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.

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 2020 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, 2020

Drug name Tier Category Notes
HARVONI® PELLET PK 5 Antivirals: Anti-hepatitis C (HCV) agents, direct acting PA, QL (28 EA per 28 days)
SOLTAMOX® 20MG/10ML SOLUTION 4 Antineoplastics: Antiestrogens/Modifiers
SOVALDI® PELLET PACKET 5 Antivirals: Anti-hepatitis C (HCV) agents, direct acting PA, QL (30 EA per 30 days)
TIVICAY® PD 4 Antivirals: Anti-Hiv agents, integrase inhibitors (Insti) QL (180 EA per 30 days)

Additions effective July 1, 2020

Drug name Tier Category Notes
AIMOVIG® 4 Antimigraine agents: Prophylactic
PA, QL (1 ML per 30 days)
AJOVY® 4 Antimigraine agents: Prophylactic PA, QL (1.5 ML per 30 days)
diazoxide oral suspension 50mg/ml 3 Antiparasitics: Antiprotozoals
DULERA® 50-5MCG/ACT 3 Respiratory tract/Pulmonary agents: Bronchodilators, sympathomimetic QL (13 GM per 30 days)
EMGALITY® 4 Antimigraine agents: Prophylactic PA
GVOKE HYPOPENTM 0.5MG/0.1ML 3 Blood glucose regulators: Antidiabetic agents QL (0.4 ML per 30 days)
GVOKE HYPOPENTM 1MG/0.2ML 3 Blood glucose regulators: Antidiabetic agents QL (0.8 ML per 30 days)
haloperidol deconate 50mg/ml 2 Antipsychotics: 1st generation/typical
KOSELUGOTM 5 Antineoplastics: Molecular target inhibitors PA
micafungin vial 100mg 5 Antifungals
micafungin vial 500mg 4 Antifungals
NOVOLIN® N FLEXPEN® 4 Blood glucose regulators: Insulins ST
NOVOLIN® R FLEXPEN® 4 Blood glucose regulators: Insulins ST
PEMAZYRETM 5 Antineoplastics: Molecular target inhibitors PA
PROCYSBI® GRAULE PACKET 300MG, 75MG 5 Genetic or enzyme disorder: Replacement, modifiers, treatment
PROMACTA® SUSPENSION PACKET 25MG 5 Blood products/modifiers/volume expanders: Blood formation modifiers PA, LA
QINLOCKTM
5 Antineoplastics: Enzyme inhibitors
PA
RETEVMOTM 5 Antineoplastics: Enzyme inhibitors PA
TABRECTATM 5 Antineoplastics: Enzyme inhibitors PA
TDVAXTM 3 Immunological agents: Vaccines
TRIJARDY® XR EXTENDED RELEASE 24 HOUR TABLET 10-5-1000MG, 25-5-1000MG 3 Blood glucose regulators: Glycemic agent QL (30 EA per 30 days)
TRIJARDY® XR EXTENDED RELEASE 24 HOUR TABLET 12.5-2.5-1000MG, 5-2.5-1000MG 3 Blood glucose regulators: Glycemic agent QL (60 EA per 30 days)
TUKYSATM 5 Antineoplastics: Enzyme inhibitors PA
XCOPRITM 250MG DAILY DOSE, 350MG DAILY DOSE 5 Anticonvulsants: Anticonvulsants, other QL (56 EA per 28 days)
XCOPRITM TABLET 100MG, 50MG 5 Anticonvulsants: Anticonvulsants, other QL (30 EA per 30 days)
XCOPRITM TABLET 150MG, 200MG
5  Anticonvulsants: Anticonvulsants, other QL (60 EA per 30 days)
XCOPRITM TITRATION PACK
5  Anticonvulsants: Anticonvulsants, other QL (28 EA per 365 days)

Additions effective June 1, 2020

Drug name Tier Category Notes
IBRANCE® TABLET 5 Antineoplastics, other PA, QL (21 EA per 28 days)
ketoprofen oral capsule 50mg, 75mg 2 Analgesics: Nonsteroidal anti-inflammatory drugs
NEXLETOLTM 4 Cardiovascular agents, other PA, QL (30 EA per 30 days)
NOVOLIN® 70/30 FLEXPEN® 4 Blood glucose regulators: Insulins ST

Additions effective May 1, 2020

Drug name Tier Category Notes
BIVIGAM® 5 Immunological agents: Immunizing agents, passive PA
SECUADO® 5 Antipsychotics: 2nd generation/atypical ST, QL (30 EA per 30 days)
TAZVERIKTM 5 Antineoplastics: Molecular target inhibitors PA, QL (120 EA per 30 days)
VALTOCO® 10MG DOSE LIQUID 10MG/0.1ML NASAL 4 Anticonvulsants: Gamma-aminobutyric acid (Gaba) augmenting agents QL (4 EA per 30 days)
VALTOCO® 15MG DOSE LIQUID 7.5MG/0.1ML NASAL 4 Anticonvulsants: Gamma-aminobutyric acid (Gaba) augmenting agents QL (8 EA per 30 days)
VALTOCO® 20MG DOSE LIQUID 10MG/0.1ML NASAL 4 Anticonvulsants: Gamma-aminobutyric acid (Gaba) augmenting agents QL (8 EA per 30 days)
VALTOCO® 5MG DOSE LIQUID 5MG/0.1ML NASAL 4 Anticonvulsants: Gamma-aminobutyric acid (Gaba) augmenting agents QL (4 EA per 30 days)
ZIEXTENZO® 5 Blood products/modifiers/volume expanders: Blood formation modifiers QL (1.2ML per 28 days)

Additions effective April 1, 2020

Drug name Tier Category Notes
AYVAKITTM 5 Antineoplastics: Molecular target inhibitors PA, QL (30 EA per 30 days)
EUTHYROX® 4 Hormonal agents, stimulant/replacement/modifying (thyroid)
insulin asp prot & asp flex pen suspension pen-injector (70/30) 4 Blood glucose regulators: Insulins ST
insulin aspart flexpen solution pen-injector 4 Blood glucose regulators: Insulins ST
insulin aspart penfill solution cartridge 4 Blood glucose regulators: Insulins ST
insulin aspart prot & aspart suspension (70/30) prot-in 4 Blood glucose regulators: Insulins ST
insulin aspart solution 4 Blood glucose regulators: Insulins ST
mesalamine 0.375 gram oral capsule 3 Inflammatory bowel disease agents: Aminosalicylates
penicillamine oral tablet 4 Immunological agents: Immunosuppressives
PRETOMANID 4 Antimycobacterials: Antituberculars PA, QL (30 EA per 30 days)
triamcinolone acetonide 0.05% topical ointment 2 Dermatological agents

Additions effective March 1, 2020

Drug name Tier Category Notes
BRUKINSATM 5 Antineoplastics: Molecular target inhibitors PA, QL (120 EA per 30 days)
deferasirox tablet 180mg 5 Electrolytes/minerals/metals/vitamins: Electrolyte/mineral/metal modifiers
DIVIGEL® PACKET 1.25MG 3 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers): Estrogens  
GLUCAGON 1 MG EMERGENCY KIT 3 Blood glucose regulators: Glycemic agents
hydrocodone er capsule 4 Analgesics: Opioid analgesics, long-acting PA, QL (60 EA per 30 days)
NOVOLIN® N FLEXPEN 4 Blood glucose regulators: Insulins ST
NOVOLIN® R FLEXPEN 4 Blood glucose regulators: Insulins ST
penicillamine tablet 250mg 4 Immunological agents: Immunosuppressives
sucralfate oral suspension 100mg 4 Gastrointestinal agents: Protectants
travoprost 0.004% eye drop 4 Ophthalmic agents: Ophthalmic prostaglandin and prostamide analogs ST
TRIKAFTATM 5 Respiratory tract/pulmonary agents: Cystic fibrosis agents PA, QL (84 EA per 28 days)
XELJANZ XR® 22MG 5 Immunological agents: Immunomodulators PA

Additions effective February 1, 2020

Drug name Tier Category Notes
beserTM lotion 0.05% 2 Dermatological agents
CORLANOR® ORAL SUSPENSION 4 Cardiovascular agents, other ST
deferasirox tablet 360mg, 90mg 5 Electrolyte/mineral/metal modifiers
dottiTM patch 2 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers): Estrogens
DRIZALMA SPRINKLETM 4 Antidepressants: SSRIs/SNRIs (Selective serotonin reuptake inhibitors/serotonin and norepinephrine reuptake inhibitors) PA, QL (30 ea per 30 days)
EVENITY® 5 Metabolic  bone disease agents PA, QL (2.34 ml per 30 days)
everolimus tablet 5 Antineoplastics: Molecular target inhibitors PA
FASENRA® PEN 5 Respiratory tract/pulmonary agents, other PA
FIASP® PENFILL 4 Blood glucose regulators: Insulins ST
GVOKETM 0.5MG/0.1ML 3 Blood glucose regulators: Glycemic agents QL (0.4 ml per 30 days)
GVOKETM 1MG/0.2ML 3 Blood glucose regulators: Glycemic agents QL (0.8 ml per 30 days)
HARVONI® 45MG-200MG 5 Antivirals: Anti-hepatitis C (Hcv) agents, direct acting agents PA, QL (28 ea per 28 days)
isotretinoin oral capsule 30 mg 2 Dermatological agents
ivermectin 1% cream 4 Dermatological agents ST
meropenem 4 Antibacterials: Beta-lactam, other
methotrexate sodium injection solution 50mg/2ml 2 Immunological agents: Immune suppressants
methylphenidate er 18mg, 36mg, 54mg 4 Central nervous system agents: Attention deficit hyperactivity disorder agents, non-amphetamines PA, QL (30 ea per 30 days)
methylphenidate er 27mg 4 Central nervous system agents: Attention deficit hyperactivity disorder agents, non-amphetamines PA, QL (60 ea per 30 days)
NAYZILAM® 4 Anticonvulsants: Gamma-aminobutyric acid (Gaba) augmenting agents QL (4 ea per 30 days)
nitisinone 5 Genetic or enzyme disorder: Replacement, modifiers, treatment LA
NUCALA AUTOINJECTOR, PREFILLE SYRINGE 5 Respiratory tract/pulmonary agents, other PA
OLUMIANT® 1MG 5 Immunological agents: Immunomodulators PA, QL (30 ea per 30 days)
pentamidine inhalation powder 3 Anitparasitics: Antiprotozoals PA
posaconazole 100mg tablet 5 Antifungals
ROZLYTREKTM 5 Antineoplastics: Molecular target inhibitors PA, QL (90 ea per 30 days)
SIKLOS® 5 Antineoplastics: Antimetabolites PA
SOVALDI® 200MG 5 Antivirals: Anti-hepatitis C (Hcv) agents, direct acting agents PA, QL (30 ea per 30 days)
TALTZ® SYRINGE 80MG/ML 5 Dermatological agents PA
TEGSEDITM 5 Hormonal agents, stimulant/replacement/modifying (pituitary) PA, QL (6ml per 28 days)
TEMIXYSTM 5 Antivirals: Anti-HIV agents, nucleoside and nucleotide reverse transcriptase inhibitors (Nrti) QL (30 ea per 30 days)
VYNDAMAX® 5 Hormonal agents, stimulant/replacement/modifying (pituitary) PA, QL (30 ea per 30 days)
zolpidem tartrate sublingual tablet sublingual 3.5 mg 4 Sleep disorder agents: Gaba receptor  modulators PA, QL (90 ea per 365 days)

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Changes to/removals from the formulary

Changes/deletions effective August 1, 2020

Drug name Tier Notes
GEODON® INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG N/A Removed brand from formulary; generic added
JADENU® 180MG TABLET N/A Removed brand from formulary; generic added
MYCAMINE® INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 100MG N/A Removed brand from formulary; generic added
ORFADIN® 2MG, 5MG, 10MG CAPSULE N/A Removed brand from formulary; generic added

Changes/deletions effective July 1, 2020

Drug name Tier Notes
DARAPRIM® TABLET 25MG N/A Removed brand from formulary; generic added
PROGLYCEM® ORAL SUSPENSION 50 MG/ML N/A Removed brand from formulary; generic added

Changes/deletions effective June 1, 2020

Drug name Tier Notes
EUTHYROX® ORAL TABLET 1 Lowered tier
ZORTRESS® ORAL TABLET 0.25 MG N/A Removed brand from formulary; generic added
ZORTRESS® ORAL TABLET 0.5 MG N/A Removed brand from formulary; generic added
ZORTRESS® ORAL TABLET 0.75 MG N/A Removed brand from formulary; generic added

Changes/deletions effective April 1, 2020

Drug name Tier Notes
DEPEN® TITRATABS N/A Removed brand from formulary; generic added
DIASTAT® ACUDIALTM N/A Removed brand from formulary; generic added
DIASTAT® PEDIATRIC N/A Removed brand from formulary; generic added
NOVOLOG® N/A Removed brand from formulary; generic added
NOVOLOG® FLEXPEN® SUBCUTANEOUS SOLUTION PEN-INJECTOR N/A Removed brand from formulary; generic added
NOVOLOG® MIX 70/30 N/A Removed brand from formulary; generic added
NOVOLOG® MIX 70/30 FLEXPEN® SUBCUTANEOUS SUSPENSION PEN-INJECTOR N/A Removed brand from formulary; generic added
NOVOLOG® PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE N/A Removed brand from formulary; generic added
ZOHYDRO® ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT N/A Removed brand from formulary; generic added

Changes/deletions effective March 1, 2020

Drug name Tier Notes
TRAVATAN-Z® N/A Removed brand from formulary; generic added
NEBUPENT® N/A Removed brand from formulary; generic added
AFINITOR® 2.5MG, 5MG, 7.5MG N/A Removed brand from formulary; generic added
CARAFATE® ORAL SUSPENSION N/A Removed brand from formulary; generic added

Changes/deletions effective February 1, 2020

Drug name Tier Notes
JADENU® TABLET 360MG, 90MG N/A Removed brand from formulary; generic added
NOXAFIL® 100MG TABLET N/A Removed brand from formulary; generic added
pregabalin 2 Lowered tier
solifenacin succinate 2 Lowered tier
SOOLANTRA® 1% CREAM N/A Removed brand from formulary; generic added