Formulary search tool and updates

November 2024

Additions:

• Baclofen Solution 5 mg / 5 mL (Quantity Level Limit)
• Clobazam Suspension 2.5 mg/ mL (Prior Authorization, Quantity Level Limit)
• Clobazam Tablet 10 mg (Prior Authorization, Quantity Level Limit)
• Clobazam Tablet 20 mg (Prior Authorization, Quantity Level Limit)
• Entresto Sprinkle Capsule (Prior Authorization, Quantity Level Limit)
• 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 Limit)
• 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, Quantity Level Limit)
• Rufinamide Tablet 200 mg (Prior Authorization, Quantity Level Limit)
• Rufinamide Tablet 400 mg (Prior Authorization, Quantity Level Limit)
• 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)
• 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)
• Sevelamer Carbonate Tablet 800 mg (Remove Step Therapy)

October 2024

Additions:

• None

Removals:

• None

Other Updates:

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

September 2024

Additions:

• 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 20mg (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:

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

Other Updates:

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

July 2024

Additions:

• None

Removals:

• None

Other Updates:

• None

June 2024

Additions:

• None

Removals:

• None

Other Updates:

• Mayvret Tablet 100-40 mg (Prior Authorization)
• Mayvret Packet 50-20 mg (Prior Authorization)
• Sofosbuvir-Velpatasvir Tablet 400-100 mg (Prior Authorization)

May 2024

Additions:

• Adapalene Gel 0.3% (Step Therapy, Quantity Level Limit)
• Adapalene/Benzoyl Peroxide Gel 0.1-2.5% (Age Limit, Quantity Level Limit)
• Azelaic Acid Gel 0.15% (Quantity Level Limit)
• Clindamycin/Benzoyl Peroxide Gel 1.2-5% (Quantity Level Limit)
• Clindamycin/Benzoyl Peroxide Gel 1-5% (Quantity Level Limit)
• Diphenhydramine-Zinc Acetate Cream 2-0.1%
• Doxycycline Hyclate Tablet 75 mg
• Doxycycline Monohydrate Tablet 50 mg
• Doxycycline Monohydrate Tablet 75 mg
• Erythromycin/Benzoyl Peroxide Gel 3-5% (Quantity Level Limit)
• Fluticasone Propionate Powder Inhaler 100 mcg (Quantity Level Limit)
• Fluticasone Propionate Powder Inhaler 250 mcg (Quantity Level Limit)
• Fluticasone Propionate Powder Inhaler 50 mcg (Quantity Level Limit)
• Isosorbide Dinitrate-Hydralazine Hydrochloride Tablet 20-37.5 mg (Quantity Level Limit)
• Menthol-Methyl Salicylate Cream
• Opill Tablet 0.075 mg
• Oxycodone Hydrochloride Extended-Release Tablet 10 mg (Quantity Level Limit)
• Oxycodone Hydrochloride Extended-Release Tablet 20 mg (Quantity Level Limit)
• Oxycodone Hydrochloride Extended-Release Tablet 40 mg (Quantity Level Limit)
• Oxycodone Hydrochloride Extended-Release Tablet 80 mg (Quantity Level Limit)

Removals:

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

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)
• 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)
• Apixaban Tablet 2.5 mg (Quantity Level Limit)
• Apixaban Tablet 5 mg (Quantity Level Limit)
• Baclofen Tablet 10 mg (Quantity Level Limit)
• Baclofen Tablet 20 mg (Quantity Level Limit)
• Bupropion Hydrochloride Tablet 100 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)
• 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)
• Dextroamphetamine Sulfate Capsule Extended Release 24-hour 10 mg (Quantity Level Limit)
• Dextroamphetamine Sulfate Capsule Extended Release 24-hour 15 mg (Quantity Level Limit)
• Dextroamphetamine Sulfate Tablet 10 mg (Quantity Level Limit)
• Dextroamphetamine Sulfate Tablet 5 mg (Quantity Level Limit)
• Febuxostat Tablet 40 mg (Quantity Level Limit)
• Febuxostat Tablet 80 mg (Quantity Level 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)
• Mavyret Powder Pack 50-20 mg (Quantity Level Limit)
• Meloxicam Tablet 15 mg (Quantity Level Limit)
• Methocarbamol Tablet 500 mg (Quantity Level Limit)
• Methocarbamol Tablet 750 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 Chewable Tablet 10 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 Solution 5 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)
• Orphenadrine Citrate Tablet Extended Release 12-hour 100 mg (Quantity Level Limit)
• Prochlorperazine Maleate Tablet 10 mg (Base Equivalent) (Quantity Level Limit)
• Prochlorperazine Maleate Tablet 5 mg (Base Equivalent) (Quantity Level Limit)
• Prochlorperazine Suppository 25 mg (Quantity Level Limit)
• Rivaroxaban Tablet 10 mg (Quantity Level Limit)
• Rivaroxaban Tablet 15 mg (Quantity Level Limit)
• Rivaroxaban Tablet 20 mg (Quantity Level Limit)
• 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% (Quantity Level Limit)
• Tacrolimus Ointment 0.1% (Quantity Level Limit)
• 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)

May 2024

Additions:

• 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:

• None

Other Updates:

• *Blood Glucose Monitoring Kit With Device*** (Quantity Level Limit)
• Dabigatran 110 mg Capsule (Quantity Level Limit)

March 2024

Additions:

• Zenpep Capsule 60000 Unit

Removals:

• None

Other Updates:

• None

February 2024

Additions:

• Adalimumab-Adaz Auto-Injector 40 mg/0.4 mL (Prior Authorization)                    
• Adalimumab-Adaz Prefilled Syringe 40 mg/0.4 mL (Prior Authorization)                    
• Adalimumab-Fkjp Auto-Injector Kit 40 mg/0.8 mL (Prior Authorization)                    
• Adalimumab-Fkjp Prefilled Syringe Kit 20 mg /0.4 mL (Prior Authorization)                    
• Adalimumab-Fkjp Prefilled Syringe Kit 40 mg /0.8 mL (Prior Authorization)         
• 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/1.14 mL (Prior Authorization)
• Dupixent Injection 200 mg (Prior Authorization)            
• Dupixent Injection 300 mg/2 mL (Prior Authorization)                        
• Fesoterodine Fumarate Tablet 24 hour 4 mg (Step Therapy, Quantity Level Limit)
• Fesoterodine Fumarate Tablet 24 hour 8 mg (Step Therapy, Quantity Level Limit)
• Hadlima Auto-Injector 40 mg/0.4 mL (Prior Authorization)                  
• Hadlima Auto-Injector 40mg /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 Vial                         
• Insulin Lispro Injection 100 Units / mL                                                         
• Insulin Lispro Injection Junior                                                           
• Lantus Pen Injector                                                     
• Lantus Vial                        
• Lurasidone Hydrochloride Tablet 120 mg                       
• Lurasidone Hydrochloride Tablet 20 mg              
• Lurasidone Hydrochloride Tablet 40 mg                         
• Lurasidone Hydrochloride Tablet 60 mg                         
• Lurasidone Hydrochloride Tablet 80 mg (Quantity Level Limit)
• Ondansetron Hydrochloride Oral Solution 4 mg /5 mL (Quantity Level Limit)
• Orilissa Tablet 150 mg (Prior Authorization)                  
• Orilissa Tablet 200 mg (Prior Authorization)                  
• Otezla Starter Pack 10 mg/20 mg/30 mg (Prior Authorization)            
• Otezla Tablet 30 mg (Prior Authorization)           
• Rexulti Tablet 0.25 mg (Prior Authorization)                            
• Rexulti Tablet 0.5 mg (Prior Authorization)                    
• Rexulti Tablet 1 mg (Prior Authorization)                       
• Rexulti Tablet 2 mg (Prior Authorization)                       
• Rexulti Tablet 3 mg (Prior Authorization)                       
• Rexulti Tablet 4 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)                             
• Vraylar Capsule 1.5-3 mg (Prior Authorization)                        
• Vraylar Capsule 1.5 mg (Prior Authorization)                 
• Vraylar Capsule 3 mg (Prior Authorization)                    
• Vraylar Capsule 4.5 mg (Prior Authorization)                           
• Vraylar Capsule 6 mg (Prior Authorization)                    

Removals:

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

Other Updates:

• Acarbose Tablet 100 mg (Quantity Level Limit)
• Acarbose Tablet 25 mg (Quantity Level Limit)
• Acarbose Tablet 50 mg (Quantity Level Limit)
• Albuterol Sulfate Nebulizer Solution 0.083% (2.5 mg/3 mL) (Quantity Level Limit)
• Albuterol Sulfate Nebulizer Solution 0.5% (5 mg/ mL) (Quantity Level Limit)
• Alfuzosin Hydrochloride Tablet Extended Release 24 Hour 10 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 12.5-15 mg (Quantity Level Limit)
• Alogliptin-Pioglitazone Tablet 12.5-30 mg (Quantity Level Limit)
• Alogliptin-Pioglitazone Tablet 12.5-45 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)
• 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)
• Anastrozole Tablet 1 mg (Quantity Level Limit)
• Benazepril Hydrochloride Tablet 10 mg (Quantity Level Limit)
• Benazepril Hydrochloride Tablet 20 mg (Quantity Level Limit)
• Benazepril Hydrochloride Tablet 40 mg (Quantity Level Limit)
• Benazepril Hydrochloride Tablet 5 mg (Quantity Level Limit)
• Bicalutamide Tablet 50 mg (Quantity Level Limit)
• Bimatoprost Ophthalmic Solution 0.03% (Quantity Level Limit)
• Bisoprolol Fumarate Tablet 5 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)
• Carvedilol Tablet 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 Tablet 300 mg (Quantity Level Limit)
• Cimetidine Tablet 400 mg (Quantity Level Limit)
• Cimetidine Tablet 800 mg (Quantity Level Limit)
• Citalopram Hydrobromide Tablet 10 mg (Base Equivalent) (Quantity Level Limit)
• Citalopram Hydrobromide Tablet 20 mg (Base Equivalent) (Quantity Level Limit)
• Diltiazem Hydrochloride Capsule Extended Release 24 hour 120 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 120 mg (Quantity Level Limit)
• Diltiazem Hydrochloride Extended Release Beads Capsule Extended Release 24 hour 300 mg (Quantity Level Limit)
• Diltiazem Hydrochloride Extended Release Beads Capsule Extended Release 24 hour 360 mg (Quantity Level Limit)
• Diltiazem Hydrochloride Extended Release Beads Capsule Extended Release 24 hour 420 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 10 mg (Quantity Level Limit)
• Enalapril Maleate Tablet 2.5 mg (Quantity Level Limit)
• Enalapril Maleate Tablet 20 mg (Quantity Level Limit)
• Enalapril Maleate Tablet 5 mg (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 (Base Equivalent) (Quantity Level Limit)
• Esomeprazole Magnesium Capsule Delayed Release 40mg (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)
• Exemestane Tablet 25 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)
• 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)
• Fexofenadine-Pseudoephedrine Tablet Extended Release 12 hour 60-120 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)
• Fluvoxamine Maleate Tablet 50 mg (Quantity Level Limit)
• Fosinopril Sodium Tablet 10 mg (Quantity Level Limit)
• Fosinopril Sodium Tablet 20 mg (Quantity Level Limit)
• Fosinopril Sodium Tablet 40 mg (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)
• Imatinib Mesylate Tablet 100 mg (Base Equivalent) (Quantity Level Limit)
• Imatinib Mesylate Tablet 400 mg (Base Equivalent) (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)
• 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)
• Lansoprazole Capsule Delayed Release 30 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)
• 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 Rapidly-Disintegrating Tablet 10 mg (Quantity Level Limit)
• Loratadine Tablet 10 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)
• Losartan Potassium Tablet 25 mg (Quantity Level Limit)
• Losartan Potassium Tablet 50 mg (Quantity Level Limit)
• Mesalamine Cap Extended Release 24 hour 0.375 GM (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)
• Metoprolol Succinate Tablet Extended Release 24 hour 100 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)
• Mirtazapine Orally Disintegrating Tablet 30 mg (Quantity Level Limit)
• Mirtazapine Tablet 30 mg (Quantity Level Limit)
• Mirtazapine Tablet 45 mg (Quantity Level Limit)
• Nateglinide Tablet 120 mg (Quantity Level Limit)
• Nateglinide Tablet 60 mg (Quantity Level Limit)
• Nifedipine Tablet Extended Release 24 hour Osmotic Release 60 mg (Quantity Level Limit)
• Nilotinib Hydrochloride Capsule 150 mg (Base Equivalent) (Quantity Level Limit)
• Nilotinib Hydrochloride Capsule 200 mg (Base Equivalent) (Quantity Level Limit)
• Nizatidine Capsule 150 mg (Quantity Level Limit)
• Nizatidine Capsule 300 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)
• 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 Syrup 5 mg/ 5mL (Quantity Level Limit)
• Oxybutynin Chloride Tablet 5 mg (Quantity Level Limit)
• Oxybutynin Chloride Tablet Extended Release 24 hour 10 mg (Quantity Level Limit)
• Oxybutynin Chloride Tablet Extended Release 24 hour 15 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 20 mg (Quantity Level Limit)
• Pantoprazole Sodium Enteric Coated Tablet 40 mg (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)
• 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)
• Quinapril Hydrochloride Tablet 10 mg (Quantity Level Limit)
• Quinapril Hydrochloride Tablet 20 mg (Quantity Level Limit)
• Quinapril Hydrochloride Tablet 40 mg (Quantity Level Limit)
• Quinapril Hydrochloride Tablet 5 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 1.25 mg (Quantity Level Limit)
• Ramipril Capsule 10 mg (Quantity Level Limit)
• Ramipril Capsule 2.5 mg (Quantity Level Limit)
• Ramipril Capsule 5 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)
• Sertraline Hydrochloride Tablet 100 mg (Quantity Level Limit)
• Sertraline Hydrochloride Tablet 25 mg (Quantity Level Limit)
• Sprycel Tablet 20 mg (Quantity Level Limit)
• Sunitinib Malate Capsule 50 mg (Base Equivalent) (Quantity Level Limit)
• Terazosin Hydrochloride Capsule 10 mg (Base Equivalent) (Quantity Level Limit)
• Terazosin Hydrochloride Capsule 2 mg (Base Equivalent) (Quantity Level Limit)
• Terazosin Hydrochloride Capsule 5 mg (Base Equivalent) (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)
• 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)
• Verapamil Hydrochloride Capsule Extended Release 24 hour 240 mg (Quantity Level Limit)

January 2024

Additions:

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

Removals:

• None

Other Updates:

• None

December 2023

Additions:

• None

Removals:

• None

Other Updates:

• None

November 2023

Additions:

• Ciprofloxacin-Dexamethasone Otic Suspension 0.3-0.1% (Quantity Level Limit)
• 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 (Quantity Level Limit)
• Takhzyro Injection 150 mg / mL (Prior Authorization, Quantity Level Limit)
• Takhzyro Injection 300 / 2 mL (Prior Authorization, Quantity Level Limit)

Removals:

• Proctofoam Aerosol Hydrocortisone 1%

Other Updates:

• Auranofin Capsule 3 mg (Remove Prior Authorization)
• Cabergoline Tablet 0.5 mg (Remove Prior Authorization)
• Clotrimazole Cream 1% (Remove Step Therapy)
• Darunavir Oral Suspension 100 mg / mL (Quantity Level Limit)
• Darunavir Tablet 150 mg (Quantity Level Limit)
• Darunavir Tablet 75 mg (Quantity Level Limit)
• 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)
• Efavirenz Capsule 200 mg (Quantity Level Limit)
• Efavirenz Capsule 50 mg (Quantity Level Limit)
• Ella Tablet 30 mg (Quantity Level Limit)
• Escitalopram Solution 5 mg / 5 mL (Quantity Level Limit)
• Fluconazole Tablet 100 mg (Quantity Level Limit)
• Fluconazole Tablet 200 mg (Quantity Level Limit)
• Fluconazole Tablet 50 mg (Quantity Level Limit)
• Isentress Tablet 400 Mg (Base Equivalent) (Quantity Level Limit)
• Itraconazole Capsule 100 mg (Quantity Level Limit)
• Ivermectin Tablet 3 mg (Remove Prior Authorization)
• Ketoconazole Tablet 200 mg (Quantity Level Limit)
• Levocarnitine Oral Solution 1 GM / 10 mL (10%) (Remove Prior Authorization)
• Levocarnitine Tablet 330 mg (Remove Prior Authorization)
• Lopinavir-Ritonavir Solution 400-100 mg / 5 mL (80-20 mg / mL) (Quantity Level Limit)
• Mavyret Tablet 100-40 mg (Quantity Level Limit)
• Nayzilam Spray 5 mg (Quantity Level Limit)
• Sofosbuvir-Velpatasvir Tablet 400-100 mg (Quantity Level Limit)
• Stavudine Capsule 15 mg (Quantity Level Limit)
• Stavudine Capsule 20 mg (Quantity Level Limit)
• Terbinafine Hydrochloride Tablet 250 mg (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)
• Tretinoin Capsule 10 mg (Add Prior Authorization)
• Valtoco Spray 10 mg (Age Limit, Quantity Level Limit)
• Valtoco Spray 15 mg (Age Limit, Quantity Level Limit)
• Valtoco Spray 20 mg (Age Limit, Quantity Level Limit)
• Valtoco Spray 5 mg (Age Limit, Quantity Level Limit)
• Varenicline Tablet 0.5 mg (Quantity Level Limit)
• Varenicline Tablet 1 mg (Quantity Level Limit)

October 2023

Additions:

• Austedo Extended-Release Tablet Titration Kit (Prior Authorization, Quantity Level Limit)
• Buprenorphine Extended-Release Solution Prefilled Syringe (Weekly) 8 mg / 0.16 mL (Quantity Level Limit)
• Buprenorphine Extended-Release Solution Prefilled Syringe (Weekly) 16 mg / 0.32 mL (Quantity Level Limit)
• Buprenorphine Extended-Release Solution Prefilled Syringe (Weekly) 24 mg / 0.48 mL (Quantity Level Limit)
• Buprenorphine Extended-Release Solution Prefilled Syringe (Weekly) 32 mg / 0.64 mL (Quantity Level Limit)
• Buprenorphine Extended-Release Solution Prefilled Syringe 128 mg / 0.36 mL (Quantity Level Limit)
• Buprenorphine Extended-Release Solution Prefilled Syringe 64 mg / 0.18 mL (Quantity Level Limit)
• Buprenorphine Extended-Release Solution Prefilled Syringe 96 mg / 0.27 mL (Quantity Level Limit)

Removals:

• None

Other Updates:

• Aripiprazole Intramuscular Extended-Release Suspension Prefilled Syringe 300 mg (Quantity Level Limit, Age Limit)
• Aripiprazole Intramuscular Extended-Release Suspension Prefilled Syringe 400 mg (Quantity Level Limit, Age Limit)
• Aripiprazole Intramuscular for Extended-Release Suspension 300 mg (Quantity Level Limit, Age Limit)
• Aripiprazole Intramuscular for Extended-Release Suspension 400 mg (Quantity Level Limit, Age Limit)
• Aripiprazole Lauroxil Intramuscular Extended-Release Suspension Prefilled Syringe 441 mg / 1.6 mL (Quantity Level Limit, Age Limit)
• Aripiprazole Lauroxil Intramuscular Extended-Release Suspension Prefilled Syringe 662 mg / 2.4 mL (Quantity Level Limit, Age Limit)
• Aripiprazole Lauroxil Intramuscular Extended-Release Suspension Prefilled Syringe882 mg / 3.2 mL (Quantity Level Limit, Age Limit)
• Aripiprazole Lauroxil Intramuscular Extended-Release Suspension Prefilled Syringe 1064 mg / 3.9 mL (Quantity Level Limit, Age Limit)
• Aripiprazole Tablet 10 mg (Quantity Level Limit, Age Limit)
• Aripiprazole Tablet 15 mg (Quantity Level Limit, Age Limit)
• Aripiprazole Tablet 2 mg (Quantity Level Limit, Age Limit)
• Aripiprazole Tablet 20 mg (Quantity Level Limit, Age Limit)
• Aripiprazole Tablet 30 mg (Quantity Level Limit, Age Limit)
• Aripiprazole Tablet 5 mg (Quantity Level Limit, Age Limit)
• Armodafinil Tablet 150 mg (Quantity Level Limit, Age Limit)
• Armodafinil Tablet 200 mg (Age Limit)
• Armodafinil Tablet 250 mg (Quantity Level Limit, Age Limit)
• Armodafinil Tablet 50 mg (Quantity Level Limit, Age Limit)
• Clozapine Tab 100 mg (Quantity Level Limit, Age Limit)
• Clozapine Tab 200 mg (Quantity Level Limit, Age Limit)
• Clozapine Tab 25 mg (Quantity Level Limit, Age Limit)
• Clozapine Tab 50 mg (Quantity Level Limit, Age Limit)
• Desvenlafaxine Succinate Tablet Extended Release 24-hour 25 mg (Base Equivalent) (Quantity Level Limit, Age Limit)
• Desvenlafaxine Succinate Tablet Extended Release 24-hour 50 mg (Base Equivalent) (Quantity Level Limit, Age Limit)
• Desvenlafaxine Succinate Tablet Extended Release24 hour 100 mg (Base Equivalent) (Quantity Level Limit, Age Limit)
• Fluphenazine Decanoate Injection 25 mg/ mL
• Haloperidol Lactate Oral Concentration 2 mg / mL (Quantity Level Limit, Age Limit)
• Haloperidol Tablet 0.5 mg (Quantity Level Limit, Age Limit)
• Haloperidol Tablet 1 mg (Quantity Level Limit, Age Limit)
• Haloperidol Tablet 10 mg (Quantity Level Limit, Age Limit)
• Haloperidol Tablet 2 mg (Quantity Level Limit, Age Limit)
• Haloperidol Tablet 20 mg (Quantity Level Limit, Age Limit)
• Haloperidol Tablet 5 mg (Quantity Level Limit, Age Limit)
• Lithium Carbonate Capsule 150 mg (Quantity Level Limit, Age Limit)
• Lithium Carbonate Capsule 300 mg (Quantity Level Limit, Age Limit)
• Lithium Carbonate Capsule 600 mg (Quantity Level Limit, Age Limit)
• Lithium Carbonate Tablet 300 mg (Quantity Level Limit, Age Limit)
• Lithium Carbonate Tablet Extended Release 300 mg (Quantity Level Limit, Age Limit)
• Lithium Carbonate Tablet Extended Release 450 mg (Quantity Level Limit, Age Limit)
• Loxapine Succinate Capsule 10 mg (Quantity Level Limit, Age Limit)
• Loxapine Succinate Capsule 25 mg (Quantity Level Limit, Age Limit)
• Loxapine Succinate Capsule 5 mg (Quantity Level Limit, Age Limit)
• Loxapine Succinate Capsule 50 mg (Quantity Level Limit, Age Limit)
• Olanzapine Orally Disintegrating Tablet 10 mg (Quantity Level Limit, Age Limit)
• Olanzapine Orally Disintegrating Tablet 15 mg (Quantity Level Limit, Age Limit)
• Olanzapine Orally Disintegrating Tablet 20 mg (Quantity Level Limit, Age Limit)
• Olanzapine Orally Disintegrating Tablet 5 mg (Quantity Level Limit, Age Limit)
• Olanzapine Tablet 10 mg (Quantity Level Limit, Age Limit)
• Olanzapine Tablet 15 mg (Quantity Level Limit, Age Limit)
• Olanzapine Tablet 2.5 mg (Quantity Level Limit, Age Limit)
• Olanzapine Tablet 20 mg (Quantity Level Limit, Age Limit)
• Olanzapine Tablet 5 mg (Quantity Level Limit, Age Limit)
• Olanzapine Tablet 7.5 mg (Quantity Level Limit, Age Limit)
• Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 39 mg /0.25 mL (Quantity Level Limit, Age Limit)
• Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 78 mg /0.5 mL (Quantity Level Limit, Age Limit)
• Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 117 mg /0.75 mL (Quantity Level Limit, Age Limit)
• Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 156 mg / mL (Quantity Level Limit, Age Limit)
• Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 234 mg /1.5 mL (Quantity Level Limit, Age Limit)
• Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 273 mg /0.875 mL (Quantity Level Limit, Age Limit)
• Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 410 mg /1.315 mL (Quantity Level Limit, Age Limit)
• Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 546 mg/ 1.75 mL (Quantity Level Limit, Age Limit)
• Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 819 mg/ 2.625 mL (Quantity Level Limit, Age Limit)
• Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 1,092 mg/ 3.5 mL (Quantity Level Limit, Age Limit)
• Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 1,560 mg/ 5 mL (Quantity Level Limit, Age Limit)
• Perphenazine Tablet 16 mg (Quantity Level Limit, Age Limit)
• Perphenazine Tablet 2 mg (Quantity Level Limit, Age Limit)
• Perphenazine Tablet 4 mg (Quantity Level Limit, Age Limit)
• Perphenazine Tablet 8 mg (Quantity Level Limit, Age Limit)
• Phenelzine Sulfate Tablet 15 mg (Quantity Level Limit, Age Limit)
• Quetiapine Fumarate Tablet 100 mg (Quantity Level Limit, Age Limit)
• Quetiapine Fumarate Tablet 200 mg (Quantity Level Limit, Age Limit)
• Quetiapine Fumarate Tablet 25 mg (Quantity Level Limit, Age Limit)
• Quetiapine Fumarate Tablet 300 mg (Quantity Level Limit, Age Limit)
• Quetiapine Fumarate Tablet 400 mg (Quantity Level Limit, Age Limit)
• Quetiapine Fumarate Tablet 50 mg (Quantity Level Limit, Age Limit)
• Quetiapine Fumarate Tablet Sustained Release 24-hour 150 mg (Quantity Level Limit, Age Limit)
• Quetiapine Fumarate Tablet Sustained Release 24-hour 200 mg (Quantity Level Limit, Age Limit)
• Quetiapine Fumarate Tablet Sustained Release 24-hour 300 mg (Quantity Level Limit, Age Limit)
• Quetiapine Fumarate Tablet Sustained Release 24-hour 400 mg (Quantity Level Limit, Age Limit)
• Quetiapine Fumarate Tablet Sustained Release 24-hour 50 mg (Quantity Level Limit, Age Limit)
• Ramelteon Tablet 8 mg (Quantity Level Limit, Age Limit)
• Risperidone Microspheres for Intramuscular Extended-Release Suspension 12.5 mg (Quantity Level Limit, Age Limit)
• Risperidone Microspheres for Intramuscular Extended-Release Suspension 25 mg (Quantity Level Limit, Age Limit)
• Risperidone Microspheres for Intramuscular Extended-Release Suspension 37.5 mg (Quantity Level Limit, Age Limit)
• Risperidone Microspheres for Intramuscular Extended-Release Suspension 50 mg (Quantity Level Limit, Age Limit)
• Risperidone Orally Disintegrating Tab 0.25 mg (Quantity Level Limit, Age Limit)
• Risperidone Orally Disintegrating Tab 0.5 mg (Quantity Level Limit, Age Limit)
• Risperidone Orally Disintegrating Tab 1 mg (Quantity Level Limit, Age Limit)
• Risperidone Orally Disintegrating Tab 2 mg (Quantity Level Limit, Age Limit)
• Risperidone Orally Disintegrating Tab 3 mg (Quantity Level Limit, Age Limit)
• Risperidone Orally Disintegrating Tab 4 mg (Quantity Level Limit, Age Limit)
• Risperidone Solution 1 mg/ mL (Quantity Level Limit, Age Limit)
• Risperidone Tablet 0.25 mg (Quantity Level Limit, Age Limit)
• Risperidone Tablet 0.5 mg (Quantity Level Limit, Age Limit)
• Risperidone Tablet 1 mg (Quantity Level Limit, Age Limit)
• Risperidone Tablet 2 mg (Quantity Level Limit, Age Limit)
• Risperidone Tablet 3 mg (Quantity Level Limit, Age Limit)
• Risperidone Tablet 4 mg (Quantity Level Limit, Age Limit)
• Thioridazine Hydrochloride Tablet 10 mg (Quantity Level Limit, Age Limit)
• Thioridazine Hydrochloride Tablet 100 mg (Quantity Level Limit, Age Limit)
• Thioridazine Hydrochloride Tablet 25 mg (Quantity Level Limit, Age Limit)
• Thioridazine Hydrochloride Tablet 50 mg (Quantity Level Limit, Age Limit)
• Thiothixene Capsule 1 mg (Quantity Level Limit, Age Limit)
• Thiothixene Capsule 10 mg (Quantity Level Limit, Age Limit)
• Thiothixene Capsule 2 mg (Quantity Level Limit, Age Limit)
• Thiothixene Capsule 5 mg (Quantity Level Limit, Age Limit)
• Trifluoperazine Hydrochloride Tablet 1 mg (Quantity Level Limit, Age Limit)
• Trifluoperazine Hydrochloride Tablet 2 mg (Quantity Level Limit, Age Limit)
• Trifluoperazine Hydrochloride Tablet 5 mg (Quantity Level Limit, Age Limit)
• Trifluoperazine Hydrochloride Tablet10 mg (Quantity Level Limit, Age Limit)
• Venlafaxine Hydrochloride Capsule Sustained Release 24-hour 150 mg (Base Equivalent) (Quantity Level Limit, Age Limit)
• Venlafaxine Hydrochloride Capsule Sustained Release 24-hour 37.5 mg (Base Equivalent) (Quantity Level Limit, Age Limit)
• Venlafaxine Hydrochloride Capsule Sustained Release 24-hour 75 mg (Base Equivalent) (Quantity Level Limit, Age Limit)
• Venlafaxine Hydrochloride Tablet 100 mg (Quantity Level Limit, Age Limit)
• Venlafaxine Hydrochloride Tablet 25 mg (Quantity Level Limit, Age Limit)
• Venlafaxine Hydrochloride Tablet 37.5 mg (Quantity Level Limit, Age Limit)
• Venlafaxine Hydrochloride Tablet 50 mg (Quantity Level Limit, Age Limit)
• Venlafaxine Hydrochloride Tablet 75 mg (Quantity Level Limit, Age Limit)
• Ziprasidone Hydrochloride Capsule 20 mg (Quantity Level Limit, Age Limit)
• Ziprasidone Hydrochloride Capsule 40 mg (Quantity Level Limit, Age Limit)
• Ziprasidone Hydrochloride Capsule 60 mg (Quantity Level Limit, Age Limit)
• Ziprasidone Hydrochloride Capsule 80 mg (Quantity Level Limit, Age Limit)

September 2023

Additions:

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

Removals:

• None

Other Updates:

• None

August 2023

Additions:

• *Multiple Vitamin Tablet**
• *Pediatric Multiple Vitamin With Minerals Chewable Tablet**
• *Pediatric Multiple Vitamins With Fluoride-Ferrous Drops 0.25-10 mg /mL**
• *Pediatric Multiple Vitamins With Fluoride Solution 0.5 mg /mL***
• *Pediatric Multiple Vitamins With Iron Drops 11 mg /mL**
• Ascorbic Acid Chewable Tablet 250 mg
• Ascorbic Acid Chewable Tablet 500 mg
• Ascorbic Acid Tablet 1000 mg
• Ascorbic Acid Tablet 250 mg
• Ascorbic Acid Tablet 500 mg
• Austedo Tablet Extended Release 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)
• Calcium Carbonate-Cholecalciferol Chewable Tablet 500 mg-10 mcg (400 Unit)
• Calcium Carbonate-Cholecalciferol Tablet 500 mg-3.125 mcg (125 Unit)
• Calcium Carbonate-Vitamin D With Minerals Tablets 600 mg-200 Unit
• Calcium Carbonate-Vitamin D With Minerals Tablets 600 mg-400 Unit
• Calcium Tablet 500 mg
• Calcium Tablet 600 mg
• Carbonyl Iron Chewable Tablet 15 mg (Elemental Iron)
• Carbonyl Iron Chewable Tablet 18 mg (Elemental Iron)
• Carboxymethylcellulose-Glycerin Ophthalmic Solution 0.5-0.9%
• Ferrous Fumarate Tablet 324 mg (106 mg Elemental Iron)
• Ferrous Gluconate Tablet 240 mg (27 mg Elemental Iron)
• Ferrous Gluconate Tablet 324 mg (37.5 mg Elemental Iron)
• Ferrous Gluconate Tablet 324 mg (38 mg Elemental Iron)
• Ferrous Sulfate Dried Tablet Extended Release 143 mg (45 mg Ferrous Equivalent)
• Flavoring Agent - Liquid
• Fluocinolone Acetonide Oil 0.01% (Body Oil) (Quantity Level Limit)
• Folic Acid-Vitamin B6-Vitamin B12 Tablet 2.2-25-0.5 mg
• Gelatin Capsules (Empty)
• Glucose Urine Test- (Glucose Oxidase) Strip
• Glycerin Liquid
• Ibandronate Sodium Intravenous Solution 3 mg / 3 mL (Base Equivalent) (Quantity Level Limit)
• Iron-Vitamin C-Vitamin B12-Folic Acid Tablet 100-250-0.025-1 mg
• Ketone Blood Test Strip
• Lactose Monohydrate Powder
• Melatonin Tablet 1 mg
• Melatonin Tablet 3 mg
• Melatonin Tablet 5 mg
• Mineral Oil-Hydrophilic Petrolatum Ointment
• Naloxone Hydrochloride Solution Prefilled Syringe 2 mg/ 2mL (Quantity Level Limit)
• 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)
• Omega-3 Fatty Acids Capsule Delayed Release 1200 mg
• Oral Vehicles For Suspension
• Pamidronate Disodium Intravenous Solution 3 mg/ mL
• Pamidronate Disodium Intravenous Solution 6 mg/ mL
• Pamidronate Disodium Intravenous Solution 9 mg/ mL
• Pediatric Multiple Vitamins With Iron Chewable Tablet 15 mg
• Pediatric Multiple Vitamins With Iron Chewable Tablet 18 mg
• Pediatric Vitamins A, C and D With Fluoride Solution 0.25 mg/ mL
• Pediatric Vitamins A, C and D With Fluoride Solution 0.5 mg/ mL
• Potassium Chloride Tablet Extended Release 20 Milliequivalent (1500 mg)
• Pyridoxine Hydrochloride Tablet 100 mg
• Pyridoxine Hydrochloride Tablet 50 mg
• Raspberry Syrup
• Simple - Syrup
• Sodium Chloride Irrigation Solution 0.9%
• Sorbitol Lollipop Base Flakes
• Sorbitol Powder
• Sorbitol Solution (Bulk)
• Sterile Water
• Stevia (Bulk) Powder
• Stevia (Bulk) Powder 90%
• Stevia (Stevia Rebaudiana) Powder Pack 100 mg
• Steviol Glycosides (Bulk) Powder 95%
• Stevioside (Bulk) Fluid Extract 15%
• Tranexamic Acid Tablet 650 mg (Quantity Level Limit)
• Water For Injection
• Water For Irrigation, Sterile Irrigation Solution
• Xanthan Gum Powder

Removals:

• *Alcohol Sheets***
• *B-Complex With Vitamin C & Folic Acid Capsule 1 mg***
• *B-Complex With Vitamin C & Folic Acid Tablet 1 mg***
• *Blood Glucose Monitoring Miscellaneous***
• *Blood Glucose Monitoring Supplies***
• *Distilled Water***
• *Ferrous Asparto Glycinate-Ferrous Fumarate-Succinic Acid-Vitamin C-Threonic Acid-B12-Folic Acid Tablet
• *Ferrous Asparto Glycinic-Succinic Acid-Vitamin C-Threonic Acid-B12-Dessicated Stomach Substance Tablet
• *Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid-B Complex-Vitamin C-Zinc-Manganese-Copper Capsule
• *Ferrous Fumarate-Iron Polysaccharide Complex-Folic-B Complex-Vitamin C-Biotin Capsule
• *Ferrous Fumarate-Folic-B Complex-Vitamin C-Zinc-Magnesium-Manganese-Copper Capsule 106-1 mg
• *Ferrous Fumarate-Folic-B Complex-Vitamin C-Zinc-Magnesium-Manganese Tablet 106-1 mg
• *Injection Device - Kit***
• *Injection Device - Miscellaneous***
• *Prenatal Without Vitamin A With Ferrous Fumarate-Ferrous Poly-Folic Capsule 85-1 mg***
• *Prenatal-Ferrous Bisglycinate-Iron Protein Succinylate-Folic Acid-Calcium Tablet & Omega 3 Capsule 200 Pack**
• *Urine Glucose Monitoring Supplies***
• Aminocaproic Acid Oral Solution 0.25 GM/ mL
• Aminocaproic Acid Tablet 1000 mg
• Aminocaproic Acid Tablet 500 mg
• 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
• Calcium Carbonate Tablet 1250 mg (500 mg Elemental Calcium)
• Calcium Citrate Tablet 250 mg
• Cholecalciferol Capsule 10000 Unit
• Cholecalciferol Tablet 50000 Unit
• Ciprofloxacin Hydrochloride Tablet 100 mg
• Dexbrompheniramine Maleate Tablet 2 mg
• Ferrous Fumarate With B12-Vitamin C-Folic Acid-Intrinsic Factor Capsule 110-0.015-75-0.5-24
• Fenoprofen Calcium Powder
• Fluocinonide Ointment 0.05%
• Folic Acid-Vitamin B6-Vitamin B12 Tablet 2.5-25-1 mg
• Fosinopril Sodium & Hydrochlorothiazide Tablet 10-12.5 mg
• Fosinopril Sodium & Hydrochlorothiazide Tablet 20-12.5 mg
• Injection Device For Insulin
• Insulin Glulisine Injection 100 Unit/ mL
• Irbesartan Tablet 150 mg
• Irbesartan Tablet 300 mg
• Irbesartan Tablet 75 mg
• Iron Polysaccharide Complex-Vitamin B12-Folic Capsule 150-0.025-1 mg
• Ketoprofen Capsule 50 mg
• Magnesium Oxide Tablet 250 mg (Magnesium Supplement)
• Methylergonovine Maleate Tablet 0.2 mg
• Needle (Disposable) 26 X 1/2"
• Needle (Disposable) 26 X 1-1/2"
• Needle (Disposable) 26 X 3/8"
• Needle (Disposable) 26 X 5/8"
• Needle (Disposable) 27 X 1/2"
• Needle (Disposable) 27 X 1-1/2"
• Needle (Disposable) 27 X 1-1/4"
• Needle (Disposable) 27 X 5/8"
• Paroxetine Hydrochloride Oral Suspension 10 mg/ 5 mL (Base Equivalent)
• Potassium Chloride Injection 10 Milliequivalent /50 mL
• Potassium Chloride Injection 20 Milliequivalent /50 mL
• Pseudoephedrine-Guaifenesin Tablet Sustained Release 12 hour 120-1200 mg
• Rimantadine Hydrochloride Tablet 100 mg
• Sodium Chloride Preservative Free (Prefilled) Injection 0.9%
• Syringe (Disposable) 1 mL
• Syringe (Disposable) 10 mL
• Syringe (Disposable) 12 mL
• Syringe (Disposable) 140 mL
• Syringe (Disposable) 20 mL
• Syringe (Disposable) 3 mL
• Syringe (Disposable) 30 mL
• Syringe (Disposable) 35 mL
• Syringe (Disposable) 5 mL
• Syringe (Disposable) 6 mL
• Syringe (Disposable) 60 mL
• Syringe (Disposable) 70 mL
• Syringe/Needle (Disposable) 1 mL 26 X 3/8"
• Syringe/Needle (Disposable) 1 mL 30 X 1/2"
• Syringe/Needle (Disposable) 6 mL 18 X 1"
• Telmisartan Tab 20 mg
• Telmisartan Tab 40 mg
• Telmisartan Tab 80 mg
• Tolnaftate Aerosol 1%
• Tuberculin/Allergy Syringe/Needle (Disposable) 1 mL 21 X 1"
• Tuberculin/Allergy Syringe/Needle (Disposable) 1 mL 25 X 1"
• Tuberculin/Allergy Syringe/Needle (Disposable) 1 mL 25 X 5/8"
• Tuberculin/Allergy Syringe/Needle (Disposable) 1 mL 26 X 3/8"
• Tuberculin/Allergy Syringe/Needle (Disposable) 1 mL 26 X 5/8"
• Tuberculin/Allergy Syringe/Needle (Disposable) 1 mL 27 X 1/2"
• Tuberculin/Allergy Syringe/Needle (Disposable) 1 mL 27 X 3/8"
• Tuberculin/Allergy Syringe/Needle (Disposable) 1 mL 28 X 1/2"
• Tuberculin/Allergy Syringe/Needle (Disposable) 1/2 mL 27 X ½”
• Tuberculin/Allergy Syringe/Needle (Disposable) 1/2 mL 28 X ½”

Other Updates:

• Bisoprolol Fumarate Tablet 10 mg (Quantity Level Limit)
• Desmopressin Acetate Nasal Spray Solution 0.01% (Quantity Level Limit)
• Hydrocortisone Acetate Cream 1% (Quantity Level Limit)
• Lisinopril & Hydrochlorothiazide Tablet 20-12.5 Mg (Quantity Level Limit)
• Methadone Hydrochloride Solution 10 mg/ 5 mL (Quantity Level Limit)
• Methadone Hydrochloride Solution 5 mg/ 5 mL (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:

• Vancomycin Solution 250 mg / 5 mL

Other Updates:

• Teriflunomide Tablet 7 mg
• Teriflunomide Tablet 14 mg
• Vancomycin Hydrochloride For Oral Solution 25 mg/ mL (Base Equivalent)
• Vancomycin Hydrochloride For Oral Solution 50 mg/ mL (Base Equivalent)

May 2023

Additions:

• Amjevita Injection 40mg /0.8 mL (Prior Authorization)
• Breztri Inhalation Aerosol 160-9-4.8 mcg/Actuation (Quantity Level Limit, Step Therapy)
• Diaper Rash Ointment
• Emgality Auto-Injector 120 mg/ mL (Quantity Level Limit, Step Therapy)
• Emgality Prefilled Syringe 120 mg/ mL (Quantity Level Limit, Step Therapy)
• Emollient - Cream
• Emollient - Lotion
• Emollient - Ointment
• Fexofenadine Hydrochloride Suspension 30 mg/ mL (Quantity Level Limit)
• Fluticasone-Salmeterol Inhalation Powder 250-50 mcg/Actuation (Quantity Level Limit)
• Fluticasone-Salmeterol Inhalation Powder 500-50 mcg/Actuation (Quantity Level Limit)
• Gilenya Capsule 0.25 mg (Add Prior Authorization, Quantity Level Limit)
• Lidocaine Hydrochloride Cream 4%
• Rizatriptan Oral Disintegrating Tablet 10 mg (Quantity Level Limit)
• Rizatriptan Oral Disintegrating Tablet 5 mg (Quantity Level Limit)
• Salicylic Acid Liquid 17%
• Trikafta Tablets
• Urea Cream 20%
• Vitamins A & D Ointment

Removals:

• *B-Complex With C & Folic Acid Tablet***
• *Multiple Vitamin Liquid**
• *Multiple Vitamins With Minerals Liquid**
• *Omega-3 Fatty Acids Capsule 435 mg**
• *Prenatal Vitamin A With Document Sodium-Iron Carbonyl-Folic Acid Tablet 90-1 mg***
• *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**
• A+D First Ointment Aid
• Acetaminophen Elixir 160 mg/ 5 mL
• Aloe Vesta Ointment Protect
• Amiloride Hydrochloride Powder
• Betaseron Injection 0.3 mg
• Capsaicin Cream 0.1%
• Carboxymethylcellulose Sodium Ophthalmic Solution 0.25%
• Carboxymethylcellulose-Glycerin Ophthalmic Solution 0.5-0.9%
• Chlorpheniramine Maleate Powder
• Cholecalciferol Capsule 400 Unit
• Cholecalciferol Chewable Tablet 2000 Unit
• Cholecalciferol Chewable Tablet 5000 Unit
• Cholecalciferol Chewable Wafer 50000 Unit
• Cholecalciferol Drops 400 Unit/ 0.028 mL (Per Drop)
• Cholecalciferol Drops 400 Unit /0.03 mL (Per Drop)
• Cholecalciferol Oral Liquid 1000 Unit /10 mL
• Cholecalciferol Oral Liquid 1200 Unit /15 mL
• Cholecalciferol Tablet 3000 Unit
• Cholecalciferol Tablet 4000 Unit
• Coal Tar Shampoo 1%
• Coal Tar Shampoo 10%
• Coal Tar Shampoo 2.5%
• Creon Capsule
• Diphenhydramine Hydrochloride (Sleep) Tablet 50 mg
• Diphenhydramine Hydrochloride Cream 2%
• Diphenhydramine Hydrochloride Gel 2%
• Diphenhydramine Hydrochloride Solution 2%
• Diphenhydramine-Zinc Acetate Liquid 2-0.1%
• Elmiron Capsules
• Ergocalciferol Tablet 2000 Unit
• Ergocalciferol Tablet 400 Unit
• Ergocalciferol Tablet 400 Unit
• Fluocinolone Acetonide Cream 0.01%
• Fluocinonide Emulsified Base Cream 0.05%
• Glyburide Powder
• Heparin Sodium Injection 20,000 Units/ mL
• Heparin Sodium Injection 5,000 Units/ 0.5 mL
• Hypromellose Preservative Free (Pf) Ophthalmic Solution 0.3%
• Kitabis Pak Nebulizer 300 mg / 5 ml
• Lidocaine Cream 3%
• Lidocaine Cream 4%
• Lidocaine Hydrochloride Solution 4%
• Magnesium Tablet 400 Mg
• Metaproterenol Sulfate Powder
• Mexiletine Hydrochloride Capsule 150 mg
• Mexiletine Hydrochloride Capsule 200 mg
• Mexiletine Hydrochloride Capsule 250 mg
• Mexsana Powder
• Miconazole Nitrate Vaginal Applicator 100 mg & 2% Cream 9 gram Kit
• Niacin Powder
• Niacin Tablet 50 mg
• Niacin Tablet 250 mg
• Niacin Tablet Controlled Release 250 mg
• Psyllium Powder 30.9%
• Psyllium Powder 68%
• Quinidine Sulfate Tablets 200mg
• Quinidine Sulfate Tablets 300mg
• Scalpicin Solution 1%
• Sorbitol Rectal Solution 70%
• Stiolto Inhalation Spray 2.5-2.5 mcg/Actuation
• Thiamine Mononitrate Powder
• Triamcinolone Acetonide Ointment 0.05%
• Zinc Oxide Ointment 12.8%
• Zinc Oxide Ointment 16%

Other Updates:

• Albendazole Tablet 200 mg (Add Prior Authorization, Remove Step Therapy)
• Albuterol Sulfate Nebulized Solution 0.63 mg/ 3 mL (Remove Step Therapy, Add Quantity Level Limit)
• Albuterol Sulfate Nebulized Solution 1.25 mg/ 3 mL (Remove Step Therapy, Add Quantity Level Limit)
• Betamethasone Dipropionate Ointment 0.05% (Add Quantity Level Limit)
• Enoxaparin Sodium Injection (Remove Quantity Level Limit)
• Enoxaparin Sodium Prefilled Syringe (Remove Quantity Level Limit)
• Extavia Injection 0.3 mg (Add Prior Authorization)
• 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
• Tobramycin Nebulizer Solution 300 mg/ 5 mL (Add Prior Authorization)
• 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:

• None

Other Updates:

• None

February 2023

Additions:

• Aspirin-Acetaminophen-Caffeine Tablet 250-250-65 mg
• Budesonide Tablet extended release 9 mg
• Buspirone Tablet 30 mg (Quantity Level Limit, Age Minimum)
• Carboxymethylcell-Glycerin-Polysorb 80 Ophthalmic Solution 0.5-1-0.5%
• Carboxymethylcellulose-Glycerin (preservative free) Ophthalmic Solution 0.5-1%
• Carboxymethylcellulose-Glycerin Ophthalmic Gel 1-0.9%
• Climara Pro Dis Weekly (Quantity Level Limit)
• Cyclosporine (ophthalmic) Emulsion 0.05% (Quantity Level Limit, Prior Authorization Required)
• Desvenlaf(P) Tablet 100 mg extended release (Quantity Level Limit)
• Desvenlaf(P) Tablet 25 mg extended release (Quantity Level Limit)
• Desvenlaf(P) Tablet 50 mg extended release (Quantity Level Limit)
• Dificid Suspension (Prior Authorization Required)
• Dificid Tablet 200 mg (Prior Authorization Required)
• Esomepra Magnesium Capsule 40 mg Delayed Release (Quantity Level Limit)
• Estradiol Vaginal Cream 0.1 mg/GM (Quantity Level Limit)
• Ethacrynic Tablet Acid 25 mg
• Fluocin Acet Oil Ear 0.01% (Quantity Level Limit)
• Glucose Gel 40%
• Glucose Gel 77.4%
• Glycerin-Hypromellose-Peg 400 Ophthalmic Solution 0.2-0.2-1%
• Hypromellose Ophthalmic Gel 0.3%
• Imbruvica Tablet 140 mg (Quantity Level Limit, Prior Authorization Required)
• Imbruvica Tablet 280 mg (Quantity Level Limit, Prior Authorization Required)
• Imbruvica Tablet 420 mg (Quantity Level Limit, Prior Authorization Required)
• Imbruvica Tablet 560 mg (Quantity Level Limit, Prior Authorization Required)
• Invega Hafye Injection 1092 mg (Prior Authorization Required)
• Invega Hafye Injection 1560 mg (Prior Authorization Required)
• Lactobacillus Acidophilus-Pectin Capsule
• Lactobacillus Capsule
• Lactobacillus Tablet
• Lidocaine 5% Rectal Cream (Quantity Level Limit)
• Magnesium Citrate Solution
• Naphazoline W/ Pheniramine Ophthalmic Solution0.025-0.3%
• Naphazoline W/ Pheniramine Ophthalmic Solution0.027-0.315%
• Neomycin-Polymyxin W/ Pramoxine Cream 1%
• Ozempic Injection 2 mg/3 mL (Step Therapy, Quantity Level Limit)
• Phenylephrine hydrochloride Tablet 10 mg
• Phenylephrine W/ Dm-Gg Liquid 10-18-200 mg/15mL (Quantity Level Limit)
• Phenylephrine W/ Dm-Gg Liquid 2.5-5-100 mg/5mL (Quantity Level Limit)
• Pramoxine Aer 1% Rectal (Quantity Level Limit)
• Probiotic Product - Capsule
• Pseudoephed-Dexchlorphen-Chlophedianol Liquid 30-1-12.5 mg/5mL (Quantity Level Limit)
• Quetiapine Tablet 150 mg extended release
• Quetiapine Tablet 200 mg extended release
• Quetiapine Tablet 300 mg extended release
• Quetiapine Tablet 400 mg extended release
• Quetiapine Tablet 50 mg extended release
• RivastiGMine Dis 13.3 mg/24 (Prior Authorization Required)
• RivastiGMine Dis 4.6 mg/24 (Prior Authorization Required)
• RivastiGMine Dis 9.5 mg/24 (Prior Authorization Required)
• Saline Nasal Gel
• Saline Nasal Solution 0.65%
• Saline Nasal Spray 0.65%
• Sod Fluoride Gel 1.1-5%
• Sod Fluoride Paste 1.1%
• Sodium Phosphates – Enema (Quantity Level Limit)
• Tetrahydrozoline Hydrochloride Ophthalmic Solution 0.05%
• Tramadol Hydrochloride Tablet extended release 24hr 100 mg (Quantity Level Limit, Prior Authorization Required, Age Minimum)
• Tramadol Hydrochloride Tablet extended release 24hr 200 mg (Quantity Level Limit, Prior Authorization Required, Age Minimum)
• Tramadol Hydrochloride Tablet extended release 24hr 300 mg (Quantity Level Limit, Prior Authorization Required, Age Minimum)
• Vancomycin Capsule 125 mg (Quantity Level Limit)
• Vancomycin Capsule 250 mg (Quantity Level Limit)
• Xifaxan Tablet 550 mg (Prior Authorization Required)

Removals:

• Auryxia 210 mg Tablet
• Brimonidine Tartrate-Timolol Maleate Ophthalmic Solution 0.2-0.5%
• Brinzolamide Ophthalmic Suspension 1%
• Butalbital-Acetaminophen-Caff W/ Cod Capsule 50-300-40-30 mg
• Butalbital-Acetaminophen-Caff W/ Cod Capsule 50-325-40-30 mg
• Butalbital-Acetaminophen-Caffeine Capsule 50-325-40 mg
• Butalbital-Aspirin-Caff W/ Codeine Capsule 50-325-40-30 mg
• Butalbital-Aspirin-Caffeine Capsule 50-325-40 mg
• Celontin Capsule 300 mg
• Cequa
• Colchicine Capsule 0.6 mg
• Desmopressin Spray Ref 0.01%
• Diphenoxylate W/ Atropine Liquid 2.5-0.025 mg/5mL
• Duloxetine Capsule 40 mg Delayed Release
• Esbriet 267 mg Capsule
• Estring
• Ibrance Tablet 100 mg
• Ibrance Tablet 125 mg
• Ibrance Tablet 75 mg
• Levofloxacin Ophthalmic Solution 0.5%
• Lidocaine Solution 4%
• Methylphenid Capsule 10 mg long acting
• Methylphenid Capsule 20 mg long acting
• Methylphenid Capsule 30 mg long acting
• Methylphenid Capsule 40 mg long acting
• Methylphenid Capsule 60 mg long acting
• Miconazole Nitrate Ointment 2%
• Miconazole Nitrate Solution 2%
• Naproxen Tablet enteric coated 500 mg
• Oxymorphone Hydrochloride Tablet extended release 12hr 10 mg
• Oxymorphone Hydrochloride Tablet extended release 12hr 15 mg
• Oxymorphone Hydrochloride Tablet extended release 12hr 20 mg
• Oxymorphone Hydrochloride Tablet extended release 12hr 30 mg
• Oxymorphone Hydrochloride Tablet extended release 12hr 40 mg
• Oxymorphone Hydrochloride Tablet extended release 12hr 5 mg
• Oxymorphone Hydrochloride Tablet extended release 12hr 7.5 mg
• Pot & Sod Citrates W/ Cit Ac Solution 550-500-334 mg/5mL
• Sulfacetamide Sodium Ophthalmic Ointment 10%

Other Updates:

• Atomoxetine Capsule 100 mg (Remove Step Therapy, Added Age Minimum)
• Atomoxetine Capsule 10 mg (Remove Step Therapy, Added Age Minimum)
• Atomoxetine Capsule 18 mg (Remove Step Therapy, Added Age Minimum)
• Atomoxetine Capsule 25 mg (Remove Step Therapy, Added Age Minimum)
• Atomoxetine Capsule 40 mg (Remove Step Therapy, Added Age Minimum)
• Atomoxetine Capsule 60 mg (Remove Step Therapy, Added Age Minimum)
• Atomoxetine Capsule 80 mg (Remove Step Therapy, Added Age Minimum)
• Bacitracin Ophthalmic Ointment 500 Unit/GM (Added Quantity Level Limit)
• Bacitracin-Polymyxin B Ophthalmic Ointment (Added Quantity Level Limit)
• Benzonatate Capsule 100 mg
• Benzonatate Capsule 200 mg
• Carboxymethylcellulose Sodium Ophthalmic Gel 1%
• Duloxetine Capsule 20 mg Delayed Release (Quantity Level Limit)
• Erythromycin Ophthalmic Ointment 5 mg/GM (Added Quantity Level Limit)
• Gentamicin Sulfate Ophthalmic Ointment 0.3% (Added Quantity Level Limit)
• Glucose Blood Test Strip
• Hydroc/Homat Tablet 5-1.5 mg
• Hydrocod/Hom Syrup 5-1.5/5
• Levonorgestr Tablet 1.5 mg
• Miconazole Nitrate Vaginal Suppository 1200 mg & 2% Cream Kit

January 2023

Additions:

• Zenpep Cap 40000unt

Removals:

• All Non OneTouch Delica and Delica Plus Lancets and Devices

Other Updates:

• Fingolimod Hcl Cap 0.5 Mg (Base Equiv)

December 2022

Additions:

• Actimmune Inj 2mu/0.5 (Prior A
• uthorization Required)
• Aspercreme   Cre Lidoc 4%
• Aspercreme   Cre Lidocain
• Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 325 Mg
• Bacitracin-Polymyxin-Neomycin-Hc Ophth Oint 1% (Quantity Level Limit)
• Balsalazide Disodium Cap 750 Mg
• Buprenorphine Td Patch Weekly 10 Mcg/Hr (Prior Authorization Required, Quantity Level Limit)
• Buprenorphine Td Patch Weekly 15 Mcg/Hr (Prior Authorization Required, Quantity Level Limit)
• Buprenorphine Td Patch Weekly 20 Mcg/Hr (Prior Authorization Required, Quantity Level Limit)
• Buprenorphine Td Patch Weekly 5 Mcg/Hr (Prior Authorization Required, Quantity Level Limit)
• Buprenorphine Td Patch Weekly 7.5 Mcg/Hr (Prior Authorization Required, Quantity Level Limit)
• Castor Oil 100%
• Cromolyn Sodium Nasal Aerosol Soln 5.2 Mg/Act (4%) (Quantity Level Limit)
• Cyclopentolate Hcl Ophth Soln 2% (Quantity Level Limit)
• Dextromethorphan Hbr Cap 15 Mg
• Dextromethorphan Hbr Liquid 15 Mg/5ml (Quantity Level Limit)
• Dextromethorphan Hbr Syrup 15 Mg/5ml (Quantity Level Limit)
• Dextromethorphan Polistirex Extended Release Susp 30 Mg/5ml (Quantity Level Limit)
• Dextromethorphan-Phenylephrine-Apap Cap 10-5-325 Mg (Quantity Level Limit)
• Dimenhydrinate Tab 50 Mg (Quantity Level Limit)
• Esomeprazole Magnesium Cap Delayed Release 20 Mg (Base Eq)
• Everolimus Tab 10mg (Prior Authorization Required, Quantity Level
  Limit)
• Everolimus Tab 2.5mg (Prior Authorization Required, Quantity Level
• Everolimus Tab 5mg (Prior Authorization Required, Quantity Level
• Everolimus Tab 7.5mg (Prior Authorization Required, Quantity Level
• Foam Antacid Chw 80-20mg
• Glyburide Micronized Tab 1.5 Mg (Quantity Level Limit)
• Glyburide Micronized Tab 3 Mg (Quantity Level Limit)
• Glyburide Micronized Tab 6 Mg (Quantity Level Limit)
• Hydrocortisone Perianal Cream 1%
• Ibandronate Sodium Tab 150 Mg (Base Equivalent) (Quantity Level Limit)
• Intron A Inj 10mu (Prior Authorization Required)
• Intron A Inj 18mu (Prior Authorization Required)
• Intron A Inj 50mu (Prior Authorization Required)
• Konsyl Daily Pow 100%
• Levetiracetam Tab Er 24hr 500 Mg (Quantity Level Limit)
• Levetiracetam Tab Er 24hr 750 Mg (Quantity Level Limit)
• Levonorgestrel-Ethinyl Estradiol (Continuous) Tab 90-20 Mcg
• Lohist-Dm Syp 5-2-10mg
• Magnesium Hydroxide Susp 400 Mg/5ml
• Mineral Oil Heavy
• Mineral Oil Light
• Natacyn Sus 5% Op (Quantity Level Limit)
• Norgestimate-Eth Estrad Tab 0.18-25/0.215-25/0.25-25 Mg-Mcg
• Omeprazole Cap Delayed Release 10 Mg (Quantity Level Limit)
• Phenazopyridine Hcl Tab 99.5 Mg
• Phenol Liquid 1.4%
• Polyethylene Glycol 3350 Oral Packet 17 Gm (Quantity Level Limit)
• Potassium Citrate Tab Er 15 Meq (1620 Mg)
• Promacta Tab 12.5mg (Prior Authorization Required, Quantity Level Limit)
• Promacta Tab 25mg (Prior Authorization Required, Quantity Level Limit)
• Promacta Tab 50mg (Prior Authorization Required, Quantity Level Limit)
• Promacta Tab 75mg (Prior Authorization Required, Quantity Level Limit)
• Simethicone Cap 125 Mg
• Simethicone Cap 180 Mg
• Simethicone Chew Tab 125 Mg
• Simethicone Chew Tab 80 Mg
• Sirolimus Tab 1 Mg
• Sirolimus Tab 2 Mg
• Sodium Chloride Aero Soln 0.9%
• Sodium Chloride Soln Nebu 10%
• Sodium Chloride Soln Nebu 3%
• Sodium Chloride Soln Nebu 7%
• Sodium Fluoride Cream 1.1%
• Sodium Fluoride Gel 1.1% (0.5% F)
• Sodium Fluoride Rinse 0.2%
• Sodium Pow Bicarbon
• Soltamox Sol 10mg/5ml
• Sorbitol Sol 70%
• Synagis Inj 100mg/Ml (Prior Authorization Required)
• Synagis Inj 50mg (Prior Authorization Required)
• Temozolomide Cap 100 Mg
• Temozolomide Cap 140 Mg
• Temozolomide Cap 180 Mg
• Temozolomide Cap 20 Mg
• Temozolomide Cap 250 Mg
• Temozolomide Cap 5 Mg
• Testosterone Td Gel 10mg/Act (2%) (Prior Authorization Required, Quantity Level Limit)
• Today Sponge Mis (Quantity Level Limit)
• White Petrolatum-Mineral Oil Ophth Ointment

Removals:

• Benztropine Inj 2mg/2ml
• Brompheniramine & Phenylephrine Elixir 1-2.5 Mg/5ml
• Brompheniramine & Pseudoephedrine Elixir 1-15 Mg/5ml
• Calcitriol Inj 1 Mcg/Ml
• Calcium Carbonate (Antacid) Chew Tab 420 Mg
• Calcium Carbonate-Simethicone Chew Tab 1000-60 Mg
• Cascara Ext Sagrada
• Chlorpheniramine & Phenylephrine Tab 4-10 Mg
• Chlorpheniramine & Pseudoephedrine Tab 4-60 Mg
• Chlorpromazine Hcl Inj 25 Mg/Ml
• Chlorpromazine Hcl Inj 50 Mg/2ml
• Cvs Daily Pow Fiber
• Dexamethasone Sod Phosphate Preservative Free Inj 10 Mg/Ml
• Dextromethorphan-Guaifenesin Liquid 30-200 Mg/5ml
• Di-Gel Sus
• Docusate Sodium Cap 50 Mg
• Fleet Liquid Ene Glycerin
• Fluphenazine Hcl Oral Conc 5 Mg/Ml
• Guaifenesin-Codeine Liquid 225-7.5 Mg/5ml
• Hycamtin Cap 0.25mg
• Hycamtin Cap 1mg
• Hydrocil Ins Pow 95%
• Hydrocod Polst-Chlorphen Polst Er Susp 10-8 Mg/5ml
• Hydrocodone-Ibuprofen Tab 10-200 Mg
• Hydrocodone-Ibuprofen Tab 5-200 Mg
• Ibuprofen-Diphenhydramine Citrate Tab 200-38 Mg
• Isopto Tears Sol 0.5% Op
• Ketoprofen Cap 200mg Er
• Konsyl Daily Pow 28.3%
• Konsyl Daily Pow 60.3%
• Konsyl-D Pow 52.3%
• Lansoprazole Tab Delayed Release Orally Disintegrating 15 Mg
• Lansoprazole Tab Delayed Release Orally Disintegrating 30 Mg
• Linzess Cap 145mcg
• Linzess Cap 290mcg
• Linzess Cap 72mcg
• Lohist-D Liq
• Lorazepam Inj 2 Mg/Ml
• Magnesium Oxide Tab 250 Mg
• Magnesium Oxide Tab 420 Mg
• Metamucil Pow 28%
• Metamucil Pow 58.12%
• Metamucil Pow Mh/Orig
• Mineral Oil Enema
• Mycophenolic Tab 180mg Dr
• Mycophenolic Tab 360mg Dr
• Nilutamide Tab 150 Mg
• Norethindrone & Ethinyl Estradiol-Fe Chew Tab 0.4 Mg-35 Mcg
• Norethindrone & Ethinyl Estradiol-Fe Chew Tab 0.8 Mg-25 Mcg
• Nozin Nasal Kit Sanitize
• Nozin Nasal Mis Sanitize
• Prednisolone Sod Phos Orally Disintegr Tab 10 Mg (Base Eq)
• Prednisolone Sod Phos Orally Disintegr Tab 15 Mg (Base Eq)
• Prednisolone Sod Phos Orally Disintegr Tab 30 Mg (Base Eq)
• Prednisolone Sod Phosphate Oral Soln 20 Mg/5ml (Base Equiv)
• Prednisone Con 5mg/Ml
• Pseudoephedrine-Guaifenesin Syrup 30-100 Mg/5ml
• Pseudoephedrine-Guaifenesin Tab 40-400 Mg
• Psyllium Powder 100%
• Psyllium Powder 95%
• Rowasa Sf Ene 4gm X 28
• Simethicone Liquid 40 Mg/0.6ml
• Sucralfate Susp 1 Gm/10ml
• Triamcinolone Acetonide Cream 0.1%
• Trimipramine Maleate Cap 100 Mg
• Trimipramine Maleate Cap 25 Mg
• Trimipramine Maleate Cap 50 Mg
• Tusnel Liq

Other Updates:

• Fingolimod Hcl Cap 0.5 Mg (Base Equiv)
• Fluticasone Propionate Nasal Susp 50 Mcg/Act
• Histex Pd Dro 0.938mg
• Isotretinoin Cap 10 Mg
• Isotretinoin Cap 20 Mg
• Isotretinoin Cap 30 Mg
• Isotretinoin Cap 40 Mg
• Lidocaine Hcl Cream 4% (Quantity Level Limit)

November 2022

Additions:

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

Removals:

• None

Other Updates:

• Artificial Sol Tears
• Guaifenesin Tab Er 12hr 1200 Mg
• Lubricant Dro Eye 0.6%
• Olopatadine Dro 0.1%
• Pseudoephedrine-Guaifenesin Tab Er 12hr 60-600 Mg

October 2022

Additions:

• None

Removals:

• Meloxicam Susp 7.5 Mg/ 5Ml

Other Updates:

• Lenalidomide Cap 2.5 Mg
• Lenalidomide Cap 5 Mg
• Lenalidomide Cap 10 Mg
• Lenalidomide Cap 15 Mg
• Lenalidomide Cap 20 Mg
• Lenalidomide Cap 25 Mg
• Dabigatran Etexilate Mesylate Cap 75 Mg
• Dabigatran Etexilate Mesylate Cap 150 Mg 

September 2022

Additions:

• Benzoyl Peroxide Liquid 4%
• Benzoyl Peroxide Lotion 5%
• Bicillin L-A Suspension 2400000 Unit/4ml (Penicillin G Benzathine)
• Calamine Lotion
• Calamine-Zinc Oxide Lotion 8-8%
• Cefixime Cap 400mg (Quantity Level Limit)
• Doxycycline Monohydrate Tab 100 Mg
• Doxycycline Sus 25mg/5ml (Age Limit)
• Eplerenone Tab 25 Mg
• Eplerenone Tab 50 Mg
• Fenofibrate Tab 145 Mg
• Fenofibrate Tab 48 Mg
• Fluocinonide Cream 0.1% (Quantity Level Limit)
• Glucagon Kit (Quantity Level Limit)
• Ivermectin Lotion 0.5% (Step Therapy Required, Quantity Level Limit)
• Memantine Tab Hcl 10 Mg (Quantity Level Limit)
• Memantine Tab Hcl 5 Mg (Quantity Level Limit)
• Methenam Man Tab 1000 Mg
• Methenam Man Tab 500 Mg
• Metronidazole Gel 1% (Step Therapy Required, Quantity Level Limit)
• Olmesartan Medoxomil Tab 20 Mg (Quantity Level Limit)
• Olmesartan Medoxomil Tab 40 Mg (Quantity Level Limit)
• Olmesartan Medoxomil Tab 5 Mg (Quantity Level Limit)
• Olopatadine Ophth Soln 0.2% Otc
• One Touch Ultra 2 System Kit
• One Touch Ultra 2 System Kit (With One Touch Delica Plus)
• One Touch Ultra Mini System Kit Silver Moon
• One Touch Verio Flex System Kit
• One Touch Verio IQ System Kit
• One Touch Verio Reflect
• One Touch Verio System Kit
• Pataday Ophth Soln 0.7% Otc
• Permethrin Liquid 1%
• Phospho-Trin K500 Tab 500 Mg
• Propranolol Sol 20 Mg/5 Ml
• Selenium Sulfide Shampoo 1%
• Symjepi Prefilled Syringe 0.15 Mg/0.3ml Injection (Quantity Level Limit)
• Symjepi Prefilled Syringe 0.3 Mg/0.3ml Injection (Quantity Level Limit)
• Tetrabenazin Tab 12.5 Mg (Prior Authorization, Quantity Limit)
• Tetrabenazin Tab 25 Mg (Prior Authorization, Quantity Limit)
• Triamcinolone Acetonide Ointment 0.05% (Quantity Level Limit)
• Triprolidine Hcl Drops 0.938 Mg
• PediaClear PD Liquid 0.625 mg (Triprolidine Hcl Liquid)
• Histex Syrup 2.5 Mg/5ml (Triprolidine Hcl Syrup)
• Voriconazole Tab 200 Mg (Prior Authorization)
• Voriconazole Tab 50 Mg (Prior Authorization)

Removals:

• Adapalene Cream 0.1%
• Amcinonide Ointment 0.1%
• Amiodarone Hcl Tablet 400mg
• Amoxicillin & K Clavulanate Tab Er 12hr 1000-62.5 Mg
• Atovaquone Sus 750/5ml
• Benzepro Aer 5.3%
• Capzasin-P Cre 0.035%
• Carbinoxamin Sol 4mg/5ml
• Carbinoxamine Maleate Tablet 4mg
• Cefaclor Cap 250 Mg
• Cefaclor Cap 500 Mg
• Cefpodoxime Proxetil For Susp 100 Mg/5ml
• Cefpodoxime Proxetil For Susp 50 Mg/5ml
• Clemastine Tab 12 Hour
• Diltiazem Cap 120mg Er
• Diltiazem Cap 60mg Er
• Diltiazem Cap 90mg Er
• Diphenhydram Chw 12.5mg
• Diphenhydram Elx 12.5/5ml
• Diphenhydramine Tab 12.5mg
• Flunisolide Nasal Spray
• Fluvastatin Sodium Tab Er 24 Hr 80 Mg (Base Equivalent)
• Glucagen Kit
• Isradipine Cap 2.5mg
• Isradipine Cap 5mg
• Itraconazole Sol 10mg/Ml
• K-Phos Tab
• Lidocaine Cre 3%
• Lidocaine Jelly 2%
• Methazolamide Tab 25 Mg
• Methazolamide Tab 50 Mg
• Metronidazole Cap 375 Mg
• Mometasone Furoate Nasal Spray 50mcg
• Nicardipine Cap 20mg
• Nicardipine Cap 30mg
• Nystat/Triam Cre
• Nystat/Triam Oin
• Olmesart Hct Tab 20-12.5
• Olmesart Hct Tab 40-12.5
• Olmesart Hct Tab 40-25mg
• Ovace Plus Cre 10%
• Perindopril Erbumine Tab 2 Mg
• Perindopril Erbumine Tab 4 Mg
• Perindopril Erbumine Tab 8 Mg
• Propafenone Cap 225mg Er
• Propafenone Cap 325mg Er
• Propafenone Cap 425mg Er
• Pyrethrins-Piperonyl Butoxide Shampoo
• Ryclora Sol 2mg/5ml
• Selenium Sulfide Shampoo 2.25%
• Sulfacetamide Sodium Liquid 10%
• Vancomycin Hcl Iv Soln 1250 Mg/250ml (Base Equivalent)
• Vancomycin Hcl Iv Soln 1750 Mg/350ml (Base Equivalent)
• Vancomycin Hcl Iv Soln 750 Mg/150ml (Base Equivalent)
• Vemlidy
• Zafirlukast Tab 10mg
• Zafirlukast Tab 20mg

Other Updates:

• Acyclovir Cap 200 Mg (Removed Quantity Level Limit)
• Acyclovir Tab 400 Mg (Removed Quantity Level Limit)
• Acyclovir Tab 800 Mg (Removed Quantity Level Limit)
• Epinephrine Solution Auto-Injector 0.15 Mg/0.15ml (1:1000) (Added Quantity Level Limit)
• Epinephrine Solution Auto-Injector 0.15 Mg/0.3ml (1:2000) (Added Quantity Level Limit)
• Epinephrine Solution Auto-Injector 0.3 Mg/0.3ml (1:1000) (Added Quantity Level Limit)
• Ezetimibe Tab 10 Mg (Removed Step Therapy)
• Glucagon Inj Emergncy (Added Quantity Level Limit)
• Omega-3-Acid Ethyl Esters Cap 1 Gm (Removed Step Therapy)
• Valacyclovir Hcl Tab 1 Gm (Removed Quantity Level Limit)
• Valacyclovir Hcl Tab 500 Mg (Removed Quantity Level Limit)

August 2022

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

July 2022

Additions:

• Apretude Susp IM ER 600mg/3ml
• Cabenuva Susp IM ER 400 & 600mg/2ml
• Cabenuva Susp IM ER 600 & 900mg/3ml
• Cimduo Tab 300-300mg
• Delstrigo Tab 100-300-300mg
• Isentress Packet 100mg
• Pifeltro Tab 100mg
• Rukobia Tab ER 600mg
• Trogarzo Soln 200mg/1.33ml IV
• Vitekta Tab 150mg
• Vitekta Tab 85mg
• Vocabria Tab 30mg

Removals:

• Oxycodone/Acetaminophen Soln 5-325mg/5ml

Other Updates:

• HIV Medications (Removed Prior Authorization, Step Therapy)
• Tivicay PD Tab Soluble 5mg (Removed Age Limit)

June 2022

Additions:

• Bacitracin-Polymyxin B Oint
• Benzoyl Peroxide Gel 10%
• Clotrimazole Sol 1% (Quantity Limit)
• Ery Pad 2%
• Fexofenadine Tab 180mg (Quantity Limit)
• Fexofenadine Tab 60mg (Quantity Limit)
• Gvoke Hypo 1 Inj .5/.1ml (Quantity Limit)
• Gvoke Pfs1pk Syn 1mg/0.2 (Quantity Limit)
• Pregabalin Cap 200mg (Prior Authorization, Quantity Limit)

Removals:

• No updates

Other Updates:

• No updates

May 2022

Additions:

• Ozempic Inj 8mg/3ml (Step Therapy, Quantity Limit)
• Triumeq Pd Tab (Prior Authorization, Quantity Limit)

Removals:

• No updates

Other Updates:

• No updates

April 2022

Additions:

• Descovy Tab 120-15MG (Prior Authorization, Quantity Limit)

Removals:

• No updates

Other Updates:

• No updates

March 2022

Additions:

• No updates

Removals:

• No updates

Other Updates:

• No updates

February 2022

Additions:

• Naloxone Hcl Nasal Spray 4 Mg/0.1ml (Quantity Limit)

Removals:

• Narcan Hcl Nasal Spray 4 Mg/0.1ml

Other Updates:

• No updates

January 2022

Additions:

Etravirine Tab 100mg (Prior Authorization, Quantity Limit)

Etravirine Tab 200mg (Prior Authorization, Quantity Limit)

Gvoke Kit Inj 1mg/0.2 (Quantity Limit)

Atropine Sul Sol 1% Op

Removals:

Intelence TAB 100MG

Intelence TAB 200MG

Isopto Atropine Sol 1%

Concept Ob Cap

Mynatal Tab

Pr Natal 400 Pak

Other Updates:

No updates

December 2021

Additions:

Esomepra Mag Otc Tab 20 Mg

Insulin Glar Inj 100u/Ml

Insulin Glar Sol 100u/Ml

Mavyret Pak 50-20mg (Prior Authorization)

Removals:

Semglee      Sol 100u/Ml

Other Updates:

No updates

November 2021

Additions:

No updates

Removals:

Buprenorphine Extended Release Soln Pref Syr 100 Mg/0.5

Buprenorphine Extended Release Soln Pref Syr 300 Mg/1.5

Other Updates:

No updates

October 2021

Additions:

Sunitinib Cap 12.5mg

Sunitinib Cap 25mg

Sunitinib Cap 37.5mg

Sunitinib Cap 50mg

Removals:

Sutent CAP 12.5MG

Sutent CAP 25MG

Sutent CAP 37.5MG

Sutent CAP 50MG

Other Updates:

No updates

September 2021

Additions:

No updates

Removals:

No updates

Other Updates:

No updates

August 2021

Additions:

Baqsimi Pow 3mg/Dose (Quantity Limit)

Endari Pow 5gm (Prior Authorization)

Inlyta Tab 1mg (Prior Authorization, Quantity Limit)

Inlyta Tab 5mg (Prior Authorization, Quantity Limit)

Nayzilam Spr 5mg) (Prior Authorization, Quantity Limit)

Pregabalin Cap 100 Mg (Quantity Limit)

Pregabalin Cap 150 Mg (Quantity Limit)

Pregabalin Cap 225 Mg (Quantity Limit)

Pregabalin Cap 25 Mg (Quantity Limit)

Pregabalin Cap 300 Mg (Quantity Limit)

Pregabalin Cap 50 Mg (Quantity Limit)

Pregabalin Cap 75 Mg (Quantity Limit)

Prolia Sol 60mg/Ml (Prior Authorization, Quantity Limit)

Semglee Sol 100u/Ml

Sofos/Velpat Tab 400-100 (Prior Authorization, Quantity Limit)

Removals:

Ibrance Cap 100mg

Ibrance Cap 125mg

Ibrance Cap 75mg

Lidocaine-Hydrocortisone Ace Cream 3-0.5% rectal

Methoxsalen Cap 10mg

Nexavar Tab 200mg

Other Updates:

No updates

July 2021

Additions:

No updates

Removals:

No updates

Other Updates:

No updates

June 2021

Additions:

No updates

Removals:

No updates

Other Updates:

Trulicity pen-inj 0.75mg/0.5mL (Added Quantity Level Limit)

Trulicity pen-inj 1.5mg/0.5mL (Added Quantity Level Limit)

Trulicity pen-inj 3mg/0.5mL (Added Quantity Level Limit)

Trulicity pen-inj 4.5mg/0.5mL (Added Quantity Level Limit)

May 2021

Additions:

No updates

Removals:

No updates

Other Updates:

No updates

April 2021

Additions:

Brinzolamide Sus 1% (Quantity Level Limit, Step Therapy)

Removals:

Azopt Sus 1%

Other Updates:

No updates

March 2021

Additions:

Bevespi Aerosol 9-4.8mcg (Quantity Level Limit)

Cequa Solution 0.09% PF (Prior Authorization Required)

Doxycycline Hyclate Cap 50mg, 100mg

Doxycycline Hyclate Tab 100mg

Esbriet Cap 267mg (Prior Authorization Required)

Esbriet Tab 267mg, 801mg (Prior Authorization Required)

Fluticasone-Salmeterol Aerosol 100-50mcg (Quantity Level Limit)

Hizentra Injection 1gm/ml, 2gm/10ml, 4gm/20ml (Prior Authorization Required)

Hizentra Solution 20% (Prior Authorization Required)

Hizentra Vial 1gm/5ml, 10gm/50ml (Prior Authorization Required)

Icosapent Cap 1gm (Quantity Level Limit)

Myleran Tab 2mg

Ocrevus Injection 300/10ml (Quantity Level Limit)

Potassium & Sodium Citrate W/ Citric Acid Solution 550-500-334mg/5ml

Privigen Injection 40grams (Prior Authorization Required)

Rabeprazole Tab 20mg (Quantity Level Limit)

Trulicity Injection 0.75mg/0.5ml, 1.5mg/0.5ml, 3mg/0.5ml, 4.5mg/0.5ml (Step Therapy Required)

Tukysa Tab 50mg, 150mg (Prior Authorization Required)

Valtoco Liquid 20mg (Quantity Level Limit)

Valtoco Spray 5mg, 10mg (Quantity Level Limit)

Removals

Anoro Ellipta Aero 62.5-25mcg/inh

Atrovent Hfa Aero 17mcg

Breo Ellipta Inhaler 100-25mcg/inh, 200-25mcg/inh

Cefaclor For Suspension 125mg/5ml, 250mg/5ml, 375mg/5ml

Clarithromycin Tab Extended Release 24Hr 500mg

Combivent Aero 20-100mcg/act

Diazepam Intensol 5mg/ml

Doxycycline Monohydrate Tab 50mg, 75mg, 100mg

Epogen Injecton 2000/ml, 3000/ml, 4000/ml, 10000/ml, 20000/ml

Fulphila Injection 6mg/0.6ml

Gammaked Injection 1gm/10ml, 5gm/50ml, 10gm/100ml, 20gm/200ml

Hyoscyamine Drops 0.125mg/ml

Janumet Tab 50-500mg, 50-1000mg

Janumet Xr Tab 50-500mg, 50-1000mg, 100-1000mg

Januvia Tab 25mg, 50mg, 100mg

Nivestym Injection 300mcg, 480mcg

Nivestym Injection Syringe 300mcg/0.5ml, 480mcg/0.8ml

Ofev Cap 100mg, 150mg

Victoza Injection 18mg/3ml

 

Other Updates:

Albuterol Aero Hfa (Changed Quantity Level Limit)

Arnuity Ellipta Inhaler 50mcg, 100mcg, 200mcg (Added Quantity Level Limit)

Azithromycin Suspension 100mg/5ml, 200mg/5ml (Added Age Limit)

Cefadroxil Suspension 250mg/5ml, 500mg/ml (Added Age Limit)

Cefdinir Suspension 125mg/5ml, 250mg/5ml (Added Age Limit)

Cefpodoxime Proxetil Suspension 50mg/5ml, 100mg/5ml (Added Age Limit)

Cefprozil Suspension 125mg/5ml, 250mg/5ml (Added Age Limit)

Cephalexin Suspension 125mg/5ml, 250mg/5ml (Added Age Limit)

Clarithromycin Suspension 125mg/5ml, 250mg/5ml (Added Age Limit)

Extavia Injection 0.3mg (Added Quantity Level Limit)

Glatiramer Injection 40mg/ml (Added Quantity Level Limit)

Levalbuterol Tartrate Aerosol 45mcg/Act (Added Quantity Level Limit)

Levofloxacin Solution 25mg/ml (Added Age Limit)

Neomycin-Polymyxin-Dexamethasone Ophthalmic Ointment 0.1% (Added Quantity Level Limit)

Ondansetron Tablet Dispersible 4mg (Changed Quantity Level Limit)

Phenylephrine Hcl Ophthalmic Solution 2.5% (Added Quantity Level Limit)

Rebif Injection 44mcg/0.5ml (Added Quantity Level Limit)

Rebif Rebido Injection 22mcg/0.5ml, 44mcg/0.5ml (Added Quantity Level Limit)

Rebif Rebidose Titration Pack (Added Quantity Level Limit)

Rebif Titration Injection Pack (Added Quantity Level Limit)

Santyl Ointment 250 Unit/gm (Added Quantity Level Limit)

February 2021

No updates

January 2021

Additions:

Retacrit Injection 20000 Units (Prior Authorization Required)

December 2020

Additions:

Trelegy Ellipta Aerosol 200-62.5-25mcg (Step Therapy Required, Quantity Level Limit)

November 2020

Additions:

 

Demethyl Fumarate Starter Pack 120mg & 240mg (Prior Authorization Required, Quantity Level Limit)

 

 

Emtricitabine Cap 200mg (Prior Authorization Required, Quantity Level Limit)

 

 

Removals:

 

Emtriva Cap

 

 

Tecfidera Starter Pack 120mg & 240mg

 

 

 

October 2020

Additions:

 

Dimethyl Fumarate Delayed Release Caps 120mg, 240mg (Prior Authorization Required, Quantity Level Limit)

 

 

Efavirenz-Lamivudine-Tenofovir DF Tabs 400-300-300mg, 600-300-300mg (Prior Authorization Required, Quantity Level Limit)

 

 

Emtricitabine-Tenofovir Disoproxil Fumarate Tab 200-300mg (Prior Authorization Required, Quantity Level Limit)

 

 

Vancomycin HCL IV Sol’n 750mg/150ml, 1250mg/250ml, 1750mg/350ml

 

 

Removals:

 

Prenatrix Tab

 

 

Psyldex Powder 30%

 

 

SB Fiber Laxative Powder 33%

 

 

SB Natural Fiber Laxative Power 49%

 

 

Symfi Lo Tab 400-300-300mg

 

 

Symfi Tab 600-300-300mg

 

 

Tecfidera Caps Delayed Release 120mg, 240mg

 

 

Vitrexyl Tabs

 

 

Truvada Tab 200-300mg

 

 

September 2020

Additions:

 

Abiraterone Tab 250mg (Prior Authorization Required)

 

 

Alecensa Cap 150mg (Prior Authorization Required)

 

 

Austedo Tabs 6mg, 9mg, 12mg (Prior Authorization Required)

 

 

Bexarotene Cap 75mg (Prior Authorization Required) 

 

 

Budesonide Cap 3mg (Step Therapy Required, Quantity Level Limit)

 

 

Caprelsa Tabs 100mg, 300mg (Prior Authorization Required)

 

 

Cinacalcet Tabs 30mg, 60mg, 90mg (Prior Authorization Required)

 

 

Cyclophosphamide Caps 25mg, 50mg 

 

 

Enbrel Inj 25mg/0.5ml (Prior Authorization Required, Quantity Level Limit)

 

 

Erivedge Cap 150mg (Prior Authorization Required)

 

 

Gilotrif Tabs 20mg, 30mg, 40mg (Prior Authorization Required)

 

 

Jakafi Tabs 5mg, 10mg, 15mg, 20mg, 25mg (Prior Authorization Required) 

 

 

Kalydeco Pak 25mg, 50mg, 75mg (Prior Authorization Required)

 

 

Kalydeco Tab 150mg (Prior Authorization Required)

 

 

Lenvima Caps Therapy Pack 4mg, 8mg, 10mg, 12mg, 14mg, 18mg, 20mg, 24mg (Prior Authorization Required)

 

 

Linezolid Tab 600mg (Prior Authorization Required) 

 

 

Mekinist Tabs 0.5mg, 2mg (Prior Authorization Required)

 

 

Ofev Caps 100mg, 150mg (Prior Authorization Required)

 

 

Omeprazole DR Tab 20mg (OTC) (Quantity Level Limit)

 

 

Repatha Inj 140mg/ml (Prior Authorization Required) 

 

 

Repatha Push Inj 420/3.5ml (Prior Authorization Required)

 

 

Repatha Sure Inj 140mg/ml (Prior Authorization Required)

 

 

Rydapt Cap 25mg (Prior Authorization Required)

 

 

Soliris Inj 10mg/ml (Prior Authorization Required) 

 

 

Symdeko Tabs 50-75mg, 100-150mg (Prior Authorization Required)

 

 

Tafinlar Caps 50mg, 75mg (Prior Authorization Required)

 

 

Venclexta Tab Starter Pak (Prior Authorization Required)

 

 

Venclexta Tabs 10mg, 50mg, 100mg (Prior Authorization Required) 

 

 

Xolair Inj 75/0.5ml, 100mg/ml (Prior Authorization Required)

 

 

Xolair Sol 150mg (Prior Authorization Required)

 

 

Removals:

Travoprost (BAK Free) 0.004% Ophthalmic Sol

Other updates:

 

Aripiprazole Tabs 2mg, 5mg, 10mg, 15mg, 20mg, 30mg (Age Limit)

 

 

Clozapine Tabs 25mg, 50mg, 100mg, 200mg (Age Limit)

 

 

Olanzapine ODT Tabs 5mg, 10mg, 15mg, 20mg (Age Limit)

 

 

Olanzapine Tabs 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg (Age Limit)

 

 

Proton Pump Inhibitors (Quantity Level Limit)

 

 

Quetiapine Tabs 25mg, 50mg, 100mg, 200mg, 300mg, 400mg (Age Limit)

 

 

Risperidone ODT Tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg (Age Limit)

 

 

Risperidone Solution 1mg/ml (Age Limit)

 

 

Risperidone Tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg (Age Limit)

 

 

Ziprasidone Caps 20mg, 40mg, 60mg, 80mg (Age Limit)

 

 

August 2020

Additions:

 

Amitiza Caps 8mcg, 24mcg (Prior Authorization Required, Age Limit, Quantity Level Limit)

 

 

Athlete's Foot (Miconazole Nitrate) Powder 2% (Quantity Level Limit)

 

 

Diclofenac Solution 1.5% (Step Therapy Required, Quantity Level Limit)

 

 

Ibrance Caps 75mg, 100mg, 125mg (Prior Authorization Required, Quantity Level Limit)

 

 

Ibrance Tabs 75mg, 100mg, 125mg (Prior Authorization Required, Quantity Level Limit)

 

 

Lynparza Tabs 10mg, 15mg (Prior Authorization Required, Quantity Level Limit)

 

 

Miconazole Nitrate Aerosol Powder 2% (Quantity Level Limit)

 

 

Poly-Vi-Sol Solution 50mg/ml

 

 

Ropinirole ER Tabs 2mg, 4mg, 6mg, 8mg, 12mg (Step Therapy Required)

 

 

Solifenacin Succinate Tabs 5mg, 10mg (Step Therapy Required, Quantity Level Limit)

 

 

Symproic Tab 0.2mg (Prior Authorization Required, Quantity Level Limit)

 

 

Testosterone Gel 1.62% (Prior Authorization Required, Quantity Level Limit)

 

 

Testosterone Gel Pump 1% (Prior Authorization Required)

 

 

Testosterone TD Solution 30mg/Actuation (Prior Authorization Required, Quantity Level Limit)

 

 

Tivicay PD Tab 5mg (Prior Authorization Required, Age Limit)

 

 

Trelegy Ellipta Inhaler 100-62.5-25mcg (Step Therapy Required, Quantity Level Limit)

 

 

Tri-Vi-Sol Solution A/C/D

 

 

Removals:

 

Cimduo Tab 300-300mg

 

 

Fluocinolone Acetonide Solution 0.01%

 

 

Fluorouracil Cream 0.5%

 

 

Humulin 70/30

 

 

Humulin N

 

 

Humulin R

 

 

Kitabis Solution 300mg/5ml

 

 

Naproxen Sodium Tab 275mg 

 

 

Nimodipine Cap 30mg

 

 

Targretin Gel 1%

 

 

Tolmetin Cap 400mg

 

 

Tolmetin Tabs 200mg, 600mg

 

 

Other updates:

 

Acetic Acid/Hydrocortisone OTIC Solution (Quantity Level Limit)

 

 

Adapalene Gel 0.1% RX (Removed Step Therapy)

 

 

Auryxia Tab 210mg (Step Therapy Required)

 

 

Betamethasone Dipropionate Aug 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 HCl Cream 1% (Quantity Level Limit)

 

 

Candesartan Cilexetil – Hydrochlorothiazide Tabs 16-12.5mg, 32-12.5mg, 32-25mg (Step Therapy Required)

 

 

Candesartan Cilexetil Tabs 4mg, 8mg, 16mg, 32mg (Step Therapy Required)

 

 

Ciclopirox Olamine Cream 0.77% (Quantity Level Limit)

 

 

Ciclopirox Olamine Suspension 0.77% (Quantity Level Limit)

 

 

Ciclopirox Shampoo 1% (Quantity Level Limit)

 

 

Ciclopirox Solution 8% (Quantity Level Limit) 

 

 

Ciprofloxacin OTIC Solution 0.2% (Quantity Level Limit)

 

 

Clindamycin Gel 1% (Quantity Level Limit)

 

 

Clindamycin Lotion 1% (Quantity Level Limit)

 

 

Clindamycin Pads 1% (Quantity Level Limit)

 

 

Clindamycin Solution 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 Tabs 250mg, 500mg (Quantity Level Limit)

 

 

Ear Drops (Carbamide Peroxide) OTIC Solution 6.5% (Quantity Level Limit)

 

 

Erythromycin Gel 2% (Quantity Level Limit)

 

 

Erythromycin Solution 2% (Quantity Level Limit)

 

 

Fluocinonide Cream 0.05% (Quantity Level Limit)

 

 

Fluocinonide Solution 0.05% (Quantity Level Limit)

 

 

Fluvastatin Caps 20mg, 40mg (Step Therapy Required)

 

 

Hydrocortisone Cream 0.5%, 1%, 2.5% (Quantity Level Limit) 

 

 

Hydrocortisone Lotion 1%, 2.5% (Quantity Level Limit)

 

 

Hydrocortisone Ointment 0.5%, 1%, 2.5% (Quantity Level Limit)

 

 

Ketoconazole Cream 2% (Quantity Level Limit)

 

 

Ketoconazole Shampoo 2% (Quantity Level Limit)

 

 

Lidocaine Ointment 5% (Quantity Level Limit)

 

 

Linzess Caps 72mcg, 145mcg, 290mcg (Prior Authorization Required)

 

 

Liothyronine Tab 25mcg (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 Tab 50mg (Quantity Level Limit)

 

 

Neomycin-Polymyxin-HC OTIC Solution 1% (Quantity Level Limit)

 

 

Neomycin-Polymyxin-HC OTIC Suspension 3.5mg/ml-10000 Unit/ml (Quantity Level Limit)

 

 

Nystatin Cream 100000 Units/gm (Quantity Level Limit)

 

 

Nystatin Ointment 100000 Units/gm (Quantity Level Limit) 

 

 

Nystatin Topical Powder 100000 Units/gm (Quantity Level Limit)

 

 

Ofloxacin OTIC Solution 0.3% (Quantity Level Limit)

 

 

Permethrin Cream 5% (Quantity Level Limit)

 

 

Permethrin Lotion 1% (Quantity Level Limit)

 

 

Prednicarbate Ointment 0.1% (Quantity Level Limit)

 

 

Scalp Relief Max Strength (Hydrocortisone) Solution 1% (Quantity Level Limit)

 

 

Stop Lice Maximum Strength (Pyrethrins-Piperonyl Butoxide) Liquid 0.33-4% (Quantity Level Limit)

 

 

Sulfacetamide Lotion 10% (Quantity Level Limit) 

 

 

Terbinafine Cream 1% (Quantity Level Limit)

 

 

Tolnaftate Cream 1% (Quantity Level Limit)

 

 

Triamcinolone Acetonide Cream 0.025%, 0.1%, 0.5% (Quantity Level Limit)

 

 

Triamcinolone Acetonide Lotion 0.025%, 0.1% (Quantity Level Limit)

 

 

Triamcinolone Acetonide Ointment 0.025%, 0.5% (Quantity Level Limit)

 

 

July 2020

Additions:

Gvoke PFS Injection 0.5mg/0.1ml (Quantity Level Limit)

Other updates:

 

Glucagon Emergency Kit 1mg (Quantity Level Limit)

 

 

Matulane Cap 50mg (Prior Authorization Required)

 

 

June 2020

Additions:

 

Acne Medication Lotion (Benzoyl Peroxide) 10%

 

 

Alahist-D Tab 17.5-10mg

 

 

Atovaquone-Proguanil Tabs 62.5-25mg, 250mg-100mg (Quantity Level Limit)

 

 

Benzoyl Peroxide Gel 2.5%

 

 

Claravis Caps 10mg, 20mg, 30mg, 40mg (Step Therapy, Quantity Level Limit)

 

 

Dovato Tab 50-300mg (Quantity Level Limit)

 

 

Gvoke Hypopen Inj (Quantity Level Limit)

 

 

Isotretinoin Caps 10mg, 20mg, 30mg, 40mg (Step Therapy, Quantity Level Limit)

 

 

Jock Itch/Athlete’s Foot Spray (Tolnaftate) Aerosol Powder 1% (Quantity Level Limit)

 

 

Primaquine Tab 26.3mg (Quantity Level Limit)

 

 

Other updates:

Clotrimazole Solution 1% (Removed Step Therapy)

May 2020

Additions:

 

Dexamethasone Concentrate 1mg/ml

 

 

Dexamethasone Vials 20mg/5ml, 120mg/30ml, 10mg/ml

 

 

Solu-Cortef PF Vial 100mg, 250mg, 500mg, 1000mg

 

 

Pyrimethamine Tab 25mg (Generic) (Prior Authorization Required)

 

 

Removals:

Daraprim Tab (Brand)

April 2020

Additions:

 

Aripiprazole Tab 2mg, 5mg, 10mg, 15mg, 20mg, 30mg (Generic) (Age Limit, Quantity Level Limit)

 

 

Omeprazole Tab Delayed Release Disintegrating 20 Mg (OTC) (Quantity Level Limit) 

 

 

Orkambi Packet 100-125mg, 200-125mg (Prior Authorization Required)

 

 

Orkambi Tab 100-125mg, 200-125mg (Prior Authorization Required) 

 

 

Tramadol Hcl Tab 100mg (Quantity Level Limit)

 

 

Removals:

 

Diphenhydramine Hcl Liquid 6.25mg/ml

 

 

Polyethylene Glycol 3350 Oral Packet

 

 

Psyllium Powder Packet 100%

 

 

Sennosides Tab 17.2mg

 

 

Sodium Bicarbonate Powder

 

 

Other updates:

 

Chloroquine Tabs 250mg, 500mg (Prior Authorization Required, Quantity Level Limit)

 

 

Hydroxychloroquine Tab 200mg (Prior Authorization Required, Quantity Level Limit)

 

 

Kaletra Tabs (Quantity Level Limit)

 

 

Lopinavir-Ritonavir Solution 400-100mg/5ml (Quantity Level Limit) 

 

 

March 2020

Additions:

 

Budesonide-Formoterol Inhaler 80-4.5mcg, 160-4.5mcg (Quantity Level Limit)

 

 

Mesalamine Caps ER 0.375mg (Generic)

 

 

Nicotine Polacrilex Gum 2mg, 4mg (Age Limit)

 

 

Novolin R FlexPen 100 units/ml (Age Limit)  

 

 

OneTouch Verio Flex Kit (Quantity Level Limit)

 

 

Penicillamine Tab 250mg (Prior Authorization Required, Quantity Level Limit)   

 

 

Removals:

 

Ambi 60pse/400gfn Tab

 

 

Apriso Caps ER 0.375gm (Brand)

 

 

Artificial Tears Solution 1% Ophthalmic

 

 

Diflunisal Powder

 

 

Fluoritab Solution 0.275 (0.125 F) Mg/Drop

 

 

Hydrocodone-Acetaminophen Solution 10-325 Mg/15ml

 

 

PR Natal 430 Pak

 

 

PR Natal 400, 430 Pak Ec

 

 

Prevident Solution Rinse

 

 

Regenecare Ha Gel 2%

 

 

Robitussin Syrup 7.5 Mg/5ml

 

 

Sodium Chloride Solution 0.9% Injection

 

 

February 2020

Additions:

 

Bimatoprost Solution 0.03% (Step Therapy)

 

 

Ethinyl Estradiol – Etonogestrel Ring 0.015/0.12mg (Quantity Level Limit)

 

 

Travoprost Ophthalmic Solution

 

 

Removals:

 

Alprazolam Concentrate 1mg/ml Solution

 

 

Chlorothiazide Tabs 250mg, 500mg

 

 

Demeclocycline Tabs 150mg, 300mg

 

 

Doxycycline Monohydrate Tab 150mg

 

 

First-Vanco Solution 25mg/ml, 50mg/ml

 

 

Methyclothiazide Tabs 5mg

 

 

Mirena

 

 

Nausea Liquid Relief (fructose-dextrose-phosphoric acid) 

 

 

Nizatidine Solution 15mg/ml

 

 

Nuvaring (Brand)

 

 

Rabeprazole EC Caps 20mg

 

 

Ranitidine Caps 150mg, 300mg

 

 

Skyla

 

 

Travatan Z Ophthalmic Solution (Brand)

 

 

Other updates:

 

Atropine Sulfate Ophthalmic Ointment 1% (Quantity Level Limit)

 

 

Atropine Sulfate Ophthalmic Solution 1% (Quantity Level Limit)

 

 

Buspirone Tabs 5mg, 7.5mg, 10mg 15mg (Age Limit)

 

 

Combigan Solution 0.2%/0.5% (Quantity Level Limit)

 

 

Diazepam Concentrate Solution 5mg/ml (Quantity Level Limit)

 

 

Diazepam Oral Solution (Quantity Level Limit)

 

 

Diazepam Tabs 2mg, 5mg, 10mg (Quantity Level Limit)

 

 

Divalproex Er Tabs 250mg, 500mg (Prior Authorization Required)

 

 

Dorzolamide Hcl-Timolol Maleate Ophthalmic Solution 22.3-6.8mg/ml (Step Therapy, Quantity Level Limit)

 

 

Doxycycline Monohydrate Suspension 25mg/ml (Age Limit)

 

 

Granisetron Tab 1mg (Step Therapy)

 

 

Hydroxyzine Hcl Syrup 10mg/5ml (Quantity Level Limit)

 

 

Hydroxyzine Hcl Tab 50mg (Quantity Level Limit)

 

 

Hydroxyzine Pamoate Caps 25mg, 50mg, 100mg (Quantity Level Limit)

 

 

Ibrandronate Inj 3mg/3ml (Quantity Level Limit)

 

 

Levofloxacin Solution 0.5% (Quantity Level Limit) 

 

 

Lorazepam Conc 2mg/ml (Age Limit, Quantity Level Limit)

 

 

Memantine Hcl Tabs 5mg, 10mg (Quantity Level Limit)

 

 

Methazolamide Tabs 25mg, 50mg (Step Therapy)

 

 

Tazarotene Cream 0.1% (Step Therapy)

 

 

Timolol Gel Ophthalmic Solution 0.25%, 0.5% (Quantity Level Limit)

 

 

Trifluridine Ophthalmic Solution 1% (Quantity Level Limit)

 

 

January 2020

Removals:

Ventolin HFA Inhaler (Brand)

December 2019

Additions:

 

Bunavail Buccal Film 2.1-0.3mg, 4.2-0.7mg, 6.3-1mg (Brand) (Step Therapy Required, Quantity Level Limit)

 

 

Buprenorphine-Naloxone Film 2-0.5mg, 4-1mg, 8-2mg, 12-3mg (Generic) (Step Therapy Required, Quantity Level Limit)

 

 

Suboxone Film 2-0.5mg, 4-1mg, 8-2mg, 12-3mg (Brand) (Step Therapy Required, Quantity Level Limit)

 

 

Zubsolv Sublingual Tablets 0.7-0.18mg, 1.4-0.36mg, 2.9-0.71mg, 5.7-1.4mg, 8.6-2.1mg, 11.4-2.9mg (Brand) (Step Therapy Required, Quantity Level Limit)

 

 

Removals:

PreNata Chewable Tab 29-1mg

November 2019

Additions:

Aminocaproic Acid 0.25gm/ml Solution

Removals:

Amicar 0.25gm/ml Solution (Brand)