Drug Changes

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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:

• Request for Medicare Prescription Drug Coverage Determination Form, updated 10/1/2023

Votrient Tablet 200 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
PAZOPanib HCl Tablet 200 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Vyvanse Capsule 10 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Lisdexamfetamine Dimesylate Capsule 10 MG Oral	Tier 2	QL	Attention Deficit Hyperactivity Disorder Agents, Amphetamines
* Please reference your Evidence of Coverage for applicable cost-sharing.

Vyvanse Capsule 20 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Lisdexamfetamine Dimesylate Capsule 20 MG Oral	Tier 2	QL	Attention Deficit Hyperactivity Disorder Agents, Amphetamines
* Please reference your Evidence of Coverage for applicable cost-sharing.

Vyvanse Capsule 30 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Lisdexamfetamine Dimesylate Capsule 30 MG Oral	Tier 2	QL	Attention Deficit Hyperactivity Disorder Agents, Amphetamines
* Please reference your Evidence of Coverage for applicable cost-sharing.

Vyvanse Capsule 40 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Lisdexamfetamine Dimesylate Capsule 40 MG Oral	Tier 2	QL	Attention Deficit Hyperactivity Disorder Agents, Amphetamines
* Please reference your Evidence of Coverage for applicable cost-sharing.

Vyvanse Capsule 50 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Lisdexamfetamine Dimesylate Capsule 50 MG Oral	Tier 2	QL	Attention Deficit Hyperactivity Disorder Agents, Amphetamines
* Please reference your Evidence of Coverage for applicable cost-sharing.

Vyvanse Capsule 60 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Lisdexamfetamine Dimesylate Capsule 60 MG Oral	Tier 2	QL	Attention Deficit Hyperactivity Disorder Agents, Amphetamines
* Please reference your Evidence of Coverage for applicable cost-sharing.

Vyvanse Capsule 70 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Lisdexamfetamine Dimesylate Capsule 70 MG Oral	Tier 2	QL	Attention Deficit Hyperactivity Disorder Agents, Amphetamines
* Please reference your Evidence of Coverage for applicable cost-sharing.

Zulresso Solution 100 MG/20ML Intravenous

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Citalopram Hydrobromide Tablet 10 MG Oral	Tier 1		SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
Citalopram Hydrobromide Tablet 20 MG Oral	Tier 1		SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
Citalopram Hydrobromide Tablet 40 MG Oral	Tier 1		SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
FLUoxetine HCl Capsule 10 MG Oral	Tier 1		SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
FLUoxetine HCl Capsule 20 MG Oral	Tier 1		SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
FLUoxetine HCl Capsule 40 MG Oral	Tier 1		SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
Sertraline HCl Tablet 100 MG Oral	Tier 1		SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
Sertraline HCl Tablet 25 MG Oral	Tier 1		SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
Sertraline HCl Tablet 50 MG Oral	Tier 1		SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Alphagan P Solution 0.1 % Ophthalmic

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Brimonidine Tartrate Solution 0.1 % Ophthalmic	Tier 2		Ophthalmic Intraocular Pressure Lowering Agents, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Ciprodex Suspension 0.3-0.1 % Otic

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Ciprofloxacin-Dexamethasone Suspension 0.3-0.1 % Otic	Tier 2		Otic Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Condylox Gel 0.5 % External

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Podofilox Gel 0.5 % External	Tier 4		Dermatological Agents, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Livalo Tablet 1 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Pitavastatin Calcium Tablet 1 MG Oral	Tier 2	QL	Dyslipidemics, HMG CoA Reductase Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Livalo Tablet 2 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Pitavastatin Calcium Tablet 2 MG Oral	Tier 2	QL	Dyslipidemics, HMG CoA Reductase Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Livalo Tablet 4 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Pitavastatin Calcium Tablet 4 MG Oral	Tier 2	QL	Dyslipidemics, HMG CoA Reductase Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.