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Formulary search tool and updates

Stay up to date with your medicine. A formulary is a list of medicines we cover. It can help you manage your medicines. CCC Plus members who are enrolled in Medicare Part A and/or Part B should use the Dual eligible formulary. Additionally, a printed version of the formulary is available. Just check our pharmacy benefits page to learn more.

Questions?

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Your formulary search tool

There are many different things that you can do with your formulary search tool. You can:

 

  • Search for your medicine by name or class

  • Find generic alternatives to your medicine

  • See if your medicine has quantity limits, has age limits or needs prior authorization 

July 2022

 

Additions:

 

  • Dexmethylphenidate 10 Mg Tab (Age Limit)
  • Dexmethylphenidate 2.5 Mg Tab (Age Limit)
  • Dexmethylphenidate 5 Mg Tab (Age Limit)
  • Dimethyl Fumarate 120 Mg Cap Dr
  • Dimethyl Fumarate 240 Mg Cap Dr
  • Dimethyl Fumarate Starter Pack 120 Mg & 240 Mg
  • Insulin Aspart 100 Unit/Ml
  • Makena Auto-Injector 275 Mg/1.1ml
  • Mesalamine Cap CR 500 Mg
  • Nurtec ODT 75 Mg Tab (Age Limit, Quantity Limit, Step Therapy)
  • Progesterone 100 Mg Cap
  • Progesterone 200 Mg Cap
  • Spiriva Respimat 1.25 Mcg Inh
  • Spiriva Respimat 2.5 Mcg Inh
  • Xarelto Sus 1mg/Ml
  • Zimhi Sol 5 Mg/0.5ml

 

Removals:

 

  • Acyclovir Cream 5%
  • Clozapine ODT 100 Mg Tab
  • Clozapine ODT 12.5 Mg Tab
  • Clozapine ODT 150 Mg Tab
  • Clozapine ODT 200 Mg Tab
  • Clozapine ODT 25 Mg Tab
  • Focalin 10 Mg Tab
  • Focalin 2.5 Mg Tab
  • Focalin 5 Mg Tab
  • Glatiramer Inj 20 Mg/Ml
  • Glatiramer Inj 40 Mg/Ml
  • Glatopa Inj 20 Mg/Ml
  • Glyxambi 10 Mg-5 Mg Tab
  • Glyxambi 25 Mg-5 Mg Tab
  • Hydroxyprogesterone Caproate Im Oil 250 Mg/Ml
  • Renflexis 100 Mg Vial
  • Tecfidera 120 Mg Cap
  • Tecfidera 240 Mg Cap
  • Tecfidera Starter Pack 120 Mg & 240 Mg
  • Ubrelvy 100 Mg Tab
  • Ubrelvy 50 Mg Tab
  • Urea Nail Gel 45%
  • Zovirax Cream 5%

 

Other Updates:

 

  • Norethindrone Acetate 5 Mg Tab (Step Therapy Termed)

 

June 2022

 

Additions:

 

No updates

 

Removals:

 

  • No updates

 

Other Updates:

 

  • No updates

 

May 2022

 

Additions:

 

  • No updates

 

Removals:

 

  • No updates

 

Other Updates:

 

  • No updates

 

April 2022

 

Additions:

 

  • Baclofen 5 Mg/5 Ml Solution
  • Cimduo 300-300 Mg Tab OTC (Quantity Limit)
  • Delstrigo 100-300-300 Mg Tab OTC (Quantity Limit)
  • Descovy 120-15 Mg Tablet (Quantity Limit)
  • Digoxin 62.5 Mcg Tablet
  • Efavirenz400-Lamiv300-Tenof300 OTC (Quantity Limit)
  • Efavirenz600-Lamiv300-Tenof300 OTC (Quantity Limit)
  • Fexofenadine Hcl 180 Mg Tablet (Generic Only)
  • Maraviroc 150 Mg Tablet (Quantity Limit)
  • Maraviroc 300 Mg Tablet (Quantity Limit)
  • Pifeltro 100 Mg Tab OTC (Quantity Limit)
  • Rukobia Er 600 Mg Tablet OTC (Quantity Limit)
  • Symtuza 800-150-200-10 Mg Tab OTC (Quantity Limit)

 

Removals:

 

  • Allegra 180 Mg Tablet

 

Other Updates:

 

  • Abacavir 20 Mg/Ml Solution (Added Quantity Limit)
  • Abacavir 300 Mg Tablet (Added Quantity Limit)
  • Abacavir-Lamivudine 600-300 Mg (Added Quantity Limit)
  • Abacavir-Lamivudine-Zidov Tab (Added Quantity Limit)
  • Aptivus 250 Mg Capsule (Added Quantity Limit)
  • Atazanavir Sulfate 150 Mg Cap (Added Quantity Limit)
  • Atazanavir Sulfate 200 Mg Cap (Added Quantity Limit)
  • Atazanavir Sulfate 300 Mg Cap (Added Quantity Limit)
  • Atripla Tablet (Added Quantity Limit)
  • Biktarvy 30-120-15 Mg Tablet (Added Quantity Limit)
  • Biktarvy 50-200-25 Mg Tablet (Added Quantity Limit)
  • Complera Tablet (Added Quantity Limit)
  • Descovy 200-25 Mg Tablet (Added Quantity Limit)
  • Dovato 50-300 Mg Tablet (Added Quantity Limit)
  • Edurant 25 Mg Tablet (Added Quantity Limit)
  • Efavirenz 200 Mg Capsule (Added Quantity Limit)
  • Efavirenz 50 Mg Capsule (Added Quantity Limit)
  • Efavirenz 600 Mg Tablet (Added Quantity Limit)
  • Emtricitabine 200 Mg Capsule (Added Quantity Limit)
  • Emtricitabine-Tenofv 100-150mg (Added Quantity Limit)
  • Emtricitabine-Tenofv 133-200mg (Added Quantity Limit)
  • Emtricitabine-Tenofv 167-250mg (Added Quantity Limit)
  • Emtricitabine-Tenofv 200-300mg (Added Quantity Limit)
  • Emtriva 10 Mg/Ml Solution (Added Quantity Limit)
  • Etravirine 100 Mg Tablet (Added Quantity Limit)
  • Etravirine 200 Mg Tablet (Added Quantity Limit)
  • Evotaz 300 Mg-150 Mg Tablet (Added Quantity Limit)
  • Fosamprenavir 700 Mg Tablet (Added Quantity Limit)
  • Fuzeon 90 Mg Vial (Added Quantity Limit)
  • Genvoya Tablet (Added Quantity Limit)
  • Intelence 25 Mg Tablet (Added Quantity Limit)
  • Invirase 500 Mg Tablet (Added Quantity Limit)
  • Isentress 100 Mg Powder Packet (Added Quantity Limit)
  • Isentress 100 Mg Tablet Chew (Added Quantity Limit)
  • Isentress 25 Mg Tablet Chew (Added Quantity Limit)
  • Isentress 400 Mg Tablet (Added Quantity Limit)
  • Juluca 50-25 Mg Tablet (Added Quantity Limit)
  • Lamivudine 10 Mg/Ml Oral Soln (Added Quantity Limit)
  • Lamivudine 150 Mg Tablet (Added Quantity Limit)
  • Lamivudine 300 Mg Tablet (Added Quantity Limit)
  • Lamivudine-Zidovudine Tablet (Added Quantity Limit)
  • Lexiva 50 Mg/Ml Suspension (Added Quantity Limit)
  • Lopinavir-Ritonavir 80-20mg/Ml (Added Quantity Limit)
  • Lopinavir-Ritonavr 100-25mg Tb (Added Quantity Limit)
  • Lopinavir-Ritonavr 200-50mg Tb (Added Quantity Limit)
  • Nevirapine 200 Mg Tablet (Added Quantity Limit)
  • Nevirapine 50 Mg/5 Ml Susp (Added Quantity Limit)
  • Nevirapine Er 100 Mg Tablet (Added Quantity Limit)
  • Nevirapine Er 400 Mg Tablet (Added Quantity Limit)
  • Norvir 100 Mg Powder Packet (Added Quantity Limit)
  • Norvir 80 Mg/Ml Solution (Added Quantity Limit)
  • Odefsey Tablet (Added Quantity Limit)
  • Prezcobix 800 Mg-150 Mg Tablet (Added Quantity Limit)
  • Prezista 100 Mg/Ml Suspension (Added Quantity Limit)
  • Prezista 150 Mg Tablet (Added Quantity Limit)
  • Prezista 600 Mg Tablet (Added Quantity Limit)
  • Prezista 75 Mg Tablet (Added Quantity Limit)
  • Prezista 800 Mg Tablet (Added Quantity Limit)
  • Reyataz 50 Mg Powder Packet (Added Quantity Limit)
  • Ritonavir 100 Mg Tablet (Added Quantity Limit)
  • Selzentry 25 Mg Tablet (Added Quantity Limit)
  • Selzentry 75 Mg Tablet (Added Quantity Limit)
  • Stavudine 15 Mg Capsule (Added Quantity Limit)
  • Stavudine 20 Mg Capsule (Added Quantity Limit)
  • Stavudine 40 Mg Capsule (Added Quantity Limit)
  • Stribild Tablet (Added Quantity Limit)
  • Tenofovir Disop Fum 300 Mg Tb (Added Quantity Limit)
  • Tivicay 10 Mg Tablet (Added Quantity Limit)
  • Tivicay 25 Mg Tablet (Added Quantity Limit)
  • Tivicay 50 Mg Tablet (Added Quantity Limit)
  • Triumeq Tablet (Added Quantity Limit)
  • Tybost 150 Mg Tablet (Added Quantity Limit)
  • Viracept 250 Mg Tablet (Added Quantity Limit)
  • Viracept 625 Mg Tablet (Added Quantity Limit)
  • Viread 150 Mg Tablet (Added Quantity Limit)
  • Viread 200 Mg Tablet (Added Quantity Limit)
  • Viread 250 Mg Tablet (Added Quantity Limit)
  • Viread Powder (Added Quantity Limit)
  • Zidovudine 100 Mg Capsule (Added Quantity Limit)
  • Zidovudine 50 Mg/5 Ml Syrup (Added Quantity Limit)

 

March 2022

 

Additions:


• Brimonidine Tart-Timolol 0.2-0.5% Soln

 

Removals:


• No updates

 

Other Updates:


• No updates

 

February 2022

 

Additions:

 

  • Dexcom G5 Mis Receiver (Prior Authorization, Quantity Limit)
  • Dexcom G5 Mis Transmit (Prior Authorization, Quantity Limit)
  • Dexcom G6 Mis Receiver (Prior Authorization, Quantity Limit)
  • Dexcom G6 Mis Sensor (Prior Authorization, Quantity Limit)
  • Dexcom G6 Mis Transmit (Prior Authorization, Quantity Limit)
  • Freestyle 10 Reader Libre (Prior Authorization, Quantity Limit)
  • Freestyle 10 Sen Libre (Prior Authorization, Quantity Limit)
  • Freestyle 14 Reader Libre (Prior Authorization, Quantity Limit)
  • Freestyle 14 Reader Libre 2 (Prior Authorization, Quantity Limit)
  • Freestyle 14 Sen Libre (Prior Authorization, Quantity Limit)
  • Freestyle 14 Sen Libre 2 (Prior Authorization, Quantity Limit)
  • G5/G4 Plati Mis Sensor (Prior Authorization, Quantity Limit)
  • Kloxxado 8 Mg Nasal Spray
  • Levocetirizine 5mg tablets (Quantity Limit)
  • Megestrol Suspension
  • Ziextenzo (Prior Authorization)

 

Removals:

 

  • Estradiol Vaginal Cream
  • Megestrol Suspension
  • Udenyca

 

Other Updates:

 

  • No Updates

 

January 2022


Additions:

 

  • Gvoke Kit Inj 1mg/0.2 (Quantity Limit)


Removals:

 

  • Mynatal Tab


Other Updates:

  • Eucrisa 2% Ointment (Prior Authorization Added, Age Limit Added)
  • Tetrabenazine 25 Mg Tablet (Prior Authorization Added, Quantity Limit Added)
  • Tetrabenazine 12.5 Mg Tablet (Prior Authorization Added, Quantity Limit Added)
  • Ingrezza 40 Mg Capsule (Prior Authorization Added, Quantity Limit Added)
  • Ingrezza 80 Mg Capsule (Prior Authorization Added, Quantity Limit Added)
  • Ingrezza Initiation Pack (Prior Authorization Added, Quantity Limit Added)
  • Ingrezza 60 Mg Capsule (Prior Authorization Added, Quantity Limit Added)
  • Glecaprevir-Pibrentasvir Tab 100-40 Mg (Quantity Limit Added)
  • Sofosbuvir-Velpatasvir Tab 400-100 Mg (Quantity Limit Added)
  • Deutetrabenazine Tab 6 Mg (Prior Authorization Added, Quantity Limit Added)
  • Deutetrabenazine Tab 9 Mg (Prior Authorization Added, Quantity Limit Added)
  • Deutetrabenazine Tab 12 Mg (Prior Authorization Added, Quantity Limit Added)
  • Cannabidiol Soln 100 Mg/Ml (Prior Authorization Added, Age Limit Added)
  • Pimecrolimus Cream 1% (Prior Authorization Added, Age Limit Added)
  • Tacrolimus Oint 0.03% (Prior Authorization Added, Age Limit Added)
  • Tacrolimus Oint 0.1% (Prior Authorization Added, Age Limit Added)
  • Linagliptin Tab 5 Mg (Step Therapy Termed)
  • Sitagliptin Phosphate Tab 25 Mg (Base Equiv) (Step Therapy Termed)
  • Sitagliptin Phosphate Tab 50 Mg (Base Equiv) (Step Therapy Termed)
  • Sitagliptin Phosphate Tab 100 Mg (Base Equiv) (Step Therapy Termed)
  • Canagliflozin Tab 100 Mg (Step Therapy Termed)
  • Canagliflozin Tab 300 Mg (Step Therapy Termed)
  • Dapagliflozin Propanediol Tab 5 Mg (Base Equivalent) (Step Therapy Termed)
  • Dapagliflozin Propanediol Tab 10 Mg (Base Equivalent) (Step Therapy Termed)
  • Empagliflozin Tab 10 Mg (Step Therapy Termed)
  • Empagliflozin Tab 25 Mg (Step Therapy Termed)
  • Linagliptin-Metformin Hcl Tab 2.5-500 Mg (Step Therapy Termed)
  • Linagliptin-Metformin Hcl Tab 2.5-850 Mg (Step Therapy Termed)
  • Linagliptin-Metformin Hcl Tab 2.5-1000 Mg (Step Therapy Termed)
  • Sitagliptin-Metformin Hcl Tab 50-500 Mg (Step Therapy Termed)
  • Sitagliptin-Metformin Hcl Tab 50-1000 Mg (Step Therapy Termed)
  • Sitagliptin-Metformin Hcl Tab Er 24hr 50-500 Mg (Step Therapy Termed)
  • Sitagliptin-Metformin Hcl Tab Er 24hr 50-1000 Mg (Step Therapy Termed)
  • Sitagliptin-Metformin Hcl Tab Er 24hr 100-1000 Mg (Step Therapy Termed)
  • Canagliflozin-Metformin Hcl Tab 50-500 Mg (Step Therapy Termed)
  • Canagliflozin-Metformin Hcl Tab 50-1000 Mg (Step Therapy Termed)
  • Canagliflozin-Metformin Hcl Tab 150-500 Mg (Step Therapy Termed)
  • Canagliflozin-Metformin Hcl Tab 150-1000 Mg (Step Therapy Termed)
  • Canagliflozin-Metformin Hcl Tab Er 24hr 50-500 Mg (Step Therapy Termed)
  • Canagliflozin-Metformin Hcl Tab Er 24hr 50-1000 Mg (Step Therapy Termed)
  • Canagliflozin-Metformin Hcl Tab Er 24hr 150-500 Mg (Step Therapy Termed)
  • Canagliflozin-Metformin Hcl Tab Er 24hr 150-1000 Mg (Step Therapy Termed)
  • Dapagliflozin-Metformin Hcl Tab Er 24hr 2.5-1000 Mg (Step Therapy Termed)
  • Dapagliflozin-Metformin Hcl Tab Er 24hr 5-500 Mg (Step Therapy Termed)
  • Dapagliflozin-Metformin Hcl Tab Er 24hr 5-1000 Mg (Step Therapy Termed)
  • Dapagliflozin-Metformin Hcl Tab Er 24hr 10-500 Mg (Step Therapy Termed)
  • Dapagliflozin-Metformin Hcl Tab Er 24hr 10-1000 Mg (Step Therapy Termed)
  • Empagliflozin-Metformin Hcl Tab 5-500 Mg (Step Therapy Termed)
  • Empagliflozin-Metformin Hcl Tab 5-1000 Mg (Step Therapy Termed)
  • Empagliflozin-Metformin Hcl Tab 12.5-500 Mg (Step Therapy Termed)
  • Empagliflozin-Metformin Hcl Tab 12.5-1000 Mg (Step Therapy Termed)
  • Empagliflozin-Linagliptin Tab 10-5 Mg (Step Therapy Termed)
  • Empagliflozin-Linagliptin Tab 25-5 Mg (Step Therapy Termed)

December 2020

 

Additions:

 

  • Trelegy Ellipta Aerosol 200-62.5-25mcg (Step Therapy Required, Quantity Level Limit)

November 2020

 

Additions:

 

  • Demethyl Fumarate Starter Pack 120mg & 240mg (Prior Authorization Required, Quantity Level Limit)

  • Emtricitabine Cap 200mg (Prior Authorization Required, Quantity Level Limit)

     

Removals:

 

  • Emtriva Cap

  • Tecfidera Starter Pack 120mg & 240mg

     

     

October 2020

 

Additions:

 

  • Dimethyl Fumarate Delayed Release Caps 120mg, 240mg (Prior Authorization Required, Quantity Level Limit)

  • Efavirenz-Lamivudine-Tenofovir DF Tabs 400-300-300mg, 600-300-300mg (Prior Authorization Required, Quantity Level Limit)

  • Emtricitabine-Tenofovir Disoproxil Fumarate Tab 200-300mg (Prior Authorization Required, Quantity Level Limit)

  • Vancomycin HCL IV Sol’n 750mg/150ml, 1250mg/250ml, 1750mg/350ml

     

Removals:

 

  • Prenatrix Tab

  • Psyldex Powder 30%

  • SB Fiber Laxative Powder 33%

  • SB Natural Fiber Laxative Power 49%

  • Symfi Lo Tab 400-300-300mg

  • Symfi Tab 600-300-300mg

  • Tecfidera Caps Delayed Release 120mg, 240mg

  • Vitrexyl Tabs

  • Truvada Tab 200-300mg

     

September 2020

 

Additions:

 

  • Abiraterone Tab 250mg (Prior Authorization Required)

  • Alecensa Cap 150mg (Prior Authorization Required)

  • Austedo Tabs 6mg, 9mg, 12mg (Prior Authorization Required)

  • Bexarotene Cap 75mg (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 Inj 25mg/0.5ml (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 Therapy Pack 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)

  • Omeprazole DR Tab 20mg (OTC) (Quantity Level Limit)

  • Repatha Inj 140mg/ml (Prior Authorization Required) 

  • Repatha Push Inj 420/3.5ml (Prior Authorization Required)

  • Repatha Sure Inj 140mg/ml (Prior Authorization Required)

  • Rydapt Cap 25mg (Prior Authorization Required)

  • Soliris Inj 10mg/ml (Prior Authorization Required) 

  • Symdeko Tabs 50-75mg, 100-150mg (Prior Authorization Required)

  • Tafinlar Caps 50mg, 75mg (Prior Authorization Required)

  • Venclexta Tab Starter Pak (Prior Authorization Required)

  • Venclexta Tabs 10mg, 50mg, 100mg (Prior Authorization Required) 

  • Xolair Inj 75/0.5ml, 100mg/ml (Prior Authorization Required)

  • Xolair Sol 150mg (Prior Authorization Required)

     

Removals:

 

  • Travoprost (BAK Free) 0.004% Ophthalmic Sol

 

Other updates:

 

  • Aripiprazole Tabs 2mg, 5mg, 10mg, 15mg, 20mg, 30mg (Age Limit)

  • Clozapine Tabs 25mg, 50mg, 100mg, 200mg (Age Limit)

  • Olanzapine ODT Tabs 5mg, 10mg, 15mg, 20mg (Age Limit)

  • Olanzapine Tabs 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg (Age Limit)

  • Proton Pump Inhibitors (Quantity Level Limit)

  • Quetiapine Tabs 25mg, 50mg, 100mg, 200mg, 300mg, 400mg (Age Limit)

  • Risperidone ODT Tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg (Age Limit)

  • Risperidone Solution 1mg/ml (Age Limit)

  • Risperidone Tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg (Age Limit)

  • Ziprasidone Caps 20mg, 40mg, 60mg, 80mg (Age Limit)

     

August 2020

 

Additions:

 

  • Amitiza Caps 8mcg, 24mcg (Prior Authorization Required, Age Limit, Quantity Level Limit)

  • Athlete's Foot (Miconazole Nitrate) Powder 2% (Quantity Level Limit)

  • Diclofenac Solution 1.5% (Step Therapy Required, 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)

  • Miconazole Nitrate Aerosol Powder 2% (Quantity Level Limit)

  • Poly-Vi-Sol Solution 50mg/ml

  • Ropinirole ER Tabs 2mg, 4mg, 6mg, 8mg, 12mg (Step Therapy Required)

  • Solifenacin Succinate Tabs 5mg, 10mg (Step Therapy Required, Quantity Level Limit)

  • Symproic Tab 0.2mg (Prior Authorization Required, Quantity Level Limit)

  • Testosterone Gel 1.62% (Prior Authorization Required, Quantity Level Limit)

  • Testosterone Gel Pump 1% (Prior Authorization Required)

  • Testosterone TD Solution 30mg/Actuation (Prior Authorization Required, Quantity Level Limit)

  • Tivicay PD Tab 5mg (Prior Authorization Required, Age Limit)

  • Trelegy Ellipta Inhaler 100-62.5-25mcg (Step Therapy Required, 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 Solution 300mg/5ml

  • Naproxen Sodium Tab 275mg 

  • Nimodipine Cap 30mg

  • Targretin Gel 1%

  • Tolmetin Cap 400mg

  • Tolmetin Tabs 200mg, 600mg

     

Other updates:

 

  • Acetic Acid/Hydrocortisone OTIC Solution (Quantity Level Limit)

  • Adapalene Gel 0.1% RX (Removed Step Therapy)

  • Auryxia Tab 210mg (Step Therapy Required)

  • Betamethasone Dipropionate Aug 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 OTIC Solution 0.2% (Quantity Level Limit)

  • Clindamycin Gel 1% (Quantity Level Limit)

  • Clindamycin Lotion 1% (Quantity Level Limit)

  • Clindamycin Pads 1% (Quantity Level Limit)

  • Clindamycin Solution 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)

  • Erythromycin Gel 2% (Quantity Level Limit)

  • Erythromycin Solution 2% (Quantity Level Limit)

  • Fluocinonide Cream 0.05% (Quantity Level Limit)

  • Fluocinonide Solution 0.05% (Quantity Level Limit)

  • Fluvastatin 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)

  • 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 Tab 25mcg (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-Polymyxin-HC OTIC Solution 1% (Quantity Level Limit)

  • Neomycin-Polymyxin-HC OTIC Suspension 3.5mg/ml-10000 Unit/ml (Quantity Level Limit)

  • Nystatin Cream 100000 Units/gm (Quantity Level Limit)

  • Nystatin Ointment 100000 Units/gm (Quantity Level Limit) 

  • Nystatin Topical Powder 100000 Units/gm (Quantity Level Limit)

  • Ofloxacin OTIC Solution 0.3% (Quantity Level Limit)

  • Permethrin Cream 5% (Quantity Level Limit)

  • Permethrin Lotion 1% (Quantity Level Limit)

  • Prednicarbate Ointment 0.1% (Quantity Level Limit)

  • Scalp Relief Max Strength (Hydrocortisone) Solution 1% (Quantity Level Limit)

  • Stop Lice Maximum Strength (Pyrethrins-Piperonyl Butoxide) Liquid 0.33-4% (Quantity Level Limit)

  • Sulfacetamide Lotion 10% (Quantity Level Limit) 

  • Terbinafine Cream 1% (Quantity Level Limit)

  • Tolnaftate Cream 1% (Quantity Level Limit)

  • Triamcinolone Acetonide Cream 0.025%, 0.1%, 0.5% (Quantity Level Limit)

  • Triamcinolone Acetonide Lotion 0.025%, 0.1% (Quantity Level Limit)

  • Triamcinolone Acetonide Ointment 0.025%, 0.5% (Quantity Level Limit)

     

July 2020

 

Additions:

 

  • Gvoke PFS Injection 0.5mg/0.1ml (Quantity Level Limit)

 

Other updates:

 

  • Glucagon Emergency Kit 1mg (Quantity Level Limit)

  • Matulane Cap 50mg (Prior Authorization Required)

     

June 2020

 

Additions:

 

  • Acne Medication Lotion (Benzoyl Peroxide) 10%

  • Alahist-D Tab 17.5-10mg

  • Atovaquone-Proguanil Tabs 62.5-25mg, 250mg-100mg (Quantity Level Limit)

  • Benzoyl Peroxide Gel 2.5%

  • Claravis Caps 10mg, 20mg, 30mg, 40mg (Step Therapy, Quantity Level Limit)

  • Dovato Tab 50-300mg (Quantity Level Limit)

  • Gvoke Hypopen Inj (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)

  • Primaquine Tab 26.3mg (Quantity Level Limit)

     

Other updates:

 

  • Clotrimazole Solution 1% (Removed Step Therapy)

 

May 2020

 

Additions:

 

  • Dexamethasone Concentrate 1mg/ml

  • Dexamethasone Vials 20mg/5ml, 120mg/30ml, 10mg/ml

  • Solu-Cortef PF Vial 100mg, 250mg, 500mg, 1000mg

  • Pyrimethamine Tab 25mg (Generic) (Prior Authorization Required)

     

Removals:

 

  • Daraprim Tab (Brand)

 

April 2020

 

Additions:

 

  • Aripiprazole Tab 2mg, 5mg, 10mg, 15mg, 20mg, 30mg (Generic) (Age Limit, Quantity Level Limit)

  • Omeprazole Tab Delayed Release Disintegrating 20 Mg (OTC) (Quantity Level Limit) 

  • Orkambi Packet 100-125mg, 200-125mg (Prior Authorization Required)

  • Orkambi Tab 100-125mg, 200-125mg (Prior Authorization Required) 

  • Tramadol Hcl Tab 100mg (Quantity Level Limit)

     

Removals:

 

  • Diphenhydramine Hcl Liquid 6.25mg/ml

  • Polyethylene Glycol 3350 Oral Packet

  • Psyllium Powder Packet 100%

  • Sennosides Tab 17.2mg

  • Sodium Bicarbonate Powder

     

Other updates:

 

  • Chloroquine Tabs 250mg, 500mg (Prior Authorization Required, Quantity Level Limit)

  • Hydroxychloroquine Tab 200mg (Prior Authorization Required, Quantity Level Limit)

  • Kaletra Tabs (Quantity Level Limit)

  • Lopinavir-Ritonavir Solution 400-100mg/5ml (Quantity Level Limit) 

     

March 2020

 

Additions:

 

  • Budesonide-Formoterol Inhaler 80-4.5mcg, 160-4.5mcg (Quantity Level Limit)

  • Mesalamine Caps ER 0.375mg (Generic)

  • Nicotine Polacrilex Gum 2mg, 4mg (Age Limit)

  • Novolin R FlexPen 100 units/ml (Age Limit)  

  • OneTouch Verio Flex Kit (Quantity Level Limit)

  • Penicillamine Tab 250mg (Prior Authorization Required, Quantity Level Limit)   

     

Removals:

 

  • Ambi 60pse/400gfn Tab

  • Apriso Caps ER 0.375gm (Brand)

  • Artificial Tears Solution 1% Ophthalmic

  • Diflunisal Powder

  • Fluoritab Solution 0.275 (0.125 F) Mg/Drop

  • Hydrocodone-Acetaminophen Solution 10-325 Mg/15ml

  • PR Natal 430 Pak

  • PR Natal 400, 430 Pak Ec

  • Prevident Solution Rinse

  • Regenecare Ha Gel 2%

  • Robitussin Syrup 7.5 Mg/5ml

  • Sodium Chloride Solution 0.9% Injection

     

February 2020

 

Additions:

 

  • Bimatoprost Solution 0.03% (Step Therapy)

  • Ethinyl Estradiol – Etonogestrel Ring 0.015/0.12mg (Quantity Level Limit)

  • Travoprost Ophthalmic Solution

     

Removals:

 

  • Alprazolam Concentrate 1mg/ml Solution

  • Chlorothiazide Tabs 250mg, 500mg

  • Demeclocycline Tabs 150mg, 300mg

  • Doxycycline Monohydrate Tab 150mg

  • First-Vanco Solution 25mg/ml, 50mg/ml

  • Methyclothiazide Tabs 5mg

  • Mirena

  • Nausea Liquid Relief (fructose-dextrose-phosphoric acid) 

  • Nizatidine Solution 15mg/ml

  • Nuvaring (Brand)

  • Rabeprazole EC Caps 20mg

  • Ranitidine Caps 150mg, 300mg

  • Skyla

  • Travatan Z Ophthalmic Solution (Brand)

     

Other updates:

 

  • Atropine Sulfate Ophthalmic Ointment 1% (Quantity Level Limit)

  • Atropine Sulfate Ophthalmic Solution 1% (Quantity Level Limit)

  • Buspirone Tabs 5mg, 7.5mg, 10mg 15mg (Age Limit)

  • Combigan Solution 0.2%/0.5% (Quantity Level Limit)

  • Diazepam Concentrate Solution 5mg/ml (Quantity Level Limit)

  • Diazepam Oral Solution (Quantity Level Limit)

  • Diazepam Tabs 2mg, 5mg, 10mg (Quantity Level Limit)

  • Divalproex Er Tabs 250mg, 500mg (Prior Authorization Required)

  • Dorzolamide Hcl-Timolol Maleate Ophthalmic Solution 22.3-6.8mg/ml (Step Therapy, Quantity Level Limit)

  • Doxycycline Monohydrate Suspension 25mg/ml (Age Limit)

  • Granisetron Tab 1mg (Step Therapy)

  • Hydroxyzine Hcl Syrup 10mg/5ml (Quantity Level Limit)

  • Hydroxyzine Hcl Tab 50mg (Quantity Level Limit)

  • Hydroxyzine Pamoate Caps 25mg, 50mg, 100mg (Quantity Level Limit)

  • Ibrandronate Inj 3mg/3ml (Quantity Level Limit)

  • Levofloxacin Solution 0.5% (Quantity Level Limit) 

  • Lorazepam Conc 2mg/ml (Age Limit, Quantity Level Limit)

  • Memantine Hcl Tabs 5mg, 10mg (Quantity Level Limit)

  • Methazolamide Tabs 25mg, 50mg (Step Therapy)

  • Tazarotene Cream 0.1% (Step Therapy)

  • Timolol Gel Ophthalmic Solution 0.25%, 0.5% (Quantity Level Limit)

  • Trifluridine Ophthalmic Solution 1% (Quantity Level Limit)

     

January 2020

 

Removals:

 

  • Ventolin HFA Inhaler (Brand)

December 2019

 

Additions:

 

  • Bunavail Buccal Film 2.1-0.3mg, 4.2-0.7mg, 6.3-1mg (Brand) (Step Therapy Required, Quantity Level Limit)

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

  • Suboxone Film 2-0.5mg, 4-1mg, 8-2mg, 12-3mg (Brand) (Step Therapy Required, Quantity Level Limit)

  • Zubsolv Sublingual Tablets 0.7-0.18mg, 1.4-0.36mg, 2.9-0.71mg, 5.7-1.4mg, 8.6-2.1mg, 11.4-2.9mg (Brand) (Step Therapy Required, Quantity Level Limit)

     

Removals:

 

  • PreNata Chewable Tab 29-1mg

 

November 2019

 

Additions:

 

  • Aminocaproic Acid 0.25gm/ml Solution

 

Removals:

 

  • Amicar 0.25gm/ml Solution (Brand)