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Drug Changes

Here you will find a listing of the drugs that have been changed on our drug list (formulary) for the indicated plan year.


Amicar Tablet 1000 MG Oral


Post Date:
2/15/2021
Effective Date:
2/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Aminocaproic Acid Tablet 1000 MG Oral Tier 1 Hemostatics - Systemic
* Please reference your Evidence of Coverage for applicable cost-sharing.

Amicar Tablet 500 MG Oral


Post Date:
2/15/2021
Effective Date:
2/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Apriso Capsule Extended Release 24 Hour 0.375 GM Oral


Post Date:
2/15/2021
Effective Date:
2/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Atripla Tablet 600-200-300 MG Oral


Post Date:
2/15/2021
Effective Date:
2/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Carafate Suspension 1 GM/10ML Oral


Post Date:
2/15/2021
Effective Date:
2/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Ciprodex Suspension 0.3-0.1 % Otic


Post Date:
2/15/2021
Effective Date:
2/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Samsca Tablet 15 MG Oral


Post Date:
2/15/2021
Effective Date:
2/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Samsca Tablet 30 MG Oral


Post Date:
2/15/2021
Effective Date:
2/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Emtriva Capsule 200 MG Oral


Post Date:
2/15/2021
Effective Date:
2/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Symfi Lo Tablet 400-300-300 MG Oral


Post Date:
2/15/2021
Effective Date:
2/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Symfi Tablet 600-300-300 MG Oral


Post Date:
2/15/2021
Effective Date:
2/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Truvada Tablet 200-300 MG Oral


Post Date:
2/15/2021
Effective Date:
2/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Kuvan Packet 100 MG Oral


Post Date:
2/15/2021
Effective Date:
2/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Kuvan Packet 500 MG Oral


Post Date:
2/15/2021
Effective Date:
2/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Kuvan Tablet Soluble 100 MG Oral


Post Date:
2/15/2021
Effective Date:
2/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Invokamet TABLET 150-1000 MG ORAL


Post Date:
7/15/2021
Effective Date:
7/15/2021
Type of Change:
Utilization management added
Reason Changed:
Prior authorization is required

Invokamet TABLET 150-500 MG ORAL


Post Date:
7/15/2021
Effective Date:
7/15/2021
Type of Change:
Utilization management added
Reason Changed:
Prior authorization is required

Invokamet TABLET 50-1000 MG ORAL


Post Date:
7/15/2021
Effective Date:
7/15/2021
Type of Change:
Utilization management added
Reason Changed:
Prior authorization is required

Invokamet TABLET 50-500 MG ORAL


Post Date:
7/15/2021
Effective Date:
7/15/2021
Type of Change:
Utilization management added
Reason Changed:
Prior authorization is required

Invokamet XR Tablet Extended Release 24 Hour 150-1000 MG Oral


Post Date:
7/15/2021
Effective Date:
7/15/2021
Type of Change:
Utilization management added
Reason Changed:
Prior authorization is required

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Segluromet Tablet 7.5-1000 MG Oral Tier 2 QL, ST Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb
* Please reference your Evidence of Coverage for applicable cost-sharing.

Invokamet XR Tablet Extended Release 24 Hour 150-500 MG Oral


Post Date:
7/15/2021
Effective Date:
7/15/2021
Type of Change:
Utilization management added
Reason Changed:
Prior authorization is required

Invokamet XR Tablet Extended Release 24 Hour 50-1000 MG Oral


Post Date:
7/15/2021
Effective Date:
7/15/2021
Type of Change:
Utilization management added
Reason Changed:
Prior authorization is required

Invokamet XR Tablet Extended Release 24 Hour 50-500 MG Oral


Post Date:
7/15/2021
Effective Date:
7/15/2021
Type of Change:
Utilization management added
Reason Changed:
Prior authorization is required

Arcalyst Solution Reconstituted 220 MG Subcutaneous


Post Date:
7/15/2021
Effective Date:
7/15/2021
Type of Change:
Utilization management added
Reason Changed:
Quantity limit updated

Banzel Suspension 40 MG/ML Oral


Post Date:
7/15/2021
Effective Date:
7/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Biktarvy Tablet 50-200-25 MG Oral


Post Date:
7/13/2021
Effective Date:
7/15/2021
Type of Change:
Utilization management added
Reason Changed:
Quantity limit updated

Proventil HFA Aerosol Solution 108 (90 Base) MCG/ACT Inhalation


Post Date:
7/13/2021
Effective Date:
7/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Ventolin HFA Aerosol Solution 108 (90 Base) MCG/ACT Inhalation


Post Date:
7/13/2021
Effective Date:
7/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Febuxostat Tablet 40 MG Oral


Post Date:
7/13/2021
Effective Date:
7/15/2021
Type of Change:
Utilization management added
Reason Changed:
Quantity limit updated

Febuxostat Tablet 80 MG Oral


Post Date:
7/13/2021
Effective Date:
7/15/2021
Type of Change:
Utilization management added
Reason Changed:
Quantity limit updated

Ferriprox Tablet 500 MG Oral


Post Date:
7/13/2021
Effective Date:
7/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Brovana Nebulization Solution 15 MCG/2ML Inhalation


Post Date:
10/13/2021
Effective Date:
10/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Intelence Tablet 100 MG Oral


Post Date:
10/13/2021
Effective Date:
10/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Intelence Tablet 200 MG Oral


Post Date:
10/13/2021
Effective Date:
10/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Ivermectin TABLET 3 MG ORAL


Post Date:
10/13/2021
Effective Date:
10/15/2021
Type of Change:
Utilization management added
Reason Changed:
Prior authorization is required

Kaletra Tablet 100-25 MG Oral


Post Date:
10/13/2021
Effective Date:
10/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Kaletra Tablet 200-50 MG Oral


Post Date:
10/13/2021
Effective Date:
10/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Truvada Tablet 100-150 MG Oral


Post Date:
10/13/2021
Effective Date:
10/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Truvada Tablet 133-200 MG Oral


Post Date:
10/13/2021
Effective Date:
10/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Truvada Tablet 167-250 MG Oral


Post Date:
10/13/2021
Effective Date:
10/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Alinia Tablet 500 MG Oral


Post Date:
10/13/2021
Effective Date:
10/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Alternative Drugs


Drug Tier* Drug Restrictions Therapy Class
Nitazoxanide Tablet 500 MG Oral Tier 1 QL Antiprotozoal Agents
* Please reference your Evidence of Coverage for applicable cost-sharing.

NovoLOG Mix 70/30 FlexPen Suspension Pen-Injector (70-30) 100 UNIT/ML Subcutaneous


Post Date:
10/13/2021
Effective Date:
10/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

NovoLOG Mix 70/30 Suspension (70-30) 100 UNIT/ML Subcutaneous


Post Date:
10/13/2021
Effective Date:
10/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Banzel Tablet 200 MG Oral


Post Date:
10/13/2021
Effective Date:
10/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Banzel Tablet 400 MG Oral


Post Date:
10/13/2021
Effective Date:
10/15/2021
Type of Change:
Drug removed
Reason Changed:
Generic therapeutically equivalent product available

Potassium Chloride Packet 20 MEQ Oral


Post Date:
10/13/2021
Effective Date:
10/15/2021
Type of Change:
Drug removed
Reason Changed:
High cost medication with alternative lower cost medications available

Potassium Chloride Solution 40 MEQ/15ML (20%) Oral


Post Date:
10/13/2021
Effective Date:
10/15/2021
Type of Change:
Drug removed
Reason Changed:
High cost medication with alternative lower cost medications available


There are currently no changes for 2022