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 2021 approved drug list
- Jump down to Changes/removals from the 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 May 1, 2021 |
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| Drug name | Tier | Category | Notes |
|---|---|---|---|
| brinzolamide 1% eye drop | 4 | Ophthalmic agents: Ophthalmic intraocular pressure lowering agents, other | |
| CYCLOPHOSPHAMIDE TABLET 25mg, 50mg | 3 | Antineoplastics: Alkylating agents | B/D |
| estarylla™ | 2 | Hormonal agents, simulant/replacement/modifying (sex hormones/modifiers): Estrogens | |
| HUMIRA® (CF) PEN PEDI UC 80mg | 5 | Immunological agents: Immunosuppressants | PA |
| KLISYRI® | 5 | Dermatological agents, other | ST, QL (5 EA per 365 days) |
| lidocaine hcl urethral/mucosal gel 2% external | 2 | Anesthetics: Local anesthetics | |
| lyllana™ twice weekly patch | 2 | Hormonal agents, simulant/replacement/modifying (sex hormones/modifiers): Estrogens | |
| nymyo™ | 2 | Hormonal agents, simulant/replacement/modifying (sex hormones/modifiers): Estrogens | |
| NYVEPRIA™ | 5 | Blood products and modifiers, other | QL (1.2 ML per 28 days) |
| ORLADEYO™ | 5 | Cardiovascular agents, other | PA, QL (30 EA per 30 days) |
| OZEMPIC® 1mg DOSE PEN (3ml) | 4 | Blood glucose regulators: Antidiabetic agents | ST |
| pacerone® 200mg tablet | 2 | Cardiovascular agents: Antiarrhythmics | |
| PLEGRIDY® 125 mcg/0.5ml SYRINGE | 5 | Central nervous system agents: Multiple sclerosis agents | QL (1 ML per 28 days) |
| tri-nymyo™ | 2 | Hormonal agents, simulant/replacement/modifying (sex hormones/modifiers): Estrogens | |
| XTANDI® 40mg TABLET | 5 | Antineoplastics: antiandrogens | PA, QL (120 EA per 30 days), LA |
| XTANDI® 80mg TABLET | 5 | Antineoplastics: antiandrogens | PA, QL (60 EA per 30 days), LA |
| XYWAV™ | 5 | Sleep disorder agents: Wakefulness promoting agents | PA, QL (540 ML per 30 days) |
Additions effective April 1, 2021 |
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| Drug name | Tier | Category | Notes |
| deferasirox tablet 180mg 360mg, 90mg | 5 | Electrolytes/minerals/metals/vitamins: Electroyte/mineral/metal modifiers | |
| ICLUSIG® 10mg | 5 | Antineoplastics: Molecular target inhibitors | PA, QL (30 EA per 30 days) |
| loteprednol gel 0.5% ophthalmic | 4 | Ophthalmic agents: Ophthalmic anti-inflammatories | ST |
| ORGOVYX™ | 5 | Antineoplastics, other | PA, QL (30 EA per 30 days) |
| TEPMETKO® 225mg TABLET | 5 | Antineoplastics, other | PA, QL (60 EA per 30 days) |
| XELJANZ™ 1mg/ml ORAL SOLUTION | 5 | Immunological agents, other | PA, QL (300 ml per 30 days) |
Additions effective March 1, 2021 |
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| Drug name | Tier | Category | Notes |
| asenapine maleate | 5 | Antipsychotics: 2nd generation/atypical | ST, QL (60 EA per 30 days) |
| denta 5000 plus cream 1.1% dental | 2 | Dental and oral agents | |
| diclofenac sodium er tablet | 2 | Analgesics: Nonsteroidal anti-inflammatory drugs | |
| diltiazem hcl er coated beads capsule extended release 24 hour 120mg, 180mg, 240mg | 2 | Cardiovascular agents: Calcium channel blocking agents, nondihydropyridines | |
| emtricitabine-tenofovir 100-150mg, 133-200mg, 167-250mg | 5 | Antivirals: Anti-HIV agents, nucleoside and nucleotide reverse transcriptase inhibitors (NRTI) | |
| EYSUVIS™ | 4 | Ophthalmic agents: Ophthalmic anti-inflammatories | QL (33.2ML per 365 days) |
| ICLUSIG® TABLET 30mg | 5 | Antineoplastics: Molecular target inhibitors | PA |
| ONGENTYS® CAPSULE 25mg | 4 | Antiparkinson agents, other | ST, QL (30 EA per 30 days) |
| RETACRIT® 20,000 UNIT/2ml VIAL | 4 | Blood products and modifiers, other | B/D |
| sf 5000 plus cream 1.1% dental | 2 | Dental and oral agents | |
| sf gel 1.1% dental | 2 | Dental and oral agents | |
Additions effective February 1, 2021 |
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| Drug name | Tier | Category | Notes |
| abiraterone tablet 500mg | 5 | Antineoplastics: Antiandrogens | PA, QL (60 EA per 30 days) |
| albuterol sulfate HFA aerosol solution 108mcg/act inhalation | 2 | Respiratory tract/pulmonary agents: Bronchodilators, sympathomimetic | |
| cyclobenzaprine tablet 10mg, 5mg | 4 | Skeletal muscle relaxants | |
| CYSTADROPS® | 5 | Ophthalmic agents, other | PA, QL (20ml per 30 days) |
| deferiprone tablet 500mg | 5 | Electrolytes/minerals/metals/vitamins: Electrolyte/mineral/metal modifiers | |
| DIACOMIT® | 5 | Anticonvulsants, other | PA |
| DIFICID® SUSPENSION 40mg/ml | 5 | Antibacterials: Macrolides | ST, QL (100ml per 30 days) |
| dimethyl fumarate cap 120mg, 240mg | 5 | Central nervous system agents: Multiple sclerosis agents | |
| dimethyl fumarate starter pack | 5 | Central nervous system agents: Multiple sclerosis agents | |
| efavirenz-emtricitabine-tenofovir tablet 600mg-200mg-300mg | 5 | Antivirals: Anti-HIV agents, nucleoside and nucleotide reverse transcriptase inhibitors (NRTI) | |
| efavirenz-lamivudine-tenofovir tablet 400mg-300mg-300mg, 600mg-300mg-300mg | 5 | Antivirals: Anti-HIV agents, nucleoside and nucleotide reverse transcriptase inhibitors (NRTI) | QL (30 EA per 30 days) |
| emtricitabine capsule 200mg | 3 | Antivirals: Anti-HIV agents, nucleoside and nucleotide reverse transcriptase inhibitors (NRTI) | |
| emtricitabine-tenofovir tablet 200mg-300mg | 5 | Antivirals: Anti-HIV agents, nucleoside and nucleotide reverse transcriptase inhibitors (NRTI) | |
| ENSPRYNG™ | 5 | Immunological agents: Immunosuppressants | PA, QL (1ml per 30 days) |
| EPCLUSA® 200mg-50mg | 5 | Antivirals: Anti-hepatitis C (HCV) agents | PA |
| EVRYSDI™ | 5 | Central nervous system agents, other | PA, QL (240ml per 30 days) |
| FARYDAK® 15mg | 5 | Antineoplastics: Molecular target inhibitors | PA |
| fosfomycin sachet 3gm | 3 | Antibacterials, other | |
| GAVRETO™ | 5 | Antineoplastics, other | PA, QL (120 EA per 30 days) |
| HEMADY™ | 5 | Hormonal agents, stimulant/replacement/modifying (adrenal) | PA, QL (30 EA per 30 days) |
| hydroxyzine hcl 10mg, 25mg, 50mg | 4 | Respiratory tract/pulmonary agents: Antihistamines | |
| hydroxyzine pamoate 25mg, 50mg | 4 | Anxiolytic agents, other | |
| icosapent ethyl capsule 1gm | 4 | Cardiovascular agents: Dyslipidemics, other | PA |
| ivermectin lotion 0.5% | 4 | Dermatological agents: Pediculides/scabicides | QL (117gm per 14 days) |
| KESIMPTA® | 5 | Central nervous system agents: Multiple sclerosis agents | QL (0.4ml per 28 days) |
| lapatinib ditosylate tablet 250mg | 5 | Antineoplastics: Molecular target inhibitors | PA |
| LOKELMA® PACKET 10gm ORAL | 4 | Electrolytes/minerals/metals/vitamins: Potassium binders | QL (90 EA per 30 days) |
| LOKELMA® PACKET 5gm ORAL | 4 | Electrolytes/minerals/metals/vitamins: Potassium binders | QL (30 EA per 30 days) |
| LYUMJEV™ | 2 | Blood glucose regulators: Insulins | |
| MENQUADFI™ | 3 | Immunological agents: Vaccines | |
| metyrosine capsule 250mg | 4 | Cardiovascular agents, other | |
| mupirocin (calcium) cream 2% external | 4 | Dermatological agents: Topical anti-infectives | QL (60gm per 30 days) |
| NEXLIZET™ | 4 | Cardiovascular agents, other | PA, QL (30 EA per 30 days) |
| nitazoxanide tablet 500mg | 5 | Antiparasitics: Antiprotozoals | |
| ONGENTYS® | 4 | Antiparkinson agents, other | ST |
| ONUREG® | 5 | Antineoplastics: Antimetabolites | PA, QL (14 EA per 28 days) |
| RETACRIT® VIAL 20,000 unit/ml | 4 | Blood products and modifiers, other | B/D |
| REYVOW™ 100mg | 4 | Antimigraine agents: Serotonin (5-HT) receptor agonist | PA, QL (8 EA per 30 days) |
| REYVOW™ 50mg | 4 | Antimigraine agents: Serotonin (5-HT) receptor agonist | PA, QL (4 EA per 30 days) |
| RHOPRESSA® | 3 | Ophthalmic agents: Ophthalmic prostaglandin and prostamide analogs | |
| ROCKLATAN® | 3 | Ophthalmic agents, other | |
| rufinamide oral suspension 40mg/ml | 5 | Anticonvulsants: Sodium channel agents | PA |
| sapropterin | 5 | Genetic or enzyme or protein disorder: Replacement, modifiers, treatment | |
| TRELEGY ELLIPTA 200-62.5-25 | 3 | Respiratory Ttract/pulmonary agents: Respiratory tract agents, other | |
| TRULICITY® PEN 3 mg/0.5ml, 4.5 mg/0.5ml | 3 | Blood glucose regulators: Antidiabetic agents | |
| UBRELVY™ | 4 | Antimigraine agents: Prophylactic | PA, QL (10 EA per 30 days) |
Changes/removals from the approved drug list
Changes/removals effective May 1, 2021 |
||
| Drug name | Tier | Notes |
|---|---|---|
| LOTEMAX® 0.5% OPHTHALMIC GEL | 4 | Removed brand from formulary; generic added |
| PROAIR HFA | 3 | Removed brand from formulary; generic added |
| TRUVADA™ ORAL TABLET 100-150mg, 133-200mg, 167-250mg | 5 | Removed brand from formulary; generic added |
Changes/removals effective April 1, 2021 |
||
| Drug name | Tier | Notes |
| ALINIA® ORAL TABLET 500mg | 5 | Removed brand from formulary; generic added |
| SKLICE® EXTERNAL LOTION 0.5% | 4 | Removed brand from formulary; generic added |
| XULTOPHY® | 3 | Removed quantity limit |
Changes/removals effective March 1, 2021 |
||
| Drug name | Tier | Notes |
| BANZEL® ORAL SUSPENSION 40mg/ml | 5 | Removed brand from formulary; generic added |
| SAPHRIS® | 5 | Removed brand from formulary; generic added |
| TECFIDERA® 120mg & 240mg STARTER PACK | 5 | Removed brand from formulary; generic added |
| VASCEPA® 1gm | 5 | Removed brand from formulary; generic added |
Changes/removals effective February 1, 2021 |
||
| Drug name | Tier | Notes |
| amitriptyline hcl oral | 4 | Removed prior authorization requirement |
| ATRIPLA® | 5 | Removed brand from formulary; generic added |
| benztropine mesylate oral | 4 | Removed prior authorization requirement |
| DEMSER® ORAL CAPSULE 250mg | 4 | Removed brand from formulary; generic added |
| digitek® oral tablet 125mcg | 4 | Removed quantity limit |
| digitek® oral tablet 250mcg | 4 | Removed prior authorization requirement |
| digox® oral tablet 12 mcg | 4 | Removed quantity limit |
| digox® oral tablet 250mcg | 4 | Removed prior authorization requirement |
| digoxin oral solution | 4 | Removed prior authorization requirement |
| digoxin oral tablet 125mcg | 4 | Removed quantity limit |
| digoxin oral tablet 250mcg | 4 | Removed prior authorization requirement |
| EMTRIVA® CAPSULE 200mg | 3 | Removed brand from formulary; generic added |
| eszopiclone | 4 | Removed prior authorization requirement |
| FERRIPROX® | 5 | Removed brand from formulary; generic added |
| ketoconazole 2% external cream | 2 | Increased quantity limit to 180gm per 30 days |
| KUVAN® | 5 | Removed brand from formulary; generic added |
| MONUROL® ORAL PACKET 3gm | 3 | Removed brand from formulary; generic added |
| mupirocin 2% external ointment | 2 | Increased quantity limit to 440gm per 30 days |
| nystatin external powder | 2 | Increased quantity limit to 480gm per 30 days |
| promethazine hcl oral tablet | 2 | Removed prior authorization requirement |
| SYMFI® | 5 | Removed brand from formulary; generic added |
| SYMFI LO® | 5 | Removed brand from formulary; generic added |
| TECFIDERA® 120mg, 240mg | 5 | Removed brand from formulary; generic added |
| TRUVADA™ 200mg-300mg | 5 | Removed brand from formulary; generic added |
| TYKERB® | 5 | Removed brand from formulary; generic added |
| zaleplon | 4 | Removed prior authorization requirement |
| zolpidem tartrate er | 4 | Removed prior authorization requirement |
| zolpidem tartrate oral | 4 | Removed prior authorization requirement |
Questions?
Call Customer Service (toll‑free)
888.389.6648 (TTY 711)
8 a.m. to 8 p.m., seven days a week
Drug tiers
Tier 1: Preferred Generic
Tier 2: Generic
Tier 3: Preferred Brand
Tier 4: Non-Preferred Drug
Tier 5: Specialty