Effective August 1, 2024
B3, M1, M2, and M4 drug lists
B3 drug list
Drug name
Description of change
Cost-effective alternatives*
No changes
M1 and M2 drug lists
Drug name
Description of change
Cost-effective alternatives*
Carbinoxamine 6mg tablets (effective 9/1/2024)
No longer covered
carbinoxamine 4mg tablets
Emflaza oral suspension
No longer covered
prednisone, deflazacort
Folic acid 5mg capsules
No longer covered
folic acid tablets
Folic acid vials
No longer covered
Covered under medical benefit
Glucagon 1mg vials
No longer covered
glucagon 1mg emergency kit
Metronidazole 375mg capsules (effective 9/1/2024)
No longer covered
metronidazole 250mg, 500mg tablets
Nexplanon 68mg implant (effective 9/1/2024)
Covered on the medical benefit
oral contraceptives
Nityr tablets
No longer covered
nitisinone capsules
Oxistat 1% lotion
No longer covered
ciclopirox, clotrimazole, econazole, ketoconazole, nystatin
R-tanna tablets
No longer covered
promethazine/phenylephrine
Ravicti liquid (effective 9/1/2024)
No longer covered
carglumic acid tablets
Sulconazole 1% solution
No longer covered
ciclopirox, clotrimazole, econazole, ketoconazole, nystatin
Zenzedi 2.5mg & 7.5mg tablets
No longer covered
dextroamphetamine tablets
M4 drug list
Drug name
Description of change
Cost-effective alternatives*
Carbinoxamine 6mg tablets (effective 9/1/2024)
No longer covered
carbinoxamine 4mg tablets
Emflaza oral suspension
No longer covered
prednisone, deflazacort
Folic acid 5mg capsules
No longer covered
folic acid tablets
Folic acid vials
No longer covered
Covered under medical benefit
Glucagon 1mg vials
No longer covered
glucagon 1mg emergency kit
Metronidazole 375mg capsules (effective 9/1/2024)
No longer covered
metronidazole 250mg, 500mg tablets
Nexplanon 68mg implant (effective 9/1/2024)
Covered on the medical benefit
oral contraceptives
Nityr tablets
No longer covered
nitisinone capsules
Oxistat 1% lotion
No longer covered
ciclopirox, clotrimazole, econazole, ketoconazole, nystatin
R-tanna tablets
No longer covered
promethazine/phenylephrine
Ravicti liquid (effective 9/1/2024)
No longer covered
carglumic acid tablets
Sulconazole 1% solution
No longer covered
ciclopirox, clotrimazole, econazole, ketoconazole, nystatin
Zenzedi 2.5mg & 7.5mg tablets
No longer covered
dextroamphetamine tablets
*These drugs have been selected by an independent group of experts made up of doctors and pharmacists. This group reviews drugs to see how well they work relative to their cost. They also compare their effectiveness to similar drugs used to treat the same condition. Please talk with your doctor to see if these new options are right for you.