Formulary search tool and updates

March 2026

 

Additions:

 

• Hydrocodone 10 mg/ acetaminophen 300 mg per 15 mL solution
• Metoclopramide 5 mg per mL solution
• Qfitlia 20 mg per 0.2 mL solution (Age Limit)
• Qfitlia 50 mg per 0.5 mL solution (Age Limit)

 

 

Removals:

 

• Ferrous sulfate 300 mg per 5 mL oral solution

 

 

Other Updates:

 

• Ajovy 225 mg per 1.5 mL auto-injector (Changed Age Limit)
• Ajovy 225 mg per 1.5 mL syringe (Changed Age Limit)
• Nebivolol 10 mg tablet (Removed Quantity Limit)
• Nebivolol 2.5 mg tablet (Removed Quantity Limit)
• Nebivolol 20 mg tablet (Removed Quantity Limit)
• Nebivolol 5 mg tablet (Removed Quantity Limit)
• Promethegan 50 mg suppository (Added Age Limit)

 

February 2026

 

Additions:

 

• Lanthanum carbonate 1000 mg chewable tablet (Step Therapy, Quantity Limit)
• Lanthanum carbonate 500 mg chewable tablet (Step Therapy, Quantity Limit)
• Lanthanum carbonate 750 mg chewable tablet (Step Therapy, Quantity Limit)
• Metoprolol tartate 12.5 mg tablet
• Rezvoglar kwikpen 100 units per mL pen-injector

 

Removals:

 

• Clonidine 0.1 mg per 24 hours weekly patch
• Clonidine 0.2 mg per 24 hours weekly patch
• Clonidine 0.3 mg per 24 hours weekly patch

 

Other Updates:

 

• Siklos 100 mg tablet (Removed Prior Authorization)
• Siklos 1000 mg tablet (Removed Prior Authorization)
• Xromi 100 mg per mL solution (Added Age Limit)

 

January 2026

 

Additions:

 

• Adalimumab-adbm 10 mg per 0.2 mL prefilled syringe kit (Auto-PA, Age Limit)
• Adalimumab-adbm 20 mg per 0.4 mL prefilled syringe kit (Auto-PA, Age Limit)
• Adalimumab-adbm 40 mg per 0.4 mL prefilled syringe kit (Auto-PA, Age Limit)
• Adalimumab-adbm 40 mg per 0.8 mL auto-injector kit (Auto-PA, Age Limit)
• Adalimumab-adbm 40 mg per 0.8 mL prefilled syringe kit (Auto-PA, Age Limit)
• Eversense 365 sensor (Prior Authorization)
• Eversense e3 smart transmitter (Prior Authorization)
• Eversense sensor (Prior Authorization)
• Eversense smart 365 transmitter (Prior Authorization)
• Eversense smart transmitter (Prior Authorization)
• Freestyle libre 14 day reader device (Prior Authorization)
• Freestyle libre 14 day sensor (Prior Authorization)
• Freestyle libre 2 plus sensor (Prior Authorization)
• Freestyle libre 2 reader device (Prior Authorization)
• Freestyle libre 2 sensor (Prior Authorization)
• Freestyle libre 3 plus sensor (Prior Authorization)
• Freestyle libre 3 reader device (Prior Authorization)
• Freestyle libre 3 sensor (Prior Authorization)
• Freestyle libre reader device (Prior Authorization)
• Guardian 4 glucose sensor (Prior Authorization)
• Guardian 4 transmitter (Prior Authorization)
• Guardian connect transmitter (Prior Authorization)
• Guardian link 3 transmitter (Prior Authorization)
• Guardian sensor 3 (Prior Authorization)
• Hadlima 40 mg per 0.4 mL prefilled syringe (Auto-PA, Age Limit)
• Hadlima 40 mg per 0.8 mL prefilled syringe (Auto-PA, Age Limit)
• Hadlima pushtouch 40 mg per 0.4 mL auto-injector (Auto-PA, Age Limit)
• Hadlima pushtouch 40 mg per 0.8 mL auto-injector (Auto-PA, Age Limit)
• Minimed instinct glucose sensor (Prior Authorization)
• Nadolol 20 mg tablet
• Nadolol 40 mg tablet
• Nadolol 80 mg tablet
• Pyzchiva 130 mg per 26 mL vial (Prior Authorization, Age Limit)
• Pyzchiva 45 mg per 0.5 mL prefilled syringe (Prior Authorization, Age Limit)
• Pyzchiva 45 mg per 0.5 mL vial (Prior Authorization, Age Limit)
• Pyzchiva 90 mg per mL prefill syringe (Prior Authorization, Age Limit)
• Simplera sensor (Prior Authorization)
• Simplera sync sensor (Prior Authorization)
• Simplera system (Prior Authorization)
• Sodium sulfate 17.5 GM/ potassium sulfate 3.13 GM/ magnesium sulfate 1.6 GM per 177 mL oral solution
• Telmisartan 20 mg tablet
• Telmisartan 40 mg tablet
• Telmisartan 40 mg/ hydrochlorothiazide 12.5 mg tablet
• Telmisartan 80 mg tablet
• Telmisartan 80 mg/ hydrochlorothiazide 12.5 mg tablet
• Telmisartan 80 mg/ hydrochlorothiazide 25 mg tablet
• Xromi 100 mg per mL solution

 

Removals:

 

• Carbamazepine 200 mg chewable tablet
• Humira 10 mg per 0.1 mL syringe kit
• Humira 20 mg per 0.2 mL syringe kit
• Humira 40 mg per 0.4 mL auto-injector kit
• Humira 40 mg per 0.4 mL prefilled syringe kit
• Humira 40 mg per 0.8 mL auto-injector kit
• Humira 40 mg per 0.8 mL prefilled syringe kit
• Humira 80 mg per 0.8 mL auto-injector kit
• Humira/psoriasis/uveit 80 mg per 0.8 mL/ 40 mg per 0.4 mL auto-injector starter kit
• Metoclopramide 10 mg per 2 mL syringe
• Nuvessa 1.3% gel
• Topiramate 50 mg sprinkle capsule
• Zaditor 0.025% drops

 

 

Other Updates:

 

• Dexcom g6 sensor (Removed Quantity Limit)
• Dexcom g6 transmitter (Removed Quantity Limit)
• Dexcom g7 15 day sensor (Removed Quantity Limit)
• Dexcom g7 sensor (Removed Quantity Limit)
• Esomeprazole delayed release 20 mg capsule (Changed Quantity Limit)
• Esomeprazole delayed release 40 mg capsule (Changed Quantity Limit)
• Lansoprazole delayed release 15 mg capsule (Changed Quantity Limit)
• Lansoprazole delayed release 30 mg capsule (Changed Quantity Limit)
• Nexium delayed release 20 mg tablet (Changed Quantity Limit)
• Omeprazole delayed release 10 mg capsule (Changed Quantity Limit)
• Omeprazole delayed release 20 mg capsule (Changed Quantity Limit)
• Omeprazole delayed release 20 mg dispersible tablet (Changed Quantity Limit)
• Omeprazole delayed release 20 mg tablet (Changed Quantity Limit)
• Omeprazole delayed release 40 mg capsule (Changed Quantity Limit)
• Pantoprazole 40 mg packet (Changed Quantity Limit)
• Pantoprazole delayed release 20 mg tablet (Changed Quantity Limit)
• Pantoprazole delayed release 40 mg tablet (Changed Quantity Limit)
• Protonix 40 mg packet (Changed Quantity Limit)
• Rabeprazole delayed release 20 mg tablet (Changed Quantity Limit)

December 2025

 

Additions:

 

• Acidophilus chewable tablet
• Bosentan 32 mg tablet for oral suspension (Quantity Limit)

 

 

Removals:

 

• BP 2.5% wash liquid
• Floranex packet
• Lactobacillus packet

 

 

Other Updates:

 

• N/A

 

November 2025

 

Additions:

 

• Clobetasol propionate 0.05% foam (Quantity Limit)
• Tetracycline 250 mg capsule
• Tetracycline 500 mg capsule

 

 

Removals:

 

• Diastat acudial 10 mg rectal gel
• Diastat acudial 20 mg rectal gel
• Peg 3350 100 GM solution
• Retin-a 0.01% gel
• Retin-a 0.025% cream
• Retin-a 0.025% gel
• Retin-a 0.05% cream
• Retin-a 0.1% cream
• Ridaura 3 mg capsule
• Ropinirole hydrochloride extended release 12 mg tablet
• Ropinirole hydrochloride extended release 2 mg tablet
• Ropinirole hydrochloride extended release 4 mg tablet
• Ropinirole hydrochloride extended release 6 mg tablet
• Ropinirole hydrochloride extended release 8 mg tablet
• Zovirax 5% ointment

 

 

 

Other Updates:

 

• N/A

 

October 2025

 

Additions:

 

• Eliquis 0.15 mg sprinkle capsules
• Eliquis 0.5 mg tablet packet for suspension
• Eliquis 1.5 mg tablet packet for suspension
• Eliquis 2 mg tablet packet for suspension
• Kerendia 40 mg tablet (Prior Authorization)
• Tretinoin 0.01% gel (Age Limit)
• Tretinoin 0.025% cream (Age Limit)
• Tretinoin 0.05% cream (Age Limit)
• Tretinoin 0.1% cream (Age Limit)
• Tretinoin 0.25% gel (Age Limit)

 

 

Removals:

 

• N/A

 

Other Updates:

 

• Bupropion extended release 150 mg tablet (Added Quantity Limit)
• Creon delayed release 12000 unit capsule (Added Quantity Limit)
• Creon delayed release 24000 unit capsule (Added Quantity Limit)
• Creon delayed release 36000 unit capsule (Added Quantity Limit)
• Lacosamide 100 mg tablet (Added Quantity Limit)
• Lacosamide 150 mg tablet (Added Quantity Limit)
• Lacosamide 200 mg tablet (Added Quantity Limit)
• Lacosamide 50 mg tablet (Added Quantity Limit)
• Levetiracetam 100 mg per mL solution (Added Quantity Limit)
• Levetiracetam 1000 mg tablet (Added Quantity Limit)
• Levetiracetam 250 mg tablet (Added Quantity Limit)
• Levetiracetam 500 mg tablet (Added Quantity Limit)
• Levetiracetam 750 mg tablet (Added Quantity Limit)
• Vraylar 1.5 mg capsule (Added Quantity Limit)
• Vraylar 3 mg capsule (Added Quantity Limit)
• Vraylar 4.5 mg capsule (Added Quantity Limit)
• Vraylar 6 mg capsule (Added Quantity Limit)

 

September 2025

 

Additions:

 

• Sacubitral 24 mg/valsartan 26 mg tablets (Quantity Limit)
• Sacubitral 49 mg/valsartan 51 mg tablets (Quantity Limit)
• Sacubitral 97 mg/valsartan 103 mg tablets (Quantity Limit)
• Sodium chloride 0.9% intravenous solution

 

Removals:

 

• N/A

 

Other Updates:

 

• Infliximab 100 mg intravenous solution (Added Auto-pa)

 

August 2025

 

Additions:

 

• Alhemo 150 mg per 1.5 mL pen (Age Limit)
• Alhemo 60 mg per 1.5 mL pen (Age Limit)
• Baclofen 15 mg tablet
• Budesonide 2 mg rectal foam
• Epysqli 300 mg per 30 mL solution (Prior Authorization)
• Kerendia 10 mg tablet (Prior Authorization)
• Kerendia 20 mg tablet (Prior Authorization)
• Mycophenolic 180 mg delayed release tablet
• Mycophenolic 360 mg delayed release tablet
• Prednisolone 10 mg per 5 mL solution
• Prednisolone 20 mg per 5 mL solution
• Prucalopride 1 mg tablet (Prior Authorization, Quantity Limit)
• Prucalopride 2 mg tablet (Prior Authorization, Quantity Limit)
• Ticagrelor 60 mg tablet
• Venlafaxine extended release 37.5 mg capsule (Quantity Limit)
• Venlafaxine extended release 75 mg capsule (Quantity Limit)

 

Removals:

 

• Pentazocine 50 mg/naloxone 0.5 mg tablet
• Phenylephrine 10 mg tablet
• Phenylephrine dm gg 10 mg/18 mg/200 mg per 15 mL liquid
• Phenylephrine dm gg 2.5 mg/5 mg/100 mg per 5 mL liquid
• Revlimid 10 mg capsule
• Revlimid 15 mg capsule
• Revlimid 2.5 mg capsule
• Revlimid 20 mg capsule
• Revlimid 25 mg capsule
• Revlimid 5 mg capsule
• Soliris 10 mg per mL injection

 

Other Updates:

 

• Adbry 150 mg per mL syringe (Changed Age Limit)
• Clindamycin phosphate 1% lotion (Removed Quantity Limit)
• Emtricitabine 100 mg/tenofovir 150 mg df tablet (Added Age Limit)
• Emtricitabine 133 mg/tenofovir 200 mg df tablet (Added Age Limit)
• Emtricitabine 167 mg/tenofovir 250 mg df tablet (Added Age Limit)
• Valtoco 10 mg nasal spray (Changed Age Limit)
• Valtoco 15 mg nasal spray (Changed Age Limit)
• Valtoco 20 mg nasal spray (Changed Age Limit)
• Valtoco 5 mg nasal spray (Changed Age Limit)

 

July 2025

 

Additions:

• Bicillin l a 1,200,000 units per 2 mL prefilled syringe
• Bicillin l a 600,000 units per mL prefilled syringe
• Eltrombopag olamine 12.5 mg pack (Prior Authorization, Quantity Limit)
• Eltrombopag olamine 25 mg pack (Prior Authorization, Quantity Limit)
• Paxlovid 150 mg/100 mg dose pack (Age Limit, Quantity Limit)
• Paxlovid 300 mg/100 mg dose pack (Age Limit, Quantity Limit)
• Paxlovid 300 mg/100 mg/150 mg dose pack (Age Limit, Quantity Limit)
• Relion true metrix air glucose meter kit with device
• Relion true metrix glucose test strip in vitro
• True metrix air glucose meter kit with device
• True metrix glucose test strip
• True metrix meter kit with device

 

Removals:

• Firvanq 25 mg per mL solution
• Firvanq 50 mg per mL solution
• Humalog 100 units per mL cartridge
• Humalog 100 units per mL kwikpen
• Humalog 100 units per mL vial
• Humalog jr 100 units per mL kwikpen
• Onetouch ultra 2 kit with device
• Onetouch ultra blue test strip in vitro
• Onetouch ultra strip in vitro
• Onetouch verio flex system kit with device
• Onetouch verio reflect kit with device
• Onetouch verio strip in vitro
• Proair respiclick 108 mcg per actuation inhaler
• Restasis 0.05% multidose eye drops

 

 

Other Updates:

• Budesonide 0.25 mg per 2 mL suspension (Added Age Limit)
• Budesonide 0.5 mg per 2 mL suspension (Added Age Limit)
• Budesonide 1 mg per 2 mL suspension (Added Age Limit)
• Cefixime 400 mg capsule (Changed Quantity Limit)
• Depo-testosterone 100 mg per mL solution (Changed Quantity Limit)
• Testosterone cypionate 100 mg per mL solution (Changed Quantity Limit)
• Vraylar 1.5 mg capsule (Added Auto-Pa)
• Vraylar 1.5 mg/3 mg pack (Added Auto-Pa)
• Vraylar 3 mg capsule (Added Auto-Pa)
• Vraylar 4.5 mg capsule (Added Auto-Pa)
• Vraylar 6 mg capsule (Added Auto-Pa)

 

June 2025

 

Additions:

• Bisoprolol fumarate 2.5 mg tablet
• Ivizia 0.5% dry eye gel
• Sunlenca 300 mg tablet (Age Limit)
• Ticagrelor 90 mg tablet
• Vivotif delayed release capsule (Age Limit)

 

Removals:

• Fluocinolone acetonide 0.01% body oil

 

Other Updates:

• Ivermectin 0.5% lotion (Changed Step Therapy)
• Malathion 0.5% lotion (Changed Step Therapy)
• Ribavirin 200 mg capsule (Removed Step Therapy)
• Ribavirin 200 mg tablet (Removed Step Therapy)
• Spinosad 0.9% suspension (Changed Step Therapy)

 

May 2025

 

Additions:

• Diclofenac sodium 3% gel
• Diphenhydramine 50 mg per 1 mL solution
• Itovebi 3 mg tablet (Prior Authorization, Quantity Limit)
• Itovebi 9 mg tablet (Prior Authorization, Quantity Limit)
• Kaletra solution (Quantity Limit)

 

Removals:

• Kalydeco 13.4 mg ganules packet
• Kalydeco 150 mg tablet
• Kalydeco 25 mg packet
• Kalydeco 50 mg packet
• Kalydeco 75 mg packet
• Lopinavir ritonavir solution
• Orkambi 100 mg/125 mg granules packet
• Orkambi 100 mg/125 mg tablet
• Orkambi 150 mg/128 mg granules packet
• Orkambi 200 mg/125 mg tablet
• Orkambi 75 mg/94 mg granules packet
• Symdeko 100 mg/150 mg/150 mg tablet
• Symdeko 50 mg/75 mg/75 mg tablet
• Trikafta 100 mg/50 mg/75 mg/150 mg therapy pack
• Trikafta 50 mg/25 mg/37.5 mg/75 mg therapy pack
• Trikafta 59.5 mg packet
• Trikafta 75 mg packet

 

 

Other Updates:

• Nifedipine extended release 30 mg osmotic tablet (Added Quantity Limit)
• Nifedipine extended release 30 mg tablet (Added Quantity Limit)
• Nifedipine extended release 60 mg osmotic tablet (Added Quantity Limit)
• Nifedipine extended release 60 mg tablet (Added Quantity Limit)
• Nifedipine extended release 90 mg osmotic tablet (Added Quantity Limit)
• Nifedipine extended release 90 mg tablet (Added Quantity Limit)

 

April 2025

 

Additions:

 

• Alhemo 300 mg per mL pen-injector (Age Limit)
• Methylphenidate extended release 10 mg tablet (Age Limit, Quantity Limit)
• Methylphenidate extended release 18 mg tablet (Age Limit, Quantity Limit)
• Methylphenidate extended release 20 mg tablet (Age Limit, Quantity Limit)
• Methylphenidate extended release 27 mg tablet (Age Limit, Quantity Limit)
• Methylphenidate extended release 36 mg tablet (Age Limit, Quantity Limit)
• Methylphenidate extended release 54 mg tablet (Age Limit, Quantity Limit)
• Methylphenidate extended release osm 18 mg tablet (Age Limit, Quantity Limit)
• Methylphenidate extended release osm 27 mg tablet (Age Limit, Quantity Limit)
• Methylphenidate extended release osm 36 mg tablet (Age Limit, Quantity Limit)
• Methylphenidate extended release osm 54 mg tablet (Age Limit, Quantity Limit)

 

Removals:

• Androgel 20.25 mg per actuation gel pump
• Betaseron 0.3 mg kit
• Concerta extended release 18 mg tablet
• Concerta extended release 27 mg tablet
• Concerta extended release 36 mg tablet
• Concerta extended release 54 mg tablet
• Glimepiride 3 mg tablet

 

 

Other Updates:

 

• Amphetamine-dextroamphetamine extended release 10 mg capsule (Changed Age Limit)
• Amphetamine-dextroamphetamine extended release 15 mg capsule (Changed Age Limit)
• Amphetamine-dextroamphetamine extended release 20 mg capsule (Changed Age Limit)
• Amphetamine-dextroamphetamine extended release 25 mg capsule (Changed Age Limit)
• Amphetamine-dextroamphetamine extended release 30 mg capsule (Changed Age Limit)
• Amphetamine-dextroamphetamine extended release 5 mg capsule (Changed Age Limit)
• Daytrana 10 mg per 9 hours patch (Changed Age Limit)
• Daytrana 15 mg per 9 hours patch (Changed Age Limit)
• Daytrana 20 mg per 9 hours patch (Changed Age Limit)
• Daytrana 30 mg per 9 hours patch (Changed Age Limit)
• Dexmethylphenidate 10 mg tablet (Changed Age Limit)
• Dexmethylphenidate 2.5 mg tablet (Changed Age Limit)
• Dexmethylphenidate 5 mg tablet (Changed Age Limit)
• Dexmethylphenidate extended release 10 mg capsule (Changed Age Limit)
• Dexmethylphenidate extended release 15 mg capsule (Changed Age Limit)
• Dexmethylphenidate extended release 20 mg capsule (Changed Age Limit)
• Dexmethylphenidate extended release 25 mg capsule (Changed Age Limit)
• Dexmethylphenidate extended release 30 mg capsule (Changed Age Limit)
• Dexmethylphenidate extended release 35 mg capsule (Changed Age Limit)
• Dexmethylphenidate extended release 40 mg capsule (Changed Age Limit)
• Dexmethylphenidate extended release 5 mg capsule (Changed Age Limit)
• Dextroamphetamine sulphate extended release 10 mg capsule (Changed Age Limit)
• Dextroamphetamine sulphate extended release 15 mg capsule (Changed Age Limit)
• Dextroamphetamine sulphate extended release 5 mg capsule (Changed Age Limit)
• Xolair 150 mg per mL auto-injector (Removed Age Limit)
• Xolair 150 mg per mL syringe (Removed Age Limit)
• Xolair 150 mg per mL vial (Removed Age Limit)
• Xolair 300 mg per 2 mL auto-injector (Removed Age Limit)
• Xolair 300 mg per 2 mL syringe (Removed Age Limit)
• Xolair 75 mg per 0.5 mL auto-injector (Removed Age Limit)
• Xolair 75 mg per 0.5 mL syringe (Removed Age Limit)

 

March 2025

 

Additions:

 

• Austedo extended release 12 mg/18 mg/24 mg/30 mg titration packet (Prior Authorization, Age Limit, Quantity Limit)
• Austedo extended release 18 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Carbamazepine 200 mg chewable tablet
• E.E.S. granules 200 mg per 5 mL suspension
• Espercoct 4000 unit vial
• Hympavzi 150 mg per mL auto-injector (Age Limit)
• Insulin glargine solostar 300 units per mL pen-injector (Step Therapy)
• Mirabegron extended release 25 mg tablet
• Mirabegron extended release 50 mg tablet

 

Removals:

 

• Baclofen 15 mg tablet
• Digoxin 62.5 mcg tablet
• Diltiazem 125 mg per 25 mL solution
• Diltiazem 25 mg per 5 mL solution
• Diltiazem 50 mg per 10 mL solution
• Fluocinolone acetonide powder
• Hydrocortisone acetate powder
• Kogenate 1000 unit kit
• Kogenate 2000 unit kit
• Leucovorin calcium powder
• Metronidazle 125 mg tablet
• Pyrimethamine powder
• Sodium polystyrene sulfonate 30 gm per 120 mL rectal suspension

 

Other Updates:

 

• Amphetamine dextroamphetamine 10 mg tablet (Added Quantity Limit)
• Amphetamine dextroamphetamine 12.5 mg tablet (Added Quantity Limit)
• Amphetamine dextroamphetamine 15 mg tablet (Added Quantity Limit)
• Amphetamine dextroamphetamine 20 mg tablet (Added Quantity Limit)
• Amphetamine dextroamphetamine 30 mg tablet (Added Quantity Limit)
• Amphetamine salts 5 mg tablet (Added Quantity Limit)
• Amphetamine salts 7.5 mg tablet (Added Quantity Limit)
• Asmanex 50 mcg per actuation inhaler (Added Age Limit)
• Dextroamphetamine 10 mg tablet (Added Quantity Limit)
• Dextroamphetamine 15 mg tablet (Added Quantity Limit)
• Dextroamphetamine 2.5 mg tablet (Added Quantity Limit)
• Dextroamphetamine 20 mg tablet (Added Quantity Limit)
• Dextroamphetamine 30 mg tablet (Added Quantity Limit)
• Dextroamphetamine 5 mg tablet (Added Quantity Limit)
• Dextroamphetamine 7.5 mg tablet (Added Quantity Limit)
• Dextroamphetamine extended release 10 mg capsule (Changed Quantity Limit)
• Dextroamphetamine sulfate extended release 15 mg capsule (Changed Quantity Limit)
• Dextroamphetamine sulfate extended release 5 mg capsule (Changed Quantity Limit)
• Emgality 120 mg per mL (Changed Quantity Limit)
• Emtricitabine 100 mg/ tenofovir 150 mg tablet (Removed Age Limit)
• Emtricitabine 133 mg/ tenofovir 200 mg tablet (Removed Age Limit)
• Emtricitabine 167 mg/ tenofovir 250 mg tablet (Removed Age Limit)
• Enbrel 25 mg per 0.5 mL prefilled syringe (Changed Quantity Limit)
• Enbrel 25 mg per 0.5 mL vial (Changed Quantity Limit)
• Enbrel 50 mg per 1 mL mini cartridge (Changed Quantity Limit)
• Enbrel 50 mg per 1 mL prefilled syringe (Changed Quantity Limit)
• Enbrel sureclick 50 mg per mL auto-injector (Changed Quantity Limit)
• Mavyret 100 mg/40 mg tablet (Changed Quantity Limit)
• Mavyret 50 mg/20 mg pellet packet (Changed Quantity Limit)
• Nayzilam 5 mg nasal spray (Removed Prior Authorization)
• Opvee 2.7 mg nasal spray (Changed Quantity Limit)

 

February 2025

 

Additions:

 

• Colchicine 0.6 mg capsule
• Estradiol valerate 20 mg per mL oil (Quantity Limit)
• Estradiol valerate 40 mg per mL oil (Quantity Limit)
• Omnipod 5 (Dexcom G7/G6) intro gen 5 kit (Prior Authorization, Quantity Limit)
• Omnipod 5 (Dexcom G7/G6) pods (Prior Authorization, Quantity Limit)
• Omnipod 5 (Libre 2 plus G6) kit (Prior Authorization, Quantity Limit)
• Omnipod 5 (Libre 2 plus G6) pods (Prior Authorization, Quantity Limit)
• Omnipod DASH gen 4 intro kit (Prior Authorization, Quantity Limit)
• Omnipod DASH gen 4 PDM kit (Prior Authorization, Quantity Limit)
• Omnipod DASH gen 4 pods (Prior Authorization, Quantity Limit)
• Omnipod Go 10 unit per 24 hour kit (Prior Authorization, Quantity Limit)
• Omnipod Go 15 unit per 24 hour kit (Prior Authorization, Quantity Limit
• Omnipod Go 20 unit per 24 hour kit (Prior Authorization, Quantity Limit)
• Omnipod Go 25 unit per 24 hour kit (Prior Authorization, Quantity Limit)
• Omnipod Go 30 unit per 24 hour kit (Prior Authorization, Quantity Limit)
• Omnipod Go 35 unit per 24 hour kit (Prior Authorization, Quantity Limit)
• Omnipod Go 40 unit per 24 hour kit (Prior Authorization, Quantity Limit)
• Twiist refill kit (Prior Authorization, Quantity Limit)
• Twiist refill kit infusion set (Prior Authorization, Quantity Limit)
• Twiist starter kit (Prior Authorization, Quantity Limit)

 

Removals:

 

• Freestyle libre 14 day reader device
• Freestyle libre 14 day sensor
• Freestyle libre 2 reader
• Freestyle libre 2 reader device
• Freestyle libre 2 sensor
• Freestyle libre 3 reader device
• Freestyle libre 3 sensor
• Myrbetriq extended release 8 mg per mL suspension
• Testosterone 10 mg per actuation gel pump
• Testosterone 12.5 mg per actuation gel pump
• Testosterone 25 mg per 2.5 gm gel
• Testosterone 50 mg per 5 gm gel

 

Other Updates:

 

• N/A

 

January 2025

 

Additions:

 

• Adbry 300 mg per 2 mL auto-injector (Prior Authorization, Age Limit, Quantity Limit)
• Balfaxar 1000 unit solution (Age Limit)
• Balfaxar 500 unit solution (Age Limit)
• Depakote delayed release 125 mg sprinkle capsule
• Hydrocodone 2.5 mg/ acetaminophen 325 mg tablet (Quantity Limit)
• Myrbetriq extended release 25 mg tablet
• Myrbetriq extended release 50 mg tablet
• Myrbetriq extended release 8 mg per mL suspension
• Pimecrolimus 1% cream (Prior Authorization, Age Limit, Quantity Limit)
• Sezaby 100 mg solution
• Siklos 100 mg tablet (Prior Authorization, Age Limit)
• Siklos 1000 mg tablet (Prior Authorization, Age Limit)
• Toujeo solostar 300 units per mL pen-injector (Step Therapy)
• Zamicet 10 mg/325 mg per 15 mL solution (Quantity Limit)

 

Removals:

 

• Divalproex delayed release 125 mg sprinkle capsule
• Gabitril 12 mg tablet
• Gabitril 16 mg tablet
• Gabitril 2 mg tablet
• Gabitril 4 mg tablet
• Ketorolac tromethamine 0.4% ophthalmic solution
• Lamotrigine 100 mg dispersible tablet
• Lamotrigine 200 mg dispersible tablet
• Lamotrigine 25 mg dispersible tablet
• Lamotrigine 50 mg dispersible tablet
• Sorbitol 70% oral solution
• Sorbitol 70% rectal solution
• Tiagabine 12 mg tablet
• Tiagabine 16 mg tablet
• Tiagabine 2 mg tablet
• Tiagabine 4 mg tablet
• Toviaz extended release 4 mg tablet
• Toviaz extended release 8 mg tablet
• Xenazine 12.5 mg tablet
• Xenazine 25 mg tablet

 

Other Updates:

 

• Gavilyte-g 236 GM solution (Removed Quantity Limit)

December 2024

 

Additions:

 

• Dasatinib 100 mg tablet (Prior Authorization, Quantity Limit)
• Dasatinib 140 mg tablet (Prior Authorization, Quantity Limit)
• Dasatinib 20 mg tablet (Prior Authorization, Quantity Limit)
• Dasatinib 50 mg tablet (Prior Authorization, Quantity Limit)
• Dasatinib 70 mg tablet (Prior Authorization, Quantity Limit)
• Dasatinib 80 mg tablet (Prior Authorization, Quantity Limit)

 

Removals:

 

• Lamictal blue starter kit
• Lamictal green starter kit
• Lamictal orange starter kit
• Sprycel 100 mg tablet
• Sprycel 140 mg tablet
• Sprycel 20 mg tablet
• Sprycel 50 mg tablet
• Sprycel 70 mg tablet
• Sprycel 80 mg tablet
• Vascepa 0.5 gm capsule
• Vascepa 1 gm capsule

 

 

Other updates:

 

• Ondansetron 16 mg oral disintegrating tablet (Added Step Therapy)

 

November 2024

 

Additions:

 

• Baclofen 5 mg per 5 mL solution (Quantity Limit)
• Folivane ob 85 mg/1 mg capsule (Quantity Limit)
• Ojemda 100 mg tablet (Prior Authorization, Quantity Limit)
• Ojemda 25 mg per mL solution (Prior Authorization, Quantity Limit)

 

Removals:

 

• Lamivudine 100 mg tablet
• Opsumit 10 mg tablet

 

Other updates:

 

• Emflaza 18 mg tablet (Added Prior Authorization, Added Age Limit)
• Emflaza 22.75 mg per mL oral suspension (Added Prior Authorization, Added Age Limit)
• Emflaza 30 mg tablet (Added Prior Authorization, Added Age Limit)
• Emflaza 36 mg tablet (Added Prior Authorization, Added Age Limit)
• Emflaza 6 mg tablet (Added Prior Authorization, Added Age Limit)
• Entecavir 0.5 mg tablet (Added Age Limit)
• Entecavir 1 mg tablet (Added Age Limit)

 

October 2024

 

Additions:

 

• Alvesco 160 mcg per actuation inhaler
• Alvesco 80 mcg per actuation inhaler
• Amphetamine-dextroamphetamine extended release 10 mg capsule (Age Limit, Quantity Limit)
• Amphetamine-dextroamphetamine extended release 15 mg capsule (Age Limit, Quantity Limit)
• Amphetamine-dextroamphetamine extended release 20 mg capsule (Age Limit, Quantity Limit)
• Amphetamine-dextroamphetamine extended release 25 mg capsule (Age Limit, Quantity Limit)
• Amphetamine-dextroamphetamine extended release 30 mg capsule (Age Limit, Quantity Limit)
• Amphetamine-dextroamphetamine extended release 5 mg capsule (Age Limit, Quantity Limit)
• Asmanex hfa 100 mcg per actuation inhaler
• Asmanex hfa 200 mcg per actuation inhaler
• Asmanex hfa 50 mcg per actuation inhaler
• Darunavir 600 mg tablet (Quantity Limit)
• Dextroamphetamine sulfate extended release 10 mg capsule (Age Limit, Quantity Limit)
• Dextroamphetamine sulfate extended release 15 mg capsule (Age Limit, Quantity Limit)
• Dextroamphetamine sulfate extended release 5 mg capsule (Age Limit, Quantity Limit)
• Emflaza 18 mg tablet
• Emflaza 22.75 mg per mL oral suspension
• Emflaza 30 mg tablet
• Emflaza 36 mg tablet
• Emflaza 6 mg tablet
• Fulphila 6 mg per 0.6 mL prefilled syringe
• Glimepiride 3 mg tablet
• Hydrocodone 10 mg/acetaminophen 325 mg per 15 mL oral solution (Quantity Limit)
• Neupogen 300 mcg per 0.5 mL prefilled syringe
• Neupogen 300 mcg per 1 mL vial
• Neupogen 480 mcg per 0.8 mL prefilled syringe
• Neupogen 480 mcg per 1.6 mL vial
• Qvar redihaler 40 mcg per actuation inhaler
• Qvar redihaler 80 mcg per actuation inhaler
• Synjardy extended release 10 mg/ 1000 mg tablet (Age Limit)
• Synjardy extended release 12.5 mg/ 1000 mg tablet (Age Limit)
• Synjardy extended release 25 mg/ 1000 mg tablet (Age Limit)
• Synjardy extended release 5 mg/ 1000 mg tablet (Age Limit)
• Zegalogue 0.6 mg per 0.6 mL auto-injector
• Zegalogue 0.6 mg per 0.6 mL prefilled syringe

 

Removals:

 

• Adderall extended release 10 mg capsule
• Adderall extended release 15 mg capsule
• Adderall extended release 20 mg capsule
• Adderall extended release 25 mg capsule
• Adderall extended release 30 mg capsule
• Adderall extended release 5 mg capsule
• Amitiza 24 mcg capsule
• Amitiza 8 mcg capsule
• Fluticasone propionate 100 mcg per actuation diskus
• Fluticasone propionate 250 mcg per actuation diskus
• Fluticasone propionate 50 mcg per actuation diskus
• Fluticasone propionate hfa 110 mcg per actuation
• Fluticasone propionate hfa 220 mcg per actuation
• Fluticasone propionate hfa 44 mcg per actuation
• Glucagon 1 mg emergency kit
• Granix 300 mcg per 0.5 mL prefilled syringe
• Granix 300 mcg per 0.5 mL safe syringe
• Granix 480 mcg per 0.8 mL prefilled syringe
• Granix 480 mcg per 0.8 mL syringe
• Gvoke 1 mg per 0.2 mL kit
• Gvoke 1 mg per 0.2 mL syringe
• Gvoke hypopen 0.5 mg per 0.1 mL auto-injector
• Gvoke hypopen 1 mg per 0.2 mL auto-injector
• Invokamet 150 mg/ 1000 mg tablet
• Invokamet 150 mg/ 500 mg tablet
• Invokamet 50 mg/ 1000 mg tablet
• Invokana 100 mg tablet
• Invokana 300 mg tablet
• Leukine 250 mcg injection
• Nutropin aq nuspin 10 mg per 2 mL pen-injector
• Nutropin aq nuspin 20 mg per 2 mL pen-injector
• Nutropin aq nuspin 5 mg per 2 mL pen-injector
• Prezista 100 mg per mL oral suspension
• Prezista 150 mg tablet
• Prezista 600 mg tablet
• Prezista 75 mg tablet
• Saxenda 18 mg per 3 mL pen
• Valtoco 10 mg nasal spray
• Valtoco 15 mg nasal spray
• Valtoco 20 mg nasal spray
• Valtoco 5 mg nasal spray
• Vyvanse 10 mg chewable tablet
• Vyvanse 20 mg chewable tablet
• Vyvanse 30 mg chewable tablet
• Vyvanse 40 mg chewable tablet
• Vyvanse 50 mg chewable tablet
• Vyvanse 60 mg chewable tablet
• Wegovy 0.25 mg per 0.5 mL pen
• Wegovy 0.5 mg per 0.5 mL pen
• Wegovy 1 mg per 0.5 mL pen
• Wegovy 1.7 mg per 0.75 mL pen
• Wegovy 2.4 mg per 0.75 mL pen
• Ziextenzo 6 mg per 0.6 mL syringe

 

Other updates:

 

• Promacta 50 mg tablet (Changed Quantity Limit)
• Promacta 75 mg tablet (Changed Quantity Limit)

 

September 2024

 

Additions:

 

• Desvenlafaxine extended release 100 mg tablet
• Desvenlafaxine extended release 50 mg tablet
• Fentanyl citrate 1200 mcg buccal lozenge (Prior Authorization, Quantity Limit)
• Fentanyl citrate 1600 mcg buccal lozenge (Prior Authorization, Quantity Limit)
• Fentanyl citrate 200 mcg buccal lozenge (Prior Authorization, Quantity Limit)
• Fentanyl citrate 400 mcg buccal lozenge (Prior Authorization, Quantity Limit)
• Fentanyl citrate 600 mcg buccal lozenge (Prior Authorization, Quantity Limit)
• Fentanyl citrate 800 mcg buccal lozenge (Prior Authorization, Quantity Limit)
• Hydroxyprogesterone caproate 1.25 gm per 5 mL solution
• Ingrezza 40 mg capsules (Prior Authorization, Age Limit, Quantity Limit)
• Ingrezza 60 mg capsules (Prior Authorization, Age Limit, Quantity Limit)
• Ingrezza 80 mg capsules (Prior Authorization, Age Limit, Quantity Limit)
• Rextovy 4 mg per 0.25 mL nasal liquid

 

Removals:

 

• Baclofen 5 mg per 5 mL solution
• Benzphetamine 25 mg tablet
• Cimetidine 30 mg per 5 mL solution
• Clonidine extended release 0.17 mg tablet
• E.E.S. 200 mg per 5 mL granules
• Flurazepam 15 mg capsule
• Flurazepam 30 mg capsule
• Metformin 625 mg tablet
• Phentermine 8 mg tablet
• Prednicarbate 0.1% ointment
• Timolol maleate 0.5% eye drops

 

Other updates:

 

• Acid reducer delayed release 20 mg capsule (Changed Quantity Limit)
• Arnuity ellipta 50 mcg per actuation inhaler (Added Age Limit)
• Austedo extended release 12 mg tablets (Changed Quantity Limit)
• Austedo extended release 24 mg tablets (Changed Quantity Limit)
• Austedo extended release 6 mg tablets (Changed Quantity Limit)
• Avonex 30 mcg per 0.5 mL auto injector (Added Age Limit)
• Avonex 30 mcg per 0.5 mL prefilled syringe (Added Age Limit)
• Azelaic acid 15% gel (Added Age Limit)
• Benzphetamine 50 mg tablet (Added Age Limit)
• Betaseron 0.3 mg kit (Added Age Limit)
• Biktarvy 30 mg/120 mg/15 mg tablet (Added Age Limit)
• Byetta 10 mcg per 0.04 mL pen injector (Added Auto-PA)
• Byetta 5 mcg per 0.02 mL pen injector (Added Auto-PA)
• Citalopram hydrobromide 10 mg per 5 mL solution (Removed Quantity Limit)
• Copaxone 20 mg per mL syringe (Added Age Limit)
• Dayvigo 10 mg tablet (Added Age Limit)
• Dayvigo 5 mg tablet (Added Age Limit)
• Diethylpropion 25 mg tablet (Added Age Limit)
• Diethylpropion extended release 75 mg tablet (Added Age Limit)
• Dimethyl fumarate delayed release 120 mg capsule (Added Age Limit)
• Dimethyl fumarate delayed release 120 mg/240 mg capsule starter pack (Added Age Limit)
• Dimethyl fumarate delayed release 240 mg capsule (Added Age Limit)
• Dulera 50 mcg/5 mcg per actuation inhaler (Added Age Limit)
• Emgality 120 mg per mL auto injector (Added Quantity Limit)
• Emgality 120 mg per mL prefilled syringe (Added Quantity Limit)
• Fasenra 30 mg per mL auto injector (Changed Age Limit)
• Fasenra 30 mg per mL prefilled syringe (Changed Age Limit)
• Isentress 100 mg chewable tablet (Added Age Limit)
• Isentress 100 mg packet (Added Age Limit)
• Isentress 25 mg chewable tablet (Added Age Limit)
• Levetiracetam 250 mg tablet (Removed Quantity Limit)
• Omeprazole delayed release 20 mg dispersible tablet (Changed Quantity Limit)
• Phendimetrazine 35 mg tablet (Added Age Limit)
• Phendimetrazine extended release 105 mg capsule (Added Age Limit)
• Phentermine 15 mg capsule (Added Age Limit)
• Phentermine 30 mg capsule (Added Age Limit)
• Phentermine 37.5 mg capsule (Added Age Limit)
• Selzentry 75 mg tablet (Added Age Limit)
• Sildenafil 10 mg per mL oral suspension (Added Age Limit)
• Sildenafil 20 mg tablet (Added Age Limit)
• Tivicay 10 mg tablet (Added Age Limit)
• Tivicay 25 mg tablet (Added Age Limit)
• Tivicay pd 5 mg tablet for suspension (Added Age Limit)
• Triumeq pd 60 mg/5 mg/30 mg tablet for suspension (Added Age Limit)
• Trulicity 0.75 mg per 0.5 mL pen (Added Auto-PA)
• Trulicity 1.5 mg per 0.5 mL pen (Added Auto-PA)
• Trulicity 3 mg per 0.5 mL pen (Added Auto-PA)
• Trulicity 4.5 mg per 0.5 mL pen (Added Auto-PA)
• Truvada 100 mg/150 mg tablet (Added Age Limit)
• Truvada 133 mg/200 mg tablet (Added Age Limit)
• Truvada 167 mg/250 mg tablet (Added Age Limit)
• Varenicline 0.5 mg tablet (Removed Quantity Limit)
• Varenicline 1 mg tablet (Removed Quantity Limit)
• Victoza 18 mg per 3 mL pen (Added Auto-PA, Changed Quantity Limit)
• Xolair 75 mg per 0.5 mL prefilled syringe (Removed Quantity Limit)

 

August 2024

 

Additions:

 

• Derma smooth 0.01% scalp oil (Quantity Limit)
• Eletriptan hydrobromide 20 mg tablet (Quantity Limit)
• Eletriptan hydrobromide 40 mg tablet (Quantity Limit)
• Fasenra 10 mg per 0.5 mL prefilled syringe (Prior Authorization, Age Limit)
• Naloxone 0.4 mg per mL prefilled syringe
• Nexletol 180 mg tablet (Prior Authorization, Quantity Limit)
• Ondansetron 16 mg orally disintegrating tablet (Quantity Limit)
• Tinidazole 250 mg tablet
• Tinidazole 500 mg tablet

 

Removals:

 

• Alclometasone dipropionate 0.05% cream
• Alclometasone dipropionate 0.05% ointment
• Fluocinolone acetonide 0.025% cream

 

Other updates:

 

• Albendazole 200 mg tablet (Removed Prior Authorization)
• Linezolid 600 mg tablet (Removed Prior Authorization, Added Quantity Limit)

 

July 2024

 

Additions:

 

• Armodafinil 150 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Armodafinil 200 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Armodafinil 250 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Armodafinil 50 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Austedo extended release 30 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Austedo extended release 36 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Austedo extended release 42 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Austedo extended release 48 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Brixadi 128 mg per 0.36 mL prefilled syringe (Age Limit)
• Brixadi 16 mg per 0.32 mL prefilled syringe (Age Limit)
• Brixadi 24 mg per 0.48 mL prefilled syringe (Age Limit)
• Brixadi 32 mg per 0.64 mL prefilled syringe (Age Limit)
• Brixadi 64 mg per 0.18 mL prefilled syringe (Age Limit)
• Brixadi 8 mg per 0.16 mL prefilled syringe (Age Limit)
• Brixadi 96 mg per 0.27 mL prefilled syringe (Age Limit)
• Erythromycin 250 mg delayed release tablet
• Erythromycin 333 mg delayed release tablet
• Erythromycin 500 mg delayed release tablet
• Fasenra 30 mg per mL pen injector (Prior Authorization, Age Limit)
• Fasenra 30 mg per mL syringe (Prior Authorization, Age Limit)
• Modafinil 100 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Modafinil 200 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Qulipta 10 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Qulipta 30 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Qulipta 60 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Sunosi 150 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Sunosi 75 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Teriflunomide 7 mg tablet (Auto-PA, Age Limit)
• Teriflunomide 14 mg tablet (Auto-PA, Age Limit)
• Timolol maleate 0.5% ophthalmic solution (Quantity Limit)

 

Removals:

 

• N/A

 

Other updates:

 

• Nurtec 75 mg dispersible tablet (Changed Quantity Limit)

 

June 2024

 

Additions:

 

• N/A

 

Removals:

 

• N/A

 

Other updates:

 

• Accutane 10 mg capsule (Changed Step Therapy)
• Accutane 20 mg capsule (Changed Step Therapy)
• Accutane 30 mg capsule (Changed Step Therapy)
• Accutane 40 mg capsule (Changed Step Therapy)
• Amnesteem 10 mg capsule (Changed Step Therapy)
• Amnesteem 20 mg capsule (Changed Step Therapy)
• Amnesteem 40 mg capsule (Changed Step Therapy)
• Claravis 10 mg capsule (Changed Step Therapy)
• Claravis 20 mg capsule (Changed Step Therapy)
• Claravis 30 mg capsule (Changed Step Therapy)
• Claravis 40 mg capsule (Changed Step Therapy)
• Griseofulvin microsize 500 mg tablet (Changed Step Therapy)
• Griseofulvin ultramicrosize 125 mg tablet (Changed Step Therapy)
• Griseofulvin ultramicrosize 250 mg tablet (Changed Step Therapy)
• Isotretinoin 10 mg capsule (Changed Step Therapy)
• Isotretinoin 20 mg capsule (Changed Step Therapy)
• Isotretinoin 30 mg capsule (Changed Step Therapy)
• Isotretinoin 40 mg capsule (Changed Step Therapy)
• Myorisan 10 mg capsule (Changed Step Therapy)
• Myorisan 20 mg capsule (Changed Step Therapy)
• Myorisan 30 mg capsule (Changed Step Therapy)
• Myorisan 40 mg capsule (Changed Step Therapy)
• Zenatane 10 mg capsule (Changed Step Therapy)
• Zenatane 20 mg capsule (Changed Step Therapy)
• Zenatane 30 mg capsule (Changed Step Therapy)
• Zenatane 40 mg capsule (Changed Step Therapy)

 

May 2024

 

Additions:

 

• Adapalene 0.1%/benzoyl peroxide 2.5% gel (Quantity Limit)
• Adapalene 0.3% gel (Step Therapy, Quantity Limit)
• Azelaic acid 0.15 gel (Quantity Limit)
• Baclofen 15 mg tablet
• Benzoyl peroxide 5%/ erythromycin 3 % gel (Quantity Limit)
• Clindamycin phosphate 1%/benzoyl peroxide 5% gel (Quantity Limit)
• Doxycycline hyclate 75 mg tablet
• Doxycycline monohydrate 50 mg tablet
• Doxycycline monohydrate 75 mg tablet
• Isosorbide dinitrate 20 mg/hydralazine 37.5 mg tablet (Quantity Limit)
• Nitroglycerin 0.4% ointment (Prior Authorization)
• Oxycodone extended release 10 mg tablet (Prior Authorization, Quantity Limit)
• Oxycodone extended release 20 mg tablet (Prior Authorization, Quantity Limit)
• Oxycodone extended release 40 mg tablet (Prior Authorization, Quantity Limit)
• Oxycodone extended release 80 mg tablet (Prior Authorization, Quantity Limit)

 

Removals:

 

• Tretinoin 0.01% gel
• Tretinoin 0.025% cream
• Tretinoin 0.025% gel
• Tretinoin 0.05% cream
• Tretinoin 0.1% cream

 

Other updates:

 

• Ciclopirox olamine 0.77% cream (Removed Step Therapy)
• Clindamycin phosphate 1% gel (Removed Quantity Limit)
• Lopinavir 400 mg/ ritonavir 100 mg per 5 mL solution (Changed Quantity Limit)
• Retrovir 100 mg capsule (Changed Quantity Limit)
• Zidovudine 100 mg capsule (Changed Quantity Limit)

 

April 2024

 

Additions:

 

• Hemlibra 12 mg per 0.4 mL solution
• Xolair 300 mg per 2 mL solution (Prior Authorization)
• Xolair 300 mg per 2 mL auto-injection (Prior Authorization)
• Xolair 75 mg per 0.5 mL auto-injection (Prior Authorization)
• Xolair 150 mg per mL solution (Prior Authorization)

 

Removals:

 

• Baby skin protectant 41% ointment
• Daily moisturizer 41% ointment
• Petrolatum 42% ointment

 

Other updates:

 

• N/A

 

March 2024

 

Additions:

 

• Freestyle libre 3 reader (Prior Authorization, Quantity Limit)

 

Removals:

 

• N/A

 

Other updates:

 

• Aubagio 14 mg tablet (Added Prior Authorization)
• Aubagio 7 mg tablet (Added Prior Authorization)
• Avonex 30 mcg per 0.5 mL kit (Added Prior Authorization)
• Avonex 30 mcg prefilled syringe kit (Added Prior Authorization)
• Betaseron 0.3 mg kit (Added Prior Authorization)
• Copaxone 20 mg per mL syringe (Added Prior Authorization)
• Dimethyl fumarate 120 mg capsule (Added Prior Authorization)
• Dimethyl fumarate 240 mg capsule (Added Prior Authorization)
• Dimethyl fumarate starter pack (Added Prior Authorization)
• Dupixent 100 mg per 0.67 mL syringe (Removed Quantity Limit)
• Dupixent 200 mg per 1.14 mL pen (Removed Quantity Limit)
• Dupixent 200 mg per 1.14 mL syringe (Removed Quantity Limit)
• Dupixent 300 mg per 2 mL pen (Removed Quantity Limit)
• Dupixent 300 mg per 2 mL safe syringe (Removed Quantity Limit)
• Fingolimod 0.5 mg capsule (Added Prior Authorization)
• Icosapent ethyl 0.5 gm capsule (Removed Prior Authorization)
• Icosapent ethyl 1 gm capsule (Removed Prior Authorization)
• Kesimpta 20 mg per 0.4 mL pen (Removed Step Therapy, Added Prior Authorization)
• Nurtec 75 mg oral disintegrating tablet (Removed Step Therapy, Added Prior Authorization)
• Opvee 2.7 mg nasal spray (Removed Prior Authorization)
• Promethazine 6.25 mg per 5 mL solution (Removed Quantity Limit)
• Vascepa 0.5 gm capsule (Removed Prior Authorization)
• Vascepa 1 gm capsule (Removed Prior Authorization)

 

February 2024

 

Additions:

 

• Austedo 6 mg/12 mg/24 mg extended release titration kit (Prior authorization, Quantity Limit)
• Dexamphetamine 2.5 mg tablet (Age Limit)
• Dexamphetamine 7.5 mg tablet (Age Limit)
• Lifems Naloxone 2 mg per 2 mL prefilled syringe
• Lintera 10% wash (Age Limit)
• Meclizine 50 mg tablet
• Naloxone 4 mg per 0.1 mL nasal spray OTC
• Opvee 2.7 mg nasal spray (Prior authorization, Age Limit)
• Orlissa 150 mg tablet (Prior Authorization)
• Orlissa 200 mg tablet (Prior Authorization)
• Teriparatide 620 mcg per 2.48 mL pen injector (Prior Authorization, Quantity Limit)
• Zenpep 60,000 unit delayed release capsule (Prior Authorization)

 

 

Removals:

 

• Admelog 100 unit per mL injection solution
• Admelog solostar 100 unit per mL solution pen injector
• Basaglar 100 unit per mL solution pen injector
• Basaglar Kwikpen 100 unit per mL solution pen injector
• Bromocriptine 2.5 mg tablet
• Bromocriptine 5 mg capsule
• Carisoprodol 200 mg/aspirin 325 mg/codeine 16 mg tablet
• Climaro Pro 0.045-0.015 mg per day patch
• Combipatch 0.05-0.14 mg per day patch
• Combipatch 0.05-0.25 mg per day patch
• Diflunisal 500 mg tablet
• Insulin glargine-yfgn 100 unit per mL solution
• Insulin glargine-yfgn 100 unit per mL solution pen injector
• Non-BD brand syringes
• Proair HFA 108 mcg per act (90 base) aerosol solution
• Salsalate 500 mg tablet
• Salsalate 750 mg tablet
• Semglee (yfgn) 100 unit per mL solution
• Semglee (yfgn) 100 unit per mL solution pen injector
• Tramadol 100 mg tablet
• Viokace 10440 unit tablet
• Viokace 20880 unit tablet

 

 

Other updates:

 

• Antifungal 1% cream (Removed Quantity Limit)
• Athlete foot 1% cream (Removed Quantity Limit)
• Austedo 24 mg extended release tablet (Changed Quantity Limit)
• Clotrimazole 1% cream (Removed Quantity Limit)
• Diclegis 10/10 mg delayed release tablet (Added Prior authorization)
• Doxylamine-Pyridoxine 10/10 mg delayed release tablet (Added Prior authorization)
• Esomeprazole magnesium 40 mg delayed release capsule (Added Quantity Limit)
• Ethosuximide 250 mg capsule (Added Age Limit)
• Lansoprazole 20 mg delayed release capsule (Added Quantity Limit)
• Nurtec 75 mg oral disintegrating tablet (Changed Quantity Limit)
• Omeprazole 10 mg delayed release capsule (Added Quantity Limit)
• Omeprazole 20 mg delayed release capsule (Added Quantity Limit)
• Omeprazole 40 mg delayed release capsule (Added Quantity Limit)
• Pantoprazole sodium 20 mg delayed release capsule (Added Quantity Limit)
• Pantoprazole sodium 40 mg delayed release capsule (Added Quantity Limit)
• Protonix 40 mg suspension (Added Quantity Limit)
• Risperdal Consta 12.5 mg syringe (Added Quantity Limit)
• Roflumilast 250 mcg tablet (Added Age Limit)
• Sumatriptan 4 mg per 0.5 mL solution auto-injector (Changed Quantity Limit)
• Sumatriptan 6 mg per 0.5 mL solution (Changed Quantity Limit)
• Sumatriptan 6 mg per 0.5 mL solution auto-injector (Changed Quantity Limit)
• Tivicay 10 mg tablet (Changed Quantity Limit)
• Tivicay 25 mg tablet (Changed Quantity Limit)
• Tivicay 50 mg tablet (Changed Quantity Limit)

 

January 2024

 

Additions:

 

• Abilify asimtufii 720 mg per 2.4 mL prefilled syringe (Age Limit)
• Abilify asimtufii 960 mg per 3.2 mL prefilled syringe (Age Limit)
• Adbry 150 mg per mL syringe (Prior Authorization, Quantity Limit, Age Limit)
• Arnuity ellipta 100 mcg per actuation inhalation
• Arnuity ellipta 200 mcg per actuation inhalation
• Arnuity ellipta 50 mcg per actuation inhalation
• Dexcom G7 receiver (Quantity Limit)
• Dexcom G7 sensor (Quantity Limit)
• Diclegis 10 mg/10 mg delayed release tablet (Age Limit)
• Doxylamine pyridoxine 10 mg/10 mg delayed release tablet (Age Limit)
• Fluticasone propionate diskus 100 mcg per actuation
• Fluticasone propionate diskus 250 mcg per actuation
• Fluticasone propionate diskus 50 mcg per actuation
• Glucagon 1 mg emergency kit
• Icatibant acetate 30 mg per 3 mL prefilled syringe (Prior Authorization, Age Limit)
• Metformin 625 mg tablet
• Nutropin aq nuspin 10 mg per 2 mL pen-injector (Prior Authorization)
• Nutropin aq nuspin 20 mg per 2 mL pen-injector (Prior Authorization)
• Nutropin aq nuspin 5 mg per 2 mL pen-injector (Prior Authorization)
• Pazopanib 200 mg tablet (Quantity Limit)
• Proair respiclick 108 mcg per actuation
• Roflumilast 250 mcg tablet (Prior Authorization)
• Roflumilast 500 mcg tablet (Prior Authorization)
• Sajazir 30 mg per 3 mL prefilled syringe (Prior Authorization, Age Limit)
• Tiagabine 12 mg tablet
• Tiagabine 16 mg tablet
• Tiagabine 2 mg tablet
• Tiagabine 4 mg tablet
• Trelegy ellipta 100 mcg per actuation
• Trelegy ellipta 200 mcg per actuation
• Uzedy 100 mg per 0.28 mL extended release syringe (Age Limit)
• Uzedy 125 mg per 0.35 mL extended release syringe (Age Limit)
• Uzedy 150 mg per 0.42 mL extended release syringe (Age Limit)
• Uzedy 200 mg per 0.56 mL extended release syringe (Age Limit)
• Uzedy 250 mg per 0.7 mL extended release syringe (Age Limit)
• Uzedy 50 mg per 0.14 mL extended release syringe (Age Limit)
• Uzedy 75 mg per 0.21 mL extended release syringe (Age Limit)

 

Removals:

 

• Aptivus 250 mg capsule
• Atripla 600 mg/200 mg/300 mg tablet
• Combivir 150 mg/300 mg tablet
• Darunavir 600 mg tablet
• Darunavir 800 mg tablet
• Didanosine 250 mg delayed release capsule
• Didanosine 400 mg delayed release capsule
• Efavirenz 200 mg capsule
• Efavirenz 400 mg/lamivudine 300 mg/tenofovir 300 mg tablet
• Efavirenz 50 mg capsule
• Efavirenz 600 mg/lamivudine 300 mg/tenofovir 300 mg tablet
• Epivir 150 mg tablet
• Epivir 300 mg tablet
• Epzicom 600 mg/300 mg tablet
• Kaletra 100 mg/25 mg tablet
• Kaletra 200 mg/50 mg tablet
• Kaletra 400 mg/100 mg per 5 mL solution
• Lexiva 50 mg per mL suspension
• Norvir 100 mg tablet
• Retrovir 10 mg per mL syrup
• Reyataz 150 mg capsule
• Reyataz 200 mg capsule
• Reyataz 300 mg capsule
• Stavudine 15 mg capsule
• Stavudine 20 mg capsule
• Stavudine 40 mg capsule
• Sustiva 200 mg capsule
• Sustiva 50 mg capsule
• Trizivir 300 mg/150 mg/300 mg tablet
• Viibryd 10 mg tablet
• Viibryd 20 mg tablet
• Viibryd 40 mg tablet
• Viracept 250 mg tablet
• Viracept 625 mg tablet
• Viread 150 mg tablet
• Viread 200 mg tablet
• Viread 250 mg tablet
• Viread 300 mg tablet
• Votrient 200 mg tablet
• Ziagen 300 mg tablet

 

Other updates:

 

• Chlorzoxazone 250 mg tablet (Added Quantity Limit, Added Age Limit)
• Chlorzoxazone 375 mg tablet (Added Quantity Limit, Added Age Limit)
• Chlorzoxazone 500 mg tablet (Added Quantity Limit, Added Age Limit)
• Chlorzoxazone 750 mg tablet (Added Quantity Limit, Added Age Limit)
• Cyclobenzaprine 10 mg tablet (Added Quantity Limit, Added Age Limit)
• Cyclobenzaprine 5 mg tablet (Added Quantity Limit, Added Age Limit)
• Cyclobenzaprine 7.5 mg tablet (Added Quantity Limit, Added Age Limit)
• Ketorolac 10 mg tablet (Added Quantity Limit)
• Methocarbamol 500 mg tablet (Added Age Limit)
• Methocarbamol 750 mg tablet (Added Age Limit)
• Multaq 400 mg tablet (Removed Step Therapy, Added Prior Authorization)
• Orphenadrine 100 mg extended release tablet (Added Quantity Limit, Added Age Limit)
• Tizanidine 2 mg tablet (Added Quantity Limit, Added Age Limit)
• Tizanidine 4 mg tablet (Added Quantity Limit, Added Age Limit)

December 2023

 

Additions:

 

• Donepezil 23 mg tablet
• Glipizide 2.5 mg tablet
• Onetouch delica plus lancet 30g
• Onetouch delica plus lancet 33g
• Onetouch delica plus lancing
• Onetouch delica safety lancing
• Onetouch ultra 2 kit with device
• Onetouch ultra strip in vitro
• Onetouch verio flex system kit with device
• Onetouch verio reflect kit with device
• Onetouch verio strip in vitro

 

Removals:

 

• N/A

 

Other updates:

 

• Byetta 10 mcg per 0.4 mL pen-injector (Removed Prior Authorization)
• Byetta 5 mcg per 0.2 mL pen-injector (Removed Prior Authorization)
• Restasis 0.05% eye emulsion (Added Quantity Limit)
• Trulicity 0.75 mg per 0.5 mL pen-injector (Removed Prior Authorization, Changed Age Limit)
• Trulicity 1.5 mg per 0.5 mL pen-injector (Removed Prior Authorization, Changed Age Limit)
• Trulicity 3 mg per 0.5 mL pen-injector (Removed Prior Authorization, Changed Age Limit)
• Trulicity 4.5 mg per 0.5 mL pen-injector (Removed Prior Authorization, Changed Age Limit)
• Victoza 18 mg per 3 mL pen-injector (Removed Prior Authorization, Changed Age Limit)
• Xiidra 5% eye drops (Added Quantity Limit)

 

November 2023

 

Additions:

 

• Altuviiio 1000 unit vial
• Altuviiio 2000 unit vial
• Altuviiio 250 unit vial
• Altuviiio 3000 unit vial
• Altuviiio 4000 unit vial
• Altuviiio 500 unit vial
• Brimonidine tartate 0.1% drops
• Calcium acetate (phos binder) 667 mg tablet
• Calphron 667 mg tablet
• Dayvigo 10 mg tablet (Prior Authorization, Quantity Limit)
• Dayvigo 5 mg tablet (Prior Authorization, Quantity Limit)
• Enoxaparin 150 mg per mL syringe
• Gefitinib 250 mg tablet (Prior Authorization, Quantity Limit)
• Liqrev 10 mg per mL suspension (Prior Authorization, Quantity Limit)

 

Removals:

 

• Proctofoam 1% rectal foam

 

Other updates:

 

• 12 hour nasal relief 0.05% spray solution (Added Quantity Limit)
• 8 hour pain reliever 650 mg extended release tablet (Added Quantity Limit)
• Acetaminophen 650 mg extended release tablet (Added Quantity Limit)
• Allergy childrens 12.5 mg per 5 mL liquid (Added Quantity Limit)
• Allergy relief childrens 12.5 mg per 5 mL liquid (Added Quantity Limit)
• Anecream 5% cream (Added Quantity Limit)
• Anefrin 0.05% nasal solution (Added Quantity Limit)
• Arthritis 650 mg extended release tablet (Added Quantity Limit)
• Benzonatate 100 mg capsule (Added Quantity Limit, Added Age Limit)
• Benzonatate 200 mg capsule (Added Quantity Limit, Added Age Limit)
• Chlorpheniramine maleate 12 mg extended release tablet (Added Quantity Limit)
• Chlor-trimeton 12 mg extended release tablet (Added Quantity Limit)
• Citalopram 10 mg per 5 mL solution (Added Quantity Limit)
• Clearlax 17 gm per scoop powder (Added Quantity Limit)
• Cold and cough childrens 2.5 mg/1 mg/5 mg per 5 mL liquid (Added Quantity Limit)
• Concept dha 53.5 mg/38 mg/1 mg capsule (Added Quantity Limit)
• Cortizone 10 eczema 1% lotion (Added Quantity Limit)
• Cortizone 10 psoriasis 1% lotion (Added Quantity Limit)
• Cough dm childrens 30 mg per 5 mL extended release suspension (Added Quantity Limit)
• Cromolyn sodium 5.2 mg per actuation nasal aerosol solution (Added Quantity Limit)
• Cyclopentolate 1% ophthalmic solution (Added Quantity Limit)
• Cyclopentolate 1% ophthalmic solution (Added Quantity Limit)
• Daytime pe cold and flu relief 10 mg/5 mg/325 mg capsule (Added Quantity Limit)
• Delsym childrens cough 30 mg per 5 mL extended release suspension (Added Quantity Limit)
• Dextromethorphan 10 mg/guaifenesin 100 mg per 5 mL liquid (Added Quantity Limit)
• Dextromethorphan 10 mg/guaifenesin 100 mg per 5 mL syrup (Added Quantity Limit)
• Dextromethorphan 10 mg/guaifenesin 200 mg per 5 mL liquid (Added Quantity Limit)
• Dextromethorphan 10 mg/phenylephrine 5 mg/acetaminophen 325 mg capsule (Added Quantity Limit)
• Dextromethorphan 5 mg/guaifenesin 100 mg per 5 mL liquid (Added Quantity Limit)
• Dextromethorphan polistirex 30 mg per 5 mL suspension (Added Quantity Limit)
• Ed chlorped 2 mg per 5 mL oral syrup (Added Quantity Limit)
• Ella 30 mg tablet (Added Quantity Limit)
• Eq clearlax 17 gm per scoop powder (Added Quantity Limit)
• Escitalopram 5 mg per mL solution (Added Quantity Limit)
• Fleet 7 gm/19 gm per 118 mL enema (Added Quantity Limit)
• Gavilax 17 gm per scoop powder (Added Quantity Limit)
• Gnp 0.05% nasal spray extra moist solution (Added Quantity Limit)
• Gnp 0.05% nasal spray solution (Added Quantity Limit)
• Gnp clearlax 17 gram packet (Added Quantity Limit)
• Gnp cough dm 30 mg per 5 mL extended release suspension (Added Quantity Limit)
• Gnp tussin cough long acting 15 mg per 5 mL syrup (Added Quantity Limit)
• Gnp tussin mucus and chest congestion 100 mg per 5 mL liquid (Added Quantity Limit)
• Goodsense cough dm 30 mg per 5 mL extended release suspension (Added Quantity Limit)
• Guaifenesin 100 mg per 5 mL liquid (Added Quantity Limit)
• Hm enema 7 gm/19 gm per 118 mL (Added Quantity Limit)
• Hydrocortisone 0.5% ointment (Added Quantity Limit)
• Hydrocortisone 1% lotion (Added Quantity Limit)
• Hydroxyzine 10 mg tablet (Added Quantity Limit)
• Hydroxyzine 25 mg tablet (Added Quantity Limit)
• Hydroxyzine 50 mg tablet (Added Quantity Limit)
• Leuprolide acetate 1 mg per 0.2 mL injection kit (Added Quantity Limit)
• Levetiracetam 250 mg tablet (Added Quantity Limit)
• Lidocaine 4% cream (Added Quantity Limit)
• Lidocaine anorectal 5% cream (Added Quantity Limit)
• Lithium carbonate 150 mg capsule (Added Quantity Limit)
• Lithium carbonate 300 mg capsule (Added Quantity Limit)
• Lithium carbonate 300 mg extended release capsule (Added Quantity Limit)
• Lithium carbonate 450 mg extended release capsule (Added Quantity Limit)
• Lithium carbonate 600 mg capsule (Added Quantity Limit)
• Long acting 0.05% nasal solution (Added Quantity Limit)
• Mucinex childrens cough 5 mg/100 mg per 5 mL liquid (Added Quantity Limit)
• Mucus relief chest congestion 400 mg per 20 mL liquid (Added Quantity Limit)
• Multi prenatal 27 mg/0.8 mg tablets (Added Quantity Limit)
• Multi symptom childrens cold 2.5 mg/5 mg/100 mg per 5 mL liquid (Added Quantity Limit)
• Musuc relief 2.5 mg/5 mg/100 mg per 5 mL childrens liquid (Added Quantity Limit)
• Nasal decongestant 0.05% spray solution (Added Quantity Limit)
• Nasal relief 0.05% solution (Added Quantity Limit)
• Nasal spray 12 hour 0.05% solution (Added Quantity Limit)
• Nasal spray extra moisturizing 0.05% solution (Added Quantity Limit)
• Nasal spray max strength 0.05% solution (Added Quantity Limit)
• Niva plus 27 mg/1 mg tablet (Added Quantity Limit)
• Peg 3350 17 gm packet (Added Quantity Limit)
• Peg 3350 17 gm per scoop powder (Added Quantity Limit)
• Phenylephrine 10 mg/dextromethorphan 18 mg/guaifenesin 200 mg per 15 mL liquid (Added Quantity Limit)
• Phenylephrine 2.5 mg/brompheniramine 1 mg/dextromethorphan 5 mg per 5 mL liquid (Added Quantity Limit)
• Phenylephrine 2.5 mg/dextromethorphan 5 mg/guaifenesin 100 mg per 5 mL liquid (Added Quantity Limit)
• Pnv prenatal plus multivitamin 27 mg/1 mg tablet (Added Quantity Limit)
• Polyethylene glycol 3350 17 gm packet (Added Quantity Limit)
• Pramoxine 1% rectal foam (Added Quantity Limit)
• Prenatabs rx 29 mg/1 mg tablets (Added Quantity Limit)
• Prenatal 19 chewable tablet (Added Quantity Limit)
• Prenatal 19 tablet (Added Quantity Limit)
• Prenatal one daily 27 mg/0.8 mg tablets (Added Quantity Limit)
• Prenatal plus 27 mg/1 mg tablet (Added Quantity Limit)
• Prenatal u 106.5 mg/1 mg capsule (Added Quantity Limit)
• Prenatal vitamin and mineral 28 mg/0.8 mg tablet (Added Quantity Limit)
• Proctofoam 1% rectal foam (Added Quantity Limit)
• Promethazine 6.25 mg per 5 mL syrup (Added Quantity Limit)
• Promethazine 6.25 mg/dextromethorphan 15 mg per 5 mL syrup (Added Quantity Limit)
• Promethazine 6.25 mg/phenylephrine 5 mg per 5 mL syrup (Added Quantity Limit)
• Pseudoephedrine 30 mg/bromphen 2 mg/dextromethorphan 10 mg per 5 mL syrup (Added Quantity Limit)
• Pseudoephedrine30 mg/codeine 10 mg/guaifenesin 100 mg per 5 mL syrup (Added Quantity Limit, Added Age Limit)
• Qc cough relief 15 mg per 5 mL oral liquid (Added Quantity Limit)
• Qc enema 16 gm/6 gm per 118 mL (Added Quantity Limit)
• Qc no drip nasal relief 0.05% solution (Added Quantity Limit)
• Qc pain relieving and lidocaine 4% cream (Added Quantity Limit)
• Right step prenatal 27 mg/0.8 mg tablet (Added Quantity Limit)
• Sm cough relief 15 mg per 5 mL syrup (Added Quantity Limit)
• Sm nasal spray 12 hour 0.05% solution (Added Quantity Limit)
• Smooth lax 17 gm packet (Added Quantity Limit)
• Synagis 100 mg per 1 mL injection (Added Quantity Limit)
• Synagis 50 mg per 0.5 mL injection (Added Quantity Limit)
• Testosterone cypionate 100 mg per mL oil for injection (Added Quantity Limit)
• Testosterone cypionate 200 mg per mL oil for injection (Added Quantity Limit)
• Testosterone enanthate 200 mg per mL oil for injection (Added Quantity Limit)
• Theranatal core nutrition 27 mg/1 mg tablet (Added Quantity Limit)
• Trinatal rx 30 mg/1 mg tablet (Added Quantity Limit)
• Trinate tablet (Added Quantity Limit)
• Tussin 100 mg/dextromethorphan 10 mg per 5 mL liquid (Added Quantity Limit)
• Tylenol 8 hour 650 mg extended release tablet (Added Quantity Limit)
• Valganciclovir 450 mg tablet (Added Quantity Limit)
• Valtoco 10 mg per 0.1 mL liquid dose (Added Age Limit)
• Valtoco 15 mg per 0.1 mL liquid dose (Added Age Limit)
• Valtoco 20 mg per 0.1 mL liquid dose (Added Age Limit)
• Valtoco 5 mg per 0.1 mL liquid dose (Added Age Limit)
• Vanacof dm 10 mg/18 mg/200 mg per 15 mL liquid (Added Quantity Limit)
• Varenicline 0.5 mg tablet (Added Quantity Limit)
• Varenicline 1 mg tablet (Added Quantity Limit)
• Vinate ll 29 mg/1 mg tablet (Added Quantity Limit)
• Vinate one 60 mg/1 mg tablet (Added Quantity Limit)

 

October 2023

 

Additions:

 

• N/A

 

Removals:

 

• N/A

 

Other updates:

 

• Byetta 10 mcg per 0.04 mL pen injector (Added Prior Authorization)
• Byetta 5 mcg per 0.02 mL pen injector (Added Prior Authorization)
• Tacrolimus 0.1% ointment (Changed Age Limit)
• Trulicity 0.75 mg per 0.5 mL pen injector (Added Prior Authorization)
• Trulicity 1.5 mg per 0.5 mL pen injector (Added Prior Authorization)
• Trulicity 3 mg per 0.5 mL pen injector (Added Prior Authorization)
• Trulicity 4.5 mg per 0.5 mL pen injector (Added Prior Authorization)
• Victoza 18 mg per 3 mL pen injector (Added Prior Authorization)

 

September 2023

 

Additions:

 

• Aimovig 140 mg per mL auto-injector (Quantity Limit)
• Aimovig 70 mg per mL auto-injector (Quantity Limit)
• Ajovy 225 mg per 1.5 mL auto-injector (Quantity Limit)
• Ajovy 225 mg per 1.5 mL syringe (Quantity Limit)
• Austedo 12 mg extended release tablet (Age Limit, Prior Authorization, Quantity Limit)
• Austedo 24 mg extended release tablet (Age Limit, Prior Authorization, Quantity Limit)
• Austedo 6 mg extended release tablet (Age Limit, Prior Authorization, Quantity Limit)
• Oxbryta 300 mg tablets (Age Limit)
• Oxybutynin 2.5 mg tablet
• Primidone 125 mg tablet
• Sunlenca 300 mg (4) tablet therapy pack (Age Limit)
• Sunlenca 300 mg (5) tablet therapy pack (Age Limit)
• Sunlenca 463.5 mg per 1.5 mL vial (Age Limit)
• Ubrelvy 100 mg tablet (Quantity Limit)
• Ubrelvy 50 mg tablet (Quantity Limit)

 

Removals:

 

• Glucagon 1 mg hypokit
• Hydromorphone extended release 12 mg tablets
• Tabloid 40 mg tablet

 

Other updates:

 

• Diastat 10 mg rectal gel (Changed Quantity Limit
• Diastat 2.5 mg rectal gel (Changed Quantity Limit)
• Diastat 20 mg rectal gel (Changed Quantity Limit)
• Diazepam 10 mg rectal gel (Changed Quantity Limit)
• Diazepam 2.5 mg rectal gel (Changed Quantity Limit)
• Diazepam 20 mg rectal gel (Changed Quantity Limit)
• Jardiance 10 mg tablet (Changed Age Limit)
• Jardiance 25 mg tablet (Changed Age Limit)
• Linzess 72 mcg capsule (Changed Age Limit)
• Nayzilam 5 mg per 0.1 mL nasal solution (Added Quantity Limit)
• Olanzapine 10 mg oral disintegrating tablet (Removed Quantity Limit)
• Olanzapine 10 mg tablet (Removed Quantity Limit)
• Olanzapine 2.5 mg tablet (Removed Quantity Limit)
• Olanzapine 5 mg oral disintegrating tablet (Removed Quantity Limit)
• Olanzapine 5 mg tablet (Removed Quantity Limit)
• Olanzapine 7.5 mg tablet (Removed Quantity Limit)
• Synjardy 12.5 mg/1000 mg tablet (Changed Age Limit)
• Synjardy 12.5 mg/500 mg tablet (Changed Age Limit)
• Synjardy 5 mg/1000 mg tablet (Changed Age Limit)
• Synjardy 5 mg/500 mg tablet (Changed Age Limit)
• Ubrelvy 100 mg tablet (Added Age Limit)
• Ubrelvy 50 mg tablet (Added Age Limit)
• Valtoco 10 mg nasal spray (Changed Quantity Limit)
• Valtoco 15 mg nasal spray (Changed Quantity Limit)
• Valtoco 20 mg nasal spray (Changed Quantity Limit)
• Valtoco 5 mg nasal spray (Changed Quantity Limit)

 

August 2023

 

Additions:

 

• Derma-smooth 0.01% oil (Quantity Limit)
• Fluocinolone acetonide 0.01% oil (Quantity Limit)
• Nebivolol (base equivalent) 10 mg tablet (Quantity Limit)
• Nebivolol (base equivalent) 2.5 mg tablet (Quantity Limit)
• Nebivolol (base equivalent) 20 mg tablet (Quantity Limit)
• Nebivolol (base equivalent) 5 mg tablet (Quantity Limit)
• Tranexamic acid 650 mg tablets (Quantity Limit)

 

Removals:

 

• Fluocinonide 0.05% ointment
• Fosinopril sodium 10 mg/ hydrochlorothiazide 12.5 mg tablet
• Fosinopril sodium 20 mg/ hydrochlorothiazide 12.5 mg tablet
• Hydrocortisone micronized powder
• Hydrocortisone powder
• Rimantadine hydrochloride 100 mg tablet

 

Other updates:

 

• Desmopressin acetate 0.01% nasal spray solution (Added Quantity Limit)
• Praziquantel 600 mg tablet (Removed Prior Authorization)

 

July 2023

 

Additions:

 

• Aimovig 140 mg per ml auto-injector (Age Limit, Prior Authorization)
• Aimovig 70 mg per ml auto-injector (Age Limit, Prior Authorization)
• Aubagio 14 mg tablet
• Aubagio 7 mg tablet
• Azelastine fluticasone 137 mg/50 mg per actuation nasal spray (Age Limit)
• Dalfampridine extended release 10 mg tablet
• Dymista nasal spray (Age Limit)
• Fingolimod 0.5 mg (base equivalent) capsule (Age Limit)
• Infliximab 100 mg injection
• Insulin glargine yfgn 100 unit pen
• Insulin glargine yfgn 100 unit vial
• Jentadueto extended release 2.5 mg/1000 mg tablet (Age Limit)
• Jentadueto extended release 5 mg/1000 mg tablet (Age Limit)
• Kalydeco 13.4 mg granules (Prior Authorization)
• Kombiglyze extended release 2.5 mg/1000 mg tablets (Age Limit)
• Kombiglyze extended release 5 mg/1000 mg tablets (Age Limit)
• Kombiglyze extended release 5 mg/500 mg tablets (Age Limit)
• Lamotrigine 100 mg oral disintegrating tablet
• Lamotrigine 200 mg oral disintegrating tablet
• Lamotrigine 25 mg oral disintegrating tablet
• Lamotrigine 50 mg oral disintegrating tablet
• Mekinist 0.05 mg per ml solution (Prior Authorization)
• Methylphenidate 10 mg per 5 ml solution (Age Limit)
• Methylphenidate 5 mg per 5 ml solution (Age Limit)
• Nayzilam 5 mg nasal spray (Age Limit, Prior Authorization)
• Onglyza 2.5 mg tablet (Age Limit)
• Onglyza 5 mg tablet (Age Limit)
• Perseris extended release 120 mg syringe kit (Age Limit)
• Perseris extended release 90 mg syringe kit (Age Limit)
• Tafinlar 10 mg tablet (Prior Authorization)
• Trikafta 59.5 mg pak (Prior Authorization)
• Trikafta 75 mg pak (Prior Authorization)
• Ubrelvy 100 mg tablet (Age Limit, Step Therapy)
• Ubrelvy 50 mg tablet (Age Limit, Step Therapy)
• Viibryd 10 mg tablet
• Viibryd 20 mg tablet
• Viibryd 40 mg tablet
• Vraylar 1.5 mg capsule (Age Limit, Prior Authorization)
• Vraylar 1.5 mg/3 mg pack (Age Limit, Prior Authorization)
• Vraylar 3 mg capsule (Age Limit, Prior Authorization)
• Vraylar 4.5 mg capsule (Age Limit, Prior Authorization)
• Vraylar 6 mg capsule (Age Limit, Prior Authorization)

 

Removals:

 

• Allopurinol 200 mg tablet
• Inflectra 100 mg vial
• Invokamet extended release 150 mg/1000 mg tablet
• Invokamet extended release 150 mg/500 mg tablet
• Invokamet extended release 50 mg/1000 mg tablet
• Invokamet extended release 50 mg/500 mg tablet
• Lamictal 25 mg oral disintegrating tablet
• Lamictal 50 mg oral disintegrating tablet
• Lamictal 100 mg oral disintegrating tablet
• Lamictal 200 mg oral disintegrating tablet
• Metrocream 0.75% external cream
• Metrogel 1% gel
• Mycozyl al 1% liquid

 

Other updates:

 

• Ajovy 225 mg per 1.5 ml auto-injector (Removed Step Therapy, Added Prior Authorization)
• Ajovy 225 mg per 1.5 ml prefilled syringe (Removed Step Therapy, Added Prior Authorization)
• Emgality 120 mg per ml auto-injector (Removed Step Therapy, Added Prior Authorization)
• Emgality 120 mg per ml prefilled syringe (Removed Step Therapy, Added Prior Authorization)
• Mycozyl ac 1% topical cream (Added Quantity Limit)

 

June 2023

 

Additions:

 

• Pantoprazole enteric coated 20 mg tablet
• Rabeprazole enteric coated 20 mg tablet

 

 

Removals:

 

• Benzoyl peroxide 4% Gel
• Benzoyl peroxide 8% Gel

 

Other updates:

 

• Androgel 20.25 mg per actuation transdermal gel pump (Added Age Limit)
• Diastat 2.5 mg pediatric rectal gel (Added Quantity Limit)
• Diastat acudial 10 mg rectal gel (Added Quantity Limit)
• Diastat acudial 20 mg rectal gel (Added Quantity Limit)
• Diazepam 10 mg rectal gel (Added Quantity Limit)
• Diazepam 2.5 mg rectal gel (Added Quantity Limit)
• Diazepam 20 mg rectal gel (Added Quantity Limit)
• Escitalopram 20 mg tablet (Added Quantity Limit)
• Esomeprazole magnesium 40mg capsule (Removed Quantity Limit)
• Pantoprazole enteric coated 40 mg tablet (Removed Quantity Limit)
• Testosterone 20.25 mg per actuation transdermal gel (Added Age Limit)
• Valtoco 10 mg nasal spray (Added Quantity Limit)
• Valtoco 15 mg nasal spray (Added Quantity Limit)
• Valtoco 20 mg nasal spray (Added Quantity Limit)
• Valtoco 5 mg nasal spray (Added Quantity Limit)
• Venlafaxine extended release 150 mg capsules (Added Quantity Limit)
• Victoza 18 mg per 3 ml pen-injector solution (Changed Quantity Limit)
• Vyvanse 10 mg capsule (Added Quantity Limit)
• Vyvanse 10 mg chewable tablet (Added Quantity Limit)
• Vyvanse 20 mg chewable tablet (Added Quantity Limit)
• Vyvanse 30 mg chewable tablet (Added Quantity Limit)
• Vyvanse 40 mg chewable tablet (Added Quantity Limit)
• Vyvanse 50 mg chewable tablet (Added Quantity Limit)
• Vyvanse 60 mg chewable tablet (Added Quantity Limit)

 

May 2023

 

Additions:

 

• Bismuth metronidazole tetracycline 140 mg/125 mg/125 mg capsules
• Lurasidone 120 mg tablets
• Lurasidone 20 mg tablets
• Lurasidone 40 mg tablets
• Lurasidone 60 mg tablets
• Lurasidone 80 mg tablets
• Trikafta 100 mg/50 mg/75 mg/150 mg tablets (Prior Authorization)
• Trikafta 50 mg/25 mg/37.5 mg/75 mg tablets (Prior Authorization)

 

Removals:

 

• Elmiron 100 mg capsules
• Fluocinolone acetonide 0.01% cream
• Heparin sodium (porcine) 20,000 units per ml solution
• Heparin sodium (porcine) 5,000 units per 0.5 ml solution
• Hydroxyprogesterone caproate powder
• Latuda 120 mg tablets
• Latuda 20 mg tablets
• Latuda 40 mg tablets
• Latuda 60 mg tablets
• Latuda 80 mg tablets
• Lidocaine 4% solution
• Makena 275 mg per 1.1 ml auto-injector
• Mexiletine 150 mg capsules
• Mexiletine 200 mg capsules
• Mexiletine 250 mg capsules
• Quinidine sulfate 200 mg tablets
• Quinidine sulfate 300 mg tablets
• Scalpicin 1% solution
• Triamcinolone acetonide powder

 

Other updates:

 

• Albendazole 200 mg tablets (Removed Step Therapy, Added Prior Authorization)
• Aspercreme 4% cream (Removed Quantity Limit)
• Betamethasone dipropionate 0.05% ointment (Changed Quantity Limit)
• Cefixime 400 mg capsules (Added Quantity Limit)
• Epinephrine solution 0.15 mg per 0.15 ml auto-injector (Added Quantity Limit)
• Epinephrine solution 0.15 mg per 0.3 ml auto-injector (Added Quantity Limit)
• Epinephrine solution 0.15 mg per 0.3 ml prefilled syringe (Added Quantity Limit)
• Epinephrine solution 0.3 mg per 0.3 ml auto-injector (Added Quantity Limit)
• Epinephrine solution 0.3 mg per 0.3 ml prefilled syringe (Added Quantity Limit)
• Fluocinolone acetonide 0.025% cream (Changed Quantity Limit)
• Fluocinolone acetonide 0.025% ointment (Changed Quantity Limit)
• Lidocaine 5% ointment (Removed Prior Authorization)
• Tradjenta 5 mg tablets (Added Quantity Limit)
• Victoza 2-pack 18 mg per 3 ml pen (Added Age Limit)
• Wegovy 0.25 mg/0.5 ml pen (Changed Quantity Limit)
• Wegovy 0.5 mg/0.5 ml pen (Changed Quantity Limit)
• Wegovy 1 mg/0.5 ml pen (Changed Quantity Limit)
• Wegovy 1.7 mg/0.75 ml pen (Changed Quantity Limit)
• Wegovy 2.4 mg/0.75 ml pen (Changed Quantity Limit)

 

April 2023

 

Additions:

 

• Oxybutynin 5 mg per 5 ml solution
• Rebinyn 3000 unit vial

 

Removals:

 

• Allevyn ag sacrum silver wound dressing
• Ammonium lactate 70% solution
• Aspirin extended release 162.5 mg capsule
• Cholecalciferol liquid
• Clotrimazole crystals
• Coal tar (crude) solution
• Coal tar (crude) tar
• Coal tar 20% solution
• CVS nerve pain relief ointment
• Cyanocobalamin 1000 mcg per ml injectable kit
• Dextromethorphan hydrobromide crystals
• Homeopathic ointment products
• Hydrocortisone 2.5% cream kit
• Hypromellose intraocular 2% solution
• Magnesium chloride crystals
• Recura cream
• Salicylic acid 6% cream
• Salicylic acid 6% shampoo and salicylic acid 6% gel kit
• Salicylic acid extended release 28.5% film-forming solution
• Urea beads

 

Other updates:

 

• Baqsimi 3 mg one pack spray (Removed Quantity Limit)
• Glucagon 1 mg emergency kit (Removed Quantity Limit)
• Gvoke 0.5 mg per 0.1 ml syringe (Removed Quantity Limit)
• Gvoke 1 mg per 0.2 ml kit (Removed Quantity Limit)
• Gvoke 1 mg per 0.2 ml syringe (Removed Quantity Limit)
• Gvoke hypopen 0.5 mg per 0.1 ml (Removed Quantity Limit)
• Gvoke hypopen 1 mg per 0.2 ml (Removed Quantity Limit)
• Invokamet 150 mg/1000 mg tablet (Removed Quantity Limit)
• Invokamet 150 mg/500 mg tablet (Removed Quantity Limit)
• Invokamet 50 mg/1000 mg tablet (Removed Quantity Limit)
• Invokamet 50 mg/500 mg tablet (Removed Quantity Limit)
• Invokamet extended release 150 mg/1000 mg tablet (Removed Quantity Limit)
• Invokamet extended release 150 mg/500 mg tablet (Removed Quantity Limit)
• Invokamet extended release 50 mg/1000 mg tablet (Removed Quantity Limit)
• Invokamet extended release 50 mg/500 mg tablet (Removed Quantity Limit)
• Janumet extended release 100 mg/1000 mg tablet (Removed Quantity Limit)
• Janumet extended release 50 mg/1000 mg tablet (Removed Quantity Limit)
• Janumet extended release 50 mg/500 mg tablet (Removed Quantity Limit)
• Jentadueto 2.5 mg/1000 mg tablet (Removed Quantity Limit)
• Jentadueto 2.5 mg/500 mg tablet (Removed Quantity Limit)
• Jentadueto 2.5 mg/850 mg tablet (Removed Quantity Limit)
• Olanzapine 15 mg oral disintegrating tablet (Removed Quantity Limit)
• Olanzapine 15 mg tablet (Removed Quantity Limit)
• Olanzapine 20 mg oral disintegrating tablet (Removed Quantity Limit)
• Olanzapine 20 mg tablet (Removed Quantity Limit)
• Quetiapine extended release 300 mg tablet (Removed Quantity Limit)
• Quetiapine extended release 400 mg tablet (Removed Quantity Limit)
• Quetiapine extended release 50 mg tablet (Removed Quantity Limit)
• Synjardy 12.5 mg/1000 mg tablet (Removed Quantity Limit)
• Synjardy 12.5 mg/500 mg tablet (Removed Quantity Limit)
• Synjardy 5 mg/1000 mg tablet (Removed Quantity Limit)
• Synjardy 5 mg/500 mg tablet (Removed Quantity Limit)
• Tradjenta 5 mg tablet (Removed Quantity Limit)
• Xigduo extended release 10 mg/1000 mg tablet (Removed Quantity Limit)
• Xigduo extended release 10 mg/500 mg tablet (Removed Quantity Limit)
• Xigduo extended release 2.5 mg/1000 mg tablet (Removed Quantity Limit)
• Xigduo extended release 5 mg/ 500 mg tablet (Removed Quantity Limit)
• Xigduo extended release 5 mg/1000 mg tablet (Removed Quantity Limit)
• Ziprasidone 20 mg capsule (Removed Quantity Limit)
• Ziprasidone 40 mg capsule (Removed Quantity Limit)
• Ziprasidone 60 mg capsule (Removed Quantity Limit)
• Ziprasidone 80 mg capsule (Removed Quantity Limit)

 

March 2023

 

Additions:
 

• Allopurinol 200 mg tablet
• Clonidine extended release 0.17 mg tablet
• Glucagen 1 mg hypokit (Quantity Limit)
• Guaifenesin 100 mg/ Codeine 6.33 mg per 5 ml solution (Age Limit, Quantity Limit)
• Quetiapine 150 mg tablet (Age Limit)
• Rebinyn 1000 unit vial
• Rebinyn 2000 unit vial
• Rebinyn 500 unit vial
• Tretten 2,500 unit vial

 

Removals:

 

• Acid reducer complete 10 mg/800 mg/165 mg chewable tablet
• Alevazol 1% ointment
• Azelastine 0.15% nasal spray
• Benzefoam 5.3% emollient foam
• Betoptic-S 0.25% ophthalmic solution
• BPO 6% foaming cloths
• Budesonide extended release 9 mg tablet
• Bupropion extended release 450 mg tablet
• Carisoprodol 250 mg tablet
• Cetirizine 10 mg capsule
• Cetirizine 10 mg chewable tablet
• Cetirizine 5 mg chewable tablet
• Clindamycin-Benzoyl peroxide 1%/5% solution
• Colesevelam 625 mg tablet
• Dermacinrx atrix 2% wash
• Dorzolamide-Timolol maleate 22.3 mg/6.8 mg per ml ophthalmic solution
• Erythromycin 250 mg filmtab
• Erythromycin 333 mg delayed release tablet
• Erythromycin 400 mg per 5 ml suspension
• Erythromycin 500 mg delayed release tablet
• Erythromycin 500 mg filmtab
• Everolimus 3 mg tablet for oral suspension
• Everolimus 5 mg tablet for oral suspension
• Fexofenadine 30 mg per 5 ml solution
• Fexofenadine 30 mg per 5 ml suspension
• Fluocinonide-E 0.05% cream
• Fluticasone propionate 0.05% lotion
• Fungoid 2% tincture
• Hydrocortisone butyrate 0.1% cream
• Hydrocortisone butyrate 0.1% ointment
• Hydrocortisone butyrate 0.1% solution
• Hydrocortisone butyrate hydrophilic lipo base 0.1% cream
• Ketoprofen 50 mg capsule
• Ketoprofen 75 mg capsule
• Levocetirizine 2.5 mg per 5 ml solution
• Levorphanol 2 mg tablet
• Lidocaine 2% gel
• Meperidine 50 mg per 5 ml solution
• Miglitol 100 mg tablet
• Miglitol 25 mg tablet
• Miglitol 50 mg tablet
• Morphine sulfate extended release 10 mg capsule
• Morphine sulfate extended release 100 mg capsule
• Morphine sulfate extended release 20 mg capsule
• Morphine sulfate extended release 30 mg capsule
• Morphine sulfate extended release 50 mg capsule
• Morphine sulfate extended release 60 mg capsule
• Morphine sulfate extended release 80 mg capsule
• Nexium 20 mg capsule
• Oxycodone 100 mg per 5 ml solution
• Oxymorphone 10 mg tablet
• Oxymorphone 5 mg tablet
• Prilosec delayed release 10 mg suspension
• Prilosec delayed release 2.5 mg suspension
• Rhofade 1% cream
• Sevelamer 400 mg tablet
• Sevelamer 800 mg tablet
• Texacort 2.5% Solution
• Timolol 0.5% eye drops
• Tretinoin 0.05% gel
  
  

Other Updates:
 

• Ambrisentan 10 mg tablet (Added Quantity Limit)
• Ambrisentan 5 mg tablet (Added Quantity Limit)
• Austedo 12 mg tablet (Added Age Limit)
• Austedo 6 mg tablet (Added Age Limit)
• Austedo 9 mg tablet (Added Age Limit)
• Baqsimi 3 mg one pack spray (Added Quantity Limit)
• Berinert 500 unit kit (Added Quantity Limit)
• Bosentan 125 mg tablet (Added Quantity Limit)
• Bosentan 62.5 mg tablet (Added Quantity Limit)
• Buprenorphine 10 mcg per 1 hour patch (Updated Quantity Limit)
• Buprenorphine 15 mcg per 1 hour patch (Updated Quantity Limit)
• Buprenorphine 20 mcg per 1 hour patch (Updated Quantity Limit)
• Buprenorphine 5 mcg per 1 hour patch (Updated Quantity Limit)
• Buprenorphine 7.5 mcg per 1 hour patch (Updated Quantity Limit)
• Byetta 10 mcg pen injector (Added Age Limit)
• Byetta 5 mcg pen injector (Added Age Limit)
• Dupixent 100 mg per 0.67 ml syringe (Added Quantity Limit)
• Dupixent 200 mg per 1.14 ml pen (Added Quantity Limit)
• Dupixent 200 mg per 1.14 ml syringe (Added Quantity Limit)
• Dupixent 300 mg per 2 ml pen (Added Quantity Limit)
• Dupixent 300 mg per 2 ml safe syringe (Added Quantity Limit)
• Estazolam 1 mg tablet (Added Age Limit)
• Estazolam 2 mg tablet (Added Age Limit)
• Eszopiclone 1 mg tablet (Added Age Limit, Added Quantity Limit)
• Eszopiclone 2 mg tablet (Added Age Limit, Added Quantity Limit)
• Eszopiclone 3 mg tablet (Added Age Limit, Added Quantity Limit)
• Eucrisa 2% ointment (Updated Quantity Limit)
• Fentanyl 100 mcg per 1 hour patch (Updated Quantity Limit)
• Fentanyl 12 mcg per 1 hour patch (Updated Quantity Limit)
• Fentanyl 25 mcg per 1 hour patch (Updated Quantity Limit)
• Fentanyl 50 mcg per 1 hour patch (Updated Quantity Limit)
• Fentanyl 75 mcg per 1 hour patch (Updated Quantity Limit)
• Flurazepam 15 mg capsule (Added Age Limit)
• Flurazepam 30 mg capsule (Added Age Limit)
• Glucagon 1 mg emergency kit (Added Quantity Limit)
• Gvoke 0.5 mg per 0.1 ml syringe (Added Quantity Limit)
• Gvoke 1 mg per 0.2 ml kit (Added Quantity Limit)
• Gvoke 1 mg per 0.2 ml syringe (Added Quantity Limit)
• Gvoke hypopen 0.5 mg per 0.1 ml (Added Quantity Limit)
• Gvoke hypopen 1 mg per 0.2 ml (Added Quantity Limit)
• Hydrocodone 5 mg/Homatropine 1.5 mg tablet (Updated Age Limit)
• Hydromet 5 mg/1.5 mg solution (Updated Age Limit)
• Hydromorphone 2 mg tablet (Updated Quantity Limit)
• Ingrezza 40 mg capsule (Added Age Limit)
• Ingrezza 60 mg capsule (Added Age Limit)
• Ingrezza 80 mg capsule (Added Age Limit)
• Ingrezza initiation pack (Added Age Limit)
• Invokamet 150 mg/1000 mg tablet (Added Quantity Limit)
• Invokamet 150 mg/500 mg tablet (Added Quantity Limit)
• Invokamet 50 mg/1000 mg tablet (Added Quantity Limit)
• Invokamet 50 mg/500 mg tablet (Added Quantity Limit)
• Invokamet extended release 150 mg/1000 mg tablet (Added Quantity Limit)
• Invokamet extended release 150 mg/500 mg tablet (Added Quantity Limit)
• Invokamet extended release 50 mg/1000 mg tablet (Added Quantity Limit)
• Invokamet extended release 50 mg/500 mg tablet (Added Quantity Limit)
• Janumet extended release 100 mg/1000 mg tablet (Added Quantity Limit)
• Janumet extended release 50 mg/1000 mg tablet (Added Quantity Limit)
• Janumet extended release 50 mg/500 mg tablet (Added Quantity Limit)
• Jardiance 10 mg tablet (Added Quantity Limit)
• Jardiance 25 mg tablet (Added Quantity Limit)
• Jentadueto 2.5 mg/1000 mg tablet (Added Quantity Limit)
• Jentadueto 2.5 mg/500 mg tablet (Added Quantity Limit)
• Jentadueto 2.5 mg/850 mg tablet (Added Quantity Limit)
• Kalbitor 10 mg per ml vial (Updated Quantity Limit)
• Morphine sulfate extended release 60 mg tablet (Updated Quantity Limit)
• Olanzapine 15 mg oral disintegrating tablet (Added Quantity Limit)
• Olanzapine 15 mg tablet (Added Quantity Limit)
• Olanzapine 20 mg oral disintegrating tablet (Added Quantity Limit)
• Olanzapine 20 mg tablet (Updated Quantity Limit)
• Oxymorphone extended release 10 mg tablet (Updated Quantity Limit)
• Oxymorphone extended release 7.5 mg tablet (Updated Quantity Limit)
• Ramelteon 8 mg tablet (Added Quantity Limit)
• Sumatriptan 20 mg nasal spray (Added Quantity Limit)
• Sumatriptan 4 mg per 0.5 ml cartridge (Added Quantity Limit)
• Sumatriptan 4 mg per 0.5 ml injection (Added Quantity Limit)
• Sumatriptan 5 mg nasal spray (Added Quantity Limit)
• Sumatriptan 6 mg per 0.5 ml cartridge (Added Quantity Limit)
• Sumatriptan 6 mg per 0.5 ml injection (Added Quantity Limit)
• Sumatriptan 6 mg per 0.5 ml vial (Added Quantity Limit)
• Synjardy 12.5 mg/1000 mg tablet (Added Quantity Limit)
• Synjardy 12.5 mg/500 mg tablet (Added Quantity Limit)
• Synjardy 5 mg/1000 mg tablet (Added Quantity Limit)
• Synjardy 5 mg/500 mg tablet (Added Quantity Limit)
• Temazepam 15 mg capsule (Added Age Limit, Added Quantity Limit)
• Temazepam 30 mg tablet (Added Age Limit, Added Quantity Limit)
• Testosterone 1.62% gel pump (Removed Age Limit)
• Tetrabenazine 12.5 mg tablet (Added Age Limit)
• Tetrabenazine 12.5 mg tablet (Added Age Limit)
• Tetrabenazine 25 mg tablet (Added Age Limit)
• Tetrabenazine 25 mg tablet (Added Age Limit)
• Tradjenta 5 mg tablet (Added Quantity Limit)
• Trulicity 0.75 mg per 0.5 ml pen (Added Age Limit, Added Quantity Limit)
• Trulicity 1.5 mg per 0.5 ml pen (Added Age Limit, Added Quantity Limit)
• Trulicity 3 mg per 0.5 ml pen (Added Age Limit, Added Quantity Limit)
• Trulicity 4.5 mg per 0.5 ml pen (Added Age Limit, Added Quantity Limit)
• Vivitrol 380 mg vial plus diluent (Added Quantity Limit)
• Xigduo extended release 10 mg/1000 mg tablet (Added Quantity Limit)
• Xigduo extended release 10 mg/500 mg tablet (Added Quantity Limit)
• Xigduo extended release 2.5 mg/1000 mg tablet (Added Quantity Limit)
• Xigduo extended release 5 mg/1000 mg tablet (Added Quantity Limit)
• Xigduo extended release 5 mg/500 mg tablet (Added Quantity Limit)
• Zaleplon 10 mg capsule (Added Age Limit, Added Quantity Limit)
• Zaleplon 5 mg capsule (Added Age Limit, Added Quantity Limit)
• Ziprasidone 20 mg capsule (Added Quantity Limit)
• Ziprasidone 40 mg capsule (Added Quantity Limit)
• Ziprasidone 60 mg capsule (Added Quantity Limit)
• Ziprasidone 80 mg capsule (Added Quantity Limit)
• Zolpidem tartate 10 mg tablet (Added Age Limit, Added Quantity Limit)

 

February 2023

 

Additions:

 

• Acidophilus 100 mg capsule
• Amethia 0.01 mg-0.15 mg-0.03 mg tablet
• Artificial tears 0.2%/0.2%/1% ophthalmic solution
• Ashlyna 0.01 mg-0.15 mg-0.03 mg tablet
• Aurovela 24 Fe 1 mg/20 mcg tablet
• Blisovi 24 Fe 1 mg/20 mcg tablet
• Buspirone 30 mg tablet (Age Limit, Quantity Limit)
• Camrese 0.01 mg-0.15 mg-0.03 mg tablet
• Climara Pro (Quantity Limit) weekly patch
• Daysee 0.01 mg-0.15 mg-0.03 mg tablet
• Esomeprazole magnesium DR 40 mg capsule (Quantity Limit)
• Estradiol vaginal 0.1 mg cream
• Fluocinolone acetonide (otic) 0.01% oil (Quantity Limit)
• Hailey 24 Fe 1 mg/20 mcg tablet
• Imbruvica 140 mg tablet (Prior Authorization, Quantity Limit)
• Imbruvica 280 mg tablet (Prior Authorization, Quantity Limit)
• Imbruvica 420 mg tablet (Prior Authorization, Quantity Limit)
• Imbruvica 560 mg tablet (Prior Authorization, Quantity Limit)
• Jaimiess 0.01 mg-0.15 mg-0.03 mg tablet
• Junel Fe 24 Fe 1 mg/20 mcg tablet
• Larin 24 Fe 1 mg/20 mcg tablet
• Levonorgestrel-ethinyl estradiol (91-day) 0.01 mg-0.15 mg-0.03 mg tablet
• Microgestin Fe 1 mg/20 mcg tablet
• Pseudoephedrine 30 mg/dexchlorpheniramine 1 mg/chlophedianol 12.5 mg per 5mL liquid (Quantity Limit)
• Refresh Relieva (PF) 0.5-1% ophthalmic solution
• Saline nasal gel
• Simpesse 0.01 mg-0.15 mg-0.03 mg tablet
• Sodium fluoride 1.1%/potassium nitrate 5% gel
• Sodium fluoride 1.1% paste
• Tarina 24 Fe 1 mg/20 mcg tablet
• Tolterodine tartrate ER 2 mg capsule
• Tolterodine tartrate ER 4 mg capsule
• Tramadol ER 100 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Tramadol ER 200 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Tramadol ER 300 mg tablet (Prior Authorization, Age Limit, Quantity Limit)
• Vanacof 30 mg/1 mg/12.5 mg per 5mL liquid (Quantity Limit)

 

Removals:

 

• Alendronate 70 mg/75mL solution
• Ascomp/codeine 50 mg/325 mg/40 mg/30 mg capsule
• Auryxia 210 mg tablet
• Butalbital/acetaminophen 50 mg/325 mg tablet
• Butalbital/acetaminophen/caffeine/codeine 50 mg/325 mg/40 mg/30 mg capsule
• Butalbital/aspirin/caffeine 50 mg/325 mg/40 mg capsule
• Butalbital/aspirin/caffeine/codeine 50 mg/325 mg/40 mg/30 mg capsule
• Colchicine 0.6 mg capsule
• Desmopressin acetate 0.01% nasal spray
• Diphenoxylate 2.5 mg/atropine 0.025 mg per 5mL liquid
• Docusol Plus mini-enema 20 mg/283 mg rectal enema
• Duloxetine DR 40 mg capsule
• Enemeez Plus 20 mg/283 mg rectal enema
• Esbriet 267 mg capsule
• Estring 2 mg vaginal ring
• Fleet bisacodyl 10 mg/30mL enema
• Ibrance 100 mg tablet
• Ibrance 125 mg tablet
• Ibrance 75 mg tablet
• Levofloxacin 0.5% ophthalmic solution
• Lidocaine HCL 4% solution
• Milk of magnesia 2400 mg/10mL concentrate suspension
• Mitigare 0.6 mg capsule
• Oxymorphone HCL ER 10 mg tablet
• Oxymorphone HCL ER 15 mg tablet
• Oxymorphone HCL ER 20 mg tablet
• Oxymorphone HCL ER 30 mg tablet
• Oxymorphone HCL ER 40 mg tablet
• Oxymorphone HCL ER 5 mg tablet
• Oxymorphone HCL ER 7.5 mg tablet
• Potassium 550 mg/sodium citrates 500 mg/citric acid 334 mg per 5mL solution
• Sulfacetamide sodium 10% ophthalmic ointment
• Tricitrates 550 mg/500 mg/334 mg per 5mL solution

 

Other updates:

 

• Aftera 1.5 mg tablet (Added Quantity Limit)
• Bacitracin 500 unit/gm ophthalmic ointment (Added Quantity Limit)
• Bacitracin/polymyxin/neomycin HC 1% ophthalmic ointment (Added Quantity Limit)
• Celecoxib 100 mg capsule (Removed Step Therapy)
• Celecoxib 200 mg capsule (Removed Step Therapy)
• Celecoxib 400 mg capsule (Removed Step Therapy)
• Celecoxib 50 mg capsule (Removed Step Therapy)
• EContra EZ 1.5 mg tablet (Added Quantity Limit)
• EContra One-Step 1.5 mg tablet (Added Quantity Limit)
• Levonorgestrel 1.5 mg tablet (Updated Quantity Limit)
• My Choice Tab 1.5 mg tablet (Added Quantity Limit)
• My Way 1.5 mg tablet (Added Quantity Limit)
• Neo-Polycin HC 1% ophthalmic ointment (Added Quantity Limit)
• New Day 1.5 mg tablet (Added Quantity Limit)
• Next Choice One Dose 1.5 mg tablet (Added Quantity Limit)
• Opcicon One-Step 1.5 mg tablet (Added Quantity Limit)
• Option 2 1.5 mg tablet (Added Quantity Limit)
• React 1.5 mg tablet (Added Quantity Limit)
• Take Action 1.5 mg tablet (Added Quantity Limit)

 

January 2023

 

Additions:

• Advate Vial 1201-1800unit
• Advate Vial 3601-4800unit
• Adynovate Vial 1251-2500unit
• Adynovate Vial 1500unit
• Adynovate Vial 200-400unit
• Adynovate Vial 3000unit
• Adynovate Vial 401-800unit
• Adynovate Vial 750unit
• Adynovate Vial 801-1250unit
• Afstyla Vial 1000unit
• Afstyla Vial 1500unit
• Afstyla Vial 2000unit
• Afstyla Vial 2500unit
• Afstyla Vial 250unit
• Afstyla Vial 3000unit
• Afstyla Vial 500unit
• Alphanate Vial 1000-400unit
• Alphanate Vial 1500-600unit
• Alphanate Vial 2000-800unit
• Alphanate Vial 250-100unit
• Alphanate Vial 500-200unit
• Alphanine SD Vial 1000unit
• Alphanine SD Vial 1500unit
• Alphanine SD Vial 500unit
• Alprolix Nominal 1000unit
• Alprolix Nominal 2000unit
• Alprolix Nominal 250unit
• Alprolix Nominal 3000unit
• Alprolix Nominal 4000unit
• Alprolix Nominal 500unit
• Arformoterol Soln 15mcg/2ml
• Benefix Range 1000unit
• Benefix Range 2000unit
• Benefix Range 250unit
• Benefix Range 3000unit
• Benefix Range 500unit
• Calcium Acetate Tab 668mg
• Clonidine Patch 0.1mg/day
• Clonidine Patch 0.2mg/day
• Clonidine Patch 0.3mg/day
• Coagadex Vial 250unit
• Coagadex Vial 500unit
• Corifact Kit
• Dexmethylphenidate ER Caps 10mg (Age Limit, Quantity Level Limit)
• Dexmethylphenidate ER Caps 15mg (Age Limit, Quantity Level Limit)
• Dexmethylphenidate ER Caps 20mg (Age Limit, Quantity Level Limit)
• Dexmethylphenidate ER Caps 25mg (Age Limit, Quantity Level Limit)
• Dexmethylphenidate ER Caps 30mg (Age Limit, Quantity Level Limit)
• Dexmethylphenidate ER Caps 35mg (Age Limit, Quantity Level Limit)
• Dexmethylphenidate ER Caps 40mg (Age Limit, Quantity Level Limit)
• Dexmethylphenidate ER Caps 5mg (Age Limit, Quantity Level Limit)
• Dupixent Pen-injector Solution 200mg/1.14mL (Prior Authorization)
• Dupixent Pen-Injector Solution 300mg/2mL (Prior Authorization)
• Dupixent Prefilled Syringe 100mg/0.67mL (Prior Authorization)
• Dupixent Prefilled Syringe 200mg/1.14mL (Prior Authorization)
• Dupixent Prefilled Syringe 300mg/2mL (Prior Authorization)
• Eloctate Nominal 1000unit
• Eloctate Nominal 1500unit
• Eloctate Nominal 2000unit
• Eloctate Nominal 250unit
• Eloctate Nominal 3000unit
• Eloctate Nominal 4000unit
• Eloctate Nominal 5000unit
• Eloctate Nominal 500unit
• Eloctate Nominal 6000unit
• Eloctate Nominal 750unit
• Epipen 2-Pak Auto-inj 0.3mg
• Epipen JR 2-Pak Inj 0.15mg
• Esperoct Vial 1000unit
• Esperoct Vial 1500unit
• Esperoct Vial 2000unit
• Esperoct Vial 3000unit
• Esperoct Vial 500unit
• Feiba NF Nominal 1000unit
• Feiba NF Nominal 2500unit
• Feiba NF Nominal 500unit
• Gvoke Kit 1mg/0.2ml
• Hemlibra Vial 105mg/0.7ml
• Hemlibra Vial 150mg/ml
• Hemlibra Vial 30mg/ml
• Hemlibra Vial 60mg/0.4ml
• Hemofil M Nominal 1000unit
• Hemofil M Nominal 1700unit
• Hemofil M Nominal 250unit
• Hemofil M Nominal 500unit
• Humate-P VWF:RCO 1200unit
• Humate-P VWF:RCO 2400unit
• Humate-P VWF:RCO 600unit
• Idelvion Vial 1000unit
• Idelvion Vial 2000unit
• Idelvion Vial 250unit
• Idelvion Vial 3500unit
• Idelvion Vial 500unit
• Ixinity Range 1000unit
• Ixinity Range 1500unit
• Ixinity Range 2000unit
• Ixinity Range 250unit
• Ixinity Range 3000unit
• Ixinity Range 500unit
• Jivi Vial 1000unit
• Jivi Vial 2000unit
• Jivi Vial 3000unit
• Jivi Vial 500unit
• Kogenate FS Vial 1000unit
• Kogenate FS Vial 2000unit
• Kogenate FS Vial 250unit
• Kogenate FS Vial 3000unit
• Kogenate FS Vial 500unit
• Kovaltry Kit 1000unit
• Kovaltry Kit 2000unit
• Kovaltry Kit 250unit
• Kovaltry Kit 3000unit
• Kovaltry Kit 500unit
• Lacosamide Soln 10mg/ml
• Lacosamide Tab 100mg
• Lacosamide Tab 150mg
• Lacosamide Tab 200mg
• Lacosamide Tab 50mg
• Novoeight Vial 1000unit
• Novoeight Vial 1500unit
• Novoeight Vial 2000unit
• Novoeight Vial 250unit
• Novoeight Vial 3000unit
• Novoeight Vial 500unit
• Novoseven RT Vial 1mg
• Novoseven RT Vial 2mg
• Novoseven RT Vial 5mg
• Novoseven RT Vial 8mg
• Nuwiq Vial 1000unit
• Nuwiq Vial 1500unit
• Nuwiq Vial 2000unit
• Nuwiq Vial 2500unit
• Nuwiq Vial 250unit
• Nuwiq Vial 3000unit
• Nuwiq Vial 4000unit
• Nuwiq Vial 500unit
• Nuwiq Vial Pack 1000unit
• Nuwiq Vial Pack 1500unit
• Nuwiq Vial Pack 2000unit
• Nuwiq Vial Pack 2500unit
• Nuwiq Vial Pack 250unit
• Nuwiq Vial Pack 3000unit
• Nuwiq Vial Pack 4000unit
• Nuwiq Vial Pack 500unit
• Obizur Vial 500unit
• Orlistat Cap 120mg (Prior Authorization, Age Limit)
• Oxbryta Tab 300mg for Suspension (Age Limit)
• Oxbryta Tab 500mg (Age Limit)
• Profilnine Vial 1000units
• Profilnine Vial 1500units
• Profilnine Vial 500units
• Proglycem Oral Susp 50mg/ml
• Recombinate Vial 1241-1800unit
• Recombinate Vial 1801-2400unit
• Recombinate Vial 220-400unit
• Recombinate Vial 401-800unit
• Recombinate Vial 801-1240unit
• Rivastigmine Patch 13.3mg/24hr
• Rivastigmine Patch 4.6mg/24hr
• Rivastigmine Patch 9.5mg/24hr
• Saxenda Pen 18mg/3ml (Prior Authorization, Age Limit)
• Sevenfact Vial 1mg
• Sevenfact Vial 5mg
• Tobramycin Ampule 300mg/5ml (Age Limit, Quantity Level Limit)
• Vonvendi Vial 1300unit
• Vonvendi Vial 650unit
• Wegovy Pen 0.25mg/0.5ml (Prior Authorization, Age Limit)
• Wegovy Pen 0.5mg/0.5ml (Prior Authorization, Age Limit)
• Wegovy Pen 1.7mg/0.75ml (Prior Authorization, Age Limit)
• Wegovy Pen 1mg/0.5ml (Prior Authorization, Age Limit)
• Wegovy Pen 2.4mg/0.75ml (Prior Authorization, Age Limit)
• Wilate Vial 1000-1000unit
• Wilate Vial 500-500unit
• Xenical Cap 120mg (Prior Authorization, Age Limit)
• Xynthia Kit 1000unit
• Xynthia Kit 2000unit
• Xynthia Kit 250unit
• Xynthia Kit 500unit
• Xynthia Solofuse Kit 3000unit

Removals:

• Accu-Chek FastClix Lancet KIT
• Accu-Chek Multiclix Lancet Dev KIT
• Accu-Chek Softclix Lancet Dev KIT
• Autolet II Clinisafe KIT
• Autolet Lite Clinisafe KIT
• Autolet Lite Starter Pack KIT
• Autolet Platforms
• Exelon Patch 13.3mg/24hr
• Exelon Patch 4.6mg/24hr
• Exelon Patch 9.5mg/24hr
• Fiasp Injection Solution 100unit/Ml
• Fiasp PenFill Solution Cartridge 100unit/Ml
• Focalin XR Caps 10mg
• Focalin XR Caps 15mg
• Focalin XR Caps 20mg
• Focalin XR Caps 25mg
• Focalin XR Caps 30mg
• Focalin XR Caps 35mg
• Focalin XR Caps 40mg
• Focalin XR Caps 5mg
• Gentle-Let Platforms
• Hypolance AST Lancing KIT
• Lancet Transporter Case
• Monojector End Caps
• Monojector OPD End Caps
• Multi-Lancet Device 2 KIT
• OneTouch SureSoft Lancing Dev
• Penlet II Blood Sampler Kit
• Penlet II Replacement Cap
• PSS Select Platforms
• ReliOn Lancing Device KIT
• Rightest Alternate Site Adapt
• Select-Lite Device/Lancets KIT
• SteriLance PA
• UltraLance
• Unistik 1
• Unistik 2
• Unistik 2 Comfort
• Unistik 2 Extra
• Unistik 2 Neonatal
• Unistik 2 Normal
• Unistik 2 Super
• Unistik 3
• Unistik 3 Comfort
• Unistik 3 Extra
• Unistik 3 Neonatal
• Unistik 3 Normal
• Unistik CZT Comfort
• Unistik CZT Normal
• Vimpat Soln 10mg/ml
• Vimpat Tab 100mg
• Vimpat Tab 150mg
• Vimpat Tab 200mg
• Vimpat Tab 50mg

 

Other updates:

 

• Baqsimi Spray 3mg (Removed Quantity Level Limit)
• Droxia Caps 200mg (Added Age Limit)
• Droxia Caps 300mg (Added Age Limit)
• Droxia Caps 400mg (Added Age Limit)
• Elidel Cream 1% (Added Quantity Level Limit)
• Endari Powder Packet 5GM (Added Age Limit, Removed Prior Authorization)
• Eucrisa Ointment 2% (Added Quantity Level Limit)
• Glucagon 1mg Emergency Kit (Removed Quantity Level Limit)
• Qsymia Cap 15mg-92mg (Added Age Limit)
• Tobramycin Inhal Cap 28mg (Changed Step Therapy)
• Qsymia Cap 3.75mg-23mg (Added Age Limit)
• Contrave ER Tab 8-90mg (Added Prior Authorization, Added Age Limit)
• Gvoke Hypopen Solution Auto-Injector 0.5 Mg/0.1ml (Removed Quantity Level Limit)
• Gvoke Pfs Solution Prefilled Syringe 0.5 Mg/0.1ml (Removed Quantity Level Limit)
• Tacrolimus Oint 0.1% (Added Quantity Level Limit)
• Gvoke Hypopen Solution Auto-Injector 1 Mg/0.2ml (Removed Quantity Level Limit)
• Gvoke Pfs Solution Prefilled Syringe 1 Mg/0.2ml (Removed Quantity Level Limit)
• Tacrolimus Oint 0.03% (Added Quantity Level Limit)
• Qsymia Cap 7.5mg-46mg (Added Age Limit)
• Qsymia Cap 11.25mg-69mg (Added Age Limit)

December 2022

Additions:

 

• Accutane Cap 10mg (Quantity Level Limit, Step Therapy)
• Accutane Cap 20mg (Quantity Level Limit, Step Therapy)
• Accutane Cap 30mg (Quantity Level Limit, Step Therapy)
• Accutane Cap 40mg (Quantity Level Limit, Step Therapy)
• Amnesteem Cap 10mg (Quantity Level Limit, Step Therapy)
• Amnesteem Cap 20mg (Quantity Level Limit, Step Therapy)
• Amnesteem Cap 40mg (Quantity Level Limit, Step Therapy)
• Claravis Cap 30mg (Quantity Level Limit, Step Therapy)
• Claravis Cap 40mg (Quantity Level Limit, Step Therapy)
• Flonase Nasal Suspension 50mcg/act
• Histex PD Liquid 0.938mg/mL
• Isotretinoin Cap 10mg (Quantity Level Limit, Step Therapy)
• Isotretinoin Cap 20mg (Quantity Level Limit, Step Therapy)
• Isotretinoin Cap 30mg (Quantity Level Limit, Step Therapy)
• Isotretinoin Cap 40mg (Quantity Level Limit, Step Therapy)
  
  

Removals:
 

• No Updates
  
  

Other Updates:
 

• No Updates

 

November 2022
 

Additions:
 

• Depo-Subq Provera Susp Prefilled Syringe 104mg/0.65Ml
• Icosapent Cap 0.5gm (Prior Authorization, Quantity Limit Level)
• Imbruvica Susp 70mg/mL (Prior Authorization, Quantity Limit Level)
• Orkambi Granules 75-94mg (Prior Authorization)
  
  

Removals:
 

• No Updates
  
  

Other Updates:
 

• No Updates

 

October 2022
 

Additions:
 

• Aftera Tab 1.5mg
• Econtra EZ Tab 1.5mg
• Econtra OS   TAB 1.5mg
• Levonorgestrel TAB 1.5mg
• My Choice Tab 1.5mg
• My Way Tab 1.5mg
• New Day Tab 1.5mg
• Opcicon Tab 1.5mg
• React Tab 1.5mg
• Take Action Tab 1.5mg
• Lenalidomide Cap 2.5mg (Prior Authorization, Quantity Limit Level)
• Lenalidomide Cap 5mg (Prior Authorization, Quantity Limit Level)
• Lenalidomide Cap 10mg (Prior Authorization, Quantity Limit Level)
• Lenalidomide Cap 15mg (Prior Authorization, Quantity Limit Level)
• Lenalidomide Cap 20mg (Prior Authorization, Quantity Limit Level)
• Lenalidomide Cap 25mg (Prior Authorization, Quantity Limit Level)
  
  

Removals:
 

• No Updates
  
  

Other Updates:
 

• Benzoyl Peroxide Cloth 6% (Added Age Limit)
• Butalbital-Acetaminophen-Caffeine With Codeine Cap 50-325-40-30mg (Added Age Limit)
• Butalbital-Aspirin-Caffeine With Codeine Cap 50-325-40-30mg (Added Age Limit)
• Carisoprodol With Aspirin & Codeine Tab 200-325-16mg (Added Age Limit)
• Codeine Sulfate Tab 15mg (Added Age Limit)
• Codeine Sulfate Tab 30mg (Added Age Limit)
• Codeine Sulfate Tab 30mg (Added Age Limit)
• Pegintron Kit 50mcg (Removed Prior Authorization)
• Salicylic Acid Liquid 2% (Added Age Limit)

 

September 2022
 

Additions:
 

• Chlorpromazine 100 Mg/Ml Conc (Age Limit)
• Chlorpromazine 30 Mg/Ml Conc (Age Limit)
• Diazepam 10 Mg Rectal Gel Syst (Age Limit)
• Diazepam 2.5 Mg Rectal Gel Sys (Age Limit)
• Diazepam 20 Mg Rectal Gel Syst (Age Limit)
• E.E.S. 200 Mg/5 Ml Granules
• Fesoterodine Fumarate Tab Er 24hr 4 Mg
• Fesoterodine Fumarate Tab Er 24hr 8 Mg
• Imitrex Solution 20 Mg/Act Nasal (Brand)
• Oxycodone-Acetaminophn 5-325 Mg/5 Ml (Quantity Level Limit)
• Phospho-Trin K500 Tab 500 Mg
• Triumeq Pd 60-5-30 Mg Tab Susp (Quantity Level Limit)
• Vandazole Vaginal 0.75% Gel
• Varenicline Tartrate 0.5 Mg X 11 & 1 Mg X 42 Starting Box
• Zaditor 0.025% (0.035%) Drops
  
  

Removals:
 

• Bevespi Aerosphere Inhaler
• Crinone 4% Gel
• Enoxaparin Sodium Subcutaneous Soln 60 Mg/0.6ml
• Enoxaparin Sodium Subcutaneous Soln 80 Mg/0.8ml
• Pegasys 180 Mcg/Ml Vial
• Zomacton 5 Mg Vial
  
  

Other Updates:
 

• Ambrisentan 10 Mg Tab (Added Age Limit)
• Ambrisentan 5 Mg Tab (Added Age Limit)
• Androgel 1.62% Gel Pump (Added Age Limit)
• Codeine-Guaifen 10-100 Mg/5 Ml (Added Age Limit)
• Ethosuximide 250 Mg/5 Ml Soln (Added Age Limit)
• Hydrocodone-Acetamin 5-300 Mg Tab (Removed Age Limit)
• Kesimpta 20 Mg/0.4 Ml Pen (Added Age Limit)
• Kitabis Pak 300 Mg/5 Ml (Changed Quantity Level Limit)
• Levocetirizine 5 Mg Tab (Removed Quantity Level Limit)
• Linzess 145 Mcg Cap (Added Age Limit)
• Linzess 290 Mcg Cap (Added Age Limit)
• Linzess 72 Mcg Cap (Added Age Limit)
• Mavyret 100-40 Mg Tab (Changed Age Limit)
• Pantoprazole Sodium Packet 40 Mg (Removed Quantity Level Limit)
• Promethazine-Codeine Syrup 6.25-10 Mg/5ml (Added Age Limit)
• Tadalafil 20 Mg Tab (Added Age Limit)
• Testosterone Gel 20.25 Mg/Act (1.62%) (Added Age Limit)
• Venlafaxine Hcl Er 37.5 Mg Cap (Added Age Limit)
• Virtussin Dac Liquid (Added Age Limit)

 

August 2022

Additions:
 

• Bicillin L-A Suspension 2400000 Unit/4ml
• Doxycycline Monohydrate Tab 100 Mg
• Eplerenone Tab 25 Mg
• Eplerenone Tab 50 Mg
• Fluocinonide Cream 1% (Quantity Level Limit)
• Furosemide Oral Soln 8 Mg/Ml
• Glucagon Emergency Solution Reconstituted 1 Mg/Ml (Quantity Level Limit)
• Ivermectin Lotion 0.5% (Quantity Level Limit, Step Therapy)
• Symjepi Solution Prefilled Syringe 0.15 Mg/0.3ml
• Symjepi Solution Prefilled Syringe 0.3 Mg/0.3ml
• Triprolidine Hcl Drops 0.938mg
• Triprolidine Hcl Syrup 2.5mg/5ml
• Voriconazole Tab 200 Mg (Prior Authorization)
• Voriconazole Tab 50 Mg (Prior Authorization)
  
  

Removals:
 

• Amcinonide Ointment 0.1%
• Amiodarone Hcl Tab 100mg
• Amiodarone Hcl Tab 400mg
• Amoxicillin-Pot Clavulanate Er Tab Extended Release 12 Hour 1000-62.5 Mg
• Carbinoxamine Maleate Tab 4mg
• Cefpodoxime Proxetil For Susp 100 Mg/5ml
• Cefpodoxime Proxetil For Susp 50 Mg/5ml
• Flunisolide Nasal Spray 25 Mcg/Act (0.025%)
• Fluvastatin Sodium Tab Er 24 Hr 80 Mg (Base Equivalent)
• GlucaGen HypoKit 1Mg
• Isradipine Cap 2.5mg
• Isradipine Cap 5mg
• Lidocaine Jelly 2%
• Memantine Hcl Tab 28 X 5 Mg & 21 X 10 Mg Titration Pack
• Methazolamide Tab 25 Mg
• Methazolamide Tab 50 Mg
• Metronidazole Cap 375 Mg
• Mometasone Furoate Nasal Spray 50mcg
• Nicardipine Cap 20mg
• Nicardipine Cap 30mg
• Perindopril Erbumine Tab 2 Mg
• Perindopril Erbumine Tab 4 Mg
• Perindopril Erbumine Tab 8 Mg
• Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4%
• Salicylic Acid Shampoo 6%
• Selenium Sulfide Shampoo 2.25%
• Sulfacetamide Sodium Liquid 10%
• Suprax Suspension Reconstituted 500 MG/5ML
• Vancomycin Hcl For Iv Soln 10 Gm (Base Equivalent)
• Vancomycin Hcl For Iv Soln 500 Mg (Base Equivalent)
• Vancomycin Hcl Iv Soln 1250 Mg/250ml (Base Equivalent)
• Vancomycin Hcl Iv Soln 1750 Mg/350ml (Base Equivalent)
• Vancomycin Hcl Iv Soln 750 Mg/150ml (Base Equivalent)
• Vancomycin HCl Solution Reconstituted 1 GM
• Vancomycin HCl Solution Reconstituted 5 GM
• Vemlidy Tab 25 Mg
• Zafirlukast Tab 10mg
• Zafirlukast Tab 20mg
  
  

Other Updates:
 

• Ceftriaxone Sodium For Inj 1 Gm
• Ceftriaxone Sodium For Inj 2 Gm
• Ceftriaxone Sodium For Inj 250 Mg
• Ceftriaxone Sodium For Inj 500 Mg
• Gvoke Hypopen Solution Auto-Injector 0.5 Mg/0.1ml (Changed Quantity Level Limit)
• Gvoke Hypopen Solution Auto-Injector 1 Mg/0.2ml (Changed Quantity Level Limit)
• Gvoke Pfs Solution Prefilled Syringe 0.5 Mg/0.1ml (Changed Quantity Level Limit)
• Gvoke Pfs Solution Prefilled Syringe 1 Mg/0.2ml (Changed Quantity Level Limit)
• Omega-3-Acid Ethyl Esters Cap 1 Gm (Removed Step Therapy)

 

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

Removals:
 

• Allegra 180 Mg Tab
  
  

Other Updates:
 

• Abacavir 20 Mg/Ml Solution (Added Quantity Level Limit)
• Abacavir 300 Mg Tab (Added Quantity Level Limit)
• Abacavir-Lamivudine 600-300 Mg (Added Quantity Level Limit)
• Abacavir-Lamivudine-Zidov Tab (Added Quantity Level Limit)
• Aptivus 250 Mg Cap (Added Quantity Level Limit)
• Atazanavir Sulfate 150 Mg Cap (Added Quantity Level Limit)
• Atazanavir Sulfate 200 Mg Cap (Added Quantity Level Limit)
• Atazanavir Sulfate 300 Mg Cap (Added Quantity Level Limit)
• Atripla Tab (Added Quantity Level Limit)
• Biktarvy 30-120-15 Mg Tab (Added Quantity Level Limit)
• Biktarvy 50-200-25 Mg Tab (Added Quantity Level Limit)
• Complera Tab (Added Quantity Level Limit)
• Descovy 200-25 Mg Tab (Added Quantity Level Limit)
• Dovato 50-300 Mg Tab (Added Quantity Level Limit)
• Edurant 25 Mg Tab (Added Quantity Level Limit)
• Efavirenz 200 Mg Cap (Added Quantity Level Limit)
• Efavirenz 50 Mg Cap (Added Quantity Level Limit)
• Efavirenz 600 Mg Tab (Added Quantity Level Limit)
• Emtricitabine 200 Mg Cap (Added Quantity Level Limit)
• Emtricitabine-Tenofv 100-150mg (Added Quantity Level Limit)
• Emtricitabine-Tenofv 133-200mg (Added Quantity Level Limit)
• Emtricitabine-Tenofv 167-250mg (Added Quantity Level Limit)
• Emtricitabine-Tenofv 200-300mg (Added Quantity Level Limit)
• Emtriva 10 Mg/Ml Solution (Added Quantity Level Limit)
• Etravirine 100 Mg Tab (Added Quantity Level Limit)
• Etravirine 200 Mg Tab (Added Quantity Level Limit)
• Evotaz 300 Mg-150 Mg Tab (Added Quantity Level Limit)
• Fosamprenavir 700 Mg Tab (Added Quantity Level Limit)
• Fuzeon 90 Mg Vial (Added Quantity Level Limit)
• Genvoya Tab (Added Quantity Level Limit)
• Intelence 25 Mg Tab (Added Quantity Level Limit)
• Invirase 500 Mg Tab (Added Quantity Level Limit)
• Isentress 100 Mg Powder Packet (Added Quantity Level Limit)
• Isentress 100 Mg Tab Chew (Added Quantity Level Limit)
• Isentress 25 Mg Tab Chew (Added Quantity Level Limit)
• Isentress 400 Mg Tab (Added Quantity Level Limit)
• Juluca 50-25 Mg Tab (Added Quantity Level Limit)
• Lamivudine 10 Mg/Ml Oral Soln (Added Quantity Level Limit)
• Lamivudine 150 Mg Tab (Added Quantity Level Limit)
• Lamivudine 300 Mg Tab (Added Quantity Level Limit)
• Lamivudine-Zidovudine Tab (Added Quantity Level Limit)
• Lexiva 50 Mg/Ml Suspension (Added Quantity Level Limit)
• Lopinavir-Ritonavir 80-20mg/Ml (Added Quantity Level Limit)
• Lopinavir-Ritonavr 100-25mg Tb (Added Quantity Level Limit)
• Lopinavir-Ritonavr 200-50mg Tb (Added Quantity Level Limit)
• Nevirapine 200 Mg Tab (Added Quantity Level Limit)
• Nevirapine 50 Mg/5 Ml Susp (Added Quantity Level Limit)
• Nevirapine Er 100 Mg Tab (Added Quantity Level Limit)
• Nevirapine Er 400 Mg Tab (Added Quantity Level Limit)
• Norvir 100 Mg Powder Packet (Added Quantity Level Limit)
• Norvir 80 Mg/Ml Solution (Added Quantity Level Limit)
• Odefsey Tab (Added Quantity Level Limit)
• Prezcobix 800 Mg-150 Mg Tab (Added Quantity Level Limit)
• Prezista 100 Mg/Ml Suspension (Added Quantity Level Limit)
• Prezista 150 Mg Tab (Added Quantity Level Limit)
• Prezista 600 Mg Tab (Added Quantity Level Limit)
• Prezista 75 Mg Tab (Added Quantity Level Limit)
• Prezista 800 Mg Tab (Added Quantity Level Limit)
• Reyataz 50 Mg Powder Packet (Added Quantity Level Limit)
• Ritonavir 100 Mg Tab (Added Quantity Level Limit)
• Selzentry 25 Mg Tab (Added Quantity Level Limit)
• Selzentry 75 Mg Tab (Added Quantity Level Limit)
• Stavudine 15 Mg Cap (Added Quantity Level Limit)
• Stavudine 20 Mg Cap (Added Quantity Level Limit)
• Stavudine 40 Mg Cap (Added Quantity Level Limit)
• Stribild Tab (Added Quantity Level Limit)
• Tenofovir Disop Fum 300 Mg Tb (Added Quantity Level Limit)
• Tivicay 10 Mg Tab (Added Quantity Level Limit)
• Tivicay 25 Mg Tab (Added Quantity Level Limit)
• Tivicay 50 Mg Tab (Added Quantity Level Limit)
• Triumeq Tab (Added Quantity Level Limit)
• Tybost 150 Mg Tab (Added Quantity Level Limit)
• Viracept 250 Mg Tab (Added Quantity Level Limit)
• Viracept 625 Mg Tab (Added Quantity Level Limit)
• Viread 150 Mg Tab (Added Quantity Level Limit)
• Viread 200 Mg Tab (Added Quantity Level Limit)
• Viread 250 Mg Tab (Added Quantity Level Limit)
• Viread Powder (Added Quantity Level Limit)
• Zidovudine 100 Mg Cap (Added Quantity Level Limit)
• Zidovudine 50 Mg/5 Ml Syrup (Added Quantity Level 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 Level Limit)
• Dexcom G5 Mis Transmit (Prior Authorization, Quantity Level Limit)
• Dexcom G6 Mis Receiver (Prior Authorization, Quantity Level Limit)
• Dexcom G6 Mis Sensor (Prior Authorization, Quantity Level Limit)
• Dexcom G6 Mis Transmit (Prior Authorization, Quantity Level Limit)
• Freestyle 10 Reader Libre (Prior Authorization, Quantity Level Limit)
• Freestyle 10 Sen Libre (Prior Authorization, Quantity Level Limit)
• Freestyle 14 Reader Libre (Prior Authorization, Quantity Level Limit)
• Freestyle 14 Reader Libre 2 (Prior Authorization, Quantity Level Limit)
• Freestyle 14 Sen Libre (Prior Authorization, Quantity Level Limit)
• Freestyle 14 Sen Libre 2 (Prior Authorization, Quantity Level Limit)
• G5/G4 Plati Mis Sensor (Prior Authorization, Quantity Level Limit)
• Kloxxado 8 Mg Nasal Spray
• Levocetirizine 5mg tabs (Quantity Level 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 Level Limit)
  
  

Removals:
 

• Mynatal Tab
  
  

Other Updates:
 

• Eucrisa 2% Ointment (Prior Authorization Added, Age Limit Added)
• Tetrabenazine 25 Mg Tab (Prior Authorization Added, Quantity Level Limit Added)
• Tetrabenazine 12.5 Mg Tab (Prior Authorization Added, Quantity Level Limit Added)
• Ingrezza 40 Mg Cap (Prior Authorization Added, Quantity Level Limit Added)
• Ingrezza 80 Mg Cap (Prior Authorization Added, Quantity Level Limit Added)
• Ingrezza Initiation Pack (Prior Authorization Added, Quantity Level Limit Added)
• Ingrezza 60 Mg Cap (Prior Authorization Added, Quantity Level Limit Added)
• Glecaprevir-Pibrentasvir Tab 100-40 Mg (Quantity Level Limit Added)
• Sofosbuvir-Velpatasvir Tab 400-100 Mg (Quantity Level Limit Added)
• Deutetrabenazine Tab 6 Mg (Prior Authorization Added, Quantity Level Limit Added)
• Deutetrabenazine Tab 9 Mg (Prior Authorization Added, Quantity Level Limit Added)
• Deutetrabenazine Tab 12 Mg (Prior Authorization Added, Quantity Level 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 2021
 

Additions:
 

• Everolimus Tab 10mg
  
• Esomepra Mag Tab 20 Mg
• Insulin Glar Sol 100u/Ml
• Insulin Glar Inj 100u/Ml
   

Removals:
 

• Afinitor Tab 10mg
   

Other Updates:
 

• No updates

 

November 2021
 

Additions:
 

• Difluprednat Emu 0.05%
• Varenicline Tab 0.5mg
• Varenicline Tab 1mg
   

Removals:
 

• No updates
   

Other Updates:
 

• No updates

 

October 2021
 

Additions:
 

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

Removals:
 

• Sutent Cap 12.5mg
• Sutent Cap 25mg
• Sutent Cap 37.5mg
• Sutent Cap 50mg
   

Other Updates:
 

• No updates

 

September 2021
 

Additions:
 

• No updates
   

Removals:
 

• No updates
   

Other Updates:
 

• No updates
  
  

August 2021
 

Additions:
 

• Baqsimi Pow 3mg/Dose (Quantity Limit)
• Endari       Pow 5gm (Prior Authorization)
• Inlyta Tab 1mg (Prior Authorization, Quantity Limit)
• Inlyta Tab 5mg (Prior Authorization, Quantity Limit)
• Nayzilam Spr 5mg (Prior Authorization, Quantity Limit)
• Prolia Sol 60mg/Ml (Prior Authorization, Quantity Limit)
• Semglee      Sol 100u/Ml
   

Removals:
 

• Caffeine Pow Citrated
• Ibrance Cap 100mg
• Ibrance Cap 125mg
• Ibrance Cap 75mg
• Lidocaine-Hydrocortisone Ace Cream 3-0.5% rectal
• Methoxsalen  Cap 10mg
• Nexavar Tab 200mg\

 

Other Updates:
 

No updates

 

July 2021
 

Additions:
 

• Ajovy 225 Mg/1.5 Ml Autoinject (Prior Authorization)
• Ajovy 225 Mg/1.5 Ml Syringe (Prior Authorization)
• Androgel 1.62% Gel Pump (Quantity Limit, Age Limit)
• Colchicine 0.6 Mg Tablet
• Diclofenac Sodium Gel 1%
• Dimethyl Fumarate 30d Start Pk
• Dimethyl Fumarate Dr 120 Mg Cp
• Dimethyl Fumarate Dr 240 Mg Cp
• Erythromycin Ethylsuccinate Susp 200mg/5Ml
• Kesimpta     Inj 20/.4ml (Prior Authorization)
• Renflexis    Inj 100mg
• Sildenafil 10 Mg/Ml Oral Susp (Prior Authorization, Age Limit)
• Sumatriptan 5 Mg Nasal Spray
• Testosterone Td Patch 24hr 4 Mg/24hr (Prior Authorization)
• Trulicity 0.75 Mg/0.5 Ml Pen
• Trulicity 1.5 Mg/0.5 Ml Pen
• Trulicity 3 Mg/0.5 Ml Pen
• Trulicity 4.5 Mg/0.5 Ml Pen
   

Removals:
 

• Eryped 200 Mg/5 Ml Suspension
• Fingolimod Hcl Cap 0.25 Mg (Base Equiv)
• Fingolimod Hcl Cap 0.5 Mg (Base Equiv)
• Interferon Beta-1a Auto-Inj 6x8.8 Mcg/0.2ml & 6x22 Mcg/
• Interferon Beta-1a Pref Syr 6x8.8 Mcg/0.2ml & 6x22 Mcg/
• Interferon Beta-1a Soln Auto-Inj 22 Mcg/0.5ml (12mu/Ml)
• Interferon Beta-1a Soln Auto-Inj 44 Mcg/0.5ml (24mu/Ml)
• Interferon Beta-1a Soln Pref Syr 22 Mcg/0.5ml (12mu/Ml)
• Interferon Beta-1a Soln Pref Syr 44 Mcg/0.5ml (24mu/Ml)
   

Other Updates:
 

• Budesonide-Formoterol Fumarate Dihyd Aerosol 160-4.5 Mcg/Act (Age Limit Removed)
• Budesonide-Formoterol Fumarate Dihyd Aerosol 80-4.5 Mcg/Act (Age Limit Removed)
• Buprenorphine Extended Release Soln Pref Syr 100 Mg/0.5 (Prior Authorization Removed)
• Buprenorphine Extended Release Soln Pref Syr 300 Mg/1.5 (Prior Authorization Removed)
• Emgality 120 Mg/Ml Pen (Age Limit Removed)
• Emgality 120 Mg/Ml Syringe (Age Limit Removed)
• Fingolimod Hcl Cap 0.25 Mg (Base Equiv) (Step Therapy Removed)
• Fingolimod Hcl Cap 0.5 Mg (Base Equiv) (Step Therapy Removed)
• Fluticasone-Salmeterol Inhal Aerosol 115-21 Mcg/Act (Age Limit Removed)
• Fluticasone-Salmeterol Inhal Aerosol 230-21 Mcg/Act (Age Limit Removed)
• Fluticasone-Salmeterol Inhal Aerosol 45-21 Mcg/Act (Age Limit Removed)
• Formoterol Fumarate Inhal Cap 12 Mcg (Prior Authorization Removed, Age Limit Removed)
• Glycopyrrolate-Formoterol Fumarate Aerosol 9-4.8 Mcg/Act (Age Limit Removed)
• Indacaterol Maleate Inhal Powder Cap 75 Mcg (Base Equiv) (Prior Authorization Removed, Age Limit Removed)
• Mometasone Furoate-Formoterol Fumarate Aerosol 100-5 Mcg/Act (Age Limit Removed)
• Mometasone Furoate-Formoterol Fumarate Aerosol 200-5 Mcg/Act (Age Limit Removed)
• Mometasone Furoate-Formoterol Fumarate Aerosol 50-5 Mcg/Act (Age Limit Removed)
• Olodaterol Hcl Inhal Aerosol Soln 2.5 Mcg/Act (Base Equiv) (Prior Authorization Removed, Age Limit Removed)
• Salmeterol Xinafoate Aer Pow Ba 50 Mcg/Dose (Base Equiv) (Age Limit Removed)
• Tiotropium Br-Olodaterol Inhal Aero Soln 2.5-2.5 Mcg/Act (Age Limit Removed)
• Umeclidinium-Vilanterol Aero Powd Ba 62.5-25 Mcg/Inh (Age Limit Removed)

 

June 2021
 

Additions:
 

• No updates
   

Removals:
 

• No updates
   

Other Updates:
 

• No updates

 

May 2021
 

Additions:
 

• Tadalafil 5 Mg Tablet (Age Limit)
• Tadalafil 2.5 Mg Tablet (Age Limit)
• Pantoprazole 40 Mg Suspension (Quantity Level Limit)
• Baxdela 300 Mg Vial
   

Removals:
 

• No updates
   

Other Updates:
 

• No updates

 

April 2021
 

Additions:
 

• Brinzolamide Sus 1%

Removals:
 

• No updates
   

Other Updates:
 

• Buprenorphine Hcl-Naloxone Hcl Sl Film 2-0.5 Mg (Prior Authorization Removed)
• Buprenorphine Hcl-Naloxone Hcl Sl Film 4-1 Mg (Prior Authorization Removed)
• Buprenorphine Hcl-Naloxone Hcl Sl Film 8-2 Mg (Prior Authorization Removed)
• Buprenorphine Hcl-Naloxone Hcl Sl Film 12-3 Mg (Prior Authorization Removed)

 

March 2021
 

Additions:
 

• Cequa Sol 0.09% Pf (Prior Authorization)
• Doxycycl Hyc Cap 100mg
• Doxycycl Hyc Cap 50mg
• Doxycycl Hyc Tab 100mg
• Esbriet      Cap 267mg (Prior Authorization)
• Esbriet      Tab 267mg (Prior Authorization)
• Esbriet      Tab 801mg (Prior Authorization)
• Hizentra Inj 1gm/5ml (Prior Authorization)
• Hizentra Inj 2gm/10ml (Prior Authorization)
• Hizentra Inj 4gm/20ml (Prior Authorization)
• Hizentra Sol 20% (Prior Authorization)
• Hizentra Via 10gm/50m (Prior Authorization)
• Hizentra Via 1gm/5ml (Prior Authorization)
• Icosapent    Cap 1gm (Prior Authorization, Quantity Level Limit)
• Pot & Sod Citrates W/ Cit Ac Soln 550-500-334 Mg/5ml
• Privigen Inj 10grams (Prior Authorization)
• Privigen Inj 40grams (Prior Authorization)
• Privigen Inj 5 Grams (Prior Authorization)
• Privigen Via 20grams (Prior Authorization)
• Rabeprazole  Tab 20 (Quantity Level Limit)
• Santyl Oint 250 Unit/Gm (Quantity Level Limit)
• Tukysa       Tab 150mg (Prior Authorization)
• Tukysa       Tab 50mg (Prior Authorization)
• Visco-3      Inj 25/2.5ml (Prior Authorization)
   

Removals:
 

• Acetazolamide Cap Sr 12hr 500 Mg
• Amlodipine-Valsartan-Hydrochlorothiazide Tab 10-160-12.
• Amlodipine-Valsartan-Hydrochlorothiazide Tab 10-160-25
• Amlodipine-Valsartan-Hydrochlorothiazide Tab 10-320-25
• Amlodipine-Valsartan-Hydrochlorothiazide Tab 5-160-12.5
• Amlodipine-Valsartan-Hydrochlorothiazide Tab 5-160-25 M
• Cefaclor For Susp 125 Mg/5ml
• Cefaclor For Susp 250 Mg/5ml
• Cefaclor For Susp 375 Mg/5ml
• Clarithromycin Tab Er 24 Hr 500 Mg
• Clemastine Fumarate Tab 1.34 Mg (1 Mg Base Equiv)
• Clemastine Fumarate Tab 2.68 Mg
• Diazepam Con 5mg/Ml
• Doxycyc Mono Tab 100mg
• Doxycyc Mono Tab 50mg
• Doxycyc Mono Tab 75mg
• Flebogamma DIF Sol 10GM/100ML
• Flebogamma DIF Sol 20GM/200ML
• Flebogamma DIF Sol 5GM/50ML
• Fulphila     Inj 6/0.6ml
• Gammaked Sol 10GM/100ML Inj
• Gammaked Sol 1GM/10ML Inj
• Gammaked Sol 20GM/200ML Inj
• Gammaked Sol 5GM/50ML Inj
• Hyalgan      Inj 20mg/2ml
• Hyoscyamine Dro 0.125/Ml
• Nivestym     Inj 300/0.5
• Nivestym     Inj 300mcg
• Nivestym     Inj 480/0.8
• Nivestym     Inj 480mcg
• Ofev         Cap 100mg
• Ofev         Cap 150mg
• Trospium Chloride Cap Sr 24hr 60 Mg
• Verzenio     Tab 100mg
• Verzenio     Tab 150mg
• Verzenio     Tab 200mg
• Verzenio     Tab 50mg
   

Other Updates:
 

• Candesartan Cilexetil Tab 16 Mg (Step Therapy Added)
• Candesartan Cilexetil Tab 32 Mg (Step Therapy Added)
• Candesartan Cilexetil Tab 4 Mg (Step Therapy Added)
• Candesartan Cilexetil Tab 8 Mg (Step Therapy Added)
• Candesartan Cilexetil-Hydrochlorothiazide Tab 16-12.5 M (Step Therapy Added)
• Candesartan Cilexetil-Hydrochlorothiazide Tab 32-12.5 M (Step Therapy Added)
• Candesartan Cilexetil-Hydrochlorothiazide Tab 32-25 Mg (Step Therapy Added)
• Cefadroxil Sus 250/5 Ml (Age Limit Added)
• Cefadroxil Sus 500/5 Ml (Age Limit Added)
• Cefpodo Prox Sus 100/5 Ml (Age Limit Added)
• Cefpodo Prox Sus 50mg/5ml (Age Limit Added)
• Cephalexin Sus 125/5ml (Age Limit Added)
• Cephalexin Sus 250/5ml (Age Limit Added)
• Juluca       Tab 50-25mg (Prior Authorization Added)
• Levofloxacin Sol 25mg/Ml (Age Limit Added)
• Phenylephrine Hcl Ophth Soln 2.5% (Quantity Level Limit Added)

 

February 2021
 

Additions:
 

• No updates
   

Removals:
 

• No updates
   

Other Updates:
 

• No updates

 

January 2021
 

Additions:
 

• No updates
  
  

Removals:
 

• Letairis 10 MG Tab
• Letairis 5 MG Tab
   

Other Updates:
 

• Sertraline Hcl Oral Concentrate For Solution 20 Mg/Ml (Age Limit Termed)

December 2020
 

Additions:
 

• No updates
  
  

Removals:
 

• No updates
  
  

Other Updates:
 

• No updates

 

November 2020
 

Additions:
 

• Emtricitabin Cap 200mg (Quantity Level Limit)
  
  

Removals:
 

• Emtriva Cap 200mg
  
  

Other Updates:
 

• No updates

 

October 2020
 

Additions:
 

• Vancomycin Hcl Iv Soln 750 Mg/150ml (Base Equivalent)      
• Vancomycin Hcl Iv Soln 1250 Mg/250ml (Base Equivalent)     
• Vancomycin Hcl Iv Soln 1750 Mg/350ml (Base Equivalent)     
• Ciprofloxacin-Dexamethasone Otic Susp 0.3-0.1%
• Efavirenz-Lamivudine-Tenofovir Df Tab 400-300-300 Mg
• Efavirenz-Lamivudine-Tenofovir Df Tab 600-300-300 Mg

Removals:
 

• Ciprodex Otic Susp 0.3-0.1%
• Symfi Lo Df Tab 400-300-300mg
• Symfi Df Tab 600-300-300mg
  
  

Other Updates:
 

• No updates

 

September 2020
 

Additions:
 

• Abiraterone  Tab 250mg (Prior Authorization)
• Alecensa     Cap 150mg (Prior Authorization)
• Austedo      Tab 12mg (Prior Authorization)
• Austedo      Tab 6mg (Prior Authorization)
• Austedo      Tab 9mg (Prior Authorization)
• Bexarotene   Cap 75mg (Prior Authorization)
• Caprelsa     Tab 100mg (Prior Authorization)
• Caprelsa     Tab 300mg (Prior Authorization)
• Cinacalcet   Tab 30mg (Prior Authorization)
• Cinacalcet   Tab 60mg (Prior Authorization)
• Cinacalcet   Tab 90mg (Prior Authorization)
• Cyclophosph  Cap 25mg
• Cyclophosph  Cap 50mg
• Erivedge     Cap 150mg (Prior Authorization)
• Gilotrif     Tab 20mg (Prior Authorization)
• Gilotrif     Tab 30mg (Prior Authorization)
• Gilotrif     Tab 40mg (Prior Authorization)
• Jakafi       Tab 10mg (Prior Authorization)
• Jakafi       Tab 15mg (Prior Authorization)
• Jakafi       Tab 20mg (Prior Authorization)
• Jakafi       Tab 25mg (Prior Authorization)
• Jakafi       Tab 5mg (Prior Authorization)
• Kalydeco     Pak 25mg (Prior Authorization)
• Kalydeco     Pak 50mg (Prior Authorization)
• Kalydeco     Pak 75mg (Prior Authorization)
• Kalydeco     Tab 150mg (Prior Authorization)
• Lenvima      Cap 10 Mg (Prior Authorization)
• Lenvima      Cap 12mg (Prior Authorization)
• Lenvima      Cap 14 Mg (Prior Authorization)
• Lenvima      Cap 18 Mg (Prior Authorization)
• Lenvima      Cap 20 Mg (Prior Authorization)
• Lenvima      Cap 24 Mg (Prior Authorization)
• Lenvima      Cap 4mg (Prior Authorization)
• Lenvima      Cap 8 Mg (Prior Authorization)
• Linezolid    Tab 600mg (Prior Authorization)
• Mekinist     Tab 0.5mg (Prior Authorization)
• Mekinist     Tab 2mg (Prior Authorization)
• Ofev         Cap 100mg (Prior Authorization)
• Ofev         Cap 150mg (Prior Authorization)
• Omeprazole Tab 20mg Dr
• Repatha      Inj 140mg/Ml (Prior Authorization)
• Repatha Push Inj 420/3.5 (Prior Authorization)
• Repatha Sure Inj 140mg/Ml (Prior Authorization)
• Rydapt       Cap 25mg (Prior Authorization)
• Soliris      Inj 10mg/Ml (Prior Authorization)
• Symdeko      Tab 100-150 (Prior Authorization)
• Symdeko      Tab 50-75mg (Prior Authorization)
• Tafinlar     Cap 50mg (Prior Authorization)
• Tafinlar     Cap 75mg (Prior Authorization)
• Venclexta    Tab 100mg (Prior Authorization)
• Venclexta    Tab 10mg (Prior Authorization)
• Venclexta    Tab 50mg (Prior Authorization)
• Venclexta    Tab Start Pk (Prior Authorization)
• Xolair       Inj 150mg/Ml (Prior Authorization)
• Xolair       Inj 75/0.5 (Prior Authorization)
• Xolair       Sol 150mg (Prior Authorization)
• Zykadia      Cap 150mg (Prior Authorization)
  
  

Removals:
 

• Prilosec OTC Tab 20mg DR
  
  

Other Updates:
 

• No updates

 

August 2020
 

Additions:

• Diclofenac Sodium Soln 1.5% (Step Therapy, Quantity Level Limit)
• Fluphenazine Decanoate Inj 25 Mg/Ml
• Ibrance      Cap 100mg (Prior Authorization, Quantity Level Limit)
• Ibrance      Cap 75mg (Prior Authorization, Quantity Level Limit)
• Ibrance      Tab 100mg (Prior Authorization, Quantity Level Limit)
• Ibrance      Tab 125mg (Prior Authorization, Quantity Level Limit)
• Ibrance      Tab 75mg (Prior Authorization, Quantity Level Limit)
• Ibrance Cap 125mg (Prior Authorization, Quantity Level Limit)
• Lynparza     Tab 10 (Prior Authorization, Quantity Level Limit)
• Lynparza     Tab 15 (Prior Authorization, Quantity Level Limit)
• Symtuza      Tab (Prior Authorization)
• Testosterone Gel 1.62% (Prior Authorization, Quantity Level Limit)
• Testosterone Td Soln 30 Mg/Act (Prior Authorization, Quantity Level Limit)
  
  

Removals:
 

• Arformoterol Tartrate Soln Nebu 15 Mcg/2ml (Base Equiv)
• Cimduo 300-300
• Ec-Naproxen  Tab 375mg
• Estradiol Td Patch Twice Weekly 0.025 Mg/24hr
• Estradiol Td Patch Twice Weekly 0.0375 Mg/24hr
• Estradiol Td Patch Twice Weekly 0.075 Mg/24hr
• Estradiol Vg Vtb 10mcg
• Mesalamine Tab Delayed Release 800 Mg
• Naproxen Sod Tab 550mg
• Naproxen Sodium Tab 275 Mg
• Nimodipine Cap 30 Mg
• Targretin Gel 1%
• Tolmetin Sodium Cap 400
• Tolmetin Sodium Tab 200
• Tolmetin Sodium Tab 600
• Zolmitriptan 5 Mg Tab
• Zolmitriptan Odt 5 Mg Tab
• Aripiprazole Im For Extended Release Susp 300 Mg
• Aripiprazole Im For Extended Release Susp 400 Mg
• Epoetin Alfa Inj 10000 Unit/Ml
• Epoetin Alfa Inj 2000 Unit/Ml
• Epoetin Alfa Inj 20000 Unit/Ml
• Epoetin Alfa Inj 3000 Unit/Ml
• Epoetin Alfa Inj 4000 Unit/Ml
• Exenatide For Inj Extended Release Susp 2 Mg
• Fluphenazine Decanoate Inj 25 Mg/Ml
• Haloperidol Decanoate Im Soln 100 Mg/Ml
• Haloperidol Decanoate Im Soln 50 Mg/Ml
• Methylphenidate Hcl For Er Susp 25 Mg/5ml (5 Mg/Ml)
• Paliperidone Palm Er Susp Pref Syr 175 Mg/0.875ml (Base Eq)
• Paliperidone Palm Er Susp Pref Syr 263 Mg/1.315ml (Base Eq)
• Paliperidone Palm Er Susp Pref Syr 525 Mg/2.625ml (Base Eq)
• Paliperidone Palmitate Im Extended-Release Susp 156 Mg/
• Paliperidone Palmitate Im Extended-Release Susp 234 Mg/
• Paliperidone Palmitate Im Extended-Release Susp 39 Mg/0
• Paliperidone Palmitate Im Extended-Release Susp 78 Mg/0
• Paliperidone Palmitate Im Extend-Release Susp 117 Mg/0.
• Paliperidone Palmitate Im Extend-Release Susp 273 Mg/0.
• Paliperidone Palmitate Im Extend-Release Susp 410 Mg/1.
• Paliperidone Palmitate Im Extend-Release Susp 546 Mg/1.
• Paliperidone Palmitate Im Extend-Release Susp 819 Mg/2.
• Risperidone Microspheres For Inj 25 Mg
• Risperidone Microspheres For Inj 50 Mg
• Risperidone Microspheres For Inj 37.5 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-40 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 5-40 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 10-40 Mg
• Olanzapine-Fluoxetine Hcl Cap 6-50 Mg
• Olanzapine-Fluoxetine Hcl Cap 12-50 Mg
• Paliperidone Palm Er Susp Pref Syr 350 Mg/1.75ml (Base Eq)
• Amlodipine Besylate-Atorvastatin Calcium Tab 5-80 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 10-80 Mg
• Olanzapine-Fluoxetine Hcl Cap 3-25 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-10 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 5-10 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-20 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 5-20 Mg
• Olanzapine-Fluoxetine Hcl Cap 6-25 Mg
• Estradiol Td Patch Twice Weekly 0.1 Mg/24hr
• Fluocinolone Acetonide Solution 0.01%
• Clonidine Hcl Td Patch Weekly 0.1 Mg/24hr
• Clonidine Hcl Td Patch Weekly 0.2 Mg/24hr
• Clonidine Hcl Td Patch Weekly 0.3 Mg/24hr
• Estradiol Td Patch Twice Weekly 0.05 Mg/24hr
• Fluorouracil Cream 0.5%
• Mesalamine Tab Delayed Release 1.2 Gm
• Aftera Tab 1.5mg
• Econtra Ez Tab 1.5mg
• Econtra Os Tab 1.5mg
• Levonorgestr Tab 1.5mg
• My Choice Tab 1.5mg
• My Way Tab 1.5mg
• New Day Tab 1.5mg
• Opcicon Tab 1.5mg
• Plan B Tab 1.5mg
• React Tab 1.5mg
• Take Action Tab 1.5mg
• Zolmitraptan Odt 2.5 Mg Tab
• Zolmitriptan 2.5 Mg
• Risperidone Microspheres For Inj 12.5 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 10-10 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 10-20 Mg
• Olanzapine-Fluoxetine Hcl Cap 12-25 Mg
  
  

Other Updates:
 

• Auryxia (Step Therapy)
• 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)
• Buprenorp-Nalox 8-2 Mg Sl Film (Quantity Level Limit)
• Butenafine Hcl Cream 1% (Quantity Level Limit)
• Byetta 10 Mcg Dose Pen Inj (Quantity Level Limit)
• Byetta 5 Mcg Dose Pen Inj (Quantity Level Limit)
• Canagliflozin Tab 100 Mg (Step Therapy)
• Canagliflozin Tab 300 Mg (Step Therapy)
• Carbamide Peroxide 6.5% Otic Soln (Quantity Level Limit)
• Ciclopirox Olamine Cream 0.77% (Quantity Level Limit)
• Ciclopirox Olamine Susp 0.77% (Quantity Level Limit)
• Ciclopirox Shampoo 1% (Quantity Level Limit)
• Clindamycin Phosphate Gel 1% (Quantity Level Limit)
• Clindamycin Phosphate Lotion 1% (Quantity Level Limit)
• Clindamycin Phosphate Soln 1% (Quantity Level Limit)
• Dapagliflozin Propanediol Tab 10 Mg (Base Equivalent) (Step Therapy)
• Dapagliflozin Propanediol Tab 5 Mg (Base Equivalent) (Step Therapy)
• Erythromycin Gel 2% (Quantity Level Limit)
• Erythromycin Pads 2% (Quantity Level Limit)
• Flunisolide Nasal Soln 25 Mcg/Act (0.025%) (Step Therapy)
• Fluocinonide Cream 0.05% (Quantity Level Limit)
• Fluvastatin Sodium Cap 20 Mg (Step Therapy)
• Fluvastatin Sodium Cap 40 Mg (Step Therapy)
• Hydrocortisone W/ Acetic Acid Otic Soln 1-2% (Quantity Level Limit)
• Janumet 50-1,000 Mg Tab (Step Therapy, Age Limit)
• Janumet 50-500 Mg Tab (Step Therapy, Age Limit)
• Janumet Xr 100-1,000 Mg Tab (Step Therapy, Age Limit, Quantity Level Limit)
• Janumet Xr 50-1,000 Mg Tab (Step Therapy, Age Limit, Quantity Level Limit)
• Janumet Xr 50-500 Mg Tab (Step Therapy, Age Limit, Quantity Level Limit)
• Januvia 100 Mg Tab (Step Therapy, Age Limit)
• Januvia 25 Mg Tab (Step Therapy, Age Limit)
• Januvia 50 Mg Tab (Step Therapy, Age Limit)
• Jardiance 10 Mg Tab (Age Limit)
• Jardiance 25 Mg Tab (Age Limit)
• Jentadueto 2.5 Mg-1000 Mg Tab (Step Therapy, Age Limit)
• Jentadueto 2.5 Mg-500 Mg Tab (Step Therapy, Age Limit)
• Jentadueto 2.5 Mg-850 Mg Tab (Step Therapy, Age Limit)
• Lidocaine Oint 5% (Quantity Level Limit)
• Liothyronine Sodium Tab 25 Mcg (Quantity Level Limit)
• Mavyret 100-40 Mg Tab (Quantity Level Limit)
• Permethrin Cream 5% (Quantity Level Limit)
• Permethrin Lotion 1% (Quantity Level Limit)
• Prednicarbate Oint 0.1% (Quantity Level Limit)
• Proton Pump Inhibitors (Quantity Level Limit)
• Pyrethrins-Piperonyl Butoxide Liq 0.33-4% (Quantity Level Limit)
• Ropinirole Hydrochloride Tab Er 24hr 12 Mg (Step Therapy)
• Ropinirole Hydrochloride Tab Er 24hr 2 Mg (Step Therapy)
• Ropinirole Hydrochloride Tab Er 24hr 4 Mg (Step Therapy)
• Ropinirole Hydrochloride Tab Er 24hr 6 Mg (Step Therapy)
• Ropinirole Hydrochloride Tab Er 24hr 8 Mg (Step Therapy)
• Sulfacetamide Sodium Lotion 10% (Acne) (Quantity Level Limit)
• Tradjenta 5 Mg Tab (Step Therapy, Age Limit)
• Victoza 3-Pak 18 Mg/3 Ml Pen (Quantity Level Limit)

 

July 2020
 

Additions:
 

• Fluticasone-Salmeterol 113-14 (Age Limit)
• Fluticasone-Salmeterol 232-14 (Age Limit)
• Fluticasone-Salmeterol 55-14 (Age Limit)
• Gvoke Pfs (Quantity Level Limit)
• Invokamet 150-1,000mg Tab (Step Therapy)
• Invokamet 150-500mg Tab (Step Therapy)
• Invokamet 50-1,000mg Tab (Step Therapy)
• Invokamet 50-500 Mg Tab (Step Therapy)
• Invokamet Xr 150-1,000 Mg Tab (Step Therapy)
• Invokamet Xr 150-500mg Tab (Step Therapy)
• Invokamet Xr 50-1,000 Mg Tab (Step Therapy)
• Invokamet Xr 50-500mg Tab (Step Therapy)
• Pegintron 50 Mcg Kit (Prior Authorization)
• Solifenacin 10 Mg Tab
• Solifenacin 5 Mg Tab
• Xigduo Xr 10 Mg-500mg Tab (Step Therapy)
• Xigduo Xr 10mg-1,000 Mg Tab (Step Therapy)
• Xigduo Xr 2.5mg-1,000 Mg Tab (Step Therapy)
• Xigduo Xr 5 Mg-1,000mg Tab (Step Therapy)
• Xigduo Xr 5 Mg-500mg Tab (Step Therapy)
  
  

Removals:
 

• Dyanavel Xr 2.5mg/Ml Susp
• Quillichew Er 20 Mg Chew Tab
• Quillichew Er 30 Mg Chew Tab
• Quillichew Er 40 Mg Chew Tab
• Quillivant Xr 25 Mg/5ml Susp
• Relpax 20 Mg Tab
• Relpax 40 Mg Tab
• Testosterone Gel 20.25 Mg/ 1.25 Gm (1.62%) Transdermal
• Testosterone Gel 40.5 Mg/ 2.5 Gm (1.62%) Transdermal
• Vesicare 10mg Tab
• Vesicare 5mg Tab

 

June 2020
 

Additions:
 

• Alahist D    Tab             
• Dovato       Tab 50-300mg (Quantity Level Limit)
• Gvoke Hypopen   Inj (Quantity Level Limit)            
• Atovaquone-Proguanil Tabs 250-100mg (Quantity Level Limit)
• Atovaquone-Proguanil Tabs 62.5-25mg (Quantity Level Limit)
• Primaquine Tab 26.3 Mg (Quantity Level Limit)
• Phenazopyridine Tab 95 Mg
• Phenytoin Chew Tab 50mg
  
  

Removals:
 

• Dilantin Chew Tab 50mg
• Nicotrol Inhaler 10 Mg Inhalation,
• Nicotrol NS Solution 10mg/Ml Nasal
• Phenytoin Sodium Extended Cap 30 Mg
• Humalog Kwikpen Solution Pen-Injector 200 Unit/ML Subcutaneous
• Permethrin Cream 5%
• Calcium Acetate (Phosphate Binder) CAP 667 Mg
  
  

Other Updates:
 

• Lancets (Quantity Level Limit)
• Alcohol Swabs (Quantity Level Limit)
• Collagenase Ointment 250 Unit/Gm (Quantity Level Limit)
• Insulin Syringe (Disp) U-100 0.3 Ml (Quantity Level Limit)
• Insulin Syringe (Disp) U-100 1/2 Ml (Quantity Level Limit)
• Insulin Syringe (Disp) U-100 1 Ml (Quantity Level Limit)
• Insulin Syringe/Needle U-100 0.3 Ml 29 G (Quantity Level Limit)
• Insulin Syringe/Needle U-100 0.3 Ml 30 G (Quantity Level Limit)
• Insulin Syringe/Needle U-100 0.3 Ml 29 X 1/2" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 0.3 Ml 30 X 5/16" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 0.3 Ml 30 X 1/2" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1/2 Ml 27 X 1/2" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1/2 Ml 29 G (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1/2 Ml 30 G (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1/2 Ml 30 X 3/8" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1/2 Ml 31 X 5/16" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1/2 Ml 28 X 5/16" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1/2 Ml 28 X 1/2" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1/2 Ml 29 X 5/16" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1/2 Ml 29 X 1/2" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1/2 Ml 30 X 5/16" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1/2 Ml 30 X 1/2" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1 Ml 25 X 5/8" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 0.3 Ml 31 X 15/64" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1 Ml 25 X 1" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1 Ml 26 X 1/2" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1 Ml 27 X 1/2" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1 Ml 27 X 5/8" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1 Ml 28 X 5/16" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1 Ml 28 X 1/2" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1 Ml 29 X 1/2" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1 Ml 29 X 5/16" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1 Ml 30 G (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1 Ml 30 X 5/16" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1 Ml 30 X 1/2" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1 Ml 31 X 5/16" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 0.3 Ml 31 X 5/16" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 2 Ml 27.5 X 5/8" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1/2 Ml 31 X 15/64" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 0.3 Ml 29 X 1" (Quantity Level Limit)
• Insulin Syringe/Needle U-100 1 Ml 31 X 15/64" (Quantity Level Limit)
• Umeclidinium-Vilanterol Aero Powd Ba 62.5-25 Mcg/Inh (Age Limit)
• Tiotropium Br-Olodaterol Inhal Aero Soln 2.5-2.5 Mcg/Ac (Age Limit)
• Clotrimazole 1% Solution (Rx) (Step Therapy Removed)
• Tramadol Hcl Tab 50 Mg (Age Limit)
• Tramadol Hcl Tab 100 Mg (Age Limit)
• Metformin Hcl Tab 500 Mg (Age Limit)
• Metformin Hcl Tab 850 Mg (Age Limit)
• Metformin Hcl Tab 1000 Mg (Age Limit)
• Metformin Hcl Tab Sr 24hr 500 Mg (Age Limit)
• Metformin Hcl Tab Sr 24hr 750 Mg (Age Limit)

 

May 2020
 

Additions:
 

• Dexameth Pho Inj 20mg/5ml
• Dexameth Pho Mdv 10mg/Ml
• Dexameth Pho Via 120mg/30
• Dexamethason Con 1mg/Ml
• Dexamethason Via 10mg/Ml
• Dexamethason Via 4mg/Ml
• Hydrocortisone Sodium Succinate Pf For Inj 100 Mg
• Hydrocortisone Sodium Succinate Pf For Inj 1000 Mg
• Hydrocortisone Sodium Succinate Pf For Inj 250 Mg
• Hydrocortisone Sodium Succinate Pf For Inj 500 Mg
• Pyrimethamine Tab 25mg (Prior Authorization Required)
  
  

Removals:
 

• Daraprim Tab 25mg
• Diphenhydramine-Acetaminophen Tab 12.5-325 Mg
• Phytonadione (Bulk)

 

April 2020
 

Additions:
 

• Moxifloxacin Ophth Sol 0.5%
• Omeprazole Tab Delayed Release Disintegrating 20 Mg     
• Orkambi Granules 100-125 Mg (Prior Authorization Required)
• Orkambi Granules 200-125 Mg (Prior Authorization Required)
• Orkambi Tab 100-125 Mg (Prior Authorization Required)
• Orkambi Tab 200-125 Mg (Prior Authorization Required)
• Pantoprazole Sodium Ec Tab 20 Mg
• Pantoprazole Sodium Ec Tab 40 Mg
• Tramadol Hcl Tab 100mg  (Quantity Level Limit)     

 

March 2020
 

Additions:
 

• Gel-One      Inj 30mg/3mL (Prior Authorization Required)
• Hyalgan      Inj 20mg/2mL (Prior Authorization Required)   
• Penicillamine Tab 250mg (Prior Authorization Required, Quantity Level Limit)
  
  

Removals:

• Allevyn Ag Pad 3"X3"
• Allevyn Ag Pad 3"X3"
• Allevyn Ag Pad 5"X5"
• Allevyn Ag Pad 5"X5"
• Allevyn Ag Pad 7"X7"
• Allevyn Ag Pad 7"X7"
• Bp Wash Liq 7%
• Bp Wash Liq 7%
• Cem-Urea Sol 45%
• Cem-Urea Sol 45%
• Cyanocobalam Cry
• Cyanocobalam Cry
• Fluoritab Dro 0.125mg
• Isop Alcohol Sol 70%
• Isop Alcohol Sol 70%
• Prevident Sol Rinse
• Propylene Liq Glycol
• Propylene Liq Glycol
• Restore Silv Pad 2"X2"
• Restore Silv Pad 2"X2"
• Restore Silv Pad 4"X4.75"
• Restore Silv Pad 4"X4.75"
• Salicylic Ac Sol 26%
• Salicylic Ac Sol 26%
• Urea Cre 45%
• Urea Cre 45%

 

February 2020
 

Additions:
 

• Bimatoprost  sol 0.03% (Step Therapy Required)
  
  

Removals:
 

• Alprazolam Concentrate 1MG/ML Solution
• Chlorothiazide Tabs 250mg
• Chlorothiazide Tabs 500mg
• Demeclocycline 150mg Tab
• Demeclocycline 300mg Tab
• Doxycycline Monohydrate Tab 150mg
• First-vanco Sol 25mg/ml
• First-vanco Sol 50mg/ml
• Methyclothiazide Tab 5MG
• Nausea Liquid Relief (fructose-dextrose-phosphoric acid)
• Nizatidine Soln 15MG/ML
• Phospholine (ECHOTHIOPHATE IODIDE) opth solution 0.125%
• Propantheline 15mg Cap
• Rabeprazole EC 20mg Cap
• Ranitidine Cap 150 mg
• Ranitidine Cap 300 mg
  
  

Other Updates:
 

• Atropine sul oin 1% op (Quantity Level Limit Added)
• Atropine sul sol 1% op (Quantity Level Limit Added)
• Buspirone    tab 10mg (Age Limit Added)
• Buspirone    tab 15mg (Age Limit Added)
• Buspirone    tab 5mg (Age Limit Added)
• Buspirone    tab 7.5mg (Age Limit Added)
• Doxycycline monohydrate susp 25mg/5ml (Age Limit Added)
• Granisetron  tab 1mg (Step Therapy Required)
• Hydroxyz hcl syp 10mg/5ml (Quantity Level Limit Added)
• Hydroxyz pam cap 100mg (Quantity Level Limit Added)
• Hydroxyz pam cap 25mg (Quantity Level Limit Added)
• Hydroxyz pam cap 50mg (Quantity Level Limit Added)
• Ibandronate  inj 3mg/3ml (Quantity Level Limit Added)
• Levofloxacin sol 0.5% (Quantity Level Limit Added)
• Lorazepam    con 2mg/ml (Quantity Level Limit Added, Age Limit Added)
• Methazolamide tab  50 mg (Step Therapy Required)
• Methazolamide tab 25 mg (Step Therapy Required)
• Natacyn      sus 5% op (Quantity Level Limit Added)
• Tazarotene   cre 0.1% (Step Therapy Required)
• Trifluridine sol 1% op (Quantity Level Limit Added)

 

January 2020
 

Additions:
 

• Alyq 20mg Tab (Prior Authorization Required)
• Clobazam Tab 10mg (Prior Authorization Required, Age Limit Added)
• Clobazam Tab 20mg (Prior Authorization Required, Age Limit Added)
• Irbesartan-HCTZ Tab 150-12.5mg
• Irbesartan-HCTZ Tab 300-12.5mg
• Mesalamine DR 1.2gm Tab
• Norditropin flexpro 10mg/1.5 (Prior Authorization Required)
• Norditropin flexpro 15mg/1.5 (Prior Authorization Required)
• Norditropin flexpro 30mg/1.5 (Prior Authorization Required)
• Norditropin flexpro 5mg/1.5 (Prior Authorization Required)
• Olmesartan Medoxomil Tab 20mg
• Olmesartan Medoxomil Tab 40mg
• Olmesartan Medoxomil Tab 5mg
• Olmesartan-HCTZ  Tab 20-12.5mg
• Olmesartan-HCTZ  Tab 40-12.5mg
• Olmesartan-HCTZ  Tab 40-25mg
• Phenytoin 100mg Cap
• Rhopressa 0.02% Ophth Soln
• Rocklatan 0.02%-0.005% Ophth Soln
• Sevelamer 800mg Tab
  
  

Removals:
 

• Dilantin 100mg Cap
• Levocetirizine 5mg Tab OTC
• Lialda DR 1.2gm Tab
• Moxifloxacin 0.5% Ophth Soln
• Nutropin AQ Nuspin 10 Inj
• Nutropin AQ Nuspin 20 Inj
• Nutropin AQ Nuspin 5 Inj
• Renvela 800mg Tab
• Simbrinza 1%-0.2% Ophth Soln
  
  

Other Updates:
 

• Pregabalin Caps (Removed Step Therapy)