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 2024 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 Dec. 1, 2024 |
|||
| Drug Name | Tier | Category: Class | Notes |
|---|---|---|---|
| acetamin-codeine 300-30 mg/12.5 ml | 4 | Analgesics: Opioid Analgesics, Short-Actings | QL (2700 ML per 30 days) |
| AUGTYRO™ CAPSULE 160MG |
5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (60 EA per 30 days) |
| COBENFY™ CAPSULE 100 MG-20 MG, 125 MG-30 MG, 50 MG-20MG |
5 | Antispychotics: Antispychotics, Other | PA, QL (60 EA per 30 days) |
| COBENFY™ STARTER PACK |
5 | Antispychotics: Antispychotics, Other |
PA, QL (56 EA per 28 days) |
| LUMAKRAS® TABLET 240MG |
5 | Antineoplastics: Antineoplastics, Other |
PA, QL (120 EA per 30 days) |
| octreotide acet ER IM vial 20 mg, 30 mg |
5 | Hormonal Agents, Suppressant (Pituitary): Hormonal Agents, Suppressant (Pituitary) |
|
| VORANIGO® TABLET 10 MG |
5 | Antineoplastics: Antineoplastics, Other |
PA, QL (60 EA per 30 days) |
| VORANIGO® TABLET 40 MG |
5 | Antineoplastics: Antineoplastics, Other |
PA, QL (30 EA per 30 days) |
Additions effective Nov. 1, 2024 |
|||
| Drug Name | Tier | Category: Class | Notes |
|---|---|---|---|
| dasatinib tablet 100 mg, 50 mg, 70 mg, 80 mg | 5 | Antineoplastics: Molecular Target Inhibitors | PA. QL (60 EA per 30 days) |
| dasatinib tablet 140 mg |
5 | Antineoplastics: Molecular Target Inhibitors | PA. QL (30 EA per 30 days) |
| dasatinib tablet 20 mg |
5 | Antineoplastics: Molecular Target Inhibitors | PA. QL (90 EA per 30 days) |
| gavilyte™-n |
2 | Gastrointestinal Agents: Gastrointestinal Agents, Other |
|
| hydrocortisone ss vial 100 mg |
4 | Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal): Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) |
|
| LAZCLUZE™ TABLET 240 MG |
5 | Antineoplastics: Molecular Target Inhibitors |
PA, QL (30 EA per 30 days) |
| LAZCLUZE™ TABLET 80 MG |
5 | Antineoplastics: Molecular Target Inhibitors |
PA, QL (60 EA per 30 days) |
| OGSIVEO® ORAL TABLET 150 MG |
5 | Antineoplastics: Enzyme Inhibitors |
PA, QL (56 EA per 28 days) |
| TYENNE® 162 MG/0.9 ML AUTOINJCT, SYRINGE |
5 | Immunological Agents: Immunosuppressants |
PA, QL (3.6 ML per 28 days) |
| VAXCHORA® |
3 | Immunological Agents: Vaccines |
|
Additions effective Oct. 1, 2024 |
|||
| Drug Name | Tier | Category: Class | Notes |
|---|---|---|---|
| DRIZALMA SPRINKLE™ | 4 | Antidepressants: SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors | PA,QL (60 EA per 30 days) |
| hydrocodone-acetaminophen 10-325/15 ml oral solution | 4 | Analgesics: Opioid Analgesics, Short-acting | QL (5520 ML per 30 days) |
| VANCOMYCIN HCL INTRAVENOUS SOLUTION RECONSTITUTED 1.75 GM, 2 GM | 2 | Antibacterials: Antibacterials, Other | HI |
| VIGAFYDE™ ORAL SOLUTION 100MG/ML |
5 | Anticonvulsants: Gamma-Aminobutyric Acid (Gaba) Augmenting Agents |
PA, QL (750 ML per 30 days) |
Additions effective Sep. 1, 2024 |
|||
| Drug Name | Tier | Category: Class | Notes |
|---|---|---|---|
| LIRAGLUTIDE 2-PAK 18 MG/3 ML, 3-PAK 18 MG/3 ML | 4 | Blood Glucose Regulators: Antidiabetic Agents | PA, QL (9 ML per 30 days) |
| MRESVIA® SYRINGE 50 MCG/0.5 ML | 3 | Immunological Agents: Vaccines | QL (0.5 ML per 720 days) |
| OJEMDA™ ORAL SUSPENSION 25MG/ML | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (96 ML per 28 days) |
| OJEMDA™ TABLET 100MG | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (24 EA per 28 days) |
| OPSYNVI® |
5 | Respiratory Tract/Pulmonary Agents: Pumonary Antihypertensives | PA, QL (30 EA per 30 days) |
| OTEZLA® STARTER PACK 10-20MG 28-DAY |
5 | Immunological Agents: Immunosuppresants |
PA, QL (55 EA per 28 days) |
| OTEZLA® TABLET 20MG |
5 | Immunological Agents: Immunosuppresants |
PA, QL (60 EA per 30 days) |
| RETEVMO® TABLET 120MG, 160MG, 80MG |
5 | Antineoplastics: Antineoplastics, Other |
PA, QL (60 EA per 30 days) |
| RETEVMO® TABLET 40MG |
5 | Antineoplastics: Antineoplastics, Other |
PA, QL (90 EA per 30 days) |
| REZDIFFRA™ | 5 | Gastrointestinal Agents: Gastrointestinal Agents, Other | PA, QL (30 EA per 30 days) |
| VOYDEYA™ | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (180 EA per 30 days) |
| WINREVAIR™ |
5 | Respiratory Tract/Pulmonary Agents: Pumonary Antihypertensives |
PA, QL (1 EA per 21 days) |
Additions effective Aug. 1, 2024 |
|||
| Drug Name | Tier | Category: Class | Notes |
|---|---|---|---|
| ACTHAR® SELFJECT 40 UNIT/0.5 ML, 80 UNIT/1 ML | 5 | Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) | PA |
| AUSTEDO® XR ORAL TABLET EXTENDED RELEASE 24 HOUR 18 MG | 5 | Central Nervous System Agents: Central Nervous System, Other | PA, QL (30 EA per 30 days) |
| AUSTEDO® XR PATIENT TITRATION ORAL TABLET EXTENDED RELEASE THERAPY PACK 12 & 18 & 24 & 30 MG | 5 | Central Nervous System Agents: Central Nervous System, Other | PA, QL (28 EA per 28 days) |
| ivabradine tablet 5mg, 7.5mg | 4 | Cardiovascular Agents: Cardiovascular Agents, Other | |
| SECMBLIX® TABLET 100MG |
5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (120 EA per 30 days) |
Additions effective July 1, 2024 |
|||
| Drug Name | Tier | Category: Class | Notes |
|---|---|---|---|
| AUSTEDO® XR TABLET 30MG, 36MG, 42MG, 48MG | 5 | Central Nervous System Agents: Central Nervous System, Other | PA, QL (30 EA per 30 days) |
| EOHILIA™ STICK PACK 2MG/10ML | 5 | Gastrointestinal Agents: Gastrointestinal Agents, Other | PA, QL (600 ML per 30 days) |
| FILSUVEZ® GEL 10% | 5 | Dermatological Agents: Dermatological Agents, Other | PA, QL (351 GM per 30 days) |
| JYLAMVO® ORAL SOLUTION 2MG/ML | 4 | Antineoplastics: Antineoplastics, Other | PA |
| LANREOTIDE SYRINGE 120 MG/0.5 ML |
5 | Hormonal Agents, Suppressants (Pituitary) | |
| MYHIBBIN™ SUSPENSION 200MG/ML | 4 | Immunological Agents: Immunosuppressants | B/D |
| RINVOQ® LQ SOLUTION 1 MG/ML | 5 | Immunological Agents: Immunological Agents, Other | PA, QL (360 ML per 30 days) |
| RIVFLOZA™ SYRINGE 128MG/0.8ML | 5 | Genitourinary Agents: Genitourinary Agents, Other | PA, QL (0.8ML per 30 days) |
| RIVFLOZA™ SYRINGE 160MG/ML | 5 | Genitourinary Agents: Genitourinary Agents, Other | PA, QL (1 ML per 30 days) |
| RIVFLOZA™ VIAL 80MG/0.5ML |
5 | Genitourinary Agents: Genitourinary Agents, Other |
PA, QL (1 ML per 30 days) |
| RYBELSUS® |
3 | Blood Glucose Regulators: Antidiabetic Agents |
PA, QL (30 EA per 30 days) |
| tridacaine™ ii patch 5% |
3 | Anesthetics: Local Anesthetics |
PA, QL (90 EA per 30 days) |
| VIJOICE™ GRANULE PACKET 50MG |
5 | Genetic Or Enzyme Or Protein Disorder: Replacement, Modifiers, Treatment |
PA, QL (56 EA per 28 days) |
Additions effective June 1, 2024 |
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| Drug Name | Tier | Category: Class | Notes |
|---|---|---|---|
| dihydroergotamine mesylate solution 4mg/ml nasal | 5 | Antimigraine Agents: Ergot Alkaloids | PA, QL (8 ML per 30 days) |
| EMZAHH™ TABLET 0.35 MG | 2 | Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Progestins | |
| INGREZZA® SPRINKLE CAP 40MG, 60MG, 80MG | 5 | Central Nervous System Agents: Central Nervous System, Other | PA, QL (30 EA per 30 days) |
| LIDOCAN™ IV EXTERNAL PATCH 5 % | 3 | Anesthetics: Local Anesthetics | PA, QL (90 EA per 30 days) |
| LIDOCAN™ V EXTERNAL PATCH 5 % | 3 | Anesthetics: Local Anesthetics | PA, QL (90 EA per 30 days) |
| OGSIVEO™ TABLET 150MG | 5 | Antineoplastics: Enzyme Inhibitors | PA, QL (56 EA per 28 days) |
| XCOPRI® TABLET 25MG | 5 | Anticonvulsants: Anticonvulsants, Other | QL (30 EA per 30 days) |
Additions effective May 1, 2024 |
|||
| Drug Name | Tier | Category: Class | Notes |
|---|---|---|---|
| FABHALTA® | 5 | Blood Products and Modifiers: Blood Products and Modifiers, Other | PA, QL (60 EA per 30 days) |
| heather® 28-day | 2 | Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones): Progestins | |
| tiopronin dr tablet 100 mg | 4 | Genitourinary Agents: Genitourinary Agents, Other | PA, QL (240 EA per 30 days) |
| tiopronin dr tablet 300 mg | 4 | Genitourinary Agents: Genitourinary Agents, Other | PA, QL (90 EA per 30 days) |
| tiopronin tablet 100 mg | 4 | Genitourinary Agents: Genitourinary Agents, Other | PA, QL (240 EA per 30 days) |
| WAINUA™ | 5 | Genetic Or Enzyme Or Protein Disorder: Replacement, Modifiers, Treatment | PA, QL (0.8 ML per 30 days) |
| XOLAIR® AUTOINJECTOR 150 MG/ML | 5 | Immunological Agents: Immunological Agents, Other | PA |
| XOLAIR® AUTOINJECTOR 300 MG/2 ML | 5 | Immunological Agents: Immunological Agents, Other | PA |
| XOLAIR® AUTOINJECTOR 75 MG/0.5 ML | 5 | Immunological Agents: Immunological Agents, Other | PA |
| ZILBRYSQ® SYRINGE 16.6 MG/0.416 ML |
5 | Genetic Or Enzyme Or Protein Disorder: Replacement, Modifiers, Treatment |
PA, QL (12.48 ML per 30 days) |
| ZILBRYSQ® SYRINGE 23 MG/0.574 ML |
5 | Genetic Or Enzyme Or Protein Disorder: Replacement, Modifiers, Treatment |
PA, QL (17.22 ML per 30 days) |
| ZILBRYSQ® SYRINGE 32.4 MG/0.81 ML |
5 | Genetic Or Enzyme Or Protein Disorder: Replacement, Modifiers, Treatment |
PA, QL (24.3 ML per 30 days) |
Additions effective April 1, 2024 |
|||
| Drug Name | Tier | Category: Class | Notes |
|---|---|---|---|
| IXCHIQ® VIAL | 3 | Immunological Agents: Vaccines | QL (1 EA per 720 days) |
| mifepristone tablet 300mg | 5 | Blood Glucose Regulators: Glycemic Agents | PA, QL (120 EA per 30 days) |
| nitroglycerin ointment 0.4% | 4 | Cardiovascular Agents: Vasodilators, Direct-Acting Arterial/Venous | QL (30 GM per 30 days) |
Additions effective March 1, 2024 |
|||
| Drug Name | Tier | Category: Class | Notes |
|---|---|---|---|
| CAMZYOS® | 5 | Cardiovascular Agents: Cardiovascular Agents, Other | PA, QL (30 EA per 30 days) |
| dabigatran etexilate 110 mg capsule | 4 | Blood Products and Modifiers: Anticoagulants | QL (60 EA per 30 days)) |
| IWILFIN™ 192 MG TABLET | 5 | Antineoplastics: Antineoplastics, Other | PA, QL (240 EA per 30 days) |
| lidocan™ iii | 3 | Anesthetics: Local Anesthetics | PA, QL (90 EA per 30 days) |
| OPFOLDA™ 65 MG CAPSULE | 4 | Genetic Or Enzyme Or Protein Disorder: Replacement, Modifiers, Treatment: Genetic Or Enzyme Or Protein Disorder: Replacement, Modifiers, Treatment | PA, QL (8 EA per 28 days) |
| PENBRAYA™ KIT | 3 | Immunological Agents: Vaccines | |
| ROZLYTREK® 50 MG PELLET PACKET | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (84 EA per 28 days) |
| vigpoder™ 500mg powder packet | 5 | Anticonvulsants: Gamma-Aminobutyric Acid (GABA) Augmenting Agents | |
| XOLAIR® 300 MG/2 ML SYRINGE | 5 | Immunological Agents: Immunological Agents, Other | PA |
Additions effective Feb. 1, 2024 |
|||
| Drug Name | Tier | Category: Class | Notes |
|---|---|---|---|
| AUGTYRO™ CAPSULE | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (240 EA per 30 days) |
| BOSULIF® ORAL CAPSULE 100 MG | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (180 EA per 30 days) |
| BOSULIF® ORAL CAPSULE 50 MG | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (30 EA per 30 days) |
| ENILLORING® | 4 | Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers): Estrogens | |
| FRUZAQLA™ CAPSULE 1MG | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (84 EA per 28 days) |
| FRUZAQLA™ CAPSULE 5MG | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (21 EA per 28 days) |
| kourzeq™ 0.1% oral paste | 2 | Dental and Oral Agents | |
| OGSIVEO™ TABLET | 5 | Antineoplastics: Antineoplastics, Other | PA, QL (180 EA per 30 days) |
| TRUQAP™ TABLET | 5 | Antineoplastics: Molecular Target Inhibitors | PA, QL (64 EA per 28 days) |
| XDEMVY™ SOLUTION 0.25% OPHTHALMIC | 5 | Ophthalmic Agents: Ophthalmic Agents, Other |
PA, QL (10 ML per 365 days) |
| ZENPEP® ORAL CAPSULE DELAYED RELEASE PARTICLES 60000-189600 UNIT |
4 | Genetic Or Enzyme Or Protein Disorder: Replacement, Modifiers, Treatment: Genetic Or Enzyme Or Protein Disorder: Replacement, Modifiers, Treatment |
ST |
| ZURZUVAE™ CAPSULE 20MG, 25MG |
5 | Antidepressants: Antidepressants, Other |
PA, QL (28 EA per 365 days) |
| ZURZUVAE™ CAPSULE 30MG |
5 | Antidepressants: Antidepressants, Other |
PA, QL (14 EA per 365 days) |
Changes/removals from the approved drug list
Changes/removals effective Dec. 1, 2024 |
||
| Drug Name | Tier | Notes |
|---|---|---|
| fentanyl citrate lozenge on a handle buccal 200mcg |
4 | Obsolete. Removed from CMS's reference file; removed from formulary. |
| fentanyl citrate lozenge on a handle buccal 400mcg, 600mcg, 800mcg, 1200mcg, 1600mcg |
5 | Obsolete. Removed from CMS's reference file; removed from formulary. |
| naloxone hcl nasal liquid 4 mg/0.1 ml |
2 | Obsolete. Removed from CMS's reference file; removed from formulary. |
| SANDOSTATIN® LAR DEPOT 20 MG, 30 MG |
5 | Removed brand from formulary; generic added |
| TRIZIVIR® |
2 | No longer available. Removed from CMS's reference file; removed from formulary |
Changes/removals effective Nov. 1, 2024 |
||
| Drug Name | Tier | Notes |
|---|---|---|
| efavirenz |
2 | No longer available. Removed from CMS's reference file; removed from formulary |
| PAXLOVID™ (150/100) |
3 | Increased QL to 40 EA per 180 days |
| PAXLOVID™ (300/100) |
3 | Increased QL to 60 EA per 180 days |
Changes/removals effective Oct. 1, 2024 |
||
| Drug Name | Tier | Notes |
|---|---|---|
| CORLANOR® |
4 | Removed brand from formulary; generic added |
| ERYTHROCIN® STEARATE ORAL TABLET 250 MG |
3 | Removed from CMS's reference file; removed from formulary |
| LACRISERT® OPHTHALMIC INSERT 5 MG |
4 | Obsolete. Removed from CMS's reference file; removed from formulary. |
| LEXIVA® ORAL SUSPENSION 50 MG/ML |
4 | Obsolete. Removed from CMS's reference file; removed from formulary. |
Changes/removals effective Sep. 1, 2024 |
||
| Drug Name | Tier | Notes |
|---|---|---|
| GLUCAGEN® HYPOKIT® |
3 | Obsolete. Removed from CMS's reference file; removed from formulary. |
| taztia xt™ |
2 | Obsolete. Removed from CMS's reference file; removed from formulary. |
Changes/removals effective Aug. 1, 2024 |
||
| Drug Name | Tier | Notes |
|---|---|---|
| EXKIVITY™ CAPSULE 40MG | 5 | Removed from the market. Removed from formulary. |
| RETEVMO® CAPSULE 40MG |
5 | Increased quantity limit to 180 EA per 30 days |
| SOMATULINE® DEPOT SOLUTION 120MG/0.5ML SUB-Q |
5 | Removed brand from formulary; generic added |
Changes/removals effective July 1, 2024 |
||
| Drug Name | Tier | Notes |
|---|---|---|
| lurasidone | 3 | Lowered tier, removed step therapy requirements |
| olopatadine hcl ophthalmic solution 0.2% |
2 | Removed from formulary; no longer Part D eligible |
| OZEMPIC® |
3 | Lowered tier |
Changes/removals effective June 1, 2024 |
||
| Drug Name | Tier | Notes |
|---|---|---|
| RECTIV® RECTAL OINTMENT 0.4 % | 4 | Removed brand from formulary; generic added |
| RELYVRIO™ | 5 | Removed from formulary; removed from market. |
| SORINE® ORAL TABLET 80 MG |
2 | Removed from formulary; marketing end date of 5/31/2024. |
| sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml |
4 | Removed from formulary; obsolete. |
| VRAYLAR® ORAL CAPSULE THERAPY PACK 1.5 & 3 MG |
4 | Removed from formulary; marketing end date of 5/31/2024. |
Changes/removals effective May 1, 2024 |
||
| Drug Name | Tier | Notes |
|---|---|---|
| KORLYM® TABLET 300 MG | 5 | Removed brand from formulary; generic added |
| PRADAXA® CAPSULE 110 MG |
4 | Removed brand from formulary; generic added |
Changes/removals effective April 1, 2024 |
||
| Drug Name | Tier | Notes |
|---|---|---|
| RISPERDAL CONSTA® INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 12.5 MG | 4 | Removed brand from formulary; generic added |
| RISPERDAL CONSTA® INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 25 MG, 37.5 MG, 50 MG | 5 | Removed brand from formulary; generic added |
| TRUDHESA® NASAL AEROSOL SOLUTION 0.725 MG/ACT |
4 | Removed from formulary. No longer Part D eligible. |
Changes/removals effective March 1, 2024 |
||
| Drug Name | Tier | Notes |
|---|---|---|
| amabelz™ oral tablet 1-0.5 mg | 2 | Removed from CMS's reference file; removed from formulary - no longer payable under Medicare Part D |
| dextromaphetamine/amphet 25 mg oral capsule | 4 | Increased quantity limit to 60 EA per 30 days |
| pentamidine isethionate inhalation |
3 | changed from traditional PA to B vs. D |
| SORINE® ORAL TABLET 240 MG |
2 | Removed from CMS's reference file; removed from formulary - obsolete |
| ZORBTIVE® |
5 | Removed from CMS's reference file; removed from formulary - obsolete |
Changes/removals effective Feb. 1, 2024 |
||
| Drug Name | Tier | Notes |
|---|---|---|
| adalimumab-fkjp subcutaneous prefilled syringe kit | 5 | Increased quantity limit to 6 EA per 28 days |
| cefaclor oral suspension 25mg/ml, 75mg/ml | 2 | Removed from CMS's reference file; removed from formulary |
| ciprofloxacin tablet 100mg | 4 | Removed from CMS's reference file; removed from formulary |
| FIRVANQ™ SOLUTION 50MG/ML ORAL | 3 | Removed brand from formulary; generic added |
| ISTURISA® TABLET 10MG | 5 | Removed from CMS's reference file; removed from formulary - obsolete |
| KOMBIGLYZE® XR |
4 | Removed brand from formulary; generic added |
| olopatadine hcl ophthalmic |
2 | Removed from CMS's reference file; removed from formulary - obsolete |
| ONGLYZA™ |
4 | Removed brand from formulary; generic added |
| SUPRAX® ORAL SUSPENSION RECONSTITUTED 500 MG/5ML |
3 | Removed from CMS's reference file; removed from formulary - no longer available |
| SUPRAX® ORAL TABLET CHEWABLE |
3 | Removed from CMS's reference file; removed from formulary - no longer available |
| SYNRIBO™ |
5 | Removed from CMS's reference file; removed from formulary - obsolete |
| VOTRIENT® TABLET 200MG |
5 | Removed brand from formulary; generic added |
| XALKORI® ORAL CAPSULE |
5 | Increased quantity limit to 120 EA per 30 days |
Drug tiers
Tier 1: Preferred Generic
Tier 2: Generic
Tier 3: Preferred Brand
Tier 4: Non-Preferred Drug
Tier 5: Specialty