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 2025 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 Apr. 1, 2025 |
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| Drug Name | Tier | Category: Class | Notes |
|---|---|---|---|
| abirtega tablet 250 mg | 5 | Antineoplastics: Antiandrogens | PA, QL (120 EA per 30 days) |
| EVRYSDI® ORAL TABLET 5 MG | 5 | Central Nervous System Agents: Central Nervous System, Other | PA, QL (30 EA per 30 days) |
| GOMEKLI™ ORAL CAPSULE 1 MG, 2 MG | 5 | Antineoplastics: Molecular Target Inhibitors | PA |
| GOMEKLI™ TABLET FOR ORAL SUSPENSION 1 MG | 5 | Antineoplastics: Molecular Target Inhibitors | PA |
| mercaptopurine oral suspension 20 mg/ml | 5 | Antineoplastics: Antimetabolites | PA |
| REVUFORJ® TABLET 25 MG | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (240 EA per 30 days) |
| SELARSDI™ SRYINGE 45 MG/0.5 ML | 5 | Immunological Agents: Immunological Agents, Other | PA, QL (0.5 ML per 28 days) |
| SELARSDI™ SRYINGE 90 MG/ML | 5 | Immunological Agents: Immunological Agents, Other | PA, QL (1 ML per 28 days) |
| XPOVIO® (40 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK 40 MG | 5 | Antineoplastics: Antineoplastics, Other | PA, QL (16 EA per 28 days) |
| YESITNEK™ SRYINGE 45 MG/0.5 ML | 5 | Immunological Agents: Immunological Agents, Other | PA, QL (0.5 ML per 28 days) |
| YESINTEK™ SRYINGE 90 MG/ML | 5 | Immunological Agents: Immunological Agents, Other | PA, QL (1 ML per 28 days) |
| YESITNEK™ VIAL 45 MG/0.5 ML | 5 | Immunological Agents: Immunological Agents, Other | PA, QL (0.5 ML per 28 days) |
Additions effective Mar. 1, 2025 |
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| Drug Name | Tier | Category: Class | Notes |
|---|---|---|---|
| IMKELDI ORAL SOLUTION 80 MG/ML | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (280 ML per 28 days) |
Additions effective Feb. 1, 2025 |
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| Drug Name | Tier | Category: Class | Notes |
|---|---|---|---|
| adalimumab-adaz subcutaneous solution pen 80 mg/0.8 ml | 5 | Immunological Agents: Immunosuppressants | PA, QL (3.2 ML per 28 days) |
| DANZITEN™ | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (112 EA per 28 days) |
| hydrocodone-acetaminophen tablet 2.5-325 mg | 4 | Analgesics: Opioid Analgesics, Short-acting | QL (360 EA per 30 days) |
| IQIRVO® | 5 | Gastrointestinal Agents: Gastrointestinal Agents, Other | PA, QL (30 EA per 30 days) |
| ITOVEBI™ TABLET 3 MG | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (56 EA per 28 days) |
| ITOVEBI™ TABLET 9 MG | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (28 EA per 28 days) |
| LIVDELZI® | 5 | Gastrointestinal Agents: Gastrointestinal Agents, Other | PA, QL (30 EA per 30 days) |
| mesna tablet 400mg | 5 | Antineoplastics: Treatment Adjuncts | |
| NP THYROID® | 4 | Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) | |
| OPIPZA™ FILM 10 MG | 5 | Antipsychotics: 2nd Generation, Atypical | PA, QL (90 EA per 30 days) |
| OPIPZA™ FILM 2 MG | 5 | Antipsychotics: 2nd Generation, Atypical | PA, QL (30 EA per 30 days) |
| OPIPZA™ FILM 5 MG | 5 | Antipsychotics: 2nd Generation, Atypical | PA, QL (120 EA per 30 days) |
| PREVYMIS® PELLET PACKET 120 MG, 20 MG | 5 | Antivirals: Anti-Cytomegalovirus (CMV) Agents | PA, QL (120 EA per 30 days) |
| REVUFORJ® | 5 | Antineoplastics: Molecular Target Inhibitors | PA |
| YORVIPATH® PEN 168 MCG/0.56 ML | 5 | Metabolic Bone Disease Agents | PA, QL (1.12 ML per 30 days) |
| YORVIPATH® PEN 294 MCG/0.98 ML | 5 | Metabolic Bone Disease Agents | PA, QL (1.96 ML per 30 days) |
| YORVIPATH® PEN 420 MCG/1.4 ML | 5 | Metabolic Bone Disease Agents | PA, QL (2.8 ML per 30 days) |
Changes/removals from the approved drug list
Changes/removals effective Apr. 1, 2025 |
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| Drug Name | Tier | Notes |
|---|---|---|
| AUGTYRO™ ORAL CAPSULE 40 MG | 5 | Decreased quantity limit to 180 EA per 30 days |
| AUSTEDO® XR ORAL TABLET EXTENDED RELEASE 12 MG | 5 | Decreased quantity limit to 30 EA per 30 days |
| AUSTEDO® XR ORAL TABLET EXTENDED RELEASE 24 MG | 5 | Decreased quantity limit to 30 EA per 30 days |
| MESNEX® ORAL TABLET 400 MG | 5 | Removed brand from formulary; generic added |
| NURTECT® ODT TABLET DISPERSIBLE 75 MG | 3 | Added quantity limit of 18 EA per 30 days |
| RETEVMO® ORAL CAPSULE 40 MG | 5 | Decreased quantity limit to 90 EA per 30 days |
| RETEVMO® ORAL CAPSULE 80 MG | 5 | Decreased quantity limit to 60 EA per 30 days |
| SCEMBLIX® ORAL TABLET 40MG | 5 | Decreased quantity limit to 240 EA per 30 days |
| UPTRAVI® ORAL TABLET 200 MCG | 5 | Increased quantity limit to 140 EA per 28 days |
Changes/removals effective Mar. 1, 2025 |
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| Drug Name | Tier | Notes |
|---|---|---|
| methylphenidate hcl er oral tablet extended release 24 hour 36 mg | 4 | Increased quantity limit to 60 per 30 days |
| PREHEVBRIO | 3 | Removed from CMS's reference file; removed from formulary - discontinued by manufacturer |
| DROXIA® ORAL CAPSULE 200 MG, 300 MG, 400 MG | 3 | Removed from CMS's reference file; removed from formulary - discontinued by manufacturer |
| phenytoin sodium extended oral capsule 200 mg, 300 mg | 2 | Removed from CMS's reference file; removed from formulary - other strengths available |
Changes/removals effective Feb. 1, 2025 |
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| Drug Name | Tier | Notes |
|---|---|---|
| amethia™ oral tablet 0.15-0.03 & 0.01 mg |
2 | Removed from CMS's reference file; alternatives available on formulary |
| APRETUDE INTRAMUSCULAR SUSPENSION EXTENDED RELEASE 600 MG/3ML | 5 | Removed from formulary. No longer payable under Part D. |
| azithromycin oral packet 1 gm | 2 | Removed from CMS's reference file; other dosing available |
| diphtheria-tetanus toxoids dt intramuscular suspension 25-5 lfu/0.5ml | 3 | Removed from CMS's reference file; removed from formulary - discontinued by manufacturer |
| ENTADFI™ ORAL CAPSULE 5-5 MG | 4 | Removed from CMS's reference file; removed from formulary - discontinued by manufacturer |
| fentanyl citrate lozenge on a handle | 4, 5 | Removed from CMS's reference file; removed from formulary - obsolete |
| HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML | 3 | Removed from formulary. No longer payable under Part D. |
| levofloxacin ophthalmic solution 0.5 % | 2 | Removed from CMS's reference file; alternatives available on formulary |
| methylphenidate hcl er (osm) oral tablet extended release 36 mg | 4 | Increased quantity limit to 60 per 30 days |
| MICROGESTIN® 24 FE ORAL TABLET 1-20 MG-MCG | 4 | Removed from CMS's reference file; off market |
| naloxone hcl nasal liquid 4 mg/0.1ml | 3 | Removed from CMS's reference file; removed from formulary - obsolete |
| nymyo™ oral tablet 0.25-35 mg-mcg | 2 | Removed from CMS's reference file; alternatives available on formulary |
| roflumilast | 4 | Removed prior authorization requirement |
| SPRYCEL® | 5 | Removed brand from formulary; generic added |
| travoprost (bak free) ophthalmic solution 0.004 % | 3 | Lowered tier |
| TRIDERM® EXTERNAL CREAM 0.1 % | 3 | Removed from CMS's reference file; alternatives available on formulary |
| tri-nymyo™ oral tablet 0.18/0.215/0.25 mg-35 mcg | 2 | Removed from CMS's reference file; off market |
| TYVASO DPI™ MAINTENANCE KIT INHALATION POWDER 112 X 32MCG & 112 X48MCG | 5 | Removed from CMS's reference file; removed from formulary - obsolete |
Drug tiers
Tier 1: Preferred Generic
Tier 2: Generic
Tier 3: Preferred Brand
Tier 4: Non-Preferred Drug
Tier 5: Specialty