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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 NameDescription of Change*Copay AmountEffective Date of Change
Kerendia (finerenone)Addition to formulary with PA$301/01/2022
Benlysta (belimumab) subcutaneousAddition to formulary with PA$301/01/2022
Lupkynis (voclosporin)Addition to formulary with PA$301/01/2022
Eucrisa (crisaborole) ointmentAddition to formulary with PA$301/01/2022
Free Style Libre 14-Day Receiver and SensorAddition to formulary with QL$001/01/2022
Free Style Libre 2 Receiver and SensorAddition to formulary with QL$001/01/2022
Dexcom G6 Receiver, Transmitter, and SensorAddition to formulary with QL$001/01/2022
 
Free Style Libre 14-Day Receiver and SensorAddition of PA$002/01/2022
Free Style Libre 2 Receiver and SensorAddition of PA$002/01/2022
Dexcom G6 Receiver, Transmitter, and SensorAddition of PA$002/01/2022
 
Welireg (belzutifan)Addition to formulary with PA$304/01/2022
Exkivity (mobocertinib)Addition to formulary with PA$304/01/2022
Scemblix (asciminib)Addition to formulary with PA$304/01/2022
Primsol 50mg/5mL solutionFormulary DeletionN/A04/01/2022
Trimethoprim 100mg tabletFormulary DeletionN/A04/01/2022
Amlodipine-valsartan-hydrochlorothiazide tabletsFormulary DeletionN/A04/01/2022
Intron A 25MU injectionFormulary DeletionN/A04/01/2022
Crixivan 400mg capsuleFormulary DeletionN/A04/01/2022
Oscimin SR 0.375mg tabletFormulary DeletionN/A04/01/2022
Selzentry (brand) 150mg and 300mg tabletsFormulary DeletionN/A04/01/2022
Maraviroc tab 150 mg and 300mg tablets (generics of Selzentry)Addition to formulary$104/01/2022
Atropine sulfate ophthalmic solution 1% (generic of brand Atropine sulfate)Addition to formulary$104/01/2022
Brimonidine tartrate-timolol maleate ophthalmic solution 0.2-0.5% (generic of Combigan)Addition to formulary$104/01/2022
Sulfadiazine 500 mg tablet (generic)Addition to formulary$104/01/2022

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