/vitamin k 40 mcg chewable tablet
• Calcium 500 mg/vitamin d 200 unit/vitamin k 40 mcg chewable tablet
• Calcium 500 mg/vitamin d 500 unit/vitamin k 40 mcg chewable tablet
• Calcium 600 mg/magnesium 40 mg/vitamin d 500 unit extended release tablet
• Calcium acetate 668 mg tablet
• Calcium ascorbate 500 mg tablet
• Calcium carbonate 500 mg/cholecalciferol 100 unit chewable tablet
• Calcium carbonate 500 mg/cholecalciferol 600 unit tablet
• Calcium chloride 10% injection
• Calcium citrate 200 mg/vitamin d 250 unit tablet
• Calcium citrate 315 mg/vitamin d 250 unit tablet
• Calcium citrate 315 mg/vitamin d tab 200 unit tablet
• Calcium gluconate 10% injection
• Calcium/magnesium/zinc/d3 tablet
• Calcium-boron 500 mg/1.5 mg tablet
• Carbonyl iron 45 mg tablet
• Centratex 106 mg/1 mg capsule
• Centrum performance tablet
• Chemstrip bg log book
• Cholecalciferol 25 mcg (1000 unit) spray
• Cholecalciferol 250 mcg (10000 unit) capsule
• Cholecalciferol 250 mcg (10000 unit) tablet
• Chromic chloride 40 mcg per 10 mL injection
• Ciprofloxacin 100 mg tablet
• Citranatal b-calm 20 mg/1 mg/25 mg tablet
• Clinimix 4.25%/dextrose 10% intravenous solution
• Clinimix 4.25%/dextrose 5% intravenous solution
• Clinimix 5%/dextrose 15% intravenous solution
• Clinimix 5%/dextrose 20% intravenous solution
• Clinimix 8%/dextrose 10%intravenous solution
• Clinimix 8%/dextrose 14% intravenous solution
• Clinimix e 2.75%/dextrose 5% intravenous solution
• Clinimix e 4.25%/dextrose 10% intravenous solution
• Clinimix e 4.25%/dextrose 5% intravenous solution
• Clinimix e 5%/dextrose 15% intravenous solution
• Clinimix e 5%/dextrose 20% intravenous solution
• Clinimix e 8%/dextrose 10% intravenous solution
• Clinimix e 8%/dextrose 14% intravenous solution
• Clinimix/dextrose 6% intravenous solution
• Clinisol sf 15% intravenous solution
• Coagadex 250 unit reconstituted intravenous solution
• Coagadex 500 unit reconstituted intravenous solution
• Coconut oil 1000 mg capsule
• Cola syrup
• Collodion
• Collodion flexible
• Complete natal dha 29 mg/1 mg/200 mg/200 mg capsule
• Corifact 1000 unit/1600 unit kit
• Corn syrup
• Corticotropin gel 80 unit per mL injection
• Cromolyn sodium 100 mg per 5 mL oral concentration
• Cupric chloride 0.4 mg per mL injection
• Custom polyglycol troche base wax
• Cvs flaxseed oil 1000 mg capsule
• Cyclosporine 50 mg per mL intravenous solution
• Deferoxamine mesylate 2 gm for injection
• Deferoxamine mesylate 500 mg for injection
• Dekas plus oral liquid
• Delflex-sm/1.5% dextrose solution 398 mosm per L intraperitoneal
• Delflex-sm/2.5% dextrose solution 347 mosm per L intraperitoneal
• Delstrigo tab
• Dextrose 10% injection
• Dextrose 10%/sodium chloride 0.2%
• Dextrose 10%/sodium chloride 0.45%
• Dextrose 2.5%/sodium chloride 0.45%
• Dextrose 20% injection
• Dextrose 25% injection
• Dextrose 30% injection
• Dextrose 40% injection
• Dextrose 5% in lactated ringers
• Dextrose 5% injection
• Dextrose 5%/electrolyte 48 intravenous solution
• Dextrose 5%/sodium chloride 0.2%
• Dextrose 5%/sodium chloride 0.225%
• Dextrose 5%/sodium chloride 0.3%
• Dextrose 5%/sodium chloride 0.33%
• Dextrose 5%/sodium chloride 0.45%
• Dextrose 5%/sodium chloride 0.9%
• Dextrose 50% injection
• Dextrose 70% injection
• Dialyvite 3000 mg/3 mg tablet
• Dialyvite 5000 mg/5 mg tablet
• Dialyvite tablet
• Dialyvite zinc tablet
• Dobutamine 1 mg per mL in d5w injection
• Dobutamine 12.5 mg per mL injection
• Dobutamine 2 mg per mL in d5w injection
• Dobutamine 4 mg per mL in d5w injection
• Droperidol 2.5 mg per mL injection
• Dupilumab subcutaneous 100 mg per 0.67 mL prefilled syringe solution
• Dupilumab subcutaneous 200 mg per 1.14 mL pen injector solution
• Dupilumab subcutaneous 200 mg per 1.14 mL prefilled syringe solution
• Dupilumab subcutaneous 300 mg per 2 mL pen injector solution
• Dupilumab subcutaneous 300 mg per 2 mL prefilled syringe solution
• Ecolate 1000 unit reconstituted intravenous solution
• Ecolate 1500 unit reconstituted intravenous solution
• Ecolate 2000 unit reconstituted intravenous solution
• Ecolate 250 unit reconstituted intravenous solution
• Ecolate 3000 unit reconstituted intravenous solution
• Ecolate 4000 unit reconstituted intravenous solution
• Ecolate 500 unit reconstituted intravenous solution
• Ecolate 5000 unit reconstituted intravenous solution
• Ecolate 6000 unit reconstituted intravenous solution
• Ecolate 750 unit reconstituted intravenous solution
• Esperoct 1000 unit reconstituted intravenous solution
• Esperoct 1500 unit reconstituted intravenous solution
• Esperoct 2000 unit reconstituted intravenous solution
• Esperoct 3000 unit reconstituted intravenous solution
• Esperoct 500 unit reconstituted intravenous solution
• Esterified estrogens 0.625 mg/methyltestosterone 1.25 mg tablet
• Esterified estrogens 1.25 mg/methyltestosterone 2.5 mg tablet
• Ethyl alcohol 100%
• Famotidine 200 mg per 20 mL injection
• Famotidine 40 mg per 4 mL injection
• Famotidine in nacl 0.9% 20 mg per 50 mL intravenous solution
• Famotidine preservative free 20 mg per 2 mL injection
• Fasenra 30 mg per mL auto-injector
• Fasenra subcutaneous solution 30 mg per mL prefilled syringe
• Fat emulsion plant based (soy) iv emulsion 20%
• Fat emulsion plant based (soy) iv emulsion 30%
• Ferrex 150 forte plus 50 mg/100 mg capsule
• Ferrex 28 tablet
• Ferrex plus 150 mg/50 mg/50 mg capsule
• Ferrous fumarate/folic acid/docusate sodium/b complex/vitamin c tablet
• Fish oil 1000 mg/cholecalciferol 1000 unit capsule
• Fish oil 1200 mg/cholecalciferol 1000 unit capsule
• Fish oil 875 mg chewable tablet
• Fish oil adult gummies 113.5 mg chewable tablet
• Fish oil triple strength 1360 mg capsule
• Fixed oil suspension liquid
• Flaxseed oil 1300 mg capsule
• Fluocinonide 0.05% ointment
• Foamil liquid
• Folic acid 5 mg per mL injection
• Folivane-ob 85 mg/1 mg capsule
• Foltrate 500 mcg/1 mg tablet
• Fos-a liquid
• Fosinopril sodium/hydrochlorothiazide 10 mg/12.5 mg tablet
• Fosinopril sodium/hydrochlorothiazide 20 mg/12.5 mg tablet
• Freedom peg troche base powder
• Furosemide 10 mg per mL injection
• Genadek liquid drops
• Gentamicin in saline 0.8 mg per mL injection
• Gentamicin in saline 1 mg per mL injection
• Gentamicin in saline 1.2 mg per mL injection
• Gentamicin in saline 1.6 mg per mL injection
• Gentamicin in saline 2 mg per mL injection
• Gentamicin sulfate 10 mg per mL injection
• Gentamicin sulfate 40 mg per mL injection
• Glassia injection
• Glucagon diagnostic 1 mg for injection
• Glucocom autolink telemonitor
• Glycine diluent for injection
• Gnp fish oil delayed release 840 mg capsule
• Gold bond friction defense stick
• Granisetron 1 mg per mL injection
• Guaifenesin 100 mg per 5 mL syrup
• Gum base gelatin gel
• Hemofil m 1000 unit reconstituted intravenous solution
• Hemofil m 1700 unit reconstituted intravenous solution
• Hemofil m 250 unit reconstituted intravenous solution
• Hemofil m 500 unit reconstituted intravenous solution
• Hepatitis b immune globulin (human) 312 unit per mL intramuscular solution
• Humate-p 1000 unit/2400 unit reconstituted intravenous solution
• Humate-p 250 unit/600 unit reconstituted intravenous solution
• Humate-p 500 unit/1200 unit reconstituted intravenous solution
• Icatibant acetate subcutaneous 30 mg per 3 mL prefilled syringe solution
• Idelvion 1000 unit reconstituted intravenous solution
• Idelvion 2000 unit reconstituted intravenous solution
• Idelvion 250 unit reconstituted intravenous solution
• Idelvion 3500 unit reconstituted intravenous solution
• Idelvion 500 unit reconstituted intravenous solution
• Infant drinking water
• Infuvite intravenous injectable
• Infuvite pediatric intravenous solution
• Ionosol-mb in dextrose 5% intravenous solution
• Irbesartan 150 mg tablet
• Irbesartan 300 mg tablet
• Irbesartan 75 mg tablet
• Iron polysacch complex 150 mg/vitamin b12 0.025 mg/folic acid 1 mg capsule
• Isolyte-p in dextrose 5% intravenous solution
• Isolyte-s intravenous solution
• Isolyte-s pH 7.4 intravenous solution
• Ixinity 1000 unit reconstituted intravenous solution
• Ixinity 1500 unit reconstituted intravenous solution
• Ixinity 2000 unit reconstituted intravenous solution
• Ixinity 250 unit reconstituted intravenous solution
• Ixinity 3000 unit reconstituted intravenous solution
• Ixinity 500 unit reconstituted intravenous solution
• Jivi 1000 unit reconstituted intravenous solution
• Jivi 2000 unit reconstituted intravenous solution
• Jivi 3000 unit reconstituted intravenous solution
• Jivi 500 unit reconstituted intravenous solution
• Kesimpta 20 mg per 0.4 mL
• Koate 1000 unit reconstituted intravenous solution
• Koate 250 unit reconstituted intravenous solution
• Koate 500 unit reconstituted intravenous solution
• Kogenate fs 1000 unit intravenous kit
• Kogenate fs 2000 unit intravenous kit
• Kogenate fs 250 unit intravenous kit
• Kogenate fs 3000 unit intravenous kit
• Kogenate fs 500 unit intravenous kit
• Lactated ringers for irrigation
• Lactated ringers solution
• Lidocaine 0.5%/epinephrine 1:200000 injection
• Lidocaine 1%/epinephrine 1:100000 injection
• Lidocaine 1.5%/epinephrine 1:200000 injection
• Lidocaine 2%/epinephrine 1:100000 injection
• Lidocaine 2%/epinephrine 1:200000 injection
• Lidocaine 2%/epinephrine 1:50000 injection
• Lidocaine local preservative free 1% injection
• Lidocaine local 0.5% injection
• Lidocaine local 1% injection
• Lidocaine local 2% injection
• Lidocaine local preservative free 0.5% injection
• Lidocaine local preservative free 1.5% injection
• Lidocaine local preservative free 2% injection
• Lidocaine local preservative free 4% injection
• L-methylfolate 15 mg tablet
• L-methylfolate 7.5 mg tablet
• Lozibase
• Magnesium chloride 200 mg per mL injection
• Magnesium oxide 200 mg tablet
• Magnesium oxide 250 mg tablet
• Magnesium oxide 400 mg capsule
• Magnesium oxide 500 mg capsule
• Magnesium sulfate 20 gm per 500 mL intravenous solution
• Magnesium sulfate 4 gm per 100 mL intravenous solution
• Magnesium sulfate 4 gm per 50 mL intravenous solution
• Magnesium sulfate 40 gm per 1000 mL intravenous solution
• Magnesium sulfate 50% injection
• Manganese chloride 0.1 mg per mL intravenous solution
• Meloxicam 30 mg per mL intravenous solution
• Miglustat 100 mg capsule
• Milk thistle (silybum marianum) 175 mg capsule
• Milk thistle (silybum marianum) 175 mg tablet
• Milk thistle (silybum marianum) 300 mg capsule
• Milk thistle (silybum marianum) 87.5 mg capsule
• Milrinone lactate 10 mg per 10 mL intravenous solution (base equivalent)
• Milrinone lactate 20 mg per 100 mL in dextrose 5% intravenous solution (base equivalent)
• Milrinone lactate 20 mg per 20 mL intravenous solution (base equivalent)
• Milrinone lactate 40 mg per 200 mL in dextrose 5% intravenous solution (base equivalent)
• Milrinone lactate 50 mg per 50 mL intravenous solution (base equivalent)
• Multiple vitamin injection
• Mvw complete formulation pediatric oral solution
• Mycophenolate mofetil 500 mg for intravenous solution (base equiv)
• Naloxone 8 mg per 0.1 mL nasal spray
• Nephplex tablet
• Nephron fa tablet
• Nice distilled water
• Normosol-m in dextrose 5% intravenous solution
• Normosol-r in dextrose 5% intravenous solution
• Normosol-r intravenous solution
• Normosol-r pH 7.4 intravenous solution
• Novoeight 1000 unit reconstituted intravenous solution
• Novoeight 1500 unit reconstituted intravenous solution
• Novoeight 2000 unit reconstituted intravenous solution
• Novoeight 250 unit reconstituted intravenous solution
• Novoeight 3000 unit reconstituted intravenous solution
• Novoeight 500 unit reconstituted intravenous solution
• Novoseven rt 1 mg intravenous solution
• Novoseven rt 2 mg intravenous solution
• Novoseven rt 5 mg intravenous solution
• Novoseven rt 8 mg intravenous solution
• Nuedexta 20 mg/10 mg capsule
• Nuwiq 1000 unit kit
• Nuwiq 1000 unit reconstituted intravenous solution
• Nuwiq 1500 unit kit
• Nuwiq 1500 unit reconstituted intravenous solution
• Nuwiq 2000 unit kit
• Nuwiq 2000 unit reconstituted intravenous solution
• Nuwiq 250 unit kit
• Nuwiq 250 unit reconstituted intravenous solution
• Nuwiq 2500 unit kit
• Nuwiq 2500 unit reconstituted intravenous solution
• Nuwiq 3000 unit kit
• Nuwiq 3000 unit reconstituted intravenous solution
• Nuwiq 4000 unit kit
• Nuwiq 4000 unit reconstituted intravenous solution
• Nuwiq 500 unit kit
• Nuwiq 500 unit reconstituted intravenous solution
• Obizur 500 unit reconstituted intravenous solution
• Omega-3 delayed release 350 mg capsule
• Omega-3 fish oil 880 mg capsule
• Onabotulinumtoxina 100 unit for injection
• Onabotulinumtoxina 200 unit for injection
• Ondansetron 4 mg per 2 mL injection
• Ondansetron 4 mg per 2 mL prefilled syringe
• Ondansetron 40 mg per 20 mL injection
• Oxycodone 5 mg/acetaminophen 325 mg per 5 mL solution
• Palonosetron 0.25 mg per 5 mL intravenous solution (base equivalent)
• Pcca pracamac base oil
• Pediatric multiple vitamins intravenous solution
• Pediatric multiple vitamins with minerals liquid
• Pediatric multiple vitamins with minerals oral solution
• Pentamidine isethionate 300 mg for nebulization solution
• Phytonadione 1 mg per 0.5 mL injection
• Phytonadione 10 mg per mL injection
• Pifeltro 100 mg tablet
• Pimozide 1 mg tablet
• Pimozide 2 mg tablet
• Plasma-lyte a intravenous solution
• Pnv-dha 27 mg/0.6 mg/0.4 mg/300 mg capsule
• Polysaccharide iron-fa-vit b12 cap 150 mg-1 mg-25 mcg
• Poly-vi-flor 0.25 mg per mL oral suspension
• Poly-vi-flor with iron 0.25 mg/7 mg per mL suspension
• Poly-vi-flor with iron 0.5 mg/10 mg chewable tablet
• Potassion chloride 20 meq per L (0.15%) in sodium chloride 0.45% injection
• Potassium acetate 2 meq per mL injection
• Potassium bicarbonate-citric acid 10 meq effer tablet
• Potassium bicarbonate-citric acid 20 meq effer tablet
• Potassium chloride 10 meq per 100 mL injection
• Potassium chloride 10 meq per 50 mL injection
• Potassium chloride 10 meq per L (0.075%) in dextrose 5% and sodium chloride 0.45% injection
• Potassium chloride 10% oral solution
• Potassium chloride 2 meq per mL injection
• Potassium chloride 20 meq per 100 mL injection
• Potassium chloride 20 meq per 50 mL injection
• Potassium chloride 20 meq per L (0.15%) in dextrose 5% and sodium chloride 0.2% injection
• Potassium chloride 20 meq per L (0.15%) in dextrose 5% and sodium chloride 0.225% injection
• Potassium chloride 20 meq per L (0.15%) in dextrose 5% and sodium chloride 0.45% injection
• Potassium chloride 20 meq per L (0.15%) in dextrose 5% and sodium chloride 0.9% injection
• Potassium chloride 20 meq per L (0.15%) in dextrose 5% injection
• potassium chloride 20 meq per L (0.15%) in dextrose 5% lactated ringers
• Potassium chloride 20 meq per L (0.15%) in sodium chloride 0.9% injection
• Potassium chloride 20 meq powder packet
• Potassium chloride 20% oral solution
• Potassium chloride 30 meq per L (0.224%) in dextrose 5% and sodium chloride 0.45% injection
• Potassium chloride 40 meq per 100 mL injection
• Potassium chloride 40 meq per L (0.3%) in dextrose 5% and sodium chloride 0.45% injection
• Potassium chloride 40 meq per L (0.3%) in dextrose 5% and sodium chloride 0.9% injection
• Potassium chloride 40 meq per L (0.3%) in sodium chloride 0.9% injection
• Potassium phosphates 15 mm per 5 mL injection
• Potassium phosphates 150 mm per 50 mL injection
• Potassium phosphates 45 mm per 15 mL injection
• Potassium phosphates 45 mm per 15 mL injection
• Prenate enhance 28 mg/0.6 mg/0.4 mg/400 mg capsule
• Profilnine 1000 unit reconstituted intravenous solution
• Profilnine 1500 unit reconstituted intravenous solution
• Profilnine 500 unit reconstituted intravenous solution
• Prolastin-c 1000 mg vial
• Prosol 20% intravenous solution
• Purevit dualfe plus 162 mg/115.2 mg/1 mg capsule
• Pyridostigmine bromide 30 mg tablet
• Pyridostigmine bromide 60 mg per 5 mL oral solution
• Pyridostigmine bromide extended release 180 mg tablet
• Pyridoxine 100 mg per mL injection
• Rebinyn 1000 unit reconstituted intravenous solution
• Rebinyn 2000 unit reconstituted intravenous solution
• Rebinyn 500 unit reconstituted intravenous solution
• Recombinate 1241 unit/1800 unit reconstituted intravenous solution
• Recombinate 1801 unit/2400 unit reconstituted intravenous solution
• Recombinate 220 unit/400 unit reconstituted intravenous solution
• Recombinate 401 unit/800 unit reconstituted intravenous solution
• Recombinate 801 unit/1240 unit reconstituted intravenous solution
• Reyataz 50 mg powder
• Rheospray liquid
• Rifampin 600 mg for injection
• Rimantadine hydrochloride 100 mg tablet
• Ringer's solution
• Ringer's solution for irrigation
• Rose water
• Rukobia 600 mg extended release tablet
• Salicylic acid 27.5% film forming liquid
• Select-ob and dha 29 mg/1 mg/250 mg capsule
• Selenious acid 40 mcg per mL injection
• Selzentry 20 mg per mL solution
• Seraqua liquid
• Sevenfact 1 mg reconstituted intravenous solution
• Sevenfact 5 mg reconstituted intravenous solution
• Sm fish oil 554 mg capsule
• Sodium acetate 2 meq per mL injection
• Sodium acetate 4 meq per mL injection
• Sodium bicarbonate 4.2% intravenous solution
• Sodium chloride 0.45% intravenous solution
• Sodium chloride 0.9% intravenous solution
• Sodium chloride 2.5 meq per mL injection
• Sodium chloride 3% intravenous solution
• Sodium chloride 4 meq per mL intravenous solution
• Sodium chloride 5% intravenous solution
• Sodium chloride preservative free 0.9% injection
• Sodium ferric glucose complex 12.5 mg per mL in sucrose intravenous solution
• Sodium phosphates 45 mm per 15 mL injection
• Sodium zirconium cyclosilicate 10 gm packet for suspension
• Sodium zirconium cyclosilicate 5 gm packet for suspension
• Solydra liquid
• Supposibase f powder
• Syringe/needle 1 ml 30 x 1/2"
• Taliglucerase alfa 200 unit for injection
• Techna 20 sf troche base flakes
• Telmisartan 20 mg tablet
• Telmisartan 40 mg tablet
• Telmisartan 80 mg tablet
• Tetracaine 1% injection
• The very finest fish oil oral liquid
• Thiamine 100 mg per mL injection
• Tinidazole 250 mg tablet
• Tinidazole 500 mg tablet
• Tobramycin sulfate 1.2 gm per 30 mL (base equivalent)
• Tobramycin sulfate 10 mg per mL (base equivalent)
• Tobramycin sulfate 2 gm per 50 mL injection (base equivalent)
• Tobramycin sulfate 80 mg per 2 mL (base equivalent)
• Tpn electrolytes concentrate
• Tranexamic acid 1000 mg per 10 mL intravenous solution
• Tranexamic acid 1000 mg per 100 mL/sodium chloride 0.7% intravenous solution
• Tretten 2000 unit/3125 unit reconstituted intravenous solution
• Tri-vi-flor 0.25 mg per mL oral suspension
• Tri-vi-flor 0.5 mg per mL oral suspension
• Trochibase s flakes
• Trogarzo 150 mg per mL injection
• U-mild shampoo
• Vehicle s
• Versapro shampoo
• Vitafol fe 90 mg/0.6 mg/0.4 mg/200 mg capsule
• Vitafol gummies 3.33 mg/0.333 mg/34.8 mg chewable tablet
• Vitafol ultra 29 mg/0.6 mg/0.4 mg/200 mg capsule
• Vitafol-nano 18 mg/0.6 mg/0.4 mg tablet
• Vitafol-ob and dha 65 mg/1 mg/250 mg capsule
• Vitafol-ob tablet
• Vitafol-one 29 mg/1 mg/200 mg capsule
• Vital-d 1 mg tablet
• Vitamin b12 500mg/folic acid 400 mcg tablet
• Vitamin c bioflavonoids extended release 1000 mg/100 mg tablet
• Vitamin c chewable tablet
• Vonvendi 1300 unit reconstituted intravenous solution
• Vonvendi 650 unit reconstituted intravenous solution
• Wilate 1000 unit/1000 unit kit
• Wilate 500 unit/500 unit kit
• Xyntha 1000 unit kit
• Xyntha 2000 unit kit
• Xyntha 250 unit kit
• Xyntha 500 unit kit
• Xyntha solofuse 1000 unit kit
• Xyntha solofuse 2000 unit kit
• Xyntha solofuse 250 unit kit
• Xyntha solofuse 3000 unit kit
• Xyntha solofuse 500 unit kit
• Zidovudine 10 mg per mL intravenous solution
• Zinc chloride 1 mg per mL injection
• Zinc sulfate 1 mg per mL injection
• Zinc sulfate 3 mg per mL injection
• Zinc sulfate 5 mg per mL injection

Other Updates:

• Bisoprolol fumarate 10 mg tablet (Added Quantity Limit)
• Desmopressin acetate 0.01% nasal spray solution (Added Quantity Limit)
• Fluocinolone acetonide 0.01% oil (Added Quantity Limit)
• Hydrocortisone acetate 1% cream (Added Quantity Limit)
• Lisinopril 20 mg/ hydrochlorothiazide 12.5 mg tablet (Added Quantity Limit)
• Methadone 10 mg per 5 mL solution (Added Quantity Limit)
• Methadone 10 mg per mL concentration (Added Quantity Limit)
• Methadone 10 mg tablet (Added Quantity Limit)
• Methadone 5 mg per 5 mL solution (Added Quantity Limit)
• Methadone 5 mg tablet (Added Quantity Limit)
• Propranolol extended release 120 mg capsule (Added Quantity Limit)
• Propranolol extended release 160 mg capsule (Added Quantity Limit)
• Sildenafil citrate 20 mg tablet (Added Quantity Limit)

July 2023

Additions:

• Algae based calcium tablet
• Ceravite antioxidant senior tablet
• Ceravite antioxidant tablet
• Cerovite senior tablet
• Compete tablet
• Dermavite tablet
• Dialyvite ultra d 800 mg tablet
• Ex-lax 15 mg chewable tablet
• Gaviscon 95 mg/358 mg per 15 ml oral suspension
• Gaviscon extra strength 160 mg/105 mg chewable tablet
• Gnp healthy eyes tablet
• Gnp mega multi for men tablet
• Gnp mega multi for women tablet
• Gnp mens one daily lycopene tablet
• GNP motion sickness 25 mg tablet
• Gnp one daily mens health 50+ tablet
• Gnp one daily womens health 50+ tablet
• Gnp womens one daily tablet
• Hm 500 mg antacid chewable
• Icaps areds formula tablet
• Icaps mv tablet
• I-vite tablet
• Kalydeco 13.4 mg granules (Prior Authorization)
• Mekinist 0.05 mg per ml solution (Prior Authorization)
• Ocuvite extra tablet
• Ocuvite eye multi tablet
• Ocuvite-lutein tablet
• Oncovite tablet
• Prenatal 19 tablet
• Preservision areds tablet
• Prorenal plus d tablet
• Prosight tablet
• Qc antacid 500 mg chewable tablet
• Qc antacid 750 mg extended release chewable tablet
• Qc daily multivitamin and multimineral tablet
• Qc mens daily multivitamin tablet
• Qc multi-vite 50+ tablet
• Qc multi-vite tablet
• Qc therin-m tablet
• Qc womens daily multivitamin tablet
• Renaplex tablet
• Renaplex-d tablet
• Sentry senior tablet
• Sm complete advanced formula tablet
• Sm complete senior formula tablet
• Sm complete tablet
• Sm daily diet support tablet
• Sm motion sickness 25 mg tablet
• Sm opti-vitamins tablet
• Systane icaps areds2 tablet
• Tafinlar 10 mg tablet (Prior Authorization)
• Thera m plus tablet
• Thera m tablet
• Therems m tablet
• Trikafta 59.5 mg pak (Prior Authorization)
• Trikafta 75 mg pak (Prior Authorization)
• Tums 500 mg chewable tablet
• Tums 750 mg chewable tablet
• Tums extra strength 750 mg chewable tablet
• Tums ultra 1000 mg chewable tablet
• Wes-phos 250 neutral 155 mg/852 mg/130 mg tablet

Removals:

• A + D personal care lotion
• Advanced healing baby ointment
• Afatinib dimaleate 20 mg base equivalent tablet
• Afatinib dimaleate 30 mg base equivalent tablet
• Afatinib dimaleate 40 mg base equivalent tablet
• Alectinib 150 mg base equivalent capsule
• Alemtuzumab 30 mg per ml intravenous injection
• Allantoin 0.2% cream
• Alogliptin-pioglitazone 12.5 mg/15 mg tablet
• Alogliptin-pioglitazone 12.5 mg/45 mg tablet
• Amino acid 5.2% infusion
• Amino acid 8.5% infusion
• Amino acid electrolyte 3.5% infusion
• Amino acid electrolyte 7% infusion
• Amino acid electrolyte 8.5% infusion
• Antacid flavor 750 mg chewable tablets
• Aqua glycolic hand and body lotion
• Aqua lacten lotion
• Aquamed lotion
• Aquaphor 41% advanced protection healing ointment
• Aquaphor ointment
• Aromatic elixir
• Aveeno daily moisturizing lotion
• Aveeno stress relief lotion
• Bacmin tablet
• Bacteriostatic water for injection
• Bacteriostatic water for injection (parabens)
• Butalbital 50 mg Aspirin 325 mg and caffeine 40 mg tablet
• Calcium carbonate 500 mg and vitamin d 125 unit tablet
• Cam lotion
• Cefazolin sodium 20 gm for injection
• Cefotetan disodium 1 gm and dextrose 3.58% per 50 ml intravenous solution
• Cefotetan disodium 10 gm for injection
• Cefotetan disodium 2 gm and dextrose 2.08% per 50 ml intravenous solution
• Cefuroxime sodium 7.5 gm for injection
• Centany 2% ointment
• Ceritinib 150 mg capsule
• Cetaphil advanced relief lotion
• Cetaphil moisturizing lotion
• Cimetidine 300 mg per 5 ml solution
• Colloidal oatmeal pack 100% and colloidal oatmeal cream 1% kit
• Corvita tablet
• Cvc special care lotion
• Cvs advanced healing ointment
• Cvs antacid maximun strength 1000 mg chewable tablet
• Cvs beauty 360 dry skin lotion
• Cvs daily ultra moisture lotion
• Cvs gentle skin cleanser lotion
• Cvs glycerin 2 gm adult rectal suppository
• Cvs heartburn relief 160 mg/105 mg chewable tablet
• Cvs miconazole 1200 mg/2 mg 1% vaginal kit
• Dental base gel
• Dermacinrx multitam tablet
• Dermacinrx ribotin-e tablet
• Dermacinrx zintrexyl-c tablet
• Derma-g mild liquid
• Dermal therapy 1% face care therapy
• Dermal therapy 1% foot massage lotion
• Dermal therapy extra strength 10% lotion
• Dermal therapy hand and elbow 15% lotion
• Dermal therapy heel care 25% lotion
• Dexpanthenol 2% cream
• Dextrose diagnostic aid 5% injection
• Dialyvite supreme d tablet
• Didanosine delayed release 250 mg capsule
• Didanosine delayed release 400 mg capsule
• Eculizumab 300 mg per 30 ml intravenous solution
• Electrolyte-b in dextrose 5% solution
• Emollient aerosol foam
• Emollient cream and wound dressing gel kit
• Emollient emulsion
• Emollient foam and wound dressing gel kit
• Emollient with antiseptic lotion
• Epclusa 400 mg/100 mg tablet
• Epilyt lotion
• Epirubicin 200 mg for intravenous injection
• Eq antacid ultra strength 1000 mg chewable tablet
• Eq miconazole 1200 mg/2 mg 1% vaginal kit
• Etanercept 25 mg for subcutaneous injection
• Eucerin baby lotion
• Eucerin daily hydration lotion
• Eucerin daily protection SPF 30 lotion
• Eucerin intense repair lotion
• External vehicles solution
• Fish oil 1000 mg and vitamin d 1000 unit capsule
• Floriva plus 0.25 mg per ml solution
• Fluticasone propionate 110 mcg per actuation inhalation
• Fluticasone propionate 220 mcg per actuation inhalation
• Fluticasone propionate 44 mcg per actuation inhalation
• Foliflex tablet
• Folitin-z tablet
• Gentamicin 1.4 mg per ml in saline for injection
• Gentamicin sulphate 0.3% ophthalmic ointment
• Glycerin and rose water
• Glycerin/mineral oil/petrolatum/cetostearyl alc cream
• Goodsense antacid 500 mg chewable tablet
• Granisetron 0.1 mg per ml injection
• Grape oral syrup
• Griseofulvin ultramicrosize 135 mg tablet
• Griseofulvin ultramicrosize 330 mg tablet
• Human serum albumin diluent for injection
• Humulin 70/30 100 units per ml pen-injector
• Humulin 70/30 100 units per ml subcutaneous
• Humulin N 100 units per ml pen-injector
• Humulin N 100 units per ml subcutaneous
• Humulin R 100 units per ml subcutaneous
• Hyaluronate sodium 0.1% lotion
• Hyaluronate sodium 0.2% gel
• Hyaluronate sodium lotion
• Hydrocortisone acetate 2.5% with pramoxine perianal 1% cream
• Hydrocortisone with aloe vera 1% cream
• Icatibant acetate 30 mg per 3 ml injection
• Insulin syringe/needle U-100 0.3 ml 28 x ½”
• Insulin syringe/needle U-100 0.3 ml 29 G
• Insulin syringe/needle U-100 0.3 ml 29 x 1”
• Insulin syringe/needle U-100 0.3 ml 29 x 7/16”
• Insulin syringe/needle U-100 0.3 ml 30 G
• Insulin syringe/needle U-100 0.3 ml 30 x 3/8”
• Insulin syringe/needle U-100 0.3 ml 30 x 7/16”
• Insulin syringe/needle U-100 0.3 ml 31 x 3/8”
• Insulin syringe/needle U-100 0.5 ml 28 x 5/16”
• Insulin syringe/needle U-100 0.5 ml 29 G
• Insulin syringe/needle U-100 0.5 ml 29 x 5/16”
• Insulin syringe/needle U-100 0.5 ml 29 x 7/16”
• Insulin syringe/needle U-100 0.5 ml 30 G
• Insulin syringe/needle U-100 0.5 ml 30 x 3/8”
• Insulin syringe/needle U-100 0.5 ml 30 x 7/16”
• Insulin syringe/needle U-100 0.5 ml 31 x 3/8”
• Insulin syringe/needle U-100 1 ml 29 G
• Insulin syringe/needle U-100 1 ml 29 x 7/16”
• Insulin syringe/needle U-100 1 ml 30 G
• Insulin syringe/needle U-100 1 ml 30 x 3/8”
• Insulin syringe/needle U-100 1 ml 30 x 7/16”
• Insulin syringe/needle U-100 1 ml 31 x 3/8”
• Insulin syringe/needle U-100 2 ml 29 x ½”
• Insulin syringe/needle U-40 1 ml 25 x 5/8”
• Interferon alfa-2b 10,000,000 units for injction
• Interferon alfa-2b 18,000,000 units for injction
• Interferon alfa-2b 50,000,000 units for injction
• Isopto atropine 1% ophthalmic solution
• Johnson’s skin nourish moist lotion
• Keri advanced moisture therapy lotion
• Keri basic essentials lotion
• Keri nourishing shea butter lotion
• Keri original daily moisture lotion
• Keri overnight lotion
• Keri renewal milk body lotion
• Keri renewal skin firming lotion
• Keri renewal stretch mark lotion
• Keri sentitive skin lotion
• Ketotifen fumarate 0.025% preservative free ophthalmic solution
• Lactic acid 10% cream
• Lactic acid 12% foam
• Lamivudine 5 mg per ml oral solution
• Lamivudine tenofovir disoproxil fumarate 300 mg/300 mg tablet
• Lenvatinib 10 mg therapy pack
• Lenvatinib 10 mg therapy pack (20 mg daily dose)
• Lenvatinib 4 mg therapy pack (12 mg)
• Lenvatinib 4 mg therapy pack (4 mg daily dose)
• Lenvatinib 4 mg therapy pack (8 mg daily dose)
• Lenvatinib 4 mg/10 mg therapy pack (14 mg daily dose)
• Lenvatinib 4 mg/10 mg therapy pack (18 mg daily dose)
• Lenvatinib 4 mg/10 mg therapy pack (24 mg daily dose)
• Lidocaine 5% in 7.5% dextrose intraspinal solution
• Liqua spen syrup
• Loratadine syrup 5 mg per 5 ml
• Lubrisoft lotion
• Magnesium oxide 400 mg capsule
• Melatonin 3 mg controlled release capsule
• Methotrexate sodium 200 mg per 8 ml preservative free injection
• Methotrexate sodium 25 mg per ml injection
• Mouthwash compounding base liquid
• Nicadan tablet
• Nivea original moisture lotion
• Nivea visage lotion
• Nutraderm advanced formula lotion
• Nutricap tablet
• Nutrifac zx tablet
• Oral vehicles
• Orange flower water
• Orange syrup
• Paliperidone palmitate extended release 117 mg per 0.75 ml intramuscular suspension
• Paliperidone palmitate extended release 156 mg per ml intramuscular suspension
• Paliperidone palmitate extended release 175 mg per 0.875 ml prefilled syringe
• Paliperidone palmitate extended release 234 mg per 1.5 ml intramuscular suspension
• Paliperidone palmitate extended release 263 mg per 1.315 ml prefilled syringe
• Paliperidone palmitate extended release 273 mg per 0.875 ml intramuscular suspension
• Paliperidone palmitate extended release 350 mg per 1.75 ml prefilled syringe
• Paliperidone palmitate extended release 39 mg per 0.25 ml intramuscular suspension
• Paliperidone palmitate extended release 410 mg per 1.315 ml intramuscular suspension
• Paliperidone palmitate extended release 525 mg per 2.625 ml prefilled syringe
• Paliperidone palmitate extended release 546 mg per 1.75 ml intramuscular suspension
• Paliperidone palmitate extended release 78 mg per 0.5 ml intramuscular suspension
• Paliperidone palmitate extended release 819 mg per 2.625 ml intramuscular suspension
• Parenteral electrolyte solution
• Pediatric multiple vitamins with calcium and iron chewable tablet
• Pediatric multiple vitamins with extra calcium and iron chewable tablet
• Pediatric multiple vitamins with fluoride 0.5 mg and iron 10 mg biphasic chewable tablet
• Pediatric multiple vitamins with fluoride biphasic 0.25 mg chewable tablet
• Pediatric multiple vitamins with fluoride biphasic 0.5 mg chewable tablet
• Pediatric multiple vitamins with fluoride biphasic 1 mg chewable tablet
• Pediatric multiple vitamins with minerals and calcium 45 mg per 0.5 ml drops
• Penicillin g benzathine 2400000 units per 4 ml intramuscular suspension
• Potassium chloride 10 meq per L in dextrose 5% and sodium chloride 0.2% injection
• Potassium chloride 20 meq per L in dextrose 5% and sodium chloride 0.33% injection
• Potassium chloride 30 meq per 100 ml injection
• Potassium chloride 30 meq per L in dextrose 5% and sodium chloride 0.2% injection
• Potassium chloride 30 meq per L in dextrose 5% injection
• Potassium chloride 40 med per L in dextrose and lactated ringers
• Potassium chloride 40 meq per L in dextrose 5% and sodium chloride 0.2% injection
• Potassium chloride 40 meq per L in dextrose 5% injection
• Prednicarbate 0.1% ointment
• Prednisolone syrup 15 mg per 5 ml
• Propylene glycol
• PureFe ob plus 162 mg/115.2 mg/1 mg capsules
• Quflora pediatric 0.25 mg per ml solution
• Relion 70% alcohol pads
• Risperidone microspheres 12.5 mg for injection
• Risperidone microspheres 25 mg for injection
• Risperidone microspheres 37.5 mg for injection
• Risperidone microspheres 50 mg for injection
• Ritonavir 80 mg per ml oral solution
• Rose essence soluble
• Saccharin 0.05% solution
• Saccharin 0.05% suspension
• Saline with parabens injection
• Saline/benzyl/alcohol injection solution
• Saquinavir mesylate 500 mg tablet
• Semaglutide solution 2 mg per 1.5 ml pen injector (0.25 mg or 0.5 mg per dose)
• Semaglutide solution 2 mg per 1.5 ml pen injector (1 mg per dose)
• Simple syrup
• Sodium iodide 100 mcg per ml injection
• Sorbitol with saccharin syrup
• Sterile water for injection
• Strovite one tablet
• Sure comfort 70% alcohol prep pads
• Syringe/needle 12 ml 20 x 1”
• Syringe/needle 12 ml 22 x 1”
• Syringe/needle 6 ml 20 x 1”
• Syringe/needle 6 ml 21 x 1 ¼”
• Syringe/needle 6 ml 22 x 1 ¼”
• Syringe/needle 6 ml 22 x 1”
• Syringe/needle 6 ml 23 x 1”
• Syrspend sugar free alka reconstituted suspension
• Tretinoin emollient 0.02% cream
• Tretinoin emollient 0.05% cream
• Tucatinib 150 mg tablet
• Tucatinib 50 mg tablet
• Udamin sp tablet
• Unispend anhydrous sweetened oral suspension
• Urea 10% cream
• Urea 10% lotion
• Urea 15% lotion
• Urea 2% cream
• Urea 20% cream
• Urea 20% lotion
• Urea 22% ointment
• Urea 25% lotion
• Urea 30% cream
• Urea 40% cream
• Urea 40% ointment
• Urea 5% lotion
• Vancomycin 25 mg per ml oral solution compound kit
• Vancomycin 50 mg per ml oral solution compound kit
• Vandazole 0.75% vaginal gel
• Varenicline tartrate 0.5 mg and 1 mg starter pack
• Vehicle a
• Vehicle n
• Venexa fe tablet
• Venexa tablet
• Ventrixyl fe tablet
• Ventrixyl tablet
• Vita s forte tablet
• Vitamin a and e emulsion
• Vitamin a and d with aloe and zinc oxide cream
• Vitamin c lotion
• Vitamin e 100 unit per gram cream
• Vitamin e shampoo
• Vitamin e with a and d ointment
• Vitamins a and d cream
• Vitamins a and d liquid
• Vitamins a and d with zinc oxide ointment
• Vitramyn tablet
• Vitranol fe tablet
• Vitrexate fe tablet
• Vitrexate tablet
• Vitrexyl and iron tablet
• Vitrexyl tablet
• Vp-pnv-dha 28mg/1mg/215.8 mg capsules
• Wibi lotion
• Wild cherry flavor extract
• Zevrx sterile 70% alcohol prep pad

Other Updates:

• N/A

June 2023

Additions:

• N/A

Removals:

• Firvanq 50 mg per ml solution

Other Updates:

• N/A

May 2023

Additions:

• Breztri aerosphere 160mcg/9 mcg/4.8 mcg inhalation (Step Therapy, Quantity Limit)
• CVS pinworm 50 mg per ml suspension
• Fexofenadine HCL 30 mg per ml suspension (Quantity Limit)
• Gilenya 0.25 mg capsules (Prior Authorization, Quantity Limit)
• GNP hydrocortisone max strength 1% ointment
• Trikafta 100 mg/50 mg/75 mg/150 mg tablets (Prior Authorization)
• Trikafta 50 mg/25 mg/37.5 mg/75 mg tablets (Prior Authorization)
• Urea 20% cream

Removals:

• Amphotericin b 50 mg reconstituted intravenous solution
• Aztreonam 1 gm solution for injection
• Aztreonam 2 gm solution for injection
• Cholecalciferol 125 mcg per ml drops
• Cholecalciferol 2000 unit chewable tablets
• Cholecalciferol 3000 unit tablets
• Cholecalciferol 400 unit capsules
• Cholecalciferol 4000 unit capsules
• Clindamycin phosphate 300 mg per 2 ml injection
• Clindamycin phosphate 600 mg per 4 ml injection
• Clindamycin phosphate 9 gm per 60 ml injection
• Clindamycin phosphate 900 mg per 6 ml injection
• Colestipol 5 gm granule packets
• Colestipol 5 gm granules
• Colistimethate sodium150 mg solution for injection
• Creon delayed release 12000-38000 unit capsules
• Creon delayed release 24000-76000 unit capsules
• Creon delayed release 3000-9500 unit capsules
• Creon delayed release 36000-114000 unit capsules
• Creon delayed release 6000-19000 unit capsules
• Dekas essential oral liquid
• Diuril 250 mg per 5 ml oral suspension
• Elmiron 100 mg capsules
• Enfamil expecta 28 mg/0.8 mg/200 mg capsules
• Ergocalciferol 2000 unit tablets
• Ergocalciferol 400 unit tablets
• Fluconazole 100 mg in sodium chloride 0.9% per 50 ml intervenous solution
• Fluconazole 200 mg in sodium chloride 0.9% per 100 ml intervenous solution
• Fluconazole 400 mg in sodium chloride 0.9% per 200 ml intervenous solution
• Fluocinolone acetonide 0.01% cream
• Fluocinolone acetonide 0.01% scalp oil
• Ganciclovir sodium 500 mg per 10 ml intravenous solution
• Ganciclovir sodium 500 mg reconstituted intravenous solution
• Heparin sodium (porcine) 20000 units per ml injection
• Heparin sodium (porcine) 5000 units per 0.5 ml injection
• Hydroxychloroquine sulfate 100 mg tablets
• Hydroxychloroquine sulfate 300 mg tablets
• Hydroxychloroquine sulfate 400 mg tablets
• Hydroxyprogesterone caproate bulk powder
• Hydroxyprogesterone caproate oil 250 mg per ml injection
• Hydroxyprogesterone caproate solution 275 mg per 1.1 ml auto-injector
• Imipenem-cilastatin 250 mg intravenous solution
• Imipenem-cilastatin 500 mg intravenous solution
• Isosorbide dinitrate 40 mg tablets
• Lidocaine 4% cream
• Lidocaine HCL 4% solution
• Lincomycin HCL 300 mg per ml injection
• Magnesium 400 mg tablet
• Makena 275 mg per 1.1 ml auto-injector
• Meropenem 1 gm and sodium chloride 0.9% per 50 ml intravenous solution
• Meropenem 1 gm intravenous solution
• Meropenem 500 mg and sodium chloride 0.9% per 50 ml intravenous solution
• Meropenem 500 mg intravenous solution
• Metronidazole 500 mg per 100 ml intravenous solution
• Mexiletine HCL 150 mg capsules
• Mexiletine HCL 200 mg capsules
• Mexiletine HCL 250 mg capsules
• Niacin extended release 1000 mg tablets
• Niacin extended release 500 mg tablets
• Niacin extended release 750 mg tablets
• Olmesartan hydrochlorothiazide 20 mg/12.5 mg tablets
• Olmesartan hydrochlorothiazide 40 mg/12.5 mg tablets
• Olmesartan hydrochlorothiazide 40 mg/25 mg tablets
• Omega-3 fatty acids 435 mg capsules
• Pediatric multiple vitamins with minerals chewable tablets
• Polymyxin b sulfate 500,000 unit solution for injection
• Posaconazole delayed release 100 mg tablets
• Quinidine sulfate 200 mg tablets
• Quinidine sulfate 300 mg tablets
• Ranolazine extended release 1000 mg tablet
• Ranolazine extended release 500 mg tablet
• Ribavirin 6 gm reconstituted inhalation solution
• Stiolto Respimat 2.5-2.5 mcg per actuation inhaler
• Triamcinolone acetonide 0.05% ointment
• Valganciclovir 50 mg per ml reconstituted oral solution
• Vancomycin 1 gm and sodium chloride 0.9% per 200 ml intravenous solution
• Vancomycin 500 mg and dextrose 5% per 100 ml intravenous solution
• Vancomycin 500 mg and sodium chloride 0.9% per 100 ml intravenous solution
• Vancomycin 750 mg and sodium chloride 0.9% per 150 ml intravenous solution

Other Updates:

• Albendazole 200 mg tablets (Added Auto Prior Authorization, Removed Quantity Limit)
• Betamethasone dipropionate 0.05% ointment (Changed Quantity Limit)
• Emgality 120 mg per ml injection (Added Step Therapy, Added Quantity Limit, Removed Age Limit)
• Emgality 120 mg per ml prefilled syringe (Added Step Therapy, Added Quantity Limit, Removed Age Limit)
• Fluocinolone acetonide 0.025% cream (Changed Quantity Limit)
• Fluocinolone acetonide 0.025% ointment (Changed Quantity Limit)
• Fluticasone-Salmeterol 100 mcg/50 mcg inhaler (Removed Age Limit, Added Quantity Limit)
• Fluticasone-Salmeterol 250 mcg/50 mcg inhaler (Removed Age Limit, Added Quantity Limit)
• Fluticasone-Salmeterol 500 mcg/50 mcg inhaler (Removed Age Limit, Added Quantity Limit)
• Lidocaine 5% ointment (Removed Prior Authorization)
• Ozempic 2 mg per 1.5 ml pen injector (Added Step Therapy)
• Ozempic 2 mg per 3 ml pen injector (Added Step Therapy)
• Trulicity 0.75 mg per 0.5 ml pen injector (Added Step Therapy)
• Trulicity 1.5 mg per 0.5 ml pen injector (Added Step Therapy)
• Trulicity 3 mg per 0.5 ml pen injector (Added Step Therapy)
• Trulicity 4.5 mg per 0.5 ml pen injector (Added Step Therapy)

April 2023

Additions:

• N/A

Removals:

• N/A

Other Updates:

• N/A

March 2023

Additions:

• Guaifenesin 100 mg/codeine 6.33 mg solution (Age Limit, Quantity Limit)

Removals:

• Advair HFA 115 mcg/21 mcg inhalation
• Advair HFA 230 mcg/21 mcg inhalation
• Advair HFA 45 mcg/21 mcg inhalation
• Ampicillin and sulbactam sodium 1.5 gm for injection
• Ampicillin and sulbactam sodium 1.5 gm for intravenous solution
• Ampicillin and sulbactam sodium 15 gm for intravenous solution
• Ampicillin and sulbactam sodium 3 gm for injection
• Ampicillin and sulbactam sodium 3 gm for intravenous solution
• Ampicillin sodium 1 gm for injection
• Ampicillin sodium 1 gm for intravenous solution
• Ampicillin sodium 10 gm for intravenous solution
• Ampicillin sodium 125 mg for injection
• Ampicillin sodium 2 gm for injection
• Ampicillin sodium 2 gm for intravenous solution
• Ampicillin sodium 250 mg for injection
• Ampicillin sodium 500 mg for injection
• Anoro Ellipta 62.5 mcg/25 mcg inhalation
• Asmanex 110 mcg 30 puff inhalation
• Asmanex 220 mcg 120 puff inhalation
• Azithromycin 500 mg intravenous for solution
• Cefazolin sodium 1 gm for injection
• Cefazolin sodium 1 gm for intravenous solution
• Cefazolin sodium 10 gm for injection
• Cefazolin sodium 2 gm for injection
• Cefazolin sodium 500 mg for injection
• Cefepime hydrochloric acid 1 gm for injection
• Cefepime hydrochloric acid 2 gm for injection
• Cefepime hydrochloric acid 2 gm for intravenous solution
• Cefotaxime sodium 1 gm for injection
• Cefotetan disodium 1 gm for injection
• Cefotetan disodium 2 gm for injection
• Cefoxitin sodium 1 gm and dextrose 4% per 50 mL
• Cefoxitin sodium 1 gm for intravenous solution
• Cefoxitin sodium 1 gm/dextrose 4% per 50 mL intravenous solution
• Cefoxitin sodium 10 gm for intravenous solution
• Cefoxitin sodium 2 gm and dextrose 2.2% per 50 mL
• Cefoxitin sodium 2 gm for intravenous solution
• Ceftriaxone sodium 1 gm and dextrose 3.74% in 50 mL intravenous solution
• Ceftriaxone sodium 10 gm for injection
• Ceftriaxone sodium 2 gm and dextrose 2.22% in 50 mL intravenous solution
• Ceftriaxone sodium 20 mg per mL in dextrose injection
• Ceftriaxone sodium 40 mg per mL in dextrose injection
• Cefuroxime sodium 1 gm for intravenous solution
• Cefuroxime sodium 1.5 gm for intravenous solution
• Cefuroxime sodium 2 gm for intravenous solution
• Cefuroxime sodium 750 mg for injection
• Cephalexin 750 mg capsule
• Ciprofloxacin 200 mg per 100 mL in dextrose water
• Ciprofloxacin 250 mg per 5 mL for oral suspension
• Ciprofloxacin 400 mg per 200 mL in dextrose water
• Ciprofloxacin 500 mg per 5 mL for oral suspension
• Doxycycline hyclate 150 mg tablet
• Doxycycline hyclate 50 mg tablet
• Doxycycline hyclate 75 mg tablet
• Dulera 100 mcg/5 mcg inhalation
• Dulera 200 mcg/5 mcg inhalation
• Dulera 50 mcg/5 mcg inhalation
• Erythromycin ethylsuccinate 200 mg per 5 ml for suspension
• Heparin sodium (porcine) 100 unit per mL lock flush
• Heparin sodium (porcine) 5000 unit per 0.5 mL prefilled syringe
• Heparin sodium (porcine) 5000 unit per mL injection
• Levofloxacin 250 mg per 50 mL in dextrose water intravenous solution
• Levofloxacin 500 mg per 100 mL in dextrose water intravenous solution
• Levofloxacin 750 mg per 150 mL in dextrose water intravenous solution
• Penicillin g procaine 600,000 unit per mL intramuscular suspension
• Penicillin g sodium 5,000,000 unit for injection
• Piperacillin sodium and tazobactam sodium 13.5 gm for injection
• Piperacillin sodium and tazobactam sodium 2.25 gm for injection
• Piperacillin sodium and tazobactam sodium 3.375 gm for injection
• Piperacillin sodium and tazobactam sodium 4.5 gm for injection
• Piperacillin sodium and tazobactam sodium 40.5 gm for injection
• Procaine 1,200,000 unit per 2 mL suspension
• Procaine 900,000 unit/300,000 unit per 2 mL injection
• Pulmicort Flexhaler 180 mcg inhalation
• Pulmicort Flexhaler 90 mcg inhalation
• Rivaroxaban 2.5 mg tablet
• Rivaroxaban for suspension 1 mg per mL
• Severent diskus 50 mcg inhalation
• Terbutaline sulfate 1 mg per mL injection
• Theo-24 extended release 100 mg capsule
• Theo-24 extended release 200 mg capsule
• Theo-24 extended release 300 mg capsule
• Theo-24 extended release 400 mg capsule
• Tobramycin 300 mg per 4 mL nebulizer solution

Other Updates:

• N/A

February 2023

Additions:

• Acid gone 160 mg/105 mg chewable tablet
• Acid gone 95 mg/358 mg per 15 mL suspension
• Afrin saline 0.65% nasal spray
• Budesonide extended release 9 mg tablet
• Carboxymethylcellulose sodium 1% ophthalmic gel
• Carboxymethylcellulose sodium preservative free 1% ophthalmic gel
• Cold and cough 2.5 mg/1 mg/5 mg per 5 mL liquid (Quantity Limit)
• CVS disposable rectal enema 19 gm/7 gm per 118mL
• CVS dry eye relief 0.2%/0.2%/1% ophthalmic solution
• CVS eye allergy relief 0.027%/0.315% ophthalmic solution
• CVS fiber 0.52 gm capsule
• CVS lubricating/dry eye 0.5%/0.9% ophthalmic solution
• Daily fiber 0.52 gm capsule
• Deep sea 0.65% nasal spray
• Dificid 200 mg tablet (Prior Authorization)
• Dificid 40 mg per mL suspension (Prior Authorization)
• Dimaphen dextromethorphan 2.5 mg/1 mg/5 mg per 5 mL liquid (Quantity Limit)
• Dry eye relief drops 0.2%/0.2%/1% ophthalmic solution
• Endacof dextromethorphan 2.5 mg/1 mg/5 mg per 5 mL liquid (Quantity Limit)
• EQ multi symptom cold 2.5 mg/5 mg/100 mg per 5 mL liquid (Quantity Limit)
• Esomeprazole magnesium delayed release 40 mg capsule (Quantity Limit)
• Estradiol 0.01 mg/gm vaginal cream (Quantity Limit)
• Ethacrynic acid 25 mg tablet
• Fiber laxative 0.52 gm capsule
• Fiber laxative 625 mg tablet
• Fiber laxative plus calcium 625 mg tablet
• GenTeal severe 0.3% ophthalmic gel
• Glycerin childrens 1 gm rectal suppository 
• GNP anorectal 5% cream (Quantity Limit)
• GNP antacid extra strength 160 mg/105 mg chewable
• GNP cold and cough 2.5 mg/1 mg/5 mg per 5 mL liquid (Quantity Limit)
• GNP natural fiber 0.52 gm capsule
• Gvoke kit 1 mg per 0.2 mL subcutaneous solution (Quantity Limit)
• Headache relief 250 mg/250 mg/65 mg tablet
• Hemorrhoidal relief 5% cream (Quantity Limit)
• HM cold and cough 2.5 mg/1 mg/5 mg per 5 mL liquid (Quantity Limit)
• HM saline 0.65% nasal spray
• Imbruvica 140 mg tablet (Prior Authorization, Quantity Limit)
• Imbruvica 280 mg tablet (Prior Authorization, Quantity Limit)
• Imbruvica 420 mg tablet (Prior Authorization, Quantity Limit)
• Imbruvica 560 mg tablet (Prior Authorization, Quantity Limit)
• Invega Hafyera 1092 mg per 3.5 mL prefilled syringe (Prior Authorization, Quantity Limit)
• Invega Hafyera 1560 mg per 5 mL prefilled syringe (Prior Authorization, Quantity Limit)
• Lidocaine anorectal 5% cream (Quantity Limit)
• Loratadine 5 mg per 5 mL syrup (Quantity Limit)
• Lubricant eye drops 0.4%/0.3% ophthalmic solution
• Magnesium citrate 1.745 gm per 30 mL solution
• Miconazole nitrate vaginal suppository 1200 mg & 2% cream kit
• Migraine relief 250 mg/250 mg/65 mg tablet
• Mucinex free severe congestion and cough 10 mg/20 mg/400 mg per 20 mL liquid (Quantity Limit)
• Mucus relief 2.5 mg/5 mg/100 mg per 5 mL liquid (Quantity Limit)
• Naphcon-A 0.025%/0.3% ophthalmic solution
• Ocean kids 0.65% nasal solution
• Phenylephrine 10 mg tablet
• Phenylephrine 10 mg/dextromethorphan 18 mg/guaifenesin 200 mg per 15 mL liquid (Quantity Limit)
• Phenylephrine 2.5 mg/dextromethorphan 5 mg/guaifenesin 100 mg per 5 mL liquid (Quantity Limit)
• Pramoxine 1% external foam (Quantity Limit)
• Pseudoephedrine extended release 120 mg tablet
• QC dibromm childrens cold and cough 2.5 mg/1 mg/5 mg per 5 mL liquid (Quantity Limit)
• QC mucus relief severe congestion and cough 2.5 mg/5 ml/100 mg per 5 mL liquid (Quantity Limit)
• Rectasmoothe 5% cream
• Refresh Celluvisc 1% ophthalmic gel
• Refresh Digital 0.5%/1%/0.5% ophthalmic solution
• Refresh Liquigel 1% ophthalmic gel
• Refresh Optive 1%/0.9% ophthalmic gel
• Refresh Optive Advanced 0.5%/1%/0.5% ophthalmic solution
• Refresh Optive preservative 0.5%/0.9% ophthalmic solution
• Refresh Relieva preservative free 0.5%/0.9% ophthalmic solution
• Refresh Relieva preservative free 0.5%/1% ophthalmic solution
• Rynex dextromethorphan 2.5 mg/1 mg/5 mg per 5 mL liquid (Quantity Limit)
• Saline mist 0.65% nasal spray
• SM cold and cough dextromethorphan 2.5 mg/1 mg/5 mg per 5 mL liquid (Quantity Limit)
• SM dry eye relief 0.2%/0.2%/1% ophthalmic solution
• SM lubricant 0.4%/0.3% ophthalmic solution
• SM severe congestion and cough 10 mg/20 mg/400 mg per 20 mL liquid (Quantity Limit)
• Sudogest phenylephrine 10 mg tablet
• Suphedrine extended release 120 mg tablet
• Systane Ultra 0.4%/0.3% ophthalmic solution
• Tramadol extended release 100 mg tablet (Auto Prior Authorization, Quantity Limit, Age Limit)
• Tramadol extended release 200 mg tablet (Auto Prior Authorization, Quantity Limit, Age Limit)
• Tramadol extended release 300 mg tablet (Auto Prior Authorization, Quantity Limit, Age Limit)
• Vanacof 30 mg/1 mg/12.5 mg per 5 mL liquid (Quantity Limit)
• Xifaxan 550 mg tablet (Prior Authorization)

Removals:

• Acitretin 10 mg capsule
• Acitretin 17.5 mg capsule
• Acitretin 25 mg capsule
• Acyclovir 5% cream
• Adapaline 0.1%/benzocaine 2.5% gel
• Aimovig auto-injector 140 mg per mL subcutaneous solution
• Aimovig auto-injector 70 mg per mL subcutaneous solution
• Alcohol sheets 70%
• Alendronate 70 mg per 75 mL solution
• Allantoin 0.5% cream, gel, and lotion
• Aloe grande 10000 unit/1500 unti per 30mL lotion
• Aloe grande 100000 unit/1500 unit per gm cream
• Ammonium lactate 10% lotion
• Ammonium lactate 5% lotion
• Aquastat 0.9% intravenous solution
• Aranesp (albumin free) 10 mcg per 0.4mL prefilled syringe injection solution
• Aranesp (albumin free) 100 mcg per 0.5mL prefilled syringe injection solution
• Aranesp (albumin free) 100 mcg per mL injection solution
• Aranesp (albumin free) 150 mcg per 0.3mL prefilled syringe injection solution
• Aranesp (albumin free) 200 mcg per 0.4mL prefilled syringe injection solution
• Aranesp (albumin free) 200 mcg per mL injection solution
• Aranesp (albumin free) 25 mcg per 0.42mL prefilled syringe injection solution
• Aranesp (albumin free) 25 mcg per mL injection solution
• Aranesp (albumin free) 300 mcg per 0.6mL prefilled syringe injection solution
• Aranesp (albumin free) 40 mcg per 0.4mL prefilled syringe injection solution
• Aranesp (albumin free) 40 mcg per mL injection solution
• Aranesp (albumin free) 500 mcg per mL prefilled syringe injection solution
• Aranesp (albumin free) 60 mcg per 0.3mL prefilled syringe injection solution
• Aranesp (albumin free) 60 mcg per mL injection solution
• Atopiclair cream
• Auryxia 210 mg tablet
• Aveeno calm & restore gel
• Aveeno calm & restore serum liquid
• Aveeno creamy moisturize oil
• Aveeno daily moisturize oil
• Azelaic acid 15% gel
• Bacteriostatic sodium chloride 0.9% injection solution
• BD Posiflush 0.9% intravenous solution
• Benzocaine 20 mg/docusate sodium 283 mg rectal enema
• Benzoyl peroxide 5%/erythromycin 3% gel
• Betaseron 0.3 mg injection
• Bisacodyl 10 mg per 30 mL enema
• Brimonidine tartate 0.2%/timolol maleate 0.5% ophthalmic solution
• Brinzolamide 1% ophthalmic solution
• Butalbital 50 mg/acetaminophen 325 mg tablet
• Butalbital 50 mg/acetaminophen 325 mg/caffeine 40 mg/codeine 30 mg capsule
• Butalbital 50 mg/aspirin 325 mg/caffeine 40 mg capsule
• Byetta 10 mcg pen-injector solution
• Byetta 5 mcg pen-injector solution
• Carbinoxamine maleate 4 mg per 5 mL solution
• Cavilon emollient cream
• Cavilon foot & dry skin cream
• Cavilon foot and dry skin cream
• Celotin 300 mg capsule
• Cequa 0.09% ophthalmic solution
• Cetaphil Pro eczema soothing 1% Lotion
• Clean & clear watermelon moist gel
• Clindamycin phosphate 1.5%/benzoyl peroxide 5% gel
• Clorazepate dipotassium 15 mg tablet
• Clorazepate dipotassium 3.75 mg tablet
• Clorazepate dipotassium 7.5 mg tablet
• Colchicine 0.6 mg capsule
• CVS beauty 360 pure vitamin-e 28000 unit per 29mL oil
• CVS beauty 360 soothing bath packet
• CVS eczema care 1% cream
• CVS eczema relief 1% cream
• CVS scar gel
• CVS vitamin-E moisturizing cream
• CVS vitamin-E moisturizing oil
• Dalfampridine extended release 12-hour 10 mg tablet
• Denavir 1% cream
• DermaZinc cream
• Dexeryl cream
• Diazoxide 50 mg per mL suspension
• Diclofenac 3% gel
• Diltiazem extended release 12-hour 120 mg capsule
• Diltiazem extended release 12-hour 60 mg capsule
• Diltiazem extended release 12-hour 90 mg capsule
• Diltiazem extended release 24-hour 360 mg coated beads capsule
• Diphenhydramine injection 50 mg per mL solution
• Diphenoxylate 2.5 mg/atropine 0.025 mg per 5 mL liquid
• Dofetilide 125 mcg capsule
• Dofetilide 250 mcg capsule
• Dofetilide 500 mcg capsule
• Doxepin 5% cream
• Econazole nitrate 1% cream
• Eczema moisturizing 1% lotion
• Eletone cream
• Esbriet 267 mg capsule
• Estring ring 2 mg vaginal
• Eucerin baby eczema relief 1% cream
• Eucerin eczema relief 1% cream
• Eucerin eczema relief 2% cream
• Eucrisa 2% ointment
• Farxiga 10 mg tablet
• Farxiga 5 mg tablet
• Fexofenadine 180 mg/pseudoephedrin 240 mg extended release 24-hour tablet
• Gel lined heel sleeves
• Gel lined moisturizing booties
• Gel lined moisturizing gloves
• Glyxambi 10 mg/5 mg tablet
• Glyxambi 25 mg/5 mg tablet
• Gordons-Vite-A 100000 unit lotion
• Gordons-Vite-A 100000 unit per gm cream
• Hylaguard cream
• Hylatopic plus cream
• Hylatopic plus lotion
• Ibrance 100 mg tablet
• Ibrance 125 mg tablet
• Ibrance 75 mg tablet
• Ingrezza 40 mg capsule
• Ingrezza 60 mg capsule
• Ingrezza 80 mg capsule
• Invokamet 150 mg/1000 mg tablet
• Invokamet 150 mg/500 mg tablet
• Invokamet 50 mg/1000 mg tablet
• Invokamet 50 mg/500 mg tablet
• Invokana 100 mg tablet
• Invokana 300 mg tablet
• Isotretinoin 25 mg capsule
• Isotretinoin 30 mg capsule
• Jentadueto 2.5 mg/1000 mg tablet
• Jentadueto 2.5 mg/500 mg tablet
• Jentadueto 2.5 mg/850 mg tablet
• Keri renewal serum liquid
• Kombiglyze XR extended release 2.5 mg/1000 mg tablet
• Kombiglyze XR extended release 5 mg/1000 mg tablet
• Kombiglyze XR extended release 5 mg/500 mg tablet
• Lactic acid 10%/vitamin e 3500 units per 30 gm cream
• Lamisilk repair complex serum liquid
• Leukine 250 mcg reconstitued injection solution
• Levocetirizine dihydrochloride 2.5 mg per 5 mL solution
• Levofloxacin 0.5% ophthalmic solution
• Lidocaine 3% cream
• Lidocaine 4% ointment
• Lidocaine 4% solution
• Magnexium hydroxide 2400 mg per 10 mL suspension
• Mederma advanced scar gel
• Methylphenidate LA extended release 20 mg capsule
• Methylphenidate LA extended release 30 mg capsule
• Methylphenidate LA extended release 40 mg capsule
• Methylphenidate LA extended release 60 mg capsule
• Naproxen enteric coated delayed release 500 mg tablet
• Natural vitamin-e moisturizing gel
• Neuac 1.2%/5% gel
• Neupogen 300 mcg injection solution
• Neupogen 300 mcg per 0.5 mL prefilled syringe injection solution
• Neupogen 480 mcg injection solution
• Neupogen 480 mcg per 0.8 mL prefilled syringe injection solution
• Nimodipine 30 mg capsule
• Nivestym 300 mcg per 0.5 mL prefilled syringe injection solution
• Nivestym 480 mcg per 0.8 mL prefilled syringe injection solution
• Normal saline flush 0.9% intravenous solution
• Nurtec 75 mg oral disintegrating tablet
• Nutraseb cream
• Nystatin 100000 units/triamcinolone 0.1% per gram cream
• Nystatin 100000 units/triamcinolone 0.1% per gram ointment
• Nyvepria 6 mg per 0.6 mL prefilled syringe injection solution
• Onglyza 2.5 mg tablet
• Onglyza 5 mg tablet
• Oxymorphone extended release 12-hour 10 mg tablet
• Oxymorphone extended release 12-hour 15 mg tablet
• Oxymorphone extended release 12-hour 20 mg tablet
• Oxymorphone extended release 12-hour 30 mg tablet
• Oxymorphone extended release 12-hour 40 mg tablet
• Oxymorphone extended release 12-hour 5 mg tablet
• Oxymorphone extended release 12-hour 7.5 mg tablet
• Pancreaze delayed release 10500 unit capsule
• Pancreaze delayed release 16800 unit capsule
• Pancreaze delayed release 21000 unit capsule
• Pancreaze delayed release 2600 unit capsule
• Pancreaze delayed release 37000 unit capsule
• Pancreaze delayed release 4200 unit capsule
• Pertyze delayed release 1600 unit capsule
• Pertyze delayed release 2400 unit capsule
• Pertyze delayed release 4000 unit capsule
• Pertyze delayed release 8000 unit capsule
• Pimecrolimus 1% cream
• Potassium 550 mg/sodium citrate 500 mg/citric acid 334 mg per 5 mL solution
• Prevacare total skin care solution
• Promethazine 25 mg per mL injection solution
• Promethazine 50 mg per mL injection solution
• Promiseb cream
• Qulipta 10 mg tablet
• Qulipta 30 mg tablet
• Qulipta 60 mg tablet
• Salimez 6% cream
• Saline 0.4%/phenol 0.9% injection solution
• Santyl 250 units per gm ointment
• Sardoettes pads
• Sildenafil 10 mg per mL suspension
• Silver nitrate 0.5% solution
• Sulfacetamide sodium 10% ophthalmic ointment
• Super E hand/body lotion
• Super E ointment
• Symlinpen 120 pen-injector 2400 mcg per 2.7 mL solution
• Symlinpen 60 pen-injector 1500 mcg per 1.5 mL solution
• Synjardy 12.5 mg/1000 mg tablet
• Synjardy 12.5 mg/500 mg tablet
• Synjardy 5 mg/1000 mg tablet
• Synjardy 5 mg/500 mg tablet
• Tetrix cream
• Tradjenta 5 mg tablet
• Ubrelvy 100 mg tablet
• Ubrelvy 50 mg tablet
• Urea 40% cream
• Ventavis 10 mcg per mL inhalation solution
• Ventavis 20 mcg per mL inhalation solution
• Victoza pen-injector 18 mg per 3 mL solution
• Vitamin E & C beauty lotion
• Vitamin-A wrinkle treatment gel
• Vitamin-E & vitamin-K beautiful skin oil
• Vitamin-E 1000 unit/vitamin-A 14000 unit per 52mL beauty oil
• Vitamin-E 24000 unit liquid
• Vitamin-E 24000 unit per 52mL beauty oil
• Vitamin-E 400 unit/vitamin-D 14000 unit per 52mL beauty oil
• Vitamin-E complex cream
• Vitamin-E Skin 4000 unit cream
• Vitamin-E skin oil
• Vitamin-E with vitamin A & D cream
• Vita-Ray cream
• Vosevi 400 mg/100 mg/100 mg tablet
• WaxWel paraffin bath kit
• Xeljanz 1 mg per mL solution
• Xeljanz 10 mg tablet
• Xeljanz 5 mg tablet
• Xigduo XR extended release 24-hour 10 mg-1000 mg tablet
• Xigduo XR extended release 24-hour 10 mg-500 mg tablet
• Xigduo XR extended release 24-hour 2.5 mg-1000 mg tablet
• Xigduo XR extended release 24-hour 5 mg-1000 mg tablet
• Xigduo XR extended release 24-hour 5 mg-500 mg tablet
• Zegalogue auto-injector 0.6 mg per 0.6mL solution
• Ztlido 1.8% patch

Other Updates:

• Acamprosate calcium delayed release 333 mg tablet (Added Prior Authorization)
• Actimmune 2000000 unit per 0.5 mL injection (Added Prior Authorization)
• Aftera 1.5 mg tablet (Added Quantity Limit)
• All proton pump inhibitors (Added Quantity Limit of 180 tablets per 365 days)
• Bacitracin 500 unit/polymyxin b 10000 unit per gm opthalmic ointment (Added Quantity Limit)
• Bacitracin 500 units per gm ophthalmic ointment (Added Quantity Limit)
• Bacitracin/polymyxin/neomycin/hydrocortisone 1% ophthalmic ointment (Added Quantity Limit)
• Benzonatate 100 mg capsule (Added Quantity Limit)
• Benzonatate 200 mg capsule (Added Quantity Limit)
• Budesonide delayed release 3 mg capsule (Removed Step Therapy)
• Calcipotriene 0.005% cream (Removed Auto PA)
• Calcipotriene 0.005% ointment (Removed Auto PA)
• Climara pro weekly 0.045 mg/0.015 mg per day patch (Added Quantity Limit)
• Dorzolamide 22.3 mg/timolol maleate 6.8 mg per mL ophthalmic solution (Removed Step Therapy)
• EContra EZ 1.5 mg tablet (Added Quantity Limit)
• EContra One-Step 1.5 mg tablet (Added Quantity Limit)
• Erythromycin 5 mg per gm ophthalmic Ointment (Added Quantity Limit)
• Fluocinolone acetonide 0.01% otic oil (Added Quantity Limit)
• Gentak 0.3% ophthalmic ointment (Added Quantity Limit)
• Hydrocodone 5 mg/homatropine 1.5 mg per 5 mL solution (Added Quantity Limit)
• Hydrocodone 5 mg/homatropine 1.5 mg tablet (Added Quantity Limit)
• Hydromet 5mg/1.5 mg per 5 mL solution (Added Quantity Limit)
• Intron-A injection 10000000 unit reconstituted solution (Added Prior Authorization)
• Intron-A injection 50000000 unit reconstituted solution (Added Prior Authorization)
• Jardiance 10 mg tablet (Added Prior Authorization)
• Jardiance 25 mg tablet (Added Prior Authorization)
• Levonorgestrel 1.5 mg tablet (Added Quantity Limit)
• Movantik 12.5 mg tablet (Removed Auto PA)
• Movantik 25 mg tablet (Removed Auto PA)
• My Choice 1.5 mg tablet (Added Quantity Limit)
• My Way 1.5 mg tablet (Added Quantity Limit)
• New Day 1.5 mg tablet (Added Quantity Limit)
• Nuedexta 20 mg/10 mg capsule (Added Prior Authorization)
• OneTouch Ultra strip (Added Quantity Limit)
• OneTouch Verio strip (Added Quantity Limit)
• Opcicon One-Step 1.5 mg tablet (Added Quantity Limit)
• Option 2 1.5 mg tablet (Added Quantity Limit)
• Ranolazine extended release 1000 mg tablet (Added Prior Authorization)
• Ranolazine extended release 500 mg tablet (Added Prior Authorization)
• React 1.5 mg tablet (Added Quantity Limit)
• Rivastigmine 13.3 mg 24-hour patch (Added Prior Authorization)
• Rivastigmine 4.6 mg 24-hour patch (Added Prior Authorization)
• Rivastigmine 9.5 mg 24-hour patch (Added Prior Authorization)
• Take Action 1.5 mg tablet (Added Quantity Limit)
• Tolterodine tartrate 1 mg tablet (Removed Step Therapy)
• Tolterodine tartrate 2 mg tablet (Removed Step Therapy)
• Tolterodine tartrate extended release 2 mg capsule (Removed Step Therapy)
• Tolterodine tartrate extended release 4 mg capsule (Removed Step Therapy)
• Trospium chloride 20 mg tablet (Removed Step Therapy)
• Vancomycin 125 mg capsule (Added Quantity Limit)
• Vancomycin 250 mg capsule (Added Quantity Limit)

January 2023

Additions:

• OneTouch Delica Lancets 30G
• OneTouch Delica Lancets 33G
• OneTouch Delica Lancing Device
• OneTouch Delica Plus Lancets 30G
• OneTouch Delica Plus Lancets 33G
• OneTouch Delica Plus Lancing Device

Removals:

• Accu-Chek FastClix Lancet Device Kit
• Accu-Chek FastClix Lancet Kit
• Accu-Chek FastClix Lancets
• Accu-Chek Safe-T Pro Lancets
• Accu-Chek Softclix Lancets
• Advanced Mobile Lancet
• BD Lancet Ultrafine 30G
• BD Lancet Ultrafine 33G
• BD Microtainer Lancets
• Clever Chek Lancets
• Clever Choice Lancets 21G
• Clever Choice Lancets 23G
• Clever Choice Lancets 28G
• CoaguChek Lancets
• Comfort Assured Lancets 28G
• Comfort Assured Lancets 33G
• CVS Lancets 21G
• CVS Lancets Micro Thin 33G
• CVS Lancets Original
• CVS Lancets Thin 26G
• CVS Lancets Ultra Thin 30G
• CVS Lancets Ultra-Thin 30G
• CVS Lancing Device
• CVS Ultra Thin Lancets
• Drug Mart Lancets Thin 26G
• Drug Mart Lancing Device
• Easy Comfort Lancets Twist Top
• EQL Color Lancets 21G
• EQL Color Lancets Micro 33G
• EQL Super Thin Lancets 30G
• EQL Thin Lancets 26G
• E-Z Ject Lancet Micro-Thin 33G
• E-Z Ject Lancet Super Thin 30G
• E-Z Ject Lancets 21G
• E-Z Ject Lancets Thin 26G
• Fine 30
• Fingerstix Lancets
• FreeStyle Lancets
• FreeStyle Unistick II Lancets
• Gilenya Cap 0.5mg
• Global Inject Ease Lancets 28G
• Global Inject Ease Lancets 30G
• Global Lancing Device
• GNP Lancets 21G
• GNP Lancets Thin 26G
• GoodSense Lancets 26G Univ
• GoodSense Lancets 30G
• GoodSense Lancets 33G
• GoodSense Lancets 33G Univ
• GoodSense Lancing Device
• Kroger Lancets 21G
• Kroger Lancets Micro Thin 33G
• Kroger Lancets Thin 26G
• Kroger Lancets UltraThin 30G
• Kroger Lancing Device
• Lancets 30G
• Lancets 33G
• Lancets Micro Thin 33G
• Lancets Super Thin 28G
• Lancets Thin
• Lancets Ultra Thin
• Lancets Ultra Thin 30G
• Lancing Device
• LifeScan Unistik 2
• LifeScan Unistik II Lancets
• Longs Lancets Standard
• Longs Lancets Thin
• Longs Lancets Ultra Thin
• Medlance Extra 21G
• Medlance Lite 25G
• Medlance Plus Lancets
• Medlance Universal 21G
• Meijer Lancets
• Meijer Lancets Thin
• Meijer Lancets Universal 33G
• Meijer Super Thin Lancets
• Microlet Lancets
• Microlet Next Lancing Device
• OneTouch Club Lancets Fine Pt
• OneTouch Delica Safety Lancing
• OneTouch FinePoint Lancets
• OneTouch SureSoft Lancing Device
• OneTouch UltraSoft Lancets
• Penlet 2 Blood Sampler Kit
• Penlet 2 Lancing Replacement Cap
• Pharmacist Choice Lancets
• Pharmacy Counter Lancets
• Preferred Plus Lancets Colored
• Preferred Plus Lancets Thin
• Pro Comfort Lancets 30G
• Pro Comfort Lancets 31G
• RA E-Zject Lancets 28G
• RA E-Zject Lancets Thin 26G
• RA E-Zject Lancets Thin 28G
• RA E-Zject Lancets Ultra Thin
• ReliOn Lancet Devices 30G
• ReliOn Lancets Thin 26G
• ReliOn Lancets Ultra-Thin 30G
• ReliOn Lancing Device
• ReliOn Ultra Thin Lancets 30G
• ReliOn Ultra Thin Plus Lancets
• Rexall Lancets Ultra Thin 30G
• Safety Lancet 30G/Pressure Act
• SAPS health Twist Top Lancets
• SAPS Twist Top Lancets
• Simple Diagnostics Lancing Dev
• Single-Let
• SM Lancets 33G
• Smart Sense Color Lancets 33G
• Smart Sense Standard Lancets
• Smart Sense Super Thin Lancets
• Smart Sense Thin Lancets 26G
• Super Thin Lancets
• Sure Comfort Lancets 18G
• Sure Comfort Lancets 21G
• Sure Comfort Lancets 23G
• Sure Comfort Lancets 28G
• Sure Comfort Lancets 30G
• Sure Comfort Lancing Pen
• TGT Lancet Micro Thin 33G
• TGT Lancet Thin 26G
• TGT Lancet Ultra Thin 30G
• TopCare Lancets Micro-Thin 33G
• Travel Lancets Advanced 28G
• TRUEdraw Lancing Device
• TRUEplus Lancets 26G
• TRUEplus Lancets 28G
• TRUEplus Lancets 30G
• TRUEplus Lancets 33G
• TRUEplus Safety Lancets 28G
• Ultra Thin Lancets 31G
• Ultra-Care Lancets 30G
• Universal 1 Lancets Thin 26G
• Universal 1 Lancets Ultra Thin
• Value Plus Lancet Standard 21G
• Value Plus Lancets Super Thin
• Value Plus Lancets Thin 26G
• Value Plus Lancing Device
• Walgreens Lancets
• Walgreens Lancets Micro Thin
• Walgreens Lancets Super Thin
• Walgreens Thin Lancets
• Walgreens Ultra Thin Lancets
• ZevRx Twist Top Lancets 30G

Other Updates:

• N/A