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 2016 approved drug list

KEY:

  • ALL CAPS = Brand names
  • lower case = generic names
  • B/D = Coverage varies under Medicare Part B (hospitalization) vs. Part D (prescription) benefits
  • FF = "Free first fill" drug will be provided at zero cost-sharing the first time you fill it
  • HI = Home infusion drug
  • LA = Limited availability (available only at certain pharmacies)
  • PA = Prior authorization from Priority Health is needed
  • QL = Quantity limits apply
  • ST = Step therapy (trying other drugs first) is required

Additions to approved drug list

Additions effective November 1, 2016
Drug name Tier Category Notes
OXYCONTIN 10MG, 20MG, 40MG 3 Analgesics / Opioid analgesics, Long-acting QL (60 EA per 30 days)
daptomycin solr 500mg 5 Antibacterials / Antibacterials, Other

NAMZARIC 10MG; 7MG, 10MG; 21MG 4 Central nervous system agents / Central nervous system, Other PA QL (30 EA per 30 days)
YONDELIS 5 Antineoplastics / Alkylating agents B/D
JENTADUETO XR 3 Blood glucose regulators / Antidiabetic agents QL (30 EA per 30 days)
nitrolglycerin sublingual tab 0.3mg, 0.4mg, 0.6mg 2 Cardiovascular agents / Vasodilators, Direct-acting arterial/Venous
ZINBRYTA 5 Central nervous system agents / Multiple sclerosis agents PA QL (1 ML per 30 days)
OCALIVA 5 Gastrointestinal agents / Gastrointestinal agents, Other PA QL (30 EA per 30 days)
DEPO-PROVERA SUPS 400MG/ML 4 Hormonal agents, Stimulant/Replacement/Modifying (Sex hormones/Modifiers) / Progestins
paricalcitol soln 2mcg/ml, 5mcg/ml 2 Metabolic bone disease agents / Metabolic bone disease agents
SMOFLIPID 5 Miscellaneous therapeutic agents / Miscellaneous therapeutic agents
B/D
XIIDRA 4 Ophthalmic agents / Ophthalmic agents, Other QL (60 EA per 30 days)
BEVESPI AEROSPHERE 4 Respiratory tract/Pulmonary agents / Bronchodilators, Sympathomimetic QL (10.70 GM per 30 days)
Additions effective October 1, 2016
Drug name Tier Category Notes
EMEND oral suspension 4 Antiemetics / Emetogenic therapy adjuncts B/D
QL (3 EA per 30 days)
gengraf capsure 50mg 2 Immunological agents / Immune suppressants B/D
HUMIRA pen - Psoriasis Starter 5 Immunological agents / Immune suppressants PA
levoleucovorin solution 50mg 5 Antineoplastics / Antineoplastics, other
mesalamine DR 800mg 3 Inflammatory bowel disease agents / Aminosalicylates
ONZETRA XSAIL 4 Antimigraine agents / Serotonin (5-HT) 1b/1d receptor agonists
ORENCIA CLICKJECT 5 Immunological agents / Immune suppressants PA
ORFADIN capsule 20mg 5 Enzyme replacement / Modifiers ST
OTREXUP 12.5mg/0.4ml 4 Immunological agents / Immune suppressants LA
RELISTOR tablet 150mg 5 Gastrointestinal agents / Gastrointestinal agents, other PA
QL (90 ea. per 30 days)
VIERKIRA XR 5 Antivirals / Anti-hepatitis C (HCV) PA
QL (28 ea. per 28 days)
Additions effective Sept. 1, 2016
Drug name Tier Category Notes
armodafinil 4 Sleep disorder agents / Sleep disorders, other PA
QL (30 ea. per 30 days)
dofetilide 4 Cardiovascular agents / Antiarrhythmics
doxorubicin HCL liposome injection 2MG/ML 2 Antineoplastics/ Antineoplastics, other
EPCLUSA 5 Antivirals /Anti-hepatitis C (HCV) agents PA
ethacrynic acid 4 Cardiovascular agents / Diuretics, loop
FYCOMPA oral suspension 0.5MG/ML 4 Anticonvulsants / Anticonvulsants, other QL (180ML per 30 days)
IMPAVIDO 5 Antibacterials / Antibacterials, other PA
LAZANDA 5 Analgesics / Opioid analgesics, short-acting PA
QL (23 ea. per 30 days)
nilutamide tablet 150MG 5 Antineoplastics / Androgens
ORFADIN suspension 4MG/ML 5 Miscellaneous therapeutic agents LA
REPATHA PUSHTRONEX SYSTEM 5 Cardiovascular agents / Cardiovascular agents, other PA
QL (3.5ML per 30 days)
SERNIVO 5 Dermatological agents ST
TIVICAY tablet 10MG 4 Anti-HIV agents / Integrase inhibitors (INSTI) QL (30 ea. per 30 days)
TIVICAY tablet 25MG 5 Anti-HIV agents / Integrase inhibitors (INSTI) QL (30 ea. per 30 days)
Additions effective August 1, 2016
Drug name Tier Category Notes
ELITEK injection 7.5MG 5 Antineoplastics / Antimetabolites
LENVIMA, 8MG daily dose 5 Antineoplastics / Molecular target inhibitors QL (60 ea. per 30 days)
PA
LA
LENVIMA, 18MG daily dose 5 Antineoplastics/Molecular target inhibitors QL (90 ea. per 30 days)
PA
LA
TECENTRIQ 5 Antineoplastics / Monoclonal antibodies B/D
TRINTELLIX 4 Antidepressants /Antidepressants, other QL (30 ea. per 30 days)
TRUVADA, 100mg, 150mg, 133mg, 200mg, 167mg, 250mg 2 Antivirals / Anti-HIV agents, nucleoside and nucleotide reverse transcriptase inhibitors (NRTI)
VENCLEXTA 50mg 4 Antineoplastics / Antineoplastics, other PA
Additions effective July 1, 2016
Drug name Tier Category Notes
azathioprine solution 100mg 5 Immunological agents/Immune suppressants B/D
BERINERT 5 Immunological agents/Angiodema (HAE) agents PA
BRIVIACT 5 Anticonvulsants/ Anticonvulsants, other
CABOMETYX 5 Antineoplastics/Molecular target inhibitors PA
DAKLINZA tablet, 90mg 5 Antivirals/Anti-hepatitis C (HCV) agents PA
miglitol 2 Blood glucose regulators / Antidiabetic agents
mitomycin injection, 40mg 5 Antineoplastics / Antineoplastics, other B/D
mitomycin injection, 5mg 2 Antineoplastics / Antineoplastics, other B/D
NUPLAZID 5 Antipsychotics PA
rosuvastatin calcium 2 Cardiovascular agents/ Dyslipidemics, HMC CoA reductase inhibitors
roweepra 2 Anticonvulsants/ Anticonvulsants, other
TALTZ 5 Dermatological agents PA
VELTASSA 3 Therapeutic nutrients/ Minerals/ Electrolytes, Electrolyte/Mineral modifiers QL (30 ea. per 30 days)
VISTOGARD 5 Miscellaneous therapeutic agents QL (20 ea. per 5 days)
VRAYLAR capsule therapy pack 4 Antipsychotics/ 2nd generation, atypical ST
ZEPATIER 5 Antivirals PA
Additions effective June 1, 2016
Drug name Tier Category Notes
BELBUCA 75mcg, 300mcg, 450mcg, 150mcg, 600mcg 4 Analgesics: Opioid analgesics, long-acting QL (60 ea. per 30 days)
ST
DESCOVY 5 Antivirals: Anti-HIV agents, nucleoside and nucleotide reverse transcriptase inhibitors (NRTI)
diclofenac sodium gel 1% 4 Dermatological agents: Dermatological agents
frovatriptan succinate 4 Antimigraine agents: Serotonin (5-HT) 1b/1d receptor agonists QL (18 ea. per 30 days)
VENCLEXTA 5 Antineoplastics: Antineoplastics, other PA
Additions effective May 1, 2016
Drug name Tier Category Notes
BELBUCA 750mcg, 900mcg 5 Analgesics: Opioid analgesics, long-acting QL (60 ea. per 30 days)
carbamazepine ER 100mg 2 Anticonvulsants: Sodium channel agents
darifenacin hydrobromide 3 Genitourinary agents: Antispasmodics, urinary
endocet 2 Analgesics: Opioid analgesics, long-acting QL (360 ea. per 30 days)
ENSTILAR 5 Dermatological agents
HUMULIN R U-500 Kwikpen 2 Blood glucose regulators: Antidiabetic agents
KANUMA 5 Enzyme replacement/Modifiers
metformin HCL ER tablet extended release 24-hour 4 Blood glucose regulators: Antidiabetic agents
metoprolol tartrate tablet 37.5mg, 75mg 3 Cardiovascular agents: Beta-adrenergic blocking agents
molindone hydrochloride 2 Antipsychotics
mometasone furaoate suspension 50mcg/act 4 Respiratory tract/ Pulmonary agents: Anti-inflammatories, inhaled corticosteroids
NARCAN 3 Anti-addiction/ Substance abuse treatment agents: Opioid reversal agents QL (2 ea. per 30 days)
ODEFSEY 5 Antivirals: Anti-HIV agents, non-nucleoside reverse transcriptase inhibitors (NNRTI) QL (30 ea. per 30 days)
oxiconazole nitrate cream 1% 4 Antifungals
oxycodone ER 15mg, 30mg, 60mg 3 Analgesics: Opioid analgesics, long-acting QL (60 ea. per 30 days)
SPRITAM 250mg 4 Anticonvulsants: Anticonvulsants, other QL (60 ea. per 30 days)
SPRITAM 500mg, 750mg, 1000mg 4 Anticonvulsants: Anticonvulsants, other QL (90 ea. per 30 days)
UPTRAVI 5 Respiratory tract/ Pulmonary agents: Pulmonary antihypertensives PA
VRAYLAR 5 Antipsychotics ST
XELJANZ XR 5 Immunological agents: Immunomodulators PA
Additions effective March 1, 2016
Drug name Tier Category Notes
acetaminophen/ caffeine/ dihydrocodeine 320.5mg; 30mg; 16mg capsule 2 Analgesics: Opioid analgesics, short-acting QL (300 ea. per 30 days)
ALECENSA 5 Antineoplastics: Molecular target inhibitors
almotriptan malate 2 Antimigraine agents: Serotonin (5-HT) 1b/1d receptor agonists QL (12 ea. per 30 days)
aripiprazole, 1mg/ml solution 4 Antipsychotics: 2nd generation/Atypical PA
aripiprazole ODT 4 Antipsychotics: 2nd generation/atypical PA
QL (60 ea. per 30 days)
ARISTADA 5 Antipsychotics: 2nd generation/atypical
AVASTIN, 400mg/16ml 5 Antineoplastics: Monoclonal antibodies
BENDEKA 5 Antineoplastics: Alkylating agents
bexarotene, 75mg capsule 5 Antineoplastics: Retinoids
BEXSERO 3 Immunological agents: Vaccines
Drug name Tier Category Notes
BRILINTA 60mg tablet 3 Blood products/modifiers/volume expanders: Platelet modifying agents QL (60 ea. per 30 days)
budesonide, 1mg/2ml suspension 3 Respiratory tract/pulmonary agents: Anti-inflammatories, inhaled corticosteroids B/D
CLINIMIX, E 4.25%/dextrose 10% 3 Therapeutic nutrients/ minerals/ electrolytes: Electrolyte/ mineral replacement B/D
clobetasol propionate, 0.05% liquid 4 Hormonal agents, stimulant/replacement/modifying (adrenal)
COSENTYX 5 Dermatological agents PA
COSENTYX SENSOREADY PEN 5 Dermatological agents PA
COTELLIC 5 Antineoplastics: Antineoplastics, other PA, LA
CRESEMBA 5 Antifungals
CYRAMZA 5 Antineoplastics: Monoclonal antibodies PA
DAKLINZA 5 Antivirals :Anti-hepatitis C (HCV) agents PA
Drug name Tier Category Notes
DARZALEX 5 Antineoplastics: Monoclonal antibodies B/D, LA
dutasteride 2 Genitourinary agents: Benign prostatic hypertrophy agents
dutasteride/tamsulosin hydrochloride 2 Genitourinary agents: Benign prostatic hypertrophy agents
EMPLICITI 5 Antineoplastics: Monoclonal antibodies B/D
ENTRESTO 3 Cardiovascular Agents: Angiotensin II receptor antagonists PA QL (60 ea. per 30 days)
ENVARSUS XR 4 Immunological agents: Immune suppressants B/D
fluvastatin sodium ER 2 Cardiovascular agents: Dyslipidemics, HMG CoA reductase inhibitors
gentamicin sulfate, 0.3% ointment 2 Antibacterials: Aminoglycosides
gentamicin sulfate, 10mg/ml solution 2 Antibacterials: Aminoglycosides
GENVOYA 5 Antivirals: Anti-HIV agents, integrase inhibitors (INSTI) (30 EA per 30 days)
Drug name Tier Category Notes
GLEOSTINE 3 Antineoplastics: Alkylating agents
HALOG, 0.1% ointment 4 Hormonal agents, stimulant/replacement/modifying (Adrenal)
HUMIRA, 10mg/0.2ml 5 Immunological agents: Immune suppressants PA QL (2 ea. per 28 days)
imatinib mesylate 5 Antineoplastics: Molecular target inhibitors PA
IRESSA 5 Antineoplastics: Molecular target inhibitors PA
JADENU 5 Therapeutic nutrients/ minerals/ electrolytes: Electrolyte/mineral modifiers
jevantique LO 2 Hormonal agents, stimulant/ replacement/ modifying (sex hormones/ modifiers): Estrogens
KEVEYIS 5 Miscellaneous therapeutic agents PA
linezolid, 100mg/5ml suspension 5 Antibacterials: Antibacterials, other PA
LONSURF 5 Antineoplastics: Antimetabolites PA
Drug name Tier Category Notes
megestrol acetate suspension, 625mg/5ml 5 Hormonal agents, stimulant/ replacement/ modifying (sex hormones/ modifiers): Progestins
memantine hydrochloride solution, 2mg/ml 2 Antidementia Agents: N-methyl-D-aspartate (NMDA) receptor antagonist
methenamine mandelate 2 Antibacterials: Antibacterials, other
metoclopramide ODT 2 Gastrointestinal agents: Gastrointestinal agents, other
molindone HCL 2 Antipsychotics: 1st generation/typical
MOVANTIK 4 Gastrointestinal agents: Gastrointestinal agents, other QL (30 ea. per 30 days); ST
NAMZARIC 4 Central nervous system agents: Central nervous system, other PA; QL (30 ea. per 30 days)
nevirapine ER, 100mg 3 Antivirals: Anti-HIV agents, non-nucleoside reverse transcriptase inhibitors (NNRTI) QL (60 ea. per 30 days)
NINLARO 5 Antineoplastics: Antineoplastics, other QL (3ea. per 28 days)
NUVESSA 4 Antibacterials: Antibacterials, other ST
ODOMZO 5 LA, PA, QL (30 ea. per 30 days)
Drug name Tier Category Notes
olopatadine HCL 2 Ophthalmic agents: Ophthalmic anti-allergy agents
ORKAMBI 5 Respiratory tract/ pulmonary agents: Cystic fibrosis agents PA, QL (120 ea. per 30 days)
OTEZLA pack 5 Immunological agents: Immunomodulators PA, QL (60 ea. per 30 days)
OTREXUP, 7.5mg/0.4ml 4 Immunological agents: Immune suppressants ST
OXYCONTIN, 80mg 5 Analgesics: Opioid analgesics, long-acting QL (60 ea. per 30 days)
paliperidone ER, 1.5mg, 3mg, 9mg 3 Antipsychotics: 2nd generation/ atypical QL (30 ea. per 30 days)
paliperidone ER, 6mg 3 Antipsychotics: 2nd generation/ atypical QL (60 ea. per 30 days)
pimozide 2 Antipsychotics: 1st Ggeneration/ typical
PORTRAZZA 5 Antineoplastics: Antineoplastics, other B/D
PRADAXA 4 Blood products/ modifiers/ volume expanders: Anticoagulants QL (60 ea. per 30 days)
Drug name Tier Category Notes
PRALUENT 5 Cardiovascular agents: Cardiovascular agents, other PA, QL (2 ml per 28 days)
pramipexole dihydrochloride ER tablet, 2.25mg, 4.5mg 2 Antiparkinson agents: Dopamine agonists
PRISTIQ, 25MG 4 Antidepressants: SSRIs/SNRIs (selective serotonin reuptake inhibitors/ serotonin and norepinephrine reuptake inhibitor QL (30 ea. per 30 days)
proparacaine HCL,0.5% solution 2 Ophthalmic agents: Ophthalmic agents, other
RASUVO 4 Immunological agents: Immune suppressants ST
repaglinide/metformin hydrochloride 2 Blood glucose regulators: Antidiabetic agents
REPATHA 5 Cardiovascular agents: Cardiovascular agents, other PA, QL (3ml per 30 days)
REPATHA SURECLICK 5 Cardiovascular agents: Cardiovascular agents, other PA, QL (3ml per 30 days)
rivastigmine transdermal system 2 Antidementia agents: Cholinesterase inhibitors
SEEBRI NEOHALER 3 Respiratory tract/ pulmonary agents: Bronchodilators, anticholinergic QL (60 ea. per 30 days)
Drug name Tier Category Notes
SOMAVERT, 25MG, 30MG 5 Hormonal agents, suppressant (pituitary) LA
SOOLANTRA, 1% CREAM 3 Dermatological agents
SPIRIVA RESPIMAT 3 Respiratory tract/ pulmonary agents: Bronchodilators, anticholinergic QL (8 gm per 30 days)
STIOLTO RESPIMAT 4 Respiratory tract/ pulmonary agents: Respiratory tract agents, other QL (4 gm per 30 days)
STRENSIQ 5 Enzyme replacement/ modifiers LA, PA
SUMAVEL DOSEPRO, 4MG/0.5ML 4 Antimigraine agents: Serotonin (5-HT) 1b/1d receptor agonists LA, PA, QL (30 ea. per 30 days)
TAGRISSO 5 Antineoplastics: Antineoplastics, other
TECHNIVIE 5 Antivirals: Anti-hepatitis C (HCV) agents PA
tetrabenazine tablet 5 Central nervous system agents: Central nervous system, other
tobramycin inhalation solution pack 5

Respiratory tract/ pulmonary agents: Cystic fibrosis agents

PA, QL (280 ml per 56 days)
Drug name Tier Category Notes
TOLAK, 4% CREAM 4 Dermatological agents QL (40 gm per 30 days)
TREANDA, 45MG/0.5ML 5 Antineoplastics: Alkylating agents
TRESIBA FLEXTOUCH 4 Blood glucose regulators: Insulins
tretinoin ,0.05% gel 2 Dermatological agents
trimipramine maleate 2 Antidepressants: Tricyclics
trinessa LO 2 Hormonal agents, stimulant/ replacement/ modifying (sex hormones/modifiers): Estrogens
TRUMENBA 3 Immunological agents: Vaccines
UTIBRON NEOHALER 3 Respiratory tract/ pulmonary agents: Bronchodilators, sympathomimetic QL (60 ea. per 30 days)
vicodin, 300mg; 5mg tablet 2 Analgesics: Opioid analgesics, short-acting QL (390 ea. per 30 days)
vicodin ES, 300mg; 7.5mg tablet 2 Analgesics: Opioid analgesics, short-acting QL (390 ea. per 30 days)
Drug name Tier Category Notes
vicodin hp 300mg; 10mg tablet 2 Analgesics: Opioid analgesics, short-acting QL (390 ea. per 30 days)
VIIBRYD starter pack 4 Antidepressants: SSRIs/SNRIs (selective serotonin reuptake inhibitors/ serotonin and norepinephrine reuptake inhibitor QL (30 ea. per 30 days)
VYVANSE, 10MG capsule 4 Central nervous system agents: Attention deficit hyperactivity disorder agents, amphetamines QL (30 ea. per 30 days)
XARELTO starter pack 4 Blood products/ modifiers/ volume expanders: Anticoagulants
ZARXIO 5 Blood products/ modifiers/ volume expanders: Blood formation modifiers
ZENPEP, 218000 unit; 40000 unit; 136000 unit 4 Enzyme replacement/ modifiers
ZUBSOLV, 11.4MG; 2.9MG 4 Anti-addiction/ substance abuse treatment agents: Opioid dependence treatments PA, QL (30 ea. per 30 days)
ZUBSOLV, 2.9MG; 0.71MG Anti-addiction/ substance abuse treatment agents: Opioid dependence treatments PA, QL (30 ea. per 30 days)

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Changes to/removals from approved drug list

Changes/deletions effective June 1, 2016
Drug name New tier Notes
AVANDIA 4 No longer LA (limited availability)
Changes/deletions effective May 1, 2016
Drug name New tier Notes
DALVANCE 5 Removed PA
Changes/deletions effective March 1, 2016
Drug name New tier Notes
acetylcysteine solution 2 Removed PA for B/D determination
amphetamine/ dextroamphetamine capsule, extended release, 24 hour, 20mg 4 Increased QL to 60 ea. per 30 days
amphetamine/ dextroamphetamine capsule, extended release, 24 hour, 30mg 4 Increased QL to 60 ea. per 30 days
AXIRON 3 Lowered tier, still requires PA
BELEODAQ 5 Now B/D determination
BLINCYTO -

Removed from formulary, covered under Part B medical coverage only
Alt. drug: GAZYVA, tier 5

budeprion SR tablet, extended release 12-hour, 150mg - Removed, drug is obsolete
Alt. drug: buproprion HCL SR, tier 2
cefditoren pivoxil Removed
Alt drug: cefaclor, tier 2
celecoxib 2 Lowered tier
CELESTONE - Removed, drug is obsolete.
Drug name New tier Notes
CINRYZE 5 Removed PA for B/D determination
cyclophosphamide injection 2 Removed PA for B/D determination
DOCEFREZ 5 Removed PA for B/D determination
ELAPRASE 5 Removed PA for B/D determination
ELIQUIS 3 Increased QL (74 ea. per 30 days)
ETOPOSIDE capsule -

Drug covered under Part B medical coverage only
Alt. drug: ZYDELIG, tier 5, PA, QL (60 ea. per 30 days)

foscarnet sodium Removed
Alt. drug: ZIRGAN, tier 4
GAZYVA 3 Changed to B/D determination
GILENYA 5 Removed ST requirements
GRANIX 5 Removed PA for B/D determination
Drug name New tier Notes
hydrocodone bitartrate/ acetaminophen tablet 750mg; 10mg - Removed, drug is obsolete
Alt. drug: hydrocodone bitartrate/ acetaminophen tablet 325 mg; 2.5mg, tier 2, QL (360 ea. per 30 days)
hydrocodone bitartrate/ acetaminophen tablet 660mg; 10mg - Removed, drug is obsolete
Alt. drug: vicodin HP 300mg; 10mg tablet, tier 2, QL (360 ea. per 30 days)
ibandronate sodium injection 2 Removed PA for B/D determination
QL (3ml per 90 days)
IFEX 4 Removed PA for B/D determination
IMOVAX rabies (H.D.C.V.) 3 Removed PA for B/D determination
INFERGEN - Removed, drug is obsolete
Alt. drug: PEG-INTRON, tier 5
IPOL inactivated IPV - Removed
Alt. drug: ROTATEQ, tier 3
JEVTANA 5 Changed to B/D determination
KADCYLA 5 Changed to B/D determination
KALBITOR 5 Removed PA for B/D determination
Drug name New tier Notes
KEYTRUDA 5 Changed to B/D determination
leucovorin calcium injection 2 Removed PA for B/D determination
LIPTRUZET - Removed
Alt. drug: simvastatin, tier 1
LUMIZYME 5 LA; removed PA for B/D determination
LUPRON DEPOT 5 Removed PA for B/D determination
LUPRON DEPOT-PED injection 11.25mg, 15mg, 7.5mg 5 Removed PA for B/D determination
MAKENA 5 Removed PA for B/D determination
NULOJIX 5 Removed PA for B/D determination
ONSOLIS - Removed, drug is obsolete
Alt. drug: ABSTRAL, tier 5
OPDIVO 5 Removed PA for B/D determination
Drug name New tier Notes
potassium chloride injection, 30meq/ 100ml - Removed, drug is obsolete
Alt. drug: potassium chloride injection, 20meq/ 100mg, tier 2, HI
PREZISTA tablet, 400mg - Removed, drug is no longer marketed
Alt. drug: PREZISTA tablet 600mg, tier 5
RABAVERT 3 Removed PA for B/D determination
RITUXAN 5 Changed to B/D determination
SOMATULINE DEPOT 5 Removed PA for B/D determination
SYLVANT 5 Changed to B/D determination
testosterone gel 3 Lowered tier
testosterone pump 3 Lowered tier
TYSABRI 5 Changed to B/D determination
VECTIBIX injection 100mg/5ml 5 Changed to B/D determination
Drug name New tier Notes
VENTAVIS 5 Changed to B/D determination
VIBATIV injection, 250mg 3 Removed PA for B/D determination
XGEVA 5 Removed PA for B/D determination
YERVOY 5 Changed to B/D determination
ZALTRAP 5 Removed PA for B/D determination
ZOLEDRONIC acid injection 4mg/ 100ml, 4mg/ 5ml, 5mg/ 100ml 4 Removed PA for B/D determination
ZOMETA injection 4mg/ 100ml 5 Removed PA for B/D determination