Retiree RxCare may add or remove drugs from our formulary during the year. If we remove drugs from our formulary or add prior authorization, quantity limits and/or step therapy restrictions to a drug and/or move a drug to a higher cost-sharing tier, we will notify you of the change at least 60 days before the date that the change becomes effective.
There are two exceptions to the 60-day advance member notification requirement:
1. If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary.
2. When the FDA approves a first time generic for a brand name drug, we may immediately allow a brand to generic substitution. Notification to the member will be made but can occur after the substitution is made.
FORMULARY CHANGES EFFECTIVE 05/01/2021
Medication Name Change Description
ABILIFY MYCITE 10 MG MAINT KIT
aripiprazole
- Added
- QL Added: 30 / 30 DAYS
- ST Added: Abilify Mycite - sCORE ABILIFY MYCITE 10 MG START KIT
aripiprazole
- Added
- QL Added: 60 / 365 OVER TIME - ST Added: Abilify Mycite - sCORE ABILIFY MYCITE 15 MG MAINT KIT
aripiprazole
- Added
- QL Added: 30 / 30 DAYS
- ST Added: Abilify Mycite - sCORE ABILIFY MYCITE 15 MG START KIT
aripiprazole
- Added
- QL Added: 60 / 365 OVER TIME - ST Added: Abilify Mycite - sCORE ABILIFY MYCITE 2 MG MAINT KIT
aripiprazole
- Added
- QL Added: 30 / 30 DAYS
- ST Added: Abilify Mycite - sCORE ABILIFY MYCITE 2 MG START KIT
aripiprazole
- Added
- QL Added: 60 / 365 OVER TIME - ST Added: Abilify Mycite - sCORE ABILIFY MYCITE 20 MG MAINT KIT
aripiprazole
- Added
- QL Added: 30 / 30 DAYS
- ST Added: Abilify Mycite - sCORE ABILIFY MYCITE 20 MG START KIT
aripiprazole
- Added
- QL Added: 60 / 365 OVER TIME - ST Added: Abilify Mycite - sCORE
ABILIFY MYCITE 30 MG MAINT KIT
aripiprazole
- Added
- QL Added: 30 / 30 DAYS
- ST Added: Abilify Mycite - sCORE ABILIFY MYCITE 30 MG START KIT
aripiprazole
- Added
- QL Added: 60 / 365 OVER TIME - ST Added: Abilify Mycite - sCORE ABILIFY MYCITE 5 MG MAINT KIT
aripiprazole
- Added
- QL Added: 30 / 30 DAYS
- ST Added: Abilify Mycite - sCORE ABILIFY MYCITE 5 MG START KIT
aripiprazole
- Added to
- QL Added: 60 / 365 OVER TIME - ST Added: Abilify Mycite - sCORE ELEPSIA XR 1,000 MG TABLET
levetiracetam - Added
ELEPSIA XR 1,500 MG TABLET
levetiracetam - Added
FOTIVDA 0.89 MG CAPSULE
tivozanib hcl
- Added
- PA Added: Fotivda (s) FOTIVDA 1.34 MG CAPSULE
tivozanib hcl
- Added
- PA Added: Fotivda (s)
glipizide/metformin hcl 2.5-250 mg tablet - ST Removed: INJECTABLE GLP1 AGONISTS - sCORE
glipizide/metformin hcl 2.5-500 mg tablet - ST Removed: ORAL GLP1 AGONIST - sCORE
glipizide/metformin hcl 5 mg-500mg tablet - ST Removed: INJECTABLE GLP1 AGONISTS - sCORE
glyburide/metformin hcl 1.25-250mg tablet - ST Removed: ORAL GLP1 AGONIST - sCORE
glyburide/metformin hcl 2.5-500 mg tablet - ST Removed: ORAL GLP1 AGONIST - sCORE
glyburide/metformin hcl 5 mg-500mg tablet
- ST Removed: INJECTABLE GLP1 AGONISTS - sCORE
metformin hcl 1000 mg tablet - ST Removed: INJECTABLE GLP1 AGONISTS - sCORE
metformin hcl 500 mg tab er 24h - ST Removed: INJECTABLE GLP1 AGONISTS - sCORE
metformin hcl 500 mg tablet - ST Removed: ORAL GLP1 AGONIST - sCORE
metformin hcl 500 mg/5ml solution - ST Removed: ORAL GLP1 AGONIST - sCORE
metformin hcl 750 mg tab er 24h - ST Removed: INJECTABLE GLP1 AGONISTS - sCORE
metformin hcl 850 mg tablet - ST Removed: INJECTABLE GLP1 AGONISTS - sCORE
metformin/blood sugar diagnost 500 mg cmbtabstrp
- ST Removed: INJECTABLE GLP1 AGONISTS - sCORE
OZEMPIC 0.25-0.5 MG DOSE PEN
semaglutide - ST Removed: INJECTABLE GLP1
AGONISTS - sCORE OZEMPIC 1 MG DOSE PEN (1.5 ML)
semaglutide - ST Removed: INJECTABLE GLP1
AGONISTS - sCORE pioglitazone hcl/metformin hcl 15mg-
500mg tablet
- ST Removed: INJECTABLE GLP1 AGONISTS - sCORE
pioglitazone hcl/metformin hcl 15mg- 850mg tablet
- ST Removed: ORAL GLP1 AGONIST - sCORE
RYBELSUS 14 MG TABLET
semaglutide - ST Removed: ORAL GLP1 AGONIST -
sCORE RYBELSUS 3 MG TABLET
semaglutide - ST Removed: ORAL GLP1 AGONIST -
sCORE RYBELSUS 7 MG TABLET
semaglutide - ST Removed: ORAL GLP1 AGONIST -
sCORE VICTOZA 2-PAK 18 MG/3 ML PEN
liraglutide - ST Removed: INJECTABLE GLP1
AGONISTS - sCORE VICTOZA 3-PAK 18 MG/3 ML PEN
liraglutide - ST Removed: INJECTABLE GLP1
AGONISTS - sCORE
FORMULARY CHANGES EFFECTIVE 03/01/2021
Medication Name Change Description
BAVENCIO 200 MG/10 ML VIAL
avelumab
- Added
- PA Added: BAVENCIO (s) BRONCHITOL 40 MG INHALE CAP
mannitol
- Added
- QL Added: 560 / 28 DAYS - PA Added: Bronchitol (s)
CABENUVA 400 MG-600 MG ER SUSP
cabotegravir/rilpivirine - Added
CABENUVA 600 MG-900 MG ER SUSP
cabotegravir/rilpivirine - Added
DYSPORT 300 UNIT VIAL
abobotulinumtoxina
- Added
- PA Added: Dysport (s) DYSPORT 500 UNITS VIAL
abobotulinumtoxina
- Added
- PA Added: Dysport (s) emtricitabine/tenofovir (tdf) 100-150 mg
tablet
- Added
- QL Added: 30 / 30 DAYS emtricitabine/tenofovir (tdf) 133-200 mg
tablet
- Added
- QL Added: 30 / 30 DAYS emtricitabine/tenofovir (tdf) 167-250 mg
tablet
- Added
- QL Added: 30 / 30 DAYS epinephrine 0.1 mg/ml syringe - Added
fluorouracil 2 % solution - ST Added: Skin Cancer Agents - sCORE fluorouracil 5 % cream (g) - ST Added: Skin Cancer Agents - sCORE fluorouracil 5 % solution - ST Added: Skin Cancer Agents - sCORE glucagon,human recombinant 1 mg vial - Added
ICLUSIG 10 MG TABLET
ponatinib hcl
- Added
- QL Added: 30 / 30 DAYS - PA Added: ICLUSIG (s) ICLUSIG 30 MG TABLET
ponatinib hcl
- Added
- PA Added: ICLUSIG (s) IMFINZI 120 MG/2.4 ML VIAL
durvalumab
- Added
- PA Added: IMFINZI (s) IMFINZI 500 MG/10 ML VIAL
durvalumab
- Added
- PA Added: IMFINZI (s) imiquimod 3.75 % cream pack - Added
imiquimod 5 % cream pack - ST Added: Skin Cancer Agents - sCORE isotretinoin 10 mg capsule - Added
- PA Added: ISOTRETINOIN (s)
isotretinoin 20 mg capsule - Added
- PA Added: ISOTRETINOIN (s) isotretinoin 30 mg capsule - Added
- PA Added: ISOTRETINOIN (s) isotretinoin 40 mg capsule - Added
- PA Added: ISOTRETINOIN (s) KEYTRUDA 100 MG/4 ML VIAL
pembrolizumab
- Added
- PA Added: KEYTRUDA (s) KLISYRI 1% OINTMENT PACKET
tirbanibulin
- Added
- ST Added: Skin Cancer Agents - sCORE LIBTAYO 350 MG/7 ML VIAL
cemiplimab-rwlc
- Added
- PA Added: LIBTAYO (s) LUPKYNIS 7.9 MG CAPSULE
voclosporin
- Added
- QL Added: 180 / 30 DAYS - PA Added: Lupkynis (s) MAYZENT 0.25 MG STARTER PACK
siponimod
- Added
- QL Added: 24 / 365 OVER TIME - PA Added: MAYZENT (s)
norethindrone-e.estradiol-iron 1mg-20(24) capsule
- Added
OPDIVO 100 MG/10 ML VIAL
nivolumab
- Added
- PA Added: OPDIVO (s) OPDIVO 240 MG/24 ML VIAL
nivolumab
- Added
- PA Added: OPDIVO (s) OPDIVO 40 MG/4 ML VIAL
nivolumab
- Added
- PA Added: OPDIVO (s) TECENTRIQ 1,200 MG/20 ML VIAL
atezolizumab
- Added
- PA Added: TECENTRIQ (s) TECENTRIQ 840 MG/14 ML VIAL
atezolizumab
- Added
- PA Added: TECENTRIQ (s) TOTECT 500 MG VIAL
dexrazoxane hcl - Added
YERVOY 200 MG/40 ML VIAL
ipilimumab
- Added
- PA Added: YERVOY (s)
YERVOY 50 MG/10 ML VIAL
ipilimumab
- Added
- PA Added: YERVOY (s)
FORMULARY CHANGES EFFECTIVE 02/01/2021
Medication Name Change Description
GAMIFANT 10 MG/2 ML VIAL
emapalumab-lzsg
- Added
- PA Added: Gamifant (s) GAMIFANT 50 MG/10 ML VIAL
emapalumab-lzsg
- Added
- PA Added: Gamifant (s) loperamide hcl 1mg/7.5ml liquid - Removed From Coverage ORGOVYX 120 MG TABLET
relugolix
- Added
- PA Added: Orgovyx (s) RIABNI 100 MG/10 ML VIAL
rituximab-arrx
- Added
- PA Added: Riabni (s) RIABNI 500 MG/50 ML VIAL
rituximab-arrx
- Added
- PA Added: Riabni (s) ZOKINVY 50 MG CAPSULE
lonafarnib
- Added
- QL Added: 120 / 30 DAYS - PA Added: Zokinvy (s) ZOKINVY 75 MG CAPSULE
lonafarnib
- Added
- QL Added: 120 / 30 DAYS - PA Added: Zokinvy (s)
QL = Quantity Limit, PA = Prior Authorization, ST = Step Therapy, B/D = Medicare Part B versus Part D determination
AER = Aerosol, CAP = Capsule, CON = Concentrate, CRE = Cream, DRO = Drops, ER = Extended Release, ENE = Enema, GRA = Granules, INH = Inhalation, INJ = Injection, LOT = Lotion, NEB = Nebulizer, ODT = Orally Disintegrating, OIN = Ointment, OP = Ophthalmic, POW = Powder, SHA = Shampoo, SOL = Solution, SPR = Spray, SUB = Sublingual, SUP = Suppository, SUS = Suspension, TAB = Tablet, CHW = Chewable
Formulary ID: 20307
Last Updated: 4/2021
