Pharmacy benefits

Getting the prescription drugs you need is an important part of your health care. We want to make it as convenient for you as possible. Learn more about your pharmacy benefits by clicking on the + in the expandable boxes below.

If you need medicine, your provider will choose a drug from our list of formulary drugs.

CCC Plus (nondual beneficiaries) and Medallion/FAMIS 4.0 Formulary

Dual-eligible Formulary

*Applies only to members who have Medicare coverage.

  • Your provider will write you a prescription. Ask your provider to make sure that the medicine is on our formulary list.
  • Take your prescription to a pharmacy that’s in our network.
  • Show your Aetna Better Health of Virginia member ID card at the pharmacy.

Check the list of network pharmacies and look for one in your area. If you need help, just call Member Services:

Medallion/FAMIS – Member Services

1-800-279-1878 (TTY 711)
24 hours a day, 7 days a week

CCC Plus – Member Services

1-855-652-8249 (TTY 711)
24 hours a day, 7 days a week

They’ll be glad to help you find a network pharmacy near you.

Always remember to fill your prescription at a network pharmacy. Your prescriptions won’t be covered at other pharmacies.

To prevent extra costs, check that your medicines are on the preferred drug list. This is called the formulary.

CCC Plus (nondual beneficiaries) and Medallion/FAMIS 4.0 Formulary

Dual-eligible formulary

*Applies only to members who have Medicare coverage.

If you have questions, just call Member Services:

Medallion/FAMIS – Member Services

1-800-279-1878 (TTY 711)
24 hours a day, 7 days a week

CCC Plus – Member Services

1-855-652-8249 (TTY 711)
24 hours a day, 7 days a week

Have a list of your prescriptions ready when you call. Ask us to look up your medicines to see if they’re on the list. 

You now have the ability to search for drugs using our new Formulary Search Tool.

CCC Plus and Medallion/FAMIS 4.0 Formulary Search Tool

Searches can be performed by drug name or by drug class. The tool will provide formulary status, generic alternatives and if there are any clinical edits (Prior Authorization, Quantity Limits, Age Limits etc.).

If your medicine is not on the formulary, there are some things you can do.

  • Ask your provider for a similar drug that is on the list.
  • Ask your provider to seek "prior authorization" (pre-approval) from Aetna Better Health of Virginia to cover this medicine. Your provider knows how to do this.

For certain kinds of drugs, you can use the plan’s mail-order services. Generally, the drugs available through mail order are drugs that you take regularly for a chronic or long-term medical condition. The drugs that are available through the CVS Caremark mail-order service are marked with “Drug eligible for 90 day supply fill for FAMIS 4.0 and CCC plus members only.” under the Prescriber Note section on the searchable formulary.

Our plan’s mail-order service allows you to order up to a 90-day supply for FAMIS 4.0 or CCC plus members.

Download the Prescription Drug Mail-order Form EnglishSpanish

To get order forms or get more information about filling your prescriptions by mail, call our Member Services at:

FAMIS 4.0 members: 1-800-279-1878 (TTY: 711) 24 hours a day, 7 days a week.

CCC Plus members: 1-855-652-8249 (TTY: 711) 24 hours a day, 7 days a week.

You can also request a mail order form by registering online with CVS Caremark. Once registered, you will be able to order refills, renew your prescription and check the status of your order.

Ask your doctor to write a new prescription(s) for up to the maximum mail order day supply. Please be advised that our mail order pharmacy will call you to obtain consent before shipping or delivering any prescriptions you do not personally initiate.

Fill out the order form completely, including your member ID#, your doctor's name, medications you are taking and any allergies, illnesses or medical conditions you may have.

Mail the order form and the prescription(s) to:

CVS Caremark
PO BOX 2110
Pittsburgh, PA 15230-2110

Generally, it takes CVS Caremark up to 21 days to process your order and ship it to you. If your mail order is delayed 21 days or more, the pharmacy should contact you. After 21 days, if you haven’t received your order, just call CVS Caremark Customer Care at 1-855-271-6603  (TTY: 1-800-231-4403). They’ll send you a replacement. You will receive your order quickly. Calls to this number are free.

Aetna Better Health also covers certain over-the-counter drugs, if they are on our formulary. Some are covered, under certain rules. If the rules for that drug are met, Aetna Better Health will cover the drug. Like other drugs, over-the-counter drugs must have a prescription from a provider for them to be covered.

You can look to see if your over-the-counter medicines are on our formulary. You can also check with Member Services:

Medallion/FAMIS – Member Services

1-800-279-1878 (TTY 711)
24 hours a day, 7 days a week

CCC Plus – Member Services

1-855-652-8249 (TTY 711)
24 hours a day, 7 days a week

When you call, have a list of your over-the-counter medicines ready. Ask the representative to look up your medicines to see if they’re on the list.

Your medicine bottle label says how many refills you can have. If your provider hasn’t ordered refills, and you think you need one, you must call him or her at least five days before your medicine runs out. When you call, ask your provider about getting a refill. He or she may want to see you first.

June 2020

Additions:

  • Alahist D Tab             
  • Dovato Tab 50-300mg (Quantity Level Limit)
  • Gvoke Hypopen Inj (Quantity Level Limit)            
  • Atovaquone-Proguanil Tablets 250-100mg (Quantity Level Limit)
  • Atovaquone-Proguanil Tablets 62.5-25mg (Quantity Level Limit)
  • Primaquine Tablet 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 Tablet 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 Auhtorization Required)
  • Pantoprazole Sodium Ec Tab 20 Mg
  • Pantoprazole Sodium Ec Tab 40 Mg
  • Tramadol Hcl Tab 100 Mg (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 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 Tablet
  • Demeclocycline 300mg Tablet
  • 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 Capsule 150 mg
  • Ranitidine Capsule 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

 

December 2019

No Changes

 

November 2019

No Changes

 

October 2019

No Changes

 

September 2019

Additions:

  • Ambrisentan Tab 10mg (Age Limit Added)  
  • Ambrisentan Tab 5mg (Age Limit Added)  
  • Bosentan Tab 125mg (Age Limit Added)  
  • Bosentan Tab 62.5mg (Age Limit Added)   
  • Febuxostat Tab 40mg  (Step Therapy Required) 
  • Febuxostat Tab 80mg (Step Therapy Required)
  • Ramelteon Tab 8mg (Step Therapy Required)

Removals:

  • Uloric Tab 40mg
  • Uloric Tab 80mg
  • Rozerem Tab 8mg

 

August 2019

Additions:

  • Butenafine HCL Cream 1%
  • Emtricitabine-Rilpivirine-Tenofovir Af Tab 200-25-25 mg (Quantity Level Limit)
  • Lidocaine Crm 4%
  • Lidocaine Patch 4% (Quantity Level Limit)
  • NP Thyroid 120mg Tab (Quantity Level Limit)
  • NP Thyroid 15mg Tab (Quantity Level Limit)
  • NP Thyroid 30mg Tab (Quantity Level Limit)
  • Pegfilgrastim-Cbqv Soln Prefilled Syr 6 Mg/0.6mL (Prior Authorization Required)
  • Pegfilgrastim-Jmdb Soln Prefilled Syr 6 Mg/0.6mL (Prior Authorization Required)
  • Thyroid 120mg Tab (Quantity Level Limit)
  • Thyroid 15mg Tab (Quantity Level Limit)
  • Thyroid 30mg Tab (Quantity Level Limit)

Other Updates:

  • Abacavir Sulfate Soln 20 Mg/mL (Base Equiv) (Quantity Level Limit Added)
  • Abacavir Sulfate Tab 300 Mg (Base Equiv) (Quantity Level Limit Added)
  • Abacavir Sulfate-Lamivudine Tab 600-300mg (Quantity Level Limit Added)
  • Abacavir Sulfate-Lamivudine-Zidovudine Tab 300-150-300mg (Quantity Level Limit Added)
  • Armour Thyroid 180mg Tab (Quantity Level Limit)
  • Armour Thyroid 240mg Tab (Quantity Level Limit)
  • Armour Thyroid 300mg Tab (Quantity Level Limit)
  • Aspercreme Cre Lidoc 4% (Quantity Level Limit Added)
  • Aspercreme Cre Lidoc 4% (Quantity Level Limit Added)
  • Atazanavir Sulfate Oral Powder Packet 50 Mg (Base Equiv) (Quantity Level Limit Added)
  • Atazanavir Sulfate-Cobicistat Tab 300-150mg (Base Equiv) (Prior Authorization, Quantity Limit Added)
  • Azelastine HCL Ophth Soln 0.05% (Quantity Level Limit Added)
  • Betamethasone Dipropionate Oint 0.05% (Quantity Level Limit Added)
  • Ciclopirox Olamine Cream 0.77% (Step Therapy Added)
  • Ciclopirox Olamine Susp 0.77% (Step Therapy Added)
  • Ciclopirox Shampoo 1% (Step Therapy Added)
  • Clotrimazole Soln 1% (Rx Only) (Step Therapy Added)
  • Darunavir-Cobic-Emtricitab-Tenofov Af Tab 800-150-200-10mg (Quantity Level Limit Added)
  • Darunavir-Cobicistat Tab 800-150mg (Prior Authorization, Quantity Limit Added)
  • Delavirdine Mesylate Tab 200mg (Prior Authorization, Quantity Limit Added)
  • Didanosine Delayed Release Capsule 200 Mg (Quantity Level Limit Added)
  • Didanosine Delayed Release Capsule 250 Mg (Quantity Level Limit Added)
  • Didanosine Delayed Release Capsule 400 Mg (Quantity Level Limit Added)
  • Didanosine For Soln 2 Gm (Quantity Level Limit Added)
  • Didanosine For Soln 4 Gm (Quantity Level Limit Added)
  • Dolutegravir Sodium-Rilpivirine HCL Tab 50-25mg (Base Eq) (Prior Authorization Required)
  • Efavirenz Cap 200mg (Quantity Level Limit Added)
  • Efavirenz Cap 50mg (Quantity Level Limit Added)
  • Efavirenz Tab 600mg (Quantity Level Limit Added)
  • Elvitegrav-Cobic-Emtricitab-Tenofovdf Tab 150-150-200-300mg (Prior Authorization Required)
  • Emtricitabine Caps 200mg (Quantity Level Limit Added)
  • Emtricitabine Soln 10mg/mL (Quantity Level Limit Added)
  • Emtricitabine-Rilpivirine-Tenofovir Df Tab 200-25-300mg (Quantity Level Limit Added)
  • Enfuvirtide For Inj 90 mg (Prior Authorization, Quantity Limit Added)
  • Etravirine Tab 100mg (Prior Authorization, Quantity Limit Added)
  • Etravirine Tab 200mg (Prior Authorization, Quantity Limit Added)
  • Etravirine Tab 25mg (Prior Authorization Required)
  • Fluocinolone Acetonide Cream 0.025% (Quantity Level Limit Added)
  • Fluocinolone Acetonide Oint 0.025% (Quantity Level Limit Added)
  • Fosamprenavir Calcium Susp 50mg/mL (Base Equiv) (Prior Authorization, Quantity Limit Added)
  • Fosamprenavir Calcium Tab 700mg (Base Equiv) (Prior Authorization, Quantity Limit Added)
  • Gilenya Cap 0.5mg (Step Therapy Added)
  • Griseofulvin Tab Micr 500 (Step Therapy Added)
  • Griseofulvin Tab Ultr 125mg (Step Therapy Added)
  • Griseofulvin Tab Ultr 250mg (Step Therapy Added)
  • Indinavir Sulfate Cap 200mg (Prior Authorization, Quantity Limit Added)
  • Indinavir Sulfate Cap 400mg (Prior Authorization, Quantity Limit Added)
  • Lamivudine Oral Soln 10mg/mL (Quantity Level Limit Added)
  • Lamivudine Tab 150mg (Quantity Level Limit Added)
  • Lamivudine Tab 300mg (Quantity Level Limit Added)
  • Lamivudine-Zidovudine Tab 150-300mg (Quantity Level Limit Added)
  • Lidocaine 5% Ointment (Prior Authorization Required)
  • Lidocaine HCL Gel 2% (Quantity Level Limit Added)
  • Lidocaine-Prilocaine Cre 2.5-2.5% (Quantity Level Limit Added)
  • Liothyronine Sodium Tab 50mcg (Quantity Level Limit Added)
  • Liothyronine Sodium Tab 5mcg (Quantity Level Limit Added)
  • Lopinavir-Ritonavir Soln 400-100mg/5ml (80-20 Mg/mL) (Prior Authorization, Quantity Limit Added)
  • Lopinavir-Ritonavir Tab 100-25mg (Prior Authorization, Quantity Limit Added)
  • Lopinavir-Ritonavir Tab 200-50mg (Prior Authorization, Quantity Limit Added)
  • Maraviroc Tab 150mg (Prior Authorization Required)
  • Maraviroc Tab 25mg (Prior Authorization Required)
  • Maraviroc Tab 300mg (Prior Authorization Required)
  • Maraviroc Tab 75mg (Prior Authorization Required)
  • Nelfinavir Mesylate Tab 250mg (Prior Authorization, Quantity Limit Added)
  • Nelfinavir Mesylate Tab 625mg (Prior Authorization, Quantity Limit Added)
  • Nevirapine Susp 50mg/5mL (Quantity Level Limit Added)
  • Nevirapine Tab 200mg (Quantity Level Limit Added)
  • Nevirapine Tab ER 24hr 100mg (Quantity Level Limit Added)
  • Nevirapine Tab ER 24hr 400mg (Quantity Level Limit Added)
  • Norethindrone Tab 0.35 Mg (Step Therapy Added)
  • Pegfilgrastim-Cbqv Soln Prefilled Syringe 6mg/0.6ml (Prior Authorization Required)
  • Pegfilgrastim-Jmdb Soln Prefilled Syringe 6mg/0.6ml (Prior Authorization Required)
  • Raltegravir Potassium Packet For Susp 100 Mg (Base Equiv) (Quantity Level Limit Added)
  • Rilpivirine HCL Tab 25mg (Base Equivalent) (Quantity Level Limit Added)
  • Ritonavir Oral Soln 80 Mg/mL (Quantity Level Limit Added)
  • Ritonavir Tab 100 Mg (Quantity Level Limit Added)
  • Sertraline HCL Oral Concentrate For Solution 20mg/mL (Age Limit Added)
  • Stavudine Cap 15mg (Quantity Level Limit Added)
  • Stavudine Cap 20mg (Quantity Level Limit Added)
  • Stavudine Cap 30mg (Quantity Level Limit Added)
  • Tenofovir Disoproxil Fumarate Oral Powder 40mg/GM (Prior Authorization, Quantity Limit Added)
  • Thyroid Tab 60mg (1 Grain) (Quantity Level Limit Added)
  • Thyroid Tab 90mg (1 1/2 Grain) (Quantity Level Limit Added)
  • Zidovudine Cap 100mg (Quantity Level Limit Added)
  • Zidovudine Syrup 10mg/mL (Quantity Level Limit Added)
  • Zidovudine Tab 300mg (Quantity Level Limit Added)

Removals:

  • Armour Thyroid 120mg Tab
  • Armour Thyroid 15mg Tab
  • Armour Thyroid 30mg Tab
  • Aubagio Tab 14mg
  • Aubagio Tab 7mg
  • Butalbital-Acetaminophen-Caff W/ Cod Cap 50-300-40-30mg
  • Butalbital-Acetaminophen-Caffeine Cap 50-300-40mg
  • Butalbital-Acetaminophen-Caffeine Cap 50-325-40mg
  • Calcium Acetate (Phosphate Binder) Oral Soln 667 Mg/5mL
  • Ciclopirox Gel 0.77%
  • Clotrimazole W/ Betamethasone Lotion 1-0.05%
  • Colestipol HCL Granule Packets 5 GM
  • Colestipol HCL Granules 5 GM
  • Entecavir Oral Soln 0.05 Mg/mL
  • Epinastine HCL Ophth Soln 0.05%
  • Esterified Estrogens Tab 0.3mg
  • Esterified Estrogens Tab 0.625mg
  • Esterified Estrogens Tab 1.25mg
  • Estradiol Tab 1 mg(15)/Estrad-Norgestimate Tab 1-0.09mg(15)
  • Etodolac Tab ER 24hr 400mg
  • Etodolac Tab ER 24hr 500mg
  • Etodolac Tab ER 24hr 600mg
  • Extavia Inj 0.3mg
  • Extavia Inj 0.3mg
  • Extavia Inj 0.3mg
  • HC Valerate Cre 0.2%
  • HC Valerate Oin 0.2%
  • LC-4 Lidocaine 4%
  • Lidocaine-Prilocaine Cream Kit 2.5-2.5%
  • Lindane Shampoo 1%
  • LMX 4 Crm 4%
  • Metformin HCL Tab ER 24hr Modified Release 1000 mg
  • Metformin HCL Tab ER 24hr Modified Release 500 mg
  • Moexipril HCL Tab 15mg
  • Moexipril HCL Tab 7.5mg
  • Naproxen Sodium Tab ER 24hr 375 Mg (Base Equiv)
  • Naproxen Sodium Tab ER 24hr 500 Mg (Base Equiv)
  • Olopatadine HCL Ophth Soln 0.2%
  • Quinidine Gluconate Tab ER 324 mg
  • Tecfidera Cap 120mg
  • Tecfidera Cap 240mg
  • Tecfidera Mis Starter

July 2019

Additions:

  • Budesonide 0.25mg/2mL Inh Sus
  • Budesonide 0.5mg/2mL Inh Sus
  • Budesonide 1mg/2mL Inh Sus
  • Cefixime 400mg Cap
  • Dalfampridine ER 10mg Tab
  • Dyanavel Xr 2.5 MG/mL Sus (Prior Authorization Required, Age Limit Added)
  • Emgality 120mg-mL Pen (Prior Authorization Required, Age Limit Added)
  • Emgality 120mg-mL Syr (Prior Authorization Required, Age Limit Added)
  • Erlotinib 150mg Tab (Prior Authorization, Quantity Limit Added)
  • Kitabis Pak Neb 300/5mL (Quantity Limit Added, Age Limit Added)
  • Mesalamine 400mg Cap
  • Sofosbuvir-Velpatasvir 400-100mg
  • Solifenacin 10mg Tab
  • Solifenacin 5mg Tab
  • Sublocade 100 MG/0.5 mL Syr (Prior Authorization Required)
  • Sublocade 300 MG/1.5 mL Syr (Prior Authorization Required)
  • Testosterone 1.62% (1.25 G) Pkt (Prior Authorization Required, Age Limit Added)
  • Testosterone 1.62% (2.5 G) Pkt (Prior Authorization Required, Age Limit Added)
  • Testosterone 1.62% Gel Pump (Prior Authorization Required, Age Limit Added)
  • Testosterone 12.5 MG/1.25 GM (Prior Authorization Required, Age Limit Added)
  • Testosterone 25 MG/2.5 GM Pkt (Prior Authorization Required, Age Limit Added)
  • Testosterone 50 MG/5 GM Pkt (Prior Authorization Required, Age Limit Added)
  • Tobramycin   Neb 300/5mL (Quantity Limit Added, Age Limit Added)
  • Xarelto Starter Pack

Other Updates:

  • Atomoxetine HCL 100Mg Cap (Age Limit Removed)
  • Atomoxetine HCL 10Mg Cap (Age Limit Removed)
  • Atomoxetine HCL 18Mg Cap (Age Limit Removed)
  • Atomoxetine HCL 25Mg Cap (Age Limit Removed)
  • Atomoxetine HCL 40Mg Cap (Age Limit Removed)
  • Atomoxetine HCL 60Mg Cap (Age Limit Removed)
  • Atomoxetine HCL 80Mg Cap (Age Limit Removed)
  • Clonidine HCL ER 0.1Mg Tab (Age Limit Removed)
  • Guanfacine HCL ER 1Mg Tab (Age Limit Removed)
  • Guanfacine HCL ER 2Mg Tab (Age Limit Removed)
  • Guanfacine HCL ER 3Mg Tab (Age Limit Removed)
  • Guanfacine HCL ER 4Mg Tab (Age Limit Removed)
  • Tramadol-Acetaminophn 37.5-325mg (Age Limit Removed)

Removals:

  • Ampyra Tab 10mg
  • AndroGel Gel 20.25mg-1.25GM (1.62%)
  • AndroGel Gel 25mg-2.5GM (1%)
  • AndroGel Gel 40.5mg-2.5GM (1.62%)
  • AndroGel Gel 50mg-5GM (1%)
  • AndroGel Pump Gel 20.25mg (1.62%)
  • Aranesp 10 MCG/0.4 mL Syr
  • Aranesp 100 MCG/0.5 mL Syr
  • Aranesp 100 MCG/mL Vial
  • Aranesp 150 MCG/0.3mL Syr
  • Aranesp 200 MC /mL Vial
  • Aranesp 200 MCG/0.4mL Syr
  • Aranesp 25 MCG/0.42mL Syr
  • Aranesp 25 MCG/mL Vial
  • Aranesp 300 MCG/0.6mL Syr
  • Aranesp 300 MCG/mL Vial
  • Aranesp 40 MCG/0.4mL Syr
  • Aranesp 40 MCG/mL Vial
  • Aranesp 500 MCG/1mL Syr
  • Aranesp 60 MCG/0.3mL Syr
  • Aranesp 60 MCG/mL Vial
  • Cefixime 100mg/5mL Sus
  • Cefixime 200mg/5mL Sus
  • Delzicol Cap 400mg
  • Ery-Tab Ec 250mg Tablet
  • Ery-Tab Ec 333mg Tablet
  • Ery-Tab Ec 500mg Tablet
  • Erythrocin 250mg Film tab
  • Erythromycin Es 400mg Tab
  • Procrit 10,000 Units/mL Vial
  • Procrit 2,000 Units/mL Vial
  • Procrit 20,000 Units/mL Vial
  • Procrit 3,000 Units/mL Vial
  • Procrit 4,000 Units/mL Vial
  • Procrit 40,000 Units/mL Vial
  • Pulmicort Sus 0.25mg-2mL
  • Pulmicort Sus 0.5mg-2mL
  • Pulmicort Sus 1mg-2mL
  • Relenza 5mg Diskhaler
  • Suprax Cap 400mg
  • Tarceva Tab 150mg
  • Testim Gel 50mg-5GM (1%)
  • Tobramycin Neb 300/5mL
  • Vogelxo Pump Gel 12.5mg (1%)
  • Vogelxo Pump Gel 50mg-5GM (1%)

 

June 2019

Additions:

  • DM-GG-Phenyl Tab
  • Docosanol Crm 10%

 Other Updates:

  • Aptivus Cap 250mg (Step Therapy added)
  • Aptivus Sol 100mg-mL (Step Therapy added)
  • Invirase Cap 200mg (Step Therapy added)
  • Invirase Tab 500mg (Step Therapy added)
  • Prezista Sus 100mg/mL (Step Therapy added)
  • Prezista Tab 150mg (Step Therapy added)
  • Prezista Tab 600mg (Step Therapy added)
  • Prezista Tab 75mg (Step Therapy added)
  • Prezista Tab 800mg (Step Therapy added)

 May 2019

Additions:

  • Nivestym Inj 300mcg (Prior Authorization Required)
  • Nivestym Inj 480mcg (Prior Authorization Required)
  • Erythromycin Sup 400/5mL
  • Sirolimus Sol 1mg/mL

Removals:

  • EryPed 400 Sus
  • Rapamune Sol 1mg/mL

April 2019

Additions:

  • Acyclovir Cre 5%
  • Clonidine ER 0.1mg Tab (Age Limit, Step Therapy Required)
  • Colesevelam HCl Tab 625mg
  • Epinephrine 0.15mg
  • Sevelamer HCl Tab 400mg
  • Sevelamer HCl Tab 800mg

Removals:

  • Kapvay ER 0.1mg Tab

Other Updates:

  • Symbicort Aer 80-4.5 (Decreased Age Limit)

March 2019

Additions:

  • Buprenorphine Patch 7.5mcg/hr
  • Mesalamine Sup 1000mg
  • Pimecrolimus Cream 1%
  • Toremifene Tab 60mg

Removals:

  • Fareston Tab 60mg
  • Norethin Acet & Estrad-Fe (24)
  • Onexton Gel 1.2-3.75

Other Updates:

  • Berinert Inj 500unit (Added Quantity Level Limit)
  • Butalbital-Acetaminophen-Caffeine Tab 50-325-40mg (Added Quantity Level Limit)
  • Butalbital-Aspirin-Caffeine Cap 50-325-40mg (Added Quantity Level Limit)
  • Butalbital-Acetaminophen-Caff W/ Cod Cap 50-300-40-30mg (Added Quantity Level Limit)

February 2019

Additions:

  • Eligard Kit 22.5mg (Prior Authorization Required)
  • Eligard Kit 30 mg (Prior Authorization Required)
  • Eligard Kit 45 mg (Prior Authorization Required)
  • Eligard Kit 7.5mg (Prior Authorization Required)
  • Immune Globulin (Human) IV Or Subcutaneous Soln 1 gm/10ml (Prior Authorization Required)
  • Immune Globulin (Human) IV Or Subcutaneous Soln 10 gm/100ml (Prior Authorization Required)
  • Immune Globulin (Human) IV Or Subcutaneous Soln 2.5 gm/25ml (Prior Authorization Required)
  • Immune Globulin (Human) IV Or Subcutaneous Soln 20 gm/200ml (Prior Authorization Required)
  • Immune Globulin (Human) IV Or Subcutaneous Soln 30 gm/300ml (Prior Authorization Required)
  • Immune Globulin (Human) IV Or Subcutaneous Soln 40 gm/400ml (Prior Authorization Required)
  • Immune Globulin (Human) IV Or Subcutaneous Soln 5 gm/50ml (Prior Authorization Required)
  • Immune Globulin (Human) IV Soln 10 Gm/100ml (Prior Authorization Required)
  • Immune Globulin (Human) IV Soln 20 Gm/200ml (Prior Authorization Required)
  • Immune Globulin (Human) IV Soln 5 Gm/50ml (Prior Authorization Required)
  • Leuprolide Acetate Kit 1mg/0.2ml (Prior Authorization Required)
  • Levonorgestrel Tab 1.5 mg
  • Zoladex Imp 10.8mg (Prior Authorization Required)
  • Zoladex Imp 3.6mg (Prior Authorization Required)

Removals:

  • Alprazolam ODT
  • Asmanex HFA
  • Clorazepate Dipotassium Tab
  • Cortifoam Aer Rectal
  • Dihydroergotamine
  • Ergot/Caffen
  • Ergotamine
  • Levonor/Ethi Tab Estradio
  • Levonor/Ethi Tab Estradio
  • Lidocaine/Hc Kit 20x7gm
  • Lidocaine/Hc Kit 3%-1%
  • Meprobamate Tab
  • Miconazole 3 Sup 200mg
  • Penicillamine Cap 250 mg
  • Podofilox Gel 0.5%
  • Terconazole Vaginal Suppos 80 mg
  • Thalomid Cap
  • Triazolam Capsules
  • Trimethobenzamide HCL Cap 300 mg

Other Updates:

  • Suboxone Film SL 12-3mg (Increased Quantity Level Limit)
  • Suboxone Film SL 8-2mg (Increased Quantity Level Limit)
  • Synagis Inj 100mg/ml (Removed Quantity Level Limit)
  • Synagis Inj 50mg (Removed Quantity Level Limit)
  • Glatiramer Inj 40mg/ml (Removed Prior Authorization)

January 2019

Additions:

  • Anora Ellipta Aerosol 62.5-25mcg/inh
  • Aristada Initio Inj 675mg/2.4ml (Age Limit)
  • Olanzapine Inj 10mg (Age Limit)
  • Stiolto Respimat 2.5-2.5mcg/inh
  • Zyprexa Inj 10mg (Age Limit)

Removals:

  • Aripiprazole Oral Solution 1mg/ml
  • Benziq Wash Liquid 2.5%
  • Betopic-S Ophth Susp 0.25%
  • Biotuss Liquid
  • BP Wash Liquid 2.5%
  • Brompheniramine Chewable Tab 12mg
  • Calcium Carbonate Powder
  • Chlorhexidine Gluconate Soln (bulk)
  • Chlorhexidine Gluconate Soln 20%
  • Cortane-B Lotion
  • Diastat Rectal Gel 2.5mg, 10mg, 12.5-20mg (Brand Only)
  • Diltiazem LA (all strengths)
  • First-Lansoprazole Susp 3mg/ml
  • First-Omeprazole Susp 2mg/ml
  • Fluorabon Drops 0.25mg/0.6ml
  • Fluoridex Concentrate Daily 0.63%
  • Fluoroplex Cream 1%
  • Flura-Drops 0.25mg/drop
  • Gentamicin Sulfate Powder
  • Geodon IM Inj 20mg
  • Homatropine Ophth Soln 5%
  • Hypersal Neb 3.5%
  • Memantine Oral Solution 2mg/ml
  • Nature-Throids Tab 2GR
  • Nebusal Neb 6%
  • Neomycin-Polymyxin-Gramicidin Opth Soln
  • Olopatadine Nasal Spray 0.6%
  • Patanase Nasal Spray 0.6%
  • Phytonadione Liquid (bulk)
  • Qvar Inhaler 40mcg, 80mcg
  • Scalacort Lotion 2%
  • Silver Nitrate Applicators
  • Sodium Fluoride Tab 0.5mg, 1mg
  • Sulfacetamide Sodium Ophth Soln 10%
  • Tegretol XR Tab 100mg, 200mg, 400mg (Brand Only)
  • Tracleer Tab 32mg
  • Zetia Tab 10mg (Brand only)

December 2018

Additions:

  • Filgrastim-AAFI Soln Prefilled Syringe 300mcg/0.5ml (Prior Authorization Required)
  • Filgrastim-AAFI Soln Prefilled Syringe 480mcg/0.8ml (Prior Authorization Required)

Removals:

  • Natesto Gel 5.5mg
  • J-Max 5-200mg Syp
  • Trixaicin 0.025% Cre

November 2018

Additions:

  • Albendazole Tab 200mg (Step Therapy Required)
  • Claritin

Removals:

  • Albenza Tab 200mg

October 2018

Additions:

  • Loratadine Chw 5mg Tab (Quantity Level Limit)
  • Tadalafil 20mg (PAH) (Quantity Level Limit)
  • Tazarotene Cre 0.1% (Quantity Level Limit)
  • Tymlos Pen 3120mcg (Prior Authorization Required, Quantity Level Limit)
  • Valganciclov Tab 450mg

Removals:

  • Adcirca Tab 20mg

Other Updates:

  • Adderall XR Cap (Removed Step Therapy)
  • Estradiol Tab (Removed Quantity Level Limit)
  • Ondansetron HCl Tab 4mg (Increased Quantity Level Limit)
  • Ondansetron HCl Tab 8mg (Increased Quantity Level Limit)

September 2018

Additions:

  • Symtuza Tab (Quantity Level Limit)

August 2018

Additions:

  • Alvesco Inh –All Strengths
  • Asmanex Hfa Inhaler 100mcg
  • Asmanex Hfa Inhaler 200mcg
  • Cimduo Tabs (Quantity Level Limit)
  • Crinone Gel 4% Vaginal
  • Delzicol Cap 400mg
  • Depo-Provera Mdv 400/ ml
  • Enbrel Mini Injection 50mg/ml (Age Limit, Quantity Level Limit)
  • Fluticasone Lotion 0.05%
  • Focalin Tab 10mg (Age Limit)
  • Hydromorphon Tab 12mg ER (Prior Authorization Required, Quantity Level Limit)
  • Hydroxyprogesterone Caproate Injection 250mg/ml
  • Levorphanol Tab 2mg (Quantity Level Limit)
  • Lialda
  • Makena Auto-Injector 275mg
  • Meperidine Sol 50mg/5ml (Quantity Level Limit)
  • Metformin Tab ER – All Strengths
  • Methyldopate Inj 250/5ml
  • Niacin Tab 500mg ER
  • Omega-3-Acid Cap 1gm (Quantity Level Limit, Step Therapy Required)
  • Onexton Gel 1.2-3.75
  • Patanase
  • Proben/Colch Tab 500/.5mg
  • Retacrit Injection – All Strengths
  • Tiagabine Tab 12mg
  • Tiagabine Tab 16mg
  • Tracleer Tab 32mg (Age Limit)
  • Vemlidy Tab 25mg (Quantity Level Limit)
  • Verzenio - All Strengths (Prior Authorization Required, Quantity Level Limit)
  • Vopac Mds Kit 1.5%

Removals:

  • Betaxolol - All Strengths
  • Calcitriol Sol 1mcg/ml
  • Captopril Tab - All Strengths
  • Captopril-Hydrochlorothiazide - All Strengths
  • Climara Pro Patch Weekly
  • Colcrys Tab 0.6mg
  • Desipramine - All Strengths
  • Femring - All Strengths
  • Fenofibric Cap DR - All Strengths
  • Fenoprofen Tab 600mg
  • Gabitril Tab 12mg
  • Gabitril Tab 16mg
  • Lidocaine Cream 3%
  • Marplan 10mg Tab
  • Meclofenamate Sod Cap
  • Methyltestos Cap 10mg
  • Nadolol - All Strengths
  • Nisoldipine Tab ER
  • Ondansetron Solution 4mg/5ml
  • Oxaprozin Tab 600mg
  • Oxytrol Patch
  • Pindolol - All Strengths
  • Pioglitazone-Glimepiride - All Strengths
  • Pioglitazone-Metformin - All Strengths
  • Potassium/Sodium Citrates & Citric Acid Solution
  • Premarin Tabs - All Strengths
  • Prempro And Premphase Tabs - All Strengths
  • Probenicin/Colchicine Tab 500/.5mg
  • Protriptyline - All Strengths
  • Qvar Aerosol –All Strengths
  • Tolazamide - All Strengths
  • Tolbutamide 500mg Tab
  • Tranylcypromine 10mg Tab
  • Verapamil Extended Release 24 Hour Cap 100mg
  • Verapamil Extended Release 24 Hour Cap 200mg
  • Verapamil Extended Release 24 Hour Cap 300mg

Other Updates:

  • Adderall XR Cap – All Strengths (Added Age Limit, Added Quantity Level Limit)
  • Atomoxetine Cap –All Strengths (Added Age Limit, Added Quantity Level Limit)
  • Baraclude Sol 0.05mg/ml (Added Quantity Level Limit)
  • Berinert 500 Unit Kit (Removed Quantity Level Limit)
  • Bethkis 300mg/4ml amp (Added Age Limit, Removed Prior Authorization)
  • Byetta –All Strengths (Added Quantity Level Limit)
  • Concerta Tab – All Strengths (Decreased Age Limit, Added Quantity Level Limit)
  • Dexmethylphenidate Cap ER – All Strengths (Added Age Limit, Removed Prior Authorization, Added Quantity Level Limit)
  • Dextoamph-Amphetamin 15mg Tab (Added Age Limit, Removed Prior Authorization, Added Quantity Level Limit)
  • Elmiron (Added Prior Authorization)
  • Enbrel (Added Quantity Level Limit)
  • Genotropin –All Strengths (Remove Age Limit)
  • Guanfacine ER Tab – All Strengths (Added Age Limit, Removed Prior Authorization)
  • Ipratropium Spray (Remove Quantity Level Limit)
  • Kapvay ER 0.1mg Tab (Decreased Age Limit)
  • Kitabis Pak 300mg/5ml (Added Quantity Level Limit)
  • Levalbuterol Aer 45/Act (Added Quantity Level Limit)
  • Methylphenidate TD Patch (Added Age Limit, Removed Prior Authorization, Added Quantity Level Limit)
  • Morphine Suppository –All Strengths (Added Quantity Level Limit)
  • Nutropin AQ –All Strengths (Removed Age Limit)
  • Oxycodone Tab 30mg (Increased Quantity Level Limit)
  • Propranolol Cap 80mg ER (Decreased Quantity Level Limit)
  • Proventil Aer HFA (Added Quantity Level Limit)
  • Sevelamer Tab 800mg (Added Step Therapy)
  • Tenofovir Tab 300mg (Added Quantity Level Limit)
  • Tretinoin Gel 0.05% (Removed Prior Authorization
  • Victoza 18mg/3ml Pen (Added Quantity Level Limit)
  • Vyvanse –All Strengths (Added Age Limit, Removed Prior Authorization, Added Quantity Level Limit)

July 2018

Additions:

  • Baclofen Tab 5 Mg
  • Concert Tab ER (Age Limit)
  • Diphenhydramine Liq 6.25mg
  • E.E.S. Granules
  • Glyxambi Tab (Step Therapy Required)
  • Jardiance Tab (Step Therapy Required)
  • Norvir POW 100mg      
  • Oseltamivir Phosphate For Susp 6 Mg/Ml
  • Pediatric Multiple Vitamins W/ Iron Drops 11 Mg/Ml
  • Phytonadione Tab 5mg
  • Synjardy Tab (Step Therapy Required)
  • Zenpep Cap 15000 Unit
  • Zenpep Cap 3000 Unit    

Removal:

  • Adapalene Cream 0.1%
  • Adapalene Gel 0.3%
  • Adapalene Lotion 0.1%
  • Beclomethasone Diprop Hfa Breath Act Inh Aer 40 Mcg/Act
  • Beclomethasone Diprop Hfa Breath Act Inh Aer 80 Mcg/Act
  • BenzaClin Gel 1-5%
  • Erythromycin Ethylsuccinate For Susp 200 Mg/5ml
  • Mephyton Tab 5mg
  • Nystatin-Triamcinolone Cream 100000-0.1 Unit/Gm-%
  • Nystatin-Triamcinolone Oint 100000-0.1 Unit/Gm-%
  • Tapentadol Hcl Tab 100 Mg
  • Tapentadol Hcl Tab 50 Mg
  • Tapentadol Hcl Tab 75 Mg

Other Updates:

  • Atomoxetine Cap (Add Age Limit)

June 2018

Additions:

  • Praziquantel Tab 600mg (Prior Authorization Required)
  • Symfi (Quantity Level Limit)
  • Tasigna 50mg (Prior Authorization Required, Quantity Level Limit)
  • Zenpep 10000 Unit

Removal:

  • Biltricide Tab 600mg

May 2018

Additions:

  • Firvanq Solution
  • Imbruvica 70 Mg, 420 Mg, And 560 Mg (Prior Authorization Required)
  • Rionavir 100â—¦Symfi Lo

April 2018

Additions:

  • Biktarvy
  • Zenpep 5000-17000-24000 Unit And 25000-79000-105000 Units

March 2018

  • No Formulary Updates

February 2018

Additions:

  • Albuterol ER Tablets
  • Albuterol Tablets
  • Amcinonide Cream 0.1%
  • Amcinonide Lotion 1%
  • Cefaclor Er Tablets 500mg
  • Cephalexin Tablets
  • Ciloxan Ointment 0.3%
  • Ciprofloxacin Er Tablets
  • Clobetasol 0.05% Foam
  • Clobetasol Lotion 05%
  • Clobetasol Shampoo 05%
  • Desonide Cream 0.05%
  • Desonide Lotion 05%
  • Desonide Ointment 05%
  • Desoximetasone Cream 0.05% And 25%
  • Desoximetasone Gel 0.05%
  • Desoximetasone Ointment 05% And 0.25%
  • Diflorasone Cream 0.05%
  • Diflorasone Ointment 0.05%
  • Fluocinonide Cream 0.1%
  • Fluticasone Lotion 05%
  • Fml Forte 25%
  • Fondaparinux
  • Fragmin
  • Gatifloxacin Solution 5%
  • Neomycin/Polymixin/Hydrocortisone Suspension
  • Sprycel (Prior Authorization Required)

Removals:

  • Non-BD Brand Pen Needles
  • Ofloxacin Tablets
  • Pred Mild 0.12%
  • Prednicarbate Cream 0.1%
  • Suprax Chew Tablets
  • Terbutaline Tablets
  • Tobrex Ointment 0.3%

Other Updates:

  • Naproxen Suspension (Add Step Therapy)

January 2018

Additions:

  • Azelastine Nasal 0.15%
  • BD Pen Needles (Step Therapy Required)
  • Bevespi
  • Clindesse Cream 2%
  • Desvenlafaxine ER
  • Dutasteride
  • Levocetirizine
  • Mavyret (Prior Authorization Required)
  • Opsumit (Prior Authorization Required)
  • Vyvanse Chewable (Prior Authorization Required)

Removals:

  • Epclusa
  • Epipen And Epipen Jr
  • Haldol IM
  • Harvoni
  • Technivie
  • Trileptal Suspension
  • Viekira Pak
  • Viekira XR

We want you to be as healthy as possible. And you’ll want to know more about the different medicines you take. To help you, here’s a list of questions you should always ask your provider when he or she gives you a prescription:

  • Why am I taking this medicine?
  • What is it supposed to do for me?
  • How should I take this medicine? When? For how many days?
  • Are there any side effects or possible allergic reactions to this medicine?
  • What should I do if I have a side effect or allergic reaction?
  • What will happen if I don't take this medicine?

Carefully read the drug information given with your medicine. It will tell you what you should and shouldn’t do while taking the medicine. If you still have questions after you get your medicine, ask to speak with the pharmacist or call your provider.

Questions about your pharmacy benefits?

Please call Member Services. We are here to help.

Medallion/FAMIS – Member Services

1-800-279-1878 (TTY 711)
24 hours a day, 7 days a week

CCC Plus – Member Services

1-855-652-8249 (TTY 711)
24 hours a day, 7 days a week

HMO SNP - Member Services


1-855-463-0933 (TTY users should call 711)
24 hours a day, 7 days a week