Effective Date: Jan. 1, 2026
The table below describes all formulary changes going into effect for our Medicare members in 2026. For our Commercial members, this table highlights the most highly impacted drugs. For a comprehensive listing of all plans see: 2026 Summary of Companies, Lines of Business, Networks & Benefit Plans.
See the applicable 2026 plan formularies for all coverage rules:
Note: Affected members were notified of these changes separately.
Medicare Advantage Plans Drugs Moving to Non-Formulary in 2026 |
|
Drug |
Alternative(s) |
CYCLOSPORINE OP |
RESTASIS (BRAND) |
MIRABEGRON |
MYRBETRIQ (BRAND) |
ICOSAPENT |
VASCEPA |
ROCKLATAN |
BETAXOLOL, BRIMONIDINE, |
BRILINTA |
TICAGRELOR (GENERIC) |
EPLERENONE |
SPIRONOLACTONE |
RHOPRESSA |
BETAXOLOL, BRIMONIDINE, |
MEMANTINE ER |
MEMANTINE IR |
TIOTROPIUM |
INCRUSE, SPIRIVA |
QVAR |
ARNUITY, ASMANEX |
SUCRALFATE SUSP |
SUCRALFATE TAB |
BRIMONIDINE 0.1% |
BRIMONIDINE 0.15%, BRIMONIDINE 0.2% |
FEBUXOSTAT |
ALLOPURINOL |
TROSPIUM |
MYRBETRIQ, OXYBUTYNIN, SOLIFENACIN, TOLTERODINE |
SIMBRINZA |
DORZOLOMIDE, BRIMONIDINE |
PITAVASTATIN |
ATORVASTATIN, FLUVASTATIN, LOVASTATIN, PRAVASTATIN, ROSUVASTATIN, SIMVASTATIN |
SAXAGLIPTIN |
JANUVIA, TRAJENTA |
TRULANCE |
LINZESS, LUBIPROSTONE |
HUMIRA |
HADLIMA, SIMLANDI |
VYNDAMAX |
ATTRUBY |
CYCLOSPORINE OP |
RESTASIS (BRAND) |
MIRABEGRON |
MYRBETRIQ (BRAND) |
Medicare Advantage Plans New Tier 5 Drugs |
CAPLYTA CAP 10.5MG |
CAPLYTA CAP 10.5MG |
CAPLYTA CAP 21MG |
CAPLYTA CAP 21MG |
CAPLYTA CAP 42MG |
ENVARSUS XR TAB 4MG |
NUPLAZID CAP 34MG |
NUPLAZID CAP 34MG |
REXULTI TAB 0.25MG |
REXULTI TAB 0.5MG |
REXULTI TAB 0.5MG |
REXULTI TAB 1MG |
REXULTI TAB 1MG |
REXULTI TAB 2MG |
REXULTI TAB 2MG |
REXULTI TAB 3MG |
Medicare Advantage Plans New Preauthorization Requirements for Listed Drugs in 2026 |
ARIPIPRAZOLE |
ASENAPINE |
ATOVAQUONE |
BUDESONIDE |
CHLORPROMAZ |
CINACALCET |
CLOZAPINE |
CORLANOR |
DICYCLOMINE |
DIHYDROERGOT |
DIPHEN/ATROP |
EPOGEN |
FLUPHENAZ |
FLUPHENAZINE |
GLATIRAMER |
GLATOPA |
HALOPER |
HALOPERIDOL |
IMATINIB |
IMIQUIMOD |
LIDO/PRILOCN |
LINEZOLID |
LOXAPINE |
LURASIDONE |
METHYLPHENID |
MIEBO |
OLANZAPINE |
PALIPERIDONE |
PERPHENAZINE |
PIRFENIDONE |
PROCRIT |
PYRIMETHAMIN |
QUETIAPINE |
QUININE |
REXULTI |
RISPERIDONE |
ROFLUMILAST |
SCOPOLAMINE |
TADALAFIL |
TERIPARATIDE |
TRETINOIN |
TRIFLUOPERAZ |
XIIDRA |
Medicare Advantage Members New Quantity Limits for 2026 |
|
Amount/Frequency |
|
TAMSULOSIN CAP 0.4MG |
60 CAPS/30 DAYS |
ALFUZOSIN TAB 10MG ER |
30 TABS/30 DAYS |
CELECOXIB CAP 200MG |
60 CAPS/30 DAYS |
DUTASTERIDE CAP 0.5MG |
30 CAPS/30 DAYS |
EZETIMIBE TAB 10MG |
30 TABS/30 DAYS |
FINASTERIDE TAB 5MG |
30 TABS/30 DAYS |
IBUPROFEN TAB 400MG |
240 TABS/30 DAYS |
IBUPROFEN TAB 600MG |
150 TABS/30 DAYS |
IBUPROFEN TAB 800MG |
120 TABS/30 DAYS |
IRBESARTAN TAB 150MG |
30 TABS/30 DAYS |
IRBESARTAN TAB 300MG |
30 TABS/30 DAYS |
LANTUS SOLOS INJ 100/ML |
20 PENS/30 DAYS |
LATANOPROST SOL 0.005% |
15 MLS/75 DAYS |
LOSARTAN POT TAB 100MG |
30 TABS/30 DAYS |
LOSARTAN POT TAB 25MG |
60 TABS/30 DAYS |
LOSARTAN POT TAB 50MG |
60 TABS/30 DAYS |
LOSARTAN/HCT TAB 100-12.5 |
30 TABS/30 DAYS |
LOSARTAN/HCT TAB 100-25 |
30 TABS/30 DAYS |
LOSARTAN/HCT TAB 50-12.5 |
30 TABS/30 DAYS |
LUMIGAN SOL 0.01% OP |
15 MLS/75 DAYS |
MIRTAZAPINE TAB 15MG |
45 TABS/30 DAYS |
MIRTAZAPINE TAB 7.5MG |
30 TABS/30 DAYS |
NAPROXEN TAB 500MG |
90 TABS/30 DAYS |
NOVOLOG INJ FLEXPEN |
20 PENS/30 DAYS |
OLMESA MEDOX TAB 40MG |
30 TABS/30 DAYS |
OXYBUTYNIN TAB 10MG ER |
90 TABS/30 DAYS |
TOUJEO SOLO INJ 300/ML |
60 MLS/30 DAYS |
VALSARTAN TAB 160MG |
60 TABS/30 DAYS |
VALSARTAN TAB 320MG |
30 TABS/30 DAYS |
VALSARTAN TAB 80MG |
60 TABS/30 DAYS |
TAMSULOSIN CAP 0.4MG |
60 CAPS/30 DAYS |
Medicare Advantage Plans Drugs Removed from Formulary in 2026 |
|
ABACA/LAMIVU TAB 600-300 |
BALSALAZIDE CAP 750MG |
ABIRATERONE TAB 500MG |
BELBUCA MIS 900MCG |
ADBRY INJ 150MG/ML |
BETA DIPROP CRE 0.05% |
ALPRAZOLAM TAB 0.5MG ER |
BICALUTAMIDE TAB 50MG |
ALVESCO AER 160MCG |
BREYNA AER 160/4.5 |
ALVESCO AER 80MCG |
BREYNA AER 80/4.5 |
AMLOD/ATORVA TAB 10-10MG |
BRILINTA TAB 60MG |
AMLOD/ATORVA TAB 2.5-40MG |
BROMFENAC DRO 0.07% OP |
AMLOD/ATORVA TAB 5-10MG |
BUPREN/NALOX MIS 12-3MG |
AMLOD/ATORVA TAB 5-20MG |
BUPREN/NALOX MIS 8-2MG |
AMOX/K CLAV SUS 200/5ML |
BUPRENORPHIN DIS 15MCG/HR |
AMOX/K CLAV SUS 400/5ML |
BUPRENORPHIN DIS 5MCG/HR |
AMOX/K CLAV SUS 600/5ML |
BUPRENORPHIN DIS 5MCG/HR |
APAP/CODEINE TAB 300-30MG |
BUPRENORPHIN SUB 2MG |
APTIOM TAB 200MG |
BUPROPION TAB 150MG SR |
ARIPIPRAZOLE TAB 10MG |
BYETTA INJ 10MCG |
ARIPIPRAZOLE TAB 2MG |
CAPLYTA CAP 10.5MG |
ARISTADA INJ 1064MG |
CAPLYTA CAP 21MG |
ARISTADA INJ 882MG/3 |
CARB/LEVO100 TAB /ENTACAP |
ATROVENT HFA AER 17MCG |
CARB/LEVO125 TAB /ENTACAP |
CARBAMAZEPIN CAP 200MG ER |
DEXAMETH PHO SOL 0.1% OP |
CARBAMAZEPIN CAP 300MG ER |
DEXAMETHASON TAB 1.5MG |
CARBAMAZEPIN TAB 200MG |
DICLOFEN POT TAB 50MG |
CELECOXIB CAP 400MG |
DICLOFENAC TAB 25MG DR |
CEVIMELINE CAP 30MG |
DILTIAZEM TAB 240MG ER |
CIPRO/DEXA SUS 0.3-0.1% |
DILTIAZEM TAB 300MG ER |
CLINDAMYCIN LOT 1% |
DIVALPROEX CAP 125MG DR |
CLOBETASOL SHA 0.05% |
DOPTELET TAB 20MG |
CLONAZEP ODT TAB 0.25MG |
DOXEPIN TAB 3MG |
CLOTRIMAZOLE SOL 1% |
DOXYCYC MONO TAB 100MG |
CLOZAPINE TAB 200MG |
DOXYCYCL HYC TAB 50MG |
COLESEVELAM TAB 625MG |
DOXYCYCLINE SUS 25MG/5ML |
COMBIVENT AER 20-100 |
DUAVEE TAB 0.45-20 |
COMPLERA TAB |
EDARBYCLOR TAB 40-12.5 |
CORLANOR TAB 5MG |
ESZOPICLONE TAB 2MG |
CRYSELLE-28 TAB 28 TABS |
ESZOPICLONE TAB 3MG |
CYCLOPHOSPH CAP 50MG |
FAMCICLOVIR TAB 250MG |
DESIPRAMINE TAB 10MG |
FAMCICLOVIR TAB 500MG |
DESVENLAFAX TAB 25MG ER |
FASENRA PEN INJ 30MG/ML |
DESVENLAFAX TAB 50MG ER |
FEBUXOSTAT TAB 40MG |
FENOFIBRATE CAP 200MG |
LOPIN/RITON TAB 200-50MG |
FLUCONAZOLE SUS 40MG/ML |
MEDROXYPR AC INJ 150MG/ML |
FLUTICAS HFA AER 44MCG |
MEFLOQUINE TAB 250MG |
FULPHILA INJ 6/0.6ML |
MEMANTINE SOL 2MG/ML |
GALANTAMINE TAB 12MG |
METOCLOPRAM SOL 5MG/5ML |
GATIFLOXACIN SOL 0.5% |
METOLAZONE TAB 5MG |
GATTEX KIT 5MG |
MEXILETINE CAP 200MG |
GAVILYTE-G SOL |
MIDODRINE TAB 10MG |
GLYXAMBI TAB 25-5 MG |
MIDODRINE TAB 5MG |
HALOPERIDOL TAB 20MG |
MIRABEGRON TAB 25MG ER |
HUMIRA PEN INJ 40MG/0.8 |
MIRABEGRON TAB 50MG ER |
HUMIRA PEN INJ 80/0.8ML |
MOMETASONE SPR 50MCG |
ISIBLOOM TAB |
MORPHINE SUL TAB 100MG ER |
ISOSORB DIN TAB 5MG |
MORPHINE SUL TAB 15MG |
ISOSORB MONO TAB 60MG ER |
MOXIFLOXACIN SOL 0.5% |
LAMIVUD/ZIDO TAB 150-300 |
NADOLOL TAB 40MG |
LAMOTRIGINE TAB 150MG |
NADOLOL TAB 80MG |
LAMOTRIGINE TAB 25MG |
NALOXONE SPR 4MG |
LEVOCETIRIZI SOL 2.5/5ML |
NALOXONE HCL SPR 4MG |
LIDOCAINE OIN 5% |
NAPROXEN SOD TAB 275MG |
NEBIVOLOL TAB 20MG |
OXERVATE SOL 20MCG/ML |
NEBIVOLOL TAB 5MG |
OXYBUTYNIN SOL 5MG/5ML |
NEUPRO DIS 2MG/24HR |
OXYBUTYNIN TAB 5MG ER |
NEUPRO DIS 3MG/24HR |
OXYCONTIN TAB 30MG ER |
NEUPRO DIS 4MG/24HR |
OXYCONTIN TAB 40MG ER |
NEUPRO DIS 6MG/24HR |
OXYCONTIN TAB 60MG ER |
NEXLETOL TAB 180MG |
OXYCONTIN TAB 80MG ER |
NEXLIZET TAB 180/10MG |
PACERONE TAB 400MG |
NIFEDIPINE TAB 60MG ER |
PEG-3350 SOL ELECTROL |
NITROGLYCRN SPR 400MCG |
PERIOGARD SOL 0.12% |
NIVESTYM INJ 300/0.5 |
PHENYTOIN CHW 50MG |
NUCALA INJ 100MG |
PITAVASTATIN TAB 2MG |
NUCALA INJ 100MG/ML |
PITAVASTATIN TAB 4MG |
NYAMYC POW 100000 |
POT CHLORIDE POW 20MEQ |
NYSTAT/TRIAM CRE |
PREDNISOLONE SUS 1% OP |
NYSTAT/TRIAM OIN |
PREDNISONE CON 5MG/ML |
NYSTATIN TAB 500000 |
PREDNISONE TAB 10MG |
NYVEPRIA INJ 6/0.6ML |
PREDNISONE TAB 50MG |
OMEGA-3-ACID CAP 1GM |
PREDNISONE TAB 5MG |
OPSUMIT TAB 10MG |
PREMARIN TAB 0.3MG |
PREMARIN TAB 0.625MG |
RIVASTIGMINE CAP 4.5MG |
PRIFTIN TAB 150MG |
RIZATRIPTAN TAB 10MG |
PROMACTA TAB 25MG |
RIZATRIPTAN TAB 10MG ODT |
PROPAFENONE TAB 225MG |
RIZATRIPTAN TAB 5MG |
PROPRANOLOL CAP 80MG ER |
ROPINIROLE TAB 6MG ER |
PROPRANOLOL TAB 10MG |
ROPINIROLE TAB 8MG ER |
PYRIDOSTIGMI TAB ER 180MG |
SAXAGLIPTIN TAB 2.5MG |
QUETIAPINE TAB 200MG ER |
SAXAGLIPTIN TAB 5MG |
QUETIAPINE TAB 400MG ER |
SELEGILINE CAP 5MG |
RANOLAZINE TAB 500MG ER |
SIMBRINZA SUS 1-0.2% |
RETACRIT INJ 10000UNT |
SODIUM CHLOR SOL 0.9% IRR |
REVLIMID CAP 2.5MG |
SOFOS/VELPAT TAB 400-100 |
REVLIMID CAP 25MG |
SOTYKTU TAB 6MG |
REVLIMID CAP 5MG |
STEGLATRO TAB 15MG |
RILUZOLE TAB 50MG |
SUCRAID SOL 8500/ML |
RISPERIDONE INJ 12.5MG |
SUCRALFATE SUS 1GM/10ML |
RISPERIDONE INJ 25MG ER |
SYMPROIC TAB 0.2MG |
RISPERIDONE TAB 0.25MG |
TASIGNA CAP 150MG |
RISPERIDONE TAB 0.5MG |
TELMIS/AMLOD TAB 80-5MG |
RISPERIDONE TAB 3MG |
TERBUTALINE TAB 2.5MG |
TERIFLUNOMID TAB 14MG |
VERAPAMIL CAP 100MG ER |
TESTOSTERONE SOL 30MG/ACT |
VERAPAMIL CAP 120MG SR |
THEOPHYLLINE SOL 80/15ML |
VERAPAMIL CAP 300MG ER |
THEOPHYLLINE TAB 400MG ER |
VIENVA TAB 0.1-20 |
THEOPHYLLINE TAB 600MG ER |
VILAZODONE TAB 20MG |
TIOTROP BROM CAP 18MCG |
XOFLUZA TAB 80MG |
TOBRADEX OIN 0.3-0.1% |
ZEPOSIA 7DAY CAP STR PACK |
TOBRAMYCIN NEB 300/4ML |
ZIPRASIDONE CAP 20MG |
TOLTERODINE CAP 2MG ER |
ZIPRASIDONE CAP 40MG |
TOPIRAMATE CAP 25MG |
ZIRGAN GEL 0.15% |
TRETINOIN GEL 0.01% |
ZUBSOLV SUB 5.7-1.4 |
TRETINOIN GEL 0.05% |
VERAPAMIL CAP 100MG ER |
TRIAMCINOLON PST DEN 0.1% |
VERAPAMIL CAP 120MG SR |
UBRELVY TAB 100MG |
VERAPAMIL CAP 300MG ER |
URSODIOL TAB 500MG |
VILAZODONE TAB 20MG |
UZEDY INJ 100MG |
XOFLUZA TAB 80MG |
UZEDY INJ 125MG |
ZEPOSIA 7DAY CAP STR PACK |
UZEDY INJ 150MG |
|
| Tier Changes For 2026 |
||
Drug |
Change |
2025 Tier |
ALBUTEROL AER HFA |
Tier Increased |
3 |
ALBUTEROL AER HFA |
Tier Increased |
3 |
AMLOD/VALSAR TAB /HCTZ |
Tier Decreased |
6 |
ANASTROZOLE TAB 1MG |
Tier Decreased |
1 |
ANASTROZOLE TAB 1MG |
Tier Decreased |
1 |
BRIMONIDINE SOL 0.15% OP |
Tier Increased |
4 |
BUDES/FORMOT AER 160-4.5 |
Tier Increased |
4 |
BUDES/FORMOT AER 80-4.5 |
Tier Increased |
4 |
BUPROPION TAB 150MG XL |
Tier Increased |
3 |
BUPROPION TAB 300MG XL |
Tier Increased |
3 |
COLESTIPOL TAB 1GM |
Tier Decreased |
3 |
DORZOL/TIMOL SOL 2-0.5%OP |
Tier Decreased |
1 |
DORZOL/TIMOL SOL 2-0.5%OP |
Tier Decreased |
1 |
EFAVIR/EMTRI TAB TENOFOVI |
Tier Decreased |
4 |
ESTRADIOL CRE 0.01% |
Tier Decreased |
3 |
ESTRADIOL CRE 0.01% |
Tier Decreased |
3 |
EZETIM/SIMVA TAB 10-10MG |
Tier Decreased |
6 |
EZETIM/SIMVA TAB 10-20MG |
Tier Decreased |
6 |
EZETIM/SIMVA TAB 10-40MG |
Tier Decreased |
6 |
EZETIM/SIMVA TAB 10-80MG |
Tier Decreased |
6 |
FAMOTIDINE TAB 20MG |
Tier Increased |
2 |
FAMOTIDINE TAB 40MG |
Tier Increased |
2 |
FENOFIBRATE TAB 145MG |
Tier Increased |
3 |
FENOFIBRIC CAP 135MG DR |
Tier Decreased |
3 |
FENOFIBRIC CAP 45MG DR |
Tier Decreased |
3 |
HYDROXYCHLOR TAB 200MG |
Tier Increased |
3 |
ISOSORB MONO TAB 30MG ER |
Tier Increased |
2 |
ISOSORB MONO TAB 60MG ER |
Tier Increased |
2 |
LANSOPRAZOLE CAP 15MG DR |
Tier Decreased |
2 |
LANSOPRAZOLE CAP 30MG DR |
Tier Decreased |
2 |
LUBIPROSTONE CAP 24MCG |
Tier Decreased |
3 |
LUBIPROSTONE CAP 8MCG |
Tier Decreased |
3 |
METHIMAZOLE TAB 10MG |
Tier Decreased |
1 |
METHIMAZOLE TAB 5MG |
Tier Decreased |
1 |
MONTELUKAST TAB 10MG |
Tier Increased |
2 |
NATEGLINIDE TAB 120MG |
Tier Decreased |
6 |
NATEGLINIDE TAB 60MG |
Tier Decreased |
6 |
NEBIVOLOL TAB 10MG |
Tier Increased |
4 |
NEBIVOLOL TAB 5MG |
Tier Increased |
4 |
NIFEDIPINE TAB 30MG ER |
Tier Increased |
3 |
NIFEDIPINE TAB 30MG ER |
Tier Increased |
3 |
NIFEDIPINE TAB 60MG ER |
Tier Increased |
3 |
NIFEDIPINE TAB 60MG ER |
Tier Increased |
3 |
NIFEDIPINE TAB 90MG ER |
Tier Increased |
3 |
NIFEDIPINE TAB 90MG ER |
Tier Increased |
3 |
OMEGA-3-ACID CAP 1GM |
Tier Increased |
3 |
OXYBUTYNIN TAB 10MG ER |
Tier Increased |
3 |
OXYBUTYNIN TAB 5MG ER |
Tier Increased |
3 |
PROGESTERONE CAP 100MG |
Tier Decreased |
2 |
RALOXIFENE TAB 60MG |
Tier Increased |
3 |
RANOLAZINE TAB 500MG ER |
Tier Increased |
4 |
REPAGLINIDE TAB 0.5MG |
Tier Decreased |
6 |
REPAGLINIDE TAB 1MG |
Tier Decreased |
6 |
REPAGLINIDE TAB 2MG |
Tier Decreased |
6 |
TACROLIMUS CAP 1MG |
Tier Increased |
4 |
TAMSULOSIN CAP 0.4MG |
Tier Increased |
2 |
TELMISA/HCTZ TAB 40-12.5 |
Tier Decreased |
6 |
TELMISA/HCTZ TAB 80-12.5 |
Tier Decreased |
6 |
TELMISA/HCTZ TAB 80-25MG |
Tier Decreased |
6 |
TRAVOPROST DRO 0.004% |
Tier Increased |
4 |
Medicare - CNY PDP New Quantity Limits for 2026 |
|
Drug |
Amount/Frequency |
ALFUZOSIN TAB 10MG ER |
30 TABS/30 DAYS |
CELECOXIB CAP 200MG |
60 CAPS/30 DAYS |
ELIQUIS TAB 2.5MG |
60 TABS/30 DAYS |
ELIQUIS TAB 5MG |
74 TABS/30 DAYS |
EZETIMIBE TAB 10MG |
30 TABS/30 DAYS |
FINASTERIDE TAB 5MG |
30 TABS/30 DAYS |
HUMALOG KWIK INJ 100/ML |
20 PENS/30 DAYS |
HYDROCORT CRE 2.5% |
454 GRAMS/30 DAYS |
IBUPROFEN TAB 600MG |
150 TABS/30 DAYS |
IBUPROFEN TAB 800MG |
120 TABS/30 DAYS |
LANTUS SOLOS INJ 100/ML |
20 PENS/30 DAYS |
LATANOPROST SOL 0.005% |
15 MLS/75 DAYS |
LOSARTAN POT TAB 100MG |
30 TABS/30 DAYS |
LOSARTAN POT TAB 25MG |
60 TABS/30 DAYS |
LOSARTAN POT TAB 50MG |
60 TABS/30 DAYS |
LOSARTAN/HCT TAB 100-25 |
30 TABS/30 DAYS |
MELOXICAM TAB 15MG |
30 TABS/30 DAYS |
MIRTAZAPINE TAB 15MG |
45 TABS/30 DAYS |
NAPROXEN TAB 500MG |
90 TABS/30 DAYS |
OLMESA MEDOX TAB 20MG |
30 TABS/30 DAYS |
OLMESA MEDOX TAB 40MG |
30 TABS/30 DAYS |
OMEPRAZOLE CAP 40MG |
60 CAPS/30 DAYS |
OSELTAMIVIR CAP 75MG |
84 CAPS/365 DAYS |
PANTOPRAZOLE TAB 40MG |
60 TABS/30 DAYS |
SHINGRIX INJ 50/0.5ML |
2 VACCNS/ LIFETI |
TAMSULOSIN CAP 0.4MG |
60 CAPS/30 DAYS |
TRIAMCINOLON CRE 0.1% |
454 GRAMS/30 DAYS |
TRIAMCINOLON OIN 0.1% |
454 GRAMS/30 DAYS |
VALSARTAN TAB 160MG |
60 TABS/30 DAYS |
XARELTO TAB 20MG |
30 TABS/30 DAYS |
Emblem City of NY PPO Drugs Removed from Formulary In 2026 |
||
Drug Class |
Non-covered | Formulary Alternatives |
INFLAMMATORY BOWEL AGENTS |
MESALAMINE ER CAP 500MG PENTASA |
balsalazide capsule, budesonide capsule, mesalamine enema, mesalamine DR capsule 400mg, mesalamine DR tablet 1.2gm, mesalamine ER capsule 0.375gm (generic APRISO), sulfasalazine tablet |
TESTOSTERONE PRODUCTS |
JATENZO TESTOSTERONE |
testosterone gel (generic ANDROGEL), testosterone gel 1.62% pump (generic ANDROGEL), testosterone solution, testosterone cypionate solution, testosterone enanthate solution, testosterone topical solution (generic AXIRON), XYOSTED |
ANTIARRHYTHMICS |
AMIODARONE HCL 400MG |
AMIODARONE HCL 200mg |
BETA BLOCKERS |
SOTYLIZE COREG CR TIMOLOL MALEATE |
atenolol, bisoprolol, carvedilol, HEMANGEOL, labetalol, metoprolol, nebivolol, PROPRANOLOL SOLUTION, propranolol tablet |
LAXATIVES: CIC, IBS-C, OIC |
LACTULOSE Packets LUBIPROSTONE (generic AMITIZA) PRUCALOPRIDE (generic MOTEGRITY) |
LINZESS, MOVANTIK, SYMPROIC, TRULANCE |
ANTICONVULSANTS |
ELEPSIA XR LAMOTRIGINE ODT |
levetiracetam, levetiracetam ER, topiramate, topiramate ER, topiramate sprinkle ER, lacosamide tablet, zonisamide capsule |
ANTIDIABETIC AGENTS |
BYETTA CYCLOSET LIRAGLUTIDE METFORMIN HYDROCHLORIDE 750mg METFORMIN HYDROCHLORIDE ER OSM PIOGLITAZONE HCL-GLIMEPIRIDE RIOMET SAXAGLIPTIN HYDROCHLORIDE SAXAGLIPTIN HYDROCHLORIDE/METFORMIN HYDROCHLORIDE ER SEGLUROMET STEGLATRO SYMLINPEN 120 SYMLINPEN 60 |
GLYXAMBI, JANUMET, JANUMET XR, pioglitazone/metformin, SYNJARDY, SYNJARDY XR, TRIJARDY XR, XIGDUO XR, metformin, metformin ER (generic GLUCOPHAGE XR), MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY, BYDUREON
|
ANTIGOUT |
ALLOPURINOL TABLET 200mg FEBUXOSTAT |
Allopurinol 100mg & 300mg, colchicine tablet (generic COLCRYS), probenecid, probenecid/colchicine |
ANTILEUKOTRIENES |
MONTELUKAST SODIUM oral granules packet ZILEUTON ER ZYFLO |
montelukast sodium chew tab, montelukast sodium tab, zafirlukast tab 10 mg, 20 mg (Accolate) |
PARKINSON AGENTS |
AMANTADINE HYDROCHLORIDE TAB NOURIANZ ONGENTYS |
amantadine capsule, amantadine syrup, entacapone tablet, INBRIJA, KYNMOBI, pramipexole tablet, rasagiline tablet, ropinirole tablet, selegiline capsule, selegiline tablet, tolcapone tablet
|
URINARY INCONTINENCE |
DARIFENACIN HYDROBROMIDE ER FESOTERODINE FUMARATE ER FLAVOXATE HCL OXYTROL |
mirabegron, MYRBETRIQ GRANULES, MYRBETRIQ TABLET, oxybutynin, oxybutynin ER, oxybutynin syrup, solifenacin tablet, tolterodine, tolterodine ER, trospium, trospium ER, GEMTESA
|
ADHD AND NARCOLEPSY |
ADZENYS XR-ODT AMPHETAMINE SULFATE AMPHETAMINE/DEXTROAMPHETAMINE ER (generic MYDAYIS) DESOXYN ZENZEDI COTEMPLA XR-ODT METHYLPHENIDATE METHYLPHENIDATE HYDROCHLORIDE ER (LA) METHYLPHENIDATE HYDROCHLORIDE ER (OSM) METHYLPHENIDATE HYDROCHLORIDE ER (XR) QELBREE |
amphetamine/dextroamphetamine, amphetamine/dextroamphetamine XR, armodafinil, atomoxetine, AZSTARYS, dexmethylphenidate ER, dextroamphetamine solution, dextroamphetamine, JORNAY PM, methylphenidate, methylphenidate ER (generic CONCERTA), modafinil, QUILLICHEW ER, QUILLIVANT XR SUSPENSION, SUNOSI, LUMRYZ, SODIUM OXYBATE (authorized generic of XYREM by Hikma), XYWAV |
MENTAL HEALTH |
THIORIDAZINE HYDROCHLORIDE ABILIFY MYCITE MAINTENANCE KIT NUPLAZID OLANZAPINE/FLUOXETINE SYMBYAX |
aripiprazole, asenapine, lurasidone, olanzapine, quetiapine er, quetiapine fumarate, REXULTI, risperidone, VRAYLAR, ziprasidone, CAPLYTA, LYBALVI |
BPH |
CARDURA XL DUTASTERIDE/TAMSULOSIN HYDROCHLORIDE |
alfuzosin ER, dutasteride, finasteride, silodosin capsule, tadalafil 5mg, tamsulosin, terazosin |
COPD & BRONCHODILATORS |
YUPELRI FORMOTEROL FUMARATE (Perforomist) |
INCRUSE ELLIPTA, SPIRIVA HANDIHALER, SPIRIVA RESPIMAT, ATROVENT, ARFORMOTEROL NEB 15/2ML, SEREVENT DIS AER 50MCG, STRIVERDI AER 2.5MCG, IPRATROPIUM SOL 0.02%INH |
CALCIUM CHANNEL BLOCKERS |
ISRADIPINE NICARDIPINE HYDROCHLORIDE NISOLDIPINE ER DILTIAZEM HCL CD DILTIAZEM HYDROCHLORIDE ER TABS VERAPAMIL HCL ER CAPS VERAPAMIL HCL SR |
amlodipine, diltiazem ER capsule (except 360mg), felodipine ER, nifedipine, verapamil, verapamil ER tabs (Calan sr) |
CARDIOVASCULAR AGENTS |
ALISKIREN AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM CADUET CAPTOPRIL/HYDROCHLOROTHIAZIDE ENTRESTO TELMISARTAN/HYDROCHLOROTHIAZIDE TRANDOLAPRIL/VERAPAMIL HCL ER PRESTALIA |
enalapril, irbesartan, lisinopril, losartan, valsartan, amlodipine/benazepril, amlodipine/olmesartan, amlodipine/valsartan, amlodipine/valsartan/HCTZ, olmesartan/amlodipine/HCTZ |
CNS |
FLUOXETINE HYDROCHLORIDE TAB PAROXETINE CAP (Brisdelle) PAROXETINE HCL ER TIGLUTIK VEOZAH NEFAZODONE HYDROCHLORIDE |
citalopram, escitalopram, fluoxetine capsule, fluvoxamine, paroxetine, sertraline concentrate, sertraline tablet, desvenlafaxine ER, duloxetine, venlafaxine |
ALZHEIMER'S AGENTS |
ADLARITY ERGOLOID MESYLATES MEMANTINE HYDROCHLORIDE ER CAPS NAMZARIC |
donepezil tablet, memantine tablet, memantine solution, rivastigmine patch
|
CYSTIC FIBROSIS AGENTS |
BRONCHITOL |
KALYDECO, PULMOZYME SOL 1MG/ML, ACETYLCYST SOL 20% |
DIURETICS |
ETHACRYNIC ACID FUROSEMIDE ORAL SOLN 8 MG/ML |
bumetanide, furosemide solution 10mg/mL, furosemide tablet, torsemide |
PARKINSON'S AGENTS |
PRAMIPEXOLE DIHYDROCHLORIDE ER ROPINIROLE ER CREXONT |
amantadine capsule, amantadine syrup, entacapone tablet, INBRIJA, KYNMOBI, pramipexole tablet, rasagiline tablet, ropinirole tablet, selegiline capsule, selegiline tablet, tolcapone tablet, carbidopa & levodopa tab er25-100 mg, 50-200 mg (Sinemet cr) |
HIGH CHOLESTEROL |
FENOFIBRATE CAP 43 & 130MG FENOFIBRATE TAB 40 & 120MG FENOFIBRIC ACID DR FIBRICOR FLOLIPID FLUVASTATIN LESCOL XL PITAVASTATIN CALCIUM ZYPITAMAG CHOLESTYRAMINE CHOLESTYRAMINE LIGHT COLESEVELAM HYDROCHLORIDE OMEGA-3-ACID ETHYL ESTERS ROSZET |
atorvastatin tablet, ezetimibe/simvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, cholestyramine powder, cholestyramine light powder, colesevelam tablet, prevalite powder, FENOFIBRATE CAP 67MG, FENOFIBRATE CAP 67MG, FENOFIBRATE TAB 145MG, FENOFIBRATE TAB 160MG, FENOFIBRATE TAB 48MG, FENOFIBRATE TAB 54MG
|
ELECTROLYTE/MINERAL/METAL MODIFIERS |
FERRIPROX TWICE-A-DAY |
DEFERIPRONE TAB 1000MG, DEFERIPRONE TAB 500MG |
FIBROMYALGIA AGENTS |
SAVELLA PREGABALIN ER |
duloxetine, pregabalin, GRALISE, HORIZANT
|
ANTICONVULSANTS: BENZODIAZEPINES |
SYMPAZAN |
clobazam, clonazepam
|
PRIMARY BILIARY CHOLANGITIS (PBC) |
OCALIVA URSODIOL |
URSODIOL TAB 250MG, URSODIOL CAP 300MG, URSODIOL TAB 500MG |
GENETIC, ENZYME OR PROTEIN DISORDER |
DOJOLVI OLPRUVA PANCREAZE VIOKACE XURIDEN |
sodium phenylbutyrate powder, sodium phenylbutyrate tablet PHEBURANE, RAVICTI CREON, ZENPEP
|
H2 ANTAGONISTS |
CIMETIDINE FAMOTIDINE TAB 20 MG NIZATIDINE |
FAMOTIDINE TAB 40MG, FAMOTIDINE SUS 40MG/5ML |
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY) |
NOCDURNA |
desmopressin acetate tab 0.1 mg,0.2 mg (Ddavp)
|
HORMONAL AGENTS |
ANNOVERA LEVONORGESTREL/ETHINYL ESTRADIOL/FERROUS BISGLYCINATE MERZEE |
NUVARING MIS, ZAFEMY DIS 150/35, TRI-LO- TAB SPRINTEC, ENPRESSE-28 TAB, SRONYX TAB, NORTREL TAB 1/35, AVIANE TAB, NORGEST/ETHI TAB ESTRADIO, ETHY ETH EST TAB 1-35, TRI-NYMYO TAB, AUROVELA TAB 1/20, ISIBLOOM TAB, AZURETTE TAB |
IMMUNOLOGICAL AGENTS |
TAVNEOS VELSIPITY VOYDEYA |
Azathioprine, ADALIMUMAB biosimilars LOW WAC (YUFLYMA, Hyrimoz & Hadlima), ENTYVIO, OMVOH, STELARA, RINVOQ, SIMPONI 100mg, SIMLANDI, SKYRIZI, XELJANZ/XR, ZEPOSIA, CIMZIA, ZYMFENTRA |
INSULINS |
BASAGLAR KWIKPEN BASAGLAR TEMPO PEN |
HUMULIN N, HUMULIN R U-500, LEVEMIR, NOVOLIN N, SEMGLEE-YFGN, TOUJEO, TRESIBA
|
METABOLIC BONE DISEASE |
BINOSTO CALCITRIOL DOXERCALCIFEROL FOSAMAX PLUS D PARICALCITOL RISEDRONATE SODIUM DR ZEMPLAR |
calcitriol capsule, RAYALDEE, ALENDRONATE TAB 70MG, IBANDRONATE TAB 150MG, risedronate sodium tab 5 mg,30 mg, 35 mg, 150 mg (Actonel)
|
MINERALOCORTICOID RECEPTOR ANTAGONISTS |
SPIRONOLACTONE SUSP 25 MG/5ML |
spironolactone tab 25 mg, 50 mg, 100 mg
|
MULTIPLE SCLEROSIS |
BAFIERTAM PONVORY |
AVONEX, BETASERON, dimethyl fumarate, fingolimod, glatiramer, glatopa, KESIMPTA, MAVENCLAD, MAYZENT, PLEGRIDY, REBIF, teriflunomide, VUMERITY, ZEPOSIA, GILENYA 0.25mg
|
NSAIDS |
DICLOFENAC SODIUM ER FENOPROFEN CALCIUM IBUPROFEN/FAMOTIDINE INDOMETHACIN KETOPROFEN KETOPROFEN ER LOFENA MECLOFENAMATE SODIUM MEFENAMIC ACID MELOXICAM NAPROSYN NAPROXEN SODIUM ER NAPROXEN/ESOMEPRAZOLE MAGNESIUM TOLECTIN 600 TOLMETIN SODIUm |
diclofenac tablet, ibuprofen tablet, indomethacin capsule, meloxicam tablet, naproxen tablet, oxaprozin 600mg |
OPHTHALMIC AGENTS |
BRIMONIDINE TARTRATE/TIMOLOL MALEATE CEQUA DORZOLAMIDE HYDROCHLORIDE/TIMOLOL MALEATE PF MIEBO TROPICAMIDE VEVYE XIIDRA BETOPTIC-S TIMOLOL HEMIHYDRATE TIMOLOL MALEATE TIMOLOL MALEATE OPHTHALMIC GEL FORMING ALPHAGAN P BRINZOLAMIDE PHOSPHOLINE IODIDE BIMATOPROST TAFLUPROST TRAVOPROST |
EYSUVIS, RESTASIS SINGLE DOSE VIALS, TYRVAYA, apraclonidine solution, brimonidine solution 0.2%, SIMBRINZA, betaxolol solution, dorzolamide solution, dorzolamide/timolol solution, timolol solution, latanoprost, LUMIGAN, VYZULTA
|
PHOSPHATE BINDERS |
VELPHORO CHW 500MG |
calcium acetate, lanthanum carbonate, sevelamer carbonate, sevelamer, VELPHORO, AURYXIA
|
PHOSPHODIESTERASE INHIBITORS |
THEOPHYLLINE TAB 200MG ER |
theophylline tab er 12hr 300 mg,450 mg, theophylline tab er 24hr 400mg, 600 mg
|
PROGESTINS |
MEGESTROL ACETATE SUSP 625 MG/5ML |
megestrol acetate tab 20 mg, 40 mg, megestrol acetate susp 40mg/ml (Megace oral)
|
PROTECTANTS |
SUCRALFATE SUSP 1 GM/10ML |
sucralfate tablet
|
PROTON PUMP INHIBITORS |
DEXLANSOPRAZOLE ESOMEPRAZOLE MAGNESIUM LANSOPRAZOLE ODT OMEPRAZOLE/SODIUM BICARBONATE PANTOPRAZOLE SODIUM SUSP PACKET RABEPRAZOLE SODIUM |
OMEPRAZOLE CAP 20MG, PANTOPRAZOLE TAB 20MG, ESOMEPRAZOLE GRA 40MG DR, NEXIUM GRA 5MG DR |
PULMONARY HTN
|
OPSYNVI |
ambrisentan, bosentan, OPSUMIT, sildenafil suspension, sildenafil tablet, tadalafil 20mg, TRACLEER, UPTRAVI, ADEMPAS, ORENITRAM, TYVASO NEBULIZED SOLUTION, VENTAVIS, WINREVAIR
|
RESPIRATORY TRACT AGENTS |
FASENRA NUCALA |
FASENRA PEN- benralizumab subcutaneous soln auto-injector30 mg/ml, NUCALA- mepolizumab subcutaneous solution auto-injector100 mg/ml, NUCALA- mepolizumab subcutaneous solution pref syringe40 mg/0.4ml, 100 mg/ml
|
SSRIS/SNRIS |
DESVENLAFAXINE ER DULOXETINE HCL ENTERIC COATED PELLETS CAP FLUOXETINE HCL TAB FLUVOXAMINE MALEATE ER PAXIL TRAZODONE HCL 300MG VENLAFAXINE HYDROCHLORIDE ER |
DESVENLAFAXINE SUCCINATE TAB ER (PRISTIQ), DULOXETINE CAP 30MG, VENLAFAXINE CAP 150MG ER, DULOXETINE CAP 60MG, DULOXETINE CAP 30MG, VENLAFAXINE TAB 50MG, VENLAFAXINE TAB 75MG, VENLAFAXINE CAP 75MG ER, VENLAFAXINE TAB 100MG, FLUOXETINE CAP 40MG, FLUOXETINE SOL 20MG/5ML, CITALOPRAM TAB 20MG, ESCITALOPRAM TAB 10MG, PAROXETINE TAB 40MG, SERTRALINE TAB 100MG, CITALOPRAM SOL 10MG/5ML, ESCITALOPRAM SOL 5MG/5ML, SERTRALINE CON 20MG/ML, FLUVOXAMINE TAB 100MG, TRAZODONE TAB 100MG |
TRICYCLICS |
AMOXAPINE IMIPRAMINE PAMOATE |
imipramine hcl tab 10mg, 25mg, 50mg (Tofranil)
|
VASODILATORS |
ISORDIL TITRADOSE 40MG |
ISOSORB MONO TAB 30MG ER, ISOSORB MONO TAB 60MG ER, ISOSORB MONO TAB 120MG ER, NITROGLYCER DIS 0.1MG/HR
|
Emblem City of NY HMO Drugs Removed from Formulary In 2026 |
||
Drug Class |
Non-covered |
Formulary Alternatives |
INFLAMMATORY BOWEL AGENTS |
MESALAMINE ER CAP 500MG PENTASA |
balsalazide capsule, budesonide capsule, mesalamine enema, mesalamine DR capsule 400mg, mesalamine DR tablet 1.2gm, mesalamine ER capsule 0.375gm (generic APRISO), sulfasalazine tablet |
TESTOSTERONE PRODUCTS |
JATENZO TESTOSTERONE |
testosterone gel (generic ANDROGEL), testosterone gel 1.62% pump (generic ANDROGEL), testosterone solution, testosterone cypionate solution, testosterone enanthate solution, testosterone topical solution (generic AXIRON), XYOSTED |
ANTIARRHYTHMICS |
AMIODARONE HCL 400MG |
AMIODARONE HCL 200mg |
BETA BLOCKERS |
SOTYLIZE COREG CR TIMOLOL MALEATE |
atenolol, bisoprolol, carvedilol, HEMANGEOL, labetalol, metoprolol, nebivolol, PROPRANOLOL SOLUTION, propranolol tablet |
LAXATIVES: CIC, IBS-C, OIC |
LACTULOSE Packets LUBIPROSTONE (generic AMITIZA) PRUCALOPRIDE (generic MOTEGRITY) |
LINZESS, MOVANTIK, SYMPROIC, TRULANCE |
ANTICONVULSANTS |
ELEPSIA XR LAMOTRIGINE ODT |
levetiracetam, levetiracetam ER, topiramate, topiramate ER, topiramate sprinkle ER, lacosamide tablet, zonisamide capsule |
ANTIDIABETIC AGENTS |
BYETTA CYCLOSET LIRAGLUTIDE METFORMIN HYDROCHLORIDE 750mg METFORMIN HYDROCHLORIDE ER OSM PIOGLITAZONE HCL-GLIMEPIRIDE RIOMET SAXAGLIPTIN HYDROCHLORIDE SAXAGLIPTIN HYDROCHLORIDE/METFORMIN HYDROCHLORIDE ER SEGLUROMET STEGLATRO SYMLINPEN 120 SYMLINPEN 60 |
GLYXAMBI, JANUMET, JANUMET XR, pioglitazone/metformin, SYNJARDY, SYNJARDY XR, TRIJARDY XR, XIGDUO XR, metformin, metformin ER (generic GLUCOPHAGE XR), MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY, BYDUREON
|
ANTIGOUT |
ALLOPURINOL TABLET 200mg FEBUXOSTAT |
Allopurinol 100mg & 300mg, colchicine tablet (generic COLCRYS), probenecid, probenecid/colchicine |
ANTILEUKOTRIENES |
MONTELUKAST SODIUM oral granules packet ZILEUTON ER ZYFLO |
montelukast sodium chew tab, montelukast sodium tab, zafirlukast tab 10 mg, 20 mg (Accolate) |
PARKINSON AGENTS |
AMANTADINE HYDROCHLORIDE TAB NOURIANZ ONGENTYS |
amantadine capsule, amantadine syrup, entacapone tablet, INBRIJA, KYNMOBI, pramipexole tablet, rasagiline tablet, ropinirole tablet, selegiline capsule, selegiline tablet, tolcapone tablet
|
URINARY INCONTINENCE |
DARIFENACIN HYDROBROMIDE ER FESOTERODINE FUMARATE ER FLAVOXATE HCL OXYTROL |
mirabegron, MYRBETRIQ GRANULES, MYRBETRIQ TABLET, oxybutynin, oxybutynin ER, oxybutynin syrup, solifenacin tablet, tolterodine, tolterodine ER, trospium, trospium ER, GEMTESA
|
MENTAL HEALTH |
THIORIDAZINE HYDROCHLORIDE ABILIFY MYCITE MAINTENANCE KIT NUPLAZID OLANZAPINE/FLUOXETINE SYMBYAX |
aripiprazole, asenapine, lurasidone, olanzapine, quetiapine er, quetiapine fumarate, REXULTI, risperidone, VRAYLAR, ziprasidone, CAPLYTA, LYBALVI |
BPH |
CARDURA XL DUTASTERIDE/TAMSULOSIN HYDROCHLORIDE |
alfuzosin ER, dutasteride, finasteride, silodosin capsule, tadalafil 5mg, tamsulosin, terazosin |
COPD & BRONCHODILATORS |
YUPELRI FORMOTEROL FUMARATE (Perforomist) |
INCRUSE ELLIPTA, SPIRIVA HANDIHALER, SPIRIVA RESPIMAT, ATROVENT, ARFORMOTEROL NEB 15/2ML, SEREVENT DIS AER 50MCG, STRIVERDI AER 2.5MCG, IPRATROPIUM SOL 0.02%INH |
CALCIUM CHANNEL BLOCKERS |
ISRADIPINE NICARDIPINE HYDROCHLORIDE NISOLDIPINE ER DILTIAZEM HCL CD DILTIAZEM HYDROCHLORIDE ER TABS VERAPAMIL HCL ER CAPS VERAPAMIL HCL SR |
amlodipine, diltiazem ER capsule (except 360mg), felodipine ER, nifedipine, verapamil, verapamil ER tabs (Calan sr) |
CARDIOVASCULAR AGENTS |
ALISKIREN AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM CADUET CAPTOPRIL/HYDROCHLOROTHIAZIDE ENTRESTO TELMISARTAN/HYDROCHLOROTHIAZIDE TRANDOLAPRIL/VERAPAMIL HCL ER PRESTALIA |
enalapril, irbesartan, lisinopril, losartan, valsartan, amlodipine/benazepril, amlodipine/olmesartan, amlodipine/valsartan, amlodipine/valsartan/HCTZ, olmesartan/amlodipine/HCTZ |
CNS |
FLUOXETINE HYDROCHLORIDE TAB PAROXETINE CAP (Brisdelle) PAROXETINE HCL ER TIGLUTIK VEOZAH NEFAZODONE HYDROCHLORIDE |
citalopram, escitalopram, fluoxetine capsule, fluvoxamine, paroxetine, sertraline concentrate, sertraline tablet, desvenlafaxine ER, duloxetine, venlafaxine |
ALZHEIMER'S AGENTS |
ADLARITY ERGOLOID MESYLATES MEMANTINE HYDROCHLORIDE ER CAPS NAMZARIC |
donepezil tablet, memantine tablet, memantine solution, rivastigmine patch
|
CYSTIC FIBROSIS AGENTS |
BRONCHITOL |
KALYDECO, PULMOZYME SOL 1MG/ML, ACETYLCYST SOL 20% |
DIURETICS |
ETHACRYNIC ACID FUROSEMIDE ORAL SOLN 8 MG/ML |
bumetanide, furosemide solution 10mg/mL, furosemide tablet, torsemide |
PARKINSON'S AGENTS |
PRAMIPEXOLE DIHYDROCHLORIDE ER ROPINIROLE ER CREXONT |
amantadine capsule, amantadine syrup, entacapone tablet, INBRIJA, KYNMOBI, pramipexole tablet, rasagiline tablet, ropinirole tablet, selegiline capsule, selegiline tablet, tolcapone tablet, carbidopa & levodopa tab er25-100 mg, 50-200 mg (Sinemet cr) |
HIGH CHOLESTEROL |
FENOFIBRATE CAP 43 & 130MG FENOFIBRATE TAB 40 & 120MG FENOFIBRIC ACID DR FIBRICOR FLOLIPID FLUVASTATIN LESCOL XL PITAVASTATIN CALCIUM ZYPITAMAG CHOLESTYRAMINE CHOLESTYRAMINE LIGHT COLESEVELAM HYDROCHLORIDE OMEGA-3-ACID ETHYL ESTERS ROSZET |
atorvastatin tablet, ezetimibe/simvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, cholestyramine powder, cholestyramine light powder, colesevelam tablet, prevalite powder, FENOFIBRATE CAP 67MG, FENOFIBRATE CAP 67MG, FENOFIBRATE TAB 145MG, FENOFIBRATE TAB 160MG, FENOFIBRATE TAB 48MG, FENOFIBRATE TAB 54MG
|
ELECTROLYTE/MINERAL/METAL MODIFIERS |
FERRIPROX TWICE-A-DAY |
DEFERIPRONE TAB 1000MG, DEFERIPRONE TAB 500MG |
FIBROMYALGIA AGENTS |
SAVELLA PREGABALIN ER |
duloxetine, pregabalin, GRALISE, HORIZANT
|
ANTICONVULSANTS: BENZODIAZEPINES |
SYMPAZAN |
clobazam, clonazepam
|
PRIMARY BILIARY CHOLANGITIS (PBC) |
OCALIVA URSODIOL |
URSODIOL TAB 250MG, URSODIOL CAP 300MG, URSODIOL TAB 500MG |
GENETIC, ENZYME OR PROTEIN DISORDER |
DOJOLVI OLPRUVA PANCREAZE VIOKACE XURIDEN |
sodium phenylbutyrate powder, sodium phenylbutyrate tablet PHEBURANE, RAVICTI CREON, ZENPEP
|
H2 ANTAGONISTS |
CIMETIDINE FAMOTIDINE TAB 20 MG NIZATIDINE |
FAMOTIDINE TAB 40MG, FAMOTIDINE SUS 40MG/5ML |
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY) |
NOCDURNA |
desmopressin acetate tab 0.1 mg,0.2 mg (Ddavp)
|
HORMONAL AGENTS |
ANNOVERA LEVONORGESTREL/ETHINYL ESTRADIOL/FERROUS BISGLYCINATE MERZEE |
NUVARING MIS, ZAFEMY DIS 150/35, TRI-LO- TAB SPRINTEC, ENPRESSE-28 TAB, SRONYX TAB, NORTREL TAB 1/35, AVIANE TAB, NORGEST/ETHI TAB ESTRADIO, ETHY ETH EST TAB 1-35, TRI-NYMYO TAB, AUROVELA TAB 1/20, ISIBLOOM TAB, AZURETTE TAB |
IMMUNOLOGICAL AGENTS |
TAVNEOS VELSIPITY VOYDEYA |
Azathioprine, ADALIMUMAB biosimilars LOW WAC (YUFLYMA, Hyrimoz & Hadlima), ENTYVIO, OMVOH, STELARA, RINVOQ, SIMPONI 100mg, SIMLANDI, SKYRIZI, XELJANZ/XR, ZEPOSIA, CIMZIA, ZYMFENTRA |
INSULINS |
BASAGLAR KWIKPEN BASAGLAR TEMPO PEN |
HUMULIN N, HUMULIN R U-500, LEVEMIR, NOVOLIN N, SEMGLEE-YFGN, TOUJEO, TRESIBA
|
METABOLIC BONE DISEASE |
BINOSTO CALCITRIOL DOXERCALCIFEROL FOSAMAX PLUS D PARICALCITOL RISEDRONATE SODIUM DR ZEMPLAR |
calcitriol capsule, RAYALDEE, ALENDRONATE TAB 70MG, IBANDRONATE TAB 150MG, risedronate sodium tab 5 mg,30 mg, 35 mg, 150 mg (Actonel)
|
MINERALOCORTICOID RECEPTOR ANTAGONISTS |
SPIRONOLACTONE SUSP 25 MG/5ML |
spironolactone tab 25 mg, 50 mg, 100 mg
|
MULTIPLE SCLEROSIS |
BAFIERTAM PONVORY |
AVONEX, BETASERON, dimethyl fumarate, fingolimod, glatiramer, glatopa, KESIMPTA, MAVENCLAD, MAYZENT, PLEGRIDY, REBIF, teriflunomide, VUMERITY, ZEPOSIA, GILENYA 0.25mg
|
NSAIDS |
DICLOFENAC SODIUM ER FENOPROFEN CALCIUM IBUPROFEN/FAMOTIDINE INDOMETHACIN KETOPROFEN KETOPROFEN ER LOFENA MECLOFENAMATE SODIUM MEFENAMIC ACID MELOXICAM NAPROSYN NAPROXEN NAPROXEN DR NAPROXEN SODIUM NAPROXEN SODIUM CR NAPROXEN SODIUM ER NAPROXEN/ESOMEPRAZOLE MAGNESIUM TOLECTIN 600 TOLMETIN SODIUM |
diclofenac tablet, ibuprofen tablet, indomethacin capsule, meloxicam tablet, naproxen tablet, oxaprozin 600mg |
OPHTHALMIC AGENTS |
BRIMONIDINE TARTRATE/TIMOLOL MALEATE CEQUA DORZOLAMIDE HYDROCHLORIDE/TIMOLOL MALEATE PF MIEBO TROPICAMIDE VEVYE XIIDRA BETOPTIC-S TIMOLOL HEMIHYDRATE TIMOLOL MALEATE TIMOLOL MALEATE OPHTHALMIC GEL FORMING ALPHAGAN P BRINZOLAMIDE PHOSPHOLINE IODIDE BIMATOPROST TAFLUPROST TRAVOPROST |
EYSUVIS, RESTASIS SINGLE DOSE VIALS, TYRVAYA, apraclonidine solution, brimonidine solution 0.2%, SIMBRINZA, betaxolol solution, dorzolamide solution, dorzolamide/timolol solution, timolol solution, latanoprost, LUMIGAN, VYZULTA
|
PHOSPHATE BINDERS |
VELPHORO CHW 500MG |
calcium acetate, lanthanum carbonate, sevelamer carbonate, sevelamer, VELPHORO, AURYXIA
|
PHOSPHODIESTERASE INHIBITORS |
THEOPHYLLINE TAB 200MG ER |
theophylline tab er 12hr 300 mg,450 mg, theophylline tab er 24hr 400mg, 600 mg
|
PROGESTINS |
MEGESTROL ACETATE SUSP 625 MG/5ML |
megestrol acetate tab 20 mg, 40 mg, megestrol acetate susp 40mg/ml (Megace oral)
|
PROTON PUMP INHIBITORS |
DEXLANSOPRAZOLE ESOMEPRAZOLE MAGNESIUM LANSOPRAZOLE ODT OMEPRAZOLE/SODIUM BICARBONATE PANTOPRAZOLE SODIUM SUSP PACKET RABEPRAZOLE SODIUM |
OMEPRAZOLE CAP 20MG, PANTOPRAZOLE TAB 20MG, ESOMEPRAZOLE GRA 40MG DR, NEXIUM GRA 5MG DR |
PULMONARY HTN
|
OPSYNVI |
ambrisentan, bosentan, OPSUMIT, sildenafil suspension, sildenafil tablet, tadalafil 20mg, TRACLEER, UPTRAVI ADEMPAS, ORENITRAM, TYVASO NEBULIZED SOLUTION, VENTAVIS, WINREVAIR
|
RESPIRATORY TRACT AGENTS |
FASENRA NUCALA |
FASENRA PEN- benralizumab subcutaneous soln auto-injector30 mg/ml, NUCALA- mepolizumab subcutaneous solution auto-injector100 mg/ml, NUCALA- mepolizumab subcutaneous solution pref syringe40 mg/0.4ml, 100 mg/ml
|
SSRIS/SNRIS |
DESVENLAFAXINE ER DULOXETINE HCL ENTERIC COATED PELLETS CAP FLUOXETINE HCL TAB FLUVOXAMINE MALEATE ER PAXIL TRAZODONE HCL 300MG VENLAFAXINE HYDROCHLORIDE ER |
DESVENLAFAXINE SUCCINATE TAB ER (PRISTIQ), DULOXETINE CAP 30MG, VENLAFAXINE CAP 150MG ER, DULOXETINE CAP 60MG, DULOXETINE CAP 30MG, VENLAFAXINE TAB 50MG, VENLAFAXINE TAB 75MG, VENLAFAXINE CAP 75MG ER, VENLAFAXINE TAB 100MG, FLUOXETINE CAP 40MG, FLUOXETINE SOL 20MG/5ML, CITALOPRAM TAB 20MG, ESCITALOPRAM TAB 10MG, PAROXETINE TAB 40MG, SERTRALINE TAB 100MG, CITALOPRAM SOL 10MG/5ML, ESCITALOPRAM SOL 5MG/5ML, SERTRALINE CON 20MG/ML, FLUVOXAMINE TAB 100MG, TRAZODONE TAB 100MG |
TRICYCLICS |
AMOXAPINE IMIPRAMINE PAMOATE |
imipramine hcl tab 10mg, 25mg, 50mg (Tofranil)
|
VASODILATORS |
ISORDIL TITRADOSE 40MG |
ISOSORB MONO TAB 30MG ER, ISOSORB MONO TAB 60MG ER, ISOSORB MONO TAB 120MG ER, NITROGLYCER DIS 0.1MG/HR
|
Emblem Small Group/Essential/Individual Plans Drugs Removed from Formulary In 2026 |
||
Drug Class |
Non-covered |
Formulary Alternatives |
MENTAL HEALTH |
ABILIFY ABILIFY MYCITE COBENFY GEODON INVEGA LATUDA LYBALVI OLANZAPINE-FLUOXETINE OPIPZA QUETIAPINE RISPERAL SAPHRIS SEROQUEL SYMBYAX ZYPREXA |
ARIPIPRAZOLE TAB 10MG, ARIPIPRAZOLE SOL 1MG/ML, ARIPIPRAZOLE TAB 10MG ODT, QUETIAPINE TAB 150MG ER, QUETIAPINE TAB 100MG, OLANZAPINE TAB 10MG, RISPERIDONE TAB 2MG, RISPERIDONE TAB 2MG ODT, PALIPERIDONE TAB ER 6MG, ASENAPINE SUB 5MG, ZIPRASIDONE CAP 40MG, OLANZAPINE TAB 15MG ODT, REXULTI TAB 2MG, VRAYLAR CAP 3MG, CAPLYTA CAP 21MG |
INFLAMMATORY BOWEL AGENTS |
MESALAMINE ER CAP 500MG PENTASA LIALDA DELZICOL APRISO AZULFIDINE |
balsalazide capsule, budesonide capsule, mesalamine enema, mesalamine DR capsule 400mg, mesalamine DR tablet 1.2gm, mesalamine ER capsule 0.375gm (generic APRISO), sulfasalazine tablet |
TESTOSTERONE PRODUCTS |
TESTOSTERONE VOGELXO TESTIM |
testosterone gel (generic ANDROGEL), testosterone gel 1.62% pump (generic ANDROGEL), testosterone solution, testosterone cypionate solution, testosterone enanthate solution, testosterone topical solution (generic AXIRON) |
ANTIARRHYTHMICS |
AMIODARONE HCL BETAPACE RYTHMOL TIKOSYN |
AMIODARONE HCL 200mg, SOTALOL AF TAB 120MG, PROPRANOLOL SOL 20MG/5ML, PROPRANOLOL TAB 80MG, PROPRANOLOL CAP 80MG ER, PINDOLOL TAB 5MG, DOFETILIDE CAP |
BETA BLOCKERS |
SOTYLIZE INDERAL LA INNOPRAN XL TENORMIN BETAPACE |
atenolol, bisoprolol, carvedilol, HEMANGEOL, labetalol, metoprolol, nebivolol, PROPRANOLOL SOLUTION, propranolol tablet |
LAXATIVES: CIC, IBS-C, OIC |
LACTULOSE Packets AMITIZA LINZESS
|
LUBIPROSTONE CAP 24MCG, TRULANCE TAB 3MG, ENULOSE SOL 10GM/15, GENERLAC SOL 10GM/15, LACTULOSE SOL 10GM/15, CONSTULOSE SOL 10GM/15, IBSRELA TAB 50MG, MOTEGRITY TAB 1MG |
ANTICONVULSANTS |
APTIOM ELEPSIA XR FYCOMPA LAMOTRIGINE ODT MOTOPOLY XR ONFI |
LEVETIRACETAM, LEVETIRACETAM ER, TOPIRAMATE, TOPIRAMATE ER, TOPIRAMATE SPRINKLE ER, LACOSAMIDE TABLET, ZONISAMIDE CAPSULE, PERAMPANEL TAB, CLOBAZAM SUS, FELBAMATE SUS |
ALZHEIMER'S AGENTS |
ERGOLOID MESYLATES MEMANTINE HCL ER CAPS NAMZARIC ADLARITY |
DONEPEZIL TABLET, MEMANTINE TABLET, MEMANTINE SOLUTION, RIVASTIGMINE PATCH |
ANTIDIABETIC AGENTS |
BYETTA CYCLOSET LIRAGLUTIDE ONGLYZA PIOGLITAZONE HCL-GLIMEPIRIDE RIOMET SAXAGLIPTIN HCL SAXAGLIPTIN HCL/METFORMIN HCL ER SEGLUROMET STEGLATRO SYMLINPEN 120 SYMLINPEN 60 |
GLYXAMBI, JANUMET, JANUMET XR, pioglitazone/metformin, SYNJARDY, SYNJARDY XR, TRIJARDY XR, XIGDUO XR, metformin, metformin ER (generic GLUCOPHAGE XR), MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY, BYDUREON, ALOGLIPTAN
|
ANTIGOUT |
ALLOPURINOL 200MG ULORIC |
Allopurinol 100mg & 300mg, colchicine tablet (generic COLCRYS), probenecid, probenecid/colchicine, FEBUXOSTAT |
ANTILEUKOTRIENES |
MONTELUKAST SODIUM GRANULES PACKET 4 MG ZYFLO |
montelukast sodium chew tab, montelukast sodium tab, zafirlukast tab 10 mg, 20 mg (Accolate) |
PARKINSON AGENTS |
AMANTADINE HCL TAB NOURIANZ ONGENTYS |
amantadine capsule, amantadine syrup, entacapone tablet, INBRIJA, KYNMOBI, pramipexole tablet, rasagiline tablet, ropinirole tablet, selegiline capsule, selegiline tablet, tolcapone tablet, ROPINORELE
|
URINARY INCONTINENCE |
AVODART FESOTERODINE FUMARATE ER FLOMAX OXYTROL TOVIAZ |
mirabegron, MYRBETRIQ GRANULES, MYRBETRIQ TABLET, oxybutynin, oxybutynin ER, oxybutynin syrup, solifenacin tablet, tolterodine, tolterodine ER, trospium, trospium ER, GEMTESA
|
ADHD AND NARCOLEPSY |
ADZENYS XR-ODT AMPHETAMINE/DEXTROAMPHETAMINE ER (generic MYDAYIS) DESOXYN ZENZEDI COTEMPLA XR-ODT METHYLPHENIDATE METHYLPHENIDATE HCL ER (LA) METHYLPHENIDATE HCL ER (OSM) METHYLPHENIDATE HCL ER (XR) QELBREE |
amphetamine/dextroamphetamine, amphetamine/dextroamphetamine XR, armodafinil, atomoxetine, AZSTARYS, dexmethylphenidate ER, dextroamphetamine solution, dextroamphetamine, JORNAY PM, methylphenidate, methylphenidate ER (generic CONCERTA), modafinil, QUILLICHEW ER, QUILLIVANT XR SUSPENSION, SUNOSI, LUMRYZ, SODIUM OXYBATE (authorized generic of XYREM by Hikma), XYWAV |
BPH |
CARDURA XL DUTASTERIDE/TAMSULOSIN HCL |
alfuzosin ER, dutasteride, finasteride, silodosin capsule, tadalafil 5mg, tamsulosin, terazosin |
COPD & BRONCHODILATORS |
YUPELRI FORMOTEROL FUMARATE (Perforomist) |
INCRUSE ELLIPTA, SPIRIVA HANDIHALER, SPIRIVA RESPIMAT, ATROVENT, ARFORMOTEROL NEB 15/2ML, SEREVENT DIS AER 50MCG, STRIVERDI AER 2.5MCG, IPRATROPIUM SOL 0.02%INH |
CALCIUM CHANNEL BLOCKERS |
CARDIZEM ISRADIPINE NICARDIPINE HCL NISOLDIPINE ER DILTIAZEM HCL CD DILTIAZEM HCL ER TABS VERAPAMIL HCL ER CAPS VERAPAMIL HCL SR |
amlodipine, diltiazem ER capsule), felodipine ER, nifedipine, verapamil, verapamil ER tabs (Calan sr), ISOSORBIDE TABS |
CARDIOVASCULAR AGENTS |
ALISKIREN AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM CADUET CAPTOPRIL/HYDROCHLOROTHIAZIDE ENTRESTO TELMISARTAN/HYDROCHLOROTHIAZIDE TRANDOLAPRIL/VERAPAMIL HCL ER PRESTALIA |
enalapril, irbesartan, lisinopril, losartan, valsartan, amlodipine/benazepril, amlodipine/olmesartan, amlodipine/valsartan, amlodipine/valsartan/HCTZ, olmesartan/amlodipine/HCTZ |
CYSTIC FIBROSIS AGENTS |
BRONCHITOL |
PULMOZYME SOL 1MG/ML, ACETYLCYST SOL 20% |
DIURETICS |
ETHACRYNIC ACID FUROSEMIDE ORAL SOLN 8 MG/ML |
bumetanide, furosemide solution 10mg/mL, furosemide tablet, torsemide |
PARKINSON'S AGENTS |
PRAMIPEXOLE DIHYDROCHLORIDE ER ROPINIROLE ER CREXONT |
amantadine capsule, amantadine syrup, entacapone tablet, INBRIJA, KYNMOBI, pramipexole tablet, rasagiline tablet, ropinirole tablet, selegiline capsule, selegiline tablet, tolcapone tablet, carbidopa & levodopa tab er25-100 mg, 50-200 mg (Sinemet cr)
|
HIGH CHOLESTEROL |
FENOFIBRATE CAP 43 & 130MG FENOFIBRATE TAB 40 & 120MG FENOFIBRIC ACID DR FIBRICOR FLOLIPID FLUVASTATIN LESCOL XL PITAVASTATIN CALCIUM ZYPITAMAG CHOLESTYRAMINE CHOLESTYRAMINE LIGHT COLESEVELAM HCL PACKET FOR SUSP 3.75 GM OMEGA-3-ACID ETHYL ESTERS ROSZET |
atorvastatin tablet, ezetimibe/simvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, cholestyramine powder, cholestyramine light powder, colesevelam tablet, prevalite powder, FENOFIBRATE CAP 67MG, FENOFIBRATE CAP 67MG, FENOFIBRATE TAB 145MG, FENOFIBRATE TAB 160MG, FENOFIBRATE TAB 48MG, FENOFIBRATE TAB 54MG
|
ELECTROLYTE/MINERAL/METAL MODIFIERS |
FERRIPROX TWICE-A-DAY |
DEFERIPRONE TAB 1000MG, DEFERIPRONE TAB 500MG |
FIBROMYALGIA AGENTS |
SAVELLA PREGABALIN ER |
duloxetine, pregabalin, GRALISE, HORIZANT |
ANTICONVULSANTS: BENZODIAZEPINES |
SYMPAZAN |
clobazam, clonazepam
|
PRIMARY BILIARY CHOLANGITIS (PBC) |
OCALIVA URSODIOL CAP 200MG & 400MG |
URSODIOL TAB 250MG, URSODIOL CAP 300MG, URSODIOL TAB 500MG |
GENETIC, ENZYME OR PROTEIN DISORDER |
DOJOLVI OLPRUVA PANCREAZE VIOKACE XURIDEN |
sodium phenylbutyrate powder, sodium phenylbutyrate tablet PHEBURANE, RAVICTI CREON, ZENPEP
|
H2 ANTAGONISTS |
CIMETIDINE CIMETIDINE HCL SOLN 300 MG/5ML FAMOTIDINE TAB 20 MG NIZATIDINE |
FAMOTIDINE TAB 40MG, FAMOTIDINE SUS 40MG/5ML |
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY) |
NGENLA NOCDURNA SEROSTIM |
GENOTROPIN, OMNITROPE, SKYTROFA, desmopressin acetate tab 0.1 mg,0.2 mg (Ddavp)
|
HORMONAL AGENTS |
ANNOVERA LEVONORGESTREL/ETHINYL ESTRADIOL/FERROUS BISGLYCINATE MERZEE |
NUVARING MIS, ZAFEMY DIS 150/35, TRI-LO- TAB SPRINTEC, ENPRESSE-28 TAB, SRONYX TAB, NORTREL TAB 1/35, AVIANE TAB, NORGEST/ETHI TAB ESTRADIO, ETHY ETH EST TAB 1-35, TRI-NYMYO TAB, AUROVELA TAB 1/20, ISIBLOOM TAB, AZURETTE TAB |
IMMUNOLOGICAL AGENTS |
ACTEMRA TALTZ TAVNEOS VELSIPITY VOYDEYA CYLTEZO |
TYENNE, ADALIMUMAB biosimilars LOW WAC (YUFLYMA, Hyrimoz & Hadlima), ENTYVIO, OMVOH, RINVOQ, SIMPONI 100mg, SKYRIZI, XELJANZ/XR, ZEPOSIA, CIMZIA, ZYMFENTRA |
IMMUNOSUPPRESSANTS |
RASUVO |
methotrexate injection, methotrexate tablet, OTREXUP, REDITREX |
INSULINS |
BASAGLAR KWIKPEN BASAGLAR TEMPO PEN |
HUMULIN N, HUMULIN R U-500, LEVEMIR, NOVOLIN N, SEMGLEE-YFGN, TOUJEO, TRESIBA |
METABOLIC BONE DISEASE |
BINOSTO CALCITRIOL ORAL SOLN 1 MCG/ML DOXERCALCIFEROL FOSAMAX PLUS D PARICALCITOL RISEDRONATE SODIUM DR ZEMPLAR |
calcitriol capsule, RAYALDEE, ALENDRONATE TAB 70MG, IBANDRONATE TAB 150MG, risedronate sodium tab 5 mg,30 mg, 35 mg, 150 mg (Actonel)
|
MINERALOCORTICOID RECEPTOR ANTAGONISTS |
SPIRONOLACTONE SUSP 25 MG/5ML |
spironolactone tab 25mg, 50mg, 100mg
|
MULTIPLE SCLEROSIS |
BAFIERTAM PONVORY |
AVONEX, BETASERON, dimethyl fumarate, fingolimod, glatiramer, glatopa, KESIMPTA, MAVENCLAD, MAYZENT, PLEGRIDY, REBIF, teriflunomide, VUMERITY, ZEPOSIA, GILENYA 0.25mg |
NSAIDS |
ANAPROX DS ARHTORTEC CELEBREX FENOPROFEN CALCIUM IBUPROFEN/FAMOTIDINE INDOMETHACIN SUPPOS 50 MG INDOMETHACIN SUSP 25 MG/5ML KETOPROFEN KETOPROFEN ER LOFENA MELOXICAM CAP NAPROXEN SUSP NAPROXEN TAB EC NAPROXEN DR NAPROXEN SODIUM CR NAPROXEN SODIUM ER NAPROXEN/ESOMEPRAZOLE MAGNESIUM (generic VIMOVO) TOLECTIN 600 TOLMETIN SODIUM ZORVOLEX |
diclofenac tablet, ibuprofen tablet, indomethacin capsule, meloxicam tablet, naproxen tablet, oxaprozin 600mg, KEOTROLAC |
OPHTHALMIC AGENTS |
ALPHAGAN P BETOPTIC-S BRIMONIDINE TARTRATE/TIMOLOL MALEATE CEQUA DORZOLAMIDE HCL/TIMOLOL MALEATE PF MIEBO PHOSPHOLINE IODIDE TAFLUPROST TIMOLOL HEMIHYDRATE TIMOLOL MALEATE TIMOLOL MALEATE OPHTHALMIC GEL FORMING TRAVOPROST TROPICAMIDE VEVYE VERKAZYA XIIDRA |
EYSUVIS, RESTASIS SINGLE DOSE VIALS, TYRVAYA, apraclonidine solution, brimonidine solution 0.2%, SIMBRINZA, betaxolol solution, dorzolamide solution, dorzolamide/timolol solution, timolol solution, latanoprost, LUMIGAN, VYZULTA
|
PHOSPHATE BINDERS |
XPHOZAH |
calcium acetate, lanthanum carbonate, sevelamer carbonate, sevelamer, VELPHORO, AURYXIA
|
PHOSPHODIESTERASE INHIBITORS |
THEOPHYLLINE TAB ER 100MG & 200MG |
theophylline tab er 12hr 300 mg,450 mg, theophylline tab er 24hr 400mg, 600 mg |
PROTECTANTS |
SUCRALFATE SUSP 1 GM/10ML |
sucralfate tablet
|
PROTON PUMP INHIBITORS |
DEXLANSOPRAZOLE ESOMEPRAZOLE MAGNESIUM LANSOPRAZOLE OMEPRAZOLE/SODIUM BICARBONATE PANTOPRAZOLE SODIUM SUSP PACKET RABEPRAZOLE SODIUM ZEGERID |
OMEPRAZOLE CAP 20MG, PANTOPRAZOLE TAB 20MG, ESOMEPRAZOLE GRA 40MG DR, NEXIUM GRA 5MG DR |
PULMONARY HTN |
OPSYNVI |
TADALAFIL TAB, ALYQ TAB, AMBRISENTAN TAB, BOSENTAN TAB, SILDENAFIL TAB, SILDENAFIL SUS 10MG/ML, UPTRAVI TAB |
TRICYCLICS |
IMIPRAMINE PAMOATE |
imipramine hcl tab 10mg, 25mg, 50mg (Tofranil) |
VASODILATORS |
ISOSORBIDE DINITRATE NITROSTAT |
ISOSORB MONO TAB 30MG ER, ISOSORB MONO TAB 60MG ER, ISOSORB MONO TAB 120MG ER, NITROGLYCER DIS 0.1MG/HR, NITROGLYCERIN |
VITAMIN B12 |
cyanocobalamin nasal spray |
cyanocobalamin injection |
HIV |
COMBIVIR EMTRIVA EPIVIR KALETRA |
EMTRIC/RILPI TAB TENOF DF, ABACA/LAMIVU TAB 600-300, LAMIVUD/ZIDO TAB 150-300, TRUVADA TAB 100-150, EFAVIR/LAMIV TAB TENOFOVI, ODEFSEY TAB, BIKTARVY TAB, DELSTRIGO TAB, TRIUMEQ TAB, COMPLERA TAB |
Emblem Commercial Large Group Drugs Removed from Formulary In 2026 |
||
Drug Class |
Non-covered |
Formulary Alternatives |
MENTAL HEALTH |
THIORIDAZINE HCL ABILIFY MAINTENA ABILIFY MYCITE MAINTENANCE KIT ARISTADA NUPLAZID OLANZAPINE/FLUOXETINE SYMBYAX |
aripiprazole, asenapine, lurasidone, olanzapine, quetiapine er, quetiapine fumarate, REXULTI, risperidone, VRAYLAR, ziprasidone, CAPLYTA, LYBALVI |
INFLAMMATORY BOWEL AGENTS |
MESALAMINE ER CAP 500MG PENTASA |
balsalazide capsule, budesonide capsule, mesalamine enema, mesalamine DR capsule 400mg, mesalamine DR tablet 1.2gm, mesalamine ER capsule 0.375gm (generic APRISO), sulfasalazine tablet |
TESTOSTERONE PRODUCTS |
JATENZO TESTOSTERONE |
testosterone gel (generic ANDROGEL), testosterone gel 1.62% pump (generic ANDROGEL), testosterone solution, testosterone cypionate solution, testosterone enanthate solution, testosterone topical solution (generic AXIRON), XYOSTED |
ANTIARRHYTHMICS |
AMIODARONE HCL |
AMIODARONE HCL 200mg |
BETA BLOCKERS |
SOTYLIZE COREG CR TIMOLOL MALEATE |
atenolol, bisoprolol, carvedilol, HEMANGEOL, labetalol, metoprolol, nebivolol, PROPRANOLOL SOLUTION, propranolol tablet |
LAXATIVES: CIC, IBS-C, OIC |
LACTULOSE Packets LUBIPROSTONE (generic AMITIZA) PRUCALOPRIDE (generic MOTEGRITY) |
LINZESS, MOVANTIK, SYMPROIC, TRULANCE |
ANTICONVULSANTS |
ELEPSIA XR LAMOTRIGINE ODT |
LEVETIRACETAM, LEVETIRACETAM ER, TOPIRAMATE, TOPIRAMATE ER, TOPIRAMATE SPRINKLE ER, LACOSAMIDE TABLET, ZONISAMIDE CAPSULE |
ALZHEIMER'S AGENTS |
ERGOLOID MESYLATES MEMANTINE HCL ER CAPS NAMZARIC ADLARITY |
DONEPEZIL TABLET, MEMANTINE TABLET, MEMANTINE SOLUTION, RIVASTIGMINE PATCH |
ANTIDIABETIC AGENTS |
BYETTA CYCLOSET LIRAGLUTIDE METFORMIN HCL 750MG METFORMIN HCL ER OSM METFORMIN HCL ER MODIFIED PIOGLITAZONE HCL-GLIMEPIRIDE RIOMET SAXAGLIPTIN HCL SAXAGLIPTIN HCL/METFORMIN HCL ER SEGLUROMET STEGLATRO SYMLINPEN 120 SYMLINPEN 60 |
GLYXAMBI, JANUMET, JANUMET XR, pioglitazone/metformin, SYNJARDY, SYNJARDY XR, TRIJARDY XR, XIGDUO XR, metformin, metformin ER (generic GLUCOPHAGE XR), MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY, BYDUREON
|
ANTIGOUT |
ALLOPURINOL 200MG FEBUXOSTAT |
Allopurinol 100mg & 300mg, colchicine tablet (generic COLCRYS), probenecid, probenecid/colchicine |
ANTILEUKOTRIENES |
MONTELUKAST SODIUM GRANULES PACKET 4 MG ZILEUTON ER ZYFLO |
montelukast sodium chew tab, montelukast sodium tab, zafirlukast tab 10 mg, 20 mg (Accolate) |
PARKINSON AGENTS |
AMANTADINE HCL TAB NOURIANZ ONGENTYS |
amantadine capsule, amantadine syrup, entacapone tablet, INBRIJA, KYNMOBI, pramipexole tablet, rasagiline tablet, ropinirole tablet, selegiline capsule, selegiline tablet, tolcapone tablet
|
URINARY INCONTINENCE |
DARIFENACIN HYDROBROMIDE ER FESOTERODINE FUMARATE ER FLAVOXATE HCL OXYTROL |
mirabegron, MYRBETRIQ GRANULES, MYRBETRIQ TABLET, oxybutynin, oxybutynin ER, oxybutynin syrup, solifenacin tablet, tolterodine, tolterodine ER, trospium, trospium ER, GEMTESA
|
ADHD AND NARCOLEPSY |
ADZENYS XR-ODT AMPHETAMINE SULFATE AMPHETAMINE/DEXTROAMPHETAMINE ER (generic MYDAYIS) DESOXYN ZENZEDI COTEMPLA XR-ODT METHYLPHENIDATE METHYLPHENIDATE HCL ER (LA) METHYLPHENIDATE HCL ER (OSM) METHYLPHENIDATE HCL ER (XR) QELBREE |
amphetamine/dextroamphetamine, amphetamine/dextroamphetamine XR, armodafinil, atomoxetine, AZSTARYS, dexmethylphenidate ER, dextroamphetamine solution, dextroamphetamine, JORNAY PM, methylphenidate, methylphenidate ER (generic CONCERTA), modafinil, QUILLICHEW ER, QUILLIVANT XR SUSPENSION, SUNOSI, LUMRYZ, SODIUM OXYBATE (authorized generic of XYREM by Hikma), XYWAV |
BPH |
CARDURA XL DUTASTERIDE/TAMSULOSIN HCL |
alfuzosin ER, dutasteride, finasteride, silodosin capsule, tadalafil 5mg, tamsulosin, terazosin |
COPD & BRONCHODILATORS |
YUPELRI FORMOTEROL FUMARATE (Perforomist) |
INCRUSE ELLIPTA, SPIRIVA HANDIHALER, SPIRIVA RESPIMAT, ATROVENT, ARFORMOTEROL NEB 15/2ML, SEREVENT DIS AER 50MCG, STRIVERDI AER 2.5MCG, IPRATROPIUM SOL 0.02%INH |
CALCIUM CHANNEL BLOCKERS |
ISRADIPINE NICARDIPINE HCL NISOLDIPINE ER DILTIAZEM HCL CD DILTIAZEM HCL ER TABS VERAPAMIL HCL ER CAPS VERAPAMIL HCL SR |
amlodipine, diltiazem ER capsule (except 360mg), felodipine ER, nifedipine, verapamil, verapamil ER tabs (Calan sr) |
CARDIOVASCULAR AGENTS |
ALISKIREN AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM CADUET CAPTOPRIL/HYDROCHLOROTHIAZIDE ENTRESTO TELMISARTAN/HYDROCHLOROTHIAZIDE TRANDOLAPRIL/VERAPAMIL HCL ER PRESTALIA |
enalapril, irbesartan, lisinopril, losartan, valsartan, amlodipine/benazepril, amlodipine/olmesartan, amlodipine/valsartan, amlodipine/valsartan/HCTZ, olmesartan/amlodipine/HCTZ |
CNS |
FLUOXETINE HCL TAB PAROXETINE CAP (Brisdelle) PAROXETINE HCL ER TAB PAROXETINE ORAL SUSP TIGLUTIK VEOZAH DESVENLAFAXINE ER TAB DULOXETINE HCL DR FLUOXETINE HCL 60MG TAB FLUVOXAMINE MALEATE ER NEFAZODONE HCL TRAZODONE HCL 300MG VENLAFAXINE HCL ER TAB |
citalopram, escitalopram, fluoxetine capsule, fluvoxamine, paroxetine, sertraline concentrate, sertraline tablet, desvenlafaxine ER, duloxetine, venlafaxine, venlafaxine ER CAPS |
CYSTIC FIBROSIS AGENTS |
BRONCHITOL |
KALYDECO, PULMOZYME SOL 1MG/ML, ACETYLCYST SOL 20% |
DIURETICS |
ETHACRYNIC ACID FUROSEMIDE ORAL SOLN 8 MG/ML |
bumetanide, furosemide solution 10mg/mL, furosemide tablet, torsemide |
PARKINSON'S AGENTS |
PRAMIPEXOLE DIHYDROCHLORIDE ER ROPINIROLE ER CREXONT |
amantadine capsule, amantadine syrup, entacapone tablet, INBRIJA, KYNMOBI, pramipexole tablet, rasagiline tablet, ropinirole tablet, selegiline capsule, selegiline tablet, tolcapone tablet, carbidopa & levodopa tab er25-100 mg, 50-200 mg (Sinemet cr)
|
HIGH CHOLESTEROL |
FENOFIBRATE CAP 43 & 130MG FENOFIBRATE TAB 40 & 120MG FENOFIBRIC ACID DR FIBRICOR FLOLIPID FLUVASTATIN LESCOL XL PITAVASTATIN CALCIUM ZYPITAMAG CHOLESTYRAMINE CHOLESTYRAMINE LIGHT COLESEVELAM HCL PACKET FOR SUSP 3.75 GM OMEGA-3-ACID ETHYL ESTERS ROSZET |
atorvastatin tablet, ezetimibe/simvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, cholestyramine powder, cholestyramine light powder, colesevelam tablet, prevalite powder, FENOFIBRATE CAP 67MG, FENOFIBRATE CAP 67MG, FENOFIBRATE TAB 145MG, FENOFIBRATE TAB 160MG, FENOFIBRATE TAB 48MG, FENOFIBRATE TAB 54MG
|
ELECTROLYTE/MINERAL/METAL MODIFIERS |
FERRIPROX TWICE-A-DAY |
DEFERIPRONE TAB 1000MG, DEFERIPRONE TAB 500MG |
FIBROMYALGIA AGENTS |
SAVELLA PREGABALIN ER |
duloxetine, pregabalin, GRALISE, HORIZANT |
ANTICONVULSANTS: BENZODIAZEPINES |
SYMPAZAN |
clobazam, clonazepam
|
PRIMARY BILIARY CHOLANGITIS (PBC) |
OCALIVA URSODIOL CAP 200MG & 400MG |
URSODIOL TAB 250MG, URSODIOL CAP 300MG, URSODIOL TAB 500MG |
GENETIC, ENZYME OR PROTEIN DISORDER |
DOJOLVI OLPRUVA PANCREAZE VIOKACE XURIDEN |
sodium phenylbutyrate powder, sodium phenylbutyrate tablet PHEBURANE, RAVICTI CREON, ZENPEP
|
|
CRYSVITA |
Coverage through medical benefit |
H2 ANTAGONISTS |
CIMETIDINE CIMETIDINE HCL SOLN 300 MG/5ML FAMOTIDINE TAB 20 MG NIZATIDINE |
FAMOTIDINE TAB 40MG, FAMOTIDINE SUS 40MG/5ML |
LIPODYSTROPHY AGENTS |
EGRIFTA SV
|
NO FORMULARY ALTERNATIVES |
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY) |
NGENLA NOCDURNA SEROSTIM |
GENOTROPIN, OMNITROPE, SKYTROFA, desmopressin acetate tab 0.1 mg,0.2 mg (Ddavp)
|
HORMONAL AGENTS |
ANNOVERA LEVONORGESTREL/ETHINYL ESTRADIOL/FERROUS BISGLYCINATE MERZEE |
NUVARING MIS, ZAFEMY DIS 150/35, TRI-LO- TAB SPRINTEC, ENPRESSE-28 TAB, SRONYX TAB, NORTREL TAB 1/35, AVIANE TAB, NORGEST/ETHI TAB ESTRADIO, ETHY ETH EST TAB 1-35, TRI-NYMYO TAB, AUROVELA TAB 1/20, ISIBLOOM TAB, AZURETTE TAB |
IMMUNOLOGICAL AGENTS |
ACTEMRA TALTZ TAVNEOS VELSIPITY VOYDEYA CYLTEZO |
TYENNE, ADALIMUMAB biosimilars LOW WAC (YUFLYMA, Hyrimoz & Hadlima), ENTYVIO, OMVOH, RINVOQ, SIMPONI 100mg, SKYRIZI, XELJANZ/XR, ZEPOSIA, CIMZIA, ZYMFENTRA |
IMMUNOSUPPRESSANTS |
RASUVO |
methotrexate injection, methotrexate tablet, OTREXUP, REDITREX |
INSULINS |
BASAGLAR KWIKPEN BASAGLAR TEMPO PEN |
HUMULIN N, HUMULIN R U-500, LEVEMIR, NOVOLIN N, SEMGLEE-YFGN, TOUJEO, TRESIBA |
METABOLIC BONE DISEASE |
BINOSTO CALCITRIOL ORAL SOLN 1 MCG/ML DOXERCALCIFEROL FOSAMAX PLUS D PARICALCITOL RISEDRONATE SODIUM DR ZEMPLAR |
calcitriol capsule, RAYALDEE, ALENDRONATE TAB 70MG, IBANDRONATE TAB 150MG, risedronate sodium tab 5 mg,30 mg, 35 mg, 150 mg (Actonel)
|
MINERALOCORTICOID RECEPTOR ANTAGONISTS |
SPIRONOLACTONE SUSP 25 MG/5ML |
spironolactone tab 25mg, 50mg, 100mg
|
MULTIPLE SCLEROSIS |
BAFIERTAM PONVORY |
AVONEX, BETASERON, dimethyl fumarate, fingolimod, glatiramer, glatopa, KESIMPTA, MAVENCLAD, MAYZENT, PLEGRIDY, REBIF, teriflunomide, VUMERITY, ZEPOSIA, GILENYA 0.25mg |
NSAIDS |
DICLOFENAC SODIUM ER FENOPROFEN CALCIUM IBUPROFEN/FAMOTIDINE INDOMETHACIN SUPPOS 50 MG INDOMETHACIN SUSP 25 MG/5ML KETOPROFEN KETOPROFEN ER LOFENA MECLOFENAMATE SODIUM MEFENAMIC ACID MELOXICAM CAP NAPROXEN SUSP 125 MG/5ML NAPROXEN TAB EC NAPROXEN DR NAPROXEN SODIUM CR NAPROXEN SODIUM ER NAPROXEN/ESOMEPRAZOLE MAGNESIUM (generic VIMOVO) TOLECTIN 600 TOLMETIN SODIUM |
diclofenac tablet, ibuprofen tablet, indomethacin capsule, meloxicam tablet, naproxen tablet, oxaprozin 600mg |
OPHTHALMIC AGENTS |
BRIMONIDINE TARTRATE/TIMOLOL MALEATE CEQUA DORZOLAMIDE HCL/TIMOLOL MALEATE PF MIEBO TROPICAMIDE VEVYE XIIDRA BETOPTIC-S TIMOLOL HEMIHYDRATE TIMOLOL MALEATE TIMOLOL MALEATE OPHTHALMIC GEL FORMING ALPHAGAN P BRINZOLAMIDE PHOSPHOLINE IODIDE BIMATOPROST TAFLUPROST TRAVOPROST |
EYSUVIS, RESTASIS SINGLE DOSE VIALS, TYRVAYA, apraclonidine solution, brimonidine solution 0.2%, SIMBRINZA, betaxolol solution, dorzolamide solution, dorzolamide/timolol solution, timolol solution, latanoprost, LUMIGAN, VYZULTA
|
PHOSPHATE BINDERS |
VELPHORO CHW 500MG |
calcium acetate, lanthanum carbonate, sevelamer carbonate, sevelamer, VELPHORO, AURYXIA
|
PHOSPHODIESTERASE INHIBITORS |
THEOPHYLLINE TAB ER 100MG & 200MG |
theophylline tab er 12hr 300 mg,450 mg, theophylline tab er 24hr 400mg, 600 mg |
PROGESTINS |
MEGESTROL ACETATE SUSP 625 MG/5ML |
megestrol acetate tab 20 mg, 40 mg, megestrol acetate susp 40mg/ml (Megace oral)
|
PROTECTANTS |
SUCRALFATE SUSP 1 GM/10ML |
sucralfate tablet
|
PROTON PUMP INHIBITORS |
DEXLANSOPRAZOLE ESOMEPRAZOLE MAGNESIUM LANSOPRAZOLE OMEPRAZOLE/SODIUM BICARBONATE PANTOPRAZOLE SODIUM SUSP PACKET RABEPRAZOLE SODIUM |
OMEPRAZOLE CAP 20MG, PANTOPRAZOLE TAB 20MG, ESOMEPRAZOLE GRA 40MG DR, NEXIUM GRA 5MG DR |
PULMONARY HTN |
OPSYNVI TYVASO DPI MAINTENANCE KIT |
ambrisentan, bosentan, OPSUMIT, sildenafil suspension, sildenafil tablet, tadalafil 20mg, TRACLEER, UPTRAVI, ADEMPAS, ORENITRAM, TYVASO NEBULIZED SOLUTION, VENTAVIS, WINREVAIR |
RESPIRATORY TRACT AGENTS |
FASENRA NUCALA |
FASENRA PEN- benralizumab subcutaneous soln auto-injector30 mg/ml, NUCALA- mepolizumab subcutaneous solution auto-injector100 mg/ml, NUCALA- mepolizumab subcutaneous solution pref syringe40 mg/0.4ml, 100 mg/ml |
TRICYCLICS |
AMOXAPINE IMIPRAMINE PAMOATE |
imipramine hcl tab 10mg, 25mg, 50mg (Tofranil) |
VASODILATORS |
ISOSORBIDE DINITRATE |
ISOSORB MONO TAB 30MG ER, ISOSORB MONO TAB 60MG ER, ISOSORB MONO TAB 120MG ER, NITROGLYCER DIS 0.1MG/HR |
JP69830 10/2025
