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Use the Formulary Search Tool to find out which medications are on the formulary drug lists. You can search by drug name or drug class. The search tool will show formulary status, generic alternatives and if there are any requirements, such as prior authorization, quantity limits or age limits. The formularies can change.

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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 & 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)

January 2023

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 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:

Removals:

None

Other Updates:

None

November 2022

Additions:

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

Removals:

None

Other Updates:

None

October 2022

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)

September 2022

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:

Other Updates:

None

August 2022

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

July 2022

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

June 2022

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

May 2022

Additions:

None

Removals:

None

Other Updates:

None

April 2022

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

March 2022

Additions:

Diclofenac 1% gel (Quantity Limit, OTC)

Removals:

None

Other Updates:

None

February 2022

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)

January 2022

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 Tab
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/2 mL inhalation suspension (Age Limit Removed)
Budesonide 0.5 mg/2 mL inhalation (Age Limit Removed)
Budesonide 1 mg/2 mL inhalation (Age Limit Removed)
Clonazepam 0.125mg ODT (Age Limit Removed)
Clonazepam 0.25mg ODT (Age Limit Removed)
Clonazepam 0.5mg ODT (Age Limit Removed)
Clonazepam 1mg ODT (Age Limit Removed)
Clonazepam 2mg 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)

December 2021

Additions:

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

Removals:

Afinitor 3mg
Afinitor 5mg
Afinitor 10mg

Other Updates:

None

November 2021

Additions:

Kloxxado 8mg

Removals:

None

Other Updates:

None

October 2021

Additions:

Aimovig 140mg/ml Autoinjector (Prior Authorization Required)
Aimovig 70mg/ml Autoinjector (Prior Authorization Required
Anoro Ellipta 62.5-25mcg Inhaler (Prior Authorization Required)
Avsola 100mg Vial (Prior Authorization Required)
Cafergot Tablet 1-100mg (Brand Only)
Enbrel 25mg/0.5ml Vial (Prior Authorization Required)
Ivermectin 3mg Tablet (Quantity Limit)
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)
Ritalin LA 10mg Capsule (Brand Only)
Ritalin LA 20mg Capsule (Brand Only)
Ritalin LA 30mg Capsule (Brand Only)
Ritalin LA 40mg Capsule (Brand Only)
Ubrelvy 100mg Tablet (Prior Authorization Required)
Ubrelvy 50mg Tablet (Prior Authorization Required)

Removals:

Other Updates:

None

September 2021

Additions:

None

Removals:

None

Other Updates:

None

August 2021

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

July 2021

Additions:

None

Removals:

BP Foam Aer 9.8%
Vitamax Pediatric Sol oral

Other Updates:

None

June 2021

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)

May 2021

Additions:

None

Removals:

None

Other Updates:

None

April 2021

Additions:

Removals:

Other Updates:

None

March 2021

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)

February 2021

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

January 2021

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)

December 2020

Additions:

None

Removals:

None

Other Updates:

None

November 2020

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)
Dimethyl Fumarate Capsule DR Starter Pack 120 Mg & 240 Mg (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
Tecfidera Capsule DR Starter Pack 120 Mg & 240 Mg

Other Updates:

Linaclotide capsules (Step Therapy Updated)

October 2020

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:

Other Updates:

None

September 2020

Additions:

Removals:

None

Other Updates:

None

August 2020

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)

July 2020

Additions:

None

Removals:

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

Other Updates:

None

June 2020

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

May 2020

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

April 2020

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)

March 2020

Additions:

None

Removals:

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

Other Updates:

None

February 2020

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)

January 2020

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:

Other Updates:

None

December 2019

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

November 2019

Additions:

Aminocaproic Acid Sol 0.25gm/ml

Removals:

Amicar Sol 0.25gm/ml

Other Updates:

None

October 2019

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

September 2019

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

August 2019

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
Bosentan Tab For Oral Susp 32mg
Bupropion HCl Tab EERr 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
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
Prefest
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)

July 2019

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:

Other Updates:

None

June 2019

Additions:

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

Removals:

Abreva Cream 10%

Other Updates:

None

May 2019

Additions:

Concerta Tab ER (Age Limit, Quantity Level 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
Ranexa Tab 1000mg ER
Rapamune Sol 1mg/ml

Other Updates:

None

April 2019

Additions:

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

Removals:

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

March 2019

Additions:

Aminocaproic 500mg, 1000mg Tab
Carbidopa 25mg Tab
Cinacalcet HCL 30mg, 60mg, 90mg Tab added with PA
Mesalamine Supp 1000mg added with QL 30/30 days
Toremifene Citrate 60mg Tab added with PA

Removals:

Amicar 500mg, 1000mg Tab
Canasa 1000mg Supp
Fareston 60mg Tab
Norethin Ace & Estrad-FE (24)
Sensipar 30mg, 60mg, 90mg Tab

February 2019

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
Gammagard added with PA
Gammaked added with PA
Gamunex-C added with PA
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

January 2019

Additions:

Albendazole 200mg tab added with Step

Changes:

Celecoxib 50mg, 100mg caps QL 60/30 days

Removals:

Synagis 50mg/0.5mL solution
Synagis 100mg/mL solution
Albenza 200mg tab

December 2018

Additions:

Changes:

Famciclovir 125mg, 250mg, 500mg tabs added with PA
Femring 0.05mg/24hr added with PA
Femring 0.1mg/24hr added with PA
Testosterone 40.5mg/2.5gm (1.62%) gel added with PA
Travatan Z 0.0004% opth solution added with PA

Removals:

Advanced Allergy Kit 2.5%
Armour Thyroid 1.5GR Tab
Armour Thyroid 1/2GR Tab
Armour Thyroid 1/4GR Tab
Armour Thyroid 1GR Tab
Armour Thyroid 2GR Tab
Benazepril-HCTZ 5-6.25mg tab
BPO 4% gel
Carafate 1gm/10mL suspension
Lanoxin 0.125mg Tab
Lanoxin 0.25mg Tab
Lotrimin 2% AF Aerosol
Menest 2.5mg tab
MG217 Psoriasis Anti-itch 1% gel
MultiNatal Plus 30-1mg tab
MultiNatal Plus 40-1mg chew
Omeprazole-Sodium Bicarbonate 20-1100mg cap
Sulfacetamide Sodium-Sulfur 10-5% emulsion

November 2018

Additions:

Albendazole added with STEP

Removals:

Clotrimazole ointment – no longer marketed
Cytra-K all NDCs on market are DESI
Albenza

October 2018

Additions:

Arcapta added with QLL 30capsules for inhalation per 30days
Aristada Initio added with QLL 2 per year, age < 18 requires PA
Atomoxetine capsules
Cyanocobalamin injection
Dutasteride 0.5mg
Fluocinonide cream
Glatopa 40mg added with PA
Loratadine chew 5mg added with QLL 60/30days
Lotrimin Ultra cream
Metoprolol 75mg tab
Prasugrel added with QLL 30/30days
Procrit added with PA
Striverdi Respimat added with QLL 1 inhaler per 30days
Tadalafil added with step
Tazarotene 0.1% cream added with QLL 90gm/30days
Tymlos added with PA and QLL 1 pen/30days
Vyvanse chewable tablets added with QLL 30/30days

Removals:

Acebutolol cap
Adcirca
Alclometasone dip cream and ointment
Betamethasone dp Aug lotion, gel and ointment
Betamethasone dp cream, ointment
Cardura XL
Ciclopirox gel and shampoo
Clobetasol foam, lotion, gel, shampoo
Clotrimazole/betamethasone lotion
Copaxone 40mg
Desonide cream, lotion, ointment
Diltiazem 24hr ER tab
Flucytosine
Fluocinolone solution, cream, ointment
Fluocinonide E 0.05% cream
Fluticasone prop lotion
Griseofulvin ultra
Hydrocortisone butyr cream, ointment
Hydrocortisone val cream, ointment
Isradipine
Itraconazole
Ketoconazole tab
Methylphenidate chew tabs
Nicardipine
Nimodipine
Nisoldipine
Noxafil
Nystatin topical powder
Pindolol
Prednicarbate ointment
Strattera
Timolol tab
Triamcinolone spray
Trianex oil
Voriconazole

Changes:

Antipsychotics: PA removed for Acute (ACC), age edits and QL still apply
Ondansetron 4mg QLL changed to 90/30days
Valgancyclovir PA removed, added QLL 60/30days

September 2018

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 added with QLL #30/30days

Removals:

Eurax PA removed

Changes:

Eliquis starter pack QLL changed to 74/30days

August 2018

Additions:

Aripiprazole ODT added for ALTCS, QLL = 30/30days
Aripiprazole solution added for ALTCS, QLL = 150ml/30days
Baraclude solution added QLL 600ml/30days
Diazepam rectal gel added QLL of 2/rx
Diclofenac gel 1% added with QLL 200gm/30days
Elmiron added PA
Hydrocod-homatropin tab age < 18 requires PA
Omega-3 (1gram) cap added with Step and QLL 120/30days
Premarin Vaginal Cream added PA
Telmisartan added with QLL 30/30days
Testosterone cypionate added PA
Vemlidy added with QLL 30/30days
Verzenio added with PA and QLL 60/30days

Removals:

Changes:

Amlodipine 2.5mg and 5mg increased QLL to 60/30days
Hydrocod-homatropine syrup increased QLL to 900ml/30days
Lidocaine 5% ointment changed STEP to PA

July 2018

Additions:

Baclofen 5mg
Bevespi Aerosphere (Added Prior Authorization)
Diphenhydramine liq 6.25mg
Glyxambi (Added Prior Authorization)
Levalbuterol solution (Prior Authorization) not required for (Age Limit) < 4
Naratriptan added with (Quantity Level Limit) 9/30days
Norvir powder
Pediatric MVI with iron 11mg/ml
Phytonadione tab
Prescription opioid cough and cold products (Age Limit) < 18 requires (Prior Authorization)
Renagel (Added Prior Authorization)
Renvela (brand only) (Added with Prior Authorization)
Servent Diskus (Added Prior Authorization)
Stiolto Respimat (Added Prior Authorization)
Zolmitriptan added with (Quantity Level Limit) 9/30days

Removals:

Sevelamer
Albuterol solution (Step Therapy) removed
Arcapta
Estazolam
Eszopiclone
Flurazepam
Foradil
Fosrenol
Mephyton
Meprobamate
Metaproterenol
Silenor
Striverdi
Triazolam
Zafirlukast
Zaleplon
Zolpidem ER
Zolpidem SL
Zolpimist

Other Updates:

Montelukast granules changed to (Prior Authorization) required for (Age Limit) > 4
Rizatriptan (Quantity Level Limit) changed from 12/30days to 9/30days
Rozerem- must use temazepam and zolpidem first
Sildenafil specialist requirement removed

June 2018

Additions:

Lansoprazole ODT (Prior Authorization, Quantity Level Limit)
Praziquantel
Symfi (Quantity Level Limit)

Removals:

Biltricide
Prevacid Solu Tab

May 2018

Additions:

Colchicine capsules
Firvanq
Jardiance (Step Therapy Required)
Ritonavir tablets
Symfilo
Synjardy, Synjardy XR (Step Therapy Required)

Removals:

Norvir tablets

Other Updates:

Rosuvastatin (Prior Authorization Removed, Step Therapy Added)

April 2018

Additions:

Aprepitant combo pack
Biktarvy
Pulmicort Flexhaler
Tramadol ER (Prior Authorization Required)

Removals:

Emend combo pack

March 2018

Additions:

Efavirenz Tab
Methergine

Removals:

Sustiva Tab

February 2018

Additions:

BD Pen needles
Efavirenz
Estradiol 0.01% vaginal cream
One Touch Verio High
Tenofovir
Vancomycin capsules (Prior Authorization Required-use First Vancomycin compounding kit)

Removals:

Other Updates:

Brimonidine 0.2% ophthalmic (Added Quantity Level Limit)
Combigan ophthalmic (Added Step Therapy)
Fentanyl lozenge (Added Prior Authorization)
Halobetasol topical (Added Quantity Level Limit)
Sprycel (Added Quantity Level Limit)
Timolol ophthalmic gel (Added Step Therapy)

January 2018

Additions:

Armodafinil (Prior Authorization Required, Quantity Level Limit)
Carboxymethycellulose sodium ophth solun 0.25%
Cardura XL
Epinephrine 0.15 mg and 0.3mg Auto-Inject (Mylan)
Opsumit (Prior Authorization Required)
Oseltamivir suspension
Xtampza ER(Prior Authorization Required)

Removals:

Other Updates:

Suboxone Film (Removed Prior Authorization)
Vivitrol (Removed Prior Authorization)

December 2017

Additions:

Abacavir solution
Mavyret (Prior Authorization Required per AHCCCS)

Removals:

Ziagen Solution

Other Updates:

Tretinoin cream/gel (Removed Step Therapy per AHCCCS)

November 2017

Additions:

Humulin R U-500 added PA per AHCCCS
Fosamprenavir

Removals:

Lamotrigine IR QLL removed
Lexiva

Other Updates:

Lamotrigine IR (Removed Quantity Level Limit)

October 2017

Additions:

Aptensio XR (Age Edit, Quantity Level Limit)
Clonidine patch (Age Edit, Quantity Level Limit)
Doxepin HCL capsules and concentrate (Quantity Level Limit)
Doxylamine succinate 25mg
Enoxaparin (Quantity Level Limit)
Eszopiclone (Age Edit, Quantity Level Limit)
Lamotrogine XR
Meprobamate (Age Edit, Quantity Level Limit)
Novolog 100 unit/ml Flexpen
Novolog 100unit/ml cartridge
Novolog 100unit/ml vial
Novolog Mix 70/30 Flexpen
Novolog Mix 70/30 vial
Paroxetine solution (Quantity Level Limit)
Paxil suspension (Quantity Level Limit)
Pyridoxine 25mg
Silenor (Prior Authorization required)
Triazolam (Age Edit, Quantity Level Limit)
Vitamin B12 SL
Xarelto starter pack
Zolpidem CR (Prior Authorization Required)
Zolpidem SL (Prior Authorization Required)
Zolpimist (Prior Authorization Required)
Zolpimist (Prior Authorization Required)

Removals:

Diclegis
Lovenox
Metadate CD
Somnote (drug no longer marketed)

Other Updates:

Anxiolytics (Added Age Edit)
Bupropion tablets, XR, SR (Added Quantity Level Limit)
Buspirone (Added Age Edit)
Estazolam (Added Age Edit)
Flurazepam (Added Age Edit)
Hydroxyzine hcl tablets (Added Quantity Level Limit)
Hydroxyzine pamoate (Added Quantity Level Limit)
Hydroxyzine syrup (Added Quantity Level Limit)
Mirtazapine tab, ODT (Added Age Edit)
Nefazodone (Added Quantity Level Limit)
Rozerem (Added Age Edit)
Sertraline solution (Added Quantity Level Limit)
Temazepam (Added Age Edit)
Trazodone (Added Quantity Level Limit)
Tybost (Prior Authorization Removed)
Venlafaxine ER (Added Quantity Level Limit)
Venlafaxine IR (Added Quantity Level Limit)
Zaleplon (Added Age Edit)
Zolpidem (Added Age Edit)

September 2017

Additions:

Artificial tears ointment OTC
Mesalamine 1.2GM
Moxifloxacin 0.5% ophthalmic
Sevelamer

Removals:

Renvela
Vigamox

Other Updates:

Ceftriaxone inj. (Removed Quantity Level Limit)

August 2017

Additions:

Adcirca (Step Therapy Required - use sildenafil)
Albenza (Step Therapy Required - use ivermectin or pyrantel)
Corlanor (Step Therapy Required - use beta blocker AND ACEI or ARB)
Ergocal 2500 Unit cap
Extavia (Prior Authorization Required)
Isentress HD 600mg tablet
Letairis (Quantity Level Limit)
Lidocaine Patch (Prior Authorization Required)
Malathion (Step Therapy Required - permethrin or pyrethrin)
Melphalan 2mg
Multaq (Step Therapy Required - use other antiarrhythmics first)
Olopatadine 0.1% and 0.2% (Step Thearapy Required - use Ketotifen OTC)
Permethrin lotion1% (Quantity Level Limit)
Tracleer (Quantity Level Limit)

Removals:

Alkeran 2mg
Econazole cream
Potassium chloride 10%, 20% solution
Potassium chloride packet 20meq, 25meq
Ulesfia

July 2017

Additions:

Bydureon pen and vial (Prior Authorization Required)
Kombiglyze XR (Prior Authorization Required)
Lidocaine 3% (Step Thearapy Required - use Aspercreme OTC)
Lidocaine 5% (Step Thearapy Required - use Aspercreme OTC)
Onglyza (Prior Authorization Required)

June 2017

Additions:

Apriso
Desvenlafaxine ER (Prior Authorization Required, Age Limit)
Dofetilide (Prior Authorization Required

Removals:

Meloxicam liquid
Pristiq brand
Tikosyn brand

Other Updates:

Adapalene cream, gel (Added Step Therapy - use Differin Gel OTC)
Tretinoin cream, gel (Added Step Therapy - use Differin Gel OTC)

May 2017

Additions:

Odefsey

Other Updates:

Abilify Maintenna (Quantity Level Limit Added)
Abreva (Quantity Level Limit Removed)
Alendronate (Quantity Level Limit Removed)
Arcapta (Quantity Level Limit Removed)
Aristada QLL (Quantity Level Limit Added)
Desmopressin nasal spray (Quantity Level Limit Removed)
Estradiol patches (Quantity Level Limit Removed)
Estring (Quantity Level Limit Removed)
Fexofenadine (Quantity Level Limit Changed)
Medroxyprogesterone IM (Quantity Level Limit Removed)
Mupirocin cream (Quantity Level Limit Removed)
Paroxetine solution (Quantity Level Limit Removed)
Polyethylene glycol 3350 (Quantity Level Limit Removed)
Prenatal vitamins (Quantity Level Limit Removed)
Pseudoephedrine (Quantity Level Limit Removed)
Rimantadine (Quantity Level Limit Removed)
Risperidone Consta (Quantity Level Limit Added)
Sertraline solution (Quantity Level Limit Removed)
Spinosad suspension (Quantity Level Limit Removed)
Tretinoin topical (Quantity Level Limit Removed)
Vancomycin oral (Quantity Level Limit Removed)
Ventolin HFA (Quantity Level Limit Removed)

Some prescriptions require prior authorization from Mercy Care before they can be filled. Requests for medications requiring Prior Authorization (PA) will be reviewed based on the PA Guidelines/Criteria for that medication.

Medications that don't have a specific PA guideline will follow the AHCCCS Fee-For-Service Prior Authorization Criteria for Non-Preferred Drugs. Additional information may be required on a case-by-case basis to allow for adequate review.

Here are the guidelines for:

AHCCCS Fee-For-Service Program Pharmacy Prior Authorization Criteria - Effective January 1, 2023

AHCCCS Fee-For-Service Program Pharmacy Prior Authorization Criteria - Effective December 1, 2022

Mercy Care Prior Authorization Guidelines

Botulinum Toxins

Concomitant Antipsychotic Under Age 18

Diabetic Testing Supplies

Injectable Osteoporosis Agents (Prolia, Evenity, Zoledronic Acid)

OmniPod

Opioids 5-Day Supply Limit

Smoking cessation

Step Therapy Prior Authorization Guidelines (PDF)

Viscosupplements

Mercy Care requires prior authorization for certain drugs on the formulary and for all non-formulary drug requests.

You can request prior authorization by calling 602-263-3000 or 1-800-624-3879, or you can print the required prior authorization form below and fax it along with supporting clinical notes to 1-800-854-7614. You can get a prior authorization request form faxed to you, just contact the Mercy Care Pharmacy Prior Authorization team at 602-263-3000 or 1-800-624-3879. You can also submit the request via electronic prior authorization (ePA) through CoverMyMeds® and SureScripts. See the Electronic Prior Authorization (ePA) section below for additional information.

These are fax forms for drugs in our prior authorization program. Select the drug name to download the prior authorization request form. If the drug you're requesting is not listed, please use the Universal Pharmacy Prior Authorization Form. Most drugs will require use of the Universal Pharmacy Prior Authorization Form.

We are committed to making sure our providers receive the best possible information, and the latest technology and tools available.

We have partnered with CoverMyMeds® and SureScripts to provide you a new way to request a pharmacy prior authorization through the implementation of Electronic Prior Authorization (ePA) program.

With Electronic Prior Authorization (ePA), you can look forward to:

Time saving
- Decreasing paperwork, phone calls and faxes for requests for prior authorization
Quicker Determinations
- Reduces average wait times, resolution often within minutes
Accommodating & Secure
- HIPAA compliant via electronically submitted requests Getting started is easy. Choose ways to enroll:
- No cost required! Let us help get you started!

Visit the CoverMyMeds® website
Call CoverMyMeds® toll-free at 866-452-5017
Visit the SureScripts website
Call SureScripts toll-free at 866-797-3239

Billing Information:

BIN: 610591

PCN: ADV

Group: RX8805

E-Prescribing

Drugs with QT Prolonging Effects

Lab Monitoring

Informed Consent

Over-the-counter product list

How to order specialty drugs for patients CVS Caremark Specialty Pharmacy offers medications that are not often available at local pharmacies for a variety of conditions, such as cancer, hemophilia, immune deficiency, multiple sclerosis and rheumatoid arthritis.

Specialty medications require prior authorization before they can be filled and delivered. These medications can be delivered to the provider’s office, member’s home or other location as requested.

For providers who prefer to purchase the specialty drug and bill through the member’s Medical Insurance:

Call 602-263-3000 or toll-free at 1-800-624-3879 to initiate prior authorization for the requested specialty medication.

For providers who prefer to bill through the member’s Pharmacy Insurance directly:

Complete the applicable Pharmacy Prior Authorization form and fax it to 1-800-854-7614.

Click here for the Specialty Drug List

CVS/Coram pharmacy enrollment form

You work with patients every day, and there may be times when you believe we should add a drug to the formulary. If you want to ask for a change to Mercy Care’s Preferred Drug List (PDL), include the following information in your request:

Basic product information
Indications for use
Therapeutic advantage
Which drug(s) it would replace in the current PDL
Any supporting literature from medical journals

The requesting physician may be invited to attend the Pharmacy and Therapeutics Committee meeting to support the PDL addition request and answer questions.

Requests should be sent to: Aetna Corporate Pharmacy Director 4500 E. Cotton Center Blvd. Phoenix, AZ 85040

The Controlled Substance Prescription Monitoring Program (CSPMP) is a program developed to promote public health and welfare by detecting diversion, abuse, and misuse of prescription medications classified as controlled substances. Every physician who possesses DEA registration is required to also possess a CSPMP registration.

Step 1: Register

Register for CSPMP. Click on ‘Register now’ and fill out the ‘New Registration’ information.

Step 2: Verify

After you submit the registration form, you will receive a verification email with your CSPMP ID number and verification code.
Follow the email link to verify your email address.

Step 3: Login

Once you login, you will then be able to complete your registration profile with your CSPMP ID and DEA number.

Fill out the ‘Registration Details’ and certify that the application is complete and accurate, then ‘Print Certificate’.

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

These links provide access to our formulary JSON files which can be downloaded by third parties and used to review data. Files meet CMS standards and regulations.

JSON - Mercy Care Formulary