Drug List Changes

Effective April 01, 2023

Formulary Changes to the Preferred B3 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Daliresp Tablet	Moving to Tier 3	roflumilast tablet
Denavir Cream	Moving to Tier 3	penciclovir cream
Divigel Gel Packet	Moving to Tier 3	estradiol gel packet
Gilenya Capsule	Moving to Tier 3	fingolimod capsule
Selzentry 150 mg & 300 mg Tablet	Moving to Tier 3	maraviroc tablet
Vascepa 0.5gm Capsule	Moving to Tier 3	icosapent capsule

Formulary Changes to the Preferred B4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Daliresp Tablet	Moving to Tier 3	roflumilast tablet
Denavir Cream	Moving to Tier 3	penciclovir cream
Divigel Gel Packet	Moving to Tier 3	estradiol gel packet
Selzentry 150 mg & 300 mg Tablet	Moving to Tier 3	maraviroc tablet
Vascepa 0.5gm Capsule	Moving to Tier 3	icosapent capsule

Formulary Changes to the Select C4 drug list

Drug Name	Description of Change	Cost-effective Alternatives*
Daliresp Tablet	Moving to Tier 3	roflumilast tablet
Selzentry 150 mg & 300 mg Tablet	Moving to Tier 3	maraviroc tablet

Formulary Changes to the E1 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
No changes

Formulary Changes to the E4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Divigel Gel Packet	Moving to Tier 4	estradiol gel packet
Gilenya Capsule	Moving to Tier 4	fingolimod capsule
Selzentry 150 mg & 300 mg Tablet	Moving to Tier 4	maraviroc tablet
Vascepa 0.5gm Capsule	Moving to Tier 4	icosapent capsule

Formulary Changes to the M1 and M2 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Daliresp Tablet	No Longer Covered	roflumilast tablet
Dexilant 60 mg Capsule	No Longer Covered	dexlansoprazole 60 mg capsule
Denavir Cream	No Longer Covered	penciclovir cream
Divigel Gel Packet	No Longer Covered	estradiol gel packet
Gilenya Capsule	No Longer Covered	fingolimod capsule
Selzentry 150 mg & 300 mg Tablet	No Longer Covered	maraviroc tablet
Suprep Bowel Prep Kit	No Longer Covered	sod sul-potass sul-mag sul solution
Vascepa 0.5gm Capsule	No Longer Covered	icosapent capsule

Formulary Changes to the M4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Daliresp Tablet	No Longer Covered	roflumilast tablet
Dexilant 60 mg Capsule	No Longer Covered	dexlansoprazole 60 mg capsule
Denavir Cream	No Longer Covered	penciclovir cream
Divigel Gel Packet	No Longer Covered	estradiol gel packet
Gilenya Capsule	No Longer Covered	fingolimod capsule
Selzentry 150 mg & 300 mg Tablet	No Longer Covered	maraviroc tablet
Suprep Bowel Prep Kit	No Longer Covered	sod sul-potass sul-mag sul solution
Vascepa 0.5gm Capsule	No Longer Covered	icosapent capsule

*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.