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 60 days before the date that the change becomes effective. The exceptions to this 60-day notice are when the FDA decides a drug is not safe, or if a drug manufacturer removes the drug from the market.

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 2017 approved drug list

KEY:

  • ALL CAPS = Brand names
  • lower case = generic names
  • B/D = Coverage varies under Medicare Part B (hospitalization) vs. Part D (prescription) benefits
  • FF = "Free first fill" drug will be provided at zero cost-sharing the first time you fill it
  • HI = Home infusion drug
  • LA = Limited availability (available only at certain pharmacies)
  • PA = Prior authorization from Priority Health is needed
  • QL = Quantity limits apply
  • ST = Step therapy (trying other drugs first) is required

Additions to the approved drug list

Additions effective October 1, 2017
Drug name Tier Category Notes
eletriptan hydrobromide
4 Antimigraine agents: Serotonin (5-HT) 1b/1d receptor agonists QL (12 ea. pr 30 days)
ST
LYNPARZA® tablet 100mg
5 Antineoplastics: Antineoplastics, other QL (120 ea. per 30 days)
PA
LYNPARZA® tablet 150mg
5 Antineoplastics: Antineoplastics, other PA
mesalamine DR 1.2gm
3 Inflammatory bowel disease agents: Aminosalicylates
prasugrel
3 Blood products/Modifiers/Volume expanders: Platelet modifying agents
RENFLEXIS™
5 Immunological agents: Immune suppressants PA
sevelamer carbonate tablet 800mg
4 Genitourinary agents: Phosphate binders
scopolamine patch 1mg/3 days
3 Antiemetics: Antiemetics, other
vigabatrin pack 500mg
5 Anticonvulsants: Gamma-aminobutyric acid (GABA) augmenting agents LA
Additions effective September 1, 2017
Drug name Tier Category Notes
AFREZZA® 12 unit, 8 unit
4 Blood glucose regulators: Insulins ST
AUSTEDO™ tablet, 12 mg 5 Central nervous system agents: Central nervous system agents, other QL (120 ea. per 30 days)
PA  
AUSTEDO™ tablet, 9 mg
5 Central nervous system agents: Central nervous system agents, other
QL (150 ea. per 30 days)
PA
AUSTEDO™ tablet, 6 mg 5 Central nervous system agents: Central nervous system agents, other QL (240 ea. per 30 days)
PA
BENLYSTA® 200mg/ml auto injector, syringe
5 Immunological agents: Immune suppressants
DIASTAT® ACUDIAL™ 10mg, 20mg
4 Anticonvulsants: Gamma-aminobutyric acid (GABA) augmenting agents
DIASTAT® pediatric, 2.5mg
4 Anticonvulsants: Gamma-aminobutyric acid (GABA) augmenting agents
DUPIXENT®
5 Dermatological agents: Dermatological agents QL (4 ml per 30 days)
PA
INGREZZA™
5 Central nervous system agents: Central nervous system agents, other
QL (60 ea. per 30 days)
PA
JADENU® sprinkle
5 Therapeutic nutrients/minerals/electrolytes: Electrolyte/mineral modifiers
moxifloxacin HCL ophthalmic drops 0.5%
2 Antibacterials: Quinolones
ORENCIA® INJECTION 50mg/0.4ml, 87.5mg/0.7ml
5 Immunological agents: Immune suppressants PA
RITUXAN HYCELA™
5 Antineoplastics: Monoclonal antibodies B/D
testosterone topical solution 30mg/1.5ml 3 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers): Adrogens PA
TYMLOS™
5 Hormonal agents, stimulant/replacement/modifying (thyroid)
QL (1.56ml per 30 days
PA
VARIZIG®
3 Immunological agents: Vaccines
Additions effective August 1, 2017
Drug name Tier Category Notes
ALUNBRIG™ 5 Antineoplastics: Molecular target inhibitors PA
ARISTADA® 1064mg/3.9ml 5 Antipsychotics: 2nd generation/atypical
atomoxetine 4 Central nervous system agents: ADHD agents, non-amphetamines
buprenorphine patch 4 Anti-addiction/substance abuse treatment agents: Opioid dependence treatments QL (4 ea. per 28 days)
clofarabine solution 1mg/ml 4 Antineoplastics: Antimetabolites B/D
fluticasone propionate/salmeterol inhaler 2 Respiratory tract/pulmonary agents: Anti-inflammatories, inhaled corticosteroids
IMFINZI™ 5 Antineoplastics: Monoclonal antibodies B/D
ISENTRESS® HD 5 Antivirals: Anti-HIV agents, integrase inhibitors (INSTI)
KISQALI® FEMARA® Co-pack 5 Antineoplastics: Alkylating agents PA
olmesartan medoxomil 2 Cardiovascular agents: Angiotensin II receptor antagonists
olmesartan medoxomil /hydrochlorothiazide 2 Cardiovascular agents: Angiotensin II receptor antagonists
olopatadine ophthalmic solution 0.2% 2 Ophthalmic agents: Ophthalmic anti-allergy agents  
ORENITRAM® tablet, extended release 5mg 5 Respiratory tract/pulmonary agents: Pulmonary antihypertensives PA
ROWEEPRA™ 500mg, 750mg, 1000mg 2 Anticonvulsants: Anticonvulsants, other
RUBRACA™ tablet 250mg 5 Antineoplastics: Antineoplastics, other PA
QL (120 ea. per 30 days)
RYDAPT® 5 Antineoplastics: Antineoplastics, other PA
SELZENTRY® solution 20mg/ml 5 Antivirals: Anti-HIV agents, other QL (450 ml per 30 days)
sevelamer carbonate pack 0.8gm, 2.4gm 5 Genitourinary agents: Phosphate binders
XATMEP™ 4 Immunological agents: Immune suppressants PA
ZEJULA™ 5 Antineoplastics: Antineoplastics, other PA
QL (90 ea. per 30 days)
Additions effective July 1, 2017
Drug name Tier Category Notes
BAVENCIO® 5 Antineoplastics: Monoclonal antibodies B/D
BROMSITE™ 3 Ophthalmic agents: Ophthalmic anti-inflammatories
busulfan solution 6mg/ml 4 Antineoplastics: Alkylating agents
RHOFADE™
4 Dermatological agents: Dermatological agents PA
QL (30 gm per 30 days)
ROWEEPRA™ tablet 1000mg, 750mg 2 Anticonvulsants: Anticonvulsants, other
tazarotene cream 0.1% 4 Dermatological agents: Dermatological agents
VYVANSE® chewable 4 Central nervous system agents: ADHD agents, amphetamines QL (30 ea. per 30 days)
XERMELO™
5 Gastrointestinal agents: Gastrointestinal agents, other PA
XULTOPHY® 4 Blood glucose regulators: Insulins QL (15 ml per 30 days)
zileuton ER 5 Respiratory Tract/Pulmonary agents: Antileukotrienes QL (120 ea. per 30 days)
ZYTIGA® tablet 500mg 5 Antineoplastics: Antineoplastics, other PA
LA
Additions effective June 1, 2017
Drug name Tier Category Notes
diclofenac sodium solution 1.5% 4 Dermatological agents
Esbreit tablet 267 mg 5 Respiratory tract/Pulmonary agents: Respiratory tract agents, other PA
QL (270 ea. per 30 days)
Esbreit tablet 801 mg
5 Respiratory tract/Pulmonary agents: Respiratory tract agents, other
PA
QL (90 ea. per 30 days)
ezetimibe/simvastatin 4 Cardiovascular agents: Dyslipidemics, other
fayosim 4 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers): Estrogens
rivelsa 4 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers): Estrogens


zolpidem tartrate sublingual 4 Sleep disorder agents: GABA receptor modulators PA
QL (90 ea. per 365 days)
Additions effective May 1, 2017
Drug name Tier Category Notes
desvenlafaxine succinate ER (generic PRISTIQ) 4 Antidepressants: SSRIs/SNRIs (Selective serotonin reuptake inhibitors/Serotonin and norepinephrine reuptake inhibitor QL (30 ea. per 30 days)
KISQALI 5 Antineoplastics: Antineoplastics, other PA
LARTRUVO 190mg/19ml 5 Antineoplastics: Antineoplastics, other
B/D
ADLYXIN 4 Blood glucose regulators: Antidiabetic agents
ADLYXIN starter pack 4 Blood glucose regulators: Antidiabetic agents
BASAGLAR Quickpen 4 Blood glucose regulators: Antidiabetic agents
SOLIQUA 100/33 4 Blood glucose regulators: Antidiabetic agents
prednisone sodium phosphate oral solution, 10mg/5ml, 20mg/5ml 4 Hormonal agents, stimulant/ Replacement/ Modifying, Adrenal
miebelas 24 FE 4 Hormonal agents, stimulant/ Replacement/ Modifying, Sex hormones/ Modifiers): Estrogen

ILARIS 150mg/ml 5 Immunological agents: Immunomodulators PA
epinephrine 0.3mg/0.3ml auto-injector (generic EPI-PEN - Mylan) 3 Respiratory tract/ Pulmonary agents: Bronchodilators, sympathomimetic QL (4 ea. per 30 days)
Additions effective April 1, 2017
Drug name Tier Category Notes
AUVI-Q 5 Respiratory tract/Pulmonary agents: Brochodialtors, sympathomimetic  QL (2 ea. per 30 days)
PA
flurandrenolide 0.05% ointment 4 Hormonal agents, stimulant/ Replacement/ Modifying (Adrenal)
LINZESS 72mcg 3 Gastrointestinal agents: Irritable bowel syndrome agents QL (30 ea. per 30 days) 
SELZENTRY 25mg, 75mg 5 Antivirals: Anti-HIV agents, other
Additions effective March 1, 2017
Drug name Tier Category Notes
abacavir/lamivudine 600mg; 300mg 5 Antivirals: Anti-HIV agents, nucleoside and nucleotide reverse  
ACTEMRA injection 400mg/20ml, 80mg/4ml 5 Immunological agents: Immunomodulators PA
adriamycin solution 2mg/ml 2 Antineoplastics: Antineoplastics, other  
AFREZZA 4 Blood glucose regulators: Insulins ST
ALIMTA injection 100mg 5 Antineoplastics: Antimetabolites  
amlodipine/olmesartan medoxomil 4 Cardiovascular agents: Calcium channel blocking agents  
aprepitant capsule 4 Antiemetics: Emetogenic therapy adjuncts QL (6 ea per 30 days)
B/D
ARANESP albumin free injection 100mcg/0.4ml 4 Blood products/ Modifiers /Volume expanders: Blood formation modifiers B/D
azithromycin tablet 250mg 2 Antibacterials: Macrolides  
BEVESPI AEROSPHERE 4 Respiratory tract /Pulmonary agents: Bronchodilators, sympathomimetic QL (10.70 gm per 30 days)
cholestyramine light powder 4gm/dose 2 Cardiovascular agents: Dyslipidemics, other  
ciprofloxacin otic solution 0.2% 2 Antibacterials: Quinolones  
CUVITRU 5 Immunological agents: Immunizing agents, passive PA
daptomycin solution 500mg 2 Antibacterials: Antibacterials, other
DEPO-PROVERA 400mg/ml 4 Hormonal agents, stimulant /Replacement /Modifying (Sex hormones /Modifiers): Progestins
dexmethylphenidate HCl ER capsule extended release 24 hour 25mg, 35mg 4 Central nervous system agents: ADHD agents, non-amphetamines QL (30 ea per 30 days)
dextrose 5%/lactated ringers 2 Therapeutic nutrients /Minerals /Electrolytes: Electrolyte /Mineral replacement
digitek tablet 0.125mg 2 Cardiovascular agents: Cardiovascular agents, other QL (30 ea per 30 days)
digitek tablet 0.25mg q Cardiovascular agents: Cardiovascular agents, other PA
doxepin hydrochloride cream 5% 4 Dermatological agents: Dermatological agents
EMEND suspension 125mg 4 Antiemetics: Emetogenic therapy adjuncts QL (3 ea per 30 days)
B/D
EPCLUSA tablet 400mg; 100mg 5 Antivirals: Anti-hepatitis C (HCV) agents PA
epinephrine auto-injector 0.15mg/0.3ml 3 Respiratory tract /Pulmonary agents: Bronchodilators, sympathomimetic QL (4 ea per 30 days)
epirubicin vial 200mg/100ml 2 Antineoplastics: Antineoplastics, other
ERAXIS vial 50mg 4 Antifungals: Antifungals
ERBITUX injection 200mg/100ml 2 Analgesics/Opioid analgesics, short-acting PA
ethacrynic acid tablet 25mg 4 Cardiovascular agents: Diuretics, loop
ezetimibe tablet 10mg 4 Cardiovascular agents: Dyslipidemics, other
fluconazole in NaCl injection 200mg/100ml; 0.9% 2 Antifungals: Antifungals HI
flurandrenolide cream and lotion 0.05% 2 Hormonal agents, stimulant /Replacement/Modifying (Adrenal)
furosemide oral solution 8mg/ml 1 Cardiovascular agents: Diuretics, loop
furosemide syringe 10mg/ml 1 Cardiovascular agents: Diuretics, loop HI
fyavolv 2 Hormonal agents, stimulant /Replacement /Modifying (Sex hormones /Modifiers): Estrogens
GAMASTAN S/D 3 Immunological agents: Immunizing agents, passive PA
GAMMAGARD S/D 10gm, 5gm 5 Immunological agents: Immunizing agents, passive PA
gavilyte-h 2 Analgesics/Opioid analgesics, short-acting
gengraf capsule 50mg 2 Immunological agents: Immune suppressants B/D
granisetron solution 4mg/4ml 2 Antiemetics: Emetogenic therapy adjuncts HI
HUMIRA PEN - psoriasis starter 5 Immunological agents: Immune suppressants PA
hydromorphone HCl vial 50mg/5ml 2 Analgesics: Opioid analgesics, short-acting QL (120 ml per 30 days)
IMPAVIDO 5 Antibacterials: Antibacterials, other PA
INFLECTRA 5 Immunological agents: Immune suppressants

isotonic gentamicin 2 Antibacterials: Aminoglycosides
HI
IXEMPRA KIT injection 15mg 5 Antineoplastics: Antineoplastics, other

JENTADUETO XR 3 Blood glucose regulators: Antidiabetic agents QL (30 ea per 30 days)
KCl 0.075%/D5W/NaCl 0.45% 2 Therapeutic nutrients /Minerals /Electrolytes: Electrolyte /Mineral replacement
ketoconazole foam 2% 4 Antifungals: Antifungals
klor-con sprinkle 10meq, 8meq 2 Therapeutic nutrients /Minerals /Electrolytes: Electrolyte /Mineral replacement

KUVAN packet 100mg 5 Enzyme replacements /Modifiers: Enzyme replacements /Modifiers LA
KYPROLIS 5 Antineoplastics: Enzyme inhibitors PA
LARTRUVO 5 Antineoplastics: Antineoplastics, other
B/D
levalbuterol tartrate HFA 4 Respiratory tract /Pulmonary agents: Bronchodilators, sympathomimetic

levofloxacin in D5W injection 5%; 750mg/150ml 2 Antibacterials: Quinolones
levoleucovorin vial 50mg 5 Antineoplastics: Antineoplastics, other

lidocaine HCl injectable solution 0.5% 2 Anesthetics: Local anesthetics
lidocaine HCl jelly 2% 2 Anesthetics: Local anesthetics

lopinavir/ritonavir oral solution 400mg/5ml; 100mg/5ml 5 Antivirals: Anti-HIV agents, protease inhibitors
MERREM injection 1gm 4 Antibacterials: Beta-lactam, other
methotrexate sodium injection 50mg/2ml 2 Immunological agents: Immune suppressants
methyltestosterone capsule 10mg 5 Hormonal agents, stimulant /Replacement /Modifying (Sex hormones /Modifiers): Androgens PA
MINIVELLE patch twice weekly 0.025mg/24hr 4 Hormonal agents, stimulant /Replacement /Modifying (Sex hormones /Modifiers): Estrogens

mycophenolate mofetil intravenous 500mg 4 Immunological agents: Immune suppressants B/D
NAMZARIC 10mg; 21mg, 10mg; 7mg 4 Antidementia agents: Antidementia agents, other QL (30 ea per 30days)
PA
NAMZARIC titration pack 4 Antidementia agents: Antidementia agents, other
QL (28 ea per 28 days)
PA
naproxen sodium CR 24 hour tablet 375mg 2 Analgesics: Nonsteroidal anti-inflammatory drugs
naproxen sodium ER 24 hour tablet 500mg 2 Analgesics: Nonsteroidal anti-inflammatory drugs

neuac gel 5%; 1.2% 2 Dermatological agents: Dermatological agents
NEUPOGEN injection 300mcg/ml 5 Blood products /Modifiers /Volume expanders: Blood formation modifiers PA
nifedipine ER 90mg 2 Cardiovascular agents: Vasodilators, direct-acting arterial /Venous
norethindrone acetate/ethinyl estradiol tablet 5mcg; 1mg 2 Hormonal agents, stimulant /Replacement /Modifying (Sex hormones /Modifiers): Estrogens

NOVOLOG PENFILL 4 Blood glucose regulators: Insulins ST
NUTROPIN AQ NUSPIN 5, 10, 20 5 Hormonal agents, stimulant /Replacement /Modifying (Pituitary)
PA
OCALIVA 5 Gastrointestinal agents: Gastrointestinal agents, other QL (30 ea per 30 days)
PA
olmesartan medoxomil/amlodipine/hydrochlorothiazide tablet 4 Cardiovascular agents: Calcium channel blocking agents

ondansetron HCl syringe 4mg/2ml 2 Antiemetics: Emetogenic therapy adjuncts HI
ONZETRA XSAIL 4 Antimigraine agents: Serotonin (5-HT) 1b/1d receptor agonists ST
ORENCIA CLICKJECT 5 Immunological agents: Immune suppressants PA
ORFADIN CAPSULE 20mg 5 Enzyme replacement modifiers: Enzyme replacement modifiers LA
ORKAMBI 125mg; 100mg 5 Respiratory tract /Pulmonary agents: Cystic Fibrosis agents QL (120 ea per 30 days)
PA
oseltamivir phosphate capsule 30mg 3 Antivirals: Anti-influenza agents QL (112 ea per 365 days)
oseltamivir phosphate capsule 45mg, 75mg 3 Antivirals: Anti-influenza agents
QL (56 ea per 365 days)
OTREXUP injection 12.5mg/0.4ml 4 Immunological agents: Immune suppressants
ST
OXYCONTIN 10mg, 20mg 4 Analgesics: Opioid analgesics, long-acting
QL (60 ea per 30 days)
OXYCONTIN 40mg 4 Analgesics: Opioid analgesics, long-acting
PANCREAZE 10850 unit; 2600 unit; 6200 unitT 4 Enzyme replacement /Modifiers ST
paricalcitol injection 2mcg/ml, 5mcg/ml 2 Metabolic bone disease agents
peg-3350/NaCl/Na bicarbonate/KCl 2 Gastrointestinal agents: Laxatives
phenoxybenzamine hydrochloride capsule 10mg 2 Cardiovascular agents: Alpha-adrenergic blocking agents
piperacillin/tazobactam injection 36gm; 4.5gm 2 Antibacterials: Beta-lactam, penicillins HI
PLEGRIDY starter pack 5 Central nervous system agents: Multiple Sclerosis agents QL (1 ml per 28 days)
ST
potassium chloride 0.15% D5W/NaCl 0.33% and 022% D5W/NaCl 0.45% 2 Therapeutic nutrients /Minerals /Electrolytes: Electrolyte /Mineral replacement
potassium chloride ER tablet extended release 8meq 2 Therapeutic nutrients /Minerals /Electrolytes: Electrolyte /Mineral replacement

pramipexole dihydrochloride ER tablet extended release 24 hour 3.75mg 2 Antiparkinson agents: Dopamine agents
prednisolone sodium phosphate ODT 10mg, 15mg, 30mg 2 Hormonal agents, stimulant /Replacement /Modifying (Adrenal)

PROAIR RESPICLICK 3 Respiratory tract /Pulmonary agents: Bronchodilators, sympathomimetic
promethazine HCl injection 50mg/ml 2 Antiemetics: Antiemetics, other
quetiapine fumarate ER
4 Antipsychotics: 2nd generation /Atypical QL (30 ea per 30 days)
PA
rasagiline mesylate 3 Antiparkinson agents: Monoamine oxidase B (MAO-B) inhibitors
RAYALDEE 5 Therapeutic nutrients /Minerals /Electrolytes: Vitamins PA
RELISTOR syringe 12mg/0.6ml 4 Gastrointestinal agents: Gastrointestinal agents, other PA
RELISTOR tablet 150mg
5 Gastrointestinal agents: Gastrointestinal agents, other
QL (90 ea per 30 days)
PA
REPATHA PUSHTRONEX SYSTEM 5 Gastrointestinal agents: Gastrointestinal agents, other
QL (3.50 ml per 30 days
PA
RESTASIS MULTIDOSE 3 Ophthalmic agents: Ophthalmic agents, other
ribavirin nebulizer solution 6g 5 Respiratory tract /Pulmonary agents: Respiratory tract agents, other B/D
RUBRACA 5 Antineoplastics: Antineoplastics, other QL (120 ea per 30 days)
PA
SIMPONI pen 5 Immunological agents: Immune suppressants PA
SIMULECT injection 10mg 4 Immunological agents: Immunomodulators

SMOFLIPID 5 Miscellaneous therapeutic agents B/D
STELARA vial 5 Immunological agents: Immunomodulators
PA
sumatriptan succinate pen 6mg/0.5ml 2 Antimigraine agents: Serotonin (5-HT) 1b/1d receptor agonists QL (4 ml per 30 days)
SUSTOL 5 Antiemetics: Emetogenic therapy adjuncts B/D
TAYTULLA 4 Hormonal agents, stimulant /Replacement /Modifying (Sex hormones /Modifiers): Estrogens

tigecycline solution 3 Antibacterials: Antibacterials, other HI
TREXIMET 60mg; 10mg4
Analgesics/Opioid analgesics, short-acting
VASCEPA CAPSULE 0.5 GM 4 Cardiovascular agents: Dyslipidemics, other PA
VEMLIDY 5 Antivirals: Anti-hepatitis B (HBV) agents
verapamil HCl ER tablet extended release 120mg 2 Cardiovascular agents: Calcium channel blocking agents
VIEKIRA XR 5 Antivirals: Anti-hepatitis B (HBV) agents
QL (28 ea per 28 days)
PA
XIIDRA 4 Ophthalmic agents: Ophthalmic agents, other QL (60 ea per 30 days)
YONDELIS 5 Antineoplastics: Alkylating agents B/D
yuvafem 3 Hormonal agents, stimulant /Replacement /Modifying (Sex hormones /Modifiers): Estrogens

ZERIT oral solution 1mg/ml 5 Antivirals: Anti-HIV agents, neucleoside and nucleotide reverse transcriptase inhibitors (NRTI)
ZINBRYTA 5 Central nervous system agents: Multiple Sclerosis agents
QL (1 ml per 30 days)
PA
ZUBSOLV sublingual tablet 0.7mg; 0.18mg 4 Anti-addiction /Substance abuse treatment agents: Opioid dependence treatments QL (60 ea per 30days)
PA

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Changes to/removals from approved drug list

Changes/deletions effective October 1, 2017
Drug name New tier Notes
clopidogrel tablet 75 mg 1 Lowered tier
ezetimibe 2 Lowered tier
Changes/deletions effective September 1, 2017
Drug name New tier Notes
SELZENTRY® oral solution 5 Increased QL from 450ml to 460ml per 30 days
Changes/deletions effective June 1, 2017
Drug name New tier Notes
jantoven 1 Previously tier 2
Changes/deletions effective April 1, 2017
Drug name New tier Notes
COPAXONE 5 Removed PA requirement
ENTRESTO 5 Previously tier 3
QL (60 ea. per 30 days)
Removed PA requirement
quetiapine fumarate ER 300mg, 400mg 4 Increased QL  (60 ea. per 30 days)
PA
TECFIDERA 5 Removed QL
TECFIDERA Starter Pack 5 Removed QL
Changes/deletions effective March 1, 2017
Drug name New tier Notes
dicolfenac sodium gel 1% 2 Previously tier 4
fentanyl citrate injection 100mcg/2ml 2 Increased QL (400ml per 30 days)
HI
hydromorphone HCl injection 1mg/ml, 4mg/ml 2 Increased QL (1mg: 300ml per 30 days, 4mg: 75ml per 30 days)
INFUMORPH 500 3 Increased QL (80ml per 30 days)
methadone concentrate 10mg/ml 2 Increased QL (200ml per 30 days)
methadone HCl tablet soluble 2 Increased QL (50 ea per 30 days)
morphine sulfate injection 0.5mg/ml 2 Increased QL (4000ml per 30 days)
morphine sulfate injection 150mg/30ml 2 Increased QL (400ml per 30 days)
morphine sulfate injection 1mg/ml 2 Increased QL (2000ml per 30 days)
morphine sulfate injection 1mg/ml 2 Increased QL (2000ml per 30 days)