Plan Benefits
Priority Partners Formulary Changes
2024 Formulary Changes
The table below outlines all the changes to our formulary since the formulary list was last printed on 07/01/2024.
| Drug Name | Description of Change* | Copay Amount | Effective Date of Change |
|---|---|---|---|
| Dexcom G7 Receiver and Sensor | Addition of PA with QL | $0 | 01/01/2024 |
| Free Style Libre 3 Sensor | Addition of PA with QL | $0 | 01/01/2024 |
| Cyclosporine Ophthalmic emulsion 0.05% (generic Restasis) Single-Use vials | Addition with QL | $1 | 01/01/2024 |
| Vanflyta (quizartinib) | Addition to formulary with PA | $3 | 01/01/2024 |
| Xdemvy drops 0.25% (lotilaner) | Addition to formulary with PA | $1 | 04/01/2024 |
| Ojjaara (momelotinib) | Addition to formulary with PA | $1 | 04/01/2024 |
| Paxlovid (co-packaged nirmatrelvir tablets and ritonavir tablets) | Addition with QL | $1 | 04/01/2024 |
| Minocycline 50mg tablet | Addition to formulary | $1 | 04/01/2024 |
| Ibandronate 150mg tablet | Addition to formulary | $1 | 04/01/2024 |
| Levocarnitine 1gm/10mL oral solution | Addition to formulary | $1 | 04/01/2024 |
| Acebutolol capsules | Addition to formulary | $1 | 04/01/2024 |
| Olmesartan-hydrochlorothiazide tablets | Addition to formulary | $1 | 04/01/2024 |
| Cholestyramine Powder Packets | Addition to formulary | $1 | 04/01/2024 |
| Desloratadine 5mg tablet | Addition to formulary | $1 | 04/01/2024 |
| Dextromethorphan-guaifenesin Liquid 5-00mg/5mL | Addition to formulary | $1 | 04/01/2024 |
| Desloratadine 5mg tablet | Addition to formulary | $1 | 04/01/2024 |
| Dextromethorphan-guaifenesin Liquid 5-00mg/5mL | Addition to formulary | $1 | 04/01/2024 |
| Roflumilast tablets | Addition to formulary | $1 | 04/01/2024 |
| Docusate sodium 250mg capsule | Addition to formulary | $1 | 04/01/2024 |
| Sodium sulfate-Potassium sulfate-Magnesium sulfate Oral solution (generic of Suprep Bowel Prep Kit) | Addition to formulary | $1 | 04/01/2024 |
| Glycopyrrolate 1mg/5mL oral solution | Addition to formulary | $1 | 04/01/2024 |
| Scopolamine 1mg/3day patch | Addition to formulary | $1 | 04/01/2024 |
| Dronabinol 2.5mg capsule | Addition to formulary | $1 | 04/01/2024 |
| Potassium Citrate-citric acid oral solution | Addition to formulary | $1 | 04/01/2024 |
| Silodosin capsules | Addition to formulary | $1 | 04/01/2024 |
| Acetaminophen 650mg suppository | Addition to formulary | $1 | 04/01/2024 |
| Codeine sulfate 30mg tablet | Addition to formulary | $1 | 04/01/2024 |
| Hydromorphone ER tablets | Addition to formulary with PA | $1 | 04/01/2024 |
| Hydrocodone-ibuprofen tablets | Addition to formulary | $1 | 04/01/2024 |
| Indomethacin ER capsules | Addition to formulary | $1 | 04/01/2024 |
| Amantadine tablets | Addition to formulary | $1 | 04/01/2024 |
| Ropinirole ER tablets | Addition to formulary | $1 | 04/01/2024 |
| Cyclobenzaprine 7.5mg tablet | Addition to formulary | $1 | 04/01/2024 |
| Vitamin D3 5000 unit tablet | Addition to formulary | $1 | 04/01/2024 |
| Wescaps (B-Complex w/Folic Acid) capsules | Addition to formulary | $1 | 04/01/2024 |
| Cyclopentol ophthalmic solution 1% | Addition to formulary | $1 | 04/01/2024 |
| Mupirocin cream 2% | Addition to formulary | $1 | 04/01/2024 |
| Lidocaine 5% patch | Addition with QL | $1 | 04/01/2024 |
| Truqap (capivasertib) | Addition to formulary with PA | $1 | 07/01/2024 |
| Fruzaqla (fruquintinib) | Addition to formulary with PA | $1 | 07/01/2024 |
| Iwilfin (eflornithine) | Addition to formulary with PA | $1 | 07/01/2024 |
| Ogsiveo (nirogacestat) | Addition to formulary with PA | $1 | 07/01/2024 |
| Augtyro (repotrectinib) | Addition to formulary with PA | $1 | 07/01/2024 |
| Free Style Libre 3 Reader | Addition of PA with QL | $0 | 07/01/2024 |
| Cosentyx Auto-injector and syringe | Addition with QL | $1 | 07/01/2024 |
| Cabenuva (cabotegravir-rilpivirine) injection | Addition to formulary with PA | $1 | 10/01/2024 |
| Apretude (cabotegravir) injection | Addition to formulary | $1 | 10/01/2024 |
| Sunlenca (lenacapavir) oral tablets | Addition to formulary with PA | $1 | 10/01/2024 |
| Sunlenca (lenacapavir) injection | Addition to formulary | $1 | 10/01/2024 |
| Pregnyl (chorionic gonadotropin) injection | Addition to formulary | $1 | 10/01/2024 |
| Ovidrel (choriogonadotropin alfa) injection | Addition to formulary | $1 | 10/01/2024 |
| Novarel (chorionic gonadotropin) injection | Addition to formulary | $1 | 10/01/2024 |
| Generic Chorionic gonadotropin injection | Addition to formulary | $1 | 10/01/2024 |
| Follistim AQ (follitropin beta) injection | Addition to formulary | $1 | 10/01/2024 |
| Gonal-f (follitropin alfa) injection | Addition to formulary | $1 | 10/01/2024 |
| Gonal-f-RFF (follitropin alfa/beta) injection | Addition to formulary | $1 | 10/01/2024 |
| Gonal-f-RFF Redi-Ject (follitropin alfa/beta) injection | Addition to formulary | $1 | 10/01/2024 |
| Ganirelix Acetate Injection | Addition to formulary | $1 | 10/01/2024 |
| Leuprolide acetate injection (generic of Lupron) | Addition to formulary with PA | $1 | 10/01/2024 |
| Cetrotide (cetrorelix acetate) injection | Addition to formulary | $1 | 10/01/2024 |
| Menopur (menotropins) injection | Addition to formulary | $1 | 10/01/2024 |
*QL = Quantity Limit, PA = Prior Authorization, ST = Step Therapy, NF = Non Formulary, N/A = Not Applicable
Member Resources
Member Documents Can Be Mailed to You.
All documents are available in paper form without charge. To request a paper copy, please call Customer Service at:
Monday through Friday, 8 a.m. to 5 p.m.
