Drug List Changes

  • Effective January 01, 2023

    Formulary Changes to the Preferred B3 Drug List

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

    Formulary Changes to the Preferred B4 Drug List

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

    Formulary Changes to the Select C4 drug list

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

    Formulary Changes to the E1 Drug List

    Drug Name Description of Change Cost-effective Alternatives*
    ALA-SCALP HP lotionNo longer coveredHYDROCORTISONE lotion
    Alkindi Sprinkle CapsuleNo longer coveredHydrocortisone Tablet
    Antara CapsuleNo longer coveredFenofibrate Tablet Generic
    Astagraf Xl CapsuleNo longer coveredTacrolimus Capsule
    AvarNo longer coveredTretinoin Gel
    Avar LsNo longer coveredTretinoin Gel
    Avar-ENo longer coveredTretinoin Gel
    Avar-E Ls CreamNo longer coveredTretinoin Gel
    BANZEL tablet and oral suspensionNo longer coveredRUFINAMIDE tablet and oral suspension
    Benzepro ToweletteNo longer coveredBenzoyl Peroxide Gel
    Beser LotionNo longer coveredFluticasone Cream
    Betamethasone ValerateNo longer coveredBetamethasone Valerate Cream
    BPO ToweletteNo longer coveredBenzoyl Peroxide Gel
    Bupropion Xl BrandNo longer coveredBupropion Generic
    Citalopram Capsule BrandNo longer coveredCitalopram Tablet
    Clenia PlusNo longer coveredTretinoin Gel
    Clobetasol Emulsion FoamNo longer coveredClobetasol Cream
    Clobetasol Propionate FoamNo longer coveredClobetasol Cream
    Conzip CapsuleNo longer coveredTramadol Tablet Generic
    CUVPOSA oral solutionNo longer coveredGLYCOPYRROLATE oral solution
    CYMBALTA capsuleNo longer coveredDULOXETINE capsule
    CYSTADANE powederNo longer coveredBETAINE powder
    Dexlansoprazole Dr Capsule BrandNo longer coveredLansoprazole Capsule
    Diclofenac Potassium CapsuleNo longer coveredDiclofenac Sodium Tablet
    Diclofenac Potassium TabletNo longer coveredDiclofenac Sodium Tablet
    Doxycycline Hyclate TabletNo longer coveredDoxycycline Monohydrate Tablet
    Edluar Sublingual TabletNo longer coveredZolpidem Tablet
    EFFEXOR XR capsuleNo longer coveredVENLAFAXINE ER capsule
    Envarsus Xr TabletNo longer coveredTacrolimus Capsule
    Fenofibrate Capsule BrandNo longer coveredFenofibrate Tablet Generic
    FERAHEMENo longer coveredFERUMOXYTOL
    Fleqsuvy Oral SuspensionNo longer coveredBaclofen Tablet
    Fluticasone Propionate LotionNo longer coveredFluticasone Cream
    Halcinonide CreamNo longer coveredBetamethasone Valerate Cream
    Hydrocortisone Butyrate LotionNo longer coveredHydrocortisone Cream
    Hydrocortisone LotionNo longer coveredHydrocortisone Cream
    Incruse ElliptaNo longer coveredSpiriva Respimat Inhaler
    Ketodan FoamNo longer coveredKetoconazole Cream
    KLONOPIN tabletNo longer coveredCLONAZEPAM tablet
    Levothyroxine CapsuleNo longer coveredLevothyroxine Tablet
    Lipofen CapsuleNo longer coveredFenofibrate Tablet Generic
    Lofena TabletNo longer coveredDiclofenac Sodium Tablet
    NORPACE capsuleNo longer coveredDISOPYRAMIDE capsule
    PlexionNo longer coveredTretinoin Gel
    PRISTIQ tabletNo longer coveredDESVENLAFAXINE tablet
    PROZAC capsuleNo longer coveredFLUOXETINE capsule
    PYRIDIUM tabletNo longer coveredPHENAZOPYRIDINE tablet
    ROSANIL cleanserNo longer coveredSULFACETAMIDE SODIUM/SULFUR cleanser
    RosulaNo longer coveredTretinoin Gel
    SABRIL tablet and powder packetNo longer coveredVIGABATRIN tablet and powder packet
    Samsca TabletNo longer coveredtolvaptan tablet
    SAPHRIS sublinicual tabletNo longer coveredASENAPINE sublingual tablet
    Selenium Sulfide 2.3% ShampooNo longer coveredSelenium Sulfide 2.25% Shampoo
    Selrx ShampooNo longer coveredSelenium Sulfide 2.25% Shampoo
    Sodium Sulfacetamide CleanserNo longer coveredSulfacetamide Sodium Topical Suspension
    Sodium Sulfacetamide/SulfurNo longer coveredTretinoin Gel
    Sss 10-5No longer coveredTretinoin Gel
    Sulfacetamide Sodium-SulfurNo longer coveredTretinoin Gel
    SumadanNo longer coveredTretinoin Gel
    SumaxinNo longer coveredTretinoin Gel
    Sumaxin CpNo longer coveredTretinoin Gel
    SUMAXIN medicated padsNo longer coveredSULFACETAMIDE SODIUM/SULFUR medicated pads
    Sumaxin TsNo longer coveredTretinoin Gel
    Tavaborole SolutionNo longer coveredCiclopirox Solution
    Tazarotene FoamNo longer coveredTazarotene Cream
    Tovet Emollient FoamNo longer coveredClobetasol Cream
    Tramadol Er CapsuleNo longer coveredTramadol Tablet Generic
    Tramadol Tablet BrandNo longer coveredTramadol Tablet Generic
    Zolmitriptan Nasal SprayNo longer coveredZolmitriptan Odt Tablet
    Zyflo TabletNo longer coveredZileuton Er Tablet

    Formulary Changes to the E4 Drug List

    Drug Name Description of Change Cost-effective Alternatives*
    ALA-SCALP HP lotionNo longer coveredHYDROCORTISONE lotion
    Alkindi Sprinkle CapsuleNo longer coveredHydrocortisone Tablet
    Antara CapsuleNo longer coveredFenofibrate Tablet Generic
    Astagraf Xl CapsuleNo longer coveredTacrolimus Capsule
    AvarNo longer coveredTretinoin Gel
    Avar LsNo longer coveredTretinoin Gel
    Avar-ENo longer coveredTretinoin Gel
    Avar-E Ls CreamNo longer coveredTretinoin Gel
    BANZEL tablet and oral suspensionNo longer coveredRUFINAMIDE tablet and oral suspension
    Benzepro ToweletteNo longer coveredBenzoyl Peroxide Gel
    Beser LotionNo longer coveredFluticasone Cream
    Betamethasone ValerateNo longer coveredBetamethasone Valerate Cream
    BPO ToweletteNo longer coveredBenzoyl Peroxide Gel
    Bupropion Xl BrandNo longer coveredBupropion Generic
    Citalopram Capsule BrandNo longer coveredCitalopram Tablet
    Clenia PlusNo longer coveredTretinoin Gel
    Clobetasol Emulsion FoamNo longer coveredClobetasol Cream
    Clobetasol Propionate FoamNo longer coveredClobetasol Cream
    Conzip CapsuleNo longer coveredTramadol Tablet Generic
    CUVPOSA oral solutionNo longer coveredGLYCOPYRROLATE oral solution
    CYMBALTA capsuleNo longer coveredDULOXETINE capsule
    CYSTADANE powederNo longer coveredBETAINE powder
    Dexlansoprazole Dr Capsule BrandNo longer coveredLansoprazole Capsule
    Diclofenac Potassium CapsuleNo longer coveredDiclofenac Sodium Tablet
    Diclofenac Potassium TabletNo longer coveredDiclofenac Sodium Tablet
    Doxycycline Hyclate TabletNo longer coveredDoxycycline Monohydrate Tablet
    Edluar Sublingual TabletNo longer coveredZolpidem Tablet
    EFFEXOR XR capsuleNo longer coveredVENLAFAXINE ER capsule
    Envarsus Xr TabletNo longer coveredTacrolimus Capsule
    Esbriet tablet 267 mg & 801 mgMoving To Tier 4pirfenidone tablet 267 mg and 801 mg
    Fenofibrate Capsule BrandNo longer coveredFenofibrate Tablet Generic
    FERAHEMENo longer coveredFERUMOXYTOL
    Fleqsuvy Oral SuspensionNo longer coveredBaclofen Tablet
    Fluticasone Propionate LotionNo longer coveredFluticasone Cream
    Halcinonide CreamNo longer coveredBetamethasone Valerate Cream
    Hydrocortisone Butyrate LotionNo longer coveredHydrocortisone Cream
    Hydrocortisone LotionNo longer coveredHydrocortisone Cream
    Incruse ElliptaNo longer coveredSpiriva Respimat Inhaler
    Ketodan FoamNo longer coveredKetoconazole Cream
    KLONOPIN tabletNo longer coveredCLONAZEPAM tablet
    Levothyroxine CapsuleNo longer coveredLevothyroxine Tablet
    Lipofen CapsuleNo longer coveredFenofibrate Tablet Generic
    Lofena TabletNo longer coveredDiclofenac Sodium Tablet
    NORPACE capsuleNo longer coveredDISOPYRAMIDE capsule
    Omeclamox-Pakmoving to Tier 4Lansoprazole-Amoxicilin-Clarithromycin Combo Pack
    Ketodan FoamNo longer coveredKetoconazole Cream
    PlexionNo longer coveredTretinoin Gel
    PRISTIQ tabletNo longer coveredDESVENLAFAXINE tablet
    PROZAC capsuleNo longer coveredFLUOXETINE capsule
    PYRIDIUM tabletNo longer coveredPHENAZOPYRIDINE tablet
    ROSANIL cleanserNo longer coveredSULFACETAMIDE SODIUM/SULFUR cleanser
    RosulaNo longer coveredTretinoin Gel
    SABRIL tablet and powder packetNo longer coveredVIGABATRIN tablet and powder packet
    Samsca TabletNo longer coveredtolvaptan tablet
    SAPHRIS sublinicual tabletNo longer coveredASENAPINE sublingual tablet
    Selenium Sulfide 2.3% ShampooNo longer coveredSelenium Sulfide 2.25% Shampoo
    Selrx ShampooNo longer coveredSelenium Sulfide 2.25% Shampoo
    Sodium Sulfacetamide CleanserNo longer coveredSulfacetamide Sodium Topical Suspension
    Sodium Sulfacetamide/SulfurNo longer coveredTretinoin Gel
    Sss 10-5No longer coveredTretinoin Gel
    Sulfacetamide Sodium-SulfurNo longer coveredTretinoin Gel
    SumadanNo longer coveredTretinoin Gel
    SumaxinNo longer coveredTretinoin Gel
    Sumaxin CpNo longer coveredTretinoin Gel
    SUMAXIN medicated padsNo longer coveredSULFACETAMIDE SODIUM/SULFUR medicated pads
    Sumaxin TsNo longer coveredTretinoin Gel
    Targretin gelMoving To Tier 4bexarotene gel
    Tavaborole SolutionNo longer coveredCiclopirox Solution
    Tazarotene FoamNo longer coveredTazarotene Cream
    Tovet Emollient FoamNo longer coveredClobetasol Cream
    Tramadol Er CapsuleNo longer coveredTramadol Tablet Generic
    Tramadol Tablet BrandNo longer coveredTramadol Tablet Generic
    Zolmitriptan Nasal SprayNo longer coveredZolmitriptan Odt Tablet
    Zyflo TabletNo longer coveredZileuton Er Tablet

    Formulary Changes to the M1 and M2 Drug Lists

    Drug Name Description of Change Cost-effective Alternatives*
    Beser LotionNo longer coveredFluticasone Cream
    Betamethasone ValerateNo longer coveredBetamethasone Valerate Cream
    BPO ToweletteNo longer coveredBenzoyl Peroxide Gel
    Clobetasol Emulsion FoamNo longer coveredClobetasol Cream
    Clobetasol Propionate FoamNo longer coveredClobetasol Cream
    Dapsone Gel and Dapsone Gel with PumpNo longer coveredTretinoin Gel
    Deferiprone tablet (only applicable to M2)Moving to Tier 2Consult doctor
    Diflorasone cream and ointmentNo longer coveredBetamethasone Valerate Cream
    Doxycycline Hyclate TabletNo longer coveredDoxycycline Monohydrate Tablet
    Edular sublingual tabletNo longer coveredZolpidem Tablet
    Esbriet tablet 267 mg & 801 mgNo longer coveredpirfenidone tablet 267 mg and 801 mg
    Ferriprox tabletNo longer coveredDeferiprone tablet
    Flurandrenolide lotionNo longer coveredFlurandrenolide cream
    Fluticasone Propionate LotionNo longer coveredFluticasone Cream
    Halcinonide CreamNo longer coveredBetamethasone Valerate Cream
    Hydrocortisone LotionNo longer coveredHydrocortisone Cream
    Incruse ElliptaNo longer coveredSpiriva Respimat Inhaler
    Ketoconazole FoamNo longer coveredKetoconazole Cream
    Ketodan FoamNo longer coveredKetoconazole Cream
    Menostar patchNo longer coveredEstradiol patch
    Nexavar tabletNo longer coveredsorafenib tablet
    Relexxii tabletNo longer coveredmethylphenidate ER capsule or tablet
    Samsca TabletNo longer coveredtolvaptan tablet
    Scalacort lotionNo longer coveredHydrocortisone Cream
    Selenium Sulfide 2.3% ShampooNo longer coveredSelenium Sulfide 2.25% Shampoo
    Targretin gelNo longer coveredbexarotene gel
    Toviaz tabletNo longer coveredfesoterodine tablet
    Triamcinolone acetonide ointmentNo longer coveredTriamcinolone acetonide cream
    Vimpat oral solutionNo longer coveredlacosamide oral solution
    Zyflo TabletNo longer coveredZileuton Er Tablet

    Formulary Changes to the M4 Drug List

    Drug Name Description of Change Cost-effective Alternatives*
    Acyclovir creammoving to Tier 3Acyclovir tablet
    Asmanex inhaler & Asmanex HFA inhalermoving to Tier 3Flovent HFA inhaler
    Beser LotionNo longer coveredFluticasone Cream
    Betamethasone ValerateNo longer coveredBetamethasone Valerate Cream
    BPO ToweletteNo longer coveredBenzoyl Peroxide Gel
    Clobetasol Emulsion FoamNo longer coveredClobetasol Cream
    Clobetasol Propionate FoamNo longer coveredClobetasol Cream
    Clocortolone CreamMoving To Tier 3Fluocinolone Cream
    Dapsone Gel and Dapsone Gel with PumpNo longer coveredTretinoin Gel
    Deferiprone tabletMoving to Tier 4Consult doctor
    Diflorasone cream and ointmentNo longer coveredBetamethasone Valerate Cream
    Dovato tabletmoving to Tier 3Consult doctor
    Doxycycline Hyclate TabletNo longer coveredDoxycycline Monohydrate Tablet
    Dutasteride-Tamsulosin capsulemoving to Tier 3tamsulosin capsule
    Edular sublingual tabletNo longer coveredZolpidem Tablet
    Esbriet tablet 267 mg & 801 mgNo longer coveredpirfenidone tablet 267 mg and 801 mg
    Ferriprox tabletNo longer coveredDeferiprone tablet
    Flurandrenolide lotionNo longer coveredFlurandrenolide cream
    Fluticasone Propionate LotionNo longer coveredFluticasone Cream
    Genvoya tabletmoving to Tier 3Consult doctor
    Halcinonide CreamNo longer coveredBetamethasone Valerate Cream
    Hydrocortisone LotionNo longer coveredHydrocortisone Cream
    Incruse ElliptaNo longer coveredSpiriva Respimat Inhaler
    Ketoconazole FoamNo longer coveredKetoconazole Cream
    Ketodan FoamNo longer coveredKetoconazole Cream
    Menostar patchNo longer coveredEstradiol patch
    Mesalamine enteric coated tabletmoving to Tier 3Mesalamine enteric coated capsule
    Nexavar tabletNo longer coveredsorafenib tablet
    Odefsey tabletmoving to Tier 3Consult doctor
    Ofloxacin tabletmoving to Tier 3Ciprofloxacin tablet
    Oxycodone-Acetaminophen 2.5-300 Mgmoving to Tier 3Oxycodone W/Acetaminophen 2.5-325 Mg
    Paliperidone ER tabletmoving to Tier 3Olanzapine tablet
    Prezcobix tabletmoving to Tier 3Consult doctor
    Relexxii tabletNo longer coveredmethylphenidate ER capsule or tablet
    Samsca TabletNo longer coveredtolvaptan tablet
    Scalacort lotionNo longer coveredHydrocortisone Cream
    Selenium Sulfide 2.3% ShampooNo longer coveredSelenium Sulfide 2.25% Shampoo
    Targretin gelNo longer coveredbexarotene gel
    Toviaz tabletNo longer coveredfesoterodine tablet
    Triamcinolone acetonide ointmentNo longer coveredTriamcinolone acetonide cream
    Triumeq tabletmoving to Tier 3Consult doctor
    Vimpat oral solutionNo longer coveredlacosamide oral solution
    Zyflo TabletNo longer coveredZileuton 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.