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Pharmacy benefits

We cover a wide range of prescription and over-the-counter (OTC) medications to help keep our members as healthy as they can be. Members can fill prescriptions at any network pharmacy

Covered medications

Covered medications

Prescription medications

We cover the prescription medications on our formulary/preferred drug list or PDL (PDF) If your patient needs medication, you’ll want to check the right list for:

  • Quantity or age limits 

  • Updates

These lists can change, so check them regularly. If a medication isn’t on the formulary, you can: 

  • Prescribe a similar one that’s on the list 

  • Get PA for coverage

Check the information that follows to learn about drug lists for each plan. Still not sure if we cover a specific medication? Just contact us. We can check it for you. 

 

You can download the formulary/preferred drug list or PDL (PDF) or check it online with the formulary search tool. 

You can also see a list of over-the-counter products (PDF) we cover.

In emergencies, we may be able to provide a limited supply for medications that aren’t on these lists.

These lists are based on the Arizona Health Care Cost Containment System (AHCCCS)-approved drug list. The medications are generally covered under the plan when medically necessary. Members can fill their prescriptions at any network pharmacy.

You’ll want to review these preferred drug lists for any restrictions or recommendations before prescribing medication to members of Mercy Care ACC-RBHA with SMI.

  1. Behavioral Health Preferred Drug List (PDF) (updated quarterly): behavioral health medications for members who qualify under:

    • Non-Title 19/21 determined to have a serious mental illness (SMI)

    • Non-Title 19/21 children with a serious emotional disturbance (SED)

  2. Use the Behavioral Health Preferred Drug List Search Tool to find out if a certain medication is on the list.

  3. Integrated Preferred Drug List (PDF) (updated quarterly): behavioral and physical health medications for Title 19/21 SMI members

  4. Use the Integrated Preferred Drug List Search Tool to find out if a certain medication is on the list.

  5. Crisis Medication List (PDF): medications that help stabilize members in crisis and bridge them to a follow-up outpatient appointment. We cover up to a 7-day supply of drugs on this list with 1 refill. This list is for adults or children who are Non-Title 19/21 and Non-SMI who present in crisis at any Maricopa County:

    • Facility-based psychiatric urgent care centers

    • Detox facilities 

    • Access point 

  6. Substance Use Block Grant Medication List (PDF): For Non-Title 19/21 members with SUDs and primary substance use and misuse.

In emergencies, we may be able to provide a limited supply for medications that aren’t on these lists. 

Need to learn more about pharmacy benefits? Check your provider manual and other plan materials. Or call 602-586-1841 or 1-800-564-5465 (TTY 711). We’re here for you 24 hours a day, 7 days a week.

 

Specialty medications

Specialty medications

Not all pharmacies carry specialty medications. CVS Specialty® offers medications for a variety of conditions, like:  

  • Cancer

  • Hemophilia

  • Immune deficiency

  • Multiple sclerosis

  • Rheumatoid arthritis

Members can choose delivery to their home, provider’s office or other convenient location. They can also call CVS Specialty pharmacy at 1-800-237-2767 (TTY 711) with questions.

 

  • If you bill through members’ medical insurance (your practice purchases the specialty medications): Contact us by plan to start PA for the requested specialty medication. 

  • If you bill through members’ pharmacy benefit directly: Complete the right PA form. You can find PA forms in the next section. Then, fax the form to the number on the form.

You can also check the specialty drug list (PDF). Or find the CVS Specialty and Coram® pharmacy enrollment forms.

 

Pharmacy PA

Some prescriptions require PA from Mercy Care before members can fill them. We’ll review requests for medications requiring PA based on the PA guidelines and criteria for that medication.

 

We may need more information on a case-by-case basis to allow for adequate review.

We can also fax you the right form. Just contact us by plan.

By phone: Just contact us by plan.

By fax: Print the right PA form and fax it to the number at the top of each form. Be sure to include your supporting clinical notes. 

Online with electronic PA (ePA): You need the right tools and technology to help our members. That’s why we’ve partnered with CoverMyMeds® and Surescripts to provide electronic pharmacy PA requests.

Billing for Mercy Care ACC-RBHA, DCS CHP, Long Term Care and Developmental Disabilities

There is no cost for ePA and getting started is easy. You’ll need this information to enroll:

  • BIN: 610591

  • PCN: ADV

  • Group: RX8805

Billing for Mercy Care ACC-RBHA with SMI

  • BIN: 610591

  • PCN: ADV

  • Group: RX8822

Choose ways to enroll:

 

These PA forms are for Mercy Care ACC-RBHA. Choose the right form by finding the drug name. Then, you can download the form, print, complete and fax it back to us.

These PA forms are for Mercy Care ACC-RBHA with SMI. Choose the right form by finding the drug name. Then, you can download the form, print, complete and fax it back to us.

Title 19/21 serious mental illness (SMI) PA forms

Physical and behavioral health

Non-Title 19/21 SMI or Non-Title 19/21 SED PA request forms

Behavioral health

These PA forms are for Mercy Care DCS CHP. Choose the right form by finding the drug name. Then, you can download the form, print, complete and fax it back to us.

These PA forms are for Mercy Care Long Term Care. Choose the right form by finding the drug name. Then, you can download the form, print, complete and fax it back to us.

These PA forms are for Mercy Care Developmental Disabilities. Choose the right form by finding the drug name. Then, you can download the form, print, complete and fax it back to us.

 

More pharmacy info

Learn more about member drug benefits, see formularies and read formulary updates.
Help your patients get the prescription drugs they need in an easy and cost-effective way.

When members take maintenance medication for an ongoing health condition, they can get it by mail. We work with CVS Caremark® to provide this service at no extra cost. Each order is checked for safety. And members can speak with a pharmacist anytime on the phone. 

To get started, members will need their:

  • Plan member ID card

  • Mailing address, including ZIP code

  • Provider’s first and last name and phone number

  • List of allergies and other health conditions

  • Original prescription from their provider (if they have it)

Mail service makes it easy

Members can sign up for mail service:

Online

Members can visit CVS Caremark and sign in or register (for new users). Then, they can order refills, renew prescriptions and check their orders. 

By mail

Members will ask you to write a prescription for a 90-day supply with up to one year of refills. Then, they can fill out a mail service order form English (PDF) | Español (PDF). Or, they can contact us and we’ll send them a form. Members can mail the completed form, along with their prescription, to the address on the form.

Mercy Care network pharmacies include:

  • Any CVS Pharmacy® (including those inside Target® stores), Walmart®, Safeway®, Fry’s®, Albertsons® and Sam’s Club®

  • Most local neighborhood pharmacies

  • Many hospital pharmacies

Walgreens® is no longer in our Medicaid pharmacy network (since February 2020). If you electronically transmit or call in prescriptions for members, be sure the pharmacy is NOT Walgreens. 

Find a pharmacy

You can see our Medicaid pharmacy network directory. Just go to the top of this page. Then, choose “Find a provider.” Members can also contact us for help finding a pharmacy near them.

The member, or the member’s Health Care Decision Maker (HCDM), must give informed consent for each psychotropic medication prescribed. The comprehensive clinical record includes documentation of the essential elements for getting informed consent. Essential elements for getting informed consent for medication are in the document Informed Consent  Assent For Psychotropic Medication Treatment Attachment A (DOC). The use of Attachment A is recommended as a tool to document informed consent for psychotropic medications.

CSPMP promotes public health and welfare by detecting diversion, abuse and misuse of prescription medications classified as controlled substances. If you have a DEA registration, you’re also required to have a CSPMP registration.

  1. Register: Go to CSPMP. 
  2. Verify. After you submit the registration form, you’ll receive a verification email with your CSPMP ID number and verification code. Follow the email link to verify your email address.
  3. Log in. Then, you’ll be able to complete your registration profile with your CSPMP ID and DEA number.
  4. Fill out the Registration Details and certify that the application is complete and accurate. Then, Print Certificate.

You can ask for a change or addition to our formulary. Be sure to include this information in your request:

  • Basic product information

  • Indications for use

  • Therapeutic advantage

  • Which medication it would replace in the current formulary, if any

  • Any supporting literature from medical journals

Send your request in writing to:

Aetna Corporate Pharmacy Director 

4500 E. Cotton Center Blvd. 

Phoenix, AZ 85040

June 2024

 

Additions:

 

  • None

 

Removals:

 

  • None

 

Other Updates:

 

  • Spravato 56mg solution (Added Quantity Limit)
  • Spravato 84mg solution (Added Quantity Limit)

 

May 2024

 

Additions:

 

  • Azelaic acid 15% gel (Quantity Limit)
  • Doxycycline hyclate 75 mg tablet
  • Doxycycline monohydrate 50 mg tablet
  • Doxycycline monohydrate 75 mg tablet
  • Isosorbide dinitrate 20 mg / Hydralazine 37.5mg tablet (Quantity Limit)

 

Removals:

 

  • None

 

Other Updates:

 

  • None

 

April 2024

 

Additions:

 

  • Alyq 20 mg tablet
  • Imatinib mesylate 100 mg tablet (Prior Authorization)
  • Imatinib mesylate 400 mg tablet (Prior Authorization)
  • Lenalidomide 10 mg capsule (Prior Authorization)  
  • Lenalidomide 15 mg capsule (Prior Authorization)  
  • Lenalidomide 2.5 mg capsule (Prior Authorization)
  • Lenalidomide 20 mg capsule (Prior Authorization)
  • Lenalidomide 25 mg capsule (Prior Authorization)
  • Lenalidomide 5 mg capsule (Prior Authorization)   
  • Liqrev 10 mg per mL suspension (Age Limit)
  • Neupogen 300 mcg per 0.5mL prefilled syringe solution (Prior Authorization)
  • Neupogen 300 mcg per mL solution (Prior Authorization)
  • Neupogen 480 mcg per 0.8mL prefilled syringe solution (Prior Authorization)
  • Neupogen 480 mcg per 1.6mL solution (Prior Authorization)
  • Nyvepria 6 mg per 0.6mL prefilled syringe solution (Prior Authorization)
  • Orenitram 0.125 mg extended release tablet (Prior Authorization)
  • Orenitram 0.25 mg extended release tablet (Prior Authorization)
  • Orenitram 1 mg extended release tablet (Prior Authorization)
  • Orenitram 1 month titration pack extended release tablet (Prior Authorization)
  • Orenitram 2 month titration pack extended release tablet (Prior Authorization)
  • Orenitram 2.5 mg extended release tablet (Prior Authorization)
  • Orenitram 3 month titration pack extended release tablet (Prior Authorization)
  • Orenitram 5 mg extended release tablet (Prior Authorization)
  • Skyclarys 50 mg capsule (Prior Authorization)
  • Tadalafil (PAH) 20 mg tablet (Prior Authorization)
  • Testosterone 1.62% gel (Prior Authorization)
  • Udenyca 6 mg per 0.6mL auto-injector solution (Prior Authorization)
  • Xiidra 5% ophthalmic solution (Prior Authorization)
  • Zurzuvae 20 mg capsule (Prior Authorization)
  • Zurzuvae 25 mg capsule (Prior Authorization)
  • Zurzuvae 30 mg capsule (Prior Authorization)

 

 

Removals:

 

  • Adcirca 20 mg tablet
  • AndroGel Pump 1.62% gel
  • Aranesp 10 mcg per 0.4 mL prefilled syringe solution
  • Aranesp 100 mcg per 0.5 mL prefilled syringe solution
  • Aranesp 100 mcg per mL vial solution
  • Aranesp 150 mcg per 0.3 mL prefilled syringe solution
  • Aranesp 200 mcg per 0.4 mL prefilled syringe solution
  • Aranesp 200 mcg per mL vial solution
  • Aranesp 25 mcg per 0.42 mL prefilled syringe solution
  • Aranesp 25 mcg per mL vial solution
  • Aranesp 300 mcg per 0.6 mL prefilled syringe solution
  • Aranesp 40 mcg per 0.4 mL prefilled syringe solution
  • Aranesp 40 mcg per mL vial solution
  • Aranesp 500 mcg per 1 mL prefilled syringe solution
  • Aranesp 60 mcg per 0.3 mL prefilled syringe solution
  • Aranesp 60 mcg per mL vial solution
  • Gleevec 100 mg tablet
  • Gleevec 400 mg tablet
  • Iclusig 10 mg tablet
  • Iclusig 15 mg tablet
  • Iclusig 30 mg tablet
  • Iclusig 45 mg tablet
  • Procrit 10000 unit per mL injection
  • Procrit 2000 unit per mL injection
  • Procrit 20000 unit per mL injection
  • Procrit 3000 unit per mL injection
  • Procrit 4000 unit per mL injection
  • Procrit 40000 unit per mL injection
  • Revatio 10 mg per mL suspension
  • Revlimid 10 mg tablet
  • Revlimid 15 mg tablet
  • Revlimid 2.5 mg tablet
  • Revlimid 20 mg tablet
  • Revlimid 25 mg tablet
  • Revlimid 5 mg tablet
  • Sildenafil citrate 10 mg per mL suspension
  • Thalomid 100 mg capsule
  • Thalomid 150 mg capsule
  • Thalomid 200 mg capsule
  • Thalomid 50 mg capsule

 

Other Updates:

 

  • None

 

March 2024

 

Additions:

 

  • Mesalamine delayed release 1.2 gm tablet

 

Removals:

 

  • Asacol HD 800 mg tablet
  • Lialda 1.2 gm tablet

 

Other Updates:

 

  • None

 

February 2024

 

Additions:

 

  • None

 

Removals:

 

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

 

Other Updates:

 

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

 

January 2024

 

Additions:

 

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

 

Removals:

 

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

 

Other Updates:

 

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

 

December 2023

 

Additions:

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

 

Removals:

  • None

 

Other Updates:

  • None

 

November 2023

Additions:

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

 

Removals:

  • Proctofoam HC 1%-1% rectal foam

 

Other Updates:

  • Haloperidol 0.5 mg tablet (Age Limit Updated)
  • Haloperidol 1 mg tablet (Age Limit Updated)
  • Haloperidol 10 mg tablet (Age Limit Updated)
  • Haloperidol 2 mg tablet (Age Limit Updated)
  • Haloperidol 20 mg tablet (Age Limit Updated)
  • Haloperidol 5 mg tablet (Age Limit Updated)
  • Haloperidol lactate 2 mg per mL oral concentrate (Age Limit Updated)
  • Haloperidol lactate 5 mg per mL solution injection (Age Limit Updated)
  • Loxapine succinate 10 mg capsule (Age Limit Updated)
  • Loxapine succinate 25 mg capsule (Age Limit Updated)
  • Loxapine succinate 5 mg capsule (Age Limit Updated)
  • Loxapine succinate 50 mg capsule (Age Limit Updated)
  • Nayzilam 5mg per 0.1 mL nasal spray (Quantity Limit Updated, Age Limit Added)
  • Perphenazine 16 mg tablet (Age Limit Updated)
  • Perphenazine 2 mg tablet (Age Limit Updated)
  • Perphenazine 4 mg tablet (Age Limit Updated)
  • Perphenazine 8 mg tablet (Age Limit Updated)
  • Pimozide 1 mg tablet (Age Limit Updated)
  • Pimozide 2 mg tablet (Age Limit Updated)
  • Thioridazine HCl 10 mg tablet (Age Limit Updated)
  • Thioridazine HCl 100 mg tablet (Age Limit Updated)
  • Thioridazine HCl 25 mg tablet (Age Limit Updated)
  • Thioridazine HCl 50 mg tablet (Age Limit Updated)
  • Thiothixene 1 mg capsule (Age Limit Updated)
  • Thiothixene 10 mg capsule (Age Limit Updated)
  • Thiothixene 2 mg capsule (Age Limit Updated)
  • Thiothixene 5 mg capsule (Age Limit Updated)
  • Trifluoperazine HCl 1 mg tablet (Age Limit Updated)
  • Trifluoperazine HCl 10 mg tablet (Age Limit Updated)
  • Trifluoperazine HCl 2 mg tablet (Age Limit Updated)
  • Trifluoperazine HCl 5 mg tablet (Age Limit Updated)
  • Valtoco 10 mg nasal spray (Quantity Limit Updated, Age Limit Added)
  • Valtoco 15 mg nasal spray (Quantity Limit Updated, Age Limit Added)
  • Valtoco 20 mg nasal spray (Quantity Limit Updated, Age Limit Added)
  • Valtoco 5 mg nasal spray (Quantity Limit Updated, Age Limit Added)

 

October 2023

Additions

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

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

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

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

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

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

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

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

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

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

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

  • Infliximab 100 mg intravenous solution (prior authorization)

  • Lintera 10% wash

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

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

  • Spiriva Respimat 1.25 mcg per inhalation solution

  • Spiriva Respimat 2.5 mcg per inhalation solution

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

Removals

  • Aimovig auto-injector 140 mg per mL solution

  • Aimovig auto-injector 70 mg per mL solution

  • Avsola 100 mg reconstituted solution

  • Ergotamine tartrate 2 mg and caffeine 100 mg suppository

  • Focalin XR 10 mg capsule

  • Focalin XR 15 mg capsule

  • Focalin XR 20 mg capsule

  • Focalin XR 25 mg capsule

  • Focalin XR 30 mg capsule

  • Focalin XR 35 mg capsule

  • Focalin XR 40 mg capsule

  • Focalin XR 5 mg capsule

  • Makena 250 mg per mL oil

  • Makena auto-injector 275 mg per 1.1 mL solution

  • Pradaxa 100 mg packet

  • Pradaxa 150 mg packet

  • Pradaxa 20 mg packet

  • Pradaxa 30 mg packet

  • Pradaxa 40 mg packet

  • Pradaxa 50 mg packet

Other updates

  • Levocarnitine 330 mg tablet (prior authorization removed)

September 2023

Additions: None

Removals: None

Other updates: None

August 2023

Additions

  • Tranexamic acid 650 mg tablet (prior authorization)

Removals

  • Imbruvica 140 mg tablet (prior authorization)

  • Tranexamic acid 650 mg tablet (prior authorization)

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

Other updates: None

July 2023

Additions

  • Gefitinib 250 mg tablet (prior authorization)

  • Kalydeco 13.4 mg packet (prior authorization)

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

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

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

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

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

  • Mekinist 0.05 mg per mL solution (prior authorization)

  • Tafinlar 10 mg tablet (prior authorization)

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

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

Removals

  • Esomeprazole magnesium delayed release 40 mg capsule

  • Iressa 250 mg tablet

  • Latuda 120 mg tablet

  • Latuda 20 mg tablet

  • Latuda 40 mg tablet

  • Latuda 60 mg tablet

  • Latuda 80 mg tablet

  • Omega-3 ethyl esters 1 gm capsule

  • Sucraid 8500 unit per mL solution

Other updates: None

June 2023

Additions

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

  • Tinidazole 250 mg tablet

  • Tinidazole 500 mg tablet

  • Vancomycin 25 mg per mL oral solution

  • Vancomycin 50 mg per mL oral solution

Removals

  • Firvanq 25 mg per mL oral solution

  • Firvanq 50 mg per mL oral solution

  • Repatha prefilled syringe 140 mg per mL solution

  • Repatha Pushtronex cartridge 420 mg per 3.5mL solution

  • Repatha SureClick auto-injector 140 mg per mL solution

 Other updates: None

May 2023

Additions

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

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

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

Removals

  • Capsaicin 0.1% cream

  • Lidocaine 4% cream

  • Triamcinolone acetonide powder

Other updates

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

  • Fingolimod 0.5 mg capsule (added quantity limit)

  • Freestyle Libre 14 Day Sensor (changed quantity limit)

  • Freestyle Libre 2 Sensor (changed quantity limit)

  • Freestyle Libre 3 Sensor (changed quantity limit)

April 2023

Additions

  • Ambrisentan 10 mg tablet (prior authorization)

  • Ambrisentan 5 mg tablet (prior authorization)

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

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

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

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

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

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

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

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

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

  • Armour Thyroid 120 mg tablet

  • Armour Thyroid 15 mg tablet

  • Armour Thyroid 30 mg tablet

  • Armour Thyroid 60 mg tablet

  • Armour Thyroid 90 mg tablet

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

  • Bosentan 125 mg tablet (prior authorization)

  • Bosentan 62.5 mg tablet (prior authorization)

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

  • Nivestym 300 mcg per mL solution (prior authorization)

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

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

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

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

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

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

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

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

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

  • Pradaxa 110 mg pellet packet (quantity limit)

  • Pradaxa 150 mg pellet packet (quantity limit)

  • Pradaxa 20 mg pellet packet (quantity limit)

  • Pradaxa 30 mg pellet packet (quantity limit)

  • Pradaxa 40 mg pellet packet (quantity limit)

  • Pradaxa 50 mg pellet packet (quantity limit)

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

  • Xembify 1 gm per 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 capsule

  • Imbruvica 140 mg tablet

  • Imbruvica 280 mg tablet

  • Imbruvica 420 mg tablet

  • Imbruvica 560 mg tablet

  • Imbruvica 70 mg capsule

  • Imbruvica 70 mg per mL suspension

  • Jakafi 10 mg tablet

  • Jakafi 15 mg tablet

  • Jakafi 20 mg tablet

  • Jakafi 25 mg tablet

  • Jakafi 5 mg tablet

  • Lenalidomide 10 mg capsule

  • Lenalidomide 15 mg capsule

  • Lenalidomide 20 mg capsule

  • Lenalidomide 25 mg capsule

  • Lenalidomide 5 mg capsule

  • Letairis 10 mg tablet

  • Letairis 5 mg tablet

  • Leukeran 2 mg tablet

  • Myleran 2 mg tablet

  • Neupogen 300 mcg per 0.5 mL prefilled syringe

  • Neupogen 300 mcg per 0.5 mL vial

  • Neupogen 480 mcg per 0.8 mL prefilled syringe

  • Neupogen 480 mcg per 1.6 mL vial

  • Nyvepria 6 mg per 0.6 mL prefilled syringe

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

  • Revlimid 10 mg capsule

  • Revlimid 15 mg capsule

  • Revlimid 2.5 mg capsule

  • Revlimid 20 mg capsule

  • Revlimid 25 mg capsule

  • Revlimid 5 mg capsule

  • Rydapt 25 mg capsule

  • Salicylic acid 6% cream

  • Salicylic acid 6% shampoo

  • Sprycel 100 mg tablet

  • Sprycel 140 mg tablet

  • Sprycel 20 mg tablet

  • Sprycel 50 mg tablet

  • Sprycel 70 mg tablet

  • Sprycel 80 mg tablet

  • Tabloid 40 mg tablet

  • Tamiflu 30 mg capsule

  • Tamiflu 45 mg capsule

  • Tamiflu 6 mg per mL suspension

  • Tamiflu 75 mg capsule

  • Tracleer 125 mg tablet

  • Tracleer 62.5 mg tablet

  • Udenyca 6 mg per 0.6 mL prefilled syringe

  • Venclexta 10 mg tablet

  • Venclexta 100 mg tablet

  • Venclexta 50 mg tablet

  • Venclexta starting pack

  • Xofluza 40 mg therapy pack

  • Xofluza 80 mg therapy pack

Other updates

  • None

March 2023

Additions

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

Removals: None

Other updates

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

February 2023

Additions

  • Dificid 200 mg tablet (prior authorization)

  • Dificid 40 mg/mL suspension (prior authorization)

  • Ethacrynic acid 25 mg tablet

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

  • Lactobacillus extra strength capsule (OTC)

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

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

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

  • Probiotic capsule (OTC)

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

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

  • Sodium fluoride 1.1%/5% gel

  • Xifaxan 550 mg tablet (prior authorization)

Removals

  • Benzocaine 20 mg/docusate sodium 283 mg rectal enema

  • Bisacodyl 10 mg/30 mL enema (OTC)

  • Brimonidine tartrate 0.2%/timolol 0.5% ophthalmic solution

  • Celontin 300 mg capsule

  • Colchicine 0.6 mg capsule

  • Ibrance 100 mg tablet

  • Ibrance 125 mg tablet

  • Ibrance 75 mg tablet

  • Levofloxacin 0.5% ophthalmic solution

  • Magnesium hydroxide concentrate 2400 mg/10 mL

  • Naproxen delayed release, enteric coated 500 mg tablet

  • Pirfenidone 267 mg capsule

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

Other updates

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

  • Celecoxib 100 mg capsule (removed step therapy)

  • Celecoxib 200 mg capsule (removed step therapy)

  • Celecoxib 400 mg capsule (removed step therapy)

  • Celecoxib 50 mg capsule (removed step therapy)

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

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

January 2023

Additions

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

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

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

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

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

  • Eucrisa 2% ointment (prior authorization)

  • Pimecrolimus 1% cream (prior authorization)

  • Berinert kit 500 unit (prior authorization)

  • Cinryze vial 500 unit (prior authorization)

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

  • Kalbitor vial 10 mg/mL (prior authorization)

  • Orladeyo 110 mg capsule (prior authorization)

  • Orladeyo 150 mg capsule (prior authorization)

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

  • Symfi 600 mg/300 mg/300 mg tablet

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

  • Vfend 40 mg/mL suspension

  • Ella 30 mg tablet (quantity limit)

  • Tafluprost (PF) ophthalmic 0.0015% suspension

Removals

  • Invirase 200 mg capsule

  • Invirase 500 mg tablet

  • Stavudine 15 mg capsule

  • Stavudine 20 mg capsule

  • Stavudine 30 mg capsule

  • Stavudine 40 mg capsule

  • Viracept 250 mg tablet

  • Viracept 625 mg tablet

  • Zioptan ophthalmic 0.0015% solution

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

Other updates: None

December 2022

Additions

  • Accutane 10 mg capsule

  • Accutane 20 mg capsule

  • Accutane 30 mg capsule

  • Accutane 40 mg capsule

  • Amnesteem 10 mg capsule

  • Amnesteem 20 mg capsule

  • Amnesteem 40 mg capsule

  • Flonase nasal suspension 50 mcg/act

  • Histex PD 0.938 mg/mL liquid (OTC)

Removals: None

Other updates: None

November 2022

Additions

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

  • Orkambi Granule 75 to 94 mg (prior authorization)

Removals: None

Other updates: None

June 2024

 

Title 19/21 SMI Drug List Updates:

Additions:

 

  • None

 

Removals:

 

  • None

 

Other Updates:

 

  • Spravato 56mg solution (Added Quantity Limit)
  • Spravato 84mg solution (Added Quantity Limit)

 

Non-Title 19/21 Drug List Updates:

Additions:

 

  • None

 

Removals:

 

  • None

 

Other Updates:

 

  • Spravato 56mg solution (Added Quantity Limit)
  • Spravato 84mg solution (Added Quantity Limit)

 

May 2024

 

Title 19/21 SMI Drug List Updates:

 

Additions:

  • Azelaic acid 15% gel (Quantity Limit)
  • Doxycycline hyclate 75 mg tablet
  • Doxycycline monohydrate 50 mg tablet
  • Doxycycline monohydrate 75 mg tablet
  • Isosorbide dinitrate 20 mg / Hydralazine 37.5mg tablet (Quantity Limit)

 

Removals:

 

  • None

 

Other Updates:

 

  • None

 

Non-Title 19/21 Drug List Updates:

Additions:

 

  • None

 

Removals:

 

  • None

 

Other Updates:

 

  • None

 

April 2024

 

Title 19/21 SMI Drug List Updates:

Additions:

 

  • Alyq 20 mg tablet
  • Imatinib mesylate 100 mg tablet (Prior Authorization)
  • Imatinib mesylate 400 mg tablet (Prior Authorization)
  • Lenalidomide 10 mg capsule (Prior Authorization)  
  • Lenalidomide 15 mg capsule (Prior Authorization)  
  • Lenalidomide 2.5 mg capsule (Prior Authorization)
  • Lenalidomide 20 mg capsule (Prior Authorization)
  • Lenalidomide 25 mg capsule (Prior Authorization)
  • Lenalidomide 5 mg capsule (Prior Authorization)   
  • Liqrev 10 mg per mL suspension (Age Limit)
  • Neupogen 300 mcg per 0.5mL prefilled syringe solution (Prior Authorization)
  • Neupogen 300 mcg per mL solution (Prior Authorization)
  • Neupogen 480 mcg per 0.8mL prefilled syringe solution (Prior Authorization)
  • Neupogen 480 mcg per 1.6mL solution (Prior Authorization)
  • Nyvepria 6 mg per 0.6mL prefilled syringe solution (Prior Authorization)
  • Orenitram 0.125 mg extended release tablet (Prior Authorization)
  • Orenitram 0.25 mg extended release tablet (Prior Authorization)
  • Orenitram 1 mg extended release tablet (Prior Authorization)
  • Orenitram 1 month titration pack extended release tablet (Prior Authorization)
  • Orenitram 2 month titration pack extended release tablet (Prior Authorization)
  • Orenitram 2.5 mg extended release tablet (Prior Authorization)
  • Orenitram 3 month titration pack extended release tablet (Prior Authorization)
  • Orenitram 5 mg extended release tablet (Prior Authorization)
  • Skyclarys 50 mg capsule (Prior Authorization)
  • Tadalafil (PAH) 20 mg tablet (Prior Authorization)  
  • Testosterone 1.62% gel (Prior Authorization)
  • Udenyca 6 mg per 0.6mL auto-injector solution (Prior Authorization)
  • Xiidra 5% ophthalmic solution (Prior Authorization)
  • Zurzuvae 20 mg capsule (Prior Authorization)
  • Zurzuvae 25 mg capsule (Prior Authorization)
  • Zurzuvae 30 mg capsule (Prior Authorization)

 

Removals:

 

  • Adcirca 20 mg tablet
  • AndroGel Pump 1.62% gel
  • Aranesp 10 mcg per 0.4 mL prefilled syringe solution
  • Aranesp 100 mcg per 0.5 mL prefilled syringe solution
  • Aranesp 100 mcg per mL vial solution
  • Aranesp 150 mcg per 0.3 mL prefilled syringe solution
  • Aranesp 200 mcg per 0.4 mL prefilled syringe solution
  • Aranesp 200 mcg per mL vial solution
  • Aranesp 25 mcg per 0.42 mL prefilled syringe solution
  • Aranesp 25 mcg per mL vial solution
  • Aranesp 300 mcg per 0.6 mL prefilled syringe solution
  • Aranesp 40 mcg per 0.4 mL prefilled syringe solution
  • Aranesp 40 mcg per mL vial solution
  • Aranesp 500 mcg per 1 mL prefilled syringe solution
  • Aranesp 60 mcg per 0.3 mL prefilled syringe solution
  • Aranesp 60 mcg per mL vial solution
  • Gleevec 100 mg tablet
  • Gleevec 400 mg tablet
  • Iclusig 10 mg tablet
  • Iclusig 15 mg tablet
  • Iclusig 30 mg tablet
  • Iclusig 45 mg tablet
  • Procrit 10000 unit per mL injection
  • Procrit 2000 unit per mL injection
  • Procrit 20000 unit per mL injection
  • Procrit 3000 unit per mL injection
  • Procrit 4000 unit per mL injection
  • Procrit 40000 unit per mL injection
  • Revatio 10 mg per mL suspension
  • Revlimid 10 mg tablet
  • Revlimid 15 mg tablet
  • Revlimid 2.5 mg tablet
  • Revlimid 20 mg tablet
  • Revlimid 25 mg tablet
  • Revlimid 5 mg tablet
  • Sildenafil citrate 10 mg per mL suspension
  • Thalomid 100 mg capsule
  • Thalomid 150 mg capsule
  • Thalomid 200 mg capsule
  • Thalomid 50 mg capsule

 

Other Updates:

 

  • None

 

Non-Title 19/21 Drug List Updates:

Additions:

 

  • Zurzuvae 20 mg capsule (Prior Authorization)
  • Zurzuvae 25 mg capsule (Prior Authorization)
  • Zurzuvae 30 mg capsule (Prior Authorization)

 

Removals:

 

  • None

 

Other Updates:

 

  • None

 

 

March 2024

 

Title 19/21 SMI Drug List Updates:

Additions:

 

  • Mesalamine delayed release 1.2 gm tablet

 

Removals:

 

  • Asacol HD 800 mg tablet
  • Lialda 1.2 gm tablet

 

Other Updates:

 

  • None

 

Non-Title 19/21 Drug List Updates:

Additions:

 

  • None

 

Removals:

 

  • None

 

Other Updates:

 

  • None

 

February 2024

 

Title 19/21 SMI Drug List Updates:

Additions:

 

  • None

 

Removals:

 

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

 

Other Updates:

 

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

 

Non-Title 19/21 Drug List Updates:

 

Additions:

 

  • None

 

Removals:

 

  • None

 

Other Updates:

 

  • None

 

 

January 2024

 

Title 19/21 SMI Drug List Updates:

 

Additions:

 

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

Removals:

 

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

 

Other Updates:

 

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

 

 

Non-Title 19/21 Drug List Updates:

 

Additions:

 

  • Austedo XR 12 mg tablet (Prior Authorization)
  • Austedo XR 24 mg tablet (Prior Authorization)
  • Austedo XR 6 mg / 12 mg / 24 mg titration pack tablet (Prior Authorization)
  • Austedo XR 6 mg tablet (Prior Authorization)

 

Removals:

 

  • Equetro extended release 100 mg capsule
  • Equetro extended release 200 mg capsule
  • Equetro extended release 300 mg capsule

 

Other Updates:

 

  • None

 

December 2023

 

Title 19/21 SMI Drug List Updates:

Additions:

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

 

Removals:

  • None

 

Other Updates:

  • None

 

Non-Title 19/21 Drug List Updates:

Additions:

  • None

 

Removals:

  • None

 

Other Updates:

  • None

 

November 2023

 

Title 19/21 SMI Drug List Updates:

 

Additions:

 

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

 

Removals

  • Proctofoam HC 1% to 1% rectal foam

Other updates

  • Haloperidol 0.5 mg tablet (age limit updated)

  • Haloperidol 1 mg tablet (age limit updated)

  • Haloperidol 10 mg tablet (age limit updated)

  • Haloperidol 2 mg tablet (age limit updated)

  • Haloperidol 20 mg tablet (age limit updated)

  • Haloperidol 5 mg tablet (age limit updated)

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

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

  • Loxapine succinate 10 mg capsule (age limit updated)

  • Loxapine succinate 25 mg capsule (age limit updated)

  • Loxapine succinate 5 mg capsule (age limit updated)

  • Loxapine succinate 50 mg capsule (age limit updated)

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

  • Perphenazine 16 mg tablet (age limit updated)

  • Perphenazine 2 mg tablet (age limit updated)

  • Perphenazine 4 mg tablet (age limit updated)

  • Perphenazine 8 mg tablet (age limit updated)

  • Pimozide 1 mg tablet (age limit updated)

  • Pimozide 2 mg tablet (age limit updated)

  • Thioridazine HCl 10 mg tablet (age limit updated)

  • Thioridazine HCl 100 mg tablet (age limit updated)

  • Thioridazine HCl 25 mg tablet (age limit updated)

  • Thioridazine HCl 50 mg tablet (age limit updated)

  • Thiothixene 1 mg capsule (age limit updated)

  • Thiothixene 10 mg capsule (age limit updated)

  • Thiothixene 2 mg capsule (age limit updated)

  • Thiothixene 5 mg capsule (age limit updated)

  • Trifluoperazine HCl 1 mg tablet (age limit updated)

  • Trifluoperazine HCl 10 mg tablet (age limit updated)

  • Trifluoperazine HCl 2 mg tablet (age limit updated)

  • Trifluoperazine HCl 5 mg tablet (age limit updated)

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

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

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

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

Non-Title 19/21 drug list updates

Additions: None

Removals: None

Other updates

  • Haloperidol 0.5 mg tablet (age limit updated)
  • Haloperidol 1 mg tablet (age limit updated)
  • Haloperidol 10 mg tablet (age limit updated)
  • Haloperidol 2 mg tablet (age limit updated)
  • Haloperidol 20 mg tablet (age limit updated)
  • Haloperidol 5 mg tablet (age limit updated)
  • Haloperidol lactate 2 mg per mL oral concentrate (age limit updated)
  • Haloperidol lactate 5 mg per mL solution injection (age limit updated)
  • Loxapine succinate 10 mg capsule (age limit updated)
  • Loxapine succinate 25 mg capsule (age limit updated)
  • Loxapine succinate 5 mg capsule (age limit updated)
  • Loxapine succinate 50 mg capsule (age limit updated)
  • Perphenazine 16 mg tablet (age limit updated)
  • Perphenazine 2 mg tablet (age limit updated)
  • Perphenazine 4 mg tablet (age limit updated)
  • Perphenazine 8 mg tablet (age limit updated)
  • Pimozide 1 mg tablet (age limit updated)
  • Pimozide 2 mg tablet (age limit updated)
  • Thioridazine HCl 10 mg tablet (age limit updated)

October 2023

Title 19/21 SMI drug list updates

Additions

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

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

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

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

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

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

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

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

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

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

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

  • Infliximab 100 mg intravenous solution (prior authorization)

  • Lintera 10% wash

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

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

  • Spiriva Respimat 1.25 mcg per inhalation solution

  • Spiriva Respimat 2.5 mcg per inhalation solution

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

Removals

  • Aimovig auto-injector 140 mg per mL solution

  • Aimovig auto-injector 70 mg per mL solution

  • Avsola 100 mg reconstituted solution

  • Ergotamine tartrate 2 mg and caffeine 100 mg suppository

  • Focalin XR 10 mg capsule

  • Focalin XR 15 mg capsule

  • Focalin XR 20 mg capsule

  • Focalin XR 25 mg capsule

  • Focalin XR 30 mg capsule

  • Focalin XR 35 mg capsule

  • Focalin XR 40 mg capsule

  • Focalin XR 5 mg capsule

  • Makena 250 mg per mL oil

  • Makena auto-injector 275 mg per 1.1 mL solution

  • Pradaxa 100 mg packet

  • Pradaxa 150 mg packet

  • Pradaxa 20 mg packet

  • Pradaxa 30 mg packet

  • Pradaxa 40 mg packet

  • Pradaxa 50 mg packet

Other updates

  • Levocarnitine 330 mg tablet (prior authorization removed)

Non-Title 19/21 drug list updates

Additions: None

Removals: None

Other updates: None

September 2023

Title 19/21 SMI drug list updates

Additions: None

Removals: None

Other updates: None

Non-Title 19/21 drug list updates

Additions: None

Removals: None

Other updates: None

August 2023

Title 19/21 SMI drug list updates

Additions

  • Imbruvica 140 mg tablet (prior authorization)

  • Tranexamic acid 650 mg tablet (prior authorization)

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

Removals

  • Telmisartan 20 mg tablet

  • Telmisartan 40 mg tablet

  • Telmisartan 80 mg tablet

Other updates: None

Non-Title 19/21 drug list updates

Additions: 

  • Naloxone 4 mg nasal spray (OTC)

Removals: None

Other updates: None

July 2023

Title 19/21 SMI drug list updates

Additions

  • Gefitinib 250 mg tablet (prior authorization)

  • Kalydeco 13.4 mg packet (prior authorization)

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

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

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

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

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

  • Mekinist 0.05 mg per mL solution (prior authorization)

  • Tafinlar 10 mg tablet (prior authorization)

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

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

Removals

  • Esomeprazole magnesium delayed release 40 mg capsule

  • Iressa 250 mg tablet

  • Latuda 120 mg tablet

  • Latuda 20 mg tablet

  • Latuda 40 mg tablet

  • Latuda 60 mg tablet

  • Latuda 80 mg tablet

  • Omega-3 ethyl esters 1 gm capsule

  • Sucraid 8500 unit per mL solution

Other updates: None

Non-Title 19/21 drug list updates

Additions: None

 Removals: None

 Other updates: None

June 2023

Title 19/21 SMI drug list updates

Additions

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

  • Tinidazole 250 mg tablet

  • Tinidazole 500 mg tablet

  • Vancomycin 25 mg per mL oral solution

  • Vancomycin 50 mg per mL oral solution

Removals

  • Firvanq 25 mg per mL oral solution

  • Firvanq 50 mg per mL oral solution

  • Repatha prefilled syringe 140 mg per mL solution

  • Repatha Pushtronex cartridge 420 mg per 3.5mL 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 5 mL (20%) solution vial (prior authorization)

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

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

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

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

  • Zovirax 5% ointment (quantity limit)

Removals

  • Acyclovir 5% ointment

  • Aubagio 14 mg tablet

  • Aubagio 7 mg tablet

  • Fulphila 6 mg per 0.6 mL prefilled syringe

  • Imbruvica 140 mg 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 5 mL solution (quantity limit, age limit, OTC)

Removals: None

Other updates

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 and 2% cream kit (OTC)

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

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

  • Probiotic capsule (OTC)

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

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

  • Sodium fluoride 1.1%/5% gel

  • Xifaxan 550 mg tablet (prior authorization)

Removals

  • Benzocaine 20 mg/docusate sodium 283 mg rectal enema

  • Bisacodyl 10 mg/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 5 mL solution

Other updates

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

  • Celecoxib 100 mg capsule (removed step therapy)

  • Celecoxib 200 mg capsule (removed step therapy)

  • Celecoxib 400 mg capsule (removed step therapy)

  • Celecoxib 50 mg capsule (removed step therapy)

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

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

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/1.14 mL solution (prior authorization)

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

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

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

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

  • Eucrisa 2% ointment (prior authorization)

  • Pimecrolimus 1% cream (prior authorization)

  • Berinert kit 500 unit (prior authorization)

  • Cinryze vial 500 unit (prior authorization)

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

  • Kalbitor vial 10 mg/mL (prior authorization)

  • Orladeyo 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 serious mental illness (SMI) drug list updates

Additions

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

  • Orkambi Granule 75 to 94 mg (prior authorization)

Removals: None

Other updates: None

Non-Title 19/21 drug list updates

Additions: None

Removals: None

Other updates: None

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

You can also get info about drug safety alerts.

Questions?

Questions? Check out your provider manual. Or contact us.