Formulary Changes

The table below outlines all the changes to our formulary since the formulary list was last printed on 04/01/2022.

Drug Name	Description of Change*	Copay Amount	Effective Date of Change
Kerendia (finerenone)	Addition to formulary with PA	$3	01/01/2022
Benlysta (belimumab) subcutaneous	Addition to formulary with PA	$3	01/01/2022
Lupkynis (voclosporin)	Addition to formulary with PA	$3	01/01/2022
Eucrisa (crisaborole) ointment	Addition to formulary with PA	$3	01/01/2022
Free Style Libre 14-Day Receiver and Sensor	Addition to formulary with QL	$0	01/01/2022
Free Style Libre 2 Receiver and Sensor	Addition to formulary with QL	$0	01/01/2022
Dexcom G6 Receiver, Transmitter, and Sensor	Addition to formulary with QL	$0	01/01/2022

Free Style Libre 14-Day Receiver and Sensor	Addition of PA	$0	02/01/2022
Free Style Libre 2 Receiver and Sensor	Addition of PA	$0	02/01/2022
Dexcom G6 Receiver, Transmitter, and Sensor	Addition of PA	$0	02/01/2022

Welireg (belzutifan)	Addition to formulary with PA	$3	04/01/2022
Exkivity (mobocertinib)	Addition to formulary with PA	$3	04/01/2022
Scemblix (asciminib)	Addition to formulary with PA	$3	04/01/2022
Primsol 50mg/5mL solution	Formulary Deletion	N/A	04/01/2022
Trimethoprim 100mg tablet	Formulary Deletion	N/A	04/01/2022
Amlodipine-valsartan-hydrochlorothiazide tablets	Formulary Deletion	N/A	04/01/2022
Intron A 25MU injection	Formulary Deletion	N/A	04/01/2022
Crixivan 400mg capsule	Formulary Deletion	N/A	04/01/2022
Oscimin SR 0.375mg tablet	Formulary Deletion	N/A	04/01/2022
Selzentry (brand) 150mg and 300mg tablets	Formulary Deletion	N/A	04/01/2022
Maraviroc tab 150 mg and 300mg tablets (generics of Selzentry)	Addition to formulary	$1	04/01/2022
Atropine sulfate ophthalmic solution 1% (generic of brand Atropine sulfate)	Addition to formulary	$1	04/01/2022
Brimonidine tartrate-timolol maleate ophthalmic solution 0.2-0.5% (generic of Combigan)	Addition to formulary	$1	04/01/2022
Sulfadiazine 500 mg tablet (generic)	Addition to formulary	$1	04/01/2022