Formulary search tool and updates

December 2024

Additions:

• Ocrevus Injection Zunovo (Prior Authorization, Quantity Level Limit)

Removals:

• None

Other Updates:

• None

November 2024

Additions:

• Baclofen Solution 5 mg / 5 mL (Quantity Level Limit)
• Clobazam Suspension 2.5 mg / mL (Prior Authorization)
• Clobazam Tablet 10mg (Prior Authorization)
• Clobazam Tablet 20 mg (Prior Authorization)
• Entresto Sprinkle Capsule (Prior Authorization, Quantity Level Limit)
• Folivane-Ob Capsule 85-1 mg (Quantity Level Limit)
• Libervant Buccal Film (Quantity Level Limit)
• Liraglutide (Step Therapy, Quantity Level Limit)
• Naloxone Hydrochloride Syringe 0.4 mg / mL (Quantity Level Limiy)
• Ojemda Suspension (Prior Authorization, Quantity Level Limit)
• Ojemda Tablet 100 mg (Prior Authorization, Quantity Level Limit)
• Rextovy Nasal Spray (Quantity Level Limit)
• Rufinamide Suspension 40 mg / mL (Prior Authorization)
• Rufinamide Tablet 200 mg (Prior Authorization)
• Rufinamide Tablet 400 mg (Prior Authorization)
• Tiotropium Bromide Handihaler (Quantity Level Limit)

Removals:

• Opsumit

Other Updates:

• Abilify Maintena (Remove Prior Authorization, Add Age Limit)
• Aristada (Remove Prior Authorization, Add Age Limit)
• Aristada Initio (Remove Prior Authorization, Add Age Limit)
• Clobazam (Quantity Level Limit)
• Emgality Injection 120 mg / mL (Update Step Therapy)
• Invega Hafyera (Remove Prior Authorization, Add Age Limit)
• Invega Sustenna (Remove Prior Authorization, Add Age Limit)
• Invega Trinza (Remove Prior Authorization, Add Age Limit)
• Pregabalin Capsule 100 mg (Remove Prior Authorization)
• Pregabalin Capsule 150 mg (Remove Prior Authorization)
• Pregabalin Capsule 200 mg (Remove Prior Authorization)
• Pregabalin Capsule 225 mg (Remove Prior Authorization)
• Pregabalin Capsule 25 mg (Remove Prior Authorization)
• Pregabalin Capsule 300 mg (Remove Prior Authorization)
• Pregabalin Capsule 50 mg (Remove Prior Authorization)
• Pregabalin Capsule 75 mg (Remove Prior Authorization)
• Risperidone Injection (Remove Prior Authorization, Add Age Limit)
• Rufinamide (Quantity Level Limit)
• Sevelamer Carbonate Tablet 800mg (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:

• None

Removals:

• None

Other Updates:

• None

August 2024

Additions:

• Austedo Extended Release 30 mg (Quantity Level Limit, Prior Authorization)
• Austedo Extended Release 36 mg (Quantity Level Limit, Prior Authorization)
• Austedo Extended Release 42 mg (Quantity Level Limit, Prior Authorization)
• Austedo Extended Release 48 mg (Quantity Level Limit, Prior Authorization)
• 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)
• Rinvoq Oral Solution 1 mg/ mL (Prior Authorization)
• Tinidazole Tablet 250 mg
• Tinidazole Tablet 500 mg

Removals:

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

Other updates:

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

July 2024

Additions:

• None

Removals:

• None

Other updates:

• None

June 2024

Additions:

• Penicillin G Benzathine For Intramuscular Suspension 1200000 Units
• Penicillin G Benzathine For Intramuscular Suspension 2400000 Units

Removals:

• None

Other Updates:

• None

May 2024

Additions:

• Adapalene Gel 0.3% (Step Therapy, Quantity Level Limit)
• Adapalene/Benzoyl Peroxide Gel 0.1-2.5% (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)
• 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 Aerosol Powder Breath Activated 250 mcg/ Actuations (Quantity Level Limit)
• Fluticasone Propionate Powder Inhaler 100 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
• Narcan Spray 4 mg
• Oxycodone Hydrochloride Extended-Release Tablet 10 mg (Prior Authorization, Quantity Level Limit)
• Oxycodone Hydrochloride Extended-Release Tablet 20mg (Prior Authorization, Quantity Level Limit)
• Oxycodone Hydrochloride Extended-Release Tablet 40mg (Prior Authorization, Quantity Level Limit)
• Oxycodone Hydrochloride Extended-Release Tablet 80mg (Prior Authorization, Quantity Level Limit)

Removals:

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

Other Updates:

• Acetaminophen Tablet 325 mg (Quantity Level Limit)
• Acetaminophen Tablet 500 mg (Quantity Level Limit)
• Acetaminophen Tablet Extended Release 650 mg (Quantity Level Limit)
• Acyclovir Ointment 5%
• Amphetamine-Dextroamphetamine Capsule Extended Release 24-hour 10 mg (Quantity Level Limit)
• Amphetamine-Dextroamphetamine Capsule Extended Release 24-hour 15 mg (Quantity Level Limit)
• Amphetamine-Dextroamphetamine Capsule Extended Release 24-hour 30 mg (Quantity Level Limit)
• Amphetamine-Dextroamphetamine Capsule Extended Release 24-hour 5 mg (Quantity Level Limit)
• Amphetamine-Dextroamphetamine Tablet 10 mg (Quantity Level Limit)
• Amphetamine-Dextroamphetamine Tablet 12.5 mg (Quantity Level Limit)
• Amphetamine-Dextroamphetamine Tablet 15 mg (Quantity Level Limit)
• Amphetamine-Dextroamphetamine Tablet 20 mg (Quantity Level Limit)
• Amphetamine-Dextroamphetamine Tablet 5 mg (Quantity Level Limit)
• Amphetamine-Dextroamphetamine Tablet 7.5 mg (Quantity Level Limit)
• Baclofen Tablet 20 mg (Quantity Level Limit)
• Bupropion Hydrochloride (Smoking Deterrent) Tablet Extended Release 12-hour 150 mg (Quantity Level Limit)
• Bupropion Hydrochloride Tablet 100 mg (Quantity Level Limit)
• Bupropion Hydrochloride Tablet Extended Release 12-hour 200 mg (Quantity Level Limit)
• Bupropion Hydrochloride Tablet Extended Release 24-hour 300 mg (Quantity Level Limit)
• Calcipotriene Cream 0.005% (Quantity Level Limit)
• Calcipotriene Ointment 0.005% (Quantity Level Limit)
• Calcipotriene Solution 0.005% (50 mcg / mL) (Quantity Level Limit)
• Carbamazepine Capsule Extended Release 12-hour 200 mg (Quantity Level Limit)
• Carbamazepine Capsule Extended Release 12-hour 300 mg (Quantity Level Limit)
• Carbamazepine Tablet Extended Release 12-hour 100 mg (Quantity Level Limit)
• Carbamazepine Tablet Extended Release 12-hour 200 mg (Quantity Level Limit)
• Celecoxib Capsule 400 mg (Quantity Level Limit)
• Chlorzoxazone Tablet 500 mg (Quantity Level Limit)
• Ciclopirox Olamine Cream 0.77% (Step Therapy)
• Clopidogrel Bisulfate Tablet 75 mg (Base Equivalent) (Quantity Level Limit)
• Cyclobenzaprine Hydrochloride Tablet 10 mg (Quantity Level Limit)
• Cyclobenzaprine Hydrochloride Tablet 5 mg (Quantity Level Limit)
• Dantrolene Sodium Capsule 100 mg (Quantity Level Limit)
• Dantrolene Sodium Capsule 25 mg (Quantity Level Limit)
• Dantrolene Sodium Capsule 50 mg (Quantity Level Limit)
• Dexmethylphenidate Hydrochloride Capsule Extended Release 24-hour 10 mg (Quantity Level Limit)
• Dexmethylphenidate Hydrochloride Capsule Extended Release 24-hour 20 mg (Quantity Level Limit)
• Dexmethylphenidate Hydrochloride Capsule Extended Release 24-hour 25 mg (Quantity Level Limit)
• Dexmethylphenidate Hydrochloride Capsule Extended Release 24-hour 35 mg (Quantity Level Limit)
• Dextroamphetamine Sulfate Tablet 10 mg (Quantity Level Limit)
• Promacta Tablet 12.5 mg (Base Equivalent) (Quantity Level Limit)
• Promacta Tablet 25 mg (Base Equivalent) (Quantity Level Limit)
• Febuxostat Tablet 40 mg (Quantity Level Limit)
• Febuxostat Tablet 80 mg (Quantity Level Limit)
• Fluticasone Propionate Hfa Inhaler (Age Limit)
• Galantamine Hydrobromide Oral Solution 4 mg / mL (Quantity Level Limit)
• Ibuprofen Capsule 200 mg (Quantity Level Limit)
• Ibuprofen Tablet 200 mg (Quantity Level Limit)
• Lamotrigine Tablet 100 mg (Quantity Level Limit)
• Lamotrigine Tablet 150 mg (Quantity Level Limit)
• Lamotrigine Tablet 200 mg (Quantity Level Limit)
• Lamotrigine Tablet 25 mg (Quantity Level Limit)
• Lamotrigine Tablet Chewable Dispersible 5 mg (Quantity Level Limit)
• Leflunomide Tablet 10 mg (Quantity Level Limit)
• Leflunomide Tablet 20 mg (Quantity Level Limit)
• Levetiracetam Tablet 1000 mg (Quantity Level Limit)
• Levetiracetam Tablet 500 mg (Quantity Level Limit)
• Levetiracetam Tablet 750 mg (Quantity Level Limit)
• Levetiracetam Tablet Extended Release 24-hour 500 mg (Quantity Level Limit)
• Levetiracetam Tablet Extended Release 24-hour 750 mg (Quantity Level Limit)
• Mavyret Powder Pack 50-20 mg (Quantity Level Limit)
• Meloxicam Tablet 15 mg (Quantity Level Limit)
• Methylphenidate Hydrochloride Capsule Extended Release 10 mg (Cd) (Quantity Level Limit)
• Methylphenidate Hydrochloride Capsule Extended Release 20 mg (Cd) (Quantity Level Limit)
• Methylphenidate Hydrochloride Capsule Extended Release 30 mg (Cd) (Quantity Level Limit)
• Methylphenidate Hydrochloride Capsule Extended Release 40 mg (Cd) (Quantity Level Limit)
• Methylphenidate Hydrochloride Capsule Extended Release 50 mg (Cd) (Quantity Level Limit)
• Methylphenidate Hydrochloride Capsule Extended Release 60 mg (Cd) (Quantity Level Limit)
• Methylphenidate Hydrochloride Capsule Extended-Release Osmotic Release (Osmotic) 36 mg (Quantity Level Limit)
• Methylphenidate Hydrochloride Chewable Tablet 2.5 mg (Quantity Level Limit)
• Methylphenidate Hydrochloride Chewable Tablet 5 mg (Quantity Level Limit)
• Methylphenidate Hydrochloride Solution 10 mg / 5 mL (Quantity Level Limit)
• Methylphenidate Hydrochloride Tablet Extended Release 24-hour 18 mg (Quantity Level Limit)
• Methylphenidate Hydrochloride Tablet Extended Release 24-hour 27 mg (Quantity Level Limit)
• Methylphenidate Hydrochloride Tablet Extended Release 24-hour 36 mg (Quantity Level Limit)
• Methylphenidate Hydrochloride Tablet Extended Release 24-hour 54 mg (Quantity Level Limit)
• Nabumetone Tablet 500 mg (Quantity Level Limit)
• Nicotine Transdermal Patch 24-hour 14 mg/ 24-hour (Quantity Level Limit)
• Nicotine Transdermal Patch 24-hour 21 mg/ 24-hour (Quantity Level Limit)
• Nicotine Transdermal Patch 24-hour 7 mg/ 24-hour (Quantity Level Limit)
• Nicotine Transdermal Patch 24-hour Kit 21-14-7 mg / 24-hour (Quantity Level Limit)
• Orphenadrine Citrate Tablet Extended Release 12-hour 100 mg (Quantity Level Limit)
• Retin-A Cream
• Retin-A Gel 0.01%
• Retin-A Gel 0.025%
• Ropinirole Hydrochloride Tablet Extended Release 24-hour 12 mg (Base Equivalent) (Quantity Level Limit)
• Ropinirole Hydrochloride Tablet Extended Release 24-hour 2 mg (Base Equivalent) (Quantity Level Limit)
• Ropinirole Hydrochloride Tablet Extended Release 24-hour 4 mg (Base Equivalent) (Quantity Level Limit)
• Ropinirole Hydrochloride Tablet Extended Release 24-hour 6 mg (Base Equivalent) (Quantity Level Limit)
• Tacrolimus Ointment 0.03% (Step Therapy)
• Tacrolimus Ointment 0.1% (Step Therapy)
• Tiagabine Hydrochloride Tablet 12 mg (Quantity Level Limit)
• Tiagabine Hydrochloride Tablet 16 mg (Quantity Level Limit)
• Tiagabine Hydrochloride Tablet 4 mg (Quantity Level Limit)
• Topiramate Tablet 200 mg (Quantity Level Limit)
• Venlafaxine Hydrochloride Capsule Extended Release 24-hour 150 mg (Base Equivalent) (Quantity Level Limit)
• Zovirax Ointment 5%

April 2024

Additions:

• Dabigatran 110 mg Capsule (Quantity Level Limit)
• Xolair 300 mg / 2 mL Prefilled Syringe (Prior Authorization)
• Xolair 300 mg / 2 mL Pen (Prior Authorization)
• Xolair 75 mg / 0.5 mL Pen (Prior Authorization)
• Xolair 150 mg / mL (Prior Authorization)

Removals:

• No updates

Other Updates:

• No updates

March 2024

Additions:

• Zenpep Capsule 60000 Unit

Removals:

• No updates

Other Updates:

• No updates

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)
• Aristada Initio Prefilled Syringe 675 mg/ 2.4 mL (Prior Authorization, Quantity Level Limit)
• 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 Units/ mL
• Insulin Lispro Injection Junior
• Insulin Lispro Vial
• Lurasidone Hydrochloride Tablet 120 mg (Quantity Level Limit, Age Limit)
• Lurasidone Hydrochloride Tablet 20 mg (Quantity Level Limit, Age Limit)
• Lurasidone Hydrochloride Tablet 40 mg (Quantity Level Limit, Age Limit)
• Lurasidone Hydrochloride Tablet 60 mg (Quantity Level Limit, Age Limit)
• Lurasidone Hydrochloride Tablet 80 mg (Quantity Level Limit, Age Limit)
• Ondansetron Hydrochloride Oral Solution 4 mg/ 5 mL (Quantity Level Limit)
• Orilissa Tablet 150 mg (Prior Authorization)
• Orilissa Tablet 200 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
• Benzoyl Peroxide Liquid Wash 4%
• Bromocriptine Mesylate Capsule 5 mg (Base Equivalent)
• Bromocriptine Mesylate Tablet 2.5 mg (Base Equivalent)
• 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
• Humalog Vial 100 units /mL
• Humalog Vial 100 units /mL
• Humira Injection 10 mg /0.1 mL
• Humira Injection 20 mg /0.2 mL
• Humira Injection 40 mg/0.4 mL
• Humira Kit 40 mg/0.8
• Humira Pediatric Injection Crohns
• Humira Pediatric 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
• Ins Aspart FlexPen 70/30
• Insulin Aspart Protein Injection Flexpen
• 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 Tablet Delayed Release 800 mg
• Nayzilam
• Novolog Mix Injection Flex ReliOn
• Novolog Mix Vial 70/30
• Salsalate Tablet 500 mg
• Salsalate Tablet 750 mg
• Tramadol Tablet 100mg
• Viokace Tablet 10440 Units
• Viokace Tablet 20880 Units

Other Updates:

• *Sodium Phosphates - Enema*** (Quantity Level Limit)
• Acarbose Tablet 100 mg (Quantity Level Limit)
• Acarbose Tablet 25 mg (Quantity Level Limit)
• Acarbose Tablet 50 mg (Quantity Level Limit)
• Albuterol Sulfate Solution Nebulizer 0.083% (2.5 mg/3 mL) (Quantity Level Limit)
• Albuterol Sulfate Solution Nebulizer 0.5% (5 mg/mL) (Quantity Level Limit)
• Albuterol Sulfate Solution Nebulizer 0.63 mg/3 mL (Base Equivalent) (Quantity Level Limit)
• Albuterol Sulfate Solution Nebulizer 1.25 mg/3 mL (Base Equivalent) (Quantity Level Limit)
• Alfuzosin Hydrochloride Tablet Extended Release 24 Hour 10 mg (Quantity Level Limit)
• Alogliptin-Pioglitazone Tablet 12.5-15 mg (Quantity Level Limit)
• Alogliptin-Pioglitazone Tablet 12.5-45 mg (Quantity Level Limit)
• Alprazolam Tablet Extended Release 24 Hour 0.5 mg (Quantity Level Limit)
• Alprazolam Tablet Extended Release 24 Hour 1 mg (Quantity Level Limit)
• Alprazolam Tablet Extended Release 24 Hour 2 mg (Quantity Level Limit)
• Alprazolam Tablet Extended Release 24 Hour 3 mg (Quantity Level Limit)
• Amlodipine Besylate-Benazepril Hydrochloride Capsule 10-20 mg (Quantity Level Limit)
• Amlodipine Besylate-Benazepril Hydrochloride Capsule 10-40 mg (Quantity Level Limit)
• Amlodipine Besylate-Benazepril Hydrochloride Capsule 2.5-10 mg (Quantity Level Limit)
• Amlodipine Besylate-Benazepril Hydrochloride Capsule 5-10 mg (Quantity Level Limit)
• Amlodipine Besylate-Benazepril Hydrochloride Capsule 5-20 mg (Quantity Level Limit)
• Amlodipine Besylate-Benazepril Hydrochloride Capsule 5-40 mg (Quantity Level Limit)
• Benazepril Hydrochloride Tablet 40 mg (Quantity Level Limit)
• Bimatoprost Ophthalmic Solution 0.3% (Quantity Level Limit)
• Buprenorphine Hydrochloride Sublingual Tablet 2 mg (Quantity Level Limit)
• Buprenorphine Hydrochloride Sublingual Tablet 8 mg (Quantity Level Limit)
• Buspirone Hydrochloride Tablet 10 mg (Quantity Level Limit)
• Buspirone Hydrochloride Tablet 15 mg (Quantity Level Limit)
• Buspirone Hydrochloride Tablet 5 mg (Quantity Level Limit)
• Buspirone Hydrochloride Tablet 7.5 mg (Quantity Level Limit)
• Candesartan Cilexetil Tablet 16 mg (Quantity Level Limit)
• Candesartan Cilexetil Tablet 32 mg (Quantity Level Limit)
• Candesartan Cilexetil Tablet 4 mg (Quantity Level Limit)
• Candesartan Cilexetil Tablet 8 mg (Quantity Level Limit)
• Candesartan Cilexetil-Hydrochlorothiazide Tablet 16-12.5 mg (Quantity Level Limit)
• Candesartan Cilexetil-Hydrochlorothiazide Tablet 32-12.5 mg (Quantity Level Limit)
• Candesartan Cilexetil-Hydrochlorothiazide Tablet 32-25 mg (Quantity Level Limit)
• Cetirizine Hydrochloride Tablet 10 mg (Quantity Level Limit)
• Cetirizine Hydrochloride Tablet 5 mg (Quantity Level Limit)
• Chlorpheniramine Maleate Tablet Extended Release 12 mg (Quantity Level Limit)
• Cimetidine Tab 800 mg (Quantity Level Limit)
• Cimetidine Tablet 300 mg (Quantity Level Limit)
• Cimetidine Tablet 400 mg (Quantity Level Limit)
• Citalopram Hydrobromide Tablet 10 mg (Base Equivalent) (Quantity Level Limit)
• Citalopram Hydrobromide Tablet 20 mg (Base Equivalent) (Quantity Level Limit)
• Darunavir Tablet 600 mg (Quantity Level Limit)
• Darunavir Tablet 800 mg (Quantity Level Limit)
• Diltiazem Hydrochloride Capsule Extended Release 24 Hour 240 mg (Quantity Level Limit)
• Diltiazem Hydrochloride Coated Beads Capsule Extended Release 24 Hour 120 mg (Quantity Level Limit)
• Diltiazem Hydrochloride Extended Release Beads Capsule Extended Release 24 Hour 240 mg (Quantity Level Limit)
• Doxazosin Mesylate Tablet 8 mg (Quantity Level Limit)
• Duloxetine Hydrochloride Enteric Coated Pellets Capsule 60 mg (Base Equivalent) (Quantity Level Limit)
• Enalapril Maleate & Hydrochlorothiazide Tablet 10-25 mg (Quantity Level Limit)
• Enalapril Maleate & Hydrochlorothiazide Tablet 5-12.5 mg (Quantity Level Limit)
• Enalapril Maleate Tablet 20 mg (Quantity Level Limit)
• Esomeprazole Magnesium Capsule Delayed Release 40 mg (Quantity Level Limit)
• Ezetimibe Tablet 10 mg (Quantity Level Limit)
• Famotidine Tablet 10 mg (Quantity Level Limit)
• Famotidine Tablet 40 mg (Quantity Level Limit)
• Finasteride Tablet 5 mg (Quantity Level Limit)
• Flavoxate Hydrochloride Tablet 100 mg (Quantity Level Limit)
• Fluoxetine Hydrochloride Capsule 20 mg (Quantity Level Limit)
• Fluvastatin Sodium Capsule 20 mg (Base Equivalent) (Quantity Level Limit)
• Fluvoxamine Maleate Tablet 50 mg (Quantity Level Limit)
• Fosinopril Sodium Tablet 40 mg (Quantity Level Limit)
• Ibrutinib Tablet 420 mg (Quantity Level Limit)
• Ibrutinib Tablet 560 mg (Quantity Level Limit)
• Ipratropium-Albuterol Nebulizer Solution 0.5-2.5(3) mg/3 mL (Quantity Level Limit)
• Irbesartan-Hydrochlorothiazide Tablet 300-12.5 mg (Quantity Level Limit)
• Lansoprazole Capsule Delayed Release 30 mg (Quantity Level Limit)
• Lisinopril & Hydrochlorothiazide Tablet 10-12.5 mg (Quantity Level Limit)
• Lisinopril & Hydrochlorothiazide Tablet 20-25 mg (Quantity Level Limit)
• Loratadine & Pseudoephedrine Tablet Extended Release 12 Hour 5-120 mg (Quantity Level Limit)
• Loratadine & Pseudoephedrine Tablet Extended Release 24 Hour 10-240 mg (Quantity Level Limit)
• Losartan Potassium & Hydrochlorothiazide Tablet 100-12.5 mg (Quantity Level Limit)
• Losartan Potassium & Hydrochlorothiazide Tablet 100-25 mg (Quantity Level Limit)
• Losartan Potassium & Hydrochlorothiazide Tablet 50-12.5 mg (Quantity Level Limit)
• Losartan Potassium Tablet 100 mg (Quantity Level Limit)
• Mesalamine Capsule Extended Release 24 Hour 0.375 GM (Quantity Level Limit)
• Mirtazapine Orally Disintegrating Tablet 30 mg (Quantity Level Limit)
• Mirtazapine Tablet 30 mg (Quantity Level Limit)
• Mirtazapine Tablet 45 mg (Quantity Level Limit)
• Montelukast Sodium Chewable Tablet 4 mg (Base Equivalent) (Quantity Level Limit)
• Montelukast Sodium Chewable Tablet 5 mg (Base Equivalent) (Quantity Level Limit)
• Montelukast Sodium Oral Granules Packet 4 mg (Base Equivalent) (Quantity Level Limit)
• Montelukast Sodium Tablet 10 mg (Base Equivalent) (Quantity Level Limit)
• Nelfinavir Mesylate Tablet 250 mg (Quantity Level Limit)
• Nizatidine Capsule 150 mg (Quantity Level Limit)
• Nizatidine Capsule 300 mg (Quantity Level Limit)
• Omeprazole Capsule Delayed Release 40 mg (Quantity Level Limit)
• Oxazepam Capsule 10 mg (Age Limit)
• Oxazepam Capsule 15 mg (Age Limit)
• Oxazepam Capsule 30 mg (Age Limit)
• Oxybutynin Chloride Tablet Extended Release 24 Hour 10 mg (Quantity Level Limit)
• Oxybutynin Chloride Tablet Extended Release 24 Hour 5 mg (Quantity Level Limit)
• Oxymetazoline Hydrochloride Nasal Solution 0.05% (Quantity Level Limit)
• Pantoprazole Sodium Enteric Coated Tablet 40 mg (Quantity Level Limit)
• Paroxetine Hydrochloride Tablet 30 mg (Quantity Level Limit)
• Paroxetine Hydrochloride Tablet 40 mg (Quantity Level Limit)
• Polyethylene Glycol 3350 Oral Packet 17 GM (Quantity Level Limit)
• Polyethylene Glycol 3350 Oral Powder 17 GM/Scoop (Quantity Level Limit)
• Prazosin Hydrochloride Capsule 1 mg (Quantity Level Limit)
• Prazosin Hydrochloride Capsule 2 mg (Quantity Level Limit)
• Prazosin Hydrochloride Capsule 5 mg (Quantity Level Limit)
• Quinapril Hydrochloride Tablet 40 mg (Quantity Level Limit)
• Quinapril-Hydrochlorothiazide Tablet 20-12.5 mg (Quantity Level Limit)
• Quinapril-Hydrochlorothiazide Tablet 20-25 mg (Quantity Level Limit)
• Ramipril Capsule 10 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)
• Sertraline Hydrochloride Tablet 100 mg (Quantity Level Limit)
• Sertraline Hydrochloride Tablet 25 mg (Quantity Level Limit)
• Tamsulosin Hydrochloride Capsule 0.4 mg (Quantity Level Limit)
• Terazosin Hydrochloride Capsule 2 mg (Base Equivalent) (Quantity Level Limit)
• Terazosin Hydrochloride Capsule 5 mg (Base Equivalent) (Quantity Level Limit)
• Tobramycin Nebulizer Solution 300 mg/5 mL (Quantity Level Limit)
• Tolterodine Tartrate Tablet 1 mg (Quantity Level Limit)
• Tolterodine Tartrate Tablet 2 mg (Quantity Level Limit)
• Trandolapril Tablet 1 mg (Quantity Level Limit)
• Trandolapril Tablet 2 mg (Quantity Level Limit)
• Trandolapril Tablet 4 mg (Quantity Level Limit)
• Valsartan Tablet 160 mg (Quantity Level Limit)
• Valsartan Tablet 320 mg (Quantity Level Limit)
• Valsartan Tablet 40 mg (Quantity Level Limit)
• Valsartan Tablet 80 mg (Quantity Level Limit)
• Zidovudine Syrup 10 mg/ mL (Quantity Level Limit)

January 2024

Additions:

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

Removals:

• Benzoyl Peroxide Liquid Wash 0.04%

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)
• Dayvigo Tablet 10 mg (Prior Authorization, Quantity Level Limit)
• Dayvigo Tablet 5 mg (Prior Authorization, 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
• Prezcobix Tablet 800-150 (Prior Authorization, Quantity Level Limit)
• Takhzyro Injection 150 mg / mL (Prior Authorization, Quantity Level Limit)
• Takhzyro Injection 300 / 2 mL (Prior Authorization, Quantity Level Limit)
• Takhzyro Injection 300 / 2 mL (Prior Authorization, Quantity Level Limit)

Removals:

• Proctofoam Aerosol Hydrocortisone 1%

Other Updates:

• Abacavir Sulfate Solution 20 mg / mL (Base Equivalent) (Quantity Level Limit)
• Abacavir Sulfate Tablet 300 mg (Base Equivalent) (Quantity Level Limit)
• Abacavir Sulfate-Lamivudine Tablet 600-300 mg (Quantity Level Limit)
• Abacavir Sulfate-Lamivudine-Zidovudine Tablet 300-150-300 mg (Quantity Level Limit)
• Acarbose Tablet 100 mg (Quantity Level Limit)
• Acarbose Tablet 25 mg (Quantity Level Limit)
• Acarbose Tablet 50 mg (Quantity Level Limit)
• Alogliptin Benzoate Tablet 12.5 mg (Base Equivalent) (Quantity Level Limit)
• Alogliptin Benzoate Tablet 25 mg (Base Equivalent) (Quantity Level Limit)
• Alogliptin Benzoate Tablet 6.25 mg (Base Equivalent) (Quantity Level Limit)
• Alogliptin-Metformin Hydrochloride Tablet 12.5-1000 mg (Quantity Level Limit)
• Alogliptin-Metformin Hydrochloride Tablet 12.5-500 mg (Quantity Level Limit)
• Alogliptin-Pioglitazone Tablet 12.5-30 mg (Quantity Level Limit)
• Alogliptin-Pioglitazone Tablet 25-15 mg (Quantity Level Limit)
• Alogliptin-Pioglitazone Tablet 25-30 mg (Quantity Level Limit)
• Alogliptin-Pioglitazone Tablet 25-45 mg (Quantity Level Limit)
• Anastrozole Tablet 1 mg (Quantity Level Limit)
• Atazanavir Sulfate Capsule 150 mg (Base Equivalent) (Quantity Level Limit)
• Atazanavir Sulfate Capsule 200 mg (Base Equivalent) (Quantity Level Limit)
• Atazanavir Sulfate Capsule 300 mg (Base Equivalent) (Quantity Level Limit)
• Bicalutamide Tablet 50 mg (Quantity Level Limit)
• Bisoprolol Fumarate Tablet 5 mg (Quantity Level Limit)
• Carvedilol Tablet 12.5 mg (Quantity Level Limit)
• Carvedilol Tablet 25 mg (Quantity Level Limit)
• Carvedilol Tablet 3.125 mg (Quantity Level Limit)
• Carvedilol Tablet 6.25 mg (Quantity Level Limit)
• Complera Tablet (Quantity Level Limit)
• Darunavir Oral Suspension 100 mg / mL (Quantity Level Limit)
• Darunavir Tablet 150 mg (Quantity Level Limit)
• Darunavir Tablet 75 mg (Quantity Level Limit)
• Diazepam Rectal Gel 10 mg 2's (Quantity Level Limit)
• Diazepam Rectal Gel 2.5 mg 2s (Quantity Level Limit)
• Diazepam Rectal Gel 20 mg 2's (Quantity Level Limit)
• Edurant Tablet 25 mg (Base Equivalent) (Quantity Level Limit)
• Efavirenz Capsule 200 mg (Quantity Level Limit)
• Efavirenz Capsule 50 mg (Quantity Level Limit)
• Efavirenz Tablet 600 mg (Quantity Level Limit)
• Efavirenz-Emtricitabine-Tenofovir Df Tablet 600-200-300 mg (Quantity Level Limit)
• Ella Tablet 30 mg (Quantity Level Limit)
• Emtricitabine Capsules 200 mg (Quantity Level Limit)
• Emtricitabine Solution 10 mg / mL (Quantity Level Limit)
• Erlotinib Hydrochloride Tablet 100 mg (Base Equivalent) (Quantity Level Limit)
• Erlotinib Hydrochloride Tablet 150 mg (Base Equivalent) (Quantity Level Limit)
• Erlotinib Hydrochloride Tablet 25 mg (Add Prior Authorization, Quantity Level Limit)
• Estradiol & Norethindrone Acetate Tablet 0.5-0.1 mg (Quantity Level Limit)
• Estradiol & Norethindrone Acetate Tablet 1-0.5 mg (Quantity Level Limit)
• Etoposide Capsule 50 mg (Remove Prior Authorization)
• Etravirine Tablet 100 mg (Quantity Level Limit)
• Etravirine Tablet 200 mg (Quantity Level Limit)
• Etravirine Tablet 25 mg (Quantity Level Limit)
• Everolimus Tablet 10 mg (Quantity Level Limit)
• Everolimus Tablet 2.5 mg (Quantity Level Limit)
• Everolimus Tablet 5 mg (Quantity Level Limit)
• Everolimus Tablet 7.5 mg (Quantity Level Limit)
• Evotaz Tablet 300-150 (Quantity Level Limit)
• Exemestane Tablet 25 mg (Quantity Level Limit)
• Felodipine Tablet Extended Release 24-hour 10 mg (Quantity Level Limit)
• Felodipine Tablet Extended Release 24-hour 2.5 mg (Quantity Level Limit)
• Felodipine Tablet Extended Release 24-hour 5 mg (Quantity Level Limit)
• Fluconazole Tablet 100 mg (Quantity Level Limit)
• Fluconazole Tablet 200 mg (Quantity Level Limit)
• Fluconazole Tablet 50 mg (Quantity Level Limit)
• Fosamprenavir Calcium Suspension 50 mg / mL (Base Equivalent) (Quantity Level Limit)
• Fosamprenavir Calcium Tablet 700 mg (Base Equivalent) (Quantity Level Limit)
• Fuzeon (Quantity Level Limit)
• Glipizide Tablet Extended Release 24-hour 10 mg (Quantity Level Limit)
• Glipizide Tablet Extended Release 24-hour 2.5 mg (Quantity Level Limit)
• Glipizide Tablet Extended Release 24-hour 5 mg (Quantity Level Limit)
• Glipizide-Metformin Hydrochloride Tablet 2.5-250 mg (Quantity Level Limit)
• Glipizide-Metformin Hydrochloride Tablet 2.5-500 mg (Quantity Level Limit)
• Glipizide-Metformin Hydrochloride Tablet 5-500 mg (Quantity Level Limit)
• Glyburide-Metformin Tablet 1.25-250 mg (Quantity Level Limit)
• Glyburide-Metformin Tablet 2.5-500 mg (Quantity Level Limit)
• Glyburide-Metformin Tablet 5-500 mg (Quantity Level Limit)
• Imatinib Mesylate Tablet 100 mg (Base Equivalent) (Quantity Level Limit)
• Imatinib Mesylate Tablet 400 mg (Base Equivalent) (Quantity Level Limit)
• Imbruvica Tablet 420 mg (Add Prior Authorization, Quantity Level Limit)
• Imbruvica Tablet 560 mg (Add Prior Authorization)
• Isentress Chewable Tablet 100 mg (Base Equivalent) (Quantity Level Limit)
• Isentress Chewable Tablet 25 mg (Base Equivalent) (Quantity Level Limit)
• Isentress For Suspension 100 mg (Base Equivalent) (Quantity Level Limit)
• Isentress Tablet 400 mg (Base Equivalent) (Quantity Level Limit)
• Isosorbide Mononitrate Tablet Extended Release 24-hour 120 mg (Quantity Level Limit)
• Isosorbide Mononitrate Tablet Extended Release 24-hour 30 mg (Quantity Level Limit)
• Isosorbide Mononitrate Tablet Extended Release 24-hour 60 mg (Quantity Level Limit)
• Itraconazole Capsule 100 mg (Quantity Level Limit)
• Ketoconazole Tablet 200 mg (Quantity Level Limit)
• Lamivudine Oral Solution 10 mg / mL (Quantity Level Limit)
• Lamivudine Tablet 150 mg (Quantity Level Limit)
• Lamivudine Tablet 300 mg (Quantity Level Limit)
• Lamivudine-Zidovudine Tablet 150-300 mg (Quantity Level Limit)
• Letrozole Tablet 2.5 mg (Quantity Level Limit)
• Levothyroxine Sodium Tablet 100 mcg (Quantity Level Limit)
• Levothyroxine Sodium Tablet 112 mcg (Quantity Level Limit)
• Levothyroxine Sodium Tablet 125 mcg (Quantity Level Limit)
• Levothyroxine Sodium Tablet 137 mcg (Quantity Level Limit)
• Levothyroxine Sodium Tablet 150 mcg (Quantity Level Limit)
• Levothyroxine Sodium Tablet 175 mcg (Quantity Level Limit)
• Levothyroxine Sodium Tablet 200 mcg (Quantity Level Limit)
• Levothyroxine Sodium Tablet 25 mcg (Quantity Level Limit)
• Levothyroxine Sodium Tablet 300 mcg (Quantity Level Limit)
• Levothyroxine Sodium Tablet 50 mcg (Quantity Level Limit)
• Levothyroxine Sodium Tablet 75 mcg (Quantity Level Limit)
• Levothyroxine Sodium Tablet 88 mcg (Quantity Level Limit)
• Lopinavir-Ritonavir Solution 400-100 mg / 5 mL (80-20 mg / mL) (Quantity Level Limit)
• Lopinavir-Ritonavir Tablet 100-25 mg (Quantity Level Limit)
• Lopinavir-Ritonavir Tablet 200-50 mg (Quantity Level Limit)
• Mavyret Tablet 100-40 mg (Quantity Level Limit)
• Metformin Hydrochloride Tablet Extended Release 24-hour 500 mg (Quantity Level Limit)
• Metformin Hydrochloride Tablet Extended Release 24-hour 750 mg (Quantity Level Limit)
• Methadone Hydrochloride Powder (Remove Prior Authorization)
• Metoprolol Succinate Tablet Extended Release 24-hour 100 mg (Tartrate Equivalent) (Quantity Level Limit)
• Metoprolol Succinate Tablet Extended Release 24-hour 200 mg (Tartrate Equivalent) (Quantity Level Limit)
• Metoprolol Succinate Tablet Extended Release 24-hour 25 mg (Tartrate Equivalent) (Quantity Level Limit)
• Metoprolol Succinate Tablet Extended Release 24-hour 50 mg (Tartrate Equivalent) (Quantity Level Limit)
• Metronidazole Gel 1% (Remove Step Therapy)
• Nateglinide Tablet 120 mg (Quantity Level Limit)
• Nateglinide Tablet 60 mg (Quantity Level Limit)
• Nayzilam Spray 5 mg (Remove Prior Authorization, Add Quantity Level Limit)
• Nelfinavir Mesylate Tablet 250 mg (Quantity Level Limit)
• Nelfinavir Mesylate Tablet 625 mg (Quantity Level Limit)
• Nevirapine Susp 50 mg / 5 mL (Quantity Level Limit)
• Nevirapine Tablet 200 mg (Quantity Level Limit)
• Nevirapine Tablet Extended Release 24-hour 100 mg (Quantity Level Limit)
• Nevirapine Tablet Extended Release 24-hour 400 mg (Quantity Level Limit)
• Nifedipine Tablet Extended Release 24-hour 30 mg (Quantity Level Limit)
• Nifedipine Tablet Extended Release 24-hour 60 mg (Quantity Level Limit)
• Nifedipine Tablet Extended Release 24-hour 90 mg (Quantity Level Limit)
• Nifedipine Tablet Extended Release 24-hour Osmotic Release 30 mg (Quantity Level Limit)
• Nifedipine Tablet Extended Release 24-hour Osmotic Release 60 mg (Quantity Level Limit)
• Nifedipine Tablet Extended Release 24-hour Osmotic Release 90 mg (Quantity Level Limit)
• Norethindrone Acetate-Ethinyl Estradiol Tablet 0.5 mg - 2.5 mcg (Quantity Level Limit)
• Norethindrone Acetate-Ethinyl Estradiol Tablet 1 mg - 5 mcg (Quantity Level Limit)
• Norethindrone Tablet 0.35 mg (Quantity Level Limit)
• Paricalcitol Capsule 1 mcg (Quantity Level Limit)
• Paricalcitol Capsule 2 mcg (Quantity Level Limit)
• Paricalcitol Capsule 4 mcg (Quantity Level Limit)
• Progesterone Capsule 100 mg (Quantity Level Limit)
• Progesterone Capsule 200 mg (Quantity Level Limit)
• Propranolol Hydrochloride Capsule Extended Release 24-hour 60 mg (Quantity Level Limit)
• Raloxifene Hydrochloride Tablet 60 mg (Quantity Level Limit)
• Repaglinide Tablet 0.5 mg (Quantity Level Limit)
• Repaglinide Tablet 1 mg (Quantity Level Limit)
• Repaglinide Tablet 2 mg (Quantity Level Limit)
• Ritonavir Tablet 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)
• Stavudine Capsule 30 mg (Quantity Level Limit)
• Stavudine Capsule 40 mg (Quantity Level Limit)
• Sunitinib Malate Capsule 50 mg (Base Equivalent) (Quantity Level Limit)
• Tasigna Capsule 150 mg (Quantity Level Limit)
• Tasigna Capsule 200 mg (Quantity Level Limit)
• Tenofovir Disoproxil Fumarate Oral Powder 40 mg / GM (Quantity Level Limit)
• Tenofovir Disoproxil Fumarate Tablet 150 mg (Quantity Level Limit)
• Tenofovir Disoproxil Fumarate Tablet 200 mg (Quantity Level Limit)
• Tenofovir Disoproxil Fumarate Tablet 250 mg (Quantity Level Limit)
• Terbinafine Hydrochloride Tablet 250 mg (Quantity Level Limit)
• Testosterone Transdermal Gel 25 mg / 2.5 GM (1%) (Quantity Level Limit)
• Testosterone Transdermal Gel 50 mg / 5 GM (1%) (Quantity Level Limit)
• Tipranavir Capsule 250 mg (Quantity Level Limit)
• Tivicay 10 mg (Base Equivalent) (Quantity Level Limit)
• Tobramycin Nebulizer Solution 300 mg / 5 mL (Quantity Level Limit)
• Trelstar Mix Injection 11.25 mg (Remove Prior Authorization)
• Trelstar Mix Injection 22.5 mg (Remove Prior Authorization)
• Trelstar Mix Injection 3.75 mg (Remove Prior Authorization)
• Triumeq Tablet (Quantity Level Limit)
• Tybost Tablet 150 mg (Quantity Level Limit)
• Valtoco Spray 10 mg (Quantity Level Limit)
• Valtoco Spray 15 mg (Quantity Level Limit)
• Valtoco Spray 20 mg (Quantity Level Limit)
• Valtoco Spray 5 mg (Quantity Level Limit)
• Varenicline Tablet 0.5 mg (Quantity Level Limit)
• Varenicline Tablet 1 mg (Quantity Level Limit)
• Verapamil Hydrochloride Capsule Extended Release 24-hour 120 mg (Quantity Level Limit)
• Verapamil Hydrochloride Capsule Extended Release 24-hour 180 mg (Quantity Level Limit)
• Zidovudine Capsule 100 mg (Quantity Level Limit)
• Zidovudine Syrup 10 mg / ml (Quantity Level Limit)
• Zidovudine Tablet 300 mg (Quantity Level Limit)

October 2023

Additions:

• Humatrope Injection 6 mg (Prior Authorization)
• Humatrope Injection 12 mg (Prior Authorization)
• Humatrope Injection 24 mg (Prior Authorization)

Removals:

• None

Other Updates:

• None

September 2023

Additions:

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

Removals:

• None

Other Updates:

• None

August 2023

Additions:

• * Prenatal WithFerrous Fumarate-Ferrous Polysaccharide-Folic Acid-Omega 3 Capsule 53.5-38-1 mg
• 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 24 hour 12 mg (Prior Authorization, Quantity Level Limit)
• Austedo Tablet Extended Release 24 hour 24 mg (Prior Authorization, Quantity Level Limit)
• Austedo Tablet Extended Release 24 hour 6 mg (Prior Authorization, Quantity Level Limit)
• Biktarvy Tablet 30-120-15 mg (Prior Authorization, Quantity Level Limit)
• Buprenorphine Hydrochloride Sublingual Tablet 2 mg (Base Equivalent) (Prior Authorization, Quantity Level Limit)
• Buprenorphine Hydrochloride Sublingual Tablet 8 mg (Base Equivalent) (Prior Authorization, Quantity Level Limit)
• Cholecalciferol Capsule 1.25 mg (50000 Unit)
• Fluocinolone Acetonide Oil 0.01% (Body Oil) (Quantity Level Limit)
• Ibandronate Sodium Intravenous Solution 3 mg/ 3 mL (Base Equivalent)
• 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)
• Nitroglycerin Capsule Extended Release 2.5 mg
• Nonoxynol-9 Film 28% (Quantity Level Limit)
• Novolin N Injection 100 Unit
• Odefsey Tablet (Prior Authorization, Quantity Level Limit)
• Pamidronate Disodium Intravenous Solution 3 mg/ mL
• Pamidronate Disodium Intravenous Solution 6 mg/ mL
• Pamidronate Disodium Intravenous Solution 9 mg/ mL
• Tranexamic Acid Tablet 650 mg (Quantity Level Limit)

Removals:

• *Alcohol Sheets***
• *B-Complex W/ Minerals Liquid**
• *Blood Glucose Calibration - Liquid - Low***
• *Blood Glucose Calibration - Liquid - Normal***
• *Calcium Alginate-Silver Pad 2" X 2"***
• *Calcium Alginate-Silver Pad 4" X 4.75"***
• *Calcium Carbonate-Vitamin D With Minerals Chewable Tablet 600 mg-400 Unit***
• *Carboxymethylcellulose- Calcium Alginate-Silver Pad 2"X2"***
• *Carboxymethylcellulose- Calcium Alginate-Silver Pad 4"X4.75"***
• *Carboxymethylcellulose- Calcium Alginate-Silver Pad 4"X5"***
• *Carboxymethylcellulose- Calcium Alginate-Silver Pad 6"X6"***
• *Condoms - Male***
• *Cream Base**
• *Diapers & Supplies***
• *Hearing Aid Batteries-Miscellaneous***
• *Incontinence Supplies - Miscellaneous ***
• *Incontinence Supplies Disposable - Miscellaneous ***
• *Multiple Vitamin Liquid**
• *Pediatric Multiple Vitamin Liquid**
• *Pediatric Multiple Vitamin With Minerals & Vitamin C Drops 45 mg/ mL**
• *Pediatric Multiple Vitamin With Minerals Oral Solution**
• *Prenatal Vitamin With Docusate Sodium-Iron Carbonyl-Folic Acid Tab 90-1 mg***
• *Prenatal Without A Vitamin With Ferrous Fumarate-Folic Acid Tablet Chewable 40-1 mg***
• *Prenatal Without A With Ferrous Fumarate-Fe Poly-Folic Acid Capsule 85-1 mg***
• *Sanitary Napkins & Tampons - Pads***
• *Silver - Pad 12.5 cm X 12.5 cm***
• *Silver - Pad 17.5 cm X 17.5 cm***
• *Silver - Pad 2-3/8"X3-1/8"***
• *Silver - Pad 3"X14"***
• *Silver - Pad 4-3/4"X10"***
• *Silver - Pad 7.5 cm X 7.5 cm***
• *Silver Wound Dressings - Miscellaneous***
• *Throat Lozenges - Lozenges**
• *Wound Dressings - Pads***
• Alogliptin-Pioglitazone Tablet 12.5-15 mg
• Alogliptin-Pioglitazone Tablet 12.5-45 mg
• Aluminum & Magnesium Hydroxide-Simethicone Chewable Tablet 200-200-25 mg
• Aluminum Chloride Solution 20%
• Aminocaproic Acid Tablet 500 mg
• Aspirin Suppository 600 mg
• Atazanavir Sulfate Oral Powder Packet 50 mg (Base Equivalent)
• 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
• Benzoyl Peroxide Lotion 8%
• Bethanechol Chloride (Bulk) Powder
• Buprenorphine Hydrochloride-Naloxone Hydrochloride Sublingual Film 12-3 mg (Base Equivalent)
• Buprenorphine Hydrochloride-Naloxone Hydrochloride Sublingual Film 2-0.5 mg (Base Equivalent)
• Buprenorphine Hydrochloride-Naloxone Hydrochloride Sublingual Film 4-1 mg (Base Equivalent)
• Buprenorphine Hydrochloride-Naloxone Hydrochloride Sublingual Film 8-2 mg (Base Equivalent)
• Buprenorphine-Naloxone Buccal Film 2.1-0.3 mg (Base Equivalent)
• Buprenorphine-Naloxone Buccal Film 4.2-0.7 mg (Base Equivalent)
• Buprenorphine-Naloxone Buccal Film 6.3-1 mg (Base Equivalent)
• Butalbital-Aspirin-Caffeine Tablet 50-325-40 mg
• Caffeine Powder
• Calcium & Phosphorus With Vitamin D Tablet 105 mg-81 mg-120 Unit
• Calcium Carbonate-Magnesium Hydroxide Chewable Tablet 550-110 mg
• Calcium Carbonate-Magnesium Hydroxide Suspension 400-135 mg / 5 mL
• Calcium Carbonate-Vitamin D Tablet 600 mg-10 mcg (400 Unit)
• Calcium Citrate-Vitamin D Tablet 200 mg-6.25 mcg(250 Unit) (Elemental Calcium)
• Calcium Citrate-Vitamin D Tablet 315 mg-6.25 mcg(250 Unit) (Elemental Calcium)
• Calcium Citrate-Vitamin D Tablet 315 mg-5 mcg (200 Unit) (Elemental Calcium)
• Carboxymethylcellulose Sodium (Preservative-Free) Ophthalmic Solution 0.25%
• Carboxymethylcellulose Sodium Ophthalmic Solution 1%
• Carisoprodol With Aspirin & Codeine Tablet 200-325-16 mg
• Cimetidine Hydrochloride Solution 300 mg /5 mL
• Ciprofloxacin Hydrochloride Tablet 100 mg
• Clemastine Fumarate Syrup 0.67 mg/ 5 mL (0.5 mg/ 5 mL Base Equivalent)
• Coal Tar Shampoo 2%
• Coal Tar Shampoo 2.5%
• Corn Starch Topical Powder
• Cyclophosphamide Tablet 25 mg
• Cyclophosphamide Tablet 50 mg
• Desmopressin Acetate Nasal Solution 0.01% (Refrigerated)
• Dextromethorphan-Guaifenesin Liquid 30-200 mg/ 5 mL
• Didanosine Delayed Release Capsule 200 mg
• Didanosine Delayed Release Capsule 250 mg
• Didanosine Delayed Release Capsule 400 mg
• Diflunisal Powder
• Diphenhydramine Hydrochloride Liquid 12.5 mg/ 5 mL
• Diphenhydramine Hydrochloride Liquid 6.25 mg/ mL
• Diphenhydramine-Acetaminophen Tablet 25-500 mg (Sleep)
• Ergocalciferol Capsule 62.5 mcg (2500 Unit)
• Esterified Estrogens Tab 2.5 mg
• Etanercept For Subcutaneous Injection 25 mg
• Fenoprofen Calcium Powder
• Fluocinonide Ointment 0.05%
• Flurazepam Hydrochloride Capsule 15 mg
• Flurazepam Hydrochloride Capsule 30 mg
• Fosinopril Sodium & Hydrochlorothiazide Tablet 10-12.5 mg
• Fosinopril Sodium & Hydrochlorothiazide Tablet 20-12.5 mg
• Gentamicin Sulfate Ophthalmic Ointment 0.3%
• Glyburide Powder
• Glycopyrrolate Injection 0.2 mg/ mL
• Glycopyrrolate Injection 0.4 mg/ 2 mL (0.2 mg/ mL)
• Glycopyrrolate Injection 1 mg/ 5 mL (0.2 mg/ mL)
• Glycopyrrolate Injection 4 mg/20 mL (0.2 mg/ mL)
• Guaifenesin-Codeine Liquid 200-10 mg/ 5 mL
• Histrelin Acetate Implant Kit 50 mg
• Hydrocortisone Acetate Suppository 30 mg
• Hydrocortisone Powder
• Indacaterol Maleate Inhalation Powder Capsule 75 mcg (Base Equivalent)
• Indinavir Sulfate Capsule 400 mg
• Insulin Syringe/Needle U-100 1/2 mL 30 X 3/8"
• Interferon Alfa-2b For Injection 10000000 Unit
• Interferon Alfa-2b For Injection 18000000 Unit
• Interferon Alfa-2b For Injection 50000000 Unit
• Irbesartan Tablet 150 mg
• Irbesartan Tablet 300 mg
• Irbesartan Tablet 75 mg
• Ketoprofen Capsule 50 mg
• Ketoprofen Capsule 75 mg
• Lamivudine Oral Solution 5 mg/ mL (Hepatitis B virus)
• Lamivudine-Tenofovir Disoproxil Fumarate Tablet 300-300 mg
• Lidocaine-Hydrocortisone Acetate Cream 3-0.5%
• Loperamide Hydrochloride Liquid 1 mg/ 5 mL (0.2 mg/ mL)
• Loratadine Syrup 5 mg/ 5 mL
• Magnesium Oxide Capsule 500 mg (Elemental mg)
• Magnesium Oxide Tablet 250 mg (mg Supplement)
• Magnesium Tablet 200 mg
• Magnesium Tablet 400 mg
• Maprotiline Hydrochloride Tablet 25 mg
• Maprotiline Hydrochloride Tablet 50 mg
• Maprotiline Hydrochloride Tablet 75 mg
• Meloxicam Suspension 7.5 mg/ 5 mL
• Methadone Hydrochloride Tablet For Oral Suspension 40 mg
• Methyldopa & Hydrochlorothiazide Tablet 250-15 mg
• Methyldopa & Hydrochlorothiazide Tablet 250-25 mg
• Miconazole Nitrate Vaginal Applicator 100 mg & 2% Cream 9 GM Kit
• Naltrexone For Intramuscular Extended Release Suspension 380 mg
• Niacin Powder
• Omeprazole (Bulk) Powder
• Oxybutynin Chloride (Bulk) Powder
• Oxycodone-Aspirin Tablet 4.8355-325 mg
• Peginterferon Alfa-2b For Injection Kit 50 mcg /0.5 mL
• Phenylephrine With Dm-Gg Liquid 10-15-300 mg/ 5 mL
• Plerixafor Subcutaneous Injection 24 mg/ 1.2 mL (20 mg/ mL)
• Potassium & Sodium Citrates With Citric Acid Syrup 550-500-334 mg/ 5 mL
• Prednicarbate Ointment 0.1%
• Propranolol & Hydrochlorothiazide Tablet 40-25 mg
• Propranolol & Hydrochlorothiazide Tablet 80-25 mg
• Pseudoephedrine-Brompheniramine-Codeine Liquid 10-1.33-6.33 mg/ 5 mL
• Psyllium Powder Packet 58.6%
• Rimantadine Hydrochloride Tablet 100 mg
• Ritonavir Oral Solution 80 mg/ mL
• Rosiglitazone Maleate Tablet 2 mg (Base Equivalent)
• Rosiglitazone Maleate Tablet 4 mg (Base Equivalent)
• Salicylic Acid Cream 6%
• Saquinavir Mesylate Tablet 500 mg
• Semaglutide Solution Pen-Injection 0.25 Or 0.5 mg/Dose (2 mg/ 1.5mL)
• Semaglutide Solution Pen-Injection 1 mg/ Dose (2 mg/1.5 mL)
• Silver Nitrate-Potassium Nitrate Applicator 75-25%
• Simethicone Liquid 40 mg/ 0.6 mL
• Sodium Chloride Solution Nebulizer 6%
• Sodium Fluoride Solution 0.125 mg/ Drop Fluoride (0.275 mg/Drop Sodium Fluoride)
• Sodium Fluoride Tablet 0.5 mg Fluoride (From 1.1 mg Sodium Fluoride)
• Sodium Fluoride Tablet 1 mg Fluoride (From 2.2 mg Sodium Fluoride)
• Sodium Fluoride-Potassium Nitrate Paste 1.1-5%
• Stannous Fluoride Concentrated 0.63%
• Sumatriptan Succinate Solution Prefilled Syringe 6 mg/0.5ml
• Syringe/Needle (Disposable) 12 mL 20 X 1"
• Syringe/Needle (Disposable) 12 mL 22 X 1"
• Syringe/Needle (Disposable) 6 mL 20 X 1"
• Syringe/Needle (Disposable) 6 mL 21 X 1-1/4"
• Syringe/Needle (Disposable) 6 mL 22 X 1"
• Syringe/Needle (Disposable) 6 mL 22 X 1-1/4"
• Telmisartan Tablet 20 mg
• Telmisartan Tablet 40 mg
• Telmisartan Tablet 80 mg
• Temsirolimus Solution For Intravenous Infusion 25 mg/ mL
• Tipranavir Oral Solution 100 mg/ mL
• Tolnaftate Aerosol Powder 1%
• Zidovudine Intravenous Solution 10 mg/ mL

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)
• 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:

• Kalydeco 13.4 mg (Prior Authorization)
• Mekinist Solution 0.05 mg/ mL (Prior Authorization)
• Tafinlar Tablet 10 mg (Prior Authorization)
• Trikafta Packet 59.5 mg (Prior Authorization)
• Trikafta Packet 75 mg (Prior Authorization)

Removals:

• None

Other Updates:

• None

June 2023
 

Additions:
 

• None

Removals:
 

• None

Other Updates:
 

• None

May 2023
 

Additions:
 

• 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 Pfs 120 mg / mL (Add Step Therapy, Quantity Level Limit)
• Fexofenadine Hydrochloride Suspension 30 mg / mL (Quantity Level Limit)
• Fluticasone-Salmeterol Inhalation Powder 250-50 mcg / Actuation (Add Quantity Level Limit)
• Fluticasone-Salmeterol Inhalation Powder 500-50 mcg / Actuation (Add Quantity Level Limit)
• Gilenya Capsule 0.25mg (Add Prior Authorization, Quantity Level Limit)
• Salicylic Acid Liquid 17%
• Trikafta Tablets (Add Prior Authorization)
• Urea Cream 20%

Removals:
 

• *Multiple Vitamins With Minerals Liquid**
• *Omega-3 Fatty Acids Capsule 435 mg**
• *Pediatric Multiple Vitamin With Minerals & Vitamin C Chewable Tablet**
• *Pediatric Multiple Vitamins With Iron Drops 10 mg/mL**
• *Prenatal Without A With/Ferrous Fumarate-Ferrous Polysaccharide-Folic Acid Capsule 130-92.4-1 mg**
• *Prenatal Without A With/Ferrous Fumarate-Ferrous Polysaccharide -Folic Acid Capsule 20-20-1.25 mg**
• Acetaminophen Elixir 160 mg/ 5 mL
• Amiloride Hydrochloride Powder
• Calcium Carbonate Powder
• Capsaicin Cream 0.1%
• Carboxymethylcellulose Sodium Ophthalmic Solution 0.25%
• Chlorhexidine Gluconate Solution 20%
• Cholecalciferol Capsule 400 Unit
• Cholecalciferol Chewable Wafer 50000 Unit
• Creon Capsule
• Diphenhydramine Hydrochloride (Sleep) Tablet 50 mg
• Elmiron Capsules
• Ergocalciferol Tablet 400 Unit
• Fluocinolone Acetonide Cream 0.01%
• Fluocinonide Emulsified Base Cream 0.05%
• Fluticasone Propionate Lotion 0.05%
• Gentamicin Sulfate Powder
• Heparin Sodium Injection 20,000 Units/ mL
• Heparin Sodium Injection 5,000 Units/ 0.5 mL
• Lidocaine Cream 4%
• Lidocaine Hydrochloride Solution 4%
• Mexiletine Hydrochloride Capsule 150 mg
• Mexiletine Hydrochloride Capsule 200 mg
• Mexiletine Hydrochloride Capsule 250 mg
• Niacin Tablet 50 mg
• Niacin Tablet 250 mg
• Niacin Tablet Controlled Release 250 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
• Scalpicin Solution 1%
• Sorbitol Rectal Solution 70%
• Stiolto Inhalation Spray 2.5-2.5 mcg / Actuation
• Triamcinolone Acetonide Ointment 0.05%

Other Updates:
 

• Albendazole Tablet 200 mg (Add Prior Authorization, Remove Step Therapy)
• Betamethasone Dipropionate Ointment 0.05% (Add Quantity Level Limit)
• Enoxaparin Sodium Injection 100 mg / mL (Remove Quantity Level Limit)
• Enoxaparin Sodium Injection 120 mg / 0.8 mL (Remove Quantity Level Limit)
• Enoxaparin Sodium Injection 150 mg / mL (Remove Quantity Level Limit)
• Enoxaparin Sodium Injection 30 mg / 0.3 mL (Remove Quantity Level Limit)
• Enoxaparin Sodium Injection 40 mg / 0.4 mL (Remove Quantity Level Limit)
• Enoxaparin Sodium Injection 60 mg / 0.6 mL (Remove Quantity Level Limit)
• Enoxaparin Sodium Injection 80 mg / 0.8 mL (Remove Quantity Level Limit)
• Enoxaparin Sodium Injection Solution 60 mg / 0.6 mL (Remove Quantity Level Limit)
• Enoxaparin Sodium Injection Solution 80 mg / 0.8 mL (Remove Quantity Level Limit)
• 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 Ointment 5% (Remove Prior Authorization)
• Ozempic Pen-Injector
• Trulicity Pen-Injector

April 2023
 

Additions:
 

• None

Removals:
 

• None
  
  

Other Updates:
 

• 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)

March 2023
 

Additions:
 

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

Removals:
 

• Doxycycline Capsule 150 mg
• Fluocinolone Acetonide Powder
• Hydrocortisone Acetate Powder
• Hydrocortisone-Pramoxine-Chloroxylenol Lotion 10-10-1 mg/mL
• Itraconazole Oral Solution 10 mg/mL
• Metaproterenol Sulfate Powder
• Triamcinolone Acetonide Powder
  
  

Other Updates:
 

• Tobramycin Nebulizer Solution 300 mg/5 mL (Prior Authorization Required)

February 2023
 

Additions:
 

• Atomoxetine Capsule 100 mg (Quantity Level Limit, Age Minimum)
• Atomoxetine Capsule 10 mg (Quantity Level Limit, Age Minimum)
• Atomoxetine Capsule 18 mg (Quantity Level Limit, Age Minimum)
• Atomoxetine Capsule 25 mg (Quantity Level Limit, Age Minimum)
• Atomoxetine Capsule 40 mg (Quantity Level Limit, Age Minimum)
• Atomoxetine Capsule 60 mg (Quantity Level Limit, Age Minimum)
• Atomoxetine Capsule 80 mg (Quantity Level Limit, Age Minimum)
• Budesonide Tablet Extended-Release 9 mg
• Buspirone Tablet 30 mg (Quantity Level Limit, Age Minimum)
• Calcium Polycarbophil Tablet 625 mg
• Carboxymethylcellulose-Glycerin-Polysorbate 80 Ophthalmic Solution 0.5-1-0.5%
• 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%
• 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)
• Desvenlafaxine (P) Tablet 100 mg Extended Release (Quantity Level Limit)
• Desvenlafaxine (P) Tablet 25 mg Extended Release (Quantity Level Limit)
• Desvenlafaxine (P) Tablet 50 mg Extended Release (Quantity Level Limit)
• Dificid Suspension (Prior Authorization Required)
• Dificid Tablet 200 mg (Prior Authorization Required)
• Esomeprazole Magnesium Capsule 40 mg Delayed Release (Quantity Level Limit)
• Estradiol Vaginal Cream 0.1 mg/gm (Quantity Level Limit)
• Ethacrynic Tablet Acid 25 mg
• Fexofenadine Hydrochloride Tablet 180 mg (Quantity Level Limit)
• Fexofenadine Hydrochloride Tablet 60 mg (Quantity Level Limit)
• Fluocinolone Acetonide Oil Ear 0.01% (Quantity Level Limit)
• Glucose Gel 40%
• Glucose Gel 77.4%
• Glycerin Suppository 1 gm
• Glycerin-Hypromellose- Polyethylene Glycol 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)
• Invega Hafyera Injection 1092 mg (Prior Authorization Required, Quantity Level Limit)
• Invega Hafyera Injection 1560 mg (Prior Authorization Required, Quantity Level Limit)
• Lactobacillus Acidophilus-Pectin Capsule
• Lactobacillus Capsule
• Lactobacillus Tablet
• Levonorgestrel-Ethinyl Estradiol (91-Day) Tablet 0.01/0.15/0.03 mg
• Lidocaine 5% Rectal Cream (Quantity Level Limit)
• Magnesium Citrate Solution
• Miconazole Nitrate Vaginal Suppository 1200 mg & 2% Cream Kit
• Naphazoline with Pheniramine Ophthalmic Solution 0.025-0.3%
• Naphazoline with Pheniramine Ophthalmic Solution 0.027-0.315%
• Norethindrone Acetate & Estradiol-Ferrous 24 Tablet 1/0.02 mg (Quantity Level Limit)
• Phenylephrine Hydrochloride Tablet 10 mg
• Phenylephrine-Dextromethorphan-Guaifenesin Liquid 10-18-200 mg/15 mL (Quantity Level Limit)
• Phenylephrine-Dextromethorphan-Guaifenesin Liquid 2.5-5-100 mg/5 mL (Quantity Level Limit)
• Phenylephrine-Brompheniramine- Dextromethorphan 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
• Pseudoephedrine- Brompheniramine- Dextromethorphan Syrup 30-2-10 mg/5 mL (Quantity Level Limit)
• Pseudoephedrine- Dexchlorpheniramine -Chlophedianol Liquid 30-1-12.5 mg/5mL (Quantity Level Limit)
• Pseudoephedrine Hydrochloride Tablet Extended Release 12-hour 120 mg
• Quetiapine Tablet 150 mg Extended-Release (Quantity Level Limit, Age Minimum)
• Quetiapine Tablet 200 mg Extended-Release (Quantity Level Limit, Age Minimum)
• Quetiapine Tablet 300 mg Extended-Release (Quantity Level Limit, Age Minimum)
• Quetiapine Tablet 400 mg Extended-Release (Quantity Level Limit, Age Minimum)
• Quetiapine Tablet 50 mg Extended-Release (Quantity Level Limit, Age Minimum)
• Rivastigmine Disc 13.3 mg/24 hour (Prior Authorization Required)
• Rivastigmine Disc 4.6 mg/24 hour (Prior Authorization Required)
• Rivastigmine Disc 9.5 mg/24 hour (Prior Authorization Required)
• Saline Nasal Gel
• Saline Nasal Solution 0.65%
• Tetrahydrozoline Hydrochloride Ophthalmic Solution 0.05%
• Tramadol Hydrochloride Tablet Extended Release 24-hour 100 mg (Prior Authorization Required, Quantity Level Limit, Age Minimum)
• Tramadol Hydrochloride Tablet Extended Release 24-hour 200 mg (Prior Authorization Required, Quantity Level Limit, Age Minimum)
• Tramadol Hydrochloride Tablet Extended Release 24-hour 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 Solution 70 mg/75 mL
• Auryxia 210 mg Tablet
• Benzocaine-Docusate Sodium Rectal Enema 20-283 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-Caffeine with Codeine Capsule 50-300-40-30 mg
• Butalbital-Acetaminophen-Caffeine with Codeine Capsule 50-325-40-30 mg
• Butalbital-Aspirin-Caffeine with Codeine Capsule 50-325-40-30 mg
• Butalbital-Aspirin-Caffeine Capsule 50-325-40 mg
• Celontin Capsule 300 mg
• Cequa
• Coal Tar Shampoo 1%
• Coal Tar Shampoo 10%
• Colchicine Capsule 0.6 mg
• Dermatological Products Miscellaneous - Cream
• Dermatological Products Miscellaneous - Lotion
• Dermazinc Cream
• Desmopressin Spray Ref 0.01%
• Diltiazem Extended-Release Capsule 120 mg/12 hour
• Diphenoxylate with Atropine Liquid 2.5-0.025 mg/5 mL
• Duloxetine Capsule 40 mg Delayed Release
• Esbriet 267 mg Capsule
• Estring
• Ibrance Tablet 100 mg
• Ibrance Tablet 125 mg
• Ibrance Tablet 75 mg
• Leukine Injection 250 mcg
• Levofloxacin Ophthalmic Solution 0.5%
• Lidocaine Solution 4%
• Magnesium Hydroxide Suspension Concentrate 2400 mg/10 mL
• Methylphenidate Capsule 20 mg Long Acting
• Methylphenidate Capsule 30 mg Long Acting
• Methylphenidate Capsule 40 mg Long Acting
• Methylphenidate Capsule 60 mg Long Acting
• Naproxen Tablet Enteric Coated 500 mg
• Neomycin-Bacitracin-Polymyxin with Lidocaine Ointment 4%
• Orencia Intravenous Injection 250 mg
• Oxymorphone Hydrochloride Tablet Extended Release 12-hour 10 mg
• Oxymorphone Hydrochloride Tablet Extended Release 12-hour 15 mg
• Oxymorphone Hydrochloride Tablet Extended Release 12-hour 20 mg
• Oxymorphone Hydrochloride Tablet Extended Release 12-hour 30 mg
• Oxymorphone Hydrochloride Tablet Extended Release 12-hour 40 mg
• Oxymorphone Hydrochloride Tablet Extended Release 12-hour 5 mg
• Oxymorphone Hydrochloride Tablet Extended Release 12-hour 7.5 mg
• Potassium-Sodium Citrates & Citric Acid Solution 550-500-334 mg/5 mL
• Remicade Injection 100 mg
• Sulfacetamide Sodium Ophthalmic Ointment 10%
  
  

Other Updates:
 

• Azelastine Hydrochloride Ophthalmic Solution 0.05% (Remove Step Therapy)
• Bacitracin Ophthalmic Ointment 500 unit/gm (Quantity Level Limit)
• Bacitracin-Polymyxin B Ophthalmic Ointment (Quantity Level Limit)
• Bacitracin-Polymyxin-Neomycin-Hydrocortisone Ophthalmic Ointment 1% (Quantity Level Limit)
• Benzonatate Capsule 100 mg
• Benzonatate Capsule 200 mg
• Budesonide Capsule 3 mg Delayed Release (Remove Step Therapy)
• Calcipotriene Cream 0.005%
• Calcipotriene Ointment 0.005%
• Calcipotriene Solution 0.005% (50 mcg/mL)
• Carboxymethylcellulose Sodium Ophthalmic Gel 1%
• Celecoxib Capsule 50 mg (Remove Step Therapy)
• Celecoxib Capsule 100 mg (Remove Step Therapy)
• Celecoxib Capsule 200 mg (Remove Step Therapy)
• Celecoxib Capsule 400 mg (Remove Step Therapy)
• Divalproex Tablet 250 mg Extended Release (Remove Prior Authorization)
• Divalproex Tablet 500 mg Extended Release (Remove Prior Authorization)
• Dorzolamide Hydrochloride-Timolol Maleate Ophthalmic Solution 22.3-6.8 mg/mL (Remove Step Therapy)
• Duloxetine Capsule 20 mg Delayed Release (Quantity Level Limit)
• Erythromycin Ophthalmic Ointment 5 mg/gm (Quantity Level Limit)
• Fentanyl Oral Transmucosal Lozenge 1200 mcg (Added Prior Authorization)
• Fentanyl Oral Transmucosal Lozenge 1600 mcg (Added Prior Authorization)
• Fentanyl Oral Transmucosal Lozenge 200 mcg (Added Prior Authorization)
• Fentanyl Oral Transmucosal Lozenge 400 mcg (Added Prior Authorization)
• Fentanyl Oral Transmucosal Lozenge 600 mcg (Added Prior Authorization)
• Fentanyl Oral Transmucosal Lozenge 800 mcg (Added Prior Authorization)
• Gentamicin Sulfate Ophthalmic Ointment 0.3% (Quantity Level Limit)
• Levonorgestrel Tablet 1.5 mg (Quantity Level Limit)
• Tolterodine Tartrate Capsule Extended Release 24-hour 2 mg (Remove Step Therapy and Prior Authorization)
• Tolterodine Tartrate Capsule Extended Release 24-hour 4 mg (Remove Step Therapy and Prior Authorization)
• Tolterodine Tartrate Tablet 1 mg (Remove Step Therapy)
• Tolterodine Tartrate Tablet 2 mg (Remove Step Therapy)
• Trospium Chloride Tablet 20 mg (Remove Step Therapy)

January 2023

Additions:
 

• None
  
  

Removals:
 

• All Non OneTouch Delica and Delica Plus Lancets and Devices
  
  

Other Updates:
 

• None

December 2022
 

Additions:
 

• Benzoyl Peroxide Gel 2.5%
  
  

Removals:
 

• Iodoquinol-Hydrocortisone Cream 1-1%
  
  

Other Updates:
 

• Fingolimod Hydrochloride Capsule 0.5 mg (Base Equivalent)
• Histex PD Drop 0.938 mg
• Isotretinoin Capsule 10 mg
• Isotretinoin Capsule 20 mg
• Isotretinoin Capsule 30 mg
• Isotretinoin Capsule 40 mg
  
  

November 2022
 

Additions:
 

• Actimmune Injection 2 mu/0.5 (Prior Authorization Required)
• Cromolyn Sodium Nasal Aerosol Solution 5.2 mg/Actuation (4%) (Added Quantity Level Limit)
• Dextromethorphan Polistirex Extended-Release Suspension 30 mg/5 mL (Added Quantity Level Limit)
• Dextromethorphan-Phenylephrine-Acetaminophen Capsule 10-5-325 mg (Added Quantity Level Limit)
• Dimenhydrinate Tablet 50 mg (Added Quantity Level Limit)
• Fexofenadine-Pseudoephedrine Tablet Extended Release 12-hour 60-120 mg (Added Quantity Level Limit)
• Guaifenesin Tablet 200 mg
• Guaifenesin Tablet 400 mg
• Guaifenesin Tablet Extended Release 12-hour 1200 mg
• Icosapent Capsule 0.5 gm (Prior Authorization Required, Quantity Level Limit)
• Imbruvica Suspension 70 mg/mL (Prior Authorization Required, Quantity Level Limit)
• Intron A Injection 10 mu (Prior Authorization Required)
• Intron A Injection 18 mu (Prior Authorization Required)
• Intron A Injection 50 mu (Prior Authorization Required)
• Mineral Oil Heavy
• Mineral Oil Light
• Omeprazole Capsule Delayed Release 10 mg (Added Quantity Level Limit)
• Orkambi Granules 75-94 mg (Prior Authorization Required)
• Polyethylene Glycol-Propylene Glycol Preservative Free Ophthalmic Solution 0.4-0.3%
• Polyvinyl Alcohol-Povidone Ophthalmic Solution 5-6 mg/mL (0.5-0.6%)
• Pseudoephedrine Hydrochloride Tablet 30 mg
• Pseudoephedrine-Guaifenesin Tablet Extended Release 12hr 60-600 mg
• Refresh Ophthalmic Drops
• Sodium Chloride Hypertonic Ophthalmic Ointment 5%
• Sodium Fluoride Gel 1.1% (0.5% Fluoride)
• White Petrolatum-Mineral Oil Ophthalmic Ointment

Removals:
 

• Butalbital-Acetaminophen-Caffeine Capsule 50-300-40 mg
• Butalbital-Acetaminophen-Caffeine Capsule 50-325-40 mg
• Calcium Carbonate (Antacid) Chewable Tablet 420 mg
• Dexamethasone Sodium Phosphate Preservative Free Injection 10 mg/mL
• Dextromethorphan Hydrobromide Syrup 10 mg/5 mL
• Divalproex Sodium Capsule Delayed Release Sprinkle 125 mg
• Docusate Sodium Capsule 50 mg
• Etodolac Tablet Extended Release 24-hour 400 mg
• Etodolac Tablet Extended Release 24-hour 500 mg
• Etodolac Tablet Extended Release 24-hour 600 mg
• Fluphenazine Hydrochloride Oral Concentrate 5 mg/mL
• Hepagam B Injection
• Hycamtin Capsule 0.25 mg
• Hycamtin Capsule 1 mg
• Hyperhep B Injection
• Ibuprofen-Diphenhydramine Citrate Tablet 200-38 mg
• Iressa Tablet 250 mg
• Lansoprazole Tablet Delayed Release Orally Disintegrating 15 mg
• Lansoprazole Tablet Delayed Release Orally Disintegrating 30 mg
• Levonorgestrel-Ethinyl Estradiol Tablet 0.1-0.02 mg (84) & Ethinyl Estradiol Tablet 0.01 mg (7)
• Magnesium Oxide (Laxative) Tablet 500 mg
• Magnesium Oxide Tablet 250 mg
• Magnesium Oxide Tablet 420 mg
• Menest Tablet 0.3 mg
• Menest Tablet 0.625 mg
• Menest Tablet 1.25 mg
• Metamucil Powder Multihealth/Original
• Mycophenolic Tablet 180mg Delayed Release
• Mycophenolic Tablet 360mg Delayed Release
• Nabi-Hb Injection
• Nicotrol Inhaler 10 mg
• Nicotrol Nasal Spray 4 x 10 mL
• Nilutamide Tablet 150 mg
• Nozin Nasal Kit Sanitize
• Nozin Nasal Mis Sanitize
• Olanzapine-Fluoxetine Hydrochloride Capsule 12-25 mg
• Olanzapine-Fluoxetine Hydrochloride Capsule 12-50 mg
• Olanzapine-Fluoxetine Hydrochloride Capsule 3-25 mg
• Olanzapine-Fluoxetine Hydrochloride Capsule 6-25 mg
• Olanzapine-Fluoxetine Hydrochloride Capsule 6-50 mg
• Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 10 mg
• Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 15 mg
• Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 20 mg
• Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 30 mg
• Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 40 mg
• Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 60 mg
• Oxycodone Hydrochloride Tablet Extended Release 12-hour Deterrent 80 mg
• Paroxetine Hydrochloride Oral Suspension 10 mg/5 mL (Base Equivalent)
• Phenylephrine-Shark Liver Oil-Cocoa Butter Suppository 0.25-3-85.5%
• Prednisolone Sodium Phosphate Orally Disintegrating Tablet 10 mg (Base Equivalent)
• Prednisolone Sodium Phosphate Orally Disintegrating Tablet 15 mg (Base Equivalent)
• Prednisolone Sodium Phosphate Orally Disintegrating Tablet 30 mg (Base Equivalent)
• Prefest Tablet
• Prilosec Powder 10 mg
• Prilosec Powder 2.5 mg
• Psyllium Powder 100%
• Psyllium Powder 95%
• Rufinamide Suspension 40 mg/mL
• Sennosides Tablet 17.2 mg
• Sodium Phosphates - Enema (Pediatric)
• Somatuline Injection 120 mg/0.5 mL
• Somatuline Injection 60 mg/0.2 mL
• Somatuline Injection 90 mg/0.3 mL
• Sucralfate Suspension 1 gm/10 mL
• Zoladex Implant 10.8 mg
• Zoladex Implant 3.6 mg
• Zolinza Capsule 100 mg
  
  

Other Updates:
 

• Aprepitant Capsule 125 mg (Added Quantity Level Limit)
• Aprepitant Capsule 40 mg (Added Quantity Level Limit)
• Artificial Tears Solution
• Aspirin Suppository 300 mg
• Atropine Sulfate Ophthalmic Ointment 1%
• Codeine Sulfate Tablet 15 mg (Added Quantity Level Limit and Age Minimum)
• Codeine Sulfate Tablet 60 mg (Added Quantity Level Limit and Age Minimum)
• Dextromethorphan-Guaifenesin Tablet Extended Release 12-hour 60-1200 mg
• Feverall Sup 325 mg
• Hydromorphone Suppository 3 mg (Added Quantity Level Limit)
• Lohist-Dextromethorphan Syrup 5-2-10 mg
• Lubricant Drops Eye 0.6%
• Lubricating Drops 0.5%
• Tusnel C Syrup (Added Quantity Level Limit and Age Minimum)

October 2022
 

Additions:
 

• None
  
  

Removals:
 

• None
  
  

Other Updates:
 

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

September 2022

Additions:
 

• Phospho-Trin K500 Tablet
  
  

Removals:
 

• Hypersal Nebulization Solution 3.5 % 
  
  

Other Updates:
 

• K-Phos Tablet 500 mg (Brand)

August 2022
 

Additions:
 

• Bicillin L-A Suspension 2400000 Unit/4mL
• Calamine Lotion (Quantity Level Limit)
• Calamine-Zinc Oxide Lotion 8-8%
• Doxycycline Monohydrate Tablet 100mg
• Eplerenone Tablet 25 mg
• Eplerenone Tablet 50 mg
• Fenofibrate Tablet 145 mg
• Fenofibrate Tablet 48 mg
• Fluocinonide Cream 0.1%
• Glucagon Emergency Solution Kit 1 mg/mL (Quantity Level Limit)
• Hydrocortisone Acetate Ointment 1% (Quantity Level Limit)
• Ivermectin Lotion 0.5% (Quantity Level Limit, Step Therapy)
• Metronidazole Gel 1% (Quantity Level Limit, Step Therapy)
• Olmesartan Medoxomil Tablet 20 mg (Quantity Level Limit)
• Olmesartan Medoxomil Tablet 40 mg (Quantity Level Limit)
• Olmesartan Medoxomil Tablet 5 mg (Quantity Level Limit)
• Olopatadine Hydrochloride Ophthalmic Solution 0.2% (Over the Counter)
• OneTouch Ultra 2 Kit with Device
• OneTouch Verio Flex System Kit with Device
• OneTouch Verio Reflect Kit with Device
• Pataday Solution 0.7% Ophthalmic
• Permethrin Liquid 1%
• Selenium Sulfide Shampoo 1%
• Symjepi Solution Prefilled Syringe 0.15 mg/0.3 mL (Quantity Level Limit)
• Symjepi Solution Prefilled Syringe 0.3 mg/0.3 mL (Quantity Level Limit)
• Tetrabenazine Tablet 12.5 mg (Prior Authorization Required, Quantity Level Limit)
• Triamcinolone Acetonide Ointment 0.05% (Quantity Level Limit)
• Triprolidine Hydrochloride Drops 0.938 mg/mL
• Triprolidine Hydrochloride Liquid 0.625 mg/mL (Pediaclear PD Liquid)
• Voriconazole Tablet 200 mg (Prior Authorization Required)
• Voriconazole Tablet 50 mg (Prior Authorization Required)
  
  

Removals:
 

• Adapalene Cream 0.1%
• Amcinonide Ointment 0.1%
• Amiodarone Hydrochloride Tablet 100 mg
• Amiodarone Hydrochloride Tablet 400 mg
• Amlodipine Besylate-Atorvastatin Calcium Tablet 10-10 mg
• Amlodipine Besylate-Atorvastatin Calcium Tablet 10-20 mg
• Amlodipine Besylate-Atorvastatin Calcium Tablet 10-40 mg
• Amlodipine Besylate-Atorvastatin Calcium Tablet 10-80 mg
• Amlodipine Besylate-Atorvastatin Calcium Tablet 2.5-10 mg
• Amlodipine Besylate-Atorvastatin Calcium Tablet 2.5-20 mg
• Amlodipine Besylate-Atorvastatin Calcium Tablet 2.5-40 mg
• Amlodipine Besylate-Atorvastatin Calcium Tablet 5-10 mg
• Amlodipine Besylate-Atorvastatin Calcium Tablet 5-20 mg
• Amlodipine Besylate-Atorvastatin Calcium Tablet 5-40 mg
• Amlodipine Besylate-Atorvastatin Calcium Tablet 5-80 mg
• Amoxicillin & Potassium Clavulanate Tablet Extended Release 12-hour 1000-62.5 mg
• Baraclude Solution 0.05 mg/mL
• Benzoyl Peroxide Wash Liquid 2.5%
• Capzasin-P Cream 0.035%
• Carbinoxamine Maleate Solution 4 mg/5 mL
• Carbinoxamine Maleate Tablet 4 mg
• Cefaclor Capsule 250 mg
• Cefaclor Capsule 500 mg
• Cefpodoxime Proxetil For Suspension 100 mg/5 mL
• Cefpodoxime Proxetil For Suspension 50 mg/5 mL
• Clemastine Fumarate Tablet 12-Hour 1.34 mg
• Colesevelam Hydrochloride Packet 3.75 gm 
• Diltiazem Hydrochloride Extended-Release Capsule Extended Release 12-Hour 60 mg
• Diltiazem Hydrochloride Extended-Release Capsule Extended Release 12-Hour 90 mg
• Diphenhydramine Dispersible Tablet 12.5 mg
• Diphenhydramine Hydrochloride Tablet Chewable 12.5 mg
• Doxycycline Monohydrate Capsule 150 mg
• Erythromycin Ethylsuccinate for Suspension 200 mg/5 mL
• Erythromycin Ethylsuccinate for Suspension 400 mg/5 mL
• Fexofenadine Hydrochloride Childrens Suspension 30mg/5 mL
• Flunisolide Nasal Spray 25 mcg/Actuation (0.025%)
• Fluvastatin Sodium Tablet Extended Release 24-hour 80 mg (Base Equivalent)
• Glucagen Hypokit Solution Reconstituted 1 mg
• Isradipine Capsule 2.5 mg
• Isradipine Capsule 5 mg
• Lidocaine Hydrochloride Urethral/Mucosal Gel 2%
• Lidocaine-Prilocaine Kit 2.5-2.5%
• Memantine Hydrochloride Oral Solution 2 mg/mL
• Memantine Hydrochloride Tablet 28 X 5 mg & 21 X 10 mg Titration Pack
• Methazolamide Tablet 25 mg
• Methazolamide Tablet 50 mg
• Metronidazole Capsule 375 mg
• Nicardipine Capsule 20 mg
• Nicardipine Capsule 30 mg
• Nitazoxanide Tablet 500 mg
• OneTouch Kit Ultra Mini
• OneTouch Solutions Starter Kit with Well Device
• Perindopril Erbumine Tablet 2 mg
• Perindopril Erbumine Tablet 4 mg
• Perindopril Erbumine Tablet 8 mg
• Propafenone Capsule Extended Release 12-Hour 325 mg
• Propafenone Capsule Extended Release 12-Hour 425 mg
• Propafenone Hydrochloride Extended-Release Capsule Extended Release 12-Hour 225 mg
• Proxivol Gel 2%
• Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4%
• Rivastigmine Patch 24 Hour 13.3 mg/24 hour
• Rivastigmine Patch 24 Hour 4.6 mg/24 hour
• Rivastigmine Patch 24 Hour 9.5 mg/24 hour
• Salicylic Acid Shampoo 6%
• Santyl Ointment 250 unit/gm
• Selenium Sulfide Shampoo 2.25%
• Sulfacetamide Sodium Liquid Wash 10%
• Vancomycin + Syrspen Sf Hydrochloride Oral Suspension 50 mg/mL (Compound Kit)
• Vancomycin Hydrochloride for Intravenous Solution 1 gm (Base Equivalent)
• Vancomycin Hydrochloride for Intravenous Solution 10 gm (Base Equivalent)
• Vancomycin Hydrochloride for Intravenous Solution 5 gm (Base Equivalent)
• Vancomycin Hydrochloride for Intravenous Solution 500 mg (Base Equivalent)
• Vancomycin Hydrochloride Intravenous Solution 1250 mg/250 mL (Base Equivalent)
• Vancomycin Hydrochloride Intravenous Solution 1750 mg/350 mL (Base Equivalent)
• Vancomycin Hydrochloride Intravenous Solution 750 mg/150 mL (Base Equivalent)
• Vemlidy Tablet 25 mg
• Zafirlukast Tablet 10 mg
• Zafirlukast Tablet 20 mg
  
  

Other Updates:
 

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

July 2022
 

Additions:
 

• None
  
  

Removals:
 

• None
  
  

Other Updates:
 

• None

June 2022
 

Additions:
 

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

Removals:
 

• None
  
  

Other Updates:
 

• None

May 2022
 

Additions:
 

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

Removals:
 

• None
  
  

Other Updates:
 

• None

April 2022
 

Additions:
 

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

Removals:
 

• None
  
  

Other Updates:
 

• None

March 2022
 

Additions:
 

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

Removals:
 

• Combigan Ophthalmic Solution 0.2-0.5%
• Dry Eye Relief Drops 0.4-0.3%
• Selzentry Tablet 150 mg
• Selzentry Tablet 300 mg
  
  

Other Updates:
 

• None

February 2022
 

Additions:
 

• Dexcom G5 Mobile Receiver Kit (Prior Authorization Required, Quantity Level Limit)
• Dexcom G5 Mobile Transmitter Kit (Prior Authorization Required, Quantity Level Limit)
• Dexcom G5 Mobile/G4 Platinum Sensor Kit (Prior Authorization Required, Quantity Level Limit)
• Dexcom G6 Receiver (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 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)
• Freestyle Libre Reader Device (Prior Authorization Required, Quantity Level Limit)
• Freestyle Libre Sensor System (Prior Authorization Required, Quantity Level Limit)
• Levocetirizine Tablet 5 mg (Quantity Level Limit)
• Naloxone Nasal Liquid 4 mg/0.1 mL (generic)
• Norditropin Flexpro Injection 10 mg/1.5 mL (Prior Authorization Required)
• Norditropin Flexpro Injection 15 mg/1.5 mL (Prior Authorization Required)
• Norditropin Flexpro Injection 30 mg/3 mL (Prior Authorization Required)
• Norditropin Flexpro Injection 5 mg/1.5 mL (Prior Authorization Required)
• Ziextenzo (Prior Authorization Required)
  
  

Removals:
 

• Diphenhydramine Elixir 12.5 mg/5 mL
• Estradiol Vaginal Cream 0.1 mg/gm
• Felbamate Suspension 600 mg/5 mL
• Felbamate Tablet 400 mg
• Felbamate Tablet 600 mg
• Megestrol Suspension 625 mg/5 mL
• Omnitrope Injection 5.8 mg
• Udenyca Injection 6 mg/0.6 mL
  
  

Other Updates:
 

• Diphenhydramine Hydrochloride Liquid 12.5 mg/5 mL (Added Quantity Level Limit)
• Eliquis Deep Vein Thrombosis/Pulmonary Embolism Starter Pack Tablet 5 mg (Removed Prior Authorization Required)
• Eliquis Tablet 2.5 mg (Removed Prior Authorization Required)
• Eliquis Tablet 5 mg (Removed Prior Authorization Required)
• Promethazine Hydrochloride Syrup 6.25 mg/5 mL (Added Quantity Level Limit)
• Xarelto 10 mg (Removed Prior Authorization Required)
• Xarelto 15 mg (Removed Prior Authorization Required)
• Xarelto 20 mg (Removed Prior Authorization Required)
• Xarelto Starter Pack 15/20 mg (Removed Prior Authorization Required)

January 2022
 

Additions:
 

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

Removals:
 

• Intelence Tablet 100 mg
• Intelence Tablet 200 mg
  
  

Other Updates:
 

• None

December 2021
 

Additions:
 

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

Removals:
 

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

Other Updates:
 

• None

November 2021
 

Additions:
 

• None
  
  

Removals:
 

• None
  
  

Other Updates:
 

• None

October 2021
 

Additions:
 

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

Removals:
 

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

Other Updates:
 

• None

September 2021
 

Additions:
 

• None
  
  

Removals:
 

• None
  
  

Other Updates:
 

• None

August 2021
 

Additions:
 

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

Removals:
 

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

Other Updates:
 

• None

July 2021
 

Additions:
 

• None
  
  

Removals:
 

• None
  
  

Other Updates:
 

• None

June 2021
 

Additions:
 

• None
  
  

Removals:
 

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

Other Updates:
 

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

May 2021
 

Additions:
 

• None
  
  

Removals:
 

• None
  
  

Other Updates:
 

• None

April 2021
 

Additions:
 

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

March 2021
 

Additions:
 

• Bevespi Aerosphere 9-4.8 mcg (Quantity Level Limit)
• Cequa Solution 0.09% Preservative Free (Prior Authorization Required)
• Doxycycline Hyclate Capsule 100 mg
• Doxycycline Hyclate Capsule 50 mg
• Doxycycline Hyclate Tablet 100 mg
• Esbriet Capsule 267 mg (Prior Authorization Required)
• Esbriet Tablet 267 mg (Prior Authorization Required)
• Esbriet Tablet 801 mg (Prior Authorization Required)
• Fluticasone/Salmeterol Aerosol 100 mcg/50 mcg (Age Level Limit, Quantity Level Limit)
• Hizentra Injection 1 gm/5 mL (Prior Authorization Required)
• Hizentra Injection 2 gm/10 mL (Prior Authorization Required)
• Hizentra Injection 2 gm/10 mL (Prior Authorization Required)
• Hizentra Injection 4 gm/20 mL (Prior Authorization Required)
• Hizentra Solution 20% (Prior Authorization Required)
• Hizentra Vial 10 gm/50 mL (Prior Authorization Required)
• Hizentra Vial 1 gm/5 mL (Prior Authorization Required)
• Icosapent Capsule 1 gm (Prior Authorization Required, Quantity Level Limit)
• Myleran Tablet 2 mg
• Ocrevus Injection 300 mg/10 mL (Prior Authorization Required, Quantity Level Limit)
• Potassium-Sodium Citrates & Citric Acid Solution 550-500-334 mg/5 mL
• Privigen Injection 40 gm (Prior Authorization Required)
• Rabeprazole Tablet 20 mg (Quantity Level Limit)
• Sodium Citrate & Citric Acid Solution 500-334 mg/5 mL
• Trulicity Injection 0.75 mg/0.5 mL (Step Therapy Required)
• Trulicity Injection 1.5 mg/0.5 mL (Step Therapy Required)
• Trulicity Injection 3 mg/0.5 mL (Step Therapy Required)
• Trulicity Injection 4.5 mg/0.5 mL (Step Therapy Required)
• Tukysa Tablet 150 mg (Prior Authorization Required)
• Tukysa Tablet 50 mg (Prior Authorization Required)
• Valtoco Liquid 15 mg (Quantity Level Limit)
• Valtoco Liquid 20 mg (Quantity Level Limit)
• Valtoco Spray 10 mg (Quantity Level Limit)
• Valtoco Spray 5 mg (Quantity Level Limit)
• Visco-3 Injection 25/2.5 mL (Prior Authorization Required)
  
  

Removals:
 

• Anoro Ellipta Aerosolizer 62.5-25 mcg
• Atrovent HFA Aerosol 17 mcg
• Breo Ellipta Inhaler 100-25 mcg
• Breo Ellipta Inhaler 200-25 mcg
• Cefaclor for Suspension 125 mg/5 mL
• Cefaclor for Suspension 250 mg/5 mL
• Cefaclor for Suspension 375 mg/5 mL
• Clarithromycin Tablet Extended Release 24-hour 500 mg
• Combivent Aerosol 20 mcg-100 mcg
• Diazepam Concentrate 5 mg/mL
• Doxycycline Monohydrate Tablet 100 mg
• Doxycycline Monohydrate Tablet 150 mg
• Doxycycline Monohydrate Tablet 50 mg
• Doxycycline Monohydrate Tablet 75 mg
• Epogen Injection 10000 units/mL
• Epogen Injection 2000 units/mL
• Epogen Injection 20000 units/mL
• Epogen Injection 3000 units/mL
• Epogen Injection 4000 units/mL
• Flebogamma Injection 10 gm/200 mL
• Flebogamma Injection Dif 5%
• Fulphila Injection 6 mg/0.6 mL
• Hyalgan Injection 20 mg/2 mL
• Hyoscyamine Drops 0.125 mg/mL
• Janumet Tablet 50-1000 mg
• Janumet Tablet 50-500 mg
• Janumet Extended-Release Tablet 100-1000 mg
• Janumet Extended-Release Tablet 50-1000 mg
• Janumet Extended-Release Tablet 50-500 mg
• Januvia Tablet 100 mg
• Januvia Tablet 25 mg
• Januvia Tablet 50 mg
• Nivestym Injection 300 mcg/0.5 ml
• Nivestym Injection 300 mcg
• Nivestym Injection 480 mcg/0.8 ml
• Nivestym Injection 480 mcg
• Ofev Capsule 100 mg
• Ofev Capsule 150 mg
• Verzenio Tablet 100 mg
• Verzenio Tablet 150 mg
• Verzenio Tablet 200 mg
• Verzenio Tablet 50 mg
• Victoza Injection 18 mg/3 mL
  
  

Other Updates:
 

• Albuterol Aerosol HFA (Added Quantity Level Limit)
• Arnuity Ellipta Inhaler 100 mcg (Added Quantity Level Limit)
• Arnuity Ellipta Inhaler 200 mcg (Added Quantity Level Limit)
• Arnuity Ellipta Inhaler 50 mcg (Added Quantity Level Limit)
• Azithromycin Suspension 100 mg/5 mL (Added Age Limit)
• Azithromycin Suspension 200 mg/5 mL (Added Age Limit)
• Cefadroxil Suspension 250 mg/5 mL (Added Age Limit)
• Cefadroxil Suspension 500 mg/5 mL (Added Age Limit)
• Cefdinir Suspension 125 mg/5 mL (Added Age Limit)
• Cefdinir Suspension 250 mg/5 mL (Added Age Limit)
• Cefpodoxime Proxetil Suspension 100 mg/5 mL (Added Age Limit)
• Cefpodoxime Proxetil Suspension 50 mg/5 mL (Added Age Limit)
• Cefprozil Suspension 125 mg/5 mL (Added Age Limit)
• Cefprozil Suspension 250 mg/5 mL (Added Age Limit)
• Cephalexin Suspension 125 mg/5 mL (Added Age Limit)
• Cephalexin Suspension 250 mg/5 mL (Added Age Limit)
• Clarithromycin Suspension 125 mg/5 mL (Added Age Limit)
• Clarithromycin Suspension 250 mg/5 mL (Added Age Limit)
• Extavia Injection 0.3 mg (Added Quantity Level Limit)
• Gilenya Capsule 0.5 mg (Added Quantity Level Limit)
• Glatiramer Injection 20 mg/mL (Added Quantity Level Limit)
• Glatiramer Injection 40 mg/mL (Added Quantity Level Limit)
• Juluca Tablet 50-25 mg (Added Prior Authorization)
• Levalbuterol Aerosol 45 mcg/Actuation (Added Quantity Level Limit)
• Levofloxacin Solution 25 mg/mL (Added Age Limit)
• Neomycin-Polymyxin-Dexamethasone Ophthalmic Ointment 0.1% (Added Quantity Level Limit)
• Ondansetron Tablet Dispersible 4 mg Oral (Added Quantity Level Limit)
• Ondansetron Tablet Dispersible 8 mg Oral (Added Quantity Level Limit)
• Phenylephrine Hydrochloride Ophthalmic Solution 2.5% (Added Quantity Level Limit)
• Rebif Injection 22 mcg/0.5 mL (Added Quantity Level Limit)
• Rebif Injection 44 mcg/0.5 mL (Added Quantity Level Limit)
• Rebif Rebidose Injection 22 mcg/0.5 mL (Added Quantity Level Limit)
• Rebif Rebidose Injection 44 mcg/0.5 mL (Added Quantity Level Limit)
• Rebif Rebidose Injection Titration (Added Quantity Level Limit)
• Rebif Titration Injection Pack (Added Quantity Level Limit)
• Santyl Ointment 250 unit/gm (Added Quantity Level Limit)

February 2021
 

Additions:
 

• None
  
  

Removals:
 

• None
  
  

Other Updates:
 

• None

January 2021
 

Additions:
 

• Retacrit Injection 20000 units (Prior Authorization Required)
  
  

Removals:
 

• None
  
  

Other Updates:
 

• None

December 2020
 

Additions:
 

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

Removals:
 

• None
  
  

Other Updates:
 

• None

November 2020
 

Additions:
 

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

Removals:
 

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

Other Updates:
 

• None
  
  

October 2020

Additions:
 

• Efavirenz-Lamivudine-Tenofovir Disoproxil Fumarate Tablet 400-300-300 mg
• Efavirenz-Lamivudine-Tenofovir Disoproxil Fumarate Tablet 600-300-300 mg
  
  

Removals:
 

• Symfi Lo Tablet 400-300-300 mg
• Symfi Tablet 600-300-300 mg
  
  

Other Updates:
 

• None

Septmeber 2020
 

Additions:
 

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

Removals:
 

• None
  
  

Other Updates:
 

• Soliris Injection 10 mg/mL (Prior Authorization Required)
• Proton Pump Inhibitors (Quantity Level Limit)

August 2020
 

Additions:
 

• Amitiza Capsule 8 mcg, 24 mcg (Prior Authorization Required, Quantity Level Limit)
• Buprenorphine Weekly Patch 5 mcg, 7.5 mcg, 10 mcg, 15 mcg, 20 mcg (Prior Authorization Required, Quantity Level Limit)
• Diclofenac Sodium Solution 1.5% (Step Therapy, Quantity Level Limit)
• Ibrance Capsule 75 mg, 100 mg, 125 mg (Prior Authorization Required, Quantity Level Limit)
• Lynparza Tablet 10 mg, 15 mg (Prior Authorization Required, Quantity Level Limit)
• Omeprazole Over the Counter Tablet 20 mg (Generic)
• Poly-Vi-Sol Solution 50 mg/mL
• Solifenacin Succinate Tablet 5 mg, 10 mg (Step Therapy, Quantity Level Limit)
• Symproic Tablet 0.2 mg (Prior Authorization Required, Quantity Level Limit)
• Testosterone Transdermal Solution 30mg/Actuation (Prior Authorization Required, Quantity Level Limit)
• Tivicay PD Tablet 5 mg (Diagnosis Confirmation Required, Age Limit)
• Trelegy Ellipta (Step Therapy, Quantity Level Limit)
• Tri-Vi-Sol Solution A/C/D
  
  

Removals:
 

• Cimduo Tablet 300-300 mg
• Fluocinolone Acetonide Solution 0.01%
• Fluorouracil Cream 0.5%
• Humulin 70/30
• Humulin N
• Humulin R
• Kitabis Nebule Solution 300 mg/5 mL
• Naproxen Sodium Tablet 275 mg
• Nimodipine Capsule 30 mg
• Prilosec Over the Counter Tablet 20 mg (Brand)
• Targretin Gel 1%
• Tolmetin Sodium Capsule 400 mg
• Tolmetin Sodium Tablet 200 mg, 600 mg
  
  

Other Updates:
 

• Adapalene Gel 0.1% (Removed Step Therapy from Prescription Product)
• Athletes Foot (Miconazole Nitrate) Powder 2% (Quantity Level Limit)
• Auryxia Tablet 210 mg (Step Therapy Required)
• Betamethasone Dipropionate Augmented Cream 0.05% (Quantity Level Limit)
• Betamethasone Dipropionate Cream 0.05% (Quantity Level Limit)
• Betamethasone Dipropionate Lotion 0.05% (Quantity Level Limit)
• Betamethasone Valerate Cream 0.1% (Quantity Level Limit)
• Betamethasone Valerate Lotion 0.1% (Quantity Level Limit)
• Betamethasone Valerate Ointment 0.1% (Quantity Level Limit)
• Butenafine Hydrochloride Cream 1% (Quantity Level Limit)
• Candesartan Cilexetil–Hydrochlorothiazide Tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg (Step Therapy Required)
• Candesartan Cilexetil Tablet 4 mg, 8 mg, 16 mg, 32 mg (Step Therapy Required)
• Ciclopirox Olamine Cream 0.77% (Quantity Level Limit)
• Ciclopirox Olamine Suspension 0.77% (Quantity Level Limit)
• Ciclopirox Shampoo 1% (Quantity Level Limit)
• Ciclopirox Solution 8% (Quantity Level Limit)
• Ciprofloxacin Hydrochloride Otic Solution 0.2% (Quantity Level Limit)
• Clindamycin Phosphate Gel 1% (Quantity Level Limit)
• Clindamycin Phosphate Lotion 1% (Quantity Level Limit)
• Clindamycin Phosphate Solution 1% (Quantity Level Limit)
• Clindamycin Phosphate Swab 1% (Quantity Level Limit)
• Clotrimazole Cream 1% (Quantity Level Limit)
• Clotrimazole Solution 1% (Quantity Level Limit)
• Clotrimazole-Betamethasone Cream 1-0.05% (Quantity Level Limit)
• Disulfiram Tablet 250 mg, 500 mg (Quantity Level Limit)
• Ear Drops (Carbamide Peroxide) Otic Solution 6.5% (Quantity Level Limit)
• Ery Pad (Erythromycin) 2% (Quantity Level Limit)
• Erythromycin Gel 2% (Quantity Level Limit)
• Erythromycin Solution 2% (Quantity Level Limit)
• Flunisolide Nasal Solution 25 mcg/Actuation (Step Therapy Required)
• Fluocinonide Cream 0.05% (Quantity Level Limit)
• Fluocinonide Solution 0.05% (Quantity Level Limit)
• Fluvastatin Sodium Capsule 20 mg, 40 mg (Step Therapy Required)
• Hydrocortisone Cream 0.5%, 1%, 2.5% (Quantity Level Limit)
• Hydrocortisone Lotion 1%, 2.5% (Quantity Level Limit)
• Hydrocortisone Ointment 0.5%, 1%, 2.5% (Quantity Level Limit)
• Hydrocortisone-Acetic Acid Otic Solution 1-2% (Quantity Level Limit)
• Ketoconazole Cream 2% (Quantity Level Limit)
• Ketoconazole Shampoo 2% (Quantity Level Limit)
• Lidocaine Ointment 5% (Quantity Level Limit)
• Linzess Capsule 72 mcg, 145 mcg, 290 mcg (Prior Authorization Required)
• Liothyronine Sodium Tablet 25 mcg (Quantity Level Limit)
• Miconazole Nitrate Aerosol Powder 2% (Quantity Level Limit)
• Miconazole Nitrate Cream 2% (Quantity Level Limit)
• Mometasone Furoate Cream 0.1% (Quantity Level Limit)
• Mometasone Furoate Ointment 0.1% (Quantity Level Limit)
• Mometasone Furoate Solution 0.1% (Quantity Level Limit)
• Naltrexone Tablet 50mg (Quantity Level Limit)
• Neomycin-Polymyxin-Hydrocortisone Otic Solution 1% (Quantity Level Limit)
• Neomycin-Polymyxin-Hydrocortisone Otic Suspension 3.5 mg/mL-10000 unit/mL (Quantity Level Limit)
• Nystatin Cream 100,000 units/gm (Quantity Level Limit)
• Nystatin Ointment 100,000 units/gm (Quantity Level Limit)
• Nystatin Powder 100,000 units/gm (Quantity Level Limit)
• Ofloxacin Otic Solution 0.3% (Quantity Level Limit)
• Permethrin Cream 5% (Quantity Level Limit)
• Prednicarbate Ointment 0.1% (Quantity Level Limit)
• Proton Pump Inhibitors (Quantity Level Limit)
• Ropinirole Hydrochloride Extended-Release Tablet 2 mg, 4 mg, 8 mg, 6 mg, 12 mg (Step Therapy Required)
• Scalp Relief Max Strength (Hydrocortisone 1%) Solution (Quantity Level Limit)
• Stop Lice Maximum Strength (Pyrethrins-Piperonyl Butoxide) Liquid 0.33-4% (Quantity Level Limit)
• Sulfacetamide Sodium (Acne) Lotion 10% (Quantity Level Limit)
• Terbinafine Hydrochloride Cream 1% (Quantity Level Limit)
• Testosterone Gel 1.62% (Prior Authorization Required, Quantity Level Limit)
• Tolnaftate Cream 1% (Quantity Level Limit)
• Triamcinolone Acetonide Cream 0.025%, 0.1%, 0.5% (Quantity Level Limit)
• Triamcinolone Acetonide Lotion 0.0.25%, 0.1% (Quantity Level Limit)
• Triamcinolone Acetonide Ointment 0.025%, 0.05% (Quantity Level Limit)

July 2020
 

Additions:
 

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

June 2020
 

Additions:
 

• Acne Medication Lotion (Benzoyl Peroxide) 10%
• Alahist D Tablet
• Atovaquone-Proguanil Tablet (Quantity Level Limit)
• Claravis Capsule 10 mg, 20 mg, 30 mg, 40 mg (Step Therapy, Quantity Level Limit)
• Dovato Tablet 50-300 mg (Diagnosis Confirmation Required, Quantity Level Limit)
• Gvoke Hypopen Injection (Quantity Level Limit)
• Isotretinoin Capsule 10 mg, 20 mg, 30 mg, 40 mg (Step Therapy, Quantity Level Limit)
• Jock Itch/Athlete’s Foot Spray (Tolnaftate) Aerosol Powder 1% (Quantity Level Limit)
• Phenazopyridine Tablet 95 mg
• Primaquine Tablet 26.3 mg (Quantity Level Limit)
• Tolnaftate Powder 1% (Quantity Level Limit)
  
  

Removals:
 

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

May 2020
 

Additions:
 

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

Removals:
 

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

April 2020
 

Additions:
 

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

Removals:
 

• Carafate Suspension 1 gm/10 mL (Brand)

March 2020
 

Additions:
 

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

Removals:
 

• Apriso Capsule 0.375 gm (Brand)
  
  

Other Updates:
 

• Prenatal Vitamin Tablet (Quantity Level Limit)

February 2020
 

Additions:
 

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

Removals:
 

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

Other Updates:
 

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

January 2020
 

Additions:
 

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

Removals:
 

• Ventolin HFA Inhaler (Brand name)