Formulary Drug Lists
Get information about our pharmacy benefits, how prescription drugs may be covered, and recent drug list changes.
2025 Covered formulary drug lists
Different plans have different lists of covered drugs. Drug list codes can be found on member ID cards.
Individual
Drug approval and benefit levels
Effective January 1, 2025
B3 formulary drug list
| Drug name | Description of change | Generic or more cost-effective option |
|---|---|---|
| Adrenalin vials | Covered under medical benefit | |
| ANALPRAM HC 2.5%-1% CREAM | Moving to Tier 3 | hydrocortisone/pramoxine 2.5-1% cream |
| Epinephrine vials | Covered under medical benefit | |
| HYRIMOZ(CF) SYRINGES/PENS | Moving to Tier 3 | ADALIMUMAB-ADAZ, ADALIMUMAB-ADBM, ADALIMUMAB-RYVK, CYLTEZO, HUMIRA, SIMLANDI |
| IBRANCE CAPSULES & TABLETS | Moving to Tier 3 | KISQALI, VERZENIO |
| SPIRIVA HANDIHALER | Moving to Tier 3 | tiotropium inhalers |
| UDENYCA SYRINGES, ONBODY, & PENS | Moving to Tier 3 | FULPHILA, NYVEPRIA |
| Vitamin D2/D3 400 unit capsules/tablets | No longer covered | vitamin D2/D3 unit capsules/tablets [over-the-counter (OTC)] |
| ZIEXTENZO SYRINGES | Moving to Tier 3 | FULPHILA, NYVEPRIA |
B4 formulary drug list
| Drug name | Description of change | Generic or more cost-effective option |
|---|---|---|
| Adrenalin vials | Covered under medical benefit | |
| ANALPRAM HC 2.5%-1% CREAM | Moving to Tier 3 | hydrocortisone/pramoxine 2.5-1% cream |
| Epinephrine vials | Covered under medical benefit | |
| SPIRIVA HANDIHALER | Moving to Tier 3 | tiotropium inhaler |
| Vitamin D2/D3 400 unit capsules/tablets | No longer covered | vitamin D2/D3 unit capsules/tablets [over-the-counter (OTC)] |
M1 and M2 formulary drug lists
| Drug name | Description of change | Generic or more cost-effective option |
|---|---|---|
| Adrenalin vials | Covered under medical benefit | |
| ALBUTEROL HFA INHALERS (BRAND) | No longer covered | albuterol HFA inhalers (generic) |
| Aliskiren tablets | Moving to Tier 3 | benazepril tablets, lisinopril tablets, losartan tablets, ramipril capsules, valsartan tablets |
| Amlodipine/valsartan/HCTZ tablets | Moving to Tier 3 | amlodipine/olmesartan/HCTZ tablets |
| AMPYRA TABLETS | Tier 4 (already non-formulary) | dalfampridine tablets |
| Aripiprazole ODT tablets | Moving to Tier 3 | aripiprazole, olanzapine, quetiapine, risperidone tablets |
| Aspirin 325mg tablets | No longer covered | aspirin [over-the-counter (OTC)] |
| ASTRINGYN WOUND SOLUTION | Covered under medical benefit | |
| Atovaquone suspension | Moving to Tier 3 | trimethoprim/sulfamethoxazole tablets/suspension |
| AUBAGIO TABLETS | Tier 4 (already non-formulary) | teriflunomide tablets |
| Baclofen suspension | Moving to Tier 3 | baclofen tablets |
| Bexarotene gel | Moving to Tier 3 | |
| Bimatoprost 0.03% eye drops | Moving to Tier 3 | latanoprost 0.005% eye drops, travoprost 0.004% eye drops |
| Brimonidine 0.15% eye drops | Moving to Tier 3 | brimonidine 0.2% eye drops |
| Bromfenac 0.09% eye drops | Moving to Tier 3 | diclofenac 0.1% eye drops, ketorolac 0.5% eye drops, flurbiprofen 0.03% eye drops |
| Buprenorphine-naloxone SL films | Moving to Tier 3 | buprenorphine SL tablets |
| Carvedilol ER capsules | Moving to Tier 3 | carvedilol tablets |
| Cephalexin tablets | No longer covered | cephalexin capsules |
| CHANTIX TABLETS | No longer covered | bupropion SR tablets, varenicline tablets |
| Chlorzoxazone 250mg, 375mg & 750mg tablets | No longer covered | chlorzoxazone 500mg tablets, cyclobenzaprine tablets, baclofen tablets, tizanidine tablets, methocarbamol tablets |
| Ciclopirox 8% treatment kit | No longer covered | ciclopirox 8% solution |
| Clindamycin/Clindacin 1% foam & medicated pads | No longer covered | clindamycin gel/lotion/solution |
| Clindamycin-tretinoin 1.2%-0.025% gel | No longer covered | clindamycin gel/lotion/solution, tretinoin cream/gel |
| Colchicine capsules | Moving to Tier 3 | colchicine tablets |
| CORLANOR TABLETS | No longer covered | ivabradine tablets |
| CYCLOSET 0.8 MG TABLET | No longer covered | repaglinide tablets |
| Desoximetasone 0.25% Spray | No longer covered | desoximetasone 0.25% cream/gel/ointment |
| Dexamethasone syringes & vials | Covered under medical benefit | |
| Dextroamphetamine solution | Moving to Tier 3 | dextroamphetamine tablets |
| Diazepam rectal kits | Moving to Tier 3 | |
| Doxycycline monohydrate capsules & tablets | No longer covered | doxycycline hyclate capsules & tablets |
| Doxylamine-pyridoxine tablets | No longer covered | doxylamine [over-the-counter (OTC)], pyridoxine [over-the-counter (OTC)] |
| E.E.S./erythromycin ES tablets | Moving to Tier 3 | erythromycin DR tablets, erythromycin tablets |
| Eletriptan tablets | Moving to Tier 3 | sumatriptan, rizatriptan, zolmitriptan tablets |
| EMPAVELI VIALS | No longer covered | FABHALTA CAPSULES |
| Enalapril solution | Moving to Tier 3 | enalapril tablets |
| Epinephrine vials | Covered under medical benefit | |
| Erythromycin capsules | Moving to Tier 3 | erythromycin tablets |
| ESBRIET CAPSULES | Tier 4 (already non-formulary) | pirfenidone capsules/tablets |
| Everolimus tablets | Moving to Tier 3 | cyclosporine capsules, sirolimus tablets, tacrolimus capsules |
| FARXIGA TABLETS | No longer covered | JARDIANCE TABLETS |
| Fenofibrate 40 mg tablets | No longer covered | fenofibrate 48 mg tablets |
| Fenofibrate 120 mg tablets | No longer covered | fenofibrate 145 mg tablets |
| Fentanyl patches | Moving to Tier 3 | hydromorphone, morphine, oxymorphone tablets |
| Ferrous sulfate (iron) drops, including FER-IN-SOL | No longer covered | ferrous sulfate (iron) drops [over-the-counter (OTC)] |
| Griseofulvin suspension/tablets | Moving to Tier 3 | terbinafine tablets |
| HEMLIBRA VIALS | Covered under medical benefit | |
| Hydrocortisone enemas | Moving to Tier 3 | hydrocortisone cream |
| Hydrocortisone valerate cream/ointment | Moving to Tier 3 | betamethasone, fluocinolone cream/ointment |
| Hydromorphone suppositories | Moving to Tier 3 | hydromorphone liquid/tablets, morphine suppositories |
| HYDROMORPHONE SYRINGES | Covered under medical benefit | |
| HYRIMOZ(CF) SYRINGES/PENS | No longer covered | ADALIMUMAB-ADAZ, ADALIMUMAB-ADBM, ADALIMUMAB-RYVK, CYLTEZO, HUMIRA, SIMLANDI |
| IBRANCE CAPSULES & TABLETS | No longer covered | KISQALI, VERZENIO |
| ILUMYA SYRINGES | No longer covered | ADALIMUMAB-ADAZ, ADALIMUMAB-ADBM, ADALIMUMAB-RYVK, CYLTEZO, ENBREL, HUMIRA, OTEZLA, SIMLANDI, SKYRIZI, STELARA, TALTZ, TREMFYA |
| INSULIN ASPARTATE 100 UNIT/ML VIALS | No longer covered | INSULIN LISPRO 100 UNIT/ML VIALS |
| IRESSA TABLETS | No longer covered | gefitinib tablets |
| ISTURISA TABLETS | No longer covered | ketoconazole tablets |
| Javygtor powder packets & tablets | No longer covered | sapropterin powder packets & tablets |
| KEVZARA PENS & SYRINGES | No longer covered | ADALIMUMAB-ADAZ, ADALIMUMAB-ADBM, ADALIMUMAB-RYVK, CYLTEZO, ENBREL, HUMIRA, SIMLANDI |
| LANREOTIDE SYRINGES (BRAND) | Tier 4 (already non-formulary) | lanreotide syringes (generic) |
| Lanthanum chewable tablets | Moving to Tier 3 | calcium acetate capsules, sevelamer tablets |
| LEVALBUTEROL HFA INHALERS | No longer covered | albuterol HFA inhalers (generic) |
| Levofloxacin solution | Moving to Tier 3 | levofloxacin tablets |
| Lidocaine-prilocaine cream kit | No longer covered | lidocaine-prilocaine cream |
| LIDOCAINE-TETRACAINE 7%-7% CREAM | No longer covered | lidocaine-prilocaine cream |
| Lisdexamfetamine chewable tablets | Moving to Tier 3 | dexmethylphenidate capsules/tablets, dextroamphetamine tablets, dextroamphetamine-amphetamine capsules, lisdexamfetamine capsules, methylphenidate tablets |
| Mafenide powder packets | Moving to Tier 3 | silver sulfadiazine cream |
| MAVENCLAD TABLETS | No longer covered | fingolimod capsules, teriflunomide tablets |
| MAVYRET PELLET PACKS & TABLETS | No longer covered | EPCLUSA, HARVONI, ZEPATIER |
| Meperidine solution/tablets | Moving to Tier 3 | hydromorphone, morphine, oxycodone, oxymorphone tablets |
| Mesalamine enemas/suppositories | Moving to Tier 3 | |
| Metformin ER osmotic tablets (generic Fortamet) | No longer covered | metformin HCl ER tablets, metformin HCl tablets |
| Methoxsalen | Moving to Tier 3 | |
| Mondoxyne capsules | No longer covered | doxycycline hyclate capsules & tablets |
| Morphine ER capsules | Moving to Tier 3 | morphine ER tablets |
| Naproxen DR/EC tablets | Moving to Tier 3 | naproxen tablets |
| NEUPOGEN SYRINGES & VIALS | No longer covered | FULPHILA, NYVEPRIA |
| NORPACE CR CAPSULES | No longer covered | disopyramide capsules |
| NOVOLOG 100 UNIT/ML VIALS | No longer covered | INSULIN LISPRO 100 UNIT/ML VIALS |
| NUPLAZID CAPSULES & TABLETS | No longer covered | clozapine tablets, quetiapine tablets |
| NUZYRA TABLETS | No longer covered | levofloxacin tablets |
| Olanzapine-fluoxetine capsules | No longer covered | fluoxetine capsules, olanzapine tablets |
| PALYNZIQ SYRINGES | No longer covered | sapropterin powder packets & tablets |
| Paroxetine capsules | Moving to Tier 3 | paroxetine tablets |
| Penicillamine tablets | Moving to Tier 3 | |
| Potassium iodide solution | Moving to Tier 3 | potassium iodide [over-the-counter (OTC)] |
| Praziquantel tablets | Moving to Tier 3 | |
| Procentra solution | Moving to Tier 3 | dextroamphetamine tablets |
| Pyridostigmine ER tablets | Moving to Tier 3 | pyridostigmine tablets |
| Pyridoxine vials | Covered under medical benefit | |
| RADICAVA SUSPENSION | No longer covered | riluzole tablets |
| Rifabutin capsules | Moving to Tier 3 | ethambutolm isoniazid, pyrazinamide tablets |
| Rivastigmine patches | Moving to Tier 3 | donepezil tablets, rivastigmine capsules |
| Spinosad suspension | Moving to Tier 3 | permethrin cream, over-the-counter (OTC) products |
| SPIRIVA HANDIHALERS | Tier 3 (already non-formulary) | tiotropium inhalers |
| SSKI SOLUTION | Moving to Tier 3 | potassium iodide [over-the-counter (OTC)] |
| Sumatriptan-naproxen tablets | No longer covered | naproxen tablets, sumatriptan tablets |
| SYMBICORT INHALERS | Tier 3 (already non-formulary) | budesonide/formoterol inhalers, fluticaseon/salmeterol inhalers |
| T-SLIM CARTRIDGES | Tier 3 (already non-formulary) | |
| Tetracycline tablets | No longer covered | tetracycline capsules |
| Thiamine vials | Covered under medical benefit | |
| Tiagabine tablets | Moving to Tier 3 | carbamazepine, lamotrigine, levetiracetam, oxcarbazepine, phenytoin, valproic acid |
| TOBRAMYCIN PAK | No longer covered | tobramycin ampules for nebulization |
| Tretinoin gel micro 0.04% & 0.1% pumps | No longer covered | tretinoin cream/gel |
| UDENYCA SYRINGES, ONBODY, & PENS | No longer covered | FULPHILA, NYVEPRIA |
| Vancomycin solution | Moving to Tier 3 | vancomycin capsules |
| Vitamin D2/D3 400 unit capsules/tablets | No longer covered | vitamin D2/D3 unit capsules/tablets [over-the-counter (OTC)] |
| Voriconazole tablets/suspension | Moving to Tier 3 | itraconazole capsules |
| VYVANSE CHEWABLE TABLETS | No longer covered | dexmethylphenidate capsules/tablets, dextroamphetamine tablets, dextroamphetamine-amphetamine capsules, lisdexamfetamine capsules, methylphenidate tablets |
| XIGDUO TABLETS | No longer covered | SYNJARDY TABLETS, SYNJARDY XR TABLETS |
| XOLAIR PENS & SYRINGES | No longer covered | DUPIXENT, FASENRA, TEZSPIRE |
| XURIDEN PACKETS | No longer covered | VISTOGARD PACKETS |
| ZARXIO SYRINGES | No longer covered | GRANIX, NIVESTYM |
| ZIEXTENZO SYRINGES | No longer covered | FULPHILA, NYVEPRIA |
| Zolpidem SL tablets | Moving to Tier 3 | zolpidem tablets |
| ZYPITAMAG TABLETS | No longer covered | atorvastatin, rosuvastatin, simvastatin tablets |
| ZYTIGA TABLETS | Tier 4 (already non-formulary) | abiraterone tablets |
M4 formulary drug list
| Drug name | Description of change | Generic or more cost-effective option |
|---|---|---|
| Adrenalin vials | Covered under medical benefit | |
| ALBUTEROL HFA INHALERS (BRAND) | No longer covered | albuterol HFA inhalers (generic) |
| Aliskiren tablets | Moving to Tier 3 | benazepril tablets, lisinopril tablets, losartan tablets, ramipril capsules, valsartan tablets |
| Amlodipine/valsartan/HCTZ tablets | Moving to Tier 3 | amlodipine/olmesartan/HCTZ tablets |
| AMPYRA TABLETS | Tier 4 (already non-formulary) | dalfampridine tablets |
| Aripiprazole ODT tablets | Moving to Tier 3 | aripiprazole, olanzapine, quetiapine, risperidone tablets |
| Aspirin 325mg tablets | No longer covered | aspirin [over-the-counter (OTC)] |
| ASTRINGYN WOUND SOLUTION | Covered under medical benefit | |
| Atovaquone suspension | Moving to Tier 3 | trimethoprim/sulfamethoxazole tablets/suspension |
| AUBAGIO TABLETS | Tier 4 (already non-formulary) | teriflunomide tablets |
| Baclofen suspension | Moving to Tier 3 | baclofen tablets |
| Bexarotene gel | Moving to Tier 3 | |
| Bimatoprost 0.03% eye drops | Moving to Tier 3 | latanoprost 0.005% eye drops, travoprost 0.004% eye drops |
| Brimonidine 0.15% eye drops | Moving to Tier 3 | brimonidine 0.2% eye drops |
| Bromfenac 0.09% eye drops | Moving to Tier 3 | diclofenac 0.1% eye drops, ketorolac 0.5% eye drops, flurbiprofen 0.03% eye drops |
| Buprenorphine-naloxone SL films | Moving to Tier 3 | buprenorphine SL tablets |
| Carvedilol ER capsules | Moving to Tier 3 | carvedilol tablets |
| Cephalexin tablets | No longer covered | cephalexin capsules |
| CHANTIX TABLETS | No longer covered | bupropion SR tablets, varenicline tablets |
| Chlorzoxazone 250mg, 375mg & 750mg tablets | No longer covered | chlorzoxazone 500mg tablets, cyclobenzaprine tablets, baclofen tablets, tizanidine tablets, methocarbamol tablets |
| Ciclopirox 8% treatment kit | No longer covered | ciclopirox 8% solution |
| Clindamycin/Clindacin 1% foam & medicated pads | No longer covered | clindamycin gel/lotion/solution |
| Clindamycin-tretinoin 1.2%-0.025% gel | No longer covered | clindamycin gel/lotion/solution, tretinoin cream/gel |
| Colchicine capsules | Moving to Tier 3 | colchicine tablets |
| CORLANOR TABLETS | No longer covered | ivabradine tablets |
| CYCLOSET 0.8 MG TABLET | No longer covered | repaglinide tablets |
| Desoximetasone 0.25% Spray | No longer covered | desoximetasone 0.25% cream/gel/ointment |
| Dexamethasone syringes & vials | Covered under medical benefit | |
| Dextroamphetamine solution | Moving to Tier 3 | dextroamphetamine tablets |
| Diazepam rectal kits | Moving to Tier 3 | |
| Doxycycline monohydrate capsules & tablets | No longer covered | doxycycline hyclate capsules & tablets |
| Doxylamine-pyridoxine tablets | No longer covered | doxylamine [over-the-counter (OTC)], pyridoxine [over-the-counter (OTC)] |
| E.E.S./erythromycin ES tablets | Moving to Tier 3 | erythromycin DR tablets, erythromycin tablets |
| Eletriptan tablets | Moving to Tier 3 | sumatriptan, rizatriptan, zolmitriptan tablets |
| EMPAVELI VIALS | No longer covered | FABHALTA CAPSULES |
| Enalapril solution | Moving to Tier 3 | enalapril tablets |
| Epinephrine vials | Covered under medical benefit | |
| Erythromycin capsules | Moving to Tier 3 | erythromycin tablets |
| ESBRIET CAPSULES | Tier 4 (already non-formulary) | pirfenidone capsules/tablets |
| Everolimus tablets | Moving to Tier 3 | cyclosporine capsules, sirolimus tablets, tacrolimus capsules |
| FARXIGA TABLETS | No longer covered | JARDIANCE TABLETS |
| Fenofibrate 40 mg tablets | No longer covered | fenofibrate 48 mg tablets |
| Fenofibrate 120 mg tablets | No longer covered | fenofibrate 145 mg tablets |
| Fentanyl patches | Moving to Tier 3 | hydromorphone, morphine, oxymorphone tablets |
| Ferrous sulfate (iron) drops, including FER-IN-SOL | No longer covered | ferrous sulfate (iron) drops [over-the-counter (OTC)] |
| Griseofulvin suspension/tablets | Moving to Tier 3 | terbinafine tablets |
| HEMLIBRA VIALS | Covered under medical benefit | |
| Hydrocortisone enemas | Moving to Tier 3 | hydrocortisone cream |
| Hydrocortisone valerate cream/ointment | Moving to Tier 3 | betamethasone, fluocinolone cream/ointment |
| Hydromorphone suppositories | Moving to Tier 3 | hydromorphone liquid/tablets, morphine suppositories |
| HYDROMORPHONE SYRINGES | Covered under medical benefit | |
| HYRIMOZ(CF) SYRINGES/PENS | No longer covered | ADALIMUMAB-ADAZ, ADALIMUMAB-ADBM, ADALIMUMAB-RYVK, CYLTEZO, HUMIRA, SIMLANDI |
| IBRANCE CAPSULES & TABLETS | No longer covered | KISQALI, VERZENIO |
| ILUMYA SYRINGES | No longer covered | ADALIMUMAB-ADAZ, ADALIMUMAB-ADBM, ADALIMUMAB-RYVK, CYLTEZO, ENBREL, HUMIRA, OTEZLA, SIMLANDI, SKYRIZI, STELARA, TALTZ, TREMFYA |
| INSULIN ASPARTATE 100 UNIT/ML VIALS | No longer covered | INSULIN LISPRO 100 UNIT/ML VIALS |
| IRESSA TABLETS | No longer covered | gefitinib tablets |
| ISTURISA TABLETS | No longer covered | ketoconazole tablets |
| Javygtor powder packets & tablets | No longer covered | sapropterin powder packets & tablets |
| KEVZARA PENS & SYRINGES | No longer covered | ADALIMUMAB-ADAZ, ADALIMUMAB-ADBM, ADALIMUMAB-RYVK, CYLTEZO, ENBREL, HUMIRA, SIMLANDI |
| LANREOTIDE SYRINGES (BRAND) | Tier 4 (already non-formulary) | lanreotide syringes (generic) |
| Lanthanum chewable tablets | Moving to Tier 3 | calcium acetate capsules, sevelamer tablets |
| LEVALBUTEROL HFA INHALERS | No longer covered | albuterol HFA inhalers (generic) |
| Levofloxacin solution | Moving to Tier 3 | levofloxacin tablets |
| Lidocaine-prilocaine cream kit | No longer covered | lidocaine-prilocaine cream |
| LIDOCAINE-TETRACAINE 7%-7% CREAM | No longer covered | lidocaine-prilocaine cream |
| Lisdexamfetamine chewable tablets | Moving to Tier 3 | dexmethylphenidate capsules/tablets, dextroamphetamine tablets, dextroamphetamine-amphetamine capsules, lisdexamfetamine capsules, methylphenidate tablets |
| Mafenide powder packets | Moving to Tier 3 | silver sulfadiazine cream |
| MAVENCLAD TABLETS | No longer covered | fingolimod capsules, teriflunomide tablets |
| MAVYRET PELLET PACKS & TABLETS | No longer covered | EPCLUSA, HARVONI, ZEPATIER |
| Meperidine solution/tablets | Moving to Tier 3 | hydromorphone, morphine, oxycodone, oxymorphone tablets |
| Mesalamine enemas/suppositories | Moving to Tier 3 | |
| Metformin ER osmotic tablets (generic Fortamet) | No longer covered | metformin HCl ER tablets, metformin HCl tablets |
| Methoxsalen | Moving to Tier 3 | |
| Mondoxyne capsules | No longer covered | doxycycline hyclate capsules & tablets |
| Morphine ER capsules | Moving to Tier 3 | morphine ER tablets |
| Naproxen DR/EC tablets | Moving to Tier 3 | naproxen tablets |
| NEUPOGEN SYRINGES & VIALS | No longer covered | FULPHILA, NYVEPRIA |
| NORPACE CR CAPSULES | No longer covered | disopyramide capsules |
| NOVOLOG 100 UNIT/ML VIALS | No longer covered | INSULIN LISPRO 100 UNIT/ML VIALS |
| NUPLAZID CAPSULES & TABLETS | No longer covered | clozapine tablets, quetiapine tablets |
| NUZYRA TABLETS | No longer covered | levofloxacin tablets |
| Olanzapine-fluoxetine capsules | No longer covered | fluoxetine capsules, olanzapine tablets |
| PALYNZIQ SYRINGES | No longer covered | sapropterin powder packets & tablets |
| Paroxetine capsules | Moving to Tier 3 | paroxetine tablets |
| Penicillamine tablets | Moving to Tier 3 | |
| Potassium iodide solution | Moving to Tier 3 | potassium iodide [over-the-counter (OTC)] |
| Praziquantel tablets | Moving to Tier 3 | |
| Procentra solution | Moving to Tier 3 | dextroamphetamine tablets |
| Pyridostigmine ER tablets | Moving to Tier 3 | pyridostigmine tablets |
| Pyridoxine vials | Covered under medical benefit | |
| RADICAVA SUSPENSION | No longer covered | riluzole tablets |
| Rifabutin capsules | Moving to Tier 3 | ethambutolm isoniazid, pyrazinamide tablets |
| Rivastigmine patches | Moving to Tier 3 | donepezil tablets, rivastigmine capsules |
| Spinosad suspension | Moving to Tier 3 | permethrin cream, over-the-counter (OTC) products |
| SPIRIVA HANDIHALERS | Tier 3 (already non-formulary) | tiotropium inhalers |
| SSKI SOLUTION | Moving to Tier 3 | potassium iodide [over-the-counter (OTC)] |
| Sumatriptan-naproxen tablets | No longer covered | naproxen tablets, sumatriptan tablets |
| SYMBICORT INHALERS | Tier 3 (already non-formulary) | budesonide/formoterol inhalers, fluticaseon/salmeterol inhalers |
| T-SLIM CARTRIDGES | Tier 3 (already non-formulary) | |
| Tetracycline tablets | No longer covered | tetracycline capsules |
| Thiamine vials | Covered under medical benefit | |
| Tiagabine tablets | Moving to Tier 3 | carbamazepine, lamotrigine, levetiracetam, oxcarbazepine, phenytoin, valproic acid |
| TOBRAMYCIN PAK | No longer covered | tobramycin ampules for nebulization |
| Tretinoin gel micro 0.04% & 0.1% pumps | No longer covered | tretinoin cream/gel |
| UDENYCA SYRINGES, ONBODY, & PENS | No longer covered | FULPHILA, NYVEPRIA |
| Vancomycin solution | Moving to Tier 3 | vancomycin capsules |
| Vitamin D2/D3 400 unit capsules/tablets | No longer covered | vitamin D2/D3 unit capsules/tablets [over-the-counter (OTC)] |
| Voriconazole tablets/suspension | Moving to Tier 3 | itraconazole capsules |
| VYVANSE CHEWABLE TABLETS | No longer covered | dexmethylphenidate capsules/tablets, dextroamphetamine tablets, dextroamphetamine-amphetamine capsules, lisdexamfetamine capsules, methylphenidate tablets |
| XIGDUO TABLETS | No longer covered | SYNJARDY TABLETS, SYNJARDY XR TABLETS |
| XOLAIR PENS & SYRINGES | No longer covered | DUPIXENT, FASENRA, TEZSPIRE |
| XURIDEN PACKETS | No longer covered | VISTOGARD PACKETS |
| ZARXIO SYRINGES | No longer covered | GRANIX, NIVESTYM |
| ZIEXTENZO SYRINGES | No longer covered | FULPHILA, NYVEPRIA |
| Zolpidem SL tablets | Moving to Tier 3 | zolpidem tablets |
| ZYPITAMAG TABLETS | No longer covered | atorvastatin, rosuvastatin, simvastatin tablets |
| ZYTIGA TABLETS | Tier 4 (already non-formulary) | abiraterone tablets |
Effective December 1, 2024
No changes
Effective November 1, 2024
No changes
Effective January 1, 2025
B3 formulary drug list (no changes for A1/A2 list)
| Drug name | Description of change | Generic or more cost-effective option |
|---|---|---|
| Adrenalin vials | Covered under medical benefit | |
| ANALPRAM HC 2.5%-1% CREAM | Moving to Tier 3 | hydrocortisone/pramoxine 2.5-1% cream |
| Epinephrine vials | Covered under medical benefit | |
| HYRIMOZ(CF) SYRINGES/PENS | Moving to Tier 3 | ADALIMUMAB-ADAZ, ADALIMUMAB-ADBM, ADALIMUMAB-RYVK, CYLTEZO, HUMIRA, SIMLANDI |
| IBRANCE CAPSULES & TABLETS | Moving to Tier 3 | KISQALI, VERZENIO |
| SPIRIVA HANDIHALER | Moving to Tier 3 | tiotropium inhalers |
| UDENYCA SYRINGES, ONBODY, & PENS | Moving to Tier 3 | FULPHILA, NYVEPRIA |
| Vitamin D2/D3 400 unit capsules/tablets | No longer covered | vitamin D2/D3 unit capsules/tablets [over-the-counter (OTC)] |
| ZIEXTENZO SYRINGES | Moving to Tier 3 | FULPHILA, NYVEPRIA |
B4 formulary drug list
| Drug name | Description of change | Generic or more cost-effective option |
|---|---|---|
| Adrenalin vials | Covered under medical benefit | |
| ANALPRAM HC 2.5%-1% CREAM | Moving to Tier 3 | hydrocortisone/pramoxine 2.5-1% cream |
| Epinephrine vials | Covered under medical benefit | |
| SPIRIVA HANDIHALER | Moving to Tier 3 | tiotropium inhaler |
| Vitamin D2/D3 400 unit capsules/tablets | No longer covered | vitamin D2/D3 unit capsules/tablets [over-the-counter (OTC)] |
Effective December 1, 2024
No changes
Effective November 1, 2024
No changes
*These drugs have been selected by an independent group of experts made up of doctors and pharmacists. This group reviews drugs to see how well they work relative to their cost. They also compare their effectiveness to similar drugs used to treat the same condition. Please talk with your doctor to see if these new options are right for you.