2025 EmblemHealth Formulary Changes

10/29/2024

Effective Date: Jan. 1, 2025

The tables below describe all formulary changes going into effect for our Medicare and Medicaid members in 2025. For our Commercial members, these tables highlight the most highly impacted drugs. For a comprehensive listing of all plans see: 2025 Summary Lines of Business, Networks & Benefit Plans.

See the applicable 2025 plan formularies for all coverage rules:

Note: Affected members were notified of these changes separately.

Medicare Advantage Plans (EmblemHealth Plan, Inc. (formerly GHI) and HIP)
Medicare CNY PDP (City Retirees’ Prescription Drug Plan Only)
City of NY PPO
City of NY HMO
Commercial Small Group/Essential/Individual Plans
Commercial Large Group

Medicare Advantage Plans Step Therapy Added in 2025
Drug	Alternative(s)
FANAPT 1 MG	RISPERIDONE, LURASIDONE, ARIPIPRAZOLE
FANAPT 10 MG	RISPERIDONE, LURASIDONE, ARIPIPRAZOLE
FANAPT 12 MG	RISPERIDONE, LURASIDONE, ARIPIPRAZOLE
FANAPT 2 MG	RISPERIDONE, LURASIDONE, ARIPIPRAZOLE
FANAPT 4 MG	RISPERIDONE, LURASIDONE, ARIPIPRAZOLE
FANAPT 6 MG	RISPERIDONE, LURASIDONE, ARIPIPRAZOLE
FANAPT TITRATION PACK	RISPERIDONE, LURASIDONE, ARIPIPRAZOLE
RELISTOR 12 MG/0.6 ML VIAL	SYMPROIC
RELISTOR 12 MG/0.6 ML SYRINGE	SYMPROIC
RELISTOR 8 MG/0.4 ML SYRINGE	SYMPROIC
FLUTICASONE PROP HFA 44 MCG	BUDESONIDE, PULMICORT, ASMANEX
FLUTICASONE PROP HFA 110 MCG	BUDESONIDE, PULMICORT, ASMANEX
FLUTICASONE PROP HF 220 MCG	BUDESONIDE, PULMICORT, ASMANEX

Medicare Advantage Plans Drugs Moving to Non-Formulary in 2025
Drug	Alternative(s)
ADALIMUMAB-ADAZ(CF) 40 MG SYRG	HUMIRA, ENBREL, STELARA
ADALIMUMAB-ADAZ(CF) PEN 40 MG	HUMIRA, ENBREL, STELARA
ADALIMUMAB-ADBM(CF) 10 MG SYRG	HUMIRA, ENBREL, STELARA
ADALIMUMAB-ADBM(CF) 20 MG SYRG	HUMIRA, ENBREL, STELARA
ADALIMUMAB-ADBM(CF) 40 MG SYRG	HUMIRA, ENBREL, STELARA
ADALIMUMAB-ADBM(CF) CRHN 40MG	HUMIRA, ENBREL, STELARA
ADALIMUMAB-ADBM(CF) PEN 40 MG	HUMIRA, ENBREL, STELARA
ADALIMUMAB-ADBM(CF) PS-UV 40MG	HUMIRA, ENBREL, STELARA
ALREX 0.2% EYE DROPS	LOTEPREDNOL ETABONATE 0.2% EYE DROPS, LOTEPREDNOL ETABONATE 0.5% EYE DROPS
APOKYN 30 MG/3 ML CARTRIDGE	BENZTROPINE, AMANTADINE, CARBIDOPA-LEVODOPA
APOMORPHINE 30 MG/3 ML CARTRDG	BENZTROPINE, AMANTADINE, CARBIDOPA-LEVODOPA
AZASITE 1% EYE DROPS	CIPROFLOXACIN EYE DROP, ERYTHROMYCIN EYE OINTMENT, MOXIFLOXACIN EYE DROP
BEPOTASTINE 1.5% EYE DROP	OLOPATADINE EYE DROPS, AZELASTINE EYE DROPS
BESIVANCE 0.6% SUSP	CIPROFLOXACIN EYE DROP, ERYTHROMYCIN EYE OINTMENT, MOXIFLOXACIN EYE DROP
BICILLIN C-R 1.2 MILLION UNIT	BICILLIN L-A, AMPICILLIN, NAFCILLIN
BICILLIN C-R 900-300 SYRINGE	BICILLIN L-A, AMPICILLIN, NAFCILLIN
BROMSITE 0.075% EYE DROPS	BROMFENAC EYE DROPS, KETOROLAC OPHTHALMIC SOLUTION, DEXAMETHASONE EYE DROP
CALCITRIOL 3 MCG/G OINTMENT	CALCIPOTRIENE, TAZAROTENE
CEFACLOR ER 500 MG TABLET	CEFACLOR CAPSULE/SUSPENSION, CEFUROXIME
CHENODAL 250 MG TABLET	URSODIOL
CHOLBAM 250 MG CAPSULE	URSODIOL
CHOLBAM 50 MG CAPSULE	URSODIOL
CIMETIDINE 200 MG TABLET	FAMOTIDINE, NIZATIDINE
CIMETIDINE 300 MG TABLET	FAMOTIDINE, NIZATIDINE
CIMETIDINE 300 MG/5 ML SOLN	FAMOTIDINE, NIZATIDINE
CIMETIDINE 400 MG TABLET	FAMOTIDINE, NIZATIDINE
CIMETIDINE 400 MG/6.67 ML SOLN	FAMOTIDINE, NIZATIDINE
CIMETIDINE 800 MG TABLET	FAMOTIDINE, NIZATIDINE
CLODAN 0.05% SHAMPOO	CICLODAN 8% SOLUTION, CICLOPIROX, KETOCONAZOLE
CORLANOR 5 MG/5 ML ORAL SOLN	CORLANOR TABLETS
DESONIDE 0.05% GEL	DESONIDE 0.05% OINTMENT, DESONIDE 0.05% CREAM
DESONIDE 0.05% LOTION	DESONIDE 0.05% OINTMENT, DESONIDE 0.05% CREAM
DESRX 0.05% GEL	DESONIDE, BETAMETHASONE
DIGOXIN 62.5 MCG TABLET	DIGOXIN 125 MCG TABLET, DIGOXIN 250 MCG TABLET
DIPHENHYDRAMINE 12.5 MG/5 ML CUP	HYDROXYZINE, PROMETHAZINE
DIPHENHYDRAMINE 25 MG/10 ML CUP	HYDROXYZINE, PROMETHAZINE
E.E.S. 400 MG TABLET	ERYTHROMYCIN, AZITHROMYCIN, CLARITHROMYCIN
ELETRIPTAN HBR 20 MG TABLET	SUMATRIPTAN, RIZATRIPTAN, NARATRIPTAN
ELETRIPTAN HBR 40 MG TABLET	SUMATRIPTAN, RIZATRIPTAN, NARATRIPTAN
EMEND 125 MG POWDER PACKET	APREPITANT, FOSAPREPITANT
EPCLUSA 150-37.5 MG PELLET PKT	SOFOSBUVIR-VELPATASVIR, LEDIPASVIR-SOFOSBUVIR
EPCLUSA 200 MG-50 MG TABLET	SOFOSBUVIR-VELPATASVIR, LEDIPASVIR-SOFOSBUVIR
EPCLUSA 200-50 MG PELLET PACK	SOFOSBUVIR-VELPATASVIR, LEDIPASVIR-SOFOSBUVIR
EPCLUSA 400 MG-100 MG TABLET	SOFOSBUVIR-VELPATASVIR, LEDIPASVIR-SOFOSBUVIR
FESOTERODINE ER 4 MG TABLET	TOLTERODINE TARTRATE, OXYBUTYNIN, SOLIFENACIN
FESOTERODINE ER 8 MG TABLET	TOLTERODINE TARTRATE, OXYBUTYNIN, SOLIFENACIN
FIRDAPSE 10 MG TABLET	DALFAMPRIDINE
FLAVOXATE HCL 100 MG TABLET	OXYBUTYNIN, TOLTERODINE, TROSPIUM CHLORIDE
FLUOXETINE DR 90 MG CAPSULE	FLUOXETINE CAPSULE, CITALOPRAM, SERTRALINE
FLUOXETINE HCL 10 MG TABLET	FLUOXETINE CAPSULE, CITALOPRAM, SERTRALINE
FLUOXETINE HCL 20 MG TABLET	FLUOXETINE CAPSULE, CITALOPRAM, SERTRALINE
FLUVOXAMINE ER 100 MG CAPSULE	FLUVOXAMINE MALEATE TABLETS, FLUOXETINE CAPSULE, CITALOPRAM
FLUVOXAMINE ER 150 MG CAPSULE	FLUVOXAMINE MALEATE TABLETS, FLUOXETINE CAPSULE, CITALOPRAM
FOLOTYN 20 MG/ML VIAL	PRALATREXATE, METHOTREXATE
FOLOTYN 40 MG/2 ML VIAL	PRALATREXATE, METHOTREXATE
FOSAMAX PLUS D 70 MG-2800 UNIT	ALENDRONATE, IBANDRONATE, RISEDRONATE
FOSAMAX PLUS D 70 MG-5600 UNIT	ALENDRONATE, IBANDRONATE, RISEDRONATE
GLYCOPYRROLATE 1.5 MG TABLET	GLYCOPYRROLATE 1 MG TABET, GLYCOPYRROLATE 2 MG TABLET
GRALISE ER 300 MG TABLET	GABAPENTIN ER TABLET, PREGABALIN CAPSULE
GRALISE ER 450 MG TABLET	GABAPENTIN ER TABLET, PREGABALIN CAPSULE
GRALISE ER 600 MG TABLET	GABAPENTIN ER TABLET, PREGABALIN CAPSULE
GRALISE ER 750 MG TABLET	GABAPENTIN ER TABLET, PREGABALIN CAPSULE
GRALISE ER 900 MG TABLET	GABAPENTIN ER TABLET, PREGABALIN CAPSULE
HALAVEN 1 MG/2 ML VIAL	ERIBULIN MESYLATE
HARVONI 33.75-150 MG PELLET PK	LEDIPASVIR-SOFOSBUVIR, SOFOSBUVIR-VELPATASVIR
HARVONI 45-200 MG PELLET PACKT	LEDIPASVIR-SOFOSBUVIR, SOFOSBUVIR-VELPATASVIR
HARVONI 45-200 MG TABLET	LEDIPASVIR-SOFOSBUVIR, SOFOSBUVIR-VELPATASVIR
HARVONI 90-400 MG TABLET	LEDIPASVIR-SOFOSBUVIR, SOFOSBUVIR-VELPATASVIR
HYDROCODONE-ACETAMINOPHEN 10-300 MG	HYDROCODONE-ACETAMINOPHEN 10-325 MG, HYDROCODONE-ACETAMINOPHEN 7.5-325 MG, HYDROCODONE-ACETAMINOPHEN 5-325 MG
HYDROCODONE-ACETAMINOPHEN 5-300 MG	HYDROCODONE-ACETAMINOPHEN 5-325 MG, HYDROCODONE-ACETAMINOPHEN 7.5-325 MG, HYDROCODONE-ACETAMINOPHEN 10-325 MG
HYDROCODONE-ACETAMINOPHEN 7.5-300	HYDROCODONE-ACETAMINOPHEN 7.5-325 MG, HYDROCODONE-ACETAMINOPHEN 5-325 MG, HYDROCODONE-ACETAMINOPHEN 10-325 MG
HYDROCODONE-IBUPROFEN 10-200	HYDROCODONE-IBUPROFEN 7.5-200, HYDROCODONE-ACETAMINOPHEN
HYDROCODONE-IBUPROFEN 5-200 MG	HYDROCODONE-IBUPROFEN 7.5-200, HYDROCODONE-ACETAMINOPHEN
HYRIMOZ(CF) 10 MG/0.1 ML SYRNG	HUMIRA, ENBREL, STELARA
HYRIMOZ(CF) 20 MG/0.2 ML SYRNG	HUMIRA, ENBREL, STELARA
HYRIMOZ(CF) 40 MG/0.4 ML SYRNG	HUMIRA, ENBREL, STELARA
HYRIMOZ(CF) PEDI CROHN 80 MG	HUMIRA, ENBREL, STELARA
HYRIMOZ(CF) PEDI CROHN 80-40 MG	HUMIRA, ENBREL, STELARA
HYRIMOZ(CF) PEN 40 MG/0.4 ML	HUMIRA, ENBREL, STELARA
HYRIMOZ(CF) PEN 80 MG/0.8 ML	HUMIRA, ENBREL, STELARA
HYRIMOZ(CF) PEN CROHN-UC 80 MG	HUMIRA, ENBREL, STELARA
HYRIMOZ(CF) PEN PSORIA 80-40 MG	HUMIRA, ENBREL, STELARA
IMIPRAMINE PAMOATE 100 MG CAP	IMIPRAMINE TABLET, TRIMIPRAMINE MALEATE CAP
IMIPRAMINE PAMOATE 125 MG CAP	IMIPRAMINE TABLET, TRIMIPRAMINE MALEATE CAP
IMIPRAMINE PAMOATE 150 MG CAP	IMIPRAMINE TABLET, TRIMIPRAMINE MALEATE CAP
IMIPRAMINE PAMOATE 75 MG CAP	IMIPRAMINE TABLET, TRIMIPRAMINE MALEATE CAP
INSULIN GLARGINE 100 UNIT/ML	LANTUS VIAL, LANTUS SOLOSTAR, TOUJEO SOLOSTAR
INSULIN GLARGINE SOLOSTAR U100	LANTUS VIAL, LANTUS SOLOSTAR, TOUJEO SOLOSTAR
ISOTRETINOIN 25 MG CAPSULE	ISOTRETINOIN 20 MG CAPSULE, ISOTRETINOIN 30 MG CAPSULE, ISOTRETINOIN 40 MG CAPSULE
ISOTRETINOIN 35 MG CAPSULE	ISOTRETINOIN 20 MG CAPSULE, ISOTRETINOIN 30 MG CAPSULE, ISOTRETINOIN 40 MG CAPSULE
IVERMECTIN 1% CREAM	AZELAIC ACID 15% GEL, TOPICAL METRONIDAZOLE
JUXTAPID 10 MG CAPSULE	STATIN MEDICATIONS, REPATHA
JUXTAPID 20 MG CAPSULE	STATIN MEDICATIONS, REPATHA
JUXTAPID 30 MG CAPSULE	STATIN MEDICATIONS, REPATHA
JUXTAPID 5 MG CAPSULE	STATIN MEDICATIONS, REPATHA
KORLYM 300 MG TABLET	MIFEPRISTONE 300 MG TABLET
LAMOTRIGINE ODT KIT (BLUE)	LAMOTRIGINE ODT, LAMOTRIGINE, LAMOTRIGINE ER
LAMOTRIGINE ODT KIT (GREEN)	LAMOTRIGINE ODT, LAMOTRIGINE, LAMOTRIGINE ER
LAMOTRIGINE ODT KIT (ORANGE)	LAMOTRIGINE ODT, LAMOTRIGINE, LAMOTRIGINE ER
LAMOTRIGINE TAB START KIT-BLUE	LAMOTRIGINE ODT, LAMOTRIGINE, LAMOTRIGINE ER
LAMOTRIGINE TAB START KT-GREEN	LAMOTRIGINE ODT, LAMOTRIGINE, LAMOTRIGINE ER
LAMOTRIGINE TAB START KT-ORANG	LAMOTRIGINE ODT, LAMOTRIGINE, LAMOTRIGINE ER
LEUKINE 250 MCG VIAL	RELEUKO, FULPHILA, NIVESTYM
LEVALBUTEROL 0.31 MG/3 ML SOL	ALBUTEROL SOLUTION, ALBUTEROL INHALER
LEVALBUTEROL 0.63 MG/3 ML SOL	ALBUTEROL SOLUTION, ALBUTEROL INHALER
LEVALBUTEROL 1.25 MG/3 ML SOL	ALBUTEROL SOLUTION, ALBUTEROL INHALER
LEVALBUTEROL CONC 1.25 MG/0.5	ALBUTEROL SOLUTION, ALBUTEROL INHALER
LEVONO-E ESTRAD 0.15-0.03-0.01	LEVONOR-E ESTRAD 0.1-0.02-0.01, LEVONOR-ETH ESTRAD 0.1-0.02
LEVONOR-ETH ESTRA 0.09-0.02 MG	LEVONOR-ETH ESTRAD 0.1-0.02, LEVONOR-E ESTRAD 0.1-0.02-0.01
MENEST 0.3 MG TABLET	ESTRADIOL, PREMARIN, MIMVEY
MENEST 0.625 MG TABLET	ESTRADIOL, PREMARIN, MIMVEY
MENEST 1.25 MG TABLET	ESTRADIOL, PREMARIN, MIMVEY
MENEST 2.5 MG TABLET	ESTRADIOL, PREMARIN, MIMVEY
METOPROLOL TARTRATE 37.5 MG TB	METOPROLOL 25 MG TAB, METOPROLOL 50 MG TAB, METOPROLOL 100 MG TAB
METOPROLOL TARTRATE 75 MG TAB	METOPROLOL 25 MG TAB, METOPROLOL 50 MG TAB, METOPROLOL 100 MG TAB
MOVANTIK 12.5 MG TABLET	SYMPROIC, RELISTOR
MOVANTIK 25 MG TABLET	SYMPROIC, RELISTOR
MOZOBIL 24 MG/1.2 ML VIAL	PLERIXAFOR
NAFTIFINE HCL 1% CREAM	NAFTIFINE GEL, TOPICAL KETOCONAZOLE, TOPICAL NYSTATIN
NAFTIFINE HCL 2% CREAM	NAFTIFINE GEL, TOPICAL KETOCONAZOLE, TOPICAL NYSTATIN
NISOLDIPINE ER 17 MG TABLET	AMLODIPINE, FELODIPINE ER, NIFEDIPINE ER
NISOLDIPINE ER 20 MG TABLET	AMLODIPINE, FELODIPINE ER, NIFEDIPINE ER
NISOLDIPINE ER 25.5 MG TABLET	AMLODIPINE, FELODIPINE ER, NIFEDIPINE ER
NISOLDIPINE ER 30 MG TABLET	AMLODIPINE, FELODIPINE ER, NIFEDIPINE ER
NISOLDIPINE ER 34 MG TABLET	AMLODIPINE, FELODIPINE ER, NIFEDIPINE ER
NISOLDIPINE ER 40 MG TABLET	AMLODIPINE, FELODIPINE ER, NIFEDIPINE ER
NISOLDIPINE ER 8.5 MG TABLET	AMLODIPINE, FELODIPINE ER, NIFEDIPINE ER
OLANZAPINE-FLUOXETINE 12-25 MG	OLANZAPINE; FLUOXETINE (SEPARATE)
OLANZAPINE-FLUOXETINE 12-50 MG	OLANZAPINE; FLUOXETINE (SEPARATE)
OLANZAPINE-FLUOXETINE 3-25 MG	OLANZAPINE; FLUOXETINE (SEPARATE)
OLANZAPINE-FLUOXETINE 6-25 MG	OLANZAPINE; FLUOXETINE (SEPARATE)
OLANZAPINE-FLUOXETINE 6-50 MG	OLANZAPINE; FLUOXETINE (SEPARATE)
OMNIPOD CLASSIC PDM KIT (GEN 3)	OMNIPOD 5, OMNIPOD GO, OMNIPOD DASH
OMNIPOD CLASSIC PODS (GEN3) 5-PK	OMNIPOD 5, OMNIPOD GO, OMNIPOD DASH
PEG3350 100-7.5-2.691-1.01-5.9	GAVILYTE-C, GAVILYTE-G, PEG-3350 AND ELECTROLYTES SOLUTION
PENTASA 250 MG CAPSULE	MESALAMINE, SULFASALAZINE, BALSALAZIDE
PERSERIS ER 120 MG SYRINGE KIT	RISPERIDONE, LURASIDONE, ZIPRASIDONE
PERSERIS ER 90 MG SYRINGE KIT	RISPERIDONE, LURASIDONE, ZIPRASIDONE
PHOSPHOLINE IODIDE 0.125% DROP	BRIMONIDINE, TIMOLOL, LATANOPROST
PLASMA-LYTE A PH 7.4 SOLUTION	ISOLYTE S IV SOLUTION PH 7.4, MULTIPLE ELECTROYLTES T1 PH 7.4
PROLENSA 0.07% EYE DROPS	BROMFENAC EYE DROPS, KETOROLAC OPHTHALMIC SOLUTION PREDNISOLONE EYE DROP
QTERN 10 MG-5 MG TABLET	GLYXAMBI, FARXIGA
QTERN 5 MG-5 MG TABLET	GLYXAMBI, FARXIGA
RECTIV 0.4% OINTMENT	NITROGLYCERIN 4% OINTMENT
RISPERDAL CONSTA 12.5 MG VIAL	RISPERIDONE ER VIAL, ZIPRASIDONE VIAL, INVEGA
RISPERDAL CONSTA 25 MG VIAL	RISPERIDONE ER VIAL, ZIPRASIDONE VIAL, INVEGA
RISPERDAL CONSTA 37.5 MG VIAL	RISPERIDONE ER VIAL, ZIPRASIDONE VIAL, INVEGA
RISPERDAL CONSTA 50 MG VIAL	RISPERIDONE ER VIAL, ZIPRASIDONE VIAL, INVEGA
SILODOSIN 4 MG CAPSULE	TAMSULOSIN, ALFUZOSIN ER
SILODOSIN 8 MG CAPSULE	TAMSULOSIN, ALFUZOSIN ER
SIMLANDI(CF) AI 40 MG/0.4 ML	HUMIRA, ENBREL, STELARA
SUBVENITE TAB START KIT (BLUE)	SUBVENITE 25 MG TABLET, SUBVENITE 100 MG TABLET, SUBVENITE 150 MG TABLET
SUBVENITE TAB START KIT(GREEN)	SUBVENITE 25 MG TABLET, SUBVENITE 100 MG TABLET, SUBVENITE 150 MG TABLET
SUBVENITE TAB START KT(ORANGE)	SUBVENITE 25 MG TABLET, SUBVENITE 100 MG TABLET, SUBVENITE 150 MG TABLET
TAFLUPROST 0.0015% EYE DROP	LATANOPROST EYE DROPS, TRAVOPROST EYE DROP
TALTZ 20 MG/0.25 ML SYRINGE	HUMIRA, ENBREL, STELARA
TALTZ 40 MG/0.5 ML SYRINGE	HUMIRA, ENBREL, STELARA
TALTZ 80 MG/ML AUTOINJ (2-PK)	HUMIRA, ENBREL, STELARA
TALTZ 80 MG/ML AUTOINJ (3-PK)	HUMIRA, ENBREL, STELARA
TALTZ 80 MG/ML AUTOINJECTOR	HUMIRA, ENBREL, STELARA
TALTZ 80 MG/ML SYRINGE	HUMIRA, ENBREL, STELARA
TARINA 24 FE 1 MG-20 MCG TAB	TARINA FE 1-20 EQ TABLET, LARIN FE, TRI-LOW SPRINTEC
TESTOSTERONE 10 MG GEL PUMP	TESTOSTERONE 1.62% GEL PUMP, TESTOSTERONE CYPIONATE
THEO-24 ER 100 MG CAPSULE	THEOPHYLLINE, ELIXOPHYLLIN
THEO-24 ER 200 MG CAPSULE	THEOPHYLLINE, ELIXOPHYLLIN
THEO-24 ER 300 MG CAPSULE	THEOPHYLLINE, ELIXOPHYLLIN
THEO-24 ER 400 MG CAPSULE	THEOPHYLLINE, ELIXOPHYLLIN
VANCOMYCIN HCL 100 GM SMARTPAK	VANCOMYCIN VIALS
VANDAZOLE VAGINAL 0.75% GEL	METRONIDAZOLE VAGINAL GEL, CLINDAMYCIN VAGINAL GEL
VECAMYL 2.5 MG TABLET	LISINOPRIL
VEKLURY 100 MG VIAL	PAXLOVID
V-GO 20 DISPOSABLE DEVICE	OMNIPOD, CEQUR SIMPLICITY
V-GO 30 DISPOSABLE DEVICE	OMNIPOD, CEQUR SIMPLICITY
V-GO 40 DISPOSABLE DEVICE	OMNIPOD, CEQUR SIMPLICITY
VIIBRYD 10-20 MG STARTER PACK	VILAZODONE
VIOKACE 10,440-39,150 UNIT TAB	CREON, ZENPEP
VIOKACE 20,880-78,300 UNITS TB	CREON, ZENPEP
VOTRIENT 200 MG TABLET	PAZOPANIB
XATMEP 2.5 MG/ML ORAL SOLUTION	METHOTREXATE, JYLAMVO
ZARXIO 300 MCG/0.5 ML SYRINGE	RELEUKO, NIVESTYM, FULPHILA
ZARXIO 480 MCG/0.8 ML SYRINGE	RELEUKO, NIVESTYM, FULPHILA
ZEGALOGUE 0.6 MG/0.6 ML SYRING	BAQSIMI, GVOKE
ZEGALOGUE 0.6 MG/0.6 ML AUTOINJ	BAQSIMI, GVOKE
ZIEXTENZO 6 MG/0.6 ML SYRINGE	RELEUKO,FULPHILA , NIVESTYM
ZOLMITRIPTAN 2.5 MG ODT	SUMATRIPTAN, RIZATRIPTAN, NARATRIPTAN
ZOLMITRIPTAN 2.5 MG TABLET	SUMATRIPTAN, RIZATRIPTAN, NARATRIPTAN
ZOLMITRIPTAN 5 MG ODT	SUMATRIPTAN, RIZATRIPTAN, NARATRIPTAN
ZOLMITRIPTAN 5 MG TABLET	SUMATRIPTAN, RIZATRIPTAN, NARATRIPTAN

Medicare Advantage Plans New Tier 5 Drugs
CINACALCET HCL 90 MG
COLISTIMETHATE 150 MG VIAL
DIAZOXIDE 50 MG/ML ORAL SUSP
EMTRICITBINE-TENOFV 100 MG-150 MG

Medicare Advantage Plans New Preauthorization Requirements for Listed Drugs in 2025
ADVOCATE ALCOHOL 70% PREP PADS	BD UF MINI PEN NEEDLE 5 MM X 31 G	PHARM CHOICE ALCOHOL PREP PADS
ALCOHOL 70% PADS	BD UF NANO PEN NEEDLE 4 MM X 32 G	PREP EASE ALCOHOL PADS
ALCOHOL 70% PREP PADS	BD UF ORIG PEN NDL 12.7 MM X 29 G	PRO COMFORT ALCOHOL 70% PADS
ALCOHOL 70% SWABS	BD UF SHORT PEN NEEDLE 8 MM X 31 G	PURE COMFORT ALCOHOL 70% PADS
ALCOHOL 70% WIPES	BD VEO INS 0.3 ML 6 MM X 31 G (1/2)	QC ALCOHOL 70% SWABS
ALCOHOL PREP PADS	BD VEO INS SYRING 1 ML 6 MM X 31 G	RA ALCOHOL SWABS
ALCOHOL SWAB	BD VEO INS SYRN 0.3 ML 6 MM X 31 G	RA GAUZE PADS 2" X 2"
ALCOHOL SWABS	BD VEO INS SYRN 0.5 ML 6 MM X 31 G	RA ISOPROPYL ALCOHOL 70% WIPES
BAND-AID GAUZE PADS 2" X 2"	BORDERED GAUZE 2" X 2"	RA STERILE PADS 2" X 2"
BD AUTOSHIELD DUO NDL 5 MM X 30 G	CARETOUCH ALCOHOL 70% PREP PAD	RELEUKO 300 MCG/0.5 ML SYRINGE
BD ECLIPSE 30 G X 1/2" SYRINGE	COSENTYX 125 MG/5 ML VIAL	RELEUKO 300 MCG/ML VIAL
BD INS SYR 0.3 ML 8 MM X 31 G (1/2)	COSENTYX 150 MG/ML SYRINGE	RELEUKO 480 MCG/0.8 ML SYRINGE
BD INS SYR U-500 ½ ML 6 MM X 31 G	COSENTYX 300 MG DOSE-2 SYRINGE	RELEUKO 480 MCG/1.6 ML VIAL
BD INS SYR UF 0.3 ML 12.7 MM X 30 G	COSENTYX 75 MG/0.5 ML SYRINGE	RELION ALCOHOL 70% SWABS
BD INS SYR UF 0.5 ML 12.7 MM X 30 G	COSENTYX SENSOREADY 150 MG PEN	SAPS ALCOHOL 70% PREP PADS
BD INS SYRN UF 1 ML 12.7 MM X 30 G	COSENTYX SNRDY 300 MG DOSE-2PEN	SM ALCOHOL 70% PREP PADS
BD INS SYRN UF 1 ML 30 G X 12.7 MM	COSENTYX UNOREADY 300 MG PEN	SM STERILE PADS 2" X 2"
BD INS SYRNG 0.3 ML 29 G X 12.7 MM	CURITY ALCOHOL PREPS	SOFOSBUVIR-VELPATASVIR 400-100
BD INS SYRNG 0.5 ML 29 G X 12.7 MM	CURITY GAUZE SPONGES	SOTYKTU 6 MG TABLET
BD INS SYRNG UF 0.3 ML 8 MM X 31 G	CURITY GUAZE PADS	STERILE GAUZE PADS 2" X 2"
BD INS SYRNG UF 0.5 ML 8 MM X 31 G	CVS ALCOHOL 70% PREP PADS	STERILE PADS 2" X 2"
BD INSULIN SYR 0.5 ML 28 G X 1/2"	CVS GAUZE PADS 2" X 2"	SURE COMFORT ALCOHOL PREP PADS
BD INSULIN SYR 1 ML 25 G X 1"	CVS ISOPROPYL ALCOHOL 70% WIPE	SURE-PREP ALCOHOL PREP PADS
BD INSULIN SYR 1 ML 25 G X 5/8"	DERMACEA 2" X 2" GAUZE	SWI ALCOHOL 70% PREP PADS
BD INSULIN SYR 1 ML 26 G X 1/2"	DERMACEA GAUZE 2" X 2" SPONGE	TADALAFIL 2.5 MG TABLET
BD INSULIN SYR 1 ML 27 G X 12.7MM	DERMACEA NON-WOVEN 2" X 2" SPNGE	TADALAFIL 5 MG TABLET
BD INSULIN SYR 1 ML 27 G X 5/8"	DROPSAFE ALCOHOL 70% PREP PADS	TREMFYA 100 MG/ML INJECTOR
BD INSULIN SYR 1 ML 28 G X 1/2"	EASY COMFORT ALCOHOL 70% PAD	TREMFYA 100 MG/ML SYRINGE
BD INSULIN SYR 1 ML 29 G X 12.7 MM	EASY TOUCH ALCOHOL 70% PADS	TRUE COMFORT ALCOHOL 70% PADS
BD INSULIN SYR UF 1 ML 8 MM X 31 G	ESTRADIOL 0.06% 1.25 G GEL PUMP	TRUE COMFORT PRO ALCOHOL PADS
BD INSULIN SYRINGE 1 ML	FIFTY50 ALCOHOL PREP PADS	ULTILET ALCOHOL STERL SWAB
BD LUER-LOK SYRINGE 1 ML	FULPHILA 6 MG/0.6 ML SYRINGE	VERSALON ALL PURPOSE SPONGE
BD NANO 2 GEN PEN NDL 32 G 4 MM	GAUZE PADS 2" X 2"	VOWST CAPSULE
BD SAFETGLD INS 0.3 ML 29 G 13 MM	GNP ALCOHOL SWAB	WEBCOL ALCOHOL PREPS
BD SAFETGLD INS 0.5 ML 13 MM X 29 G	HEB INCONTROL ALCOHOL 70% PADS	XIFAXAN 200 MG TABLET
BD SAFETYGLD INS 0.3 ML 31G 8 MM	HM ALCOHOL 70% PREP PADS	XIFAXAN 550 MG TABLET
BD SAFETYGLD INS 0.5 ML 30 G 8 MM	IV PREP ANTISEPTIC WIPES	YUFLYMA(CF) 20 MG/0.2 ML SYRNG
BD SAFETYGLD INS 1 ML 29 G 13 MM	LEDIPASVIR-SOFOSBUVIR 90-400 MG	YUFLYMA(CF) 40 MG/0.4 ML SYRNG
BD SAFETYGLID INS 1 ML 6 MM X 31 G	LISCO SPONGES	YUFLYMA(CF) 40 MG/0.4 ML AUTOINJ
BD SAFETYGLIDE SYRINGE 27 G X 5/8	LIVTENCITY 200 MG TABLET	YUFLYMA(CF) 80 MG/0.8 ML AUTOINJ
BD SAFTYGLD INS 0.3 ML 6 MM X 31 G	MAVYRET 100-40 MG TABLET	YUFLYMA(CF) AI CROHNS-UC-HS 80
BD SAFTYGLD INS 0.5 ML 6 MM X 31 G	MAVYRET 50-20 MG PELLET PACKET	PHARM CHOICE ALCOHOL PREP PADS
BD SAFTYGLD INS 0.5 ML 29 G 13 MM	NOVOFINE 32 G NEEDLES	PREP EASE ALCOHOL PADS
BD SINGLE USE SWAB	NOVOFINE AUTOCOVER 30 G NEEDLE	PRO COMFORT ALCOHOL 70% PADS
BD UF MICRO PEN NEEDLE 6 MM X 32 G	NOVOFINE PLUS PEN NDL 32 G X 1/6"	PURE COMFORT ALCOHOL 70% PADS

Medicare Advantage Members New Quantity Limits for 2025
Drug	Amount/Frequency
ADEMPAS TABLET	90/MONTH
ALINIA 500 MG TABLET	12/MONTH
AMBRISENTAN TABLET	30/MONTH
BOSENTAN TABLET	60/MONTH
BOSULIF 100 MG CAPSULE	180/MONTH
BOSULIF 50 MG CAPSULE	330/MONTH
DABIGATRAN ETEXILATE CP	60/MONTH
ELIQUIS TABLET	60/MONTH
ELIQUIS DVT-PE TREAT START 5 MG	74/6 MONTHS
ELYXYB 120 MG/4.8 ML SOLUTION	57.6/21 DAYS
FRUZAQLA 5 MG CAPSULE	21/21 DAYS
ISTURISA 5 MG TABLET	360/MONTH
LETAIRIS 10 MG TABLET	30/MONTH
LETAIRIS 5 MG TABLET	30/MONTH
LIQREV 10 MG/ML ORAL SUSP	244.2 ML/MONTH
LUMAKRAS 120 MG TABLET	240/MONTH
LUMAKRAS 320 MG TABLET	90/MONTH
LYTGOBI 12 MG DOSE (3 X 4 MG TB)	90/MONTH
LYTGOBI 16 MG DOSE (4 X 4 MG TB)	120/MONTH
LYTGOBI 20 MG DOSE (5 X 4 MG TB)	150/MONTH
MIEBO 100% EYE DROP	12 ML/MONTH
NITAZOXANIDE 500 MG TABLET	12/MONTH
OPSUMIT 10 MG TABLET	30/MONTH
ORENITRAM ER 0.125 MG TABLET	90/MONTH
ORENITRAM ER 0.25 MG TABLET	90/MONTH
ORENITRAM ER 1 MG TABLET	90/MONTH
ORENITRAM ER 2.5 MG TABLET	90/MONTH
ORENITRAM ER 5 MG TABLET	24/DAY
ORENITRAM MONTH 1 TITRATION KT	168/180DAY
ORENITRAM MONTH 2 TITRATION KT	336/180DAYS
ORENITRAM MONTH 3 TITRATION KT	252/180DAYS
PIQRAY 200 MG DAILY DOSE PACK	30/MONTH
PIQRAY 250 MG DAILY DOSE PACK	60/MONTH
PIQRAY 300 MG DAILY DOSE PACK	60/MONTH
POMALYST CAPSULE	21/21DAYS
PRADAXA 110 MG CAPSULE	60/MONTH
PRADAXA 110 MG PELLET PACK	120/MONTH
PRADAXA 150 MG CAPSULE	60/MONTH
PRADAXA 150 MG PELLET PACK	60/MONTH
PRADAXA 20 MG PELLET PACK	60/MONTH
PRADAXA 30 MG PELLET PACK	120/MONTH
PRADAXA 40 MG PELLET PACK	120/MONTH
PRADAXA 50 MG PELLET PACK	120/MONTH
PRADAXA 75 MG CAPSULE	60/MONTH
SAVAYSA TABLET	30/MONTH
SOTYKTU 6 MG TABLET	30/MONTH
TRACLEER 125 MG TABLET	60/MONTH
TRACLEER 32 MG TABLET FOR SUSP	120/MONTH
TRACLEER 62.5 MG TABLET	60/MONTH
TRUQAP 160 MG TABLET	64/21DAYS
TRUQAP 200 MG TABLET	64/21DAYS
TYVASO 1.74 MG/2.9 ML SOLUTION	81.2 ML/28DAYS
TYVASO DPI 16 MCG CARTRIDGE	4/DAY
TYVASO DPI 16-32 MCG TITR KIT	196/180DAYS
TYVASO DPI 16-32-48 MCG TITRAT	252/180DAYS
TYVASO DPI 32 MCG CARTRIDGE	4/DAY
TYVASO DPI 32-48 MCG MAINT KIT	8/DAY
TYVASO DPI 48 MCG CARTRIDGE	4/DAY
TYVASO DPI 64 MCG CARTRIDGE	4/DAY
TYVASO INHALATION REFILL KIT	2.9/DAY
TYVASO INHALATION STARTER KIT	81.2/180 DAYS
TYVASO INSTITUTIONAL START KIT	11.6/180 DAYS
UPTRAVI 1,000 MCG TABLET	60/MONTH
UPTRAVI 1,200 MCG TABLET	60/MONTH
UPTRAVI 1,400 MCG TABLET	60/MONTH
UPTRAVI 1,600 MCG TABLET	60/MONTH
UPTRAVI 200 MCG TABLET	60/MONTH
UPTRAVI 200-800 TITRATION PACK	200/180 DAYS
UPTRAVI 400 MCG TABLET	60/MONTH
UPTRAVI 600 MCG TABLET	60/MONTH
UPTRAVI 800 MCG TABLET	60/MONTH
VENTAVIS SOLUTION	9/DAY
VTAMA 1% CREAM	60/23 DAYS
XARELTO 1 MG/ML SUSPENSION	27.68/DAY
XARELTO 10 MG TABLET	30/MONTH
XARELTO 15 MG TABLET	30/MONTH
XARELTO 2.5 MG TABLET	60/MONTH
XARELTO 20 MG TABLET	30/MONTH
XARELTO DVT-PE TREAT START 30D	51/180 DAYS
ZORYVE 0.3% CREAM	60/23 DAYS
ZURZUVAE 20 MG CAPSULE	28/265 DAYS
ZURZUVAE 25 MG CAPSULE	28/365 DAYS
ZURZUVAE 30 MG CAPSULE	14/365 DAYS

Medicare Advantage Plans Drugs Removed from Formulary in 2025
ADALIMUMAB-ADAZ (CF) 40 MG SYRG
ADALIMUMAB-ADAZ (CF) PEN 40 MG
ADALIMUMAB-ADBM (CF) 10 MG SYRG
ADALIMUMAB-ADBM (CF) 20 MG SYRG
ADALIMUMAB-ADBM (CF) 40 MG SYRG
ADALIMUMAB-ADBM (CF) CRHN 40 MG
ADALIMUMAB-ADBM (CF) PEN 40 MG
ADALIMUMAB-ADBM (CF) PS-UV 40 MG
AFLURIA TRIVA 2024-25 (3 YR UP)
AFLURIA TRIVALENT 2024-25 VIAL
ALREX 0.2% EYE DROPS
APOKYN 30 MG/3 ML CARTRIDGE
APOMORPHINE 30 MG/3 ML CARTRDG
AZASITE 1% EYE DROPS
BEPOTASTINE 1.5% EYE DROP
BESIVANCE 0.6% SUSP
BICILLIN C-R 1.2 MILLION UNIT
BICILLIN C-R 900-300 SYRINGE
BROMSITE 0.075% EYE DROPS
CALCITRIOL 3 MCG/G OINTMENT
CALCIUM ACETATE 667 MG CAPSULE
CALCIUM ACETATE 667 MG GELCAP
CALCIUM ACETATE 667 MG TABLET
CEFACLOR ER 500 MG TABLET
CHENODAL 250 MG TABLET
CHOLBAM 250 MG CAPSULE
CHOLBAM 50 MG CAPSULE
CIMETIDINE 200 MG TABLET
CIMETIDINE 300 MG TABLET
CIMETIDINE 300 MG/5 ML SOLUTION
CIMETIDINE 400 MG TABLET
CIMETIDINE 400 MG/6.67 ML SOLUTION
CIMETIDINE 800 MG TABLET
CLODAN 0.05% SHAMPOO
COMIRNATY 2024-25(12Y UP) SYRG
CORLANOR 5 MG/5 ML ORAL SOLUTION
DESONIDE 0.05% GEL
DESONIDE 0.05% LOTION
DESRX 0.05% GEL
DIGOXIN 62.5 MCG TABLET
DIPHENHYDRAMINE 12.5 MG/5 ML CUP
DIPHENHYDRAMINE 25 MG/10 ML CUP
E.E.S. 400 MG TABLET
ELETRIPTAN HBR 20 MG TABLET
ELETRIPTAN HBR 40 MG TABLET
EMEND 125 MG POWDER PACKET
EPCLUSA 150-37.5 MG PELLET PKT
EPCLUSA 200 MG-50 MG TABLET
EPCLUSA 200-50 MG PELLET PACK
EPCLUSA 400 MG-100 MG TABLET
FESOTERODINE ER 4 MG TABLET
FESOTERODINE ER 8 MG TABLET
FIRDAPSE 10 MG TABLET
FLAVOXATE HCL 100 MG TABLET
FLUAD TRIVALENT 2024-2025 SYR
FLUARIX TRIVALENT 2024-25 SYRG
FLUBLOK TRIVALENT 2024-25 SYRG
FLUCELVAX TRIVAL 2024-2025 SYR
FLUCELVAX TRIVAL 2024-2025 VL
FLULAVAL TRIVALENT 2024-25 SYR
FLUMIST TRIVALNT NASAL 2024-25
FLUOXETINE DR 90 MG CAPSULE
FLUOXETINE HCL 10 MG TABLET
FLUOXETINE HCL 20 MG TABLET
FLUVOXAMINE ER 100 MG CAPSULE
FLUVOXAMINE ER 150 MG CAPSULE
FLUZONE HIGH-DOSE TRIV 2024-25
FLUZONE TRIVALENT 2024-25 SYRG
FLUZONE TRIVALENT 2024-25 VIAL
FOLOTYN 20 MG/ML VIAL
FOLOTYN 40 MG/2 ML VIAL
FOSAMAX PLUS D 70 MG-2800 UNIT
FOSAMAX PLUS D 70 MG-5600 UNIT
GLYCOPYRROLATE 1.5 MG TABLET
GRALISE ER 300 MG TABLET
GRALISE ER 450 MG TABLET
GRALISE ER 600 MG TABLET
GRALISE ER 750 MG TABLET
GRALISE ER 900 MG TABLET
HALAVEN 1 MG/2 ML VIAL
HARVONI 33.75-150 MG PELLET PK
HARVONI 45-200 MG PELLET PACKT
HARVONI 45-200 MG TABLET
HARVONI 90-400 MG TABLET
HYDROCODONE-ACETAMIN 10-300 MG
HYDROCODONE-ACETAMIN 5-300 MG
HYDROCODONE-ACETAMIN 7.5-300
HYDROCODONE-IBUPROFEN 10-200
HYDROCODONE-IBUPROFEN 5-200 MG
HYRIMOZ(CF) 10 MG/0.1 ML SYRNG
HYRIMOZ(CF) 20 MG/0.2 ML SYRNG
HYRIMOZ(CF) 40 MG/0.4 ML SYRNG
HYRIMOZ(CF) PEDI CROHN 80 MG
HYRIMOZ(CF) PEDI CROHN 80-40 MG
HYRIMOZ(CF) PEN 40 MG/0.4 ML
HYRIMOZ(CF) PEN 80 MG/0.8 ML
HYRIMOZ(CF) PEN CROHN-UC 80 MG
HYRIMOZ(CF) PEN PSORIA 80-40 MG
IMIPRAMINE PAMOATE 100 MG CAP
IMIPRAMINE PAMOATE 125 MG CAP
IMIPRAMINE PAMOATE 150 MG CAP
IMIPRAMINE PAMOATE 75 MG CAP
INSULIN GLARGINE 100 UNIT/ML
INSULIN GLARGINE SOLOSTAR U100
ISOTRETINOIN 25 MG CAPSULE
ISOTRETINOIN 35 MG CAPSULE
IVERMECTIN 1% CREAM
JUXTAPID 10 MG CAPSULE
JUXTAPID 20 MG CAPSULE
JUXTAPID 30 MG CAPSULE
JUXTAPID 5 MG CAPSULE
KEPIVANCE 5.16 MG VIAL
KEPIVANCE 6.25 MG VIAL
KORLYM 300 MG TABLET
LAGEVRIO 200 MG CAP (EUA)
LAMOTRIGINE ODT KIT (BLUE)
LAMOTRIGINE ODT KIT (GREEN)
LAMOTRIGINE ODT KIT (ORANGE)
LAMOTRIGINE TAB START KIT-BLUE
LAMOTRIGINE TAB START KT-GREEN
LAMOTRIGINE TAB START KT-ORANG
LEUKINE 250 MCG VIAL
LEVALBUTEROL 0.31 MG/3 ML SOL
LEVALBUTEROL 0.63 MG/3 ML SOL
LEVALBUTEROL 1.25 MG/3 ML SOL
LEVALBUTEROL CONC 1.25 MG/0.5
LEVONO-E ESTRAD 0.15-0.03-0.01
LEVONOR-ETH ESTRA 0.09-0.02 MG
MENEST 0.3 MG TABLET
MENEST 0.625 MG TABLET
MENEST 1.25 MG TABLET
MENEST 2.5 MG TABLET
METOPROLOL TARTRATE 37.5 MG TB
METOPROLOL TARTRATE 75 MG TAB
MODERNA COVID 24-25(6M-11Y)EUA
MOVANTIK 12.5 MG TABLET
MOVANTIK 25 MG TABLET
MOZOBIL 24 MG/1.2 ML VIAL
MYALEPT 11.3 MG (5 MG/ML) VIAL
NAFTIFINE HCL 1% CREAM
NAFTIFINE HCL 2% CREAM
NISOLDIPINE ER 17 MG TABLET
NISOLDIPINE ER 20 MG TABLET
NISOLDIPINE ER 25.5 MG TABLET
NISOLDIPINE ER 30 MG TABLET
NISOLDIPINE ER 34 MG TABLET
NISOLDIPINE ER 40 MG TABLET
NISOLDIPINE ER 8.5 MG TABLET
OLANZAPINE-FLUOXETINE 12-25 MG
OLANZAPINE-FLUOXETINE 12-50 MG
OLANZAPINE-FLUOXETINE 3-25 MG
OLANZAPINE-FLUOXETINE 6-25 MG
OLANZAPINE-FLUOXETINE 6-50 MG
OMNIPOD CLASSIC PDM KIT (GEN 3)
OMNIPOD CLASSIC PODS (GEN 3) 5-PK
PEG3350 100-7.5-2.691-1.01-5.9
PENTASA 250 MG CAPSULE
PERSERIS ER 120 MG SYRINGE KIT
PERSERIS ER 90 MG SYRINGE KIT
PFIZER COVID 2024-25(5-11Y) EUA
PFIZER COVID 2024-25(6M-4Y) EUA
PHOSPHOLINE IODIDE 0.125% DROP
PLASMA-LYTE A PH 7.4 SOLUTION
PREVIDENT 5000 1.1% DRY MOUTH
PREVIDENT 5000 BOOSTER PLUS
PROLENSA 0.07% EYE DROPS
QTERN 10 MG-5 MG TABLET
QTERN 5 MG-5 MG TABLET
RECTIV 0.4% OINTMENT
REVCOVI 2.4 MG/1.5 ML VIAL
RISPERDAL CONSTA 12.5 MG VIAL
RISPERDAL CONSTA 25 MG VIAL
RISPERDAL CONSTA 37.5 MG VIAL
RISPERDAL CONSTA 50 MG VIAL
SEVELAMER CARBONATE 800 MG TAB
SILODOSIN 4 MG CAPSULE
SILODOSIN 8 MG CAPSULE
SIMLANDI(CF) AI 40 MG/0.4 ML
SOMATULINE DEPOT 120 MG/0.5 ML
SPIKEVAX 2024-25 (12Y UP) SYRG
SUBVENITE TAB START KIT (BLUE)
SUBVENITE TAB START KIT (GREEN)
SUBVENITE TAB START KT (ORANGE)
TAFLUPROST 0.0015% EYE DROP
TALTZ 20 MG/0.25 ML SYRINGE
TALTZ 40 MG/0.5 ML SYRINGE
TALTZ 80 MG/ML AUTOINJ (2-PK)
TALTZ 80 MG/ML AUTOINJ (3-PK)
TALTZ 80 MG/ML AUTOINJECTOR
TALTZ 80 MG/ML SYRINGE
TARINA 24 FE 1 MG-20 MCG TAB
TESTOSTERONE 10 MG GEL PUMP
THEO-24 ER 100 MG CAPSULE
THEO-24 ER 200 MG CAPSULE
THEO-24 ER 300 MG CAPSULE
THEO-24 ER 400 MG CAPSULE
VANCOMYCIN HCL 100 GM SMARTPAK
VANDAZOLE VAGINAL 0.75% GEL
VECAMYL 2.5 MG TABLET
VEKLURY 100 MG VIAL
VELPHORO 500 MG CHEWABLE TAB
V-GO 20 DISPOSABLE DEVICE
V-GO 30 DISPOSABLE DEVICE
V-GO 40 DISPOSABLE DEVICE
VIIBRYD 10-20 MG STARTER PACK
VIOKACE 10,440-39,150 UNIT TAB
VIOKACE 20,880-78,300 UNITS TB
VOTRIENT 200 MG TABLET
XATMEP 2.5 MG/ML ORAL SOLUTION
ZARXIO 300 MCG/0.5 ML SYRINGE
ZARXIO 480 MCG/0.8 ML SYRINGE
ZEGALOGUE 0.6 MG/0.6 ML SYRING
ZEGALOGUE 0.6 MG/0.6 ML AUTOINJ
ZIEXTENZO 6 MG/0.6 ML SYRINGE
ZOLMITRIPTAN 2.5 MG ODT
ZOLMITRIPTAN 2.5 MG TABLET
ZOLMITRIPTAN 5 MG ODT

Medicare Advantage Plans Tier Changes For 2025
Drug	Change	2025 Tier
CAPTOPRIL 100 MG TABLET	Tier Decreased	1
CAPTOPRIL 50 MG TABLET	Tier Decreased	1
CROMOLYN 20 MG/2 ML NEB SOLN	Tier Decreased	3
DEFERASIROX 125 MG TB FOR SUSP	Tier Decreased	3
DEFERASIROX 180 MG TABLET	Tier Decreased	3
DEFERASIROX 360 MG TABLET	Tier Decreased	3
DEFERASIROX 90 MG TABLET	Tier Decreased	3
DEPO-SUBQ PROVERA 104 SYRINGE	Tier Decreased	3
ELURYNG VAGINAL RING	Tier Decreased	3
ENALAPRIL-HCTZ 10-25 MG TABLET	Tier Increased	1
ETONOGESTREL-EE VAGINAL RING	Tier Decreased	3
EVEROLIMUS 0.25 MG TABLET	Tier Decreased	3
FELBAMATE 600 MG/5 ML SUSP	Tier Decreased	4
GAVILYTE-C SOLUTION	Tier Decreased	1
GAVILYTE-G SOLUTION	Tier Decreased	1
GAVILYTE-N SOLUTION	Tier Decreased	1
GLEOSTINE 10 MG CAPSULE	Tier Decreased	4
LEUPROLIDE 2WK 14 MG/2.8 ML KT	Tier Decreased	4
LURASIDONE HCL 120 MG TABLET	Tier Decreased	4
LURASIDONE HCL 20 MG TABLET	Tier Decreased	4
LURASIDONE HCL 40 MG TABLET	Tier Decreased	4
LURASIDONE HCL 60 MG TABLET	Tier Decreased	4
LURASIDONE HCL 80 MG TABLET	Tier Decreased	4
MEROPENEM IV 1 GM VIAL	Tier Decreased	3
MEROPENEM IV 500 MG VIAL	Tier Decreased	3
MESALAMINE ER 500 MG CAPSULE	Tier Decreased	4
MICAFUNGIN 100 MG VIAL	Tier Decreased	4
MICAFUNGIN 50 MG VIAL	Tier Decreased	4
NAYZILAM 5 MG NASAL SPRAY	Tier Decreased	3
NEXPLANON 68 MG IMPLANT	Tier Decreased	3
PAXLOVID 150-100 MG DOSE PACK	Tier Increased	2
PAXLOVID 300-100 MG DOSE PACK	Tier Increased	2
PEG 3350-ELECTROLYTE SOLUTION	Tier Decreased	1
PEG-3350 AND ELECTROLYTES SOLN	Tier Decreased	1
STAMARIL VIAL	Tier Decreased	1
TRIUMEQ PD 60-5-30 MG TAB SUSP	Tier Decreased	4
VALTOCO 10 MG NASAL SPRAY	Tier Decreased	3
VALTOCO 15 MG NASAL SPRAY	Tier Decreased	3
VALTOCO 20 MG NASAL SPRAY	Tier Decreased	3
VALTOCO 5 MG NASAL SPRAY	Tier Decreased	3
VENCLEXTA 10 MG TAB (10 MG X 2)	Tier Decreased	3
VENCLEXTA 10 MG TABLET	Tier Decreased	3
XULANE 150-35 MCG/DAY PATCH	Tier Decreased	3
ZAFEMY 150-35 MCG/DAY PATCH	Tier Decreased	3
AMOXICILLIN 125 MG/5 ML SUSP	Tier Increased	2
AMOXICILLIN 250 MG CAPSULE	Tier Increased	2
AMOXICILLIN 400 MG/5 ML SUSP	Tier Increased	2
AMOXICILLIN 500 MG CAPSULE	Tier Increased	2
AMOXICILLIN 500 MG TABLET	Tier Increased	2
AMOXICILLIN 875 MG TABLET	Tier Increased	2
AZELASTINE HCL 0.05% DROPS	Tier Increased	3
BETAMETHASONE DP 0.05% CRM	Tier Increased	3
BETAMETHASONE DP 0.05% LOT	Tier Increased	3
BETAMETHASONE DP 0.05% OINT	Tier Increased	3
BETAMETHASONE DP AUG 0.05% GEL	Tier Increased	3
BETAMETHASONE DP AUG 0.05% LOT	Tier Increased	3
BETAMETHASONE DP AUG 0.05% OIN	Tier Increased	3
BETAMETHASONE VA 0.1% CREAM	Tier Increased	3
BETAMETHASONE VA 0.1% LOTION	Tier Increased	3
BETAMETHASONE VALER 0.1% OINTM	Tier Increased	3
CARBAMAZEPINE 100 MG TAB CHEW	Tier Increased	2
CARBAMAZEPINE 200 MG TABLET	Tier Increased	2
CARBIDOPA 25 MG TABLET	Tier Increased	4
CINACALCET HCL 90 MG TABLET	Tier Increased	5
CIPROFLOXACIN HCL 250 MG TAB	Tier Increased	2
CIPROFLOXACIN HCL 500 MG TAB	Tier Increased	2
COLISTIMETHATE 150 MG VIAL	Tier Increased	5
DIAZOXIDE 50 MG/ML ORAL SUSP	Tier Increased	5
DONEPEZIL HCL ODT 10 MG TABLET	Tier Increased	2
DONEPEZIL HCL ODT 5 MG TABLET	Tier Increased	2
EMTRICITABINE-TENOFV 100-150 MG	Tier Increased	5
HYDROCORTISONE-ACETIC EAR DROP	Tier Increased	4
LACOSAMIDE 50 MG TABLET	Tier Increased	4
LANSOPRAZOLE DR 15 MG CAPSULE	Tier Increased	3
LANSOPRAZOLE DR 30 MG CAPSULE	Tier Increased	3
LITHIUM CARBONATE 150 MG CAP	Tier Increased	2
LITHIUM CARBONATE 300 MG CAP	Tier Increased	2
LITHIUM CARBONATE 300 MG TAB	Tier Increased	2
LITHIUM CARBONATE 600 MG CAP	Tier Increased	2
LITHIUM CARBONATE ER 300 MG TB	Tier Increased	2
LITHIUM CARBONATE ER 450 MG TB	Tier Increased	2
METHIMAZOLE 10 MG TABLET	Tier Increased	2
METHIMAZOLE 5 MG TABLET	Tier Increased	2
METHOTREXATE 2.5 MG TABLET	Tier Increased	2
METOCLOPRAMIDE 10 MG TABLET	Tier Increased	2
METOCLOPRAMIDE 5 MG TABLET	Tier Increased	2
NEOMYCIN-POLY-HC EYE DROPS	Tier Increased	4
OXCARBAZEPINE 150 MG TABLET	Tier Increased	3
OXCARBAZEPINE 300 MG TABLET	Tier Increased	3
OXCARBAZEPINE 300 MG/5 ML CUP	Tier Increased	4
OXCARBAZEPINE 300 MG/5 ML SUSP	Tier Increased	4
OXCARBAZEPINE 600 MG TABLET	Tier Increased	3
PERIOGARD 0.12% ORAL RINSE	Tier Increased	2
PREGABALIN 100 MG CAPSULE	Tier Increased	3
PREGABALIN 150 MG CAPSULE	Tier Increased	3
PREGABALIN 20 MG/ML SOLUTION	Tier Increased	3
PREGABALIN 200 MG CAPSULE	Tier Increased	3
PREGABALIN 225 MG CAPSULE	Tier Increased	3
PREGABALIN 25 MG CAPSULE	Tier Increased	3
PREGABALIN 300 MG CAPSULE	Tier Increased	3
PREGABALIN 50 MG CAPSULE	Tier Increased	3
PREGABALIN 75 MG CAPSULE	Tier Increased	3
PROGESTERONE 100 MG CAPSULE	Tier Increased	3
PROGESTERONE 200 MG CAPSULE	Tier Increased	3
TESTOSTERONE 1% (25 MG/2.5 G) PK	Tier Increased	4
TESTOSTERONE 1% (50 MG/5 G) PK	Tier Increased	4
TESTOSTERONE 50 MG/5 GRAM GEL	Tier Increased	4
TILIA FE 28 TABLET	Tier Increased	4
TRI-LEGEST FE-28 DAY TABLET	Tier Increased	4
ZYPREXA RELPREVV 210 MG VL KIT	Tier Increased	4

Medicare - CNY PDP New Quantity Limits for 2025
Drug	Amount/Frequency
SOTYKTU 6 MG	1/DAY
PIQRAY 200 MG	1/DAY
PIQRAY 250 MG, 300 MG	2/DAY
LYTGOBI 12 MG	3/DAY
LYTGOBI 16 MG	4/DAY
LYTGOBI 20 MG	5/DAY
LUMAKRAS 120 MG	8/DAY
LUMAKRAS 320 MG	3/DAY
ISTURISA 5 MG	12/DAY
VTAMA	60 GM/23 DAYS
ZURZUVAE 20 MG, 25 MG	28/365 DAYS
ZURZUVAE 30 MG	14/365 DAYS
ZORYVE 0.3% CREAM	60 GM/23 DAYS
PAXLOVID 150-100	20 UNIT/90 DAYS
ORAL PAXLOVID 300-100 MG/150 (2)	30/90 DAYS

City of NY PPO Removed From Formulary in 2025
Drug	Alternative(s)
STEGLATRO	FARXIGA, JARDIANCE
TRUDHESA	DIHYDROERGOTAMINE MESYLATE
RELISTOR	LUBIPROSTONE
VYZULTA	BIMATOPROST, LATANOPROST
BASAGLAR TEMPO PEN U-100	INSULIN GLARGINE-YFGN, SEMGLEE (YFGN) PEN, TOUJEO SOLOSTAR
KARBINAL ER	CARBINOXAMINE MALEATE, CETIRIZINE HCL, CLEMASTINE FUMARATE
LUMIGAN	BIMATOPROST
HUMALOG	INSULIN LISPRO
SEGLUROMET	SYNJARDY, SYNJARDY XR, XIGDUO XR
DYMISTA	AZELASTINE-FLUTICASONE
BASAGLAR KWIKPEN U-100	INSULIN GLARGINE-YFGN, SEMGLEE (YFGN) PEN, TOUJEO SOLOSTAR
WEGOVY, ZEPBOUND
ALVESCO	ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, QVAR REDIHALER
FLOVENT DISKUS	ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, QVAR REDIHALER
FLOVENT HFA	ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, QVAR REDIHALER
XYREM	SODIUM OXYBATE, XYWAV
GILENYA	FINGOLIMOD
METHYLPHENIDATE ER	METHYLPHENIDATE ER CAPSULES/TABLETS (EXCEPT 45MG, 63MG OR 72MG.) OR ER TABLETS (EXCEPT 45MG, DYANAVEL XR, MYDAYVIS, QUILLICHEW ER, QUILLIVANT XR, VYVANSE MYDAYIS, QUILLICHEW ER, VYVANSE
ADVAIR DISKUS	FLUTICASONE PROPIONATE - SALMETEROL XINAFOATE
FANAPT	ARIPIPRAZOLE, ASENAPINE, LURASIDONE, OLANZAPINE, QUETIAPINE

City of NY HMO Drugs Removed from Formulary In 2025
Drug	Alternative(s)
EUFLEXXA	MONOVISC, ORTHOVISC
STEGLATRO	FARXIGA, JARDIANCE
FORTEO	TERIPARATIDE
RELISTOR	LUBIPROSTONE, MOVANTIK, SYMPROIC
VYZULTA	BIMATOPROST, LATANOPROST, TAFLUPROST
BASAGLAR TEMPO PEN U-100	INSULIN GLARGINE-YFGN, SEMGLEE (YFGN) PEN, TOUJEO SOLOSTAR
HUMIRA PEN	ADALIMUMAB-ADAZ (CF) PEN, ADALIMUMAB-ADBM(CF)PEN, ADALIMUMAB-RYVK (CF) AUTOINJECT
HUMIRA	ADALIMUMAB-ADAZ (CF) PEN, ADALIMUMAB-ADBM(CF)PEN, ADALIMUMAB-RYVK (CF) AUTOINJECT
HUMIRA (CF)	ADALIMUMAB-ADAZ (CF) PEN, ADALIMUMAB-ADBM(CF)PEN, ADALIMUMAB-RYVK (CF) AUTOINJECT
LUMIGAN	BIMATOPROST, LATANOPROST, TAFLUPROST
HUMALOG	INSULIN LISPRO
HUMIRA (CF) PEN CROHN'S-UC-HS	ADALIMUMAB-ADAZ(CF) PEN , ADALIMUMAB-ADBM (CF) PEN, ADALIMUMAB-RYVK(CF) AUTOINJECT
SEGLUROMET	SYNJARDY, SYNJARDY XR, XIGDUO XR
BASAGLAR KWIKPEN U-100	INSULIN GLARGINE-YFGN, SEMGLEE (YFGN) PEN, TOUJEO SOLOSTAR
HUMIRA (CF) PEN	ADALIMUMAB-ADAZ (CF) PEN, ADALIMUMAB-ADBM (CF) PEN, ADALIMUMAB-RYVK (CF) AUTOINJECT
WEGOVY, ZEPBOUND
ADVAIR DISKUS	FLUTICASONE-SALMETEROL,
ALVESCO	ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER,
APLENZIN	BUPROPION XL
AUBAGIO
BOTOX	DYSPORT, MYOBLOC, MIGRAINE - AIMOVIG, AJOVY, EMGALITY, QULIPTA
CHORIONIC GONADOTROPIN	NOVAREL, OVIDREL
CITRANATAL ASSURE
COPAXONE	GENERIC EQUIVALENT AVAILABLE, GLATIRAMER ACETATE
DYANAVEL XR	DEXTROAMPHETAMINE ER, DEXTROAMPHETAMINE/AMPHETAMINE
FLOVENT DISKUS	ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER
FLOVENT HFA	ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER
IBRANCE	KISQALI, VERZENIO
LATUDA	LURASIDONE HCL
LEVEMIR FLEXPEN	SEMGLEE (YFGN) PEN, TOUJEO SOLOSTAR, TRESIBA FLEXTOUCH U-100
LEVEMIR FLEXTOUCH	SEMGLEE (YFGN) PEN, TOUJEO SOLOSTAR, TRESIBA FLEXTOUCH U-100
NORDITROPIN FLEXPRO	GENOTROPIN, OMNITROPE
QUILLIVANT XR	DEXMETHYLPHENIDATE ER, DEXTROAMPHETAMINE/AMPHETAMINE
SEREVENT DISKUS	STRIVERDI RESPIMAT
SYMBICORT	BREYNA, BUDESONIDE-FORMOTEROL FUMARATE
ZARXIO	NIVESTYM

Small Group/Essential/Individual Plans Removed From Formulary in 2025
Drug	Alternative(s)
EUFLEXXA	MONOVISC, ORTHOVISC
STEGLATRO	FARXIGA, JARDIANCE
FANAPT	ARIPIPRAZOLE, ASENAPINE MALEATE, LURASIDONE HCL
FORTEO	TERIPARATIDE
RELISTOR	LUBIPROSTONE, MOVANTIK, SYMPROIC
VYZULTA	BIMATOPROST, LATANOPROST, TAFLUPROST
HUMIRA PEN	ADALIMUMAB-ADAZ (CF) PEN, ADALIMUMAB-ADBM(CF)PEN, ADALIMUMAB-RYVK (CF) AUTOINJECT
HUMIRA (CF)	ADALIMUMAB-ADAZ(CF) PEN, ADALIMUMAB-ADBM (CF) PEN, ADALIMUMAB-RYVK (CF) AUTOINJECT
LUMIGAN	BIMATOPROST, LATANOPROST, TAFLUPROST
HUMALOG	INSULIN LISPRO
HUMIRA (CF) PEN CROHN'S-UC-HS	ADALIMUMAB-ADAZ (CF) PEN, ADALIMUMAB-ADBM (CF) PEN, ADALIMUMAB-RYVK (CF) AUTOINJECT
SEGLUROMET	SYNJARDY, SYNJARDY XR, XIGDUO XR
BASAGLAR KWIKPEN U-100	INSULIN GLARGINE-YFGN, SEMGLEE (YFGN) PEN, TOUJEO SOLOSTAR
HUMIRA (CF) PEN	ADALIMUMAB-ADAZ (CF) PEN, ADALIMUMAB-ADBM (CF) PEN, ADALIMUMAB-RYVK (CF) AUTOINJECT
SAXENDA	WEGOVY, ZEPBOUND
ALVESCO	ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, QVAR REDIHALER
FLOVENT DISKUS	ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, QVAR REDIHALER
FLOVENT HFA	ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, QVAR REDIHALER
XYREM	SODIUM OXYBATE, XYWAV
ADVAIR DISKUS	FLUTICASONE PROPIONATE - SALMETEROL XINAFOATE
COPAXONE	GLATIRAMER ACETATE
ENDOMETRIN	CRINONE 8%

Commercial Large Group Drugs Removed from Formulary In 2025
Drug	Alternative(s)
EUFLEXXA	MONOVISC, ORTHOVISC
STEGLATRO	FARXIGA, JARDIANCE
FORTEO	TERIPARATIDE
RELISTOR	LUBIPROSTONE, MOVANTIK. SYMPROIC
VYZULTA	BIMATOPROST, LATANOPROST, TAFLUPROST
BASAGLAR TEMPO PEN U-100	INSULIN GLARGINE-YFGN, SEMGLEE (YFGN) PEN, TOUJEO SOLOSTAR
HUMIRA PEN	ADALIMUMAB-ADAZ (CF) PEN, ADALIMUMAB-ADBM (CF) PEN, ADALIMUMAB-RYVK (CF) AUTOINJECT
HUMIRA	ADALIMUMAB-ADAZ (CF) PEN, ADALIMUMAB-ADBM (CF) PEN, ADALIMUMAB-RYVK (CF) AUTOINJECT
HUMIRA(CF)	ADALIMUMAB-ADAZ (CF) PEN, ADALIMUMAB-ADBM (CF) PEN, ADALIMUMAB-RYVK (CF) AUTOINJECT
LUMIGAN	BIMATOPROST, LATANOPROST, TAFLUPROST
HUMALOG	INSULIN LISPRO
HUMIRA (CF) PEN CROHN'S-UC-HS	ADALIMUMAB-ADAZ (CF) PEN, ADALIMUMAB-ADBM (CF) PEN, ADALIMUMAB-RYVK (CF) AUTOINJECT
SEGLUROMET	SYNJARDY, SYNJARDY XR, XIGDUO XR
BASAGLAR KWIKPEN U-100	INSULIN GLARGINE-YFGN, SEMGLEE (YFGN) PEN, TOUJEO SOLOSTAR
HUMIRA (CF) PEN	ADALIMUMAB-ADAZ (CF) PEN, ADALIMUMAB-ADBM (CF) PEN, ADALIMUMAB-RYVK (CF) AUTOINJECT
SAXENDA	WEGOVY, ZEPBOUND
ADVAIR DISKUS	FLUTICASONE-SALMETEROL,
ALVESCO	ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER,
APLENZIN	BUPROPION XL
AUBAGIO
BOTOX	DYSPORT, MYOBLOC, MIGRAINE - AIMOVIG, AJOVY, EMGALITY, QULIPTA
CHORIONIC GONADOTROPIN	NOVAREL, OVIDREL
CITRANATAL ASSURE
COPAXONE	GENERIC EQUIVALENT AVAILABLE, GLATIRAMER ACETATE
DYANAVEL XR	DEXTROAMPHETAMINE ER, DEXTROAMPHETAMINE/AMPHETAMINE,
FLOVENT DISKUS	ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER,
FLOVENT HFA	ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER,
IBRANCE	KISQALI, VERZENIO
LATUDA	LURASIDONE HCL
LEVEMIR FLEXPEN	SEMGLEE (YFGN) PEN, TOUJEO SOLOSTAR, TRESIBA FLEXTOUCH U-100
LEVEMIR FLEXTOUCH	SEMGLEE (YFGN) PEN, TOUJEO SOLOSTAR, TRESIBA FLEXTOUCH U-100
NORDITROPIN FLEXPRO	GENOTROPIN, OMNITROPE
QUILLIVANT XR	DEXMETHYLPHENIDATE ER, DEXTROAMPHETAMINE/AMPHETAMINE
SEREVENT DISKUS	STRIVERDI RESPIMAT
SYMBICORT	BREYNA, BUDESONIDE-FORMOTEROL FUMARATE
ZARXIO	NIVESTYM

JP67293: 10/2024

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