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Formulary search tool and updates

Stay up-to-date with your medicine. A formulary is a list of medicines we cover. To help you manage your medicines and your loved ones’ medicines.

Your formulary search tool

There are many different things 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 requires prior authorization

December 2022

 

Additions:

 

  • Icosapent Cap 0.5gm (Prior Authorization Required, Quantity Level Limit)
  • Imbruvica Sus 70mg/Ml (Prior Authorization Required, Quantity Level Limit)
  • Orkambi Gra 75-94mg (Prior Authorization Required)

 

Removals:

 

  • None

 

Other Updates:

 

  • Artificial Sol Tears
  • Aspirin Sup 300mg
  • Feverall Sup 325mg
  • Lubricating Dro 0.5%
  • Lubricant Dro Eye 0.6%

 

November 2022

 

Additions:

 

  • Acetaminophen Disintegrating Tab 160 Mg
  • Alum & Mag Hydroxide-Simethicone Susp 200-200-20 Mg/5ml
  • Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 325 Mg
  • Aspirin Effer Tab 325 Mg
  • Bisacodyl Suppos 10 Mg
  • Bisacodyl Tab Delayed Release 5 Mg
  • Bismuth Subsalicylate Chew Tab 262 Mg
  • Bismuth Subsalicylate Susp 262 Mg/15ml
  • Bismuth Subsalicylate Susp 525 Mg/15ml
  • Bismuth Subsalicylate Tab 262 Mg
  • Calcium Carbonate (Antacid) Chew Tab 1000 Mg
  • Calcium Carbonate (Antacid) Chew Tab 400 Mg
  • Calcium Carbonate (Antacid) Chew Tab 500 Mg
  • Calcium Carbonate (Antacid) Chew Tab 750 Mg
  • Carboxymethylcellulose Sodium Ophth Soln 0.5% (Added Quantity Level Limit)
  • Clotrimazole Vaginal Cream 1%
  • Clotrimazole Vaginal Cream 2%
  • Dextromethorphan Polistirex Extended Release Susp 30 Mg/5ml (Added Quantity Level Limit)
  • Dextromethorphan-Guaifenesin Tab Er 12hr 30-600 Mg
  • Dextromethorphan-Guaifenesin Tab Er 12hr 60-1200 Mg
  • Docusate Calcium Cap 240 Mg
  • Docusate Sodium Cap 100 Mg
  • Docusate Sodium Syrup 60 Mg/15ml
  • Glycerin Suppos 2 Gm
  • Guaifenesin Tab 200 Mg
  • Guaifenesin Tab 400 Mg
  • Guaifenesin Tab Er 12hr 1200 Mg
  • Ibuprofen Chew Tab 100 Mg
  • Ibuprofen Susp 40 Mg/Ml
  • Loperamide Hcl Liq 1 Mg/7.5ml
  • Loperamide Hcl Tab 2 Mg
  • Magnesium Hydroxide Susp 400 Mg/5ml
  • Methotrexate Sodium Inj 250 Mg/10ml (25 Mg/Ml) (Added Quantity Level Limit)
  • Methotrexate Sodium Inj 50 Mg/2ml (25 Mg/Ml) (Added Quantity Level Limit)
  • Miconazole Nitrate Vaginal Cream 2%
  • Miconazole Nitrate Vaginal Cream 4% (200 Mg/5gm)
  • Miconazole Nitrate Vaginal Suppos 100 Mg
  • Omeprazole Magnesium Delayed Release Tab 20 Mg (Base Equiv) (Added Quantity Level Limit)
  • Polyethylene Glycol 3350 Oral Powder 17 Gm/Scoop (Added Quantity Level Limit)
  • Polyethylene Glycol-Propylene Glycol Pf Op Soln 0.4-0.3%
  • Polyvinyl Alcohol-Povidone Ophth Soln 5-6 Mg/Ml (0.5-0.6%)
  • Pseudoephedrine Hcl Tab 30 Mg
  • Pseudoephedrine-Guaifenesin Tab Er 12hr 60-600 Mg
  • Psyllium Powder 48.57%
  • Refresh Dro Op
  • Sennosides Chew Tab 15 Mg
  • Sennosides Tab 15 Mg
  • Sennosides Tab 25 Mg
  • Sennosides Tab 8.6 Mg
  • Sennosides-Docusate Sodium Tab 8.6-50 Mg
  • Simethicone Cap 180 Mg
  • Simethicone Chew Tab 125 Mg
  • Simethicone Chew Tab 80 Mg
  • Sodium Chloride Hypertonic Ophth Oint 5%
  • Sodium Chloride Hypertonic Ophth Soln 5%
  • Triaminic Syp Infant (Added Quantity Level Limit)
  • White Petrolatum-Mineral Oil Ophth Ointment

 

Removals:

 

  • Phenylephrine W/ Dm-Gg Liqd 5-10-100 Mg/5ml
  • Promacta Pak 25mg
  • Promacta Pow 12.5mg

 

Other Updates:

 

  • None

 

October 2022

 

Removals:

 

  • Vancomycin HCL For IV Solution 1 Gm
  • Vancomycin HCL For IV Solution 5 Gm

 

Other Updates:

 

  • Ceftriaxone Sodium For Inj 250 Mg (Quantity Level Limit)
  • Ceftriaxone Sodium For Inj 500 Mg (Quantity Level Limit)
  • Ceftriaxone Sodium For Inj 1 Gm (Quantity Level Limit)
  • Ceftriaxone Sodium For Inj 2 Gm (Quantity Level Limit)

 

September 2022

 

Additions:

 

  • Methylprednisolone Tab Therapy Pack 4 Mg 
  • Phospho-Trin K500 Tab 500 Mg
  • Prednisone Tab Therapy Pack 10 Mg (21)
  • Prednisone Tab Therapy Pack 10 Mg (48)
  • Prednisone Tab Therapy Pack 5 Mg (21)
  • Prednisone Tab Therapy Pack 5 Mg (48)
  • Sodium Fluoride Solution 0.2 % Mouth/Throat
  • Sore Throat Spray Liquid 1.4 % Mouth/Throat

 

Removals:

 

  • Dexamethasone Sod Phosphate Pf Solution 10 Mg/M Inj
  • K-Phos Tab 500 Mg
  • Hyperhep B Solution Prefilled Syringe 220 Unit/Ml Im
  • Gralise Tab 600mg
  • Hepagam B Solution 312 Unit/Ml Inj
  • Hyperhep B Solution 220 Unit/Ml Im
  • Gralise Tab 300mg
  • Nabi-Hb Solution 312 Unit/Ml Im
  • Levonorgest-Eth Est & Eth Est Tab 42-21-21-7 Days
  • Norethin-Eth Estradiol-Fe Tab Chewable 0.4-35 Mg-Mcg 
  • Drospiren-Eth Estrad-Levomefol Tab 3-0.02-0.451 Mg
  • Drospiren-Eth Estrad-Levomefol Tab 3-0.03-0.451 Mg
  • Norethin Ace-Eth Estrad-Fe Tab Chewable 1-20 Mg-Mcg(24)
  • Natazia Tab 3/2-2/2-3/1 Mg
  • Hyperhep B Solution Prefilled Syringe 110 Unit/0.5ml Im
  • Hypersal Nebulization Solution 3.5 %
  • Norethin-Eth Estradiol-Fe Tab Chewable 0.8-25 Mg-Mcg

 

Other Updates:

 

  • No Updates

 

August 2022

 

Additions:

 

  • Anti-Dandruff Shampoo 1% (Selenium Sulfide Shampoo)
  • Benzoyl Peroxide Creamy Wash Liquid 4% (PanOxyl Creamy Wash)
  • Bicillin L-A Suspension 2400000 Unit/4ml
  • Calamine Lotion
  • Calamine-Zinc Oxide Lotion 8-8%
  • Doxycycline Monohydrate Tab 100 Mg
  • Eplerenone Tab 25 Mg
  • Eplerenone Tab 50 Mg
  • Fenofibrate Tab 145 Mg
  • Fenofibrate Tab 48 Mg
  • Fluocinonide Cream 1% (Quantity Level Limit)
  • Furosemide Oral Soln 8 Mg/Ml
  • Galantamine Sol 4mg/Ml (Age Limit, Quantity Level Limit)
  • Hydrocortisone Acetate Ointment 1% (Quantity Level Limit)
  • Ivermectin Lotion 0.5% (Step Therapy, Quantity Level Limit)
  • Metronidazole Gel 1% (Step Therapy, Quantity Level Limit)
  • Olmesartan Medoxomil Tab 20 Mg (Quantity Level Limit)
  • Olmesartan Medoxomil Tab 40 Mg (Quantity Level Limit)
  • Olmesartan Medoxomil Tab 5 Mg (Quantity Level Limit)
  • Olopatadine Ophth Soln 0.2% OTC
  • Onetouch Ultra 2 Kit W/ Device
  • Onetouch Verio Flex System Kit W/ Device
  • Onetouch Verio Reflect Kit W/ Device
  • Pataday Ophth Soln 0.7% OTC
  • Permethrin Liquid 1% (Step Therapy, Quantity Level Limit)
  • Symjepi Solution Prefilled Syringe 0.15 Mg/0.3ml (Quantity Level Limit)
  • Symjepi Solution Prefilled Syringe 0.3 Mg/0.3ml (Quantity Level Limit)
  • Tetrabenazine Tab 25 Mg (Prior Authorization Required, Quantity Level Limit)
  • Tetrabenazine Tab12.5 Mg (Prior Authorization Required, Quantity Level Limit)
  • Triprolidine Hcl Drops 0.938mg
  • Triprolidine Hcl Liquid 0.625mg (PediaClear PD Liquid)
  • Triprolidine Hcl Syrup 2.5mg/5ml (Histex Syrup)
  • Voriconazole Tab 200 Mg (Prior Authorization Required)
  • Voriconazole Tab 50 Mg (Prior Authorization Required)

 

Removals:

 

  • Adapalene Cream 0.1%
  • Amcinonide Ointment 0.1%
  • Amiodarone Hcl Tablet 100mg
  • Amiodarone Hcl Tablet 400mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 10-10 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 10-20 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 10-40 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 10-80 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-10 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-20 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-40 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 5-10 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 5-20 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 5-40 Mg
  • Amlodipine Besylate-Atorvastatin Calcium Tab 5-80 Mg
  • Amoxicillin & K Clavulanate Tab Er 12hr 1000-62.5 Mg
  • Antioxidant Cap 250-10000-200 (Multiple Vitamin)
  • Carbinoxamine Maleate Tab 4mg
  • Cefaclor Cap 250 Mg
  • Cefaclor Cap 500 Mg
  • Cefpodoxime Proxetil For Susp 100 Mg/5ml
  • Cefpodoxime Proxetil For Susp 50 Mg/5ml
  • Fish Oil Capsule Delayed Release 1200 Mg
  • Flunisolide Solution 25 Mcg/Act (0.025%) Nasal
  • Fluvastatin Sodium Tab Er 24 Hr 80 Mg (Base Equivalent)
  • Glucagen Hypokit Solution Reconstituted 1 Mg
  • Hydrocortisone Soln 1%
  • Isosorbide Dinitrate Tab 40 Mg
  • Isradipine Cap 2.5mg
  • Isradipine Cap 5mg
  • Lidocaine Hcl Urethral/Mucosal Gel 2 %
  • Memantine Hcl Oral Solution 2 Mg/Ml
  • 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
  • Onetouch Solutions Starter Kit Kit W/ Well Device
  • Pc-Tar Shampoo 1 % (Coal Tar Shampoo)
  • Perindopril Erbumine Tab 2 Mg
  • Perindopril Erbumine Tab 4 Mg
  • Perindopril Erbumine Tab 8 Mg
  • Psyllium Powder 30.9%
  • Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4%
  • Salicylic Acid Shampoo 6%
  • Selenium Sulfide Shampoo 2.25%
  • Stress B-Complex/Vitamin C/Zinc Tab
  • Sulfacetamide Sodium Liquid 10%
  • 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)
  • Vemlidy Tablet 25 Mg
  • Vitamin D (Cholecalciferol) Tab Chewable 10 Mcg (400 Unit) 
  • Zafirlukast Tab 10mg
  • Zafirlukast Tab 20mg

 

Other Updates:

 

  • Acyclovir Cap 200 Mg (Removed Quantity Level Limit)
  • Acyclovir Tab 400 Mg (Removed Quantity Level Limit)
  • Acyclovir Tab 800 Mg (Removed Quantity Level Limit)
  • Austedo Tab 12mg (Added Quantity Level Limit)
  • Austedo Tab 6mg (Added Quantity Level Limit)
  • Austedo Tab 9mg (Added Quantity Level Limit)
  • Ezetimibe Tab 10 Mg (Removed Step Therapy)
  • Glucagon Emergency Kit 1 Mg (Changed Quantity Level Limit)
  • 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)
  • Olopatadine Ophth Soln 0.1% Otc (Removed Step Therapy)
  • Omega-3-Acid Ethyl Esters Cap 1 Gm (Removed Step Therapy)
  • Valacyclovir Hcl Tab 1 Gm (Removed Quantity Level Limit)
  • Valacyclovir Hcl Tab 500 Mg (Removed Quantity Level Limit)

 

July 2022

 

No updates

 

June 2022

 

Additions:

 

  • Capsaicin Cream 0.1%
  • Chlorpheniramine Maleate Tab Er 12mg (Quantity Level Limit)
  • Hydrocortisone Acetate Cream 1%
  • Ozempic Inj 8mg/3ml (Quantity Level Limit, Step Therapy)
  • Triple Antibiotic Oint 3.5-400-5000 External
  • Triumeq Pd Tab 60-5-30mg (Prior Authorization Required, Quantity Level Limit)

 

Removals:

 

None

 

Other Updates:

 

  • None

 

May 2022

 

Additions:

 

  • Descovy 120-15mg Tab (Prior Authorization Required, Quantity Level Limit)

 

Removals:

 

  • B Complex-C-Folic Acid Tab

 

Other Updates:

 

  • None

 

April 2022

 

  • No updates

 

March 2022

 

Additions:

 

  • Dexcom G5 Mobile Receiver Device (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G5 Mobile Transmitter (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G5 Mobile/G4 Platinum Sensor Kit (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G5 Receiver Kit Device (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G6 Receiver Device (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G6 Sensor (Prior Authorization Required, Quantity Level Limit)
  • Dexcom G6 Transmitter (Prior Authorization Required, Quantity Level Limit)
  • Freestyle Libre Reader Device (Prior Authorization Required, Quantity Level Limit)
  • Freestyle Libre 14 Day Reader Device (Prior Authorization Required, Quantity Level Limit)
  • Freestyle Libre 14 Day Sensor (Prior Authorization Required, Quantity Level Limit)
  • Freestyle Libre 2 Reader Device (Prior Authorization Required, Quantity Level Limit)
  • Freestyle Libre 2 Sensor (Prior Authorization Required, Quantity Level Limit)
  • Hydroxyprogesterone Caproate Im Oil 250mg/ml (Prior Authorization Required)
  • Levocetirizine Tab 5mg (Quantity Level Limit)
  • Makena Inj 275mg (Prior Authorization Required)
  • Medroxyprogesterone Acetate Prefilled Syringe 150mg/ml (Quantity Level Limit)
  • Molnupiravir Cap 200mg (Age Limit, Quantity Level Limit)
  • Norditropin Flexpro Injection 10mg/1.5ml (Prior Authorization Required)
  • Norditropin Flexpro Injection 15mg/1.5ml (Prior Authorization Required)
  • Norditropin Flexpro injection 30mg/3ml (Prior Authorization Required)
  • Norditropin Flexpro Injection 5mg/1.5ml (Prior Authorization Required)
  • Paxlovid Tab (Age Limit, Quantity Level Limit)
  • Ziextenzo Inj 6mg/0.6ML (Prior Authorization Required)

 

Removals:

 

  • Combigan Ophth Soln 0.2-0.5%
  • Diphenhydramine Hcl Elixir 12.5mg/5ml
  • Estradiol Vaginal Cream 0.1mg/Gm
  • Megestrol Suspension 625mg/5ml
  • Omnitrope Inj 5.8mg
  • Udenyca Inj 6mg/0.6ml

 

Other Updates:

 

  • Diphenhydramine Hcl Liquid 12.5mg/5ml (Changed Quantity Level Limit)
  • Eliquis Starter Pack 5mg (Removed Prior Authorization Required)
  • Eliquis Tab 2.5mg, 5mg (Removed Prior Authorization Required)
  • Humalog Kwikpen 100 Unit/ml (75-25) (Removed Age Limit)    
  • Humalog Mix 50/50 Kwikpen 100Unit/ml (Removed Age Limit)
  • Humulin R U-500 Kwikpen Pen Injector (Removed Age Limit)
  • Insulin Lispro Kwikpen 100 Unit/ml (Removed Age Limit)
  • Novolin 70/30 Flexpen 100 Unit/ml (Removed Age Limit)
  • Novolin N Flexpen 100 Unit/ml (Removed Age Limit)
  • Novolin R Flexpen 100 Unit/ml (Removed Age Limit)
  • Novolog Flexpen 100 Unit/ml (70-30) (Removed Age Limit)
  • Promethazine Hcl Syrup 6.25mg/5ml (Changed Quantity Level Limit)
  • Xarelto Starter Pack 15mg/20mg (Removed Prior Authorization Required)
  • Xarelto Tab 10mg, 15mg, 20mg (Removed Prior Authorization Required)

 

February 2022

 

Additions:

 

  • None

 

Removals:

 

  • Calcium Carbonate Vitamin D Tablet 600-200mg unit
  • Calcium Carbonate Vitamin D Tablet 600-400mg unit
  • Concept OB Capsule 130-92.4-1mg
  • Father Johns Medicine Syrup 10mg/5ml
  • Gas-X Infant Drops Liquid 20mg/0.3ml
  • Metaproterenol Sulfate Syrup 10mg/5ml
  • Mynatal Tablet
  • Nozin Nasal Sanitizer Kit 62%

 

Other Updates:

 

  • None

 

January 2022

 

Additions:

 

  • Gvoke Kit Solution 1mg/0.2ml (Quantity Level Limit)
  • Insulin Glargine-Yfgn Solution Vial 100unit/ml
  • Insulin Glargine-Yfgn Solution Pen-Injector 100unit/ml
  • Mavyret Oral Packet 50-20mg (Prior Authorization Required)

 

Removals:

 

  • Semglee Pen-Injector 100unit/ml
  • Semglee Vial (Solution) 100unit/ml

 

Other Updates:

 

  • None

 

December 2021

 

Additions:

 

    Esomeprazole Tab Delayed Release 20mg

    Everolimus Tab 10mg (Prior Authorization Required, Quantity Level Limit)

 

Removals:

 

    Afinitor Tab 10mg

 

Other Updates:

 

    None

 

November 2021

 

No Updates

 

October 2021

 

Additions:

 

    Sunitinib Caps 12.5mg, 25mg, 37.5mg, 50mg (Prior Authorization Required, Quantity Level Limit)

 

Removals:

 

    Sutent (brand) Caps 12.5mg, 25mg, 37.5mg, 50mg

 

Other Updates:

 

    None

 

September 2021

 

No Updates

 

August 2021

 

Additions:

 

    Baqsimi Powder 3mg/dose (Quantity Level Limit)

    Endari Powder Packet 5gm (Prior Authorization Required)

    Inlyta Tab 1mg, 5mg (Prior Authorization Required, Quantity Level Limit)

    Prolia Solution Prefilled Syringe 60mg/ml (Prior Authorization Required, Quantity Level Limit)

    Semglee Pen-Injector 100unit/ml

    Semglee Vial (Solution) 100unit/ml

 

Removals:

 

    Caffeine Citrate Powder

    Ibrance Cap 75mg, 100mg, 125mg

    Lidocaine-Hydrocortisone Acetate Cream 3-0.5%

    Methoxsalen Rapid Cap 10mg

    Nexavar Tab 200mg

 

Other Updates:

 

    None

 

July 2021

 

Additions:

 

    None

 

Removals

 

    Allergy Relief Disintegrating Tablet 12.5mg

    Calcium Carbonate Tab 1250mg (500mg Elemental Ca)

    Centrum Liquid

    Fish Oil Cap 435mg

    Nozin Nasal Sanitizer

    Slow Release Iron Tab 47.5mg

 

Other Updates:

 

    None

 

June 2021

 

Additions:

 

    None

 

Removals:

 

    None

 

Other Updates:

 

    Trulicity Injection 0.75mg/0.5ml, 1.5mg/0.5ml, 3mg/0.5ml, 4.5mg/0.5ml (Added Quantity Level Limit)

 

May 2021

 

No Updates

 

April 2021

 

Additions:

 

    Brinzolamide 1% Ophthalmic Suspension (Quantity Level Limit, Step Therapy)

 

Removals:

 

    Anti-Diarrheal Liquid 1mg/8ml

    Azopt 1% Ophthalmic Suspension

    NovaMV Pediatric Multi-Vitamin Drops

    Santyl Ointment 250unit/gm

 

March 2021

 

Additions:

 

    Bevespi Aerosol 9-4.8mcg (Quantity Level Limit)

    Cequa Solution 0.09% PF (Prior Authorization Required)

    Doxycycline Hyclate Cap 50mg, 100mg

    Doxycycline Hyclate Tab 100mg

    Esbriet Cap 267mg (Prior Authorization Required)

    Esbriet Tab 267mg, 801mg (Prior Authorization Required)

    Fluticasone-Salmeterol Aerosol 100-50mcg (Quantity Level Limit)

    Hizentra Injection 1gm/ml, 2gm/10ml, 4gm/20ml (Prior Authorization Required)

    Hizentra Solution 20%(Prior Authorization Required)

    Hizentra Vial 1gm/5ml, 10gm/50ml (Prior Authorization Required)

    Icosapent Cap 1gm (Quantity Level Limit)

    Myleran Tab 2mg

    Ocrevus Injection 300/10ml (Quantity Level Limit)

    Potassium & Sodium Citrate W/ Citric Acid Solution 550-500-334mg/5ml

    Privigen Injection 40grams (Prior Authorization Required)

    Rabeprazole Tab 20mg (Quantity Level Limit)

    Trulicity Injection 0.75mg/0.5ml, 1.5mg/0.5ml, 3mg/0.5ml, Inj 4.5mg/0.5ml (Step Therapy Required)

    Tukysa Tab 50mg, 150mg (Prior Authorization Required)

    Visco-3 Injection 25/2.5ml (Prior Authorization Required)

 

Removals:

 

    Anoro Ellipta Aero 62.5-25mcg/inh

    Atrovent Hfa Aero 17mcg

    Breo Ellipta Inhaler 100-25mcg/inh, 200-25mcg/inh

    Cefaclor For Suspension 125mg/5ml, 250mg/5ml, 375mg/5ml

    Clarithromycin Tab Extended Release 24Hr 500mg

    Combivent Aero 20-100mcg/act

    Doxycycline Monohydrate Tab 50mg, 75mg, 100mg

    Epogen Injection 2000/ml, 3000/ml, 4000/ml 10000/ml, 20000/ml

    Fulphila Injection 6mg/0.6ml

    Gammaked Injection 1gm/10ml, 5gm/50ml, 10gm/100ml, 20gm/200ml

    Hyoscyamine Drops 0.125mg/ml

    Janumet Tab 50-500mg, 50-1000mg

    Janumet Xr Tab 50-500mg, 50-1000mg, 100-1000mg

    Januvia Tab 25mg, 50mg, 100mg

    Nivestym Injection 300mcg, 480mcg

    Nivestym Injection Syringe 300mcg/0.5ml, 480mcg/0.8ml

    Ofev Cap 100mg, 150mg

    Victoza Injection 18mg/3ml

 

Other Updates:

 

    Albuterol Aero Hfa (Changed Quantity Level Limit)

    Arnuity Ellipta Inhaler 50mcg, 100mcg, 200mcg (Changed Quantity Level Limit)

    Azithromycin Suspension 100mg/5ml, 200mg/5ml (Added Age Limit)

    Cefadroxil Suspension 250mg/5ml, 500mg/ml (Added Age Limit)

    Cefdinir Suspension 125mg/5ml, 250mg/5ml (Added Age Limit)

    Cefpodoxime Proxetil Suspension 50mg/5ml, 100mg/5ml (Added Age Limit)

    Cefprozil Suspension 125mg/5ml, 250mg/5ml (Added Age Limit)

    Cephalexin Suspension 125mg/5ml, 250mg/5ml (Added Age Limit)

    Clarithromycin Suspension 125mg/5ml, 250mg/5ml (Added Age Limit)

    Extavia Injection 0.3mg (Changed Quantity Level Limit)

    Glatiramer Injection 40mg/ml (Added Quantity Level Limit)

    Levalbuterol Tartrate Aerosol 45mcg/Act (Added Quantity Level Limit)

    Levofloxacin Solution 25mg/ml (Added Age Limit)

    Neomycin-Polymyxin-Dexamethasone Ophthalmic Ointment 0.1% (Added Quantity Level Limit)

    Ondansetron Tablet Dispersible 4mg, 8mg (Changed Quantity Level Limit)

    Phenylephrine Hcl Ophthalmic Solution 2.5% (Added Quantity Level Limit)

    Rebif Injection 44mcg/0.5ml (Added Quantity Level Limit)

    Rebif Rebido Injection 22mcg/0.5ml, 44mcg/0.5ml (Added Quantity Level Limit)

    Rebif Rebidose Titration Pack (Added Quantity Level Limit)

    Rebif Titration Injection Pack (Added Quantity Level Limit)

    Santyl Ointment 250 Unit/gm (Added Quantity Level Limit)

 

February 2021

 

No Updates

 

January 2021

 

Additions:

 

    Retacrit Injection 20000units (Prior Authorization Required)

 

 

Removals:

 

    Calcium Carbonate Tab

    Mag Ox Tab 420mg

 

December 2020

 

 

Additions:

 

 

    Trelegy Ellipta Aerosol 200-62.5-25mcg (Step Therapy Required, Quantity Level Limit)

 

 

 

November 2020

 

 

Additions:

 

 

    Dimethyl Fumarate Caps Delayed Release 120mg, 240mg (Prior Authorization Required, Quantity Level Limit)

    Dimethyl Fumarate Starter Pack 120mg & 240mg (Prior Authorization Required, Quantity Level Limit)

    Efavirenz-Lamivudine-Tenofovir DF Tabs 400-300-300mg, 600-300-300mg (Quantity Level Limit)

    Emtricitabine Cap 200mg (Quantity Level Limit)

    Vancomycin HCL IV Sol’n 750mg/150ml, 1250mg/250ml, 1750mg/350ml

 

 

Removals:

 

 

    Emtriva Cap 200mg

    Symfi Lo Tab 400-300-300mg

    Symfi Tab 600-300-300mg

    Tecfidera Caps Delayed Release 120mg, 240mg

 

 

October 2020

 

 

Additions:

 

 

    Enbrel 25mg/0.5ml (Prior Authorization Required, Quantity Level Limit)

 

 

Removals:

 

 

    Psyldex Powder 30%

    SB Fiber Laxative Powder 33%

 

 

September 2020

 

 

Additions:

 

 

    Abiraterone tab 250mg (prior authorization required)

    Alecensa cap 150mg (prior authorization required)

    Austedo tabs 5mg, 9mg, 12mg (prior authorization required)

    Bexarotene cap 75mg (prior authorization required)

    Budesonide cap 3mg (step therapy Required, quantity level limit)

    Caprelsa tabs 100mg, 300mg (prior authorization required)

    Cinacalcet tabs 30mg, 60mg, 90mg (prior authorization required)

    Cyclophosphamide caps 25mg, 50mg

    Erivedge cap 150mg (prior authorization required)

    Gilotrif tabs 20mg, 30mg, 40mg (prior authorization required)

    Jakafi tabs 5mg, 10mg, 15mg, 20mg, 25mg (prior authorization required)

    Kalydeco pak 25mg, 50mg, 75mg (prior authorization required)

    Kalydeco tab 150mg (prior authorization required)

    Lenvima caps 4mg, 8mg, 10mg, 12mg, 14mg, 18mg, 20mg, 24mg (prior authorization required)

    Linezolid tab 600mg (prior authorization required)

    Mekinist tabs 0.5mg, 2mg (prior authorization required)

    Ofev caps 100mg, 150mg (prior authorization required)

    Poly-Vi-Sol solution 50mg/ml

    Repatha injection 140mg/ml, 420mg/3.5ml (prior authorization required)

    Rydapt cap 25mg (prior authorization required)

    Soliris injection 10mg/ml (prior authorization required)

    Symdeko tabs 50-75mg, 100-150mg (prior authorization required)

    Tafinlar caps 50mg, 75mg (prior authorization required)

    Tivicay PD tab 5mg (prior authorization required, age limit)

    Tri-Vi-Sol solution A/C/D

    Venclexta Start Pack (prior authorization required)

    Venclexta tabs 10mg, 50mg, 100mg (prior authorization required)

    Xolair injection 75mg/0.5ml, 150mg/ml (prior authorization required)

 

 

Other updates:

 

 

    Proton Pump inhibitors (quantity level limit)

 

August 2020

 

 

Additions:

 

 

    Amitiza caps 8mcg, 24mcg (prior authorization required, quantity level limit)

    Buprenorphine Weekly Patches 5mcg, 7.5mcg, 10mcg, 15mcg, 20mcg (prior authorization required, quantity level limit)

    Diclofenac sodium solution 1.5% (step therapy, quantity level limit)

    Dovato tab 50-300mg (prior authorization required, quantity level limit)

    HM urinary pain relief (phenazopyridine) tab 99.5mg

    Ibrance caps 75mg, 100mg, 125mg (prior authorization required, quantity level limit)

    Ibrance tabs 75mg, 100mg, 125mg (prior authorization required, quantity level limit)

    Lynparza tabs 10mg, 15mg (prior authorization required, quantity level limit)

    Solifenacin succinate tabs 5mg, 10mg (step therapy, quantity level limit)

    Symproic tab 0.2mg (prior authorization required, quantity level limit)

    Testosterone gel 1.62% (prior authorization required, quantity level limit)

    Testosterone TD solution 30mg/actuation (prior authorization required, quantity level limit)

    Tolnaftate cream 1% (quantity level limit)

    Trelegy Ellipta (step therapy, quantity level limit)

    Triamcinolone acetonine ointment 0.05% (quantity level limit)

 

 

Removals:

 

 

    Cimduo tab 300mg

    Fluocinolone acetonine solution 0.01%

    Fluorouracil cream 0.5%

    Humulin 70/30

    Humulin N

    Humulin R

    Kitabis Nebule solution 300mg/5ml

    Maalox Children’s chewable tab

    Naproxen sodium tab 275mg

    Nimodipine cap 30mg

    Targretin gel 1%

    Tolmetin sodium cap 400mg

    Tolmetin sodium tabs 200mg, 600mg

    Videx EC cap 125mg

    Videx powder 2gm

    Videx solution 4gm

 

Other updates:

 

 

    Athletes Foot (Miconazole Nitrate) powder 2% (quantity level limit)

    Auryxia tab 210mg (step therapy Required)

    Betamethasone Dipropionate Augmented cream 0.05% (quantity level limit)

    Betamethasone Dipropionate cream 0.05%, 0.1% (quantity level limit)

    Betamethasone Dipropionate lotion 0.05%, 0.1% (quantity level limit)

    Betamethasone Valerate ointment 0.1% (quantity level limit)

    Butenafine HCL cream 1% (quantity level limit)

    Candesartan Cilexetil – Hydrochlorothiazide tabs 16-12.5mg, 32-12.5mg, 32-25mg (step therapy Required)

    Candesartan Cilexetil tabs 4mg, 8mg, 16mg, 32mg (step therapy Required)

    Ciclopirox Olamine cream 0.77% (quantity level limit)

    Ciclopirox Olamine suspension 0.77% (quantity level limit)

    Ciclopirox shampoo 1% (quantity level limit)

    Ciclopirox solution 8% (quantity level limit)

    Ciprofloxacin HCL OTIC solution 0.2% (quantity level limit)

    Clindamycin Phosphate gel 1% (quantity level limit)

    Clindamycin Phosphate lotion 1% (quantity level limit)

    Clindamycin Phosphate solution 1% (quantity level limit)

    Clindamycin Phosphate swab 1% (quantity level limit)

    Clotrimazole cream 1% (quantity level limit)

    Clotrimazole solution 1% (quantity level limit)

    Clotrimazole-Betamethasone cream 1-0.05% (quantity level limit)

    Ear Drops (Carbamide Peroxide) OTIC solution 6.5% (quantity level limit)

    Ery Pad (Erythromycin) 2% (quantity level limit)

    Erythromycin gel 2% (quantity level limit)

    Erythromycin solution 2% (quantity level limit)

    Fluocinonide cream 0.05% (quantity level limit)

    Fluocinonide solution 0.05% (quantity level limit)

    Fluvastatin sodium caps 20mg, 40mg (step therapy Required)

    Hydrocortisone cream 0.5%, 1%, 2.5% (quantity level limit)

    Hydrocortisone lotion 1%, 2.5% (quantity level limit)

    Hydrocortisone ointment 0.5%, 1%, 2.5% (quantity level limit)

    Hydrocortisone-Acetic Acid OTIC solution 1-2% (quantity level limit)

    Ketoconazole cream 2% (quantity level limit)

    Ketoconazole shampoo 2% (quantity level limit)

    Lidocaine ointment 5% (quantity level limit)

    Linzess caps 72mcg, 145mcg, 290mcg (prior authorization required)

    Liothyronine sodium tab 25mcg (quantity level limit)

    Miconazole Nitrate Aerosol powder 2% (quantity level limit)

    Miconazole Nitrate cream 2% (quantity level limit)

    Mometasone Furoate cream 0.1% (quantity level limit)

    Mometasone Furoate ointment 0.1% (quantity level limit)

    Mometasone Furoate solution 0.1% (quantity level limit)

    Neomycin-Polymixin-HC OTIC solution 1% (quantity level limit)

    Neomycin-Polymixin-HC OTIC suspension 3.5mg/ml-10000 Unit/ml (quantity level limit)

    Nystatin cream 100,000 units/Gm (quantity level limit)

    Nystatin ointment 100,000 units/Gm (quantity level limit)

    Nystatin powder 100,000 units/Gm (quantity level limit)

    Ofloxacin OTIC solution 0.3% (quantity level limit)

    Permethrin cream 5% (quantity level limit)

    Prednicarbate ointment 0.1% (quantity level limit)

    Proton Pump inhibitors (quantity level limit)

    Ropinirole Hydrochloride Extended Release tabs 2mg, 4mg, 8mg, 6mg, 12mg (step therapy Required)

    Scalp Relief Max Strength (Hydrocortisone 1%) solution (quantity level limit)

    Stop Lice Maximum Strength (pyrethrins-Piperonyl Butoxide) Liquid 0.33-4% (quantity level limit)

    Sulfacetamide sodium (Acne) lotion 10% (quantity level limit)

    Triamcinolone acetonine cream 0.025%, 0.1%, 0.5% (quantity level limit)

    Triamcinolone acetonine lotion 0.0.25%, 0.1% (quantity level limit)

    Triamcinolone acetonine ointment 0.025%, 0.05% (quantity level limit)

 

July 2020

 

 

Additions:

 

 

    Gvoke Hypopen 0.5mg/0.1ml, 1mg/0.2ml (quantity level limit)

    Gvoke PFS 0.5mg/0.1ml, 1mg/0.2ml (quantity level limit)

    Urinary Pain Relief (phenazopyridine) 95mg tab

 

Other updates:

 

 

    Azithromycin tab 250mg (changed quantity level limit)

    Chloroquine tabs 250mg, 500mg (removed quantity level limit)

    Hydroxychloroquine tab 500mg (removed quantity level limit)

 

 

June 2020

 

 

Additions:

 

 

    Acne Medication 10 (Benzoyl Peroxide) lotion 10%

    Alahist-D tab 17.5-10mg

    Atovaquone-Proguanil tabs 62.5-25mg, 250mg-100mg (quantity level limit)

    Benzoyl Peroxide gel 2.5%

    Claravis caps 10mg, 20mg, 30mg, 40mg (step therapy, quantity level limit)

    Clotrimazole cream 1% (Legend Products)

    Dexamethasone vials 4mg/ml

    Isosorbide Dinitrate tab 40mg

    Isotretinoin caps 10mg, 20mg, 30mg, 40mg (step therapy, quantity level limit)

    Jock Itch/Athlete’s foot spray (Tolnaftate) Aerosol powder 1% (quantity level limit)

    Lice Killing shampoo (pyrethrins-Piperonyl Butoxide) 0.33-4% (quantity level limit)

    Primaquine Phosphate tab 26.3mg (quantity level limit)

    Promacta powder Pack 12.5mg, 25mg (prior authorization required, quantity level limit)

    Pyrimethamine tab 25mg (prior authorization required)

    Solu-Cortef vials 250mg, 500mg, 1000mg

    Tolnaftate powder 1% (quantity level limit)

 

 

Removals:

 

 

    Daraprim tab 25mg (brand)

 

 

Other updates:

 

 

    Clotrimazole solution 1% (removed step therapy)

 

 

May 2020

 

 

Additions:

 

 

    Budesonide-Formoterol inhaler 80-4.5mcg, 160-4.5mcg (quantity level limit)

    Dexamethasone concentrate 1mg/ml

    Dexamethasone vials 20mg/5ml, 120mg/30ml, 10mg/ml

    Erlotinib tabs 25mg, 100mg (prior authorization required, quantity level limit)

    Solu-Cortef vial 100mg

    Novolin R FlexPen 100 units/ml (Age limit)

    Omeprazole orally disintegrating tab 20mg (quantity level limit)

    Orkambi granules 100-125mg, 200-125mg (prior authorization required)

    Orkambi tabs 100-125mg, 200-125mg (prior authorization required)

    Tramadol tab 100mg (quantity level limit, age limit)

 

Removals:

 

 

    Tarceva tabs 25mg, 100mg (Brand)

 

April 2020

 

 

Additions:

 

    Mesalamine ER cap 0.375gm (quantity level limit)

    Penicillamine tab 250mg (prior authorization required, quantity level limit)

 

 

Removals:

 

    Apriso ER cap 0.375gm (Brand)

 

 

Other updates:

 

    Azithromycin tabs 250mg (quantity level limit)

    Chloroquine tabs 250mg, 500mg (prior authorization required, quantity level limit)

    Hydroxychloroquine tab 200mg (prior authorization required, quantity level limit)

    Kaletra tabs (quantity level limit)

    Lopinavir-Ritonavir solution 100--400mg/5ml (quantity level limit)

 

 

March 2020

 

 

Removals:

 

 

    Carboxymethylcellulose sodium ophthalmic solution 1%

    Corn Starch topical powder

    Hydrocodone-Acetaminophen solution 10-325mg/10ml

    Lidocaine hydrochloride gel 2%

    Sodium Fluoride rinse 0.2%

    Sodium Fluoride solution 0.125mg/drop

 

 

February 2020

 

Additions:

 

    Bimatoprost Ophthalmic solution 0.03% (step therapy Required)

    Ethinyl Estradiol – etonogestrel ring 0.015/0.12mg (quantity level limit)

    Everolimus tabs 2.5mg, 5mg, 7.5mg (prior authorization required, quantity level limit)

 

Removals:

 

    Afinitor tabs 2.5mg, 5mg, 7.5mg (Brand)

    Chlorothiazide tabs 250mg, 500mg

    Demeclocycine tabs 150mg, 300mg

    Doxycycline Monohydrate tab 150mg

    First-Vanco solution 25mg/ml, 50mg/ml

    Homatropoine Ophthalmic solution 5%

    Kyleena IUD

    Methylclothiazide tab 5mg

    Mirena IUD

    Nausea relief liquid

    Nizatidine solution 15mg/ml

    Nuvaring (brand)

    Phospholine ophthalmic solution 0.125%

    Propantheline cap 15mg

    Rabeprazole EC cap 20mg

    Ranitidine caps 150mg, 300mg

    Skyla IUD

 

Other updates:

 

    Atropine Ophthalmic ointment 1% (quantity level limit)

    Atropine Ophthalmic solution 1% (quantity level limit)

    Combigan Ophthalmic solution 0.2/0.5% (quantity level limit)

    Dorzolamide-Timolol Ophthalmic solution 22.3-6.5% (step therapy Required, quantity level limit)

    Doxycycline Monohydrate suspension 25mg/5ml (Age limit)

    Granisetron tab 1mg (step therapy Required)

    Ibandronate injection 3mg/3ml (quantity level limit)

    Levofloxacin Ophthalmic solution 0.5% (quantity level limit)

    Memantine tabs 5mg, 10mg (quantity level limit)

    Methazolamide tabs 25mg, 50mg (step therapy Required)

    Natacyn Ophthalmic suspension 5% (quantity level limit)

    Tazarotene cream 0.1% (step therapy Required)

    Trifluridine Ophthalmic solution 1% (quantity level limit)

 

 

January 2020

 

Additions:

 

    Abacavir solution 20mg/ml (prior authorization required, quantity level limit)

    Abacavir tab 300mg (prior authorization required, quantity level limit)

    Abacavir-Lamivudine tab 600-300mg (prior authorization required, quantity level limit)

    Abacavir-Lamivudine-Zidovudine tab 300-150-300mg (prior authorization required, quantity level limit)

    Aptivus cap 250mg (prior authorization required, quantity level limit)

    Aptivus solution 100mg/ml (prior authorization required, quantity level limit)

    Atazanavir Sulfate caps 150mg, 200mg, 300mg (prior authorization required, quantity level limit)

    Atripla tablet (prior authorization required, quantity level limit)

    Biktarvy tab 50-200-25mg (prior authorization required, quantity level limit)

    Complera tab (prior authorization required, quantity level limit)

    Crixivan caps 200mg, 400mg (prior authorization required, quantity level limit)

    Descovy tab 200-25mg (prior authorization required, quantity level limit)

    Didansoine DR caps 250mg, 400mg (prior authorization required, quantity level limit)

    Edurant tab 25mg (prior authorization required, quantity level limit)

    Efavirenz caps 50mg, 200mg (prior authorization required, quantity level limit)

    Efavirenz tab 600mg (prior authorization required, quantity level limit)

    Emtriva cap 200mg (prior authorization required, quantity level limit)

    Emtriva solution 10mg/ml (prior authorization required, quantity level limit)

    Fosamprenavir tab 700mg (prior authorization required, quantity level limit)

    Fuzeon vial 90mg (prior authorization required, quantity level limit)

    Genvoya tab (prior authorization required, quantity level limit)

    Intelence tabs 25mg, 100mg, 200mg (prior authorization required, quantity level limit)

    Invirase tab 500mg (prior authorization required, quantity level limit)

    Isentress chew tab 25mg, 100mg (prior authorization required, quantity level limit)

    Isentress HD tab 600mg (prior authorization required, quantity level limit)

    Isentress tab 400mg (prior authorization required, quantity level limit)

    Juluca tab 50-25mg (prior authorization required, quantity level limit)

    Kaletra tabs 100-25mg, 200-50mg (prior authorization required, quantity level limit)

    Lamivudine solution 10mg/ml (prior authorization required, quantity level limit)

    Lamivudine tabs 150mg, 300mg (prior authorization required, quantity level limit)

    Lamivudine-Zidovudine tab 150-300mg (prior authorization required, quantity level limit)

    Lexiva suspension 50mg/ml (prior authorization required, quantity level limit)

    Lopinavir-Ritonavir tab 80-20mg (prior authorization required, quantity level limit)

    Nevirapine ER tabs 100mg, 400mg (prior authorization required, quantity level limit)

    Nevirapine suspension 50mg/5ml (prior authorization required, quantity level limit)

    Nevirapine tab 200mg (prior authorization required, quantity level limit)

    Norvir powder packet 100mg (prior authorization required)

    Norvir solution 80mg/ml (prior authorization required, quantity level limit)

    Odefsey tab (prior authorization required, quantity level limit)

    Prezista suspension 100mg/ml (prior authorization required, quantity level limit)

    Prezista tabs 75mg, 150mg, 800mg (prior authorization required, quantity level limit)

    Rescriptor tab 200mg (prior authorization required, quantity level limit)

    Ritonavir tab 100mg (prior authorization required, quantity level limit)

    Selzentry tabs 25mg, 75mg, 150mg, 300mg (prior authorization required, quantity level limit)

    Stavudine caps 15mg, 20mg, 30mg, 40mg (prior authorization required, quantity level limit)

    Stribild tab (prior authorization required)

    Symfi Lo tab 400-300-300mg (prior authorization required, quantity level limit)

    Symfi tab 600-300-300mg (prior authorization required, quantity level limit)

    Symtuza tab 800-150-200-10mg (prior authorization required, quantity level limit)

    Tenofovir Disop Fum tab 300mg (prior authorization required, quantity level limit)

    Tivicay tabs 10mg, 25mg, 50mg (prior authorization required, quantity level limit)

    Triumeq tab 600-50-300mg (prior authorization required, quantity level limit)

    Truvada tabs 100-150mg, 200-300mg (prior authorization required, quantity level limit)

    Truvada tabs 133-200mg, 167-250mg (prior authorization required)

    Videx pediatric solution 2gm, 4gm (prior authorization required, quantity level limit)

    Viracept tabs 250mg, 625mg (prior authorization required, quantity level limit)

    Viread powder (prior authorization required, quantity level limit)

    Viread tabs 150mg, 200mg, 250mg (prior authorization required, quantity level limit)

    Zidovudine cap 100mg (prior authorization required, quantity level limit)

    Zidovudine Syrup 50mg/5ml (prior authorization required, quantity level limit)

    Zidovudine tab 300mg (prior authorization required, quantity level limit)

 

 

Removals:

 

    Ventolin HFA inhaler (brand removed)

 

December 2019

 

Removals:

    Aminocaproic Acid solution 0.25gm/ml

    PreNata chewable tab 29-1mg

    Digoxin tabs 62.5mcg, 187.5mcg

 

 

November 2019

 

Additions:

 

    Aminocaproic Acid solution 0.25gm/ml

October 2019

 

    No updates

September 2019

 

Additions:

    Ambrisentan tabs 5mg, 10mg (prior authorization required, quantity level limit)

    Bosentan tabs 62.5mg, 125mg (prior authorization required, quantity level limit)

    Febuxostat tabs 40mg, 80mg (step therapy Required)

Removals:

 

    Letairis tabs 5mg, 10mg (brand)

    Tracleer tabs 62.5mg, 125mg (brand)

    Uloric tabs 40mg, 80mg (brand)

August 2019

 

Additions:

 

    Aspercreme with Lidocaine 4% (quantity level limit)

    Butenafine HCl cream 1%

    Fulphila injection 6mg/0.6ml (prior authorization required)

    Nivestym injection 300mcg, 480mcg (prior authorization required)

Removals:

 

    Butalbital-Acetaminophen-Caffeine capsules 50-300-40mg, 40-325-40mg

    Calcium Acetate oral solution 667mg/5ml

    Ciclopirox gel 0.77%

    Colestipol HCl granule packets 5gm

    Entecavir oral solution 0.05mg/ml

    Epinastine HCl Ophthalmic solution 0.05%

    Erythromycin Ethylsuccinate suspension 200mg/5ml, 400mg/5ml

    Esterified estrogens tabs 0.3mg, 0.625mg, 1.25mg

    Estradiol tab 1mg (15)/Estradiol-Norgestimate tab 1-0.09mg(15)

    Etodolac ER tab 400mg, 500mg, 600mg

    Lindane shampoo 1%

    Moexipril HCl tabs 7.5mg, 15mg

    Olopatadine HCl Ophthalmic solution 0.2%

    Quinidine Gluconate CR tab 324mg

Other updates:

 

    Azelastine HCl Ophthalmic solution 0.05% (quantity level limit)

    Calcipotriene cream 0.005% (prior authorization required, quantity level limit)

    Calcipotriene ointment 0.005% (prior authorization required, quantity level limit)

    Calcipotriene solution 0.005% (prior authorization required, quantity level limit)

    Ciclopirox Olamine cream 0.77% (step therapy)

    Ciclopirox Olamine suspension 0.77% (step therapy)

    Ciclopirox shampoo 1% (step therapy)

    Clotrimazole (RX) solution 1% (step therapy)

    Estradiol vaginal tablet 10mcg (quantity level limit)

    Fluocinolone acetonine cream 0.025% (quantity level limit)

    Fluocinolone acetonine ointment 0.025% (quantity level limit)

    Ketoconazole cream 2% (step therapy, quantity level limit)

    Lidocaine HCl gel 2% (quantity level limit)

    Lidocaine-Prilocaine cream 2.5-2.5% (quantity level limit)

    Liothyronine sodium tabs 5mcg, 50mcg (quantity level limit)

    Norethindrone tab 5mg (step therapy)

    Thyroid tabs 15mg, 30mg, 60mg, 90mg, 120mg, 180mg, 240mg, 300mg (quantity level limit)

July 2019

 

Additions:

 

    Mesalamine cap 400mg DR (quantity level limit)

    Cefixime cap 400mg (quantity level limit)

    Erlotinib tab 150mg (quantity level limit, Prior authorization required)

Removals:

 

    Suprax cap 400mg

    Tarceva tab 150mg

Other updates:

 

    Right now, there are no other updates.

June 2019

 

Additions:

 

    Docosanol cream 10%

Removals:

 

    Abreva cream 10%

Other updates:

 

    Right now, there are no other updates.

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You can call Member Services at 1-866-827-2710 (TTY: 711).

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