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March 2025
Additions:
- None
Removals:
- None
Other Updates:
- None
February 2025
Additions:
- None
Removals:
- None
Other Updates:
- Flovent Diskus 100 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
- Flovent Diskus 250 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
- Flovent Diskus 50 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
- Flovent HFA 110 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
- Flovent HFA 220 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
- Flovent HFA 44 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
- Fluticasone propionate diskus 100 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
- Fluticasone propionate diskus 250 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
- Fluticasone propionate diskus 50 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
- Fluticasone propionate HFA 110 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
- Fluticasone propionate HFA 220 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
- Fluticasone propionate HFA 44 mcg per act inhaler (Updated to Tier 2 with Prior Authorization)
- Qvar RediHaler 40 mcg per act inhaler (Updated to Tier 1)
- Qvar RediHaler 80 mcg per act inhaler (Updated to Tier 1)
- Wixela 100 mcg / 50 mcg per act inhaler (Removed Prior Authorization)
- Wixela 250 mcg / 50 mcg per act inhaler (Removed Prior Authorization)
- Wixela 500 mcg / 50 mcg per act inhaler (Removed Prior Authorization)
January 2025
Additions:
- None
Removals:
- None
Other Updates:
- None
-
December 2024
Additions:
- None
Removals:
- None
Other Updates:
- None
November 2024
Additions:
- None
Removals:
- None
Other Updates:
- None
October 2024
Additions:
- None
Removals:
- None
Other Updates:
- None
September 2024
Additions:
- None
Removals:
- Oxbryta 300 mg soluble tablet
- Oxbryta 300 mg tablet
- Oxbryta 500 mg tablet
Other Updates:
- Alclometasone 0.05% ointment (Updated to Tier 2)
- Calcipotriene 0.005% / betamethasone dipropionae 0.064% ointment (Updated to Tier 3)
- Calcipotriene 0.005% / betamethasone dipropionae 0.064% suspension (Updated to Tier 3)
- Clindacin ETZ 1% cleanser kit (Updated to Special PA)
- Clobetasol 0.05% spray (Updated to Tier 2)
- Clocortolone 0.1% cream (Updated to Tier 3)
- Cloderm 0.1% cream (Updated to Tier 3)
- Halcinonide 0.1% cream (Updated to Tier 3)
- Halog 0.1% cream (Updated to Tier 3)
- Halog 0.1% ointment (Updated to Tier 3)
- Halog 0.1% solution (Updated to Tier 3)
- Hydrocodone 10 mg / acetaminophen 300 mg tablet (Updated to Special PA)
- Hydrocodone 5 mg / acetaminophen 300 mg tablet (Updated to Special PA)
- Hydrocodone 7.5 mg / acetaminophen 300 mg tablet (Updated to Special PA)
- Hydrocodone 7.5 mg / acetaminophen 325 mg per 15 mL solution (Updated to Special PA)
- Hydrocortisone 0.1% lotion (Updated to Tier 3)
- Hydrocortisone butyrate 0.1% cream (Updated to Tier 3)
- Hydrocortisone valerate 0.2% cream (Updated to Tier 1)
- Locoid 0.1% lotion (Updated to Tier 3)
- Methadone 10 mg per 5 mL solution (Updated to Special PA)
- Methadone 5 mg per 5 mL solution (Updated to Special PA)
- Nalocet 2.5 mg/300 mg tablet (Updated to Special PA)
- Prolate 10 mg / 300 mg per 5 mL solution (Updated to Special PA)
- Prolate 10 mg / 300 mg tablet (Updated to Special PA)
- Prolate 5 mg / 300 mg tablet (Updated to Special PA)
- Prolate 7.5 mg / 300 mg tablet (Updated to Special PA)
- Taclonex 0.005% / 0.064% ointment (Updated to Tier 3)
- Taclonex 0.005% / 0.064% suspension (Updated to Tier 3)
August 2024
Additions:
- None
Removals:
- None
Other Updates:
- None
July 2024
Additions:
- None
Removals:
- None
Other Updates:
- Aveed 750 gm per 3 mL intramuscular injection (Updated to Special PA)
- Baclofen 5 mg tablet (Updated to Special PA)
- Bismuth 140 mg /metronidazole 125 mg/ tetracycline 125 mg capsule (Removed Brand Preferred, Updated to Special PA)
- Combogesic 1000 mg/300 mg per 100 mL intravenous solution (Updated to Special PA)
- Elyxyb 120 mg per 4.8 mL oral solution (Updated to Special PA)
- Farxiga 10 mg tablet (Added to Brand Preferred)
- Farxiga 5 mg tablet (Added to Brand Preferred)
- Insulin glargine-yfgn 100 unit per mL injection (Removed Prior Authorization)
- Insulin glargine-yfgn 100 unit per mL pen-injector solution (Removed Prior Authorization)
- Invokamet 150/1000 mg tablet (Updated to Tier 2)
- Invokamet 150/500 mg tablet (Updated to Tier 2)
- Invokamet 50/1000 mg tablet (Updated to Tier 2)
- Invokamet 50/500 mg tablet (Updated to Tier 2)
- Invokamet XR 150/1000 mg tablet (Updated to Tier 2)
- Invokamet XR 150/500 mg tablet (Updated to Tier 2)
- Invokamet XR 50/1000 mg tablet (Updated to Tier 2)
- Invokamet XR 50/500 mg tablet (Updated to Tier 2)
- Invokana 100 mg tablet (Updated to Tier 2)
- Invokana 300 mg tablet (Updated to Tier 2)
- Kombiglyze XR 2.5/1000 mg tablet (Updated to Special PA)
- Kombiglyze XR 5/1000 mg tablet (Updated to Special PA)
- Kombiglyze XR 5/500 mg tablet (Updated to Special PA)
- Natesto 5.5 mg per actuation nasal gel (Updated to Special PA)
- Neo-synalar 0.5/0.025% cream (Updated to Tier 2)
- Olopatadine 0.6 % nasal spray (Updated to Tier 2)
- Omnaris 50 mcg nasal spray (Updated to Tier 1)
- Onglyza 2.5 mg tablet (Updated to Special PA)
- Onglyza 5 mg tablet (Updated to Special PA)
- Saxagliptin 2.5 mg tablet (Updated to Special PA)
- Saxagliptin 2.5 mg/ metformin 1000 mg ER tablet (Updated to Special PA)
- Saxagliptin 5 mg tablet (Updated to Special PA)
- Saxagliptin 5 mg/ metformin 1000 mg ER tablet (Updated to Special PA)
- Saxagliptin 5 mg/ metformin 500 mg ER tablet (Updated to Special PA)
- Xigduo XR 10/1000 mg tablet (Added to Brand Preferred)
- Xigduo XR 10/500 mg tablet (Added to Brand Preferred)
- Xigduo XR 2.5/1000 mg tablet (Added to Brand Preferred)
- Xigduo XR 5/1000 mg tablet (Added to Brand Preferred)
- Xigduo XR 5/500 mg tablet (Added to Brand Preferred)
- Zetonna 37 mcg nasal solution (Updated to Tier 1)
June 2024
Additions:
- None
Removals:
- None
Other Updates:
- Amoxicillin 500 mg capsule/clarithromycin 500 mg tablet/lansoprazole 30 mg capsule (Updated to Special PA)
- Bismuth 140 mg/metronidazole 125 mg/tetracycline 125 mg capsule (Updated to Special PA)
- Dapagliflozin 10 mg tablet (Updated to Special PA)
- Dapagliflozin 10mg/metformin 1000 mg ER tablet (Updated to Special PA)
- Dapagliflozin 5 mg tablet (Updated to Special PA)
- Dapagliflozin 5mg/metformin 1000 mg ER tablet (Updated to Special PA)
- Farxiga 10 mg tablet (Added to Brand Preferred)
- Farxiga 5 mg tablet (Added to Brand Preferred)
- Glipizide 2.5 mg tablet (Updated to Special PA)
- Inpefa 200 mg tablet (Updated to Special PA)
- Inpefa 400 mg tablet (Updated to Special PA)
- Invokamet 150/1000 mg tablet (Updated to Tier 2)
- Invokamet 150/500 mg tablet (Updated to Tier 2, Added Step Therapy)
- Invokamet 50/1000 mg tablet (Updated to Tier 2, Added Step Therapy)
- Invokamet 50/500 mg tablet (Updated to Tier 2, Added Step Therapy)
- Invokamet XR 150/1000 mg tablet (Updated to Tier 2, Added Step Therapy)
- Invokamet XR 150/500 mg tablet (Updated to Tier 2, Added Step Therapy)
- Invokamet XR 50/1000 mg tablet (Updated to Tier 2, Added Step Therapy)
- Invokamet XR 50/500 mg tablet (Updated to Tier 2, Added Step Therapy)
- Invokana 100 mg tablet (Updated to Tier 2, Added Step Therapy)
- Invokana 300 mg tablet (Updated to Tier 2, Added Step Therapy)
- Kombiglyze XR 2.5/1000 mg tablet (Updated to Special PA, Removed Step Therapy))
- Kombiglyze XR 5/1000 mg tablet (Updated to Special PA, Removed Step Therapy))
- Kombiglyze XR 5/500 mg tablet (Updated to Special PA, Removed Step Therapy))
- Ngenla 24 mg per 1.2 mL injection (Updated to Tier 2)
- Ngenla 60 mg per 1.2 mL injection (Updated to Tier 2)
- Onglyza 2.5 mg tablet (Updated to Special PA, Removed Step Therapy)
- Onglyza 5 mg tablet (Updated to Special PA, Removed Step Therapy)
- Pylera capsule (Updated to Special PA, Removed from Brand Preferred)
- Saxagliptin 2.5 mg tablet (Updated to Special PA)
- Saxagliptin 2.5 mg/metformin 1000 mg tablet (Updated to Special PA)
- Voquenza 10 mg tablet (Updated to Special PA)
- Voquenza 20 mg tablet (Updated to Special PA)
- Voquenza dual pak (Updated to Special PA)
- Voquenza triple pak (Updated to Special PA)
- Xigduo XR 10/1000 mg tablet (Added to Brand Preferred)
- Xigduo XR 10/500 mg tablet (Added to Brand Preferred)
- Xigduo XR 2.5/1000 mg tablet (Added to Brand Preferred)
- Xigduo XR 5/1000 mg tablet (Added to Brand Preferred)
- Xigduo XR 5/500 mg tablet (Added to Brand Preferred)
- Zituvio 100 mg tablet (Updated to Special PA)
- Zituvio 25 mg tablet (Updated to Special PA)
- Zituvio 50 mg tablet (Updated to Special PA)
May 2024
Additions:
- None
Removals:
- None
Other Updates:
- Aptensio XR 10 mg capsule (Removed from Brand preferred)
- Aptensio XR 15 mg capsule (Removed from Brand preferred)
- Aptensio XR 20 mg capsule (Removed from Brand preferred)
- Aptensio XR 30 mg capsule (Removed from Brand preferred)
- Aptensio XR 40 mg capsule (Removed from Brand preferred)
- Aptensio XR 50 mg capsule (Removed from Brand preferred)
- Aptensio XR 60 mg capsule (Removed from Brand preferred)
- Dynavel XR 2.5 mg per mL suspension (Updated to Tier 3)
- Nuvigil 150mg tablet (Removed from Brand preferred)
- Nuvigil 200mg tablet (Removed from Brand preferred)
- Nuvigil 250mg tablet (Removed from Brand preferred)
- Nuvigil 50mg tablet (Removed from Brand preferred)
April 2024
Additions
- To come
Removals- To come
Other updates- To come