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Preferred drug list
search tool and updates

Stay up-to-date with your medicine. A preferred drug list is a list of medicines we cover. We keep it up-to-date for you. And make it easy to manage your medicines and your loved ones’ medicines.

 

Find out if your medicine is covered

 

Search our preferred drug list

Our preferred drug list search tool

There are many different things that you can do with our preferred drug list search tool. You can:

 

  • Search for your medicine by name or class
  • Find generic alternatives to your medicine
  • See if your medicine has quantity limits, has age limits or requires prior authorization 

  • July 2026 Additions:

     

    • No updates

     

    July 2026 Removals:

     

    • No updates

     

    July 2026 Other Updates:

     

    • No updates

     

     

    June 2026 Additions:

     

    • No updates

     

    June 2026 Removals:

     

    • No updates

     

    June 2026 Other Updates:

     

    • Armodafinil Tablet 150 mg (Age Limit)
    • Armodafinil Tablet 200 mg (Age Limit)
    • Armodafinil Tablet 250 mg (Age Limit)
    • Armodafinil Tablet 50 mg (Age Limit)
    • Modafinil Tablet 100 mg (Age Limit)
    • Modafinil Tablet 200 mg (Age Limit)

     

    May 2026 Additions:

     

    • Clonidine Hydrochloride Tablet 0.05 mg
    • Ozempic Tablet 1.5 mg (Add Prior Authorization)
    • Ozempic Tablet 4 mg (Add Prior Authorization)
    • Ozempic Tablet 9 mg (Add Prior Authorization)

     

    May 2026 Removals:

     

    • No updates

     

    May 2026 Other Updates:

     

    • No updates

     

    April 2026 Additions:

     

    • *Omega-3 Fatty Acids Capsule 500 mg**
    • Calcium Carbonate Tablet 1250 mg (500 mg Elemental Calcium)
    • Contour Plus Blood Glucose Monitoring Kit (Quantity Level Limit)
    • Contour Plus Blood Glucose Test Strips (Quantity Level Limit)
    • Ferrous Gluconate Tablet 240 mg (27 mg Elemental Iron)
    • Ferrous Sulfate Solution 75 mg/mL (15 mg/mL Elemental Iron)
    • Ferrous Sulfate Tablet Enteric Coated 324 mg (65 mg Iron Equivalent)
    • Zolgensma Suspension for Injection (Add Prior Authorization)

     

    April 2026 Removals:

     

    • Accu-Chek Aviva Blood Glucose Monitoring Kit
    • Accu-Chek Guide Blood Glucose Monitoring Kit
    • Accu-Chek Guide Me Blood Glucose Monitoring Kit
    • Accu-Chek Aviva Plus Blood Glucose Test Strips                                                                               
    • Accu-Chek Guide Blood Glucose Test Strips
    • Accu-Chek Smartview Glucose Test Strips                                                                          
    • Freestyle Freedom Lite Blood Glucose Monitoring Kit
    • Freestyle Lite Blood Glucose Monitoring Kit
    • Freestyle Precision Neo Blood Glucose Monitoring Kit
    • Freestyle Blood Glucose Test Strips
    • Freestyle Insulinx Glucose Test Strips
    • Freestyle Lite Blood Glucose Test Strips
    • Freestyle Precision Neo Blood Glucose Test Strips
    • Glycerin Suppository 80.7%
    • OneTouch Ultra 2 Blood Glucose Monitoring Kit
    • OneTouch Verio Flex Blood Glucose Monitoring Kit
    • OneTouch Verio Reflect Blood Glucose Monitoring Kit
    • OneTouch Ultra Test Strips
    • OneTouch Ultra Blue Test Strips
    • OneTouch Verio Test Strips
    • Polyethylene Glycol 3350 Oral Packet 8.5 GM

     

    April 2026 Other Updates:

     

    • Rinvoq Oral Solution 1 mg/mL (Add Prior Authorization)
    • Rinvoq Tablet Extended Release 24-hour 15 mg (Add Prior Authorization)
    • Rinvoq Tablet Extended Release 24-hour 30 mg (Add Prior Authorization)
    • Rinvoq Tablet Extended Release 24-hour 45 mg (Add Prior Authorization)
    • Vyepti Intravenous Solution 100 mg / mL (Add Prior Authorization)
    • Zavezpret Hydrochloride Nasal Spray 10 mg / Actuations (Add Prior Authorization)

     

    March 2026 Additions:

     

    • No updates

     

    March 2026 Removals:

     

    • No updates

     

    March 2026 Other Updates:

     

    • Pramoxine Hydrochloride Perianal Foam 1% (Quantity Level Limit)

     

    February 2026 Additions:

     

    • *Skin Protectants Miscellaneous - Cream***

     

    February 2026 Removals:

     

    • Cetirizine Hydrochloride Chewable Tablet 5 mg
    • Cetirizine Hydrochloride Chewable Tablet 10 mg

     

    February 2026 Other Updates:

     

    • Ninguna

     

    January 2026 Additions:

    • Ninguna

     

    January 2026 Removals:

    • Ninguna

     

    January 2026 Other Updates:

    • Onyda Extended Release (Prior Authorization, Age Limit)
    • Qelbree (Add Age Limit)
    • Quillichew Extended Release (Prior Authorization, Age Limit)
    • Quillivant Extended Release (Prior Authorization, Age Limit)

  • December 2025 Additions:

    • *Bacillus Coagulans-Inulin Capsule**
    • *Lactobacillus Acidophilus-Pectin Tablet**
    • *Probiotic Product - Chewable Tablet**
    • *Probiotic Product - Tablet**
    • Saccharomyces Boulardii Capsule 250 mg

     

    December 2025 Removals:

    • Ninguna

     

    December 2025 Other Updates:

    • Ninguna

     

    November 2025 Additions:

    • Ninguna

     

    November 2025 Removals:

    • Ninguna

     

    November 2025 Other Updates:

    • Ubrogepant Tablet 50 mg (Quantity Level Limit)
    • Ubrogepant Tablet 100 mg (Quantity Level Limit)
    • Permethrin Cream 5% (Add Age Limit)

     

    October 2025 Additions:

    • Ninguna

     

    October 2025 Removals:

    • Ninguna

     

    October 2025 Other Updates:

    • Alhemo Pen-Injector 300 mg / 3 mL (100 mg / mL) (Prior Authorization)
    • Skytrofa Injection Cartridge 0.7 mg (Prior Authorization)
    • Skytrofa Injection Cartridge 1.4 mg (Prior Authorization)
    • Skytrofa Injection Cartridge 1.8 mg (Prior Authorization)
    • Skytrofa Injection Cartridge 2.1 mg (Prior Authorization)
    • Skytrofa Injection Cartridge 2.5 mg (Prior Authorization)
    • Hympavzi Auto-Injection 150 mg/mL (Prior Authorization)
    • Pertzye Capsule 16000-57500-60500 Unit (Prior Authorization)
    • Pertzye Capsule 24000-86250-90750 Unit (Prior Authorization)
    • Pertzye Capsule 4000-14375-15125 Unit (Prior Authorization)
    • Pertzye Capsule 8000-28750-30250 Unit (Prior Authorization)
    • Inluriyo 200 mg (Age Limit)

     

    September 2025 Additions:

    • *B-Complex with Vitamin C & Folic Acid Tablet 0.8 mg***
    • Calcium Carbonate-Cholecalciferol Tablet 600 mg-20 mcg
    • Cholecalciferol Capsule 10 mcg (400 Unit)
    • Cyanocobalamin Tablet 1000 mcg
    • Cyanocobalamin Tablet 250 mcg
    • Cyanocobalamin Tablet 500 mcg
    • Folic Acid Tablet 400 mcg
    • Sodium Chloride Tablet 1 GM
    • Thiamine Hydrochloride Tablet 100 mg
    • Thiamine Mononitrate Tablet 100 mg
    • Vitamin E Capsule 180 mg (400 Unit) 

     

    September 2025 Removals:

    • No updates

     

    September 2025 Other Updates:

    • No updates

     

    August 2025 Additions:

    • No updates

     

    August 2025 Removals:

    • Phenylephrine Tablet 10 mg

     

    August 2025 Other Updates:

    • Finerenone Tablet 40 mg (Prior Authorization)

     

    July 2025 Additions:

    • Iloperidone Tablet 1 mg and 2 mg and 6 mg Titration Pak (Age Limit)
    • Iloperidone Tablet 1 mg and 2 mg and 6 mg and 8 mg Titration Pak (Age Limit)

     

    July 2025 Removals:

    • No updates

     

    July 2025 Other Updates:

    • Cefixime Capsule 400 mg (Quantity Level Limit)
    • Skytrofa for Subcutaneous Injection Cartridge 3 mg (Prior Authorization)
    • Skytrofa for Subcutaneous Injection Cartridge 3.6 mg (Prior Authorization)
    • Skytrofa for Subcutaneous Injection Cartridge 4.3 mg (Prior Authorization)
    • Skytrofa for Subcutaneous Injection Cartridge 5.2 mg (Prior Authorization)
    • Skytrofa for Subcutaneous Injection Cartridge 6.3 mg (Prior Authorization)
    • Skytrofa for Subcutaneous Injection Cartridge 7.6 mg (Prior Authorization)
    • Skytrofa for Subcutaneous Injection Cartridge 9.1 mg (Prior Authorization)
    • Skytrofa for Subcutaneous Injection Cartridge 11 mg (Prior Authorization)
    • Skytrofa for Subcutaneous Injection Cart 13.3 mg (Prior Authorization)
    • Ngenla Solution Pen-Injector 24 mg / 1.2 mL (20 mg / mL) (Prior Authorization)
    • Ngenla Solution Pen-Injector 60 mg / 1.2 mL (50 mg / mL) (Prior Authorization)
    • Benzoyl Peroxide Foam 9.8% (Age Limit Update)

     

    June 2025 Additions:

    • No updates

     

    June 2025 Removals:

    • Testosterone Transdermal Gel 20.25 mg / Actuations (1.62%)

     

    June 2025 Other Updates:

    • Guardian 4 Glucose Sensor
    • Guardian 4 Transmitter Kit 
    • Guardian Connect Transmitter
    • Guardian Connect Transmitter Kit   
    • Guardian Link 3 Transmitter Kit 
    • Guardian Sensor 3  

     

    May 2025 Additions:

    • Atomoxetine Hydrochloride Capsule 10 mg (Age Limit, Quantity Level Limit)
    • Atomoxetine Hydrochloride Capsule 18 mg (Age Limit, Quantity Level Limit)
    • Atomoxetine Hydrochloride Capsule 25 mg (Age Limit, Quantity Level Limit)
    • Atomoxetine Hydrochloride Capsule 40 mg (Age Limit, Quantity Level Limit)
    • Atomoxetine Hydrochloride Capsule 60 mg (Age Limit, Quantity Level Limit)
    • Atomoxetine Hydrochloride Capsule 80 mg (Age Limit, Quantity Level Limit)
    • Atomoxetine Hydrochloride Capsule 100 mg (Age Limit, Quantity Level Limit)
    • Bisoprolol Tablet 2.5 mg
    • Sunlenca Tablet 300 mg (Prior Authorization)
    • Paxlovid Pak (Age Limit, Quantity Level Limit)
    • Umeclidinium-Vilanterol Aerosol Powder 62.5-25 mcg/actuation
    • Tymlos Subcutaneous Solution Pen-Injector 3120 mcg /1.56 mL (Add Prior Authorization, Quantity Level Limit)
    • Prolia Injection Solution Prefilled Syringe 60 mg / mL (Add Prior Authorization, Quantity Level Limit)
    • Teriparatide Solution Pen-Injection 620 mcg/ 2.48 mL (Add Prior Authorization, Quantity Level Limit)

     

    May 2025 Removals:

    • No updates

     

    May 2025 Other Updates:

    • No updates

     

    April 2025 Additions:

    • Simlandi Auto-Injector Kit 80 mg/0.8 mL (Prior Authorization)
    • SevenFACT Solution 2 mg (Prior Authorization)

     

    April 2025 Removals:

    • Twiist Refill Kit
    • Twiist refill Kit/Infusion Set

     

    April 2025 Other Updates:

    • No updates

     

    March 2025 Additions:

    • Baqsimi Nasal Powder 3 mg
    • Insulin Degludec Injection 100 unit/mL
    • Insulin Degludec FlexTouch 100 unit/mL
    • Contour Plus Blood Glucose Monitor Kit (Quantity Level Limit)
    • Contour Plus Blood Glucose Test Strips (Quantity Level Limit)
    • Guardian Sensor 3 (Prior Authorization)
    • Guardian 4 Glucose Sensor (Prior Authorization)
    • Guardian 4 Transmitter Kit (Prior Authorization)
    • Guardian Connect Transmitter Kit (Prior Authorization)
    • Guardian Link 3 Transmitter Kit (Prior Authorization)
    • Cequr Simplicity 2U (Prior Authorization)
    • Cequr Simplicity Inserter (Prior Authorization)
    • Ilet Insulin Pump (Prior Authorization)
    • Ilet Starter Kit Inset 23 (Prior Authorization)
    • Ilet Starter Kit Inset 32 (Prior Authorization)
    • Ilet Insulin Infusion Kit 23 (Prior Authorization)
    • Ilet Insulin Infusion Kit 32 (Prior Authorization)
    • Carbaglu Tablet 200 mg (Prior Authorization)
    • Caplyta Capsule 10.5 mg (Age Limit)
    • Caplyta Capsule 21 mg (Age Limit)
    • Caplyta Capsule 42 mg (Age Limit)
    • Rexulti Tablet 0.25 mg (Age Limit)
    • Rexulti Tablet 0.5 mg (Age Limit)
    • Rexulti Tablet 1 mg (Age Limit)
    • Rexulti Tablet 2 mg (Age Limit)
    • Rexulti Tablet 3 mg (Age Limit)
    • Rexulti Tablet 4 mg (Age Limit)
    • Vraylar Capsule 1.5 mg (Age Limit)
    • Vraylar Capsule 3 mg (Age Limit)
    • Vraylar Capsule 4.5 mg (Age Limit)
    • Vraylar Capsule 6 mg (Age Limit)
    • Austedo Extended-Release Tablet 30 mg (Prior Authorization)
    • Austedo Extended-Release Tablet 36 mg (Prior Authorization)
    • Austedo Extended-Release Tablet 42 mg (Prior Authorization)
    • Austedo Extended-Release Tablet 48 mg (Prior Authorization)
    • Austedo Extended-Release Tablet Titration Kit (Prior Authorization)
    • Ingrezza Sprinkle Capsule 40 mg (Prior Authorization)
    • Ingrezza Sprinkle Capsule 60 mg (Prior Authorization)
    • Ingrezza Sprinkle Capsule 80 mg (Prior Authorization)
    • Siklos Tablet 100 mg (Age Limit)
    • Siklos Tablet 1000 mg (Age Limit)
    • Airsupra Aerosol 90-80 mcg/Actuation
    • Pulmicort Flexhaler 90 mcg
    • Pulmicort Flexhaler 180 mcg
    • Arnuity Ellipta 50 mcg
    • Arnuity Ellipta 100 mcg
    • Arnuity Ellipta 200 mcg
    • Fluticasone Propionate Aerosol Powder 50 mcg/actuation
    • Fluticasone Propionate Aerosol Powder 100 mcg/actuation
    • Fluticasone Propionate Aerosol Powder 250 mcg/actuation
    • Cinqair Injection 100 mg/10 mL (Prior Authorization)
    • Tezspire Prefilled Syringe 210 mg/1.91 mL (Prior Authorization)
    • Tezspire Auto-Injector 210 mg/1.91 mL (Prior Authorization)
    • Xolair Auto-Injector 300 mg/2 mL (Prior Authorization)
    • Xolair Prefilled Syringe 300 mg/2 mL (Prior Authorization)
    • Rezdiffra Tablet 60 mg (Prior Authorization)
    • Rezdiffra Tablet 80 mg (Prior Authorization)
    • Rezdiffra Tablet 100 mg (Prior Authorization)
    • Adalimumab-ADBM Auto-Injector Kit 40 mg/0.4 mL (Prior Authorization)
    • Adalimumab-ADBM Prefilled Syringe Kit 10 mg/0.2 mL (Prior Authorization)
    • Adalimumab-ADBM Prefilled Syringe Kit 20 mg/0.4 mL (Prior Authorization)
    • Adalimumab-ADBM Prefilled Syringe Kit 40 mg/0.4 mL (Prior Authorization)
    • Simlandi Prefilled Syringe Kit 20 mg/0.2 mL (Prior Authorization)
    • Simlandi Prefilled Syringe Kit 40 mg/0.4 mL (Prior Authorization)
    • Simlandi Prefilled Syringe Kit 80 mg/0.8 mL (Prior Authorization)
    • Simlandi Auto-Injector Kit 40 mg/0.4 mL (Prior Authorization)
    • Glucagen Injection Hypokit 1 mg
    • Glucagon Kit 1 mg
    • Mirabegron Tablet 25 mg
    • Mirabegron Tablet 50 mg
    • Myrbetriq Tablet 25 mg
    • Myrbetriq Tablet 50 mg
    • Myrbetriq Oral Suspension 8 mg/mL
    • Gemtesa Tablet 75 mg
    • Glatopa Prefilled Syringe 20 mg/mL
    • Glatopa Prefilled Syringe 40 mg/mL
    • Maraviroc Tablet 150 mg
    • Maraviroc Tablet 300 mg
    • Pifeltro Tablet 100 mg
    • Prezcobix Tablet 800-150 mg
    • Juluca Tablet 50-25 mg
    • Zurzuvae Capsule 20 mg
    • Zurzuvae Capsule 25 mg
    • Zurzuvae Capsule 30 mg
    • Tramadol Tablet 75 mg (Age Limit)
    • Esperoct Injection 4000 Units (Prior Authorization)
    • Hemlibra Subcutaneous Solution 12 mg/0.4 mL (Prior Authorization)
    • Jivi Injection 4000 Units (Prior Authorization)

     

    March 2025 Removals:

    • Ciprofloxacin Tablet 100 mg
    • Humira Auto-Injector Kit 40 mg/0.4 mL
    • Humira Auto-Injector Kit 40 mg/0.8 mL
    • Humira Auto-Injector Kit 80 mg/0.8 mL
    • Humira Auto-Injector Kit 80 mg/0.8 mL & 40 mg/0.4 mL
    • Humira Prefilled Syringe Kit 10 mg/0.1 mL
    • Humira Prefilled Syringe Kit 20 mg/0.2 mL
    • Humira Prefilled Syringe Kit 40 mg/0.4 mL
    • Humira Prefilled Syringe Kit 40 mg/0.8 mL
    • OneTouch Ultra 2 Blood Glucose Monitoring Kit
    • OneTouch Verio Flex Blood Glucose Monitoring Kit
    • OneTouch Ultra Test Strips
    • OneTouch Ultra Blue Test Strips
    • OneTouch Verio Test Strips
    • Didanosine Capsule 250 mg
    • Didanosine Capsule 400 mg
    • Invirase Tablet 500 mg
    • Stavudine Capsule 15 mg
    • Stavudine Capsule 20 mg
    • Stavudine Capsule 40 mg
    • Permethrin Cream 5%
    • Kogenate FS Injection 1000 Units
    • Kogenate FS Injection 2000 Units

     

    March 2025 Other Updates:

    • Cabenuva Extended-Release Injection Kit 400 mg/600 mg (Remove Prior Authorization)
    • Cabenuva Extended-Release Injection Kit 600 mg/900 mg (Remove Prior Authorization)
    • Rukobia Tablet 600 mg (Remove Prior Authorization)
    • Estradiol Valerate Multi Dose Vial 20 mg/ mL (Remove Quantity Level Limit)
    • Estradiol Valerate Multi Dose Vial 40 mg/ mL (Remove Quantity Level Limit)

     

    February 2025 Additions:

    • Estradiol Valerate Multi Dose Vial 20 mg/ mL (Quantity Level Limit)
    • Estradiol Valerate Multi Dose Vial 40 mg/ mL (Quantity Level Limit)
    • Sodium/Potassium Solution Magnesium (Quantity Level Limit)

     

    February 2025 Removals:

    • Testosterone (AndroGel) Pak 1%(50mg)
    • Testosterone (Fortesta) Gel Pump 2%
    • Testosterone Gel 1%(25mg)
    • Testosterone Gel Pump 1%

     

    February 2025 Other Updates:

    • Oxybutynin Tablet 10 mg Extended Release (Quantity Level Limit)

     

    January 2025 Additions:

    • No updates

     

    January 2025 Removals:

    • No updates

     

    January 2025 Other Updates:

    • No updates

  • December 2024 Additions:

    • No updates

     

    December 2024 Removals:

    • No updates

     

    December 2024 Other Updates:

    • No updates

     

    November 2024 Additions:

    • Ninguna

     

    November 2024 Removals:

    • None

     

    November 2024 Other Updates:

    • None

     

    October 2024 Additions:

    • No updates

     

    October 2024 Removals:

    • No updates

     

    October 2024 Other Updates:

    • No updates

     

    September 2024 Additions:

    • No updates

     

    September 2024 Removals:

    • No updates

     

    September 2024 Other Updates:

    • No updates

     

    August 2024 Additions:

     

    • No updates

     

    August 2024 Removals:

     

    • No updates

     

    August 2024 Other Updates:

     

    • No updates

     

    July 2024 Additions:

     

    • No updates

     

    July 2024 Removals:

     

    • No updates

     

    July 2024 Other Updates:

     

    • No updates

     

    June 2024 Additions:

     

    • No updates

     

    June 2024 Removals:

     

    • No updates

     

    June 2024 Other Updates:

     

    • No updates

     

    May 2024 Additions:

     

    • No updates

     

    May 2024 Removals:

     

    • No updates

     

    May 2024 Other Updates:

     

    • No updates

     

    April 2024 Additions:

     

    • No updates

     

    April 2024 Removals:

     

    • No updates

     

    April 2024 Other Updates:

     

    • No updates

     

    March 2024 Additions:

     

    • No updates

     

    March 2024 Removals:

     

    • No updates

     

    March 2024 Other Updates:

     

    • No updates

     

    February 2024 Additions:

     

    • No updates

     

    February 2024 Removals:

     

    • No updates

     

    February 2024 Other Updates:

     

    • No updates

     

    January 2024 Additions:

    • No updates
    January 2024 Removals:
    • No updates
    January 2024 Other Updates:
    • No updates

  • December 2023 Additions:

     

    • No updates

     

    December 2023 Removals:

     

    • No updates

     

    December 2023 Other Updates:

     

    • No updates

     

    November 2023 Additions:

     

    • No updates

     

    November 2023 Removals:

     

    • No updates

     

    November 2023 Other Updates:

     

    • No updates

     

    October 2023 Additions:

     

    • No updates

     

    October 2023 Removals:

     

    • No updates

     

    October 2023 Other Updates:

     

    • No updates

     

    September 2023 Additions:

     

    • No updates

     

    September 2023 Removals:

     

    • No updates

     

    September 2023 Other Updates:

     

    • No updates

     

    August 2023 Additions:

     

    • No updates

     

    August 2023 Removals:

     

    • No updates

     

    August 2023 Other Updates:

     

    • No updates

     

    July 2023 Additions:

     

    • No updates

     

    July 2023 Removals:

     

    • No updates

     

    July 2023 Other Updates:

     

    • No updates

     

    June 2023 Additions:

     

    • No updates

     

    June 2023 Removals:

     

    • No updates

     

    June 2023 Other Updates:

     

    • Mavyret Pellet Pack 50-20 mg (Quantity Level Limit, Removed Prior Authorization)
    • Mavyret Tablet 100-40 mg (Quantity Level Limit, Removed Prior Authorization)
    • Sofosbuvir-Velpatasvir Tablet 400-100 mg (Quantity Level Limit, Removed Prior Authorization)

     

    May 2023 Additions:

     

    • No updates

     

    May 2023 Removals:

     

    • No updates

     

    May 2023 Other Updates:

     

    • No updates

     

    April 2023 Additions:

     

    • No updates

     

    April 2023 Removals:

     

    • *Calcium Alginate Wound Dressing***
    • *Neomycin-Bacitracin-Polymyxin with Lidocaine Ointment 4%***
    • *Pediatric Multiple Vitamin with Minerals & C Chewable Tablet**
    • *Pediatric Multiple Vitamins with Iron Drops 10 mg/mL**
    • Cholecalciferol Drops 10 mcg/0.025 mL (400 Unit/0.025ml)
    • Cholecalciferol Drops 125 mcg/ mL (5000 Unit/mL)
    • Cholecalciferol Drops 400 Unit/0.028 mL (Per Drop)
    • Formaldehyde Solution 10%
    • Loperamide Hydrochloride Liquid 1 mg/5 mL (0.2 mg/mL)
    • Magnesium Salicylate Tablet 500 mg
    • Magnesium Tablet 400 mg
    • Phenylephrine-Shark Liver Oil-Mineral oil-Petrolatum Ointment 0.25-3-14-71.9%
    • Psyllium Capsule 400 mg
    • Psyllium Powder 30%
    • Psyllium Powder 30.9%
    • Psyllium Powder 33%
    • Psyllium Powder 49%
    • Uridine Triacetate Oral Granules Packet 10 gm

     

    April 2023 Other Updates:

     

    • Betamethasone Dipropionate Ointment 0.05% (Quantity Level Limit)
    • Fluocinolone Acetonide Cream 0.025% (Quantity Level Limit)
    • Fluocinolone Acetonide Ointment 0.025% (Quantity Level Limit)
    • Fluconazole Tablet 150 mg (Quantity Level Limit)
    • Freestyle 14 Sensor Libre (Quantity Level Limit)
    • Freestyle 14 Sensor Libre 2 (Quantity Level Limit)
    • Freestyle 14 Sensor Libre 3 (Quantity Level Limit)
    • *Pediatric Multiple Vitamins with Fluoride Chewable Tablet 0.25 mg***
    • *Pediatric Multiple Vitamins with Fluoride Chewable Tablet 0.5 mg***
    • *Pediatric Multiple Vitamins with Fluoride Chewable Tablet 1 mg***

     

    March 2023 Additions:

     

    • Guaifenesin-Codeine Solution 100-6.33 mg/5 mL (Quantity Level Limit, Age Limit)

     

    March 2023 Removals:

     

    • No updates

     

    March 2023 Other Updates:

     

    • No updates

     

    February 2023 Additions:

     

    • No updates

     

    February 2023 Removals:

     

    • No updates

     

    February 2023 Other Updates:

     

    • No updates

     

    January 2023 Additions:

     

    • No updates

     

    January 2023 Removals:

     

    • Testosterone Td Gel 40.5 Mg/2.5 GM (1.62%)

     

    January 2023 Other Updates:

     

    • Testosterone Td Soln 30 Mg/Act (Prior Authorization Required)
    • Testosterone Td Gel 25 Mg/2.5gm (1%) (Prior Authorization Required)
    • Testosterone Td Gel 50 Mg/5gm (1%) (Prior Authorization Required)
    • Testosterone Td Gel 12.5 Mg/Act (1%) (Prior Authorization Required)
    • Testosterone Td Gel 20.25 Mg/Act (1.62%) (Prior Authorization Required)
    • Testosterone Td Gel 10mg/Act (2%) (Prior Authorization Required)
    • Testosterone Cypionate Im Inj In Oil 100 Mg/Ml (Prior Authorization Required)
    • Testosterone Cypionate Im Inj In Oil 200 Mg/Ml (Prior Authorization Required)
    • Testosterone Enanthate Im Inj In Oil 200 Mg/Ml (Prior Authorization Required)

  • December 2022 Additions:

     

    • No updates

     

    December 2022 Removals:

     

    • No updates

     

    December 2022 Other Updates:

     

    • No updates

     

    November 2022 Additions:

     

    • No updates

     

    November 2022 Removals:

     

    • No updates

     

    November 2022 Other Updates:

     

    • No updates

     

    October 2022 Additions:

     

    • No updates

     

    October 2022 Removals:

     

    • No updates

     

    October 2022 Other Updates:

     

    • No updates

     

    September 2022 Additions:

     

    • No updates

     

    September 2022 Removals:

     

    • No updates

     

    September 2022 Other Updates:

     

    • Ceftriaxone Sodium For Inj 1 Gm (Changed Quantity Level Limit)
    • Ceftriaxone Sodium For Inj 2 Gm (Changed Quantity Level Limit)
    • Ceftriaxone Sodium For Inj 250 Mg (Changed Quantity Level Limit)
    • Ceftriaxone Sodium For Inj 500 Mg (Changed Quantity Level Limit)

     

    August 2022 Additions:

     

    • No updates

     

    August 2022 Removals:

     

    • No updates

     

    August 2022 Other Updates:

     

    • No updates

     

    July 2022 Additions:

     

    • No updates

     

    July 2022 Removals:

     

    • No updates

     

    July 2022 Other Updates:

     

    • No updates

     

    June 2022 Additions:

     

    • No updates

     

    June 2022 Removals:

     

    • No updates

     

    June 2022 Other Updates:

     

    • No updates

     

    May 2022 Additions:

     

    • No updates

     

    May 2022 Removals:

     

    • No updates

     

    May 2022 Other Updates:

     

    • No updates

     

    April 2022 Additions:

     

    • No updates

     

    April 2022 Removals:

     

    • No updates

     

    April 2022 Other Updates:

     

    • No updates

     

    March 2022 Additions:

     

    • No updates

     

    March 2022 Removals:

     

    • No updates

     

    March 2022 Other Updates:

     

    • No updates

     

    February 2022 Additions:

     

    • Levocetirizine 5mg Tablets (Quantity Limit)
    • Dexcom G5 Mis Transmit (Quantity Limit)
    • Dexcom G6 Mis Transmit (Quantity Limit)
    • G5/G4 Plati Mis Sensor (Quantity Limit)
    • Dexcom G6 Mis Sensor (Quantity Limit)
    • Dexcom G5 Mis Receiver (Quantity Limit)
    • Dexcom G6 Mis Receiver (Quantity Limit)
    • Freestyle 10 Sen Libre (Quantity Limit)
    • Freestyle 10 Reader Libre (Quantity Limit)
    • Freestyle 14 Sen Libre (Quantity Limit)
    • Freestyle 14 Reader Libre (Quantity Limit)
    • Freestyle 14 Sen Libre 2 (Quantity Limit)
    • Freestyle 14 Reader Libre 2 (Quantity Limit)

     

    February 2022 Removals:

     

    • Diphenhydramine elixir

     

    February 2022 Other Updates:

     

    • Medroxyprogesterone Acetate 150mg/mL Syringe (Quantity Limit updated)
    • Diphenhydramine liquid (Quantity Limit updated)
    • Promethazine syrup (Quantity Limit updated)

     

    January 2022 Additions:

     

    • No updates

     

    January 2022 Removals:

     

    • Nozin Nasal Kit Sanitize
    • Calcium 600 Tab +D

     

    January 2022 Other Updates:

     

    • No updates

     

  • December 2021 Additions:

     

    • No updates

     

    December 2021 Removals:

     

    • No updates

     

    December 2021 Other Updates:

     

    • No updates

     

    November 2021 Additions:

     

    • No updates

     

    November 2021 Removals:

     

    • No updates

     

    November 2021 Other Updates:

     

    • No updates

     

    October 2021 Additions:

     

    • No updates

     

    October 2021 Removals:

     

    • No updates

     

    October 2021 Other Updates:

     

    • No updates

     

    September 2021 Additions:

     

    • No updates

     

    September 2021 Removals:

     

    • No updates

     

    September 2021 Other Updates:

     

    • No updates

     

    August 2021 Additions:

     

    • No updates

     

    August 2021 Removals:

     

    • No updates

     

    August 2021 Other Updates:

     

    • No updates

     

    July 2021 Additions:

     

    • No updates

     

    July 2021 Removals:

     

    • No updates

     

    July 2021 Other Updates:

     

    • No updates

     

    June 2021 Additions:

     

    • No updates

     

    June 2021 Removals:

     

    • No updates

     

    June 2021 Other Updates:

     

    • No updates

     

    May 2021 Additions:

     

    • No updates

     

    May 2021 Removals:

     

    • No updates

     

    May 2021 Other Updates:

     

    • No updates

     

    April 2021 Additions:

     

    • No updates

     

    April 2021 Removals:

     

    • No updates

     

    April 2021 Other Updates:

     

    • No updates

     

    March 2021 Additions:

     

    • Hizentra Inj 1gm/5ml (Prior Authorization)
    • Hizentra Inj 2gm/10ml (Prior Authorization)
    • Hizentra Inj 2gm/10ml (Prior Authorization)
    • Hizentra Inj 4gm/20ml (Prior Authorization)
    • Hizentra Sol 20% (Prior Authorization)
    • Hizentra Via 10gm/50m (Prior Authorization)
    • Hizentra Via 1gm/5ml (Prior Authorization)
    • Immune Globulin (Human) Iv Or Subcutaneous Soln 1 Gm/10 (Prior Authorization)
    • Immune Globulin (Human) Iv Or Subcutaneous Soln 10 Gm/1 (Prior Authorization)
    • Immune Globulin (Human) Iv Or Subcutaneous Soln 20 Gm/2 (Prior Authorization)
    • Immune Globulin (Human) Iv Or Subcutaneous Soln 5 Gm/50 (Prior Authorization)
    • Privigen Inj 10grams (Prior Authorization)
    • Privigen Inj 40grams (Prior Authorization)
    • Privigen Inj 5 Grams (Prior Authorization)
    • Privigen Via 20grams (Prior Authorization)

     

    March 2021 Other Updates:

     

    • Arnuity Elpt Inh 100mcg (Quantity Limit Added)
    • Arnuity Elpt Inh 200mcg (Quantity Limit Added)
    • Arnuity Elpt Inh 50mcg (Quantity Limit Added)
    • Bevespi      Aer 9-4.8mcg (Quantity Limit Added)
    • Levofloxacin Sol 25mg/Ml (Quantity Limit, Age Limit Added)
    • Neomycin-Polymyxin-Dexamethasone Ophth Oint 0.1% (Quantity Limit Added)
    • Phenylephrine Hcl Ophth Soln 2.5% (Quantity Limit Added)
    • Rabeprazole  Tab 20 (Quantity Limit Added)

     

    February 2021 Additions:

     

    • No updates

     

    February 2021 Removals:

     

    • No updates

     

    February 2021 Other Updates:

     

    • No updates

     

    January 2021 Removals:

     

    • Ogestrel Tablet 0.5-50mg-mcg

     

    January 2021 Other Updates:

     

    • Antabuse 250mg, 500mg (Removed Quantity Level Limit)
    • Buprenorphine-Naloxone 2-0.5mg, 8-2mg sublingual tablet (Removed Quantity Level Limit)
    • Buprenorphine 2mg, 8mg sublingual tablet (Removed Quantity Level Limit)
    • Naloxone 0.4mg/mL injection solution (Removed Quantity Level Limit)
    • Naloxone 0.4mg/mL injection syringe (Removed Quantity Level Limit)
    • Naloxone 1mg/mL injection syringe (Removed Quantity Level Limit)
    • Narcan 4mg/actuation nasal spray (Removed Quantity Level Limit)
    • Probuphine 74.2mg subdermal implant (Removed Quantity Level Limit)
    • Sublocade 100mg/0.5ml, 300mg/1.5ml solution, extended release subcutaneous syringe (Removed Quantity Level Limit)

Have questions?

Call Member Services at
1-866-329-4701 (TTY: 711).

Also of interest:

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