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.

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

Banks Apothecary

Caremark Specialty Pharmacy

Einstein at Center One Pharmacy

Elwyn Specialty Care

Giant Eagle Pharmacy

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

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.

Updates are made regularly to the Statewide Preferred Drug List.

 

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

 

 

December 2022

Additions:

  • Benzoyl Peroxide Gel 2.5%

Removals:

  • Iodoquinol-Hc Cream 1-1%

Other Updates:

  • Fingolimod Hcl Cap 0.5 Mg (Base Equiv)
  • Histex Pd Dro 0.938mg
  • Isotretinoin Cap 10 Mg
  • Isotretinoin Cap 20 Mg
  • Isotretinoin Cap 30 Mg
  • Isotretinoin Cap 40 Mg

 

November 2022

Additions:

  • Actimmune Inj 2mu/0.5 (Prior Authorization Required)
  • Cromolyn Sodium Nasal Aerosol Soln 5.2 Mg/Act (4%) (Added Quantity Level Limit)
  • Dextromethorphan Polistirex Extended Release Susp 30 Mg/5ml (Added Quantity Level Limit)
  • Dextromethorphan-Phenylephrine-Apap Cap 10-5-325 Mg (Added Quantity Level Limit)
  • Dimenhydrinate Tab 50 Mg (Added Quantity Level Limit)
  • Fexofenadine-Pseudoephedrine Tab Er 12hr 60-120 Mg (Added Quantity Level Limit)
  • Guaifenesin Tab 200 Mg
  • Guaifenesin Tab 400 Mg
  • Guaifenesin Tab Er 12hr 1200 Mg
  • Icosapent Cap 0.5gm (Prior Authorization Required, Quantity Level Limit)
  • Imbruvica Sus 70mg/Ml (Prior Authorization Required, Quantity Level Limit)
  • Intron A Inj 10mu (Prior Authorization Required)
  • Intron A Inj 18mu (Prior Authorization Required)
  • Intron A Inj 50mu (Prior Authorization Required)
  • Mineral Oil Heavy
  • Mineral Oil Light
  • Omeprazole Cap Delayed Release 10 Mg (Added Quantity Level Limit)
  • Orkambi Gra 75-94mg (Prior Authorization Required)
  • Polyethylene Glycol-Propylene Glycol Pf Op Soln 0.4-0.3%
  • Polyvinyl Alcohol-Povidone Ophth Soln 5-6 Mg/Ml (0.5-0.6%)
  • Pseudoephedrine Hcl Tab 30 Mg
  • Pseudoephedrine-Guaifenesin Tab Er 12hr 60-600 Mg
  • Refresh Dro Op
  • Sodium Chloride Hypertonic Ophth Oint 5%
  • Sodium Fluoride Gel 1.1% (0.5% F)
  • White Petrolatum-Mineral Oil Ophth Ointment

 

Removals:

  • Butalbital-Acetaminophen-Caffeine Cap 50-300-40 Mg
  • Butalbital-Acetaminophen-Caffeine Cap 50-325-40 Mg
  • Calcium Carbonate (Antacid) Chew Tab 420 Mg
  • Dexamethasone Sod Phosphate Preservative Free Inj 10 Mg/Ml
  • Dextromethorphan Hbr Syp 10mg/5ml
  • Divalproex Sodium Cap Delayed Release Sprinkle 125 Mg
  • Docusate Sodium Cap 50 Mg
  • Etodolac Tab Er 24hr 400 Mg
  • Etodolac Tab Er 24hr 500 Mg
  • Etodolac Tab Er 24hr 600 Mg
  • Fluphenazine Hcl Oral Conc 5 Mg/Ml
  • Hepagam B Inj
  • Hycamtin Cap 0.25mg
  • Hycamtin Cap 1mg
  • Hyperhep B Inj
  • Ibuprofen-Diphenhydramine Citrate Tab 200-38 Mg
  • Iressa Tab 250mg
  • Lansoprazole Tab Delayed Release Orally Disintegrating 15 Mg
  • Lansoprazole Tab Delayed Release Orally Disintegrating 30 Mg
  • Levonorg-Eth Est Tab 0.1-0.02mg(84) & Eth Est Tab 0.01mg(7)
  • Magnesium Oxide (Laxative) Tab 500 Mg
  • Magnesium Oxide Tab 250 Mg
  • Magnesium Oxide Tab 420 Mg
  • Menest Tab 0.3mg
  • Menest Tab 0.625mg
  • Menest Tab 1.25mg
  • Metamucil Pow Mh/Orig
  • Mycophenolic Tab 180mg Dr
  • Mycophenolic Tab 360mg Dr
  • Nabi-Hb Inj
  • Nicotrol Inh 10mg
  • Nicotrol Ns Spr 4x10ml
  • Nilutamide Tab 150 Mg
  • Nozin Nasal Kit Sanitize
  • Nozin Nasal Mis Sanitize
  • Olanzapine-Fluoxetine Hcl Cap 12-25 Mg
  • Olanzapine-Fluoxetine Hcl Cap 12-50 Mg
  • Olanzapine-Fluoxetine Hcl Cap 3-25 Mg
  • Olanzapine-Fluoxetine Hcl Cap 6-25 Mg
  • Olanzapine-Fluoxetine Hcl Cap 6-50 Mg
  • Oxycodone Hcl Tab Er 12hr Deter 10 Mg
  • Oxycodone Hcl Tab Er 12hr Deter 15 Mg
  • Oxycodone Hcl Tab Er 12hr Deter 20 Mg
  • Oxycodone Hcl Tab Er 12hr Deter 30 Mg
  • Oxycodone Hcl Tab Er 12hr Deter 40 Mg
  • Oxycodone Hcl Tab Er 12hr Deter 60 Mg
  • Oxycodone Hcl Tab Er 12hr Deter 80 Mg
  • Paroxetine Hcl Oral Susp 10 Mg/5ml (Base Equiv)
  • Phenyleph-Shark Liver Oil-Cocoa Butter Suppos 0.25-3-85.5%
  • Prednisolone Sod Phos Orally Disintegr Tab 10 Mg (Base Eq)
  • Prednisolone Sod Phos Orally Disintegr Tab 15 Mg (Base Eq)
  • Prednisolone Sod Phos Orally Disintegr Tab 30 Mg (Base Eq)
  • Prefest Tab
  • Prilosec Pow 10mg
  • Prilosec Pow 2.5mg
  • Psyllium Powder 100%
  • Psyllium Powder 95%
  • Rufinamide Susp 40 Mg/Ml
  • Sennosides Tab 17.2 Mg
  • Sodium Phosphates - Enema (Pediatric)
  • Somatuline Inj 120/.5ml
  • Somatuline Inj 60/0.2ml
  • Somatuline Inj 90/0.3ml
  • Sucralfate Susp 1 Gm/10ml
  • Zoladex Imp 10.8mg
  • Zoladex Imp 3.6mg
  • Zolinza Cap 100mg

Other Updates:

  • Aprepitant Capsule 125 Mg (Added Quantity Level Limit)
  • Aprepitant Capsule 40 Mg (Added Quantity Level Limit)
  • Artificial Sol Tears
  • Aspirin Sup 300mg
  • Atropine Sulfate Ophth Oint 1%
  • Codeine Sulf Tab 15mg (Added Quantity Level Limit and Age Minimum)
  • Codeine Sulf Tab 60mg (Added Quantity Level Limit and Age Minimum)
  • Dextromethorphan-Guaifenesin Tab Er 12hr 60-1200 Mg
  • Feverall Sup 325mg
  • Hydromorphon Sup 3mg (Added Quantity Level Limit)
  • Lohist-Dm Syp 5-2-10mg
  • Lubricant Dro Eye 0.6%
  • Lubricating Dro 0.5%
  • Tusnel C Syp (Added Quantity Level Limit and Age Minimum)

 

October 2022

Additions:

  • None

Removals:

  • None

Other Updates:

  • Lenalidomide Cap 2.5Mg
  • Lenalidomide Cap 5Mg
  • Lenalidomide Cap 10Mg
  • Lenalidomide Cap 15Mg
  • Lenalidomide Cap 20Mg
  • Lenalidomide Cap 25Mg
  • Varenicline Tartrate Tab 0.5Mg X 11 & Tab 1Mg X 42 PA

 

September 2022

Additions:

  • Phospho-Trin K500 Tab

Removals:

  • Hypersal Nebulization Solution 3.5 % 

Other Updates:

  • K-Phos Tab 500 mg (Brand)

 

August 2022

Additions:

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

Removals:

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

Other Updates:

  • Acyclovir Cap 200 Mg (Removed Quantity Level Limit)
  • Acyclovir Tab 400 Mg (Removed Quantity Level Limit)
  • Acyclovir Tab 800 Mg (Removed Quantity Level Limit)
  • Austedo Tab 12mg (Added Quantity Level Limit)
  • Austedo Tab 6mg (Added Quantity Level Limit)
  • Austedo Tab 9mg (Added Quantity Level Limit)
  • Ceftriaxone Sodium For Inj 1 Gm (Changed Quantity Level Limit)
  • Ceftriaxone Sodium For Inj 2 Gm (Changed Quantity Level Limit)
  • Ceftriaxone Sodium For Inj 250 Mg (Changed Quantity Level Limit)
  • Ceftriaxone Sodium For Inj 500 Mg (Changed Quantity Level Limit)
  • Ezetimibe Tab 10 Mg (Removed Step Therapy)
  • Glucagon Emergency Kit 1mg Injection (Changed Quantity Level Limit)
  • Gvoke Hypopen Solution Auto-Injector 0.5mg/0.1ml (Changed Quantity Level Limit)
  • Gvoke Hypopen Solution Auto-Injector 1mg/0.2ml (Changed Quantity Level Limit)
  • Gvoke Pfs Solution Prefilled Syringe 0.5mg/0.1ml (Changed Quantity Level Limit)
  • Gvoke Pfs Solution Prefilled Syringe 1mg/0.2ml (Changed Quantity Level Limit)
  • Olopatadine Hcl Ophth Soln 0.1% (OTC) (Removed Step Therapy)
  • Omega-3-Acid Ethyl Esters Cap 1 Gm (Removed Step Therapy)
  • Valacyclovir Hcl Tab 1gm (Removed Quantity Level Limit)
  • Valacyclovir Hcl Tab 500 Mg (Removed Quantity Level Limit)

 

July 2022

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

June 2022

Additions:

  • Epivir HBV Soln 5mg/ml (Quantity Level Limit)
  • Gvoke Hypopen 1-Pack 0.5mg/0.1ml (Quantity Level Limit)
  • Gvoke PFS INJ 1mg/0.2ml (Quantity Level Limit)
  • Lamivudine Tab 100mg (Quantity Level Limit)
  • Pregabalin Cap 200mg (Prior Authorization Required, Quantity Level Limit)

Removals:

  • None

Other Updates:

  • None

 

May 2022

Additions:

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

Removals:

  • None

Other Updates:

  • None

 

April 2022

Additions:

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

Removals:

  • None

Other Updates:

  • None

 

March 2022

Additions:

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

Removals:

  • Combigan Ophth Soln 0.2-0.5%
  • Dry Eye Relief Drops 0.4-0.3%
  • Selzentry Tab 150mg
  • Selzentry Tab 300mg

Other Updates:

  • None

 

February 2022

Additions:

  • Dexcom G5 Mobile Receiver Kit (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G5 Mobile Transmitter Kit (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G5 Mobile/G4 Platinum Sensor Kit (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G6 Receiver (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G6 Sensor (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G6 Transmitter (Prior Authorization Required, Quantity Level Limit)
  • Freestyle Libre 14 Day Reader Device (Prior Authorization Required, Quantity Level Limit)
  • Freestyle Libre 14 Day Sensor (Prior Authorization Required, Quantity Level Limit)
  • Freestyle Libre 2 Reader Device (Prior Authorization Required, Quantity Level Limit)
  • Freestyle Libre 2 Sensor (Prior Authorization Required, Quantity Level Limit)
  • Freestyle Libre Reader Device (Prior Authorization Required, Quantity Level Limit)
  • Freestyle Libre Sensor System (Prior Authorization Required, Quantity Level Limit)
  • Levocetirizine Tablet 5mg (Quantity Level Limit)
  • Naloxone Nasal Liquid 4mg/0.1ml (generic)
  • Norditropin Flexpro Injection 10mg/1.5ml (Prior Authorization Required)
  • Norditropin Flexpro Injection 15mg/1.5ml (Prior Authorization Required)
  • Norditropin Flexpro injection 30mg/3ml (Prior Authorization Required)
  • Norditropin Flexpro Injection 5mg/1.5ml (Prior Authorization Required)
  • Ziextenzo (Prior Authorization Required)

Removals:

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

Other Updates:

  • Diphenhydramine Hcl Liquid 12.5mg/5ml (Added Quantity Level Limit)
  • Eliquis DVT/PE Starter Pack Tablet 5mg (Removed Prior Authorization Required)
  • Eliquis Tablet 2.5mg (Removed Prior Authorization Required)
  • Eliquis Tablet 5mg (Removed Prior Authorization Required)
  • Promethazine Hcl Syrup 6.25mg/5ml (Added Quantity Level Limit)
  • Xarelto 10mg (Removed Prior Authorization Required)
  • Xarelto 15mg (Removed Prior Authorization Required)
  • Xarelto 20mg (Removed Prior Authorization Required)
  • Xarelto Starter Pack 15/20mg (Removed Prior Authorization Required)

 

January 2022

Additions:

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

Removals:

  • Intelence Tab 100mg
  • Intelence Tab 200mg

Other Updates:

  • None

 

December 2021

Additions:

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

Removals:

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

Other Updates:

  • None

 

November 2021

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

October 2021

Additions:

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

Removals:

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

Other Updates:

  • None

 

September 2021

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

August 2021

Additions:

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

Removals:

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

Other Updates:

  • None

 

July 2021

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

June 2021

Additions:

  • None

Removals:

  • Linzess Cap 72mcg
  • Linzess Cap 145mcg
  • Linzess Cap 290mcg

Other Updates:

  • Trulicity Inj 0.75/0.5 (Added Quantity Level Limit)
  • Trulicity Inj 1.5/0.5 (Added Quantity Level Limit)
  • Trulicity Inj 3/0.5 (Added Quantity Level Limit)
  • Trulicity Inj 4.5/0.5 (Added Quantity Level Limit)

 

May 2021

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 Aer 9-4.8mcg (Quantity Level Limit)
  • Cequa Sol 0.09% PF (Prior Authorization Required)
  • Doxycycl Hyc Cap 100mg
  • Doxycycl Hyc Cap 50mg
  • Doxycycl Hyc Tab 100mg
  • Esbriet Cap 267mg (Prior Authorization Required)
  • Esbriet Tab 267mg (Prior Authorization Required)
  • Esbriet Tab 801mg (Prior Authorization Required)
  • Flutic/Salme Aer 100/50 (Age Level Limit, Quantity Level Limit)
  • Hizentra Inj 1gm/5ml (Prior Authorization Required)
  • Hizentra Inj 2gm/10ml (Prior Authorization Required)
  • Hizentra Inj 2gm/10ml (Prior Authorization Required)
  • Hizentra Inj 4gm/20ml (Prior Authorization Required)
  • Hizentra Sol 20% (Prior Authorization Required)
  • Hizentra Via 10gm/50m (Prior Authorization Required)
  • Hizentra Via 1gm/5ml (Prior Authorization Required)
  • Icosapent Cap 1gm (Prior Authorization Required, Quantity Level Limit)
  • Myleran Tab 2mg
  • Ocrevus Inj 300/10ml (Prior Authorization Required, Quantity Level Limit)
  • Pot & Sod Citrates W/ Cit Ac Soln 550-500-334 Mg/5ml
  • Privigen Inj 40grams (Prior Authorization Required)
  • Rabeprazole Tab 20 (Quantity Level Limit)
  • Sodium Citrate & Citric Acid Soln 500-334 Mg/5ml
  • Trulicity Inj 0.75/0.5 (Step Therapy Required)
  • Trulicity Inj 1.5/0.5 (Step Therapy Required)
  • Trulicity Inj 3/0.5 (Step Therapy Required)
  • Trulicity Inj 4.5/0.5 (Step Therapy Required)
  • Tukysa Tab 150mg (Prior Authorization Required)
  • Tukysa Tab 50mg (Prior Authorization Required)
  • Valtoco Liq 15 Mg (Quantity Level Limit)
  • Valtoco Liq 20 Mg (Quantity Level Limit)
  • Valtoco Spr 10mg (Quantity Level Limit)
  • Valtoco Spr 5mg (Quantity Level Limit)
  • Visco-3 Inj 25/2.5ml (Prior Authorization Required)

Removals:

  • Anoro Ellipt Aer 62.5-25
  • Atrovent HFA Aer 17mcg
  • Breo Ellipta Inh 100-25
  • Breo Ellipta Inh 200-25
  • Cefaclor For Susp 125mg/5ml
  • Cefaclor For Susp 250 Mg/5ml
  • Cefaclor For Susp 375 Mg/5ml
  • Clarithromycin Tab ER 24 HR 500mg
  • Combivent Aer 20-100
  • Diazepam Con 5mg/ml
  • Doxycyc Mono Tab 100mg
  • Doxycyc Mono Tab 150mg
  • Doxycyc Mono Tab 50mg
  • Doxycyc Mono Tab 75mg
  • Epogen Inj 10000/ml
  • Epogen Inj 2000/ml
  • Epogen Inj 20000/ml
  • Epogen Inj 3000/ml
  • Epogen Inj 4000/ml
  • Flebogamma Inj 10/200ml
  • Flebogamma Inj 10/200ml
  • Flebogamma Inj Dif 5%
  • Flebogamma Inj Dif 5%
  • Flebogamma Inj Dif 5%
  • Fulphila Inj 6/0.6ml
  • Hyalgan Inj 20mg/2ml
  • Hyalgan Inj 20mg/2ml
  • Hyoscyamine Dro 0.125/ml
  • Janumet Tab 50-1000
  • Janumet Tab 50-500mg
  • Janumet XR Tab 100-1000
  • Janumet XR Tab 50-1000
  • Janumet XR Tab 50-500mg
  • Januvia Tab 100mg
  • Januvia Tab 25mg
  • Januvia Tab 50mg
  • Nivestym Inj 300/0.5
  • Nivestym Inj 300mcg
  • Nivestym Inj 480/0.8
  • Nivestym Inj 480mcg
  • Ofev Cap 100mg
  • Ofev Cap 150mg
  • Verzenio Tab 100mg
  • Verzenio Tab 150mg
  • Verzenio Tab 200mg
  • Verzenio Tab 50mg
  • Victoza Inj 18mg/3ml

Other Updates:

  • Albuterol Aer HFA (Added Quantity Level Limit)
  • Arnuity Elpt Inh 100mcg (Added Quantity Level Limit)
  • Arnuity Elpt Inh 200mcg (Added Quantity Level Limit)
  • Arnuity Elpt Inh 50mcg (Added Quantity Level Limit)
  • Azithromycin Sus 100mg/5ml (Added Age Limit)
  • Azithromycin Sus 200 Mg/5ml (Added Age Limit)
  • Cefadroxil Sus 250/5 ml (Added Age Limit)
  • Cefadroxil Sus 500/5 ml (Added Age Limit)
  • Cefdinir Sus 125/5ml (Added Age Limit)
  • Cefdinir Sus 250/5ml (Added Age Limit)
  • Cefpodo Prox Sus 100/5ml (Added Age Limit)
  • Cefpodo Prox Sus 50mg/5ml (Added Age Limit)
  • Cefprozil Sus 125/5ml (Added Age Limit)
  • Cefprozil Sus 250/5ml (Added Age Limit)
  • Cephalexin Sus 125/5ml (Added Age Limit)
  • Cephalexin Sus 250/5ml (Added Age Limit)
  • Clarithromycin Sus 125mg/5ml (Added Age Limit)
  • Clarithromycin Sus 250mg/5ml (Added Age Limit)
  • Extavia Inj 0.3mg (Added Quantity Level Limit)
  • Gilenya Cap 0.5mg (Added Quantity Level Limit)
  • Glatiramer Inj 20mg/ml (Added Quantity Level Limit)
  • Glatiramer Inj 40mg/ml (Added Quantity Level Limit)
  • Juluca Tab 50-25mg (Added Prior Authorization)
  • Levalbuterol Aer 45/Act (Added Quantity Level Limit)
  • Levofloxacin Sol 25mg/ml (Added Age Limit)
  • Neomycin-Polymyxin-Dexamethasone Ophth Oint 0.1% (Added Quantity Level Limit)
  • Ondansetron Tablet Dispersible 4mg Oral (Added Quantity Level Limit)
  • Ondansetron Tablet Dispersible 8mg Oral (Added Quantity Level Limit)
  • Phenylephrine HCl Ophth Soln 2.5% (Added Quantity Level Limit)
  • Rebif Inj 22/0.5 (Added Quantity Level Limit)
  • Rebif Inj 44/0.5 (Added Quantity Level Limit)
  • Rebif Rebido Inj 22/0.5 (Added Quantity Level Limit)
  • Rebif Rebido Inj 44/0.5 (Added Quantity Level Limit)
  • Rebif Rebido Inj Titratn (Added Quantity Level Limit)
  • Rebif Titrtn Inj Pack (Added Quantity Level Limit)
  • Santyl Oin 250 Unit/gm (Added Quantity Level Limit)

 

February 2021

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

January 2021

Additions:

  • Retacrit Inj 20000uni (Prior Authorization Required)

Removals:

  • None

Other Updates:

  • None

 

December 2020

Additions:

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

Removals:

  • None

Other Updates:

  • None

 

November 2020

Additions:

  • Dimethyl Fum Cap 120mg DR (Quantity Level Limit, Prior Authorization Required)
  • Dimethyl Fum Cap 240mg DR (Quantity Level Limit, Prior Authorization Required)
  • Dimethyl Fumarate Capsule DR Starter Pack 120 Mg & 240 Mg (Quantity Level Limit, Prior Authorization Required)
  • Emtricitabin Cap 200mg (Prior Authorization Required)

Removals:

  • Emtriva Cap 200mg
  • Tecfidera Cap 120mg DR
  • Tecfidera Cap 240mg DR
  • Tecfidera Capsule DR Starter Pack 120 Mg & 240 Mg

Other Updates:

  • None

 

October 2020

Additions:

  • Efavirenz-Lamivudine-Tenofovir Df Tab 400-300-300mg
  • Efavirenz-Lamivudine-Tenofovir Df Tab 600-300-300mg

Removals:

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

Other Updates:

  • None

 

Septmeber 2020

Additions:

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

Removals:

  • None

Other Updates:

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

 

August 2020

Additions:

  • Amitiza Caps 8mcg, 24mcg (Prior Authorization Required, Quantity Level Limit)
  • Buprenorphine Weekly Patches 5mcg, 7.5mcg, 10mcg, 15mcg, 20mcg (Prior Authorization Required, Quantity Level Limit)
  • Diclofenac Sodium Solution 1.5% (Step Therapy, Quantity Level Limit)
  • Ibrance Caps 75mg, 100mg, 125mg (Prior Authorization Required, Quantity Level Limit)
  • Ibrance Tabs 75mg, 100mg, 125mg (Prior Authorization Required, Quantity Level Limit)
  • Lynparza Tabs 10mg, 15mg (Prior Authorization Required, Quantity Level Limit)
  • Omeprazole OTC Tab 20mg (Generic)
  • Poly-Vi-Sol Solution 50mg/ml
  • Solifenacin Succinate Tabs 5mg, 10mg (Step Therapy, Quantity Level Limit)
  • Symproic Tab 0.2mg (Prior Authorization Required, Quantity Level Limit)
  • Testosterone TD Solution 30mg/actuation (Prior Authorization Required, Quantity Level Limit)
  • Tivicay PD Tab 5mg (Diagnosis Confirmation Required, Age Limit)
  • Trelegy Ellipta (Step Therapy, Quantity Level Limit)
  • Tri-Vi-Sol Solution A/C/D

Removals:

  • Cimduo Tab 300-300mg
  • Fluocinolone Acetonide Solution 0.01%
  • Fluorouracil Cream 0.5%
  • Humulin 70/30
  • Humulin N
  • Humulin R
  • Kitabis Nebule Solution 300mg/5ml
  • Naproxen Sodium Tab 275mg
  • Nimodipine Cap 30mg
  • Prilosec OTC Tab 20mg (Brand)
  • Targretin Gel 1%
  • Tolmetin Sodium Cap 400mg
  • Tolmetin Sodium Tabs 200mg, 600mg

Other Updates:

  • Adapalene Gel 0.1% (Removed Step Therapy from Rx Product)
  • Athletes Foot (Miconazole Nitrate) Powder 2% (Quantity Level Limit)
  • Auryxia Tab 210mg (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 HCL Cream 1% (Quantity Level Limit)
  • Candesartan Cilexetil – Hydrochlorothiazide Tabs 16-12.5mg, 32-12.5mg, 32-25mg (Step Therapy Required)
  • Candesartan Cilexetil Tabs 4mg, 8mg, 16mg, 32mg (Step Therapy Required)
  • Ciclopirox Olamine Cream 0.77% (Quantity Level Limit)
  • Ciclopirox Olamine Suspension 0.77% (Quantity Level Limit)
  • Ciclopirox Shampoo 1% (Quantity Level Limit)
  • Ciclopirox Solution 8% (Quantity Level Limit)
  • Ciprofloxacin HCL 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 Tabs 250mg, 500mg (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 25mcg/Actuation (Step Therapy Required)
  • Fluocinonide Cream 0.05% (Quantity Level Limit)
  • Fluocinonide Solution 0.05% (Quantity Level Limit)
  • Fluvastatin Sodium Caps 20mg, 40mg (Step Therapy Required)
  • Hydrocortisone Cream 0.5%, 1%, 2.5% (Quantity Level Limit)
  • Hydrocortisone Lotion 1%, 2.5% (Quantity Level Limit)
  • Hydrocortisone Ointment 0.5%, 1%, 2.5% (Quantity Level Limit)
  • 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 Caps 72mcg, 145mcg, 290mcg (Prior Authorization Required)
  • Liothyronine Sodium Tab 25mcg (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 Tab 50mg (Quantity Level Limit)
  • Neomycin-Polymixin-HC OTIC Solution 1% (Quantity Level Limit)
  • Neomycin-Polymixin-HC OTIC Suspension 3.5mg/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 Tabs 2mg, 4mg, 8mg, 6mg, 12mg (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 HCL 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 Injection 0.5mg/0.1ml (Quantity Level Limit)
  • HM Urinary Pain Relief (Phenazopyridine) Tab 99.5mg

 

June 2020

Additions:

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

Removals:

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

 

May 2020

Additions:

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

Removals:

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

 

April 2020

Additions:

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

Removals:

  • Carafate Suspension 1gm/10ml (Brand)

 

March 2020

Additions:

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

Removals:

  • Apriso Cap 0.375gm (Brand)

Other Updates:

  • Prenatal Vitamin Tabs (Quantity Level Limit)

 

February 2020

Additions:

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

Removals:

  • Afinitor Tab 2.5mg, 5mg, 7.5mg (Brand)
  • Alprazolam Concentrate Solution 1mg/ml
  • Chlorothiazide Tabs
  • Demeclocycline Tabs
  • Doxycycline Monohydrate Tab 150mg
  • First-Vanco Solution 25mg/ml, 50mg/ml
  • Homatropine Ophthalmic Solution 5%
  • Kyleena IUD
  • Methylclothiazide Tab 5mg
  • Mirena IUD
  • Nausea Relief Liquid
  • Nizatidine Solution 15mg/ml
  • Nuvaring (Brand)
  • Phospholine Ophthalmic Solution 0.125%
  • Propantheline Cap 15mg
  • Rabeprazole EC Cap 20mg
  • Ranitidine Caps 150mg, 300mg
  • Skyla IUD

Other Updates:

  • Atropine Ophthalmic Ointment 1% (Quantity Level Limit)
  • Atropine Ophthalmic Solution 1% (Quantity Level Limit)
  • Buspirone Tabs 5mg, 7.5mg, 10mg, 15mg (Age Limit)
  • Combigan Ophthalmic Solution 0.5/0.5% (Quantity Level Limit)
  • Diazepam Concentrate 5mg/ml (Quantity Level Limit)
  • Diazepam Oral Solution (Quantity Level Limit)
  • Diazepam Tabs 2mg, 5mg, 10mg (Quantity Level Limit)
  • Divalproex ER Tab 250mg, 500mg (Prior Authorization Required)
  • Dorzolamide-Timolol Ophthalmic Solution 22.3-6.8% (Quantity Level Limit, Step Therapy Required)
  • Doxycycline Monohydrate Suspension 25mg/5ml (Age Limit)
  • Granisetron Tab 1mg (Step Therapy Required)
  • Hydroxyzine Pamoate Caps 25mg, 50mg, 100mg (Quantity Level Limit)
  • Hydroxyzine Tab 50mg (Quantity Level Limit)
  • Levofloxacin Ophthalmic Solution 0.5% (Quantity Level Limit)
  • Lorazepam Concentrate 2mg/ml (Age Limit, Quantity Level Limit)
  • Memantine Tabs 5mg, 10mg (Quantity Level Limit)
  • Methazolamide Tabs 25mg, 50mg (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 Films 2-0.5mg, 4-1mg, 8-2mg, 12-3mg (Quantity Level Limit)

Removals:

  • Ventolin HFA Inhaler (brand name)

 

 

December 2019

Removals:

  • PreNata Chewable Tab 29-1mg

 

 

November 2019

No Updates

 

 

October 2019

Other Updates:

  • Cetirizine Solution 1mg/ml (Quantity Level Limit)

 

 

September 2019

Additions:

  • Ambrisentan Tabs 5mg, 10mg (Prior Authorization Required, Quantity Level Limit)
  • Bosentan Tabs 62.5mg, 125mg (Prior Authorization Required, Quantity Level Limit)
  • Febuxostat Tabs 40mg, 80mg (Step Therapy Required)
  • Ramelteon Tab 8mg (Step Therapy Required, Quantity Level Limit)
  • Ribavirin Tab/Cap 200mg (Step Therapy Required)

Removals:

  • Letairis Tabs 5mg, 10mg (Brand)
  • Rozerem Tab 8mg (Brand)
  • Tracleer Tabs 62.5mg, 125mg (Brand)
  • Uloric Tabs 40mg, 80mg (Brand)

 

 

August 2019

Additions:

  • Aquadeks Drops
  • Butenafine Cream 1% (OTC)
  • Lidocaine Patch 4% (Quantity Level Limit)
  • Thyroid Tabs 180mg, 240mg, 300mg (Quantity Level Limit)

Removals:

  • Ciclopirox Gel 0.77%
  • Clotrimazole w/ Betamethasone Lotion 1-0.05%
  • Colestipol Granules 5gm
  • Epinastine Ophthalmic Solution 0.05%
  • Fluphenazine Elixir 2.5mg/5ml
  • Fluphenazine Injection 2.5mg/ml
  • Lindane Shampoo 1%
  • Moexipril Tabs 7.5mg, 15mg
  • Nitroglycerin Cap 2.5mg
  • Olopatadine Ophthalmic Solution 0.2%
  • Quinidine Gluconate CR Tab 324mg
  • Thyroid Tab 130mg

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 Tabs 5mcg, 50mcg (Quantity Level Limit)
  • Norethindrone Tab 5mg (Step Therapy Required)
  • Olanzapine ODT Tabs (Age Limit)
  • Olanzapine Tabs (Age Limit)
  • Quetiapine Tabs (Age Limit)
  • Risperidone ODT Tabs (Age Limit)
  • Risperidone Oral Solution 1mg/ml (Age Limit)
  • Risperidone Tabs (Age Limit)
  • Sertraline Concentrate Oral Solution 20mg/ml (Age Limit)
  • Thyroid Tabs 15mg, 30mg, 60mg, 90mg, 120mg (Quantity Level Limit)

 

 

July 2019

Additions:

  • Cefixime Cap 400mg (Quantity Level Limit)
  • Erlotinib Tab 150mg (Prior Authorization Required)
  • Mesalamine DR Cap 400mg (Quantity Level Limit)

Removals:

  • Suprax Cap 400mg (brand)
  • Tarceva Tab 150mg (brand)

 

 

June 2019

Additions:

  • Docosanol Cream 10% (Quantity Level Limit)
  • Melatonin Tabs 1mg, 3mg, 5mg

Removals:

  • Abreva Cream 10% (brand)

 

 

May 2019

Additions:

  • Erythromycin Ethylsuccinate Suspension 400mg/5ml
  • Fulphila Injection 6mg/0.6ml (Prior Authorization Required)
  • Nivestym Injection 300mcg, 480mcg (Prior Authorization Required)
  • Sirolimus Solution 1mg/ml
  • Udenyca Injection 6mg/0.6ml (Prior Authorization Required)

Removals:

  • Eryped Suspension (brand) 400mg/5ml
  • Rapamune Solution (brand) 1mg/ml

 

 

April 2019

Other Updates:

  • Antiretroviral Medications (Diagnosis Confirmation Required)

 

 

March 2019

Additions:

  • Admelog Vial 300 units/3mL
  • Albuterol HFA Inhaler 90mcg – generic Ventolin HFA (Quantity Level Limit)
  • Arthritis Pain Relieving Cream 0.075%
  • Carafate Oral Suspension 1gm/10ml (Age Limit)
  • Mesalamine Suppository 1000mg
  • Toremifene Tab 60mg

Removals:

  • Canasa Suppository 1000mg
  • Fareston Tab 60mg
  • Norethindrone Acetate & Estradiol-FE Tab 1mg-20mcg (24)

Other Updates:

  • Attention Deficit/Hyperactivity Disorder Stimulant Medications (Age Limit, Removed Prior Authorization)
  • Butalbital Containing Products (Quantity Level Limit)
  • Citalopram Oral Solution 10mg/5ml (Age Limit)
  • Dicyclomine Oral Solution 10mg/ml (Age Limit)
  • Escitalopram Oral Solution 5mg/5ml (Age Limit)
  • Famotidine Oral Suspension 40mg/5ml (Age Limit)
  • Lansoprazole Oral Suspension 3mg/ml (Age Limit)
  • Nitrofurantoin Oral Suspension 25mg/5ml (Age Limit)
  • Nortriptyline Oral Solution 10mg/5ml (Age Limit)
  • Omeprazole Oral Suspension 2mg/ml (Age Limit)
  • Oseltamivir Cap 30mg (Removed Age Limit)
  • Oseltamivir Oral Suspension 6mg/ml (Removed Age Limit)
  • Prednisone Oral Solution 5mg/5ml (Age Limit)

 

 

February 2019

Additions:

  • Arnuity Ellipta Inhaler
  • Eligard Kit 7.5mg, 22.5mg, 30mg, 45mg (Prior Authorization Required)
  • Flebogamma IV Solution 5gm/50ml, 10gm/100ml, 20gm/200ml (Prior Authorization Required)
  • Immune Globulin IV Solution 1gm/10ml, 2.5gm/25ml, 5gm/50ml, 10gm/100ml, 20gm/200ml, 30gm/300ml, 40gm/400ml (Prior Authorization Required)
  • Leuprolide Acetate Kit 1mg/0.2ml (Prior Authorization Required)
  • Ozempic Injection (Quantity Level Limit, Step Therapy Required)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 27-0.8mg (Quantity Level Limit)
  • Prenatal Vitamin with Iron Carbonyl-Folic Acid Tab 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Minerals-Ferrous Fumarate-Folic Acid-DHA Pack 28-0.8-200mg (Quantity Level Limit)
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Folic Acid Chewable Tab 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid Cap 20-20-1.25mg (Quantity Level Limit)
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid Cap 130-92.4-1mg (Quantity Level Limit)
  • Segluromet Tabs (Quantity Level Limit, Step Therapy Required)
  • Steglatro Tabs (Quantity Level Limit, Step Therapy Required)
  • Victoza Injection (Quantity Level Limit, Step Therapy Required)

Removals:

  • Alprazolam Orally Disintegrating Tabs
  • Cleocin Vaginal Ovule 100mg
  • Clorazepate Dipotassium Tabs
  • Condylox Gel 0.5%
  • Cortifoam Rectal Aerosol
  • Cuprimine Cap 250mg
  • Dihydroergotamine Mesylate Nasal Spray 4mg/ml
  • Dulera Inhaler
  • Elidel Cream 1%
  • Ergotamine SL Tab 2mg
  • Ergotamine-Caffeine Suppository 2-100mg
  • Ergotamine-Caffeine Tab 1-100mg
  • Flovent Diskus
  • Humalog Pens/Cartridges
  • Humalog Vials
  • Invokamet Tabs
  • Invokana Tabs
  • Levonorgestrel-Ethinyl Estradiol Tab 0.15-0.03mg (84) & Ethinyl Estradiol Tab 0.01mg (7)
  • Lidocaine-Hydrocortisone Rectal Kit 20x7gm
  • Lidocaine-Hydrocortisone Rectal Kit 3-1%
  • Meprobamate Tabs
  • Miconazole 3 Suppository 200mg
  • Nitro-Bid Cream Packets 2%
  • Novolog Pens/Cartridges
  • Novolog Vials
  • Plan B Tab (Brand Only)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 65-1mg
  • Prenatal Vitamin with Ferrous Fumarate-L Methylfolate-Folic Acid Tab 27-0.6-0.4mg
  • Prenatal Vitamin with Iron Polysaccharide Complex-Folic Acid Chew Tab 29-1mg
  • Prenatal Vitamin with Iron Polysaccharide Complex-L Methylfolate-Folic Acid Chew Tab 29-0.6-0.4mg
  • Prenatal Vitamin with Minerals with Iron Poly Saccharide Complex-Folic Acid-DHA Cap 29-1-200mg
  • Prenatal Vitamin with Minerals with Iron Poly Saccharide Complex-Folic Acid-DHA Pack 1mg & 250mg
  • Prenatal Vitamin without Vit A with Ferrous Asparto Glyc-L Methylfolate-Folic Acid- DHA Cap 10-0.6-0.4-200mg
  • Prenatal Vitamin without Vit A with Ferrous Asparto Glyc-L Methylfolate-Folic Acid- DHA Cap 18-0.6-0.4-300mg
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-DSS-Folic Acid-DHA Cap 27-1.25-300mg
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-L Methylfolate-Folic Acid-DHA Cap 27-0.6-0.4-300mg
  • Pulmicort Flexhaler
  • Qvar Inhaler
  • Relenza Diskhaler
  • Synjardy Tabs
  • Terconazole Vaginal Suppository 80mg
  • Thalomid Caps
  • Triazolam Caps
  • Trimethobenzamide Cap 300mg
  • Trulicity Injection

Other Updates:

  • Abilify Maintena Injection (Quantity Level Limit)
  • Acyclovir Suspension 200mg/5ml (Age Limit)
  • Alprazolam SR Tabs 0.5mg, 1mg, 2mg, 3mg (Age Limit)
  • Alprazolam Tabs 0.25mg, 0.5mg, 1mg, 2mg (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 Caps 5mg, 10mg, 25mg (Quantity Level Limit)
  • Citalopram Solution 10mg/5ml (Age Limit)
  • Clozapine Tabs (Quantity Level Limit)
  • Dicyclomine Solution 10mg/ml (Age Limit)
  • Escitalopram Solution 5mg/5ml (Age Limit)
  • Famotidine Suspension 40mg/5ml (Age Limit)
  • Flovent HFA Inhaler (Age Limit)
  • Fluphenazine Concentrate 5mg/ml (Quantity Level Limit)
  • Fluphenazine Elixir 2.5mg/5ml (Quantity Level Limit)
  • Fluphenazine Injection 2.5mg/ml (Quantity Level Limit)
  • Fluphenazine Injection 25mg/ml (Quantity Level Limit)
  • Haloperidol Concentrate 2mg/ml (Quantity Level Limit)
  • Haloperidol Decanoate Injection 100mg/ml (Quantity Level Limit)
  • Haloperidol Decanoate Injection 50mg/ml (Quantity Level Limit)
  • Haloperidol Lactate Injection 5mg/ml (Quantity Level Limit)
  • Haloperidol Tabs (Quantity Level Limit)
  • Hydroxyzine Tabs 10mg, 25mg, 50mg (Quantity Level Limit)
  • Invega Sustena Injection (Quantity Level Limit)
  • Invega Trinza Injection (Quantity Level Limit)
  • Jardiance Tabs (Remove Step Therapy, Add Prior Authorization Required)
  • Lansoprazole Suspension 3mg/ml (Age Limit)
  • Lithium Carbonate Caps (Quantity Level Limit)
  • Lithium Carbonate ER Tab 300mg, 450mg (Quantity Level Limit)
  • Lithium Carbonate Tab 300mg (Quantity Level Limit)
  • Lithium Solution 8meq/5ml (Quantity Level Limit)
  • Lorazepam Tabs 0.5mg, 1mg, 2mg (Quantity Level Limit)
  • Loxapine Caps (Quantity Level Limit)
  • Nitrofurantoin Suspension 25mg/5ml (Age Limit)
  • Nortriptyline Solution 10mg/5ml (Age Limit)
  • Olanzapine Orally Disintegrating Tabs (Quantity Level Limit)
  • Olanzapine Tabs (Quantity Level Limit)
  • Omeprazole Suspension 2mg/ml (Age Limit)
  • Oseltamivir Cap 30mg (Quantity Level Limit, Age Limit)
  • Oseltamivir Caps 45mg, 75mg (Quantity Level Limit)
  • Oseltamivir Suspension 6mg/ml (Quantity Level Limit, Age Limit)
  • Oxazepam Caps 10mg, 15mg, 30mg (Quantity Level Limit)
  • Perphenazine Tabs (Quantity Level Limit)
  • Prednisone Solution 5mg/5ml (Age Limit)
  • Prenatal Vitamin with Docusate-Ferrous Fumarate-Folic Acid Tab 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Chewable Tab 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 27-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 28-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 60-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid-Omega 3 Cap 38-1mg (Quantity Level Limit)
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Folic Acid Cap 106.5-1mg (Quantity Level Limit)
  • Prochlorperazine Suppository 25mg (Quantity Level Limit)
  • Prochlorperazine Tabs (Quantity Level Limit)
  • Quetiapine Tabs (Quantity Level Limit)
  • Risperdal Consta Injection (Quantity Level Limit)
  • Risperidone Orally Disintegrating Tabs (Quantity Level Limit)
  • Risperidone Solution 1mg/ml (Quantity Level Limit)
  • Risperidone Tabs (Quantity Level Limit)
  • Thioridazine Tabs (Quantity Level Limit)
  • Thiothixene Caps (Quantity Level Limit)
  • Trifluoperazine Tabs (Quantity Level Limit)
  • Ziprasidone Caps (Quantity Level Limit)

 

January 2019

No Changes

 

December 2018

Additions:

  • Itraconazole Solution 10mg/ml
  • Nivestym Injection 300mcg, 480mcg (Prior Authorization Required)

Removals:

  • Gleostine Caps 10mg, 40mg, 100mg
  • Mometasone Nasal Spray
  • Nasonex Nasal Spray
  • Sporanox Solution 10mg/ml

 

November 2018

Additions:

  • Albendazole Tab 200mg (Step Therapy Required)

Removals:

  • Albenza Tab 200mg

 

October 2018

Additions:

  • Admelog Vial
  • Loratadine Chewable Tab 5mg (Quantity Level Limit)
  • Prasugrel Tabs (Quantity Level Limit)
  • Tadalafil Tab 20mg (Step Therapy, Quantity Level Limit)
  • Tazarotene Cream 0.1% (Quantity Level Limit)
  • Tymlos Pen (Prior Authorizations Required, Quantity Level Limit)
  • Valganciclovir Tab 450mg (Quantity Level Limit)

Removals:

  • Adcirca Tab 20mg

Other Updates:

  • Ondansetron Tabs 4mg, 8mg (Quantity Level Limit)
  • Tizanidine Tabs 2mg, 4mg (Quantity Level Limit)

 

September 2018

Additions:

  • Colesevelam HCL Packet 3.75gm
  • Diclofenac Gel 1% (Quantity Level Limit)
  • Humira Pen CD/UC/HS Starter Kit 80mg/0.8ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Pen PS/UV Starter Kit 80mg/0.8ml and 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
  • Hydroxyprogesterone Caproate Injection 250mg/ml (Prior Authorization Required)
  • Omega 3 Ethyl Esters Acid 1gm Cap (Step Therapy, Quantity Level Limit)
  • Sevelamer Tab 800mg (Step Therapy)
  • Symtuza Tab (Quantity Level Limit)
  • Telmisartan Tab 20mg, 40mg, 80mg (Quantity Level Limit)
  • Tolterodine ER Cap 2mg, 4mg (Step Therapy, Quantity Level Limit)
  • Vemlidy Tab 25mg (Quantity Level Limit)
  • Verzenio Tabs 50mg, 100mg, 150mg, 200mg (Prior Authorization Required, Quantity Level Limit)

Removals:

  • Amlodipine-Valsartan-Hydrochlorothiazide Tabs
  • Betaxolol Tabs
  • Calcitriol Solution
  • Captopril Tabs
  • Captopril-Hydrochlorothiazide Tabs
  • Chlorpropramide Tabs
  • Climara Pro Patch Weekly
  • Desipramine Tabs
  • Diltiazem CD Cap 360mg
  • Femring
  • Fenofibrate Tab 48mg, 145mg
  • Fenofibric DR Caps
  • Fenoprofen Tab 600mg
  • Lidocaine Cream 3%
  • Makena Injection 250mg/ml
  • Marplan Tab 10mg
  • Meclofenamate Sodium Caps
  • Methyltestosterone Cap 10mg
  • Nadolol Tabs
  • Nisoldipine ER Tabs
  • Ondansetron Solution
  • Oxaprozin Tab 600mg
  • Pindolol Tabs
  • Pioglitazone-Glimepiride Tabs
  • Pioglitazone-Metformin Tabs
  • Potassium-Sodium Citrates & Citric Acid Solution
  • Premarin Tabs
  • Premphase Tabs
  • Prempro Tabs
  • Protriptyline Tabs
  • Tolazamide Tabs
  • Tolbutamide Tab 500mg
  • Tranylcypromine Tab 10mg
  • Verapamil ER 24hr Cap 300mg

Other Updates:

  • Amlodipine Tab 2.5mg, 5mg (Quantity Level Limit)
  • Baraclude Solution (Quantity Level Limit)
  • Benazepril Tab 5mg, 10mg, 20mg (Quantity Level Limit)
  • Benzonatate Caps 100mg, 200mg (Age Limit, Quantity Level Limit)
  • Clonidine Patches (Step Therapy)
  • Diazepam Rectal Gel 2.5mg, 10mg, 20mg (Quantity Level Limit)
  • Diltiazem CD Cap 180mg (Quantity Level Limit)
  • Diltiazem ER Beads Cap 180mg (Quantity Level Limit)
  • Diltiazem ER Cap 180mg (Quantity Level Limit)
  • Elmiron Cap (Prior Authorization Required)
  • Enalapril Tabs 2.5mg, 5mg, 10mg (Quantity Level Limit)
  • Estradiol Vaginal Cream 0.01% (Prior Authorization Required)
  • Estring Vaginal Ring 2mg (Quantity Level Limit)
  • Flunisolide Nasal Solution 0.025% (Quantity Level Limit)
  • Fosinopril Tabs 10mg, 20mg (Quantity Level Limit)
  • Gabapentin Tabs (Cumulative Maximum Dose)
  • Griseofulvin Suspension (Step Therapy)
  • Griseofulvin Microsize Tabs (Step Therapy)
  • Griseofulvin Ultramicrosize Tabs (Step Therapy)
  • Hydrocodone-Homatropine Syrup (Age Limit, Quantity Level Limit)
  • Hydrocodone-Homatropine Tabs (Age Limit, Quantity Level Limit)
  • Lidocaine Ointment 5% (Prior Authorization Required)
  • Lisinopril Tabs 2.5mg, 5mg, 10mg, 20mg, 30mg (Quantity Level Limit)
  • Losartan Potassium Tabs 25mg, 50mg (Quantity Level Limit)
  • Mometasone Furoate Nasal Suspension 50mcg/actuation (Quantity Level Limit)
  • Oxybutynin ER Tab 15mg (Quantity Level Limit)
  • Oxybutynin IR Tab 5mg (Quantity Level Limit)
  • Oxybutynin Syrup (Quantity Level Limit)
  • Propranolol ER Cap 80mg (Quantity Level Limit)
  • Quinapril Tabs 5mg, 10mg, 20mg (Quantity Level Limit)
  • Ramipril Caps 1.25mg, 2.5mg, 5mg (Quantity Level Limit)
  • Tenofovir Tab 300mg (Quantity Level Limit)
  • Tolterodine Tabs 1mg, 2mg (Step Therapy)
  • Trospium ER Cap 60mg (Step Therapy)
  • Trospium IR Tab 20mg (Step Therapy)

 

August 2018

Additions:

  • Retacrit Injection (Prior Authorization Required)
  • Cimduo Tabs (Quantity Level Limit)

Other Updates:

  • Loratadine Tab 10mg (Added Quantity Level Limit)
  • Loratadine Orally Disintegrating Tab 10mg (Added Quantity Level Limit)

 

July 2018

Additions:

  • Baclofen Tab 5mg (Quantity Level Limit)
  • Diphenhydramine Liquid 6.25mg/ml
  • Norvir Powder Packets 100mg
  • Pediatric Multiple Vitamins with Iron Drops 11mg/ml
  • Phytonadione Tab 5mg
  • Zenpep Cap 15,000 Units
  • Zenpep Cap 3000 Units

Removals:

  • Mephyton Tab 5mg

 

June 2018

Additions:

  • Humira Pediatric Crohn’s Prefilled Syringe Kit 80mg/0.8ml and 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Pediatric Crohn’s Prefilled Syringe Kit 80mg/0.8ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Pen-Injector Kit 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Prefilled Syringe Kit 10mg/0.1ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Prefilled Syringe Kit 20mg/0.2ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Prefilled Syringe Kit 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
  • Lansoprazole ODT
  • Praziquantel Tab 600mg (Prior Authorization Required)
  • Symfi Tab (Quantity Level Limit)
  • Tasigna Cap 50mg (Prior Authorization Required, Quantity Level Limit)
  • Zenpep Cap 10,000 Units

Removals:

  • Biltricide Tab 600mg
  • Fluorouracil Cream 1%
  • Pramoxine-HC-Chloroxylenol OTIC solution
  • Prevacid ODT

Other Updates:

  • Flunisolide Nasal Spray (Removed Step Therapy)
  • Fluticasone Nasal Spray (Removed Step Therapy)
  • Lansoprazole ODT (Removed Prior Auth)
  • Levonorgestrel Tab 1.5mg (Removed Quantity Level Limit)
  • Mometasone Nasal Spray (Removed Step Therapy)

 

May 2018

Additions:

  • Colchicine Cap 0.6mg (Quantity Level Limit)
  • Firvanq Sol
  • Imbruvica Cap 70mg (Quantity Level Limit)
  • Imbruvica Tab 420mg (Quantity Level Limit)
  • Imbruvica Tab 560mg (Quantity Level Limit)
  • Jardiance Tab (Quantity Level Limit, Step Therapy Required)
  • Refresh Tear Drop 0.5%
  • Ritonavir 100mg tab
  • Symfi Lo tab (Quantity Level Limit)
  • Synjardi Tab (Quantity Level Limit, Step Therapy Required)
  • Synjardi XR 10mg/1000mg (Quantity Level Limit, Step Therapy Required)
  • Synjardi XR 12.5mg/1000mg (Quantity Level Limit, Step Therapy Required)
  • Synjardi XR 25mg/1000mg (Quantity Level Limit, Step Therapy Required)
  • Synjardi XR 5mg/1000mg (Quantity Level Limit, Step Therapy Required)
  • Virt-PN DHA tab
  • Virt-PN tab

Removals:

  • BP Folinatal Tab Plus B
  • BP Multinatal Chw Plus
  • BP Multinatal Plus
  • Norvir 100 tablet
  • PNV-DHA
  • PNV-Select

Other Updates:

  • Rosuvastatin Tab (Removed Prior Authorization, Added Step Therapy)

 

April 2018

Additions:

  • Biktarvy (Quantity Level Limit)

 

March 2018

Additions:

  • Armodafinil tablets (Prior Authorization Required, Quantity Level Limit)
  • Avonex (Prior Authorization Required, Quantity Level Limit)
  • Betaxolol 0.5% soln (Quantity Level Limit)
  • Brinzolamide (Quantity Level Limit)
  • Ciprofloxacin 250mg/5mlsuspension (Quantity Level Limit)
  • Combigan (Step Therapy Required)
  • Levobunolol 0.5% soln (Quantity Level Limit)
  • Metipranolol 0.3% soln (Quantity Level Limit)
  • Sprycel (Prior Authorization Required, Quantity Level Limit)

Removals:

  • Betoptic-S suspension 0.25%
  • Brimonidine 0.15%
  • Brompheniramine Chew
  • Cefaclor ER tablets
  • Cefixime suspension
  • Cephalexin tablets
  • Ciloxan ointment
  • Ciprofloxacin ER tablets
  • Fluoprolex Cream 1%
  • Fluorabon Drops
  • FML Forte 0.25%
  • Gatifloxacin solution
  • Homotropine Solution 5% Ophthalmic Drops
  • Jentadueto
  • Jentadueto XR
  • Modafinil tablets
  • Morphine ER capsules
  • Moxifloxacin
  • Nature-Throid
  • Neomycin/Polymyxin/HC drops
  • Non-BD diabetic supplies
  • Ofloxacin
  • Oxycodone 20mg/ml concentrated soln
  • Oxycodone 5mg capsules
  • Oxymorphone
  • Oxymorphone IR
  • Pred Mild 0.12%
  • Silver Nitrate Applicator
  • Sodium Fluoride Tablets
  • Suprax chew tablets
  • TobraDex ointment
  • Tobramycin/Dexamethasone drops
  • Tobrex ointment
  • Tradjenta

Other Updates:

  • Carteolol 1% soln (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 Aug 0.05% lotion, gel & ointment (Quantity Level Limit)
  • Clobetasol 0.05% gel & ointment (Quantity Level Limit)
  • Clobetasol 0.05% solution (Quantity Level Limit)
  • Clobetasol emol 0.05% cream (Quantity Level Limit)
  • Duloxetine 20mg, 30mg (Quantity Level Limit)
  • Duloxetine 40mg DR (Quantity Level Limit)
  • Duloxetine 60mg (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 XR (Step Therapy Required)
  • Januvia (Step Therapy Required)
  • Naproxen 125mg/5ml (Step Therapy Required)
  • Opsumit (Prior Authorization Required, Quantity Level Limit)
  • Risperdal Consta (Prior Authorization Required)

Removals:

  • Albuterol 2mg & 4mg tab
  • Albuterol ER 4mg & 8mg tab
  • Amcinonide 0.1% cream & lotion
  • Capex Shampoo 0.01%
  • Clobetasol 0.05% lotion & shampoo
  • Clobetasol Aer 0.05% foam & emolient
  • Desonide 0.05% cream, lotion, &ointment
  • Desoximetasone 0.05% cream, gel, & ointment
  • Desoximetasone 0.25% cream & ointment
  • Diflorasone 0.05% cream & ointment
  • Fluocin Body & Scalp Oil 0.01%
  • Fluocinonide 0.05% Lotion
  • Fluocinonide 0.1% Cream
  • Fluticasone 0.05% Lotion
  • Fondaparinux
  • Fragmin
  • HC Butyrate 0.1% cream & ointment
  • HC Valerate 0.2% cream & ointment
  • Hydrocort sol but
  • Pramosone-HC cream 1-1%
  • Prednicarbt 0.1% cream
  • Terbutaline 2.5mg & 5mg tab
  • TobraDex ST suspension
  • Trianex 0.05% oint
  • Triderm cream 0.1% (select NDC #’s only)
  • Vancomycin Capsule 125mg & 250mg

Other Updates:

  • Brimonidine 0.2% (Changed Quantity Level Limit)
  • Timolol 0.25% & 0.5% sol (Changed Quantity Level Limit)

Prior authorization for drugs

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

 

Antidepressants   

Atypical Antipsychotics Long-Acting Injectables  

Atypical Antipsychotics Oral       

CNS Stimulants (ADD/ADHD Medications)  

Corlanor    

Egrifta     

Hepatitis C  

Monoamine Depletors (Austedo, Ingrezza, tetrabenzaine) 

Opioids Long and Short Acting  

Synagis 

Tepezza 

 

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:

Billing Information: 

BIN: 610591

PCN: ADV

Group: (Medicaid) RX8813

Group: (CHIP) RX8814

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)

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 

                                       

Antihyperlipidemics                                                                           

Botulinum Toxins                                                    

Colony Stimulating Factors                       

Cytokine and CAM Antagonists 

Endari      

Growth Hormone                                           

Hepatitis C 

Hereditary Angioedema Agents                                 

Immune Globulins 

Injectable Osteoporosis Agents                                        

Multiple Sclerosis Agents 

Nayzilam

Opioids Long and Short Acting

Trial Dose Program 

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

Banks Apothecary

Caremark Specialty Pharmacy

Einstein at Center One Pharmacy

Elwyn Specialty Care

Giant Eagle Pharmacy

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

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.

Specialty locations

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.

Coming Soon!

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.

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:

  1. Submit the appeal in writing to Aetna Better Health to the address above.
  2. Include all supporting documentation with the appeal submission:
    1. Chains/PSAOs
      1. Documentation of denied Pricing Appeal outcome from the PBM
      2. Documentation that outreach regarding the denied outcome of appeal has been made to their PSAO or Corporate Headquarters with no resolution
    2. Independent Pharmacies not affiliated with a PSAO
      1. Documentation of denied Pricing Appeal outcome from the PBM
    3. Claim information that includes:
      1. Pharmacy NCPDP number
      2. Pharmacy Name
      3. Name of PSAO (if applicable)
      4. Prescription number
      5. NDC
      6. Drug Name
      7. Date of Fill
    4. 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
  3. We will acknowledge a Pharmacy Provider Appeal within five (5) business days after receipt.
  4. The appeal documentation will be reviewed, and a decision will be rendered within thirty (30) business days after receipt.
  5. 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.