EFFECTIVE 01/02/2018 TYPHIM VI 25 MCG/0.5 ML VIAL typhoid vaccine vi capsular polysaccharide PAGE 1 LAST UPDATED 09/2018
EFFECTIVE 01/05/2018 atazanavir sulfate 150 mg capsule atazanavir sulfate 200 mg capsule atazanavir sulfate 300 mg capsule PAGE 2 LAST UPDATED 09/2018
EFFECTIVE 01/08/2018 LATUDA 40 MG TABLET lurasidone hcl LATUDA 80 MG TABLET lurasidone hcl - QL Added: 30 / 30 DAYS - QL Added: 60 / 30 DAYS nafcillin sodium 10 g vial PAGE 3 LAST UPDATED 09/2018
EFFECTIVE 01/12/2018 BYETTA 10 MCG DOSE PEN INJ exenatide BYETTA 5 MCG DOSE PEN INJ exenatide OPDIVO 240 MG/24 ML VIAL nivolumab PROLASTIN C 1,000 MG/20 ML VL alpha-1-proteinase inhibitor - QL Added: 2.4 / 30 DAYS - ST Added: GLP1 AGONIST THERAPY - QL Added: 1.2 / 30 DAYS - ST Added: GLP1 AGONIST THERAPY - PA Added: Opdivo - LA Added: Limited Access - PA Added: Alpha-1 Proteinase Inhibitors estradiol 0.01 % cream/appl PAGE 4 LAST UPDATED 09/2018
EFFECTIVE 01/15/2018 CIALIS 2.5 MG TABLET tadalafil CIALIS 5 MG TABLET tadalafil linezolid 600 mg tablet - Added to Tier 3 - QL Added: 30 / 30 DAYS - PA Added: Cialis - Added to Tier 3 - QL Added: 30 / 30 DAYS - PA Added: Cialis - QL Added: 60 / 30 DAYS sertraline hcl 100 mg tablet - ST Added: ANTIDEPRESSANT THERAPY sertraline hcl 25 mg tablet - ST Added: ANTIDEPRESSANT THERAPY sertraline hcl 50 mg tablet - ST Added: ANTIDEPRESSANT THERAPY PAGE 5 LAST UPDATED 09/2018
EFFECTIVE 01/18/2018 BYETTA 10 MCG DOSE PEN INJ exenatide BYETTA 5 MCG DOSE PEN INJ exenatide - Added to Tier 3 - Added to Tier 3 PAGE 6 LAST UPDATED 09/2018
EFFECTIVE 01/19/2018 ALUNBRIG 180 MG TABLET brigatinib ALUNBRIG 90 MG TABLET brigatinib ALUNBRIG 90 MG-180 MG TAB PACK brigatinib - QL Added: 30 / 30 DAYS - PA Added: Alunbrig - PA Added: Alunbrig - QL Added: 60 / 30 DAYS - QL Added: 30 / 30 DAYS - PA Added: Alunbrig bortezomib 3.5 mg vial - PA Added: Velcade CINVANTI 130 MG/18 ML VIAL aprepitant romidepsin 10 mg/2 ml vial - PA Added: Istodax gemcitabine hcl 100 mg/ml vial PAGE 7 LAST UPDATED 09/2018
EFFECTIVE 01/23/2018 BYSTOLIC 2.5 MG TABLET nebivolol hcl BYSTOLIC 5 MG TABLET nebivolol hcl GAMMAPLEX 10 GRAM/100 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 - Added to Tier 3 - QL Added: 30 / 30 DAYS - Added to Tier 3 - QL Added: 90 / 30 DAYS - PA Added: IVIG - PA Added: IVIG - ST Added: ATYPICAL ANTIPSYCHOTICS - QL Added: 60 / 30 DAYS - ST Added: ATYPICAL ANTIPSYCHOTICS - QL Added: 60 / 30 DAYS PAGE 8 LAST UPDATED 09/2018
EFFECTIVE 01/26/2018 AZACTAM 1 GM VIAL aztreonam AZACTAM 2 GM VIAL aztreonam cefazolin sodium/dextrose,iso 1 g/50 ml froz.piggy cefazolin sodium/dextrose,iso 1 g/50 ml piggyback cefepime hcl in dextrose 5 % 1 g/50 ml piggyback cefepime hcl in dextrose 5 % 2 g/50 ml piggyback cefepime in iso-osm dextrose 1 g/50 ml froz.piggy cefepime in iso-osm dextrose 2 g/100 ml froz.piggy cefoxitin sodium/dextrose,iso 1 g/50 ml piggyback cefoxitin sodium/dextrose,iso 2 g/50 ml piggyback ceftriaxone in is-osm dextrose 1 g/50 ml froz.piggy ceftriaxone in is-osm dextrose 1 g/50 ml piggyback ceftriaxone in is-osm dextrose 2 g/50 ml froz.piggy ceftriaxone in is-osm dextrose 2 g/50 ml piggyback CLINDACIN ETZ KIT clindamycin phosphate/skin cleanser comb no.19 heparin sod,pork in 0.45% nacl 25000/250 iv soln - Added to Tier 2 PAGE 9 LAST UPDATED 09/2018
EFFECTIVE 01/26/2018 heparin sod,pork in 0.45% nacl 25000/500 iv soln heparin sodium,porcine/d5w 20k/500ml iv soln heparin sodium,porcine/d5w 25000/250 iv soln heparin sodium,porcine/d5w 25000/500 iv soln - Added to Tier 2 - Added to Tier 2 - Added to Tier 2 lidocaine hcl/pf 20 mg/ml ampul - Added to Tier 2 lidocaine hcl/pf 20 mg/ml vial - Added to Tier 2 LITETOUCH SYR 0.5 ML 30GX5/16" syringe with needle,insulin,0.5 ml METRO IV 500 MG/100 ML metronidazole in sodium chloride - Added to Tier 2 morphine sulfate 10 mg/ml syringe - Added to Tier 2 morphine sulfate 2 mg/ml syringe morphine sulfate 4 mg/ml syringe - Added to Tier 2 morphine sulfate 8 mg/ml syringe - Added to Tier 2 nafcillin in dextrose,iso-osm 1 g/50 ml froz.piggy NEUAC 1.2-5% KIT clindamycin phosphate/benzoyl peroxide/emollient comb no.94 SPS 30 GM/120 ML ENEMA sodium polystyrene sulfonate/sorbitol solution - Added to Tier 2 timolol maleate 0.5 % drop daily tobramycin/nebulizer 300 mg/5ml ampulneb - QL Added: 280 / 56 DAYS PAGE 10 LAST UPDATED 09/2018
EFFECTIVE 01/26/2018 ZOSYN 2.25 GRAM VIAL piperacillin sodium/tazobactam sodium ZOSYN 3.375 GRAM VIAL piperacillin sodium/tazobactam sodium PAGE 11 LAST UPDATED 09/2018
EFFECTIVE 02/01/2018 bortezomib 3.5 mg vial BYDUREON BCISE 2 MG AUTOINJECT exenatide microspheres CALQUENCE 100 MG CAPSULE acalabrutinib heparin sod,pork in 0.45% nacl 12500/250 iv soln heparin sodium,porcine 5000/ml syringe heparin sodium,porcine 5000/ml(1) cartridge heparin sodium,porcine/d5w 12500/250 iv soln heparin sodium,porcine/ns/pf 1000/500ml iv soln heparin sodium,porcine/ns/pf 2k/1000ml iv soln heparin sodium,porcine/pf 1000/ml vial heparin sodium,porcine/pf 5000/0.5ml syringe heparin sodium,porcine/pf 5000/0.5ml vial levocarnitine 200 mg/ml vial TREANDA 25 MG VIAL bendamustine hcl TRISENOX 12 MG/6 ML VIAL arsenic trioxide VIVITROL 380 MG VIAL + DILUENT naltrexone microspheres heparin sodium,porcine/ns/pf 2k/1000ml iv soln - PA Added: Bortezomib - QL Added: 3.4 / 28 DAYS - PA Added: Calquence - QL Added: 60 / 30 DAYS - PA Removed: PAGE 12 LAST UPDATED 09/2018
EFFECTIVE 02/02/2018 ELIQUIS 5 MG STARTER PACK apixaban haloperidol decanoate 100 mg/ml vial haloperidol decanoate 50 mg/ml ampul haloperidol decanoate 50 mg/ml vial haloperidol decanoate 100 mg/ml ampul haloperidol decanoate 100 mg/ml vial - Added to Tier 3 - QL Added: 74 / 30 DAYS - PA Removed: - PA Removed: - PA Removed: - PA Removed: - PA Removed: PAGE 13 LAST UPDATED 09/2018
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 methylphenidate hcl 72 mg tab er 24 - QL Added: 30 / 30 DAYS efavirenz 600 mg tablet isotretinoin 10 mg capsule isotretinoin 20 mg capsule isotretinoin 30 mg capsule isotretinoin 40 mg capsule methylphenidate hcl 36 mg tab er 24 - QL Added: 60 / 30 DAYS PAGE 14 LAST UPDATED 09/2018
EFFECTIVE 02/16/2018 haloperidol lactate 5 mg/ml syringe - Added to Tier 2 norgestimate-ethinyl estradiol 0.25-0.035 tablet norgestimate-ethinyl estradiol 7daysx3 28 tablet PAGE 15 LAST UPDATED 09/2018
EFFECTIVE 02/23/2018 trientine hcl 250 mg capsule - ST Added: PENICILLAMINE THERAPY PAGE 16 LAST UPDATED 09/2018
EFFECTIVE 02/25/2018 levetiracetam 750 mg tab er 24h - Added to Tier 2 - QL Added: 120 / 30 DAYS levetiracetam 500 mg tab er 24h - Added to Tier 2 - QL Added: 180 / 30 DAYS PAGE 17 LAST UPDATED 09/2018
EFFECTIVE 03/01/2018 BIKTARVY 50-200-25 MG TABLET bictegravir sodium/emtricitabine/tenofovir alafenamide fumar - QL Added: 30 / 30 DAYS doripenem 500 mg vial estradiol 0.01 % cream/appl - Added to Tier 2 PAGE 18 LAST UPDATED 09/2018
EFFECTIVE 03/09/2018 MAKENA 275 MG/1.1 ML AUTOINJCT hydroxyprogesterone caproate/pf - PA Added: MAKENA (s) methylphenidate hcl 10 mg cpbp 50-50 - QL Added: 30 / 30 DAYS PAGE 19 LAST UPDATED 09/2018
EFFECTIVE 03/10/2018 ONETOUCH ULTRA BLUE TEST STRP blood sugar diagnostic PAGE 20 LAST UPDATED 09/2018
EFFECTIVE 03/16/2018 ethynodiol d-ethinyl estradiol 1 mg-50mcg tablet PAGE 21 LAST UPDATED 09/2018
EFFECTIVE 03/17/2018 ibuprofen 400 mg tablet ibuprofen 600 mg tablet ibuprofen 800 mg tablet ibuprofen 400 mg tablet ibuprofen 600 mg tablet ibuprofen 800 mg tablet PAGE 22 LAST UPDATED 09/2018
EFFECTIVE 03/23/2018 ritonavir 100 mg tablet tiagabine hcl 12 mg tablet tiagabine hcl 16 mg tablet ibuprofen 400 mg tablet ibuprofen 600 mg tablet ibuprofen 800 mg tablet PAGE 23 LAST UPDATED 09/2018
EFFECTIVE 03/31/2018 OMNIPOD 10 PACK insulin pump cartridge OMNIPOD 5 PACK POD insulin pump cartridge OMNIPOD STARTER KIT subcutaneous insulin pump - Added to Tier 3 - Added to Tier 3 - Added to Tier 3 PAGE 24 LAST UPDATED 09/2018
EFFECTIVE 04/01/2018 DALIRESP 250 MCG TABLET roflumilast ENDARI 5 GRAM POWDER PACKET glutamine ERLEADA 60 MG TABLET apalutamide 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 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 lidocaine 5 % oint. (g) lidocaine hcl 4 % solution - QL Added: 30 / 30 DAYS - PA Added: Daliresp - QL Added: 180 / 30 DAYS - PA Added: Endari - QL Added: 120 / 30 DAYS - PA Added: ERLEADA - PA Added: HEMLIBRA - PA Added: HEMLIBRA - PA Added: HEMLIBRA - PA Added: HEMLIBRA - PA Added: Imbruvica - QL Added: 30 / 30 DAYS - PA Added: Imbruvica - QL Added: 30 / 30 DAYS - PA Added: Imbruvica - QL Added: 30 / 30 DAYS - PA Added: Imbruvica - QL Added: 30 / 30 DAYS - PA Added: Imbruvica - QL Added: 30 / 30 DAYS PAGE 25 LAST UPDATED 09/2018
EFFECTIVE 04/01/2018 lidocaine hcl 40 mg/ml solution lidocaine/prilocaine 2.5 %-2.5% kit LIDORXKIT lidocaine/skin cleanser combination no.37 paricalcitol 2 mcg/ml vial paricalcitol 5 mcg/ml vial PREVYMIS 240 MG TABLET letermovir PREVYMIS 240 MG/12 ML VIAL letermovir PREVYMIS 480 MG TABLET letermovir PREVYMIS 480 MG/24 ML VIAL letermovir VIDEX EC 125 MG CAPSULE didanosine lidocaine/prilocaine 2.5 %-2.5% cream (g) methotrexate sodium 2.5 mg tablet prochlorperazine maleate 10 mg tablet prochlorperazine maleate 5 mg tablet - QL Added: 30 / 30 DAYS - QL Added: 30 / 30 DAYS PAGE 26 LAST UPDATED 09/2018
EFFECTIVE 04/06/2018 SYMFI LO 400-300-300 MG TABLET efavirenz/lamivudine/tenofovir disoproxil fumarate - QL Added: 30 / 30 DAYS palonosetron hcl 0.25mg/2ml vial palonosetron hcl 0.25mg/5ml vial PAGE 27 LAST UPDATED 09/2018
EFFECTIVE 04/12/2018 VIDEX EC 125 MG CAPSULE didanosine PAGE 28 LAST UPDATED 09/2018
EFFECTIVE 04/13/2018 EASY GLIDE PEN NEEDLE 4MM 33G pen needle, diabetic TOUJEO MAX SOLOSTAR 300UNIT/ML insulin glargine,human recombinant analog TROGARZO 200 MG/1.33 ML VIAL ibalizumab-uiyk VIDEX EC 125 MG CAPSULE didanosine - Added to Tier 3 PAGE 29 LAST UPDATED 09/2018
EFFECTIVE 04/15/2018 TASIGNA 50 MG CAPSULE nilotinib hcl - PA Added: Tasigna - QL Added: 240 / 30 DAYS PAGE 30 LAST UPDATED 09/2018
EFFECTIVE 04/20/2018 BAXDELA 300 MG VIAL delafloxacin meglumine BAXDELA 450 MG TABLET delafloxacin meglumine 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 FASENRA 30 MG/ML SYRINGE benralizumab FIASP 100 UNIT/ML FLEXTOUCH insulin aspart (niacinamide) FIASP 100 UNIT/ML VIAL insulin aspart (niacinamide) OZEMPIC 0.25-0.5 MG DOSE PEN semaglutide OZEMPIC 1 MG DOSE PEN semaglutide QTERN 10 MG-5 MG TABLET dapagliflozin propanediol/saxagliptin hcl - PA Added: BAXDELA - PA Added: BAXDELA - PA Added: FASENRA - Added to Tier 3 - Added to Tier 3 - QL Added: 1.5 / 28 DAYS - QL Added: 3 / 28 DAYS - QL Added: 30 / 30 DAYS timolol maleate 0.5 % drop daily TRELEGY ELLIPTA 100-62.5-25 fluticasone furoate/umeclidinium bromide/vilanterol trifenat - QL Added: 60 / 30 DAYS PAGE 31 LAST UPDATED 09/2018
EFFECTIVE 04/27/2018 miglustat 100 mg capsule - PA Added: Zavesca - LA Added: Limited Access PAGE 32 LAST UPDATED 09/2018
EFFECTIVE 04/30/2018 CIMDUO 300-300 MG TABLET lamivudine/tenofovir disoproxil fumarate EPIPEN 2-PAK 0.3 MG AUTO-INJCT epinephrine EPIPEN JR 2-PAK 0.15 MG INJCTR epinephrine SYLVANT 400 MG VIAL siltuximab SYMFI 600-300-300 MG TABLET efavirenz/lamivudine/tenofovir disoproxil fumarate VIRAMUNE 50 MG/5 ML SUSP nevirapine - QL Added: 30 / 30 DAYS - Added to Tier 3 - QL Added: 2 / 30 DAYS - ST Added: EPINEPHRINE AUTO- INJECTOR THERAPY - Added to Tier 3 - QL Added: 2 / 30 DAYS - ST Added: EPINEPHRINE AUTO- INJECTOR THERAPY - PA Removed: - QL Added: 30 / 30 DAYS palonosetron hcl 0.25mg/2ml vial palonosetron hcl 0.25mg/5ml vial PAGE 33 LAST UPDATED 09/2018
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 dexamethasone 0.5 mg/5ml elixir - Added to Tier 2 ganciclovir sodium 500mg/10ml vial - Added to Tier 2 praziquantel 600 mg tablet - Added to Tier 2 PAGE 34 LAST UPDATED 09/2018
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 HUMIRA PED CROHNS 80 MG/0.8 ML adalimumab HUMIRA PEDIATR CROHN'S 80-40MG 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) - PA Added: Humira - QL Added: 2 / 28 DAYS - PA Added: Humira - QL Added: 2 / 28 DAYS - PA Added: Humira - QL Added: 2 / 28 DAYS - PA Added: Humira - QL Added: 2 / 28 DAYS - PA Added: Humira - QL Added: 3 / 28 DAYS - PA Added: Humira - QL Added: 2 / 28 DAYS PAGE 35 LAST UPDATED 09/2018
EFFECTIVE 05/11/2018 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 36 LAST UPDATED 09/2018
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 - Added to Tier 2 colesevelam hcl 625 mg tablet - Added to Tier 2 norgestimate-ethinyl estradiol 0.25-0.035 tablet PAGE 37 LAST UPDATED 09/2018
EFFECTIVE 06/01/2018 BAXDELA 300 MG VIAL delafloxacin meglumine BAXDELA 450 MG TABLET delafloxacin meglumine BENZNIDAZOLE 100 MG TABLET benznidazole BENZNIDAZOLE 12.5 MG TABLET benznidazole norgestimate-ethinyl estradiol 7daysx3 28 tablet - PA Removed: - PA Removed: - Added to Tier 2 - Added to Tier 2 testosterone 10 mg (2%) gel md pmp - Added to Tier 2 testosterone 12.5/1.25g gel md pmp - Added to Tier 2 testosterone 25mg(1%) gel packet - Added to Tier 2 testosterone 50 mg (1%) gel (gram) - Added to Tier 2 testosterone 50 mg (1%) gel packet - Added to Tier 2 PAGE 38 LAST UPDATED 09/2018
EFFECTIVE 06/08/2018 ARNUITY ELLIPTA 50 MCG INH fluticasone furoate FLUOR-A-DAY 0.25 MG TAB CHEW sodium fluoride/xylitol FLUOR-A-DAY 0.5 MG TAB CHEW sodium fluoride/xylitol FLUOR-A-DAY 1 MG TABLET CHEW sodium fluoride/xylitol - Added to Tier 3 - QL Added: 30 / 30 DAYS fluoride (sodium) 0.5(1.1)mg tab chew fluoride (sodium) 1mg(2.2mg) tab chew FLUORITAB 1 MG TABLET CHEW fluoride (sodium) 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 fluoride (sodium) 0.25(0.55) tab chew fluoride (sodium) 0.5(1.1)mg tab chew fluoride (sodium) 1mg(2.2mg) tab chew norethindrone 0.35 mg tablet PAGE 39 LAST UPDATED 09/2018
EFFECTIVE 06/15/2018 EPINEPHRINE 0.15 MG AUTO-INJCT epinephrine EPINEPHRINE 0.3 MG AUTO-INJECT epinephrine EPIPEN 2-PAK 0.3 MG AUTO-INJCT epinephrine EPIPEN JR 2-PAK 0.15 MG INJCTR epinephrine KEVZARA 150 MG/1.14 ML PEN INJ sarilumab KEVZARA 200 MG/1.14 ML PEN INJ sarilumab KIONEX 15 GM/60 ML SUSPENSION sodium polystyrene sulfonate/sorbitol solution - Added to Tier 2 Epinephrine Auto-injector Therapy - QL Added: 2.28 / 28 DAYS - PA Added: Kevzara - QL Added: 2.28 / 28 DAYS - PA Added: Kevzara - Added to Tier 2 epinephrine 0.15/0.15 auto injct - Added to Tier 2 epinephrine 0.3mg/0.3 auto injct - Added to Tier 2 lamotrigine 100 mg tablet lamotrigine 150 mg tablet lamotrigine 200 mg tablet lamotrigine 25 mg tablet PAGE 40 LAST UPDATED 09/2018
EFFECTIVE 06/29/2018 ASSURE ID PEN NEEDLE 31GX3/16" pen needle, diabetic, safety buprenorphine hcl/naloxone hcl 8 mg-2 mg film - Added to Tier 2 - QL Added: 90 / 30 DAYS daptomycin 350 mg vial PAGE 41 LAST UPDATED 09/2018
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 hydromorphone hcl/pf 4 mg/ml vial - Added to Tier 2 vigabatrin 500 mg powd pack - QL Added: 180 / 30 DAYS - LA Added: Limited Access - PA Added: Sabril PAGE 42 LAST UPDATED 09/2018
EFFECTIVE 07/13/2018 ARISTADA INITIO ER 675 MG/2.4 aripiprazole lauroxil, submicronized - Removed From Coverage - QL Removed: ritonavir 100 mg tablet - Added to Tier 2 SYMDEKO 100/150 MG-150 MG TABS tezacaftor/ivacaftor TROGARZO 200 MG/1.33 ML VIAL ibalizumab-uiyk hydromorphone hcl/pf 1 mg/ml vial - QL Added: 56 / 28 DAYS - Removed From Coverage PAGE 43 LAST UPDATED 09/2018
EFFECTIVE 07/20/2018 CUPRIMINE 250 MG CAPSULE penicillamine DEPEN 250 MG TITRATAB penicillamine SYPRINE 250 MG CAPSULE trientine hcl trientine hcl 250 mg capsule XELJANZ 10 MG TABLET tofacitinib citrate - PA Added: Xeljanz - QL Added: 60 / 30 DAYS budesonide 9 mg tabdr - er - ST Added: UCERIS ORAL THERAPY hydroxyprogesterone caproat/pf 250 mg/ml vial - PA Added: MAKENA (s) ketoprofen 25 mg capsule - Added to Tier 2 PAGE 44 LAST UPDATED 09/2018
EFFECTIVE 07/27/2018 ALPHAGAN P 0.1% DROPS brimonidine tartrate AZOPT 1% EYE DROPS brinzolamide betaxolol hcl 0.5 % drops COMBIGAN 0.2%-0.5% EYE DROPS brimonidine tartrate/timolol maleate COSOPT PF EYE DROPS dorzolamide hcl/timolol maleate/pf KIONEX 15 GM/60 ML SUSPENSION sodium polystyrene sulfonate/sorbitol solution latanoprost 0.005 % drops LUMIGAN 0.01% EYE DROPS bimatoprost metipranolol 0.3 % drops RHOPRESSA 0.02% OPHTH SOLUTION netarsudil mesylate SIMBRINZA 1%-0.2% EYE DROPS brinzolamide/brimonidine tartrate timolol maleate 0.25 % sol-gel timolol maleate 0.5 % drop daily timolol maleate 0.5 % sol-gel TRAVATAN Z 0.004% EYE DROP travoprost travoprost (benzalkonium) 0.004 % drops VYZULTA 0.024% OPHTH SOLUTION latanoprostene bunod bimatoprost 0.03 % drops brimonidine tartrate 0.15 % drops - Added to Tier 2 PAGE 45 LAST UPDATED 09/2018
EFFECTIVE 07/27/2018 brimonidine tartrate 0.2 % drops carteolol hcl 1 % drops colesevelam hcl 3.75 g powd pack - Added to Tier 2 dorzolamide hcl 2 % drops dorzolamide hcl/timolol maleat 22.3-6.8/1 drops levobunolol hcl 0.5 % drops norethindrone 0.35 mg tablet timolol maleate 0.25 % drops timolol maleate 0.25 % sol-gel timolol maleate 0.5 % drops timolol maleate 0.5 % sol-gel PAGE 46 LAST UPDATED 09/2018
EFFECTIVE 07/28/2018 ILARIS 150 MG/ML VIAL canakinumab/pf - LA Added: Limited Access - PA Added: Ilaris - QL Added: 2 / 28 DAYS PAGE 47 LAST UPDATED 09/2018
EFFECTIVE 08/01/2018 YONSA 125 MG TABLET abiraterone acetate, submicronized - PA Added: YONSA PAGE 48 LAST UPDATED 09/2018
EFFECTIVE 08/03/2018 ILARIS 150 MG/ML VIAL canakinumab/pf - LA Added: Limited Access - PA Added: Ilaris - QL Added: 2 / 28 DAYS immun glob g(igg)/pro/iga 0-50 10 % vial - PA Added: IVIG NUPLAZID 10 MG TABLET pimavanserin tartrate NUPLAZID 34 MG CAPSULE pimavanserin tartrate - PA Added: NUPLAZID - QL Added: 30 / 30 DAYS - PA Added: NUPLAZID - QL Added: 30 / 30 DAYS bendamustine hcl 25 mg/ml vial crotamiton 10 % lotion PAGE 49 LAST UPDATED 09/2018
EFFECTIVE 08/06/2018 immun glob g(igg)/pro/iga 0-50 10 % vial - PA Added: IVIG PAGE 50 LAST UPDATED 09/2018
EFFECTIVE 08/10/2018 GAMASTAN VIAL immune globulin,gamma(igg)/glycine HEPLISAV-B 20 MCG/0.5 ML SYRNG hepatitis b vaccine recombinant/vaccine adjuvant cpg 1018/pf HUMIRA PEN CROHN-UC-HS 80 MG adalimumab HUMIRA PEN PSOR-UVEI 80MG-40MG adalimumab dorzolamide/timolol/pf 2 %-0.5 % droperette - Added to Tier 3 - PA Added: Gamastan S/D - PA Added: Humira - QL Added: 3 / 28 DAYS - PA Added: Humira - QL Added: 3 / 28 DAYS - ST Added: RHOPRESSA PAGE 51 LAST UPDATED 09/2018
EFFECTIVE 08/17/2018 DROPSAFE PEN NEEDLE 31GX1/4" pen needle, diabetic, safety DROPSAFE PEN NEEDLE 31GX5/16" pen needle, diabetic, safety immun glob g(igg)/pro/iga 0-50 10 % vial - PA Added: IVIG KYPROLIS 10 MG VIAL carfilzomib PLENVU POWDER PACKETS peg 3350/sodium sulfate/sod chloride/kcl/ascorbate sod/vit c levonorgestrel-ethin estradiol 0.1-0.02mg tablet levonorgestrel-ethin estradiol 0.15-0.03 tablet - PA Added: KYPROLIS - Added to Tier 3 PAGE 52 LAST UPDATED 09/2018
EFFECTIVE 08/24/2018 ADRIAMYCIN 50 MG VIAL doxorubicin hcl OMNIPOD DASH 5 PACK POD insulin pump cartridge - Added to Tier 2 - Added to Tier 3 doxorubicin hcl 10 mg vial - Added to Tier 2 hydroxyprogesterone caproate 250 mg/ml vial - PA Added: MAKENA (s) metformin hcl 500 mg/5ml solution - QL Added: 750 / 30 DAYS tadalafil 20 mg tablet - PA Added: Adcirca - QL Added: 60 / 30 DAYS temsirolimus fdn 30mg/3 vial PAGE 53 LAST UPDATED 09/2018
EFFECTIVE 08/31/2018 BRAFTOVI 50 MG CAPSULE encorafenib BRAFTOVI 75 MG CAPSULE encorafenib MEKTOVI 15 MG TABLET binimetinib SYMTUZA 800-150-200-10 MG TAB darunavir eth/cobicistat/emtricitabine/tenofovir alafenamide TIBSOVO 250 MG TABLET ivosidenib - PA Added: Braftovi - PA Added: Braftovi - PA Added: Mektovi - QL Added: 30 / 30 DAYS - QL Added: 60 / 30 DAYS - PA Added: Tibsovo imiquimod 3.75 % crm md pmp PAGE 54 LAST UPDATED 09/2018
EFFECTIVE 09/14/2018 LENVIMA 12 MG DAILY DOSE lenvatinib mesylate LENVIMA 4 MG CAPSULE lenvatinib mesylate POTELIGEO 20 MG/5 ML VIAL mogamulizumab-kpkc - PA Added: Lenvima - PA Added: Lenvima PAGE 55 LAST UPDATED 09/2018
EFFECTIVE 09/15/2018 SAPHRIS 10 MG TAB SUBLINGUAL asenapine maleate SAPHRIS 5 MG TAB SUBLINGUAL asenapine maleate - ST Added: ATYPICAL ANTIPSYCHOTICS - QL Added: 60 / 30 DAYS - ST Added: ATYPICAL ANTIPSYCHOTICS - QL Added: 60 / 30 DAYS PAGE 56 LAST UPDATED 09/2018
EFFECTIVE 09/21/2018 SAPHRIS 10 MG TAB SUBLINGUAL asenapine maleate SAPHRIS 5 MG TAB SUBLINGUAL asenapine maleate - ST Added: ATYPICAL ANTIPSYCHOTICS - QL Added: 60 / 30 DAYS - ST Added: ATYPICAL ANTIPSYCHOTICS - QL Added: 60 / 30 DAYS dalfampridine 10 mg tab er 12h - LA Added: Limited Access - PA Added: Ampyra - QL Added: 60 / 30 DAYS PAGE 57 LAST UPDATED 09/2018
EFFECTIVE 09/22/2018 TECHLITE PEN NEEDLE 31GX3/16" pen needle, diabetic PAGE 58 LAST UPDATED 09/2018