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

Paxil SUSPENSION 10 MG/5ML ORAL

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Afinitor Disperz TABLET SOLUBLE 3 MG ORAL

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Everolimus Tablet Soluble 3 MG Oral	Tier 5	PA	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Afinitor Disperz TABLET SOLUBLE 5 MG ORAL

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Alternative Drugs

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

Afinitor TABLET 10 MG ORAL

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Everolimus Tablet 10 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Cyclobenzaprine HCl Tablet 7.5 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Cyclobenzaprine HCl Tablet 5 MG Oral	Tier 1	ST	Skeletal Muscle Relaxants
* Please reference your Evidence of Coverage for applicable cost-sharing.

Toprol XL Tablet Extended Release 24 Hour 100 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Metoprolol Succinate ER Tablet Extended Release 24 Hour 100 MG Oral	Tier 2		Beta-adrenergic Blocking Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Toprol XL Tablet Extended Release 24 Hour 25 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG Oral	Tier 2		Beta-adrenergic Blocking Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Epiduo Forte Gel 0.3-2.5 % External

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Adapalene-Benzoyl Peroxide Gel 0.3-2.5 % External	Tier 4	PA	Acne and Rosacea Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Zortress Tablet 1 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Everolimus Tablet 1 MG Oral	Tier 5	PA, QL	Immunosuppressants
* Please reference your Evidence of Coverage for applicable cost-sharing.

Selzentry Tablet 150 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Maraviroc Tablet 150 MG Oral	Tier 5		Anti-HIV Agents, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Selzentry Tablet 300 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Maraviroc Tablet 300 MG Oral	Tier 5		Anti-HIV Agents, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Vimpat Tablet 100 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Lacosamide Tablet 100 MG Oral	Tier 4		Sodium Channel Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Vimpat Tablet 150 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Lacosamide Tablet 150 MG Oral	Tier 4		Sodium Channel Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Vimpat Tablet 200 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Lacosamide Tablet 200 MG Oral	Tier 4		Sodium Channel Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Vimpat Tablet 50 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Lacosamide Tablet 50 MG Oral	Tier 4		Sodium Channel Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Apokyn Solution Cartridge 30 MG/3ML Subcutaneous

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Apomorphine HCl Solution Cartridge 30 MG/3ML Subcutaneous	Tier 5		Dopamine Agonists
* Please reference your Evidence of Coverage for applicable cost-sharing.

Cystadane Powder Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Betaine Powder Oral	Tier 5		Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment
* Please reference your Evidence of Coverage for applicable cost-sharing.