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 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)

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