Drug List Changes

  • Effective July 01, 2022

    Formulary Changes to the Preferred B3 Drug List

    Drug Name Description of Change Cost-effective Alternatives*
    Cycloset 0.8 Mg TabletMoving to Tier 3meformin, glimperide, glipizide, or glyburide
    Exelderm 1 % CreamMoving to Tier 3ciclopirox cream
    Exelderm 1 % Topical SolutionMoving to Tier 3ciclopirox topical solution
    Fenofibrate 150 Mg Capsule BrandMoving to Tier 3fenofibrate generic
    Fenofibrate 160 Mg Tablet BrandMoving to Tier 3fenofibrate generic
    Methylphenidate Er 72 Mg Tablet BrandMoving to Tier 3methylphenidate generic
    Multaq TabletMoving to Tier 3amiodarone, dofetilide, flecainide, propafenone, or sotalol
    Narcan Nasal SprayMoving to Tier 3naloxone nasal spray
    Noritate 1 % CreamMoving to Tier 3metronidazole cream
    Plexion 9.8%-4.8% CleanserMoving to Tier 3sulfacetamide-sulfur cleanser
    Plexion 9.8%-4.8% CreamMoving to Tier 3sulfacetamide-sulfur cream
    Plexion 9.8%-4.8% LotionMoving to Tier 3sulfacetamide-sulfur lotion
    Selrx 2.3 % ShampooMoving to Tier 3selenium sulfide shampoo
    Tazorac 0.05 % Cream And GelMoving to Tier 3tazarotene cream
    Tazorac 0.1 % GelMoving to Tier 3tazarotene cream
    Testosterone 50 Mg (1%) Gel In Packet BrandMoving to Tier 3testosterone gel generic
    Theo-24 CapsuleMoving to Tier 3theophylline anhydrous ER tablet
    Trezix CapsuleMoving to Tier 3acetaminophen-caffeine-dihydrocodeine capsule

    Formulary Changes to the Preferred B4 Drug List

    Drug Name Description of Change Cost-effective Alternatives*
    Cycloset 0.8 Mg TabletMoving to Tier 3meformin, glimperide, glipizide, or glyburide
    Exelderm 1 % CreamMoving to Tier 3ciclopirox cream
    Exelderm 1 % Topical SolutionMoving to Tier 3ciclopirox topical solution
    Fenofibrate 150 Mg Capsule BrandMoving to Tier 3fenofibrate generic
    Fenofibrate 160 Mg Tablet BrandMoving to Tier 3fenofibrate generic
    Methylphenidate Er 72 Mg Tablet BrandMoving to Tier 3methylphenidate generic
    Multaq TabletMoving to Tier 3amiodarone, dofetilide, flecainide, propafenone, or sotalol
    Narcan Nasal SprayMoving to Tier 3naloxone nasal spray
    Noritate 1 % CreamMoving to Tier 3metronidazole cream
    Plexion 9.8%-4.8% CleanserMoving to Tier 3sulfacetamide-sulfur cleanser
    Plexion 9.8%-4.8% CreamMoving to Tier 3sulfacetamide-sulfur cream
    Plexion 9.8%-4.8% LotionMoving to Tier 3sulfacetamide-sulfur lotion
    Selrx 2.3 % ShampooMoving to Tier 3selenium sulfide shampoo
    Tazorac 0.05 % Cream And GelMoving to Tier 3tazarotene cream
    Tazorac 0.1 % GelMoving to Tier 3tazarotene cream
    Testosterone 50 Mg (1%) Gel In Packet BrandMoving to Tier 3testosterone gel generic
    Theo-24 CapsuleMoving to Tier 3theophylline anhydrous ER tablet
    Trezix CapsuleMoving to Tier 3acetaminophen-caffeine-dihydrocodeine capsule

    Formulary Changes to the Select C4 Drug List

    Drug Name Description of Change Cost-effective Alternatives*
    Cycloset 0.8 Mg TabletMoving to Tier 3meformin, glimperide, glipizide, or glyburide
    Multaq TabletMoving to Tier 3amiodarone, dofetilide, flecainide, propafenone, or sotalol
    Narcan Nasal SprayMoving to Tier 3naloxone nasal spray
    Testosterone 50 Mg (1%) Gel In Packet BrandMoving to Tier 3testosterone gel generic
    Theo-24 CapsuleMoving to Tier 3theophylline anhydrous ER tablet
    Trezix CapsuleNo longer coveredacetaminophen-caffeine-dihydrocodeine capsule

    Formulary Changes to the E1 Drug List

    Drug Name Description of Change Cost-effective Alternatives*
    Durezol DropsNo longer covereddifluprednate eye drops
    Seglentis TabletNo longer coveredcelecoxib capsule and tramadol tablet

    Formulary Changes to the E4 Drug List

    Drug Name Description of Change Cost-effective Alternatives*
    Atrovent HFAMoving to Tier 4Incruse Ellipta inhaler
    Durezol DropsNo longer covereddifluprednate eye drops
    Fenofibrate 150 Mg Capsule BrandMoving to Tier 4fenofibrate generic
    Fenofibrate 160 Mg Tablet BrandMoving to Tier 4fenofibrate generic
    Prevident 0.2 % Solution, Non-OralMoving to Tier 4SF 5000 plus dental Cream
    Prevident 1.1 % Cream, Gel, Or PasteMoving to Tier 4SF 5000 plus dental Cream
    Prevident 5000 Enamel Protect 1.1 %-5 % PasteMoving to Tier 4SF 5000 plus dental Cream
    Prevident 5000 Sensitive 1.1 %-5 % PasteMoving to Tier 4SF 5000 plus dental Cream
    Seglentis TabletNo longer coveredcelecoxib capsule and tramadol tablet

    Formulary Changes to the M1 and M2 Drug Lists

    Drug Name Description of Change Cost-effective Alternatives*
    Cloderm CreamNo longer coveredclocortolone pivalate cream
    Ferriprox tabletNo longer covereddeferiprone tablet
    Narcan nasal sprayNo longer coverednaloxone nasal spray

    Formulary Changes to the M4 Drug List

    Drug Name Description of Change Cost-effective Alternatives*
    Cloderm CreamNo longer coveredclocortolone pivalate cream
    Fenofibrate 150 Mg Capsule BrandMoving to Tier 3fenofibrate generic
    Fenofibrate 160 Mg Tablet BrandMoving to Tier 3fenofibrate generic
    Ferriprox tabletNo longer covereddeferiprone tablet
    Narcan nasal sprayNo longer coverednaloxone nasal spray

    *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.