Pharmacy

Mail-order prescriptions

If you take medicine for an ongoing health condition, you may be able to have those medicines mailed to your home. These may be medications for conditions such as high blood pressure or arthritis. You can start the mail-order process by completing a mail-order request form.

By mail

Call Mercy Care ACC-RBHA Member Services at 1-800-564-5465; (TTY/TDD 711) to request a mail-order form. Or, you can download a mail-order service form here:

Mail-order service form - English | Mail-order service form - Spanish

Online

You can register for mail order online with CVS Caremark at www.caremark.com. Once you're registered, you can order refills, renew your prescription and check on your order.

Preferred drug list updates

June 2023

Title 19/21 SMI Drug List Updates:

Additions:

• First-metronidazole 50 mg/mL suspension (Age Limit)
• Tinidazole 250mg tablet
• Tinidazole 500mg 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 3.5mL solution
• Repatha SureClick auto-injector 140 mg per mL solution

 Other Updates:

• None

  

Non-Title 19/21 Drug List Updates:

Additions:

• None

 Removals:

• None

 Other Updates:

• None

 

May 2023

Title 19/21 SMI Drug List Updates:

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)

 

Non-Title 19/21 Drug List Updates:

Additions:

• None

 Removals:

• None

 Other Updates:

• None

 

April 2023

Title 19/21 SMI Drug List Updates:

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 5mL (20%) solution vial (Prior Authorization)
• Xembify 10 gm per 50mL (20%) solution vial (Prior Authorization)
• Xembify 2 gm per 10mL (20%) solution vial (Prior Authorization)
• Xembify 4 gm per 20mL (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 tablet
• Imbruvica 280 mg tablet
• Imbruvica 420 mg tablet
• Imbruvica 560 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
• Rydapt 25 mg capsule
• Salicylic acid 6% cream
• Salicylic acid 6% shampoo
• 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

 

Non-Title 19/21 Drug List Updates:

Additions:

• 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)

 Removals:

• Latuda 120 mg tablet
• Latuda 20 mg tablet
• Latuda 40 mg tablet
• Latuda 60 mg tablet
• Latuda 80 mg tablet

 Other Updates:

• None

 

March 2023

Title 19/21 SMI Drug List Updates:

Additions:

• Guaifenesin 100 mg/codeine 6.33 mg per 5mL 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)

 

Non-Title 19/21 Drug List Updates:

Additions:

• None

 Removals:

• None

 Other Updates:

• None

 

February 2023

Title 19/21 SMI Drug List Updates:

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 & 2% cream kit (OTC)
• Phenylephrine 10 mg/dextromethorphan 18 mg/guaifenesin 200 mg per 15mL 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 5mL 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/30mL 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 5mL 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)

 

Non-Title 19/21 Drug List Updates:

Additions:

• None

 Removals:

• None

 Other Updates:

• None

  

January 2023

Title 19/21 SMI Drug List Updates:

Additions:

• Dupixent pen-injector 200 mg/1.14mL solution (Prior Authorization)
• Dupixent pen-injector 300 mg/2mL solution (Prior Authorization)
• Dupixent prefilled syringe 100 mg/0.67mL solution (Prior Authorization)
• Dupixent prefilled syringe 200 mg/1.14mL solution (Prior Authorization)
• Dupixent prefilled syringe 300 mg/2mL 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/3mL (Prior Authorization)
• Kalbitor vial 10 mg/mL (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

 

Non-Title 19/21 Drug List Updates:

Additions:

• None

 Removals:

• None

 Other Updates:

• None

  

December 2022

Title 19/21 SMI Drug List Updates:

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

 

Non-Title 19/21 Drug List Updates:

Additions:

• None

 Removals:

• None

 Other Updates:

• None

 

November 2022

Title 19/21 SMI Drug List Updates:

Additions:

• Imbruvica 70 mg/mL suspension (Prior Authorization, Quantity Limit)
• Orkambi 75 mg/94 mg granule (Prior Authorization)

 Removals:

• None

 Other Updates:

• None

 

Non-Title 19/21 Drug List Updates:

Additions:

• None

 Removals:

• None

 Other Updates:

• None

  

October 2022

Title 19/21 SMI Drug List Updates:

Additions:

• Albuterol HFA inhaler
• Gvoke Hypopen 1 Pack 0.5 mg/0.1mL (Quantity Limit)
• Gvoke Hypopen 2 Pack 1 mg/0.2mL (Quantity Limit)
• Invega Hafyera 1092 mg/3.5mL (Quantity Limit, Age Restriction)
• Invega Hafyera 1560 mg/3.5mL (Quantity Limit, Age Restriction)
• Orencia Clickject 125 mg/mL (Prior Authorization)
• Orencia Syringe 125 mg/mL (Prior Authorization)
• Orencia Syringe 50 mg/0.4mL (Prior Authorization)
• Orencia Syringe5 mg/0.7mL (Prior Authorization)
• Pancreaze DR 10500 Unit Capsule (Quantity Limit)
• Pancreaze DR 16800 Unit Capsule (Quantity Limit)
• Pancreaze DR 21000 Unit Capsule (Quantity Limit)
• Pancreaze DR 2600 Unit Capsule (Quantity Limit)
• Pancreaze DR 37000 Unit Capsule (Quantity Limit)
• Pancreaze DR 4200 Unit Capsule (Quantity Limit)

 Removals:

• Glyxambi 10 mg/5 mg tablet
• Glyxambi 25 mg/5 mg tablet
• Humulin N Vial 100 Unit/mL
• Humulin R Vial 100 Unit/mL
• Proair HFA Inhaler

 Other Updates:

• Mavyret 50 mg/20 mg packet (Prior Authorization Removed, Quantity Level Limit 280 Packets Per Lifetime Added)
• Mavyret 100 mg/40 mg tablet (Prior Authorization Removed, Quantity Level Limit 168 Tablets Per Lifetime Added)
• Sofosbuvir-Velpatasvir 400 mg/100 mg tablet (Prior Authorization Removed, Quantity Level Limit 168 Tablets Per Lifetime Added)

 

Non-Title 19/21 Drug List Updates:

Additions:

• Invega Hafyera 1092 mg/3.5mL (Quantity Limit, Age Restriction)
• Invega Hafyera 1560 mg/3.5mL (Quantity Limit, Age Restriction)

 Removals:

• None

 Other Updates:

• None

 

September 2022

Title 19/21 SMI Drug List Updates:

Additions:

• Herzuma 150 mg solution (Prior Authorization)
• Herzuma 420mg solution (Prior Authorization)
• Kanjinti 150 mg solution (Prior Authorization)
• Kanjinti 420 mg solution (Prior Authorization)
• Mvasi 100 mg/4mL solution (Prior Authorization)
• Mvasi 400 mg/16mL solution (Prior Authorization)
• Ogivri 150 mg solution (Prior Authorization)
• Ogivri 420 mg solution (Prior Authorization)
• Riabni IV 100 mg/10mL solution (Prior Authorization)
• Riabni IV 500 mg/50mL solution (Prior Authorization)
• Ruxience IV 100 mg/10mL solution (Prior Authorization)
• Ruxience IV 500 mg/50mL solution (Prior Authorization)
• Trazimera 150 mg solution (Prior Authorization)
• Trazimera 420 mg solution (Prior Authorization)
• Truxima 100 mg/10mL solution (Prior Authorization)
• Truxima 500 mg/50mL solution (Prior Authorization)
• Zirabev 100 mg/4mL solution (Prior Authorization)
• Zirabev 400 mg/16mL solution (Prior Authorization)

 Removals:

• Avastin 25 mg/mL solution
• Herceptin 150 mg solution
• Herceptin 440 mg solution
• Ontruzant 150 mg solution
• Ontruzant 420 mg solution
• Rituxan 10 mg/mL solution

 Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

 Removals:

• None

 Other Updates:

• None

 

August 2022

Title 19/21 SMI Drug List Updates:

Additions:

• Calamine lotion
• Doxycycline monohydrate 100 mg Tablet
• Metronidazole 1% gel (Step Therapy Required, Quantity Limit)
• Olmesartan 20 mg tablet (Quantity Limit)
• Olmesartan 40 mg tablet (Quantity Limit)
• Olmesartan 5 mg tablet (Quantity Limit)
• Selenium sulfide 1% shampoo
• Triamcinolone acetonide 0.05% ointment
• Triprolidine HCL 0.938 mg drops
• Triprolidine HCL 0.625 mg liquid (PediaClear PD liquid)
• Triprolidine HCL 2.5 mg/5mL syrup (Histex syrup)

 Removals:

• Amcinonide 0.1% ointment
• Lidocaine Jlly 2% jelly
• Memantine HCL titration pack tablet
• Metronidazole 375 mg capsule
• Mometasone furoate 50mcg/act nasal spray
• Selenium sulfide 2.25% shampoo
• Vemlidy 25 mg tablet

 Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

 Removals:

• None

 Other Updates:

• None

 

July 2022

Title 19/21 SMI Drug List Updates:

Additions:

• Lacosamide 10 mg/mL solution (Prior Authorization)
• Sorafenib 200 mg tablet (Prior Authorization)
• Omeprazole 20 mg ODT (OTC)

 Removals:

• Lidocaine HCL 3% lotion
• Nexavar 200 mg tablet
• Oxycodone 5 mg/acetaminophen 325 mg per 5mL
• Vimpat 10 mg/mL solution

 Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

 Removals:

• None

 Other Updates:

• None

 

June 2022

Title 19/21 SMI Drug List Updates:

Additions:

• Bortezomib 3.5 mg injection (Prior Authorization)
• Lacosamide 100 mg tablet (Prior Authorization)
• Lacosamide 150 mg tablet (Prior Authorization)
• Lacosamide 200 mg tablet (Prior Authorization)
• Lacosamide 50 mg tablet (Prior Authorization)
• Novolin 70/30 100 unit/mL
• Novolin N 100 unit/mL
• Novolin R 100 unit/mL
• Short acting opioids and opioid combinations (Quantity Limit)

 Removals:

• Velcade 3.5 mg injection
• Vimpat 100 mg tablet
• Vimpat 150 mg tablet
• Vimpat 200 mg tablet
• Vimpat 50 mg tablet

 Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

 Removals:

• None

 Other Updates:

• None

 

May 2022

Title 19/21 SMI Drug List Updates:

Additions:

• None

 Removals:

• None

 Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

 Removals:

• None

 Other Updates:

• None

  

April 2022

Title 19/21 SMI Drug List Updates:

Additions:

• Asacol HD Dr 800 mg tablet
• Cipro Hc otic suspension
• Zovirax 5% cream
• Livtencity 200 mg tablet (Prior Authorization)
• Kerendia 10 mg tablet (Prior Authorization)
• Kerendia 20 mg tablet (Prior Authorization)
• Rezurock 200 mg tablet (Prior Authorization)
• Zovirax 5% ointment (Quantity Limit)
• Amphotericin 50 mg injection
• Descovy 120 mg/15 mg tablet

 Removals:

• Acyclovir 5% ointment

 Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

 Removals:

• None

 Other Updates:

• None

  

March 2022

Title 19/21 SMI Drug List Updates:

Additions:

• Diclofenac 1% gel (Quantity Limit, OTC)

 Removals:

• None

 Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

 Removals:

• None

 Other Updates:

• None

 

February 2022

Title 19/21 SMI Drug List Updates:

Additions:

• Dexcom G5 receiver (Prior Authorization, Quantity Limit)
• Dexcom G5 transmitter (Prior Authorization, Quantity Limit)
• Dexcom G6 receiver (Prior Authorization, Quantity Limit)
• Dexcom G6 sensor (Prior Authorization, Quantity Limit)
• Dexcom G6 transmitter (Prior Authorization, Quantity Limit)
• Freestyle Libre 10 reader (Prior Authorization, Quantity Limit)
• Freestyle Libre 10 sensor (Prior Authorization, Quantity Limit)
• Freestyle Libre 14 reader (Prior Authorization, Quantity Limit)
• Freestyle Libre 14 sensor (Prior Authorization, Quantity Limit)
• Freestyle Libre 2 14 reader (Prior Authorization, Quantity Limit)
• Freestyle Libre 2 14 sensor (Prior Authorization, Quantity Limit)
• G5/G4 platinum sensor (Prior Authorization, Quantity Limit)
• Molnupiravir 200 mg capsule (Quantity Limit)
• Paxlovid tablet pack (Quantity Limit)

 Removals:

• None

 Other Updates:

• Levocetirizine 5 mg tablet (Quantity Limit Added)
• Promethazine 6.25 mg/5mL syrup (Quantity Limit Added)

  

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

 Removals:

• None

 Other Updates:

• None

 

January 2022

Title 19/21 SMI Drug List Updates:

Additions:

• Betamethasone 0.05% cream
• Biktarvy 30 mg/120 mg/15 mg
• Clobetasol 0.05% shampoo
• Delstrigo 100 mg/300 mg/300 mg tablet
• Efavirenz 600 mg/emtricitabine 200 mg/tenofovir 300 mg tablet
• Ingrezza 40 mg tablet (Prior Authorization)
• Ingrezza 60 mg tablet (Prior Authorization)
• Ingrezza 80 mg tablet (Prior Authorization)
• Tivicay PD 5 mg tablet for suspension

 Removals:

• Concept OB Cap
• Edurant 25 mg tablet
• Efavirenz 400 mg/lamivudine 300 mg/tenofovir 300 mg tablet
• Efavirenz 600 mg/lamivudine 300 mg/tenofovir 300 mg tablet
• Intelence 25 mg tablet
• Mynatal tablet
• Temixys 300 mg/300 mg tablet
• Viread 150 mg tablet
• Viread 200 mg tablet
• Viread 250 mg tablet
• Zolmitriptan 2.5mg nasal spray
• Zolmitriptan 5mg nasal spray

 Other Updates:

• Budesonide 0.25 mg/2mL inhalation suspension (Age Limit Removed)
• Budesonide 0.5 mg/2mL inhalation (Age Limit Removed)
• Budesonide 1 mg/2mL inhalation (Age Limit Removed)
• Clonazepam 0.125 mg ODT (Age Limit Removed)
• Clonazepam 0.25 mg ODT (Age Limit Removed)
• Clonazepam 0.5 mg ODT (Age Limit Removed)
• Clonazepam 1 mg ODT (Age Limit Removed)
• Clonazepam 2 mg ODT (Age Limit Removed)
• Juluca 50 mg/25 mg tablet (Prior Authorization Removed)
• Symtuza 800 mg/150 mg/200 mg/10 mg tablet (Prior Authorization Removed)

 

 GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• Amphetamine/dextroamphetamine ER 10 mg capsule
• Amphetamine/dextroamphetamine ER 15 mg capsule
• Amphetamine/dextroamphetamine ER 20 mg capsule
• Amphetamine/dextroamphetamine ER 25 mg capsule
• Amphetamine/dextroamphetamine ER 30 mg capsule
• Amphetamine/dextroamphetamine ER 5 mg capsule
• Amphetamine/dextroamphetamine 5 mg tablet
• Amphetamine/dextroamphetamine 7.5 mg tablet
• Amphetamine/dextroamphetamine 10 mg tablet
• Amphetamine/dextroamphetamine 12.5 mg tablet
• Amphetamine/dextroamphetamine 15 mg tablet
• Amphetamine/dextroamphetamine 20 mg tablet
• Amphetamine/dextroamphetamine 30 mg tablet
• Buprenorphine/naloxone 12-3 mg film
• Buprenorphine/naloxone 2-0.5 mg film
• Buprenorphine/naloxone 4-1 mg film
• Buprenorphine/naloxone 8-2 mg film
• Dexmethylphenidate ER 10 mg capsule
• Dexmethylphenidate ER 15 mg capsule
• Dexmethylphenidate ER 20 mg capsule
• Dexmethylphenidate ER 25 mg capsule
• Dexmethylphenidate ER 30 mg capsule
• Dexmethylphenidate ER 35 mg capsule
• Dexmethylphenidate ER 40 mg capsule
• Dexmethylphenidate ER 5 mg capsule
• Methylphenidate ER 10 mg capsule
• Methylphenidate ER 20 mg capsule
• Methylphenidate ER 30 mg capsule
• Methylphenidate ER 40 mg capsule
• Methylphenidate ER 18 mg tablet
• Methylphenidate ER 27 mg tablet
• Methylphenidate ER 36 mg tablet
• Methylphenidate ER 54 mg tablet
• Ramelteon 8 mg tablet (Requires Step Therapy)

 Removals:

• Adderall 10 mg tablet
• Adderall 12.5 mg tablet
• Adderall 15 mg tablet
• Adderall 20 mg tablet
• Adderall 30 mg tablet
• Adderall 5 mg tablet
• Adderall 7.5 mg tablet
• Adderall XR 10 mg capsule
• Adderall XR 15 mg capsule
• Adderall XR 20 mg capsule
• Adderall XR 25 mg capsule
• Adderall XR 30 mg capsule
• Adderall XR 5 mg capsule
• Concerta 18 mg tablet
• Concerta 27 mg tablet
• Concerta 36 mg tablet
• Concerta 54 mg tablet
• 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
• Ritalin LA 10 mg capsule
• Ritalin LA 20 mg capsule
• Ritalin LA 30 mg capsule
• Ritalin LA 40 mg capsule
• Rozerem 8 mg tablet
• Suboxone 12-3 mg film
• Suboxone 2-0.5 mg film
• Suboxone 4-1 mg film
• Suboxone 8-2 mg film

 Other Updates:

• Clonazepam 0.125 mg ODT (Age Limit Removed)
• Clonazepam 0.25 mg ODT (Age Limit Removed)
• Clonazepam 0.5 mg ODT (Age Limit Removed)
• Clonazepam 1 mg ODT (Age Limit Removed)
• Clonazepam 2 mg ODT (Age Limit Removed)

 

December 2021

Title 19/21 SMI Drug List Updates:

Additions:

• Calcium Acetate 668mg OTC
• Everolimus 10mg
• Everolimus 3mg
• Everolimus 5mg
• Norethindrone 5mg

Removals:

• Afinitor 3mg
• Afinitor 5mg
• Afinitor 10mg

Other Updates:

• None

 

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

November 2021

Title 19/21 SMI Drug List Updates:

 Additions:

• Kloxxado 8mg

 Removals:

• None

Other Updates:

• None

 

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

October 2021

Title 19/21 SMI Drug List Updates:

 Additions:

• Aimovig 140mg/ml Autoinjector (Prior Authorization Required)
• Aimovig 70mg/ml Autoinjector (Prior Authorization Required
• Anoro Ellipta 62.5-25mcg Inhaler (Prior Authorization Required)
• Cafergot Tablet 1-100mg (Brand Only)
• Enbrel 25mg/0.5ml Vial (Prior Authorization Required)
• Jentadueto XR 2.5-1000mg (Prior Authorization Required)
• Jentadueto XR 5-1000mg (Prior Authorization Required)
• Kazano 12.5-1000mg Tablet (Brand Only, Prior Authorization Required)
• Kazano 12.5-500mg Tablet (Brand Only, Prior Authorization Required)
• Nesina 12.5mg Tablet (Brand Only, Prior Authorization Required)
• Nesina 25mg Tablet (Brand Only, Prior Authorization Required)
• Nesina 6.25mg Tablet (Brand Only, Prior Authorization Required)
• Oseni 12.5-15mg Tablet (Brand Only, Prior Authorization Required)
• Oseni 12.5-30mg Tablet (Brand Only, Prior Authorization Required)
• Oseni 12.5-45mg Tablet (Brand Only, Prior Authorization Required)
• Oseni 25-15mg Tablet (Brand Only, Prior Authorization Required)
• Oseni 25-30mg Tablet (Brand Only, Prior Authorization Required)
• Oseni 25-45mg Tablet (Brand Only, Prior Authorization Required)
• Perseris ER 120mg Syringe (Age Limit)
• Perseris ER 90mg Syringe (Age Limit)
• Proglycem 50mg/ml (Brand Only)
• Ubrelvy 100mg Tablet (Prior Authorization Required)
• Ubrelvy 50mg Tablet (Prior Authorization Required)
• Ritalin LA 10mg Capsule (Brand Only)
• Ritalin LA 20mg Capsule (Brand Only)
• Ritalin LA 30mg Capsule (Brand Only)
• Ritalin LA 40mg Capsule (Brand Only)
• Avsola 100mg Vial (Prior Authorization Required)
• Ivermectin 3mg Tablet (Quantity Limit)

 Removals:

• Aptensio XR 10mg Capsule
• Aptensio XR 15mg Capsule
• Aptensio XR 20mg Capsule
• Aptensio XR 30mg Capsule
• Aptensio XR 40mg Capsule
• Aptensio XR 50mg Capsule
• Aptensio XR 60mg Capsule
• Bevespi Aerosphere Inhaler 9-4.8mcg/act
• Depo-Provera 400mg/ml Vial
• Gvoke Hypopen 1mg/0.2ml
• Humulin N 100Unit/ml Kwikpen
• Humalog Mix 50-50 Kwikpen
• Methylphenidate LA 60mg Capsule
• Norethindrone 5mg Tablet
• Renflexis 100mg Vial
• Vyvanse 10mg Chewable Tablet
• Vyvanse 20mg Chewable Tablet
• Vyvanse 30mg Chewable Tablet
• Vyvanse 40mg Chewable Tablet
• Vyvanse 50mg Chewable Tablet
• Vyvanse 60mg Chewable Tablet

Other Updates:

• None

 

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• Perseris ER 90mg Syringe (Age Limit)
• Perseris ER 120mg Syringe (Age Limit)
• Ritalin LA 10mg Capsule (Brand Only)
• Ritalin LA 20mg Capsule (Brand Only)
• Ritalin LA 30mg Capsule (Brand Only)
• Ritalin LA 40mg Capsule (Brand Only)

Removals:

• Aptensio XR 10mg Capsule
• Aptensio XR 15mg Capsule
• Aptensio XR 20mg Capsule
• Aptensio XR 30mg Capsule
• Aptensio XR 40mg Capsule
• Aptensio XR 50mg Capsule
• Aptensio XR 60mg Capsule
• Methylphenidate LA 60mg Capsule
• Vyvanse 10mg Chewable Tablet
• Vyvanse 20mg Chewable Tablet
• Vyvanse 30mg Chewable Tablet
• Vyvanse 40mg Chewable Tablet
• Vyvanse 50mg Chewable Tablet
• Vyvanse 60mg Chewable Tablet

 

September 2021

Title 19/21 SMI Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals

• None

Other Updates

• None

 

August 2021

Title 19/21 SMI Drug List Updates:

Additions:

• Endari Powder 5mg (Prior Authorization Required)
• Hydrochlorothiazide tablet 12.5mg
• Insulin Aspart 100u/ml Cartridge
• Insulin Aspart 100u/ml Pen
• Insulin Aspart 100u/ml Vial
• Insulin Aspart Mix 70/30 Pen
• Insulin Aspart Mix 70/30 Vial
• Insulin Lispro 100u/ml Pen
• Insulin Lispro 100u/ml Vial
• Insulin Lispro Jr 100u/ml Pen
• Insulin Lispro Jr 100u/ml Vial
• Insulin Lispro Mix 75/25 Pen
• Insulin Lispro Mix 75/25 Vial
• Nayzilam (Prior Authorization Required, Quantity Level Limit)

 Removals:

• Caffeine Powder Citrated
• Humalog 100u/ml Kwikpen
• Humalog 100u/ml Vial
• Humalog Jr 100u/ml Kwikpen
• Ibrance 100mg Cap
• Ibrance 125mg Cap
• Ibrance 75mg Cap
• Lidocaine- Hydrocortisone Cream Rectal 3-0.5%
• Methoxsalen Cap 10mg
• Novolog 100u/ml Flexpen
• Novolog 100u/ml Penfill
• Novolog 100u/ml Vial
• Novolog Mix 70/30 Vial

  Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

July 2021

Title 19/21 SMI Drug List Updates:

Additions:

• None

Removals:

• BP Foam Aer 9.8%
• Vitamax Pediatric Sol oral

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• Gralise 300mg
• Gralise 600mg
• Gralise 300mg & 600mg Package
• Horizant ER 300mg
• Horizant ER 600mg

Other Updates:

• None

 

June 2021

Title 19/21 SMI Drug List Updates:

Additions:

• Renflexis 100 Mg Vial (Prior Authorization Required)

Removals:

• Tretinoin Cream 0.025%
• Tretinoin Cream 0.05%
• Tretinoin Cream 0.1%
• Tretinoin Gel 0.01%
• Tretinoin Gel 0.025%

Other Updates:

• Sumatriptan Succinate Inj 6 Mg/0.5ml (Quantity Level Limit)
• Sumatriptan Succinate Solution Auto-Injector 4 Mg/0.5ml (Quantity Level Limit)
• Sumatriptan Succinate Solution Auto-Injector 6 Mg/0.5ml (Quantity Level Limit)
• Sumatriptan Succinate Solution Cartridge 4 Mg/0.5ml (Quantity Level Limit)
• Sumatriptan Succinate Solution Cartridge 6 Mg/0.5ml (Quantity Level Limit)

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

May 2021

Title 19/21 SMI Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

April 2021

Title 19/21 SMI Drug List Updates:

Additions:

• Alkeran 2mg Tablet (Prior Authorization Required)
• Androgel 1% (25 Mg/2.5 G) Pkt (Prior Authorization Required)
• Androgel 1% (50 Mg/5 G) Pkt (Prior Authorization Required)
• Androgel 1.62% Gel Pump (Prior Authorization Required)
• Androgel 1.62%(1.25g) Gel Pckt (Prior Authorization Required)
• Androgel 1.62%(2.5g) Gel Pckt (Prior Authorization Required)
• Apriso ER 0.375 Gram Capsule
• Brinzolamide Sus 1% (Step Therapy Required)
• Canasa 1,000mg Suppository
• Delzicol Dr 400mg Capsule
• Gammaked Solution 10 GM/100mL (Prior Authorization Required)
• Gleevec 100mg Tablet (Prior Authorization Required)
• Gleevec 400mg Tablet (Prior Authorization Required)
• Hizentra 1 Gram/5ml Syringe (Prior Authorization Required)
• Hizentra 2 Gram/10ml Syringe (Prior Authorization Required)
• Hizentra 4 Gram/10ml Syringe (Prior Authorization Required)
• Invokamet 150-1,000mg Tablet (Prior Authorization Required)
• Invokamet 150-500mg Tablet (Prior Authorization Required)
• Invokamet 50-1,000mg Tablet (Prior Authorization Required)
• Invokamet 50-500mg Tablet (Prior Authorization Required)
• Lialda Dr 1.2gm Tablet
• Nivestym 300mcg/0.5ml Syringe (Prior Authorization Required)
• Nivestym 480mcg/0.8ml Syringe (Prior Authorization Required)
• Nyvepria 6mg/0.6ml Syringe (Prior Authorization Required)
• Ofloxacin 0.3% Ear Drops
• Privigen 10 GM/100mL Vial (Prior Authorization Required)
• Privigen 10% Vial (Prior Authorization Required)
• Privigen 20 GM/200mL Vial (Prior Authorization Required)
• Privigen 5 GM/50mL Vial (Prior Authorization Required)
• Sfrowasa 4gm/60ml Enema
• Synjardy 12.5-1,000mg Tablet (Prior Authorization Required)
• Synjardy 12.5-500mg Tablet (Prior Authorization Required)
• Synjardy 5-1,000mg Tablet (Prior Authorization Required)
• Synjardy 5-500mg Tablet (Prior Authorization Required)
• Trijardy XR 10-5-1,000mg Tab (Prior Authorization Required)
• Trijardy XR 12.5-2.5-1,000mg (Prior Authorization Required)
• Trijardy XR 25-5-1,000mg Tab (Prior Authorization Required)
• Trijardy XR 5-2.5-1,000mg Tab (Prior Authorization Required)
• Trulicity 0.75mg/0.5ml Pen (Prior Authorization Required)
• Trulicity 1.5mg/0.5ml Pen (Prior Authorization Required)
• Trulicity 3mg/0.5ml Pen (Prior Authorization Required)
• Trulicity 4.5mg/0.5ml Pen (Prior Authorization Required)
• Xigduo XR 10mg-1,000mg Tab (Prior Authorization Required)
• Xigduo XR 10mg-500mg Tablet (Prior Authorization Required)
• Xigduo XR 2.5mg-1,000mg Tab (Prior Authorization Required)
• Xigduo XR 5mg-1,000mg Tablet (Prior Authorization Required)
• Xigduo XR 5mg-500mg Tablet (Prior Authorization Required)

Removals:

• Azopt Sus 1%
• Balsalazide Disodium 750mg Cp
• Bivigam 5 GM/50mL Vial
• Dipentum 250mg Capsule
• Gamastan S-D Vial
• Imatinib Mesylate 100mg Tablet
• Imatinib Mesylate 400mg Tablet
• Mesalamine 1,000mg Suppository
• Mesalamine 4 gm/60ml Enema
• Mesalamine 800 mg DR Tablet
• Mesalamine DR 1.2gm Tablet
• Mesalamine DR 400mg Capsule
• Mesalamine ER 0.375 Gram Capsule
• Santyl Oin 250u/gm
• Testosterone 1% (25 Mg/2.5 G) Pkt
• Testosterone 1% (50 Mg/5 G) Pkt
• Testosterone 1.62% Gel Pump
• Testosterone 1.62%(1.25g) Gel Pckt
• Testosterone 1.62%(2.5g) Gel Pckt
• Testosterone 12.5mg/1.25 Gram
• Testosterone 30mg/1.5ml Pump

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

March 2021

Title 19/21 SMI Drug List Updates:

Additions:

• Esbriet Cap 267mg (Prior Authorization Required)
• Esbriet Tab 267mg (Prior Authorization Required)
• Esbriet Tab 801mg (Prior Authorization Required)
• Myleran Tab 2mg
• Ocrevus Inj 300/10ml (Prior Authorization Required, Quantity Level Limit)
• Pot & Sod Citrates W/ Cit Ac Soln 550-500-334mg/5ml
• Tukysa Tab 150mg (Prior Authorization Required)
• Tukysa Tab 50mg (Prior Authorization Required)
• Valtoco Liq 15mg (Quantity Level Limit)
• Valtoco Liq 20mg (Quantity Level Limit)
• Valtoco Spr 10mg (Quantity Level Limit)
• Valtoco Spr 5mg (Quantity Level Limit)
• Visco-3 Inj 25/2.5ml (Prior Authorization Required)

Removals:

• Doxycycline Monohydrate Tab 100mg
• Hyalgan Inj 20mg/2ml
• Hyoscyamine Dro 0.125/ml
• Ofev Cap 100mg
• Ofev Cap 150mg

Other Updates:

• Ondansetron Tablet Dispersible 4mg Oral (Changed Quantity Level Limit)
• Phenylephrine HCl Ophth Soln 2.5% (Added Quantity Level Limit)
• Extavia Inj 0.3mg (Added Quantity Level Limit)
• Santyl Oin 250 Unit/Gm (Added Quantity Level Limit)
• Juluca Tab 50-25mg (Added Prior Authorization)

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

February 2021

Title 19/21 SMI Drug List Updates:

Additions:

• Calamine-Zinc Oxide Lotion
• Calcium Carbonate-Cholecalciferol Chew Tab 500 Mg-400 Unit
• Diaper Rash Products - Ointment (Age Limit)
• Dimethicone-Zinc Oxide-Vitamin A-Vitamin D Cream 1-10% (Age Limit)
• Glycerin Liquid Suppos 2.8 Gm (2.7 Ml)
• Glycerin Suppos 1 Gm
• Glycerin Suppos 1.2 Gm
• Glycerin Suppos 2 Gm
• Lubiprostone Cap 24mcg (Quantity Level Limit)
• Lubiprostone Cap 8mcg (Quantity Level Limit)
• Mineral Oil
• Pediatric Multiple Vitamin W/ C & Fa Chew Tab
• Pediatric Multiple Vitamin W/ Extra C & Fa Chew Tab
• Pediatric Multiple Vitamins W/ Iron Chew Tab 18 Mg
• Sodium Fluoride Cream 1.1%
• Sodium Fluoride Paste 1.1%
• Sucralfate Susp 1 Gm/10ml (Age Limit)
• Tretinoin Cream 0.025% (Age Limit)
• Tretinoin Cream 0.05% (Age Limit)
• Tretinoin Cream 0.1% (Age Limit)
• Tretinoin Gel 0.01% (Age Limit)
• Tretinoin Gel 0.025% (Age Limit)
• Zinc Oxide Cream 13% (Age Limit)

Removals:

• Amitiza Cap 24mcg
• Amitiza Cap 8mcg

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

January 2021

Title 19/21 SMI Drug List Updates:

Additions:

• Levonorgest-Eth Estrad 91-Day TABLET 0.15-0.03 &0.01 MG
• Norethin Ace-Eth Estrad-FE Tablet 1-20 MG-MCG(24)
• Benzoyl Peroxide 6% Cleanser
• Clind Ph-Benzoyl Perox 1.2-5%
• Detrol 1 MG Tablet
• Detrol 2 MG Tablet
• Detrol LA 2 MG Capsule
• Detrol LA 4 MG Capsule
• Esomeprazole DR 10 Mg Packet (Age Limit)
• Esomeprazole DR 20 Mg Packet (Age Limit)
• Esomeprazole DR 40 Mg Packet (Age Limit)
• Esomeprazole Mag DR 40 Mg Cap
• Fish Oil EC 1,000 Mg Softgel
• Krill Oil 300 Mg Softgel
• Kyleena 19.5 Mg System
• Norethin Ace-Eth Estrad-FE Tablet Chewable 1-20 MG-MCG(24)
• Mirena 52 Mg System
• Nadolol 20 Mg Tablet (Age Limit)
• Nadolol 40 Mg Tablet (Age Limit)
• Nadolol 80 Mg Tablet (Age Limit)
• Nuvaring Vaginal Ring
• Plan B One-Step Tablet 1.5mg
• Pantoprazole Sodium Packet 40 MG Oral (Age Limit)
• Protonix 40 Mg Suspension (Age Limit)
• Retacrit Inj 20000uni (Prior Authorization Required)
• Retin-A 0.025% Cream
• Retin-A 0.05% Cream
• Retin-A 0.1% Cream
• Retin-A 0.025% Gel
• Retin-A 0.01% Gel
• Rufinamide Sus 40mg/ml (Prior Authorization Required)
• Skyla 13.5 Mg System
• SM Omega 3-6-9 Softgel
• Toviaz ER 4 Mg Tablet
• Toviaz ER 8 Mg Tablet

Removals:

• Adapalene 0.1% Cream
• Amantadine 100 Mg Tablet
• Carbidopa 25 Mg Tablet
• Carbidopa-Levo 25-100 Mg ODT
• Carbidopa-Levo 25-250 Mg ODT
• Carbidopa-Levodopa 100 Mg-Enta
• Carbidopa-Levodopa 125 Mg-Enta
• Carbidopa-Levodopa 150 Mg-Enta
• Carbidopa-Levodopa 200 Mg-Enta
• Carbidopa-Levodopa 50 Mg-Enta
• Carbidopa-Levodopa 75 Mg-Enta
• Ciclopirox 0.77% Topical Susp
• Colestipol HCl Granules
• Colestipol HCl Granules Packet
• Ella 30 Mg Tablet
• Erythromycin 2% Pads
• Erythromycin 2% Gel
• Etonogestrel-Ethinyl Estradiol Ring 0.12-0.015 MG/24HR Vaginal
• Flavoxate HCl 100 Mg Tablet
• Fluvastatin ER 80 Mg Tablet
• Fluvastatin Sodium 20 Mg Cap
• Fluvastatin Sodium 40 Mg Cap
• Niacin 500 Mg Tablet
• Omeprazole Dr 20 Mg Tablet
• Omeprazole Mag Dr 20.6 Mg Cap
• Banzel Sus 40mg/ml
• Selegiline HCl 5 Mg Capsule
• Selegiline HCl 5 Mg Tablet
• Sod Sulfacetamide 10% Shampoo
• Sodium Sulfacetamide 10% Wash
• Solifenacin 10 Mg Tablet
• Solifenacin 5 Mg Tablet
• Sulfacetamide Sod 10% Top Susp
• Tazarotene 0.1% Cream
• Tolterodine Tartrate Tablet 1 MG Oral
• Tolterodine Tartrate Tablet 2 MG Oral
• Tolterodine Tartrate ER Capsule Extended Release 24 Hour 2 MG Oral
• Tolterodine Tartrate ER Capsule Extended Release 24 Hour 4 MG Oral
• Tretinoin Cream 0.025 %
• Tretinoin Cream 0.05 %
• Tretinoin Cream 0.1 %
• Tretinoin Gel 0.01 %
• Tretinoin Gel 0.025 %
• Trospium Chloride 20 Mg Tablet
• Trospium Chloride ER 60 Mg Cap
• Verapamil ER PM 100 Mg Capsule
• Verapamil ER PM 200 Mg Capsule
• Verapamil ER PM 300 Mg Capsule

Other Updates:

• Detrol 1 Mg Tablet (Removed Step Therapy)
• Detrol 2 Mg Tablet (Removed Step Therapy)
• Detrol LA 2 Mg Capsule (Removed Step Therapy)
• Detrol LA 4 Mg Capsule (Removed Step Therapy)
• Ezetimibe 10 Mg Tablet (Removed Step Therapy)
• Lansoprazole ODT 15 Mg Tablet (Removed Prior Authorization, Added Age Limit)
• Lansoprazole ODT 30 Mg Tablet (Removed Prior Authorization, Added Age Limit)
• Montelukast Sod 4 Mg Granules (Updated Age Limit)
• Retin-A 0.01% Gel (Removed Step Therapy)
• Retin-A 0.025% Cream (Removed Step Therapy)
• Retin-A 0.025% Gel (Removed Step Therapy)
• Retin-A 0.05% Cream (Removed Step Therapy)
• Retin-A 0.1% Cream (Removed Step Therapy)
• Rosuvastatin Calcium 10 Mg Tab (Removed Step Therapy)
• Rosuvastatin Calcium 20 Mg Tab (Removed Step Therapy)
• Rosuvastatin Calcium 40 Mg Tab (Removed Step Therapy)
• Rosuvastatin Calcium 5 Mg Tab (Removed Step Therapy)
• Sevelamer Carbonate 800 Mg Tab (Removed Prior Authorization)

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• Fish Oil EC 1,000 Mg Softgel
• Krill Oil 300 Mg Softgel
• SM Omega 3-6-9 Softgel

Removals:

• Amantadine 100 Mg Tablet
• Selegiline HCl 5 Mg Capsule
• Selegiline HCl 5 Mg Tablet

 

December 2020

Title 19/21 SMI Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

November 2020

Title 19/21 SMI Drug List Updates:

Additions:

• Cetirizine Cap 10mg
• Dimethyl Fum Cap 120mg DR (Quantity Level Limit, Prior Authorization Required)
• Dimethyl Fum Cap 240mg DR (Quantity Level Limit, Prior Authorization Required)
• Diphenhydramine Chw 12.5mg
• Emtricitabin Cap 200mg
• Guaifenesin Tab 400mg
• Levocetirizi Sol 2.5mg/5
• Levocetirizi Tab 5mg
• Nebulizers
• Phenylephrine Tab 10mg
• Saline Gel Nasal

Removals:

• Emtriva Cap 200mg
• Tamiflu Cap 30mg
• Tamiflu Cap 45mg
• Tamiflu Cap 75mg
• Tamiflu Susp 6mg/ml
• Tecfidera Cap DR 120mg
• Tecfidera Cap DR 240mg

Other Updates:

• Linaclotide capsules (Step Therapy Updated)

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

October 2020

Title 19/21 SMI Drug List Updates:

Additions:

• Advair Diskus 100-50 mcg/dose (Step Therapy Required)
• Advair Diskus 250-50 mcg/dose (Step Therapy Required)
• Advair Diskus 500-50 mcg/dose (Step Therapy Required)
• Ajovy Inj 225/1.5 (Prior Authorization Required)
• Ajovy Syn 225/1.5 (Prior Authorization Required)
• Efavirenz-Lamivudine-Tenofovir Df Tab 400-300-300 Mg
• Efavirenz-Lamivudine-Tenofovir Df Tab 600-300-300 Mg
• Flovent Disk Aer 100mcg
• Flovent Disk Aer 250mcg
• Flovent Disk Inh 50mcg
• Humalog Jr Inj 100/ml
• Humulin 5's Pen 70/30kwp
• Humulin N Pen U-100kwp
• Dulera Aerosol 50-5mcg (Step Therapy Required)

Removals:

• Aimovig Inj 70mg/ml
• Aimovig Pen 140mg/ml
• Artificial Tears 1% Solution
• Dyanavel XR Sus 2.5mg/ml
• Insulin Lispro Junior Kwikpen
• Insulin Lispro Protamine Mix Kwikpen
• Novolin 70/30 Vial
• Psyllium Powder 30%
• Psyllium Powder 33%
• Psyllium Powder 49%
• Quillichew Chw 20mg ER
• Quillichew Chw 30mg ER
• Quillichew Chw 40mg ER
• Quillivantxr Sus 25mg/5ml
• Symfi Lo Tablet 400-300-300mg
• Symfi Tablet 600-300-300mg
• Symjepi Inj 0.15mg
• Symjepi Inj 0.3mg

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• Dyanavel XR Sus 2.5mg/ml
• Psyllium Powder 30%
• Psyllium Powder 33%
• Psyllium Powder 49%
• Quillichew Chw 20mg ER
• Quillichew Chw 30mg ER
• Quillichew Chw 40mg ER
• Quillivantxr Sus 25mg/5ml

Other Updates:

• None

 

September 2020

Title 19/21 SMI Drug List Updates:

Additions:

• Cyclophosph Cap 25mg
• Cyclophosph Cap 50mg
• Erivedge Cap 150mg (Prior Authorization Required)
• Abiraterone Tab 250mg (Prior Authorization Required)
• Venclexta Tab 10mg (Prior Authorization Required)
• Venclexta Tab 50mg (Prior Authorization Required)
• Venclexta Tab 100mg (Prior Authorization Required)
• Venclexta Tab Start Pk (Prior Authorization Required)
• Tafinlar Cap 50mg (Prior Authorization Required)
• Tafinlar Cap 75mg (Prior Authorization Required)
• Rydapt Cap 25mg (Prior Authorization Required)
• Mekinist Tab 0.5mg (Prior Authorization Required)
• Mekinist Tab 2mg (Prior Authorization Required)
• Gilotrif Tab 20mg (Prior Authorization Required)
• Gilotrif Tab 30mg (Prior Authorization Required)
• Gilotrif Tab 40mg (Prior Authorization Required)
• Alecensa Cap 150mg (Prior Authorization Required)
• Zykadia Cap 150mg (Prior Authorization Required)
• Jakafi Tab 5mg (Prior Authorization Required)
• Jakafi Tab 10mg (Prior Authorization Required)
• Jakafi Tab 15mg (Prior Authorization Required)
• Jakafi Tab 20mg (Prior Authorization Required)
• Jakafi Tab 25mg (Prior Authorization Required)
• Kalydeco Tab 150mg (Prior Authorization Required)
• Kalydeco Pak 25mg (Prior Authorization Required)
• Kalydeco Pak 50mg (Prior Authorization Required)
• Kalydeco Pak 75mg (Prior Authorization Required)
• Ofev Cap 100mg (Prior Authorization Required)
• Ofev Cap 150mg (Prior Authorization Required)
• Austedo Tab 6mg (Prior Authorization Required)
• Austedo Tab 9mg (Prior Authorization Required)
• Austedo Tab 12mg (Prior Authorization Required)
• Soliris Inj 10mg/Ml (Prior Authorization Required)
• Lenvima Cap 4mg (Prior Authorization Required)
• Lenvima Cap 8 Mg (Prior Authorization Required)
• Lenvima Cap 10 Mg (Prior Authorization Required)
• Lenvima Cap 12mg (Prior Authorization Required)
• Lenvima Cap 20 Mg (Prior Authorization Required)
• Lenvima Cap 14 Mg (Prior Authorization Required)
• Lenvima Cap 18 Mg (Prior Authorization Required)
• Lenvima Cap 24 Mg (Prior Authorization Required)
• Repatha Push Inj 420/3.5 (Prior Authorization Required)
• Repatha Inj 140mg/ml (Prior Authorization Required)
• Xolair Inj 75/0.5 (Prior Authorization Required)
• Xolair Inj 150mg/ml (Prior Authorization Required)
• Symdeko Tab 50-75mg (Prior Authorization Required)
• Symdeko Tab 100-150 (Prior Authorization Required)

Removals:

• None

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

August 2020

Title 19/21 SMI Drug List Updates:

Additions:

• Diclofenac Sodium Soln 1.5% (Quantity Level Limit, Step Therapy Required)
• Ibrance Cap 100mg (Prior Authorization Required, Quantity Level Limit)
• Ibrance Cap 125mg (Prior Authorization Required, Quantity Level Limit)
• Ibrance Cap 75mg (Prior Authorization Required, Quantity Level Limit)
• Ibrance Tab 100mg (Prior Authorization Required, Quantity Level Limit)
• Ibrance Tab 125mg (Prior Authorization Required, Quantity Level Limit)
• Ibrance Tab 75mg (Prior Authorization Required, Quantity Level Limit)
• Temixys 300-300 (Quantity Level Limit)
• Lynparza Tab 100mg (Prior Authorization Required, Quantity Level Limit)
• Lynparza Tab 150mg (Prior Authorization Required, Quantity Level Limit)
• Solifenacin Succinate Tab 10 Mg (Quantity Level Limit, Step Therapy Required)
• Solifenacin Succinate Tab 5 Mg (Quantity Level Limit, Step Therapy Required)
• Symproic Tab 0.2mg (Prior Authorization Required, Quantity Level Limit)

Removals:

• Fluorouracil Cream 0.5%
• Naproxen Sodium Tab 275 Mg
• Tolmetin Sodium Cap 400
• Tolmetin Sodium Tab 200
• Tolmetin Sodium Tab 600

Other Updates:

• Symtuza Tab (Added Prior Authorization)
• Testosterone TD Soln 30 Mg/Act (Added Quantity Level Limit)
• Testosterone Gel 1.62% (Added Quantity Level Limit)
• Candesartan Cilexetil Tab 4 Mg (Added Step Therapy)
• Candesartan Cilexetil Tab 8 Mg (Added Step Therapy)
• Candesartan Cilexetil Tab 16 Mg (Added Step Therapy)
• Candesartan Cilexetil Tab 32 Mg (Added Step Therapy)
• Candesartan Cilexetil-Hydrochlorothiazide Tab 16-12.5 Mg (Added Step Therapy)
• Candesartan Cilexetil-Hydrochlorothiazide Tab 32-12.5 Mg (Added Step Therapy)
• Candesartan Cilexetil-Hydrochlorothiazide Tab 32-25 Mg (Added Step Therapy)
• Fluvastatin Sodium Cap 20 Mg (Added Step Therapy)
• Fluvastatin Sodium Cap 40 Mg (Added Step Therapy)
• Carbamide Peroxide 6.5% Otic Soln (Added Quantity Level Limit)
• Betamethasone Dipropionate Augmented Cream 0.05% (Added Quantity Level Limit)
• Lidocaine Oint 5% (Changed Quantity Level Limit)

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

July 2020

Title 19/21 SMI Drug List Updates:

Additions:

• None

Removals:

• Videx EC Cap 125mg
• Videx Ped Pow 2gm
• Videx Sol 4gm
• Zaclir Lot 8%

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

June 2020

Title 19/21 SMI Drug List Updates:

Additions:

• Alahist D Tab
• Dovato Tab 50-300mg (Quantity Level Limit)
• Gvoke Hypopen Inj (Quantity Level Limit)
• Phenazopyridine Tab 95 Mg

Removals:

• None

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

May 2020

Title 19/21 SMI Drug List Updates:

Additions:

• Dexameth Pho Inj 20mg/5ml
• Dexameth Pho Mdv 10mg/ml
• Dexameth Pho Via 120mg/30
• Dexamethason Via 10mg/ml
• Dexamethason Via 4mg/ml
• Everolimus Tab 0.25mg (Prior Authorization Required)
• Everolimus Tab 0.5mg (Prior Authorization Required)
• Everolimus Tab 0.75mg (Prior Authorization Required)
• Pyrimethamine Tab 25mg (Prior Authorization Required)

Removals:

• Daraprim Tab 25mg
• Zortress Tablet 0.25mg
• Zortress Tablet 0.5mg
• Zortress Tablet 0.75mg

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

April 2020

Title 19/21 SMI Drug List Updates:

Additions:

• Erlotinib Hcl Tab 100 Mg (Prior Authorization Required)
• Erlotinib Hcl Tab 25 Mg (Prior Authorization Required)
• Ferrous Fumarate Tab 325 Mg
• Forteo Inj 600 Mcg/2.4ml (Prior Authorization Required)
• Glycerin Suppos 2.1 Gm
• Ibandronate Sodium 150 Mg Tab
• Imatinib Mesylate 100 Mg Tab (Prior Authorization Required)
• Imatinib Mesylate 400 Mg Tab (Prior Authorization Required)
• Mesalamine Cap ER 24hr 0.375 Gm (Quantity Level Limit)
• Nevirapine Susp 50 Mg/5ml
• Orkambi Granules 100-125 Mg (Prior Authorization Required)
• Orkambi Granules 200-125 Mg (Prior Authorization Required)
• Orkambi Tab 100-125 Mg (Prior Authorization Required)
• Orkambi Tab 200-125 Mg (Prior Authorization Required)
• Omeprazole Tablet Delayed Release Disintegrating 20 Mg (Quantity Level Limit)
• Prolia Syringe 60 Mg/Ml (Prior Authorization Required)
• Tramadol Hcl Tab 100mg (Quantity Level Limit)
• Zinc Oxide Oint 40%

Removals:

• Apriso Cap ER 24Hr 0.375GM
• Bivigam Solution
• Carimune Nf Inj
• Diphenhydramine HCl Liquid 6.25 Mg/mL
• Ferrous Sulfate Syrup 300 Mg/5ml (60 Mg/5ml Elemental)
• Gleevec Tab
• Konsyl Daily Fiber Packet 100%
• Levalbuterol HCL Sol Nebulizer
• Polyethylene Glycol 3350 Oral Packet
• Sennosides Tab 17.2 Mg
• Sodium Bicarbonate Powder
• Tarceva Tab
• Viramune Susp 50mg/ml

Other Updates:

• Valacyclovir Tab 1gm (Termed Quantity Limit)
• Valacyclovir Tab 500mg (Termed Quantity Limit)

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• Konsyl Daily Fiber Packet 100%
• Sennosides Tab 17.2 Mg

Other Updates:

• None

 

March 2020

Title 19/21 SMI Drug List Updates:

Additions:

• None

Removals:

• Fluoritab Dro 0.125mg
• Prenatal Without A Vit W/ Fe Fumarate-Folic

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

February 2020

Title 19/21 SMI Drug List Updates:

Additions:

• Bimatoprost Sol 0.03% (Step Therapy Required)
• Ethinyl Estradiol 0.015mg and Etonogestrel 0.12mg Ring
• Everolimus Tab 2.5mg (PA Required)
• Everolimus Tab 5mg (PA Required)
• Everolimus Tab 7.5mg (PA Required)
• Flebogamma Dif 5% Vial (PA Required)
• Hydrocortisone 1% Ointment
• Travoprost Dro 0.004% (PA Required)
• Triamcinolone 0.05% Ointment

Removals:

• Afinitor Tab 2.5mg
• Afinitor Tab 5mg
• Afinitor Tab 7.5mg
• First-Vanco Sol 25mg/ml
• First-Vanco Sol 50mg/ml
• Kyleena
• Methyclothiazide Tab 5mg
• Mirena
• NuvaRing 0.12-0.015mg/24hr
• Phospholine (Echothiophate Iodide) Opth Solution 0.125%
• Rabeprazole EC 20 Mg Cap
• Skyla
• Travatan Z Solution 0.004%

Other Updates:

• Combigan Sol 0.2/0.5% (Added Quantity Level Limit)
• Ibandronate Inj 3mg/3ml (Added Quantity Level Limit)
• Levofloxacin Sol 0.5% (Added Quantity Level Limit)
• Memantine Tab HCl 10mg (Added Quantity Level Limit)
• Memantine Tab HCl 5mg (Added Quantity Level Limit)
• Tazarotene Cre 0.1% (Added Step Therapy Required)

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

January 2020

Title 19/21 SMI Drug List Updates:

Additions:

• Anusol-HC Cream 2.5%
• Calc Acetate Tab 667mg
• Clobetasol Gel 0.05% (Quantity Level Limit)
• Derma-Smoothe/FS Oil 0.01% Body
• Derma-Smoothe/FS Oil 0.01% Scalp
• Eszopiclone Tab 1mg (Age Limit, Quantity Level Limit)
• Eszopiclone Tab 2mg (Age Limit, Quantity Level Limit)
• Eszopiclone Tab 3mg (Age Limit, Quantity Level Limit)
• Imitrex Spr 20mg/ACT (Quantity Level Limit)
• Imitrex Spr 5mg/ACT (Quantity Level Limit)
• Metoprolol Tab 37.5mg
• Sevelamer Tab 800mg
• Zomig Spr 2.5mg (Quantity Level Limit)
• Zomig Spr 5mg (Quantity Level Limit)

Removals:

• Calc Acetate Tab 668mg
• Clobetasol Lot 0.05%
• Fluocinolone Acet Oil 0.01% Body
• Fluocinolone Acet Oil 0.01% Sc
• Nadolol Tab 20mg
• Nadolol Tab 40mg
• Nadolol Tab 80mg
• Nadolol/Bend Tab 40-5mg
• Renagel Tab 800mg
• Renagel Tab 400mg
• Renvela Tab 800mg
• Scalpicin Sol 1%
• Sumatriptan Inj 6mg/0.5
• Sumatriptan  Spr 20mg/Act
• Sumatriptan  Spr 5mg/Act
• Verapamil Cap 360mg Sr

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• Buprenorphine HCl-Naloxone Hcl SL Tab 2-0.5mg
• Buprenorphine HCl-Naloxone Hcl SL Tab 8-2mg
• Eszopiclone Tab 1mg (Age Limit, Quantity Level Limit)
• Eszopiclone Tab 2mg (Age Limit, Quantity Level Limit)
• Eszopiclone Tab 3mg (Age Limit, Quantity Level Limit)

Removals:

• Nadolol Tab 20mg
• Nadolol Tab 40mg
• Nadolol Tab 80mg

Other Updates:

• None

 

December 2019

Title 19/21 SMI Drug List Updates:

Additions:

• Synagis Inj 100mg/ml (Age Limit, Quantity Level Limit)
• Synagis Inj 50mg/0.5ml (Age Limit, Quantity Level Limit)

Removals:

• Benzoyl Peroxide Liq 7%

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

November 2019

Title 19/21 SMI Drug List Updates:

Additions:

• Aminocaproic Acid Sol 0.25gm/ml

Removals:

• Amicar Sol 0.25gm/ml

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

October 2019

Title 19/21 SMI Drug List Updates:

Additions:

• Aimovig Inj 70mg/ml (Prior Authorization Required)
• Aquadeks Chw
• Aquadeks Dro
• Budesonide Sus 1mg/2ml (Age Limit)
• Bupren/Nalox Sub 2-0.5mg Tab
• Bupren/Nalox Sub 8-2mg Tab
• Dekas Cap Essential
• Dekas Liq Essential
• Dekas Plus Chw
• Dekas Plus Liq
• Dexmethylph Tab 10mg (Age Limit, Quantity Level Limit)
• Dexmethylph Tab 2.5mg (Age Limit, Quantity Level Limit)
• Dexmethylph Tab 5mg (Age Limit, Quantity Level Limit)
• Dyanavel XR Sus 2.5mg/ml (Age Limit, Quantity Level Limit)
• Emgality Inj 120mg/ml (Prior Authorization Required)
• Emgality Inj 120mg/ml (Prior Authorization Required)
• Multivitamin Chw Children
• Mvw Complete Chw
• Mvw Complete Chw
• Otezla Tab 10/20/30 (Prior Authorization Required)
• Otezla Tab 30mg (Prior Authorization Required)
• Pifeltro Tab 100mg
• Sofos/Velpat Tab 400-100 (Prior Authorization Required)
• Sublocade Inj 100/0.5 (Prior Authorization Required)
• Sublocade Inj 300/1.5 (Prior Authorization Required)
• Symjepi Inj 0.15mg (Quantity Level Limit)
• Symjepi Inj 0.3mg (Quantity Level Limit)
• Tudorza Pres Aer 400/Act (Quantity Level Limit)
• Vitamax Chw
• Vitamax Ped Dro
• Xarelto Tab 2.5mg (Quantity Level Limit)
• Xeljanz Tab 10mg (Prior Authorization Required)
• Xeljanz Tab 5mg (Prior Authorization Required)

Removals:

• Advair Disku Aer 100/50
• Advair Disku Aer 250/50
• Advair Disku Aer 500/50
• Aripiprazole Sol 1mg/ml
• Aripiprazole Tab 10mg ODT
• Aripiprazole Tab 15mg ODT
• Dextroamphet Cap 10mg ER
• Dextroamphet Cap 15mg ER
• Dextroamphet Cap 5mg ER
• Epinephrine Inj 0.15mg (Generic Adrenaclick)
• Focalin Tab 10mg
• Focalin Tab 2.5mg
• Focalin Tab 5mg
• Pulmicort Sus 1mg/2ml
• Saphris Sub 10mg
• Saphris Sub 2.5mg
• Saphris Sub 5mg

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• Dexmethylph Tab 5mg (Age Limit, Quantity Level Limit)
• Dexmethylph Tab 10mg (Age Limit, Quantity Level Limit)
• Bupren/Nalox Sub 2-0.5mg Tab
• Bupren/Nalox Sub 8-2mg Tab
• Sublocade Inj 100/0.5 (Prior Authorization Required)
• Sublocade Inj 300/1.5 (Prior Authorization Required)
• Dyanavel XR Sus 2.5mg/ml (Age Limit)
• Dexmethylph Tab 2.5mg (Age Limit, Quantity Level Limit)

Removals:

• Aripiprazole Sol 1mg/ml
• Aripiprazole Tab 10mg ODT
• Aripiprazole Tab 15mg ODT
• Dextroamphet Cap 10mg ER
• Dextroamphet Cap 15mg ER
• Dextroamphet Cap 5mg ER
• Focalin Tab 10mg
• Focalin Tab 2.5mg
• Focalin Tab 5mg
• Saphris Sub 10mg
• Saphris Sub 2.5mg
• Saphris Sub 5mg

Other Updates:

• None

 

September 2019

Title 19/21 SMI Drug List Updates:

Additions:

• Febuxostat Tab (Quantity Level Limit, Step Therapy)
• Multiple Vitamin
• Pediatric Multiple Vitamin
• Pregabalin Cap (Prior Authorization Required)
• Pregabalin Sol (Prior Authorization Required)

Removals:

• Uloric Tab
• Lyrica Cap
• Lyrica Sol

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

August 2019

Title 19/21 SMI Drug List Updates:

Additions:

• Adcirca – Brand only (Prior Authorization Required)
• Alendronate Sodium Soln
• Bicillin L-A 1200000 Unit/2ml
• Bicillin L-A 2400000 Unit/4ml
• Bicillin L-A 600000 Unit/ml
• Bivigam (Prior Authorization Required)
• Carimune NF Nanofiltered (Prior Authorization Required)
• Cerdelga (Prior Authorization Required)
• Elelyso (Prior Authorization Required)
• Farxiga (Prior Authorization Required)
• Flebogamma Dif (Prior Authorization Required)
• Fulphila (Prior Authorization Required)
• Gamastan S-D (Prior Authorization Required)
• Gammagard S-D (Prior Authorization Required)
• Gleevec – Brand only (Prior Authorization Required)
• Hizentra (Prior Authorization Required)
• Imbruvica Tablets (Prior Authorization Required)
• Invokana (Prior Authorization Required)
• Letairis – Brand only (Prior Authorization Required)
• Leukeran (Prior Authorization Required)
• Lidocaine Patch 4% (Quantity Level Limit)
• Lorcaserin HCl Tab ER 24hr 20mg (Prior Authorization Required, Quantity Level Limit)
• Miglustat (Prior Authorization Required)
• Nplate (Prior Authorization Required)
• ProAir – Brand only
• Retacrit (Prior Authorization Required)
• Revatio solution – Brand only (Prior Authorization Required for age > 12)
• Tracleer – Brand only (Prior Authorization Required)
• Udenyca (Prior Authorization Required)
• Vpriv (Prior Authorization Required)

Removals:

• Arcapta Neohaler
• Bupropion HCl Tab ER 24hr 450mg
• Butalbital-Acetaminophen-Caffeine Cap 50-300-40mg
• Butalbital-Acetaminophen-Caffeine Cap 50-325-40mg
• Desvenlafaxine Succinate ER
• Emsam
• Epinastine HCl Ophth Soln 0.05%
• Epogen
• Erythromycin Ethylsuccinate For Susp
• Escitalopram Oxalate Soln
• Prefest
• Etidronate Disodium
• Etodolac Tab ER 24hr
• Fluoxetine DR
• Fluvoxamine Maleate ER
• Glipizide-Metformin
• Iclusig
• Imatinib
• Isocaboxazid
• Jakafi
• Marplan
• Melphalan
• Nefazodone HCl
• Neulasta
• Ofloxacin Otic
• Olopatadine HCl Ophth Soln 0.2%
• Opsumit
• Paroxetine ER
• Paxil Sus 10mg/5ml
• Pexeva
• Phenelzine Sulfate
• Procrit
• Purixan Solution
• Riomet
• Segluromet
• Steglatro
• Striverdi Respimat
• Tasigna
• Thalomid
• Tranylcypromine Sulfate
• Tymlos
• Tyvaso
• Ventavis
• Ventolin HFA
• Viibryd
• Zolinza

Other Updates:

• Azelastine Ophth Soln 0.2% (Added Quantity Level Limit)
• Baraclude Oral Soln 0.05 mg/ml (Prior Authorization Required)
• Butalbital-Acetaminophen-Caffeine Tab 50-325-40mg (Added Quantity Level Limit)
• Calcipotriene Soln 0.005%, Calcipotriene cream 0.005%, Calcipotriene Oint 0.005% (Prior Authorization Required)
• Citalopram Hydrobromide Oral Soln 10mg/5ml (Added Age Limit)
• Evotaz Tablet 300-150mg (Added Quantity Level Limit)
• Fluoxetine HCl Solution 20mg/5ml (Added Age Limit)
• Sertraline HCl Oral Concentrate For Solution 20mg/ml (Added Age Limit)

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• Desvenlafaxine Succinate ER
• Emsam
• Escitalopram Oxalate Soln 5 Mg/5ml
• Fluoxetine DR
• Fluvoxamine Maleate ER
• Marplan
• Nefazodone HCl
• Paroxetine ER
• Paxil Sus 10mg/5ml
• Pexeva
• Phenelzine Sulfate
• Tranylcypromine Sulfate
• Viibryd

Other Updates:

• Citalopram Hydrobromide Oral Soln 10mg/5ml (Added Age Limit)
• Fluoxetine HCl Solution 20mg/5ml (Added Age Limit)
• Sertraline HCl Oral Concentrate for Solution 20mg/ml (Added Age Limit)

 

July 2019

Title 19/21 SMI Drug List Updates:

Additions:

• Avastin Inj
• Cefixime Cap 400mg (Quantity Level Limit)
• Erlotinib Tab 150mg (Prior Authorization Required)
• Herceptin Inj
• Mesalamine Cap 400mg DR (Quantity Level Limit)
• Penicillamine Capsule
• Sildenafil Sus 10mg/ml (Prior Authorization Required)

Removals:

• Benziq Wash Liq 5.25%
• Bio-Statin Cap 1000000
• Bio-Statin Cap 500000 U
• Bio-Statin Pow
• Bocasal Pow
• Calcium Carb Pow Ppt/Heav
• Cuprimine Capsule
• Delzicol Cap 400mg DR
• Ergocal Cap 2500unit
• Fluorabon Dro
• Fluoroplex Cre 1%
• Flura-Drops Dro 4drp=1mg
• Gentamicin Pow Sulfate
• Homatropine Sol 5% Op
• Nature-Throi Tab 2gr
• Revatio Sus 10mg/ml
• Sod Fluoride Tab 0.5mg F
• Sod Fluoride Tab 1mg F
• Suprax Cap 400mg
• Tarceva Tab 150mg

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

 

June 2019

Title 19/21 SMI Drug List Updates:

Additions:

• Docosanol Cream 10%
• Melatonin Tab 1 Mg
• Melatonin Tab 3 Mg
• Melatonin Tab 5 Mg

Removals:s

• Abreva Cream 10%

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• Melatonin Tab 1 Mg
• Melatonin Tab 3 Mg
• Melatonin Tab 5 Mg

Removals:

• None

Other Updates:

• None

 

May 2019

Title 19/21 SMI Drug List Updates:

Additions:

• Concerta Tab ER (Age Limit, Quantity Limit)
• Erythrom Eth Sus 400/5ml
• Ranolazine Tab 1000mg ER (Prior Authorization Required)
• Sirolimus Sol 1mg/ml

Removals:

• EryPed 400 Sus 400/5ml
• Methylphenidate Tab ER
• Methylphenidate Tab ER
• Prochlorperazine Maleate Tab 10 Mg (Base Equivalent)
• Prochlorperazine Maleate Tab 5 Mg (Base Equivalent)
• Prochlorperazine Suppos 25 Mg
• Ranexa Tab 1000mg ER
• Rapamune Sol 1mg/ml

Other Updates:

• None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• Concerta Tab ER

Removals:

• Methylphenidate Tab ER

Other Updates:

• None

 

April 2019

Title 19/21 SMI Drug List Updates:

Additions:

• Ranolazine Tab ER 500mg (Prior Authorization)
• Ritalin LA Cap 20mg, 30mg, 40mg (Age Limit, Quantity Level Limit)
• Treprostinil Sol 1mg/mL, 2.5mg/mL, 5mg/mL, 10mg/mL (Prior Authorization)

Removals:

• Ranexa Tab ER 500mg
• Remodulin Sol 1mg/mL, 2.5mg/mL, 5mg/mL, 10mg/mL

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• Ritalin LA Cap 20mg, 30mg, 40mg (Age Limit, Quantity Level Limit)

Removals:

• None

 

 

March 2019

Title 19/21 SMI Drug List Updates:

Additions:

• Cinacalcet tablet added with PA
• Aminocaproic acid tablet
• Carbidopa 25mg tablet
• Toremifene tablet added with PA
• Mesalamine 1000mg Suppositories added with QLL (30/30days)
• Clonidine 0.1mg ER tablet added with QLL (120/30 days) and PA < 6 years of age

Removals:

• Sensipar
• Amicar
• Fareston
• Canasa Suppositories
• Norethindrone- ethinyl estradiol- ferrous fumarate 1-20 mg-mcg (24) tablets
• Kapvay

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• Clonidine 0.1mg ER tablet added with QLL (120/30 days) and PA < 6 years of age

Removals:

• Kapvay

 

February 2019

Title 19/21 SMI Drug List Updates:

Additions:

• Calcipotriene cre 0.005% QLL added (200gm/30days)
• Calcipotriene oint 0.005% QLL added (200gm/30days)
• Calcipotriene soln 0.005% (50 mcg/ml) QLL added (200ml/30days)
• Clonidine HCL ER 0.1mg Tab
• Flebogamma added with PA (must be filled at Contracted Home Infusion Pharmacy)
• Gammagard added with PA (must be filled at Contracted Home Infusion Pharmacy)
• Gammaked added with PA (must be filled at Contracted Home Infusion Pharmacy)
• Gamunex-C added with PA (must be filled at Contracted Home Infusion Pharmacy)
• Jardiance PA added
• Nitrofurantoin Suspension PA > 12 years added
• Prenatal mv & min w/fe fumarate-fa-dha 28-0.8-200mg pack added with QLL (100/90 days)
• Prenatal vit w/ docusate-fe fumarate-folic acid 29-1mg tab added with QLL (100/90 days)
• Prenatal vit w/ ferrous fumarate-folic acid 27-0.8mg tab added with QLL (100/90 days)
• Prenatal vit w/ ferrous fumarate-folic acid 27-1mg tab added with QLL (100/90 days)
• Prenatal vit w/ ferrous fumarate-folic acid 28-1mg tab added with QLL (100/90 days)
• Prenatal vit w/ ferrous fumarate-folic acid 29-1mg chew tab added with QLL (100/90 days)
• Prenatal vit w/ ferrous fumarate-folic acid 29-1mg tab added with QLL (100/90 days)
• Prenatal without a vit w/ fe fumarate-folic acid 29-1mg chew tab added with QLL (100/90 days)
• Prenatal without a vit w/ fe fum-iron polysacch complex –fa 130-92.4-1mg cap added with QLL (100/90 days)
• Prenatal without a vit w/ fe fum-iron polysacch complex –fa 20-20-1.25mg cap added with QLL (100/90 days)
• Segluromet added with ST and QLL (60/30 days
• Steglatro added with ST and QLL (30/30days)

Removals:

• Condolyx gel
• Dihydroergotamine Nasal Solution
• Elidel Cream 1%
• Ergomar SL Tablet
• Invokana tablet
• Invokanamet tablet
• Jardiance ST removed
• Kapvay ER 0.1mg Tab
• Levonor/ethi tab estradio
• Lidocaine/hc kit 20x7gm
• Lidocaine/hc kit 3%-1%
• Lo Loestrin tablet
• Nitro-bid 2% packets
• Prenatal multivitamins & minerals w/ l-methylfolate-fa 0.6-0.4mg chew tab
• Prenatal mv & min w/fe polysaccharide complex-fa-dha 29-1mg & 250mg pack
• Prenatal vit w/ ferrous fumarate-folic acid 65-1mg tab
• Prenatal vit w/ ferrous fumarate-l methylfolate-folic acid 27-0.6-0.4mg tab
• Prenatal vit w/ iron carbonyl-fe aspart glyc-fa-omega 3 27-1mg cap
• Prenatal vit w/ iron carbonyl-folic acid 50-1.25mg tab
• Prenatal vit w/ iron polysaccharide complex-folic acid 29-1 chew tab
• Prenatal w/o vit a w/ fe carbonyl-fe asp glyc-methfol-fa-dha 18-0.6-0.4-350mg cap
• Prenatal w/o vit a w/ fe carbonyl-fe gluconate-dss-fa-dha 27-1mg & 250mg pack
• Prenatal w/o vit a w/ fe fumarate-dss-fa-dha 27-1.25-300mg cap
• Prenatal without a w/ fe fumarate-l methylfolate-fa-dha 27-0.6-0.4-300mg cap
• Prenatal without a w/ fe fumarate-l methylfolate-fa-omega 3 28-0.6-0.4-340mg cap
• Synjardy and Synjardy XR tablet
• Terconazole vaginal suppos 80 mg
• Trimethobenzamide hcl cap 300 mg

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

 

January 2019

Title 19/21 SMI Drug List Updates:

Additions:

• Celecoxib 50mg and 100mg QLL added (60/30 days)

Removals:

• None

Title 19/21 Non-SMI & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

 

December 2018

Title 19/21 SMI Drug List Updates:

Additions:

• Donepezil, donepezil ODT PA added
• Memantine PA added
• Mesalamine enema QLL (120ml/day)
• Pentasa QLL (270 /30days)
• Sildenafil citrate suspension 10 mg/mL with PA
• Sulfasalazine QLL (240/30)
• Tretinoin cream/gel age limitation of 26

Removals:

• Benazepril & hydrochlorothiazide tab 5-6.25 mg
• Interferon alfa-2b for inj 50000000 unit
• Methotrexate sodium inj pf 100 mg/4ml (25 mg/ml)
• Methotrexate sodium inj pf 200 mg/8ml (25 mg/ml)
• Peginterferon alfa-2b for inj kit 80 mcg/0.5ml
• Sodium fluoride-xylitol chew tab 1.1 (0.5 mg f)-236.79
• Sodium sulfacetamide/ sulfur 10-5% emulsion
• Telbivudine tab 600 mg
• Tretinoin cream/gel age limitation of 35

 

Title 19/21 Non-SMI & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

 

November 2018

Title 19/21 SMI Drug List Updates:

Additions:

• Albendazole added with ST

Removals:

• Albenza
• Clotrimazole ointment (no longer marketed)
• Cytra-K (all NDCs are DESI)

Title 19/21 Non-SMI & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

 

October 2018

Title 19/21 SMI Drug List Updates:

Additions:

• Arcapta Neohaler added with QLL (30 caps/ 30 days)
• Aristada Initio added with QLL (2/365days)
• Atomoxetine added with QLL (30/30days)
• Butenafine cream
• Cascara sagrada
• Dutasteride
• Fiber tablet, powder, capsule
• Glatopa 40mg
• Loratadine chew tab added with QLL (60/30days)
• Magnesium Citrate soln
• Magnesium Oxide tab
• Methylcellulose powder, tab
• Ondansetron 4mg tablet and ODT QLL changed to 90tabs/30days
• Prasugrel added with QLL (30/30 days)
• Procrit added with PA
• Senna syrup, liquid, tab
• Striverdi Respimat added with QLL (1/30days)
• Tadalafil (generic Adcirca) added with STEP
• Tazarotene cream added with QLL (90gm/30days)
• Tymlos added with PA and QLL (1/30days)
• Valganciclovir QLL added (60/30days)
• Vitamin E Chew tab
• Vyvanse chewable tablet added with QLL (30/30days)

Removals:

• Acebutolol
• Aclometasone
• Adcirca
• Capex shampoo
• Cardura XL
• Copaxone 40mg
• Desonide
• Diltiazem 24hr ER tablet
• Diltiazem IR and ER QLL removed
• Fluocinolone cream, solution
• Griseofulvin ultramicrosize
• Hydrocortisone butyrate
• Hydrocortisone valerate
• Isradipine
• Itraconazole
• Ketoconazole
• MatzimLA
• Methylphenidate chewable tablet
• Nicardipine
• Nimodipine
• Nisoldipine
• Noxafil suspension
• Pindolol
• Sporanox solution
• Strattera
• Timolol tablet
• Voriconazole

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• Aristada Initio added with QLL (2/365 days) and age limit (PA for < 18 years)
• Atomoxetine added with QLL (30/30 days) and age limit (PA for <6 years)
• Bisacodyl enema, supp, tab
• Cascara sagrada capsule
• Fiber tablet, powder, capsule
• Lithium age limit added (PA for <6 years)
• Magnesium Citrate soln
• Magnesium Oxide tab
• Methylcellulose powder, tab
• Niacin tablet, chew tab, and ER tab
• Pimozide age limit added (PA for <12 years)
• Senna syrup, liquid, tab
• Vitamin E Chew tab
• Vyvanse chewable tablet added with QLL (30/30days ) and age limt (PA for <6 years)

Removals:

• Methylphenidate chewable tablet
• Strattera

 

September 2018

Title 19/21 SMI Drug List Updates:

Additions

• Eliquis starter pack  added with QLL (74/30days)
• Makena 275mg /1.1ml Auto Inj added with PA
• Phosphorous 250mg powder for solution
• Pyrethrins-piperonyl Butoxide Gel
• Symtuza tablets added with QLL (30/30days)

Removals

• Eurax PA removed
• PHOS-NAK

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions

• None

Removals

• None

 

July 2018

Title 19/21 SMI Drug List Updates

Additions:

• Naratriptan tablets added with QLL (9/30 days)
• Rizatriptan QLL changed (9/30days)
• Zolmitriptan tablets and ODT added with QLL (9/30days)
• Rozerem ST and QLL added (30/30 days)
• Novolog Mix 70/30 Flexpen and Vial
• Novolog 100Units/Ml Vial, Flexpen, and cartridge
• Glyxambi added with PA
• Norvir powder added
• Phytonadione
• Renagel PA added
• Renvela Brand Only added with PA
• Levalbuterol solution added (no PA required for age <4)
• Montelukast chewable tabs added with QLL (30/30days)
• Montelukast granules PA added for age > 4
• Bevespi Aerosphere added with PA
• Stiolto Respimat added with PA
• Alprazolam ER QLL changed (30/30days)
• Lorazepam 2mg tablet QLL changed (60/30)
• Lorazepam Intensol QLL changed (60ml/30)
• Chlordiazepoxide QLL added (60/30days)
• Clorazepate 3.75mg and 7.5mg QLL added (120/30)
• Clorazepate 15mg QLL added (60/30)
• Oxazepam QLL added (60/30days)
• Xarelto Starter Pack QLL changed to 51/30
• Servent Diskus PA added

Removals:

• Meprobamate
• Estazolam
• Flurazepam
• Eszopiclone
• Triazolam
• Rozerem PA removed
• Zaleplon
• Zolpidem ER
• Intermezzo SL/ Edular
• Zolpimist
• Silenor
• Mephyton
• Auryxia
• Fosrenol
• Sevelamer generic
• Levalbuterol HFA
• Montelukast granules PA removed for age > 2
• Arcapta Neohaler
• Foradil
• Metaproterenol
• Striverdi Respimat
• Zafirlukast

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• Rozerem ST and QLL added (30/30)
• Haloperidol decanoate PA added for age < 18
• Fluphenazine decanoate PA added for age < 18
• Alprazolam ER QLL changed (30/30days)
• Chlordiazepoxide QLL added (60/30days)
• Clorazepate 3.75mg and 7.5mg QLL added (120/30)
• Clorazepate 15mg QLL added (60/30)
• Oxazepam QLL added (60/30days)
• Lorazepam 2mg tablet QLL changed (60/30)
• Lorazepam Intensol QLL changed (60ml/30)

Removals:

• Pexeva QLL removed
• Silenor
• Meprobamate
• Estazolam
• Flurazepam
• Eszopiclone
• Triazolam
• Rozerem PA removed
• Zaleplon
• Zolpidem ER
• Intermezzo SL/ Edular
• Zolpimist

 

June 2018

Title 19/21 SMI Drug List Updates

Additions:

• Symfi added with QLL (30/30 days)
• Praziquantel
• Lansoprazole ODT added with PA and QLL (30/30 days)
• Tasigna 50mg added with PA and QLL (120/30 days)

Removals:

• Biltricide
• Sensipar smart edit PA for nephrologists
• Prevacid ODT

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

 

May 2018

Title 19/21 SMI Drug List Updates

Additions:

• Colchicine 0.6mg capsule
• Firvanq solution
• Jardiance added (Quantity Level Limit, Step Therapy Required)
• Ritonavir 100mg tablet
• Symfi Lo (Quantity Level Limit)
• Synjardy (Quantity Level Limit, Step Therapy Required)
• Synjardy XR 10/1000mg and 25/1000mg (Quantity Level Limit, Step Therapy Required)
• Synjardy XR 5/1000mg and 12.5/1000mg (Quantity Level Limit, Step Therapy Required)

Removals:

• Norvir tablet

Other Updates:

• Rosuvastatin (Removed Prior Authorization, Added Step Therapy)

GMH/SU & Non-Title 19/21 Drug List Updates

• No Monthly Updates

 

April 2018

Title 19/21 SMI Drug List Updates

Additions:

• Biktarvy
• Pulmicort Flexhaler
• Tramadol ER tablets (Prior Authorization Required)

Removals:

• Emend

Other Updates:

• Aprepitant (Added Quantity Level Limit)

GMH/SU & Non-Title 19/21 Drug List Updates

• No Monthly Updates

 

March 2018

Title 19/21 SMI Drug List Updates

Additions:

• Efavirenz
• Methergine

Removals:

• Sustiva

 

April 2018

GMH/SU & Non-Title 19/21 Drug List Updates

• No Monthly Updates

 

February 2018

Title 19/21 SMI Drug List Updates

Additions:

• Atazanavir tablets
• BD Pen Needles
• Efavirenz
• Estradiol 0.01% vaginal cream
• Juluca (Quantity Level Limit)
• Tenofovir
• Vancomycin capsules (Prior Authorization Required -use First Vancomycin Solution)

Removals:

• Albuterol tablets, IR and ER
• Amcinonide cream/lotion
• Betopic S ophthalmic
• Brimonidine 0.15% ophthalmic
• Cefaclor ER
• Estrace vaginal cream
• FML forte ophthalmic
• Gatifloxacin 0.5% ophthalmic solution
• Hydromorphone suppositories
• Neomycin/polymyxin HC ophthalmic
• One Touch Verio High
• Oxymorphone IR
• Pen Needles (any brand other than BD)
• Pramosone-HC 1%-1% topical cream
• Prednicarbate topical
• Reyataz tablets
• Sustiva
• Terbutaline tablets
• Viread

Other Updates:

• Brimonidine 0.2% ophthalmic (Added Quantity Level Limit)
• Ciprofloxacin 250mg/5ml (Added Quantity Level Limit)
• Clobetasol Cream Emollient 0.05% (Added Quantity Level Limit)
• Combigan (Added Step Therapy)
• Fentanyl lozenges (Added Prior Authorization)
• Halobetasol topical (Added Quantity Level Limit)
• Sprycel (Added Quantity Level Limit)
• Timolol gel (Added Step Therapy)

GMH/SU & Non-Title 19/21 Drug List Updates

• No Monthly Updates

 

January 2018

Title 19/21 SMI Drug List Updates

Additions:

• Armodafinil (Prior Authorization Required, Quantity Level Limit)
• Carboxymethycellulose sodium ophth soln 0.25%
• Epinephrine 0.3mg/0.3ml and 0.15mg/0.15ml Pens (Mylan)
• Opsumit (Prior Authorization Required)
• Xtampza ER (Prior Authorization Required)

Removals:

• Epclusa
• Epinephrine by Impax Labs
• Epipen, Epipen Jr
• Harvoni
• Hysingla
• Oxycontin
• Technivie
• Viekiera Pak
• Viekiera Pak XR
• Zepatier

Other Updates:

• Adcirca (Removed Quantity Level Limit)
• Benzonatate (Removed Quantity Level Limit)
• Brilinta (Removed Quantity Level Limit)
• Brompheniramine-dm-pseudoephedrine (Removed Quantity Level Limit)
• Budesonide (Removed Quantity Level Limit)
• Clopidogrel (Removed Quantity Level Limit)
• Cyclobenzaprine 5mg, 10mg (Removed Quantity Level Limit)
• Descovy (Removed Quantity Level Limit)
• Donepezil/ donepezil ODT (Removed Quantity Level Limit)
• Ella (Removed Quantity Level Limit)
• Emend (Changed Quantity Level Limit)
• Fluocinonide 0.05% gel, ointment (Removed Quantity Level Limit)
• Foradil (Removed Quantity Level Limit)
• Gabapentin (Removed Quantity Level Limit)
• Galantamine (Removed Quantity Level Limit)
• Gemfibrozil (Removed Quantity Level Limit)
• Genvoya (Removed Quantity Level Limit)
• Imbruvica (Removed Quantity Level Limit)
• Isentress tabs, chew tabs, suspension (Removed Quantity Level Limit)
• Lamivudine (Removed Quantity Level Limit)
• Lansoprazole (Rx) (Removed Quantity Level Limit)
• Letairis (Removed Quantity Level Limit)
• Levonorgestrel 0.75mg (Removed Quantity Level Limit)
• Lidocaine-prilocaine topical (Removed Quantity Level Limit)
• Lisinopril (Removed Quantity Level Limit)
• Methocarbamol (Removed Quantity Level Limit)
• Nexavar (Removed Quantity Level Limit)
• Next Choice, Next Choice One Dose (Removed Quantity Level Limit)
• Nisoldipine (Removed Quantity Level Limit)
• Omeprazole (Rx) (Removed Quantity Level Limit)
• Pantoprazole (Removed Quantity Level Limit)
• Pioglitazine/ pioglitazine-metformin (Removed Quantity Level Limit)
• Plan B One Step (Removed Quantity Level Limit)
• Raloxifene (Removed Quantity Level Limit)
• Revlimid (Removed Quantity Level Limit)
• Rivastigamine (Removed Quantity Level Limit)
• Ropinirole (Removed Quantity Level Limit)
• Sildenafil (Removed Quantity Level Limit)
• Spiriva (Removed Quantity Level Limit)
• Stribild (Removed Quantity Level Limit)
• Sutent (Removed Quantity Level Limit)
• Tamsulosin (Removed Quantity Level Limit)
• Tasigna (Removed Quantity Level Limit)
• Terazosin (Removed Quantity Level Limit)
• Thalomid (Removed Quantity Level Limit)
• Tivicay (Removed Quantity Level Limit)
• Tobradex ointment (Removed Quantity Level Limit)
• Tracleer (Removed Quantity Level Limit)
• Trospium (Removed Quantity Level Limit)
• Tykerb (Removed Quantity Level Limit)
• Valsartan/ Valsartan HCTZ (Removed Quantity Level Limit)
• Verapamil IR (Removed Quantity Level Limit)
• VIread (Removed Quantity Level Limit)
• Votrient (Removed Quantity Level Limit)
• Zafirlukast (Removed Quantity Level Limit)
• Zonisamide (Removed Quantity Level Limit)

GMH/SU & Non-Title 19/21 Drug List Updates

• No Monthly Updates

Over-the-counter product list for dual eligible T19/21 SMI members

Over-the-counter product list

How to get your prescriptions

If you need medicine, your provider chooses a medication from our list of preferred drugs. Your provider writes you a prescription. Ask your provider to make sure that the medicine is on the list.

• Take the prescription to a network pharmacy to have it filled. (Find a network pharmacy) Walgreens is not a network pharmacy.
• Show your Mercy Care member ID card at the pharmacy.

How to find a network pharmacy

You can find a network pharmacy by:

• Searching for a pharmacy in your area. Walgreens is not a network pharmacy.
• Calling Mercy Care ACC-RBHA Member Services at 602-586-1841 or 1‑800‑564-5465; (TTY/TDD: 711). Ask the representative to help you find a network pharmacy in your area.

All prescriptions must be filled at a network pharmacy. Mercy Care does not cover prescriptions filled at other pharmacies.

Specialty Pharmacy

Mercy Care specialty drugs are filled by CVS Specialty Pharmacy. A specialty pharmacy fills drugs and has other services to help you. The Specialty Drug Program has special services for you:

• You can talk 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 drugs to your home or doctor’s office at no cost to you
• You can drop off your prescription and pick up your drug at any CVS Pharmacy (including those inside Target stores)

You can call CVS Specialty Pharmacy at 1-800-237-2767, TTY 1-800-863-5488. CVS Specialty Pharmacy will help you with filling your specialty drug. The specialty drug list lists all the specialty drugs available.

 

Medicine not on the approved-drug lists

If your medicine is not on an approved-drug list, you can:

• Ask your provider for a similar drug that is on the list.
• Ask your provider to ask Mercy Care to cover your drug. Your provider will go through the prior authorization process. Your provider will know how to do this.

Prescription refills

Your medicine bottle label says how many refills you can have. If you think you may need a refill, you must contact your provider at least five days before you run out of medicine. When you call, ask your provider about getting a refill. Your provider may want you to make an appointment before giving you a refill.

Questions to ask about your medicine

Mercy Care wants you to be as healthy as possible. This includes knowing about the different medicines you need to take. 

To help, we have included a list of questions you should always ask your provider when about a prescription.

• Why am I taking this medicine? What is it supposed to do for me?
• How should the medicine be taken? When? For how many days?
• Are there any side effects or possible allergic reactions to this medicine?
• What should I do if I have a side effect or allergic reaction?
• What will happen if I don’t take this medicine?

Carefully read the drug information the pharmacy gives you with your medicine. It will tell you what you should and should not do while taking the medicine. If you have questions after you get your medicine, ask to talk with the pharmacist or call your provider.

It's important you tell all your healthcare providers, including your dentist, about prescriptions you're already taking. Also, tell them about non-prescription medicine, vitamins or herbal supplements you take.

Also, check out Mercy Care's Patient Checklist for more tips to prepare you for a doctor’s visit.

Drug safety alerts

Drug safety alerts can provide important information about the safety of medications, click here for more.