Formulary Change(s)


CMS Formulary ID Effective Date Drug Name Change Description Reason Description Alternate Drugs And Tier
21042 03/01/2021 BANZEL 40 MG/ML ORAL ORAL SUSP BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT RUFINAMIDE 40 MG/ML ORAL ORAL SUSP-5
21042 05/01/2021 RANITIDINE HCL 15 MG/ML ORAL SYRUP DELETION OF DRUG FROM FORMULARY REMOVAL OF DRUG FROM FORMULARY DUE TO FDA MANDATED MARKET WITHDRAWAL
21042 05/01/2021 RANITIDINE HCL 150 MG ORAL TABLET DELETION OF DRUG FROM FORMULARY REMOVAL OF DRUG FROM FORMULARY DUE TO FDA MANDATED MARKET WITHDRAWAL
21042 05/01/2021 RANITIDINE HCL 25 MG/ML INJECTION VIAL DELETION OF DRUG FROM FORMULARY REMOVAL OF DRUG FROM FORMULARY DUE TO FDA MANDATED MARKET WITHDRAWAL
21042 05/01/2021 RANITIDINE HCL 300 MG ORAL TABLET DELETION OF DRUG FROM FORMULARY REMOVAL OF DRUG FROM FORMULARY DUE TO FDA MANDATED MARKET WITHDRAWAL
21042 05/01/2021 RANITIDINE HCL 50 MG/2 ML INJECTION VIAL DELETION OF DRUG FROM FORMULARY REMOVAL OF DRUG FROM FORMULARY DUE TO FDA MANDATED MARKET WITHDRAWAL
21042 03/01/2021 SAPHRIS 10 MG SUBLINGUAL TAB SUBL BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT ASENAPINE MALEATE 10 MG SUBLINGUAL TAB SUBL-2
21042 03/01/2021 SAPHRIS 2.5 MG SUBLINGUAL TAB SUBL BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT ASENAPINE MALEATE 2.5 MG SUBLINGUAL TAB SUBL-2
21042 03/01/2021 SAPHRIS 5 MG SUBLINGUAL TAB SUBL BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT ASENAPINE MALEATE 5 MG SUBLINGUAL TAB SUBL-2
21042 03/01/2021 TECFIDERA 120-240 MG ORAL CAPSULE DR BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT DIMETHYL FUMARATE 120-240 MG ORAL CAPSULE DR-5
21042 05/01/2021 BETHKIS 300 MG/4ML INHALATION AMPUL-NEB BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT TOBRAMYCIN 300 MG/4ML INHALATION AMPUL-NEB-5
21042 05/01/2021 DEMSER 250 MG ORAL CAPSULE BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT METYROSINE 250 MG ORAL CAPSULE-5
21042 05/01/2021 SYMFI LO 400-300 MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT EFAVIRENZ-LAMIVU-TENOFOV DISOP 400-300 MG ORAL TABLET-5
21042 05/01/2021 ATRIPLA 600-200MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT EFAVIRENZ-EMTRIC-TENOFOV DISOP 600-200MG ORAL TABLET-5
21042 05/01/2021 SYMFI 600-300MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT EFAVIRENZ-LAMIVU-TENOFOV DISOP 600-300MG ORAL TABLET-5
21042 05/01/2021 KUVAN 100 MG ORAL TABLET SOL BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT SAPROPTERIN DIHYDROCHLORIDE 100 MG ORAL TABLET SOL-5
21042 05/01/2021 EMTRIVA 200 MG ORAL CAPSULE BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT EMTRICITABINE 200 MG ORAL CAPSULE-2
21042 05/01/2021 FERRIPROX 500 MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT DEFERIPRONE 500 MG ORAL TABLET-5
21042 05/01/2021 TECFIDERA 120 MG ORAL CAPSULE DR BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT DIMETHYL FUMARATE 120 MG ORAL CAPSULE DR-5
21042 05/01/2021 TECFIDERA 240 MG ORAL CAPSULE DR BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT DIMETHYL FUMARATE 240 MG ORAL CAPSULE DR-5
21042 05/01/2021 TYKERB 250 MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT LAPATINIB 250 MG ORAL TABLET-5
21042 05/01/2021 TRUVADA 200-300 MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT EMTRICITABINE-TENOFOVIR DISOP 200-300 MG ORAL TABLET-5
21042 02/27/2021 ALINIA 500 MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT NITAZOXANIDE 500 MG ORAL TABLET-5
21042 04/03/2021 TRUVADA 100-150 MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT EMTRICITABINE-TENOFOVIR DISOP 100-150 MG ORAL TABLET-5
21042 04/03/2021 TRUVADA 133-200 MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT EMTRICITABINE-TENOFOVIR DISOP 133-200 MG ORAL TABLET-5
21042 04/03/2021 LOTEMAX 0.5 % OPHTHALMIC DROPS GEL BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT LOTEPREDNOL ETABONATE 0.5 % OPHTHALMIC DROPS GEL-2
21042 04/03/2021 TRUVADA 167-250 MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT EMTRICITABINE-TENOFOVIR DISOP 167-250 MG ORAL TABLET-5
21042 05/01/2021 NORTHERA 100 MG ORAL CAPSULE BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT DROXIDOPA 100 MG ORAL CAPSULE-5
21042 05/01/2021 NORTHERA 200 MG ORAL CAPSULE BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT DROXIDOPA 200 MG ORAL CAPSULE-5
21042 05/01/2021 NORTHERA 300 MG ORAL CAPSULE BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT DROXIDOPA 300 MG ORAL CAPSULE-5
21042 07/03/2021 THIOLA 100 MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT TIOPRONIN 100 MG ORAL TABLET-5