Formulary Search Tool/Updates

Updates are made regularly to the Aetna Better Health of California formulary and can be viewed below and through the on-line formulary search tool. Formulary changes to identify include:

  • Addition/removal of a drug from the formulary
  • Addition/removal of quantity limits
  • Addition/removal of prior authorization requirements

 

 

November 2019

Additions:

  • Heplisav Pfs 20 Mcg/0.5ml (Age Limit)
  • Methylergonovine 0.2 Mg Tab
  • Methylergonovine Inj 0.2 Mg/Ml
  • Penicillin G Procaine Im 600000iu/Ml
  • Rhopressa Soln 0.02%
  • Shingrix 50 Mcg/0.5ml (Age Limit)
  • Symlin Pen 60 Inj 1500mcg/1.5ml (Prior Authorization Required)
  • Thiamine Hcl Cap 50 Mg
  • Thiamine Hcl Elixir 2.25 Mg/5ml
  • Thiamine Hcl Tab 10 Mg
  • Thiamine Hcl Tab 100 Mg
  • Thiamine Hcl Tab 25 Mg
  • Thiamine Hcl Tab 250 Mg
  • Thiamine Hcl Tab 5 Mg
  • Thiamine Hcl Tab 50 Mg
  • Thiamine Hcl Tab 500 Mg
  • Thiamine Mononitrate Tab 100 Mg
  • Thiamine Mononitrate Tab 250 Mg
  • Thiamine Pyrophosphate Tab 20 Mg
  • Twinrix Pfs 720-20 Mcg/Ml (Age Limit)

 

October 2019

No Changes

 

September 2019

Additions:

  • Ambrisentan Tab 10mg (Prior Authorization Required, Quantity Limit)
  • Ambrisentan Tab 5mg (Prior Authorization Required, Quantity Limit)
  • Bosentan Tab 125mg (Prior Authorization Required, Quantity Limit)
  • Bosentan Tab 62.5mg (Prior Authorization Required, Quantity Limit)
  • Febuxostat Tab 80mg (Step Therapy Required, Quantity Limit)
  • Febuxostat Tab 80mg (Step Therapy Required, Quantity Limit)

Removals:

  • Letairis Tab 10mg
  • Letairis Tab 5mg
  • Tracleer Tab 125mg
  • Tracleer Tab 62.5mg
  • Uloric Tab 40mg
  • Uloric Tab 80mg

 

August 2019

Additions:

  • Butenafine Hcl Cream 1%
  • Lidocaine Patch 4% (Quantity Limit)
  • Lorcaserin Hcl Tab Er 24hr 20mg (Prior Authorization Required, Quantity Limit)
  • Pegfilgrastim-Cbqv Soln Prefilled Syringe 6mg/0.6ml (Prior Authorization Required)
  • Pegfilgrastim-Jmdb Soln Prefilled Syringe 6mg/0.6ml (Prior Authorization Required)

Removals:

  • Butalbital-Acetaminophen-Caff W/ Cod Cap 50-300-40-30 Mg
  • Butalbital-Acetaminophen-Caffeine Cap 50-300-40 Mg
  • Butalbital-Acetaminophen-Caffeine Cap 50-325-40 Mg
  • Calcium Acetate (Phosphate Binder) Oral Soln 667 Mg/5ml
  • Ciclopirox Gel 0.77%
  • Clotrimazole W/ Betamethasone Lotion 1-0.05%
  • Colestipol Hcl Granule Packets 5 Gm
  • Colestipol Hcl Granules 5 Gm
  • Entecavir Oral Soln 0.05 Mg/Ml
  • Epinastine Hcl Ophth Soln 0.05%
  • Erythromycin Ethylsuccinate For Susp 200 Mg/5ml
  • Erythromycin Ethylsuccinate For Susp 400 Mg/5ml
  • Esterified Estrogens Tab 0.3 Mg
  • Esterified Estrogens Tab 0.625 Mg
  • Esterified Estrogens Tab 1.25 Mg
  • Estradiol Tab 1 Mg(15)/Estrad-Norgestimate Tab 1-0.09mg(15)
  • Etodolac Tab Er 24hr 400 Mg
  • Etodolac Tab Er 24hr 500 Mg
  • Etodolac Tab Er 24hr 600 Mg
  • Lindane Shampoo 1%
  • Moexipril Hcl Tab 15 Mg
  • Moexipril Hcl Tab 7.5 Mg
  • Olopatadine Hcl Ophth Soln 0.2%
  • Quinidine Gluconate Tab Er 324 Mg
  • Thyroid Tab 130 Mg
  • Vagifem Tab 10mcg

Other Updates:

  • Anecream Cre 4% (Added Quantity Level Limit)
  • Armour Thyroid 180mg Tab (Quantity Level Limit)
  • Armour Thyroid 240mg Tab (Quantity Level Limit)
  • Armour Thyroid 300mg Tab (Quantity Level Limit)
  • Azelastine Hcl Ophth Soln 0.05% (Added Quantity Level Limit)
  • Betamethasone Dipropionate Oint 0.05% (Added Quantity Level Limit)
  • Calcipotriene Cream 0.005% (Added Prior Authorization Required, Quantity Limit)
  • Calcipotriene Oint 0.005% (Added Prior Authorization Required, Quantity Limit)
  • Calcipotriene Soln 0.005% (50 Mcg/Ml) (Added Prior Authorization Required, Quantity Limit)
  • Ciclopirox Olamine Cream 0.77% (Added Step Therapy)
  • Ciclopirox Olamine Susp 0.77% (Added Step Therapy)
  • Ciclopirox Shampoo 1% (Added Step Therapy)
  • Clotrimazole Soln 1% (Rx Only) (Added Step Therapy)
  • Estradiol Tab 10mcg (Quantity Level Limit)
  • Fluocinolone Acetonide Cream 0.025% (Added Quantity Level Limit)
  • Fluocinolone Acetonide Oint 0.025% (Added Quantity Level Limit)
  • Ketoconazole Cream 2% (Added Step Therapy, Quantity Limit)
  • Lc-4 Lidocne Cre 4% (Added Quantity Level Limit)
  • Lidocaine Cre 4% (Added Quantity Level Limit)
  • Lidocaine Hcl Gel 2% (Added Quantity Level Limit)
  • Lidocaine-Prilocaine Cream Kit 2.5-2.5%
  • Liothyronine Sodium Tab 5 Mcg (Added Quantity Level Limit)
  • Liothyronine Sodium Tab 50 Mcg (Added Quantity Level Limit)
  • Norethindrone Tab 0.35 Mg (Added Step Therapy)
  • Sertraline conc 20mg/mL (Added Age Limit)
  • Thyroid Tab 120 Mg (2 Grain) (Added Quantity Level Limit)
  • Thyroid Tab 15 Mg (1/4 Grain) (Added Quantity Level Limit)
  • Thyroid Tab 30 Mg (1/2 Grain) (Added Quantity Level Limit)
  • Thyroid Tab 60 Mg (1 Grain) (Added Quantity Level Limit)
  • Thyroid Tab 90 Mg (1 1/2 Grain) (Added Quantity Level Limit)

 

July 2019

Additions:

  • Mesalamine Cap 400mg (Quantity Limit)
  • Cefixime Cap 400mg (Quantity Limit)
  • Erlotinib Tab 25mg, 100mg, 150mg (Quantity Limit)

Removals:

  • Suprax Cap 400mg
  • Tarceva Tab 25mg, 100mg, 150mg

 

June 2019

Additions:

  • Docosanol Crm 10%
  • Insulin Lispro Pen Injector 100u/mL (Age Limit)
  • Insulin Lispro Sol 100u/mL

Removals:

  • Humalog Kwik Pen 100u/mL
  • Humalog Vial 100u/mL
  • Novolog Flex Pen 100u/mL
  • Novolog Sol 100u/mL

 

May 2019

Additions:

  • Nivestym Inj 300mcg (Prior Authorization Required)
  • Nivestym Inj 480mcg (Prior Authorization Required)
  • Erythromycin Sup 400/5mL
  • Sirolimus Sol 1mg/mL

Removals:

  • EryPed 400 Sus
  • Rapamune Sol 1mg/mL

 

April 2019

No Changes

 

March 2019

Additions:

  • Albuterol Aer HFA (Quantity Level Limit)        
  • Butalbital-Aspirin-Caffeine Tab 50-325-40mg (Quantity Level Limit)
  • Mesalamine Sup 1000mg        
  • Methylpred Tab 4mg (Quantity Level Limit)    
  • Nicotrol Inh  
  • Nicotrol NS Spr 10mg/ml
  • Tolnaftate Cre 1%
  • Toremifene Tab 60mg  
  • Vigabatrin Tab 500mg

Removals:

  • Canasa Suppository 1000mg
  • Fareston Tablet 60mg
  • Norethin Acet & Estrad-Fe (24)

Other Updates:

  • Butalbital-Acetaminophen-Caffeine Cap 50-325-40mg (Decreased Quantity Level Limit)
  • Butalbital-Acetaminophen-Caffeine Tab 50-325-40mg (Decreased Quantity Level Limit)
  • Butalbital-Aspirin-Caffeine Cap 50-325-40mg (Decreased Quantity Level Limit)
  • Chantix (Removed Prior Authorization

 

February 2019

Additions:

  • Arnuity Elpt 100mcg/Act
  • Arnuity Elpt 200mcg/Act
  • Arnuity Elpt 50mcg/Act
  • Calcipotrien Cre 0.005% (Quantity Level Limit)
  • Immune Globulin (Human) Iv Or Subcutaneous Soln 1 Gm/10ml (Prior Authorization Required)
  • Immune Globulin (Human) Iv Or Subcutaneous Soln 10 Gm/100ml (Prior Authorization Required)
  • Immune Globulin (Human) Iv Or Subcutaneous Soln 2.5 Gm/25ml (Prior Authorization Required)
  • Immune Globulin (Human) Iv Or Subcutaneous Soln 20 Gm/200ml (Prior Authorization Required)
  • Immune Globulin (Human) Iv Or Subcutaneous Soln 30 Gm/300ml (Prior Authorization Required)
  • Immune Globulin (Human) Iv Or Subcutaneous Soln 40 Gm/400ml (Prior Authorization Required)
  • Immune Globulin (Human) Iv Or Subcutaneous Soln 5 Gm/50ml
  • Immune Globulin (Human) Iv Soln 10 Gm/100ml (Prior Authorization Required)
  • Immune Globulin (Human) Iv Soln 20 Gm/200ml (Prior Authorization Required)
  • Immune Globulin (Human) Iv Soln 5 Gm/50ml (Prior Authorization Required)
  • Ozempic Inj (Quantity Level Limit, Step Therapy Required)
  • Ozempic Inj (Quantity Level Limit, Step Therapy Required)
  • Prenatal Mv & Min W/Fe Bisglyc-Fe Prot Succ-Fa-Ca-Omega 3 29-1-200-250mg Pack (Quantity Level Limit)
  • Prenatal Mv & Min W/Fe Fumarate-Fa-Dha 28-0.8-200mg Pack (Quantity Level Limit)
  • Prenatal Vit W/ Ferrous Fumarate-Folic Acid 27-0.8mg Tab (Quantity Level Limit)
  • Prenatal Vit W/ Ferrous Fumarate-Folic Acid 28-0.8mg Tab (Quantity Level Limit)
  • Prenatal Vit W/ Ferrous Fumarate-Folic Acid 29-1mg Tab (Quantity Level Limit)
  • Prenatal Without A Vit W/ Fe Fumarate-Folic Acid 29-1mg Chew Tab (Quantity Level Limit)
  • Prenatal Without A Vit W/ Fe Fum-Iron Polysacch Complex –Fa 130-92.4-1mg Cap (Quantity Level Limit)
  • Prenatal Without A Vit W/ Fe Fum-Iron Polysacch Complex –Fa 20-20-1.25mg Cap (Quantity Level Limit)
  • Segluromet 2.5-1000tab (Quantity Level Limit, Step Therapy Required)
  • Segluromet 2.5-500tab (Quantity Level Limit, Step Therapy Required)
  • Segluromet 7.5-1000 Tab (Quantity Level Limit, Step Therapy Required)
  • Segluromet 7.5-500 Tab (Quantity Level Limit, Step Therapy Required)
  • Steglatro 10mg Tab (Quantity Level Limit, Step Therapy Required)
  • Steglatro 5mg Tab (Quantity Level Limit, Step Therapy Required)
  • Victoza Inj (Quantity Level Limit, Step Therapy Required)
  • Eligard Kit 22.5mg (Prior Authorization Required)
  • Eligard Kit 30 Mg (Prior Authorization Required)
  • Eligard Kit 45 Mg (Prior Authorization Required)
  • Eligard Kit 7.5mg (Prior Authorization Required)
  • Leuprolide Acetate Kit 1mg/0.2ml (Prior Authorization Required)
  • Prenatal Vit W/ Docusate-Fe Fumarate-Folic Acid 29-1mg Tab (Quantity Level Limit)
  • Prenatal Vit W/ Fe Fum-Iron Polysacch Complex -Fa-Omega 3 53.5-38-1mg Cap (Quantity Level Limit)
  • Prenatal Vit W/ Ferrous Fumarate-Folic Acid 28-1mg Tab (Quantity Level Limit)
  • Prenatal Vit W/ Ferrous Fumarate-Folic Acid 29-1mg Chew Tab (Quantity Level Limit)
  • Prenatal Vit W/ Ferrous Fumarate-Folic Acid 60-1mg Tab (Quantity Level Limit)
  • Prenatal Vit W/ Iron Carbonyl-Folic Acid 29-1mg Tab (Quantity Level Limit)
  • Prenatal Without A Vit W/ Fe Fumarate-Folic Acid 106.5-1mg Cap (Quantity Level Limit)
  • Zoladex Imp 10.8mg (Prior Authorization Required)
  • Zoladex Imp 3.6mg (Prior Authorization Required)

Removals:

  • Alprazolam ODT
  • Cleocin Vag Ovu 100mg
  • Clorazepate Dipotassium Tab
  • Cortifoam Aer Rectal
  • Dihydroergotamine
  • Dulera Aer
  • Ergot/Caffen
  • Ergotamine
  • Fluticasone Propionate Aer Pow Ba 100 Mcg/Blister
  • Fluticasone Propionate Aer Pow Ba 250 Mcg/Blister
  • Fluticasone Propionate Aer Pow Ba 50 Mcg/Blister
  • Invokamet
  • Invokana Tab
  • Levonor/Ethi Tab Estradio
  • Lidocaine/Hc Kit 20x7gm
  • Lidocaine/Hc Kit 3%-1%
  • Meprobamate Tab
  • Miconazole 3 Sup 200mg
  • Neonatal Pls
  • Nitro-Bid 2% Packets
  • Penicillamine Cap 250 Mg
  • Pimecrolimus Cream 1%
  • Podofilox Gel 0.5%
  • Prenatal Mv & Min W/Fe Polysaccharide Complex-Fa-Dha 29-1mg & 250mg Pack
  • Prenatal Vit W/ Ferrous Fumarate-Folic Acid 65-1mg Tab
  • Prenatal Vit W/ Ferrous Fumarate-L Methylfolate-Folic Acid 27-0.6-0.4mg Tab
  • Prenatal Vit W/ Iron Polysaccharide Complex-Folic Acid 29-1 Chew Tab
  • Prenatal W/O Vit A W/ Fe Carbonyl-Fe Gluconate-Dss-Fa-Dha 27-1mg & 250mg Pack
  • Prenatal W/O Vit A W/ Fe Fumarate-Dss-Fa-Dha 27-1.25-300mg Cap
  • Prenatal Without A W/ Fe Fumarate-L Methylfolate-Fa-Dha 27-0.6-0.4-300mg Cap
  • Pulmicrt Flx
  • Qvar
  • Relenza     Mis Diskhale
  • Synjardy
  • Terconazole Vaginal Suppos 80 Mg
  • Thalomid Cap
  • Triazolam Capsules
  • Tricare Tab Prenatal
  • Trimethobenzamide Hcl Cap 300 Mg
  • Trulicity Inj

 

January 2019

Additions:

  • None

Removals:

  • Ibalizumab-uiyk (Trogarzo) 200mg/1.33mL IV solution

 

December 2018

Additions:

  • Filgrastim-AAFI Soln Prefilled Syringe 300mcg/0.5ml (Prior Authorization Required)
  • Filgrastim-AAFI Soln Prefilled Syringe 480mcg/0.8ml (Prior Authorization Required)

Removals:

  • Tamiflu Caps

 

November 2018

Additions:

  • Abelcet Inj 5mg/ml (Prior Authorization required)
  • Acyclovir Na Inj 500mg (Prior Authorization required)
  • Acyclovir Na Inj 50mg/ml (Prior Authorization required)
  • Albendazole Tab 200mg
  • Ambisome Inj 50mg (Prior Authorization required)
  • Aminosyn 7% Inj /Lytes (Prior Authorization required)
  • Aminosyn II Inj 8.5/Lyte (Prior Authorization required)
  • Aminosyn II Inj 7% (Prior Authorization required)
  • Aminosyn II Inj 8.5% (Prior Authorization required)
  • Aminosyn M Inj 3.5% (Prior Authorization required)
  • Aminosyn-Rf Inj 5.2% (Prior Authorization required)
  • Ampicillin Inj 10gm (Prior Authorization required)
  • Ampicillin Inj 1gm (Prior Authorization required)
  • Ampicillin Inj 2gm (Prior Authorization required)
  • Amp-Sulbacta Inj 1.5gm (Prior Authorization required)
  • Amp-Sulbacta Inj 15gm (Prior Authorization required)
  • Amp-Sulbacta Inj 3gm (Prior Authorization required)
  • Ascor Sol 25000mg (Prior Authorization required)
  • Avelox Inj (Prior Authorization required)
  • Avycaz Inj 2-0.5gm (Prior Authorization required)
  • Azactam/Dex Inj 1gm (Prior Authorization required)
  • Azactam/Dex Inj 2gm (Prior Authorization required)
  • Bactocill Inj Dex 1gm (Prior Authorization required)
  • Bactocill Inj Dex 2gm (Prior Authorization required)
  • Baxdela Inj 300mg (Prior Authorization required)
  • Calcium Cl Inj 10% (Prior Authorization required)
  • Cancidas Inj 50mg (Prior Authorization required)
  • Cancidas Inj 70mg (Prior Authorization required)
  • Cefazln/NaCl Sol 3g/100ml (Prior Authorization required)
  • Cefazol/NaCl Inj 1gm/10ml (Prior Authorization required)
  • Cefazol/NaCl Sol 2gm/100 (Prior Authorization required)
  • Cefazol/NaCl Sol 2gm/10ml (Prior Authorization required)
  • Cefazol/NaCl Sol 2gm/50ml (Prior Authorization required)
  • Cefazolin Inj 1gm (Prior Authorization required)
  • Cefazolin Inj 1gm/10ml (Prior Authorization required)
  • Cefazolin Inj 1gm/50ml (Prior Authorization required)
  • Cefazolin Inj 2gm/20ml (Prior Authorization required)
  • Cefazolin Inj 2gm/50ml (Prior Authorization required)
  • Cefazolin Sol (Prior Authorization required)
  • Cefazoln Sod Sol 3gm/20ml (Prior Authorization required)
  • Cefepime Inj 1gm (Prior Authorization required)
  • Cefepime Inj 2gm (Prior Authorization required)
  • Cefoxitin Inj 1gm (Prior Authorization required)
  • Cefoxitin Inj 1gm (Prior Authorization required)
  • Cefoxitin Inj 2gm (Prior Authorization required)
  • Cefoxitin Inj 2gm (Prior Authorization required)
  • Ceftriaxone Inj 10gm (Prior Authorization required)
  • Ceftriaxone Inj 1gm (Prior Authorization required)
  • Ceftriaxone Inj 2gm (Prior Authorization required)
  • Cefuroxime Inj 1.5gm (Prior Authorization required)
  • Chloramphen Inj 1gm (Prior Authorization required)
  • Cidofovir Inj 75mg/ml (Prior Authorization required)
  • Ciprofloxacn Inj 200mg (Prior Authorization required)
  • Ciprofloxacn Inj 200mg (Prior Authorization required)
  • Ciprofloxacn Inj 400mg (Prior Authorization required)
  • Ciprofloxacn Inj 400mg (Prior Authorization required)
  • Claforan Inj 1gm (Prior Authorization required)
  • Claforan Inj 2gm (Prior Authorization required)
  • Cleocin Phos Inj 600/4ml (Prior Authorization required)
  • Cleocin Phos Inj 900/6ml (Prior Authorization required)
  • Cleocin/D5W Inj 300mg (Prior Authorization required)
  • Cleocin/D5W Inj 600mg (Prior Authorization required)
  • Cleocin/D5W Inj 900mg (Prior Authorization required)
  • Clindamycin Inj 300/2ml (Prior Authorization required)
  • Clindmyc/NaC Inj 300/50ml (Prior Authorization required)
  • Clindmyc/NaC Inj 600/50ml (Prior Authorization required)
  • Clindmyc/NaC Inj 900/50ml (Prior Authorization required)
  • Clinimix E Inj 2.75/D10 (Prior Authorization required)
  • Clinimix E Inj 2.75/D5W (Prior Authorization required)
  • Clinimix E Inj 4.25/D10 (Prior Authorization required)
  • Clinimix E Inj 4.25/D25 (Prior Authorization required)
  • Clinimix E Inj 4.25/D5W (Prior Authorization required)
  • Clinimix E Inj 5%/D15W (Prior Authorization required)
  • Clinimix E Inj 5%/D20W (Prior Authorization required)
  • Clinimix E Inj 5%/D25W (Prior Authorization required)
  • Clinimix Inj 2.75/D5W (Prior Authorization required)
  • Clinimix Inj 4.25/D10 (Prior Authorization required)
  • Clinimix Inj 4.25/D20W (Prior Authorization required)
  • Clinimix Inj 4.25/D25 (Prior Authorization required)
  • Clinimix Inj 4.25/D5W (Prior Authorization required)
  • Clinimix Inj 5%/D15W (Prior Authorization required)
  • Clinimix Inj 5%/D20W (Prior Authorization required)
  • Clinimix Inj 5%/D25W (Prior Authorization required)
  • Clinimix Sol 2.75% (Prior Authorization required)
  • Clinimix Sol 4.25% (Prior Authorization required)
  • Clinisol SF Inj 15% (Prior Authorization required)
  • Cresemba Inj 372mg (Prior Authorization required)
  • Cubicin Sol 500mg (Prior Authorization required)
  • Cupric Chlor Inj 0.4mg/ml (Prior Authorization required)
  • Cytogam Inj (Prior Authorization required)
  • Cytovene Inj 500mg (Prior Authorization required)
  • D10w/NaCl Inj 0.2%
  • D10W/NaCl Inj 0.225%
  • D10w/NaCl Inj 0.45%
  • D2.5w/NaCl Inj 0.45%
  • D5W/LR Inj
  • D5W/Lytes Inj #48
  • D5w/NaCl Inj 0.2%
  • D5W/NaCl Inj 0.225%
  • D5W/NaCl Inj 0.3%
  • D5w/NaCl Inj 0.33%
  • D5w/NaCl Inj 0.45%
  • D5w/NaCl Inj 0.9%
  • Dalvance Sol 500mg (Prior Authorization required)
  • Daptomycin Sol 350mg (Prior Authorization required)
  • Darzalex Sol (Prior Authorization required)
  • Dextrose Inj 10%
  • Dextrose Inj 20% (Prior Authorization required)
  • Dextrose Inj 25% (Prior Authorization required)
  • Dextrose Inj 30% (Prior Authorization required)
  • Dextrose Inj 40% (Prior Authorization required)
  • Dextrose Inj 5%
  • Dextrose Inj 50% (Prior Authorization required)
  • Dextrose Inj 70% (Prior Authorization required)
  • Docetaxel Inj (Prior Authorization required)
  • Doribax Inj 250mg (Prior Authorization required)
  • Doribax Inj 500mg (Prior Authorization required)
  • Doxorubicin Inj 2mg/ml (Prior Authorization required)
  • Doxy 100 Inj 100mg (Prior Authorization required)
  • Eraxis Inj 100mg (Prior Authorization required)
  • Eraxis Inj 50mg (Prior Authorization required)
  • Erythrocin Inj 500mg (Prior Authorization required)
  • Fluconazole/ Inj Dex 200 (Prior Authorization required)
  • Fluconazole/ Inj Dex 400 (Prior Authorization required)
  • Fluconazole/ Inj Nacl 100 (Prior Authorization required)
  • Fluconazole/ Inj Nacl 200 (Prior Authorization required)
  • Fluconazole/ Inj Nacl 400 (Prior Authorization required)
  • Fluticasone-Salmeterol Aer Powder Ba 113-14 Mcg/Act (Quantity Level Limit)
  • Fluticasone-Salmeterol Aer Powder Ba 232-14 Mcg/Act (Quantity Level Limit)
  • Fluticasone-Salmeterol Aer Powder Ba 55-14 Mcg/Act (Quantity Level Limit)
  • Fortaz Inj 1gm (Prior Authorization required)
  • Fortaz Inj 2gm (Prior Authorization required)
  • Foscavir Inj 24mg/ml (Prior Authorization required)
  • Freamine Hbc Inj 6.9% (Prior Authorization required)
  • Freamine III Inj 10% (Prior Authorization required)
  • Ganciclovir Inj 500/25 (Prior Authorization required)
  • Ganciclovir Inj 500mg (Prior Authorization required)
  • Gentam/NaCl Inj 0.9mg/ml (Prior Authorization required)
  • Gentam/NaCl Inj 1.4mg/ml (Prior Authorization required)
  • Gentam/NaCl Inj 100mg (Prior Authorization required)
  • Gentam/NaCl Inj 100mg (Prior Authorization required)
  • Gentam/NaCl Inj 60mg (Prior Authorization required)
  • Gentam/NaCl Inj 80mg (Prior Authorization required)
  • Gentam/NaCl Inj 80mg (Prior Authorization required)
  • Hepatamine Sol 8% (Prior Authorization required)
  • Herceptin Inj 150mg (Prior Authorization required)
  • Hyperlyte-Cr Inj
  • Infuvite Inj (Prior Authorization required)
  • Infuvite Inj Pediatri (Prior Authorization required)
  • Injectafer Inj 750/15ml (Prior Authorization required)
  • Intralipid Inj 20% (Prior Authorization required)
  • Intralipid Inj 30% (Prior Authorization required)
  • Invanz Inj 1gm (Prior Authorization required)
  • Ionosol-B/ Inj D5W
  • Ionosol-Mb Inj /D5W
  • Isolyte-P Inj /D5W
  • Isolyte-S Inj
  • Isolyte-S Inj Ph 7.4
  • Kabiven EMU (Prior Authorization required)
  • KCl/D5W/Lact Inj 20meq/L
  • KCl/D5W/Lact Inj 40meq/L
  • KCl/D5W/NaCl Inj .075/.45
  • KCl/D5W/NaCl Inj .15-.45%
  • KCl/D5W/NaCl Inj .15/.33%
  • KCl/D5W/NaCl Inj .224/.45
  • KCl/D5W/NaCl Inj 0.15/0.2
  • Kcl/D5W/Nacl Inj 0.15/0.2
  • KCl/D5W/NaCl Inj 0.15/0.9
  • KCl/D5W/NaCl Inj 0.3/0.45
  • KCl/D5W/NaCl Inj 0.3/0.9%
  • KCl/Lido/D5W Sol 20/100ml
  • KCl/Lidocain Inj NaCl
  • KCl/NaCl Inj 10/100ml
  • KCl/NaCl Inj 30/100ml
  • KCl/NaCl Inj 40/250ml
  • Lactated Rin Inj
  • Lartruvo Inj (Prior Authorization required)
  • L-Cysteine Inj 50mg/ml (Prior Authorization required)
  • Levoflox/D5W Inj 250/50ml (Prior Authorization required)
  • Levoflox/D5W Inj 500/100ml (Prior Authorization required)
  • Levoflox/D5W Inj 750/150ml (Prior Authorization required)
  • Levofloxacin Inj 25mg/ml (Prior Authorization required)
  • Linezolid Inj 2mg/ml (Prior Authorization required)
  • Liquilift Kit Trace (Prior Authorization required)
  • Maxipime Inj 1gm (Prior Authorization required)
  • Maxipime Inj 2gm (Prior Authorization required)
  • Merrem Inj 1gm (Prior Authorization required)
  • Merrem Inj 500mg (Prior Authorization required)
  • Metron/Nacl Inj 500mg (Prior Authorization required)
  • Metronidazol Inj 5mg/ml (Prior Authorization required)
  • Metronidazol Inj 5mg/ml (Prior Authorization required)
  • Minocin Inj 100mg (Prior Authorization required)
  • Moxifloxacin Inj (Prior Authorization required)
  • Multitrace-4 Inj (Prior Authorization required)
  • Multitrace-4 Inj Conc (Prior Authorization required)
  • Multitrace-4 Inj Neonatal (Prior Authorization required)
  • Multitrace-4 Inj Ped (Prior Authorization required)
  • Multitrace-5 Inj Conc (Prior Authorization required)
  • Multitrace-5 Inj Regular (Prior Authorization required)
  • Mycamine Inj 100mg (Prior Authorization required)
  • Mycamine Inj 50mg (Prior Authorization required)
  • Nafcillin Inj 10gm (Prior Authorization required)
  • Nafcillin Inj 1gm (Prior Authorization required)
  • Nafcillin Inj 1gm/50ml (Prior Authorization required)
  • Nafcillin Inj 2gm (Prior Authorization required)
  • Nafcillin Inj 2gm/100 (Prior Authorization required)
  • Nephramine   Inj 5.4% (Prior Authorization required)
  • Norml Saline Inj Flush
  • Normosol -M Inj /D5W
  • Normosol -R Inj
  • Normosol -R Inj /D5W
  • Normosol-R Inj Ph 7.4
  • Noxafil Inj 300/16.7 (Prior Authorization required)
  • Nutrilyte Inj
  • Opdivo Inj (Prior Authorization required)
  • Oral Electrolyte Sol
  • Orbactiv Sol 400mg (Prior Authorization required)
  • Penicill Gk/ Inj Dex 1MU (Prior Authorization required)
  • Penicill Gk/ Inj Dex 2MU (Prior Authorization required)
  • Penicill Gk/ Inj Dex 3MU (Prior Authorization required)
  • Perikabiven EMU (Prior Authorization required)
  • Piper/Tazoba Inj 12-1.5gm (Prior Authorization required)
  • Plasma-Lyte Inj -148
  • Plasma-Lyte Inj -A
  • Plasma-Lyte Inj 56/D5W
  • Pot Chl/D5W Inj 20meq/L
  • Pot Chl/D5W Inj 40meq/L
  • Pot Chl/NaCl Inj 20meq/L
  • Pot Chl/NaCl Inj 20meq/L
  • Pot Chl/NaCl Inj 40meq/L
  • Potassium Ch Inj NaCl
  • Potassium Ch Inj NaCl
  • Prevymis Inj 240/12 (Prior Authorization required)
  • Prevymis Inj 480/24 (Prior Authorization required)
  • Primaxin IV Inj 250mg (Prior Authorization required)
  • Primaxin IV Inj 500mg (Prior Authorization required)
  • Procalamine Inj 3% (Prior Authorization required)
  • Proparacaine Sol 0.5% Op
  • Prosol Inj 20% (Prior Authorization required)
  • Rapivab Inj 200mg/20 (Prior Authorization required)
  • Retrovir Inj 10mg/ml (Prior Authorization required)
  • Rifadin Inj 600 mg (Prior Authorization required)
  • Ringers Inj
  • Rituxan Inj 500mg (Prior Authorization required)
  • Selenium Inj 40mcg/ml (Prior Authorization required)
  • Sensipar Tab
  • Sivextro Inj 200mg (Prior Authorization required)
  • Smoflipid EMU (Prior Authorization required)
  • SMZ-TMP Inj 400-80/5 (Prior Authorization required)
  • Sod Acetate Inj 2meq/ml (Prior Authorization required)
  • Sod Acetate Inj 4meq/ml (Prior Authorization required)
  • Sod Chloride Inj 0.45%
  • Sod Chloride Inj 0.9%
  • Sod Chloride Inj 23.4%
  • Sod Chloride Inj 3%
  • Sod Chloride Inj 5%
  • Sod Cit-Gent Inj 4%-320 (Prior Authorization required)
  • Steril Water Inj
  • Sterile Dilu Sol Flolan
  • Synercid Inj 500mg (Prior Authorization required)
  • Tazicef Inj 1gm (Prior Authorization required)
  • Tazicef Inj 1gm/50ml (Prior Authorization required)
  • Tazicef Inj 2gm (Prior Authorization required)
  • Teflaro Inj 400mg (Prior Authorization required)
  • Teflaro Inj 600mg (Prior Authorization required)
  • Trace Elem 4 Inj Ped (Prior Authorization required)
  • Trogarzo Inj 150mg/ml (Prior Authorization required)
  • Trophamine   Inj 6% (Prior Authorization required)
  • Tygacil Inj 50mg (Prior Authorization required)
  • Vabomere Inj 2gm(1-1) (Prior Authorization required)
  • Vancomycin Inj 1000mg (Prior Authorization required)
  • Vancomycin Inj 100gm (Prior Authorization required)
  • Vancomycin Inj 10gm (Prior Authorization required)
  • Vancomycin Inj 1gm (Prior Authorization required)
  • Vancomycin Inj 500mg (Prior Authorization required)
  • Vancomycin Inj 500mg (Prior Authorization required)
  • Vancomycin Inj 5gm (Prior Authorization required)
  • Vancomycin Inj 750mg (Prior Authorization required)
  • Vancomycin Inj 750mg (Prior Authorization required)
  • Venofer Inj 20mg/ml (Prior Authorization required)
  • Vfend IV Inj 200mg (Prior Authorization required)
  • Vibativ Inj 250mg (Prior Authorization required)
  • Vibativ Inj 750mg (Prior Authorization required)
  • Vincristine Inj 1mg/ml (Prior Authorization required)
  • Zemdri Inj 500mg/10 (Prior Authorization required)
  • Zerbaxa Inj 1.5gm (Prior Authorization required)
  • Zinacef Inj 750mg (Prior Authorization required)
  • Zithromax Inj 500mg (Prior Authorization required)
  • Zosyn Inj 2-0.25gm (Prior Authorization required)
  • Zosyn Inj 3-0.375g (Prior Authorization required)
  • Zosyn Inj 36-4.5gm (Prior Authorization required)
  • Zosyn Inj 4-0.5gm (Prior Authorization required)
  • Zosyn Sol 2-0.25gm (Prior Authorization required)
  • Zosyn Sol 3-0.375g (Prior Authorization required)
  • Zosyn Sol 4-0.50gm (Prior Authorization required)
  • Zyvox Sol 2mg/ml (Prior Authorization required)
  • Zyvox Sol 2mg/ml (Prior Authorization required)

Removals:

  • Albenza Tab 200mg

 

October 2018

Additions:

  • Loratadine Chw 5mg Tab (Quantity Level Limit)
  • Prasugrel Tab 10mg (Quantity Level Limit)
  • Prasugrel Tab 5mg (Quantity Level Limit)
  • Tadalafil 20mg (PAH) (Quantity Level Limit)
  • Tazarotene Cre 0.1% (Quantity Level Limit)
  • Tizanidine HCl Tab 2mg (Quantity Level Limit)
  • Tizanidine HCl Tab 4mg (Quantity Level Limit)
  • Tymlos Pen 3120mcg (Prior Authorization Required, Quantity Level Limit)
  • Valganciclov Tab 450mg (Quantity Level Limit)

Removals:

  • Adcirca Tab 20mg

Other Updates:

  • Ondansetron HCl Tab 4mg (Increased Quantity Level Limit)
  • Ondansetron HCl Tab 8mg (Increased Quantity Level Limit)

 

September 2018

Additions:

  • Humira Pen Kit CD/UC/HS Starter Kit 80mg/0.8ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Pen 80mg/ml and 40mg/0.4ml Kit PS/UV Starter Kit (Prior Authorization Required, Quantity Level Limit)

 

August 2018

Additions:

  • Epoetin Alfa-Epbx Inj (Prior Authorization Required)
  • Hydroxyprogesterone Inj 250mg/ml
  • Ibuprofen Tab 100mg Jr
  • Omega-3-Acid Cap 1gm (Quantity Level Limit, Step Therapy Required)
  • Sevelamer Tab 800mg (Step Therapy Required)
  • Telmisartan Tab (Quantity Level Limit)
  • Tolterodine Cap ER (Quantity Level Limit, Step Therapy Required)
  • Verzenio Tab (Prior Authorization Required, Quantity Level Limit)

Removals:

  • Amlodipine-Valsartan-Hydrochlorothiazide
  • Benzonatate Cap 150mg
  • Betaxolol
  • Captopril Tab
  • Captopril-Hydrochlorothiazide
  • Chlorpropamide
  • Climara Pro Patch Weekly
  • Desipramine
  • Diltiazem CD Cap 360/24hr
  • Femring
  • Fenofibrate Tab 145mg
  • Fenofibrate Tab 48mg
  • Fenofibric Cap DR
  • Fenoprofen Tab 600mg
  • Lidocaine Cre 3%
  • Makena Oil 250mg/ml
  • Meclofenamate Sod Cap
  • Methyltestos Cap 10mg
  • Nadolol
  • Nisoldipine Tab ER
  • Ondansetron Sol 4mg/5ml
  • Oxaprozin Tab 600mg
  • Oxytrol Patch
  • Pindolol
  • Pioglitazone-Glimepiride
  • Pioglitazone-Metformin
  • Potassium/Sodium Citrates & Citric Acid
  • Premarin Tabs
  • Premarin Vag Cre 0.625mg
  • Prempro And Premphase Tabs
  • Protriptyline
  • Tolazamide
  • Tolbutamide 500mg Tab
  • Verapamil Extended Release 24 Hour Cap 200mg
  • Verapamil Extended Release 24 Hour Cap 300mg

Other Updates:

  • Amlodipine Besylate Tab 2.5mg, 5mg (Increased Quantity Level Limit)
  • Baraclude Sol .05mg/ml (Added Quantity Level Limit)
  • Benazepril Tab 5mg, 10mg, 20mg (Quantity Level Limit Increased)
  • Benzonatate Cap 100mg, 200mg (Added Age Limit, Added Quantity Level Limit)
  • Bupropion SR (Removed Prior Authorization)
  • Clonidine-TTS Dis (Added Step Therapy)
  • Diclofenac Gel 1% (Removed Prior Authorization, Added Quantity Level Limit)
  • Diltiazem CD Capsule Extended Release 24 Hour 180mg (Increased Quantity Level Limit)
  • Diltiazem HCl ER Capsule Extended Release 24hr 180mg Oral (Increased Quantity Level Limit)
  • Diltiazem HCl ER Beads Capsule Extended Release 24 Hour 180mg (Increased Quantity Level Limit)
  • Elmiron Cap 100mg (Added Prior Authorization)
  • Enalapril Tab 2.5mg, 5mg, 10mg (Increased Quantity Level Limit)
  • Estradiol Vag Cre 0.01% (Added Prior Authorization)
  • Flunisolide Nasal Soln 25mcg/Act (0.025%) (Added Quantity Level Limit)
  • Fosinopril Tab 10mg, 20mg (Increased Quantity Level Limit)
  • Griseofulvin Sus 125/5ml (Added Step Therapy)
  • Griseofulvin Tab Micr 500mg (Added Step Therapy)
  • Griseofulvin Tab Ultr (Added Step Therapy)
  • Hydrocodone W/ Homatropine Syrup, Tablet (Added Age Limit, Added Quantity Level Limit)
  • Lidocaine 5% Ointment (Added Prior Authorization)
  • Lisinopril Tab 2.5mg, 5mg, 10mg, 20mg, 30mg (Increased Quantity Level Limit)
  • Losartan Potassium Tab 25mg, 50mg (Increased Quantity Level Limit)
  • Mometasone Furoate Nasal Susp 50mcg/ACT (Added Quantity Level Limit)
  • Oxybutynin ER 15mg Tablet (Increased Quantity Level Limit)
  • Oxybutynin IR 5mg Tablet (Increased Quantity Level Limit)
  • Oxybutynin Syrup (Added Quantity Level Limit)
  • Propranolol Cap 80mg ER (Decreased Quantity Level Limit)
  • Quinapril Tab 5mg, 10mg, 20mg (Increased Quantity Level Limit)
  • Ramipril Cap 1.25mg, 2.5mg, 5mg (Increased Quantity Level Limit)
  • Tolterodine Tab (Added Step Therapy)
  • Verapamil HCl ER Tablet Extended Release 120mg (Increased Quantity Level Limit)

 

July 2018

Additions:

  • Baclofen Tab 5 Mg (Quantity Level Limit)
  • Diphenhydramine Liq 6.25mg
  • Pediatric Multiple Vitamins W/ Iron Drops 11 Mg/Ml
  • Phytonadione Tab 5mg
  • Zenpep Cap 15000 Unit
  • Zenpep Cap 3000 Unit    

Removals:

  • Mephyton Tab 5mg

 

June 2018

Additions:

  • Humira Pedia Inj Crohns Prefilled Syringe Kit 80mg/0.8ml & 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Pedia Inj Crohns Prefilled Syringe Kit 80mg/0.8ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Pen-injector kit 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Prefilled Syringe Kit 10mg/0.1ml, 20mg/0.2ml, 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
  • Polyethylene Glycol 3350 Powder (Quantity Level Limit)
  • Praziqueantel Tab 600mg
  • Tasigna 50mg (Prior Authorization Required, Quantity Level Limit)
  • Zenpep 10000 Unit

Removals:

  • Biltricide Tab 600mg

 

May 2018

Additions:

  • Colchicine Cap 0.6mg (Quantity Level Limit)
  • Firvanq Sol 25mg/Ml; 50mg/Ml
  • Flovent Hfa 44mcg , 110mcg, 220mcg (Quantity Level Limit)
  • Imbruvica Cap 70mg (Quantity Level Limit)
  • Jardiance Tablet (Quantity Level Limit, Step Therapy Required)
  • Synjardy Tablet & Synjardy Xr 5mg/1000mg; 12.5mg/1000mg; 10mg/1000mg; 25mg/1000mg (Quantity Level Limit, Step Therapy Required)

Other Updates:

  • Rosuvastatin Tablets (Remove Prior Authorization, Added Step Therapy)

 

April 2018

Additions:

  • Zenpep Cap 5000-17000-24000 UNIT; 25000-79000-105000 UNIT

 

March 2018

  • No Formulary Updates

 

February 2018

Additions:

  • Armodafanil 50, 150, 200, 250 mg tablets (Prior Authorization Required, Quantity Level Limit)
  • Estradiol   Cre 0.01%    
  • Janumet 50-1000 MG, 50-500 MG (Quantity Level Limit, Step Therapy Required)
  • Janumet XR ER 24HR 50-1000 MG, 50-500 MG, 00-1000 MG (Quantity Level Limit, Step Therapy Required)
  • Januvia 100 MG, 25 MG, 50 MG (Quantity Level Limit, Step Therapy Required)
  • Qvar Rediha Aer 40MCG, 80MCG (Quantity Level Limit)
  • Sprycel tablets, all strengths (Prior Authorization Required, Quantity Level Limit)
  • Tamiflu 30 mg, 45mg, 75mg (Quantity Level Limit)

Removals:

  • Betoptic-S susp 0.25%
  • Brimonidine 0.15% ophth soln
  • Cefaclor ER tablets 500 mg; Use Cefaclor IR
  • Cefixime Suspension, all strengths
  • Cephalexin tablets, all strengths; Use capsules
  • Ciloxan ointment 0.3%
  • Ciprofloxacin ER tablets, all strengths; Use ciprofloxacin IR
  • Estrace Cream 0.01%
  • FML Forte 0.25%
  • Fondaparinux, all strengths
  • Fragmin, all strengths
  • Gatifloxacin solution 0.5%
  • Jentadueto 2.5/1000 mg, 2.5/850 mg, 2.5/500 mg tablets
  • Jentadueto XR 2.5-1000 MG, 5-1000 MG
  • Modafinil tablets 100 MG, 200 MG
  • Morphine ER Capsule (generic Kadian), all strengths
  • Moxifloxacin Solution 0.5%
  • Neomycin/polymixin/HC Susp
  • Ofloxacin tablets, all strengths
  • Oxycodone 5mg CAPSULE, Use tablets
  • Oxycodone concentrated solution (20mg/mL)
  • Oxycontin, all strengths
  • Oxymorphone IR tablets, all strengths
  • Pen needles; Use BD brand
  • Pred Mild 0.12%
  • Suprax chew tablets, all strengths
  • Tobradex Ointment 0.3-0.1%
  • Tobradex ST Suspension 0.3-0.05%
  • Tobramycin/dexamethasone Suspension 0.3-0.1%
  • Tobrex Ointment 0.3%
  • Tradjenta 5mg