Drug List Changes

  • Effective October 01, 2019

    Formulary Changes to the Preferred B2 Drug List

    Drug Name Description of Change Cost-effective Alternatives*
    Analpram-HC 2.5%-1% creamNo longer coveredhydrocortisone/pramoxine cream
    Colyte oral solutionNo longer coveredpolyethylene glycol 3350 electrolyte oral solution
    Copaxone syringeNo longer coveredglatiramer syringe
    Cuprimine capsuleNo longer coveredpenicillamine capsule
    Delzicol delayed-release capsuleNo longer coveredmesalamine delayed-release capsule
    Derma-Smoothe-FS oilNo longer coveredfluocinolone acetonide oil
    Exjade tablet for oral suspensionNo longer covereddeferasirox tablet for oral suspension
    Letairis tabletNo longer coveredambrisentan tablet
    Micardis tabletNo longer coveredtelmisartan tablet
    Quartette tabletNo longer coveredlevonorgestrel/ethinyl estradiol tablet
    Safyral tabletNo longer covereddrospirenone/ethinyl estradiol/levomefolate tablet
    Tarceva tabletNo longer coverederlotinib tablet
    Tracleer tablet No longer coveredbosentan tablet
    Vesicare tabletNo longer coveredsolifenacin tablet
    Victoza [Change Effective November 1, 2019]No longer coveredBydureon, Byetta, Ozempic, or Trulicity

    Formulary Changes to the Preferred B3 and B4 Drug Lists

    Drug Name Description of Change Cost-effective Alternatives*
    Analpram-HC 2.5%-1% creamMoving to a higher levelhydrocortisone/pramoxine cream
    Colyte oral solutionMoving to a higher levelpolyethylene glycol 3350 electrolyte oral solution
    Copaxone syringeMoving to a higher levelglatiramer syringe
    Cuprimine capsuleMoving to a higher levelpenicillamine capsule
    Delzicol delayed-release capsuleMoving to a higher levelmesalamine delayed-release capsule
    Derma-Smoothe-FS oilMoving to a higher levelfluocinolone acetonide oil
    Exjade tablet for oral suspensionMoving to a higher leveldeferasirox tablet for oral suspension
    Letairis tabletMoving to a higher levelambrisentan tablet
    Micardis tabletMoving to a higher leveltelmisartan tablet
    Quartette tabletMoving to a higher levellevonorgestrel/ethinyl estradiol tablet
    Safyral tabletMoving to a higher leveldrospirenone/ethinyl estradiol/levomefolate tablet
    Tarceva tabletMoving to a higher levelerlotinib tablet
    Tracleer tablet Moving to a higher levelbosentan tablet
    Vesicare tabletMoving to a higher levelsolifenacin tablet
    Victoza [Change Effective November 1, 2019]Moving to a higher levelBydureon, Byetta, Ozempic, or Trulicity

    Formulary Changes to the E4 Drug List

    Drug Name Description of Change Cost-effective Alternatives*
    Cuprimine capsuleMoving to a higher levelpenicillamine capsule
    Letairis tabletMoving to a higher levelambrisentan tablet
    Revatio suspensionMoving to a higher levelsildenafil suspension
    Tarceva tabletMoving to a higher levelerlotinib tablet
    Tracleer tabletMoving to a higher levelbosentan tablet
    Victoza [Change Effective November 1, 2019]Moving to a higher levelBydureon, Byetta, Ozempic, or Trulicity

    Formulary Changes to the M1, M2 and M4 (2019) Drug Lists

    Drug Name Description of Change Cost-effective Alternatives*
    Cialis tabletNo longer coveredtadalafil tablet
    Cuprimine capsuleNo longer coveredpenicillamine capsule
    Diclegis delayed-release tabletNo longer covereddoxylamine/pyridoxine delayed-release tablet
    Ertaczo creamNo longer coveredeconazole cream
    Exjade tablet for oral suspensionNo longer covereddeferasirox tablet for oral suspension
    Extavia kitNo longer coveredBetaseron kit
    Flarex eye dropsNo longer coveredprednisolone eye drops
    Halog ointmentNo longer coveredbetamethasone ointment
    Kineret injectionNo longer coveredConsult Doctor
    Letairis tabletNo longer coveredambrisentan tablet
    Livalo tabletNo longer coveredatorvastatin tablet
    Lotemax eye dropsNo longer coveredloteprednol eye drops
    Oracea capsuleNo longer covereddoxycycline capsule
    Pradaxa capsuleNo longer coveredConsult Doctor
    Quartette tabletNo longer coveredlevonorgestrel/ethinyl estradiol tablet
    Safyral tabletNo longer covereddrospirenone/ethinyl estradiol/levomefolate tablet
    sumatriptan/naproxen tabletNo longer coveredsumatriptan tablet
    Revatio suspensionNo longer coveredsildenafil suspension
    Suprax capsuleNo longer coveredcefixime capsule
    Tarceva tabletNo longer coverederlotinib tablet
    Tracleer tabletNo longer coveredbosentan tablet
    Uloric tabletNo longer coveredfebuxostat tablet
    Vesicare tabletNo longer coveredsolifenacin tablet
    Xopenex HFA inhalerNo longer coveredlevalbuterol HFA inhaler
    Zioptan eye dropsNo longer coveredlatanoprost eye drops
    Zyclara cream pumpNo longer coveredimiquimod cream

    Formulary Changes to the M4 (2019) Drug Lists

    Drug Name Description of Change Cost-effective Alternatives*
    Atripla tabletMoving to a higher levelConsult Doctor
    Chlorzoxazone 250 mg tabletMoving to a higher levelchlorzoxazone 500 mg tablet
    Chlorzoxazone 375 mg tabletMoving to a higher levelchlorzoxazone 500 mg tablet
    Chlorzoxazone 750 mg tabletMoving to a higher levelchlorzoxazone 500 mg tablet
    Ciclopirox 8% solutionMoving to a higher levelConsult Doctor
    Edurant tabletMoving to a higher levelConsult Doctor
    Kaletra tabletMoving to a higher levelConsult Doctor
    Victoza [Change Effective November 1, 2019]Moving to a higher levelBydureon, Byetta, Ozempic, or Trulicity

    Formulary Changes to the M1, M2 and M4 (2018) Drug Lists

    Drug Name Description of Change Cost-effective Alternatives*
    Cialis tabletNo longer coveredtadalafil tablet
    Cuprimine capsuleNo longer coveredpenicillamine capsule
    Delzicol delayed-release capsuleNo longer coveredmesalamine delayed-release capsule
    Diclegis delayed-release tabletNo longer covereddoxylamine/pyridoxine delayed-release tablet
    Ertaczo creamNo longer coveredeconazole cream
    Exjade tablet for oral suspensionNo longer covereddeferasirox tablet for oral suspension
    Extavia kitNo longer coveredBetaseron kit
    Flarex eye dropsNo longer coveredprednisolone eye drops
    Halog ointmentNo longer coveredbetamethasone ointment
    Kineret injectionNo longer coveredConsult Doctor
    Letairis tabletNo longer coveredambrisentan tablet
    Livalo tabletNo longer coveredatorvastatin tablet
    Lotemax eye dropsNo longer coveredloteprednol eye drops
    Oracea capsuleNo longer covereddoxycycline capsule
    Pradaxa capsuleNo longer coveredConsult Doctor
    Quartette tabletNo longer coveredlevonorgestrel/ethinyl estradiol tablet
    Safyral tabletNo longer covereddrospirenone/ethinyl estradiol/levomefolate tablet
    sumatriptan/naproxen tabletNo longer coveredsumatriptan tablet
    Revatio suspensionNo longer coveredsildenafil suspension
    Suprax capsuleNo longer coveredcefixime capsule
    Tarceva tabletNo longer coverederlotinib tablet
    Tracleer tabletNo longer coveredbosentan tablet
    Uloric tabletNo longer coveredfebuxostat tablet
    Vesicare tabletNo longer coveredsolifenacin tablet
    Xopenex HFA inhalerNo longer coveredlevalbuterol HFA inhaler
    Zioptan eye dropsNo longer coveredlatanoprost eye drops
    Zyclara cream pumpNo longer coveredimiquimod cream

    Formulary Changes to the M4 (2018) Drug Lists

    Drug Name Description of Change Cost-effective Alternatives*
    Atripla tabletMoving to a higher levelConsult Doctor
    Chlorzoxazone 250 mg tabletMoving to a higher levelchlorzoxazone 500 mg tablet
    Chlorzoxazone 375 mg tabletMoving to a higher levelchlorzoxazone 500 mg tablet
    Chlorzoxazone 750 mg tabletMoving to a higher levelchlorzoxazone 500 mg tablet
    Ciclopirox 8% solutionMoving to a higher levelConsult Doctor
    Edurant tabletMoving to a higher levelConsult Doctor
    Kaletra tabletMoving to a higher levelConsult Doctor
    Victoza [Change Effective November 1, 2019]Moving to a higher levelBydureon, Byetta, Ozempic, Trulicity

    Formulary Changes to the Select C4 Drug List

    Drug Name Description of Change Cost-effective Alternatives*
    Tarceva tabletMoving to a higher levelerlotinib tablet
    Victoza [Change Effective November 1, 2019]Moving to a higher levelBydureon, Byetta, Ozempic, or Trulicity

    *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.