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
- 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, 2020 |
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|---|---|---|---|
| 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 |
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| 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) |
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 | |
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