Formulary Changes Effective July 01, 2014

Formulary Changes to the Preferred B2 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Avelox tablet	Moving to Non-preferred	moxifloxacin tablet in Tier 1
Evista tablet	Moving to Non-preferred	raloxifene tablet in Tier 1
Incivek tablet	Moving to Non-preferred	Olysio capsule in Tier 2; Sovaldi tablet in Tier 2
Mepron suspension	Moving to Non-preferred	atovaquone suspension in Tier 1
Micardis HCT tablet	Moving to Non-preferred	telmisartan/hydrochlorothiazide tablet in Tier 1
Myfortic tablet	Moving to Non-preferred	mycophenolate tablet in Tier 1
Neulasta injection	Moving to Non-preferred	Granix injection in Tier 2
Neupogen injection	Moving to Non-preferred	Granix injection in tier 2
Twynsta tablet	Moving to Non-preferred	telmisartan/amlodipine tablet in Tier 1
Victrelis capsule	Moving to Non-preferred	Olysio capsule in Tier 2; Sovaldi tablet in Tier 2
Xeloda tablet	Moving to Non-preferred	capecitabine tablet in Tier 1

Formulary Changes to the Preferred B3 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Avelox tablet	Moving to Tier 3 from Tier 2	moxifloxacin tablet in Tier 1
Evista tablet	Moving to Tier 3 from Tier 2	raloxifene tablet in Tier 1
Incivek tablet	Moving to Tier 3 from Tier 2	Olysio capsule in Tier 2; Sovaldi tablet in Tier 2
Mepron suspension	Moving to Tier 3 from Tier 2	atovaquone suspension in Tier 1
Micardis HCT tablet	Moving to Tier 3 from Tier 2	telmisartan/hydrochlorothiazide tablet in Tier 1
Myfortic tablet	Moving to Tier 3 from Tier 2	mycophenolate tablet in Tier 1
Neulasta injection	Moving to Tier 3 from Tier 2	Granix injection in Tier 2
Neupogen injection	Moving to Tier 3 from Tier 2	Granix injection in tier 2
Twynsta tablet	Moving to Tier 3 from Tier 2	telmisartan/amlodipine tablet in Tier 1
Victrelis capsule	Moving to Tier 3 from Tier 2	Olysio capsule in Tier 2; Sovaldi tablet in Tier 2
Xeloda tablet	Moving to Tier 3 from Tier 2	capecitabine tablet in Tier 1

Formulary Changes to the Preferred B4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Avelox tablet	Moving to Tier 3 from Tier 2	moxifloxacin tablet in Tier 1
Evista tablet	Moving to Tier 3 from Tier 2	raloxifene tablet in Tier 1
Mepron suspension	Moving to Tier 3 from Tier 2	atovaquone suspension in Tier 1
Micardis HCT tablet	Moving to Tier 3 from Tier 2	telmisartan/hydrochlorothiazide tablet in Tier 1
Myfortic tablet	Moving to Tier 3 from Tier 2	mycophenolate tablet in Tier 1
Twynsta tablet	Moving to Tier 3 from Tier 2	telmisartan/amlodipine tablet in Tier 1

Formulary Changes to the X3 and X4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Avelox tablet	Moving to Non-preferred	moxifloxacin tablet in Tier 1
Cloderm cream	Moving to Non-preferred	clocortolone cream in Tier 1
Evista tablet	Moving to Non-preferred	raloxifene tablet in Tier 1
Hectoral capsule	Moving to Non-preferred	doxercalciferol capsule in Tier 1
Incivek tablet	Moving to Non-preferred	Olysio capsule in Specialty Tier ; Sovaldi tablet in Specialty Tier
Mepron suspension	Moving to Non-preferred	atovaquone suspension in Tier 1
Neulasta injection	Moving to Non-preferred	Granix injection in Specialty Tier
Neupogen injection	Moving to Non-preferred	Granix injection in Specialty Tier
Rapamune 0.5mg tablet	Moving to Non-preferred	sirolimus 0.5mg tablet in Tier 1
Trilipix capsule	Moving to Non-preferred	fenofibric acid capsule in Tier 1
Victrelis capsule	Moving to Non-preferred	Olysio capsule in Specialty Tier; Sovaldi tablet in Specialty Tier
Xeloda tablet	Moving to Non-preferred	capecitabine tablet in Tier 1

Formulary Changes to the Value-Based V1 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Avelox tablet	Moving to Tier 4 from Tier 2	moxifloxacin tablet in Tier 1
Avinza capsule	Moving to Tier 4 from Tier 3	morphine sulfate extended-release capsule in Tier 1
Cloderm cream	Moving to Tier 4 from Tier 3	clocortolone cream in Tier 3
Detrol LA capsule	Moving to Tier 4 from Tier 2	tolterodine extended-release capsule in Tier 1
Evista tablet	Moving to Tier 4 from Tier 2	raloxifene tablet in Tier 1
Hectorol capsule	Moving to Tier 4 from Tier 3	doxercalciferol capsule in Tier 1
Lodosyn tablet	Moving to Tier 4 from Tier 3	carbidopa tablet in Tier 1
Mepron suspension	Moving to Tier 4 from Tier 2	atovaquone suspension in Tier 1
Myfortic tablet	Moving to Tier 4 from Tier 3	mycophenolate tablet in Tier 1
pioglitazone tablet	Moving to Tier 2 from Tier 1	metformin tablet in Tier 1
Rapamune 0.5 mg tablet	Moving to Tier 4 from Tier 3	sirolimus tablet in Tier 1
Twynsta tablet	Moving to Tier 4 from Tier 2	telmisartan/amlodipine tablet in Tier 1
Urocit-K tablet	Moving to Tier 4 from Tier 3	potassium citrate tablet in Tier 1
Vanos cream	Moving to Tier 4 from Tier 3	fluocinonide cream in Tier 1
Zutripro solution	Moving to Tier 4 from Tier 3	chlorpheniramine/hydrocodone/pseudoephedrine solution in Tier 1

Formulary Changes to the Select C4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Avelox tablet	Moving to Tier 3 from Tier 2	moxifloxacin tablet in Tier 1
Incivek tablet	Moving to Tier 3 from Tier 2	Olysio capsule in Tier 2; Sovaldi tablet in Tier 2
Neulasta injection	Moving to Tier 3 from Tier 2	Granix injection in Tier 2
Neupogen injection	Moving to Tier 3 from Tier 2	Granix injection in Tier 2
Victrelis capsule	Moving to Tier 3 from Tier 2	Olysio capsule in Tier 2; Sovaldi tablet in Tier 2
Xeloda tablet	Moving to Tier 3 from Tier 2	capecitabine tablet in Tier 1

*These drugs have been selected by an independent group of experts made up of doctors and pharmacists. This group reviews drugs to see how well they work relative to their cost. They also compare their effectiveness to similar drugs used to treat the same condition. Please talk with your doctor to see if these new options are right for you.