Summary of Formulary Changes Effective Date Affected ......PA= Prior Authorization; ST= Step Therapy; QL= Quantity Limit; AR= Age Restriction October 1 Summary of Formulary Changes

PA= Prior Authorization; ST= Step Therapy; QL= Quantity Limit; AR= Age Restriction

Summary of Formulary Changes

Effective Date Affected Drugs Description of Change

October 1st, 2020 HYDROXYCHLOROQUINE 200 MG TAB • Removal of PA

October 1st, 2020 CHLOROQUINE PH 250 MG TABLET • Removal of PA

October 1st, 2020 CHLOROQUINE PH 500 MG TABLET • Removal of PA

October 1st, 2020 BUDESONIDE ER 9 MG TABLET • Update QL 60 tablets/180 days

November 1st, 2020 QUINIDINE GLUC 80 MG/ML VIAL • Removal from formulary

November 1st, 2020 ZINECARD 250 MG VIAL • Removal from formulary

November 1st, 2020 ZINECARD 500 MG VIAL • Removal from formulary

November 1st, 2020 BICNU 100 MG VIAL • Removal from formulary

November 1st, 2020 INFED 100 MG/2 ML VIAL • Removal from formulary

November 1st, 2020 PREMARIN 25 MG VIAL • Removal from formulary

November 1st, 2020 ALBUMINAR-25 IV SOLUTION • Removal from formulary

November 1st, 2020 DOXORUBICIN 10 MG/5 ML VIAL • Removal from formulary







November 1st, 2020 DESFERAL 2 GRAM VIAL • Removal from formulary

November 1st, 2020 DESFERAL MESYLATE 500 MG VL • Removal from formulary

November 1st, 2020 BLEOMYCIN SULFATE 15 UNIT VIAL • Removal from formulary

November 1st, 2020 BLEOMYCIN SULFATE 30 UNIT VIAL • Removal from formulary

November 1st, 2020 DEXRAZOXANE 250 MG VIAL • Removal from formulary

November 1st, 2020 DEXRAZOXANE 500 MG VIAL • Removal from formulary

November 1st, 2020 CEFAZOLIN 1 GM VIAL • Removal from formulary

November 1st, 2020 MITOMYCIN 20 MG VIAL • Removal from formulary

November 1st, 2020 THIOTEPA 15 MG VIAL • Removal from formulary

November 1st, 2020 LEUCOVORIN CALCIUM 200 MG VIAL • Removal from formulary

November 1st, 2020 ADRIAMYCIN 10 MG/5 ML VIAL • Removal from formulary







November 1st, 2020 ETOPOSIDE 100 MG/5 ML VIAL • Removal from formulary

November 1st, 2020 CISPLATIN 50 MG/50 ML VIAL • Removal from formulary

November 1st, 2020 DAUNORUBICIN 50 MG/10 ML VIAL • Removal from formulary




November 1st, 2020 GLYCOPYRROLATE 4 MG/20 ML VIAL • Removal from formulary

November 1st, 2020 CEFTRIAXONE 10 GM VIAL • Removal from formulary

November 1st, 2020 GRANISETRON HCL 1 MG/ML VIAL • Removal from formulary



November 1st, 2020 CEFTRIAXONE 500 MG VIAL • Removal from formulary

November 1st, 2020 CEFTRIAXONE 250 MG VIAL • Removal from formulary




November 1st, 2020 ONDANSETRON 40 MG/20 ML VIAL • Removal from formulary

November 1st, 2020 ONDANSETRON HCL 4 MG/2 ML VIAL • Removal from formulary

November 1st, 2020 CEFAZOLIN 500 MG VIAL • Removal from formulary

November 1st, 2020 ZOFRAN 2 MG/ML VIAL • Removal from formulary

November 1st, 2020 SODIUM CHLORIDE 0.9% SOLUTION • Removal from formulary

November 1st, 2020 POTASSIUM CL 2 MEQ/ML CONC • Removal from formulary

November 1st, 2020 METRO IV 500 MG/100 ML • Removal from formulary

November 1st, 2020 STERILE WATER FOR INJECTION • Removal from formulary

November 1st, 2020 MANNITOL 20% IV SOLUTION • Removal from formulary

November 1st, 2020 D5%-1/2NS-KCL 10 MEQ/L IV SOL • Removal from formulary

November 1st, 2020 KCL 20 MEQ IN D5W-0.45% NACL • Removal from formulary







November 1st, 2020 KCL 20 MEQ IN D5W-NS • Removal from formulary


November 1st, 2020 SALINE 0.45% SOLN-EXCEL CON • Removal from formulary

November 1st, 2020 SODIUM CHLORIDE 3% IV SOLN • Removal from formulary

November 1st, 2020 SODIUM CHLORIDE 5% IV SOLN • Removal from formulary

November 1st, 2020 KCL 20 MEQ-NS 1,000 ML IV SOLN • Removal from formulary

November 1st, 2020 DOXIL 20 MG/10 ML VIAL • Removal from formulary

November 1st, 2020 OSMITROL 10% IV SOLUTION • Removal from formulary

November 1st, 2020 OSMITROL 20% IV SOLUTION • Removal from formulary

November 1st, 2020 SODIUM CHLORIDE 0.9% SOLUTION • Removal from formulary

November 1st, 2020 POTASSIUM CL 20 MEQ/50 ML SOL • Removal from formulary








November 1st, 2020 KCL 40 MEQ IN D5W-NACL 0.9% • Removal from formulary

November 1st, 2020 METRONIDAZOLE 500 MG/100 ML • Removal from formulary

November 1st, 2020 IFEX 1 GM VIAL • Removal from formulary

November 1st, 2020 SODIUM CHLORIDE 0.9% VIAL • Removal from formulary

November 1st, 2020 ONDANSETRON 4 MG/2 ML ISECURE • Removal from formulary

November 1st, 2020 SODIUM CHLORIDE 4 MEQ/ML VL • Removal from formulary

November 1st, 2020 GENTAMICIN 80 MG/2 ML VIAL • Removal from formulary

November 1st, 2020 ATROPINE 1 MG/10 ML SYRINGE • Removal from formulary

November 1st, 2020 CALCIUM CHLORIDE 10% SYRINGE • Removal from formulary

November 1st, 2020 FUROSEMIDE 100 MG/10 ML SYRING • Removal from formulary

November 1st, 2020 PROCAINAMIDE 1,000 MG/10 ML VL • Removal from formulary

November 1st, 2020 PROCAINAMIDE 500 MG/ML VIAL • Removal from formulary

November 1st, 2020 BACTERIOSTATIC SALINE VIAL • Removal from formulary




November 1st, 2020 DESMOPRESSIN AC 4 MCG/ML AMP • Removal from formulary

November 1st, 2020 CORLOPAM 10 MG/ML AMPUL • Removal from formulary

November 1st, 2020 DEFEROXAMINE 500 MG VIAL • Removal from formulary

November 1st, 2020 DEFEROXAMINE 2 GRAM VIAL • Removal from formulary

November 1st, 2020 POTASSIUM ACET 100 MEQ/50 ML • Removal from formulary

November 1st, 2020 METOCLOPRAMIDE 10 MG/2 ML VIAL • Removal from formulary

November 1st, 2020 BACTERIOSTATIC WATER VIAL • Removal from formulary

November 1st, 2020 WATER FOR INJECTION AMPUL • Removal from formulary

November 1st, 2020 MANNITOL 25% VIAL • Removal from formulary

November 1st, 2020 ZINC CHLORIDE 10 MG/10 ML VIAL • Removal from formulary

November 1st, 2020 AMINOCAPROIC ACID 5 G/20 ML VL • Removal from formulary

November 1st, 2020 AMINOPHYLLINE 250 MG/10 ML VL • Removal from formulary

November 1st, 2020 AMINOPHYLLINE 500 MG/20 ML VL • Removal from formulary

November 1st, 2020 SODIUM CHLORIDE 50 MEQ/20 ML • Removal from formulary





November 1st, 2020 SODIUM CHLORIDE 0.45% SOLN • Removal from formulary

November 1st, 2020 EPINEPHRINE 1 MG/ML AMPUL • Removal from formulary

November 1st, 2020 CEFTRIAXONE 1 GM ADD-VANT VIAL • Removal from formulary




November 1st, 2020 VITAMIN K-1 1 MG/0.5 ML AMPUL • Removal from formulary

November 1st, 2020 VITAMIN K-1 10 MG/ML AMPUL • Removal from formulary

November 1st, 2020 PROGRAF 5 MG/ML AMPULE • Removal from formulary

November 1st, 2020 ATROPINE 0.4 MG/ML VIAL • Removal from formulary

November 1st, 2020 METHYLERGONOVINE 0.2 MG/ML VL • Removal from formulary

November 1st, 2020 CYCLOSPORINE 250 MG/5 ML AMPUL • Removal from formulary

November 1st, 2020 ATROPINE 1 MG/ML VIAL • Removal from formulary




November 1st, 2020 DICYCLOMINE 20 MG/2 ML VIAL • Removal from formulary

November 1st, 2020 CALCIUM CHLORIDE 10% VIAL • Removal from formulary

November 1st, 2020 WATER FOR INJECTION VIAL • Removal from formulary

November 1st, 2020 CALCIUM GLUCONATE 10% VIAL • Removal from formulary

November 1st, 2020 HYDROXYZINE 25 MG/ML VIAL • Removal from formulary

November 1st, 2020 HYDROXYZINE 50 MG/ML VIAL • Removal from formulary

November 1st, 2020 ZINC SULFATE 10 MG/10 ML VIAL • Removal from formulary

November 1st, 2020 ZINC SULFATE 25 MG/5 ML VIAL • Removal from formulary

November 1st, 2020 RHOGAM ULTRA-FILTERED PLUS SYR • Removal from formulary

November 1st, 2020 MICRHOGAM ULTRA-FILTD PLUS SYR • Removal from formulary

November 1st, 2020 ORPHENADRINE 60 MG/2 ML AMP • Removal from formulary

November 1st, 2020 GLUCAGEN DIAGNOSTIC 1 MG VIAL • Removal from formulary

November 1st, 2020 DIPHENHYDRAMINE 50 MG/ML VIAL • Removal from formulary

November 1st, 2020 PHENOBARBITAL 65 MG/ML VIAL • Removal from formulary




November 1st, 2020 PHENOBARBITAL 130 MG/ML VIAL • Removal from formulary

November 1st, 2020 PROMETHAZINE 25 MG/ML VIAL • Removal from formulary

November 1st, 2020 PROMETHAZINE 50 MG/ML VIAL • Removal from formulary

November 1st, 2020 FAMOTIDINE 200 MG/20 ML VIAL • Removal from formulary

November 1st, 2020 FAMOTIDINE 20 MG/2 ML VIAL • Removal from formulary

November 1st, 2020 PHENERGAN 25 MG/ML AMPUL • Removal from formulary

November 1st, 2020 PHENERGAN 50 MG/ML AMPUL • Removal from formulary

November 1st, 2020 ROBINUL 0.2 MG/ML VIAL • Removal from formulary

November 1st, 2020 OXYTOCIN 10 UNIT/ML VIAL • Removal from formulary

November 1st, 2020 PROCHLORPERAZINE 10 MG/2 ML VL • Removal from formulary

November 1st, 2020 AMIKACIN SULF 1 GRAM/4 ML VIAL • Removal from formulary

November 1st, 2020 AMIKACIN SULF 500 MG/2 ML VIAL • Removal from formulary

November 1st, 2020 OCTREOTIDE ACET 50 MCG/ML VIAL • Removal from formulary

November 1st, 2020 OCTREOTIDE ACET 100 MCG/ML VL • Removal from formulary




November 1st, 2020 OCTREOTIDE ACET 500 MCG/ML VL • Removal from formulary

November 1st, 2020 OCTREOTIDE 1,000 MCG/5 ML VIAL • Removal from formulary

November 1st, 2020 OCTREOTIDE 5,000 MCG/5 ML VIAL • Removal from formulary

November 1st, 2020 PACLITAXEL 30 MG/5 ML VIAL • Removal from formulary

November 1st, 2020 VINORELBINE 10 MG/ML VIAL • Removal from formulary

November 1st, 2020 VINORELBINE 50 MG/5 ML VIAL • Removal from formulary

November 1st, 2020 VINCASAR PFS 1 MG/ML VIAL • Removal from formulary

November 1st, 2020 VINCASAR PFS 2 MG/2 ML VIAL • Removal from formulary

November 1st, 2020 ZANOSAR 1 GM POWDER VIAL • Removal from formulary

November 1st, 2020 MITOXANTRONE 25 MG/12.5 ML VL • Removal from formulary

November 1st, 2020 MESNA 1 GRAM/10 ML VIAL • Removal from formulary

November 1st, 2020 DACARBAZINE 200 MG VIAL • Removal from formulary

November 1st, 2020 TOPOSAR 100 MG/5 ML VIAL • Removal from formulary

November 1st, 2020 GRANISETRON HCL 0.1 MG/ML VIAL • Removal from formulary




November 1st, 2020 SULFAMETHOXAZOLE-TMP IV VIAL • Removal from formulary

November 1st, 2020 ISONIAZID 100 MG/ML VIAL • Removal from formulary

November 1st, 2020 CYCLOPHOSPHAMIDE 500 MG VIAL • Removal from formulary

November 1st, 2020 CYCLOPHOSPHAMIDE 1 GM VIAL • Removal from formulary

November 1st, 2020 CYCLOPHOSPHAMIDE 2 GM VIAL • Removal from formulary

November 1st, 2020 ANECTINE 200 MG/10 ML VIAL • Removal from formulary

November 1st, 2020 DIANEAL PD-2 WITH 4.25% DEXT • Removal from formulary

November 1st, 2020 BUMINATE 5% IV SOLUTION • Removal from formulary

November 1st, 2020 GAMMAGARD S-D 5 G (IGA<1) SOLN • Removal from formulary

November 1st, 2020 GAMMAGARD S-D 10 G (IGA<1) SOL • Removal from formulary

November 1st, 2020 ONCASPAR 3,750 UNIT/5 ML VIAL • Removal from formulary

November 1st, 2020 PROVISC 10 MG/ML DISP SYRNG • Removal from formulary

November 1st, 2020 NERIA 29G INFUSION SET • Removal from formulary

November 1st, 2020 IFOSFAMIDE 1 GM VIAL • Removal from formulary




November 1st, 2020 IFOSFAMIDE 3 GM VIAL • Removal from formulary

November 1st, 2020 HYPERRHO S-D 1,500 UNIT SYRING • Removal from formulary

November 1st, 2020 GAMASTAN S-D VIAL • Removal from formulary

November 1st, 2020 HYPERHEP B S-D VIAL • Removal from formulary

November 1st, 2020 HYPERRHO S-D 250 UNIT SYRINGE • Removal from formulary

November 1st, 2020 PLASBUMIN-25 IV SOLUTION • Removal from formulary

November 1st, 2020 MITOMYCIN 5 MG VIAL • Removal from formulary

November 1st, 2020 HYDRALAZINE 20 MG/ML VIAL • Removal from formulary

November 1st, 2020 MELPHALAN 50 MG VIAL W-DILUENT • Removal from formulary

November 1st, 2020 GRANISETRON HCL 1 MG/ML VIAL • Removal from formulary

November 1st, 2020 LEUCOVORIN CALCIUM 500 MG VL • Removal from formulary

November 1st, 2020 REVONTO 20 MG VIAL • Removal from formulary

November 1st, 2020 FOLIC ACID 50 MG/10 ML VIAL • Removal from formulary

November 1st, 2020 APLISOL 5T UNIT/0.1 ML VIAL • Removal from formulary




November 1st, 2020 PITOCIN 100 UNIT/10 ML VIAL • Removal from formulary

November 1st, 2020 DANTRIUM 20 MG VIAL • Removal from formulary

November 1st, 2020 ACTIMMUNE 100 MCG/0.5 ML VIAL • Removal from formulary

November 1st, 2020 ALBURX (HUMAN) 25% VIAL • Removal from formulary

November 1st, 2020 CARIMUNE NF 6 GM VIAL • Removal from formulary

November 1st, 2020 TENIPOSIDE 50 MG/5 ML AMPULE • Removal from formulary

November 1st, 2020 AMIFOSTINE 500 MG VIAL • Removal from formulary

November 1st, 2020 TUBERSOL 5T UNIT/0.1 ML VIAL • Removal from formulary

November 1st, 2020 HERCEPTIN 440 MG VIAL • Removal from formulary

November 1st, 2020 ALKERAN 50 MG VIAL • Removal from formulary

November 1st, 2020 ALFERON N 5 MILLION UNITS VIAL • Removal from formulary

November 1st, 2020 SILDENAFIL 10 MG/12.5 ML VIAL • Removal from formulary

November 1st, 2020 COSMEGEN 0.5 MG VIAL • Removal from formulary

November 1st, 2020 MUSTARGEN 10 MG VIAL • Removal from formulary




November 1st, 2020 PROCHLORPERAZINE 50 MG/10 ML • Removal from formulary

November 1st, 2020 NABI-HB VIAL • Removal from formulary

November 1st, 2020 NABI-HB VIAL • Removal from formulary

November 1st, 2020 SODIUM THIOSULFAT 12.5 G/50 ML • Removal from formulary

November 1st, 2020 VINCRISTINE 1 MG/ML VIAL • Removal from formulary

November 1st, 2020 VINCRISTINE 2 MG/2 ML VIAL • Removal from formulary

November 1st, 2020 PENTAM 300 VIAL • Removal from formulary

November 1st, 2020 DAUNORUBICIN 20 MG VIAL • Removal from formulary

November 1st, 2020 CARBOPLATIN 150 MG VIAL • Removal from formulary

November 1st, 2020 BACTERIOSTATIC WATER VIAL • Removal from formulary

November 1st, 2020 VINBLASTINE 1 MG/ML VIAL • Removal from formulary

November 1st, 2020 BEBULIN 200-1,200 UNITS VIAL • Removal from formulary

November 1st, 2020 SODIUM CHLORIDE 0.9% SYRINGE • Removal from formulary

November 1st, 2020 HEPARIN FLUSH 10 UNITS/ML SYR • Removal from formulary




November 1st, 2020 HEPARIN IV FLUSH 100 UNITS/ML • Removal from formulary

November 1st, 2020 NAVELBINE 10 MG/ML VIAL • Removal from formulary

November 1st, 2020 NAVELBINE 50 MG/5 ML VIAL • Removal from formulary

November 1st, 2020 PROLEUKIN 22 MILLION UNIT VIAL • Removal from formulary

November 1st, 2020 COMFORT INFUSION SET 43" 17MM • Removal from formulary

November 1st, 2020 CONTACT DETACH INFUSN SET 23" • Removal from formulary



November 1st, 2020 COMFORT SHORT INFUSION SET 23" • Removal from formulary




November 1st, 2020 ETHYOL 500 MG VIAL • Removal from formulary

November 1st, 2020 B-COMPLEX 100 INJECTION • Removal from formulary




November 1st, 2020 RANITIDINE HCL 50 MG/2 ML VIAL • Removal from formulary

November 1st, 2020 DOXORUBICIN 50 MG VIAL • Removal from formulary

November 1st, 2020 DOXORUBICIN 10 MG VIAL • Removal from formulary

November 1st, 2020 PROFILNINE 500 UNIT VIAL • Removal from formulary

November 1st, 2020 ALBUTEIN 5% VIAL • Removal from formulary

November 1st, 2020 ALBUTEIN 25% VIAL • Removal from formulary

November 1st, 2020 METOCLOPRAMIDE 10 MG/2 ML SYR • Removal from formulary

November 1st, 2020 DIPHENHYDRAMINE 50 MG/ML SYR • Removal from formulary

November 1st, 2020 HEPARIN SOD 5,000 UNIT/ML SYR • Removal from formulary

November 1st, 2020 QUICK RELEASE TEFLN CANNULA • Removal from formulary

November 1st, 2020 SOF-SET ULTIMATE QR SET • Removal from formulary

November 1st, 2020 SOF-SET MICRO INFUSION SET • Removal from formulary

November 1st, 2020 SILHOUETTE INFUSION SET 43" • Removal from formulary

November 1st, 2020 SILHOUETTE INFUSION SET 23" • Removal from formulary




November 1st, 2020 QUICK-SET PARADIGM SET 32" • Removal from formulary

November 1st, 2020 MINIMED INFUSION SET • Removal from formulary

November 1st, 2020 MIO INFUSION SET 18" • Removal from formulary

November 1st, 2020 EPINEPHRINE 30 MG/30 ML VIAL • Removal from formulary






November 1st, 2020 CLEO 90 INFUSION SET 24" 6MM • Removal from formulary

November 1st, 2020 CLEO 90 INFUSION SET 31" 6MM • Removal from formulary

November 1st, 2020 CELECOXIB 100 MG CAPSULE • Addition to formulary, QL 60 capsules/30 days






November 1st, 2020 DICLOFENAC POT 50 MG TABLET • Removal from formulary

November 1st, 2020 DICLOFENAC SOD EC 25 MG TAB • Removal from formulary

November 1st, 2020 ETODOLAC 200 MG CAPSULE • Removal from formulary

November 1st, 2020 ETODOLAC 300 MG CAPSULE • Removal from formulary

November 1st, 2020 ETODOLAC ER 400 MG TABLET • Removal from formulary

November 1st, 2020 ETODOLAC 400 MG TABLET • Removal from formulary


November 1st, 2020 ETODOLAC 500 MG TABLET • Removal from formulary


November 1st, 2020 FENOPROFEN 600 MG TABLET • Removal from formulary

November 1st, 2020 FLURBIPROFEN 100 MG TABLET • Removal from formulary

November 1st, 2020 FLURBIPROFEN 50 MG TABLET • Removal from formulary

November 1st, 2020 KETOPROFEN ER 200 MG CAPSULE • Removal from formulary

November 1st, 2020 KETOPROFEN 50 MG CAPSULE • Removal from formulary




November 1st, 2020 KETOPROFEN 75 MG CAPSULE • Removal from formulary

November 1st, 2020 KETOROLAC 15 MG/ML ISECURE SYR • Removal from formulary

November 1st, 2020 KETOROLAC 15 MG/ML VIAL • Removal from formulary

November 1st, 2020 KETOROLAC 30 MG/ML CARPUJECT • Removal from formulary

November 1st, 2020 KETOROLAC 300 MG/10 ML VIAL • Removal from formulary

November 1st, 2020 KETOROLAC 60 MG/2 ML CARPUJECT • Removal from formulary

November 1st, 2020 KETOROLAC 60 MG/2 ML VIAL • Removal from formulary

November 1st, 2020 MECLOFENAMATE 100 MG CAPSULE • Removal from formulary

November 1st, 2020 MECLOFENAMATE 50 MG CAPSULE • Removal from formulary

November 1st, 2020 NAPROXEN 125 MG/5 ML SUSPEN • Removal from formulary

November 1st, 2020 EC-NAPROXEN DR 375 MG TABLET • Addition to formulary

November 1st, 2020 EC-NAPROXEN DR 500 MG TABLET • Addition to formulary

November 1st, 2020 OXAPROZIN 600 MG TABLET • Removal from formulary

November 1st, 2020 TOLMETIN SODIUM 200 MG TAB • Removal from formulary




November 1st, 2020 TOLMETIN SODIUM 400 MG CAP • Removal from formulary

November 1st, 2020 TOLMETIN SODIUM 600 MG TAB • Removal from formulary

November 1st, 2020 IBUPROFEN 100 MG CHEW TB • Addition to formulary

November 1st, 2020 MIDOL 220 MG CAPLET • Removal from formulary

November 1st, 2020 DIFLUNISAL 500 MG TABLET • Removal from formulary

November 1st, 2020 SALSALATE 750 MG TABLET • Removal from formulary

November 1st, 2020 SALSALATE 500 MG TABLET • Removal from formulary

November 1st, 2020 BAYER ASPIRIN 500 MG TABLET • Removal from formulary

November 1st, 2020 BAYER ADVANCED 500 MG TABLET • Removal from formulary

November 1st, 2020 LIDOCAINE-PRILOCAINE CREAM • Addition to formulary

November 1st, 2020 ETHYL CHLORIDE SPRAY • Removal from formulary

November 1st, 2020 LIDOCAINE 3% CREAM • Removal from formulary

November 1st, 2020 LIDOCAINE 4% CREAM • Removal from formulary

November 1st, 2020 FINTEPLA 2.2 MG/ML SOLUTION • Addition to formulary, PA, QL 395ml/30 days




November 1st, 2020 KOSELUGO 10 MG CAPSULE • Addition to Formulary, PA, QL 120 capsules/30 days

November 1st, 2020 KOSELUGO 25 MG CAPSULE • Addition to Formulary, PA, QL 120 capsules/30 days

November 1st, 2020 RETEVMO 40 MG CAPSULE • Addition to Formulary, PA, QL 120 capsules/30 days

November 1st, 2020 RETEVMO 80 MG CAPSULE • Addition to Formulary, PA, QL 120 capsules/30 days

November 1st, 2020 RUKOBIA ER 600 MG TABLET • Addition to Formulary, PA, QL 60 tablets/30 days

November 1st, 2020 TABRECTA 150 MG TABLET • Addition to Formulary, PA, QL 120 tablets/30 days

November 1st, 2020 TABRECTA 200 MG TABLET • Addition to Formulary, PA, QL 120 tablets/30 days

November 1st, 2020 KETOROLAC 30 MG/ML VIAL • Addition of QL 10ml/30 days

November 1st, 2020 MELOXICAM 7.5 MG TABLET • Addition to formulary, QL 60 tablets/30 days

Documents

Summary of Formulary Changes Effective Date Affected ......PA= Prior Authorization; ST= Step Therapy; QL= Quantity Limit; AR= Age Restriction October 1 Summary of Formulary Changes