2021 Priority Partners Formulary Changes

 

The table below outlines all the changes to our formulary since the formulary list was last printed on 01/01/2021.

 

 

Drug Name Description of Change* Copay Amount Effective Date
of Change
Palforzia (Peanut allergen oral immunotherapy powder) Addition to formulary with PA $3 01/01/2021
Qinlock (ripretinib) Addition to formulary with PA $3 01/01/2021
Retevmo (selpercatinib) Addition to formulary with PA $3 01/01/2021
Inqovi (decitabine-cedazuridine) Addition to formulary with PA $3 01/01/2021
Semglee (insulin glargine) Addition of QL (20 pens per 25 days; 6 vials per 25 days) $3 01/01/2021
Oxycodone-acetaminophen oral solution Formulary Deletion N/A 01/01/2021
Onureg (azacitidine) Addition to formulary with PA $3 04/01/2021
Gavreto (pralsetinib) Addition to formulary with PA $3 04/01/2021
Dificid oral suspension (fidaxomicin) Addition to formulary with PA $3 04/01/2021
Orgovyx (relugolix) Addition to formulary with PA $3 04/01/2021
Rybelsus (oral semaglutide) Addition to formulary with ST $3 04/01/2021
Rosuvastatin (generic for Crestor) Addition to formulary $1 04/01/2021
Tepmetko (tepotinib) Addition to formulary with PA $3 07/01/2021
Ukoniq (umbralisib) Addition to formulary with PA $3 07/01/2021
Incruse Ellipta (umeclidinium) Addition to formulary $3 07/01/2021
Cefadroxil suspension 250mg/5mL and 500mg/5mL Addition to formulary $1 07/01/2021
Spiriva Respimat and Spiriva HandiHaler (tiotropium) Formulary Deletion N/A 07/01/2021
Synjardy and Synjardy XR (empagliflozin-metformin) Formulary Deletion N/A 07/01/2021

*QL = Quantity Limit, PA = Prior Authorization, ST = Step Therapy, NF = Non Formulary, N/A = Not Applicable