Drug List Changes

Effective October 01, 2017

Formulary Changes to the Preferred B2 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Alkeran tablet	No longer covered	melphalan tablet
Imuran tablet	No longer covered	azathioprine tablet
Lialda delayed release tablet	No longer covered	mesalamine delayed release tablet
Loprox 0.77% cream	No longer covered	ciclopirox 0.77% cream
Loprox 0.77% suspension	No longer covered	ciclopirox 0.77% suspension
Metrogel 1% gel	No longer covered	metronidazole 1% gel
Pataday 0.2% eye drops	No longer covered	olopatadine 0.2% eye drops
Protopic ointment	No longer covered	tacrolimus ointment
Renvela tablet	No longer covered	sevelamer tablet
Strattera capsule	No longer covered	atomoxetine capsule
Vytorin tablet	No longer covered	ezetimibe/simvastatin tablet

Formulary Changes to the Preferred B3 and B4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Alkeran tablet	Moving to a higher level	melphalan tablet
Imuran tablet	Moving to a higher level	azathioprine tablet
Lialda delayed release tablet	Moving to a higher level	mesalamine delayed release tablet
Loprox 0.77% cream	Moving to a higher level	ciclopirox 0.77% cream
Loprox 0.77% suspension	Moving to a higher level	ciclopirox 0.77% suspension
Metrogel 1% gel	Moving to a higher level	metronidazole 1% gel
Pataday 0.2% eye drops	Moving to a higher level	olopatadine 0.2% eye drops
Protopic ointment	Moving to a higher level	tacrolimus ointment
Renvela tablet	Moving to a higher level	sevelamer tablet
Strattera capsule	Moving to a higher level	atomoxetine capsule
Vytorin tablet	Moving to a higher level	ezetimibe/simvastatin tablet

Formulary Changes to the E1 and E4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Alkeran tablet	Moving to a higher level	melphalan tablet
Ancobon capsule	Moving to a higher level	flucytosine capsule
Atacand tablet	Moving to a higher level	candesartan tablet
Combivir tablet	Moving to a higher level	lamivudine/zidovudine tablet
Epivir HBV tablet	Moving to a higher level	lamivudine tablet
Lialda delayed release tablet	Moving to a higher level	mesalamine delayed release tablet
Myambutol tablet	Moving to a higher level	ethambutol tablet
Nulytely with Flavor Packs solution	Moving to a higher level	PEG-3350 electrolyte with flavor packs solution

Formulary Changes to the X1, X3 and X4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Alkeran tablet	No longer covered	melphalan tablet
Axiron 2% topical solution	No longer covered	testosterone 2% topical solution
Cordran 0.05% ointment	No longer covered	flurandrenolide 0.05% ointment
Lialda delayed release tablet	No longer covered	mesalamine delayed release tablet
Pataday 0.2% eye drops	No longer covered	olopatadine 0.2% eye drops
Renvela powder packet	No longer covered	sevelamer powder packet
Renvela tablet	No longer covered	sevelamer tablet
Strattera capsule	No longer covered	atomoxetine capsule
Vigamox eye drops	No longer covered	moxifloxacin eye drops
Vytorin tablet	No longer covered	ezetimibe/simvastatin tablet

Formulary Changes to the M1, M2 and M4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Alkeran tablet	No longer covered	melphalan tablet
Axiron 2% topical solution	No longer covered	testosterone 2% topical solution
Cordran 0.05% ointment	No longer covered	flurandrenolide 0.05% ointment
Lialda delayed release tablet	No longer covered	mesalamine delayed release tablet
Pataday 0.2% eye drops	No longer covered	olopatadine 0.2% eye drops
Renvela powder packet	No longer covered	sevelamer powder packet
Renvela tablet	No longer covered	sevelamer tablet
Strattera capsule	No longer covered	atomoxetine capsule
Vigamox eye drops	No longer covered	moxifloxacin eye drops
Vytorin tablet	No longer covered	ezetimibe/simvastatin tablet

Formulary Changes to the Select C4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Alkeran tablet	Moving to a higher level	melphalan tablet
Epivir 10mg/ml solution	Moving to a higher level	lamivudine 10mg/ml solution
Imuran tablet	Moving to a higher level	azathioprine tablet

Formulary Changes to the Value-Based V1 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Acticlate tablet	Moving to a higher level	doxycycline tablet
Adderall tablet	Moving to a higher level	dextroamphetamine/amphetamine tablet
Analpram HC cream	Moving to a higher level	hydrocortisone/pramoxine cream
Ancobon capsule	Moving to a higher level	flucytosine capsule
Bleph-10 eye drops	Moving to a higher level	sulfacetamide eye drops
Cordran 0.05% ointment	Moving to a higher level	flurandrenolide 0.05% ointment
Derma Smoothe FS 0.01% body oil	Moving to a higher level	fluocinolone 0.01% body oil
Dibenzyline capsule	Moving to a higher level	phenoxybenzamine capsule
Efudex 5% cream	Moving to a higher level	fluorouracil 5% cream
Epivir 10mg/ml solution	Moving to a higher level	lamivudine 10mg/ml solution
Epivir HBV tablet	Moving to a higher level	lamivudine tablet
Exforge tablet	Moving to a higher level	amlodipine/valsartan tablet
Exforge HCT tablet	Moving to a higher level	amlodipine/valsartan/hydrochlorothiazide tablet
Gastrocrom solution	Moving to a higher level	cromolyn solution
Hepsera tablet	Moving to a higher level	adefovir tablet
Imuran tablet	Moving to a higher level	azathioprine tablet
Klaron 10% lotion	Moving to a higher level	sodium sulfacetamide 10% lotion
Lialda delayed release tablet	Moving to a higher level	mesalamine delayed release tablet
Pataday 0.2% eye drops	Moving to a higher level	olopatadine 0.2% eye drops
Phenytek capsule	Moving to a higher level	phenytoin extended release capsule
Protopic ointment	Moving to a higher level	tacrolimus ointment
Razadyne ER capsule	Moving to a higher level	galantamine extended release capsule
Renvela powder packet	Moving to a higher level	sevelamer powder packet
Sandostatin injectable solution	Moving to a higher level	octreotide injectable solution
Soriatane capsule	Moving to a higher level	acitretin capsule
Strattera capsule	Moving to a higher level	atomoxetine capsule
Tobi 300mg/5ml solution	Moving to a higher level	tobramycin 300mg/5ml solution
Trizivir tablet	Moving to a higher level	abacavir/lamivudine/zidovudine tablet
Vigamox eye drops	Moving to a higher level	moxifloxacin eye drops
Zomig tablet	Moving to a higher level	zolmitriptan tablet
Zomig ZMT tablet	Moving to a higher level	zolmitriptan orally disintegrating tablet

*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.