EFFECTIVE 01/04/2019 ONE-DAILY MULTI-VIT POWDER PKT. - Added to Tier 2 ONE-DAILY MULTIVIT-MINERAL PWD. - Added to Tier 2.
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- Terence Hodge
- 5 years ago
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1 EFFECTIVE 01/04/2019 ONE-DAILY MULTI-VIT POWDER PKT multivitamin ONE-DAILY MULTIVIT-MINERAL PWD multivitamin-mineral/ferrous sulfate PAGE 1 LAST UPDATED 03/2019
2 EFFECTIVE 01/05/2018 ZYPREXA ZYDIS 10 MG TABLET olanzapine ZYPREXA ZYDIS 15 MG TABLET olanzapine ZYPREXA ZYDIS 20 MG TABLET olanzapine ZYPREXA ZYDIS 5 MG TABLET olanzapine - PA Added: PA APPLIES - PA Added: PA APPLIES - PA Added: PA APPLIES - PA Added: PA APPLIES PAGE 2 LAST UPDATED 03/2019
3 EFFECTIVE 01/05/2019 pantoprazole sodium 20 mg tablet dr pantoprazole sodium 40 mg tablet dr PROTONIX DR 20 MG TABLET pantoprazole sodium PROTONIX DR 40 MG TABLET pantoprazole sodium - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES PAGE 3 LAST UPDATED 03/2019
4 EFFECTIVE 01/12/2018 LATUDA 40 MG TABLET lurasidone hcl LATUDA 80 MG TABLET lurasidone hcl PAGE 4 LAST UPDATED 03/2019
5 EFFECTIVE 01/18/2019 CEROVITE JR TABLET CHEW pediatric multivitamin no.158/ferrous fumarate/phytonadione PAGE 5 LAST UPDATED 03/2019
6 EFFECTIVE 01/19/2018 multivit-min/folic/vit k/lycop tablet sertraline hcl 100 mg tablet sertraline hcl 25 mg tablet sertraline hcl 50 mg tablet PAGE 6 LAST UPDATED 03/2019
7 EFFECTIVE 01/25/2019 MICRODOT PEN NEEDLE 31GX6MM pen needle, diabetic MICRODOT PEN NEEDLE 32GX4MM pen needle, diabetic MICRODOT PEN NEEDLE 33GX4MM pen needle, diabetic PAGE 7 LAST UPDATED 03/2019
8 EFFECTIVE 01/26/2018 INFED 100 MG/2 ML VIAL iron dextran complex SAPHRIS 5 MG TAB SUBLINGUAL asenapine maleate ZOFRAN ODT 8 MG TABLET ondansetron - PA Added: PA APPLIES PAGE 8 LAST UPDATED 03/2019
9 EFFECTIVE 01/27/2018 multivit-min/fa/lycopen/lutein tablet VENLAFAXINE HCL ER 225 MG TAB venlafaxine hcl PAGE 9 LAST UPDATED 03/2019
10 EFFECTIVE 02/01/2018 ACCU-CHEK AVIVA CONNECT METER blood-glucose meter ACCU-CHEK AVIVA PLUS METER blood-glucose meter ACCU-CHEK AVIVA PLUS TEST STRP ACCU-CHEK AVIVA TEST STRIPS ACCU-CHEK COMPACT PLUS KIT blood-glucose meter, drum-type ACCU-CHEK COMPACT PLUS STRIPS, drum-type ACCU-CHEK GUIDE MONITOR SYSTEM blood-glucose meter ACCU-CHEK GUIDE TEST STRIP ACCU-CHEK NANO SMARTVIEW METER blood-glucose meter ACCU-CHEK SMARTVIEW TEST STRIP ONETOUCH ULTRA2 GLUCOSE SYST blood-glucose meter ONETOUCH ULTRAMINI METER blood-glucose meter ONETOUCH VERIO FLEX SYSTEM KIT blood-glucose meter ONETOUCH VERIO IQ METER blood-glucose meter ONETOUCH VERIO METER SYSTEM blood-glucose meter ONETOUCH VERIO SYNC SYST KIT blood-glucose meter - Removed From Coverage - Removed From Coverage - QL Removed: 1 / 365 day(s) - Removed From Coverage - Removed From Coverage PAGE 10 LAST UPDATED 03/2019
11 EFFECTIVE 02/01/2018 ONETOUCH VERIO TEST STRIP - Removed From Coverage PAGE 11 LAST UPDATED 03/2019
12 EFFECTIVE 02/01/2019 ibuprofen 200 mg tablet PAGE 12 LAST UPDATED 03/2019
13 EFFECTIVE 02/02/2018 ferrous sulfate 27 mg iron tablet pedi multivit no.140/iron fum 18 mg tab chew PAGE 13 LAST UPDATED 03/2019
14 EFFECTIVE 02/03/2018 LITE TOUCH 28G LANCETS lancets PAGE 14 LAST UPDATED 03/2019
15 EFFECTIVE 02/06/2019 NARCAN 4 MG NASAL SPRAY naloxone hcl - PA Removed: PA APPLIES - Added: IN PATIENTS TAKING >90 MED, CONCURRENT BENZO, OR INCREASED RISK OF OVERDOSE ONLY PAGE 15 LAST UPDATED 03/2019
16 EFFECTIVE 02/08/2019 TRUE COMFORT PEN NDL 31GX5MM pen needle, diabetic TRUE COMFORT PEN NDL 31GX6MM pen needle, diabetic TRUE COMFORT PEN NDL 32GX4MM pen needle, diabetic PAGE 16 LAST UPDATED 03/2019
17 EFFECTIVE 02/09/2018 CEROVITE JR TABLET CHEW pediatric multivitamin no.158/ferrous fumarate/phytonadione multivit-minerals/folic acid 0.4 mg tablet multivit-minerals/folic acid 200 mcg tab chew pediatric multivitamin no.120 tab chew PAGE 17 LAST UPDATED 03/2019
18 EFFECTIVE 02/15/2018 QVAR REDIHALER 40 MCG beclomethasone dipropionate QVAR REDIHALER 80 MCG beclomethasone dipropionate PAGE 18 LAST UPDATED 03/2019
19 EFFECTIVE 02/15/2019 MUCUS-CHEST CONG 200 MG/10 ML guaifenesin PAGE 19 LAST UPDATED 03/2019
20 EFFECTIVE 02/16/2018 ferrous fumarate/ascorbic acid 65mg-25 mg tablet er PAGE 20 LAST UPDATED 03/2019
21 EFFECTIVE 02/22/2019 acetaminophen 325 mg tablet PAGE 21 LAST UPDATED 03/2019
22 EFFECTIVE 03/01/2019 eletriptan hydrobromide 20 mg tablet eletriptan hydrobromide 40 mg tablet fluticasone propion/salmeterol mcg blst w/dev fluticasone propion/salmeterol mcg blst w/dev fluticasone propion/salmeterol mcg blst w/dev RELPAX 20 MG TABLET eletriptan hydrobromide RELPAX 40 MG TABLET eletriptan hydrobromide - QL Removed: 12 / 30 DAYS - QL Removed: 12 / 30 DAYS - QL Added: 2 / DAY - QL Added: 2 / DAY - QL Added: 2 / DAY - QL Removed: 12 / 30 DAYS - QL Removed: 12 / 30 DAYS PAGE 22 LAST UPDATED 03/2019
23 EFFECTIVE 03/02/2018 ADULTS' DAILY FORMULA TABLET multivitamin with minerals/ferrous fumarate/vitamin k PAGE 23 LAST UPDATED 03/2019
24 EFFECTIVE 03/08/2019 PRENATAL DAILY DUO COMBO PACK multivit-min/iron/folic acid/omega3/dha/epa/herbal/digestive PRO COMFORT PEN NDL 4MM 32G pen needle, diabetic progesterone 50 mg/ml vial ULTICARE PEN NEEDLES 6MM 32G pen needle, diabetic PAGE 24 LAST UPDATED 03/2019
25 EFFECTIVE 03/09/2018 ferrous sulfate, dried 144(45) mg tablet er methylphenidate hcl 10 mg cpbp Tier Decreased: Tier 2 to Tier 1 PAGE 25 LAST UPDATED 03/2019
26 EFFECTIVE 03/10/2018 ARTHRITIS HOT PAIN RELIEF CRM methyl salicylate/menthol - Removed From Coverage PAGE 26 LAST UPDATED 03/2019
27 EFFECTIVE 03/15/2019 dexamethasone 1.5mg (21) tab ds pk MVW COMPLETE FORMUL D5000 CHEW pediatric multivit no.22/cholecalciferol(d3)/phytonadione(k) NOVAMV MULTIVITAMIN DROP pediatric multivitamin no.173 POLY-VI-SOL 0.5 ML ORAL SYRING pediatric multivitamin no.81 prenatal no.144/folic acid 400 mcg tab chew PAGE 27 LAST UPDATED 03/2019
28 EFFECTIVE 03/16/2018 DINO-LIFE IRON-ZINC TAB CHEW pediatric multivitamin no.159/ferrous sulfate HONEY BEARS IRON-ZINC TAB CHEW pediatric multivitamin no.159/ferrous sulfate HONEY BEARS-IRON-ZINC TAB CHEW pediatric multivitamin no.159/ferrous sulfate - Tier Increased: Tier 1 to Tier 2 - Tier Increased: Tier 1 to Tier 2 - Tier Increased: Tier 1 to Tier 2 PAGE 28 LAST UPDATED 03/2019
29 EFFECTIVE 03/17/2018 ibuprofen 600 mg tablet ibuprofen 800 mg tablet PAGE 29 LAST UPDATED 03/2019
30 EFFECTIVE 03/23/2018 ABDEK MULTIVITAMIN CHEW TAB pediatric multivit 153/cholecalciferol(d3)/phytonadione(k) ABDEK MULTIVITAMIN DROP pediatric multivit 152/cholecalciferol(d3)/phytonadione(k) ABDEK MULTIVITAMIN SOFTGEL multivitamin-minerals no.58/cholecalciferol (vit d3)/vit k1 multivit-min/iron/folic acid/k tablet - Tier Increased: Tier 1 to Tier 2 - Tier Increased: Tier 1 to Tier 2 - Tier Increased: Tier 1 to Tier 2 PAGE 30 LAST UPDATED 03/2019
31 EFFECTIVE 03/30/2018 acetaminophen 160 mg tab chew cholecalciferol (vitamin d3) unit capsule DEKAS BARIATRIC CHEW TABLET multivit-minerals/iron fum/folic acid/vit k1/choline/coq10 MAXIMUM D3 10,000 UNIT CAPSULE cholecalciferol (vitamin d3) - Tier Increased: Tier 1 to Tier 2 PAGE 31 LAST UPDATED 03/2019
32 EFFECTIVE 04/06/2018 acetaminophen 160 mg tab chew FER-IN-SOL 15 MG/ML DROPS ferrous sulfate - Tier Increased: Tier 1 to Tier 2 ferrous sulfate 15 mg/ml drops PAGE 32 LAST UPDATED 03/2019
33 EFFECTIVE 04/13/2018 EASY GLIDE PEN NEEDLE 4MM 33G pen needle, diabetic multivit-minerals/ferrous gluc 9 mg/15 ml liquid vit a palmitate/vit c/vit d /ml drops PAGE 33 LAST UPDATED 03/2019
34 EFFECTIVE 04/20/2018 ASSURE ID SYR 0.5 ML 29GX1/2" syringe with needle, insulin, safety, 0.5 ml ASSURE ID SYR 1 ML 29GX1/2" syringe with needle, insulin, safety, 1 ml BD SAFETYGLID INS 1 ML 6MMX31G syringe with needle, insulin, safety, 1 ml BD SAFTYGLD INS 0.3 ML 6MMX31G syringe with needle, insulin, safety, 0.3 ml BD SAFTYGLD INS 0.5 ML 6MMX31G syringe with needle, insulin, safety, 0.5 ml EASY TOUCH PEN NEEDLE 30GX5/16 pen needle, diabetic PAGE 34 LAST UPDATED 03/2019
35 EFFECTIVE 04/27/2018 acetaminophen 325 mg tablet diphenhydramine hcl 25 mg tablet FLORIVA PLUS 0.25 MG/ML DROP pediatric multivitamin no.161/sodium fluoride iron/fa/c/e/b12/bio/copper/dss tablet PEDIA POLY-VITE WITH IRON DROP pediatric multivitamin no.160/ferrous sulfate PAGE 35 LAST UPDATED 03/2019
36 EFFECTIVE 05/04/2018 aspirin 81 mg tab chew BD INS SYRNG UF 0.3 ML 8MMX31G syringe with needle,insulin,0.3 ml BD INS SYRNG UF 0.5 ML 8MMX31G syringe with needle,insulin,0.5 ml BD INSULIN SYR UF 1 ML 8MMX31G syringe with needle,disposable,insulin 1 ml dexamethasone 0.5 mg/5ml elixir multivit34/folic ac/nadh/coq mg tablet TECHLITE INS SYR 1 ML 29GX12MM syringe with needle,disposable,insulin 1 ml TECHLITE INS SYR 1 ML 30GX12MM syringe with needle,disposable,insulin 1 ml TECHLITE INS SYR 1 ML 30GX8MM syringe with needle,disposable,insulin 1 ml TECHLITE INS SYR 1 ML 31GX6MM syringe with needle,disposable,insulin 1 ml TECHLITE INS SYR 1 ML 31GX8MM syringe with needle,disposable,insulin 1 ml PAGE 36 LAST UPDATED 03/2019
37 EFFECTIVE 05/11/2018 LITETOUCH SYR 0.5 ML 30GX5/16" syringe with needle,insulin,0.5 ml TECHLITE 0.3 ML 29GX12MM (1/2) syringe with needle,insulin 0.3 ml (half unit mark) TECHLITE 0.3 ML 30GX12MM (1/2) syringe with needle,insulin 0.3 ml (half unit mark) TECHLITE 0.3 ML 30GX8MM (1/2) syringe with needle,insulin 0.3 ml (half unit mark) TECHLITE 0.3 ML 31GX6MM (1/2) syringe with needle,insulin 0.3 ml (half unit mark) TECHLITE 0.3 ML 31GX8MM (1/2) syringe with needle,insulin 0.3 ml (half unit mark) TECHLITE 0.5 ML 29GX12MM (1/2) syringe with needle,insulin 0.5 ml (half unit mark) TECHLITE 0.5 ML 30GX12MM (1/2) syringe with needle,insulin 0.5 ml (half unit mark) TECHLITE 0.5 ML 30GX8MM (1/2) syringe with needle,insulin 0.5 ml (half unit mark) TECHLITE 0.5 ML 31GX6MM (1/2) syringe with needle,insulin 0.5 ml (half unit mark) TECHLITE 0.5 ML 31GX8MM (1/2) syringe with needle,insulin 0.5 ml (half unit mark) PAGE 37 LAST UPDATED 03/2019
38 EFFECTIVE 05/18/2018 HEMAX TABLET iron,carbonyl/methylfolate/vit c/vit e/vit b12/biotin/copper ONETOUCH SURESOFT 18G LANC DEV lancets ONETOUCH SURESOFT 21G LANC DEV lancets UNISTIK PRO 21G LANCET lancets UNISTIK PRO 25G LANCET lancets UNISTIK PRO 28G LANCET lancets - QL Change: 1 / 365 DAYS to 200 / 30 day(s) - QL Change: 1 / 365 DAYS to 200 / 30 day(s) - QL Added: 200 / 30 day(s) - QL Added: 200 / 30 day(s) - QL Added: 200 / 30 day(s) PAGE 38 LAST UPDATED 03/2019
39 EFFECTIVE 05/19/2018 sennosides/docusate sodium 8.6mg- 50mg tablet PAGE 39 LAST UPDATED 03/2019
40 EFFECTIVE 05/25/2018 BD INS SYRNG 0.3 ML 29GX12.7MM syringe with needle,insulin,0.3 ml BD INS SYRNG 0.5 ML 29GX12.7MM syringe with needle,insulin,0.5 ml BD INSULIN SYR 1 ML 27GX12.7MM syringe with needle,disposable,insulin 1 ml BD INSULIN SYR 1 ML 29GX12.7MM syringe with needle,disposable,insulin 1 ml PAGE 40 LAST UPDATED 03/2019
41 EFFECTIVE 06/01/2018 benzoyl peroxide 10 % cleanser methylphenidate hcl 40 mg cpbp MVW COMPLETE FORM MULTIVI SFGL pediatric multivit 163/cholecalciferol(d3)/phytonadione(k) pedi mv no.164/ferrous sulfate 11 mg/ml drops sod phos di, mono/k phos mono 250 mg tablet sodium,potassium phosphates mg powd pack vit a palmitate/vit c/vit d mg/1 drops - PA Added: PA APPLIES PAGE 41 LAST UPDATED 03/2019
42 EFFECTIVE 06/08/2018 ACTIVE FE TABLET iron,carbonyl/folic acid/multivit with minerals ELDERCAPS CAPSULE multivitamin with minerals no.5/folic acid ferrous fum/vit c/b12-if/folic mg capsule iron,carb/vit c/vit b12/folic tablet iron/dss/b12-if/folic ac/mv-mn mg tab er 24h multivitamin no.44/vit d3/k capsule MULTIVITAMINS PEDIATRIC DROPS pedi multivit 65/cholecalciferol(vit d3)/phytonadione(vit k) MYKIDZ IRON FL SUSPENSION ferrous sulfate/sodium fluoride/vit a palm/vit c/vitamin d3 omeg3/calcium/d3/folic/mvit mg- 200 combo. pkg ped multivit no.150 w-fluoride 0.5 mg/ml drops ped mvit a,c,d3 no.21/fluoride 0.25 mg/ml drops pedi multivit 22/vit d3/vit k tab chew pedi multivit 45/fluoride/iron /ml drops pedi multivit 75/fluoride/iron /ml drops pedi multivit no.16 w-fluoride 0.25 mg tab chew PAGE 42 LAST UPDATED 03/2019
43 EFFECTIVE 06/08/2018 pedi multivit no.16 w-fluoride 0.5 mg tab chew pedi multivit no.16 w-fluoride 1 mg tab chew pedi multivit no.2 w-fluoride 0.25 mg/ml drops pedi multivit no.2 w-fluoride 0.5 mg/ml drops pedi multivit no.82 w-fluoride 0.5 mg/ml drops SUPERVITE EC CAPLET multivitamin-minerals no.21/folic acid TEXAVITE LQ DROPS pediatric multivitamin no.108/iron fumarate/sodium fluoride PAGE 43 LAST UPDATED 03/2019
44 EFFECTIVE 06/15/2018 acetaminophen 500 mg tablet KIONEX 15 GM/60 ML SUSPENSION sodium polystyrene sulfonate/sorbitol solution LITE TOUCH 28G LANCETS lancets multivit-min/fa/lycopen/lutein tablet pediatric multivitamin no.165 drops PRO COMFORT 0.5 ML 30GX1/2" syringe with needle,insulin,0.5 ml PRO COMFORT 0.5 ML 30GX5/16" syringe with needle,insulin,0.5 ml PRO COMFORT 0.5 ML 31GX5/16" syringe with needle,insulin,0.5 ml PRO COMFORT 1 ML 30GX1/2" syringe with needle,disposable,insulin 1 ml PRO COMFORT 1 ML 30GX5/16" syringe with needle,disposable,insulin 1 ml PRO COMFORT 1 ML 31GX5/16" syringe with needle,disposable,insulin 1 ml PAGE 44 LAST UPDATED 03/2019
45 EFFECTIVE 06/22/2018 KIONEX 15 GM/60 ML SUSPENSION sodium polystyrene sulfonate/sorbitol solution mv-mn/folic/cal/vit k/b comp,c mg tablet TRUE METRIX PRO TEST STRIP - QL Added: 200 / 30 day(s) PAGE 45 LAST UPDATED 03/2019
46 EFFECTIVE 06/29/2018 levothyroxine sodium 100 mcg vial oxycodone hcl 20 mg/ml oral conc PAGE 46 LAST UPDATED 03/2019
47 EFFECTIVE 07/06/2018 SCOT-TUSSIN EXPECTORANT LIQUID guaifenesin PAGE 47 LAST UPDATED 03/2019
48 EFFECTIVE 07/13/2018 aspirin 81 mg tab chew PAGE 48 LAST UPDATED 03/2019
49 EFFECTIVE 07/19/2018 KIONEX 15 GM/60 ML SUSPENSION sodium polystyrene sulfonate/sorbitol solution PAGE 49 LAST UPDATED 03/2019
50 EFFECTIVE 07/20/2018 lactulose 10 g/15 ml solution sennosides/docusate sodium 8.6mg- 50mg tablet PAGE 50 LAST UPDATED 03/2019
51 EFFECTIVE 07/27/2018 miconazole nitrate 4 % cream/appl ULTRA-CARE 30G LANCETS lancets - QL Added: 200 / 30 day(s) PAGE 51 LAST UPDATED 03/2019
52 EFFECTIVE 08/01/2018 clonazepam mg tab rapdis - QL Change: 90 / 30 DAYS to 120 / 30 day(s) clonazepam 0.25 mg tab rapdis - QL Change: 90 / 30 DAYS to 120 / 30 day(s) clonazepam 0.5 mg tab rapdis - QL Change: 90 / 30 DAYS to 120 / 30 day(s) clonazepam 0.5 mg tablet - QL Change: 90 / 30 DAYS to 120 / 30 day(s) clonazepam 1 mg tab rapdis - QL Change: 90 / 30 DAYS to 120 / 30 day(s) clonazepam 1 mg tablet - QL Change: 90 / 30 DAYS to 120 / 30 day(s) clonazepam 2 mg tab rapdis - QL Change: 90 / 30 DAYS to 120 / 30 day(s) clonazepam 2 mg tablet - QL Change: 90 / 30 DAYS to 120 / 30 day(s) KLONOPIN 0.5 MG TABLET clonazepam KLONOPIN 1 MG TABLET clonazepam KLONOPIN 2 MG TABLET clonazepam SYMTUZA MG TAB darunavir eth/cobicistat/emtricitabine/tenofovir alafenamide - QL Change: 90 / 30 DAYS to 120 / 30 day(s) - QL Change: 90 / 30 DAYS to 120 / 30 day(s) - QL Change: 90 / 30 DAYS to 120 / 30 day(s) - QL Added: 1 / day(s) PAGE 52 LAST UPDATED 03/2019
53 EFFECTIVE 08/03/2018 bismuth subsalicylate 262mg/15ml oral susp dexamethasone 1.5mg (21) tab ds pk dexamethasone 1.5mg (35) tab ds pk dexamethasone 1.5mg (51) tab ds pk EVENCARE PROVIEW TEST STRIP mag hydrox/aluminum hyd/simeth oral susp multivit-minerals/ferrous gluc 9 mg/15 ml liquid mv-min/iron/folic/calcium/vitk tablet ULTRA FINE 30G LANCETS lancets - QL Added: 200 / 30 day(s) - QL Added: 200 / 30 day(s) PAGE 53 LAST UPDATED 03/2019
54 EFFECTIVE 08/10/2018 pedi multivit no.17 w-fluoride 0.25 mg tab chew pedi multivit no.17 w-fluoride 0.5 mg tab chew pedi multivit no.17 w-fluoride 1 mg tab chew PAGE 54 LAST UPDATED 03/2019
55 EFFECTIVE 08/15/2018 abacavir sulfate 20 mg/ml solution abacavir sulfate 300 mg tablet abacavir sulfate/lamivudine mg tablet abacavir/lamivudine/zidovudine mg tablet - PA Removed: PA APPLIES - PA Removed: PA APPLIES acetaminophen 160 mg tab rapdis acetaminophen 160 mg/5ml liquid acetaminophen 160 mg/5ml oral susp acetaminophen 160 mg/5ml solution acetaminophen 325/10.15 solution acetaminophen 650mg/20.3 solution acetaminophen 80 mg tab chew acetaminophen 80 mg tab rapdis acetaminophen 80mg/0.8ml drops susp APTIVUS 100 MG/ML SOLUTION tipranavir/vitamin e tpgs APTIVUS 250 MG CAPSULE tipranavir atazanavir sulfate 150 mg capsule atazanavir sulfate 200 mg capsule atazanavir sulfate 300 mg capsule ATRIPLA TABLET efavirenz/emtricitabine/tenofovir disoproxil fumarate BETIMOL 0.25% EYE DROPS timolol - Removed From Coverage PAGE 55 LAST UPDATED 03/2019
56 EFFECTIVE 08/15/2018 BETIMOL 0.5% EYE DROPS timolol BIKTARVY MG TABLET bictegravir sodium/emtricitabine/tenofovir alafenamide fumar - Removed From Coverage bimatoprost 0.03 % drops - QL Change: 5 / 28 days (75% allowable) to 5 / 28 DAYS CHANTIX 0.5 MG TABLET varenicline tartrate CHANTIX 1 MG CONT MONTH BOX varenicline tartrate CHANTIX 1 MG TABLET varenicline tartrate CHANTIX STARTING MONTH BOX varenicline tartrate CHILDREN'S TYLENOL 160 MG/5 ML acetaminophen CIMDUO MG TABLET lamivudine/tenofovir disoproxil fumarate COMBIVIR TABLET lamivudine/zidovudine COMPLERA TABLET emtricitabine/rilpivirine hcl/tenofovir disoproxil fumarate COMPLETE OMEGA SOFTGEL omega 3,5,6,7,9 combination no.1/salmon oil DESCOVY MG TABLET emtricitabine/tenofovir alafenamide fumarate EDURANT 25 MG TABLET rilpivirine hcl - PA Removed: PA APPLIES - PA Removed: PA APPLIES - PA Removed: PA APPLIES - PA Removed: PA APPLIES - QL Change: 53 / 28 days (75% RTS allowable) to 53 / 28 days - PA Removed: PA APPLIES efavirenz 200 mg capsule efavirenz 50 mg capsule PAGE 56 LAST UPDATED 03/2019
57 EFFECTIVE 08/15/2018 efavirenz 600 mg tablet ELIQUIS 2.5 MG TABLET apixaban ELIQUIS 5 MG STARTER PACK apixaban ELIQUIS 5 MG TABLET apixaban EMTRIVA 10 MG/ML SOLUTION emtricitabine EMTRIVA 200 MG CAPSULE emtricitabine EPIVIR 10 MG/ML ORAL SOLN lamivudine EPIVIR 150 MG TABLET lamivudine EPIVIR 300 MG TABLET lamivudine EPIVIR HBV 100 MG TABLET lamivudine EPZICOM TABLET abacavir sulfate/lamivudine EVOTAZ 300 MG-150 MG TABLET atazanavir sulfate/cobicistat - PA Removed: PA APPLIES - PA Removed: PA APPLIES - PA Removed: PA APPLIES - PA Removed: PA APPLIES fosamprenavir calcium 700 mg tablet FUZEON 90 MG VIAL enfuvirtide GENVOYA TABLET elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide INFANTS' TYLENOL 160 MG/5 ML acetaminophen INTELENCE 100 MG TABLET etravirine - QL Change: 6 / day(s) to 6 / DAY PAGE 57 LAST UPDATED 03/2019
58 EFFECTIVE 08/15/2018 INTELENCE 200 MG TABLET etravirine INTELENCE 25 MG TABLET etravirine INVIRASE 200 MG CAPSULE saquinavir mesylate INVIRASE 500 MG TABLET saquinavir mesylate ISENTRESS 100 MG POWDER PACKET raltegravir potassium ISENTRESS 100 MG TABLET CHEW raltegravir potassium ISENTRESS 25 MG TABLET CHEW raltegravir potassium ISENTRESS 400 MG TABLET raltegravir potassium ISENTRESS HD 600 MG TABLET raltegravir potassium ISTALOL 0.5% EYE DROPS timolol maleate JULUCA MG TABLET dolutegravir sodium/rilpivirine hcl KALETRA MG TABLET lopinavir/ritonavir KALETRA MG TABLET lopinavir/ritonavir KALETRA 80 MG-20 MG/ML SOLN lopinavir/ritonavir - Removed From Coverage lamivudine 10 mg/ml solution - Tier Increased: Tier 1 to Tier 2 - PA Removed: PA APPLIES lamivudine 100 mg tablet lamivudine 150 mg tablet - PA Removed: PA APPLIES - PA Removed: PA APPLIES PAGE 58 LAST UPDATED 03/2019
59 EFFECTIVE 08/15/2018 lamivudine 300 mg tablet lamivudine/zidovudine mg tablet LEXIVA 50 MG/ML SUSPENSION fosamprenavir calcium LEXIVA 700 MG TABLET fosamprenavir calcium - PA Removed: PA APPLIES - PA Removed: PA APPLIES lopinavir/ritonavir /5 solution LUMIGAN 0.01% EYE DROPS bimatoprost MAG-TAB SR 84 MG CAPLET magnesium l-lactate - QL Change: 5 / 28 days (75% allowable) to 5 / 28 DAYS magnesium 200 mg tablet magnesium 250 mg tablet magnesium 30 mg tablet magnesium gluconate 27 mg(500) tablet magnesium gluconate 27.5 (500) tablet magnesium l-lactate 84 mg tablet er magnesium oxide 400 mg capsule magnesium oxide 500 mg capsule MAXEPA 1,000 MG SOFTGEL omega-3 fatty acids MAXEPA CAPSULE omega-3 fatty acids MINOCIN 100 MG PELLETIZED CAP minocycline hcl MINOCIN 50 MG PELLETIZED CAP minocycline hcl PAGE 59 LAST UPDATED 03/2019
60 EFFECTIVE 08/15/2018 MINOCIN 75 MG PELLETIZED CAP minocycline hcl minocycline hcl 100 mg capsule minocycline hcl 50 mg capsule minocycline hcl 75 mg capsule nevirapine 100 mg tab er 24h nevirapine 200 mg tablet - PA Removed: PA APPLIES nevirapine 400 mg tab er 24h nevirapine 50 mg/5 ml oral susp NICODERM CQ 14 MG/24HR PATCH nicotine NICODERM CQ 7 MG/24HR PATCH nicotine NICORETTE 2 MG CHEWING GUM nicotine polacrilex NICORETTE 2 MG LOZENGE nicotine polacrilex NICORETTE 2 MG MINI LOZENGE nicotine polacrilex NICORETTE 4 MG CHEWING GUM nicotine polacrilex NICORETTE 4 MG LOZENGE nicotine polacrilex NICORETTE 4 MG MINI LOZENGE nicotine polacrilex - Tier Increased: Tier 1 to Tier 2 - QL Change: 98 DAYS / 1 YEAR to 1 / DAY - Tier Increased: Tier 1 to Tier 2 - QL Change: 98 DAYS / 1 YEAR to 1 / DAY - QL Change: 98 DAYS / 1 YEAR to 12 / DAY - QL Change: 98 DAYS / 1 YEAR to 12 / DAY - QL Change: 98 DAYS / 1 YEAR to 12 / DAY - QL Change: 98 DAYS / 1 YEAR to 12 / DAY - QL Change: 98 DAYS / 1 YEAR to 12 / DAY - QL Change: 98 DAYS / 1 YEAR to 12 / DAY nicotine 14mg/24hr patch td24 - Tier Increased: Tier 1 to Tier 2 - QL Change: 98 DAYS / 1 YEAR to 1 / DAY PAGE 60 LAST UPDATED 03/2019
61 EFFECTIVE 08/15/2018 nicotine 21 mg/24hr patch td24 - Tier Increased: Tier 1 to Tier 2 - QL Change: 98 DAYS / 1 YEAR to 1 / DAY nicotine mg patch dysq - QL Change: 98 DAYS / 1 YEAR to 1 / DAY nicotine 22 mg/24hr patch td24 - QL Change: 98 DAYS / 1 YEAR to 1 / DAY nicotine 7mg/24hr patch td24 - Tier Increased: Tier 1 to Tier 2 - QL Change: 98 DAYS / 1 YEAR to 1 / DAY nicotine polacrilex 2 mg gum - Tier Increased: Tier 1 to Tier 2 - QL Change: 98 DAYS / 1 YEAR to 12 / DAY nicotine polacrilex 2 mg lozenge - QL Change: 98 DAYS / 1 YEAR to 12 / DAY nicotine polacrilex 2 mg lozng mini - QL Change: 98 DAYS / 1 YEAR to 12 / DAY nicotine polacrilex 4 mg gum - QL Change: 98 DAYS / 1 YEAR to 12 / DAY nicotine polacrilex 4 mg lozenge - QL Change: 98 DAYS / 1 YEAR to 12 / DAY nicotine polacrilex 4 mg lozng mini - QL Change: 98 DAYS / 1 YEAR to 12 / DAY NORVIR 100 MG SOFTGEL CAP ritonavir NORVIR 100 MG TABLET ritonavir NORVIR 80 MG/ML SOLUTION ritonavir - Removed From Coverage - PA Removed: PA APPLIES - PA Removed: PA APPLIES PAGE 61 LAST UPDATED 03/2019
62 EFFECTIVE 08/15/2018 ODEFSEY TABLET emtricitabine/rilpivirine hcl/tenofovir alafenamide fumarate omega-3 fatty acids 1000 mg capsule omega-3 fatty acids 500 mg capsule oseltamivir phosphate 30 mg capsule - QL Change: 30 / 7 MONTHS to 30 / 180 DAYS oseltamivir phosphate 45 mg capsule oseltamivir phosphate 6 mg/ml susp recon oseltamivir phosphate 75 mg capsule PREZCOBIX 800 MG-150 MG TABLET darunavir ethanolate/cobicistat PREZISTA 100 MG/ML SUSPENSION darunavir ethanolate PREZISTA 150 MG TABLET darunavir ethanolate PREZISTA 600 MG TABLET darunavir ethanolate PREZISTA 75 MG TABLET darunavir ethanolate PREZISTA 800 MG TABLET darunavir ethanolate RETROVIR 100 MG CAPSULE zidovudine REYATAZ 150 MG CAPSULE atazanavir sulfate REYATAZ 200 MG CAPSULE atazanavir sulfate - QL Change: 30 / 180 DAYS (75% RTS is allowable) to 30 / 180 DAYS - QL Change: 225 / 7 MONTHS to 225 ML / 180 DAYS - QL Change: 30 / 180 DAYS (75% RTS is allowable) to 30 / 180 DAYS - PA Removed: PA APPLIES PAGE 62 LAST UPDATED 03/2019
63 EFFECTIVE 08/15/2018 REYATAZ 300 MG CAPSULE atazanavir sulfate REYATAZ 50 MG POWDER PACKET atazanavir sulfate ritonavir 100 mg tablet SELZENTRY 150 MG TABLET maraviroc SELZENTRY 20 MG/ML ORAL SOLN maraviroc SELZENTRY 25 MG TABLET maraviroc SELZENTRY 300 MG TABLET maraviroc SELZENTRY 75 MG TABLET maraviroc SHINGRIX VIAL KIT varicella-zoster virus glycoprotein e,rec/as01b adjuvant/pf STRIBILD TABLET elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil SUPER TWIN EPA-DHA 1,250 MG omega-3 fatty acids SUSTIVA 200 MG CAPSULE efavirenz SUSTIVA 50 MG CAPSULE efavirenz SUSTIVA 600 MG TABLET efavirenz SYMFI MG TABLET efavirenz/lamivudine/tenofovir disoproxil fumarate SYMFI LO MG TABLET efavirenz/lamivudine/tenofovir disoproxil fumarate - QL Change: 2 / day(s) to 2 / DAY PAGE 63 LAST UPDATED 03/2019
64 EFFECTIVE 08/15/2018 TAMIFLU 30 MG CAPSULE oseltamivir phosphate TAMIFLU 45 MG CAPSULE oseltamivir phosphate TAMIFLU 6 MG/ML SUSPENSION oseltamivir phosphate TAMIFLU 75 MG CAPSULE oseltamivir phosphate TIVICAY 10 MG TABLET dolutegravir sodium TIVICAY 25 MG TABLET dolutegravir sodium TIVICAY 50 MG TABLET dolutegravir sodium TRIUMEQ MG TABLET abacavir sulfate/dolutegravir sodium/lamivudine TRIZIVIR TABLET abacavir sulfate/lamivudine/zidovudine TRUVADA 100 MG-150 MG TABLET emtricitabine/tenofovir disoproxil fumarate TRUVADA 133 MG-200 MG TABLET emtricitabine/tenofovir disoproxil fumarate TRUVADA 167 MG-250 MG TABLET emtricitabine/tenofovir disoproxil fumarate TYBOST 150 MG TABLET cobicistat VIRAMUNE 200 MG TABLET nevirapine VIRAMUNE 50 MG/5 ML SUSP nevirapine VIRAMUNE XR 100 MG TABLET nevirapine - QL Change: 30 / 180 DAYS (75% RTS is allowable) to 30 / 180 DAYS - QL Change: 30 / 7 MONTHS to 30 / 180 DAYS - QL Change: 225 / 7 MONTHS to 225 ML / 180 DAYS - QL Change: 60 / 6 MONTHS to 30 / 180 DAYS - PA Removed: PA APPLIES PAGE 64 LAST UPDATED 03/2019
65 EFFECTIVE 08/15/2018 VIRAMUNE XR 400 MG TABLET nevirapine VIREAD 300 MG TABLET tenofovir disoproxil fumarate ZIAGEN 20 MG/ML SOLUTION abacavir sulfate ZIAGEN 300 MG TABLET abacavir sulfate - Tier Decreased: Tier 2 to Tier 1 - PA Removed: PA APPLIES - PA Removed: PA APPLIES - PA Removed: PA APPLIES zidovudine 10 mg/ml syrup zidovudine 100 mg capsule - PA Removed: PA APPLIES zidovudine 300 mg tablet PAGE 65 LAST UPDATED 03/2019
66 EFFECTIVE 08/24/2018 ADRIAMYCIN 50 MG VIAL doxorubicin hcl - PA Added: PA APPLIES doxorubicin hcl 10 mg vial - PA Added: PA APPLIES ped mvit a,c,d3 no.21/fluoride 0.25 mg/ml drops ped mvit a,c,d3 no.21/fluoride 0.5 mg/ml drops PAGE 66 LAST UPDATED 03/2019
67 EFFECTIVE 09/01/2018 ADVAIR HFA MCG INHALER fluticasone propionate/salmeterol xinafoate ADVAIR HFA MCG INHALER fluticasone propionate/salmeterol xinafoate ADVAIR HFA MCG INHALER fluticasone propionate/salmeterol xinafoate ANORO ELLIPTA MCG INH umeclidinium bromide/vilanterol trifenatate ASMANEX TWISTHALER 110 MCG #30 mometasone furoate ASMANEX TWISTHALER 110 MCG #7 mometasone furoate ASMANEX TWISTHALER 220 MCG #14 mometasone furoate ASMANEX TWISTHALER 220 MCG #30 mometasone furoate ASMANEX TWISTHALER 220 MCG #60 mometasone furoate ASMANEX TWISTHALR 220 MCG #120 mometasone furoate DOLOPHINE HCL 10 MG TABLET methadone hcl DOLOPHINE HCL 5 MG TABLET methadone hcl DURAGESIC 100 MCG/HR PATCH fentanyl DURAGESIC 12 MCG/HR PATCH fentanyl DURAGESIC 25 MCG/HR PATCH fentanyl DURAGESIC 50 MCG/HR PATCH fentanyl - QL Removed: 1 / 30 DAYS - QL Removed: 0.07 / DAY - QL Removed: 0.07 / DAY - QL Removed: 1 / 30 DAYS - QL Removed: 1 / 30 DAYS - QL Removed: 1 / 30 DAYS - QL Removed: 240 / 30 DAYS - QL Removed: 240 / 30 DAYS - QL Removed: 10 / 30 DAYS - QL Removed: 0.34 / DAY - QL Removed: 0.34 / DAY - QL Removed: 10 / 30 DAYS PAGE 67 LAST UPDATED 03/2019
68 EFFECTIVE 09/01/2018 DURAGESIC 75 MCG/HR PATCH fentanyl ENTRESTO 24 MG-26 MG TABLET sacubitril/valsartan ENTRESTO 49 MG-51 MG TABLET sacubitril/valsartan ENTRESTO 97 MG-103 MG TABLET sacubitril/valsartan fentanyl 100 mcg/hr patch td72 fentanyl 12 mcg/hr patch td72 fentanyl 25 mcg/hr patch td72 - QL Removed: 10 / 30 DAYS - QL Removed: 0.34 / DAY - QL Removed: 10 / 30 DAYS - QL Removed: 10 / 30 DAYS fentanyl 37.5mcg/hr patch td72 - QL Removed: 0.34 / DAY fentanyl 50mcg/hr patch td72 fentanyl 75mcg/hr patch td72 FLOVENT 250 MCG DISKUS fluticasone propionate FLOVENT 50 MCG DISKUS fluticasone propionate FLOVENT HFA 44 MCG INHALER fluticasone propionate GLUCOPHAGE XR 500 MG TAB metformin hcl GLUCOPHAGE XR 750 MG TAB metformin hcl INCRUSE ELLIPTA 62.5 MCG INH umeclidinium bromide INVOKAMET 150-1,000 MG TABLET canagliflozin/metformin hcl INVOKAMET MG TABLET canagliflozin/metformin hcl - QL Removed: 10 / 30 DAYS - QL Removed: 0.34 / DAY PAGE 68 LAST UPDATED 03/2019
69 EFFECTIVE 09/01/2018 INVOKAMET 50-1,000 MG TABLET canagliflozin/metformin hcl INVOKAMET MG TABLET canagliflozin/metformin hcl INVOKAMET XR 150-1,000 MG TAB canagliflozin/metformin hcl INVOKAMET XR MG TABLET canagliflozin/metformin hcl INVOKAMET XR 50-1,000 MG TAB canagliflozin/metformin hcl INVOKAMET XR MG TABLET canagliflozin/metformin hcl INVOKANA 300 MG TABLET canagliflozin JANUMET 50-1,000 MG TABLET sitagliptin phosphate/metformin hcl JANUMET MG TABLET sitagliptin phosphate/metformin hcl JANUMET XR 100-1,000 MG TABLET sitagliptin phosphate/metformin hcl JANUMET XR 50-1,000 MG TABLET sitagliptin phosphate/metformin hcl JANUMET XR MG TABLET sitagliptin phosphate/metformin hcl lansoprazole 15 mg tab rap dr - Tier Decreased: Tier 2 to Tier 1 - Change: Restricted to patients unable to swallow or on G-tube to Restricted to patients unable to swallow or on G-tube lansoprazole 30 mg tab rap dr - Change: Restricted to patients unable to swallow or on G-tube to Restricted to patients unable to swallow or on G-tube PAGE 69 LAST UPDATED 03/2019
70 EFFECTIVE 09/01/2018 LATUDA 60 MG TABLET lurasidone hcl metformin hcl 500 mg tab er 24h metformin hcl 750 mg tab er 24h methadone hcl 10 mg tablet methadone hcl 10 mg/5 ml solution methadone hcl 5 mg tablet methadone hcl 5 mg/5 ml solution morphine sulfate 30 mg tablet er MS CONTIN ER 30 MG TABLET morphine sulfate olanzapine 10 mg tab rapdis olanzapine 15 mg tab rapdis olanzapine 20 mg tab rapdis olanzapine 5 mg tab rapdis - QL Removed: 8 / DAY - QL Removed: 60 ML / DAY - QL Removed: 8 / DAY - QL Removed: 60 ML / DAY - QL Removed: 4 / DAY - QL Removed: 120 / 30 DAYS - PA Removed: PA APPLIES - PA Removed: PA APPLIES - PA Removed: PA APPLIES - PA Removed: PA APPLIES oxycodone hcl 10 mg tab er 12h - QL Removed: 2 / DAY oxycodone hcl 15 mg tab er 12h - QL Removed: 60 / 30 DAYS oxycodone hcl 20 mg tab er 12h - QL Removed: 2 / DAY oxycodone hcl 30 mg tab er 12h - QL Removed: 60 / 30 DAYS oxycodone hcl 40 mg tab er 12h - QL Removed: 60 / 30 DAYS oxycodone hcl 60 mg tab er 12h - QL Removed: 2 / DAY PAGE 70 LAST UPDATED 03/2019
71 EFFECTIVE 09/01/2018 oxycodone hcl 80 mg tab er 12h - QL Removed: 60 / 30 DAYS OXYCONTIN ER 10 MG TABLET oxycodone hcl OXYCONTIN ER 15 MG TABLET oxycodone hcl OXYCONTIN ER 20 MG TABLET oxycodone hcl OXYCONTIN ER 30 MG TABLET oxycodone hcl OXYCONTIN ER 40 MG TABLET oxycodone hcl OXYCONTIN ER 60 MG TABLET oxycodone hcl OXYCONTIN ER 80 MG TABLET oxycodone hcl PREVACID 15 MG SOLUTAB lansoprazole PREVACID 30 MG SOLUTAB lansoprazole PULMICORT 180 MCG FLEXHALER budesonide PULMICORT 90 MCG FLEXHALER budesonide quetiapine fumarate 150 mg tab er 24h quetiapine fumarate 200 mg tab er 24h quetiapine fumarate 50 mg tab er 24h - QL Removed: 60 / 30 DAYS - QL Removed: 60 / 30 DAYS - QL Removed: 60 / 30 DAYS - QL Removed: 2 / DAY - QL Removed: 2 / DAY - QL Removed: 2 / DAY - QL Removed: 60 / 30 DAYS - QL Added: 1 / day(s) - Added: Restricted to patients unable to swallow or on G-tube - Change: Restricted to patients unable to swallow or on G-tube to Restricted to patients unable to swallow or on G-tube - QL Removed: 1 / DAY - QL Removed: 1 / DAY - QL Removed: 1 / DAY PAGE 71 LAST UPDATED 03/2019
72 EFFECTIVE 09/01/2018 QVAR 40 MCG ORAL INHALER beclomethasone dipropionate QVAR 80 MCG ORAL INHALER beclomethasone dipropionate SEROQUEL XR 150 MG TABLET quetiapine fumarate SEROQUEL XR 200 MG TABLET quetiapine fumarate SEROQUEL XR 50 MG TABLET quetiapine fumarate SPIRIVA RESPIMAT 1.25 MCG INH tiotropium bromide SPIRIVA RESPIMAT 2.5 MCG INH tiotropium bromide SYMBICORT MCG INHALER budesonide/formoterol fumarate SYMBICORT MCG INHALER budesonide/formoterol fumarate SYNJARDY ,000 MG TABLET empagliflozin/metformin hcl SYNJARDY MG TABLET empagliflozin/metformin hcl SYNJARDY 5-1,000 MG TABLET empagliflozin/metformin hcl SYNJARDY MG TABLET empagliflozin/metformin hcl SYNJARDY XR 10-1,000 MG TABLET empagliflozin/metformin hcl SYNJARDY XR ,000 MG TAB empagliflozin/metformin hcl SYNJARDY XR 25-1,000 MG TABLET empagliflozin/metformin hcl - Removed From Coverage - Removed From Coverage - QL Removed: 1 / DAY - QL Removed: 1 / DAY - QL Removed: 1 / DAY - Removed From Coverage - Removed From Coverage PAGE 72 LAST UPDATED 03/2019
73 EFFECTIVE 09/01/2018 SYNJARDY XR 5-1,000 MG TABLET empagliflozin/metformin hcl tramadol hcl/acetaminophen mg tablet TRULICITY 0.75 MG/0.5 ML PEN dulaglutide TRULICITY 1.5 MG/0.5 ML PEN dulaglutide ULTRACET TABLET tramadol hcl/acetaminophen ZYPREXA ZYDIS 10 MG TABLET olanzapine ZYPREXA ZYDIS 15 MG TABLET olanzapine ZYPREXA ZYDIS 20 MG TABLET olanzapine ZYPREXA ZYDIS 5 MG TABLET olanzapine - PA Removed: PA APPLIES - PA Removed: PA APPLIES - PA Removed: PA APPLIES - PA Removed: PA APPLIES PAGE 73 LAST UPDATED 03/2019
74 EFFECTIVE 09/07/2018 OBTREX DHA COMBO PACK prenatal vitamins no.12/iron carbonyl/methylfolate/dha PAGE 74 LAST UPDATED 03/2019
75 EFFECTIVE 09/15/2018 SAPHRIS 10 MG TAB SUBLINGUAL asenapine maleate SAPHRIS 5 MG TAB SUBLINGUAL asenapine maleate PAGE 75 LAST UPDATED 03/2019
76 EFFECTIVE 09/20/2018 ASMANEX TWISTHALER 110 MCG #30 mometasone furoate ASMANEX TWISTHALER 110 MCG #7 mometasone furoate ASMANEX TWISTHALR 220 MCG #120 mometasone furoate FLOVENT HFA 110 MCG INHALER fluticasone propionate FLOVENT HFA 220 MCG INHALER fluticasone propionate FLOVENT HFA 44 MCG INHALER fluticasone propionate - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES PAGE 76 LAST UPDATED 03/2019
77 EFFECTIVE 09/21/2018 ALIVE ONCE DAILY WOMEN 50 PLUS multivit with minerals/folic acid/vit k1/herbal no.289 ALIVE PRENATAL GUMMY prenatal vitamins no.138/folic acid/docosahexanoic acid bisacodyl 5 mg tablet dr ibuprofen 200 mg tablet SULFATRIM PEDIATRIC SUSPENSION sulfamethoxazole/trimethoprim TWIST LANCETS 30G lancets TWIST LANCETS 32G lancets - QL Added: 200 / 30 DAYS - QL Added: 200 / 30 DAYS PAGE 77 LAST UPDATED 03/2019
78 EFFECTIVE 09/22/2018 aspirin 81 mg tablet dr polyethylene glycol g/dose powder TECHLITE PEN NEEDLE 31GX3/16" pen needle, diabetic PAGE 78 LAST UPDATED 03/2019
79 EFFECTIVE 09/25/2018 NORVIR 100 MG POWDER PACKET ritonavir - QL Added: 12 / day(s) PAGE 79 LAST UPDATED 03/2019
80 EFFECTIVE 09/28/2018 aspirin 81 mg tablet dr HAIR, SKIN AND NAILS TABLET multivitamin/folic acid/biotin PAGE 80 LAST UPDATED 03/2019
81 EFFECTIVE 10/01/2018 ACCU-CHEK AVIVA PLUS TEST STRP ACCU-CHEK GUIDE TEST STRIP ACCU-CHEK SMARTVIEW TEST STRIP ACCUTREND GLUCOSE TEST STRIP ADVAIR DISKUS fluticasone propionate/salmeterol xinafoate ADVAIR DISKUS fluticasone propionate/salmeterol xinafoate ADVAIR DISKUS fluticasone propionate/salmeterol xinafoate ADVOCATE REDI-CODE TEST STRIP ADVOCATE REDI-CODE+ TEST STRIP ADVOCATE TEST STRIP AGAMATRIX AMP TEST STRIPS ASSURE 4 TEST STRIPS ASSURE PLATINUM TEST STRIPS ASSURE PRISM MULTI TEST STRIPS BASAGLAR 100 UNIT/ML KWIKPEN insulin glargine,human recombinant analog BLOOD GLUCOSE TEST STRIPS - PA Removed: PA APPLIES - QL Added: 2 / DAY - PA Removed: PA APPLIES - QL Added: 2 / DAY - PA Removed: PA APPLIES - QL Added: 2 / DAY - QL Added: 2 ML / DAY PAGE 81 LAST UPDATED 03/2019
82 EFFECTIVE 10/01/2018 BLOOD GLUCOSE TEST STRIP CAREONE BLOOD GLUCOSE TST STRP CARESENS N TEST STRIPS CARETOUCH TEST STRIP CHOICEDM CLARUS TEST STRIPS CLEVER CHOICE MICRO TEST STRIP CLEVER CHOICE PRO TEST STRIP CLEVER CHOICE TALK TEST STRIPS CLEVER CHOICE TEST STRIPS CLEVER CHOICE VOICE+ TST STRIP CONTOUR NEXT TEST STRIP CONTOUR TEST STRIP CONTROL AST TEST STRIP COOL GLUCOSE TEST STRIP CVS ADVANCED GLUCOSE TEST STR DARIO BLOOD GLUCOSE TEST STRIP - QL Added: 5 / DAY PAGE 82 LAST UPDATED 03/2019
83 EFFECTIVE 10/01/2018 DIATRUE PLUS TEST STRIP EASY GLUCO G2 TEST STRIP EASY PLUS GLUCOSE TEST STRIP EASY PLUS II TEST STRIPS EASY PLUS II TEST STRIP EASY STEP GLUCOSE TEST STRIPS EASY TALK GLUCOSE TEST STRIP EASY TOUCH GLUCOSE TEST STRIP EASY TRAK GLUCOSE TEST STRIP EASYGLUCO PLUS TEST STRIPS EASYGLUCO TEST STRIPS EASYMAX 15 GLUCOSE TEST STRIP EASYMAX GLUCOSE TEST STRIPS ELEMENT COMPACT TEST STRIPS ELEMENT TEST STRIPS EMBRACE EVO TEST STRIPS PAGE 83 LAST UPDATED 03/2019
84 EFFECTIVE 10/01/2018 EMBRACE GLUCOSE TEST STRIPS EMBRACE PRO TEST STRIPS EMBRACE PRO TEST STRIP EMBRACE TEST STRIPS EQ BLOOD GLUCOSE TEST STRIP EVENCARE G2 TEST STRIP EVENCARE G3 TEST STRIP EVENCARE GLUCOSE TST STRIPS EVENCARE MINI GLUCOSE TEST STR EVENCARE PROVIEW TEST STRIP EVOLUTION TEST STRIPS EZ SMART PLUS TEST STRIPS EZ SMART TEST STRIPS FIFTY50 GLUCOSE TEST STRIP FLOVENT 100 MCG DISKUS fluticasone propionate FORA 6 CONNECT GLUCOSE STRIP - QL Change: 200 / 30 day(s) to 5 / DAY - QL Added: 2 / DAY - QL Added: 5 / DAY PAGE 84 LAST UPDATED 03/2019
85 EFFECTIVE 10/01/2018 FORA BLOOD GLUCOSE TEST STRIP FORA D15G GLUCOSE TEST STRIPS FORA D20 GLUCOSE TEST STRIPS FORA D40-G31 TEST STRIPS FORA G20 GLUCOSE TEST STRIPS FORA G30-PREMIUM V10 TEST STRP FORA GD50 TEST STRIPS FORA TN'G VOICE TEST STRIPS FORA V10 GLUCOSE TEST STRIP FORA V10-V12-D10-D20 STRIPS FORA V12 GLUCOSE TEST STRIP FORA V20 GLUCOSE TEST STRIPS FORA V30A GLUCOSE TEST STRIP FORACARE GD20 TEST STRIPS FORACARE GD40 GLUCOSE STRIPS FORTISCARE GLUCOSE TEST STRIPS - QL Removed: 200 / 30 DAYS - QL Removed: 200 / 30 DAYS - QL Removed: 200 / 30 DAYS - QL Removed: 200 / 30 DAYS - QL Removed: 200 / 30 DAYS - QL Removed: 200 / 30 DAYS - QL Removed: 200 / 30 DAYS - QL Removed: 200 / 30 DAYS - QL Removed: 200 / 30 DAYS - QL Removed: 200 / 30 DAYS - QL Removed: 200 / 30 DAYS - QL Removed: 200 / 30 DAYS - QL Removed: 200 / 30 DAYS - QL Removed: 200 / 30 DAYS - QL Removed: 200 / 30 DAYS PAGE 85 LAST UPDATED 03/2019
86 EFFECTIVE 10/01/2018 FREESTYLE INSULINX STRIP NFRS FREESTYLE INSULINX TEST STRIPS FREESTYLE INSULINX TEST STRIP FREESTYLE LITE TEST STRIP NFRS FREESTYLE LITE TEST STRIP FREESTYLE PREC NEO TEST STRIPS FREESTYLE TEST STRIPS NFRS FREESTYLE TEST STRIPS GE100 BLOOD GLUCOSE TEST STRIP GENSTRIP GLUCOSE TEST STRIP GENULTIMATE TEST STRIP GHT BLOOD GLUCOSE TEST STRIP GLUCO NAVII GLUCOSE TEST STRIP GLUCOCARD 01 SENSOR PLUS STRIP GLUCOCARD EXPRESSION TEST STRP GLUCOCARD SHINE TEST STRIPS PAGE 86 LAST UPDATED 03/2019
87 EFFECTIVE 10/01/2018 GLUCOCARD VITAL SENSOR STRIP GLUCOCARD VITAL TEST STRIPS GLUCOCOM GLUCOSE TEST STRIP GLUCOPHAGE 1,000 MG TABLET metformin hcl GLUCOPHAGE 500 MG TABLET metformin hcl GLUCOPHAGE 850 MG TABLET metformin hcl GMATE TEST STRIPS GNP EASY TOUCH GLUC TEST STRIP GOODLIFE AC-302 TEST STRIP GS BLOOD GLUCOSE TEST STRIP HARMONY GLUCOSE TEST STRIP HEALTHPRO GLUCOSE TEST STRIPS HUMANA TRUE METRIX TEST STRIP HUMANA TRUETEST TEST STRIPS IGLUCOSE TEST STRIP INFINITY TEST STRIPS - QL Added: 2 / DAY - QL Added: 5 / DAY - QL Added: 3 / DAY - QL Added: 5 / DAY - QL Added: 5 / DAY PAGE 87 LAST UPDATED 03/2019
88 EFFECTIVE 10/01/2018 INFINITY VOICE TEST STRIP INVOKANA 100 MG TABLET canagliflozin JANUVIA 100 MG TABLET sitagliptin phosphate JANUVIA 25 MG TABLET sitagliptin phosphate JANUVIA 50 MG TABLET sitagliptin phosphate KRO PREMIUM BLOOD GLUCOSE TEST LANTUS SOLOSTAR 100 UNIT/ML insulin glargine,human recombinant analog LIBERTY TEST STRIPS MEIJER BLOOD GLUCOSE TEST STRP metformin hcl 1000 mg tablet metformin hcl 500 mg tablet metformin hcl 850 mg tablet MICRODOT TEST STRIPS MICRODOT XTRA TEST STRIPS morphine sulfate 100 mg tablet er morphine sulfate 15 mg tablet er morphine sulfate 60 mg tablet er MS CONTIN ER 100 MG TABLET morphine sulfate - QL Added: 5 / DAY - QL Added: 1 / DAY - QL Added: 2 / DAY - QL Added: 2 / DAY - QL Added: 2 / DAY - QL Added: 2 ML / DAY - QL Added: 2 / DAY - QL Added: 5 / DAY - QL Added: 3 / DAY - QL Removed: 120 / 30 DAYS - QL Removed: 120 / 30 DAYS - QL Removed: 120 / 30 DAYS - QL Removed: 120 / 30 DAYS PAGE 88 LAST UPDATED 03/2019
89 EFFECTIVE 10/01/2018 MS CONTIN ER 15 MG TABLET morphine sulfate MS CONTIN ER 60 MG TABLET morphine sulfate MYGLUCOHEALTH TEST STRIPS NEUTEK 2TEK TEST STRIPS NOVA MAX GLUCOSE TEST STRIP NOVOLOG 100 UNIT/ML FLEXPEN insulin aspart NOVOLOG 100 UNIT/ML VIAL insulin aspart NOVOLOG MIX FLEXPEN SYRN insulin aspart protamine human/insulin aspart NOVOLOG MIX VIAL insulin aspart protamine human/insulin aspart - QL Removed: 120 / 30 DAYS - QL Removed: 120 / 30 DAYS - QL Added: 2 ML / DAY - QL Added: 2 ML / DAY - QL Added: 2 ML / DAY - QL Added: 2 ML / DAY omeprazole 20 mg capsule dr - QL Added: 3 / DAY ON CALL EXPRESS TEST STRIP ON CALL PLUS TEST STRIP ON CALL VIVID TEST STRIP ONETOUCH ULTRA BLUE TEST STRP ONETOUCH VERIO TEST STRIP OPTIUM EZ TEST STRIP PAGE 89 LAST UPDATED 03/2019
90 EFFECTIVE 10/01/2018 OPTIUM TEST STRIP OPTUMRX TEST STRIP pantoprazole sodium 20 mg tablet dr pantoprazole sodium 40 mg tablet dr PHARMACIST CHOICE TEST STRIPS PRECISION PCX PLUS TEST STR PRECISION PCX TEST STRIPS PRECISION POINT OF CARE STR PRECISION Q-I-D TEST STRIPS PRECISION XTRA TEST STRIPS PREMIUM BLOOD GLUCOSE TEST STR PREMIUM BLOOD GLUCOSE TST STRP PREMIUM V10 GLUCOSE TEST STRIP PRO VOICE V8-V9 TEST STRIP PROAIR HFA 90 MCG INHALER albuterol sulfate PRODIGY NO CODING TEST STRIPS - QL Removed: 1 / DAY - QL Removed: 30 / 30 DAYS - QL Added: 5 / DAY - QL Added: 0.57 / DAY PAGE 90 LAST UPDATED 03/2019
91 EFFECTIVE 10/01/2018 PROTONIX DR 20 MG TABLET pantoprazole sodium PROTONIX DR 40 MG TABLET pantoprazole sodium PROVENTIL HFA 90 MCG INHALER albuterol sulfate QUINTET AC GLUCOSE TEST STRIPS QUINTET GLUCOSE TEST STRIPS REFUAH PLUS TEST STRIPS RELION CONFIRM-MICRO TEST STRP RELION MICRO TEST STRIPS RELION PREMIER TEST STRIP RELION PRIME TEST STRIPS RELION ULTIMA TEST STRIPS REVEAL TEST STRIP REXALL BLOOD GLUCOSE TEST STRP RIGHTEST GS100 TEST STRIPS RIGHTEST GS250S TEST STRIPS RIGHTEST GS260 TEST STRIPS - QL Removed: 1 / DAY - QL Removed: 30 / 30 DAYS - QL Added: 0.45 / DAY - QL Added: 5 / DAY PAGE 91 LAST UPDATED 03/2019
92 EFFECTIVE 10/01/2018 RIGHTEST GS300 TEST STRIPS RIGHTEST GS550 TEST STRIPS SMART SENSE TEST STRIPS SMARTEST TEST STRIPS SOLUS V2 AUDIBLE TEST STRIPS SURE-TEST EASYPLUS MINI STRIP TD GOLD TEST STRIP TELCARE TEST STRIPS TEST N'GO GLUCOSE TEST STRIP tramadol hcl 50 mg tablet TRUE METRIX GLUCOSE TEST STRIP TRUE METRIX PRO TEST STRIP TRUETEST GLUCOSE TEST STRIPS TRUETEST GLUCOSE TEST STRIP TRUETRACK GLUCOSE TEST STRIPS ULTIMA TEST STRIPS ULTRAM 50 MG TABLET tramadol hcl - QL Added: 240 / 30 DAYS - QL Change: 200 / 30 day(s) to 5 / DAY - QL Added: 240 / 30 DAYS PAGE 92 LAST UPDATED 03/2019
93 EFFECTIVE 10/01/2018 ULTRATRAK TEST STRIP ULTRATRAK ULTIMATE TEST STRIPS UNISTRIP1 GLUCOSE TEST STRIP UP & UP BLOOD GLUCOSE TST STRP V-R GLUCOSE TEST STRIP VERASENS TEST STRIP WAVESENSE JAZZ TEST STRIPS WAVESENSE PRESTO TEST STRIPS - QL Added: 5 / DAY PAGE 93 LAST UPDATED 03/2019
94 EFFECTIVE 10/05/2018 BRAINSTRONG PRENATAL COMBO PAC prenatal vitamins no.139/iron,carbonyl/folic acid/dha PRO COMFORT PEN NDL 31GX5/16" pen needle, diabetic psyllium husk/aspartame 3.5 g powd pack PAGE 94 LAST UPDATED 03/2019
95 EFFECTIVE 10/08/2018 terconazole 0.8 % cream/appl PAGE 95 LAST UPDATED 03/2019
96 EFFECTIVE 10/12/2018 acetaminophen 500 mg tablet ADDERALL 10 MG TABLET dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate ADDERALL 15 MG TABLET dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate ADDERALL 20 MG TABLET dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate ADDERALL 30 MG TABLET dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate ADDERALL 5 MG TABLET dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate - Added: Restricted to ADHD patients between ages of Added: Restricted to ADHD patients between ages of Added: Restricted to ADHD patients between ages of Added: Restricted to ADHD patients between ages of Added: Restricted to ADHD patients between ages of 4-21 alprazolam 1 mg/ml oral conc carbamide peroxide 6.5 % drops CENTRUM MULTIVIT-MINERAL LIQ multivitamin with minerals/ferrous gluconate CHLD ALLEGRA ALLERGY 30 MG ODT fexofenadine hcl DELTASONE 20 MG TABLET prednisone - QL Added: 1 / DAY dexamethasone 1 mg/ml drops DEXEDRINE 10 MG TABLET dextroamphetamine sulfate DILANTIN 100 MG CAPSULE phenytoin sodium extended DILANTIN 30 MG CAPSULE phenytoin sodium extended - Added: Restricted to ADHD patients between ages of 4-21 diphenhydramine hcl 12.5mg/5ml liquid PAGE 96 LAST UPDATED 03/2019
97 EFFECTIVE 10/12/2018 EPINEPHRINE 0.15 MG AUTO-INJCT epinephrine EPINEPHRINE 0.3 MG AUTO-INJECT epinephrine fenofibrate 160 mg tablet fenofibrate 54 mg tablet guaifenesin/dextromethorphan mg/5 syrup iron/mv,stress form tablet LAMISIL AT 1% CREAM terbinafine hcl lecithin/pyridoxine/kelp capsule lecithin/pyridoxine/kelp tablet loperamide hcl 2 mg capsule lorazepam 2 mg/ml oral conc LOTRIMIN AF 1% CREAM clotrimazole multivit,stress formula/zinc tablet multivitamin tablet multivitamin with folic acid 400 mcg tablet multivitamin with iron tablet multivitamin with minerals tablet naphazoline hcl/glycerin % drops neomycin/bacitracin/polymyxinb k oint. (g) PAGE 97 LAST UPDATED 03/2019
98 EFFECTIVE 10/12/2018 NICORETTE 4 MG CHEWING GUM nicotine polacrilex - QL Added: 12 / DAY nicotine 21 mg/24hr patch td24 - QL Added: 1 / DAY norethindrone 0.35 mg tablet pedi multivit no.156/iron fum 12 mg tab chew pedi multivit no.46/iron sulf /ml drops pediatric multivitamin no /1 drops PEPCID 20 MG TABLET famotidine PEPCID 40 MG TABLET famotidine PHENERGAN 12.5 MG SUPPOSITORY promethazine hcl PHENERGAN 25 MG SUPPOSITORY promethazine hcl PHENERGAN 50 MG SUPPOSITORY promethazine hcl piperonyl butox/pyrethr/permet % kit PRANDIN 1 MG TABLET repaglinide PRANDIN 2 MG TABLET repaglinide - ST Added: ST APPLIES - ST Added: ST APPLIES prednisone 5 mg/ml oral conc QUESTRAN LIGHT POWDER cholestyramine/aspartame QUESTRAN PACKET cholestyramine (with sugar) PAGE 98 LAST UPDATED 03/2019
99 EFFECTIVE 10/12/2018 QUESTRAN POWDER cholestyramine (with sugar) ranitidine hcl 75 mg tablet selenium sulfide 1 % shampoo sennosides 15 mg tab chew UNIFINE PENTIPS 32GX1/4" pen needle, diabetic UNIFINE PENTIPS 33GX5/32" pen needle, diabetic UNIFINE PENTIPS PLUS 33GX5/32" pen needle, diabetic urea 20 % cream (g) VENLAFAXINE HCL ER 150 MG TAB venlafaxine hcl VENLAFAXINE HCL ER 225 MG TAB venlafaxine hcl VENLAFAXINE HCL ER 37.5 MG TAB venlafaxine hcl VENLAFAXINE HCL ER 75 MG TAB venlafaxine hcl vit b comp/c/folic/iron/vit e tablet PAGE 99 LAST UPDATED 03/2019
100 EFFECTIVE 10/15/2018 DELSTRIGO MG TAB doravirine/lamivudine/tenofovir disoproxil fumarate JANUMET XR 100-1,000 MG TABLET sitagliptin phosphate/metformin hcl JANUMET XR 50-1,000 MG TABLET sitagliptin phosphate/metformin hcl JANUMET XR MG TABLET sitagliptin phosphate/metformin hcl JANUVIA 100 MG TABLET sitagliptin phosphate JANUVIA 25 MG TABLET sitagliptin phosphate JANUVIA 50 MG TABLET sitagliptin phosphate PIFELTRO 100 MG TABLET doravirine TRULICITY 0.75 MG/0.5 ML PEN dulaglutide TRULICITY 1.5 MG/0.5 ML PEN dulaglutide VICTOZA 2-PAK 18 MG/3 ML PEN liraglutide VICTOZA 3-PAK 18 MG/3 ML PEN liraglutide - QL Added: 1 / day(s) - ST Added: ST APPLIES - ST Added: ST APPLIES - ST Added: ST APPLIES - ST Added: ST APPLIES - ST Added: ST APPLIES - ST Added: ST APPLIES - QL Added: 1 / day(s) - ST Added: ST APPLIES - ST Added: ST APPLIES - ST Added: ST APPLIES - ST Added: ST APPLIES PAGE 100 LAST UPDATED 03/2019
101 EFFECTIVE 10/19/2018 SCOT-TUSSIN EXPECTORANT LIQUID guaifenesin PAGE 101 LAST UPDATED 03/2019
102 EFFECTIVE 10/20/2018 ABILIFY MAINTENA ER 300 MG SYR aripiprazole ABILIFY MAINTENA ER 300 MG VL aripiprazole ABILIFY MAINTENA ER 400 MG SYR aripiprazole ABILIFY MAINTENA ER 400 MG VL aripiprazole ARISTADA ER 441 MG/1.6 ML SYRN aripiprazole lauroxil ARISTADA ER 662 MG/2.4 ML SYRN aripiprazole lauroxil ARISTADA ER 882 MG/3.2 ML SYRN aripiprazole lauroxil INVEGA TRINZA 273 MG/0.875 ML paliperidone palmitate INVEGA TRINZA 410 MG/1.315 ML paliperidone palmitate INVEGA TRINZA 546 MG/1.75 ML paliperidone palmitate INVEGA TRINZA 819 MG/2.625 ML paliperidone palmitate REXULTI 0.25 MG TABLET brexpiprazole REXULTI 0.5 MG TABLET brexpiprazole REXULTI 1 MG TABLET brexpiprazole REXULTI 2 MG TABLET brexpiprazole REXULTI 3 MG TABLET brexpiprazole - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES PAGE 102 LAST UPDATED 03/2019
103 EFFECTIVE 10/20/2018 REXULTI 4 MG TABLET brexpiprazole SYMBICORT MCG INHALER budesonide/formoterol fumarate SYMBICORT MCG INHALER budesonide/formoterol fumarate - ST Removed: ST APPLIES - ST Removed: ST APPLIES - ST Removed: ST APPLIES PAGE 103 LAST UPDATED 03/2019
104 EFFECTIVE 10/26/2018 CHLD ALLEGRA ALLERGY 30 MG ODT fexofenadine hcl - QL Added: 1 / DAY docusate sodium 100 mg capsule EMBRACE TALK TEST STRIP - QL Added: 5 / DAY PAGE 104 LAST UPDATED 03/2019
105 EFFECTIVE 10/29/2018 carbamide peroxide 6.5 % drops guaifenesin/dextromethorphan mg/5 syrup iron/mv,stress form tablet multivitamin tablet MULTIVITAMINS PEDIATRIC DROPS pedi multivit 65/cholecalciferol(vit d3)/phytonadione(vit k) naphazoline hcl/glycerin % drops pedi multivit no.156/iron fum 12 mg tab chew pedi multivit no.46/iron sulf /ml drops pediatric multivitamin no /1 drops VENLAFAXINE HCL ER 225 MG TAB venlafaxine hcl vit b comp/c/folic/iron/vit e tablet - Tier Increased: Tier 1 to Tier 2 PAGE 105 LAST UPDATED 03/2019
106 EFFECTIVE 11/01/2018 HUMULIN 70/30 KWIKPEN insulin nph human isophane/insulin regular, human NARCAN 4 MG NASAL SPRAY naloxone hcl nateglinide 120 mg tablet nateglinide 60 mg tablet NOVOLIN FLEXPEN insulin nph human isophane/insulin regular, human PRANDIN 0.5 MG TABLET repaglinide PRANDIN 1 MG TABLET repaglinide PRANDIN 2 MG TABLET repaglinide PROVENTIL HFA 90 MCG INHALER albuterol sulfate RELION NOVOLIN FLEXPEN insulin nph human isophane/insulin regular, human repaglinide 0.5 mg tablet repaglinide 1 mg tablet repaglinide 2 mg tablet STARLIX 120 MG TABLET nateglinide STARLIX 60 MG TABLET nateglinide - QL Added: 2 / day(s) - PA Added: PA APPLIES - ST Removed: ST APPLIES - QL Added: 3 / day(s) - ST Removed: ST APPLIES - QL Added: 3 / day(s) - QL Added: 2 / day(s) - ST Removed: ST APPLIES - QL Change: 3 / day(s) to 4 / day(s) - ST Removed: ST APPLIES - QL Added: 8 / day(s) - ST Removed: ST APPLIES - QL Added: 8 / day(s) - QL Removed: 0.45 / DAY - QL Added: 2 / day(s) - ST Removed: ST APPLIES - QL Added: 4 / day(s) - ST Removed: ST APPLIES - QL Added: 8 / day(s) - ST Removed: ST APPLIES - QL Added: 8 / day(s) - ST Removed: ST APPLIES - QL Added: 3 / day(s) - ST Removed: ST APPLIES - QL Added: 3 / day(s) PAGE 106 LAST UPDATED 03/2019
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Abstral (fentanyl) sl tab all strength Acetaminophen Actonel Actonel 35mg Adderall XR 5mg, 10mg, 15mg 240 per 34 days 3 gm/day 2 every 28 days 4 every 28 days Advair Diskus. No more than 180 every 30 days
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JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET BYDUREON BCISE 2 MG/0.
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Value Based Tier Drugs are selected for the management of Asthma, Diabetes, Hypertension and Hyperlipidemia. These drugs are covered at no charge or at a reduced cost share. Medications are under continual
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Analgesics Opioid Analgesics, Long-acting fentanyl 100 mcg/hr patch td72 morphine sulfate 30 mg tablet er Opioid Analgesics, Short-acting fentanyl citrate 200 mcg lozenge hd hydrocodone/acetaminophen 5
TABLE OF CONTENTS (Click on a link below to view the section.)
Follow the links below to access the complete formularies for Plans: Health Plan Acne Allergy Allergic Anaphylactic Reaction Allergic Conjunctivitis Allergic Rhinitis Asthma Atopic Dermatitis Behavioral
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Removed from formulary. Removed from formulary. Added to formulary. Quanitity limit changed. Removed from formulary. Removed from formulary
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