Year-to-Date Updates

NCQA Certified

|

Medicare Assured^® HMO SNP

|

|

Medicaid Online Formulary:
Year to Date Updates

Download Printable Formulary (pdf)

Request Medicaid Drug Exception Form

Search the Formulary

View Recent Updates

View Year to Date Updates

*Notes
GC - Generic Covered	PA - Prior Authorization
ST - Step Therapy	QL - Quantity Limited
GA - Generic Available	SPN - Specialty Pharmacy
Last updated: 2/3/2012

Generic Name: Rivaroxaban	Brand Name: Xarelto
Therapeutic Category: CARDIOVASCULAR	Therapeutic Class: CIRCULATION/COAGULATION
Notes:
Effective Date: 2/1/2012
Reason: Formulary Addition

Generic Name: Collagenase	Brand Name: Santyl
Therapeutic Category: DERMATOLOGY	Therapeutic Class: TOPICAL ENZYMES
Notes:
Effective Date: 1/1/2012
Reason: Formulary Removal

Generic Name: Sitagliptin/Simvastatin	Brand Name: Juvisync
Therapeutic Category: ENDOCRINE	Therapeutic Class: DIABETES, ORAL
Notes:
Effective Date: 2/1/2012
Reason: Formulary Addition

Generic Name: Lansoprazole	Brand Name: Prevacid
Therapeutic Category: GASTROINTESTINAL	Therapeutic Class: ULCER THERAPY
Notes: GC QL
Effective Date: 1/1/2012
Reason: Step Edit Removal

Generic Name: Pantoprazole	Brand Name: Protonix
Therapeutic Category: GASTROINTESTINAL	Therapeutic Class: ULCER THERAPY
Notes: GC QL
Effective Date: 1/1/2012
Reason: Formulary Addition