Drug List Changes

Effective October 01, 2018

Formulary Changes to the Preferred B2 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Mephyton 5mg tablet	No longer covered	phytonadione 5mg tablet

Formulary Changes to the Preferred B3 and B4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Mephyton 5mg tablet	Moving to a higher level	phytonadione 5mg tablet

Formulary Changes to the E4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Mephyton 5mg tablet	Moving to a higher level	phytonadione 5mg tablet

Formulary Changes to the M1, M2 and M4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Biltricide tablet	No longer covered	praziquantel tablet
DermacinRx Lexitral PharmaPak solution	No longer covered	diclofenac 1.5% solution
Lido-K 3% lotion	No longer covered	lidocaine 3% cream
Lidopril 2.5%-2.5% cream	No longer covered	lidocaine 2.5%/prilocaine 2.5% cream
LidoRx 3% gel	No longer covered	lidocaine 3% cream
Lidozion 3% lotion	No longer covered	lidocaine 3% cream
Welchol tablet	No longer covered	colesevelam tablet
Zavesca capsule	No longer covered	miglustat capsule

Formulary Changes to the Value-Based V1 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Biltricide tablet	Moving to a higher level	praziquantel tablet
Mephyton 5mg tablet	Moving to a higher level	phytonadione 5mg tablet
Welchol tablet	Moving to a higher level	colesevelam 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.