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Pharmacy benefits

Need medicine? Your pharmacy benefits include a wide range of prescription and over-the-counter (OTC) medicines to keep you as healthy as you can be.

Contact us

Questions? Check your member handbook. Or call Member Services at ${MS_phone_1} or ${MS_phone_2} (TTY 711) We’re here for you ${MS_hours}. 

Medicine your plan covers

Medicine your plan covers

Prescription medicine

We cover prescription medicine when you:

  • Have a prescription for a medicine on our formulary (preferred drug list or PDL)
  • Have a prescription that is medically necessary — you need it to manage a health condition
  • Fill the prescription at a network pharmacy (Walgreens isn’t in our network)

You can check the formulary. 

Formulary (PDF)

You can also use the formulary search tool. Search by the name or type of medicine. 
 

  • Status (on the formulary)
  • Generic versions of the same medicine
  • Any requirements, quantity limits, age limits or prior authorization (PA)

Some medicines need PA or permission in advance. Your provider will follow a process for coverage approval. Just ask them to complete PA. They can also call ${MS_phone_1} or ${MS_phone_2} (TTY 711).

Our formulary can change any time, so you’ll want to check for updates. And ask your doctor to prescribe medicines from this list. For monthly changes, you can review the formulary updates later on this page. 
 

Ask your provider to:

  • Prescribe a similar one that’s on the formulary
  • Get PA for coverage if you can’t take another medicine
  • The preferred glucose meter and test strips are Lifescan OneTouch® products. 
  • The preferred lancets and lancing devices are Lifescan OneTouch Delica® and Delica® Plus. 

Non-preferred diabetes supplies need PA.
 

Still not sure if we cover your medicine? Just call ${MS_phone_1} or ${MS_phone_2} (TTY 711). When you call, have a list of your prescription medicines ready. We can check them for you.

We also cover some over-the-counter (OTC) products (PDF)  at no cost when you: 

  • Meet any added requirements (for some medicines) 
  • Get a prescription from your provider 
  • Fill your OTC prescription at a network pharmacy (Walgreens isn’t in our network)

Still not sure if we cover your medicine? Just call ${MS_phone_1} or ${MS_phone_2} (TTY 711). When you call, have a list of your OTC medicines ready. We can check them for you. 

CVS Specialty® fills your specialty medicine. They also have other special services for you:

  • Access to a pharmacist 24 hours a day, 7 days a week
  • Counseling about your drug and disease
  • Coordination of care with you and your doctor
  • Delivery of specialty medicine to your home or doctor’s office at no cost 
  • Use of any CVS Pharmacy® (including those inside Target stores) for prescription drop-off and medicine pickup

Call CVS Specialty at 1-800-237-2767 (TTY 1-800-863-5488) for help. You can also check the specialty drug list (PDF) to see your options.

Get medicine and refills

Get medicine and refills

If you need medicine, your provider will write you a prescription for one on our formulary. You’ll want to:

  • Ask your provider to make sure the medicine is on our formulary
  • Take your prescription to a network pharmacy (Walgreens isn’t in our network) 
  • Show your plan member ID card at the pharmacy 
     

Your doctor can also send prescriptions to pharmacies electronically. This can help save you time and an extra trip. Ask your doctor if this is an option.

Your medicine label notes how many refills you have. Call your pharmacy to order a refill well before you run out of medicine. If you’re out of refills, check with your provider at least 5 days before you run out of medicine. They may want to see you before adding refills. And you can only get one refill at a time.

Fill your prescriptions at a network pharmacy (Walgreens isn’t in our network). In some cases, AHCCCS members have copays for prescriptions. For example, ACC-RBHA members pay $2.30 for generics and $2.30 for brands.

Do you have other insurance? We can only pay copays if your medicine is on our formulary. If you pay for a copay and it wasn’t required, we won’t be able to pay you back. 

Fill your prescriptions

 

In person

You can fill your prescriptions at any network pharmacy (Walgreens isn’t in our network). We can’t cover medicines that you fill at other pharmacies. Need help finding a network pharmacy? Call ${MS_phone_1} or ${MS_phone_2} (TTY 711). Or search online:

Find a pharmacy near me

By mail

Save time with mail-order prescription drugs. Do you take medicine on a regular basis for an ongoing condition, like high blood pressure or arthritis? Then you may be able to join our mail-order maintenance prescription drug program. This service delivers medicine to your home.

 

Get started with mail service

 

Understand your medicine

Understand your medicine

Providers may prescribe medicine to help you manage a health condition. Understand what your medicine is for and how to take it. 
 

Before you leave the office, get answers to these questions:

  • Why am I taking this medicine?
  • How does it help me?
  • How and when do I take the medicine? 
  • For how many days?
  • What are the possible side effects or allergic reactions?
  • What should I do if a side effect happens?
  • What will happen if I don’t take this medicine? 

Tell all your providers, including your dentist, about everything you take: 

  • Prescription medicine
  • Over-the counter medicine
  • Vitamins
  • Supplements

Some medicines can cause harm when you take them together. When providers know what you’re taking, they can help prevent this problem.

Read the info from the pharmacy when you fill your prescription. It will explain what to do and not do, as well as side effects to watch for.

Questions about medicine? Talk with the pharmacist or your provider. You can also review our patient checklist (PDF) with your provider.

Formulary updates

February 2024

 

Additions:

 

  • None

 

Removals:

 

  • Climara Pro 0.045-0.015 mg per day weekly patch
  • All insulin syringes (Excluding BD Products)
  • CombiPatch 0.05-0.14 mg per day twice weekly patch
  • CombiPatch 0.05-0.25 mg per day twice weekly patch

 

Other Updates:

 

  • Bimatoprost 0.03% ophthalmic solution (Added Quantity Limit)
  • Omeprazole 40 mg capsule (Added Quantity Limit)
  • Pantoprazole 20 mg tablet (Added Quantity Limit)
  • Pantoprazole 40 mg tablet (Added Quantity Limit)

 

January 2024

 

Additions:

 

  • Adbry 150 mg per mL prefilled syringe solution (Prior Authorization)
  • Aranesp 100 mcg per mL vial (Prior Authorization)
  • Aranesp 200 mcg per mL vial (Prior Authorization)
  • Aranesp 25 mcg per mL vial (Prior Authorization)
  • Aranesp 40 mcg per mL vial (Prior Authorization)
  • Aranesp 60 mcg per mL vial (Prior Authorization)
  • Austedo XR 12 mg tablet (Prior Authorization)
  • Austedo XR 24 mg tablet (Prior Authorization)
  • Austedo XR 6 mg / 12 mg / 24 mg titration pack tablet (Prior Authorization)
  • Austedo XR 6 mg tablet (Prior Authorization)
  • Banzel 200 mg tablet (Prior Authorization)
  • Banzel 40 mg per mL suspension (Prior authorization)
  • Banzel 400 mg tablet (Prior Authorization)
  • Betamethasone dipropionate 0.05 % ointment
  • Carbatrol extended release 100 mg capsule
  • Carbatrol extended release 200 mg capsule
  • Carbatrol extended release 300 mg capsule
  • Celontin 300 mg capsule
  • Copaxone 40 mg per mL prefilled syringe (Prior Authorization)
  • Dalfampridine extended release 10 mg tablet (Prior Authorization)
  • Dexcom G7 Receiver (Prior Authorization, Age Limit, Quantity Limit)
  • Dexcom G7 Sensor (Prior Authorization, Age Limit, Quantity Limit)
  • Diastat AcuDial 10 mg rectal gel (Quantity Limit)
  • Diastat AcuDial 20 mg rectal gel (Quantity Limit)
  • Diastat pediatric 2.5 mg rectal gel (Quantity Limit)
  • Dimethyl fumarate delayed release 120 mg / 240 mg starter pack tablet (Prior Authorization)
  • Dimethyl fumarate delayed release 120 mg tablet (Prior Authorization)
  • Dimethyl fumarate delayed release 240 mg tablet (Prior Authorization)
  • Edurant 25 mg tablet
  • Emtricitabine 100 mg / Tenofovir DF 150 mg tablet (Quantity Limit)
  • Emtricitabine 133 mg / Tenofovir DF 133 mg tablet (Quantity Limit)
  • Emtricitabine 167 mg / Tenofovir DF 250 mg tablet (Quantity Limit)
  • Emtricitabine 200 mg / Tenofovir DF 300 mg tablet (Quantity Limit)
  • Epidiolex 100 mg per mL solution (Prior Authorization)
  • Fluocinolone acetonide 0.01 % solution
  • Fycompa 0.5 mg per mL suspension (Prior Authorization)
  • Fycompa 10 mg tablet (Prior Authorization)
  • Fycompa 12 mg tablet (Prior Authorization)
  • Fycompa 2 mg tablet (Prior Authorization)
  • Fycompa 4 mg tablet (Prior Authorization)
  • Fycompa 6 mg tablet (Prior Authorization)
  • Fycompa 8 mg tablet (Prior Authorization)
  • Glatopa 40 mg per mL prefilled syringe (Prior Authorization)
  • Haegarda 2000 unit solution (Prior Authorization)
  • Haegarda 3000 unit solution (Prior Authorization)
  • Icatibant 30 mg per 3 mL prefilled syringe (Prior Authorization)
  • Kesimpta 20 mg per 0.4 mL auto-injector (Prior Authorization)
  • Ocrevus 300 mg per 10 mL solution (Prior Authorization)
  • Oxcarbazepine 300 mg per 5mL suspension
  • Pazopanib 200 mg tablet (Prior Authorization)
  • Rebif 22 mcg per 0.5 mL prefilled syringe (Prior Authorization)
  • Rebif 44 mcg per 0.5 mL prefilled syringe (Prior Authorization)
  • Rebif 8.5mcg and 22 mcg prefilled syringe titration pack (Prior Authorization)
  • Teriflunomide 14 mg tablet (Prior Authorization)
  • Teriflunomide 7 mg tablet (Prior Authorization)
  • Topiramate extended release 100 mg sprinkle capsule (Prior Authorization)
  • Topiramate extended release 150 mg sprinkle capsule (Prior Authorization)
  • Topiramate extended release 200 mg sprinkle capsule (Prior Authorization)
  • Topiramate extended release 25 mg sprinkle capsule (Prior Authorization)
  • Topiramate extended release 50 mg sprinkle capsule (Prior Authorization)
  • Trileptal 300 mg per 5mL suspension
  • Trokendi XR 100 mg tablet (Prior Authorization)
  • Trokendi XR 200 mg tablet (Prior Authorization)
  • Trokendi XR 25 mg tablet (Prior Authorization)
  • Trokendi XR 50 mg tablet (Prior Authorization)
  • Tysabri concentrate 300 mg per 15 mL (Prior Authorization)
  • Xcopri 100 mg / 150 mg daily dose therapy pack (Prior Authorization)
  • Xcopri 100 mg tablet (Prior Authorization)
  • Xcopri 12.5 mg / 25 mg titration pack tablet (Prior Authorization)
  • Xcopri 150 mg / 200 mg daily dose therapy pack (Prior Authorization)
  • Xcopri 150 mg / 200 mg titration pack tablet (Prior Authorization)
  • Xcopri 150 mg tablet (Prior Authorization)
  • Xcopri 200 mg tablet (Prior Authorization)
  • Xcopri 50 mg / 100 mg titration pack tablet (Prior Authorization)
  • Xcopri 50 mg tablet (Prior Authorization)
  • Zenpep 60000 unit capsule (Prior Authorization, Quantity Limit)
  • Zolpidem tartrate extended release 12.5 mg tablet (Age Limit)
  • Zolpidem tartrate extended release 6.25 mg tablet (Age Limit)

 

Removals:

 

  • Aptivus 250 mg capsule
  • Benzoyl peroxide 4% liquid wash
  • Betaseron 0.3 mg injection kit
  • Clotrimazole 1% solution (OTC)
  • Equetro extended release 100 mg capsule
  • Equetro extended release 200 mg capsule
  • Equetro extended release 300 mg capsule
  • Extavia 0.3 mg injection kit
  • Firazyr 30 mg per 3 mL prefilled syringe
  • Gilenya 0.25 mg capsule
  • Glatopa 40 mg per mL prefilled syringe
  • Norliqva 1 mg per mL solution
  • Orladeyo 110 mg capsule
  • Orladeyo 150 mg capsule
  • Oxcarbazepine 300 mg per 5mL suspension
  • PanOxyl 4% liquid wash
  • Rufinamide 40 mg per mL suspension
  • Sajazir 30mg / 3 mL syringe
  • Votrient 200mg tablet

 

Other Updates:

 

  • Nayzilam 5 mg per 0.1 mL nasal solution (Removed Prior Authorization, Removed Age Limit, Updated Quantity Limit)
  • Tiagabine HCl tablet 12mg (Prior Authorization Added)
  • Tiagabine HCl tablet 16mg (Prior Authorization Added)
  • Tiagabine HCl tablet 20mg (Prior Authorization Added)
  • Tiagabine HCl tablet 2mg (Prior Authorization Added)
  • Tiagabine HCl tablet 4mg (Prior Authorization Added)
  • Valtoco 10 mg per 0.1 mL nasal solution (Removed Age Limit, Updated Quantity Limit)
  • Valtoco 15 mg therapy pack nasal solution (Removed Age Limit, Updated Quantity Limit)
  • Valtoco 20 mg therapy pack nasal solution (Removed Age Limit, Updated Quantity Limit)
  • Valtoco 5 mg per 0.1 mL nasal solution (Removed Age Limit, Updated Quantity Limit)

December 2023

 

Additions:

  • Arnuity Ellipta 100 mcg inhaler
  • Arnuity Ellipta 200 mcg inhaler
  • Arnuity Ellipta 50 mcg inhaler
  • Asmanex HFA 100 mcg inhaler
  • Asmanex HFA 200 mcg inhaler
  • Asmanex HFA 50 mcg inhaler
  • Fluticasone propionate diskus breath activated 100 mcg powder
  • Fluticasone propionate diskus breath activated 250 mcg powder
  • Fluticasone propionate diskus breath activated 50 mcg powder
  • Qvar RediHaler 40 mcg inhaler
  • Qvar RediHaler 80 mcg inhaler

 

Removals:

  • None

 

Other Updates:

  • None

 

November 2023

Title 19/21 SMI drug list updates

Additions:

  • Omnitrope 5.8 mg solution (Prior Authorization)
  • Omnitrope cartridge 10 mg per 1.5mL solution (Prior Authorization)
  • Omnitrope cartridge 5 mg per 1.5mL solution (Prior Authorization)
  • Zomactron 10 mg solution (Prior Authorization)
  • Zomactron 5 mg solution (Prior Authorization)

Removals

  • Proctofoam HC 1% to 1% rectal foam

 Other updates

  • Haloperidol 0.5 mg tablet (age limit updated)

  • Haloperidol 1 mg tablet (age limit updated)

  • Haloperidol 10 mg tablet (age limit updated)

  • Haloperidol 2 mg tablet (age limit updated)

  • Haloperidol 20 mg tablet (age limit updated)

  • Haloperidol 5 mg tablet (age limit updated)

  • Haloperidol lactate 2 mg per mL oral concentrate (age limit updated)

  • Haloperidol lactate 5 mg per mL solution injection (age limit updated)

  • Loxapine succinate 10 mg capsule (age limit updated)

  • Loxapine succinate 25 mg capsule (age limit updated)

  • Loxapine succinate 5 mg capsule (age limit updated)

  • Loxapine succinate 50 mg capsule (age limit updated)

  • Nayzilam 5mg per 0.1 mL nasal spray (quantity limit updated, age limit added)

  • Perphenazine 16 mg tablet (age limit updated)

  • Perphenazine 2 mg tablet (age limit updated)

  • Perphenazine 4 mg tablet (age limit updated)

  • Perphenazine 8 mg tablet (age limit updated)

  • Pimozide 1 mg tablet (age limit updated)

  • Pimozide 2 mg tablet (age limit updated)

  • Thioridazine HCl 10 mg tablet (age limit updated)

  • Thioridazine HCl 100 mg tablet (age limit updated)

  • Thioridazine HCl 25 mg tablet (age limit updated)

  • Thioridazine HCl 50 mg tablet (age limit updated)

  • Thiothixene 1 mg capsule (age limit updated)

  • Thiothixene 10 mg capsule (age limit updated)

  • Thiothixene 2 mg capsule (age limit updated)

  • Thiothixene 5 mg capsule (age limit updated)

  • Trifluoperazine HCl 1 mg tablet (age limit updated)

  • Trifluoperazine HCl 10 mg tablet (age limit updated)

  • Trifluoperazine HCl 2 mg tablet (age limit updated)

  • Trifluoperazine HCl 5 mg tablet (age limit updated)

  • Valtoco 10 mg nasal spray (quantity limit updated, age limit added)

  • Valtoco 15 mg nasal spray (quantity limit updated, age limit added)

  • Valtoco 20 mg nasal spray (quantity limit updated, age limit added)

  • Valtoco 5 mg nasal spray (quantity limit updated, age limit added)


October 2023

Additions

  • Dexmethylphenidate extended release 10 mg capsule (quantity limit, age limit)

  • Dexmethylphenidate extended release 15 mg capsule (quantity limit, age limit)

  • Dexmethylphenidate extended release 20 mg capsule (quantity limit, age limit)

  • Dexmethylphenidate extended release 25 mg capsule (quantity limit, age limit)

  • Dexmethylphenidate extended release 30 mg capsule (quantity limit, age limit)

  • Dexmethylphenidate extended release 35 mg capsule (quantity limit, age limit)

  • Dexmethylphenidate extended release 40 mg capsule (quantity limit, age limit)

  • Dexmethylphenidate extended release 5 mg capsule (quantity limit, age limit)

  • Gvoke Kit 1 mg per 0.2 mL solution (quantity limit)

  • Gvoke prefilled syringe 0.5 mg per 0.1 mL solution (quantity limit)

  • Gvoke prefilled syringe 1 mg per 0.2 mL solution (quantity limit)

  • Infliximab 100 mg intravenous solution (prior authorization)

  • Lintera 10% wash

  • Naloxone 4 mg per 0.1 mL nasal liquid (OTC)

  • Octagam 25 gm per 500 mL (5%) intravenous solution (prior authorization)

  • Spiriva Respimat 1.25 mcg per inhalation solution

  • Spiriva Respimat 2.5 mcg per inhalation solution

  • Zegalogue auto-injector 0.6 mg per 0.6 mL solution (quantity limit)

Removals

  • Aimovig auto-injector 140 mg per mL solution

  • Aimovig auto-injector 70 mg per mL solution

  • Avsola 100 mg reconstituted solution

  • Ergotamine tartrate 2 mg and caffeine 100 mg suppository

  • Focalin XR 10 mg capsule

  • Focalin XR 15 mg capsule

  • Focalin XR 20 mg capsule

  • Focalin XR 25 mg capsule

  • Focalin XR 30 mg capsule

  • Focalin XR 35 mg capsule

  • Focalin XR 40 mg capsule

  • Focalin XR 5 mg capsule

  • Makena 250 mg per mL oil

  • Makena auto-injector 275 mg per 1.1 mL solution

  • Pradaxa 100 mg packet

  • Pradaxa 150 mg packet

  • Pradaxa 20 mg packet

  • Pradaxa 30 mg packet

  • Pradaxa 40 mg packet

  • Pradaxa 50 mg packet

Other updates

  • Levocarnitine 330 mg tablet (prior authorization removed)


September 2023

Additions: None

Removals: None

Other updates: None


August 2023

Additions

  • Tranexamic acid 650 mg tablet (prior authorization)

Removals

  • Imbruvica 140 mg tablet (prior authorization)

  • Tranexamic acid 650 mg tablet (prior authorization)

  • Vogelxo 50 mg per 5 gram gel packet (prior authorization)

Other updates: None


July 2023

Additions

  • Gefitinib 250 mg tablet (prior authorization)

  • Kalydeco 13.4 mg packet (prior authorization)

  • Lurasidone 120 mg tablet (quantity limit, age limit)

  • Lurasidone 20 mg tablet (quantity limit, age limit)

  • Lurasidone 40 mg tablet (quantity limit, age limit)

  • Lurasidone 60 mg tablet (quantity limit, age limit)

  • Lurasidone 80 mg tablet (quantity limit, age limit)

  • Mekinist 0.05 mg per mL solution (prior authorization)

  • Tafinlar 10 mg tablet (prior authorization)

  • Trikafta 100 mg/50 mg/75 mg/75 mg therapy pack (prior authorization)

  • Trikafta 80 mg/40 mg/60 mg/59.5 mg therapy pack (prior authorization)

Removals

  • Esomeprazole magnesium delayed release 40 mg capsule

  • Iressa 250 mg tablet

  • Latuda 120 mg tablet

  • Latuda 20 mg tablet

  • Latuda 40 mg tablet

  • Latuda 60 mg tablet

  • Latuda 80 mg tablet

  • Omega-3 ethyl esters 1 gm capsule

  • Sucraid 8500 unit per mL solution

Other updates: None


June 2023

Additions

  • First-metronidazole 50 mg/mL suspension (age limit)

  • Tinidazole 250 mg tablet

  • Tinidazole 500 mg tablet

  • Vancomycin 25 mg per mL oral solution

  • Vancomycin 50 mg per mL oral solution

Removals

  • Firvanq 25 mg per mL oral solution

  • Firvanq 50 mg per mL oral solution

  • Repatha prefilled syringe 140 mg per mL solution

  • Repatha Pushtronex cartridge 420 mg per 3.5 mL solution

  • Repatha SureClick auto-injector 140 mg per mL solution

 Other updates: None


May 2023

Additions

  • Gilenya 0.25 mg capsule (prior authorization, quantity limit)

  • Trikafta 100 mg/50 mg/75 mg/150 mg tablet (prior authorization)

  • Trikafta 50 mg/25 mg/37.5 mg/75 mg tablet (prior authorization)

Removals

  • Capsaicin 0.1% cream

  • Lidocaine 4% cream

  • Triamcinolone acetonide powder

Other updates

  • Fexofenadine 30 mg per 5 mL (changed quantity limit)

  • Fingolimod 0.5 mg capsule (added quantity limit)

  • Freestyle Libre 14 Day Sensor (changed quantity limit)

  • Freestyle Libre 2 Sensor (changed quantity limit)

  • Freestyle Libre 3 Sensor (changed quantity limit)


April 2023

Additions

  • Ambrisentan 10 mg tablet (prior authorization)

  • Ambrisentan 5 mg tablet (prior authorization)

  • Aranesp 10 mcg per 0.4 mL prefilled syringe solution (prior authorization)

  • Aranesp 100 mcg per 0.5 mL prefilled syringe solution (prior authorization)

  • Aranesp 150 mcg per 0.3 mL prefilled syringe solution (prior authorization)

  • Aranesp 200 mcg per 0.4 mL prefilled syringe solution (prior authorization)

  • Aranesp 25 mcg per 0.42 mL prefilled syringe solution (prior authorization)

  • Aranesp 300 mcg per 0.6 mL prefilled syringe solution (prior authorization)

  • Aranesp 40 mcg per 0.4 mL prefilled syringe solution (prior authorization)

  • Aranesp 500 mcg per 1 mL prefilled syringe solution (prior authorization)

  • Aranesp 60 mcg per 0.3 mL prefilled syringe solution (prior authorization)

  • Armour Thyroid 120 mg tablet

  • Armour Thyroid 15 mg tablet

  • Armour Thyroid 30 mg tablet

  • Armour Thyroid 60 mg tablet

  • Armour Thyroid 90 mg tablet

  • Bivigam 5 gm per 50 mL intravenous solution (prior authorization)

  • Bosentan 125 mg tablet (prior authorization)

  • Bosentan 62.5 mg tablet (prior authorization)

  • Fylnetra 6 mg per 0.6 mL prefilled syringe (prior authorization)

  • Nivestym 300 mcg per mL solution (prior authorization)

  • Nivestym 480 mcg per 1.6 mL solution (prior authorization)

  • Octagam 1 gm per 200 mL (5%) intravenous solution (prior authorization)

  • Octagam 10 gm per 100 mL (10%) intravenous solution (prior authorization)

  • Octagam 10 gm per 200 mL (5%) intravenous solution (prior authorization)

  • Octagam 2 gm per 20 mL (10%) intravenous solution (prior authorization)

  • Octagam 20 gm per 200 mL (10%) intravenous solution (prior authorization)

  • Octagam 30 gm per 300 mL (10%) intravenous solution (prior authorization)

  • Octagam 5 gm per 100 mL (5%) intravenous solution (prior authorization)

  • Octagam 5 gm per 50 mL (10%) intravenous solution (prior authorization)

  • Pradaxa 110 mg pellet packet (quantity limit)

  • Pradaxa 150 mg pellet packet (quantity limit)

  • Pradaxa 20 mg pellet packet (quantity limit)

  • Pradaxa 30 mg pellet packet (quantity limit)

  • Pradaxa 40 mg pellet packet (quantity limit)

  • Pradaxa 50 mg pellet packet (quantity limit)

  • Testosterone 50 mg per 5 gm (1%) gel (prior authorization) (limited to one NDC)

  • Xembify 1 gm per 5 mL (20%) solution vial (prior authorization)

  • Xembify 10 gm per 50 mL (20%) solution vial (prior authorization)

  • Xembify 2 gm per 10 mL (20%) solution vial (prior authorization)

  • Xembify 4 gm per 20 mL (20%) solution vial (prior authorization)

  • Ziextenzo 6 mg per 0.6 mL prefilled syringe (prior authorization)

  • Zovirax 5% ointment (quantity limit)

Removals

  • Acyclovir 5% ointment

  • Aubagio 14 mg tablet

  • Aubagio 7 mg tablet

  • Fulphila 6 mg per 0.6 mL prefilled syringe

  • Imbruvica 140 mg capsule

  • Imbruvica 140 mg tablet

  • Imbruvica 280 mg tablet

  • Imbruvica 420 mg tablet

  • Imbruvica 560 mg tablet

  • Imbruvica 70 mg capsule

  • Imbruvica 70 mg per mL suspension

  • Jakafi 10 mg tablet

  • Jakafi 15 mg tablet

  • Jakafi 20 mg tablet

  • Jakafi 25 mg tablet

  • Jakafi 5 mg tablet

  • Lenalidomide 10 mg capsule

  • Lenalidomide 15 mg capsule

  • Lenalidomide 20 mg capsule

  • Lenalidomide 25 mg capsule

  • Lenalidomide 5 mg capsule

  • Letairis 10 mg tablet

  • Letairis 5 mg tablet

  • Leukeran 2 mg tablet

  • Myleran 2 mg tablet

  • Neupogen 300 mcg per 0.5 mL prefilled syringe

  • Neupogen 300 mcg per 0.5 mL vial

  • Neupogen 480 mcg per 0.8 mL prefilled syringe

  • Neupogen 480 mcg per 1.6 mL vial

  • Nyvepria 6 mg per 0.6 mL prefilled syringe

  • Provida OB 20 mg/20 mg/1.5 mg capsule

  • Revlimid 10 mg capsule

  • Revlimid 15 mg capsule

  • Revlimid 2.5 mg capsule

  • Revlimid 20 mg capsule

  • Revlimid 25 mg capsule

  • Revlimid 5 mg capsule

  • Rydapt 25 mg capsule

  • Salicylic acid 6% cream

  • Salicylic acid 6% shampoo

  • Sprycel 100 mg tablet

  • Sprycel 140 mg tablet

  • Sprycel 20 mg tablet

  • Sprycel 50 mg tablet

  • Sprycel 70 mg tablet

  • Sprycel 80 mg tablet

  • Tabloid 40 mg tablet

  • Tamiflu 30 mg capsule

  • Tamiflu 45 mg capsule

  • Tamiflu 6 mg per mL suspension

  • Tamiflu 75 mg capsule

  • Tracleer 125 mg tablet

  • Tracleer 62.5 mg tablet

  • Udenyca 6 mg per 0.6 mL prefilled syringe

  • Venclexta 10 mg tablet

  • Venclexta 100 mg tablet

  • Venclexta 50 mg tablet

  • Venclexta starting pack

  • Xofluza 40 mg therapy pack

  • Xofluza 80 mg therapy pack

Other updates

  • None


March 2023

Additions

  • Guaifenesin 100 mg/codeine 6.33 mg per 5 mL solution (quantity limit, age limit, OTC)

Removals: None

Other updates

  • Advair Diskus 100 mcg/50 mcg per actuation (removed step therapy)

  • Advair Diskus 250 mcg/50 mcg per actuation (removed step therapy)

  • Advair Diskus 500 mcg/50 mcg per actuation (removed step therapy)

  • Advair HFA 115 mcg/21 mcg per actuation (removed step therapy)

  • Advair HFA 230 mcg/21 mcg per actuation (removed step therapy)

  • Advair HFA 45 mcg/21 mcg per actuation (removed step therapy)

  • Dulera 100 mcg/5 mcg per actuation (removed step therapy)

  • Dulera 200 mcg/5 mcg per actuation (removed step therapy)

  • Dulera 50 mcg/5 mcg per actuation (removed step therapy)

  • Pregabalin 100 mg capsule (removed prior authorization, updated quantity limit)

  • Pregabalin 150 mg capsule (removed prior authorization, updated quantity limit)

  • Pregabalin 20 mg per mL solution (removed prior authorization, updated quantity limit)

  • Pregabalin 200 mg capsule (removed prior authorization, updated quantity limit)

  • Pregabalin 225 mg capsule (removed prior authorization, updated quantity limit)

  • Pregabalin 25 mg capsule (removed prior authorization, updated quantity limit)

  • Pregabalin 300 mg capsule (removed prior authorization, updated quantity limit)

  • Pregabalin 50 mg capsule (removed prior authorization, updated quantity limit)

  • Pregabalin 75 mg capsule (removed prior authorization, updated quantity limit)

  • Symbicort 160 mcg/4.5 mcg per actuation (removed step therapy)

  • Symbicort 80 mcg/4.5 mcg per actuation (removed step therapy)


February 2023

Additions

  • Dificid 200 mg tablet (prior authorization)

  • Dificid 40 mg/mL suspension (prior authorization)

  • Ethacrynic acid 25 mg tablet

  • Fluocinolone acetonide 0.01% otic oil (quantity limit, OTC)

  • Lactobacillus extra strength capsule (OTC)

  • Miconazole nitrate vaginal suppository 1200 mg and 2% cream kit (OTC)

  • Phenylephrine 10 mg/dextromethorphan 18 mg/guaifenesin 200 mg per 15 mL liquid (quantity limit, OTC)

  • Pramoxine hydrochloride (perianal) 1% foam (quantity limit, OTC)

  • Probiotic capsule (OTC)

  • Pseudoephedrine 30 mg/dexchlorpheniramine 1 mg/chlophedianol 5 mg per 5 mL liquid (quantity limit, OTC)

  • Refresh Relieva 0.5/1% preservative free ophthalmic solution (OTC)

  • Sodium fluoride 1.1%/5% gel

  • Xifaxan 550 mg tablet (prior authorization)

Removals

  • Benzocaine 20 mg/docusate sodium 283 mg rectal enema

  • Bisacodyl 10 mg/30 mL enema (OTC)

  • Brimonidine tartrate 0.2%/timolol 0.5% ophthalmic solution

  • Celontin 300 mg capsule

  • Colchicine 0.6 mg capsule

  • Ibrance 100 mg tablet

  • Ibrance 125 mg tablet

  • Ibrance 75 mg tablet

  • Levofloxacin 0.5% ophthalmic solution

  • Magnesium hydroxide concentrate 2400 mg/10 mL

  • Naproxen delayed release, enteric coated 500 mg tablet

  • Pirfenidone 267 mg capsule

  • Potassium citrate 550 mg/sodium citrates 500 mg/citric acid 334 mg per 5 mL solution

Other updates

  • Azelastine HCl 0.05% ophthalmic solution (removed step therapy)

  • Celecoxib 100 mg capsule (removed step therapy)

  • Celecoxib 200 mg capsule (removed step therapy)

  • Celecoxib 400 mg capsule (removed step therapy)

  • Celecoxib 50 mg capsule (removed step therapy)

  • Vancomycin HCl 125 mg capsule (removed prior authorization, added quantity limit)

  • Vancomycin HCl 250 mg capsule (removed prior authorization, added quantity limit)


January 2023

Additions

  • Dupixent pen-injector 200 mg/1.14 mL solution (prior authorization)

  • Dupixent pen-injector 300 mg/2 mL solution (prior authorization)

  • Dupixent prefilled syringe 100 mg/0.67 mL solution (prior authorization)

  • Dupixent prefilled syringe 200 mg/1.14 mL solution (prior authorization)

  • Dupixent prefilled syringe 300 mg/2 mL solution (prior authorization)

  • Eucrisa 2% ointment (prior authorization)

  • Pimecrolimus 1% cream (prior authorization)

  • Berinert kit 500 unit (prior authorization)

  • Cinryze vial 500 unit (prior authorization)

  • Firazyr syringe 30 mg/3 mL (prior authorization)

  • Kalbitor vial 10 mg/mL (prior authorization)

  • Orladeyo 110 mg capsule (prior authorization)

  • Orladeyo 150 mg capsule (prior authorization)

  • Symfi Lo 400 mg/300 mg/300 mg tablet

  • Symfi 600 mg/300 mg/300 mg tablet

  • Triumeq PD 60 mg/5 mg/30 mg soluble tablet

  • Vfend 40 mg/mL suspension

  • Ella 30 mg tablet (quantity limit)

  • Tafluprost (PF) ophthalmic 0.0015% suspension

Removals

  • Invirase 200 mg capsule

  • Invirase 500 mg tablet

  • Stavudine 15 mg capsule

  • Stavudine 20 mg capsule

  • Stavudine 30 mg capsule

  • Stavudine 40 mg capsule

  • Viracept 250 mg tablet

  • Viracept 625 mg tablet

  • Zioptan ophthalmic 0.0015% solution

  • All Non-OneTouch Delica and Delica Plus Lancets and Lancet Devices

Other updates: None

December 2022

Additions

  • Accutane 10 mg capsule

  • Accutane 20 mg capsule

  • Accutane 30 mg capsule

  • Accutane 40 mg capsule

  • Amnesteem 10 mg capsule

  • Amnesteem 20 mg capsule

  • Amnesteem 40 mg capsule

  • Flonase nasal suspension 50 mcg/act

  • Histex PD 0.938 mg/mL liquid (OTC)

Removals: None

Other updates: None


November 2022

Additions

  • Imbruvica Susp 70 mg/mL (prior authorization, quantity limit)

  • Orkambi Granule 75 to 94 mg (prior authorization)

Removals: None

Other updates: None

Recalls and alerts

Need info about medicine recalls? Just call the U.S. Food and Drug Administration (FDA) at 1-888-463-6332

You can also get info about drug safety alerts.