Drug List Changes

Effective October 01, 2019

Formulary Changes to the Preferred B2 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Analpram-HC 2.5%-1% cream	No longer covered	hydrocortisone/pramoxine cream
Colyte oral solution	No longer covered	polyethylene glycol 3350 electrolyte oral solution
Copaxone syringe	No longer covered	glatiramer syringe
Cuprimine capsule	No longer covered	penicillamine capsule
Delzicol delayed-release capsule	No longer covered	mesalamine delayed-release capsule
Derma-Smoothe-FS oil	No longer covered	fluocinolone acetonide oil
Exjade tablet for oral suspension	No longer covered	deferasirox tablet for oral suspension
Letairis tablet	No longer covered	ambrisentan tablet
Micardis tablet	No longer covered	telmisartan tablet
Quartette tablet	No longer covered	levonorgestrel/ethinyl estradiol tablet
Safyral tablet	No longer covered	drospirenone/ethinyl estradiol/levomefolate tablet
Tarceva tablet	No longer covered	erlotinib tablet
Tracleer tablet	No longer covered	bosentan tablet
Vesicare tablet	No longer covered	solifenacin tablet
Victoza [Change Effective November 1, 2019]	No longer covered	Bydureon, Byetta, Ozempic, or Trulicity

Formulary Changes to the Preferred B3 and B4 Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Analpram-HC 2.5%-1% cream	Moving to a higher level	hydrocortisone/pramoxine cream
Colyte oral solution	Moving to a higher level	polyethylene glycol 3350 electrolyte oral solution
Copaxone syringe	Moving to a higher level	glatiramer syringe
Cuprimine capsule	Moving to a higher level	penicillamine capsule
Delzicol delayed-release capsule	Moving to a higher level	mesalamine delayed-release capsule
Derma-Smoothe-FS oil	Moving to a higher level	fluocinolone acetonide oil
Exjade tablet for oral suspension	Moving to a higher level	deferasirox tablet for oral suspension
Letairis tablet	Moving to a higher level	ambrisentan tablet
Micardis tablet	Moving to a higher level	telmisartan tablet
Quartette tablet	Moving to a higher level	levonorgestrel/ethinyl estradiol tablet
Safyral tablet	Moving to a higher level	drospirenone/ethinyl estradiol/levomefolate tablet
Tarceva tablet	Moving to a higher level	erlotinib tablet
Tracleer tablet	Moving to a higher level	bosentan tablet
Vesicare tablet	Moving to a higher level	solifenacin tablet
Victoza [Change Effective November 1, 2019]	Moving to a higher level	Bydureon, Byetta, Ozempic, or Trulicity

Formulary Changes to the E4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Cuprimine capsule	Moving to a higher level	penicillamine capsule
Letairis tablet	Moving to a higher level	ambrisentan tablet
Revatio suspension	Moving to a higher level	sildenafil suspension
Tarceva tablet	Moving to a higher level	erlotinib tablet
Tracleer tablet	Moving to a higher level	bosentan tablet
Victoza [Change Effective November 1, 2019]	Moving to a higher level	Bydureon, Byetta, Ozempic, or Trulicity

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

Drug Name	Description of Change	Cost-effective Alternatives*
Cialis tablet	No longer covered	tadalafil tablet
Cuprimine capsule	No longer covered	penicillamine capsule
Diclegis delayed-release tablet	No longer covered	doxylamine/pyridoxine delayed-release tablet
Ertaczo cream	No longer covered	econazole cream
Exjade tablet for oral suspension	No longer covered	deferasirox tablet for oral suspension
Extavia kit	No longer covered	Betaseron kit
Flarex eye drops	No longer covered	prednisolone eye drops
Halog ointment	No longer covered	betamethasone ointment
Kineret injection	No longer covered	Consult Doctor
Letairis tablet	No longer covered	ambrisentan tablet
Livalo tablet	No longer covered	atorvastatin tablet
Lotemax eye drops	No longer covered	loteprednol eye drops
Oracea capsule	No longer covered	doxycycline capsule
Pradaxa capsule	No longer covered	Consult Doctor
Quartette tablet	No longer covered	levonorgestrel/ethinyl estradiol tablet
Safyral tablet	No longer covered	drospirenone/ethinyl estradiol/levomefolate tablet
sumatriptan/naproxen tablet	No longer covered	sumatriptan tablet
Revatio suspension	No longer covered	sildenafil suspension
Suprax capsule	No longer covered	cefixime capsule
Tarceva tablet	No longer covered	erlotinib tablet
Tracleer tablet	No longer covered	bosentan tablet
Uloric tablet	No longer covered	febuxostat tablet
Vesicare tablet	No longer covered	solifenacin tablet
Xopenex HFA inhaler	No longer covered	levalbuterol HFA inhaler
Zioptan eye drops	No longer covered	latanoprost eye drops
Zyclara cream pump	No longer covered	imiquimod cream

Formulary Changes to the M4 (2019) Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Atripla tablet	Moving to a higher level	Consult Doctor
Chlorzoxazone 250 mg tablet	Moving to a higher level	chlorzoxazone 500 mg tablet
Chlorzoxazone 375 mg tablet	Moving to a higher level	chlorzoxazone 500 mg tablet
Chlorzoxazone 750 mg tablet	Moving to a higher level	chlorzoxazone 500 mg tablet
Ciclopirox 8% solution	Moving to a higher level	Consult Doctor
Edurant tablet	Moving to a higher level	Consult Doctor
Kaletra tablet	Moving to a higher level	Consult Doctor
Victoza [Change Effective November 1, 2019]	Moving to a higher level	Bydureon, Byetta, Ozempic, or Trulicity

Formulary Changes to the M1, M2 and M4 (2018) Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Cialis tablet	No longer covered	tadalafil tablet
Cuprimine capsule	No longer covered	penicillamine capsule
Delzicol delayed-release capsule	No longer covered	mesalamine delayed-release capsule
Diclegis delayed-release tablet	No longer covered	doxylamine/pyridoxine delayed-release tablet
Ertaczo cream	No longer covered	econazole cream
Exjade tablet for oral suspension	No longer covered	deferasirox tablet for oral suspension
Extavia kit	No longer covered	Betaseron kit
Flarex eye drops	No longer covered	prednisolone eye drops
Halog ointment	No longer covered	betamethasone ointment
Kineret injection	No longer covered	Consult Doctor
Letairis tablet	No longer covered	ambrisentan tablet
Livalo tablet	No longer covered	atorvastatin tablet
Lotemax eye drops	No longer covered	loteprednol eye drops
Oracea capsule	No longer covered	doxycycline capsule
Pradaxa capsule	No longer covered	Consult Doctor
Quartette tablet	No longer covered	levonorgestrel/ethinyl estradiol tablet
Safyral tablet	No longer covered	drospirenone/ethinyl estradiol/levomefolate tablet
sumatriptan/naproxen tablet	No longer covered	sumatriptan tablet
Revatio suspension	No longer covered	sildenafil suspension
Suprax capsule	No longer covered	cefixime capsule
Tarceva tablet	No longer covered	erlotinib tablet
Tracleer tablet	No longer covered	bosentan tablet
Uloric tablet	No longer covered	febuxostat tablet
Vesicare tablet	No longer covered	solifenacin tablet
Xopenex HFA inhaler	No longer covered	levalbuterol HFA inhaler
Zioptan eye drops	No longer covered	latanoprost eye drops
Zyclara cream pump	No longer covered	imiquimod cream

Formulary Changes to the M4 (2018) Drug Lists

Drug Name	Description of Change	Cost-effective Alternatives*
Atripla tablet	Moving to a higher level	Consult Doctor
Chlorzoxazone 250 mg tablet	Moving to a higher level	chlorzoxazone 500 mg tablet
Chlorzoxazone 375 mg tablet	Moving to a higher level	chlorzoxazone 500 mg tablet
Chlorzoxazone 750 mg tablet	Moving to a higher level	chlorzoxazone 500 mg tablet
Ciclopirox 8% solution	Moving to a higher level	Consult Doctor
Edurant tablet	Moving to a higher level	Consult Doctor
Kaletra tablet	Moving to a higher level	Consult Doctor
Victoza [Change Effective November 1, 2019]	Moving to a higher level	Bydureon, Byetta, Ozempic, Trulicity

Formulary Changes to the Select C4 Drug List

Drug Name	Description of Change	Cost-effective Alternatives*
Tarceva tablet	Moving to a higher level	erlotinib tablet
Victoza [Change Effective November 1, 2019]	Moving to a higher level	Bydureon, Byetta, Ozempic, or Trulicity

*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.