| Drug Name |
Description of Change |
Cost-effective Alternatives |
| ANDROGEL 1.62% (1.25G) GEL PACKETS |
Moving to Tier 3 |
testosterone 1.62% (1.25 g) packets |
| BETIMOL 0.5% EYE DROPS |
Moving to Tier 3 |
timolol 0.5% eye drops |
| ELIGARD SYRINGE KITS |
No longer covered |
Covered under medical benefit only. |
| HUMIRA (ALL STRENGTHS & DOSAGE FORMS) |
Moving to Tier 3 |
adalimumab-adaz, adalimumab-adbm, adalimumab-ryvk, Cyltezo, Simlandi |
| HYCODAN 5 MG-1.5 MG/5 ML SOLUTION |
Moving to Tier 3 |
hydrocodone/homatropine solution, promethazine/codeine syrup, promethazine/DM syrup |
| LEUPROLIDE DEPOT |
No longer covered |
Covered under medical benefit only. |
| LUPRON DEPOT/LUPRON DEPOT-PED |
No longer covered |
Covered under medical benefit only. |
| NEXIUM 2.5 MG & 5 MG PACKETS |
Moving to Tier 3 |
omeprazole capsules, esomeprazole packets |
| NYVEPRIA 6 MG/0.6 ML SYRINGES |
Moving to Tier 3 |
Fulphila, Udenyca |
| PRIMAQUINE 26.3 MG TABLETS (BRAND) |
Moving to Tier 3 |
primaquine 26.3mg tablets (generic) |
| VICTOZA 2-PAK & 3-PAK PENS |
Moving to Tier 3 |
liraglutide 2-pak & 3-pak pens |