EFFECTIVE 01/05/2018 atazanavir sulfate 150 mg capsule TYPHIM VI 25 MCG/0.5 ML VIAL typhoid vaccine vi capsular polysaccharide atazanavir sulfate 200 mg capsule atazanavir sulfate 300 mg capsule PAGE 1
EFFECTIVE 01/12/2018 LATUDA 40 MG TABLET lurasidone hcl LATUDA 80 MG TABLET lurasidone hcl OPDIVO 240 MG/24 ML VIAL nivolumab PROLASTIN C 1,000 MG/20 ML VL alpha-1-proteinase inhibitor - PA Added: ALPHA-1 PROTEINASE INHIBITOR estradiol 0.01 % cream/appl PAGE 2
EFFECTIVE 01/19/2018 ALUNBRIG 180 MG TABLET brigatinib ALUNBRIG 90 MG TABLET brigatinib ALUNBRIG 90 MG-180 MG TAB PACK brigatinib - PA Added: BRIGATINIB - PA Added: BRIGATINIB - PA Added: BRIGATINIB romidepsin 10 mg/2 ml vial sertraline hcl 100 mg tablet sertraline hcl 25 mg tablet sertraline hcl 50 mg tablet PAGE 3
EFFECTIVE 01/26/2018 GAMMAPLEX 10 GRAM/100 ML VIAL immune globulin,gamma (igg)/glycine/iga 0 to 50 mcg/ml GAMMAPLEX 20 GRAM/200 ML VIAL immune globulin,gamma (igg)/glycine/iga 0 to 50 mcg/ml GAMMAPLEX 5 GRAM/50 ML VIAL immune globulin,gamma (igg)/glycine/iga 0 to 50 mcg/ml SAPHRIS 10 MG TAB SUBLINGUAL asenapine maleate SAPHRIS 5 MG TAB SUBLINGUAL asenapine maleate - PA Added: IMMUNOGLOBULINS IV - PA Added: IMMUNOGLOBULINS IV - PA Added: IMMUNOGLOBULINS IV - PA Added: ASENAPINE - PA Added: ASENAPINE PAGE 4
EFFECTIVE 01/27/2018 b complex w-c no.20/folic acid 1 mg capsule multivit-min/fa/lycopen/lutein.4-300-250 tablet VENLAFAXINE HCL ER 225 MG TAB venlafaxine hcl PAGE 5
EFFECTIVE 02/01/2018 dextrose 5 % in water pggybk prt dextrose 5 % in water pgy vl prt dextrose 5 % in water 5 % iv soln dextrose 5 % in water 5 % vial - PA Removed: - PA Removed: - PA Removed: - PA Removed: PAGE 6
EFFECTIVE 02/02/2018 b complex w-c no.20/folic acid 1 mg capsule ELIQUIS 5 MG STARTER PACK apixaban LITETOUCH SYR 0.5 ML 30GX5/16" syringe with needle,insulin,0.5 ml nutritional supplement/fiber liquid psyllium husk (with sugar) 3.4 g/12 g powder psyllium husk (with sugar) 3.4 g/7 g powder psyllium husk 3.4 g/5.4g powder psyllium husk/aspartame 3.4g/5.8g powder QVAR REDIHALER 40 MCG beclomethasone dipropionate QVAR REDIHALER 80 MCG beclomethasone dipropionate PAGE 7
EFFECTIVE 02/09/2018 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 efavirenz 600 mg tablet levonorgestrel 1.5 mg tablet PAGE 8
EFFECTIVE 02/16/2018 norethindrone-ethinyl estrad 0.5-0.035 tablet PAGE 9
EFFECTIVE 02/17/2018 SILACE 50 MG/5 ML LIQUID docusate sodium SILACE 60 MG/15 ML SYRUP docusate sodium PAGE 10
EFFECTIVE 02/18/2018 docusate sodium 100 mg capsule PAGE 11
EFFECTIVE 02/23/2018 trientine hcl 250 mg capsule PAGE 12
EFFECTIVE 02/24/2018 methyl salicylate/menthol 15%-10% cream (g) PAGE 13
EFFECTIVE 02/25/2018 levetiracetam 750 mg tab er 24h levetiracetam 500 mg tab er 24h PAGE 14
EFFECTIVE 02/27/2018 levetiracetam 750 mg tab er 24h levetiracetam 500 mg tab er 24h - Removed From Coverage - Removed From Coverage PAGE 15
EFFECTIVE 03/01/2018 ADACEL TDAP SYRINGE diphtheria,pertussis(acellular),tetanus vaccine/pf BIKTARVY 50-200-25 MG TABLET bictegravir sodium/emtricitabine/tenofovir alafenamide fumar bortezomib 3.5 mg vial - PA Added: Part D vs Part B haloperidol lactate 5 mg/ml syringe HAVRIX 1,440 UNITS/ML SYRINGE hepatitis a virus vaccine/pf HERCEPTIN 150 MG VIAL trastuzumab HUMALOG JR 100 UNIT/ML KWIKPEN insulin lispro meropenem-0.9% sodium chloride 1 g/50 ml piggyback norgestimate-ethinyl estradiol 0.25-0.035 tablet norgestimate-ethinyl estradiol 7daysx3 28 tablet TWINRIX VACCINE SYRINGE hepatitis a virus and hepatitis b virus vaccine/pf VAQTA 25 UNITS/0.5 ML VIAL hepatitis a virus vaccine/pf VAQTA 50 UNITS/ML VIAL hepatitis a virus vaccine/pf desogestrel-ethinyl estradiol 0.15-0.03 tablet - PA Added: TRASTUZUMAB - ST Added: DIABETES digoxin 125 mcg tablet digoxin 250 mcg tablet isotretinoin 10 mg capsule PAGE 16
EFFECTIVE 03/01/2018 isotretinoin 20 mg capsule isotretinoin 30 mg capsule isotretinoin 40 mg capsule levetiracetam 1000 mg tablet levetiracetam 500 mg tablet levetiracetam 750 mg tablet levonorgestrel-ethin estradiol 0.15-0.03 tablet PAGE 17
EFFECTIVE 03/02/2018 memantine hcl 14 mg cap spr 24 memantine hcl 21 mg cap spr 24 memantine hcl 7 mg cap spr 24 ZENPEP DR 25,000 UNIT CAPSULE lipase/protease/amylase ZENPEP DR 5,000 UNIT CAPSULE lipase/protease/amylase memantine hcl 28 mg cap spr 24 PAGE 18
EFFECTIVE 03/09/2018 glatiramer acetate 40 mg/ml syringe - PA Added: GLATIRAMER IMBRUVICA 140 MG TABLET ibrutinib IMBRUVICA 280 MG TABLET ibrutinib IMBRUVICA 420 MG TABLET ibrutinib IMBRUVICA 560 MG TABLET ibrutinib IMBRUVICA 70 MG CAPSULE ibrutinib - PA Added: IBRUTINIB - PA Added: IBRUTINIB - PA Added: IBRUTINIB - PA Added: IBRUTINIB - PA Added: IBRUTINIB PAGE 19
EFFECTIVE 03/10/2018 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 PAGE 20
EFFECTIVE 03/16/2018 ethynodiol d-ethinyl estradiol 1 mg-50mcg tablet PAGE 21
EFFECTIVE 03/17/2018 ibuprofen 400 mg tablet - ST Added: Inflammation ibuprofen 600 mg tablet - ST Added: INFLAMMATION ibuprofen 800 mg tablet - ST Added: INFLAMMATION terbinafine hcl 1 % cream (g) ibuprofen 400 mg tablet - ST Added: Inflammation ibuprofen 600 mg tablet - ST Added: INFLAMMATION ibuprofen 800 mg tablet - ST Added: INFLAMMATION PAGE 22
EFFECTIVE 03/23/2018 DALIRESP 250 MCG TABLET roflumilast - PA Added: ROFLUMILAST ibuprofen 600 mg tablet - ST Added: INFLAMMATION ritonavir 100 mg tablet tiagabine hcl 12 mg tablet tiagabine hcl 16 mg tablet ibuprofen 400 mg tablet - ST Added: INFLAMMATION ibuprofen 800 mg tablet - ST Added: INFLAMMATION PAGE 23
EFFECTIVE 04/01/2018 ERLEADA 60 MG TABLET apalutamide SYMFI LO 400-300-300 MG TABLET efavirenz/lamivudine/tenofovir disoproxil fumarate - QL Added: 120 / 30 DAYS - PA Added: ANTINEOPLASTIC AGENTS Miscellaneous PAGE 24
EFFECTIVE 04/06/2018 EPINEPHRINE 0.3 MG AUTO-INJECT epinephrine TASIGNA 50 MG CAPSULE nilotinib hcl - QL Added: 2.2 / 31 DAYS - PA Added: NILOTINIB palonosetron hcl 0.25mg/2ml vial - PA Added: Part D vs Part B palonosetron hcl 0.25mg/5ml vial - PA Added: Part D vs Part B PAGE 25
EFFECTIVE 04/12/2018 VIDEX EC 125 MG CAPSULE didanosine PAGE 26
EFFECTIVE 04/13/2018 EASY GLIDE PEN NEEDLE 4MM 33G pen needle, diabetic PAGE 27
EFFECTIVE 04/15/2018 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 - PA Removed: - PA Removed: - PA Removed: - PA Removed: PAGE 28
EFFECTIVE 04/20/2018 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 29
EFFECTIVE 04/27/2018 ZENPEP DR 10,000 UNIT CAPSULE lipase/protease/amylase acetaminophen 325 mg tablet miglustat 100 mg capsule PAGE 30
EFFECTIVE 05/01/2018 VIDEX EC 125 MG CAPSULE didanosine PAGE 31
EFFECTIVE 05/04/2018 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 BD VEO INS 0.3ML 6MMX31G (1/2) syringe with needle,insulin 0.3 ml (half unit mark) BD VEO INS SYRING 1 ML 6MMX31G syringe with needle,disposable,insulin 1 ml BD VEO INS SYRN 0.3 ML 6MMX31G syringe with needle,insulin,0.3 ml BD VEO INS SYRN 0.5 ML 6MMX31G syringe with needle,insulin,0.5 ml 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 aspirin 81 mg tab chew praziquantel 600 mg tablet PAGE 32
EFFECTIVE 05/11/2018 HUMIRA 10 MG/0.1 ML SYRINGE adalimumab HUMIRA 20 MG/0.2 ML SYRINGE adalimumab HUMIRA 40 MG/0.4 ML PEN adalimumab HUMIRA 40 MG/0.4 ML SYRINGE adalimumab KYMRIAH INFUSION BAG tisagenlecleucel 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) - PA Added: ADALIMUMAB - PA Added: ADALIMUMAB - PA Added: ADALIMUMAB - PA Added: ADALIMUMAB - PA Added: ANTINEOPLASTIC AGENTS Miscellaneous PAGE 33
EFFECTIVE 05/15/2018 RUBRACA 250 MG TABLET rucaparib camsylate SYLVANT 400 MG VIAL siltuximab vancomycin hcl 1 g vial vancomycin hcl 1 g vial port vancomycin hcl 500 mg vial vancomycin hcl 500 mg vial port vancomycin hcl 750 mg vial vancomycin hcl 750 mg vial port vancomycin hcl in 5 % dextrose 1g/200ml froz.piggy vancomycin hcl in 5 % dextrose 500mg/0.1l froz.piggy vancomycin hcl in 5 % dextrose 750mg/.15l froz.piggy vancomycin/0.9 % sod chloride 1g/200ml froz.piggy VIRAMUNE 50 MG/5 ML SUSP nevirapine - PA Added: RUCAPARIB - PA Removed: - PA Removed: - PA Removed: - PA Removed: - PA Removed: - PA Removed: - PA Removed: - PA Removed: - PA Removed: - PA Removed: ganciclovir sodium 500mg/10ml vial - PA Added: Part D vs Part B vancomycin hcl 10 g vial vancomycin hcl 5 g vial - PA Removed: - PA Removed: PAGE 34
EFFECTIVE 05/18/2018 ZENPEP DR 15,000 UNIT CAPSULE lipase/protease/amylase PAGE 35
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 NORVIR 100 MG POWDER PACKET ritonavir baclofen 5 mg tablet colesevelam hcl 625 mg tablet PAGE 36
EFFECTIVE 06/01/2018 CIMDUO 300-300 MG TABLET lamivudine/tenofovir disoproxil fumarate HEMLIBRA 105 MG/0.7 ML VIAL emicizumab-kxwh HEMLIBRA 150 MG/ML VIAL emicizumab-kxwh HEMLIBRA 30 MG/ML VIAL emicizumab-kxwh HEMLIBRA 60 MG/0.4 ML VIAL emicizumab-kxwh SYMFI 600-300-300 MG TABLET efavirenz/lamivudine/tenofovir disoproxil fumarate ZENPEP DR 3,000 UNIT CAPSULE lipase/protease/amylase - QL Added: 30 / 30 DAYS - PA Removed: - PA Removed: - PA Removed: - PA Removed: - QL Added: 30 / 30 DAYS lansoprazole 15 mg capsule dr - QL Added: 60 / 30 DAYS - ST Added: PROTON PUMP INHIBITORS lansoprazole 30 mg capsule dr - QL Added: 60 / 30 DAYS - ST Added: PROTON PUMP INHIBITORS PAGE 37
EFFECTIVE 06/08/2018 FLUOR-A-DAY 1 MG TABLET CHEW sodium fluoride/xylitol fluoride (sodium) 0.125/drop drops fluoride (sodium) 0.5(1.1)mg tab chew fluoride (sodium) 1mg(2.2mg) tab chew fluoride/iron/vitamins a,c,d 0.25 mg/ml drops FLUORITAB 1 MG TABLET CHEW fluoride (sodium) K-PHOS NEUTRAL TABLET sodium phosphate,dibasic/pot phos,monob/sod phosphate mono 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 THRIVITE 19 TABLET multivit-mins no.59/ferrous fumarate/folic acid/docusate sod VOL-NATE TABLET multivitamin with minerals no.64/ferrous fumarate/folic acid VOL-PLUS TABLET multivitamin-minerals no.60/ferrous fumarate/folic acid PAGE 38
EFFECTIVE 06/08/2018 VOL-TAB RX TABLET multivitamin with minerals no.50/iron,carbonyl/folic acid fluoride (sodium) 0.25(0.55) tab chew fluoride (sodium) 0.5 mg/ml drops fluoride (sodium) 0.5(1.1)mg tab chew fluoride (sodium) 1mg(2.2mg) tab chew multivit-mins60/iron fum/folic 27 mg-1 mg tablet sod phos di, mono/k phos mono 250 mg tablet PAGE 39
EFFECTIVE 06/15/2018 KIONEX 15 GM/60 ML SUSPENSION sodium polystyrene sulfonate/sorbitol solution prenatal no.123/iron/folic ac 50-1.25 mg tablet - ST Added: PATIROMER CALCIUM lamotrigine 100 mg tablet lamotrigine 150 mg tablet lamotrigine 200 mg tablet lamotrigine 25 mg tablet lamotrigine 25(42)-100 tab ds pk lamotrigine 25(84)-100 tab ds pk lamotrigine 25mg (35) tab ds pk norgestimate-ethinyl estradiol 0.25-0.035 tablet norgestimate-ethinyl estradiol 7daysx3 28 tablet PAGE 40
EFFECTIVE 06/29/2018 ASSURE ID PEN NEEDLE 31GX3/16" pen needle, diabetic, safety daptomycin 350 mg vial - PA Added: Part D vs Part B PAGE 41
EFFECTIVE 07/01/2018 JANUMET XR 100-1,000 MG TABLET sitagliptin phosphate/metformin hcl JANUMET XR 50-1,000 MG TABLET sitagliptin phosphate/metformin hcl JANUMET XR 50-500 MG TABLET sitagliptin phosphate/metformin hcl - QL Added: 30 / 30 DAYS - ST Added: DDP4 INHIBITORS - ST Added: DDP4 INHIBITORS - QL Added: 60 / 30 DAYS - ST Added: DDP4 INHIBITORS - QL Added: 60 / 30 DAYS norethindrone 0.35 mg tablet PAGE 42
EFFECTIVE 07/06/2018 ASSURE ID PEN NEEDLE 30GX3/16" pen needle, diabetic, safety ASSURE ID PEN NEEDLE 30GX5/16" pen needle, diabetic, safety ertapenem sodium 1 g vial vigabatrin 500 mg powd pack - PA Added: VIGABATRIN POWDER PAGE 43
EFFECTIVE 07/13/2018 aspirin 81 mg tab chew aspirin 81 mg tab chew PAGE 44
EFFECTIVE 07/20/2018 ketoprofen 25 mg capsule - ST Added: INFLAMMATION PAGE 45
EFFECTIVE 08/01/2018 naratriptan hcl 1 mg tablet naratriptan hcl 2.5 mg tablet rizatriptan benzoate 10 mg tab rapdis rizatriptan benzoate 10 mg tablet rizatriptan benzoate 5 mg tab rapdis rizatriptan benzoate 5 mg tablet - QL Added: 9 / 30 OVER TIME - QL Added: 9 / 30 OVER TIME - QL Added: 12 / 30 OVER TIME - QL Added: 12 / 30 OVER TIME - QL Added: 12 / 30 OVER TIME - QL Added: 12 / 30 OVER TIME PAGE 46
EFFECTIVE 08/03/2018 bismuth subsalicylate 262mg/15ml oral susp NUPLAZID 10 MG TABLET pimavanserin tartrate NUPLAZID 34 MG CAPSULE pimavanserin tartrate bismuth subsalicylate 262mg/15ml oral susp - PA Added: Pimavanserin - PA Added: Pimavanserin PAGE 47
EFFECTIVE 08/10/2018 bismuth subsalicylate 262mg/15ml oral susp GAMASTAN VIAL immune globulin,gamma(igg)/glycine HEPLISAV-B 20 MCG/0.5 ML SYRNG hepatitis b vaccine recombinant/vaccine adjuvant cpg 1018/pf bismuth subsalicylate 262mg/15ml oral susp - PA Added: IMMUNOGLOBULINS IV - PA Added: Part D vs Part B PAGE 48
EFFECTIVE 08/15/2018 mesalamine w/cleansing wipes 4 g/60 ml enema kit SYMTUZA 800-150-200-10 MG TAB darunavir eth/cobicistat/emtricitabine/tenofovir alafenamide YONSA 125 MG TABLET abiraterone acetate, submicronized - QL Added: 30 / 30 DAYS - QL Added: 120 / 30 DAYS - PA Added: Yonsa norethindrone 0.35 mg tablet PAGE 49
EFFECTIVE 08/17/2018 DROPSAFE PEN NEEDLE 31GX1/4" pen needle, diabetic, safety DROPSAFE PEN NEEDLE 31GX5/16" pen needle, diabetic, safety KYPROLIS 10 MG VIAL carfilzomib ORKAMBI 100-125 MG GRANULE PKT lumacaftor/ivacaftor ORKAMBI 150-188 MG GRANULE PKT lumacaftor/ivacaftor - PA Added: CARFILZOMIB - Added: NON-EXTENDED DAY SUPPLY - PA Added: LUMACAFTOR/IVACAFTOR - Added: NON-EXTENDED DAY SUPPLY - PA Added: LUMACAFTOR/IVACAFTOR PAGE 50
EFFECTIVE 08/24/2018 ADRIAMYCIN 50 MG VIAL doxorubicin hcl - PA Added: Part D vs Part B doxorubicin hcl 10 mg vial - PA Added: Part D vs Part B metformin hcl 500 mg/5ml solution - ST Added: DIABETES tadalafil 20 mg tablet - QL Added: 60 / 30 DAYS - PA Added: TADALAFIL temsirolimus fdn 30mg/3 vial PAGE 51
EFFECTIVE 08/31/2018 LENVIMA 12 MG DAILY DOSE lenvatinib mesylate LENVIMA 4 MG CAPSULE lenvatinib mesylate - PA Added: LENVATINIB - PA Added: LENVATINIB PAGE 52
EFFECTIVE 09/01/2018 ANALPRAM HC 1% CREAM hydrocortisone acetate/pramoxine hcl ANALPRAM HC 2.5%-1% CREAM hydrocortisone acetate/pramoxine hcl ARMOUR THYROID 120 MG TABLET thyroid,pork ARMOUR THYROID 15 MG TABLET thyroid,pork ARMOUR THYROID 180 MG TABLET thyroid,pork ARMOUR THYROID 240 MG TABLET thyroid,pork ARMOUR THYROID 30 MG TABLET thyroid,pork ARMOUR THYROID 300 MG TABLET thyroid,pork ARMOUR THYROID 60 MG TABLET thyroid,pork ARMOUR THYROID 90 MG TABLET thyroid,pork cyanocobalamin (vitamin b-12) 2000 mcg tablet er guaifenesin 200 mg tablet guaifenesin 600 mg tab er 12h hydrocortisone/pramoxine 1 %-1 % cream/appl hydrocortisone/pramoxine 2.5 %-1 % cream (g) hydrocortisone/pramoxine 2.5 %-1 % cream/appl KRO MUCUS RELIEF ER 600 MG TAB guaifenesin PAGE 53
EFFECTIVE 09/01/2018 MUCINEX ER 600 MG TABLET guaifenesin NATURE-THROID 130 MG TABLET thyroid,pork NATURE-THROID 16.25 MG TABLET thyroid,pork NATURE-THROID 195 MG TABLET thyroid,pork NATURE-THROID 260 MG TABLET thyroid,pork NATURE-THROID 32.5 MG TABLET thyroid,pork NATURE-THROID 325 MG TABLET thyroid,pork NATURE-THROID 48.75 MG TABLET thyroid,pork NATURE-THROID 65 MG TABLET thyroid,pork NATURE-THROID 97.5 MG TABLET thyroid,pork PRAMOSONE 2.5%-1% CREAM hydrocortisone acetate/pramoxine hcl PYRIDIUM 100 MG TABLET phenazopyridine hcl WESTHROID 130 MG TABLET thyroid,pork WESTHROID 195 MG TABLET thyroid,pork WESTHROID 32.5 MG TABLET thyroid,pork WESTHROID 65 MG TABLET thyroid,pork PAGE 54
EFFECTIVE 09/01/2018 WESTHROID 97.5 MG TABLET thyroid,pork WP THYROID 130 MG TABLET thyroid,pork WP THYROID 16.25 MG TABLET thyroid,pork WP THYROID 32.5 MG TABLET thyroid,pork WP THYROID 48.75 MG TABLET thyroid,pork WP THYROID 65 MG TABLET thyroid,pork WP THYROID 97.5 MG TABLET thyroid,pork guaifenesin 200 mg tablet guaifenesin 600 mg tab er 12h hydrocortisone/pramoxine 2.5 %-1 % cream (g) levonorgestrel-ethin estradiol 0.1-0.02mg tablet levonorgestrel-ethin estradiol 0.15-0.03 tablet phenazopyridine hcl 100 mg tablet thyroid,pork 120 mg tablet thyroid,pork 15 mg tablet thyroid,pork 30 mg tablet thyroid,pork 60 mg tablet thyroid,pork 90 mg tablet PAGE 55
EFFECTIVE 09/15/2018 SAPHRIS 10 MG TAB SUBLINGUAL asenapine maleate SAPHRIS 5 MG TAB SUBLINGUAL asenapine maleate - PA Added: ASENAPINE - PA Added: ASENAPINE ibuprofen 200 mg tablet PAGE 56
EFFECTIVE 09/21/2018 SAPHRIS 10 MG TAB SUBLINGUAL asenapine maleate SAPHRIS 5 MG TAB SUBLINGUAL asenapine maleate - PA Added: ASENAPINE - PA Added: ASENAPINE dalfampridine 10 mg tab er 12h - QL Added: 60 / 30 DAYS ibuprofen 200 mg tablet PAGE 57
EFFECTIVE 09/22/2018 aspirin 81 mg tablet dr TECHLITE PEN NEEDLE 31GX3/16" pen needle, diabetic aspirin 81 mg tablet dr PAGE 58
EFFECTIVE 10/01/2018 acetaminophen 500 mg capsule acetaminophen 500 mg tablet acetaminophen 650 mg tablet er BELSOMRA 10 MG TABLET suvorexant BELSOMRA 15 MG TABLET suvorexant BELSOMRA 20 MG TABLET suvorexant BELSOMRA 5 MG TABLET suvorexant BRAFTOVI 50 MG CAPSULE encorafenib BRAFTOVI 75 MG CAPSULE encorafenib HUMIRA PEN CROHN-UC-HS 80 MG adalimumab HUMIRA PEN PSOR-UVEI 80MG-40MG adalimumab - Removed From Coverage - Removed From Coverage - Removed From Coverage - QL Added: 30 / 30 DAYS - QL Added: 30 / 30 DAYS - QL Added: 30 / 30 DAYS - QL Added: 30 / 30 DAYS - QL Added: 120 / 30 DAYS - PA Added: Encorafenib - QL Added: 180 / 30 DAYS - PA Added: Encorafenib - PA Added: ADALIMUMAB - PA Added: ADALIMUMAB lidocaine 4 % adh. patch - QL Added: 30 / 30 DAYS lorazepam 2 mg/ml syringe lorazepam 2 mg/ml vial lorazepam 4 mg/ml syringe lorazepam 4 mg/ml vial MEKTOVI 15 MG TABLET binimetinib - QL Added: 180 / 30 DAYS - PA Added: BINIMETINIB PAGE 59
EFFECTIVE 10/01/2018 PAIN & FEVER 500 MG TABLET acetaminophen TAVALISSE 100 MG TABLET fostamatinib disodium TAVALISSE 150 MG TABLET fostamatinib disodium TIBSOVO 250 MG TABLET ivosidenib TYLENOL 8 HOUR 650 MG CAPLET acetaminophen - Removed From Coverage - PA Added: FOSTAMATINIB - LA Added: Limited Access - QL Added: 60 / 30 DAYS - PA Added: FOSTAMATINIB - LA Added: Limited Access - QL Added: 60 / 30 DAYS - QL Added: 30 / 30 DAYS - PA Added: Ivosidenib - Removed From Coverage verapamil hcl 2.5 mg/ml ampul verapamil hcl 2.5 mg/ml vial VYVANSE 10 MG CAPSULE lisdexamfetamine dimesylate VYVANSE 10 MG CHEWABLE TABLET lisdexamfetamine dimesylate VYVANSE 20 MG CAPSULE lisdexamfetamine dimesylate VYVANSE 20 MG CHEWABLE TABLET lisdexamfetamine dimesylate VYVANSE 30 MG CAPSULE lisdexamfetamine dimesylate VYVANSE 30 MG CHEWABLE TABLET lisdexamfetamine dimesylate VYVANSE 40 MG CAPSULE lisdexamfetamine dimesylate VYVANSE 40 MG CHEWABLE TABLET lisdexamfetamine dimesylate - QL Added: 30 / 30 DAYS - QL Added: 30 / 30 DAYS - QL Added: 30 / 30 DAYS - QL Added: 30 / 30 DAYS - QL Added: 30 / 30 DAYS - QL Added: 30 / 30 DAYS - QL Added: 30 / 30 DAYS - QL Added: 30 / 30 DAYS PAGE 60
EFFECTIVE 10/01/2018 VYVANSE 50 MG CAPSULE lisdexamfetamine dimesylate VYVANSE 50 MG CHEWABLE TABLET lisdexamfetamine dimesylate VYVANSE 60 MG CAPSULE lisdexamfetamine dimesylate VYVANSE 60 MG CHEWABLE TABLET lisdexamfetamine dimesylate VYVANSE 70 MG CAPSULE lisdexamfetamine dimesylate acetaminophen 500 mg capsule acetaminophen 500 mg tablet acetaminophen 650 mg tablet er atomoxetine hcl 10 mg capsule atomoxetine hcl 100 mg capsule atomoxetine hcl 18 mg capsule atomoxetine hcl 25 mg capsule atomoxetine hcl 40 mg capsule atomoxetine hcl 60 mg capsule atomoxetine hcl 80 mg capsule - QL Added: 30 / 30 DAYS - QL Added: 30 / 30 DAYS - QL Added: 30 / 30 DAYS - QL Added: 30 / 30 DAYS - QL Added: 30 / 30 DAYS - Removed From Coverage - Removed From Coverage - Removed From Coverage - QL Removed: - QL Removed: - QL Removed: - QL Removed: - QL Removed: - QL Removed: - QL Removed: lidocaine 4 % adh. patch - QL Added: 30 / 30 DAYS lorazepam 2 mg/ml oral conc - QL Added: 120 / 30 DAYS vancomycin hcl 250 mg vial verapamil hcl 2.5 mg/ml vial PAGE 61