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Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc.
MPC011711 Page 1 of 14 Updated 09/01/2020
NOTIFICATION OF FORMULARY CHANGES
The following summary describes changes to the Presbyterian Individual and Family Metal Plan/Employer Group Metal Plan Formularies effective 2020.
For the most recent list of drugs, information on obtaining a coverage determination or exception, or other questions, please contact the Presbyterian Customer Service Center. You can reach
them Monday through Friday from 8:00 a.m. to 5:00 p.m.
Phone: (505) 923-5678 or 1-855-356-2219
TTY: 711 Online: www.phs.org
Effective Date
of Change
Drug Name Description of Change Formulary Coverage Formulary Alternative(s) and Tier (if applicable
for formulary removals)
01/01/2020 Actemra (tocilizumab)
162mg/0.9mL auto-injector and pre-filled
syringes
Formulary Addition T5, PA, SP, QL
01/01/2020 Afirmelle (levonorgestrel/ethinyl estradiol)
0.1mg/20mcg tablet
Formulary Addition $0
01/01/2020 Aubagio® (teriflunomide)
7mg, 14mg tablet
Criteria Removal T5, QL, SP
01/01/2020 Avonex® (interferon beta-1A)
30mcg/0.5ml auto-injector and prefilled
syringe; 33mcg(6.6mu) vial
Criteria Removal T5, QL, SP
01/01/2020 Ayuna (levonorgestrel/ethinyl estradiol)
0.1mg/30mcg tablet
Formulary Addition T2
01/01/2020 Baqsimi (glucagon)
3mg intranasal device
Formulary Addition T3
Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc.
MPC011711 Page 2 of 14 Updated 09/01/2020
Effective Date
of Change
Drug Name Description of Change Formulary Coverage Formulary Alternative(s) and Tier (if applicable
for formulary removals)
01/01/2020 benzphetamine HCl (generic for Didrex®)
25mg, 50mg tablet
Formulary Addition T4, PA, QL
01/01/2020 Berinert® (C1 esterase inhibitor, human)
500unit kit
Criteria Update T5, PA, SP
01/01/2020 budesonide (generic for Entocort EC®)
3mg capsule
Quantity Limit added T4, QL
01/01/2020 Cimzia® (certolizumab)
200 mg single dose vial, 200 mg/mL prefilled
syringe, 200mg/mL x 6 prefilled syringes
starter kit
Formulary Addition T5, PA, SP, QL
01/01/2020 Cinryze® (C1 esterase inhibitor, human)
500unit Kit
Criteria Update T5, PA, SP
01/01/2020 Darzalex® (daratumumab)
100mg/5mL and 400mg/20mL single-dose vial
Formulary Addition MB, PA
01/01/2020 Dexcom G6 receiver device Formulary Addition T3, PA, QL
01/01/2020 Dexcom G6 Sensor Formulary Addition T3, PA, QL
01/01/2020 Dexcom G6 Transmitter Formulary Addition T3, PA, QL
01/01/2020 diethylpropion HCl (generic for Tenuate®)
75mg extended release and 25mg immediate
release tablet
Formulary Addition T4, PA, QL
01/01/2020 Dotti (estradiol)
0.025mg/24hr,0.0375mg/24hr,0.05mg/24hr,
0.075mg/24hr,0.1mg/24hr
Formulary Addition T2, QL
01/01/2020 Dulera® (mometasone furoate/formoterol
fumarte dihydrate) 50mcg/5mcg/actuation
Formulary Addition T4, ST, QL
Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc.
MPC011711 Page 3 of 14 Updated 09/01/2020
Effective Date
of Change
Drug Name Description of Change Formulary Coverage Formulary Alternative(s) and Tier (if applicable
for formulary removals)
01/01/2020 Enbrel®(etanercept)
50 mg/mL auto-injecctor, cartridge, prefilled
syringe; 25 mg/0.5mL prefilled syringe
Formulary Removal NF
01/01/2020 Entyvio® (vedolizumab)
300mg vial
Formulary Addition MB, PA
01/01/2020 Ery-TAB (erythromycin)250mg,333mg,500mg
Delayed Release Tablet
Formulary Addition T5
01/01/2020 famotidine oral suspension
40mg/5ml
Formulary Addition T2
01/01/2020 Flucelvax® Quadrivalent (influenza virus
vaccine (subvirion))
60mcg/0.5mL
Formulary Addition $0, QL
01/01/2020 Flumist® (influenza virus vaccine (live))
0.1mL intranasal suspension
Formulary Addition $0, QL, AL
01/01/2020 Freestyle Libre® 14 day reader device Formulary Addition T3, PA, QL
01/01/2020 Freestyle Libre® 14 day sensor Formulary Addition T3, PA, QL
01/01/2020 Freestyle Libre® Reader Device Formulary Addition T3, PA, QL
01/01/2020 Freestyle Libre® Sensor System Formulary Addition T3, PA, QL
01/01/2020 Haegarda® (C1 esterase inhibitor, human)
2000unit, 3000unit
Formulary Addition T5, PA, SP
01/01/2020 Hailey (norethinedrone/ethinyl estradiol)
1.5mg/30mcg Tablet
Formulary Addition T2
01/01/2020 icatibant (Generic for Firzayr®)
30mg/3ml Syringe
Criteria Update T5, PA, SP
Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc.
MPC011711 Page 4 of 14 Updated 09/01/2020
Effective Date
of Change
Drug Name Description of Change Formulary Coverage Formulary Alternative(s) and Tier (if applicable
for formulary removals)
01/01/2020 isosorbide dinitrate
30mg tablets
Tier Change (moved from T2 to T3) T3
01/01/2020 isotretinoin
20mg, 30mg, 40mg capsule
Formulary Addition T4, PA, QL, AL
01/01/2020 Jakafi® (ruxolitinib)
5 mg, 10 mg, 15 mg, 20 mg, 25 mg tablet
Criteria Update T5, PA, QL, SP
01/01/2020 Kalbitor® (ecallantide)
10mg/ml vial
Formulary Addition MB, PA, SP
01/01/2020 Kalliga (desogestrel/ethinyl estradiol)
0.15mg/30mcg Tablet Formulary Addition $0
01/01/2020 Kalydeco (ivacaftor)
150 mg tablets; 25mg, 50mg, 75 mg packets
Criteria Update T5, PA, SP, QL
01/01/2020 Kombiglyze Xr® (saxagliptin/metformin)
2.5/1000mg, 5/1000mg, 5/500mg
Criteria Update T4, PA, QL
01/01/2020 Latuda® (lurasidone)
20mg, 40mg, 60mg, 80mg, 120mg
Criteria Update T4, PA, QL, AL
01/01/2020 Lo-Zumandimine (drospirenone/ethinyl
estradiol)
3/0.02mg tablet
Formulary Addition T2
01/01/2020 Mavyret® (glecarprevir/pibrentasvir)
100/40mg tablet
Criteria Update T5, PA, QL, SP
01/01/2020 methylphenidate (generic for Methylin®)
5mg/5ml, 10mg/5ml solution
Formulary Addition T4, PA, QL, AL
01/01/2020 Nubeqa ® (darolutamide)
300mg tablets
Formulary Addition T5, PA, QL, SP
01/01/2020 Onglyza® (saxagliptin HCl)
2.5mg, 5mg
Criteria Update
T4, PA, QL
Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc.
MPC011711 Page 5 of 14 Updated 09/01/2020
Effective Date
of Change
Drug Name Description of Change Formulary Coverage Formulary Alternative(s) and Tier (if applicable
for formulary removals)
01/01/2020 Orencia® (abatacept)
125mg/mL auto-injector; 50mg/0.4mL, 87.5
mg/0.7 mL, 125 mg/mL prefilled syringes
Formulary Addition T5, PA, SP, QL
01/01/2020 Otezla®(apremilast)
10 mg, 20 mg, 30 mg tablet ,30 mg Therapy
pack
Formulary Addition T5, PA, SP, QL
01/01/2020 oxazepam
10mg,15mg,30mg capsule
Tier Change (moved from T2 to T3) T3, QL Lorazepam tablet (0.5mg, 1mg, 2mg)- T2, QL
01/01/2020 phendimetrazine (generic for Bontril®)
105mg extended release and 35mg immediate
release tablet
Formulary Addition T4, PA, QL
01/01/2020 Piqray® (alpelisib)
50mg, 150mg, 200mg tablets
Formulary Addition T5, PA, QL, SP
01/01/2020 Polivy® (polatuzumab vedotin-piiq)
140mg vial
Formulary Addition MB, PA
01/01/2020 Rebif® (interferon beta-1A)
22mcg/0.5ml, 44mcg/0.5ml auto-injector,
prefilled syringe, 4.2ml titration kits)
Criteria Removal T5, QL, SP
01/01/2020 Remicade® (infliximab)
100mg/20ml vial
Criteria Update MB, PA, SP
01/01/2020 Renflexis® (infliximab-abda)
100mg/20ml vial
Criteria Update MB, PA, SP
01/01/2020 Rinvoq® (upadacitinib)
15mg tablet Formulary Addition T5, PA, SP, QL
01/01/2020 Simpesse® (levonorgestrel/ethinyl estradiol
(ee))
0.15mg/0.03mg (84) & ee (7)
Formulary Addition $0
Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc.
MPC011711 Page 6 of 14 Updated 09/01/2020
Effective Date
of Change
Drug Name Description of Change Formulary Coverage Formulary Alternative(s) and Tier (if applicable
for formulary removals)
01/01/2020 Skyrizi®(risankizumab)
75mg/0.83mL prefilled syringe
Formulary Addition T5, PA, SP, QL
01/01/2020 solifenacin (generic for Vesicare®)
5mg, 10mg
Tier Change (moved from T4 to T2) T2, QL
01/01/2020 Soliris® (eculizumab)
300 mg/30 mL vial
Criteria Update MB, PA, SP
01/01/2020 Spiriva Respimat ® (tiotropium bromide)
1.25mcg/actuation inhaler Formulary Addition T3
01/01/2020 Stelara®(ustekinumab)
45mg/0.5mL subcutaneous solution;
45mg/0.5mL prefilled syringe
Formulary Addition T5, PA, QL, SP
01/01/2020 Symdeko®
(tezacaftor 50mg/ivacaftor 75mg; ivacaftor
75mg)
Formulary Addition T5, PA, QL, SP
01/01/2020 Symjepi® (epinephrine)
0.15mg/0.3ml injection solution
Formulary Addition T2
01/01/2020 Takhzyro® (lanadelumab-flyo)
300mg/2ml vial
Formulary Addition T5, PA, SP
01/01/2020 Taltz®(ixekizumab)
80mg/mL auto-injector or prefilled syringe
Formulary Addition T5, PA, SP, QL
01/01/2020 Trelstar® (triptorelin pamoate)
3.75mg, 11.25mg, 22.5mg intramuscular
suspension
Prior Authorization Criteria Addition MB, PA, SP
01/01/2020 triameterene (generic for Dyrenium)
50mg and 100mg capsule
Tier Change (changed from Tier 3 to
Tier 4)
T4 spirinolactone tablet (25mg, 50mg, 100mg) -T2
01/01/2020 Tudorza Pressair® (aclidinium bromide)
400mcg/actuation
Tier change (moved from T4 to T2) T3, QL
Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc.
MPC011711 Page 7 of 14 Updated 09/01/2020
Effective Date
of Change
Drug Name Description of Change Formulary Coverage Formulary Alternative(s) and Tier (if applicable
for formulary removals)
01/01/2020 Xeljanz®(tofacitinib)
10mg immediate release or 11mg extended
release tablet
Criteria Update T5, PA, SP, QL
01/01/2020 Zumandimine (drospirenone/ethinyl estradiol)
3/0.03mg tablet
Formulary Addition T2
03/01/2020 Divigel® (estradiol) 1.25mg/1.25gm transdermal gel
Formulary Addition T3
03/01/2020 Katerzia™ (amlodipine) 1 mg/mL oral suspension
Formulary Addition T4, AL
03/01/2020 lamotrigine ER (generic for Lamictal XR®) 50mg/100mg/200mg/250mg/ 300mg tablets
Formulary Addition T4, PA, QL
03/01/2020 levetiracetam ER (generic for Keppra XR®) 500mg/750mg tablets
Formulary Addition T4, QL
03/01/2020 Lokelma® (sodium zirconium cyclosilicate) 5g/10g packet
Formulary Addition T5, PA, QL
03/01/2020 Mavenclad® (cladribine) 10mg tablets
Formulary Addition T5, PA, QL, SP
03/01/2020 Mayzent® (siponimod) 0.25mg/2mg tablets
Formulary Addition T5, PA, QL, SP
03/01/2020 olopatadine
0.1% (5mL), 0.2% (2.5mL)
solution (generic for Patanol® and Pataday®)
Step Removal T2, QL (0.01%)
T4, QL (0.02%)
03/01/2020 Nitro-Time® (nitroglycerin)
2.5mg ER capsules Tier Change (moved from T1 to T2) T3
03/01/2020 Rozlytrek™ (entrectinib)
100mg/200mg capsules Formulary Addition T5, PA, SP
03/01/2020 Secuado® (asenapine)
3.8mg/24hr, 5.7mg/24hr, 7.6mg/24hr
transdermal patch
Formulary Addition T5, QL, PA, AL
Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc.
MPC011711 Page 8 of 14 Updated 09/01/2020
Effective Date
of Change
Drug Name Description of Change Formulary Coverage Formulary Alternative(s) and Tier (if applicable
for formulary removals)
03/01/2020 Veltassa® (patiromer)
8.4g/16.8g/25.2g packet
Formulary Addition T5, PA, QL
03/01/2020 Actemra® (tocilizumab)
80mg/4mL, 200mg/10mL, 400mg/20mL
intravenous solution; 162mg/0.9mL
auto-injector and prefilled syringes
Criteria Update T5, PA, SP, QL
03/01/2020 Cinvanti® (aprepitant)
130mg single-dose vial
Criteria Update MB, PA
03/01/2020 Cipro® (ciprofloxacin)
500mg/5mL (10%) oral suspension Tier Change (moved from T1 to T2) T3
03/01/2020 Crysvita® (burosumab-twza)
10/20/30 mg/mL in a single-dose vial Criteria Update MB, PA
03/01/2020 diclofenac gel 1% (generic for Voltaren
Gel®) 1% topical gel Update Quantity T3, QL (300 grams per 30 days)
03/01/2020 Dysport® (abobotulinumtoxinA)
300 or 500 unit powder for injection Criteria Update MB, PA
03/01/2020 eszopiclone (generic for Lunesta®)
1mg/2mg/3mg Criteria Removal T2, QL
03/01/2020 Extavia® (interferon Beta-1B)
0.3mg subcutaneous kit Step Removal T5, QL, SP
03/01/2020 Flumadine® (rimantadine HCl)
100mg tablet
Tier Change (moved from T1 to T2) T3
03/01/2020 Myobloc® (rimabotulinutoxinB)
2,500/5,000/10,000 unit vial
Criteria Addition MB, PA
03/01/2020 naratriptan (generic for Amerge®)
1mg/2.5 mg tablet Step Removal
1mg: T4, QL
2.5mg: T2, QL
03/01/2020 pregabalin (generic for Lyrica®)
25mg/50mg/75mg/100mg/150mg/200m
g/225mg/ 300mg capsules
Criteria Removal T2, QL
Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc.
MPC011711 Page 9 of 14 Updated 09/01/2020
Effective Date
of Change
Drug Name Description of Change Formulary Coverage Formulary Alternative(s) and Tier (if applicable
for formulary removals)
03/01/2020 Phenergan® (promethazine)
50mg suppositories
Formulary Removal Not Covered promethazine 12.5mg, 25mg suppositories
03/01/2020 quetiapine fumarate ER
(generic for Seroquel XR®)
50mg/150mg/200mg/300mg/400mg
Formulary Addition T4, QL
03/01/2020 Quibron-T SR® (theophylline)
300mg ER 12-hour tablets Tier Change (moved from T1 to T2) T3
03/01/2020 rizatriptan tablets and orally disintegrating
tablets (generic for Maxalt®, Maxalt ODT®)
5mg/10mg tablets
Step Removal T2, QL
03/01/2020 Ultomiris® (ravulizumab-cwvz)
300mg/30mL single-dose vial Criteria Update MB, PA, SP
03/01/2020 Verelan® (verapamil)
100mg/200mg/300mg capsules Tier Change (moved from T1 to T2) T3
03/01/2020 Videx EC® (didanosine)
400mg capsules Tier Change (moved from T1 to T2) T3, QL
03/01/2020 Xulane® (norelgestromin/ethinyl
estradiol)
35mcg/150 mcg transdermal patch
Step Removal $0, QL, AL
06/01/2020 Ameluz® (aminolevulinic acid)
10% gel
Formulary Addition MB
06/01/2020 Ayvakit™ (avapritinib)
100 mg, 200 mg and 300 mg tablets
Formulary Addition T5, PA, SP, QL
06/01/2020 Brukinsa™ (zanubrutinib)
80 mg capsules
Formulary Addition T5, PA, SP, QL
06/01/2020 Caplyta® (lumateperone)
42 mg capsules
Formulary Addition T5, PA, QL, AL
06/01/2020 chlorzoxazone (generic for Lorzone®)
500 mg tablet
Tier Change (moved from T3 to T2) T2
06/01/2020 dapsone 7.5% topical gel (generic for
Aczone®)
Formulary Addition T4, PA
Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc.
MPC011711 Page 10 of 14 Updated 09/01/2020
Effective Date
of Change
Drug Name Description of Change Formulary Coverage Formulary Alternative(s) and Tier (if applicable
for formulary removals)
7.5% topical gel
06/01/2020 Dexcom G6 receiver device Criteria Update T3, PA, QL
06/01/2020 Dexcom G6 Sensor Criteria Update T3, PA, QL
06/01/2020 Dexcom G6 Transmitter Criteria Update T3, PA, QL
06/01/2020 didanosine (Videx EC®)
250mg capsules Tier Change (moved from T2 to T3) T3, QL
06/01/2020 Dulera® (mometasone furoate/formoterol
fumarate dihydrate)
50/5mcg,100/5mcg, 200/5mcg per actuation
Formulary Addition T4, ST, QL
06/01/2020 Enhertu® (fam-trastuzumab deruxtecan-nxki )
100 mg vial
Formulary Addition MB, PA
06/01/2020 everolimus (generic for Zortress®)
0.25mg, 0.5mg, 0.75mg oral tablet
Formulary Addition T5, PA
06/01/2020 Freestyle Libre® 14 day reader device Criteria Update T3, PA, QL
06/01/2020 Freestyle Libre® 14 day sensor Criteria Update T3, PA, QL
06/01/2020 Freestyle Libre® Reader Device Criteria Update T3, PA, QL
06/01/2020 Freestyle Libre® Sensor System Criteria Update T3, PA, QL
06/01/2020 Guardian™ 3 Sensor Formulary Addition T3, PA, QL
06/01/2020 Guardian™ 3 Transmitter Formulary Addition T3, PA, QL
06/01/2020 Humulin® U-500 (insulin, human regular)
20 mL vial, 3 mL flexpen Criteria Update T4, PA, QL
Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc.
MPC011711 Page 11 of 14 Updated 09/01/2020
Effective Date
of Change
Drug Name Description of Change Formulary Coverage Formulary Alternative(s) and Tier (if applicable
for formulary removals)
06/01/2020 hydrochlorothiazide
12.5 mg tablet
Formulary addition T2
06/01/2020 hydroxychloroquine 200mg tablets
Criteria Added T2, PA
06/01/2020 Ibrance® (palbociclib)
75mg, 100mg, 125mg oral tablet
Formulary Addition T5, PA, SP, QL
06/01/2020 Jaimiess (levonorgestrel/ethinyl estradiol/
ethinyl estradiol)
(0.15-0.03mg (84)/0.01)
Formulary Addition $0
06/01/2020 Lo-Jaimiess (levonorgestrel/ethinyl estradiol/
ethinyl estradiol)
0.1-0.02mg (84)/0.01 mg tablets
Formulary Addition $0
06/01/2020 Mavenclad® (cladribine)
10 mg tablet Criteria Update T5, PA, SP, QL
06/01/2020 Nerlynx® (neratinib)
40 mg tablets Formulary Addition T5, PA, QL, SP
06/01/2020 nitrofurantoin
25 mg/5mL oral suspension Criteria Update T4, AL, QL
06/01/2020 Padcev™ (enfortumab vedotin-ejfv)
For Injection: 20 mg and 30 mg Formulary Addition MB, PA
06/01/2020 penicillamine (generic for Depen®)
250 mg tablet Formulary Addition T5, PA, QL
06/01/2020 Sarclisa® (isatuximab-irfc)
100 mg/5 mL, 500 mg/25 mL vials Formulary Addition MB, PA
06/01/2020 Sunosi™ (solriamfetol)
75mg and 150 mg tablets Formulary Addition T5, PA, QL, AL
06/01/2020 Tazverik™ (tazemetostat)
200 mg tablets Formulary Addition T5, SP, QL
06/01/2020 testosterone enanthate (generic for Delatestryl®) 200mg/ml for injection
Tier Change T3, PA
Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc.
MPC011711 Page 12 of 14 Updated 09/01/2020
Effective Date
of Change
Drug Name Description of Change Formulary Coverage Formulary Alternative(s) and Tier (if applicable
for formulary removals)
06/01/2020 Tiadylt ER® (diltiazem extended release beads
capsules)
120mg/24hr, 180mg/24hr, 240mg/24hr,
300mg/24hr, 420/24hr
Formulary Addition T1
06/01/2020 Volnea® (desogestrel; ethinyl estradiol)
(0.15-0.02/0.01mg (21/5))
Formulary Addition $0
06/01/2020 Xeljanz XR® (tofacitinib citrate)
22mg base equivalent
Formulary Addition T5, PA, SP, QL
06/01/2020 Xyrem® (sodium oxybate)
500 mg/mL solution Criteria Update T5, PA, AL, QL
06/01/2020 zinc sulfate
3mg/mL IV solution Formulary Addition MB
09/01/2020 Braftovi® (encorafenib)
75 mg capsules Specialty Pharmacy Mandate Addition T5, PA, QL, SP
09/01/2020 Dayvigo™ (lemborexant)
5 mg, 10 mg tablets Formulary Addition T5, PA, QL
09/01/2020 Delstrigo™ (doravirine, lamivudine, and
tenofovir disoproxil fumarate)
100 mg/300 mg/300 mg tablets
Formulary Addition T5, QL
09/01/2020 Epclusa® AG (sofosbuvir/velpatasvir)
400/100mg oral tablet
Formulary Addition T5, PA, QL, SP
09/01/2020 Eucrisa® (crisaborole)
50 gram, 100 gram tube
Criteria Update T5, PA, QL
09/01/2020 Farxiga® (Dapagliflozin propandediol)
5mg, 10mg tablet
Tier Change T3, ST, QL
09/01/2020 Flowtuss® (hydrocodone/guaifenesin)
2.5 mg /200 mg/5 ml solution
Formulary Addition T4, QL
09/01/2020 isoniazid
100 mg tablets
Tier Change T3
09/01/2020 Jelmyto® (mitomycin)
40mg vials
Formulary Addition MB, PA, QL
Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc.
MPC011711 Page 13 of 14 Updated 09/01/2020
Effective Date
of Change
Drug Name Description of Change Formulary Coverage Formulary Alternative(s) and Tier (if applicable
for formulary removals)
09/01/2020 Mavyret® (glecaprevir/pibrentasvir)
100 mg/40 mg tablets
Criteria Update T5, PA, SP, QL
09/01/2020 midazolam
2 mg/2 mL, 5 mg/5 mL, 5 mg/ml, 10 mg/2 mL
solution for injection
Formulary Addition T2, ST
09/01/2020 Nayzilam® (midazolam)
5mg/0.1mL bottle Formulary Addition T5, PA, QL
09/01/2020 nicardipine HCl
20mg/200ml, 40mg/200mL intravenous
solution
Formulary Addition MB
09/01/2020 Ofev® (nintedanib)
100 mg, 150 mg tablets
Update prior authorization criteria.
Criteria Update T5, PA, QL, SP
09/01/2020 Oriahnn® (elagolix, estradiol, norethindrone)
300mg/1mg/0.5mg tablets
Formulary Addition T5, PA, QL
09/01/2020 Pemazyre™ (pemigatinib)
4.5 mg, 9 mg, and 13.5 mg tablets
Formulary Addition T5, PA, QL, SP
09/01/2020 PifeltroTM (doravirine)
100mg oral tablet
Formulary Addition T5, QL
09/01/2020 ribavirin
200 mg tablet, 200 mg capsule
Criteria Update T5, PA, SP
09/01/2020 romidepsin
27.5mg/5.5mL intravenous solution
Formulary Addition MB, PA
09/01/2020 Strattera® (atomoxetine)
10mg, 18mg, 25mg, 40mg, 60mg, 80mg,
100mg capsule
Criteria Update T4, PA, QL, AL
09/01/2020 Trodelvy™ (sacituzumab govitecan-hziy)
180 mg single-dose vials Formulary Addition MB, PA
09/01/2020 Tukysa™ (tucatinib)
50 mg and 150 mg tablets Formulary Addition T5, PA, QL, SP
Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc.
MPC011711 Page 14 of 14 Updated 09/01/2020
Effective Date
of Change
Drug Name Description of Change Formulary Coverage Formulary Alternative(s) and Tier (if applicable
for formulary removals)
09/01/2020 Udenyca® (pegfilgrastim-cbqv)
6 mg/0.6 mL pre-filled syringes
Formulary Addition MB, PA, SP
09/01/2020 Voltaren® (diclofenac sodium)
1% gel
Formulary Removal NF Naproxen (T2)
09/01/2020 Wakix® (pitolisant HCl)
4.45mg, 17.8mg tablet
Formulary Addition T5, PA, QL, AL
09/01/2020 Xigduo® (dapagliflozin/metformin)
10/1000mg, 10/500mg, 2.5/1000mg, 5/1000mg,
5/500mg oral tablet
Tier Change T3, ST, QL
09/01/2020 Xyrem® (sodium oxybate)
500mg/ml oral solution Formulary Addition T5, PA, QL, AL
09/01/2020 Xyrem® (sodium oxybate)
500mg/ml oral solution Criteria Update T5, PA, QL, AL
09/01/2020 Ziextenzo® (pegfilgrastim-cbqv)
6 mg/0.6 mL pre-filled syringes Formulary Addition MB, PA, SP
09/01/2020 Zyrtec® (cetirizine)
5mg, 10mg oral tablet Formulary Addition T2, QL
MB= Medical Benefit, PA = Prior Authorization required, QL = Quantity Limit, SP = Specialty Pharmacy required, ST = Step Therapy
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