Commercial Pharmacy Formulary Changes effective October 1, 2018 • Changes apply to both Tufts Health Plan and Tufts Health Freedom Plan members • Affected members were notified of the changes by mail Oral Chemo Brands to Non-Covered (Large Commercial Formularies) We will no longer cover these brand oral cancer medications for which a generic alternative is available. Alkeran tablets Hydrea capsule Arimidex tablets Nilandron tablet Aromasin tablets Targretin capsule Casodex tablets Temodar capsule Femara tablets Xeloda tablet Gleevec tablets Brands to Non-Covered (Large Commercial Formularies) Tier Of Covered Brand Drugs Moving to Not Covered Covered Lower Tier Alternative Drug* Alternative Aldara® cream imiquimod cream Tier 1 Bactroban® cream mupirocin cream Tier 1 Biltricide® tablets praziquantel tablets Tier 2 Celebrex® capsules celecoxib capsules Tier 2 Condylox® solution podofilox solution Tier 1 Gabitri® 12 mg, 16mg tablets tiagabine 12mg and 16 mg tablets Tier 2 Mephyton® tablets phytonadione tablets Tier 2 Natroba™ suspension spinosad suspension Tier 1 Ovide® lotion malathion lotion Tier 1 Pennsaid® 2% solution diclofenac sodium solution Tier 1 Prevacid® SolutabTM orally lansoprazole soluble tablets Tier 3, PA disintegrating tablets omeprazole capsules Tier 2 Viroptic® solution trifluridine solution Tier 2 Welchol® tablets colesevelam tablets Tier 2 Zavesca® capsules Cerdelga® capsules Tier 2 Zovirax® 5% ointment acyclovir ointment Tier 1 *Covered lower tier alternative may be the generic for the referenced brand or may be a therapeutic alternative Drugs Excluded from Coverage (All Commercial Formularies) Donnatal® elixir Duexis® Nucort® lotion Scar management gels Vimovo® Drugs Moving to Tier 4 (All Commercial Formularies) Bethkis nebulizer solution Prevymis tablets Cayston inhalation solution Pulmozyme inhalation solution CellCept capsules, suspension, and tablets Rapamune solution and tablets etoposide capsules tobramycin nebulizer solution glatiramer syringes Tobi nebulizer solution Kalydeco oral granules and tablets Tobi Podhaler inhalation solution Kitabis Pak inhalation solution Xermelo tablets Orkambi tablets Zortress tablets Drugs Moving to a Higher Tier (All Commercial Formularies) Tier of Drug(s) Moving to Tier 3 Lower Tier Alternative Drug(s) Alternative Drug(s) Claravis® capsules N/A N/A ketoconazole 2% foam ketoconazole 2% cream Tier 1 Norvir® capsules ritonavir tablets Tier 2 Tier of Drug(s) Moving to Tier 2 Lower Tier Alternative Drug(s) Alternative Drug(s) acyclovir 5% ointment Podofilox 0.5% solution Tier 1 ciclopirox 1% shampoo ciclopirox 0.77% gel Tier 1 clotrimazole/betamethasone 1%-0.05% clotrimazole/betamethasone 1%-0.05% cream Tier 1 lotion fenofibrate 130 mg capsules fenofibrate micronized capsules Tier 1 malathion 0.5% lotion permethrin 5% cream Tier 1 mupirocin 2% cream mupirocin 2% ointment Tier 1 spinosad 0.9% suspension lindane 1% shampoo Tier 1 Drugs Added to Specialty Pharmacy Program (excluding RI) CerdelgaTM (eliglustat) Ofev® (nintedanib) .