Formulary search tool and updates

December 2024

Additions:

• None

Removals:

• None

Other Updates:

• None

November 2024

Additions:

• Baclofen Solution 5 mg / 5 mL (Quantity Level Limit)
• Entresto Sprinkle Capsule (Quantity Level Limit, Prior Authorization)
• Folivane-Ob Capsule 85-1 mg (Quantity Level Limit)
• Liraglutide (Quantity Level Limit, Step Therapy)
• Ojemda Suspension (Quantity Level Limit, Prior Authorization)
• Ojemda Tablet 100 mg (Quantity Level Limit, Prior Authorization)
• Tiotropium Bromide Handihaler (Quantity Level Limit)

Removals:

• Opsumit

Other Updates:

• Emgality Injection 120 mg / mL (Update Step Therapy)
• Sevelamer Carbonate Tablet 800 mg (Remove Step Therapy)

October 2024

Additions:

• None

Removals:

• None

Other Updates:

• Promacta Tablet 50 mg (Quantity Level Limit)
• Promacta Tablet 75 mg (Quantity Level Limit)

September 2024

Additions:

• Austedo Extended Release 30 mg (Add Prior Authorization, Quantity Limit)
• Austedo Extended Release 36 mg (Add Prior Authorization, Quantity Limit)
• Austedo Extended Release 42 mg (Add Prior Authorization, Quantity Limit)
• Austedo Extended Release 48 mg (Add Prior Authorization, Quantity Limit)
• Rinvoq Oral Solution 1 mg / mL (Add Prior Authorization)

Removals:

• None

Other Updates:

• None

August 2024

Additions:

• Derma-Smooth Scalp Oil 0.01% (Quantity Level Limit)
• Eletriptan Hydrobromide Tablet 20 mg (Quantity Level Limit)
• Eletriptan Hydrobromide Tablet 40 mg (Quantity Level Limit)
• Nexletol Tablet 180 mg (Prior Authorization, Quantity Level Limit)
• Tinidazole Tablet 250 mg
• Tinidazole Tablet 500 mg

Removals:

• Alclometasone Dipropionate Cream 0.05%
• Alclometasone Dipropionate Ointment 0.05%
• Fluocinolone Acetonide Cream 0.025%
• Tabloid Tablet 40 mg
• Vancomycin Solution 25 mg/ mL
• Vancomycin Solution 50 mg/ mL

Other Updates:

• Albendazole Tablet 200 mg (Remove Prior Authorization)
• Clobetasol Propionate Gel 0.05% (Remove Step Therapy)
• Linezolid Tablet 600 mg (Remove Prior Authorization, Add Quantity Level Limit)

July 2024

Additions:

• None

Removals:

• None

Other Updates:

• None

June 2024

Additions:

• None

Removals:

• None

Other Updates:

• None

May 2024

Additions:

• Adapalene Gel 0.3% (Age Limit, Quantity Level Limit, Step Therapy)
• Adapalene/Benzoyl Peroxide Gel 0.1-2.5% (Age Limit, Quantity Level Limit)
• Azelaic Acid Gel 0.15% (Quantity Level Limit)
• Clindamycin/Benzoyl Peroxide Gel 1.2-5% (Quantity Level Limit)
• Clindamycin/Benzoyl Peroxide Gel 1-5% (Quantity Level Limit)
• Dabigatran 110 mg Capsule (Quantity Level Limit)
• Diphenhydramine-Zinc Acetate Cream 2-0.1%
• Doxycycline Hyclate Tablet 75 mg
• Doxycycline Monohydrate Tablet 50 mg
• Doxycycline Monohydrate Tablet 75 mg
• Erythromycin/Benzoyl Peroxide Gel 3-5% (Quantity Level Limit)
• Fluticasone Propionate Powder Inhaler 100 mcg (Quantity Level Limit)
• Fluticasone Propionate Powder Inhaler 250 mcg (Quantity Level Limit)
• Fluticasone Propionate Powder Inhaler 50 mcg (Quantity Level Limit)
• Isosorbide Dinitrate-Hydralazine Hydrochloride Tablet 20-37.5 mg (Quantity Level Limit)
• Menthol-Methyl Salicylate Cream
• Oxycodone Hydrochloride Extended-Release Tablet 10 mg (Prior Authorization, Quantity Level Limit)
• Oxycodone Hydrochloride Extended-Release Tablet 20 mg (Prior Authorization, Quantity Level Limit)
• Oxycodone Hydrochloride Extended-Release Tablet 40 mg (Prior Authorization, Quantity Level Limit)
• Oxycodone Hydrochloride Extended-Release Tablet 80 mg (Prior Authorization, Quantity Level Limit)
• Xolair 150 mg/ mL (Prior Authorization)
• Xolair 300 mg/ 2 mL Pen (Prior Authorization)
• Xolair 300 mg/ 2 mL Prefilled Syringe (Prior Authorization)
• Xolair 75 mg/ 0.5 mL Pen (Prior Authorization)

Removals:

• Arnuity Aerosol Powder Inhaler
• Cefadroxil Tablet 1 GM
• Glucagon Injection 1 mg

Other Updates:

• Budesonide Inhalation Suspension (Age Limit)
• Ciclopirox Olamine Cream 0.77% (Step Therapy)
• Fluticasone Propionate Hfa Inhaler (Age Limit)
• Mavyret Powder Pack 50-20 mg (Quantity Level Limit)
• Retin-A Cream
• Retin-A Gel 0.01%
• Retin-A Gel 0.025%
• Zovirax Ointment 5%

April 2024

Additions:

• None

Removals:

• None

Other Updates:

• *Blood Glucose Monitoring Kit With Device*** (Quantity Level Limit)

March 2024

Additions:

• Zenpep Capsule 60000 Unit

Removals:

• None

Other Updates:

• None

February 2024

Additions:

• Adalimumab-Adaz Auto-Injector 40 mg/ 0.4 mL (Prior Authorization)
• Adalimumab-Adaz Prefilled Syringe 40 mg/ 0.4 mL (Prior Authorization)
• Adalimumab-Fkjp Auto-Injector Kit 40 mg/ 0.8 mL (Prior Authorization)
• Adalimumab-Fkjp Prefilled Syringe Kit 20 mg/ 0.4 mL (Prior Authorization)
• Adalimumab-Fkjp Prefilled Syringe Kit 40 mg/ 0.8 mL (Prior Authorization)
• Dupixent Injection 100 mg / 0.67 mL (Prior Authorization)
• Dupixent Injection 200 mg (Prior Authorization)
• Dupixent Injection 200 mg/ 1.14 mL (Prior Authorization)
• Dupixent Injection 300 mg/ 2 mL (Prior Authorization)
• Fesoterodine Fumarate Tablet Extended Release 24 hour 4 mg (Step Therapy, Quantity Level Limit)
• Fesoterodine Fumarate Tablet Extended Release 24 hour 8 mg (Step Therapy, Quantity Level Limit)
• Hadlima Auto-Injector 40 mg/ 0.4 mL (Prior Authorization)
• Hadlima Auto-Injector 40 mg/ 0.8 mL (Prior Authorization)
• Hadlima Prefilled Syringe 40 mg/ 0.4 mL (Prior Authorization)
• Hadlima Prefilled Syringe 40 mg/ 0.8 mL (Prior Authorization)
• Insulin Lispro Injection 100 unit/ mL
• Insulin Lispro Injection Junior
• Insulin Lispro Vial
• Lantus Pen Injector
• Lantus Vial
• Ondansetron Hydrochloride Oral Solution 4 mg/ 5 mL (Quantity Level Limit)
• Orilissa Tablet 150 mg (Prior Authorization)
• Orilissa Tablet 200 mg (Prior Authorization)
• Otezla Starter Pack 10 mg/20 mg/30 mg (Prior Authorization)
• Otezla Tablet 30 mg (Prior Authorization)
• Rinvoq Tablet 15 mg Extended Release (Prior Authorization)
• Rinvoq Tablet 30 mg Extended Release (Prior Authorization)
• Rinvoq Tablet 45 mg Extended Release (Prior Authorization)
• Teriparatide Pen Injector 620 mcg/ 2.48 mL (Prior Authorization, Quantity Level Limit)
• Ubrelvy Tablet 100 mg (Step Therapy)
• Ubrelvy Tablet 50 mg (Step Therapy)
• Ultra-Fine U-100 (BD)
• Ultra-Fine U-500 (BD)

Removals:

• Admelog Pen Injector
• Admelog Vial
• Amjevita Injection 40 mg/ 0.8 mL
• Basaglar
• Benzoyl Peroxide Liquid Wash 4%
• Bromocriptine Mesylate Capsule 5 mg (Base Equivalent)
• Bromocriptine Mesylate Tablet 2.5 mg (Base Equivalent)
• Climara Pro Patch
• Combipatch Dis 0.05/ 0.14 mg
• Combipatch Dis 0.05/0.25 mg
• Diflunisal Tablet
• Glyburide Micronized Tablet 1.5 mg
• Glyburide Micronized Tablet 3 mg
• Glyburide Micronized Tablet 6 mg
• Glyburide Tablet 1.25 mg
• Glyburide Tablet 2.5 mg
• Glyburide Tablet 5 mg
• Glyburide-Metformin Tablet 1.25-250 mg
• Glyburide-Metformin Tablet 2.5-500 mg
• Glyburide-Metformin Tablet 5-500 mg
• Humira Injection 10 mg/ 0.1 mL
• Humira Injection 20 mg/ 0.2 mL
• Humira Injection 40 mg/ 0.4 mL
• Humira Kit 40mg/ 0.8 mL
• Humira Pedia Injection Crohns
• Humira Pen Injection 40 mg/ 0.4 mL
• Humira Pen Injection 40 mg/ 0.8 mL
• Humira Pen Injection 80 mg/ 0.8 mL
• Humira Pen Kit Psoriasis/Uveitis
• Insulin Aspart Flex Pen 70/30
• Insulin Aspart Protein Injection Flex pen
• Insulin Aspart Vial 70/30 mix
• Insulin Glargine - Yfgn Pen Injector
• Insulin Glargine - Yfgn Vial
• Insulin Syringe (Disposable) U-100 0.3 mL
• Insulin Syringe (Disposable) U-100 1 mL
• Insulin Syringe (Disposable) U-100 1/2 mL
• Insulin Syringe/Needle U-100 0.3 mL 29 X 1/2"
• Insulin Syringe/Needle U-100 0.3 mL 30 X 1/2"
• Insulin Syringe/Needle U-100 0.3 mL 30 X 5/16"
• Insulin Syringe/Needle U-100 0.3 mL 31 X 15/64"
• Insulin Syringe/Needle U-100 0.3 mL 31 X 5/16"
• Insulin Syringe/Needle U-100 1 mL 25 X 1"
• Insulin Syringe/Needle U-100 1 mL 25 X 5/8"
• Insulin Syringe/Needle U-100 1 mL 26 X 1/2"
• Insulin Syringe/Needle U-100 1 mL 27 X 1/2"
• Insulin Syringe/Needle U-100 1 mL 27 X 5/8"
• Insulin Syringe/Needle U-100 1 mL 28 X 1/2"
• Insulin Syringe/Needle U-100 1 mL 28 X 5/16"
• Insulin Syringe/Needle U-100 1 mL 29 X 1/2"
• Insulin Syringe/Needle U-100 1 mL 29 X 5/16"
• Insulin Syringe/Needle U-100 1 mL 30 X 1/2"
• Insulin Syringe/Needle U-100 1 mL 30 X 5/16"
• Insulin Syringe/Needle U-100 1 mL 31 X 15/64"
• Insulin Syringe/Needle U-100 1 mL 31 X 5/16"
• Insulin Syringe/Needle U-100 1/2 mL 27 X 1/2"
• Insulin Syringe/Needle U-100 1/2 mL 28 X 1/2"
• Insulin Syringe/Needle U-100 1/2 mL 29 X 1/2"
• Insulin Syringe/Needle U-100 1/2 mL 30 X 1/2"
• Insulin Syringe/Needle U-100 1/2 mL 30 X 5/16"
• Insulin Syringe/Needle U-100 1/2 mL 31 X 15/64"
• Insulin Syringe/Needle U-100 1/2 mL 31 X 5/16"
• Insulin Syringe/Needle U-100 2 mL 27.5 X 5/8"
• Ketorolac Tromethamine Ophthalmic Solution 0.4%
• Mesalamine Delayed Release Tablets 800 mg
• Novolog Mix Injection Flex ReliOn
• Novolog ReliOn Injection 70/30
• Salsalate Tablet 500 mg
• Salsalate Tablet 750 mg
• Tramadol Tablet 100 mg
• Trelegy 100 Inhalation Ellipta
• Trelegy 200 Inhalation Ellipta
• Viokace Tablet 10440 Units
• Viokace Tablet 20880 Units

Other Updates:

• Albuterol Sulfate Solution Nebulizer 0.5% (5 mg/ mL) (Quantity Level Limit)
• Alogliptin-Pioglitazone Tablet 12.5-15 mg (Quantity Level Limit)
• Alogliptin-Pioglitazone Tablet 12.5-45 mg (Quantity Level Limit)
• Bimatoprost Ophthalmic Solution 0.03%
• Empagliflozin Tablet 10 mg
• Empagliflozin Tablet 25 mg
• Emtricitabine-Tenofovir Disoproxil Fumarate Tablet 133-200 mg (Quantity Level Limit)
• Emtricitabine-Tenofovir Disoproxil Fumarate Tablet 167-250 mg (Quantity Level Limit)
• Esomeprazole Magnesium Capsule Delayed Release 40 mg (Quantity Level Limit)
• Glimepiride Tablet 1 mg (Quantity Level Limit)
• Glimepiride Tablet 2 mg (Quantity Level Limit)
• Glimepiride Tablet 4 mg (Quantity Level Limit)
• Lansoprazole Capsule Delayed Release 30 mg (Quantity Level Limit)
• Omeprazole Capsule Delayed Release 40 mg (Quantity Level Limit)
• Oxymetazoline Hydrochloride Nasal Solution 0.05% (Quantity Level Limit)
• Pantoprazole Sodium Enteric Coated Tablet 20 mg (Quantity Level Limit)
• Pantoprazole Sodium Enteric Coated Tablet 40 mg (Quantity Level Limit)
• Rosuvastatin Calcium Tablet 10 mg (Quantity Level Limit)
• Rosuvastatin Calcium Tablet 20 mg (Quantity Level Limit)
• Rosuvastatin Calcium Tablet 40 mg (Quantity Level Limit)
• Rosuvastatin Calcium Tablet 5 mg (Quantity Level Limit)
• Stribild Tablet (Quantity Level Limit)
• Terazosin Hydrochloride Capsule 5 mg (Base Equivalent)
• Tobramycin Nebulizer Solution 300 mg/ 5 mL (Quantity Level Limit)

January 2024

Additions:

• Dexcom G7 Receiver (Prior Authorization, Quantity Level Limit)
• Dexcom G7 Sensor (Prior Authorization, Quantity Level Limit)

Removals:

• None

Other Updates:

• None

December 2023

Additions:

• None

Removals:

• None

Other Updates:

• None

November 2023

Additions:

• Ciprofloxacin-Dexamethasone Otic Suspension 0.3-0.1% (Quantity Level Limit)
• Gefitinib Tablet 250 mg (Prior Authorization, Quantity Level Limit)
• Haegarda Injection 2000 unit (Prior Authorization)
• Haegarda Injection 3000 unit (Prior Authorization)
• Liqrev (Prior Authorization, Quantity Level Limit)
• Phenylephrine-Mineral Oil-Petrolatum Rectal Ointment
• Takhzyro Injection 150 mg / mL (Prior Authorization, Quantity Level Limit)
• Takhzyro Injection 300 / 2 mL (Prior Authorization, Quantity Level Limit)

Removals:

• Proctofoam Aerosol Hydrocortisone 1%

Other Updates:

• Carvedilol Tablet 25 mg (Quantity Level Limit)
• Chloroquine Phosphate Tablet 250 mg (Remove Prior Authorization)
• Chloroquine Phosphate Tablet 500 mg (Remove Prior Authorization)
• Clobetasol Propionate Emollient Base Cream 0.05% (Step Therapy)
• Darunavir Oral Suspension 100 mg / mL (Quantity Level Limit)
• Darunavir Tablet 150 mg (Quantity Level Limit)
• Darunavir Tablet 75 mg (Quantity Level Limit)
• Efavirenz Capsule 200 mg (Quantity Level Limit)
• Efavirenz Capsule 50 mg (Quantity Level Limit)
• Ella Tablet 30 mg (Quantity Level Limit)
• Glipizide-Metformin Hydrochloride Tablet 2.5-500 mg (Quantity Level Limit)
• Hydroxychloroquine Sulfate Tablet 200 mg (Remove Prior Authorization)
• Isentress Tablet 400 mg (Base Equivalent) (Quantity Level Limit)
• Ketoconazole Tablet 200 mg (Quantity Level Limit)
• Lopinavir-Ritonavir Solution 400-100 mg / 5 mL (80-20 mg /mL) (Quantity Level Limit)
• Matulane Capsule 50 mg (Add Prior Authorization)
• Mavyret Tablet 100-40 mg (Quantity Level Limit)
• Metronidazole Gel 1% (Step Therapy)
• Nifedipine Tablet Extended Release 24-hour Osmotic Release 60 mg (Quantity Level Limit)
• Norethindrone Acetate-Ethinyl Estradiol Tablet 0.5 mg-2.5 mcg (Quantity Level Limit)
• Norethindrone Tablet 0.35 mg (Quantity Level Limit)
• Prezcobix Tablet 800-150 (Quantity Level Limit)
• Promacta Pack 25 mg (Remove Prior Authorization)
• Promacta Powder 12.5 mg (Remove Prior Authorization)
• Sofosbuvir-Velpatasvir Tablet 400-100 mg (Quantity Level Limit)
• Sprycel Tablet 20 mg (Quantity Level Limit)
• Stavudine Capsule 15 mg (Quantity Level Limit)
• Stavudine Capsule 20 mg (Quantity Level Limit)
• Tivicay 10 mg (Base Equivalent) (Quantity Level Limit)
• Tobramycin Nebulizer Solution 300 mg / 5 mL (Quantity Level Limit)
• Tretinoin Capsule 10 mg (Add Prior Authorization)

October 2023

Additions:

• Austedo Extended Release Tablet Titration Kit (Prior Authorization, Quantity Level Limit)

Removals:

• None

Other Updates:

• None

September 2023

Additions:

• None

Removals:

• None

Other Updates:

• None

August 2023

Additions:

• *Pediatric Multiple Vitamin With Minerals Chewable Tablet**
• Albuterol Sulfate Solution Nebulizer 0.5% (5 mg /mL)
• Ascorbic Acid Chewable Tablet 250 mg
• Ascorbic Acid Chewable Tablet 500 mg
• Ascorbic Acid Tablet 1000 mg
• Ascorbic Acid Tablet 250 mg
• Ascorbic Acid Tablet 500 mg
• Austedo Tablet Extended Release 24hr 12 mg (Prior Authorization, Quantity Level Limit)
• Austedo Tablet Extended Release 24hr 24 mg (Prior Authorization, Quantity Level Limit)
• Austedo Tablet Extended Release 24hr 6 mg (Prior Authorization, Quantity Level Limit)
• Biktarvy Tablet 30-120-15 mg (Diagnosis Required, Quantity Level Limit)
• Cholecalciferol Capsule 1.25 mg (50000 Unit)
• Cholecalciferol Chewable Tablet 10 mcg (400 Unit)
• Cholecalciferol Oral Liquid 10 mcg/ mL (400 Unit/ mL)
• Evotaz Tablet 300-150 mg (Base Equivalent) (Diagnosis Required, Quantity Level Limit)
• Fluocinolone Acetonide Oil 0.01% (Body Oil) (Quantity Level Limit)
• Kalydeco Granules 13.4 mg (Prior Authorization)
• Levonorgestrol-Ethinyl Estradiol Tablet 0.15-0.03 mg (84) & Ethinyl Estradiol Tablet 0.01 mg (7)
• Mekinist Solution 0.05 mg/ mL (Prior Authorization)
• Melatonin Tablet 1 mg
• Melatonin Tablet 3 mg
• Melatonin Tablet 5 mg
• Mineral Oil
• Nebivolol Hydrochloride Tablet 10 mg (Base Equivalent) (Quantity Level Limit)
• Nebivolol Hydrochloride Tablet 2.5 mg (Base Equivalent) (Quantity Level Limit)
• Nebivolol Hydrochloride Tablet 20 mg (Base Equivalent) (Quantity Level Limit)
• Nebivolol Hydrochloride Tablet 5 mg (Base Equivalent) (Quantity Level Limit)
• Niacin Tablet Extended Release 500 mg
• Oxymetazoline Hydrochloride Nasal Solution 0.05%
• Pediatric Multiple Vitamins With Iron Chewable Tablet 18 mg
• Tafinlar Tablet 10 mg (Prior Authorization)
• Tranexamic Acid Tablet 650 mg (Quantity Level Limit)
• Trikafta Pak 59.5 mg (Prior Authorization)
• Trikafta Pak 75 mg (Prior Authorization)
• Tybost Tablet 150 mg (Diagnosis Required, Quantity Level Limit)

Removals:

• *Alcohol Sheets***
• *B-Complex With Minerals Liquid**
• *Blood Glucose Calibration - Liquid - Low***
• *Blood Glucose Calibration - Liquid - Normal***
• *Blood Glucose Monitoring Miscellaneous.***
• *Cream Base**
• *Dermatological Products Miscellaneous - Cream**
• *Dermatological Products Miscellaneous - Lotion**
• *Non Gelatin Capsules (Empty)**
• *Prenatal Without A Vitamin With Ferrous Fumarate -Folic Acid Tablet Chewable 40-1 mg***
• *Prenatal Without Vitamin A With Ferrous Fumarate -Ferrous Polysaccharide-Folic Acid Capsule 85-1 mg***
• *Prenatal-Ferrous Bisglycinate-Iron Protein Succinylate-Folic Acid-Calcium Tablet & Omega 3 Capsule 200 Pk**
• *Respiratory Therapy Supplies - Devices**
• *Spacer/Aerosol-Holding Chamber Supplies - Masks***
• *Specialty Vitamin Product Tablet**
• *Sunscreen Lotion**
• Benazepril & Hydrochlorothiazide Tablet 10-12.5 mg
• Benazepril & Hydrochlorothiazide Tablet 20-12.5 mg
• Benazepril & Hydrochlorothiazide Tablet 20-25 mg
• Benazepril & Hydrochlorothiazide Tablet 5-6.25 mg
• Caffeine Powder
• Ciprofloxacin Hydrochloride Tablet 100 mg
• Cortisone Acetate Tablet 25 mg
• Fluocinonide Ointment 0.05%
• Fosinopril Sodium & Hydrochlorothiazide Tablet 10-12.5 mg
• Fosinopril Sodium & Hydrochlorothiazide Tablet 20-12.5 mg
• Glucose Oral Liquid 15 GM/ 59 mL
• Guaifenesin Syrup 100 mg/ 5 mL
• Hydrocortisone Micronized Powder
• Hydrocortisone Powder
• Hydroxyprogesterone Caproate (Bulk) Powder
• Irbesartan Tablet 150 mg
• Irbesartan Tablet 300 mg
• Irbesartan Tablet 75 mg
• Ketoprofen Capsule 50 mg
• Lactobacillus Acidophilus Powder
• Leucovorin Calcium Powder
• Methadone Hydrochloride Tablet For Oral Suspension 40 mg
• Methsuximide Capsule 300 mg
• Pyrimethamine (Bulk) Powder
• Rimantadine Hydrochloride Tablet 100 mg
• Syringe/Needle (Disposable) 1 mL 30 X 1/2"
• Telmisartan Tablet 20 mg
• Telmisartan Tablet 40 mg
• Telmisartan Tablet 80 mg
• Tolnaftate Aerosol Powder 1%

Other Updates:

• Bisoprolol Fumarate Tablet 10 mg (Quantity Level Limit)
• Desmopressin Acetate Nasal Spray Solution 0.01% (Quantity Level Limit)
• Hydrocortisone Acetate Cream 1% (Quantity Level Limit)
• Lisinopril & Hydrochlorothiazide Tablet 20-12.5 mg (Quantity Level Limit)
• Methadone Hydrochloride Concentration 10 mg/ mL (Quantity Level Limit)
• Methadone Hydrochloride Solution 10 mg/ 5 mL (Quantity Level Limit)
• Methadone Hydrochloride Solution 5 mg/ 5 mL (Quantity Level Limit)
• Methadone Hydrochloride Tablet 10 mg (Quantity Level Limit)
• Methadone Hydrochloride Tablet 5 mg (Quantity Level Limit)
• Oseltamivir Phosphate Capsule 30 mg (Quantity Level Limit)
• Praziquantel Tablet 600 mg (Remove Prior Authorization)
• Propranolol Hydrochloride Capsule Extended Release 24 hour 120 mg (Quantity Level Limit)
• Propranolol Hydrochloride Capsule Extended Release 24 hour 160 mg (Quantity Level Limit)
• Rosuvastatin Calcium Tablet 10 mg (Remove Step Therapy)
• Rosuvastatin Calcium Tablet 20 mg (Remove Step Therapy)
• Rosuvastatin Calcium Tablet 40 mg (Remove Step Therapy)
• Rosuvastatin Calcium Tablet 5 mg (Remove Step Therapy)
• Sildenafil Citrate Tablet 20 mg (Quantity Level Limit)

July 2023

Additions:

• None

Removals:

• None

Other Updates:

• None

June 2023

Additions:

• Gilenya Capsule 0.25 mg (Prior Authorization, Quantity Level Limit)

Removals:

• None

Other Updates:

• None

May 2023

Additions:

• Amjevita Auto-Injector 40 mg / 0.8 mL (Add Prior Authorization)
• Breztri Inhalation Aerosol 160-9-4.8 mcg / Actuation (Step Therapy, Quantity Level Limit)
• Emgality Auto-Injector 120 mg / mL (Step Therapy, Quantity Level Limit)
• Emgality Prefilled Syringe 120 mg / mL (Step Therapy, Quantity Level Limit)
• Fexofenadine Hydrochloride Suspension 30 mg / mL (Quantity Level Limit)
• Fluticasone-Salmeterol Inhalation Powder 250-50 mcg / Actuation (Quantity Level Limit)
• Fluticasone-Salmeterol Inhalation Powder 500-50 mcg / Actuation (Quantity Level Limit)
• Salicylic Acid Liquid 17%
• Trikafta Tablets (Add Prior Authorization)
• Urea Cream 20%

Removals:

• *Pediatric Multiple Vitamins With Iron Chewable Tablet**
• *Pediatric Multiple Vitamins With Iron Drops 10 mg / mL**
• *Prenatal Without A With Iron Fumarate-Iron Polysaccharide-Folic Acid Capsule 20-20-1.25 mg**
• Calcium Carbonate Powder
• Capsaicin Cream 0.1%
• Carboxymethylcellulose-Glycerin Ophthalmic Solution 0.5-0.9%
• Chlorhexidine Gluconate Solution 20%
• Cholecalciferol Capsule 400 Unit
• Cholecalciferol Chewable Wafer 50000 Unit
• Creon Capsule
• Elmiron Capsules
• Ergocalciferol Tablet 400 Unit
• Fluocinolone Acetonide Cream 0.01%
• Fluocinonide Emulsified Base Cream 0.05%
• Gentamicin Sulfate Powder
• Heparin Sodium Injection 20,000 Units / mL
• Heparin Sodium Injection 5,000 Units / 0.5 mL
• Lidocaine Hydrochloride Solution 4%
• Mexiletine Hydrochloride Capsule 150 mg
• Mexiletine Hydrochloride Capsule 200 mg
• Mexiletine Hydrochloride Capsule 250 mg
• Niacin Tablet 250 mg
• Niacin Tablet 50 mg
• Prenatal With Ferrous Fumarate-Folic Acid Tablet 28-0.8 mg & Docosahexaenoic Acid Capsule 200 mg Pack
• Quinidine Sulfate Tablets 200 mg
• Quinidine Sulfate Tablets 300 mg
• Salicylic Acid Cream 6%
• Sodium Chloride Solution Nebulizer 6%
• Sorbitol Rectal Solution 70%
• Triamcinolone Acetonide Ointment 0.05%
• Vancomycin Hydrochloride For Intravenous Solution 1 gm (Base Equivalent)
• Vancomycin Hydrochloride For Intravenous Solution 5 gm (Base Equivalent)

Other Updates:

• Albendazole Tablet 200 mg (Add Prior Authorization, Remove Step Therapy)
• Albuterol Sulfate Nebulized Solution 0.63 mg/3 mL (Remove Step Therapy, Remove Age Maximum)
• Albuterol Sulfate Nebulized Solution 1.25 mg/3 mL (Remove Step Therapy, Remove Age Maximum)
• Betamethasone Dipropionate Ointment 0.05% (Add Quantity Level Limit)
• Enoxaparin Sodium Injection (Remove Max Days Supply)
• Enoxaparin Sodium Prefilled Syringe (Remove Max Days Supply)
• Fluconazole Tablet 150 mg (Add Quantity Level Limit)
• Fluocinolone Acetonide Cream 0.025% (Add Quantity Level Limit)
• Fluocinolone Acetonide Ointment 0.025% (Add Quantity Level Limit)
• Fluticasone-Salmeterol Inhalation Powder 100-50 mcg / Actuation (Remove Age Limit)
• Lidocaine Hydrochloride Cream 4%
• Lidocaine Ointment 5% (Remove Prior Authorization)
• Ozempic Pen-Injector
• Trulicity Pen-Injector

April 2023

Additions:

• Guaifenesin-Codeine Solution 100-6.33 mg per 5 mL (Quantity Level Limit, Age Minimum)

Removals:

• None

Other Updates:

• Descovy 200 mg/25 mg tablet (Added Prior Authorization)
• Emtricitabine/tenofovir DF 100 mg/150 mg tablet (Added Prior Authorization)
• Emtricitabine/tenofovir DF 133 mg/200 mg tablet (Added Prior Authorization)
• Emtricitabine/tenofovir DF 167 mg/250 mg tablet (Added Prior Authorization)
• Emtricitabine/tenofovir DF 200 mg/300 mg tablet (Added Prior Authorization)
• Freestyle 14 Sensor Libre (Updated Quantity Level Limit)
• Freestyle 14 Sensor Libre 2 (Updated Quantity Level Limit)
• Freestyle 14 Sensor Libre 3 (Updated Quantity Level Limit)
• Isentress 100 mg chewable tablet (Added Prior Authorization)
• Isentress 100 mg packet (Added Prior Authorization)
• Isentress 25 mg chewable tablet (Added Prior Authorization)
• Isentress 400 mg tablet (Added Prior Authorization)
• Isentress HD 600 mg tablet (Added Prior Authorization)
• Lamivudine 10 mg per 10 mL (Added Prior Authorization)
• Lamivudine 150 mg tablet (Added Prior Authorization)
• Lamivudine 300 mg tablet (Added Prior Authorization)
• Lamivudine/zidovudine 150 mg/ 300 mg tablet (Added Prior Authorization)
• Norvir 100 mg packet (Added Prior Authorization)
• Norvir 80 mg per mL (Added Prior Authorization)
• Ritonavir 100 mg tablet (Added Prior Authorization)
• Tivicay 10 mg tablet (Added Prior Authorization)
• Tivicay 25 mg tablet (Added Prior Authorization)
• Tivicay 50 mg tablet (Added Prior Authorization)
• Tivicay PD 5 mg soluble tablet (Added Prior Authorization)
• Zidovudine 50 mg per 5 mL syrup (Added Prior Authorization)
• Zidovudine 100 mg capsule (Added Prior Authorization)
• Zidovudine 300 mg tablet (Added Prior Authorization)

March 2023

Additions:

• Ozempic Injection 2 mg/3 mL (Quantity Level Limit, Step Therapy)

Removals:

• Ciprofloxacin For Oral Suspension 250 mg/5 mL (5%) (5 gm/100 mL)
• Ciprofloxacin For Oral Suspension 500 mg/5 mL (10%) (10 gm/100 mL)
• Fluocinolone Acetonide Powder
• Hydrocortisone Acetate Powder
• Rivaroxaban Tablet 2.5 mg
• Triamcinolone Acetonide Powder

Other Updates:

• None

February 2023

Additions:

• Aluminum Hydroxide-Magnesium Carbonate Chewable Tablet 160-105 mg
• Aluminum Hydroxide-Magnesium Carbonate Suspension 95-358 mg/15mL
• Aspirin-Acetaminophen-Caffeine Tablet 250-250-65 mg
• Budesonide Tablet Extended Release 9 mg
• Calcium Polycarbophil Tablet 625 mg
• Carboxymethylcell-Glycerin-Polysorb 80 Ophthalmic Solution 0.5-1-0.5%
• Carboxymethylcellulose Sodium (Preservative Free) Ophthalmic Gel 1%
• Carboxymethylcellulose Sodium Ophthalmic Gel 1%
• Carboxymethylcellulose-Glycerin (Preservative Free) Ophthalmic Solution 0.5-0.9%
• Carboxymethylcellulose-Glycerin (Preservative Free) Ophthalmic Solution 0.5-1%
• Carboxymethylcellulose-Glycerin Ophthalmic Gel 1-0.9%
• Carboxymethylcellulose-Glycerin Ophthalmic Solution 0.5-0.9%
• Climara Pro Dis Weekly (Quantity Level Limit)
• Cyclosporine (Ophthalmic) Emulsion 0.05% (Prior Authorization Required, Quantity Level Limit)
• Dabigatran Capsule 150 mg (Quantity Level Limit)
• Dabigatran Capsule 75 mg (Quantity Level Limit)
• Dificid Suspension (Prior Authorization Required)
• Dificid Tablet 200 mg (Prior Authorization Required)
• Esomepra Mag Capsule 40 mg Delayed Release (Quantity Level Limit)
• Estradiol Vaginal Cream 0.1 mg/Gm (Quantity Level Limit)
• Ethacrynic Tablet Acid 25 mg
• Extavia Injection 0.3 mg
• Fluocin Acet Oil Ear 0.01% (Quantity Level Limit)
• Gel-One Injection 30 mg/3 mL (Prior Authorization Required)
• Glycerin Suppository 1 Gm
• Glycerin-Hypromellose-Peg 400 Ophthalmic Solution 0.2-0.2-1%
• Hypromellose Ophthalmic Gel 0.3%
• Imbruvica Tablet 140 mg (Prior Authorization Required, Quantity Level Limit)
• Imbruvica Tablet 280 mg (Prior Authorization Required, Quantity Level Limit)
• Imbruvica Tablet 420 mg (Prior Authorization Required, Quantity Level Limit)
• Imbruvica Tablet 560 mg (Prior Authorization Required, Quantity Level Limit)
• Lactobacillus Acidophilus-Pectin Capsule
• Lactobacillus Capsule
• Lactobacillus Tablet
• Lidocaine 5% Rectal Cream (Quantity Level Limit)
• Magnesium Citrate Solution
• Miconazole Nitrate Vaginal Suppository 1200 mg & 2% Cream Kit
• Naphazoline W/ Pheniramine Ophthalmic Solution 0.025-0.3%
• Naphazoline W/ Pheniramine Ophthalmic Solution 0.027-0.315%
• Phenylephrine Hydrochloride Tablet 10 mg
• Phenylephrine W/ Dm-Gg Liquid 10-18-200 mg/15mL (Quantity Level Limit)
• Phenylephrine W/ Dm-Gg Liquid 2.5-5-100 mg/5 mL (Quantity Level Limit)
• Phenylephrine-Brompheniramine-Dm Liquid 2.5-1-5 mg/5 mL (Quantity Level Limit)
• Polyethylene Glycol-Propylene Glycol Ophthalmic Solution 0.4-0.3%
• Pramoxine Aerosol 1% Rectal (Quantity Level Limit)
• Probiotic Product - Capsule
• Pseudoephed-Bromphen-Dm Syrup 30-2-10 mg/5 mL (Quantity Level Limit)
• Pseudoephed-Dexchlorphen-Chlophedianol Liquid 30-1-12.5 mg/5 mL (Quantity Level Limit)
• Pseudoephedrine Hydrochloride Tablet Extended Release 12hr 120 mg
• Psyllium Capsule 0.52 Gm
• Rivastigmine Dis 13.3/24 (Prior Authorization Required)
• Rivastigmine Dis 4.6 mg/24 (Prior Authorization Required)
• Rivastigmine Dis 9.5 mg/24 (Prior Authorization Required)
• Saline Nasal Gel
• Saline Nasal Solution 0.65%
• Saline Nasal Spray 0.65%
• Sod Fluoride Gel 1.1-5%
• Sod Fluoride Paste 1.1%
• Sodium Phosphates – Enema (Quantity Level Limit)
• Tetrahydrozoline Hydrochloride Ophthalmic Solution 0.05%
• Tramadol Hydrochloride Tablet Extended Release 24hr 100 mg (Prior Authorization Required, Quantity Level Limit, Age Minimum)
• Tramadol Hydrochloride Tablet Extended Release 24hr 200 mg (Prior Authorization Required, Quantity Level Limit, Age Minimum)
• Tramadol Hydrochloride Tablet Extended Release 24hr 300 mg (Prior Authorization Required, Quantity Level Limit, Age Minimum)
• Vancomycin Capsule 125 mg (Quantity Level Limit)
• Vancomycin Capsule 250 mg (Quantity Level Limit)
• Xifaxan Tablet 550 mg (Prior Authorization Required)

Removals:

• Alendronate Sol 70/75mL
• Auryxia 210 mg Tablet
• Benzocaine-Docusate Sodium Rectal Enema 20-283 mg
• Betaseron Injection 0.3 mg
• Bisacodyl Enema 10 mg/30 mL
• Brimonidine Tartrate-Timolol Maleate Ophthalmic Solution 0.2-0.5%
• Brinzolamide Ophthalmic Suspension 1%
• Butalbital-Acetaminophen Tablet 50-325 mg
• Butalbital-Acetaminophen-Caff W/ Cod Capsule 50-300-40-30 mg
• Butalbital-Acetaminophen-Caff W/ Cod Capsule 50-325-40-30 mg
• Butalbital-Aspirin-Caff W/ Codeine Capsule 50-325-40-30 mg
• Butalbital-Aspirin-Caffeine Capsule 50-325-40 mg
• Cequa
• Colchicine Capsule 0.6 mg
• Dermazinc Cream
• Desmopressin Spray Ref 0.01%
• Diphenoxylate W/ Atropine Liquid 2.5-0.025 mg/5 mL
• Esbriet 267mg Capsule
• Estring
• Fexofenadine-Pseudoephedrine Tablet Extended Release 24hr 180-240 mg
• Ibrance Tablet 100 mg
• Ibrance Tablet 125 mg
• Ibrance Tablet 75 mg
• Levofloxacin Ophthalmic Solution 0.5%
• Lidocaine Solution 4%
• Magnesium Hydroxide Suspension Concentrate 2400 mg/10 mL
• Naproxen Tablet Enteric Coated 500 mg
• Omnitrope Injection 10/1.5 mL
• Omnitrope Injection 5/1.5 mL
• Oxymorphone Hydrochloride Tablet Extended Release 12hr 10 mg
• Oxymorphone Hydrochloride Tablet Extended Release 12hr 15 mg
• Oxymorphone Hydrochloride Tablet Extended Release 12hr 20 mg
• Oxymorphone Hydrochloride Tablet Extended Release 12hr 30 mg
• Oxymorphone Hydrochloride Tablet Extended Release 12hr 40 mg
• Oxymorphone Hydrochloride Tablet Extended Release 12hr 5 mg
• Oxymorphone Hydrochloride Tablet Extended Release 12hr 7.5 mg
• Pot & Sod Citrates W/ Cit Ac Solution 550-500-334 mg/5 mL
• Sulfacetamide Sodium Ophthalmic Ointment 10%

Other Updates:

• Azelastine Hydrochloride Ophthalmic Solution 0.05% (Remove Step Therapy)
• Bacitracin Ophthalmic Ointment 500 Unit/Gm (Added Quantity Level Limit)
• Bacitracin-Polymyxin B Ophthalmic Ointment (Added Quantity Level Limit)
• Bacitracin-Polymyxin-Neomycin-Hc Ophthalmic Ointment 1% (Added Quantity Level Limit)
• Benzonatate Capsule 100 mg (Added Quantity Level Limit)
• Benzonatate Capsule 200 mg (Added Quantity Level Limit)
• Budesonide Capsule 3 mg Delayed Release (Remove Step Therapy)
• Calcipotriene Cream 0.005% (Remove Prior Authorization)
• Calcipotriene Ointment 0.005% (Remove Prior Authorization)
• Calcipotriene Solution 0.005% (50 mcg/mL) (Remove Prior Authorization)
• Celecoxib Capsule 100 mg (Remove Step Therapy)
• Celecoxib Capsule 200 mg (Remove Step Therapy)
• Celecoxib Capsule 400 mg (Remove Step Therapy)
• Celecoxib Capsule 50 mg (Remove Step Therapy)
• Dorzolamide Hydrochloride-Timolol Maleate Ophthalmic Solution 22.3-6.8 mg/mL (Remove Step Therapy)
• Erythromycin Ophthalmic Ointment 5 mg/Gm (Added Quantity Level Limit)
• Gentamicin Sulfate Ophthalmic Ointment 0.3% (Added Quantity Level Limit)
• Hydroc/Homat Tablet 5-1.5 mg (Added Quantity Level Limit)
• Hydrocod/Hom Syrup 5-1.5/5 (Added Quantity Level Limit)
• Levonorgestr Tablet 1.5 mg (Quantity Level Limit)
• Tolterodine Tartrate Capsule Extended Release 24hr 2 mg (Remove Step Therapy)
• Tolterodine Tartrate Capsule Extended Release 24hr 4 mg (Remove Step Therapy)
• Tolterodine Tartrate Tablet 1 mg (Remove Step Therapy)
• Tolterodine Tartrate Tablet 2 mg (Remove Step Therapy)
• Trospium Chloride Tablet 20 mg (Remove Step Therapy)

January 2023

Additions:

• Raltegravir Potassium Packet For Susp 100 Mg (Base Equiv) (Quantity Level Limit)

Removals:

• All Non OneTouch Delica and Delica Plus Lancets and Devices

Other Updates:

• Dolutegravir Sodium Tab 10 Mg (Base Equiv) (Remove Prior Authorization)
• Dolutegravir Sodium Tab 25 Mg (Base Equiv) (Remove Prior Authorization)
• Dolutegravir Sodium Tab 50 Mg (Base Equiv) (Remove Prior Authorization)
• Dolutegravir Sodium Tab For Oral Susp 5 Mg (Base Equiv) (Remove Prior Authorization)
• Emtricitabine-Tenofovir Alafenamide Fumarate Tab 120-15 Mg (Remove Prior Authorization)
• Emtricitabine-Tenofovir Alafenamide Fumarate Tab 200-25 Mg (Remove Prior Authorization)
• Emtricitabine-Tenofovir Disoproxil Fumarate Tab 100-150 Mg (Remove Prior Authorization)
• Emtricitabine-Tenofovir Disoproxil Fumarate Tab 133-200 Mg (Remove Prior Authorization)
• Emtricitabine-Tenofovir Disoproxil Fumarate Tab 167-250 Mg (Remove Prior Authorization)
• Emtricitabine-Tenofovir Disoproxil Fumarate Tab 200-300 Mg (Remove Prior Authorization)
• Fluticasone Propionate Nasal Susp 50 Mcg/Act (Remove Step Therapy)
• Histex Pd Dro 0.938mg
• Lamivudine Oral Soln 10 Mg/Ml (Remove Prior Authorization)
• Lamivudine Tab 150 Mg (Remove Prior Authorization)
• Lamivudine Tab 300 Mg (Remove Prior Authorization)
• Lamivudine-Zidovudine Tab 150-300 Mg (Remove Prior Authorization)
• Raltegravir Potassium Chew Tab 100 Mg (Base Equiv) (Remove Prior Authorization)
• Raltegravir Potassium Chew Tab 25 Mg (Base Equiv) (Remove Prior Authorization)
• Raltegravir Potassium Tab 400 Mg (Base Equiv) (Remove Prior Authorization)
• Raltegravir Potassium Tab 600 Mg (Base Equiv) (Remove Prior Authorization)
• Ritonavir Oral Soln 80 Mg/Ml (Remove Prior Authorization)
• Ritonavir Powder Packet 100 Mg (Remove Prior Authorization)
• Ritonavir Tab 100 Mg (Remove Prior Authorization)
• Zidovudine Cap 100 Mg (Remove Prior Authorization)
• Zidovudine Syrup 10 Mg/Ml (Remove Prior Authorization)
• Zidovudine Tab 300 Mg (Remove Prior Authorization)

December 2022

Additions:

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

Removals:

• None

Other Updates:

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

November 2022

Additions:

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

Removals:

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

Other Updates:

• None

October 2022

Removals:

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

Other Updates:

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

September 2022

Additions:

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

Removals:

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

Other Updates:

• No Updates

August 2022

Additions:

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

Removals:

• Adapalene Cream 0.1%
• Amcinonide Ointment 0.1%
• Amiodarone Hcl Tablet 100mg
• Amiodarone Hcl Tablet 400mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 10-10 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 10-20 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 10-40 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 10-80 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-10 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-20 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 2.5-40 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 5-10 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 5-20 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 5-40 Mg
• Amlodipine Besylate-Atorvastatin Calcium Tab 5-80 Mg
• Amoxicillin & K Clavulanate Tab Er 12hr 1000-62.5 Mg
• Antioxidant Cap 250-10000-200 (Multiple Vitamin)
• Carbinoxamine Maleate Tab 4mg
• Cefaclor Cap 250 Mg
• Cefaclor Cap 500 Mg
• Cefpodoxime Proxetil For Susp 100 Mg/5ml
• Cefpodoxime Proxetil For Susp 50 Mg/5ml
• Fish Oil Capsule Delayed Release 1200 Mg
• Flunisolide Solution 25 Mcg/Act (0.025%) Nasal
• Fluvastatin Sodium Tab Er 24 Hr 80 Mg (Base Equivalent)
• Glucagen Hypokit Solution Reconstituted 1 Mg
• Hydrocortisone Soln 1%
• Isosorbide Dinitrate Tab 40 Mg
• Isradipine Cap 2.5mg
• Isradipine Cap 5mg
• Lidocaine Hcl Urethral/Mucosal Gel 2 %
• Memantine Hcl Oral Solution 2 Mg/Ml
• Memantine Hcl Tab 28 X 5 Mg & 21 X 10 Mg Titration Pack
• Methazolamide Tab 25 Mg
• Methazolamide Tab 50 Mg
• Metronidazole Cap 375 Mg
• Mometasone Furoate Nasal Spray 50mcg
• Nicardipine Cap 20mg
• Nicardipine Cap 30mg
• Onetouch Solutions Starter Kit Kit W/ Well Device
• Pc-Tar Shampoo 1 % (Coal Tar Shampoo)
• Perindopril Erbumine Tab 2 Mg
• Perindopril Erbumine Tab 4 Mg
• Perindopril Erbumine Tab 8 Mg
• Psyllium Powder 30.9%
• Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4%
• Salicylic Acid Shampoo 6%
• Selenium Sulfide Shampoo 2.25%
• Stress B-Complex/Vitamin C/Zinc Tab
• Sulfacetamide Sodium Liquid 10%
• Vancomycin Hcl For Iv Soln 10 Gm (Base Equivalent)
• Vancomycin Hcl For Iv Soln 500 Mg (Base Equivalent)
• Vancomycin Hcl Iv Soln 1250 Mg/250ml (Base Equivalent)
• Vancomycin Hcl Iv Soln 1750 Mg/350ml (Base Equivalent)
• Vancomycin Hcl Iv Soln 750 Mg/150ml (Base Equivalent)
• Vemlidy Tablet 25 Mg
• Vitamin D (Cholecalciferol) Tab Chewable 10 Mcg (400 Unit) 
• Zafirlukast Tab 10mg
• Zafirlukast Tab 20mg

Other Updates:

• Acyclovir Cap 200 Mg (Removed Quantity Level Limit)
• Acyclovir Tab 400 Mg (Removed Quantity Level Limit)
• Acyclovir Tab 800 Mg (Removed Quantity Level Limit)
• Austedo Tab 12mg (Added Quantity Level Limit)
• Austedo Tab 6mg (Added Quantity Level Limit)
• Austedo Tab 9mg (Added Quantity Level Limit)
• Ezetimibe Tab 10 Mg (Removed Step Therapy)
• Glucagon Emergency Kit 1 Mg (Changed Quantity Level Limit)
• Gvoke Hypopen Solution Auto-Injector 0.5 Mg/0.1ml (Changed Quantity Level Limit)
• Gvoke Hypopen Solution Auto-Injector 1 Mg/0.2ml (Changed Quantity Level Limit)
• Gvoke Pfs Solution Prefilled Syringe 0.5 Mg/0.1ml (Changed Quantity Level Limit)
• Gvoke Pfs Solution Prefilled Syringe 1 Mg/0.2ml (Changed Quantity Level Limit)
• Olopatadine Ophth Soln 0.1% Otc (Removed Step Therapy)
• Omega-3-Acid Ethyl Esters Cap 1 Gm (Removed Step Therapy)
• Valacyclovir Hcl Tab 1 Gm (Removed Quantity Level Limit)
• Valacyclovir Hcl Tab 500 Mg (Removed Quantity Level Limit)

July 2022

No updates

June 2022

Additions:

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

Removals:

None

Other Updates:

• None

May 2022

Additions:

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

Removals:

• B Complex-C-Folic Acid Tab

Other Updates:

• None

April 2022

• No updates

March 2022

Additions:

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

Removals:

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

Other Updates:

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

February 2022

Additions:

• None

Removals:

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

Other Updates:

• None

January 2022

Additions:

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

Removals:

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

Other Updates:

• None

December 2021

Additions:

• Esomeprazole Tab Delayed Release 20mg
• Everolimus Tab 10mg (Prior Authorization Required, Quantity Level Limit)

Removals
 

• Afinitor Tab 10mg

Other Updates:

• None

November 2021

• No Updates

October 2021

Additions:

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

Removals:

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

Other Updates:

• None

September 2021

• No Updates

August 2021

Additions:

• Baqsimi Powder 3mg/dose (Quantity Level Limit)
• Endari Powder Packet 5gm (Prior Authorization Required)
• Inlyta Tab 1mg, 5mg (Prior Authorization Required, Quantity Level Limit)
• Prolia Solution Prefilled Syringe 60mg/ml (Prior Authorization Required, Quantity Level Limit)
• Semglee Pen-Injector 100unit/ml
• Semglee Vial (Solution) 100unit/ml

Removals:

• Caffeine Citrate Powder
• Ibrance Cap 75mg, 100mg, 125mg
• Lidocaine-Hydrocortisone Acetate Cream 3-0.5%
• Methoxsalen Rapid Cap 10mg
• Nexavar Tab 200mg

Other Updates:

• None

July 2021

Additions:

• None

Removals

• Allergy Relief Disintegrating Tablet 12.5mg
• Calcium Carbonate Tab 1250mg (500mg Elemental Ca)
• Centrum Liquid
• Fish Oil Cap 435mg
• Nozin Nasal Sanitizer
• Slow Release Iron Tab 47.5mg

Other Updates:

• None

June 2021

Additions:

• None

Removals:

• None

Other Updates:

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

May 2021

• No Updates

April 2021

Additions:

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

Removals:

• Anti-Diarrheal Liquid 1mg/8ml
• Azopt 1% Ophthalmic Suspension
• NovaMV Pediatric Multi-Vitamin Drops
• Santyl Ointment 250unit/gm

March 2021

Additions:

• Bevespi Aerosol 9-4.8mcg (Quantity Level Limit)
• Cequa Solution 0.09% PF (Prior Authorization Required)
• Doxycycline Hyclate Cap 50mg, 100mg
• Doxycycline Hyclate Tab 100mg
• Esbriet Cap 267mg (Prior Authorization Required)
• Esbriet Tab 267mg, 801mg (Prior Authorization Required)
• Fluticasone-Salmeterol Aerosol 100-50mcg (Quantity Level Limit)
• Hizentra Injection 1gm/ml, 2gm/10ml, 4gm/20ml (Prior Authorization Required)
• Hizentra Solution 20%(Prior Authorization Required)
• Hizentra Vial 1gm/5ml, 10gm/50ml (Prior Authorization Required)
• Icosapent Cap 1gm (Quantity Level Limit)
• Myleran Tab 2mg
• Ocrevus Injection 300/10ml (Quantity Level Limit)
• Potassium & Sodium Citrate W/ Citric Acid Solution 550-500-334mg/5ml
• Privigen Injection 40grams (Prior Authorization Required)
• Rabeprazole Tab 20mg (Quantity Level Limit)
• Trulicity Injection 0.75mg/0.5ml, 1.5mg/0.5ml, 3mg/0.5ml, Inj 4.5mg/0.5ml (Step Therapy Required)
• Tukysa Tab 50mg, 150mg (Prior Authorization Required)
• Visco-3 Injection 25/2.5ml (Prior Authorization Required)

Removals:

• Anoro Ellipta Aero 62.5-25mcg/inh
• Atrovent Hfa Aero 17mcg
• Breo Ellipta Inhaler 100-25mcg/inh, 200-25mcg/inh
• Cefaclor For Suspension 125mg/5ml, 250mg/5ml, 375mg/5ml
• Clarithromycin Tab Extended Release 24Hr 500mg
• Combivent Aero 20-100mcg/act
• Doxycycline Monohydrate Tab 50mg, 75mg, 100mg
• Epogen Injection 2000/ml, 3000/ml, 4000/ml 10000/ml, 20000/ml
• Fulphila Injection 6mg/0.6ml
• Gammaked Injection 1gm/10ml, 5gm/50ml, 10gm/100ml, 20gm/200ml
• Hyoscyamine Drops 0.125mg/ml
• Janumet Tab 50-500mg, 50-1000mg
• Janumet Xr Tab 50-500mg, 50-1000mg, 100-1000mg
• Januvia Tab 25mg, 50mg, 100mg
• Nivestym Injection 300mcg, 480mcg
• Nivestym Injection Syringe 300mcg/0.5ml, 480mcg/0.8ml
• Ofev Cap 100mg, 150mg
• Victoza Injection 18mg/3ml

Other Updates:

• Albuterol Aero Hfa (Changed Quantity Level Limit)
• Arnuity Ellipta Inhaler 50mcg, 100mcg, 200mcg (Changed Quantity Level Limit)
• Azithromycin Suspension 100mg/5ml, 200mg/5ml (Added Age Limit)
• Cefadroxil Suspension 250mg/5ml, 500mg/ml (Added Age Limit)
• Cefdinir Suspension 125mg/5ml, 250mg/5ml (Added Age Limit)
• Cefpodoxime Proxetil Suspension 50mg/5ml, 100mg/5ml (Added Age Limit)
• Cefprozil Suspension 125mg/5ml, 250mg/5ml (Added Age Limit)
• Cephalexin Suspension 125mg/5ml, 250mg/5ml (Added Age Limit)
• Clarithromycin Suspension 125mg/5ml, 250mg/5ml (Added Age Limit)
• Extavia Injection 0.3mg (Changed Quantity Level Limit)
• Glatiramer Injection 40mg/ml (Added Quantity Level Limit)
• Levalbuterol Tartrate Aerosol 45mcg/Act (Added Quantity Level Limit)
• Levofloxacin Solution 25mg/ml (Added Age Limit)
• Neomycin-Polymyxin-Dexamethasone Ophthalmic Ointment 0.1% (Added Quantity Level Limit)
• Ondansetron Tablet Dispersible 4mg, 8mg (Changed Quantity Level Limit)
• Phenylephrine Hcl Ophthalmic Solution 2.5% (Added Quantity Level Limit)
• Rebif Injection 44mcg/0.5ml (Added Quantity Level Limit)
• Rebif Rebido Injection 22mcg/0.5ml, 44mcg/0.5ml (Added Quantity Level Limit)
• Rebif Rebidose Titration Pack (Added Quantity Level Limit)
• Rebif Titration Injection Pack (Added Quantity Level Limit)
• Santyl Ointment 250 Unit/gm (Added Quantity Level Limit)

February 2021

• No Updates

January 2021

Additions:

• Retacrit Injection 20000units (Prior Authorization Required)

Removals:

• Calcium Carbonate Tab
• Mag Ox Tab 420mg

December 2019

Removals:

• Aminocaproic Acid solution 0.25gm/ml
• PreNata chewable tab 29-1mg
• Digoxin tabs 62.5mcg, 187.5mcg
  

November 2019

Additions:

• Aminocaproic Acid solution 0.25gm/ml
  

October 2019

• No updates
  

September 2019

Additions:

• Ambrisentan tabs 5mg, 10mg (prior authorization required, quantity level limit)
• Bosentan tabs 62.5mg, 125mg (prior authorization required, quantity level limit)
• Febuxostat tabs 40mg, 80mg (step therapy Required)
  

Removals:

• Letairis tabs 5mg, 10mg (brand)
• Tracleer tabs 62.5mg, 125mg (brand)
• Uloric tabs 40mg, 80mg (brand)
  

August 2019

Additions:

• Aspercreme with Lidocaine 4% (quantity level limit)
• Butenafine HCl cream 1%
• Fulphila injection 6mg/0.6ml (prior authorization required)
• Nivestym injection 300mcg, 480mcg (prior authorization required)
  

Removals:

• Butalbital-Acetaminophen-Caffeine capsules 50-300-40mg, 40-325-40mg
• Calcium Acetate oral solution 667mg/5ml
• Ciclopirox gel 0.77%
• Colestipol HCl granule packets 5gm
• Entecavir oral solution 0.05mg/ml
• Epinastine HCl Ophthalmic solution 0.05%
• Erythromycin Ethylsuccinate suspension 200mg/5ml, 400mg/5ml
• Esterified estrogens tabs 0.3mg, 0.625mg, 1.25mg
• Estradiol tab 1mg (15)/Estradiol-Norgestimate tab 1-0.09mg(15)
• Etodolac ER tab 400mg, 500mg, 600mg
• Lindane shampoo 1%
• Moexipril HCl tabs 7.5mg, 15mg
• Olopatadine HCl Ophthalmic solution 0.2%
• Quinidine Gluconate CR tab 324mg
  

Other updates:

• Azelastine HCl Ophthalmic solution 0.05% (quantity level limit)
• Calcipotriene cream 0.005% (prior authorization required, quantity level limit)
• Calcipotriene ointment 0.005% (prior authorization required, quantity level limit)
• Calcipotriene solution 0.005% (prior authorization required, quantity level limit)
• Ciclopirox Olamine cream 0.77% (step therapy)
• Ciclopirox Olamine suspension 0.77% (step therapy)
• Ciclopirox shampoo 1% (step therapy)
• Clotrimazole (RX) solution 1% (step therapy)
• Estradiol vaginal tablet 10mcg (quantity level limit)
• Fluocinolone acetonine cream 0.025% (quantity level limit)
• Fluocinolone acetonine ointment 0.025% (quantity level limit)
• Ketoconazole cream 2% (step therapy, quantity level limit)
• Lidocaine HCl gel 2% (quantity level limit)
• Lidocaine-Prilocaine cream 2.5-2.5% (quantity level limit)
• Liothyronine sodium tabs 5mcg, 50mcg (quantity level limit)
• Norethindrone tab 5mg (step therapy)
• Thyroid tabs 15mg, 30mg, 60mg, 90mg, 120mg, 180mg, 240mg, 300mg (quantity level limit)
  

July 2019

Additions:

• Mesalamine cap 400mg DR (quantity level limit)
• Cefixime cap 400mg (quantity level limit)
• Erlotinib tab 150mg (quantity level limit, Prior authorization required)
  

Removals:

• Suprax cap 400mg
• Tarceva tab 150mg
  

Other updates:

• Right now, there are no other updates.
  

June 2019

Additions:

• Docosanol cream 10%
  

Removals:

• Abreva cream 10%
  

Other updates:

• Right now, there are no other updates.