Drug Changes


Here you will find a listing of the drugs that have been changed on our drug list (formulary) for the plan year you select.

To request Medicare Part D prescription drug coverage determinations (including tiering or formulary exception requests) please use the following form:



There are currently no changes for 2018


Budesonide ER CAPSULE EXTENDED RELEASE 24 HOUR 3 MG ORAL


Post Date:
12/9/2016
Effective Date:
1/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Budesonide CAPSULE DELAYED RELEASE PARTICLES 3 MG ORAL Tier 5 Irritable Bowel Syndrome Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

DaunoXome INJECTABLE 2 MG/ML INTRAVENOUS


Post Date:
12/9/2016
Effective Date:
1/1/2017
Type of Change:
Drug removed
Reason Changed:
Drug is no longer Part D eligible.
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
DOXOrubicin HCl SOLUTION 2 MG/ML INTRAVENOUS Tier 2 PA Antineoplastics
* Please reference your Evidence of Coverage for applicable cost-sharing.

DexPak 13 Day TABLET 1.5 MG ORAL


Post Date:
12/9/2016
Effective Date:
1/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
DexPak 13 Day 1.5 MG (51) ORAL Tier 4 Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Divalproex Sodium CAPSULE SPRINKLE 125 MG ORAL


Post Date:
12/9/2016
Effective Date:
1/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Divalproex Sodium 125 MG ORAL Tier 2 ST Gamma-aminobutyric Acid (GABA) Augmenting Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Enbrel KIT 25 MG SUBCUTANEOUS


Post Date:
12/9/2016
Effective Date:
1/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Enbrel 25 MG/0.5ML SUBCUTANEOUS Tier 5 PA, QL Immune Suppressants
* Please reference your Evidence of Coverage for applicable cost-sharing.

Enjuvia TABLET 0.3 MG ORAL


Post Date:
12/9/2016
Effective Date:
1/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Estradiol PATCH BIWEEKLY 0.025 MG/24HR TRANSDERMAL Tier 2 Estrogens
Estradiol TABLET 0.5 MG ORAL Tier 2 Estrogens
* Please reference your Evidence of Coverage for applicable cost-sharing.

Enjuvia TABLET 0.45 MG ORAL


Post Date:
12/9/2016
Effective Date:
1/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Estradiol PATCH BIWEEKLY 0.0375 MG/24HR TRANSDERMAL Tier 2 Estrogens
Estradiol TABLET 0.5 MG ORAL Tier 2 Estrogens
* Please reference your Evidence of Coverage for applicable cost-sharing.

Enjuvia TABLET 0.625 MG ORAL


Post Date:
12/9/2016
Effective Date:
1/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Estradiol PATCH WEEKLY 0.06 MG/24HR TRANSDERMAL Tier 2 Estrogens
Estradiol TABLET 0.5 MG ORAL Tier 2 Estrogens
* Please reference your Evidence of Coverage for applicable cost-sharing.

Enjuvia TABLET 0.9 MG ORAL


Post Date:
12/9/2016
Effective Date:
1/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Estradiol PATCH WEEKLY 0.05 MG/24HR TRANSDERMAL Tier 2 Estrogens
Estradiol TABLET 1 MG ORAL Tier 2 Estrogens
* Please reference your Evidence of Coverage for applicable cost-sharing.

Enjuvia TABLET 1.25 MG ORAL


Post Date:
12/9/2016
Effective Date:
1/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Estradiol TABLET 1 MG ORAL Tier 2 Estrogens
Premarin TABLET 1.25 MG ORAL Tier 4 Estrogens
* Please reference your Evidence of Coverage for applicable cost-sharing.

Flo-Pred SUSPENSION 16.7 (15 Base) MG/5ML ORAL


Post Date:
12/9/2016
Effective Date:
1/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Veripred 20 SOLUTION 20 MG/5ML ORAL Tier 4 Glucocorticoids
* Please reference your Evidence of Coverage for applicable cost-sharing.

PredniSONE (Pak) TABLET 10 MG ORAL


Post Date:
12/9/2016
Effective Date:
1/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
PredniSONE TABLET 10 MG ORAL Tier 1 Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Simcor TABLET EXTENDED RELEASE 24 HR 1000-20 MG ORAL


Post Date:
12/9/2016
Effective Date:
1/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Niacin ER (Antihyperlipidemic) TABLET EXTENDEDRELEASE 1000 MG ORAL Tier 2 Dyslipidemics, Other
Simvastatin TABLET 20 MG ORAL Tier 6 ST Dyslipidemics, HMG CoA Reductase Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Simcor TABLET EXTENDED RELEASE 24 HR 1000-40 MG ORAL


Post Date:
12/9/2016
Effective Date:
1/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Niacin ER (Antihyperlipidemic) TABLET EXTENDEDRELEASE 1000 MG ORAL Tier 2 Dyslipidemics, Other
Simvastatin TABLET 40 MG ORAL Tier 6 ST Dyslipidemics, HMG CoA Reductase Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Simcor TABLET EXTENDED RELEASE 24 HR 500-20 MG ORAL


Post Date:
12/9/2016
Effective Date:
1/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Niacin ER (Antihyperlipidemic) TABLET EXTENDEDRELEASE 500 MG ORAL Tier 2 Dyslipidemics, Other
Simvastatin TABLET 20 MG ORAL Tier 6 ST Dyslipidemics, HMG CoA Reductase Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Simcor TABLET EXTENDED RELEASE 24 HR 500-40 MG ORAL


Post Date:
12/9/2016
Effective Date:
1/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Niacin ER (Antihyperlipidemic) TABLET EXTENDEDRELEASE 500 MG ORAL Tier 2 Dyslipidemics, Other
Simvastatin TABLET 40 MG ORAL Tier 6 ST Dyslipidemics, HMG CoA Reductase Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Simcor TABLET EXTENDED RELEASE 24 HR 750-20 MG ORAL


Post Date:
12/9/2016
Effective Date:
1/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Niacin ER (Antihyperlipidemic) TABLET EXTENDEDRELEASE 750 MG ORAL Tier 2 Dyslipidemics, Other
Simvastatin TABLET 40 MG ORAL Tier 6 ST Dyslipidemics, HMG CoA Reductase Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Suclear KIT ORAL


Post Date:
12/9/2016
Effective Date:
1/1/2017
Type of Change:
Drug removed
Reason Changed:
Product no longer Medicare Part D eligible.
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
GaviLyte-C SOLUTION RECONSTITUTED 240 GM ORAL Tier 2 Laxatives
Golytely SOLUTION RECONSTITUTED 227.1 GM ORAL Tier 3 Laxatives
* Please reference your Evidence of Coverage for applicable cost-sharing.

A-Hydrocort SOLUTION RECONSTITUTED 100 MG INJECTION


Post Date:
3/3/2017
Effective Date:
3/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Hydrocortisone TABLET 10 MG ORAL Tier 2 Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Hydrocortisone TABLET 20 MG ORAL Tier 2 Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Cervarix SUSPENSION INTRAMUSCULAR


Post Date:
3/3/2017
Effective Date:
3/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Gardasil 9 SUSPENSION Intramuscular Tier 3 Vaccines
Gardasil SUSPENSION Intramuscular Tier 3 Vaccines
* Please reference your Evidence of Coverage for applicable cost-sharing.

Nutropin AQ Pen SOLUTION 20 MG/2ML SUBCUTANEOUS


Post Date:
3/3/2017
Effective Date:
3/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Nutropin AQ NuSpin 20 SOLUTION 20 MG/2ML Subcutaneous Tier 5 PA Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Plasma-Lyte-56 in D5W SOLUTION INTRAVENOUS


Post Date:
3/3/2017
Effective Date:
3/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Dextrose in Lactated Ringers SOLUTION 5 % Intravenous Tier 2 PA Therapeutic Nutrients/ Minerals/ Electrolytes
Dextrose-NaCl SOLUTION 10-0.2 % Intravenous Tier 4 PA Therapeutic Nutrients/ Minerals/ Electrolytes
* Please reference your Evidence of Coverage for applicable cost-sharing.

Reserpine TABLET 0.1 MG ORAL


Post Date:
3/3/2017
Effective Date:
3/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Lisinopril TABLET 40 MG Oral Tier 6 Angiotensin-converting Enzyme (ACE) Inhibitors
Losartan Potassium TABLET 100 MG Oral Tier 6 ST Angiotensin II Receptor Antagonists
* Please reference your Evidence of Coverage for applicable cost-sharing.

Reserpine TABLET 0.25 MG ORAL


Post Date:
3/3/2017
Effective Date:
3/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Lisinopril TABLET 20 MG Oral Tier 6 Angiotensin-converting Enzyme (ACE) Inhibitors
Losartan Potassium TABLET 25 MG ORAL Tier 6 ST Angiotensin II Receptor Antagonists
* Please reference your Evidence of Coverage for applicable cost-sharing.

VariZIG SOLUTION 125 UNIT/1.2ML INTRAMUSCULAR


Post Date:
3/3/2017
Effective Date:
3/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Zostavax SOLUTION RECONSTITUTED 19400 UNT/0.65ML Subcutaneous Tier 3 QL Vaccines
* Please reference your Evidence of Coverage for applicable cost-sharing.

Ammonium Chloride SOLUTION 5 MEQ/ML Intravenous


Post Date:
4/3/2017
Effective Date:
4/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
AcetaZOLAMIDE ER CAPSULE EXTENDED RELEASE 12 HOUR 500 MG ORAL Tier 2 Diuretics, Carbonic Anhydrase Inhibitors
AcetaZOLAMIDE TABLET 125 MG ORAL Tier 2 Diuretics, Carbonic Anhydrase Inhibitors
AcetaZOLAMIDE TABLET 250 MG ORAL Tier 2 Diuretics, Carbonic Anhydrase Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Atropine Sulfate Solution Prefilled Syringe 0.5 MG/5ML Injection


Post Date:
8/3/2017
Effective Date:
8/1/2017
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Atropine Sulfate Solution Prefilled Syringe 0.25 MG/5ML Injection Tier 2 Antispasmodics, Gastrointestinal
* Please reference your Evidence of Coverage for applicable cost-sharing.