Formulary search tool and updates

Stay up to date with your medicine. A formulary is a list of medicines we cover. It can help you manage your medicines and your loved ones’ medicines. 

Find out if your medicine is covered

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Your formulary search tool

There are many different things that you can do with your formulary search tool. Usted puede:

Search for your medicine by name or class
Find generic alternatives to your medicine
See if your medicine has quantity limits, has age limits, or requires prior authorization

October 2026 Additions:

Ninguna

October 2026 Removals:

Ninguna

October 2026 Other Updates:

Ninguna

September 2026 Additions:

Ozempic 1.5 mg Tablet (Step Therapy, Diagnosis Required, Quantity Level Limit)
Ozempic 4 mg Tablet (Step Therapy, Diagnosis Required, Quantity Level Limit)
Ozempic 9 mg Tablet (Step Therapy, Diagnosis Required, Quantity Level Limit)

September 2026 Removals:

Ninguna

September 2026 Other Updates:

Ninguna

August 2026 Additions:

Avtozma Injection 162 mg / 0.9 mL (Prior Authorization)
Avtozma Injection 200 mg / 10 mL (Prior Authorization)
Avtozma Injection 400 mg / 20 mL (Prior Authorization)
Avtozma Injection 80 mg / 4 mL (Prior Authorization)
Breztri 160-18-4.8 mg (Step Therapy, Quantity Level Limit)
Capsaicin Cream 0.1% (Quantity Level Limit)
Enoby Solution 60 mg / mL (Prior Authorization)
Fluphenazine Hydrochloride Tablet 1 mg (Age Limit, Quantity Level Limit)
Fluphenazine Hydrochloride Tablet 10 mg (Age Limit, Quantity Level Limit)
Fluphenazine Hydrochloride Tablet 2.5 mg (Age Limit, Quantity Level Limit)
Fluphenazine Hydrochloride Tablet 5 mg (Age Limit, Quantity Level Limit)
Lidocaine Cream 4% (Quantity Level Limit)
Pramoxine-Calamine Lotion 1-8% (Quantity Level Limit)
Prenatal Vitamin with Ferrous Carbonyl-Folic Acid (Quantity Level Limit)
Prenatal without Vitamin A With Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid (Quantity Level Limit)
Prenatal without Vitamin A With Ferrous Fumarate-Methylfolate-Folic Acid- Docosahexaenoic Acid (DHA) (Quantity Level Limit)
Prenatal-Ferrous Bisglycinate-Ferrous Protein Succinylate-Folic Acid-Calcium + Docosahexaenoic Acid (DHA) (Quantity Level Limit)
Tofacitinib Solution 1 mg / mL (Prior Authorization)
Tofacitinib Tablet 10 mg (Prior Authorization)
Tofacitinib Tablet 11 mg Extended Release (Prior Authorization)
Tofacitinib Tablet 22 mg Extended Release (Prior Authorization)
Tofacitinib Tablet 5 mg (Prior Authorization)

August 2026 Removals:

Bevespi Aerosol 9-4.8 mcg
Rinvoq Liquid Solution 1 mg / mL
Rinvoq Tablet 15 mg Extended Release
Rinvoq Tablet 30 mg Extended Release
Rinvoq Tablet 45 mg Extended Release
Prolia Injection 60 mg / mL

August 2026 Other Updates:

Ciclopirox Shampoo 1% (Remove Step Therapy)

July 2026 Additions:

Accu-Chek Aviva Plus Blood Glucose Test Strip (Quantity Level Limit)
Accu-Chek Guide Blood Glucose Test Strip (Quantity Level Limit)
Accu-Chek SmartView Blood Glucose Test Strip (Quantity Level Limit)
Accu-Chek Guide Blood Glucose Monitoring Kit (Quantity Level Limit)
Accu-Chek Guide Me Blood Glucose Monitoring Kit (Quantity Level Limit)

July 2026 Removals:

Ninguna

July 2026 Other Updates:

Ninguna

June 2026 Additions:

Acamprosate Calcium Tablet Delayed Release 333 mg (Quantity Level Limit)

June 2026 Removals:

Ninguna

June 2026 Other Updates:

Ninguna

May 2026 Additions:

Histex Pdx Drops 1.25 mg / mL
Tobramycin-Dexamethasone Ophthalmic Suspension 0.3-0.1%(Quantity Level Limit)
Tyrvaya Nasal Solution 0.03 mg / Actuations (Quantity Level Limit)

May 2026 Removals:

·       Clindamycin Phosphate Gel 1% (Once Daily)
·       Hyoscyamine Disintegrating Tablet 0.125 mg
·       Hyoscyamine Elixir 0.125 mg / 5 mL
·       Hyoscyamine Extended-Release Tablet 12 Hour 0.375 mg
·       Hyoscyamine Sublingual Tablet 0.125 mg
·       Hyoscyamine Tablet 0.125 mg

May 2026 Other Updates:

Isotretinoin (Remove Step Therapy)

April 2026 Additions:

*Omega-3 Fatty Acids Capsule 500 mg**
*Soap & Cleansers - Liquid***
Calcium Carbonate Chewable Tablet 1250 mg (500 mg Elemental Calcium)
Calcium Carbonate Tablet 1250 mg (500 mg Elemental Calcium)
Calcium Citrate Tablet 250 Mg
Sodium Bicarbonate Intravenous Solution 8.4%

April 2026 Removals:

*Omega-3 Fatty Acids Capsule Delayed Release 1200 mg**
*Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tablet 28-1 mg***
*Probiotic Product - Capsule Delayed Release**
Acetaminophen Disintegrating Tablet 80 mg
Calcium Carbonate-Cholecalciferol Tablet 600 mg-3.125 mcg (125 Unit)
Calcium Carbonate (Antacid) Chewable Tablet 400 mg
Calcium Carbonate-Vitamin D Tablet 600 mg-5 mg (200 Unit)
Carbonyl Iron Chewable Tablet 18 mg (Elemental Iron)
Carboxymethylcellulose-Glycerin Ophthalmic Solution 0.5-0.9%
Cyclopentolate Hydrochloride Ophthalmic Solution 2%
Dextromethorphan-Guaifenesin Liquid 10-200 mg / 5 mL
Epinephrine Solution Prefilled Syringe 0.3 mg / 0.3 mL (1:1000)
Glucose Chewable Tablet 5 GM
Heparin Sodium (Porcine) Prefilled Injection 5000 Unit / mL
Hydrocortisone Acetate Ointment 1%
Hydrocortisone Perivaginal Cream 1%
Iron-Vitamin C-Vitamin B12-Folic Acid Tablet 100-250-0.025-1 mg
Niacin Capsule Extended Release 500 mg
Paromomycin Sulfate Capsule 250 mg
Potassium Citrate & Citric Acid Powder Pack 3300-1002 mg
Salicylic Acid Liquid 3%
Sodium Chloride Aerosol Solution 0.9%
Tolnaftate Aerosol Powder 1%

April 2026 Other Updates:

Ninguna

March 2026 Additions:

Rezvoglar Injection 100 Units / mL

March 2026 Removals:

Ninguna

March 2026 Other Updates:

Ninguna

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)
Fiasp Flex Injection Touch
Fiasp Injection 100 Units / mL
Fiasp Penfil Injection U-100 units
Icatibant Acetate Syringe 30 mg/ 3 mL (Prior Authorization)
Imuldosa (Prior Authorization)
Lanthanum Carbonate Chewable Tablet 1000 mg (Elemental) (Quantity Level Limit, Step Therapy)
Lanthanum Carbonate Chewable Tablet 500 mg (Elemental) (Quantity Level Limit, Step Therapy)
Lanthanum Carbonate Chewable Tablet 750 mg (Elemental) (Quantity Level Limit, Step Therapy)
Moxifloxacin Hydrochloride 0.5% Solution (Quantity Level Limit)
Novolog Injection 100 Units / mL
Novolog Injection Flex Relion
Novolog Injection Flexpen
Novolog Injection Penfill
Novolog Mix Injection 70/30
Novolog Mix Injection Flex Relion
Novolog Mix Injection Flexpen
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
Insulin Lisp Injection Protamine
Insulin Lispro Injection 100 Units / mL
Insulin Lispro Injection Junior
Insulin Lispro Protamine & Lispro Injection 100 Units / mL (50-50)
Insulin Lispro Protamine & Lispro Injection 100 Units / mL (75-25)
Insulin Lispro Protamine & Lispro Suspension Pen-Injectable 100 Units / mL (50-50)
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

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:

Ninguna

January 2026 Removals:

Ninguna

January 2026 Other Updates:

Ninguna
December 2025 Additions:

*Bacillus Coagulans-Inulin Capsule**
*Lactobacillus Acidophilus-Pectin Tablet**
*Probiotic Product - Chewable Tablet**
*Probiotic Product - Tablet**
Saccharomyces Boulardii Capsule 250 mg

December 2025 Removals:

Ninguna

December 2025 Other Updates:

Ninguna

November 2025 Additions:

Clobetasol Propionate Foam 0.05% (Quantity Level 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:

Ninguna

October 2025 Additions:

Acyclovir Ointment 5% (Step Therapy, Quantity Level Limit)
Kerendia Tablet 40 mg (Prior Authorization)
Prezcobix Tablet 675-150 mg (Quantity Level Limit)
Rivaroxaban For Suspension 1 mg / mL (Quantity Level Limit, Age Limit)
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)

October 2025 Removals:

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

October 2025 Other Updates:

Ninguna

September 2025 Additions:

*B-Complex with Vitamin C & Folic Acid Tablet 0.8 mg***
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 Tablet 1 GM
Sodium Chloride Intravenous Solution 0.9%
Thiamine Hydrochloride Tablet 100 mg
Thiamine Mononitrate Tablet 100 mg
Vitamin E Capsule 180 mg (400 Unit)

September 2025 Removals:

Ninguna

September 2025 Other Updates:

Ninguna

August 2025 Additions:

Budesonide Aerosol 2 mg / Actuation Rectal Foam
Epysqli Injection 300 mg / 30 mL (Prior Authorization)
Exenatide Injection 10 mcg (Step Therapy, Quantity Level Limit)
Exenatide Injection 5 mcg (Step Therapy, Quantity Level Limit)
Kerendia Tablet 10 mg (Prior Authorization)
Kerendia Tablet 20 mg (Prior Authorization)
Mirabegron Tablet 25 mg Extended Release (Add Step Therapy, Quantity Level Limit)
Mirabegron Tablet 50 mg Extended Release (Add Step Therapy, Quantity Level Limit)
Mycophenolic Tablet 180 mg Delayed Release
Mycophenolic Tablet 360 mg Delayed Release
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 mcg (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:

Ninguna

July 2025 Additions:

*Lancet Devices***
*Lancets***
Bicillin L-A Injection 1200000 Units
Bicillin L-A Injection 600000 Units
Eltrombopag Olamine Powder Pack for Suspension 12.5 mg (Base Equivalent) (Quantity Level Limit, Prior Authorization)
Eltrombopag Olamine Powder Pack for Suspension 25 mg (Base Equivalent) (Quantity Level Limit, Prior Authorization)
Paxlovid Tablet Pack (Quantity Level Limit, Age Limit)
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:

OneTouch Kit Ultra 2 Kit with Device
One Touch Kit Verio Flex System Kit
One Touch Kit Verio Reflect Kit with Device
One Touch Test Ultra
One Touch Test Verio

July 2025 Other Updates:

Cefixime Capsule 400 mg (Quantity Level Limit)

June 2025 Additions:

Ivizia Dry Gel 0.5%

June 2025 Removals:

Kalydeco Tablet 150 mg
Kalydeco Granules 13.4 mg
Kalydeco Packet 25 mg
Kalydeco Packet 50 mg
Kalydeco Packet 75 mg
Orkambi Tablet 100-125 mg
Orkambi Tablet 200-125 mg
Orkambi Granules 75-94 mg
Orkambi Granules 100-125 mg
Orkambi Granules 150-188 mg
Symdeko Tablet 50-75 mg
Symdeko Tablet 100-150 mg
Trikafta Packet 59.5 mg
Trikafta Packet 75 mg
Trikafta Tablet

June 2025 Other Updates:

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

May 2025 Additions:

Arformoterol Nebulizer 15 mg / 2 mL (Quantity Level Limit)
Dapagliflozin – Metformin Tablet 10-1000 mg (Step Therapy, Quantity Level Limit)
Dapagliflozin – Metformin Tablet 5-1000 mg (Step Therapy, Quantity Level Limit)
Dapagliflozin Tablet 10 mg (Step Therapy, Quantity Level Limit)
Dapagliflozin Tablet 5mg (Step Therapy, Quantity Level Limit)
Diclofenac Sodium Gel 3%
Diphenhydramine Injection 50 mg/ mL
Itovebi Tablet 3 mg (Prior Authorization, Quantity Level Limit)
Itovebi Tablet 9 mg (Prior Authorization, Quantity Level Limit)
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

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:

Ninguna

April 2025 Removals:

Ninguna

April 2025 Other Updates:

Ninguna

March 2025 Additions:

Ninguna

March 2025 Removals:

Ninguna

March 2025 Other Updates:

Ninguna

February 2025 Additions:

Asmanex 120 Inhalation 220mcg (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 50 mcg (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)
Ingrezza Capsule 40 mg (Add Prior Authorization, Quantity Level Limit)
Ingrezza Capsule 40-80 mg (Add Prior Authorization, Quantity Level Limit)
Ingrezza Capsule 60 mg (Add Prior Authorization, Quantity Level Limit)
Ingrezza Capsule 80 mg (Add Prior Authorization, Quantity Level Limit)
Ingrezza Sprinkle Capsule 40 mg (Add Prior Authorization, Quantity Level Limit)
Ingrezza Sprinkle Capsule 60 mg (Add Prior Authorization, Quantity Level Limit)
Ingrezza Sprinkle Capsule 80 mg (Add Prior Authorization, Quantity Level Limit)
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, Quantity Level Limit)
Twiist Refills (Add Prior Authorization, Quantity Level Limit)

February 2025 Removals:

Austedo Tablet 12 mg
Austedo Tablet 9 mg
Austedo Tablet 6 mg
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
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 Kit Sensor
Freestyle Mis Reader
Freestyle Mis Reader
Qvar Redihaler Inhalation 40 mcg
Qvar Redihaler Inhalation 80 mcg
Testosterone (Androgel) Pak 1% (50mg)
Testosterone (Fortesta) Gel Pump 2%
Testosterone Gel 1%(25mg)
Testosterone Gel Pump 1%
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:

Ninguna

January 2025 Removals:

Ninguna

January 2025 Other Updates:

Ninguna
December 2024 Additions:

Ocrevus Injection Zunovo (Prior Authorization, Quantity Level Limit)

December 2024 Removals:

Ninguna

December 2024 Other Updates:

Ninguna

November 2024 Additions:

Baclofen Solution 5 mg / 5 mL (Quantity Level Limit)
Clobazam Suspension 2.5 mg/ mL (Prior Authorization, Quantity Level Limit)
Clobazam Tablet 10 mg (Prior Authorization, Quantity Level Limit)
Clobazam Tablet 20 mg (Prior Authorization, Quantity Level Limit)
Entresto Sprinkle Capsule (Prior Authorization, Quantity Level Limit)
Entresto Sprinkle Capsule (Prior Authorization, Quantity Level Limit)
Folivane-Ob Capsule 85 – 1 mg (Quantity Level Limit)
Libervant Buccal Film (Quantity Level Limit)
Liraglutide (Step Therapy, Quantity Level Limit)
Naloxone Hydrochloride Syringe 0.4 mg/ mL (Quantity Level Limit)
Ojemda Suspension (Prior Authorization, Quantity Level Limit)
Ojemda Tablet 100 mg (Prior Authorization, Quantity Level Limit)
Rextovy Nasal Spray (Quantity Level Limit)
Rufinamide Suspension 40 mg / mL (Prior Authorization, Quantity Level Limit)
Rufinamide Tablet 200 mg (Prior Authorization, Quantity Level Limit)
Rufinamide Tablet 400 mg (Prior Authorization, Quantity Level Limit)
Tiotropium Bromide Handihaler (Quantity Level Limit)

November 2024 Removals:

Opsumit

November 2024 Other Updates:

Abilify Maintena (Remove Prior Authorization, Add Age Limit)
Aristada (Remove Prior Authorization, Add Age Limit)
Aristada Initio (Remove Prior Authorization, Add Age Limit)
Invega Hafyera (Remove Prior Authorization, Add Age Limit)
Invega Sustenna (Remove Prior Authorization, Add Age Limit)
Invega Trinza (Remove Prior Authorization, Add Age Limit)
Pregabalin Capsule 100 mg (Remove Prior Authorization)
Pregabalin Capsule 150 mg (Remove Prior Authorization)
Pregabalin Capsule 200 mg (Remove Prior Authorization)
Pregabalin Capsule 225 mg (Remove Prior Authorization)
Pregabalin Capsule 25 mg (Remove Prior Authorization)
Pregabalin Capsule 300 mg (Remove Prior Authorization)
Pregabalin Capsule 50 mg (Remove Prior Authorization)
Pregabalin Capsule 75 mg (Remove Prior Authorization)
Risperidone Injection (Remove Prior Authorization, Add Age Limit)
Sevelamer Carbonate Tablet 800 mg (Remove Step Therapy)

October 2024 Additions:

Ninguna

October 2024 Removals:

Ninguna

October 2024 Other Updates:

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

September 2024 Additions:

Ninguna

September 2024 Removals:

Ninguna

September 2024 Other Updates:

Ninguna

August 2024 Additions:

Austedo Extended Release 30 mg (Quantity Level Limit, Prior Authorization)
Austedo Extended Release 36 mg (Quantity Level Limit, Prior Authorization)
Austedo Extended Release 42 mg (Quantity Level Limit, Prior Authorization)
Austedo Extended Release 48 mg (Quantity Level Limit, Prior Authorization)
Derma-Smooth Scalp Oil 0.01% (Quantity Level Limit)
Eletriptan Hydrobromide Tablet 20mg (Quantity Level Limit)
Eletriptan Hydrobromide Tablet 40 mg (Quantity Level Limit)
Nexletol Tablet 180 mg (Prior Authorization, Quantity Level Limit)
Rinvoq Oral Solution 1 mg/ mL (Prior Authorization)
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:

Ninguna

July 2024 Removals:

Ninguna

July 2024 Other Updates:

Ninguna

June 2024 Additions:

Ninguna

June 2024 Removals:

Ninguna

June 2024 Other Updates:

Mayvret Tablet 100-40 mg (Prior Authorization)
Mayvret Packet 50-20 mg (Prior Authorization)
Sofosbuvir-Velpatasvir Tablet 400-100 mg (Prior Authorization)

May 2024 Additions:

Adapalene Gel 0.3% (Step Therapy, Quantity Level Limit)
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)
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
Opill Tablet 0.075 mg
Oxycodone Hydrochloride Extended-Release Tablet 10 mg (Quantity Level Limit)
Oxycodone Hydrochloride Extended-Release Tablet 20 mg (Quantity Level Limit)
Oxycodone Hydrochloride Extended-Release Tablet 40 mg (Quantity Level Limit)
Oxycodone Hydrochloride Extended-Release Tablet 80 mg (Quantity Level Limit)

May 2024 Removals:

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

May 2024 Other Updates:

Acetaminophen Tablet 325 mg (Quantity Level Limit)
Acetaminophen Tablet 500 mg (Quantity Level Limit)
Acetaminophen Tablet Extended Release 650 mg (Quantity Level Limit)
Amphetamine-Dextroamphetamine Capsule Extended Release 24-hour 10 mg (Quantity Level Limit)
Amphetamine-Dextroamphetamine Capsule Extended Release 24-hour 15 mg (Quantity Level Limit)
Amphetamine-Dextroamphetamine Capsule Extended Release 24-hour 30 mg (Quantity Level Limit)
Amphetamine-Dextroamphetamine Capsule Extended Release 24-hour 5 mg (Quantity Level Limit)
Apixaban Tablet 2.5 mg (Quantity Level Limit)
Apixaban Tablet 5 mg (Quantity Level Limit)
Baclofen Tablet 10 mg (Quantity Level Limit)
Baclofen Tablet 20 mg (Quantity Level Limit)
Bupropion Hydrochloride Tablet 100 mg (Quantity Level Limit)
Carbamazepine Tablet Extended Release 12-hour 100 mg (Quantity Level Limit)
Carbamazepine Tablet Extended Release 12-hour 200 mg (Quantity Level Limit)
Celecoxib Capsule 400 mg (Quantity Level Limit)
Chlorzoxazone Tablet 500 mg (Quantity Level Limit)
Ciclopirox Olamine Cream 0.77% (Step Therapy)
Cyclobenzaprine Hydrochloride Tablet 10 mg (Quantity Level Limit)
Cyclobenzaprine Hydrochloride Tablet 5 mg (Quantity Level Limit)
Dantrolene Sodium Capsule 100 mg (Quantity Level Limit)
Dantrolene Sodium Capsule 25 mg (Quantity Level Limit)
Dantrolene Sodium Capsule 50 mg (Quantity Level Limit)
Dextroamphetamine Sulfate Capsule Extended Release 24-hour 10 mg (Quantity Level Limit)
Dextroamphetamine Sulfate Capsule Extended Release 24-hour 15 mg (Quantity Level Limit)
Dextroamphetamine Sulfate Tablet 10 mg (Quantity Level Limit)
Dextroamphetamine Sulfate Tablet 5 mg (Quantity Level Limit)
Febuxostat Tablet 40 mg (Quantity Level Limit)
Febuxostat Tablet 80 mg (Quantity Level Limit)
Galantamine Hydrobromide Oral Solution 4 mg/ mL (Quantity Level Limit)
Ibuprofen Capsule 200 mg (Quantity Level Limit)
Ibuprofen Tablet 200 mg (Quantity Level Limit)
Lamotrigine Tablet 100 mg (Quantity Level Limit)
Lamotrigine Tablet 150 mg (Quantity Level Limit)
Lamotrigine Tablet 200 mg (Quantity Level Limit)
Lamotrigine Tablet 25 mg (Quantity Level Limit)
Lamotrigine Tablet Chewable Dispersible 5 mg (Quantity Level Limit)
Leflunomide Tablet 10 mg (Quantity Level Limit)
Leflunomide Tablet 20 mg (Quantity Level Limit)
Levetiracetam Tablet 1000 mg (Quantity Level Limit)
Levetiracetam Tablet 500 mg (Quantity Level Limit)
Levetiracetam Tablet 750 mg (Quantity Level Limit)
Mavyret Powder Pack 50-20 mg (Quantity Level Limit)
Meloxicam Tablet 15 mg (Quantity Level Limit)
Methocarbamol Tablet 500 mg (Quantity Level Limit)
Methocarbamol Tablet 750 mg (Quantity Level Limit)
Methylphenidate Hydrochloride Capsule Extended Release 10 mg (Cd) (Quantity Level Limit)
Methylphenidate Hydrochloride Capsule Extended Release 20 mg (Cd) (Quantity Level Limit)
Methylphenidate Hydrochloride Capsule Extended Release 30 mg (Cd) (Quantity Level Limit)
Methylphenidate Hydrochloride Capsule Extended Release 40 mg (Cd) (Quantity Level Limit)
Methylphenidate Hydrochloride Capsule Extended Release 50 Mg (Cd) (Quantity Level Limit)
Methylphenidate Hydrochloride Capsule Extended Release 60 Mg (Cd) (Quantity Level Limit)
Methylphenidate Hydrochloride Chewable Tablet 10 mg (Quantity Level Limit)
Methylphenidate Hydrochloride Chewable Tablet 2.5 mg (Quantity Level Limit)
Methylphenidate Hydrochloride Chewable Tablet 5 mg (Quantity Level Limit)
Methylphenidate Hydrochloride Solution 10 mg/ 5 mL (Quantity Level Limit)
Methylphenidate Hydrochloride Solution 5 mg/ 5 mL (Quantity Level Limit)
Methylphenidate Hydrochloride Tablet Extended Release 24-hour 18 mg (Quantity Level Limit)
Methylphenidate Hydrochloride Tablet Extended Release 24-hour 27 mg (Quantity Level Limit)
Methylphenidate Hydrochloride Tablet Extended Release 24-hour 36 mg (Quantity Level Limit)
Methylphenidate Hydrochloride Tablet Extended Release 24-hour 54 mg (Quantity Level Limit)
Nabumetone Tablet 500 mg (Quantity Level Limit)
Orphenadrine Citrate Tablet Extended Release 12-hour 100 mg (Quantity Level Limit)
Prochlorperazine Maleate Tablet 10 mg (Base Equivalent) (Quantity Level Limit)
Prochlorperazine Maleate Tablet 5 mg (Base Equivalent) (Quantity Level Limit)
Prochlorperazine Suppository 25 mg (Quantity Level Limit)
Rivaroxaban Tablet 10 mg (Quantity Level Limit)
Rivaroxaban Tablet 15 mg (Quantity Level Limit)
Rivaroxaban Tablet 20 mg (Quantity Level Limit)
Ropinirole Hydrochloride Tablet Extended Release 24-hour 12 mg (Base Equivalent) (Quantity Level Limit)
Ropinirole Hydrochloride Tablet Extended Release 24-hour 2 mg (Base Equivalent) (Quantity Level Limit)
Ropinirole Hydrochloride Tablet Extended Release 24-hour 4 mg (Base Equivalent) (Quantity Level Limit)
Ropinirole Hydrochloride Tablet Extended Release 24-hour 6 mg (Base Equivalent) (Quantity Level Limit)
Tacrolimus Ointment 0.03% (Quantity Level Limit)
Tacrolimus Ointment 0.1% (Quantity Level Limit)
Tiagabine Hydrochloride Tablet 12 mg (Quantity Level Limit)
Tiagabine Hydrochloride Tablet 16 mg (Quantity Level Limit)
Tiagabine Hydrochloride Tablet 4 mg (Quantity Level Limit)
Topiramate Tablet 200 mg (Quantity Level Limit)
Venlafaxine Hydrochloride Capsule Extended Release 24-hour 150 mg (Base Equivalent) (Quantity Level Limit)

April 2024 Additions:

Xolair 300 mg /2 mL Prefilled Syringe (Prior Authorization)
Xolair 300 mg/2 mL Pen (Prior Authorization)
Xolair 75 mg/0.5 mL Pen (Prior Authorization)
Xolair 150 mg/ mL (Prior Authorization)

April 2024 Removals:

Ninguna

April 2024 Other Updates:

*Blood Glucose Monitoring Kit With Device*** (Quantity Level Limit)
Dabigatran 110 mg Capsule (Quantity Level Limit)

March 2024 Additions:

Zenpep Capsule 60000 Unit

March 2024 Removals:

Ninguna

March 2024 Other Updates:

Ninguna

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)
Aristada Initio Prefilled Syringe 675 mg/2.4 mL (Prior Authorization, Quantity Level Limit)
Dupixent Injection 100 mg/0.67 mL (Prior Authorization)
Dupixent Injection 200 mg/1.14 mL (Prior Authorization)
Dupixent Injection 200 mg (Prior Authorization)
Dupixent Injection 300 mg/2 mL (Prior Authorization)
Fesoterodine Fumarate Tablet 24 hour 4 mg (Step Therapy, Quantity Level Limit)
Fesoterodine Fumarate Tablet 24 hour 8 mg (Step Therapy, Quantity Level Limit)
Hadlima Auto-Injector 40 mg/0.4 mL (Prior Authorization)
Hadlima Auto-Injector 40mg /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 Vial
Insulin Lispro Injection 100 Units / mL
Insulin Lispro Injection Junior
Lantus Pen Injector
Lantus Vial
Lurasidone Hydrochloride Tablet 120 mg
Lurasidone Hydrochloride Tablet 20 mg
Lurasidone Hydrochloride Tablet 40 mg
Lurasidone Hydrochloride Tablet 60 mg
Lurasidone Hydrochloride Tablet 80 mg (Quantity Level Limit)
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)
Rexulti Tablet 0.25 mg (Prior Authorization)
Rexulti Tablet 0.5 mg (Prior Authorization)
Rexulti Tablet 1 mg (Prior Authorization)
Rexulti Tablet 2 mg (Prior Authorization)
Rexulti Tablet 3 mg (Prior Authorization)
Rexulti Tablet 4 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)
Vraylar Capsule 1.5-3 mg (Prior Authorization)
Vraylar Capsule 1.5 mg (Prior Authorization)
Vraylar Capsule 3 mg (Prior Authorization)
Vraylar Capsule 4.5 mg (Prior Authorization)
Vraylar Capsule 6 mg (Prior Authorization)

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 parche
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 40 mg/0.8 mL
Humira Pediatrics Injection Crohns
Humira Pediatrics 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 Protamine Injection FlexPen
Insulin Aspart FlexPen 70/30
Insulin Aspart Vial 70/30 mix
Insulin Glargine - Yfgn Pen Injector
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
Nayzilam
Novolog Mix Injection Flex ReliOn
Novolog ReliOn Injection 70/30
Salsalate Tablet 500 mg
Salsalate Tablet 750 mg
Tramadol Tablet 100 mg
Trelegy 100 Inhaler Ellipta
Trelegy 200 Inhaler Ellipta
Viokace Tablet 10440 Units
Viokace Tablet 20880 Units

February 2024 Other Updates:

Acarbose Tablet 100 mg (Quantity Level Limit)
Acarbose Tablet 25 mg (Quantity Level Limit)
Acarbose Tablet 50 mg (Quantity Level Limit)
Albuterol Sulfate Nebulizer Solution 0.083% (2.5 mg/3 mL) (Quantity Level Limit)
Albuterol Sulfate Nebulizer Solution 0.5% (5 mg/ mL) (Quantity Level Limit)
Alfuzosin Hydrochloride Tablet Extended Release 24 Hour 10 mg (Quantity Level Limit)
Alogliptin Benzoate Tablet 12.5 mg (Base Equivalent) (Quantity Level Limit)
Alogliptin Benzoate Tablet 25 mg (Base Equivalent) (Quantity Level Limit)
Alogliptin Benzoate Tablet 6.25 mg (Base Equivalent) (Quantity Level Limit)
Alogliptin-Metformin Hydrochloride Tablet 12.5-1000 mg (Quantity Level Limit)
Alogliptin-Metformin Hydrochloride Tablet 12.5-500 mg (Quantity Level Limit)
Alogliptin-Pioglitazone Tablet 12.5-15 mg (Quantity Level Limit)
Alogliptin-Pioglitazone Tablet 12.5-30 mg (Quantity Level Limit)
Alogliptin-Pioglitazone Tablet 12.5-45 mg (Quantity Level Limit)
Alogliptin-Pioglitazone Tablet 25-15 mg (Quantity Level Limit)
Alogliptin-Pioglitazone Tablet 25-30 mg (Quantity Level Limit)
Alogliptin-Pioglitazone Tablet 25-45 mg (Quantity Level Limit)
Alprazolam Tablet Extended Release 24 hour 0.5 mg (Quantity Level Limit)
Alprazolam Tablet Extended Release 24 hour 1 mg (Quantity Level Limit)
Alprazolam Tablet Extended Release 24 hour 2 mg (Quantity Level Limit)
Alprazolam Tablet Extended Release 24 hour 3 mg (Quantity Level Limit)
Amlodipine Besylate-Benazepril Hydrochloride Capsule 10-20 mg (Quantity Level Limit)
Amlodipine Besylate-Benazepril Hydrochloride Capsule 10-40 mg (Quantity Level Limit)
Amlodipine Besylate-Benazepril Hydrochloride Capsule 2.5-10 mg (Quantity Level Limit)
Amlodipine Besylate-Benazepril Hydrochloride Capsule 5-10 mg (Quantity Level Limit)
Amlodipine Besylate-Benazepril Hydrochloride Capsule 5-20 mg (Quantity Level Limit)
Amlodipine Besylate-Benazepril Hydrochloride Capsule 5-40 mg (Quantity Level Limit)
Anastrozole Tablet 1 mg (Quantity Level Limit)
Benazepril Hydrochloride Tablet 10 mg (Quantity Level Limit)
Benazepril Hydrochloride Tablet 20 mg (Quantity Level Limit)
Benazepril Hydrochloride Tablet 40 mg (Quantity Level Limit)
Benazepril Hydrochloride Tablet 5 mg (Quantity Level Limit)
Bicalutamide Tablet 50 mg (Quantity Level Limit)
Bimatoprost Ophthalmic Solution 0.03% (Quantity Level Limit)
Bisoprolol Fumarate Tablet 5 mg (Quantity Level Limit)
Buspirone Hydrochloride Tablet 10 mg (Quantity Level Limit)
Buspirone Hydrochloride Tablet 15 mg (Quantity Level Limit)
Buspirone Hydrochloride Tablet 5 mg (Quantity Level Limit)
Buspirone Hydrochloride Tablet 7.5 mg (Quantity Level Limit)
Candesartan Cilexetil Tablet 16 mg (Quantity Level Limit)
Candesartan Cilexetil Tablet 32 mg (Quantity Level Limit)
Candesartan Cilexetil Tablet 4 mg (Quantity Level Limit)
Candesartan Cilexetil Tablet 8 mg (Quantity Level Limit)
Candesartan Cilexetil-Hydrochlorothiazide Tablet 16-12.5 mg (Quantity Level Limit)
Candesartan Cilexetil-Hydrochlorothiazide Tablet 32-12.5 mg (Quantity Level Limit)
Candesartan Cilexetil-Hydrochlorothiazide Tablet 32-25 mg (Quantity Level Limit)
Carvedilol Tablet 25 mg (Quantity Level Limit)
Cetirizine Hydrochloride Tablet 10 mg (Quantity Level Limit)
Cetirizine Hydrochloride Tablet 5 mg (Quantity Level Limit)
Chlorpheniramine Maleate Tablet Extended Release 12 mg (Quantity Level Limit)
Cimetidine Tablet 300 mg (Quantity Level Limit)
Cimetidine Tablet 400 mg (Quantity Level Limit)
Cimetidine Tablet 800 mg (Quantity Level Limit)
Citalopram Hydrobromide Tablet 10 mg (Base Equivalent) (Quantity Level Limit)
Citalopram Hydrobromide Tablet 20 mg (Base Equivalent) (Quantity Level Limit)
Diltiazem Hydrochloride Capsule Extended Release 24 hour 120 mg (Quantity Level Limit)
Diltiazem Hydrochloride Coated Beads Capsule Extended Release 24 hour 120 mg (Quantity Level Limit)
Diltiazem Hydrochloride Extended Release Beads Capsule Extended Release 24 hour 120 mg (Quantity Level Limit)
Diltiazem Hydrochloride Extended Release Beads Capsule Extended Release 24 hour 300 mg (Quantity Level Limit)
Diltiazem Hydrochloride Extended Release Beads Capsule Extended Release 24 hour 360 mg (Quantity Level Limit)
Diltiazem Hydrochloride Extended Release Beads Capsule Extended Release 24 hour 420 mg (Quantity Level Limit)
Doxazosin Mesylate Tablet 8 mg (Quantity Level Limit)
Duloxetine Hydrochloride Enteric Coated Pellets Capsule 60 mg (Base Equivalent) (Quantity Level Limit)
Enalapril Maleate & Hydrochlorothiazide Tablet 10-25 mg (Quantity Level Limit)
Enalapril Maleate & Hydrochlorothiazide Tablet 5-12.5 mg (Quantity Level Limit)
Enalapril Maleate Tablet 10 mg (Quantity Level Limit)
Enalapril Maleate Tablet 2.5 mg (Quantity Level Limit)
Enalapril Maleate Tablet 20 mg (Quantity Level Limit)
Enalapril Maleate Tablet 5 mg (Quantity Level Limit)
Erlotinib Hydrochloride Tablet 100 mg (Base Equivalent) (Quantity Level Limit)
Erlotinib Hydrochloride Tablet 150 mg (Base Equivalent) (Quantity Level Limit)
Erlotinib Hydrochloride Tablet 25 mg (Base Equivalent) (Quantity Level Limit)
Esomeprazole Magnesium Capsule Delayed Release 40mg (Quantity Level Limit)
Estradiol & Norethindrone Acetate Tablet 0.5-0.1 mg (Quantity Level Limit)
Estradiol & Norethindrone Acetate Tablet 1-0.5 mg (Quantity Level Limit)
Exemestane Tablet 25 mg (Quantity Level Limit)
Ezetimibe Tablet 10 mg (Quantity Level Limit)
Famotidine Tablet 10 mg (Quantity Level Limit)
Famotidine Tablet 40 mg (Quantity Level Limit)
Felodipine Tablet Extended Release 24 hour 10 mg (Quantity Level Limit)
Felodipine Tablet Extended Release 24 hour 2.5 mg (Quantity Level Limit)
Felodipine Tablet Extended Release 24 hour 5 mg (Quantity Level Limit)
Fexofenadine-Pseudoephedrine Tablet Extended Release 12 hour 60-120 mg (Quantity Level Limit)
Finasteride Tablet 5 mg (Quantity Level Limit)
Flavoxate Hydrochloride Tablet 100 mg (Quantity Level Limit)
Fluoxetine Hydrochloride Capsule 20 mg (Quantity Level Limit)
Fluvoxamine Maleate Tablet 50 mg (Quantity Level Limit)
Fosinopril Sodium Tablet 10 mg (Quantity Level Limit)
Fosinopril Sodium Tablet 20 mg (Quantity Level Limit)
Fosinopril Sodium Tablet 40 mg (Quantity Level Limit)
Glipizide Tablet Extended Release 24 hour 10 mg (Quantity Level Limit)
Glipizide Tablet Extended Release 24 hour 2.5 mg (Quantity Level Limit)
Glipizide Tablet Extended Release 24 hour 5 mg (Quantity Level Limit)
Glipizide-Metformin Hydrochloride Tablet 2.5-250 mg (Quantity Level Limit)
Glipizide-Metformin Hydrochloride Tablet 2.5-500 mg (Quantity Level Limit)
Glipizide-Metformin Hydrochloride Tablet 5-500 mg (Quantity Level Limit)
Imatinib Mesylate Tablet 100 mg (Base Equivalent) (Quantity Level Limit)
Imatinib Mesylate Tablet 400 mg (Base Equivalent) (Quantity Level Limit)
Ipratropium-Albuterol Nebulizer Solution 0.5-2.5(3) mg/ 3 mL (Quantity Level Limit)
Irbesartan-Hydrochlorothiazide Tablet 300-12.5 mg (Quantity Level Limit)
Isosorbide Mononitrate Tablet Extended Release 24 hour 120 mg (Quantity Level Limit)
Isosorbide Mononitrate Tablet Extended Release 24 hour 30 mg (Quantity Level Limit)
Isosorbide Mononitrate Tablet Extended Release 24 hour 60 mg (Quantity Level Limit)
Lansoprazole Capsule Delayed Release 30 mg (Quantity Level Limit)
Letrozole Tablet 2.5 mg (Quantity Level Limit)
Levothyroxine Sodium Tablet 100 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 112 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 125 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 137 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 150 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 175 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 200 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 25 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 300 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 50 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 75 mcg (Quantity Level Limit)
Levothyroxine Sodium Tablet 88 mcg (Quantity Level Limit)
Lisinopril & Hydrochlorothiazide Tablet 10-12.5 mg (Quantity Level Limit)
Lisinopril & Hydrochlorothiazide Tablet 20-25 mg (Quantity Level Limit)
Loratadine & Pseudoephedrine Tablet Extended Release 12 hour 5-120 mg (Quantity Level Limit)
Loratadine Rapidly-Disintegrating Tablet 10 mg (Quantity Level Limit)
Loratadine Tablet 10 mg (Quantity Level Limit)
Losartan Potassium & Hydrochlorothiazide Tablet 100-12.5 mg (Quantity Level Limit)
Losartan Potassium & Hydrochlorothiazide Tablet 100-25 mg (Quantity Level Limit)
Losartan Potassium & Hydrochlorothiazide Tablet 50-12.5 mg (Quantity Level Limit)
Losartan Potassium Tablet 100 mg (Quantity Level Limit)
Losartan Potassium Tablet 25 mg (Quantity Level Limit)
Losartan Potassium Tablet 50 mg (Quantity Level Limit)
Mesalamine Cap Extended Release 24 hour 0.375 GM (Quantity Level Limit)
Metformin Hydrochloride Tablet Extended Release 24 hour 500 mg (Quantity Level Limit)
Metformin Hydrochloride Tablet Extended Release 24 hour 750 mg (Quantity Level Limit)
Metoprolol Succinate Tablet Extended Release 24 hour 100 mg (Tartrate Equivalent) (Quantity Level Limit)
Metoprolol Succinate Tablet Extended Release 24 hour 25 mg (Tartrate Equivalent) (Quantity Level Limit)
Metoprolol Succinate Tablet Extended Release 24 hour 50 mg (Tartrate Equivalent) (Quantity Level Limit)
Mirtazapine Orally Disintegrating Tablet 30 mg (Quantity Level Limit)
Mirtazapine Tablet 30 mg (Quantity Level Limit)
Mirtazapine Tablet 45 mg (Quantity Level Limit)
Nateglinide Tablet 120 mg (Quantity Level Limit)
Nateglinide Tablet 60 mg (Quantity Level Limit)
Nifedipine Tablet Extended Release 24 hour Osmotic Release 60 mg (Quantity Level Limit)
Nilotinib Hydrochloride Capsule 150 mg (Base Equivalent) (Quantity Level Limit)
Nilotinib Hydrochloride Capsule 200 mg (Base Equivalent) (Quantity Level Limit)
Nizatidine Capsule 150 mg (Quantity Level Limit)
Nizatidine Capsule 300 mg (Quantity Level Limit)
Norethindrone Acetate-Ethinyl Estradiol Tablet 0.5 mg-2.5 mcg (Quantity Level Limit)
Norethindrone Acetate-Ethinyl Estradiol Tablet 1 mg-5 mcg (Quantity Level Limit)
Norethindrone Tablet 0.35 mg (Quantity Level Limit)
Omeprazole Capsule Delayed Release 40 mg (Quantity Level Limit)
Oxazepam Capsule 10 mg (Age Limit)
Oxazepam Capsule 15 mg (Age Limit)
Oxazepam Capsule 30 mg (Age Limit)
Oxybutynin Chloride Syrup 5 mg/ 5mL (Quantity Level Limit)
Oxybutynin Chloride Tablet 5 mg (Quantity Level Limit)
Oxybutynin Chloride Tablet Extended Release 24 hour 10 mg (Quantity Level Limit)
Oxybutynin Chloride Tablet Extended Release 24 hour 15 mg (Quantity Level Limit)
Oxybutynin Chloride Tablet Extended Release 24 hour 5 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)
Polyethylene Glycol 3350 Oral Powder 17 GM/Scoop (Quantity Level Limit)
Prazosin Hydrochloride Capsule 1 mg (Quantity Level Limit)
Prazosin Hydrochloride Capsule 2 mg (Quantity Level Limit)
Prazosin Hydrochloride Capsule 5 mg (Quantity Level Limit)
Progesterone Capsule 100 mg (Quantity Level Limit)
Progesterone Capsule 200 mg (Quantity Level Limit)
Propranolol Hydrochloride Capsule Extended Release 24 hour 60 mg (Quantity Level Limit)
Quinapril Hydrochloride Tablet 10 mg (Quantity Level Limit)
Quinapril Hydrochloride Tablet 20 mg (Quantity Level Limit)
Quinapril Hydrochloride Tablet 40 mg (Quantity Level Limit)
Quinapril Hydrochloride Tablet 5 mg (Quantity Level Limit)
Quinapril-Hydrochlorothiazide Tablet 20-12.5 mg (Quantity Level Limit)
Quinapril-Hydrochlorothiazide Tablet 20-25 mg (Quantity Level Limit)
Ramipril Capsule 1.25 mg (Quantity Level Limit)
Ramipril Capsule 10 mg (Quantity Level Limit)
Ramipril Capsule 2.5 mg (Quantity Level Limit)
Ramipril Capsule 5 mg (Quantity Level Limit)
Repaglinide Tablet 0.5 mg (Quantity Level Limit)
Repaglinide Tablet 1 mg (Quantity Level Limit)
Repaglinide Tablet 2 mg (Quantity Level Limit)
Sertraline Hydrochloride Tablet 100 mg (Quantity Level Limit)
Sertraline Hydrochloride Tablet 25 mg (Quantity Level Limit)
Sprycel Tablet 20 mg (Quantity Level Limit)
Sunitinib Malate Capsule 50 mg (Base Equivalent) (Quantity Level Limit)
Terazosin Hydrochloride Capsule 10 mg (Base Equivalent) (Quantity Level Limit)
Terazosin Hydrochloride Capsule 2 mg (Base Equivalent) (Quantity Level Limit)
Terazosin Hydrochloride Capsule 5 mg (Base Equivalent) (Quantity Level Limit)
Testosterone Transdermal Gel 25 mg/ 2.5 GM (1%) (Quantity Level Limit)
Testosterone Transdermal Gel 50 mg / 5 GM (1%) (Quantity Level Limit)
Tobramycin Nebulizer Solution 300 mg / 5 mL (Quantity Level Limit)
Tolterodine Tartrate Tablet 1 mg (Quantity Level Limit)
Tolterodine Tartrate Tablet 2 mg (Quantity Level Limit)
Trandolapril Tablet 1 mg (Quantity Level Limit)
Trandolapril Tablet 2 mg (Quantity Level Limit)
Trandolapril Tablet 4 mg (Quantity Level Limit)
Valsartan Tablet 160 mg (Quantity Level Limit)
Valsartan Tablet 320 mg (Quantity Level Limit)
Valsartan Tablet 40 mg (Quantity Level Limit)
Valsartan Tablet 80 mg (Quantity Level Limit)
Verapamil Hydrochloride Capsule Extended Release 24 hour 240 mg (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:

Ninguna

January 2024 Other Updates:

Ninguna
December 2023 Additions:

Ninguna

December 2023 Removals:

Ninguna

December 2023 Other Updates:

Ninguna

November 2023 Additions:

Ciprofloxacin-Dexamethasone Otic Suspension 0.3-0.1% (Quantity Level Limit)
Dayvigo Tablet 10 mg (Prior Authorization, Quantity Level Limit)
Dayvigo Tablet 5 mg (Prior Authorization, Quantity Level Limit)
Gefitinib Tablet 250 mg (Prior Authorization, Quantity Level Limit)
Haegarda Injection 2000 unit (Prior Authorization)
Haegarda Injection 3000 unit (Prior Authorization)
Liqrev (Prior Authorization, Quantity Level Limit)
Phenylephrine-Mineral Oil-Petrolatum Rectal Ointment (Quantity Level Limit)
Takhzyro Injection 150 mg / mL (Prior Authorization, Quantity Level Limit)
Takhzyro Injection 300 / 2 mL (Prior Authorization, Quantity Level Limit)

November 2023 Removals:

Proctofoam Aerosol Hydrocortisone 1%

November 2023 Other Updates:

Auranofin Capsule 3 mg (Remove Prior Authorization)
Cabergoline Tablet 0.5 mg (Remove Prior Authorization)
Clotrimazole Cream 1% (Remove Step Therapy)
Darunavir Oral Suspension 100 mg / mL (Quantity Level Limit)
Darunavir Tablet 150 mg (Quantity Level Limit)
Darunavir Tablet 75 mg (Quantity Level Limit)
Diazepam Rectal Gel 10 mg 2's (Quantity Level Limit)
Diazepam Rectal Gel 2.5 mg 2s (Quantity Level Limit)
Diazepam Rectal Gel 20 mg 2's (Quantity Level Limit)
Efavirenz Capsule 200 mg (Quantity Level Limit)
Efavirenz Capsule 50 mg (Quantity Level Limit)
Ella Tablet 30 mg (Quantity Level Limit)
Escitalopram Solution 5 mg / 5 mL (Quantity Level Limit)
Fluconazole Tablet 100 mg (Quantity Level Limit)
Fluconazole Tablet 200 mg (Quantity Level Limit)
Fluconazole Tablet 50 mg (Quantity Level Limit)
Isentress Tablet 400 Mg (Base Equivalent) (Quantity Level Limit)
Itraconazole Capsule 100 mg (Quantity Level Limit)
Ivermectin Tablet 3 mg (Remove Prior Authorization)
Ketoconazole Tablet 200 mg (Quantity Level Limit)
Levocarnitine Oral Solution 1 GM / 10 mL (10%) (Remove Prior Authorization)
Levocarnitine Tablet 330 mg (Remove Prior Authorization)
Lopinavir-Ritonavir Solution 400-100 mg / 5 mL (80-20 mg / mL) (Quantity Level Limit)
Mavyret Tablet 100-40 mg (Quantity Level Limit)
Nayzilam Spray 5 mg (Quantity Level Limit)
Sofosbuvir-Velpatasvir Tablet 400-100 mg (Quantity Level Limit)
Stavudine Capsule 15 mg (Quantity Level Limit)
Stavudine Capsule 20 mg (Quantity Level Limit)
Terbinafine Hydrochloride Tablet 250 mg (Quantity Level Limit)
Tipranavir Capsule 250 mg (Quantity Level Limit)
Tivicay 10 mg (Base Equivalent) (Quantity Level Limit)
Tobramycin Nebulizer Solution 300 mg / 5 mL (Quantity Level Limit)
Tretinoin Capsule 10 mg (Add Prior Authorization)
Valtoco Spray 10 mg (Age Limit, Quantity Level Limit)
Valtoco Spray 15 mg (Age Limit, Quantity Level Limit)
Valtoco Spray 20 mg (Age Limit, Quantity Level Limit)
Valtoco Spray 5 mg (Age Limit, Quantity Level Limit)
Varenicline Tablet 0.5 mg (Quantity Level Limit)
Varenicline Tablet 1 mg (Quantity Level Limit)

October 2023 Additions:

Austedo Extended-Release Tablet Titration Kit (Prior Authorization, Quantity Level Limit)
Buprenorphine Extended-Release Solution Prefilled Syringe (Weekly) 8 mg / 0.16 mL (Quantity Level Limit)
Buprenorphine Extended-Release Solution Prefilled Syringe (Weekly) 16 mg / 0.32 mL (Quantity Level Limit)
Buprenorphine Extended-Release Solution Prefilled Syringe (Weekly) 24 mg / 0.48 mL (Quantity Level Limit)
Buprenorphine Extended-Release Solution Prefilled Syringe (Weekly) 32 mg / 0.64 mL (Quantity Level Limit)
Buprenorphine Extended-Release Solution Prefilled Syringe 128 mg / 0.36 mL (Quantity Level Limit)
Buprenorphine Extended-Release Solution Prefilled Syringe 64 mg / 0.18 mL (Quantity Level Limit)
Buprenorphine Extended-Release Solution Prefilled Syringe 96 mg / 0.27 mL (Quantity Level Limit)

October 2023 Removals:

Ninguna

October 2023 Other Updates:

Aripiprazole Intramuscular Extended-Release Suspension Prefilled Syringe 300 mg (Quantity Level Limit, Age Limit)
Aripiprazole Intramuscular Extended-Release Suspension Prefilled Syringe 400 mg (Quantity Level Limit, Age Limit)
Aripiprazole Intramuscular for Extended-Release Suspension 300 mg (Quantity Level Limit, Age Limit)
Aripiprazole Intramuscular for Extended-Release Suspension 400 mg (Quantity Level Limit, Age Limit)
Aripiprazole Lauroxil Intramuscular Extended-Release Suspension Prefilled Syringe 441 mg / 1.6 mL (Quantity Level Limit, Age Limit)
Aripiprazole Lauroxil Intramuscular Extended-Release Suspension Prefilled Syringe 662 mg / 2.4 mL (Quantity Level Limit, Age Limit)
Aripiprazole Lauroxil Intramuscular Extended-Release Suspension Prefilled Syringe882 mg / 3.2 mL (Quantity Level Limit, Age Limit)
Aripiprazole Lauroxil Intramuscular Extended-Release Suspension Prefilled Syringe 1064 mg / 3.9 mL (Quantity Level Limit, Age Limit)
Aripiprazole Tablet 10 mg (Quantity Level Limit, Age Limit)
Aripiprazole Tablet 15 mg (Quantity Level Limit, Age Limit)
Aripiprazole Tablet 2 mg (Quantity Level Limit, Age Limit)
Aripiprazole Tablet 20 mg (Quantity Level Limit, Age Limit)
Aripiprazole Tablet 30 mg (Quantity Level Limit, Age Limit)
Aripiprazole Tablet 5 mg (Quantity Level Limit, Age Limit)
Armodafinil Tablet 150 mg (Quantity Level Limit, Age Limit)
Armodafinil Tablet 200 mg (Age Limit)
Armodafinil Tablet 250 mg (Quantity Level Limit, Age Limit)
Armodafinil Tablet 50 mg (Quantity Level Limit, Age Limit)
Clozapine Tab 100 mg (Quantity Level Limit, Age Limit)
Clozapine Tab 200 mg (Quantity Level Limit, Age Limit)
Clozapine Tab 25 mg (Quantity Level Limit, Age Limit)
Clozapine Tab 50 mg (Quantity Level Limit, Age Limit)
Desvenlafaxine Succinate Tablet Extended Release 24-hour 25 mg (Base Equivalent) (Quantity Level Limit, Age Limit)
Desvenlafaxine Succinate Tablet Extended Release 24-hour 50 mg (Base Equivalent) (Quantity Level Limit, Age Limit)
Desvenlafaxine Succinate Tablet Extended Release24 hour 100 mg (Base Equivalent) (Quantity Level Limit, Age Limit)
Fluphenazine Decanoate Injection 25 mg/ mL
Haloperidol Lactate Oral Concentration 2 mg / mL (Quantity Level Limit, Age Limit)
Haloperidol Tablet 0.5 mg (Quantity Level Limit, Age Limit)
Haloperidol Tablet 1 mg (Quantity Level Limit, Age Limit)
Haloperidol Tablet 10 mg (Quantity Level Limit, Age Limit)
Haloperidol Tablet 2 mg (Quantity Level Limit, Age Limit)
Haloperidol Tablet 20 mg (Quantity Level Limit, Age Limit)
Haloperidol Tablet 5 mg (Quantity Level Limit, Age Limit)
Lithium Carbonate Capsule 150 mg (Quantity Level Limit, Age Limit)
Lithium Carbonate Capsule 300 mg (Quantity Level Limit, Age Limit)
Lithium Carbonate Capsule 600 mg (Quantity Level Limit, Age Limit)
Lithium Carbonate Tablet 300 mg (Quantity Level Limit, Age Limit)
Lithium Carbonate Tablet Extended Release 300 mg (Quantity Level Limit, Age Limit)
Lithium Carbonate Tablet Extended Release 450 mg (Quantity Level Limit, Age Limit)
Loxapine Succinate Capsule 10 mg (Quantity Level Limit, Age Limit)
Loxapine Succinate Capsule 25 mg (Quantity Level Limit, Age Limit)
Loxapine Succinate Capsule 5 mg (Quantity Level Limit, Age Limit)
Loxapine Succinate Capsule 50 mg (Quantity Level Limit, Age Limit)
Olanzapine Orally Disintegrating Tablet 10 mg (Quantity Level Limit, Age Limit)
Olanzapine Orally Disintegrating Tablet 15 mg (Quantity Level Limit, Age Limit)
Olanzapine Orally Disintegrating Tablet 20 mg (Quantity Level Limit, Age Limit)
Olanzapine Orally Disintegrating Tablet 5 mg (Quantity Level Limit, Age Limit)
Olanzapine Tablet 10 mg (Quantity Level Limit, Age Limit)
Olanzapine Tablet 15 mg (Quantity Level Limit, Age Limit)
Olanzapine Tablet 2.5 mg (Quantity Level Limit, Age Limit)
Olanzapine Tablet 20 mg (Quantity Level Limit, Age Limit)
Olanzapine Tablet 5 mg (Quantity Level Limit, Age Limit)
Olanzapine Tablet 7.5 mg (Quantity Level Limit, Age Limit)
Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 39 mg /0.25 mL (Quantity Level Limit, Age Limit)
Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 78 mg /0.5 mL (Quantity Level Limit, Age Limit)
Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 117 mg /0.75 mL (Quantity Level Limit, Age Limit)
Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 156 mg / mL (Quantity Level Limit, Age Limit)
Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 234 mg /1.5 mL (Quantity Level Limit, Age Limit)
Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 273 mg /0.875 mL (Quantity Level Limit, Age Limit)
Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 410 mg /1.315 mL (Quantity Level Limit, Age Limit)
Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 546 mg/ 1.75 mL (Quantity Level Limit, Age Limit)
Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 819 mg/ 2.625 mL (Quantity Level Limit, Age Limit)
Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 1,092 mg/ 3.5 mL (Quantity Level Limit, Age Limit)
Paliperidone Palmitate Extended-Release Suspension Prefilled Syringe 1,560 mg/ 5 mL (Quantity Level Limit, Age Limit)
Perphenazine Tablet 16 mg (Quantity Level Limit, Age Limit)
Perphenazine Tablet 2 mg (Quantity Level Limit, Age Limit)
Perphenazine Tablet 4 mg (Quantity Level Limit, Age Limit)
Perphenazine Tablet 8 mg (Quantity Level Limit, Age Limit)
Phenelzine Sulfate Tablet 15 mg (Quantity Level Limit, Age Limit)
Quetiapine Fumarate Tablet 100 mg (Quantity Level Limit, Age Limit)
Quetiapine Fumarate Tablet 200 mg (Quantity Level Limit, Age Limit)
Quetiapine Fumarate Tablet 25 mg (Quantity Level Limit, Age Limit)
Quetiapine Fumarate Tablet 300 mg (Quantity Level Limit, Age Limit)
Quetiapine Fumarate Tablet 400 mg (Quantity Level Limit, Age Limit)
Quetiapine Fumarate Tablet 50 mg (Quantity Level Limit, Age Limit)
Quetiapine Fumarate Tablet Sustained Release 24-hour 150 mg (Quantity Level Limit, Age Limit)
Quetiapine Fumarate Tablet Sustained Release 24-hour 200 mg (Quantity Level Limit, Age Limit)
Quetiapine Fumarate Tablet Sustained Release 24-hour 300 mg (Quantity Level Limit, Age Limit)
Quetiapine Fumarate Tablet Sustained Release 24-hour 400 mg (Quantity Level Limit, Age Limit)
Quetiapine Fumarate Tablet Sustained Release 24-hour 50 mg (Quantity Level Limit, Age Limit)
Ramelteon Tablet 8 mg (Quantity Level Limit, Age Limit)
Risperidone Microspheres for Intramuscular Extended-Release Suspension 12.5 mg (Quantity Level Limit, Age Limit)
Risperidone Microspheres for Intramuscular Extended-Release Suspension 25 mg (Quantity Level Limit, Age Limit)
Risperidone Microspheres for Intramuscular Extended-Release Suspension 37.5 mg (Quantity Level Limit, Age Limit)
Risperidone Microspheres for Intramuscular Extended-Release Suspension 50 mg (Quantity Level Limit, Age Limit)
Risperidone Orally Disintegrating Tab 0.25 mg (Quantity Level Limit, Age Limit)
Risperidone Orally Disintegrating Tab 0.5 mg (Quantity Level Limit, Age Limit)
Risperidone Orally Disintegrating Tab 1 mg (Quantity Level Limit, Age Limit)
Risperidone Orally Disintegrating Tab 2 mg (Quantity Level Limit, Age Limit)
Risperidone Orally Disintegrating Tab 3 mg (Quantity Level Limit, Age Limit)
Risperidone Orally Disintegrating Tab 4 mg (Quantity Level Limit, Age Limit)
Risperidone Solution 1 mg/ mL (Quantity Level Limit, Age Limit)
Risperidone Tablet 0.25 mg (Quantity Level Limit, Age Limit)
Risperidone Tablet 0.5 mg (Quantity Level Limit, Age Limit)
Risperidone Tablet 1 mg (Quantity Level Limit, Age Limit)
Risperidone Tablet 2 mg (Quantity Level Limit, Age Limit)
Risperidone Tablet 3 mg (Quantity Level Limit, Age Limit)
Risperidone Tablet 4 mg (Quantity Level Limit, Age Limit)
Thioridazine Hydrochloride Tablet 10 mg (Quantity Level Limit, Age Limit)
Thioridazine Hydrochloride Tablet 100 mg (Quantity Level Limit, Age Limit)
Thioridazine Hydrochloride Tablet 25 mg (Quantity Level Limit, Age Limit)
Thioridazine Hydrochloride Tablet 50 mg (Quantity Level Limit, Age Limit)
Thiothixene Capsule 1 mg (Quantity Level Limit, Age Limit)
Thiothixene Capsule 10 mg (Quantity Level Limit, Age Limit)
Thiothixene Capsule 2 mg (Quantity Level Limit, Age Limit)
Thiothixene Capsule 5 mg (Quantity Level Limit, Age Limit)
Trifluoperazine Hydrochloride Tablet 1 mg (Quantity Level Limit, Age Limit)
Trifluoperazine Hydrochloride Tablet 2 mg (Quantity Level Limit, Age Limit)
Trifluoperazine Hydrochloride Tablet 5 mg (Quantity Level Limit, Age Limit)
Trifluoperazine Hydrochloride Tablet10 mg (Quantity Level Limit, Age Limit)
Venlafaxine Hydrochloride Capsule Sustained Release 24-hour 150 mg (Base Equivalent) (Quantity Level Limit, Age Limit)
Venlafaxine Hydrochloride Capsule Sustained Release 24-hour 37.5 mg (Base Equivalent) (Quantity Level Limit, Age Limit)
Venlafaxine Hydrochloride Capsule Sustained Release 24-hour 75 mg (Base Equivalent) (Quantity Level Limit, Age Limit)
Venlafaxine Hydrochloride Tablet 100 mg (Quantity Level Limit, Age Limit)
Venlafaxine Hydrochloride Tablet 25 mg (Quantity Level Limit, Age Limit)
Venlafaxine Hydrochloride Tablet 37.5 mg (Quantity Level Limit, Age Limit)
Venlafaxine Hydrochloride Tablet 50 mg (Quantity Level Limit, Age Limit)
Venlafaxine Hydrochloride Tablet 75 mg (Quantity Level Limit, Age Limit)
Ziprasidone Hydrochloride Capsule 20 mg (Quantity Level Limit, Age Limit)
Ziprasidone Hydrochloride Capsule 40 mg (Quantity Level Limit, Age Limit)
Ziprasidone Hydrochloride Capsule 60 mg (Quantity Level Limit, Age Limit)
Ziprasidone Hydrochloride Capsule 80 mg (Quantity Level Limit, Age Limit)

September 2023 Additions:

Austedo Extended-Release Tablet Titration Kit (Prior Authorization, Quantity Level Limit)

September 2023 Removals:

Ninguna

September 2023 Other Updates:

Ninguna

August 2023 Additions:

*Multiple Vitamin Tablet**
*Pediatric Multiple Vitamin With Minerals Chewable Tablet**
*Pediatric Multiple Vitamins With Fluoride-Ferrous Drops 0.25-10 mg /mL**
*Pediatric Multiple Vitamins With Fluoride Solution 0.5 mg /mL***
*Pediatric Multiple Vitamins With Iron Drops 11 mg /mL**
Ascorbic Acid Chewable Tablet 250 mg
Ascorbic Acid Chewable Tablet 500 mg
Ascorbic Acid Tablet 1000 mg
Ascorbic Acid Tablet 250 mg
Ascorbic Acid Tablet 500 mg
Austedo Tablet Extended Release 24 hour 12 mg (Prior Authorization, Quantity Level Limit)
Austedo Tablet Extended Release 24 hour 24 mg (Prior Authorization, Quantity Level Limit)
Austedo Tablet Extended Release 24 hour 6 mg (Prior Authorization, Quantity Level Limit)
Calcium Carbonate-Cholecalciferol Chewable Tablet 500 mg-10 mcg (400 Unit)
Calcium Carbonate-Cholecalciferol Tablet 500 mg-3.125 mcg (125 Unit)
Calcium Carbonate-Vitamin D With Minerals Tablets 600 mg-200 Unit
Calcium Carbonate-Vitamin D With Minerals Tablets 600 mg-400 Unit
Calcium Tablet 500 mg
Calcium Tablet 600 mg
Carbonyl Iron Chewable Tablet 15 mg (Elemental Iron)
Carbonyl Iron Chewable Tablet 18 mg (Elemental Iron)
Carboxymethylcellulose-Glycerin Ophthalmic Solution 0.5-0.9%
Ferrous Fumarate Tablet 324 mg (106 mg Elemental Iron)
Ferrous Gluconate Tablet 240 mg (27 mg Elemental Iron)
Ferrous Gluconate Tablet 324 mg (37.5 mg Elemental Iron)
Ferrous Gluconate Tablet 324 mg (38 mg Elemental Iron)
Ferrous Sulfate Dried Tablet Extended Release 143 mg (45 mg Ferrous Equivalent)
Flavoring Agent - Liquid
Fluocinolone Acetonide Oil 0.01% (Body Oil) (Quantity Level Limit)
Folic Acid-Vitamin B6-Vitamin B12 Tablet 2.2-25-0.5 mg
Gelatin Capsules (Empty)
Glucose Urine Test- (Glucose Oxidase) Strip
Glycerin Liquid
Ibandronate Sodium Intravenous Solution 3 mg / 3 mL (Base Equivalent) (Quantity Level Limit)
Iron-Vitamin C-Vitamin B12-Folic Acid Tablet 100-250-0.025-1 mg
Ketone Blood Test Strip
Lactose Monohydrate Powder
Melatonin Tablet 1 mg
Melatonin Tablet 3 mg
Melatonin Tablet 5 mg
Mineral Oil-Hydrophilic Petrolatum Ointment
Naloxone Hydrochloride Solution Prefilled Syringe 2 mg/ 2mL (Quantity Level Limit)
Nebivolol Hydrochloride Tablet 10 mg (Base Equivalent) (Quantity Level Limit)
Nebivolol Hydrochloride Tablet 2.5 mg (Base Equivalent) (Quantity Level Limit)
Nebivolol Hydrochloride Tablet 20 mg (Base Equivalent) (Quantity Level Limit)
Nebivolol Hydrochloride Tablet 5 mg (Base Equivalent) (Quantity Level Limit)
Omega-3 Fatty Acids Capsule Delayed Release 1200 mg
Oral Vehicles For Suspension
Pamidronate Disodium Intravenous Solution 3 mg/ mL
Pamidronate Disodium Intravenous Solution 6 mg/ mL
Pamidronate Disodium Intravenous Solution 9 mg/ mL
Pediatric Multiple Vitamins With Iron Chewable Tablet 15 mg
Pediatric Multiple Vitamins With Iron Chewable Tablet 18 mg
Pediatric Vitamins A, C and D With Fluoride Solution 0.25 mg/ mL
Pediatric Vitamins A, C and D With Fluoride Solution 0.5 mg/ mL
Potassium Chloride Tablet Extended Release 20 Milliequivalent (1500 mg)
Pyridoxine Hydrochloride Tablet 100 mg
Pyridoxine Hydrochloride Tablet 50 mg
Raspberry Syrup
Simple - Syrup
Sodium Chloride Irrigation Solution 0.9%
Sorbitol Lollipop Base Flakes
Sorbitol Powder
Sorbitol Solution (Bulk)
Sterile Water
Stevia (Bulk) Powder
Stevia (Bulk) Powder 90%
Stevia (Stevia Rebaudiana) Powder Pack 100 mg
Steviol Glycosides (Bulk) Powder 95%
Stevioside (Bulk) Fluid Extract 15%
Tranexamic Acid Tablet 650 mg (Quantity Level Limit)
Water For Injection
Water For Irrigation, Sterile Irrigation Solution
Xanthan Gum Powder

August 2023 Removals:

*Alcohol Sheets***
*B-Complex With Vitamin C & Folic Acid Capsule 1 mg***
*B-Complex With Vitamin C & Folic Acid Tablet 1 mg***
*Blood Glucose Monitoring Miscellaneous***
*Blood Glucose Monitoring Supplies***
*Distilled Water***
*Ferrous Asparto Glycinate-Ferrous Fumarate-Succinic Acid-Vitamin C-Threonic Acid-B12-Folic Acid Tablet
*Ferrous Asparto Glycinic-Succinic Acid-Vitamin C-Threonic Acid-B12-Dessicated Stomach Substance Tablet
*Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid-B Complex-Vitamin C-Zinc-Manganese-Copper Capsule
*Ferrous Fumarate-Iron Polysaccharide Complex-Folic-B Complex-Vitamin C-Biotin Capsule
*Ferrous Fumarate-Folic-B Complex-Vitamin C-Zinc-Magnesium-Manganese-Copper Capsule 106-1 mg
*Ferrous Fumarate-Folic-B Complex-Vitamin C-Zinc-Magnesium-Manganese Tablet 106-1 mg
*Injection Device - Kit***
*Injection Device - Miscellaneous***
*Prenatal Without Vitamin A With Ferrous Fumarate-Ferrous Poly-Folic Capsule 85-1 mg***
*Prenatal-Ferrous Bisglycinate-Iron Protein Succinylate-Folic Acid-Calcium Tablet & Omega 3 Capsule 200 Pack**
*Urine Glucose Monitoring Supplies***
Aminocaproic Acid Oral Solution 0.25 GM/ mL
Aminocaproic Acid Tablet 1000 mg
Aminocaproic Acid Tablet 500 mg
Benazepril & Hydrochlorothiazide Tablet 10-12.5 mg
Benazepril & Hydrochlorothiazide Tablet 20-12.5 mg
Benazepril & Hydrochlorothiazide Tablet 20-25 mg
Benazepril & Hydrochlorothiazide Tablet 5-6.25 mg
Calcium Carbonate Tablet 1250 mg (500 mg Elemental Calcium)
Calcium Citrate Tablet 250 mg
Cholecalciferol Capsule 10000 Unit
Cholecalciferol Tablet 50000 Unit
Ciprofloxacin Hydrochloride Tablet 100 mg
Dexbrompheniramine Maleate Tablet 2 mg
Ferrous Fumarate With B12-Vitamin C-Folic Acid-Intrinsic Factor Capsule 110-0.015-75-0.5-24
Fenoprofen Calcium Powder
Fluocinonide Ointment 0.05%
Folic Acid-Vitamin B6-Vitamin B12 Tablet 2.5-25-1 mg
Fosinopril Sodium & Hydrochlorothiazide Tablet 10-12.5 mg
Fosinopril Sodium & Hydrochlorothiazide Tablet 20-12.5 mg
Injection Device For Insulin
Insulin Glulisine Injection 100 Unit/ mL
Irbesartan Tablet 150 mg
Irbesartan Tablet 300 mg
Irbesartan Tablet 75 mg
Iron Polysaccharide Complex-Vitamin B12-Folic Capsule 150-0.025-1 mg
Ketoprofen Capsule 50 mg
Magnesium Oxide Tablet 250 mg (Magnesium Supplement)
Methylergonovine Maleate Tablet 0.2 mg
Needle (Disposable) 26 X 1/2"
Needle (Disposable) 26 X 1-1/2"
Needle (Disposable) 26 X 3/8"
Needle (Disposable) 26 X 5/8"
Needle (Disposable) 27 X 1/2"
Needle (Disposable) 27 X 1-1/2"
Needle (Disposable) 27 X 1-1/4"
Needle (Disposable) 27 X 5/8"
Paroxetine Hydrochloride Oral Suspension 10 mg/ 5 mL (Base Equivalent)
Potassium Chloride Injection 10 Milliequivalent /50 mL
Potassium Chloride Injection 20 Milliequivalent /50 mL
Pseudoephedrine-Guaifenesin Tablet Sustained Release 12 hour 120-1200 mg
Rimantadine Hydrochloride Tablet 100 mg
Sodium Chloride Preservative Free (Prefilled) Injection 0.9%
Syringe (Disposable) 1 mL
Syringe (Disposable) 10 mL
Syringe (Disposable) 12 mL
Syringe (Disposable) 140 mL
Syringe (Disposable) 20 mL
Syringe (Disposable) 3 mL
Syringe (Disposable) 30 mL
Syringe (Disposable) 35 mL
Syringe (Disposable) 5 mL
Syringe (Disposable) 6 mL
Syringe (Disposable) 60 mL
Syringe (Disposable) 70 mL
Syringe/Needle (Disposable) 1 mL 26 X 3/8"
Syringe/Needle (Disposable) 1 mL 30 X 1/2"
Syringe/Needle (Disposable) 6 mL 18 X 1"
Telmisartan Tab 20 mg
Telmisartan Tab 40 mg
Telmisartan Tab 80 mg
Tolnaftate Aerosol 1%
Tuberculin/Allergy Syringe/Needle (Disposable) 1 mL 21 X 1"
Tuberculin/Allergy Syringe/Needle (Disposable) 1 mL 25 X 1"
Tuberculin/Allergy Syringe/Needle (Disposable) 1 mL 25 X 5/8"
Tuberculin/Allergy Syringe/Needle (Disposable) 1 mL 26 X 3/8"
Tuberculin/Allergy Syringe/Needle (Disposable) 1 mL 26 X 5/8"
Tuberculin/Allergy Syringe/Needle (Disposable) 1 mL 27 X 1/2"
Tuberculin/Allergy Syringe/Needle (Disposable) 1 mL 27 X 3/8"
Tuberculin/Allergy Syringe/Needle (Disposable) 1 mL 28 X 1/2"
Tuberculin/Allergy Syringe/Needle (Disposable) 1/2 mL 27 X ½”
Tuberculin/Allergy Syringe/Needle (Disposable) 1/2 mL 28 X ½”

August 2023 Other Updates:

Bisoprolol Fumarate Tablet 10 mg (Quantity Level Limit)
Desmopressin Acetate Nasal Spray Solution 0.01% (Quantity Level Limit)
Hydrocortisone Acetate Cream 1% (Quantity Level Limit)
Lisinopril & Hydrochlorothiazide Tablet 20-12.5 Mg (Quantity Level Limit)
Methadone Hydrochloride Solution 10 mg/ 5 mL (Quantity Level Limit)
Methadone Hydrochloride Solution 5 mg/ 5 mL (Quantity Level Limit)
Oseltamivir Phosphate Capsule 30 mg (Quantity Level Limit)
Praziquantel Tablet 600 mg (Remove Prior Authorization)
Propranolol Hydrochloride Capsule Extended Release 24 hour 120 mg (Quantity Level Limit)
Propranolol Hydrochloride Capsule Extended Release 24 hour 160 mg (Quantity Level Limit)
Rosuvastatin Calcium Tablet 10 mg (Remove Step Therapy)
Rosuvastatin Calcium Tablet 20 mg (Remove Step Therapy)
Rosuvastatin Calcium Tablet 40 mg (Remove Step Therapy)
Rosuvastatin Calcium Tablet 5 mg (Remove Step Therapy)
Sildenafil Citrate Tablet 20 mg (Quantity Level Limit)

July 2023 Additions:

Kalydeco 13.4 mg (Prior Authorization)
Mekinist Solution 0.05 mg/ mL (Prior Authorization)
Tafinlar Tablet 10 mg (Prior Authorization)
Trikafta Packet 59.5 mg (Prior Authorization)
Trikafta Packet 75 mg (Prior Authorization)

July 2023 Removals:

Ninguna

July 2023 Other Updates:

Ninguna

June 2023 Additions:

Ninguna

June 2023 Removals:

Vancomycin Solution 250 mg / 5 mL

June 2023 Other Updates:

Teriflunomide Tablet 7 mg
Teriflunomide Tablet 14 mg
Vancomycin Hydrochloride For Oral Solution 25 mg/ mL (Base Equivalent)
Vancomycin Hydrochloride For Oral Solution 50 mg/ mL (Base Equivalent)

May 2023 Additions:

Amjevita Injection 40mg /0.8 mL (Prior Authorization)
Breztri Inhalation Aerosol 160-9-4.8 mcg/Actuation (Quantity Level Limit, Step Therapy)
Diaper Rash Ointment
Emgality Auto-Injector 120 mg/ mL (Quantity Level Limit, Step Therapy)
Emgality Prefilled Syringe 120 mg/ mL (Quantity Level Limit, Step Therapy)
Emollient - Cream
Emollient - Lotion
Emollient - Ointment
Fexofenadine Hydrochloride Suspension 30 mg/ mL (Quantity Level Limit)
Fluticasone-Salmeterol Inhalation Powder 250-50 mcg/Actuation (Quantity Level Limit)
Fluticasone-Salmeterol Inhalation Powder 500-50 mcg/Actuation (Quantity Level Limit)
Gilenya Capsule 0.25 mg (Add Prior Authorization, Quantity Level Limit)
Lidocaine Hydrochloride Cream 4%
Rizatriptan Oral Disintegrating Tablet 10 mg (Quantity Level Limit)
Rizatriptan Oral Disintegrating Tablet 5 mg (Quantity Level Limit)
Salicylic Acid Liquid 17%
Trikafta Tablets
Urea Cream 20%
Vitamins A & D Ointment

May 2023 Removals:

*B-Complex With C & Folic Acid Tablet***
*Multiple Vitamin Liquid**
*Multiple Vitamins With Minerals Liquid**
*Omega-3 Fatty Acids Capsule 435 mg**
*Prenatal Vitamin A With Document Sodium-Iron Carbonyl-Folic Acid Tablet 90-1 mg***
*Prenatal Without A With/Ferrous Fumarate-Ferrous Polysaccharide-Folic Acid Capsule 130-92.4-1 mg**
*Prenatal Without A With/Ferrous Fumarate-Ferrous Polysaccharide -Folic Acid Capsule 20-20-1.25 mg**
A+D First Ointment Aid
Acetaminophen Elixir 160 mg/ 5 mL
Aloe Vesta Ointment Protect
Amiloride Hydrochloride Powder
Betaseron Injection 0.3 mg
Capsaicin Cream 0.1%
Carboxymethylcellulose Sodium Ophthalmic Solution 0.25%
Carboxymethylcellulose-Glycerin Ophthalmic Solution 0.5-0.9%
Chlorpheniramine Maleate Powder
Cholecalciferol Capsule 400 Unit
Cholecalciferol Chewable Tablet 2000 Unit
Cholecalciferol Chewable Tablet 5000 Unit
Cholecalciferol Chewable Wafer 50000 Unit
Cholecalciferol Drops 400 Unit/ 0.028 mL (Per Drop)
Cholecalciferol Drops 400 Unit /0.03 mL (Per Drop)
Cholecalciferol Oral Liquid 1000 Unit /10 mL
Cholecalciferol Oral Liquid 1200 Unit /15 mL
Cholecalciferol Tablet 3000 Unit
Cholecalciferol Tablet 4000 Unit
Coal Tar Shampoo 1%
Coal Tar Shampoo 10%
Coal Tar Shampoo 2.5%
Creon Capsule
Diphenhydramine Hydrochloride (Sleep) Tablet 50 mg
Diphenhydramine Hydrochloride Cream 2%
Diphenhydramine Hydrochloride Gel 2%
Diphenhydramine Hydrochloride Solution 2%
Diphenhydramine-Zinc Acetate Liquid 2-0.1%
Elmiron Capsules
Ergocalciferol Tablet 2000 Unit
Ergocalciferol Tablet 400 Unit
Ergocalciferol Tablet 400 Unit
Fluocinolone Acetonide Cream 0.01%
Fluocinonide Emulsified Base Cream 0.05%
Glyburide Powder
Heparin Sodium Injection 20,000 Units/ mL
Heparin Sodium Injection 5,000 Units/ 0.5 mL
Hypromellose Preservative Free (Pf) Ophthalmic Solution 0.3%
Kitabis Pak Nebulizer 300 mg / 5 ml
Lidocaine Cream 3%
Lidocaine Cream 4%
Lidocaine Hydrochloride Solution 4%
Magnesium Tablet 400 Mg
Metaproterenol Sulfate Powder
Mexiletine Hydrochloride Capsule 150 mg
Mexiletine Hydrochloride Capsule 200 mg
Mexiletine Hydrochloride Capsule 250 mg
Mexsana Powder
Miconazole Nitrate Vaginal Applicator 100 mg & 2% Cream 9 gram Kit
Niacin Powder
Niacin Tablet 50 mg
Niacin Tablet 250 mg
Niacin Tablet Controlled Release 250 mg
Psyllium Powder 30.9%
Psyllium Powder 68%
Quinidine Sulfate Tablets 200mg
Quinidine Sulfate Tablets 300mg
Scalpicin Solution 1%
Sorbitol Rectal Solution 70%
Stiolto Inhalation Spray 2.5-2.5 mcg/Actuation
Thiamine Mononitrate Powder
Triamcinolone Acetonide Ointment 0.05%
Zinc Oxide Ointment 12.8%
Zinc Oxide Ointment 16%

May 2023 Other Updates:

Albendazole Tablet 200 mg (Add Prior Authorization, Remove Step Therapy)
Albuterol Sulfate Nebulized Solution 0.63 mg/ 3 mL (Remove Step Therapy, Add Quantity Level Limit)
Albuterol Sulfate Nebulized Solution 1.25 mg/ 3 mL (Remove Step Therapy, Add Quantity Level Limit)
Betamethasone Dipropionate Ointment 0.05% (Add Quantity Level Limit)
Enoxaparin Sodium Injection (Remove Quantity Level Limit)
Enoxaparin Sodium Prefilled Syringe (Remove Quantity Level Limit)
Extavia Injection 0.3 mg (Add Prior Authorization)
Fluconazole Tablet 150 mg (Add Quantity Level Limit)
Fluocinolone Acetonide Cream 0.025% (Add Quantity Level Limit)
Fluocinolone Acetonide Ointment 0.025% (Add Quantity Level Limit)
Fluticasone-Salmeterol Inhalation Powder 100-50 mcg/ Actuation (Remove Age Limit)
Lidocaine Ointment 5% (Remove Prior Authorization)
Ozempic Pen-Injector
Tobramycin Nebulizer Solution 300 mg/ 5 mL (Add Prior Authorization)
Trulicity Pen-Injector

April 2023 Additions:

Ninguna

April 2023 Removals:

Ninguna

April 2023 Other Updates:

Freestyle 14 Sensor Libre (Updated Quantity Level Limit)
Freestyle 14 Sensor Libre 2 (Updated Quantity Level Limit)
Freestyle 14 Sensor Libre 3 (Updated Quantity Level Limit)

March 2023 Additions:

Guaifenesin-Codeine Solution 100-6.33 mg/5 mL (Quantity Level Limit, Age Minimum)

March 2023 Removals:

Ninguna

March 2023 Other Updates:

Ninguna

February 2023 Additions:

Aspirin-Acetaminophen-Caffeine Tablet 250-250-65 mg
Budesonide Tablet extended release 9 mg
Buspirone Tablet 30 mg (Quantity Level Limit, Age Minimum)
Carboxymethylcell-Glycerin-Polysorb 80 Ophthalmic Solution 0.5-1-0.5%
Carboxymethylcellulose-Glycerin (preservative free) Ophthalmic Solution 0.5-1%
Carboxymethylcellulose-Glycerin Ophthalmic Gel 1-0.9%
Climara Pro Dis Weekly (Quantity Level Limit)
Cyclosporine (ophthalmic) Emulsion 0.05% (Quantity Level Limit, Prior Authorization Required)
Desvenlaf(P) Tablet 100 mg extended release (Quantity Level Limit)
Desvenlaf(P) Tablet 25 mg extended release (Quantity Level Limit)
Desvenlaf(P) Tablet 50 mg extended release (Quantity Level Limit)
Dificid Suspension (Prior Authorization Required)
Dificid Tablet 200 mg (Prior Authorization Required)
Esomepra Magnesium Capsule 40 mg Delayed Release (Quantity Level Limit)
Estradiol Vaginal Cream 0.1 mg/GM (Quantity Level Limit)
Ethacrynic Tablet Acid 25 mg
Fluocin Acet Oil Ear 0.01% (Quantity Level Limit)
Glucose Gel 40%
Glucose Gel 77.4%
Glycerin-Hypromellose-Peg 400 Ophthalmic Solution 0.2-0.2-1%
Hypromellose Ophthalmic Gel 0.3%
Imbruvica Tablet 140 mg (Quantity Level Limit, Prior Authorization Required)
Imbruvica Tablet 280 mg (Quantity Level Limit, Prior Authorization Required)
Imbruvica Tablet 420 mg (Quantity Level Limit, Prior Authorization Required)
Imbruvica Tablet 560 mg (Quantity Level Limit, Prior Authorization Required)
Invega Hafye Injection 1092 mg (Prior Authorization Required)
Invega Hafye Injection 1560 mg (Prior Authorization Required)
Lactobacillus Acidophilus-Pectin Capsule
Lactobacillus Capsule
Lactobacillus Tablet
Lidocaine 5% Rectal Cream (Quantity Level Limit)
Magnesium Citrate Solution
Naphazoline W/ Pheniramine Ophthalmic Solution0.025-0.3%
Naphazoline W/ Pheniramine Ophthalmic Solution0.027-0.315%
Neomycin-Polymyxin W/ Pramoxine Cream 1%
Ozempic Injection 2 mg/3 mL (Step Therapy, Quantity Level Limit)
Phenylephrine hydrochloride Tablet 10 mg
Phenylephrine W/ Dm-Gg Liquid 10-18-200 mg/15mL (Quantity Level Limit)
Phenylephrine W/ Dm-Gg Liquid 2.5-5-100 mg/5mL (Quantity Level Limit)
Pramoxine Aer 1% Rectal (Quantity Level Limit)
Probiotic Product - Capsule
Pseudoephed-Dexchlorphen-Chlophedianol Liquid 30-1-12.5 mg/5mL (Quantity Level Limit)
Quetiapine Tablet 150 mg extended release
Quetiapine Tablet 200 mg extended release
Quetiapine Tablet 300 mg extended release
Quetiapine Tablet 400 mg extended release
Quetiapine Tablet 50 mg extended release
RivastiGMine Dis 13.3 mg/24 (Prior Authorization Required)
RivastiGMine Dis 4.6 mg/24 (Prior Authorization Required)
RivastiGMine Dis 9.5 mg/24 (Prior Authorization Required)
Saline Nasal Gel
Saline Nasal Solution 0.65%
Aerosol nasal salino al 0.65%
Sod Fluoride Gel 1.1-5%
Sod Fluoride Paste 1.1%
Sodium Phosphates – Enema (Quantity Level Limit)
Tetrahydrozoline Hydrochloride Ophthalmic Solution 0.05%
Tramadol Hydrochloride Tablet extended release 24hr 100 mg (Quantity Level Limit, Prior Authorization Required, Age Minimum)
Tramadol Hydrochloride Tablet extended release 24hr 200 mg (Quantity Level Limit, Prior Authorization Required, Age Minimum)
Tramadol Hydrochloride Tablet extended release 24hr 300 mg (Quantity Level Limit, Prior Authorization Required, Age Minimum)
Vancomycin Capsule 125 mg (Quantity Level Limit)
Vancomycin Capsule 250 mg (Quantity Level Limit)
Xifaxan Tablet 550 mg (Prior Authorization Required)

February 2023 Removals:

Auryxia 210 mg Tablet
Brimonidine Tartrate-Timolol Maleate Ophthalmic Solution 0.2-0.5%
Brinzolamide Ophthalmic Suspension 1%
Butalbital-Acetaminophen-Caff W/ Cod Capsule 50-300-40-30 mg
Butalbital-Acetaminophen-Caff W/ Cod Capsule 50-325-40-30 mg
Butalbital-Acetaminophen-Caffeine Capsule 50-325-40 mg
Butalbital-Aspirin-Caff W/ Codeine Capsule 50-325-40-30 mg
Butalbital-Aspirin-Caffeine Capsule 50-325-40 mg
Celontin Capsule 300 mg
Cequa
Colchicine Capsule 0.6 mg
Desmopressin Spray Ref 0.01%
Diphenoxylate W/ Atropine Liquid 2.5-0.025 mg/5mL
Duloxetine Capsule 40 mg Delayed Release
Esbriet 267 mg Capsule
Estring
Ibrance Tablet 100 mg
Ibrance Tablet 125 mg
Ibrance Tablet 75 mg
Levofloxacin Ophthalmic Solution 0.5%
Lidocaine Solution 4%
Methylphenid Capsule 10 mg long acting
Methylphenid Capsule 20 mg long acting
Methylphenid Capsule 30 mg long acting
Methylphenid Capsule 40 mg long acting
Methylphenid Capsule 60 mg long acting
Miconazole Nitrate Ointment 2%
Miconazole Nitrate Solution 2%
Naproxen Tablet enteric coated 500 mg
Oxymorphone Hydrochloride Tablet extended release 12hr 10 mg
Oxymorphone Hydrochloride Tablet extended release 12hr 15 mg
Oxymorphone Hydrochloride Tablet extended release 12hr 20 mg
Oxymorphone Hydrochloride Tablet extended release 12hr 30 mg
Oxymorphone Hydrochloride Tablet extended release 12hr 40 mg
Oxymorphone Hydrochloride Tablet extended release 12hr 5 mg
Oxymorphone Hydrochloride Tablet extended release 12hr 7.5 mg
Pot & Sod Citrates W/ Cit Ac Solution 550-500-334 mg/5mL
Sulfacetamide Sodium Ophthalmic Ointment 10%

February 2023 Other Updates:

Atomoxetine Capsule 100 mg (Remove Step Therapy, Added Age Minimum)
Atomoxetine Capsule 10 mg (Remove Step Therapy, Added Age Minimum)
Atomoxetine Capsule 18 mg (Remove Step Therapy, Added Age Minimum)
Atomoxetine Capsule 25 mg (Remove Step Therapy, Added Age Minimum)
Atomoxetine Capsule 40 mg (Remove Step Therapy, Added Age Minimum)
Atomoxetine Capsule 60 mg (Remove Step Therapy, Added Age Minimum)
Atomoxetine Capsule 80 mg (Remove Step Therapy, Added Age Minimum)
Bacitracin Ophthalmic Ointment 500 Unit/GM (Added Quantity Level Limit)
Bacitracin-Polymyxin B Ophthalmic Ointment (Added Quantity Level Limit)
Benzonatate Capsule 100 mg
Benzonatate Capsule 200 mg
Carboxymethylcellulose Sodium Ophthalmic Gel 1%
Duloxetine Capsule 20 mg Delayed Release (Quantity Level Limit)
Erythromycin Ophthalmic Ointment 5 mg/GM (Added Quantity Level Limit)
Gentamicin Sulfate Ophthalmic Ointment 0.3% (Added Quantity Level Limit)
Glucose Blood Test Strip
Hydroc/Homat Tablet 5-1.5 mg
Hydrocod/Hom Syrup 5-1.5/5
Levonorgestr Tablet 1.5 mg
Miconazole Nitrate Vaginal Suppository 1200 mg & 2% Cream Kit

January 2023 Additions:

Zenpep Cap 40000unt

January 2023 Removals:

All Non OneTouch Delica and Delica Plus Lancets and Devices

January 2023 Other Updates:

Fingolimod Hcl Cap 0.5 Mg (Base Equiv)
December 2022 Additions:

Actimmune Inj 2mu/0.5 (Prior A
uthorization Required)
Aspercreme Cre Lidoc 4%
Aspercreme Cre Lidocain
Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 325 Mg
Bacitracin-Polymyxin-Neomycin-Hc Ophth Oint 1% (Quantity Level Limit)
Balsalazide Disodium Cap 750 Mg
Buprenorphine Td Patch Weekly 10 Mcg/Hr (Prior Authorization Required, Quantity Level Limit)
Buprenorphine Td Patch Weekly 15 Mcg/Hr (Prior Authorization Required, Quantity Level Limit)
Buprenorphine Td Patch Weekly 20 Mcg/Hr (Prior Authorization Required, Quantity Level Limit)
Buprenorphine Td Patch Weekly 5 Mcg/Hr (Prior Authorization Required, Quantity Level Limit)
Buprenorphine Td Patch Weekly 7.5 Mcg/Hr (Prior Authorization Required, Quantity Level Limit)
Castor Oil 100%
Cromolyn Sodium Nasal Aerosol Soln 5.2 Mg/Act (4%) (Quantity Level Limit)
Cyclopentolate Hcl Ophth Soln 2% (Quantity Level Limit)
Dextromethorphan Hbr Cap 15 Mg
Dextromethorphan Hbr Liquid 15 Mg/5ml (Quantity Level Limit)
Dextromethorphan Hbr Syrup 15 Mg/5ml (Quantity Level Limit)
Dextromethorphan Polistirex Extended Release Susp 30 Mg/5ml (Quantity Level Limit)
Dextromethorphan-Phenylephrine-Apap Cap 10-5-325 Mg (Quantity Level Limit)
Dimenhydrinate Tab 50 Mg (Quantity Level Limit)
Esomeprazole Magnesium Cap Delayed Release 20 Mg (Base Eq)
Everolimus Tab 10mg (Prior Authorization Required, Quantity Level
Limit)
Everolimus Tab 2.5mg (Prior Authorization Required, Quantity Level
Everolimus Tab 5mg (Prior Authorization Required, Quantity Level
Everolimus Tab 7.5mg (Prior Authorization Required, Quantity Level
Foam Antacid Chw 80-20mg
Glyburide Micronized Tab 1.5 Mg (Quantity Level Limit)
Glyburide Micronized Tab 3 Mg (Quantity Level Limit)
Glyburide Micronized Tab 6 Mg (Quantity Level Limit)
Hydrocortisone Perianal Cream 1%
Ibandronate Sodium Tab 150 Mg (Base Equivalent) (Quantity Level Limit)
Intron A Inj 10mu (Prior Authorization Required)
Intron A Inj 18mu (Prior Authorization Required)
Intron A Inj 50mu (Prior Authorization Required)
Konsyl Daily Pow 100%
Levetiracetam Tab Er 24hr 500 Mg (Quantity Level Limit)
Levetiracetam Tab Er 24hr 750 Mg (Quantity Level Limit)
Levonorgestrel-Ethinyl Estradiol (Continuous) Tab 90-20 Mcg
Lohist-Dm Syp 5-2-10mg
Magnesium Hydroxide Susp 400 Mg/5ml
Mineral Oil Heavy
Mineral Oil Light
Natacyn Sus 5% Op (Quantity Level Limit)
Norgestimate-Eth Estrad Tab 0.18-25/0.215-25/0.25-25 Mg-Mcg
Omeprazole Cap Delayed Release 10 Mg (Quantity Level Limit)
Phenazopyridine Hcl Tab 99.5 Mg
Phenol Liquid 1.4%
Polyethylene Glycol 3350 Oral Packet 17 Gm (Quantity Level Limit)
Potassium Citrate Tab Er 15 Meq (1620 Mg)
Promacta Tab 12.5mg (Prior Authorization Required, Quantity Level Limit)
Promacta Tab 25mg (Prior Authorization Required, Quantity Level Limit)
Promacta Tab 50mg (Prior Authorization Required, Quantity Level Limit)
Promacta Tab 75mg (Prior Authorization Required, Quantity Level Limit)
Simethicone Cap 125 Mg
Simethicone Cap 180 Mg
Simethicone Chew Tab 125 Mg
Simethicone Chew Tab 80 Mg
Sirolimus Tab 1 Mg
Sirolimus Tab 2 Mg
Sodium Chloride Aero Soln 0.9%
Sodium Chloride Soln Nebu 10%
Sodium Chloride Soln Nebu 3%
Sodium Chloride Soln Nebu 7%
Sodium Fluoride Cream 1.1%
Sodium Fluoride Gel 1.1% (0.5% F)
Sodium Fluoride Rinse 0.2%
Sodium Pow Bicarbon
Soltamox Sol 10mg/5ml
Sorbitol Sol 70%
Synagis Inj 100mg/Ml (Prior Authorization Required)
Synagis Inj 50mg (Prior Authorization Required)
Temozolomide Cap 100 Mg
Temozolomide Cap 140 Mg
Temozolomide Cap 180 Mg
Temozolomide Cap 20 Mg
Temozolomide Cap 250 Mg
Temozolomide Cap 5 Mg
Testosterone Td Gel 10mg/Act (2%) (Prior Authorization Required, Quantity Level Limit)
Today Sponge Mis (Quantity Level Limit)
White Petrolatum-Mineral Oil Ophth Ointment

December 2022 Removals:

Benztropine Inj 2mg/2ml
Brompheniramine & Phenylephrine Elixir 1-2.5 Mg/5ml
Brompheniramine & Pseudoephedrine Elixir 1-15 Mg/5ml
Calcitriol Inj 1 Mcg/Ml
Calcium Carbonate (Antacid) Chew Tab 420 Mg
Calcium Carbonate-Simethicone Chew Tab 1000-60 Mg
Cascara Ext Sagrada
Chlorpheniramine & Phenylephrine Tab 4-10 Mg
Chlorpheniramine & Pseudoephedrine Tab 4-60 Mg
Chlorpromazine Hcl Inj 25 Mg/Ml
Chlorpromazine Hcl Inj 50 Mg/2ml
Cvs Daily Pow Fiber
Dexamethasone Sod Phosphate Preservative Free Inj 10 Mg/Ml
Dextromethorphan-Guaifenesin Liquid 30-200 Mg/5ml
Di-Gel Sus
Docusate Sodium Cap 50 Mg
Fleet Liquid Ene Glycerin
Fluphenazine Hcl Oral Conc 5 Mg/Ml
Guaifenesin-Codeine Liquid 225-7.5 Mg/5ml
Hycamtin Cap 0.25mg
Hycamtin Cap 1mg
Hydrocil Ins Pow 95%
Hydrocod Polst-Chlorphen Polst Er Susp 10-8 Mg/5ml
Hydrocodone-Ibuprofen Tab 10-200 Mg
Hydrocodone-Ibuprofen Tab 5-200 Mg
Ibuprofen-Diphenhydramine Citrate Tab 200-38 Mg
Isopto Tears Sol 0.5% Op
Ketoprofen Cap 200mg Er
Konsyl Daily Pow 28.3%
Konsyl Daily Pow 60.3%
Konsyl-D Pow 52.3%
Lansoprazole Tab Delayed Release Orally Disintegrating 15 Mg
Lansoprazole Tab Delayed Release Orally Disintegrating 30 Mg
Linzess Cap 145mcg
Linzess Cap 290mcg
Linzess Cap 72mcg
Lohist-D Liq
Lorazepam Inj 2 Mg/Ml
Magnesium Oxide Tab 250 Mg
Magnesium Oxide Tab 420 Mg
Metamucil Pow 28%
Metamucil Pow 58.12%
Metamucil Pow Mh/Orig
Mineral Oil Enema
Mycophenolic Tab 180mg Dr
Mycophenolic Tab 360mg Dr
Nilutamide Tab 150 Mg
Norethindrone & Ethinyl Estradiol-Fe Chew Tab 0.4 Mg-35 Mcg
Norethindrone & Ethinyl Estradiol-Fe Chew Tab 0.8 Mg-25 Mcg
Nozin Nasal Kit Sanitize
Nozin Nasal Mis Sanitize
Prednisolone Sod Phos Orally Disintegr Tab 10 Mg (Base Eq)
Prednisolone Sod Phos Orally Disintegr Tab 15 Mg (Base Eq)
Prednisolone Sod Phos Orally Disintegr Tab 30 Mg (Base Eq)
Prednisolone Sod Phosphate Oral Soln 20 Mg/5ml (Base Equiv)
Prednisone Con 5mg/Ml
Pseudoephedrine-Guaifenesin Syrup 30-100 Mg/5ml
Pseudoephedrine-Guaifenesin Tab 40-400 Mg
Psyllium Powder 100%
Psyllium Powder 95%
Rowasa Sf Ene 4gm X 28
Simethicone Liquid 40 Mg/0.6ml
Sucralfate Susp 1 Gm/10ml
Triamcinolone Acetonide Cream 0.1%
Trimipramine Maleate Cap 100 Mg
Trimipramine Maleate Cap 25 Mg
Trimipramine Maleate Cap 50 Mg
Tusnel Liq

December 2022 Other Updates:

Fingolimod Hcl Cap 0.5 Mg (Base Equiv)
Fluticasone Propionate Nasal Susp 50 Mcg/Act
Histex Pd Dro 0.938mg
Isotretinoin Cap 10 Mg
Isotretinoin Cap 20 Mg
Isotretinoin Cap 30 Mg
Isotretinoin Cap 40 Mg
Lidocaine Hcl Cream 4% (Quantity Level Limit)

November 2022 Additions:

Icosapent Cap 0.5gm (Prior Authorization Required, Quantity Level Limit)
Imbruvica Sus 70mg/Ml (Prior Authorization Required, Quantity Level Limit)
Orkambi Gra 75-94mg (Prior Authorization Required)

November 2022 Removals:

Ninguna

November 2022 Other Updates:

Artificial Sol Tears
Guaifenesin Tab Er 12hr 1200 Mg
Lubricant Dro Eye 0.6%
Olopatadine Dro 0.1%
Pseudoephedrine-Guaifenesin Tab Er 12hr 60-600 Mg

October 2022 Additions:

Ninguna

October 2022 Removals:

Meloxicam Susp 7.5 Mg/ 5Ml

October 2022 Other Updates:

Lenalidomide Cap 2.5 Mg
Lenalidomide Cap 5 Mg
Lenalidomide Cap 10 Mg
Lenalidomide Cap 15 Mg
Lenalidomide Cap 20 Mg
Lenalidomide Cap 25 Mg
Dabigatran Etexilate Mesylate Cap 75 Mg
Dabigatran Etexilate Mesylate Cap 150 Mg

September 2022 Additions:

Benzoyl Peroxide Liquid 4%
Benzoyl Peroxide Lotion 5%
Bicillin L-A Suspension 2400000 Unit/4ml (Penicillin G Benzathine)
Calamine Lotion
Calamine-Zinc Oxide Lotion 8-8%
Cefixime Cap 400mg (Quantity Level Limit)
Doxycycline Monohydrate Tab 100 Mg
Doxycycline Sus 25mg/5ml (Age Limit)
Eplerenone Tab 25 Mg
Eplerenone Tab 50 Mg
Fenofibrate Tab 145 Mg
Fenofibrate Tab 48 Mg
Fluocinonida crema al 0.1% (límite de nivel de cantidad)
Glucagon Kit (Quantity Level Limit)
Ivermectin Lotion 0.5% (Step Therapy Required, Quantity Level Limit)
Memantine Tab Hcl 10 Mg (Quantity Level Limit)
Memantine Tab Hcl 5 Mg (Quantity Level Limit)
Methenam Man Tab 1000 Mg
Methenam Man Tab 500 Mg
Metronidazole Gel 1% (Step Therapy Required, Quantity Level Limit)
Olmesartan Medoxomil Tab 20 Mg (Quantity Level Limit)
Olmesartan Medoxomil Tab 40 Mg (Quantity Level Limit)
Olmesartan Medoxomil Tab 5 Mg (Quantity Level Limit)
Olopatadine Ophth Soln 0.2% Otc
One Touch Ultra 2 System Kit
One Touch Ultra 2 System Kit (With One Touch Delica Plus)
One Touch Ultra Mini System Kit Silver Moon
One Touch Verio Flex System Kit
One Touch Verio IQ System Kit
One Touch Verio Reflect
One Touch Verio System Kit
Pataday Ophth Soln 0.7% Otc
Permethrin Liquid 1%
Phospho-Trin K500 Tab 500 Mg
Propranolol Sol 20 Mg/5 Ml
Selenium Sulfide Shampoo 1%
Symjepi Prefilled Syringe 0.15 Mg/0.3ml Injection (Quantity Level Limit)
Symjepi Prefilled Syringe 0.3 Mg/0.3ml Injection (Quantity Level Limit)
Tetrabenazin Tab 12.5 Mg (Prior Authorization, Quantity Limit)
Tetrabenazin Tab 25 Mg (Prior Authorization, Quantity Limit)
Triamcinolone Acetonide Ointment 0.05% (Quantity Level Limit)
Triprolidine Hcl Drops 0.938 Mg
PediaClear PD Liquid 0.625 mg (Triprolidine Hcl Liquid)
Histex Syrup 2.5 Mg/5ml (Triprolidine Hcl Syrup)
Voriconazole Tab 200 Mg (Prior Authorization)
Voriconazole Tab 50 Mg (Prior Authorization)

September 2022 Removals:

Adapalene Cream 0.1%
Amcinonide Ointment 0.1%
Amiodarone Hcl Tablet 400mg
Amoxicillin & K Clavulanate Tab Er 12hr 1000-62.5 Mg
Atovaquone Sus 750/5ml
Benzepro Aer 5.3%
Capzasin-P Cre 0.035%
Carbinoxamin Sol 4mg/5ml
Carbinoxamine Maleate Tablet 4mg
Cefaclor Cap 250 Mg
Cefaclor Cap 500 Mg
Cefpodoxime Proxetil For Susp 100 Mg/5ml
Cefpodoxime Proxetil For Susp 50 Mg/5ml
Clemastine Tab 12 Hour
Diltiazem Cap 120mg Er
Diltiazem Cap 60mg Er
Diltiazem Cap 90mg Er
Diphenhydram Chw 12.5mg
Diphenhydram Elx 12.5/5ml
Diphenhydramine Tab 12.5mg
Flunisolide Nasal Spray
Fluvastatin Sodium Tab Er 24 Hr 80 Mg (Base Equivalent)
Glucagen Kit
Isradipine Cap 2.5mg
Isradipine Cap 5mg
Itraconazole Sol 10mg/Ml
K-Phos Tab
Lidocaine Cre 3%
Lidocaine Jelly 2%
Methazolamide Tab 25 Mg
Methazolamide Tab 50 Mg
Metronidazole Cap 375 Mg
Mometasone Furoate Nasal Spray 50mcg
Nicardipine Cap 20mg
Nicardipine Cap 30mg
Nystat/Triam Cre
Nystat/Triam Oin
Olmesart Hct Tab 20-12.5
Olmesart Hct Tab 40-12.5
Olmesart Hct Tab 40-25mg
Ovace Plus Cre 10%
Perindopril Erbumine Tab 2 Mg
Perindopril Erbumine Tab 4 Mg
Perindopril Erbumine Tab 8 Mg
Propafenone Cap 225mg Er
Propafenone Cap 325mg Er
Propafenone Cap 425mg Er
Pyrethrins-Piperonyl Butoxide Shampoo
Ryclora Sol 2mg/5ml
Selenium Sulfide Shampoo 2.25%
Sulfacetamide Sodium Liquid 10%
Vancomycin Hcl Iv Soln 1250 Mg/250ml (Base Equivalent)
Vancomycin Hcl Iv Soln 1750 Mg/350ml (Base Equivalent)
Vancomycin Hcl Iv Soln 750 Mg/150ml (Base Equivalent)
Vemlidy
Zafirlukast Tab 10mg
Zafirlukast Tab 20mg

September 2022 Other Updates:

Acyclovir Cap 200 Mg (Removed Quantity Level Limit)
Acyclovir Tab 400 Mg (Removed Quantity Level Limit)
Acyclovir Tab 800 Mg (Removed Quantity Level Limit)
Epinephrine Solution Auto-Injector 0.15 Mg/0.15ml (1:1000) (Added Quantity Level Limit)
Epinephrine Solution Auto-Injector 0.15 Mg/0.3ml (1:2000) (Added Quantity Level Limit)
Epinephrine Solution Auto-Injector 0.3 Mg/0.3ml (1:1000) (Added Quantity Level Limit)
Ezetimibe Tab 10 Mg (Removed Step Therapy)
Glucagon Inj Emergncy (Added Quantity Level Limit)
Omega-3-Acid Ethyl Esters Cap 1 Gm (Removed Step Therapy)
Valacyclovir Hcl Tab 1 Gm (Removed Quantity Level Limit)
Valacyclovir Hcl Tab 500 Mg (Removed Quantity Level Limit)

August 2022 Additions:

Sin actualizaciones

August 2022 Removals:

Sin actualizaciones

August 2022 Other Updates:

Sin actualizaciones

July 2022 Additions:

Apretude suspensión IM de liberación prolongada 600 mg/3 ml
Cabenuva suspensión IM de liberación prolongada 400 y 600 mg/2 ml
Cabenuva suspensión IM de liberación prolongada 600 y 900mg/3ml
Cimduo Tab 300-300mg
Delstrigo comprimidos 100-300-300 mg
Isentress paquete 100 mg
Pifeltro comprimidos 100 mg
Rukobia comprimidos de liberación prolongada 600 mg
Trogarzo solución intravenosa 200 mg/1.33 ml
Vitekta comprimidos 150mg
Vitekta comprimidos 85 mg
Vocabria comprimidos 30 mg

July 2022 Removals:

Oxicodona/acetaminofeno solución 5-325 mg/5 ml

July 2022 Other Updates:

Medicamentos para VIH (autorización previa eliminada, terapia escalonada)
Tivicay PD comprimidos solubles 5 mg (límite de edad eliminado)

June 2022 Additions:

Bacitracina-polimixina B ungüento
Peróxido de benzoilo gel al 10%
Clotrimazol solución al 1% (límite de cantidad)
Eritromicina en toallitas al 2%
Fexofenadina comprimidos 180 mg (límite de cantidad)
Fexofenadina comprimidos 60mg (límite de cantidad)
Gvoke Hypopen 1 inyección 0.5/0.1 ml (límite de cantidad)
Gvoke PFS 1 paquete 1 mg/0.2 (límite de cantidad)
Pregabalina cápsulas 200 mg (autorización previa, límite de cantidad)

June 2022 Removals:

Sin actualizaciones

June 2022 Other Updates:

Sin actualizaciones

May 2022 Additions:

Ozempic Inj 8mg/3ml (Step Therapy, Quantity Limit)
Triumeq Pd Tab (Prior Authorization, Quantity Limit)

May 2022 Removals:

Sin actualizaciones

May 2022 Other Updates:

Sin actualizaciones

April 2022 Additions:

Descovy Tab 120-15MG (Prior Authorization, Quantity Limit)

April 2022 Removals:

Sin actualizaciones

April 2022 Other Updates:

Sin actualizaciones

March 2022 Additions:

Sin actualizaciones

March 2022 Removals:

Sin actualizaciones

March 2022 Other Updates:

Sin actualizaciones

February 2022 Additions:

Naloxone Hcl Nasal Spray 4 Mg/0.1ml (Quantity Limit)

February 2022 Removals:

Narcan Hcl Nasal Spray 4 Mg/0.1ml

February 2022 Other Updates:

Sin actualizaciones

January 2022 Additions:

Etravirine Tab 100mg (Prior Authorization, Quantity Limit)

Etravirine Tab 200mg (Prior Authorization, Quantity Limit)

Gvoke Kit Inj 1mg/0.2 (Quantity Limit)

Atropine Sul Sol 1% Op

January 2022 Removals:

Intelence TAB 100MG

Intelence TAB 200MG

Isopto Atropine Sol 1%

Concept Ob Cap

Mynatal Tab

PR Natal 400 Pak

January 2022 Other Updates:

Sin actualizaciones
December 2021 Additions:

Esomepra Mag Otc Tab 20 Mg

Insulin Glar Inj 100u/Ml

Insulin Glar Sol 100u/Ml

Mavyret Pak 50-20mg (Prior Authorization)

December 2021 Removals:

Semglee Sol 100u/Ml

December 2021 Other Updates:

Sin actualizaciones

November 2021 Additions:

Sin actualizaciones

November 2021 Removals:

Buprenorphine Extended Release Soln Pref Syr 100 Mg/0.5

Buprenorphine Extended Release Soln Pref Syr 300 Mg/1.5

November 2021 Other Updates:

Sin actualizaciones

October 2021 Additions:

Sunitinib Cap 12.5mg

Sunitinib Cap 25mg

Sunitinib Cap 37.5mg

Sunitinib Cap 50mg

October 2021 Removals:

Sutent CAP 12.5MG

Sutent CAP 25MG

Sutent CAP 37.5MG

Sutent CAP 50MG

October 2021 Other Updates:

Sin actualizaciones

September 2021 Additions:

Sin actualizaciones

September 2021 Removals:

Sin actualizaciones

September 2021 Other Updates:

Sin actualizaciones

August 2021 Additions:

Baqsimi Pow 3mg/Dose (Quantity Limit)

Endari Pow 5gm (Prior Authorization)

Inlyta Tab 1mg (Prior Authorization, Quantity Limit)

Inlyta Tab 5mg (Prior Authorization, Quantity Limit)

Nayzilam Spr 5mg) (Prior Authorization, Quantity Limit)

Pregabalin Cap 100 Mg (Quantity Limit)

Pregabalin Cap 150 Mg (Quantity Limit)

Pregabalin Cap 225 Mg (Quantity Limit)

Pregabalin Cap 25 Mg (Quantity Limit)

Pregabalin Cap 300 Mg (Quantity Limit)

Pregabalin Cap 50 Mg (Quantity Limit)

Pregabalin Cap 75 Mg (Quantity Limit)

Prolia Sol 60mg/Ml (Prior Authorization, Quantity Limit)

Semglee Sol 100u/Ml

Sofos/Velpat Tab 400-100 (Prior Authorization, Quantity Limit)

August 2021 Removals:

Ibrance Cap 100mg

Ibrance Cap 125mg

Ibrance Cap 75mg

Lidocaine-Hydrocortisone Ace Cream 3-0.5% rectal

Methoxsalen Cap 10mg

Nexavar Tab 200mg

August 2021 Other Updates:

Sin actualizaciones

July 2021 Additions:

Sin actualizaciones

July 2021 Removals:

Sin actualizaciones

July 2021 Other Updates:

Sin actualizaciones

June 2021 Additions:

Sin actualizaciones

June 2021 Removals:

Sin actualizaciones

June 2021 Other Updates:

Trulicity pluma inyectable 0.75 mg/0.5 ml (límite de nivel de cantidad agregado)

Trulicity pluma inyectable 1.5 mg/0.5 ml (límite de nivel de cantidad agregado)

Trulicity pluma inyectable 3 mg/0.5 ml (límite de nivel de cantidad agregado)

Trulicity pluma inyectable 4.5 mg/0.5 ml (límite de nivel de cantidad agregado)

May 2021 Additions:

Sin actualizaciones

May 2021 Removals:

Sin actualizaciones

May 2021 Other Updates:

Sin actualizaciones

April 2021 Additions:

Brinzolamida suspensión al 1% (límite de nivel de cantidad, terapia escalonada)

April 2021 Removals:

Azopt suspensión al 1%

April 2021 Other Updates:

Sin actualizaciones

March 2021 Additions:

Bevespi aerosol 9-4.8 mcg (límite de nivel de cantidad)

Cequa solución al 0.09% PF (se requiere autorización previa)

Hiclato de doxiciclina cápsulas 50 mg, 100 mg

Hiclato de doxiciclina comprimidos 100 mg

Esbriet cápsulas 267 mg (se requiere autorización previa)

Esbriet comprimidos 267 mg, 801 mg (se requiere autorización previa)

Fluticatisona-Salmeterol aerosol 100-50 mcg (límite de nivel de cantidad)

Hizentra inyección 1 g/ml, 2 g/10 ml, 4 g/20 ml (se requiere autorización previa)

Hizentra solución al 20% (se requiere autorización previa)

Hizentra vial 1 g/5 ml, 10 g/50 ml (se requiere autorización previa)

Icosapent cápsulas 1 g (límite de nivel de cantidad)

Myleran comprimidos 2 mg

Ocrevus inyección 300/10 ml (límite de nivel de cantidad)

Citratos de potasio y sodio c/solución de ácido cítrico 550-500-334 mg/5 ml

Privigen inyección 40 gramos (se requiere autorización previa)

Rabeprazol comprimidos 20 mg (límite de nivel de cantidad)

Trulicity inyección 0.75 mg/0.5 ml, 1.5 mg/0.5 ml, 3 mg/0.5 ml, 4.5 mg/0.5 ml (se requiere terapia escalonada)

Tukysa comprimidos 50 mg, 150 mg (se requiere autorización previa)

Valtoco líquido 20 mg (límite de nivel de cantidad)

Valtoco aerosol 5 mg, 10 mg (límite de nivel de cantidad)

March 2021 Removals

Anoro Ellipta aerosol 62.5-25 mcg/inh

Atrovent HFA aerosol 17 mcg

Breo Ellipta inhalador 100-25 mcg/inh, 200-25 mcg/inh

Cefaclor para suspensión 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

Caritromicina comprimidos de liberación prolongada 24 h 500 mg

Combivent aerosol 20-100 mcg/dosis

Diazepam Intensol 5 mg/ml

Monohidrato de doxiciclina comprimidos 50 mg, 75 mg, 100 mg

Epogen inyección 2000/ml, 3000/ml, 4000/ml, 10000/ml, 20000/ml

Fulphila inyección 6 mg/0.6 ml

Gammaked inyección 1 g/10 ml, 5 g/50 ml, 10 g/100 ml, 20 g/200 ml

Hiosciamina en gotas de 0.125 mg/ml

Janumet comprimidos 50-500 mg, 50-1000 mg

Janumet XR comprimidos 50-500 mg, 50-1000 mg, 100-1000 mg

Januvia comprimidos 25 mg, 50 mg, 100 mg

Nivestym inyección 300 mcg, 480 mcg

Nivestym jeringa para inyección 300 mcg/0.5 ml, 480 mcg/0.8 ml

Ofev cápsulas 100 mg, 150 mg

Victoza inyección 18 mg/3 ml

March 2021 Other Updates:

Albuterol aerosol HFA (se cambió el límite de nivel de cantidad)

Arnuity Ellipta inhalador 50 mcg, 100 mcg, 200 mcg (se agregó límite de nivel de cantidad)

Azitromicina suspensión 100 mg/5 ml, 200 mg/5 ml (se agregó límite de edad)

Cefadroxil suspensión 250 mg/5 ml, 500 mg/ml (se agregó límite de edad)

Cefdinir suspensión 125 mg/5 ml, 250 mg/5 ml (se agregó límite de edad)

Cefpodoxima proxetil suspensión 50 mg/5 ml, 100 mg/5 ml (se agregó límite de edad)

Cefprozil suspensión 125 mg/5 ml, 250 mg/5 ml (se agregó límite de edad)

Cefalexina suspensión 125 mg/5 ml, 250 mg/5 ml (se agregó límite de edad)

Claritromicina suspensión 125 mg/5 ml, 250 mg/5 ml (se agregó límite de edad)

Extavia inyección 0.3 mg (se agregó límite de nivel de cantidad)

Glatiramer inyección 40 mg/ml (se agregó límite de nivel de cantidad)

Tartrato de levalbuterol aerosol 45 mcg/dosis (se agregó límite de nivel de cantidad)

Levofloxacina solución 25 mg/ml (se agregó límite de edad)

Neomicina-polimixina-dexametasona ungüento oftálmico al 0.1% (se agregó límite de nivel de cantidad)

Ondansetrón comprimidos de fácil dispersión 4 mg (se cambió el límite de nivel de cantidad)

Clorhidrato de fenilefrina solución oftálmica al 2.5% (se agregó límite de nivel de cantidad)

Rebif inyección 44 mcg/0.5 ml (se agregó límite de nivel de cantidad)

Rebif/Rebidose inyección 22 mcg/0.5 ml, 44 mcg/0.5 ml (se agregó límite de nivel de cantidad)

Rebif/Rebidose paquete para ajuste de la dosis (se agregó límite de nivel de cantidad)

Rebif paquete para ajuste de la dosis inyectable (se agregó límite de nivel de cantidad)

Santyl ungüento 250 unidades/g (se agregó límite de nivel de cantidad)

February 2021 No updates

Sin actualizaciones

January 2021 Additions:

Retacrit inyección 20000 unidades (se requiere autorización previa)
December 2020 Additions:

Aerosol Trelegy Ellipta de 200/62.5/25 mcg (se requiere tratamiento escalonado, límite de nivel de cantidad)

November 2020 Additions:

Paquete inicial de dimetilfumarato 120 mg y 240 mg (se requiere autorización previa, límite de nivel de cantidad)

Cápsulas de emtricitabina de 200 mg (se requiere autorización previa, límite de nivel de cantidad)

November 2020 Removals:

Emtriva Cap

Paquete inicial de Tecfidera de 120 mg y 240 mg

October 2020 Additions:

Cápsulas de dimetilfumarato de liberación tardía de 120 mg, 240 mg (se requiere autorización previa, límite de nivel de cantidad)

Efavirenz-Lamivudine-Tenofovir DF comprimidos de 400-300-300 mg, 600-300-300 mg (se requiere autorización previa, límite de nivel de cantidad)

Comprimidos de emtricitabina-tenofovir disoproxil fumarato de 200-300 mg (se requiere autorización previa, límite de nivel de cantidad)

Vancomycin HCL IV Sol’n 750mg/150ml, 1250mg/250ml, 1750mg/350ml

October 2020 Removals:

Prenatrix comprimidos

Psyldex polvo, 30%

SB laxante en polvo de fibra 33%

SB Natural laxante en polvo de fibra 49%

Symfi Lo comprimidos de 400-300-300 mg

Symfi Tab 600-300-300mg

Cápsulas de Tecfidera de liberación retardada 120 mg, 240 mg

Vitrexyl comprimidos

Truvada comprimidos de 200-300 mg

September 2020 Additions:

Abiraterone comprimidos de 250 mg (se requiere autorización previa)

Alecensa cápsulas de 150 mg (se requiere autorización previa)

Austedo comprimidos de 6 mg, 9 mg, 12 mg (se requiere autorización previa)

Bexarotene cápsulas de 75 mg (se requiere autorización previa)

Budesonide cápsulas de 3 mg (requiere terapia escalonada, límite de nivel de cantidad)

Caprelsa comprimidos de 100 mg, 300 mg (se requiere autorización previa)

Cinacalcet comprimidos de 30 mg, 60 mg, 90 mg (se requiere autorización previa)

Cyclophosphamide cápsulas de 25 mg, 50 mg

Enbrel Inj 25mg/0.5ml (Prior Authorization Required, Quantity Level Limit)

Erivedge cápsulas de 150 mg (se requiere autorización previa)

Gilotrif comprimidos de 20 mg, 30 mg, 40 mg (se requiere autorización previa)

Jakafi Tabs 5mg, 10mg, 15mg, 20mg, 25mg (Prior Authorization Required)

Kalydeco paquete de 25 mg, 50 mg, 75 mg (se requiere autorización previa)

Kalydeco comprimidos de 150 mg (se requiere autorización previa)

Paquete para terapia de lenvima cápsulas de 4 mg, 8 mg, 10 mg, 12 mg, 14 mg, 18 mg, 20 mg, 24 mg (se requiere autorización previa)

Linezolid Tab 600mg (Prior Authorization Required)

Mekinist comprimidos de 0.5 mg, 2 mg (se requiere autorización previa)

Ofev Caps 100mg, 150mg (Prior Authorization Required)

Omeprazol comprimidos de liberación retardada de 20 mg (OTC) (límite de nivel de cantidad)

Repatha Inj 140mg/ml (Prior Authorization Required)

Repatha inyectable de 420/3.5 ml (se requiere autorización previa)

Repatha Sure Inj 140mg/ml (Prior Authorization Required)

Rydapt cápsulas de 25 mg (se requiere autorización previa)

Soliris Inj 10mg/ml (Prior Authorization Required)

Symdeko comprimidos de 50-75 mg, 100-150 mg (se requiere autorización previa)

Tafinlar cápsulas de 50 mg, 75 mg (se requiere autorización previa)

Kit de inicio de Venclexta comprimidos (se requiere autorización previa)

Venclexta Tabs 10mg, 50mg, 100mg (Prior Authorization Required)

Xolair inyectable de 75/0.5 ml, 100 mg/ml (se requiere autorización previa)

Xolair solución de 150 mg (se requiere autorización previa)

September 2020 Removals:

Travoprost (sin BAK) solución oftálmica del 0,004%

September 2020 Other updates:

Aripiprazol comprimidos de 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg (límite de edad)

Clozapina comprimidos 25 mg, 50 mg, 100 mg, 200 mg (límite de edad)

Olanzapina comprimidos de disolución bucal 5 mg, 10 mg, 15 mg, 20 mg (límite de edad)

Olanzapina comprimidos 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg (límite de edad)

Inhibidores de la bomba de protones (límite de nivel de cantidad)

Quetiapina comprimidos de 25 mg, 50 mg, 100 mg, 200 mg, 300 mg, 400 mg (límite de edad)

Risperidona comprimidos de disolución bucal de 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg (límite de edad)

Risperidona solución de 1 mg/ml (límite de edad)

Risperidona comprimidos de 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg (límite de edad)

Ziprasidona cápsulas 20 mg, 40 mg, 60 mg, 80 mg (límite de edad)

August 2020 Additions:

Amitiza cápsulas de 8 mcg, 24 mcg (se requiere autorización previa, límite de edad, límite de nivel de cantidad)

Athlete's Foot (Miconazole Nitrate) Powder 2% (Quantity Level Limit)

Diclofenaco solución al 1.5% (requiere tratamiento escalonado, límite de nivel de cantidad)

Ibrance Caps 75mg, 100mg, 125mg (Prior Authorization Required, Quantity Level Limit)

Ibrance Tabs 75mg, 100mg, 125mg (Prior Authorization Required, Quantity Level Limit)

Lynparza comprimidos de 10 mg, 15 mg (se requiere autorización previa, límite de nivel de cantidad)

Nitrato de miconazol aerosol y polvo al 2% (límite de nivel de cantidad)

Solución Poly-Vi-Sol de 50 mg/ml

Ropinirole ER comprimidos de 2 mg, 4 mg, 6 mg, 8 mg, 12 mg de liberación prolongada (se requiere tratamiento escalonado)

Succinato de solifenacina comprimidos de 5 mg, 10 mg (se requiere tratamiento escalonado, límite de nivel de cantidad)

Symproic comprimidos de 0.2 mg (se requiere autorización previa, límite de nivel de cantidad)

Testosterona en gel al 1.62% (se requiere autorización previa, límite de nivel de cantidad)

Bomba de gel de testosterona al 1% (se requiere autorización previa)

Testosterona transdermal solución de 30 mg/dosis (se requiere autorización previa, límite de nivel de cantidad)

Tivicay PD Tab 5mg (Prior Authorization Required, Age Limit)

Trelegy Ellipta Inhaler 100-62.5-25mcg (Step Therapy Required, Quantity Level Limit)

Solución Tri-Vi-Sol A/C/D

August 2020 Removals:

Cimduo comprimidos de 300/300 mg

Acetónido de fluocinolona solución al 0.01%

Fluorouracil crema al 0.5%

Humulin 70/30

Humulin N

Humulin R

Kitabis Solution 300mg/5ml

Solución de naproxeno comprimidos de 275 mg

Nimodipina cápsulas 30 mg

Targretin en gel al 1%

Tolmetina cápsulas de 400 mg

Tolmetina comprimidos de 200 mg, 600 mg

August 2020 Other updates:

Ácido acético/hidrocortisona solución ótica (límite de nivel de cantidad)

Adapaleno en gel al 0.1% con receta (tratamiento escalonado eliminado)

Auryxia Tab 210mg (Step Therapy Required)

Dipropionato de betametasona ungüento crema al 0.05% (límite de nivel de cantidad)

Dipropionato de betametasona crema al 0.05% (límite de nivel de cantidad)

Dipropionato de betametasona loción al 0.05% (límite de nivel de cantidad)

Valerato de betametasona crema al 0.1% (límite de nivel de cantidad)

Valerato de betametasona loción al 0.1% (límite de nivel de cantidad)

Valerato de betametasona ungüento al 0.1% (límite de nivel de cantidad)

Clorhidrato de butenafina crema al 1% (límite de nivel de cantidad)

Candesartan Cilexetil - Comprimidos de hidroclorotiazida de 16/12.5 mg, 32/12.5 mg, 32/25 mg (se requiere tratamiento escalonado)

Candesartan Cilexetil comprimidos de 4 mg, 8 mg, 16 mg, 32 mg (se requiere tratamiento escalonado)

Acetónido de fluocinolona crema al 0.77% (límite de nivel de cantidad)

Ciclopiroxolamina suspensión al 0.77% (límite de nivel de cantidad)

Ciclopirox champú al 1% (límite de nivel de cantidad)

Ciclopirox Solution 8% (Quantity Level Limit)

Ciprofloxacina solución ótica al 0.2% (límite de nivel de cantidad)

Clindamicina en gel al 1% (límite de nivel de cantidad)

Permetrina loción al 1% (límite de nivel de cantidad)

Clindamicina en toallitas al 1% (límite de nivel de cantidad)

Clindamicina solución al 1% (límite de nivel de cantidad)

Clotrimazol crema al 1% (límite de nivel de cantidad)

Clotrimazol solución al 1% (límite de nivel de cantidad)

Clotrimazol-betametasona crema al 1 - 0.05% (límite de nivel de cantidad)

Disulfiram comprimidos de 250 mg, 500 mg (límite de nivel de cantidad)

Gotas para los oídos (peróxido de carbamida) solución ótica al 6.5% (límite de nivel de cantidad)

Eritromicina en gel al 2% (límite de nivel de cantidad)

Eritromicina solución al 2% (límite de nivel de cantidad)

Fluocinonida crema al 0.05% (límite de nivel de cantidad)

Fluocinonida solución al 0.05% (límite de nivel de cantidad)

Fluvastatina comprimidos de 20 mg, 40 mg (se requiere tratamiento escalonado)

Hidrocortisona crema al 0.5%, 1%, 2.5% (límite de nivel de cantidad)

Hidrocortisona loción al 1%, 2.5% (límite de nivel de cantidad)

Hidrocortisona ungüento al 0.5%, 1%, 2.5% (límite de nivel de cantidad)

Ketoconazol crema al 2% (límite de nivel de cantidad)

Ketoconazol champú al 2% (límite de nivel de cantidad)

Lidocaína ungüento al 5% (límite de nivel de cantidad)

Linzess cápsulas 72 mcg, 145 mcg, 290 mcg (se requiere autorización previa)

Liotironina comprimidos de 25 mcg (límite de nivel de cantidad)

Nitrato de miconazol crema al 2% (límite de nivel de cantidad)

Furoato de mometasona crema al 0.1% (límite de nivel de cantidad)

Furoato de mometasona ungüento al 0.1% (límite de nivel de cantidad)

Furoato de mometasona solución al 0.1% (límite de nivel de cantidad)

Naltrexona comprimidos de 50 mg (límite de nivel de cantidad)

Neomycin-Polymyxin-HC OTIC Solution 1% (Quantity Level Limit)

Neomycin-Polymyxin-HC OTIC Suspension 3.5mg/ml-10000 Unit/ml (Quantity Level Limit)

Nistatina crema de 100,000 unidades/g (límite de nivel de cantidad)

Nislatina ungüento de 100,000 unidades/g (límite de nivel de cantidad)

Nistatina polvo tópico de 100,000 unidades/g (límite de nivel de cantidad)

Ofloxacina solución ótica al 0.3% (límite de nivel de cantidad)

Permetrina crema al 5% (límite de nivel de cantidad)

Permetrina loción al 1% (límite de nivel de cantidad)

Prednicarbato ungüento al 0.1% (límite de nivel de cantidad)

Solución de fuerza máxima para aliviar el cuero cabelludo (hidrocortisona) al 1% (límite de nivel de cantidad)

Líquido de fuerza máxima para matar los piojos (piretrina-butóxido de piperonilo) al 0.33 - 4% (límite de nivel de cantidad)

Sulfacetamide Lotion 10% (Quantity Level Limit)

Terbinafina crema al 1% (límite de nivel de cantidad)

Tolnaftato crema al 1% (límite de nivel de cantidad)

Acetónido de triamcinolona crema al 0.025%, 0.1%, 0.5% (límite de nivel de cantidad)

Acetónido de triamcinolona loción al 0.025%, 0.1% (límite de nivel de cantidad)

Acetónido de triamcinolona ungüento al 0.025%, 0.5% (límite de nivel de cantidad)

July 2020 Additions:

Gvoke PFS inyección 0.5 mg/0.1 ml (límite de nivel de cantidad)

July 2020 Other updates:

Glucagón kit de emergencias 1 mg (límite de nivel de cantidad)

Matulane cápsulas 50 mg (se requiere autorización previa)

June 2020 Additions:

Medicamento para el acné loción (peróxido de benzoilo) al 10%

Alahist-D comprimidos 17.5-10 mg

Atovaquona-proguanil comprimidos 62.5-25 mg, 250 mg-100 mg (límite de nivel de cantidad)

Peróxido de benzoilo gel al 2.5%

Claravis Caps 10mg, 20mg, 30mg, 40mg (Step Therapy, Quantity Level Limit)

Dovato Tab 50-300mg (Quantity Level Limit)

Gvoke Hypopen Inj (Quantity Level Limit)

Isotretinoína cápsulas 10 mg, 20 mg, 30 mg, 40 mg (terapia escalonada, límite de nivel de cantidad)

Tiña inguinal/aerosol para el pie de atleta (tolnaftato) polvo en aerosol al 1% (límite de nivel de cantidad)

Primaquina comprimidos 26.3 mg (límite de nivel de cantidad)

June 2020 Other updates:

Clotrimazol solución al 1% (se eliminó la terapia escalonada)

May 2020 Additions:

Dexametasona concentrado 1 mg/ml

Dexametasona viales 20 mg/5 ml, 120 mg/30 ml, 10 mg/ml

Solu-Cortef PF Vial 100mg, 250mg, 500mg, 1000mg

Pirimetamina comprimidos 25 mg (Genérico) (se requiere autorización previa)

May 2020 Removals:

Daraprim comprimidos (marca)

April 2020 Additions:

Aripiprazol, comprimidos 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg (genérico) (límite de edad, límite de nivel de cantidad)

Omeprazol, comprimidos de liberación retardada que se desintegran 20 mg (OTC) (límite de nivel de cantidad)

Orkambi, paquete 100-125 mg, 200-125 mg (se requiere autorización previa)

Orkambi, comprimidos 100-125 mg, 200-125 mg (se requiere autorización previa)

Tramadol Hcl, comprimidos 100 mg (límite de nivel de cantidad)

April 2020 Removals:

Diphenhydramine Hcl Liquid 6.25mg/ml

Polietilenglicol 3350 oral, paquete

Psyllium, paquete de polvo 100%

Senósidos, comprimidos 17.2 mg

Bicarbonato de sodio en polvo

April 2020 Other updates:

Cloroquina comprimidos 250 mg, 500 mg (se requiere autorización previa, límite de nivel de cantidad)

Hidroxicloroquina comprimidos 200 mg (se requiere autorización previa, límite de nivel de cantidad)

Kaletra comprimidos (límite de nivel de cantidad)

Lopinavir y ritonavir solución 400-100 mg/5 ml (límite de nivel de cantidad)

March 2020 Additions:

Inhalador de budesonida y formoterol 80-4.5 mcg, 160-4.5 mcg (límite de nivel de cantidad)

Mesalamina, cápsulas de liberación prolongada 0.375 mg (genérico)

Chicle de nicotina Polacrilex 2 mg, 4 mg (límite de edad)

Novolin R pluma flexible 100 unidades/ml (límite de edad)

OneTouch Verio Flex Kit (Quantity Level Limit)

Penicilamina comprimidos 250 mg (se requiere autorización previa, límite de nivel de cantidad)

March 2020 Removals:

Ambi 60pse/400gfn Tab

Apriso, cápsulas de liberación prolongada 0.375 g (marca)

Lágrimas artificiales solución oftálmica al 1%

Polvo Diflunisal

Fluoritab Solution 0.275 (0.125 F) Mg/Drop

Hidrocodona-acetaminofeno solución 10-325 mg/15 ml

PR Natal 430 Pak

PR Natal 400, 430 Pak Ec

Prevident solución enjuague

Regenecare HA Gel 2%

Robitussin jarabe 7.5 mg/5 ml

Cloruro de sodio solución al 0.9% inyección

February 2020 Additions:

Bimatoprost solución al 0.03% (terapia escalonada)

Ethinyl Estradiol – Etonogestrel Ring 0.015/0.12mg (Quantity Level Limit)

Travoprost solución oftálmica

February 2020 Removals:

Alprazolam concentrado 1 mg/ml solución

Clorotiazida comprimidos 250 mg, 500 mg

Demeclociclina comprimidos 150 mg, 300 mg

Monohidrato de doxiciclina comprimidos 150 mg

First-Vanco Solution 25mg/ml, 50mg/ml

Meticlotiazida comprimidos 5 mg

Mirena

Nausea Liquid Relief (fructose-dextrose-phosphoric acid)

Nizatidina solución 15 mg/ml

Nuvaring (marca)

Rabeprazol EC cápsulas 20 mg

Ranitidina cápsulas 150 mg, 300 mg

Skyla

Travatan Z solución oftálmica (marca)

February 2020 Other updates:

Sulfato de atropina ungüento oftálmico al 1% (límite de nivel de cantidad)

Sulfato de atropina solución oftálmica al 1% (límite de nivel de cantidad)

Buspirona comprimidos 5 mg, 7.5 mg, 10 mg, 15 mg (límite de edad)

Combigan solución al 0.2%/0.5% (límite de nivel de cantidad)

Diazepam concentrado solución 5 mg/ml (límite de nivel de cantidad)

Diazepam solución oral (límite de nivel de cantidad)

Diazepam comprimidos 2 mg, 5 mg, 10 mg (límite de nivel de cantidad)

Divalproex Er comprimidos 250 mg, 500 mg (se requiere autorización previa)

Dorzolamida Hcl-Timolol maleato solución oftálmica 22.3-6.8 mg/ml (terapia escalonada, límite de nivel de cantidad)

Monohidrato de doxiciclina suspensión 25 mg/ml (límite de edad)

Granisetrón comprimidos 1 mg (terapia escalonada)

Hidroxicina Hcl jarabe 10 mg/5 ml (límite de nivel de cantidad)

Hydroxyzine Hcl Tab 50mg (Quantity Level Limit)

Hidroxicina en pamoato cápsulas 25 mg, 50 mg, 100 mg (límite de nivel de cantidad)

Ibandronato inyectable 3 mg/3 ml (límite de nivel de cantidad)

Levofloxacin Solution 0.5% (Quantity Level Limit)

Lorazepam concentrado 2 mg/ml (límite de edad, límite de nivel de cantidad)

Memantina Hcl comprimidos 5 mg, 10 mg (límite de nivel de cantidad)

Metazolamida comprimidos 25 mg y 50 mg (terapia escalonada)

Tazaroteno crema 0.1% (terapia escalonada)

Timolol gel solución oftálmica al 0.25%, 0.5% (límite de nivel de cantidad)

Trifluridina solución oftálmica al 1% (límite de nivel de cantidad)

January 2020 Removals:

Ventolin HFA inhalador (marca)
December 2019 Additions:

Bunavail hoja sublingual 2.1-0.3 mg, 4.2-0.7 mg, 6.3-1 mg (marca) (se requiere terapia escalonada, límite de nivel de cantidad)

Buprenorfina y naloxona hoja sublingual 2-0.5 mg, 4-1 mg, 8-2 mg, 12-3 mg (genérico) (se requiere terapia escalonada, límite de nivel de cantidad)

Suboxone hoja sublingual 2-0.5 mg, 4-1 mg, 8-2 mg, 12-3 mg (marca) (se requiere terapia escalonada, límite de nivel de cantidad)

Zubsolv Sublingual Tablets 0.7-0.18mg, 1.4-0.36mg, 2.9-0.71mg, 5.7-1.4mg, 8.6-2.1mg, 11.4-2.9mg (Brand) (Step Therapy Required, Quantity Level Limit)

December 2019 Removals:

PreNata comprimidos masticables 29-1 mg

November 2019 Additions:

0.25 g/ml de solución de ácido aminocaproico

November 2019 Removals:

Amicar solución 0.25 g/ml (marca)

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