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) | Hloov cov qauv kev tso cai ua ntej |
| Climara, Menostar, Vivelle-Dot, Minivelle, Alora, Estrogel, Elestrin, Divigel, Evamist | Hloov cov qauv kev tso cai ua ntej |
| Estring, Femring | Hloov cov qauv kev tso cai ua ntej |
| 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 | Hloov cov qauv kev tso cai ua ntej |
| 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 | Hloov cov qauv kev tso cai ua ntej |
| 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 | Hloov cov qauv kev tso cai ua ntej |
| Lub npe | Action |
| Emgality | Hloov cov qauv kev tso cai ua ntej |
| Ajovy | Hloov cov qauv kev tso cai ua ntej |
| Actiq | Hloov cov qauv kev tso cai ua ntej |
| Fentora | Hloov cov qauv kev tso cai ua ntej |
| Onsolis | Hloov cov qauv kev tso cai ua ntej |
| Abstral | Hloov cov qauv kev tso cai ua ntej |
| Subsys | Hloov cov qauv kev tso cai ua ntej |
| Lazanda | Hloov cov qauv kev tso cai ua ntej |
| Butrans | New prior authorization criteria |
| Methadone | Hloov cov qauv kev tso cai ua ntej |
| 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 |
