Farmacia

PLEASE NOTE: Effective September 1, 2022, Aetna Better Health of Pennsylvania MEDICAID, no longer serves MEDICAID therefore, is no longer reviewing new prior authorizations for your patient.

Providers can verify patient’s eligibility by using The PROMISeTM Eligibility Verification System (EVS) http://promise.dpw.state.pa.us/

Our Aetna Better Health KIDS (CHIP) plan will continue as usual in our 41-county coverage area. Please reference appropriate links below

Formulary/Preferred Drug Lists

 

Medicaid Member Preferred Drug List

For Medicaid members, the list of covered drugs is the Statewide Preferred Drug List (PDL) from the Pennsylvania Department of Human Services (DHS). 

Aetna Better Health of Pennsylvania also covers drugs and products that are not on the DHS Preferred Drug List.  This list is called the supplemental formulary.  You also have the ability to search the supplemental formulary by using the supplemental formulary search tool.

Please review the PDL, Quantity Level Limits document, and/or supplemental formulary for restrictions or recommendations regarding prescription drugs before prescribing a medication to an Aetna Better Health of Pennsylvania member.

Prescriptions must be filled at an Aetna Better Health network pharmacy, and other plan rules must be followed.

To initiate an electronic prior authorization (ePA), please click here.

For information on key pharmacy benefits we offer to our Medicaid members, click here. Select the Pharmacy drop down and select the Pharmacy Benefit Flyer (MA). You will find a pharmacy brochure specific to our Medicaid pharmacy benefits that you can review with patients when in your office.

Aetna Better Health Kids Preferred Drug List

The Formulary is a list of drugs chosen by Aetna Better Health and a team of doctors and pharmacists that are generally covered under the plan as long as they are medically necessary. Prescriptions must be filled at an Aetna Better Health network pharmacy, and other plan rules must be followed. View our latest formulary drug list.

You now have the ability to search for drugs using our new  Formulary Search Tool. Searches can be performed by drug name or by drug class. The tool will provide formulary status, generic alternatives and if there are any clinical edits (Prior Authorization, Quantity Limits, Age Limits etc).

Please review the Formulary for any restrictions or recommendations regarding prescription drugs before prescribing a medication to an Aetna Better Health patient.  To initiate an electronic prior authorization (ePA), please click here.

For information on key pharmacy benefits we offer to our CHIP members, click here. Select the Pharmacy drop down and select the Pharmacy Benefit Flyer (CHIP). You will find a pharmacy brochure specific to our CHIP pharmacy benefits that you can review with patients when in your office.

Visit Pharmacy Provider Search to view all the Aetna Better Health pharmacy providers.

 

Check back frequently as the formulary, prior authorization guidelines, and prior authorization forms are updated regularly.

You can view a list of recent formulary updates below.

Careful handling and quick delivery for specialty drugs

Our preferred Specialty Pharmacy providers are Accuserv Pharmacy, Caremark Specialty Pharmacy, Einstein at Center One Pharmacy, Elwyn Specialty Care, Giant Eagle Pharmacy, Pharmblue LLC and Senderra Rx Pharmacy.

These pharmacies fill prescriptions for Specialty Drugs .* These types of drugs may be injected, infused or taken by mouth. Usually, you can't get these drugs at a local retail pharmacy. They often need special storage and handling. And they need to be delivered quickly.

Our preferred Specialty Pharmacies provide many helpful services, including:

  • Free, secure delivery (usually within 48 hours of confirming your order)
  • Envío a su domicilio, al consultorio del médico o a cualquier otro lugar que elija.
  • Package tracking for prompt delivery
  • Capacitación para que pueda inyectarse el medicamento.
  • Free injection supplies, such as needles, syringes, alcohol swabs, adhesive bandages and containers for needle waste

Cómo comenzar

We have several ways for you to fill a prescription through one of our preferred Specialty Pharmacies.

Existing prescriptions: To transfer an existing prescription, call one of our Preferred Specialty pharmacies.

New prescriptions: For a new prescription, your doctor can:

  • Send a prescription electronically.
  • Fax your prescription
  • Call one of preferred specialty pharmacies
  • You or the doctor can mail the prescription order.

After the pharmacy receives your prescription, your first order should ship within 48 hours. It may take longer if they need to contact your doctor about the prescription. 

Accuserv Pharmacy

Banks Apothecary

Caremark Specialty Pharmacy

Einstein at Center One Pharmacy

Elwyn Specialty Care

Giant Eagle Pharmacy

Pharmblue LLC

  • You or your doctor can visit the web site for an enrollment form: https://www.pharmblue.com
  • Phone: 855-779-4720
  • Fax: 844-818-7550

Senderra Rx Pharmacy

A personal care plan and ongoing support

Each of our preferred Specialty Pharmacies has a team of experienced nurses and pharmacists to help you understand how to use your medicine. They can answer your questions and help you cope with your condition throughout your therapy.

You can talk to them 24 hours a day, 7 days a week.

Get extra support for your complex medical condition

Skilled nurses and pharmacists offer extra support to patients with complex medical conditions, such as the any of the following:

  • Anemia
  • Asma
  • Cáncer
  • Chronic renal failure
  • Crohn's disease
  • Gaucher disease
  • Growth hormone deficiency
  • Hematologic conditions
  • Hemofilia
  • Hepatitis
  • HIV/AIDS
  • Immune system disorders
  • Esclerosis múltiple
  • Neurologic conditions
  • Osteoarthritis
  • Psoriasis
  • Pulmonary diseases
  • Respiratory syncytial virus (RSV)
  • Artritis reumatoide
  • Transplant

Joining our preferred Specialty Pharmacy network

Are you a pharmacy interested in joining our preferred specialty pharmacy network? You can get the application process started by sending an email to Specialtypharmacyapplications@cvscaremark.com. Thank you for your interest in supporting our commitment to high-quality care.

Updates are made regularly to the Statewide Preferred Drug List.

 

 

2023 de enero

No hay actualizaciones

 

Diciembre de 2022

Sin actualizaciones

 

Noviembre de 2022

Sin actualizaciones

 

2022.º de octubre

Sin actualizaciones

 

Septiembre de 2022

Sin actualizaciones

 

Agosto de 2022

Sin actualizaciones

 

Julio de 2022

Sin actualizaciones

 

Junio de 2022

Sin actualizaciones

 

Mayo de 2022

Incorporaciones:

  • Sodium Chloride Tab 1gm

 

Abril de 2022

Sin actualizaciones

 

Marzo de 2022

Sin actualizaciones

 

February 2022

Incorporaciones:

  • Kit de receptor móvil Dexcom G5 (se requiere autorización previa, límite de cantidad)
  • Kit de transmisor móvil Dexcom G5 (se requiere autorización previa, límite de cantidad)
  • Kit de sensores Dexcom G5 Mobile/G4 Platinum (se requiere autorización previa, límite de cantidad)
  • Receptor Dexcom G6 (se requiere autorización previa, límite de cantidad)
  • Sensor Dexcom G6 (se requiere autorización previa, límite de cantidad)
  • Transmisor Dexcom G6 (se requiere autorización previa, límite de cantidad)
  • Dispositivo de lectura Freestyle Libre 14 días (se requiere autorización previa, límite de cantidad)
  • Freestyle Libre 14 Day Sensor (se requiere autorización previa, límite de cantidad)
  • Dispositivo de lectura Freestyle Libre 2 (se requiere autorización previa, límite de cantidad)
  • Sensor Freestyle Libre 2 (se requiere autorización previa, límite de cantidad)
  • Dispositivo de lectura Freestyle Libre (se requiere autorización previa, límite de cantidad)

Información eliminada:

  • Ninguno

Otras actualizaciones

  • Diphenhydramine Hcl Liquid 12.5mg/5ml (Added Quantity Level Limit)

 

January 2022

Sin actualizaciones

 

December 2021

Sin actualizaciones

 

November 2021

Sin actualizaciones

 

Octubre de 2021

Información eliminada:

  • Dermacinrx Ventrixyl Fe Caplet
  • Santyl Ointment 250Unit/GM

 

September 2021

Sin actualizaciones

 

Agosto de 2021

Sin actualizaciones

 

Julio de 2021

Sin actualizaciones

 

June 2021

Sin actualizaciones

 

May 2021

Sin actualizaciones

 

Abril de 2021

Sin actualizaciones

 

Marzo de 2021

Sin actualizaciones

 

 

 

2023 de febrero

Incorporaciones:

  • Atomoxetine Capsule 100 mg (Quantity Level Limit, Age Minimum)
  • Atomoxetine Capsule 10 mg (Quantity Level Limit, Age Minimum)
  • Atomoxetine Capsule 18 mg (Quantity Level Limit, Age Minimum)
  • Atomoxetine Capsule 25 mg (Quantity Level Limit, Age Minimum)
  • Atomoxetine Capsule 40 mg (Quantity Level Limit, Age Minimum)
  • Atomoxetine Capsule 60 mg (Quantity Level Limit, Age Minimum)
  • Atomoxetine Capsule 80 mg (Quantity Level Limit, Age Minimum)
  • Budesonide Tablet Extended Release 9 mg
  • Buspirona Comprimido 30 mg (Cantidad Límite, Edad Mínima)
  • Calcium Polycarbophil Tablet 625 mg
  • Solución oftálmica de carboximetilcela-glicerina-polisorb 80 0,5-1-0,5%.
  • Carboxymethylcellulose-Glycerin (Preservative Free) Ophthalmic Solution 0.5-0.9%
  • Carboxymethylcellulose-Glycerin (Preservative Free) Ophthalmic Solution 0.5-1%
  • Gel oftálmico de carboximetilcelulosa-glicerina 1-0,9
  • Carboxymethylcellulose-Glycerin Ophthalmic Solution 0.5-0.9%
  • 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)
  • Desvenlaf(P) Tablet 100 mg Extended Release (Quantity Level Limit)
  • Desvenlaf(P) Tablet 25 mg Extended Release (Quantity Level Limit)
  • Desvenlaf(P) Tablet 50 mg Extended Release (Quantity Level Limit)
  • Dificid Sus (Prior Authorization Required)
  • Dificid Comprimido 200 mg (requiere autorización previa)
  • Esomepra Mag Capsule 40 mg Delayed Release (Quantity Level Limit)
  • Estradiol Crema Vaginal 0,1 mg/GM (Cantidad Límite)
  • Ethacrynic Ácido Comprimido 25 mg
  • Fexofenadine Hydrochloride Tablet 180 mg (Quantity Level Limit)
  • Fexofenadine Hydrochloride Tablet 60 mg (Quantity Level Limit)
  • Fluocin Acet Oil Ear 0,01% (Cantidad Límite)
  • Gel de glucosa al 40%
  • Gel de glucosa 77,4
  • Glycerin Suppository 1 GM
  • Glicerina-Hipromelosa-Peg 400 Solución oftálmica 0,2-0,2-1%.
  • Hipromelosa Gel Oftálmico 0,3%
  • Imbruvica Tablet 140 mg (Prior Authorization Required, Quantity Level Limit)
  • Imbruvica Tablet 280 mg (Prior Authorization Required, Quantity Level Limit)
  • Invega Hafye Injection 1092 mg (Prior Authorization Required, Quantity Level Limit)
  • Invega Hafye Injection 1560 mg (Prior Authorization Required, Quantity Level Limit)
  • Cápsula de Lactobacillus Acidophilus-Pectina
  • Cápsula de Lactobacillus
  • Lactobacillus Comprimidos
  • Levonorgestrel-Ethinyl Estradiol (91-Day) Tablet 0.01/0.15/0.03mg
  • Lidocaína 5% Crema Rectal (Cantidad Límite)
  • Solución de citrato de magnesio
  • 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%
  • Norethin Acet & Estrad-Fe 24 Tablet 1/0.02 mg (Quantity Level Limit)
  • Phenylephrine Hydrochloride Tablet 10 mg
  • Phenylephrine W/ Dm-Gg Liquid 10-18-200 mg/15 mL (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)
  • Producto probiótico - Cápsula
  • Pseudoephed-Bromphen-Dm Syrup 30-2-10 mg/5 mL (Quantity Level Limit)
  • Pseudoefed-Dexclorfeno-Clofedianol Líquido 30-1-12,5 mg/5mL (Cantidad Límite)
  • Pseudoephedrine Hydrochloride Tablet Extended Release 12hr 120 mg
  • Quetiapine Tablet 150 mg Extended Release (Quantity Level Limit, Age Minimum)
  • Quetiapine Tablet 200 mg Extended Release (Quantity Level Limit, Age Minimum)
  • Quetiapine Tablet 300 mg Extended Release (Quantity Level Limit, Age Minimum)
  • Quetiapine Tablet 400 mg Extended Release (Quantity Level Limit, Age Minimum)
  • Quetiapine Tablet 50 mg Extended Release (Quantity Level Limit, Age Minimum)
  • 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)
  • Gel nasal salino
  • Solución salina nasal 0,65
  • Solución oftálmica de clorhidrato de tetrahidrozolina al 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)
  • Vancomicina Cápsula 125 mg (Cantidad Límite)
  • Vancomicina Cápsula 250 mg (Cantidad Límite)
  • Xifaxan Comprimido 550 mg (requiere autorización previa)

Información eliminada:

  • Alendronate Solution 70/75 mL
  • Auryxia 210 mg Comprimido
  • Benzocaine-Docusate Sodium Rectal Enema 20-283 mg
  • Bisacodyl Enema 10 mg/30mL
  • Tartrato de Brimonidina-Maleato de Timolol Solución Oftálmica 0,2-0,5%.
  • Brinzolamida en suspensión oftálmica 1%.
  • Butalbital-Acetaminophen Tablet 50-325 mg
  • Butalbital-Acetaminofeno-Caff con Bacalao Cápsula 50-300-40-30 mg
  • Butalbital-Acetaminofeno-Caff con Bacalao Cápsula 50-325-40-30 mg
  • Butalbital-Aspirina-Caff Con Codeína Cápsula 50-325-40-30 mg
  • Butalbital-Aspirina-Cafeína Cápsula 50-325-40 mg
  • Celontin Cápsula 300 mg
  • Cequa
  • Coal Tar Shampoo 1%
  • Coal Tar Shampoo 10%
  • Colchicina Cápsula 0,6 mg
  • Dermatological Products Misc - Cream
  • Dermatological Products Misc - Lotion
  • Dermazinc Cream
  • Desmopresina Spray Ref 0.01%
  • Diltiazem Extended Release Capsule 120 mg/12
  • Difenoxilato c/ Atropina Líquido 2,5-0,025 mg/5mL
  • Duloxetina cápsula 40 mg de liberación retardada
  • Esbriet 267 mg Cápsula
  • Estring
  • Ibrance Comprimido 100 mg
  • Ibrance Comprimido 125 mg
  • Ibrance Comprimido 75 mg
  • Leukine Injection 250 mcg
  • Levofloxacino solución oftálmica 0,5%.
  • Lidocaine, solución, 4 %
  • Magnesium Hydroxide Suspension Concentrate 2400 mg/10 mL
  • Methylphenid Capsule 20 mg Long Acting
  • Methylphenid Capsule 30 mg Long Acting
  • Methylphenid Capsule 40 mg Long Acting
  • Methylphenid Capsule 60 mg Long Acting
  • Naproxen Tablet Enteric Coated 500 mg
  • Neomycin-Bacitracin-Polymyxin W/ Lidocaine Ointment 4%
  • Orencia Iv Injection 250 mg
  • 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 Citratos con solución Cit Ac 550-500-334 mg/5mL
  • Remicade Injection 100 mg
  • Sulfacetamida sódica pomada oftálmica 10%.

Otras actualizaciones

  • Azelastine Hydrochloride Ophthalmic Solution 0.05% (Remove Step Therapy)
  • Bacitracin Ophthalmic Ointment 500 Unit/GM (Quantity Level Limit)
  • Bacitracin-Polymyxin B Ophthalmic Ointment (Quantity Level Limit)
  • Bacitracin-Polymyxin-Neomycin-Hc Ophthalmic Ointment 1% (Quantity Level Limit)
  • Benzonatato Cápsula 100 mg
  • Benzonatato Cápsula 200 mg
  • Budesonide Capsule 3mg Delayed Release (Remove Step Therapy)
  • Calcipotriene Cream 0.005% (Added Prior Authorization)
  • Calcipotriene Ointment 0.005% (Added Prior Authorization)
  • Calcipotriene Solution 0.005% (50 Mcg/mL) (Added Prior Authorization)
  • Gel oftálmico de carboximetilcelulosa sódica 1%.
  • Celecoxib Capsule 50 Mg (Remove Step Therapy)
  • Celecoxib Capsule 100 Mg (Remove Step Therapy)
  • Celecoxib Capsule 200 Mg (Remove Step Therapy)
  • Celecoxib Capsule 400 Mg (Remove Step Therapy)
  • Divalproex Tablet 250mg Extended Release (Remove Prior Authorization)
  • Divalproex Tablet 500mg Extended Release (Remove Prior Authorization)
  • Dorzolamide Hydrochloride-Timolol Maleate Ophthalmic Solution 22.3-6.8 Mg/mL (Remove Step Therapy)
  • Duloxetine Capsule 20 mg Delayed Release (Cantidad Límite)
  • Erythromycin Ophthalmic Ointment 5 mg/GM (Quantity Level Limit)
  • Fentanyl Ot Lozenge 1200mcg (Added Prior Authorization)
  • Fentanyl Ot Lozenge 1600mcg (Added Prior Authorization)
  • Fentanyl Ot Lozenge 200mcg (Added Prior Authorization)
  • Fentanyl Ot Lozenge 400mcg (Added Prior Authorization)
  • Fentanyl Ot Lozenge 600mcg (Added Prior Authorization)
  • Fentanyl Ot Lozenge 800mcg (Added Prior Authorization)
  • Gentamicin Sulfate Ophthalmic Ointment 0.3% (Quantity Level Limit)
  • Levonorgestr Tablet 1.5 mg (Quantity Level Limit)
  • Tolterodine Tartrate Capsule Extended Release 24hr 2 Mg (Remove Step Therapy and Prior Authorization)
  • Tolterodine Tartrate Capsule Extended Release 24hr 4 Mg (Remove Step Therapy and Prior Authorization)
  • Tolterodine Tartrate Tablet 1 Mg (Remove Step Therapy)
  • Tolterodine Tartrate Tablet 2 Mg (Remove Step Therapy)
  • Trospium Chloride Tablet 20 Mg (Remove Step Therapy)

 

 

2023 de enero

Incorporaciones:

  • Ninguno

Información eliminada:

  • Todas las lancetas y dispositivos no OneTouch Delica y Delica Plus

Otras actualizaciones

  • Ninguno

 

 

Diciembre de 2022

Incorporaciones:

  • Benzoyl Peroxide, gel, 2.5 %

Información eliminada:

  • Iodoquinol-Hc Cream 1-1%

Otras actualizaciones

  • Fingolimod Hydrochloride Capsule 0.5 Mg (Base Equiv)
  • Histex Pd Dro 0.938mg
  • Isotretinoin Capsule 10 Mg
  • Isotretinoin Capsule 20 Mg
  • Isotretinoin Capsule 30 Mg
  • Isotretinoin Capsule 40 Mg

 

 

Noviembre de 2022

Incorporaciones:

  • Actimmune Injection 2mu/0.5 (Prior Authorization Required)
  • Cromolyn Sodium Nasal Aerosol Solution 5.2 Mg/Act (4%) (Added Quantity Level Limit)
  • Dextromethorphan Polistirex Extended Release Suspension 30 Mg/5mL (Added Quantity Level Limit)
  • Dextromethorphan-Phenylephrine-Apap Capsule 10-5-325 Mg (Added Quantity Level Limit)
  • Dimenhydrinate Tablet 50 Mg (Added Quantity Level Limit)
  • Fexofenadine-Pseudoephedrine Tablet Extended Release 12hr 60-120 Mg (Added Quantity Level Limit)
  • Guaifenesin Tablet 200 Mg
  • Guaifenesin Tablet 400 Mg
  • Guaifenesin Tablet Extended Release 12hr 1200 Mg
  • Icosapent Capsule 0.5gm (Prior Authorization Required, Quantity Level Limit)
  • Imbruvica Sus 70mg/ML (Prior Authorization Required, Quantity Level Limit)
  • Intron A Injection 10mu (Prior Authorization Required)
  • Intron A Injection 18mu (Prior Authorization Required)
  • Intron A Injection 50mu (Prior Authorization Required)
  • Aceite mineral pesado
  • Aceite mineral ligero
  • Omeprazole Capsule Delayed Release 10 Mg (Added Quantity Level Limit)
  • Orkambi Gra, 75-94 mg (se requiere autorización previa)
  • Polyethylene Glycol-Propylene Glycol Pf Op Solution 0.4-0.3%
  • Polyvinyl Alcohol-Povidone Ophthalmic Solution 5-6 Mg/ML (0.5-0.6%)
  • Pseudoephedrine Hydrochloride Tablet 30 Mg
  • Pseudoephedrine-Guaifenesin Tablet Extended Release 12hr 60-600 Mg
  • Refresh Ophthalmic Drops
  • Sodium Chloride Hypertonic Ophthalmic Ointment 5%
  • Gel de fluoruro de sodio 1,1% (0,5% F)
  • White Petrolatum-Mineral Oil Ophthalmic Ointment

 

Información eliminada:

  • Butalbital-Acetaminophen-Caffeine Capsule 50-300-40 Mg
  • Butalbital-Acetaminophen-Caffeine Capsule 50-325-40 Mg
  • Calcium Carbonate (Antacid) Chewable Tablet 420 Mg
  • Dexamethasone Sod Phosphate Preservative Free Injection 10 Mg/ML
  • Dextromethorphan Hbr Syrup 10mg/5mL
  • Divalproex Sodium Capsule Delayed Release Sprinkle 125 Mg
  • Docusate Sodium Capsule 50 Mg
  • Etodolac Tablet Extended Release 24hr 400 Mg
  • Etodolac Tablet Extended Release 24hr 500 Mg
  • Etodolac Tablet Extended Release 24hr 600 Mg
  • Fluphenazine Hydrochloride Oral Conc 5 Mg/ML
  • Hepagam B Injection
  • Hycamtin Capsule 0.25mg
  • Hycamtin Capsule 1mg
  • Hyperhep B Injection
  • Ibuprofen-Diphenhydramine Citrate Tablet 200-38 Mg
  • Iressa Tablet 250mg
  • Lansoprazole Tablet Delayed Release Orally Disintegrating 15 Mg
  • Lansoprazole Tablet Delayed Release Orally Disintegrating 30 Mg
  • Levonorg-Eth Est Tablet 0.1-0.02mg(84) & Eth Est Tablet 0.01mg(7)
  • Magnesium Oxide (Laxative) Tablet 500 Mg
  • Magnesium Oxide Tablet 250 Mg
  • Magnesium Oxide Tablet 420 Mg
  • Menest Tablet 0.3mg
  • Menest Tablet 0.625mg
  • Menest Tablet 1.25mg
  • Metamucil Pow Mh/Orig
  • Mycophenolic Tablet 180mg Delayed Release
  • Mycophenolic Tablet 360mg Delayed Release
  • Nabi-Hb Injection
  • Nicotrol Inhaler 10mg
  • Nicotrol Ns Spray 4x10mL
  • Nilutamide Tablet 150 Mg
  • Nozin Nasal Kit Sanitize
  • Nozin Nasal Mis Sanitize
  • Olanzapine-Fluoxetine Hydrochloride Capsule 12-25 Mg
  • Olanzapine-Fluoxetine Hydrochloride Capsule 12-50 Mg
  • Olanzapine-Fluoxetine Hydrochloride Capsule 3-25 Mg
  • Olanzapine-Fluoxetine Hydrochloride Capsule 6-25 Mg
  • Olanzapine-Fluoxetine Hydrochloride Capsule 6-50 Mg
  • Oxycodone Hydrochloride Tablet Extended Release 12hr Deter 10 Mg
  • Oxycodone Hydrochloride Tablet Extended Release 12hr Deter 15 Mg
  • Oxycodone Hydrochloride Tablet Extended Release 12hr Deter 20 Mg
  • Oxycodone Hydrochloride Tablet Extended Release 12hr Deter 30 Mg
  • Oxycodone Hydrochloride Tablet Extended Release 12hr Deter 40 Mg
  • Oxycodone Hydrochloride Tablet Extended Release 12hr Deter 60 Mg
  • Oxycodone Hydrochloride Tablet Extended Release 12hr Deter 80 Mg
  • Paroxetine Hydrochloride Oral Suspension 10 Mg/5mL (Base Equiv)
  • Phenyleph-Shark Liver Oil-Cocoa Butter Suppository 0.25-3-85.5%
  • Prednisolone Sod Phosphate Orally Disintegrating Tablet 10 Mg (Base Eq)
  • Prednisolone Sod Phosphate Orally Disintegrating Tablet 15 Mg (Base Eq)
  • Prednisolone Sod Phosphate Orally Disintegrating Tablet 30 Mg (Base Eq)
  • Prefest Tablet
  • Prilosec Pow 10mg
  • Prilosec Pow 2.5mg
  • Psyllium en polvo 100 %.
  • Psyllium en polvo 95%
  • Rufinamide Suspension 40 Mg/ML
  • Sennosides Tablet 17.2 Mg
  • Sodium Phosphates - Enema (Pediatric)
  • Somatuline Injection 120/.5mL
  • Somatuline Injection 60/0.2mL
  • Somatuline Injection 90/0.3mL
  • Sucralfate Suspension 1 Gm/10mL
  • Zoladex Imp 10.8mg
  • Zoladex Imp 3.6mg
  • Zolinza Capsule 100mg

Otras actualizaciones

  • Aprepitant Capsule 125 Mg (Added Quantity Level Limit)
  • Aprepitant Capsule 40 Mg (Added Quantity Level Limit)
  • Solución oftálmica de lágrimas artificiales
  • Aspirin Sup 300mg
  • Atropine Sulfate Ophthalmic Ointment 1%
  • Codeine Sulfate Tablet 15mg (Added Quantity Level Limit and Age Minimum)
  • Codeine Sulfate Tablet 60mg (Added Quantity Level Limit and Age Minimum)
  • Dextromethorphan-Guaifenesin Tablet Extended Release 12hr 60-1200 Mg
  • Feverall Sup 325mg
  • Hydromorphon Sup 3mg (Added Quantity Level Limit)
  • Lohist-Dm Syrup 5-2-10mg
  • Lubricant Drops Eye 0.6%
  • Lubricating Drops 0.5%
  • Tusnel C Syrup (Added Quantity Level Limit and Age Minimum)

 

2022.º de octubre

Incorporaciones:

  • Ninguno

Información eliminada:

  • Ninguno

Otras actualizaciones

  • Lenalidomide Capsule 2.5Mg
  • Lenalidomide Capsule 5Mg
  • Lenalidomide Capsule 10Mg
  • Lenalidomide Capsule 15Mg
  • Lenalidomide Capsule 20Mg
  • Lenalidomide Capsule 25Mg
  • Varenicline Tartrate Tablet 0.5Mg X 11 & Tablet 1Mg X 42 PA

 

Septiembre de 2022

Incorporaciones:

  • Phospho-Trin K500 Tablet

Información eliminada:

  • Hypersal Nebulization Solution 3.5 % 

Otras actualizaciones

  • K-Phos Tablet 500 mg (Brand)

 

Agosto de 2022

Incorporaciones:

  • Bicillin L-A Suspension 2400000 Unit/4mL
  • Calamine Lotion (Quantity Level Limit)
  • Loción de calamina-óxido de zinc 8-8%
  • Doxycycline Monohydrate Tablet 100mg
  • Eplerenone Tablet 25mg
  • Eplerenone Tablet 50 Mg
  • Fenofibrate Tablet 145 Mg
  • Fenofibrate Tablet 48 Mg
  • Fluocinonide Cream 0.1%
  • Glucagon Emergency Solution Kit 1mg/ML (Quantity Level Limit)
  • Hydrocortisone Acetate Ointment 1% (Quantity Level Limit)
  • Ivermectina Loción 0,5% (Cantidad Límite, Terapia Escalonada)
  • Metronidazole Gel 1% (Quantity Level Limit, Step Therapy)
  • Olmesartan Medoxomil Tablet 20 Mg (Quantity Level Limit)
  • Olmesartan Medoxomil Tablet 40 Mg (Quantity Level Limit)
  • Olmesartan Medoxomil Tablet 5 Mg (Quantity Level Limit)
  • Olopatadine Hydrochloride Ophthalmic Solution 0.2% (OTC)
  • Onetouch Ultra 2 Kit W/ Device
  • Onetouch Verio Flex System Kit W/ Device
  • Onetouch Verio Reflect Kit W/ Device
  • Pataday Solution 0.7% Ophthalmic
  • Permetrina líquida al 1%
  • Champú de sulfuro de selenio 1%.
  • Symjepi Solution Prefilled Syringe 0.15mg/0.3mL (Quantity Level Limit)
  • Symjepi Solution Prefilled Syringe 0.3 Mg/0.3mL (Quantity Level Limit)
  • Tetrabenazine Tablet 12.5mg (Prior Authorization Required, Quantity Level Limit)
  • Pomada de acetónido de triamcinolona al 0,05% (límite de cantidad)
  • Triprolidine Hydrochloride Drops 0.938mg/ML
  • Triprolidine Hydrochloride Liquid 0.625mg/ML (Pediaclear PD Liquid)
  • Voriconazole Tablet 200mg (Prior Authorization Required)
  • Voriconazole Tablet 50mg (Prior Authorization Required)

Información eliminada:

  • Adapalene Crema 0,1%
  • Pomada de amcinonida 0,1%
  • Amiodarone Hydrochloride Tablet 100mg
  • Amiodarone Hydrochloride Tablet 400mg
  • AmLodipine Besylate-Atorvastatin Calcium Tablet 10-10 Mg
  • AmLodipine Besylate-Atorvastatin Calcium Tablet 10-20 Mg
  • AmLodipine Besylate-Atorvastatin Calcium Tablet 10-40 Mg
  • AmLodipine Besylate-Atorvastatin Calcium Tablet 10-80 Mg
  • AmLodipine Besylate-Atorvastatin Calcium Tablet 2.5-10 Mg
  • AmLodipine Besylate-Atorvastatin Calcium Tablet 2.5-20 Mg
  • AmLodipine Besylate-Atorvastatin Calcium Tablet 2.5-40 Mg
  • AmLodipine Besylate-Atorvastatin Calcium Tablet 5-10 Mg
  • AmLodipine Besylate-Atorvastatin Calcium Tablet 5-20 Mg
  • AmLodipine Besylate-Atorvastatin Calcium Tablet 5-40 Mg
  • AmLodipine Besylate-Atorvastatin Calcium Tablet 5-80 Mg
  • Amoxicillin & K Clavulanate Tablet Extended Release 12hr 1000-62.5 Mg
  • Baraclude Solution 0.05mg/ML
  • Bp Wash Liquid 2.5%
  • Capsulezasin-P Cream 0.035%
  • Carbinoxamine Maleate Solution 4 Mg/5mL
  • Maleato de carbinoxamina comprimido 4mg
  • Cefaclor Capsule 250 Mg
  • Cefaclor Capsule 500 Mg
  • Cefpodoxime Proxetil For Suspension 100 Mg/5mL
  • Cefpodoxime Proxetil For Suspension 50 Mg/5mL
  • Clemastine Fumarate Tablet 12-Hour 1.34mg
  • Colesevelam Hydrochloride Packet 3.75gm 
  • Diltiazem Hydrochloride Extended Release Capsule Extended Release 12-Hour 60mg
  • Diltiazem Hydrochloride Extended Release Capsule Extended Release 12-Hour 90mg
  • Diphenhydramine Dispersible Tablet 12.5mg
  • Diphenhydramine Hydrochloride Tablet Chewable 12.5mg
  • Doxycycline Monohydrate Capsule 150mg
  • Erythromycin Ethylsuccinate For Suspension 200mg/5mL
  • Erythromycin Ethylsuccinate For Suspension 400mg/5mL
  • Fexofenadine Hydrochloride Childrens Suspension 30mg/5mL
  • Flunisolide Nasal Spray 25mcg/Act (0.025%)
  • Fluvastatin Sodium Tablet Extended Release 24 Hr 80 Mg (Base Equivalent)
  • Glucagen Hypokit Solution Reconstituted 1mg
  • Isradipine Capsule 2.5mg
  • Isradipine Capsule 5mg
  • Lidocaine Hydrochloride Urethral/Mucosal Gel 2%
  • Lidocaine-Prilocaine Kit 2.5-2.5%
  • Memantine Hydrochloride Oral Solution 2 Mg/ML
  • Memantine Hydrochloride Tablet 28 X 5 Mg & 21 X 10 Mg Titration Pack
  • Methazolamide Tablet 25 Mg
  • Methazolamide Tablet 50 Mg
  • Metronidazole Capsule 375mg
  • Nicardipine Capsule 20mg
  • Nicardipine Capsule 30mg
  • Nitazoxanide Tablet 500mg
  • OneTouch Kit Ultra Mini
  • Onetouch Solutions Starter Kit Kit W/ Well Device
  • Perindopril Erbumine Tablet 2 Mg
  • Perindopril Erbumine Tablet 4 Mg
  • Perindopril Erbumine Tablet 8 Mg
  • Propafenone Capsule Extended Release 12-Hour 325mg
  • Propafenone Capsule Extended Release 12-Hour 425mg
  • Propafenone Hydrochloride Extended Release Capsule Extended Release 12-Hour 225mg
  • Proxivol Gel 2%
  • Champú de piretrinas y butóxido de piperonilo 0,33-4%.
  • Rivastigmine Patch 24 Hour 13.3mg/24hr
  • Rivastigmine Patch 24 Hour 4.6mg/24hr
  • Rivastigmine Patch 24 Hour 9.5mg/24hr
  • Champú de ácido salicílico al 6%.
  • Santyl Ointment 250 Unit/Gm
  • Selenium Sulfide, champú, 2.25 %
  • Sulfacetamide Sodium Liquid Wash 10%
  • Vancomycin + Syringespen Sf Hydrochloride Oral Suspension 50mg/ML (Compound Kit)
  • Vancomycin Hydrochloride For Iv Solution 1 Gm (Base Equivalent)
  • Vancomycin Hydrochloride For Iv Solution 10gm (Base Equivalent)
  • Vancomycin Hydrochloride For Iv Solution 5 Gm (Base Equivalent)
  • Vancomycin Hydrochloride For Iv Solution 500mg (Base Equivalent)
  • Vancomycin Hydrochloride Iv Solution 1250mg/250mL (Base Equivalent)
  • Vancomycin Hydrochloride Iv Solution 1750mg/350mL (Base Equivalent)
  • Vancomycin Hydrochloride Iv Solution 750mg/150mL (Base Equivalent)
  • VemLidy Tablet 25mg
  • Zafirlukast Tablet 10mg
  • Zafirlukast Tablet 20mg

Otras actualizaciones

  • Acyclovir Capsule 200 Mg (Removed Quantity Level Limit)
  • Acyclovir Tablet 400 Mg (Removed Quantity Level Limit)
  • Acyclovir Tablet 800 Mg (Removed Quantity Level Limit)
  • Austedo Tablet 12mg (Added Quantity Level Limit)
  • Austedo Tablet 6mg (Added Quantity Level Limit)
  • Austedo Tablet 9mg (Added Quantity Level Limit)
  • Ceftriaxone Sodium For Injection 1 Gm (Changed Quantity Level Limit)
  • Ceftriaxone Sodium For Injection 2 Gm (Changed Quantity Level Limit)
  • Ceftriaxone Sodium For Injection 250 Mg (Changed Quantity Level Limit)
  • Ceftriaxone Sodium For Injection 500 Mg (Changed Quantity Level Limit)
  • Ezetimibe Tablet 10 Mg (Removed Step Therapy)
  • Glucagon Emergency Kit 1mg Injection (Changed Quantity Level Limit)
  • Gvoke Hypopen Solution Auto-Injector 0.5mg/0.1mL (Changed Quantity Level Limit)
  • Gvoke Hypopen Solution Auto-Injector 1mg/0.2mL (Changed Quantity Level Limit)
  • Gvoke Pfs Solution Prefilled Syringe 0.5mg/0.1mL (Changed Quantity Level Limit)
  • Gvoke Pfs Solution Prefilled Syringe 1mg/0.2mL (Changed Quantity Level Limit)
  • Olopatadine Hydrochloride Ophthalmic Solution 0.1% (OTC) (Removed Step Therapy)
  • Omega-3-Acid Ethyl Esters Capsule 1 Gm (Removed Step Therapy)
  • Valacyclovir Hydrochloride Tablet 1gm (Removed Quantity Level Limit)
  • Valacyclovir Hydrochloride Tablet 500 Mg (Removed Quantity Level Limit)

 

Julio de 2022

Incorporaciones:

  • Ninguno

Información eliminada:

  • Ninguno

Otras actualizaciones

  • Ninguno

 

Junio de 2022

Incorporaciones:

  • Epivir HBV Solution 5mg/mL (Quantity Level Limit)
  • Gvoke Hypopen 1-Pack 0.5mg/0.1mL (Quantity Level Limit)
  • Gvoke PFS INJECTION 1mg/0.2mL (Quantity Level Limit)
  • Lamivudine Tablet 100mg (Quantity Level Limit)
  • Pregabalin Capsule 200mg (Prior Authorization Required, Quantity Level Limit)

Información eliminada:

  • Ninguno

Otras actualizaciones

  • Ninguno

 

Mayo de 2022

Incorporaciones:

  • Ozempic (2mg/Dose) 8mg/3mL (Quantity Level Limit, Step Therapy)
  • Triumeq PD Tablet 60-5-30mg (Prior Authorization Required, Quantity Level Limit)

Información eliminada:

  • Ninguno

Otras actualizaciones

  • Ninguno

 

Abril de 2022

Incorporaciones:

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

Información eliminada:

  • Ninguno

Otras actualizaciones

  • Ninguno

 

Marzo de 2022

Incorporaciones:

  • Brimonidine Tartrate-Timolol Maleate Ophthalmic Solution 0.2-0.5% (Quantity Level Limit, Step Therapy)
  • Maraviroc Tablet 150mg
  • Maraviroc Tablet 300mg
  • Systane Gel Drops, gotas oftálmicas lubricantes al 0.4-0.3 %

Información eliminada:

  • Combigan Ophthalmic Solution 0.2-0.5%
  • Gotas para aliviar la sequedad ocular al 0.4-0.3 %
  • Selzentry Tablet 150mg
  • Selzentry Tablet 300mg

Otras actualizaciones

  • Ninguno

 

Febrero de 2022

Incorporaciones:

  • Kit de receptor móvil Dexcom G5 (se requiere autorización previa, límite de cantidad)
  • Kit de transmisor móvil Dexcom G5 (se requiere autorización previa, límite de cantidad)
  • Kit de sensores Dexcom G5 Mobile/G4 Platinum (se requiere autorización previa, límite de cantidad)
  • Receptor Dexcom G6 (se requiere autorización previa, límite de cantidad)
  • Sensor Dexcom G6 (se requiere autorización previa, límite de cantidad)
  • Transmisor Dexcom G6 (se requiere autorización previa, límite de cantidad)
  • Dispositivo de lectura Freestyle Libre 14 días (se requiere autorización previa, límite de cantidad)
  • Freestyle Libre 14 Day Sensor (se requiere autorización previa, límite de cantidad)
  • Dispositivo de lectura Freestyle Libre 2 (se requiere autorización previa, límite de cantidad)
  • Sensor Freestyle Libre 2 (se requiere autorización previa, límite de cantidad)
  • Dispositivo de lectura Freestyle Libre (se requiere autorización previa, límite de cantidad)
  • Freestyle Libre Sensor System (Prior Authorization Required, Quantity Level Limit)
  • Levocetirizine Tablet 5mg (Quantity Level Limit)
  • Naloxone Nasal Liquid 4mg/0.1mL (generic)
  • 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)
  • Ziextenzo (Prior Authorization Required)

Información eliminada:

  • Diphenhydramine Elixir 12.5mg/5mL
  • Estradiol, crema vaginal, 0.1 mg/gm
  • Felbamate Suspension 600mg/5mL
  • Felbamato, comprimidos, 400 mg
  • Felbamate Tablet 600mg
  • Megestrol Suspension 625mg/5mL
  • Omnitrope, inyección, 5.8 mg
  • Udenyca Injection 6mg/0.6mL

Otras actualizaciones

  • Diphenhydramine Hydrochloride Liquid 12.5mg/5mL (Added Quantity Level Limit)
  • ELiquiduis DVT/PE Starter Pack Tablet 5mg (Removed Prior Authorization Required)
  • ELiquiduis Tablet 2.5mg (Removed Prior Authorization Required)
  • ELiquiduis Tablet 5mg (Removed Prior Authorization Required)
  • Promethazine Hydrochloride Syrup 6.25mg/5mL (Added Quantity Level Limit)
  • Xarelto 10mg (Removed Prior Authorization Required)
  • Xarelto 15mg (Removed Prior Authorization Required)
  • Xarelto 20mg (Removed Prior Authorization Required)
  • Xarelto Starter Pack 15/20mg (Removed Prior Authorization Required)

 

Enero de 2022

Incorporaciones:

  • Etravirine Tablet 100mg (Prior Authorization Required)
  • Etravirine Tablet 200mg (Prior Authorization Required)
  • Gvoke Kit Solution 1mg/0.2mL (Quantity Level Limit)

Información eliminada:

  • Intelence Tablet 100mg
  • Intelence Tablet 200mg

Otras actualizaciones

  • Ninguno

 

Diciembre de 2021

Incorporaciones:

  • Esomeprazole Tablet Delayed Release 20mg
  • Everolimus Tablet 10mg (Prior Authorization Required)
  • Insulin Glargine-Yfgn Solution Vial 100unit/mL
  • Insulin Glargine-Yfgn Solution Pen-Injector 100unit/mL
  • Lopinavir-Ritonavir Tablet 100-25mg (Prior Authorization Required)
  • Lopinavir-Ritonavir Tablet 200-25mg (Prior Authorization Required)
  • Mavyret Packet 50-20mg (Prior Authorization Required)

Información eliminada:

  • Afinitor Tablet 10mg
  • Kaletra Tablet 100-25mg
  • Kaletra Tablet 200-25mg
  • Semglee Pen-Injector 100unit/mL
  • Semglee Vial (Solution) 100unit/mL

Otras actualizaciones

  • Ninguno

 

Noviembre de 2021

Incorporaciones:

  • Ninguno

Información eliminada:

  • Ninguno

Otras actualizaciones

  • Ninguno

 

Octubre de 2021

Incorporaciones:

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

Información eliminada:

  • Sutent Capsule 12.5mg (Brand)
  • Sutent Capsule 25mg (Brand)
  • Sutent Capsule 37.5mg (Brand)
  • Sutent Capsule 50mg (Brand)

Otras actualizaciones

  • Ninguno

 

Septiembre de 2021

Incorporaciones:

  • Ninguno

Información eliminada:

  • Ninguno

Otras actualizaciones

  • Ninguno

 

Agosto de 2021

Incorporaciones:

  • Baqsimi Powder 3mg/Dose (Quantity Level Limit)
  • Endari Powder 5gm (Prior Authorization Required)
  • Inlyta Tablet 1mg (Prior Authorization Required, Quantity Level Limit)
  • Inlyta Tablet 5mg (Prior Authorization Required, Quantity Level Limit)
  • Nayzilam Spray 5mg (Prior Authorization Required, Quantity Level Limit)
  • Pregabalin Capsule 100mg (Prior Authorization Required, Quantity Level Limit)
  • Pregabalin Capsule 150mg (Prior Authorization Required, Quantity Level Limit)
  • Pregabalin Capsule 225mg (Prior Authorization Required, Quantity Level Limit)
  • Pregabalin Capsule 25mg (Prior Authorization Required, Quantity Level Limit)
  • Pregabalin Capsule 300mg (Prior Authorization Required, Quantity Level Limit)
  • Pregabalin Capsule 50mg (Prior Authorization Required, Quantity Level Limit)
  • Pregabalin Capsule 75mg (Prior Authorization Required, Quantity Level Limit)
  • Prolia Solution (Prior Authorization Required, Quantity Level Limit)
  • Semglee Injection 100-Unit Pen-Injector
  • Semglee Injection 100-Unit Vial Solution
  • Sofosbuvir-Velpatasvir Tablet 400-100mg (Prior Authorization Required, Quantity Level Limit)

Información eliminada:

  • Citrato de cafeína, polvo
  • Ibrance Capsule 100mg
  • Ibrance Capsule 125mg
  • Ibrance Capsule 75mg
  • Lidocaína e hidrocortisona acetato, crema, 3-0.5 %
  • Methoxsalen Rapid Capsule 10mg
  • Nexavar Tablet 200mg

Otras actualizaciones

  • Ninguno

 

Julio de 2021

Incorporaciones:

  • Ninguno

Información eliminada:

  • Ninguno

Otras actualizaciones

  • Ninguno

 

Junio de 2021

Incorporaciones:

  • Ninguno

Información eliminada:

  • Linzess Capsule 72mcg
  • Linzess Capsule 145mcg
  • Linzess Capsule 290mcg

Otras actualizaciones

  • Trulicity Injection 0.75/0.5 (Added Quantity Level Limit)
  • Trulicity Injection 1.5/0.5 (Added Quantity Level Limit)
  • Trulicity Injection 3/0.5 (Added Quantity Level Limit)
  • Trulicity Injection 4.5/0.5 (Added Quantity Level Limit)

 

Mayo de 2021

Incorporaciones:

  • Ninguno

Información eliminada:

  • Ninguno

Otras actualizaciones

  • Ninguno

 

Abril de 2021

Incorporaciones:

  • Brinzolamida 1 %, suspensión oftálmica (límite de cantidad, terapia escalonada)
  • Azopt 1 %, suspensión oftálmica

 

Marzo de 2021

Incorporaciones:

  • Bevespi Aer 9-4.8mcg (Quantity Level Limit)
  • Cequa Sol 0.09% PF (Prior Authorization Required)
  • Doxycycl Hyc Capsule 100mg
  • Doxycycl Hyc Capsule 50mg
  • Doxycycl Hyc Tablet 100mg
  • Esbriet Capsule 267mg (Prior Authorization Required)
  • Esbriet Tablet 267mg (Prior Authorization Required)
  • Esbriet Tablet 801mg (Prior Authorization Required)
  • Flutic/Salme Aer 100/50 (Age Level Limit, Quantity Level Limit)
  • Hizentra Injection 1gm/5mL (Prior Authorization Required)
  • Hizentra Injection 2gm/10mL (Prior Authorization Required)
  • Hizentra Injection 2gm/10mL (Prior Authorization Required)
  • Hizentra Injection 4gm/20mL (Prior Authorization Required)
  • Hizentra Sol 20% (Prior Authorization Required)
  • Hizentra Via 10gm/50m (Prior Authorization Required)
  • Hizentra Via 1gm/5mL (Prior Authorization Required)
  • Icosapent Capsule 1gm (Prior Authorization Required, Quantity Level Limit)
  • Myleran Tablet 2mg
  • Ocrevus Injection 300/10mL (Prior Authorization Required, Quantity Level Limit)
  • Pot & Sod Citrates W/ Cit Ac Solution 550-500-334 Mg/5mL
  • Privigen, inyección, 40 g (se requiere autorización previa)
  • Rabeprazole Tablet 20 (Quantity Level Limit)
  • Sodium Citrate & Citric Acid Solution 500-334 Mg/5mL
  • Trulicity Injection 0.75/0.5 (Step Therapy Required)
  • Trulicity Injection 1.5/0.5 (Step Therapy Required)
  • Trulicity Injection 3/0.5 (Step Therapy Required)
  • Trulicity Injection 4.5/0.5 (Step Therapy Required)
  • Tukysa Tablet 150mg (Prior Authorization Required)
  • Tukysa Tablet 50mg (Prior Authorization Required)
  • Valtoco Liquid 15 Mg (Quantity Level Limit)
  • Valtoco Liquid 20 Mg (Quantity Level Limit)
  • Valtoco Spr 10mg (Quantity Level Limit)
  • Valtoco Spr 5mg (Quantity Level Limit)
  • Visco-3 Injection 25/2.5mL (Prior Authorization Required)

Información eliminada:

  • Anoro Ellipt, aerosol, 62.5‑25
  • Atrovent, aerosol HFA, 17 mcg
  • Breo Ellipta Inhaler 100-25
  • Breo Ellipta Inhaler 200-25
  • Cefaclor For Suspension 125mg/5mL
  • Cefaclor For Suspension 250 Mg/5mL
  • Cefaclor For Suspension 375 Mg/5mL
  • Clarithromycin Tablet Extended Release 24 HR 500mg
  • Combivent, aerosol, 20‑100
  • Diazepam Con 5mg/mL
  • Doxycyc Mono Tablet 100mg
  • Doxycyc Mono Tablet 150mg
  • Doxycyc Mono Tablet 50mg
  • Doxycyc Mono Tablet 75mg
  • Epogen Injection 10000/mL
  • Epogen Injection 2000/mL
  • Epogen Injection 20000/mL
  • Epogen Injection 3000/mL
  • Epogen Injection 4000/mL
  • Flebogamma Injection 10/200mL
  • Flebogamma Injection 10/200mL
  • Flebogamma Injection Dif 5%
  • Flebogamma Injection Dif 5%
  • Flebogamma Injection Dif 5%
  • Fulphila Injection 6/0.6mL
  • Hyalgan Injection 20mg/2mL
  • Hyalgan Injection 20mg/2mL
  • Hyoscyamine Dro 0.125/mL
  • Janumet Tablet 50-1000
  • Janumet Tablet 50-500mg
  • Janumet XR Tablet 100-1000
  • Janumet XR Tablet 50-1000
  • Janumet XR Tablet 50-500mg
  • Januvia Tablet 100mg
  • Januvia Tablet 25mg
  • Januvia Tablet 50mg
  • Nivestym Injection 300/0.5
  • Nivestym Injection 300mcg
  • Nivestym Injection 480/0.8
  • Nivestym Injection 480mcg
  • Ofev Capsule 100mg
  • Ofev Capsule 150mg
  • Verzenio Tablet 100mg
  • Verzenio Tablet 150mg
  • Verzenio Tablet 200mg
  • Verzenio Tablet 50mg
  • Victoza Injection 18mg/3mL

Otras actualizaciones

  • Albuterol Aer HFA (Added Quantity Level Limit)
  • Arnuity Elpt Inhaler 100mcg (Added Quantity Level Limit)
  • Arnuity Elpt Inhaler 200mcg (Added Quantity Level Limit)
  • Arnuity Elpt Inhaler 50mcg (Added Quantity Level Limit)
  • Azithromycin Sus 100mg/5mL (Added Age Limit)
  • Azithromycin Sus 200 Mg/5mL (Added Age Limit)
  • Cefadroxil Sus 250/5 mL (Added Age Limit)
  • Cefadroxil Sus 500/5 mL (Added Age Limit)
  • Cefdinir Sus 125/5mL (Added Age Limit)
  • Cefdinir Sus 250/5mL (Added Age Limit)
  • Cefpodo Prox Sus 100/5mL (Added Age Limit)
  • Cefpodo Prox Sus 50mg/5mL (Added Age Limit)
  • Cefprozil Sus 125/5mL (Added Age Limit)
  • Cefprozil Sus 250/5mL (Added Age Limit)
  • Cephalexin Sus 125/5mL (Added Age Limit)
  • Cephalexin Sus 250/5mL (Added Age Limit)
  • Clarithromycin Sus 125mg/5mL (Added Age Limit)
  • Clarithromycin Sus 250mg/5mL (Added Age Limit)
  • Extavia Injection 0.3mg (Cantidad añadida límite)
  • Gilenya Capsule 0.5mg (Added Quantity Level Limit)
  • Glatiramer Injection 20mg/mL (Added Quantity Level Limit)
  • Glatiramer Injection 40mg/mL (Added Quantity Level Limit)
  • Juluca Tablet 50-25mg (Added Prior Authorization)
  • Levalbuterol Aer 45/Act (Added Quantity Level Limit)
  • Levofloxacin Sol 25mg/mL (Added Age Limit)
  • Neomicina-polimixina-dexametasona, ungüento oftálmico, 0.1 % (se agregó el límite de cantidad)
  • Ondansetron Tablet Dispersible 4mg Oral (Added Quantity Level Limit)
  • Ondansetron Tablet Dispersible 8mg Oral (Added Quantity Level Limit)
  • Phenylephrine Hydrochloride Ophthalmic Solution 2.5% (Added Quantity Level Limit)
  • Rebif Injection 22/0.5 (Added Quantity Level Limit)
  • Rebif Injection 44/0.5 (Added Quantity Level Limit)
  • Rebif Rebido Injection 22/0.5 (Added Quantity Level Limit)
  • Rebif Rebido Injection 44/0.5 (Added Quantity Level Limit)
  • Rebif Rebido Injection Titratn (Added Quantity Level Limit)
  • Rebif Titrtn Injection Pack (Added Quantity Level Limit)
  • Santyl Oin 250 Unit/gm (Added Quantity Level Limit)

 

Febrero de 2021

Incorporaciones:

  • Ninguno

Información eliminada:

  • Ninguno

Otras actualizaciones

  • Ninguno

 

Enero de 2021

Incorporaciones:

  • Retacrit Injection 20000uni (Prior Authorization Required)

Información eliminada:

  • Ninguno

Otras actualizaciones

  • Ninguno

 

Diciembre de 2020

Incorporaciones:

  • Trelegy Aer Ellipta 200-62.5-25mcg/Inhaler (Quality Level Limit, Step Therapy Required)

Información eliminada:

  • Ninguno

Otras actualizaciones

  • Ninguno

 

Noviembre de 2020

Incorporaciones:

  • Dimethyl Fum Capsule 120mg Delayed Release (Quantity Level Limit, Prior Authorization Required)
  • Dimethyl Fum Capsule 240mg Delayed Release (Quantity Level Limit, Prior Authorization Required)
  • Dimethyl Fumarate Capsule Delayed Release Starter Pack 120 Mg & 240 Mg (Quantity Level Limit, Prior Authorization Required)
  • EmtriciTabletin Capsule 200mg (Prior Authorization Required)

Información eliminada:

  • Emtriva Capsule 200mg
  • Tecfidera Capsule 120mg Delayed Release
  • Tecfidera Capsule 240mg Delayed Release
  • Tecfidera Capsule Delayed Release Starter Pack 120 Mg & 240 Mg

Otras actualizaciones

  • Ninguno

 

Octubre de 2020

Incorporaciones:

  • Efavirenz-Lamivudine-Tenofovir Df Tablet 400-300-300mg
  • Efavirenz-Lamivudine-Tenofovir Df Tablet 600-300-300mg

Información eliminada:

  • Symfi Lo, comprimidos, 400-300-300 mg
  • Symfi, comprimidos, 600-300-300 mg

Otras actualizaciones

  • Ninguno

 

Septmeber 2020

Incorporaciones:

  • Abiraterone Tablet 250mg (Prior Authorization Required)
  • Alecensa Capsule 150mg (Prior Authorization Required)
  • Austedo Tablets 5mg, 9mg, 12mg (Prior Authorization Required)
  • Budesonide Capsule 3mg (Step Therapy Required, Quantity Level Limit)
  • Capsulerelsa Tablets 100mg, 300mg (Prior Authorization Required)
  • Cinacalcet Tablets 30mg, 60mg, 90mg (Prior Authorization Required)
  • Cyclophosphamide Capsules 25mg, 50mg
  • Enbrel Injection 25mg (Prior Authorization Required, Quantity Level Limit)
  • Erivedge Capsule 150mg (Prior Authorization Required)
  • Gilotrif Tablets 20mg, 30mg, 40mg (Prior Authorization Required)
  • Jakafi Tablets 5mg, 10mg, 15mg, 20mg, 25mg (Prior Authorization Required)
  • Kalydeco, paquete, 25 mg, 50 mg, 75 mg (se requiere autorización previa)
  • Kalydeco Tablet 150mg (Prior Authorization Required)
  • Lenvima Capsules 4mg, 8mg, 10mg, 12mg, 14mg, 18mg, 20mg, 24mg (Prior Authorization Required)
  • Linezolid Tablet 600mg (Prior Authorization Required)
  • Mekinist Tablets 0.5mg, 2mg (Prior Authorization Required)
  • Ofev Capsules 100mg, 150mg (Prior Authorization Required)
  • Repatha Injection 140mg/mL, 420mg/3.5mL (Prior Authorization Required)
  • Rydapt Capsule 25mg (Prior Authorization Required)
  • Symdeko Tablets 50-75mg, 100-150mg (Prior Authorization Required)
  • Tafinlar Capsules 50mg, 75mg (Prior Authorization Required)
  • Venclexta Start Pack (Prior Authorization Required)
  • Venclexta Tablets 10mg, 50mg, 100mg (Prior Authorization Required)
  • Xolair Injection 75mg/0.5mL, 150mg/mL (Prior Authorization Required)
  • Zykadia Capsule 150mg (Prior Authorization Required)

Información eliminada:

  • Ninguno

Otras actualizaciones

  • Soliris Injection 10mg/mL (Prior Authorization Required)
  • Inhibidores de la bomba de protones (límite de cantidad)

 

Agosto de 2020

Incorporaciones:

  • Amitiza Capsules 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)
  • Ibrance Capsules 75mg, 100mg, 125mg (Prior Authorization Required, Quantity Level Limit)
  • Ibrance Tablets 75mg, 100mg, 125mg (Prior Authorization Required, Quantity Level Limit)
  • Lynparza Tablets 10mg, 15mg (Prior Authorization Required, Quantity Level Limit)
  • Omeprazole OTC Tablet 20mg (Generic)
  • Poly-Vi-Sol Solution 50mg/mL
  • Solifenacin Succinate Tablets 5mg, 10mg (Step Therapy, Quantity Level Limit)
  • Symproic Tablet 0.2mg (Prior Authorization Required, Quantity Level Limit)
  • Testosterone TD Solution 30mg/actuation (Prior Authorization Required, Quantity Level Limit)
  • Tivicay PD Tablet 5mg (Diagnosis Confirmation Required, Age Limit)
  • Trelegy Ellipta (Step Therapy, Quantity Level Limit)
  • Tri-Vi-Sol, solución, suplemento de vitaminas A/C/D

Información eliminada:

  • Cimduo Tablet 300-300mg
  • Fluocinolone Acetonide, solución, 0.01 %
  • Fluorouracil, crema, 0.5 %
  • Humulin 70/30
  • Humulin N
  • Humulin R
  • KiTabletis Nebule Solution 300mg/5mL
  • Naproxen Sodium Tablet 275mg
  • Nimodipine Capsule 30mg
  • Prilosec OTC Tablet 20mg (Brand)
  • Targretin, gel, 1 %
  • Tolmetin Sodium Capsule 400mg
  • Tolmetin Sodium Tablets 200mg, 600mg

Otras actualizaciones

  • Adapalene Gel 0.1% (Removed Step Therapy from Rx Product)
  • Miconazole Nitrate, polvo para tratar el pie de atleta, 2 % (límite de cantidad)
  • Auryxia Tablet 210mg (Step Therapy Required)
  • Betamethasone Dipropionate Augmented Cream 0.05% (Cantidad Límite)
  • Betamethasone Dipropionate, crema, 0.05 % (límite de cantidad)
  • Betamethasone Dipropionate, loción, 0.05 % (límite de cantidad)
  • Betamethasone Valerate, crema, 0.1 % (límite de cantidad)
  • Betamethasone Valerate, loción, 0.1 % (límite de cantidad)
  • Betamethasone Valerate, ungüento, 0.1 % (límite de cantidad)
  • Butenafine Hydrochloride Cream 1% (Quantity Level Limit)
  • Candesartan Cilexetil – Hydrochlorothiazide Tablets 16-12.5mg, 32-12.5mg, 32-25mg (Step Therapy Required)
  • Candesartan Cilexetil Tablets 4mg, 8mg, 16mg, 32mg (Step Therapy Required)
  • Ciclopirox Olamine, crema, 0.77 % (límite de cantidad)
  • Ciclopirox Olamine, suspensión, 0.77 % (límite de cantidad)
  • Ciclopirox, champú, 1 % (límite de cantidad)
  • Ciclopirox, solución, 8 % (límite de cantidad)
  • Ciprofloxacin Hydrochloride OTIC Solution 0.2% (Quantity Level Limit)
  • Clindamicina Fosfato Gel 1% (Cantidad Límite)
  • Clindamicina Fosfato Loción 1% (Cantidad Límite)
  • Clindamycin Phosphate Solution 1% (Quantity Level Limit)
  • Clindamycin Phosphate Swab 1% (Quantity Level Limit)
  • Clotrimazole, crema, 1 % (límite de cantidad)
  • Clotrimazole, solución, 1 % (límite de cantidad)
  • Clotrimazole-Betamethasone, crema, 1-0.05 % (límite de cantidad)
  • Disulfiram Tablets 250mg, 500mg (Quantity Level Limit)
  • Carbamide Peroxide, gotas para los oídos, solución ótica, 6.5 % (límite de cantidad)
  • Ery Pad (Erythromycin) 2% (Quantity Level Limit)
  • Erythromycin, gel, 2 % (límite de cantidad)
  • Erythromycin, solución, 2 % (límite de cantidad)
  • Flunisolide Nasal Solution 25mcg/Actuation (Step Therapy Required)
  • Fluocinonide, crema, 0.05 % (límite de cantidad)
  • Fluocinonide, solución, 0.05 % (límite de cantidad)
  • Fluvastatin Sodium Capsules 20mg, 40mg (Step Therapy Required)
  • Hydrocortisone, crema, 0.5 %, 1 %, 2.5 % (límite de cantidad)
  • Hydrocortisone, loción, 1 %, 2.5 % (límite de cantidad)
  • Hydrocortisone, ungüento, 0.5 %, 1 %, 2.5 % (límite de cantidad)
  • Hydrocortisone-Acetic Acid OTIC Solution 1-2% (Quantity Level Limit)
  • Ketoconazole, crema, 2 % (límite de cantidad)
  • Ketoconazole, champú, 2 % (límite de cantidad)
  • Lidocaine, ungüento, 5 % (límite de cantidad)
  • Linzess Capsules 72mcg, 145mcg, 290mcg (Prior Authorization Required)
  • Liothyronine Sodium Tablet 25mcg (Quantity Level Limit)
  • Miconazole Nitrate, polvo en aerosol, 2 % (límite de cantidad)
  • Miconazole Nitrate, crema, 2 % (límite de cantidad)
  • Mometasone Furoate, crema, 0.1 % (límite de cantidad)
  • Mometasone Furoate, ungüento, 0.1 % (límite de cantidad)
  • Mometasone Furoate, solución, 0.1 % (límite de cantidad)
  • Naltrexone Tablet 50mg (Quantity Level Limit)
  • Neomycin-Polymixin-HC, solución ótica, 1 % (límite de cantidad)
  • 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, solución ótica, 0.3 % (límite de cantidad)
  • Permethrin, crema, 5 % (límite de cantidad)
  • Prednicarbate, ungüento, 0.1 % (límite de cantidad)
  • Inhibidores de la bomba de protones (límite de cantidad)
  • Ropinirole Hydrochloride Extended Release Tablets 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)
  • Terbinafine Hydrochloride Cream 1% (Quantity Level Limit)
  • Testosterone, gel, 1.62 % (se requiere autorización previa; límite de cantidad)
  • Tolnaftate, crema, 1 % (límite de cantidad)
  • Triamcinolone Acetonide, crema, 0.025 %, 0.1 %, 0.5 % (límite de cantidad)
  • Triamcinolone Acetonide Lotion 0.0.25%, 0.1% (Quantity Level Limit)
  • Triamcinolone Acetonide Ointment 0.025%, 0.05% (Quantity Level Limit)

 

Julio de 2020

Incorporaciones:

  • Gvoke PFS Injection 0.5mg/0.1mL (Quantity Level Limit)
  • HM Urinary Pain Relief (Phenazopyridine) Tablet 99.5mg

 

Junio de 2020

Incorporaciones:

  • Benzoyl Peroxide, medicamento para tratar el acné, loción, 10 %
  • Alahist D Tablet
  • Atovaquone-Proguanil Tablets (Quantity Level Limit)
  • Claravis Capsules 10mg, 20mg, 30mg, 40mg (Step Therapy, Quantity Level Limit)
  • Dovato Tablet 50-300mg (Diagnosis Confirmation Required, Quantity Level Limit)
  • Gvoke Hypopen Injection (Quantity Level Limit)
  • Isotretinoin Capsules 10mg, 20mg, 30mg, 40mg (Step Therapy, Quantity Level Limit)
  • Tolnaftate, tratamiento de la tiña inguinal y el pie de atleta, polvo en aerosol, 1 % (límite de cantidad)
  • Phenazopyridine Tablet 95mg
  • Primaquine Tablet 26.3mg (Quantity Level Limit)
  • Tolnaftate, polvo, 1 % (límite de cantidad)

Información eliminada:

  • Clotrimazole Solution 1% - RX (Removed Step Therapy)

 

Mayo de 2020

Incorporaciones:

  • Dexamethasone Concentrate Solution 1mg/mL
  • Dexamethasone Vials 4mg/mL, 10mg/mL, 20mg/5mL, 120mg/30mL
  • Hydrocortisone Sodium Succinate PF Vials 100mg, 250mg, 500mg, 1000mg
  • Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4% (Quantity Level Limit)
  • Pyrimethamine Tablet 25mg (Prior Authorization Required)

Información eliminada:

  • Ala Scalp Lotion 2%
  • Daraprim Tablet 25mg (Brand)

 

Abril de 2020

Incorporaciones:

  • Aripiprazole Tablets 2mg, 5mg, 10mg, 15mg, 20mg, 30mg (Age Limit, Quantity Level Limit)
  • Budesonide-Formoterol Inhalers 80-4.5mcg, 160-4.5mcg (Quantity Level Limit)
  • Novolin R FlexPen 100 units/mL
  • Omeprazole Disintegrating ating Tablet 20mg (Quantity Level Limit)
  • Orkambi Granules 100-125mg, 200-125mg (Prior Authorization Required)
  • Orkambi Tablets 100-125mg, 200-125mg (Prior Authorization Required)
  • Tramadol Tablet 100mg (Quantity Level Limit)

Información eliminada:

  • Carafate Suspension 1gm/10mL (Brand)

 

Marzo de 2020

Incorporaciones:

  • Mesalamine Capsule 0.375gm
  • Penicillamine Tablet 250mg (Prior Authorization Required, Quantity Level Limit)

Información eliminada:

  • Apriso Capsule 0.375gm (Brand)

Otras actualizaciones

  • Prenatal Vitamin Tablets (Quantity Level Limit)

 

Febrero de 2020

Incorporaciones:

  • Bimatoprost Ophthalmic Solution 0.03% (Step Therapy Required)
  • Ethinyl Estradiol – Etonogestrel Ring 0.015mg-0.12mg (Quantity Level Limit)
  • Everolimus Tablets 2.5mg, 5mg, 7mg (Prior Authorization Required)
  • Liletta IUD 19.5mcg/day

Información eliminada:

  • Afinitor Tablet 2.5mg, 5mg, 7.5mg (Brand)
  • Alprazolam Concentrate Solution 1mg/mL
  • Chlorothiazide Tablets
  • Demeclocycline Tablets
  • Doxycycline Monohydrate Tablet 150mg
  • First-Vanco Solution 25mg/mL, 50mg/mL
  • Homatropine Ophthalmic Solution 5%
  • Kyleena, DIU
  • Methylclothiazide Tablet 5mg
  • Mirena, DIU
  • Nausea Relief Liquid
  • Nizatidine Solution 15mg/mL
  • Nuvaring (Brand)
  • Phospholine Ophthalmic Solution 0.125%
  • Propantheline Capsule 15mg
  • Rabeprazole Enteric Coated Capsule 20mg
  • Ranitidine Capsules 150mg, 300mg
  • Skyla, DIU

Otras actualizaciones

  • Atropine Ophthalmic Ointment 1% (Quantity Level Limit)
  • Atropine Ophthalmic Solution 1% (Quantity Level Limit)
  • Buspirone Tablets 5mg, 7.5mg, 10mg, 15mg (Age Limit)
  • Combigan Ophthalmic Solution 0.5/0.5% (Quantity Level Limit)
  • Diazepam Concentrate 5mg/mL (Quantity Level Limit)
  • Diazepam, solución oral (límite de cantidad)
  • Diazepam Tablets 2mg, 5mg, 10mg (Quantity Level Limit)
  • Divalproex Extended Release Tablet 250mg, 500mg (Prior Authorization Required)
  • Dorzolamide-Timolol Ophthalmic Solution 22.3-6.8% (Quantity Level Limit, Step Therapy Required)
  • Doxycycline Monohydrate Suspension 25mg/5mL (Age Limit)
  • Granisetron Tablet 1mg (Step Therapy Required)
  • Hydroxyzine Pamoate Capsules 25mg, 50mg, 100mg (Quantity Level Limit)
  • Hydroxyzine Tablet 50mg (Quantity Level Limit)
  • Levofloxacin Ophthalmic Solution 0.5% (Quantity Level Limit)
  • Lorazepam Concentrate 2mg/mL (Age Limit, Quantity Level Limit)
  • Memantine Tablets 5mg, 10mg (Quantity Level Limit)
  • Methazolamide Tablets 25mg, 50mg (Step Therapy Required)
  • Natacyn Ophthalmic Suspension 5% (Quantity Level Limit)
  • Tazarotene Cream 1% (Step Therapy Required)
  • Timolol Ophthalmic Gel Solution 0.25%, 0.5% (Quantity Level Limit)
  • Trifluridine, solución oftálmica, 1 % (límite de cantidad)

 

 

Enero de 2020

Incorporaciones:

  • Buprenorphine-Naloxone Films 2-0.5mg, 4-1mg, 8-2mg, 12-3mg (Quantity Level Limit)

Información eliminada:

  • Ventolin HFA Inhaler (brand name)

 

 

Diciembre de 2019

Información eliminada:

  • PreNata Chewable Tablet 29-1mg

 

 

Noviembre de 2019

Sin actualizaciones

 

 

Octubre de 2019

Otras actualizaciones

  • Cetirizine Solution 1mg/mL (Quantity Level Limit)

 

 

Septiembre de 2019

Incorporaciones:

  • Ambrisentan Tablets 5mg, 10mg (Prior Authorization Required, Quantity Level Limit)
  • Bosentan Tablets 62.5mg, 125mg (Prior Authorization Required, Quantity Level Limit)
  • Febuxostat Tablets 40mg, 80mg (Step Therapy Required)
  • Ramelteon Tablet 8mg (Step Therapy Required, Quantity Level Limit)
  • Ribavirin Tablet/Capsule 200mg (Step Therapy Required)

Información eliminada:

  • Letairis Tablets 5mg, 10mg (Brand)
  • Rozerem Tablet 8mg (Brand)
  • Tracleer Tablets 62.5mg, 125mg (Brand)
  • Uloric Tablets 40mg, 80mg (Brand)

 

 

Agosto de 2019

Incorporaciones:

  • Aquadeks Drops
  • Butenafine Cream 1% (OTC)
  • Lidocaine Patch 4% (Quantity Level Limit)
  • Thyroid Tablets 180mg, 240mg, 300mg (Quantity Level Limit)

Información eliminada:

  • Ciclopirox Gel 0.77%
  • Clotrimazole w/ Betamethasone Lotion 1-0.05%
  • Colestipol Granules 5gm
  • Epinastine Ophthalmic Solution 0.05%
  • Fluphenazine Elixir 2.5mg/5mL
  • Fluphenazine Injection 2.5mg/mL
  • Lindane Shampoo 1%
  • Moexipril Tablets 7.5mg, 15mg
  • Nitroglycerin Capsule 2.5mg
  • Olopatadine Ophthalmic Solution 0.2%
  • Quinidine Gluconate CR Tablet 324mg
  • Thyroid Tablet 130mg

Otras actualizaciones

  • Azelastine Ophthalmic Solution 0.05% (Quantity Level Limit)
  • Ciclopirox Cream 0.77% (Step Therapy Required)
  • Ciclopirox Shampoo 1% (Step Therapy Required)
  • Ciclopirox Suspension 0.77% (Step Therapy Required)
  • Fluocinolone Cream 0.025% (Quantity Level Limit)
  • Fluocinolone Ointment 0.025% (Quantity Level Limit)
  • Lidocaine Cream 4% (Quantity Level Limit)
  • Lidocaine Gel 2% (Quantity Level Limit)
  • Lidocaine-Prilocaine Cream 2.5-2.5% (Quantity Level Limit)
  • Liothyronine Tablets 5mcg, 50mcg (Quantity Level Limit)
  • Norethindrone Tablet 5mg (Step Therapy Required)
  • Olanzapine ODT Tablets (Age Limit)
  • Olanzapine Tablets (Age Limit)
  • Quetiapine Tablets (Age Limit)
  • Risperidone ODT Tablets (Age Limit)
  • Risperidone Oral Solution 1mg/mL (Age Limit)
  • Risperidone Tablets (Age Limit)
  • Sertraline Concentrate Oral Solution 20mg/mL (Age Limit)
  • Thyroid Tablets 15mg, 30mg, 60mg, 90mg, 120mg (Quantity Level Limit)

 

 

Julio de 2019

Incorporaciones:

  • Cefixime Capsule 400mg (Quantity Level Limit)
  • Erlotinib Tablet 150mg (Prior Authorization Required)
  • Mesalamine Delayed Release Capsule 400mg (Quantity Level Limit)

Información eliminada:

  • Suprax Capsule 400mg (brand)
  • Tarceva Tablet 150mg (brand)

 

 

Junio de 2019

Incorporaciones:

  • Docosanol Cream 10% (Quantity Level Limit)
  • Melatonin Tablets 1mg, 3mg, 5mg

Información eliminada:

  • Abreva Cream 10% (brand)

 

 

Mayo de 2019

Incorporaciones:

  • Erythromycin Ethylsuccinate Suspension 400mg/5mL
  • Fulphila Injection 6mg/0.6mL (Prior Authorization Required)
  • Nivestym Injection 300mcg, 480mcg (Prior Authorization Required)
  • Sirolimus Solution 1mg/mL
  • Udenyca Injection 6mg/0.6mL (Prior Authorization Required)

Información eliminada:

  • Eryped Suspension (brand) 400mg/5mL
  • Rapamune Solution (brand) 1mg/mL

 

 

Abril de 2019

Otras actualizaciones

  • Antiretroviral Medications (Diagnosis Confirmation Required)

 

 

Marzo de 2019

Incorporaciones:

  • Admelog Vial 300 units/3mL
  • Albuterol HFA Inhaler 90mcg – generic Ventolin HFA (Quantity Level Limit)
  • Arthritis Pain Relieving Cream 0.075%
  • Carafate Oral Suspension 1gm/10mL (Age Limit)
  • Mesalamine Suppository 1000mg
  • Toremifene Tablet 60mg

Información eliminada:

  • Canasa Suppository 1000 mg
  • Fareston Tablet 60 mg
  • Norethindrone Acetate & Estradiol-FE Tablet 1mg-20mcg (24)

Otras actualizaciones

  • Attention Deficit/Hyperactivity Disorder Stimulant Medications (Age Limit, Removed Prior Authorization)
  • Butalbital Containing Products (Quantity Level Limit)
  • Citalopram Oral Solution 10mg/5mL (Age Limit)
  • Dicyclomine Oral Solution 10mg/mL (Age Limit)
  • Escitalopram Oral Solution 5mg/5mL (Age Limit)
  • Famotidine Oral Suspension 40mg/5mL (Age Limit)
  • Lansoprazole Oral Suspension 3mg/mL (Age Limit)
  • Nitrofurantoin Oral Suspension 25mg/5mL (Age Limit)
  • Nortriptyline Oral Solution 10mg/5mL (Age Limit)
  • Omeprazole Oral Suspension 2mg/mL (Age Limit)
  • Oseltamivir Capsule 30mg (Removed Age Limit)
  • Oseltamivir Oral Suspension 6mg/mL (Removed Age Limit)
  • Prednisone Oral Solution 5mg/5mL (Age Limit)

 

 

Febrero de 2019

Incorporaciones:

  • Arnuity Ellipta Inhaler
  • Eligard Kit 7.5mg, 22.5mg, 30mg, 45mg (Prior Authorization Required)
  • Flebogamma IV Solution 5gm/50mL, 10gm/100mL, 20gm/200mL (Prior Authorization Required)
  • Immune Globulin IV Solution 1gm/10mL, 2.5gm/25mL, 5gm/50mL, 10gm/100mL, 20gm/200mL, 30gm/300mL, 40gm/400mL (Prior Authorization Required)
  • Leuprolide Acetate Kit 1mg/0.2mL (Prior Authorization Required)
  • Ozempic Injection (Quantity Level Limit, Step Therapy Required)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tablet 27-0.8mg (Quantity Level Limit)
  • Prenatal Vitamin with Iron Carbonyl-Folic Acid Tablet 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Minerals-Ferrous Fumarate-Folic Acid-DHA Pack 28-0.8-200mg (Quantity Level Limit)
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Folic Acid Chewable Tablet 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid Capsule 20-20-1.25mg (Quantity Level Limit)
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid Capsule 130-92.4-1mg (Quantity Level Limit)
  • Segluromet Tablets (Quantity Level Limit, Step Therapy Required)
  • Steglatro Tablets (Quantity Level Limit, Step Therapy Required)
  • Victoza Injection (Quantity Level Limit, Step Therapy Required)

Información eliminada:

  • Alprazolam Orally Disintegrating Tablets
  • Cleocin Vaginal Ovule 100mg
  • Clorazepate Dipotassium Tablets
  • Condylox Gel 0.5%
  • Cortifoam Rectal Aerosol
  • Cuprimine Capsule 250mg
  • Dihydroergotamine Mesylate Nasal Spray 4mg/mL
  • Dulera Inhaler
  • Elidel Cream 1%
  • Ergotamine SL Tablet 2mg
  • Ergotamine-Caffeine Suppository 2-100mg
  • Ergotamine-Caffeine Tablet 1-100mg
  • Flovent Diskus
  • Humalog Pens/Cartridges
  • Humalog Vials
  • Invokamet Tablets
  • Invokana Tablets
  • Levonorgestrel-Ethinyl Estradiol Tablet 0.15-0.03mg (84) & Ethinyl Estradiol Tablet 0.01mg (7)
  • Lidocaine-Hydrocortisone Rectal Kit 20x7gm
  • Lidocaine-Hydrocortisone Rectal Kit 3-1%
  • Meprobamate Tablets
  • Miconazole 3 Suppository 200mg
  • Nitro-Bid Cream Packets 2%
  • Novolog Pens/Cartridges
  • Novolog Vials
  • Plan B Tablet (Brand Only)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tablet 65-1mg
  • Prenatal Vitamin with Ferrous Fumarate-L Methylfolate-Folic Acid Tablet 27-0.6-0.4mg
  • Prenatal Vitamin with Iron Polysaccharide Complex-Folic Acid Chewable Tablet 29-1mg
  • Prenatal Vitamin with Iron Polysaccharide Complex-L Methylfolate-Folic Acid Chewable Tablet 29-0.6-0.4mg
  • Prenatal Vitamin with Minerals with Iron Poly Saccharide Complex-Folic Acid-DHA Capsule 29-1-200mg
  • Prenatal Vitamin with Minerals with Iron Poly Saccharide Complex-Folic Acid-DHA Pack 1mg & 250mg
  • Prenatal Vitamin without Vit A with Ferrous Asparto Glyc-L Methylfolate-Folic Acid- DHA Capsule 10-0.6-0.4-200mg
  • Prenatal Vitamin without Vit A with Ferrous Asparto Glyc-L Methylfolate-Folic Acid- DHA Capsule 18-0.6-0.4-300mg
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-DSS-Folic Acid-DHA Capsule 27-1.25-300mg
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-L Methylfolate-Folic Acid-DHA Capsule 27-0.6-0.4-300mg
  • Pulmicort Flexhaler
  • Qvar Inhaler
  • Relenza Diskhaler
  • Synjardy Tablets
  • Terconazole Vaginal Suppository 80mg
  • Thalomid Capsules
  • Triazolam Capsules
  • Trimethobenzamide Capsule 300mg
  • Trulicity Injection

Otras actualizaciones

  • Abilify Maintena Injection (Quantity Level Limit)
  • Acyclovir Suspension 200mg/5mL (Age Limit)
  • Alprazolam SR Tablets 0.5mg, 1mg, 2mg, 3mg (Age Limit)
  • Alprazolam Tablets 0.25mg, 0.5mg, 1mg, 2mg (Quantity Level Limit)
  • Aristada Injection (Quantity Level Limit)
  • Breo Ellipta Inhaler (Age Limit)
  • Calcipotriene Cream 0.005% (Quantity Level Limit)
  • Calcipotriene Ointment 0.005% (Quantity Level Limit)
  • Calcipotriene Solution 0.005% (Quantity Level Limit)
  • Chlordiazepoxide Capsules 5mg, 10mg, 25mg (Quantity Level Limit)
  • Citalopram Solution 10mg/5mL (Age Limit)
  • Clozapine Tablets (Quantity Level Limit)
  • Dicyclomine Solution 10mg/mL (Age Limit)
  • Escitalopram Solution 5mg/5mL (Age Limit)
  • Famotidine Suspension 40mg/5mL (Age Limit)
  • Flovent HFA Inhaler (Age Limit)
  • Fluphenazine Concentrate 5mg/mL (Quantity Level Limit)
  • Fluphenazine Elixir 2.5mg/5mL (Quantity Level Limit)
  • Fluphenazine Injection 2.5mg/mL (Quantity Level Limit)
  • Fluphenazine Injection 25mg/mL (Quantity Level Limit)
  • Haloperidol Concentrate 2mg/mL (Quantity Level Limit)
  • Haloperidol Decanoate Injection 100mg/mL (Quantity Level Limit)
  • Haloperidol Decanoate Injection 50mg/mL (Quantity Level Limit)
  • Haloperidol Lactate Injection 5mg/mL (Quantity Level Limit)
  • Haloperidol Tablets (Quantity Level Limit)
  • Hydroxyzine Tablets 10mg, 25mg, 50mg (Quantity Level Limit)
  • Invega Sustena Injection (Quantity Level Limit)
  • Invega Trinza Injection (Quantity Level Limit)
  • Jardiance Tablets (Remove Step Therapy, Add Prior Authorization Required)
  • Lansoprazole Suspension 3mg/mL (Age Limit)
  • Lithium Carbonate Capsules (Quantity Level Limit)
  • Lithium Carbonate Extended Release Tablet 300mg, 450mg (Quantity Level Limit)
  • Lithium Carbonate Tablet 300mg (Quantity Level Limit)
  • Lithium Solution 8meq/5mL (Quantity Level Limit)
  • Lorazepam Tablets 0.5mg, 1mg, 2mg (Quantity Level Limit)
  • Loxapine Capsules (Quantity Level Limit)
  • Nitrofurantoin Suspension 25mg/5mL (Age Limit)
  • Nortriptyline Solution 10mg/5mL (Age Limit)
  • Olanzapine Orally Disintegrating Tablets (Quantity Level Limit)
  • Olanzapine Tablets (Quantity Level Limit)
  • Omeprazole Suspension 2mg/mL (Age Limit)
  • Oseltamivir Capsule 30mg (Quantity Level Limit, Age Limit)
  • Oseltamivir Capsules 45mg, 75mg (Quantity Level Limit)
  • Oseltamivir Suspension 6mg/mL (Quantity Level Limit, Age Limit)
  • Oxazepam Capsules 10mg, 15mg, 30mg (Quantity Level Limit)
  • Perphenazine Tablets (Quantity Level Limit)
  • Prednisone Solution 5mg/5mL (Age Limit)
  • Prenatal Vitamin with Docusate-Ferrous Fumarate-Folic Acid Tablet 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Chewable Tablet 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tablet 27-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tablet 28-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tablet 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tablet 60-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid-Omega 3 Capsule 38-1mg (Quantity Level Limit)
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Folic Acid Capsule 106.5-1mg (Quantity Level Limit)
  • Prochlorperazine Suppository 25mg (Quantity Level Limit)
  • Prochlorperazine Tablets (Quantity Level Limit)
  • Quetiapine Tablets (Quantity Level Limit)
  • Risperdal Consta Injection (Quantity Level Limit)
  • Risperidone Orally Disintegrating Tablets (Quantity Level Limit)
  • Risperidone Solution 1mg/mL (Quantity Level Limit)
  • Risperidone Tablets (Quantity Level Limit)
  • Thioridazine Tablets (Quantity Level Limit)
  • Thiothixene Capsules (Quantity Level Limit)
  • Trifluoperazine Tablets (Quantity Level Limit)
  • Ziprasidone Capsules (Quantity Level Limit)

 

Enero de 2019

No Changes

 

Diciembre de 2018

Incorporaciones:

  • Itraconazole Solution 10mg/mL
  • Nivestym Injection 300mcg, 480mcg (Prior Authorization Required)

Información eliminada:

  • Gleostine Capsules 10mg, 40mg, 100mg
  • Mometasone Nasal Spray
  • Nasonex Nasal Spray
  • Sporanox Solution 10mg/mL

 

Noviembre de 2018

Incorporaciones:

  • Albendazole Tablet 200mg (Step Therapy Required)

Información eliminada:

  • Albenza Tablet 200mg

 

Octubre de 2018

Incorporaciones:

  • Admelog Vial
  • Loratadine Chewable Tablet 5mg (Quantity Level Limit)
  • Prasugrel Tablets (Quantity Level Limit)
  • Tadalafil Tablet 20mg (Step Therapy, Quantity Level Limit)
  • Tazarotene Cream 0.1% (Quantity Level Limit)
  • TymLos Pen (Prior Authorizations Required, Quantity Level Limit)
  • Valganciclovir Tablet 450mg (Quantity Level Limit)

Información eliminada:

  • Adcirca Tablet 20mg

Otras actualizaciones

  • Ondansetron Tablets 4mg, 8mg (Quantity Level Limit)
  • Tizanidine Tablets 2mg, 4mg (Quantity Level Limit)

 

Septiembre de 2018

Incorporaciones:

  • Colesevelam Hydrochloride Packet 3.75gm
  • Diclofenac Gel 1% (Quantity Level Limit)
  • Humira Pen CD/UC/HS Starter Kit 80mg/0.8mL (Prior Authorization Required, Quantity Level Limit)
  • Humira Pen PS/UV Starter Kit 80mg/0.8mL and 40mg/0.4mL (Prior Authorization Required, Quantity Level Limit)
  • Hydroxyprogesterone Capsuleroate Injection 250mg/mL (Prior Authorization Required)
  • Omega 3 Ethyl Esters Acid 1gm Capsule (Step Therapy, Quantity Level Limit)
  • Sevelamer Tablet 800mg (Step Therapy)
  • Symtuza Tablet (Quantity Level Limit)
  • Telmisartan Tablet 20mg, 40mg, 80mg (Quantity Level Limit)
  • Tolterodine Extended Release Capsule 2mg, 4mg (Step Therapy, Quantity Level Limit)
  • VemLidy Tablet 25mg (Quantity Level Limit)
  • Verzenio Tablets 50mg, 100mg, 150mg, 200mg (Prior Authorization Required, Quantity Level Limit)

Información eliminada:

  • AmLodipine-Valsartan-Hydrochlorothiazide Tablets
  • Betaxolol Tablets
  • Calcitriol Solution
  • Capsuletopril Tablets
  • Capsuletopril-Hydrochlorothiazide Tablets
  • Chlorpropramide Tablets
  • Climara Pro Patch Weekly
  • Desipramine Tablets
  • Diltiazem CD Capsule 360mg
  • Femring
  • Fenofibrate Tablet 48mg, 145mg
  • Fenofibric Delayed Release Capsules
  • Fenoprofen Tablet 600mg
  • Lidocaine Cream 3%
  • Makena Injection 250mg/mL
  • Marplan Tablet 10mg
  • Meclofenamate Sodium Capsules
  • Methyltestosterone Capsule 10mg
  • Nadolol Tablets
  • Nisoldipine Extended Release Tablets
  • Ondansetron Solution
  • Oxaprozin Tablet 600mg
  • Pindolol Tablets
  • Pioglitazone-Glimepiride Tablets
  • Pioglitazone-Metformin Tablets
  • Potassium-Sodium Citrates & Citric Acid Solution
  • Premarin Tablets
  • Premphase Tablets
  • Prempro Tablets
  • Protriptyline Tablets
  • Tolazamide Tablets
  • Tolbutamide Tablet 500mg
  • Tranylcypromine Tablet 10mg
  • Verapamil Extended Release 24hr Capsule 300mg

Otras actualizaciones

  • AmLodipine Tablet 2.5mg, 5mg (Quantity Level Limit)
  • Baraclude Solution (Quantity Level Limit)
  • Benazepril Tablet 5mg, 10mg, 20mg (Quantity Level Limit)
  • Benzonatate Capsules 100mg, 200mg (Age Limit, Quantity Level Limit)
  • Clonidine Patches (Step Therapy)
  • Diazepam Rectal Gel 2.5mg, 10mg, 20mg (Quantity Level Limit)
  • Diltiazem CD Capsule 180mg (Quantity Level Limit)
  • Diltiazem Extended Release Beads Capsule 180mg (Quantity Level Limit)
  • Diltiazem Extended Release Capsule 180mg (Quantity Level Limit)
  • Elmiron Capsule (Prior Authorization Required)
  • Enalapril Tablets 2.5mg, 5mg, 10mg (Quantity Level Limit)
  • Estradiol Vaginal Cream 0.01% (Prior Authorization Required)
  • Estring Vaginal Ring 2mg (Quantity Level Limit)
  • Flunisolide Nasal Solution 0.025% (Quantity Level Limit)
  • Fosinopril Tablets 10mg, 20mg (Quantity Level Limit)
  • Gabapentin Tablets (Cumulative Maximum Dose)
  • Griseofulvin Suspension (Step Therapy)
  • Griseofulvin Microsize Tablets (Step Therapy)
  • Griseofulvin Ultramicrosize Tablets (Step Therapy)
  • Hydrocodone-Homatropine Syringe (Age Limit, Quantity Level Limit)
  • Hydrocodone-Homatropine Tablets (Age Limit, Quantity Level Limit)
  • Lidocaine Ointment 5% (Prior Authorization Required)
  • Lisinopril Tablets 2.5mg, 5mg, 10mg, 20mg, 30mg (Quantity Level Limit)
  • Losartan Potassium Tablets 25mg, 50mg (Quantity Level Limit)
  • Mometasone Furoate Nasal Suspension 50mcg/actuation (Quantity Level Limit)
  • Oxybutynin Extended Release Tablet 15mg (Quantity Level Limit)
  • Oxybutynin IR Tablet 5mg (Quantity Level Limit)
  • Oxybutynin Syringe (Quantity Level Limit)
  • Propranolol Extended Release Capsule 80mg (Quantity Level Limit)
  • Quinapril Tablets 5mg, 10mg, 20mg (Quantity Level Limit)
  • Ramipril Capsules 1.25mg, 2.5mg, 5mg (Quantity Level Limit)
  • Tenofovir Tablet 300mg (Quantity Level Limit)
  • Tolterodine Tablets 1mg, 2mg (Step Therapy)
  • Trospium Extended Release Capsule 60mg (Step Therapy)
  • Trospium IR Tablet 20mg (Step Therapy)

 

Agosto de 2018

Incorporaciones:

  • Retacrit Injection (Prior Authorization Required)
  • Cimduo Tablets (Quantity Level Limit)

Otras actualizaciones

  • Loratadine Tablet 10mg (Added Quantity Level Limit)
  • Loratadine Orally Disintegrating Tablet 10mg (Added Quantity Level Limit)

 

Julio de 2018

Incorporaciones:

  • Baclofen Tablet 5mg (Quantity Level Limit)
  • Diphenhydramine Liquid 6.25mg/mL
  • Norvir Powder Packets 100mg
  • Pediatric Multiple Vitamins with Iron Drops 11mg/mL
  • Phytonadione Tablet 5mg
  • Zenpep Capsule 15,000 Units
  • Zenpep Capsule 3000 Units

Información eliminada:

  • Mephyton Tablet 5mg

 

Junio de 2018

Incorporaciones:

  • Humira Pediatric Crohn’s Prefilled Syringe Kit 80mg/0.8mL and 40mg/0.4mL (Prior Authorization Required, Quantity Level Limit)
  • Humira Pediatric Crohn’s Prefilled Syringe Kit 80mg/0.8mL (Prior Authorization Required, Quantity Level Limit)
  • Humira Pen-Injection Kit 40mg/0.4mL (Prior Authorization Required, Quantity Level Limit)
  • Humira Prefilled Syringe Kit 10mg/0.1mL (Prior Authorization Required, Quantity Level Limit)
  • Humira Prefilled Syringe Kit 20mg/0.2mL (Prior Authorization Required, Quantity Level Limit)
  • Humira Prefilled Syringe Kit 40mg/0.4mL (Prior Authorization Required, Quantity Level Limit)
  • Lansoprazole ODT
  • Praziquantel Tablet 600mg (Prior Authorization Required)
  • Symfi Tablet (Quantity Level Limit)
  • Tasigna Capsule 50mg (Prior Authorization Required, Quantity Level Limit)
  • Zenpep Capsule 10,000 Units

Información eliminada:

  • Biltricide Tablet 600mg
  • Fluorouracil Cream 1%
  • Pramoxine-HC-Chloroxylenol OTIC solution
  • Prevacid ODT

Otras actualizaciones

  • Flunisolide Nasal Spray (Removed Step Therapy)
  • Fluticasone Nasal Spray (Removed Step Therapy)
  • Lansoprazole ODT (Removed Prior Auth)
  • Levonorgestrel Tablet 1.5mg (Removed Quantity Level Limit)
  • Mometasone Nasal Spray (Removed Step Therapy)

 

Mayo de 2018

Incorporaciones:

  • Colchicine Capsule 0.6mg (Quantity Level Limit)
  • Firvanq Sol
  • Imbruvica Capsule 70mg (Quantity Level Limit)
  • Imbruvica Tablet 420mg (Quantity Level Limit)
  • Imbruvica Tablet 560mg (Quantity Level Limit)
  • Jardiance Tablet (límite de cantidad; se requiere terapia escalonada)
  • Refresh Tear Drops 0.5%
  • Ritonavir 100mg Tablet
  • Symfi Lo Tablet (Quantity Level Limit)
  • Synjardi Tablet (Quantity Level Limit, Step Therapy Required)
  • Synjardi XR 10mg/1000mg (Quantity Level Limit, Step Therapy Required)
  • Synjardi XR 12.5mg/1000mg (Quantity Level Limit, Step Therapy Required)
  • Synjardi XR 25mg/1000mg (Quantity Level Limit, Step Therapy Required)
  • Synjardi XR 5mg/1000mg (Quantity Level Limit, Step Therapy Required)
  • Virt-PN DHA Tablet
  • Virt-PN Tablet

Información eliminada:

  • BP Folinatal Tablet Plus B
  • BP Multinatal Chw Plus
  • BP Multinatal Plus
  • Norvir 100 Tablet
  • PNV-DHA
  • PNV-Select

Otras actualizaciones

  • Rosuvastatin Tablet (Removed Prior Authorization, Added Step Therapy)

 

April 2018

Incorporaciones:

  • Biktarvy (Quantity Level Limit)

 

March 2018

Incorporaciones:

  • Armodafinil Tablets (Prior Authorization Required, Quantity Level Limit)
  • Avonex (Prior Authorization Required, Quantity Level Limit)
  • Betaxolol 0.5% Solution (Quantity Level Limit)
  • Brinzolamide (Quantity Level Limit)
  • Ciprofloxacin 250 mg/5 mL Suspension (Quantity Level Limit)
  • Combigan (Step Therapy Required)
  • Levobunolol 0.5% Solution (Quantity Level Limit)
  • Metipranolol 0.3% Solution (Quantity Level Limit)
  • Sprycel (Prior Authorization Required, Quantity Level Limit)

Información eliminada:

  • Betoptic-S Suspension 0.25%
  • Brimonidine 0.15%
  • Brompheniramine Chewable
  • Cefaclor Extended Release Tablets
  • Cefixime Suspension
  • Cephalexin Tablets
  • Ciloxan Ointment
  • Ciprofloxacin Extended Release Tablets
  • Fluoprolex Cream 1%
  • Fluorabon Drops
  • FML Forte 0.25%
  • Gatifloxacin solution
  • Homotropine Solution 5% Ophthalmic Drops
  • Jentadueto
  • Jentadueto XR
  • Modafinil Tablets
  • Morphine Extended Release Capsules
  • Moxifloxacin
  • Nature-Throid
  • Neomycin/Polymyxin/HC drops
  • Non-BD diabetic supplies
  • Ofloxacin
  • Oxycodone 20mg/mL concentrated Solution
  • Oxycodone 5mg Capsules
  • Oxymorphone
  • Oxymorphone IR
  • Pred Mild 0.12%
  • Silver Nitrate Applicator
  • Sodium Fluoride Tablets
  • Suprax chewable Tablets
  • TobraDex Ointment
  • Tobramycin/Dexamethasone drops
  • Tobrex Ointment
  • Tradjenta

Otras actualizaciones

  • Carteolol 1% Solution (Added Quantity Level Limit)
  • Timolol gel 0.25% & 0.5% (Added Step Therapy)

 

February 2018

Incorporaciones:

  • Abilify Maintena (Prior Authorization Required)
  • BD Pen Needles
  • Betamethasone Dipropionate 0.05% (Quantity Level Limit)
  • Betamethasone Dipropionate Aug 0.05% lotion, gel & Ointment (Quantity Level Limit)
  • Clobetasol 0.05% gel & Ointment (Quantity Level Limit)
  • Clobetasol 0.05% solution (Quantity Level Limit)
  • Clobetasol emollient 0.05% cream (Quantity Level Limit)
  • Duloxetine 20 mg, 30mg (Quantity Level Limit)
  • Duloxetine 40 mg Delayed Release (Quantity Level Limit)
  • Duloxetine 60 mg (Quantity Level Limit)
  • ELiquiduis (Prior Authorization Required)
  • Fluociononide 0.05% gel & Ointment (Quantity Level Limit)
  • Halobetasol 0.05% Ointment & cream (Quantity Level Limit)
  • Invega Sustenna (Prior Authorization Required)
  • Invega Trinza (Prior Authorization Required)
  • Janumet (Step Therapy Required)
  • Janumet Xtended Release (Step Therapy Required)
  • Januvia (Step Therapy Required)
  • Naproxen 125mg/5mL (Step Therapy Required)
  • Opsumit (Prior Authorization Required, Quantity Level Limit)
  • Risperdal Consta (Prior Authorization Required)

Información eliminada:

  • Albuterol 2mg & 4mg Tablet
  • Albuterol Extended Release 4mg & 8mg Tablet
  • Amcinonide 0.1% cream & lotion
  • Capsuleex Shampoo 0.01%
  • Clobetasol 0.05% lotion & shampoo
  • Clobetasol Aer 0.05% foam & emollient
  • Desonide 0.05% cream, lotion, &Ointment
  • Desoximetasone 0.05% cream, gel, & Ointment
  • Desoximetasone 0.25% cream & Ointment
  • Diflorasone 0.05% cream & Ointment
  • Fluocin Body & Scalp Oil 0.01%
  • Fluocinonide 0.05% Lotion
  • Fluocinonide 0.1% Cream
  • Fluticasone 0.05% Lotion
  • Fondaparinux
  • Fragmin
  • HC Butyrate 0.1% cream & Ointment
  • HC Valerate 0.2% cream & Ointment
  • Hydrocort sol but
  • Pramosone-HC cream 1-1%
  • Prednicarbt 0.1% cream
  • Terbutaline 2.5mg & 5mg Tablet
  • TobraDex ST Suspension
  • Trianex 0.05% Ointment
  • Triderm cream 0.1% (select NDC #’s only)
  • Vancomycin Capsule 125mg & 250mg

Otras actualizaciones

  • Brimonidine 0.2% (Changed Quantity Level Limit)
  • Timolol 0.25% & 0.5% sol (Changed Quantity Level Limit)

¿Necesita información sobre la retirada de medicamentos?  Llama a EE.UU. Food and Drug Administration (FDA) en 1-888-463-6332.  O visite la página página de retirada de medicamentos en el sitio web de la FDA.

Prior authorization for drugs

If the drug you are requesting is not listed below, use the Universal Pharmacy Prior Authorization Fax Form . Also view our list of Step Therapy guidelines.  To initiate an electronic prior authorization (ePA) request, please click here.

To quickly find a prior authorization form, click "CTRL F" on your keyboard and type in the form name. 

Universal Pharmacy Prior Authorization Fax Form CHIP

 

Antidepressants   

Corlanor    

Egrifta     

Hepatitis C  

Monoamine Depletors (Austedo, Ingrezza, tetrabenzaine) 

Opioids Long and Short Acting  

Synagis 

Tepezza 

 

We are committed to making sure our providers receive the best possible information, and the latest technology and tools available.

We have partnered with CoverMyMeds® and SureScripts to provide you a new way to request a pharmacy prior authorization through the implementation of Electronic Prior Authorization (ePA) program.

With Electronic Prior Authorization (ePA), you can look forward to:

  • Time saving
    • Decreasing paperwork, phone calls and faxes for requests for prior authorization
  • Quicker Determinations
    • Reduces average wait times, resolution often within minutes
  • Accommodating & Secure
    • HIPAA compliant via electronically submitted requests

No cost required! Let us help get you started!

Getting started is easy. Choose ways to enroll:

Billing Information: 

BIN: 610591

PCN: ADV

Group: (Medicaid) RX8813

Group: (CHIP) RX8814

Aetna Better Health used the Department of Human Services (DHS) Drug Criteria and our custom Prior Authorization Guidelines to make decisions when you send in a request for a drug on the Statewide PDL/formulary that needs a review prior to being dispensed. To have a copy of these guidelines sent to you or to have any questions answered, just call:

Medicaid Provider Relations at 1-866-838-1232

 

Aetna's Custom Prior Authorization Guidelines

Acamprosate (PARP approved 9/2021)       

Anthelmintics (PARP approved 11/2020)

Continuous Glucose Monitoring (PARP approved 05/2020)                                                                                                                               

Compound Guideline (PARP approved 10/2020)

Corlanor (PARP approved 11/2020)

Cystic Fibrosis (PARP approved 08/2020)

Daraprim (PARP approved 06/2018)    

Egrifta (PARP approved 09/2021)

Elmiron (PARP approved 09/2021)

Gene Based Therapy for Duchenne Muscular Dystrophy (PARP approved 09/2021)

Generic Substitution (PARP approved 12/2019)                                        

HP Acthar (PARP approved 09/2020)                                              

Interferons (non-Hepatitis C) (PARP approved 08/2021)  

IVIG Products  (PARP approved 10/2020) 

L-Methylfolate Products (PARP approved 09/2020)

Lucemyra (PARP approved 02/2019)                                                 

Multaq (PARP approved 11/2020)

Non-Formulary Medication (PARP approved 09/2021)

Nuedexta (PARP approved 10/2020)

Off Label Use (PARP approved 10/2020)

Oxbryta (PARP approved 08/2020)

Quantity Limits (PARP approved 09/2021)

Sensipar (PARP approved 09/2021)

Somatostatin Analogs  (PARP approved 10/2020)

Spinraza (PARP approved 09/2021)

Synagis (PARP approved 09/2020)

Tranexamic Acid (PARP approved 11/2020)

Trial Dose Program (PARP approved 10/2014)

Zolgensma (PARP approved 09/2020)

To quickly find a prior authorization guideline, click "CTRL F" on your keyboard and type in the guideline name.

Non-Formulary and Prior Authorization Guidelines 

                                       

Acamprosate Calcium

Amitiza

Amphetamine Products

Antihyperlipidemics 

Aripiprazole Injection

Atypical Antipsychotics Oral-Transdermal                                                                          

Botulinum Toxins  

Calcipotriene     

Cequa and Cyclosporine Ophthalmic Emulsion                                           

Colony Stimulating Factors                       

Cytokine and CAM Antagonists 

Daraprim

Dificid

Endari      

Global Exception

Growth Hormone                                           

Hepatitis C 

Hereditary Angioedema Agents                                 

Immune Globulins 

Injectable Osteoporosis Agents   

Invega Sustenna         

Invega Trinza        

Lidocaine Topical Patch       

Linzess     

Methylphenidate Products 

Movantik   

Multiple Sclerosis Agents 

Nayzilam

Onychomycosis

Opioids

Pregabalin Immediate Release

Risperdal Consta

Rivastigmine Patch

Symproic

Trial Dose Program 

Tyrvaya

Xifaxan 200mg

Xifaxan 550mg

Xiidra

Careful handling and quick delivery for specialty drugs

Our preferred Specialty Pharmacy providers are Accuserv Pharmacy, Caremark Specialty Pharmacy, Einstein at Center One Pharmacy, Elwyn Specialty Care, Giant Eagle Pharmacy, Pharmblue LLC and Senderra Rx Pharmacy.

These pharmacies fill prescriptions for Specialty Drugs.* These types of drugs may be injected, infused or taken by mouth. Usually, you can't get these drugs at a local retail pharmacy. They often need special storage and handling. And they need to be delivered quickly.

Our preferred Specialty Pharmacies provide many helpful services, including:

  • Free, secure delivery (usually within 48 hours of confirming your order)
  • Envío a su domicilio, al consultorio del médico o a cualquier otro lugar que elija.
  • Package tracking for prompt delivery
  • Capacitación para que pueda inyectarse el medicamento.
  • Free injection supplies, such as needles, syringes, alcohol swabs, adhesive bandages and containers for needle waste

Cómo comenzar

We have several ways for you to fill a prescription through one of our preferred Specialty Pharmacies.

Existing prescriptions: To transfer an existing prescription, call one of our Preferred Specialty pharmacies.

New prescriptions: For a new prescription, your doctor can:

  • Send a prescription electronically.
  • Fax your prescription
  • Call one of preferred specialty pharmacies
  • You or the doctor can mail the prescription order.

After the pharmacy receives your prescription, your first order should ship within 48 hours. It may take longer if they need to contact your doctor about the prescription. 

Accuserv Pharmacy

Banks Apothecary

Caremark Specialty Pharmacy

Einstein at Center One Pharmacy

Elwyn Specialty Care

Giant Eagle Pharmacy

Pharmblue LLC

  • You or your doctor can visit the web site for an enrollment form: https://www.pharmblue.com
  • Phone: 855-779-4720
  • Fax: 844-818-7550

Senderra Rx Pharmacy

A personal care plan and ongoing support

Each of our preferred Specialty Pharmacies has a team of experienced nurses and pharmacists to help you understand how to use your medicine. They can answer your questions and help you cope with your condition throughout your therapy.

You can talk to them 24 hours a day, 7 days a week.

Get extra support for your complex medical condition

Skilled nurses and pharmacists offer extra support to patients with complex medical conditions, such as the any of the following:

  • Anemia
  • Asma
  • Cáncer
  • Chronic renal failure
  • Crohn's disease
  • Gaucher disease
  • Growth hormone deficiency
  • Hematologic conditions
  • Hemofilia
  • Hepatitis
  • HIV/AIDS
  • Immune system disorders
  • Esclerosis múltiple
  • Neurologic conditions
  • Osteoarthritis
  • Psoriasis
  • Pulmonary diseases
  • Respiratory syncytial virus (RSV)
  • Artritis reumatoide
  • Transplant

Joining our preferred Specialty Pharmacy network

Are you a pharmacy interested in joining our preferred specialty pharmacy network? You can get the application process started by sending an email to Specialtypharmacyapplications@cvscaremark.com. Thank you for your interest in supporting our commitment to high-quality care.

Specialty locations

The step therapy program requires certain first-line drugs, such as generic drugs or formulary brand drugs, to be prescribed prior to approval of specific, second-line drugs. Drugs with step therapy guidelines are identified on the formulary as “STEP.”

To request an override for the step therapy, please fax the correct pharmacy Prior Authorization request form to 1-877-309-8077. You can include any supporting medical records that will assist with the review of the request.

Muy pronto.

The Aetna Better Health® of Pennsylvania/Kids Pharmacy & Therapeutics (P&T) Committee develops and reviews the supplemental formulary (Medicaid) and the formulary for CHIP.  The committee also reviews all clinical criteria for utilization management.  All P&T changes for the supplemental formulary are submitted to the Department for review and approval prior to implementation.

Pharmacy Provider Appeals

You can request Aetna Better Health for a second level appeal after your pricing appeal to the pharmacy benefit manager (PBM) has been denied.

For questions concerning the Provider Appeal process, contact the Provider Appeal Department at 1-860-754-1757.

To submit a formal Provider Appeal in writing, send to the address below:

 

Aetna Better Health of Pennsylvania

Attention: Provider Appeals

2000 Market Street, Suite 850

Philadelphia, PA 19103

 

Submission steps:

  1. Submit the appeal in writing to Aetna Better Health to the address above.
  2. Include all supporting documentation with the appeal submission:
    1. Chains/PSAOs
      1. Documentation of denied Pricing Appeal outcome from the PBM
      2. Documentation that outreach regarding the denied outcome of appeal has been made to their PSAO or Corporate Headquarters with no resolution
    2. Independent Pharmacies not affiliated with a PSAO
      1. Documentation of denied Pricing Appeal outcome from the PBM
    3. Claim information that includes:
      1. Pharmacy NCPDP number
      2. Pharmacy Name
      3. Name of PSAO (if applicable)
      4. Prescription number
      5. NDC
      6. Drug Name
      7. Date of Fill
    4. Documentation of pricing information from at least two (2) wholesalers, if applicable, inclusive of any additional rebates or discounts, showing that the wholesaler prices are not equal to or less than the MAC price
  3. We will acknowledge a Pharmacy Provider Appeal within five (5) business days after receipt.
  4. The appeal documentation will be reviewed, and a decision will be rendered within thirty (30) business days after receipt.
  5. Failure to submit support documentation may result in denial of the Provider Appeal.

Also, we have a Pharmacy Provider Appeals Committee to review and render a decision. The decision of the Provider Clinical Appeals Committee is final. We send decision notification letters to the requesting provider within five (5) business days of the committee decision. We will not take any punitive action against a provider for using the Provider Appeal Process.