The table below describes all formulary changes going into effect for our Medicaid (until March 31, 2023) and Medicare members in 2023. For our Commercial members, this table highlights the most highly impacted drugs. For a comprehensive listing of all plans see: 2023 Summary of Companies, Lines of Business, Networks & Benefit Plans.
See the applicable 2023 plan formularies for all coverage rules:
Medicaid and HARP Brand Removal in 2023 |
|
|---|---|
| Drug | Alterative(s) |
Vimpat |
LACOSAMIDE (generic) |
Medicare Advantage Plans (EmblemHealth Plan, Inc. (formerly GHI) and HIP) Step Therapy Added in 2023 |
|
|---|---|
| Drug | Alterative(s) |
LIVALO |
ATORVASTATIN CALCIUM, ROSUVASTATIN CALCIUM, SIMVASTATIN |
Medicare Advantage Plans (EmblemHealth Plan, Inc. (formerly GHI) and HIP) Drugs Removed from Formulary in 2023 |
|---|
CYANOCOBALAMIN 1,000 MCG/ML VL |
CYANOCOBALAMIN 30,000 MCG/30ML |
DODEX 1,000 MCG/ML VIAL |
VENOFER 100 MG/5 ML VIAL |
VENOFER 200 MG/10 ML VIAL |
Medicare Advantage Plans (EmblemHealth Plan, Inc. (formerly GHI) and HIP) New Tier 5 Drugs |
|---|
ACTEMRA 162 MG/0.9 ML SYRINGE |
ACTEMRA ACTPEN 162 MG/0.9 ML |
ARFORMOTEROL 15 MCG/2 ML SOLN |
EYLEA 2 MG/0.05 ML SYRINGE |
EYLEA 2 MG/0.05 ML VIAL |
NUCALA 100 MG/ML AUTO-INJECTOR |
TALTZ 80 MG/ML AUTOINJECTOR |
Medicare Advantage Plans (EmblemHealth Plan, Inc. (formerly GHI) and HIP) New Preauthorization Requirements for Listed Drugs in 2023 |
||
|---|---|---|
BENZTROPINE |
HYDROXYCHLOROQUINE |
TESTOSTERON ENANTHATE |
BYDUREON BCISE AUTOINJECT |
JINTELI |
TESTOSTERONE TOPICAL GEL |
BYDUREON PEN INJECT |
MEMANTINE |
TOBRAMYCIN AMPULE |
CINACALCET |
MEMANTINE ER |
TOPIRAMATE |
CYCLOSPORINE MODIFIED |
MOUNJARO PEN |
TOPIRAMATE SPRINKLE CAPSULE |
DALIRESP |
NILUTAMIDE 150 MG |
TRULICITY PEN |
DEFERASIROX |
NUCALA 100 MG/ML AUTO-INJECTOR |
VICTOZA PEN |
DIMETHYL FUMARATE |
OZEMPIC PEN |
VUMERITY |
DUPIXENT PEN |
PLEGRIDY PEN |
XTANDI |
ENVARSUS XR |
PROLIA SYRINGE |
|
ERLEADA |
RILUZOLE |
|
ESTRADIOL PATCH(1/WK) |
RYBELSUS |
|
ESTRADIOL PATCH(2/WK) |
SILDENAFIL |
|
ESTRADIOL TABLET |
SIROLIMUS |
|
Medicare Advantage Plans (EmblemHealth Plan, Inc. (formerly GHI) and HIP) Drugs Moving to Non-Formulary in 2023 |
|---|
| Drug | Alterative(s) |
|---|---|
MULTAQ 400 MG TABLET |
AMIODARONE HCL, DOFETILIDE, FLECAINIDE ACETATE |
BYSTOLIC |
ATENOLOL, CARVEDILOL, METOPROLOL SUCCINATE |
ADVOCATE INS 0.5 ML 31GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
ADVOCATE INS 1 ML 31GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
ADVOCATE INS SYR 1 ML 30GX5/16 |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
CA INS SYR 0.3 ML 31GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
CA INS SYR 0.5 ML 30GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
CAREONE SYR 1 ML 31GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
COMFORT EZ INS 1 ML 31GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
COMFORT EZ INSULIN SYR 0.5 ML |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
COMFORT EZ SYR 0.5 ML 29GX1/2" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
COMFORT EZ SYR 1 ML 29GX1/2" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
EASY COMFORT 0.5 ML 30GX1/2" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
EASY COMFORT 0.5 ML SYRINGE |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
EASY COMFORT INSULIN 1 ML SYR |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
EASY TOUCH 1 ML SYR 30GX1/2" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
EASY TOUCH INSULIN SYR 0.3 ML |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
EASY TOUCH INSULIN SYR 0.5 ML |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
EASY TOUCH INSULIN SYR 1 ML |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
EASY-TOUCH INS 1 ML 31GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
INSULIN 1 ML SYRINGE |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
INSULIN 3/10 ML SYRINGE |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
INSULIN SYRIN 0.5 ML 29GX1/2" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
INSULIN SYRIN 0.5 ML 31GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
KINRAY SYRING 0.5 ML 31GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
MONOJECT INSULIN SYR U-100 |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
PREFERRED PLUS SYRINGE 0.5 ML |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
RELION INS SYR 1 ML 31GX15/64" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
RELION INS SYR 1 ML 31GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
RELION SYRING 0.3 ML 31GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
RELION SYRING 0.5 ML 31GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
SURE COMFORT 0.5 ML SYRINGE |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
SURE COMFORT 1 ML SYRINGE |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
SURE COMFORT 3/10 ML SYRINGE |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
SURE-JECT INSU SYR U100 0.5 ML |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
TRUEPLUS SYR 0.3ML 30GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
TRUEPLUS SYR 0.3ML 31GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
TRUEPLUS SYR 0.5ML 28GX1/2" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
TRUEPLUS SYR 0.5ML 30GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
TRUEPLUS SYR 0.5ML 31GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
TRUEPLUS SYR 1ML 29GX1/2" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
TRUEPLUS SYR 1ML 30GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
TRUEPLUS SYR 1ML 31GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
ULTICARE INS 0.5 ML 30GX1/2" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
ULTICARE INS SYR 1 ML 29GX1/2" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
ULTICARE SYR 0.3 ML 30GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
ULTICARE SYR 0.5 ML 29GX1/2" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
ULTICARE SYR 0.5 ML 30GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
ULTICARE SYR 1 ML 30GX5/16" |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
ULTRA COMFORT 0.5 ML SYRINGE |
B-D INSULIN SYRINGE, B-D SAFETYGLIDE |
1ST TIER UNIFINE PNTIP 4MM 32G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
1ST TIER UNIFINE PNTP 29GX1/2" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
1ST TIER UNIFINE PNTP 31GX1/4" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
1ST TIER UNIFINE PNTP 31GX3/16 |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
1ST TIER UNIFINE PNTP 32GX5/32 |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
ADVOCATE PEN NEEDLES 5MM 31G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
ADVOCATE PEN NEEDLES 8MM 31G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
CAREFINE PEN NEEDLES 6MM 32G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
CAREONE UNIFINE PENTIP 4MM 32G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
CAREONE UNIFINE PENTIP 5MM 31G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
CAREONE UNIFINE PENTIP 6MM 31G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
CAREONE UNIFINE PENTIP 8MM 31G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
CAREONE UNIFINE PENTP 31GX1/4" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
CAREONE UNIFINE PNTP 31GX3/16" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
CAREONE UNIFINE PNTP 31GX5/16" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
CAREONE UNIFINE PNTP 32GX5/32" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
COMFORT EZ PEN NEEDLES 4MM 32G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
COMFORT EZ PEN NEEDLES 4MM 33G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
COMFORT EZ PEN NEEDLES 5MM 31G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
COMFORT EZ PEN NEEDLES 5MM 32G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
COMFORT EZ PEN NEEDLES 5MM 33G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
COMFORT EZ PEN NEEDLES 6MM 31G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
COMFORT EZ PEN NEEDLES 6MM 32G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
COMFORT EZ PEN NEEDLES 6MM 33G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
COMFORT EZ PEN NEEDLES 8MM 31G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
EASY COMFORT PEN NDL 31GX3/16" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
EASY COMFORT PEN NDL 31GX5/16" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
EASY TOUCH PEN NEEDLE 29GX1/2" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
EASY TOUCH PEN NEEDLE 31GX1/4" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
EASY TOUCH PEN NEEDLE 31GX3/16 |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
EASY TOUCH PEN NEEDLE 31GX5/16 |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
EASY TOUCH PEN NEEDLE 32GX1/4" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
EASY TOUCH PEN NEEDLE 32GX3/16 |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
GNP ULTICARE PEN NDL 4MM 32G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
GNP ULTICARE PEN NDL 8MM 31G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
GS PEN NEEDLE 31G X 6MM |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
HM ULTICARE PEN NEEDLE 4MM 32G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE
|
INCONTROL PEN NEEDLE 4MM 32G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE
|
PEN NEEDLE 29G 12MM |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
PEN NEEDLE 31G 5MM |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
PEN NEEDLE 31G 6MM |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
PEN NEEDLE 31G 8MM |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
PEN NEEDLE 31G X 1/4" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
PEN NEEDLE 32G 4MM |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
PEN NEEDLE 32G X 5/32" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
PEN NEEDLES 12MM 29G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
PEN NEEDLES 4MM 32G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
PEN NEEDLES 6MM 31G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
PEN NEEDLES 8MM 31G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
PENTIPS PEN NEEDLE 31GX3/16" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
PENTIPS PEN NEEDLE 31GX5/16" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
PENTIPS PEN NEEDLE 32GX5/32" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
PV UNIFINE PENTIP PLUS 31GX8MM |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
RA PEN NEEDLE 31GX3/16" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
RELION PEN 31G NEEDLE |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
RELION PEN NEEDLE 31GX5/16" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
RELION PEN NEEDLE 32GX5/32" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
SURE COMFORT 31G PEN NEEDLE |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
SURE COMFORT PEN NDL 31GX3/16" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
SURE-FINE PEN NEEDLES 5MM |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
ULTICARE PEN NDL 12.7 MM 29G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
ULTICARE PEN NEEDLE 8 MM 31G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
ULTICARE PEN NEEDLES 12MM 29G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
ULTICARE PEN NEEDLES 4MM 32G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
ULTICARE PEN NEEDLES 6MM 31G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
ULTICARE PEN NEEDLES 8MM 31G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
UNIFINE PENTIPS 12MM 29G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
UNIFINE PENTIPS 31GX3/16" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
UNIFINE PENTIPS 32GX5/32" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
UNIFINE PENTIPS 6MM 31G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
UNIFINE PENTIPS 6MM NEEDLE |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
UNIFINE PENTIPS 8MM 31G |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
UNIFINE PENTIPS 8MM NEEDLE |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
UNIFINE PENTIPS PLUS 31GX1/4" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
UNIFINE PENTIPS PLUS 31GX3/16" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
UNIFINE PENTIPS PLUS 32GX5/32" |
BD NANO PEN NEEDLE, BD ULTRA-FINE PEN NEEDLE, NOVOFINE |
COMBIGAN 0.2%-0.5% EYE DROPS |
BETAXOLOL HCL, BRIMONIDINE TARTRATE, DORZOLAMIDE HCL |
TRIHEXYPHENIDYL |
CARBIDOPA/LEVODOPA |
VIIBRYD |
CITALOPRAM HBR, ESCITALOPRAM OXALATE, FLUOXETINE HCL |
MITIGARE |
COLCHICINE |
RESTASIS EYE EMULSION |
CYCLOSPORINE 0.05% EYE EMULS |
BETIMOL 0.25% EYE DROPS |
DORZOLAMIDE HCL, LEVOBUNOLOL HCL, ALPHAGAN P |
PRADAXA |
ELIQUIS, XARELTO |
COSENTYX |
ENBREL, HUMIRA, ORENCIA |
ARNUITY ELLIPTA |
FLOVENT HFA, QVAR REDIHALER, ASMANEX |
VIMPAT |
GABAPENTIN, LAMOTRIGINE, OXCARBAZEPINE |
GLYBURIDE |
GLIPIZIDE, GLIMEPIRIDE |
VASCEPA |
ICOSAPENT ETHYL, OMEGA-3 ACID ETHYL ESTERS |
DESLORATADINE |
LEVOCETIRIZINE |
SYNTHROID |
LEVOTHYROXINE SODIUM, LEVOXYL |
LUBIPROSTONE CAPSULE |
LINZESS, TRULANCE |
ELIGARD SYRINGE KIT |
LUPRON DEPOT, FIRMAGON, TRELSTAR |
TOVIAZ ER |
OXYBUTYNIN CHLORIDE ER, TOLTERODINE TARTRATE ER, TROSPIUM CHLORIDE |
TROSPIUM CHLORIDE ER |
OXYBUTYNIN CHLORIDE ER, TOLTERODINE TARTRATE ER, MYRBETRIQ |
PRALUENT PEN |
REPATHA PUSHTRONEX, REPATHA SURECLICK |
AURYXIA 210 MG TABLET |
SEVELAMER CARBONATE |
FORTEO 600 MCG/2.4 ML PEN INJ |
TERIPARATIDE |
INGREZZA |
TETRABENAZINE |
BASAGLAR KWIKPEN |
TOUJEO MAX SOLOSTAR, LANTUS, TOUJEO SOLOSTAR |
LEVEMIR |
TOUJEO SOLOSTAR, TOUJEO MAX SOLOSTAR, LANTUS |
TRESIBA |
TOUJEO SOLOSTAR, TOUJEO MAX SOLOSTAR, LANTUS |
VENLAFAXINE HCL ER TAB |
VENLAFAXINE HCL ER CAP |
Medicare Advantage Plans (EmblemHealth Plan, Inc. (formerly GHI) and HIP) New Quantity Limits for 2023 |
|---|
| Drug | Amount/Frequency |
|---|---|
ADVAIR HFA |
1/MONTH |
AJOVY |
1/MONTH |
ALBUTEROL INHALER (GEN PROVENTIL HFA) |
2/MONTH |
ALENDRONATE SODIUM |
4/MONTH |
ASMANEX TWISTHALER |
1/MONTH |
ATORVASTATIN |
30/MONTH |
BRIVIACT |
60/MONTH |
BUDESONIDE INH SUSP |
60ML/MONTH |
BUPROPION SR |
60/MONTH |
BUPROPION XL |
30/MONTH |
CARDURA |
30/MONTH |
CELEXA |
30/MONTH |
CIMZIA SYRINGE KIT |
1/MONTH |
CITALOPRAM |
30/MONTH |
CLIMARA PATCH |
4/MONTH |
CLOBAZAM |
60/MONTH |
CLONAZEPAM |
90/MONTH |
CLOPIDOGREL |
30/MONTH |
CRESTOR 10 MG TABLET |
30/MONTH |
CYCLOSPORINE 0.05% EYE EMULS |
60/MONTH |
CYMBALTA 30 MG CAPSULE |
60/MONTH |
DALIRESP 250 MCG TABLET |
30/MONTH |
DESLORATADINE 2.5 MG ODT |
30/MONTH |
DESVENLAFAXINE SUCCNT ER |
30/MONTH |
DEXLANSOPRAZOLE |
30/MONTH |
DULOXETINE |
60/MONTH |
DUPIXENT PEN |
2/MONTH |
EFFEXOR XR |
30/MONTH |
ENTRESTO |
60/MONTH |
ESCITALOPRAM |
30/MONTH |
ESOMEPRAZOLE |
30/MONTH |
ESTRADIOL (1/WK) |
4/MONTH |
ESTRADIOL (2/WK) |
8/MONTH |
FLUOXETINE |
30/MONTH |
FLUOXETINE 90MG |
4/MONTH |
FLUVOXAMINE ER CAPSULE |
60/MONTH |
FLUVOXAMINE MALEATE |
60/MONTH |
GLIMEPIRIDE |
60/MONTH |
GLIPIZIDE |
120/MONTH |
GLIPIZIDE ER |
60/MONTH |
HORIZANT ER |
30/MONTH |
INCRUSE ELLIPTA INH |
1/MONTH |
INVOKANA |
30/MONTH |
IPRATROPIUM SPRAY |
1/MONTH |
JANUMET |
30/MONTH |
JARDIANCE |
30/MONTH |
KEVZARA PEN INJ |
2/MONTH |
LACOSAMIDE |
60/MONTH |
LANSOPRAZOLE |
30/MONTH |
LANTHANUM CARB TB CHW |
4.5/DAY |
LATUDA |
30/MONTH |
LOVASTATIN |
30/MONTH |
LYRICA |
90/MONTH |
LYRICA 225 MG CAPSULE |
60/MONTH |
MELOXICAM |
30/MONTH |
METFORMIN HCL 1,000 MG TABLET |
75/MONTH |
METFORMIN HCL 500 MG TABLET |
150/MONTH |
NATEGLINIDE |
90/MONTH |
NEXIUM |
30/MONTH |
OLANZAPINE |
30/MONTH |
OMEPRAZOLE |
30/MONTH |
OMEPRAZOLE-BICARB 20-1,680 PKT |
30/MONTH |
ONFI |
60/MONTH |
PANTOPRAZOLE |
30/MONTH |
PAROXETINE |
30/MONTH |
PAROXETINE CR/ER |
60/MONTH |
PIOGLITAZONE |
30/MONTH |
PRAVASTATIN |
30/MONTH |
QUETIAPINE ER 150 MG TABLET |
30/MONTH |
QUETIAPINE ER 300 MG TABLET |
60/MONTH |
QUETIAPINE ER 50 MG TABLET |
60/MONTH |
QUETIAPINE FUMARATE |
90/MONTH |
REXULTI |
30/MONTH |
RISEDRONATE SODIUM |
4/MONTH |
RISPERIDONE |
60/MONTH |
SERTRALINE |
60/MONTH |
SEVELAMER 0.8 GM POWDER PACKET |
6/DAY |
SEVELAMER 2.4 GM POWDER PACKET |
3/DAY |
SEVELAMER CARBONATE 800 MG TAB |
9/DAY |
SUBOXONE 8 MG-2 MG SL FILM |
90/MONTH |
TALTZ AUTOINJECTOR |
1/MONTH |
TESTOSTERONE 1.62% GEL PUMP |
150GM/MONTH |
TESTOSTERONE GEL PACKET |
38/MONTH |
TRADJENTA |
30/MONTH |
TRINTELLIX |
30/MONTH |
TRULICITY PEN |
2ML/MONTH |
VALACYCLOVIR HCL 1 GRAM TABLET |
120/MONTH |
VALACYCLOVIR HCL 500 MG TABLET |
60/MONTH |
VELPHORO CHEWABLE TAB |
180/MONTH |
VENLAFAXINE TABLET |
90/MONTH |
VENLAFAXINE HCL ER |
30/MONTH |
VENLAFAXINE HCL ER 75 MG CAP |
90/MONTH |
VERQUVO |
30/MONTH |
VIIBRYD |
30/MONTH |
VIMPAT |
60/MONTH |
VRAYLAR |
30/MONTH |
XIFAXAN 550MG TAB |
90/MONTH |
ZIPRASIDONE |
60/MONTH |
ZUBSOLV TABLET SL |
30/MONTH |
ZYPITAMAG TABLET |
30/MONTH |
Medicare Advantage Plans (EmblemHealth Plan, Inc. (formerly GHI) and HIP) Tier Changes For 2023 |
|---|
Drug |
Change |
2023 Tier |
|---|---|---|
ABACAVIR-LAMIVUDINE 600-300 MG |
TIER DECREASE |
Tier 3 |
ABIRATERONE ACETATE |
TIER DECREASE |
Tier 4 |
AMLODIPINE-VALSARTAN |
TIER DECREASE |
Tier 6 |
APTIOM 600 MG TABLET |
TIER DECREASE |
Tier 4 |
ARIPIPRAZOLE TABLET |
TIER DECREASE |
Tier 2 |
ATORVASTATIN |
TIER DECREASE |
Tier 6 |
ATROPINE 1% EYE DROPS |
TIER DECREASE |
Tier 3 |
BACLOFEN 5 MG TABLET |
TIER DECREASE |
Tier 2 |
BENAZEPRIL |
TIER DECREASE |
Tier 6 |
BISOPROLOL-HCTZ |
TIER DECREASE |
Tier 1 |
BREZTRI AEROSPHERE INHALER |
TIER DECREASE |
Tier 3 |
BRIMONIDINE TARTRATE 0.15% DRP |
TIER DECREASE |
Tier 3 |
BUPRENORPHINE-NALOX 2-0.5MG FM |
TIER DECREASE |
Tier 3 |
BUPRENORPHINE-NALOX 4-1MG FILM |
TIER DECREASE |
Tier 3 |
BUPRENORPHINE-NALOX 8-2MG FILM |
TIER DECREASE |
Tier 3 |
CAPLYTA 42 MG CAPSULE |
TIER DECREASE |
Tier 4 |
CINACALCET HCL 60 MG TABLET |
TIER DECREASE |
Tier 4 |
CINACALCET HCL 90 MG TABLET |
TIER DECREASE |
Tier 4 |
CLOPIDOGREL 75 MG TABLET |
TIER DECREASE |
Tier 1 |
COLCHICINE 0.6 MG TABLET |
TIER DECREASE |
Tier 2 |
COMBIVENT RESPIMAT 20-100 MCG |
TIER DECREASE |
Tier 3 |
CREON DR 12,000 UNIT CAPSULE |
TIER DECREASE |
Tier 3 |
CREON DR 24,000 UNIT CAPSULE |
TIER DECREASE |
Tier 3 |
CREON DR 36,000 UNIT CAPSULE |
TIER DECREASE |
Tier 3 |
DALFAMPRIDINE ER 10 MG TABLET |
TIER DECREASE |
Tier 3 |
DAPSONE |
TIER DECREASE |
Tier 3 |
DAPSONE |
TIER DECREASE |
Tier 3 |
DILANTIN 30 MG CAPSULE |
TIER DECREASE |
Tier 3 |
DONEPEZIL HCL 10 MG TABLET |
TIER DECREASE |
Tier 1 |
DONEPEZIL HCL 5 MG TABLET |
TIER DECREASE |
Tier 1 |
DONEPEZIL HCL ODT 10 MG TABLET |
TIER DECREASE |
Tier 1 |
DONEPEZIL HCL ODT 5 MG TABLET |
TIER DECREASE |
Tier 1 |
EDARBI |
TIER DECREASE |
Tier 3 |
EDARBYCLOR |
TIER DECREASE |
Tier 3 |
ENALAPRIL MALEATE |
TIER DECREASE |
Tier 6 |
ENALAPRIL-HCTZ |
TIER DECREASE |
Tier 6 |
ESCITALOPRAM 10 MG TABLET |
TIER DECREASE |
Tier 1 |
ESCITALOPRAM 20 MG TABLET |
TIER DECREASE |
Tier 1 |
ESCITALOPRAM 5 MG TABLET |
TIER DECREASE |
Tier 1 |
ESOMEPRAZOLE |
TIER DECREASE |
Tier 3 |
ESTRADIOL 10 MCG VAGINAL INSRT |
TIER DECREASE |
Tier 4 |
ESTRING 2 MG VAGINAL RING |
TIER DECREASE |
Tier 3 |
FETZIMA ER |
TIER DECREASE |
Tier 3 |
FLUOXETINE HCL 10 MG CAPSULE |
TIER DECREASE |
Tier 1 |
FLUOXETINE HCL 20 MG CAPSULE |
TIER DECREASE |
Tier 1 |
FLUOXETINE HCL 40 MG CAPSULE |
TIER DECREASE |
Tier 1 |
FOSINOPRIL SODIUM |
TIER DECREASE |
Tier 6 |
FYAVOLV 1 MG-5 MCG TABLET |
TIER DECREASE |
Tier 4 |
GALANTAMINE ER 16 MG CAPSULE |
TIER DECREASE |
Tier 3 |
GLIMEPIRIDE |
TIER DECREASE |
Tier 6 |
GLIPIZIDE |
TIER DECREASE |
Tier 6 |
GLIPIZIDE ER |
TIER DECREASE |
Tier 6 |
GLIPIZIDE XL |
TIER DECREASE |
Tier 6 |
GLIPIZIDE-METFORMIN |
TIER DECREASE |
Tier 6 |
ICOSAPENT ETHYL 1 GRAM CAPSULE |
TIER DECREASE |
Tier 2 |
IRBESARTAN |
TIER DECREASE |
Tier 6 |
IRBESARTAN-HCTZ |
TIER DECREASE |
Tier 6 |
JANTOVEN 1 MG TABLET |
TIER DECREASE |
Tier 1 |
JANTOVEN 2 MG TABLET |
TIER DECREASE |
Tier 1 |
JANTOVEN 2.5 MG TABLET |
TIER DECREASE |
Tier 1 |
JANTOVEN 3 MG TABLET |
TIER DECREASE |
Tier 1 |
JANTOVEN 4 MG TABLET |
TIER DECREASE |
Tier 1 |
JANTOVEN 5 MG TABLET |
TIER DECREASE |
Tier 1 |
KERENDIA |
TIER DECREASE |
Tier 3 |
LACOSAMIDE 50 MG TABLET |
TIER DECREASE |
Tier 3 |
LAMIVUDINE-ZIDOVUDINE TABLET |
TIER DECREASE |
Tier 3 |
LAMOTRIGINE |
TIER DECREASE |
Tier 1 |
LATANOPROST 0.005% EYE DROPS |
TIER DECREASE |
Tier 1 |
LEVOXYL 100 MCG TABLET |
TIER DECREASE |
Tier 1 |
LEVOXYL 150 MCG TABLET |
TIER DECREASE |
Tier 1 |
LEVOXYL 50 MCG TABLET |
TIER DECREASE |
Tier 1 |
LEVOXYL 75 MCG TABLET |
TIER DECREASE |
Tier 1 |
LISINOPRIL |
TIER DECREASE |
Tier 6 |
LISINOPRIL-HCTZ |
TIER DECREASE |
Tier 6 |
LIVALO |
TIER DECREASE |
Tier 3 |
LOKELMA POWDER PACKET |
TIER DECREASE |
Tier 3 |
LOSARTAN POTASSIUM |
TIER DECREASE |
Tier 6 |
LOSARTAN-HCTZ |
TIER DECREASE |
Tier 6 |
LOVASTATIN |
TIER DECREASE |
Tier 6 |
MEGESTROL ACET 40 MG/ML SUSP |
TIER DECREASE |
Tier 3 |
MESALAMINE 800 MG DR TABLET |
TIER DECREASE |
Tier 4 |
METFORMIN HCL 1,000 MG TABLET |
TIER DECREASE |
Tier 6 |
METFORMIN HCL 500 MG TABLET |
TIER DECREASE |
Tier 6 |
METFORMIN HCL 850 MG TABLET |
TIER DECREASE |
Tier 6 |
METFORMIN HCL ER 500 MG TABLET |
TIER DECREASE |
Tier 6 |
METFORMIN HCL ER 750 MG TABLET |
TIER DECREASE |
Tier 6 |
METHIMAZOLE |
TIER DECREASE |
Tier 1 |
METOPROLOL SUCC ER |
TIER DECREASE |
Tier 1 |
MOMETASONE FUROATE 50 MCG SPRY |
TIER DECREASE |
Tier 2 |
MOTEGRITY 2 MG TABLET |
TIER DECREASE |
Tier 4 |
NEXLETOL 180 MG TABLET |
TIER DECREASE |
Tier 3 |
NUPLAZID CAPSULE |
TIER DECREASE |
Tier 4 |
OCALIVA 10 MG TABLET |
TIER DECREASE |
Tier 4 |
OMEPRAZOLE |
TIER DECREASE |
Tier 1 |
PANTOPRAZOLE |
TIER DECREASE |
Tier 1 |
PIOGLITAZONE |
TIER DECREASE |
Tier 6 |
PRAVASTATIN SODIUM |
TIER DECREASE |
Tier 6 |
PREMARIN 0.3 MG TABLET |
TIER DECREASE |
Tier 3 |
PREMARIN 0.625 MG TABLET |
TIER DECREASE |
Tier 3 |
PREMARIN VAGINAL CREAM-APPL |
TIER DECREASE |
Tier 3 |
PROLIA 60 MG/ML SYRINGE |
TIER DECREASE |
Tier 3 |
PROPRANOLOL |
TIER DECREASE |
Tier 1 |
QUETIAPINE ER 150 MG TABLET |
TIER DECREASE |
Tier 3 |
QUETIAPINE ER 400 MG TABLET |
TIER DECREASE |
Tier 3 |
QUETIAPINE ER 50 MG TABLET |
TIER DECREASE |
Tier 3 |
QUINAPRIL |
TIER DECREASE |
Tier 6 |
RAMIPRIL |
TIER DECREASE |
Tier 6 |
RANOLAZINE ER |
TIER DECREASE |
Tier 3 |
REXULTI |
TIER DECREASE |
Tier 4 |
RISPERIDONE |
TIER DECREASE |
Tier 1 |
ROSUVASTATIN CALCIUM |
TIER DECREASE |
Tier 6 |
SILODOSIN 8 MG CAPSULE |
TIER DECREASE |
Tier 4 |
SIMBRINZA 1%-0.2% EYE DROP |
TIER DECREASE |
Tier 4 |
SIMVASTATIN |
TIER DECREASE |
Tier 6 |
SPIRONOLACTONE |
TIER DECREASE |
Tier 1 |
TACROLIMUS 5 MG CAPSULE (IR) |
TIER DECREASE |
Tier 3 |
TAMSULOSIN HCL 0.4 MG CAPSULE |
TIER DECREASE |
Tier 1 |
TEKTURNA HCT 150-12.5 MG TAB |
TIER DECREASE |
Tier 3 |
TESTOSTERONE 50 MG/5 GRAM GEL |
TIER DECREASE |
Tier 3 |
TOLTERODINE TART ER |
TIER DECREASE |
Tier 3 |
TRAZODONE |
TIER DECREASE |
Tier 1 |
TRIAMTERENE-HCTZ 37.5-25 MG CP |
TIER DECREASE |
Tier 1 |
TRIAMTERENE-HCTZ 37.5-25 MG TB |
TIER DECREASE |
Tier 1 |
TRIAMTERENE-HCTZ 75-50 MG TAB |
TIER DECREASE |
Tier 1 |
TRINTELLIX 20 MG TABLET |
TIER DECREASE |
Tier 3 |
TRULANCE 3 MG TABLET |
TIER DECREASE |
Tier 3 |
VALSARTAN |
TIER DECREASE |
Tier 6 |
VALSARTAN-HCTZ |
TIER DECREASE |
Tier 6 |
VRAYLAR |
TIER DECREASE |
Tier 4 |
WIXELA INHUB |
TIER DECREASE |
Tier 3 |
YUVAFEM 10 MCG VAGINAL INSERT |
TIER DECREASE |
Tier 4 |
ABACAVIR |
TIER INCREASE |
Tier 3 |
ACAMPROSATE |
TIER INCREASE |
Tier 4 |
ACEBUTOLOL |
TIER INCREASE |
Tier 2 |
ACETAZOLAMIDE |
TIER INCREASE |
Tier 3 |
ACYCLOVIR 200 MG/5 ML SUSP |
TIER INCREASE |
Tier 4 |
ALBUTEROL HFA 90 MCG INHALER |
TIER INCREASE |
Tier 3 |
ALBUTEROL SULFATE |
TIER INCREASE |
Tier 4 |
ALENDRONATE SOD 70 MG/75 ML |
TIER INCREASE |
Tier 2 |
AMILORIDE HCL-HCTZ 5-50 MG TAB |
TIER INCREASE |
Tier 2 |
AMLODIPINE-ATORVASTATIN |
TIER INCREASE |
Tier 2 |
AMLODIPINE-OLMESARTAN |
TIER INCREASE |
Tier 2 |
AMLOD-VALSA-HCTZ |
TIER INCREASE |
Tier 2 |
ANAGRELIDE HCL |
TIER INCREASE |
Tier 3 |
ATAZANAVIR SULFATE |
TIER INCREASE |
Tier 4 |
ATENOLOL-CHLORTHALIDONE |
TIER INCREASE |
Tier 2 |
ATOMOXETINE |
TIER INCREASE |
Tier 4 |
AZATHIOPRINE 50 MG TABLET |
TIER INCREASE |
Tier 2 |
AZELASTINE 0.1% (137 MCG) SPRY |
TIER INCREASE |
Tier 3 |
AZELASTINE 0.15% NASAL SPRAY |
TIER INCREASE |
Tier 3 |
BETAXOLOL |
TIER INCREASE |
Tier 3 |
BETAXOLOL HCL 0.5% EYE DROP |
TIER INCREASE |
Tier 3 |
BRIMONIDINE-TIMOLOL 0.2%-0.5% |
TIER INCREASE |
Tier 3 |
BROMOCRIPTINE 2.5 MG TABLET |
TIER INCREASE |
Tier 4 |
BROMOCRIPTINE 5 MG CAPSULE |
TIER INCREASE |
Tier 4 |
BUDESONIDE NEB SUSP |
TIER INCREASE |
Tier 4 |
CABERGOLINE 0.5 MG TABLET |
TIER INCREASE |
Tier 3 |
CALCITONIN-SALMON 200 UNITS SP |
TIER INCREASE |
Tier 3 |
CALCITRIOL 1 MCG/ML SOLUTION |
TIER INCREASE |
Tier 4 |
CALCIUM ACETATE 667 MG CAPSULE |
TIER INCREASE |
Tier 3 |
CALCIUM ACETATE 667 MG GELCAP |
TIER INCREASE |
Tier 3 |
CALCIUM ACETATE 667 MG TABLET |
TIER INCREASE |
Tier 3 |
CANDESARTAN CILEXETIL |
TIER INCREASE |
Tier 2 |
CANDESARTAN-HCTZ |
TIER INCREASE |
Tier 2 |
CAPTOPRIL |
TIER INCREASE |
Tier 2 |
CARBAMAZEPINE ER CAP |
TIER INCREASE |
Tier 3 |
CARBAMAZEPINE ER TABLET |
TIER INCREASE |
Tier 3 |
CARBIDOPA-LEVODOPA-ENTACAPONE |
TIER INCREASE |
Tier 4 |
CARTEOLOL HCL 1% EYE DROPS |
TIER INCREASE |
Tier 2 |
CEVIMELINE HCL 30 MG CAPSULE |
TIER INCREASE |
Tier 4 |
CHLORPROMAZINE TABLET |
TIER INCREASE |
Tier 4 |
CHOLESTYRAMINE LIGHT PACKET |
TIER INCREASE |
Tier 3 |
CHOLESTYRAMINE LIGHT POWDER |
TIER INCREASE |
Tier 3 |
CHOLESTYRAMINE PACKET |
TIER INCREASE |
Tier 3 |
CHOLESTYRAMINE POWDER |
TIER INCREASE |
Tier 3 |
CITALOPRAM HBR 10 MG/5 ML SOLN |
TIER INCREASE |
Tier 3 |
CLOMIPRAMINE CAPSULE |
TIER INCREASE |
Tier 4 |
CLONIDINE HCL ER 0.1 MG TABLET |
TIER INCREASE |
Tier 4 |
CLOZAPINE ODT 100 MG TABLET |
TIER INCREASE |
Tier 4 |
CLOZAPINE TABLET |
TIER INCREASE |
Tier 3 |
COLESEVELAM 625 MG TABLET |
TIER INCREASE |
Tier 4 |
COLESEVELAM HCL 3.75 G PACKET |
TIER INCREASE |
Tier 4 |
COLESTIPOL HCL 1 GM TABLET |
TIER INCREASE |
Tier 4 |
COLESTIPOL HCL GRANULES PACKET |
TIER INCREASE |
Tier 4 |
CROMOLYN 100 MG/5 ML ORAL CONC |
TIER INCREASE |
Tier 4 |
CROMOLYN 20 MG/2 ML NEB SOLN |
TIER INCREASE |
Tier 4 |
CYCLOSPORINE 100 MG CAPSULE |
TIER INCREASE |
Tier 3 |
CYCLOSPORINE 25 MG CAPSULE |
TIER INCREASE |
Tier 3 |
CYCLOSPORINE MODIFIED 100 MG |
TIER INCREASE |
Tier 3 |
CYCLOSPORINE MODIFIED 100MG/ML |
TIER INCREASE |
Tier 3 |
CYCLOSPORINE MODIFIED 25 MG |
TIER INCREASE |
Tier 3 |
CYCLOSPORINE MODIFIED 50 MG |
TIER INCREASE |
Tier 3 |
DANTROLENE SODIUM CAP |
TIER INCREASE |
Tier 4 |
DESMOPRESSIN 10 MCG/0.1 ML SPR |
TIER INCREASE |
Tier 3 |
DESMOPRESSIN ACETATE TB |
TIER INCREASE |
Tier 3 |
DESVENLAFAXINE SUCCNT ER |
TIER INCREASE |
Tier 3 |
DEXTROAMP-AMPHETAM TAB |
TIER INCREASE |
Tier 3 |
DICLOFENAC-MISOPROST TAB |
TIER INCREASE |
Tier 4 |
DIFLUNISAL 500 MG TABLET |
TIER INCREASE |
Tier 3 |
DIGITEK 125 MCG TABLET |
TIER INCREASE |
Tier 2 |
DIGOXIN 0.125 MG TABLET |
TIER INCREASE |
Tier 2 |
DIGOXIN 0.25 MG TABLET |
TIER INCREASE |
Tier 2 |
DIGOXIN 125 MCG TABLET |
TIER INCREASE |
Tier 2 |
DIGOXIN 250 MCG TABLET |
TIER INCREASE |
Tier 2 |
DIGOXIN 62.5 MCG TABLET |
TIER INCREASE |
Tier 3 |
DOFETILIDE CAPSULE |
TIER INCREASE |
Tier 4 |
DONEPEZIL HCL 23 MG TABLET |
TIER INCREASE |
Tier 4 |
DOXEPIN 10 MG/ML ORAL CONC |
TIER INCREASE |
Tier 4 |
DOXEPIN CAPSULE |
TIER INCREASE |
Tier 4 |
DUTASTERIDE-TAMSULOSIN 0.5-0.4 |
TIER INCREASE |
Tier 4 |
EC-NAPROXEN DR TABLET |
TIER INCREASE |
Tier 2 |
EDURANT 25 MG TABLET |
TIER INCREASE |
Tier 5 |
EFAVIRENZ 600 MG TABLET |
TIER INCREASE |
Tier 4 |
EMSAM 6 MG/24 HOURS PATCH |
TIER INCREASE |
Tier 5 |
ENTACAPONE 200 MG TABLET |
TIER INCREASE |
Tier 4 |
EPLERENONE TABLET |
TIER INCREASE |
Tier 3 |
ESTRADIOL 0.01% CREAM |
TIER INCREASE |
Tier 4 |
ESTRADIOL 0.025 MG PATCH(1/WK) |
TIER INCREASE |
Tier 3 |
ESTRADIOL 0.025 MG PATCH(2/WK) |
TIER INCREASE |
Tier 3 |
ESTRADIOL 0.0375MG PATCH(1/WK) |
TIER INCREASE |
Tier 3 |
ESTRADIOL 0.0375MG PATCH(2/WK) |
TIER INCREASE |
Tier 3 |
ESTRADIOL 0.05 MG PATCH (1/WK) |
TIER INCREASE |
Tier 3 |
ESTRADIOL 0.05 MG PATCH (2/WK) |
TIER INCREASE |
Tier 3 |
ESTRADIOL 0.06 MG PATCH (1/WK) |
TIER INCREASE |
Tier 3 |
ESTRADIOL 0.075 MG PATCH(2/WK) |
TIER INCREASE |
Tier 3 |
ESTRADIOL 0.1 MG PATCH (1/WK) |
TIER INCREASE |
Tier 3 |
ESTRADIOL 0.1 MG PATCH (2/WK) |
TIER INCREASE |
Tier 3 |
ESTRADIOL TABLET |
TIER INCREASE |
Tier 4 |
ESTRADIOL VALERATE 100 MG/5 ML |
TIER INCREASE |
Tier 4 |
ETHOSUXIMIDE 250 MG CAPSULE |
TIER INCREASE |
Tier 3 |
ETODOLAC CAPSULE |
TIER INCREASE |
Tier 3 |
ETODOLAC ER TABLET |
TIER INCREASE |
Tier 4 |
ETODOLAC TABLET |
TIER INCREASE |
Tier 3 |
ETRAVIRINE 200 MG TABLET |
TIER INCREASE |
Tier 5 |
EXEMESTANE 25 MG TABLET |
TIER INCREASE |
Tier 4 |
EZETIMIBE-SIMVASTATIN TABLET |
TIER INCREASE |
Tier 2 |
FAMOTIDINE 40 MG/5 ML SUSP |
TIER INCREASE |
Tier 4 |
FEBUXOSTAT TABLET |
TIER INCREASE |
Tier 3 |
FELODIPINE ER TABLET |
TIER INCREASE |
Tier 2 |
FENOFIBRIC ACID DR 135 MG CAP |
TIER INCREASE |
Tier 4 |
FENOFIBRIC ACID DR 45 MG CAP |
TIER INCREASE |
Tier 4 |
FLUNISOLIDE 0.025% SPRAY |
TIER INCREASE |
Tier 3 |
FLUPHENAZINE DEC 125 MG/5 ML |
TIER INCREASE |
Tier 4 |
FLUPHENAZINE TABLET |
TIER INCREASE |
Tier 4 |
FLUTAMIDE 125 MG CAPSULE |
TIER INCREASE |
Tier 3 |
FLUTICASONE-SALMETEROL INHALER |
TIER INCREASE |
Tier 3 |
FLUVOXAMINE ER 100 MG CAPSULE |
TIER INCREASE |
Tier 4 |
FLUVOXAMINE ER 150 MG CAPSULE |
TIER INCREASE |
Tier 4 |
FORMOTEROL 20 MCG/2 ML NEB VL |
TIER INCREASE |
Tier 5 |
FOSINOPRIL-HCTZ TAB |
TIER INCREASE |
Tier 2 |
FUROSEMIDE 10 MG/ML SOLUTION |
TIER INCREASE |
Tier 2 |
GABAPENTIN 250 MG/5 ML SOLN |
TIER INCREASE |
Tier 3 |
GALANTAMINE 4 MG/ML ORAL SOLN |
TIER INCREASE |
Tier 4 |
GALANTAMINE TABLET |
TIER INCREASE |
Tier 3 |
GENGRAF 100 MG CAPSULE |
TIER INCREASE |
Tier 3 |
GENGRAF 25 MG CAPSULE |
TIER INCREASE |
Tier 3 |
GLYCOPYRROLATE TABLET |
TIER INCREASE |
Tier 3 |
HALOPERIDOL DEC 100 MG/ML AMP |
TIER INCREASE |
Tier 4 |
HALOPERIDOL DEC 100 MG/ML VIAL |
TIER INCREASE |
Tier 4 |
HALOPERIDOL DEC 50 MG/ML VIAL |
TIER INCREASE |
Tier 4 |
HALOPERIDOL LAC 2 MG/ML CONC |
TIER INCREASE |
Tier 2 |
HYDROXYCHLOROQUINE 200 MG TAB |
TIER INCREASE |
Tier 2 |
IMIPRAMINE HCL TABLET |
TIER INCREASE |
Tier 4 |
IMIPRAMINE PAMOATE 75 MG CAP |
TIER INCREASE |
Tier 4 |
ISENTRESS 400 MG TABLET |
TIER INCREASE |
Tier 5 |
KLOR-CON 20 MEQ PACKET |
TIER INCREASE |
Tier 4 |
LAMIVUDINE 150 MG TABLET |
TIER INCREASE |
Tier 3 |
LAMIVUDINE 300 MG TABLET |
TIER INCREASE |
Tier 3 |
LAMIVUDINE HBV 100 MG TABLET |
TIER INCREASE |
Tier 3 |
LEVALBUTEROL 0.63 MG/3 ML SOL |
TIER INCREASE |
Tier 4 |
LEVALBUTEROL 1.25 MG/3 ML SOL |
TIER INCREASE |
Tier 4 |
LEVOBUNOLOL 0.5% EYE DROPS |
TIER INCREASE |
Tier 2 |
LEVOCARNITINE 1 G/10 ML SOLN |
TIER INCREASE |
Tier 4 |
LEVOCARNITINE 330 MG TABLET |
TIER INCREASE |
Tier 4 |
LEVOCETIRIZINE 5 MG TABLET |
TIER INCREASE |
Tier 2 |
LOPINAVIR-RITONAVR 200-50MG TB |
TIER INCREASE |
Tier 3 |
MEMANTINE HCL 2 MG/ML SOLUTION |
TIER INCREASE |
Tier 3 |
MEMANTINE HCL ER CAPSULE |
TIER INCREASE |
Tier 4 |
MERCAPTOPURINE 50 MG TABLET |
TIER INCREASE |
Tier 3 |
MESALAMINE 4 GM/60 ML ENEMA |
TIER INCREASE |
Tier 4 |
MESALAMINE 4 GM/60 ML KIT |
TIER INCREASE |
Tier 4 |
MESALAMINE DR 1.2 GM TABLET |
TIER INCREASE |
Tier 4 |
MESALAMINE ER 0.375 GRAM CAP |
TIER INCREASE |
Tier 4 |
METHAZOLAMIDE TABLET |
TIER INCREASE |
Tier 4 |
METHYLPHENIDATE 10 MG TABLET |
TIER INCREASE |
Tier 3 |
METHYLPHENIDATE 20 MG TABLET |
TIER INCREASE |
Tier 3 |
METHYLPHENIDATE 5 MG TABLET |
TIER INCREASE |
Tier 3 |
METHYLPHENIDATE ER 10 MG TAB |
TIER INCREASE |
Tier 4 |
METHYLPHENIDATE ER 20 MG TAB |
TIER INCREASE |
Tier 4 |
METHYLPHENIDATE ER(LA) 10MG CP |
TIER INCREASE |
Tier 4 |
METHYLPHENIDATE ER(LA) 20MG CP |
TIER INCREASE |
Tier 4 |
METHYLPHENIDATE ER(LA) 30MG CP |
TIER INCREASE |
Tier 4 |
METHYLPHENIDATE LA 20 MG CAP |
TIER INCREASE |
Tier 4 |
METHYLPHENIDATE LA 30 MG CAP |
TIER INCREASE |
Tier 4 |
MEXILETINE CAPSULE |
TIER INCREASE |
Tier 3 |
MIRTAZAPINE 30 MG ODT |
TIER INCREASE |
Tier 3 |
MIRTAZAPINE 45 MG ODT |
TIER INCREASE |
Tier 3 |
MISOPROSTOL TABLET |
TIER INCREASE |
Tier 3 |
MODAFINIL TABLET |
TIER INCREASE |
Tier 3 |
MYCOPHENOLATE 200 MG/ML SUSP |
TIER INCREASE |
Tier 5 |
MYCOPHENOLATE 250 MG CAPSULE |
TIER INCREASE |
Tier 3 |
MYCOPHENOLATE 500 MG TABLET |
TIER INCREASE |
Tier 3 |
MYCOPHENOLIC ACID DR 180 MG TB |
TIER INCREASE |
Tier 4 |
MYCOPHENOLIC ACID DR 360 MG TB |
TIER INCREASE |
Tier 4 |
NADOLOL TABLET |
TIER INCREASE |
Tier 4 |
NAPROXEN DR TABLET |
TIER INCREASE |
Tier 2 |
NATEGLINIDE TABLET |
TIER INCREASE |
Tier 2 |
NEBIVOLOL TABLET |
TIER INCREASE |
Tier 2 |
NEFAZODONE HCL 150 MG TABLET |
TIER INCREASE |
Tier 4 |
NEVIRAPINE 200 MG TABLET |
TIER INCREASE |
Tier 3 |
NEVIRAPINE ER 400 MG TABLET |
TIER INCREASE |
Tier 4 |
NIACIN ER TABLET |
TIER INCREASE |
Tier 4 |
NILUTAMIDE 150 MG TABLET |
TIER INCREASE |
Tier 5 |
NITROGLYCERIN 400 MCG SPRAY |
TIER INCREASE |
Tier 4 |
OCTREOTIDE ACET 100 MCG/ML SYR |
TIER INCREASE |
Tier 4 |
OLANZAPINE ODT TABLET |
TIER INCREASE |
Tier 4 |
OLANZAPINE-FLUOXETINE 6-50 MG |
TIER INCREASE |
Tier 4 |
OLMSRTN-AMLDPN-HCTZ TAB |
TIER INCREASE |
Tier 2 |
OXAPROZIN 600 MG TABLET |
TIER INCREASE |
Tier 4 |
PAROXETINE CR TABLET |
TIER INCREASE |
Tier 4 |
PAROXETINE ER TABLET |
TIER INCREASE |
Tier 4 |
PAROXETINE HCL TABLET |
TIER INCREASE |
Tier 2 |
PERPHENAZINE TABLET |
TIER INCREASE |
Tier 4 |
PHENELZINE SULFATE 15 MG TAB |
TIER INCREASE |
Tier 4 |
PHENOBARBITAL TABLET |
TIER INCREASE |
Tier 3 |
PILOCARPINE EYE DROPS |
TIER INCREASE |
Tier 3 |
PILOCARPINE HCL 5 MG TABLET |
TIER INCREASE |
Tier 4 |
PILOCARPINE HCL 7.5 MG TABLET |
TIER INCREASE |
Tier 4 |
PIMOZIDE 1 MG TABLET |
TIER INCREASE |
Tier 4 |
PINDOLOL TABLET |
TIER INCREASE |
Tier 3 |
PIROXICAM 20 MG CAPSULE |
TIER INCREASE |
Tier 3 |
POTASSIUM CL 10% (20 MEQ/15ML) |
TIER INCREASE |
Tier 4 |
POTASSIUM CL 20 MEQ PACKET |
TIER INCREASE |
Tier 4 |
POTASSIUM CL 20% (40 MEQ/15ML) |
TIER INCREASE |
Tier 4 |
PRASUGREL 10 MG TABLET |
TIER INCREASE |
Tier 3 |
PRASUGREL 5 MG TABLET |
TIER INCREASE |
Tier 3 |
PREVALITE PACKET |
TIER INCREASE |
Tier 3 |
PREVALITE POWDER |
TIER INCREASE |
Tier 3 |
PROBENECID 500 MG TABLET |
TIER INCREASE |
Tier 3 |
PROBENECID-COLCHICINE TABLET |
TIER INCREASE |
Tier 3 |
PROPAFENONE HCL ER CAP |
TIER INCREASE |
Tier 4 |
PYRIDOSTIGMINE BR 60 MG TABLET |
TIER INCREASE |
Tier 3 |
PYRIDOSTIGMINE ER 180 MG TAB |
TIER INCREASE |
Tier 3 |
REPAGLINIDE TABLET |
TIER INCREASE |
Tier 2 |
RILUZOLE 50 MG TABLET |
TIER INCREASE |
Tier 3 |
RISEDRONATE SOD DR 35 MG TAB |
TIER INCREASE |
Tier 4 |
RISEDRONATE SODIUM 150 MG TAB |
TIER INCREASE |
Tier 3 |
RISEDRONATE SODIUM 35 MG TAB |
TIER INCREASE |
Tier 3 |
RISEDRONATE SODIUM 5 MG TABLET |
TIER INCREASE |
Tier 3 |
RISPERIDONE 0.25 MG ODT |
TIER INCREASE |
Tier 4 |
RISPERIDONE 0.5 MG ODT |
TIER INCREASE |
Tier 4 |
RISPERIDONE 2 MG ODT |
TIER INCREASE |
Tier 4 |
RISPERIDONE 3 MG ODT |
TIER INCREASE |
Tier 4 |
RITONAVIR 100 MG TABLET |
TIER INCREASE |
Tier 3 |
RIVASTIGMINE CAPSULE |
TIER INCREASE |
Tier 3 |
ROPINIROLE HCL ER TABLET |
TIER INCREASE |
Tier 4 |
SERTRALINE 20 MG/ML ORAL CONC |
TIER INCREASE |
Tier 4 |
SEVELAMER CARBONATE 800 MG TAB |
TIER INCREASE |
Tier 4 |
SILDENAFIL 20 MG TABLET |
TIER INCREASE |
Tier 3 |
SIROLIMUS TABLET |
TIER INCREASE |
Tier 4 |
SUCRALFATE 1 GM/10 ML SUSP |
TIER INCREASE |
Tier 4 |
SULFASALAZINE 500 MG TABLET |
TIER INCREASE |
Tier 2 |
SYMLINPEN 60 PEN INJECTOR |
TIER INCREASE |
Tier 5 |
TACROLIMUS CAPSULE (IR) |
TIER INCREASE |
Tier 3 |
TELMISARTAN TABLET |
TIER INCREASE |
Tier 2 |
TELMISARTAN-HCTZ TB |
TIER INCREASE |
Tier 2 |
TENOFOVIR DISOP FUM 300 MG TB |
TIER INCREASE |
Tier 4 |
TESTOSTERON CYP 1,000 MG/10 ML |
TIER INCREASE |
Tier 3 |
TESTOSTERON CYP 2,000 MG/10 ML |
TIER INCREASE |
Tier 3 |
TESTOSTERON ENAN 1,000 MG/5 ML |
TIER INCREASE |
Tier 3 |
TESTOSTERONE 1.62% (2.5 G) PKT |
TIER INCREASE |
Tier 3 |
TESTOSTERONE 1.62% GEL PUMP |
TIER INCREASE |
Tier 3 |
TESTOSTERONE 1.62%(1.25 G) PKT |
TIER INCREASE |
Tier 3 |
TESTOSTERONE CYP 200 MG/ML |
TIER INCREASE |
Tier 3 |
THIORIDAZINE TABLET |
TIER INCREASE |
Tier 3 |
THIOTHIXENE CAPSULE |
TIER INCREASE |
Tier 2 |
TIMOLOL 0.25% GEL-SOLUTION |
TIER INCREASE |
Tier 4 |
TIMOLOL 0.25% GFS GEL-SOLUTION |
TIER INCREASE |
Tier 4 |
TIMOLOL 0.5% GEL-SOLUTION |
TIER INCREASE |
Tier 4 |
TIMOLOL 0.5% GFS GEL-SOLUTION |
TIER INCREASE |
Tier 4 |
TOLTERODINE TARTRATE 1 MG TAB |
TIER INCREASE |
Tier 3 |
TOLTERODINE TARTRATE 2 MG TAB |
TIER INCREASE |
Tier 3 |
TRANDOLAPR-VERAPAM ER 4-240 MG |
TIER INCREASE |
Tier 2 |
TRANEXAMIC ACID 650 MG TABLET |
TIER INCREASE |
Tier 3 |
TRANYLCYPROMINE SULF 10 MG TAB |
TIER INCREASE |
Tier 4 |
TRAVOPROST 0.004% EYE DROP |
TIER INCREASE |
Tier 3 |
TRIFLUOPERAZINE TABLET |
TIER INCREASE |
Tier 3 |
URSODIOL |
TIER INCREASE |
Tier 3 |
VIRACEPT 625 MG TABLET |
TIER INCREASE |
Tier 5 |
VIVITROL 380 MG VIAL-DILUENT |
TIER INCREASE |
Tier 5 |
XIFAXAN 550MG TAB |
TIER INCREASE |
Tier 5 |
ZAFIRLUKAST 20 MG TABLET |
TIER INCREASE |
Tier 4 |
ZIPRASIDONE HCL CAPSULE |
TIER INCREASE |
Tier 3 |
Medicare CNY PDP (City Retirees' Prescription Drug Plan Only) New Quantity Limits for 2023 |
|
|---|---|
| Drug | Amount/Frequency |
ARMODAFINIL TABLET |
1/DAY |
MODAFINIL TABLET |
1/DAY |
NUVIGIL |
1/DAY |
Medicare CNY PDP (City Retirees' Prescription Drug Plan Only) Step Therapy Added for 2023 |
|
|---|---|
| Drug | Alterative(s) |
STRATTERA |
ATOMOXETINE HCL, METHYLPHENIDATE HCL, DEXTROAMPHETAMINE-AMPHETAMINE |
LIVALO |
ATORVASTATIN CALCIUM, ROSUVASTATIN CALCIUM, SIMVASTATIN |
CRESTOR |
ATORVASTATIN CALCIUM, ROSUVASTATIN CALCIUM, SIMVASTATIN |
EZALLOR SPRINKLE 40 MG CAPSULE |
ATORVASTATIN CALCIUM, ROSUVASTATIN CALCIUM, SIMVASTATIN |
ROSUVASTATIN-EZETIMIBE |
ATORVASTATIN CALCIUM, ROSUVASTATIN CALCIUM, SIMVASTATIN |
ROSZET |
ATORVASTATIN CALCIUM, ROSUVASTATIN CALCIUM, SIMVASTATIN |
VYTORIN |
ATORVASTATIN CALCIUM, ROSUVASTATIN CALCIUM, SIMVASTATIN |
LESCOL XL |
ATORVASTATIN CALCIUM, ROSUVASTATIN CALCIUM, SIMVASTATIN |
LIPITOR |
ATORVASTATIN CALCIUM, ROSUVASTATIN CALCIUM, SIMVASTATIN |
ZOCOR |
ATORVASTATIN CALCIUM, ROSUVASTATIN CALCIUM, SIMVASTATIN |
ARNUITY ELLIPTA |
FLOVENT HFA, ASMANEX HFA, QVAR REDIHALER |
VASCEPA |
ICOSAPENT ETHYL, OMEGA-3 ACID ETHYL ESTERS |
SYNTHROID |
LEVOTHYROXINE SODIUM, LEVOXYL, UNITHROID |
GEMTESA |
MYRBETRIQ |
XULTOPHY |
SOLIQUA 100-33 |
City of NY PPO Removed From Formulary in 2023 |
|---|
| Drug | Alterative(s) |
|---|---|
GLUCAGEN |
BAQSIMI, GLUCAGON EMERGENCY KIT, GVOKE |
GLUCAGON EMERGENCY KIT |
BAQSIMI, GLUCAGON EMERGENCY KIT, GVOKE |
ONFI |
CLOBAZAM |
KLONOPIN |
CLONAZEPAM |
FENOFIBRATE |
FENOFIBRATE, FENOFIBRIC ACID |
LIPOFEN |
FENOFIBRATE, FENOFIBRIC ACID |
COMFORT EZ INSULIN SYRINGE |
INSULIN SYRINGE |
DROPLET INSULIN SYRINGE |
INSULIN SYRINGE |
EASY COMFORT INSULIN SYRINGE |
INSULIN SYRINGE |
EASY TOUCH |
INSULIN SYRINGE |
INSULIN SYRINGE |
INSULIN SYRINGE |
MONOJECT INSULIN SYRINGE |
INSULIN SYRINGE |
SURE COMFORT |
INSULIN SYRINGE |
TRUEPLUS INSULIN SYRINGE |
INSULIN SYRINGE |
ULTRA COMFORT |
INSULIN SYRINGE |
VIMPAT |
LACOSAMIDE |
MOTEGRITY |
LINZESS, TRULANCE |
RITALIN LA |
METHYLPHENIDATE ER (LA) |
LOVAZA |
OMEGA-3 ACID ETHYL ESTERS |
OXISTAT |
OXICONAZOLE NITRATE, CICLOPIROX, CLOTRIMAZOLE |
COMFORT EZ INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
DROPLET INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
EASY TOUCH |
SAFETYGLIDE INSULIN SYRINGE |
EASY TOUCH INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
EASY-TOUCH INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
MONOJECT INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
SURE COMFORT |
SAFETYGLIDE INSULIN SYRINGE |
TRUEPLUS INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
ULTICARE |
SAFETYGLIDE INSULIN SYRINGE |
INCRUSE ELLIPTA |
SPIRIVA RESPIMAT, SPIRIVA HANDIHALER |
CONZIP |
TRAMADOL HCL ER |
1ST TIER UNIFINE PENTIPS |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
1ST TIER UNIFINE PENTIPS PLUS |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
ADVOCATE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
ADVOCATE PEN NEEDLES |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
ASSURE ID PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
CAREFINE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
COMFORT EZ PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
COMFORT TOUCH PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
DROPLET MICRON PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
DROPLET PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
DROPSAFE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
EASY COMFORT PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
EASY COMFORT PEN NEEDLES |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
EASY TOUCH PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
LITE TOUCH |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
MINI PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
NOVOFINE 32 |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
NOVOFINE AUTOCOVER |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
NOVOFINE PLUS |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
NOVOTWIST |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
PEN NEEDLES |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
PENTIPS |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
PRO COMFORT PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
PURE COMFORT PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
SAFETY PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
SURE COMFORT |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
TECHLITE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
TRUE COMFORT PRO PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
TRUEPLUS PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
ULTICARE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
ULTRACARE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
UNIFINE PENTIPS |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
UNIFINE PENTIPS PLUS |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
TECHLITE INSULIN SYRINGE |
VEO INSULIN SYRINGE |
Commercial Small Group/Essential/Individual Plans Removed From Formulary in 2023 |
|---|
| Drug | Alterative(s) |
|---|---|
GLUCAGEN |
BAQSIMI, GLUCAGON EMERGENCY KIT, GVOKE |
GLUCAGON EMERGENCY KIT |
BAQSIMI, GLUCAGON EMERGENCY KIT, GVOKE |
ONFI |
CLOBAZAM |
KLONOPIN |
CLONAZEPAM |
FENOFIBRATE |
FENOFIBRATE, FENOFIBRIC ACID |
INSULIN SYRINGE |
INSULIN SYRINGE |
EASY TOUCH |
INSULIN SYRINGE |
COMFORT EZ INSULIN SYRINGE |
INSULIN SYRINGE |
DROPLET INSULIN SYRINGE |
INSULIN SYRINGE |
SURE COMFORT |
INSULIN SYRINGE |
TRUEPLUS INSULIN SYRINGE |
INSULIN SYRINGE |
EASY COMFORT INSULIN SYRINGE |
INSULIN SYRINGE |
VIMPAT |
LACOSAMIDE |
MOTEGRITY |
LINZESS, TRULANCE |
LOVAZA |
OMEGA-3 ACID ETHYL ESTERS |
ABRAXANE |
PACLITAXEL PROTEIN-BOUND |
PYRIDIUM |
PHENAZOPYRIDINE HCL |
CONDYLOX |
PODOFILOX, IMIQUIMOD |
INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
ULTRACARE INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
DROPLET INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
SURE COMFORT |
SAFETYGLIDE INSULIN SYRINGE |
EASY TOUCH |
SAFETYGLIDE INSULIN SYRINGE |
EASY-TOUCH INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
EASY COMFORT INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
MONOJECT INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
TRUEPLUS INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
ULTICARE |
SAFETYGLIDE INSULIN SYRINGE |
INCRUSE ELLIPTA |
SPIRIVA RESPIMAT, SPIRIVA HANDIHALER |
DROPLET PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
COMFORT EZ PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
EASY COMFORT PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
UNIFINE PENTIPS |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
EASY COMFORT PEN NEEDLES |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
ULTRACARE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
UNIFINE PENTIPS PLUS |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
ULTICARE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
EASY TOUCH PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
TRUEPLUS PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
PRO COMFORT PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
ADVOCATE PEN NEEDLES |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
NOVOFINE PLUS |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
PENTIPS |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
SURE COMFORT |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
TECHLITE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
NOVOFINE 32 |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
COMFORT TOUCH PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
NOVOFINE AUTOCOVER |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
1ST TIER UNIFINE PENTIPS PLUS |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
SECURESAFE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
1ST TIER UNIFINE PENTIPS |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
PEN NEEDLES |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
NOVOTWIST |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
MINI PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
EASY GLIDE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
MINI ULTRA-THIN II |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
SABRIL |
VIGABATRIN, VIGADRONE |
Commercial Large Group Drugs Removed from Formulary In 2023 |
|---|
| Drug | Alterative(s) |
|---|---|
NORPACE CR |
AMIODARONE HCL, QUINIDINE SULFATE, SOTALOL |
GLUCAGEN |
BAQSIMI, GLUCAGON EMERGENCY KIT |
ONFI |
CLOBAZAM |
KLONOPIN |
CLONAZEPAM |
FENOFIBRATE |
FENOFIBRATE, FENOFIBRIC ACID |
LIPOFEN |
FENOFIBRATE, FENOFIBRIC ACID |
PERFOROMIST |
FORMOTEROL FUMARATE |
COMFORT EZ INSULIN SYRINGE |
INSULIN SYRINGE |
MONOJECT INSULIN SYRINGE |
INSULIN SYRINGE |
SURE COMFORT |
INSULIN SYRINGE |
DROPLET INSULIN SYRINGE |
INSULIN SYRINGE |
TRUEPLUS INSULIN SYRINGE |
INSULIN SYRINGE |
EASY COMFORT INSULIN SYRINGE |
INSULIN SYRINGE |
INSULIN SYRINGE |
INSULIN SYRINGE |
ADVOCATE SYRINGES |
INSULIN SYRINGE |
EASY TOUCH |
INSULIN SYRINGE |
VIMPAT |
LACOSAMIDE |
MOTEGRITY |
LINZESS, TRULANCE |
RITALIN LA |
METHYLPHENIDATE ER (LA) |
RITALIN |
METHYLPHENIDATE HCL |
VUSION |
MICONAZOLE NITRATE, CLOTRIMAZOLE, KETOCONAZOLE |
LOVAZA |
OMEGA-3 ACID ETHYL ESTERS |
OXISTAT |
OXICONAZOLE NITRATE, CICLOPIROX, CLOTRIMAZOLE |
CONDYLOX |
PODOFILOX, IMIQUIMOD |
BANZEL |
RUFINAMIDE |
COMFORT EZ INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
DROPLET INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
SURE COMFORT |
SAFETYGLIDE INSULIN SYRINGE |
INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
EASY TOUCH |
SAFETYGLIDE INSULIN SYRINGE |
TRUEPLUS INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
EASY-TOUCH INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
ADVOCATE SYRINGES |
SAFETYGLIDE INSULIN SYRINGE |
EASY COMFORT INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
MONOJECT INSULIN SYRINGE |
SAFETYGLIDE INSULIN SYRINGE |
INCRUSE ELLIPTA |
SPIRIVA RESPIMAT, SPIRIVA HANDIHALER |
NOVOFINE AUTOCOVER |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
SAFETY PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
PURE COMFORT PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
DROPLET PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
SURE COMFORT |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
PEN NEEDLES |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
DROPSAFE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
1ST TIER UNIFINE PENTIPS PLUS |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
UNIFINE PENTIPS |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
TRUEPLUS PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
SECURESAFE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
UNIFINE PENTIPS PLUS |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
PRO COMFORT PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
ADVOCATE PEN NEEDLES |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
ADVOCATE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
COMFORT EZ PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
EASY COMFORT PEN NEEDLES |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
EASY TOUCH PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
UNIFINE SAFECONTROL |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
NOVOFINE 32 |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
MINI PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
TECHLITE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
TRUE COMFORT PRO PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
ULTICARE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
INSUPEN |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
NOVOFINE PLUS |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
TRUEPLUS PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
PENTIPS |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
1ST TIER UNIFINE PENTIPS |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
EASY COMFORT PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
EASY GLIDE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
ULTICARE SAFETY PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
ULTRACARE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
CAREFINE PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
COMFORT TOUCH PEN NEEDLE |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
NOVOTWIST |
ULTRA-FINE SHORT PEN NEEDLE, ULTRA-FINE NANO PEN NEEDLE |
JP59776: 11/2022
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