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:


Jadenu TABLET 360 MG ORAL


Post Date:
2/1/2020
Effective Date:
2/1/2020
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 360 MG Oral Tier 5 PA Electrolyte/Mineral/Metal Modifiers
* Please reference your Evidence of Coverage for applicable cost-sharing.

Jadenu TABLET 90 MG ORAL


Post Date:
2/1/2020
Effective Date:
2/1/2020
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 90 MG Oral Tier 5 PA Electrolyte/Mineral/Metal Modifiers
* Please reference your Evidence of Coverage for applicable cost-sharing.

Afinitor Tablet 2.5 MG Oral


Post Date:
3/1/2020
Effective Date:
3/1/2020
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
Everolimus Tablet 2.5 MG Oral Tier 5 PA, QL Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Afinitor Tablet 5 MG Oral


Post Date:
3/1/2020
Effective Date:
3/1/2020
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
Everolimus Tablet 5 MG Oral Tier 5 PA, QL Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Afinitor Tablet 7.5 MG Oral


Post Date:
3/1/2020
Effective Date:
3/1/2020
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
Everolimus Tablet 7.5 MG Oral Tier 5 PA, QL Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Carafate Suspension 1 GM/10ML Oral


Post Date:
3/1/2020
Effective Date:
3/1/2020
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
Sucralfate Suspension 1 GM/10ML Oral Tier 4 Protectants
* Please reference your Evidence of Coverage for applicable cost-sharing.

Nebupent Solution Reconstituted 300 MG Inhalation


Post Date:
3/1/2020
Effective Date:
3/1/2020
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
Pentamidine Isethionate Solution Reconstituted 300 MG Inhalation Tier 2 PA Antiprotozoals
* Please reference your Evidence of Coverage for applicable cost-sharing.

NuvaRing Ring 0.12-0.015 MG/24HR Vaginal


Post Date:
3/1/2020
Effective Date:
3/1/2020
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
EluRyng Ring 0.12-0.015 MG/24HR Vaginal Tier 2 Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)
Etonogestrel-Ethinyl Estradiol Ring 0.12-0.015 MG/24HR Vaginal Tier 2 Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Pentam Solution Reconstituted 300 MG Injection


Post Date:
3/1/2020
Effective Date:
3/1/2020
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
Pentamidine Isethionate Solution Reconstituted 300 MG Injection Tier 4 Antiprotozoals
* Please reference your Evidence of Coverage for applicable cost-sharing.

Zortress Tablet 0.25 MG Oral


Post Date:
6/1/2020
Effective Date:
6/1/2020
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
Everolimus Tablet 0.25 MG Oral Tier 4 PA Immune Suppressants
* Please reference your Evidence of Coverage for applicable cost-sharing.

Zortress Tablet 0.5 MG Oral


Post Date:
6/1/2020
Effective Date:
6/1/2020
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
Everolimus Tablet 0.5 MG Oral Tier 5 PA Immune Suppressants
* Please reference your Evidence of Coverage for applicable cost-sharing.

Zortress Tablet 0.75 MG Oral


Post Date:
6/1/2020
Effective Date:
6/1/2020
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
Everolimus Tablet 0.75 MG Oral Tier 5 PA Immune Suppressants
* Please reference your Evidence of Coverage for applicable cost-sharing.