Mercy Care home

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:

Covered medications
Step therapy requirements
Prior authorization (PA) requirements

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.

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)
Use the Behavioral Health Preferred Drug List Search Tool to find out if a certain medication is on the list.
Integrated Preferred Drug List (PDF) (updated quarterly): behavioral and physical health medications for Title 19/21 SMI members
Use the Integrated Preferred Drug List Search Tool to find out if a certain medication is on the list.
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
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

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.

AHCCCS Fee-For-Service Prior Authorization Criteria for Non-Preferred Drugs (PDF): For medications not on the fomulary and don't have a specific PA guideline
AHCCCS Fee-For-Service Prior Authorization Criteria for Preferred Drugs (PDF): For medications on the formulary but don't have a specific PA guideline

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:

Visit CoverMyMeds or call 1-866-452-5017

Visit SureScripts or call 1-866-797-3239

Here are the guidelines for: AHCCCS Fee-For-Service Program Pharmacy Prior Authorization Criteria (PDF).

Mercy Care PA guidelines (* also applies to Non-Title 19/21 Non-SMI members) for:

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.

Opioids Long and Short Acting (PDF)

Sublocade-Brixadi (PDF

Xolair (PDF)

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.

Drugs with QT Prolonging Effects (PDF)

Behavioral Health Lab Monitoring (PDF)

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.

Register: Go to CSPMP. 
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.
Log in. Then, you’ll be able to complete your registration profile with your CSPMP ID and DEA number.
Fill out the Registration Details and certify that the application is complete and accurate. Then, Print Certificate.

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

February 2025

Additions:

Colchicine 0.6 mg capsule
Estradiol valerate 20 mg per mL oil (Quantity Limit)
Estradiol valerate 40 mg per mL oil (Quantity Limit)
Omnipod 5 (Dexcom G7/G6) intro gen 5 kit (Prior Authorization, Quantity Limit)
Omnipod 5 (Dexcom G7/G6) pods (Prior Authorization, Quantity Limit)
Omnipod 5 (Libre 2 plus G6) kit (Prior Authorization, Quantity Limit)
Omnipod 5 (Libre 2 plus G6) pods (Prior Authorization, Quantity Limit)
Omnipod DASH gen 4 intro kit (Prior Authorization, Quantity Limit)
Omnipod DASH gen 4 PDM kit (Prior Authorization, Quantity Limit)
Omnipod DASH gen 4 pods (Prior Authorization, Quantity Limit)
Omnipod Go 10 unit per 24 hour kit (Prior Authorization, Quantity Limit)
Omnipod Go 15 unit per 24 hour kit (Prior Authorization, Quantity Limit)
Omnipod Go 20 unit per 24 hour kit (Prior Authorization, Quantity Limit)
Omnipod Go 25 unit per 24 hour kit (Prior Authorization, Quantity Limit)
Omnipod Go 30 unit per 24 hour kit (Prior Authorization, Quantity Limit)
Omnipod Go 35 unit per 24 hour kit (Prior Authorization, Quantity Limit)
Omnipod Go 40 unit per 24 hour kit (Prior Authorization, Quantity Limit)
Sodium sulfate 17.5 gm / Potassium sulfate 3.13 gm / Magnesium sulfate 1.6 gm per 177 mL solution (Quantity Limit)
Twiist refill kit (Prior Authorization, Quantity Limit)
Twiist refill kit/Infusion set (Prior Authorization, Quantity Limit)
Twiist starter kit (Prior Authorization, Quantity Limit)

Removals:

Urine Glucose-Ketones Test Strips

Other Updates:

None

January 2025

Additions:

Eletriptan hydrobromide 20 mg tablet
Eletriptan hydrobromide 40 mg tablet
Maraviroc 150 mg tablet (Prior Authorization)
Maraviroc 300 mg tablet (Prior Authorization)
Nebivolol 10 mg tablet
Nebivolol 2.5 mg tablet
Nebivolol 20 mg tablet
Nebivolol 5 mg tablet
Voriconazole 200 mg tablet
Voriconazole 50 mg tablet

Removals:

Haegarda 2000 unit solution
Haegarda 3000 unit solution
Selzentry 150 mg tablet
Selzentry 300 mg tablet
Truvada 100 mg / 150 mg tablet
Truvada 200 mg / 300 mg tablet
Tyblume 0.1 mg / 20 mcg chewable tablet
Viread 40 mg per gm powder

Other Updates:

None

December 2024

Additions:

None

Removals:

None

Other Updates:

None

November 2024

Additions:

Baclofen 5 mg per 5 mL solution (Quantity Limit)
Banzel 200 mg tablet (Quantity Limit)
Banzel 400 mg tablet (Quantity Limit)
Banzel 40 mg per mL suspension (Quantity Limit)
Clobazam 10 mg tablet (Quantity Limit)
Clobazam 2.5 mg per mL suspension (Quantity Limit)
Clobazam 20 mg tablet (Quantity Limit)
Ojemda 100 mg tablet (Prior Authorization, Quantity Limit)
Ojemda 25 mg per mL (Prior Authorization, Quantity Limit)
Rufinamide 200 mg tablet (Quantity Limit)
Rufinamide 400 mg tablet (Quantity Limit)

Removals:

None

Other Updates:

Entresto 15 mg / 16 mg sprinkle capsule (Removed Prior Authorization, Added Quantity Limit)
Entresto 24 mg / 26 mg tablet (Removed Prior Authorization, Added Quantity Limit)
Entresto 49 mg / 51 mg tablet (Removed Prior Authorization, Added Quantity Limit)
Entresto 6 mg / 6 mg sprinkle capsule (Removed Prior Authorization, Added Quantity Limit)
Entresto 97 mg / 103 mg tablet (Removed Prior Authorization, Added Quantity Limit)

October 2024

Additions:

Aimovig Auto-Injector 140 mg per mL (Prior Authorization)
Aimovig Auto-Injector 70 mg per mL (Prior Authorization)
AirDuo RespiClick powder breath 113-14 mcg per actuation inhalation
AirDuo RespiClick powder breath 232-14 mcg per actuation inhalation
AirDuo RespiClick powder breath 55-14 mcg per actuation inhalation
Amphetamine-dextroamphetamine ER 10 mg capsule (Quantity Limit, Age Limit)
Amphetamine-dextroamphetamine ER 15 mg capsule (Quantity Limit, Age Limit)
Amphetamine-dextroamphetamine ER 20 mg capsule (Quantity Limit, Age Limit)
Amphetamine-dextroamphetamine ER 25 mg capsule (Quantity Limit, Age Limit)
Amphetamine-dextroamphetamine ER 30 mg capsule (Quantity Limit, Age Limit)
Amphetamine-dextroamphetamine ER 5 mg capsule (Quantity Limit, Age Limit)
Brixadi Monthly Prefilled Syringe 128 mg per 0.36 mL (Medical Prior Authorization, Buy & Bill)
Brixadi Monthly Prefilled Syringe 64 mg per 0.18 mL (Medical Prior Authorization, Buy & Bill)
Brixadi Monthly Prefilled Syringe 96 mg per 0.27 mL (Medical Prior Authorization, Buy & Bill)
Brixadi Weekly Prefilled Syringe 16mg per 0.32 mL (Medical Prior Authorization, Buy & Bill)
Brixadi Weekly Prefilled Syringe 24 mg per 0.48 mL (Medical Prior Authorization, Buy & Bill)
Brixadi Weekly Prefilled Syringe 32 mg per 0.64 mL (Medical Prior Authorization, Buy & Bill)
Brixadi Weekly Prefilled Syringe 8 mg per 0.16 mL (Medical Prior Authorization, Buy & Bill)
Dihydroergotamine mesylate 4 mg per mL nasal solution (Coverage Limited To NDC: 68682035710) (Prior Authorization)
Elidel 1% cream (Prior Authorization)
Insulin degludec 100 unit per mL vial
Insulin degludec FlexTouch 100 unit per mL pen-injector
Insulin degludec FlexTouch 200 unit per mL pen-injector
Opzelura 1.5% cream (Prior Authorization)
Xeljanz XR 11 mg tablet (Prior Authorization)
Xeljanz XR 22 mg tablet (Prior Authorization)

Removals:

Adderall XR 10 mg capsule
Adderall XR 15 mg capsule
Adderall XR 20 mg capsule
Adderall XR 25 mg capsule
Adderall XR 30 mg capsule
Adderall XR 5 mg capsule
Ajovy Auto-Injector 225 mg per 1.5 mL solution
Ajovy prefilled syringe 225 mg per 1.5 mL solution
Dupixent 100 mg per 0.67 mL prefilled syringe solution
Dupixent 200 mg per 1.14 mL pen-injector solution
Dupixent 200 mg per 1.14 mL prefilled syringe solution
Dupixent 300 mg per 2 mL pen-injector solution
Dupixent 300 mg per 2 mL prefilled syringe solution
Genotropin 12 mg reconstituted solution
Genotropin 5 mg cartridge
Kombiglyze XR 2.5 mg / 1000 mg tablet
Kombiglyze XR 5 mg / 1000 mg tablet
Kombiglyze XR 5 mg / 5000 mg tablet
Levemir 100 unit per mL vial
Levemir FlexPen 100 unit per mL pen-injector
Methylphenidate 10 mg per 5 mL solution
Methylphenidate 5 mg per 5 mL solution
Nesina 12.5 mg tablet
Nesina 25 mg tablet
Nesina 6.25 mg tablet
Omnitrope 10 mg per 1.5 mL solution cartridge
Omnitrope 5 mg per 1.5 mL solution cartridge
Omnitrope 5.8 mg reconstituted solution
Onglyza 2.5 mg tablet
Onglyza 5 mg tablet
Zomacton 10 mg reconstituted solution
Zomacton 5 mg reconstituted solution

Other Updates:

Metformin ER 500 mg tablet (Added Quantity Limit)
Metformin ER 750 mg tablet (Added Quantity Limit)

September 2024

Additions:

Adbry 300 mg per 2 mL auto-injector solution (Prior Authorization)
Rextovy 4 mg per 0.25 mL nasal spray

Removals:

None

Other Updates:

Sprycel 20 mg tablet (Brand Preferred)
Sprycel 50 mg tablet (Brand Preferred)
Sprycel 70 mg tablet (Brand Preferred)
Sprycel 80 mg tablet (Brand Preferred)
Sprycel 100 mg tablet (Brand Preferred)
Sprycel 140 mg tablet (Brand Preferred)

August 2024

Additions:

Adalimumab-ADBM 10 mg per 0.2 mL (2 Syringe) prefilled syringe kit (Prior Authorization)
Adalimumab-ADBM 20 mg per 0.4 mL (2 Syringe) prefilled syringe kit (Prior Authorization)
Adalimumab-ADBM 40 mg per 0.8 mL (2 Pen) auto-injector kit (Prior Authorization)
Adalimumab-ADBM 40 mg per 0.8 mL (2 Syringe) prefilled syringe kit (Prior Authorization)
Adalimumab-ADBM 40 mg per 0.8 mL (CD/UC/HS Starter) auto-injector kit (Prior Authorization)
Adalimumab-ADBM 40 mg per 0.8 mL (Psoriasis/Uveit Starter) auto-injector kit (Prior Authorization)
Hadlima 40 mg per 0.4 mL solution prefilled syringe (Prior Authorization)
Hadlima 40 mg per 0.8 mL solution prefilled syringe (Prior Authorization)
Hadlima PushTouch 40 mg per 0.4 mL solution auto-injector (Prior Authorization)
Hadlima PushTouch 40 mg per 0.8 mL solution auto-injector (Prior Authorization)
Simlandi 40 mg per 0.4 mL (1 Pen) auto-injector kit (Prior Authorization)
Simlandi 40 mg per 0.4 mL (2 Pen) auto-injector kit (Prior Authorization)

Removals:

Humira 10 mg per 0.1 mL (2 Syringe) prefilled syringe kit
Humira 20 mg per 0.2 mL (2 Syringe) prefilled syringe kit
Humira 20 mg per 0.2 mL (2 Syringe) prefilled syringe kit
Humira 40 mg per 0.4 mL (2 pen) pen injector
Humira 40 mg per 0.4 mL (2 Syringe) prefilled syringe kit
Humira 40 mg per 0.8 mL (2 pen) pen injector
Humira 40 mg per 0.8 mL (2 Syringe) prefilled syringe kit
Humira 80 mg per 0.8 mL & 40 mg per 0.4 mL (Psoriasis/Uveit Starter) pen-injector kit
Humira 80 mg per 0.8 mL & 40 mg per 0.4 mL pediatric Crohns starter prefilled syringe kit
Humira 80 mg per 0.8 mL (2 pen) pen injector kit
Humira 80 mg per 0.8 mL (CD/UC/HS Starter) pen-injector kit
Humira 80 mg per 0.8 mL (Pediatric UC Starter) pen-injector kit
Humira 80 mg per 0.8 mL pediatric Crohns starter prefilled syringe kit

Other Updates:

Albendazole 200 mg tablet (Removed Prior Authorization)
Derma-Smoothe 0.01% scalp oil (Added Quantity Limit Level)
Linezolid 600 mg tablet (Removed Prior Authorization, Added Quantity Limit Level)
Sofosbuvir-Velpatasvir 400 mg/100 mg tablet (Quantity Level Limit 168 Tablets Per Lifetime Added)

July 2024

Additions:

None

Removals:

None

Other Updates:

None

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

February 2025

Title 19/21 SMI Drug List Updates:

Additions:

Colchicine 0.6 mg capsule
Estradiol valerate 20 mg per mL oil (Quantity Limit)
Estradiol valerate 40 mg per mL oil (Quantity Limit)
Omnipod 5 (Dexcom G7/G6) intro gen 5 kit (Prior Authorization, Quantity Limit)
Omnipod 5 (Dexcom G7/G6) pods (Prior Authorization, Quantity Limit)
Omnipod 5 (Libre 2 plus G6) kit (Prior Authorization, Quantity Limit)
Omnipod 5 (Libre 2 plus G6) pods (Prior Authorization, Quantity Limit)
Omnipod DASH gen 4 intro kit (Prior Authorization, Quantity Limit)
Omnipod DASH gen 4 PDM kit (Prior Authorization, Quantity Limit)
Omnipod DASH gen 4 pods (Prior Authorization, Quantity Limit)
Omnipod Go 10 unit per 24 hour kit (Prior Authorization, Quantity Limit)
Omnipod Go 15 unit per 24 hour kit (Prior Authorization, Quantity Limit)
Omnipod Go 20 unit per 24 hour kit (Prior Authorization, Quantity Limit)
Omnipod Go 25 unit per 24 hour kit (Prior Authorization, Quantity Limit)
Omnipod Go 30 unit per 24 hour kit (Prior Authorization, Quantity Limit)
Omnipod Go 35 unit per 24 hour kit (Prior Authorization, Quantity Limit)
Omnipod Go 40 unit per 24 hour kit (Prior Authorization, Quantity Limit)
Sodium sulfate 17.5 gm / Potassium sulfate 3.13 gm / Magnesium sulfate 1.6 gm per 177 mL solution (Quantity Limit)
Twiist refill kit (Prior Authorization, Quantity Limit)
Twiist refill kit/Infusion set (Prior Authorization, Quantity Limit)
Twiist starter kit (Prior Authorization, Quantity Limit)

Removals:

Urine Glucose-Ketones Test Strips

Other Updates:

None

Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

January 2025

Title 19/21 SMI Drug List Updates:

Additions:

Eletriptan hydrobromide 20 mg tablet
Eletriptan hydrobromide 40 mg tablet
Maraviroc 150 mg tablet (Prior Authorization)
Maraviroc 300 mg tablet (Prior Authorization)
Nebivolol 10 mg tablet
Nebivolol 2.5 mg tablet
Nebivolol 20 mg tablet
Nebivolol 5 mg tablet
Voriconazole 200 mg tablet
Voriconazole 50 mg tablet

Removals:

Haegarda 2000 unit solution
Haegarda 3000 unit solution
Selzentry 150 mg tablet
Selzentry 300 mg tablet
Truvada 100 mg / 150 mg tablet
Truvada 200 mg / 300 mg tablet
Tyblume 0.1 mg / 20 mcg chewable tablet
Viread 40 mg per gm powder

Other Updates:

None

Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

December 2024

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

November 2024

Title 19/21 SMI Drug List Updates:

Additions:

Baclofen 5 mg per 5 mL solution (Quantity Limit)
Banzel 200 mg tablet (Quantity Limit)
Banzel 400 mg tablet (Quantity Limit)
Banzel 40 mg per mL suspension (Quantity Limit)
Clobazam 10 mg tablet (Quantity Limit)
Clobazam 2.5 mg per mL suspension (Quantity Limit)
Clobazam 20 mg tablet (Quantity Limit)
Ojemda 100 mg tablet (Prior Authorization, Quantity Limit)
Ojemda 25 mg per mL (Prior Authorization, Quantity Limit)
Rufinamide 200 mg tablet (Quantity Limit)
Rufinamide 400 mg tablet (Quantity Limit)

Removals:

None

Other Updates:

Entresto 15 mg / 16 mg sprinkle capsule (Removed Prior Authorization, Added Quantity Limit)
Entresto 24 mg / 26 mg tablet (Removed Prior Authorization, Added Quantity Limit)
Entresto 49 mg / 51 mg tablet (Removed Prior Authorization, Added Quantity Limit)
Entresto 6 mg / 6 mg sprinkle capsule (Removed Prior Authorization, Added Quantity Limit)
Entresto 97 mg / 103 mg tablet (Removed Prior Authorization, Added Quantity Limit)

Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

October 2024

Title 19/21 SMI Drug List Updates:

Additions:

Aimovig Auto-Injector 140 mg per mL (Prior Authorization)
Aimovig Auto-Injector 70 mg per mL (Prior Authorization)
AirDuo RespiClick powder breath 113-14 mcg per actuation inhalation
AirDuo RespiClick powder breath 232-14 mcg per actuation inhalation
AirDuo RespiClick powder breath 55-14 mcg per actuation inhalation
Amphetamine-dextroamphetamine ER 10 mg capsule (Quantity Limit, Age Limit)
Amphetamine-dextroamphetamine ER 15 mg capsule (Quantity Limit, Age Limit)
Amphetamine-dextroamphetamine ER 20 mg capsule (Quantity Limit, Age Limit)
Amphetamine-dextroamphetamine ER 25 mg capsule (Quantity Limit, Age Limit)
Amphetamine-dextroamphetamine ER 30 mg capsule (Quantity Limit, Age Limit)
Amphetamine-dextroamphetamine ER 5 mg capsule (Quantity Limit, Age Limit)
Brixadi Monthly Prefilled Syringe 128 mg per 0.36 mL (Medical Prior Authorization, Buy & Bill)
Brixadi Monthly Prefilled Syringe 64 mg per 0.18 mL (Medical Prior Authorization, Buy & Bill)
Brixadi Monthly Prefilled Syringe 96 mg per 0.27 mL (Medical Prior Authorization, Buy & Bill)
Brixadi Weekly Prefilled Syringe 16mg per 0.32 mL (Medical Prior Authorization, Buy & Bill)
Brixadi Weekly Prefilled Syringe 24 mg per 0.48 mL (Medical Prior Authorization, Buy & Bill)
Brixadi Weekly Prefilled Syringe 32 mg per 0.64 mL (Medical Prior Authorization, Buy & Bill)
Brixadi Weekly Prefilled Syringe 8 mg per 0.16 mL (Medical Prior Authorization, Buy & Bill)
Dihydroergotamine mesylate 4 mg per mL nasal solution (Coverage Limited To NDC: 68682035710) (Prior Authorization)
Elidel 1% cream (Prior Authorization)
Insulin degludec 100 unit per mL vial
Insulin degludec FlexTouch 100 unit per mL pen-injector
Insulin degludec FlexTouch 200 unit per mL pen-injector
Opzelura 1.5% cream (Prior Authorization)
Xeljanz XR 11 mg tablet (Prior Authorization)
Xeljanz XR 22 mg tablet (Prior Authorization)

Removals:

Adderall XR 10 mg capsule
Adderall XR 15 mg capsule
Adderall XR 20 mg capsule
Adderall XR 25 mg capsule
Adderall XR 30 mg capsule
Adderall XR 5 mg capsule
Ajovy Auto-Injector 225 mg per 1.5 mL solution
Ajovy prefilled syringe 225 mg per 1.5 mL solution
Dupixent 100 mg per 0.67 mL prefilled syringe solution
Dupixent 200 mg per 1.14 mL pen-injector solution
Dupixent 200 mg per 1.14 mL prefilled syringe solution
Dupixent 300 mg per 2 mL pen-injector solution
Dupixent 300 mg per 2 mL prefilled syringe solution
Genotropin 12 mg reconstituted solution
Genotropin 5 mg cartridge
Kombiglyze XR 2.5 mg / 1000 mg tablet
Kombiglyze XR 5 mg / 1000 mg tablet
Kombiglyze XR 5 mg / 5000 mg tablet
Levemir 100 unit per mL vial
Levemir FlexPen 100 unit per mL pen-injector
Methylphenidate 10 mg per 5 mL solution
Methylphenidate 5 mg per 5 mL solution
Nesina 12.5 mg tablet
Nesina 25 mg tablet
Nesina 6.25 mg tablet
Omnitrope 10 mg per 1.5 mL solution cartridge
Omnitrope 5 mg per 1.5 mL solution cartridge
Omnitrope 5.8 mg reconstituted solution
Onglyza 2.5 mg tablet
Onglyza 5 mg tablet
Zomacton 10 mg reconstituted solution
Zomacton 5 mg reconstituted solution

Other Updates:

Metformin ER 500 mg tablet (Added Quantity Limit)
Metformin ER 750 mg tablet (Added Quantity Limit)

Non-Title 19/21 Drug List Updates:

Additions:

Brixadi Monthly Prefilled Syringe 128 mg per 0.36 mL (Medical Prior Authorization, Buy & Bill)
Brixadi Monthly Prefilled Syringe 64 mg per 0.18 mL (Medical Prior Authorization, Buy & Bill)
Brixadi Monthly Prefilled Syringe 96 mg per 0.27 mL (Medical Prior Authorization, Buy & Bill)
Brixadi Weekly Prefilled Syringe 16mg per 0.32 mL (Medical Prior Authorization, Buy & Bill)
Brixadi Weekly Prefilled Syringe 24 mg per 0.48 mL (Medical Prior Authorization, Buy & Bill)
Brixadi Weekly Prefilled Syringe 32 mg per 0.64 mL (Medical Prior Authorization, Buy & Bill)
Brixadi Weekly Prefilled Syringe 8 mg per 0.16 mL (Medical Prior Authorization, Buy & Bill)

Removals:

None

Other Updates:

None

September 2024

Additions:

Adbry 300 mg per 2 mL auto-injector solution (Prior Authorization)
Rextovy 4 mg per 0.25 mL nasal spray

Removals:

None

Other Updates:

Sprycel 20 mg tablet (Brand Preferred)
Sprycel 50 mg tablet (Brand Preferred)
Sprycel 70 mg tablet (Brand Preferred)
Sprycel 80 mg tablet (Brand Preferred)
Sprycel 100 mg tablet (Brand Preferred)
Sprycel 140 mg tablet (Brand Preferred)

Non-Title 19/21 Drug List Updates:

Additions:

Rextovy 4 mg per 0.25 mL nasal spray

Removals:

None

Other Updates:

None

August 2024

Title 19/21 SMI Drug List Updates:

Additions:

Adalimumab-ADBM 10 mg per 0.2 mL (2 Syringe) prefilled syringe kit (Prior Authorization)
Adalimumab-ADBM 20 mg per 0.4 mL (2 Syringe) prefilled syringe kit (Prior Authorization)
Adalimumab-ADBM 40 mg per 0.8 mL (2 Pen) auto-injector kit (Prior Authorization)
Adalimumab-ADBM 40 mg per 0.8 mL (2 Syringe) prefilled syringe kit (Prior Authorization)
Adalimumab-ADBM 40 mg per 0.8 mL (CD/UC/HS Starter) auto-injector kit (Prior Authorization)
Adalimumab-ADBM 40 mg per 0.8 mL (Psoriasis/Uveit Starter) auto-injector kit (Prior Authorization)
Hadlima 40 mg per 0.4 mL solution prefilled syringe (Prior Authorization)
Hadlima 40 mg per 0.8 mL solution prefilled syringe (Prior Authorization)
Hadlima PushTouch 40 mg per 0.4 mL solution auto-injector (Prior Authorization)
Hadlima PushTouch 40 mg per 0.8 mL solution auto-injector (Prior Authorization)
Simlandi 40 mg per 0.4 mL (1 Pen) auto-injector kit (Prior Authorization)
Simlandi 40 mg per 0.4 mL (2 Pen) auto-injector kit (Prior Authorization)

Removals:

Humira 10 mg per 0.1 mL (2 Syringe) prefilled syringe kit
Humira 20 mg per 0.2 mL (2 Syringe) prefilled syringe kit
Humira 20 mg per 0.2 mL (2 Syringe) prefilled syringe kit
Humira 40 mg per 0.4 mL (2 pen) pen injector
Humira 40 mg per 0.4 mL (2 Syringe) prefilled syringe kit
Humira 40 mg per 0.8 mL (2 pen) pen injector
Humira 40 mg per 0.8 mL (2 Syringe) prefilled syringe kit
Humira 80 mg per 0.8 mL & 40 mg per 0.4 mL (Psoriasis/Uveit Starter) pen-injector kit
Humira 80 mg per 0.8 mL & 40 mg per 0.4 mL pediatric Crohns starter prefilled syringe kit
Humira 80 mg per 0.8 mL (2 pen) pen injector kit
Humira 80 mg per 0.8 mL (CD/UC/HS Starter) pen-injector kit
Humira 80 mg per 0.8 mL (Pediatric UC Starter) pen-injector kit
Humira 80 mg per 0.8 mL pediatric Crohns starter prefilled syringe kit

Other Updates:

Albendazole 200 mg tablet (Removed Prior Authorization)
Derma-Smoothe 0.01% scalp oil (Added Quantity Limit Level)
Linezolid 600 mg tablet (Removed Prior Authorization, Added Quantity Limit Level)
Sofosbuvir-Velpatasvir 400 mg/100 mg tablet (Quantity Level Limit 168 Tablets Per Lifetime Added)

Non-Title 19/21 Drug List Updates:

Additions:

Aripiprazole 2 mg tablet (Added to Crisis Formulary)
Aripiprazole 5 mg tablet (Added to Crisis Formulary)
Aripiprazole 10 mg tablet (Added to Crisis Formulary)
Aripiprazole 15 mg tablet (Added to Crisis Formulary)
Aripiprazole 20 mg tablet (Added to Crisis Formulary)
Aripiprazole 30 mg tablet (Added to Crisis Formulary)

Removals:

None

Other Updates:

None

July 2024

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

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.

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