Medications we cover

Your plan has a list of medications we cover. This is called the preferred drug list (PDL). Medicaid and Florida Healthy Kids (FHK) each have their own PDL.

Questions?

Your plan’s PDL

Medicaid

Medicaid plans use the Florida Medicaid PDL. You can check the PDL to see if we cover your medication. You can also check a list of recent updates to the PDL on their site.

Florida Healthy Kids

FHK has a searchable PDL you can check for your or your child’s medication. You can also check the updates section on this page. It lists the recent changes to the FHK PDL.

There are many different things that you can do with your or your child’s PDL search tool. You can

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

PDL changes and updates

You can find the latest changes to the Medicaid PDL on the Florida Agency for Health Care Administration (AHCA) website. Just look for the document called “Changes Summary Report.”

Diabetic supplies

Your plan has a list of Diabetic Supplies that we cover. This is called the Preferred Product List (PPL). Medicaid and Florida Healthy Kids (FHK) each have their own PPL for Diabetic Supplies.

Medicaid Diabetes supplies (PDF)

Florida Healthy Kids Diabetes supplies (PDF)

Florida Healthy Kids PDL updates

December 2024

Additions:

Ocrevus zunovo 920 mg/23000 mg per 23 mL solution (Prior Authorization, Quantity Limit)

Removals:

Other Updates:

November 2024

Additions:

Baclofen 5 mg per 5 mL solution (Quantity Limit)
Clobazam 10 mg tablet (Prior Authorization)
Clobazam 2.5 mg per mL suspension (Prior Authorization)
Clobazam 20 mg tablet (Prior Authorization)
Entresto 15 mg/16 mg sprinkle capsule (Prior Authorization, Quantity Limit)
Entresto 6 mg/6 mg sprinkle capsule (Prior Authorization, Quantity Limit)
Folivane ob 85 mg/1 mg capsule (Quantity Limt)
Libervant 10 mg buccal film (Quantity Limit)
Libervant 12.5 mg buccal film (Quantity Limit)
Libervant 15 mg buccal film (Quantity Limit)
Libervant 5 mg buccal film (Quantity Limit)
Libervant 7.5 mg buccal film (Quantity Limit)
Liraglutide 18 mg per 3 mL pen injector (Step Therapy, Quantity Limit)
Naloxone 0.4 mg per mL prefilled syringe (Quantity Limit)
Ojemda 100 mg tablet (Prior Authorization, Quantity Limit)
Ojemda 25 mg per mL reconstituted suspension (Prior Authorization, Quantity Limit)
Rextovy 4 mg per 0.25 mL nasal spray (Quantity Limit)
Rufinamide 200 mg tablet (Prior Authorization)
Rufinamide 40 mg per mL suspension (Prior Authorization)
Rufinamide 400 mg tablet (Prior Authorization)
Tiotropium bromide 18 mcg inhaler (Quantity Limit)

Removals:

Opsumit 10 mg tablet

Other Updates:

Abilify maintena 300 mg extended release prefilled syringe (Removed Prior Authorization, Added Age Limit)
Abilify maintena 300 mg extended release reconstituted suspension (Removed Prior Authorization, Added Age Limit)
Abilify maintena 400 mg extended release prefilled syringe (Removed Prior Authorization, Added Age Limit)
Abilify maintena 400 mg extended release reconstituted suspension (Removed Prior Authorization, Added Age Limit)
Aristada 1064 mg per 3.9 mL prefilled syringe (Removed Prior Authorization, Added Age Limit)
Aristada 441 mg per 1.6 mL prefilled syringe (Removed Prior Authorization, Added Age Limit)
Aristada 662 mg per 2.4 mL prefilled syringe (Removed Prior Authorization, Added Age Limit)
Aristada 882 mg per 3.2 mL prefilled syringe (Removed Prior Authorization, Added Age Limit)
Aristada initio 675 mg per 2.4 mL prefilled syringe (Removed Prior Authorization, Added Age Limit)
Emgality 120 mg per mL auto injector (Changed Step Therapy)
Emgality 120 mg per mL prefilled syringe (Changed Step Therapy)
Invega hafyera 1092 mg per 3.5 mL prefilled syringe (Removed Prior Authorization, Added Age Limit)
Invega hafyera 1560 mg per 5 mL prefilled syringe (Removed Prior Authorization, Added Age Limit)
Invega sustenna 117 mg per 0.75 mL prefilled syringe (Removed Prior Authorization, Added Age Limit)
Invega sustenna 156 mg per mL prefilled syringe (Removed Prior Authorization, Added Age Limit)
Invega sustenna 234 mg per 1.5 mL prefilled syringe (Removed Prior Authorization, Added Age Limit)
Invega sustenna 39 mg per 0.25 mL prefilled syringe (Removed Prior Authorization, Added Age Limit)
Invega sustenna 78 mg per 0.5 mL prefilled syringe (Removed Prior Authorization, Added Age Limit)
Invega trinza 273 mg per 0.88 mL prefilled syringe (Removed Prior Authorization, Added Age Limit)
Invega trinza 410 mg per 1.32 mL prefilled syringe (Removed Prior Authorization, Added Age Limit)
Invega trinza 546 mg per 1.75 mL prefilled syringe (Removed Prior Authorization, Added Age Limit)
Invega trinza 819 mg per 2.63 mL prefilled syringe (Removed Prior Authorization, Added Age Limit)
Pregabalin 100 mg capsule (Removed Prior Authorization)
Pregabalin 150 mg capsule (Removed Prior Authorization)
Pregabalin 200 mg capsule (Removed Prior Authorization)
Pregabalin 225 mg capsule (Removed Prior Authorization)
Pregabalin 25 mg capsule (Removed Prior Authorization)
Pregabalin 300 mg capsule (Removed Prior Authorization)
Pregabalin 50 mg capsule (Removed Prior Authorization)
Pregabalin 75 mg capsule (Removed Prior Authorization)
Risperidone microspheres 12.5 mg extended release suspension (Removed Prior Authorization, Added Age Limit)
Risperidone microspheres 25 mg extended release suspension (Removed Prior Authorization, Added Age Limit)
Risperidone microspheres 37.5 mg extended release suspension (Removed Prior Authorization, Added Age Limit)
Risperidone microspheres 50 mg extended release suspension (Removed Prior Authorization, Added Age Limit)
Sevelamer carbonate 800 mg tablet (Removed Step Therapy)

October 2024

Additions:

Removals:

Other Updates:

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

September 2024

Additions:

Removals:

Other Updates:

August 2024

Additions:

Austedo 30 mg extended release tablet (Prior Authorization, Quantity Limit)
Austedo 36 mg extended release tablet (Prior Authorization, Quantity Limit)
Austedo 42 mg extended release tablet (Prior Authorization, Quantity Limit)
Austedo 48 mg extended release tablet (Prior Authorization, Quantity Limit)
Derma-smooth 0.01% scalp oil (Quantity Limit)
Eletriptan hydrobromide 20 mg tablet (Quantity Limit)
Eletriptan hydrobromide 40 mg tablet (Quantity Limit)
Nexletol 180 mg tablet (Prior Authorization, Quantity Limit)
Rinvoq 1 mg per mL oral solution (Prior Authorization)
Tinidazole 250 mg tablet
Tinidazole 500 mg tablet

Removals:

Alclometasone dipropionate 0.05% cream
Alclometasone dipropionate 0.05% ointment
Fluocinolone acetonide 0.025% cream
Tabloid 40 mg tablet
Vancomycin 25 mg per mL reconstituted solution
Vancomycin 50 mg per mL reconstituted solution

Other Updates:

Albendazole 200 mg tablet (Removed Prior Authorization)
Clobetasol propionate 0.05% gel (Removed Step Therapy)
Linezolid 600 mg tablet (Removed Prior Authorization, Added Quantity Limit)

July 2024

Additions:

Removals:

Other Updates:

June 2024

Additions:

Hemlibra 12 mg per 0.4 mL solution
Hemlibra 300 mg per 2 mL solution

Removals:

Other Updates:

May 2024

Additions:

Adapalene 0.3% gel (Age Limit, Quantity Limit, Step Therapy)
Adapalene benzoyl peroxide 0.1%-2.5% gel (Age Limit, Quantity Limit)
Anti itch 2%-0.1% cream
Azelaic acid 15% gel (Quantity Limit)
Banophen 2%-0.1% cream
Capasil 2%-10% cream
Clindamycin phosphate benzoyl 1%-5% gel (Quantity Limit)
Clindamycin phosphate benzoyl 1.2%-5% gel (Quantity Limit)
Diphenhydramine zinc acetate 2%-0.1% cream
Doxycycline hyclate 75 mg tablet
Doxycycline monohydrate 50 mg tablet
Doxycycline monohydrate 75 mg tablet
Erythromycin benzoyl peroxide 5%-3% gel (Quantity Limit)
Fluticasone propionate 100 mcg per actuation inhalation (Quantity Limit)
Fluticasone propionate 250 mcg per actuation inhalation (Quantity Limit)
Fluticasone propionate 50 mcg per actuation inhalation (Quantity Limit)
Galantamine hydrobromide 12 mg tablet (Quantity Limit)
Galantamine hydrobromide 4 mg per mL oral solution (Quantity Limit)
Galantamine hydrobromide 4 mg tablet (Quantity Limit)
Galantamine hydrobromide 8 mg tablet (Quantity Limit)
Galantamine hydrobromide extended release 16 mg capsule (Quantity Limit)
Galantamine hydrobromide extended release 24 mg capsule (Quantity Limit)
Galantamine hydrobromide extended release 8 mg capsule (Quantity Limit)
Isosorb dinitrate 20 mg/hydralazine 37.5 mg tablet (Quantity Limit)
Itch relief extra strength 2%-0.1% cream
Mencylate 2%-10% cream
Muscle rub 10%-15% cream
Narcan 4 mg per 0.1 mL nasal liquid (Quantity Limit)
Nitroglycerin 0.4% ointment (Prior Authorization, Age Limit)
Oxycodone extended release 10 mg tablet (Auto Prior Authorization, Quantity Limit)
Oxycodone extended release 20 mg tablet (Auto Prior Authorization, Quantity Limit)
Oxycodone extended release 40 mg tablet (Auto Prior Authorization, Quantity Limit)
Oxycodone extended release 80 mg tablet (Auto Prior Authorization, Quantity Limit)
Pain relieving cream
Retin-A 0.01% gel (Age Limit, Step Therapy)
Retin-A 0.025% cream (Age Limit, Step Therapy)
Retin-A 0.025% gel (Age Limit, Step Therapy)
Retin-A 0.05% cream (Age Limit, Step Therapy)
Retin-A 0.1% cream (Age Limit, Step Therapy)
Rivastigmine tartate 1.5 mg capsule (Quantity Limit)
Rivastigmine tartate 3 mg capsule (Quantity Limit)
Rivastigmine tartate 4.5 mg capsule (Quantity Limit)
Rivastigmine tartate 6 mg capsule (Quantity Limit)
Teriflunomide 14mg tablet (Prior Authorization, Age Limit, Quantity Limit)
Teriflunomide 7mg tablet (Prior Authorization, Age Limit, Quantity Limit)
Thera gesic 1%-15% cream
Zovirax 5% ointment (Age Limit, Quantity Limit, Step Therapy)

Removals:

Acyclovir 5% ointment
Arnuity ellipta 100 mcg per actuation inhalation
Arnuity ellipta 200 mcg per actuation inhalation
Arnuity ellipta 50 mcg per actuation inhalation
Aubagio 14 mg tablet
Aubagio 7 mg tablet
Cefadroxil 1 gm tablet
Glucagon 1 mg per mL injection
Rectiv 0.4% ointment
Tretinoin 0.01% gel
Tretinoin 0.025% cream
Tretinoin 0.025% gel
Tretinoin 0.05% cream
Tretinoin 0.1% cream

Other Updates:

Accutane 10 mg capsule (Added Quantity Limit)
Accutane 20 mg capsule (Added Quantity Limit)
Accutane 30 mg capsule (Added Quantity Limit)
Acetaminophen extended release 650 mg tablet (Added Quantity Limit)
Amnesteem 10 mg capsule (Added Quantity Limit)
Amnesteem 20 mg capsule (Added Quantity Limit)
Amphetamine dextroamphetamine 10 mg tablet (Added Quantity Limit)
Amphetamine dextroamphetamine 12.5 mg tablet (Added Quantity Limit)
Amphetamine dextroamphetamine 15 mg tablet (Added Quantity Limit)
Amphetamine dextroamphetamine 20 mg tablet (Added Quantity Limit)
Amphetamine dextroamphetamine 30 mg tablet (Added Quantity Limit)
Amphetamine dextroamphetamine 5 mg tablet (Added Quantity Limit)
Amphetamine dextroamphetamine 7.5 mg tablet (Added Quantity Limit)
Amphetamine dextroamphetamine extended release 10 mg capsule (Added Quantity Limit)
Amphetamine dextroamphetamine extended release 15 mg capsule (Added Quantity Limit)
Amphetamine dextroamphetamine extended release 30 mg capsule (Added Quantity Limit)
Amphetamine dextroamphetamine extended release 5 mg capsule (Added Quantity Limit)
Aripiprazole 10 mg tablet (Added Quantity Limit)
Aripiprazole 15 mg tablet (Added Quantity Limit)
Atomoxetine 10 mg capsule (Added Quantity Limit)
Atomoxetine 100 mg capsule (Added Quantity Limit)
Atomoxetine 18 mg capsule (Added Quantity Limit)
Atomoxetine 25 mg capsule (Added Quantity Limit)
Atomoxetine 40 mg capsule (Added Quantity Limit)
Atomoxetine 60 mg capsule (Added Quantity Limit)
Atomoxetine 80 mg capsule (Added Quantity Limit)
Baclofen 10 mg tablet (Changed Quantity Limit)
Baclofen 5 mg tablet (Added Quantity Limit)
Budesonide 0.25mg per 2 mL inhalation (Removed Age Limit)
Budesonide 0.5mg per 2 mL inhalation (Removed Age Limit)
Budesonide 1 mg per 2 mL inhalation (Removed Age Limit)
Bupropion 100 mg tablet (Changed Quantity Limit)
Carbamazipine extended release 100 mg capsule (Added Quantity Limit)
Carbamazipine extended release 100 mg tablet (Added Quantity Limit)
Carbamazipine extended release 200 mg capsule (Added Quantity Limit)
Carbamazipine extended release 200 mg tablet (Added Quantity Limit)
Carbamazipine extended release 300 mg capsule (Added Quantity Limit)
Carbidopa 12.5 mg/levodopa 50 mg/entacapone 200 mg tablets (Added Quantity Limit)
Carbidopa 18.75 mg/levodopa 75 mg/entacapone 200 mg tablets (Added Quantity Limit)
Carbidopa 25 mg/levodopa 100 mg/entacapone 200 mg tablets (Added Quantity Limit)
Carbidopa 31.25 mg/levodopa 125 mg/entacapone 200 mg tablets (Added Quantity Limit)
Carbidopa 37.5 mg/levodopa 150 mg/entacapone 200 mg tablets (Added Quantity Limit)
Carbidopa 50 mg/levodopa 200 mg/entacapone 200 mg tablets (Added Quantity Limit)
Celecoxib 100 mg capsule (Changed Quantity Limit)
Celecoxib 200 mg capsule (Changed Quantity Limit)
Celecoxib 50 mg capsule (Changed Quantity Limit)
Chlorzoxazone 500 mg tablet (Added Quantity Limit)
Ciclopirox olamine 0.77% cream (Removed Step Therapy)
Claravis 10 mg capsule (Added Quantity Limit)
Claravis 20 mg capsule (Added Quantity Limit)
Claravis 30 mg capsule (Added Quantity Limit)
Clindamycin phosphate 1% gel (Added Quantity Limit)
Clindamycin phosphate 1% lotion (Added Quantity Limit)
Clindamycin phosphate 1% swab (Added Quantity Limit)
Clopidogrel bisulfate 75 mg tablet (Added Quantity Limit)
Clozapine 100 mg tablet (Added Quantity Limit)
Clozapine 200 mg tablet (Added Quantity Limit)
Clozapine 25 mg tablet (Added Quantity Limit)
Cyclobenzaprine 10 mg tablet (Added Quantity Limit)
Cyclobenzaprine 5 mg tablet (Added Quantity Limit)
Cyclosporine 0.05% ophthalmic emulsion (Added Quantity Limit)
Dexmethylphenidate 10 mg tablet (Added Quantity Limit)
Dexmethylphenidate 2.5 mg tablet (Added Quantity Limit)
Dexmethylphenidate 5 mg tablet (Added Quantity Limit)
Dexmethylphenidate extended release 10 mg capsule (Added Quantity Limit)
Dexmethylphenidate extended release 15 mg capsule (Added Quantity Limit)
Dexmethylphenidate extended release 20 mg capsule (Added Quantity Limit)
Dexmethylphenidate extended release 25 mg capsule (Added Quantity Limit)
Dexmethylphenidate extended release 30 mg capsule (Added Quantity Limit)
Dexmethylphenidate extended release 35 mg capsule (Added Quantity Limit)
Dexmethylphenidate extended release 40 mg capsule (Added Quantity Limit)
Dexmethylphenidate extended release 5 mg capsule (Added Quantity Limit)
Dextroamphetamine sulfate 10 mg tablet (Added Quantity Limit)
Dextroamphetamine sulfate 5 mg tablet (Added Quantity Limit)
Donepezil hydrochloride 10 mg tablet (Added Quantity Limit)
Donepezil hydrochloride 5 mg tablet (Changed Quantity Limit)
Donepezil hydrochloride orally disintegrating 10 mg tablet (Added Quantity Limit)
Donepezil hydrochloride orally disintegrating 5 mg tablet (Changed Quantity Limit)
Eliquis 5 mg tablet (Changed Quantity Limit)
Entacapone 200 mg tablet (Changed Quantity Limit)
Fluticasone propionate 110 mcg per actuation inhalation (Removed Age Limit)
Fluticasone propionate 220 mcg per actuation inhalation (Removed Age Limit)
Fluticasone propionate 44 mcg per actuation inhalation (Removed Age Limit)
Gabapentin 100 mg capsule (Added Quantity Limit)
Gabapentin 300 mg capsule (Added Quantity Limit)
Gabapentin 400 mg capsule (Added Quantity Limit)
Gabapentin 600 mg tablet (Added Quantity Limit)
Gabapentin 800 mg tablet (Added Quantity Limit)
Glatiramer acetate 20 mg per mL prefilled syringe (Changed Quantity Limit)
Glatopa 20 mg per mL prefilled syringe (Changed Quantity Limit)
Guanfacine extended release 1 mg tablet (Added Quantity Limit)
Guanfacine extended release 2 mg tablet (Added Quantity Limit)
Guanfacine extended release 4 mg tablet (Added Quantity Limit)
Haloperidol 0.5 mg tablet (Added Quantity Limit)
Haloperidol 10 mg tablet (Added Quantity Limit)
Haloperidol 20 mg tablet (Added Quantity Limit)
Haloperidol 5 mg tablet (Added Quantity Limit)
Haloperidol lactate 2 mg per mL oral concentrate (Added Quantity Limit)
Haloperidol lactate 5 mg per mL injection (Added Quantity Limit)
Isotretinoin 10 mg capsule (Added Quantity Limit)
Isotretinoin 20 mg capsule (Added Quantity Limit)
Isotretinoin 30 mg capsule (Added Quantity Limit)
Lamotrigine 100 mg tablet (Added Quantity Limit)
Lamotrigine 150 mg tablet (Added Quantity Limit)
Lamotrigine 200 mg tablet (Added Quantity Limit)
Lamotrigine 25 mg tablet (Added Quantity Limit)
Lamotrigine 5 mg chewable tablet (Added Quantity Limit)
Leflunomide 10 mg tablet (Added Quantity Limit)
Leflunomide 20 mg tablet (Added Quantity Limit)
Levetiracetam 1000 mg tablet (Added Quantity Limit)
Levetiracetam 250 mg tablet (Added Quantity Limit)
Levetiracetam 500 mg tablet (Added Quantity Limit)
Levetiracetam 750 mg tablet (Added Quantity Limit)
Levetiracetam extended release 500 mg tablet (Added Quantity Limit)
Levetiracetam extended release 750 mg tablet (Added Quantity Limit)
Lidocaine 2.5%/Prilocaine 2.5% cream (Added Quantity Limit)
Lidocaine 5% patch (Added Quantity Limit)
Loxapine succinate 25 mg capsule (Changed Quantity Limit)
Loxapine succinate 50 mg capsule (Changed Quantity Limit)
Meloxicam 15 mg tablet (Added Quantity Limit)
Meloxicam 7.5 mg tablet (Added Quantity Limit)
Methocarbamol 500 mg tablet (Added Quantity Limit)
Methocarbamol 750 mg tablet (Added Quantity Limit)
Methylphenidate 10 mg chewable tablet (Added Quantity Limit)
Methylphenidate 10 mg per 5 mL solution (Added Quantity Limit)
Methylphenidate 10 mg tablet (Added Quantity Limit)
Methylphenidate 2.5 mg chewable tablet (Added Quantity Limit)
Methylphenidate 20 mg tablet (Added Quantity Limit)
Methylphenidate 5 mg chewable tablet (Added Quantity Limit)
Methylphenidate 5 mg per 5 mL solution (Added Quantity Limit)
Methylphenidate 5 mg tablet (Added Quantity Limit)
Methylphenidate extended release 10 mg capsule (Added Quantity Limit)
Methylphenidate extended release 10 mg tablet (Added Quantity Limit)
Methylphenidate extended release 18 mg tablet (Added Quantity Limit)
Methylphenidate extended release 20 mg capsule (Added Quantity Limit)
Methylphenidate extended release 20 mg tablet (Added Quantity Limit)
Methylphenidate extended release 27 mg tablet (Added Quantity Limit)
Methylphenidate extended release 30 mg capsule (Added Quantity Limit)
Methylphenidate extended release 36 mg tablet (Added Quantity Limit)
Methylphenidate extended release 40 mg capsule (Added Quantity Limit)
Methylphenidate extended release 50 mg capsule (Added Quantity Limit)
Methylphenidate extended release 50 mg capsule (Added Quantity Limit)
Methylphenidate extended release 54 mg tablet (Added Quantity Limit)
Methylphenidate osmotic release 18 mg tablet (Added Quantity Limit)
Methylphenidate osmotic release 27 mg tablet (Added Quantity Limit)
Methylphenidate osmotic release 36 mg tablet (Added Quantity Limit)
Methylphenidate osmotic release 54 mg tablet (Added Quantity Limit)
Nabumetone 500 mg tablet (Added Quantity Limit)
Nabumetone 750 mg tablet (Added Quantity Limit)
Nicotine 14 mg per 24 hours patch (Added Quantity Limit)
Nicotine 21 mg per 24 hours patch (Added Quantity Limit)
Nicotine 21 mg/14 mg/7 mg per 24 hours patch (Added Quantity Limit)
Nicotine 7 mg per 24 hours patch (Added Quantity Limit)
Olanzapine 10 mg orally disintegrating tablet (Added Quantity Limit)
Olanzapine 10 mg tablet (Added Quantity Limit)
Olanzapine 15 mg orally disintegrating tablet (Added Quantity Limit)
Olanzapine 15 mg tablet (Added Quantity Limit)
Olanzapine 2.5 mg tablet (Added Quantity Limit)
Olanzapine 20 mg orally disintegrating tablet (Added Quantity Limit)
Olanzapine 20 mg tablet (Added Quantity Limit)
Olanzapine 5 mg orally disintegrating tablet (Added Quantity Limit)
Olanzapine 5 mg tablet (Added Quantity Limit)
Olanzapine 7.5 mg tablet (Added Quantity Limit)
Orphenadrine citrate extended release 100 mg tablet (Added Quantity Limit)
Perphenazine 16 mg tablet (Added Quantity Limit)
Perphenazine 2 mg tablet (Added Quantity Limit)
Perphenazine 4 mg tablet (Added Quantity Limit)
Perphenazine 8 mg tablet (Added Quantity Limit)
Pregabalin 300 mg capsule (Added Quantity Limit)
Prochlorperazine maleate 10 mg tablet (Added Quantity Limit)
Prochlorperazine maleate 5 mg tablet (Added Quantity Limit)
Promacta 12.5 mg tablet (Added Quantity Limit)
Promacta 25 mg tablet (Added Quantity Limit)
Promacta 50 mg tablet (Added Quantity Limit)
Promacta 75 mg tablet (Added Quantity Limit)
Quetiapine fumarate 100 mg tablet (Changed Quantity Limit)
Quetiapine fumarate 200 mg tablet (Added Quantity Limit)
Quetiapine fumarate 25 mg tablet (Added Quantity Limit)
Quetiapine fumarate 300 mg tablet (Added Quantity Limit)
Quetiapine fumarate 400 mg tablet (Added Quantity Limit)
Quetiapine fumarate 50 mg tablet (Added Quantity Limit)
Risperidone 0.25 mg orally disintegrating tablet (Added Quantity Limit)
Risperidone 0.25 mg tablet (Added Quantity Limit)
Risperidone 0.5 mg orally disintegrating tablet (Added Quantity Limit)
Risperidone 0.5 mg tablet (Added Quantity Limit)
Risperidone 1 mg orally disintegrating tablet (Added Quantity Limit)
Risperidone 1 mg per mL solution (Changed Quantity Limit)
Risperidone 1 mg tablet (Added Quantity Limit)
Risperidone 2 mg orally disintegrating tablet (Added Quantity Limit)
Risperidone 2 mg tablet (Added Quantity Limit)
Risperidone 3 mg orally disintegrating tablet (Added Quantity Limit)
Risperidone 3 mg tablet (Added Quantity Limit)
Risperidone 4 mg orally disintegrating tablet (Added Quantity Limit)
Risperidone 4 mg tablet (Added Quantity Limit)
Ropinirole hydrochloride 0.25 mg tablet (Added Quantity Limit)
Ropinirole hydrochloride 0.5 mg tablet (Added Quantity Limit)
Ropinirole hydrochloride 1 mg tablet (Added Quantity Limit)
Ropinirole hydrochloride 2 mg tablet (Added Quantity Limit)
Ropinirole hydrochloride 3 mg tablet (Added Quantity Limit)
Ropinirole hydrochloride 4 mg tablet (Added Quantity Limit)
Ropinirole hydrochloride 5 mg tablet (Added Quantity Limit)
Ropinirole hydrochloride extended release 12 mg tablet (Added Quantity Limit)
Ropinirole hydrochloride extended release 2 mg tablet (Added Quantity Limit)
Ropinirole hydrochloride extended release 4 mg tablet (Added Quantity Limit)
Ropinirole hydrochloride extended release 6 mg tablet (Added Quantity Limit)
Ropinirole hydrochloride extended release 8 mg tablet (Added Quantity Limit)
Tacrolimus 0.01% ointment (Changed Step Therapy)
Tacrolimus 0.03% ointment (Changed Step Therapy)
Temazepam 15 mg capsule (Added Quantity Limit)
Temazepam 30 mg capsule (Added Quantity Limit)
Thioridazine 10 mg tablet (Added Quantity Limit)
Thioridazine 100 mg tablet (Added Quantity Limit)
Thioridazine 25 mg tablet (Added Quantity Limit)
Thioridazine 50 mg tablet (Added Quantity Limit)
Thiothixene 10 mg capsule (Added Quantity Limit)
Tiagabine 12 mg tablet (Added Quantity Limit)
Tiagabine 16 mg tablet (Added Quantity Limit)
Tiagabine 4 mg tablet (Added Quantity Limit)
Topiramate 15 mg sprinkle capsule (Added Quantity Limit)
Topiramate 200 mg tablet (Added Quantity Limit)
Topiramate 25 mg sprinkle capsule (Added Quantity Limit)
Topiramate 25 mg tablet (Added Quantity Limit)
Topiramate 50 mg tablet (Added Quantity Limit)
Trifluoperazine 1 mg tablet (Added Quantity Limit)
Trifluoperazine 10 mg tablet (Added Quantity Limit)
Trifluoperazine 2 mg tablet (Added Quantity Limit)
Xarelto 10 mg tablet (Added Quantity Limit)
Xarelto 15 mg tablet (Added Quantity Limit)
Xarelto 20 mg tablet (Added Quantity Limit)
Zaleplon 5 mg capsule (Changed Quantity Limit)
Zenatane 10 mg capsule (Added Quantity Limit)
Zenatane 20 mg capsule (Added Quantity Limit)
Zenatane 30 mg capsule (Added Quantity Limit)
Ziprasidone 20 mg capsule (Added Quantity Limit)
Ziprasidone 40 mg capsule (Added Quantity Limit)
Ziprasidone 60 mg capsule (Added Quantity Limit)
Ziprasidone 80 mg capsule (Added Quantity Limit)
Zolpidem tartrate 10 mg tablet (Added Quantity Limit)
Zolpidem tartrate 5 mg tablet (Changed Quantity Limit)
Zonisamide 100 mg capsule (Added Quantity Limit)
Zonisamide 25 mg capsule (Added Quantity Limit)
Zonisamide 50 mg capsule (Added Quantity Limit)

April 2024

Additions:

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

Removals:

Other Updates:

Dabigatran 75 mg capsule (Added Quantity Limit)
Dabigatran 110 mg capsule (Added Quantity Limit)
Dabigatran 150 mg capsule (Added Quantity Limit)
Pradaxa 75 mg capsule (Added Quantity Limit)

March 2024

Additions:

Derma smoothe 0.01% oil (Quantity Limit)
Freestyle libre 3 reader (Prior Authorization, Quantity Limit)
Zenpep 60000 unit delayed release capsule

Removals:

Fluocinolone acetonide 0.01% oil

Other Updates:

Ubrelvy 100 mg tablet (Added Quantity Limit)
Ubrelvy 50 mg tablet (Added Quantity Limit)

February 2024

Additions:

Adalimumab adaz 40 mg per 0.4 mL auto injector (Prior Authorization)
Adalimumab adaz 40 mg per 0.4 mL prefilled syringe (Prior Authorization)
Adalimumab fkjp 20 mg per 0.4 mL prefilled syringe kit (Prior Authorization)
Adalimumab fkjp 40 mg per 0.8 mL auto injector kit (Prior Authorization)
Adalimumab fkjp 40 mg per 0.8 mL prefilled syringe kit (Prior Authorization)
Aristada initio 675 mg per 2.4 mL prefilled syringe (Prior Authorization, Quantity Limit)
Dupixent 200 mg injection (Prior Authorization)
Dupixent 200 mg per 1.14 mL injection (Prior Authorization)
Dupixent 300 mg per 2 mL injection (Prior Authorization)
Dupixent 300 mg per 2 mL injection (Prior Authorization)
Fesoterodine fumarate extended release 4 mg tablet (Step Therapy, Quantity Limit)
Fesoterodine fumarate extended release 8 mg tablet (Step Therapy, Quantity Limit)
Hadlima push touch 40 mg per 0.4 mL auto injector (Prior Authorization)
Hadlima push touch 40 mg per 0.4 mL prefilled syringe (Prior Authorization)
Hadlima push touch 40 mg per 0.8 mL auto injector (Prior Authorization)
Hadlima push touch 40 mg per 0.8 mL prefilled syringe (Prior Authorization)
Lurasidone 120 mg tablet (Age Limit, Quantity Limit)
Lurasidone 20 mg tablet (Age Limit, Quantity Limit)
Lurasidone 40 mg tablet (Age Limit, Quantity Limit)
Lurasidone 60 mg tablet (Age Limit, Quantity Limit)
Lurasidone 80 mg tablet (Age Limit, Quantity Limit)
Orilissa 150 mg tablet (Prior Authorization)
Orilissa 200 mg tablet (Prior Authorization)
Rinvoq 15 mg extended release tablet (Prior Authorization)
Rinvoq 30 mg extended release tablet (Prior Authorization)
Rinvoq 45 mg extended release tablet (Prior Authorization)
Teriparatide 620 mg per 2.48 mL pen injector (Prior Authorization, Quantity Limit)
Ubrelvy 100 mg tablet (Step Therapy)
Ubrelvy 50 mg tablet (Step Therapy)

Removals:

Bromocriptine mesylate 2.5 mg capsule
Bromocriptine mesylate 5 mg capsule
Climara pro patch 0.045/0.015 mg per day
Combipatch 0.05/0.14 mg per day
Combipatch 0.05/0.25 mg per day
Diflunisal 500 mg tablet
Glyburide 1.25 mg tablet
Glyburide 1.25 mg/metformin 250 mg tablet
Glyburide 2.5 mg tablet
Glyburide 2.5 mg/metformin 500 mg tablet
Glyburide 5 mg tablet
Glyburide 5 mg/metformin 500 mg tablet
Glyburide micronized 1.5 mg tablet
Glyburide micronized 3 mg tablet
Glyburide micronized 6 mg tablet
Humalog 100 units per mL cartridge
Humalog 200 units per mL kwik pen
Humira 10 mg per 0.1 mL pen injector
Humira 20 mg per 0.2 mL pen injector
Humira 40 mg per 0.4 mL pen injector
Humira 40 mg per 0.4 mL pen injector kit
Humira 40 mg per 0.8 mL pen injector
Humira 40 mg per 0.8 mL pen injector kit
Humira 80 mg per 0.8 mL pediatric starter kit
Humira 80 mg per 0.8 mL pen injector
Humira 80 mg per 0.8 mL/40 mg per 0.4 mL pediatric starter kit
Humira-psoriasis uviet 80 mg per 0.8 mL/40 mg per 0.4 mL pen injector starter kit
Insulin aspart 100 unit per mL cartridge
Insulin aspart 100 unit per mL injection
Insulin aspart 100 unit per mL pen injector
Ketorolac tromethamine 0.004% ophthalmic solution
Kevzara 150 mg per 1.14 mL auto injector
Kevzara 150 mg per 1.14 mL prefilled syringe
Kevzara 200 mg per 1.14 mL auto injector
Kevzara 200 mg per 1.14 mL prefilled syringe
Mesalamine delayed release 800 mg tablets
Nayzilam 5 mg per 0.1 mL nasal solution
Non bd brand insulin syringes
Salsalate 500 mg tablet
Salsalate 750 mg tablet
Viokace 10440 unit/39150 unit tablet
Viokace 20880 unit/78300 unit tablet

Other Updates:

Acarbose 100 mg tablet (Changed Quantity Limit)
Acarbose 25 mg tablet (Changed Quantity Limit)
Acarbose 50 mg tablet (Changed Quantity Limit)
Albuterol sulfate 0.083% nebulizer solution (Changed Quantity Limit)
Albuterol sulfate 0.5% nebulizer solution (Changed Quantity Limit)
Albuterol sulfate 0.63 mg per 3 mL nebulizer solution (Changed Quantity Limit)
Albuterol sulfate 1.25 mg per 3 mL nebulizer solution (Changed Quantity Limit)
Alfuzosin 10 mg extended release tablet (Added Quantity Limit)
Alprazolam 0.25 mg tablet (Changed Quantity Limit)
Alprazolam 0.5 mg tablet (Changed Quantity Limit)
Alprazolam 1 mg tablet (Changed Quantity Limit)
Amlodipine besylate 10 mg/benazepril 20 mg capsule (Added Quantity Limit)
Amlodipine besylate 10 mg/benazepril 40 mg capsule (Added Quantity Limit)
Amlodipine besylate 10 mg/valsartan 160 mg tablet (Added Quantity Limit)
Amlodipine besylate 10 mg/valsartan 320 mg tablet (Added Quantity Limit)
Amlodipine besylate 2.5 mg/benazepril 10 mg capsule (Added Quantity Limit)
Amlodipine besylate 5 mg/benazepril 10 mg capsule (Added Quantity Limit)
Amlodipine besylate 5 mg/benazepril 20 mg capsule (Added Quantity Limit)
Amlodipine besylate 5 mg/benazepril 40 mg capsule (Added Quantity Limit)
Amlodipine besylate 5 mg/valsartan 160 mg tablet (Added Quantity Limit)
Amlodipine besylate 5 mg/valsartan 320 mg tablet (Added Quantity Limit)
Benazepril 10 mg tablet (Added Quantity Limit)
Benazepril 20 mg tablet (Added Quantity Limit)
Benazepril 40 mg tablet (Added Quantity Limit)
Benazepril 5 mg tablet (Added Quantity Limit)
Benzonatate 100 mg capsule (Added Quantity Limit)
Benzonatate 200 mg capsule (Added Quantity Limit)
Bimatoprost 0.0003% ophthalmic solution (Added Quantity Limit)
Buspirone 10 mg tablet (Added Quantity Limit)
Buspirone 15 mg tablet (Added Quantity Limit)
Buspirone 30 mg tablet (Added Quantity Limit)
Buspirone 5 mg tablet (Added Quantity Limit)
Buspirone 7.5 mg tablet (Added Quantity Limit)
Candesartan cilexetil 16 mg tablet (Changed Quantity Limit)
Candesartan cilexetil 4 mg tablet (Changed Quantity Limit)
Candesartan cilexetil 8 mg tablet (Changed Quantity Limit)
Cetirizine 10 mg tablet (Changed Quantity Limit)
Cetirizine 5 mg tablet (Changed Quantity Limit)
Cetirizine 5 mg/pseudoephedrine 120 mg extended release tablet (Added Quantity Limit)
Chlordiazepoxide 10 mg capsule (Added Quantity Limit)
Chlordiazepoxide 25 mg capsule (Added Quantity Limit)
Chlordiazepoxide 5 mg capsule (Added Quantity Limit)
Citalopram hydrobromide 10 mg tablet (Added Quantity Limit)
Citalopram hydrobromide 20 mg tablet (Changed Quantity Limit)
Diazepam 1 mg per mL oral solution (Added Quantity Limit)
Diazepam 10 mg tablet (Added Quantity Limit)
Diazepam 2 mg tablet (Added Quantity Limit)
Diazepam 5 mg tablet (Added Quantity Limit)
Doxazosin mesylate 1 mg tablet (Changed Quantity Limit)
Doxazosin mesylate 2 mg tablet (Changed Quantity Limit)
Doxazosin mesylate 4 mg tablet (Changed Quantity Limit)
Duloxetine 30 mg enteric coated pellets capsule (Changed Quantity Limit)
Enalapril maleate 10 mg tablet (Added Quantity Limit)
Enalapril maleate 10 mg/ hydrochlorothiazide 25 mg tablet (Added Quantity Limit)
Enalapril maleate 2.5 mg tablet (Added Quantity Limit)
Enalapril maleate 20 mg tablet (Added Quantity Limit)
Enalapril maleate 5 mg tablet (Added Quantity Limit)
Enalapril maleate 5 mg/ hydrochlorothiazide 12.5 mg tablet (Added Quantity Limit)
Esomeprazole magnesium 40 mg delayed release capsule (Changed Quantity Limit)
Famotidine 40 mg tablet (Added Quantity Limit)
Finasteride 5 mg tablet (Added Quantity Limit)
Fluoxetine 10 mg capsule (Added Quantity Limit)
Fluoxetine 20 mg capsule (Added Quantity Limit)
Fluoxetine 40 mg capsule (Added Quantity Limit)
Fluvastatin sodium 20 mg capsule (Changed Quantity Limit)
Fluvoxamine maleate 100 mg tablet (Added Quantity Limit)
Fluvoxamine maleate 25 mg tablet (Added Quantity Limit)
Fluvoxamine maleate 50 mg tablet (Added Quantity Limit)
Fosinopril sodium 10 mg tablet (Changed Quantity Limit)
Fosinopril sodium 20 mg tablet (Changed Quantity Limit)
Fosinopril sodium 40 mg tablet (Changed Quantity Limit)
Gemfibrozil 600 mg tablet (Added quantity Limit)
Glimepiride 4 mg tablet (Removed Quantity Limit)
Guanfacine 1 mg tablet (Added Quantity Limit)
Guanfacine 2 mg tablet (Added Quantity Limit)
Hydroxyzine 50 mg tablet (Changed Quantity Limit)
Ipratropium 0.5 mg/albuterol 2.5 mg per 3 mL nebulizer solution (Added Quantity Limit)
Irbesartan 300 mg/ hydrochlorothiazide 12.5 mg tablet (Added Quantity Limit)
Lansoprazole delayed release 30 mg capsule (Added Quantity Limit)
Lisinopril 10 mg/ hydrochlorothiazide 12.5 mg tablet (Added Quantity Limit)
Lisinopril 20 mg/ hydrochlorothiazide 25 mg tablet (Added Quantity Limit)
Loratadine 10 mg rapidly disintegrating tablet (Added Quantity Limit)
Loratadine 10 mg tablet (Added Quantity Limit)
Loratadine 10 mg/pseudoephedrine 240 mg extended release tablet (Added Quantity Limit)
Loratadine 5 mg/pseudoephedrine 120 mg extended release tablet (Added Quantity Limit)
Lorazepam 0.5 mg tablet (Changed Quantity Limit)
Lorazepam 1 mg tablet (Changed Quantity Limit)
Losartan potassium 100 mg tablet (Changed Quantity Limit)
Losartan potassium 100 mg/ hydrochlorothiazide 12.5 mg tablet (Added Quantity Limit)
Losartan potassium 100 mg/ hydrochlorothiazide 25 mg tablet (Added Quantity Limit)
Losartan potassium 25 mg tablet (Changed Quantity Limit)
Losartan potassium 50 mg tablet (Changed Quantity Limit)
Losartan potassium 50 mg/ hydrochlorothiazide 12.5 mg tablet (Added Quantity Limit)
Lovastatin 10 mg tablet (Changed Quantity Limit)
Lovastatin 20 mg tablet (Changed Quantity Limit)
Lovastatin 40 mg tablet (Added Quantity Limit)
Mesalamine 0.375 gm extended release capsules (Added Quantity Limit)
Mesalamine 400 mg delayed release capsules (Added Quantity Limit)
Mirtazapine 15 mg orally disintegrating tablet (Added Quantity Limit)
Mirtazapine 15 mg tablet (Added Quantity Limit)
Mirtazapine 30 mg orally disintegrating tablet (Added Quantity Limit)
Mirtazapine 30 mg tablet (Added Quantity Limit)
Mirtazapine 45 mg orally disintegrating tablet (Added Quantity Limit)
Mirtazapine 45 mg tablet (Added Quantity Limit)
Mirtazapine 7.5 mg tablet (Added Quantity Limit)
Montelukast sodium 10 mg tablet (Changed Quantity Limit)
Montelukast sodium 4 mg chewable tablet (Changed Quantity Limit)
Montelukast sodium 4 mg granules packet (Changed Quantity Limit)
Montelukast sodium 5 mg chewable tablet (Changed Quantity Limit)
Nifedipine extended release 90 mg tablet (Added Quantity Limit)
Omega 3 acid ethyl esters 1 gm capsule (Added Quantity Limit)
Omeprazole delayed release 40 mg capsule (Changed Quantity Limit)
Ondansetron 4 mg oral disintegrating tablet (Changed Quantity Limit)
Ondansetron 4 mg per 5 mL oral solution (Changed Quantity Limit)
Ondansetron 4 mg tablet (Added Quantity Limit)
Ondansetron 8 mg oral disintegrating tablet (Changed Quantity Limit)
Ondansetron 8 mg tablet (Added Quantity Limit)
Oxazepam 10 mg capsule (Added Age Limit, Added Quantity Limit)
Oxazepam 15 mg capsule (Added Age Limit, Added Quantity Limit)
Oxazepam 30 mg capsule (Added Age Limit, Added Quantity Limit)
Oxybutynin chloride 10 mg extended release tablet (Added Quantity Limit)
Oxybutynin chloride 15 mg extended release tablet (Added Quantity Limit)
Oxybutynin chloride 5 mg extended release tablet (Added Quantity Limit)
Oxybutynin chloride 5 mg tablet (Added Quantity Limit)
Pantoprazole sodium 20 mg tablet (Changed Quantity Limit)
Paroxetine 10 mg tablet (Changed Quantity Limit)
Paroxetine 20 mg tablet (Changed Quantity Limit)
Paroxetine 40 mg tablet (Changed Quantity Limit)
Polyethylene glycol 3350 oral packet 17 gm (Added Quantity Limit)
Polyethylene glycol 3350 oral powder 17 gm per scoop (Added Quantity Limit)
Pravastatin sodium 10 mg tablet (Changed Quantity Limit)
Pravastatin sodium 20 mg tablet (Changed Quantity Limit)
Pravastatin sodium 40 mg tablet (Changed Quantity Limit)
Pravastatin sodium 80 mg tablet (Added Quantity Limit)
Prazosin 1 mg capsule (Added Quantity Limit)
Prazosin 2 mg capsule (Added Quantity Limit)
Prazosin 5 mg capsule (Added Quantity Limit)
Prezista 600 mg tablet (Added Quantity Limit)
Prezista 800 mg tablet (Added Quantity Limit)
Pulmozyme 2.5 mg per 2.5 mL inhalation solution (Added Quantity Limit)
Ramipril 1.25 mg capsule (Added Quantity Limit)
Ramipril 10 mg capsule (Added Quantity Limit)
Ramipril 2.5 mg capsule (Added Quantity Limit)
Ramipril 5 mg capsule (Added Quantity Limit)
Rosuvastatin calcium 10 mg tablet (Added Quantity Limit)
Rosuvastatin calcium 20 mg tablet (Added Quantity Limit)
Rosuvastatin calcium 40 mg tablet (Added Quantity Limit)
Rosuvastatin calcium 5 mg tablet (Added Quantity Limit)
Segluroment 2.5 mg/500 mg tablet (Changed Quantity Limit)
Sertraline 100 mg tablet (Added Quantity Limit)
Sertraline 25 mg tablet (Added Quantity Limit)
Sertraline 50 mg tablet (Added Quantity Limit)
Simvastatin 10 mg tablet (Changed Quantity Limit)
Simvastatin 20 mg tablet (Changed Quantity Limit)
Simvastatin 40 mg tablet (Changed Quantity Limit)
Simvastatin 5 mg tablet (Changed Quantity Limit)
Simvastatin 80 mg tablet (Added Quantity Limit)
Terazosin 1 mg base equivalent capsule (Changed Quantity Limit)
Terazosin 10 mg base equivalent capsule (Changed Quantity Limit)
Terazosin 2 mg base equivalent capsule (Added Quantity Limit)
Terazosin 5 mg base equivalent capsule (Changed Quantity Limit)
Tivicay 25 mg tablet (Changed Quantity Limit)
Tivicay 50 mg tablet (Changed Quantity Limit)
Tolterodine tartate 2 mg extended release capsule (Added Quantity Limit)
Tolterodine tartate 4 mg extended release capsule (Added Quantity Limit)
Tracleer 32 mg soluble tablet (Added Quantity Limit)
Trandolapril 1 mg tablet (Changed Quantity Limit)
Trandolapril 2 mg tablet (Changed Quantity Limit)
Triumeq pd 60 mg/5 mg/30 mg soluble tablet (Changed Quantity Limit)
Valsartan 160 mg tablet (Added Quantity Limit)
Valsartan 160 mg/hydrochlorothiazide 12.5 mg tablet (Added Quantity Limit)
Valsartan 160 mg/hydrochlorothiazide 25 mg tablet (Added Quantity Limit)
Valsartan 320 mg tablet (Added Quantity Limit)
Valsartan 320 mg/hydrochlorothiazide 12.5 mg tablet (Added Quantity Limit)
Valsartan 320 mg/hydrochlorothiazide 25 mg tablet (Added Quantity Limit)
Valsartan 40 mg tablet (Added Quantity Limit)
Valsartan 80 mg tablet (Added Quantity Limit)
Valsartan 80 mg/hydrochlorothiazide 12.5 mg tablet (Added Quantity Limit)
Viracept 250 mg tablet (Changed Quantity Limit)
Zidovudine 50 mg per 5 mL syrup (Changed Quantity Limit)

January 2024

Additions:

Dexcom G7 receiver (Quantity Limit)
Dexcom G7 sensor (Quantity Limit)
Methylin 10 mg per 5 mL solution
Methylin 5 mg per 5 mL solution

Removals:

Benzoyl peroxide 0.04% liquid wash
Panoxyl 4% creamy wash liquid

Other Updates:

Paxlovid 150 mg/100 mg tablets (Added Quantity Limit, Added Age Limit)

December 2023

Additions:

OneTouch delica plus 30g lancet
OneTouch delica plus 33g lancet
OneTouch delica plus lancing
OneTouch delica safety lancing
OneTouch ultra 2 kit with device
OneTouch verio flex system kit with device
OneTouch verio in vitro strip
OneTouch verio reflect kit with device

Removals:

Other Updates:

November 2023

Additions:

Dayvigo 5 mg tablet (Prior Authorization, Quantity Limit)
Dayvigo 10 mg tablet (Prior Authorization, Quantity Limit)
Haegarda 2000 unit injection (Prior Authorization)
Haegarda 3000 unit injection (Prior Authorization)
Takhzyro 300 mg per 2 mL injection (Prior Authorization, Quantity Limit)
Takhzyro 150 mg per mL injection (Prior Authorization, Quantity Limit)
Gefitinib 250 mg tablet (Prior Authorization, Quantity Limit)
Liqrev 10 mg per mL suspension (Prior Authorization, Quantity Limit)
Ciprofloxacin-Dexmethasone 0.3%/0.1% otic suspension (Quantity Limit)
Goodsense 0.25-14-74.9% hemorrhoidal ointment
Gnp 0.25-14-74.9% hemorrhoidal ointment

Removals:

Cinryze 500 unit solution
Proctofoam 1% rectal foam

Other Updates:

Abacavir sulfate 20 mg per mL solution (Added Quantity Limit)
Abacavir sulfate 300 mg tablet (Added Quantity Limit)
Abacavir sulfate 600 mg/lamivudine 300 mg tablet (Added Quantity Limit)
Abilify maintena 300 mg extended release injection (Added Prior Authorization)
Abilify maintena 300 mg prefilled syringe (Added Prior Authorization)
Abilify maintena 400 mg prefilled syringe (Added Prior Authorization)
Acarbose 100 mg tablet (Added Quantity Limit)
Acarbose 25 mg tablet (Added Quantity Limit)
Acarbose 50 mg tablet (Added Quantity Limit)
Alendronate sodium 10 mg tablet (Added Quantity Limit)
Amabelz 0.5 mg/0.1 mg tablet (Added Quantity Limit)
Amabelz 1 mg/0.5 mg tablet (Added Quantity Limit)
Amlodipine besylate 10 mg tablet (Added Quantity Limit)
Amlodipine besylate 2.5 mg tablet (Added Quantity Limit)
Amlodipine besylate 5 mg tablet (Added Quantity Limit)
Aripiprazole 10 mg tablet (Removed Prior Authorization)
Aripiprazole 15 mg tablet (Removed Prior Authorization)
Aripiprazole 2 mg tablet (Removed Prior Authorization)
Aripiprazole 20 mg tablet (Removed Prior Authorization)
Aripiprazole 30 mg tablet (Removed Prior Authorization)
Aripiprazole 5 mg tablet (Removed Prior Authorization)
Aristada 1064 mg per 3.9 mL prefilled syringe (Added Prior Authorization)
Aristada 441 mg per 1.6 mL prefilled syringe (Added Prior Authorization)
Aristada 662 mg per 2.4 mL prefilled syringe (Added Prior Authorization)
Aristada 882 mg per 3.2 mL prefilled syringe (Added Prior Authorization)
Armodafinil 150 mg tablet (Added Prior Authorization)
Armodafinil 250 mg tablet (Added Prior Authorization)
Armodafinil 50 mg tablet (Added Prior Authorization)
Armour thyroid 180 mg tablet (Added Quantity Limit)
Armour thyroid 240 mg tablet (Added Quantity Limit)
Armour thyroid 300 mg tablet (Added Quantity Limit)
Atazanavir sulfate 150 mg capsule (Added Quantity Limit)
Atazanavir sulfate 200 mg capsule (Added Quantity Limit)
Atazanavir sulfate 300 mg capsule (Added Quantity Limit)
Bisoprolol fumarate 5 mg tablet (Added Quantity Limit)
Capecitabine 150 mg tablet (Added Prior Authorization)
Capecitabine 500 mg tablet (Added Prior Authorization)
Carbamazepine 100 mg extended release capsule (Removed Prior Authorization)
Carbamazepine 100 mg extended release tablet (Removed Prior Authorization)
Carbamazepine 100 mg per 5 mL suspension (Removed Prior Authorization)
Carbamazepine 200 mg extended release capsule (Removed Prior Authorization)
Carbamazepine 200 mg extended release tablet (Removed Prior Authorization)
Carbamazepine 200 mg tablet (Removed Prior Authorization)
Carbamazepine 300 mg extended release capsule (Removed Prior Authorization)
Carbamazepine 400 mg extended release tablet (Removed Prior Authorization)
Cartia 120 mg extended release capsule (Added Quantity Limit)
Cartia 180 mg extended release capsule (Added Quantity Limit)
Cartia 240 mg extended release capsule (Added Quantity Limit)
Carvedilol 12.5 mg tablet (Added Quantity Limit)
Carvedilol 25 mg tablet (Added Quantity Limit)
Carvedilol 3.125 mg tablet (Added Quantity Limit)
Carvedilol 6.25 mg tablet (Added Quantity Limit)
Ceftriaxone sodium 2 gm for injection (Added Quantity Limit)
Ceftriaxone sodium 250 mg for injection (Added Quantity Limit)
Ceftriaxone sodium 500 mg for injection (Added Quantity Limit)
Chloroquine phosphate 250 mg tablet (Removed Prior Authorization)
Chloroquine phosphate 500 mg tablet (Removed Prior Authorization)
Ciclopirox olamine 0.77% cream (Added Step Therapy)
Ciclopirox olamine 0.77% suspension (Added Step Therapy)
Citalopram 10 mg per 5 mL solution (Changed Quantity Limit)
Clindamycin phosphate 1% gel (Removed Step Therapy)
Clindamycin phosphate 1% lotion (Removed Step Therapy)
Clobetasol propionate 0.05% solution (Removed Step Therapy)
Clonidine 0.1 mg per 24 hour weekly patch (Added Step Therapy)
Clonidine 0.2 mg per 24 hour weekly patch (Added Step Therapy)
Clonidine 0.3 mg per 24 hour weekly patch (Added Step Therapy)
Clozapine 100 mg tablet (Removed Prior Authorization)
Clozapine 200 mg tablet (Removed Prior Authorization)
Clozapine 25 mg tablet (Removed Prior Authorization)
Clozapine 50 mg tablet (Removed Prior Authorization)
Cyclosporine 0.05 ophthalmic emulsion (Added Prior Authorization)
Darunavir 100 mg per mL suspension (Added Quantity Limit)
Darunavir 150 mg tablet (Added Quantity Limit)
Darunavir 75 mg tablet (Added Quantity Limit)
Descovy 120 mg/15 mg tablet (Added Quantity Limit)
Desmopressin acetate 0.1 mg tablet (Added Quantity Limit)
Desmopressin acetate 0.2 mg tablet (Added Quantity Limit)
Diazepam 10 mg rectal gel (Changed Quantity Limit, Removed Age Limit)
Diazepam 2.5 mg rectal gel (Changed Quantity Limit, Removed Age Limit)
Diazepam 20 mg rectal gel (Changed Quantity Limit, Removed Age Limit)
Diltiazem 120 mg extended release beads capsule (Added Quantity Limit)
Diltiazem 120 mg extended release capsule (Added Quantity Limit)
Diltiazem 120 mg extended release coated beads capsule (Added Quantity Limit)
Diltiazem 120 mg tablet (Added Quantity Limit)
Diltiazem 180 mg extended release beads capsule (Added Quantity Limit)
Diltiazem 180 mg extended release capsule (Added Quantity Limit)
Diltiazem 180 mg extended release coated beads capsule (Added Quantity Limit)
Diltiazem 240 mg extended release beads capsule (Added Quantity Limit)
Diltiazem 240 mg extended release capsule (Added Quantity Limit)
Diltiazem 240 mg extended release coated beads capsule (Added Quantity Limit)
Diltiazem 30 mg tablet (Added Quantity Limit)
Diltiazem 300 mg extended release beads capsule (Added Quantity Limit)
Diltiazem 360 mg extended release beads capsule (Added Quantity Limit)
Diltiazem 420 mg extended release beads capsule (Added Quantity Limit)
Diltiazem 60 mg tablet (Added Quantity Limit)
Diltiazem 90 mg tablet (Added Quantity Limit)
Dilt-xr 120 mg extended release capsule (Added Quantity Limit)
Dilt-xr 180 mg extended release capsule (Added Quantity Limit)
Dilt-xr 240 mg extended release capsule (Added Quantity Limit)
Dimethyl fumarate 120 mg delayed release capsule (Added Prior Authorization)
Dimethyl fumarate 240 mg delayed release capsule (Added Prior Authorization)
Divalproex sodium 125 mg delayed release tablet (Removed Prior Authorization)
Divalproex sodium 250 mg delayed release tablet (Removed Prior Authorization)
Divalproex sodium 250 mg extended release tablet (Removed Prior Authorization)
Divalproex sodium 500 mg delayed release tablet (Removed Prior Authorization)
Divalproex sodium 500 mg extended release tablet (Removed Prior Authorization)
Doxazosin mesylate 8 mg tablet (Changed Quantity Limit)
Efavirenz 200 mg capsule (Added Quantity Limit)
Efavirenz 50 mg capsule (Added Quantity Limit)
Efavirenz 600 mg capsule (Added Quantity Limit)
Efavirenz 600 mg/emtricitabine 200 mg/tenofovir 300 mg tablet (Added Quantity Limit)
Ella 30 mg tablet (Changed Quantity Limit, Removed Age Limit)
Emtricitabine 10 mg per mL solution (Added Quantity Limit)
Emtricitabine 200 mg capsule (Added Quantity Limit)
Entecavir 0.5 mg tablet (Added Quantity Limit)
Entecavir 1 mg tablet (Added Quantity Limit)
Epoprostenol sodium 0.5 mg injection (Added Prior Authorization)
Epoprostenol sodium 1.5 mg injection (Added Prior Authorization)
Estradiol 0.5 mg/norethindrone acetate 0.1 mg tablet (Added Quantity Limit)
Estradiol 1 mg/norethindrone acetate 0.5 mg tablet (Added Quantity Limit)
Ethosuximide 250 mg capsule (Removed Prior Authorization)
Ethosuximide 250 mg per 5 mL solution (Removed Prior Authorization)
Etravirine 100 mg tablet (Added Quantity Limit)
Etravirine 200 mg tablet (Added Quantity Limit)
Etravirine 25 mg tablet (Added Quantity Limit)
Euthyrox 100 mcg tablet (Added Quantity Limit)
Euthyrox 125 mcg tablet (Added Quantity Limit)
Euthyrox 137 mcg tablet (Added Quantity Limit)
Euthyrox 150 mcg tablet (Added Quantity Limit)
Euthyrox 175 mcg tablet (Added Quantity Limit)
Euthyrox 200 mcg tablet (Added Quantity Limit)
Euthyrox 50 mcg tablet (Added Quantity Limit)
Euthyrox 75 mcg tablet (Added Quantity Limit)
Euthyrox 88 mcg tablet (Added Quantity Limit)
Everolimus 10 mg tablet (Added Quantity Limit)
Everolimus 2.5 mg tablet (Added Quantity Limit)
Everolimus 5 mg tablet (Added Quantity Limit)
Everolimus 7.5 mg tablet (Added Quantity Limit)
Felodipine 10 mg extended release tablet (Added Quantity Limit)
Felodipine 2.5 mg extended release tablet (Added Quantity Limit)
Felodipine 5 mg extended release tablet (Added Quantity Limit)
Fingolimod 0.5 mg capsule (Added Prior Authorization)
Fluconazole 100 mg tablet (Added Quantity Limit)
Fluconazole 200 mg tablet (Added Quantity Limit)
Fluconazole 50 mg tablet (Added Quantity Limit)
Fosamprenavir calcium 50 mg per mL suspension tablet (Added Quantity Limit)
Fosamprenavir calcium 700 mg tablet (Added Quantity Limit)
Fuzeon 90 mg reconstituted solution (Added Quantity Limit)
Fyavolv 0.5 mg/2.5 mcg tablet (Added Quantity Limit)
Fyavolv 1 mg/5 mcg tablet (Added Quantity Limit)
Gabapentin 100 mg capsule (Removed Prior Authorization)
Gabapentin 250 mg per 5 mL oral solution (Removed Prior Authorization)
Gabapentin 300 mg capsule (Removed Prior Authorization)
Gabapentin 400 mg capsule (Removed Prior Authorization)
Gabapentin 600 mg tablet (Removed Prior Authorization)
Gabapentin 800 mg tablet (Removed Prior Authorization)
Glatiramer acetate 20 mg per mL prefilled syringe (Added Prior Authorization)
Glipizide 10 mg extended release tablet (Added Quantity Limit)
Glipizide 2.5 mg extended release tablet (Added Quantity Limit)
Glipizide 2.5 mg/metformin 250 mg tablet (Added Quantity Limit)
Glipizide 2.5 mg/metformin 500 mg tablet (Added Quantity Limit)
Glipizide 5 mg extended release tablet (Added Quantity Limit)
Glipizide 5 mg/metformin 500 mg tablet (Added Quantity Limit)
Glyburide 1.25 mg/metformin 250 mg tablet (Added Quantity Limit)
Glyburide 2.5 mg/metformin 500 mg tablet (Added Quantity Limit)
Glyburide 5 mg/metformin 500 mg tablet (Added Quantity Limit)
Griseofulvin microsize 125 mg per 5 mL suspension (Added Step Therapy)
Haloperidol 0.5 mg tablet (Removed Prior Authorization)
Haloperidol 1 mg tablet (Removed Prior Authorization)
Haloperidol 10 mg tablet (Removed Prior Authorization)
Haloperidol 2 mg tablet (Removed Prior Authorization)
Haloperidol 20 mg tablet (Removed Prior Authorization)
Haloperidol 5 mg tablet (Removed Prior Authorization)
Haloperidol lactate 2 mg per mL concentrate (Removed Prior Authorization)
Haloperidol lactate 5 mg per mL injection (Removed Prior Authorization)
Hydroxychloroquine sulfate 200 mg tablet (Removed Prior Authorization)
Hydroxyurea 200 mg capsule (Removed Prior Authorization)
Hydroxyurea 300 mg capsule (Removed Prior Authorization)
Hydroxyurea 400 mg capsule (Removed Prior Authorization)
Hydroxyurea 500 mg capsule (Removed Prior Authorization, Removed Quantity Limit)
Imatinib mesylate 100 mg tablet (Added Prior Authorization)
Imatinib mesylate 400 mg tablet (Added Prior Authorization)
Interferon beta-1a 30 mcg per 0.5 mL auto injector kit (Added Prior Authorization)
Interferon beta-1a 30 mcg per 0.5 mL prefilled syringe kit (Added Prior Authorization)
Interferon beta-1b 0.3 mg kit for injection (Added Prior Authorization)
Invega hafyera 1092 mg per 3.5 mL injection (Added Prior Authorization)
Invega hafyera 1560 mg per 5 mL injection (Added Prior Authorization)
Invega sustenna 117 mg per 0.75 mL injection (Added Prior Authorization)
Invega sustenna 156 mg per 1 mL injection (Added Prior Authorization)
Invega sustenna 234 mg per 1.5 mL injection (Added Prior Authorization)
Invega sustenna 39 mg per 0.25 mL injection (Added Prior Authorization)
Invega sustenna 78 mg per 0.5 mL injection (Added Prior Authorization)
Invega trinza 273 mg per 0.88 mL injection (Added Prior Authorization)
Invega trinza 410 mg per 1.32 mL injection (Added Prior Authorization)
Invega trinza 546 mg per 1.75 mL injection (Added Prior Authorization)
Invega trinza 819 mg per 2.63 mL injection (Added Prior Authorization)
Isentress 100 mg chewable tablet (Added Quantity Limit)
Isentress 100 mg for suspension (Added Quantity Limit)
Isentress 25 mg chewable tablet (Added Quantity Limit)
Isentress 400 mg tablet (Added Quantity Limit)
Isentress 600 mg tablet (Added Quantity Limit)
Isosorbide mononitrate 120 mg extended release tablet (Added Quantity Limit)
Isosorbide mononitrate 30 mg extended release tablet (Added Quantity Limit)
Isosorbide mononitrate 60 mg extended release tablet (Added Quantity Limit)
Itraconazole 100 mg capsule (Changed Quantity Limit)
Jinteli 1 mg/5 mcg tablet (Added Quantity Limit)
Ketoconazole 2% cream (Added Step Therapy)
Ketoconazole 200 mg tablet (Changed Quantity Limit)
Lamivudine 10 mg per mL solution (Added Quantity Limit)
Lamivudine 100 mg tablet (Added Quantity Limit)
Lamivudine 150 mg tablet (Added Quantity Limit)
Lamivudine 150 mg/zidovudine 300 mg tablet (Added Quantity Limit)
Lamivudine 300 mg tablet (Added Quantity Limit)
Lamotrigine 100 mg tablet (Removed Prior Authorization)
Lamotrigine 150 mg tablet (Removed Prior Authorization)
Lamotrigine 200 mg tablet (Removed Prior Authorization)
Lamotrigine 25 mg chewable dispersible tablet (Removed Prior Authorization)
Lamotrigine 25 mg tablet (Removed Prior Authorization)
Lamotrigine 5 mg chewable dispersible tablet (Removed Prior Authorization)
Lenalidomide 10 mg capsules (Added Prior Authorization)
Lenalidomide 15 mg capsules (Added Prior Authorization)
Lenalidomide 2.5 mg capsules (Added Prior Authorization)
Lenalidomide 20 mg capsules (Added Prior Authorization)
Lenalidomide 25 mg capsules (Added Prior Authorization)
Lenalidomide 5 mg capsules (Added Prior Authorization)
Levalbuterol tartate 45 mcg per actuation inhaler (Added Step Therapy)
Levetiracetam 100 mg per mL oral solution (Removed Prior Authorization)
Levetiracetam 1000 mg tablet (Removed Prior Authorization)
Levetiracetam 250 mg tablet (Removed Prior Authorization)
Levetiracetam 500 mg extended release tablet (Removed Prior Authorization)
Levetiracetam 500 mg tablet (Removed Prior Authorization)
Levetiracetam 750 mg extended release tablet (Removed Prior Authorization)
Levetiracetam 750 mg tablet (Removed Prior Authorization)
Levo-t 100 mcg tablet (Added Quantity Limit)
Levo-t 125 mcg tablet (Added Quantity Limit)
Levo-t 137 mcg tablet (Added Quantity Limit)
Levo-t 150 mcg tablet (Added Quantity Limit)
Levo-t 175 mcg tablet (Added Quantity Limit)
Levo-t 200 mcg tablet (Added Quantity Limit)
Levo-t 50 mcg tablet (Added Quantity Limit)
Levo-t 75 mcg tablet (Added Quantity Limit)
Levo-t 88 mcg tablet (Added Quantity Limit)
Levothyroxine sodium 100 mcg tablet (Added Quantity Limit)
Levothyroxine sodium 112 mcg tablet (Added Quantity Limit)
Levothyroxine sodium 125 mcg tablet (Added Quantity Limit)
Levothyroxine sodium 137 mcg tablet (Added Quantity Limit)
Levothyroxine sodium 150 mcg tablet (Added Quantity Limit)
Levothyroxine sodium 175 mcg tablet (Added Quantity Limit)
Levothyroxine sodium 200 mcg tablet (Added Quantity Limit)
Levothyroxine sodium 25 mcg tablet (Added Quantity Limit)
Levothyroxine sodium 300 mcg tablet (Added Quantity Limit)
Levothyroxine sodium 50 mcg tablet (Added Quantity Limit)
Levothyroxine sodium 75 mcg tablet (Added Quantity Limit)
Levothyroxine sodium 88 mcg tablet (Added Quantity Limit)
Levoxyl 100 mcg tablet (Added Quantity Limit)
Levoxyl 112 mcg tablet (Added Quantity Limit)
Levoxyl 125 mcg tablet (Added Quantity Limit)
Levoxyl 137 mcg tablet (Added Quantity Limit)
Levoxyl 150 mcg tablet (Added Quantity Limit)
Levoxyl 175 mcg tablet (Added Quantity Limit)
Levoxyl 200 mcg tablet (Added Quantity Limit)
Levoxyl 88 mcg tablet (Added Quantity Limit)
Liothyronine sodium 5 mcg tablet (Added Quantity Limit)
Liothyronine sodium 50 mcg tablet (Added Quantity Limit)
Lisinopril 10 mg tablet (Added Quantity Limit)
Lisinopril 2.5 mg tablet (Added Quantity Limit)
Lisinopril 20 mg tablet (Added Quantity Limit)
Lisinopril 30 mg tablet (Added Quantity Limit)
Lisinopril 40 mg tablet (Added Quantity Limit)
Lisinopril 5 mg tablet (Added Quantity Limit)
Lopinavir 400 mg/ritonavir 100 mg per 5 mL solution (Added Quantity Limit)
Loxapine succinate 10 mg capsule (Removed Prior Authorization)
Loxapine succinate 25 mg capsule (Removed Prior Authorization)
Loxapine succinate 5 mg capsule (Removed Prior Authorization)
Loxapine succinate 50 mg capsule (Removed Prior Authorization)
Malathion 0.5% lotion (Added Step Therapy)
Mercaptopurine 50 mg tablet (Removed Prior Authorization, Removed Quantity Limit)
Metformin 500 mg extended release tablet (Added Quantity Limit)
Metformin 750 mg extended release tablet (Added Quantity Limit)
Metoprolol succinate 100 mg extended release tablet (Added Quantity Limit)
Metoprolol succinate 200 mg extended release tablet (Added Quantity Limit)
Metoprolol succinate 25 mg extended release tablet (Added Quantity Limit)
Metoprolol succinate 50 mg extended release tablet (Added Quantity Limit)
Mimvey 1 mg/0.5 mg tablet (Added Quantity Limit)
Naproxen 125 mg per 5 mL suspension (Added Step Therapy)
Nateglinide 120 mg tablet (Added Quantity Limit)
Nateglinide 60 mg tablet (Added Quantity Limit)
Nelfinavir mesylate 250 mg tablet (Added Quantity Limit)
Nelfinavir mesylate 625 mg tablet (Added Quantity Limit)
Nevirapine 100 mg extended release tablet (Added Quantity Limit)
Nevirapine 200 mg tablet (Added Quantity Limit)
Nevirapine 400 mg extended release tablet (Added Quantity Limit)
Nevirapine 50 mg per 5 mL suspension (Added Quantity Limit)
Nifedipine 30 mg extended release tablet (Added Quantity Limit)
Nifedipine 30 mg osmotic release tablet (Added Quantity Limit)
Nifedipine 60 mg extended release tablet (Added Quantity Limit)
Nifedipine 60 mg osmotic release tablet (Added Quantity Limit)
Nifedipine 90 mg osmotic release tablet (Added Quantity Limit)
Norethindrone acetate 0.5 mg/ethinyl estradiol 2.5 mcg tablet (Added Quantity Limit)
Norethindrone acetate 1 mg/ethinyl estradiol 5 mcg tablet (Added Quantity Limit)
Norethindrone acetate 5 mg tablet (Added Step Therapy)
Np thyroid 120 mg tablet (2 grain) (Added Quantity Limit)
Np thyroid 15 mg tablet (1/4 grain) (Added Quantity Limit)
Np thyroid 30 mg tablet (1/2 grain) (Added Quantity Limit)
Np thyroid 60 mg tablet (1 grain) (Added Quantity Limit)
Np thyroid 90 mg tablet (1 1/2 grain) (Added Quantity Limit)
Octreotide acetate 100 mcg per mL injection (Added Prior Authorization)
Octreotide acetate 100 mcg per mL prefilled syringe (Added Prior Authorization)
Octreotide acetate 1000 mcg per mL injection (Added Prior Authorization)
Octreotide acetate 200 mcg per mL injection (Added Prior Authorization)
Octreotide acetate 50 mcg per mL injection (Added Prior Authorization)
Octreotide acetate 50 mcg per mL prefilled syringe (Added Prior Authorization)
Octreotide acetate 500 mcg per mL injection (Added Prior Authorization)
Octreotide acetate 500 mcg per mL prefilled syringe (Added Prior Authorization)
Olanzapine 10 mg orally disintegrating tablet (Removed Prior Authorization)
Olanzapine 10 mg tablet (Removed Prior Authorization)
Olanzapine 15 mg orally disintegrating tablet (Removed Prior Authorization)
Olanzapine 15 mg tablet (Removed Prior Authorization)
Olanzapine 2.5 mg tablet (Removed Prior Authorization)
Olanzapine 20 mg orally disintegrating tablet (Removed Prior Authorization)
Olanzapine 20 mg tablet (Removed Prior Authorization)
Olanzapine 5 mg orally disintegrating tablet (Removed Prior Authorization)
Olanzapine 5 mg tablet (Removed Prior Authorization)
Olanzapine 7.5 mg tablet (Removed Prior Authorization)
Oxcarbazepine 150 mg tablet (Removed Prior Authorization)
Oxcarbazepine 300 mg per 5 mL suspension (Removed Prior Authorization)
Oxcarbazepine 300 mg tablet (Removed Prior Authorization)
Oxcarbazepine 600 mg tablet (Removed Prior Authorization)
Paricalcitol 1 mcg capsule (Added Step Therapy, Added Quantity Limit)
Paricalcitol 2 mcg capsule (Added Step Therapy, Added Quantity Limit)
Paricalcitol 4 mcg capsule (Added Step Therapy, Added Quantity Limit)
PazoPanib 200 mg tablet (Added Prior Authorization, Added Quantity Limit)
Perphenazine 16 mg tablet (Removed Prior Authorization)
Perphenazine 2 mg tablet (Removed Prior Authorization)
Perphenazine 2 mg/amitriptyline 10 mg tablet (Removed Prior Authorization)
Perphenazine 2 mg/amitriptyline 25 mg tablet (Removed Prior Authorization)
Perphenazine 4 mg tablet (Removed Prior Authorization)
Perphenazine 4 mg/amitriptyline 10 mg tablet (Removed Prior Authorization)
Perphenazine 4 mg/amitriptyline 25 mg tablet (Removed Prior Authorization)
Perphenazine 4 mg/amitriptyline 50 mg tablet (Removed Prior Authorization)
Perphenazine 8 mg tablet (Removed Prior Authorization)
Phenytoin 125 mg per 5 mL suspension (Removed Prior Authorization)
Phenytoin 50 mg chewable tablet (Removed Prior Authorization)
Phenytoin sodium 100 mg extended release capsule (Removed Prior Authorization)
Phenytoin sodium 200 mg extended release capsule (Removed Prior Authorization)
Phenytoin sodium 300 mg extended release capsule (Removed Prior Authorization)
Pioglitazone 15 mg tablet (Added Quantity Limit)
Pioglitazone 30 mg tablet (Added Quantity Limit)
Pioglitazone 45 mg tablet (Added Quantity Limit)
Primidone 250 mg tablet (Removed Prior Authorization)
Primidone 50 mg tablet (Removed Prior Authorization)
Prochlorperazine maleate 10 mg tablet (Removed Prior Authorization)
Prochlorperazine maleate 5 mg tablet (Removed Prior Authorization)
Progesterone 100 mg capsule (Added Quantity Limit)
Progesterone 200 mg capsule (Added Quantity Limit)
Propranolol 60 mg extended release capsule (Added Quantity Limit)
Propranolol 80 mg extended release capsule (Added Quantity Limit)
Quetiapine fumarate 100 mg tablet (Removed Prior Authorization)
Quetiapine fumarate 150 mg extended release tablet (Removed Prior Authorization)
Quetiapine fumarate 200 mg extended release tablet (Removed Prior Authorization)
Quetiapine fumarate 200 mg tablet (Removed Prior Authorization)
Quetiapine fumarate 25 mg tablet (Removed Prior Authorization)
Quetiapine fumarate 300 mg extended release tablet (Removed Prior Authorization)
Quetiapine fumarate 300 mg tablet (Removed Prior Authorization)
Quetiapine fumarate 400 mg extended release tablet (Removed Prior Authorization)
Quetiapine fumarate 400 mg tablet (Removed Prior Authorization)
Quetiapine fumarate 50 mg extended release tablet (Removed Prior Authorization)
Quetiapine fumarate 50 mg tablet (Removed Prior Authorization)
Raloxifene 60 mg tablet (Added Quantity Limit)
Ramelteon 8 mg tablet (Added Step Therapy)
Ramipril 1.25 mg capsule (Removed Prior Authorization, Removed Quantity Limit)
Ramipril 2.5 mg capsule (Removed Prior Authorization, Removed Quantity Limit)
Ramipril 5 mg capsule (Removed Prior Authorization, Removed Quantity Limit)
Repaglinide 0.5 mg tablet (Added Quantity Limit)
Repaglinide 1 mg tablet (Added Quantity Limit)
Repaglinide 2 mg tablet (Added Quantity Limit)
Revlimid 10 mg capsule (Added Prior Authorization)
Revlimid 15 mg capsule (Added Prior Authorization)
Revlimid 2.5 mg capsule (Added Prior Authorization)
Revlimid 20 mg capsule (Added Prior Authorization)
Revlimid 25 mg capsule (Added Prior Authorization)
Revlimid 5 mg capsule (Added Prior Authorization)
Risperdal consta 12.5 mg extended release injection (Added Prior Authorization)
Risperdal consta 25 mg extended release injection (Added Prior Authorization)
Risperdal consta 37.5 mg extended release injection (Added Prior Authorization)
Risperdal consta 50 mg extended release injection (Added Prior Authorization)
Risperidone 0.25 mg orally disintegrating tablet (Removed Prior Authorization, Added Age Limit)
Risperidone 0.25 mg tablet (Removed Prior Authorization)
Risperidone 0.5 mg orally disintegrating tablet (Removed Prior Authorization)
Risperidone 0.5 mg tablet (Removed Prior Authorization)
Risperidone 1 mg orally disintegrating tablet (Removed Prior Authorization)
Risperidone 1 mg per mL solution (Removed Prior Authorization)
Risperidone 1 mg tablet (Removed Prior Authorization)
Risperidone 2 mg orally disintegrating tablet (Removed Prior Authorization)
Risperidone 2 mg tablet (Removed Prior Authorization)
Risperidone 3 mg orally disintegrating tablet (Removed Prior Authorization)
Risperidone 3 mg tablet (Removed Prior Authorization)
Risperidone 4 mg orally disintegrating tablet (Removed Prior Authorization, Added Age Limit)
Risperidone 4 mg tablet (Removed Prior Authorization)
Ritonavir 100 mg tablet (Added Quantity Limit)
Sevelamer carbonate 800 mg tablet (Added Step Therapy)
Sodium chloride 10% nebulizer (Removed Prior Authorization)
Sodium chloride 3% nebulizer (Removed Prior Authorization)
Sodium chloride 7% nebulizer (Removed Prior Authorization)
Spinosad 0.9% suspension (Added Step Therapy)
Sprycel 20 mg tablet (Changed Quantity Limit)
Sprycel 80 mg tablet (Changed Quantity Limit)
Stavudine 15 mg capsule (Changed Quantity Limit)
Stavudine 20 mg capsule (Changed Quantity Limit)
Sunitinib malate 12.5 mg capsule (Added Prior Authorization)
Sunitinib malate 25 mg capsule (Added Prior Authorization)
Sunitinib malate 37.5 mg capsule (Added Prior Authorization)
Sunitinib malate 50 mg capsule (Added Prior Authorization)
Tacrolimus 0.03% ointment (Added Step Therapy)
Tacrolimus 0.1% ointment (Added Step Therapy)
Tadalafil 20 mg tablet (Removed Prior Authorization, Added Step Therapy, Added Quantity Limit)
Taztia 120 mg extended release capsule (Added Quantity Limit)
Taztia 180 mg extended release capsule (Added Quantity Limit)
Taztia 240 mg extended release capsule (Added Quantity Limit)
Taztia 300 mg extended release capsule (Added Quantity Limit)
Taztia 360 mg extended release capsule (Added Quantity Limit)
Tenofovir disoproxil fumarate 150 mg tablet (Added Quantity Limit)
Tenofovir disoproxil fumarate 200 mg tablet (Added Quantity Limit)
Tenofovir disoproxil fumarate 250 mg tablet (Added Quantity Limit)
Tenofovir disoproxil fumarate 300 mg tablet (Added Quantity Limit)
Tenofovir disoproxil fumarate 40 mg per gm oral powder (Added Quantity Limit)
Teriflunomide 14 mg tablet (Added Prior Authorization)
Teriflunomide 7 mg tablet (Added Prior Authorization)
Testosterone 25 mg per 2.5 gm transdermal gel (Added Quantity Limit)
Testosterone 50 mg per 5 gm transdermal gel (Added Quantity Limit)
Testosterone cypionate 100 mg per mL injection (Added Prior Authorization)
Testosterone cypionate 200 mg per mL injection (Added Prior Authorization)
Testosterone enanthate 200 mg per mL injection (Added Prior Authorization)
Thioridazine 10 mg tablet (Removed Prior Authorization)
Thioridazine 100 mg tablet (Removed Prior Authorization)
Thioridazine 25 mg tablet (Removed Prior Authorization)
Thioridazine 50 mg tablet (Removed Prior Authorization)
Thiothixene 1 mg capsule (Removed Prior Authorization)
Thiothixene 10 mg capsule (Removed Prior Authorization)
Thiothixene 2 mg capsule (Removed Prior Authorization)
Thiothixene 5 mg capsule (Removed Prior Authorization)
Thyroid 120 mg tablet (2 grain) (Added Quantity Limit)
Thyroid 15 mg tablet (1/4 grain) (Added Quantity Limit)
Thyroid 180 mg tablet (3 grain) (Added Quantity Limit)
Thyroid 240 mg tablet (4 grain) (Added Quantity Limit)
Thyroid 30 mg tablet (1/2 grain) (Added Quantity Limit)
Thyroid 300 mg tablet (5 grain) (Added Quantity Limit)
Thyroid 60 mg tablet (1 grain) (Added Quantity Limit)
Thyroid 90 mg tablet (1 1/2 grain) (Added Quantity Limit)
Tiadylt 120 mg extended release Capsule (Added Quantity Limit)
Tiadylt 180 mg extended release Capsule (Added Quantity Limit)
Tiadylt 240 mg extended release Capsule (Added Quantity Limit)
Tiadylt 300 mg extended release Capsule (Added Quantity Limit)
Tiadylt 360 mg extended release Capsule (Added Quantity Limit)
Tiadylt 420 mg extended release Capsule (Added Quantity Limit)
Tiagabine 12 mg tablet (Removed Prior Authorization)
Tiagabine 16 mg tablet (Removed Prior Authorization)
Tiagabine 2 mg tablet (Removed Prior Authorization)
Tiagabine 4 mg tablet (Removed Prior Authorization)
Timolol maleate 0.25% gel forming ophthalmic solution (Added Step Therapy)
Timolol maleate 0.5% gel forming ophthalmic solution (Added Step Therapy)
Tipranavir 250 mg capsule (Added Quantity Limit)
Tivicay 10 mg tablet (Added Quantity Limit)
Tivicay 25 mg tablet (Added Quantity Limit)
Tivicay 50 mg tablet (Added Quantity Limit)
Tobramycin 300 mg per 5 mL nebulizer solution (Changed Quantity Limit)
Tretinoin 10 mg capsule (Added Prior Authorization)
Trifluoperazine 1 mg tablet (Removed Prior Authorization)
Trifluoperazine 10 mg tablet (Removed Prior Authorization)
Trifluoperazine 2 mg tablet (Removed Prior Authorization)
Trifluoperazine 5 mg tablet (Removed Prior Authorization)
Unithroid 100 mcg tablet (Added Quantity Limit)
Unithroid 112 mcg tablet (Added Quantity Limit)
Unithroid 125 mcg tablet (Added Quantity Limit)
Unithroid 137 mcg tablet (Added Quantity Limit)
Unithroid 150 mcg tablet (Added Quantity Limit)
Unithroid 175 mcg tablet (Added Quantity Limit)
Unithroid 200 mcg tablet (Added Quantity Limit)
Unithroid 50 mcg tablet (Added Quantity Limit)
Unithroid 88 mcg tablet (Added Quantity Limit)
Valganciclovir 450 mg tablet (Added Quantity Limit)
Valsartan 160 mg tablet (Removed Prior Authorization)
Valsartan 40 mg tablet (Removed Prior Authorization)
Valsartan 80 mg tablet (Removed Prior Authorization)
Valtoco 10 mg spray (Changed Quantity Limit)
Valtoco 15 mg spray (Changed Quantity Limit)
Valtoco 20 mg spray (Changed Quantity Limit)
Valtoco 5 mg spray (Changed Quantity Limit)
Varenicline 0.5 mg tablet (Removed Age Limit, Removed Quantity Limit)
Varenicline 1 mg tablet (Removed Age Limit, Removed Quantity Limit)
Verapamil 120 mg extended release capsule (Added Quantity Limit)
Verapamil 120 mg extended release tablet (Added Quantity Limit)
Verapamil 120 mg tablet (Added Quantity Limit)
Verapamil 180 mg extended release capsule (Added Quantity Limit)
Verapamil 180 mg extended release tablet (Added Quantity Limit)
Verapamil 240 mg extended release capsule (Added Quantity Limit)
Verapamil 240 mg extended release tablet (Added Quantity Limit)
Verapamil 360 mg extended release capsule (Added Quantity Limit)
Verapamil 40 mg tablet (Added Quantity Limit)
Verapamil 80 mg tablet (Added Quantity Limit)
Viokace 10440 unit/39150 unit tablet (Removed Prior Authorization)
Viokace 20880 unit/78300 unit tablet (Removed Prior Authorization)
Zenpep 10000 unit/32000 unit delayed release particles capsule (Removed Prior Authorization)
Zenpep 15000 unit/47000 unit delayed release particles capsule (Removed Prior Authorization)
Zenpep 20000 unit/63000 unit delayed release particles capsule (Removed Prior Authorization)
Zenpep 25000 unit/79000 unit delayed release particles capsule (Removed Prior Authorization)
Zenpep 3000 unit/10000 unit delayed release particles capsule (Removed Prior Authorization)
Zenpep 40000 unit/126000 unit delayed release particles capsule (Removed Prior Authorization)
Zenpep 5000 unit/24000 unit delayed release particles capsule (Removed Prior Authorization)
Zidovudine 10 mg per mL syrup (Added Quantity Limit)
Zidovudine 100 mg capsule (Added Quantity Limit)
Zidovudine 300 mg tablet (Added Quantity Limit)
Ziprasidone 20 mg capsule (Removed Prior Authorization)
Ziprasidone 40 mg capsule (Removed Prior Authorization)
Ziprasidone 60 mg capsule (Removed Prior Authorization)
Ziprasidone 80 mg capsule (Removed Prior Authorization)
Zolpidem tartrate 10 mg tablet (Removed Prior Authorization, Added Age Limit)
Zolpidem tartrate 5 mg tablet (Added Age Limit)

October 2023

Additions:

Humatrope 12 mg injection (Prior Authorization)
Humatrope 24 mg injection (Prior Authorization)
Humatrope 6 mg injection (Prior Authorization)

Removals:

Other Updates:

Abiraterone acetate 250 mg tablet (Added Diagnosis Exclusion)
Alora patch twice weekly 0.05 mg per 24 hours (Added Diagnosis Exclusion)
Alora patch twice weekly 0.075 mg per 24 hours (Added Diagnosis Exclusion)
Alora patch twice weekly 0.1 mg per 24 hours (Added Diagnosis Exclusion)
Amabelz 0.5 mg/0.1 mg tablet (Added Diagnosis Exclusion)
Amabelz 1 mg/0.5 mg tablet (Added Diagnosis Exclusion)
Anastrozole 1 mg tablet (Added Diagnosis Exclusion)
Bicalutamide 50 mg tablet (Added Diagnosis Exclusion)
Climara pro patch weekly 0.045 mg/0.015 mg per day (Added Diagnosis Exclusion)
CombiPatch patch twice weekly 0.05 mg/0.14 mg per day (Added Diagnosis Exclusion)
CombiPatch patch twice weekly 0.05 mg/0.25 mg per day (Added Diagnosis Exclusion)
Danazol 100 mg capsule (Added Diagnosis Exclusion)
Danazol 200 mg capsule (Added Diagnosis Exclusion)
Danazol 50 mg capsule (Added Diagnosis Exclusion)
Dotti patch twice weekly 0.025 mg per 24 hours (Added Diagnosis Exclusion)
Dotti patch twice weekly 0.0375 mg per 24 hours (Added Diagnosis Exclusion)
Dotti patch twice weekly 0.05 mg per 24 hours (Added Diagnosis Exclusion)
Dotti patch twice weekly 0.075 mg per 24 hours (Added Diagnosis Exclusion)
Dotti patch twice weekly 0.1 mg per 24 hours (Added Diagnosis Exclusion)
Eligard 22.5 mg subcutaneous kit (Added Diagnosis Exclusion)
Eligard 30 mg subcutaneous kit (Added Diagnosis Exclusion)
Eligard 45 mg subcutaneous kit (Added Diagnosis Exclusion)
Eligard 7.5 mg subcutaneous kit (Added Diagnosis Exclusion)
Emcyt 140 mg capsule (Added Diagnosis Exclusion)
Estradiol patch twice weekly 0.025 mg per 24 hours (Added Diagnosis Exclusion)
Estradiol patch twice weekly 0.0375 mg per 24 hours (Added Diagnosis Exclusion)
Estradiol patch twice weekly 0.05 mg per 24 hours (Added Diagnosis Exclusion)
Estradiol patch twice weekly 0.075 mg per 24 hours (Added Diagnosis Exclusion)
Estradiol patch twice weekly 0.1 mg per 24 hours (Added Diagnosis Exclusion)
Estradiol patch weekly 0.025 mg per 24 hours (Added Diagnosis Exclusion)
Estradiol patch weekly 0.0375 mg per 24 hours (Added Diagnosis Exclusion)
Estradiol patch weekly 0.05 mg per 24 hours (Added Diagnosis Exclusion)
Estradiol patch weekly 0.06 mg per 24 hours (Added Diagnosis Exclusion)
Estradiol patch weekly 0.075 mg per 24 hours (Added Diagnosis Exclusion)
Estradiol patch weekly 0.1 mg per 24 hours (Added Diagnosis Exclusion)
Estradiol 0.5 mg tablet (Added Diagnosis Exclusion)
Estradiol 1 mg tablet (Added Diagnosis Exclusion)
Estradiol 2 mg tablet (Added Diagnosis Exclusion)
Estradiol-Norethindrone 0.5 mg/0.1 mg tablet (Added Diagnosis Exclusion)
Estradiol-Norethindrone 1 mg/0.5 mg tablet (Added Diagnosis Exclusion)
Exemestane 25 mg tablet (Added Diagnosis Exclusion)
Flutamide 125 mg capsule (Added Diagnosis Exclusion)
Fyavolv 0.5 mg/2.5 mcg tablet (Added Diagnosis Exclusion)
Fyavolv 1 mg/5 mcg tablet (Added Diagnosis Exclusion)
Hydroxyprogesterone caproate 250 mg per mL intramuscular oil (Added Diagnosis Exclusion)
Hydroxyprogesterone caproate 1.25 gm per 5 mL intramuscular solution (Added Diagnosis Exclusion)
Jinteli 1 mg/5 mcg tablet (Added Diagnosis Exclusion)
Letrozole 2.5 mg tablet (Added Diagnosis Exclusion)
Leuprolide acetate 1 mg per 0.2mL injection (Added Diagnosis Exclusion)
Lyllana patch twice weekly 0.025 mg per 24 hours (Added Diagnosis Exclusion)
Lyllana patch twice weekly 0.0375 mg per 24 hours (Added Diagnosis Exclusion)
Lyllana patch twice weekly 0.05 mg per 24 hours (Added Diagnosis Exclusion)
Lyllana patch twice weekly 0.075 mg per 24 hours (Added Diagnosis Exclusion)
Lyllana patch twice weekly 0.1 mg per 24 hours (Added Diagnosis Exclusion)
Lysodren 500 mg tablet (Added Diagnosis Exclusion)
Medroxyprogesterone acetate 10 mg tablet (Added Diagnosis Exclusion)
Medroxyprogesterone acetate 2.5 mg tablet (Added Diagnosis Exclusion)
Medroxyprogerterone acetate 5 mg tablet (Added Diagnosis Exclusion)
Megestrol acetate 40 mg per mL oral suspension (Added Diagnosis Exclusion)
Megestrol acetate 400 mg per 10 mL oral suspension (Added Diagnosis Exclusion)
Megestrol acetate 20 mg tablet (Added Diagnosis Exclusion)
Megestrol acetate 40 mg tablet (Added Diagnosis Exclusion)
Mimvey 1mg/0.5 mg tablet (Added Diagnosis Exclusion)
Norethindrone acetate 5 mg tablet (Added Diagnosis Exclusion)
Oriahnn 300 mg/1-0.5 mg/300 mg therapy pack (Added Diagnosis Exclusion)
Progesterone 100 mg capsule (Added Diagnosis Exclusion)
Progesterone 200 mg capsule (Added Diagnosis Exclusion)
Soltamox 10 mg per 5 L oral solution (Added Diagnosis Exclusion)
Tamoxifen citrate 10 mg tablet (Added Diagnosis Exclusion)
Tamoxifen citrate 20 mg tablet (Added Diagnosis Exclusion)
Testosterone cypionate 100 mg per mL intramuscular solution (Added Diagnosis Exclusion)
Testosterone cypionate 200 mg per mL intramuscular solution (Added Diagnosis Exclusion)
Testosterone enanthate 200 mg per mL intramuscular solution (Added Diagnosis Exclusion)
Testosterone 1.62 % transdermal gel (Added Diagnosis Exclusion)
Testosterone 10 mg per actuation (2%) transdermal gel (Added Diagnosis Exclusion)
Testosterone 12.5 mg per actuation (1%) transdermal gel (Added Diagnosis Exclusion)
Testosterone 20.25 mg per actuation (1.62%) transdermal gel (Added Diagnosis Exclusion)
Testosterone 25 mg per 2.5 gm (1%) transdermal gel (Added Diagnosis Exclusion)
Testosterone 50 mg per 5 gm (1%) transdermal gel (Added Diagnosis Exclusion)
Testosterone Solution 30 mg per actuation transdermal gel (Added Diagnosis Exclusion)
Toremifene citrate 60 mg tablet (Added Diagnosis Exclusion)

September 2023

Additions:

Austedo extended release titration kit (Prior Authorization, Quantity Limit)

Removals:

Other Updates:

August 2023

Additions:

Ace aerosol cloud enhancer
Adult aerosol mask
Austedo extended release 24 mg tablet (Prior Authorization, Quantity Limit)
Austedo extended release 12 mg tablet (Prior Authorization, Quantity Limit)
Austedo extended release 6 mg tablet (Prior Authorization, Quantity Limit)
Bd glucose 5 gm chewable tablet
Ebase controller kit
Filter air pp
Gnp oral mineral oil
Litetouch mask
Melatonin 3 mg tablet
Melatonin 5 mg tablet
Melatonin maxmum strength 5 mg tablet
Multivitamin infant/toddler oral solution
Multivitamin with iron 11 mg per mL infant/toddler solution
Nebivolol 10 mg tablet (Quantity Limit)
Nebivolol 2.5 mg tablet (Quantity Limit)
Nebivolol 20 mg tablet (Quantity Limit)
Nebivolol 5 mg tablet (Quantity Limit)
Niacin 100 mg tablet
Niacin extended release 500 mg tablet
Pari altera nebulizer handset
Pari baby conversion kit
Pari baby smart mask
Pari erapid nebulizer handset
Pari trek s combo kit
Pflex
Pharmacist choice mask wipes
Qc castor oil
Replacement filters
Sidestream adult face mask
Sidestream pediatric face mask
Sm sweet oil
Threshold imt
Threshold pep device
Tubing/wing tip
Tyblume 0.1 mg/20 mg/0.02 mcg chewable tablet
Vitamin a 250 mcg/vitamin c 10 mcg/vitamin d 50 mg per mL infant/toddler drops

Removals:

1^st base cream
A thru z advantage tablet
Abobotulinumtoxina 300 unit intramuscular injection
Abobotulinumtoxina 500 unit intramuscular injection
Acacia syrup
Acamprosate calcium 333 mg delayed release tablet
Acetylcysteine 200 mg per mL injection
Activite 1 mg tablet
Advance intuition control liquid normal in vitro
Advate 1000 unit reconstituted intravenous solution
Advate 1500 unit reconstituted intravenous solution
Advate 2000 unit reconstituted intravenous solution
Advate 250 unit reconstituted intravenous solution
Advate 3000 unit reconstituted intravenous solution
Advate 4000 unit reconstituted intravenous solution
Advate 500 unit reconstituted intravenous solution
Advocate control solution liquid low in vitro
Adynovate 1000 unit reconstituted intravenous solution
Adynovate 1500 unit reconstituted intravenous solution
Adynovate 2000 unit reconstituted intravenous solution
Adynovate 250 unit reconstituted intravenous solution
Adynovate 3000 unit reconstituted intravenous solution
Adynovate 500 unit reconstituted intravenous solution
Adynovate 750 unit reconstituted intravenous solution
Afstyla 1000 unit kit
Afstyla 1500 unit kit
Afstyla 2000 unit kit
Afstyla 250 unit kit
Afstyla 2500 unit kit
Afstyla 3000 unit kit
Afstyla 500 unit kit
Agamatrix control solution normal in vitro
Aloe vera 25 mg capsule
Alphanate 1000 unit reconstituted intravenous solution
Alphanate 1500 unit reconstituted intravenous solution
Alphanate 2000 unit reconstituted intravenous solution
Alphanate 250 unit reconstituted intravenous solution
Alphanate 500 unit reconstituted intravenous solution
Alphanine sd 1000 unit reconstituted intravenous solution
Alphanine sd 1500 unit reconstituted intravenous solution
Alphanine sd 500 unit reconstituted intravenous solution
Alprolix 1000 unit reconstituted intravenous solution
Alprolix 2000 unit reconstituted intravenous solution
Alprolix 250 unit reconstituted intravenous solution
Alprolix 3000 unit reconstituted intravenous solution
Alprolix 4000 unit reconstituted intravenous solution
Alprolix 500 unit reconstituted intravenous solution
Altaderm cream
Alteplase 2 mg for injection
Amino acid 2.4%/dextrose 6.8%/lipid 3.5%/electrolyte 0.5% intravenous emulsion
Amino acid 3.3%/dextrose 9.8%/lipid 3.9%/electrolyte 0.7% intravenous emulsion
Aminocaproic acid 0.25 gm per mL oral solution
Aminocaproic acid 1000 mg tablet
Aminocaproic acid 250 mg per mL injection
Aminocaproic acid 500 mg tablet
Aminosyn 10% intravenous solution
Aminosyn-pf 7% intravenous solution
Amlodipine besylate/olmesartan medoxomil 10 mg/20 mg tablet
Amlodipine besylate/olmesartan medoxomil 10 mg/40 mg tablet
Amlodipine besylate/olmesartan medoxomil 5 mg/20 mg tablet
Amlodipine besylate/olmesartan medoxomil 5 mg/40 mg tablet
Antiinhibitor coagulant complex 1000 unit for intravenous solution
Antiinhibitor coagulant complex 2500 unit for intravenous solution
Antiinhibitor coagulant complex 500 unit for intravenous solution
Apretude 600 mg extended release suspension
Aquaphor healing balm baby stick
Aralast np 500 mg injection
Ascorbic acid 100 mg tablet
Ascorbic acid 500 mg capsule
Ascorbic acid 500 mg wafer
Ascorbic acid 60 mg lozenge
Ascorbic acid chewable 125 mg tablet
Ascorbic acid extended release 1000 mg tablet
Ascorbic acid extended release 1500 mg tablet
Ascorbic acid extended release 500 mg capsule
Ascorbic acid extended release 500 mg tablet
Ascorbic acid oral powder
Atovaquone 750 mg per 5 mL suspension
Benazepril 10 mg/hydrochlorothiazide 12.5 mg tablet
Benazepril 20 mg/hydrochlorothiazide 12.5 mg tablet
Benazepril 20 mg/hydrochlorothiazide 25 mg tablet
Benazepril 5 mg/hydrochlorothiazide 6.25 mg tablet
Benefix 1000 unit kit
Benefix 2000 unit kit
Benefix 250 unit kit
Benefix 3000 unit kit
Benefix 500 unit kit
Bioflavonoid chewable tablets
Bioflavonoid extended release tablet
Bss plus intraocular solution
Bumetanide 0.25 mg per mL injection
Bupivacaine 0.25% injection
Bupivacaine 0.25%/epinephrine 1:200000 (pf) injection
Bupivacaine 0.25%/epinephrine 1:200000 injection
Bupivacaine 0.5% injection
bupivacaine 0.5%/epinephrine 1:200000 (pf) injection
bupivacaine 0.5%/epinephrine 1:200000 injection
Bupivacaine preservative free 0.25% injection
Bupivacaine preservative free 0.5% injection
Bupivacaine preservative free 0.75% injection
C complex extended release tablet
C1 esterase inhibitor (human) 500 unit for intravenous injection kit
Cabenuva 400 mg/600 mg suspension
Cabenuva 600 mg/900 mg suspension
Caffeine citrate 60 mg per 3 mL injection
Calcium 250 mg/phosphorus 107 mg/vitamin d 500 unit chewable tablet
Calcium 500 mg/vitamin c 10 mg/vitamin d 250 unit chewable tablet
Calcium 500 mg/vitamin d 100 unit/vitamin k 40 mcg chewable tablet
Calcium 500 mg/vitamin d 1000 unit/vitamin k 40 mcg chewable tablet
Calcium 500 mg/vitamin d 200 unit/vitamin k 40 mcg chewable tablet
Calcium 500 mg/vitamin d 500 unit/vitamin k 40 mcg chewable tablet
Calcium 600 mg/magnesium 40 mg/vitamin d 500 unit extended release tablet
Calcium acetate 668 mg tablet
Calcium ascorbate 500 mg tablet
Calcium carbonate 500 mg/cholecalciferol 100 unit chewable tablet
Calcium carbonate 500 mg/cholecalciferol 600 unit tablet
Calcium chloride 10% injection
Calcium citrate 200 mg/vitamin d 250 unit tablet
Calcium citrate 315 mg/vitamin d 250 unit tablet
Calcium citrate 315 mg/vitamin d tab 200 unit tablet
Calcium gluconate 10% injection
Calcium/magnesium/zinc/d3 tablet
Calcium-boron 500 mg/1.5 mg tablet
Carbonyl iron 45 mg tablet
Centratex 106 mg/1 mg capsule
Centrum performance tablet
Chemstrip bg log book
Cholecalciferol 25 mcg (1000 unit) spray
Cholecalciferol 250 mcg (10000 unit) capsule
Cholecalciferol 250 mcg (10000 unit) tablet
Chromic chloride 40 mcg per 10 mL injection
Ciprofloxacin 100 mg tablet
Citranatal b-calm 20 mg/1 mg/25 mg tablet
Clinimix 4.25%/dextrose 10% intravenous solution
Clinimix 4.25%/dextrose 5% intravenous solution
Clinimix 5%/dextrose 15% intravenous solution
Clinimix 5%/dextrose 20% intravenous solution
Clinimix 8%/dextrose 10%intravenous solution
Clinimix 8%/dextrose 14% intravenous solution
Clinimix e 2.75%/dextrose 5% intravenous solution
Clinimix e 4.25%/dextrose 10% intravenous solution
Clinimix e 4.25%/dextrose 5% intravenous solution
Clinimix e 5%/dextrose 15% intravenous solution
Clinimix e 5%/dextrose 20% intravenous solution
Clinimix e 8%/dextrose 10% intravenous solution
Clinimix e 8%/dextrose 14% intravenous solution
Clinimix/dextrose 6% intravenous solution
Clinisol sf 15% intravenous solution
Coagadex 250 unit reconstituted intravenous solution
Coagadex 500 unit reconstituted intravenous solution
Coconut oil 1000 mg capsule
Cola syrup
Collodion
Collodion flexible
Complete natal dha 29 mg/1 mg/200 mg/200 mg capsule
Corifact 1000 unit/1600 unit kit
Corn syrup
Corticotropin gel 80 unit per mL injection
Cromolyn sodium 100 mg per 5 mL oral concentration
Cupric chloride 0.4 mg per mL injection
Custom polyglycol troche base wax
Cvs flaxseed oil 1000 mg capsule
Cyclosporine 50 mg per mL intravenous solution
Deferoxamine mesylate 2 gm for injection
Deferoxamine mesylate 500 mg for injection
Dekas plus oral liquid
Delflex-sm/1.5% dextrose solution 398 mosm per L intraperitoneal
Delflex-sm/2.5% dextrose solution 347 mosm per L intraperitoneal
Delstrigo tab
Dextrose 10% injection
Dextrose 10%/sodium chloride 0.2%
Dextrose 10%/sodium chloride 0.45%
Dextrose 2.5%/sodium chloride 0.45%
Dextrose 20% injection
Dextrose 25% injection
Dextrose 30% injection
Dextrose 40% injection
Dextrose 5% in lactated ringers
Dextrose 5% injection
Dextrose 5%/electrolyte 48 intravenous solution
Dextrose 5%/sodium chloride 0.2%
Dextrose 5%/sodium chloride 0.225%
Dextrose 5%/sodium chloride 0.3%
Dextrose 5%/sodium chloride 0.33%
Dextrose 5%/sodium chloride 0.45%
Dextrose 5%/sodium chloride 0.9%
Dextrose 50% injection
Dextrose 70% injection
Dialyvite 3000 mg/3 mg tablet
Dialyvite 5000 mg/5 mg tablet
Dialyvite tablet
Dialyvite zinc tablet
Dobutamine 1 mg per mL in d5w injection
Dobutamine 12.5 mg per mL injection
Dobutamine 2 mg per mL in d5w injection
Dobutamine 4 mg per mL in d5w injection
Droperidol 2.5 mg per mL injection
Dupilumab subcutaneous 100 mg per 0.67 mL prefilled syringe solution
Dupilumab subcutaneous 200 mg per 1.14 mL pen injector solution
Dupilumab subcutaneous 200 mg per 1.14 mL prefilled syringe solution
Dupilumab subcutaneous 300 mg per 2 mL pen injector solution
Dupilumab subcutaneous 300 mg per 2 mL prefilled syringe solution
Ecolate 1000 unit reconstituted intravenous solution
Ecolate 1500 unit reconstituted intravenous solution
Ecolate 2000 unit reconstituted intravenous solution
Ecolate 250 unit reconstituted intravenous solution
Ecolate 3000 unit reconstituted intravenous solution
Ecolate 4000 unit reconstituted intravenous solution
Ecolate 500 unit reconstituted intravenous solution
Ecolate 5000 unit reconstituted intravenous solution
Ecolate 6000 unit reconstituted intravenous solution
Ecolate 750 unit reconstituted intravenous solution
Esperoct 1000 unit reconstituted intravenous solution
Esperoct 1500 unit reconstituted intravenous solution
Esperoct 2000 unit reconstituted intravenous solution
Esperoct 3000 unit reconstituted intravenous solution
Esperoct 500 unit reconstituted intravenous solution
Esterified estrogens 0.625 mg/methyltestosterone 1.25 mg tablet
Esterified estrogens 1.25 mg/methyltestosterone 2.5 mg tablet
Ethyl alcohol 100%
Famotidine 200 mg per 20 mL injection
Famotidine 40 mg per 4 mL injection
Famotidine in nacl 0.9% 20 mg per 50 mL intravenous solution
Famotidine preservative free 20 mg per 2 mL injection
Fasenra 30 mg per mL auto-injector
Fasenra subcutaneous solution 30 mg per mL prefilled syringe
Fat emulsion plant based (soy) iv emulsion 20%
Fat emulsion plant based (soy) iv emulsion 30%
Ferrex 150 forte plus 50 mg/100 mg capsule
Ferrex 28 tablet
Ferrex plus 150 mg/50 mg/50 mg capsule
Ferrous fumarate/folic acid/docusate sodium/b complex/vitamin c tablet
Fish oil 1000 mg/cholecalciferol 1000 unit capsule
Fish oil 1200 mg/cholecalciferol 1000 unit capsule
Fish oil 875 mg chewable tablet
Fish oil adult gummies 113.5 mg chewable tablet
Fish oil triple strength 1360 mg capsule
Fixed oil suspension liquid
Flaxseed oil 1300 mg capsule
Fluocinonide 0.05% ointment
Foamil liquid
Folic acid 5 mg per mL injection
Folivane-ob 85 mg/1 mg capsule
Foltrate 500 mcg/1 mg tablet
Fos-a liquid
Fosinopril sodium/hydrochlorothiazide 10 mg/12.5 mg tablet
Fosinopril sodium/hydrochlorothiazide 20 mg/12.5 mg tablet
Freedom peg troche base powder
Furosemide 10 mg per mL injection
Genadek liquid drops
Gentamicin in saline 0.8 mg per mL injection
Gentamicin in saline 1 mg per mL injection
Gentamicin in saline 1.2 mg per mL injection
Gentamicin in saline 1.6 mg per mL injection
Gentamicin in saline 2 mg per mL injection
Gentamicin sulfate 10 mg per mL injection
Gentamicin sulfate 40 mg per mL injection
Glassia injection
Glucagon diagnostic 1 mg for injection
Glucocom autolink telemonitor
Glycine diluent for injection
Gnp fish oil delayed release 840 mg capsule
Gold bond friction defense stick
Granisetron 1 mg per mL injection
Guaifenesin 100 mg per 5 mL syrup
Gum base gelatin gel
Hemofil m 1000 unit reconstituted intravenous solution
Hemofil m 1700 unit reconstituted intravenous solution
Hemofil m 250 unit reconstituted intravenous solution
Hemofil m 500 unit reconstituted intravenous solution
Hepatitis b immune globulin (human) 312 unit per mL intramuscular solution
Humate-p 1000 unit/2400 unit reconstituted intravenous solution
Humate-p 250 unit/600 unit reconstituted intravenous solution
Humate-p 500 unit/1200 unit reconstituted intravenous solution
Icatibant acetate subcutaneous 30 mg per 3 mL prefilled syringe solution
Idelvion 1000 unit reconstituted intravenous solution
Idelvion 2000 unit reconstituted intravenous solution
Idelvion 250 unit reconstituted intravenous solution
Idelvion 3500 unit reconstituted intravenous solution
Idelvion 500 unit reconstituted intravenous solution
Infant drinking water
Infuvite intravenous injectable
Infuvite pediatric intravenous solution
Ionosol-mb in dextrose 5% intravenous solution
Irbesartan 150 mg tablet
Irbesartan 300 mg tablet
Irbesartan 75 mg tablet
Iron polysacch complex 150 mg/vitamin b12 0.025 mg/folic acid 1 mg capsule
Isolyte-p in dextrose 5% intravenous solution
Isolyte-s intravenous solution
Isolyte-s pH 7.4 intravenous solution
Ixinity 1000 unit reconstituted intravenous solution
Ixinity 1500 unit reconstituted intravenous solution
Ixinity 2000 unit reconstituted intravenous solution
Ixinity 250 unit reconstituted intravenous solution
Ixinity 3000 unit reconstituted intravenous solution
Ixinity 500 unit reconstituted intravenous solution
Jivi 1000 unit reconstituted intravenous solution
Jivi 2000 unit reconstituted intravenous solution
Jivi 3000 unit reconstituted intravenous solution
Jivi 500 unit reconstituted intravenous solution
Kesimpta 20 mg per 0.4 mL
Koate 1000 unit reconstituted intravenous solution
Koate 250 unit reconstituted intravenous solution
Koate 500 unit reconstituted intravenous solution
Kogenate fs 1000 unit intravenous kit
Kogenate fs 2000 unit intravenous kit
Kogenate fs 250 unit intravenous kit
Kogenate fs 3000 unit intravenous kit
Kogenate fs 500 unit intravenous kit
Lactated ringers for irrigation
Lactated ringers solution
Lidocaine 0.5%/epinephrine 1:200000 injection
Lidocaine 1%/epinephrine 1:100000 injection
Lidocaine 1.5%/epinephrine 1:200000 injection
Lidocaine 2%/epinephrine 1:100000 injection
Lidocaine 2%/epinephrine 1:200000 injection
Lidocaine 2%/epinephrine 1:50000 injection
Lidocaine local preservative free 1% injection
Lidocaine local 0.5% injection
Lidocaine local 1% injection
Lidocaine local 2% injection
Lidocaine local preservative free 0.5% injection
Lidocaine local preservative free 1.5% injection
Lidocaine local preservative free 2% injection
Lidocaine local preservative free 4% injection
L-methylfolate 15 mg tablet
L-methylfolate 7.5 mg tablet
Lozibase
Magnesium chloride 200 mg per mL injection
Magnesium oxide 200 mg tablet
Magnesium oxide 250 mg tablet
Magnesium oxide 400 mg capsule
Magnesium oxide 500 mg capsule
Magnesium sulfate 20 gm per 500 mL intravenous solution
Magnesium sulfate 4 gm per 100 mL intravenous solution
Magnesium sulfate 4 gm per 50 mL intravenous solution
Magnesium sulfate 40 gm per 1000 mL intravenous solution
Magnesium sulfate 50% injection
Manganese chloride 0.1 mg per mL intravenous solution
Meloxicam 30 mg per mL intravenous solution
Miglustat 100 mg capsule
Milk thistle (silybum marianum) 175 mg capsule
Milk thistle (silybum marianum) 175 mg tablet
Milk thistle (silybum marianum) 300 mg capsule
Milk thistle (silybum marianum) 87.5 mg capsule
Milrinone lactate 10 mg per 10 mL intravenous solution (base equivalent)
Milrinone lactate 20 mg per 100 mL in dextrose 5% intravenous solution (base equivalent)
Milrinone lactate 20 mg per 20 mL intravenous solution (base equivalent)
Milrinone lactate 40 mg per 200 mL in dextrose 5% intravenous solution (base equivalent)
Milrinone lactate 50 mg per 50 mL intravenous solution (base equivalent)
Multiple vitamin injection
Mvw complete formulation pediatric oral solution
Mycophenolate mofetil 500 mg for intravenous solution (base equiv)
Naloxone 8 mg per 0.1 mL nasal spray
Nephplex tablet
Nephron fa tablet
Nice distilled water
Normosol-m in dextrose 5% intravenous solution
Normosol-r in dextrose 5% intravenous solution
Normosol-r intravenous solution
Normosol-r pH 7.4 intravenous solution
Novoeight 1000 unit reconstituted intravenous solution
Novoeight 1500 unit reconstituted intravenous solution
Novoeight 2000 unit reconstituted intravenous solution
Novoeight 250 unit reconstituted intravenous solution
Novoeight 3000 unit reconstituted intravenous solution
Novoeight 500 unit reconstituted intravenous solution
Novoseven rt 1 mg intravenous solution
Novoseven rt 2 mg intravenous solution
Novoseven rt 5 mg intravenous solution
Novoseven rt 8 mg intravenous solution
Nuedexta 20 mg/10 mg capsule
Nuwiq 1000 unit kit
Nuwiq 1000 unit reconstituted intravenous solution
Nuwiq 1500 unit kit
Nuwiq 1500 unit reconstituted intravenous solution
Nuwiq 2000 unit kit
Nuwiq 2000 unit reconstituted intravenous solution
Nuwiq 250 unit kit
Nuwiq 250 unit reconstituted intravenous solution
Nuwiq 2500 unit kit
Nuwiq 2500 unit reconstituted intravenous solution
Nuwiq 3000 unit kit
Nuwiq 3000 unit reconstituted intravenous solution
Nuwiq 4000 unit kit
Nuwiq 4000 unit reconstituted intravenous solution
Nuwiq 500 unit kit
Nuwiq 500 unit reconstituted intravenous solution
Obizur 500 unit reconstituted intravenous solution
Omega-3 delayed release 350 mg capsule
Omega-3 fish oil 880 mg capsule
Onabotulinumtoxina 100 unit for injection
Onabotulinumtoxina 200 unit for injection
Ondansetron 4 mg per 2 mL injection
Ondansetron 4 mg per 2 mL prefilled syringe
Ondansetron 40 mg per 20 mL injection
Oxycodone 5 mg/acetaminophen 325 mg per 5 mL solution
Palonosetron 0.25 mg per 5 mL intravenous solution (base equivalent)
Pcca pracamac base oil
Pediatric multiple vitamins intravenous solution
Pediatric multiple vitamins with minerals liquid
Pediatric multiple vitamins with minerals oral solution
Pentamidine isethionate 300 mg for nebulization solution
Phytonadione 1 mg per 0.5 mL injection
Phytonadione 10 mg per mL injection
Pifeltro 100 mg tablet
Pimozide 1 mg tablet
Pimozide 2 mg tablet
Plasma-lyte a intravenous solution
Pnv-dha 27 mg/0.6 mg/0.4 mg/300 mg capsule
Polysaccharide iron-fa-vit b12 cap 150 mg-1 mg-25 mcg
Poly-vi-flor 0.25 mg per mL oral suspension
Poly-vi-flor with iron 0.25 mg/7 mg per mL suspension
Poly-vi-flor with iron 0.5 mg/10 mg chewable tablet
Potassion chloride 20 meq per L (0.15%) in sodium chloride 0.45% injection
Potassium acetate 2 meq per mL injection
Potassium bicarbonate-citric acid 10 meq effer tablet
Potassium bicarbonate-citric acid 20 meq effer tablet
Potassium chloride 10 meq per 100 mL injection
Potassium chloride 10 meq per 50 mL injection
Potassium chloride 10 meq per L (0.075%) in dextrose 5% and sodium chloride 0.45% injection
Potassium chloride 10% oral solution
Potassium chloride 2 meq per mL injection
Potassium chloride 20 meq per 100 mL injection
Potassium chloride 20 meq per 50 mL injection
Potassium chloride 20 meq per L (0.15%) in dextrose 5% and sodium chloride 0.2% injection
Potassium chloride 20 meq per L (0.15%) in dextrose 5% and sodium chloride 0.225% injection
Potassium chloride 20 meq per L (0.15%) in dextrose 5% and sodium chloride 0.45% injection
Potassium chloride 20 meq per L (0.15%) in dextrose 5% and sodium chloride 0.9% injection
Potassium chloride 20 meq per L (0.15%) in dextrose 5% injection
potassium chloride 20 meq per L (0.15%) in dextrose 5% lactated ringers
Potassium chloride 20 meq per L (0.15%) in sodium chloride 0.9% injection
Potassium chloride 20 meq powder packet
Potassium chloride 20% oral solution
Potassium chloride 30 meq per L (0.224%) in dextrose 5% and sodium chloride 0.45% injection
Potassium chloride 40 meq per 100 mL injection
Potassium chloride 40 meq per L (0.3%) in dextrose 5% and sodium chloride 0.45% injection
Potassium chloride 40 meq per L (0.3%) in dextrose 5% and sodium chloride 0.9% injection
Potassium chloride 40 meq per L (0.3%) in sodium chloride 0.9% injection
Potassium phosphates 15 mm per 5 mL injection
Potassium phosphates 150 mm per 50 mL injection
Potassium phosphates 45 mm per 15 mL injection
Potassium phosphates 45 mm per 15 mL injection
Prenate enhance 28 mg/0.6 mg/0.4 mg/400 mg capsule
Profilnine 1000 unit reconstituted intravenous solution
Profilnine 1500 unit reconstituted intravenous solution
Profilnine 500 unit reconstituted intravenous solution
Prolastin-c 1000 mg vial
Prosol 20% intravenous solution
Purevit dualfe plus 162 mg/115.2 mg/1 mg capsule
Pyridostigmine bromide 30 mg tablet
Pyridostigmine bromide 60 mg per 5 mL oral solution
Pyridostigmine bromide extended release 180 mg tablet
Pyridoxine 100 mg per mL injection
Rebinyn 1000 unit reconstituted intravenous solution
Rebinyn 2000 unit reconstituted intravenous solution
Rebinyn 500 unit reconstituted intravenous solution
Recombinate 1241 unit/1800 unit reconstituted intravenous solution
Recombinate 1801 unit/2400 unit reconstituted intravenous solution
Recombinate 220 unit/400 unit reconstituted intravenous solution
Recombinate 401 unit/800 unit reconstituted intravenous solution
Recombinate 801 unit/1240 unit reconstituted intravenous solution
Reyataz 50 mg powder
Rheospray liquid
Rifampin 600 mg for injection
Rimantadine hydrochloride 100 mg tablet
Ringer's solution
Ringer's solution for irrigation
Rose water
Rukobia 600 mg extended release tablet
Salicylic acid 27.5% film forming liquid
Select-ob and dha 29 mg/1 mg/250 mg capsule
Selenious acid 40 mcg per mL injection
Selzentry 20 mg per mL solution
Seraqua liquid
Sevenfact 1 mg reconstituted intravenous solution
Sevenfact 5 mg reconstituted intravenous solution
Sm fish oil 554 mg capsule
Sodium acetate 2 meq per mL injection
Sodium acetate 4 meq per mL injection
Sodium bicarbonate 4.2% intravenous solution
Sodium chloride 0.45% intravenous solution
Sodium chloride 0.9% intravenous solution
Sodium chloride 2.5 meq per mL injection
Sodium chloride 3% intravenous solution
Sodium chloride 4 meq per mL intravenous solution
Sodium chloride 5% intravenous solution
Sodium chloride preservative free 0.9% injection
Sodium ferric glucose complex 12.5 mg per mL in sucrose intravenous solution
Sodium phosphates 45 mm per 15 mL injection
Sodium zirconium cyclosilicate 10 gm packet for suspension
Sodium zirconium cyclosilicate 5 gm packet for suspension
Solydra liquid
Supposibase f powder
Syringe/needle 1 ml 30 x 1/2"
Taliglucerase alfa 200 unit for injection
Techna 20 sf troche base flakes
Telmisartan 20 mg tablet
Telmisartan 40 mg tablet
Telmisartan 80 mg tablet
Tetracaine 1% injection
The very finest fish oil oral liquid
Thiamine 100 mg per mL injection
Tinidazole 250 mg tablet
Tinidazole 500 mg tablet
Tobramycin sulfate 1.2 gm per 30 mL (base equivalent)
Tobramycin sulfate 10 mg per mL (base equivalent)
Tobramycin sulfate 2 gm per 50 mL injection (base equivalent)
Tobramycin sulfate 80 mg per 2 mL (base equivalent)
Tpn electrolytes concentrate
Tranexamic acid 1000 mg per 10 mL intravenous solution
Tranexamic acid 1000 mg per 100 mL/sodium chloride 0.7% intravenous solution
Tretten 2000 unit/3125 unit reconstituted intravenous solution
Tri-vi-flor 0.25 mg per mL oral suspension
Tri-vi-flor 0.5 mg per mL oral suspension
Trochibase s flakes
Trogarzo 150 mg per mL injection
U-mild shampoo
Vehicle s
Versapro shampoo
Vitafol fe 90 mg/0.6 mg/0.4 mg/200 mg capsule
Vitafol gummies 3.33 mg/0.333 mg/34.8 mg chewable tablet
Vitafol ultra 29 mg/0.6 mg/0.4 mg/200 mg capsule
Vitafol-nano 18 mg/0.6 mg/0.4 mg tablet
Vitafol-ob and dha 65 mg/1 mg/250 mg capsule
Vitafol-ob tablet
Vitafol-one 29 mg/1 mg/200 mg capsule
Vital-d 1 mg tablet
Vitamin b12 500mg/folic acid 400 mcg tablet
Vitamin c bioflavonoids extended release 1000 mg/100 mg tablet
Vitamin c chewable tablet
Vonvendi 1300 unit reconstituted intravenous solution
Vonvendi 650 unit reconstituted intravenous solution
Wilate 1000 unit/1000 unit kit
Wilate 500 unit/500 unit kit
Xyntha 1000 unit kit
Xyntha 2000 unit kit
Xyntha 250 unit kit
Xyntha 500 unit kit
Xyntha solofuse 1000 unit kit
Xyntha solofuse 2000 unit kit
Xyntha solofuse 250 unit kit
Xyntha solofuse 3000 unit kit
Xyntha solofuse 500 unit kit
Zidovudine 10 mg per mL intravenous solution
Zinc chloride 1 mg per mL injection
Zinc sulfate 1 mg per mL injection
Zinc sulfate 3 mg per mL injection
Zinc sulfate 5 mg per mL injection

Other Updates:

Bisoprolol fumarate 10 mg tablet (Added Quantity Limit)
Desmopressin acetate 0.01% nasal spray solution (Added Quantity Limit)
Fluocinolone acetonide 0.01% oil (Added Quantity Limit)
Hydrocortisone acetate 1% cream (Added Quantity Limit)
Lisinopril 20 mg/ hydrochlorothiazide 12.5 mg tablet (Added Quantity Limit)
Methadone 10 mg per 5 mL solution (Added Quantity Limit)
Methadone 10 mg per mL concentration (Added Quantity Limit)
Methadone 10 mg tablet (Added Quantity Limit)
Methadone 5 mg per 5 mL solution (Added Quantity Limit)
Methadone 5 mg tablet (Added Quantity Limit)
Propranolol extended release 120 mg capsule (Added Quantity Limit)
Propranolol extended release 160 mg capsule (Added Quantity Limit)
Sildenafil citrate 20 mg tablet (Added Quantity Limit)

July 2023

Additions:

Algae based calcium tablet
Ceravite antioxidant senior tablet
Ceravite antioxidant tablet
Cerovite senior tablet
Compete tablet
Dermavite tablet
Dialyvite ultra d 800 mg tablet
Ex-lax 15 mg chewable tablet
Gaviscon 95 mg/358 mg per 15 ml oral suspension
Gaviscon extra strength 160 mg/105 mg chewable tablet
Gnp healthy eyes tablet
Gnp mega multi for men tablet
Gnp mega multi for women tablet
Gnp mens one daily lycopene tablet
GNP motion sickness 25 mg tablet
Gnp one daily mens health 50+ tablet
Gnp one daily womens health 50+ tablet
Gnp womens one daily tablet
Hm 500 mg antacid chewable
Icaps areds formula tablet
Icaps mv tablet
I-vite tablet
Kalydeco 13.4 mg granules (Prior Authorization)
Mekinist 0.05 mg per ml solution (Prior Authorization)
Ocuvite extra tablet
Ocuvite eye multi tablet
Ocuvite-lutein tablet
Oncovite tablet
Prenatal 19 tablet
Preservision areds tablet
Prorenal plus d tablet
Prosight tablet
Qc antacid 500 mg chewable tablet
Qc antacid 750 mg extended release chewable tablet
Qc daily multivitamin and multimineral tablet
Qc mens daily multivitamin tablet
Qc multi-vite 50+ tablet
Qc multi-vite tablet
Qc therin-m tablet
Qc womens daily multivitamin tablet
Renaplex tablet
Renaplex-d tablet
Sentry senior tablet
Sm complete advanced formula tablet
Sm complete senior formula tablet
Sm complete tablet
Sm daily diet support tablet
Sm motion sickness 25 mg tablet
Sm opti-vitamins tablet
Systane icaps areds2 tablet
Tafinlar 10 mg tablet (Prior Authorization)
Thera m plus tablet
Thera m tablet
Therems m tablet
Trikafta 59.5 mg pak (Prior Authorization)
Trikafta 75 mg pak (Prior Authorization)
Tums 500 mg chewable tablet
Tums 750 mg chewable tablet
Tums extra strength 750 mg chewable tablet
Tums ultra 1000 mg chewable tablet
Wes-phos 250 neutral 155 mg/852 mg/130 mg tablet

Removals:

A + D personal care lotion
Advanced healing baby ointment
Afatinib dimaleate 20 mg base equivalent tablet
Afatinib dimaleate 30 mg base equivalent tablet
Afatinib dimaleate 40 mg base equivalent tablet
Alectinib 150 mg base equivalent capsule
Alemtuzumab 30 mg per ml intravenous injection
Allantoin 0.2% cream
Alogliptin-pioglitazone 12.5 mg/15 mg tablet
Alogliptin-pioglitazone 12.5 mg/45 mg tablet
Amino acid 5.2% infusion
Amino acid 8.5% infusion
Amino acid electrolyte 3.5% infusion
Amino acid electrolyte 7% infusion
Amino acid electrolyte 8.5% infusion
Antacid flavor 750 mg chewable tablets
Aqua glycolic hand and body lotion
Aqua lacten lotion
Aquamed lotion
Aquaphor 41% advanced protection healing ointment
Aquaphor ointment
Aromatic elixir
Aveeno daily moisturizing lotion
Aveeno stress relief lotion
Bacmin tablet
Bacteriostatic water for injection
Bacteriostatic water for injection (parabens)
Butalbital 50 mg Aspirin 325 mg and caffeine 40 mg tablet
Calcium carbonate 500 mg and vitamin d 125 unit tablet
Cam lotion
Cefazolin sodium 20 gm for injection
Cefotetan disodium 1 gm and dextrose 3.58% per 50 ml intravenous solution
Cefotetan disodium 10 gm for injection
Cefotetan disodium 2 gm and dextrose 2.08% per 50 ml intravenous solution
Cefuroxime sodium 7.5 gm for injection
Centany 2% ointment
Ceritinib 150 mg capsule
Cetaphil advanced relief lotion
Cetaphil moisturizing lotion
Cimetidine 300 mg per 5 ml solution
Colloidal oatmeal pack 100% and colloidal oatmeal cream 1% kit
Corvita tablet
Cvc special care lotion
Cvs advanced healing ointment
Cvs antacid maximun strength 1000 mg chewable tablet
Cvs beauty 360 dry skin lotion
Cvs daily ultra moisture lotion
Cvs gentle skin cleanser lotion
Cvs glycerin 2 gm adult rectal suppository
Cvs heartburn relief 160 mg/105 mg chewable tablet
Cvs miconazole 1200 mg/2 mg 1% vaginal kit
Dental base gel
Dermacinrx multitam tablet
Dermacinrx ribotin-e tablet
Dermacinrx zintrexyl-c tablet
Derma-g mild liquid
Dermal therapy 1% face care therapy
Dermal therapy 1% foot massage lotion
Dermal therapy extra strength 10% lotion
Dermal therapy hand and elbow 15% lotion
Dermal therapy heel care 25% lotion
Dexpanthenol 2% cream
Dextrose diagnostic aid 5% injection
Dialyvite supreme d tablet
Didanosine delayed release 250 mg capsule
Didanosine delayed release 400 mg capsule
Eculizumab 300 mg per 30 ml intravenous solution
Electrolyte-b in dextrose 5% solution
Emollient aerosol foam
Emollient cream and wound dressing gel kit
Emollient emulsion
Emollient foam and wound dressing gel kit
Emollient with antiseptic lotion
Epclusa 400 mg/100 mg tablet
Epilyt lotion
Epirubicin 200 mg for intravenous injection
Eq antacid ultra strength 1000 mg chewable tablet
Eq miconazole 1200 mg/2 mg 1% vaginal kit
Etanercept 25 mg for subcutaneous injection
Eucerin baby lotion
Eucerin daily hydration lotion
Eucerin daily protection SPF 30 lotion
Eucerin intense repair lotion
External vehicles solution
Fish oil 1000 mg and vitamin d 1000 unit capsule
Floriva plus 0.25 mg per ml solution
Fluticasone propionate 110 mcg per actuation inhalation
Fluticasone propionate 220 mcg per actuation inhalation
Fluticasone propionate 44 mcg per actuation inhalation
Foliflex tablet
Folitin-z tablet
Gentamicin 1.4 mg per ml in saline for injection
Gentamicin sulphate 0.3% ophthalmic ointment
Glycerin and rose water
Glycerin/mineral oil/petrolatum/cetostearyl alc cream
Goodsense antacid 500 mg chewable tablet
Granisetron 0.1 mg per ml injection
Grape oral syrup
Griseofulvin ultramicrosize 135 mg tablet
Griseofulvin ultramicrosize 330 mg tablet
Human serum albumin diluent for injection
Humulin 70/30 100 units per ml pen-injector
Humulin 70/30 100 units per ml subcutaneous
Humulin N 100 units per ml pen-injector
Humulin N 100 units per ml subcutaneous
Humulin R 100 units per ml subcutaneous
Hyaluronate sodium 0.1% lotion
Hyaluronate sodium 0.2% gel
Hyaluronate sodium lotion
Hydrocortisone acetate 2.5% with pramoxine perianal 1% cream
Hydrocortisone with aloe vera 1% cream
Icatibant acetate 30 mg per 3 ml injection
Insulin syringe/needle U-100 0.3 ml 28 x ½”
Insulin syringe/needle U-100 0.3 ml 29 G
Insulin syringe/needle U-100 0.3 ml 29 x 1”
Insulin syringe/needle U-100 0.3 ml 29 x 7/16”
Insulin syringe/needle U-100 0.3 ml 30 G
Insulin syringe/needle U-100 0.3 ml 30 x 3/8”
Insulin syringe/needle U-100 0.3 ml 30 x 7/16”
Insulin syringe/needle U-100 0.3 ml 31 x 3/8”
Insulin syringe/needle U-100 0.5 ml 28 x 5/16”
Insulin syringe/needle U-100 0.5 ml 29 G
Insulin syringe/needle U-100 0.5 ml 29 x 5/16”
Insulin syringe/needle U-100 0.5 ml 29 x 7/16”
Insulin syringe/needle U-100 0.5 ml 30 G
Insulin syringe/needle U-100 0.5 ml 30 x 3/8”
Insulin syringe/needle U-100 0.5 ml 30 x 7/16”
Insulin syringe/needle U-100 0.5 ml 31 x 3/8”
Insulin syringe/needle U-100 1 ml 29 G
Insulin syringe/needle U-100 1 ml 29 x 7/16”
Insulin syringe/needle U-100 1 ml 30 G
Insulin syringe/needle U-100 1 ml 30 x 3/8”
Insulin syringe/needle U-100 1 ml 30 x 7/16”
Insulin syringe/needle U-100 1 ml 31 x 3/8”
Insulin syringe/needle U-100 2 ml 29 x ½”
Insulin syringe/needle U-40 1 ml 25 x 5/8”
Interferon alfa-2b 10,000,000 units for injction
Interferon alfa-2b 18,000,000 units for injction
Interferon alfa-2b 50,000,000 units for injction
Isopto atropine 1% ophthalmic solution
Johnson’s skin nourish moist lotion
Keri advanced moisture therapy lotion
Keri basic essentials lotion
Keri nourishing shea butter lotion
Keri original daily moisture lotion
Keri overnight lotion
Keri renewal milk body lotion
Keri renewal skin firming lotion
Keri renewal stretch mark lotion
Keri sentitive skin lotion
Ketotifen fumarate 0.025% preservative free ophthalmic solution
Lactic acid 10% cream
Lactic acid 12% foam
Lamivudine 5 mg per ml oral solution
Lamivudine tenofovir disoproxil fumarate 300 mg/300 mg tablet
Lenvatinib 10 mg therapy pack
Lenvatinib 10 mg therapy pack (20 mg daily dose)
Lenvatinib 4 mg therapy pack (12 mg)
Lenvatinib 4 mg therapy pack (4 mg daily dose)
Lenvatinib 4 mg therapy pack (8 mg daily dose)
Lenvatinib 4 mg/10 mg therapy pack (14 mg daily dose)
Lenvatinib 4 mg/10 mg therapy pack (18 mg daily dose)
Lenvatinib 4 mg/10 mg therapy pack (24 mg daily dose)
Lidocaine 5% in 7.5% dextrose intraspinal solution
Liqua spen syrup
Loratadine syrup 5 mg per 5 ml
Lubrisoft lotion
Magnesium oxide 400 mg capsule
Melatonin 3 mg controlled release capsule
Methotrexate sodium 200 mg per 8 ml preservative free injection
Methotrexate sodium 25 mg per ml injection
Mouthwash compounding base liquid
Nicadan tablet
Nivea original moisture lotion
Nivea visage lotion
Nutraderm advanced formula lotion
Nutricap tablet
Nutrifac zx tablet
Oral vehicles
Orange flower water
Orange syrup
Paliperidone palmitate extended release 117 mg per 0.75 ml intramuscular suspension
Paliperidone palmitate extended release 156 mg per ml intramuscular suspension
Paliperidone palmitate extended release 175 mg per 0.875 ml prefilled syringe
Paliperidone palmitate extended release 234 mg per 1.5 ml intramuscular suspension
Paliperidone palmitate extended release 263 mg per 1.315 ml prefilled syringe
Paliperidone palmitate extended release 273 mg per 0.875 ml intramuscular suspension
Paliperidone palmitate extended release 350 mg per 1.75 ml prefilled syringe
Paliperidone palmitate extended release 39 mg per 0.25 ml intramuscular suspension
Paliperidone palmitate extended release 410 mg per 1.315 ml intramuscular suspension
Paliperidone palmitate extended release 525 mg per 2.625 ml prefilled syringe
Paliperidone palmitate extended release 546 mg per 1.75 ml intramuscular suspension
Paliperidone palmitate extended release 78 mg per 0.5 ml intramuscular suspension
Paliperidone palmitate extended release 819 mg per 2.625 ml intramuscular suspension
Parenteral electrolyte solution
Pediatric multiple vitamins with calcium and iron chewable tablet
Pediatric multiple vitamins with extra calcium and iron chewable tablet
Pediatric multiple vitamins with fluoride 0.5 mg and iron 10 mg biphasic chewable tablet
Pediatric multiple vitamins with fluoride biphasic 0.25 mg chewable tablet
Pediatric multiple vitamins with fluoride biphasic 0.5 mg chewable tablet
Pediatric multiple vitamins with fluoride biphasic 1 mg chewable tablet
Pediatric multiple vitamins with minerals and calcium 45 mg per 0.5 ml drops
Penicillin g benzathine 2400000 units per 4 ml intramuscular suspension
Potassium chloride 10 meq per L in dextrose 5% and sodium chloride 0.2% injection
Potassium chloride 20 meq per L in dextrose 5% and sodium chloride 0.33% injection
Potassium chloride 30 meq per 100 ml injection
Potassium chloride 30 meq per L in dextrose 5% and sodium chloride 0.2% injection
Potassium chloride 30 meq per L in dextrose 5% injection
Potassium chloride 40 med per L in dextrose and lactated ringers
Potassium chloride 40 meq per L in dextrose 5% and sodium chloride 0.2% injection
Potassium chloride 40 meq per L in dextrose 5% injection
Prednicarbate 0.1% ointment
Prednisolone syrup 15 mg per 5 ml
Propylene glycol
PureFe ob plus 162 mg/115.2 mg/1 mg capsules
Quflora pediatric 0.25 mg per ml solution
Relion 70% alcohol pads
Risperidone microspheres 12.5 mg for injection
Risperidone microspheres 25 mg for injection
Risperidone microspheres 37.5 mg for injection
Risperidone microspheres 50 mg for injection
Ritonavir 80 mg per ml oral solution
Rose essence soluble
Saccharin 0.05% solution
Saccharin 0.05% suspension
Saline with parabens injection
Saline/benzyl/alcohol injection solution
Saquinavir mesylate 500 mg tablet
Semaglutide solution 2 mg per 1.5 ml pen injector (0.25 mg or 0.5 mg per dose)
Semaglutide solution 2 mg per 1.5 ml pen injector (1 mg per dose)
Simple syrup
Sodium iodide 100 mcg per ml injection
Sorbitol with saccharin syrup
Sterile water for injection
Strovite one tablet
Sure comfort 70% alcohol prep pads
Syringe/needle 12 ml 20 x 1”
Syringe/needle 12 ml 22 x 1”
Syringe/needle 6 ml 20 x 1”
Syringe/needle 6 ml 21 x 1 ¼”
Syringe/needle 6 ml 22 x 1 ¼”
Syringe/needle 6 ml 22 x 1”
Syringe/needle 6 ml 23 x 1”
Syrspend sugar free alka reconstituted suspension
Tretinoin emollient 0.02% cream
Tretinoin emollient 0.05% cream
Tucatinib 150 mg tablet
Tucatinib 50 mg tablet
Udamin sp tablet
Unispend anhydrous sweetened oral suspension
Urea 10% cream
Urea 10% lotion
Urea 15% lotion
Urea 2% cream
Urea 20% cream
Urea 20% lotion
Urea 22% ointment
Urea 25% lotion
Urea 30% cream
Urea 40% cream
Urea 40% ointment
Urea 5% lotion
Vancomycin 25 mg per ml oral solution compound kit
Vancomycin 50 mg per ml oral solution compound kit
Vandazole 0.75% vaginal gel
Varenicline tartrate 0.5 mg and 1 mg starter pack
Vehicle a
Vehicle n
Venexa fe tablet
Venexa tablet
Ventrixyl fe tablet
Ventrixyl tablet
Vita s forte tablet
Vitamin a and e emulsion
Vitamin a and d with aloe and zinc oxide cream
Vitamin c lotion
Vitamin e 100 unit per gram cream
Vitamin e shampoo
Vitamin e with a and d ointment
Vitamins a and d cream
Vitamins a and d liquid
Vitamins a and d with zinc oxide ointment
Vitramyn tablet
Vitranol fe tablet
Vitrexate fe tablet
Vitrexate tablet
Vitrexyl and iron tablet
Vitrexyl tablet
Vp-pnv-dha 28mg/1mg/215.8 mg capsules
Wibi lotion
Wild cherry flavor extract
Zevrx sterile 70% alcohol prep pad

Other Updates:

June 2023

Additions:

Removals:

Firvanq 50 mg per ml solution

Other Updates:

May 2023

Additions:

Breztri aerosphere 160mcg/9 mcg/4.8 mcg inhalation (Step Therapy, Quantity Limit)
CVS pinworm 50 mg per ml suspension
Fexofenadine HCL 30 mg per ml suspension (Quantity Limit)
Gilenya 0.25 mg capsules (Prior Authorization, Quantity Limit)
GNP hydrocortisone max strength 1% ointment
Trikafta 100 mg/50 mg/75 mg/150 mg tablets (Prior Authorization)
Trikafta 50 mg/25 mg/37.5 mg/75 mg tablets (Prior Authorization)
Urea 20% cream

Removals:

Amphotericin b 50 mg reconstituted intravenous solution
Aztreonam 1 gm solution for injection
Aztreonam 2 gm solution for injection
Cholecalciferol 125 mcg per ml drops
Cholecalciferol 2000 unit chewable tablets
Cholecalciferol 3000 unit tablets
Cholecalciferol 400 unit capsules
Cholecalciferol 4000 unit capsules
Clindamycin phosphate 300 mg per 2 ml injection
Clindamycin phosphate 600 mg per 4 ml injection
Clindamycin phosphate 9 gm per 60 ml injection
Clindamycin phosphate 900 mg per 6 ml injection
Colestipol 5 gm granule packets
Colestipol 5 gm granules
Colistimethate sodium150 mg solution for injection
Creon delayed release 12000-38000 unit capsules
Creon delayed release 24000-76000 unit capsules
Creon delayed release 3000-9500 unit capsules
Creon delayed release 36000-114000 unit capsules
Creon delayed release 6000-19000 unit capsules
Dekas essential oral liquid
Diuril 250 mg per 5 ml oral suspension
Elmiron 100 mg capsules
Enfamil expecta 28 mg/0.8 mg/200 mg capsules
Ergocalciferol 2000 unit tablets
Ergocalciferol 400 unit tablets
Fluconazole 100 mg in sodium chloride 0.9% per 50 ml intervenous solution
Fluconazole 200 mg in sodium chloride 0.9% per 100 ml intervenous solution
Fluconazole 400 mg in sodium chloride 0.9% per 200 ml intervenous solution
Fluocinolone acetonide 0.01% cream
Fluocinolone acetonide 0.01% scalp oil
Ganciclovir sodium 500 mg per 10 ml intravenous solution
Ganciclovir sodium 500 mg reconstituted intravenous solution
Heparin sodium (porcine) 20000 units per ml injection
Heparin sodium (porcine) 5000 units per 0.5 ml injection
Hydroxychloroquine sulfate 100 mg tablets
Hydroxychloroquine sulfate 300 mg tablets
Hydroxychloroquine sulfate 400 mg tablets
Hydroxyprogesterone caproate bulk powder
Hydroxyprogesterone caproate oil 250 mg per ml injection
Hydroxyprogesterone caproate solution 275 mg per 1.1 ml auto-injector
Imipenem-cilastatin 250 mg intravenous solution
Imipenem-cilastatin 500 mg intravenous solution
Isosorbide dinitrate 40 mg tablets
Lidocaine 4% cream
Lidocaine HCL 4% solution
Lincomycin HCL 300 mg per ml injection
Magnesium 400 mg tablet
Makena 275 mg per 1.1 ml auto-injector
Meropenem 1 gm and sodium chloride 0.9% per 50 ml intravenous solution
Meropenem 1 gm intravenous solution
Meropenem 500 mg and sodium chloride 0.9% per 50 ml intravenous solution
Meropenem 500 mg intravenous solution
Metronidazole 500 mg per 100 ml intravenous solution
Mexiletine HCL 150 mg capsules
Mexiletine HCL 200 mg capsules
Mexiletine HCL 250 mg capsules
Niacin extended release 1000 mg tablets
Niacin extended release 500 mg tablets
Niacin extended release 750 mg tablets
Olmesartan hydrochlorothiazide 20 mg/12.5 mg tablets
Olmesartan hydrochlorothiazide 40 mg/12.5 mg tablets
Olmesartan hydrochlorothiazide 40 mg/25 mg tablets
Omega-3 fatty acids 435 mg capsules
Pediatric multiple vitamins with minerals chewable tablets
Polymyxin b sulfate 500,000 unit solution for injection
Posaconazole delayed release 100 mg tablets
Quinidine sulfate 200 mg tablets
Quinidine sulfate 300 mg tablets
Ranolazine extended release 1000 mg tablet
Ranolazine extended release 500 mg tablet
Ribavirin 6 gm reconstituted inhalation solution
Stiolto Respimat 2.5-2.5 mcg per actuation inhaler
Triamcinolone acetonide 0.05% ointment
Valganciclovir 50 mg per ml reconstituted oral solution
Vancomycin 1 gm and sodium chloride 0.9% per 200 ml intravenous solution
Vancomycin 500 mg and dextrose 5% per 100 ml intravenous solution
Vancomycin 500 mg and sodium chloride 0.9% per 100 ml intravenous solution
Vancomycin 750 mg and sodium chloride 0.9% per 150 ml intravenous solution

Other Updates:

Albendazole 200 mg tablets (Added Auto Prior Authorization, Removed Quantity Limit)
Betamethasone dipropionate 0.05% ointment (Changed Quantity Limit)
Emgality 120 mg per ml injection (Added Step Therapy, Added Quantity Limit, Removed Age Limit)
Emgality 120 mg per ml prefilled syringe (Added Step Therapy, Added Quantity Limit, Removed Age Limit)
Fluocinolone acetonide 0.025% cream (Changed Quantity Limit)
Fluocinolone acetonide 0.025% ointment (Changed Quantity Limit)
Fluticasone-Salmeterol 100 mcg/50 mcg inhaler (Removed Age Limit, Added Quantity Limit)
Fluticasone-Salmeterol 250 mcg/50 mcg inhaler (Removed Age Limit, Added Quantity Limit)
Fluticasone-Salmeterol 500 mcg/50 mcg inhaler (Removed Age Limit, Added Quantity Limit)
Lidocaine 5% ointment (Removed Prior Authorization)
Ozempic 2 mg per 1.5 ml pen injector (Added Step Therapy)
Ozempic 2 mg per 3 ml pen injector (Added Step Therapy)
Trulicity 0.75 mg per 0.5 ml pen injector (Added Step Therapy)
Trulicity 1.5 mg per 0.5 ml pen injector (Added Step Therapy)
Trulicity 3 mg per 0.5 ml pen injector (Added Step Therapy)
Trulicity 4.5 mg per 0.5 ml pen injector (Added Step Therapy)

April 2023

Additions:

Removals:

Other Updates:

March 2023

Additions:

Guaifenesin 100 mg/codeine 6.33 mg solution (Age Limit, Quantity Limit)

Removals:

Advair HFA 115 mcg/21 mcg inhalation
Advair HFA 230 mcg/21 mcg inhalation
Advair HFA 45 mcg/21 mcg inhalation
Ampicillin and sulbactam sodium 1.5 gm for injection
Ampicillin and sulbactam sodium 1.5 gm for intravenous solution
Ampicillin and sulbactam sodium 15 gm for intravenous solution
Ampicillin and sulbactam sodium 3 gm for injection
Ampicillin and sulbactam sodium 3 gm for intravenous solution
Ampicillin sodium 1 gm for injection
Ampicillin sodium 1 gm for intravenous solution
Ampicillin sodium 10 gm for intravenous solution
Ampicillin sodium 125 mg for injection
Ampicillin sodium 2 gm for injection
Ampicillin sodium 2 gm for intravenous solution
Ampicillin sodium 250 mg for injection
Ampicillin sodium 500 mg for injection
Anoro Ellipta 62.5 mcg/25 mcg inhalation
Asmanex 110 mcg 30 puff inhalation
Asmanex 220 mcg 120 puff inhalation
Azithromycin 500 mg intravenous for solution
Cefazolin sodium 1 gm for injection
Cefazolin sodium 1 gm for intravenous solution
Cefazolin sodium 10 gm for injection
Cefazolin sodium 2 gm for injection
Cefazolin sodium 500 mg for injection
Cefepime hydrochloric acid 1 gm for injection
Cefepime hydrochloric acid 2 gm for injection
Cefepime hydrochloric acid 2 gm for intravenous solution
Cefotaxime sodium 1 gm for injection
Cefotetan disodium 1 gm for injection
Cefotetan disodium 2 gm for injection
Cefoxitin sodium 1 gm and dextrose 4% per 50 mL
Cefoxitin sodium 1 gm for intravenous solution
Cefoxitin sodium 1 gm/dextrose 4% per 50 mL intravenous solution
Cefoxitin sodium 10 gm for intravenous solution
Cefoxitin sodium 2 gm and dextrose 2.2% per 50 mL
Cefoxitin sodium 2 gm for intravenous solution
Ceftriaxone sodium 1 gm and dextrose 3.74% in 50 mL intravenous solution
Ceftriaxone sodium 10 gm for injection
Ceftriaxone sodium 2 gm and dextrose 2.22% in 50 mL intravenous solution
Ceftriaxone sodium 20 mg per mL in dextrose injection
Ceftriaxone sodium 40 mg per mL in dextrose injection
Cefuroxime sodium 1 gm for intravenous solution
Cefuroxime sodium 1.5 gm for intravenous solution
Cefuroxime sodium 2 gm for intravenous solution
Cefuroxime sodium 750 mg for injection
Cephalexin 750 mg capsule
Ciprofloxacin 200 mg per 100 mL in dextrose water
Ciprofloxacin 250 mg per 5 mL for oral suspension
Ciprofloxacin 400 mg per 200 mL in dextrose water
Ciprofloxacin 500 mg per 5 mL for oral suspension
Doxycycline hyclate 150 mg tablet
Doxycycline hyclate 50 mg tablet
Doxycycline hyclate 75 mg tablet
Dulera 100 mcg/5 mcg inhalation
Dulera 200 mcg/5 mcg inhalation
Dulera 50 mcg/5 mcg inhalation
Erythromycin ethylsuccinate 200 mg per 5 ml for suspension
Heparin sodium (porcine) 100 unit per mL lock flush
Heparin sodium (porcine) 5000 unit per 0.5 mL prefilled syringe
Heparin sodium (porcine) 5000 unit per mL injection
Levofloxacin 250 mg per 50 mL in dextrose water intravenous solution
Levofloxacin 500 mg per 100 mL in dextrose water intravenous solution
Levofloxacin 750 mg per 150 mL in dextrose water intravenous solution
Penicillin g procaine 600,000 unit per mL intramuscular suspension
Penicillin g sodium 5,000,000 unit for injection
Piperacillin sodium and tazobactam sodium 13.5 gm for injection
Piperacillin sodium and tazobactam sodium 2.25 gm for injection
Piperacillin sodium and tazobactam sodium 3.375 gm for injection
Piperacillin sodium and tazobactam sodium 4.5 gm for injection
Piperacillin sodium and tazobactam sodium 40.5 gm for injection
Procaine 1,200,000 unit per 2 mL suspension
Procaine 900,000 unit/300,000 unit per 2 mL injection
Pulmicort Flexhaler 180 mcg inhalation
Pulmicort Flexhaler 90 mcg inhalation
Rivaroxaban 2.5 mg tablet
Rivaroxaban for suspension 1 mg per mL
Severent diskus 50 mcg inhalation
Terbutaline sulfate 1 mg per mL injection
Theo-24 extended release 100 mg capsule
Theo-24 extended release 200 mg capsule
Theo-24 extended release 300 mg capsule
Theo-24 extended release 400 mg capsule
Tobramycin 300 mg per 4 mL nebulizer solution

Other Updates:

February 2023

Additions:

Acid gone 160 mg/105 mg chewable tablet
Acid gone 95 mg/358 mg per 15 mL suspension
Afrin saline 0.65% nasal spray
Budesonide extended release 9 mg tablet
Carboxymethylcellulose sodium 1% ophthalmic gel
Carboxymethylcellulose sodium preservative free 1% ophthalmic gel
Cold and cough 2.5 mg/1 mg/5 mg per 5 mL liquid (Quantity Limit)
CVS disposable rectal enema 19 gm/7 gm per 118mL
CVS dry eye relief 0.2%/0.2%/1% ophthalmic solution
CVS eye allergy relief 0.027%/0.315% ophthalmic solution
CVS fiber 0.52 gm capsule
CVS lubricating/dry eye 0.5%/0.9% ophthalmic solution
Daily fiber 0.52 gm capsule
Deep sea 0.65% nasal spray
Dificid 200 mg tablet (Prior Authorization)
Dificid 40 mg per mL suspension (Prior Authorization)
Dimaphen dextromethorphan 2.5 mg/1 mg/5 mg per 5 mL liquid (Quantity Limit)
Dry eye relief drops 0.2%/0.2%/1% ophthalmic solution
Endacof dextromethorphan 2.5 mg/1 mg/5 mg per 5 mL liquid (Quantity Limit)
EQ multi symptom cold 2.5 mg/5 mg/100 mg per 5 mL liquid (Quantity Limit)
Esomeprazole magnesium delayed release 40 mg capsule (Quantity Limit)
Estradiol 0.01 mg/gm vaginal cream (Quantity Limit)
Ethacrynic acid 25 mg tablet
Fiber laxative 0.52 gm capsule
Fiber laxative 625 mg tablet
Fiber laxative plus calcium 625 mg tablet
GenTeal severe 0.3% ophthalmic gel
Glycerin childrens 1 gm rectal suppository
GNP anorectal 5% cream (Quantity Limit)
GNP antacid extra strength 160 mg/105 mg chewable
GNP cold and cough 2.5 mg/1 mg/5 mg per 5 mL liquid (Quantity Limit)
GNP natural fiber 0.52 gm capsule
Gvoke kit 1 mg per 0.2 mL subcutaneous solution (Quantity Limit)
Headache relief 250 mg/250 mg/65 mg tablet
Hemorrhoidal relief 5% cream (Quantity Limit)
HM cold and cough 2.5 mg/1 mg/5 mg per 5 mL liquid (Quantity Limit)
HM saline 0.65% nasal spray
Imbruvica 140 mg tablet (Prior Authorization, Quantity Limit)
Imbruvica 280 mg tablet (Prior Authorization, Quantity Limit)
Imbruvica 420 mg tablet (Prior Authorization, Quantity Limit)
Imbruvica 560 mg tablet (Prior Authorization, Quantity Limit)
Invega Hafyera 1092 mg per 3.5 mL prefilled syringe (Prior Authorization, Quantity Limit)
Invega Hafyera 1560 mg per 5 mL prefilled syringe (Prior Authorization, Quantity Limit)
Lidocaine anorectal 5% cream (Quantity Limit)
Loratadine 5 mg per 5 mL syrup (Quantity Limit)
Lubricant eye drops 0.4%/0.3% ophthalmic solution
Magnesium citrate 1.745 gm per 30 mL solution
Miconazole nitrate vaginal suppository 1200 mg & 2% cream kit
Migraine relief 250 mg/250 mg/65 mg tablet
Mucinex free severe congestion and cough 10 mg/20 mg/400 mg per 20 mL liquid (Quantity Limit)
Mucus relief 2.5 mg/5 mg/100 mg per 5 mL liquid (Quantity Limit)
Naphcon-A 0.025%/0.3% ophthalmic solution
Ocean kids 0.65% nasal solution
Phenylephrine 10 mg tablet
Phenylephrine 10 mg/dextromethorphan 18 mg/guaifenesin 200 mg per 15 mL liquid (Quantity Limit)
Phenylephrine 2.5 mg/dextromethorphan 5 mg/guaifenesin 100 mg per 5 mL liquid (Quantity Limit)
Pramoxine 1% external foam (Quantity Limit)
Pseudoephedrine extended release 120 mg tablet
QC dibromm childrens cold and cough 2.5 mg/1 mg/5 mg per 5 mL liquid (Quantity Limit)
QC mucus relief severe congestion and cough 2.5 mg/5 ml/100 mg per 5 mL liquid (Quantity Limit)
Rectasmoothe 5% cream
Refresh Celluvisc 1% ophthalmic gel
Refresh Digital 0.5%/1%/0.5% ophthalmic solution
Refresh Liquigel 1% ophthalmic gel
Refresh Optive 1%/0.9% ophthalmic gel
Refresh Optive Advanced 0.5%/1%/0.5% ophthalmic solution
Refresh Optive preservative 0.5%/0.9% ophthalmic solution
Refresh Relieva preservative free 0.5%/0.9% ophthalmic solution
Refresh Relieva preservative free 0.5%/1% ophthalmic solution
Rynex dextromethorphan 2.5 mg/1 mg/5 mg per 5 mL liquid (Quantity Limit)
Saline mist 0.65% nasal spray
SM cold and cough dextromethorphan 2.5 mg/1 mg/5 mg per 5 mL liquid (Quantity Limit)
SM dry eye relief 0.2%/0.2%/1% ophthalmic solution
SM lubricant 0.4%/0.3% ophthalmic solution
SM severe congestion and cough 10 mg/20 mg/400 mg per 20 mL liquid (Quantity Limit)
Sudogest phenylephrine 10 mg tablet
Suphedrine extended release 120 mg tablet
Systane Ultra 0.4%/0.3% ophthalmic solution
Tramadol extended release 100 mg tablet (Auto Prior Authorization, Quantity Limit, Age Limit)
Tramadol extended release 200 mg tablet (Auto Prior Authorization, Quantity Limit, Age Limit)
Tramadol extended release 300 mg tablet (Auto Prior Authorization, Quantity Limit, Age Limit)
Vanacof 30 mg/1 mg/12.5 mg per 5 mL liquid (Quantity Limit)
Xifaxan 550 mg tablet (Prior Authorization)

Removals:

Acitretin 10 mg capsule
Acitretin 17.5 mg capsule
Acitretin 25 mg capsule
Acyclovir 5% cream
Adapaline 0.1%/benzocaine 2.5% gel
Aimovig auto-injector 140 mg per mL subcutaneous solution
Aimovig auto-injector 70 mg per mL subcutaneous solution
Alcohol sheets 70%
Alendronate 70 mg per 75 mL solution
Allantoin 0.5% cream, gel, and lotion
Aloe grande 10000 unit/1500 unti per 30mL lotion
Aloe grande 100000 unit/1500 unit per gm cream
Ammonium lactate 10% lotion
Ammonium lactate 5% lotion
Aquastat 0.9% intravenous solution
Aranesp (albumin free) 10 mcg per 0.4mL prefilled syringe injection solution
Aranesp (albumin free) 100 mcg per 0.5mL prefilled syringe injection solution
Aranesp (albumin free) 100 mcg per mL injection solution
Aranesp (albumin free) 150 mcg per 0.3mL prefilled syringe injection solution
Aranesp (albumin free) 200 mcg per 0.4mL prefilled syringe injection solution
Aranesp (albumin free) 200 mcg per mL injection solution
Aranesp (albumin free) 25 mcg per 0.42mL prefilled syringe injection solution
Aranesp (albumin free) 25 mcg per mL injection solution
Aranesp (albumin free) 300 mcg per 0.6mL prefilled syringe injection solution
Aranesp (albumin free) 40 mcg per 0.4mL prefilled syringe injection solution
Aranesp (albumin free) 40 mcg per mL injection solution
Aranesp (albumin free) 500 mcg per mL prefilled syringe injection solution
Aranesp (albumin free) 60 mcg per 0.3mL prefilled syringe injection solution
Aranesp (albumin free) 60 mcg per mL injection solution
Atopiclair cream
Auryxia 210 mg tablet
Aveeno calm & restore gel
Aveeno calm & restore serum liquid
Aveeno creamy moisturize oil
Aveeno daily moisturize oil
Azelaic acid 15% gel
Bacteriostatic sodium chloride 0.9% injection solution
BD Posiflush 0.9% intravenous solution
Benzocaine 20 mg/docusate sodium 283 mg rectal enema
Benzoyl peroxide 5%/erythromycin 3% gel
Betaseron 0.3 mg injection
Bisacodyl 10 mg per 30 mL enema
Brimonidine tartate 0.2%/timolol maleate 0.5% ophthalmic solution
Brinzolamide 1% ophthalmic solution
Butalbital 50 mg/acetaminophen 325 mg tablet
Butalbital 50 mg/acetaminophen 325 mg/caffeine 40 mg/codeine 30 mg capsule
Butalbital 50 mg/aspirin 325 mg/caffeine 40 mg capsule
Byetta 10 mcg pen-injector solution
Byetta 5 mcg pen-injector solution
Carbinoxamine maleate 4 mg per 5 mL solution
Cavilon emollient cream
Cavilon foot & dry skin cream
Cavilon foot and dry skin cream
Celotin 300 mg capsule
Cequa 0.09% ophthalmic solution
Cetaphil Pro eczema soothing 1% Lotion
Clean & clear watermelon moist gel
Clindamycin phosphate 1.5%/benzoyl peroxide 5% gel
Clorazepate dipotassium 15 mg tablet
Clorazepate dipotassium 3.75 mg tablet
Clorazepate dipotassium 7.5 mg tablet
Colchicine 0.6 mg capsule
CVS beauty 360 pure vitamin-e 28000 unit per 29mL oil
CVS beauty 360 soothing bath packet
CVS eczema care 1% cream
CVS eczema relief 1% cream
CVS scar gel
CVS vitamin-E moisturizing cream
CVS vitamin-E moisturizing oil
Dalfampridine extended release 12-hour 10 mg tablet
Denavir 1% cream
DermaZinc cream
Dexeryl cream
Diazoxide 50 mg per mL suspension
Diclofenac 3% gel
Diltiazem extended release 12-hour 120 mg capsule
Diltiazem extended release 12-hour 60 mg capsule
Diltiazem extended release 12-hour 90 mg capsule
Diltiazem extended release 24-hour 360 mg coated beads capsule
Diphenhydramine injection 50 mg per mL solution
Diphenoxylate 2.5 mg/atropine 0.025 mg per 5 mL liquid
Dofetilide 125 mcg capsule
Dofetilide 250 mcg capsule
Dofetilide 500 mcg capsule
Doxepin 5% cream
Econazole nitrate 1% cream
Eczema moisturizing 1% lotion
Eletone cream
Esbriet 267 mg capsule
Estring ring 2 mg vaginal
Eucerin baby eczema relief 1% cream
Eucerin eczema relief 1% cream
Eucerin eczema relief 2% cream
Eucrisa 2% ointment
Farxiga 10 mg tablet
Farxiga 5 mg tablet
Fexofenadine 180 mg/pseudoephedrin 240 mg extended release 24-hour tablet
Gel lined heel sleeves
Gel lined moisturizing booties
Gel lined moisturizing gloves
Glyxambi 10 mg/5 mg tablet
Glyxambi 25 mg/5 mg tablet
Gordons-Vite-A 100000 unit lotion
Gordons-Vite-A 100000 unit per gm cream
Hylaguard cream
Hylatopic plus cream
Hylatopic plus lotion
Ibrance 100 mg tablet
Ibrance 125 mg tablet
Ibrance 75 mg tablet
Ingrezza 40 mg capsule
Ingrezza 60 mg capsule
Ingrezza 80 mg capsule
Invokamet 150 mg/1000 mg tablet
Invokamet 150 mg/500 mg tablet
Invokamet 50 mg/1000 mg tablet
Invokamet 50 mg/500 mg tablet
Invokana 100 mg tablet
Invokana 300 mg tablet
Isotretinoin 25 mg capsule
Isotretinoin 30 mg capsule
Jentadueto 2.5 mg/1000 mg tablet
Jentadueto 2.5 mg/500 mg tablet
Jentadueto 2.5 mg/850 mg tablet
Keri renewal serum liquid
Kombiglyze XR extended release 2.5 mg/1000 mg tablet
Kombiglyze XR extended release 5 mg/1000 mg tablet
Kombiglyze XR extended release 5 mg/500 mg tablet
Lactic acid 10%/vitamin e 3500 units per 30 gm cream
Lamisilk repair complex serum liquid
Leukine 250 mcg reconstitued injection solution
Levocetirizine dihydrochloride 2.5 mg per 5 mL solution
Levofloxacin 0.5% ophthalmic solution
Lidocaine 3% cream
Lidocaine 4% ointment
Lidocaine 4% solution
Magnexium hydroxide 2400 mg per 10 mL suspension
Mederma advanced scar gel
Methylphenidate LA extended release 20 mg capsule
Methylphenidate LA extended release 30 mg capsule
Methylphenidate LA extended release 40 mg capsule
Methylphenidate LA extended release 60 mg capsule
Naproxen enteric coated delayed release 500 mg tablet
Natural vitamin-e moisturizing gel
Neuac 1.2%/5% gel
Neupogen 300 mcg injection solution
Neupogen 300 mcg per 0.5 mL prefilled syringe injection solution
Neupogen 480 mcg injection solution
Neupogen 480 mcg per 0.8 mL prefilled syringe injection solution
Nimodipine 30 mg capsule
Nivestym 300 mcg per 0.5 mL prefilled syringe injection solution
Nivestym 480 mcg per 0.8 mL prefilled syringe injection solution
Normal saline flush 0.9% intravenous solution
Nurtec 75 mg oral disintegrating tablet
Nutraseb cream
Nystatin 100000 units/triamcinolone 0.1% per gram cream
Nystatin 100000 units/triamcinolone 0.1% per gram ointment
Nyvepria 6 mg per 0.6 mL prefilled syringe injection solution
Onglyza 2.5 mg tablet
Onglyza 5 mg tablet
Oxymorphone extended release 12-hour 10 mg tablet
Oxymorphone extended release 12-hour 15 mg tablet
Oxymorphone extended release 12-hour 20 mg tablet
Oxymorphone extended release 12-hour 30 mg tablet
Oxymorphone extended release 12-hour 40 mg tablet
Oxymorphone extended release 12-hour 5 mg tablet
Oxymorphone extended release 12-hour 7.5 mg tablet
Pancreaze delayed release 10500 unit capsule
Pancreaze delayed release 16800 unit capsule
Pancreaze delayed release 21000 unit capsule
Pancreaze delayed release 2600 unit capsule
Pancreaze delayed release 37000 unit capsule
Pancreaze delayed release 4200 unit capsule
Pertyze delayed release 1600 unit capsule
Pertyze delayed release 2400 unit capsule
Pertyze delayed release 4000 unit capsule
Pertyze delayed release 8000 unit capsule
Pimecrolimus 1% cream
Potassium 550 mg/sodium citrate 500 mg/citric acid 334 mg per 5 mL solution
Prevacare total skin care solution
Promethazine 25 mg per mL injection solution
Promethazine 50 mg per mL injection solution
Promiseb cream
Qulipta 10 mg tablet
Qulipta 30 mg tablet
Qulipta 60 mg tablet
Salimez 6% cream
Saline 0.4%/phenol 0.9% injection solution
Santyl 250 units per gm ointment
Sardoettes pads
Sildenafil 10 mg per mL suspension
Silver nitrate 0.5% solution
Sulfacetamide sodium 10% ophthalmic ointment
Super E hand/body lotion
Super E ointment
Symlinpen 120 pen-injector 2400 mcg per 2.7 mL solution
Symlinpen 60 pen-injector 1500 mcg per 1.5 mL solution
Synjardy 12.5 mg/1000 mg tablet
Synjardy 12.5 mg/500 mg tablet
Synjardy 5 mg/1000 mg tablet
Synjardy 5 mg/500 mg tablet
Tetrix cream
Tradjenta 5 mg tablet
Ubrelvy 100 mg tablet
Ubrelvy 50 mg tablet
Urea 40% cream
Ventavis 10 mcg per mL inhalation solution
Ventavis 20 mcg per mL inhalation solution
Victoza pen-injector 18 mg per 3 mL solution
Vitamin E & C beauty lotion
Vitamin-A wrinkle treatment gel
Vitamin-E & vitamin-K beautiful skin oil
Vitamin-E 1000 unit/vitamin-A 14000 unit per 52mL beauty oil
Vitamin-E 24000 unit liquid
Vitamin-E 24000 unit per 52mL beauty oil
Vitamin-E 400 unit/vitamin-D 14000 unit per 52mL beauty oil
Vitamin-E complex cream
Vitamin-E Skin 4000 unit cream
Vitamin-E skin oil
Vitamin-E with vitamin A & D cream
Vita-Ray cream
Vosevi 400 mg/100 mg/100 mg tablet
WaxWel paraffin bath kit
Xeljanz 1 mg per mL solution
Xeljanz 10 mg tablet
Xeljanz 5 mg tablet
Xigduo XR extended release 24-hour 10 mg-1000 mg tablet
Xigduo XR extended release 24-hour 10 mg-500 mg tablet
Xigduo XR extended release 24-hour 2.5 mg-1000 mg tablet
Xigduo XR extended release 24-hour 5 mg-1000 mg tablet
Xigduo XR extended release 24-hour 5 mg-500 mg tablet
Zegalogue auto-injector 0.6 mg per 0.6mL solution
Ztlido 1.8% patch

Other Updates:

Acamprosate calcium delayed release 333 mg tablet (Added Prior Authorization)
Actimmune 2000000 unit per 0.5 mL injection (Added Prior Authorization)
Aftera 1.5 mg tablet (Added Quantity Limit)
All proton pump inhibitors (Added Quantity Limit of 180 tablets per 365 days)
Bacitracin 500 unit/polymyxin b 10000 unit per gm opthalmic ointment (Added Quantity Limit)
Bacitracin 500 units per gm ophthalmic ointment (Added Quantity Limit)
Bacitracin/polymyxin/neomycin/hydrocortisone 1% ophthalmic ointment (Added Quantity Limit)
Benzonatate 100 mg capsule (Added Quantity Limit)
Benzonatate 200 mg capsule (Added Quantity Limit)
Budesonide delayed release 3 mg capsule (Removed Step Therapy)
Calcipotriene 0.005% cream (Removed Auto PA)
Calcipotriene 0.005% ointment (Removed Auto PA)
Climara pro weekly 0.045 mg/0.015 mg per day patch (Added Quantity Limit)
Dorzolamide 22.3 mg/timolol maleate 6.8 mg per mL ophthalmic solution (Removed Step Therapy)
EContra EZ 1.5 mg tablet (Added Quantity Limit)
EContra One-Step 1.5 mg tablet (Added Quantity Limit)
Erythromycin 5 mg per gm ophthalmic Ointment (Added Quantity Limit)
Fluocinolone acetonide 0.01% otic oil (Added Quantity Limit)
Gentak 0.3% ophthalmic ointment (Added Quantity Limit)
Hydrocodone 5 mg/homatropine 1.5 mg per 5 mL solution (Added Quantity Limit)
Hydrocodone 5 mg/homatropine 1.5 mg tablet (Added Quantity Limit)
Hydromet 5mg/1.5 mg per 5 mL solution (Added Quantity Limit)
Intron-A injection 10000000 unit reconstituted solution (Added Prior Authorization)
Intron-A injection 50000000 unit reconstituted solution (Added Prior Authorization)
Jardiance 10 mg tablet (Added Prior Authorization)
Jardiance 25 mg tablet (Added Prior Authorization)
Levonorgestrel 1.5 mg tablet (Added Quantity Limit)
Movantik 12.5 mg tablet (Removed Auto PA)
Movantik 25 mg tablet (Removed Auto PA)
My Choice 1.5 mg tablet (Added Quantity Limit)
My Way 1.5 mg tablet (Added Quantity Limit)
New Day 1.5 mg tablet (Added Quantity Limit)
Nuedexta 20 mg/10 mg capsule (Added Prior Authorization)
OneTouch Ultra strip (Added Quantity Limit)
OneTouch Verio strip (Added Quantity Limit)
Opcicon One-Step 1.5 mg tablet (Added Quantity Limit)
Option 2 1.5 mg tablet (Added Quantity Limit)
Ranolazine extended release 1000 mg tablet (Added Prior Authorization)
Ranolazine extended release 500 mg tablet (Added Prior Authorization)
React 1.5 mg tablet (Added Quantity Limit)
Rivastigmine 13.3 mg 24-hour patch (Added Prior Authorization)
Rivastigmine 4.6 mg 24-hour patch (Added Prior Authorization)
Rivastigmine 9.5 mg 24-hour patch (Added Prior Authorization)
Take Action 1.5 mg tablet (Added Quantity Limit)
Tolterodine tartrate 1 mg tablet (Removed Step Therapy)
Tolterodine tartrate 2 mg tablet (Removed Step Therapy)
Tolterodine tartrate extended release 2 mg capsule (Removed Step Therapy)
Tolterodine tartrate extended release 4 mg capsule (Removed Step Therapy)
Trospium chloride 20 mg tablet (Removed Step Therapy)
Vancomycin 125 mg capsule (Added Quantity Limit)
Vancomycin 250 mg capsule (Added Quantity Limit)

January 2023

Additions:

OneTouch Delica Lancets 30G
OneTouch Delica Lancets 33G
OneTouch Delica Lancing Device
OneTouch Delica Plus Lancets 30G
OneTouch Delica Plus Lancets 33G
OneTouch Delica Plus Lancing Device

Removals:

Accu-Chek FastClix Lancet Device Kit
Accu-Chek FastClix Lancet Kit
Accu-Chek FastClix Lancets
Accu-Chek Safe-T Pro Lancets
Accu-Chek Softclix Lancets
Advanced Mobile Lancet
BD Lancet Ultrafine 30G
BD Lancet Ultrafine 33G
BD Microtainer Lancets
Clever Chek Lancets
Clever Choice Lancets 21G
Clever Choice Lancets 23G
Clever Choice Lancets 28G
CoaguChek Lancets
Comfort Assured Lancets 28G
Comfort Assured Lancets 33G
CVS Lancets 21G
CVS Lancets Micro Thin 33G
CVS Lancets Original
CVS Lancets Thin 26G
CVS Lancets Ultra Thin 30G
CVS Lancets Ultra-Thin 30G
CVS Lancing Device
CVS Ultra Thin Lancets
Drug Mart Lancets Thin 26G
Drug Mart Lancing Device
Easy Comfort Lancets Twist Top
EQL Color Lancets 21G
EQL Color Lancets Micro 33G
EQL Super Thin Lancets 30G
EQL Thin Lancets 26G
E-Z Ject Lancet Micro-Thin 33G
E-Z Ject Lancet Super Thin 30G
E-Z Ject Lancets 21G
E-Z Ject Lancets Thin 26G
Fine 30
Fingerstix Lancets
FreeStyle Lancets
FreeStyle Unistick II Lancets
Gilenya Cap 0.5mg
Global Inject Ease Lancets 28G
Global Inject Ease Lancets 30G
Global Lancing Device
GNP Lancets 21G
GNP Lancets Thin 26G
GoodSense Lancets 26G Univ
GoodSense Lancets 30G
GoodSense Lancets 33G
GoodSense Lancets 33G Univ
GoodSense Lancing Device
Kroger Lancets 21G
Kroger Lancets Micro Thin 33G
Kroger Lancets Thin 26G
Kroger Lancets UltraThin 30G
Kroger Lancing Device
Lancets 30G
Lancets 33G
Lancets Micro Thin 33G
Lancets Super Thin 28G
Lancets Thin
Lancets Ultra Thin
Lancets Ultra Thin 30G
Lancing Device
LifeScan Unistik 2
LifeScan Unistik II Lancets
Longs Lancets Standard
Longs Lancets Thin
Longs Lancets Ultra Thin
Medlance Extra 21G
Medlance Lite 25G
Medlance Plus Lancets
Medlance Universal 21G
Meijer Lancets
Meijer Lancets Thin
Meijer Lancets Universal 33G
Meijer Super Thin Lancets
Microlet Lancets
Microlet Next Lancing Device
OneTouch Club Lancets Fine Pt
OneTouch Delica Safety Lancing
OneTouch FinePoint Lancets
OneTouch SureSoft Lancing Device
OneTouch UltraSoft Lancets
Penlet 2 Blood Sampler Kit
Penlet 2 Lancing Replacement Cap
Pharmacist Choice Lancets
Pharmacy Counter Lancets
Preferred Plus Lancets Colored
Preferred Plus Lancets Thin
Pro Comfort Lancets 30G
Pro Comfort Lancets 31G
RA E-Zject Lancets 28G
RA E-Zject Lancets Thin 26G
RA E-Zject Lancets Thin 28G
RA E-Zject Lancets Ultra Thin
ReliOn Lancet Devices 30G
ReliOn Lancets Thin 26G
ReliOn Lancets Ultra-Thin 30G
ReliOn Lancing Device
ReliOn Ultra Thin Lancets 30G
ReliOn Ultra Thin Plus Lancets
Rexall Lancets Ultra Thin 30G
Safety Lancet 30G/Pressure Act
SAPS health Twist Top Lancets
SAPS Twist Top Lancets
Simple Diagnostics Lancing Dev
Single-Let
SM Lancets 33G
Smart Sense Color Lancets 33G
Smart Sense Standard Lancets
Smart Sense Super Thin Lancets
Smart Sense Thin Lancets 26G
Super Thin Lancets
Sure Comfort Lancets 18G
Sure Comfort Lancets 21G
Sure Comfort Lancets 23G
Sure Comfort Lancets 28G
Sure Comfort Lancets 30G
Sure Comfort Lancing Pen
TGT Lancet Micro Thin 33G
TGT Lancet Thin 26G
TGT Lancet Ultra Thin 30G
TopCare Lancets Micro-Thin 33G
Travel Lancets Advanced 28G
TRUEdraw Lancing Device
TRUEplus Lancets 26G
TRUEplus Lancets 28G
TRUEplus Lancets 30G
TRUEplus Lancets 33G
TRUEplus Safety Lancets 28G
Ultra Thin Lancets 31G
Ultra-Care Lancets 30G
Universal 1 Lancets Thin 26G
Universal 1 Lancets Ultra Thin
Value Plus Lancet Standard 21G
Value Plus Lancets Super Thin
Value Plus Lancets Thin 26G
Value Plus Lancing Device
Walgreens Lancets
Walgreens Lancets Micro Thin
Walgreens Lancets Super Thin
Walgreens Thin Lancets
Walgreens Ultra Thin Lancets
ZevRx Twist Top Lancets 30G

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2024

April 2024

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March 2024

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February 2024

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January 2024

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2023

December 2023

Additions:

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November 2023

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October 2023

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September 2023

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August 2023

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July 2023

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June 2023

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May 2023

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April 2023

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March 2023

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February 2023

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January 2023

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Other Updates:

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