Formulary search tool and updates

June 2026 Additions:

• None

June 2026 Removals:

• None

June 2026 Other Updates:

• None

May 2026 Additions:

• *Omega-3 Fatty Acids Capsule 500 mg**
• Calcium Carbonate Chewable Tablet 1250 mg (500 mg Elemental Calcium)
• Calcium Carbonate Tablet 1250 mg (500 mg Elemental Calcium)
• Carboxymethylcellulose-Glycerin Ophthalmic Solution 0.5-0.9%
• Dexamethasone Sodium Phosphate Preservative Free Injection 10 mg / mL
• Ferrous Fumarate Tablet 324 mg (106 mg Elemental Iron)
• Ferrous Gluconate Tablet 240 mg (27 mg Elemental Iron)
• Ferrous Sulfate Solution 75 mg/ mL (15 mg / mL Elemental Iron)
• Ferrous Sulfate Tablet Enteric Coated 324 mg (65 mg Iron Equivalent)
• Histex Pediatric Drops 1.25 mg / mL
• Polysaccharide Iron Complex Capsule 150 mg (Iron Equivalent)
• Sodium Polystyrene Sulfonate Rectal Suspension 30 GM / 120 mL
• Tobramycin-Dexamethasone Ophthalmic Suspension 0.3-0.1% (Add Quantity Level Limit)

May 2026 Removals:

• *Calamine Lotion***
• *Calcium Carbonate-Vitamin D with Minerals Tablets 600 mg-200 Unit***
• *Calcium Carbonate-Vitamin D with Minerals Tablets 600 mg-400 Unit***
• *Multiple Vitamins with Minerals Tablet Extended Release**
• *Omega-3 Fatty Acids Capsule 1400 mg**
• *Prenatal Vitamins with Iron Bisglycinate Chelate-Folic Acid Tablet 29-1 mg
• *Prenatal Vitamins with Iron Fumarate-Folic Acid Tablet 28-1 mg***
• *Prenatal without A Vitamin with Iron Fumarate-Folic Acid Capsule 106.5-1 mg***
• *Probiotic Product - Capsule Delayed Release**
• *Soap & Cleansers - Lotion***
• Acetaminophen Disintegrating Tablet 160 mg
• Acetaminophen Disintegrating Tablet 80 mg
• Alendronate Sodium Tablet 5 mg
• Aspirin Tablet 500 mg
• Calcium Carbonate (Antacid) Chewable Tablet 400 mg
• Calcium Carbonate-Cholecalciferol Tablet 500 mg - 125 Unit
• Calcium Carbonate-Cholecalciferol Tablet 600 Mg-3.125 Mcg (125 Unit)
• Calcium Carbonate-Vitamin D Tablet 500 mg - 200 Unit
• Calcium Tablet 500 mg
• Calcium Tablet 600 mg
• Carbonyl Iron Chewable Tablet 18 mg (Elemental Iron)
• Clindamycin Phosphate Gel 1% (Once-Daily)
• Cyclopentolate Hydrochloride Ophthalmic Solution 2%
• Dextran 70-Hypromellose Ophthalmic Solution 0.1-0.3%
• Dextromethorphan-Guaifenesin Liquid 10-200 mg / 5 mL
• Epinephrine Solution Prefilled Syringe 0.3 mg / 0.3 mL (1:1000)
• Ferrous Sulfate Tablet 27 mg (Elemental Iron)
• Ferrous Sulfate Tablet 28 mg (Elemental Iron)
• Glucose Chewable Tablet 5 GM
• Glycerin Suppository 80.7%
• Glycerin Topical Liquid
• Heparin Sodium (Porcine) Prefilled Injection 5000 Unit/ mL
• Hydrocortisone Perivaginal Cream 1%
• Ibuprofen Tablet 100 mg
• Insulin Regular (Human) Injection 100 Unit / mL
• Iron-Vitamin C-Vitamin B12-Folic Acid Tablet 100-250-0.025-1 mg
• Loperamide Hydrochloride Suspension 1 mg / 7.5 mL
• Niacin Capsule Extended Release 500 mg
• Paromomycin Sulfate Capsule 250 mg
• Polyethylene Glycol 3350 Oral Packet 8.5 GM
• Potassium Citrate & Citric Acid Powder Pack 3300-1002 mg
• Pramoxine-Phenylephrine-Glycerin-Petrolatum Perianal Cream 1-0.25-14.4-15%
• Salicylic Acid Liquid 3%
• Sodium Chloride Aerosol Solution 0.9%
• Tolnaftate Aerosol 1%

May 2026 Other Updates:

• Isotretinoin (Remove Step Therapy)

April 2026 Additions:

• None

April 2026 Removals:

• None

April 2026 Other Updates:

• None

March 2026 Additions:

• None

March 2026 Removals:

• None

March 2026 Other Updates:

• None

February 2026 Additions:

• *Skin Protectants Miscellaneous - Cream***
• Berinert Intravenous 500 Units (Prior Authorization)
• Cosentyx Injection 125 mg / 5 mL (Prior Authorization)
• Cosentyx Injection 150 mg / mL (Prior Authorization)
• Cosentyx Injection 300 mg dose (Prior Authorization)
• Cosentyx Injection 75 mg / 0.5 mL (Prior Authorization)
• Cosentyx Pen Injection 150 mg / mL (Prior Authorization)
• Cosentyx Pen Injection 300 mg dose (Prior Authorization)
• Cosentyx Uno Injection 300 mg / 2 mL (Prior Authorization)
• Delstrigo (Diagnosis Required, Quantity Level Limit)
• Fiasp Flex Injection Touch
• Fiasp Injection 100 Unites / mL
• Fiasp Penfill Injection U-100
• Icatibant Acetate Syringe 30 mg / 3 mL (Prior Authorization)
• Imuldosa (Prior Authorization)
• Lanthanum Carbonate Chewable Tablet 1000 mg (Elemental) (Step Therapy, Quantity Level Limit)
• Lanthanum Carbonate Chewable Tablet 500 mg (Elemental) (Step Therapy, Quantity Level Limit)
• Lanthanum Carbonate Chewable Tablet 750 mg (Elemental) (Step Therapy, Quantity Level Limit)
• Moxifloxacin Hydrochloride 0.5% Solution (Quantity Level Limit)
• Novolog Injection 100 Units / mL
• Novolog Injection Flexpen
• Novolog Injection Flexpen Relion
• Novolog Injection Penfill
• Novolog Mix Injection 70/30
• Novolog Mix Injection Flexpen
• Novolog Mix Injection Flexpen Relion
• Rezvoglar
• Steqeyma (Prior Authorization)

February 2026 Removals:

• Clonidine Transdermal Patch 0.1 mg / 24 hour
• Clonidine Transdermal Patch 0.2 mg / 24 hour
• Clonidine Transdermal Patch 0.3 mg / 24 hour
• Genvoya
• Insulin Lispro Injection 100 Units / mL
• Insulin Lispro Injection Junior
• Insulin Lispro Injection Protamine
• Insulin Lispro Protamine & Lispro Injectable 100 Units / mL (75-25)
• Insulin Lispro Protamine & Lispro Suspension Pen-Injectable 100 Units / mL (50-50)
• Insulin Lispro Protamine & Lispro Injectable 100 Units / mL (50-50)
• Juluca
• Rebif Injection 22 mg /0.5 mL
• Rebif Injection 44 mg /0.5 mL
• Rebif Rebidose Injection 22 mg /0.5 mL
• Rebif Rebidose Injection 44 mg/0.5 mL
• Rebif Rebidose Injection Titration
• Rebif Titration Injection Pack
• Stribild

February 2026 Other Updates:

• Sacubitril-Valsartan Tablet 24-26 mg (Remove Prior Authorization)
• Sacubitril-Valsartan Tablet 49-51 mg (Remove Prior Authorization)
• Sacubitril-Valsartan Tablet 97-103 mg (Remove Prior Authorization)
• Tacrolimus Ointment 0.03% (Remove Step Therapy, Add Age Limit)
• Tacrolimus Ointment 0.1% (Remove Step Therapy, Add Age Limit)

January 2026 Additions:

• *Bacillus Coagulans-Inulin Capsule**
• *Lactobacillus Acidophilus-Pectin Tablet**
• *Probiotic Product - Chewable Tablet**
• *Probiotic Product - Tablet**
• Eliquis Capsule 0.15 mg
• Eliquis Tablet 0.5 mg
• Eliquis Tablet 1.5 mg
• Eliquis Tablet 2 mg
• Otezla Extended-Release 75 mg (Quantity Level Limit, Prior Authorization)
• Otezla Extended-Release Starter Pack (Quantity Level Limit, Prior Authorization)
• Saccharomyces Boulardii Capsule 250 mg

January 2026 Removals:

• None

January 2026 Other Updates:

• None

December 2025 Additions:
 

• None

December 2025  Removals:
 

• None

December 2025  Other Updates:
 

• None

November 2025 Additions:
 

• Clobetasol Propionate Foam 0.05% (Quantity Level Limit)
• Prezcobix Tablet 675-150 mg (Prior Authorization, Quantity Level Limit)
• Kerendia Tablet 40 mg (Prior Authorization)
• Rivaroxaban For Suspension 1 mg / mL (Quantity Level Limit, Age Limit)
• Tetracycline Hydrochloride Capsule 250 mg
• Tetracycline Hydrochloride Capsule 500 mg

November 2025 Removals:
 

• Auranofin Capsule 3 mg
• Nifedipine Capsule 10 mg
• Nifedipine Capsule 20 mg
• Ropinirole Hydrochloride Tablet Extended Release 24-hour 12 mg (Base Equivalent)
• Ropinirole Hydrochloride Tablet Extended Release 24-hour 2 mg (Base Equivalent)
• Ropinirole Hydrochloride Tablet Extended Release 24-hour 4 mg (Base Equivalent)
• Ropinirole Hydrochloride Tablet Extended Release 24-hour 6 mg (Base Equivalent)
• Ropinirole Hydrochloride Tablet Extended Release 24-hour 8 mg (Base Equivalent)

November 2025 Other Updates:
 

• None

October 2025 Additions:
 

• *B-Complex with Vitamin C and Folic Acid Tablet 0.8 mg***
• Acyclovir Ointment 5% (Step Therapy, Quantity Level Limit)
• Calcium Carbonate-Cholecalciferol Tablet 600 mg-20 mcg
• Cholecalciferol Capsule 10 mcg (400 Unit)
• Cyanocobalamin Tablet 1000 mcg
• Cyanocobalamin Tablet 250 mcg
• Cyanocobalamin Tablet 500 mcg
• Folic Acid Tablet 400 mcg
• Sodium Chloride Intravenous Solution 0.9%
• Sodium Chloride Tablet 1 GM
• Thiamine Hydrochloride Tablet 100 mg
• Thiamine Mononitrate Tablet 100 mg
• Tretinoin Cream (Step Therapy, Quantity Level Limit, Age Limit)
• Tretinoin gel 0.01% (Step Therapy, Quantity Level Limit, Age Limit)
• Tretinoin gel 0.025% (Step Therapy, Quantity Level Limit, Age Limit)
• Vitamin E Capsule 180 mg (400 Unit)

October 2025 Removals:
 

• Retin-A Cream
• Retin-A Gel 0.01%
• Retin-A Gel 0.025%
• Zovirax Ointment 5%

October 2025 Other Updates:
 

• None

September 2025 Additions:
 

• None

September 2025 Removals:
 

• None

September 2025 Other Updates:
 

None

August 2025 Additions:
 

• Bicillin L-A Injection 1200000 units
• Bicillin L-A Injection 600000 units
• Budesonide Aerosol 2 mg / Actuation Rectal Foam
• Epysqli Injection 300 mg / 30 mL (Prior Authorization)
• Exenatide Injection 10 mcg (Add Step Therapy, Quantity Level Limit)
• Exenatide Injection 5 mcg (Add Step Therapy, Quantity Level Limit)
• Kerendia Tablet 10 mg (Prior Authorization)
• Kerendia Tablet 20 mg (Prior Authorization)
• Mirabegron Tab 50mg Extended Release (Add Step Therapy, Quantity Level Limit)
• Mirabegron Tablet 25 mg Extended Release (Add Step Therapy, Quantity Level Limit)
• Mycophenolic Tablet 180 mg Delayed Release
• Mycophenolic Tablet 360 mg Delayed Release
• Paxlovid Tablet Pack (Quantity Level Limit, Age Limit)
• Eltrombopag Olamine Powder Pack for Suspension 12.5 mg (Base Equivalent) (Prior Authorization, Quantity Level Limit)
• Eltrombopag Olamine Powder Pack for Suspension 25 mg (Base Equivalent) (Prior Authorization, Quantity Level Limit)
• Prucalopride Tablet 1 mg (Prior Authorization, Quantity Level Limit)
• Prucalopride Tablet 2 mg (Prior Authorization, Quantity Level Limit)
• Rivaroxaban Tablet 2.5 mg (Prior Authorization, Quantity Level Limit)
• Tyenne Injection 162 mg / 0.9 mL (Prior Authorization)
• Tyenne Injection 200 mg / 10 mL (Prior Authorization)
• Tyenne Injection 400 mg / 20 mL (Prior Authorization)
• Tyenne Injection 80 mg / 4 mL (Prior Authorization)
• Umeclidinium-Vilanterol Aerosol 62.5 mcg – 25 mg (Quantity Level Limit)

August 2025 Removals:
 

• Pentazocine / Naloxone Tablet 50 mg-0.5 mg
• Phenylephrine Tablet 10 mg
• Phenylephrine with Dextromethorphan - Guaifenesin Liquid 10-18-200 mg / 15 mL
• Phenylephrine with Dextromethorphan - Guaifenesin Liquid 2.5-5-100 mg / 5 mL
• Soliris Injection 10 mg / mL

August 2025 Other Updates:
 

• Cefixime Capsule 400 mg (Quantity Level Limit)

July 2025 Additions:
 

• *Lancet Devices***
• *Lancets***
• Relion True Kit Meter Air (Quantity Level Limit)
• Relion True Test Metrix (Quantity Level Limit)
• True Metrix Kit Air (Quantity Level Limit)
• True Metrix Kit Meter (Quantity Level Limit)
• True Metrix Test Glucose (Quantity Level Limit)

July 2025 Removals:
 

• One Touch Kit Ultra 2
• One Touch Kit Ultra 2 Kit with Device
• OneTouch Kit Ultra Mini Kit with Device
• One Touch Kit Verio Flex System Kit
• One Touch Kit Verio IQ System Kit with Device
• One Touch Kit Verio Kit with Device
• One Touch Kit Verio Reflect Kit with Device
• One Touch Test Ultra
• One Touch Test Ultra Blood
• One Touch Test Verio

July 2025 Other Updates:
 

• None

June 2025 Additions:
 

• Ivizia Dry Gel 0.5%

June 2025 Removals:
 

• None

June 2025  Other Updates:
 

• Ribavirin Capsule 200 mg (Step Therapy Removal)
• Ribavirin Tablet 200 mg (Step Therapy Removal)

May 2025 Additions:
 

• Arformoterol Nebulizer 15 / 2 mL (Quantity Level Limit)
• Dapagliflozi - Metformin Tablet 10-1000 mg (Quantity Level Limit, Add Step Therapy)
• Dapagliflozi - Metformin Tablet 5-1000 mg (Quantity Level Limit, Add Step Therapy)
• Dapagliflozi Tablet 10 mg (Quantity Level Limit, Add Step Therapy)
• Dapagliflozi Tablet 5 mg (Quantity Level Limit, Add Step Therapy)
• Diclofenac Sodium Gel 3%
• Diphenhydramine Injection 50 mg / mL
• Itovebi Tablet 3 mg (Quantity Level Limit, Prior Authorization)
• Itovebi Tablet 9 mg (Quantity Level Limit, Prior Authorization)
• Saxagliptin /Metformin Tablet 2.5-1000 mg (Quantity Level Limit)
• Saxagliptin /Metformin Tablet 5-1000 mg (Quantity Level Limit)
• Saxagliptin /Metformin Tablet 5-500 mg (Quantity Level Limit)
• Saxagliptin Hydrochloride Tablet 2.5 mg (Quantity Level Limit)
• Saxagliptin Hydrochloride Tablet 5 mg (Quantity Level Limit)
• Yesintek Injection 130 mg / 26 mL (Prior Authorization)
• Yesintek Injection 45 mg / 0.5 ML (Prior Authorization)
• Yesintek Prefilled Syringe 45 mg /0.5 mL (Prior Authorization)
• Yesintek Prefilled Syringe 90 mg / mL (Prior Authorization)

May 2025  Removals:
 

• Gentamicin Sulfate Ophthalmic Ointment
• Jardiance Tablet 10 mg
• Jardiance Tablet 25 mg
• Kalydeco Granules 13.4 mg
• Kalydeco Packet 25 mg
• Kalydeco Packet 50 mg
• Kalydeco Packet 75 mg
• Kalydeco Tablet 150 mg
• Orkambi Granules 100-125 mg
• Orkambi Granules 150-188 mg
• Orkambi Granules 75-94 mg
• Orkambi Tablet 100-125 mg
• Orkambi Tablet 200-125 mg
• Symdeko Tablet 100-150 mg
• Symdeko Tablet 50-75 mg
• Trikafta Packet 59.5 mg
• Trikafta Packet 75 mg
• Trikafta Tablet

May 2025 Other Updates:
 

• Calcipotriene Cream (Remove Prior Authorization)
• Calcipotriene Solution (Remove Prior Authorization)
• Nifedipine Tablet 30 mg Extended Release (Quantity Level Limit)
• Nifedipine Tablet 60 mg Extended Release (Quantity Level Limit)
• Nifedipine Tablet Extended Release 24-hour Osmotic Release (Quantity Level Limit)

April 2025 Additions:
 

• None

April 2025  Removals:
 

• None

April 2025 Other Updates:
 

• None

March 2025 Additions:
 

• None

March 2025 Removals:
 

• None

March 2025 Other Updates:
 

• None

February 2025 Additions:
 

• Asmanex 120 Inhalation 220 mcg (Quantity Level Limit)
• Asmanex 30 Inhalation 110 mcg (Quantity Level Limit)
• Asmanex Hfa Inhalation 100 mcg (Quantity Level Limit)
• Asmanex Hfa Inhalation 200 mcg (Quantity Level Limit)
• Asmanex Hfa Inhalation 50mcg (Quantity Level Limit)
• Colchicine Capsule 0.6 mg (Quantity Level Limit)
• Estradiol Valerate Multidose Vial 20 mg/ mL (Quantity Level Limit)
• Estradiol Valerate Multidose Vial 40 mg / mL (Quantity Level Limit)
• Eucrisa Ointment 2% (Quantity Level Limit, Add Prior Authorization)
• Omnipod Go Kit 10 Unit/ Day (Add Prior Authorization, Quantity Level Limit)
• Omnipod Go Kit 15 Unit/ Day (Add Prior Authorization, Quantity Level Limit)
• Omnipod Go Kit 20 Unit/ Day (Add Prior Authorization, Quantity Level Limit)
• Omnipod Go Kit 25 Unit/ Day (Add Prior Authorization, Quantity Level Limit)
• Omnipod Go Kit 30 Unit/ Day (Add Prior Authorization, Quantity Level Limit)
• Omnipod Go Kit 35 Unit/ Day (Add Prior Authorization, Quantity Level Limit)
• Omnipod Go Kit 40 Unit/ Day (Add Prior Authorization, Quantity Level Limit)
• Omnipod Kits (Add Prior Authorization, Quantity Level Limit)
• Omnipod Pods (Add Prior Authorization, Quantity Level Limit)
• Sodium/Potassium Solution Magnesium (Quantity Level Limit)
• Twiist Kit (Add Prior Authorization)
• Twiist Refills (Add Prior Authorization)

February 2025 Removals:
 

• Austedo Extended Release Tablet 12 mg
• Austedo Extended Release Tablet 24 mg
• Austedo Extended Release Tablet 30 mg
• Austedo Extended Release Tablet 36 mg
• Austedo Extended Release Tablet 42 mg
• Austedo Extended Release Tablet 48 mg
• Austedo Extended Release Tablet 6 mg
• Austedo Extended Release Tablet Titration Kit
• Austedo Tablet 12 mg
• Austedo Tablet 9 mg
• Austedo Tablet 6 mg
• Freestyle Kit Sensor
• Freestyle Libre Kit 2 Sensor
• Freestyle Libre Kit 2 Sensor
• Freestyle Libre Kit 3 Sensor
• Freestyle Libre Mis 2 Reader
• Freestyle Libre Mis 2 Reader
• Freestyle Libre Mis 3 Reader
• Freestyle Mis Reader
• Freestyle Mis Reader
• Qvar Redihaler Inhalation 40 mcg
• Qvar Redihaler Inhalation 80 mcg
• Trulicity Injection 0.75 mg / 0.5 mL
• Trulicity Injection 1.5 mg / 0.5 mL
• Trulicity Injection 3 mg / 0.5 mL
• Trulicity Injection 4.5 mg / 0.5 mL

February 2025 Other Updates:
 

• Oxybutynin Tablet 10 mg Extended Release (Quantity Level Limit)

January 2025 Additions:
 

• Ocrevus Injection Zunovo (Prior Authorization, Quantity Level Limit)

January 2025 Removals:
 

• None

January 2025 Other Updates:
 

• None

December 2024 Additions:

• None

December 2024 Removals:

• None

December 2024 Other Updates:

• None

November 2024 Additions:

• Baclofen Solution 5 mg / 5 mL (Quantity Level Limit)
• Entresto Sprinkle Capsule (Quantity Level Limit, Prior Authorization)
• Folivane-Ob Capsule 85-1 mg (Quantity Level Limit)
• Liraglutide (Quantity Level Limit, Step Therapy)
• Ojemda Suspension (Quantity Level Limit, Prior Authorization)
• Ojemda Tablet 100 mg (Quantity Level Limit, Prior Authorization)
• Tiotropium Bromide Handihaler (Quantity Level Limit)

November 2024 Removals:

• Opsumit

November 2024 Other Updates:

• Emgality Injection 120 mg / mL (Update Step Therapy)
• Sevelamer Carbonate Tablet 800 mg (Remove Step Therapy)

October 2024 Additions:

• None

October 2024  Removals:

• None

October 2024 Other Updates:

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

September 2024 Additions:

• Austedo Extended Release 30 mg (Add Prior Authorization, Quantity Limit)
• Austedo Extended Release 36 mg (Add Prior Authorization, Quantity Limit)
• Austedo Extended Release 42 mg (Add Prior Authorization, Quantity Limit)
• Austedo Extended Release 48 mg (Add Prior Authorization, Quantity Limit)
• Rinvoq Oral Solution 1 mg / mL (Add Prior Authorization)

September 2024 Removals:

• None

September 2024 Other Updates:

• None

August 2024 Additions:

• Derma-Smooth Scalp Oil 0.01% (Quantity Level Limit)
• Eletriptan Hydrobromide Tablet 20 mg (Quantity Level Limit)
• Eletriptan Hydrobromide Tablet 40 mg (Quantity Level Limit)
• Nexletol Tablet 180 mg (Prior Authorization, Quantity Level Limit)
• Tinidazole Tablet 250 mg
• Tinidazole Tablet 500 mg

August 2024 Removals:

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

August 2024 Other Updates:

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

July 2024 Additions:

• None

July 2024 Removals:

• None

July 2024 Other Updates:

• None

June 2024 Additions:

• None

June 2024 Removals:

• None

June 2024 Other Updates:

• None

May 2024 Additions:

• Adapalene Gel 0.3% (Age Limit, Quantity Level Limit, Step Therapy)
• Adapalene/Benzoyl Peroxide Gel 0.1-2.5% (Age Limit, Quantity Level Limit)
• Azelaic Acid Gel 0.15% (Quantity Level Limit)
• Clindamycin/Benzoyl Peroxide Gel 1.2-5% (Quantity Level Limit)
• Clindamycin/Benzoyl Peroxide Gel 1-5% (Quantity Level Limit)
• Dabigatran 110 mg Capsule (Quantity Level Limit)
• Diphenhydramine-Zinc Acetate Cream 2-0.1%
• Doxycycline Hyclate Tablet 75 mg
• Doxycycline Monohydrate Tablet 50 mg
• Doxycycline Monohydrate Tablet 75 mg
• Erythromycin/Benzoyl Peroxide Gel 3-5% (Quantity Level Limit)
• Fluticasone Propionate Powder Inhaler 100 mcg (Quantity Level Limit)
• Fluticasone Propionate Powder Inhaler 250 mcg (Quantity Level Limit)
• Fluticasone Propionate Powder Inhaler 50 mcg (Quantity Level Limit)
• Isosorbide Dinitrate-Hydralazine Hydrochloride Tablet 20-37.5 mg (Quantity Level Limit)
• Menthol-Methyl Salicylate Cream
• Oxycodone Hydrochloride Extended-Release Tablet 10 mg (Prior Authorization, Quantity Level Limit)
• Oxycodone Hydrochloride Extended-Release Tablet 20 mg (Prior Authorization, Quantity Level Limit)
• Oxycodone Hydrochloride Extended-Release Tablet 40 mg (Prior Authorization, Quantity Level Limit)
• Oxycodone Hydrochloride Extended-Release Tablet 80 mg (Prior Authorization, Quantity Level Limit)
• Xolair 150 mg/ mL (Prior Authorization)
• Xolair 300 mg/ 2 mL Pen (Prior Authorization)
• Xolair 300 mg/ 2 mL Prefilled Syringe (Prior Authorization)
• Xolair 75 mg/ 0.5 mL Pen (Prior Authorization)

May 2024 Removals:

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

May 2024 Other Updates:

• Budesonide Inhalation Suspension (Age Limit)
• Ciclopirox Olamine Cream 0.77% (Step Therapy)
• Fluticasone Propionate Hfa Inhaler (Age Limit)
• Mavyret Powder Pack 50-20 mg (Quantity Level Limit)
• Retin-A Cream
• Retin-A Gel 0.01%
• Retin-A Gel 0.025%
• Zovirax Ointment 5%

April 2024 Additions:

• None

April 2024 Removals:

• None

April 2024 Other Updates:

• *Blood Glucose Monitoring Kit With Device*** (Quantity Level Limit)

March 2024 Additions:

• Zenpep Capsule 60000 Unit

March 2024  Removals:

• None

March 2024  Other Updates:

• None

February 2024 Additions:

• Adalimumab-Adaz Auto-Injector 40 mg/ 0.4 mL (Prior Authorization)
• Adalimumab-Adaz Prefilled Syringe 40 mg/ 0.4 mL (Prior Authorization)
• Adalimumab-Fkjp Auto-Injector Kit 40 mg/ 0.8 mL (Prior Authorization)
• Adalimumab-Fkjp Prefilled Syringe Kit 20 mg/ 0.4 mL (Prior Authorization)
• Adalimumab-Fkjp Prefilled Syringe Kit 40 mg/ 0.8 mL (Prior Authorization)
• Dupixent Injection 100 mg / 0.67 mL (Prior Authorization)
• Dupixent Injection 200 mg (Prior Authorization)
• Dupixent Injection 200 mg/ 1.14 mL (Prior Authorization)
• Dupixent Injection 300 mg/ 2 mL (Prior Authorization)
• Fesoterodine Fumarate Tablet Extended Release 24 hour 4 mg (Step Therapy, Quantity Level Limit)
• Fesoterodine Fumarate Tablet Extended Release 24 hour 8 mg (Step Therapy, Quantity Level Limit)
• Hadlima Auto-Injector 40 mg/ 0.4 mL (Prior Authorization)
• Hadlima Auto-Injector 40 mg/ 0.8 mL (Prior Authorization)
• Hadlima Prefilled Syringe 40 mg/ 0.4 mL (Prior Authorization)
• Hadlima Prefilled Syringe 40 mg/ 0.8 mL (Prior Authorization)
• Insulin Lispro Injection 100 unit/ mL
• Insulin Lispro Injection Junior
• Insulin Lispro Vial
• Lantus Pen Injector
• Lantus Vial
• Ondansetron Hydrochloride Oral Solution 4 mg/ 5 mL (Quantity Level Limit)
• Orilissa Tablet 150 mg (Prior Authorization)
• Orilissa Tablet 200 mg (Prior Authorization)
• Otezla Starter Pack 10 mg/20 mg/30 mg (Prior Authorization)
• Otezla Tablet 30 mg (Prior Authorization)
• Rinvoq Tablet 15 mg Extended Release (Prior Authorization)
• Rinvoq Tablet 30 mg Extended Release (Prior Authorization)
• Rinvoq Tablet 45 mg Extended Release (Prior Authorization)
• Teriparatide Pen Injector 620 mcg/ 2.48 mL (Prior Authorization, Quantity Level Limit)
• Ubrelvy Tablet 100 mg (Step Therapy)
• Ubrelvy Tablet 50 mg (Step Therapy)
• Ultra-Fine U-100 (BD)
• Ultra-Fine U-500 (BD)

February 2024 Removals:

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

February 2024 Other Updates:

• Albuterol Sulfate Solution Nebulizer 0.5% (5 mg/ mL) (Quantity Level Limit)
• Alogliptin-Pioglitazone Tablet 12.5-15 mg (Quantity Level Limit)
• Alogliptin-Pioglitazone Tablet 12.5-45 mg (Quantity Level Limit)
• Bimatoprost Ophthalmic Solution 0.03%
• Empagliflozin Tablet 10 mg
• Empagliflozin Tablet 25 mg
• Emtricitabine-Tenofovir Disoproxil Fumarate Tablet 133-200 mg (Quantity Level Limit)
• Emtricitabine-Tenofovir Disoproxil Fumarate Tablet 167-250 mg (Quantity Level Limit)
• Esomeprazole Magnesium Capsule Delayed Release 40 mg (Quantity Level Limit)
• Glimepiride Tablet 1 mg (Quantity Level Limit)
• Glimepiride Tablet 2 mg (Quantity Level Limit)
• Glimepiride Tablet 4 mg (Quantity Level Limit)
• Lansoprazole Capsule Delayed Release 30 mg (Quantity Level Limit)
• Omeprazole Capsule Delayed Release 40 mg (Quantity Level Limit)
• Oxymetazoline Hydrochloride Nasal Solution 0.05% (Quantity Level Limit)
• Pantoprazole Sodium Enteric Coated Tablet 20 mg (Quantity Level Limit)
• Pantoprazole Sodium Enteric Coated Tablet 40 mg (Quantity Level Limit)
• Rosuvastatin Calcium Tablet 10 mg (Quantity Level Limit)
• Rosuvastatin Calcium Tablet 20 mg (Quantity Level Limit)
• Rosuvastatin Calcium Tablet 40 mg (Quantity Level Limit)
• Rosuvastatin Calcium Tablet 5 mg (Quantity Level Limit)
• Stribild Tablet (Quantity Level Limit)
• Terazosin Hydrochloride Capsule 5 mg (Base Equivalent)
• Tobramycin Nebulizer Solution 300 mg/ 5 mL (Quantity Level Limit)

January 2024 Additions:
 

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

January 2024 Removals:
 

• None

January 2024 Other Updates:
 

• None