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:



Brisdelle CAPSULE 7.5 MG Oral


Post Date:
3/3/2018
Effective Date:
5/1/2018
Type of Change:
Drug removed
Reason Changed:
This brand named drug will be removed and replaced with the generic equivalent.
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
PARoxetine Mesylate CAPSULE 7.5 MG Oral Tier 2 SSRIs/ SNRIs
* Please reference your Evidence of Coverage for applicable cost-sharing.

Budesonide SUSPENSION 32 MCG/ACT Nasal


Post Date:
3/3/2018
Effective Date:
3/3/2018
Type of Change:
Drug removed - Manufacturer not contracted
Reason Changed:
This drug is not a covered benefit under Medicare part D regulations.
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Flunisolide SOLUTION 25 MCG/ACT (0.025%) Nasal Tier 2 QL, ST Anti-inflammatories, Inhaled Corticosteroids
Fluticasone Propionate SUSPENSION 50 MCG/ACT Nasal Tier 1 QL, ST Anti-inflammatories, Inhaled Corticosteroids
* Please reference your Evidence of Coverage for applicable cost-sharing.

Aczone GEL 5 % External


Post Date:
3/3/2018
Effective Date:
5/1/2018
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
This brand named drug will be removed and replaced with the generic equivalent.
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Dapsone GEL 5 % External Tier 4 Dermatological Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sustiva CAPSULE 50 MG Oral


Post Date:
3/3/2018
Effective Date:
5/1/2018
Type of Change:
Drug removed
Reason Changed:
This brand named drug will be removed and replaced with the generic equivalent.
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Efavirenz CAPSULE 50 MG Oral Tier 3 Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Cosmegen SOLUTION RECONSTITUTED 0.5 MG Intravenous


Post Date:
3/3/2018
Effective Date:
5/1/2018
Type of Change:
Drug removed
Reason Changed:
This brand named drug will be removed and replaced with the generic equivalent.
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
DACTINomycin SOLUTION RECONSTITUTED 0.5 MG Intravenous Tier 5 PA Antineoplastics
* Please reference your Evidence of Coverage for applicable cost-sharing.

Lexiva TABLET 700 MG Oral


Post Date:
3/3/2018
Effective Date:
5/1/2018
Type of Change:
Drug removed
Reason Changed:
This brand named drug will be removed and replaced with the generic equivalent.
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Fosamprenavir Calcium TABLET 700 MG Oral Tier 5 Anti-HIV Agents, Protease Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Estrace CREAM 0.1 MG/GM Vaginal


Post Date:
4/1/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent.
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Estradiol CREAM 0.1 MG/GM Vaginal Tier 2 Estrogens
* Please reference your Evidence of Coverage for applicable cost-sharing.

Reyataz CAPSULE 150 MG Oral


Post Date:
4/1/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent.
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Atazanavir Sulfate CAPSULE 150 MG Oral Tier 5 Anti-HIV Agents, Protease Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Reyataz CAPSULE 200 MG Oral


Post Date:
4/1/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent.
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Atazanavir Sulfate CAPSULE 200 MG Oral Tier 5 Anti-HIV Agents, Protease Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Reyataz CAPSULE 300 MG Oral


Post Date:
4/1/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent.
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Atazanavir Sulfate CAPSULE 300 MG Oral Tier 5 Anti-HIV Agents, Protease Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Viread TABLET 300 MG Oral


Post Date:
4/1/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent.
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Tenofovir Disoproxil Fumarate TABLET 300 MG Oral Tier 5 Anti-hepatitis B (HBV) Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Estrace CREAM 0.1 MG/GM Vaginal


Post Date:
5/2/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Estradiol CREAM 0.1 MG/GM Vaginal Tier 2 Estrogens
* Please reference your Evidence of Coverage for applicable cost-sharing.

Reyataz CAPSULE 150 MG Oral


Post Date:
5/2/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Atazanavir Sulfate CAPSULE 150 MG Oral Tier 5 Anti-HIV Agents, Protease Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Reyataz CAPSULE 200 MG Oral


Post Date:
5/2/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Atazanavir Sulfate CAPSULE 200 MG Oral Tier 5 Anti-HIV Agents, Protease Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Reyataz CAPSULE 300 MG Oral


Post Date:
5/2/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Atazanavir Sulfate CAPSULE 300 MG Oral Tier 5 Anti-HIV Agents, Protease Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Viread TABLET 300 MG Oral


Post Date:
5/2/2018
Effective Date:
6/1/2018
Type of Change:
Drug removed
Reason Changed:
Brand drug removed from formulary and has been replaced with the generic equivalent
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Tenofovir Disoproxil Fumarate Tablet 300 MG Oral Tier 5 Anti-hepatitis B (HBV) Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 7 MG Oral


Post Date:
5/4/2018
Effective Date:
7/1/2018
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
Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 7 MG Oral Tier 4 ST N-methyl-D-aspartate (NMDA) Receptor Antagonist
* Please reference your Evidence of Coverage for applicable cost-sharing.

Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 14 MG Oral


Post Date:
5/4/2018
Effective Date:
7/1/2018
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
Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 14 MG Oral Tier 4 ST N-methyl-D-aspartate (NMDA) Receptor Antagonist
* Please reference your Evidence of Coverage for applicable cost-sharing.

Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 21 MG Oral


Post Date:
5/4/2018
Effective Date:
7/1/2018
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
Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 21 MG Oral Tier 4 ST N-methyl-D-aspartate (NMDA) Receptor Antagonist
* Please reference your Evidence of Coverage for applicable cost-sharing.

Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 28 MG Oral


Post Date:
5/4/2018
Effective Date:
7/1/2018
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
Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 28 MG Oral Tier 4 ST N-methyl-D-aspartate (NMDA) Receptor Antagonist
* Please reference your Evidence of Coverage for applicable cost-sharing.

Syprine CAPSULE 250 MG Oral


Post Date:
5/4/2018
Effective Date:
7/1/2018
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
Trientine HCl CAPSULE 250 MG Oral Tier 5 Electrolyte/Mineral/Metal Modifiers
* Please reference your Evidence of Coverage for applicable cost-sharing.

Ziagen SOLUTION 20 MG/ML Oral


Post Date:
5/4/2018
Effective Date:
7/1/2018
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
Abacavir Sulfate SOLUTION 20 MG/ML Oral Tier 4 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Gabitril Tablet 12 MG Oral


Post Date:
6/1/2018
Effective Date:
8/1/2018
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
TiaGABine HCl Tablet 12 MG Oral Tier 4 Gamma-aminobutyric Acid (GABA) Augmenting Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Gabitril Tablet 16 MG Oral


Post Date:
6/1/2018
Effective Date:
8/1/2018
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
TiaGABine HCl Tablet 16 MG Oral Tier 4 Gamma-aminobutyric Acid (GABA) Augmenting Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Norvir CAPSULE 100 MG ORAL


Post Date:
6/1/2018
Effective Date:
8/1/2018
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
Ritonavir Tablet 100 MG Oral Tier 2 Anti-HIV Agents, Protease Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Desmopressin Ace Rhinal Tube Solution 0.01 % Nasal


Post Date:
9/3/2018
Effective Date:
9/1/2018
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
Abilify Maintena Suspension Reconstituted ER 300 MG Intramuscular Tier 5 PA 2nd Generation/Atypical
Desmopressin Ace Spray Refrig SOLUTION 0.01 % NASAL Tier 2 Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)
Desmopressin Acetate Tablet 0.1 MG Oral Tier 2 Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Gabitril Tablet 12 MG Oral


Post Date:
9/3/2018
Effective Date:
9/1/2018
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
TiaGABine HCl Tablet 12 MG Oral Tier 4 Gamma-aminobutyric Acid (GABA) Augmenting Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Gabitril Tablet 16 MG Oral


Post Date:
9/3/2018
Effective Date:
9/1/2018
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
TiaGABine HCl Tablet 16 MG Oral Tier 4 Gamma-aminobutyric Acid (GABA) Augmenting Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 14 MG Oral


Post Date:
9/3/2018
Effective Date:
9/1/2018
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
Memantine HCl ER Capsule Extended Release 24 Hour 14 MG Oral Tier 4 N-methyl-D-aspartate (NMDA) Receptor Antagonist
* Please reference your Evidence of Coverage for applicable cost-sharing.

Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 21 MG Oral


Post Date:
9/3/2018
Effective Date:
9/1/2018
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
Memantine HCl ER Capsule Extended Release 24 Hour 21 MG Oral Tier 4 N-methyl-D-aspartate (NMDA) Receptor Antagonist
* Please reference your Evidence of Coverage for applicable cost-sharing.

Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 28 MG Oral


Post Date:
9/3/2018
Effective Date:
9/1/2018
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
Memantine HCl ER Capsule Extended Release 24 Hour 28 MG Oral Tier 4 N-methyl-D-aspartate (NMDA) Receptor Antagonist
* Please reference your Evidence of Coverage for applicable cost-sharing.

Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 7 MG Oral


Post Date:
9/3/2018
Effective Date:
9/1/2018
Type of Change:
Cost sharing change
Reason Changed:
Generic therapeutically equivalent product available
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Memantine HCl ER Capsule Extended Release 24 Hour 7 MG Oral Tier 4 N-methyl-D-aspartate (NMDA) Receptor Antagonist
* Please reference your Evidence of Coverage for applicable cost-sharing.

Norvir Tablet 100 MG Oral


Post Date:
9/3/2018
Effective Date:
9/1/2018
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
Ritonavir Tablet 100 MG Oral Tier 2 Anti-HIV Agents, Protease Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Zenpep Capsule Delayed Release Particles 10000 UNIT Oral


Post Date:
9/3/2018
Effective Date:
9/1/2018
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
Creon CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT ORAL Tier 3 Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment
Zenpep Capsule Delayed Release Particles 10000-32000 UNIT Oral Tier 4 Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment
* Please reference your Evidence of Coverage for applicable cost-sharing.

Cefuroxime Sodium Solution Reconstituted 1.5 GM Injection


Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
This product is no longer available commercially.
Applies To:
All Rx Plans

Dalvance SOLUTION RECONSTITUTED 500 MG Intravenous


Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
The GPI changed, but the RXCUI remains the same and no change in placement.
Applies To:
All Rx Plans

Zenpep Capsule Delayed Release Particles 15000-51000 UNIT Oral


Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
This product is no longer available commercially.
Applies To:
All Rx Plans

Zenpep Capsule Delayed Release Particles 25000 UNIT Oral


Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
This product is no longer available commercially.
Applies To:
All Rx Plans

Zenpep Capsule Delayed Release Particles 3000-10000 UNIT Oral


Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
This product is no longer available commercially.
Applies To:
All Rx Plans

Zmax Suspension Reconstituted 2 GM Oral


Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
This product is no longer available commercially.
Applies To:
All Rx Plans

Polyethylene Glycol 3350 Packet Oral


Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
This product is not eligible under Medicare part D benefits.
Applies To:
All Rx Plans

Gleostine Capsule 5 MG Oral


Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
This product is not eligible under Medicare part D benefits.
Applies To:
All Rx Plans

Vancomycin HCl Capsule 125 MG Oral


Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
The GPI changed, but the RXCUI remains the same and no change in placement.
Applies To:
All Rx Plans

Vancomycin HCl Capsule 250 MG Oral


Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
The GPI changed, but the RXCUI remains the same and no change in placement.
Applies To:
All Rx Plans

Vancomycin HCl SOLUTION RECONSTITUTED 10 GM Intravenous


Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
The GPI changed, but the RXCUI remains the same and no change in placement.
Applies To:
All Rx Plans

Vancomycin HCl Solution Reconstituted 500 MG Intravenous


Post Date:
12/11/2018
Effective Date:
12/11/2018
Type of Change:
Invalid Negative Change
Reason Changed:
The GPI changed, but the RXCUI remains the same and no change in placement.
Applies To:
All Rx Plans


Acanya Gel 1.2-2.5 % External


Post Date:
2/1/2019
Effective Date:
2/1/2019
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
Clindamycin Phos-Benzoyl Perox Gel 1.2-2.5 % External Tier 4 Dermatological Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Finacea Gel 15 % External


Post Date:
2/1/2019
Effective Date:
2/1/2019
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
Azelaic Acid Gel 15 % External Tier 2 Dermatological Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Forfivo XL Tablet Extended Release 24 Hour 450 MG Oral


Post Date:
2/1/2019
Effective Date:
2/1/2019
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
BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 450 MG Oral Tier 4 QL, ST Antidepressants, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

INVanz Solution Reconstituted 1 GM Injection


Post Date:
2/1/2019
Effective Date:
2/1/2019
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
Ertapenem Sodium Solution Reconstituted 1 GM Injection Tier 4 Beta-lactam, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Onfi Suspension 2.5 MG/ML Oral


Post Date:
2/1/2019
Effective Date:
2/1/2019
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
CloBAZam Suspension 2.5 MG/ML Oral Tier 4 PA, ST Gamma-aminobutyric Acid (GABA) Augmenting Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Onfi Tablet 10 MG Oral


Post Date:
2/1/2019
Effective Date:
2/1/2019
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
CloBAZam Tablet 10 MG Oral Tier 4 PA, ST Gamma-aminobutyric Acid (GABA) Augmenting Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Onfi Tablet 20 MG Oral


Post Date:
2/1/2019
Effective Date:
2/1/2019
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
CloBAZam Tablet 20 MG Oral Tier 4 PA, ST Gamma-aminobutyric Acid (GABA) Augmenting Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sodium Chloride Solution 2.5 MEQ/ML Injection


Post Date:
2/1/2019
Effective Date:
2/1/2019
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
Sodium Chloride SOLUTION 3 % Intravenous Tier 2 Electrolyte/ Mineral Replacement
Sodium Chloride SOLUTION 5 % Intravenous Tier 2 Electrolyte/ Mineral Replacement
* Please reference your Evidence of Coverage for applicable cost-sharing.

Albenza Tablet 200 MG Oral


Post Date:
4/1/2019
Effective Date:
4/1/2019
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
Albendazole Tablet 200 MG Oral Tier 5 Anthelmintics
* Please reference your Evidence of Coverage for applicable cost-sharing.

Viramune Suspension 50 MG/5ML Oral


Post Date:
4/1/2019
Effective Date:
4/1/2019
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
Nevirapine Suspension 50 MG/5ML Oral Tier 2 Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
* Please reference your Evidence of Coverage for applicable cost-sharing.

Biltricide Tablet 600 MG Oral


Post Date:
5/1/2019
Effective Date:
5/1/2019
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
Praziquantel Tablet 600 MG Oral Tier 2 Anthelmintics
* Please reference your Evidence of Coverage for applicable cost-sharing.

Canasa Suppository 1000 MG Rectal


Post Date:
5/1/2019
Effective Date:
5/1/2019
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
Mesalamine Suppository 1000 MG Rectal Tier 2 QL Aminosalicylates
* Please reference your Evidence of Coverage for applicable cost-sharing.

Fareston Tablet 60 MG Oral


Post Date:
5/1/2019
Effective Date:
5/1/2019
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
Toremifene Citrate Tablet 60 MG Oral Tier 4 Antiestrogens/Modifiers
* Please reference your Evidence of Coverage for applicable cost-sharing.

Rapamune Solution 1 MG/ML Oral


Post Date:
5/1/2019
Effective Date:
5/1/2019
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
Sirolimus Solution 1 MG/ML Oral Tier 5 PA Immune Suppressants
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sabril Tablet 500 MG Oral


Post Date:
5/1/2019
Effective Date:
5/1/2019
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
Vigabatrin Tablet 500 MG Oral Tier 5 PA Gamma-aminobutyric Acid (GABA) Augmenting Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Adcirca Tablet 20 MG Oral


Post Date:
6/1/2019
Effective Date:
6/1/2019
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
Alyq Tablet 20 MG Oral Tier 5 PA Pulmonary Antihypertensives
* Please reference your Evidence of Coverage for applicable cost-sharing.

Elidel Cream 1 % External


Post Date:
6/1/2019
Effective Date:
6/1/2019
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
Pimecrolimus Cream 1 % External Tier 1 PA Dermatological Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Flector Patch 1.3 % Transdermal


Post Date:
6/1/2019
Effective Date:
6/1/2019
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
Diclofenac Epolamine Patch 1.3 % Transdermal Tier 2 PA, QL Nonsteroidal Anti-inflammatory Drugs
* Please reference your Evidence of Coverage for applicable cost-sharing.

Mestinon Syrup 60 MG/5ML Oral


Post Date:
6/1/2019
Effective Date:
6/1/2019
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
Pyridostigmine Bromide Solution 60 MG/5ML Oral Tier 2 Parasympathomimetics
* Please reference your Evidence of Coverage for applicable cost-sharing.

Rapaflo Capsule 4 MG Oral


Post Date:
6/1/2019
Effective Date:
6/1/2019
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
Silodosin Capsule 4 MG Oral Tier 2 ST Benign Prostatic Hypertrophy Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Rapaflo Capsule 8 MG Oral


Post Date:
6/1/2019
Effective Date:
6/1/2019
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
Silodosin Capsule 8 MG Oral Tier 2 ST Benign Prostatic Hypertrophy Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Tekturna Tablet 150 MG Oral


Post Date:
6/1/2019
Effective Date:
6/1/2019
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
Aliskiren Fumarate Tablet 150 MG Oral Tier 2 PA Cardiovascular Agents, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Tekturna Tablet 300 MG Oral


Post Date:
6/1/2019
Effective Date:
6/1/2019
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
Aliskiren Fumarate Tablet 300 MG Oral Tier 2 PA Cardiovascular Agents, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

EryPed 400 Suspension Reconstituted 400 MG/5ML Oral


Post Date:
7/1/2019
Effective Date:
7/1/2019
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
Erythromycin Ethylsuccinate Suspension Reconstituted 400 MG/5ML Oral Tier 2 Macrolides
* Please reference your Evidence of Coverage for applicable cost-sharing.

VESIcare Tablet 10 MG Oral


Post Date:
7/1/2019
Effective Date:
7/1/2019
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
Solifenacin Succinate Tablet 10 MG Oral Tier 4 Antispasmodics, Urinary
* Please reference your Evidence of Coverage for applicable cost-sharing.

VESIcare Tablet 5 MG Oral


Post Date:
7/1/2019
Effective Date:
7/1/2019
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
Solifenacin Succinate Tablet 5 MG Oral Tier 4 Antispasmodics, Urinary
* Please reference your Evidence of Coverage for applicable cost-sharing.

Exjade Tablet Soluble 125 MG Oral


Post Date:
7/1/2019
Effective Date:
7/1/2019
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
Deferasirox Tablet Soluble 125 MG Oral Tier 5 PA Electrolyte/Mineral/Metal Modifiers
* Please reference your Evidence of Coverage for applicable cost-sharing.

Exjade Tablet Soluble 250 MG Oral


Post Date:
7/1/2019
Effective Date:
7/1/2019
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
Deferasirox Tablet Soluble 250 MG Oral Tier 5 PA Electrolyte/Mineral/Metal Modifiers
* Please reference your Evidence of Coverage for applicable cost-sharing.

Exjade Tablet Soluble 500 MG Oral


Post Date:
7/1/2019
Effective Date:
7/1/2019
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
Deferasirox Tablet Soluble 500 MG Oral Tier 5 PA Electrolyte/Mineral/Metal Modifiers
* Please reference your Evidence of Coverage for applicable cost-sharing.

Lotemax Suspension 0.5 % Ophthalmic


Post Date:
8/1/2019
Effective Date:
8/1/2019
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
Loteprednol Etabonate Suspension 0.5 % Ophthalmic Tier 2 Ophthalmic Anti-inflammatories
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sensipar Tablet 30 MG Oral


Post Date:
8/1/2019
Effective Date:
8/1/2019
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
Cinacalcet HCl Tablet 30 MG Oral Tier 2 PA Metabolic Bone Disease Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sensipar Tablet 60 MG Oral


Post Date:
8/1/2019
Effective Date:
8/1/2019
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
Cinacalcet HCl Tablet 60 MG Oral Tier 5 PA Metabolic Bone Disease Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sensipar Tablet 90 MG Oral


Post Date:
8/1/2019
Effective Date:
8/1/2019
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
Cinacalcet HCl Tablet 90 MG Oral Tier 5 PA Metabolic Bone Disease Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Tarceva Tablet 100 MG Oral


Post Date:
8/1/2019
Effective Date:
8/1/2019
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
Erlotinib HCl Tablet 100 MG Oral Tier 5 PA, QL Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Tarceva Tablet 150 MG Oral


Post Date:
8/1/2019
Effective Date:
8/1/2019
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
Erlotinib HCl Tablet 150 MG Oral Tier 5 PA, QL Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Tarceva Tablet 25 MG Oral


Post Date:
8/1/2019
Effective Date:
8/1/2019
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
Erlotinib HCl Tablet 25 MG Oral Tier 5 PA, QL Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Tracleer Tablet 125 MG Oral


Post Date:
8/1/2019
Effective Date:
8/1/2019
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
Bosentan Tablet 125 MG Oral Tier 5 PA Pulmonary Antihypertensives
* Please reference your Evidence of Coverage for applicable cost-sharing.

Tracleer Tablet 62.5 MG Oral


Post Date:
8/1/2019
Effective Date:
8/1/2019
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
Bosentan Tablet 62.5 MG Oral Tier 5 PA Pulmonary Antihypertensives
* Please reference your Evidence of Coverage for applicable cost-sharing.

Triamcinolone Acetonide Aerosol 55 MCG/ACT Nasal


Post Date:
9/1/2019
Effective Date:
9/1/2019
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
Applies To:
All Rx Plans

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Flunisolide Solution 25 MCG/ACT (0.025%) Nasal Tier 2 QL Anti-inflammatories, Inhaled Corticosteroids
Mometasone Furoate SUSPENSION 50 MCG/ACT Nasal Tier 2 Anti-inflammatories, Inhaled Corticosteroids
* Please reference your Evidence of Coverage for applicable cost-sharing.

Veripred 20 Solution 20 MG/5ML Oral


Post Date:
9/1/2019
Effective Date:
9/1/2019
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
PrednisoLONE Sodium Phosphate Solution 20 MG/5ML Oral Tier 4 Glucocorticoids
* Please reference your Evidence of Coverage for applicable cost-sharing.

Fentora Tablet 100 MCG Buccal


Post Date:
9/1/2019
Effective Date:
9/1/2019
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
fentaNYL Citrate Tablet 100 MCG Buccal Tier 5 PA, QL Opioid Analgesics, Short-acting
* Please reference your Evidence of Coverage for applicable cost-sharing.

Fentora Tablet 200 MCG Buccal


Post Date:
9/1/2019
Effective Date:
9/1/2019
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
fentaNYL Citrate Tablet 200 MCG Buccal Tier 5 PA, QL Opioid Analgesics, Short-acting
* Please reference your Evidence of Coverage for applicable cost-sharing.

Fentora Tablet 400 MCG Buccal


Post Date:
9/1/2019
Effective Date:
9/1/2019
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
fentaNYL Citrate Tablet 400 MCG Buccal Tier 5 PA, QL Opioid Analgesics, Short-acting
* Please reference your Evidence of Coverage for applicable cost-sharing.

Fentora Tablet 600 MCG Buccal


Post Date:
9/1/2019
Effective Date:
9/1/2019
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
fentaNYL Citrate Tablet 600 MCG Buccal Tier 5 PA, QL Opioid Analgesics, Short-acting
* Please reference your Evidence of Coverage for applicable cost-sharing.

Fentora Tablet 800 MCG Buccal


Post Date:
9/1/2019
Effective Date:
9/1/2019
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
fentaNYL Citrate Tablet 800 MCG Buccal Tier 5 PA, QL Opioid Analgesics, Short-acting
* Please reference your Evidence of Coverage for applicable cost-sharing.

Letairis Tablet 10 MG Oral


Post Date:
9/1/2019
Effective Date:
9/1/2019
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
Ambrisentan Tablet 10 MG Oral Tier 5 PA Pulmonary Antihypertensives
* Please reference your Evidence of Coverage for applicable cost-sharing.

Letairis Tablet 5 MG Oral


Post Date:
9/1/2019
Effective Date:
9/1/2019
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
Ambrisentan Tablet 5 MG Oral Tier 5 PA Pulmonary Antihypertensives
* Please reference your Evidence of Coverage for applicable cost-sharing.

Ranexa Tablet Extended Release 12 Hour 1000 MG Oral


Post Date:
9/1/2019
Effective Date:
9/1/2019
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
Ranolazine ER Tablet Extended Release 12 Hour 1000 MG Oral Tier 2 QL Cardiovascular Agents, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Ranexa Tablet Extended Release 12 Hour 500 MG Oral


Post Date:
9/1/2019
Effective Date:
9/1/2019
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
Ranolazine ER Tablet Extended Release 12 Hour 500 MG Oral Tier 2 QL Cardiovascular Agents, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.