Drug List Changes

  • M4 Drug List Changes Effective January 1, 2021

    Drug Name Description of Change Cost-effective Alternatives
    Aczone 7.5% gel No longer covered tretinoin gel
    Apidra vial No longer covered Novolog vial
    Apidra Solostar pen No longer covered Novolog pen
    Atripla tablet No longer covered Consult a doctor
    Benzoyl peroxide wash No longer covered benzepro topical towelette
    Ciprodex ear drops No longer covered ciprofloxacin/dexamethasone ear drops
    Colcrys tablet No longer covered colchicine tablet
    Delstrigo tablet No longer covered Consult doctor
    Demser capsule No longer covered metyrosine capsule
    Emtriva capsule No longer covered emtricitabine capsule
    Finacea 15% foam No longer covered azelaic acid 15% gel
    Firdapse tablet No longer covered Ruzurgi tablet
    Jadenu Sprinkle oral granules No longer covered deferasirox oral granules
    Moviprep oral solution No longer covered polyethylene glycol oral solution
    Mycophenolate suspension No longer covered mycophenolate capsule or mycophenolate tablet
    Neulasta syringe No longer covered Udenyca syringe or Ziextenzo syringe
    Nucynta tablet No longer covered Consult doctor
    Praluent syringe No longer covered Repatha syringe
    Pentasa capsule No longer covered mesalamine extended-release capsule
    Proair Respiclick inhaler No longer covered albuterol HFA inhaler
    Proctofoam-HC foam No longer covered hydrocortisone/pramoxine cream
    Procysbi delayed-release capsule No longer covered Cystagon capsule
    Procysbi delayed-release granules No longer covered Cystagon capsule
    Qbrexza cloth No longer covered Drysol solution
    Sulconazole cream No longer covered ketoconazole cream
    Sulconazole solution No longer covered ketoconazole cream
    Sulfacetamide/sulfur topical No longer covered metronidazole gel and azelaic acid gel
    Tavalisse tablet No longer covered Promacta tablet or Doptelet tablet
    Transderm Scop patch No longer covered scopolamine patch
    Ventolin HFA inhaler No longer covered albuterol HFA inhaler
    Zelapar orally disintegrating tablet No longer covered rasagiline tablet