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

Denavir Cream 1 % External

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Alternative Drugs

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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.

Tazorac Gel 0.05 % External

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Alternative Drugs

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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.

Tazorac Gel 0.1 % External

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Alternative Drugs

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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.