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Formulary search tool and updates

Stay up to date with your medicine. A formulary is a list of medicines we cover. It can help you manage your medicines. 

Questions?

Call us at 1-800-822-2447 (TTY: 711). We’re here for you Monday through Friday, 8 AM to 5 PM.

Your formulary search tool

There are many different things that 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 needs prior authorization 

Updates to the formulary

March 2024

 

Additions:

 

  • Zenpep Capsule 60000 Unit

 

Removals:

 

  • No updates

 

Other Updates:

 

  • No updates

 

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)
  • Aristada Initio Prefilled Syringe 675 mg/ 2.4 mL (Prior Authorization, Quantity Level Limit)
  • 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 Units/ mL
  • Insulin Lispro Injection Junior
  • Insulin Lispro Vial
  • Lurasidone Hydrochloride Tablet 120 mg (Quantity Level Limit, Age Limit)
  • Lurasidone Hydrochloride Tablet 20 mg (Quantity Level Limit, Age Limit)
  • Lurasidone Hydrochloride Tablet 40 mg (Quantity Level Limit, Age Limit)
  • Lurasidone Hydrochloride Tablet 60 mg (Quantity Level Limit, Age Limit)
  • Lurasidone Hydrochloride Tablet 80 mg (Quantity Level Limit, Age Limit)
  • Ondansetron Hydrochloride Oral Solution 4 mg/ 5 mL (Quantity Level Limit)
  • Orilissa Tablet 150 mg (Prior Authorization)
  • Orilissa Tablet 200 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
  • Benzoyl Peroxide Liquid Wash 4%
  • Bromocriptine Mesylate Capsule 5 mg (Base Equivalent)
  • Bromocriptine Mesylate Tablet 2.5 mg (Base Equivalent)
  • 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
  • Humalog Vial 100 units /mL
  • Humalog Vial 100 units /mL
  • Humira Injection 10 mg /0.1 mL
  • Humira Injection 20 mg /0.2 mL
  • Humira Injection 40 mg/0.4 mL
  • Humira Kit 40 mg/0.8
  • Humira Pediatric Injection Crohns
  • Humira Pediatric 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
  • Ins Aspart FlexPen 70/30
  • Insulin Aspart Protein Injection Flexpen
  • 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 Tablet Delayed Release 800 mg
  • Nayzilam
  • Novolog Mix Injection Flex ReliOn
  • Novolog Mix Vial 70/30
  • Salsalate Tablet 500 mg
  • Salsalate Tablet 750 mg
  • Tramadol Tablet 100mg
  • Viokace Tablet 10440 Units
  • Viokace Tablet 20880 Units

 

Other Updates:

 

  • *Sodium Phosphates - Enema*** (Quantity Level Limit)
  • Acarbose Tablet 100 mg (Quantity Level Limit)
  • Acarbose Tablet 25 mg (Quantity Level Limit)
  • Acarbose Tablet 50 mg (Quantity Level Limit)
  • Albuterol Sulfate Solution Nebulizer 0.083% (2.5 mg/3 mL) (Quantity Level Limit)
  • Albuterol Sulfate Solution Nebulizer 0.5% (5 mg/mL) (Quantity Level Limit)
  • Albuterol Sulfate Solution Nebulizer 0.63 mg/3 mL (Base Equivalent) (Quantity Level Limit)
  • Albuterol Sulfate Solution Nebulizer 1.25 mg/3 mL (Base Equivalent) (Quantity Level Limit)
  • Alfuzosin Hydrochloride Tablet Extended Release 24 Hour 10 mg (Quantity Level Limit)
  • Alogliptin-Pioglitazone Tablet 12.5-15 mg (Quantity Level Limit)
  • Alogliptin-Pioglitazone Tablet 12.5-45 mg (Quantity Level Limit)
  • Alprazolam Tablet Extended Release 24 Hour 0.5 mg (Quantity Level Limit)
  • Alprazolam Tablet Extended Release 24 Hour 1 mg (Quantity Level Limit)
  • Alprazolam Tablet Extended Release 24 Hour 2 mg (Quantity Level Limit)
  • Alprazolam Tablet Extended Release 24 Hour 3 mg (Quantity Level Limit)
  • Amlodipine Besylate-Benazepril Hydrochloride Capsule 10-20 mg (Quantity Level Limit)
  • Amlodipine Besylate-Benazepril Hydrochloride Capsule 10-40 mg (Quantity Level Limit)
  • Amlodipine Besylate-Benazepril Hydrochloride Capsule 2.5-10 mg (Quantity Level Limit)
  • Amlodipine Besylate-Benazepril Hydrochloride Capsule 5-10 mg (Quantity Level Limit)
  • Amlodipine Besylate-Benazepril Hydrochloride Capsule 5-20 mg (Quantity Level Limit)
  • Amlodipine Besylate-Benazepril Hydrochloride Capsule 5-40 mg (Quantity Level Limit)
  • Benazepril Hydrochloride Tablet 40 mg (Quantity Level Limit)
  • Bimatoprost Ophthalmic Solution 0.3% (Quantity Level Limit)
  • Buprenorphine Hydrochloride Sublingual Tablet 2 mg (Quantity Level Limit)
  • Buprenorphine Hydrochloride Sublingual Tablet 8 mg (Quantity Level Limit)
  • Buspirone Hydrochloride Tablet 10 mg (Quantity Level Limit)
  • Buspirone Hydrochloride Tablet 15 mg (Quantity Level Limit)
  • Buspirone Hydrochloride Tablet 5 mg (Quantity Level Limit)
  • Buspirone Hydrochloride Tablet 7.5 mg (Quantity Level Limit)
  • Candesartan Cilexetil Tablet 16 mg (Quantity Level Limit)
  • Candesartan Cilexetil Tablet 32 mg (Quantity Level Limit)
  • Candesartan Cilexetil Tablet 4 mg (Quantity Level Limit)
  • Candesartan Cilexetil Tablet 8 mg (Quantity Level Limit)
  • Candesartan Cilexetil-Hydrochlorothiazide Tablet 16-12.5 mg (Quantity Level Limit)
  • Candesartan Cilexetil-Hydrochlorothiazide Tablet 32-12.5 mg (Quantity Level Limit)
  • Candesartan Cilexetil-Hydrochlorothiazide Tablet 32-25 mg (Quantity Level Limit)
  • Cetirizine Hydrochloride Tablet 10 mg (Quantity Level Limit)
  • Cetirizine Hydrochloride Tablet 5 mg (Quantity Level Limit)
  • Chlorpheniramine Maleate Tablet Extended Release 12 mg (Quantity Level Limit)
  • Cimetidine Tab 800 mg (Quantity Level Limit)
  • Cimetidine Tablet 300 mg (Quantity Level Limit)
  • Cimetidine Tablet 400 mg (Quantity Level Limit)
  • Citalopram Hydrobromide Tablet 10 mg (Base Equivalent) (Quantity Level Limit)
  • Citalopram Hydrobromide Tablet 20 mg (Base Equivalent) (Quantity Level Limit)
  • Darunavir Tablet 600 mg (Quantity Level Limit)
  • Darunavir Tablet 800 mg (Quantity Level Limit)
  • Diltiazem Hydrochloride Capsule Extended Release 24 Hour 240 mg (Quantity Level Limit)
  • Diltiazem Hydrochloride Coated Beads Capsule Extended Release 24 Hour 120 mg (Quantity Level Limit)
  • Diltiazem Hydrochloride Extended Release Beads Capsule Extended Release 24 Hour 240 mg (Quantity Level Limit)
  • Doxazosin Mesylate Tablet 8 mg (Quantity Level Limit)
  • Duloxetine Hydrochloride Enteric Coated Pellets Capsule 60 mg (Base Equivalent) (Quantity Level Limit)
  • Enalapril Maleate & Hydrochlorothiazide Tablet 10-25 mg (Quantity Level Limit)
  • Enalapril Maleate & Hydrochlorothiazide Tablet 5-12.5 mg (Quantity Level Limit)
  • Enalapril Maleate Tablet 20 mg (Quantity Level Limit)
  • Esomeprazole Magnesium Capsule Delayed Release 40 mg (Quantity Level Limit)
  • Ezetimibe Tablet 10 mg (Quantity Level Limit)
  • Famotidine Tablet 10 mg (Quantity Level Limit)
  • Famotidine Tablet 40 mg (Quantity Level Limit)
  • Finasteride Tablet 5 mg (Quantity Level Limit)
  • Flavoxate Hydrochloride Tablet 100 mg (Quantity Level Limit)
  • Fluoxetine Hydrochloride Capsule 20 mg (Quantity Level Limit)
  • Fluvastatin Sodium Capsule 20 mg (Base Equivalent) (Quantity Level Limit)
  • Fluvoxamine Maleate Tablet 50 mg (Quantity Level Limit)
  • Fosinopril Sodium Tablet 40 mg (Quantity Level Limit)
  • Ibrutinib Tablet 420 mg (Quantity Level Limit)
  • Ibrutinib Tablet 560 mg (Quantity Level Limit)
  • Ipratropium-Albuterol Nebulizer Solution 0.5-2.5(3) mg/3 mL (Quantity Level Limit)
  • Irbesartan-Hydrochlorothiazide Tablet 300-12.5 mg (Quantity Level Limit)
  • Lansoprazole Capsule Delayed Release 30 mg (Quantity Level Limit)
  • Lisinopril & Hydrochlorothiazide Tablet 10-12.5 mg (Quantity Level Limit)
  • Lisinopril & Hydrochlorothiazide Tablet 20-25 mg (Quantity Level Limit)
  • Loratadine & Pseudoephedrine Tablet Extended Release 12 Hour 5-120 mg (Quantity Level Limit)
  • Loratadine & Pseudoephedrine Tablet Extended Release 24 Hour 10-240 mg (Quantity Level Limit)
  • Losartan Potassium & Hydrochlorothiazide Tablet 100-12.5 mg (Quantity Level Limit)
  • Losartan Potassium & Hydrochlorothiazide Tablet 100-25 mg (Quantity Level Limit)
  • Losartan Potassium & Hydrochlorothiazide Tablet 50-12.5 mg (Quantity Level Limit)
  • Losartan Potassium Tablet 100 mg (Quantity Level Limit)
  • Mesalamine Capsule Extended Release 24 Hour 0.375 GM (Quantity Level Limit)
  • Mirtazapine Orally Disintegrating Tablet 30 mg (Quantity Level Limit)
  • Mirtazapine Tablet 30 mg (Quantity Level Limit)
  • Mirtazapine Tablet 45 mg (Quantity Level Limit)
  • Montelukast Sodium Chewable Tablet 4 mg (Base Equivalent) (Quantity Level Limit)
  • Montelukast Sodium Chewable Tablet 5 mg (Base Equivalent) (Quantity Level Limit)
  • Montelukast Sodium Oral Granules Packet 4 mg (Base Equivalent) (Quantity Level Limit)
  • Montelukast Sodium Tablet 10 mg (Base Equivalent) (Quantity Level Limit)
  • Nelfinavir Mesylate Tablet 250 mg (Quantity Level Limit)
  • Nizatidine Capsule 150 mg (Quantity Level Limit)
  • Nizatidine Capsule 300 mg (Quantity Level Limit)
  • Omeprazole Capsule Delayed Release 40 mg (Quantity Level Limit)
  • Oxazepam Capsule 10 mg (Age Limit)
  • Oxazepam Capsule 15 mg (Age Limit)
  • Oxazepam Capsule 30 mg (Age Limit)
  • Oxybutynin Chloride Tablet Extended Release 24 Hour 10 mg (Quantity Level Limit)
  • Oxybutynin Chloride Tablet Extended Release 24 Hour 5 mg (Quantity Level Limit)
  • Oxymetazoline Hydrochloride Nasal Solution 0.05% (Quantity Level Limit)
  • Pantoprazole Sodium Enteric Coated Tablet 40 mg (Quantity Level Limit)
  • Paroxetine Hydrochloride Tablet 30 mg (Quantity Level Limit)
  • Paroxetine Hydrochloride Tablet 40 mg (Quantity Level Limit)
  • Polyethylene Glycol 3350 Oral Packet 17 GM (Quantity Level Limit)
  • Polyethylene Glycol 3350 Oral Powder 17 GM/Scoop (Quantity Level Limit)
  • Prazosin Hydrochloride Capsule 1 mg (Quantity Level Limit)
  • Prazosin Hydrochloride Capsule 2 mg (Quantity Level Limit)
  • Prazosin Hydrochloride Capsule 5 mg (Quantity Level Limit)
  • Quinapril Hydrochloride Tablet 40 mg (Quantity Level Limit)
  • Quinapril-Hydrochlorothiazide Tablet 20-12.5 mg (Quantity Level Limit)
  • Quinapril-Hydrochlorothiazide Tablet 20-25 mg (Quantity Level Limit)
  • Ramipril Capsule 10 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)
  • Sertraline Hydrochloride Tablet 100 mg (Quantity Level Limit)
  • Sertraline Hydrochloride Tablet 25 mg (Quantity Level Limit)
  • Tamsulosin Hydrochloride Capsule 0.4 mg (Quantity Level Limit)
  • Terazosin Hydrochloride Capsule 2 mg (Base Equivalent) (Quantity Level Limit)
  • Terazosin Hydrochloride Capsule 5 mg (Base Equivalent) (Quantity Level Limit)
  • Tobramycin Nebulizer Solution 300 mg/5 mL (Quantity Level Limit)
  • Tolterodine Tartrate Tablet 1 mg (Quantity Level Limit)
  • Tolterodine Tartrate Tablet 2 mg (Quantity Level Limit)
  • Trandolapril Tablet 1 mg (Quantity Level Limit)
  • Trandolapril Tablet 2 mg (Quantity Level Limit)
  • Trandolapril Tablet 4 mg (Quantity Level Limit)
  • Valsartan Tablet 160 mg (Quantity Level Limit)
  • Valsartan Tablet 320 mg (Quantity Level Limit)
  • Valsartan Tablet 40 mg (Quantity Level Limit)
  • Valsartan Tablet 80 mg (Quantity Level Limit)
  • Zidovudine Syrup 10 mg/ mL (Quantity Level Limit)

 

January 2024

 

Additions:

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

Removals:

  • Benzoyl Peroxide Liquid Wash 0.04%

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)
  • Dayvigo Tablet 10 mg (Prior Authorization, Quantity Level Limit)
  • Dayvigo Tablet 5 mg (Prior Authorization, 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
  • Prezcobix Tablet 800-150 (Prior Authorization, Quantity Level Limit)
  • Takhzyro Injection 150 mg / mL (Prior Authorization, Quantity Level Limit)
  • Takhzyro Injection 300 / 2 mL (Prior Authorization, Quantity Level Limit)
  • Takhzyro Injection 300 / 2 mL (Prior Authorization, Quantity Level Limit)

 

Removals:

 

  • Proctofoam Aerosol Hydrocortisone 1%

 

Other Updates:

 

 

  • Abacavir Sulfate Solution 20 mg / mL (Base Equivalent) (Quantity Level Limit)
  • Abacavir Sulfate Tablet 300 mg (Base Equivalent) (Quantity Level Limit)
  • Abacavir Sulfate-Lamivudine Tablet 600-300 mg (Quantity Level Limit)
  • Abacavir Sulfate-Lamivudine-Zidovudine Tablet 300-150-300 mg (Quantity Level Limit)
  • Acarbose Tablet 100 mg (Quantity Level Limit)
  • Acarbose Tablet 25 mg (Quantity Level Limit)
  • Acarbose Tablet 50 mg (Quantity Level Limit)
  • Alogliptin Benzoate Tablet 12.5 mg (Base Equivalent) (Quantity Level Limit)
  • Alogliptin Benzoate Tablet 25 mg (Base Equivalent) (Quantity Level Limit)
  • Alogliptin Benzoate Tablet 6.25 mg (Base Equivalent) (Quantity Level Limit)
  • Alogliptin-Metformin Hydrochloride Tablet 12.5-1000 mg (Quantity Level Limit)
  • Alogliptin-Metformin Hydrochloride Tablet 12.5-500 mg (Quantity Level Limit)
  • Alogliptin-Pioglitazone Tablet 12.5-30 mg (Quantity Level Limit)
  • Alogliptin-Pioglitazone Tablet 25-15 mg (Quantity Level Limit)
  • Alogliptin-Pioglitazone Tablet 25-30 mg (Quantity Level Limit)
  • Alogliptin-Pioglitazone Tablet 25-45 mg (Quantity Level Limit)
  • Anastrozole Tablet 1 mg (Quantity Level Limit)
  • Atazanavir Sulfate Capsule 150 mg (Base Equivalent) (Quantity Level Limit)
  • Atazanavir Sulfate Capsule 200 mg (Base Equivalent) (Quantity Level Limit)
  • Atazanavir Sulfate Capsule 300 mg (Base Equivalent) (Quantity Level Limit)
  • Bicalutamide Tablet 50 mg (Quantity Level Limit)
  • Bisoprolol Fumarate Tablet 5 mg (Quantity Level Limit)
  • Carvedilol Tablet 12.5 mg (Quantity Level Limit)
  • Carvedilol Tablet 25 mg (Quantity Level Limit)
  • Carvedilol Tablet 3.125 mg (Quantity Level Limit)
  • Carvedilol Tablet 6.25 mg (Quantity Level Limit)
  • Complera Tablet (Quantity Level Limit)
  • Darunavir Oral Suspension 100 mg / mL (Quantity Level Limit)
  • Darunavir Tablet 150 mg (Quantity Level Limit)
  • Darunavir Tablet 75 mg (Quantity Level Limit)
  • Diazepam Rectal Gel 10 mg 2's (Quantity Level Limit)
  • Diazepam Rectal Gel 2.5 mg 2s (Quantity Level Limit)
  • Diazepam Rectal Gel 20 mg 2's (Quantity Level Limit)
  • Edurant Tablet 25 mg (Base Equivalent) (Quantity Level Limit)
  • Efavirenz Capsule 200 mg (Quantity Level Limit)
  • Efavirenz Capsule 50 mg (Quantity Level Limit)
  • Efavirenz Tablet 600 mg (Quantity Level Limit)
  • Efavirenz-Emtricitabine-Tenofovir Df Tablet 600-200-300 mg (Quantity Level Limit)
  • Ella Tablet 30 mg (Quantity Level Limit)
  • Emtricitabine Capsules 200 mg (Quantity Level Limit)
  • Emtricitabine Solution 10 mg / mL (Quantity Level Limit)
  • Erlotinib Hydrochloride Tablet 100 mg (Base Equivalent) (Quantity Level Limit)
  • Erlotinib Hydrochloride Tablet 150 mg (Base Equivalent) (Quantity Level Limit)
  • Erlotinib Hydrochloride Tablet 25 mg (Add Prior Authorization, Quantity Level Limit)
  • Estradiol & Norethindrone Acetate Tablet 0.5-0.1 mg (Quantity Level Limit)
  • Estradiol & Norethindrone Acetate Tablet 1-0.5 mg (Quantity Level Limit)
  • Etoposide Capsule 50 mg (Remove Prior Authorization)
  • Etravirine Tablet 100 mg (Quantity Level Limit)
  • Etravirine Tablet 200 mg (Quantity Level Limit)
  • Etravirine Tablet 25 mg (Quantity Level Limit)
  • Everolimus Tablet 10 mg (Quantity Level Limit)
  • Everolimus Tablet 2.5 mg (Quantity Level Limit)
  • Everolimus Tablet 5 mg (Quantity Level Limit)
  • Everolimus Tablet 7.5 mg (Quantity Level Limit)
  • Evotaz Tablet 300-150 (Quantity Level Limit)
  • Exemestane Tablet 25 mg (Quantity Level Limit)
  • Felodipine Tablet Extended Release 24-hour 10 mg (Quantity Level Limit)
  • Felodipine Tablet Extended Release 24-hour 2.5 mg (Quantity Level Limit)
  • Felodipine Tablet Extended Release 24-hour 5 mg (Quantity Level Limit)
  • Fluconazole Tablet 100 mg (Quantity Level Limit)
  • Fluconazole Tablet 200 mg (Quantity Level Limit)
  • Fluconazole Tablet 50 mg (Quantity Level Limit)
  • Fosamprenavir Calcium Suspension 50 mg / mL (Base Equivalent) (Quantity Level Limit)
  • Fosamprenavir Calcium Tablet 700 mg (Base Equivalent) (Quantity Level Limit)
  • Fuzeon (Quantity Level Limit)
  • Glipizide Tablet Extended Release 24-hour 10 mg (Quantity Level Limit)
  • Glipizide Tablet Extended Release 24-hour 2.5 mg (Quantity Level Limit)
  • Glipizide Tablet Extended Release 24-hour 5 mg (Quantity Level Limit)
  • Glipizide-Metformin Hydrochloride Tablet 2.5-250 mg (Quantity Level Limit)
  • Glipizide-Metformin Hydrochloride Tablet 2.5-500 mg (Quantity Level Limit)
  • Glipizide-Metformin Hydrochloride Tablet 5-500 mg (Quantity Level Limit)
  • Glyburide-Metformin Tablet 1.25-250 mg (Quantity Level Limit)
  • Glyburide-Metformin Tablet 2.5-500 mg (Quantity Level Limit)
  • Glyburide-Metformin Tablet 5-500 mg (Quantity Level Limit)
  • Imatinib Mesylate Tablet 100 mg (Base Equivalent) (Quantity Level Limit)
  • Imatinib Mesylate Tablet 400 mg (Base Equivalent) (Quantity Level Limit)
  • Imbruvica Tablet 420 mg (Add Prior Authorization, Quantity Level Limit)
  • Imbruvica Tablet 560 mg (Add Prior Authorization)
  • Isentress Chewable Tablet 100 mg (Base Equivalent) (Quantity Level Limit)
  • Isentress Chewable Tablet 25 mg (Base Equivalent) (Quantity Level Limit)
  • Isentress For Suspension 100 mg (Base Equivalent) (Quantity Level Limit)
  • Isentress Tablet 400 mg (Base Equivalent) (Quantity Level Limit)
  • Isosorbide Mononitrate Tablet Extended Release 24-hour 120 mg (Quantity Level Limit)
  • Isosorbide Mononitrate Tablet Extended Release 24-hour 30 mg (Quantity Level Limit)
  • Isosorbide Mononitrate Tablet Extended Release 24-hour 60 mg (Quantity Level Limit)
  • Itraconazole Capsule 100 mg (Quantity Level Limit)
  • Ketoconazole Tablet 200 mg (Quantity Level Limit)
  • Lamivudine Oral Solution 10 mg / mL (Quantity Level Limit)
  • Lamivudine Tablet 150 mg (Quantity Level Limit)
  • Lamivudine Tablet 300 mg (Quantity Level Limit)
  • Lamivudine-Zidovudine Tablet 150-300 mg (Quantity Level Limit)
  • Letrozole Tablet 2.5 mg (Quantity Level Limit)
  • Levothyroxine Sodium Tablet 100 mcg (Quantity Level Limit)
  • Levothyroxine Sodium Tablet 112 mcg (Quantity Level Limit)
  • Levothyroxine Sodium Tablet 125 mcg (Quantity Level Limit)
  • Levothyroxine Sodium Tablet 137 mcg (Quantity Level Limit)
  • Levothyroxine Sodium Tablet 150 mcg (Quantity Level Limit)
  • Levothyroxine Sodium Tablet 175 mcg (Quantity Level Limit)
  • Levothyroxine Sodium Tablet 200 mcg (Quantity Level Limit)
  • Levothyroxine Sodium Tablet 25 mcg (Quantity Level Limit)
  • Levothyroxine Sodium Tablet 300 mcg (Quantity Level Limit)
  • Levothyroxine Sodium Tablet 50 mcg (Quantity Level Limit)
  • Levothyroxine Sodium Tablet 75 mcg (Quantity Level Limit)
  • Levothyroxine Sodium Tablet 88 mcg (Quantity Level Limit)
  • Lopinavir-Ritonavir Solution 400-100 mg / 5 mL (80-20 mg / mL) (Quantity Level Limit)
  • Lopinavir-Ritonavir Tablet 100-25 mg (Quantity Level Limit)
  • Lopinavir-Ritonavir Tablet 200-50 mg (Quantity Level Limit)
  • Mavyret Tablet 100-40 mg (Quantity Level Limit)
  • Metformin Hydrochloride Tablet Extended Release 24-hour 500 mg (Quantity Level Limit)
  • Metformin Hydrochloride Tablet Extended Release 24-hour 750 mg (Quantity Level Limit)
  • Methadone Hydrochloride Powder (Remove Prior Authorization)
  • Metoprolol Succinate Tablet Extended Release 24-hour 100 mg (Tartrate Equivalent) (Quantity Level Limit)
  • Metoprolol Succinate Tablet Extended Release 24-hour 200 mg (Tartrate Equivalent) (Quantity Level Limit)
  • Metoprolol Succinate Tablet Extended Release 24-hour 25 mg (Tartrate Equivalent) (Quantity Level Limit)
  • Metoprolol Succinate Tablet Extended Release 24-hour 50 mg (Tartrate Equivalent) (Quantity Level Limit)
  • Metronidazole Gel 1% (Remove Step Therapy)
  • Nateglinide Tablet 120 mg (Quantity Level Limit)
  • Nateglinide Tablet 60 mg (Quantity Level Limit)
  • Nayzilam Spray 5 mg (Remove Prior Authorization, Add Quantity Level Limit)
  • Nelfinavir Mesylate Tablet 250 mg (Quantity Level Limit)
  • Nelfinavir Mesylate Tablet 625 mg (Quantity Level Limit)
  • Nevirapine Susp 50 mg / 5 mL (Quantity Level Limit)
  • Nevirapine Tablet 200 mg (Quantity Level Limit)
  • Nevirapine Tablet Extended Release 24-hour 100 mg (Quantity Level Limit)
  • Nevirapine Tablet Extended Release 24-hour 400 mg (Quantity Level Limit)
  • Nifedipine Tablet Extended Release 24-hour 30 mg (Quantity Level Limit)
  • Nifedipine Tablet Extended Release 24-hour 60 mg (Quantity Level Limit)
  • Nifedipine Tablet Extended Release 24-hour 90 mg (Quantity Level Limit)
  • Nifedipine Tablet Extended Release 24-hour Osmotic Release 30 mg (Quantity Level Limit)
  • Nifedipine Tablet Extended Release 24-hour Osmotic Release 60 mg (Quantity Level Limit)
  • Nifedipine Tablet Extended Release 24-hour Osmotic Release 90 mg (Quantity Level Limit)
  • Norethindrone Acetate-Ethinyl Estradiol Tablet 0.5 mg - 2.5 mcg (Quantity Level Limit)
  • Norethindrone Acetate-Ethinyl Estradiol Tablet 1 mg - 5 mcg (Quantity Level Limit)
  • Norethindrone Tablet 0.35 mg (Quantity Level Limit)
  • Paricalcitol Capsule 1 mcg (Quantity Level Limit)
  • Paricalcitol Capsule 2 mcg (Quantity Level Limit)
  • Paricalcitol Capsule 4 mcg (Quantity Level Limit)
  • Progesterone Capsule 100 mg (Quantity Level Limit)
  • Progesterone Capsule 200 mg (Quantity Level Limit)
  • Propranolol Hydrochloride Capsule Extended Release 24-hour 60 mg (Quantity Level Limit)
  • Raloxifene Hydrochloride Tablet 60 mg (Quantity Level Limit)
  • Repaglinide Tablet 0.5 mg (Quantity Level Limit)
  • Repaglinide Tablet 1 mg (Quantity Level Limit)
  • Repaglinide Tablet 2 mg (Quantity Level Limit)
  • Ritonavir Tablet 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)
  • Stavudine Capsule 30 mg (Quantity Level Limit)
  • Stavudine Capsule 40 mg (Quantity Level Limit)
  • Sunitinib Malate Capsule 50 mg (Base Equivalent) (Quantity Level Limit)
  • Tasigna Capsule 150 mg (Quantity Level Limit)
  • Tasigna Capsule 200 mg (Quantity Level Limit)
  • Tenofovir Disoproxil Fumarate Oral Powder 40 mg / GM (Quantity Level Limit)
  • Tenofovir Disoproxil Fumarate Tablet 150 mg (Quantity Level Limit)
  • Tenofovir Disoproxil Fumarate Tablet 200 mg (Quantity Level Limit)
  • Tenofovir Disoproxil Fumarate Tablet 250 mg (Quantity Level Limit)
  • Terbinafine Hydrochloride Tablet 250 mg (Quantity Level Limit)
  • Testosterone Transdermal Gel 25 mg / 2.5 GM (1%) (Quantity Level Limit)
  • Testosterone Transdermal Gel 50 mg / 5 GM (1%) (Quantity Level Limit)
  • Tipranavir Capsule 250 mg (Quantity Level Limit)
  • Tivicay 10 mg (Base Equivalent) (Quantity Level Limit)
  • Tobramycin Nebulizer Solution 300 mg / 5 mL (Quantity Level Limit)
  • Trelstar Mix Injection 11.25 mg (Remove Prior Authorization)
  • Trelstar Mix Injection 22.5 mg (Remove Prior Authorization)
  • Trelstar Mix Injection 3.75 mg (Remove Prior Authorization)
  • Triumeq Tablet (Quantity Level Limit)
  • Tybost Tablet 150 mg (Quantity Level Limit)
  • Valtoco Spray 10 mg (Quantity Level Limit)
  • Valtoco Spray 15 mg (Quantity Level Limit)
  • Valtoco Spray 20 mg (Quantity Level Limit)
  • Valtoco Spray 5 mg (Quantity Level Limit)
  • Varenicline Tablet 0.5 mg (Quantity Level Limit)
  • Varenicline Tablet 1 mg (Quantity Level Limit)
  • Verapamil Hydrochloride Capsule Extended Release 24-hour 120 mg (Quantity Level Limit)
  • Verapamil Hydrochloride Capsule Extended Release 24-hour 180 mg (Quantity Level Limit)
  • Zidovudine Capsule 100 mg (Quantity Level Limit)
  • Zidovudine Syrup 10 mg / ml (Quantity Level Limit)
  • Zidovudine Tablet 300 mg (Quantity Level Limit)

 

October 2023

 

Additions:

 

  • Humatrope Injection 6 mg (Prior Authorization)
  • Humatrope Injection 12 mg (Prior Authorization)
  • Humatrope Injection 24 mg (Prior Authorization)

 

Removals:

 

  • None

 

Other Updates:

 

  • None

 

September 2023

 

Additions:

 

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

 

Removals:

 

  • None

 

Other Updates:

 

  • None

 

August 2023

 

Additions:

 

  • * Prenatal WithFerrous Fumarate-Ferrous Polysaccharide-Folic Acid-Omega 3 Capsule 53.5-38-1 mg
  • 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 24 hour 12 mg (Prior Authorization, Quantity Level Limit)
  • Austedo Tablet Extended Release 24 hour 24 mg (Prior Authorization, Quantity Level Limit)
  • Austedo Tablet Extended Release 24 hour 6 mg (Prior Authorization, Quantity Level Limit)
  • Biktarvy Tablet 30-120-15 mg (Prior Authorization, Quantity Level Limit)
  • Buprenorphine Hydrochloride Sublingual Tablet 2 mg (Base Equivalent) (Prior Authorization, Quantity Level Limit)
  • Buprenorphine Hydrochloride Sublingual Tablet 8 mg (Base Equivalent) (Prior Authorization, Quantity Level Limit)
  • Cholecalciferol Capsule 1.25 mg (50000 Unit)
  • Fluocinolone Acetonide Oil 0.01% (Body Oil) (Quantity Level Limit)
  • Ibandronate Sodium Intravenous Solution 3 mg/ 3 mL (Base Equivalent)
  • 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)
  • Nitroglycerin Capsule Extended Release 2.5 mg
  • Nonoxynol-9 Film 28% (Quantity Level Limit)
  • Novolin N Injection 100 Unit
  • Odefsey Tablet (Prior Authorization, Quantity Level Limit)
  • Pamidronate Disodium Intravenous Solution 3 mg/ mL
  • Pamidronate Disodium Intravenous Solution 6 mg/ mL
  • Pamidronate Disodium Intravenous Solution 9 mg/ mL
  • Tranexamic Acid Tablet 650 mg (Quantity Level Limit)

 

Removals:

 

  • *Alcohol Sheets***
  • *B-Complex W/ Minerals Liquid**
  • *Blood Glucose Calibration - Liquid - Low***
  • *Blood Glucose Calibration - Liquid - Normal***
  • *Calcium Alginate-Silver Pad 2" X 2"***
  • *Calcium Alginate-Silver Pad 4" X 4.75"***
  • *Calcium Carbonate-Vitamin D With Minerals Chewable Tablet 600 mg-400 Unit***
  • *Carboxymethylcellulose- Calcium Alginate-Silver Pad 2"X2"***
  • *Carboxymethylcellulose- Calcium Alginate-Silver Pad 4"X4.75"***
  • *Carboxymethylcellulose- Calcium Alginate-Silver Pad 4"X5"***
  • *Carboxymethylcellulose- Calcium Alginate-Silver Pad 6"X6"***
  • *Condoms - Male***
  • *Cream Base**
  • *Diapers & Supplies***
  • *Hearing Aid Batteries-Miscellaneous***
  • *Incontinence Supplies - Miscellaneous ***
  • *Incontinence Supplies Disposable - Miscellaneous ***
  • *Multiple Vitamin Liquid**
  • *Pediatric Multiple Vitamin Liquid**
  • *Pediatric Multiple Vitamin With Minerals & Vitamin C Drops 45 mg/ mL**
  • *Pediatric Multiple Vitamin With Minerals Oral Solution**
  • *Prenatal Vitamin With Docusate Sodium-Iron Carbonyl-Folic Acid Tab 90-1 mg***
  • *Prenatal Without A Vitamin With Ferrous Fumarate-Folic Acid Tablet Chewable 40-1 mg***
  • *Prenatal Without A With Ferrous Fumarate-Fe Poly-Folic Acid Capsule 85-1 mg***
  • *Sanitary Napkins & Tampons - Pads***
  • *Silver - Pad 12.5 cm X 12.5 cm***
  • *Silver - Pad 17.5 cm X 17.5 cm***
  • *Silver - Pad 2-3/8"X3-1/8"***
  • *Silver - Pad 3"X14"***
  • *Silver - Pad 4-3/4"X10"***
  • *Silver - Pad 7.5 cm X 7.5 cm***
  • *Silver Wound Dressings - Miscellaneous***
  • *Throat Lozenges - Lozenges**
  • *Wound Dressings - Pads***
  • Alogliptin-Pioglitazone Tablet 12.5-15 mg
  • Alogliptin-Pioglitazone Tablet 12.5-45 mg
  • Aluminum & Magnesium Hydroxide-Simethicone Chewable Tablet 200-200-25 mg
  • Aluminum Chloride Solution 20%
  • Aminocaproic Acid Tablet 500 mg
  • Aspirin Suppository 600 mg
  • Atazanavir Sulfate Oral Powder Packet 50 mg (Base Equivalent)
  • 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
  • Benzoyl Peroxide Lotion 8%
  • Bethanechol Chloride (Bulk) Powder
  • Buprenorphine Hydrochloride-Naloxone Hydrochloride Sublingual Film 12-3 mg (Base Equivalent)
  • Buprenorphine Hydrochloride-Naloxone Hydrochloride Sublingual Film 2-0.5 mg (Base Equivalent)
  • Buprenorphine Hydrochloride-Naloxone Hydrochloride Sublingual Film 4-1 mg (Base Equivalent)
  • Buprenorphine Hydrochloride-Naloxone Hydrochloride Sublingual Film 8-2 mg (Base Equivalent)
  • Buprenorphine-Naloxone Buccal Film 2.1-0.3 mg (Base Equivalent)
  • Buprenorphine-Naloxone Buccal Film 4.2-0.7 mg (Base Equivalent)
  • Buprenorphine-Naloxone Buccal Film 6.3-1 mg (Base Equivalent)
  • Butalbital-Aspirin-Caffeine Tablet 50-325-40 mg
  • Caffeine Powder
  • Calcium & Phosphorus With Vitamin D Tablet 105 mg-81 mg-120 Unit
  • Calcium Carbonate-Magnesium Hydroxide Chewable Tablet 550-110 mg
  • Calcium Carbonate-Magnesium Hydroxide Suspension 400-135 mg / 5 mL
  • Calcium Carbonate-Vitamin D Tablet 600 mg-10 mcg (400 Unit)
  • Calcium Citrate-Vitamin D Tablet 200 mg-6.25 mcg(250 Unit) (Elemental Calcium)
  • Calcium Citrate-Vitamin D Tablet 315 mg-6.25 mcg(250 Unit) (Elemental Calcium)
  • Calcium Citrate-Vitamin D Tablet 315 mg-5 mcg (200 Unit) (Elemental Calcium)
  • Carboxymethylcellulose Sodium (Preservative-Free) Ophthalmic Solution 0.25%
  • Carboxymethylcellulose Sodium Ophthalmic Solution 1%
  • Carisoprodol With Aspirin & Codeine Tablet 200-325-16 mg
  • Cimetidine Hydrochloride Solution 300 mg /5 mL
  • Ciprofloxacin Hydrochloride Tablet 100 mg
  • Clemastine Fumarate Syrup 0.67 mg/ 5 mL (0.5 mg/ 5 mL Base Equivalent)
  • Coal Tar Shampoo 2%
  • Coal Tar Shampoo 2.5%
  • Corn Starch Topical Powder
  • Cyclophosphamide Tablet 25 mg
  • Cyclophosphamide Tablet 50 mg
  • Desmopressin Acetate Nasal Solution 0.01% (Refrigerated)
  • Dextromethorphan-Guaifenesin Liquid 30-200 mg/ 5 mL
  • Didanosine Delayed Release Capsule 200 mg
  • Didanosine Delayed Release Capsule 250 mg
  • Didanosine Delayed Release Capsule 400 mg
  • Diflunisal Powder
  • Diphenhydramine Hydrochloride Liquid 12.5 mg/ 5 mL
  • Diphenhydramine Hydrochloride Liquid 6.25 mg/ mL
  • Diphenhydramine-Acetaminophen Tablet 25-500 mg (Sleep)
  • Ergocalciferol Capsule 62.5 mcg (2500 Unit)
  • Esterified Estrogens Tab 2.5 mg
  • Etanercept For Subcutaneous Injection 25 mg
  • Fenoprofen Calcium Powder
  • Fluocinonide Ointment 0.05%
  • Flurazepam Hydrochloride Capsule 15 mg
  • Flurazepam Hydrochloride Capsule 30 mg
  • Fosinopril Sodium & Hydrochlorothiazide Tablet 10-12.5 mg
  • Fosinopril Sodium & Hydrochlorothiazide Tablet 20-12.5 mg
  • Gentamicin Sulfate Ophthalmic Ointment 0.3%
  • Glyburide Powder
  • Glycopyrrolate Injection 0.2 mg/ mL
  • Glycopyrrolate Injection 0.4 mg/ 2 mL (0.2 mg/ mL)
  • Glycopyrrolate Injection 1 mg/ 5 mL (0.2 mg/ mL)
  • Glycopyrrolate Injection 4 mg/20 mL (0.2 mg/ mL)
  • Guaifenesin-Codeine Liquid 200-10 mg/ 5 mL
  • Histrelin Acetate Implant Kit 50 mg
  • Hydrocortisone Acetate Suppository 30 mg
  • Hydrocortisone Powder
  • Indacaterol Maleate Inhalation Powder Capsule 75 mcg (Base Equivalent)
  • Indinavir Sulfate Capsule 400 mg
  • Insulin Syringe/Needle U-100 1/2 mL 30 X 3/8"
  • Interferon Alfa-2b For Injection 10000000 Unit
  • Interferon Alfa-2b For Injection 18000000 Unit
  • Interferon Alfa-2b For Injection 50000000 Unit
  • Irbesartan Tablet 150 mg
  • Irbesartan Tablet 300 mg
  • Irbesartan Tablet 75 mg
  • Ketoprofen Capsule 50 mg
  • Ketoprofen Capsule 75 mg
  • Lamivudine Oral Solution 5 mg/ mL (Hepatitis B virus)
  • Lamivudine-Tenofovir Disoproxil Fumarate Tablet 300-300 mg
  • Lidocaine-Hydrocortisone Acetate Cream 3-0.5%
  • Loperamide Hydrochloride Liquid 1 mg/ 5 mL (0.2 mg/ mL)
  • Loratadine Syrup 5 mg/ 5 mL
  • Magnesium Oxide Capsule 500 mg (Elemental mg)
  • Magnesium Oxide Tablet 250 mg (mg Supplement)
  • Magnesium Tablet 200 mg
  • Magnesium Tablet 400 mg
  • Maprotiline Hydrochloride Tablet 25 mg
  • Maprotiline Hydrochloride Tablet 50 mg
  • Maprotiline Hydrochloride Tablet 75 mg
  • Meloxicam Suspension 7.5 mg/ 5 mL
  • Methadone Hydrochloride Tablet For Oral Suspension 40 mg
  • Methyldopa & Hydrochlorothiazide Tablet 250-15 mg
  • Methyldopa & Hydrochlorothiazide Tablet 250-25 mg
  • Miconazole Nitrate Vaginal Applicator 100 mg & 2% Cream 9 GM Kit
  • Naltrexone For Intramuscular Extended Release Suspension 380 mg
  • Niacin Powder
  • Omeprazole (Bulk) Powder
  • Oxybutynin Chloride (Bulk) Powder
  • Oxycodone-Aspirin Tablet 4.8355-325 mg
  • Peginterferon Alfa-2b For Injection Kit 50 mcg /0.5 mL
  • Phenylephrine With Dm-Gg Liquid 10-15-300 mg/ 5 mL
  • Plerixafor Subcutaneous Injection 24 mg/ 1.2 mL (20 mg/ mL)
  • Potassium & Sodium Citrates With Citric Acid Syrup 550-500-334 mg/ 5 mL
  • Prednicarbate Ointment 0.1%
  • Propranolol & Hydrochlorothiazide Tablet 40-25 mg
  • Propranolol & Hydrochlorothiazide Tablet 80-25 mg
  • Pseudoephedrine-Brompheniramine-Codeine Liquid 10-1.33-6.33 mg/ 5 mL
  • Psyllium Powder Packet 58.6%
  • Rimantadine Hydrochloride Tablet 100 mg
  • Ritonavir Oral Solution 80 mg/ mL
  • Rosiglitazone Maleate Tablet 2 mg (Base Equivalent)
  • Rosiglitazone Maleate Tablet 4 mg (Base Equivalent)
  • Salicylic Acid Cream 6%
  • Saquinavir Mesylate Tablet 500 mg
  • Semaglutide Solution Pen-Injection 0.25 Or 0.5 mg/Dose (2 mg/ 1.5mL)
  • Semaglutide Solution Pen-Injection 1 mg/ Dose (2 mg/1.5 mL)
  • Silver Nitrate-Potassium Nitrate Applicator 75-25%
  • Simethicone Liquid 40 mg/ 0.6 mL
  • Sodium Chloride Solution Nebulizer 6%
  • Sodium Fluoride Solution 0.125 mg/ Drop Fluoride (0.275 mg/Drop Sodium Fluoride)
  • Sodium Fluoride Tablet 0.5 mg Fluoride (From 1.1 mg Sodium Fluoride)
  • Sodium Fluoride Tablet 1 mg Fluoride (From 2.2 mg Sodium Fluoride)
  • Sodium Fluoride-Potassium Nitrate Paste 1.1-5%
  • Stannous Fluoride Concentrated 0.63%
  • Sumatriptan Succinate Solution Prefilled Syringe 6 mg/0.5ml
  • Syringe/Needle (Disposable) 12 mL 20 X 1"
  • Syringe/Needle (Disposable) 12 mL 22 X 1"
  • Syringe/Needle (Disposable) 6 mL 20 X 1"
  • Syringe/Needle (Disposable) 6 mL 21 X 1-1/4"
  • Syringe/Needle (Disposable) 6 mL 22 X 1"
  • Syringe/Needle (Disposable) 6 mL 22 X 1-1/4"
  • Telmisartan Tablet 20 mg
  • Telmisartan Tablet 40 mg
  • Telmisartan Tablet 80 mg
  • Temsirolimus Solution For Intravenous Infusion 25 mg/ mL
  • Tipranavir Oral Solution 100 mg/ mL
  • Tolnaftate Aerosol Powder 1%
  • Zidovudine Intravenous Solution 10 mg/ mL

 

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)
  • 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:

 

  • Kalydeco 13.4 mg (Prior Authorization)
  • Mekinist Solution 0.05 mg/ mL (Prior Authorization)
  • Tafinlar Tablet 10 mg (Prior Authorization)
  • Trikafta Packet 59.5 mg (Prior Authorization)
  • Trikafta Packet 75 mg (Prior Authorization)

 

Removals:

 

  • None

 

Other Updates:

 

  • None

 

June 2023
 

Additions:
 

  • None

Removals:
 

  • None

Other Updates:
 

  • None

 

May 2023
 

Additions:
 

  • 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 Pfs 120 mg / mL (Add Step Therapy, Quantity Level Limit)
  • Fexofenadine Hydrochloride Suspension 30 mg / mL (Quantity Level Limit)
  • Fluticasone-Salmeterol Inhalation Powder 250-50 mcg / Actuation (Add Quantity Level Limit)
  • Fluticasone-Salmeterol Inhalation Powder 500-50 mcg / Actuation (Add Quantity Level Limit)
  • Gilenya Capsule 0.25mg (Add Prior Authorization, Quantity Level Limit)
  • Salicylic Acid Liquid 17%
  • Trikafta Tablets (Add Prior Authorization)
  • Urea Cream 20%

Removals:
 

  • *Multiple Vitamins With Minerals Liquid**
  • *Omega-3 Fatty Acids Capsule 435 mg**
  • *Pediatric Multiple Vitamin With Minerals & Vitamin C Chewable Tablet**
  • *Pediatric Multiple Vitamins With Iron Drops 10 mg/mL**
  • *Prenatal Without A With/Ferrous Fumarate-Ferrous Polysaccharide-Folic Acid Capsule 130-92.4-1 mg**
  • *Prenatal Without A With/Ferrous Fumarate-Ferrous Polysaccharide -Folic Acid Capsule 20-20-1.25 mg**
  • Acetaminophen Elixir 160 mg/ 5 mL
  • Amiloride Hydrochloride Powder
  • Calcium Carbonate Powder
  • Capsaicin Cream 0.1%
  • Carboxymethylcellulose Sodium Ophthalmic Solution 0.25%
  • Chlorhexidine Gluconate Solution 20%
  • Cholecalciferol Capsule 400 Unit
  • Cholecalciferol Chewable Wafer 50000 Unit
  • Creon Capsule
  • Diphenhydramine Hydrochloride (Sleep) Tablet 50 mg
  • Elmiron Capsules
  • Ergocalciferol Tablet 400 Unit
  • Fluocinolone Acetonide Cream 0.01%
  • Fluocinonide Emulsified Base Cream 0.05%
  • Fluticasone Propionate Lotion 0.05%
  • Gentamicin Sulfate Powder
  • Heparin Sodium Injection 20,000 Units/ mL
  • Heparin Sodium Injection 5,000 Units/ 0.5 mL
  • Lidocaine Cream 4%
  • Lidocaine Hydrochloride Solution 4%
  • Mexiletine Hydrochloride Capsule 150 mg
  • Mexiletine Hydrochloride Capsule 200 mg
  • Mexiletine Hydrochloride Capsule 250 mg
  • Niacin Tablet 50 mg
  • Niacin Tablet 250 mg
  • Niacin Tablet Controlled Release 250 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
  • Scalpicin Solution 1%
  • Sorbitol Rectal Solution 70%
  • Stiolto Inhalation Spray 2.5-2.5 mcg / Actuation
  • Triamcinolone Acetonide Ointment 0.05%

Other Updates:
 

  • Albendazole Tablet 200 mg (Add Prior Authorization, Remove Step Therapy)
  • Betamethasone Dipropionate Ointment 0.05% (Add Quantity Level Limit)
  • Enoxaparin Sodium Injection 100 mg / mL (Remove Quantity Level Limit)
  • Enoxaparin Sodium Injection 120 mg / 0.8 mL (Remove Quantity Level Limit)
  • Enoxaparin Sodium Injection 150 mg / mL (Remove Quantity Level Limit)
  • Enoxaparin Sodium Injection 30 mg / 0.3 mL (Remove Quantity Level Limit)
  • Enoxaparin Sodium Injection 40 mg / 0.4 mL (Remove Quantity Level Limit)
  • Enoxaparin Sodium Injection 60 mg / 0.6 mL (Remove Quantity Level Limit)
  • Enoxaparin Sodium Injection 80 mg / 0.8 mL (Remove Quantity Level Limit)
  • Enoxaparin Sodium Injection Solution 60 mg / 0.6 mL (Remove Quantity Level Limit)
  • Enoxaparin Sodium Injection Solution 80 mg / 0.8 mL (Remove Quantity Level Limit)
  • 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 Ointment 5% (Remove Prior Authorization)
  • Ozempic Pen-Injector
  • Trulicity Pen-Injector

 

April 2023
 

Additions:
 

  • None

Removals:
 

  • None

Other Updates:
 

  • 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)

 

March 2023
 

Additions:
 

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

Removals:
 

  • Doxycycline Capsule 150 mg
  • Fluocinolone Acetonide Powder
  • Hydrocortisone Acetate Powder
  • Hydrocortisone-Pramoxine-Chloroxylenol Lotion 10-10-1 mg/mL
  • Itraconazole Oral Solution 10 mg/mL
  • Metaproterenol Sulfate Powder
  • Triamcinolone Acetonide Powder

Other Updates:
 

  • Tobramycin Nebulizer Solution 300 mg/5 mL (Prior Authorization Required)

 

February 2023
 

Additions:
 

  • Atomoxetine Capsule 100 mg (Quantity Level Limit, Age Minimum)
  • Atomoxetine Capsule 10 mg (Quantity Level Limit, Age Minimum)
  • Atomoxetine Capsule 18 mg (Quantity Level Limit, Age Minimum)
  • Atomoxetine Capsule 25 mg (Quantity Level Limit, Age Minimum)
  • Atomoxetine Capsule 40 mg (Quantity Level Limit, Age Minimum)
  • Atomoxetine Capsule 60 mg (Quantity Level Limit, Age Minimum)
  • Atomoxetine Capsule 80 mg (Quantity Level Limit, Age Minimum)
  • Budesonide Tablet Extended-Release 9 mg
  • Buspirone Tablet 30 mg (Quantity Level Limit, Age Minimum)
  • Calcium Polycarbophil Tablet 625 mg
  • Carboxymethylcellulose-Glycerin-Polysorbate 80 Ophthalmic Solution 0.5-1-0.5%
  • 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%
  • 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)
  • Desvenlafaxine (P) Tablet 100 mg Extended Release (Quantity Level Limit)
  • Desvenlafaxine (P) Tablet 25 mg Extended Release (Quantity Level Limit)
  • Desvenlafaxine (P) Tablet 50 mg Extended Release (Quantity Level Limit)
  • Dificid Suspension (Prior Authorization Required)
  • Dificid Tablet 200 mg (Prior Authorization Required)
  • Esomeprazole Magnesium Capsule 40 mg Delayed Release (Quantity Level Limit)
  • Estradiol Vaginal Cream 0.1 mg/gm (Quantity Level Limit)
  • Ethacrynic Tablet Acid 25 mg
  • Fexofenadine Hydrochloride Tablet 180 mg (Quantity Level Limit)
  • Fexofenadine Hydrochloride Tablet 60 mg (Quantity Level Limit)
  • Fluocinolone Acetonide Oil Ear 0.01% (Quantity Level Limit)
  • Glucose Gel 40%
  • Glucose Gel 77.4%
  • Glycerin Suppository 1 gm
  • Glycerin-Hypromellose- Polyethylene Glycol 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)
  • Invega Hafyera Injection 1092 mg (Prior Authorization Required, Quantity Level Limit)
  • Invega Hafyera Injection 1560 mg (Prior Authorization Required, Quantity Level Limit)
  • Lactobacillus Acidophilus-Pectin Capsule
  • Lactobacillus Capsule
  • Lactobacillus Tablet
  • Levonorgestrel-Ethinyl Estradiol (91-Day) Tablet 0.01/0.15/0.03 mg
  • Lidocaine 5% Rectal Cream (Quantity Level Limit)
  • Magnesium Citrate Solution
  • Miconazole Nitrate Vaginal Suppository 1200 mg & 2% Cream Kit
  • Naphazoline with Pheniramine Ophthalmic Solution 0.025-0.3%
  • Naphazoline with Pheniramine Ophthalmic Solution 0.027-0.315%
  • Norethindrone Acetate & Estradiol-Ferrous 24 Tablet 1/0.02 mg (Quantity Level Limit)
  • Phenylephrine Hydrochloride Tablet 10 mg
  • Phenylephrine-Dextromethorphan-Guaifenesin Liquid 10-18-200 mg/15 mL (Quantity Level Limit)
  • Phenylephrine-Dextromethorphan-Guaifenesin Liquid 2.5-5-100 mg/5 mL (Quantity Level Limit)
  • Phenylephrine-Brompheniramine- Dextromethorphan 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
  • Pseudoephedrine- Brompheniramine- Dextromethorphan Syrup 30-2-10 mg/5 mL (Quantity Level Limit)
  • Pseudoephedrine- Dexchlorpheniramine -Chlophedianol Liquid 30-1-12.5 mg/5mL (Quantity Level Limit)
  • Pseudoephedrine Hydrochloride Tablet Extended Release 12-hour 120 mg
  • Quetiapine Tablet 150 mg Extended-Release (Quantity Level Limit, Age Minimum)
  • Quetiapine Tablet 200 mg Extended-Release (Quantity Level Limit, Age Minimum)
  • Quetiapine Tablet 300 mg Extended-Release (Quantity Level Limit, Age Minimum)
  • Quetiapine Tablet 400 mg Extended-Release (Quantity Level Limit, Age Minimum)
  • Quetiapine Tablet 50 mg Extended-Release (Quantity Level Limit, Age Minimum)
  • Rivastigmine Disc 13.3 mg/24 hour (Prior Authorization Required)
  • Rivastigmine Disc 4.6 mg/24 hour (Prior Authorization Required)
  • Rivastigmine Disc 9.5 mg/24 hour (Prior Authorization Required)
  • Saline Nasal Gel
  • Saline Nasal Solution 0.65%
  • Tetrahydrozoline Hydrochloride Ophthalmic Solution 0.05%
  • Tramadol Hydrochloride Tablet Extended Release 24-hour 100 mg (Prior Authorization Required, Quantity Level Limit, Age Minimum)
  • Tramadol Hydrochloride Tablet Extended Release 24-hour 200 mg (Prior Authorization Required, Quantity Level Limit, Age Minimum)
  • Tramadol Hydrochloride Tablet Extended Release 24-hour 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 Solution 70 mg/75 mL
  • Auryxia 210 mg Tablet
  • Benzocaine-Docusate Sodium Rectal Enema 20-283 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-Caffeine with Codeine Capsule 50-300-40-30 mg
  • Butalbital-Acetaminophen-Caffeine with Codeine Capsule 50-325-40-30 mg
  • Butalbital-Aspirin-Caffeine with Codeine Capsule 50-325-40-30 mg
  • Butalbital-Aspirin-Caffeine Capsule 50-325-40 mg
  • Celontin Capsule 300 mg
  • Cequa
  • Coal Tar Shampoo 1%
  • Coal Tar Shampoo 10%
  • Colchicine Capsule 0.6 mg
  • Dermatological Products Miscellaneous - Cream
  • Dermatological Products Miscellaneous - Lotion
  • Dermazinc Cream
  • Desmopressin Spray Ref 0.01%
  • Diltiazem Extended-Release Capsule 120 mg/12 hour
  • Diphenoxylate with Atropine Liquid 2.5-0.025 mg/5 mL
  • Duloxetine Capsule 40 mg Delayed Release
  • Esbriet 267 mg Capsule
  • Estring
  • Ibrance Tablet 100 mg
  • Ibrance Tablet 125 mg
  • Ibrance Tablet 75 mg
  • Leukine Injection 250 mcg
  • Levofloxacin Ophthalmic Solution 0.5%
  • Lidocaine Solution 4%
  • Magnesium Hydroxide Suspension Concentrate 2400 mg/10 mL
  • Methylphenidate Capsule 20 mg Long Acting
  • Methylphenidate Capsule 30 mg Long Acting
  • Methylphenidate Capsule 40 mg Long Acting
  • Methylphenidate Capsule 60 mg Long Acting
  • Naproxen Tablet Enteric Coated 500 mg
  • Neomycin-Bacitracin-Polymyxin with Lidocaine Ointment 4%
  • Orencia Intravenous Injection 250 mg
  • Oxymorphone Hydrochloride Tablet Extended Release 12-hour 10 mg
  • Oxymorphone Hydrochloride Tablet Extended Release 12-hour 15 mg
  • Oxymorphone Hydrochloride Tablet Extended Release 12-hour 20 mg
  • Oxymorphone Hydrochloride Tablet Extended Release 12-hour 30 mg
  • Oxymorphone Hydrochloride Tablet Extended Release 12-hour 40 mg
  • Oxymorphone Hydrochloride Tablet Extended Release 12-hour 5 mg
  • Oxymorphone Hydrochloride Tablet Extended Release 12-hour 7.5 mg
  • Potassium-Sodium Citrates & Citric Acid Solution 550-500-334 mg/5 mL
  • Remicade Injection 100 mg
  • Sulfacetamide Sodium Ophthalmic Ointment 10%

Other Updates:
 

  • Azelastine Hydrochloride Ophthalmic Solution 0.05% (Remove Step Therapy)
  • Bacitracin Ophthalmic Ointment 500 unit/gm (Quantity Level Limit)
  • Bacitracin-Polymyxin B Ophthalmic Ointment (Quantity Level Limit)
  • Bacitracin-Polymyxin-Neomycin-Hydrocortisone Ophthalmic Ointment 1% (Quantity Level Limit)
  • Benzonatate Capsule 100 mg
  • Benzonatate Capsule 200 mg
  • Budesonide Capsule 3 mg Delayed Release (Remove Step Therapy)
  • Calcipotriene Cream 0.005%
  • Calcipotriene Ointment 0.005%
  • Calcipotriene Solution 0.005% (50 mcg/mL)
  • Carboxymethylcellulose Sodium Ophthalmic Gel 1%
  • Celecoxib Capsule 50 mg (Remove Step Therapy)
  • Celecoxib Capsule 100 mg (Remove Step Therapy)
  • Celecoxib Capsule 200 mg (Remove Step Therapy)
  • Celecoxib Capsule 400 mg (Remove Step Therapy)
  • Divalproex Tablet 250 mg Extended Release (Remove Prior Authorization)
  • Divalproex Tablet 500 mg Extended Release (Remove Prior Authorization)
  • Dorzolamide Hydrochloride-Timolol Maleate Ophthalmic Solution 22.3-6.8 mg/mL (Remove Step Therapy)
  • Duloxetine Capsule 20 mg Delayed Release (Quantity Level Limit)
  • Erythromycin Ophthalmic Ointment 5 mg/gm (Quantity Level Limit)
  • Fentanyl Oral Transmucosal Lozenge 1200 mcg (Added Prior Authorization)
  • Fentanyl Oral Transmucosal Lozenge 1600 mcg (Added Prior Authorization)
  • Fentanyl Oral Transmucosal Lozenge 200 mcg (Added Prior Authorization)
  • Fentanyl Oral Transmucosal Lozenge 400 mcg (Added Prior Authorization)
  • Fentanyl Oral Transmucosal Lozenge 600 mcg (Added Prior Authorization)
  • Fentanyl Oral Transmucosal Lozenge 800 mcg (Added Prior Authorization)
  • Gentamicin Sulfate Ophthalmic Ointment 0.3% (Quantity Level Limit)
  • Levonorgestrel Tablet 1.5 mg (Quantity Level Limit)
  • Tolterodine Tartrate Capsule Extended Release 24-hour 2 mg (Remove Step Therapy and Prior Authorization)
  • Tolterodine Tartrate Capsule Extended Release 24-hour 4 mg (Remove Step Therapy and Prior Authorization)
  • 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:
 

  • None

Removals:
 

  • All Non OneTouch Delica and Delica Plus Lancets and Devices

Other Updates:
 

  • None

December 2022
 

Additions:
 

  • Benzoyl Peroxide Gel 2.5%

Removals:
 

  • Iodoquinol-Hydrocortisone Cream 1-1%

Other Updates:
 

  • Fingolimod Hydrochloride Capsule 0.5 mg (Base Equivalent)
  • Histex PD Drop 0.938 mg
  • Isotretinoin Capsule 10 mg
  • Isotretinoin Capsule 20 mg
  • Isotretinoin Capsule 30 mg
  • Isotretinoin Capsule 40 mg

November 2022
 

Additions:
 

  • Actimmune Injection 2 mu/0.5 (Prior Authorization Required)
  • Cromolyn Sodium Nasal Aerosol Solution 5.2 mg/Actuation (4%) (Added Quantity Level Limit)
  • Dextromethorphan Polistirex Extended-Release Suspension 30 mg/5 mL (Added Quantity Level Limit)
  • Dextromethorphan-Phenylephrine-Acetaminophen Capsule 10-5-325 mg (Added Quantity Level Limit)
  • Dimenhydrinate Tablet 50 mg (Added Quantity Level Limit)
  • Fexofenadine-Pseudoephedrine Tablet Extended Release 12-hour 60-120 mg (Added Quantity Level Limit)
  • Guaifenesin Tablet 200 mg
  • Guaifenesin Tablet 400 mg
  • Guaifenesin Tablet Extended Release 12-hour 1200 mg
  • Icosapent Capsule 0.5 gm (Prior Authorization Required, Quantity Level Limit)
  • Imbruvica Suspension 70 mg/mL (Prior Authorization Required, Quantity Level Limit)
  • Intron A Injection 10 mu (Prior Authorization Required)
  • Intron A Injection 18 mu (Prior Authorization Required)
  • Intron A Injection 50 mu (Prior Authorization Required)
  • Mineral Oil Heavy
  • Mineral Oil Light
  • Omeprazole Capsule Delayed Release 10 mg (Added Quantity Level Limit)
  • Orkambi Granules 75-94 mg (Prior Authorization Required)
  • Polyethylene Glycol-Propylene Glycol Preservative Free Ophthalmic Solution 0.4-0.3%
  • Polyvinyl Alcohol-Povidone Ophthalmic Solution 5-6 mg/mL (0.5-0.6%)
  • Pseudoephedrine Hydrochloride Tablet 30 mg
  • Pseudoephedrine-Guaifenesin Tablet Extended Release 12hr 60-600 mg
  • Refresh Ophthalmic Drops
  • Sodium Chloride Hypertonic Ophthalmic Ointment 5%
  • Sodium Fluoride Gel 1.1% (0.5% Fluoride)
  • White Petrolatum-Mineral Oil Ophthalmic Ointment

 

Removals:
 

  • Butalbital-Acetaminophen-Caffeine Capsule 50-300-40 mg
  • Butalbital-Acetaminophen-Caffeine Capsule 50-325-40 mg
  • Calcium Carbonate (Antacid) Chewable Tablet 420 mg
  • Dexamethasone Sodium Phosphate Preservative Free Injection 10 mg/mL
  • Dextromethorphan Hydrobromide Syrup 10 mg/5 mL
  • Divalproex Sodium Capsule Delayed Release Sprinkle 125 mg
  • Docusate Sodium Capsule 50 mg
  • Etodolac Tablet Extended Release 24-hour 400 mg
  • Etodolac Tablet Extended Release 24-hour 500 mg
  • Etodolac Tablet Extended Release 24-hour 600 mg
  • Fluphenazine Hydrochloride Oral Concentrate 5 mg/mL
  • Hepagam B Injection
  • Hycamtin Capsule 0.25 mg
  • Hycamtin Capsule 1 mg
  • Hyperhep B Injection
  • Ibuprofen-Diphenhydramine Citrate Tablet 200-38 mg
  • Iressa Tablet 250 mg
  • Lansoprazole Tablet Delayed Release Orally Disintegrating 15 mg
  • Lansoprazole Tablet Delayed Release Orally Disintegrating 30 mg
  • Levonorgestrel-Ethinyl Estradiol Tablet 0.1-0.02 mg (84) & Ethinyl Estradiol Tablet 0.01 mg (7)
  • Magnesium Oxide (Laxative) Tablet 500 mg
  • Magnesium Oxide Tablet 250 mg
  • Magnesium Oxide Tablet 420 mg
  • Menest Tablet 0.3 mg
  • Menest Tablet 0.625 mg
  • Menest Tablet 1.25 mg
  • Metamucil Powder Multihealth/Original
  • Mycophenolic Tablet 180mg Delayed Release
  • Mycophenolic Tablet 360mg Delayed Release
  • Nabi-Hb Injection
  • Nicotrol Inhaler 10 mg
  • Nicotrol Nasal Spray 4 x 10 mL
  • Nilutamide Tablet 150 mg
  • Nozin Nasal Kit Sanitize
  • Nozin Nasal Mis Sanitize
  • Olanzapine-Fluoxetine Hydrochloride Capsule 12-25 mg
  • Olanzapine-Fluoxetine Hydrochloride Capsule 12-50 mg
  • Olanzapine-Fluoxetine Hydrochloride Capsule 3-25 mg
  • Olanzapine-Fluoxetine Hydrochloride Capsule 6-25 mg
  • Olanzapine-Fluoxetine Hydrochloride Capsule 6-50 mg
  • Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 10 mg
  • Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 15 mg
  • Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 20 mg
  • Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 30 mg
  • Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 40 mg
  • Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 60 mg
  • Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 80 mg
  • Paroxetine Hydrochloride Oral Suspension 10 mg/5 mL (Base Equivalent)
  • Phenylephrine-Shark Liver Oil-Cocoa Butter Suppository 0.25-3-85.5%
  • Prednisolone Sodium Phosphate Orally Disintegrating Tablet 10 mg (Base Equivalent)
  • Prednisolone Sodium Phosphate Orally Disintegrating Tablet 15 mg (Base Equivalent)
  • Prednisolone Sodium Phosphate Orally Disintegrating Tablet 30 mg (Base Equivalent)
  • Prefest Tablet
  • Prilosec Powder 10 mg
  • Prilosec Powder 2.5 mg
  • Psyllium Powder 100%
  • Psyllium Powder 95%
  • Rufinamide Suspension 40 mg/mL
  • Sennosides Tablet 17.2 mg
  • Sodium Phosphates - Enema (Pediatric)
  • Somatuline Injection 120 mg/0.5 mL
  • Somatuline Injection 60 mg/0.2 mL
  • Somatuline Injection 90 mg/0.3 mL
  • Sucralfate Suspension 1 gm/10 mL
  • Zoladex Implant 10.8 mg
  • Zoladex Implant 3.6 mg
  • Zolinza Capsule 100 mg

Other Updates:
 

  • Aprepitant Capsule 125 mg (Added Quantity Level Limit)
  • Aprepitant Capsule 40 mg (Added Quantity Level Limit)
  • Artificial Tears Solution
  • Aspirin Suppository 300 mg
  • Atropine Sulfate Ophthalmic Ointment 1%
  • Codeine Sulfate Tablet 15 mg (Added Quantity Level Limit and Age Minimum)
  • Codeine Sulfate Tablet 60 mg (Added Quantity Level Limit and Age Minimum)
  • Dextromethorphan-Guaifenesin Tablet Extended Release 12-hour 60-1200 mg
  • Feverall Sup 325 mg
  • Hydromorphone Suppository 3 mg (Added Quantity Level Limit)
  • Lohist-Dextromethorphan Syrup 5-2-10 mg
  • Lubricant Drops Eye 0.6%
  • Lubricating Drops 0.5%
  • Tusnel C Syrup (Added Quantity Level Limit and Age Minimum)

 

October 2022
 

Additions:
 

  • None

Removals:
 

  • None

Other Updates:
 

  • Lenalidomide Capsule 2.5 mg
  • Lenalidomide Capsule 5 mg
  • Lenalidomide Capsule 10 mg
  • Lenalidomide Capsule 15 mg
  • Lenalidomide Capsule 20 mg
  • Lenalidomide Capsule 25 mg
  • Varenicline Tartrate Tablet 0.5 mg X 11 & Tablet 1 mg X 42 Pack

September 2022

Additions:
 

  • Phospho-Trin K500 Tablet

Removals:
 

  • Hypersal Nebulization Solution 3.5 % 

Other Updates:
 

  • K-Phos Tablet 500 mg (Brand)

 

August 2022
 

Additions:
 

  • Bicillin L-A Suspension 2400000 Unit/4mL
  • Calamine Lotion (Quantity Level Limit)
  • Calamine-Zinc Oxide Lotion 8-8%
  • Doxycycline Monohydrate Tablet 100mg
  • Eplerenone Tablet 25 mg
  • Eplerenone Tablet 50 mg
  • Fenofibrate Tablet 145 mg
  • Fenofibrate Tablet 48 mg
  • Fluocinonide Cream 0.1%
  • Glucagon Emergency Solution Kit 1 mg/mL (Quantity Level Limit)
  • Hydrocortisone Acetate Ointment 1% (Quantity Level Limit)
  • Ivermectin Lotion 0.5% (Quantity Level Limit, Step Therapy)
  • Metronidazole Gel 1% (Quantity Level Limit, Step Therapy)
  • Olmesartan Medoxomil Tablet 20 mg (Quantity Level Limit)
  • Olmesartan Medoxomil Tablet 40 mg (Quantity Level Limit)
  • Olmesartan Medoxomil Tablet 5 mg (Quantity Level Limit)
  • Olopatadine Hydrochloride Ophthalmic Solution 0.2% (Over the Counter)
  • OneTouch Ultra 2 Kit with Device
  • OneTouch Verio Flex System Kit with Device
  • OneTouch Verio Reflect Kit with Device
  • Pataday Solution 0.7% Ophthalmic
  • Permethrin Liquid 1%
  • Selenium Sulfide Shampoo 1%
  • Symjepi Solution Prefilled Syringe 0.15 mg/0.3 mL (Quantity Level Limit)
  • Symjepi Solution Prefilled Syringe 0.3 mg/0.3 mL (Quantity Level Limit)
  • Tetrabenazine Tablet 12.5 mg (Prior Authorization Required, Quantity Level Limit)
  • Triamcinolone Acetonide Ointment 0.05% (Quantity Level Limit)
  • Triprolidine Hydrochloride Drops 0.938 mg/mL
  • Triprolidine Hydrochloride Liquid 0.625 mg/mL (Pediaclear PD Liquid)
  • Voriconazole Tablet 200 mg (Prior Authorization Required)
  • Voriconazole Tablet 50 mg (Prior Authorization Required)

Removals:
 

  • Adapalene Cream 0.1%
  • Amcinonide Ointment 0.1%
  • Amiodarone Hydrochloride Tablet 100 mg
  • Amiodarone Hydrochloride Tablet 400 mg
  • Amlodipine Besylate-Atorvastatin Calcium Tablet 10-10 mg
  • Amlodipine Besylate-Atorvastatin Calcium Tablet 10-20 mg
  • Amlodipine Besylate-Atorvastatin Calcium Tablet 10-40 mg
  • Amlodipine Besylate-Atorvastatin Calcium Tablet 10-80 mg
  • Amlodipine Besylate-Atorvastatin Calcium Tablet 2.5-10 mg
  • Amlodipine Besylate-Atorvastatin Calcium Tablet 2.5-20 mg
  • Amlodipine Besylate-Atorvastatin Calcium Tablet 2.5-40 mg
  • Amlodipine Besylate-Atorvastatin Calcium Tablet 5-10 mg
  • Amlodipine Besylate-Atorvastatin Calcium Tablet 5-20 mg
  • Amlodipine Besylate-Atorvastatin Calcium Tablet 5-40 mg
  • Amlodipine Besylate-Atorvastatin Calcium Tablet 5-80 mg
  • Amoxicillin & Potassium Clavulanate Tablet Extended Release 12-hour 1000-62.5 mg
  • Baraclude Solution 0.05 mg/mL
  • Benzoyl Peroxide Wash Liquid 2.5%
  • Capzasin-P Cream 0.035%
  • Carbinoxamine Maleate Solution 4 mg/5 mL
  • Carbinoxamine Maleate Tablet 4 mg
  • Cefaclor Capsule 250 mg
  • Cefaclor Capsule 500 mg
  • Cefpodoxime Proxetil For Suspension 100 mg/5 mL
  • Cefpodoxime Proxetil For Suspension 50 mg/5 mL
  • Clemastine Fumarate Tablet 12-Hour 1.34 mg
  • Colesevelam Hydrochloride Packet 3.75 gm 
  • Diltiazem Hydrochloride Extended-Release Capsule Extended Release 12-Hour 60 mg
  • Diltiazem Hydrochloride Extended-Release Capsule Extended Release 12-Hour 90 mg
  • Diphenhydramine Dispersible Tablet 12.5 mg
  • Diphenhydramine Hydrochloride Tablet Chewable 12.5 mg
  • Doxycycline Monohydrate Capsule 150 mg
  • Erythromycin Ethylsuccinate for Suspension 200 mg/5 mL
  • Erythromycin Ethylsuccinate for Suspension 400 mg/5 mL
  • Fexofenadine Hydrochloride Childrens Suspension 30mg/5 mL
  • Flunisolide Nasal Spray 25 mcg/Actuation (0.025%)
  • Fluvastatin Sodium Tablet Extended Release 24-hour 80 mg (Base Equivalent)
  • Glucagen Hypokit Solution Reconstituted 1 mg
  • Isradipine Capsule 2.5 mg
  • Isradipine Capsule 5 mg
  • Lidocaine Hydrochloride Urethral/Mucosal Gel 2%
  • Lidocaine-Prilocaine Kit 2.5-2.5%
  • Memantine Hydrochloride Oral Solution 2 mg/mL
  • Memantine Hydrochloride Tablet 28 X 5 mg & 21 X 10 mg Titration Pack
  • Methazolamide Tablet 25 mg
  • Methazolamide Tablet 50 mg
  • Metronidazole Capsule 375 mg
  • Nicardipine Capsule 20 mg
  • Nicardipine Capsule 30 mg
  • Nitazoxanide Tablet 500 mg
  • OneTouch Kit Ultra Mini
  • OneTouch Solutions Starter Kit with Well Device
  • Perindopril Erbumine Tablet 2 mg
  • Perindopril Erbumine Tablet 4 mg
  • Perindopril Erbumine Tablet 8 mg
  • Propafenone Capsule Extended Release 12-Hour 325 mg
  • Propafenone Capsule Extended Release 12-Hour 425 mg
  • Propafenone Hydrochloride Extended-Release Capsule Extended Release 12-Hour 225 mg
  • Proxivol Gel 2%
  • Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4%
  • Rivastigmine Patch 24 Hour 13.3 mg/24 hour
  • Rivastigmine Patch 24 Hour 4.6 mg/24 hour
  • Rivastigmine Patch 24 Hour 9.5 mg/24 hour
  • Salicylic Acid Shampoo 6%
  • Santyl Ointment 250 unit/gm
  • Selenium Sulfide Shampoo 2.25%
  • Sulfacetamide Sodium Liquid Wash 10%
  • Vancomycin + Syrspen Sf Hydrochloride Oral Suspension 50 mg/mL (Compound Kit)
  • Vancomycin Hydrochloride for Intravenous Solution 1 gm (Base Equivalent)
  • Vancomycin Hydrochloride for Intravenous Solution 10 gm (Base Equivalent)
  • Vancomycin Hydrochloride for Intravenous Solution 5 gm (Base Equivalent)
  • Vancomycin Hydrochloride for Intravenous Solution 500 mg (Base Equivalent)
  • Vancomycin Hydrochloride Intravenous Solution 1250 mg/250 mL (Base Equivalent)
  • Vancomycin Hydrochloride Intravenous Solution 1750 mg/350 mL (Base Equivalent)
  • Vancomycin Hydrochloride Intravenous Solution 750 mg/150 mL (Base Equivalent)
  • Vemlidy Tablet 25 mg
  • Zafirlukast Tablet 10 mg
  • Zafirlukast Tablet 20 mg

Other Updates:
 

  • Acyclovir Capsule 200 mg (Removed Quantity Level Limit)
  • Acyclovir Tablet 400 mg (Removed Quantity Level Limit)
  • Acyclovir Tablet 800 mg (Removed Quantity Level Limit)
  • Austedo Tablet 12 mg (Added Quantity Level Limit)
  • Austedo Tablet 6 mg (Added Quantity Level Limit)
  • Austedo Tablet 9 mg (Added Quantity Level Limit)
  • Ceftriaxone Sodium for Injection 1 gm (Changed Quantity Level Limit)
  • Ceftriaxone Sodium for Injection 2 gm (Changed Quantity Level Limit)
  • Ceftriaxone Sodium for Injection 250 mg (Changed Quantity Level Limit)
  • Ceftriaxone Sodium for Injection 500 mg (Changed Quantity Level Limit)
  • Ezetimibe Tablet 10 mg (Removed Step Therapy)
  • Glucagon Emergency Kit 1 mg Injection (Changed Quantity Level Limit)
  • Gvoke Hypopen Solution Auto-Injector 0.5 mg/0.1 mL (Changed Quantity Level Limit)
  • Gvoke Hypopen Solution Auto-Injector 1 mg/0.2 mL (Changed Quantity Level Limit)
  • Gvoke PFS Solution Prefilled Syringe 0.5 mg/0.1 mL (Changed Quantity Level Limit)
  • Gvoke PFS Solution Prefilled Syringe 1 mg/0.2 mL (Changed Quantity Level Limit)
  • Olopatadine Hydrochloride Ophthalmic Solution 0.1% (Over the Counter) (Removed Step Therapy)
  • Omega-3-Acid Ethyl Esters Capsule 1 gm (Removed Step Therapy)
  • Valacyclovir Hydrochloride Tablet 1 gm (Removed Quantity Level Limit)
  • Valacyclovir Hydrochloride Tablet 500 mg (Removed Quantity Level Limit)

 

July 2022
 

Additions:
 

  • None

Removals:
 

  • None

Other Updates:
 

  • None

 

June 2022
 

Additions:
 

  • Epivir HBV Solution 5 mg/mL (Quantity Level Limit)
  • Gvoke Hypopen 1-Pack 0.5 mg/0.1 mL (Quantity Level Limit)
  • Gvoke PFS Prefilled Syringe Injection 1 mg/0.2 mL (Quantity Level Limit)
  • Lamivudine Tablet 100 mg (Quantity Level Limit)
  • Pregabalin Capsule 200 mg (Prior Authorization Required, Quantity Level Limit)

Removals:
 

  • None

Other Updates:
 

  • None

 

May 2022
 

Additions:
 

  • Ozempic (2 mg/Dose) 8 mg/3 mL (Quantity Level Limit, Step Therapy)
  • Triumeq PD Tablet 60-5-30 mg (Prior Authorization Required, Quantity Level Limit)

Removals:
 

  • None

Other Updates:
 

  • None

 

April 2022
 

Additions:
 

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

Removals:
 

  • None

Other Updates:
 

  • None

 

March 2022
 

Additions:
 

  • Brimonidine Tartrate-Timolol Maleate Ophthalmic Solution 0.2-0.5% (Quantity Level Limit, Step Therapy)
  • Maraviroc Tablet 150 mg
  • Maraviroc Tablet 300 mg
  • Systane Gel Drop 0.4-0.3%

Removals:
 

  • Combigan Ophthalmic Solution 0.2-0.5%
  • Dry Eye Relief Drops 0.4-0.3%
  • Selzentry Tablet 150 mg
  • Selzentry Tablet 300 mg

Other Updates:
 

  • None

 

February 2022
 

Additions:
 

  • Dexcom G5 Mobile Receiver Kit (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G5 Mobile Transmitter Kit (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G5 Mobile/G4 Platinum Sensor Kit (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G6 Receiver (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 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)
  • Freestyle Libre Reader Device (Prior Authorization Required, Quantity Level Limit)
  • Freestyle Libre Sensor System (Prior Authorization Required, Quantity Level Limit)
  • Levocetirizine Tablet 5 mg (Quantity Level Limit)
  • Naloxone Nasal Liquid 4 mg/0.1 mL (generic)
  • Norditropin Flexpro Injection 10 mg/1.5 mL (Prior Authorization Required)
  • Norditropin Flexpro Injection 15 mg/1.5 mL (Prior Authorization Required)
  • Norditropin Flexpro Injection 30 mg/3 mL (Prior Authorization Required)
  • Norditropin Flexpro Injection 5 mg/1.5 mL (Prior Authorization Required)
  • Ziextenzo (Prior Authorization Required)

Removals:
 

  • Diphenhydramine Elixir 12.5 mg/5 mL
  • Estradiol Vaginal Cream 0.1 mg/gm
  • Felbamate Suspension 600 mg/5 mL
  • Felbamate Tablet 400 mg
  • Felbamate Tablet 600 mg
  • Megestrol Suspension 625 mg/5 mL
  • Omnitrope Injection 5.8 mg
  • Udenyca Injection 6 mg/0.6 mL

Other Updates:
 

  • Diphenhydramine Hydrochloride Liquid 12.5 mg/5 mL (Added Quantity Level Limit)
  • Eliquis Deep Vein Thrombosis/Pulmonary Embolism Starter Pack Tablet 5 mg (Removed Prior Authorization Required)
  • Eliquis Tablet 2.5 mg (Removed Prior Authorization Required)
  • Eliquis Tablet 5 mg (Removed Prior Authorization Required)
  • Promethazine Hydrochloride Syrup 6.25 mg/5 mL (Added Quantity Level Limit)
  • Xarelto 10 mg (Removed Prior Authorization Required)
  • Xarelto 15 mg (Removed Prior Authorization Required)
  • Xarelto 20 mg (Removed Prior Authorization Required)
  • Xarelto Starter Pack 15/20 mg (Removed Prior Authorization Required)

 

January 2022
 

Additions:
 

  • Etravirine Tablet 100 mg (Prior Authorization Required)
  • Etravirine Tablet 200 mg (Prior Authorization Required)
  • Gvoke Kit Solution 1 mg/0.2 mL (Quantity Level Limit)

Removals:
 

  • Intelence Tablet 100 mg
  • Intelence Tablet 200 mg

Other Updates:
 

  • None

December 2021
 

Additions:
 

  • Esomeprazole Tablet Delayed Release 20 mg
  • Everolimus Tablet 10 mg (Prior Authorization Required)
  • Insulin Glargine-YFGN Solution Vial 100 unit/mL
  • Insulin Glargine-YFGN Solution Pen-Injector 100 unit/mL
  • Lopinavir-Ritonavir Tablet 100-25 mg (Prior Authorization Required)
  • Lopinavir-Ritonavir Tablet 200-25 mg (Prior Authorization Required)
  • Mavyret Packet 50-20 mg (Prior Authorization Required)

Removals:
 

  • Afinitor Tablet 10 mg
  • Kaletra Tablet 100-25 mg
  • Kaletra Tablet 200-25 mg
  • Semglee Pen-Injector 100 unit/mL
  • Semglee Vial (Solution) 100 unit/mL

Other Updates:
 

  • None

 

November 2021
 

Additions:
 

  • None

Removals:
 

  • None

Other Updates:
 

  • None

 

October 2021
 

Additions:
 

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

Removals:
 

  • Sutent Capsule 12.5 mg (Brand)
  • Sutent Capsule 25 mg (Brand)
  • Sutent Capsule 37.5 mg (Brand)
  • Sutent Capsule 50 mg (Brand)

Other Updates:
 

  • None

 

September 2021
 

Additions:
 

  • None

Removals:
 

  • None

Other Updates:
 

  • None

 

August 2021
 

Additions:
 

  • Baqsimi Powder 3 mg/Dose (Quantity Level Limit)
  • Endari Powder 5 gm (Prior Authorization Required)
  • Inlyta Tablet 1 mg (Prior Authorization Required, Quantity Level Limit)
  • Inlyta Tablet 5 mg (Prior Authorization Required, Quantity Level Limit)
  • Nayzilam Spray 5 mg (Prior Authorization Required, Quantity Level Limit)
  • Pregabalin Capsule 100 mg (Prior Authorization Required, Quantity Level Limit)
  • Pregabalin Capsule 150 mg (Prior Authorization Required, Quantity Level Limit)
  • Pregabalin Capsule 225 mg (Prior Authorization Required, Quantity Level Limit)
  • Pregabalin Capsule 25 mg (Prior Authorization Required, Quantity Level Limit)
  • Pregabalin Capsule 300 mg (Prior Authorization Required, Quantity Level Limit)
  • Pregabalin Capsule 50 mg (Prior Authorization Required, Quantity Level Limit)
  • Pregabalin Capsule 75 mg (Prior Authorization Required, Quantity Level Limit)
  • Prolia Solution (Prior Authorization Required, Quantity Level Limit)
  • Semglee Injection 100-Unit Pen-Injector
  • Semglee Injection 100-Unit Vial Solution
  • Sofosbuvir-Velpatasvir Tablet 400-100 mg (Prior Authorization Required, Quantity Level Limit)

Removals:
 

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

Other Updates:
 

  • None

 

July 2021
 

Additions:
 

  • None

Removals:
 

  • None

Other Updates:
 

  • None

 

June 2021
 

Additions:
 

  • None

Removals:
 

  • Linzess Capsule 72 mcg
  • Linzess Capsule 145 mcg
  • Linzess Capsule 290 mcg

Other Updates:
 

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

 

May 2021
 

Additions:
 

  • None

Removals:
 

  • None

Other Updates:
 

  • None

 

April 2021
 

Additions:
 

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

 

March 2021
 

Additions:
 

  • Bevespi Aerosphere 9-4.8 mcg (Quantity Level Limit)
  • Cequa Solution 0.09% Preservative Free (Prior Authorization Required)
  • Doxycycline Hyclate Capsule 100 mg
  • Doxycycline Hyclate Capsule 50 mg
  • Doxycycline Hyclate Tablet 100 mg
  • Esbriet Capsule 267 mg (Prior Authorization Required)
  • Esbriet Tablet 267 mg (Prior Authorization Required)
  • Esbriet Tablet 801 mg (Prior Authorization Required)
  • Fluticasone/Salmeterol Aerosol 100 mcg/50 mcg (Age Level Limit, Quantity Level Limit)
  • Hizentra Injection 1 gm/5 mL (Prior Authorization Required)
  • Hizentra Injection 2 gm/10 mL (Prior Authorization Required)
  • Hizentra Injection 2 gm/10 mL (Prior Authorization Required)
  • Hizentra Injection 4 gm/20 mL (Prior Authorization Required)
  • Hizentra Solution 20% (Prior Authorization Required)
  • Hizentra Vial 10 gm/50 mL (Prior Authorization Required)
  • Hizentra Vial 1 gm/5 mL (Prior Authorization Required)
  • Icosapent Capsule 1 gm (Prior Authorization Required, Quantity Level Limit)
  • Myleran Tablet 2 mg
  • Ocrevus Injection 300 mg/10 mL (Prior Authorization Required, Quantity Level Limit)
  • Potassium-Sodium Citrates & Citric Acid Solution 550-500-334 mg/5 mL
  • Privigen Injection 40 gm (Prior Authorization Required)
  • Rabeprazole Tablet 20 mg (Quantity Level Limit)
  • Sodium Citrate & Citric Acid Solution 500-334 mg/5 mL
  • Trulicity Injection 0.75 mg/0.5 mL (Step Therapy Required)
  • Trulicity Injection 1.5 mg/0.5 mL (Step Therapy Required)
  • Trulicity Injection 3 mg/0.5 mL (Step Therapy Required)
  • Trulicity Injection 4.5 mg/0.5 mL (Step Therapy Required)
  • Tukysa Tablet 150 mg (Prior Authorization Required)
  • Tukysa Tablet 50 mg (Prior Authorization Required)
  • Valtoco Liquid 15 mg (Quantity Level Limit)
  • Valtoco Liquid 20 mg (Quantity Level Limit)
  • Valtoco Spray 10 mg (Quantity Level Limit)
  • Valtoco Spray 5 mg (Quantity Level Limit)
  • Visco-3 Injection 25/2.5 mL (Prior Authorization Required)

Removals:
 

  • Anoro Ellipta Aerosolizer 62.5-25 mcg
  • Atrovent HFA Aerosol 17 mcg
  • Breo Ellipta Inhaler 100-25 mcg
  • Breo Ellipta Inhaler 200-25 mcg
  • Cefaclor for Suspension 125 mg/5 mL
  • Cefaclor for Suspension 250 mg/5 mL
  • Cefaclor for Suspension 375 mg/5 mL
  • Clarithromycin Tablet Extended Release 24-hour 500 mg
  • Combivent Aerosol 20 mcg-100 mcg
  • Diazepam Concentrate 5 mg/mL
  • Doxycycline Monohydrate Tablet 100 mg
  • Doxycycline Monohydrate Tablet 150 mg
  • Doxycycline Monohydrate Tablet 50 mg
  • Doxycycline Monohydrate Tablet 75 mg
  • Epogen Injection 10000 units/mL
  • Epogen Injection 2000 units/mL
  • Epogen Injection 20000 units/mL
  • Epogen Injection 3000 units/mL
  • Epogen Injection 4000 units/mL
  • Flebogamma Injection 10 gm/200 mL
  • Flebogamma Injection Dif 5%
  • Fulphila Injection 6 mg/0.6 mL
  • Hyalgan Injection 20 mg/2 mL
  • Hyoscyamine Drops 0.125 mg/mL
  • Janumet Tablet 50-1000 mg
  • Janumet Tablet 50-500 mg
  • Janumet Extended-Release Tablet 100-1000 mg
  • Janumet Extended-Release Tablet 50-1000 mg
  • Janumet Extended-Release Tablet 50-500 mg
  • Januvia Tablet 100 mg
  • Januvia Tablet 25 mg
  • Januvia Tablet 50 mg
  • Nivestym Injection 300 mcg/0.5 ml
  • Nivestym Injection 300 mcg
  • Nivestym Injection 480 mcg/0.8 ml
  • Nivestym Injection 480 mcg
  • Ofev Capsule 100 mg
  • Ofev Capsule 150 mg
  • Verzenio Tablet 100 mg
  • Verzenio Tablet 150 mg
  • Verzenio Tablet 200 mg
  • Verzenio Tablet 50 mg
  • Victoza Injection 18 mg/3 mL

Other Updates:
 

  • Albuterol Aerosol HFA (Added Quantity Level Limit)
  • Arnuity Ellipta Inhaler 100 mcg (Added Quantity Level Limit)
  • Arnuity Ellipta Inhaler 200 mcg (Added Quantity Level Limit)
  • Arnuity Ellipta Inhaler 50 mcg (Added Quantity Level Limit)
  • Azithromycin Suspension 100 mg/5 mL (Added Age Limit)
  • Azithromycin Suspension 200 mg/5 mL (Added Age Limit)
  • Cefadroxil Suspension 250 mg/5 mL (Added Age Limit)
  • Cefadroxil Suspension 500 mg/5 mL (Added Age Limit)
  • Cefdinir Suspension 125 mg/5 mL (Added Age Limit)
  • Cefdinir Suspension 250 mg/5 mL (Added Age Limit)
  • Cefpodoxime Proxetil Suspension 100 mg/5 mL (Added Age Limit)
  • Cefpodoxime Proxetil Suspension 50 mg/5 mL (Added Age Limit)
  • Cefprozil Suspension 125 mg/5 mL (Added Age Limit)
  • Cefprozil Suspension 250 mg/5 mL (Added Age Limit)
  • Cephalexin Suspension 125 mg/5 mL (Added Age Limit)
  • Cephalexin Suspension 250 mg/5 mL (Added Age Limit)
  • Clarithromycin Suspension 125 mg/5 mL (Added Age Limit)
  • Clarithromycin Suspension 250 mg/5 mL (Added Age Limit)
  • Extavia Injection 0.3 mg (Added Quantity Level Limit)
  • Gilenya Capsule 0.5 mg (Added Quantity Level Limit)
  • Glatiramer Injection 20 mg/mL (Added Quantity Level Limit)
  • Glatiramer Injection 40 mg/mL (Added Quantity Level Limit)
  • Juluca Tablet 50-25 mg (Added Prior Authorization)
  • Levalbuterol Aerosol 45 mcg/Actuation (Added Quantity Level Limit)
  • Levofloxacin Solution 25 mg/mL (Added Age Limit)
  • Neomycin-Polymyxin-Dexamethasone Ophthalmic Ointment 0.1% (Added Quantity Level Limit)
  • Ondansetron Tablet Dispersible 4 mg Oral (Added Quantity Level Limit)
  • Ondansetron Tablet Dispersible 8 mg Oral (Added Quantity Level Limit)
  • Phenylephrine Hydrochloride Ophthalmic Solution 2.5% (Added Quantity Level Limit)
  • Rebif Injection 22 mcg/0.5 mL (Added Quantity Level Limit)
  • Rebif Injection 44 mcg/0.5 mL (Added Quantity Level Limit)
  • Rebif Rebidose Injection 22 mcg/0.5 mL (Added Quantity Level Limit)
  • Rebif Rebidose Injection 44 mcg/0.5 mL (Added Quantity Level Limit)
  • Rebif Rebidose Injection Titration (Added Quantity Level Limit)
  • Rebif Titration Injection Pack (Added Quantity Level Limit)
  • Santyl Ointment 250 unit/gm (Added Quantity Level Limit)

 

February 2021
 

Additions:
 

  • None

Removals:
 

  • None

Other Updates:
 

  • None

 

January 2021
 

Additions:
 

  • Retacrit Injection 20000 units (Prior Authorization Required)

Removals:
 

  • None

Other Updates:
 

  • None

December 2020
 

Additions:
 

  • Trelegy Ellipta 200-62.5-25 mcg/Inhaler (Quality Level Limit, Step Therapy Required)

Removals:
 

  • None

Other Updates:
 

  • None

 

November 2020
 

Additions:
 

  • Dimethyl Fumarate Capsule 120 mg Delayed Release (Quantity Level Limit, Prior Authorization Required)
  • Dimethyl Fumarate Capsule 240 mg Delayed Release (Quantity Level Limit, Prior Authorization Required)
  • Dimethyl Fumarate Capsule Delayed Release Starter Pack 120 mg & 240 mg (Quantity Level Limit, Prior Authorization Required)
  • Emtricitabine Capsule 200 mg (Prior Authorization Required)

Removals:
 

  • Emtriva Capsule 200 mg
  • Tecfidera Capsule 120 mg Delayed Release
  • Tecfidera Capsule 240 mg Delayed Release
  • Tecfidera Capsule Delayed Release Starter Pack 120 mg & 240 mg

Other Updates:
 

  • None

October 2020

Additions:
 

  • Efavirenz-Lamivudine-Tenofovir Disoproxil Fumarate Tablet 400-300-300 mg
  • Efavirenz-Lamivudine-Tenofovir Disoproxil Fumarate Tablet 600-300-300 mg

Removals:
 

  • Symfi Lo Tablet 400-300-300 mg
  • Symfi Tablet 600-300-300 mg

Other Updates:
 

  • None

 

Septmeber 2020
 

Additions:
 

  • Abiraterone Tablet 250 mg (Prior Authorization Required)
  • Alecensa Capsule 150 mg (Prior Authorization Required)
  • Austedo Tablet 5 mg, 9 mg, 12 mg (Prior Authorization Required)
  • Budesonide Capsule 3 mg (Step Therapy Required, Quantity Level Limit)
  • Caprelsa Tablet 100 mg, 300 mg (Prior Authorization Required)
  • Cinacalcet Tablet 30 mg, 60 mg, 90 mg (Prior Authorization Required)
  • Cyclophosphamide Capsule 25 mg, 50 mg
  • Enbrel Injection 25 mg (Prior Authorization Required, Quantity Level Limit)
  • Erivedge Capsule 150 mg (Prior Authorization Required)
  • Gilotrif Tablet 20 mg, 30 mg, 40 mg (Prior Authorization Required)
  • Jakafi Tablet 5 mg, 10 mg, 15 mg, 20 mg, 25 mg (Prior Authorization Required)
  • Kalydeco Pak 25 mg, 50 mg, 75 mg (Prior Authorization Required)
  • Kalydeco Tablet 150 mg (Prior Authorization Required)
  • Lenvima Capsule 4 mg, 8 mg, 10 mg, 12 mg, 14 mg, 18 mg, 20 mg, 24 mg (Prior Authorization Required)
  • Linezolid Tablet 600 mg (Prior Authorization Required)
  • Mekinist Tablet 0.5 mg, 2 mg (Prior Authorization Required)
  • Ofev Capsule 100 mg, 150 mg (Prior Authorization Required)
  • Repatha Injection 140 mg/mL, 420 mg/3.5 mL (Prior Authorization Required)
  • Rydapt Capsule 25 mg (Prior Authorization Required)
  • Symdeko Tablet 50-75 mg, 100-150 mg (Prior Authorization Required)
  • Tafinlar Capsule 50 mg, 75 mg (Prior Authorization Required)
  • Venclexta Start Pack (Prior Authorization Required)
  • Venclexta Tablet 10 mg, 50 mg, 100 mg (Prior Authorization Required)
  • Xolair Injection 75 mg/0.5 mL, 150 mg/mL (Prior Authorization Required)
  • Zykadia Capsule 150 mg (Prior Authorization Required)

Removals:
 

  • None

Other Updates:
 

  • Soliris Injection 10 mg/mL (Prior Authorization Required)
  • Proton Pump Inhibitors (Quantity Level Limit)

 

August 2020
 

Additions:
 

  • Amitiza Capsule 8 mcg, 24 mcg (Prior Authorization Required, Quantity Level Limit)
  • Buprenorphine Weekly Patch 5 mcg, 7.5 mcg, 10 mcg, 15 mcg, 20 mcg (Prior Authorization Required, Quantity Level Limit)
  • Diclofenac Sodium Solution 1.5% (Step Therapy, Quantity Level Limit)
  • Ibrance Capsule 75 mg, 100 mg, 125 mg (Prior Authorization Required, Quantity Level Limit)
  • Lynparza Tablet 10 mg, 15 mg (Prior Authorization Required, Quantity Level Limit)
  • Omeprazole Over the Counter Tablet 20 mg (Generic)
  • Poly-Vi-Sol Solution 50 mg/mL
  • Solifenacin Succinate Tablet 5 mg, 10 mg (Step Therapy, Quantity Level Limit)
  • Symproic Tablet 0.2 mg (Prior Authorization Required, Quantity Level Limit)
  • Testosterone Transdermal Solution 30mg/Actuation (Prior Authorization Required, Quantity Level Limit)
  • Tivicay PD Tablet 5 mg (Diagnosis Confirmation Required, Age Limit)
  • Trelegy Ellipta (Step Therapy, Quantity Level Limit)
  • Tri-Vi-Sol Solution A/C/D

Removals:
 

  • Cimduo Tablet 300-300 mg
  • Fluocinolone Acetonide Solution 0.01%
  • Fluorouracil Cream 0.5%
  • Humulin 70/30
  • Humulin N
  • Humulin R
  • Kitabis Nebule Solution 300 mg/5 mL
  • Naproxen Sodium Tablet 275 mg
  • Nimodipine Capsule 30 mg
  • Prilosec Over the Counter Tablet 20 mg (Brand)
  • Targretin Gel 1%
  • Tolmetin Sodium Capsule 400 mg
  • Tolmetin Sodium Tablet 200 mg, 600 mg

Other Updates:
 

  • Adapalene Gel 0.1% (Removed Step Therapy from Prescription Product)
  • Athletes Foot (Miconazole Nitrate) Powder 2% (Quantity Level Limit)
  • Auryxia Tablet 210 mg (Step Therapy Required)
  • Betamethasone Dipropionate Augmented 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 Hydrochloride Cream 1% (Quantity Level Limit)
  • Candesartan Cilexetil–Hydrochlorothiazide Tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg (Step Therapy Required)
  • Candesartan Cilexetil Tablet 4 mg, 8 mg, 16 mg, 32 mg (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 Hydrochloride 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)
  • Disulfiram Tablet 250 mg, 500 mg (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)
  • Flunisolide Nasal Solution 25 mcg/Actuation (Step Therapy Required)
  • Fluocinonide Cream 0.05% (Quantity Level Limit)
  • Fluocinonide Solution 0.05% (Quantity Level Limit)
  • Fluvastatin Sodium Capsule 20 mg, 40 mg (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 Capsule 72 mcg, 145 mcg, 290 mcg (Prior Authorization Required)
  • Liothyronine Sodium Tablet 25 mcg (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)
  • Naltrexone Tablet 50mg (Quantity Level Limit)
  • Neomycin-Polymyxin-Hydrocortisone Otic Solution 1% (Quantity Level Limit)
  • Neomycin-Polymyxin-Hydrocortisone Otic Suspension 3.5 mg/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 Tablet 2 mg, 4 mg, 8 mg, 6 mg, 12 mg (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)
  • Terbinafine Hydrochloride Cream 1% (Quantity Level Limit)
  • Testosterone Gel 1.62% (Prior Authorization Required, Quantity Level Limit)
  • Tolnaftate Cream 1% (Quantity Level Limit)
  • Triamcinolone Acetonide Cream 0.025%, 0.1%, 0.5% (Quantity Level Limit)
  • Triamcinolone Acetonide Lotion 0.0.25%, 0.1% (Quantity Level Limit)
  • Triamcinolone Acetonide Ointment 0.025%, 0.05% (Quantity Level Limit)

 

July 2020
 

Additions:
 

  • Gvoke PFS Pre Filled Syringe Injection 0.5 mg/0.1 mL (Quantity Level Limit)
  • HM Urinary Pain Relief (Phenazopyridine) Tablet 99.5 mg

 

June 2020
 

Additions:
 

  • Acne Medication Lotion (Benzoyl Peroxide) 10%
  • Alahist D Tablet
  • Atovaquone-Proguanil Tablet (Quantity Level Limit)
  • Claravis Capsule 10 mg, 20 mg, 30 mg, 40 mg (Step Therapy, Quantity Level Limit)
  • Dovato Tablet 50-300 mg (Diagnosis Confirmation Required, Quantity Level Limit)
  • Gvoke Hypopen Injection (Quantity Level Limit)
  • Isotretinoin Capsule 10 mg, 20 mg, 30 mg, 40 mg (Step Therapy, Quantity Level Limit)
  • Jock Itch/Athlete’s Foot Spray (Tolnaftate) Aerosol Powder 1% (Quantity Level Limit)
  • Phenazopyridine Tablet 95 mg
  • Primaquine Tablet 26.3 mg (Quantity Level Limit)
  • Tolnaftate Powder 1% (Quantity Level Limit)

Removals:
 

  • Clotrimazole Solution 1% - prescription (Removed Step Therapy)

 

May 2020
 

Additions:
 

  • Dexamethasone Concentrate Solution 1 mg/mL
  • Dexamethasone Vial 4 mg/mL, 10 mg/mL, 20 mg/5 mL, 120 mg/30 mL
  • Hydrocortisone Sodium Succinate PF Vials 100 mg, 250 mg, 500 mg, 1000 mg
  • Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4% (Quantity Level Limit)
  • Pyrimethamine Tablet 25 mg (Prior Authorization Required)

Removals:
 

  • Ala Scalp Lotion 2%
  • Daraprim Tablet 25 mg (Brand)

 

April 2020
 

Additions:
 

  • Aripiprazole Tablet 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg (Age Limit, Quantity Level Limit)
  • Budesonide-Formoterol Inhaler 80-4.5 mcg, 160-4.5 mcg (Quantity Level Limit)
  • Novolin R FlexPen 100 units/mL
  • Omeprazole Disintegrating Tablet 20 mg (Quantity Level Limit)
  • Orkambi Granules 100-125 mg, 200-125 mg (Prior Authorization Required)
  • Orkambi Tablet 100-125 mg, 200-125 mg (Prior Authorization Required)
  • Tramadol Tablet 100 mg (Quantity Level Limit)

Removals:
 

  • Carafate Suspension 1 gm/10 mL (Brand)

 

March 2020
 

Additions:
 

  • Mesalamine Capsule 0.375 gm
  • Penicillamine Tablet 250 mg (Prior Authorization Required, Quantity Level Limit)

Removals:
 

  • Apriso Capsule 0.375 gm (Brand)

Other Updates:
 

  • Prenatal Vitamin Tablet (Quantity Level Limit)

 

February 2020
 

Additions:
 

  • Bimatoprost Ophthalmic Solution 0.03% (Step Therapy Required)
  • Ethinyl Estradiol–Etonogestrel Ring 0.015 mg-0.12 mg (Quantity Level Limit)
  • Everolimus Tablet 2.5 mg, 5 mg, 7 mg (Prior Authorization Required)
  • Liletta Intrauterine Device 19.5 mcg/day

Removals:
 

  • Afinitor Tablet 2.5 mg, 5 mg, 7.5 mg (Brand)
  • Alprazolam Concentrate Solution 1 mg/mL
  • Chlorothiazide Tablet
  • Demeclocycline Tablet
  • Doxycycline Monohydrate Tablet 150 mg
  • First-Vanco Solution 25 mg/mL, 50 mg/mL
  • Homatropine Ophthalmic Solution 5%
  • Kyleena Intrauterine Device
  • Methyclothiazide Tablet 5 mg
  • Mirena Intrauterine Device
  • Nausea Relief Liquid
  • Nizatidine Solution 15 mg/mL
  • Nuvaring (Brand)
  • Phospholine Ophthalmic Solution 0.125%
  • Propantheline Capsule 15 mg
  • Rabeprazole Enteric Coated Capsule 20 mg
  • Ranitidine Capsule 150 mg, 300 mg
  • Skyla Intrauterine Device

Other Updates:
 

  • Atropine Ophthalmic Ointment 1% (Quantity Level Limit)
  • Atropine Ophthalmic Solution 1% (Quantity Level Limit)
  • Buspirone Tablet 5 mg, 7.5 mg, 10 mg, 15 mg (Age Limit)
  • Combigan Ophthalmic Solution 0.5/0.5% (Quantity Level Limit)
  • Diazepam Concentrate 5 mg/mL (Quantity Level Limit)
  • Diazepam Oral Solution (Quantity Level Limit)
  • Diazepam Tablet 2 mg, 5 mg, 10 mg (Quantity Level Limit)
  • Divalproex Extended-Release Tablet 250 mg, 500 mg (Prior Authorization Required)
  • Dorzolamide-Timolol Ophthalmic Solution 22.3-6.8% (Quantity Level Limit, Step Therapy Required)
  • Doxycycline Monohydrate Suspension 25 mg/5 mL (Age Limit)
  • Granisetron Tablet 1 mg (Step Therapy Required)
  • Hydroxyzine Pamoate Capsule 25 mg, 50 mg, 100 mg (Quantity Level Limit)
  • Hydroxyzine Tablet 50 mg (Quantity Level Limit)
  • Levofloxacin Ophthalmic Solution 0.5% (Quantity Level Limit)
  • Lorazepam Concentrate 2 mg/mL (Age Limit, Quantity Level Limit)
  • Memantine Tablet 5 mg, 10 mg (Quantity Level Limit)
  • Methazolamide Tablet 25 mg, 50 mg (Step Therapy Required)
  • Natacyn Ophthalmic Suspension 5% (Quantity Level Limit)
  • Tazarotene Cream 1% (Step Therapy Required)
  • Timolol Ophthalmic Gel Solution 0.25%, 0.5% (Quantity Level Limit)
  • Trifluridine Ophthalmic Solution 1% (Quantity Level Limit)

 

January 2020
 

Additions:
 

  • Buprenorphine-Naloxone Film 2-0.5 mg, 4-1 mg, 8-2 mg, 12-3 mg (Quantity Level Limit)

Removals:
 

  • Ventolin HFA Inhaler (Brand name)

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