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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