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April 2024
Additions:
- None
Removals:
- None
Other Updates:
- *Blood Glucose Monitoring Kit With Device*** (Quantity Level Limit)
March 2024
Additions:
- Zenpep Capsule 60000 Unit
Removals:
- None
Other Updates:
- None
February 2024
Additions:
- Adalimumab-Adaz Auto-Injector 40 mg/ 0.4 mL (Prior Authorization)
- Adalimumab-Adaz Prefilled Syringe 40 mg/ 0.4 mL (Prior Authorization)
- Adalimumab-Fkjp Auto-Injector Kit 40 mg/ 0.8 mL (Prior Authorization)
- Adalimumab-Fkjp Prefilled Syringe Kit 20 mg/ 0.4 mL (Prior Authorization)
- Adalimumab-Fkjp Prefilled Syringe Kit 40 mg/ 0.8 mL (Prior Authorization)
- Dupixent Injection 100 mg / 0.67 mL (Prior Authorization)
- Dupixent Injection 200 mg (Prior Authorization)
- Dupixent Injection 200 mg/ 1.14 mL (Prior Authorization)
- Dupixent Injection 300 mg/ 2 mL (Prior Authorization)
- Fesoterodine Fumarate Tablet Extended Release 24 hour 4 mg (Step Therapy, Quantity Level Limit)
- Fesoterodine Fumarate Tablet Extended Release 24 hour 8 mg (Step Therapy, Quantity Level Limit)
- Hadlima Auto-Injector 40 mg/ 0.4 mL (Prior Authorization)
- Hadlima Auto-Injector 40 mg/ 0.8 mL (Prior Authorization)
- Hadlima Prefilled Syringe 40 mg/ 0.4 mL (Prior Authorization)
- Hadlima Prefilled Syringe 40 mg/ 0.8 mL (Prior Authorization)
- Insulin Lispro Injection 100 unit/ mL
- Insulin Lispro Injection Junior
- Insulin Lispro Vial
- Lantus Pen Injector
- Lantus Vial
- Ondansetron Hydrochloride Oral Solution 4 mg/ 5 mL (Quantity Level Limit)
- Orilissa Tablet 150 mg (Prior Authorization)
- Orilissa Tablet 200 mg (Prior Authorization)
- Otezla Starter Pack 10 mg/20 mg/30 mg (Prior Authorization)
- Otezla Tablet 30 mg (Prior Authorization)
- Rinvoq Tablet 15 mg Extended Release (Prior Authorization)
- Rinvoq Tablet 30 mg Extended Release (Prior Authorization)
- Rinvoq Tablet 45 mg Extended Release (Prior Authorization)
- Teriparatide Pen Injector 620 mcg/ 2.48 mL (Prior Authorization, Quantity Level Limit)
- Ubrelvy Tablet 100 mg (Step Therapy)
- Ubrelvy Tablet 50 mg (Step Therapy)
- Ultra-Fine U-100 (BD)
- Ultra-Fine U-500 (BD)
Removals:
- Admelog Pen Injector
- Admelog Vial
- Amjevita Injection 40 mg/ 0.8 mL
- Basaglar
- Benzoyl Peroxide Liquid Wash 4%
- Bromocriptine Mesylate Capsule 5 mg (Base Equivalent)
- Bromocriptine Mesylate Tablet 2.5 mg (Base Equivalent)
- Climara Pro Patch
- Combipatch Dis 0.05/ 0.14 mg
- Combipatch Dis 0.05/0.25 mg
- Diflunisal Tablet
- Glyburide Micronized Tablet 1.5 mg
- Glyburide Micronized Tablet 3 mg
- Glyburide Micronized Tablet 6 mg
- Glyburide Tablet 1.25 mg
- Glyburide Tablet 2.5 mg
- Glyburide Tablet 5 mg
- Glyburide-Metformin Tablet 1.25-250 mg
- Glyburide-Metformin Tablet 2.5-500 mg
- Glyburide-Metformin Tablet 5-500 mg
- Humira Injection 10 mg/ 0.1 mL
- Humira Injection 20 mg/ 0.2 mL
- Humira Injection 40 mg/ 0.4 mL
- Humira Kit 40mg/ 0.8 mL
- Humira Pedia Injection Crohns
- Humira Pen Injection 40 mg/ 0.4 mL
- Humira Pen Injection 40 mg/ 0.8 mL
- Humira Pen Injection 80 mg/ 0.8 mL
- Humira Pen Kit Psoriasis/Uveitis
- Insulin Aspart Flex Pen 70/30
- Insulin Aspart Protein Injection Flex pen
- Insulin Aspart Vial 70/30 mix
- Insulin Glargine - Yfgn Pen Injector
- Insulin Glargine - Yfgn Vial
- Insulin Syringe (Disposable) U-100 0.3 mL
- Insulin Syringe (Disposable) U-100 1 mL
- Insulin Syringe (Disposable) U-100 1/2 mL
- Insulin Syringe/Needle U-100 0.3 mL 29 X 1/2"
- Insulin Syringe/Needle U-100 0.3 mL 30 X 1/2"
- Insulin Syringe/Needle U-100 0.3 mL 30 X 5/16"
- Insulin Syringe/Needle U-100 0.3 mL 31 X 15/64"
- Insulin Syringe/Needle U-100 0.3 mL 31 X 5/16"
- Insulin Syringe/Needle U-100 1 mL 25 X 1"
- Insulin Syringe/Needle U-100 1 mL 25 X 5/8"
- Insulin Syringe/Needle U-100 1 mL 26 X 1/2"
- Insulin Syringe/Needle U-100 1 mL 27 X 1/2"
- Insulin Syringe/Needle U-100 1 mL 27 X 5/8"
- Insulin Syringe/Needle U-100 1 mL 28 X 1/2"
- Insulin Syringe/Needle U-100 1 mL 28 X 5/16"
- Insulin Syringe/Needle U-100 1 mL 29 X 1/2"
- Insulin Syringe/Needle U-100 1 mL 29 X 5/16"
- Insulin Syringe/Needle U-100 1 mL 30 X 1/2"
- Insulin Syringe/Needle U-100 1 mL 30 X 5/16"
- Insulin Syringe/Needle U-100 1 mL 31 X 15/64"
- Insulin Syringe/Needle U-100 1 mL 31 X 5/16"
- Insulin Syringe/Needle U-100 1/2 mL 27 X 1/2"
- Insulin Syringe/Needle U-100 1/2 mL 28 X 1/2"
- Insulin Syringe/Needle U-100 1/2 mL 29 X 1/2"
- Insulin Syringe/Needle U-100 1/2 mL 30 X 1/2"
- Insulin Syringe/Needle U-100 1/2 mL 30 X 5/16"
- Insulin Syringe/Needle U-100 1/2 mL 31 X 15/64"
- Insulin Syringe/Needle U-100 1/2 mL 31 X 5/16"
- Insulin Syringe/Needle U-100 2 mL 27.5 X 5/8"
- Ketorolac Tromethamine Ophthalmic Solution 0.4%
- Mesalamine Delayed Release Tablets 800 mg
- Novolog Mix Injection Flex ReliOn
- Novolog ReliOn Injection 70/30
- Salsalate Tablet 500 mg
- Salsalate Tablet 750 mg
- Tramadol Tablet 100 mg
- Trelegy 100 Inhalation Ellipta
- Trelegy 200 Inhalation Ellipta
- Viokace Tablet 10440 Units
- Viokace Tablet 20880 Units
Other Updates:
- Albuterol Sulfate Solution Nebulizer 0.5% (5 mg/ mL) (Quantity Level Limit)
- Alogliptin-Pioglitazone Tablet 12.5-15 mg (Quantity Level Limit)
- Alogliptin-Pioglitazone Tablet 12.5-45 mg (Quantity Level Limit)
- Bimatoprost Ophthalmic Solution 0.03%
- Empagliflozin Tablet 10 mg
- Empagliflozin Tablet 25 mg
- Emtricitabine-Tenofovir Disoproxil Fumarate Tablet 133-200 mg (Quantity Level Limit)
- Emtricitabine-Tenofovir Disoproxil Fumarate Tablet 167-250 mg (Quantity Level Limit)
- Esomeprazole Magnesium Capsule Delayed Release 40 mg (Quantity Level Limit)
- Glimepiride Tablet 1 mg (Quantity Level Limit)
- Glimepiride Tablet 2 mg (Quantity Level Limit)
- Glimepiride Tablet 4 mg (Quantity Level Limit)
- Lansoprazole Capsule Delayed Release 30 mg (Quantity Level Limit)
- Omeprazole Capsule Delayed Release 40 mg (Quantity Level Limit)
- Oxymetazoline Hydrochloride Nasal Solution 0.05% (Quantity Level Limit)
- Pantoprazole Sodium Enteric Coated Tablet 20 mg (Quantity Level Limit)
- Pantoprazole Sodium Enteric Coated Tablet 40 mg (Quantity Level Limit)
- Rosuvastatin Calcium Tablet 10 mg (Quantity Level Limit)
- Rosuvastatin Calcium Tablet 20 mg (Quantity Level Limit)
- Rosuvastatin Calcium Tablet 40 mg (Quantity Level Limit)
- Rosuvastatin Calcium Tablet 5 mg (Quantity Level Limit)
- Stribild Tablet (Quantity Level Limit)
- Terazosin Hydrochloride Capsule 5 mg (Base Equivalent)
- Tobramycin Nebulizer Solution 300 mg/ 5 mL (Quantity Level Limit)
January 2024
Additions:
- Dexcom G7 Receiver (Prior Authorization, Quantity Level Limit)
- Dexcom G7 Sensor (Prior Authorization, Quantity Level Limit)
Removals:
- None
Other Updates:
- None
December 2023
Additions:
- None
Removals:
- None
Other Updates:
- None
November 2023
Additions:
- Ciprofloxacin-Dexamethasone Otic Suspension 0.3-0.1% (Quantity Level Limit)
- Gefitinib Tablet 250 mg (Prior Authorization, Quantity Level Limit)
- Haegarda Injection 2000 unit (Prior Authorization)
- Haegarda Injection 3000 unit (Prior Authorization)
- Liqrev (Prior Authorization, Quantity Level Limit)
- Phenylephrine-Mineral Oil-Petrolatum Rectal Ointment
- Takhzyro Injection 150 mg / mL (Prior Authorization, Quantity Level Limit)
- Takhzyro Injection 300 / 2 mL (Prior Authorization, Quantity Level Limit)
Removals:
- Proctofoam Aerosol Hydrocortisone 1%
Other Updates:
- Carvedilol Tablet 25 mg (Quantity Level Limit)
- Chloroquine Phosphate Tablet 250 mg (Remove Prior Authorization)
- Chloroquine Phosphate Tablet 500 mg (Remove Prior Authorization)
- Clobetasol Propionate Emollient Base Cream 0.05% (Step Therapy)
- Darunavir Oral Suspension 100 mg / mL (Quantity Level Limit)
- Darunavir Tablet 150 mg (Quantity Level Limit)
- Darunavir Tablet 75 mg (Quantity Level Limit)
- Efavirenz Capsule 200 mg (Quantity Level Limit)
- Efavirenz Capsule 50 mg (Quantity Level Limit)
- Ella Tablet 30 mg (Quantity Level Limit)
- Glipizide-Metformin Hydrochloride Tablet 2.5-500 mg (Quantity Level Limit)
- Hydroxychloroquine Sulfate Tablet 200 mg (Remove Prior Authorization)
- Isentress Tablet 400 mg (Base Equivalent) (Quantity Level Limit)
- Ketoconazole Tablet 200 mg (Quantity Level Limit)
- Lopinavir-Ritonavir Solution 400-100 mg / 5 mL (80-20 mg /mL) (Quantity Level Limit)
- Matulane Capsule 50 mg (Add Prior Authorization)
- Mavyret Tablet 100-40 mg (Quantity Level Limit)
- Metronidazole Gel 1% (Step Therapy)
- Nifedipine Tablet Extended Release 24-hour Osmotic Release 60 mg (Quantity Level Limit)
- Norethindrone Acetate-Ethinyl Estradiol Tablet 0.5 mg-2.5 mcg (Quantity Level Limit)
- Norethindrone Tablet 0.35 mg (Quantity Level Limit)
- Prezcobix Tablet 800-150 (Quantity Level Limit)
- Promacta Pack 25 mg (Remove Prior Authorization)
- Promacta Powder 12.5 mg (Remove Prior Authorization)
- Sofosbuvir-Velpatasvir Tablet 400-100 mg (Quantity Level Limit)
- Sprycel Tablet 20 mg (Quantity Level Limit)
- Stavudine Capsule 15 mg (Quantity Level Limit)
- Stavudine Capsule 20 mg (Quantity Level Limit)
- Tivicay 10 mg (Base Equivalent) (Quantity Level Limit)
- Tobramycin Nebulizer Solution 300 mg / 5 mL (Quantity Level Limit)
- Tretinoin Capsule 10 mg (Add Prior Authorization)
October 2023
Additions:
- Austedo Extended Release Tablet Titration Kit (Prior Authorization, Quantity Level Limit)
Removals:
- None
Other Updates:
- None
September 2023
Additions:
- None
Removals:
- None
Other Updates:
- None
August 2023
Additions:
- *Pediatric Multiple Vitamin With Minerals Chewable Tablet**
- Albuterol Sulfate Solution Nebulizer 0.5% (5 mg /mL)
- Ascorbic Acid Chewable Tablet 250 mg
- Ascorbic Acid Chewable Tablet 500 mg
- Ascorbic Acid Tablet 1000 mg
- Ascorbic Acid Tablet 250 mg
- Ascorbic Acid Tablet 500 mg
- Austedo Tablet Extended Release 24hr 12 mg (Prior Authorization, Quantity Level Limit)
- Austedo Tablet Extended Release 24hr 24 mg (Prior Authorization, Quantity Level Limit)
- Austedo Tablet Extended Release 24hr 6 mg (Prior Authorization, Quantity Level Limit)
- Biktarvy Tablet 30-120-15 mg (Diagnosis Required, Quantity Level Limit)
- Cholecalciferol Capsule 1.25 mg (50000 Unit)
- Cholecalciferol Chewable Tablet 10 mcg (400 Unit)
- Cholecalciferol Oral Liquid 10 mcg/ mL (400 Unit/ mL)
- Evotaz Tablet 300-150 mg (Base Equivalent) (Diagnosis Required, Quantity Level Limit)
- Fluocinolone Acetonide Oil 0.01% (Body Oil) (Quantity Level Limit)
- Kalydeco Granules 13.4 mg (Prior Authorization)
- Levonorgestrol-Ethinyl Estradiol Tablet 0.15-0.03 mg (84) & Ethinyl Estradiol Tablet 0.01 mg (7)
- Mekinist Solution 0.05 mg/ mL (Prior Authorization)
- Melatonin Tablet 1 mg
- Melatonin Tablet 3 mg
- Melatonin Tablet 5 mg
- Mineral Oil
- Nebivolol Hydrochloride Tablet 10 mg (Base Equivalent) (Quantity Level Limit)
- Nebivolol Hydrochloride Tablet 2.5 mg (Base Equivalent) (Quantity Level Limit)
- Nebivolol Hydrochloride Tablet 20 mg (Base Equivalent) (Quantity Level Limit)
- Nebivolol Hydrochloride Tablet 5 mg (Base Equivalent) (Quantity Level Limit)
- Niacin Tablet Extended Release 500 mg
- Oxymetazoline Hydrochloride Nasal Solution 0.05%
- Pediatric Multiple Vitamins With Iron Chewable Tablet 18 mg
- Tafinlar Tablet 10 mg (Prior Authorization)
- Tranexamic Acid Tablet 650 mg (Quantity Level Limit)
- Trikafta Pak 59.5 mg (Prior Authorization)
- Trikafta Pak 75 mg (Prior Authorization)
- Tybost Tablet 150 mg (Diagnosis Required, Quantity Level Limit)
Removals:
- *Alcohol Sheets***
- *B-Complex With Minerals Liquid**
- *Blood Glucose Calibration - Liquid - Low***
- *Blood Glucose Calibration - Liquid - Normal***
- *Blood Glucose Monitoring Miscellaneous.***
- *Cream Base**
- *Dermatological Products Miscellaneous - Cream**
- *Dermatological Products Miscellaneous - Lotion**
- *Non Gelatin Capsules (Empty)**
- *Prenatal Without A Vitamin With Ferrous Fumarate -Folic Acid Tablet Chewable 40-1 mg***
- *Prenatal Without Vitamin A With Ferrous Fumarate -Ferrous Polysaccharide-Folic Acid Capsule 85-1 mg***
- *Prenatal-Ferrous Bisglycinate-Iron Protein Succinylate-Folic Acid-Calcium Tablet & Omega 3 Capsule 200 Pk**
- *Respiratory Therapy Supplies - Devices**
- *Spacer/Aerosol-Holding Chamber Supplies - Masks***
- *Specialty Vitamin Product Tablet**
- *Sunscreen Lotion**
- Benazepril & Hydrochlorothiazide Tablet 10-12.5 mg
- Benazepril & Hydrochlorothiazide Tablet 20-12.5 mg
- Benazepril & Hydrochlorothiazide Tablet 20-25 mg
- Benazepril & Hydrochlorothiazide Tablet 5-6.25 mg
- Caffeine Powder
- Ciprofloxacin Hydrochloride Tablet 100 mg
- Cortisone Acetate Tablet 25 mg
- Fluocinonide Ointment 0.05%
- Fosinopril Sodium & Hydrochlorothiazide Tablet 10-12.5 mg
- Fosinopril Sodium & Hydrochlorothiazide Tablet 20-12.5 mg
- Glucose Oral Liquid 15 GM/ 59 mL
- Guaifenesin Syrup 100 mg/ 5 mL
- Hydrocortisone Micronized Powder
- Hydrocortisone Powder
- Hydroxyprogesterone Caproate (Bulk) Powder
- Irbesartan Tablet 150 mg
- Irbesartan Tablet 300 mg
- Irbesartan Tablet 75 mg
- Ketoprofen Capsule 50 mg
- Lactobacillus Acidophilus Powder
- Leucovorin Calcium Powder
- Methadone Hydrochloride Tablet For Oral Suspension 40 mg
- Methsuximide Capsule 300 mg
- Pyrimethamine (Bulk) Powder
- Rimantadine Hydrochloride Tablet 100 mg
- Syringe/Needle (Disposable) 1 mL 30 X 1/2"
- Telmisartan Tablet 20 mg
- Telmisartan Tablet 40 mg
- Telmisartan Tablet 80 mg
- Tolnaftate Aerosol Powder 1%
Other Updates:
- Bisoprolol Fumarate Tablet 10 mg (Quantity Level Limit)
- Desmopressin Acetate Nasal Spray Solution 0.01% (Quantity Level Limit)
- Hydrocortisone Acetate Cream 1% (Quantity Level Limit)
- Lisinopril & Hydrochlorothiazide Tablet 20-12.5 mg (Quantity Level Limit)
- Methadone Hydrochloride Concentration 10 mg/ mL (Quantity Level Limit)
- Methadone Hydrochloride Solution 10 mg/ 5 mL (Quantity Level Limit)
- Methadone Hydrochloride Solution 5 mg/ 5 mL (Quantity Level Limit)
- Methadone Hydrochloride Tablet 10 mg (Quantity Level Limit)
- Methadone Hydrochloride Tablet 5 mg (Quantity Level Limit)
- Oseltamivir Phosphate Capsule 30 mg (Quantity Level Limit)
- Praziquantel Tablet 600 mg (Remove Prior Authorization)
- Propranolol Hydrochloride Capsule Extended Release 24 hour 120 mg (Quantity Level Limit)
- Propranolol Hydrochloride Capsule Extended Release 24 hour 160 mg (Quantity Level Limit)
- Rosuvastatin Calcium Tablet 10 mg (Remove Step Therapy)
- Rosuvastatin Calcium Tablet 20 mg (Remove Step Therapy)
- Rosuvastatin Calcium Tablet 40 mg (Remove Step Therapy)
- Rosuvastatin Calcium Tablet 5 mg (Remove Step Therapy)
- Sildenafil Citrate Tablet 20 mg (Quantity Level Limit)
July 2023
Additions:
- None
Removals:
- None
Other Updates:
- None
June 2023
Additions:
- Gilenya Capsule 0.25 mg (Prior Authorization, Quantity Level Limit)
Removals:
- None
Other Updates:
- None
May 2023
Additions:
- Amjevita Auto-Injector 40 mg / 0.8 mL (Add Prior Authorization)
- Breztri Inhalation Aerosol 160-9-4.8 mcg / Actuation (Step Therapy, Quantity Level Limit)
- Emgality Auto-Injector 120 mg / mL (Step Therapy, Quantity Level Limit)
- Emgality Prefilled Syringe 120 mg / mL (Step Therapy, Quantity Level Limit)
- Fexofenadine Hydrochloride Suspension 30 mg / mL (Quantity Level Limit)
- Fluticasone-Salmeterol Inhalation Powder 250-50 mcg / Actuation (Quantity Level Limit)
- Fluticasone-Salmeterol Inhalation Powder 500-50 mcg / Actuation (Quantity Level Limit)
- Salicylic Acid Liquid 17%
- Trikafta Tablets (Add Prior Authorization)
- Urea Cream 20%
Removals:
- *Pediatric Multiple Vitamins With Iron Chewable Tablet**
- *Pediatric Multiple Vitamins With Iron Drops 10 mg / mL**
- *Prenatal Without A With Iron Fumarate-Iron Polysaccharide-Folic Acid Capsule 20-20-1.25 mg**
- Calcium Carbonate Powder
- Capsaicin Cream 0.1%
- Carboxymethylcellulose-Glycerin Ophthalmic Solution 0.5-0.9%
- Chlorhexidine Gluconate Solution 20%
- Cholecalciferol Capsule 400 Unit
- Cholecalciferol Chewable Wafer 50000 Unit
- Creon Capsule
- Elmiron Capsules
- Ergocalciferol Tablet 400 Unit
- Fluocinolone Acetonide Cream 0.01%
- Fluocinonide Emulsified Base Cream 0.05%
- Gentamicin Sulfate Powder
- Heparin Sodium Injection 20,000 Units / mL
- Heparin Sodium Injection 5,000 Units / 0.5 mL
- Lidocaine Hydrochloride Solution 4%
- Mexiletine Hydrochloride Capsule 150 mg
- Mexiletine Hydrochloride Capsule 200 mg
- Mexiletine Hydrochloride Capsule 250 mg
- Niacin Tablet 250 mg
- Niacin Tablet 50 mg
- Prenatal With Ferrous Fumarate-Folic Acid Tablet 28-0.8 mg & Docosahexaenoic Acid Capsule 200 mg Pack
- Quinidine Sulfate Tablets 200 mg
- Quinidine Sulfate Tablets 300 mg
- Salicylic Acid Cream 6%
- Sodium Chloride Solution Nebulizer 6%
- Sorbitol Rectal Solution 70%
- Triamcinolone Acetonide Ointment 0.05%
- Vancomycin Hydrochloride For Intravenous Solution 1 gm (Base Equivalent)
- Vancomycin Hydrochloride For Intravenous Solution 5 gm (Base Equivalent)
Other Updates:
- Albendazole Tablet 200 mg (Add Prior Authorization, Remove Step Therapy)
- Albuterol Sulfate Nebulized Solution 0.63 mg/3 mL (Remove Step Therapy, Remove Age Maximum)
- Albuterol Sulfate Nebulized Solution 1.25 mg/3 mL (Remove Step Therapy, Remove Age Maximum)
- Betamethasone Dipropionate Ointment 0.05% (Add Quantity Level Limit)
- Enoxaparin Sodium Injection (Remove Max Days Supply)
- Enoxaparin Sodium Prefilled Syringe (Remove Max Days Supply)
- Fluconazole Tablet 150 mg (Add Quantity Level Limit)
- Fluocinolone Acetonide Cream 0.025% (Add Quantity Level Limit)
- Fluocinolone Acetonide Ointment 0.025% (Add Quantity Level Limit)
- Fluticasone-Salmeterol Inhalation Powder 100-50 mcg / Actuation (Remove Age Limit)
- Lidocaine Hydrochloride Cream 4%
- Lidocaine Ointment 5% (Remove Prior Authorization)
- Ozempic Pen-Injector
- Trulicity Pen-Injector
April 2023
Additions:
- Guaifenesin-Codeine Solution 100-6.33 mg per 5 mL (Quantity Level Limit, Age Minimum)
Removals:
- None
Other Updates:
- Descovy 200 mg/25 mg tablet (Added Prior Authorization)
- Emtricitabine/tenofovir DF 100 mg/150 mg tablet (Added Prior Authorization)
- Emtricitabine/tenofovir DF 133 mg/200 mg tablet (Added Prior Authorization)
- Emtricitabine/tenofovir DF 167 mg/250 mg tablet (Added Prior Authorization)
- Emtricitabine/tenofovir DF 200 mg/300 mg tablet (Added Prior Authorization)
- Freestyle 14 Sensor Libre (Updated Quantity Level Limit)
- Freestyle 14 Sensor Libre 2 (Updated Quantity Level Limit)
- Freestyle 14 Sensor Libre 3 (Updated Quantity Level Limit)
- Isentress 100 mg chewable tablet (Added Prior Authorization)
- Isentress 100 mg packet (Added Prior Authorization)
- Isentress 25 mg chewable tablet (Added Prior Authorization)
- Isentress 400 mg tablet (Added Prior Authorization)
- Isentress HD 600 mg tablet (Added Prior Authorization)
- Lamivudine 10 mg per 10 mL (Added Prior Authorization)
- Lamivudine 150 mg tablet (Added Prior Authorization)
- Lamivudine 300 mg tablet (Added Prior Authorization)
- Lamivudine/zidovudine 150 mg/ 300 mg tablet (Added Prior Authorization)
- Norvir 100 mg packet (Added Prior Authorization)
- Norvir 80 mg per mL (Added Prior Authorization)
- Ritonavir 100 mg tablet (Added Prior Authorization)
- Tivicay 10 mg tablet (Added Prior Authorization)
- Tivicay 25 mg tablet (Added Prior Authorization)
- Tivicay 50 mg tablet (Added Prior Authorization)
- Tivicay PD 5 mg soluble tablet (Added Prior Authorization)
- Zidovudine 50 mg per 5 mL syrup (Added Prior Authorization)
- Zidovudine 100 mg capsule (Added Prior Authorization)
- Zidovudine 300 mg tablet (Added Prior Authorization)
March 2023
Additions:
- Ozempic Injection 2 mg/3 mL (Quantity Level Limit, Step Therapy)
Removals:
- Ciprofloxacin For Oral Suspension 250 mg/5 mL (5%) (5 gm/100 mL)
- Ciprofloxacin For Oral Suspension 500 mg/5 mL (10%) (10 gm/100 mL)
- Fluocinolone Acetonide Powder
- Hydrocortisone Acetate Powder
- Rivaroxaban Tablet 2.5 mg
- Triamcinolone Acetonide Powder
Other Updates:
- None
February 2023
Additions:
- Aluminum Hydroxide-Magnesium Carbonate Chewable Tablet 160-105 mg
- Aluminum Hydroxide-Magnesium Carbonate Suspension 95-358 mg/15mL
- Aspirin-Acetaminophen-Caffeine Tablet 250-250-65 mg
- Budesonide Tablet Extended Release 9 mg
- Calcium Polycarbophil Tablet 625 mg
- Carboxymethylcell-Glycerin-Polysorb 80 Ophthalmic Solution 0.5-1-0.5%
- Carboxymethylcellulose Sodium (Preservative Free) Ophthalmic Gel 1%
- Carboxymethylcellulose Sodium Ophthalmic Gel 1%
- Carboxymethylcellulose-Glycerin (Preservative Free) Ophthalmic Solution 0.5-0.9%
- Carboxymethylcellulose-Glycerin (Preservative Free) Ophthalmic Solution 0.5-1%
- Carboxymethylcellulose-Glycerin Ophthalmic Gel 1-0.9%
- Carboxymethylcellulose-Glycerin Ophthalmic Solution 0.5-0.9%
- Climara Pro Dis Weekly (Quantity Level Limit)
- Cyclosporine (Ophthalmic) Emulsion 0.05% (Prior Authorization Required, Quantity Level Limit)
- Dabigatran Capsule 150 mg (Quantity Level Limit)
- Dabigatran Capsule 75 mg (Quantity Level Limit)
- Dificid Suspension (Prior Authorization Required)
- Dificid Tablet 200 mg (Prior Authorization Required)
- Esomepra Mag Capsule 40 mg Delayed Release (Quantity Level Limit)
- Estradiol Vaginal Cream 0.1 mg/Gm (Quantity Level Limit)
- Ethacrynic Tablet Acid 25 mg
- Extavia Injection 0.3 mg
- Fluocin Acet Oil Ear 0.01% (Quantity Level Limit)
- Gel-One Injection 30 mg/3 mL (Prior Authorization Required)
- Glycerin Suppository 1 Gm
- Glycerin-Hypromellose-Peg 400 Ophthalmic Solution 0.2-0.2-1%
- Hypromellose Ophthalmic Gel 0.3%
- Imbruvica Tablet 140 mg (Prior Authorization Required, Quantity Level Limit)
- Imbruvica Tablet 280 mg (Prior Authorization Required, Quantity Level Limit)
- Imbruvica Tablet 420 mg (Prior Authorization Required, Quantity Level Limit)
- Imbruvica Tablet 560 mg (Prior Authorization Required, Quantity Level Limit)
- Lactobacillus Acidophilus-Pectin Capsule
- Lactobacillus Capsule
- Lactobacillus Tablet
- Lidocaine 5% Rectal Cream (Quantity Level Limit)
- Magnesium Citrate Solution
- Miconazole Nitrate Vaginal Suppository 1200 mg & 2% Cream Kit
- Naphazoline W/ Pheniramine Ophthalmic Solution 0.025-0.3%
- Naphazoline W/ Pheniramine Ophthalmic Solution 0.027-0.315%
- Phenylephrine Hydrochloride Tablet 10 mg
- Phenylephrine W/ Dm-Gg Liquid 10-18-200 mg/15mL (Quantity Level Limit)
- Phenylephrine W/ Dm-Gg Liquid 2.5-5-100 mg/5 mL (Quantity Level Limit)
- Phenylephrine-Brompheniramine-Dm Liquid 2.5-1-5 mg/5 mL (Quantity Level Limit)
- Polyethylene Glycol-Propylene Glycol Ophthalmic Solution 0.4-0.3%
- Pramoxine Aerosol 1% Rectal (Quantity Level Limit)
- Probiotic Product - Capsule
- Pseudoephed-Bromphen-Dm Syrup 30-2-10 mg/5 mL (Quantity Level Limit)
- Pseudoephed-Dexchlorphen-Chlophedianol Liquid 30-1-12.5 mg/5 mL (Quantity Level Limit)
- Pseudoephedrine Hydrochloride Tablet Extended Release 12hr 120 mg
- Psyllium Capsule 0.52 Gm
- Rivastigmine Dis 13.3/24 (Prior Authorization Required)
- Rivastigmine Dis 4.6 mg/24 (Prior Authorization Required)
- Rivastigmine Dis 9.5 mg/24 (Prior Authorization Required)
- Saline Nasal Gel
- Saline Nasal Solution 0.65%
- Saline Nasal Spray 0.65%
- Sod Fluoride Gel 1.1-5%
- Sod Fluoride Paste 1.1%
- Sodium Phosphates – Enema (Quantity Level Limit)
- Tetrahydrozoline Hydrochloride Ophthalmic Solution 0.05%
- Tramadol Hydrochloride Tablet Extended Release 24hr 100 mg (Prior Authorization Required, Quantity Level Limit, Age Minimum)
- Tramadol Hydrochloride Tablet Extended Release 24hr 200 mg (Prior Authorization Required, Quantity Level Limit, Age Minimum)
- Tramadol Hydrochloride Tablet Extended Release 24hr 300 mg (Prior Authorization Required, Quantity Level Limit, Age Minimum)
- Vancomycin Capsule 125 mg (Quantity Level Limit)
- Vancomycin Capsule 250 mg (Quantity Level Limit)
- Xifaxan Tablet 550 mg (Prior Authorization Required)
Removals:
- Alendronate Sol 70/75mL
- Auryxia 210 mg Tablet
- Benzocaine-Docusate Sodium Rectal Enema 20-283 mg
- Betaseron Injection 0.3 mg
- Bisacodyl Enema 10 mg/30 mL
- Brimonidine Tartrate-Timolol Maleate Ophthalmic Solution 0.2-0.5%
- Brinzolamide Ophthalmic Suspension 1%
- Butalbital-Acetaminophen Tablet 50-325 mg
- Butalbital-Acetaminophen-Caff W/ Cod Capsule 50-300-40-30 mg
- Butalbital-Acetaminophen-Caff W/ Cod Capsule 50-325-40-30 mg
- Butalbital-Aspirin-Caff W/ Codeine Capsule 50-325-40-30 mg
- Butalbital-Aspirin-Caffeine Capsule 50-325-40 mg
- Cequa
- Colchicine Capsule 0.6 mg
- Dermazinc Cream
- Desmopressin Spray Ref 0.01%
- Diphenoxylate W/ Atropine Liquid 2.5-0.025 mg/5 mL
- Esbriet 267mg Capsule
- Estring
- Fexofenadine-Pseudoephedrine Tablet Extended Release 24hr 180-240 mg
- Ibrance Tablet 100 mg
- Ibrance Tablet 125 mg
- Ibrance Tablet 75 mg
- Levofloxacin Ophthalmic Solution 0.5%
- Lidocaine Solution 4%
- Magnesium Hydroxide Suspension Concentrate 2400 mg/10 mL
- Naproxen Tablet Enteric Coated 500 mg
- Omnitrope Injection 10/1.5 mL
- Omnitrope Injection 5/1.5 mL
- Oxymorphone Hydrochloride Tablet Extended Release 12hr 10 mg
- Oxymorphone Hydrochloride Tablet Extended Release 12hr 15 mg
- Oxymorphone Hydrochloride Tablet Extended Release 12hr 20 mg
- Oxymorphone Hydrochloride Tablet Extended Release 12hr 30 mg
- Oxymorphone Hydrochloride Tablet Extended Release 12hr 40 mg
- Oxymorphone Hydrochloride Tablet Extended Release 12hr 5 mg
- Oxymorphone Hydrochloride Tablet Extended Release 12hr 7.5 mg
- Pot & Sod Citrates W/ Cit Ac Solution 550-500-334 mg/5 mL
- Sulfacetamide Sodium Ophthalmic Ointment 10%
Other Updates:
- Azelastine Hydrochloride Ophthalmic Solution 0.05% (Remove Step Therapy)
- Bacitracin Ophthalmic Ointment 500 Unit/Gm (Added Quantity Level Limit)
- Bacitracin-Polymyxin B Ophthalmic Ointment (Added Quantity Level Limit)
- Bacitracin-Polymyxin-Neomycin-Hc Ophthalmic Ointment 1% (Added Quantity Level Limit)
- Benzonatate Capsule 100 mg (Added Quantity Level Limit)
- Benzonatate Capsule 200 mg (Added Quantity Level Limit)
- Budesonide Capsule 3 mg Delayed Release (Remove Step Therapy)
- Calcipotriene Cream 0.005% (Remove Prior Authorization)
- Calcipotriene Ointment 0.005% (Remove Prior Authorization)
- Calcipotriene Solution 0.005% (50 mcg/mL) (Remove Prior Authorization)
- Celecoxib Capsule 100 mg (Remove Step Therapy)
- Celecoxib Capsule 200 mg (Remove Step Therapy)
- Celecoxib Capsule 400 mg (Remove Step Therapy)
- Celecoxib Capsule 50 mg (Remove Step Therapy)
- Dorzolamide Hydrochloride-Timolol Maleate Ophthalmic Solution 22.3-6.8 mg/mL (Remove Step Therapy)
- Erythromycin Ophthalmic Ointment 5 mg/Gm (Added Quantity Level Limit)
- Gentamicin Sulfate Ophthalmic Ointment 0.3% (Added Quantity Level Limit)
- Hydroc/Homat Tablet 5-1.5 mg (Added Quantity Level Limit)
- Hydrocod/Hom Syrup 5-1.5/5 (Added Quantity Level Limit)
- Levonorgestr Tablet 1.5 mg (Quantity Level Limit)
- Tolterodine Tartrate Capsule Extended Release 24hr 2 mg (Remove Step Therapy)
- Tolterodine Tartrate Capsule Extended Release 24hr 4 mg (Remove Step Therapy)
- Tolterodine Tartrate Tablet 1 mg (Remove Step Therapy)
- Tolterodine Tartrate Tablet 2 mg (Remove Step Therapy)
- Trospium Chloride Tablet 20 mg (Remove Step Therapy)
January 2023
Additions:
- Raltegravir Potassium Packet For Susp 100 Mg (Base Equiv) (Quantity Level Limit)
Removals:
- All Non OneTouch Delica and Delica Plus Lancets and Devices
Other Updates:
- Dolutegravir Sodium Tab 10 Mg (Base Equiv) (Remove Prior Authorization)
- Dolutegravir Sodium Tab 25 Mg (Base Equiv) (Remove Prior Authorization)
- Dolutegravir Sodium Tab 50 Mg (Base Equiv) (Remove Prior Authorization)
- Dolutegravir Sodium Tab For Oral Susp 5 Mg (Base Equiv) (Remove Prior Authorization)
- Emtricitabine-Tenofovir Alafenamide Fumarate Tab 120-15 Mg (Remove Prior Authorization)
- Emtricitabine-Tenofovir Alafenamide Fumarate Tab 200-25 Mg (Remove Prior Authorization)
- Emtricitabine-Tenofovir Disoproxil Fumarate Tab 100-150 Mg (Remove Prior Authorization)
- Emtricitabine-Tenofovir Disoproxil Fumarate Tab 133-200 Mg (Remove Prior Authorization)
- Emtricitabine-Tenofovir Disoproxil Fumarate Tab 167-250 Mg (Remove Prior Authorization)
- Emtricitabine-Tenofovir Disoproxil Fumarate Tab 200-300 Mg (Remove Prior Authorization)
- Fluticasone Propionate Nasal Susp 50 Mcg/Act (Remove Step Therapy)
- Histex Pd Dro 0.938mg
- Lamivudine Oral Soln 10 Mg/Ml (Remove Prior Authorization)
- Lamivudine Tab 150 Mg (Remove Prior Authorization)
- Lamivudine Tab 300 Mg (Remove Prior Authorization)
- Lamivudine-Zidovudine Tab 150-300 Mg (Remove Prior Authorization)
- Raltegravir Potassium Chew Tab 100 Mg (Base Equiv) (Remove Prior Authorization)
- Raltegravir Potassium Chew Tab 25 Mg (Base Equiv) (Remove Prior Authorization)
- Raltegravir Potassium Tab 400 Mg (Base Equiv) (Remove Prior Authorization)
- Raltegravir Potassium Tab 600 Mg (Base Equiv) (Remove Prior Authorization)
- Ritonavir Oral Soln 80 Mg/Ml (Remove Prior Authorization)
- Ritonavir Powder Packet 100 Mg (Remove Prior Authorization)
- Ritonavir Tab 100 Mg (Remove Prior Authorization)
- Zidovudine Cap 100 Mg (Remove Prior Authorization)
- Zidovudine Syrup 10 Mg/Ml (Remove Prior Authorization)
- Zidovudine Tab 300 Mg (Remove 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 Pumpinhibitors (quantitylevel 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.