Pharmacy
PLEASE NOTE: Effective September 1, 2022, Aetna Better Health of Pennsylvania MEDICAID, no longer serves MEDICAID therefore, is no longer reviewing new prior authorizations for your patient.
Providers can verify patient’s eligibility by using The PROMISeTM Eligibility Verification System (EVS) http://promise.dpw.state.pa.us/
Our Aetna Better Health KIDS (CHIP) plan will continue as usual in our 41-county coverage area. Please reference appropriate links below
Formulary/Preferred Drug Lists
Medicaid Member Preferred Drug List
For Medicaid members, the list of covered drugs is the Statewide Preferred Drug List (PDL) from the Pennsylvania Department of Human Services (DHS).
Aetna Better Health of Pennsylvania also covers drugs and products that are not on the DHS Preferred Drug List. This list is called the supplemental formulary. You also have the ability to search the supplemental formulary by using the supplemental formulary search tool.
Please review the PDL, Quantity Level Limits document, and/or supplemental formulary for restrictions or recommendations regarding prescription drugs before prescribing a medication to an Aetna Better Health of Pennsylvania member.
Prescriptions must be filled at an Aetna Better Health network pharmacy, and other plan rules must be followed.
To initiate an electronic prior authorization (ePA), please click here.
For information on key pharmacy benefits we offer to our Medicaid members, click here. Select the Pharmacy drop down and select the Pharmacy Benefit Flyer (MA). You will find a pharmacy brochure specific to our Medicaid pharmacy benefits that you can review with patients when in your office.
Aetna Better Health Kids Preferred Drug List
The Formulary is a list of drugs chosen by Aetna Better Health and a team of doctors and pharmacists that are generally covered under the plan as long as they are medically necessary. Prescriptions must be filled at an Aetna Better Health network pharmacy, and other plan rules must be followed. View our latest formulary drug list.
You now have the ability to search for drugs using our new Formulary Search Tool. Searches can be performed by drug name or by drug class. The tool will provide formulary status, generic alternatives and if there are any clinical edits (Prior Authorization, Quantity Limits, Age Limits etc).
Please review the Formulary for any restrictions or recommendations regarding prescription drugs before prescribing a medication to an Aetna Better Health patient. To initiate an electronic prior authorization (ePA), please click here.
For information on key pharmacy benefits we offer to our CHIP members, click here. Select the Pharmacy drop down and select the Pharmacy Benefit Flyer (CHIP). You will find a pharmacy brochure specific to our CHIP pharmacy benefits that you can review with patients when in your office.
Visit Pharmacy Provider Search to view all the Aetna Better Health pharmacy providers.
Check back frequently as the formulary, prior authorization guidelines, and prior authorization forms are updated regularly.
You can view a list of recent formulary updates below.
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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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January 2023
No Updates
December 2022
No Updates
November 2022
No Updates
October 2022
No Updates
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)
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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)
December 2019
Removals:
- PreNata Chewable Tablet 29-1 mg
November 2019
No Updates
October 2019
Other Updates:
- Cetirizine Solution 1 mg/mL (Quantity Level Limit)
September 2019
Additions:
- Ambrisentan Tablet 5 mg, 10 mg (Prior Authorization Required, Quantity Level Limit)
- Bosentan Tablet 62.5 mg, 125 mg (Prior Authorization Required, Quantity Level Limit)
- Febuxostat Tablet 40 mg, 80 mg (Step Therapy Required)
- Ramelteon Tablet 8 mg (Step Therapy Required, Quantity Level Limit)
- Ribavirin Tablet/Capsule 200 mg (Step Therapy Required)
Removals:
- Letairis Tablet 5 mg, 10 mg (Brand)
- Rozerem Tablet 8 mg (Brand)
- Tracleer Tablet 62.5 mg, 125 mg (Brand)
- Uloric Tablet 40 mg, 80 mg (Brand)
August 2019
Additions:
- Aquadeks Drops
- Butenafine Cream 1% (Over the Counter)
- Lidocaine Patch 4% (Quantity Level Limit)
- Thyroid Tablet 180 mg, 240 mg, 300 mg (Quantity Level Limit)
Removals:
- Ciclopirox Gel 0.77%
- Clotrimazole-Betamethasone Lotion 1-0.05%
- Colestipol Granules 5 gm
- Epinastine Ophthalmic Solution 0.05%
- Fluphenazine Elixir 2.5 mg/5 mL
- Fluphenazine Injection 2.5 mg/mL
- Lindane Shampoo 1%
- Moexipril Tablet 7.5 mg, 15 mg
- Nitroglycerin Capsule 2.5 mg
- Olopatadine Ophthalmic Solution 0.2%
- Quinidine Gluconate Controlled Release Tablet 324 mg
- Thyroid Tablet 130 mg
Other Updates:
- Azelastine Ophthalmic Solution 0.05% (Quantity Level Limit)
- Ciclopirox Cream 0.77% (Step Therapy Required)
- Ciclopirox Shampoo 1% (Step Therapy Required)
- Ciclopirox Suspension 0.77% (Step Therapy Required)
- Fluocinolone Cream 0.025% (Quantity Level Limit)
- Fluocinolone Ointment 0.025% (Quantity Level Limit)
- Lidocaine Cream 4% (Quantity Level Limit)
- Lidocaine Gel 2% (Quantity Level Limit)
- Lidocaine-Prilocaine Cream 2.5-2.5% (Quantity Level Limit)
- Liothyronine Tablet 5 mcg, 50 mcg (Quantity Level Limit)
- Norethindrone Tablet 5 mg (Step Therapy Required)
- Olanzapine Orally Disintegrating Tablet (Age Limit)
- Olanzapine Tablet (Age Limit)
- Quetiapine Tablet (Age Limit)
- Risperidone Orally Disintegrating Tablet (Age Limit)
- Risperidone Oral Solution 1 mg/mL (Age Limit)
- Risperidone Tablet (Age Limit)
- Sertraline Concentrate Oral Solution 20 mg/mL (Age Limit)
- Thyroid Tablet 15 mg, 30 mg, 60 mg, 90 mg, 120 mg (Quantity Level Limit)
July 2019
Additions:
- Cefixime Capsule 400 mg (Quantity Level Limit)
- Erlotinib Tablet 150 mg (Prior Authorization Required)
- Mesalamine Delayed Release Capsule 400 mg (Quantity Level Limit)
Removals:
- Suprax Capsule 400 mg (Brand)
- Tarceva Tablet 150 mg (Brand)
June 2019
Additions:
- Docosanol Cream 10% (Quantity Level Limit)
- Melatonin Tablet 1 mg, 3 mg, 5 mg
Removals:
- Abreva Cream 10% (Brand)
May 2019
Additions:
- Erythromycin Ethylsuccinate Suspension 400 mg/5 mL
- Fulphila Injection 6 mg/0.6 mL (Prior Authorization Required)
- Nivestym Injection 300 mcg, 480mcg (Prior Authorization Required)
- Sirolimus Solution 1 mg/mL
- Udenyca Injection 6 mg/0.6 mL (Prior Authorization Required)
Removals:
- Eryped Suspension (Brand) 400 mg/5 mL
- Rapamune Solution (Brand) 1 mg/mL
April 2019
Other Updates:
- Antiretroviral Medications (Diagnosis Confirmation Required)
March 2019
Additions:
- Admelog Vial 300 units/3 mL
- Albuterol HFA Inhaler 90 mcg – generic Ventolin HFA (Quantity Level Limit)
- Arthritis Pain Relieving Cream 0.075%
- Carafate Oral Suspension 1 gm/10 mL (Age Limit)
- Mesalamine Suppository 1000 mg
- Toremifene Tablet 60 mg
Removals:
- Canasa Suppository 1000 mg
- Fareston Tablet 60 mg
- Norethindrone Acetate & Estradiol-Ferrous Tablet 1 mg-20 mcg (24)
Other Updates:
- Attention Deficit/Hyperactivity Disorder Stimulant Medications (Age Limit, Removed Prior Authorization)
- Butalbital Containing Products (Quantity Level Limit)
- Citalopram Oral Solution 10 mg/5 mL (Age Limit)
- Dicyclomine Oral Solution 10 mg/mL (Age Limit)
- Escitalopram Oral Solution 5 mg/5 mL (Age Limit)
- Famotidine Oral Suspension 40 mg/5 mL (Age Limit)
- Lansoprazole Oral Suspension 3 mg/mL (Age Limit)
- Nitrofurantoin Oral Suspension 25 mg/5 mL (Age Limit)
- Nortriptyline Oral Solution 10 mg/5 mL (Age Limit)
- Omeprazole Oral Suspension 2 mg/mL (Age Limit)
- Oseltamivir Capsule 30 mg (Removed Age Limit)
- Oseltamivir Oral Suspension 6 mg/mL (Removed Age Limit)
- Prednisone Oral Solution 5 mg/5 mL (Age Limit)
February 2019
Additions:
- Arnuity Ellipta Inhaler
- Eligard Kit 7.5 mg, 22.5 mg, 30 mg, 45 mg (Prior Authorization Required)
- Flebogamma Intravenous Solution 5 gm/50 mL, 10 gm/100 mL, 20 gm/200 mL (Prior Authorization Required)
- Immune Globulin Intravenous Solution 1 gm/10 mL, 2.5 gm/25 mL, 5 gm/50 mL, 10 gm/100 mL, 20 gm/200 mL, 30 gm/300 mL, 40 gm/400 mL (Prior Authorization Required)
- Leuprolide Acetate Kit 1 mg/0.2 mL (Prior Authorization Required)
- Ozempic Injection (Quantity Level Limit, Step Therapy Required)
- Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tablet 27-0.8 mg (Quantity Level Limit)
- Prenatal Vitamin with Iron Carbonyl-Folic Acid Tablet 29-1 mg (Quantity Level Limit)
- Prenatal Vitamin with Minerals-Ferrous Fumarate-Folic Acid- Docosahexaenoic Acid Pack 28-0.8-200 mg (Quantity Level Limit)
- Prenatal Vitamin without Vitamin A with Ferrous Fumarate-Folic Acid Chewable Tablet 29-1 mg (Quantity Level Limit)
- Prenatal Vitamin without Vitamin A with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid Capsule 20-20-1.25 mg (Quantity Level Limit)
- Prenatal Vitamin without Vitamin A with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid Capsule 130-92.4-1 mg (Quantity Level Limit)
- Segluromet Tablet (Quantity Level Limit, Step Therapy Required)
- Steglatro Tablet (Quantity Level Limit, Step Therapy Required)
- Victoza Injection (Quantity Level Limit, Step Therapy Required)
Removals:
- Alprazolam Orally Disintegrating Tablet
- Cleocin Vaginal Ovule 100 mg
- Clorazepate Dipotassium Tablet
- Condylox Gel 0.5%
- Cortifoam Rectal Aerosol
- Cuprimine Capsule 250 mg
- Dihydroergotamine Mesylate Nasal Spray 4 mg/mL
- Dulera Inhaler
- Elidel Cream 1%
- Ergotamine Sublingual Tablet 2 mg
- Ergotamine-Caffeine Suppository 2-100 mg
- Ergotamine-Caffeine Tablet 1-100 mg
- Flovent Diskus
- Humalog Pen/Cartridge
- Humalog Vial
- Invokamet Tablet
- Invokana Tablet
- Levonorgestrel-Ethinyl Estradiol Tablet 0.15-0.03 mg (84) & Ethinyl Estradiol Tablet 0.01 mg (7)
- Lidocaine-Hydrocortisone Rectal Kit 20 x 7 gm
- Lidocaine-Hydrocortisone Rectal Kit 3-1%
- Meprobamate Tablet
- Miconazole 3 Suppository 200 mg
- Nitro-Bid Cream Packet 2%
- Novolog Pen/Cartridge
- Novolog Vial
- Plan B Tablet (Brand Only)
- Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tablet 65-1 mg
- Prenatal Vitamin with Ferrous Fumarate-L Methylfolate-Folic Acid Tablet 27-0.6-0.4 mg
- Prenatal Vitamin with Iron Polysaccharide Complex-Folic Acid Chewable Tablet 29-1 mg
- Prenatal Vitamin with Iron Polysaccharide Complex-L Methylfolate-Folic Acid Chewable Tablet 29-0.6-0.4 mg
- Prenatal Vitamin with Minerals with Iron Poly Saccharide Complex-Folic Acid- Docosahexaenoic Acid Capsule 29-1-200 mg
- Prenatal Vitamin with Minerals with Iron Poly Saccharide Complex-Folic Acid- Docosahexaenoic Acid Pack 1mg & 250 mg
- Prenatal Vitamin without Vitamin A with Ferrous Asparto Glycinate-L Methylfolate-Folic Acid-Docosahexaenoic Acid Capsule 10-0.6-0.4-200 mg
- Prenatal Vitamin without Vitamin A with Ferrous Asparto Glycinate-L Methylfolate-Folic Acid-Docosahexaenoic Acid Capsule 18-0.6-0.4-300 mg
- Prenatal Vitamin without Vitamin A with Ferrous Fumarate- Docusate Sodium-Folic Acid- Docosahexaenoic Acid Capsule 27-1.25-300 mg
- Prenatal Vitamin without Vitamin A with Ferrous Fumarate-L Methylfolate-Folic Acid- Docosahexaenoic Acid Capsule 27-0.6-0.4-300 mg
- Pulmicort Flexhaler
- Qvar Inhaler
- Relenza Diskhaler
- Synjardy Tablet
- Terconazole Vaginal Suppository 80 mg
- Thalomid Capsule
- Triazolam Capsule
- Trimethobenzamide Capsule 300 mg
- Trulicity Injection
Other Updates:
- Abilify Maintena Injection (Quantity Level Limit)
- Acyclovir Suspension 200 mg/5 mL (Age Limit)
- Alprazolam Sustained Release Tablet 0.5 mg, 1 mg, 2 mg, 3 mg (Age Limit)
- Alprazolam Tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg (Quantity Level Limit)
- Aristada Injection (Quantity Level Limit)
- Breo Ellipta Inhaler (Age Limit)
- Calcipotriene Cream 0.005% (Quantity Level Limit)
- Calcipotriene Ointment 0.005% (Quantity Level Limit)
- Calcipotriene Solution 0.005% (Quantity Level Limit)
- Chlordiazepoxide Capsule 5 mg, 10 mg, 25 mg (Quantity Level Limit)
- Citalopram Solution 10 mg/5 mL (Age Limit)
- Clozapine Tablet (Quantity Level Limit)
- Dicyclomine Solution 10 mg/mL (Age Limit)
- Escitalopram Solution 5 mg/5 mL (Age Limit)
- Famotidine Suspension 40 mg/5 mL (Age Limit)
- Flovent HFA Inhaler (Age Limit)
- Fluphenazine Concentrate 5 mg/mL (Quantity Level Limit)
- Fluphenazine Elixir 2.5 mg/5 mL (Quantity Level Limit)
- Fluphenazine Injection 2.5 mg/mL (Quantity Level Limit)
- Fluphenazine Injection 25 mg/mL (Quantity Level Limit)
- Haloperidol Concentrate 2 mg/mL (Quantity Level Limit)
- Haloperidol Decanoate Injection 100 mg/mL (Quantity Level Limit)
- Haloperidol Decanoate Injection 50 mg/mL (Quantity Level Limit)
- Haloperidol Lactate Injection 5 mg/mL (Quantity Level Limit)
- Haloperidol Tablet (Quantity Level Limit)
- Hydroxyzine Tablet 10 mg, 25 mg, 50 mg (Quantity Level Limit)
- Invega Sustenna Injection (Quantity Level Limit)
- Invega Trinza Injection (Quantity Level Limit)
- Jardiance Tablet (Remove Step Therapy, Add Prior Authorization Required)
- Lansoprazole Suspension 3 mg/mL (Age Limit)
- Lithium Carbonate Capsule (Quantity Level Limit)
- Lithium Carbonate Extended-Release Tablet 300 mg, 450 mg (Quantity Level Limit)
- Lithium Carbonate Tablet 300 mg (Quantity Level Limit)
- Lithium Solution 8 mEq/5 mL (Quantity Level Limit)
- Lorazepam Tablet 0.5 mg, 1 mg, 2 mg (Quantity Level Limit)
- Loxapine Capsule (Quantity Level Limit)
- Nitrofurantoin Suspension 25 mg/5 mL (Age Limit)
- Nortriptyline Solution 10 mg/5 mL (Age Limit)
- Olanzapine Orally Disintegrating Tablet (Quantity Level Limit)
- Olanzapine Tablet (Quantity Level Limit)
- Omeprazole Suspension 2 mg/mL (Age Limit)
- Oseltamivir Capsule 30 mg (Quantity Level Limit, Age Limit)
- Oseltamivir Capsule 45 mg, 75 mg (Quantity Level Limit)
- Oseltamivir Suspension 6 mg/mL (Quantity Level Limit, Age Limit)
- Oxazepam Capsule 10 mg, 15 mg, 30 mg (Quantity Level Limit)
- Perphenazine Tablet (Quantity Level Limit)
- Prednisone Solution 5 mg/5 mL (Age Limit)
- Prenatal Vitamin with Docusate-Ferrous Fumarate-Folic Acid Tablet 29-1 mg (Quantity Level Limit)
- Prenatal Vitamin with Ferrous Fumarate-Folic Acid Chewable Tablet 29-1 mg (Quantity Level Limit)
- Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tablet 27-1 mg (Quantity Level Limit)
- Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tablet 28-1 mg (Quantity Level Limit)
- Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tablet 29-1 mg (Quantity Level Limit)
- Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tablet 60-1 mg (Quantity Level Limit)
- Prenatal Vitamin with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid-Omega 3 Capsule 38-1 mg (Quantity Level Limit)
- Prenatal Vitamin without Vit A with Ferrous Fumarate-Folic Acid Capsule 106.5-1 mg (Quantity Level Limit)
- Prochlorperazine Suppository 25 mg (Quantity Level Limit)
- Prochlorperazine Tablet (Quantity Level Limit)
- Quetiapine Tablet (Quantity Level Limit)
- Risperdal Consta Injection (Quantity Level Limit)
- Risperidone Orally Disintegrating Tablet (Quantity Level Limit)
- Risperidone Solution 1 mg/mL (Quantity Level Limit)
- Risperidone Tablet (Quantity Level Limit)
- Thioridazine Tablet (Quantity Level Limit)
- Thiothixene Capsule (Quantity Level Limit)
- Trifluoperazine Tablet (Quantity Level Limit)
- Ziprasidone Capsule (Quantity Level Limit)
January 2019
No Changes
December 2018
Additions:
- Itraconazole Solution 10 mg/mL
- Nivestym Injection 300 mcg, 480 mcg (Prior Authorization Required)
Removals:
- Gleostine Capsule 10 mg, 40 mg, 100 mg
- Mometasone Nasal Spray
- Nasonex Nasal Spray
- Sporanox Solution 10 mg/mL
November 2018
Additions:
- Albendazole Tablet 200 mg (Step Therapy Required)
Removals:
- Albenza Tablet 200 mg
October 2018
Additions:
- Admelog Vial
- Loratadine Chewable Tablet 5 mg (Quantity Level Limit)
- Prasugrel Tablet (Quantity Level Limit)
- Tadalafil Tablet 20 mg (Step Therapy, Quantity Level Limit)
- Tazarotene Cream 0.1% (Quantity Level Limit)
- Tymlos Pen (Prior Authorizations Required, Quantity Level Limit)
- Valganciclovir Tablet 450 mg (Quantity Level Limit)
Removals:
- Adcirca Tablet 20 mg
Other Updates:
- Ondansetron Tablet 4 mg, 8 mg (Quantity Level Limit)
- Tizanidine Tablet 2 mg, 4 mg (Quantity Level Limit)
September 2018
Additions:
- Colesevelam Hydrochloride Packet 3.75 gm
- Diclofenac Gel 1% (Quantity Level Limit)
- Humira Pen Crohn's Disease/Ulcerative Colitis/Hidradenitis Suppurativa Starter Kit 80 mg/0.8 mL (Prior Authorization Required, Quantity Level Limit)
- Humira Pen Psoriasis/Uveitis Starter Kit 80 mg/0.8 mL and 40 mg/0.4 mL (Prior Authorization Required, Quantity Level Limit)
- Hydroxyprogesterone Caproate Injection 250 mg/mL (Prior Authorization Required)
- Omega 3 Ethyl Esters Acid 1 gm Capsule (Step Therapy, Quantity Level Limit)
- Sevelamer Tablet 800 mg (Step Therapy)
- Symtuza Tablet (Quantity Level Limit)
- Telmisartan Tablet 20 mg, 40 mg, 80 mg (Quantity Level Limit)
- Tolterodine Extended-Release Capsule 2 mg, 4 mg (Step Therapy, Quantity Level Limit)
- Vemlidy Tablet 25 mg (Quantity Level Limit)
- Verzenio Tablet 50 mg, 100 mg, 150 mg, 200 mg (Prior Authorization Required, Quantity Level Limit)
Removals:
- Amlodipine-Valsartan-Hydrochlorothiazide Tablet
- Betaxolol Tablet
- Calcitriol Solution
- Captopril Tablet
- Captopril-Hydrochlorothiazide Tablet
- Chlorpropamide Tablet
- Climara Pro Patch Weekly
- Desipramine Tablet
- Diltiazem CD Extended-Release Capsule 360 mg
- Femring
- Fenofibrate Tablet 48 mg, 145 mg
- Fenofibric Delayed Release Capsule
- Fenoprofen Tablet 600 mg
- Lidocaine Cream 3%
- Makena Injection 250 mg/mL
- Marplan Tablet 10 mg
- Meclofenamate Sodium Capsule
- Methyltestosterone Capsule 10 mg
- Nadolol Tablet
- Nisoldipine Extended-Release Tablet
- Ondansetron Solution
- Oxaprozin Tablet 600 mg
- Pindolol Tablet
- Pioglitazone-Glimepiride Tablet
- Pioglitazone-Metformin Tablet
- Potassium-Sodium Citrates & Citric Acid Solution
- Premarin Tablet
- Premphase Tablet
- Prempro Tablet
- Protriptyline Tablet
- Tolazamide Tablet
- Tolbutamide Tablet 500 mg
- Tranylcypromine Tablet 10 mg
- Verapamil Extended Release 24-Hour Capsule 300 mg
Other Updates:
- Amlodipine Tablet 2.5 mg, 5 mg (Quantity Level Limit)
- Baraclude Solution (Quantity Level Limit)
- Benazepril Tablet 5 mg, 10 mg, 20 mg (Quantity Level Limit)
- Benzonatate Capsule 100 mg, 200 mg (Age Limit, Quantity Level Limit)
- Clonidine Patch (Step Therapy)
- Diazepam Rectal Gel 2.5 mg, 10 mg, 20 mg (Quantity Level Limit)
- Diltiazem CD Extended-Release Capsule 180 mg (Quantity Level Limit)
- Diltiazem Extended-Release Beads Capsule 180 mg (Quantity Level Limit)
- Diltiazem Extended-Release Capsule 180 mg (Quantity Level Limit)
- Elmiron Capsule (Prior Authorization Required)
- Enalapril Tablet 2.5 mg, 5 mg, 10 mg (Quantity Level Limit)
- Estradiol Vaginal Cream 0.01% (Prior Authorization Required)
- Estring Vaginal Ring 2 mg (Quantity Level Limit)
- Flunisolide Nasal Solution 0.025% (Quantity Level Limit)
- Fosinopril Tablet 10 mg, 20 mg (Quantity Level Limit)
- Gabapentin Tablet (Cumulative Maximum Dose)
- Griseofulvin Suspension (Step Therapy)
- Griseofulvin Microsize Tablet (Step Therapy)
- Griseofulvin Ultramicrosize Tablet (Step Therapy)
- Hydrocodone-Homatropine Syringe (Age Limit, Quantity Level Limit)
- Hydrocodone-Homatropine Tablet (Age Limit, Quantity Level Limit)
- Lidocaine Ointment 5% (Prior Authorization Required)
- Lisinopril Tablet 2.5 mg, 5 mg, 10 mg, 20 mg, 30 mg (Quantity Level Limit)
- Losartan Potassium Tablet 25 mg, 50 mg (Quantity Level Limit)
- Mometasone Furoate Nasal Suspension 50 mcg/Actuation (Quantity Level Limit)
- Oxybutynin Extended-Release Tablet 15 mg (Quantity Level Limit)
- Oxybutynin Immediate Release Tablet 5 mg (Quantity Level Limit)
- Oxybutynin Syringe (Quantity Level Limit)
- Propranolol Extended-Release Capsule 80 mg (Quantity Level Limit)
- Quinapril Tablet 5 mg, 10 mg, 20 mg (Quantity Level Limit)
- Ramipril Capsule 1.25 mg, 2.5 mg, 5 mg (Quantity Level Limit)
- Tenofovir Tablet 300 mg (Quantity Level Limit)
- Tolterodine Tablet 1 mg, 2 mg (Step Therapy)
- Trospium Extended-Release Capsule 60 mg (Step Therapy)
- Trospium Immediate Release Tablet 20 mg (Step Therapy)
August 2018
Additions:
- Retacrit Injection (Prior Authorization Required)
- Cimduo Tablet (Quantity Level Limit)
Other Updates:
- Loratadine Tablet 10 mg (Added Quantity Level Limit)
- Loratadine Orally Disintegrating Tablet 10 mg (Added Quantity Level Limit)
July 2018
Additions:
- Baclofen Tablet 5 mg (Quantity Level Limit)
- Diphenhydramine Liquid 6.25 mg/mL
- Norvir Powder Packets 100 mg
- Pediatric Multiple Vitamins with Iron Drops 11 mg/mL
- Phytonadione Tablet 5 mg
- Zenpep Capsule 15,000 Units
- Zenpep Capsule 3000 Units
Removals:
- Mephyton Tablet 5 mg
June 2018
Additions:
- Humira Pediatric Crohn’s Prefilled Syringe Kit 80 mg/0.8 mL and 40 mg/0.4 mL (Prior Authorization Required, Quantity Level Limit)
- Humira Pediatric Crohn’s Prefilled Syringe Kit 80 mg/0.8 mL (Prior Authorization Required, Quantity Level Limit)
- Humira Pen-Injection Kit 40 mg/0.4 mL (Prior Authorization Required, Quantity Level Limit)
- Humira Prefilled Syringe Kit 10 mg/0.1 mL (Prior Authorization Required, Quantity Level Limit)
- Humira Prefilled Syringe Kit 20 mg/0.2 mL (Prior Authorization Required, Quantity Level Limit)
- Humira Prefilled Syringe Kit 40 mg/0.4 mL (Prior Authorization Required, Quantity Level Limit)
- Lansoprazole Orally Disintegrating Tablet
- Praziquantel Tablet 600 mg (Prior Authorization Required)
- Symfi Tablet (Quantity Level Limit)
- Tasigna Capsule 50 mg (Prior Authorization Required, Quantity Level Limit)
- Zenpep Capsule 10,000 Units
Removals:
- Biltricide Tablet 600 mg
- Fluorouracil Cream 1%
- Pramoxine-Hydrocortisone-Chloroxylenol Otic Solution
- Prevacid Orally Disintegrating Tablet
Other Updates:
- Flunisolide Nasal Spray (Removed Step Therapy)
- Fluticasone Nasal Spray (Removed Step Therapy)
- Lansoprazole Orally Disintegrating Tablet (Removed Prior Auth)
- Levonorgestrel Tablet 1.5 mg (Removed Quantity Level Limit)
- Mometasone Nasal Spray (Removed Step Therapy)
May 2018
Additions:
- Colchicine Capsule 0.6 mg (Quantity Level Limit)
- Firvanq Solution
- Imbruvica Capsule 70 mg (Quantity Level Limit)
- Imbruvica Tablet 420 mg (Quantity Level Limit)
- Imbruvica Tablet 560 mg (Quantity Level Limit)
- Jardiance Tablet (Quantity Level Limit, Step Therapy Required)
- Refresh Tear Drops 0.5%
- Ritonavir 100 mg Tablet
- Symfi Lo Tablet (Quantity Level Limit)
- Synjardy Tablet (Quantity Level Limit, Step Therapy Required)
- Synjardy Extended Release 10 mg/1000 mg (Quantity Level Limit, Step Therapy Required)
- Synjardy Extended Release 12.5 mg/1000 mg (Quantity Level Limit, Step Therapy Required)
- Synjardy Extended Release 25 mg/1000 mg (Quantity Level Limit, Step Therapy Required)
- Synjardy Extended Release 5 mg/1000 mg (Quantity Level Limit, Step Therapy Required)
- Virt-PN Docosahexaenoic Acid Tablet
- Virt-PN Tablet
Removals:
- BP Folinatal Tablet Plus B
- BP Multinatal Chew Plus
- BP Multinatal Plus
- Norvir 100 Tablet
- PNV- Docosahexaenoic Acid
- PNV-Select
Other Updates:
- Rosuvastatin Tablet (Removed Prior Authorization, Added Step Therapy)
April 2018
Additions:
- Biktarvy (Quantity Level Limit)
March 2018
Additions:
- Armodafinil Tablet (Prior Authorization Required, Quantity Level Limit)
- Avonex (Prior Authorization Required, Quantity Level Limit)
- Betaxolol 0.5% Solution (Quantity Level Limit)
- Brinzolamide (Quantity Level Limit)
- Ciprofloxacin 250 mg/5 mL Suspension (Quantity Level Limit)
- Combigan (Step Therapy Required)
- Levobunolol 0.5% Solution (Quantity Level Limit)
- Metipranolol 0.3% Solution (Quantity Level Limit)
- Sprycel (Prior Authorization Required, Quantity Level Limit)
Removals:
- Betoptic-S Suspension 0.25%
- Brimonidine 0.15%
- Brompheniramine Chewable
- Cefaclor Extended-Release Tablet
- Cefixime Suspension
- Cephalexin Tablet
- Ciloxan Ointment
- Ciprofloxacin Extended-Release Tablet
- Fluoprolex Cream 1%
- Fluorabon Drops
- FML Forte 0.25%
- Gatifloxacin Solution
- Homotropine Solution 5% Ophthalmic Drops
- Jentadueto
- Jentadueto Extended-Release
- Modafinil Tablet
- Morphine Extended-Release Capsule
- Moxifloxacin
- Nature-Throid
- Neomycin/Polymyxin/Hydrocortisone drops
- Non-BD diabetic supplies
- Ofloxacin
- Oxycodone 20 mg/mL Concentrated Solution
- Oxycodone 5 mg Capsule
- Oxymorphone
- Oxymorphone Immediate Release
- Pred Mild 0.12%
- Silver Nitrate Applicator
- Sodium Fluoride Tablet
- Suprax Chewable Tablet
- TobraDex Ointment
- Tobramycin/Dexamethasone drops
- Tobrex Ointment
- Tradjenta
Other Updates:
- Carteolol 1% Solution (Added Quantity Level Limit)
- Timolol Gel 0.25% & 0.5% (Added Step Therapy)
February 2018
Additions:
- Abilify Maintena (Prior Authorization Required)
- BD Pen Needles
- Betamethasone Dipropionate 0.05% (Quantity Level Limit)
- Betamethasone Dipropionate Augmented 0.05% Lotion, Gel & Ointment (Quantity Level Limit)
- Clobetasol 0.05% Gel & Ointment (Quantity Level Limit)
- Clobetasol 0.05% Solution (Quantity Level Limit)
- Clobetasol Emollient 0.05% cream (Quantity Level Limit)
- Duloxetine 20 mg, 30 mg (Quantity Level Limit)
- Duloxetine 40 mg Delayed Release (Quantity Level Limit)
- Duloxetine 60 mg (Quantity Level Limit)
- Eliquis (Prior Authorization Required)
- Fluociononide 0.05% Gel & Ointment (Quantity Level Limit)
- Halobetasol 0.05% Ointment & Cream (Quantity Level Limit)
- Invega Sustenna (Prior Authorization Required)
- Invega Trinza (Prior Authorization Required)
- Janumet (Step Therapy Required)
- Janumet Extended Release (Step Therapy Required)
- Januvia (Step Therapy Required)
- Naproxen 125 mg/5 mL (Step Therapy Required)
- Opsumit (Prior Authorization Required, Quantity Level Limit)
- Risperdal Consta (Prior Authorization Required)
Removals:
- Albuterol 2 mg & 4 mg tablet
- Albuterol Extended Release 4 mg & 8 mg tablet
- Amcinonide 0.1% Cream & Lotion
- Capex Shampoo 0.01%
- Clobetasol 0.05% Lotion & Shampoo
- Clobetasol Aerosol 0.05% Foam & Emollient
- Desonide 0.05% Cream, Lotion, & Ointment
- Desoximetasone 0.05% Cream, Gel, & Ointment
- Desoximetasone 0.25% Cream & Ointment
- Diflorasone 0.05% Cream & Ointment
- Fluocinolone Body & Scalp Oil 0.01%
- Fluocinonide 0.05% Lotion
- Fluocinonide 0.1% Cream
- Fluticasone 0.05% Lotion
- Fondaparinux
- Fragmin
- Hydrocortisone Butyrate 0.1% Cream & Ointment
- Hydrocortisone Valerate 0.2% Cream & Ointment
- Hydrocortisone Solution Butyrate
- Pramosone-Hydrocortisone Cream 1-1%
- Prednicarbt 0.1% Cream
- Terbutaline 2.5 mg & 5 mg Tablet
- TobraDex ST Suspension
- Trianex 0.05% Ointment
- Triderm Cream 0.1% (select NDC #’s only)
- Vancomycin Capsule 125 mg & 250 mg
Other Updates:
- Brimonidine 0.2% (Changed Quantity Level Limit)
- Timolol 0.25% & 0.5% Solution (Changed Quantity Level Limit)
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Are you eligible for Medicare Part D?
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Pharmacy Benefits
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Medication recalls
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Need information about medication recalls? Just call the U.S. Food and Drug Administration (FDA) at 1-888-463-6332. Or visit the drug recalls page on the FDA website.
Prior authorization for drugs
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Request Forms - CHIP
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If the drug you are requesting is not listed below, use the Universal Pharmacy Prior Authorization Fax Form . Also view our list of Step Therapy guidelines. To initiate an electronic prior authorization (ePA) request, please click here.
To quickly find a prior authorization form, click "CTRL F" on your keyboard and type in the form name.
Universal Pharmacy Prior Authorization Fax Form CHIP
Monoamine Depletors (Austedo, Ingrezza, tetrabenzaine)
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Electronic Prior Authorization (ePA)
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We are committed to making sure our providers receive the best possible information, and the latest technology and tools available.
We have partnered with CoverMyMeds® and SureScripts to provide you a new way to request a pharmacy prior authorization through the implementation of Electronic Prior Authorization (ePA) program.
With Electronic Prior Authorization (ePA), you can look forward to:
- Time saving
- Decreasing paperwork, phone calls and faxes for requests for prior authorization
- Quicker Determinations
- Reduces average wait times, resolution often within minutes
- Accommodating & Secure
- HIPAA compliant via electronically submitted requests
No cost required! Let us help get you started!
Getting started is easy. Choose ways to enroll:
- Visit the CoverMyMeds® website
- Call CoverMyMeds® toll-free at 866-452-5017
- Visit the SureScripts website
- Call SureScripts toll-free at 866-797-3239
Billing Information:
BIN: 610591
PCN: ADV
Group: (Medicaid) RX8813
Group: (CHIP) RX8814
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Prior Authorization Guidelines - Statewide Preferred Drug List (Medicaid)
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Aetna Better Health used the Department of Human Services (DHS) Drug Criteria and our custom Prior Authorization Guidelines to make decisions when you send in a request for a drug on the Statewide PDL/formulary that needs a review prior to being dispensed. To have a copy of these guidelines sent to you or to have any questions answered, just call:
Medicaid Provider Relations at 1-866-838-1232
Aetna's Custom Prior Authorization Guidelines
Acamprosate (PARP approved 9/2021)
Anthelmintics (PARP approved 11/2020)
Continuous Glucose Monitoring (PARP approved 05/2020)
Compound Guideline (PARP approved 10/2020)
Corlanor (PARP approved 11/2020)
Cystic Fibrosis (PARP approved 08/2020)
Daraprim (PARP approved 06/2018)
Egrifta (PARP approved 09/2021)
Elmiron (PARP approved 09/2021)
Gene Based Therapy for Duchenne Muscular Dystrophy (PARP approved 09/2021)
Generic Substitution (PARP approved 12/2019)
HP Acthar (PARP approved 09/2020)
Interferons (non-Hepatitis C) (PARP approved 08/2021)
IVIG Products (PARP approved 10/2020)
L-Methylfolate Products (PARP approved 09/2020)
Lucemyra (PARP approved 02/2019)
Multaq (PARP approved 11/2020)
Non-Formulary Medication (PARP approved 09/2021)
Nuedexta (PARP approved 10/2020)
Off Label Use (PARP approved 10/2020)
Oxbryta (PARP approved 08/2020)
Quantity Limits (PARP approved 09/2021)
Sensipar (PARP approved 09/2021)
Somatostatin Analogs (PARP approved 10/2020)
Spinraza (PARP approved 09/2021)
Synagis (PARP approved 09/2020)
Tranexamic Acid (PARP approved 11/2020)
Trial Dose Program (PARP approved 10/2014)
Zolgensma (PARP approved 09/2020)
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Prior Authorization Guidelines - CHIP
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To quickly find a prior authorization guideline, click "CTRL F" on your keyboard and type in the guideline name.
Non-Formulary and Prior Authorization Guidelines
Atypical Antipsychotics Oral-Transdermal
Cequa and Cyclosporine Ophthalmic Emulsion
Fentanyl - Oral and Intranasal
Injectable Osteoporosis Agents
One Touch Diabetic Test Strips
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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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Aetna Better Health Kids - Step Therapy
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The step therapy program requires certain first-line drugs, such as generic drugs or formulary brand drugs, to be prescribed prior to approval of specific, second-line drugs. Drugs with step therapy guidelines are identified on the formulary as “STEP.”
To request an override for the step therapy, please fax the correct pharmacy Prior Authorization request form to 1-877-309-8077. You can include any supporting medical records that will assist with the review of the request.
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Tobacco Cessation Resources
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Coming Soon!
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Incontinence supplies
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Pharmacy and Therapeutics (P&T) Committee Minutes (Supplemental Formulary and CHIP)
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The Aetna Better Health® of Pennsylvania/Kids Pharmacy & Therapeutics (P&T) Committee develops and reviews the supplemental formulary (Medicaid) and the formulary for CHIP. The committee also reviews all clinical criteria for utilization management. All P&T changes for the supplemental formulary are submitted to the Department for review and approval prior to implementation.
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Second Level Pharmacy Provider Appeals
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Pharmacy Provider Appeals
You can request Aetna Better Health for a second level appeal after your pricing appeal to the pharmacy benefit manager (PBM) has been denied.
For questions concerning the Provider Appeal process, contact the Provider Appeal Department at 1-860-754-1757.
To submit a formal Provider Appeal in writing, send to the address below:
Aetna Better Health of Pennsylvania
Attention: Provider Appeals
2000 Market Street, Suite 850
Philadelphia, PA 19103
Submission steps:
- Submit the appeal in writing to Aetna Better Health to the address above.
- Include all supporting documentation with the appeal submission:
- Chains/PSAOs
- Documentation of denied Pricing Appeal outcome from the PBM
- Documentation that outreach regarding the denied outcome of appeal has been made to their PSAO or Corporate Headquarters with no resolution
- Independent Pharmacies not affiliated with a PSAO
- Documentation of denied Pricing Appeal outcome from the PBM
- Claim information that includes:
- Pharmacy NCPDP number
- Pharmacy Name
- Name of PSAO (if applicable)
- Prescription number
- NDC
- Drug Name
- Date of Fill
- Documentation of pricing information from at least two (2) wholesalers, if applicable, inclusive of any additional rebates or discounts, showing that the wholesaler prices are not equal to or less than the MAC price
- Chains/PSAOs
- We will acknowledge a Pharmacy Provider Appeal within five (5) business days after receipt.
- The appeal documentation will be reviewed, and a decision will be rendered within thirty (30) business days after receipt.
- Failure to submit support documentation may result in denial of the Provider Appeal.
Also, we have a Pharmacy Provider Appeals Committee to review and render a decision. The decision of the Provider Clinical Appeals Committee is final. We send decision notification letters to the requesting provider within five (5) business days of the committee decision. We will not take any punitive action against a provider for using the Provider Appeal Process.