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, updated 10/1/2023

Adthyza Tablet 120 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Armour Thyroid Tablet 120 MG Oral	Tier 4		Miscellaneous Therapies (Non-FRF Drugs)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Adthyza Tablet 130 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Armour Thyroid Tablet 120 MG Oral	Tier 4		Miscellaneous Therapies (Non-FRF Drugs)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Adthyza Tablet 15 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Armour Thyroid Tablet 15 MG Oral	Tier 4		Miscellaneous Therapies (Non-FRF Drugs)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Adthyza Tablet 16.25 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Armour Thyroid Tablet 15 MG Oral	Tier 4		Miscellaneous Therapies (Non-FRF Drugs)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Adthyza Tablet 30 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Armour Thyroid Tablet 30 MG Oral	Tier 4		Miscellaneous Therapies (Non-FRF Drugs)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Adthyza Tablet 32.5 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Armour Thyroid Tablet 30 MG Oral	Tier 4		Miscellaneous Therapies (Non-FRF Drugs)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Adthyza Tablet 60 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Armour Thyroid Tablet 60 MG Oral	Tier 4		Miscellaneous Therapies (Non-FRF Drugs)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Adthyza Tablet 65 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Armour Thyroid Tablet 60 MG Oral	Tier 4		Miscellaneous Therapies (Non-FRF Drugs)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Adthyza Tablet 90 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Armour Thyroid Tablet 90 MG Oral	Tier 4		Miscellaneous Therapies (Non-FRF Drugs)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Adthyza Tablet 97.5 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Armour Thyroid Tablet 90 MG Oral	Tier 4		Miscellaneous Therapies (Non-FRF Drugs)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Amoxicillin-Pot Clavulanate Tablet Chewable 400-57 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral	Tier 4		Beta-lactam, Penicillins
* Please reference your Evidence of Coverage for applicable cost-sharing.

Bronchitol Capsule 40 MG Inhalation

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Pulmozyme Solution 2.5 MG/2.5ML Inhalation	Tier 5	PA	Cystic Fibrosis Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Brukinsa Capsule 80 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Brukinsa Tablet 160 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Diphtheria-Tetanus Toxoids DT Suspension 25-5 LFU/0.5ML Intramuscular

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Tenivac Injectable 5-2 LFU Intramuscular	Tier 3		Vaccines
* Please reference your Evidence of Coverage for applicable cost-sharing.

fentaNYL Citrate Lozenge On A Handle 1200 MCG Buccal

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
fentaNYL Patch 72 Hour 87.5 MCG/HR Transdermal	Tier 4	QL, ST	Opioid Analgesics, Long-acting
* Please reference your Evidence of Coverage for applicable cost-sharing.

fentaNYL Citrate Lozenge On A Handle 600 MCG Buccal

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
fentaNYL Patch 72 Hour 75 MCG/HR Transdermal	Tier 4	QL, ST	Opioid Analgesics, Long-acting
* Please reference your Evidence of Coverage for applicable cost-sharing.

fentaNYL Citrate Tablet 100 MCG Buccal

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
fentaNYL Patch 72 Hour 37.5 MCG/HR Transdermal	Tier 4	QL, ST	Opioid Analgesics, Long-acting
* Please reference your Evidence of Coverage for applicable cost-sharing.

fentaNYL Citrate Tablet 200 MCG Buccal

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
fentaNYL Patch 72 Hour 50 MCG/HR Transdermal	Tier 4	QL, ST	Opioid Analgesics, Long-acting
* Please reference your Evidence of Coverage for applicable cost-sharing.

Gleostine CAPSULE 10 MG ORAL

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Lomustine Capsule 10 MG Oral	Tier 4		Alkylating Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Gleostine CAPSULE 100 MG ORAL

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Lomustine Capsule 100 MG Oral	Tier 5		Alkylating Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Gleostine CAPSULE 40 MG ORAL

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Lomustine Capsule 40 MG Oral	Tier 4		Alkylating Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Kionex Suspension 15 GM/60ML Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Lokelma Packet 10 GM Oral	Tier 3		Potassium Binders
Lokelma Packet 5 GM Oral	Tier 3		Potassium Binders
* Please reference your Evidence of Coverage for applicable cost-sharing.

Ogsiveo Tablet 50 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Ogsiveo Tablet 100 MG Oral	Tier 5	PA, QL	Enzyme Inhibitors
Ogsiveo Tablet 150 MG Oral	Tier 5	PA, QL	Enzyme Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

PreHevbrio Suspension 10 MCG/ML Intramuscular

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Recombivax HB Suspension 10 MCG/ML Injection	Tier 3	PA	Vaccines
* Please reference your Evidence of Coverage for applicable cost-sharing.

Rotarix Suspension Reconstituted Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Rotarix Suspension Oral	Tier 3		Vaccines
* Please reference your Evidence of Coverage for applicable cost-sharing.

SPS Suspension 15 GM/60ML Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Lokelma Packet 10 GM Oral	Tier 3		Potassium Binders
Lokelma Packet 5 GM Oral	Tier 3		Potassium Binders
* Please reference your Evidence of Coverage for applicable cost-sharing.

SUMAtriptan Succinate Solution Auto-Injector 4 MG/0.5ML Subcutaneous

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
SUMAtriptan Succinate Solution Auto-Injector 6 MG/0.5ML Subcutaneous	Tier 4	QL	Serotonin (5-HT) Receptor Agonist
* Please reference your Evidence of Coverage for applicable cost-sharing.

TDVax Suspension 2-2 LF/0.5ML Intramuscular

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Tenivac Injectable 5-2 LFU Intramuscular	Tier 3		Vaccines
* Please reference your Evidence of Coverage for applicable cost-sharing.

Zimhi Solution Prefilled Syringe 5 MG/0.5ML Injection

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Naloxone HCl Solution Prefilled Syringe 2 MG/2ML Injection	Tier 2		Opioid Reversal Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.