Pending changes to the approved drug list
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 60 days before the date that the change becomes effective. The exceptions to this 60-day notice are when the FDA decides a drug is not safe, or if a drug manufacturer removes the drug from the market.
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 2019 approved drug list
- Jump down to Changes to/removals from the approved drug list
Additions to the formulary
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 August 1, 2019 |
|||
|---|---|---|---|
| Drug name | Tier | Category | Notes |
| KALYDECO® ORAL PACKET 25MG | 5 | Respiratory tract/Pulmonary agents: Cystic fibrosis agents | PA |
| INGREZZA® THERAPY PACK | 5 | Central nervous system agents | PA |
Additions effective July 1, 2019 |
|||
| Drug name | Tier | Category | Notes |
| loteprednol etabonate suspension 0.5% | 4 | Ophthalmic agents: Anti-inflammatories | |
| MAYZENT® 0.25mg | 5 | Central nervous system agents: Multiple sclerosis agents | QL (120 EA per 30 days) |
| MAYZENT® 2mg | 5 | Central nervous system agents: Multiple sclerosis agents | QL (30 EA per 30 days) |
| mesalamine dr tablet 400mg | 3 | Inflammatory bowel disease agents: Aminosalicylates | |
| niacin tablet 500mg | 2 | Electrolytes/Minerals/Metals/Vitamins: Vitamins | |
| SKYRIZI™ | 5 | Dermatological agents | PA, QL (2 EA per 84 days) |
| solifenacin | 3 | Genitourinary agents: Antispasmodics, urinary | |
Additions effective June 1, 2019 |
|||
| Drug name | Tier | Category | Notes |
| DOVATO® | 5 | Antivirals: Anti-HIV agents, Integrase Inhibitors (INSTI) | QL (30 each per 30 days) |
| NIVESTYM™ INJECTION SOLUTION | 5 | Blood products/Modifiers/Volume expanders: Blood formation modifiers | PA |
| PROGRAF® PACKET FOR SUSPENSION | 4 | Immunological agents: Immune suppressants | B/D |
Additions effective May 1, 2019 |
|||
| Drug name | Tier | Category | Notes |
| buprenorphine hcl-naloxone hcl sublingual film 2-0.5mg | 4 | Anti-addiction/Substance abuse treatment agents: Opioid dependence treatments | QL (90 each per 30 days) |
| FIRDAPSE® | 5 | Miscellaneous therapeutic agents | PA, QL (240 each per 30 days) |
| TIROSINT™ ORAL SOLUTION | 4 | Hormonal agents, stimulant/Replacement/Modifying (thyroid) | |
| toremifene citrate 60mg | 5 | Antineoplastics: Antiestrogens/Modifiers | |
| TRESIBA® SOLUTION | 4 | Blood glucose regulators: Insulins | |
| vigadrone pack 500mg | 5 | Anticonvulsants: Gamma-aminobutyric acid (Gaba) augmenting agents | LA |
Additions effective April 1, 2019 |
|||
| Drug name | Tier | Category | Notes |
| ARIKAYCE® | 5 | Antibacterials: Aminoglycosides | PA; QL (235.2ml per 28 days) |
| buprenorphine HCl-naloxone HCl sublingual film 12mg-3mg | 4 | Anti-addiction/Substance abuse treatment agents: Opioid dependence treatments | PA; QL (60 ea. per 30 days) |
| buprenorphine HCl-naloxone HCl sublingual film 4mg-1mg, 8mg-2mg | 4 | Anti-addiction/Substance abuse treatment agents: Opioid dependence treatments | PA; QL (90 ea. per 30 days) |
| ifosfamide intravenous solution reconstituted 3 gm | 2 | Antineoplastics: Alkylating agents | B/D |
| nevirapine oral suspension | 4 | Antivirals: Anti-HIV agents, Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI) | QL (1200ml per 30 days) |
| PROMACTA® PACK 12.5mg | 5 | Blood products/Modifiers/Volume expanders: Blood formation modifiers | PA; LA |
| REVCOVI™ | 5 | Genetic or enzyme disorder: Replacement, modifiers, treatment: Genetic or enzyme disorder: Replacement, modifiers, treatment | PA |
| sirolimus solution 1mg/ml | 5 | Immunological agents: Immune suppressants | |
| SYMPAZAN™ | 5 | Anticonvulsants: Gamma-aminobutyric Acid (GABA) augmenting agents | PA; QL (60 ea. per 30 days) |
| toremifene citrate 60mg | 5 | Antineoplastics: Antiestrogens/Modifiers | |
| XOFLUZA™ | 4 | Antivirals: Anti-influenza agents | QL (2 ea. per 365 days) |
| XYOSTED™ | 4 | Hormonal agents, stimulant/Replacement/Modifying (Sex hormones/Modifiers): Androgens | PA |
Additions effective March 1, 2019 |
|||
| Drug name | Tier | Category | Notes |
| abiraterone acetate oral tablet 250mg |
5 | Antineoplastics: Antineoplastics, other | PA |
| ACTEMRA® ACTPEN |
4 | Immunological agents: Immunomodulators | PA; QL (3.6ml per 28 days) |
| cinacalcet HCl tablet 30mg | 3 | Metabolic bone disease agents: Metabolic bone disease agents | B/D; QL (60 ea. per 30 days) |
| cinacalcet HCl tablet 60mg |
5 | Metabolic bone disease agents: Metabolic bone disease agents |
B/D; QL (60 ea. per 30 days) |
| cinacalcet HCl tablet 90mg |
5 | Metabolic bone disease agents: Metabolic bone disease agents |
B/D; QL (120 ea. per 30 days) |
| clobazam oral tablet 10mg |
4 | Anticonvulsants: Gamma-aminobutyric acid (Gaba) augmenting agents |
PA; QL (60 ea. per 30 days) |
| INVELTYS™ |
4 | Ophthalmic agents: Ophthalmic anti-inflammatories |
|
| mesalamine rectal suppository 1000mg |
4 | Inflammatory bowel disease agents: Aminosalicylates |
|
| OXERVATE™ |
5 | Ophthalmic agents: Ophthalmic agents, other |
PA |
| pimecrolimus cream 1% |
3 | Dermatological agents: Dermatological agents |
|
| TIROSINT® oral capsule 175mcg, 200mcg | 4 | Hormonal agents, stimulant/replacement/modifying (thyroid): Hormonal agents, stimulant/replacement/modifying (thyroid) |
|
| tramadol ER tablet 300mg |
2 | Analgesics: Opioid analgesics, long-acting |
QL (30 ea. per 30 days) |
| UDENYCA™ |
5 | Blood products/modifiers/volume expanders: Blood formation modifiers |
|
| vigabatrin tablet 500mg |
5 | Anticonvulsants: Gamma-aminobutyric acid (Gaba) augmenting agents |
LA |
| XELPROS™ |
3 | Ophthalmic agents: Ophthalmic prostaglandin and prostamide analogs |
|
| XOSPATA® tablet 40mg |
5 | Antineoplastics: Molecular targetinhibitors |
PA |
Additions effective February 1, 2019 |
|||
| Drug name | Tier | Category | Notes |
| ABILIFY MYCITE® | 5 | Antipsychotics: 2nd generation/atypical | PA, QL (30 ea. per 30 days) |
| albendazole tablet, 200mg | 3 | Antiparasitics: Anthelmintics | |
| amabelz™ | 2 | Hormonal agents, stimulant/replacement/modifying (Sex hormones/modifiers): Estrogens | |
| amnesteem®, 10mg, 20mg, 40mg | 2 | Dermatological agents: Dermatological agents | |
| azelaic acid topical gel, 0.15mg/mg | 4 | Dermatological agents: Dermatological agents | |
| bleomycin sulfate, 15 unit | 2 | Antineoplastics: Antineoplastics, other | B/D |
| BRAFTOVI™ | 5 | Antineoplastics: Antineoplastics, other | PA |
| bupropion HCl ER tablet, 450mg | 4 | Antidepressants: Antidepressants, other | |
| cefazolin sodium, 10gm | 2 | Antibacterials: Beta-lactam, cephalosporins | HI |
| clobazam suspension, 2.5mg/ml | 5 | Anticonvulsants:Gamma-amniobutyric acid (GABA) augmenting agents | PA |
| clobazam tablet, 20mg | 5 | Anticonvulsants: Gamma-amniobutyric acid (GABA) augmenting agents | PA, QL (60 ea. per 30 days) |
| clobetasol topical cream, 0.05% | 2 | Hormonal agents, stimulant/replacement/modifying (adrenal): Hormonal agents, stimulant/replacement/modifying (adrenal) | |
| colesevelam HCl pack, 3.75gm | 4 | Cardiovascular agents: Dislipidemics, other | |
| COPIKTRA™ | 5 | Antineoplastics: Antineoplastics, other | PA, QL (60 ea. per 30 days) |
| dacarbazine vial, 100mg | 2 | Antineoplastics: Alkylating agents | B/D |
| dalfampridine ER tablet | 5 | Central nervous system agents: Multiple sclerosis agents | PA |
| daptomycin intravenous solution, reconstituted, 350mg | 5 | Antibacterials: Antibacterials, other | HI |
| DAURISMO™ | 5 | Antineoplastics: Antineoplastics, other | PA |
| DELSTRIGO™ | 5 | Antivirals: Anti-HIV agents, integrase inhibitors (INSTI) | QL (30 ea. per 30 days) |
| desoximetasone topical spray, 0.25% | 4 | Hormonal agents, stimulant/replacement/modifying (adrenal): Hormonal agents, stimulant/replacement/modifying (adrenal) | ST |
| dexamethasone dose pack, 10-day | 4 | Hormonal agents, stimulant/replacement/modifying (adrenal): Hormonal agents, stimulant/replacement/modifying (adrenal) | |
| dexamethasone dose pack, 13-day | 4 | Hormonal agents, stimulant/replacement/modifying (adrenal): Hormonal agents, stimulant/replacement/modifying (adrenal) | |
| dexamethasone dose pack, 6-day | 4 | Hormonal agents, stimulant/replacement/modifying (adrenal): Hormonal agents, stimulant/replacement/modifying (adrenal) | |
| dorzolamide HCl/timolol maleate, preservative free | 2 | Ophthalmic agents: Ophthalmic antiglaucoma agents | |
| doxycycline hyclate tablet, 75mg, 150mg | 2 | Antibacterials: Tetracyclines | |
| DUPIXENT®, 200mg/1.14ml | 5 | Dermatological agents: Dermatological agents | PA |
| EPIDIOLEX® | 5 | Anticonvulsants: Anticonvulsants, other | PA, QL (200ml per 30 days) |
| erythromycin ethylsuccinate suspension, 200mg/5ml | 2 | Antibacterials: Macrolides | |
| ethynodiol diacetate/ethinyl estradiol, 50mcg; 1mg | 2 | Hormonal agents, stimulant/replacement/modifying (Sex hormones/modifiers): Estrogens | |
| GALAFOLD™ | 5 | Genetic or enzyme disorder; replacement, modifiers, treatment: Genetic or enzyme disorder; replacement, modifiers, treatment | PA, QL (14 ea. per 28 days) |
| GRANIX®, 300mcg/ml, 480mcg/1.6ml | 5 | Blood products/modifiers/volume expanders: Blood formation modifiers | |
| hydrocortisone butyrate lotion, 0.1% | 2 | Hormonal agents, stimulant/replacement/modifying (adrenal): Hormonal agents, stimulant/replacement/modifying (adrenal) | |
| ibuprophen, 600mg, 800mg | 1 | Analgesics: Nonsteroidal anti-inflammatory drugs | |
| imiquimod pump | 5 | Dermatological agents: Dermatological agents | |
| isotretinoin capsule, 10mg, 20mg, 40mg | 2 | Dermatological agents: Dermatological agents | |
| kelnor®, 1-50 | 2 | Hormonal agents, stimulant/replacement/modifying (Sex hormones/modifiers): Estrogens | |
| ketoprofen capsule, 25mg | 2 | Analgesics: Nonsteroidal anti-inflammatory drugs | |
| KEVZARA® auto-injector | 5 | Immunological agents: Immunomodulators | PA, QL (2.28ml per 28 days) |
| klor-con packet, 20meq | 2 | Electrolytes/minerals/metals/vitamins: Electrolyte/mineral replacement | |
| lactulose pack, 10gm | 5 | Gastrointestinal agents: Laxatives | |
| LENVIMA®, 12mg daily dose | 5 | Antineoplastics: Molecular target inhibitors | PA, QL (90 ea. per 30 days), LA |
| LENVIMA® 4mg daily dose | 5 | Antineoplastics: Molecular target inhibitors | PA, QL (30 ea. per 30 days), LA |
| LORBRENA® | 5 | Antineoplastics: Antineoplastics, other | PA |
| MEKTOVI® | 5 | Antineoplastics: Antineoplastics, other | PA |
| melodetta™ 24 FE | 2 | Hormonal agents, stimulant/replacement/modifying (Sex hormones/modifiers): Estrogens | |
| melphalan tablet, 2mg | 2 | Antineoplastics: Alkylating agents | |
| memantine HCl ER, 7mg, 14mg | 2 | Antidementia agents: N-methyl-D-aspartate (NMDA) receptor antagonist | QL (30 ea. per 30 days) |
| methylphenidate HCl ER caps, 20mg, 30mg | 2 | Central nervous system agents: Attention deficit hyperactivity disorder agents, non-amphetamines | QL (30 ea. per 30 days) |
| molindone HCl | 3 | Antipsychotics: 1st generation/typical | QL (120 ea. per 30 days) |
| morgidox® capsule, 50mg, 100mg | 2 | Antibacterials: Tetracyclines | |
| nafcillin injection, 2000mg | 2 | Antibacterials: Beta-lactam, penicillins | |
| nifedipine ER tablet, 30mg, 60mg | 2 | Cardiovascular agents: Calcium channel blocking agents | |
| NIVESTYM™ | 5 | Blood products/modifiers/volume expanders: Blood formation modifiers | PA |
| norethindrone acetate/ethinyl estradiol, 20mcg; 1mg | 2 | Hormonal agents, stimulant/replacement/modifying (Sex hormones/modifiers): Estrogens | |
| norethindrone acetate/ethinyl estradiol, 20mcg; 75mg; 1mg | 2 | Hormonal agents, stimulant/replacement/modifying (Sex hormones/modifiers): Estrogens | |
| norethindrone/ethinyl estradiol/ferrous fumarate, 35mcg; 0; 0.4mg | 2 | Hormonal agents, stimulant/replacement/modifying (Sex hormones/modifiers): Estrogens | |
| norgestimate/ethinyl estradiol | 2 | Hormonal agents, stimulant/replacement/modifying (Sex hormones/modifiers): Estrogens | |
| norgestimate/ethinyl estradiol, 35mcg; 0.25mg | 2 | Hormonal agents, stimulant/replacement/modifying (Sex hormones/modifiers): Estrogens | |
| NUPLAZID®, 10mg, 24mg | 5 | Antipsychotics: 2nd generation/atypical | PA |
| OLUMIANT® | 5 | Immunological agents: Immunomodulators | PA |
| ORKAMBI® pack | 5 | Respiratory tract/pulmonary agents: Brochodilators, sympathomimetic | PA, QL (120 ea. per 30 days) |
| PANZYGA® | 5 | Immunological agents: Immunizing agents, passive | PA |
| PERSERIS™ | 5 | Antipsychotics: 2nd generation/atypical | PA, QL (1 ea. per 28 days) |
| PIFELTRO™ | 5 | Antivirals: Anti-HIV agents, non-nucleoside reverse transcriptase inhibitors (NNRTI) | QL (30 ea. per 30 days) |
| piperacillin/tazobactam, 2gm; 0.25gm | 2 | Antibacterials: Beta-lactam, penicillins | HI |
| POTELIGEO® | 5 | Antineoplastics: Monoclonal antibody/antibody-drug conjugate | B/D |
| procto-med hc™ | 2 | Anti-inflammatory agents: Glucorticoids | |
| profeno® tablet, 600mg | 2 | Analgesics: Nonsteroidal anti-inflammatory drugs | |
| RETACRIT™ | 4 | Blood products/modifiers/volume expanders: Hemostasis agents | B/D |
| SIGNIFOR® LAR | 5 | Hormonal agents, suppressant (pituitary): Hormonal agents, suppressant (pituitary) | PA, QL (1 ea. per 28 days) |
| silodosin | 3 | Genitourinary agents: Benign prostatic hypertrophy agents | |
| sotalol hydrochloride tablet, 120mg | 2 | Cardiovascular agents: Antiarrhythmics | |
| ssd™ cream, 1% | 2 | Antibacterials: Antibacterials, other | |
| sulfatrim™ pediatric suspension | 2 | Antibacterials: Sulfonamides | |
| syeda™ | 2 | Hormonal agents, stimulant/replacement/modifying (Sex hormones/modifiers): Estrogens | |
| SYMTUZA™ | 5 | Antivirals: Anti-HIV agents, protease inhibitors | QL (30 ea. per 30 days) |
| tadalafil (pulmonary arterial hypertension) tablet, 20mg | 5 | Respiratory tract/pulmonary agents: Pulmonary antihypertensives | PA |
| tadalafil tablet, 2.5mg, 5mg | 4 | Genitourinary agents: Benign prostatic hypertrophy agents | PA, QL (30 ea. per 30 days) |
| TAKHZYRO™ | 5 | Cardiovascular agents: Cardiovascular agents, other | PA |
| TALZENNA™ | 5 | Antineoplastics: Antineoplastics, other | PA, QL (30 ea. per 30 days), LA |
| temsirolimus, 25mg/ml | 5 | Antineoplastics: Molecular target inhibitors | PA |
| testosterone topical gel, 1.62% | 4 | Hormonal agents, stimulant/replacement/modifying (Sex hormones/modifiers): Androgens | PA |
| testosterone topical gel, 40.5mg/2.5gm, 20.25mg/1.25gm | 4 | Hormonal agents, stimulant/replacement/modifying (Sex hormones/modifiers): Androgens | PA |
| TIBSOVO® | 5 | Antineoplastics: Molecular target inhibitors | PA |
| trientine HCl capsule, 250mg | 2 | Electrolytes/minerals/metals/vitamins: Electrolyte/mineral/metal modifiers | |
| tri-vylibra™ | 2 | Hormonal agents, stimulant/replacement/modifying (Sex hormones/modifiers): Estrogens | |
| tydemy™ | 2 | Hormonal agents, stimulant/replacement/modifying (Sex hormones/modifiers): Estrogens | |
| VITRAKVI® | 5 | Antineoplastics: Antineoplastics, other | PA |
| VIZIMPRO® | 5 | Antineoplastics: Molecular target inhibitors | PA |
| vylibra™ | 2 | Hormonal agents, stimulant/replacement/modifying (Sex hormones/modifiers): Estrogens | |
| XARELTO®, 2.5mg | 3 | Blood products/modifiers/volume expanders: Anticoagulants | QL (60 ea. per 30 days) |
| XOLAIR® PFS 150mg/ml, 75mg/0.5ml | 5 | Respiratory tract/pulmonary agents: Respiratory tract agents, other | PA |
| ZORTRESS® tablet, 1mg | 5 | Immunological agents: Immune suppressants | B/D |
Changes to/removals from the formulary
Changes/deletions effective May 1, 2019 |
||
|---|---|---|
| Drug name | Tier | Notes |
| epinephrine injection solution auto-injector 0.15 mg/0.3ml | 2 | Lowered tier |
| QNASL® | 4 | Updated quantity limit |
Changes/deletions effective April 1, 2019 |
||
| Drug name | Tier | Notes |
| NARCAN® | 2 | Lowered tier |
Changes/deletions effective March 1, 2019 |
||
| Drug name | Tier | Notes |
| ZYTIGA® oral tablet 250mg | N/A | Removed brand from formulary; generic added |
Changes/deletions effective February 1, 2019 |
||
| Drug name | Tier | Notes |
| ivermectin oral | 2 | Lowered tier |
| epinephrine injection solution auto-injector 0.3 mg/0.3ml | 2 | Lowered tier |
Drug tiers
Tier 1: Preferred Generic
Tier 2: Generic
Tier 3: Preferred Brand
Tier 4: Non-Preferred Drug
Tier 5: Specialty