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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:


Paxil SUSPENSION 10 MG/5ML ORAL


Post Date:
2/4/2022
Effective Date:
2/4/2022
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans

Afinitor Disperz TABLET SOLUBLE 3 MG ORAL


Post Date:
2/4/2022
Effective Date:
2/1/2022
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 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


Post Date:
2/4/2022
Effective Date:
2/1/2022
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 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


Post Date:
2/4/2022
Effective Date:
2/1/2022
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 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


Post Date:
2/28/2022
Effective Date:
2/28/2022
Type of Change:
Invalid Negative Change
Reason Changed:
High cost medication with alternative lower cost medications available
Applies To:
All Rx Plans

Alternative Drugs


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


Post Date:
2/28/2022
Effective Date:
2/28/2022
Type of Change:
Invalid Negative Change
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans

Alternative Drugs


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


Post Date:
2/28/2022
Effective Date:
2/28/2022
Type of Change:
Invalid Negative Change
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans

Alternative Drugs


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


Post Date:
3/1/2022
Effective Date:
3/1/2022
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
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


Post Date:
3/1/2022
Effective Date:
3/1/2022
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 1 MG Oral Tier 5 PA, QL Immunosuppressants
* Please reference your Evidence of Coverage for applicable cost-sharing.

Selzentry Tablet 150 MG Oral


Post Date:
5/1/2022
Effective Date:
5/1/2022
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
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


Post Date:
5/1/2022
Effective Date:
5/1/2022
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
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


Post Date:
6/1/2022
Effective Date:
6/1/2022
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
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


Post Date:
6/1/2022
Effective Date:
6/1/2022
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
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


Post Date:
6/1/2022
Effective Date:
6/1/2022
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


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


Post Date:
6/1/2022
Effective Date:
6/1/2022
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
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


Post Date:
6/1/2022
Effective Date:
6/1/2022
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
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


Post Date:
6/1/2022
Effective Date:
6/1/2022
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
Betaine Powder Oral Tier 5 Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment
* Please reference your Evidence of Coverage for applicable cost-sharing.