July 2019 Formulary Drug Removals

Formulary Drug Removals

April 2020

Updated 03/01/2020

Below is a list of medicines by drug class that have been removed from your plan's formulary. If you continue using one of the drugs listed below and identified as a Formulary Drug Removal, you may be required to pay the full cost.

If you are currently using one of the formulary drug removals, ask your doctor to choose one of the generic or brand formulary options listed below.

Category Drug Class

Allergies Antihistamines

Allergies Nasal Steroids / Combinations

Anticonvulsants

Anti-infectives, Antibacterials Erythromycins / Macrolides Anti-infectives, Antibacterials Tetracyclines

Anti-infectives, Antibacterials Miscellaneous Anti-infectives, Antivirals Cytomegalovirus * Anti-infectives, Antivirals Hepatitis B * Anti-infectives, Antivirals Hepatitis C *

Anti-infectives, Antivirals Herpes * Antiobesity

Anxiety * Benzodiazepines Asthma * Beta Agonists, Short-Acting

Formulary Drug Removals

dexchlorpheniramine RyClora CARBINOXAMINE TABLET 6 MG

BECONASE AQ OMNARIS QNASL ZETONNA

LAMICTAL LAMICTAL ODT LAMICTAL XR ZONEGRAN

ONFI

SABRIL

E.E.S. GRANULES ERYPED

ACTICLATE DORYX DORYX MPC MINOCIN TARGADOX

MACRODANTIN

VALCYTE

BARACLUDE TABLET

MAVYRET

VIEKIRA PAK ZEPATIER

acyclovir cream VALTREX

CONTRAVE QSYMIA

XANAX XANAX XR

PROAIR HFA PROAIR RESPICLICK PROVENTIL HFA VENTOLIN HFA XOPENEX HFA

Formulary Options

levocetirizine

flunisolide spray, fluticasone spray, mometasone spray, DYMISTA

carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT clobazam, lamotrigine, topiramate, TROKENDI XR vigabatrin erythromycins

doxycycline hyclate, minocycline, tetracycline

nitrofurantoin

valganciclovir

entecavir, lamivudine, VEMLIDY

EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI 1 EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6) acyclovir capsule, acyclovir tablet, valacyclovir

SAXENDA alprazolam, clonazepam, diazepam, lorazepam, oxazepam

albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol

Category Drug Class

Asthma * Leukotriene Modulators

Asthma * Steroid Inhalants

Asthma * or Chronic Obstructive Pulmonary Disease (COPD) * Steroid / Beta Agonist Combinations

Attention Deficit Hyperactivity Disorder *

Formulary Drug Removals

SINGULAIR

ALVESCO ASMANEX ASMANEX HFA DULERA

EVEKEO INTUNIV

Autoimmune Conditions

ACTEMRA CIMZIA

ENTYVIO

KINERET

ORENCIA CLICKJECT ORENCIA INTRAVENOUS ORENCIA SUBCUTANEOUS

SIMPONI

TALTZ

Cancer

GLEEVEC

Chronic Myelogenous Leukemia * TASIGNA

Cancer Prostate * Hormonal Agents, Antiandrogens

NILANDRON ZYTIGA

Cardiovascular Antiarrhythmics

BETAPACE BETAPACE AF

Cardiovascular

ZETIA

Antilipemics

Cholesterol Absorption Inhibitors

Cardiovascular Antilipemics Fibrates

fenofibrate tablet 120 mg FENOGLIDE TABLET 120 MG TRICOR

Cardiovascular Antilipemics HMG-CoA Reductase Inhibitors (HMGs or Statins) / Combinations 2

ALTOPREV CRESTOR LESCOL XL LIPITOR LIVALO

Cardiovascular Antilipemics PCSK9 Inhibitors

PRALUENT

Cardiovascular Digitalis Glycosides

LANOXIN TABLET (125 MCG and 250 MCG only)

Formulary Options

montelukast, zafirlukast, zileuton ext-rel

ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR REDIHALER ADVAIR DISKUS, ADVAIR HFA, BREO ELLIPTA, SYMBICORT

amphetamine-dextroamphetamine mixed salts, methylphenidate amphetamine-dextroamphetamine mixed salts ext-rel , atomoxetine, guanfacine ext-rel, methylphenidate ext-rel , MYDAYIS, VYVANSE ENBREL, HUMIRA, RINVOQ, XELJANZ, XELJANZ XR COSENTYX, ENBREL, HUMIRA, OTEZLA, RINVOQ, SKYRIZI, STELARA SUBCUTANEOUS, TREMFYA, XELJANZ, XELJANZ XR HUMIRA, XELJANZ, XELJANZ XR ENBREL, HUMIRA, RINVOQ, XELJANZ, XELJANZ XR COSENTYX, ENBREL, HUMIRA, OTEZLA, RINVOQ, STELARA SUBCUTANEOUS, XELJANZ, XELJANZ XR COSENTYX, ENBREL, HUMIRA, OTEZLA, RINVOQ, STELARA SUBCUTANEOUS, XELJANZ, XELJANZ XR COSENTYX, ENBREL, HUMIRA, OTEZLA, SKYRIZI, STELARA SUBCUTANEOUS, TREMFYA, XELJANZ, XELJANZ XR imatinib mesylate, BOSULIF, SPRYCEL

abiraterone, bicalutamide, XTANDI, YONSA

sotalol

ezetimibe

fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel

atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

REPATHA

digoxin

Category Drug Class

Cardiovascular Diuretics

Carnitine Deficiency

Chronic Obstructive Pulmonary Disease (COPD) * Anticholinergics

Chronic Obstructive Pulmonary Disease (COPD) * Anticholinergic / Beta Agonist Combinations

Contraceptives Monophasic

Contraceptives Biphasic

Formulary Drug Removals

DYRENIUM

CARNITOR CARNITOR SF TUDORZA

COMBIVENT RESPIMAT

BEYAZ MINASTRIN 24 FE TAYTULLA YAZ LO LOESTRIN FE

Contraceptives Triphasic

Contraceptives Four Phase

ORTHO TRI-CYCLEN LO NATAZIA

Cystic Fibrosis * Inhaled Antibiotics

TOBI TOBI PODHALER

Dental Cavity/Caries Prevention

PREVIDENT

Depression * Antidepressants, Selective Serotonin Reuptake Inhibitors (SSRIs)

LEXAPRO PROZAC

Depression * Antidepressants, Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

venlafaxine ext-rel tablet (except 225 mg) CYMBALTA EFFEXOR XR PRISTIQ

Depression * Antidepressants, Miscellaneous Agents

OLEPTRO

Depression and/or Schizophrenia * ABILIFY

Antipsychotics, Atypicals

FANAPT SEROQUEL XR

Dermatology Acne *

Vanoxide-HC ACANYA BENZACLIN ONEXTON VELTIN ZIANA

Dermatology Actinic Keratosis *

fluorouracil cream 0.5% CARAC

Formulary Options

amiloride, triamterene

levocarnitine INCRUSE ELLIPTA, SPIRIVA

ipratropium-albuterol inhalation solution, ANORO ELLIPTA, BEVESPI AEROSPHERE, STIOLTO RESPIMAT

ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron

ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate ethinyl estradiol-norgestimate

ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate tobramycin inhalation solution, BETHKIS

Consult doctor

citalopram, escitalopram, fluoxetine, paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX, VIIBRYD

desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule

trazodone

aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR adapalene, benzoyl peroxide, clindamycin gel, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, EPIDUO, TAZORAC

fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA

Category Drug Class

Dermatology Antibiotics Dermatology Antipsoriatics

Dermatology Atopic Dermatitis * Dermatology Rosacea * Dermatology Scars

Dermatology Seborrheic Dermatitis *

Dermatology Skin Inflammation and Hives * Corticosteroids

Dermatology Warts Dermatology Wound Care Products Dermatology Miscellaneous Skin Conditions

Diabetes * Biguanides Diabetes * Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Diabetes * Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations

Formulary Drug Removals

mupirocin cream

calcipotriene cream calcitriol ointment SORILUX VECTICAL

doxepin cream

FINACEA GEL NORITATE

BEAU RX CICATRACE POLYTOZA RECEDO SCARSILK PAD SIL-K PAD SILIVEX SILTREX

ketoconazole foam 2% Ketodan

XOLEGEL

clobetasol spray CLOBEX SPRAY OLUX-E

fluocinonide cream 0.1%

flurandrenolide ointment CORDRAN OINTMENT

diflorasone cream diflorasone ointment APEXICON E PSORCON

VEREGEN

Alevicyn solution ALEVICYN GEL ALEVICYN SG

ALCORTIN A ATOPADERM BENSAL HP EPICERAM KAMDOY NOVACORT SYNERDERM

FORTAMET (and its generics) GLUMETZA (and its generics) RIOMET

NESINA ONGLYZA TRADJENTA

JENTADUETO JENTADUETO XR KAZANO KOMBIGLYZE XR

OSENI

Formulary Options

gentamicin, mupirocin ointment calcipotriene ointment, calcipotriene solution desonide, hydrocortisone, pimecrolimus, tacrolimus, EUCRISA azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA Consult doctor

ketoconazole shampoo 2%, selenium sulfide lotion 2.5% ciclopirox, ketoconazole cream 2% clobetasol foam clobetasol cream hydrocortisone butyrate, mometasone, triamcinolone desoximetasone, fluocinonide (except fluocinonide cream 0.1%) imiquimod desonide, hydrocortisone desonide, hydrocortisone

metformin, metformin ext-rel (except generic FORTAMET or GLUMETZA) JANUVIA JANUMET, JANUMET XR JANUMET, JANUMET XR; JANUVIA WITH pioglitazone

Category Drug Class

Formulary Drug Removals

Formulary Options

Diabetes * Injectable Incretin Mimetics

BYDUREON BYETTA

OZEMPIC, TRULICITY, VICTOZA

Diabetes * Insulins

Diabetes * Long Acting Insulins Diabetes * Insulin Sensitizers

APIDRA HUMALOG

HUMALOG MIX 50/50

HUMALOG MIX 75/25

HUMULIN 70/30 3

HUMULIN N 3

HUMULIN R 3

NOTE: Humulin R U-500 concentrate will not be subject to removal and will continue to be covered.

LANTUS

TOUJEO

ACTOS

FIASP, NOVOLOG NOVOLOG MIX 70/30 NOVOLOG MIX 70/30 NOVOLIN 70/30 3 NOVOLIN N 3 NOVOLIN R 3

BASAGLAR, LEVEMIR TRESIBA pioglitazone

Diabetes *

INVOKANA

Sodium-Glucose

Co-transporter 2 (SGLT2) Inhibitors

FARXIGA, JARDIANCE

Diabetes * Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitor / Biguanide Combinations

INVOKAMET INVOKAMET XR

SYNJARDY, SYNJARDY XR, XIGDUO XR

Diabetes * Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitor / Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations

QTERN

GLYXAMBI

Diabetes * Supplies, Needles 4

Diabetes * Supplies, Syringes 4

NOVO NORDISK NEEDLES OWEN MUMFORD NEEDLES PERRIGO NEEDLES ULTIMED NEEDLES All other insulin needles that are not BD ULTRAFINE brand

ALLISON MEDICAL INSULIN SYRINGES TRIVIDIA INSULIN SYRINGES ULTIMED INSULIN SYRINGES All other insulin syringes that are not BD ULTRAFINE brand

BD ULTRAFINE NEEDLES BD ULTRAFINE INSULIN SYRINGES

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