Pharmacy benefits

Some medicines that don’t need a prescription are also covered when your doctor asks for them. You can get coverage for some OTC medications on the OTC product list (PDF) when you:

• Get a prescription from your provider
• Fill your OTC prescription at a network pharmacy (Walgreens isn’t in our network)

Still not sure if we cover your medicine? Just call ${MS_phone_1} or ${MS_phone_2} (TTY 711). When you call, have a list of your OTC medicines ready. We can check them for you.

CVS Specialty® fills your specialty medicine. They also have other special services for you:

• Access to a pharmacist 24 hours a day, 7 days a week
• Counseling about your drug and disease
• Coordination of care with you and your doctor
• Delivery of specialty medicine to your home or doctor’s office at no cost 
• Use of any CVS Pharmacy® (including those inside Target stores) for prescription drop-off and medicine pickup

Call CVS Specialty at 1-800-237-2767 (TTY 1-800-863-5488) for help. You can also check the specialty drug list (PDF) to see your options.

December 2024

Title 19/21 SMI Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

November 2024

Title 19/21 SMI Drug List Updates:

Additions:

• Baclofen 5 mg per 5 mL solution (Quantity Limit)
• Banzel 200 mg tablet (Quantity Limit)
• Banzel 400 mg tablet (Quantity Limit)
• Banzel 40 mg per mL suspension (Quantity Limit)
• Clobazam 10 mg tablet (Quantity Limit)
• Clobazam 2.5 mg per mL suspension (Quantity Limit)
• Clobazam 20 mg tablet (Quantity Limit)
• Ojemda 100 mg tablet (Prior Authorization, Quantity Limit)
• Ojemda 25 mg per mL (Prior Authorization, Quantity Limit)
• Rufinamide 200 mg tablet (Quantity Limit)
• Rufinamide 400 mg tablet (Quantity Limit)

Removals:

• None

Other Updates:

• Entresto 15 mg / 16 mg sprinkle capsule (Removed Prior Authorization, Added Quantity Limit)
• Entresto 24 mg / 26 mg tablet (Removed Prior Authorization, Added Quantity Limit)
• Entresto 49 mg / 51 mg tablet (Removed Prior Authorization, Added Quantity Limit)
• Entresto 6 mg / 6 mg sprinkle capsule (Removed Prior Authorization, Added Quantity Limit)
• Entresto 97 mg / 103 mg tablet (Removed Prior Authorization, Added Quantity Limit)

Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

October 2024

Title 19/21 SMI Drug List Updates:

Additions:

• Aimovig Auto-Injector 140 mg per mL (Prior Authorization)
• Aimovig Auto-Injector 70 mg per mL (Prior Authorization)
• AirDuo RespiClick powder breath 113-14 mcg per actuation inhalation
• AirDuo RespiClick powder breath 232-14 mcg per actuation inhalation
• AirDuo RespiClick powder breath 55-14 mcg per actuation inhalation
• Amphetamine-dextroamphetamine ER 10 mg capsule (Quantity Limit, Age Limit)
• Amphetamine-dextroamphetamine ER 15 mg capsule (Quantity Limit, Age Limit)
• Amphetamine-dextroamphetamine ER 20 mg capsule (Quantity Limit, Age Limit)
• Amphetamine-dextroamphetamine ER 25 mg capsule (Quantity Limit, Age Limit)
• Amphetamine-dextroamphetamine ER 30 mg capsule (Quantity Limit, Age Limit)
• Amphetamine-dextroamphetamine ER 5 mg capsule (Quantity Limit, Age Limit)
• Brixadi Monthly Prefilled Syringe 128 mg per 0.36 mL (Medical Prior Authorization, Buy & Bill)
• Brixadi Monthly Prefilled Syringe 64 mg per 0.18 mL (Medical Prior Authorization, Buy & Bill)
• Brixadi Monthly Prefilled Syringe 96 mg per 0.27 mL (Medical Prior Authorization, Buy & Bill)
• Brixadi Weekly Prefilled Syringe 16mg per 0.32 mL (Medical Prior Authorization, Buy & Bill)
• Brixadi Weekly Prefilled Syringe 24 mg per 0.48 mL (Medical Prior Authorization, Buy & Bill)
• Brixadi Weekly Prefilled Syringe 32 mg per 0.64 mL (Medical Prior Authorization, Buy & Bill)
• Brixadi Weekly Prefilled Syringe 8 mg per 0.16 mL (Medical Prior Authorization, Buy & Bill)
• Dihydroergotamine mesylate 4 mg per mL nasal solution (Coverage Limited To NDC: 68682035710) (Prior Authorization)
• Elidel 1% cream (Prior Authorization)
• Insulin degludec 100 unit per mL vial
• Insulin degludec FlexTouch 100 unit per mL pen-injector
• Insulin degludec FlexTouch 200 unit per mL pen-injector
• Opzelura 1.5% cream (Prior Authorization)
• Xeljanz XR 11 mg tablet (Prior Authorization)
• Xeljanz XR 22 mg tablet (Prior Authorization)

Removals:

• Adderall XR 10 mg capsule
• Adderall XR 15 mg capsule
• Adderall XR 20 mg capsule
• Adderall XR 25 mg capsule
• Adderall XR 30 mg capsule
• Adderall XR 5 mg capsule
• Ajovy Auto-Injector 225 mg per 1.5 mL solution
• Ajovy prefilled syringe 225 mg per 1.5 mL solution
• Dupixent 100 mg per 0.67 mL prefilled syringe solution
• Dupixent 200 mg per 1.14 mL pen-injector solution
• Dupixent 200 mg per 1.14 mL prefilled syringe solution
• Dupixent 300 mg per 2 mL pen-injector solution
• Dupixent 300 mg per 2 mL prefilled syringe solution
• Genotropin 12 mg reconstituted solution
• Genotropin 5 mg cartridge
• Kombiglyze XR 2.5 mg / 1000 mg tablet
• Kombiglyze XR 5 mg / 1000 mg tablet
• Kombiglyze XR 5 mg / 5000 mg tablet
• Levemir 100 unit per mL vial
• Levemir FlexPen 100 unit per mL pen-injector
• Methylphenidate 10 mg per 5 mL solution
• Methylphenidate 5 mg per 5 mL solution
• Nesina 12.5 mg tablet
• Nesina 25 mg tablet
• Nesina 6.25 mg tablet
• Omnitrope 10 mg per 1.5 mL solution cartridge
• Omnitrope 5 mg per 1.5 mL solution cartridge
• Omnitrope 5.8 mg reconstituted solution
• Onglyza 2.5 mg tablet
• Onglyza 5 mg tablet
• Zomacton 10 mg reconstituted solution
• Zomacton 5 mg reconstituted solution

Other Updates:

• Metformin ER 500 mg tablet (Added Quantity Limit)
• Metformin ER 750 mg tablet (Added Quantity Limit)

Non-Title 19/21 Drug List Updates:

Additions:

• Brixadi Monthly Prefilled Syringe 128 mg per 0.36 mL (Medical Prior Authorization, Buy & Bill)
• Brixadi Monthly Prefilled Syringe 64 mg per 0.18 mL (Medical Prior Authorization, Buy & Bill)
• Brixadi Monthly Prefilled Syringe 96 mg per 0.27 mL (Medical Prior Authorization, Buy & Bill)
• Brixadi Weekly Prefilled Syringe 16mg per 0.32 mL (Medical Prior Authorization, Buy & Bill)
• Brixadi Weekly Prefilled Syringe 24 mg per 0.48 mL (Medical Prior Authorization, Buy & Bill)
• Brixadi Weekly Prefilled Syringe 32 mg per 0.64 mL (Medical Prior Authorization, Buy & Bill)
• Brixadi Weekly Prefilled Syringe 8 mg per 0.16 mL (Medical Prior Authorization, Buy & Bill)

Removals:

• None

Other Updates:

• None

September 2024

Title 19/21 SMI Drug List Updates:

Additions:

• Adbry 300 mg per 2 mL auto-injector solution (Prior Authorization)
• Rextovy 4 mg per 0.25 mL nasal spray

Removals:

• None

Other Updates:

• Sprycel 20 mg tablet (Brand Preferred)
• Sprycel 50 mg tablet (Brand Preferred)
• Sprycel 70 mg tablet (Brand Preferred)
• Sprycel 80 mg tablet (Brand Preferred)
• Sprycel 100 mg tablet (Brand Preferred)
• Sprycel 140 mg tablet (Brand Preferred)

Non-Title 19/21 Drug List Updates:

Additions:

• Rextovy 4 mg per 0.25 mL nasal spray

Removals:

• None

Other Updates:

• None

August 2024

Title 19/21 SMI Drug List Updates:

Additions:

• Adalimumab-ADBM 10 mg per 0.2 mL (2 Syringe) prefilled syringe kit (Prior Authorization)
• Adalimumab-ADBM 20 mg per 0.4 mL (2 Syringe) prefilled syringe kit (Prior Authorization)
• Adalimumab-ADBM 40 mg per 0.8 mL (2 Pen) auto-injector kit (Prior Authorization)
• Adalimumab-ADBM 40 mg per 0.8 mL (2 Syringe) prefilled syringe kit (Prior Authorization)
• Adalimumab-ADBM 40 mg per 0.8 mL (CD/UC/HS Starter) auto-injector kit (Prior Authorization)
• Adalimumab-ADBM 40 mg per 0.8 mL (Psoriasis/Uveit Starter) auto-injector kit (Prior Authorization)
• Hadlima 40 mg per 0.4 mL solution prefilled syringe (Prior Authorization)
• Hadlima 40 mg per 0.8 mL solution prefilled syringe (Prior Authorization)
• Hadlima PushTouch 40 mg per 0.4 mL solution auto-injector (Prior Authorization)
• Hadlima PushTouch 40 mg per 0.8 mL solution auto-injector (Prior Authorization)
• Simlandi 40 mg per 0.4 mL (1 Pen) auto-injector kit (Prior Authorization)
• Simlandi 40 mg per 0.4 mL (2 Pen) auto-injector kit (Prior Authorization)

Removals:

• Humira 10 mg per 0.1 mL (2 Syringe) prefilled syringe kit
• Humira 20 mg per 0.2 mL (2 Syringe) prefilled syringe kit
• Humira 20 mg per 0.2 mL (2 Syringe) prefilled syringe kit
• Humira 40 mg per 0.4 mL (2 pen) pen injector
• Humira 40 mg per 0.4 mL (2 Syringe) prefilled syringe kit
• Humira 40 mg per 0.8 mL (2 pen) pen injector
• Humira 40 mg per 0.8 mL (2 Syringe) prefilled syringe kit
• Humira 80 mg per 0.8 mL & 40 mg per 0.4 mL (Psoriasis/Uveit Starter) pen-injector kit
• Humira 80 mg per 0.8 mL & 40 mg per 0.4 mL pediatric Crohns starter prefilled syringe kit
• Humira 80 mg per 0.8 mL (2 pen) pen injector kit
• Humira 80 mg per 0.8 mL (CD/UC/HS Starter) pen-injector kit
• Humira 80 mg per 0.8 mL (Pediatric UC Starter) pen-injector kit 
• Humira 80 mg per 0.8 mL pediatric Crohns starter prefilled syringe kit

Other Updates:

• Albendazole 200 mg tablet (Removed Prior Authorization)
• Derma-Smoothe 0.01% scalp oil (Added Quantity Limit Level)
• Linezolid 600 mg tablet (Removed Prior Authorization, Added Quantity Limit Level)
• Sofosbuvir-Velpatasvir 400 mg/100 mg tablet (Quantity Level Limit 168 Tablets Per Lifetime Added)

Non-Title 19/21 Drug List Updates:

Additions:

• Aripiprazole 2 mg tablet (Added to Crisis Formulary)
• Aripiprazole 5 mg tablet (Added to Crisis Formulary)
• Aripiprazole 10 mg tablet (Added to Crisis Formulary)
• Aripiprazole 15 mg tablet (Added to Crisis Formulary)
• Aripiprazole 20 mg tablet (Added to Crisis Formulary)
• Aripiprazole 30 mg tablet (Added to Crisis Formulary)

Removals:

• None

Other Updates:

• None

July 2024

Title 19/21 SMI Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

June 2024

Title 19/21 SMI Drug List Updates:

Additions:

• None

Other Updates:

• Spravato 56mg solution (Added Quantity Limit)
• Spravato 84mg solution (Added Quantity Limit)

Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• Spravato 56mg solution (Added Quantity Limit)
• Spravato 84mg solution (Added Quantity Limit)

May 2024

Title 19/21 SMI Drug List Updates:

Additions:

• Azelaic acid 15% gel (Quantity Limit)
• Doxycycline hyclate 75 mg tablet
• Doxycycline monohydrate 50 mg tablet
• Doxycycline monohydrate 75 mg tablet
• Isosorbide dinitrate 20 mg / Hydralazine 37.5mg tablet (Quantity Limit)

Removals:

• None

Other Updates:

• None

Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

April 2024

Title 19/21 SMI Drug List Updates:

Additions:

• Alyq 20 mg tablet
• Imatinib mesylate 100 mg tablet (Prior Authorization)
• Imatinib mesylate 400 mg tablet (Prior Authorization)
• Lenalidomide 10 mg capsule (Prior Authorization)  
• Lenalidomide 15 mg capsule (Prior Authorization)  
• Lenalidomide 2.5 mg capsule (Prior Authorization)
• Lenalidomide 20 mg capsule (Prior Authorization)
• Lenalidomide 25 mg capsule (Prior Authorization)
• Lenalidomide 5 mg capsule (Prior Authorization)   
• Liqrev 10 mg per mL suspension (Age Limit)
• Neupogen 300 mcg per 0.5mL prefilled syringe solution (Prior Authorization)
• Neupogen 300 mcg per mL solution (Prior Authorization)
• Neupogen 480 mcg per 0.8mL prefilled syringe solution (Prior Authorization)
• Neupogen 480 mcg per 1.6mL solution (Prior Authorization)
• Nyvepria 6 mg per 0.6mL prefilled syringe solution (Prior Authorization)
• Orenitram 0.125 mg extended release tablet (Prior Authorization)
• Orenitram 0.25 mg extended release tablet (Prior Authorization)
• Orenitram 1 mg extended release tablet (Prior Authorization)
• Orenitram 1 month titration pack extended release tablet (Prior Authorization)
• Orenitram 2 month titration pack extended release tablet (Prior Authorization)
• Orenitram 2.5 mg extended release tablet (Prior Authorization)
• Orenitram 3 month titration pack extended release tablet (Prior Authorization)
• Orenitram 5 mg extended release tablet (Prior Authorization)
• Skyclarys 50 mg capsule (Prior Authorization)
• Tadalafil (PAH) 20 mg tablet (Prior Authorization)  
• Testosterone 1.62% gel (Prior Authorization)
• Udenyca 6 mg per 0.6mL auto-injector solution (Prior Authorization)
• Xiidra 5% ophthalmic solution (Prior Authorization)
• Zurzuvae 20 mg capsule (Prior Authorization)
• Zurzuvae 25 mg capsule (Prior Authorization)
• Zurzuvae 30 mg capsule (Prior Authorization)

Removals:

• Adcirca 20 mg tablet
• AndroGel Pump 1.62% gel
• Aranesp 10 mcg per 0.4 mL prefilled syringe solution
• Aranesp 100 mcg per 0.5 mL prefilled syringe solution
• Aranesp 100 mcg per mL vial solution
• Aranesp 150 mcg per 0.3 mL prefilled syringe solution
• Aranesp 200 mcg per 0.4 mL prefilled syringe solution
• Aranesp 200 mcg per mL vial solution
• Aranesp 25 mcg per 0.42 mL prefilled syringe solution
• Aranesp 25 mcg per mL vial solution
• Aranesp 300 mcg per 0.6 mL prefilled syringe solution
• Aranesp 40 mcg per 0.4 mL prefilled syringe solution
• Aranesp 40 mcg per mL vial solution
• Aranesp 500 mcg per 1 mL prefilled syringe solution
• Aranesp 60 mcg per 0.3 mL prefilled syringe solution
• Aranesp 60 mcg per mL vial solution
• Gleevec 100 mg tablet
• Gleevec 400 mg tablet
• Iclusig 10 mg tablet
• Iclusig 15 mg tablet
• Iclusig 30 mg tablet
• Iclusig 45 mg tablet
• Procrit 10000 unit per mL injection
• Procrit 2000 unit per mL injection
• Procrit 20000 unit per mL injection
• Procrit 3000 unit per mL injection
• Procrit 4000 unit per mL injection
• Procrit 40000 unit per mL injection
• Revatio 10 mg per mL suspension
• Revlimid 10 mg tablet
• Revlimid 15 mg tablet
• Revlimid 2.5 mg tablet
• Revlimid 20 mg tablet
• Revlimid 25 mg tablet
• Revlimid 5 mg tablet
• Sildenafil citrate 10 mg per mL suspension
• Thalomid 100 mg capsule
• Thalomid 150 mg capsule
• Thalomid 200 mg capsule
• Thalomid 50 mg capsule

Other Updates:

• None

Non-Title 19/21 Drug List Updates:

Additions:

• Zurzuvae 20 mg capsule (Prior Authorization)
• Zurzuvae 25 mg capsule (Prior Authorization)
• Zurzuvae 30 mg capsule (Prior Authorization)

Removals:

• None

Other Updates:

• None

March 2024

Title 19/21 SMI Drug List Updates:

Additions:

• Mesalamine delayed release 1.2 gm tablet

Removals:

• Asacol HD 800 mg tablet
• Lialda 1.2 gm tablet

Other Updates:

• None

Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

February 2024

Title 19/21 SMI Drug List Updates:

Additions:

• None

Removals:

• Climara Pro 0.045-0.015 mg per day weekly patch
• All insulin syringes (Excluding BD Products)
• CombiPatch 0.05-0.14 mg per day twice weekly patch
• CombiPatch 0.05-0.25 mg per day twice weekly patch

Other Updates:

• Bimatoprost 0.03% ophthalmic solution (Added Quantity Limit)
• Omeprazole 40 mg capsule (Added Quantity Limit)
• Pantoprazole 20 mg tablet (Added Quantity Limit)
• Pantoprazole 40 mg tablet (Added Quantity Limit)

Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

January 2024

Title 19/21 SMI Drug List Updates:

Additions:

• Adbry 150 mg per mL prefilled syringe solution (Prior Authorization)
• Aranesp 100 mcg per mL vial (Prior Authorization)
• Aranesp 200 mcg per mL vial (Prior Authorization)
• Aranesp 25 mcg per mL vial (Prior Authorization)
• Aranesp 40 mcg per mL vial (Prior Authorization)
• Aranesp 60 mcg per mL vial (Prior Authorization)
• Austedo XR 12 mg tablet (Prior Authorization)
• Austedo XR 24 mg tablet (Prior Authorization)
• Austedo XR 6 mg / 12 mg / 24 mg titration pack tablet (Prior Authorization)
• Austedo XR 6 mg tablet (Prior Authorization)
• Banzel 200 mg tablet (Prior Authorization)
• Banzel 40 mg per mL suspension (Prior authorization)
• Banzel 400 mg tablet (Prior Authorization)
• Betamethasone dipropionate 0.05 % ointment
• Carbatrol extended release 100 mg capsule
• Carbatrol extended release 200 mg capsule
• Carbatrol extended release 300 mg capsule
• Celontin 300 mg capsule
• Copaxone 40 mg per mL prefilled syringe (Prior Authorization)
• Dalfampridine extended release 10 mg tablet (Prior Authorization)
• Dexcom G7 Receiver (Prior Authorization, Age Limit, Quantity Limit)
• Dexcom G7 Sensor (Prior Authorization, Age Limit, Quantity Limit)
• Diastat AcuDial 10 mg rectal gel (Quantity Limit)
• Diastat AcuDial 20 mg rectal gel (Quantity Limit)
• Diastat pediatric 2.5 mg rectal gel (Quantity Limit)
• Dimethyl fumarate delayed release 120 mg / 240 mg starter pack tablet (Prior Authorization)
• Dimethyl fumarate delayed release 120 mg tablet (Prior Authorization)
• Dimethyl fumarate delayed release 240 mg tablet (Prior Authorization)
• Edurant 25 mg tablet
• Emtricitabine 100 mg / Tenofovir DF 150 mg tablet (Quantity Limit)
• Emtricitabine 133 mg / Tenofovir DF 133 mg tablet (Quantity Limit)
• Emtricitabine 167 mg / Tenofovir DF 250 mg tablet (Quantity Limit)
• Emtricitabine 200 mg / Tenofovir DF 300 mg tablet (Quantity Limit)
• Epidiolex 100 mg per mL solution (Prior Authorization)
• Fluocinolone acetonide 0.01 % solution
• Fycompa 0.5 mg per mL suspension (Prior Authorization)
• Fycompa 10 mg tablet (Prior Authorization)
• Fycompa 12 mg tablet (Prior Authorization)
• Fycompa 2 mg tablet (Prior Authorization)
• Fycompa 4 mg tablet (Prior Authorization)
• Fycompa 6 mg tablet (Prior Authorization)
• Fycompa 8 mg tablet (Prior Authorization)
• Glatopa 40 mg per mL prefilled syringe (Prior Authorization)
• Haegarda 2000 unit solution (Prior Authorization)
• Haegarda 3000 unit solution (Prior Authorization)
• Icatibant 30 mg per 3 mL prefilled syringe (Prior Authorization)
• Kesimpta 20 mg per 0.4 mL auto-injector (Prior Authorization)
• Ocrevus 300 mg per 10 mL solution (Prior Authorization)
• Oxcarbazepine 300 mg per 5mL suspension
• Pazopanib 200 mg tablet (Prior Authorization)
• Rebif 22 mcg per 0.5 mL prefilled syringe (Prior Authorization)
• Rebif 44 mcg per 0.5 mL prefilled syringe (Prior Authorization)
• Rebif 8.5mcg and 22 mcg prefilled syringe titration pack (Prior Authorization)
• Teriflunomide 14 mg tablet (Prior Authorization)
• Teriflunomide 7 mg tablet (Prior Authorization)
• Topiramate extended release 100 mg sprinkle capsule (Prior Authorization)
• Topiramate extended release 150 mg sprinkle capsule (Prior Authorization)
• Topiramate extended release 200 mg sprinkle capsule (Prior Authorization)
• Topiramate extended release 25 mg sprinkle capsule (Prior Authorization)
• Topiramate extended release 50 mg sprinkle capsule (Prior Authorization)
• Trileptal 300 mg per 5mL suspension
• Trokendi XR 100 mg tablet (Prior Authorization)
• Trokendi XR 200 mg tablet (Prior Authorization)
• Trokendi XR 25 mg tablet (Prior Authorization)
• Trokendi XR 50 mg tablet (Prior Authorization)
• Tysabri concentrate 300 mg per 15 mL (Prior Authorization)
• Xcopri 100 mg / 150 mg daily dose therapy pack (Prior Authorization)
• Xcopri 100 mg tablet (Prior Authorization)
• Xcopri 12.5 mg / 25 mg titration pack tablet (Prior Authorization)
• Xcopri 150 mg / 200 mg daily dose therapy pack (Prior Authorization)
• Xcopri 150 mg / 200 mg titration pack tablet (Prior Authorization)
• Xcopri 150 mg tablet (Prior Authorization)
• Xcopri 200 mg tablet (Prior Authorization)
• Xcopri 50 mg / 100 mg titration pack tablet (Prior Authorization)
• Xcopri 50 mg tablet (Prior Authorization)
• Zenpep 60000 unit capsule (Prior Authorization, Quantity Limit)
• Zolpidem tartrate extended release 12.5 mg tablet (Age Limit)
• Zolpidem tartrate extended release 6.25 mg tablet (Age Limit)

Removals:

• Aptivus 250 mg capsule
• Benzoyl peroxide 4% liquid wash
• Betaseron 0.3 mg injection kit
• Clotrimazole 1% solution (OTC)
• Equetro extended release 100 mg capsule
• Equetro extended release 200 mg capsule
• Equetro extended release 300 mg capsule
• Extavia 0.3 mg injection kit
• Firazyr 30 mg per 3 mL prefilled syringe
• Gilenya 0.25 mg capsule
• Glatopa 40 mg per mL prefilled syringe
• Norliqva 1 mg per mL solution
• Orladeyo 110 mg capsule
• Orladeyo 150 mg capsule
• Oxcarbazepine 300 mg per 5mL suspension
• PanOxyl 4% liquid wash
• Rufinamide 40 mg per mL suspension
• Sajazir 30mg / 3 mL syringe
• Votrient 200mg tablet

Other Updates:

• Nayzilam 5 mg per 0.1 mL nasal solution (Removed Prior Authorization, Removed Age Limit, Updated Quantity Limit)
• Tiagabine HCl tablet 12mg (Prior Authorization Added)
• Tiagabine HCl tablet 16mg (Prior Authorization Added)
• Tiagabine HCl tablet 20mg (Prior Authorization Added)
• Tiagabine HCl tablet 2mg (Prior Authorization Added)
• Tiagabine HCl tablet 4mg (Prior Authorization Added)
• Valtoco 10 mg per 0.1 mL nasal solution (Removed Age Limit, Updated Quantity Limit)
• Valtoco 15 mg therapy pack nasal solution (Removed Age Limit, Updated Quantity Limit)
• Valtoco 20 mg therapy pack nasal solution (Removed Age Limit, Updated Quantity Limit)
• Valtoco 5 mg per 0.1 mL nasal solution (Removed Age Limit, Updated Quantity Limit)

Non-Title 19/21 Drug List Updates:

Additions:

• Austedo XR 12 mg tablet (Prior Authorization)
• Austedo XR 24 mg tablet (Prior Authorization)
• Austedo XR 6 mg / 12 mg / 24 mg titration pack tablet (Prior Authorization)
• Austedo XR 6 mg tablet (Prior Authorization)

Removals:

• Equetro extended release 100 mg capsule
• Equetro extended release 200 mg capsule
• Equetro extended release 300 mg capsule

Other Updates:

• None

December 2023

Title 19/21 SMI Drug List Updates:

Additions:

• Arnuity Ellipta 100 mcg inhaler
• Arnuity Ellipta 200 mcg inhaler
• Arnuity Ellipta 50 mcg inhaler
• Asmanex HFA 100 mcg inhaler
• Asmanex HFA 200 mcg inhaler
• Asmanex HFA 50 mcg inhaler
• Fluticasone propionate diskus breath activated 100 mcg powder
• Fluticasone propionate diskus breath activated 250 mcg powder
• Fluticasone propionate diskus breath activated 50 mcg powder
• Qvar RediHaler 40 mcg inhaler
• Qvar RediHaler 80 mcg inhaler

Removals:

• None

Other Updates:

• None

Non-Title 19/21 Drug List Updates:

Additions:

• None

Removals:

• None

Other Updates:

• None

November 2023

Title 19/21 SMI drug list updates

Additions:

• Omnitrope 5.8 mg solution (Prior Authorization)
• Omnitrope cartridge 10 mg per 1.5mL solution (Prior Authorization)
• Omnitrope cartridge 5 mg per 1.5mL solution (Prior Authorization)
• Zomactron 10 mg solution (Prior Authorization)
• Zomactron 5 mg solution (Prior Authorization)

Removals

• Proctofoam HC 1 % to 1% rectal foam

Other updates

• Haloperidol 0.5 mg tablet (age limit updated)

• Haloperidol 1 mg tablet (age limit updated)

• Haloperidol 10 mg tablet (age limit updated)

• Haloperidol 2 mg tablet (age limit updated)

• Haloperidol 20 mg tablet (age limit updated)

• Haloperidol 5 mg tablet (age limit updated)

• Haloperidol lactate 2 mg per mL oral concentrate (age limit updated)

• Haloperidol lactate 5 mg per mL solution injection (age limit updated)

• Loxapine succinate 10 mg capsule (age limit updated)

• Loxapine succinate 25 mg capsule (age limit updated)

• Loxapine succinate 5 mg capsule (age limit updated)

• Loxapine succinate 50 mg capsule (age limit updated)

• Nayzilam 5mg per 0.1 mL nasal spray (quantity limit updated, age limit added)

• Perphenazine 16 mg tablet (age limit updated)

• Perphenazine 2 mg tablet (age limit updated)

• Perphenazine 4 mg tablet (age limit updated)

• Perphenazine 8 mg tablet (age limit updated)

• Pimozide 1 mg tablet (age limit updated)

• Pimozide 2 mg tablet (age limit updated)

• Thioridazine HCl 10 mg tablet (age limit updated)

• Thioridazine HCl 100 mg tablet (age limit updated)

• Thioridazine HCl 25 mg tablet (age limit updated)

• Thioridazine HCl 50 mg tablet (age limit updated)

• Thiothixene 1 mg capsule (age limit updated)

• Thiothixene 10 mg capsule (age limit updated)

• Thiothixene 2 mg capsule (age limit updated)

• Thiothixene 5 mg capsule (age limit updated)

• Trifluoperazine HCl 1 mg tablet (age limit updated)

• Trifluoperazine HCl 10 mg tablet (age limit updated)

• Trifluoperazine HCl 2 mg tablet (age limit updated)

• Trifluoperazine HCl 5 mg tablet (age limit updated)

• Valtoco 10 mg nasal spray (quantity limit updated, age limit added)

• Valtoco 15 mg nasal spray (quantity limit updated, age limit added)

• Valtoco 20 mg nasal spray (quantity limit updated, age limit added)

• Valtoco 5 mg nasal spray (quantity limit updated, age limit added)

Non-Title 19/21 drug list updates

Additions: None

Removals: None

Other updates

• Haloperidol 0.5 mg tablet (age limit updated)

• Haloperidol 1 mg tablet (age limit updated)

• Haloperidol 10 mg tablet (age limit updated)

• Haloperidol 2 mg tablet (age limit updated)

• Haloperidol 20 mg tablet (age limit updated)

• Haloperidol 5 mg tablet (age limit updated)

• Haloperidol lactate 2 mg per mL oral concentrate (age limit updated)

• Haloperidol lactate 5 mg per mL solution injection (age limit updated)

• Loxapine succinate 10 mg capsule (age limit updated)

• Loxapine succinate 25 mg capsule (age limit updated)

• Loxapine succinate 5 mg capsule (age limit updated)

• Loxapine succinate 50 mg capsule (age limit updated)

• Perphenazine 16 mg tablet (age limit updated)

• Perphenazine 2 mg tablet (age limit updated)

• Perphenazine 4 mg tablet (age limit updated)

• Perphenazine 8 mg tablet (age limit updated)

• Pimozide 1 mg tablet (age limit updated)

• Pimozide 2 mg tablet (age limit updated)

• Thioridazine HCl 10 mg tablet (age limit updated)

October 2023

Title 19/21 SMI drug list updates

Additions

• Dexmethylphenidate extended release 10 mg capsule (quantity limit, age limit)

• Dexmethylphenidate extended release 15 mg capsule (quantity limit, age limit)

• Dexmethylphenidate extended release 20 mg capsule (quantity limit, age limit)

• Dexmethylphenidate extended release 25 mg capsule (quantity limit, age limit)

• Dexmethylphenidate extended release 30 mg capsule (quantity limit, age limit)

• Dexmethylphenidate extended release 35 mg capsule (quantity limit, age limit)

• Dexmethylphenidate extended release 40 mg capsule (quantity limit, age limit)

• Dexmethylphenidate extended release 5 mg capsule (quantity limit, age limit)

• Gvoke Kit 1 mg per 0.2 mL solution (quantity limit)

• Gvoke prefilled syringe 0.5 mg per 0.1 mL solution (quantity limit)

• Gvoke prefilled syringe 1 mg per 0.2 mL solution (quantity limit)

• Infliximab 100 mg intravenous solution (prior authorization)

• Lintera 10% wash

• Naloxone 4 mg per 0.1 mL nasal liquid (OTC)

• Octagam 25 gm per 500 mL (5%) intravenous solution (prior authorization)

• Spiriva Respimat 1.25 mcg per inhalation solution

• Spiriva Respimat 2.5 mcg per inhalation solution

• Zegalogue auto-injector 0.6 mg per 0.6 mL solution (quantity limit)

Removals

• Aimovig auto-injector 140 mg per mL solution

• Aimovig auto-injector 70 mg per mL solution

• Avsola 100 mg reconstituted solution

• Ergotamine tartrate 2 mg and caffeine 100 mg suppository

• Focalin XR 10 mg capsule

• Focalin XR 15 mg capsule

• Focalin XR 20 mg capsule

• Focalin XR 25 mg capsule

• Focalin XR 30 mg capsule

• Focalin XR 35 mg capsule

• Focalin XR 40 mg capsule

• Focalin XR 5 mg capsule

• Makena 250 mg per mL oil

• Makena auto-injector 275 mg per 1.1 mL solution

• Pradaxa 100 mg packet

• Pradaxa 150 mg packet

• Pradaxa 20 mg packet

• Pradaxa 30 mg packet

• Pradaxa 40 mg packet

• Pradaxa 50 mg packet

Other updates

• Levocarnitine 330 mg tablet (prior authorization removed)

Non-Title 19/21 drug list updates

Additions: None

Removals: None

Other updates: None

September 2023

Title 19/21 SMI drug list updates

Additions: None

Removals: None

Other updates: None

Non-Title 19/21 drug list updates

Additions: None

Removals: None

Other updates: None

August 2023

Title 19/21 SMI drug list updates

Additions

• Imbruvica 140 mg tablet (prior authorization)

• Tranexamic acid 650 mg tablet (prior authorization)

• Vogelxo 50 mg per 5 gram gel packet (prior authorization)

Removals

• Telmisartan 20 mg tablet

• Telmisartan 40 mg tablet

• Telmisartan 80 mg tablet

Other updates: None

Non-Title 19/21 drug list updates

Additions

• Naloxone 4 mg nasal spray (OTC)

Removals: None

Other updates: None

July 2023

Title 19/21 SMI drug list updates

Additions

• Gefitinib 250 mg tablet (prior authorization)

• Kalydeco 13.4 mg packet (prior authorization)

• Lurasidone 120 mg tablet (quantity limit, age limit)

• Lurasidone 20 mg tablet (quantity limit, age limit)

• Lurasidone 40 mg tablet (quantity limit, age limit)

• Lurasidone 60 mg tablet (quantity limit, age limit)

• Lurasidone 80 mg tablet (quantity limit, age limit)

• Mekinist 0.05 mg per mL solution (prior authorization)

• Tafinlar 10 mg tablet (prior authorization)

• Trikafta 100 mg/50 mg/75 mg/75 mg therapy pack (prior authorization)

• Trikafta 80 mg/40 mg/60 mg/59.5 mg therapy pack (prior authorization)

Removals

• Esomeprazole magnesium delayed release 40 mg capsule

• Iressa 250 mg tablet

• Latuda 120 mg tablet

• Latuda 20 mg tablet

• Latuda 40 mg tablet

• Latuda 60 mg tablet

• Latuda 80 mg tablet

• Omega-3 ethyl esters 1 gm capsule

• Sucraid 8500 unit per mL solution

Other updates: None

Non-Title 19/21 drug list updates

Additions: None

 Removals: None

 Other updates: None

June 2023

Title 19/21 SMI drug list updates

Additions

• First-metronidazole 50 mg/mL suspension (age limit)

• Tinidazole 250 mg tablet

• Tinidazole 500 mg tablet

• Vancomycin 25 mg per mL oral solution

• Vancomycin 50 mg per mL oral solution

Removals

• Firvanq 25 mg per mL oral solution

• Firvanq 50 mg per mL oral solution

• Repatha prefilled syringe 140 mg per mL solution

• Repatha Pushtronex cartridge 420 mg per 3.5 mL solution

• Repatha SureClick auto-injector 140 mg per mL solution

Other updates: None

Non-Title 19/21 drug list updates

Additions: None

Removals: None

Other updates: None

May 2023

Title 19/21 SMI drug list updates

Additions

• Gilenya 0.25 mg capsule (prior authorization, quantity limit)

• Trikafta 100 mg/50 mg/75 mg/150 mg tablet (prior authorization)

• Trikafta 50 mg/25 mg/37.5 mg/75 mg tablet (prior authorization)

Removals

• Capsaicin 0.1% cream

• Lidocaine 4% cream

• Triamcinolone acetonide powder

Other updates

• Fexofenadine 30 mg per 5 mL (changed quantity limit)

• Fingolimod 0.5 mg capsule (added quantity limit)

• Freestyle Libre 14 Day Sensor (changed quantity limit)

• Freestyle Libre 2 Sensor (changed quantity limit)

• Freestyle Libre 3 Sensor (changed quantity limit)

Non-Title 19/21 drug list updates

Additions: None

Removals: None

Other updates: None

April 2023

Title 19/21 SMI drug list updates

Additions

• Ambrisentan 10 mg tablet (prior authorization)

• Ambrisentan 5 mg tablet (prior authorization)

• Aranesp 10 mcg per 0.4 mL prefilled syringe solution (prior authorization)

• Aranesp 100 mcg per 0.5 mL prefilled syringe solution (prior authorization)

• Aranesp 150 mcg per 0.3 mL prefilled syringe solution (prior authorization)

• Aranesp 200 mcg per 0.4 mL prefilled syringe solution (prior authorization)

• Aranesp 25 mcg per 0.42 mL prefilled syringe solution (prior authorization)

• Aranesp 300 mcg per 0.6 mL prefilled syringe solution (prior authorization)

• Aranesp 40 mcg per 0.4 mL prefilled syringe solution (prior authorization)

• Aranesp 500 mcg per 1 mL prefilled syringe solution (prior authorization)

• Aranesp 60 mcg per 0.3 mL prefilled syringe solution (prior authorization)

• Armour Thyroid 120 mg tablet

• Armour Thyroid 15 mg tablet

• Armour Thyroid 30 mg tablet

• Armour Thyroid 60 mg tablet

• Armour Thyroid 90 mg tablet

• Bivigam 5 gm per 50 mL intravenous solution (prior authorization)

• Bosentan 125 mg tablet (prior authorization)

• Bosentan 62.5 mg tablet (prior authorization)

• Fylnetra 6 mg per 0.6 mL prefilled syringe (prior authorization)

• Nivestym 300 mcg per mL solution (prior authorization)

• Nivestym 480 mcg per 1.6 mL solution (prior authorization)

• Octagam 1 gm per 200 mL (5%) intravenous solution (prior authorization)

• Octagam 10 gm per 100 mL (10%) intravenous solution (prior authorization)

• Octagam 10 gm per 200 mL (5%) intravenous solution (prior authorization)

• Octagam 2 gm per 20 mL (10%) intravenous solution (prior authorization)

• Octagam 20 gm per 200 mL (10%) intravenous solution (prior authorization)

• Octagam 30 gm per 300 mL (10%) intravenous solution (prior authorization)

• Octagam 5 gm per 100 mL (5%) intravenous solution (prior authorization)

• Octagam 5 gm per 50 mL (10%) intravenous solution (prior authorization)

• Pradaxa 110 mg pellet packet (quantity limit)

• Pradaxa 150 mg pellet packet (quantity limit)

• Pradaxa 20 mg pellet packet (quantity limit)

• Pradaxa 30 mg pellet packet (quantity limit)

• Pradaxa 40 mg pellet packet (quantity limit)

• Pradaxa 50 mg pellet packet (quantity limit)

• Testosterone 50 mg per 5 gm (1%) gel (prior authorization) (limited to one NDC)

• Xembify 1 gm per 5 mL (20%) solution vial (prior authorization)

• Xembify 10 gm per 50 mL (20%) solution vial (prior authorization)

• Xembify 2 gm per 10 mL (20%) solution vial (prior authorization)

• Xembify 4 gm per 20 mL (20%) solution vial (prior authorization)

• Ziextenzo 6 mg per 0.6 mL prefilled syringe (prior authorization)

• Zovirax 5% ointment (quantity limit)

Removals

• Acyclovir 5% ointment

• Aubagio 14 mg tablet

• Aubagio 7 mg tablet

• Fulphila 6 mg per 0.6 mL prefilled syringe

• Imbruvica 140 mg tablet

• Imbruvica 280 mg tablet

• Imbruvica 420 mg tablet

• Imbruvica 560 mg tablet

• Lenalidomide 10 mg capsule

• Lenalidomide 15 mg capsule

• Lenalidomide 20 mg capsule

• Lenalidomide 25 mg capsule

• Lenalidomide 5 mg capsule

• Letairis 10 mg tablet

• Letairis 5 mg tablet

• Leukeran 2 mg tablet

• Myleran 2 mg tablet

• Neupogen 300 mcg per 0.5 mL prefilled syringe

• Neupogen 300 mcg per 0.5 mL vial

• Neupogen 480 mcg per 0.8 mL prefilled syringe

• Neupogen 480 mcg per 1.6 mL vial

• Nyvepria 6 mg per 0.6 mL prefilled syringe

• Provida OB 20 mg/ 20 mg/1.5 mg capsule

• Rydapt 25 mg capsule

• Salicylic acid 6% cream

• Salicylic acid 6% shampoo

• Tabloid 40 mg tablet

• Tamiflu 30 mg capsule

• Tamiflu 45 mg capsule

• Tamiflu 6 mg per mL suspension

• Tamiflu 75 mg capsule

• Tracleer 125 mg tablet

• Tracleer 62.5 mg tablet

• Udenyca 6 mg per 0.6 mL prefilled syringe

• Venclexta 10 mg tablet

• Venclexta 100 mg tablet

• Venclexta 50 mg tablet

• Venclexta starting pack

• Xofluza 40 mg therapy pack

• Xofluza 80 mg therapy pack

Other updates: None

Non-Title 19/21 drug list updates

Additions

• Lurasidone 120 mg tablet (quantity limit, age limit)

• Lurasidone 20 mg tablet (quantity limit, age limit)

• Lurasidone 40 mg tablet (quantity limit, age limit)

• Lurasidone 60 mg tablet (quantity limit, age limit)

• Lurasidone 80 mg tablet (quantity limit, age limit)

Removals

• Latuda 120 mg tablet

• Latuda 20 mg tablet

• Latuda 40 mg tablet

• Latuda 60 mg tablet

• Latuda 80 mg tablet

Other updates: None

March 2023

Title 19/21 SMI drug list updates

Additions

• Guaifenesin 100 mg/codeine 6.33 mg per 5 mL solution (quantity limit, age limit, OTC)

Removals: None

Other updates

• Advair Diskus 100 mcg/50 mcg per actuation (removed step therapy)

• Advair Diskus 250 mcg/50 mcg per actuation (removed step therapy)

• Advair Diskus 500 mcg/50 mcg per actuation (removed step therapy)

• Advair HFA 115 mcg/21 mcg per actuation (removed step therapy)

• Advair HFA 230 mcg/21 mcg per actuation (removed step therapy)

• Advair HFA 45 mcg/21 mcg per actuation (removed step therapy)

• Dulera 100 mcg/5 mcg per actuation (removed step therapy)

• Dulera 200 mcg/5 mcg per actuation (removed step therapy)

• Dulera 50 mcg/5 mcg per actuation (removed step therapy)

• Pregabalin 100 mg capsule (removed prior authorization, updated quantity limit)

• Pregabalin 150 mg capsule (removed prior authorization, updated quantity limit)

• Pregabalin 20 mg per mL solution (removed prior authorization, updated quantity limit)

• Pregabalin 200 mg capsule (removed prior authorization, updated quantity limit)

• Pregabalin 225 mg capsule (removed prior authorization, updated quantity limit)

• Pregabalin 25 mg capsule (removed prior authorization, updated quantity limit)

• Pregabalin 300 mg capsule (removed prior authorization, updated quantity limit)

• Pregabalin 50 mg capsule (removed prior authorization, updated quantity limit)

• Pregabalin 75 mg capsule (removed prior authorization, updated quantity limit)

• Symbicort 160 mcg/4.5 mcg per actuation (removed step therapy)

• Symbicort 80 mcg/4.5 mcg per actuation (removed step therapy)

Non-Title 19/21 drug list updates

Additions: None

Removals: None

Other updates: None

February 2023

Title 19/21 SMI drug list updates

Additions

• Dificid 200 mg tablet (prior authorization)

• Dificid 40 mg/mL suspension (prior authorization)

• Ethacrynic acid 25 mg tablet

• Fluocinolone acetonide 0.01% otic oil (quantity limit, OTC)

• Lactobacillus extra strength capsule (OTC)

• Miconazole nitrate vaginal suppository 1200 mg and 2% cream kit (OTC)

• Phenylephrine 10 mg/dextromethorphan 18 mg/guaifenesin 200 mg per 15mL liquid (quantity limit, OTC)

• Pramoxine hydrochloride (perianal) 1% foam (quantity limit, OTC)

• Probiotic capsule (OTC)

• Pseudoephedrine 30 mg/dexchlorpheniramine 1 mg/chlophedianol 5 mg per 5mL liquid (quantity limit, OTC)

• Refresh Relieva 0.5/1% preservative-free ophthalmic solution (OTC)

• Sodium fluoride 1.1%/5% gel

• Xifaxan 550 mg tablet (prior authorization)

Removals

• Benzocaine 20 mg/docusate sodium 283 mg rectal enema

• Bisacodyl 10 mg/30 mL enema (OTC)

• Brimonidine tartrate 0.2%/timolol 0.5% ophthalmic solution

• Celontin 300 mg capsule

• Colchicine 0.6 mg capsule

• Ibrance 100 mg tablet

• Ibrance 125 mg tablet

• Ibrance 75 mg tablet

• Levofloxacin 0.5% ophthalmic solution

• Magnesium hydroxide concentrate 2400 mg/10 mL

• Naproxen delayed release, enteric coated 500 mg tablet

• Pirfenidone 267 mg capsule

• Potassium citrate 550 mg/sodium citrates 500 mg/citric acid 334 mg per 5mL solution

Other updates

• Azelastine HCl 0.05% ophthalmic solution (removed step therapy)

• Celecoxib 100 mg capsule (removed step therapy)

• Celecoxib 200 mg capsule (removed step therapy)

• Celecoxib 400 mg capsule (removed step therapy)

• Celecoxib 50 mg capsule (removed step therapy)

• Vancomycin HCl 125 mg capsule (removed prior authorization, added quantity limit)

• Vancomycin HCl 250 mg capsule (removed prior authorization, added quantity limit)

Non-Title 19/21 drug list updates

Additions: None

Removals: None

Other updates: None

January 2023

Title 19/21 SMI drug list updates

Additions

• Dupixent pen-injector 200 mg/1.14 mL solution (prior authorization)

• Dupixent pen-injector 300 mg/2 mL solution (prior authorization)

• Dupixent prefilled syringe 100 mg/0.67 mL solution (prior authorization)

• Dupixent prefilled syringe 200 mg/1.14 mL solution (prior authorization)

• Dupixent prefilled syringe 300 mg/2 mL solution (prior authorization)

• Eucrisa 2% ointment (prior authorization)

• Pimecrolimus 1% cream (prior authorization)

• Berinert kit 500 unit (prior authorization)

• Cinryze vial 500 unit (prior authorization)

• Firazyr syringe 30 mg/3 mL (prior authorization)

• Kalbitor vial 10 mg/mL (prior authorization)

• Orladeyo 150 mg capsule (prior authorization)

• Symfi Lo 400 mg/300 mg/300 mg tablet

• Symfi 600 mg/300 mg/300 mg tablet

• Triumeq PD 60 mg/5 mg/30 mg soluble tablet

• Vfend 40 mg/mL suspension

• Ella 30 mg tablet (quantity limit)

• Tafluprost (PF) ophthalmic 0.0015% suspension

Removals

• Invirase 200 mg capsule

• Invirase 500 mg tablet

• Stavudine 15 mg capsule

• Stavudine 20 mg capsule

• Stavudine 30 mg capsule

• Stavudine 40 mg capsule

• Viracept 250 mg tablet

• Viracept 625 mg tablet

• Zioptan ophthalmic 0.0015% solution

• All Non-OneTouch Delica and Delica Plus Lancets and Lancet Devices

Other updates: None

Non-Title 19/21 drug list updates

Additions: None

Removals: None

Other updates: None