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

Atripla Tablet 600-200-300 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Efavirenz-Emtricitab-Tenofovir Tablet 600-200-300 MG Oral	Tier 5	QL	Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Demser Capsule 250 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
metyroSINE Capsule 250 MG Oral	Tier 5	PA	Cardiovascular Agents, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Emtriva Capsule 200 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Emtricitabine Capsule 200 MG Oral	Tier 2	QL	Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Ferriprox Tablet 500 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Deferiprone Tablet 500 MG Oral	Tier 5	PA	Electrolyte/Mineral/Metal Modifiers
* Please reference your Evidence of Coverage for applicable cost-sharing.

Kuvan Packet 100 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Sapropterin Dihydrochloride Packet 100 MG Oral	Tier 5	PA	Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment
* Please reference your Evidence of Coverage for applicable cost-sharing.

Kuvan Packet 500 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Sapropterin Dihydrochloride Packet 500 MG Oral	Tier 5	PA	Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment
* Please reference your Evidence of Coverage for applicable cost-sharing.

Kuvan Tablet Soluble 100 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Sapropterin Dihydrochloride Tablet Soluble 100 MG Oral	Tier 5	PA	Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment
* Please reference your Evidence of Coverage for applicable cost-sharing.

MoviPrep Solution Reconstituted 100 GM Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
PEG-KCl-NaCl-NaSulf-Na Asc-C Solution Reconstituted 100 GM Oral	Tier 2		Anti-Constipation Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Symfi Lo Tablet 400-300-300 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Efavirenz-lamiVUDine-Tenofovir Tablet 400-300-300 MG Oral	Tier 2		Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Symfi Tablet 600-300-300 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Efavirenz-lamiVUDine-Tenofovir Tablet 600-300-300 MG Oral	Tier 2		Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Truvada Tablet 200-300 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Emtricitabine-Tenofovir DF Tablet 200-300 MG Oral	Tier 5	QL	Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Tykerb Tablet 250 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Lapatinib Ditosylate Tablet 250 MG Oral	Tier 5	PA	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Banzel Suspension 40 MG/ML Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Rufinamide Suspension 40 MG/ML Oral	Tier 5	PA	Sodium Channel Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Saphris Tablet Sublingual 10 MG Sublingual

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Asenapine Maleate Tablet Sublingual 10 MG Sublingual	Tier 4	QL	2nd Generation/Atypical
* Please reference your Evidence of Coverage for applicable cost-sharing.

Saphris Tablet Sublingual 2.5 MG Sublingual

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Asenapine Maleate Tablet Sublingual 2.5 MG Sublingual	Tier 4	QL	2nd Generation/Atypical
* Please reference your Evidence of Coverage for applicable cost-sharing.

Saphris Tablet Sublingual 5 MG Sublingual

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Asenapine Maleate Tablet Sublingual 5 MG Sublingual	Tier 4	QL	2nd Generation/Atypical
* Please reference your Evidence of Coverage for applicable cost-sharing.

Alinia Tablet 500 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Nitazoxanide Tablet 500 MG Oral	Tier 4	QL	Antiprotozoals
* Please reference your Evidence of Coverage for applicable cost-sharing.

Truvada Tablet 100-150 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Emtricitabine-Tenofovir DF Tablet 100-150 MG Oral	Tier 5		Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Truvada Tablet 133-200 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Emtricitabine-Tenofovir DF Tablet 133-200 MG Oral	Tier 5		Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Truvada Tablet 167-250 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Emtricitabine-Tenofovir DF Tablet 167-250 MG Oral	Tier 5		Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
* Please reference your Evidence of Coverage for applicable cost-sharing.