Drug List Changes

Effective July 01, 2017

Formulary Changes to the Preferred B2 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Adderall tablet	No longer covered	amphetamine/dextroamphetamine tablet
Bupap tablet	No longer covered	butalbital/acetaminophen tablet
Copaxone 20 mg/ml syringe	No longer covered	Glatopa 20mg/ml syringe
Millipred solution	No longer covered	prednisolone sodium phosphate solution
Tazorac 0.1% cream	No longer covered	tazarotene 0.1% cream

Formulary Changes to the Preferred B3 and B4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Adderall tablet	Moving to a higher level	amphetamine/dextroamphetamine tablet
Bupap tablet	Moving to a higher level	butalbital/acetaminophen tablet
Copaxone 20 mg/ml syringe	Moving to a higher level	Glatopa 20mg/ml syringe
Millipred solution	Moving to a higher level	prednisolone sodium phosphate solution
Tazorac 0.1% cream	Moving to a higher level	tazarotene 0.1% cream

Formulary Changes to the E1 and E4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Millipred solution	Moving to a higher level	prednisolone sodium phosphate solution
Minastrin 24 FE tablet	Moving to a higher level	norethindrone/ethinyl estradiol tablet

Formulary Changes to the X1, X3 and X4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Copaxone 20 mg/ml syringe	No longer covered	Glatopa 20mg/ml syringe
Millipred solution	No longer covered	prednisolone sodium phosphate solution
Minastrin 24 FE tablet	No longer covered	norethindrone/ethinyl estradiol tablet
Pristiq tablet	No longer covered	desvenlafaxine tablet
Ritalin LA capsule	No longer covered	methylphenidate extended-release capsule
Tazorac 0.1% cream	No longer covered	tazarotene 0.1% cream
Zyflo CR tablet	No longer covered	zileuton extended-release tablet

Formulary Changes to the M1, M2 and M4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Copaxone 20 mg/ml syringe	No longer covered	Glatopa 20mg/ml syringe
Millipred solution	No longer covered	prednisolone sodium phosphate solution
Minastrin 24 FE tablet	No longer covered	norethindrone/ethinyl estradiol tablet
Pristiq tablet	No longer covered	desvenlafaxine tablet
Ritalin LA capsule	No longer covered	methylphenidate extended-release capsule
Tazorac 0.1% cream	No longer covered	tazarotene 0.1% cream
Zyflo CR tablet	No longer covered	zileuton extended-release tablet

Formulary Changes to the Value-Based V1 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Millipred solution	Moving to a higher level	prednisolone sodium phosphate solution
Minastrin 24 FE tablet	Moving to a higher level	norethindrone/ethinyl estradiol tablet
Pristiq tablet	Moving to a higher level	desvenlafaxine tablet
Ritalin LA capsule	Moving to a higher level	methylphenidate extended-release capsule
Tazorac 0.1% cream	Moving to a higher level	tazarotene 0.1% cream
Zyflo CR tablet	Moving to a higher level	zileuton extended-release 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.