Preferred drug list
search tool and updates

April 2026

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

March 2026

Additions:

• No updates

Removals:

• No updates

Other Updates:

• Pramoxine Hydrochloride Perianal Foam 1% (Quantity Level Limit)

February 2026

Additions:

• *Skin Protectants Miscellaneous - Cream***

Removals:

• Cetirizine Hydrochloride Chewable Tablet 5 mg
• Cetirizine Hydrochloride Chewable Tablet 10 mg

Other Updates:

• None

January 2026

Additions:

• None

Removals:

• None

Other Updates:

• Onyda Extended Release (Prior Authorization, Age Limit)
• Qelbree (Add Age Limit)
• Quillichew Extended Release (Prior Authorization, Age Limit)
• Quillivant Extended Release (Prior Authorization, Age Limit)

December 2025

Additions:

• *Bacillus Coagulans-Inulin Capsule**
• *Lactobacillus Acidophilus-Pectin Tablet**
• *Probiotic Product - Chewable Tablet**
• *Probiotic Product - Tablet**
• Saccharomyces Boulardii Capsule 250 mg

Removals:

• None

Other Updates:

• None

November 2025

Additions:

• None

Removals:

• None

Other Updates:

• Ubrogepant Tablet 50 mg (Quantity Level Limit)
• Ubrogepant Tablet 100 mg (Quantity Level Limit)
• Permethrin Cream 5% (Add Age Limit)

October 2025

October 2025

Additions:

• None

Removals:

• None

Other Updates:

• Alhemo Pen-Injector 300 mg / 3 mL (100 mg / mL) (Prior Authorization)
• Skytrofa Injection Cartridge 0.7 mg (Prior Authorization)
• Skytrofa Injection Cartridge 1.4 mg (Prior Authorization)
• Skytrofa Injection Cartridge 1.8 mg (Prior Authorization)
• Skytrofa Injection Cartridge 2.1 mg (Prior Authorization)
• Skytrofa Injection Cartridge 2.5 mg (Prior Authorization)
• Hympavzi Auto-Injection 150 mg/mL (Prior Authorization)
• Pertzye Capsule 16000-57500-60500 Unit (Prior Authorization)
• Pertzye Capsule 24000-86250-90750 Unit (Prior Authorization)
• Pertzye Capsule 4000-14375-15125 Unit (Prior Authorization)
• Pertzye Capsule 8000-28750-30250 Unit (Prior Authorization)
• Inluriyo 200 mg (Age Limit)

September 2025

Additions:

• *B-Complex with Vitamin C & Folic Acid Tablet 0.8 mg***
• Calcium Carbonate-Cholecalciferol Tablet 600 mg-20 mcg
• Cholecalciferol Capsule 10 mcg (400 Unit)
• Cyanocobalamin Tablet 1000 mcg
• Cyanocobalamin Tablet 250 mcg
• Cyanocobalamin Tablet 500 mcg
• Folic Acid Tablet 400 mcg
• Sodium Chloride Tablet 1 GM
• Thiamine Hydrochloride Tablet 100 mg
• Thiamine Mononitrate Tablet 100 mg
• Vitamin E Capsule 180 mg (400 Unit) 

Removals:

• No updates

Other Updates:

• No updates

August 2025

Additions:

• No updates

Removals:

• Phenylephrine Tablet 10 mg

Other Updates:

• Finerenone Tablet 40 mg (Prior Authorization)

July 2025

Additions:

• Iloperidone Tablet 1 mg and 2 mg and 6 mg Titration Pak (Age Limit)
• Iloperidone Tablet 1 mg and 2 mg and 6 mg and 8 mg Titration Pak (Age Limit)

Removals:

• No updates

Other Updates:

• Cefixime Capsule 400 mg (Quantity Level Limit)
• Skytrofa for Subcutaneous Injection Cartridge 3 mg (Prior Authorization)
• Skytrofa for Subcutaneous Injection Cartridge 3.6 mg (Prior Authorization)
• Skytrofa for Subcutaneous Injection Cartridge 4.3 mg (Prior Authorization)
• Skytrofa for Subcutaneous Injection Cartridge 5.2 mg (Prior Authorization)
• Skytrofa for Subcutaneous Injection Cartridge 6.3 mg (Prior Authorization)
• Skytrofa for Subcutaneous Injection Cartridge 7.6 mg (Prior Authorization)
• Skytrofa for Subcutaneous Injection Cartridge 9.1 mg (Prior Authorization)
• Skytrofa for Subcutaneous Injection Cartridge 11 mg (Prior Authorization)
• Skytrofa for Subcutaneous Injection Cart 13.3 mg (Prior Authorization)
• Ngenla Solution Pen-Injector 24 mg / 1.2 mL (20 mg / mL) (Prior Authorization)
• Ngenla Solution Pen-Injector 60 mg / 1.2 mL (50 mg / mL) (Prior Authorization)
• Benzoyl Peroxide Foam 9.8% (Age Limit Update)

June 2025

Additions:

• No updates

Removals:

• Testosterone Transdermal Gel 20.25 mg / Actuations (1.62%)

Other Updates:

• Guardian 4 Glucose Sensor
• Guardian 4 Transmitter Kit 
• Guardian Connect Transmitter
• Guardian Connect Transmitter Kit   
• Guardian Link 3 Transmitter Kit 
• Guardian Sensor 3  

May 2025

Additions:

• Atomoxetine Hydrochloride Capsule 10 mg (Age Limit, Quantity Level Limit)
• Atomoxetine Hydrochloride Capsule 18 mg (Age Limit, Quantity Level Limit)
• Atomoxetine Hydrochloride Capsule 25 mg (Age Limit, Quantity Level Limit)
• Atomoxetine Hydrochloride Capsule 40 mg (Age Limit, Quantity Level Limit)
• Atomoxetine Hydrochloride Capsule 60 mg (Age Limit, Quantity Level Limit)
• Atomoxetine Hydrochloride Capsule 80 mg (Age Limit, Quantity Level Limit)
• Atomoxetine Hydrochloride Capsule 100 mg (Age Limit, Quantity Level Limit)
• Bisoprolol Tablet 2.5 mg
• Sunlenca Tablet 300 mg (Prior Authorization)
• Paxlovid Pak (Age Limit, Quantity Level Limit)
• Umeclidinium-Vilanterol Aerosol Powder 62.5-25 mcg/actuation
• Tymlos Subcutaneous Solution Pen-Injector 3120 mcg /1.56 mL (Add Prior Authorization, Quantity Level Limit)
• Prolia Injection Solution Prefilled Syringe 60 mg / mL (Add Prior Authorization, Quantity Level Limit)
• Teriparatide Solution Pen-Injection 620 mcg/ 2.48 mL (Add Prior Authorization, Quantity Level Limit)

Removals:

• No updates

Other Updates:

• No updates

April 2025

Additions:

• Simlandi Auto-Injector Kit 80 mg/0.8 mL (Prior Authorization)
• SevenFACT Solution 2 mg (Prior Authorization)

Removals:

• Twiist Refill Kit
• Twiist refill Kit/Infusion Set

Other Updates:

• No updates

March 2025

Additions:

• Baqsimi Nasal Powder 3 mg
• Insulin Degludec Injection 100 unit/mL
• Insulin Degludec FlexTouch 100 unit/mL
• Contour Plus Blood Glucose Monitor Kit (Quantity Level Limit)
• Contour Plus Blood Glucose Test Strips (Quantity Level Limit)
• Guardian Sensor 3 (Prior Authorization)
• Guardian 4 Glucose Sensor (Prior Authorization)
• Guardian 4 Transmitter Kit (Prior Authorization)
• Guardian Connect Transmitter Kit (Prior Authorization)
• Guardian Link 3 Transmitter Kit (Prior Authorization)
• Cequr Simplicity 2U (Prior Authorization)
• Cequr Simplicity Inserter (Prior Authorization)
• Ilet Insulin Pump (Prior Authorization)
• Ilet Starter Kit Inset 23 (Prior Authorization)
• Ilet Starter Kit Inset 32 (Prior Authorization)
• Ilet Insulin Infusion Kit 23 (Prior Authorization)
• Ilet Insulin Infusion Kit 32 (Prior Authorization)
• Carbaglu Tablet 200 mg (Prior Authorization)
• Caplyta Capsule 10.5 mg (Age Limit)
• Caplyta Capsule 21 mg (Age Limit)
• Caplyta Capsule 42 mg (Age Limit)
• Rexulti Tablet 0.25 mg (Age Limit)
• Rexulti Tablet 0.5 mg (Age Limit)
• Rexulti Tablet 1 mg (Age Limit)
• Rexulti Tablet 2 mg (Age Limit)
• Rexulti Tablet 3 mg (Age Limit)
• Rexulti Tablet 4 mg (Age Limit)
• Vraylar Capsule 1.5 mg (Age Limit)
• Vraylar Capsule 3 mg (Age Limit)
• Vraylar Capsule 4.5 mg (Age Limit)
• Vraylar Capsule 6 mg (Age Limit)
• Austedo Extended-Release Tablet 30 mg (Prior Authorization)
• Austedo Extended-Release Tablet 36 mg (Prior Authorization)
• Austedo Extended-Release Tablet 42 mg (Prior Authorization)
• Austedo Extended-Release Tablet 48 mg (Prior Authorization)
• Austedo Extended-Release Tablet Titration Kit (Prior Authorization)
• Ingrezza Sprinkle Capsule 40 mg (Prior Authorization)
• Ingrezza Sprinkle Capsule 60 mg (Prior Authorization)
• Ingrezza Sprinkle Capsule 80 mg (Prior Authorization)
• Siklos Tablet 100 mg (Age Limit)
• Siklos Tablet 1000 mg (Age Limit)
• Airsupra Aerosol 90-80 mcg/Actuation
• Pulmicort Flexhaler 90 mcg
• Pulmicort Flexhaler 180 mcg
• Arnuity Ellipta 50 mcg
• Arnuity Ellipta 100 mcg
• Arnuity Ellipta 200 mcg
• Fluticasone Propionate Aerosol Powder 50 mcg/actuation
• Fluticasone Propionate Aerosol Powder 100 mcg/actuation
• Fluticasone Propionate Aerosol Powder 250 mcg/actuation
• Cinqair Injection 100 mg/10 mL (Prior Authorization)
• Tezspire Prefilled Syringe 210 mg/1.91 mL (Prior Authorization)
• Tezspire Auto-Injector 210 mg/1.91 mL (Prior Authorization)
• Xolair Auto-Injector 300 mg/2 mL (Prior Authorization)
• Xolair Prefilled Syringe 300 mg/2 mL (Prior Authorization)
• Rezdiffra Tablet 60 mg (Prior Authorization)
• Rezdiffra Tablet 80 mg (Prior Authorization)
• Rezdiffra Tablet 100 mg (Prior Authorization)
• Adalimumab-ADBM Auto-Injector Kit 40 mg/0.4 mL (Prior Authorization)
• Adalimumab-ADBM Prefilled Syringe Kit 10 mg/0.2 mL (Prior Authorization)
• Adalimumab-ADBM Prefilled Syringe Kit 20 mg/0.4 mL (Prior Authorization)
• Adalimumab-ADBM Prefilled Syringe Kit 40 mg/0.4 mL (Prior Authorization)
• Simlandi Prefilled Syringe Kit 20 mg/0.2 mL (Prior Authorization)
• Simlandi Prefilled Syringe Kit 40 mg/0.4 mL (Prior Authorization)
• Simlandi Prefilled Syringe Kit 80 mg/0.8 mL (Prior Authorization)
• Simlandi Auto-Injector Kit 40 mg/0.4 mL (Prior Authorization)
• Glucagen Injection Hypokit 1 mg
• Glucagon Kit 1 mg
• Mirabegron Tablet 25 mg
• Mirabegron Tablet 50 mg
• Myrbetriq Tablet 25 mg
• Myrbetriq Tablet 50 mg
• Myrbetriq Oral Suspension 8 mg/mL
• Gemtesa Tablet 75 mg
• Glatopa Prefilled Syringe 20 mg/mL
• Glatopa Prefilled Syringe 40 mg/mL
• Maraviroc Tablet 150 mg
• Maraviroc Tablet 300 mg
• Pifeltro Tablet 100 mg
• Prezcobix Tablet 800-150 mg
• Juluca Tablet 50-25 mg
• Zurzuvae Capsule 20 mg
• Zurzuvae Capsule 25 mg
• Zurzuvae Capsule 30 mg
• Tramadol Tablet 75 mg (Age Limit)
• Esperoct Injection 4000 Units (Prior Authorization)
• Hemlibra Subcutaneous Solution 12 mg/0.4 mL (Prior Authorization)
• Jivi Injection 4000 Units (Prior Authorization)

Removals:

• Ciprofloxacin Tablet 100 mg
• Humira Auto-Injector Kit 40 mg/0.4 mL
• Humira Auto-Injector Kit 40 mg/0.8 mL
• Humira Auto-Injector Kit 80 mg/0.8 mL
• Humira Auto-Injector Kit 80 mg/0.8 mL & 40 mg/0.4 mL
• Humira Prefilled Syringe Kit 10 mg/0.1 mL
• Humira Prefilled Syringe Kit 20 mg/0.2 mL
• Humira Prefilled Syringe Kit 40 mg/0.4 mL
• Humira Prefilled Syringe Kit 40 mg/0.8 mL
• OneTouch Ultra 2 Blood Glucose Monitoring Kit
• OneTouch Verio Flex Blood Glucose Monitoring Kit
• OneTouch Ultra Test Strips
• OneTouch Ultra Blue Test Strips
• OneTouch Verio Test Strips
• Didanosine Capsule 250 mg
• Didanosine Capsule 400 mg
• Invirase Tablet 500 mg
• Stavudine Capsule 15 mg
• Stavudine Capsule 20 mg
• Stavudine Capsule 40 mg
• Permethrin Cream 5%
• Kogenate FS Injection 1000 Units
• Kogenate FS Injection 2000 Units

Other Updates:

• Cabenuva Extended-Release Injection Kit 400 mg/600 mg (Remove Prior Authorization)
• Cabenuva Extended-Release Injection Kit 600 mg/900 mg (Remove Prior Authorization)
• Rukobia Tablet 600 mg (Remove Prior Authorization)
• Estradiol Valerate Multi Dose Vial 20 mg/ mL (Remove Quantity Level Limit)
• Estradiol Valerate Multi Dose Vial 40 mg/ mL (Remove Quantity Level Limit)

February 2025

Additions:

• Estradiol Valerate Multi Dose Vial 20 mg/ mL (Quantity Level Limit)
• Estradiol Valerate Multi Dose Vial 40 mg/ mL (Quantity Level Limit)
• Sodium/Potassium Solution Magnesium (Quantity Level Limit)

Removals:

• Testosterone (AndroGel) Pak 1%(50mg)
• Testosterone (Fortesta) Gel Pump 2%
• Testosterone Gel 1%(25mg)
• Testosterone Gel Pump 1%

Other Updates:

• Oxybutynin Tablet 10 mg Extended Release (Quantity Level Limit)

January 2025

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

December 2024

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

November 2024

Additions:

• None

Removals:

• None

Other Updates:

• None

October 2024

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

September 2024

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

August 2024

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

July 2024

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

June 2024

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

May 2024

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

April 2024

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

March 2024

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

February 2024

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

January 2024

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

December 2023

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

November 2023

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

October 2023

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

September 2023

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

August 2023

Additions:

• No updates

Removals:

• No updates
  

Other Updates:

• No updates

July 2023

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

June 2023

Additions:

• No updates

Removals:

• No updates

Other Updates:

• Mavyret Pellet Pack 50-20 mg (Quantity Level Limit, Removed Prior Authorization)
• Mavyret Tablet 100-40 mg (Quantity Level Limit, Removed Prior Authorization)
• Sofosbuvir-Velpatasvir Tablet 400-100 mg (Quantity Level Limit, Removed Prior Authorization)

May 2023

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

April 2023

Additions:

• No updates

Removals:

• *Calcium Alginate Wound Dressing***
• *Neomycin-Bacitracin-Polymyxin with Lidocaine Ointment 4%***
• *Pediatric Multiple Vitamin with Minerals & C Chewable Tablet**
• *Pediatric Multiple Vitamins with Iron Drops 10 mg/mL**
• Cholecalciferol Drops 10 mcg/0.025 mL (400 Unit/0.025ml)
• Cholecalciferol Drops 125 mcg/ mL (5000 Unit/mL)
• Cholecalciferol Drops 400 Unit/0.028 mL (Per Drop)
• Formaldehyde Solution 10%
• Loperamide Hydrochloride Liquid 1 mg/5 mL (0.2 mg/mL)
• Magnesium Salicylate Tablet 500 mg
• Magnesium Tablet 400 mg
• Phenylephrine-Shark Liver Oil-Mineral oil-Petrolatum Ointment 0.25-3-14-71.9%
• Psyllium Capsule 400 mg
• Psyllium Powder 30%
• Psyllium Powder 30.9%
• Psyllium Powder 33%
• Psyllium Powder 49%
• Uridine Triacetate Oral Granules Packet 10 gm

Other Updates:

• Betamethasone Dipropionate Ointment 0.05% (Quantity Level Limit)
• Fluocinolone Acetonide Cream 0.025% (Quantity Level Limit)
• Fluocinolone Acetonide Ointment 0.025% (Quantity Level Limit)
• Fluconazole Tablet 150 mg (Quantity Level Limit)
• Freestyle 14 Sensor Libre (Quantity Level Limit)
• Freestyle 14 Sensor Libre 2 (Quantity Level Limit)
• Freestyle 14 Sensor Libre 3 (Quantity Level Limit)
• *Pediatric Multiple Vitamins with Fluoride Chewable Tablet 0.25 mg***
• *Pediatric Multiple Vitamins with Fluoride Chewable Tablet 0.5 mg***
• *Pediatric Multiple Vitamins with Fluoride Chewable Tablet 1 mg***

March 2023

Additions:

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

Removals:

• No updates

Other Updates:

• No updates

February 2023

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

January 2023

Additions:

• No updates

Removals:

• Testosterone Td Gel 40.5 Mg/2.5 GM (1.62%)

Other Updates:

• Testosterone Td Soln 30 Mg/Act (Prior Authorization Required)
• Testosterone Td Gel 25 Mg/2.5gm (1%) (Prior Authorization Required)
• Testosterone Td Gel 50 Mg/5gm (1%) (Prior Authorization Required)
• Testosterone Td Gel 12.5 Mg/Act (1%) (Prior Authorization Required)
• Testosterone Td Gel 20.25 Mg/Act (1.62%) (Prior Authorization Required)
• Testosterone Td Gel 10mg/Act (2%) (Prior Authorization Required)
• Testosterone Cypionate Im Inj In Oil 100 Mg/Ml (Prior Authorization Required)
• Testosterone Cypionate Im Inj In Oil 200 Mg/Ml (Prior Authorization Required)
• Testosterone Enanthate Im Inj In Oil 200 Mg/Ml (Prior Authorization Required)

December 2022

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

November 2022

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

October 2022

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

September 2022

Additions:

• No updates

Removals:

• No updates

Other Updates:

• Ceftriaxone Sodium For Inj 1 Gm (Changed Quantity Level Limit)
• Ceftriaxone Sodium For Inj 2 Gm (Changed Quantity Level Limit)
• Ceftriaxone Sodium For Inj 250 Mg (Changed Quantity Level Limit)
• Ceftriaxone Sodium For Inj 500 Mg (Changed Quantity Level Limit)

August 2022

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

July 2022

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

June 2022

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

May 2022

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

April 2022

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

March 2022

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

February 2022

Additions:

• Levocetirizine 5mg Tablets (Quantity Limit)
• Dexcom G5 Mis Transmit (Quantity Limit)
• Dexcom G6 Mis Transmit (Quantity Limit)
• G5/G4 Plati Mis Sensor (Quantity Limit)
• Dexcom G6 Mis Sensor (Quantity Limit)
• Dexcom G5 Mis Receiver (Quantity Limit)
• Dexcom G6 Mis Receiver (Quantity Limit)
• Freestyle 10 Sen Libre (Quantity Limit)
• Freestyle 10 Reader Libre (Quantity Limit)
• Freestyle 14 Sen Libre (Quantity Limit)
• Freestyle 14 Reader Libre (Quantity Limit)
• Freestyle 14 Sen Libre 2 (Quantity Limit)
• Freestyle 14 Reader Libre 2 (Quantity Limit)

Removals:

• Diphenhydramine elixir

Other Updates:

• Medroxyprogesterone Acetate 150mg/mL Syringe (Quantity Limit updated)
• Diphenhydramine liquid (Quantity Limit updated)
• Promethazine syrup (Quantity Limit updated)

January 2022

Additions:

• No updates

Removals:

• Nozin Nasal Kit Sanitize
• Calcium 600 Tab +D

Other Updates:

• No updates

December 2021

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

November 2021

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

October 2021

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

September 2021

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

August 2021

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

July 2021

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

June 2021

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

May 2021

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

April 2021

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

March 2021

Additions:

• Hizentra Inj 1gm/5ml (Prior Authorization)
• Hizentra Inj 2gm/10ml (Prior Authorization)
• Hizentra Inj 2gm/10ml (Prior Authorization)
• Hizentra Inj 4gm/20ml (Prior Authorization)
• Hizentra Sol 20% (Prior Authorization)
• Hizentra Via 10gm/50m (Prior Authorization)
• Hizentra Via 1gm/5ml (Prior Authorization)
• Immune Globulin (Human) Iv Or Subcutaneous Soln 1 Gm/10 (Prior Authorization)
• Immune Globulin (Human) Iv Or Subcutaneous Soln 10 Gm/1 (Prior Authorization)
• Immune Globulin (Human) Iv Or Subcutaneous Soln 20 Gm/2 (Prior Authorization)
• Immune Globulin (Human) Iv Or Subcutaneous Soln 5 Gm/50 (Prior Authorization)
• Privigen Inj 10grams (Prior Authorization)
• Privigen Inj 40grams (Prior Authorization)
• Privigen Inj 5 Grams (Prior Authorization)
• Privigen Via 20grams (Prior Authorization)

Other Updates:

• Arnuity Elpt Inh 100mcg (Quantity Limit Added)
• Arnuity Elpt Inh 200mcg (Quantity Limit Added)
• Arnuity Elpt Inh 50mcg (Quantity Limit Added)
• Bevespi      Aer 9-4.8mcg (Quantity Limit Added)
• Levofloxacin Sol 25mg/Ml (Quantity Limit, Age Limit Added)
• Neomycin-Polymyxin-Dexamethasone Ophth Oint 0.1% (Quantity Limit Added)
• Phenylephrine Hcl Ophth Soln 2.5% (Quantity Limit Added)
• Rabeprazole  Tab 20 (Quantity Limit Added)

February 2021

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

January 2021

Removals:

• Ogestrel Tablet 0.5-50mg-mcg

Other Updates:

• Antabuse 250mg, 500mg (Removed Quantity Level Limit)
• Buprenorphine-Naloxone 2-0.5mg, 8-2mg sublingual tablet (Removed Quantity Level Limit)
• Buprenorphine 2mg, 8mg sublingual tablet (Removed Quantity Level Limit)
• Naloxone 0.4mg/mL injection solution (Removed Quantity Level Limit)
• Naloxone 0.4mg/mL injection syringe (Removed Quantity Level Limit)
• Naloxone 1mg/mL injection syringe (Removed Quantity Level Limit)
• Narcan 4mg/actuation nasal spray (Removed Quantity Level Limit)
• Probuphine 74.2mg subdermal implant (Removed Quantity Level Limit)
• Sublocade 100mg/0.5ml, 300mg/1.5ml solution, extended release subcutaneous syringe (Removed Quantity Level Limit)