Drug List Changes

Effective July 01, 2018

Formulary Changes to the Preferred B2 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Accu-Chek Test Strips	No longer covered	OneTouch Ultra or OneTouch Verio Test Strips
Aloxi injection	No longer covered	palonosetron injection
Breeze 2 Test Strips	No longer covered	OneTouch Ultra or OneTouch Verio Test Strips
Contour & Contour Next Test Strips	No longer covered	OneTouch Ultra or OneTouch Verio Test Strips
FreeStyle & FreeStyle Lite Test Strips	No longer covered	OneTouch Ultra or OneTouch Verio Test Strips
Norvir tablet	No longer covered	ritonavir tablet
Prodigy Test Strips	No longer covered	OneTouch Ultra or OneTouch Verio Test Strips
Sustiva tablet	No longer covered	efavirenz tablet
TRUE Metrix Test Strips	No longer covered	OneTouch Ultra or OneTouch Verio Test Strips
TRUEtrack Test Strips	No longer covered	OneTouch Ultra or OneTouch Verio Test Strips
WaveSense Test Strips	No longer covered	OneTouch Ultra or OneTouch Verio Test Strips

Formulary Changes to the Preferred B3 and B4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Accu-Chek Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
Aloxi injection	Moving to a higher level	palonosetron injection
Breeze 2 Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
Contour & Contour Next Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
FreeStyle & FreeStyle Lite Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
Norvir tablet	Moving to a higher level	ritonavir tablet
Prodigy Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
Sustiva tablet	Moving to a higher level	efavirenz tablet
TRUE Metrix Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
TRUEtrack Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
WaveSense Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips

Formulary Changes to the E1 and E4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Aubagio tablet	Moving to a higher level	Gilenya capsule or Tecfidera capsule
Norvir tablet	Moving to a higher level	ritonavir tablet
Sustiva tablet	Moving to a higher level	efavirenz tablet

Formulary Changes to the M1, M2 and M4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Gabitril tablet	No longer covered	tiagabine tablet
Namenda XR capsule	No longer covered	memantine extended-release capsule
Norvir tablet	No longer covered	ritonavir tablet
Prevacid SoluTab tablet	No longer covered	lansoprazole orally disintegrating tablet
Ritalin LA capsule	No longer covered	methylphenidate extended-release capsule
Solodyn tablet	No longer covered	minocycline extended-release tablet
Sustiva tablet	No longer covered	efavirenz tablet
Syprine capsule	No longer covered	trientine capsule
Treximet tablet	No longer covered	sumatriptan/naproxen sodium tablet

Formulary Changes to the Select C4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Accu-Chek Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
Breeze 2 Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
Contour & Contour Next Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
FreeStyle & FreeStyle Lite Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
Prodigy Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
Sustiva tablet	Moving to a higher level	efavirenz tablet
TRUE Metrix Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
TRUEtrack Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
WaveSense Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips

Formulary Changes to the Value-Based V1 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Accu-Chek Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
Aloxi injection	Moving to a higher level	palonosetron injection
Breeze 2 Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
CellCept tablet	Moving to a higher level	mycophenolate mofetil tablet
Contour & Contour Next Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
FreeStyle & FreeStyle Lite Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
Namenda XR capsule	Moving to a higher level	memantine extended-release capsule
Norvir tablet	Moving to a higher level	ritonavir tablet
Prodigy Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
Ritalin LA capsule	Moving to a higher level	methylphenidate extended-release capsule
Sulfamylon packet	Moving to a higher level	mafenide packet
Sustiva tablet	Moving to a higher level	efavirenz tablet
Syprine capsule	Moving to a higher level	trientine capsule
Treximet tablet	Moving to a higher level	sumatriptan/naproxen sodium tablet
TRUE Metrix Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
TRUEtrack Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips
WaveSense Test Strips	Moving to a higher level	OneTouch Ultra or OneTouch Verio Test Strips

*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.