2024 Medicare and MMP Formulary Changes

Date: 12/21/23

On January 1, 2024, some drugs will no longer be covered on our Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) or Medicare Part D Plan formulary(ies). To assist our providers, we have included the list below of the most commonly prescribed drugs being removed along with the drug’s 2024 formulary alternative(s).

Please refer to the list to identify the appropriate options for your patients.

Product Name	Formulary Alternative
Lantus vial, Lantus SoloStar	Basaglar KwikPen, Toujeo SoloStar, Toujeo Max SoloStar, Tresiba vial, Tresiba FlexTouch
Levemir vial, Levemir FlexPen	Basaglar KwikPen, Toujeo SoloStar, Toujeo Max SoloStar, Tresiba vial, Tresiba FlexTouch
Victoza pen injector	Bydureon Bcise auto-injector, Mounjaro pen injector, Ozempic pen injector, Rybelsus tablet, Trulicity pen injector*
Byetta pen injector	Bydureon Bcise auto-injector, Mounjaro pen injector, Ozempic pen injector, Rybelsus tablet, Trulicity pen injector*
Flovent Diskus, Flovent HFA inhaler (Discontinued by manufacturer)	Arnuity Ellipta, Pulmicort Flexhaler
Kevzara pen injector, Kevzara syringe	Diagnosis dependent: Enbrel injection, Humira injection, Rinvoq tablet, Xeljanz tablet, Xeljanz XR tablet*
Ingrezza capsule	Austedo tablet, Tetrabenazine tablet
Betoptic-S suspension eye drops	Alphagan P 0.1% eye drops, Brimonidine Tartrate eye drops, Combigan eye drops

*Prior authorization required.

If you determine that it is necessary for your patient to continue to receive the non-formulary drug in 2023, you will need to submit a Coverage Determination request on or after December 15, 2023.

Request forms are located on our websites below:

You can call 1-800-867-6564 (TTY: 711) to request authorization.