Skip to main content

Formulary search tool and updates

Stay up-to-date with your medicine. A formulary is a list of medicines we cover. To help you manage your medicines and your loved ones’ medicines.

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

February 2024

 

Additions:

 

  • Adalimumab-Adaz Auto-Injector 40 mg/ 0.4 mL (Prior Authorization)
  • Adalimumab-Adaz Prefilled Syringe 40 mg/ 0.4 mL (Prior Authorization)
  • Adalimumab-Fkjp Auto-Injector Kit 40 mg/ 0.8 mL (Prior Authorization)
  • Adalimumab-Fkjp Prefilled Syringe Kit 20 mg/ 0.4 mL (Prior Authorization)
  • Adalimumab-Fkjp Prefilled Syringe Kit 40 mg/ 0.8 mL (Prior Authorization)
  • Dupixent Injection 100 mg / 0.67 mL (Prior Authorization)
  • Dupixent Injection 200 mg (Prior Authorization)
  • Dupixent Injection 200 mg/ 1.14 mL (Prior Authorization)
  • Dupixent Injection 300 mg/ 2 mL (Prior Authorization)
  • Fesoterodine Fumarate Tablet Extended Release 24 hour 4 mg (Step Therapy, Quantity Level Limit)
  • Fesoterodine Fumarate Tablet Extended Release 24 hour 8 mg (Step Therapy, Quantity Level Limit)
  • Hadlima Auto-Injector 40 mg/ 0.4 mL (Prior Authorization)
  • Hadlima Auto-Injector 40 mg/ 0.8 mL (Prior Authorization)
  • Hadlima Prefilled Syringe 40 mg/ 0.4 mL (Prior Authorization)
  • Hadlima Prefilled Syringe 40 mg/ 0.8 mL (Prior Authorization)
  • Insulin Lispro Injection 100 unit/ mL
  • Insulin Lispro Injection Junior
  • Insulin Lispro Vial
  • Lantus Pen Injector
  • Lantus Vial
  • Ondansetron Hydrochloride Oral Solution 4 mg/ 5 mL (Quantity Level Limit)
  • Orilissa Tablet 150 mg (Prior Authorization)
  • Orilissa Tablet 200 mg (Prior Authorization)
  • Otezla Starter Pack 10 mg/20 mg/30 mg (Prior Authorization)
  • Otezla Tablet 30 mg (Prior Authorization)
  • Rinvoq Tablet 15 mg Extended Release (Prior Authorization)
  • Rinvoq Tablet 30 mg Extended Release (Prior Authorization)
  • Rinvoq Tablet 45 mg Extended Release (Prior Authorization)
  • Teriparatide Pen Injector 620 mcg/ 2.48 mL (Prior Authorization, Quantity Level Limit)
  • Ubrelvy Tablet 100 mg (Step Therapy)
  • Ubrelvy Tablet 50 mg (Step Therapy)
  • Ultra-Fine U-100 (BD)
  • Ultra-Fine U-500 (BD)

 

Removals:

 

  • Admelog Pen Injector
  • Admelog Vial
  • Amjevita Injection 40 mg/ 0.8 mL
  • Basaglar
  • Benzoyl Peroxide Liquid Wash 4%
  • Bromocriptine Mesylate Capsule 5 mg (Base Equivalent)
  • Bromocriptine Mesylate Tablet 2.5 mg (Base Equivalent)
  • Climara Pro Patch
  • Combipatch Dis 0.05/ 0.14 mg
  • Combipatch Dis 0.05/0.25 mg
  • Diflunisal Tablet
  • Glyburide Micronized Tablet 1.5 mg
  • Glyburide Micronized Tablet 3 mg
  • Glyburide Micronized Tablet 6 mg
  • Glyburide Tablet 1.25 mg
  • Glyburide Tablet 2.5 mg
  • Glyburide Tablet 5 mg
  • Glyburide-Metformin Tablet 1.25-250 mg
  • Glyburide-Metformin Tablet 2.5-500 mg
  • Glyburide-Metformin Tablet 5-500 mg
  • Humira Injection 10 mg/ 0.1 mL
  • Humira Injection 20 mg/ 0.2 mL
  • Humira Injection 40 mg/ 0.4 mL
  • Humira Kit 40mg/ 0.8 mL
  • Humira Pedia Injection Crohns
  • Humira Pen Injection 40 mg/ 0.4 mL
  • Humira Pen Injection 40 mg/ 0.8 mL
  • Humira Pen Injection 80 mg/ 0.8 mL
  • Humira Pen Kit Psoriasis/Uveitis
  • Insulin Aspart Flex Pen 70/30
  • Insulin Aspart Protein Injection Flex pen
  • Insulin Aspart Vial 70/30 mix
  • Insulin Glargine - Yfgn Pen Injector
  • Insulin Glargine - Yfgn Vial
  • Insulin Syringe (Disposable) U-100 0.3 mL
  • Insulin Syringe (Disposable) U-100 1 mL
  • Insulin Syringe (Disposable) U-100 1/2 mL
  • Insulin Syringe/Needle U-100 0.3 mL 29 X 1/2"
  • Insulin Syringe/Needle U-100 0.3 mL 30 X 1/2"
  • Insulin Syringe/Needle U-100 0.3 mL 30 X 5/16"
  • Insulin Syringe/Needle U-100 0.3 mL 31 X 15/64"
  • Insulin Syringe/Needle U-100 0.3 mL 31 X 5/16"
  • Insulin Syringe/Needle U-100 1 mL 25 X 1"
  • Insulin Syringe/Needle U-100 1 mL 25 X 5/8"
  • Insulin Syringe/Needle U-100 1 mL 26 X 1/2"
  • Insulin Syringe/Needle U-100 1 mL 27 X 1/2"
  • Insulin Syringe/Needle U-100 1 mL 27 X 5/8"
  • Insulin Syringe/Needle U-100 1 mL 28 X 1/2"
  • Insulin Syringe/Needle U-100 1 mL 28 X 5/16"
  • Insulin Syringe/Needle U-100 1 mL 29 X 1/2"
  • Insulin Syringe/Needle U-100 1 mL 29 X 5/16"
  • Insulin Syringe/Needle U-100 1 mL 30 X 1/2"
  • Insulin Syringe/Needle U-100 1 mL 30 X 5/16"
  • Insulin Syringe/Needle U-100 1 mL 31 X 15/64"
  • Insulin Syringe/Needle U-100 1 mL 31 X 5/16"
  • Insulin Syringe/Needle U-100 1/2 mL 27 X 1/2"
  • Insulin Syringe/Needle U-100 1/2 mL 28 X 1/2"
  • Insulin Syringe/Needle U-100 1/2 mL 29 X 1/2"
  • Insulin Syringe/Needle U-100 1/2 mL 30 X 1/2"
  • Insulin Syringe/Needle U-100 1/2 mL 30 X 5/16"
  • Insulin Syringe/Needle U-100 1/2 mL 31 X 15/64"
  • Insulin Syringe/Needle U-100 1/2 mL 31 X 5/16"
  • Insulin Syringe/Needle U-100 2 mL 27.5 X 5/8"
  • Ketorolac Tromethamine Ophthalmic Solution 0.4%
  • Mesalamine Delayed Release Tablets 800 mg
  • Novolog Mix Injection Flex ReliOn
  • Novolog ReliOn Injection 70/30
  • Salsalate Tablet 500 mg
  • Salsalate Tablet 750 mg
  • Tramadol Tablet 100 mg
  • Trelegy 100 Inhalation Ellipta
  • Trelegy 200 Inhalation Ellipta
  • Viokace Tablet 10440 Units
  • Viokace Tablet 20880 Units

 

Other Updates:

 

  • Albuterol Sulfate Solution Nebulizer 0.5% (5 mg/ mL) (Quantity Level Limit)
  • Alogliptin-Pioglitazone Tablet 12.5-15 mg (Quantity Level Limit)
  • Alogliptin-Pioglitazone Tablet 12.5-45 mg (Quantity Level Limit)
  • Bimatoprost Ophthalmic Solution 0.03%
  • Empagliflozin Tablet 10 mg
  • Empagliflozin Tablet 25 mg
  • Emtricitabine-Tenofovir Disoproxil Fumarate Tablet 133-200 mg (Quantity Level Limit)
  • Emtricitabine-Tenofovir Disoproxil Fumarate Tablet 167-250 mg (Quantity Level Limit)
  • Esomeprazole Magnesium Capsule Delayed Release 40 mg (Quantity Level Limit)
  • Glimepiride Tablet 1 mg (Quantity Level Limit)
  • Glimepiride Tablet 2 mg (Quantity Level Limit)
  • Glimepiride Tablet 4 mg (Quantity Level Limit)
  • Lansoprazole Capsule Delayed Release 30 mg (Quantity Level Limit)
  • Omeprazole Capsule Delayed Release 40 mg (Quantity Level Limit)
  • Oxymetazoline Hydrochloride Nasal Solution 0.05% (Quantity Level Limit)
  • Pantoprazole Sodium Enteric Coated Tablet 20 mg (Quantity Level Limit)
  • Pantoprazole Sodium Enteric Coated Tablet 40 mg (Quantity Level Limit)
  • Rosuvastatin Calcium Tablet 10 mg (Quantity Level Limit)
  • Rosuvastatin Calcium Tablet 20 mg (Quantity Level Limit)
  • Rosuvastatin Calcium Tablet 40 mg (Quantity Level Limit)
  • Rosuvastatin Calcium Tablet 5 mg (Quantity Level Limit)
  • Stribild Tablet (Quantity Level Limit)
  • Terazosin Hydrochloride Capsule 5 mg (Base Equivalent)
  • Tobramycin Nebulizer Solution 300 mg/ 5 mL (Quantity Level Limit)

 

January 2024

 

Additions:

  • Dexcom G7 Receiver (Prior Authorization, Quantity Level Limit)
  • Dexcom G7 Sensor (Prior Authorization, Quantity Level Limit)

Removals:

  • None

Other Updates:

  • None

December 2023

 

Additions:

 

  • None

 

Removals:

 

  • None

 

Other Updates:

 

  • None

 

November 2023

 

Additions:

 

  • Ciprofloxacin-Dexamethasone Otic Suspension 0.3-0.1% (Quantity Level Limit)
  • Gefitinib Tablet 250 mg (Prior Authorization, Quantity Level Limit)
  • Haegarda Injection 2000 unit (Prior Authorization)
  • Haegarda Injection 3000 unit (Prior Authorization)
  • Liqrev (Prior Authorization, Quantity Level Limit)
  • Phenylephrine-Mineral Oil-Petrolatum Rectal Ointment
  • Takhzyro Injection 150 mg / mL (Prior Authorization, Quantity Level Limit)
  • Takhzyro Injection 300 / 2 mL (Prior Authorization, Quantity Level Limit)

 

Removals:

 

  • Proctofoam Aerosol Hydrocortisone 1%

 

Other Updates:

 

  • Carvedilol Tablet 25 mg (Quantity Level Limit)
  • Chloroquine Phosphate Tablet 250 mg (Remove Prior Authorization)
  • Chloroquine Phosphate Tablet 500 mg (Remove Prior Authorization)
  • Clobetasol Propionate Emollient Base Cream 0.05% (Step Therapy)
  • Darunavir Oral Suspension 100 mg / mL (Quantity Level Limit)
  • Darunavir Tablet 150 mg (Quantity Level Limit)
  • Darunavir Tablet 75 mg (Quantity Level Limit)
  • Efavirenz Capsule 200 mg (Quantity Level Limit)
  • Efavirenz Capsule 50 mg (Quantity Level Limit)
  • Ella Tablet 30 mg (Quantity Level Limit)
  • Glipizide-Metformin Hydrochloride Tablet 2.5-500 mg (Quantity Level Limit)
  • Hydroxychloroquine Sulfate Tablet 200 mg (Remove Prior Authorization)
  • Isentress Tablet 400 mg (Base Equivalent) (Quantity Level Limit)
  • Ketoconazole Tablet 200 mg (Quantity Level Limit)
  • Lopinavir-Ritonavir Solution 400-100 mg / 5 mL (80-20 mg /mL) (Quantity Level Limit)
  • Matulane Capsule 50 mg (Add Prior Authorization)
  • Mavyret Tablet 100-40 mg (Quantity Level Limit)
  • Metronidazole Gel 1% (Step Therapy)
  • Nifedipine Tablet Extended Release 24-hour Osmotic Release 60 mg (Quantity Level Limit)
  • Norethindrone Acetate-Ethinyl Estradiol Tablet 0.5 mg-2.5 mcg (Quantity Level Limit)
  • Norethindrone Tablet 0.35 mg (Quantity Level Limit)
  • Prezcobix Tablet 800-150 (Quantity Level Limit)
  • Promacta Pack 25 mg (Remove Prior Authorization)
  • Promacta Powder 12.5 mg (Remove Prior Authorization)
  • Sofosbuvir-Velpatasvir Tablet 400-100 mg (Quantity Level Limit)
  • Sprycel Tablet 20 mg (Quantity Level Limit)
  • Stavudine Capsule 15 mg (Quantity Level Limit)
  • Stavudine Capsule 20 mg (Quantity Level Limit)
  • Tivicay 10 mg (Base Equivalent) (Quantity Level Limit)
  • Tobramycin Nebulizer Solution 300 mg / 5 mL (Quantity Level Limit)
  • Tretinoin Capsule 10 mg (Add Prior Authorization)

 

October 2023

 

Additions:

 

  • Austedo Extended Release Tablet Titration Kit (Prior Authorization, Quantity Level Limit)

 

Removals:

 

  • None

 

Other Updates:

 

  • None

 

September 2023

 

Additions:

 

  • None

 

Removals:

 

  • None

 

Other Updates:

 

  • None

 

August 2023

 

Additions:

 

  • *Pediatric Multiple Vitamin With Minerals Chewable Tablet**
  • Albuterol Sulfate Solution Nebulizer 0.5% (5 mg /mL)
  • Ascorbic Acid Chewable Tablet 250 mg
  • Ascorbic Acid Chewable Tablet 500 mg
  • Ascorbic Acid Tablet 1000 mg
  • Ascorbic Acid Tablet 250 mg
  • Ascorbic Acid Tablet 500 mg
  • Austedo Tablet Extended Release 24hr 12 mg (Prior Authorization, Quantity Level Limit)
  • Austedo Tablet Extended Release 24hr 24 mg (Prior Authorization, Quantity Level Limit)
  • Austedo Tablet Extended Release 24hr 6 mg (Prior Authorization, Quantity Level Limit)
  • Biktarvy Tablet 30-120-15 mg (Diagnosis Required, Quantity Level Limit)
  • Cholecalciferol Capsule 1.25 mg (50000 Unit)
  • Cholecalciferol Chewable Tablet 10 mcg (400 Unit)
  • Cholecalciferol Oral Liquid 10 mcg/ mL (400 Unit/ mL)
  • Evotaz Tablet 300-150 mg (Base Equivalent) (Diagnosis Required, Quantity Level Limit)
  • Fluocinolone Acetonide Oil 0.01% (Body Oil) (Quantity Level Limit)
  • Kalydeco Granules 13.4 mg (Prior Authorization)
  • Levonorgestrol-Ethinyl Estradiol Tablet 0.15-0.03 mg (84) & Ethinyl Estradiol Tablet 0.01 mg (7)
  • Mekinist Solution 0.05 mg/ mL (Prior Authorization)
  • Melatonin Tablet 1 mg
  • Melatonin Tablet 3 mg
  • Melatonin Tablet 5 mg
  • Mineral Oil
  • Nebivolol Hydrochloride Tablet 10 mg (Base Equivalent) (Quantity Level Limit)
  • Nebivolol Hydrochloride Tablet 2.5 mg (Base Equivalent) (Quantity Level Limit)
  • Nebivolol Hydrochloride Tablet 20 mg (Base Equivalent) (Quantity Level Limit)
  • Nebivolol Hydrochloride Tablet 5 mg (Base Equivalent) (Quantity Level Limit)
  • Niacin Tablet Extended Release 500 mg
  • Oxymetazoline Hydrochloride Nasal Solution 0.05%
  • Pediatric Multiple Vitamins With Iron Chewable Tablet 18 mg
  • Tafinlar Tablet 10 mg (Prior Authorization)
  • Tranexamic Acid Tablet 650 mg (Quantity Level Limit)
  • Trikafta Pak 59.5 mg (Prior Authorization)
  • Trikafta Pak 75 mg (Prior Authorization)
  • Tybost Tablet 150 mg (Diagnosis Required, Quantity Level Limit)

 

Removals:

 

  • *Alcohol Sheets***
  • *B-Complex With Minerals Liquid**
  • *Blood Glucose Calibration - Liquid - Low***
  • *Blood Glucose Calibration - Liquid - Normal***
  • *Blood Glucose Monitoring Miscellaneous.***
  • *Cream Base**
  • *Dermatological Products Miscellaneous - Cream**
  • *Dermatological Products Miscellaneous - Lotion**
  • *Non Gelatin Capsules (Empty)**
  • *Prenatal Without A Vitamin With Ferrous Fumarate -Folic Acid Tablet Chewable 40-1 mg***
  • *Prenatal Without Vitamin A With Ferrous Fumarate -Ferrous Polysaccharide-Folic Acid Capsule 85-1 mg***
  • *Prenatal-Ferrous Bisglycinate-Iron Protein Succinylate-Folic Acid-Calcium Tablet & Omega 3 Capsule 200 Pk**
  • *Respiratory Therapy Supplies - Devices**
  • *Spacer/Aerosol-Holding Chamber Supplies - Masks***
  • *Specialty Vitamin Product Tablet**
  • *Sunscreen Lotion**
  • Benazepril & Hydrochlorothiazide Tablet 10-12.5 mg
  • Benazepril & Hydrochlorothiazide Tablet 20-12.5 mg
  • Benazepril & Hydrochlorothiazide Tablet 20-25 mg
  • Benazepril & Hydrochlorothiazide Tablet 5-6.25 mg
  • Caffeine Powder
  • Ciprofloxacin Hydrochloride Tablet 100 mg
  • Cortisone Acetate Tablet 25 mg
  • Fluocinonide Ointment 0.05%
  • Fosinopril Sodium & Hydrochlorothiazide Tablet 10-12.5 mg
  • Fosinopril Sodium & Hydrochlorothiazide Tablet 20-12.5 mg
  • Glucose Oral Liquid 15 GM/ 59 mL
  • Guaifenesin Syrup 100 mg/ 5 mL
  • Hydrocortisone Micronized Powder
  • Hydrocortisone Powder
  • Hydroxyprogesterone Caproate (Bulk) Powder
  • Irbesartan Tablet 150 mg
  • Irbesartan Tablet 300 mg
  • Irbesartan Tablet 75 mg
  • Ketoprofen Capsule 50 mg
  • Lactobacillus Acidophilus Powder
  • Leucovorin Calcium Powder
  • Methadone Hydrochloride Tablet For Oral Suspension 40 mg
  • Methsuximide Capsule 300 mg
  • Pyrimethamine (Bulk) Powder
  • Rimantadine Hydrochloride Tablet 100 mg
  • Syringe/Needle (Disposable) 1 mL 30 X 1/2"
  • Telmisartan Tablet 20 mg
  • Telmisartan Tablet 40 mg
  • Telmisartan Tablet 80 mg
  • Tolnaftate Aerosol Powder 1%

 

Other Updates:

 

  • Bisoprolol Fumarate Tablet 10 mg (Quantity Level Limit)
  • Desmopressin Acetate Nasal Spray Solution 0.01% (Quantity Level Limit)
  • Hydrocortisone Acetate Cream 1% (Quantity Level Limit)
  • Lisinopril & Hydrochlorothiazide Tablet 20-12.5 mg (Quantity Level Limit)
  • Methadone Hydrochloride Concentration 10 mg/ mL (Quantity Level Limit)
  • Methadone Hydrochloride Solution 10 mg/ 5 mL (Quantity Level Limit)
  • Methadone Hydrochloride Solution 5 mg/ 5 mL (Quantity Level Limit)
  • Methadone Hydrochloride Tablet 10 mg (Quantity Level Limit)
  • Methadone Hydrochloride Tablet 5 mg (Quantity Level Limit)
  • Oseltamivir Phosphate Capsule 30 mg (Quantity Level Limit)
  • Praziquantel Tablet 600 mg (Remove Prior Authorization)
  • Propranolol Hydrochloride Capsule Extended Release 24 hour 120 mg (Quantity Level Limit)
  • Propranolol Hydrochloride Capsule Extended Release 24 hour 160 mg (Quantity Level Limit)
  • Rosuvastatin Calcium Tablet 10 mg (Remove Step Therapy)
  • Rosuvastatin Calcium Tablet 20 mg (Remove Step Therapy)
  • Rosuvastatin Calcium Tablet 40 mg (Remove Step Therapy)
  • Rosuvastatin Calcium Tablet 5 mg (Remove Step Therapy)
  • Sildenafil Citrate Tablet 20 mg (Quantity Level Limit)

 

July 2023

 

Additions:

 

  • None

 

Removals:

 

  • None

 

Other Updates:

 

  • None

 

June 2023

 

Additions:

 

  • Gilenya Capsule 0.25 mg (Prior Authorization, Quantity Level Limit)

 

Removals:

 

  • None

 

Other Updates:

 

  • None

 

May 2023

 

Additions:

 

  • Amjevita Auto-Injector 40 mg / 0.8 mL (Add Prior Authorization)
  • Breztri Inhalation Aerosol 160-9-4.8 mcg / Actuation (Step Therapy, Quantity Level Limit)
  • Emgality Auto-Injector 120 mg / mL (Step Therapy, Quantity Level Limit)
  • Emgality Prefilled Syringe 120 mg / mL (Step Therapy, Quantity Level Limit)
  • Fexofenadine Hydrochloride Suspension 30 mg / mL (Quantity Level Limit)
  • Fluticasone-Salmeterol Inhalation Powder 250-50 mcg / Actuation (Quantity Level Limit)
  • Fluticasone-Salmeterol Inhalation Powder 500-50 mcg / Actuation (Quantity Level Limit)
  • Salicylic Acid Liquid 17%
  • Trikafta Tablets (Add Prior Authorization)
  • Urea Cream 20%

 

Removals:

 

  • *Pediatric Multiple Vitamins With Iron Chewable Tablet**
  • *Pediatric Multiple Vitamins With Iron Drops 10 mg / mL**
  • *Prenatal Without A With Iron Fumarate-Iron Polysaccharide-Folic Acid Capsule 20-20-1.25 mg**
  • Calcium Carbonate Powder
  • Capsaicin Cream 0.1%
  • Carboxymethylcellulose-Glycerin Ophthalmic Solution 0.5-0.9%
  • Chlorhexidine Gluconate Solution 20%
  • Cholecalciferol Capsule 400 Unit
  • Cholecalciferol Chewable Wafer 50000 Unit
  • Creon Capsule
  • Elmiron Capsules
  • Ergocalciferol Tablet 400 Unit
  • Fluocinolone Acetonide Cream 0.01%
  • Fluocinonide Emulsified Base Cream 0.05%
  • Gentamicin Sulfate Powder
  • Heparin Sodium Injection 20,000 Units / mL
  • Heparin Sodium Injection 5,000 Units / 0.5 mL
  • Lidocaine Hydrochloride Solution 4%
  • Mexiletine Hydrochloride Capsule 150 mg
  • Mexiletine Hydrochloride Capsule 200 mg
  • Mexiletine Hydrochloride Capsule 250 mg
  • Niacin Tablet 250 mg
  • Niacin Tablet 50 mg
  • Prenatal With Ferrous Fumarate-Folic Acid Tablet 28-0.8 mg & Docosahexaenoic Acid Capsule 200 mg Pack
  • Quinidine Sulfate Tablets 200 mg
  • Quinidine Sulfate Tablets 300 mg
  • Salicylic Acid Cream 6%
  • Sodium Chloride Solution Nebulizer 6%
  • Sorbitol Rectal Solution 70%
  • Triamcinolone Acetonide Ointment 0.05%
  • Vancomycin Hydrochloride For Intravenous Solution 1 gm (Base Equivalent)
  • Vancomycin Hydrochloride For Intravenous Solution 5 gm (Base Equivalent)

 

Other Updates:

 

  • Albendazole Tablet 200 mg (Add Prior Authorization, Remove Step Therapy)
  • Albuterol Sulfate Nebulized Solution 0.63 mg/3 mL (Remove Step Therapy, Remove Age Maximum)
  • Albuterol Sulfate Nebulized Solution 1.25 mg/3 mL (Remove Step Therapy, Remove Age Maximum)
  • Betamethasone Dipropionate Ointment 0.05% (Add Quantity Level Limit)
  • Enoxaparin Sodium Injection (Remove Max Days Supply)
  • Enoxaparin Sodium Prefilled Syringe (Remove Max Days Supply)
  • Fluconazole Tablet 150 mg (Add Quantity Level Limit)
  • Fluocinolone Acetonide Cream 0.025% (Add Quantity Level Limit)
  • Fluocinolone Acetonide Ointment 0.025% (Add Quantity Level Limit)
  • Fluticasone-Salmeterol Inhalation Powder 100-50 mcg / Actuation (Remove Age Limit)
  • Lidocaine Hydrochloride Cream 4%
  • Lidocaine Ointment 5% (Remove Prior Authorization)
  • Ozempic Pen-Injector
  • Trulicity Pen-Injector

 

April 2023

 

Additions:

 

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

 

Removals:

 

  • None

 

Other Updates:

 

  • Descovy 200 mg/25 mg tablet (Added Prior Authorization)
  • Emtricitabine/tenofovir DF 100 mg/150 mg tablet (Added Prior Authorization)
  • Emtricitabine/tenofovir DF 133 mg/200 mg tablet (Added Prior Authorization)
  • Emtricitabine/tenofovir DF 167 mg/250 mg tablet (Added Prior Authorization)
  • Emtricitabine/tenofovir DF 200 mg/300 mg tablet (Added Prior Authorization)
  • Freestyle 14 Sensor Libre (Updated Quantity Level Limit)
  • Freestyle 14 Sensor Libre 2 (Updated Quantity Level Limit)
  • Freestyle 14 Sensor Libre 3 (Updated Quantity Level Limit)
  • Isentress 100 mg chewable tablet (Added Prior Authorization)
  • Isentress 100 mg packet (Added Prior Authorization)
  • Isentress 25 mg chewable tablet (Added Prior Authorization)
  • Isentress 400 mg tablet (Added Prior Authorization)
  • Isentress HD 600 mg tablet (Added Prior Authorization)
  • Lamivudine 10 mg per 10 mL (Added Prior Authorization)
  • Lamivudine 150 mg tablet (Added Prior Authorization)
  • Lamivudine 300 mg tablet (Added Prior Authorization)
  • Lamivudine/zidovudine 150 mg/ 300 mg tablet (Added Prior Authorization)
  • Norvir 100 mg packet (Added Prior Authorization)
  • Norvir 80 mg per mL (Added Prior Authorization)
  • Ritonavir 100 mg tablet (Added Prior Authorization)
  • Tivicay 10 mg tablet (Added Prior Authorization)
  • Tivicay 25 mg tablet (Added Prior Authorization)
  • Tivicay 50 mg tablet (Added Prior Authorization)
  • Tivicay PD 5 mg soluble tablet (Added Prior Authorization)
  • Zidovudine 50 mg per 5 mL syrup (Added Prior Authorization)
  • Zidovudine 100 mg capsule (Added Prior Authorization)
  • Zidovudine 300 mg tablet (Added Prior Authorization)

 

March 2023

 

Additions:

 

  • Ozempic Injection 2 mg/3 mL (Quantity Level Limit, Step Therapy)

 

Removals:

 

  • Ciprofloxacin For Oral Suspension 250 mg/5 mL (5%) (5 gm/100 mL)
  • Ciprofloxacin For Oral Suspension 500 mg/5 mL (10%) (10 gm/100 mL)
  • Fluocinolone Acetonide Powder
  • Hydrocortisone Acetate Powder
  • Rivaroxaban Tablet 2.5 mg
  • Triamcinolone Acetonide Powder

 

Other Updates:

 

  • None

 

February 2023

 

Additions:

 

  • Aluminum Hydroxide-Magnesium Carbonate Chewable Tablet 160-105 mg
  • Aluminum Hydroxide-Magnesium Carbonate Suspension 95-358 mg/15mL
  • Aspirin-Acetaminophen-Caffeine Tablet 250-250-65 mg
  • Budesonide Tablet Extended Release 9 mg
  • Calcium Polycarbophil Tablet 625 mg
  • Carboxymethylcell-Glycerin-Polysorb 80 Ophthalmic Solution 0.5-1-0.5%
  • Carboxymethylcellulose Sodium (Preservative Free) Ophthalmic Gel 1%
  • Carboxymethylcellulose Sodium Ophthalmic Gel 1%
  • Carboxymethylcellulose-Glycerin (Preservative Free) Ophthalmic Solution 0.5-0.9%
  • Carboxymethylcellulose-Glycerin (Preservative Free) Ophthalmic Solution 0.5-1%
  • Carboxymethylcellulose-Glycerin Ophthalmic Gel 1-0.9%
  • Carboxymethylcellulose-Glycerin Ophthalmic Solution 0.5-0.9%
  • Climara Pro Dis Weekly (Quantity Level Limit)
  • Cyclosporine (Ophthalmic) Emulsion 0.05% (Prior Authorization Required, Quantity Level Limit)
  • Dabigatran Capsule 150 mg (Quantity Level Limit)
  • Dabigatran Capsule 75 mg (Quantity Level Limit)
  • Dificid Suspension (Prior Authorization Required)
  • Dificid Tablet 200 mg (Prior Authorization Required)
  • Esomepra Mag Capsule 40 mg Delayed Release (Quantity Level Limit)
  • Estradiol Vaginal Cream 0.1 mg/Gm (Quantity Level Limit)
  • Ethacrynic Tablet Acid 25 mg
  • Extavia Injection 0.3 mg
  • Fluocin Acet Oil Ear 0.01% (Quantity Level Limit)
  • Gel-One Injection 30 mg/3 mL (Prior Authorization Required)
  • Glycerin Suppository 1 Gm
  • Glycerin-Hypromellose-Peg 400 Ophthalmic Solution 0.2-0.2-1%
  • Hypromellose Ophthalmic Gel 0.3%
  • Imbruvica Tablet 140 mg (Prior Authorization Required, Quantity Level Limit)
  • Imbruvica Tablet 280 mg (Prior Authorization Required, Quantity Level Limit)
  • Imbruvica Tablet 420 mg (Prior Authorization Required, Quantity Level Limit)
  • Imbruvica Tablet 560 mg (Prior Authorization Required, Quantity Level Limit)
  • Lactobacillus Acidophilus-Pectin Capsule
  • Lactobacillus Capsule
  • Lactobacillus Tablet
  • Lidocaine 5% Rectal Cream (Quantity Level Limit)
  • Magnesium Citrate Solution
  • Miconazole Nitrate Vaginal Suppository 1200 mg & 2% Cream Kit
  • Naphazoline W/ Pheniramine Ophthalmic Solution 0.025-0.3%
  • Naphazoline W/ Pheniramine Ophthalmic Solution 0.027-0.315%
  • Phenylephrine Hydrochloride Tablet 10 mg
  • Phenylephrine W/ Dm-Gg Liquid 10-18-200 mg/15mL (Quantity Level Limit)
  • Phenylephrine W/ Dm-Gg Liquid 2.5-5-100 mg/5 mL (Quantity Level Limit)
  • Phenylephrine-Brompheniramine-Dm Liquid 2.5-1-5 mg/5 mL (Quantity Level Limit)
  • Polyethylene Glycol-Propylene Glycol Ophthalmic Solution 0.4-0.3%
  • Pramoxine Aerosol 1% Rectal (Quantity Level Limit)
  • Probiotic Product - Capsule
  • Pseudoephed-Bromphen-Dm Syrup 30-2-10 mg/5 mL (Quantity Level Limit)
  • Pseudoephed-Dexchlorphen-Chlophedianol Liquid 30-1-12.5 mg/5 mL (Quantity Level Limit)
  • Pseudoephedrine Hydrochloride Tablet Extended Release 12hr 120 mg
  • Psyllium Capsule 0.52 Gm
  • Rivastigmine Dis 13.3/24 (Prior Authorization Required)
  • Rivastigmine Dis 4.6 mg/24 (Prior Authorization Required)
  • Rivastigmine Dis 9.5 mg/24 (Prior Authorization Required)
  • Saline Nasal Gel
  • Saline Nasal Solution 0.65%
  • Saline Nasal Spray 0.65%
  • Sod Fluoride Gel 1.1-5%
  • Sod Fluoride Paste 1.1%
  • Sodium Phosphates – Enema (Quantity Level Limit)
  • Tetrahydrozoline Hydrochloride Ophthalmic Solution 0.05%
  • Tramadol Hydrochloride Tablet Extended Release 24hr 100 mg (Prior Authorization Required, Quantity Level Limit, Age Minimum)
  • Tramadol Hydrochloride Tablet Extended Release 24hr 200 mg (Prior Authorization Required, Quantity Level Limit, Age Minimum)
  • Tramadol Hydrochloride Tablet Extended Release 24hr 300 mg (Prior Authorization Required, Quantity Level Limit, Age Minimum)
  • Vancomycin Capsule 125 mg (Quantity Level Limit)
  • Vancomycin Capsule 250 mg (Quantity Level Limit)
  • Xifaxan Tablet 550 mg (Prior Authorization Required)

 

Removals:

 

  • Alendronate Sol 70/75mL
  • Auryxia 210 mg Tablet
  • Benzocaine-Docusate Sodium Rectal Enema 20-283 mg
  • Betaseron Injection 0.3 mg
  • Bisacodyl Enema 10 mg/30 mL
  • Brimonidine Tartrate-Timolol Maleate Ophthalmic Solution 0.2-0.5%
  • Brinzolamide Ophthalmic Suspension 1%
  • Butalbital-Acetaminophen Tablet 50-325 mg
  • Butalbital-Acetaminophen-Caff W/ Cod Capsule 50-300-40-30 mg
  • Butalbital-Acetaminophen-Caff W/ Cod Capsule 50-325-40-30 mg
  • Butalbital-Aspirin-Caff W/ Codeine Capsule 50-325-40-30 mg
  • Butalbital-Aspirin-Caffeine Capsule 50-325-40 mg
  • Cequa
  • Colchicine Capsule 0.6 mg
  • Dermazinc Cream
  • Desmopressin Spray Ref 0.01%
  • Diphenoxylate W/ Atropine Liquid 2.5-0.025 mg/5 mL
  • Esbriet 267mg Capsule
  • Estring
  • Fexofenadine-Pseudoephedrine Tablet Extended Release 24hr 180-240 mg
  • Ibrance Tablet 100 mg
  • Ibrance Tablet 125 mg
  • Ibrance Tablet 75 mg
  • Levofloxacin Ophthalmic Solution 0.5%
  • Lidocaine Solution 4%
  • Magnesium Hydroxide Suspension Concentrate 2400 mg/10 mL
  • Naproxen Tablet Enteric Coated 500 mg
  • Omnitrope Injection 10/1.5 mL
  • Omnitrope Injection 5/1.5 mL
  • Oxymorphone Hydrochloride Tablet Extended Release 12hr 10 mg
  • Oxymorphone Hydrochloride Tablet Extended Release 12hr 15 mg
  • Oxymorphone Hydrochloride Tablet Extended Release 12hr 20 mg
  • Oxymorphone Hydrochloride Tablet Extended Release 12hr 30 mg
  • Oxymorphone Hydrochloride Tablet Extended Release 12hr 40 mg
  • Oxymorphone Hydrochloride Tablet Extended Release 12hr 5 mg
  • Oxymorphone Hydrochloride Tablet Extended Release 12hr 7.5 mg
  • Pot & Sod Citrates W/ Cit Ac Solution 550-500-334 mg/5 mL
  • Sulfacetamide Sodium Ophthalmic Ointment 10%

 

Other Updates:

 

  • Azelastine Hydrochloride Ophthalmic Solution 0.05% (Remove Step Therapy)
  • Bacitracin Ophthalmic Ointment 500 Unit/Gm (Added Quantity Level Limit)
  • Bacitracin-Polymyxin B Ophthalmic Ointment (Added Quantity Level Limit)
  • Bacitracin-Polymyxin-Neomycin-Hc Ophthalmic Ointment 1% (Added Quantity Level Limit)
  • Benzonatate Capsule 100 mg (Added Quantity Level Limit)
  • Benzonatate Capsule 200 mg (Added Quantity Level Limit)
  • Budesonide Capsule 3 mg Delayed Release (Remove Step Therapy)
  • Calcipotriene Cream 0.005% (Remove Prior Authorization)
  • Calcipotriene Ointment 0.005% (Remove Prior Authorization)
  • Calcipotriene Solution 0.005% (50 mcg/mL) (Remove Prior Authorization)
  • Celecoxib Capsule 100 mg (Remove Step Therapy)
  • Celecoxib Capsule 200 mg (Remove Step Therapy)
  • Celecoxib Capsule 400 mg (Remove Step Therapy)
  • Celecoxib Capsule 50 mg (Remove Step Therapy)
  • Dorzolamide Hydrochloride-Timolol Maleate Ophthalmic Solution 22.3-6.8 mg/mL (Remove Step Therapy)
  • Erythromycin Ophthalmic Ointment 5 mg/Gm (Added Quantity Level Limit)
  • Gentamicin Sulfate Ophthalmic Ointment 0.3% (Added Quantity Level Limit)
  • Hydroc/Homat Tablet 5-1.5 mg (Added Quantity Level Limit)
  • Hydrocod/Hom Syrup 5-1.5/5 (Added Quantity Level Limit)
  • Levonorgestr Tablet 1.5 mg (Quantity Level Limit)
  • Tolterodine Tartrate Capsule Extended Release 24hr 2 mg (Remove Step Therapy)
  • Tolterodine Tartrate Capsule Extended Release 24hr 4 mg (Remove Step Therapy)
  • Tolterodine Tartrate Tablet 1 mg (Remove Step Therapy)
  • Tolterodine Tartrate Tablet 2 mg (Remove Step Therapy)
  • Trospium Chloride Tablet 20 mg (Remove Step Therapy)

 

January 2023

 

Additions:

 

  • Raltegravir Potassium Packet For Susp 100 Mg (Base Equiv) (Quantity Level Limit)

 

Removals:

 

  • All Non OneTouch Delica and Delica Plus Lancets and Devices

 

Other Updates:

 

  • Dolutegravir Sodium Tab 10 Mg (Base Equiv) (Remove Prior Authorization)
  • Dolutegravir Sodium Tab 25 Mg (Base Equiv) (Remove Prior Authorization)
  • Dolutegravir Sodium Tab 50 Mg (Base Equiv) (Remove Prior Authorization)
  • Dolutegravir Sodium Tab For Oral Susp 5 Mg (Base Equiv) (Remove Prior Authorization)
  • Emtricitabine-Tenofovir Alafenamide Fumarate Tab 120-15 Mg (Remove Prior Authorization)
  • Emtricitabine-Tenofovir Alafenamide Fumarate Tab 200-25 Mg (Remove Prior Authorization)
  • Emtricitabine-Tenofovir Disoproxil Fumarate Tab 100-150 Mg (Remove Prior Authorization)
  • Emtricitabine-Tenofovir Disoproxil Fumarate Tab 133-200 Mg (Remove Prior Authorization)
  • Emtricitabine-Tenofovir Disoproxil Fumarate Tab 167-250 Mg (Remove Prior Authorization)
  • Emtricitabine-Tenofovir Disoproxil Fumarate Tab 200-300 Mg (Remove Prior Authorization)
  • Fluticasone Propionate Nasal Susp 50 Mcg/Act (Remove Step Therapy)
  • Histex Pd Dro 0.938mg
  • Lamivudine Oral Soln 10 Mg/Ml (Remove Prior Authorization)
  • Lamivudine Tab 150 Mg (Remove Prior Authorization)
  • Lamivudine Tab 300 Mg (Remove Prior Authorization)
  • Lamivudine-Zidovudine Tab 150-300 Mg (Remove Prior Authorization)
  • Raltegravir Potassium Chew Tab 100 Mg (Base Equiv) (Remove Prior Authorization)
  • Raltegravir Potassium Chew Tab 25 Mg (Base Equiv) (Remove Prior Authorization)
  • Raltegravir Potassium Tab 400 Mg (Base Equiv) (Remove Prior Authorization)
  • Raltegravir Potassium Tab 600 Mg (Base Equiv) (Remove Prior Authorization)
  • Ritonavir Oral Soln 80 Mg/Ml (Remove Prior Authorization)
  • Ritonavir Powder Packet 100 Mg (Remove Prior Authorization)
  • Ritonavir Tab 100 Mg (Remove Prior Authorization)
  • Zidovudine Cap 100 Mg (Remove Prior Authorization)
  • Zidovudine Syrup 10 Mg/Ml (Remove Prior Authorization)
  • Zidovudine Tab 300 Mg (Remove Prior Authorization)

December 2022

 

Additions:

 

  • Icosapent Cap 0.5gm (Prior Authorization Required, Quantity Level Limit)
  • Imbruvica Sus 70mg/Ml (Prior Authorization Required, Quantity Level Limit)
  • Orkambi Gra 75-94mg (Prior Authorization Required)

 

Removals:

 

  • None

 

Other Updates:

 

  • Artificial Sol Tears
  • Aspirin Sup 300mg
  • Feverall Sup 325mg
  • Lubricating Dro 0.5%
  • Lubricant Dro Eye 0.6%

 

November 2022

 

Additions:

 

  • Acetaminophen Disintegrating Tab 160 Mg
  • Alum & Mag Hydroxide-Simethicone Susp 200-200-20 Mg/5ml
  • Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 325 Mg
  • Aspirin Effer Tab 325 Mg
  • Bisacodyl Suppos 10 Mg
  • Bisacodyl Tab Delayed Release 5 Mg
  • Bismuth Subsalicylate Chew Tab 262 Mg
  • Bismuth Subsalicylate Susp 262 Mg/15ml
  • Bismuth Subsalicylate Susp 525 Mg/15ml
  • Bismuth Subsalicylate Tab 262 Mg
  • Calcium Carbonate (Antacid) Chew Tab 1000 Mg
  • Calcium Carbonate (Antacid) Chew Tab 400 Mg
  • Calcium Carbonate (Antacid) Chew Tab 500 Mg
  • Calcium Carbonate (Antacid) Chew Tab 750 Mg
  • Carboxymethylcellulose Sodium Ophth Soln 0.5% (Added Quantity Level Limit)
  • Clotrimazole Vaginal Cream 1%
  • Clotrimazole Vaginal Cream 2%
  • Dextromethorphan Polistirex Extended Release Susp 30 Mg/5ml (Added Quantity Level Limit)
  • Dextromethorphan-Guaifenesin Tab Er 12hr 30-600 Mg
  • Dextromethorphan-Guaifenesin Tab Er 12hr 60-1200 Mg
  • Docusate Calcium Cap 240 Mg
  • Docusate Sodium Cap 100 Mg
  • Docusate Sodium Syrup 60 Mg/15ml
  • Glycerin Suppos 2 Gm
  • Guaifenesin Tab 200 Mg
  • Guaifenesin Tab 400 Mg
  • Guaifenesin Tab Er 12hr 1200 Mg
  • Ibuprofen Chew Tab 100 Mg
  • Ibuprofen Susp 40 Mg/Ml
  • Loperamide Hcl Liq 1 Mg/7.5ml
  • Loperamide Hcl Tab 2 Mg
  • Magnesium Hydroxide Susp 400 Mg/5ml
  • Methotrexate Sodium Inj 250 Mg/10ml (25 Mg/Ml) (Added Quantity Level Limit)
  • Methotrexate Sodium Inj 50 Mg/2ml (25 Mg/Ml) (Added Quantity Level Limit)
  • Miconazole Nitrate Vaginal Cream 2%
  • Miconazole Nitrate Vaginal Cream 4% (200 Mg/5gm)
  • Miconazole Nitrate Vaginal Suppos 100 Mg
  • Omeprazole Magnesium Delayed Release Tab 20 Mg (Base Equiv) (Added Quantity Level Limit)
  • Polyethylene Glycol 3350 Oral Powder 17 Gm/Scoop (Added Quantity Level Limit)
  • Polyethylene Glycol-Propylene Glycol Pf Op Soln 0.4-0.3%
  • Polyvinyl Alcohol-Povidone Ophth Soln 5-6 Mg/Ml (0.5-0.6%)
  • Pseudoephedrine Hcl Tab 30 Mg
  • Pseudoephedrine-Guaifenesin Tab Er 12hr 60-600 Mg
  • Psyllium Powder 48.57%
  • Refresh Dro Op
  • Sennosides Chew Tab 15 Mg
  • Sennosides Tab 15 Mg
  • Sennosides Tab 25 Mg
  • Sennosides Tab 8.6 Mg
  • Sennosides-Docusate Sodium Tab 8.6-50 Mg
  • Simethicone Cap 180 Mg
  • Simethicone Chew Tab 125 Mg
  • Simethicone Chew Tab 80 Mg
  • Sodium Chloride Hypertonic Ophth Oint 5%
  • Sodium Chloride Hypertonic Ophth Soln 5%
  • Triaminic Syp Infant (Added Quantity Level Limit)
  • White Petrolatum-Mineral Oil Ophth Ointment

 

Removals:

 

  • Phenylephrine W/ Dm-Gg Liqd 5-10-100 Mg/5ml
  • Promacta Pak 25mg
  • Promacta Pow 12.5mg

 

Other Updates:

 

  • None

 

October 2022

 

Removals:

 

  • Vancomycin HCL For IV Solution 1 Gm
  • Vancomycin HCL For IV Solution 5 Gm

 

Other Updates:

 

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

 

September 2022

 

Additions:

 

  • Methylprednisolone Tab Therapy Pack 4 Mg 
  • Phospho-Trin K500 Tab 500 Mg
  • Prednisone Tab Therapy Pack 10 Mg (21)
  • Prednisone Tab Therapy Pack 10 Mg (48)
  • Prednisone Tab Therapy Pack 5 Mg (21)
  • Prednisone Tab Therapy Pack 5 Mg (48)
  • Sodium Fluoride Solution 0.2 % Mouth/Throat
  • Sore Throat Spray Liquid 1.4 % Mouth/Throat

 

Removals:

 

  • Dexamethasone Sod Phosphate Pf Solution 10 Mg/M Inj
  • K-Phos Tab 500 Mg
  • Hyperhep B Solution Prefilled Syringe 220 Unit/Ml Im
  • Gralise Tab 600mg
  • Hepagam B Solution 312 Unit/Ml Inj
  • Hyperhep B Solution 220 Unit/Ml Im
  • Gralise Tab 300mg
  • Nabi-Hb Solution 312 Unit/Ml Im
  • Levonorgest-Eth Est & Eth Est Tab 42-21-21-7 Days
  • Norethin-Eth Estradiol-Fe Tab Chewable 0.4-35 Mg-Mcg 
  • Drospiren-Eth Estrad-Levomefol Tab 3-0.02-0.451 Mg
  • Drospiren-Eth Estrad-Levomefol Tab 3-0.03-0.451 Mg
  • Norethin Ace-Eth Estrad-Fe Tab Chewable 1-20 Mg-Mcg(24)
  • Natazia Tab 3/2-2/2-3/1 Mg
  • Hyperhep B Solution Prefilled Syringe 110 Unit/0.5ml Im
  • Hypersal Nebulization Solution 3.5 %
  • Norethin-Eth Estradiol-Fe Tab Chewable 0.8-25 Mg-Mcg

 

Other Updates:

 

  • No Updates

 

August 2022

 

Additions:

 

  • Anti-Dandruff Shampoo 1% (Selenium Sulfide Shampoo)
  • Benzoyl Peroxide Creamy Wash Liquid 4% (PanOxyl Creamy Wash)
  • Bicillin L-A Suspension 2400000 Unit/4ml
  • Calamine Lotion
  • Calamine-Zinc Oxide Lotion 8-8%
  • Doxycycline Monohydrate Tab 100 Mg
  • Eplerenone Tab 25 Mg
  • Eplerenone Tab 50 Mg
  • Fenofibrate Tab 145 Mg
  • Fenofibrate Tab 48 Mg
  • Fluocinonide Cream 1% (Quantity Level Limit)
  • Furosemide Oral Soln 8 Mg/Ml
  • Galantamine Sol 4mg/Ml (Age Limit, Quantity Level Limit)
  • Hydrocortisone Acetate Ointment 1% (Quantity Level Limit)
  • Ivermectin Lotion 0.5% (Step Therapy, Quantity Level Limit)
  • Metronidazole Gel 1% (Step Therapy, Quantity Level Limit)
  • Olmesartan Medoxomil Tab 20 Mg (Quantity Level Limit)
  • Olmesartan Medoxomil Tab 40 Mg (Quantity Level Limit)
  • Olmesartan Medoxomil Tab 5 Mg (Quantity Level Limit)
  • Olopatadine Ophth Soln 0.2% OTC
  • Onetouch Ultra 2 Kit W/ Device
  • Onetouch Verio Flex System Kit W/ Device
  • Onetouch Verio Reflect Kit W/ Device
  • Pataday Ophth Soln 0.7% OTC
  • Permethrin Liquid 1% (Step Therapy, Quantity Level Limit)
  • Symjepi Solution Prefilled Syringe 0.15 Mg/0.3ml (Quantity Level Limit)
  • Symjepi Solution Prefilled Syringe 0.3 Mg/0.3ml (Quantity Level Limit)
  • Tetrabenazine Tab 25 Mg (Prior Authorization Required, Quantity Level Limit)
  • Tetrabenazine Tab12.5 Mg (Prior Authorization Required, Quantity Level Limit)
  • Triprolidine Hcl Drops 0.938mg
  • Triprolidine Hcl Liquid 0.625mg (PediaClear PD Liquid)
  • Triprolidine Hcl Syrup 2.5mg/5ml (Histex Syrup)
  • Voriconazole Tab 200 Mg (Prior Authorization Required)
  • Voriconazole Tab 50 Mg (Prior Authorization Required)

 

Removals:

 

  • Adapalene Cream 0.1%
  • Amcinonide Ointment 0.1%
  • Amiodarone Hcl Tablet 100mg
  • Amiodarone Hcl Tablet 400mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 10-10 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 10-20 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 10-40 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 10-80 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-10 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-20 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-40 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 5-10 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 5-20 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 5-40 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 5-80 Mg
  • Amoxicillin & K Clavulanate Tab Er 12hr 1000-62.5 Mg
  • Antioxidant Cap 250-10000-200 (Multiple Vitamin)
  • Carbinoxamine Maleate Tab 4mg
  • Cefaclor Cap 250 Mg
  • Cefaclor Cap 500 Mg
  • Cefpodoxime Proxetil For Susp 100 Mg/5ml
  • Cefpodoxime Proxetil For Susp 50 Mg/5ml
  • Fish Oil Capsule Delayed Release 1200 Mg
  • Flunisolide Solution 25 Mcg/Act (0.025%) Nasal
  • Fluvastatin Sodium Tab Er 24 Hr 80 Mg (Base Equivalent)
  • Glucagen Hypokit Solution Reconstituted 1 Mg
  • Hydrocortisone Soln 1%
  • Isosorbide Dinitrate Tab 40 Mg
  • Isradipine Cap 2.5mg
  • Isradipine Cap 5mg
  • Lidocaine Hcl Urethral/Mucosal Gel 2 %
  • Memantine Hcl Oral Solution 2 Mg/Ml
  • Memantine Hcl Tab 28 X 5 Mg & 21 X 10 Mg Titration Pack
  • Methazolamide Tab 25 Mg
  • Methazolamide Tab 50 Mg
  • Metronidazole Cap 375 Mg
  • Mometasone Furoate Nasal Spray 50mcg
  • Nicardipine Cap 20mg
  • Nicardipine Cap 30mg
  • Onetouch Solutions Starter Kit Kit W/ Well Device
  • Pc-Tar Shampoo 1 % (Coal Tar Shampoo)
  • Perindopril Erbumine Tab 2 Mg
  • Perindopril Erbumine Tab 4 Mg
  • Perindopril Erbumine Tab 8 Mg
  • Psyllium Powder 30.9%
  • Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4%
  • Salicylic Acid Shampoo 6%
  • Selenium Sulfide Shampoo 2.25%
  • Stress B-Complex/Vitamin C/Zinc Tab
  • Sulfacetamide Sodium Liquid 10%
  • Vancomycin Hcl For Iv Soln 10 Gm (Base Equivalent)
  • Vancomycin Hcl For Iv Soln 500 Mg (Base Equivalent)
  • 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)
  • Vemlidy Tablet 25 Mg
  • Vitamin D (Cholecalciferol) Tab Chewable 10 Mcg (400 Unit) 
  • Zafirlukast Tab 10mg
  • Zafirlukast Tab 20mg

 

Other Updates:

 

  • Acyclovir Cap 200 Mg (Removed Quantity Level Limit)
  • Acyclovir Tab 400 Mg (Removed Quantity Level Limit)
  • Acyclovir Tab 800 Mg (Removed Quantity Level Limit)
  • Austedo Tab 12mg (Added Quantity Level Limit)
  • Austedo Tab 6mg (Added Quantity Level Limit)
  • Austedo Tab 9mg (Added Quantity Level Limit)
  • Ezetimibe Tab 10 Mg (Removed Step Therapy)
  • Glucagon Emergency Kit 1 Mg (Changed Quantity Level Limit)
  • Gvoke Hypopen Solution Auto-Injector 0.5 Mg/0.1ml (Changed Quantity Level Limit)
  • Gvoke Hypopen Solution Auto-Injector 1 Mg/0.2ml (Changed Quantity Level Limit)
  • Gvoke Pfs Solution Prefilled Syringe 0.5 Mg/0.1ml (Changed Quantity Level Limit)
  • Gvoke Pfs Solution Prefilled Syringe 1 Mg/0.2ml (Changed Quantity Level Limit)
  • Olopatadine Ophth Soln 0.1% Otc (Removed Step Therapy)
  • Omega-3-Acid Ethyl Esters Cap 1 Gm (Removed Step Therapy)
  • Valacyclovir Hcl Tab 1 Gm (Removed Quantity Level Limit)
  • Valacyclovir Hcl Tab 500 Mg (Removed Quantity Level Limit)

 

July 2022

 

No updates

 

June 2022

 

Additions:

 

  • Capsaicin Cream 0.1%
  • Chlorpheniramine Maleate Tab Er 12mg (Quantity Level Limit)
  • Hydrocortisone Acetate Cream 1%
  • Ozempic Inj 8mg/3ml (Quantity Level Limit, Step Therapy)
  • Triple Antibiotic Oint 3.5-400-5000 External
  • Triumeq Pd Tab 60-5-30mg (Prior Authorization Required, Quantity Level Limit)

 

Removals:

 

None

 

Other Updates:

 

  • None

 

May 2022

 

Additions:

 

  • Descovy 120-15mg Tab (Prior Authorization Required, Quantity Level Limit)

 

Removals:

 

  • B Complex-C-Folic Acid Tab

 

Other Updates:

 

  • None

 

April 2022

 

  • No updates

 

March 2022

 

Additions:

 

  • Dexcom G5 Mobile Receiver Device (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G5 Mobile Transmitter (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G5 Mobile/G4 Platinum Sensor Kit (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G5 Receiver Kit Device (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G6 Receiver Device (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G6 Sensor (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G6 Transmitter (Prior Authorization Required, Quantity Level Limit)
  • Freestyle Libre Reader Device (Prior Authorization Required, Quantity Level Limit)
  • Freestyle Libre 14 Day Reader Device (Prior Authorization Required, Quantity Level Limit)
  • Freestyle Libre 14 Day Sensor (Prior Authorization Required, Quantity Level Limit)
  • Freestyle Libre 2 Reader Device (Prior Authorization Required, Quantity Level Limit)
  • Freestyle Libre 2 Sensor (Prior Authorization Required, Quantity Level Limit)
  • Hydroxyprogesterone Caproate Im Oil 250mg/ml (Prior Authorization Required)
  • Levocetirizine Tab 5mg (Quantity Level Limit)
  • Makena Inj 275mg (Prior Authorization Required)
  • Medroxyprogesterone Acetate Prefilled Syringe 150mg/ml (Quantity Level Limit)
  • Molnupiravir Cap 200mg (Age Limit, Quantity Level Limit)
  • Norditropin Flexpro Injection 10mg/1.5ml (Prior Authorization Required)
  • Norditropin Flexpro Injection 15mg/1.5ml (Prior Authorization Required)
  • Norditropin Flexpro injection 30mg/3ml (Prior Authorization Required)
  • Norditropin Flexpro Injection 5mg/1.5ml (Prior Authorization Required)
  • Paxlovid Tab (Age Limit, Quantity Level Limit)
  • Ziextenzo Inj 6mg/0.6ML (Prior Authorization Required)

 

Removals:

 

  • Combigan Ophth Soln 0.2-0.5%
  • Diphenhydramine Hcl Elixir 12.5mg/5ml
  • Estradiol Vaginal Cream 0.1mg/Gm
  • Megestrol Suspension 625mg/5ml
  • Omnitrope Inj 5.8mg
  • Udenyca Inj 6mg/0.6ml

 

Other Updates:

 

  • Diphenhydramine Hcl Liquid 12.5mg/5ml (Changed Quantity Level Limit)
  • Eliquis Starter Pack 5mg (Removed Prior Authorization Required)
  • Eliquis Tab 2.5mg, 5mg (Removed Prior Authorization Required)
  • Humalog Kwikpen 100 Unit/ml (75-25) (Removed Age Limit)    
  • Humalog Mix 50/50 Kwikpen 100Unit/ml (Removed Age Limit)
  • Humulin R U-500 Kwikpen Pen Injector (Removed Age Limit)
  • Insulin Lispro Kwikpen 100 Unit/ml (Removed Age Limit)
  • Novolin 70/30 Flexpen 100 Unit/ml (Removed Age Limit)
  • Novolin N Flexpen 100 Unit/ml (Removed Age Limit)
  • Novolin R Flexpen 100 Unit/ml (Removed Age Limit)
  • Novolog Flexpen 100 Unit/ml (70-30) (Removed Age Limit)
  • Promethazine Hcl Syrup 6.25mg/5ml (Changed Quantity Level Limit)
  • Xarelto Starter Pack 15mg/20mg (Removed Prior Authorization Required)
  • Xarelto Tab 10mg, 15mg, 20mg (Removed Prior Authorization Required)

 

February 2022

 

Additions:

 

  • None

 

Removals:

 

  • Calcium Carbonate Vitamin D Tablet 600-200mg unit
  • Calcium Carbonate Vitamin D Tablet 600-400mg unit
  • Concept OB Capsule 130-92.4-1mg
  • Father Johns Medicine Syrup 10mg/5ml
  • Gas-X Infant Drops Liquid 20mg/0.3ml
  • Metaproterenol Sulfate Syrup 10mg/5ml
  • Mynatal Tablet
  • Nozin Nasal Sanitizer Kit 62%

 

Other Updates:

 

  • None

 

January 2022

 

Additions:

 

  • Gvoke Kit Solution 1mg/0.2ml (Quantity Level Limit)
  • Insulin Glargine-Yfgn Solution Vial 100unit/ml
  • Insulin Glargine-Yfgn Solution Pen-Injector 100unit/ml
  • Mavyret Oral Packet 50-20mg (Prior Authorization Required)

 

Removals:

 

  • Semglee Pen-Injector 100unit/ml
  • Semglee Vial (Solution) 100unit/ml

 

Other Updates:

 

  • None

 

December 2021

Additions:

 

  • Esomeprazole Tab Delayed Release 20mg
  • Everolimus Tab 10mg (Prior Authorization Required, Quantity Level Limit)

 

Removals
 
  • Afinitor Tab 10mg

 

Other Updates:

 

  • None

 

November 2021

 

  • No Updates

 

October 2021

 

Additions:

 

  • Sunitinib Caps 12.5mg, 25mg, 37.5mg, 50mg (Prior Authorization Required, Quantity Level Limit)

 

Removals:

 

  • Sutent (brand) Caps 12.5mg, 25mg, 37.5mg, 50mg

 

Other Updates:

 

  • None

 

September 2021

 

  • No Updates

 

August 2021

 

Additions:

 

  • Baqsimi Powder 3mg/dose (Quantity Level Limit)
  • Endari Powder Packet 5gm (Prior Authorization Required)
  • Inlyta Tab 1mg, 5mg (Prior Authorization Required, Quantity Level Limit)
  • Prolia Solution Prefilled Syringe 60mg/ml (Prior Authorization Required, Quantity Level Limit)
  • Semglee Pen-Injector 100unit/ml
  • Semglee Vial (Solution) 100unit/ml

 

Removals:

 

  • Caffeine Citrate Powder
  • Ibrance Cap 75mg, 100mg, 125mg
  • Lidocaine-Hydrocortisone Acetate Cream 3-0.5%
  • Methoxsalen Rapid Cap 10mg
  • Nexavar Tab 200mg

 

Other Updates:

 

  • None

 

July 2021

 

Additions:

 

  • None

 

Removals

 

  • Allergy Relief Disintegrating Tablet 12.5mg
  • Calcium Carbonate Tab 1250mg (500mg Elemental Ca)
  • Centrum Liquid
  • Fish Oil Cap 435mg
  • Nozin Nasal Sanitizer
  • Slow Release Iron Tab 47.5mg

 

Other Updates:

 

  • None

 

June 2021

 

Additions:

 

  • None

 

Removals:

 

  • None

 

Other Updates:

 

  • Trulicity Injection 0.75mg/0.5ml, 1.5mg/0.5ml, 3mg/0.5ml, 4.5mg/0.5ml (Added Quantity Level Limit)

 

May 2021

 

  • No Updates

 

April 2021

 

Additions:

 

  • Brinzolamide 1% Ophthalmic Suspension (Quantity Level Limit, Step Therapy)

 

Removals:

 

  • Anti-Diarrheal Liquid 1mg/8ml
  • Azopt 1% Ophthalmic Suspension
  • NovaMV Pediatric Multi-Vitamin Drops
  • Santyl Ointment 250unit/gm

 

March 2021

 

Additions:

 

  • Bevespi Aerosol 9-4.8mcg (Quantity Level Limit)
  • Cequa Solution 0.09% PF (Prior Authorization Required)
  • Doxycycline Hyclate Cap 50mg, 100mg
  • Doxycycline Hyclate Tab 100mg
  • Esbriet Cap 267mg (Prior Authorization Required)
  • Esbriet Tab 267mg, 801mg (Prior Authorization Required)
  • Fluticasone-Salmeterol Aerosol 100-50mcg (Quantity Level Limit)
  • Hizentra Injection 1gm/ml, 2gm/10ml, 4gm/20ml (Prior Authorization Required)
  • Hizentra Solution 20%(Prior Authorization Required)
  • Hizentra Vial 1gm/5ml, 10gm/50ml (Prior Authorization Required)
  • Icosapent Cap 1gm (Quantity Level Limit)
  • Myleran Tab 2mg
  • Ocrevus Injection 300/10ml (Quantity Level Limit)
  • Potassium & Sodium Citrate W/ Citric Acid Solution 550-500-334mg/5ml
  • Privigen Injection 40grams (Prior Authorization Required)
  • Rabeprazole Tab 20mg (Quantity Level Limit)
  • Trulicity Injection 0.75mg/0.5ml, 1.5mg/0.5ml, 3mg/0.5ml, Inj 4.5mg/0.5ml (Step Therapy Required)
  • Tukysa Tab 50mg, 150mg (Prior Authorization Required)
  • Visco-3 Injection 25/2.5ml (Prior Authorization Required)

 

Removals:

 

  • Anoro Ellipta Aero 62.5-25mcg/inh
  • Atrovent Hfa Aero 17mcg
  • Breo Ellipta Inhaler 100-25mcg/inh, 200-25mcg/inh
  • Cefaclor For Suspension 125mg/5ml, 250mg/5ml, 375mg/5ml
  • Clarithromycin Tab Extended Release 24Hr 500mg
  • Combivent Aero 20-100mcg/act
  • Doxycycline Monohydrate Tab 50mg, 75mg, 100mg
  • Epogen Injection 2000/ml, 3000/ml, 4000/ml 10000/ml, 20000/ml
  • Fulphila Injection 6mg/0.6ml
  • Gammaked Injection 1gm/10ml, 5gm/50ml, 10gm/100ml, 20gm/200ml
  • Hyoscyamine Drops 0.125mg/ml
  • Janumet Tab 50-500mg, 50-1000mg
  • Janumet Xr Tab 50-500mg, 50-1000mg, 100-1000mg
  • Januvia Tab 25mg, 50mg, 100mg
  • Nivestym Injection 300mcg, 480mcg
  • Nivestym Injection Syringe 300mcg/0.5ml, 480mcg/0.8ml
  • Ofev Cap 100mg, 150mg
  • Victoza Injection 18mg/3ml

 

Other Updates:

 

  • Albuterol Aero Hfa (Changed Quantity Level Limit)
  • Arnuity Ellipta Inhaler 50mcg, 100mcg, 200mcg (Changed Quantity Level Limit)
  • Azithromycin Suspension 100mg/5ml, 200mg/5ml (Added Age Limit)
  • Cefadroxil Suspension 250mg/5ml, 500mg/ml (Added Age Limit)
  • Cefdinir Suspension 125mg/5ml, 250mg/5ml (Added Age Limit)
  • Cefpodoxime Proxetil Suspension 50mg/5ml, 100mg/5ml (Added Age Limit)
  • Cefprozil Suspension 125mg/5ml, 250mg/5ml (Added Age Limit)
  • Cephalexin Suspension 125mg/5ml, 250mg/5ml (Added Age Limit)
  • Clarithromycin Suspension 125mg/5ml, 250mg/5ml (Added Age Limit)
  • Extavia Injection 0.3mg (Changed Quantity Level Limit)
  • Glatiramer Injection 40mg/ml (Added Quantity Level Limit)
  • Levalbuterol Tartrate Aerosol 45mcg/Act (Added Quantity Level Limit)
  • Levofloxacin Solution 25mg/ml (Added Age Limit)
  • Neomycin-Polymyxin-Dexamethasone Ophthalmic Ointment 0.1% (Added Quantity Level Limit)
  • Ondansetron Tablet Dispersible 4mg, 8mg (Changed Quantity Level Limit)
  • Phenylephrine Hcl Ophthalmic Solution 2.5% (Added Quantity Level Limit)
  • Rebif Injection 44mcg/0.5ml (Added Quantity Level Limit)
  • Rebif Rebido Injection 22mcg/0.5ml, 44mcg/0.5ml (Added Quantity Level Limit)
  • Rebif Rebidose Titration Pack (Added Quantity Level Limit)
  • Rebif Titration Injection Pack (Added Quantity Level Limit)
  • Santyl Ointment 250 Unit/gm (Added Quantity Level Limit)

 

February 2021

 

  • No Updates

 

January 2021

 

Additions:

 

  • Retacrit Injection 20000units (Prior Authorization Required)

 

Removals:

 

  • Calcium Carbonate Tab
  • Mag Ox Tab 420mg

December 2020

Additions:
  • Trelegy Ellipta Aerosol 200-62.5-25mcg (Step Therapy Required, Quantity Level Limit)

November 2020

Additions:
  • Dimethyl Fumarate Caps Delayed Release 120mg, 240mg (Prior Authorization Required, Quantity Level Limit)
  • Dimethyl Fumarate Starter Pack 120mg & 240mg (Prior Authorization Required, Quantity Level Limit)
  • Efavirenz-Lamivudine-Tenofovir DF Tabs 400-300-300mg, 600-300-300mg (Quantity Level Limit)
  • Emtricitabine Cap 200mg (Quantity Level Limit)
  • Vancomycin HCL IV Sol’n 750mg/150ml, 1250mg/250ml, 1750mg/350ml
Removals:
  • Emtriva Cap 200mg
  • Symfi Lo Tab 400-300-300mg
  • Symfi Tab 600-300-300mg
  • Tecfidera Caps Delayed Release 120mg, 240mg

October 2020

Additions:
  • Enbrel 25mg/0.5ml (Prior Authorization Required, Quantity Level Limit)
Removals:
  • Psyldex Powder 30%
  • SB Fiber Laxative Powder 33%

September 2020

Additions:
  • Abiraterone tab 250mg (prior authorization required)
  • Alecensa cap 150mg (prior authorization required)
  • Austedo tabs 5mg, 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
  • 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 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)
  • Poly-Vi-Sol solution 50mg/ml
  • Repatha injection 140mg/ml, 420mg/3.5ml (prior authorization required)
  • Rydapt cap 25mg (prior authorization required)
  • Soliris injection 10mg/ml (prior authorization required)
  • Symdeko tabs 50-75mg, 100-150mg (prior authorization required)
  • Tafinlar caps 50mg, 75mg (prior authorization required)
  • Tivicay PD tab 5mg (prior authorization required, age limit)
  • Tri-Vi-Sol solution A/C/D
  • Venclexta Start Pack (prior authorization required)
  • Venclexta tabs 10mg, 50mg, 100mg (prior authorization required)
  • Xolair injection 75mg/0.5ml, 150mg/ml (prior authorization required)
Other updates:
  • Proton Pumpinhibitors (quantitylevel limit)

August 2020

Additions:
  • Amitiza caps 8mcg, 24mcg (prior authorization required, quantity level limit)
  • Buprenorphine Weekly Patches 5mcg, 7.5mcg, 10mcg, 15mcg, 20mcg (prior authorization required, quantity level limit)
  • Diclofenac sodium solution 1.5% (step therapy, quantity level limit)
  • Dovato tab 50-300mg (prior authorization required, quantity level limit)
  • HM urinary pain relief (phenazopyridine) tab 99.5mg
  • 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)
  • Solifenacin succinate tabs 5mg, 10mg (step therapy, 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)
  • Tolnaftate cream 1% (quantity level limit)
  • Trelegy Ellipta (step therapy, quantity level limit)
  • Triamcinolone acetonine ointment 0.05% (quantity level limit)
Removals:
  • Cimduo tab 300mg
  • Fluocinolone acetonine solution 0.01%
  • Fluorouracil cream 0.5%
  • Humulin 70/30
  • Humulin N
  • Humulin R
  • Kitabis Nebule solution 300mg/5ml
  • Maalox Children’s chewable tab
  • Naproxen sodium tab 275mg
  • Nimodipine cap 30mg
  • Targretin gel 1%
  • Tolmetin sodium cap 400mg
  • Tolmetin sodium tabs 200mg, 600mg
  • Videx EC cap 125mg
  • Videx powder 2gm
  • Videx solution 4gm
Other updates:
  • Athletes Foot (Miconazole Nitrate) powder 2% (quantity level limit)
  • Auryxia tab 210mg (step therapy Required)
  • Betamethasone Dipropionate Augmented cream 0.05% (quantity level limit)
  • Betamethasone Dipropionate cream 0.05%, 0.1% (quantity level limit)
  • Betamethasone Dipropionate lotion 0.05%, 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 HCL OTIC solution 0.2% (quantity level limit)
  • Clindamycin Phosphate gel 1% (quantity level limit)
  • Clindamycin Phosphate lotion 1% (quantity level limit)
  • Clindamycin Phosphate solution 1% (quantity level limit)
  • Clindamycin Phosphate swab 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)
  • Ear Drops (Carbamide Peroxide) OTIC solution 6.5% (quantity level limit)
  • Ery Pad (Erythromycin) 2% (quantity level limit)
  • Erythromycin gel 2% (quantity level limit)
  • Erythromycin solution 2% (quantity level limit)
  • Fluocinonide cream 0.05% (quantity level limit)
  • Fluocinonide solution 0.05% (quantity level limit)
  • Fluvastatin sodium 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)
  • Hydrocortisone-Acetic Acid OTIC solution 1-2% (quantity level limit)
  • Ketoconazole cream 2% (quantity level limit)
  • Ketoconazole shampoo 2% (quantity level limit)
  • Lidocaine ointment 5% (quantity level limit)
  • Linzess caps 72mcg, 145mcg, 290mcg (prior authorization required)
  • Liothyronine sodium tab 25mcg (quantity level limit)
  • Miconazole Nitrate Aerosol powder 2% (quantity level limit)
  • Miconazole Nitrate cream 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)
  • 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 100,000 units/Gm (quantity level limit)
  • Nystatin ointment 100,000 units/Gm (quantity level limit)
  • Nystatin powder 100,000 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)
  • Proton Pump inhibitors (quantity level limit)
  • Ropinirole Hydrochloride Extended Release tabs 2mg, 4mg, 8mg, 6mg, 12mg (step therapy Required)
  • Scalp Relief Max Strength (Hydrocortisone 1%) solution (quantity level limit)
  • Stop Lice Maximum Strength (pyrethrins-Piperonyl Butoxide) Liquid 0.33-4% (quantity level limit)
  • Sulfacetamide sodium (Acne) lotion 10% (quantity level limit)
  • Triamcinolone acetonine cream 0.025%, 0.1%, 0.5% (quantity level limit)
  • Triamcinolone acetonine lotion 0.0.25%, 0.1% (quantity level limit)
  • Triamcinolone acetonine ointment 0.025%, 0.05% (quantity level limit)

July 2020

Additions:
  • Gvoke Hypopen 0.5mg/0.1ml, 1mg/0.2ml (quantity level limit)
  • Gvoke PFS 0.5mg/0.1ml, 1mg/0.2ml (quantity level limit)
  • Urinary Pain Relief (phenazopyridine) 95mg tab
Other updates:
  • Azithromycin tab 250mg (changed quantity level limit)
  • Chloroquine tabs 250mg, 500mg (removed quantity level limit)
  • Hydroxychloroquine tab 500mg (removed quantity level limit)

June 2020

Additions:
  • Acne Medication 10 (Benzoyl Peroxide) lotion 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)
  • Clotrimazole cream 1% (Legend Products)
  • Dexamethasone vials 4mg/ml
  • Isosorbide Dinitrate tab 40mg
  • Isotretinoin caps 10mg, 20mg, 30mg, 40mg (step therapy, quantity level limit)
  • Jock Itch/Athlete’s foot spray (Tolnaftate) Aerosol powder 1% (quantity level limit)
  • Lice Killing shampoo (pyrethrins-Piperonyl Butoxide) 0.33-4% (quantity level limit)
  • Primaquine Phosphate tab 26.3mg (quantity level limit)
  • Promacta powder Pack 12.5mg, 25mg (prior authorization required, quantity level limit)
  • Pyrimethamine tab 25mg (prior authorization required)
  • Solu-Cortef vials 250mg, 500mg, 1000mg
  • Tolnaftate powder 1% (quantity level limit)
Removals:
  • Daraprim tab 25mg (brand)
Other updates:
  • Clotrimazole solution 1% (removed step therapy)

May 2020

Additions:
  • Budesonide-Formoterol inhaler 80-4.5mcg, 160-4.5mcg (quantity level limit)
  • Dexamethasone concentrate 1mg/ml
  • Dexamethasone vials 20mg/5ml, 120mg/30ml, 10mg/ml
  • Erlotinib tabs 25mg, 100mg (prior authorization required, quantity level limit)
  • Solu-Cortef vial 100mg
  • Novolin R FlexPen 100 units/ml (Age limit)
  • Omeprazole orally disintegrating tab 20mg (quantity level limit)
  • Orkambi granules 100-125mg, 200-125mg (prior authorization required)
  • Orkambi tabs 100-125mg, 200-125mg (prior authorization required)
  • Tramadol tab 100mg (quantity level limit, age limit)
Removals:
  • Tarceva tabs 25mg, 100mg (Brand)

April 2020

Additions:
  • Mesalamine ER cap 0.375gm (quantity level limit)
  • Penicillamine tab 250mg (prior authorization required, quantity level limit)
Removals:
  • Apriso ER cap 0.375gm (Brand)
Other updates:
  • Azithromycin tabs 250mg (quantity level limit)
  • Chloroquine tabs 250mg, 500mg (prior authorization required, quantity level limit)
  • Hydroxychloroquine tab 200mg (prior authorization required, quantity level limit)
  • Kaletra tabs (quantity level limit)
  • Lopinavir-Ritonavir solution 100--400mg/5ml (quantity level limit)

March 2020

Removals:
  • Carboxymethylcellulose sodium ophthalmic solution 1%
  • Corn Starch topical powder
  • Hydrocodone-Acetaminophen solution 10-325mg/10ml
  • Lidocaine hydrochloride gel 2%
  • Sodium Fluoride rinse 0.2%
  • Sodium Fluoride solution 0.125mg/drop

February 2020

Additions:
  • Bimatoprost Ophthalmic solution 0.03% (step therapy Required)
  • Ethinyl Estradiol – etonogestrel ring 0.015/0.12mg (quantity level limit)
  • Everolimus tabs 2.5mg, 5mg, 7.5mg (prior authorization required, quantity level limit)
Removals:
  • Afinitor tabs 2.5mg, 5mg, 7.5mg (Brand)
  • Chlorothiazide tabs 250mg, 500mg
  • Demeclocycine tabs 150mg, 300mg
  • Doxycycline Monohydrate tab 150mg
  • First-Vanco solution 25mg/ml, 50mg/ml
  • Homatropoine Ophthalmic solution 5%
  • Kyleena IUD
  • Methylclothiazide tab 5mg
  • Mirena IUD
  • Nausea relief liquid
  • Nizatidine solution 15mg/ml
  • Nuvaring (brand)
  • Phospholine ophthalmic solution 0.125%
  • Propantheline cap 15mg
  • Rabeprazole EC cap 20mg
  • Ranitidine caps 150mg, 300mg
  • Skyla IUD
Other updates:
  • Atropine Ophthalmic ointment 1% (quantity level limit)
  • Atropine Ophthalmic solution 1% (quantity level limit)
  • Combigan Ophthalmic solution 0.2/0.5% (quantity level limit)
  • Dorzolamide-Timolol Ophthalmic solution 22.3-6.5% (step therapy Required, quantity level limit)
  • Doxycycline Monohydrate suspension 25mg/5ml (Age limit)
  • Granisetron tab 1mg (step therapy Required)
  • Ibandronate injection 3mg/3ml (quantity level limit)
  • Levofloxacin Ophthalmic solution 0.5% (quantity level limit)
  • Memantine tabs 5mg, 10mg (quantity level limit)
  • Methazolamide tabs 25mg, 50mg (step therapy Required)
  • Natacyn Ophthalmic suspension 5% (quantity level limit)
  • Tazarotene cream 0.1% (step therapy Required)
  • Trifluridine Ophthalmic solution 1% (quantity level limit)

January 2020

Additions:
  • Abacavir solution 20mg/ml (prior authorization required, quantity level limit)
  • Abacavir tab 300mg (prior authorization required, quantity level limit)
  • Abacavir-Lamivudine tab 600-300mg (prior authorization required, quantity level limit)
  • Abacavir-Lamivudine-Zidovudine tab 300-150-300mg (prior authorization required, quantity level limit)
  • Aptivus cap 250mg (prior authorization required, quantity level limit)
  • Aptivus solution 100mg/ml (prior authorization required, quantity level limit)
  • Atazanavir Sulfate caps 150mg, 200mg, 300mg (prior authorization required, quantity level limit)
  • Atripla tablet (prior authorization required, quantity level limit)
  • Biktarvy tab 50-200-25mg (prior authorization required, quantity level limit)
  • Complera tab (prior authorization required, quantity level limit)
  • Crixivan caps 200mg, 400mg (prior authorization required, quantity level limit)
  • Descovy tab 200-25mg (prior authorization required, quantity level limit)
  • Didansoine DR caps 250mg, 400mg (prior authorization required, quantity level limit)
  • Edurant tab 25mg (prior authorization required, quantity level limit)
  • Efavirenz caps 50mg, 200mg (prior authorization required, quantity level limit)
  • Efavirenz tab 600mg (prior authorization required, quantity level limit)
  • Emtriva cap 200mg (prior authorization required, quantity level limit)
  • Emtriva solution 10mg/ml (prior authorization required, quantity level limit)
  • Fosamprenavir tab 700mg (prior authorization required, quantity level limit)
  • Fuzeon vial 90mg (prior authorization required, quantity level limit)
  • Genvoya tab (prior authorization required, quantity level limit)
  • Intelence tabs 25mg, 100mg, 200mg (prior authorization required, quantity level limit)
  • Invirase tab 500mg (prior authorization required, quantity level limit)
  • Isentress chew tab 25mg, 100mg (prior authorization required, quantity level limit)
  • Isentress HD tab 600mg (prior authorization required, quantity level limit)
  • Isentress tab 400mg (prior authorization required, quantity level limit)
  • Juluca tab 50-25mg (prior authorization required, quantity level limit)
  • Kaletra tabs 100-25mg, 200-50mg (prior authorization required, quantity level limit)
  • Lamivudine solution 10mg/ml (prior authorization required, quantity level limit)
  • Lamivudine tabs 150mg, 300mg (prior authorization required, quantity level limit)
  • Lamivudine-Zidovudine tab 150-300mg (prior authorization required, quantity level limit)
  • Lexiva suspension 50mg/ml (prior authorization required, quantity level limit)
  • Lopinavir-Ritonavir tab 80-20mg (prior authorization required, quantity level limit)
  • Nevirapine ER tabs 100mg, 400mg (prior authorization required, quantity level limit)
  • Nevirapine suspension 50mg/5ml (prior authorization required, quantity level limit)
  • Nevirapine tab 200mg (prior authorization required, quantity level limit)
  • Norvir powder packet 100mg (prior authorization required)
  • Norvir solution 80mg/ml (prior authorization required, quantity level limit)
  • Odefsey tab (prior authorization required, quantity level limit)
  • Prezista suspension 100mg/ml (prior authorization required, quantity level limit)
  • Prezista tabs 75mg, 150mg, 800mg (prior authorization required, quantity level limit)
  • Rescriptor tab 200mg (prior authorization required, quantity level limit)
  • Ritonavir tab 100mg (prior authorization required, quantity level limit)
  • Selzentry tabs 25mg, 75mg, 150mg, 300mg (prior authorization required, quantity level limit)
  • Stavudine caps 15mg, 20mg, 30mg, 40mg (prior authorization required, quantity level limit)
  • Stribild tab (prior authorization required)
  • Symfi Lo tab 400-300-300mg (prior authorization required, quantity level limit)
  • Symfi tab 600-300-300mg (prior authorization required, quantity level limit)
  • Symtuza tab 800-150-200-10mg (prior authorization required, quantity level limit)
  • Tenofovir Disop Fum tab 300mg (prior authorization required, quantity level limit)
  • Tivicay tabs 10mg, 25mg, 50mg (prior authorization required, quantity level limit)
  • Triumeq tab 600-50-300mg (prior authorization required, quantity level limit)
  • Truvada tabs 100-150mg, 200-300mg (prior authorization required, quantity level limit)
  • Truvada tabs 133-200mg, 167-250mg (prior authorization required)
  • Videx pediatric solution 2gm, 4gm (prior authorization required, quantity level limit)
  • Viracept tabs 250mg, 625mg (prior authorization required, quantity level limit)
  • Viread powder (prior authorization required, quantity level limit)
  • Viread tabs 150mg, 200mg, 250mg (prior authorization required, quantity level limit)
  • Zidovudine cap 100mg (prior authorization required, quantity level limit)
  • Zidovudine Syrup 50mg/5ml (prior authorization required, quantity level limit)
  • Zidovudine tab 300mg (prior authorization required, quantity level limit)
Removals:
  • Ventolin HFA inhaler (brand removed)

December 2019

Removals:
  • Aminocaproic Acid solution 0.25gm/ml
  • PreNata chewable tab 29-1mg
  • Digoxin tabs 62.5mcg, 187.5mcg

November 2019

Additions:
  • Aminocaproic Acid solution 0.25gm/ml

October 2019

  • No updates

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)
Removals:
  • Letairis tabs 5mg, 10mg (brand)
  • Tracleer tabs 62.5mg, 125mg (brand)
  • Uloric tabs 40mg, 80mg (brand)

August 2019

Additions:
  • Aspercreme with Lidocaine 4% (quantity level limit)
  • Butenafine HCl cream 1%
  • Fulphila injection 6mg/0.6ml (prior authorization required)
  • Nivestym injection 300mcg, 480mcg (prior authorization required)
Removals:
  • Butalbital-Acetaminophen-Caffeine capsules 50-300-40mg, 40-325-40mg
  • Calcium Acetate oral solution 667mg/5ml
  • Ciclopirox gel 0.77%
  • Colestipol HCl granule packets 5gm
  • Entecavir oral solution 0.05mg/ml
  • Epinastine HCl Ophthalmic solution 0.05%
  • Erythromycin Ethylsuccinate suspension 200mg/5ml, 400mg/5ml
  • Esterified estrogens tabs 0.3mg, 0.625mg, 1.25mg
  • Estradiol tab 1mg (15)/Estradiol-Norgestimate tab 1-0.09mg(15)
  • Etodolac ER tab 400mg, 500mg, 600mg
  • Lindane shampoo 1%
  • Moexipril HCl tabs 7.5mg, 15mg
  • Olopatadine HCl Ophthalmic solution 0.2%
  • Quinidine Gluconate CR tab 324mg
Other updates:
  • Azelastine HCl 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 Olamine cream 0.77% (step therapy)
  • Ciclopirox Olamine suspension 0.77% (step therapy)
  • Ciclopirox shampoo 1% (step therapy)
  • Clotrimazole (RX) solution 1% (step therapy)
  • Estradiol vaginal tablet 10mcg (quantity level limit)
  • Fluocinolone acetonine cream 0.025% (quantity level limit)
  • Fluocinolone acetonine ointment 0.025% (quantity level limit)
  • Ketoconazole cream 2% (step therapy, quantity level limit)
  • Lidocaine HCl gel 2% (quantity level limit)
  • Lidocaine-Prilocaine cream 2.5-2.5% (quantity level limit)
  • Liothyronine sodium tabs 5mcg, 50mcg (quantity level limit)
  • Norethindrone tab 5mg (step therapy)
  • Thyroid tabs 15mg, 30mg, 60mg, 90mg, 120mg, 180mg, 240mg, 300mg (quantity level limit)

July 2019

Additions:
  • Mesalamine cap 400mg DR (quantity level limit)
  • Cefixime cap 400mg (quantity level limit)
  • Erlotinib tab 150mg (quantity level limit, Prior authorization required)
Removals:
  • Suprax cap 400mg
  • Tarceva tab 150mg
Other updates:
  • Right now, there are no other updates.

June 2019

Additions:
  • Docosanol cream 10%
Removals:
  • Abreva cream 10%
Other updates:
  • Right now, there are no other updates.

Have a question?

You can call Member Services at 1-866-827-2710 (TTY: 711).

Also of interest: