CurrentProvidence Health PlanPolicy N/A

2026 Prescription Drug 6-Tier Formulary

This document is the Providence Health Plan 2026 prescription drug formulary covering Formulary M, N/N-HSA, P/P-HSA; it lists covered drugs by therapeutic category, tier placement (0-6), and formulary restrictions (PA, QL, ST, S, LA, PV) and provides member/provider guidance on use of the formulary.

Policy Summary

PayerProvidence Health Plan

Policy2026 Prescription Drug 6-Tier Formulary

Policy CodePolicy N/A

Change TypeClarified - formulary content and notes

Effective Date

Next Review Date

Key ActionObtain prior authorization (PA) when indicated, adhere to quantity limits (QL), and route specialty (S) or limited access (LA) drugs via the contracted specialty pharmacy as required.

SourceLink

POLICY UPDATE CHANGES

Formulary includes tier definitions, restriction abbreviations, and examples of QL/PA/ST/S/LA/PV usage.

6Formulary tiers

90Opioid cumulative dose limit (MME/day)

multipleSpecialty products (S)

multipleProducts with PA

multipleProducts with QL

Coverage Summary & Formulary Scope

Formulary Coverage Rules and Restrictions

Scope: This document is the Providence Health Plan 2026 Prescription Drug 6‑Tier Formulary. It describes the six-tier structure used across Providence formulary products (Formulary M, N/N‑HSA, P/P‑HSA) and summarizes how the Pharmacy & Therapeutics (P&T) Committee maintains and updates the formulary. It also explains what tiers mean, the common restriction abbreviations, and where to find plan‑specific exclusions and benefit exceptions.

This formulary applies to drugs dispensed by a pharmacy and self‑administered medications within the prescription drug benefit. The P&T Committee (physicians, pharmacists, and other clinical experts) continuously reviews clinical evidence and cost information to maintain the formulary and may update drug status monthly. Tier placement determines member cost‑sharing; consult the member contract/benefit summary for plan‑specific cost details. Some drugs are subject to restrictions (for example: prior authorization, step therapy, quantity limits) or excluded entirely from prescription benefit coverage. For a full list of plan‑specific exclusions and benefit limitations, refer to the member handbook, plan documents, or the member portal (myProvidence).

paragraphs':['Background: The formulary includes FDA‑approved generic, brand‑name, and specialty drugs considered safe and effective for various conditions. Specialty drugs (noted as S in the formulary) generally require specialty pharmacy distribution (for example, Credena Health) and are typically limited to a 30‑day supply. Exclusions include drugs not covered by the prescription drug benefit (e.g., non‑FDA‑approved drugs, most over‑the‑counter drugs unless required by law). For coverage questions or to request a formulary exception, members and providers may contact Providence Customer Service.'],

Policy Summary

PayerProvidence Health Plan

Policy2026 Prescription Drug 6-Tier Formulary

Policy CodePolicy N/A

Change TypeClarified - formulary content and notes

Effective Date

Next Review Date

Key ActionObtain prior authorization (PA) when indicated, adhere to quantity limits (QL), and route specialty (S) or limited access (LA) drugs via the contracted specialty pharmacy as required.

SourceLink

On This Page

Formulary Coverage Rules and Restrictions

Covered when the logical combinations below are met. Tier definitions and restriction abbreviations are shown first, followed by the nested criteria logic for coverage rules, utilization controls, and exclusions.

ALL of the following

Tier Definitions
- ACA Preventive: Tier 0 — Covered in full, zero cost share.
- Tier 1 — Generic drugs with high value.
- Tier 2 — Generic drugs.
- Tier 3 — Generic drugs and high‑value brand‑name drugs.
- Tier 4 — All other non‑specialty brand‑name drugs and high‑cost generic drugs.
- Tier 5 — Preferred specialty drugs (brand‑name and generic).
- Tier 6 — All other high‑cost specialty drugs (brand‑name and generic).
Restriction Abbreviations (may appear in formulary notes)
- PA — Prior Authorization Required: Provider or member must obtain prior approval before the drug will be covered.
- QL — Quantity Limit Applies: Limits on amount covered per fill or time period.
- ST — Step Therapy Required: Member must try specified first‑line therapy before this drug is covered.
- S — Specialty Drug: Requires use of contracted specialty pharmacy; often limited to 30‑day supply.
- LA — Limited Access Drug: Drug is limited to certain pharmacies per manufacturer; may not be available from all specialty pharmacies.
- PV — Core Preventive (HSA plans): Drug is a core preventive drug; available at the tier cost‑share but not subject to deductible; restrictions still apply.
Utilization Controls Listed
- Prior Authorization (PA): Clinical review performed before coverage; may require documentation of diagnosis, prior therapies, or clinical rationale. Without PA, drug may not be covered.
- Quantity Limits (QL): Limits are applied to ensure safe and effective use (example: sumatriptan 9 tablets per 30 days).
- Step Therapy (ST): A step process to confirm first‑line therapies have been tried; may be processed as a specialized PA.
- Specialty Pharmacy (S): Some drugs require dispensing via contracted specialty pharmacy (Credena Health) and are typically limited to a 30‑day supply.
- Limited Access (LA): Some products are limited to particular pharmacies by the manufacturer; contact Customer Service for details.
Exclusions
- Drugs not covered under the prescription benefit (for example: non‑FDA‑approved drugs, most over‑the‑counter products unless required by law).
- Plan‑specific exclusions and complete exclusion lists are available in member plan documents and the member handbook; contact Customer Service or myProvidence for details.

Formulary Drug Listings (selected groups)

Opioid Tablets & Liquids (covered/managed)mixedCovered

codeine sulfate oral tablet 15 mg	codeine sulfate oral tablet 15 mg
codeine sulfate oral tablet 30 mg	codeine sulfate oral tablet 30 mg
codeine sulfate oral tablet 60 mg	codeine sulfate oral tablet 60 mg
hydrocodone bitartrate oral capsule ER 12hr 10 mg	hydrocodone bitartrate oral capsule ER 12hr 10 mg
hydrocodone bitartrate oral capsule ER 12hr 15 mg	hydrocodone bitartrate oral capsule ER 12hr 15 mg
hydrocodone bitartrate oral capsule ER 12hr 20 mg	hydrocodone bitartrate oral capsule ER 12hr 20 mg
hydrocodone bitartrate oral capsule ER 12hr 30 mg	hydrocodone bitartrate oral capsule ER 12hr 30 mg
hydrocodone bitartrate oral capsule ER 12hr 40 mg	hydrocodone bitartrate oral capsule ER 12hr 40 mg
hydrocodone bitartrate oral capsule ER 12hr 50 mg	hydrocodone bitartrate oral capsule ER 12hr 50 mg
hydromorphone oral liquid 1 mg/ml	hydromorphone oral liquid 1 mg/ml

1–10 of 64

1/7

Combination Analgesics & Cough PreparationsmixedCovered

acetaminophen-codeine oral solution 120-12 mg/5 ml	acetaminophen-codeine oral solution 120-12 mg/5 ml
acetaminophen-codeine oral tablet 300-15 mg	acetaminophen-codeine oral tablet 300-15 mg
acetaminophen-codeine oral tablet 300-30 mg	acetaminophen-codeine oral tablet 300-30 mg
acetaminophen-codeine oral tablet 300-60 mg	acetaminophen-codeine oral tablet 300-60 mg
butalbital-acetaminop-caf-cod oral capsule 30-50-325-40 mg	butalbital-acetaminop-caf-cod oral capsule 30-50-325-40 mg
hydrocodone-acetaminophen oral solution 10-325 mg/15 ml	hydrocodone-acetaminophen oral solution 10-325 mg/15 ml
hydrocodone-ibuprofen oral tablet 5-200 mg	hydrocodone-ibuprofen oral tablet 5-200 mg
hydrocodone-ibuprofen oral tablet 7.5-200 mg	hydrocodone-ibuprofen oral tablet 7.5-200 mg
hydrocodone-ibuprofen oral tablet 10-200 mg	hydrocodone-ibuprofen oral tablet 10-200 mg
oxycodone-acetaminophen oral tablet 10-325 mg	oxycodone-acetaminophen oral tablet 10-325 mg

1–10 of 11

1/2

Butorphanol / Miscellaneous Opioid Analgesics (nasal, transdermal, patch)mixed

butorphanol nasal spray non-aerosol 10 mg/ml	butorphanol nasal spray non-aerosol 10 mg/ml
buprenorphine transdermal patch weekly 5 mcg/hour	buprenorphine transdermal patch weekly 5 mcg/hour
buprenorphine transdermal patch weekly 7.5 mcg/hour	buprenorphine transdermal patch weekly 7.5 mcg/hour
buprenorphine transdermal patch weekly 10 mcg/hour	buprenorphine transdermal patch weekly 10 mcg/hour
buprenorphine transdermal patch weekly 15 mcg/hour	buprenorphine transdermal patch weekly 15 mcg/hour
buprenorphine transdermal patch weekly 20 mcg/hour	buprenorphine transdermal patch weekly 20 mcg/hour

Non-Opioid & Novel AnalgesicsmixedCovered

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 50 MG	NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 50 MG
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG	NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 150 MG	NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 150 MG
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 200 MG	NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 200 MG
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 250 MG	NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 250 MG
TAVNEOS ORAL CAPSULE 10 MG	TAVNEOS ORAL CAPSULE 10 MG
REZUROCK ORAL TABLET 200 MG	REZUROCK ORAL TABLET 200 MG

Specialty Biologics & Injectables (Tier 5/6 examples)mixedExperimental

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML	ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML
ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML)	ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML)
ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (1 ML)	ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (1 ML)
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (1 ML)	ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (1 ML)
ADALIMUMAB-AATY SUBCUTANEOUS AUTO-INJECTOR KIT 40 MG/0.4 ML	ADALIMUMAB-AATY SUBCUTANEOUS AUTO-INJECTOR KIT 40 MG/0.4 ML
ADALIMUMAB-AATY SUBCUTANEOUS AUTO-INJECTOR KIT 80 MG/0.8 ML	ADALIMUMAB-AATY SUBCUTANEOUS AUTO-INJECTOR KIT 80 MG/0.8 ML
ADALIMUMAB-AATY SUBCUTANEOUS SYRINGE KIT 20 MG/0.2 ML	ADALIMUMAB-AATY SUBCUTANEOUS SYRINGE KIT 20 MG/0.2 ML
ADALIMUMAB-AATY SUBCUTANEOUS SYRINGE KIT 40 MG/0.4 ML	ADALIMUMAB-AATY SUBCUTANEOUS SYRINGE KIT 40 MG/0.4 ML
ADALIMUMAB-AATY(CF) AI CROHNS SUBCUTANEOUS AUTO-INJECTOR KIT 80 MG/0.8 ML	ADALIMUMAB-AATY(CF) AI CROHNS SUBCUTANEOUS AUTO-INJECTOR KIT 80 MG/0.8 ML
ADALIMUMAB-ADAZ SUBCUTANEOUS PEN INJECTOR 40 MG/0.4 ML	ADALIMUMAB-ADAZ SUBCUTANEOUS PEN INJECTOR 40 MG/0.4 ML

1–10 of 24

1/3

Antifungals, Antimicrobials & Selected Anti-InfectivesmixedCovered

CRESEMBA ORAL CAPSULE 186 MG	CRESEMBA ORAL CAPSULE 186 MG
CRESEMBA ORAL CAPSULE 74.5 MG	CRESEMBA ORAL CAPSULE 74.5 MG
ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML	ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML
THALOMID ORAL CAPSULE 50 MG	THALOMID ORAL CAPSULE 50 MG
THALOMID ORAL CAPSULE 100 MG	THALOMID ORAL CAPSULE 100 MG
benznidazole oral tablet 100 mg	benznidazole oral tablet 100 mg
benznidazole oral tablet 12.5 mg	benznidazole oral tablet 12.5 mg
SUNLENCA ORAL TABLET 300 MG	SUNLENCA ORAL TABLET 300 MG
YEZTUGO ORAL TABLET 300 MG	YEZTUGO ORAL TABLET 300 MG
RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HR 600 MG	RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HR 600 MG

1–10 of 12

1/2

Iron Chelation & Rare Disease Orphans (Tier 6 examples)mixedExperimental

FERRIPROX ORAL TABLET MODIFIED RELEASE 1000 MG	FERRIPROX ORAL TABLET MODIFIED RELEASE 1000 MG
FERRIPROX ORAL SOLUTION 100 MG/ML	FERRIPROX ORAL SOLUTION 100 MG/ML
deferasirox oral tablet, dispersible 125 mg	deferasirox oral tablet, dispersible 125 mg
deferasirox oral tablet, dispersible 250 mg	deferasirox oral tablet, dispersible 250 mg
deferasirox oral tablet, dispersible 500 mg	deferasirox oral tablet, dispersible 500 mg
deferasirox oral tablet 90 mg	deferasirox oral tablet 90 mg
deferasirox oral tablet 180 mg	deferasirox oral tablet 180 mg
deferasirox oral tablet 360 mg	deferasirox oral tablet 360 mg
deferiprone oral tablet 500 mg	deferiprone oral tablet 500 mg
deferiprone oral tablet 1000 mg	deferiprone oral tablet 1000 mg

Antiretrovirals & HIV TherapiesmixedCovered

BIKTARVY ORAL TABLET 30-120-15 MG	BIKTARVY ORAL TABLET 30-120-15 MG
BIKTARVY ORAL TABLET 50-200-25 MG	BIKTARVY ORAL TABLET 50-200-25 MG
DESCOVY ORAL TABLET 120-15 MG	DESCOVY ORAL TABLET 120-15 MG (note for PrEP coverage)
DESCOVY ORAL TABLET 200-25 MG	DESCOVY ORAL TABLET 200-25 MG (note for PrEP coverage)
PAXLOVID ORAL TABLETS (dose pack)	PAXLOVID ORAL TABLETS (dose pack)

Antibiotics — Oral (selected strengths)mixedCovered

cephalexin oral capsule 750 mg	cephalexin oral capsule 750 mg
cefadroxil oral capsule 500 mg	cefadroxil oral capsule 500 mg
MOXATAG ORAL TABLET ER MULTIPHASE 24 HR 775 MG	MOXATAG ORAL TABLET ER MULTIPHASE 24 HR 775 MG
PIVYA ORAL TABLET 185 MG	PIVYA ORAL TABLET 185 MG
albendazole oral tablet 200 mg	albendazole oral tablet 200 mg
emverm oral tablet chewable 100 mg	emverm oral tablet, chewable 100 mg
ivermectin oral tablet 3 mg	ivermectin oral tablet 3 mg
praziquantel oral tablet 600 mg	praziquantel oral tablet 600 mg
sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5 ml	sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5 ml

Antifungals & Antivirals (selected)mixedCovered

posaconazole oral suspension 200 mg/5 ml	posaconazole oral suspension 200 mg/5 ml (40 mg/ml)
posaconazole oral tablet delayed release 100 mg	posaconazole oral tablet delayed release 100 mg
voriconazole oral suspension for reconstitution 200 mg/5 ml	voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml)
voriconazole oral tablet 200 mg	voriconazole oral tablet 200 mg
voriconazole oral tablet 50 mg	voriconazole oral tablet 50 mg
valganciclovir oral recon soln 50 mg/ml	valganciclovir oral recon soln 50 mg/ml
valganciclovir oral tablet 450 mg	valganciclovir oral tablet 450 mg

Cardiovascular, Anticoagulants & Lipid Agents (selected)mixedCovered

apixaban oral tablet 2.5 mg	apixaban (ELIQUIS) oral tablet 2.5 mg
rivaroxaban DVT-PE treat start dose pack	rivaroxaban (XARELTO) DVT-PE treat start dose pack 15 mg (42) - 20 mg (9)
warfarin oral tablet 1 mg	warfarin oral tablet 1 mg
clopidogrel oral tablet 75 mg	clopidogrel oral tablet 75 mg

Respiratory, Inhaled & Nasal (selected)mixedCovered

TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML	TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML)
UPTRAVI ORAL TABLET multiple strengths	UPTRAVI ORAL TABLET (multiple mcg strengths)
EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 300 MG/3 ML	EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 300 MG/3 ML (100 MG/ML X 3)

OpenPayer

2026 Prescription Drug 6-Tier Formulary

Coverage Summary & Formulary Scope

Utilization Controls (PA / QL / ST / LA / S)

Formulary Drug Listings (selected groups)

What Providers Must Do

Devices, Supplies & DME / Site-of-Care Notes

Revision History