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

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


Return to top

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