Summary of Formulary Changes Effective Date Affected Drugs Description of Change
May 1st, 2021 HUMULIN N 100 UNIT/ML KWIKPEN • Removed from formulary
May 1st, 2021 LEVEMIR 100 UNIT/ML VIAL • Removed from formulary
May 1st, 2021 SEMGLEE 100 UNIT/ML VIAL • Added to formulary
May 1st, 2021 SEMGLEE 100 UNIT/ML PEN • Added to formulary
May 1st, 2021 TYDEMY TABLET • Removed from formulary
May 1st, 2021 TAYTULLA 1 MG-20 MCG CAPSULE • Removed from formulary
st • May 1 , 2021 LO LOESTRIN FE 1-10 TABLET Removed from formulary
May 1st, 2021 SLYND 4 MG TABLET • Removed from formulary
May 1st, 2021 ANNOVERA VAGINAL RING • Removed from formulary
May 1st, 2021 NATAZIA 28 TABLET • Removed from formulary
May 1st, 2021 OGESTREL TABLET • Removed from formulary
May 1st, 2021 NORETH-ESTRAD-FE 1-0.02(24)-75 • Removed from formulary
May 1st, 2021 GEMMILY 1 MG-20 MCG CAPSULE • Removed from formulary
May 1st, 2021 MERZEE 1 MG-20 MCG CAPSULE • Removed from formulary
PA= Prior Authorization; ST= Step Therapy; QL= Quantity Limit; AR= Age Restriction
Summary of Formulary Changes
Effective Date Affected Drugs Description of Change
May 1st, 2021 BALCOLTRA TABLET • Removed from formulary
May 1st, 2021 ECONTRA ONE-STEP 1.5 MG TABLET • Added QL #1/30 days
st May 1 , 2021 NEW DAY 1.5 MG TABLET • Added QL #1/30 days
May 1st, 2021 PLAN B ONE-STEP 1.5 MG TABLET • Added QL #1/30 days
May 1st, 2021 DEPO-SUBQ PROVERA 104 SYRINGE • Removed from formulary, Added QL #0.65ml/90 days
May 1st, 2021 NEXPLANON 68 MG IMPLANT • Removed from formulary
May 1st, 2021 ICATIBANT 30 MG/3 ML SYRINGE • Added to formulary with PA and QL #9ml/30 days
May 1st, 2021 FIRAZYR 30 MG/3 ML SYRINGE • Added PA and QL #9ml/30 days
May 1st, 2021 CINRYZE 500 UNIT VIAL • Added PA
May 1st, 2021 BERINERT 500 UNIT KIT • Added PA
May 1st, 2021 RUCONEST 2,100 UNIT VIAL • Added PA and QL #4vials/30 days
May 1st, 2021 KALBITOR 10 MG/ML VIAL • Added PA and QL #9ml/30 days
May 1st, 2021 TAKHZYRO 300 MG/2 ML VIAL • Added PA and QL #4ml/28 days
May 1st, 2021 ORLADEYO 150 MG CAPSULE • Added PA and QL #28/28
PA= Prior Authorization; ST= Step Therapy; QL= Quantity Limit; AR= Age Restriction
Summary of Formulary Changes
Effective Date Affected Drugs Description of Change
May 1st, 2021 ORGOVYX 120 MG TABLET • Added PA, added QL #30/30 days
July 1st, 2021 HUMALOG MIX 50-50 KWIKPEN • Removed from formulary
July 1st, 2021 HUMALOG MIX 50-50 VIAL • Removed from formulary
July 1st, 2021 HUMALOG MIX 75-25 KWIKPEN • Removed from formulary
July 1st, 2021 HUMALOG MIX 75-25 VIAL • Removed from formulary
July 1st, 2021 HUMULIN 70/30 KWIKPEN • Removed from formulary
July 1st, 2021 INSULIN ASPART 100 UNIT/ML PEN • Removed from formulary
July 1st, 2021 INSULIN ASPART 100 UNIT/ML VL • Removed from formulary
July 1st, 2021 INSULIN ASPART PROT (MIX70-30) • Removed from formulary
July 1st, 2021 INSULIN ASPART PROT (MIX70-30) • Removed from formulary
July 1st, 2021 INSULIN LISPRO 100 UNIT/ML PEN • Removed from formulary
July 1st, 2021 INSULIN LISPRO 100 UNIT/ML VL • Removed from formulary
July 1st, 2021 NOVOLIN 70-30 FLEXPEN • Removed from formulary
PA= Prior Authorization; ST= Step Therapy; QL= Quantity Limit; AR= Age Restriction