Drug List Changes

Effective April 01, 2020

Formulary Changes to the Preferred B2 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Restasis Multidose eye drops	No longer covered	Restasis eye drops
Sandostatin LAR Depot injection	No longer covered	Somatuline Depot injection

Formulary Changes to the Preferred B3 and B4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Bethkis inhalation solution	Moving to a higher level	tobramycin inhalation solution
Extavia injection	Moving to a higher level	Betaseron injection
Restasis Multidose eye drops	Moving to a higher level	Restasis eye drops
Sandostatin LAR Depot injection	Moving to a higher level	Somatuline Depot injection
Tobi inhalation solution	Moving to a higher level	tobramycin inhalation solution
Tobi Podhaler inhalation powder	Moving to a higher level	tobramycin inhalation solution

Formulary Changes to the E1 and E4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Apriso extended-release capsule	Moving to a higher level	mesalamine extended-release capsule
Bethkis inhalation solution	Moving to a higher level	tobramycin inhalation solution
Extavia injection	Moving to a higher level	Betaseron injection
Sandostatin LAR Depot injection	Moving to a higher level	Somatuline Depot injection

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

Drug Name	Description of Change	Cost-effective Alternatives*
Apriso extended-release capsule	No longer covered	mesalamine extended-release capsule
Aubagio tablet	No longer covered	Consult doctor
Bethkis inhalation solution	No longer covered	tobramycin inhalation solution
Ingrezza capsule	No longer covered	Austedo tablet or tetrabenazine tablet
Naftin 1% gel	No longer covered	naftifine 1% gel
Restasis Multidose eye drops	No longer covered	Restasis eye drops
Sandostatin LAR Depot injection	No longer covered	Somatuline Depot injection
Signifor LAR injection	No longer covered	Somatuline Depot injection
Tobi Podhaler inhalation powder	No longer covered	tobramycin inhalation solution

*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.