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2024 Formulary Changes

The table below outlines all the changes to our formulary since the formulary list was last printed on 04/01/2024.

Drug NameDescription of Change*Copay AmountEffective Date
of Change
Dexcom G7 Receiver and SensorAddition of PA with QL$001/01/2024
Free Style Libre 3 SensorAddition of PA with QL$001/01/2024
Cyclosporine Ophthalmic emulsion 0.05%
(generic Restasis) Single-Use vials
Addition with QL$101/01/2024
Vanflyta (quizartinib)Addition to formulary with PA$301/01/2024
Xdemvy drops 0.25% (lotilaner)Addition to formulary with PA$104/01/2024
Ojjaara (momelotinib)Addition to formulary with PA$104/01/2024
Paxlovid (co-packaged nirmatrelvir tablets and ritonavir tablets)Addition with QL$104/01/2024
Minocycline 50mg tabletAddition to formulary$104/01/2024
Ibandronate 150mg tabletAddition to formulary$104/01/2024
Levocarnitine 1gm/10mL oral solutionAddition to formulary$104/01/2024
Acebutolol capsulesAddition to formulary$104/01/2024
Olmesartan-hydrochlorothiazide tabletsAddition to formulary$104/01/2024
Cholestyramine Powder PacketsAddition to formulary$104/01/2024
Desloratadine 5mg tabletAddition to formulary$104/01/2024
Dextromethorphan-guaifenesin Liquid 5-00mg/5mLAddition to formulary$104/01/2024
Desloratadine 5mg tabletAddition to formulary$104/01/2024
Dextromethorphan-guaifenesin Liquid 5-00mg/5mLAddition to formulary$104/01/2024
Roflumilast tabletsAddition to formulary$104/01/2024
Docusate sodium 250mg capsuleAddition to formulary$104/01/2024
Sodium sulfate-Potassium sulfate-Magnesium sulfate Oral solution (generic of Suprep Bowel Prep Kit)Addition to formulary$104/01/2024
Glycopyrrolate 1mg/5mL oral solutionAddition to formulary$104/01/2024
Scopolamine 1mg/3day patchAddition to formulary$104/01/2024
Dronabinol 2.5mg capsuleAddition to formulary$104/01/2024
Potassium Citrate-citric acid oral solutionAddition to formulary$104/01/2024
Silodosin capsulesAddition to formulary$104/01/2024
Acetaminophen 650mg suppositoryAddition to formulary$104/01/2024
Codeine sulfate 30mg tabletAddition to formulary$104/01/2024
Hydromorphone ER tabletsAddition to formulary with PA$104/01/2024
Hydrocodone-ibuprofen tabletsAddition to formulary$104/01/2024
Indomethacin ER capsulesAddition to formulary$104/01/2024
Amantadine tabletsAddition to formulary$104/01/2024
Ropinirole ER tabletsAddition to formulary$104/01/2024
Cyclobenzaprine 7.5mg tabletAddition to formulary$104/01/2024
Vitamin D3 5000 unit tabletAddition to formulary$104/01/2024
Wescaps (B-Complex w/Folic Acid) capsulesAddition to formulary$104/01/2024
Cyclopentol ophthalmic solution 1%Addition to formulary$104/01/2024
Mupirocin cream 2%Addition to formulary$104/01/2024
Lidocaine 5% patchAddition with QL$104/01/2024

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

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.

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Priority Partners members whose medical care is impacted by the recent collapse of the Francis Scott Key Bridge are encouraged to call our Customer Service team for assistance at 800-654-9728.
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