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:
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. |
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. |
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. |
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. |
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. |
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. |
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. |
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. |
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. |
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. |
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. |
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. |
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. |
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. |
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. |