EFFECTIVE 01/01/2021 Medication Name Change Description 500 mg tablet - Added: Specialty Drug - QL Added: 2 / DAY

acyclovir 5 % cream (g) - QL Added: 5 / 30 DAYS

acyclovir 5 % oint. (g) - QL Added: 30 / 30 DAYS

amlodipine/valsartan/hcthiazid 10-160-25 - Added to Tier 1 tablet - QL Added: 1 / DAY

amlodipine/valsartan/hcthiazid 10-320-25 - Added to Tier 1 tablet - QL Added: 1 / DAY

amlodipine/valsartan/hcthiazid 10mg- - Added to Tier 1 160mg tablet - QL Added: 1 / DAY

amlodipine/valsartan/hcthiazid 5-160-12.5 - Added to Tier 1 tablet - QL Added: 1 / DAY

amlodipine/valsartan/hcthiazid 5-160- - Added to Tier 1 25mg tablet - QL Added: 1 / DAY

BELSOMRA 10 MG TABLET - Added to Tier 2 suvorexant

BELSOMRA 15 MG TABLET - Added to Tier 2 suvorexant

BELSOMRA 20 MG TABLET - Added to Tier 2 suvorexant

BELSOMRA 5 MG TABLET - Added to Tier 2 suvorexant

benznidazole 100 mg tablet - Added to Tier 1

benznidazole 12.5 mg tablet - Added to Tier 1

/ fumarate 160- - ST Added: 2018 HPSM MEDI ST - 4.5mcg hfa aer ad /UMECLIDIN/VILANTER

budesonide/formoterol fumarate 80-4.5 - ST Added: 2018 HPSM MEDI ST - mcg hfa aer ad FLUTICASONE/UMECLIDIN/VILANTER

COSOPT PF EYE DROPS - QL Added: 2 / DAY dorzolamide hcl/ maleate/pf

PAGE 1 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 01/01/2021 Medication Name Change Description cyclosporine 100 mg capsule - Removed From Coverage

cyclosporine 25 mg capsule - Removed From Coverage

cyclosporine, modified 50 mg capsule - Removed From Coverage

DAYVIGO 10 MG TABLET - Removed From Coverage lemborexant - PA Removed: PA APPLIES

DAYVIGO 5 MG TABLET - Removed From Coverage lemborexant - PA Removed: PA APPLIES

dorzolamide/timolol/pf 2 %-0.5 % - Added to Tier 1 droperette - QL Added: 2 / DAY

dorzolamide/timolol/pf 2 %-0.5 % drops - Added to Tier 1 - QL Added: 0.36 / DAY

hcl 5 % cream (g) - Removed From Coverage - QL Added: 45 / 30 DAYS

EUCRISA 2% OINTMENT - Added to Tier 2 crisaborole - PA Added: PA APPLIES

EXFORGE HCT 10-160-12.5 MG TAB - QL Added: 1 / DAY amlodipine besylate/valsartan/hydrochlorothiazide

EXFORGE HCT 10-160-25 MG TAB - QL Added: 1 / DAY amlodipine besylate/valsartan/hydrochlorothiazide

EXFORGE HCT 10-320-25 MG TAB - QL Added: 1 / DAY amlodipine besylate/valsartan/hydrochlorothiazide

EXFORGE HCT 5-160-12.5 MG TAB - QL Added: 1 / DAY amlodipine besylate/valsartan/hydrochlorothiazide

EXFORGE HCT 5-160-25 MG TAB - QL Added: 1 / DAY amlodipine besylate/valsartan/hydrochlorothiazide

FASENRA 30 MG/ML SYRINGE - Added to Tier 2 benralizumab - PA Added: PA APPLIES

FASENRA PEN 30 MG/ML - Added to Tier 2 benralizumab - PA Added: PA APPLIES

ferrous gluconate 225(27)mg tablet - Added to Tier 1

PAGE 2 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 01/01/2021 Medication Name Change Description fluticasone propion/ 100-50 - ST Added: 2018 HPSM MEDI ST - mcg blst w/dev FLUTICASONE/UMECLIDIN/VILANTER

fluticasone propion/salmeterol 113-14 - ST Added: 2018 HPSM MEDI ST - mcg aer pow ba FLUTICASONE/UMECLIDIN/VILANTER

fluticasone propion/salmeterol 232-14 - ST Added: 2018 HPSM MEDI ST - mcg aer pow ba FLUTICASONE/UMECLIDIN/VILANTER

fluticasone propion/salmeterol 250-50 - ST Added: 2018 HPSM MEDI ST - mcg blst w/dev FLUTICASONE/UMECLIDIN/VILANTER

fluticasone propion/salmeterol 500-50 - ST Added: 2018 HPSM MEDI ST - mcg blst w/dev FLUTICASONE/UMECLIDIN/VILANTER

fluticasone propion/salmeterol 55-14 mcg - ST Added: 2018 HPSM MEDI ST - aer pow ba FLUTICASONE/UMECLIDIN/VILANTER

miconazole nitrate 2 % powder - Added to Tier 1

NAYZILAM 5 MG NASAL SPRAY - QL Added: 10 / 30 DAYS midazolam

NEORAL 100 MG GELATIN CAPSULE - Removed From Coverage cyclosporine, modified

NEORAL 100 MG/ML SOLUTION - Removed From Coverage cyclosporine, modified

NEORAL 25 MG GELATIN CAPSULE - Removed From Coverage cyclosporine, modified

NINLARO 2.3 MG CAPSULE - Added: Non-Extended Day Supply ixazomib citrate

NINLARO 3 MG CAPSULE - Added: Non-Extended Day Supply ixazomib citrate

NINLARO 4 MG CAPSULE - Added: Non-Extended Day Supply ixazomib citrate

norethindrone-e.estradiol-iron 1mg-20(24) - Added to Tier 1 capsule

NUCALA 100 MG/ML AUTO-INJECTOR - QL Added: 0.11 / DAY mepolizumab

PAGE 3 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 01/01/2021 Medication Name Change Description NUCALA 100 MG/ML POWDER VIAL - Removed: Specialty Drug mepolizumab - QL Added: 0.11 / DAY

NUCALA 100 MG/ML SYRINGE - QL Added: 0.11 / DAY mepolizumab

NYVEPRIA 6 MG/0.6 ML SYRINGE - Added to Tier 2 pegfilgrastim-apgf - Added: Specialty Drug

PRALUENT 150 MG/ML PEN - QL Added: 2 / 28 DAYS alirocumab

PRALUENT 150 MG/ML SYRINGE - QL Added: 2 / 28 DAYS alirocumab

PRALUENT 75 MG/ML PEN - QL Added: 2 / 28 DAYS alirocumab

PRALUENT 75 MG/ML SYRINGE - QL Added: 2 / 28 DAYS alirocumab

hcl 50 mg supp.rect - Removed From Coverage

PRUDOXIN 5% CREAM - QL Added: 45 / 30 DAYS doxepin hcl

REPATHA 140 MG/ML SURECLICK - QL Added: 2 / 28 DAYS evolocumab

REPATHA 140 MG/ML SYRINGE - QL Added: 2 / 28 DAYS evolocumab

REPATHA 420 MG/3.5ML PUSHTRONX - QL Added: 3.5 / 30 DAYS evolocumab

RETACRIT 20,000 UNIT/2 ML VIAL - Added to Tier 2 epoetin alfa-epbx - QL Added: 0.43 / DAY

RETACRIT 20,000 UNIT/ML VIAL - Added to Tier 2 epoetin alfa-epbx - Added: Specialty Drug - QL Added: 0.43 / DAY

SANDIMMUNE 100 MG CAPSULE - Removed From Coverage cyclosporine

SANDIMMUNE 25 MG CAPSULE - Removed From Coverage cyclosporine

PAGE 4 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 01/01/2021 Medication Name Change Description SEMGLEE 100 UNIT/ML PEN - QL Added: 2 ML / DAY insulin glargine,human recombinant analog

SEMGLEE 100 UNIT/ML VIAL - QL Added: 2 ML / DAY insulin glargine,human recombinant analog

VAXELIS VACCINE SYRINGE - Added to Tier 2 diphtheria,pertus(acell),tetanus/hepb/polio/hib conj-meng/pf

VAXELIS VACCINE VIAL - Added to Tier 2 diphtheria,pertus(acell),tetanus/hepb/polio/hib conj-meng/pf

YONSA 125 MG TABLET - QL Added: 4 / DAY abiraterone acetate, submicronized - Added: Non-Extended Day Supply

ZONALON 5% CREAM - QL Added: 45 / 30 DAYS doxepin hcl

ZOVIRAX 5% CREAM - QL Added: 5 / 30 DAYS acyclovir

ZOVIRAX 5% OINTMENT - QL Added: 30 / 30 DAYS acyclovir

ZYTIGA 500 MG TABLET - Added: Non-Extended Day Supply abiraterone acetate - QL Added: 2 / DAY

PAGE 5 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 01/15/2021 Medication Name Change Description norethindrone-ethin. estradiol 7 days x 3 - Added to Tier 1 tablet

norgestimate-ethinyl estradiol 7daysx3 28 - Added to Tier 1 tablet

PAGE 6 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 01/22/2021 Medication Name Change Description AMITIZA 24 MCG CAPSULES - Removed From Coverage lubiprostone

AMITIZA 8 MCG CAPSULE - Removed From Coverage lubiprostone

atropine sulfate 0.4 mg/ml vial - Added to Tier 1

atropine sulfate 1 mg/ml vial - Added to Tier 1

CAREPOINT LUER LOCK SYR 3 ML - Added to Tier 2 syringe, disposable, 3 ml

lubiprostone 24mcg capsule - QL Added: 2 / DAY - ST Added: 2018 HPSM MEDI ST - Lubiprostone

lubiprostone 8 mcg capsule - QL Added: 2 / DAY - ST Added: 2018 HPSM MEDI ST - Lubiprostone

norethindrone 0.35 mg tablet - Added to Tier 1

SECURESAFE PEN NDL 30GX5/16" - Added to Tier 2 pen needle, diabetic, safety

thiamine hcl 100 mg/ml vial - Added to Tier 1

PAGE 7 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 01/29/2021 Medication Name Change Description COMFORT TOUCH PEN NDL 33G 6MM - Added to Tier 2 pen needle, diabetic

COMFORT TOUCH PEN NDL 33GX4MM - Added to Tier 2 pen needle, diabetic

COMFORT TOUCH PEN NDL 33GX5MM - Added to Tier 2 pen needle, diabetic

diclofenac potassium 50 mg tablet - Added to Tier 1

emtricitabine/tenofovir (tdf) 100-150 mg - Added: Specialty Drug tablet - QL Added: 1 / DAY

emtricitabine/tenofovir (tdf) 133-200 mg - Added: Specialty Drug tablet - QL Added: 1 / DAY

emtricitabine/tenofovir (tdf) 167-250 mg - Added: Specialty Drug tablet - QL Added: 1 / DAY

ICLUSIG 30 MG TABLET - Added to Tier 2 ponatinib hcl - Added: Non-Extended Day Supply - PA Added: PA APPLIES - QL Added: 1 / DAY

levorphanol tartrate 3 mg tablet - Added to Tier 1

NAPRELAN CR 750 MG TABLET - Removed From Coverage naproxen sodium

STIVARGA 40 MG TABLET - Added: Non-Extended Day Supply regorafenib

TRUVADA 100 MG-150 MG TABLET - Removed From Coverage emtricitabine/tenofovir disoproxil fumarate

TRUVADA 133 MG-200 MG TABLET - Removed From Coverage emtricitabine/tenofovir disoproxil fumarate

TRUVADA 167 MG-250 MG TABLET - Removed From Coverage emtricitabine/tenofovir disoproxil fumarate

PAGE 8 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 02/01/2021 Medication Name Change Description estradiol valerate 20 mg/ml vial - Added to Tier 1

estradiol valerate 40 mg/ml vial - Added to Tier 1

ferrous gluconate 256(28)mg tablet - Added to Tier 1

heparin sodium,porcine 5000/ml syringe - Added to Tier 1

heparin sodium,porcine/pf 5000/0.5ml - Added to Tier 1 syringe

HUMIRA(CF) PEN 80 MG/0.8 ML - Added to Tier 2 adalimumab - Added: Specialty Drug - PA Added: PA APPLIES

NYVEPRIA 6 MG/0.6 ML SYRINGE - PA Added: PA APPLIES pegfilgrastim-apgf

REFRESH RELIEVA PF 0.5-1% DROP - Added to Tier 2 carboxymethylcellulose sodium/glycerin/pf

RIABNI 100 MG/10 ML VIAL - Added to Tier 2 rituximab-arrx - Added: Non-Extended Day Supply - PA Added: PA APPLIES

RIABNI 500 MG/50 ML VIAL - Added to Tier 2 rituximab-arrx - Added: Non-Extended Day Supply - PA Added: PA APPLIES

TRUXIMA 100 MG/10 ML VIAL - Added: Non-Extended Day Supply rituximab-abbs

TRUXIMA 500 MG/50 ML VIAL - Added: Non-Extended Day Supply rituximab-abbs

PAGE 9 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 02/04/2021 Medication Name Change Description busulfan 60 mg/10ml vial - PA Removed: PA APPLIES

100 mg tablet - PA Added: PA APPLIES

clozapine 200 mg tablet - PA Added: PA APPLIES

clozapine 25 mg tablet - PA Removed: PA APPLIES

cyclophosphamide 1 g vial - PA Removed: PA APPLIES

cyclophosphamide 2 g vial - PA Removed: PA APPLIES

cyclophosphamide 500 mg vial - PA Removed: PA APPLIES

dimethyl fumarate 120 mg capsule dr - PA Removed: PA APPLIES

dimethyl fumarate 240 mg capsule dr - PA Added: PA APPLIES

irinotecan hcl 100 mg/5ml vial - PA Added: PA APPLIES

irinotecan hcl 40 mg/2 ml vial - PA Added: PA APPLIES

TRELSTAR 11.25 MG VIAL - PA Removed: PA APPLIES triptorelin pamoate

TRELSTAR 3.75 MG VIAL - PA Removed: PA APPLIES triptorelin pamoate

PAGE 10 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 02/05/2021 Medication Name Change Description guaifenesin 100 mg/5ml liquid - Added to Tier 1

ICLUSIG 10 MG TABLET - Added to Tier 2 ponatinib hcl - Added: Non-Extended Day Supply - PA Added: PA APPLIES - QL Added: 1 / DAY

isotretinoin 10 mg capsule - Added to Tier 1 - QL Added: 2 / DAY

isotretinoin 20 mg capsule - Added to Tier 1 - QL Added: 2 / DAY

isotretinoin 30 mg capsule - Added to Tier 1 - QL Added: 2 / DAY

isotretinoin 40 mg capsule - Added to Tier 1 - QL Added: 2 / DAY

lidocaine 4 % adh. patch - Added to Tier 1 - QL Added: 3 / DAY

PAGE 11 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 02/12/2021 Medication Name Change Description COMPRESSOR NEBULIZER SYSTEM - QL Added: 1 / 365 DAYS nebulizer and compressor

ferrous sulfate 15 mg/ml drops - Added to Tier 1

lidocaine 4 % adh. patch - Added to Tier 1 - QL Added: 3 / DAY

NABI-HB VIAL - Added to Tier 2 hepatitis b immune globulin

PEDIATRIC BEAR NEBULIZER - QL Added: 1 / 365 DAYS nebulizer and compressor

ULTICARE SAFE PEN NDL 5MM 30G - Added to Tier 2 pen needle, diabetic, safety

ULTICARE SAFE PEN NDL 8MM 30G - Added to Tier 2 pen needle, diabetic, safety

PAGE 12 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 02/19/2021 Medication Name Change Description citrate/pf 50 mcg/ml syringe - Added: Non-Extended Day Supply

GLUCAGON 1 MG EMERGENCY KIT - Removed From Coverage glucagon

hydromorphone hcl/0.9% nacl/pf - Added: Non-Extended Day Supply 0.2mg/0.2 syringe

hydromorphone hcl/0.9% nacl/pf - Added: Non-Extended Day Supply 0.5mg/.5ml syringe

pedi multivit no.16 w-fluoride 0.25 mg tab - Added to Tier 1 chew

PAGE 13 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 02/26/2021 Medication Name Change Description fentanyl citrate/pf 2500mcg/50 pump resvr - Added: Non-Extended Day Supply

simethicone 40mg/0.6ml drops susp - Added to Tier 1

TAB-A-VITE MULTIVIT WITH IRON - Tier Increased: Tier 1 to Tier 2 multivitamin/ferrous sulfate/folic acid

PAGE 14 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 03/01/2021 Medication Name Change Description LOTEMAX 0.5% OPHTHALMIC GEL - QL Added: 10 / 30 day(s) loteprednol etabonate

loteprednol etabonate 0.5 % drops gel - Added to Tier 1 - QL Added: 10 / 30 day(s)

multivit,calc,mins/iron/folic 9mg-400mcg - Added to Tier 1 tablet

XELJANZ 1 MG/ML SOLUTION - Added: Specialty Drug tofacitinib citrate - QL Added: 10 ML / DAY

PAGE 15 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 03/12/2021 Medication Name Change Description HUMIRA(CF) PEN PEDI UC 80 MG - Added to Tier 2 adalimumab - Added: Specialty Drug - PA Added: PA APPLIES

hydrocodone bitartrate 100 mg tab er 24h - Added: Non-Extended Day Supply

hydrocodone bitartrate 120 mg tab er 24h - Added: Non-Extended Day Supply

hydrocodone bitartrate 20 mg tab er 24h - Added: Non-Extended Day Supply

hydrocodone bitartrate 30 mg tab er 24h - Added: Non-Extended Day Supply

hydrocodone bitartrate 40 mg tab er 24h - Added: Non-Extended Day Supply

hydrocodone bitartrate 60 mg tab er 24h - Added: Non-Extended Day Supply

hydrocodone bitartrate 80 mg tab er 24h - Added: Non-Extended Day Supply

RIGHTEST GM700SB GLUCOSE - QL Added: 1 / 365 DAYS METER blood-glucose meter

RIGHTEST GS700 TEST STRIP - Added: 10 per day for ages under 21 blood sugar diagnostic and on insulin; 5 per day for all others

RIGHTEST GT333 GLUCOSE METER - QL Added: 1 / 365 DAYS blood-glucose meter

RIGHTEST GT333 LEV 2 CTRL SOLN - QL Added: 1 / 365 DAYS blood glucose calibration control solution, normal

RIGHTEST GT333 TEST STRIP - Added: 10 per day for ages under 21 blood sugar diagnostic and on insulin; 5 per day for all others

RIGHTEST MAX PLUS GLUCOSE MTR - QL Added: 1 / 365 DAYS blood-glucose meter

RIGHTEST MAX TEST STRIP - Added: 10 per day for ages under 21 blood sugar diagnostic and on insulin; 5 per day for all others

PAGE 16 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 03/19/2021 Medication Name Change Description AZOPT 1% EYE DROPS - Removed From Coverage brinzolamide - ST Removed: 2018 HPSM MEDI ST - Brinzolamide 1% eye drops

BIOTEL CARE BGM-4 METER - QL Added: 1 / 365 DAYS blood-glucose meter

brinzolamide 1 % drops susp - QL Added: 0.54 / DAY - ST Added: 2018 HPSM MEDI ST - Rhopressa

DROPLET GENTEEL LANCING DEVICE - Added to Tier 2 lancing device - QL Added: 1 / 180 DAYS

FORA TN'G ADVAN PRO TEST STRIP - Added: 10 per day for ages under 21 blood sugar diagnostic and on insulin; 5 per day for all others

GE333 BLOOD GLUCOSE SYSTEM - QL Added: 1 / 365 DAYS blood-glucose meter

GE333 BLOOD GLUCOSE TEST STRIP - Added: 10 per day for ages under 21 blood sugar diagnostic and on insulin; 5 per day for all others

GE333 CONTROL SOLUTION NORMAL - QL Added: 1 / 365 DAYS blood glucose calibration control solution, normal

PIP PEN NEEDLE 31G X 5MM - Added to Tier 2 pen needle, diabetic

PIP PEN NEEDLE 32G X 4MM - Added to Tier 2 pen needle, diabetic

PROLATE 10 MG-300 MG/5 ML SOLN - Added: Non-Extended Day Supply oxycodone hcl/acetaminophen

RIGHTEST GC700 LEV 2 CTRL SOLN - QL Added: 1 / 365 DAYS blood glucose calibration control solution, normal

ZENZEDI 15 MG TABLET - Added to Tier 1 dextroamphetamine sulfate - QL Added: 4 / DAY - AL Added: 4 to 21 yrs old

ZENZEDI 2.5 MG TABLET - Added to Tier 1 dextroamphetamine sulfate - QL Added: 4 / DAY - AL Added: 4 to 21 yrs old

PAGE 17 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 03/19/2021 Medication Name Change Description ZENZEDI 20 MG TABLET - Added to Tier 1 dextroamphetamine sulfate - QL Added: 4 / DAY - AL Added: 4 to 21 yrs old

ZENZEDI 30 MG TABLET - Added to Tier 1 dextroamphetamine sulfate - QL Added: 4 / DAY - AL Added: 4 to 21 yrs old

ZENZEDI 7.5 MG TABLET - Added to Tier 1 dextroamphetamine sulfate - QL Added: 4 / DAY - AL Added: 4 to 21 yrs old

PAGE 18 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 03/20/2021 Medication Name Change Description budesonide/formoterol fumarate 160- - QL Removed: 0.37 / DAY 4.5mcg hfa aer ad

budesonide/formoterol fumarate 80-4.5 - QL Removed: 0.37 / DAY mcg hfa aer ad

PAGE 19 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 03/22/2021 Medication Name Change Description TALTZ 80 MG/ML AUTOINJ (2-PK) - Removed: Specialty Drug ixekizumab

TALTZ 80 MG/ML AUTOINJ (3-PK) - Removed: Specialty Drug ixekizumab

TALTZ 80 MG/ML AUTOINJECTOR - Removed: Specialty Drug ixekizumab

TALTZ 80 MG/ML SYRINGE - Removed: Specialty Drug ixekizumab

PAGE 20 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 03/26/2021 Medication Name Change Description albuterol sulfate 90 mcg hfa aer ad - QL Added: 0.45 / DAY

POGO AUTOMATIC BLOOD GLUC SYS - QL Added: 1 / 365 DAYS blood-glucose meter

TRUE COMFORT PEN NDL 31G 8MM - Added to Tier 2 pen needle, diabetic

TRUE COMFORT PEN NDL 32G 5MM - Added to Tier 2 pen needle, diabetic

TYBLUME 0.1-0.02 MG CHEW TAB - Added to Tier 2 levonorgestrel/ethinyl estradiol

PAGE 21 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 04/01/2021 Medication Name Change Description ABILIFY MAINTENA ER 300 MG SYR - Removed: Available Via BHRS

ABILIFY MAINTENA ER 300 MG VL - Removed: Available Via BHRS aripiprazole

ABILIFY MAINTENA ER 400 MG SYR - Added: Available via BHRS aripiprazole

ABILIFY MAINTENA ER 400 MG VL - Removed: Available Via BHRS aripiprazole

ALDACTAZIDE 50-50 TABLET - Removed From Coverage spironolactone/hydrochlorothiazide

ALORA 0.025 MG PATCH - QL Added: 0.286 / DAY estradiol

ALORA 0.05 MG PATCH - QL Added: 0.286 / DAY estradiol

ALORA 0.075 MG PATCH - QL Added: 0.286 / DAY estradiol

ALORA 0.1 MG PATCH - QL Added: 0.286 / DAY estradiol

amiloride hcl 5 mg tablet - Added to Tier 1

amiloride/hydrochlorothiazide 5 mg-50 mg - Added to Tier 1 tablet

ANDROGEL 1.62% GEL PUMP - QL Added: 5 / DAY testosterone - PA Added: PA APPLIES

ASTRAZENECA COVID19 VAC(UNAPP) - QL Added: 1 / 180 DAYS covid-19 vaccine, azd-1222 (astrazeneca)/pf

/chlorthalidone 100mg-25mg - Added to Tier 1 tablet

atenolol/chlorthalidone 50 mg-25mg tablet - Added to Tier 1

bisac/nacl/nahco3/kcl/peg 3350 5 mg-210 - Added to Tier 1 g kit - QL Added: 2 / 365 DAYS

/hydrochlorothiazide 10-6.25mg - Added to Tier 1 tablet

PAGE 22 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 04/01/2021 Medication Name Change Description bisoprolol/hydrochlorothiazide 2.5-6.25mg - Added to Tier 1 tablet

bisoprolol/hydrochlorothiazide 5-6.25mg - Added to Tier 1 tablet

candesartan/hydrochlorothiazid 16- - Added to Tier 1 12.5mg tablet

candesartan/hydrochlorothiazid 32mg- - Added to Tier 1 25mg tablet

CARDIZEM LA 120 MG TABLET - Removed From Coverage diltiazem hcl

CATAPRES-TTS 1 PATCH - QL Added: 0.143 / DAY

CATAPRES-TTS 2 PATCH - QL Added: 0.143 / DAY clonidine

CATAPRES-TTS 3 PATCH - QL Added: 0.143 / DAY clonidine

chlorothiazide 250 mg tablet - Removed From Coverage - ST Removed: 2018 HPSM MEDI ST - PATIROMER

chlorothiazide 500 mg tablet - Removed From Coverage - ST Removed: 2018 HPSM MEDI ST - PATIROMER

chlorothiazide sodium 500 mg vial - Removed From Coverage

CITROMA SOLUTION - Added to Tier 2 magnesium citrate

CLIMARA 0.025 MG/DAY PATCH - QL Added: 0.143 / DAY estradiol

CLIMARA 0.0375 MG/DAY PATCH - QL Added: 0.143 / DAY estradiol

CLIMARA 0.05 MG/DAY PATCH - QL Added: 0.143 / DAY estradiol

CLIMARA 0.06 MG/DAY PATCH - QL Added: 0.143 / DAY estradiol

PAGE 23 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 04/01/2021 Medication Name Change Description CLIMARA 0.075 MG/DAY PATCH - QL Added: 0.143 / DAY estradiol

CLIMARA 0.1 MG/DAY PATCH - QL Added: 0.143 / DAY estradiol

CLIMARA PRO PATCH - QL Added: 0.143 / DAY estradiol/levonorgestrel

clonidine 0.1mg/24hr patch tdwk - QL Added: 0.143 / DAY

clonidine 0.2mg/24hr patch tdwk - QL Added: 0.143 / DAY

clonidine 0.3mg/24hr patch tdwk - QL Added: 0.143 / DAY

COMBIPATCH 0.05-0.14 MG PTCH - QL Added: 0.286 / DAY estradiol/norethindrone acetate

COMBIPATCH 0.05-0.25 MG PTCH - QL Added: 0.286 / DAY estradiol/norethindrone acetate

cyclophosphamide 25 mg capsule - Removed From Coverage

cyclophosphamide 50 mg capsule - Removed From Coverage

DEPO-ESTRADIOL 5 MG/ML VIAL - Removed From Coverage estradiol cypionate

diltiazem hcl 100 mg vial port - Removed From Coverage

diltiazem hcl 5 mg/ml vial - Removed From Coverage

DIURIL 250 MG/5 ML ORAL SUSP - Removed From Coverage chlorothiazide - ST Removed: 2018 HPSM MEDI ST - PATIROMER

DUAVEE 0.45-20 MG TABLET - Added to Tier 2 estrogens, conjugated/bazedoxifene acetate

enalapril/hydrochlorothiazide 10 mg-25mg - Added to Tier 1 tablet

enalapril/hydrochlorothiazide 5mg-12.5mg - Added to Tier 1 tablet

eprosartan mesylate 600 mg tablet - Removed From Coverage

PAGE 24 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 04/01/2021 Medication Name Change Description esomeprazole magnesium 40 mg capsule - QL Change: 1 / DAY to 2 / DAY dr

estradiol .025mg/24h patch tdsw - QL Added: 0.286 / DAY

estradiol .025mg/24h patch tdwk - QL Added: 0.143 / DAY

estradiol .0375mg/24 patch tdsw - QL Added: 0.286 / DAY

estradiol .0375mg/24 patch tdwk - QL Added: 0.143 / DAY

estradiol .075mg/24h patch tdsw - QL Added: 0.286 / DAY

estradiol .075mg/24h patch tdwk - QL Added: 0.143 / DAY

estradiol 0.05mg/24h patch tdsw - QL Added: 0.286 / DAY

estradiol 0.05mg/24h patch tdwk - QL Added: 0.143 / DAY

estradiol 0.06mg/24h patch tdwk - QL Added: 0.143 / DAY

estradiol 0.1mg/24hr patch tdsw - QL Added: 0.286 / DAY

estradiol 0.1mg/24hr patch tdwk - QL Added: 0.143 / DAY

ethacrynic acid 25 mg tablet - Removed From Coverage

GOLYTELY PACKET - QL Change: 8000 / 365 DAYS to 2 / 365 peg 3350/sod sulf/sod bicarb/sod DAYS chloride/potassium chloride

GOLYTELY SOLUTION - Added to Tier 2 peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride

KANJINTI 150 MG VIAL - Removed From Coverage trastuzumab-anns - PA Removed: PA APPLIES

LYRICA 20 MG/ML ORAL SOLUTION - QL Added: 30 ML / DAY pregabalin

LYRICA 225 MG CAPSULE - QL Change: 3 / DAY to 2 / DAY pregabalin

LYRICA 300 MG CAPSULE - QL Change: 3 / DAY to 2 / DAY pregabalin

PAGE 25 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 04/01/2021 Medication Name Change Description LYRICA CR 165 MG TABLET - QL Added: 2 / DAY pregabalin

LYRICA CR 330 MG TABLET - QL Added: 2 / DAY pregabalin

LYRICA CR 82.5 MG TABLET - QL Added: 2 / DAY pregabalin

magnesium citrate solution - Added to Tier 1

MENOSTAR 14 MCG/DAY PATCH - Removed From Coverage estradiol - QL Added: 0.143 / DAY

/hydrochlorothiazide 250mg- - Removed From Coverage 15mg tablet

methyldopa/hydrochlorothiazide 250mg- - Removed From Coverage 25mg tablet

methyltestosterone 10 mg capsule - Removed From Coverage

tartrate 5 mg/5 ml ampul - Removed From Coverage

MINIVELLE 0.025 MG PATCH - QL Added: 0.286 / DAY estradiol

MINIVELLE 0.0375 MG PATCH - QL Added: 0.286 / DAY estradiol

MINIVELLE 0.05 MG PATCH - QL Added: 0.286 / DAY estradiol

MINIVELLE 0.075 MG PATCH - QL Added: 0.286 / DAY estradiol

MINIVELLE 0.1 MG PATCH - QL Added: 0.286 / DAY estradiol

MODERNA COVID-19 VACCINE (EUA) - QL Added: 1 / 180 DAYS covid-19 vaccine, mrna-1273, lnp-s (moderna)/pf

moexipril hcl 15 mg tablet - Added to Tier 1

moexipril hcl 7.5 mg tablet - Added to Tier 1

PAGE 26 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 04/01/2021 Medication Name Change Description MOVIPREP POWDER PACKET - QL Added: 2 / 365 DAYS peg 3350/sodium sulfate/sod chloride/kcl/ascorbate sod/vit c

/bendroflumethiazide 40 mg-5 mg - Removed From Coverage tablet

nadolol/bendroflumethiazide 80 mg-5 mg - Removed From Coverage tablet

NEXIUM DR 40 MG CAPSULE - QL Change: 1 / DAY to 2 / DAY esomeprazole magnesium

niacin 500 mg tablet er - Added to Tier 1

niacin 750 mg tablet er - Added to Tier 1

nicardipine hcl 20 mg capsule - Removed From Coverage - ST Removed: 2018 HPSM MEDI ST - Nicardipine

nicardipine hcl 30 mg capsule - Removed From Coverage - ST Removed: 2018 HPSM MEDI ST - Nicardipine

nitisinone 10 mg capsule - Added to Tier 1 - Added: Non-Extended Day Supply - PA Added: PA APPLIES

nitisinone 2 mg capsule - Added to Tier 1 - Added: Non-Extended Day Supply - PA Added: PA APPLIES

nitisinone 5 mg capsule - Added to Tier 1 - Added: Non-Extended Day Supply - PA Added: PA APPLIES

NULYTELY SOLUTION - Added to Tier 2 sodium chloride/sodium bicarbonate/potassium chloride/peg

NULYTELY WITH FLAVOR PACKS SOL - Added to Tier 2 sodium chloride/sodium bicarbonate/potassium chloride/peg

OGIVRI 150 MG VIAL - Removed From Coverage trastuzumab-dkst - PA Removed: PA APPLIES

PAGE 27 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 04/01/2021 Medication Name Change Description olmesartan/amlodipin/hcthiazid 20-5-12.5 - Added to Tier 1 tablet

olmesartan/amlodipin/hcthiazid 40-10- - Added to Tier 1 12.5 tablet

olmesartan/amlodipin/hcthiazid 40-10- - Added to Tier 1 25mg tablet

olmesartan/amlodipin/hcthiazid 40-5-12.5 - Added to Tier 1 tablet

olmesartan/amlodipin/hcthiazid 40-5-25 - Added to Tier 1 mg tablet

hcl 0.1 % drops - Added to Tier 1

olopatadine hcl 0.2 % drops - Added to Tier 1

OLUMIANT 1 MG TABLET - QL Added: 1 / DAY baricitinib

OLUMIANT 2 MG TABLET - QL Added: 1 / DAY baricitinib

ONTRUZANT 150 MG VIAL - Removed From Coverage trastuzumab-dttb - PA Removed: PA APPLIES

ORFADIN 10 MG CAPSULE - Added: Non-Extended Day Supply nitisinone - PA Added: PA APPLIES

ORFADIN 2 MG CAPSULE - Added: Non-Extended Day Supply nitisinone - PA Added: PA APPLIES

ORFADIN 5 MG CAPSULE - Added: Non-Extended Day Supply nitisinone - PA Added: PA APPLIES

OXBRYTA 500 MG TABLET - QL Added: 3 / DAY voxelotor

PATADAY ONCE DAILY 0.2% DROPS - Added to Tier 2 olopatadine hcl

PATADAY ONCE DAILY 0.7% DROPS - Added to Tier 2 olopatadine hcl

PAGE 28 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 04/01/2021 Medication Name Change Description PATADAY TWICE DAILY 0.1% DROPS - Added to Tier 2 olopatadine hcl

peg3350/sod sul/nacl/kcl/asb/c 7.5-2.691g - Added to Tier 1 powd pack - QL Added: 2 / 365 DAYS

perindopril erbumine 2 mg tablet - Added to Tier 1

perindopril erbumine 4 mg tablet - Added to Tier 1

perindopril erbumine 8 mg tablet - Added to Tier 1

PREFEST TABLET - Removed From Coverage estradiol/norgestimate

pregabalin 165 mg tab er 24h - QL Added: 2 / DAY

pregabalin 20 mg/ml solution - QL Added: 30 ML / DAY

pregabalin 225 mg capsule - QL Change: 3 / DAY to 2 / DAY

pregabalin 300 mg capsule - QL Change: 3 / DAY to 2 / DAY

pregabalin 330 mg tab er 24h - QL Added: 2 / DAY

pregabalin 82.5 mg tab er 24h - QL Added: 2 / DAY

PREMPHASE 0.625-5 MG TABLET - Added to Tier 2 estrogens, conjugated/medroxyprogesterone acetate

/hydrochlorothiazid 40 mg- - Added to Tier 1 25mg tablet

propranolol/hydrochlorothiazid 80 mg- - Added to Tier 1 25mg tablet

REFRESH RELIEVA PF 0.5-0.9% - Added to Tier 2 carboxymethylcellulose sodium/glycerin/pf - ST Added: 2018 HPSM MEDI ST - Cyclosporine Eye Drops

solifenacin succinate 10 mg tablet - Added to Tier 1 - ST Added: 2018 HPSM MEDI ST - DARIFENACIN (MEDI-CCS) - QL Added: 1 / DAY

PAGE 29 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 04/01/2021 Medication Name Change Description solifenacin succinate 5 mg tablet - Added to Tier 1 - ST Added: 2018 HPSM MEDI ST - DARIFENACIN (MEDI-CCS) - QL Added: 1 / DAY

SYMBICORT 160-4.5 MCG INHALER - QL Removed: 0.37 / DAY budesonide/formoterol fumarate

SYMBICORT 80-4.5 MCG INHALER - QL Removed: 0.37 / DAY budesonide/formoterol fumarate

telmisartan/amlodipine 40 mg-10mg tablet - Added to Tier 1

telmisartan/amlodipine 40 mg-5 mg tablet - Added to Tier 1

telmisartan/amlodipine 80 mg-10mg tablet - Added to Tier 1

telmisartan/amlodipine 80 mg-5 mg tablet - Added to Tier 1

TEMIXYS 300-300 MG TABLET - Added to Tier 2 lamivudine/tenofovir disoproxil fumarate - QL Added: 1 / DAY

TESTOPEL 75 MG PELLETS - Removed From Coverage testosterone

testosterone 20.25/1.25 gel md pmp - Added to Tier 1 - QL Added: 5 / DAY - PA Added: PA APPLIES

timolol maleate 10 mg tablet - Removed From Coverage

timolol maleate 20 mg tablet - Removed From Coverage

timolol maleate 5 mg tablet - Removed From Coverage

TRAZIMERA 150 MG VIAL - Added to Tier 2 trastuzumab-qyyp - PA Added: PA APPLIES

triamterene 100 mg capsule - Removed From Coverage

triamterene 50 mg capsule - Removed From Coverage

verapamil hcl 2.5 mg/ml syringe - Removed From Coverage

VERELAN PM 100 MG CAP PELLET - Removed From Coverage verapamil hcl

PAGE 30 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 04/01/2021 Medication Name Change Description VERELAN PM 300 MG CAP PELLET - Removed From Coverage verapamil hcl

VESICARE 10 MG TABLET - QL Added: 1 / DAY solifenacin succinate

VESICARE 5 MG TABLET - QL Added: 1 / DAY solifenacin succinate

VIVELLE-DOT 0.025 MG PATCH - QL Added: 0.286 / DAY estradiol

VIVELLE-DOT 0.0375 MG PATCH - QL Added: 0.286 / DAY estradiol

VIVELLE-DOT 0.05 MG PATCH - QL Added: 0.286 / DAY estradiol

VIVELLE-DOT 0.075 MG PATCH - QL Added: 0.286 / DAY estradiol

VIVELLE-DOT 0.1 MG PATCH - QL Added: 0.286 / DAY estradiol

XTANDI 40 MG TABLET - Added to Tier 2 enzalutamide - QL Added: 4 / DAY - Added: Non-Extended Day Supply - PA Added: PA APPLIES

XTANDI 80 MG TABLET - Added to Tier 2 enzalutamide - Added: Non-Extended Day Supply - QL Added: 2 / DAY - PA Added: PA APPLIES

PAGE 31 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 04/02/2021 Medication Name Change Description CAREPOINT LL SYR 3 ML 21GX1" - Added to Tier 2 syringe with needle,disposable, 3 ml

CAREPOINT LL SYR 3 ML 21GX1.5" - Added to Tier 2 syringe with needle,disposable, 3 ml

CAREPOINT LL SYR 3 ML 22GX1" - Added to Tier 2 syringe with needle,disposable, 3 ml

CAREPOINT LL SYR 3 ML 23GX1" - Added to Tier 2 syringe with needle,disposable, 3 ml

CAREPOINT LL SYR 3 ML 23GX1.5" - Added to Tier 2 syringe with needle,disposable, 3 ml

CAREPOINT LL SYR 3 ML 25G X 1" - Added to Tier 2 syringe with needle,disposable, 3 ml

CAREPOINT LL SYR 3 ML 25GX5/8" - Added to Tier 2 syringe with needle,disposable, 3 ml

omeprazole magnesium 20 mg tablet dr - Added to Tier 1 - QL Added: 3 / day(s)

ULTICARE LDS SYR 1 ML 22G 1.5" - Added to Tier 2 syringe with needle,disposable, 1 ml

PAGE 32 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 04/09/2021 Medication Name Change Description EMBRACE LANCING DEVICE - Added to Tier 2 lancing device - QL Added: 1 / 180 DAYS

PEDIA POLY-VITE DROPS - Tier Increased: Tier 1 to Tier 2 pediatric multivitamin no.171

PAGE 33 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 04/14/2021 Medication Name Change Description CLENPIQ SOLUTION - QL Added: 640 / 365 DAYS sodium picosulfate/magnesium oxide/citric acid

eplerenone 25 mg tablet - Added to Tier 1 - ST Added: 2018 HPSM MEDI ST - EPLERENONE

eplerenone 50 mg tablet - Added to Tier 1 - ST Added: 2018 HPSM MEDI ST - EPLERENONE

estradiol 10 mcg tablet - QL Added: 0.643 / DAY

JANSSEN COVID-19 VACCINE (EUA) - QL Added: 0.5 / 180 DAYS covid-19 vac, ad26.cov2.s (janssen)/pf

OSMOPREP TABLET - QL Added: 64 / 365 DAYS sodium phosphate,monobasic/sodium phosphate,dibasic

PFIZER COVID-19 VACCINE (EUA) - QL Added: 0.6 / 180 DAYS covid-19 vaccine, mrna, bnt162b2, lnp-s ()/pf

PLENVU POWDER PACKETS - QL Added: 6 / 365 DAYS peg 3350/sodium sulfate/sod chloride/kcl/ascorbate sod/vit c

spironolact/hydrochlorothiazid 25 mg- - ST Added: 2018 HPSM MEDI ST - 25mg tablet EPLERENONE

spironolactone 100 mg tablet - ST Added: 2018 HPSM MEDI ST - EPLERENONE

spironolactone 25 mg tablet - ST Added: 2018 HPSM MEDI ST - EPLERENONE

spironolactone 50 mg tablet - ST Added: 2018 HPSM MEDI ST - EPLERENONE

SUPREP BOWEL PREP KIT - QL Added: 708 / 365 DAYS sodium sulfate/potassium sulfate/magnesium sulfate

SUTAB 1.479-0.225-0.188 GM TAB - QL Added: 48 / 365 DAYS sodium sulfate/potassium chloride/magnesium sulfate

VAGIFEM 10 MCG VAGINAL TAB - QL Added: 0.643 / DAY estradiol

PAGE 34 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 04/15/2021 Medication Name Change Description ILARIS 150 MG/ML VIAL - Removed: Specialty Drug canakinumab/pf

PAGE 35 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 04/16/2021 Medication Name Change Description COMFORT TOUCH ULT THIN 31G LAN - Added to Tier 2 lancets - Added: 10 per day for ages under 21 and on insulin; 7 per day for all others

COMFORTTOUCH PLUS SAF 30G - Added to Tier 2 LANC - Added: 10 per day for ages under 21 lancets and on insulin; 7 per day for all others

CONTOUR NEXT GLUCOSE METER - QL Added: 1 / 365 DAYS KIT blood-glucose meter

RELION PEN NEEDLE 31G 6MM - Added to Tier 2 pen needle, diabetic

SOLTAMOX 20 MG/10 ML SOLN - Added: Non-Extended Day Supply tamoxifen citrate

PAGE 36 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 04/23/2021 Medication Name Change Description POGO AUTOMATIC TEST CARTRIDGE - Added: 10 per day for ages under 21 lancets with blood glucose test strips and on insulin; 7 per day for all others

ULTRA FLO PEN NEEDLE 33G 4MM - Added to Tier 2 pen needle, diabetic

ULTRA FLO SYR 0.3 ML 31G 5/16" - Added to Tier 2 syringe with needle,insulin,0.3 ml

ULTRA FLO SYR 0.5 ML 29G 1/2" - Added to Tier 2 syringe with needle,insulin,0.5 ml

PAGE 37 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 04/30/2021 Medication Name Change Description FORTEO 620 MCG/2.48 ML PEN INJ - PA Added: PA APPLIES teriparatide

hydrocortisone/pramoxine 2.5 %-1 % - QL Removed: 30 / 30 DAYS cream/appl

levonorgestrel/ethin.estradiol 90-20 mcg - Added to Tier 1 tablet

ULTRA FLO 0.3ML 30G 1/2" (1/2) - Added to Tier 2 syringe with needle,insulin 0.3 ml (half unit mark)

ULTRA FLO 0.3ML 30G 5/16"(1/2) - Added to Tier 2 syringe with needle,insulin 0.3 ml (half unit mark)

ULTRA FLO 0.3ML 31G 5/16"(1/2) - Added to Tier 2 syringe with needle,insulin 0.3 ml (half unit mark)

PAGE 38 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 05/01/2021 Medication Name Change Description APRISO ER 0.375 GRAM CAPSULE - PA Removed: PA APPLIES mesalamine

ciclopirox/urea/camph/men/euc 8 % - Removed From Coverage solution

dalfampridine 10 mg tab er 12h - Added to Tier 1 - QL Added: 2 / DAY

DELZICOL DR 400 MG CAPSULE - PA Removed: PA APPLIES mesalamine

DUPIXENT 300 MG/2 ML PEN - Added: Specialty Drug dupilumab

FORA NORMAL CONTROL SOLUTION - Added to Tier 2 blood glucose calibration control solution, normal

STELARA 130 MG/26 ML VIAL - Added: Specialty Drug

STELARA 45 MG/0.5 ML VIAL - Added: Specialty Drug ustekinumab

XPOVIO 100 MG ONCE WEEKLY DOSE - QL Added: 8 / 28 DAYS selinexor

XPOVIO 40 MG ONCE WEEKLY DOSE - QL Added: 8 / 28 DAYS selinexor

XPOVIO 40 MG TWICE WEEKLY DOSE - QL Added: 8 / 28 DAYS selinexor

XPOVIO 60 MG ONCE WEEKLY DOSE - QL Added: 4 / 28 DAYS selinexor

XPOVIO 60 MG TWICE WEEKLY DOSE - QL Added: 24 / 28 DAYS selinexor

XPOVIO 80 MG ONCE WEEKLY DOSE - QL Added: 8 / 28 DAYS selinexor

XPOVIO 80 MG TWICE WEEKLY DOSE - QL Added: 32 / 28 DAYS selinexor

PAGE 39 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 05/07/2021 Medication Name Change Description CAREPOINT LS SYR 1 ML 25G 5/8" - Added to Tier 2 syringe with needle,disposable, 1 ml

ULTRA FLO PEN NEEDLE 31G 8MM - Added to Tier 2 pen needle, diabetic

ULTRA FLO PEN NEEDLE 32G 4MM - Added to Tier 2 pen needle, diabetic

PAGE 40 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 05/14/2021 Medication Name Change Description 10 mg tablet - Added to Tier 1

famotidine 20 mg tablet - Added to Tier 1

isotretinoin 25 mg capsule - QL Added: 2 / DAY

isotretinoin 35 mg capsule - QL Added: 2 / DAY

PAGE 41 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 05/15/2021 Medication Name Change Description acetonide 0.05 % oint. (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

PAGE 42 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 05/21/2021 Medication Name Change Description PREVIDENT 0.2% RINSE - Removed From Coverage fluoride (sodium)

PREVIDENT DENTAL RINSE - Removed From Coverage fluoride (sodium)

ULTRA FLO SYR 0.3 ML 30G 5/16" - Added to Tier 2 syringe with needle,insulin,0.3 ml

UNIFINE PEN NEEDLE 32G 4MM - Added to Tier 2 pen needle, diabetic

PAGE 43 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 06/01/2021 Medication Name Change Description APTIOM 200 MG TABLET - QL Added: 1 / DAY eslicarbazepine acetate

APTIOM 400 MG TABLET - QL Added: 1 / DAY eslicarbazepine acetate

APTIOM 600 MG TABLET - QL Added: 2 / DAY eslicarbazepine acetate

APTIOM 800 MG TABLET - QL Added: 2 / DAY eslicarbazepine acetate

diazepam 5 mg/5 ml solution - QL Change: 4 / DAY to 40 ML / DAY

PAGE 44 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 06/04/2021 Medication Name Change Description fentanyl citrate-0.9 % nacl/pf 1250mcg/25 - Added: Non-Extended Day Supply pca syring

fentanyl citrate-0.9 % nacl/pf 2500mcg/50 - Added: Non-Extended Day Supply pca syring

PAGE 45 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 06/11/2021 Medication Name Change Description EASY TOUCH BLU LINK GLUC SYST - QL Added: 1 / 365 DAYS blood-glucose meter

EASY TOUCH BLU LINK TEST STRIP - Added: 10 per day for ages under 21 blood sugar diagnostic and on insulin; 5 per day for all others

hydromorphone hcl in water/pf 10 - Added: Non-Extended Day Supply mg/50ml pca syring

rufinamide 200 mg tablet - QL Added: 8 / DAY

rufinamide 400 mg tablet - QL Added: 8 / DAY

PAGE 46 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 06/18/2021 Medication Name Change Description EASY TOUCH BLU LINK CTRL SOLN - QL Added: 1 / 365 DAYS blood glucose calibration control high and low

KALETRA 100-25 MG TABLET - Removed From Coverage lopinavir/ritonavir

KALETRA 200-50 MG TABLET - Removed From Coverage lopinavir/ritonavir

lopinavir/ritonavir 100mg-25mg tablet - Added: Specialty Drug - QL Added: 10 / DAY

lopinavir/ritonavir 200mg-50mg tablet - QL Added: 4 / DAY - Added: Specialty Drug

NERLYNX 40 MG TABLET - Added: Non-Extended Day Supply neratinib maleate

NOVA MAX PLUS GLUC-KET MTR KIT - QL Removed: 1 / 365 DAYS blood ketone and glucose monitor

NOVA MAX PLUS GLUC-KETON - QL Removed: 1 / 365 DAYS METER blood ketone and glucose monitor

PAGE 47 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 06/25/2021 Medication Name Change Description EASY TOUCH LUER LOCK 20 ML SYR - Added to Tier 2 syringe, disposable, 20 ml

EASY TOUCH LUER LOCK 60 ML SYR - Added to Tier 2 syringe, disposable, 60 ml

100 mg tablet - Added: Specialty Drug

etravirine 200 mg tablet - Added: Specialty Drug

HEMATOGEN SOFTGEL - Added to Tier 2 ferrous fumarate/ascorbic acid/cyanocobalamin

INTELENCE 100 MG TABLET - Removed From Coverage etravirine

INTELENCE 200 MG TABLET - Removed From Coverage etravirine

olopatadine hcl 0.2 % drops - Added to Tier 1

PANCREAZE DR 37,000 UNIT CAP - Added to Tier 2 lipase/protease/amylase

TRIKAFTA 50-25-37.5 MG/75 MG - Added to Tier 2 elexacaftor/tezacaftor/ivacaftor - QL Added: 3 / DAY - PA Added: PA APPLIES

PAGE 48 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/01/2021 Medication Name Change Description alclometasone dipropionate 0.05 % cream - ST Removed: 2018 HPSM MEDI ST - (g) Tacrolimus Topical

alclometasone dipropionate 0.05 % oint. - ST Removed: 2018 HPSM MEDI ST - (g) Tacrolimus Topical

hcl 10 mg tab er 24h - Added to Tier 1

alogliptin benz/metformin hcl 12.5-1000 - ST Added: 2018 HPSM MEDI ST - DPP- tablet 4 INHIBITORS

alogliptin benz/metformin hcl 12.5-500mg - ST Added: 2018 HPSM MEDI ST - DPP- tablet 4 INHIBITORS

alogliptin benz/pioglitazone 12.5-15 mg - ST Added: 2018 HPSM MEDI ST - DPP- tablet 4 INHIBITORS

alogliptin benz/pioglitazone 12.5-30 mg - ST Added: 2018 HPSM MEDI ST - DPP- tablet 4 INHIBITORS

alogliptin benz/pioglitazone 12.5-45 mg - ST Added: 2018 HPSM MEDI ST - DPP- tablet 4 INHIBITORS

alogliptin benz/pioglitazone 25 mg-15mg - ST Added: 2018 HPSM MEDI ST - DPP- tablet 4 INHIBITORS

alogliptin benz/pioglitazone 25 mg-30mg - ST Added: 2018 HPSM MEDI ST - DPP- tablet 4 INHIBITORS

alogliptin benz/pioglitazone 25 mg-45mg - ST Added: 2018 HPSM MEDI ST - DPP- tablet 4 INHIBITORS

alogliptin benzoate 12.5 mg tablet - ST Added: 2018 HPSM MEDI ST - DPP- 4 INHIBITORS

alogliptin benzoate 25 mg tablet - ST Added: 2018 HPSM MEDI ST - DPP- 4 INHIBITORS

alogliptin benzoate 6.25 mg tablet - ST Added: 2018 HPSM MEDI ST - DPP- 4 INHIBITORS

AMPYRA ER 10 MG TABLET - QL Added: 2 / DAY dalfampridine

armodafinil 150 mg tablet - PA Removed: PA APPLIES

armodafinil 200 mg tablet - PA Removed: PA APPLIES

PAGE 49 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/01/2021 Medication Name Change Description armodafinil 250 mg tablet - PA Removed: PA APPLIES

armodafinil 50 mg tablet - PA Removed: PA APPLIES

AUTOMATIC BLOOD PRESSR - Added to Tier 2 MONITOR - QL Added: 1 / 365 DAYS blood pressure test kit-large

BD HOME SHARPS CONTAINER - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

BD SHARPS COLLECTOR 1.5 QUART - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

BD SHARPS COLLECTOR 3 GAL - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

BD SHARPS COLLECTOR 3.3 QUART - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

BD SHARPS COLLECTOR 5 GAL - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

BD SHARPS COLLECTOR 5.4 QUART - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

BD SHARPS COLLECTOR 6.9 QUART - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

BD SHARPS COLLECTOR 8.2 QUART - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

BD SHARPS COLLECTOR 9 GAL - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

BD SHARPS CONTAINER 1.4QT - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

BLOOD PRESSURE MANUAL KIT - Added to Tier 2 blood pressure test kit - QL Added: 1 / 365 DAYS

BLOOD PRESSURE MONITOR KIT - Added to Tier 2 blood pressure kit-extra large - QL Added: 1 / 365 DAYS

BLOOD PRESSURE MONITOR-MEDIUM - Added to Tier 2 blood pressure test kit-medium - QL Added: 1 / 365 DAYS

PAGE 50 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/01/2021 Medication Name Change Description BLOOD PRESSURE MONITOR - Added to Tier 2 blood pressure test kit-large - QL Added: 1 / 365 DAYS

BLOOD PRESSURE MONITOR - Added to Tier 2 blood pressure test kit-medium - QL Added: 1 / 365 DAYS

BLOOD PRESSURE MONITOR - Added to Tier 2 blood pressure test kit-medium - QL Added: 1 / 365 DAYS

CARETOUCH BP MONITOR - Added to Tier 2 blood pressure test kit-large - QL Added: 1 / 365 DAYS

CARETOUCH WRIST BP MONITOR - Added to Tier 2 blood pressure test kit-wrist - QL Added: 1 / 365 DAYS

caspofungin acetate 50 mg vial - Added to Tier 1

caspofungin acetate 70 mg vial - Added to Tier 1

CATHFLO ACTIVASE 2 MG VIAL - Added to Tier 2 alteplase

clobetasol propionate 0.05 % cream (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

clobetasol propionate 0.05 % foam - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

clobetasol propionate 0.05 % gel (gram) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

clobetasol propionate 0.05 % oint. (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

clobetasol propionate 0.05 % solution - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

clobetasol propionate/emoll 0.05 % cream - ST Removed: 2018 HPSM MEDI ST - (g) Tacrolimus Topical

COSENTYX 75 MG/0.5 ML SYRINGE - Added to Tier 2 secukinumab - Added: Specialty Drug - PA Added: PA APPLIES

CVS BLOOD PRESSURE MANUAL KIT - Added to Tier 2 blood pressure test kit - QL Added: 1 / 365 DAYS

PAGE 51 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/01/2021 Medication Name Change Description CVS BLOOD PRESSURE MONITOR - Added to Tier 2 blood pressure test kit-medium - QL Added: 1 / 365 DAYS

CVS SERIES 100 BP MONITOR - Added to Tier 2 blood pressure test kit-large - QL Added: 1 / 365 DAYS

CVS SERIES 400 BP MONITOR - Added to Tier 2 blood pressure test kit-large - QL Added: 1 / 365 DAYS

CVS SERIES 400W BP MONITOR - Added to Tier 2 blood pressure test kit-wrist - QL Added: 1 / 365 DAYS

desonide 0.05 % cream (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

desonide 0.05 % lotion - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

desonide 0.05 % oint. (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

dextran 70/hypromellose 0.1%-0.3% - ST Added: 2018 HPSM MEDI ST - drops Cyclosporine Eye Drops

diphenhydramine hcl 12.5mg/5ml elixir - Removed From Coverage

dutasteride 0.5 mg capsule - Added to Tier 1

ENTRESTO 24 MG-26 MG TABLET - Added to Tier 2 sacubitril/valsartan

ENTRESTO 49 MG-51 MG TABLET - Added to Tier 2 sacubitril/valsartan

ENTRESTO 97 MG-103 MG TABLET - Added to Tier 2 sacubitril/valsartan

eplerenone 25 mg tablet - QL Added: 4 / DAY

eplerenone 50 mg tablet - QL Added: 2 / DAY

etravirine 100 mg tablet - QL Added: 4 / DAY

etravirine 200 mg tablet - QL Added: 2 / DAY

fluocinolone acetonide 0.01 % cream (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

PAGE 52 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/01/2021 Medication Name Change Description fluocinolone acetonide 0.01 % oil - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

fluocinolone acetonide 0.01 % solution - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

fluocinolone acetonide 0.025 % cream (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

fluocinolone acetonide 0.025 % oint. (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

fluocinolone/shower cap 0.01 % oil - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

fluocinonide 0.05 % cream (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

fluocinonide 0.05 % gel (gram) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

fluocinonide 0.05 % oint. (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

fluocinonide 0.05 % solution - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

fluocinonide 0.1 % cream (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

fluocinonide/emollient base 0.05 % cream - ST Removed: 2018 HPSM MEDI ST - (g) Tacrolimus Topical

fosfomycin tromethamine 3 g packet - Added to Tier 1

FOTIVDA 0.89 MG CAPSULE - Added to Tier 2 tivozanib hcl - Added: Non-Extended Day Supply - PA Added: PA APPLIES - QL Added: 0.75 / DAY

FOTIVDA 1.34 MG CAPSULE - Added to Tier 2 tivozanib hcl - Added: Non-Extended Day Supply - PA Added: PA APPLIES - QL Added: 0.75 / DAY

GNP BLOOD PRESSURE MONITOR - Added to Tier 2 blood pressure test kit-medium - QL Added: 1 / 365 DAYS

PAGE 53 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/01/2021 Medication Name Change Description HM BLOOD PRESSURE MONITOR - Added to Tier 2 blood pressure test kit-medium - QL Added: 1 / 365 DAYS

hydrocortisone 0.5 % cream (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

hydrocortisone 0.5 % oint. (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

hydrocortisone 1 % cream (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

hydrocortisone 1 % cream pack - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

hydrocortisone 1 % crm/pe app - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

hydrocortisone 1 % lotion - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

hydrocortisone 1 % oint. (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

hydrocortisone 1 % spray - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

hydrocortisone 2 % lotion - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

hydrocortisone 2.5 % cream (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

hydrocortisone 2.5 % crm/pe app - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

hydrocortisone 2.5 % lotion - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

hydrocortisone 2.5 % oint. (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

hydrocortisone acetate 0.5 % cream (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

hydrocortisone acetate 1 % cream (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

PAGE 54 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/01/2021 Medication Name Change Description hydrocortisone acetate 1 % oint. (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

hydrocortisone acetate 2.5 % crm/pe app - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

hydrocortisone acetate/urea 1 %-10 % - ST Removed: 2018 HPSM MEDI ST - cream (g) Tacrolimus Topical

hydrocortisone/aloe vera 1 % cream (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

INCONTROL ADVANCED BP MONITOR - Added to Tier 2 blood pressure test kit-large - QL Added: 1 / 365 DAYS

INCONTROL ADVNCED WRST BP - Added to Tier 2 MNTR - QL Added: 1 / 365 DAYS blood pressure test kit-wrist

INCONTROL BLOOD PRESSURE MON - Added to Tier 2 blood pressure test kit-medium - QL Added: 1 / 365 DAYS

INCONTROL DELUXE BP MONITOR - Added to Tier 2 blood pressure test kit-large - QL Added: 1 / 365 DAYS

INCONTROL PREMIUM WRST BP - Added to Tier 2 MNTR - QL Added: 1 / 365 DAYS blood pressure test kit-wrist

INSPRA 25 MG TABLET - QL Added: 4 / DAY eplerenone

INSPRA 50 MG TABLET - QL Added: 2 / DAY eplerenone

INTELENCE 100 MG TABLET - QL Change: 6 / DAY to 4 / DAY etravirine

INTELENCE 200 MG TABLET - QL Change: 6 / DAY to 2 / DAY etravirine

JANUMET 50-1,000 MG TABLET - ST Added: 2018 HPSM MEDI ST - DPP- sitagliptin phosphate/metformin hcl 4 INHIBITORS

JANUMET 50-500 MG TABLET - ST Added: 2018 HPSM MEDI ST - DPP- sitagliptin phosphate/metformin hcl 4 INHIBITORS

PAGE 55 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/01/2021 Medication Name Change Description JANUMET XR 100-1,000 MG TABLET - ST Added: 2018 HPSM MEDI ST - DPP- sitagliptin phosphate/metformin hcl 4 INHIBITORS

JANUMET XR 50-1,000 MG TABLET - ST Added: 2018 HPSM MEDI ST - DPP- sitagliptin phosphate/metformin hcl 4 INHIBITORS

JANUMET XR 50-500 MG TABLET - ST Added: 2018 HPSM MEDI ST - DPP- sitagliptin phosphate/metformin hcl 4 INHIBITORS

JANUVIA 100 MG TABLET - ST Added: 2018 HPSM MEDI ST - DPP- sitagliptin phosphate 4 INHIBITORS

JANUVIA 25 MG TABLET - ST Added: 2018 HPSM MEDI ST - DPP- sitagliptin phosphate 4 INHIBITORS

JANUVIA 50 MG TABLET - ST Added: 2018 HPSM MEDI ST - DPP- sitagliptin phosphate 4 INHIBITORS

KOMBIGLYZE XR 2.5-1,000 MG TAB - ST Added: 2018 HPSM MEDI ST - DPP- saxagliptin hcl/metformin hcl 4 INHIBITORS

KOMBIGLYZE XR 5-1,000 MG TAB - ST Added: 2018 HPSM MEDI ST - DPP- saxagliptin hcl/metformin hcl 4 INHIBITORS

KOMBIGLYZE XR 5-500 MG TABLET - ST Added: 2018 HPSM MEDI ST - DPP- saxagliptin hcl/metformin hcl 4 INHIBITORS

KROGER BLOOD PRESSURE - Added to Tier 2 MONITOR - QL Added: 1 / 365 DAYS blood pressure test kit-medium

mesalamine 0.375g cap er 24h - ST Removed: 2018 HPSM MEDI ST - Mesalamine

mesalamine 1.2 g tablet dr - ST Removed: 2018 HPSM MEDI ST - Mesalamine

mesalamine 400 mg cap(drtab) - ST Removed: 2018 HPSM MEDI ST - Mesalamine

modafinil 100 mg tablet - Added to Tier 1 - QL Added: 4 / DAY

modafinil 200 mg tablet - Added to Tier 1 - QL Added: 2 / DAY

PAGE 56 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/01/2021 Medication Name Change Description MONOJECT SHARPS 8 QT CONTAINER - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

naphazoline hcl 0.1 % drops - Removed From Coverage

NEXTSTELLIS 3-14.2 MG TABLET - Added to Tier 2 drospirenone/estetrol

nicotine 21-14-7mg patch dysq - Added to Tier 1

NOVA MAX PLUS GLUC-KETON - QL Added: 1 / 365 DAYS METER blood ketone and glucose monitor

NOVAVAX COVID19 VAC,ADJ(UNAPP) - QL Added: 1 / 180 DAYS covid-19 vaccine, nvx-cov2373 (novavax)/adjuvant-matrix/pf

NUVIGIL 150 MG TABLET - PA Removed: PA APPLIES armodafinil

NUVIGIL 200 MG TABLET - PA Removed: PA APPLIES armodafinil

NUVIGIL 250 MG TABLET - PA Removed: PA APPLIES armodafinil

NUVIGIL 50 MG TABLET - PA Removed: PA APPLIES armodafinil

ONGLYZA 2.5 MG TABLET - ST Added: 2018 HPSM MEDI ST - DPP- saxagliptin hcl 4 INHIBITORS

ONGLYZA 5 MG TABLET - ST Added: 2018 HPSM MEDI ST - DPP- saxagliptin hcl 4 INHIBITORS

oxycodone hcl/acetaminophen 5-325/5 ml - Removed From Coverage solution - QL Removed: 1846 / 30 DAYS

PANCREAZE DR 10,500 UNIT CAP - Added to Tier 2 lipase/protease/amylase

PANCREAZE DR 16,800 UNIT CAP - Added to Tier 2 lipase/protease/amylase

PANCREAZE DR 4,200 UNIT CAP - Added to Tier 2 lipase/protease/amylase

PAGE 57 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/01/2021 Medication Name Change Description pimecrolimus 1 % cream (g) - Removed From Coverage - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

prednicarbate 0.1 % cream (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

prednicarbate 0.1 % oint. (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

sodium phosphate 20 mg/5 - Added to Tier 1 ml solution

PROCARE WRIST BP MONITOR - Added to Tier 2 blood pressure test kit-wrist - QL Added: 1 / 365 DAYS

PROMACTA 12.5 MG SUSPEN PACKET - Added to Tier 2 eltrombopag olamine - Added: Specialty Drug - PA Added: PA APPLIES - QL Added: 1 / DAY

PROMACTA 12.5 MG TABLET - Added to Tier 2 eltrombopag olamine - PA Added: PA APPLIES - QL Added: 1 / DAY

PROMACTA 25 MG SUSPENSION PCKT - Added to Tier 2 eltrombopag olamine - Added: Specialty Drug - PA Added: PA APPLIES - QL Added: 1 / DAY

PROMACTA 25 MG TABLET - Added to Tier 2 eltrombopag olamine - PA Added: PA APPLIES - QL Added: 1 / DAY

PROMACTA 50 MG TABLET - Added to Tier 2 eltrombopag olamine - QL Added: 2 / DAY - PA Added: PA APPLIES

PROMACTA 75 MG TABLET - Added to Tier 2 eltrombopag olamine - QL Added: 2 / DAY - PA Added: PA APPLIES

PROVIGIL 100 MG TABLET - QL Added: 4 / DAY modafinil

PROVIGIL 200 MG TABLET - QL Added: 2 / DAY modafinil

PAGE 58 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/01/2021 Medication Name Change Description PV BLOOD PRESSURE MONITOR-MED - Added to Tier 2 blood pressure test kit-medium - QL Added: 1 / 365 DAYS

QC BLOOD PRESSURE MONITOR - Added to Tier 2 blood pressure test kit-medium - QL Added: 1 / 365 DAYS

QELBREE ER 100 MG CAPSULE - QL Added: 1 / DAY viloxazine hcl

QELBREE ER 150 MG CAPSULE - QL Added: 2 / DAY viloxazine hcl

QELBREE ER 200 MG CAPSULE - QL Added: 2 / DAY viloxazine hcl

RA BLOOD PRESSURE MONITOR - Added to Tier 2 blood pressure test kit-medium - QL Added: 1 / 365 DAYS

RELION BP100 MONITOR - Added to Tier 2 blood pressure test kit-large - QL Added: 1 / 365 DAYS

RELION BP200W WRIST MONITOR - Added to Tier 2 blood pressure test kit-wrist - QL Added: 1 / 365 DAYS

SELF-TAKING BLOOD PRESSURE KIT - Added to Tier 2 blood pressure test kit-large - QL Added: 1 / 365 DAYS

SHARPS A GATOR CONTAINER 5 QT - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

SHARPS CONTAINER - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

SHARPS-A-GATOR CONTAINER 1 GAL - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

SHARPSAFETY 18 GAL CONTAINER - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

SHARPSAFETY 2 GALLON CONTAINER - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

SHARPSAFETY 2.2 QT CONTAINER - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

SHARPSAFETY 3 GALLON CONTAINER - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

PAGE 59 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/01/2021 Medication Name Change Description SHARPSAFETY 30 GAL CONTAINER - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

SHARPSAFETY 5 QT CONTAINER - Added to Tier 2 container,empty - QL Added: 1 / 30 DAYS

SM BLOOD PRESSURE MONITOR - Added to Tier 2 blood pressure test kit-medium - QL Added: 1 / 365 DAYS

SM SERIES 600 BP MONITOR - Added to Tier 2 blood pressure test kit-large - QL Added: 1 / 365 DAYS

SURELIFE ARM BP MONITOR - Added to Tier 2 blood pressure test kit-large - QL Added: 1 / 365 DAYS

SURELIFE TALKING WRIST BP MNTR - Added to Tier 2 blood pressure test kit-wrist - QL Added: 1 / 365 DAYS

SURELIFE WRIST BP MONITOR - Added to Tier 2 blood pressure test kit-wrist - QL Added: 1 / 365 DAYS

tacrolimus 0.03 % oint. (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

tacrolimus 0.1 % oint. (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

TEPMETKO 225 MG TABLET - Added to Tier 2 tepotinib hcl - Added: Non-Extended Day Supply - QL Added: 2 / DAY - PA Added: PA APPLIES

thiamine hcl 100 mg/ml vial - Removed From Coverage

tretinoin microspheres 0.04 % gel w/pump - QL Change: 45 / 25 DAYS to 50 / 25 DAYS

tretinoin microspheres 0.1 % gel w/pump - QL Change: 45 / 25 DAYS to 50 / 25 DAYS

0.025 % cream - ST Removed: 2018 HPSM MEDI ST - (g) Tacrolimus Topical

triamcinolone acetonide 0.025 % lotion - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

PAGE 60 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/01/2021 Medication Name Change Description triamcinolone acetonide 0.025 % oint. (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

triamcinolone acetonide 0.1 % cream (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

triamcinolone acetonide 0.1 % lotion - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

triamcinolone acetonide 0.1 % oint. (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

triamcinolone acetonide 0.147mg/g - ST Removed: 2018 HPSM MEDI ST - aerosol Tacrolimus Topical

triamcinolone acetonide 0.5 % cream (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

triamcinolone acetonide 0.5 % oint. (g) - ST Removed: 2018 HPSM MEDI ST - Tacrolimus Topical

verapamil hcl 2.5 mg/ml ampul - Removed From Coverage

verapamil hcl 2.5 mg/ml vial - Removed From Coverage

VERQUVO 10 MG TABLET - QL Added: 1 / DAY vericiguat

VERQUVO 2.5 MG TABLET - QL Added: 1 / DAY vericiguat

VERQUVO 5 MG TABLET - QL Added: 1 / DAY vericiguat

VFEND 200 MG TABLET - QL Added: 2 / DAY voriconazole

VFEND 50 MG TABLET - QL Added: 2 / DAY voriconazole

voriconazole 200 mg tablet - Added to Tier 1 - QL Added: 2 / DAY

voriconazole 200 mg/5ml susp recon - Added to Tier 1

voriconazole 50 mg tablet - Added to Tier 1 - QL Added: 2 / DAY

PAGE 61 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/01/2021 Medication Name Change Description WRIST BLOOD PRESSURE MONITOR - Added to Tier 2 blood pressure test kit-wrist - QL Added: 1 / 365 DAYS

WRIST BP MONITOR 3 SERIES - Added to Tier 2 blood pressure test kit-wrist - QL Added: 1 / 365 DAYS

WRIST BP MONITOR 7 SERIES - Added to Tier 2 blood pressure test kit-wrist - QL Added: 1 / 365 DAYS

XELJANZ 1 MG/ML SOLUTION - Added to Tier 2 tofacitinib citrate - PA Added: PA APPLIES

XELJANZ 10 MG TABLET - Added to Tier 2 tofacitinib citrate - PA Added: PA APPLIES

XELJANZ 5 MG TABLET - Added to Tier 2 tofacitinib citrate - PA Added: PA APPLIES

XELJANZ XR 11 MG TABLET - Added to Tier 2 tofacitinib citrate - PA Added: PA APPLIES

XELJANZ XR 22 MG TABLET - Added to Tier 2 tofacitinib citrate - PA Added: PA APPLIES

ZEGALOGUE 0.6 MG/0.6 ML SYRING - Added to Tier 2 dasiglucagon hcl

ZEGALOGUE 0.6 MG/0.6ML AUTOINJ - Added to Tier 2 dasiglucagon hcl

zoledronic acid/mannitol-water 4 - PA Added: PA APPLIES mg/100ml pggybk btl

PAGE 62 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/02/2021 Medication Name Change Description albuterol sulfate 90 mcg hfa aer ad - QL Added: 0.45 / DAY

DUPIXENT 200 MG/1.14 ML PEN - Added: Specialty Drug dupilumab

EASYTOUCH SAF PEN NDL 30G 6MM - Added to Tier 2 pen needle, diabetic, safety

fentanyl citrate-0.9 % nacl/pf 1000mcg/20 - Added: Non-Extended Day Supply pca syring

fentanyl citrate-0.9 % nacl/pf 250mcg/5ml - Added: Non-Extended Day Supply syringe

mitomycin 40mg/10ml vial - Added to Tier 2 - PA Added: PA APPLIES

omeprazole 20 mg capsule dr - Added to Tier 1

omeprazole magnesium 20 mg capsule dr - Added to Tier 1 - QL Added: 3 / DAY

ONETOUCH ULTRA TEST STRIP - QL Removed: 200 / 30 DAYS blood sugar diagnostic

PANRETIN 0.1% GEL - Added: Non-Extended Day Supply alitretinoin

PAGE 63 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/09/2021 Medication Name Change Description omeprazole magnesium 20 mg capsule dr - QL Change: 3 / DAY to 3 / day(s)

PAGE 64 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/16/2021 Medication Name Change Description AFLURIA QUAD 2021-2022 VIAL - Added to Tier 2 influenza virus vaccine quadrivalent 2021-22 (6 mos and up)

AFLURIA QUAD 2021-22 (3YR UP) - Added to Tier 2 influenza virus vaccine quadrivalent 2021-22 (36 mos up)/pf

AFLURIA QUAD 2021-22 (6-35MO) - Added to Tier 2 influenza virus vaccine quadrival 2021-22 (6 mos- 35 mos)/pf

FLUAD QUAD 2021-2022 SYRINGE - Added to Tier 2 influenza vaccine quadrivalent 2021-22 (65 yr up)/mf59c.1/pf

FLUCELVAX QUAD 2021-2022 SYR - Added to Tier 2 flu vaccine quad 2021-2022(2 years and older)cell derived/pf

FLUCELVAX QUAD 2021-2022 VIAL - Added to Tier 2 flu vaccine quadriv 2021-2022(2 years and older)cell derived

FORTISCARE G1 TEST STRIP - Added: 10 per day for ages under 21 blood sugar diagnostic and on insulin; 5 per day for all others

FORTISCARE T1 BLOOD GLUC SYS - QL Added: 1 / 365 DAYS blood-glucose meter

TRUE COMFORT PRO ALCOHOL PADS - QL Added: 200 / 25 DAYS alcohol antiseptic pads

PAGE 65 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/23/2021 Medication Name Change Description dextrose 50 % in water 50 % iv soln - QL Added: 15 DAYS / 30 DAYS

dextrose 50 % in water 50 % vial - QL Added: 15 DAYS / 30 DAYS

FLUARIX QUAD 2021-2022 SYRINGE - Added to Tier 2 influenza virus vaccine quadrival 2021-2022(6 mos and up)/pf

FLUBLOK QUAD 2021-2022 SYRINGE - Added to Tier 2 influenza virus vaccine qv 2021-22(18 yrs and older)rcmb/pf

FLULAVAL QUAD 2021-2022 SYR - Added to Tier 2 influenza virus vaccine quadrival 2021-2022(6 mos and up)/pf

FLUZONE HIGH-DOSE QUAD 2021-22 - Added to Tier 2 influenza virus vaccine quadrival split 2021-22(65 yr up)/pf

FLUZONE QUAD 2021-2022 SYRINGE - Added to Tier 2 influenza virus vaccine quadrival 2021-2022(6 mos and up)/pf

FLUZONE QUAD 2021-2022 VIAL - Added to Tier 2 influenza virus vaccine quadrival 2021-2022(6 mos and up)/pf

FLUZONE QUAD 2021-2022 VIAL - Added to Tier 2 influenza virus vaccine quadrivalent 2021-22 (6 mos and up)

varenicline tartrate 0.5 mg tablet - QL Added: 2 / DAY

varenicline tartrate 1 mg tablet - QL Added: 2 / DAY

PAGE 66 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 07/30/2021 Medication Name Change Description RELION PREMIER CLASSIC GLU MTR - QL Added: 1 / 365 DAYS blood-glucose meter

XOFLUZA 80 MG TABLET - Added to Tier 2 baloxavir marboxil - QL Added: 1 / 30 DAYS

PAGE 67 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 08/01/2021 Medication Name Change Description AFLURIA QUAD 2020-2021 VIAL - Removed From Coverage influenza virus vaccine quadrivalent 2020-21 (6 mos and up)

AFLURIA QUAD 2020-21 (3YR UP) - Removed From Coverage influenza virus vaccine quadrivalent 2020-21 (36 mos up)/pf

AFLURIA QUAD 2020-21 (6-35MO) - Removed From Coverage influenza virus vaccine quadrival 2020-21 (6 mos- 35 mos)/pf

AIMOVIG 140 MG DOSE-2 AUTOINJ - Removed From Coverage erenumab-aooe

anastrozole 1 mg tablet - Removed: Specialty Drug

ARIMIDEX 1 MG TABLET - Removed: Specialty Drug anastrozole

ASTAGRAF XL 0.5 MG CAPSULE - Removed: Specialty Drug tacrolimus

ASTAGRAF XL 1 MG CAPSULE - Removed: Specialty Drug tacrolimus

ASTAGRAF XL 5 MG CAPSULE - Removed: Specialty Drug tacrolimus

atovaquone 750 mg/5ml oral susp - Removed: Specialty Drug

azathioprine 50 mg tablet - Removed: Specialty Drug

CARAC 0.5% CREAM - Removed: Specialty Drug fluorouracil

CELLCEPT 200 MG/ML ORAL SUSP - Removed: Specialty Drug mycophenolate mofetil

CELLCEPT 250 MG CAPSULE - Removed: Specialty Drug mycophenolate mofetil

CELLCEPT 500 MG TABLET - Removed: Specialty Drug mycophenolate mofetil

CELLCEPT 500 MG VIAL - Removed: Specialty Drug mycophenolate mofetil hcl

cyclosporine 100 mg capsule - Removed: Specialty Drug

PAGE 68 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 08/01/2021 Medication Name Change Description cyclosporine 25 mg capsule - Removed: Specialty Drug

cyclosporine 250 mg/5ml ampul - Removed: Specialty Drug

cyclosporine, modified 100 mg capsule - Removed: Specialty Drug

cyclosporine, modified 100 mg/ml solution - Removed: Specialty Drug

cyclosporine, modified 25 mg capsule - Removed: Specialty Drug

cyclosporine, modified 50 mg capsule - Removed: Specialty Drug

EFUDEX 5% CREAM - Removed: Specialty Drug fluorouracil

enoxaparin sodium 100 mg/ml syringe - Removed: Specialty After 1st Fill

enoxaparin sodium 120mg/.8ml syringe - Removed: Specialty After 1st Fill

enoxaparin sodium 150 mg/ml syringe - Removed: Specialty After 1st Fill

enoxaparin sodium 300mg/3ml vial - Removed: Specialty After 1st Fill

enoxaparin sodium 30mg/0.3ml syringe - Removed: Specialty After 1st Fill

enoxaparin sodium 40mg/0.4ml syringe - Removed: Specialty After 1st Fill

enoxaparin sodium 60mg/0.6ml syringe - Removed: Specialty After 1st Fill

enoxaparin sodium 80mg/0.8ml syringe - Removed: Specialty After 1st Fill

ENVARSUS XR 0.75 MG TABLET - Removed: Specialty Drug tacrolimus

ENVARSUS XR 1 MG TABLET - Removed: Specialty Drug tacrolimus

ENVARSUS XR 4 MG TABLET - Removed: Specialty Drug tacrolimus

everolimus 0.25 mg tablet - Removed: Specialty Drug

everolimus 0.5 mg tablet - Removed: Specialty Drug

everolimus 0.75 mg tablet - Removed: Specialty Drug

PAGE 69 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 08/01/2021 Medication Name Change Description FLUAD 2020-2021 SYRINGE - Removed From Coverage influenza vaccine tvs 2020-21 (65 yr up)/adjuvant mf59c.1/pf

FLUAD QUAD 2020-2021 SYRINGE - Removed From Coverage influenza vaccine quadrivalent 2020-21 (65 yr up)/mf59c.1/pf

FLUARIX QUAD 2020-2021 SYRINGE - Removed From Coverage influenza virus vaccine quadrival 2020-2021(6 mos and up)/pf

FLUBLOK QUAD 2020-2021 SYRINGE - Removed From Coverage influenza virus vaccine qv 2020-21(18 yrs and older)rcmb/pf

FLUCELVAX QUAD 2020-2021 SYR - Removed From Coverage flu vaccine quad 2020-2021(4 years and older)cell derived/pf

FLUCELVAX QUAD 2020-2021 VIAL - Removed From Coverage flu vaccine quadriv 2020-2021(4 years and older)cell derived

FLULAVAL QUAD 2020-2021 SYR - Removed From Coverage influenza virus vaccine quadrival 2020-2021(6 mos and up)/pf

FLUMIST QUAD NASAL 2020-21 VAC - Removed From Coverage influenza vaccine quadrivalent live 2020-2021 (2 yrs-49 yrs)

FLUOROPLEX 1% CREAM - Removed: Specialty Drug fluorouracil

fluorouracil 0.5 % cream (g) - Removed: Specialty Drug

fluorouracil 5 % cream (g) - Removed: Specialty Drug

FLUZONE HIGH-DOSE QUAD 2020-21 - Removed From Coverage influenza virus vaccine quadrival split 2020-21(65 yr up)/pf

FLUZONE QUAD 2020-2021 SYRINGE - Removed From Coverage influenza virus vaccine quadrival 2020-2021(6 mos and up)/pf

FLUZONE QUAD 2020-2021 VIAL - Removed From Coverage influenza virus vaccine quadrival 2020-2021(6 mos and up)/pf

PAGE 70 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 08/01/2021 Medication Name Change Description FLUZONE QUAD 2020-2021 VIAL - Removed From Coverage influenza virus vaccine quadrivalent 2020-21 (6 mos and up)

HUMALOG 100 UNIT/ML KWIKPEN - Removed From Coverage insulin lispro

HUMALOG 100 UNIT/ML VIAL - Removed From Coverage insulin lispro

HUMALOG JR 100 UNIT/ML KWIKPEN - Removed From Coverage insulin lispro

HUMALOG MIX 75-25 KWIKPEN - Removed From Coverage insulin lispro protamine and insulin lispro

IMURAN 50 MG TABLET - Removed: Specialty Drug azathioprine

10 mg/ml solution - Removed: Specialty Drug

itraconazole 100 mg capsule - Removed: Specialty Drug

LOVENOX 100 MG/ML SYRINGE - Removed: Specialty After 1st Fill enoxaparin sodium

LOVENOX 120 MG/0.8 ML SYRINGE - Removed: Specialty After 1st Fill enoxaparin sodium

LOVENOX 150 MG/ML SYRINGE - Removed: Specialty After 1st Fill enoxaparin sodium

LOVENOX 30 MG/0.3 ML SYRINGE - Removed: Specialty After 1st Fill enoxaparin sodium

LOVENOX 300 MG/3 ML VIAL - Removed: Specialty After 1st Fill enoxaparin sodium

LOVENOX 40 MG/0.4 ML SYRINGE - Removed: Specialty After 1st Fill enoxaparin sodium

LOVENOX 60 MG/0.6 ML SYRINGE - Removed: Specialty After 1st Fill enoxaparin sodium

LOVENOX 80 MG/0.8 ML SYRINGE - Removed: Specialty After 1st Fill enoxaparin sodium

MEPRON 750 MG/5 ML SUSPENSION - Removed: Specialty Drug atovaquone

PAGE 71 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 08/01/2021 Medication Name Change Description mineral oil/petrolatum,white 15 %-83 % - Added to Tier 1 oint. (g) - ST Added: 2018 HPSM MEDI ST - Cyclosporine Eye Drops

mycophenolate mofetil 200 mg/ml susp - Removed: Specialty Drug recon

mycophenolate mofetil 250 mg capsule - Removed: Specialty Drug

mycophenolate mofetil 500 mg tablet - Removed: Specialty Drug

mycophenolate mofetil hcl 500 mg vial - Removed: Specialty Drug

mycophenolate sodium 180 mg tablet dr - Removed: Specialty Drug

mycophenolate sodium 360 mg tablet dr - Removed: Specialty Drug

MYFORTIC 180 MG TABLET - Removed: Specialty Drug mycophenolate sodium

MYFORTIC 360 MG TABLET - Removed: Specialty Drug mycophenolate sodium

NEORAL 100 MG GELATIN CAPSULE - Removed: Specialty Drug cyclosporine, modified

NEORAL 100 MG/ML SOLUTION - Removed: Specialty Drug cyclosporine, modified

NEORAL 25 MG GELATIN CAPSULE - Removed: Specialty Drug cyclosporine, modified

norelgestromin/ethin.estradiol 150-35/24h - Added to Tier 1 patch tdwk

NOVOLOG 100 UNIT/ML CARTRIDGE - Removed From Coverage insulin aspart

NOVOLOG 100 UNIT/ML FLEXPEN - Removed From Coverage insulin aspart

NOVOLOG 100 UNIT/ML VIAL - Removed From Coverage insulin aspart

NOVOLOG MIX 70-30 FLEXPEN - Removed From Coverage insulin aspart protamine human/insulin aspart

PAGE 72 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 08/01/2021 Medication Name Change Description NOVOLOG MIX 70-30 VIAL - Removed From Coverage insulin aspart protamine human/insulin aspart

NOXAFIL 300 MG/16.7 ML VIAL - Removed: Specialty Drug posaconazole

NOXAFIL 40 MG/ML SUSPENSION - Removed: Specialty Drug posaconazole

NOXAFIL DR 100 MG TABLET - Removed: Specialty Drug posaconazole

NULOJIX 250 MG VIAL - Removed: Specialty Drug belatacept

ONMEL 200 MG TABLET - Removed: Specialty Drug itraconazole

posaconazole 100 mg tablet dr - Removed: Specialty Drug

posaconazole 200 mg/5ml oral susp - Removed: Specialty Drug

PREVNAR 20 SYRINGE - Added to Tier 2 pneumococcal 20-valent conjugate vaccine - AL Added: 19 to 999 yrs old (diphtheria crm)/pf

PROGRAF 0.5 MG CAPSULE - Removed: Specialty Drug tacrolimus

PROGRAF 1 MG CAPSULE - Removed: Specialty Drug tacrolimus

PROGRAF 5 MG CAPSULE - Removed: Specialty Drug tacrolimus

PROGRAF 5 MG/ML AMPULE - Removed: Specialty Drug tacrolimus

RAPAMUNE 0.5 MG TABLET - Removed: Specialty Drug sirolimus

RAPAMUNE 1 MG TABLET - Removed: Specialty Drug sirolimus

RAPAMUNE 1 MG/ML ORAL SOLN - Removed: Specialty Drug sirolimus

RAPAMUNE 2 MG TABLET - Removed: Specialty Drug sirolimus

PAGE 73 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 08/01/2021 Medication Name Change Description RELION NOVOLOG 100 UNIT/ML VL - Removed From Coverage insulin aspart

RELION NOVOLOG MIX 70-30 FLXPN - Removed From Coverage insulin aspart protamine human/insulin aspart

RELION NOVOLOG MIX 70-30 VIAL - Removed From Coverage insulin aspart protamine human/insulin aspart

RELION NOVOLOG U-100 FLEXPEN - Removed From Coverage insulin aspart

SANDIMMUNE 100 MG CAPSULE - Removed: Specialty Drug cyclosporine

SANDIMMUNE 100 MG/ML SOLN - Removed: Specialty Drug cyclosporine

SANDIMMUNE 25 MG CAPSULE - Removed: Specialty Drug cyclosporine

SANDIMMUNE 50 MG/ML AMPUL - Removed: Specialty Drug cyclosporine

sirolimus 0.5 mg tablet - Removed: Specialty Drug

sirolimus 1 mg tablet - Removed: Specialty Drug

sirolimus 1 mg/ml solution - Removed: Specialty Drug

sirolimus 2 mg tablet - Removed: Specialty Drug

SPORANOX 10 MG/ML SOLUTION - Removed: Specialty Drug itraconazole

SPORANOX 100 MG CAPSULE - Removed: Specialty Drug itraconazole

tacrolimus 0.5 mg capsule - Removed: Specialty Drug

tacrolimus 1 mg capsule - Removed: Specialty Drug

tacrolimus 5 mg capsule - Removed: Specialty Drug

TOLSURA 65 MG CAPSULE - Removed: Specialty Drug itraconazole

PAGE 74 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 08/01/2021 Medication Name Change Description VALCYTE 450 MG TABLET - Removed: Specialty Drug valganciclovir hcl

VALCYTE 50 MG/ML SOLUTION - Removed: Specialty Drug valganciclovir hcl

valganciclovir hcl 450 mg tablet - Removed: Specialty Drug

valganciclovir hcl 50 mg/ml soln recon - Removed: Specialty Drug

VFEND 200 MG TABLET - Removed: Specialty Drug voriconazole

VFEND 40 MG/ML SUSPENSION - Removed: Specialty Drug voriconazole

VFEND 50 MG TABLET - Removed: Specialty Drug voriconazole

VFEND IV 200 MG VIAL - Removed: Specialty Drug voriconazole

voriconazole 200 mg tablet - Removed: Specialty Drug

voriconazole 200 mg vial - Removed: Specialty Drug

voriconazole 200 mg/5ml susp recon - Removed: Specialty Drug

voriconazole 50 mg tablet - Removed: Specialty Drug

XIFAXAN 200 MG TABLET - Removed: Specialty Drug rifaximin

XIFAXAN 550 MG TABLET - Removed: Specialty Drug rifaximin

XOLAIR 150 MG/1.2 ML POWDER VL - QL Change: 6 / 28 DAYS to 8 / 28 DAYS omalizumab

XOLAIR 150 MG/ML SYRINGE - QL Change: 6 / 28 DAYS to 8 / 28 DAYS omalizumab

XOLAIR 75 MG/0.5 ML SYRINGE - QL Change: 10 / 28 DAYS to 2 / 28 omalizumab DAYS

ZORTRESS 0.25 MG TABLET - Removed: Specialty Drug everolimus

PAGE 75 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 08/01/2021 Medication Name Change Description ZORTRESS 0.5 MG TABLET - Removed: Specialty Drug everolimus

ZORTRESS 0.75 MG TABLET - Removed: Specialty Drug everolimus

ZORTRESS 1 MG TABLET - Removed: Specialty Drug everolimus

PAGE 76 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 08/06/2021 Medication Name Change Description CARETOUCH PEN NEEDLE 29G 12MM - Added to Tier 2 pen needle, diabetic

cholestyramine/aspartame 4 g powd pack - Added to Tier 1

FLUMIST QUAD NASAL 2021-22 VAC - Added to Tier 2 influenza vaccine quadrivalent live 2021-2022 (2 yrs-49 yrs)

PAGE 77 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 08/13/2021 Medication Name Change Description hcl 100 mg/ml oral conc - Added to Tier 1

chlorpromazine hcl 30 mg/ml oral conc - Added to Tier 1

PAGE 78 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 08/15/2021 Medication Name Change Description ASTRAZENECA COVID19 VAC(UNAPP) - QL Removed: 1 / 180 DAYS covid-19 vaccine, azd-1222 (astrazeneca)/pf

JANSSEN COVID-19 VACCINE (EUA) - QL Removed: 0.5 / 180 DAYS covid-19 vac, ad26.cov2.s (janssen)/pf

MODERNA COVID-19 VACCINE (EUA) - QL Removed: 1 / 180 DAYS covid-19 vaccine, mrna-1273, lnp-s (moderna)/pf

NOVAVAX COVID19 VAC,ADJ(UNAPP) - QL Removed: 1 / 180 DAYS covid-19 vaccine, nvx-cov2373 (novavax)/adjuvant-matrix/pf

PFIZER COVID-19 VACCINE (EUA) - QL Removed: 0.6 / 180 DAYS covid-19 vaccine, mrna, bnt162b2, lnp-s (pfizer)/pf

PAGE 79 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 08/19/2021 Medication Name Change Description XELJANZ 1 MG/ML SOLUTION - Removed From Coverage tofacitinib citrate - PA Removed: PA APPLIES

XELJANZ 10 MG TABLET - Removed From Coverage tofacitinib citrate - PA Removed: PA APPLIES

XELJANZ 5 MG TABLET - Removed From Coverage tofacitinib citrate - PA Removed: PA APPLIES

XELJANZ XR 11 MG TABLET - Removed From Coverage tofacitinib citrate - PA Removed: PA APPLIES

XELJANZ XR 22 MG TABLET - Removed From Coverage tofacitinib citrate - PA Removed: PA APPLIES

PAGE 80 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 08/20/2021 Medication Name Change Description levonorgestrel 1.5 mg tablet - Added to Tier 1

norethindrone-e.estradiol-iron 1mg-20(24) - Added to Tier 1 capsule

UNISTIK NORMAL 23G LANCETS - Added to Tier 2 lancets - QL Removed: 1 / 180 DAYS - Added: 10 per day for ages under 21 and on insulin; 7 per day for all others

PAGE 81 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 08/27/2021 Medication Name Change Description buprenorphine hcl 150 mcg film - Added: Non-Extended Day Supply

buprenorphine hcl 300 mcg film - Added: Non-Extended Day Supply

buprenorphine hcl 450 mcg film - Added: Non-Extended Day Supply

buprenorphine hcl 600 mcg film - Added: Non-Extended Day Supply

buprenorphine hcl 750 mcg film - Added: Non-Extended Day Supply

buprenorphine hcl 900 mcg film - Added: Non-Extended Day Supply

COMFORT TOUCH PEN NDL 31G 5MM - Added to Tier 2 pen needle, diabetic

COMFORT TOUCH PEN NDL 31G 6MM - Added to Tier 2 pen needle, diabetic

COMFORT TOUCH PEN NDL 31G 8MM - Added to Tier 2 pen needle, diabetic

COMFORT TOUCH PEN NDL 32G 4MM - Added to Tier 2 pen needle, diabetic

COMFORT TOUCH PEN NDL 32G 5MM - Added to Tier 2 pen needle, diabetic

COMFORT TOUCH PEN NDL 32G 6MM - Added to Tier 2 pen needle, diabetic

COMFORT TOUCH PEN NDL 32G 8MM - Added to Tier 2 pen needle, diabetic

dextroamphetamine sulfate 15 mg tablet - Added to Tier 1 - QL Added: 4 / DAY - AL Added: 4 to 21 yrs old

dextroamphetamine sulfate 20 mg tablet - Added to Tier 1 - QL Added: 4 / DAY - AL Added: 4 to 21 yrs old

dextroamphetamine sulfate 30 mg tablet - Added to Tier 1 - QL Added: 4 / DAY - AL Added: 4 to 21 yrs old

icatibant acetate 30 mg/3 ml syringe - Added: Specialty Drug

PAGE 82 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 08/27/2021 Medication Name Change Description sunitinib malate 12.5 mg capsule - Added: Non-Extended Day Supply - PA Added: PA APPLIES - QL Added: 1 / DAY

sunitinib malate 25 mg capsule - Added: Non-Extended Day Supply - QL Added: 1 / DAY

sunitinib malate 37.5 mg capsule - Added: Non-Extended Day Supply - QL Added: 1 / DAY

sunitinib malate 50 mg capsule - Added: Non-Extended Day Supply - QL Added: 1 / DAY

SUTENT 12.5 MG CAPSULE - Removed From Coverage sunitinib malate

SUTENT 25 MG CAPSULE - Removed From Coverage sunitinib malate

SUTENT 37.5 MG CAPSULE - Removed From Coverage sunitinib malate

SUTENT 50 MG CAPSULE - Removed From Coverage sunitinib malate

ZENZEDI 15 MG TABLET - Removed From Coverage dextroamphetamine sulfate

ZENZEDI 20 MG TABLET - Removed From Coverage dextroamphetamine sulfate

ZENZEDI 30 MG TABLET - Removed From Coverage dextroamphetamine sulfate

PAGE 83 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 09/01/2021 Medication Name Change Description CARETOUCH WRIST BP MONITOR - Removed From Coverage blood pressure test kit-wrist - QL Removed: 1 / 365 DAYS

dimethyl fumarate 120 mg capsule dr - Added: Specialty Drug

dimethyl fumarate 120-240 mg capsule dr - Added: Specialty Drug

dimethyl fumarate 240 mg capsule dr - Added: Specialty Drug

INCONTROL ADVNCED WRST BP - Removed From Coverage MNTR - QL Removed: 1 / 365 DAYS blood pressure test kit-wrist

INCONTROL PREMIUM WRST BP - Removed From Coverage MNTR - QL Removed: 1 / 365 DAYS blood pressure test kit-wrist

KLOR-CON M15 TABLET - Removed From Coverage potassium chloride

miconazole nitrate 200 mg-2 % cmb pf - Added to Tier 1 crm

PNEUMOVAX 23 VIAL - QL Removed: 1 / 365 DAYS pneumococcal 23-valent polysaccharide vaccine

PROCARE WRIST BP MONITOR - Removed From Coverage blood pressure test kit-wrist - QL Removed: 1 / 365 DAYS

RELION BP200W WRIST MONITOR - Removed From Coverage blood pressure test kit-wrist - QL Removed: 1 / 365 DAYS

SURELIFE TALKING WRIST BP MNTR - Removed From Coverage blood pressure test kit-wrist - QL Removed: 1 / 365 DAYS

SURELIFE WRIST BP MONITOR - Removed From Coverage blood pressure test kit-wrist - QL Removed: 1 / 365 DAYS

TECFIDERA DR 120 MG CAPSULE - Added: Specialty Drug dimethyl fumarate

TECFIDERA DR 240 MG CAPSULE - Added: Specialty Drug dimethyl fumarate

TECFIDERA STARTER PACK - Added: Specialty Drug dimethyl fumarate

PAGE 84 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 09/01/2021 Medication Name Change Description VAXNEUVANCE 0.5 ML SYRINGE - Added to Tier 2 pneumococcal 15-valent conjugate vaccine - AL Added: 19 to 999 yrs old (diphtheria crm)/pf

WRIST BLOOD PRESSURE MONITOR - Removed From Coverage blood pressure test kit-wrist - QL Removed: 1 / 365 DAYS

WRIST BP MONITOR 3 SERIES - Removed From Coverage blood pressure test kit-wrist - QL Removed: 1 / 365 DAYS

WRIST BP MONITOR 7 SERIES - Removed From Coverage blood pressure test kit-wrist - QL Removed: 1 / 365 DAYS

XOFLUZA 40 MG TAB (80 MG DOSE) - QL Removed: 2 / 30 DAYS baloxavir marboxil

XOFLUZA 40 MG TABLET - QL Change: 2 / 30 DAYS to 1 / 30 DAYS baloxavir marboxil

PAGE 85 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 09/03/2021 Medication Name Change Description ADVOCATE ALCOHOL 70% PREP - QL Change: 200 / 25 DAYS to 200 / 25 PADS day(s) alcohol antiseptic pads

ALCOHOL 70% PREP PADS - QL Change: 200 / 25 DAYS to 200 / 25 alcohol antiseptic pads day(s)

ALCOHOL PREP PADS - QL Change: 200 / 25 DAYS to 200 / 25 alcohol antiseptic pads day(s)

COMFORT TOUCH PEN NDL 31G 4MM - Added to Tier 2 pen needle, diabetic

CVS ALCOHOL 70% PREP PADS - QL Change: 200 / 25 DAYS to 200 / 25 alcohol antiseptic pads day(s)

FIFTY50 ALCOHOL PREP PADS - QL Change: 200 / 25 DAYS to 200 / 25 alcohol antiseptic pads day(s)

HM ALCOHOL 70% PREP PADS - QL Change: 200 / 25 DAYS to 200 / 25 alcohol antiseptic pads day(s)

KENDALL ALCOHOL 70% PREP PAD - QL Change: 200 / 25 DAYS to 200 / 25 alcohol antiseptic pads day(s)

KRO ALCOHOL 70% PREP PADS - QL Change: 200 / 25 DAYS to 200 / 25 alcohol antiseptic pads day(s)

miconazole nitrate 200 mg-2 % cmb pf - Added to Tier 1 crm

oxycodone hcl/acetaminophen 10mg- - QL Change: 120 / 30 DAYS to 120 / 30 300mg tablet day(s)

oxycodone hcl/acetaminophen 5 mg- - QL Change: 120 / 30 DAYS to 120 / 30 300mg tablet day(s)

PHARM CHOICE ALCOHOL PREP - QL Change: 200 / 25 DAYS to 200 / 25 PADS day(s) alcohol antiseptic pads

SAPS ALCOHOL 70% PREP PADS - QL Change: 200 / 25 DAYS to 200 / 25 alcohol antiseptic pads day(s)

SM ALCOHOL 70% PREP PADS - QL Change: 200 / 25 DAYS to 200 / 25 alcohol antiseptic pads day(s)

PAGE 86 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 09/03/2021 Medication Name Change Description SM ALCOHOL PREP PADS - QL Change: 200 / 25 DAYS to 200 / 25 alcohol antiseptic pads day(s)

TOSYMRA 10 MG NASAL SPRAY - QL Added: 12 / 30 DAYS sumatriptan

TRUE CMFRT PRO 0.5ML 31G 5/16" - Added to Tier 2 syringe with needle,insulin,0.5 ml

TRUE CMFRT PRO 0.5ML 32G 5/16" - Added to Tier 2 syringe with needle,insulin,0.5 ml

TRUE COMFORT PRO 1 ML 30G 1/2" - Added to Tier 2 syringe with needle,disposable,insulin 1 ml

TRUE COMFORT PRO 1ML 30G 5/16" - Added to Tier 2 syringe with needle,disposable,insulin 1 ml

TRUE COMFORT PRO 1ML 31G 5/16" - Added to Tier 2 syringe with needle,disposable,insulin 1 ml

TRUE COMFORT PRO 1ML 32G 5/16" - Added to Tier 2 syringe with needle,disposable,insulin 1 ml

TRUE METRIX BLOOD GLUCOSE MTR - QL Added: 1 / 365 DAYS blood-glucose meter

PAGE 87 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 09/10/2021 Medication Name Change Description TRUE CMFRT PRO 0.5ML 30G 5/16" - Added to Tier 2 syringe with needle,insulin,0.5 ml

TRUE COMFRT PRO 0.5ML 30G 1/2" - Added to Tier 2 syringe with needle,insulin,0.5 ml

PAGE 88 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 09/13/2021 Medication Name Change Description ADIPEX-P 37.5 MG TABLET - Added: Non-Extended Day Supply phentermine hcl - QL Added: 1 / DAY

ALLI 60 MG CAPSULE - PA Removed: PA APPLIES orlistat

CONTRAVE ER 8-90 MG TABLET - Added to Tier 2 naltrexone hcl/bupropion hcl - Added: Non-Extended Day Supply - PA Added: PA APPLIES - QL Added: 1 / DAY

diethylpropion hcl 25 mg tablet - PA Removed: PA APPLIES

diethylpropion hcl 75 mg tablet er - PA Removed: PA APPLIES

phentermine hcl 15 mg capsule - PA Removed: PA APPLIES

phentermine hcl 30 mg capsule - PA Removed: PA APPLIES

phentermine hcl 37.5 mg capsule - PA Removed: PA APPLIES - Added: Non-Extended Day Supply - QL Added: 1 / DAY

phentermine hcl 37.5 mg tablet - PA Removed: PA APPLIES

phentermine hcl 8 mg tablet - Added to Tier 2 - QL Added: 3 / DAY - Added: Non-Extended Day Supply - PA Added: PA APPLIES

QSYMIA 11.25 MG-69 MG CAPSULE - Added to Tier 2 phentermine hcl/ - Added: Non-Extended Day Supply - PA Added: PA APPLIES - QL Added: 1 / DAY

QSYMIA 15 MG-92 MG CAPSULE - Added to Tier 2 phentermine hcl/topiramate - Added: Non-Extended Day Supply - PA Added: PA APPLIES - QL Added: 1 / DAY

QSYMIA 3.75 MG-23 MG CAPSULE - Added to Tier 2 phentermine hcl/topiramate - Added: Non-Extended Day Supply - PA Added: PA APPLIES - QL Added: 1 / DAY

PAGE 89 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 09/13/2021 Medication Name Change Description QSYMIA 7.5 MG-46 MG CAPSULE - Added to Tier 2 phentermine hcl/topiramate - Added: Non-Extended Day Supply - PA Added: PA APPLIES - QL Added: 1 / DAY

WEGOVY 0.25 MG/0.5 ML PEN - Added to Tier 2 semaglutide - Added: Non-Extended Day Supply - PA Added: PA APPLIES - QL Added: 0.08 / DAY

WEGOVY 0.5 MG/0.5 ML PEN - Added to Tier 2 semaglutide - Added: Non-Extended Day Supply - PA Added: PA APPLIES - QL Added: 0.08 / DAY

WEGOVY 1 MG/0.5 ML PEN - Added to Tier 2 semaglutide - Added: Non-Extended Day Supply - PA Added: PA APPLIES - QL Added: 0.08 / DAY

WEGOVY 1.7 MG/0.75 ML PEN - Added to Tier 2 semaglutide - Added: Non-Extended Day Supply - QL Added: 0.11 / DAY - PA Added: PA APPLIES

WEGOVY 2.4 MG/0.75 ML PEN - Added to Tier 2 semaglutide - Added: Non-Extended Day Supply - QL Added: 0.11 / DAY - PA Added: PA APPLIES

PAGE 90 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 09/17/2021 Medication Name Change Description STIMATE 1.5 MG/ML NASAL SPRAY - Removed From Coverage desmopressin acetate

PAGE 91 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 09/24/2021 Medication Name Change Description ALAVERT 10 MG ODT - Added to Tier 1 loratadine

difluprednate 0.05 % drops - QL Added: 10 / 30 DAYS

DUREZOL 0.05% EYE DROPS - Removed From Coverage difluprednate

lidocaine 4 % adh. patch - Added to Tier 1 - QL Added: 3 / DAY

PAGE 92 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021 EFFECTIVE 10/01/2021 Medication Name Change Description FORA BLOOD GLUCOSE TEST STRIP - Removed From Coverage blood sugar diagnostic

PAGE 93 Formulary ID: Version 1 Last Updated: 09/24/2021 Effective Date 09/24/2021