Pending changes to the approved drug list

Page last updated on: 6/30/25

From time to time, we add or remove drugs from the approved drug list (formulary). We also may change their tier, which determines how much you pay for them. We make these changes based on the scientific evidence we have of their value in helping people get well and stay healthy.

If you are taking a drug that is being removed

If we remove drugs from the formulary during the year, we'll notify you of the change at least 30 days before the date that the change becomes effective. The exceptions to this 30-day notice are when the FDA decides a drug is not safe, or if a drug manufacturer removes the drug from the market.

We may also immediately remove a brand name drug if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provider you with information about the specific change(s) we have made.

You may ask Priority Health to make an exception for you so you can continue taking a drug that's removed from the formulary. We must make a decision within 72 hours of your request. Contact Customer Service to make these requests.

Learn more about asking for an exception.

Current and pending changes to the 2025 approved drug list

KEY:

  • ALL CAPS = Brand names
  • Lower case = Generic
  • B/D = Coverage varies under Medicare Part B (medical) vs. Part D (prescription) benefits
  • HI = Home infusion drug
  • LA = Limited availability (available only at certain pharmacies)
  • PA = Prior authorization from Priority Health is required
  • QL = Quantity limits apply
  • ST = Step therapy, trying other drugs first is required

Additions effective July 1, 2025

Drug NameTierCategory: ClassNotes
EDURANT® PED TAB FOR SUSP 2.5 MG5Antivirals: Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)QL (180 EA per 30 days)
ELIGARD® SUBCUTANEOUS KIT 22.5 MG4Hormonal Agents, Suppressant (Pituitary) 
emtricitab-rilpivir-tenofov dr tablet 200-25-300 mg5Antivirals: Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)QL (30 EA per 30 days)
perampanel tablet 2 mg4Anticonvulsants: Anticonvulsants, OtherPA, QL (30 EA per 30 days)
perampanel tablet 4 mg, 6 mg, 8 mg, 10 mg, 12 mg5Anticonvulsants: Anticonvulsants, OtherPA, QL (30 EA per 30 days)

Additions effective June 1, 2025

Drug NameTierCategory: ClassNotes
eltrombopag packet 12.5 mg5Blood Products And Modifiers: Blood Products And Modifiers, OtherPA, QL (30 EA per 30 days), LA
eltrombopag packet 25 mg5Blood Products And Modifiers: Blood Products And Modifiers, OtherPA, QL (180 EA per 30 days), LA
eltrombopag tablet 12.5 mg, 25 mg5Blood Products And Modifiers: Blood Products And Modifiers, OtherPA, QL (30 EA per 30 days), LA
eltrombopag tablet 50 mg, 75 mg5Blood Products And Modifiers: Blood Products And Modifiers, OtherPA, QL (60 EA per 30 days), LA
eslicarbazepine tablet 200 mg, 400 mg5Anticonvulsants: Sodium Channel AgentsPA, QL (30 EA per 30 days)
eslicarbazepine tablet 600 mg, 800 mg5Anticonvulsants: Sodium Channel AgentsPA, QL (60 EA per 30 days)
EULEXIN™ CAPSULE 125 MG5Antineoplastics: AntiandrogensPA
LEUKERAN® TABLET 2 MG5Antineoplastics: Alkylating Agents
NATACYN® EYE DROPS 5%4Ophthalmic Agents: Ophthalmic Anti-infectives
RALDESY™ ORAL SOLUTION 10 MG/ML5Antidepressants: SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin And Norepinephrine Reuptake Inhibitors)PA, QL (1200 ML per 30 days)
TABLOID® TABLET 40 MG4Antineoplastics: Antimetabolites
VIMKUNYA™ SYRINGE 40 MCG/0.8 ML3Immunological Agents: VaccinesQL (1 EA per 365 days)

Additions effective May 1, 2025

Drug NameTierCategory: ClassNotes
amnesteem® oral capsule 30mg3Dermatological Agents: Acne and Rosacea Agents

octreotide acetate er 10mg im vial5Hormonal Agents, Suppressant (Pituitary)

tridacaine™ ii patch 5%3Anesthetics: Local AnestheticsPA, QL (90 EA per 30 days)
tridacaine™ iii patch 5%3Anesthetics: Local AnestheticsPA, QL (90 EA per 30 days)
tridcaine™ xl patch 5%3Anesthetics: Local AnestheticsPA, QL (90 EA per 30 days)
TRYNGOLZA™ AUTOINJECTOR 80 MG/0.8 ML5Cardiovascular Agents: Cardiovascular Agents, OtherPA, QL (0.8 ml per 30 days)
VIVOTIF® DELAYED RELEASE ORAL CAPSULE3Immunological Agents: VaccinesQL (4 EA per 720 days)

Additions effective Apr. 1, 2025

Drug NameTierCategory: ClassNotes
abirtega tablet 250 mg5Antineoplastics: AntiandrogensPA, QL (120 EA per 30 days)
EVRYSDI® ORAL TABLET 5 MG5Central Nervous System Agents: Central Nervous System, OtherPA, QL (30 EA per 30 days)
GOMEKLI™ ORAL CAPSULE 1 MG, 2 MG5Antineoplastics: Molecular Target InhibitorsPA
GOMEKLI™ TABLET FOR ORAL SUSPENSION 1 MG5Antineoplastics: Molecular Target InhibitorsPA
mercaptopurine oral suspension 20 mg/ml5Antineoplastics: AntimetabolitesPA
REVUFORJ® TABLET 25 MG5Antineoplastics: Molecular Target InhibitorsPA, QL (240 EA per 30 days)
SELARSDI™ SRYINGE 90 MG/ML5Immunological Agents: Immunological Agents, OtherPA, QL (1 ML per 28 days)
XPOVIO® (40 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 40 MG5Antineoplastics: Antineoplastics, OtherPA, QL (16 EA per 28 days)
YESINTEK™ SRYINGE 90 MG/ML5Immunological Agents: Immunological Agents, OtherPA, QL (1 ML per 28 days)

Additions effective Mar. 1, 2025

Drug NameTierCategory: ClassNotes
IMKELDI ORAL SOLUTION 80 MG/ML5Antineoplastics: Molecular Target InhibitorsPA, QL (280 ML per 28 days)

Additions effective Feb. 1, 2025

Drug NameTierCategory: ClassNotes
adalimumab-adaz subcutaneous solution pen 80 mg/0.8 ml5Immunological Agents: ImmunosuppressantsPA, QL (3.2 ML per 28 days)
DANZITEN™5Antineoplastics: Molecular Target InhibitorsPA, QL (112 EA per 28 days)
hydrocodone-acetaminophen tablet 2.5-325 mg4Analgesics: Opioid Analgesics, Short-actingQL (360 EA per 30 days)
IQIRVO®5Gastrointestinal Agents: Gastrointestinal Agents, OtherPA, QL (30 EA per 30 days)
ITOVEBI™ TABLET 3 MG5Antineoplastics: Molecular Target InhibitorsPA, QL (56 EA per 28 days)
ITOVEBI™ TABLET 9 MG5Antineoplastics: Molecular Target InhibitorsPA, QL (28 EA per 28 days)
LIVDELZI®5Gastrointestinal Agents: Gastrointestinal Agents, OtherPA, QL (30 EA per 30 days)
mesna tablet 400mg5Antineoplastics: Treatment Adjuncts 
NP THYROID®4Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) 
OPIPZA™ FILM 10 MG5Antipsychotics: 2nd Generation, AtypicalPA, QL (90 EA per 30 days)
OPIPZA™ FILM 2 MG5Antipsychotics: 2nd Generation, AtypicalPA, QL (30 EA per 30 days)
OPIPZA™ FILM 5 MG5Antipsychotics: 2nd Generation, AtypicalPA, QL (120 EA per 30 days)
PREVYMIS® PELLET PACKET 120 MG, 20 MG5Antivirals: Anti-Cytomegalovirus (CMV) AgentsPA, QL (120 EA per 30 days)
REVUFORJ®5Antineoplastics: Molecular Target InhibitorsPA
YORVIPATH® PEN 168 MCG/0.56 ML5Metabolic Bone Disease AgentsPA, QL (1.12 ML per 30 days)
YORVIPATH® PEN 294 MCG/0.98 ML5Metabolic Bone Disease AgentsPA, QL (1.96 ML per 30 days)
YORVIPATH® PEN 420 MCG/1.4 ML5Metabolic Bone Disease AgentsPA, QL (2.8 ML per 30 days)

Changes/removals from the approved drug list

Changes/removals effective July 1, 2025

Drug NameTierNotes
CORLANOR® ORAL SOLUTION4Removed Prior Authorization
ivabradine hcl4Removed Prior Authorization
LIBERVANT®5Removed from CMS's reference file; removed from formulary
PROLIA® SUBCUTANEOUS SOLUTION PREFILLED SYRINGE4Removed Prior Authorization

Changes/removals effective June 1, 2025

Drug NameTierNotes
PURIXAN® ORAL SUSPENSION 2000 MG/100ML5Removed brand from formulary; generic added

Changes/removals effective May 1, 2025

Drug NameTierNotes
amoxicillin/clavulante chewable tablet 400 mg/ 57 mg2Removed from CMS's reference file; removed from formulary
ampicillin injection 125mg4Removed from CMS's reference file; removed from formulary
SANDOSTATIN® LAR DEPOT INTRAMUSCULAR KIT 10 MG5Removed brand from formulary; generic added

Changes/removals effective Apr. 1, 2025

Drug NameTierNotes
AUGTYRO™ ORAL CAPSULE 40 MG5Decreased quantity limit to 180 EA per 30 days
AUSTEDO® XR ORAL TABLET EXTENDED RELEASE 12 MG5Decreased quantity limit to 30 EA per 30 days
AUSTEDO® XR ORAL TABLET EXTENDED RELEASE 24 MG5Decreased quantity limit to 30 EA per 30 days
MESNEX® ORAL TABLET 400 MG5Removed brand from formulary; generic added
NURTECT® ODT TABLET DISPERSIBLE 75 MG3Added quantity limit of 18 EA per 30 days
RETEVMO® ORAL CAPSULE 40 MG5Decreased quantity limit to 90 EA per 30 days
RETEVMO® ORAL CAPSULE 80 MG5Decreased quantity limit to 60 EA per 30 days
SCEMBLIX® ORAL TABLET 40MG5Decreased quantity limit to 240 EA per 30 days
UPTRAVI® ORAL TABLET 200 MCG5Increased quantity limit to 140 EA per 28 days

Changes/removals effective Mar. 1, 2025

Drug NameTierNotes
methylphenidate hcl er oral tablet extended release 24 hour 36 mg4Increased quantity limit to 60 per 30 days
PREHEVBRIO3Removed from CMS's reference file; removed from formulary - discontinued by manufacturer
DROXIA® ORAL CAPSULE 200 MG, 300 MG, 400 MG3Removed from CMS's reference file; removed from formulary - discontinued by manufacturer
phenytoin sodium extended oral capsule 200 mg, 300 mg2Removed from CMS's reference file; removed from formulary - other strengths available


Changes/removals effective Feb. 1, 2025

Drug NameTierNotes
amethia™ oral tablet 0.15-0.03 & 0.01 mg
2Removed from CMS's reference file; alternatives available on formulary
APRETUDE INTRAMUSCULAR SUSPENSION EXTENDED RELEASE 600 MG/3ML5Removed from formulary. No longer payable under Part D.
azithromycin oral packet 1 gm2Removed from CMS's reference file; other dosing available
diphtheria-tetanus toxoids dt intramuscular suspension 25-5 lfu/0.5ml3Removed from CMS's reference file; removed from formulary - discontinued by manufacturer
ENTADFI™ ORAL CAPSULE 5-5 MG4Removed from CMS's reference file; removed from formulary - discontinued by manufacturer
fentanyl citrate lozenge on a handle4, 5Removed from CMS's reference file; removed from formulary - obsolete
HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML3Removed from formulary. No longer payable under Part D.
levofloxacin ophthalmic solution 0.5 %2Removed from CMS's reference file; alternatives available on formulary
methylphenidate hcl er (osm) oral tablet extended release 36 mg4Increased quantity limit to 60 per 30 days
MICROGESTIN® 24 FE ORAL TABLET 1-20 MG-MCG4Removed from CMS's reference file; off market
naloxone hcl nasal liquid 4 mg/0.1ml3Removed from CMS's reference file; removed from formulary - obsolete
nymyo™ oral tablet 0.25-35 mg-mcg2Removed from CMS's reference file; alternatives available on formulary
roflumilast4Removed prior authorization requirement
SPRYCEL®5Removed brand from formulary; generic added
travoprost (bak free) ophthalmic solution 0.004 %3Lowered tier
TRIDERM® EXTERNAL CREAM 0.1 %3Removed from CMS's reference file; alternatives available on formulary
tri-nymyo™ oral tablet 0.18/0.215/0.25 mg-35 mcg2Removed from CMS's reference file; off market
TYVASO DPI™ MAINTENANCE KIT INHALATION POWDER 112 X 32MCG & 112 X48MCG5Removed from CMS's reference file; removed from formulary - obsolete

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