Drug List Changes

Effective January 01, 2019

Formulary Changes to the Preferred B2 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Asacol HD 800 mg tablet	No longer covered	mesalamine 800 mg tablet

Formulary Changes to the Preferred B3 and B4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Asacol HD 800 mg tablet	Moving to a higher level	mesalamine 800 mg tablet

Formulary Changes to the E4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Acanya gel	Moving to a higher level	clindamycin/benzoyl peroxide gel
Adcirca tablet	Moving to a higher level	tadalafil tablet

Formulary Changes to the E1 and E4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Aktipak gel pouch	No longer covered	erythromycin/benzoyl peroxide gel
Arimidex tablet	No longer covered	anastrozole tablet
Atripla tablet	No longer covered	Symfi tablet
Benicar tablet	No longer covered	olmesartan tablet
Benicar HCT tablet	No longer covered	olmesartan/hydrochlorothiazide tablet
Brisdelle capsule	No longer covered	paroxetine mesylate capsule
Brovana solution	No longer covered	Perforomist solution
butalbital/acetaminophen tablet	No longer covered	butalbital/acetaminophen/caffeine tablet
Butrans patch	No longer covered	Buprenorphine transdermal patch
Celexa tablet	No longer covered	citalopram tablet
Climara Pro patch	No longer covered	Combipatch patch
Clindacin P pledgets	No longer covered	clindamycin pledgets
Cosopt eye drops	No longer covered	dorzolamide/timolol eye drops
Cozaar tablet	No longer covered	losartan tablet
Crestor tablet	No longer covered	rosuvastatin tablet
Diovan tablet	No longer covered	valsartan tablet
Diovan HCT tablet	No longer covered	valsartan/hydrochlorothiazide tablet
Embeda ER capsule	No longer covered	morphine sulfate extended-release tablet
Fenoprofen capsule	No longer covered	naproxen tablet
Fluorouracil 0.5% cream	No longer covered	fluorouracil solution
FML Forte eye drops	No longer covered	fluorometholone eye drops
FML Liquifilm eye drops	No longer covered	fluorometholone eye drops
Humalog Jr. Kwikpen	No longer covered	Novolog Flexpen
levalbuterol solution	No longer covered	albuterol solution
Levalbuterol HFA inhaler	No longer covered	ProAir HFA inhaler
Maxalt MLT tablet	No longer covered	rizatriptan orally-disintegrating tablet
Maxidex eye drops	No longer covered	dexamethasone eye drops
metformin ER osmotic-release tablet	No longer covered	metformin extended-release tablet
Micardis tablet	No longer covered	telmisartan tablet
Nalfon capsule	No longer covered	naproxen tablet
Neupro patch	No longer covered	ropinirole tablet
Norvasc tablet	No longer covered	amlodipine tablet
Nuvigil tablet	No longer covered	armodafinil tablet
OB Complete Petite capsule	No longer covered	PrePlus tablet
Onzetra Xsail nasal powder	No longer covered	sumatriptan nasal spray
Pradaxa capsule	No longer covered	Xarelto tablet
Prozac Pulvule capsule	No longer covered	fluoxetine capsule
Savaysa tablet	No longer covered	Xarelto tablet
Tobi Podhaler capsule	No longer covered	tobramycin inhaled
Tricor tablet	No longer covered	fenofibrate tablet
Vagifem tablet	No longer covered	estradiol tablet
Vinate DHA RF gelcap	No longer covered	PrePlus tablet
Vivelle-dot patch	No longer covered	estradiol patch
Xalatan eye drops	No longer covered	latanoprost eye drops
Zoloft tablet	No longer covered	sertraline tablet

Formulary Changes to the M4 (2019) Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
abacavir/lamivudine tablet	Moving to a higher level	Consult Doctor
Albenza tablet	Moving to a higher level	Consult Doctor
alclometasone cream	Moving to a higher level	betamethasone dipropionate cream
Alphagan P drops	Moving to a higher level	brimonidine drops
Amabelz tablet	Moving to a higher level	estradiol/norethindrone tablet
aspirin/dipyridamole capsule	Moving to a higher level	aspirin tablet
Atrovent HFA inhaler	Moving to a higher level	ipratropium inhaled
Azopt suspension	Moving to a higher level	dorzolamide drops
Betimol drops	Moving to a higher level	timolol drops
Blephamide drops	Moving to a higher level	sulfacetamide/prednisolone drops
bumetanide tablet	Moving to a higher level	furosemide tablet
butalbital/acetaminophen/caffeine/codeine capsule	Moving to a higher level	butalbital/acetaminophen/caffeine tablet
Canasa suppository	Moving to a higher level	mesalamine suppository
chlordiazepoxide/clidinium capsule	Moving to a higher level	Consult Doctor
chlorpromazine tablet	Moving to a higher level	Consult Doctor
Cialis tablet	Moving to a higher level	tamsulosin capsule
Claravis capsule	Moving to a higher level	Amnesteem capsule
Clobetasol cream	Moving to a higher level	halobetasol propionate cream
Clobetasol gel	Moving to a higher level	halobetasol propionate cream
Clobetasol solution	Moving to a higher level	halobetasol propionate solution
clonidine patch	Moving to a higher level	Consult Doctor
Colocort enema	Moving to a higher level	hydrocortisone enema
Combipatch patch	Moving to a higher level	estradiol/norethindrone tablet
Completenate tablet	Moving to a higher level	PrePlus tablet
Compro suppository	Moving to a higher level	prochlorperazine suppository
Daliresp tablet	Moving to a higher level	Consult Doctor
dapsone gel	Moving to a higher level	clindamycin topical solution
Denavir cream	Moving to a higher level	acyclovir ointment
Descovy tablet	Moving to a higher level	Consult Doctor
desonide cream	Moving to a higher level	hydrocortisone cream
desonide lotion	Moving to a higher level	hydrocortisone lotion
desonide ointment	Moving to a higher level	hydrocortisone ointment
desoximetasone cream	Moving to a higher level	betamethasone dipropionate cream
desoximetasone ointment	Moving to a higher level	betamethasone dipropionate ointment
dofetilide capsule	Moving to a higher level	Consult Doctor
dronabinol capsule	Moving to a higher level	aprepitant capsule or ondansetron tablet
Elidel cream	Moving to a higher level	tacrolimus ointment
Elmiron capsule	Moving to a higher level	Consult Doctor
Emtriva capsule	Moving to a higher level	Consult Doctor
Ery-tab tablet	Moving to a higher level	erythromycin tablet
Erythrocin tablet	Moving to a higher level	erythromycin tablet
ethacrynic acid tablet	Moving to a higher level	furosemide tablet
Eucrisa ointment	Moving to a higher level	tacrolimus ointment
Finacea foam	Moving to a higher level	tretinoin topical
Finacea gel	Moving to a higher level	tretinoin topical
Flovent Diskus inhaler	Moving to a higher level	Asmanex inhalation
Flovent HFA	Moving to a higher level	Asmanex inhalation
fluocinonide cream	Moving to a higher level	betamethasone dipropionate cream
fluocinonide gel	Moving to a higher level	betamethasone dipropionate topical
fluocinonide ointment	Moving to a higher level	betamethasone dipropionate ointment
fluocinonide solution	Moving to a higher level	betamethasone dipropionate topical
fluocinonide-e cream	Moving to a higher level	betamethasone dipropionate cream
fluorouracil cream	Moving to a higher level	Consult Doctor
G Tussin AC liquid	Moving to a higher level	guaifenesin/codeine syrup
hydrocortisone butyrate ointment	Moving to a higher level	hydrocortisone topical
Hydromet syrup	Moving to a higher level	hydrocodone/homatropine tablet
imipramine capsule	Moving to a higher level	imipramine tablet
Intelence tablet	Moving to a higher level	Consult Doctor
Invokamet XR tablet	Moving to a higher level	Invokamet tablet
isradipine capsule	Moving to a higher level	amlodipine tablet
ketoprofen capsule	Moving to a higher level	ibuprofen tablet
Lacrisert insert	Moving to a higher level	Consult Doctor
lansoprazole capsule	Moving to a higher level	pantoprazole tablet
levocetirizine tablet	Moving to a higher level	cetirizine solution
levorphanol tablet	Moving to a higher level	morphine sulfate tablet
lidocaine-tetracaine cream	Moving to a higher level	lidocaine topical
mesalamine DR tablet	Moving to a higher level	mesalamine tablet
methergine tablet	Moving to a higher level	Consult Doctor
mirtazapine tablet	Moving to a higher level	Consult Doctor
Multaq tablet	Moving to a higher level	Consult Doctor
Myorisan capsule	Moving to a higher level	Amnesteem capsule
naproxen DS tablet	Moving to a higher level	naproxen tablet
naproxen sodium tablet	Moving to a higher level	naproxen tablet
nateglinide tablet	Moving to a higher level	Consult Doctor
nefazodone tablet	Moving to a higher level	Consult Doctor
Nitro-bid ointment	Moving to a higher level	Consult Doctor
Norpace CR capsule	Moving to a higher level	disopyramide capsule
Noxafil DR tablet	Moving to a higher level	Consult Doctor
olopatadine nasal spray	Moving to a higher level	azelastine nasal spray
Onfi suspension	Moving to a higher level	Consult Doctor
Pradaxa capsule	Moving to a higher level	Xarelto tablet
pramipexole extended-release tablet	Moving to a higher level	ropinirole tablet
pramipexole tablet	Moving to a higher level	ropinirole tablet
Prempro tablet	Moving to a higher level	Covaryx tablet
Proctofoam-HC foam	Moving to a higher level	hydrocortisone cream
Procto-Med HC cream	Moving to a higher level	hydrocortisone cream
quetiapine extended-release tablet	Moving to a higher level	Consult Doctor
ramipril capsule	Moving to a higher level	lisinopril tablet
rasagiline tablet	Moving to a higher level	selegiline tablet
Relistor tablet	Moving to a higher level	Consult Doctor
repaglinide tablet	Moving to a higher level	Consult Doctor
Restasis dropperette	Moving to a higher level	Consult Doctor
Restasis multidose drops	Moving to a higher level	Consult Doctor
scopolamine patch	Moving to a higher level	Consult Doctor
Selzentry tablet	Moving to a higher level	Consult Doctor
Serevent Diskus inhaler	Moving to a higher level	Consult Doctor
sevelamer powder pack	Moving to a higher level	Consult Doctor
tetracycline capsule	Moving to a higher level	Consult Doctor
Tobradex ointment	Moving to a higher level	tobramycin/dexamethasone drops
Tobradex ST drops	Moving to a higher level	tobramycin/dexamethasone drops
vancomycin capsule	Moving to a higher level	Consult Doctor
Vemlidy tablet	Moving to a higher level	Consult Doctor
Viracept tablet	Moving to a higher level	Consult Doctor
Vyvanse chewable tablet	Moving to a higher level	Consult Doctor
Xifaxan tablet	Moving to a higher level	Consult Doctor
Xiidra dropperette	Moving to a higher level	Consult Doctor

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

Drug Name	Description of Change	Cost-effective Alternatives*
adapalene/benzoyl peroxide gel	No longer covered	benzoyl peroxide topical
Asacol HD tablet	No longer covered	mesalamine tablet
butalbital/acetaminophen tablet	No longer covered	butalbital/acetaminophen/caffeine tablet
Carospir suspension	No longer covered	spironolactone tablet
Copaxone syringe	No longer covered	glatiramer acetate syringe
Delzicol capsule	No longer covered	mesalamine tablet
doxepin cream	No longer covered	tacrolimus ointment
Emflaza tablet	No longer covered	Consult Doctor
flunisolide nasal spray	No longer covered	fluticasone nasal spray
Folbee Plus tablet	No longer covered	generic vitamin b complex + folic acid
Folbic tablet	No longer covered	generic vitamin b complex + folic acid
HPR Plus foam	No longer covered	hydrocortisone topical
mometasone nasal spray	No longer covered	fluticasone nasal spray
Nexium capsule	No longer covered	pantoprazole tablet
Norvir tablet	No longer covered	ritonavir tablet
Ortho D capsule	No longer covered	cholecalciferol + folic acid
Pertzye capsule	No longer covered	Zenpep capsule
Prevacid capsule	No longer covered	pantoprazole tablet
Qnasl nasal spray	No longer covered	fluticasone nasal spray
Segluromet tablet	No longer covered	Synjardy tablet
Steglatro tablet	No longer covered	Jardiance tablet
Taclonex topical	No longer covered	calcitriene ointment
Vyzulta drops	No longer covered	latanoprost drops
Zovirax cream	No longer covered	acyclovir ointment

*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.