Commercial Drug List Changes
Formulary Update The information contained herein is believed to be accurate at the time of posting, but changes may occur at any time without prior notice. (...) Effective Date of Changes 10/1/2022
Drug Name National Drug List Tier Status Change
National Direct Drug List Tier Status Change
Traditional Open Drug List Tier Status Change
Essential Drug List Tier Status
Change
Atopic Dermatitis Opzelura Tier 3 -> NF NF (No Change) Tier 3 (No Change) NF (No Change)
*Members should refer to their member handbook for benefit details regarding applicable copayments or coinsurance
Effective Date of Changes 4/1/2022
Drug Name National Drug List Tier Status Change
National Direct Drug List Tier Status Change
Traditional Open Drug List Tier Status Change
Essential Drug List Tier Status
Change
ADHD Mydayis Tier 3 -> NF Tier 2 (No Change) Tier 3 (No Change) Tier 3 -> NF
ALS Exservan Tier 3 -> NF NF (No Change) Tier 3 (No Change) NF (No Change)
Anaphylaxis Symjepi Tier 2 -> NF Tier 2 -> NF Tier 2 -> Tier 3 Tier 2 -> NF
Antihistamines Ryvent Tier 1 -> NF Tier 1 -> NF Tier 1 -> Tier 3 Tier 1 -> NF
Antiprotozoal Alinia Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change)
BTK Inhibitors Imbruvica Tier 3 -> Tier 2^ Tier 3 -> Tier 2^ Tier 3 -> Tier 2^ NF -> Tier 2^
Dermatology Sorilux Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Zilxi Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change)
Dosage Formulations butalbital-apap- caf feine cap 50- 325-40mg
Tier 1 -> NF Tier 1 -> NF Tier 1 -> Tier 3 Tier 1 -> NF
tizanidine cap 2,4mg
Tier 1 -> NF Tier 1 -> NF Tier 1 -> Tier 3 Tier 1 -> NF
venlafaxine tab er 37.5,75,150mg
Tier 1 -> NF Tier 1 -> NF Tier 1 -> Tier 3 Tier 1 -> NF
Zanaf lex Cap 2,4mg
Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change)
Gaucher’s Disease Cerdelga Tier 3 -> Tier 2^ Tier 2 (No Change) Tier 3 -> Tier 2^ NF -> Tier 2^ miglustat Tier 1 (No Change) Tier 1 (No Change) Tier 1 (No Change) Tier 3 -> Tier 2^
HIV/AIDS Complera Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Descovy Tier 3 -> Tier 2^ Tier 2 (No Change) Tier 3 -> Tier 2^ Tier 3 -> Tier 2^
Emtricitabine-Tenofovir Disoproxil Fumarate Tier 1 (No Change) Tier 1 (No Change) Tier 1 (No Change) Tier 2 -> Tier 1^
Odefsey Tier 3 -> Tier 2^ Tier 2 (No Change) Tier 3 -> Tier 2^ NF (No Change) Prezcobix Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Symtuza Tier 3 -> Tier 2^ Tier 2 (No Change) Tier 3 -> Tier 2^ NF (No Change)
IC/LABA budesonide- formoteral (AG Symbicort)
Tier 1 (No Change) Tier 1 -> NF Tier 1 (No Change) Tier 1 (No Change)
Symbicort Tier 2 (No Change) Tier 2 -> Tier 1 Tier 2 (No Change) Tier 2 (No Change)
Lung Cancer (ALK inhibitors) Alecensa Tier 3 -> Tier 2 Tier 2 (No Change) Tier 3 -> Tier 2 NF -> Tier 2 Alunbrig Tier 3 -> Tier 2 Tier 2 (No Change) Tier 3 -> Tier 2 NF -> Tier 2 Xalkori Tier 2 -> Tier 3 Tier 3 (No Change) Tier 2 -> Tier 3 F (No Change)
Multiple Sclerosis Extavia Tier 3 -> NF NF (No Change) Tier 3 (No Change) F -> NF
Multi-Source Brands Actoplus Met Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Amaryl Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Benzamycin Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Boniva Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Buphenyl Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Duac Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Duragesic Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Ferriprox Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Fosrenol Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Glucotrol Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Glucotrol XL Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Intermezzo Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Kuvan Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Lotronex Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Niaspan Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Northera Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Noxaf il Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Renvela Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Rocaltrol Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Silenor Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Soma Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Tarceva Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Trilpix Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Tykerb Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Xeloda Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Zytiga Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change)
Ophthalmic Alrex Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Azopt Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change)
OTIC Cipro HC Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change)
Renal Cell Carcinoma Af initor 2.5,5,7.5mg
Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change)
Af initor 10mg Tier 2 -> NF Tier 3 -> NF Tier 2 -> Tier 3 F -> NF
Af initor Disperz Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) F -> NF Cabometyx Tier 3 -> Tier 2 Tier 2 (No Change) Tier 3 -> Tier 2 NF -> Tier 2 Inlyta Tier 2 (No Change) Tier 2 (No Change) Tier 2 (No Change) Tier 3 -> Tier 2 Nexavar Tier 2 -> Tier 3 Tier 3 (No Change) Tier 2 -> Tier 3 F (No Change) Votrient Tier 2 -> Tier 3 Tier 3 (No Change) Tier 2 -> Tier 3 F (No Change)
RLS Horizant Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change)
*Members should refer to their member handbook for benefit details regarding applicable copayments or coinsurance ^ effective date 2/1/2022
Effective Date of Changes 1/1/2022
Drug Name National Drug List Tier Status Change
National Direct Drug List Tier Status Change
Traditional Open Drug List Tier Status Change
Essential Drug List Tier Status
Change ADHD
Mydayis Tier 3 (No Change) Tier 3 -> Tier 2^^ Tier 3 (No Change) Tier 3 (No Change) Antihistamines
levocetirizine tab Tier 1 (No Change) Tier 1 (No Change)
Tier 1 (No Change) NF -> Tier 1
Beta Blockers Bystolic Tier 2 -> NF^ Tier 2 -> NF^ Tier 2 -> Tier 3^ Tier 2 -> NF^
CML Iclusig Tier 2 (No Change) Tier 2 -> Tier 3^^ Tier 2 (No Change) Tier 3 (No Change)
Cystic Fibrosis
Trikaf ta Tier 3 (No Change) Tier 3 (No Change)
Tier 3 (No Change) NF -> F
Diabetes
Glyxambi NF -> Tier 2^^^ Tier 2 (No Change)
Tier 3 -> Tier 2^^^ NF -> Tier 2^^^
Trijardy NF -> Tier 2^^^ NF -> Tier 2^^^ Tier 3 -> Tier 2^^^ NF -> Tier 2^^^ Gaucher’s Disease
Cerdelga Tier 3 (No Change) Tier 3 -> Tier 2^^ Tier 3 (No Change) NF (No Change) Cerezyme Tier 3 (No Change) Tier 3 -> Tier 2^^ Tier 3 (No Change) NF (No Change)
HIV Symtuza Tier 3 (No Change) Tier 3 -> Tier 2^^ Tier 3 (No Change) NF (No Change)
IBS
Xifaxan Tier 3 (No Change) Tier 3 (No Change)
Tier 3 (No Change) NF -> 3^^^
Insulins Lyumjev NF -> Tier 2^^^ NF -> Tier 2^^^ Tier 3 -> Tier 2^^^ NF -> Tier 2^^^ Semglee Tier 3 -> NF^^ NF (No Change) Tier 3 (No Change) Tier 3 -> NF^^
Lung Cancer (ALK inhibitors) Alecensa Tier 3 (No Change) Tier 3 -> Tier 2^^ Tier 3 (No Change) NF (No Change) Alunbrig Tier 3 (No Change) Tier 3 -> Tier 2^^ Tier 3 (No Change) NF (No Change) Xalkori Tier 2 (No Change) Tier 2 -> Tier 3^^ Tier 2 (No Change) Tier 3 (No Change)
Multiple Sclerosis Vumerity NF (No Change) NF -> Tier 3^^ Tier 3 (No Change) NF (No Change)
Renal Cell Carcinoma Af initor 10mg tablet Tier 2 (No Change) Tier 2 -> Tier 3^^ Tier 2 (No Change) Tier 3 (No Change) Cabometyx Tier 3 (No Change) Tier 3 -> Tier 2^^ Tier 3 (No Change) NF (No Change) Nexavar Tier 2 (No Change) Tier 2 -> Tier 3^^ Tier 2 (No Change) Tier 3 (No Change) Votrient Tier 2 (No Change) Tier 2 -> Tier 3^^ Tier 2 (No Change) Tier 3 (No Change)
SSRIs Trintellix Tier 3 (No Change) Tier 3 -> Tier 2^^ Tier 3 (No Change) Tier 3 (No Change)
*Members should refer to their member handbook for benefit details regarding applicable copayments or coinsurance ^
effective date 12/23/2021
^^ effective date 11/1/2021
^^^ effective date 12/1/2021
Effective Date of Changes 10/1/2021
Drug Name National Drug List Tier Status Change
National Direct Drug List Tier Status Change
Traditional Open Drug List Tier Status Change
Essential Drug List Tier Status
Change Benzodiazepines
Loreev XR Tier 3 -> NF^^ NF (No Change) Tier 3 (No Change) NF (No Change) Contraceptives
Annovera Tier 3 (No Change) Tier 3 (No Change) Tier 3 (No Change) Tier 2 -> NF Balcoltra Tier 3 (No Change) Tier 3 (No Change) Tier 3 (No Change) Tier 2 -> NF Natazia Tier 3 (No Change) Tier 3 (No Change) Tier 3 (No Change) Tier 2 -> NF Slynd Tier 3 (No Change) Tier 3 (No Change) Tier 3 (No Change) Tier 2 -> NF
Generics azelastine HCl- f luticasone propionate nasal
Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 1 -> Tier 3
butalbital- acetaminophen tab 50-300mg
Tier 1 -> NF Tier 1 -> NF Tier 1 -> Tier 3 Tier 1 -> NF
calcipotriene- betamethasone dipropionate susp
Tier 1 -> Tier 2 Tier 1 -> Tier 2 Tier 1 -> Tier 2 Tier 2 -> Tier 3
calcipotriene- betamethasone dipropionate oint
Tier 1 -> Tier 2 Tier 1 -> Tier 2 Tier 1 -> Tier 2 Tier 1 -> Tier 3
clindamycin phosphate- tretinoin
Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 1 -> Tier 3
colesevelam HCl pak
Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 2 -> Tier 3
cyclobenzaprine HCl tab 7.5mg
Tier 1 -> NF Tier 1 -> NF Tier 1 -> Tier 3 Tier 1 -> NF
dapsone gel 7.5% Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 1 -> Tier 3 doxycycline monohydrate cap 150mg
Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 1 -> Tier 3
doxycycline hyclate tab DR (except 80mg)
Tier 1 -> NF Tier 1 -> NF Tier 1 -> Tier 3 Tier 1 -> NF
doxycycline hyclate tab 75mg, 150mg
Tier 1 -> NF Tier 1 -> NF Tier 1 -> Tier 3 Tier 1 -> NF
fenofibrate tab 40mg, 120mg
Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 1 -> Tier 3
fenoprofen tab 600mg
Tier 1 -> NF Tier 1 -> NF Tier 1 -> Tier 3 Tier 1 -> NF
f luvastatin tab 80mg ER
Tier 1 -> NF Tier 1 -> NF Tier 1 -> Tier 3 Tier 1 -> NF
ketoconazole aer 2%
Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 1 -> Tier 3
meprobamate tab Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 1 -> Tier 3 metformin HCl soln
Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 2 -> Tier 3
minocycline HCl tab ER
Tier 1 -> NF Tier 1 -> NF Tier 1 -> Tier 3 Tier 1 -> NF
mupirocin cream 2%
Tier 1 -> NF Tier 1 -> NF Tier 1 -> Tier 3 Tier 1 -> NF
naproxen susp Tier 1 -> NF Tier 1 -> NF Tier 1 -> Tier 3 Tier 1 -> NF oxiconazole nitrate cream
Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 1 -> Tier 3 Tier 1 -> Tier 3
penicillamine cap 250mg
Tier 1 -> NF Tier 1 -> NF Tier 1 -> Tier 3 Tier 2 -> NF
sumatriptan- naproxen sodium 85-500mg
Tier 1 -> NF Tier 1 -> NF Tier 1 -> Tier 3 Tier 2 -> NF
vardenaf il HCl tab Tier 1 -> NF Tier 1 -> NF Tier 1 -> Tier 3 Tier 1 -> NF Dry Eye
Eysuvis Tier 3 -> NF NF (No Change) Tier 3 (No Change) NF (No Change) Gallstone Agents
Chenodal Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Reltone Tier 3 -> NF NF (No Change) Tier 3 (No Change) NF (No Change)
Laxative Combinations Sutab Tier 3 -> NF NF (No Change) Tier 3 (No Change) NF (No Change)
Movement Disorders Xenazine Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change)
Multi-Source Brands Aptensio XR Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Exjade Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Firazyr Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Jadenu tab/sprinkle
Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change)
Sensipar Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change) Tracleer tab 62.5mg, 125mg
Tier 3 -> NF Tier 3 -> NF Tier 3 (No Change) NF (No Change)
Neurogenic Detrusor Overactivity (NDO) Myrbetriq susp Tier 3 (No Change) Tier 3 (No Change) Tier 3 (No Change) NF -> Tier 3^^
NSAID Combinations ibuprofen- famotidine
NF (No Change) NF (No Change) Tier 3 (No Change) Tier 2 -> NF^
Substance Abuse Disorder Bunavail Tier 3 (No Change) Tier 3 -> NF Tier 3 (No Change) NF (No Change)
Targeted Immune Modulators Taltz NF -> Tier 3 NF (No Change) Tier 3 (No Change) NF -> F
Topical Corticosteroids Combinations Wynzora Tier 3 -> NF NF (No Change) Tier 3 (No Change) NF (No Change)
* Members should refer to their member handbook for benefit details regarding applicable copayments or coinsurance ^
effective date 8/4/21
^^ effective date 9/10/21
Effective Date of Changes 7/1/2021
Drug Name National Drug List Tier Status Change
National Direct Drug List Tier Status Change
Traditional Open Drug List Tier Status Change
Essential Drug List Tier Status
Change
Insulin Pumps Cequr Tier 2 -> Tier 3^ Tier 2 -> NF^ Tier 2 -> Tier 3^ Tier 2 -> NF^ V-Go Tier 2 -> Tier 3^ Tier 2 -> NF^ Tier 2 -> Tier 3^ Tier 2 -> NF^
Opioids hydrocodone bitartrate tab ER
NF -> Tier 1 NF -> Tier 1 Tier 3 -> Tier 1 NF -> Tier 1
SGLT2/DPP-4 Glyxambi NF (No Change) NF -> Tier 2 Tier 3 (No Change) NF (No Change)
*Members should refer to their member handbook for benefit details regarding applicable copayments or coinsurance ^effective date 4/15/21
Please note: Drug list/formulary tier status changes impact commercial members using the Essential, National, National Direct and Traditional Open Drug Lists. The drug tier status changes reflected here do not impact drug coverage for members enrolled in a health insurance exchange or members who have prescription drug coverage through the Affordable Care Act.
Language:English
Score: 332925.9
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https://www.un.org/insurance/s...unbranded_formulary_update.pdf
Data Source: un