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:
Drug | Tier* | Drug Restrictions | Therapy Class |
---|---|---|---|
Penciclovir Cream 1 % External | Tier 2 | ST | Topical Anti-infectives |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Drug | Tier* | Drug Restrictions | Therapy Class |
---|---|---|---|
Tazarotene Gel 0.05 % External | Tier 4 | Acne and Rosacea Agents | |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Drug | Tier* | Drug Restrictions | Therapy Class |
---|---|---|---|
Tazarotene Gel 0.1 % External | Tier 4 | Acne and Rosacea Agents | |
* Please reference your Evidence of Coverage for applicable cost-sharing. |