June 2019

Tier Changes

Brand Name

Strength

Common Use

Tier Change

Clinical Edits

PDL Tier

Standard Formulary

Value Formulary

Performance Formulary

Advantage Formulary

Legacy Formulary

AIMOVIG

70 MG/ML AUTOINJECTOR

Migraine

From 3 to 2

PA

2

2

2

2

2

BELBUCA

75, 150, 300, 450, 600, 750, 900 MCG FILM

Moderate-to-severe pain

Remove ST

2

2

2

2

2

CARAFATE

1 GM/10 ML SUSPENSION

Gastrointestinal ulcer

From 3 to 2

2

2

2

2

COMBIGEN 

0.2%-.05% EYE DROPS

Glaucoma

From 3 to 2

2

2

2

2

2

ESBRIET

267 MG CAPSULE, 801 MG TABLET

Pulmonary fibrosis

From 3 to 2

PA

2

2

2

2

2

FLOVENT, FLOVENT HFA

50, 100, 250 MCG DISKUS; 44, 110, 220 MCG INHALER

Asthma, COPD

From 3 to 2

2

2

2

2

2

LATUDA

20, 40, 60, 80, 120 MG TABLET

Schizophrenia, bipolar disorder

From 3 to 2

2

2

2

2

2

LETAIRIS

5, 10MG TABLET

Pulmonary arterial hypertension

From 3 to 2

PA

2

2

2

2

2

LUMIGAN

0.01% EYE DROPS

Glaucoma

From 3 to 2

2

NC (no change)

2

NC (no change)

2

OFEV

100, 150 MG CAPSULE

Pulmonary fibrosis

From 3 to 2

PA

2

2

2

2

2

OPSUMIT

10 MG TABLET

Pulmonary arterial hypertension

From 3 to 2

PA

2

2

2

2

2

SOOLANTRA

1% CREAM

Rosacea

From 3 to 2

2

2

2

2

2

STRENSIQ 

18 MG/0.45 ML, 28 MG/0.7 ML, 40 MG/ML AND 80 MG/0.8 ML VIAL

Hypophosphatasia

From 3 to 2

PA

2

2

2

2

2

TOBI PODHALER 

28 MG INHALE CAP

Bacterial infection

From 3 to 2

2

2

2

2

2

TRACLEER

32, 62.5, 125 MG TABLET

Pulmonary arterial hypertension

From 3 to 2

PA

2

2

2

2

2

V-GO

20, 30 AND 40 DISPOSABLE DEVICE

Diabetes

From 3 to 2

2

2

2

2

2

XIFAXAN

200, 500 MG TABLET

Bacterial infection

From 3 to 2

2

2

2

2

2

TRACLEER

32 MG TABLET FOR SUSP

Pulmonary Anti-Htn, Endothelin Receptor Antagonist

PA

2

2

2

2

2

V-GO

20, 30 AND 40 DISPOSABLE DEVICE

Diabetic Supplies

2

2

2

2

2

XIFAXAN

200, 500 MG TABLET

Rifamycins and related Derivative Antiobiotics

2

2

2

2

2

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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