Pharmacy
Aetna Better Health’s Formulary Drug Lists
Medicaid Members
When considering medications, you and your doctor should try to use drugs that are designated as preferred on the Statewide Preferred Drug List (PDL). Drugs designated as non-preferred on the PDL remain available to you when determined to be medically necessary through the prior authorization process. To see any Quantity Level Limits (QLL), please check the QLL Document.
Aetna Better Health of Pennsylvania also covers drugs and products that are not on the DHS PDL. This is called the Supplemental Formulary. Click here to look at this list or use our Supplemental Formulary Search Tool.
Aetna Better Health Kids
To prevent extra costs, check that your medicines are on the preferred drug list. This list is called the formulary.
To view medicines that are covered on the formulary, you can search for drugs using our Formulary Search Tool. Searches can be performed by drug name or drug class. The tool will provide formulary status and if there are any clinical edits (Prior Authorization, Quantity Level Limits, Age Limits, etc.).
All Members
The formularies can change. You can see a list of added or removed drugs by reading the formulary updates below.
Ask your doctor to review the Formulary Drug List for any restrictions or recommendations regarding prescription drugs before prescribing a drug for you. Then, make sure you get your prescriptions filled at an Aetna Better Health network pharmacy. The Member Handbook tells you how much you have to pay for your medicines based on your pharmacy benefit.
You can learn about potential drug interactions, side effects and risks of the medicines you take. Just visit Krames Online and MedlinePlus.
Find a pharmacy provider
You can find the location of an in-network pharmacy by visiting the CVS Caremark pharmacy locator. This allows you to search for a pharmacy by zip code so you can find a location close to you.
Other drug lists
- Medicaid and tobacco cessation
- Incontinence list
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Specialty Pharmacy Network
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Careful handling and quick delivery for specialty drugs
Our preferred Specialty Pharmacy providers are Accuserv Pharmacy, Caremark Specialty Pharmacy, Einstein at Center One Pharmacy, Elwyn Specialty Care, Giant Eagle Pharmacy, Pharmblue LLC and Senderra Rx Pharmacy.
These pharmacies fill prescriptions for Specialty Drugs .* These types of drugs may be injected, infused or taken by mouth. Usually, you can't get these drugs at a local retail pharmacy. They often need special storage and handling. And they need to be delivered quickly.
Our preferred Specialty Pharmacies provide many helpful services, including:
- Free, secure delivery (usually within 48 hours of confirming your order)
- Delivery to your home, doctor’s office or any other place you choose
- Package tracking for prompt delivery
- Training on how to self-inject your medicine
- Free injection supplies, such as needles, syringes, alcohol swabs, adhesive bandages and containers for needle waste
How to get started
We have several ways for you to fill a prescription through one of our preferred Specialty Pharmacies.
Existing prescriptions: To transfer an existing prescription, call one of our Preferred Specialty pharmacies.
New prescriptions: For a new prescription, your doctor can:
- Send a prescription electronically.
- Fax your prescription
- Call one of preferred specialty pharmacies
- You or the doctor can mail the prescription order.
After the pharmacy receives your prescription, your first order should ship within 48 hours. It may take longer if they need to contact your doctor about the prescription.
Accuserv Pharmacy
- You or your doctor can visit the web site for an enrollment form: https://www.accuservpharmacy.com/prescribers/rx-forms/
- Phone: 724-978-0110
- Fax: 877-526-8823
Banks Apothecary
- You or your doctor can visit the web site for an enrollment form: https://banksapothecary.com/forms/
- Phone: 215-494-9403
- Fax: 215-357-2129
Caremark Specialty Pharmacy
- You or your doctor can visit the web site for an enrollment form: https://www.cvsspecialty.com/wps/portal/specialty/healthcare-professionals/enrollment-forms/
- Phone: 877-408-9742 or 1-800-237-2767
- Fax: 1-800-323-2445
Einstein at Center One Pharmacy
- You or your doctor can visit the web site for an enrollment form: https://www.einstein.edu/pharmacy/enrollment
- Phone: 1-877-218-4499
- Fax: 215-827-1934
Elwyn Specialty Care
- You or your doctor can visit the web site for an enrollment form: http://elwynspecialtycare.com/referral-forms/
- Phone: 314-919-4677
- Fax: 610-545-6030
Giant Eagle Pharmacy
- You or your doctor can visit the web site for an enrollment form: https://specialtyrx.gianteagle.com/Providers/EnrollmentForms
- Phone: 888-792-1552 or 440-356-3287
- Fax: 1-877-645-4142
Pharmblue LLC
- You or your doctor can visit the web site for an enrollment form: https://www.pharmblue.com
- Phone: 855-779-4720
- Fax: 844-818-7550
Senderra Rx Pharmacy
- You or your doctor can visit the web site for an enrollment form: https://senderrarx.com/prescribers/forms
- Phone: 1-855-460-7928
- Fax: 888-777-5645
A personal care plan and ongoing support
Each of our preferred Specialty Pharmacies has a team of experienced nurses and pharmacists to help you understand how to use your medicine. They can answer your questions and help you cope with your condition throughout your therapy.
You can talk to them 24 hours a day, 7 days a week.
Get extra support for your complex medical condition
Skilled nurses and pharmacists offer extra support to patients with complex medical conditions, such as the any of the following:
- Anemia
- Asthma
- Cancer
- Chronic renal failure
- Crohn's disease
- Gaucher disease
- Growth hormone deficiency
- Hematologic conditions
- Hemophilia
- Hepatitis
- HIV/AIDS
- Immune system disorders
- Multiple sclerosis
- Neurologic conditions
- Osteoarthritis
- Psoriasis
- Pulmonary diseases
- Respiratory syncytial virus (RSV)
- Rheumatoid arthritis
- Transplant
Joining our preferred Specialty Pharmacy network
Are you a pharmacy interested in joining our preferred specialty pharmacy network? You can get the application process started by sending an email to Specialtypharmacyapplications@cvscaremark.com. Thank you for your interest in supporting our commitment to high-quality care.
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Statewide Preferred Drug List Updates (Medicaid)
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Updates are made regularly to the Statewide Preferred Drug List.
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Supplemental Formulary Updates (Medicaid)
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September 2022
No Updates
August 2022
No Updates
July 2022
No Updates
June 2022
No Updates
May 2022
Additions:
- Sodium Chloride Tab 1gm
April 2022
No Updates
March 2022
No Updates
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)
Removals:
- None
Other Updates:
- Diphenhydramine Hcl Liquid 12.5mg/5ml (Added Quantity Level Limit)
January 2022
No Updates
December 2021
No Updates
November 2021
No Updates
October 2021
Removals:
- Dermacinrx Ventrixyl Fe Caplet
- Santyl Ointment 250Unit/GM
September 2021
No Updates
August 2021
No Updates
July 2021
No Updates
June 2021
No Updates
May 2021
No Updates
April 2021
No Updates
March 2021
No Updates
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Aetna Better Health Kids Formulary Updates (CHIP)
-
September 2022
Additions:
- Phospho-Trin K500 Tab
Removals:
- Hypersal Nebulization Solution 3.5 %
Other Updates:
- K-Phos Tab 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 Tab 100mg
- Eplerenone Tab 25mg
- Eplerenone Tab 50 Mg
- Fenofibrate Tab 145 Mg
- Fenofibrate Tab 48 Mg
- Fluocinonide Cream 0.1%
- Glucagon Emergency Soln Kit 1mg/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 Tab 20 Mg (Quantity Level Limit)
- Olmesartan Medoxomil Tab 40 Mg (Quantity Level Limit)
- Olmesartan Medoxomil Tab 5 Mg (Quantity Level Limit)
- Olopatadine Hcl Ophth Soln 0.2% (OTC)
- Onetouch Ultra 2 Kit W/ Device
- Onetouch Verio Flex System Kit W/ Device
- Onetouch Verio Reflect Kit W/ Device
- Pataday Solution 0.7% Ophth
- Permethrin Liquid 1%
- Selenium Sulfide Shampoo 1%
- Symjepi Solution Prefilled Syringe 0.15mg/0.3ml (Quantity Level Limit)
- Symjepi Solution Prefilled Syringe 0.3 Mg/0.3ml (Quantity Level Limit)
- Tetrabenazine Tab 12.5mg (Prior Authorization Required, Quantity Level Limit)
- Triamcinolone Acetonide Ointment 0.05% (Quantity Level Limit)
- Triprolidine Hcl Drops 0.938mg/Ml
- Triprolidine Hcl Liquid 0.625mg/Ml (Pediaclear PD Liquid)
- Voriconazole Tab 200mg (Prior Authorization Required)
- Voriconazole Tab 50mg (Prior Authorization Required)
Removals:
- Adapalene Cream 0.1%
- Amcinonide Ointment 0.1%
- Amiodarone Hcl Tab 100mg
- Amiodarone Hcl Tab 400mg
- Amlodipine Besylate-Atorvastatin Calcium Tab 10-10 Mg
- Amlodipine Besylate-Atorvastatin Calcium Tab 10-20 Mg
- Amlodipine Besylate-Atorvastatin Calcium Tab 10-40 Mg
- Amlodipine Besylate-Atorvastatin Calcium Tab 10-80 Mg
- Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-10 Mg
- Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-20 Mg
- Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-40 Mg
- Amlodipine Besylate-Atorvastatin Calcium Tab 5-10 Mg
- Amlodipine Besylate-Atorvastatin Calcium Tab 5-20 Mg
- Amlodipine Besylate-Atorvastatin Calcium Tab 5-40 Mg
- Amlodipine Besylate-Atorvastatin Calcium Tab 5-80 Mg
- Amoxicillin & K Clavulanate Tab Er 12hr 1000-62.5 Mg
- Baraclude Soln 0.05mg/Ml
- Bp Wash Liq 2.5%
- Capzasin-P Cream 0.035%
- Carbinoxamine Maleate Soln 4 Mg/5ml
- Carbinoxamine Maleate Tablet 4mg
- Cefaclor Cap 250 Mg
- Cefaclor Cap 500 Mg
- Cefpodoxime Proxetil For Susp 100 Mg/5ml
- Cefpodoxime Proxetil For Susp 50 Mg/5ml
- Clemastine Fumarate Tab 12-Hour 1.34mg
- Colesevelam Hcl Packet 3.75gm
- Diltiazem Hcl Er Cap Extended Release 12-Hour 60mg
- Diltiazem Hcl Er Cap Extended Release 12-Hour 90mg
- Diphenhydramine Dispersible Tab 12.5mg
- Diphenhydramine Hcl Tab Chewable 12.5mg
- Doxycycline Monohydrate Cap 150mg
- Erythromycin Ethylsuccinate For Susp 200mg/5ml
- Erythromycin Ethylsuccinate For Susp 400mg/5ml
- Fexofenadine Hcl Childrens Suspension 30mg/5ml
- Flunisolide Nasal Spray 25mcg/Act (0.025%)
- Fluvastatin Sodium Tab Er 24 Hr 80 Mg (Base Equivalent)
- Glucagen Hypokit Solution Reconstituted 1mg
- Isradipine Cap 2.5mg
- Isradipine Cap 5mg
- Lidocaine Hcl Urethral/Mucosal Gel 2%
- Lidocaine-Prilocaine Kit 2.5-2.5%
- Memantine Hcl Oral Soln 2 Mg/Ml
- Memantine Hcl Tab 28 X 5 Mg & 21 X 10 Mg Titration Pack
- Methazolamide Tab 25 Mg
- Methazolamide Tab 50 Mg
- Metronidazole Cap 375mg
- Nicardipine Cap 20mg
- Nicardipine Cap 30mg
- Nitazoxanide Tab 500mg
- OneTouch Kit Ultra Mini
- Onetouch Solutions Starter Kit Kit W/ Well Device
- Perindopril Erbumine Tab 2 Mg
- Perindopril Erbumine Tab 4 Mg
- Perindopril Erbumine Tab 8 Mg
- Propafenone Cap Extended Release 12-Hour 325mg
- Propafenone Cap Extended Release 12-Hour 425mg
- Propafenone Hcl Er Cap Extended Release 12-Hour 225mg
- Proxivol Gel 2%
- Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4%
- Rivastigmine Patch 24 Hour 13.3mg/24hr
- Rivastigmine Patch 24 Hour 4.6mg/24hr
- Rivastigmine Patch 24 Hour 9.5mg/24hr
- Salicylic Acid Shampoo 6%
- Santyl Ointment 250 Unit/Gm
- Selenium Sulfide Shampoo 2.25%
- Sulfacetamide Sodium Liquid Wash 10%
- Vancomycin + Syrspen Sf Hcl Oral Susp 50mg/Ml (Compound Kit)
- Vancomycin Hcl For Iv Soln 10gm (Base Equivalent)
- Vancomycin Hcl For Iv Soln 500mg (Base Equivalent)
- Vancomycin Hcl Iv Soln 1250mg/250ml (Base Equivalent)
- Vancomycin Hcl Iv Soln 1750mg/350ml (Base Equivalent)
- Vancomycin Hcl Iv Soln 750mg/150ml (Base Equivalent)
- Vemlidy Tab 25mg
- Zafirlukast Tab 10mg
- Zafirlukast Tab 20mg
Other Updates:
- Acyclovir Cap 200 Mg (Removed Quantity Level Limit)
- Acyclovir Tab 400 Mg (Removed Quantity Level Limit)
- Acyclovir Tab 800 Mg (Removed Quantity Level Limit)
- Austedo Tab 12mg (Added Quantity Level Limit)
- Austedo Tab 6mg (Added Quantity Level Limit)
- Austedo Tab 9mg (Added Quantity Level Limit)
- Ezetimibe Tab 10 Mg (Removed Step Therapy)
- Glucagon Emergency Kit 1mg Injection (Changed Quantity Level Limit)
- Gvoke Hypopen Solution Auto-Injector 0.5mg/0.1ml (Changed Quantity Level Limit)
- Gvoke Hypopen Solution Auto-Injector 1mg/0.2ml (Changed Quantity Level Limit)
- Gvoke Pfs Solution Prefilled Syringe 0.5mg/0.1ml (Changed Quantity Level Limit)
- Gvoke Pfs Solution Prefilled Syringe 1mg/0.2ml (Changed Quantity Level Limit)
- Olopatadine Hcl Ophth Soln 0.1% (OTC) (Removed Step Therapy)
- Omega-3-Acid Ethyl Esters Cap 1 Gm (Removed Step Therapy)
- Valacyclovir Hcl Tab 1gm (Removed Quantity Level Limit)
- Valacyclovir Hcl Tab 500 Mg (Removed Quantity Level Limit)
July 2022
Additions:
- None
Removals:
- None
Other Updates:
- None
June 2022
Additions:
- Epivir HBV Soln 5mg/ml (Quantity Level Limit)
- Gvoke Hypopen 1-Pack 0.5mg/0.1ml (Quantity Level Limit)
- Gvoke PFS INJ 1mg/0.2ml (Quantity Level Limit)
- Lamivudine Tab 100mg (Quantity Level Limit)
- Pregabalin Cap 200mg (Prior Authorization Required, Quantity Level Limit)
Removals:
- None
Other Updates:
- None
May 2022
Additions:
- Ozempic (2mg/Dose) 8mg/3ml (Quantity Level Limit, Step Therapy)
- Triumeq PD Tab 60-5-30mg (Prior Authorization Required, Quantity Level Limit)
Removals:
- None
Other Updates:
- None
April 2022
Additions:
- Descovy Tab 120-15mg (Prior Authorization Required, Quantity Level Limit)
Removals:
- None
Other Updates:
- None
March 2022
Additions:
- Brimonidine Tartrate-Timolol Maleate Ophth Soln 0.2-0.5% (Quantity Level Limit, Step Therapy)
- Maraviroc Tab 150mg
- Maraviroc Tab 300mg
- Systane Gel Drop 0.4-0.3%
Removals:
- Combigan Ophth Soln 0.2-0.5%
- Dry Eye Relief Drops 0.4-0.3%
- Selzentry Tab 150mg
- Selzentry Tab 300mg
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)
- Levocetirizine Tablet 5mg (Quantity Level Limit)
- Naloxone Nasal Liquid 4mg/0.1ml (generic)
- Norditropin Flexpro Injection 10mg/1.5ml (Prior Authorization Required)
- Norditropin Flexpro Injection 15mg/1.5ml (Prior Authorization Required)
- Norditropin Flexpro injection 30mg/3ml (Prior Authorization Required)
- Norditropin Flexpro Injection 5mg/1.5ml (Prior Authorization Required)
- Ziextenzo (Prior Authorization Required)
Removals:
- Diphenhydramine Elixir 12.5mg/5ml
- Estradiol Vaginal Cream 0.1mg/gm
- Felbamate Suspension 600mg/5ml
- Felbamate Tablet 400mg
- Felbamate Tablet 600mg
- Megestrol Suspension 625mg/5ml
- Omnitrope Injection 5.8mg
- Udenyca Injection 6mg/0.6ml
Other Updates:
- Diphenhydramine Hcl Liquid 12.5mg/5ml (Added Quantity Level Limit)
- Eliquis DVT/PE Starter Pack Tablet 5mg (Removed Prior Authorization Required)
- Eliquis Tablet 2.5mg (Removed Prior Authorization Required)
- Eliquis Tablet 5mg (Removed Prior Authorization Required)
- Promethazine Hcl Syrup 6.25mg/5ml (Added Quantity Level Limit)
- Xarelto 10mg (Removed Prior Authorization Required)
- Xarelto 15mg (Removed Prior Authorization Required)
- Xarelto 20mg (Removed Prior Authorization Required)
- Xarelto Starter Pack 15/20mg (Removed Prior Authorization Required)
January 2022
Additions:
- Etravirine Tab 100mg (Prior Authorization Required)
- Etravirine Tab 200mg (Prior Authorization Required)
- Gvoke Kit Solution 1mg/0.2ml (Quantity Level Limit)
Removals:
- Intelence Tab 100mg
- Intelence Tab 200mg
Other Updates:
- None
December 2021
Additions:
- Esomeprazole Tab Delayed Release 20mg
- Everolimus Tab 10mg (Prior Authorization Required)
- Lopinavir-Ritonavir Tab 100-25mg (Prior Authorization Required)
- Lopinavir-Ritonavir Tab 200-25mg (Prior Authorization Required)
- Mavyret Packet 50-20mg (Prior Authorization Required)
Removals:
- Afinitor Tab 10mg
- Kaletra Tab 100-25mg
- Kaletra Tab 200-25mg
- Semglee Pen-Injector 100unit/ml
- Semglee Vial (Solution) 100unit/ml
Other Updates:
- None
November 2021
No Updates
October 2021
Additions:
- Sunitinib Cap 12.5mg (Prior Authorization Required, Quantity Level Limit)
- Sunitinib Cap 25mg (Prior Authorization Required, Quantity Level Limit)
- Sunitinib Cap 37.5mg (Prior Authorization Required, Quantity Level Limit)
- Sunitinib Cap 50mg (Prior Authorization Required, Quantity Level Limit)
Removals:
- Sutent Cap 12.5mg (Brand)
- Sutent Cap 25mg (Brand)
- Sutent Cap 37.5mg (Brand)
- Sutent Cap 50mg (Brand)
Other Updates:
- None
September 2021
No Updates
August 2021
Additions:
- Baqsimi Powder 3mg/Dose (Quantity Level Limit)
- Endari Powder 5gm (Prior Authorization Required)
- Inlyta Tab 1mg (Prior Authorization Required, Quantity Level Limit)
- Inlyta Tab 5mg (Prior Authorization Required, Quantity Level Limit)
- Nayzilam Spray 5mg (Prior Authorization Required, Quantity Level Limit)
- Pregabalin Cap 100mg (Prior Authorization Required, Quantity Level Limit)
- Pregabalin Cap 150mg (Prior Authorization Required, Quantity Level Limit)
- Pregabalin Cap 225mg (Prior Authorization Required, Quantity Level Limit)
- Pregabalin Cap 25mg (Prior Authorization Required, Quantity Level Limit)
- Pregabalin Cap 300mg (Prior Authorization Required, Quantity Level Limit)
- Pregabalin Cap 50mg (Prior Authorization Required, Quantity Level Limit)
- Pregabalin Cap 75mg (Prior Authorization Required, Quantity Level Limit)
- Prolia Solution (Prior Authorization Required, Quantity Level Limit)
- Semglee Inj 100-Unit Pen-Injector
- Semglee Inj 100-Unit Vial Solution
- Sofosbuvir-Velpatasvir Tab 400-100mg (Prior Authorization Required, Quantity Level Limit
Removals:
- Caffeine Citrate Powder
- Ibrance Cap 100mg
- Ibrance Cap 125mg
- Ibrance Cap 75mg
- Lidocaine-Hydrocortisone Acetate Cream 3-0.5%
- Methoxsalen Rapid Cap 10mg
- Nexavar Tab 200mg
Other Updates:
- None
July 2021
No Updates
June 2021
Additions:
- None
Removals:
- Linzess Cap 72mcg
- Linzess Cap 145mcg
- Linzess Cap 290mcg
Other Updates:
- Trulicity Inj 0.75/0.5 (Added Quantity Level Limit)
- Trulicity Inj 1.5/0.5 (Added Quantity Level Limit)
- Trulicity Inj 3/0.5 (Added Quantity Level Limit)
- Trulicity Inj 4.5/0.5 (Added Quantity Level Limit)
May 2021
No Updates
April 2021
Additions:
- Brinzolamide 1% Ophthalmic Suspension (Quantity Level Limit, Step Therapy)
Removals:
- Azopt 1% Ophthalmic Suspension
March 2021
Additions:
- Bevespi Aer 9-4.8mcg (Quantity Level Limit)
- Cequa Sol 0.09% PF (Prior Authorization Required)
- Doxycycl Hyc Cap 100mg
- Doxycycl Hyc Cap 50mg
- Doxycycl Hyc Tab 100mg
- Esbriet Cap 267mg (Prior Authorization Required)
- Esbriet Tab 267mg (Prior Authorization Required)
- Esbriet Tab 801mg (Prior Authorization Required)
- Flutic/Salme Aer 100/50 (Age Level Limit, Quantity Level Limit)
- Hizentra Inj 1gm/5ml (Prior Authorization Required)
- Hizentra Inj 2gm/10ml (Prior Authorization Required)
- Hizentra Inj 4gm/20ml (Prior Authorization Required)
- Hizentra Sol 20% (Prior Authorization Required)
- Hizentra Via 10gm/50m (Prior Authorization Required)
- Hizentra Via 1gm/5ml (Prior Authorization Required)
- Icosapent Cap 1gm (Prior Authorization Required, Quantity Level Limit)
- Myleran Tab 2mg
- Ocrevus Inj 300/10ml (Prior Authorization Required, Quantity Level Limit)
- Pot & Sod Citrates W/ Cit Ac Soln 550-500-334 Mg/5ml
- Privigen Inj 40grams (Prior Authorization Required)
- Rabeprazole Tab 20 (Quantity Level Limit)
- Sodium Citrate & Citric Acid Soln 500-334 Mg/5ml
- Trulicity Inj 0.75/0.5 (Step Therapy Required)
- Trulicity Inj 1.5/0.5 (Step Therapy Required)
- Trulicity Inj 3/0.5 (Step Therapy Required)
- Trulicity Inj 4.5/0.5 (Step Therapy Required)
- Tukysa Tab 150mg (Prior Authorization Required)
- Tukysa Tab 50mg (Prior Authorization Required)
- Valtoco Liq 15 Mg (Quantity Level Limit)
- Valtoco Liq 20 Mg (Quantity Level Limit)
- Valtoco Spr 10mg (Quantity Level Limit)
- Valtoco Spr 5mg (Quantity Level Limit)
- Visco-3 Inj 25/2.5ml (Prior Authorization Required)
Removals:
- Anoro Ellipt Aer 62.5-25
- Atrovent HFA Aer 17mcg
- Breo Ellipta Inh 100-25
- Breo Ellipta Inh 200-25
- Cefaclor For Susp 125mg/5ml
- Cefaclor For Susp 250 Mg/5ml
- Cefaclor For Susp 375 Mg/5ml
- Clarithromycin Tab ER 24 HR 500mg
- Combivent Aer 20-100
- Diazepam Con 5mg/ml
- Doxycyc Mono Tab 100mg
- Doxycyc Mono Tab 150mg
- Doxycyc Mono Tab 50mg
- Doxycyc Mono Tab 75mg
- Epogen Inj 10000/ml
- Epogen Inj 2000/ml
- Epogen Inj 20000/ml
- Epogen Inj 3000/ml
- Epogen Inj 4000/ml
- Flebogamma Inj 10/200ml
- Flebogamma Inj 10/200ml
- Flebogamma Inj Dif 5%
- Flebogamma Inj Dif 5%
- Flebogamma Inj Dif 5%
- Fulphila Inj 6/0.6ml
- Hyalgan Inj 20mg/2ml
- Hyalgan Inj 20mg/2ml
- Hyoscyamine Dro 0.125/ml
- Janumet Tab 50-1000
- Janumet Tab 50-500mg
- Janumet XR Tab 100-1000
- Janumet XR Tab 50-1000
- Janumet XR Tab 50-500mg
- Januvia Tab 100mg
- Januvia Tab 25mg
- Januvia Tab 50mg
- Nivestym Inj 300/0.5
- Nivestym Inj 300mcg
- Nivestym Inj 480/0.8
- Nivestym Inj 480mcg
- Ofev Cap 100mg
- Ofev Cap 150mg
- Verzenio Tab 100mg
- Verzenio Tab 150mg
- Verzenio Tab 200mg
- Verzenio Tab 50mg
- Victoza Inj 18mg/3ml
Other Updates:
- Albuterol Aer HFA (Added Quantity Level Limit)
- Arnuity Elpt Inh 100mcg (Added Quantity Level Limit)
- Arnuity Elpt Inh 200mcg (Added Quantity Level Limit)
- Arnuity Elpt Inh 50mcg (Added Quantity Level Limit)
- Azithromycin Sus 100mg/5ml (Added Age Limit)
- Azithromycin Sus 200 Mg/5ml (Added Age Limit)
- Cefadroxil Sus 250/5 ml (Added Age Limit)
- Cefadroxil Sus 500/5 ml (Added Age Limit)
- Cefdinir Sus 125/5ml (Added Age Limit)
- Cefdinir Sus 250/5ml (Added Age Limit)
- Cefpodo Prox Sus 100/5ml (Added Age Limit)
- Cefpodo Prox Sus 50mg/5ml (Added Age Limit)
- Cefprozil Sus 125/5ml (Added Age Limit)
- Cefprozil Sus 250/5ml (Added Age Limit)
- Cephalexin Sus 125/5ml (Added Age Limit)
- Cephalexin Sus 250/5ml (Added Age Limit)
- Clarithromycin Sus 125mg/5ml (Added Age Limit)
- Clarithromycin Sus 250mg/5ml (Added Age Limit)
- Extavia Inj 0.3mg (Added Quantity Level Limit)
- Gilenya Cap 0.5mg (Added Quantity Level Limit)
- Glatiramer Inj 20mg/ml (Added Quantity Level Limit)
- Glatiramer Inj 40mg/ml (Added Quantity Level Limit)
- Juluca Tab 50-25mg (Added Prior Authorization)
- Levalbuterol Aer 45/Act (Added Quantity Level Limit)
- Levofloxacin Sol 25mg/ml (Added Age Limit)
- Neomycin-Polymyxin-Dexamethasone Ophth Oint 0.1% (Added Quantity Level Limit)
- Ondansetron Tablet Dispersible 4mg Oral (Added Quantity Level Limit)
- Ondansetron Tablet Dispersible 8mg Oral (Added Quantity Level Limit)
- Phenylephrine HCl Ophth Soln 2.5% (Added Quantity Level Limit)
- Rebif Inj 22/0.5 (Added Quantity Level Limit)
- Rebif Inj 44/0.5 (Added Quantity Level Limit)
- Rebif Rebido Inj 22/0.5 (Added Quantity Level Limit)
- Rebif Rebido Inj 44/0.5 (Added Quantity Level Limit)
- Rebif Rebido Inj Titratn (Added Quantity Level Limit)
- Rebif Titrtn Inj Pack (Added Quantity Level Limit)
- Santyl Oin 250 Unit/gm (Added Quantity Level Limit)
February 2021
No Updates
January 2021
Additions:
- Retacrit Inj 20000uni (Prior Authorization Required)
Removals:
- None
Other Updates:
- None
December 2020
Additions:
- Trelegy Aer Ellipta 200-62.5-25mcg/inh (Quality Level Limit, Step Therapy Required)
Removals:
- None
Other Updates:
- None
November 2020
Additions:
- Dimethyl Fum Cap 120mg DR (Quantity Level Limit, Prior Authorization Required)
- Dimethyl Fum Cap 240mg DR (Quantity Level Limit, Prior Authorization Required)
- Dimethyl Fumarate Capsule DR Starter Pack 120 Mg & 240 Mg (Quantity Level Limit, Prior Authorization Required)
- Emtricitabin Cap 200mg (Prior Authorization Required)
Removals:
- Emtriva Cap 200mg
- Tecfidera Cap 120mg DR
- Tecfidera Cap 240mg DR
- Tecfidera Capsule DR Starter Pack 120 Mg & 240 Mg
Other Updates:
- None
October 2020
Additions:
- Efavirenz-Lamivudine-Tenofovir Df Tab 400-300-300mg
- Efavirenz-Lamivudine-Tenofovir Df Tab 600-300-300mg
Removals:
- Symfi Lo Tablet 400-300-300mg
- Symfi Tablet 600-300-300mg
Other Updates:
- None
December 2021
Additions:
- Esomeprazole Tab Delayed Release 20mg
- Everolimus Tab 10mg (Prior Authorization Required)
- Mavyret Packet 50-20mg (Prior Authorization Required)
Removals:
- Afinitor Tab 10mg
Other Updates:
None
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