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2022 Formulary Changes

The table below outlines all the changes to our formulary since the formulary list was last printed on 01/01/2022.

Drug NameDescription of Change*Copay AmountEffective Date
of Change
Kerendia (finerenone)Addition to formulary with PA$301/01/2022
Benlysta (belimumab) subcutaneousAddition to formulary with PA$301/01/2022
Lupkynis (voclosporin)Addition to formulary with PA$301/01/2022
Eucrisa (crisaborole) ointmentAddition to formulary with PA$301/01/2022
Free Style Libre 14-Day Receiver and SensorAddition to formulary with QL$001/01/2022
Free Style Libre 2 Receiver and SensorAddition to formulary with QL$001/01/2022
Dexcom G6 Receiver, Transmitter, and SensorAddition to formulary with QL$001/01/2022
Free Style Libre 14-Day Receiver and SensorAddition of PA$002/01/2022
Free Style Libre 2 Receiver and SensorAddition of PA$002/01/2022
Dexcom G6 Receiver, Transmitter, and SensorAddition of PA$002/01/2022
Omnipod Classic PodsAddition to formulary$003/01/2022
Omnipod Classic PDM Starter KitAddition to formulary$003/01/2022
Omnipod Dash PodsAddition to formulary$003/01/2022
Omnipod 5 G6 PodsAddition to formulary$003/01/2022
Welireg (belzutifan)Addition to formulary with PA$304/01/2022
Exkivity (mobocertinib)Addition to formulary with PA$304/01/2022
Scemblix (asciminib)Addition to formulary with PA$304/01/2022
Maraviroc tab 150 mg and 300mg tablets (generics of Selzentry)Addition to formulary$104/01/2022
Atropine sulfate ophthalmic solution 1% (generic of brand Atropine sulfate)Addition to formulary$104/01/2022
Brimonidine tartrate-timolol maleate ophthalmic solution 0.2-0.5% (generic of Combigan)Addition to formulary$104/01/2022
Sulfadiazine 500 mg tablet (generic)Addition to formulary$104/01/2022
Lenalidomide 5mg, 10mg, 15mg, 25mg capsules (generic of Revlimid)Addition to formulary with PA$107/01/2022
Vijoice (alpelisib)Addition to formulary with PA$310/01/2022
Enalapril maleate oral 1mg/mL solution (generic of Epaned)Addition to formulary$110/01/2022
Eplerenone 25mg and 50mg tablets (generic of Inspra)Addition to formulary$110/01/2022
Fluvastatin 20mg and 40mg capsulesAddition to formulary$110/01/2022
Metformin oral 500mg/5mL solution (generic of Riomet)Addition to formulary$110/01/2022
Olmesartan Medoxomil 5mg, 20mg, 40mg tablets (generic of Benicar)Addition to formulary$110/01/2022
Testosterone Transdermal gel 20.25mg/ACT, 20.25mg/1.25gm, 40.5mg/2.5gm (1.62%) (generic of AndroGel 1.62%)Addition to formulary$110/01/2022

*QL = Quantity Limit, PA = Prior Authorization, ST = Step Therapy, NF = Non Formulary, N/A = Not Applicable

All documents are available in paper form without charge. To request a paper copy, please call Customer Service at:

Monday through Friday, 8 a.m. to 5 p.m.

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