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

Jadenu TABLET 360 MG ORAL

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Deferasirox Tablet 360 MG Oral	Tier 5	PA	Electrolyte/Mineral/Metal Modifiers
* Please reference your Evidence of Coverage for applicable cost-sharing.

Jadenu TABLET 90 MG ORAL

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Deferasirox Tablet 90 MG Oral	Tier 5	PA	Electrolyte/Mineral/Metal Modifiers
* Please reference your Evidence of Coverage for applicable cost-sharing.

Afinitor Tablet 2.5 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Everolimus Tablet 2.5 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Afinitor Tablet 5 MG Oral

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Alternative Drugs

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

Afinitor Tablet 7.5 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Everolimus Tablet 7.5 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Carafate Suspension 1 GM/10ML Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Sucralfate Suspension 1 GM/10ML Oral	Tier 4		Protectants
* Please reference your Evidence of Coverage for applicable cost-sharing.

Nebupent Solution Reconstituted 300 MG Inhalation

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Pentamidine Isethionate Solution Reconstituted 300 MG Inhalation	Tier 2	PA	Antiprotozoals
* Please reference your Evidence of Coverage for applicable cost-sharing.

NuvaRing Ring 0.12-0.015 MG/24HR Vaginal

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
EluRyng Ring 0.12-0.015 MG/24HR Vaginal	Tier 2		Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)
Etonogestrel-Ethinyl Estradiol Ring 0.12-0.015 MG/24HR Vaginal	Tier 2		Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Pentam Solution Reconstituted 300 MG Injection

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Pentamidine Isethionate Solution Reconstituted 300 MG Injection	Tier 4		Antiprotozoals
* Please reference your Evidence of Coverage for applicable cost-sharing.

Zortress Tablet 0.25 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Everolimus Tablet 0.25 MG Oral	Tier 4	PA	Immune Suppressants
* Please reference your Evidence of Coverage for applicable cost-sharing.

Zortress Tablet 0.5 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Everolimus Tablet 0.5 MG Oral	Tier 5	PA	Immune Suppressants
* Please reference your Evidence of Coverage for applicable cost-sharing.

Zortress Tablet 0.75 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Everolimus Tablet 0.75 MG Oral	Tier 5	PA	Immune Suppressants
* Please reference your Evidence of Coverage for applicable cost-sharing.