Drug List Changes

Effective January 01, 2023

Formulary Changes to the Preferred B3 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Clocortolone Cream	Moving To Tier 3	Fluocinolone Cream
Condylox Gel	Moving To Tier 3	Podofilox Topical Solution
Esbriet tablet 267 mg & 801 mg	Moving To Tier 3	pirfenidone tablet 267 mg and 801 mg
Incruse Ellipta	Moving To Tier 3	Spiriva Respimat Inhaler
Lipofen Capsule	Moving To Tier 3	Fenofibrate Tablet Generic
Nexavar tablet	Moving To Tier 3	sorafenib tablet
Norpace CR Capsule	Moving To Tier 3	Disopyramide capsule
Targretin gel	Moving To Tier 3	bexarotene gel
Tramadol ER tablet brand	Moving To Tier 3	Tramadol tablet generic
Vimpat oral solution	Moving To Tier 3	lacosamide oral solution

Formulary Changes to the Preferred B4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Clocortolone Cream	Moving To Tier 3	Fluocinolone Cream
Condylox Gel	Moving To Tier 3	Podofilox Topical Solution
Incruse Ellipta	Moving To Tier 3	Spiriva Respimat Inhaler
Lipofen Capsule	Moving To Tier 3	Fenofibrate Tablet Generic
Norpace CR Capsule	Moving To Tier 3	Disopyramide capsule
Targretin gel	Moving To Tier 3	bexarotene gel
Tramadol ER	Moving To Tier 3	Tramadol tablet generic
Vimpat oral solution	Moving To Tier 3	lacosamide oral solution

Formulary Changes to the Select C4 drug list

Drug Name	Description of Change	Cost-effective Alternatives*
Clocortolone Cream	Moving To Tier 3	Fluocinolone Cream
Condylox Gel	Moving To Tier 3	Podofilox Topical Solution
Incruse Ellipta	Moving To Tier 3	Spiriva Respimat Inhaler
Lipofen Capsule	Moving To Tier 3	Fenofibrate Tablet Generic
Norpace CR Capsule	Moving To Tier 3	Disopyramide capsule
Targretin gel	Moving To Tier 3	bexarotene gel
Tramadol ER	Moving To Tier 3	Tramadol tablet generic
Vimpat oral solution	Moving To Tier 3	lacosamide oral solution

Formulary Changes to the E1 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
ALA-SCALP HP lotion	No longer covered	HYDROCORTISONE lotion
Alkindi Sprinkle Capsule	No longer covered	Hydrocortisone Tablet
Antara Capsule	No longer covered	Fenofibrate Tablet Generic
Astagraf Xl Capsule	No longer covered	Tacrolimus Capsule
Avar	No longer covered	Tretinoin Gel
Avar Ls	No longer covered	Tretinoin Gel
Avar-E	No longer covered	Tretinoin Gel
Avar-E Ls Cream	No longer covered	Tretinoin Gel
BANZEL tablet and oral suspension	No longer covered	RUFINAMIDE tablet and oral suspension
Benzepro Towelette	No longer covered	Benzoyl Peroxide Gel
Beser Lotion	No longer covered	Fluticasone Cream
Betamethasone Valerate	No longer covered	Betamethasone Valerate Cream
BPO Towelette	No longer covered	Benzoyl Peroxide Gel
Bupropion Xl Brand	No longer covered	Bupropion Generic
Citalopram Capsule Brand	No longer covered	Citalopram Tablet
Clenia Plus	No longer covered	Tretinoin Gel
Clobetasol Emulsion Foam	No longer covered	Clobetasol Cream
Clobetasol Propionate Foam	No longer covered	Clobetasol Cream
Conzip Capsule	No longer covered	Tramadol Tablet Generic
CUVPOSA oral solution	No longer covered	GLYCOPYRROLATE oral solution
CYMBALTA capsule	No longer covered	DULOXETINE capsule
CYSTADANE poweder	No longer covered	BETAINE powder
Dexlansoprazole Dr Capsule Brand	No longer covered	Lansoprazole Capsule
Diclofenac Potassium Capsule	No longer covered	Diclofenac Sodium Tablet
Diclofenac Potassium Tablet	No longer covered	Diclofenac Sodium Tablet
Doxycycline Hyclate Tablet	No longer covered	Doxycycline Monohydrate Tablet
Edluar Sublingual Tablet	No longer covered	Zolpidem Tablet
EFFEXOR XR capsule	No longer covered	VENLAFAXINE ER capsule
Envarsus Xr Tablet	No longer covered	Tacrolimus Capsule
Fenofibrate Capsule Brand	No longer covered	Fenofibrate Tablet Generic
FERAHEME	No longer covered	FERUMOXYTOL
Fleqsuvy Oral Suspension	No longer covered	Baclofen Tablet
Fluticasone Propionate Lotion	No longer covered	Fluticasone Cream
Halcinonide Cream	No longer covered	Betamethasone Valerate Cream
Hydrocortisone Butyrate Lotion	No longer covered	Hydrocortisone Cream
Hydrocortisone Lotion	No longer covered	Hydrocortisone Cream
Incruse Ellipta	No longer covered	Spiriva Respimat Inhaler
Ketodan Foam	No longer covered	Ketoconazole Cream
KLONOPIN tablet	No longer covered	CLONAZEPAM tablet
Levothyroxine Capsule	No longer covered	Levothyroxine Tablet
Lipofen Capsule	No longer covered	Fenofibrate Tablet Generic
Lofena Tablet	No longer covered	Diclofenac Sodium Tablet
NORPACE capsule	No longer covered	DISOPYRAMIDE capsule
Plexion	No longer covered	Tretinoin Gel
PRISTIQ tablet	No longer covered	DESVENLAFAXINE tablet
PROZAC capsule	No longer covered	FLUOXETINE capsule
PYRIDIUM tablet	No longer covered	PHENAZOPYRIDINE tablet
ROSANIL cleanser	No longer covered	SULFACETAMIDE SODIUM/SULFUR cleanser
Rosula	No longer covered	Tretinoin Gel
SABRIL tablet and powder packet	No longer covered	VIGABATRIN tablet and powder packet
Samsca Tablet	No longer covered	tolvaptan tablet
SAPHRIS sublinicual tablet	No longer covered	ASENAPINE sublingual tablet
Selenium Sulfide 2.3% Shampoo	No longer covered	Selenium Sulfide 2.25% Shampoo
Selrx Shampoo	No longer covered	Selenium Sulfide 2.25% Shampoo
Sodium Sulfacetamide Cleanser	No longer covered	Sulfacetamide Sodium Topical Suspension
Sodium Sulfacetamide/Sulfur	No longer covered	Tretinoin Gel
Sss 10-5	No longer covered	Tretinoin Gel
Sulfacetamide Sodium-Sulfur	No longer covered	Tretinoin Gel
Sumadan	No longer covered	Tretinoin Gel
Sumaxin	No longer covered	Tretinoin Gel
Sumaxin Cp	No longer covered	Tretinoin Gel
SUMAXIN medicated pads	No longer covered	SULFACETAMIDE SODIUM/SULFUR medicated pads
Sumaxin Ts	No longer covered	Tretinoin Gel
Tavaborole Solution	No longer covered	Ciclopirox Solution
Tazarotene Foam	No longer covered	Tazarotene Cream
Tovet Emollient Foam	No longer covered	Clobetasol Cream
Tramadol Er Capsule	No longer covered	Tramadol Tablet Generic
Tramadol Tablet Brand	No longer covered	Tramadol Tablet Generic
Zolmitriptan Nasal Spray	No longer covered	Zolmitriptan Odt Tablet
Zyflo Tablet	No longer covered	Zileuton Er Tablet

Formulary Changes to the E4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
ALA-SCALP HP lotion	No longer covered	HYDROCORTISONE lotion
Alkindi Sprinkle Capsule	No longer covered	Hydrocortisone Tablet
Antara Capsule	No longer covered	Fenofibrate Tablet Generic
Astagraf Xl Capsule	No longer covered	Tacrolimus Capsule
Avar	No longer covered	Tretinoin Gel
Avar Ls	No longer covered	Tretinoin Gel
Avar-E	No longer covered	Tretinoin Gel
Avar-E Ls Cream	No longer covered	Tretinoin Gel
BANZEL tablet and oral suspension	No longer covered	RUFINAMIDE tablet and oral suspension
Benzepro Towelette	No longer covered	Benzoyl Peroxide Gel
Beser Lotion	No longer covered	Fluticasone Cream
Betamethasone Valerate	No longer covered	Betamethasone Valerate Cream
BPO Towelette	No longer covered	Benzoyl Peroxide Gel
Bupropion Xl Brand	No longer covered	Bupropion Generic
Citalopram Capsule Brand	No longer covered	Citalopram Tablet
Clenia Plus	No longer covered	Tretinoin Gel
Clobetasol Emulsion Foam	No longer covered	Clobetasol Cream
Clobetasol Propionate Foam	No longer covered	Clobetasol Cream
Conzip Capsule	No longer covered	Tramadol Tablet Generic
CUVPOSA oral solution	No longer covered	GLYCOPYRROLATE oral solution
CYMBALTA capsule	No longer covered	DULOXETINE capsule
CYSTADANE poweder	No longer covered	BETAINE powder
Dexlansoprazole Dr Capsule Brand	No longer covered	Lansoprazole Capsule
Diclofenac Potassium Capsule	No longer covered	Diclofenac Sodium Tablet
Diclofenac Potassium Tablet	No longer covered	Diclofenac Sodium Tablet
Doxycycline Hyclate Tablet	No longer covered	Doxycycline Monohydrate Tablet
Edluar Sublingual Tablet	No longer covered	Zolpidem Tablet
EFFEXOR XR capsule	No longer covered	VENLAFAXINE ER capsule
Envarsus Xr Tablet	No longer covered	Tacrolimus Capsule
Esbriet tablet 267 mg & 801 mg	Moving To Tier 4	pirfenidone tablet 267 mg and 801 mg
Fenofibrate Capsule Brand	No longer covered	Fenofibrate Tablet Generic
FERAHEME	No longer covered	FERUMOXYTOL
Fleqsuvy Oral Suspension	No longer covered	Baclofen Tablet
Fluticasone Propionate Lotion	No longer covered	Fluticasone Cream
Halcinonide Cream	No longer covered	Betamethasone Valerate Cream
Hydrocortisone Butyrate Lotion	No longer covered	Hydrocortisone Cream
Hydrocortisone Lotion	No longer covered	Hydrocortisone Cream
Incruse Ellipta	No longer covered	Spiriva Respimat Inhaler
Ketodan Foam	No longer covered	Ketoconazole Cream
KLONOPIN tablet	No longer covered	CLONAZEPAM tablet
Levothyroxine Capsule	No longer covered	Levothyroxine Tablet
Lipofen Capsule	No longer covered	Fenofibrate Tablet Generic
Lofena Tablet	No longer covered	Diclofenac Sodium Tablet
NORPACE capsule	No longer covered	DISOPYRAMIDE capsule
Omeclamox-Pak	moving to Tier 4	Lansoprazole-Amoxicilin-Clarithromycin Combo Pack
Ketodan Foam	No longer covered	Ketoconazole Cream
Plexion	No longer covered	Tretinoin Gel
PRISTIQ tablet	No longer covered	DESVENLAFAXINE tablet
PROZAC capsule	No longer covered	FLUOXETINE capsule
PYRIDIUM tablet	No longer covered	PHENAZOPYRIDINE tablet
ROSANIL cleanser	No longer covered	SULFACETAMIDE SODIUM/SULFUR cleanser
Rosula	No longer covered	Tretinoin Gel
SABRIL tablet and powder packet	No longer covered	VIGABATRIN tablet and powder packet
Samsca Tablet	No longer covered	tolvaptan tablet
SAPHRIS sublinicual tablet	No longer covered	ASENAPINE sublingual tablet
Selenium Sulfide 2.3% Shampoo	No longer covered	Selenium Sulfide 2.25% Shampoo
Selrx Shampoo	No longer covered	Selenium Sulfide 2.25% Shampoo
Sodium Sulfacetamide Cleanser	No longer covered	Sulfacetamide Sodium Topical Suspension
Sodium Sulfacetamide/Sulfur	No longer covered	Tretinoin Gel
Sss 10-5	No longer covered	Tretinoin Gel
Sulfacetamide Sodium-Sulfur	No longer covered	Tretinoin Gel
Sumadan	No longer covered	Tretinoin Gel
Sumaxin	No longer covered	Tretinoin Gel
Sumaxin Cp	No longer covered	Tretinoin Gel
SUMAXIN medicated pads	No longer covered	SULFACETAMIDE SODIUM/SULFUR medicated pads
Sumaxin Ts	No longer covered	Tretinoin Gel
Targretin gel	Moving To Tier 4	bexarotene gel
Tavaborole Solution	No longer covered	Ciclopirox Solution
Tazarotene Foam	No longer covered	Tazarotene Cream
Tovet Emollient Foam	No longer covered	Clobetasol Cream
Tramadol Er Capsule	No longer covered	Tramadol Tablet Generic
Tramadol Tablet Brand	No longer covered	Tramadol Tablet Generic
Zolmitriptan Nasal Spray	No longer covered	Zolmitriptan Odt Tablet
Zyflo Tablet	No longer covered	Zileuton Er Tablet

Formulary Changes to the M1 and M2 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Beser Lotion	No longer covered	Fluticasone Cream
Betamethasone Valerate	No longer covered	Betamethasone Valerate Cream
BPO Towelette	No longer covered	Benzoyl Peroxide Gel
Clobetasol Emulsion Foam	No longer covered	Clobetasol Cream
Clobetasol Propionate Foam	No longer covered	Clobetasol Cream
Dapsone Gel and Dapsone Gel with Pump	No longer covered	Tretinoin Gel
Deferiprone tablet (only applicable to M2)	Moving to Tier 2	Consult doctor
Diflorasone cream and ointment	No longer covered	Betamethasone Valerate Cream
Doxycycline Hyclate Tablet	No longer covered	Doxycycline Monohydrate Tablet
Edular sublingual tablet	No longer covered	Zolpidem Tablet
Esbriet tablet 267 mg & 801 mg	No longer covered	pirfenidone tablet 267 mg and 801 mg
Ferriprox tablet	No longer covered	Deferiprone tablet
Flurandrenolide lotion	No longer covered	Flurandrenolide cream
Fluticasone Propionate Lotion	No longer covered	Fluticasone Cream
Halcinonide Cream	No longer covered	Betamethasone Valerate Cream
Hydrocortisone Lotion	No longer covered	Hydrocortisone Cream
Incruse Ellipta	No longer covered	Spiriva Respimat Inhaler
Ketoconazole Foam	No longer covered	Ketoconazole Cream
Ketodan Foam	No longer covered	Ketoconazole Cream
Menostar patch	No longer covered	Estradiol patch
Nexavar tablet	No longer covered	sorafenib tablet
Relexxii tablet	No longer covered	methylphenidate ER capsule or tablet
Samsca Tablet	No longer covered	tolvaptan tablet
Scalacort lotion	No longer covered	Hydrocortisone Cream
Selenium Sulfide 2.3% Shampoo	No longer covered	Selenium Sulfide 2.25% Shampoo
Targretin gel	No longer covered	bexarotene gel
Toviaz tablet	No longer covered	fesoterodine tablet
Triamcinolone acetonide ointment	No longer covered	Triamcinolone acetonide cream
Vimpat oral solution	No longer covered	lacosamide oral solution
Zyflo Tablet	No longer covered	Zileuton Er Tablet

Formulary Changes to the M4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Acyclovir cream	moving to Tier 3	Acyclovir tablet
Asmanex inhaler & Asmanex HFA inhaler	moving to Tier 3	Flovent HFA inhaler
Beser Lotion	No longer covered	Fluticasone Cream
Betamethasone Valerate	No longer covered	Betamethasone Valerate Cream
BPO Towelette	No longer covered	Benzoyl Peroxide Gel
Clobetasol Emulsion Foam	No longer covered	Clobetasol Cream
Clobetasol Propionate Foam	No longer covered	Clobetasol Cream
Clocortolone Cream	Moving To Tier 3	Fluocinolone Cream
Dapsone Gel and Dapsone Gel with Pump	No longer covered	Tretinoin Gel
Deferiprone tablet	Moving to Tier 4	Consult doctor
Diflorasone cream and ointment	No longer covered	Betamethasone Valerate Cream
Dovato tablet	moving to Tier 3	Consult doctor
Doxycycline Hyclate Tablet	No longer covered	Doxycycline Monohydrate Tablet
Dutasteride-Tamsulosin capsule	moving to Tier 3	tamsulosin capsule
Edular sublingual tablet	No longer covered	Zolpidem Tablet
Esbriet tablet 267 mg & 801 mg	No longer covered	pirfenidone tablet 267 mg and 801 mg
Ferriprox tablet	No longer covered	Deferiprone tablet
Flurandrenolide lotion	No longer covered	Flurandrenolide cream
Fluticasone Propionate Lotion	No longer covered	Fluticasone Cream
Genvoya tablet	moving to Tier 3	Consult doctor
Halcinonide Cream	No longer covered	Betamethasone Valerate Cream
Hydrocortisone Lotion	No longer covered	Hydrocortisone Cream
Incruse Ellipta	No longer covered	Spiriva Respimat Inhaler
Ketoconazole Foam	No longer covered	Ketoconazole Cream
Ketodan Foam	No longer covered	Ketoconazole Cream
Menostar patch	No longer covered	Estradiol patch
Mesalamine enteric coated tablet	moving to Tier 3	Mesalamine enteric coated capsule
Nexavar tablet	No longer covered	sorafenib tablet
Odefsey tablet	moving to Tier 3	Consult doctor
Ofloxacin tablet	moving to Tier 3	Ciprofloxacin tablet
Oxycodone-Acetaminophen 2.5-300 Mg	moving to Tier 3	Oxycodone W/Acetaminophen 2.5-325 Mg
Paliperidone ER tablet	moving to Tier 3	Olanzapine tablet
Prezcobix tablet	moving to Tier 3	Consult doctor
Relexxii tablet	No longer covered	methylphenidate ER capsule or tablet
Samsca Tablet	No longer covered	tolvaptan tablet
Scalacort lotion	No longer covered	Hydrocortisone Cream
Selenium Sulfide 2.3% Shampoo	No longer covered	Selenium Sulfide 2.25% Shampoo
Targretin gel	No longer covered	bexarotene gel
Toviaz tablet	No longer covered	fesoterodine tablet
Triamcinolone acetonide ointment	No longer covered	Triamcinolone acetonide cream
Triumeq tablet	moving to Tier 3	Consult doctor
Vimpat oral solution	No longer covered	lacosamide oral solution
Zyflo Tablet	No longer covered	Zileuton Er 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.