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 2018 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 July 1, 2018

Drug name Tier Category Notes
ARNUITY® ELLIPTA® 50mcg/ACT 4 Respiratory tract/pulmonary agents: Anti-inflammatories, inhaled corticosteroids
colesevelam HCL tablet 625mg 4 Cardiovascular agents: Dyslipidemics, other
methylphenidate HCL ER capsule 10mg 2 Central nervous system agents: Non-amphetamines
OZEMPIC®
4 Blood glucose regulators: Antidiabetic agents ST
praziquantel tablet 600mg 3 Antiparasitics: Anthelmintics
SYMDEKO™
5 Respiratory tract/pulmonary agents: Cystic fibrosis agents
PA
TRELEGY™  ELLIPTA®
 
3 Respiratory tract/pulmonary agents: Respiratory tract agents, other
TROGARZO™
5 Antivirals: Anti-HIV agents, other PA

Additions effective June 1, 2018

Drug name Tier Category Notes
ABILIFY MAINTENA® 400mg 5 Antipsychotics: 2nd generation/atypical
CIMDUO 5 Antivirals: Anti-HIV agents, nucleoside and nucleotide reverse transcriptase inhibitors (NNRTI) QL (30 ea. per 30 days)
FIASP® 4 Blood glucose regulators: Insulins ST
FIASP® FLEXTOUCH® 4 Blood glucose regulators: Insulins ST
ILARIS® 150mg/ml 5 Immunological agents: Immunomodulators PA
mesalamine DR tablet 800mg
3 Inflammatory bowel disease agents: Aminosalicylates
miglustat capsule 100mg 5 Genetic or enzyme disorder: Replacement, modifiers, treatment LA
SYMFI™ 5 Antivirals: Anti-HIV agents, non-nucleoside reverse transcriptase inhibitors (NNRTI) QL (30 ea. per 30 days)
TASIGNA® capsule 50mg 5 Antineoplastics: Molecular target inhibitors PA
TOUJEO® MAX SOLOSTAR® 3 Blood glucose regulators: Insulins
ZENPEP® 42k; 10k; 32k 4 Genetic or enzyme disorder: Replacement, modifiers, treatment ST

Additions effective May 1, 2018

Drug name Tier Category Notes
DALIRESP® 250mg 4 Respiratory tract/Pulmonary agents: Phosphodiesterase inhibitors, airways disease PA, QL (30 ea. per 30 days)
digox® tablet 125mcg 2 Cardiovascular agents: Cardiovascular agents, other QL (30 ea. per 30 days)
digox® tablet 250mcg 2 Cardiovascular agents: Cardiovascular agents, other PA
glatopa® 40mg/ml 5 Central nervous system agents: Multiple sclerosis agents
haloperidol lactate solution 5mg/ml 2 Antipsychotics: 1st generation/typical
IMBRUVICA® capsule 70mg 5 Antineoplastics: Molecular target inhibitors PA, QL (30 ea. per 30 days)
IMBRUVICA® tablet 140mg, 280mg, 420mg, 560mg 5 Antineoplastics: Molecular target inhibitors PA, QL (30 ea. per 30 days)
methotrexate sodium solution 250mg/10ml 2 Immunological agents: Immune suppressants
naloxone HCL syringe 0.4mg/ml 1 Anti-addiction/aubstance abuse treatment agents: Opioid reversal agents
PREVYMIS™ 5 Antivirals: Anti-cytomegalovirus (CMV) agents PA
ritonavir tablet 100mg 4 Antivirals: Anti-HIV agents, protease inhibitors
SEGLUROMET™ 4 Blood glucose regulators: Antidiabetic agents ST, QL (60 ea. per 30 days)
STEGLATRO™ 4 Blood glucose regulators: Antidiabetic agents ST, QL (30 ea. per 30 days)
STEGLUJAN™ 4 Blood glucose regulators: Antidiabetic agents QL (30 ea. per 30 days)
SYMFI LO™ 5 Antivirals: Anti-HIV agents, non-nucleoside reverse transcriptase inhibitors (NNRTI)
tiagabine hydrochloride 12mg, 16mg 2 Anticonvulsants: Gamma-aminobutyric acid (GABA) augmenting agents
TROGARZO™ 5 Antivirals: Anti-HIV agents, other B/D
VIDEX® EC 125mg 4 Antivirals: Anti-HIV agents, nucleoside and nucleotide reverse transcriptase inhibitors (NRTI)
ZENPEP® 105K; 25K; 79K, 24K; 5K; 17K 4 Genetic or enzyme disorder: Replacement, modifiers, treatment ST

Additions effective April 1, 2018

Drug name Tier Category Notes
ALUNBRIG® pack, 90mg-180mg
5 Antineoplastics: Molecular target inhibitors PA
BIKTARVY® 5 Antivirals: Anti-HIV agents, integrase inhibitors (INSTI) QL (30 ea. per 30 days)
efavirenz tablet 600mg 3 Antivirals: Anti-HIV agents, non-nucleoside reverse transcriptase inhibitors (NNRTI) nbsp;
ELIQUIS® starter pack 3 Blood products/Modifiers/Volume Expanders: Anticoagulants QL (74 ea. per 30 days)
ERLEADA™ 4 Antineoplastics: Antiandrogens PA, QL (120 ea. per 30 days)
HERCEPTIN® injection, 150mg 4 Antineoplastics: Monoclonal antibody/Antibody-drug conjugate B/D
medroxyprogesterone syringe 150mg/ml 2 Hormonal agents, stimulant/Replacement/Modifying (Sex hormones/Modifiers): Progestins
memantine hydrochloride ER 2 Antidementia agents: N-methyl-D-aspartate (NMDA) receptor antagonist QL (30 ea. per 30 days)
roweepra XR 2 Anticonvulsants: Anticonvulsants, other
sumatriptan/naproxen sodium 550mg; 85mg 4 Antimigraine agents: Serotonin (5-HT) 1b/1d receptor agonists ST, QL (18 ea. per 30 days)

Additions effective March 1, 2018

Drug name Tier Category Notes
abacavir solution 20mg/ml 3 Antivirals: Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
ADASUVE® 5 Antipsychotics: 1st Generation/Typical PA
ALIQOPA® 5 Antineoplastics: Molecular Target Inhibitors B/D
ALTOPREV® 60mg 4 Cardiovascular Agents: Dyslipidemics, HMG CoA Reductase Inhibitors
ALUNBRIG® 90mg, 80mg 5 Antineoplastics: Molecular Target Inhibitors PA
alyacen 1/35 2 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
Amethia™ Lo 2 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
amiodarone HCl tablet 100mg 2 Cardiovascular Agents: Antiarrhythmics
atazanavir sulfate 5 Antivirals: Anti-HIV Agents, Protease Inhibitors
Drug name Tier Category Notes
AUSTEDO™ 12mg 5 Central Nervous System Agents: Central Nervous System, Other PA
QL (120 ea. per 30 days)
AUSTEDO™ 6mg 5 Central Nervous System Agents: Central Nervous System, Other PA
QL (240 ea. per 30 days)
AUSTEDO™ 9mg 5 Central Nervous System Agents: Central Nervous System, Other PA
QL (150 ea. per 30 days)
azithromycin tablet 500mg 2 Antibacterials: Macrolides
BENLYSTA® AUTO-INJECTOR, SYRINGE 200mg/ml 5 Immunological Agents: Immune Suppressants
BESPONSA™ 0.9mg 5 Antineoplastics: Monoclonal Antibody/Antibody-Drug Conjugate B/D
bortezomib 3.5mg 3 Antineoplastics: Antineoplastics, Other B/D
BOSULIF® TABLET 400mg 5 Antineoplastics: Molecular Target Inhibitors PA
QL (30 ea. per 30 days)
BYDUREON® BCISE™ 3 Blood Glucose Regulators: Antidiabetic Agents QL (3.40ml per 28 days)
calcium acetate tablet 2 Electrolytes/Minerals/Metals/Vitamins: Phosphate Binders
CALQUENCE® 5 Antineoplastics: Molecular Target Inhibitors PA
QL (60 ea. per 30 days)
Drug name Tier Category Notes
camrese Lo®
2 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
carvedilol phosphate ER 4 Cardiovascular Agents: Beta-adrenergic Blocking Agents
caspofungin acetate 5 Antifungals: Antifungals
Caziant® 2 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
cefprozil suspension reconstituted 125mg/5ml 2 Antibacterials: Beta-lactam, Cephalosporins
cholestyramine powder 2 Cardiovascular Agents: Dyslipidemics, Other
clindamycin phosphate injection 300mg/2ml, 900mg/6ml 2 Antibacterials: Antibacterials, Other
dactinomycin vial 0.5mg 5 Antineoplastics: Antineoplastics, Other B/D
desogestrel/ethinyl estradiol 0.15mg; 30mcg 2 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
DUPIXENT® 5 Dermatological Agents: Dermatological Agents PA
Drug name Tier Category Notes
efavirenz 2 Antivirals: Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
eletriptan hydrobromide 4 Antimigraine Agents: Serotonin (5-HT) 1b/1d Receptor Agonists ST
QL (12 ea. per 30 days)
ENBREL® MINI™ 5 Immunological Agents: Immune Suppressants PA
estradiol vaginal cream 0.1mg/gm 2 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
estradiol vaginal tablet 10mcg 3 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
ethynodiol diacetate/ethinyl estradiol tablet 35mcg/1mg 2 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
FASENRA™ 5 Respiratory Tract/Pulmonary Agents: Respiratory Tract Agents, Other PA
Femynor™ 2 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
fluocinonide cream emulsified base 0.05% 2 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal): Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
fosamprenavir tablet 700mg 5 Antivirals: Anti-HIV Agents, Protease Inhibitors
Drug name Tier Category Notes
glatiramer acetate 5 Central Nervous System Agents: Multiple Sclerosis Agents
HAEGARDA® 5 Miscellaneous Therapeutic Agents: Miscellaneous Therapeutic Agents PA
haloperidol decanoate vial 100mg/ml 2 Antipsychotics: 1st Generation/Typical
HUMALOG® JUNIOR KWIKPEN® 2 Blood Glucose Regulators: Insulins
hydrocortisone butyrate (lipophilic) cream 0.1% 2 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal): Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
IDHIFA® 5 Antineoplastics: Molecular Target Inhibitors PA
QL (30 ea. per 30 days)
INGREZZA® capsule 80mg 5 Central Nervous System Agents: Central Nervous System Agents, Other PA
QL (30 ea. per 30 days)
INTRON® A injection 10mu 5 Antivirals: Anti-hepatitis B (HBV) Agents
Isibloom™ 2 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
JULUCA® 5 Antivirals: Anti-HIV Agents, Integrase Inhibitors (INSTI) QL (30 ea. per 30 days)
Drug name Tier Category Notes
KALETRA® suspension 5 Antivirals: Anti-HIV Agents, Protease Inhibitors
KEVZARA® 5 Immunological Agents: Immunomodulators PA
(QL 2.28ml per 28 days)
lanthanum carbonate 5 Electrolytes/Minerals/Metals/Vitamins: Phosphate Binders
Larissia™ 2 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
LARTRUVO™ injection 190mg/19ml 5 Antineoplastics: Monoclonal Antibody/Antibody-Drug Conjugate B/D
levalbuterol HCl nebulization solution 1.25mg/0.5ml, 1.25mg/3ml 2 Respiratory Tract/Pulmonary Agents: Bronchodilators, Sympathomimetic B/D
levonorgestrel/ethinyl estradiol 0.15mg 2 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
Low-Ogestrel® 2 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
LYNPARZA® tablet 100mg 5 Antineoplastics: Antineoplastics, Other PA
(QL 120 ea. per 30 days)
LYNPARZA® tablet 150mg 5 Antineoplastics: Antineoplastics, Other PA
Drug name Tier Category Notes
LYRICA® CR 165mg, 82.5mg 4 Central Nervous System Agents: Fibromyalgia Agents QL (90 ea. per 30 days)
LYRICA® CR 330mg 4 Central Nervous System Agents: Fibromyalgia Agents QL (60 ea. per 30 days)
MAVYRET™ 5 Antivirals: Anti-hepatitis C (HCV) Agents, Direct Acting Agents PA
QL(84 ea. per 28 days)
mesalamine DR tablet 1.2gm 3 Inflammatory Bowel Disease Agents: Aminosalicylates
methotrexate sodium injection 250mg/10ml 2 Immunological Agents: Immune Suppressants
methylphenidate HCl ER capsule (LA) 20mg, 40mg, 60mg 2 Central Nervous System Agents: Attention Deficit Hyperactivity Disorder Agents, Non- amphetamines QL (30 ea. per 30 days)
methylprednisolone sodium succinate vial 1000mg 2 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal): Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) HI
moxifloxacin HCl solution 0.5% 2 Antibacterials: Quinolones
MYLOTARG™ 5 Antineoplastics: Monoclonal Antibody/Antibody-Drug Conjugate B/D
NERLYNX® 5 Antineoplastics: Antineoplastics, Other PA
QL (180 ea. per 30 days)
Drug name Tier Category Notes
nolix lotion 0.05% 4 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal): Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
norgestimate/ethinyl estradiol 2 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
NORMOSOL™-R 27mEq/L; 98mEq/L; 23mEq/L; 3mEq/L; 5MEQ/L; 140mEq/L 3 Electrolytes/Minerals/Metals/Vitamins: Electrolyte/Mineral Replacement
nyata powder 2 Antifungals: Antifungals
ofloxacin tablet 300mg 2 Antibacterials: Quinolones
olmesartan medoxomil 2 Cardiovascular Agents: Angiotensin II Receptor Antagonists
olmesartan medoxomil/hydrochlorothiazide 2 Cardiovascular Agents: Angiotensin II Receptor Antagonists
omeprazole/sodium bicarbonate 2 Gastrointestinal Agents: Proton Pump Inhibitors
ONIVYDE® vial 43mg/10ml 5 Antineoplastics: Antineoplastics, Other B/D
OPDIVO® 240mg/24ml 5 Antineoplastics: Monoclonal Antibody/Antibody-Drug Conjugate B/D
Drug name Tier Category Notes
oseltamavir oral solution 3 Antivirals: Anti-influenza Agents
oxaliplatin injection 100mg 2 Antineoplastics: Alkylating Agents B/D
paroxetine capsule 7.5mg 4 Antidepressants: SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor QL (30 ea. per 30 days)
potassium chloride injection 2mEq/ml 2 Electrolytes/Minerals/Metals/Vitamins: Electrolyte/Mineral Replacement HI
potassium chloride ER tablet 10mEq 2 Electrolytes/Minerals/Metals/Vitamins: Electrolyte/Mineral Replacement
prasugrel tablet 3 Blood Products/Modifiers/Volume Expanders): Platelet Modifying Agents
prednisone pack 10mg, 5mg 1 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal): Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
QTERN® 4 Blood Glucose Regulators: Antidiabetic Agents QL (30 ea. per 30 days)
QVAR® REDIHALER™ 3 Respiratory Tract/Pulmonary Agents: Anti-inflammatories, Inhaled Corticosteroids
RADICAVA® 5 Central Nervous System Agents: Central Nervous System Agents, Other B/D
Drug name Tier Category Notes
RENFLEXIS™ 5 Immunological Agents: Immune Suppressants PA
risedronate tablet 35mg 2 Metabolic Bone Disease Agents: Metabolic Bone Disease Agents QL (4 ea. per 28 days)
RITUXAN® INJECTION 100mg/10ml 5 Antineoplastics: Monoclonal Antibody/Antibody-Drug Conjugate B/D
romidepsin vial 10mg 5 Antineoplastics: Antineoplastics, Other B/D
scopolamine patch 1mg/3 days 3 Antiemetics: Antiemetics, Other
sevelamer carbonate tablet 800mg 4 Electrolytes/Minerals/Metals/Vitamins: Phosphate Binders
SHINGRIX® 3 Immunological Agents: Vaccines
SILIQ™ 5 Dermatological Agents: Dermatological Agents PA
QL (3ml per 28 days)
sodium phenylbutyrate tablet 500mg 5 Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment: Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment
sps suspension 15gm/60ml 2 Electrolytes/Minerals/Metals/Vitamins: Electrolyte/Mineral/Metal Modifiers
Drug name Tier Category Notes
STELARA® 45mg/0.5ml 5 Dermatological Agents: Dermatological Agents PA
sumatriptan succinate injection 4mg/0.5ml 2 Antimigraine Agents: Serotonin (5-HT) 1b/1d Receptor Agonists QL (4ml per 30 days)
SYMPROIC® 4 Gastrointestinal Agents: Gastrointestinal Agents, Other ST
QL (30 ea. per 30 days)
tenofovir disoproxil fumarate 5 Antivirals :Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
TRACLEER® 32mg 5 Respiratory Tract/Pulmonary Agents: Pulmonary Antihypertensives QL (56 ea. per 28 days), LA
TREANDA® INJECTION 25mg 5 Antineoplastics: Alkylating Agents B/D
TREMFYA® 5 Dermatological Agents: Dermatological Agents PA
QL (1ml per 56 days)
Tri-Lo-Estarylla™ 2 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
Tri-Lo-Marzia™ 2 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
Tri-Lo-Sprintec™ 2 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
Drug name Tier Category Notes
TRISENOX® 12mg/6ml 5 Antineoplastics: Antineoplastics, Other B/D
VERZENIO™ 5 Antineoplastics: Antineoplastics, Other PA
vigabatrin 500mg pack 5 Anticonvulsants: Gamma-aminobutyric Acid (GABA) Augmenting Agents LA
VYXEOS™ 5 Antineoplastics: Antimetabolites B/D
XATMEP™ 4 Immunological Agents: Immune Suppressants PA
XIGDUO® XR 2.5mg; 1000mg 3 Blood Glucose Regulators: Antidiabetic Agents
ZARAH®
2 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens
ZENPEP® 168,000 USP units; 40,000 USP units; 126,000 USP units, 84,000 USP units; 20,000 USP units; 63,000 USP units 4 Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment ST

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Changes to/removals from approved drug list

Changes/deletions effective June 1, 2018

Drug name Tier Notes
modafinil 4 Removed PA requirement

Changes/deletions effective March 1, 2018

Drug name Tier Notes
clopidogrel tablet 75 mg 1 Lowered tier
ezetimibe 2 Lowered tier
ELIGARD® 4 Removed PA for B/D
GLYXAMBI® 3 Lowered tier
leuprolide acetate injection 2 Removed PA for B/D
LUPRON DEPOT® (1-month) 5 Removed PA for B/D
LUPRON DEPOT® (3-month) 5 Removed PA for B/D
LUPRON DEPOT® (4-month) 5 Removed PA for B/D
LUPRON DEPOT® (6-month) 5 Removed PA for B/D
LUPRON DEPOT-PED® (1-month) 5 Removed PA for B/D
LUPRON DEPOT-PED® (3-month) injection, 11.25mg 5 Removed PA for B/D
naloxone hcl injection 0.4mg/ml, 2mg/2ml 1 Lowered tier
oseltamivir phosphate capsule 30mg
3 Lowered tier
oseltamivir phosphate capsule 45mg, 75mg
3 Lowered tier