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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 |
*QL = Quantity Limit, PA = Prior Authorization, ST = Step Therapy, NF = Non Formulary, N/A = Not Applicable