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

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

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

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

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

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)

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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