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:
Drug | Tier* | Drug Restrictions | Therapy Class |
---|---|---|---|
Efavirenz-Emtricitab-Tenofovir Tablet 600-200-300 MG Oral | Tier 5 | QL | Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Drug | Tier* | Drug Restrictions | Therapy Class |
---|---|---|---|
metyroSINE Capsule 250 MG Oral | Tier 5 | PA | Cardiovascular Agents, Other |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Drug | Tier* | Drug Restrictions | Therapy Class |
---|---|---|---|
Emtricitabine Capsule 200 MG Oral | Tier 2 | QL | Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Drug | Tier* | Drug Restrictions | Therapy Class |
---|---|---|---|
Deferiprone Tablet 500 MG Oral | Tier 5 | PA | Electrolyte/Mineral/Metal Modifiers |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Drug | Tier* | Drug Restrictions | Therapy Class |
---|---|---|---|
Sapropterin Dihydrochloride Packet 100 MG Oral | Tier 5 | PA | Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Drug | Tier* | Drug Restrictions | Therapy Class |
---|---|---|---|
Sapropterin Dihydrochloride Packet 500 MG Oral | Tier 5 | PA | Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Drug | Tier* | Drug Restrictions | Therapy Class |
---|---|---|---|
Sapropterin Dihydrochloride Tablet Soluble 100 MG Oral | Tier 5 | PA | Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Drug | Tier* | Drug Restrictions | Therapy Class |
---|---|---|---|
PEG-KCl-NaCl-NaSulf-Na Asc-C Solution Reconstituted 100 GM Oral | Tier 2 | Anti-Constipation Agents | |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Drug | Tier* | Drug Restrictions | Therapy Class |
---|---|---|---|
Efavirenz-lamiVUDine-Tenofovir Tablet 400-300-300 MG Oral | Tier 2 | Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) | |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Drug | Tier* | Drug Restrictions | Therapy Class |
---|---|---|---|
Efavirenz-lamiVUDine-Tenofovir Tablet 600-300-300 MG Oral | Tier 2 | Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) | |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Drug | Tier* | Drug Restrictions | Therapy Class |
---|---|---|---|
Emtricitabine-Tenofovir DF Tablet 200-300 MG Oral | Tier 5 | QL | Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Drug | Tier* | Drug Restrictions | Therapy Class |
---|---|---|---|
Lapatinib Ditosylate Tablet 250 MG Oral | Tier 5 | PA | Molecular Target Inhibitors |
* Please reference your Evidence of Coverage for applicable cost-sharing. |