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2024 EmblemHealth Formulary Changes

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2024 EmblemHealth Formulary Changes

11/01/2023

The tables below describes all formulary changes going into effect for our Medicare and Medicaid members in 2024. For our commercial members, this table highlights the most highly impacted drugs. For a comprehensive listing of all plans see: 2024 Summary of Companies, Lines of Business, Networks & Benefit Plans.

See the applicable 2024 plan formularies for all coverage rules:

Note: Affected members were notified of these changes separately.

 Advantage Plans
Removed From Formulary in 2024
Drug Alternative(s)
ALPHAGAN P 0.1% DROPS BRIMONIDINE TARTRATE
AUBAGIO 7 MG or 14 MG TABLET Fingolimod, Dimethyl Fumarate, Teriflunomide
CELONTIN 300 MG CAPSULE METHSUXIMIDE
CIPRO 5% or 10% SUSPENSION CIPROFLOXACIN
CLINDAMYCIN (PEDI) 75 MG/5 ML Clindamycin Capsules
DALIRESP 250 MCG or 500 MCG TABLET THEOPHYLLINE, QVAR REDIHALER, STRIVERDI RESPIMAT
DENAVIR 1% CREAM PENCICLOVIR
ESTRING 2 MG VAGINAL RING ESTRADIOL
ESTRING 7.5 MCG/DAY (2MG) RING ESTRADIOL
EULEXIN 125 MG CAPSULE FLUTAMIDE
FAMOTIDINE 40 MG/5 ML SUSP Famotidine Tablets, Cimetidine Solution, Cimetidine Tablets
FLOVENT 50 MCG, 100 MCG or 250 MCG DISKUS Asmanex Twisthaler, Pulmicort Flexhaler
FLOVENT HFA 44 MCG, 110 MCG or 220 MCG INHALER Qvar Redihaler, Asmanex HFA, Alvesco Inhaler
GILENYA 0.5 MG CAPSULE FINGOLIMOD
HETLIOZ 20 MG CAPSULE TASIMELTEION
KOMBIGLYZE XR 2.5-1,000 MG, 5-500 MG or 5-1,000 MG TAB Janumet, Jentadueto
LATUDA 20 MG, 40 MG, 60 MG, 80 MG or 120 MG TABLET ARIPIPRAZOLE, OLANZAPINE, PALIPERIDONE ER
LIVALO 1 MG, 2 MG or 4 MG TABLET ATORVASTATIN CALCIUM, ROSUVASTATIN CALCIUM, SIMVASTATIN
LUPRON DEPOT 11.25 MG or 22.5 MG 3MO KIT Eligard, Leuprolide
LUPRON DEPOT 45 MG 6MO KIT Eligard, Leuprolide
LUPRON DEPOT-4 MONTH KIT Eligard, Leuprolide
LUPRON DEPOT-PED 11.25 MG or 30 MG 3MO Eligard, Leuprolide
LUPRON DEPOT-PED 45 MG 6MO KIT Eligard, Leuprolide
LUPRON DEPOT-PED 7.5 MG, 11.25 MG or 15 MG KIT Eligard, Leuprolide
MOTEGRITY 1 MG or 2 MG TABLET TRULANCE
NAFTIN 2% GEL NAFTIFINE
NOVOFINE 32G NEEDLES B-D PEN NEEDLES
NOVOFINE PLUS PEN NDL 32GX1/6" B-D PEN NEEDLES
NOVOTWIST NEEDLE 32G 5MM B-D PEN NEEDLES
OCREVUS 300 MG/10 ML VIAL Glatiramer, Plegridy
ONGLYZA 2.5 MG or 5 MG TABLET Januvia, Tradjenta
ORLADEYO 110 MG or 150 MG CAPSULE Cinryze
OXANDROLONE 2.5 MG or 10 MG TABLET WITHDRAWN FROM THE MARKET
PENTASA 500 MG CAPSULE Pentasa 250mg Capsule, Sulfasalazine, Mesalamine
PREZISTA 600 MG or 800 MG TABLET DARUNAVIR
REVLIMID 2.5 MG, 5 MG, 10 MG, 15 MG, 20 MG or 25 MG CAPSULE LENALIDOMIDE, Pomalyst
SYMBICORT 80-4.5 MCG or 160-4.5 MCG INHALER BUDESONIDE/FORMOTEROL, Fluticasone-Salmeterol, Breo Ellipta
SYMJEPI 0.15 MG/0.3 ML or 0.3 MG/0.3 ML SYRINGE EPINEPHRINE
VASCEPA 0.5 GM CAPSULE ICOSAPENT ETHYL
VICTOZA 2-PAK or 3-PAK 18 MG/3 ML PEN Trulicity, Ozempic, Rybelsus
XYREM 500 MG/ML ORAL SOLUTION SODIUM OXYBATE

 

Medicare Advantage Plans

Preauthorization Requirements Added in 2024
QULIPTA 60 MG TABLET HYDROXYZINE HCL 10 MG TABLET ROFLUMILAST 250 MCG TABLET
QULIPTA 30 MG TABLET HYDROXYZINE HCL 25 MG TABLET SILDENAFIL 20 MG TABLET
ELIGARD 45 MG SYRINGE KIT HYDROXYZINE HCL 50 MG TABLET TACROLIMUS 0.03% OINTMENT
AMPICILLIN-SULBACTAM 1.5 GM VL KOSELUGO 10 MG CAPSULE TACROLIMUS 1 MG CAPSULE (IR)
AMPICILLIN-SULBACTAM 3 GM VIAL KOSELUGO 25 MG CAPSULE TADALAFIL 20 MG TABLET
CLORAZEPATE 15 MG TABLET LENALIDOMIDE 10 MG CAPSULE TERIFLUNOMIDE 14 MG TABLET
CLORAZEPATE 3.75 MG TABLET LENALIDOMIDE 2.5 MG CAPSULE TERIFLUNOMIDE 7 MG TABLET
CLORAZEPATE 7.5 MG TABLET LENALIDOMIDE 5 MG CAPSULE TOPIRAMATE 100 MG TABLET
CYCLOBENZAPRINE 10 MG TABLET LORAZEPAM 1 MG TABLET TOPIRAMATE 200 MG TABLET
DEFERASIROX 180 MG GRANULE PKT MEGESTROL 400 MG/10 ML CUP TOPIRAMATE 25 MG TABLET
DEFERASIROX 360 MG GRANULE PKT MEMANTINE HCL 10 MG TABLET TOPIRAMATE 50 MG TABLET
DIAZEPAM 5 MG TABLET MYFEMBREE 40 MG-1 MG-0.5 MG TB VANCOMYCIN 1 GM VIAL
DROXIDOPA 200 MG CAPSULE ONDANSETRON HCL 4 MG TABLET VANCOMYCIN 500 MG VIAL
ELIGARD 22.5 MG SYRINGE KIT PREVYMIS 240 MG TABLET VANCOMYCIN HCL 10 GM VIAL
ELIGARD 30 MG SYRINGE KIT PREVYMIS 480 MG TABLET VANCOMYCIN HCL 125 MG CAPSULE
ELIGARD 7.5 MG SYRINGE KIT PROMETHAZINE 6.25 MG/5 ML SOLN VANCOMYCIN HCL 250 MG CAPSULE
ENDARI 5 GRAM POWDER PACKET QULIPTA 10 MG TABLET VIGABATRIN 500 MG TABLET
ERTAPENEM 1 GRAM VIAL RADICAVA ORS 105 MG/5 ML SUSP VIGADRONE 500 MG POWDER PACKET
ESTRADIOL 1 MG TABLET RADICAVA ORS STARTER KIT SUSP  
ESTRADIOL 2 MG TABLET REZUROCK 200 MG TABLET  

 

Medicare Advantage Members
New Quantity Limits for 2024
Drug Amount/Frequency
ACETAMIN-CODEIN 300-30 MG/12.5 4500 ML/23 DAYS
ACETAMINOP-CODEINE 120-12 MG/5 4500 ML/23 DAYS
ARFORMOTEROL 15 MCG/2 ML SOLN 60 VIALS/MONTH
ARIPIPRAZOLE 2 MG, 5 MG, 10 MG or 15 MG TABLET 30/MONTH
ATORVASTATIN 10 MG, 20 MG, 40 MG or 80 MG TABLET 30/MONTH
BUPRENORPHINE-NALOX 12-3MG FLM 60/23 DAYS
BUPRENORPHINE-NALOX 2-0.5MG TB 360/23 DAYS
BUPRENORPHINE-NALOX 8-2 MG TAB 90/23 DAYS
BUPROPION HCL SR 150 MG TABLET 60/MONTH
BUPROPION HCL XL 150 MG TABLET 90/MONTH
BUPROPION HCL XL 300 MG TABLET 30/MONTH
CICLOPIROX 8% SOLUTION 6.6 ML/28 DAYS
CIPROFLOX-DEXAMETH OTIC SUSP 1 BOTTLE/WEEK
CITALOPRAM HBR 40 MG TABLET 30/MONTH
CLINDAMYCIN PH 1% SOLUTION 120 ML/23 DAYS
CLOBETASOL 0.05% GEL 120 GM/21 DAYS
CLONAZEPAM 0.5 MG TABLET 90/MONTH
CLOPIDOGREL 75 MG TABLET 30/MONTH
CLORAZEPATE 15 MG TABLET 180/MONTH
CLORAZEPATE 3.75 MG TABLET 90/MONTH
CLORAZEPATE 7.5 MG TABLET 360/MONTH
DESVENLAFAXINE SUCCNT ER 25 MG or 50 MG 30/MONTH
DIAZEPAM 5 MG TABLET 120/MONTH
DULOXETINE HCL DR 20 MG, 30 MG or 60 MG CAP 60/MONTH
ECONAZOLE NITRATE 1% CREAM 85 GM/21 DAYS
ENOXAPARIN 120 MG/0.8 ML SYR 1 SYR/MONTH
ERTAPENEM 1 GRAM VIAL 14/14 DAYS
ESCITALOPRAM 10 MG TABLET 30/MONTH
ESOMEPRAZOLE MAG DR 40 MG CAP 60/MONTH
FLUOXETINE HCL 20 MG CAPSULE 90/MONTH
FLUOXETINE HCL 40 MG CAPSULE 60/MONTH
FORMOTEROL 20 MCG/2 ML NEB VL 60 VIALS/MONTH
GABAPENTIN 600 MG TABLET 180/MONTH
GABAPENTIN 800 MG TABLET 120/MONTH
GLIMEPIRIDE 1 MG TABLET 240/MONTH
GLIMEPIRIDE 2 MG TABLET 120/MONTH
GLIMEPIRIDE 4 MG TABLET 60/MONTH
GLIPIZIDE-METFORMIN 2.5-250 MG 240/MONTH
GLIPIZIDE-METFORMIN 2.5-500 MG or 5-500 MG 120/MONTH
HUMIRA(CF) PEN 80 MG/0.8 ML 2 UNITS/FILL
HUMIRA(CF) PEN CRHN-UC-HS 80MG 1 UNIT/MONTH
HYDROCODONE-ACETAMIN 7.5-325 or 10-325 MG 360/23 DAYS
JENTADUETO  2.5 MG-500 MG TAB or 2.5 MG-1,000 MG TAB 60/MONTH
JENTADUETO XR 2.5 MG-1,000 MG 60/MONTH
JENTADUETO XR 5 MG-1,000 MG TB 30/MONTH
KALYDECO 150 MG TABLET 60/MONTH
LACOSAMIDE 10 MG/ML SOLUTION 1,200 ML/30 DAYS
LACOSAMIDE 150 MG/15 ML CUP 1,200 ML/MONTH
LACOSAMIDE 200 MG/20 ML CUP 1,200 ML/MONTH
LANSOPRAZOLE DR 30 MG CAPSULE 60/MONTH
LENALIDOMIDE 2.5 MG, 5 MG or 10 MG CAPSULE 30/MONTH
LENVIMA 10 MG DAILY DOSE 30/MONTH
LENVIMA 12 MG DAILY DOSE 90/MONTH
LENVIMA 14 MG DAILY DOSE 60/MONTH
LENVIMA 18 MG DAILY DOSE 90/MONTH
LENVIMA 20 MG DAILY DOSE 60/MONTH
LENVIMA 24 MG DAILY DOSE 90/MONTH
LENVIMA 4 MG CAPSULE 30/MONTH
LENVIMA 8 MG DAILY DOSE 60/MONTH
LIDOCAINE 5% OINTMENT 1 TUBE/23 DAYS
LIDOCAINE-PRILOCAINE CREAM 30 GM TUBE/23 DAYS
LORAZEPAM 1 MG TABLET 90/MONTH
LOVASTATIN 20 MG TABLET 60/MONTH
MELOXICAM 7.5 MG or 15 MG TABLET 30/MONTH
METFORMIN HCL 1,000 MG TABLET 75/MONTH
METFORMIN HCL 500 MG TABLET 150/MONTH
METFORMIN HCL 850 MG TABLET 90/MONTH
METFORMIN HCL ER 500 MG TABLET 120/MONTH
METFORMIN HCL ER 750 MG TABLET 60/MONTH
MORPHINE SULF 10 MG/5 ML CUP 900 ML/23 DAYS
MOVANTIK 12.5 MG or 25 MG TABLET 30/MONTH
OLANZAPINE 20 MG TABLET 30/MONTH
OMEPRAZOLE DR 40 MG CAPSULE 60/MONTH
OXYCODONE HCL (IR) 10 MG TAB 180/23 DAYS
PALIPERIDONE ER 1.5 MG, 3 MG or 9 MG TABLET 30/MONTH
PALIPERIDONE ER 6 MG TABLET 60/MONTH
PANTOPRAZOLE SOD DR 40 MG TAB 60/MONTH
PERMETHRIN 5% CREAM 60 GM TUBE/MONTH
PREGABALIN 150 MG CAPSULE 90/MONTH
QUETIAPINE FUMARATE 25 MG, 50 MG, 100 MG or 200 MG TAB 90/MONTH
QULIPTA 10 MG, 30 MG or 60 MG TABLET 30/MONTH
REGRANEX 0.01% GEL 15 GM TUBE/MONTH
REZUROCK 200 MG TABLET 30/MONTH
ROFLUMILAST 250 MCG TABLET 30/MONTH
ROSUVASTATIN CALCIUM 5 MG, 10 MG, 20 MG or 40 MG TAB 30/MONTH
RYDAPT 25 MG CAPSULE 240/MONTH
SERTRALINE HCL 100 MG TABLET 60/MONTH
SERTRALINE HCL 25 MG TABLET 30/MONTH
SEVELAMER CARBONATE 800 MG TAB 270/MONTH
SHINGRIX VIAL KIT 2 VACCINES/2 YEARS
SILDENAFIL 20 MG TABLET 90/MONTH
SYNJARDY XR 10-1,000 MG TABLET 30/MONTH
TACROLIMUS 0.03% OINTMENT 100 GM/23 DAYS
TADALAFIL 20 MG TABLET 60/MONTH
TALZENNA 0.25 MG CAPSULE 30/MONTH
TERIFLUNOMIDE 7 MG or 14 MG TABLET 30/MONTH
TRADJENTA 5 MG TABLET 30/MONTH
TRULANCE 3 MG TABLET 30/MONTH
VALACYCLOVIR HCL 1 GRAM TABLET 120/MONTH
VALACYCLOVIR HCL 500 MG TABLET 60/MONTH
VANCOMYCIN 1 GM VIAL 20/10 DAYS
VANCOMYCIN 500 MG VIAL 10/10 DAYS
VANCOMYCIN HCL 10 GM VIAL 2/10 DAYS
VANCOMYCIN HCL 125 MG CAPSULE 40/10 DAYS
VANCOMYCIN HCL 250 MG CAPSULE 80/10 DAYS
XERMELO 250 MG TABLET 90/MONTH
XOSPATA 40 MG TABLET 90/MONTH
ZIPRASIDONE HCL 80 MG CAPSULE 60/MONTH
ZOLINZA 100 MG CAPSULE 120/MONTH
ZOLPIDEM TARTRATE 5 MG TABLET 30/MONTH

 

Medicare Advantage Plans
Tier Changes for 2024
Drug Change 2024 Tier
ABIRATERONE ACETATE 250 MG TAB TIER INCREASE Tier 5
ABIRATERONE ACETATE 500 MG TAB TIER INCREASE Tier 5
APTIOM 200 MG TABLET TIER INCREASE Tier 5
APTIOM 400 MG TABLET TIER INCREASE Tier 5
APTIOM 600 MG TABLET TIER INCREASE Tier 5
APTIOM 800 MG TABLET TIER INCREASE Tier 5
ARIKAYCE 590 MG/8.4 ML VIAL TIER INCREASE Tier 5
AUGMENTIN 125-31.25 MG/5 ML TIER INCREASE Tier 4
COMPLERA TABLET TIER INCREASE Tier 5
CRESEMBA 186 MG CAPSULE TIER INCREASE Tier 5
DESMOPRESSIN 0.01% SOLUTION TIER INCREASE Tier 4
DESMOPRESSIN 10 MCG/0.1 ML SPR TIER INCREASE Tier 4
DILANTIN 30 MG CAPSULE TIER INCREASE Tier 4
EPIDIOLEX 100 MG/ML SOLN PACK TIER INCREASE Tier 5
EPIDIOLEX 100 MG/ML SOLUTION TIER INCREASE Tier 5
GLEOSTINE 10 MG CAPSULE TIER INCREASE Tier 5
GLEOSTINE 100 MG CAPSULE TIER INCREASE Tier 5
GLEOSTINE 40 MG CAPSULE TIER INCREASE Tier 5
ICOSAPENT ETHYL 0.5 GM CAPSULE TIER INCREASE Tier 3
ICOSAPENT ETHYL 1 GRAM CAPSULE TIER INCREASE Tier 3
ICOSAPENT ETHYL 500 MG CAPSULE TIER INCREASE Tier 3
LURASIDONE HCL 120 MG TABLET TIER INCREASE Tier 5
LURASIDONE HCL 20 MG TABLET TIER INCREASE Tier 5
LURASIDONE HCL 40 MG TABLET TIER INCREASE Tier 5
LURASIDONE HCL 60 MG TABLET TIER INCREASE Tier 5
LURASIDONE HCL 80 MG TABLET TIER INCREASE Tier 5
OCALIVA 10 MG TABLET TIER INCREASE Tier 5
OCALIVA 5 MG TABLET TIER INCREASE Tier 5
ONUREG 200 MG TABLET TIER INCREASE Tier 5
ONUREG 300 MG TABLET TIER INCREASE Tier 5
OXERVATE 0.002% EYE DROP TIER INCREASE Tier 5
PRIMAQUINE 26.3 MG TABLET TIER INCREASE Tier 4
PROLIA 60 MG/ML SYRINGE TIER INCREASE Tier 4
SYMTUZA 800-150-200-10 MG TAB TIER INCREASE Tier 5
TESTOSTERONE 1.62% (2.5 G) PKT TIER INCREASE Tier 3
TESTOSTERONE 1.62% GEL PUMP TIER INCREASE Tier 4
TESTOSTERONE 1.62%(1.25 G) PKT TIER INCREASE Tier 4
TESTOSTERONE 10 MG GEL PUMP TIER INCREASE Tier 4
TESTOSTERONE 30 MG/1.5 ML PUMP TIER INCREASE Tier 4
VYNDAMAX 61 MG CAPSULE TIER INCREASE Tier 5
XPOVIO 100 MG ONCE WEEKLY DOSE TIER INCREASE Tier 5
XPOVIO 40 MG ONCE WEEKLY DOSE TIER INCREASE Tier 5
XPOVIO 40 MG TWICE WEEKLY DOSE TIER INCREASE Tier 5
XPOVIO 60 MG ONCE WEEKLY DOSE TIER INCREASE Tier 5
XPOVIO 60 MG TWICE WEEKLY DOSE TIER INCREASE Tier 5
XPOVIO 80 MG ONCE WEEKLY DOSE TIER INCREASE Tier 5
XPOVIO 80 MG TWICE WEEKLY DOSE TIER INCREASE Tier 5

Medicare – CNY PDP
Step Therapy Added for 2024
PREVYMIS 480 MG TABLET NOVOLOG 100 UNIT/ML VIAL ADMELOG 100 UNIT/ML VIAL
RADICAVA ORS 105 MG/5 ML SUSP INSULIN ASPART 100 UNIT/ML VL APIDRA 100 UNIT/ML VIAL

 

Medicare – CNY PDP
Preauthorization Requirements for 2024
ONGLYZA 5 MG TABLET FLOVENT 100 MCG DISKUS NOVOFINE AUTOCOVER 30G NEEDLE
SYMBICORT 160-4.5 MCG INHALER FLOVENT HFA 110 MCG INHALER NOVOFINE PLUS PEN NDL 32GX1/6"
SYMBICORT 80-4.5 MCG INHALER KOMBIGLYZE XR 2.5-1,000 MG TAB KOMBIGLYZE XR 5-500 MG TABLET
FLOVENT 250 MCG DISKUS FLOVENT HFA 44 MCG INHALER VASCEPA 0.5 GM CAPSULE
SPIRIVA HANDIHALER 18 MCG CAP FLOVENT HFA 220 MCG INHALER FLOVENT 50 MCG DISKUS
NOVOFINE 32G NEEDLES ONGLYZA 2.5 MG TABLET KOMBIGLYZE XR 5-1,000 MG TAB

City of NY PPO
Removed From Formulary in 2024
Drug Alternative(s)
APLENZIN BUPROPION XL
AUBAGIO TERIFLUNOMIDE
ENDOMETRIN CRINONE
BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT
KEVEYIS DICHLORPHENAMIDE
LATUDA LURASIDONE HCL
LEVEMIR SEMGLEE (YFGN), TOUJEO SOLOSTAR, TRESIBA
LEVEMIR FLEXPEN SEMGLEE (YFGN) PEN, TOUJEO SOLOSTAR, TRESIBA FLEXTOUCH U-100
LEVEMIR FLEXTOUCH SEMGLEE (YFGN) PEN, TOUJEO SOLOSTAR, TRESIBA FLEXTOUCH U-100
QUILLICHEW ER DEXMETHYLPHENIDATE HCL ER, METHYLPHENIDATE HCL CD, METHYLPHENIDATE HCL ER (CD), METHYLPHENIDATE LA
QUILLIVANT XR DEXMETHYLPHENIDATE HCL ER, METHYLPHENIDATE HCL CD, METHYLPHENIDATE HCL ER (CD), METHYLPHENIDATE LA
SEREVENT DISKUS STRIVERDI RESPIMAT
STEGLUJAN GLYXAMBI
XULTOPHY 100-3.6 SOLIQUA 100-33

Small Group/Essential/Individual Plans
Removed From Formulary in 2024
Drug Alternative(s)
APLENZIN BUPROPION XL
AUBAGIO TERIFLUNOMIDE
BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT
CHORIONIC GONADOTROPIN NOVAREL, OVIDREL
CITRANATAL 90 DHA PNV-DHA, PRENA1 PEARL, VIRT-PN DHA
CITRANATAL ASSURE PNV-DHA, PRENA1 PEARL, VIRT-PN DHA
CITRANATAL HARMONY PNV-DHA, PRENA1 PEARL, VIRT-PN DHA
DYANAVEL XR DEXTROAMPHETAMINE SULFATE ER, DEXTROAMPHETAMINE-AMPHET ER, MYDAYIS, VYVANSE
ENDOMETRIN CRINONE
IBRANCE KISQALI, VERZENIO
LATUDA LURASIDONE HCL
LEVEMIR SEMGLEE (YFGN), TOUJEO SOLOSTAR, TRESIBA
LEVEMIR FLEXPEN SEMGLEE (YFGN) PEN, TOUJEO SOLOSTAR, TRESIBA FLEXTOUCH U-100
LEVEMIR FLEXPEN SEMGLEE (YFGN) PEN, TOUJEO SOLOSTAR, TRESIBA FLEXTOUCH U-100
LUPRON DEPOT-PED FENSOLVI, TRIPTODUR
NATESTO TESTOSTERONE, ANDRODERM
QUILLIVANT XR DEXMETHYLPHENIDATE HCL ER, METHYLPHENIDATE HCL CD, METHYLPHENIDATE HCL ER (CD), METHYLPHENIDATE LA
SEREVENT DISKUS STRIVERDI RESPIMAT
STEGLUJAN GLYXAMBI
XULTOPHY 100-3.6 SOLIQUA 100-33
ZARXIO NIVESTYM

Commercial Large Group
Removed From Formulary in 2024
Drug Alternative(s)
ALVESCO ARNUITY ELLIPTA, ASMANEX HFA
APLENZIN BUPROPION XL
AUBAGIO TERIFLUNOMIDE
BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT
BIDIL ISOSORBIDE DINIT-HYDRALAZINE
BRAFTOVI TAFINLAR, ZELBORAF
CARAFATE SUCRALFATE
CITRANATAL 90 DHA PNV-DHA, PRENA1 PEARL
CITRANATAL ASSURE PNV-DHA, PRENA1 PEARL
CITRANATAL HARMONY PNV-DHA, PRENA1 PEARL
DYANAVEL XR DEXTROAMPHETAMINE SULFATE ER, DEXTROAMPHETAMINE-AMPHET ER
FLOVENT DISKUS ARNUITY ELLIPTA, ASMANEX HFA
FLOVENT HFA ARNUITY ELLIPTA, ASMANEX HFA
GILENYA Generic equivalent available
IBRANCE KISQALI, VERZENIO
KEVEYIS DICHLORPHENAMIDE
LATUDA LURASIDONE HCL
LEVEMIR SEMGLEE (YFGN), TOUJEO SOLOSTAR
LEVEMIR FLEXPEN SEMGLEE (YFGN), TOUJEO SOLOSTAR
LEVEMIR FLEXTOUCH SEMGLEE (YFGN), TOUJEO SOLOSTAR
LUPRON DEPOT-PED FENSOLVI, TRIPTODUR
MEKTOVI COTELLIC, MEKINIST
METHYLPHENIDATE ER METHYLPHENIDATE ER capsules or ER tablets (except 45mg, 63mg, or 72mg), DYANAVEL XR, MYDAYIS, QUILLICHEW ER, QUILLIVANT XR,VYVANSE
NATESTO TESTOSTERONE, ANDRODERM
NORDITROPIN FLEXPRO GENOTROPIN, OMNITROPE
QUILLICHEW ER DEXMETHYLPHENIDATE HCL ER, METHYLPHENIDATE HCL CD, METHYLPHENIDATE LA
QUILLIVANT XR DEXMETHYLPHENIDATE HCL ER, METHYLPHENIDATE HCL CD, METHYLPHENIDATE LA
SEREVENT DISKUS STRIVERDI RESPIMAT
STEGLUJAN GLYXAMBI
XULTOPHY 100-3.6 SOLIQUA 100-33
XYREM SODIUM OXYBATE, XYWAV

JP59776: 10/2023

Provider Update