Formulary Changes
Nebraska Total Care continually evaluates our Value Add Formulary to make sure our members receive clinically appropriate and cost conscious drug therapy. Effective December 1, 2020, Nebraska Total Care will no longer be covering certain over-the-counter and multisource brand prescription products with formulary alternatives as a Value Add benefit. In addition, effective December 1, 2020, Nebraska Total Care will require a prior authorization for certain drugs at high risk for clinically inappropriate use.
The full list of drugs being removed from the Nebraska Total Care Value Add Formulary, the formulary alternatives, and drugs requiring a prior authorization effective December 1, 2020, can be found in the following tables.
On October 1, 2020, affected members received letters (below) notifying them of the upcoming changes. You can request a prior authorization if you think your patient should not change their medication to a formulary alternative or is currently taking a medication that will have new prior authorization requirements.
Formulary Change NF letter (PDF)
Formulary Change PA letter (PDF)
The following Brand Rx Products will no longer available on the Value Add Formulary. Changes are effective December 1, 2020.
| Brand Rx Drug Name | Formulary alternative |
|---|---|
| Absorica capsule | generic on formulary |
| Alora transdermal patch | generic on formulary |
| Amabelz 0.5 mg-0.1 mg tablet | generic on formulary |
| Amabelz 1 mg-0.5 mg tablet | generic on formulary |
| Amicar 250 mg/mL (25 %) oral solution | generic on formulary |
| Amnesteem capsule | generic on formulary |
| Aqua Care Sodium Chloride 0.9 % irrigation solution | generic on formulary |
| Aqua Care Sterile Water irrigation solution | generic on formulary |
| Bromfed DM 2 mg-30 mg-10 mg/5 mL oral syrup | generic on formulary |
| Carac 0.5 % topical cream | generic on formulary |
| Carafate 100 mg/mL oral suspension | generic on formulary |
| Claravis capsule | generic on formulary |
| Colocort 100 mg/60 mL enema | generic on formulary |
| Constulose 10 gram/15 mL oral solution | generic on formulary |
| Denta 5000 Plus 1.1 % cream | generic on formulary |
| DentaGel 1.1 % | generic on formulary |
| Diastat AcuDial rectal kit | generic on formulary |
| Ed-Spaz 0.125 mg disintegrating tablet | generic on formulary |
| Effer-K 25 mEq effervescent tablet | generic on formulary |
| Elixophyllin 80 mg/15 mL oral elixir | generic on formulary |
| EluRyng 0.12 mg-0.015 mg/24 hr vaginal ring | generic on formulary |
| Enulose 10 gram/15 mL oral solution | generic on formulary |
| Epitol 200 mg tablet | generic on formulary |
| Esgic 50 mg-325 mg-40 mg capsule | generic on formulary |
| Ethyol 500 mg intravenous solution | generic on formulary |
| Fenortho 200 mg capsule | generic on formulary |
| Flac Otic (ear) Oil 0.01 % drops | generic on formulary |
| Forfivo XL 450 mg tablet,extended release | generic on formulary |
| GaviLyte oral solution | generic on formulary |
| Generlac 10 gram/15 mL oral solution | generic on formulary |
| Geodon 20 mg/mL (final concentration) intramuscular solution | generic on formulary |
| Glydo 2 % mucosal jelly in applicator | generic on formulary |
| Hyosyne oral drops | generic on formulary |
| Isopto Atropine 1 % eye drops | generic on formulary |
| Jadenu tablet | generic on formulary |
| Klor-Con 20 mEq oral packet | generic on formulary |
| Klor-Con tablet,extended release | generic on formulary |
| K-Tab 8 mEq tablet,extended release | generic on formulary |
| Lamictal ODT | generic on formulary |
| Lidopin 3 % topical cream | generic on formulary |
| Lopreeza 1 mg-0.5 mg tablet | generic on formulary |
| Lyrica capsule | generic on formulary |
| Methergine 0.2 mg tablet | generic on formulary |
| Mimvey 1 mg-0.5 mg tablet | generic on formulary |
| Myorisan capsule | generic on formulary |
| NebuSal 3 % solution for nebulization | generic on formulary |
| NuLev 0.125 mg disintegrating tablet | generic on formulary |
| NuvaRing 0.12 mg-0.015 mg/24 hr vaginal | generic on formulary |
| Oralone 0.1 % dental paste | generic on formulary |
| Oscimin tablet | generic on formulary |
| Paroex Oral Rinse 0.12 % mouthwash | generic on formulary |
| Periogard 0.12 % mouthwash | generic on formulary |
| Phosphasal 81.6 mg-10.8 mg-40.8 mg tablet | generic on formulary |
| Pulmosal 7 % solution for nebulization | generic on formulary |
| Rosadan 0.75 % topical cream | generic on formulary |
| Rosadan 0.75 % topical gel | generic on formulary |
| Roweepra tablet | generic on formulary |
| Roweepra XR tablet,extended release | generic on formulary |
| Ryclora 2 mg/5 mL oral solution | generic on formulary |
| RyVent 6 mg tablet | generic on formulary |
| Santyl 250 unit/gram topical ointment | generic on formulary |
| SF 1.1 % dental gel | generic on formulary |
| SF 5000 Plus 1.1 % dental cream | generic on formulary |
| Slow-Mag 71.5 mg tablet,delayed release | generic on formulary |
| SPS (with sorbitol) 15 gram-20 gram/60 mL oral suspension | generic on formulary |
| SSD 1 % topical cream | generic on formulary |
| Subvenite tablet | generic on formulary |
| Sulfatrim 200 mg-40 mg/5 mL oral suspension | generic on formulary |
| Symax-SL 0.125 mg sublingual tablet | generic on formulary |
| Symax-SR 0.375 mg tablet,extended release | generic on formulary |
| Tencon 50 mg-325 mg tablet | generic on formulary |
| Tepadina 100 mg solution for injection | generic on formulary |
| TriLyte With Flavor Packets 420 gram oral solution | generic on formulary |
| Uretron D-S 81.6 mg-10.8 mg-40.8 mg tablet | generic on formulary |
| Urin DS 81.6 mg-10.8 mg-40.8 mg tablet | generic on formulary |
| Utira-C 81.6 mg-10.8 mg-40.8 mg tablet | generic on formulary |
| Vigadrone 500 mg oral powder packet | generic on formulary |
| Zebutal 50 mg-325 mg-40 mg capsule | generic on formulary |
| Zenatane capsule | generic on formulary |
The following Over the Counter Products will no longer available on the Value Add Formulary. Changes are effective December 1, 2020.
| OTC Drug Name | Formulary alternative |
|---|---|
| 4 Way 1 % nasal spray | generic on formulary |
| Allergy Relief (diphenhydramine) 12.5 mg/5 mL oral liquid | generic on formulary |
| BIOTENE DRY SPR MOIST | Aquoral mucosal spray |
| BIOTIN 5000 CAP | Complete Multivitamin tablet |
| Calcidol 200 mcg/mL (8,000 unit/mL) oral drops | generic on formulary |
| CALCIUM 500 TAB +D | calcium carb-vit D3-minerals 600 mg calcium-400 unit tablet |
| Castellani Paint Modified 1.5 % topical liquid | generic on formulary |
| Children's Iron 15 mg iron (75 mg)/mL oral drops | generic on formulary |
| Children's Mucinex Cough 5 mg-100 mg/5 mL oral liquid | generic on formulary |
| Children's Triaminic Cold and Allergy 1 mg-2.5 mg/5 mL oral solution | generic on formulary |
| Colace 100 mg capsule | generic on formulary |
| Colace 2-In-1 8.6 mg-50 mg tablet | generic on formulary |
| Coricidin HBP Cold and Flu 2 mg-325 mg tablet | generic on formulary |
| CVS PRENATAL TAB 27-0.8MG | Prenatal Vitamins Plus Low Iron 27 mg iron-1 mg tablet |
| Decara 1,250 mcg (50,000 unit) capsule | generic on formulary |
| Delsym Cough-Chest Congestion DM 5 mg-100 mg/5 mL oral liquid | generic on formulary |
| Enfamil Enfalyte oral solution | generic on formulary |
| Feosol 325 mg (65 mg iron) tablet | generic on formulary |
| Feosol Bifera 28 mg tablet | generic on formulary |
| Fleet Laxative (bisacodyl) 5 mg tablet,delayed release | generic on formulary |
| Gas-X Extra Strength 125 mg capsule | generic on formulary |
| Gas-X Ultra-Strength 180 mg capsule | generic on formulary |
| GNP PRENATAL TAB 28-0.8MG | Prenatal Vitamins Plus Low Iron 27 mg iron-1 mg tablet |
| Histex (triprolidine) 2.5 mg/5 mL oral liquid | generic on formulary |
| Histex PD 0.938 mg/mL oral drops | generic on formulary |
| ICaps AREDS 14,320 unit-226 mg-200 unit capsule | generic on formulary |
| Ionil T 1 % shampoo | generic on formulary |
| Kaopectate (bismuth subsalicylate) 262 mg/15 mL oral suspension | generic on formulary |
| Maalox Maximum Strength 400 mg-400 mg-40 mg/5 mL oral suspension | generic on formulary |
| Maxilube topical gel | generic on formulary |
| MELATONIN TAB 10MG | melatonin 5 mg tablet |
| MELATONIN TAB 1MG | melatonin 3 mg tablet |
| MOI-STIR SOL | Numoisyn oral mucosal liquid |
| MOUTH KOTE SOL | Numoisyn oral mucosal liquid |
| Mucinex Fast-Max Cold-Flu-Sore Throat 5 mg-10 mg-325 mg-200 mg tablet | generic on formulary |
| Mucinex Sinus-Max 0.05 % nasal spray | generic on formulary |
| NASAL MIST AER 0.9% | Ayr Saline Gel nasal spray |
| Os-Cal 500 + D3 500 mg (1,250 mg)-200 unit tablet | generic on formulary |
| OYST SHELL/D TAB 500-400 | Oysco 500/D 500 mg (1,250 mg)-200 unit tablet |
| Phospho-Trin 250 Neutral 250 mg tablet | generic on formulary |
| PRENATAL TAB | Prenatal Vitamins Plus Low Iron 27 mg iron-1 mg tablet |
| PRENATAL VIT TAB MINERALS | Prenatal Vitamins Plus Low Iron 27 mg iron-1 mg tablet |
| Refresh Celluvisc 1 % eye gel in a dropperette | generic on formulary |
| Sal-Plant 17 % topical gel | generic on formulary |
| Secura Protective topical ointment | generic on formulary |
| Sof-Lax 100 mg capsule | generic on formulary |
| SUPER B W/C CAP | Super B Complex-Vitamin C tablet |
| Thera-Gesic 15 %-1 % topical cream | generic on formulary |
| Therapeutic Mineral Ice 2 % topical gel | generic on formulary |
| Tums Extra Strength Smoothies 300 mg (750 mg) chewable tablet | generic on formulary |
| Tums Freshers 200 mg calcium (500 mg) chewable tablet | generic on formulary |
| Ureacin-10 10 % lotion | generic on formulary |
| Ureacin-20 20 % topical cream | generic on formulary |
| VITAMIN B-2 TAB 100MG | Complete Multivitamin tablet |
| VITAMIN C LIQ 500/5ML | C-500 500 mg chewable tablet |
The following Rx Drugs on the Value Add Formulary will now require Prior Authorization. Changes are effective December 1, 2020.
Drug Name
- Aplenzin tablet,extended release
- Benlysta injection
- calcitriol 0.5 mcg capsule
- Crinone vaginal gel
- Endari 5 gram oral powder packet
- Inflectra 100 mg intravenous solution
- Intrarosa 6.5 mg vaginal insert
- isotretinoin capsule (Accutane generic)
- Jadenu Sprinkle granules in packet
- Mulpleta 3 mg tablet
- Nityr tablet
- Nuplazid tablet
- Rayaldee 30 mcg capsule,extended release
- Renflexis 100 mg intravenous solution
- Santyl 250 unit/gram topical ointment
- Tavalisse tablet
- Triptodur 22.5 mg intramuscular suspension
- Versacloz 50 mg/mL oral suspension
- Xermelo 250 mg tablet
Prior Auth Phone: 1-844-330-7852
Prior Auth Fax: 1-877-386-4695