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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Afinitor Disperz TABLET SOLUBLE 3 MG ORAL
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
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
Effective Date:
2/28/2022
Type of Change:
Invalid Negative Change
Reason Changed:
High cost medication with alternative lower cost medications available
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
Effective Date:
2/28/2022
Type of Change:
Invalid Negative Change
Reason Changed:
Generic therapeutically equivalent product available
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
Effective Date:
2/28/2022
Type of Change:
Invalid Negative Change
Reason Changed:
Generic therapeutically equivalent product available
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
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
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
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. |