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 30 days before the date that the change becomes effective. The exceptions to this 30-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 2024 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, 2024 |
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| Drug Name | Tier | Category: Class | Notes |
|---|---|---|---|
| FABHALTA® | 5 | Blood Products and Modifiers: Blood Products and Modifiers, Other | PA, QL (60 EA per 30 days) |
| heather® 28-day | 2 | Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones): Progestins | |
| tiopronin dr tablet 100 mg | 4 | Genitourinary Agents: Genitourinary Agents, Other | PA, QL (240 EA per 30 days) |
| tiopronin dr tablet 300 mg | 4 | Genitourinary Agents: Genitourinary Agents, Other | PA, QL (90 EA per 30 days) |
| tiopronin tablet 100 mg | 4 | Genitourinary Agents: Genitourinary Agents, Other | PA, QL (240 EA per 30 days) |
| WAINUA™ | 5 | Genetic Or Enzyme Or Protein Disorder: Replacement, Modifiers, Treatment | PA, QL (0.8 ML per 30 days) |
| XOLAIR® AUTOINJECTOR 150 MG/ML | 5 | Immunological Agents: Immunological Agents, Other | PA |
| XOLAIR® AUTOINJECTOR 300 MG/2 ML | 5 | Immunological Agents: Immunological Agents, Other | PA |
| XOLAIR® AUTOINJECTOR 75 MG/0.5 ML | 5 | Immunological Agents: Immunological Agents, Other | PA |
| ZILBRYSQ® SYRINGE 16.6 MG/0.416 ML |
5 | Genetic Or Enzyme Or Protein Disorder: Replacement, Modifiers, Treatment |
PA, QL (12.48 ML per 30 days) |
| ZILBRYSQ® SYRINGE 23 MG/0.574 ML |
5 | Genetic Or Enzyme Or Protein Disorder: Replacement, Modifiers, Treatment |
PA, QL (17.22 ML per 30 days) |
| ZILBRYSQ® SYRINGE 32.4 MG/0.81 ML |
5 | Genetic Or Enzyme Or Protein Disorder: Replacement, Modifiers, Treatment |
PA, QL (24.3 ML per 30 days) |
Additions effective April 1, 2024 |
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| Drug Name | Tier | Category: Class | Notes |
|---|---|---|---|
| IXCHIQ® VIAL | 3 | Immunological Agents: Vaccines | QL (1 EA per 720 days) |
| mifepristone tablet 300mg | 5 | Blood Glucose Regulators: Glycemic Agents | PA, QL (120 EA per 30 days) |
| nitroglycerin ointment 0.4% | 4 | Cardiovascular Agents: Vasodilators, Direct-Acting Arterial/Venous | QL (30 GM per 30 days) |
Additions effective March 1, 2024 |
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| Drug Name | Tier | Category: Class | Notes |
|---|---|---|---|
| CAMZYOS® | 5 | Cardiovascular Agents: Cardiovascular Agents, Other | PA, QL (30 EA per 30 days) |
| dabigatran etexilate 110 mg capsule | 4 | Blood Products and Modifiers: Anticoagulants | QL (60 EA per 30 days)) |
| IWILFIN™ 192 MG TABLET | 5 | Antineoplastics: Antineoplastics, Other | PA, QL (240 EA per 30 days) |
| lidocan™ iii | 3 | Anesthetics: Local Anesthetics | PA, QL (90 EA per 30 days) |
| OPFOLDA™ 65 MG CAPSULE | 4 | Genetic Or Enzyme Or Protein Disorder: Replacement, Modifiers, Treatment: Genetic Or Enzyme Or Protein Disorder: Replacement, Modifiers, Treatment | PA, QL (8 EA per 28 days) |
| PENBRAYA™ KIT | 3 | Immunological Agents: Vaccines | |
| ROZLYTREK® 50 MG PELLET PACKET | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (84 EA per 28 days) |
| vigpoder™ 500mg powder packet | 5 | Anticonvulsants: Gamma-Aminobutyric Acid (GABA) Augmenting Agents | |
| XOLAIR® 300 MG/2 ML SYRINGE | 5 | Immunological Agents: Immunological Agents, Other | PA |
Additions effective Feb. 1, 2024 |
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| Drug Name | Tier | Category: Class | Notes |
|---|---|---|---|
| AUGTYRO™ CAPSULE | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (240 EA per 30 days) |
| BOSULIF® ORAL CAPSULE 100 MG | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (180 EA per 30 days) |
| BOSULIF® ORAL CAPSULE 50 MG | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (30 EA per 30 days) |
| ENILLORING® | 4 | Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens | |
| FRUZAQLA™ CAPSULE 1MG | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (84 EA per 28 days) |
| FRUZAQLA™ CAPSULE 5MG | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (21 EA per 28 days) |
| kourzeq™ 0.1% oral paste | 2 | Dental and Oral Agents | |
| OGSIVEO™ TABLET | 5 | Antineoplastics: Antineoplastics, Other | PA, QL (180 EA per 30 days) |
| TRUQAP™ TABLET | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (64 EA per 28 days) |
| XDEMVY™ SOLUTION 0.25% OPHTHALMIC | 5 | Ophthalmic Agents: Ophthalmic Agents, Other |
PA, QL (10 ML per 365 days) |
| ZENPEP® ORAL CAPSULE DELAYED RELEASE PARTICLES 60000-189600 UNIT |
4 | Genetic Or Enzyme Or Protein Disorder: Replacement, Modifiers, Treatment: Genetic Or Enzyme Or Protein Disorder: Replacement, Modifiers, Treatment |
ST |
| ZURZUVAE™ CAPSULE 20MG, 25MG |
5 | Antidepressants: Antidepressants, Other |
PA, QL (28 EA per 365 days) |
| ZURZUVAE™ CAPSULE 30MG |
5 | Antidepressants: Antidepressants, Other |
PA, QL (14 EA per 365 days) |
Changes/removals from the approved drug list
Changes/removals effective May 1, 2024 |
||
| Drug Name | Tier | Notes |
|---|---|---|
| KORLYM® TABLET 300 MG | 5 | Removed brand from formulary; generic added |
| PRADAXA® CAPSULE 110 MG |
4 | Removed brand from formulary; generic added |
Changes/removals effective April 1, 2024 |
||
| Drug Name | Tier | Notes |
|---|---|---|
| RISPERDAL CONSTA® INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 12.5 MG | 4 | Removed brand from formulary; generic added |
| RISPERDAL CONSTA® INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 25 MG, 37.5 MG, 50 MG | 5 | Removed brand from formulary; generic added |
| TRUDHESA® NASAL AEROSOL SOLUTION 0.725 MG/ACT |
4 | Removed from formulary. No longer Part D eligible. |
Changes/removals effective March 1, 2024 |
||
| Drug Name | Tier | Notes |
|---|---|---|
| amabelz™ oral tablet 1-0.5 mg | 2 | Removed from CMS's reference file; removed from formulary - no longer payable under Medicare Part D |
| dextromaphetamine/amphet 25 mg oral capsule | 4 | Increased quantity limit to 60 EA per 30 days |
| pentamidine isethionate inhalation |
3 | changed from traditional PA to B vs. D |
| SORINE® ORAL TABLET 240 MG |
2 | Removed from CMS's reference file; removed from formulary - obsolete |
| ZORBTIVE® |
5 | Removed from CMS's reference file; removed from formulary - obsolete |
Changes/removals effective Feb. 1, 2024 |
||
| Drug Name | Tier | Notes |
|---|---|---|
| adalimumab-fkjp subcutaneous prefilled syringe kit | 5 | Increased quantity limit to 6 EA per 28 days |
| cefaclor oral suspension 25mg/ml, 75mg/ml | 2 | Removed from CMS's reference file; removed from formulary |
| ciprofloxacin tablet 100mg | 4 | Removed from CMS's reference file; removed from formulary |
| FIRVANQ™ SOLUTION 50MG/ML ORAL | 3 | Removed brand from formulary; generic added |
| ISTURISA® TABLET 10MG | 5 | Removed from CMS's reference file; removed from formulary - obsolete |
| KOMBIGLYZE® XR |
4 | Removed brand from formulary; generic added |
| olopatadine hcl ophthalmic |
2 | Removed from CMS's reference file; removed from formulary - obsolete |
| ONGLYZA™ |
4 | Removed brand from formulary; generic added |
| SUPRAX® ORAL SUSPENSION RECONSTITUTED 500 MG/5ML |
3 | Removed from CMS's reference file; removed from formulary - no longer available |
| SUPRAX® ORAL TABLET CHEWABLE |
3 | Removed from CMS's reference file; removed from formulary - no longer available |
| SYNRIBO™ |
5 | Removed from CMS's reference file; removed from formulary - obsolete |
| VOTRIENT® TABLET 200MG |
5 | Removed brand from formulary; generic added |
| XALKORI® ORAL CAPSULE |
5 | Increased quantity limit to 120 EA per 30 days |
Drug tiers
Tier 1: Preferred Generic
Tier 2: Generic
Tier 3: Preferred Brand
Tier 4: Non-Preferred Drug
Tier 5: Specialty