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:
Votrient Tablet 200 MG Oral
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
Drug |
Tier* |
Drug Restrictions |
Therapy Class |
PAZOPanib HCl Tablet 200 MG Oral |
Tier 5 |
PA, QL |
Molecular Target Inhibitors |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Vyvanse Capsule 10 MG Oral
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
Drug |
Tier* |
Drug Restrictions |
Therapy Class |
Lisdexamfetamine Dimesylate Capsule 10 MG Oral |
Tier 2 |
QL |
Attention Deficit Hyperactivity Disorder Agents, Amphetamines |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Vyvanse Capsule 20 MG Oral
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
Drug |
Tier* |
Drug Restrictions |
Therapy Class |
Lisdexamfetamine Dimesylate Capsule 20 MG Oral |
Tier 2 |
QL |
Attention Deficit Hyperactivity Disorder Agents, Amphetamines |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Vyvanse Capsule 30 MG Oral
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
Drug |
Tier* |
Drug Restrictions |
Therapy Class |
Lisdexamfetamine Dimesylate Capsule 30 MG Oral |
Tier 2 |
QL |
Attention Deficit Hyperactivity Disorder Agents, Amphetamines |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Vyvanse Capsule 40 MG Oral
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
Drug |
Tier* |
Drug Restrictions |
Therapy Class |
Lisdexamfetamine Dimesylate Capsule 40 MG Oral |
Tier 2 |
QL |
Attention Deficit Hyperactivity Disorder Agents, Amphetamines |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Vyvanse Capsule 50 MG Oral
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
Drug |
Tier* |
Drug Restrictions |
Therapy Class |
Lisdexamfetamine Dimesylate Capsule 50 MG Oral |
Tier 2 |
QL |
Attention Deficit Hyperactivity Disorder Agents, Amphetamines |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Vyvanse Capsule 60 MG Oral
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
Drug |
Tier* |
Drug Restrictions |
Therapy Class |
Lisdexamfetamine Dimesylate Capsule 60 MG Oral |
Tier 2 |
QL |
Attention Deficit Hyperactivity Disorder Agents, Amphetamines |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Vyvanse Capsule 70 MG Oral
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
Drug |
Tier* |
Drug Restrictions |
Therapy Class |
Lisdexamfetamine Dimesylate Capsule 70 MG Oral |
Tier 2 |
QL |
Attention Deficit Hyperactivity Disorder Agents, Amphetamines |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Zulresso Solution 100 MG/20ML Intravenous
Type of Change:
Drug removed
Reason Changed:
Not a self-administered drug
Alternative Drugs
Drug |
Tier* |
Drug Restrictions |
Therapy Class |
Citalopram Hydrobromide Tablet 10 MG Oral |
Tier 1 |
|
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) |
Citalopram Hydrobromide Tablet 20 MG Oral |
Tier 1 |
|
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) |
Citalopram Hydrobromide Tablet 40 MG Oral |
Tier 1 |
|
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) |
FLUoxetine HCl Capsule 10 MG Oral |
Tier 1 |
|
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) |
FLUoxetine HCl Capsule 20 MG Oral |
Tier 1 |
|
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) |
FLUoxetine HCl Capsule 40 MG Oral |
Tier 1 |
|
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) |
Sertraline HCl Tablet 100 MG Oral |
Tier 1 |
|
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) |
Sertraline HCl Tablet 25 MG Oral |
Tier 1 |
|
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) |
Sertraline HCl Tablet 50 MG Oral |
Tier 1 |
|
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Alphagan P Solution 0.1 % Ophthalmic
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
Drug |
Tier* |
Drug Restrictions |
Therapy Class |
Brimonidine Tartrate Solution 0.1 % Ophthalmic |
Tier 2 |
|
Ophthalmic Intraocular Pressure Lowering Agents, Other |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Ciprodex Suspension 0.3-0.1 % Otic
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
Drug |
Tier* |
Drug Restrictions |
Therapy Class |
Ciprofloxacin-Dexamethasone Suspension 0.3-0.1 % Otic |
Tier 2 |
|
Otic Agents |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Condylox Gel 0.5 % External
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
Drug |
Tier* |
Drug Restrictions |
Therapy Class |
Podofilox Gel 0.5 % External |
Tier 4 |
|
Dermatological Agents, Other |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Livalo Tablet 1 MG Oral
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
Drug |
Tier* |
Drug Restrictions |
Therapy Class |
Pitavastatin Calcium Tablet 1 MG Oral |
Tier 2 |
QL |
Dyslipidemics, HMG CoA Reductase Inhibitors |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Livalo Tablet 2 MG Oral
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
Drug |
Tier* |
Drug Restrictions |
Therapy Class |
Pitavastatin Calcium Tablet 2 MG Oral |
Tier 2 |
QL |
Dyslipidemics, HMG CoA Reductase Inhibitors |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Livalo Tablet 4 MG Oral
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
Drug |
Tier* |
Drug Restrictions |
Therapy Class |
Pitavastatin Calcium Tablet 4 MG Oral |
Tier 2 |
QL |
Dyslipidemics, HMG CoA Reductase Inhibitors |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Korlym Tablet 300 MG Oral
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
Drug |
Tier* |
Drug Restrictions |
Therapy Class |
miFEPRIStone Tablet 300 MG Oral |
Tier 5 |
PA |
Glycemic Agents |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Rectiv Ointment 0.4 % Rectal
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
Drug |
Tier* |
Drug Restrictions |
Therapy Class |
Nitroglycerin Ointment 0.4 % Rectal |
Tier 4 |
|
Vasodilators, Direct-acting Arterial/ Venous |
* Please reference your Evidence of Coverage for applicable cost-sharing. |
Relyvrio Packet 3-1 GM Oral
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
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. |
Sorine Tablet 80 MG Oral
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
Drug |
Tier* |
Drug Restrictions |
Therapy Class |
Sotalol HCl (AF) Tablet 80 MG Oral |
Tier 2 |
|
Antiarrhythmics |
* Please reference your Evidence of Coverage for applicable cost-sharing. |