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.

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Your formulary search tool

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

Search for your medicine by name or class
Find generic alternatives to your medicine
See if your medicine has quantity limits, has age limits or needs prior authorization

December 2024

Additions:

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

Removals:

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

Other Updates:

Ondansetron 16 mg oral disintegrating tablet (Added Step Therapy)

November 2024

Additions:

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

Removals:

Lamivudine 100 mg tablet
Opsumit 10 mg tablet

Other Updates:

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

October 2024

Additions:

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

Removals:

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

Other Updates:

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

September 2024

Additions:

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

Removals:

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

Other Updates:

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

August 2024

Additions:

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

Removals:

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

Other Updates:

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

July 2024

Additions:

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

Removals:

Other Updates:

Nurtec 75 mg dispersible tablet (Changed Quantity Limit)

June 2024

Additions:

Removals:

Other Updates:

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

May 2024

Additions:

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

Removals:

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

Other Updates:

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

April 2024

Additions:

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

Removals:

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

Other Updates:

March 2024

Additions:

Freestyle libre 3 reader (Prior Authorization, Quantity Limit)

Removals:

Other Updates:

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

February 2024

Additions:

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

Removals:

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

Other Updates:

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

January 2024

Additions:

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

Removals:

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

Other Updates:

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

December 2023

Additions:

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

Removals:

Other Updates:

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

November 2023

Additions:

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

Removals:

Proctofoam 1% rectal foam

Other Updates:

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

October 2023

Additions:

Removals:

Other Updates:

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

September 2023

Additions:

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

Removals:

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

Other Updates:

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

August 2023

Additions:

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

Removals:

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

Other Updates:

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

July 2023

Additions:

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

Removals:

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

Other Updates:

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

June 2023

Additions:

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

Removals:

Benzoyl peroxide 4% Gel
Benzoyl peroxide 8% Gel

Other Updates:

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

May 2023

Additions:

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

Removals:

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

Other Updates:

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

April 2023

Additions:

Oxybutynin 5 mg per 5 ml solution
Rebinyn 3000 unit vial

Removals:

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

Other Updates:

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

March 2023

Additions:

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

Removals:

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

Other Updates:

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

February 2023

Additions:

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

Removals:

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

Other Updates:

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

January 2023

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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