Formulary Drug Lists
Get information about our pharmacy benefits, how prescription drugs may be covered, and recent drug list changes.
2025 Covered formulary drug lists
Different plans have different lists of covered drugs. Drug list codes can be found on member ID cards.
Individual
Drug approval and benefit levels
Effective July 1, 2025
Preferred B3 Formulary drug list
| Drug name | Description of change | Generic or more cost-effective option |
|---|---|---|
| ANDROGEL 1.62% (1.25G) GEL PACKETS | Moving to Tier 3 | testosterone 1.62% (1.25 g) packets |
| BETIMOL 0.5% EYE DROPS | Moving to Tier 3 | timolol 0.5% eye drops |
| ELIGARD SYRINGE KITS | No longer covered | Covered under medical benefit only. |
| HUMIRA (ALL STRENGTHS & DOSAGE FORMS) | Moving to Tier 3 | adalimumab-adaz, adalimumab-adbm, adalimumab-ryvk, Cyltezo, Simlandi |
| HYCODAN 5 MG-1.5 MG/5 ML SOLUTION | Moving to Tier 3 | hydrocodone/homatropine solution, promethazine/codeine syrup, promethazine/DM syrup |
| LEUPROLIDE DEPOT | No longer covered | Covered under medical benefit only. |
| LUPRON DEPOT/LUPRON DEPOT-PED | No longer covered | Covered under medical benefit only. |
| NEXIUM 2.5 MG & 5 MG PACKETS | Moving to Tier 3 | omeprazole capsules, esomeprazole packets |
| NYVEPRIA 6 MG/0.6 ML SYRINGES | Moving to Tier 3 | Fulphila, Udenyca |
| PRIMAQUINE 26.3 MG TABLETS (BRAND) | Moving to Tier 3 | primaquine 26.3mg tablets (generic) |
| VICTOZA 2-PAK & 3-PAK PENS | Moving to Tier 3 | liraglutide 2-pak & 3-pak pens |
M1 and M2 Formulary drug list
| Drug name | Description of change | Generic or more cost-effective option |
|---|---|---|
| BETIMOL 0.5% EYE DROPS | No longer covered | timolol 0.5% eye drops |
| ELIGARD SYRINGE KITS | No longer covered | Covered under medical benefit only. |
| HUMIRA (ALL STRENGTHS & DOSAGE FORMS) | No longer covered | adalimumab-adaz, adalimumab-adbm, adalimumab-ryvk, Cyltezo, Simlandi |
| LEUPROLIDE DEPOT | No longer covered | Covered under medical benefit only. |
| LUPRON DEPOT/LUPRON DEPOT-PED | No longer covered | Covered under medical benefit only. |
| MESNEX TABLETS | No longer covered | mesna tablets |
| NYVEPRIA 6 MG/0.6 ML SYRINGES | No longer covered | Fulphila, Udenyca |
| PRADAXA PELLET PACKS | Moving to Tier 2 | dabigatran capsules |
| PRIMAQUINE 26.3 MG TABLETS (BRAND) | No longer covered | primaquine 26.3mg tablets (generic) |
| VICTOZA 2-PAK & 3-PAK PENS | No longer covered | liraglutide 2-pak & 3-pak pens |
M4 Formulary drug list
| Drug name | Description of change | Generic or more cost-effective option |
|---|---|---|
| BETIMOL 0.5% EYE DROPS | No longer covered | timolol 0.5% eye drops |
| ELIGARD SYRINGE KITS | No longer covered | Covered under medical benefit only. |
| HUMIRA (ALL STRENGTHS & DOSAGE FORMS) | No longer covered | adalimumab-adaz, adalimumab-adbm, adalimumab-ryvk, Cyltezo, Simlandi |
| LEUPROLIDE DEPOT | No longer covered | Covered under medical benefit only. |
| LUPRON DEPOT/LUPRON DEPOT-PED | No longer covered | Covered under medical benefit only. |
| MESNEX TABLETS | No longer covered | mesna tablets |
| NYVEPRIA 6 MG/0.6 ML SYRINGES | No longer covered | Fulphila, Udenyca |
| PRADAXA PELLET PACKS | Moving to Tier 4 | dabigatran capsules |
| PRIMAQUINE 26.3 MG TABLETS (BRAND) | No longer covered | primaquine 26.3mg tablets (generic) |
| VICTOZA 2-PAK & 3-PAK PENS | No longer covered | liraglutide 2-pak & 3-pak pens |
Effective April 1, 2025
Effective April 1, 2025
B3 formulary drug list
| Drug name | Description of change | Generic or more cost-effective option |
|---|---|---|
| ANALPRAM HC 2.5%-1% CREAM | Moving to Tier 3 | hydrocortisone/pramoxine 2.5-1% cream |
| SPRYCEL TABLETS | Moving to Tier 3 | dasatinib tablets |
M1 and M2 formulary drug lists
| Drug name | Description of change | Generic or more cost-effective option |
|---|---|---|
| isotretinoin capsules (select NDCs) | No longer covered | Accutane, Amnesteem, Claravis, Zenatane |
| MIPLYFFA CAPSULES | No longer covered | AQNEURSA PACKETS |
| PONVORY TABLETS | No longer covered | fingolimod capsules, dimethyl fumarate capsules |
| SPRYCEL TABLETS | No longer covered | dasatinib tablets |
M4 formulary drug list
| Drug name | Description of change | Generic or more cost-effective option |
|---|---|---|
| isotretinoin capsules (select NDCs) | No longer covered | Accutane, Amnesteem, Claravis, Zenatane |
| MIPLYFFA CAPSULES | No longer covered | AQNEURSA PACKETS |
| PONVORY TABLETS | No longer covered | fingolimod capsules, dimethyl fumarate capsules |
| SPRYCEL TABLETS | No longer covered | dasatinib tablets |
Effective March 1, 2025
No changes
Effective July 1, 2025
Preferred B3 drug list changes
| Drug Name | Description of Change | Cost-effective Alternatives |
| ANDROGEL 1.62% (1.25G) GEL PACKETS | Moving to Tier 3 | testosterone 1.62% (1.25 g) packets |
| BETIMOL 0.5% EYE DROPS | Moving to Tier 3 | timolol 0.5% eye drops |
| ELIGARD SYRINGE KITS | No longer covered | Covered under medical benefit only. |
| HUMIRA (ALL STRENGTHS & DOSAGE FORMS) | Moving to Tier 3 | adalimumab-adaz, adalimumab-adbm, adalimumab-ryvk, Cyltezo, Simlandi |
| HYCODAN 5 MG-1.5 MG/5 ML SOLUTION | Moving to Tier 3 | hydrocodone/homatropine solution, promethazine/codeine syrup, promethazine/DM syrup |
| LEUPROLIDE DEPOT | No longer covered | Covered under medical benefit only. |
| LUPRON DEPOT/LUPRON DEPOT-PED | No longer covered | Covered under medical benefit only. |
| NEXIUM 2.5 MG & 5 MG PACKETS | Moving to Tier 3 | omeprazole capsules, esomeprazole packets |
| NYVEPRIA 6 MG/0.6 ML SYRINGES | Moving to Tier 3 | Fulphila, Udenyca |
| PRIMAQUINE 26.3 MG TABLETS (BRAND) | Moving to Tier 3 | primaquine 26.3mg tablets (generic) |
| VICTOZA 2-PAK & 3-PAK PENS | Moving to Tier 3 | liraglutide 2-pak & 3-pak pens |
M4 drug list changes
| Drug Name | Description of Change | Cost-effective Alternatives |
| BETIMOL 0.5% EYE DROPS | No longer covered | timolol 0.5% eye drops |
| ELIGARD SYRINGE KITS | No longer covered | Covered under medical benefit only. |
| HUMIRA (ALL STRENGTHS & DOSAGE FORMS) | No longer covered | adalimumab-adaz, adalimumab-adbm, adalimumab-ryvk, Cyltezo, Simlandi |
| LEUPROLIDE DEPOT | No longer covered | Covered under medical benefit only. |
| LUPRON DEPOT/LUPRON DEPOT-PED | No longer covered | Covered under medical benefit only. |
| MESNEX TABLETS | No longer covered | mesna tablets |
| NYVEPRIA 6 MG/0.6 ML SYRINGES | No longer covered | Fulphila, Udenyca |
| PRADAXA PELLET PACKS | Moving to Tier 4 | dabigatran capsules |
| PRIMAQUINE 26.3 MG TABLETS (BRAND) | No longer covered | primaquine 26.3mg tablets (generic) |
| VICTOZA 2-PAK & 3-PAK PENS | No longer covered | liraglutide 2-pak & 3-pak pens |
Effective April 1, 2025
B3 formulary drug list (no changes for A1/A2 list)
| Drug name | Description of change | Generic or more cost-effective option |
|---|---|---|
| ANALPRAM-HC 2.5 %-1 % CREAM | Moving to Tier 3 | hydrocortisone-pramoxine 2.5%-1% cream |
| SPRYCEL TABLETS | Moving to Tier 3 | dasatinib tablets |
B4 formulary drug list
| Drug name | Description of change | Generic or more cost-effective option |
|---|---|---|
| ANALPRAM HC 2.5%-1% CREAM | Moving to Tier 3 | hydrocortisone/pramoxine 2.5-1% cream |
Effective March 1, 2025
No changes
*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.