Emblem Medicaid 3Q18 Formulary Updates
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- Kristian Newman
- 5 years ago
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1 ALKERAN 2 MG TABLET Removed from Formulary 7/9/2018 AMITIZA 24 MCG CAPSULES Removed from Formulary 7/9/2018 AMITIZA 8 MCG CAPSULE Removed from Formulary 7/9/2018 avo cream topical emulsion Removed from Formulary 7/9/2018 BIKTARVY MG TABLET Added to Formulary (BRAND) with Quantity Limits 7/9/2018 BILTRICIDE 600 MG TABLET Removed from Formulary 7/9/2018 BILTRICIDE 600 MG TABLET Removed from Formulary 7/9/2018 BUPHENYL 500 MG TABLET Removed from Formulary 7/9/2018 calcipotriene 0.005% cream Added Quantity Limits (generic) 7/9/2018 calcipotriene 0.005% ointment Added Quantity Limits (generic) 7/9/2018 calcipotriene 0.005% solution Added Quantity Limits (generic) 7/9/2018 calcipotriene-betameth dp oint Added Quantity Limits (generic) 7/9/2018 calcitrene 0.005% ointment Added Quantity Limits (generic) 7/9/2018 child pain-fever 160 mg tb chw Added to Formulary (generic) 7/9/2018 CIMDUO MG TABLET Added to Formulary (BRAND) with Quantity Limits 7/9/2018 cold-allergy elixir Added to Formulary (generic) 7/9/2018 cvs acetaminophen 500 mg/15 ml Added to Formulary (generic) 7/9/2018 CVS LUBRICANT EYE DROP 0.25% Added to Formulary (BRAND) 7/9/2018 cyproheptadine 4 mg/10 ml syrp Added to Formulary (generic) 7/9/2018 DECARA 10;000 UNIT SOFTGEL Added to Formulary (BRAND) 7/9/2018 dino-life iron-zinc tab chew Removed from Formulary 7/9/2018 E.E.S. 200 MG/5 ML GRANULES Removed from Formulary 7/9/2018 econtra ez 1.5 mg tablet Removed Quantity Limits 7/9/2018 EMFLAZA 18 MG TABLET Added to Formulary (BRAND) with Prior Authorization 7/9/2018 EMFLAZA MG/ML ORAL SUSP Added to Formulary (BRAND) with Prior Authorization 7/9/2018 EMFLAZA 30 MG TABLET Added to Formulary (BRAND) with Prior Authorization 7/9/2018 EMFLAZA 36 MG TABLET Added to Formulary (BRAND) with Prior Authorization 7/9/2018 EMFLAZA 6 MG TABLET Added to Formulary (BRAND) with Prior Authorization 7/9/2018 ERLEADA 60 MG TABLET Added to Formulary (BRAND) with Quantity Limits and Prior Authorization 7/9/2018 ESTRACE 0.01% CREAM Removed from Formulary 7/9/2018
2 ezetimibe 10 mg tablet Added Quantity Limits (generic) 7/9/2018 fallback solo 1.5 mg tablet Removed Quantity Limits 7/9/2018 fentanyl 37.5 mcg/hr patch Added to Formulary (generic) 7/9/2018 fentanyl 62.5 mcg/hr patch Added to Formulary (generic) 7/9/2018 fentanyl 87.5 mcg/hr patch Added to Formulary (generic) 7/9/2018 GABITRIL 12 MG TABLET Removed from Formulary 7/9/2018 GABITRIL 12 MG TABLET Removed from Formulary 7/9/2018 GABITRIL 16 MG TABLET Removed from Formulary 7/9/2018 GABITRIL 16 MG TABLET Removed from Formulary 7/9/2018 GLYTROL LIQUID Added to Formulary (BRAND) 7/9/2018 hair regrowth treatment Removed from Formulary 7/9/2018 honey bears-iron-zinc tab chew Removed from Formulary 7/9/2018 hpr emollient foam Removed from Formulary 7/9/2018 hpr plus hydrogel kit Removed from Formulary 7/9/2018 HUMIRA 10 MG/0.1 ML SYRINGE Added to Formulary (BRAND) with Quantity Limits and Prior Authorization 7/9/2018 HUMIRA 20 MG/0.2 ML SYRINGE Added to Formulary (BRAND) with Quantity Limits and Prior Authorization 7/9/2018 HUMIRA 40 MG/0.4 ML PEN Added to Formulary (BRAND) with Quantity Limits and Prior Authorization 7/9/2018 HUMIRA 40 MG/0.4 ML SYRINGE Added to Formulary (BRAND) with Quantity Limits and Prior Authorization 7/9/2018 HUMIRA PED CROHNS 80 MG/0.8 ML Added to Formulary (BRAND) with Quantity Limits and Prior Authorization 7/9/2018 HUMIRA PEDIATR CROHN'S 80-40MG Added to Formulary (BRAND) with Quantity Limits and Prior Authorization 7/9/2018 IMBRUVICA 140 MG TABLET Added to Formulary (BRAND) with Prior Authorization 7/9/2018 IMBRUVICA 280 MG TABLET Added to Formulary (BRAND) with Prior Authorization 7/9/2018 IMBRUVICA 420 MG TABLET Added to Formulary (BRAND) with Prior Authorization 7/9/2018 IMBRUVICA 560 MG TABLET Added to Formulary (BRAND) with Prior Authorization 7/9/2018 LINZESS 145 MCG CAPSULE Removed from Formulary 7/9/2018 LINZESS 290 MCG CAPSULE Removed from Formulary 7/9/2018 LINZESS 72 MCG CAPSULE Removed from Formulary 7/9/2018 MAVYRET MG TABLET Added Quantity Limits (BRAND) 7/9/2018 mb hydrogel kit Removed from Formulary 7/9/2018 mb hydrogel kit Removed from Formulary 7/9/2018 MEPHYTON 5 MG TABLET Removed from Formulary 7/9/2018 methylphenidate la 10 mg cap Added to Formulary (generic) with Quantity Limits 7/9/2018 miglustat 100 mg capsule Added to Formulary (generic) 7/9/2018
3 minocycline er 135 mg tablet Added Step Therapy (generic) 7/9/2018 minocycline er 90 mg tablet Added Step Therapy (generic) 7/9/2018 minoxidil 2% solution Removed from Formulary 7/9/2018 minoxidil 5% solution Removed from Formulary 7/9/2018 moderiba mg dosepack Added to Formulary (generic) with Quantity Limits and Prior Authorization 7/9/2018 moderiba mg dosepack Added to Formulary (generic) with Quantity Limits and Prior Authorization 7/9/2018 my way 1.5 mg tablet Removed Quantity Limits 7/9/2018 next choice one dose 1.5 mg tb Removed Quantity Limits 7/9/2018 NORVIR 100 MG TABLET Removed from Formulary 7/9/2018 opcicon one-step 1.5 mg tablet Removed Quantity Limits 7/9/2018 option mg tablet Removed Quantity Limits 7/9/2018 oseltamivir 6 mg/ml suspension Added Quantity Limits (generic) 7/9/2018 oseltamivir phos 30 mg capsule Added Quantity Limits (generic) 7/9/2018 oseltamivir phos 45 mg capsule Added Quantity Limits (generic) 7/9/2018 oseltamivir phos 75 mg capsule Added Quantity Limits (generic) 7/9/2018 PLAN B ONE-STEP 1.5 MG TABLET Removed Quantity Limits 7/9/2018 pr cream kit Removed from Formulary 7/9/2018 praziquantel 600 mg tablet Added to Formulary (generic) 7/9/2018 pruclair nonsteroidal cream Removed from Formulary 7/9/2018 prutect topical emulsion Removed from Formulary 7/9/2018 QVAR REDIHALER 40 MCG Added Quantity Limits (BRAND) 7/9/2018 QVAR REDIHALER 80 MCG Added Quantity Limits (BRAND) 7/9/2018 ra antacid 1;000 mg chew tab Added to Formulary (generic) 7/9/2018 ra hair regrowth treatment Removed from Formulary 7/9/2018 ra renewal 5% foam Removed from Formulary 7/9/2018 react 1.5 mg tablet Removed Quantity Limits 7/9/2018 RENVELA 0.8 GM POWDER PACKET Removed from Formulary 7/9/2018 RENVELA 2.4 GM POWDER PACKET Removed from Formulary 7/9/2018 RENVELA 800 MG TABLET Removed from Formulary 7/9/2018 ritonavir 100 mg tablet Added to Formulary (generic) with Quantity Limits 7/9/2018 ROGAINE 2% SOLUTION Removed from Formulary 7/9/2018 ROGAINE 5% FOAM Removed from Formulary 7/9/2018 ROGAINE 5% SOLUTION Removed from Formulary 7/9/2018
4 selenium sulfide 2.3% shampoo Added to Formulary (generic) 7/9/2018 SIMILAC PRO-SENSTV NON-GMO LIQ Added to Formulary (BRAND) 7/9/2018 SIMILAC SENSITIVE FUSS-GAS LIQ Removed from Formulary 7/9/2018 sodium phenylbutyrate 500mg tb Added to Formulary (generic) 7/9/2018 sonafine topical emulsion Removed from Formulary 7/9/2018 sp scar management gel Removed from Formulary 7/9/2018 STOOL SOFTENER 100 MG SOFTGEL Added to Formulary (BRAND) 7/9/2018 SULFAMYLON POWDER PACKET Removed from Formulary 7/9/2018 SUSTIVA 200 MG CAPSULE Removed from Formulary 7/9/2018 SUSTIVA 50 MG CAPSULE Removed from Formulary 7/9/2018 SUSTIVA 600 MG TABLET Removed from Formulary 7/9/2018 SYMFI MG TABLET Added to Formulary (BRAND) with Quantity Limits 7/9/2018 SYMFI LO MG TABLET Added to Formulary (BRAND) with Quantity Limits 7/9/2018 TAMIFLU 6 MG/ML SUSPENSION Removed from Formulary 7/9/2018 TASIGNA 50 MG CAPSULE Added to Formulary (BRAND) with Prior Authorization 7/9/2018 tiagabine hcl 12 mg tablet Added to Formulary (generic) 7/9/2018 tiagabine hcl 16 mg tablet Added to Formulary (generic) 7/9/2018 tri-chlor 80% solution Removed from Formulary 7/9/2018 TRICHLOROACETIC ACID 100% Removed from Formulary 7/9/2018 TRICHLOROACETIC ACID 20% Removed from Formulary 7/9/2018 TRICHLOROACETIC ACID 25% Removed from Formulary 7/9/2018 TRICHLOROACETIC ACID 30% Removed from Formulary 7/9/2018 TRICHLOROACETIC ACID 35% Removed from Formulary 7/9/2018 TRICHLOROACETIC ACID 40% Removed from Formulary 7/9/2018 TRICHLOROACETIC ACID 50% Removed from Formulary 7/9/2018
5 TRICHLOROACETIC ACID 75% Removed from Formulary 7/9/2018 TRICHLOROACETIC ACID 80% Removed from Formulary 7/9/2018 TRICHLOROACETIC ACID 85% Removed from Formulary 7/9/2018 TRICHLOROACETIC ACID 90% Removed from Formulary 7/9/2018 VEMLIDY 25 MG TABLET Added Prior Authorization (BRAND) 7/9/2018 VIREAD 300 MG TABLET Removed from Formulary 7/9/2018 ZAVESCA 100 MG CAPSULE Removed from Formulary 7/9/2018 ZAVESCA 100 MG CAPSULE Removed from Formulary 7/9/2018 ZIAGEN 20 MG/ML SOLUTION Removed from Formulary 7/9/2018 ZIAGEN 300 MG TABLET Removed from Formulary 7/9/2018 TRULANCE 3 MG TABLET Added to Formulary (BRAND) 7/9/2018 estradiol 0.01% cream Added to Formulary (generic) 7/9/2018
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