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:
Oxbryta Tablet 500 MG Oral
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
Alternative Drugs
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
Type of Change:
Drug removed
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. |
Selzentry Tablet 25 MG Oral
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
Alternative Drugs
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
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
Alternative Drugs
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
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
Type of Change:
Drug removed
Reason Changed:
Drug discontinued from marketplace
Alternative Drugs
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
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
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Alternative Drugs
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
Type of Change:
Drug removed - Discontinued from marketplace
Reason Changed:
Drug discontinued from marketplace
Alternative Drugs
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
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
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available
Alternative Drugs
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. |