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June 2025
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
May 2025
Additions:
- Atomoxetine Hydrochloride Capsule 10 mg (Age Limit, Quantity Level Limit)
- Atomoxetine Hydrochloride Capsule 18 mg (Age Limit, Quantity Level Limit)
- Atomoxetine Hydrochloride Capsule 25 mg (Age Limit, Quantity Level Limit)
- Atomoxetine Hydrochloride Capsule 40 mg (Age Limit, Quantity Level Limit)
- Atomoxetine Hydrochloride Capsule 60 mg (Age Limit, Quantity Level Limit)
- Atomoxetine Hydrochloride Capsule 80 mg (Age Limit, Quantity Level Limit)
- Atomoxetine Hydrochloride Capsule 100 mg (Age Limit, Quantity Level Limit)
- Bisoprolol Tablet 2.5 mg
- Sunlenca Tablet 300 mg (Prior Authorization)
- Paxlovid Pak (Age Limit, Quantity Level Limit)
- Umeclidinium-Vilanterol Aerosol Powder 62.5-25 mcg/actuation
- Tymlos Subcutaneous Solution Pen-Injector 3120 mcg /1.56 mL (Add Prior Authorization, Quantity Level Limit)
- Prolia Injection Solution Prefilled Syringe 60 mg / mL (Add Prior Authorization, Quantity Level Limit)
- Teriparatide Solution Pen-Injection 620 mcg/ 2.48 mL (Add Prior Authorization, Quantity Level Limit)
Removals:
- No updates
Other Updates:
- No updates
April 2025
Additions:
- Simlandi Auto-Injector Kit 80 mg/0.8 mL (Prior Authorization)
- SevenFACT Solution 2 mg (Prior Authorization)
Removals:
- Twiist Refill Kit
- Twiist refill Kit/Infusion Set
Other Updates:
- No updates
March 2025
Additions:
- Baqsimi Nasal Powder 3 mg
- Insulin Degludec Injection 100 unit/mL
- Insulin Degludec FlexTouch 100 unit/mL
- Contour Plus Blood Glucose Monitor Kit (Quantity Level Limit)
- Contour Plus Blood Glucose Test Strips (Quantity Level Limit)
- Guardian Sensor 3 (Prior Authorization)
- Guardian 4 Glucose Sensor (Prior Authorization)
- Guardian 4 Transmitter Kit (Prior Authorization)
- Guardian Connect Transmitter Kit (Prior Authorization)
- Guardian Link 3 Transmitter Kit (Prior Authorization)
- Cequr Simplicity 2U (Prior Authorization)
- Cequr Simplicity Inserter (Prior Authorization)
- Ilet Insulin Pump (Prior Authorization)
- Ilet Starter Kit Inset 23 (Prior Authorization)
- Ilet Starter Kit Inset 32 (Prior Authorization)
- Ilet Insulin Infusion Kit 23 (Prior Authorization)
- Ilet Insulin Infusion Kit 32 (Prior Authorization)
- Carbaglu Tablet 200 mg (Prior Authorization)
- Caplyta Capsule 10.5 mg (Age Limit)
- Caplyta Capsule 21 mg (Age Limit)
- Caplyta Capsule 42 mg (Age Limit)
- Rexulti Tablet 0.25 mg (Age Limit)
- Rexulti Tablet 0.5 mg (Age Limit)
- Rexulti Tablet 1 mg (Age Limit)
- Rexulti Tablet 2 mg (Age Limit)
- Rexulti Tablet 3 mg (Age Limit)
- Rexulti Tablet 4 mg (Age Limit)
- Vraylar Capsule 1.5 mg (Age Limit)
- Vraylar Capsule 3 mg (Age Limit)
- Vraylar Capsule 4.5 mg (Age Limit)
- Vraylar Capsule 6 mg (Age Limit)
- Austedo Extended-Release Tablet 30 mg (Prior Authorization)
- Austedo Extended-Release Tablet 36 mg (Prior Authorization)
- Austedo Extended-Release Tablet 42 mg (Prior Authorization)
- Austedo Extended-Release Tablet 48 mg (Prior Authorization)
- Austedo Extended-Release Tablet Titration Kit (Prior Authorization)
- Ingrezza Sprinkle Capsule 40 mg (Prior Authorization)
- Ingrezza Sprinkle Capsule 60 mg (Prior Authorization)
- Ingrezza Sprinkle Capsule 80 mg (Prior Authorization)
- Siklos Tablet 100 mg (Age Limit)
- Siklos Tablet 1000 mg (Age Limit)
- Airsupra Aerosol 90-80 mcg/Actuation
- Pulmicort Flexhaler 90 mcg
- Pulmicort Flexhaler 180 mcg
- Arnuity Ellipta 50 mcg
- Arnuity Ellipta 100 mcg
- Arnuity Ellipta 200 mcg
- Fluticasone Propionate Aerosol Powder 50 mcg/actuation
- Fluticasone Propionate Aerosol Powder 100 mcg/actuation
- Fluticasone Propionate Aerosol Powder 250 mcg/actuation
- Cinqair Injection 100 mg/10 mL (Prior Authorization)
- Tezspire Prefilled Syringe 210 mg/1.91 mL (Prior Authorization)
- Tezspire Auto-Injector 210 mg/1.91 mL (Prior Authorization)
- Xolair Auto-Injector 300 mg/2 mL (Prior Authorization)
- Xolair Prefilled Syringe 300 mg/2 mL (Prior Authorization)
- Rezdiffra Tablet 60 mg (Prior Authorization)
- Rezdiffra Tablet 80 mg (Prior Authorization)
- Rezdiffra Tablet 100 mg (Prior Authorization)
- Adalimumab-ADBM Auto-Injector Kit 40 mg/0.4 mL (Prior Authorization)
- Adalimumab-ADBM Prefilled Syringe Kit 10 mg/0.2 mL (Prior Authorization)
- Adalimumab-ADBM Prefilled Syringe Kit 20 mg/0.4 mL (Prior Authorization)
- Adalimumab-ADBM Prefilled Syringe Kit 40 mg/0.4 mL (Prior Authorization)
- Simlandi Prefilled Syringe Kit 20 mg/0.2 mL (Prior Authorization)
- Simlandi Prefilled Syringe Kit 40 mg/0.4 mL (Prior Authorization)
- Simlandi Prefilled Syringe Kit 80 mg/0.8 mL (Prior Authorization)
- Simlandi Auto-Injector Kit 40 mg/0.4 mL (Prior Authorization)
- Glucagen Injection Hypokit 1 mg
- Glucagon Kit 1 mg
- Mirabegron Tablet 25 mg
- Mirabegron Tablet 50 mg
- Myrbetriq Tablet 25 mg
- Myrbetriq Tablet 50 mg
- Myrbetriq Oral Suspension 8 mg/mL
- Gemtesa Tablet 75 mg
- Glatopa Prefilled Syringe 20 mg/mL
- Glatopa Prefilled Syringe 40 mg/mL
- Maraviroc Tablet 150 mg
- Maraviroc Tablet 300 mg
- Pifeltro Tablet 100 mg
- Prezcobix Tablet 800-150 mg
- Juluca Tablet 50-25 mg
- Zurzuvae Capsule 20 mg
- Zurzuvae Capsule 25 mg
- Zurzuvae Capsule 30 mg
- Tramadol Tablet 75 mg (Age Limit)
- Esperoct Injection 4000 Units (Prior Authorization)
- Hemlibra Subcutaneous Solution 12 mg/0.4 mL (Prior Authorization)
- Jivi Injection 4000 Units (Prior Authorization)
Removals:
- Ciprofloxacin Tablet 100 mg
- Humira Auto-Injector Kit 40 mg/0.4 mL
- Humira Auto-Injector Kit 40 mg/0.8 mL
- Humira Auto-Injector Kit 80 mg/0.8 mL
- Humira Auto-Injector Kit 80 mg/0.8 mL & 40 mg/0.4 mL
- Humira Prefilled Syringe Kit 10 mg/0.1 mL
- Humira Prefilled Syringe Kit 20 mg/0.2 mL
- Humira Prefilled Syringe Kit 40 mg/0.4 mL
- Humira Prefilled Syringe Kit 40 mg/0.8 mL
- OneTouch Ultra 2 Blood Glucose Monitoring Kit
- OneTouch Verio Flex Blood Glucose Monitoring Kit
- OneTouch Ultra Test Strips
- OneTouch Ultra Blue Test Strips
- OneTouch Verio Test Strips
- Didanosine Capsule 250 mg
- Didanosine Capsule 400 mg
- Invirase Tablet 500 mg
- Stavudine Capsule 15 mg
- Stavudine Capsule 20 mg
- Stavudine Capsule 40 mg
- Permethrin Cream 5%
- Kogenate FS Injection 1000 Units
- Kogenate FS Injection 2000 Units
Other Updates:
- Cabenuva Extended-Release Injection Kit 400 mg/600 mg (Remove Prior Authorization)
- Cabenuva Extended-Release Injection Kit 600 mg/900 mg (Remove Prior Authorization)
- Rukobia Tablet 600 mg (Remove Prior Authorization)
- Estradiol Valerate Multi Dose Vial 20 mg/ mL (Remove Quantity Level Limit)
- Estradiol Valerate Multi Dose Vial 40 mg/ mL (Remove Quantity Level Limit)
February 2025
Additions:
- Estradiol Valerate Multi Dose Vial 20 mg/ mL (Quantity Level Limit)
- Estradiol Valerate Multi Dose Vial 40 mg/ mL (Quantity Level Limit)
- Sodium/Potassium Solution Magnesium (Quantity Level Limit)
Removals:
- Testosterone (AndroGel) Pak 1%(50mg)
- Testosterone (Fortesta) Gel Pump 2%
- Testosterone Gel 1%(25mg)
- Testosterone Gel Pump 1%
Other Updates:
- Oxybutynin Tablet 10 mg Extended Release (Quantity Level Limit)
January 2025
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
December 2024
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
November 2024
Additions:
- None
Removals:
- None
Other Updates:
- None
October 2024
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
September 2024
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
August 2024
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
July 2024
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
June 2024
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
May 2024
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
April 2024
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
March 2024
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
February 2024
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
January 2024
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
December 2023
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
November 2023
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
October 2023
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
September 2023
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
August 2023
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
July 2023
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
June 2023
Additions:
- No updates
Removals:
- No updates
Other Updates:
- Mavyret Pellet Pack 50-20 mg (Quantity Level Limit, Removed Prior Authorization)
- Mavyret Tablet 100-40 mg (Quantity Level Limit, Removed Prior Authorization)
- Sofosbuvir-Velpatasvir Tablet 400-100 mg (Quantity Level Limit, Removed Prior Authorization)
May 2023
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
April 2023
Additions:
- No updates
Removals:
- *Calcium Alginate Wound Dressing***
- *Neomycin-Bacitracin-Polymyxin with Lidocaine Ointment 4%***
- *Pediatric Multiple Vitamin with Minerals & C Chewable Tablet**
- *Pediatric Multiple Vitamins with Iron Drops 10 mg/mL**
- Cholecalciferol Drops 10 mcg/0.025 mL (400 Unit/0.025ml)
- Cholecalciferol Drops 125 mcg/ mL (5000 Unit/mL)
- Cholecalciferol Drops 400 Unit/0.028 mL (Per Drop)
- Formaldehyde Solution 10%
- Loperamide Hydrochloride Liquid 1 mg/5 mL (0.2 mg/mL)
- Magnesium Salicylate Tablet 500 mg
- Magnesium Tablet 400 mg
- Phenylephrine-Shark Liver Oil-Mineral oil-Petrolatum Ointment 0.25-3-14-71.9%
- Psyllium Capsule 400 mg
- Psyllium Powder 30%
- Psyllium Powder 30.9%
- Psyllium Powder 33%
- Psyllium Powder 49%
- Uridine Triacetate Oral Granules Packet 10 gm
Other Updates:
- Betamethasone Dipropionate Ointment 0.05% (Quantity Level Limit)
- Fluocinolone Acetonide Cream 0.025% (Quantity Level Limit)
- Fluocinolone Acetonide Ointment 0.025% (Quantity Level Limit)
- Fluconazole Tablet 150 mg (Quantity Level Limit)
- Freestyle 14 Sensor Libre (Quantity Level Limit)
- Freestyle 14 Sensor Libre 2 (Quantity Level Limit)
- Freestyle 14 Sensor Libre 3 (Quantity Level Limit)
- *Pediatric Multiple Vitamins with Fluoride Chewable Tablet 0.25 mg***
- *Pediatric Multiple Vitamins with Fluoride Chewable Tablet 0.5 mg***
- *Pediatric Multiple Vitamins with Fluoride Chewable Tablet 1 mg***
March 2023
Additions:
- Guaifenesin-Codeine Solution 100-6.33 mg/5 mL (Quantity Level Limit, Age Limit)
Removals:
- No updates
Other Updates:
- No updates
February 2023
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
January 2023
Additions:
- No updates
Removals:
- Testosterone Td Gel 40.5 Mg/2.5 GM (1.62%)
Other Updates:
- Testosterone Td Soln 30 Mg/Act (Prior Authorization Required)
- Testosterone Td Gel 25 Mg/2.5gm (1%) (Prior Authorization Required)
- Testosterone Td Gel 50 Mg/5gm (1%) (Prior Authorization Required)
- Testosterone Td Gel 12.5 Mg/Act (1%) (Prior Authorization Required)
- Testosterone Td Gel 20.25 Mg/Act (1.62%) (Prior Authorization Required)
- Testosterone Td Gel 10mg/Act (2%) (Prior Authorization Required)
- Testosterone Cypionate Im Inj In Oil 100 Mg/Ml (Prior Authorization Required)
- Testosterone Cypionate Im Inj In Oil 200 Mg/Ml (Prior Authorization Required)
- Testosterone Enanthate Im Inj In Oil 200 Mg/Ml (Prior Authorization Required)
December 2022
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
November 2022
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
October 2022
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
September 2022
Additions:
- No updates
Removals:
- No updates
Other Updates:
- Ceftriaxone Sodium For Inj 1 Gm (Changed Quantity Level Limit)
- Ceftriaxone Sodium For Inj 2 Gm (Changed Quantity Level Limit)
- Ceftriaxone Sodium For Inj 250 Mg (Changed Quantity Level Limit)
- Ceftriaxone Sodium For Inj 500 Mg (Changed Quantity Level Limit)
August 2022
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
July 2022
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
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:
- No updates
Removals:
- No updates
Other Updates:
- No updates
March 2022
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
February 2022
Additions:
- Levocetirizine 5mg Tablets (Quantity Limit)
- Dexcom G5 Mis Transmit (Quantity Limit)
- Dexcom G6 Mis Transmit (Quantity Limit)
- G5/G4 Plati Mis Sensor (Quantity Limit)
- Dexcom G6 Mis Sensor (Quantity Limit)
- Dexcom G5 Mis Receiver (Quantity Limit)
- Dexcom G6 Mis Receiver (Quantity Limit)
- Freestyle 10 Sen Libre (Quantity Limit)
- Freestyle 10 Reader Libre (Quantity Limit)
- Freestyle 14 Sen Libre (Quantity Limit)
- Freestyle 14 Reader Libre (Quantity Limit)
- Freestyle 14 Sen Libre 2 (Quantity Limit)
- Freestyle 14 Reader Libre 2 (Quantity Limit)
Removals:
- Diphenhydramine elixir
Other Updates:
- Medroxyprogesterone Acetate 150mg/mL Syringe (Quantity Limit updated)
- Diphenhydramine liquid (Quantity Limit updated)
- Promethazine syrup (Quantity Limit updated)
January 2022
Additions:
- No updates
Removals:
- Nozin Nasal Kit Sanitize
- Calcium 600 Tab +D
Other Updates:
- No updates
December 2021
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
November 2021
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
October 2021
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
September 2021
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
August 2021
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
July 2021
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
June 2021
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
May 2021
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
April 2021
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
March 2021
Additions:
- 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)
- Immune Globulin (Human) Iv Or Subcutaneous Soln 1 Gm/10 (Prior Authorization)
- Immune Globulin (Human) Iv Or Subcutaneous Soln 10 Gm/1 (Prior Authorization)
- Immune Globulin (Human) Iv Or Subcutaneous Soln 20 Gm/2 (Prior Authorization)
- Immune Globulin (Human) Iv Or Subcutaneous Soln 5 Gm/50 (Prior Authorization)
- Privigen Inj 10grams (Prior Authorization)
- Privigen Inj 40grams (Prior Authorization)
- Privigen Inj 5 Grams (Prior Authorization)
- Privigen Via 20grams (Prior Authorization)
Other Updates:
- Arnuity Elpt Inh 100mcg (Quantity Limit Added)
- Arnuity Elpt Inh 200mcg (Quantity Limit Added)
- Arnuity Elpt Inh 50mcg (Quantity Limit Added)
- Bevespi Aer 9-4.8mcg (Quantity Limit Added)
- Levofloxacin Sol 25mg/Ml (Quantity Limit, Age Limit Added)
- Neomycin-Polymyxin-Dexamethasone Ophth Oint 0.1% (Quantity Limit Added)
- Phenylephrine Hcl Ophth Soln 2.5% (Quantity Limit Added)
- Rabeprazole Tab 20 (Quantity Limit Added)
February 2021
Additions:
- No updates
Removals:
- No updates
Other Updates:
- No updates
January 2021
Removals:
- Ogestrel Tablet 0.5-50mg-mcg
Other Updates:
- Antabuse 250mg, 500mg (Removed Quantity Level Limit)
- Buprenorphine-Naloxone 2-0.5mg, 8-2mg sublingual tablet (Removed Quantity Level Limit)
- Buprenorphine 2mg, 8mg sublingual tablet (Removed Quantity Level Limit)
- Naloxone 0.4mg/mL injection solution (Removed Quantity Level Limit)
- Naloxone 0.4mg/mL injection syringe (Removed Quantity Level Limit)
- Naloxone 1mg/mL injection syringe (Removed Quantity Level Limit)
- Narcan 4mg/actuation nasal spray (Removed Quantity Level Limit)
- Probuphine 74.2mg subdermal implant (Removed Quantity Level Limit)
- Sublocade 100mg/0.5ml, 300mg/1.5ml solution, extended release subcutaneous syringe (Removed Quantity Level Limit)
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