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BD - Part B vs. Part D, LA - This prescription may be available only at certain pharmacies, NF - Non-Formulary, PA - Prior Authorization, QL – Quantity Limit per 30 days, ST - Step Therapy.2021 FORMULARY CHANGESDrug NameCurrentDrug TierNew Drug TierReason For ChangeAlternative Drug, Alternative Drug TierEFFECTIVE 01/01/2021Aminosyn II Solution 10 % Intravenous4 + BDNFCMS Required DeletionN/ADesogestrel-Ethinyl Estradiol Tablet 0.15-30 MG-MCG Oral2NFCMS Required DeletionN/ADexamethasone Intensol Concentrate 1 MG/ML Oral2NFCMS Required DeletionN/ADextrose-NaCl Solution 5-0.225 % Intravenous2NFCMS Required DeletionN/ADojolvi Liquid 100 % OralNF5 + PA1Formulary EnhancementN/ADrizalma Sprinkle Capsule Delayed Release Sprinkle 20 MG Oral4 + QL 603 + QL 60Formulary EnhancementN/ADrizalma Sprinkle Capsule Delayed Release Sprinkle 30 MG Oral4 + QL 603 + QL 60Formulary EnhancementN/ADrizalma Sprinkle Capsule Delayed Release Sprinkle 40 MG Oral4 + QL 603 + QL 60Formulary EnhancementN/ADrizalma Sprinkle Capsule Delayed Release Sprinkle 60 MG Oral4 + QL 603 + QL 60Formulary EnhancementN/ADupixent Solution Pen-Injector 300 MG/2ML SubcutaneousNF5 + PA1Formulary EnhancementN/AEnbrel Solution 25 MG/0.5ML SubcutaneousNF5 + PA2Formulary EnhancementN/AEnspryng Solution Prefilled Syringe 120 MG/ML SubcutaneousNF5 + PA2Formulary EnhancementN/AEvrysdi Solution Reconstituted 0.75 MG/ML OralNF5 + PA1Formulary EnhancementN/AFintepla Solution 2.2 MG/ML OralNF4 + PA2Formulary EnhancementN/AHalog Solution 0.1 % ExternalNF4Formulary EnhancementN/AInqovi Tablet 35-100 MG OralNF5 + PA2Formulary EnhancementN/AKesimpta Solution Auto-Injector 20 MG/0.4ML SubcutaneousNF5 + PA1Formulary EnhancementN/AlamoTRIgine Kit 25 & 50 & 100 MG OralNF4Formulary EnhancementN/AmetFORMIN HCl Solution 500 MG/5ML Oral43Formulary EnhancementN/ANormosol-R SOLUTION Intravenous4 + BDNFCMS Required DeletionN/ARiomet ER Suspension Reconstituted ER 500 MG/5ML Oral43Formulary EnhancementN/ARukobia Tablet Extended Release 12 Hour 600 MG OralNF5 + QL 60Formulary EnhancementN/ASirturo Tablet 20 MG OralNF5Formulary EnhancementN/ASylatron KIT 200 MCG Subcutaneous5 + PA2NFCMS Required DeletionN/ASylatron KIT 300 MCG Subcutaneous5 + PA2NFCMS Required DeletionN/ATivicay PD Tablet Soluble 5 MG OralNF4 + QL 360Formulary EnhancementN/ATolvaptan Tablet 30 MG OralNF5 + PA1Formulary EnhancementN/AXpovio (40 MG Once Weekly) Tablet Therapy Pack 20 MG OralNF5 + PA2Formulary EnhancementN/AXpovio (40 MG Twice Weekly) Tablet Therapy Pack 20 MG OralNF5 + PA2Formulary EnhancementN/AXpovio (60 MG Twice Weekly) Tablet Therapy Pack 20 MG OralNF5 + PA2Formulary EnhancementN/AZostavax SUSPENSION RECONSTITUTED 19400 UNT/0.65ML Subcutaneous3NFCMS Required DeletionN/A ................
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