CurrentProvidence Health PlanPolicy N/A
2026 Prescription Drug 6-Tier Formulary
This part of the 2026 Providence Health Plan multi-tier prescription drug formulary lists drugs (by therapeutic class and product) with assigned tiers and embedded notes indicating prior authorization (PA), quantity limits (QL), specialty/LA/S flags and other billing notes for outpatient pharmacy coverage. It governs coverage tiering, utilization management flags, and per-product QL/PA requirements for the items included in this fragment.
Policy Summary
PayerProvidence Health Plan
Policy2026 Prescription Drug 6-Tier Formulary
Policy CodePolicy N/A
Change TypeNo material change
Effective Date
Next Review Date
Key ActionProvider must obtain prior authorization (PA) for products marked 'PA' before dispensing and adhere to listed quantity limits (QL) and specialty/LA handling requirements.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes noted in this brief (has_material_change=false).
partialDocument part
manyProducts with PA
multipleProducts with QL
numerousSpecialty / Limited Access
1-6Tiers present
Coverage Summary
Applicable Codes and Product List
ENBREL (etanercept) formulationsmixed
| ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5 ML (IML 1 ML) | Enbrel solution 25 mg/0.5 mL (1 mL fill) |
| ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5) | Enbrel prefilled syringe 25 mg/0.5 mL |
| ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML) | Enbrel prefilled syringe 50 mg/mL (1 mL) |
| ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (1 ML) | Enbrel SureClick pen 50 mg/mL (1 mL) |
HADLIMA (adalimumab biosimilar) formulationsmixed
| HADLIMA PUSHTOUCH SUBCUTANEOUS AUTO-INJECTOR 40 MG/0.8 ML | Hadlima PushTouch autoinjector 40 mg/0.8 mL |
| HADLIMA SUBCUTANEOUS SYRINGE 40 MG/0.8 ML | Hadlima prefilled syringe 40 mg/0.8 mL |
| HADLIMA(CF) PUSHTOUCH SUBCUTANEOUS AUTO-INJECTOR 40 MG/0.4 ML | Hadlima (CF) PushTouch autoinjector 40 mg/0.4 mL |
| HADLIMA(CF) SUBCUTANEOUS SYRINGE 40 MG/0.4 ML | Hadlima (CF) prefilled syringe 40 mg/0.4 mL |
SIMLANDI (adalimumab biosimilar) formulationsmixed
| SIMLANDI(CF) AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR, KIT 40 MG/0.4 ML | Simlandi (CF) autoinjector kit 40 mg/0.4 mL |
| SIMLANDI(CF) AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR, KIT 80 MG/0.8 ML | Simlandi (CF) autoinjector kit 80 mg/0.8 mL |
| SIMLANDI(CF) SUBCUTANEOUS SYRINGE KIT 20 MG/0.2 ML, 40 MG/0.4 ML | Simlandi (CF) syringe kit multiple strengths |
Hydroxychloroquine / AntimalarialsmixedCovered
| hydroxychloroquine oral tablet 100 mg | Hydroxychloroquine 100 mg tablet |
| hydroxychloroquine oral tablet 200 mg | Hydroxychloroquine 200 mg tablet |
| hydroxychloroquine oral tablet 300 mg | Hydroxychloroquine 300 mg tablet |
| hydroxychloroquine oral tablet 400 mg | Hydroxychloroquine 400 mg tablet |
| PLAQUENIL ORAL TABLET 200 MG | Plaquenil (hydroxychloroquine) 200 mg tablet |
Disease-modifying antirheumatics and immunosuppressantsmixedCovered
| methotrexate sodium (pf) injection solution 25 mg/ml | Methotrexate sodium preservative-free injection 25 mg/mL |
| methotrexate sodium (pf) injection recon soln 7 gram | Methotrexate sodium preservative-free 7 g recon solution |
| methotrexate sodium oral tablet 2.5 mg | Methotrexate 2.5 mg oral tablet |
| azathioprine oral tablet 50 mg | Azathioprine 50 mg tablet |
| cyclophosphamide oral capsule 25 mg | Cyclophosphamide 25 mg capsule |
| cyclophosphamide oral capsule 50 mg | Cyclophosphamide 50 mg capsule |
| penicillamine oral capsule 250 mg | Penicillamine 250 mg capsule |
Mycophenolate, azathioprine, and related agentsmixedCovered
| CELLCEPT ORAL CAPSULE 250 MG | CellCept capsule 250 mg |
| CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION 200 MG/ML | CellCept suspension 200 mg/mL for reconstitution |
| CELLCEPT ORAL TABLET 500 MG | CellCept tablet 500 mg |
| mycophenolate mofetil oral capsule 250 mg | Mycophenolate mofetil 250 mg capsule |
| mycophenolate mofetil oral suspension for reconstitution 200 mg/ml | Mycophenolate mofetil suspension 200 mg/mL |
| mycophenolate mofetil oral tablet 500 mg | Mycophenolate mofetil tablet 500 mg |
| mycophenolate sodium oral tablet, delayed release 180 mg | Mycophenolate sodium delayed-release 180 mg |
| mycophenolate sodium oral tablet, delayed release 360 mg | Mycophenolate sodium delayed-release 360 mg |
ORENCIA (abatacept) formulationsmixed
| ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML | Orencia ClickJect autoinjector 125 mg/mL |
| ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML | Orencia prefilled syringe 125 mg/mL |
| ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML | Orencia syringe 50 mg/0.4 mL |
| ORENCIA SUBCUTANEOUS SYRINGE 87.5 MG/0.7 ML | Orencia syringe 87.5 mg/0.7 mL |
KINERET, TYENNE, and related biologicsmixed
| KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 | Kineret syringe 100 mg/0.67 mL |
| TYENNE AUTOINJECTOR SUBCUTANEOUS PEN INJECTOR 162 MG/0.9 ML | Tyenne autoinjector 162 mg/0.9 mL |
RINVOQ and JAK inhibitorsmixedCovered
| RINVOQ LQ ORAL SOLUTION 1 MG/ML | Rinvoq liquid oral solution 1 mg/mL |
| RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 MG | Rinvoq ER 15 mg |
| RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 30 MG | Rinvoq ER 30 mg |
| RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 45 MG | Rinvoq ER 45 mg |
| XELJANZ ORAL TABLET 5 MG | Xeljanz 5 mg |
| XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG | Xeljanz XR 11 mg |
Biologics and specialty immunotherapiesmixed
| BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MG/ML | Benlysta subcutaneous autoinjector 200 mg/mL |
| BENLYSTA SUBCUTANEOUS SYRINGE 200 MG/ML | Benlysta prefilled syringe 200 mg/mL |
Anti-inflammatories, NSAIDs, and analgesicsmixedCovered
| celecoxib oral capsule 50 MG | Celecoxib 50 mg capsule (also available 100-400 mg strengths) |
| ketorolac injection syringe 15 MG/ML | Ketorolac injection 15 mg/mL |
| diclofenac potassium oral tablet 50 MG | Diclofenac potassium 50 mg tablet |
| diclofenac potassium oral powder in packet 50 MG | Diclofenac potassium powder 50 mg packet |
| ibuprofen oral tablet 400 MG | Ibuprofen 400 mg tablet (also 800 mg available) |
| naproxen oral tablet 250 MG | Naproxen 250 mg tablet (also 500 mg available) |
Disease-specific anti-infectives and antiparasiticsmixedCovered
| benznidazole oral tablet 100 MG | Benznidazole 100 mg tablet (also 12.5 mg strength) |
| ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML | Alinia nitazoxanide suspension 100 mg/5 mL and 500 mg tablet |
| metronidazole oral tablet 250 MG | Metronidazole 250 mg tablet (also 500 mg) |
Antiretrovirals, HIV agents and PrEPmixedCovered
| maraviroc oral tablet 150 MG | Maraviroc 150 mg tablet |
| maraviroc oral tablet 300 MG | Maraviroc 300 mg tablet |
| SELZENTRY (maraviroc) ORAL SOLUTION 20 MG/ML | Selzentry oral solution 20 mg/mL and tablets |
| DESCOVY (emtricitabine-tenofovir) | Descovy formulations (coverage includes some PrEP-specific formulations with diagnosis) |
| emtricitabine-tenofovir (various formulations) | Emtricitabine-tenofovir combination products and other ARV combos (abacavir, lamivudine, etc.) |
| PAXLOVID ORAL TABLETS, DOSE PACK (nirmatrelvir/ritonavir) | Paxlovid dose pack |
Valganciclovir and cytomegalovirus agentsmixedCovered
| VALCYTE ORAL RECON SOLN 50 MG/ML | Valcyte (valganciclovir) oral suspension 50 mg/mL |
| VALCYTE ORAL TABLET 450 MG | Valcyte tablet 450 mg |
Oral cephalosporins and beta-lactamsmixedCovered
| cefaclor oral capsule 250 MG | Cefaclor 250 mg capsule (also 500 mg) |
| cefaclor oral suspension for reconstitution 250 MG/5 ML | Cefaclor suspension 250 mg/5 mL |
| cefprozil oral suspension for reconstitution 125 MG/5 ML | Cefprozil suspension 125 mg/5 mL (also 250 mg/5 mL) |
| cefprozil oral tablet 250 MG | Cefprozil 250 mg tablet (also 500 mg) |
| cefuroxime axetil oral tablet 250 MG | Cefuroxime axetil 250 mg (also 500 mg) |
| cefdinir oral capsule 300 MG | Cefdinir 300 mg capsule |
| cefdinir oral suspension for reconstitution 125 MG/5 ML | Cefdinir suspension 125 mg/5 mL (also 250 mg/5 mL) |
Oral fluoroquinolones and related agentsmixedCovered
| CIPRO ORAL TABLET 250 MG | Ciprofloxacin 250 mg (also 500 mg) |
| ciprofloxacin hcl oral tablet 100 MG | Ciprofloxacin 100 mg tablet (also 250, 500, 750 mg) |
| levofloxacin oral solution 250 MG/10 ML | Levofloxacin oral solution 250 mg/10 mL |
| levofloxacin oral tablet 250 MG | Levofloxacin 250 mg tablet (also 500, 750 mg) |
| moxifloxacin oral tablet 400 MG | Moxifloxacin 400 mg tablet |
Clostridioides difficile and oral vancomycin agentsmixedCovered
| FIRVANQ ORAL RECON SOLN 25 MG/ML | Firvanq (fidaxomicin) oral reconstitution 25 mg/mL, 50 mg/mL |
| DIFICID ORAL SUSPENSION FOR RECONSTITUTION 40 MG/ML | Dificid (fidaxomicin) suspension 40 mg/mL |
| VANCOCIN ORAL CAPSULE 125 MG | Vancomycin oral capsule 125 mg (also 250 mg) |
| vancomycin oral recon soln 25 MG/ML | Vancomycin oral solution 25 mg/mL (also 50 mg/mL) |
Hepatitis B and antiviral nucleos(t)idesmixedCovered
| BARACLUDE ORAL SOLUTION 0.05 MG/ML | Baraclude (entecavir) oral solution 0.05 mg/mL |
| BARACLUDE ORAL TABLET 0.5 MG | Baraclude tablet 0.5 mg (also 1 mg) |
| VIREAD ORAL POWDER 40 MG | Viread oral powder 40 mg; tablets 150-300 mg |
| VEMLIDY ORAL TABLET 25 MG | Vemlidy (tenofovir alafenamide) 25 mg |
Interferons and pegylated productsmixed
| PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML | Pegasys (peginterferon alfa-2a) 180 mcg/mL |
| PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML | Pegasys prefilled syringe 180 mcg/0.5 mL |
Hepatitis C direct-acting antivirals (selected)mixedCovered
| MAVYRET ORAL PELLETS IN PACKET 50-20 MG | Mavyret packets 50/20 mg |
| MAVYRET ORAL TABLET 100-40 MG | Mavyret tablet 100/40 mg |
| VOSEVI ORAL TABLET 400-100-100 MG | Vosevi tablet 400/100/100 mg |
| ledipasvir-sofosbuvir oral tablet 90-400 MG | Harvoni (ledipasvir-sofosbuvir) 90/400 mg |
| sofosbuvir-velpatasvir oral tablet 400-100 MG | Epclusa (sofosbuvir-velpatasvir) 400/100 mg |
Antivirals: CMV, HSV, VZVmixedCovered
| acyclovir oral capsule 200 MG | Acyclovir 200 mg capsule |
| acyclovir oral suspension 200 MG/5 ML | Acyclovir suspension 200 mg/5 mL |
| acyclovir oral tablet 400 MG | Acyclovir 400 mg tablet (also 800 mg) |
| valacyclovir oral tablet 1 GRAM | Valacyclovir 1 g tablet (also 500 mg) |
| VALTREX ORAL TABLET 1 GRAM | Valtrex 1 g tablet |
Influenza and respiratory antiviralsmixedCovered
| oseltamivir oral suspension for reconstitution 6 MG/ML | Tamiflu suspension 6 mg/mL |
| TAMIFLU ORAL CAPSULE 75 MG | Tamiflu 75 mg capsule (also 30, 45 mg) |
| RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION | Relenza zanamivir 5 mg/actuation |
Clindamycin groupmixedCovered
| CLEOCIN HCL ORAL CAPSULE 150 MG | Cleocin capsules 150 mg (also 75, 300 mg) |
| CLEOCIN PEDIATRIC ORAL RECON SOLN 75 MG/5 ML | Cleocin pediatric suspension 75 mg/5 mL |
Macrolides and relatedmixedCovered
| azithromycin oral packet 1 GRAM | Azithromycin 1 g packet |
| azithromycin oral suspension for reconstitution 100 MG/5 ML | Azithromycin suspension 100 mg/5 mL (also 200 mg/5 mL) |
| azithromycin oral tablet 250 MG | Azithromycin 250 mg tablet (also 500, 600 mg) |
| clarithromycin oral suspension for reconstitution 125 MG/5 ML | Clarithromycin suspension 125 mg/5 mL (also 250 mg/5 mL) |
| clarithromycin oral tablet 250 MG | Clarithromycin 250 mg tablet (also 500 mg) |
Antibiotics: tetracyclines, doxycycline, minocyclinemixedCovered
| minocycline oral capsule 100 MG | Minocycline 100 mg capsule (also 50 mg, 75 mg) |
| doxycycline hyclate oral capsule 100 MG | Doxycycline hyclate 100 mg capsule |
| doxycycline monohydrate oral tablet 100 MG | Doxycycline monohydrate 100 mg tablet |
Linezolid and tedizolidmixedCovered
| linezolid oral suspension for reconstitution 100 MG/5 ML | Linezolid suspension 100 mg/5 mL |
| linezolid oral tablet 600 MG | Linezolid 600 mg tablet |
| SIVEXTRO ORAL TABLET 200 MG | Sivextro (tedizolid) 200 mg tablet |
Topical, ophthalmic, and dermatologic agents (selected)mixedCovered
| EUCRISA TOPICAL OINTMENT 2 % | Eucrisa 2% ointment |
| mupirocin topical ointment 2 % | Mupirocin 2% ointment |
| QBREXZA TOPICAL TOWELETTE 2.4 % | Qbrexza towelette 2.4% |
| nystatin topical cream 100,000 UNIT/GRAM | Nystatin topical cream 100,000 U/g |
Vitamins, calcitriol and analoguesmixedCovered
| calcitriol oral capsule 0.25 MCG | Calcitriol 0.25 mcg capsule |
| calcitriol oral capsule 0.5 MCG | Calcitriol 0.5 mcg capsule |
| ROCALTROL ORAL SOLUTION 1 MCG/ML | Rocaltrol solution 1 mcg/mL |
| ZEMPLAR ORAL CAPSULE 1 MCG | Zemplar paricalcitol 1 mcg capsule (also 2 mcg) |
Transplant immunosuppressants and therapeutic mTOR/CNI agentsmixedCovered
| ASTAGRAF XL ORAL CAPSULE 0.5 MG | Astagraf XL tacrolimus 0.5 mg |
| cyclosporine modified oral capsule 100 MG | Modified cyclosporine 100 mg capsule |
| GENGRAF ORAL SOLUTION 100 MG/ML | Gengraf solution 100 mg/mL |
| PROGRAF ORAL CAPSULE 0.5 MG | Prograf tacrolimus 0.5 mg capsule |
| LUPKYNIS ORAL CAPSULE 7.9 MG | Lupkynis 7.9 mg capsule |
Policy Summary
PayerProvidence Health Plan
Policy2026 Prescription Drug 6-Tier Formulary
Policy CodePolicy N/A
Change TypeNo material change
Effective Date
Next Review Date
Key ActionProvider must obtain prior authorization (PA) for products marked 'PA' before dispensing and adhere to listed quantity limits (QL) and specialty/LA handling requirements.
SourceLink
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