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:

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

Oxbryta Tablet 500 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Hydroxyurea Capsule 500 MG Oral	Tier 2	ST	Antineoplastics, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Relyvrio Packet 3-1 GM Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Riluzole Tablet 50 MG Oral	Tier 2		Central Nervous System, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Selzentry Tablet 25 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Maraviroc Tablet 150 MG Oral	Tier 4		Anti-HIV Agents, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Selzentry Tablet 75 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Maraviroc Tablet 150 MG Oral	Tier 4		Anti-HIV Agents, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sprycel Tablet 100 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Dasatinib Tablet 100 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sprycel Tablet 140 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Dasatinib Tablet 140 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sprycel Tablet 20 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Dasatinib Tablet 20 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sprycel Tablet 50 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Dasatinib Tablet 50 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sprycel Tablet 70 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Dasatinib Tablet 70 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sprycel Tablet 80 MG Oral

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Dasatinib Tablet 80 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Tazorac Cream 0.05 % External

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Tazarotene Cream 0.05 % External	Tier 4		Acne and Rosacea Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Phenytoin Sodium Extended CAPSULE 200 MG ORAL

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Phenytek Capsule 200 MG Oral	Tier 2		Sodium Channel Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Phenytoin Sodium Extended CAPSULE 300 MG ORAL

---

Alternative Drugs

---

Drug	Tier*	Drug Restrictions	Therapy Class
Phenytek Capsule 300 MG Oral	Tier 2		Sodium Channel Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.