Formulary Changes
The table below outlines all the changes to our formulary since the formulary list was last printed on 04/01/2024.
| Drug Name | Description of Change* | Copay Amount | Effective Date of Change |
|---|---|---|---|
| Dexcom G7 Receiver and Sensor | Addition of PA with QL | $0 | 01/01/2024 |
| Free Style Libre 3 Sensor | Addition of PA with QL | $0 | 01/01/2024 |
| Cyclosporine Ophthalmic emulsion 0.05% (generic Restasis) Single-Use vials |
Addition with QL | $1 | 01/01/2024 |
| Vanflyta (quizartinib) | Addition to formulary with PA |
$3 | 01/01/2024 |
| Xdemvy drops 0.25% (lotilaner) |
Addition to formulary with PA | $3 | 04/01/2024 |
| Ojjaara (momelotinib) | Addition to formulary with PA |
$3 | 04/01/2024 |
| Paxlovid (co-packaged nirmatrelvir tablets and ritonavir tablets) | Addition with QL |
$3 | 04/01/2024 |
| Minocycline 50mg tablet |
Addition to formulary |
$1 | 04/01/2024 |
| Ibandronate 150mg tablet |
Addition to formulary | $1 |
04/01/2024 |
| Levocarnitine 1gm/10mL oral solution |
Addition to formulary | $1 |
04/01/2024 |
| Acebutolol capsules |
Addition to formulary | $1 |
04/01/2024 |
| Olmesartan-hydrochlorothiazide tablets |
Addition to formulary | $1 |
04/01/2024 |
| Cholestyramine Powder Packets |
Addition to formulary | $1 |
04/01/2024 |
| Desloratadine 5mg tablet |
Addition to formulary | $1 |
04/01/2024 |
| Dextromethorphan-guaifenesin Liquid 5-00mg/5mL |
Addition to formulary | $1 |
04/01/2024 |
| Roflumilast tablets |
Addition to formulary | $1 |
04/01/2024 |
| Docusate sodium 250mg capsule |
Addition to formulary | $1 |
04/01/2024 |
| Sodium sulfate-Potassium sulfate-Magnesium sulfate Oral solution (generic of Suprep Bowel Prep Kit) |
Addition to formulary |
$1 |
04/01/2024 |
| Glycopyrrolate 1mg/5mL oral solution |
Addition to formulary |
$1 |
04/01/2024 |
| Scopolamine 1mg/3day patch |
Addition to formulary |
$1 |
04/01/2024 |
| Dronabinol 2.5mg capsule |
Addition to formulary |
$1 |
04/01/2024 |
| Potassium Citrate-citric acid oral solution |
Addition to formulary |
$1 |
04/01/2024 |
| Silodosin capsules |
Addition to formulary |
$1 |
04/01/2024 |
| Acetaminophen 650mg suppository |
Addition to formulary |
$1 |
04/01/2024 |
| Codeine sulfate 30mg tablet |
Addition to formulary with PA |
$1 |
04/01/2024 |
| Hydromorphone ER tablets |
Addition to formulary |
$1 |
04/01/2024 |
| Hydrocodone-ibuprofen tablets |
Addition to formulary |
$1 |
04/01/2024 |
| Indomethacin ER capsules |
Addition to formulary |
$1 |
04/01/2024 |
| Amantadine tablets |
Addition to formulary |
$1 |
04/01/2024 |
| Ropinirole ER tablets |
Addition to formulary |
$1 |
04/01/2024 |
| Cyclobenzaprine 7.5mg tablet |
Addition to formulary |
$1 |
04/01/2024 |
| Vitamin D3 5000 unit tablet |
Addition to formulary |
$1 |
04/01/2024 |
| Wescaps (B-Complex w/Folic Acid) capsules |
Addition to formulary |
$1 |
04/01/2024 |
| Cyclopentol ophthalmic solution 1% |
Addition to formulary |
$1 |
04/01/2024 |
| Mupirocin cream 2% |
Addition to formulary |
$1 |
04/01/2024 |
| Lidocaine 5% patch |
Addition with QL |
$1 |
04/01/2024 |
*QL = Quantity Limit, PA = Prior Authorization, ST = Step Therapy, NF = Non Formulary, N/A = Not Applicable