The table below outlines all the changes to our formulary since the formulary list was last printed on 01/01/2023.
| Drug Name | Description of Change* | Copay Amount | Effective Date of Change |
|---|---|---|---|
| Cevimeline | Addition to formulary | $1 | 01/01/2023 |
| Estradiol transdermal patch (Dotti Patch, other generics) | Addition to formulary | $1 | 01/01/2023 |
| Eletriptan | Addition to formulary with QL | $1 | 01/01/2023 |
| Fosfomycin | Addition to formulary with QL | $1 | 01/01/2023 |
| Metaxalone | Addition to formulary | $1 | 01/01/2023 |
| Methenamine | Addition to formulary | $1 | 01/01/2023 |
| Mexiletine | Addition to formulary | $1 | 01/01/2023 |
| Nebivolol | Addition to formulary | $1 | 01/01/2023 |
| Olopatadine drops | Addition to formulary | $1 | 01/01/2023 |
| Omeprazole-Bicarbonate | Addition to formulary | $1 | 01/01/2023 |
| Paricalcitrol | Addition to formulary | $1 | 01/01/2023 |
| Radicava ORS | Addition to formulary with PA | $3 | 01/01/2023 |
| Riluzole | Addition to formulary | $1 | 01/01/2023 |
| Solifenacin | Addition to formulary | $1 | 01/01/2023 |
| Telmisartan | Addition to formulary | $1 | 01/01/2023 |
| Trimethprim | Addition to formulary | $1 | 01/01/2023 |
| Zafirkulast | Addition to formulary | $1 | 01/01/2023 |
| amlodipine besylate-valsartan (generic of Exforge) | ST removal | $1 | 01/01/2023 |
| amlodipine besylate-valsartan (generic of Exforge HCT) | ST removal | $1 | 01/01/2023 |
| latanoprost | QL removal | $1 | 01/01/2023 |
| cetirizine | QL removal | $1 | 01/01/2023 |
| clopidogrel | QL removal | $1 | 01/01/2023 |
| finasteride | QL removal | $1 | 01/01/2023 |
| Lytgobi (futibatinib) | Addition to formulary with PA | $3 | 04/01/2023 |
*QL = Quantity Limit, PA = Prior Authorization, ST = Step Therapy, NF = Non Formulary, N/A = Not Applicable