| 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 |
| Cialis tablet |
No longer covered |
tadalafil tablet |
| Ciclopirox 8% solution |
Moving to a higher level |
Consult Doctor |
| Cuprimine capsule |
No longer covered |
penicillamine capsule |
| Diclegis delayed-release tablet |
No longer covered |
doxylamine/pyridoxine delayed-release tablet |
| Edurant tablet |
Moving to a higher level |
Consult Doctor |
| 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 |
| Kaletra tablet |
Moving to a higher level |
Consult Doctor |
| 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 |
| Victoza [Change Effective November 1, 2019]
|
Moving to a higher level |
Bydureon, Byetta, Ozempic, or Trulicity |
| 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 |