PDL search tool and updates

March 2026

Additions:

• None

Removals:

• None

Other Updates:

• Amlodipine 10 mg / valsartan 160 mg / hydrochlorothiazide 12.5 tablet (Updated to Tier 2)
• Amlodipine 10 mg / valsartan 160 mg / hydrochlorothiazide 25 tablet (Updated to Tier 2)
• Amlodipine 10 mg / valsartan 320 mg / hydrochlorothiazide 25 tablet (Updated to Tier 2)
• Amlodipine 5 mg / valsartan 160 mg / hydrochlorothiazide 12.5 tablet (Updated to Tier 2)
• Amlodipine 5 mg / valsartan 160 mg / hydrochlorothiazide 25 tablet (Updated to Tier 2)
• Atacand-HCTZ 16 mg / 12.5 mg tablet (Updated to Tier 2)
• Atacand-HCTZ 32 mg / 12.5 mg tablet (Updated to Tier 2)
• Atacand-HCTZ 32 mg / 25 mg tablet (Updated to Tier 2)
• Banzel 200 mg tablet (Removed from Brand Preferred)
• Banzel 40 mg per mL suspension (Removed from Brand Preferred)
• Banzel 400 mg tablet (Removed from Brand Preferred)
• Belsomra 10 mg tablet (Updated to Tier 1)
• Belsomra 15 mg tablet (Updated to Tier 1)
• Belsomra 20 mg tablet (Updated to Tier 1)
• Belsomra 5 mg tablet (Updated to Tier 1)
• Briviact 10 mg per mL solution (Added to Brand Preferred)
• Briviact 10 mg tablet (Added to Brand Preferred)
• Briviact 100 mg tablet (Added to Brand Preferred)
• Briviact 25 mg tablet (Added to Brand Preferred)
• Briviact 50 mg per 5 mL intravenous solution (Added to Brand Preferred)
• Briviact 50 mg tablet (Added to Brand Preferred)
• Briviact 75 mg tablet (Added to Brand Preferred)
• Candesartan 16 mg / hydrochlorothiazide 12.5 mg tablet (Updated to Tier 2)
• Candesartan 32 mg / hydrochlorothiazide 12.5 mg tablet (Updated to Tier 2)
• Candesartan 32 mg / hydrochlorothiazide 25 mg tablet (Updated to Tier 2)
• Diltiazem ER coated beads 360 mg capsule (Updated to Tier 1)
• Edarbi 40 mg tablet (Updated to Tier 1)
• Edarbi 80 mg tablet (Updated to Tier 1)
• Edarbyclor 40 mg / 12.5 mg tablet (Updated to Tier 1)
• Edarbyclor 40 mg / 25 mg tablet (Updated to Tier 1)
• Enalapril 1 mg per mL solution (Updated to Special PA)
• Epaned 1 mg per mL solution (Updated to Special PA)
• Eprontia 25 mg per mL solution (Added to Brand Preferred)
• Estazolam 1 mg tablet (Updated to Tier 2)
• Estazolam 2 mg tablet (Updated to Tier 2)
• Exforge-HCTZ 10 mg / 160 mg / 12.5 tablet (Updated to Tier 2)
• Exforge-HCTZ 10 mg / 160 mg / 25 tablet (Updated to Tier 2)
• Exforge-HCTZ 10 mg / 320 mg / 25 tablet (Updated to Tier 2)
• Exforge-HCTZ 5 mg / 160 mg / 12.5 tablet (Updated to Tier 2)
• Flurazepam 15 mg capsule (Updated to Special PA)
• Flurazepam 30 mg capsule (Updated to Special PA)
• Fosinopril 10 mg / hydrochlorothiazide 12.5 mg tablet (Updated to Tier 2)
• Fosinopril 20 mg / hydrochlorothiazide 12.5 mg tablet (Updated to Tier 2)
• Fycompa 0.5 mg per mL suspension (Added to Brand Preferred, Added Prior Authorization)
• Fycompa 10 mg tablet (Added to Brand Preferred, Added Prior Authorization)
• Fycompa 12 mg tablet (Added to Brand Preferred, Added Prior Authorization)
• Fycompa 2 mg tablet (Added to Brand Preferred, Added Prior Authorization)
• Fycompa 4 mg tablet (Added to Brand Preferred, Added Prior Authorization)
• Fycompa 6 mg tablet (Added to Brand Preferred, Added Prior Authorization)
• Fycompa 8 mg tablet (Added to Brand Preferred, Added Prior Authorization)
• Insulin glargine (yfgn) 100 unit per mL solution (Removed Prior Authorization)
• Inzirqo 10 mg per mL suspension (Updated to Special PA)
• Levofloxacin 0.5% ophthalmic solution (Updated to Tier 2)
• Metaxalone 400 mg tablet (Updated to Special PA)
• Methocarbamol 1000 mg tablet (Updated to Special PA)
• Micardis 40 mg / 12.5 mg tablet (Updated to Tier 1)
• Micardis 80 mg / 12.5 mg tablet (Updated to Tier 1)
• Micardis 80 mg / 25 mg tablet (Updated to Tier 1)
• Moexipril 15 mg tablet (Updated to Tier 2)
• Moexipril 7.5 mg tablet (Updated to Tier 2)
• Naproxen delayed release 375 mg tablet (Updated to Tier 2)
• Perampanel 0.5 mg per mL suspension (Added Prior Authorization)
• Perampanel 10 mg tablet (Added Prior Authorization)
• Perampanel 12 mg tablet (Added Prior Authorization)
• Perampanel 2 mg tablet (Added Prior Authorization)
• Perampanel 4 mg tablet (Added Prior Authorization)
• Perampanel 6 mg tablet (Added Prior Authorization)
• Perampanel 8 mg tablet (Added Prior Authorization)
• Perindopril 2 mg tablet (Updated to Tier 2)
• Perindopril 4 mg tablet (Updated to Tier 2)
• Perindopril 8 mg tablet (Updated to Tier 2)
• Piroxicam 10 mg capsule (Updated to Tier 1)
• Piroxicam 20 mg capsule (Updated to Tier 1)
• Promacta 12.5 mg oral packet (Added to Brand Preferred)
• Promacta 12.5 mg tablet (Added to Brand Preferred)
• Promacta 25 mg oral packet (Added to Brand Preferred)
• Promacta 25 mg tablet (Added to Brand Preferred)
• Promacta 50 mg tablet (Added to Brand Preferred)
• Promacta 75 mg tablet (Added to Brand Preferred)
• Qbrelis 1 mg per mL solution (Updated to Special PA)
• Semglee (yfgn) 100 unit per mL solution (Removed from Brand Preferred, Removed Prior Authorization)
• Semglee (yfgn) pen-injector 100 unit per mL solution (Removed from Brand Preferred, Removed Prior Authorization)
• Tanlor 1000 mg tablet (Updated to Special PA)
• Telmisartan 40 mg / amlodipine 10 mg tablet (Updated to Tier 2)
• Telmisartan 40 mg / amlodipine 5 mg tablet (Updated to Tier 2)
• Telmisartan 40 mg / hydrochlorothiazide 12.5 mg tablet (Updated to Tier 1)
• Telmisartan 80 mg / amlodipine 10 mg tablet (Updated to Tier 2)
• Telmisartan 80 mg / amlodipine 5 mg tablet (Updated to Tier 2)
• Telmisartan 80 mg / hydrochlorothiazide 12.5 mg tablet (Updated to Tier 1)
• Telmisartan 80 mg / hydrochlorothiazide 25 mg tablet (Updated to Tier 1)
• Zylet 0.5% / 0.3% ophthalmic suspension (Added to Brand Preferred)

February 2026

Additions:

• None

Removals:

• None

Other Updates:

• None

January 2026

Additions:

• None

Removals:

• None

Other Updates:

• Adalimumab-adaz 40 mg per 0.4 mL auto-Injector solution (Updated to Tier 2)
• Adalimumab-adaz 80 mg per 0.8 mL auto-Injector solution (Updated to Tier 2)
• Adalimumab-adaz prefilled syringe 10 mg per 0.1 mL solution (Updated to Tier 2)
• Adalimumab-adaz prefilled syringe 20 mg per 0.2 mL solution (Updated to Tier 2)
• Adalimumab-adaz prefilled syringe 40 mg per 0.4 mL solution (Updated to Tier 2)
• Adalimumab-fkjp (2 Pen) 40 mg per 0.8 mL auto-injector kit (Updated to Tier 2)
• Adalimumab-fkjp (2 Syringe) 20 mg per 0.4 mL prefilled syringe kit (Updated to Tier 2)
• Adalimumab-fkjp (2 Syringe) 40 mg per 0.8 mL prefilled syringe kit (Updated to Tier 2)
• Adbry 150 mg per 1 mL prefilled syringe solution (Removed from Step Therapy, Prior Authorization Added)
• Adbry 300 mg per 2 mL auto-injector solution (Removed from Step Therapy, Prior Authorization Added)
• Alprolix 1000 unit intravenous solution (Removed Prior Authorization) 
• Alprolix 2000 unit intravenous solution (Removed Prior Authorization) 
• Alprolix 250 unit intravenous solution (Removed Prior Authorization) 
• Alprolix 3000 unit intravenous solution (Removed Prior Authorization) 
• Alprolix 4000 unit intravenous solution (Removed Prior Authorization) 
• Alprolix 500 unit intravenous solution (Removed Prior Authorization) 
• Altuviiio 1000 unit intravenous solution (Removed Prior Authorization) 
• Altuviiio 2000 unit intravenous solution (Removed Prior Authorization) 
• Altuviiio 250 unit intravenous solution (Removed Prior Authorization) 
• Altuviiio 3000 unit intravenous solution (Removed Prior Authorization) 
• Altuviiio 4000 unit intravenous solution (Removed Prior Authorization) 
• Altuviiio 500 unit intravenous solution (Removed Prior Authorization) 
• Altuviiio 750 unit intravenous solution (Removed Prior Authorization) 
• Anoro Ellipta 62.5 mcg / 25 mcg breath activated inhaler (Added to Brand Preferred, Prior Authorization Removed)
• Arnuity Ellipta 100 mcg per act inhaler (Added to Brand Preferred)
• Arnuity Ellipta 200 mcg per act inhaler (Added to Brand Preferred)
• Arnuity Ellipta 50 mcg per act inhaler (Added to Brand Preferred)
• Colchicine 0.6 mg capsule (Added Prior Authorization)
• Dexmethylphenidate ER 10 mg capsule (Updated to Tier 1)
• Dexmethylphenidate ER 15 mg capsule (Updated to Tier 1)
• Dexmethylphenidate ER 20 mg capsule (Updated to Tier 1)
• Dexmethylphenidate ER 25 mg capsule (Updated to Tier 1)
• Dexmethylphenidate ER 30 mg capsule (Updated to Tier 1)
• Dexmethylphenidate ER 35 mg capsule (Updated to Tier 1)
• Dexmethylphenidate ER 40 mg capsule (Updated to Tier 1)
• Dexmethylphenidate ER 5 mg capsule (Updated to Tier 1)
• Erzofri 117 mg per 0.75 mL prefilled syringe suspension (Updated to Tier 1, Removed Prior Authorization)
• Erzofri 156 mg per 1 mL prefilled syringe suspension (Updated to Tier 1, Removed Prior Authorization)
• Erzofri 234 mg per 1.5 mL prefilled syringe suspension (Updated to Tier 1, Removed Prior Authorization)
• Erzofri 351 mg per 2.25 mL prefilled syringe suspension (Updated to Tier 1, Removed Prior Authorization)
• Erzofri 39 mg per 0.25 mL prefilled syringe suspension (Updated to Tier 1, Removed Prior Authorization)
• Erzofri 78 mg per 0.5 mL prefilled syringe suspension (Updated to Tier 1, Removed Prior Authorization)
• Focalin XR 10 mg capsule (Removed from Brand Preferred, Prior Authorization Added)
• Focalin XR 15 mg capsule (Removed from Brand Preferred, Prior Authorization Added)
• Focalin XR 20 mg capsule (Removed from Brand Preferred, Prior Authorization Added)
• Focalin XR 25 mg capsule (Removed from Brand Preferred, Prior Authorization Added)
• Focalin XR 30 mg capsule (Removed from Brand Preferred, Prior Authorization Added)
• Focalin XR 35 mg capsule (Removed from Brand Preferred, Prior Authorization Added)
• Focalin XR 40 mg capsule (Removed from Brand Preferred, Prior Authorization Added)
• Focalin XR 5 mg capsule (Removed from Brand Preferred, Prior Authorization Added)
• Gamifant 10 mg per 2 mL intravenous solution (Updated to Special PA)
• Gamifant 100 mg per 20 mL intravenous solution (Updated to Special PA)
• Gamifant 50 mg per 10 mL intravenous solution (Updated to Special PA)
• Idelvion 1000 unit intravenous solution (Removed Prior Authorization) 
• Idelvion 2000 unit intravenous solution (Removed Prior Authorization) 
• Idelvion 250 unit intravenous solution (Removed Prior Authorization) 
• Idelvion 3500 unit intravenous solution (Removed Prior Authorization) 
• Idelvion 500 unit intravenous solution (Removed Prior Authorization) 
• Insulin Glargine (yfgn) 100 unit per mL solution (Prior Authorization Added)
• Jivi 1000 unit intravenous solution (Removed Prior Authorization) 
• Jivi 2000 unit intravenous solution (Removed Prior Authorization) 
• Jivi 3000 unit intravenous solution (Removed Prior Authorization) 
• Jivi 4000 unit intravenous solution (Removed Prior Authorization) 
• Jivi 500 unit intravenous solution (Removed Prior Authorization) 
• Natroba 0.9 % suspension (Removed from Brand Preferred)
• Rebinyn 1000 unit intravenous solution (Removed Prior Authorization) 
• Rebinyn 2000 unit intravenous solution (Removed Prior Authorization) 
• Rebinyn 3000 unit intravenous solution (Removed Prior Authorization) 
• Rebinyn 500 unit intravenous solution (Removed Prior Authorization) 
• Roflumilast 250 mcg tablet (Prior Authorization Removed)
• Roflumilast 500 mcg tablet (Prior Authorization Removed)
• Semglee (yfgn) 100 unit per mL pen-injector solution (Added to Brand Preferred)
• Semglee (yfgn) 100 unit per mL solution (Added to Brand Preferred, Prior Authorization Added)
• Simlandi (1 Pen) 40 mg per 0.4 mL auto-injector kit (Updated to Tier 2)
• Simlandi (1 Pen) 80 mg per 0.8 mL auto-injector kit (Updated to Tier 2)
• Simlandi (1 Syringe) 80 mg per 0.8 mL prefilled syringe kit (Updated to Tier 2)
• Simlandi (2 Pen) 40 mg per 0.4 mL auto-injector kit (Updated to Tier 2)
• Simlandi (2 Syringe) 20 mg per 0.2 mL prefilled syringe kit (Updated to Tier 2)
• Simlandi (2 Syringe) 40 mg per 0.4 mL prefilled syringe kit (Updated to Tier 2)
• Striverdi Respimat 2.5 mcg per actuation inhaler (Updated to Tier 1)
• Synjardy 12.5 mg / 1000 mg tablet (Updated to Tier 1, Step Therapy Removed)
• Synjardy 12.5 mg / 500 mg tablet (Updated to Tier 1, Step Therapy Removed)
• Synjardy 5 mg / 1000 mg tablet (Updated to Tier 1, Step Therapy Removed)
• Synjardy 5 mg / 500 mg tablet (Updated to Tier 1, Step Therapy Removed)
• Synjardy XR 10 mg / 1000 mg tablet (Updated to Tier 1, Step Therapy Removed)
• Synjardy XR 12.5 mg / 1000 mg tablet (Updated to Tier 1, Step Therapy Removed)
• Synjardy XR 25 mg / 1000 mg tablet (Updated to Tier 1, Step Therapy Removed)
• Synjardy XR 5 mg / 1000 mg tablet (Updated to Tier 1, Step Therapy Removed)
• Tudorza Pressair 400 mcg per actuation inhaler (Updated to Tier 2)
• Vyvanse 10 mg capsule (Removed from Brand Preferred)
• Vyvanse 20 mg capsule (Removed from Brand Preferred)
• Vyvanse 30 mg capsule (Removed from Brand Preferred)
• Vyvanse 40 mg capsule (Removed from Brand Preferred)
• Vyvanse 50 mg capsule (Removed from Brand Preferred)
• Vyvanse 60 mg capsule (Removed from Brand Preferred)
• Vyvanse 70 mg capsule (Removed from Brand Preferred)
• Xarelto 2.5 mg tablet (Removed from Brand Preferred, Prior Authorization Added)

December 2025

Additions:

• None

Removals:

• None

Other Updates:

• Auryxia 1 gram tablet (Updated to Brand Preferred)
• Fosrenol 1000 mg chewable tablet (Removed from Brand Preferred)
• Fosrenol 1000 mg powder packet (Added Prior Authorization)
• Fosrenol 750 mg powder packet (Added Prior Authorization)
• Likmez 500 mg per 5 mL suspension (Added Prior Authorization)
• Lotemax 0.5 % ophthalmic suspension (Updated to Tier 2, Removed from Brand Preferred)
• Loteprednol 0.5 % ophthalmic suspension (Updated to Tier 2)
• Metronidazole 375 mg capsule (Added Prior Authorization)
• Proctofoam 1 % / 1% HC foam (Added Prior Authorization)

November 2025

Additions:

• None

Removals:

• None

Other Updates:

• None

October 2025

Additions:

• None

Removals:

• Apriso 0.375 gm capsule
• Moviprep solution
• Plenvu solution
• Relistor 12 mg per 0.6 mL solution
• Relistor 150 mg tablet
• Relistor 8 mg per 0.4 mL solution
• Trulance 3 mg tablet
• Xifaxan 200 mg tablet
• Xifaxan 550 mg tablet

Other Updates:

• Amcinonide 0.1 % cream (Updated to Tier 3)
• Azmiro 200 mg per mL prefilled syringe solution (Updated to Special PA)
• Betamethasone dipropionate augmented 0.05% lotion (Updated to Tier 1)
• Buprenorphine 2 mg sublingual tablet (Removed Prior Authorization, and Gender Restriction)
• Buprenorphine 8 mg sublingual tablet (Removed Prior Authorization, and Gender Restriction)
• Hydrocortisone valerate 0.2% ointment (Updated to Tier 2)
• Hysingla 100 mg 24-hour extended release tablet (Updated to Brand Preferred)
• Hysingla 120 mg 24-hour extended release tablet (Updated to Brand Preferred)
• Hysingla 20 mg 24-hour extended release tablet (Updated to Brand Preferred)
• Hysingla 30 mg 24-hour extended release tablet (Updated to Brand Preferred)
• Hysingla 40 mg 24-hour extended release tablet (Updated to Brand Preferred)
• Hysingla 60 mg 24-hour extended release tablet (Updated to Brand Preferred)
• Hysingla 80 mg 24-hour extended release tablet (Updated to Brand Preferred)
• Imuldosa 130 mg per 26 mL prefilled syringe solution (Updated to Tier 2)
• Imuldosa 45 mg per 0.5 mL prefilled syringe solution (Updated to Tier 2)
• Imuldosa 90 mg per mL prefilled syringe solution (Updated to Tier 2)
• Jynarque 15 mg tablet (Updated to Brand Preferred)
• Jynarque 30 mg tablet (Updated to Brand Preferred)
• Jynarque therapy pack 15 mg tablet (Updated to Brand Preferred)
• Jynarque therapy pack 30 mg and 15 mg tablet (Updated to Brand Preferred)
• Jynarque therapy pack 45 mg and 15 mg tablet (Updated to Brand Preferred)
• Jynarque therapy pack 60 mg and 30 mg tablet (Updated to Brand Preferred)
• Jynarque therapy pack 90 mg and 30 mg tablet (Updated to Brand Preferred)
• Pyzchiva 130 mg per 26 mL intravenous solution (Updated to Tier 2)
• Pyzchiva 45 mg per 0.5 mL intravenous solution (Updated to Tier 2)
• Pyzchiva 90 mg per mL intravenous solution (Updated to Tier 2)
• Roxybond 10 mg tablet (Updated to Special PA)
• Roxybond 15 mg tablet (Updated to Special PA)
• Roxybond 30 mg tablet (Updated to Special PA)
• Roxybond 5 mg tablet (Updated to Special PA)
• Selsardi 130 mg per 26 mL intravenous solution (Updated to Tier 2)
• Selsardi 45 mg per 0.5 mL intravenous solution (Updated to Tier 2)
• Selsardi 90 mg per mL intravenous solution (Updated to Tier 2)
• Steqeyma 130 mg per 26 mL intravenous solution (Updated to Tier 2)
• Steqeyma 45 mg per 0.5 mL intravenous solution (Updated to Tier 2)
• Steqeyma 90 mg per mL intravenous solution (Updated to Tier 2)
• Testim 50 mg per 5 gm (1%) transdermal gel (Updated to Tier 2)
• Testosterone 30 mg per actuation transdermal solution (Updated to Tier 2)
• Testosterone 50 mg per 5 gm (1%) transdermal gel (Updated to Tier 2)
• Tramadol 100 mg 24-hour extended release tablet (Updated to Tier 1)
• Tramadol 200 mg 24-hour extended release tablet (Updated to Tier 1)
• Tramadol 300 mg 24-hour extended release tablet (Updated to Tier 1)
• Yesintek 130 mg per 26 mL intravenous solution (Updated to Tier 2)
• Yesintek 45 mg per 0.5 mL intravenous solution (Updated to Tier 2)
• Yesintek 90 mg per mL intravenous solution (Updated to Tier 2)

September 2025

Additions:

• None

Removals:

• None

Other Updates:

• None

August 2025

Additions:

None

Removals:

None

Other Updates:

• Opipza 2 mg film (Updated to Tier 3)
• Opipza 5 mg film (Updated to Tier 3)
• Opipza 10 mg film (Updated to Tier 3)
• Tezruly 1 mg per mL solution (Updated to Special PA)

July 2025

Additions:

• None

Removals:

• None

Other Updates:

• Adzenys XR 12.5 mg tablet (Updated to Tier 3)
• Adzenys XR 15.7 mg tablet (Updated to Tier 3)
• Adzenys XR 18.8 mg tablet (Updated to Tier 3)
• Adzenys XR 3.1 mg tablet (Updated to Tier 3)
• Adzenys XR 6.3 mg tablet (Updated to Tier 3)
• Adzenys XR 9.4 mg tablet (Updated to Tier 3)
• Byetta 10 mcg injection (Updated to Special PA)
• Byetta 5 mcg injection (Updated to Special PA)
• Denavir 1 % cream (Added to Brand Preferred)
• Dyanavel XR 10 mg tablet (Updated to Tier 3)
• Dyanavel XR 15 mg tablet (Updated to Tier 3)
• Dyanavel XR 20 mg tablet (Updated to Tier 3)
• Dyanavel XR 5 mg tablet (Updated to Tier 3)
• Exenatide 5 mcg injection (Updated to Special PA)
• Exenatide 5 mcg injection (Updated to Special PA)
• Fiasp 100 unit per mL cartridge solution (Removed Prior Authorization)
• Fiasp 100 unit per mL solution (Removed Prior Authorization)
• Fiasp Flextouch 100 unit per mL solution pen (Removed Prior Authorization)
• Glimepiride 3 mg tablet (Updated to Special PA)
• Humalog 100 unit per mL cartridge solution (Removed from Brand Preferred)
• Humalog 100 unit per mL solution (Removed from Brand Preferred)
• Humalog Kwikpen 100 unit per mL solution (Removed from Brand Preferred)
• Invokamet 150 mg / 1000 mg (Updated to Tier 3)
• Invokamet 150 mg / 500 mg (Updated to Tier 3)
• Invokamet 50 mg / 1000 mg (Updated to Tier 3)
• Invokamet 50 mg / 500 mg (Updated to Tier 3)
• Invokamet XR 150 mg / 1000 mg (Updated to Tier 3)
• Invokamet XR 150 mg / 500 mg (Updated to Tier 3)
• Invokamet XR 50 mg / 1000 mg (Updated to Tier 3)
• Invokamet XR 50 mg / 500 mg(Updated to Tier 3)
• Invokana 100 mg tablet (Updated to Tier 3)
• Invokana 300 mg tablet (Updated to Tier 3)
• Liraglutide 18 mg per 3 mL (Updated to Special PA)
• Lisdexamfetamine 10 mg capsule (Updated to Tier 2, Added Prior Authorization)
• Lisdexamfetamine 20 mg capsule (Updated to Tier 2, Added Prior Authorization)
• Lisdexamfetamine 30 mg capsule (Updated to Tier 2, Added Prior Authorization)
• Lisdexamfetamine 40 mg capsule (Updated to Tier 2, Added Prior Authorization)
• Lisdexamfetamine 50 mg capsule (Updated to Tier 2, Added Prior Authorization)
• Lisdexamfetamine 60 mg capsule (Updated to Tier 2, Added Prior Authorization)
• Lisdexamfetamine 70 mg capsule (Updated to Tier 2, Added Prior Authorization)
• Lisdexamfetamine 10 mg chewable tablet (Updated to Tier 3)
• Lisdexamfetamine 20 mg chewable tablet (Updated to Tier 3)
• Lisdexamfetamine 30 mg chewable tablet (Updated to Tier 3)
• Lisdexamfetamine 40 mg chewable tablet (Updated to Tier 3)
• Lisdexamfetamine 50 mg chewable tablet (Updated to Tier 3)
• Lisdexamfetamine 60 mg chewable tablet (Updated to Tier 3)
• Onyda XR 0.1 mg per mL suspension (Updated to Tier 3)
• Vyvanse 10 mg chewable tablet (Removed from Brand Preferred, Updated to Tier 3)
• Vyvanse 20 mg chewable tablet (Removed from Brand Preferred, Updated to Tier 3)
• Vyvanse 30 mg chewable tablet (Removed from Brand Preferred, Updated to Tier 3)
• Vyvanse 40 mg chewable tablet (Removed from Brand Preferred, Updated to Tier 3)
• Vyvanse 50 mg chewable tablet (Removed from Brand Preferred, Updated to Tier 3)
• Vyvanse 60 mg chewable tablet (Removed from Brand Preferred, Updated to Tier 3)
• Zovirax 5 % cream (Removed from Brand Preferred)

June 2025

Additions:

• None

Removals:

• None

Other Updates:

• None

May 2025

Additions:

• None

Removals:

• None

Other Updates:

• Carafate 1 gm per 10 mL suspension (Updated to Special PA)
• Dexilant DR 30 mg capsule (Updated to Tier 2)
• Dexilant DR 60 mg capsule (Updated to Tier 2)
• Dexlansoprazole 30 mg capsule (Updated to Tier 2)
• Dexlansoprazole 60 mg capsule (Updated to Tier 2)
• Sucralfate 1 gm per 10 mL suspension (Updated to Special PA)

April 2025

Additions:

• None

Removals:

• OneTouch Ultra 2 meter
• OneTouch Ultra Blue test strips
• OneTouch Ultra Mini meter
• OneTouch Ultra test strips
• OneTouch Verio Flex meter
• OneTouch Verio IQ meter
• OneTouch Verio test strips

Other Updates:

• Atacand 32 mg tablet (Updated to Tier 1, Removed Step Therapy)
• Azasite 1 % ophthalmic solution (Updated to Tier 1)
• Besivance 0.6 % ophthalmic suspension (Updated to Tier 1)
• Candesartan 32 mg tablet (Updated to Tier 1, Removed Step Therapy)
• Celebrex 400 mg capsule (Updated to Tier 1)
• Celecoxib 400 mg capsule (Updated to Tier 1)
• Ciloxan 0.3 % ophthalmic ointment (Updated to Tier 1)
• Diclofenac potassium 50 mg tablet (Updated to Tier 1)
• Diflunisal 500 mg tablet (Updated to Tier 2)
• Etodolac 200 mg capsule (Updated to Tier 1, Removed Step Therapy)
• Etodolac 300 mg capsule (Updated to Tier 1, Removed Step Therapy)
• Fenofibrate micronized 200 mg capsule (Updated to Tier 1, Removed Step Therapy)
• Flurbiprofen 100 mg tablet (Updated to Tier 2)
• Forteo 560 mcg per 2.24 mL (Updated to Brand Preferred with Prior Authorization)
• Gatifloxacin 0.5 % ophthalmic solution (Updated to Tier 2)
• Indomethacin extended release 75 mg capsule (Updated to Tier 2)
• Mefenam acid 250 mg capsule (Updated to Tier 2)
• Moxifloxacin 0.5 % ophthalmic solution (Updated to Tier 1)
• Naproxen delayed release 500 mg tablet (Updated to Tier 2)
• Neomycin 1.75 / polymyxin B 10000 / gramicidin 0.025 unit per mg per mL ophthalmic solution (Updated to Tier 2)
• Neomycin polymyxin bacitracin 1 % ophthalmic ointment (Updated to Tier 1)
• Pantoprazole sodium 40 mg per 100 ml (0.9 %) intravenous solution (Updated to Special PA)
• Pantoprazole sodium 40 mg per 50 ml (0.9 %) intravenous solution (Updated to Special PA)
• Pantoprazole sodium 80 mg per 100 ml (0.9 %) intravenous solution (Updated to Special PA)
• Sulfacetamide sodium 10 % ophthalmic solution (Updated to Tier 2)
• Tobradex 0.3 % / 0.1 % ophthalmic ointment (Updated to Tier 1)
• Tobramycin 0.3 % / dexamethasone 0.1 % ophthalmic suspension (Removed from Brand Preferred)
• Tolectin 200 mg tablet (Updated to Special PA, Removed Step Therapy)
• Tolectin 400 mg capsule (Updated to Special PA, Removed Step Therapy)
• Tolectin 600 mg tablet (Updated to Special PA, Removed Step Therapy)
• Ventolin HFA 108 mcg inhaler (Removed from Brand Preferred)
• Vigamox 0.5 % ophthalmic solution (Updated to Tier 1)
• Zylet 0.5 % / 0.3% ophthalmic suspension (Updated to Tier 1)

March 2025

Additions:

• None

Removals:

• None

Other Updates:

• None

February 2025

Additions:

• None

Removals:

• None

Other Updates:

• Flovent Diskus 100 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
• Flovent Diskus 250 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
• Flovent Diskus 50 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
• Flovent HFA 110 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
• Flovent HFA 220 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
• Flovent HFA 44 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
• Fluticasone propionate diskus 100 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
• Fluticasone propionate diskus 250 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
• Fluticasone propionate diskus 50 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
• Fluticasone propionate HFA 110 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
• Fluticasone propionate HFA 220 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
• Fluticasone propionate HFA 44 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
• Qvar RediHaler 40 mcg per act inhaler (Updated to Tier 1)
• Qvar RediHaler 80 mcg per act inhaler (Updated to Tier 1)
• Wixela 100 mcg / 50 mcg per act inhaler (Removed Prior Authorization)
• Wixela 250 mcg / 50 mcg per act inhaler (Removed Prior Authorization)
• Wixela 500 mcg / 50 mcg per act inhaler (Removed Prior Authorization)

January 2025

Additions:

• None

Removals:

• None

Other Updates:

• None

December 2024

Additions:

• None

Removals:

• None

Other Updates:

• None

November 2024

Additions:

• None

Removals:

• None

Other Updates:

• None

October 2024

Additions:

• None

Removals:

• None

Other Updates:

• None

September 2024

Additions:

• None

Removals:

• Oxbryta 300 mg soluble tablet
• Oxbryta 300 mg tablet
• Oxbryta 500 mg tablet

Other Updates:

• Alclometasone 0.05% ointment (Updated to Tier 2)
• Calcipotriene 0.005% / betamethasone dipropionae 0.064% ointment (Updated to Tier 3)
• Calcipotriene 0.005% / betamethasone dipropionae 0.064% suspension (Updated to Tier 3)
• Clindacin ETZ 1% cleanser kit (Updated to Special PA)
• Clobetasol 0.05% spray (Updated to Tier 2)
• Clocortolone 0.1% cream (Updated to Tier 3)
• Cloderm 0.1% cream (Updated to Tier 3)
• Halcinonide 0.1% cream (Updated to Tier 3)
• Halog 0.1% cream (Updated to Tier 3)
• Halog 0.1% ointment (Updated to Tier 3)
• Halog 0.1% solution (Updated to Tier 3)
• Hydrocodone 10 mg / acetaminophen 300 mg tablet (Updated to Special PA)
• Hydrocodone 5 mg / acetaminophen 300 mg tablet (Updated to Special PA)
• Hydrocodone 7.5 mg / acetaminophen 300 mg tablet (Updated to Special PA)
• Hydrocodone 7.5 mg / acetaminophen 325 mg per 15 mL solution (Updated to Special PA)
• Hydrocortisone 0.1% lotion (Updated to Tier 3)
• Hydrocortisone butyrate 0.1% cream (Updated to Tier 3)
• Hydrocortisone valerate 0.2% cream (Updated to Tier 1)
• Locoid 0.1% lotion (Updated to Tier 3)
• Methadone 10 mg per 5 mL solution (Updated to Special PA)
• Methadone 5 mg per 5 mL solution (Updated to Special PA)
• Nalocet 2.5 mg/300 mg tablet (Updated to Special PA)
• Prolate 10 mg / 300 mg per 5 mL solution (Updated to Special PA)
• Prolate 10 mg / 300 mg tablet (Updated to Special PA)
• Prolate 5 mg / 300 mg tablet (Updated to Special PA)
• Prolate 7.5 mg / 300 mg tablet (Updated to Special PA)
• Taclonex 0.005% / 0.064% ointment (Updated to Tier 3)
• Taclonex 0.005% / 0.064% suspension (Updated to Tier 3)

August 2024

Additions:

• None

Removals:

• None

Other Updates:

• None

July 2024

Additions:

• None

Removals:

• None

Other Updates:

• Aveed 750 gm per 3 mL intramuscular injection (Updated to Special PA)
• Baclofen 5 mg tablet (Updated to Special PA)
• Bismuth 140 mg /metronidazole 125 mg/ tetracycline 125 mg capsule (Removed Brand Preferred, Updated to Special PA)
• Combogesic 1000 mg/300 mg per 100 mL intravenous solution (Updated to Special PA)
• Elyxyb 120 mg per 4.8 mL oral solution (Updated to Special PA)
• Farxiga 10 mg tablet (Added to Brand Preferred)
• Farxiga 5 mg tablet (Added to Brand Preferred)
• Insulin glargine-yfgn 100 unit per mL injection (Removed Prior Authorization)
• Insulin glargine-yfgn 100 unit per mL pen-injector solution (Removed Prior Authorization)
• Invokamet 150/1000 mg tablet (Updated to Tier 2)
• Invokamet 150/500 mg tablet (Updated to Tier 2)
• Invokamet 50/1000 mg tablet (Updated to Tier 2)
• Invokamet 50/500 mg tablet (Updated to Tier 2)
• Invokamet XR 150/1000 mg tablet (Updated to Tier 2)
• Invokamet XR 150/500 mg tablet (Updated to Tier 2)
• Invokamet XR 50/1000 mg tablet (Updated to Tier 2)
• Invokamet XR 50/500 mg tablet (Updated to Tier 2)
• Invokana 100 mg tablet (Updated to Tier 2)
• Invokana 300 mg tablet (Updated to Tier 2)
• Kombiglyze XR 2.5/1000 mg tablet (Updated to Special PA)
• Kombiglyze XR 5/1000 mg tablet (Updated to Special PA)
• Kombiglyze XR 5/500 mg tablet (Updated to Special PA)
• Natesto 5.5 mg per actuation nasal gel (Updated to Special PA)
• Neo-synalar 0.5/0.025% cream (Updated to Tier 2)
• Olopatadine 0.6 % nasal spray (Updated to Tier 2)
• Omnaris 50 mcg nasal spray (Updated to Tier 1)
• Onglyza 2.5 mg tablet (Updated to Special PA)
• Onglyza 5 mg tablet (Updated to Special PA)
• Saxagliptin 2.5 mg tablet (Updated to Special PA)
• Saxagliptin 2.5 mg/ metformin 1000 mg ER tablet (Updated to Special PA)
• Saxagliptin 5 mg tablet (Updated to Special PA)
• Saxagliptin 5 mg/ metformin 1000 mg ER tablet (Updated to Special PA)
• Saxagliptin 5 mg/ metformin 500 mg ER tablet (Updated to Special PA)
• Xigduo XR 10/1000 mg tablet (Added to Brand Preferred)
• Xigduo XR 10/500 mg tablet (Added to Brand Preferred)
• Xigduo XR 2.5/1000 mg tablet (Added to Brand Preferred)
• Xigduo XR 5/1000 mg tablet (Added to Brand Preferred)
• Xigduo XR 5/500 mg tablet (Added to Brand Preferred)
• Zetonna 37 mcg nasal solution (Updated to Tier 1)

June 2024

Additions:

• None

Removals:

• None

Other Updates:

• Amoxicillin 500 mg capsule/clarithromycin 500 mg tablet/lansoprazole 30 mg capsule (Updated to Special PA)
• Bismuth 140 mg/metronidazole 125 mg/tetracycline 125 mg capsule (Updated to Special PA)
• Dapagliflozin 10 mg tablet (Updated to Special PA)
• Dapagliflozin 10mg/metformin 1000 mg ER tablet (Updated to Special PA)
• Dapagliflozin 5 mg tablet (Updated to Special PA)
• Dapagliflozin 5mg/metformin 1000 mg ER tablet (Updated to Special PA)
• Farxiga 10 mg tablet (Added to Brand Preferred)
• Farxiga 5 mg tablet (Added to Brand Preferred)
• Glipizide 2.5 mg tablet (Updated to Special PA)
• Inpefa 200 mg tablet (Updated to Special PA)
• Inpefa 400 mg tablet (Updated to Special PA)
• Invokamet 150/1000 mg tablet (Updated to Tier 2)
• Invokamet 150/500 mg tablet (Updated to Tier 2, Added Step Therapy)
• Invokamet 50/1000 mg tablet (Updated to Tier 2, Added Step Therapy)
• Invokamet 50/500 mg tablet (Updated to Tier 2, Added Step Therapy)
• Invokamet XR 150/1000 mg tablet (Updated to Tier 2, Added Step Therapy)
• Invokamet XR 150/500 mg tablet (Updated to Tier 2, Added Step Therapy)
• Invokamet XR 50/1000 mg tablet (Updated to Tier 2, Added Step Therapy)
• Invokamet XR 50/500 mg tablet (Updated to Tier 2, Added Step Therapy)
• Invokana 100 mg tablet (Updated to Tier 2, Added Step Therapy)
• Invokana 300 mg tablet (Updated to Tier 2, Added Step Therapy)
• Kombiglyze XR 2.5/1000 mg tablet (Updated to Special PA, Removed Step Therapy))
• Kombiglyze XR 5/1000 mg tablet (Updated to Special PA, Removed Step Therapy))
• Kombiglyze XR 5/500 mg tablet (Updated to Special PA, Removed Step Therapy))
• Ngenla 24 mg per 1.2 mL injection (Updated to Tier 2)
• Ngenla 60 mg per 1.2 mL injection (Updated to Tier 2)
• Onglyza 2.5 mg tablet (Updated to Special PA, Removed Step Therapy)
• Onglyza 5 mg tablet (Updated to Special PA, Removed Step Therapy)
• Pylera capsule (Updated to Special PA, Removed from Brand Preferred)
• Saxagliptin 2.5 mg tablet (Updated to Special PA)
• Saxagliptin 2.5 mg/metformin 1000 mg tablet (Updated to Special PA)
• Voquenza 10 mg tablet (Updated to Special PA)
• Voquenza 20 mg tablet (Updated to Special PA)
• Voquenza dual pak (Updated to Special PA)
• Voquenza triple pak (Updated to Special PA)
• Xigduo XR 10/1000 mg tablet (Added to Brand Preferred)
• Xigduo XR 10/500 mg tablet (Added to Brand Preferred)
• Xigduo XR 2.5/1000 mg tablet (Added to Brand Preferred)
• Xigduo XR 5/1000 mg tablet (Added to Brand Preferred)
• Xigduo XR 5/500 mg tablet (Added to Brand Preferred)
• Zituvio 100 mg tablet (Updated to Special PA)
• Zituvio 25 mg tablet (Updated to Special PA)
• Zituvio 50 mg tablet (Updated to Special PA)

May 2024

Additions:

• None

Removals:

• None

Other Updates:

• Aptensio XR 10 mg capsule (Removed from Brand preferred)
• Aptensio XR 15 mg capsule (Removed from Brand preferred)
• Aptensio XR 20 mg capsule (Removed from Brand preferred)
• Aptensio XR 30 mg capsule (Removed from Brand preferred)
• Aptensio XR 40 mg capsule (Removed from Brand preferred)
• Aptensio XR 50 mg capsule (Removed from Brand preferred)
• Aptensio XR 60 mg capsule (Removed from Brand preferred)
• Dynavel XR 2.5 mg per mL suspension (Updated to Tier 3)
• Nuvigil 150mg tablet (Removed from Brand preferred)
• Nuvigil 200mg tablet (Removed from Brand preferred)
• Nuvigil 250mg tablet (Removed from Brand preferred)
• Nuvigil 50mg tablet (Removed from Brand preferred)

April 2024

Additions

• None

Removals

• None

Other updates

• None