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:
Brisdelle CAPSULE 7.5 MG Oral
Post Date:
3/3/2018
Effective Date:
5/1/2018
Type of Change:
Drug removed
Reason Changed:
This brand named drug will be removed and replaced with the generic equivalent.
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| PARoxetine Mesylate CAPSULE 7.5 MG Oral | Tier 2 | SSRIs/ SNRIs | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Budesonide SUSPENSION 32 MCG/ACT Nasal
Post Date:
3/3/2018
Effective Date:
3/3/2018
Type of Change:
Drug removed - Manufacturer not contracted
Reason Changed:
This drug is not a covered benefit under Medicare part D regulations.
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Flunisolide SOLUTION 25 MCG/ACT (0.025%) Nasal | Tier 2 | QL, ST | Anti-inflammatories, Inhaled Corticosteroids |
| Fluticasone Propionate SUSPENSION 50 MCG/ACT Nasal | Tier 1 | QL, ST | Anti-inflammatories, Inhaled Corticosteroids |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Aczone GEL 5 % External
Post Date:
3/3/2018
Effective Date:
5/1/2018
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
This brand named drug will be removed and replaced with the generic equivalent.
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Dapsone GEL 5 % External | Tier 4 | Dermatological Agents | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Sustiva CAPSULE 50 MG Oral
Post Date:
3/3/2018
Effective Date:
5/1/2018
Type of Change:
Drug removed
Reason Changed:
This brand named drug will be removed and replaced with the generic equivalent.
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Efavirenz CAPSULE 50 MG Oral | Tier 3 | Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Cosmegen SOLUTION RECONSTITUTED 0.5 MG Intravenous
Post Date:
3/3/2018
Effective Date:
5/1/2018
Type of Change:
Drug removed
Reason Changed:
This brand named drug will be removed and replaced with the generic equivalent.
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| DACTINomycin SOLUTION RECONSTITUTED 0.5 MG Intravenous | Tier 5 | PA | Antineoplastics |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Lexiva TABLET 700 MG Oral
Post Date:
3/3/2018
Effective Date:
5/1/2018
Type of Change:
Drug removed
Reason Changed:
This brand named drug will be removed and replaced with the generic equivalent.
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Fosamprenavir Calcium TABLET 700 MG Oral | Tier 5 | Anti-HIV Agents, Protease Inhibitors | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Estrace CREAM 0.1 MG/GM Vaginal
Post Date:
4/1/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent.
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Estradiol CREAM 0.1 MG/GM Vaginal | Tier 2 | Estrogens | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Reyataz CAPSULE 150 MG Oral
Post Date:
4/1/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent.
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Atazanavir Sulfate CAPSULE 150 MG Oral | Tier 5 | Anti-HIV Agents, Protease Inhibitors | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Reyataz CAPSULE 200 MG Oral
Post Date:
4/1/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent.
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Atazanavir Sulfate CAPSULE 200 MG Oral | Tier 5 | Anti-HIV Agents, Protease Inhibitors | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Reyataz CAPSULE 300 MG Oral
Post Date:
4/1/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent.
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Atazanavir Sulfate CAPSULE 300 MG Oral | Tier 5 | Anti-HIV Agents, Protease Inhibitors | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Viread TABLET 300 MG Oral
Post Date:
4/1/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent.
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Tenofovir Disoproxil Fumarate TABLET 300 MG Oral | Tier 5 | Anti-hepatitis B (HBV) Agents | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Estrace CREAM 0.1 MG/GM Vaginal
Post Date:
5/2/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Estradiol CREAM 0.1 MG/GM Vaginal | Tier 2 | Estrogens | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Reyataz CAPSULE 150 MG Oral
Post Date:
5/2/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Atazanavir Sulfate CAPSULE 150 MG Oral | Tier 5 | Anti-HIV Agents, Protease Inhibitors | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Reyataz CAPSULE 200 MG Oral
Post Date:
5/2/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Atazanavir Sulfate CAPSULE 200 MG Oral | Tier 5 | Anti-HIV Agents, Protease Inhibitors | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Reyataz CAPSULE 300 MG Oral
Post Date:
5/2/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Atazanavir Sulfate CAPSULE 300 MG Oral | Tier 5 | Anti-HIV Agents, Protease Inhibitors | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Viread TABLET 300 MG Oral
Post Date:
5/2/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Tenofovir Disoproxil Fumarate Tablet 300 MG Oral | Tier 5 | Anti-hepatitis B (HBV) Agents | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 7 MG Oral
Post Date:
5/4/2018
Effective Date:
7/1/2018
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 7 MG Oral | Tier 4 | ST | N-methyl-D-aspartate (NMDA) Receptor Antagonist |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 14 MG Oral
Post Date:
5/4/2018
Effective Date:
7/1/2018
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 14 MG Oral | Tier 4 | ST | N-methyl-D-aspartate (NMDA) Receptor Antagonist |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 21 MG Oral
Post Date:
5/4/2018
Effective Date:
7/1/2018
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 21 MG Oral | Tier 4 | ST | N-methyl-D-aspartate (NMDA) Receptor Antagonist |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 28 MG Oral
Post Date:
5/4/2018
Effective Date:
7/1/2018
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 28 MG Oral | Tier 4 | ST | N-methyl-D-aspartate (NMDA) Receptor Antagonist |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Syprine CAPSULE 250 MG Oral
Post Date:
5/4/2018
Effective Date:
7/1/2018
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Trientine HCl CAPSULE 250 MG Oral | Tier 5 | Electrolyte/Mineral/Metal Modifiers | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Ziagen SOLUTION 20 MG/ML Oral
Post Date:
5/4/2018
Effective Date:
7/1/2018
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Abacavir Sulfate SOLUTION 20 MG/ML Oral | Tier 4 | Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Gabitril Tablet 12 MG Oral
Post Date:
6/1/2018
Effective Date:
8/1/2018
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| TiaGABine HCl Tablet 12 MG Oral | Tier 4 | Gamma-aminobutyric Acid (GABA) Augmenting Agents | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Gabitril Tablet 16 MG Oral
Post Date:
6/1/2018
Effective Date:
8/1/2018
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| TiaGABine HCl Tablet 16 MG Oral | Tier 4 | Gamma-aminobutyric Acid (GABA) Augmenting Agents | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Norvir CAPSULE 100 MG ORAL
Post Date:
6/1/2018
Effective Date:
8/1/2018
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Ritonavir Tablet 100 MG Oral | Tier 2 | Anti-HIV Agents, Protease Inhibitors | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Desmopressin Ace Rhinal Tube Solution 0.01 % Nasal
Post Date:
9/3/2018
Effective Date:
9/1/2018
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 |
|---|---|---|---|
| Abilify Maintena Suspension Reconstituted ER 300 MG Intramuscular | Tier 5 | PA | 2nd Generation/Atypical |
| Desmopressin Ace Spray Refrig SOLUTION 0.01 % NASAL | Tier 2 | Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) | |
| Desmopressin Acetate Tablet 0.1 MG Oral | Tier 2 | Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Gabitril Tablet 12 MG Oral
Post Date:
9/3/2018
Effective Date:
9/1/2018
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| TiaGABine HCl Tablet 12 MG Oral | Tier 4 | Gamma-aminobutyric Acid (GABA) Augmenting Agents | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Gabitril Tablet 16 MG Oral
Post Date:
9/3/2018
Effective Date:
9/1/2018
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| TiaGABine HCl Tablet 16 MG Oral | Tier 4 | Gamma-aminobutyric Acid (GABA) Augmenting Agents | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 14 MG Oral
Post Date:
9/3/2018
Effective Date:
9/1/2018
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Memantine HCl ER Capsule Extended Release 24 Hour 14 MG Oral | Tier 4 | N-methyl-D-aspartate (NMDA) Receptor Antagonist | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 21 MG Oral
Post Date:
9/3/2018
Effective Date:
9/1/2018
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Memantine HCl ER Capsule Extended Release 24 Hour 21 MG Oral | Tier 4 | N-methyl-D-aspartate (NMDA) Receptor Antagonist | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 28 MG Oral
Post Date:
9/3/2018
Effective Date:
9/1/2018
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Memantine HCl ER Capsule Extended Release 24 Hour 28 MG Oral | Tier 4 | N-methyl-D-aspartate (NMDA) Receptor Antagonist | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 7 MG Oral
Post Date:
9/3/2018
Effective Date:
9/1/2018
Type of Change:
Cost sharing change
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Memantine HCl ER Capsule Extended Release 24 Hour 7 MG Oral | Tier 4 | N-methyl-D-aspartate (NMDA) Receptor Antagonist | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Norvir Tablet 100 MG Oral
Post Date:
9/3/2018
Effective Date:
9/1/2018
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Ritonavir Tablet 100 MG Oral | Tier 2 | Anti-HIV Agents, Protease Inhibitors | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Zenpep Capsule Delayed Release Particles 10000 UNIT Oral
Post Date:
9/3/2018
Effective Date:
9/1/2018
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 |
|---|---|---|---|
| Creon CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT ORAL | Tier 3 | Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment | |
| Zenpep Capsule Delayed Release Particles 10000-32000 UNIT Oral | Tier 4 | Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Cefuroxime Sodium Solution Reconstituted 1.5 GM Injection
Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
This product is no longer available commercially.
Applies To:
All Rx Plans
Dalvance SOLUTION RECONSTITUTED 500 MG Intravenous
Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
The GPI changed, but the RXCUI remains the same and no change in placement.
Applies To:
All Rx Plans
Zenpep Capsule Delayed Release Particles 15000-51000 UNIT Oral
Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
This product is no longer available commercially.
Applies To:
All Rx Plans
Zenpep Capsule Delayed Release Particles 25000 UNIT Oral
Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
This product is no longer available commercially.
Applies To:
All Rx Plans
Zenpep Capsule Delayed Release Particles 3000-10000 UNIT Oral
Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
This product is no longer available commercially.
Applies To:
All Rx Plans
Zmax Suspension Reconstituted 2 GM Oral
Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
This product is no longer available commercially.
Applies To:
All Rx Plans
Polyethylene Glycol 3350 Packet Oral
Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
This product is not eligible under Medicare part D benefits.
Applies To:
All Rx Plans
Gleostine Capsule 5 MG Oral
Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
This product is not eligible under Medicare part D benefits.
Applies To:
All Rx Plans
Vancomycin HCl Capsule 125 MG Oral
Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
The GPI changed, but the RXCUI remains the same and no change in placement.
Applies To:
All Rx Plans
Vancomycin HCl Capsule 250 MG Oral
Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
The GPI changed, but the RXCUI remains the same and no change in placement.
Applies To:
All Rx Plans
Vancomycin HCl SOLUTION RECONSTITUTED 10 GM Intravenous
Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
The GPI changed, but the RXCUI remains the same and no change in placement.
Applies To:
All Rx Plans
Vancomycin HCl Solution Reconstituted 500 MG Intravenous
Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
The GPI changed, but the RXCUI remains the same and no change in placement.
Applies To:
All Rx Plans
Acanya Gel 1.2-2.5 % External
Post Date:
2/1/2019
Effective Date:
2/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Clindamycin Phos-Benzoyl Perox Gel 1.2-2.5 % External | Tier 4 | Dermatological Agents | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Finacea Gel 15 % External
Post Date:
2/1/2019
Effective Date:
2/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Azelaic Acid Gel 15 % External | Tier 2 | Dermatological Agents | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Forfivo XL Tablet Extended Release 24 Hour 450 MG Oral
Post Date:
2/1/2019
Effective Date:
2/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 450 MG Oral | Tier 4 | QL, ST | Antidepressants, Other |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
INVanz Solution Reconstituted 1 GM Injection
Post Date:
2/1/2019
Effective Date:
2/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Ertapenem Sodium Solution Reconstituted 1 GM Injection | Tier 4 | Beta-lactam, Other | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Onfi Suspension 2.5 MG/ML Oral
Post Date:
2/1/2019
Effective Date:
2/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| CloBAZam Suspension 2.5 MG/ML Oral | Tier 4 | PA, ST | Gamma-aminobutyric Acid (GABA) Augmenting Agents |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Onfi Tablet 10 MG Oral
Post Date:
2/1/2019
Effective Date:
2/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| CloBAZam Tablet 10 MG Oral | Tier 4 | PA, ST | Gamma-aminobutyric Acid (GABA) Augmenting Agents |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Onfi Tablet 20 MG Oral
Post Date:
2/1/2019
Effective Date:
2/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| CloBAZam Tablet 20 MG Oral | Tier 4 | PA, ST | Gamma-aminobutyric Acid (GABA) Augmenting Agents |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Sodium Chloride Solution 2.5 MEQ/ML Injection
Post Date:
2/1/2019
Effective Date:
2/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Sodium Chloride SOLUTION 3 % Intravenous | Tier 2 | Electrolyte/ Mineral Replacement | |
| Sodium Chloride SOLUTION 5 % Intravenous | Tier 2 | Electrolyte/ Mineral Replacement | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Albenza Tablet 200 MG Oral
Post Date:
4/1/2019
Effective Date:
4/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Albendazole Tablet 200 MG Oral | Tier 5 | Anthelmintics | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Viramune Suspension 50 MG/5ML Oral
Post Date:
4/1/2019
Effective Date:
4/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Nevirapine Suspension 50 MG/5ML Oral | Tier 2 | Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Biltricide Tablet 600 MG Oral
Post Date:
5/1/2019
Effective Date:
5/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Praziquantel Tablet 600 MG Oral | Tier 2 | Anthelmintics | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Canasa Suppository 1000 MG Rectal
Post Date:
5/1/2019
Effective Date:
5/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Mesalamine Suppository 1000 MG Rectal | Tier 2 | QL | Aminosalicylates |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Fareston Tablet 60 MG Oral
Post Date:
5/1/2019
Effective Date:
5/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Toremifene Citrate Tablet 60 MG Oral | Tier 4 | Antiestrogens/Modifiers | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Rapamune Solution 1 MG/ML Oral
Post Date:
5/1/2019
Effective Date:
5/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Sirolimus Solution 1 MG/ML Oral | Tier 5 | PA | Immune Suppressants |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Sabril Tablet 500 MG Oral
Post Date:
5/1/2019
Effective Date:
5/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Vigabatrin Tablet 500 MG Oral | Tier 5 | PA | Gamma-aminobutyric Acid (GABA) Augmenting Agents |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Adcirca Tablet 20 MG Oral
Post Date:
6/1/2019
Effective Date:
6/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Alyq Tablet 20 MG Oral | Tier 5 | PA | Pulmonary Antihypertensives |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Elidel Cream 1 % External
Post Date:
6/1/2019
Effective Date:
6/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Pimecrolimus Cream 1 % External | Tier 1 | PA | Dermatological Agents |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Flector Patch 1.3 % Transdermal
Post Date:
6/1/2019
Effective Date:
6/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Diclofenac Epolamine Patch 1.3 % Transdermal | Tier 2 | PA, QL | Nonsteroidal Anti-inflammatory Drugs |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Mestinon Syrup 60 MG/5ML Oral
Post Date:
6/1/2019
Effective Date:
6/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Pyridostigmine Bromide Solution 60 MG/5ML Oral | Tier 2 | Parasympathomimetics | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Rapaflo Capsule 4 MG Oral
Post Date:
6/1/2019
Effective Date:
6/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Silodosin Capsule 4 MG Oral | Tier 2 | ST | Benign Prostatic Hypertrophy Agents |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Rapaflo Capsule 8 MG Oral
Post Date:
6/1/2019
Effective Date:
6/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Silodosin Capsule 8 MG Oral | Tier 2 | ST | Benign Prostatic Hypertrophy Agents |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Tekturna Tablet 150 MG Oral
Post Date:
6/1/2019
Effective Date:
6/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Aliskiren Fumarate Tablet 150 MG Oral | Tier 2 | PA | Cardiovascular Agents, Other |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Tekturna Tablet 300 MG Oral
Post Date:
6/1/2019
Effective Date:
6/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Aliskiren Fumarate Tablet 300 MG Oral | Tier 2 | PA | Cardiovascular Agents, Other |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
EryPed 400 Suspension Reconstituted 400 MG/5ML Oral
Post Date:
7/1/2019
Effective Date:
7/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Erythromycin Ethylsuccinate Suspension Reconstituted 400 MG/5ML Oral | Tier 2 | Macrolides | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
VESIcare Tablet 10 MG Oral
Post Date:
7/1/2019
Effective Date:
7/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Solifenacin Succinate Tablet 10 MG Oral | Tier 4 | Antispasmodics, Urinary | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
VESIcare Tablet 5 MG Oral
Post Date:
7/1/2019
Effective Date:
7/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Solifenacin Succinate Tablet 5 MG Oral | Tier 4 | Antispasmodics, Urinary | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Exjade Tablet Soluble 125 MG Oral
Post Date:
7/1/2019
Effective Date:
7/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Deferasirox Tablet Soluble 125 MG Oral | Tier 5 | PA | Electrolyte/Mineral/Metal Modifiers |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Exjade Tablet Soluble 250 MG Oral
Post Date:
7/1/2019
Effective Date:
7/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Deferasirox Tablet Soluble 250 MG Oral | Tier 5 | PA | Electrolyte/Mineral/Metal Modifiers |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Exjade Tablet Soluble 500 MG Oral
Post Date:
7/1/2019
Effective Date:
7/1/2019
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Deferasirox Tablet Soluble 500 MG Oral | Tier 5 | PA | Electrolyte/Mineral/Metal Modifiers |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||