In This Section      

Formulary Changes

The table below outlines all the changes to our formulary since the formulary list was last printed on 01/01/2020.


Drug NameDescription of Change*Copay AmountEffective Date of Change
XospataAddition to formulary with PA$301/01/2020
BalversaAddition to formulary with PA$301/01/2020
PiqrayAddition to formulary with PA$301/01/2020
XpovioAddition to formulary with PA$301/01/2020
Nesina (alogliptin)Available at $0 copay$003/01/2020
Kazano (alogliptin/metformin)Available at $0 copay$003/01/2020
Onglyza (saxagliptin)Formulary DeletionN/A03/01/2020
Januvia (sitagliptin)Formulary DeletionN/A03/01/2020
Kombiglyze XR (saxagliptin/metformin)Formulary DeletionN/A03/01/2020
Janumet, Janumet XR (sitagliptin/metformin)Formulary DeletionN/A03/01/2020
NourianzAddition to formulary$304/01/2020
VumerityAddition to formulary with PA$304/01/2020
Chloroquine**QL added (10days supply/60days); N/A to FDA approved diagnosis$104/01/2020
Hydroxychloroquine**QL added (10days supply/60days N/A to FDA approved diagnosis$104/01/2020
Kaletra (Lopinavir-ritonavir)**QL added (10days supply/60days); N/A to FDA approved diagnosis$304/01/2020
Ulesfia (benzyl alcohol)Formulary DeletionN/A07/01/2020
Ranitidine syrup, tablets, and OTC productsFormulary DeletionN/A07/01/2020
Videx (didanosine) solutionFormulary DeletionN/A07/01/2020
Rescriptor (delavirdine)Formulary DeletionN/A07/01/2020
Ayvakit (avapritinib)Addition to formulary with PA$307/01/2020
Tazverik (tazemetostat)Addition to formulary with PA$307/01/2020
Pemazyre (pemigatinib)Addition to formulary with PA$307/01/2020
Koselugo (selumetinib)Addition to formulary with PA$307/01/2020
Tukysa (tucatinib)Addition to formulary with PA$307/01/2020

*QL = Quantity Limit, PA = Prior Authorization, ST = Step Therapy, NF= Non Formulary

**In light of the COVID-19 Public Health Emergency, to help ensure appropriate access to needed medications, Quantity limit was added to certain medications on a temporary basis. Priority Partners will continue to evaluate as needed.