Pharmacy

Learn about your pharmacy benefits

If you need medicine, your provider will choose a drug from our list of preferred drugs.

  • Your provider will write you a prescription. Ask your provider to make sure that the medicine is on our list.
  • Take your prescription to a pharmacy that’s in our network.
  • Show your Aetna Better Health of Kentucky member ID card at the pharmacy. If you use medicines from the preferred drug list (formulary), you won't have to pay for your prescriptions.

Check the list of network pharmacies and look for one in your area. If you need help, just call Member Services at 1-855-300-5528 (TTY 711). They’ll be glad to help you find a network pharmacy near you.

Always remember to fill your prescription at a network pharmacy. Your prescriptions won’t be covered at other pharmacies.

To prevent extra costs, check that your medicines are on the preferred drug list. This is called the formulary. If you have questions, just call Member Services at 1-855-300-5528, TTY 711. Have a list of your prescriptions ready when you call. Ask us to look up your medicines to see if they’re on the list.

You now have the ability to search for drugs using our new Formulary Search Tool. Searches can be performed by drug name or by drug class. The tool will provide formulary status, generic alternatives and if there are any clinical edits (Prior Authorization, Quantity Limits, Age Limits etc).

If your medicine is not on the preferred drug list, there are some things you can do.

  • Ask your provider for a similar drug that is on the list.
  • Ask your provider to seek “prior authorization” (pre-approval) from Aetna Better Health of Kentucky to cover this medicine. Your provider knows how to do this.

Aetna Better Health also covers certain over-the-counter drugs, if they are on our list. Some are covered, under certain rules. If the rules for that drug are met, Aetna Better Health will cover the drug. Like other drugs, over-the-counter drugs must have a prescription from a provider for them to be covered at no cost to you.

You can look to see if your over-the-counter medicines are on our formulary. You can also check with Member Services at 1-855-300-5528 (TTY 711). When you call, have a list of your over-the-counter medicines ready. Ask the representative to look up your medicines to see if they’re on the list.

Aetna Better Health Specialty Drugs are filled by CVS Health Specialty Pharmacy. A Specialty pharmacy fills drugs but has other services to help you. The Specialty Drug Program has special services for you:

  • You can talk to a Pharmacist 24 hours a day, seven days a week
  • Disease-specific education and counseling are available by CVS
  • Care Coordination for you and your doctor
  • Delivery of Specialty drugs to your  home and/or your doctor’s office is available for drop off and pick up at any CVS Pharmacy location (including those inside Target stores*)

You can contact CVS Specialty Pharmacy at 1-800-237-2767; TTY/TDD: 1-800-863-5488 from 7:30 a.m. (EST) to 9:00 p.m. (EST) time, Monday – Friday. CVS Specialty Pharmacy will assist you in filling your specialty drug. The specialty drug list is available here.

 

Additional Pharmacies in the specialty network:

BioPlus: Phone: 1-800-628-6965; Fax: 1-833-670-2942

BioRx (Diplomat): Phone: 1-513-792-7080; Fax: 1-513-792-3838

BriovaRx of Indiana: Phone:1-855-427-4682; Fax: 1-877-342-4596

BriovaRx of Tennessee: Phone: 1-615-791-8679; Fax: 1-888-791-7666

Duncan Prescription Center: Phone: 1-270-247-3725; Fax: 1-270-247-6033

Duncan Specialty Pharmacy: Phone: 1-270-247-3725; Fax: 1-270-247-6033

Elwyn Specialty Pharmacy: Phone: 1-855-359-9676; Fax: 1-610-545-6033

Nufactor Inc: Phone: 1-844-871-4773; Fax: 1-844-871-4776

SenderraRx Phone: 1-888-777-5547; Fax: 1-888-777-5645

SimplicityRx: Phone: 1- 513-878-1285; Fax: 1-844-513-6337

Walmart Pharmacies (Specialty Only): Phone: 1-877-453-4566; Fax: 1-866-537-0877

WellPartner Pharmacy: Phone: 1-800-473-3516; Fax: 1-877-597-3070

University of Kentucky Specialty Pharmacy: Phone: 1-844-730-5913; Fax: 1-859-218-5413

 

Your medicine bottle label says how many refills you can have. If your provider hasn’t ordered refills, and you think you need one, you must call him or her at least five days before your medicine runs out. When you call, ask your provider about getting a refill. He or she may want to see you first.

Aetna Better Health of Kentucky wants you to be as healthy as possible. And you’ll want to know more about the different medicines you take. To help you, here’s a list of questions you should always ask your provider when he or she gives you a prescription:

  • Why am I taking this medicine?
  • What is it supposed to do for me?
  • How should I take this medicine? When? For how many days?
  • Are there any side effects or possible allergic reactions to this medicine?
  • What should I do if I have a side effect or allergic reaction?
  • What will happen if I don't take this medicine?

Carefully read the drug information given with your medicine. It will tell you what you should and shouldn’t do while taking the medicine. If you still have questions after you get your medicine, ask to speak with the pharmacist or call your provider.

If you need to be paid back for the cost of a prescription, please use form below.

Aetna Better Health of Kentucky CVS Prescription Reimbursement Form 

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)
  • Erythromcyin 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-Polymixin-HC OTIC Solution 1% (Quantity Level Limit)
  • Neomycin-Polymixin-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-Cobicstat-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)
  • Enfuviritide 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)
  • Notriptyline 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