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Formulary search tool and updates

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

Questions?

You can call Member Services at 1-800-279-1878 (TTY: 711). We’re here for you 24 hours a day, 7 days a week. 

Your formulary search tool

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

 

  • Search for your medicine by name or class

  • Find generic alternatives to your medicine

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

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

  • 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 Level Limit)
  • Sunitinib Cap 25mg (Prior Authorization, Quantity Level Limit)
  • Sunitinib Cap 37.5mg (Prior Authorization, Quantity Level Limit)
  • Sunitinib Cap 50mg (Prior Authorization, Quantity Level 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 Level Limit)
  • Endari       Pow 5gm (Prior Authorization)
  • Inlyta Tab 1mg (Prior Authorization, Quantity Level Limit)
  • Inlyta Tab 5mg (Prior Authorization, Quantity Level Limit)
  • Nayzilam Spr 5mg (Prior Authorization, Quantity Level Limit)
  • Prolia Sol 60mg/Ml (Prior Authorization, Quantity Level 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 Level Limit, Age Limit)
  • Colchicine 0.6 Mg Tab
  • 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 Tab (Age Limit)
  • Tadalafil 2.5 Mg Tab (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 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
  • 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)

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