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

Oxbryta Tablet 500 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Hydroxyurea Capsule 500 MG Oral	Tier 2	ST	Antineoplastics, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Relyvrio Packet 3-1 GM Oral

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Alternative Drugs

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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.

Selzentry Tablet 25 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Maraviroc Tablet 150 MG Oral	Tier 4		Anti-HIV Agents, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Selzentry Tablet 75 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Maraviroc Tablet 150 MG Oral	Tier 4		Anti-HIV Agents, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sprycel Tablet 100 MG Oral

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Alternative Drugs

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

Sprycel Tablet 140 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Dasatinib Tablet 140 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sprycel Tablet 20 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Dasatinib Tablet 20 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sprycel Tablet 50 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Dasatinib Tablet 50 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sprycel Tablet 70 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Dasatinib Tablet 70 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Sprycel Tablet 80 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Dasatinib Tablet 80 MG Oral	Tier 5	PA, QL	Molecular Target Inhibitors
* Please reference your Evidence of Coverage for applicable cost-sharing.

Tazorac Cream 0.05 % External

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Tazarotene Cream 0.05 % External	Tier 4		Acne and Rosacea Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Phenytoin Sodium Extended CAPSULE 200 MG ORAL

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Phenytek Capsule 200 MG Oral	Tier 2		Sodium Channel Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Phenytoin Sodium Extended CAPSULE 300 MG ORAL

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Phenytek Capsule 300 MG Oral	Tier 2		Sodium Channel Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Mesnex Tablet 400 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Mesna Tablet 400 MG Oral	Tier 5		Treatment Adjuncts
* Please reference your Evidence of Coverage for applicable cost-sharing.

Spritam Tablet Disintegrating Soluble 250 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
levETIRAcetam Tablet Disintegrating Soluble 250 MG Oral	Tier 4	PA	Anticonvulsants, Other
* Please reference your Evidence of Coverage for applicable cost-sharing.

Isosorbide Mononitrate Tablet 10 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Isosorbide Mononitrate Tablet 10 MG Oral	Tier 3		Vasodilators, Direct-acting Arterial/ Venous
* Please reference your Evidence of Coverage for applicable cost-sharing.

Isosorbide Mononitrate Tablet 20 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Isosorbide Mononitrate Tablet 20 MG Oral	Tier 3		Vasodilators, Direct-acting Arterial/ Venous
* Please reference your Evidence of Coverage for applicable cost-sharing.

Purixan Suspension 2000 MG/100ML Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Mercaptopurine Suspension 2000 MG/100ML Oral	Tier 5		Antimetabolites
* Please reference your Evidence of Coverage for applicable cost-sharing.

Brilinta Tablet 90 MG Oral

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Ticagrelor Tablet 90 MG Oral	Tier 3		Platelet Modifying Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Libervant Film 10 MG Buccal

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Valtoco 10 MG Dose Liquid 10 MG/0.1ML Nasal	Tier 4	QL	Gamma-aminobutyric Acid (GABA) Modulating Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Libervant Film 12.5 MG Buccal

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Valtoco 15 MG Dose Liquid Therapy Pack 2 x 7.5 MG/0.1ML Nasal	Tier 4	QL	Gamma-aminobutyric Acid (GABA) Modulating Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Libervant Film 15 MG Buccal

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Valtoco 15 MG Dose Liquid Therapy Pack 2 x 7.5 MG/0.1ML Nasal	Tier 4	QL	Gamma-aminobutyric Acid (GABA) Modulating Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Libervant Film 5 MG Buccal

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Valtoco 5 MG Dose Liquid 5 MG/0.1ML Nasal	Tier 4	QL	Gamma-aminobutyric Acid (GABA) Modulating Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

Libervant Film 7.5 MG Buccal

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Alternative Drugs

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Drug	Tier*	Drug Restrictions	Therapy Class
Valtoco 10 MG Dose Liquid 10 MG/0.1ML Nasal	Tier 4	QL	Gamma-aminobutyric Acid (GABA) Modulating Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.