Drug List Changes

  • Effective January 01, 2022

    Formulary Changes to the E1 Drug List

    Drug Name Description of Change Cost-effective Alternatives*
    Alinia TabletsNo longer coverednitazoxanide tablet
    AlrexNo longer coveredazelastine drops; olopatadine drops
    AzoptNo longer coveredbrinzolamide eye drops
    BepreveNo longer coveredbepotastine eye drops
    BynfeziaNo longer coveredoctreotide injection
    Calcipotriene FoamNo longer coveredcalcipotriene cream
    Cipro HCNo longer coveredciprofloxacin-dexamethasone ear drops
    Ciprofloxacin/Fluocinolone Otic (Brand)No longer coveredciprofloxacin-dexamethasone ear drops
    clemastine syrup No longer coveredcetirizine
    InvokametNo longer coveredSynjardy, Synjardy XR, Xigduo XR
    Invokamet XRNo longer coveredSynjardy, Synjardy XR, Xigduo XR
    InvokanaNo longer coveredFarxiga, Jardiance
    OtovelNo longer coveredciprofloxacin-dexamethasone ear drops
    Tizanidine capsulesNo longer coveredtizanidine tablet
    Zanaflex capsuleNo longer coveredtizanidine tablet
    ZerviateNo longer coveredazelastine drops; olopatadine drops

    Formulary Changes to the E4 Drug List

    Drug Name Description of Change Cost-effective Alternatives*
    Alinia TabletsNo longer coverednitazoxanide tablet
    Alphagan P 0.1%Moving to Tier 4brimonidine 0.15% eye drops
    AlrexNo longer coveredazelastine drops; olopatadine drops
    AzoptNo longer coveredbrinzolamide eye drops
    BepreveNo longer coveredbepotastine eye drops
    BynfeziaNo longer coveredoctreotide injection
    Calcipotriene FoamNo longer coveredcalcipotriene cream
    Cipro HCNo longer coveredciprofloxacin-dexamethasone ear drops
    Ciprofloxacin/Fluocinolone Otic (Brand)No longer coveredciprofloxacin-dexamethasone ear drops
    clemastine syrup No longer coveredcetirizine
    CombiganMoving to Tier 4betaxolol, brimonidine, levobunolol, or timolol drops
    DDAVP injectionMoving to Tier 3desmopressin injection
    Deferiprone tabletMoving to Tier 3consult prescriber
    Desmopressin injectionMoving to Tier 3consult prescriber
    Ferriprox tabletMoving to Tier 3deferiprone tablet
    Intelence tablet 100 mg & 200 mgMoving to Tier 4etravirine tablet 100 mg & 200 mg
    InvokametNo longer coveredSynjardy, Synjardy XR, Xigduo XR
    Invokamet XRNo longer coveredSynjardy, Synjardy XR, Xigduo XR
    InvokanaNo longer coveredFarxiga, Jardiance
    Kaletra tabletMoving to Tier 4lopinavir/ritonavir tablet
    Matulane capsuleMoving to Tier 3consult prescriber
    OtovelNo longer coveredciprofloxacin-dexamethasone ear drops
    Perforomist nebulizer vialMoving to Tier 4formoterol nebulizer vial
    Sucraid oral solutionMoving to Tier 3consult prescriber
    Sutent tabletMoving to Tier 4sunitinib tablet
    Testopel pelletsMoving to Tier 3testosterone cypionate injection
    Thyrogen vialMoving to Tier 3consult prescriber
    tizanidine capsulesNo longer coveredtizanidine tablet
    Xyrem oral solutionMoving to Tier 3consult prescriber
    Xywav oral solutionMoving to Tier 3consult prescriber
    Zanaflex capsuleNo longer coveredtizanidine tablet
    ZerviateNo longer coveredazelastine drops; olopatadine drops
    ZykadiaMoving to Tier 4consult prescriber

    *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.