Drug List Changes

Effective August 01, 2020

Formulary Changes to the Open A1 and Preferred A2 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Alvesco inhaler	Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Asmanex HFA inhaler	Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Asmanex Twisthaler inhaler	Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Basaglar injectable	Prior authorization	Lantus, Levemir, Toujeo, or Tresiba
Invokamet tablet	Prior authorization	Synjardy, Synjardy XR, or Xigduo XR
Invokamet XR extended-release tablet	Prior authorization	Synjardy, Synjardy XR, or Xigduo XR
Invokana tablet	Prior authorization	Farxiga or Jardiance
Kombiglyze XR extended-release tablet	Prior authorization	Janumet, Janumet XR, Jentadueto, Jentadueto XR
Onglyza tablet	Prior authorization	Januvia or Tradjenta
Pulmicort Flexhaler inhaler	Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Pulmicort Respules inhalation suspension	Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Segluromet tablet	Prior authorization	Synjardy, Synjardy XR, or Xigduo XR
Steglatro tablet	Prior authorization	Farxiga or Jardiance

Formulary Changes to the Preferred B2 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Asmanex HFA inhaler	No longer covered	Arnuity Ellipta, Flovent, or Qvar
Asmanex Twisthaler inhaler	No longer covered	Arnuity Ellipta, Flovent, or Qvar
Basaglar injectable	No longer covered	Lantus, Levemir, Toujeo, or Tresiba
Carafate oral suspension [Change Effective July 1, 2020]	No longer covered	sucralfate oral suspension
Depen tablet [Change Effective July 1, 2020]	No longer covered	penicillamine tablet
Invokamet tablet	No longer covered	Synjardy, Synjardy XR, or Xigduo XR
Invokamet XR extended-release tablet	No longer covered	Synjardy, Synjardy XR, or Xigduo XR
Invokana tablet	No longer covered	Farxiga or Jardiance
Kombiglyze XR extended-release tablet	No longer covered	Janumet, Janumet XR, Jentadueto, Jentadueto XR
NuvaRing contraceptive [Change Effective July 1, 2020]	No longer covered	etonogestrel/ethinyl estradiol contraceptive
Onglyza tablet	No longer covered	Januvia or Tradjenta
Pulmicort Flexhaler inhaler	No longer covered	Arnuity Ellipta, Flovent, or Qvar
Steglatro tablet	No longer covered	Farxiga or Jardiance

Formulary Changes to the Preferred B3 and B4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Alvesco inhaler	Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Asmanex HFA inhaler	Moving to a higher level; Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Asmanex Twisthaler inhaler	Moving to a higher level; Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Basaglar injectable	Moving to a higher level; Prior authorization	Lantus, Levemir, Toujeo, or Tresiba
Carafate oral suspension [Change Effective July 1, 2020]	Moving to a higher level	sucralfate oral suspension
Depen tablet [Change Effective July 1, 2020]	Moving to a higher level	penicillamine tablet
Invokamet tablet	Moving to a higher level; Prior authorization	Synjardy, Synjardy XR, or Xigduo XR
Invokamet XR extended-release tablet	Moving to a higher level; Prior authorization	Synjardy, Synjardy XR, or Xigduo XR
Invokana tablet	Moving to a higher level; Prior authorization	Farxiga or Jardiance
Kombiglyze XR extended-release tablet	Moving to a higher level; Prior authorization	Janumet, Janumet XR, Jentadueto, Jentadueto XR
NuvaRing contraceptive [Change Effective July 1, 2020]	Moving to a higher level	etonogestrel/ethinyl estradiol contraceptive
Onglyza tablet	Moving to a higher level; Prior authorization	Januvia or Tradjenta
Pulmicort Flexhaler inhaler	Moving to a higher level; Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Pulmicort Respules inhalation suspension	Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Segluromet tablet	Prior authorization	Synjardy, Synjardy XR, or Xigduo XR
Steglatro tablet	Moving to a higher level; Prior authorization	Farxiga or Jardiance

Formulary Changes to the E1 and E4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Alvesco inhaler	Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Asmanex HFA inhaler	Moving to a higher level; Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Asmanex Twisthaler inhaler	Moving to a higher level; Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Basaglar injectable	Moving to a higher level; Prior authorization	Lantus, Levemir, Toujeo, or Tresiba
Depen tablet [Change Effective July 1, 2020]	Moving to a higher level	penicillamine tablet
Invokamet tablet	Moving to a higher level; Prior authorization	Synjardy, Synjardy XR, or Xigduo XR
Invokamet XR extended-release tablet	Moving to a higher level; Prior authorization	Synjardy, Synjardy XR, or Xigduo XR
Invokana tablet	Moving to a higher level; Prior authorization	Farxiga or Jardiance
Kombiglyze XR extended-release tablet	Moving to a higher level; Prior authorization	Janumet, Janumet XR, Jentadueto, Jentadueto XR
NuvaRing contraceptive [Change Effective July 1, 2020]	Moving to a higher level	etonogestrel/ethinyl estradiol contraceptive
Onglyza tablet	Moving to a higher level; Prior authorization	Januvia or Tradjenta
Pulmicort Flexhaler inhaler	Moving to a higher level; Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Segluromet tablet	Prior authorization	Synjardy, Synjardy XR, or Xigduo XR
Steglatro tablet	Moving to a higher level; Prior authorization	Farxiga or Jardiance

Formulary Changes to the M1, M2 and M4 (2020) Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Alvesco inhaler	Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Asmanex HFA inhaler	No longer covered	Arnuity Ellipta, Flovent, or Qvar
Asmanex Twisthaler inhaler	No longer covered	Arnuity Ellipta, Flovent, or Qvar
Basaglar injectable	No longer covered	Lantus, Levemir, Toujeo, or Tresiba
Carafate oral suspension [Change Effective July 1, 2020]	No longer covered	sucralfate oral suspension
Depen tablet [Change Effective July 1, 2020]	No longer covered	penicillamine tablet
Invokamet tablet	No longer covered	Synjardy, Synjardy XR, or Xigduo XR
Invokamet XR extended-release tablet	No longer covered	Synjardy, Synjardy XR, or Xigduo XR
Invokana tablet	No longer covered	Farxiga or Jardiance
Jadenu tablet [Change Effective July 1, 2020]	No longer covered	deferasirox tablet
Kombiglyze XR extended-release tablet	No longer covered	Janumet, Janumet XR, Jentadueto, Jentadueto XR
Moxeza eye drops [Change Effective July 1, 2020]	No longer covered	moxifloxacin eye drops
NuvaRing contraceptive [Change Effective July 1, 2020]	No longer covered	etonogestrel/ethinyl estradiol contraceptive
Onglyza tablet	No longer covered	Januvia or Tradjenta
Pulmicort Flexhaler inhaler	No longer covered	Arnuity Ellipta, Flovent, or Qvar
Steglatro tablet	No longer covered	Farxiga or Jardiance
Travatan Z eye drops [Change Effective July 1, 2020]	No longer covered	travoprost eye drops
Zohydro extended-release capsule [Change Effective July 1, 2020]	No longer covered	hydrocodone extended-release capsule

Formulary Changes to the Select C4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Alvesco inhaler	Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Asmanex HFA inhaler	Moving to a higher level; Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Asmanex Twisthaler inhaler	Moving to a higher level; Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Basaglar injectable	Prior authorization	Lantus, Levemir, Toujeo, or Tresiba
Invokamet tablet	Moving to a higher level; Prior authorization	Synjardy, Synjardy XR, or Xigduo XR
Invokamet XR extended-release tablet	Moving to a higher level; Prior authorization	Synjardy, Synjardy XR, or Xigduo XR
Invokana tablet	Moving to a higher level; Prior authorization	Farxiga or Jardiance
Kombiglyze XR extended-release tablet	Moving to a higher level; Prior authorization	Janumet, Janumet XR, Jentadueto, Jentadueto XR
NuvaRing contraceptive [Change Effective July 1, 2020]	Moving to a higher level	etonogestrel/ethinyl estradiol contraceptive
Onglyza tablet	Moving to a higher level; Prior authorization	Januvia or Tradjenta
Pulmicort Flexhaler inhaler	Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Pulmicort Respules inhalation suspension	Prior authorization	Arnuity Ellipta, Flovent, or Qvar
Segluromet tablet	Prior authorization	Synjardy, Synjardy XR, or Xigduo XR
Steglatro tablet	Prior authorization	Farxiga or Jardiance

*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.