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 2022 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 June 1, 2022

Drug name Tier Category Notes
lacosamide tablet 50mg 4 Anticonvulsants: Sodium Channel Agents QL (30 EA per 30 days)A
aztreonam injection 2gm 4 Antibacterials: Antibacterials, Other HI
CIMDUO® 5 Antivirals: Anti-HIV Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (Nrti) QL (30 EA per 30 days)
MAYZENT® 0.25MG START-1MG MAINT 5 Central Nervous System Agents: Multiple Sclerosis Agents PA
MAYZENT® 1 MG TABLET 5 Central Nervous System Agents: Multiple Sclerosis Agents PA, QL (30 EA per 30 days)
RINVOQ® ER 45 MG TABLET 5 Immunological Agents: Immunological Agents, Other
PA, QL (56 EA per 365 days)
OZEMPIC® 2 MG/DOSE (8 MG/3 ML) 4 Blood Glucose Regulators: Antidiabetic Agents ST

Additions effective May 1, 2022

Drug name Tier Category Notes
CORTROPHIN™ 5 Hormonal Agents, Stimulant/Replacement/Modifying/(Adrenal) PA
DESCOVY® 120-15 MG TABLET 5 Antivirals: Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (Nrti)
lenalidomide capsule 10mg, 15mg, 25mg, 5mg 5 Antineoplastics: Antiangiogenic Agents PA, QL (30 EA per 30 days), LA
LEQVIO® 5 Cardiovascular Agents: Dyslipidemics, Other PA, QL (4.5 ML per 365 days)
LIVTENCITY™ 5 Antivirals: Anti-cytomegalovirus (CMV) Agents PA, QL (120 EA per 30 days)
TAKHZYRO® 300 MG/2 ML SYRINGE 5 Immunological Agents: Angioedema Agents PA, QL (4 ML per 30 days)
TALZENNA® CAPSULE 0.5MG, 0.75MG 5 Antineoplastics: Molecular Target Inhibitors PA, QL (30 EA per 30 days)
TEZSPIRE™ 5 Respiratory Tract/Pulmonary Agents: Respiratory Tract Agents, Other PA, QL (1.91 ML per 30 days)
VOXZOGO™ 5 Metabolic Bone Disease Agents PA, QL (30 EA per 30 days)

Additions effective Apr. 1, 2022

Drug name Tier Category Notes
betaine 1 gram/1.9ml powder 5 Genetic Or Enzyme Or Protein Disorder: Replacement, Modifiers, Treatment LA
maraviroc tablet 150mg, 300mg 5 Antivirals: Anti-HIV Agents, Other
QUADRACEL® DTAP-IPV 3 Immunological Agents: Vaccines
RINVOQ® ER 30MG TABLET 5 Immunological Agents: Immunological Agents, Other PA, QL (30 EA per 30 days)

Additions effective Mar. 1, 2022

Drug name Tier Category Notes
APRETUDE ER 600 MG/3 ML VIAL 5 Antivirals: Anti-HIV Agents, Integrase Inhibitors (INSTI) QL (21 ML per 365 days)
BESREMI® PFS 5 Immunological Agents: Immunostimulants PA, QL (2 ML per 30 days)
DUPIXENT® 100MG/0.67ML SYRINGE 5 Immunological Agents: Immunological Agents, Other PA
EPCLUSA® 150MG-37.5MG ORAL PELLET 5 Antivirals: Anti-Hepatitis C (Hcv) Agents PA
EPCLUSA® 200MG-50MG ORAL PELLET 5 Antivirals: Anti-Hepatitis C (Hcv) Agents PA
EPRONTIA™ 25MG/ML SOLUTION 4 Anticonvulsants: Anticonvulsants, Other ST, QL (480 ML per 30 days)
everolimus 1mg tablet 5 Immunological Agents: Immunosuppressants B/D
EXKIVITY™ 5 Antineoplastics: Molecular Target Inhibitors PA, QL (120 EA per 30 days)
ezetimibe/rosuvastatin 2 Cardiovascular Agents: Dyslipidemics, Other QL (30 EA per 30 days)
naloxone hcl 4mg nasal spray 2 Anti-Addiction/Substance Abuse Treatment Agents: Opioid Reversal Agents QL (2 EA per 30 days)
nylia™ 1-35 28 tablet 2 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
SCEMBLIX® 5 Antineoplastics: Molecular Target Inhibitors PA, QL (300 EA per 30 days)
TAVNEOS™ 5 Immunological Agents: Immunological Agents, Other PA, QL (180 EA per 30 days)
TICOVAC 2.4 MCG/0.5 ML SYRINGE 3 Immunological Agents: Vaccines
TRUDHESA™ 4 Antimigraine Agents: Ergot Alkaloids PA, QL (4 ML per 30 days)
XARELTO® 1 MG/ML SUSPENSION 3 Blood Products and Modifiers: Anticoagulants QL (600 ML per 30 days)

Additions effective Feb. 1, 2022

Drug name Tier Category Notes
BIKTARVY® TABLET 30-120-15 MG ORAL 5 Antivirals: Anti-Hiv Agents, Integrase Inhibitors (Insti)
QL (30 EA per 30 days)
carglumic acid tablet 200mg oral 5 Electrolytes/Minerals/Metals/Vitamins: Electrolyte/Mineral Replacement PA, LA
DENGVAXIA® SUSPENSION RECONSTITUTED SUBCUTANEOUS 3 Immunological Agents: Vaccines
difluprednate emulsion 0.05% ophthalmic 3 Ophthalmic Agents: Ophthalmic Anti-inflammatories ST
DUPIXENT® SOLUTION PREFILLED SYRINGE 100 MG/0.67ML SUBCUTANEOUS 5 Immunological Agents: Immunological Agents, Other PA
everolimus tablet 1 mg oral 5 Immunological Agents: Immunosuppressants B/D
GVOKE® KIT SOLUTION 1 MG/0.2ML SUBCUTANEOUS 3 Blood Glucose Regulators: Antidiabetic Agents
QL (0.8 ML per 30 days)
MAVYRET® PACKET 50-20 MG ORAL 5 Antivirals: Anti-hepatitis C (HCV) Agents PA, QL (140 EA per 28 days)
meropenem 1 g 4 Antibacterials: Cabapenems
sajazir™ 5 Immunological Agents: Angioedema Agents PA

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Changes/removals from the approved drug list

Changes/removals effective Jun. 1, 2022

Drug name Tier Notes
CYSTADANE® ORAL POWDER
5 Removed brand from formulary; generic added
VIMPAT® 50MG 4 Removed brand from formulary; generic added

Changes/removals effective May 1, 2022

Drug name Tier Notes
CARBAGLU® ORAL TABLET 200 MG 5 Removed brand from formulary; generic added
INTRON® A INJECTION SOLUTION 10000000 UNIT/ML 5 Removed from formulary; discontinued
INTRON® A INJECTION SOLUTION 6000000 UNIT/ML 5 Removed from formulary; discontinued
ORGOVYX® 5 Revised QL to 32 EA per 30 days
SELZENTRY® ORAL TABLET 150 MG, 300MG 5 Removed brand from formulary; generic added
TRI-PREVIFEM® ORAL TABLET 0.18/0.215/0.25 MG-35 MCG 2 Removed from formulary; discontinued
XARELTO® 1 MG/ML SUSPENSION 3 Revised QL to 620 ML per 30 days

Changes/removals effective Mar. 1, 2022

Drug name Tier Notes
NARCAN® NASAL LIQUID 2 Removed brand from formulary; generic added
ZORTRESS® 1MG TABLET 5 Removed brand from formulary; generic added

Changes/removals effective Feb. 1, 2022

Drug name Tier Notes
AFINITOR DISPERZ® ORAL TABLET SOLUBLE
3 MG, 5 MG
5 Removed brand from formulary; generic added
AFINITOR® ORAL TABLET 10 MG 5 Removed brand from formulary; generic added
BYSTOLIC® 4 Removed brand from formulary; generic added
CHANTIX® 4 Removed brand from formulary; generic added
CHANTIX® CONTINUING MONTH PAK 4 Removed brand from formulary; generic added
ciclopirox 8% solution 2 Quantity Limit changed to 13.2 ML per 30 days
COSENTYX® (300 MG DOSE) SOLUTION PREFILLED SYRINGE 150 MG/ML SUBCUTANEOUS 5 Quantity Limit changed to 5 ML per 28 days
DUREZOL® OPHTHALMIC EMULSION 0.05 % 3 Removed brand from formulary; generic added
INVEGA TRINZA® 5 Removed Quantity Limit
loteprednol etabonate ophthalmic gel 0.5 % 3 Lowered tier
loteprednol etabonate ophthalmic suspension 0.5 % 3 Lowered tier
LUMAKRAS™ 5 Quantity Limit changed to 240 EA per 30 days
PAXIL® ORAL SUSPENSION 4 Removed brand from formulary; generic added