The information below is effective 1 de julho, 2021 and applies to all commercial employer groups that are assigned to the Net Results Plus formulary. All changes to this list are the result of a comprehensive review of relevant clinical information by the Prime Therapeutics National Pharmacy and Therapeutics Committee.

Brand name drugs available with generic equivalents (Excluded from coverage)

For application across all commercial formularies, the following brand name drugs are now available with generic equivalents, and as a result the brand name will be excluded from coverage effective 1 de julho, 2021. The generic equivalent will continue to be covered.

Alinia                                      Hycodan                                 Taytulla

Atripla                                     Kuvan                                     Timoptic Ocudose

Banzel                                     Monurol                                  Timoptic-XE

Bethkis                                    Sklice                                      Tytkerb

Ferriprox                                 Taclonex

Brand name and generic drugs with available alternatives (Excluded from coverage)

The following generic and brand name drugs with preferred alternatives will be excluded from coverage effective 1 de julho, 2021. Requests for coverage will require documented medical necessity.

Calcipotriene/betamethasone              Dipropionate doxepin hydrochloride

Tier changes

The following products have been moved to a higher copay tier effective 1 de julho, 2021. These changes generally involve a change to the next higher copay tier. There are some products that will have a change of more than one higher tier change related to formulary design – these products are designated with an asterisk.

FLURBIPROFEN*                                        PRIMLEV*   

HYDROCORTISONE BUTYRATE*           PROLATE* PYRAZINAMIDE*                 

NALOCET*                                                   PYRAZINAMIDE*

OXYCODONE/ACETAMINOPHEN*         TYBUME*

Prior authorization

The following products will require prior authorization (medical necessity) review before coverage is allowed, effective 1 de julho, 2021.

Xhance                                    Sucraid

Quantity limits

The following products will have quantity limits per dispensing, effective 1 de julho, 2021.

ELIQUIS 5mg                                    MEPERIDINE 50mg/5ml

MEPERIDINE 100mg                       MEPERIDINE 50mg/5ml