December 2018

Tier Changes

BRAND
NAME

Strength

COMMON
USE

TIER
CHANGE

CLINICAL EDITS

PDL Tier

Standard
formulary

Value
formulary

Performance
formulary

Advantage
formulary

Legacy
formulary

AMETHIA LO

0.10–0.02–0.01

Contraception

From 2 to 3

 

3

3

3

3

3

AZILECT

0.5, 1 MG

Parkinson's disease

From 2 to 3

QL

3

3

3

3

3

BILTRICIDE

600 MG

Parasitic infection

From 2 to 3

 

3

3

3

3

3

CELLCEPT

250, 500 MG; 200 MG/ML

Prevent organ rejection after transplant

From 2 to 3

 

3

3

3

3

3

COLCRYST

0.6 MG

Gout

From 2 to 3

 

3

3

3

3

3

ENTYVIO

300 MG

Crohn's disease or ulcerative colitis

From 3 to 2

PA

         

LAMICTAL ODT

25, 50, 100,

200 MG

Seizures

From 2 to 3

 

3

3

3

3

3

NEORAL

25 MG,
100 MG/ML

Prevent organ rejection after transplant

From 2 to 3

 

3

3

3

3

3

NEXIUM DR PKT

25 MG,
100 MG/ML

Acid reflux

From 3 to 2

QL

2

2

2
(no change)

2

2
(no change)

SANDIMMUNE

100 MG

Prevent organ rejection after transplant

From 2 to 3

 

3

3

3

3

3

SEASONIQUE

0.15-0.03-0.01

Contraception

From 2 to 3

 

3

3

3

3

3

TARGRETIN

75 MG

Cutaneous lymphoma

From 2 to 3

PA

3

3

3

3

3

TAZORAC

0.10%

Psoriasis

From 2 to 3

 

3

3

3

3

3

WELCHOL

625 MG,

3.75 G

Hyper-
cholesterolemia

From 2 to 3

 

3

3

3

3

3

PA: Prior authorization
QL: Quantity limit
ST: Step Therapy
T1/Tier 1: Generic
T2/Tier 2: Brand
T3/Tier 3: Non-preferred
NC: Not Covered: This drug is not covered. However, if the covered alternative is not appropriate for the customer, there is a process where his/her provider can request approval of this drug.

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