Drug List Changes

Effective April 01, 2019

Formulary Changes to the Preferred B2 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Albenza tablet	No longer covered	albendazole tablet
Amicar tablet	No longer covered	aminocaproic acid tablet
Androgel gel packet	No longer covered	testosterone gel packet
Canasa suppository	No longer covered	mesalamine suppository
Elidel topical cream	No longer covered	pimecrolimus topical cream
Finacea topical gel	No longer covered	azelaic acid topical gel
Zytiga tablet	No longer covered	abiraterone acetate tablet

Formulary Changes to the Preferred B3 and B4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Albenza tablet	Moving to a higher level	albendazole tablet
Amicar tablet	Moving to a higher level	aminocaproic acid tablet
Androgel gel packet	Moving to a higher level	testosterone gel packet
Canasa suppository	Moving to a higher level	mesalamine suppository
Elidel topical cream	Moving to a higher level	pimecrolimus topical cream
Finacea topical gel	Moving to a higher level	azelaic acid topical gel
Zytiga tablet	Moving to a higher level	abiraterone acetate tablet

Formulary Changes to the E4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Androgel gel packet	Moving to a higher level	testosterone gel packet
Zytiga tablet	Moving to a higher level	abiraterone acetate tablet

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

Drug Name	Description of Change	Cost-effective Alternatives*
Albenza tablet	No longer covered	albendazole tablet
Amicar tablet	No longer covered	aminocaproic acid tablet
Ampyra extended-release tablet	No longer covered	dalfampridine extended-release tablet
Androgel gel packet	No longer covered	testosterone gel packet
Butrans patch	No longer covered	buprenorphine patch
Canasa suppository	No longer covered	mesalamine suppository
Elidel topical cream	No longer covered	pimecrolimus topical cream
Evekeo tablet	No longer covered	amphetamine tablet
Finacea topical gel	No longer covered	azelaic acid topical gel
Fortesta topical gel	No longer covered	testosterone topical gel
Onfi suspension	No longer covered	clobazam suspension
Onfi tablet	No longer covered	clobazam tablet
Rapaflo capsule	No longer covered	silodosin capsule
Zytiga tablet	No longer covered	abiraterone acetate tablet

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

Drug Name	Description of Change	Cost-effective Alternatives*
Albenza tablet	No longer covered	albendazole tablet
Amicar tablet	No longer covered	aminocaproic acid tablet
Ampyra extended-release tablet	No longer covered	dalfampridine extended-release tablet
Androgel gel packet	No longer covered	testosterone gel packet
Butrans patch	No longer covered	buprenorphine patch
Canasa suppository	No longer covered	mesalamine suppository
Elidel topical cream	No longer covered	pimecrolimus topical cream
Evekeo tablet	No longer covered	amphetamine tablet
Finacea topical gel	No longer covered	azelaic acid topical gel
Fortesta topical gel	No longer covered	testosterone topical gel
Onfi suspension	No longer covered	clobazam suspension
Onfi tablet	No longer covered	clobazam tablet
Rapaflo capsule	No longer covered	silodosin capsule
Zytiga tablet	No longer covered	abiraterone acetate tablet

Formulary Changes to the Select C4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Amicar tablet	Moving to a higher level	aminocaproic acid tablet
Zytiga tablet	Moving to a higher level	abiraterone acetate 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.