Formulary search tool and updates

June 2022

Additions:

• Bacitracin-Polymyxin B Oint
• Benzoyl Peroxide Gel 10%
• Clotrimazole Sol 1% (Quantity Limit)
• Ery Pad 2%
• Fexofenadine Tab 180mg (Quantity Limit)
• Fexofenadine Tab 60mg (Quantity Limit)
• Gvoke Hypo 1 Inj .5/.1ml (Quantity Limit)
• Gvoke Pfs1pk Syn 1mg/0.2 (Quantity Limit)
• Pregabalin Cap 200mg (Prior Authorization, Quantity Limit)

Removals:

• No updates

Other Updates:

• No updates

May 2022

Additions:

• Ozempic Inj 8mg/3ml (Step Therapy, Quantity Limit)
• Triumeq Pd Tab (Prior Authorization, Quantity Limit)

Removals:

• No updates

Other Updates:

• No updates

April 2022

Additions:

• Descovy Tab 120-15MG (Prior Authorization, Quantity Limit)

Removals:

• No updates

Other Updates:

• No updates

March 2022

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

February 2022

Additions:

• Naloxone Hcl Nasal Spray 4 Mg/0.1ml (Quantity Limit)

Removals:

• Narcan Hcl Nasal Spray 4 Mg/0.1ml

Other Updates:

• No updates

January 2022

Additions:

Etravirine Tab 100mg (Prior Authorization, Quantity Limit)

Etravirine Tab 200mg (Prior Authorization, Quantity Limit)

Gvoke Kit Inj 1mg/0.2 (Quantity Limit)

Atropine Sul Sol 1% Op

Removals:

Intelence TAB 100MG

Intelence TAB 200MG

Isopto Atropine Sol 1%

Concept Ob Cap

Mynatal Tab

Pr Natal 400 Pak

Other Updates:

No updates

December 2021

Additions:

Esomepra Mag Otc Tab 20 Mg

Insulin Glar Inj 100u/Ml

Insulin Glar Sol 100u/Ml

Mavyret Pak 50-20mg (Prior Authorization)

Removals:

Semglee      Sol 100u/Ml

Other Updates:

No updates

November 2021

Additions:

No updates

Removals:

Buprenorphine Extended Release Soln Pref Syr 100 Mg/0.5

Buprenorphine Extended Release Soln Pref Syr 300 Mg/1.5

Other Updates:

No updates

October 2021

Additions:

Sunitinib Cap 12.5mg

Sunitinib Cap 25mg

Sunitinib Cap 37.5mg

Sunitinib Cap 50mg

Removals:

Sutent CAP 12.5MG

Sutent CAP 25MG

Sutent CAP 37.5MG

Sutent CAP 50MG

Other Updates:

No updates

September 2021

Additions:

No updates

Removals:

No updates

Other Updates:

No updates

August 2021

Additions:

Baqsimi Pow 3mg/Dose (Quantity Limit)

Endari Pow 5gm (Prior Authorization)

Inlyta Tab 1mg (Prior Authorization, Quantity Limit)

Inlyta Tab 5mg (Prior Authorization, Quantity Limit)

Nayzilam Spr 5mg) (Prior Authorization, Quantity Limit)

Pregabalin Cap 100 Mg (Quantity Limit)

Pregabalin Cap 150 Mg (Quantity Limit)

Pregabalin Cap 225 Mg (Quantity Limit)

Pregabalin Cap 25 Mg (Quantity Limit)

Pregabalin Cap 300 Mg (Quantity Limit)

Pregabalin Cap 50 Mg (Quantity Limit)

Pregabalin Cap 75 Mg (Quantity Limit)

Prolia Sol 60mg/Ml (Prior Authorization, Quantity Limit)

Semglee Sol 100u/Ml

Sofos/Velpat Tab 400-100 (Prior Authorization, Quantity Limit)

Removals:

Ibrance Cap 100mg

Ibrance Cap 125mg

Ibrance Cap 75mg

Lidocaine-Hydrocortisone Ace Cream 3-0.5% rectal

Methoxsalen Cap 10mg

Nexavar Tab 200mg

Other Updates:

No updates

July 2021

Additions:

No updates

Removals:

No updates

Other Updates:

No updates

June 2021

Additions:

No updates

Removals:

No updates

Other Updates:

Trulicity pen-inj 0.75mg/0.5mL (Added Quantity Level Limit)

Trulicity pen-inj 1.5mg/0.5mL (Added Quantity Level Limit)

Trulicity pen-inj 3mg/0.5mL (Added Quantity Level Limit)

Trulicity pen-inj 4.5mg/0.5mL (Added Quantity Level Limit)

May 2021

Additions:

No updates

Removals:

No updates

Other Updates:

No updates

April 2021

Additions:

Brinzolamide Sus 1% (Quantity Level Limit, Step Therapy)

Removals:

Azopt Sus 1%

Other Updates:

No updates

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, 4.5mg/0.5ml (Step Therapy Required)

Tukysa Tab 50mg, 150mg (Prior Authorization Required)

Valtoco Liquid 20mg (Quantity Level Limit)

Valtoco Spray 5mg, 10mg (Quantity Level Limit)

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

Diazepam Intensol 5mg/ml

Doxycycline Monohydrate Tab 50mg, 75mg, 100mg

Epogen Injecton 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 (Added 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 (Added 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 (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 20000 Units (Prior Authorization Required)

December 2020

Additions:

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

November 2020

Additions:

 

Demethyl Fumarate Starter Pack 120mg & 240mg (Prior Authorization Required, Quantity Level Limit)

 

 

Emtricitabine Cap 200mg (Prior Authorization Required, Quantity Level Limit)

 

 

Removals:

 

Emtriva Cap

 

 

Tecfidera Starter Pack 120mg & 240mg

 

 

 

October 2020

Additions:

 

Dimethyl Fumarate Delayed Release Caps 120mg, 240mg (Prior Authorization Required, Quantity Level Limit)

 

 

Efavirenz-Lamivudine-Tenofovir DF Tabs 400-300-300mg, 600-300-300mg (Prior Authorization Required, Quantity Level Limit)

 

 

Emtricitabine-Tenofovir Disoproxil Fumarate Tab 200-300mg (Prior Authorization Required, Quantity Level Limit)

 

 

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

 

 

Removals:

 

Prenatrix Tab

 

 

Psyldex Powder 30%

 

 

SB Fiber Laxative Powder 33%

 

 

SB Natural Fiber Laxative Power 49%

 

 

Symfi Lo Tab 400-300-300mg

 

 

Symfi Tab 600-300-300mg

 

 

Tecfidera Caps Delayed Release 120mg, 240mg

 

 

Vitrexyl Tabs

 

 

Truvada Tab 200-300mg

 

 

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)

 

 

Removals:

Travoprost (BAK Free) 0.004% Ophthalmic Sol

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)

 

 

Proton Pump Inhibitors (Quantity Level 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)

 

 

August 2020

Additions:

 

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

 

 

Athlete's Foot (Miconazole Nitrate) Powder 2% (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)

 

 

Miconazole Nitrate Aerosol Powder 2% (Quantity Level Limit)

 

 

Poly-Vi-Sol Solution 50mg/ml

 

 

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

 

 

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 Gel Pump 1% (Prior Authorization Required)

 

 

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

 

 

Tivicay PD Tab 5mg (Prior Authorization Required, Age Limit)

 

 

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

 

 

Tri-Vi-Sol Solution A/C/D

 

 

Removals:

 

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

 

 

Targretin Gel 1%

 

 

Tolmetin Cap 400mg

 

 

Tolmetin Tabs 200mg, 600mg

 

 

Other updates:

 

Acetic Acid/Hydrocortisone OTIC Solution (Quantity Level Limit)

 

 

Adapalene Gel 0.1% RX (Removed Step Therapy)

 

 

Auryxia Tab 210mg (Step Therapy Required)

 

 

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)

 

 

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)

 

 

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

 

 

Liothyronine Tab 25mcg (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)

 

 

Naltrexone Tab 50mg (Quantity Level Limit)

 

 

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

 

 

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

 

 

Nystatin Cream 100000 Units/gm (Quantity Level Limit)

 

 

Nystatin Ointment 100000 Units/gm (Quantity Level Limit) 

 

 

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

 

 

Ofloxacin OTIC Solution 0.3% (Quantity Level Limit)

 

 

Permethrin Cream 5% (Quantity Level Limit)

 

 

Permethrin Lotion 1% (Quantity Level Limit)

 

 

Prednicarbate Ointment 0.1% (Quantity Level Limit)

 

 

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) 

 

 

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:

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

Other updates:

 

Glucagon Emergency Kit 1mg (Quantity Level Limit)

 

 

Matulane Cap 50mg (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)

 

 

Jock Itch/Athlete’s Foot Spray (Tolnaftate) Aerosol Powder 1% (Quantity Level Limit)

 

 

Primaquine Tab 26.3mg (Quantity Level Limit)

 

 

Other updates:

Clotrimazole Solution 1% (Removed Step Therapy)

May 2020

Additions:

 

Dexamethasone Concentrate 1mg/ml

 

 

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

 

 

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

 

 

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

 

 

Removals:

Daraprim Tab (Brand)

April 2020

Additions:

 

Aripiprazole Tab 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 Tab 100-125mg, 200-125mg (Prior Authorization Required) 

 

 

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

 

 

Other updates:

 

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 400-100mg/5ml (Quantity Level Limit) 

 

 

March 2020

Additions:

 

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

 

 

Mesalamine Caps ER 0.375mg (Generic)

 

 

Nicotine Polacrilex Gum 2mg, 4mg (Age Limit)

 

 

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:

 

Ambi 60pse/400gfn Tab

 

 

Apriso Caps ER 0.375gm (Brand)

 

 

Artificial Tears Solution 1% Ophthalmic

 

 

Diflunisal Powder

 

 

Fluoritab Solution 0.275 (0.125 F) Mg/Drop

 

 

Hydrocodone-Acetaminophen Solution 10-325 Mg/15ml

 

 

PR Natal 430 Pak

 

 

PR Natal 400, 430 Pak Ec

 

 

Prevident Solution Rinse

 

 

Regenecare Ha Gel 2%

 

 

Robitussin Syrup 7.5 Mg/5ml

 

 

Sodium Chloride Solution 0.9% Injection

 

 

February 2020

Additions:

 

Bimatoprost Solution 0.03% (Step Therapy)

 

 

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

 

 

Travoprost Ophthalmic Solution

 

 

Removals:

 

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

 

 

Travatan Z Ophthalmic Solution (Brand)

 

 

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

Removals:

Ventolin HFA Inhaler (Brand)

December 2019

Additions:

 

Bunavail Buccal Film 2.1-0.3mg, 4.2-0.7mg, 6.3-1mg (Brand) (Step Therapy Required, Quantity Level Limit)

 

 

Buprenorphine-Naloxone Film 2-0.5mg, 4-1mg, 8-2mg, 12-3mg (Generic) (Step Therapy Required, Quantity Level Limit)

 

 

Suboxone Film 2-0.5mg, 4-1mg, 8-2mg, 12-3mg (Brand) (Step Therapy Required, Quantity Level Limit)

 

 

Zubsolv Sublingual Tablets 0.7-0.18mg, 1.4-0.36mg, 2.9-0.71mg, 5.7-1.4mg, 8.6-2.1mg, 11.4-2.9mg (Brand) (Step Therapy Required, Quantity Level Limit)

 

 

Removals:

PreNata Chewable Tab 29-1mg

November 2019

Additions:

Aminocaproic Acid 0.25gm/ml Solution

Removals:

Amicar 0.25gm/ml Solution (Brand)