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

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 Feb. 1, 2025
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 Feb. 1, 2025
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