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Alliance Formulary Update

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The Alliance’s April 1, 2019 pharmacy benefit change, listed below, has been reviewed and approved by the Pharmacy & Therapeutics (P&T) committee.

Lub Npe Action
Cyclosporine Modified Solution Added to the formulary for children <12 years of age
Mycophenolate mofetil suspension Added to the formulary for children <12 years of age
Xatmep Added to the formulary for children <12 years of age
Heparin Added to the formulary
Heparin Flush Added to the formulary
Lovenox Added to the formulary
Cyclosporine Modified Solution Added to the formulary for children <12 years of age
Xofluza Added to formulary
Nexplanon implant Added to formulary
Methergine (brand name) Added to formulary
Estradiol once-weekly patch (generic of Climara) Added to formulary
Yuvafem and generic estradiol vaginal tablet Added to formulary
Premarin cream Added to formulary for children ages 3 and under (for use in labial adhesion), Modified prior authorization criteria
Intrarosa vaginal insert Added to formulary
Diclofenac-misoprostol tablet Removed from formulary, Added prior authorization criteria
Meclofenamate capsule Removed from formulary, Added prior authorization criteria
Trospium ER capsule Removed from formulary, Added prior authorization criteria
Potassium citrate-citric acid solution Added to formulary
Sodium citrate-citric acid solution Added to formulary
Fyavolv (brand name) Removed from formulary, Added prior authorization criteria
Solu-cortef (brand name) Added to formulary
Oxytrol for Women patch (OTC) Added to formulary
Oxytrol patch (Rx) Modified prior authorization criteria
Climara, Menostar, Vivelle-Dot, Minivelle, Alora, Estrogel, Elestrin, Divigel, Evamist Modified prior authorization criteria
Estring, Femring Modified prior authorization criteria
Prempro, Premphase Added prior authorization criteria
Climara-Pro, Combipatch Added prior authorization criteria
Duavee Added prior authorization criteria
Covaryx, Covaryx H.S. Added prior authorization criteria
Prometrium Added prior authorization criteria
Xyosted Added prior authorization criteria
Berinert Added prior authorization criteria
Durolane, Euflexxa, Gel-One, Gelsyn-3, GenVisc 805, Supartz, Supartz FX, Hyalgan, Hymovisc, Monovisc, Orthovisc, Synvisc, Synvisc-One, TriVisc, Visco-3 Modified prior authorization criteria
Rayos Added prior authorization criteria
Zipsor Added prior authorization criteria
Tivorbex Added prior authorization criteria
Ketorolac Added prior authorization criteria
Meclofenamate capsule Added prior authorization criteria
Vivlodex Added prior authorization criteria
Triptodur Modified prior authorization criteria
Belviq XR New PA criteria
Zembrace SymTouch New prior authorization criteria
Isometheptene/ caffeine/ acetaminophen New prior authorization criteria
Butalbital/ acetaminophen 50/325mg tablet New quantity limit
Butalbital/ acetaminophen/ caffeine 50/325/40 mg tablet New quantity limit
Non-formulary butalbital formulations Modified prior authorization criteria quantity limit
Aimovig Modified prior authorization criteria
Lub Npe Action
Emgality Modified prior authorization criteria
Ajovy Modified prior authorization criteria
Actiq Modified prior authorization criteria
Fentora Modified prior authorization criteria
Onsolis Modified prior authorization criteria
Abstral Modified prior authorization criteria
Subsys Modified prior authorization criteria
Lazanda Modified prior authorization criteria
Butrans New prior authorization criteria
Methadone Modified prior authorization criteria
Primlev New prior authorization criteria
Nalocet Remove from formulary, New prior authorization criteria
Oxycodone/ ibuprofen New prior authorization criteria
Oxycodone/ aspirin New prior authorization criteria
Tramadol extended-release capsule New prior authorization criteria
RoxyBond New prior authorization criteria
Pentazocine/ naloxone New prior authorization criteria
Embeda New prior authorization criteria
Lidocaine gel syringes & applicators New prior authorization criteria