Formulary Change(s)


CMS Formulary ID Effective Date Drug Name Change Description Reason Description Alternate Drugs And Tier
20040 05/01/2020 JADENU 90 MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT DEFERASIROX 90 MG ORAL TABLET-5
20040 05/01/2020 JADENU 360 MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT DEFERASIROX 360 MG ORAL TABLET-5
20040 05/01/2020 NOXAFIL 100 MG ORAL TABLET DR BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT POSACONAZOLE 100 MG ORAL TABLET DR-5
20040 05/01/2020 EMEND 150 MG INTRAVEN. VIAL BRAND DELETION, ADD NEWLY APPROVED GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT FOSAPREPITANT DIMEGLUMINE 150 MG INTRAVEN. VIAL-4
20040 05/01/2020 TRAVATAN Z 0.004 % OPHTHALMIC DROPS BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT TRAVOPROST 0.004 % OPHTHALMIC DROPS-2
20040 05/01/2020 NEBUPENT 300 MG INHALATION VIAL-NEB BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT PENTAMIDINE ISETHIONATE 300 MG INHALATION VIAL-NEB-2
20040 05/01/2020 APRISO 0.375G ORAL CAP ER 24H BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT MESALAMINE ER 0.375G ORAL CAP ER 24H-2
20040 06/01/2020 DEPEN 250 MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT PENICILLAMINE 250 MG ORAL TABLET-5
20040 06/01/2020 PENTAM 300 300 MG INJECTION VIAL BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT PENTAMIDINE ISETHIONATE 300 MG INJECTION VIAL-4
20040 12/01/2020 VIMOVO 375MG-20MG ORAL TAB IR DR BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT NAPROXEN-ESOMEPRAZOLE MAG 500MG-20MG ORAL TAB IR DR-5
20040 12/01/2020 VIMOVO 500MG-20MG ORAL TAB IR DR BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT NAPROXEN-ESOMEPRAZOLE MAG 500MG-20MG ORAL TAB IR DR-5
20040 08/01/2020 ZORTRESS 0.25 MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT EVEROLIMUS 0.25 MG ORAL TABLET-4
20040 08/01/2020 ZORTRESS 0.75 MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT EVEROLIMUS 0.75 MG ORAL TABLET-5
20040 08/01/2020 ZORTRESS 0.5 MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT EVEROLIMUS 0.5 MG ORAL TABLET-5
20040 09/01/2020 PROGLYCEM 50 MG/ML ORAL ORAL SUSP BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT DIAZOXIDE 50 MG/ML ORAL ORAL SUSP-2
20040 09/01/2020 DARAPRIM 25 MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT PYRIMETHAMINE 25 MG ORAL TABLET-5
20040 10/01/2020 PRILOVIXIL 2.5 %-2.5% TOPICAL KIT DELETION OF DRUG FROM FORMULARY NOT A PART D COVERED DRUG
20040 10/01/2020 ORFADIN 5 MG ORAL CAPSULE BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT NITISINONE 5 MG ORAL CAPSULE-5
20040 10/01/2020 ORFADIN 2 MG ORAL CAPSULE BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT NITISINONE 2 MG ORAL CAPSULE-5
20040 10/01/2020 ORFADIN 10 MG ORAL CAPSULE BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT NITISINONE 10 MG ORAL CAPSULE-5
20040 10/01/2020 GEODON FNL 20MG/1 INTRAMUSC. VIAL BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT ZIPRASIDONE MESYLATE FNL 20MG/1 INTRAMUSC. VIAL-2
20040 10/01/2020 JADENU 180 MG ORAL TABLET BRAND DELETION, ADD FRF GENERIC REMOVAL OF BRAND NAME DRUG FROM FORMULARY DUE TO ADDITION OF NEW GENERIC EQUIVALENT DEFERASIROX 180 MG ORAL TABLET-5