December 2016 Formulary Updates ABACAVIR/LAMIVUDINE AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 10-20MG QL AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 10-40MG QL AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 5-20MG QL AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 5-40MG QL DROSPIRE/ETHINYL ESTRADIOL/LEVEOMEFOLATE TABS FEMYNOR OLMESARTAN MEDOXOMIL/AMLODIPINE/HYDROCHLOROTHIAZIDE TAB 40-10-12.5MG QL OLMESARTAN MEDOXOMIL/AMLODIPINE/HYDROCHLOROTHIAZIDE TAB 40-10-25MG QL OLMESARTAN MEDOXOMIL/AMLODIPINE/HYDROCHLOROTHIAZIDE TAB 20-5-12.5MG QL OLMESARTAN MEDOXOMIL/AMLODIPINE/HYDROCHLOROTHIAZIDE TAB 40-5-12.5MG QL OLMESARTAN MEDOXOMIL/AMLODIPINE/HYDROCHLOROTHIAZIDE TAB 40-5-25MG QL OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDETAB 20-12.5MG QL OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE TAB 40-12.5MG QL OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE TAB 40-25MG QL OLMESARTAN MEDOXOMIL TAB 20MG QL OLMESARTAN MEDOXOMIL TAB 40MG QL OLMESARTAN MEDOXOMIL TAB 5MG QL YUVAFEM INVOKAMET XR TABS 150-1000MG QL INVOKAMET XR TABS 150-500MG QL INVOKAMET XR TABS 50-1000MG QL INVOKAMET XR TABS 50-500MG QL ORKAMBI TABS 100-125MG QL; PA TRICARE PRENATAL 1 (CHEW) VASCEPA CAPS 0.5 GM
November 2016 Formulary Updates DAPTOMYCIN LARISSIA NITROGLYCERIN SUBL ORFADIN 20MG CAP PA RELISTOR 150MG TAB PA; QL
October 2016 Formulary Updates LEVOLEUCOVORIN INJ 50MG MESALAMINE DR MORGIDOX 1X 50MG NILUTAMIDE BLEO 15K PA EPCLUSA PA; QL ORFADIN Criteria Updated Humira Criteria Updated
September 2016 Formulary Updates ARMODAFINIL TAB QL; PA HYDROXYPROGESTERONE CAPROATE INJ PA FYCOMPA SUSPENSION QL; PA JARDIANCE TAB - QL JENTADUETO XR TAB REPATHA PUSHTRONEX SYSTEM QL; PA SYNJARDY TAB - QL TIVICAY TABS 10MG, 25MG - QL JANUMET TAB QL removed JANUMET XR TAB QL removed JANUVIA TAB QL removed
August 2016 Formulary Updates DOXYCYCLINE HYCLATE TABS DR 50MG, 200MG NALOXONE HCL INJ 0.4MG/ML VANCOMYCIN HCL INJ 500MG, 750MG BRIVIACT INJ - PA BRIVIACT ORAL SOLN - QL; PA BRIVIACT TABS - QL; PA LENVIMA DAILY DOSE 8MG, 18MG - PA NUPLAZID - QL; PA ORFADIN SUSP 4MG/ML - PA TECENTRIQ - PA TRINTELLIX (formerly Brintellix) QL; ST TRUVADA TABS 100MG-150MG, 133MG-200MG, 167MG-250MG QL KUVAN Criteria Revised PRALUENT Criteria Revised REPATHA Criteria Revised LENVIMA Criteria Revised
July 2016 Formulary Updates AZATHIOPRINE INJ - PA PREDNISONE PAK 5MG, 10MG PROCTO-MED HC ROWEEPRA VANCOMYCIN INJ DOFETILIDE (EFFECTIVE JULY 8, 2016) DESCOVY QL EVOMELA - PA MENHIBRIX VENCLEXTA PA; QL VENCLEXTA STARTING PACK PA; QL CABOMETYX PA; QL (EFFECTIVE JULY 15, 2016) SPRITAM (EFFECTIVE JULY 20, 2016) Prior Authorization Update KUVAN Criteria Revised Step Updates
June 2016 Formulary Updates CARBAMAZEPINE ER TB12 100MG DOXEPIN HYDROCHLORIDE ROSUVASTATIN CALCIUM - QL ACTIVE OB DUET DHA 400 DUET DHA BALANCED MISC ELITE-OB LOTEMAX MARNATAL-F MARQIBO - PA OB COMPLETE TABS ODEFSEY - QL PRENATE ENHANCE PRENATE RESTORE PRENATE STAR PROVIDA OB SELECT-OB+DHA TARON-BC VITAFOL GUMMIES VITAFOL ULTRA VITAFOL-NANO VITAFOL-OB VITAFOL-OB+DHA VITATRUE VP-CH-PLUS VP-GGR-B6 PRENATAL FASLODE - Criteria Revised IBRANCE - Criteria Revised PRALUENT - Criteria Revised REPATHA - Criteria Revised Step Updates
May 2016 Formulary Updates ASCOMP/COD - QL; PA FYAVOLV 5MCG; 1MG- PA METOPROLOL TABS 37.5MG, 75MG CIPRODEX LETAIRIS - QL; PA OFEV - QL; PA OTREXUP - ST PRALUENT - QL; PA RASUVO - ST REPATHA - QL; PA REPATHA SURECLICK - QL; PA VP-HEME ONE VRAYLAR CAPS - QL; ST VRAYLAR PACK - QL; ST HARVONI - Criteria Revised SOVALDI - Criteria Revised OPDIVO - Criteria Revised
April 2016 Formulary Updates FLUOR-A-DAY SOLN FLUORITAB SOLN IMATINIB MESYLATE TABS 100MG - QL; PA IMATINIB MESYLATE TABS 400MG - QL; PA KAITLIB FE VIENVA EDARBI - QL EDARBYCLOR - QL ARISTADA - PA removed EVZIO - PA removed MODERIBA TABS - PA removed NARCAN - PA removed RIBAVIRIN - PA removed TESTOSTERONE CYPIONATE INJ - PA removed TESTOSTERONE ENANTHATE IN - PA removed INVEGA SUSTENNA - QL removed ELIQUIS TABS 5 MG - QL 74/30 days REXULTI
March 2016 Formulary Updates BEKYREE NORGESTIMATE/ETHINYL ESTRADIOL TRI-LO-ESTARYLLA TRI-LO-SPRINTEC TRINESSA LO ALECENSA - QL; PA BENDEKA ENTRESTO - QL; PA ENVARSUS XR - PA FERRIPROX SOLN 100MG/ML - PA IRESSA - QL; PA NARCAN - PA PORTRAZZA - PA PRADAXA CAPS 110MG - QL STRIVERDI RESPIMAT - QL TRESIBA FLEXTOUCH ULORIC TABS - ST Prior Authorizations Updates
February 2016 Formulary Updates ALA CORT CREA 1% ARIPIPRAZOLE ODT TBDP 10MG - QL ARIPIPRAZOLE ODT TBDP 15MG - QL BLISOVI 24 FE TABS 20MCG; 75MG; 1MG BLISOVI FE 1/20 TABS 20MCG; 75MG; 1MG BUDESONIDE SUSP 1MG/2ML - PA CEFAZOLIN CEFTRIAXONE SODIUM INJ 100GM DUTASTERIDE/TAMSULOSIN HYDROCHLORIDE CAPS 0.5MG; 0.4M - QL FLORIVA CHEW LINEZOLID SUSR 100MG/5ML - QL; PA MICROGESTIN 24 FE MOLINDONE HYDROCHLORIDE TABS 10MG - QL MOLINDONE HYDROCHLORIDE TABS 25MG - QL MOLINDONE HYDROCHLORIDE TABS 5MG - QL OLOPATADINE SOLN 0.1% REPAGLINIDE/METFORMIN HYDROCHLORIDE TABS 500MG; 1MG - QL REPAGLINIDE/METFORMIN HYDROCHLORIDE TABS 500MG; 2MG - QL SPS COTELLIC TABS 20MG - QL; PA DARZALEX SOLN - PA EMPLICITI SOLR - PA FERRIPROX TABS 500MG - PA GENVOYA TABS 150MG; 150MG; 200MG; 10MG - QL GLEOSTINE CAPS 5MG NINLARO CAPS 2.3MG - QL; PA NINLARO CAPS 3MG - QL; PA NINLARO CAPS 4MG - QL; PA OB COMPLETE GOLD PREFERA OB TABS TAGRISSO TABS 40MG - QL; PA TAGRISSO TABS 80MG - QL; PA VITAFOL FE
Prior Authorizations Updates ONDANSETRON ODT TBDP 4MG - PA removed DIAZEPAM TABS 10MG - PA removed DIAZEPAM TABS 2MG - PA removed DIAZEPAM TABS 5MG - PA removed ONDANSETRON HCL TABS 4MG - PA removed DIAZEPAM SOLN 1MG/ML - PA removed ONDANSETRON HCL TABS 24MG - PA removed ONDANSETRON HCL SOLN 4MG/5ML - PA removed ONDANSETRON HCL TABS 8MG - PA removed ONDANSETRON ODT TBDP 8MG - PA removed INVEGA TRINZA - QL removed ANORO ELLIPTA AEPB 62.5MCG/INH; 25MCG/INH - ST removed AURYXIA TABS 210MG - ST removed BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" MISC - ST removed BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16" MISC - ST removed BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" MISC - ST removed ADVAIR DISKUS AEPB 100MCG/DOSE; 50MCG/DOSE - ST removed ADVAIR DISKUS AEPB 250MCG/DOSE; 50MCG/DOSE - ST removed ADVAIR DISKUS AEPB 500MCG/DOSE; 50MCG/DOSE - ST removed ADVAIR HFA AERO 45MCG/ACT; 21MCG/ACT - ST removed ADVAIR HFA AERO 115MCG/ACT; 21MCG/ACT - ST removed ADVAIR HFA AERO 230MCG/ACT; 21MCG/ACT - ST removed