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:
- Request for Medicare Prescription Drug Coverage Determination Form, updated 10/1/2023
Oxbryta Tablet 500 MG Oral
Post Date:
2/1/2025
Effective Date:
2/1/2025
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Hydroxyurea Capsule 500 MG Oral | Tier 2 | ST | Antineoplastics, Other |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Relyvrio Packet 3-1 GM Oral
Post Date:
2/1/2025
Effective Date:
2/1/2025
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Riluzole Tablet 50 MG Oral | Tier 2 | Central Nervous System, Other | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Selzentry Tablet 25 MG Oral
Post Date:
2/1/2025
Effective Date:
2/1/2025
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Maraviroc Tablet 150 MG Oral | Tier 4 | Anti-HIV Agents, Other | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Selzentry Tablet 75 MG Oral
Post Date:
2/1/2025
Effective Date:
2/1/2025
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Maraviroc Tablet 150 MG Oral | Tier 4 | Anti-HIV Agents, Other | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Sprycel Tablet 100 MG Oral
Post Date:
2/1/2025
Effective Date:
2/1/2025
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 |
|---|---|---|---|
| Dasatinib Tablet 100 MG Oral | Tier 5 | PA, QL | Molecular Target Inhibitors |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Sprycel Tablet 140 MG Oral
Post Date:
2/1/2025
Effective Date:
2/1/2025
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 |
|---|---|---|---|
| Dasatinib Tablet 140 MG Oral | Tier 5 | PA, QL | Molecular Target Inhibitors |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Sprycel Tablet 20 MG Oral
Post Date:
2/1/2025
Effective Date:
2/1/2025
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 |
|---|---|---|---|
| Dasatinib Tablet 20 MG Oral | Tier 5 | PA, QL | Molecular Target Inhibitors |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Sprycel Tablet 50 MG Oral
Post Date:
2/1/2025
Effective Date:
2/1/2025
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 |
|---|---|---|---|
| Dasatinib Tablet 50 MG Oral | Tier 5 | PA, QL | Molecular Target Inhibitors |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Sprycel Tablet 70 MG Oral
Post Date:
1/31/2025
Effective Date:
2/1/2025
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Dasatinib Tablet 70 MG Oral | Tier 5 | PA, QL | Molecular Target Inhibitors |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Sprycel Tablet 80 MG Oral
Post Date:
1/31/2025
Effective Date:
2/1/2025
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 |
|---|---|---|---|
| Dasatinib Tablet 80 MG Oral | Tier 5 | PA, QL | Molecular Target Inhibitors |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Tazorac Cream 0.05 % External
Post Date:
1/31/2025
Effective Date:
2/1/2025
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 |
|---|---|---|---|
| Tazarotene Cream 0.05 % External | Tier 4 | Acne and Rosacea Agents | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Phenytoin Sodium Extended CAPSULE 200 MG ORAL
Post Date:
3/1/2025
Effective Date:
3/1/2025
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Phenytek Capsule 200 MG Oral | Tier 2 | Sodium Channel Agents | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Phenytoin Sodium Extended CAPSULE 300 MG ORAL
Post Date:
3/1/2025
Effective Date:
3/1/2025
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Phenytek Capsule 300 MG Oral | Tier 2 | Sodium Channel Agents | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Mesnex Tablet 400 MG Oral
Post Date:
3/31/2025
Effective Date:
4/1/2025
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 |
|---|---|---|---|
| Mesna Tablet 400 MG Oral | Tier 5 | Treatment Adjuncts | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Spritam Tablet Disintegrating Soluble 250 MG Oral
Post Date:
3/31/2025
Effective Date:
4/1/2025
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 |
|---|---|---|---|
| levETIRAcetam Tablet Disintegrating Soluble 250 MG Oral | Tier 4 | PA | Anticonvulsants, Other |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Isosorbide Mononitrate Tablet 10 MG Oral
Post Date:
5/1/2025
Effective Date:
5/1/2025
Type of Change:
Cost sharing change
Reason Changed:
Cost sharing change
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Isosorbide Mononitrate Tablet 10 MG Oral | Tier 3 | Vasodilators, Direct-acting Arterial/ Venous | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Isosorbide Mononitrate Tablet 20 MG Oral
Post Date:
5/1/2025
Effective Date:
5/1/2025
Type of Change:
Cost sharing change
Reason Changed:
Cost sharing change
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Isosorbide Mononitrate Tablet 20 MG Oral | Tier 3 | Vasodilators, Direct-acting Arterial/ Venous | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Purixan Suspension 2000 MG/100ML Oral
Post Date:
6/1/2025
Effective Date:
6/1/2025
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 |
|---|---|---|---|
| Mercaptopurine Suspension 2000 MG/100ML Oral | Tier 5 | Antimetabolites | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Brilinta Tablet 90 MG Oral
Post Date:
6/30/2025
Effective Date:
7/1/2025
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 |
|---|---|---|---|
| Ticagrelor Tablet 90 MG Oral | Tier 3 | Platelet Modifying Agents | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Libervant Film 10 MG Buccal
Post Date:
6/30/2025
Effective Date:
7/1/2025
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Valtoco 10 MG Dose Liquid 10 MG/0.1ML Nasal | Tier 4 | QL | Gamma-aminobutyric Acid (GABA) Modulating Agents |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Libervant Film 12.5 MG Buccal
Post Date:
6/30/2025
Effective Date:
7/1/2025
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Valtoco 15 MG Dose Liquid Therapy Pack 2 x 7.5 MG/0.1ML Nasal | Tier 4 | QL | Gamma-aminobutyric Acid (GABA) Modulating Agents |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Libervant Film 15 MG Buccal
Post Date:
6/30/2025
Effective Date:
7/1/2025
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Valtoco 15 MG Dose Liquid Therapy Pack 2 x 7.5 MG/0.1ML Nasal | Tier 4 | QL | Gamma-aminobutyric Acid (GABA) Modulating Agents |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Libervant Film 5 MG Buccal
Post Date:
6/30/2025
Effective Date:
7/1/2025
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Valtoco 5 MG Dose Liquid 5 MG/0.1ML Nasal | Tier 4 | QL | Gamma-aminobutyric Acid (GABA) Modulating Agents |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Libervant Film 7.5 MG Buccal
Post Date:
6/30/2025
Effective Date:
7/1/2025
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Valtoco 10 MG Dose Liquid 10 MG/0.1ML Nasal | Tier 4 | QL | Gamma-aminobutyric Acid (GABA) Modulating Agents |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Aptiom Tablet 200 MG Oral
Post Date:
8/1/2025
Effective Date:
8/1/2025
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 |
|---|---|---|---|
| Eslicarbazepine Acetate Tablet 200 MG Oral | Tier 4 | Sodium Channel Agents | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Aptiom Tablet 400 MG Oral
Post Date:
8/1/2025
Effective Date:
8/1/2025
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 |
|---|---|---|---|
| Eslicarbazepine Acetate Tablet 400 MG Oral | Tier 5 | Sodium Channel Agents | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Aptiom Tablet 600 MG Oral
Post Date:
8/1/2025
Effective Date:
8/1/2025
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 |
|---|---|---|---|
| Eslicarbazepine Acetate Tablet 600 MG Oral | Tier 5 | Sodium Channel Agents | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Aptiom Tablet 800 MG Oral
Post Date:
8/1/2025
Effective Date:
8/1/2025
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 |
|---|---|---|---|
| Eslicarbazepine Acetate Tablet 800 MG Oral | Tier 5 | Sodium Channel Agents | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Brilinta Tablet 60 MG Oral
Post Date:
8/1/2025
Effective Date:
8/1/2025
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 |
|---|---|---|---|
| Ticagrelor Tablet 60 MG Oral | Tier 3 | Platelet Modifying Agents | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Dupixent Solution Prefilled Syringe 100 MG/0.67ML Subcutaneous
Post Date:
8/1/2025
Effective Date:
8/1/2025
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
100 mg dose removed from market. Non-FRF and GPI is inactive.
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Dupixent Solution Auto-Injector 300 MG/2ML Subcutaneous | Tier 5 | PA, QL | Immunological Agents, Other |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Exelderm Cream 1 % External
Post Date:
8/1/2025
Effective Date:
8/1/2025
Type of Change:
Drug removed
Reason Changed:
Removing from formulary as it is being promoted from non-FRF to FRF.
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Ciclopirox Solution 8 % External | Tier 2 | Topical Anti-infectives | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Lopinavir-Ritonavir Solution 400-100 MG/5ML Oral
Post Date:
8/1/2025
Effective Date:
8/1/2025
Type of Change:
Drug removed
Reason Changed:
Generic demoted to non-FRF. Added brand to ensure access to oral solution
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Kaletra Solution 400-100 MG/5ML Oral | Tier 4 | Anti-HIV Agents, Protease Inhibitors (PI) | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Retevmo Capsule 80 MG Oral
Post Date:
8/1/2025
Effective Date:
8/1/2025
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Capsules being discontinued, replacing with tablets
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Retevmo Tablet 80 MG Oral | Tier 5 | PA, QL | Antineoplastics, Other |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Complera Tablet 200-25-300 MG Oral
Post Date:
9/1/2025
Effective Date:
9/1/2025
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 |
|---|---|---|---|
| Emtricitab-Rilpivir-Tenofov DF Tablet 200-25-300 MG Oral | Tier 5 | QL | Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Retevmo Capsule 40 MG Oral
Post Date:
9/1/2025
Effective Date:
9/1/2025
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 |
|---|---|---|---|
| Retevmo Tablet 40 MG Oral | Tier 5 | PA, QL | Antineoplastics, Other |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Spritam Tablet Disintegrating Soluble 1000 MG Oral
Post Date:
9/1/2025
Effective Date:
9/1/2025
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug strength discontinued from marketplace
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Spritam Tablet Disintegrating Soluble 500 MG Oral | Tier 4 | PA | Anticonvulsants, Other |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Spritam Tablet Disintegrating Soluble 750 MG Oral
Post Date:
9/1/2025
Effective Date:
9/1/2025
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug strength discontinued from marketplace
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Spritam Tablet Disintegrating Soluble 500 MG Oral | Tier 4 | PA | Anticonvulsants, Other |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Tasigna Capsule 150 MG Oral
Post Date:
9/1/2025
Effective Date:
9/1/2025
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 |
|---|---|---|---|
| Nilotinib HCl Capsule 150 MG Oral | Tier 5 | PA, QL | Molecular Target Inhibitors |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Tasigna Capsule 200 MG Oral
Post Date:
9/1/2025
Effective Date:
9/1/2025
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 |
|---|---|---|---|
| Nilotinib HCl Capsule 200 MG Oral | Tier 5 | PA, QL | Molecular Target Inhibitors |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Tasigna Capsule 50 MG Oral
Post Date:
9/1/2025
Effective Date:
9/1/2025
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 |
|---|---|---|---|
| Nilotinib HCl Capsule 50 MG Oral | Tier 5 | PA, QL | Molecular Target Inhibitors |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Bronchitol Capsule 40 MG Inhalation
Post Date:
10/1/2025
Effective Date:
10/1/2025
Type of Change:
Cost sharing change
Reason Changed:
This was changed to Part D NO
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| 1st Tier Unifine Pentips 33G X 4 MM | Tier 3 | Miscellaneous Therapies (Non-FRF Drugs) | |
| Pulmozyme Solution 2.5 MG/2.5ML Inhalation | Tier 5 | PA | Cystic Fibrosis Agents |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Entresto Tablet 24-26 MG Oral
Post Date:
10/1/2025
Effective Date:
10/1/2025
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 |
|---|---|---|---|
| Sacubitril-Valsartan Tablet 24-26 MG Oral | Tier 2 | Cardiovascular Agents, Other | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Entresto Tablet 49-51 MG Oral
Post Date:
10/1/2025
Effective Date:
10/1/2025
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 |
|---|---|---|---|
| Sacubitril-Valsartan Tablet 49-51 MG Oral | Tier 2 | Cardiovascular Agents, Other | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Entresto Tablet 97-103 MG Oral
Post Date:
10/1/2025
Effective Date:
10/1/2025
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 |
|---|---|---|---|
| Sacubitril-Valsartan Tablet 97-103 MG Oral | Tier 2 | Cardiovascular Agents, Other | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Fycompa Tablet 10 MG Oral
Post Date:
10/1/2025
Effective Date:
10/1/2025
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 |
|---|---|---|---|
| Perampanel Tablet 10 MG Oral | Tier 4 | Anticonvulsants, Other | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Fycompa Tablet 12 MG Oral
Post Date:
10/1/2025
Effective Date:
10/1/2025
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 |
|---|---|---|---|
| Perampanel Tablet 12 MG Oral | Tier 4 | Anticonvulsants, Other | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Fycompa Tablet 2 MG Oral
Post Date:
10/1/2025
Effective Date:
10/1/2025
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 |
|---|---|---|---|
| Perampanel Tablet 2 MG Oral | Tier 4 | Anticonvulsants, Other | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Fycompa Tablet 4 MG Oral
Post Date:
10/1/2025
Effective Date:
10/1/2025
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 |
|---|---|---|---|
| Perampanel Tablet 4 MG Oral | Tier 4 | Anticonvulsants, Other | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Fycompa Tablet 6 MG Oral
Post Date:
10/1/2025
Effective Date:
10/1/2025
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 |
|---|---|---|---|
| Perampanel Tablet 6 MG Oral | Tier 4 | Anticonvulsants, Other | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Fycompa Tablet 8 MG Oral
Post Date:
10/1/2025
Effective Date:
10/1/2025
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 |
|---|---|---|---|
| Perampanel Tablet 8 MG Oral | Tier 4 | Anticonvulsants, Other | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Ixchiq Solution Reconstituted Intramuscular
Post Date:
10/1/2025
Effective Date:
10/1/2025
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Vimkunya Suspension Prefilled Syringe 40 MCG/0.8ML Intramuscular | Tier 3 | Vaccines | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Jynarque Tablet 15 MG Oral
Post Date:
10/1/2025
Effective Date:
10/1/2025
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 |
|---|---|---|---|
| Tolvaptan Tablet 15 MG Oral | Tier 5 | PA | Electrolyte/Mineral/Metal Modifiers |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Jynarque Tablet 30 MG Oral
Post Date:
10/1/2025
Effective Date:
10/1/2025
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 |
|---|---|---|---|
| Tolvaptan Tablet 30 MG Oral | Tier 5 | PA | Electrolyte/Mineral/Metal Modifiers |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Kiprofen Capsule 25 MG Oral
Post Date:
10/1/2025
Effective Date:
10/1/2025
Type of Change:
Drug removed
Reason Changed:
Removing NDC 73352050410 but maintaining coverage of GPI
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Ketoprofen Capsule 25 MG Oral | Tier 2 | Nonsteroidal Anti-inflammatory Drugs | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Norethindron-Ethinyl Estrad-Fe Tablet 1-20/1-30/1-35 MG-MCG Oral
Post Date:
10/1/2025
Effective Date:
10/1/2025
Type of Change:
Drug removed
Reason Changed:
Removing NDC 00378730353, but maintaining coverage of GPI
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Tri-Legest Fe TABLET 1-20/1-30/1-35 MG-MCG ORAL | Tier 2 | Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
prednisoLONE Sodium Phosphate Tablet Dispersible 10 MG Oral
Post Date:
10/1/2025
Effective Date:
10/1/2025
Type of Change:
Drug removed
Reason Changed:
Therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Orapred ODT Tablet Dispersible 10 MG Oral | Tier 4 | Glucocorticoids | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
prednisoLONE Sodium Phosphate Tablet Dispersible 15 MG Oral
Post Date:
10/1/2025
Effective Date:
10/1/2025
Type of Change:
Drug removed
Reason Changed:
Therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Orapred ODT Tablet Dispersible 15 MG Oral | Tier 4 | Glucocorticoids | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
prednisoLONE Sodium Phosphate Tablet Dispersible 30 MG Oral
Post Date:
10/1/2025
Effective Date:
10/1/2025
Type of Change:
Drug removed
Reason Changed:
Therapeutically equivalent product available
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| Orapred ODT Tablet Dispersible 30 MG Oral | Tier 4 | Glucocorticoids | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||
Trecator Tablet 250 MG Oral
Post Date:
10/1/2025
Effective Date:
10/1/2025
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans
Alternative Drugs
| Drug | Tier* | Drug Restrictions | Therapy Class |
|---|---|---|---|
| levoFLOXacin Tablet 750 MG Oral | Tier 2 | Quinolones | |
| * Please reference your Evidence of Coverage for applicable cost-sharing. | |||