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Formulary search tool and updates

We cover medicines listed on the Supplemental formulary. You can use this list to help you manage your medicine. To see if it’s covered, you’ll also want to check the Statewide preferred drug list. Visit our pharmacy benefits page to learn more.

Your formulary search tool

There are many different things you can do with your formulary search tool. You can: 

 

  • Search for your medicine by name or class 

  • Find generic alternatives to your medicine 

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

Supplemental formulary

To prevent extra costs, check that your medicines are on the Supplemental formulary. If you have questions, just call Member Services at 1-855-300-5528 (TTY: 711). We’re here for you Monday through Friday, from 7 AM to 7 PM ET. Have a list of your prescriptions ready when you call. We can look up your medicines to see if they’re on the list.

April 2021

 

  • No Updates

 

March 2021

 

  • No Updates

 

February 2021

 

Additions:

 

  • *Alcohol Sheets***
  • *Cream Base**
  • *Flavoring Agent - Liquid**
  • *Flavoring Agent - Oil**
  • *Gelatin Capsules (Empty)**
  • *Hearing Aid Batteries-Misc***
  • *Nebulizers***
  • *Oral Vehicles For Susp***
  • *Sodium Polystyrene Sulfonate Powder**
  • Acetone (Urine) Test Strip
  • Albumin (Urine) Test Strip
  • Alendronate Sodium Tab 40 Mg (Quantity Level Limit)
  • Alendronate Sodium Tab 5 Mg (Quantity Level Limit)
  • Amcinonide Oint 0.1%
  • Anastrozole Tab 1 Mg
  • Aspirin Suppos 300mg, 600mg
  • Aspirin Tab 325 Mg
  • Aspirin Tab Delayed Release 325 Mg
  • Auranofin Cap 3mg
  • Bacitracin Oint 500 Unit/Gm
  • Bacitracin Zinc Oint 500 Unit/Gm
  • Benzoyl Peroxide Gel 10%
  • Benzoyl Peroxide Gel 2.5%
  • Benzoyl Peroxide Gel 5%
  • Benzoyl Peroxide Liq 4%
  • Benzoyl Peroxide Liq 5%
  • Benzoyl Peroxide Lotion 10%
  • Benzoyl Peroxide Lotion 5%
  • Benzyl Alcohol
  • Bicalutamide Tab 50 Mg
  • Caffeine Citrate Oral Soln 60 Mg/3ml (10 Mg/Ml Base Equ
  • Caffeine Citrate Powder
  • Caffeine Powder
  • Capsaicin Cream 0.025%, 0.075%, 0.1%
  • Carbamide Peroxide 6.5% Otic Soln (Quantity Level Limit)
  • Carbinoxamine Maleate Tab 4 Mg
  • Cervical Cap 22mm, 26mm,30mm
  • Cetirizine-Pseudoephedrine Tab Sr 12hr 5-120 Mg (Quantity Level Limit)
  • Cherry Syrup
  • Chlorambucil Tab 2 Mg
  • Chlordiazepoxide-Amitriptyline Tab 10-25 Mg
  • Chlordiazepoxide-Amitriptyline Tab 5-12.5 Mg
  • Chlorpheniramine Maleate Syrup 2 Mg/5ml
  • Chlorpheniramine Maleate Tab Cr 12 Mg
  • Chlorpheniramine W/ Codeine Liquid 2-9 Mg/5ml (Age Limit)
  • Clemastine Fumarate Tab 1.34 Mg (1 Mg Base Equiv)
  • Clemastine Fumarate Tab 2.68 Mg
  • Cottonseed Oil
  • Cyclophosphamide Cap 25 Mg
  • Cyclophosphamide Cap 50 Mg
  • Danazol Cap 100 Mg
  • Danazol Cap 200 Mg
  • Danazol Cap 50 Mg
  • Diaphragm Wide Seal 60mm, 65mm, 70mm, 75mm, 80mm, 85mm, 90mm, 95mm
  • Digoxin Tab 125 Mcg (0.125 Mg)
  • Diphenhydramine Hcl Chew Tab 12.5 Mg
  • Diphenhydramine Hcl Elixir 12.5 Mg/5ml
  • Diphenhydramine Hcl Tab Disp 12.5 Mg
  • Disulfiram Tab 250mg, 500mg (Quantity Level Limit)
  • Docosanol Cream 10%
  • Estramustine Phosphate Sodium Cap 140 Mg
  • Etidronate Disodium Tab 200 Mg
  • Etidronate Disodium Tab 400 Mg
  • Exemestane Tab 25 Mg
  • Fexofenadine Hcl Susp 30 Mg/5ml (6 Mg/Ml)
  • Fexofenadine Hcl Tab 60mg, 180mg (Quantity Level Limit)
  • Fludrocortisone Acetate Tab 0.1 Mg
  • Fluorouracil Cream 5%
  • Fluorouracil Soln 2%
  • Fluorouracil Soln 5%
  • Flurbiprofen Tab 50 Mg
  • Flutamide Cap 125 Mg
  • Folic Acid Tab 400mcg
  • Glucose-Vitamin C Chew Tab 4-0.006 Gm
  • Glycerin Suppos 1.2 Gm
  • Glycerin Suppos 2 Gm
  • Glycerin Suppos 2.1 Gm
  • Glycerin Suppos 80.7%
  • Hydrocodone-Acetaminophen Tab 2.5-325 Mg
  • Hydrocortisone Acetate Suppos 30 Mg
  • Hydrocortisone Enema 100 Mg/60ml
  • Hydroxyprogesterone Caproate Im In Oil 1.25 Gm/5ml
  • Hydroxyurea Cap 500 Mg
  • Ibuprofen Susp 40 Mg/Ml
  • Iodoquinol-Hc Cream 1%
  • Isoniazid & Rifampin Cap 150-300 Mg
  • Ketotifen Fumarate Ophth Soln 0.025% (Base Equiv)
  • Lactobacillus Acidophilus Powder
  • Lactose Monohydrate Powder
  • Letrozole Tab 2.5 Mg
  • Leucovorin Calcium Powder
  • Lidocaine Hcl Cream 4%
  • Lidocaine Hcl Soln 4%
  • Lidocaine Hcl Urethral/Mucosal Gel 2%
  • Lidocaine Hcl Urethral/Mucosal Gel Prefilled Syringe 2%
  • Lidocaine Patch 4% (Quantity Level Limit)
  • Loperamide Hcl Liq 1 Mg/5ml (0.2 Mg/Ml)
  • Loperamide Hcl Liq 1 Mg/7.5ml
  • Loperamide Hcl Tab 2 Mg
  • Loratadine Chew Tab 5 Mg (Quantity Level Limit)
  • Loratadine Syrup 5 Mg/5ml
  • Magnesium Cl-Ca Carbonate Tab Dr 71.5-119mg (Elemental)
  • Magnesium Oxide Tab 420 Mg
  • Meclizine Hcl Chew Tab 25 Mg
  • Medroxyprogesterone Acetate Tab 10 Mg
  • Medroxyprogesterone Acetate Tab 2.5 Mg
  • Medroxyprogesterone Acetate Tab 5 Mg
  • Melphalan Tab 2 Mg
  • Mercaptopurine Tab 50 Mg
  • Mesna Tab 400 Mg
  • Metaproterenol Sulfate Syrup 10 Mg/5ml
  • Metaproterenol Sulfate Tab 10 Mg
  • Metaproterenol Sulfate Tab 20 Mg
  • Methenamine Hippurate Tab 1gm
  • Methenamine Mandelate Tab 0.5gm, 1gm
  • Methotrexate Sodium Inj 250 Mg/10ml (25 Mg/Ml)
  • Methotrexate Sodium Inj 50 Mg/2ml (25 Mg/Ml)
  • Methotrexate Sodium Inj Pf 1000 Mg/40ml (25 Mg/Ml)
  • Methotrexate Sodium Inj Pf 250 Mg/10ml (25 Mg/Ml)
  • Methotrexate Sodium Inj Pf 50 Mg/2ml (25 Mg/Ml)
  • Methotrexate Sodium Tab 2.5 Mg (Base Equiv)
  • Miconazole Nitrate Aerosol Pow 2% (Quantity Level Limit)
  • Miconazole Nitrate Cream 2% (Quantity Level Limit)
  • Miconazole Nitrate Powder 2% (Quantity Level Limit)
  • Nadolol & Bendroflumethiazide Tab 40-5 Mg
  • Nadolol & Bendroflumethiazide Tab 80-5 Mg
  • Naloxone Hcl Inj 0.4 Mg/Ml
  • Naloxone Hcl Nasal Spray 4mg/0.1ml (Quantity Level Limit)
  • Naloxone Hcl Soln Prefilled Syringe 2 Mg/2ml (Quantity Level Limit)
  • Niacin Powder
  • Nilutamide Tab 150 Mg (Quantity Level Limit)
  • Norethindrone Acetate Tab 5 Mg (Step Therapy Required)
  • Olive Oil
  • Omeprazole Susp 2 Mg/Ml (Compound Kit) (Age Limit)
  • Pamidronate Disodium For Inj 30 Mg
  • Pamidronate Disodium For Inj 90 Mg
  • Pamidronate Disodium Iv Soln 3 Mg/Ml
  • Pamidronate Disodium Iv Soln 6 Mg/Ml
  • Pamidronate Disodium Iv Soln 9 Mg/Ml
  • Permethrin Lotion 1% (Quantity Level Limit)
  • Ph Test
  • Pheniramine Maleate-Phenylephrine Hcl Tab 17.5-10 Mg
  • Prazosin Hcl Cap 1mg, 2mg, 5mg
  • Progesterone Micronized Cap 100 Mg
  • Progesterone Micronized Cap 200 Mg
  • Promethazine & Phenylephrine Syrup 6.25-5 Mg/5ml
  • Pseudoephedrine Hcl Liq 15 Mg/5ml
  • Ranitidine Hcl Syrup 15 Mg/Ml (75 Mg/5ml)
  • Ranitidine Hcl Tab 75 Mg
  • Ribavirin Soln 40 Mg/Ml (Step Therapy Required)
  • Rifapentine Tab 150 Mg
  • Riluzole Tab 50 Mg
  • Salsalate Tab 500 Mg
  • Salsalate Tab 750 Mg
  • Selenium Sulfide Lotion 2.5%
  • Selenium Sulfide Shampoo 2.25%
  • Sesame Oil
  • Simple - Syrup
  • Sorbitol Solution (Bulk)
  • Stavudine Cap 30 Mg (Quantity Level Limit)
  • Tamoxifen Citrate Oral Soln 10 Mg/5ml (Base Equivalent
  • Tamoxifen Citrate Tab 10 Mg (Base Equivalent)
  • Tamoxifen Citrate Tab 20 Mg (Base Equivalent)
  • Temozolomide Cap 5mg, 20mg, 100mg, 140mg, 180mg, 250mg
  • Terbinafine Hcl Cream 1% (Quantity Level Limit)
  • Testosterone Cypionate Im Inj In Oil 200 Mg/Ml
  • Thiamine Hcl Inj 100mg/ml
  • Thiamine Hcl Tab 100mg
  • Thioguanine Tab 40 Mg
  • Tolnaftate Aerosol 1% (Quantity Level Limit)
  • Tolnaftate Aerosol Pow 1% (Quantity Level Limit)
  • Tolnaftate Cream 1% (Quantity Level Limit)
  • Tolnaftate Powder 1% (Quantity Level Limit)
  • Toremifene Citrate Tab 60 Mg (Base Equivalent)
  • Triamcinolone Acetonide Nasal Aerosol Suspension 55 Mcg
  • Trimethoprim Tab 100 Mg
  • Vancomycin Hcl Iv Soln 1250 Mg/250ml (Base Equivalent)
  • Vancomycin Hcl Iv Soln 1750 Mg/350ml (Base Equivalent)
  • Vancomycin Hcl Iv Soln 750 Mg/150ml (Base Equivalent)
  • Water For Irrigation, Sterile Irrigation Soln
  • Zidovudine Iv Soln 10 Mg/Ml

 

January 2021

 

Additions:

 

  • Hydroxyzine Pamoate Caps 25mg, 50mg, 100mg (Quantity Level Limit)
  • Hydroxyzine Syrup 10mg/5ml
  • Hydroxyzine Tabs 10mg, 25mg, 50mg (Quantity Level Limit)
  • Ibuprofen Suspension 100mg/5ml

October 2020

 

Additions:

 

  • Efavirenz-Lamivudine-Tenofovir DF Tab 400-300-300mg, 600-300-300mg (Quantity Level Limit)

  • Vancomycin HCL IV Sol 750mg/150ml, 1250mg/250ml, 1750mg/350ml

 Removals:

 

  • Prenatrix Tab

  • Symfi Lo Tab (Brand) 400-300-300mg

  • Symfi Tab (Brand) 600-300-300mg

  • Vitrexyl Tabs

Other updates:

 

  • Aripiprazole Tabs 2mg, 5mg, 10mg, 15mg, 20mg, 30mg (Age Limit)

  • Clozapine Tabs 25mg, 50mg, 100mg, 200mg (Age Limit)

  • Olanzapine ODT Tabs 5mg, 10mg, 15mg, 20mg (Age Limit)

  • Olanzapine Tabs 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg (Age Limit)

  • Quetiapine Tabs 25mg, 50mg, 100mg, 200mg, 300mg, 400mg (Age Limit)

  • Risperidone ODT Tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg (Age Limit)

  • Risperidone Solution 1mg/ml (Age Limit)

  • Risperidone Tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg (Age Limit)

  • Ziprasidone Caps 20mg, 40mg, 60mg, 80mg (Age Limit)

 September 2020

 

Additions:

 

  • Abiraterone Tab 250mg (Prior Authorization Required)

  • Alecensa Cap 150mg (Prior Authorization Required)

  • Austedo Tabs 6mg, 9mg, 12mg (Prior Authorization Required)

  • Bexarotene Cap 75mg (Prior Authorization Required)

  • Budesonide Cap 3mg (Step Therapy Required, Quantity Level Limit)

  • Caprelsa Tabs 100mg, 300mg (Prior Authorization Required)

  • Cinacalcet Tabs 30mg, 60mg, 90mg (Prior Authorization Required)

  • Cyclophosphamide Caps 25mg, 50mg

  • Enbrel Inj 25mg/0.5ml (Prior Authorization Required, Quantity Level Limit)

  • Erivedge Cap 150mg (Prior Authorization Required)

  • Gilotrif Tabs 20mg, 30mg, 40mg (Prior Authorization Required)

  • Jakafi Tabs 5mg, 10mg, 15mg, 20mg, 25mg (Prior Authorization Required)

  • Kalydeco Pak 25mg, 50mg, 75mg (Prior Authorization Required)

  • Kalydeco Tab 150mg (Prior Authorization Required)

  • Lenvima Caps Therapy Pack 4mg, 8mg, 10mg, 12mg, 14mg, 18mg, 20mg, 24mg (Prior Authorization Required)

  • Linezolid Tab 600mg (Prior Authorization Required)

  • Mekinist Tabs 0.5mg, 2mg (Prior Authorization Required)

  • Ofev Caps 100mg, 150mg (Prior Authorization Required)

  • Omeprazole DR Tab 20mg (OTC) (Quantity Level Limit)

  • Repatha Inj 140mg/ml (Prior Authorization Required)

  • Repatha Push Inj 420/3.5ml (Prior Authorization Required)

  • Repatha Sure Inj 140mg/ml (Prior Authorization Required)

  • Rydapt Cap 25mg (Prior Authorization Required)

  • Soliris Inj 10mg/ml (Prior Authorization Required)

  • Symdeko Tabs 50-75mg, 100-150mg (Prior Authorization Required)

  • Tafinlar Caps 50mg, 75mg (Prior Authorization Required)

  • Venclexta Tab Starter Pak (Prior Authorization Required)

  • Venclexta Tabs 10mg, 50mg, 100mg (Prior Authorization Required)

  • Xolair Inj 75/0.5ml, 100mg/ml (Prior Authorization Required)

  • Xolair Sol 150mg (Prior Authorization Required)

Other updates:

 

  • Proton Pump Inhibitors (Quantity Level Limit)

August 2020

 

Additions:

 

  • Buprenorphine TD Patch Weekly 5mcg, 7.5mcg, 10mcg, 15mcg, 20mcg (Prior Authorization Required, Quantity Level Limit)

  • Diclofenac Solution 1.5% (Step Therapy Required, Quantity Level Limit)

  • Ibrance Caps 75mg, 100mg, 125mg (Prior Authorization Required, Quantity Level Limit)

  • Ibrance Tabs 75mg, 100mg, 125mg (Prior Authorization Required, Quantity Level Limit)

  • Lynparza Tabs 10mg, 15mg (Prior Authorization Required, Quantity Level Limit)

  • Poly-Vi-Sol Solution 50mg/ml

  • Solifenacin Succinate Tabs 5mg, 10mg (Step Therapy Required, Quantity Level Limit)

  • Symproic Tab 0.2mg (Prior Authorization Required, Quantity Level Limit)

  • Testosterone Gel 1.62% (Prior Authorization Required, Quantity Level Limit)

  • Testosterone TD Solution 30mg/Actuation (Prior Authorization Required, Quantity Level Limit)

  • Tivicay PD Tab 5mg (Age Limit)

  • Trelegy Ellipta Inhaler 100-62.5-25mcg (Step Therapy Required, Quantity Level Limit)

  • Tri-Vi-Sol Solution A/C/D

Removals:

 

  • Amlodipine-Atorvastatin Tabs 2.5-10mg, 2.5-20mg, 2.5-40mg, 5-10mg, 5-20mg, 5-40mg, 5-80mg, 10-10mg, 10-20mg, 10-40mg, 10-80mg

  • Cimduo Tab 300-300mg

  • Fluocinolone Acetonide Solution 0.01%

  • Fluorouracil Cream 0.5%

  • Humulin 70/30

  • Humulin N

  • Humulin R

  • Kitabis Solution 300mg/5ml

  • Naproxen Sodium Tab 275mg

  • Nimodipine Cap 30mg

  • Olanzapine-Fluoxetine Caps 3-25mg, 6-25mg, 6-50mg, 12-25mg, 12-50mg

  • Targretin Gel 1%

  • Tolmetin Cap 400mg

  • Tolmetin Tabs 200mg, 600mg

Other updates:

 

  • Auryxia Tab 210mg (Step Therapy Required)

  • Adapalene Gel 0.1% (Rx Product) (Remove Step Therapy)

  • Acetic Acid/Hydrocortisone OTIC Solution (Quantity Level Limit)

  • Betamethasone Dipropionate Aug Cream 0.05% (Quantity Level Limit)

  • Betamethasone Dipropionate Cream 0.05% (Quantity Level Limit)

  • Betamethasone Dipropionate Lotion 0.05% (Quantity Level Limit)

  • Betamethasone Valerate Cream 0.1% (Quantity Level Limit)

  • Betamethasone Valerate Lotion 0.1% (Quantity Level Limit)

  • Betamethasone Valerate Ointment 0.1% (Quantity Level Limit)

  • Butenafine HCl Cream 1% (Quantity Level Limit)

  • Candesartan Cilexetil – Hydrochlorothiazide Tabs 16-12.5mg, 32-12.5mg, 32-25mg (Step Therapy Required)

  • Candesartan Cilexetil Tabs 4mg, 8mg, 16mg, 32mg (Step Therapy Required)

  • Ciclopirox Olamine Cream 0.77% (Quantity Level Limit)

  • Ciclopirox Olamine Suspension 0.77% (Quantity Level Limit)

  • Ciclopirox Shampoo 1% (Quantity Level Limit)

  • Ciclopirox Solution 8% (Quantity Level Limit)

  • Ciprofloxacin OTIC Solution 0.2% (Quantity Level Limit)

  • Clindamycin Gel 1% (Quantity Level Limit)

  • Clindamycin Lotion 1% (Quantity Level Limit)

  • Clindamycin Pads 1% (Quantity Level Limit)

  • Clindamycin Solution 1% (Quantity Level Limit)

  • Clotrimazole Cream 1% (Quantity Level Limit)

  • Clotrimazole Solution 1% (Quantity Level Limit)

  • Clotrimazole-Betamethasone Cream 1-0.05% (Quantity Level Limit)

  • Disulfiram Tabs 250mg, 500mg (Quantity Level Limit)

  • Ear Drops (Carbamide Peroxide) OTIC Solution 6.5% (Quantity Level Limit)

  • Erythromycin Gel 2% (Quantity Level Limit)

  • Erythromycin Solution 2% (Quantity Level Limit)

  • Erythromycin Pads 2% (Quantity Level Limit)

  • Flunisolide Nasal Solution 0.025% (Step Therapy Required)

  • Fluocinonide Cream 0.05% (Quantity Level Limit)

  • Fluocinonide Solution 0.05% (Quantity Level Limit)

  • Fluvastatin Caps 20mg, 40mg (Step Therapy Required)

  • Hydrocortisone Cream 0.5%, 1%, 2.5% (Quantity Level Limit)

  • Hydrocortisone Lotion 1%, 2.5% (Quantity Level Limit)

  • Hydrocortisone Ointment 0.5%, 1%, 2.5% (Quantity Level Limit)

  • Ketoconazole Cream 2% (Quantity Level Limit)

  • Ketoconazole Shampoo 2% (Quantity Level Limit)

  • Lidocaine Ointment 5% (Quantity Level Limit)

  • Liothyronine Tab 25mcg (Quantity Level Limit)

  • Miconazole Nitrate Cream 2% (Quantity Level Limit)

  • Miconazole Nitrate Aerosol Powder 2% (Quantity Level Limit)

  • Athletes Foot (Miconazole Nitrate) Powder 2% (Quantity Level Limit)

  • Mometasone Furoate Cream 0.1% (Quantity Level Limit)

  • Mometasone Furoate Ointment 0.1% (Quantity Level Limit)

  • Mometasone Furoate Solution 0.1% (Quantity Level Limit)

  • Naltrexone Tab 50mg (Quantity Level Limit)

  • Neomycin-Polymyxin-HC OTIC Solution 1% (Quantity Level Limit)

  • Neomycin-Polymyxin-HC OTIC Suspension 3.5mg/ml-10000 Unit/ml (Quantity Level Limit)

  • Nystatin Cream 100000 Units/gm (Quantity Level Limit)

  • Nystatin Ointment 100000 Units/gm (Quantity Level Limit)

  • Nystatin Topical Powder 100000 Units/gm (Quantity Level Limit)

  • Ofloxacin OTIC Solution 0.3% (Quantity Level Limit)

  • Permethrin Cream 5% (Quantity Level Limit)

  • Prednicarbate Ointment 0.1% (Quantity Level Limit)

  • Ropinirole ER Tabs 2mg, 4mg, 6mg, 8mg, 12mg (Step Therapy Required)

  • Scalp Relief Max Strength (Hydrocortisone) Solution 1% (Quantity Level Limit)

  • Stop Lice Maximum Strength (Pyrethrins-Piperonyl Butoxide) Liquid 0.33-4% (Quantity Level Limit)

  • Sulfacetamide Lotion 10% (Quantity Level Limit)

  • Symtuza Tab (Prior Authorization Required)

  • Terbinafine Cream 1% (Quantity Level Limit)

  • Tolnaftate Cream 1% (Quantity Level Limit)

  • Triamcinolone Acetonide Cream 0.025%, 0.1%, 0.5% (Quantity Level Limit)

  • Triamcinolone Acetonide Lotion 0.025%, 0.1% (Quantity Level Limit)

  • Triamcinolone Acetonide Ointment 0.025%, 0.5% (Quantity Level Limit)

July 2020

 

Additions:

 

  • Amitiza Caps 8mcg, 24mcg (Age Limit, Prior Authorization Required, Quantity Level Limit)

  • Gvoke PFS Injection 0.5mg/0.1ml (Quantity Level Limit)

Other updates:

 

  • Glucagon Emergency Kit 1mg (Quantity Level Limit)

  • Linzess Caps 72mcg, 145mcg, 290mcg (Prior Authorization Required)

June 2020

 

Additions:

 

  • Acne Medication Lotion (Benzoyl Peroxide) 10%

  • Alahist-D Tab 17.5-10mg

  • Atovaquone-Proguanil Tabs 62.5-25mg, 250mg-100mg (Quantity Level Limit)

  • Benzoyl Peroxide Gel 2.5%

  • Claravis Caps 10mg, 20mg, 30mg, 40mg (Step Therapy, Quantity Level Limit)

  • Dovato Tab 50-300mg (Quantity Level Limit)

  • Gvoke Hypopen Inj (Quantity Level Limit)

  • Isotretinoin Caps 10mg, 20mg, 30mg, 40mg (Step Therapy, Quantity Level Limit)

  • Phenazopyridine Tab 95mg

  • Primaquine Tab 26.3mg (Quantity Level Limit)

  • Tolnaftate (Athlete’s Foot Spray) Aerosol Powder 1% (Quantity Level Limit)

  • Tolnaftate Powder 1% (Quantity Level Limit)

Other updates:

 

  • Clotrimazole Solution 1% (Removed Step Therapy)

May 2020

 

Additions:

 

  • Dexamethasone Concentrate 1mg/ml

  • Dexamethasone Vials 4mg/ml, 20mg/5ml, 120mg/30ml, 10mg/ml

  • Fexofenadine Tab 60mg and 180mg (OTC) (Quantity Level Limit)

  • Solu-Cortef PF Vial 100mg, 250mg, 500mg, 1000mg

  • Pyrethrine-Piperonyl Butoxide Shampoo 0.33-4% (OTC) (Quantity Level Limit)

  • Pyrimethamine Tab 25mg (Generic) (Prior Authorization Required)

Removals:

 

  • Daraprim Tab (Brand)

  • Hydrocortisone Lotion 2%

April 2020

 

Additions:

 

  • Aripiprazole Tabs 2mg, 5mg, 10mg, 15mg, 20mg, 30mg (Generic) (Age Limit, Quantity Level Limit)

  • Omeprazole Tab Delayed Release Disintegrating 20 Mg (OTC) (Quantity Level Limit) 

  • Orkambi Packet 100-125mg, 200-125mg (Prior Authorization Required)

  • Orkambi Tabs 100-125mg, 200-125mg (Prior Authorization Required)

  • Sublocade Prefilled Syringe 100mg and 300mg (Quantity Level Limit)

  • Tramadol Hcl Tab 100mg (Quantity Level Limit)

Removals:

 

  • Diphenhydramine Hcl Liquid 6.25mg/ml

  • Polyethylene Glycol 3350 Oral Packet

  • Psyllium Powder Packet 100%

  • Sennosides Tab 17.2mg

  • Sodium Bicarbonate Powder

March 2020

 

Additions:

 

  • Aprepitant Caps 125mg (Generic)

  • Budesonide-Formoterol Inhaler 80-4.5mcg, 160-4.5mcg (Quantity Level Limit)

  • Mesalamine Caps ER 0.375mg (Generic) 

  • Novolin R FlexPen 100 units/ml (Age Limit)

  • OneTouch Verio Flex Kit (Quantity Level Limit) 

  • Penicillamine Tab 250mg (Prior Authorization Required, Quantity Level Limit)       

Removals:

 

  • Apriso Caps ER 0.375gm (Brand)

  • Artificial Tears Solution 1% Ophthalmic

  • Cortane-B Aqueous Solution 10-10-1 Mg/Ml Otic

  • Fluoritab Solution 0.275 (0.125 F) Mg/Drop Oral

  • Hydrocodone-Acetaminophen Solution 10-325 MG/15ML Oral

  • Johnsons Baby Powder

  • Phenytek Caps (Brand)

  • PR Natal 430 PAK

  • PR Natal 400, 430 PAK EC

  • Prevident Solution Rinse

  • Regenecare HA Gel 2%

February 2020

 

Additions:

 

  • Bimatoprost Solution 0.03% (Step Therapy)

  • Ethinyl Estradiol – Etonogestrel Ring 0.015/0.12mg (Quantity Level Limit)

  • Everolimus Tabs 2.5mg, 5mg, 7.5mg (Prior Authorization Required, Quantity Level Limit)

  • Levonorgestrel Releasing IUD 19.5 mcg/day (52 mg total) (Quantity Level Limit)

Removals:

 

  • Afinitor Tabs 2.5mg, 5mg, 7.5mg (Brand)

  • Alprazolam Concentrate 1mg/ml Solution

  • Chlorothiazide Tabs 250mg, 500mg

  • Demeclocycline Tabs 150mg, 300mg

  • Doxycycline Monohydrate Tab 150mg

  • First-Vanco Solution 25mg/ml, 50mg/ml

  • Methyclothiazide Tabs 5mg

  • Mirena

  • Nausea Liquid Relief (fructose-dextrose-phosphoric acid)

  • Nizatidine Solution 15mg/ml

  • Nuvaring (Brand)

  • Rabeprazole EC Caps 20mg

  • Ranitidine Caps 150mg, 300mg

  • Skyla

Other updates:

 

  • Atropine Sulfate Ophthalmic Ointment 1% (Quantity Level Limit)

  • Atropine Sulfate Ophthalmic Solution 1% (Quantity Level Limit)

  • Buspirone Tabs 5mg, 7.5mg, 10mg 15mg (Age Limit)

  • Combigan Solution 0.2%/0.5% (Quantity Level Limit)

  • Diazepam Concentrate Solution 5mg/ml (Quantity Level Limit)

  • Diazepam Oral Solution (Quantity Level Limit)

  • Diazepam Tabs 2mg, 5mg, 10mg (Quantity Level Limit)

  • Divalproex Er Tabs 250mg, 500mg (Prior Authorization Required)

  • Dorzolamide Hcl-Timolol Maleate Ophthalmic Solution 22.3-6.8mg/ml (Step Therapy, Quantity Level Limit)

  • Doxycycline Monohydrate Suspension 25mg/ml (Age Limit)

  • Granisetron Tab 1mg (Step Therapy)

  • Hydroxyzine Hcl Syrup 10mg/5ml (Quantity Level Limit)

  • Hydroxyzine Hcl Tab 50mg (Quantity Level Limit)

  • Hydroxyzine Pamoate Caps 25mg, 50mg, 100mg (Quantity Level Limit)

  • Ibrandronate Inj 3mg/3ml (Quantity Level Limit)

  • Levofloxacin Solution 0.5% (Quantity Level Limit)

  • Lorazepam Conc 2mg/ml (Age Limit, Quantity Level Limit)

  • Memantine Hcl Tabs 5mg, 10mg (Quantity Level Limit)

  • Methazolamide Tabs 25mg, 50mg (Step Therapy)

  • Tazarotene Cream 0.1% (Step Therapy)

  • Timolol Gel Ophthalmic Solution 0.25%, 0.5% (Quantity Level Limit)

  • Trifluridine Ophthalmic Solution 1% (Quantity Level Limit)

January 2020

 

Additions:

 

  • Magnesium Citrate Solution

 Removals:

 

  • Ventolin HFA Inhaler (Brand)

December 2019 

 

Removals: 

 

  • Digoxin Tabs 62.5mcg, 187.5mcg 

  • PreNata Chewable Tab 29-1mg 

  

November 2019 

No changes 

  

October 2019 

No changes 

  

September 2019 

 

Additions: 

 

  • Ambrisentan Tabs 5mg, 10mg (Prior Authorization Required, Quantity Level Limit) 

  • Bosentan Tabs 62.5mg, 125mg (Prior Authorization Required, Quantity Level Limit) 

  • Febuxostat Tabs 40mg, 80mg (Step Therapy Required) 

  • Ramelteon Tab 8mg (Step Therapy Required, Quantity Level Limit) 

  • Ribavirin Caps 200mg (Step Therapy Required) 

  • Ribavirin Tabs 200mg (Step Therapy Required) 

Removals: 

 

  • Letairis Tabs 5mg, 10mg (Brand) 

  • Rozerem Tab 8mg (Brand) 

  • Tracleer Tabs 62.5mg, 125mg (Brand) 

  • Uloric Tabs 40mg, 80mg (Brand) 

  

August 2019 

 

Additions: 

 

  • Butenafine Cream 1% (Over the Counter) 

  • Emtricitabine-Rilpivirine-Tenofovir AF Tab 200-25-25mg (Quantity Level Limit) 

  • Lidocaine Patch 4% (Quantity Level Limit) 

  • Thyroid Tabs 180mg, 240mg, 300mg (Quantity Level Limit) 

Removals: 

 

  • Artificial Tears Ophthalmic Solution 

  • Atabex EC Tab 

  • Atabex Prenatal Chewable Tab 

  • Be Well Rounded Pak 

  • Benziq Wash Liquid 5.25% 

  • Bio-Statin Powder 

  • Biotuss Liquid 

  • BP Wash Liquid 2.5% 

  • Brainstrong Prenatal Mis 

  • Brompheniramine Chewable Tab 12mg 

  • Butalbital-Acetaminophen-Caffeine Caps 50-300-40mg, 50-325-40mg 

  • Cadeau DHA Cap 

  • Calcium Carbonate Powder 

  • Calcium Citrate Tab 200mg, 250mg 

  • Calna Tab 

  • Capzasin-P Cream 0.035% 

  • Centrum Special Prenatal Pak 

  • Children’s ASA Free Elixir 80mg/2.5ml 

  • Chlorhexidine Gluconate Solution 20% 

  • Ciclopirox Gel 0.77% 

  • Clotrimazole w/ Betamethasone Lotion 1-0.05% 

  • Colestipol Granules 5gm 

  • CVS Antacid Supreme Suspension 

  • CVS Prenatal Chewable Gummy 

  • D3 Dots Tab 2000 Units 

  • Entecavir Oral Solution 0.05mg/ml 

  • Epinastine Ophthalmic Solution 0.05% 

  • EQ Aspirin EC Tab 500mg 

  • Ergocal Cap 2500 Units 

  • Erythromycin Ethysuccinate Suspension 200mg/5ml, 400mg/5ml 

  • Esterified Estrogens Tab 0.3mg, 0.625mg, 1.25mg, 2.5mg 

  • Estradiol / Estradiol-Norgestimate Tab 1mg(15) / 1-0.09mg(15) 

  • Etodolac ER Tabs 400mg, 500mg, 600mg 

  • Eye Drops Solution 0.25% 

  • Fluorabon Drops 

  • Fluoride Sensitive Paste 1.1-5% 

  • Fluoridex Concentrate Daily 

  • Fluoroplex Cream 1% 

  • Fluphenazine Elixir 2.5mg/5ml 

  • Fluphenazine Injection 2.5mg/ml 

  • Flura-Drops 4 drops = 1mg 

  • Gas-X Infant Drops 

  • Gentamicin Sulfate Powder 

  • Gleostine Caps 

  • Glucose Chewable Tab 5gm 

  • Homatropine Ophthalmic Solution 5% 

  • Hypersal Neb 3.5% 

  • KPN Prenatal Tab 

  • Lanacort 10 Cream 1% 

  • Laxative Chewable Tab 15mg 

  • Lindane Shampoo 1% 

  • Little Tummy Laxative Drops 

  • Mag Oxide Tab 250mg 

  • Magnesium Tab 250mg, 400mg 

  • Metamucil Powder Original 

  • Moexipril Tabs 7.5mg, 15mg 

  • MV-One Caps 

  • Mynatal Cap 

  • Mynate 90 Plus Tab 

  • Nasal Mist Aerosol 0.9% 

  • Nature-Throid Tab 2gr 

  • Nebusal Neb 6% 

  • Neotuss Liquid 

  • Nexium 24hr Cap OTC 20mg 

  • Niacin Tab 50mg, 250mg 

  • Nutricion Porvida Tab 

  • Obestetrix-DHA Pak 

  • Obstetrix EC Tab 

  • Olopatadine Ophthalmic Solution 0.2% 

  • Omega-3 Fish Cap 300mg 

  • One A Day Mis Prenatal Tab 

  • One A Day Prenatal Tab 

  • Oyster Shell/D Tab 500mg, 600mg 

  • Perry Prenatal Cap 

  • Pinworm Medicine Suspension 

  • Pinworm Medicine Tabs 

  • Prenatal Formula Cap 

  • Prenatal Multi + DHA Cap 

  • Prenatal Nutrients Tab 

  • Prenatal Omega-3 Cap 

  • Prenatal Tab 

  • Prenatal Tab Complete 

  • Prenatal+DHA Mis 

  • Quinidine Gluconate CR Tab 324mg 

  • RA Aspirin Tab 500mg 

  • RA Calcium Hi-Cal Tab 

  • RA Calcium High Potassium Tab 

  • RA Col-Rite Cap 50mg 

  • RA Iron Tab 27mg 

  • RA Magnesium Cap 500mg 

  • RA Therapeutic Shampoo 

  • Replesta Wafer 50000 Units 

  • Silver Nitrate Applicators 

  • Sleep Aid Tab 50mg 

  • Sodium Fluoride Tab 0.5mg, 1mg 

  • Sorbitol Solution 70% 

  • TGT APAP Infant Drops 

  • TGT Lubricant Eye Drops 

  • Theranatal Complete Mis 

  • Theranatal One Cap 

  • Theranatal Ovavite Pak 

  • Theratears Ophthalmic Solution 

  • Thyroid Tab 130mg 

  • Titralac Chewable Tab 420mg 

  • Vancomycin Suspension + Syrspend 

  • Vazobid-PD Suspension 

  • Via-Pren Tab 

  • Vitamin D2 Tab 400 Units 

  • Vitamin D3 Cap 400 Units 

  • Vitamin D3 Chewable Tab 1000 Units, 5000 Units 

  • Vitamin for Hair Tab 

  • Wal-Mucil Powder 

  • X-Seb T Perl Shampoo 10% 

Other updates: 

 

  • Abacavir Sulfate Solution 20mg/ml (Quantity Level Limit) 

  • Abacavir Sulfate Tab 300mg (Quantity Level Limit) 

  • Abacavir Sulfate-Lamivudine Tab 600-300mg (Quantity Level Limit) 

  • Abacavir-Dolutegravir-Lamivudine Tab 600-50-300mg (Quantity Level Limit) 

  • Abacavir-Lamivudine-Zidovudine Tab 300-150-300mg (Quantity Level Limit) 

  • Atazanavir Sulfate Caps 150mg, 200mg, 300mg (Quantity Level Limit) 

  • Atazanavir Sulfate Oral Powder Packet 50mg (Quantity Level Limit) 

  • Atazanavir Sulfate-Cobicistat Tab 300-150mg (Prior Authorization Required, Quantity Level Limit) 

  • Azelastine Ophthalmic Solution 0.05% (Quantity Level Limit) 

  • Calcipotriene Cream 0.005% (Prior Authorization Required, Quantity Level Limit) 

  • Calcipotriene Ointment 0.005% (Prior Authorization Required, Quantity Level Limit) 

  • Calcipotriene Solution 0.005% (Prior Authorization Required, Quantity Level Limit) 

  • Ciclopirox Cream 0.77% (Step Therapy Required) 

  • Ciclopirox Shampoo 1% (Step Therapy Required) 

  • Ciclopirox Suspension 0.77% (Step Therapy Required) 

  • Clozapine Tabs 25mg, 50mg, 100mg, 200mg (Age Limit) 

  • Cobicistat Tab 150mg (Quantity Level Limit) 

  • Darunavir Ethanolate Suspension 100mg/ml (Prior Authorization Required, Quantity Level Limit) 

  • Darunavir Ethanolate Tabs 75mg, 150mg, 600mg, 800mg (Prior Authorization Required, Quantity Level Limit) 

  • Delavirdine Mesylate Tab 100mg (Prior Authorization Required) 

  • Delavirdine Mesylate Tab 200mg (Prior Authorization Required, Quantity Level Limit) 

  • Didanosine DR Caps 125mg, 200mg, 250mg, 400mg (Quantity Level Limit) 

  • Didanosine Solution 2gm, 4gm (Quantity Level Limit) 

  • Dolutegravir Sodium-RilpivirineTab 50-25mg (Prior Authorization Required) 

  • Efavirenz Caps 50mg, 200mg (Quantity Level Limit) 

  • Efavirenz Tab 600mg (Quantity Level Limit) 

  • Efavirenz-Emtricitabine-Tenofovir DF Tab 600-200-300mg (Quantity Level Limit) 

  • Elvitegravir-Cobicistat-Emtricitabine-Tenofovir DF Tab 150-150-200-300mg (Prior Authorization Required) 

  • Emtricitabine Cap 200mg (Quantity Level Limit) 

  • Emtricitabine Solution 10mg/ml (Quantity Level Limit) 

  • Emtricitabine-Rilpivirine-Tenofovir DF Tab 200-25-300mg (Quantity Level Limit) 

  • Enfuvirtide Injection 90mg (Prior Authorization Required, Quantity Level Limit) 

  • Estradiol Vaginal Tab 10mcg (Quantity Level Limit) 

  • Etravirine Tabs 25mg, 100mg, 200mg (Prior Authorization Required, Quantity Level Limit) 

  • Fluocinolone Cream 0.025% (Quantity Level Limit) 

  • Fluocinolone Ointment 0.025% (Quantity Level Limit) 

  • Fosamprenavir Calcium Suspension 50mg/ml (Prior Authorization Required, Quantity Level Limit) 

  • Fosamprenavir Calcium Tab 700mg (Prior Authorization Required, Quantity Level Limit) 

  • Indinavir Sulfate Caps 200mg, 400mg (Prior Authorization Required, Quantity Level Limit) 

  • Lamivudine Oral Solution 10mg/ml (Quantity Level Limit) 

  • Lamivudine Tabs 150mg, 300mg (Quantity Level Limit) 

  • Lamivudine-Zidovudine Tab 150-300mg (Quantity Level Limit) 

  • Lidocaine Cream 4% (Quantity Level Limit) 

  • Lidocaine Gel 2% (Quantity Level Limit) 

  • Lidocaine-Prilocaine Cream 2.5-2.5% (Quantity Level Limit) 

  • Liothyronine Tabs 5mcg, 50mcg (Quantity Level Limit) 

  • Lopinavir-Ritonavir Solution 400-100mg/5ml (Prior Authorization Required, Quantity Level Limit) 

  • Lopinavir-Ritonavir Tabs 100-25mg, 200-50mg (Prior Authorization Required, Quantity Level Limit) 

  • Maraviroc Tabs 25mg, 75mg, 150mg, 300mg (Prior Authorization Required) 

  • Nelfinavir Mesylate Tabs 250mg, 625mg (Prior Authorization Required, Quantity Level Limit) 

  • Nevirapine ER Tabs 100mg, 400mg (Quantity Level Limit) 

  • Nevirapine Suspension 50mg/5ml (Quantity Level Limit) 

  • Nevirapine Tab 200mg (Quantity Level Limit) 

  • Norethindrone Tab 5mg (Step Therapy Required) 

  • Olanzapine ODT Tabs (Age Limit) 

  • Olanzapine Orally Disintegrating Tabs 5mg, 10mg, 15mg, 20mg (Age Limit) 

  • Olanzapine Tabs (Age Limit) 

  • Olanzapine Tabs 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg (Age Limit) 

  • Quetiapine Tabs (Age Limit) 

  • Raltegravir Potassium Packet for Suspension 100mg (Quantity Level Limit) 

  • Raltegravir Potassium Tab 400mg (Quantity Level Limit) 

  • Rilpivirine Tab 25mg (Quantity Level Limit) 

  • Risperidone ODT Tabs (Age Limit) 

  • Risperidone Oral Solution 1mg/ml (Age Limit) 

  • Risperidone Tabs (Age Limit) 

  • Ritonavir Cap 100mg (Quantity Level Limit) 

  • Ritonavir Oral Solution 80mg/ml (Quantity Level Limit) 

  • Ritonavir Tab 100mg (Quantity Level Limit) 

  • Saquinavir Mesylate Cap 200mg (Prior Authorization Required) 

  • Saquinavir Mesylate Tab 500mg (Prior Authorization Required, Quantity Level Limit) 

  • Sertraline Concentrate Oral Solution 20mg/ml (Age Limit) 

  • Stavudine Caps 15mg, 20mg, 30mg, 40mg (Quantity Level Limit) 

  • Stavudine Oral Solution 1mg/ml (Quantity Level Limit) 

  • Tenofovir Disoproxil Fumarate Powder 40mg/gm (Prior Authorization Required, Quantity Level Limit) 

  • Thyroid Tabs 15mg, 30mg, 60mg, 90mg, 120mg (Quantity Level Limit) 

  • Tipranavir Cap 250mg (Prior Authorization Required, Quantity Level Limit) 

  • Tipranavir Oral Solution 100mg/ml (Prior Authorization Required, Quantity Level Limit) 

  • Zidovudine Cap 100mg (Quantity Level Limit) 

  • Zidovudine Syrup 10mg/ml (Quantity Level Limit) 

  • Zidovudine Tab 300mg (Quantity Level Limit) 

  • Ziprasidone Caps 20mg, 40mg, 60mg, 80mg (Age Limit) 

  

July 2019 

 

Additions: 

 

  • Cefixime Cap 400mg (Quantity Level Limit) 

  • Erlotinib Tab 150mg (Prior Authorization Required) 

  • Kevzara Injection 150mg, 200mg (Prior Authorization Required, Quantity Level Limit) 

  • Mesalamine DR Cap 400mg (Quantity Level Limit) 

  • Vivitrol Injection 380mg (Prior Authorization Required) 

Removals: 

 

  • Suprax Cap 400mg (brand) 

  • Tarceva Tab 150mg (brand) 

Other updates: 

 

  • Vivitrol Injection 380mg (Prior Authorization Removed for Substance Use Disorder)  

  

June 2019 

 

Additions: 

 

  • Docosanol Cream 10% 

  • Melatonin Tabs 1mg, 3mg, 5mg 

Removals: 

 

  • Abreva Cream 10% (brand) 

  

May 2019 

 

Additions: 

 

  • Erythromycin Ethylsuccinate Suspension 400mg/5ml 

  • Nivestym Injection 300mcg, 480mcg (Prior Authorization Required) 

  • Sirolimus Solution 1mg/ml 

Removals: 

 

  • Eryped Suspension (brand) 400mg/5ml 

  • Rapamune Solution (brand) 1mg/ml 

  

April 2019 

 

No changes 

  

March 2019 

 

Additions: 

 

  • Admelog Vial 300 units/3mL 

  • Albuterol HFA Inhaler 90mcg –Generic Ventolin HFA (Quantity Level Limit) 

  • Mesalamine Suppository 1000mg 

  • Toremifene Tab 60mg 

Removals: 

 

  • Canasa Suppository 1000mg 

  • Fareston Tab 60mg 

Other updates: 

 

  • Butalbital Containing Products (Quantity Level Limit) 

  

February 2019 

 

Additions: 

 

  • Arnuity Ellipta Inhaler 

  • Eligard Kit 7.5mg, 22.5mg, 30mg, 45mg (Prior Authorization Required) 

  • Flebogamma IV Solution 5gm/50ml, 10gm/100ml, 20gm/200ml (Prior Authorization Required) 

  • Immune Globulin IV Solution 1gm/10ml, 2.5gm/25ml, 5gm/50ml, 10gm/100ml, 20gm/200ml, 30gm/300ml, 40gm/400ml (Prior Authorization Required) 

  • Leuprolide Acetate Kit 1mg/0.2ml (Prior Authorization Required) 

  • Ozempic Injection (Step Therapy, Quantity Level Limit) 

  • Prenatal Vitamin with Docusate-Ferrous Fumarate-Folic Acid Tab 29-1mg (Quantity Level Limit) 

  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 29-1mg (Quantity Level Limit) 

  • Prenatal Vitamin with Iron Carbonyl-Folic Acid Tab 29-1mg (Quantity Level Limit) 

  • Prenatal Vitamin with Minerals-Iron Bisglyc-Iron Prot Succ-Folic Acid-Calcium-Omega 3 Pack 29-1-200-250mg (Quantity Level Limit) 

  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid Cap 20-20-1.25mg (Quantity Level Limit) 

  • Pseudoephedrine Liquid 15mg/5ml 

  • Segluromet Tabs (Step Therapy, Quantity Level Limit) 

  • Steglatro Tabs (Step Therapy, Quantity Level Limit) 

  • Victoza Injection (Step Therapy, Quantity Level Limit) 

  • Zoladex Implant 3.6mg (Prior Authorization Required) 

Removals: 

 

  • Alprazolam Orally Disintegrating Tabs 

  • Cleocin Vaginal Ovule 100mg 

  • Clorazepate Tabs 

  • Condylox Gel 0.5% 

  • Cortifoam Aerosol Rectal 

  • Dihydroergotamine Products 

  • Dulera Inhaler 

  • Elidel Cream 1% 

  • Ergotamine Products 

  • Ergotamine/Caffeine Products 

  • Flovent Diskus Inhalers 

  • Humalog Vials/Pens 

  • Invokamet Tabs 

  • Invokana Tabs 

  • Levonorgestrel/Ethinyl Estradiol Tab 0.1-0.02mg (84) & 0.01mg (7) 

  • Levonorgestrel/Ethinyl Estradiol Tab 0.15-0.03mg (84) & 0.01mg (7) 

  • Lidocaine/Hydrocortisone Kit 20x7gm 

  • Lidocaine/Hydrocortisone Kit 3-1% 

  • Meprobamate Tabs 

  • Miconazole-3 Vaginal Suppository 200mg 

  • Neonatal Plus Tab 

  • Nitro-Bid Packets 2% 

  • Novolog Vials/Pens 

  • Penicillamine Cap 250mg 

  • Plan B Tabs (Brand Only) 

  • Prenatal Vitamin and Minerals without Vit A with Iron Polysaccharide Complex-Folic Acid-Calcium-Omega 3 Pack 32-1-200mg 

  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid-DSS-Fish Oil Cap 27-1-500mg 

  • Prenatal Vitamin with Ferrous Fumarate-L Methylfolate-Folic Acid Tab 27-0.6-0.4mg 

  • Prenatal Vitamin with Ferrous-Fumarate-Folic Acid Tab 65-1mg 

  • Prenatal Vitamin with Iron Carbonyl-Iron Aspart Glyc-Folic Acid-Omega 3 Cap 27-1mg 

  • Prenatal Vitamin with Iron Polysaccharide Complex-Folic Acid Chewable Tab 29-1mg 

  • Prenatal Vitamin with Minerals-Iron Polysaccharide Complex-Folic Acid-DHA Pack 29-1 & 250mg 

  • Prenatal Vitamin without Vit A with Ferrous Fumarate-DSS-Folic Acid-DHA Cap 27-1.25-300mg 

  • Prenatal Vitamin without Vit A with Ferrous Fumarate-L Methylfolate-Folic Acid-DHA Cap 27-0.6-0.4-300mg 

  • Prenatal Vitamin without Vit A with Iron Bisglycinate-Folic Acid-Omega 3 Pack 32-1mg 

  • Prenatal Vitamin without Vit A with Iron Carbonyl-Ferrous Gluconate-Folic Acid-Vitamin B6 Pack 20-1mg 

  • Prenatal Vitamin without Vit A with Iron Carbonyl-Ferrous Gluconate-DSS-Folic Acid-DHA Pack 27-1mg & 250mg 

  • Pulmicort Flexhalers 

  • Qvar Inhalers 

  • Relenza Diskhaler 

  • Synjardy Tabs 

  • Terconazole Vaginal Suppository 80mg 

  • Thalomid Caps 

  • Triazolam Caps 

  • Tricare Tab 

  • Trimethobenzamide Caps 300mg 

  • Trulicity Injection 

Other updates: 

 

  • Abilify Maintena Injections (Quantity Level Limit) 

  • Acyclovir Suspension 200mg/5ml (Age Limit) 

  • Alprazolam SR Tabs (Age Limit) 

  • Alprazolam Tabs (Quantity Level Limit) 

  • Aristada Injections (Quantity Level Limit) 

  • Breo Ellipta Inhalers (Age Limit) 

  • Buprenorphine Tabs (Quantity Level Limit, Age Limit, Prior Authorization Required) 

  • Buprenorphine-Naloxone Tabs (Quantity Level Limit, Age Limit, Removed Prior Authorization Required, Age) 

  • Calcipotriene Ointment 0.005% (Quantity Level Limit) 

  • Calcipotriene Solution 0.005% (Quantity Level Limit) 

  • Carafate Suspension 1gm/10ml (Age Limit) 

  • Chlordiazepoxide Caps (Quantity Level Limit) 

  • Citalopram Solution 10mg/5ml (Age Limit) 

  • Clozapine Tabs (Quantity Level Limit) 

  • Codeine Containing Products (Age Limit) 

  • Dicyclomine Solution 10mg/ml (Age Limit) 

  • Escitalopram Solution 5mg/5ml (Age Limit) 

  • Famotidine Suspension 40mg/5ml (Age Limit) 

  • Flovent HFA Inhaler (Age Limit) 

  • Fluphenazine Decanoate Vial 25mg/ml (Quantity Level Limit) 

  • Fluphenazine Elixir 2.5mg/5ml (Quantity Level Limit) 

  • Fluphenazine Tabs (Quantity Level Limit) 

  • Fluphenazine vial 2.5mg/ml (Quantity Level Limit) 

  • Haloperidol Concentrate 2mg/ml (Quantity Level Limit) 

  • Haloperidol Decanoate Injections (Quantity Level Limit) 

  • Haloperidol Lactate Injection (Quantity Level Limit) 

  • Haloperidol Tabs (Quantity Level Limit) 

  • Hydrocodone Containing Products (Age Limit) 

  • Hydroxyzine HCL Tabs (Quantity Level Limit) 

  • Invega Sustena Injections (Quantity Level Limit) 

  • Invega Trinza Injections (Quantity Level Limit) 

  • Jardiance Tabs (Remove Step Therapy, Add Prior Authorization Required) 

  • Lansoprazole Suspension 3mg/ml (Age Limit) 

  • Lithium Carbonate Caps (Quantity Level Limit) 

  • Lithium Carbonate ER Tab 300mg, 450mg (Quantity Level Limit) 

  • Lithium Carbonate Tab 300mg (Quantity Level Limit) 

  • Lithium Solution 8meq/5ml (Quantity Level Limit) 

  • Lorazepam Tabs (Quantity Level Limit) 

  • Loxapine Caps (Quantity Level Limit) 

  • Nitrofurantoin Suspension 25mg/5ml (Age Limit) 

  • Nortriptyline Solution 10mg/5ml (Age Limit) 

  • Olanzapine Orally Disintegrating Tabs (Quantity Level Limit) 

  • Olanzapine Tabs (Quantity Level Limit) 

  • Omeprazole Suspension 2mg/ml (Age Limit) 

  • Oseltamivir Cap 30mg (Quantity Level Limit, Age Limit) 

  • Oseltamivir Caps 45mg, 75mg (Quantity Level Limit) 

  • Oseltamivir Suspension 6mg/ml (Quantity Level Limit, Age Limit) 

  • Oxazepam Caps (Quantity Level Limit) 

  • Perphenazine Tabs (Quantity Level Limit) 

  • Prednisone Solution 5mg/5ml (Age Limit) 

  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Chewable Tab 29-1mg (Quantity Level Limit) 

  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 27-0.8mg (Quantity Level Limit) 

  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 27-1mg (Quantity Level Limit) 

  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 28-0.8mg (Quantity Level Limit) 

  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 28-1mg (Quantity Level Limit) 

  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 60-1mg (Quantity Level Limit) 

  • Prenatal Vitamin with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid-Omega 3 Cap 53.5-38-1mg (Quantity Level Limit) 

  • Prenatal Vitamin with Minerals-Ferrous Fumarate-Folic Acid-DHA Pack 28-0.8-200mg (Quantity Level Limit) 

  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Folic Acid Cap 106.5-1mg (Quantity Level Limit) 

  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Folic Acid Chewable Tab 29-1mg (Quantity Level Limit) 

  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid Cap 130-92.4-1mg (Quantity Level Limit) 

  • Prochlorperazine Suppository 25mg (Quantity Level Limit) 

  • Prochlorperazine Tabs (Quantity Level Limit) 

  • Quetiapine Tabs (Quantity Level Limit) 

  • Risperdal Consta Injections (Quantity Level Limit) 

  • Risperidone Oral Solution 1mg/ml (Quantity Level Limit) 

  • Risperidone Orally Disintegrating Tabs (Quantity Level Limit) 

  • Risperidone Tabs (Quantity Level Limit) 

  • Thioridazine Tabs (Quantity Level Limit) 

  • Thiothixene Caps (Quantity Level Limit) 

  • Tramadol Tabs (Age Limit) 

  • Trifluoperazine Tabs (Quantity Level Limit) 

  • Ziprasidone Caps (Quantity Level Limit)

  • Zoladex Implant 10.8mg (Prior Authorization Required)

 

January 2019

 

No changes

Have a question?

You can call Member Services at 1-855-300-5528 (TTY: 711).