Drug List Changes

  • M4 Drug List Changes Effective October 1, 2019

    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