Post on 31-Mar-2021
OPTUMRxreg Utilization management updates - January 1 2020
Prior authorization mdash Premium
There are some medications that have to be authorized by a doctor before you can get them because the medications are approved or effective only for some conditions
Reviewing medications
A group of doctors and pharmacists meets often to review medications under pharmacy beneft plans They also recommend prior authorization guidelines
Safe and effective
When making recommendations the review committee focuses on medication safety effectiveness and cost including
bull US Food and Drug Administration (FDA) approved uses
bull Medication instruction labels
bull Accepted or published clinical recommendations
Getting a short-term supply
If you must take a medication that requires prior authorization right away there are two options that may work for you First ask your doctor if a sample is available Or check with your pharmacy to request a short-term supply of 5 days or less Keep in mind you will be responsible for the full cost at that time If the prior authorization request is approved then your pharmacist can fll the rest of your prescription
Requesting a prior authorization
You your pharmacist or your doctor can start the prior authorization process by contacting us We will work with your doctor to get the information needed for the review Once we receive a fnished prior authorization form from your doctor we will conduct a review within a few days and send you and your doctor a letter regarding the decision
In this drug list brand-name medications are shown in UPPERCASE (for example CLOBEX) and generic medications in lowercase (for example clobetasol)
Premium Formulary 1
Antibiotics
Antifungals
Antifungals
Antifungals
Antifungals
Antifungals
Antifungals
Antifungals
Antilipemic
Antilipemic
Antilipemic
Antilipemic
Heart Failure
ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)
Premium non-specialty prior authorization list
These medications may require prior authorization based on your beneft plan For more information contact customer service at the phone number on your member ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Anthelmintics ALBENZA (albendazole) None
Antibiotics AEMCOLO (rifamycin) None
XIFAXAN (rifaximin) None
Antifungals CICLODAN KIT (ciclopirox) None
CICLOPIROX KIT (ciclopirox) None
CNL8 NAIL KIT (ciclopirox) None
KERYDIN (tavaborole) None
ONMEL (itraconazole) None
PEDIPROX-4 (ciclopirox) nail kit None
SPORANOX (itraconazole) Soln None
SPORANOX (itraconazole) None
Antihelmintics ALBENZA (albendazole) None
Antimalarial QUALAQUIN (quinine) None
Antiretrovirals HIV Selzentry (maraviroc) None
Trogarzo (ibalizumab) None
Cardiology Antilipemic omega-3 fatty acid None
PRALUENT (alirocumab) 2 syringes28 days
REPATHA (evolocumab) 3 syringes28 days
REPATHA PUSH (evolocumab) 1 cartridge28 days
VASCEPA (icosapent ethyl) None
Heart Failure CORLANOR (ivabradine) 2 tabsday
CORLANOR (ivabradine) Soln 15 mLday
Central Nervous System ADHD Agents (PA age ADHANSIA XR (methylphenidate) 4 capsday 19+ only) 25 mg
ADHANSIA XR (methylphenidate) 1 capday
ADZENYS ER (amphetamine) 15 mLday
ADZENYS XR-ODT (amphetamine) 1 tabday
amphetamine 6 tabsday
amphetaminedetroamphetamine 2 tabsday 30 mg tab
2
ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT amphetaminedetroamphetamine 3 tabsday
amphetaminedetroamphetamine ER 1 capday
APTENSIO XR (methylphenidate) 1 capday
COTEMPLA XR-ODT (methylphenidate) 86 mg COTEMPLA XR-ODT (methylphenidate) 173 mg COTEMPLA XR-ODT (methylphenidate) 259 mg DAYTRANA (methylphenidate transdermal) DESOXYN (methamphetamine)
6 tabsday
3 tabsday
2 tabsday
1 patchday
5 tabsday
DEXEDRINE (dextroamphetamine) 10 mg DEXEDRINE (dextroamphetamine) 5 mg DEXEDRINE (dextroamphetamine) 15 mg dexmethylphenidate
6 capsday
3 capsday
4 capsday
2 tabsday
DYANAVEL XR (amphetamine) 8 mLday
EVEKEO ODT (amphetamine) 5 mg 10 mg EVEKEO ODT (amphetamine) 15 mg 20 mg FOCALIN XR (dexmethylphenidate)
3 tabsday
2 tabsday
1 capday
FOCALIN XR (dexmethylphenidate) 20 mg JORNAY PM (methylphenidate)
2 capsday
1 capday
METADATE CD (methylphenidate) 1 capday
METADATE ER (methylphenidate) 20 mg METHYLIN (methylphenidate)
3 tabsday
3 tabsday
METHYLIN (methylphenidate) Soln 10 mg5 mL
30 mLday
3
ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)19+ only)
ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT METHYLIN (methylphenidate) Soln 5 mg5 mL METHYLIN CHEW TAB (methylphenidate) METHYLIN CHEW TAB (methylphenidate) 10 mg METHYLIN ER (methylphenidate) 20 mg methylphenidate
60 mLday
3 tabsday
6 tabsday
3 tabsday
3 tabsday
METHYLPHENIDATE ER (methylphenidate) 10 mg methylphenidate ER tab osmotic release 36 mg methylphenidate ER tab osmotic release
2 tabsday
2 tabsday
1 tabday
MYDAYIS (amphetamine dextroamphetamine) PROCENTRA (dextroamphetamine) Sol
1 capday
60 mLday
QUILLICHEW ER (methylphenidate) 30 mg QUILLICHEW ER (methylphenidate)
2 tabsday
1 tabday
QUILLIVANT XR (methylphenidate) 12 mLday
RELEXXII (methylphenidate) 72 mg 1 tabday
RITALIN LA (methylphenidate) 1 capday
RITALIN SR (methylphenidate) 20 mg 3 tabsday
VYVANSE (lisdexamfetamine) 1 capday
VYVANSE CHEW TAB (lisdexamfetamine) ZENZEDI (dextroamphetamine) 30 mg ZENZEDI (dextroamphetamine)
1 tabday
2 tabsday
3 tabsday
Analgesics (non-opioid)
ZENZEDI (dextroamphetamine) 10 mg QUTENZA (capsaicin)
6 tabsday
4 patches3 months
4
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Analgesics (opioid) acetaminophencodeine soln 136 mLday 7 day supply (age 20
120-12 mg5 mL and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 1665 mLday 2 flls60 days for treatment experienced
acetaminophencodeine tab 300-15 13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
ACTIQ (fentanyl citrate) 4 lozengesday
AVINZA (morphine ext-release) 1 capday
AVINZA (morphine ext-release) 2 capsday 120 mg BELBUCA (buprenorphine) flm 2 flmsday
butorphanol nasal spray 10 mgmL 1 bottlefll 2 flls60 days
BUTRANS (buprenorphine) 4 patches28 days
codeine tab 15 mg 21 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 40 tabsday 2 flls60 days for treatment experienced
codeine tab 30 mg 10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 20 tabsday 2 flls60 days for treatment experienced
codeine tab 60 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
DEMEROL (meperidine) tab 100 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
DEMEROL (meperidine) tab 50 mg 9 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 tabsday 2 flls60 days for treatment experienced
DOLOPHINE (methadone) None
5
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT DILAUDID (hydromorphone) liq 1225 mLday 7 day supply (age 20 1 mgmL and older) 3 day supply (age less
than 20) 2 flls60 days for treatment naive 225 mLday 2 flls60 days for treatment experienced
DILAUDID (hydromorphone) 6 tabsday 7 day supply (age 20 and tab 2 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 11 tabsday 2 flls60 days for treatment experienced
DILAUDID (hydromorphone) 3 tabsday 7 day supply 2 flls60 tab 4 mg days for treatment naiumlve 5 tabsday 2
flls60 days for treatment experienced DILAUDID (hydromorphone) tab 8 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
EMBEDA (morphinenaltrexone) 2 capsday
EXALGO (hydromorphone) 2 tabsday
fentanyl transdermal patch 15 patches30 days
fentanyl transdermal patch 75 mcg 30 patches30 days hr 100 mcghr HYCET (hydrocodone 98 mLday 7 day supply (age 20 and acetaminophen) sol 75-325 mg older) 3 day supply (age less than 20) 15 mL 2 flls60 days for treatment naive 180
mLday 2 flls60 days for treatment experienced
hydrocodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
hydrocodoneacetaminophen tab 9 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
hydrocodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
6
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT hydromorphone supp 3 mg
HYSINGLA ER (hydrocodone bitartrate)
4 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 7 suppsday 2 flls60 days for treatment experienced 1 tabday
levorphanol tab 2 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
LORTAB (hydrocodone acetaminophen) elx 10-300 mg 15 mL
735 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 135 mLday 2 flls60 days for treatment experienced
meperidinepromethazine cap 50-25 mg
9 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 capsday 2 flls60 days for treatment experienced
mepridine sol 50 mg5 mL
MORPHABOND ER (morphine ext-release)
49 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 90 mLday 2 flls60 days for treatment experienced 2 tabsday
morphine sol 10 mg5 mL 245 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced
morphine sol 20 mg5 mL 1225 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 225 mLday 2 flls60 days for treatment experienced
morphine sol 20 mgmL 24 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced
7
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT morphine supp 10 mg 4 suppsday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 suppsday 2 flls60 days for treatment experienced
morphine supp 20 mg 2 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 suppsday 2 flls60 days for treatment experienced
morphine supp 30 mg 1 suppday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 suppsday 2 flls60 days for treatment experienced
morphine supp 5 mg 9 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 suppsday 2 flls60 days for treatment experienced
morphine tab 15 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
morphine tab 30 mg
morphine sulfate ER cap
MS CONTIN (morphine ext-release)
1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced 2 capsday
3 tabsday
NALOCET (oxycodone acetaminophen)
13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
OPANA (oxymorphone) tab 10 mg 1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced
8
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OPANA (oxymorphone) tab 5 mg 3 tabsday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
OXAYDO (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
OXAYDO (oxycodone) tab 75 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
oxycodoneaspirin tab 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneibuprofen tab 5-400 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
oxycodone cap 5 mg 6 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
oxycodone conc 20 mgmL 16 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 mLday 2 flls60 days for treatment experienced
oxycodone sol 5 mg5 mL 326 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodone tab 10 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
9
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
OXYCONTIN (oxycodone ext-release) 4 tabsday
oxymorphone ER 4 tabsday
pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
10
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
11
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap
11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced
TREZIX (acetaminophencaffeine dihydrocodeine) cap
12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 3
10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 4
5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
ULTRACET (tramadol acetaminophen) tab 375-325 mg
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
ULTRAM (tramadol) tab 50 mg
ULTRAM ER (tramadol ext-release)
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday
VERDROCET (hydrocodone acetaminophen) tab 25-325 mg
12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
12
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Anticonvulsants
Anticonvulsants
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12
tabsday 2 flls60 days for treatment experienced
VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9
tabsday 2 flls60 days for treatment experienced
VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135
mLday 2 flls60 days for treatment experienced
Anticonvulsants BANZEL (rufnamide) None
clobazam None
HORIZANT (gabapentin enacarbil) 2 tabsday
Antipsychotics ADASUVE (loxapine) None
Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)
CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)
13
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days
HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days
M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
promethazinephenylephrine codeine promethazinecodeine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
REZIRA (pseudoephedrine hydrocodone)
240 mLfll 2 flls60 days
14
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Antitussives (PA age lt18)
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Migraine
Migraine
Migraine
Parkinsonrsquos
Stimulants
Stimulants
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days
TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)
Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days
AIMOVIG (erenumab) 140 mgmL 1 syringe30 days
EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days
EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg
Miscellaneous NUEDEXTA (dextromethorphan None quinidine)
Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None
NUPLAZID (pimavanserin) None
Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday
Stimulants armodafnil 1 tabday
armodafnil 50 mg 2 tabsday
modafnil 1 tabday
15
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None
BELVIQ XR (lorcaserin) None
BONTRIL (phendimetrazine) None
CONTRAVE (naltrexone-bupropion) None
DIDREX (benzphetamine) None
LOMAIRA (phentermine) None
phentermine None
QSYMIA (phenterminetopiramate) None
REGIMEX (benzphetamine) None
SAXENDA (liraglutide) None
SUPRENZA (phentermine) None
TENUATE (diethylpropion) None
XENICAL (orlistat) None
Dermatology Acne (Oral) ABSORICA (isotretinoin) None
AMNESTEEM (isotretinoin) None
CLARAVIS (isotretinoin) None
MYORISAN (isotretinoin) None
ZENATANE (isotretinoin) None
Acne (PA age gt25 adapalene None only)
ATRALIN (tretinoin) None
AVITA (tretinoin) None
PLIXDA (adapalene) None
RETIN-A (tretinoin) None
tretinoin microsphere gel None
TRETIN-X (tretinoin) None
Endocrinology amp Metabolism Androgens Testosterone (Oral)
ANADROL-50 (oxymetholone) None
ANDROID (methyltestosterone) None
ANDROXY (fuoxymesterone) None
METHITEST (methyltestosterone) None
16
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)
Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)
Antidiabetic Agents
Antiemetics
Antiemetics
Antiemetics
Antiemetics
Irritable Bowel Syndrome
Allergen Extracts
Allergen Extracts
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday
OXANDRIN (oxandrolone) 10 mg 2 tabsday
TESTRED (methyltestosterone) None
Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)
DELATESTRYL (testosterone None enanthate)
TESTOPEL (testosterone pellet) None
testosterone cypionate None
Androgens ANDRODERM (testosterone) None Testosterone (Topical)
NATESTO (testosterone nasal) None
STRIANT (testosterone) None
testosterone gel 162 None
Antidiabetic Agents AFREZZA (insulin regular) None
SYMLINPEN (pramlintide) None
Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday
CESAMET (nabilone) 20 capsfll or 3 max days supply
DICLEGIS (doxylamine-pyridoxine) 4 tabsday
MARINOL (dronabinol) 2 capsday
SYNDROS (dronabinol) 120 mL30 days
Irritable Bowel LOTRONEX (alosetron) None Syndrome
VIBERZI (eluxadoline) 2 tabsday
Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday
ODACTRA (house dust mite) 1 tabday
ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR
17
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Methotrexate Auto-Injectors
Miscellaneous
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)
Immunizations VARIZIG (varicella-zoster immune None globulin)
Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None
Calcium Modifer cinacalcet None
Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors
RASUVO (methotrexate) 4 auto-injectors28 days
Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None
Oncology Miscellaneous PROVENGE (sipuleucel-T) None
Ophthalmology Miscellaneous RESTASIS (cyclosporine) None
XIIDRA (liftegrast) None
Respiratory AsthmaCOPD DALIRESP (rofumilast) None
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Premium specialty prior authorization list
These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None
18
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Antibiotics
Antifungals
Antifungals
Antifungals
Antifungals
Antifungals
Antifungals
Antifungals
Antilipemic
Antilipemic
Antilipemic
Antilipemic
Heart Failure
ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)
Premium non-specialty prior authorization list
These medications may require prior authorization based on your beneft plan For more information contact customer service at the phone number on your member ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Anthelmintics ALBENZA (albendazole) None
Antibiotics AEMCOLO (rifamycin) None
XIFAXAN (rifaximin) None
Antifungals CICLODAN KIT (ciclopirox) None
CICLOPIROX KIT (ciclopirox) None
CNL8 NAIL KIT (ciclopirox) None
KERYDIN (tavaborole) None
ONMEL (itraconazole) None
PEDIPROX-4 (ciclopirox) nail kit None
SPORANOX (itraconazole) Soln None
SPORANOX (itraconazole) None
Antihelmintics ALBENZA (albendazole) None
Antimalarial QUALAQUIN (quinine) None
Antiretrovirals HIV Selzentry (maraviroc) None
Trogarzo (ibalizumab) None
Cardiology Antilipemic omega-3 fatty acid None
PRALUENT (alirocumab) 2 syringes28 days
REPATHA (evolocumab) 3 syringes28 days
REPATHA PUSH (evolocumab) 1 cartridge28 days
VASCEPA (icosapent ethyl) None
Heart Failure CORLANOR (ivabradine) 2 tabsday
CORLANOR (ivabradine) Soln 15 mLday
Central Nervous System ADHD Agents (PA age ADHANSIA XR (methylphenidate) 4 capsday 19+ only) 25 mg
ADHANSIA XR (methylphenidate) 1 capday
ADZENYS ER (amphetamine) 15 mLday
ADZENYS XR-ODT (amphetamine) 1 tabday
amphetamine 6 tabsday
amphetaminedetroamphetamine 2 tabsday 30 mg tab
2
ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT amphetaminedetroamphetamine 3 tabsday
amphetaminedetroamphetamine ER 1 capday
APTENSIO XR (methylphenidate) 1 capday
COTEMPLA XR-ODT (methylphenidate) 86 mg COTEMPLA XR-ODT (methylphenidate) 173 mg COTEMPLA XR-ODT (methylphenidate) 259 mg DAYTRANA (methylphenidate transdermal) DESOXYN (methamphetamine)
6 tabsday
3 tabsday
2 tabsday
1 patchday
5 tabsday
DEXEDRINE (dextroamphetamine) 10 mg DEXEDRINE (dextroamphetamine) 5 mg DEXEDRINE (dextroamphetamine) 15 mg dexmethylphenidate
6 capsday
3 capsday
4 capsday
2 tabsday
DYANAVEL XR (amphetamine) 8 mLday
EVEKEO ODT (amphetamine) 5 mg 10 mg EVEKEO ODT (amphetamine) 15 mg 20 mg FOCALIN XR (dexmethylphenidate)
3 tabsday
2 tabsday
1 capday
FOCALIN XR (dexmethylphenidate) 20 mg JORNAY PM (methylphenidate)
2 capsday
1 capday
METADATE CD (methylphenidate) 1 capday
METADATE ER (methylphenidate) 20 mg METHYLIN (methylphenidate)
3 tabsday
3 tabsday
METHYLIN (methylphenidate) Soln 10 mg5 mL
30 mLday
3
ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)19+ only)
ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT METHYLIN (methylphenidate) Soln 5 mg5 mL METHYLIN CHEW TAB (methylphenidate) METHYLIN CHEW TAB (methylphenidate) 10 mg METHYLIN ER (methylphenidate) 20 mg methylphenidate
60 mLday
3 tabsday
6 tabsday
3 tabsday
3 tabsday
METHYLPHENIDATE ER (methylphenidate) 10 mg methylphenidate ER tab osmotic release 36 mg methylphenidate ER tab osmotic release
2 tabsday
2 tabsday
1 tabday
MYDAYIS (amphetamine dextroamphetamine) PROCENTRA (dextroamphetamine) Sol
1 capday
60 mLday
QUILLICHEW ER (methylphenidate) 30 mg QUILLICHEW ER (methylphenidate)
2 tabsday
1 tabday
QUILLIVANT XR (methylphenidate) 12 mLday
RELEXXII (methylphenidate) 72 mg 1 tabday
RITALIN LA (methylphenidate) 1 capday
RITALIN SR (methylphenidate) 20 mg 3 tabsday
VYVANSE (lisdexamfetamine) 1 capday
VYVANSE CHEW TAB (lisdexamfetamine) ZENZEDI (dextroamphetamine) 30 mg ZENZEDI (dextroamphetamine)
1 tabday
2 tabsday
3 tabsday
Analgesics (non-opioid)
ZENZEDI (dextroamphetamine) 10 mg QUTENZA (capsaicin)
6 tabsday
4 patches3 months
4
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Analgesics (opioid) acetaminophencodeine soln 136 mLday 7 day supply (age 20
120-12 mg5 mL and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 1665 mLday 2 flls60 days for treatment experienced
acetaminophencodeine tab 300-15 13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
ACTIQ (fentanyl citrate) 4 lozengesday
AVINZA (morphine ext-release) 1 capday
AVINZA (morphine ext-release) 2 capsday 120 mg BELBUCA (buprenorphine) flm 2 flmsday
butorphanol nasal spray 10 mgmL 1 bottlefll 2 flls60 days
BUTRANS (buprenorphine) 4 patches28 days
codeine tab 15 mg 21 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 40 tabsday 2 flls60 days for treatment experienced
codeine tab 30 mg 10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 20 tabsday 2 flls60 days for treatment experienced
codeine tab 60 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
DEMEROL (meperidine) tab 100 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
DEMEROL (meperidine) tab 50 mg 9 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 tabsday 2 flls60 days for treatment experienced
DOLOPHINE (methadone) None
5
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT DILAUDID (hydromorphone) liq 1225 mLday 7 day supply (age 20 1 mgmL and older) 3 day supply (age less
than 20) 2 flls60 days for treatment naive 225 mLday 2 flls60 days for treatment experienced
DILAUDID (hydromorphone) 6 tabsday 7 day supply (age 20 and tab 2 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 11 tabsday 2 flls60 days for treatment experienced
DILAUDID (hydromorphone) 3 tabsday 7 day supply 2 flls60 tab 4 mg days for treatment naiumlve 5 tabsday 2
flls60 days for treatment experienced DILAUDID (hydromorphone) tab 8 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
EMBEDA (morphinenaltrexone) 2 capsday
EXALGO (hydromorphone) 2 tabsday
fentanyl transdermal patch 15 patches30 days
fentanyl transdermal patch 75 mcg 30 patches30 days hr 100 mcghr HYCET (hydrocodone 98 mLday 7 day supply (age 20 and acetaminophen) sol 75-325 mg older) 3 day supply (age less than 20) 15 mL 2 flls60 days for treatment naive 180
mLday 2 flls60 days for treatment experienced
hydrocodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
hydrocodoneacetaminophen tab 9 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
hydrocodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
6
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT hydromorphone supp 3 mg
HYSINGLA ER (hydrocodone bitartrate)
4 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 7 suppsday 2 flls60 days for treatment experienced 1 tabday
levorphanol tab 2 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
LORTAB (hydrocodone acetaminophen) elx 10-300 mg 15 mL
735 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 135 mLday 2 flls60 days for treatment experienced
meperidinepromethazine cap 50-25 mg
9 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 capsday 2 flls60 days for treatment experienced
mepridine sol 50 mg5 mL
MORPHABOND ER (morphine ext-release)
49 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 90 mLday 2 flls60 days for treatment experienced 2 tabsday
morphine sol 10 mg5 mL 245 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced
morphine sol 20 mg5 mL 1225 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 225 mLday 2 flls60 days for treatment experienced
morphine sol 20 mgmL 24 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced
7
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT morphine supp 10 mg 4 suppsday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 suppsday 2 flls60 days for treatment experienced
morphine supp 20 mg 2 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 suppsday 2 flls60 days for treatment experienced
morphine supp 30 mg 1 suppday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 suppsday 2 flls60 days for treatment experienced
morphine supp 5 mg 9 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 suppsday 2 flls60 days for treatment experienced
morphine tab 15 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
morphine tab 30 mg
morphine sulfate ER cap
MS CONTIN (morphine ext-release)
1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced 2 capsday
3 tabsday
NALOCET (oxycodone acetaminophen)
13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
OPANA (oxymorphone) tab 10 mg 1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced
8
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OPANA (oxymorphone) tab 5 mg 3 tabsday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
OXAYDO (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
OXAYDO (oxycodone) tab 75 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
oxycodoneaspirin tab 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneibuprofen tab 5-400 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
oxycodone cap 5 mg 6 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
oxycodone conc 20 mgmL 16 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 mLday 2 flls60 days for treatment experienced
oxycodone sol 5 mg5 mL 326 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodone tab 10 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
9
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
OXYCONTIN (oxycodone ext-release) 4 tabsday
oxymorphone ER 4 tabsday
pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
10
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
11
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap
11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced
TREZIX (acetaminophencaffeine dihydrocodeine) cap
12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 3
10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 4
5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
ULTRACET (tramadol acetaminophen) tab 375-325 mg
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
ULTRAM (tramadol) tab 50 mg
ULTRAM ER (tramadol ext-release)
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday
VERDROCET (hydrocodone acetaminophen) tab 25-325 mg
12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
12
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Anticonvulsants
Anticonvulsants
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12
tabsday 2 flls60 days for treatment experienced
VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9
tabsday 2 flls60 days for treatment experienced
VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135
mLday 2 flls60 days for treatment experienced
Anticonvulsants BANZEL (rufnamide) None
clobazam None
HORIZANT (gabapentin enacarbil) 2 tabsday
Antipsychotics ADASUVE (loxapine) None
Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)
CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)
13
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days
HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days
M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
promethazinephenylephrine codeine promethazinecodeine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
REZIRA (pseudoephedrine hydrocodone)
240 mLfll 2 flls60 days
14
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Antitussives (PA age lt18)
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Migraine
Migraine
Migraine
Parkinsonrsquos
Stimulants
Stimulants
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days
TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)
Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days
AIMOVIG (erenumab) 140 mgmL 1 syringe30 days
EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days
EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg
Miscellaneous NUEDEXTA (dextromethorphan None quinidine)
Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None
NUPLAZID (pimavanserin) None
Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday
Stimulants armodafnil 1 tabday
armodafnil 50 mg 2 tabsday
modafnil 1 tabday
15
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None
BELVIQ XR (lorcaserin) None
BONTRIL (phendimetrazine) None
CONTRAVE (naltrexone-bupropion) None
DIDREX (benzphetamine) None
LOMAIRA (phentermine) None
phentermine None
QSYMIA (phenterminetopiramate) None
REGIMEX (benzphetamine) None
SAXENDA (liraglutide) None
SUPRENZA (phentermine) None
TENUATE (diethylpropion) None
XENICAL (orlistat) None
Dermatology Acne (Oral) ABSORICA (isotretinoin) None
AMNESTEEM (isotretinoin) None
CLARAVIS (isotretinoin) None
MYORISAN (isotretinoin) None
ZENATANE (isotretinoin) None
Acne (PA age gt25 adapalene None only)
ATRALIN (tretinoin) None
AVITA (tretinoin) None
PLIXDA (adapalene) None
RETIN-A (tretinoin) None
tretinoin microsphere gel None
TRETIN-X (tretinoin) None
Endocrinology amp Metabolism Androgens Testosterone (Oral)
ANADROL-50 (oxymetholone) None
ANDROID (methyltestosterone) None
ANDROXY (fuoxymesterone) None
METHITEST (methyltestosterone) None
16
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)
Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)
Antidiabetic Agents
Antiemetics
Antiemetics
Antiemetics
Antiemetics
Irritable Bowel Syndrome
Allergen Extracts
Allergen Extracts
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday
OXANDRIN (oxandrolone) 10 mg 2 tabsday
TESTRED (methyltestosterone) None
Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)
DELATESTRYL (testosterone None enanthate)
TESTOPEL (testosterone pellet) None
testosterone cypionate None
Androgens ANDRODERM (testosterone) None Testosterone (Topical)
NATESTO (testosterone nasal) None
STRIANT (testosterone) None
testosterone gel 162 None
Antidiabetic Agents AFREZZA (insulin regular) None
SYMLINPEN (pramlintide) None
Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday
CESAMET (nabilone) 20 capsfll or 3 max days supply
DICLEGIS (doxylamine-pyridoxine) 4 tabsday
MARINOL (dronabinol) 2 capsday
SYNDROS (dronabinol) 120 mL30 days
Irritable Bowel LOTRONEX (alosetron) None Syndrome
VIBERZI (eluxadoline) 2 tabsday
Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday
ODACTRA (house dust mite) 1 tabday
ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR
17
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Methotrexate Auto-Injectors
Miscellaneous
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)
Immunizations VARIZIG (varicella-zoster immune None globulin)
Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None
Calcium Modifer cinacalcet None
Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors
RASUVO (methotrexate) 4 auto-injectors28 days
Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None
Oncology Miscellaneous PROVENGE (sipuleucel-T) None
Ophthalmology Miscellaneous RESTASIS (cyclosporine) None
XIIDRA (liftegrast) None
Respiratory AsthmaCOPD DALIRESP (rofumilast) None
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Premium specialty prior authorization list
These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None
18
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT amphetaminedetroamphetamine 3 tabsday
amphetaminedetroamphetamine ER 1 capday
APTENSIO XR (methylphenidate) 1 capday
COTEMPLA XR-ODT (methylphenidate) 86 mg COTEMPLA XR-ODT (methylphenidate) 173 mg COTEMPLA XR-ODT (methylphenidate) 259 mg DAYTRANA (methylphenidate transdermal) DESOXYN (methamphetamine)
6 tabsday
3 tabsday
2 tabsday
1 patchday
5 tabsday
DEXEDRINE (dextroamphetamine) 10 mg DEXEDRINE (dextroamphetamine) 5 mg DEXEDRINE (dextroamphetamine) 15 mg dexmethylphenidate
6 capsday
3 capsday
4 capsday
2 tabsday
DYANAVEL XR (amphetamine) 8 mLday
EVEKEO ODT (amphetamine) 5 mg 10 mg EVEKEO ODT (amphetamine) 15 mg 20 mg FOCALIN XR (dexmethylphenidate)
3 tabsday
2 tabsday
1 capday
FOCALIN XR (dexmethylphenidate) 20 mg JORNAY PM (methylphenidate)
2 capsday
1 capday
METADATE CD (methylphenidate) 1 capday
METADATE ER (methylphenidate) 20 mg METHYLIN (methylphenidate)
3 tabsday
3 tabsday
METHYLIN (methylphenidate) Soln 10 mg5 mL
30 mLday
3
ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)19+ only)
ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT METHYLIN (methylphenidate) Soln 5 mg5 mL METHYLIN CHEW TAB (methylphenidate) METHYLIN CHEW TAB (methylphenidate) 10 mg METHYLIN ER (methylphenidate) 20 mg methylphenidate
60 mLday
3 tabsday
6 tabsday
3 tabsday
3 tabsday
METHYLPHENIDATE ER (methylphenidate) 10 mg methylphenidate ER tab osmotic release 36 mg methylphenidate ER tab osmotic release
2 tabsday
2 tabsday
1 tabday
MYDAYIS (amphetamine dextroamphetamine) PROCENTRA (dextroamphetamine) Sol
1 capday
60 mLday
QUILLICHEW ER (methylphenidate) 30 mg QUILLICHEW ER (methylphenidate)
2 tabsday
1 tabday
QUILLIVANT XR (methylphenidate) 12 mLday
RELEXXII (methylphenidate) 72 mg 1 tabday
RITALIN LA (methylphenidate) 1 capday
RITALIN SR (methylphenidate) 20 mg 3 tabsday
VYVANSE (lisdexamfetamine) 1 capday
VYVANSE CHEW TAB (lisdexamfetamine) ZENZEDI (dextroamphetamine) 30 mg ZENZEDI (dextroamphetamine)
1 tabday
2 tabsday
3 tabsday
Analgesics (non-opioid)
ZENZEDI (dextroamphetamine) 10 mg QUTENZA (capsaicin)
6 tabsday
4 patches3 months
4
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Analgesics (opioid) acetaminophencodeine soln 136 mLday 7 day supply (age 20
120-12 mg5 mL and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 1665 mLday 2 flls60 days for treatment experienced
acetaminophencodeine tab 300-15 13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
ACTIQ (fentanyl citrate) 4 lozengesday
AVINZA (morphine ext-release) 1 capday
AVINZA (morphine ext-release) 2 capsday 120 mg BELBUCA (buprenorphine) flm 2 flmsday
butorphanol nasal spray 10 mgmL 1 bottlefll 2 flls60 days
BUTRANS (buprenorphine) 4 patches28 days
codeine tab 15 mg 21 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 40 tabsday 2 flls60 days for treatment experienced
codeine tab 30 mg 10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 20 tabsday 2 flls60 days for treatment experienced
codeine tab 60 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
DEMEROL (meperidine) tab 100 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
DEMEROL (meperidine) tab 50 mg 9 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 tabsday 2 flls60 days for treatment experienced
DOLOPHINE (methadone) None
5
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT DILAUDID (hydromorphone) liq 1225 mLday 7 day supply (age 20 1 mgmL and older) 3 day supply (age less
than 20) 2 flls60 days for treatment naive 225 mLday 2 flls60 days for treatment experienced
DILAUDID (hydromorphone) 6 tabsday 7 day supply (age 20 and tab 2 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 11 tabsday 2 flls60 days for treatment experienced
DILAUDID (hydromorphone) 3 tabsday 7 day supply 2 flls60 tab 4 mg days for treatment naiumlve 5 tabsday 2
flls60 days for treatment experienced DILAUDID (hydromorphone) tab 8 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
EMBEDA (morphinenaltrexone) 2 capsday
EXALGO (hydromorphone) 2 tabsday
fentanyl transdermal patch 15 patches30 days
fentanyl transdermal patch 75 mcg 30 patches30 days hr 100 mcghr HYCET (hydrocodone 98 mLday 7 day supply (age 20 and acetaminophen) sol 75-325 mg older) 3 day supply (age less than 20) 15 mL 2 flls60 days for treatment naive 180
mLday 2 flls60 days for treatment experienced
hydrocodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
hydrocodoneacetaminophen tab 9 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
hydrocodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
6
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT hydromorphone supp 3 mg
HYSINGLA ER (hydrocodone bitartrate)
4 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 7 suppsday 2 flls60 days for treatment experienced 1 tabday
levorphanol tab 2 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
LORTAB (hydrocodone acetaminophen) elx 10-300 mg 15 mL
735 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 135 mLday 2 flls60 days for treatment experienced
meperidinepromethazine cap 50-25 mg
9 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 capsday 2 flls60 days for treatment experienced
mepridine sol 50 mg5 mL
MORPHABOND ER (morphine ext-release)
49 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 90 mLday 2 flls60 days for treatment experienced 2 tabsday
morphine sol 10 mg5 mL 245 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced
morphine sol 20 mg5 mL 1225 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 225 mLday 2 flls60 days for treatment experienced
morphine sol 20 mgmL 24 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced
7
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT morphine supp 10 mg 4 suppsday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 suppsday 2 flls60 days for treatment experienced
morphine supp 20 mg 2 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 suppsday 2 flls60 days for treatment experienced
morphine supp 30 mg 1 suppday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 suppsday 2 flls60 days for treatment experienced
morphine supp 5 mg 9 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 suppsday 2 flls60 days for treatment experienced
morphine tab 15 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
morphine tab 30 mg
morphine sulfate ER cap
MS CONTIN (morphine ext-release)
1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced 2 capsday
3 tabsday
NALOCET (oxycodone acetaminophen)
13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
OPANA (oxymorphone) tab 10 mg 1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced
8
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OPANA (oxymorphone) tab 5 mg 3 tabsday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
OXAYDO (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
OXAYDO (oxycodone) tab 75 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
oxycodoneaspirin tab 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneibuprofen tab 5-400 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
oxycodone cap 5 mg 6 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
oxycodone conc 20 mgmL 16 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 mLday 2 flls60 days for treatment experienced
oxycodone sol 5 mg5 mL 326 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodone tab 10 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
9
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
OXYCONTIN (oxycodone ext-release) 4 tabsday
oxymorphone ER 4 tabsday
pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
10
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
11
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap
11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced
TREZIX (acetaminophencaffeine dihydrocodeine) cap
12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 3
10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 4
5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
ULTRACET (tramadol acetaminophen) tab 375-325 mg
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
ULTRAM (tramadol) tab 50 mg
ULTRAM ER (tramadol ext-release)
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday
VERDROCET (hydrocodone acetaminophen) tab 25-325 mg
12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
12
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Anticonvulsants
Anticonvulsants
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12
tabsday 2 flls60 days for treatment experienced
VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9
tabsday 2 flls60 days for treatment experienced
VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135
mLday 2 flls60 days for treatment experienced
Anticonvulsants BANZEL (rufnamide) None
clobazam None
HORIZANT (gabapentin enacarbil) 2 tabsday
Antipsychotics ADASUVE (loxapine) None
Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)
CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)
13
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days
HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days
M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
promethazinephenylephrine codeine promethazinecodeine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
REZIRA (pseudoephedrine hydrocodone)
240 mLfll 2 flls60 days
14
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Antitussives (PA age lt18)
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Migraine
Migraine
Migraine
Parkinsonrsquos
Stimulants
Stimulants
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days
TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)
Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days
AIMOVIG (erenumab) 140 mgmL 1 syringe30 days
EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days
EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg
Miscellaneous NUEDEXTA (dextromethorphan None quinidine)
Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None
NUPLAZID (pimavanserin) None
Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday
Stimulants armodafnil 1 tabday
armodafnil 50 mg 2 tabsday
modafnil 1 tabday
15
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None
BELVIQ XR (lorcaserin) None
BONTRIL (phendimetrazine) None
CONTRAVE (naltrexone-bupropion) None
DIDREX (benzphetamine) None
LOMAIRA (phentermine) None
phentermine None
QSYMIA (phenterminetopiramate) None
REGIMEX (benzphetamine) None
SAXENDA (liraglutide) None
SUPRENZA (phentermine) None
TENUATE (diethylpropion) None
XENICAL (orlistat) None
Dermatology Acne (Oral) ABSORICA (isotretinoin) None
AMNESTEEM (isotretinoin) None
CLARAVIS (isotretinoin) None
MYORISAN (isotretinoin) None
ZENATANE (isotretinoin) None
Acne (PA age gt25 adapalene None only)
ATRALIN (tretinoin) None
AVITA (tretinoin) None
PLIXDA (adapalene) None
RETIN-A (tretinoin) None
tretinoin microsphere gel None
TRETIN-X (tretinoin) None
Endocrinology amp Metabolism Androgens Testosterone (Oral)
ANADROL-50 (oxymetholone) None
ANDROID (methyltestosterone) None
ANDROXY (fuoxymesterone) None
METHITEST (methyltestosterone) None
16
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)
Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)
Antidiabetic Agents
Antiemetics
Antiemetics
Antiemetics
Antiemetics
Irritable Bowel Syndrome
Allergen Extracts
Allergen Extracts
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday
OXANDRIN (oxandrolone) 10 mg 2 tabsday
TESTRED (methyltestosterone) None
Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)
DELATESTRYL (testosterone None enanthate)
TESTOPEL (testosterone pellet) None
testosterone cypionate None
Androgens ANDRODERM (testosterone) None Testosterone (Topical)
NATESTO (testosterone nasal) None
STRIANT (testosterone) None
testosterone gel 162 None
Antidiabetic Agents AFREZZA (insulin regular) None
SYMLINPEN (pramlintide) None
Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday
CESAMET (nabilone) 20 capsfll or 3 max days supply
DICLEGIS (doxylamine-pyridoxine) 4 tabsday
MARINOL (dronabinol) 2 capsday
SYNDROS (dronabinol) 120 mL30 days
Irritable Bowel LOTRONEX (alosetron) None Syndrome
VIBERZI (eluxadoline) 2 tabsday
Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday
ODACTRA (house dust mite) 1 tabday
ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR
17
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Methotrexate Auto-Injectors
Miscellaneous
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)
Immunizations VARIZIG (varicella-zoster immune None globulin)
Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None
Calcium Modifer cinacalcet None
Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors
RASUVO (methotrexate) 4 auto-injectors28 days
Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None
Oncology Miscellaneous PROVENGE (sipuleucel-T) None
Ophthalmology Miscellaneous RESTASIS (cyclosporine) None
XIIDRA (liftegrast) None
Respiratory AsthmaCOPD DALIRESP (rofumilast) None
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Premium specialty prior authorization list
These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None
18
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)19+ only)
ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT METHYLIN (methylphenidate) Soln 5 mg5 mL METHYLIN CHEW TAB (methylphenidate) METHYLIN CHEW TAB (methylphenidate) 10 mg METHYLIN ER (methylphenidate) 20 mg methylphenidate
60 mLday
3 tabsday
6 tabsday
3 tabsday
3 tabsday
METHYLPHENIDATE ER (methylphenidate) 10 mg methylphenidate ER tab osmotic release 36 mg methylphenidate ER tab osmotic release
2 tabsday
2 tabsday
1 tabday
MYDAYIS (amphetamine dextroamphetamine) PROCENTRA (dextroamphetamine) Sol
1 capday
60 mLday
QUILLICHEW ER (methylphenidate) 30 mg QUILLICHEW ER (methylphenidate)
2 tabsday
1 tabday
QUILLIVANT XR (methylphenidate) 12 mLday
RELEXXII (methylphenidate) 72 mg 1 tabday
RITALIN LA (methylphenidate) 1 capday
RITALIN SR (methylphenidate) 20 mg 3 tabsday
VYVANSE (lisdexamfetamine) 1 capday
VYVANSE CHEW TAB (lisdexamfetamine) ZENZEDI (dextroamphetamine) 30 mg ZENZEDI (dextroamphetamine)
1 tabday
2 tabsday
3 tabsday
Analgesics (non-opioid)
ZENZEDI (dextroamphetamine) 10 mg QUTENZA (capsaicin)
6 tabsday
4 patches3 months
4
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Analgesics (opioid) acetaminophencodeine soln 136 mLday 7 day supply (age 20
120-12 mg5 mL and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 1665 mLday 2 flls60 days for treatment experienced
acetaminophencodeine tab 300-15 13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
ACTIQ (fentanyl citrate) 4 lozengesday
AVINZA (morphine ext-release) 1 capday
AVINZA (morphine ext-release) 2 capsday 120 mg BELBUCA (buprenorphine) flm 2 flmsday
butorphanol nasal spray 10 mgmL 1 bottlefll 2 flls60 days
BUTRANS (buprenorphine) 4 patches28 days
codeine tab 15 mg 21 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 40 tabsday 2 flls60 days for treatment experienced
codeine tab 30 mg 10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 20 tabsday 2 flls60 days for treatment experienced
codeine tab 60 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
DEMEROL (meperidine) tab 100 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
DEMEROL (meperidine) tab 50 mg 9 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 tabsday 2 flls60 days for treatment experienced
DOLOPHINE (methadone) None
5
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT DILAUDID (hydromorphone) liq 1225 mLday 7 day supply (age 20 1 mgmL and older) 3 day supply (age less
than 20) 2 flls60 days for treatment naive 225 mLday 2 flls60 days for treatment experienced
DILAUDID (hydromorphone) 6 tabsday 7 day supply (age 20 and tab 2 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 11 tabsday 2 flls60 days for treatment experienced
DILAUDID (hydromorphone) 3 tabsday 7 day supply 2 flls60 tab 4 mg days for treatment naiumlve 5 tabsday 2
flls60 days for treatment experienced DILAUDID (hydromorphone) tab 8 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
EMBEDA (morphinenaltrexone) 2 capsday
EXALGO (hydromorphone) 2 tabsday
fentanyl transdermal patch 15 patches30 days
fentanyl transdermal patch 75 mcg 30 patches30 days hr 100 mcghr HYCET (hydrocodone 98 mLday 7 day supply (age 20 and acetaminophen) sol 75-325 mg older) 3 day supply (age less than 20) 15 mL 2 flls60 days for treatment naive 180
mLday 2 flls60 days for treatment experienced
hydrocodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
hydrocodoneacetaminophen tab 9 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
hydrocodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
6
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT hydromorphone supp 3 mg
HYSINGLA ER (hydrocodone bitartrate)
4 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 7 suppsday 2 flls60 days for treatment experienced 1 tabday
levorphanol tab 2 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
LORTAB (hydrocodone acetaminophen) elx 10-300 mg 15 mL
735 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 135 mLday 2 flls60 days for treatment experienced
meperidinepromethazine cap 50-25 mg
9 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 capsday 2 flls60 days for treatment experienced
mepridine sol 50 mg5 mL
MORPHABOND ER (morphine ext-release)
49 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 90 mLday 2 flls60 days for treatment experienced 2 tabsday
morphine sol 10 mg5 mL 245 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced
morphine sol 20 mg5 mL 1225 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 225 mLday 2 flls60 days for treatment experienced
morphine sol 20 mgmL 24 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced
7
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT morphine supp 10 mg 4 suppsday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 suppsday 2 flls60 days for treatment experienced
morphine supp 20 mg 2 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 suppsday 2 flls60 days for treatment experienced
morphine supp 30 mg 1 suppday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 suppsday 2 flls60 days for treatment experienced
morphine supp 5 mg 9 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 suppsday 2 flls60 days for treatment experienced
morphine tab 15 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
morphine tab 30 mg
morphine sulfate ER cap
MS CONTIN (morphine ext-release)
1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced 2 capsday
3 tabsday
NALOCET (oxycodone acetaminophen)
13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
OPANA (oxymorphone) tab 10 mg 1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced
8
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OPANA (oxymorphone) tab 5 mg 3 tabsday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
OXAYDO (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
OXAYDO (oxycodone) tab 75 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
oxycodoneaspirin tab 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneibuprofen tab 5-400 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
oxycodone cap 5 mg 6 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
oxycodone conc 20 mgmL 16 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 mLday 2 flls60 days for treatment experienced
oxycodone sol 5 mg5 mL 326 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodone tab 10 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
9
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
OXYCONTIN (oxycodone ext-release) 4 tabsday
oxymorphone ER 4 tabsday
pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
10
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
11
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap
11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced
TREZIX (acetaminophencaffeine dihydrocodeine) cap
12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 3
10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 4
5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
ULTRACET (tramadol acetaminophen) tab 375-325 mg
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
ULTRAM (tramadol) tab 50 mg
ULTRAM ER (tramadol ext-release)
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday
VERDROCET (hydrocodone acetaminophen) tab 25-325 mg
12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
12
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Anticonvulsants
Anticonvulsants
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12
tabsday 2 flls60 days for treatment experienced
VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9
tabsday 2 flls60 days for treatment experienced
VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135
mLday 2 flls60 days for treatment experienced
Anticonvulsants BANZEL (rufnamide) None
clobazam None
HORIZANT (gabapentin enacarbil) 2 tabsday
Antipsychotics ADASUVE (loxapine) None
Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)
CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)
13
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days
HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days
M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
promethazinephenylephrine codeine promethazinecodeine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
REZIRA (pseudoephedrine hydrocodone)
240 mLfll 2 flls60 days
14
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Antitussives (PA age lt18)
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Migraine
Migraine
Migraine
Parkinsonrsquos
Stimulants
Stimulants
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days
TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)
Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days
AIMOVIG (erenumab) 140 mgmL 1 syringe30 days
EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days
EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg
Miscellaneous NUEDEXTA (dextromethorphan None quinidine)
Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None
NUPLAZID (pimavanserin) None
Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday
Stimulants armodafnil 1 tabday
armodafnil 50 mg 2 tabsday
modafnil 1 tabday
15
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None
BELVIQ XR (lorcaserin) None
BONTRIL (phendimetrazine) None
CONTRAVE (naltrexone-bupropion) None
DIDREX (benzphetamine) None
LOMAIRA (phentermine) None
phentermine None
QSYMIA (phenterminetopiramate) None
REGIMEX (benzphetamine) None
SAXENDA (liraglutide) None
SUPRENZA (phentermine) None
TENUATE (diethylpropion) None
XENICAL (orlistat) None
Dermatology Acne (Oral) ABSORICA (isotretinoin) None
AMNESTEEM (isotretinoin) None
CLARAVIS (isotretinoin) None
MYORISAN (isotretinoin) None
ZENATANE (isotretinoin) None
Acne (PA age gt25 adapalene None only)
ATRALIN (tretinoin) None
AVITA (tretinoin) None
PLIXDA (adapalene) None
RETIN-A (tretinoin) None
tretinoin microsphere gel None
TRETIN-X (tretinoin) None
Endocrinology amp Metabolism Androgens Testosterone (Oral)
ANADROL-50 (oxymetholone) None
ANDROID (methyltestosterone) None
ANDROXY (fuoxymesterone) None
METHITEST (methyltestosterone) None
16
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)
Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)
Antidiabetic Agents
Antiemetics
Antiemetics
Antiemetics
Antiemetics
Irritable Bowel Syndrome
Allergen Extracts
Allergen Extracts
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday
OXANDRIN (oxandrolone) 10 mg 2 tabsday
TESTRED (methyltestosterone) None
Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)
DELATESTRYL (testosterone None enanthate)
TESTOPEL (testosterone pellet) None
testosterone cypionate None
Androgens ANDRODERM (testosterone) None Testosterone (Topical)
NATESTO (testosterone nasal) None
STRIANT (testosterone) None
testosterone gel 162 None
Antidiabetic Agents AFREZZA (insulin regular) None
SYMLINPEN (pramlintide) None
Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday
CESAMET (nabilone) 20 capsfll or 3 max days supply
DICLEGIS (doxylamine-pyridoxine) 4 tabsday
MARINOL (dronabinol) 2 capsday
SYNDROS (dronabinol) 120 mL30 days
Irritable Bowel LOTRONEX (alosetron) None Syndrome
VIBERZI (eluxadoline) 2 tabsday
Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday
ODACTRA (house dust mite) 1 tabday
ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR
17
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Methotrexate Auto-Injectors
Miscellaneous
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)
Immunizations VARIZIG (varicella-zoster immune None globulin)
Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None
Calcium Modifer cinacalcet None
Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors
RASUVO (methotrexate) 4 auto-injectors28 days
Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None
Oncology Miscellaneous PROVENGE (sipuleucel-T) None
Ophthalmology Miscellaneous RESTASIS (cyclosporine) None
XIIDRA (liftegrast) None
Respiratory AsthmaCOPD DALIRESP (rofumilast) None
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Premium specialty prior authorization list
These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None
18
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Analgesics (opioid) acetaminophencodeine soln 136 mLday 7 day supply (age 20
120-12 mg5 mL and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 1665 mLday 2 flls60 days for treatment experienced
acetaminophencodeine tab 300-15 13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
ACTIQ (fentanyl citrate) 4 lozengesday
AVINZA (morphine ext-release) 1 capday
AVINZA (morphine ext-release) 2 capsday 120 mg BELBUCA (buprenorphine) flm 2 flmsday
butorphanol nasal spray 10 mgmL 1 bottlefll 2 flls60 days
BUTRANS (buprenorphine) 4 patches28 days
codeine tab 15 mg 21 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 40 tabsday 2 flls60 days for treatment experienced
codeine tab 30 mg 10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 20 tabsday 2 flls60 days for treatment experienced
codeine tab 60 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
DEMEROL (meperidine) tab 100 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
DEMEROL (meperidine) tab 50 mg 9 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 tabsday 2 flls60 days for treatment experienced
DOLOPHINE (methadone) None
5
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT DILAUDID (hydromorphone) liq 1225 mLday 7 day supply (age 20 1 mgmL and older) 3 day supply (age less
than 20) 2 flls60 days for treatment naive 225 mLday 2 flls60 days for treatment experienced
DILAUDID (hydromorphone) 6 tabsday 7 day supply (age 20 and tab 2 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 11 tabsday 2 flls60 days for treatment experienced
DILAUDID (hydromorphone) 3 tabsday 7 day supply 2 flls60 tab 4 mg days for treatment naiumlve 5 tabsday 2
flls60 days for treatment experienced DILAUDID (hydromorphone) tab 8 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
EMBEDA (morphinenaltrexone) 2 capsday
EXALGO (hydromorphone) 2 tabsday
fentanyl transdermal patch 15 patches30 days
fentanyl transdermal patch 75 mcg 30 patches30 days hr 100 mcghr HYCET (hydrocodone 98 mLday 7 day supply (age 20 and acetaminophen) sol 75-325 mg older) 3 day supply (age less than 20) 15 mL 2 flls60 days for treatment naive 180
mLday 2 flls60 days for treatment experienced
hydrocodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
hydrocodoneacetaminophen tab 9 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
hydrocodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
6
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT hydromorphone supp 3 mg
HYSINGLA ER (hydrocodone bitartrate)
4 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 7 suppsday 2 flls60 days for treatment experienced 1 tabday
levorphanol tab 2 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
LORTAB (hydrocodone acetaminophen) elx 10-300 mg 15 mL
735 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 135 mLday 2 flls60 days for treatment experienced
meperidinepromethazine cap 50-25 mg
9 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 capsday 2 flls60 days for treatment experienced
mepridine sol 50 mg5 mL
MORPHABOND ER (morphine ext-release)
49 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 90 mLday 2 flls60 days for treatment experienced 2 tabsday
morphine sol 10 mg5 mL 245 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced
morphine sol 20 mg5 mL 1225 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 225 mLday 2 flls60 days for treatment experienced
morphine sol 20 mgmL 24 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced
7
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT morphine supp 10 mg 4 suppsday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 suppsday 2 flls60 days for treatment experienced
morphine supp 20 mg 2 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 suppsday 2 flls60 days for treatment experienced
morphine supp 30 mg 1 suppday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 suppsday 2 flls60 days for treatment experienced
morphine supp 5 mg 9 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 suppsday 2 flls60 days for treatment experienced
morphine tab 15 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
morphine tab 30 mg
morphine sulfate ER cap
MS CONTIN (morphine ext-release)
1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced 2 capsday
3 tabsday
NALOCET (oxycodone acetaminophen)
13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
OPANA (oxymorphone) tab 10 mg 1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced
8
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OPANA (oxymorphone) tab 5 mg 3 tabsday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
OXAYDO (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
OXAYDO (oxycodone) tab 75 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
oxycodoneaspirin tab 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneibuprofen tab 5-400 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
oxycodone cap 5 mg 6 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
oxycodone conc 20 mgmL 16 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 mLday 2 flls60 days for treatment experienced
oxycodone sol 5 mg5 mL 326 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodone tab 10 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
9
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
OXYCONTIN (oxycodone ext-release) 4 tabsday
oxymorphone ER 4 tabsday
pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
10
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
11
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap
11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced
TREZIX (acetaminophencaffeine dihydrocodeine) cap
12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 3
10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 4
5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
ULTRACET (tramadol acetaminophen) tab 375-325 mg
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
ULTRAM (tramadol) tab 50 mg
ULTRAM ER (tramadol ext-release)
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday
VERDROCET (hydrocodone acetaminophen) tab 25-325 mg
12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
12
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Anticonvulsants
Anticonvulsants
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12
tabsday 2 flls60 days for treatment experienced
VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9
tabsday 2 flls60 days for treatment experienced
VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135
mLday 2 flls60 days for treatment experienced
Anticonvulsants BANZEL (rufnamide) None
clobazam None
HORIZANT (gabapentin enacarbil) 2 tabsday
Antipsychotics ADASUVE (loxapine) None
Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)
CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)
13
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days
HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days
M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
promethazinephenylephrine codeine promethazinecodeine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
REZIRA (pseudoephedrine hydrocodone)
240 mLfll 2 flls60 days
14
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Antitussives (PA age lt18)
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Migraine
Migraine
Migraine
Parkinsonrsquos
Stimulants
Stimulants
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days
TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)
Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days
AIMOVIG (erenumab) 140 mgmL 1 syringe30 days
EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days
EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg
Miscellaneous NUEDEXTA (dextromethorphan None quinidine)
Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None
NUPLAZID (pimavanserin) None
Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday
Stimulants armodafnil 1 tabday
armodafnil 50 mg 2 tabsday
modafnil 1 tabday
15
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None
BELVIQ XR (lorcaserin) None
BONTRIL (phendimetrazine) None
CONTRAVE (naltrexone-bupropion) None
DIDREX (benzphetamine) None
LOMAIRA (phentermine) None
phentermine None
QSYMIA (phenterminetopiramate) None
REGIMEX (benzphetamine) None
SAXENDA (liraglutide) None
SUPRENZA (phentermine) None
TENUATE (diethylpropion) None
XENICAL (orlistat) None
Dermatology Acne (Oral) ABSORICA (isotretinoin) None
AMNESTEEM (isotretinoin) None
CLARAVIS (isotretinoin) None
MYORISAN (isotretinoin) None
ZENATANE (isotretinoin) None
Acne (PA age gt25 adapalene None only)
ATRALIN (tretinoin) None
AVITA (tretinoin) None
PLIXDA (adapalene) None
RETIN-A (tretinoin) None
tretinoin microsphere gel None
TRETIN-X (tretinoin) None
Endocrinology amp Metabolism Androgens Testosterone (Oral)
ANADROL-50 (oxymetholone) None
ANDROID (methyltestosterone) None
ANDROXY (fuoxymesterone) None
METHITEST (methyltestosterone) None
16
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)
Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)
Antidiabetic Agents
Antiemetics
Antiemetics
Antiemetics
Antiemetics
Irritable Bowel Syndrome
Allergen Extracts
Allergen Extracts
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday
OXANDRIN (oxandrolone) 10 mg 2 tabsday
TESTRED (methyltestosterone) None
Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)
DELATESTRYL (testosterone None enanthate)
TESTOPEL (testosterone pellet) None
testosterone cypionate None
Androgens ANDRODERM (testosterone) None Testosterone (Topical)
NATESTO (testosterone nasal) None
STRIANT (testosterone) None
testosterone gel 162 None
Antidiabetic Agents AFREZZA (insulin regular) None
SYMLINPEN (pramlintide) None
Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday
CESAMET (nabilone) 20 capsfll or 3 max days supply
DICLEGIS (doxylamine-pyridoxine) 4 tabsday
MARINOL (dronabinol) 2 capsday
SYNDROS (dronabinol) 120 mL30 days
Irritable Bowel LOTRONEX (alosetron) None Syndrome
VIBERZI (eluxadoline) 2 tabsday
Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday
ODACTRA (house dust mite) 1 tabday
ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR
17
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Methotrexate Auto-Injectors
Miscellaneous
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)
Immunizations VARIZIG (varicella-zoster immune None globulin)
Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None
Calcium Modifer cinacalcet None
Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors
RASUVO (methotrexate) 4 auto-injectors28 days
Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None
Oncology Miscellaneous PROVENGE (sipuleucel-T) None
Ophthalmology Miscellaneous RESTASIS (cyclosporine) None
XIIDRA (liftegrast) None
Respiratory AsthmaCOPD DALIRESP (rofumilast) None
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Premium specialty prior authorization list
These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None
18
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT DILAUDID (hydromorphone) liq 1225 mLday 7 day supply (age 20 1 mgmL and older) 3 day supply (age less
than 20) 2 flls60 days for treatment naive 225 mLday 2 flls60 days for treatment experienced
DILAUDID (hydromorphone) 6 tabsday 7 day supply (age 20 and tab 2 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 11 tabsday 2 flls60 days for treatment experienced
DILAUDID (hydromorphone) 3 tabsday 7 day supply 2 flls60 tab 4 mg days for treatment naiumlve 5 tabsday 2
flls60 days for treatment experienced DILAUDID (hydromorphone) tab 8 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
EMBEDA (morphinenaltrexone) 2 capsday
EXALGO (hydromorphone) 2 tabsday
fentanyl transdermal patch 15 patches30 days
fentanyl transdermal patch 75 mcg 30 patches30 days hr 100 mcghr HYCET (hydrocodone 98 mLday 7 day supply (age 20 and acetaminophen) sol 75-325 mg older) 3 day supply (age less than 20) 15 mL 2 flls60 days for treatment naive 180
mLday 2 flls60 days for treatment experienced
hydrocodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
hydrocodoneacetaminophen tab 9 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
hydrocodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
6
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT hydromorphone supp 3 mg
HYSINGLA ER (hydrocodone bitartrate)
4 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 7 suppsday 2 flls60 days for treatment experienced 1 tabday
levorphanol tab 2 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
LORTAB (hydrocodone acetaminophen) elx 10-300 mg 15 mL
735 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 135 mLday 2 flls60 days for treatment experienced
meperidinepromethazine cap 50-25 mg
9 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 capsday 2 flls60 days for treatment experienced
mepridine sol 50 mg5 mL
MORPHABOND ER (morphine ext-release)
49 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 90 mLday 2 flls60 days for treatment experienced 2 tabsday
morphine sol 10 mg5 mL 245 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced
morphine sol 20 mg5 mL 1225 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 225 mLday 2 flls60 days for treatment experienced
morphine sol 20 mgmL 24 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced
7
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT morphine supp 10 mg 4 suppsday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 suppsday 2 flls60 days for treatment experienced
morphine supp 20 mg 2 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 suppsday 2 flls60 days for treatment experienced
morphine supp 30 mg 1 suppday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 suppsday 2 flls60 days for treatment experienced
morphine supp 5 mg 9 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 suppsday 2 flls60 days for treatment experienced
morphine tab 15 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
morphine tab 30 mg
morphine sulfate ER cap
MS CONTIN (morphine ext-release)
1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced 2 capsday
3 tabsday
NALOCET (oxycodone acetaminophen)
13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
OPANA (oxymorphone) tab 10 mg 1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced
8
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OPANA (oxymorphone) tab 5 mg 3 tabsday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
OXAYDO (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
OXAYDO (oxycodone) tab 75 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
oxycodoneaspirin tab 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneibuprofen tab 5-400 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
oxycodone cap 5 mg 6 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
oxycodone conc 20 mgmL 16 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 mLday 2 flls60 days for treatment experienced
oxycodone sol 5 mg5 mL 326 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodone tab 10 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
9
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
OXYCONTIN (oxycodone ext-release) 4 tabsday
oxymorphone ER 4 tabsday
pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
10
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
11
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap
11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced
TREZIX (acetaminophencaffeine dihydrocodeine) cap
12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 3
10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 4
5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
ULTRACET (tramadol acetaminophen) tab 375-325 mg
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
ULTRAM (tramadol) tab 50 mg
ULTRAM ER (tramadol ext-release)
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday
VERDROCET (hydrocodone acetaminophen) tab 25-325 mg
12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
12
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Anticonvulsants
Anticonvulsants
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12
tabsday 2 flls60 days for treatment experienced
VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9
tabsday 2 flls60 days for treatment experienced
VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135
mLday 2 flls60 days for treatment experienced
Anticonvulsants BANZEL (rufnamide) None
clobazam None
HORIZANT (gabapentin enacarbil) 2 tabsday
Antipsychotics ADASUVE (loxapine) None
Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)
CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)
13
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days
HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days
M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
promethazinephenylephrine codeine promethazinecodeine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
REZIRA (pseudoephedrine hydrocodone)
240 mLfll 2 flls60 days
14
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Antitussives (PA age lt18)
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Migraine
Migraine
Migraine
Parkinsonrsquos
Stimulants
Stimulants
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days
TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)
Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days
AIMOVIG (erenumab) 140 mgmL 1 syringe30 days
EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days
EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg
Miscellaneous NUEDEXTA (dextromethorphan None quinidine)
Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None
NUPLAZID (pimavanserin) None
Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday
Stimulants armodafnil 1 tabday
armodafnil 50 mg 2 tabsday
modafnil 1 tabday
15
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None
BELVIQ XR (lorcaserin) None
BONTRIL (phendimetrazine) None
CONTRAVE (naltrexone-bupropion) None
DIDREX (benzphetamine) None
LOMAIRA (phentermine) None
phentermine None
QSYMIA (phenterminetopiramate) None
REGIMEX (benzphetamine) None
SAXENDA (liraglutide) None
SUPRENZA (phentermine) None
TENUATE (diethylpropion) None
XENICAL (orlistat) None
Dermatology Acne (Oral) ABSORICA (isotretinoin) None
AMNESTEEM (isotretinoin) None
CLARAVIS (isotretinoin) None
MYORISAN (isotretinoin) None
ZENATANE (isotretinoin) None
Acne (PA age gt25 adapalene None only)
ATRALIN (tretinoin) None
AVITA (tretinoin) None
PLIXDA (adapalene) None
RETIN-A (tretinoin) None
tretinoin microsphere gel None
TRETIN-X (tretinoin) None
Endocrinology amp Metabolism Androgens Testosterone (Oral)
ANADROL-50 (oxymetholone) None
ANDROID (methyltestosterone) None
ANDROXY (fuoxymesterone) None
METHITEST (methyltestosterone) None
16
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)
Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)
Antidiabetic Agents
Antiemetics
Antiemetics
Antiemetics
Antiemetics
Irritable Bowel Syndrome
Allergen Extracts
Allergen Extracts
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday
OXANDRIN (oxandrolone) 10 mg 2 tabsday
TESTRED (methyltestosterone) None
Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)
DELATESTRYL (testosterone None enanthate)
TESTOPEL (testosterone pellet) None
testosterone cypionate None
Androgens ANDRODERM (testosterone) None Testosterone (Topical)
NATESTO (testosterone nasal) None
STRIANT (testosterone) None
testosterone gel 162 None
Antidiabetic Agents AFREZZA (insulin regular) None
SYMLINPEN (pramlintide) None
Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday
CESAMET (nabilone) 20 capsfll or 3 max days supply
DICLEGIS (doxylamine-pyridoxine) 4 tabsday
MARINOL (dronabinol) 2 capsday
SYNDROS (dronabinol) 120 mL30 days
Irritable Bowel LOTRONEX (alosetron) None Syndrome
VIBERZI (eluxadoline) 2 tabsday
Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday
ODACTRA (house dust mite) 1 tabday
ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR
17
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Methotrexate Auto-Injectors
Miscellaneous
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)
Immunizations VARIZIG (varicella-zoster immune None globulin)
Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None
Calcium Modifer cinacalcet None
Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors
RASUVO (methotrexate) 4 auto-injectors28 days
Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None
Oncology Miscellaneous PROVENGE (sipuleucel-T) None
Ophthalmology Miscellaneous RESTASIS (cyclosporine) None
XIIDRA (liftegrast) None
Respiratory AsthmaCOPD DALIRESP (rofumilast) None
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Premium specialty prior authorization list
These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None
18
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT hydromorphone supp 3 mg
HYSINGLA ER (hydrocodone bitartrate)
4 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 7 suppsday 2 flls60 days for treatment experienced 1 tabday
levorphanol tab 2 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
LORTAB (hydrocodone acetaminophen) elx 10-300 mg 15 mL
735 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 135 mLday 2 flls60 days for treatment experienced
meperidinepromethazine cap 50-25 mg
9 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 capsday 2 flls60 days for treatment experienced
mepridine sol 50 mg5 mL
MORPHABOND ER (morphine ext-release)
49 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 90 mLday 2 flls60 days for treatment experienced 2 tabsday
morphine sol 10 mg5 mL 245 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced
morphine sol 20 mg5 mL 1225 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 225 mLday 2 flls60 days for treatment experienced
morphine sol 20 mgmL 24 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced
7
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT morphine supp 10 mg 4 suppsday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 suppsday 2 flls60 days for treatment experienced
morphine supp 20 mg 2 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 suppsday 2 flls60 days for treatment experienced
morphine supp 30 mg 1 suppday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 suppsday 2 flls60 days for treatment experienced
morphine supp 5 mg 9 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 suppsday 2 flls60 days for treatment experienced
morphine tab 15 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
morphine tab 30 mg
morphine sulfate ER cap
MS CONTIN (morphine ext-release)
1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced 2 capsday
3 tabsday
NALOCET (oxycodone acetaminophen)
13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
OPANA (oxymorphone) tab 10 mg 1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced
8
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OPANA (oxymorphone) tab 5 mg 3 tabsday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
OXAYDO (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
OXAYDO (oxycodone) tab 75 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
oxycodoneaspirin tab 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneibuprofen tab 5-400 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
oxycodone cap 5 mg 6 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
oxycodone conc 20 mgmL 16 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 mLday 2 flls60 days for treatment experienced
oxycodone sol 5 mg5 mL 326 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodone tab 10 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
9
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
OXYCONTIN (oxycodone ext-release) 4 tabsday
oxymorphone ER 4 tabsday
pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
10
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
11
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap
11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced
TREZIX (acetaminophencaffeine dihydrocodeine) cap
12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 3
10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 4
5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
ULTRACET (tramadol acetaminophen) tab 375-325 mg
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
ULTRAM (tramadol) tab 50 mg
ULTRAM ER (tramadol ext-release)
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday
VERDROCET (hydrocodone acetaminophen) tab 25-325 mg
12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
12
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Anticonvulsants
Anticonvulsants
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12
tabsday 2 flls60 days for treatment experienced
VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9
tabsday 2 flls60 days for treatment experienced
VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135
mLday 2 flls60 days for treatment experienced
Anticonvulsants BANZEL (rufnamide) None
clobazam None
HORIZANT (gabapentin enacarbil) 2 tabsday
Antipsychotics ADASUVE (loxapine) None
Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)
CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)
13
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days
HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days
M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
promethazinephenylephrine codeine promethazinecodeine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
REZIRA (pseudoephedrine hydrocodone)
240 mLfll 2 flls60 days
14
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Antitussives (PA age lt18)
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Migraine
Migraine
Migraine
Parkinsonrsquos
Stimulants
Stimulants
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days
TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)
Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days
AIMOVIG (erenumab) 140 mgmL 1 syringe30 days
EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days
EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg
Miscellaneous NUEDEXTA (dextromethorphan None quinidine)
Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None
NUPLAZID (pimavanserin) None
Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday
Stimulants armodafnil 1 tabday
armodafnil 50 mg 2 tabsday
modafnil 1 tabday
15
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None
BELVIQ XR (lorcaserin) None
BONTRIL (phendimetrazine) None
CONTRAVE (naltrexone-bupropion) None
DIDREX (benzphetamine) None
LOMAIRA (phentermine) None
phentermine None
QSYMIA (phenterminetopiramate) None
REGIMEX (benzphetamine) None
SAXENDA (liraglutide) None
SUPRENZA (phentermine) None
TENUATE (diethylpropion) None
XENICAL (orlistat) None
Dermatology Acne (Oral) ABSORICA (isotretinoin) None
AMNESTEEM (isotretinoin) None
CLARAVIS (isotretinoin) None
MYORISAN (isotretinoin) None
ZENATANE (isotretinoin) None
Acne (PA age gt25 adapalene None only)
ATRALIN (tretinoin) None
AVITA (tretinoin) None
PLIXDA (adapalene) None
RETIN-A (tretinoin) None
tretinoin microsphere gel None
TRETIN-X (tretinoin) None
Endocrinology amp Metabolism Androgens Testosterone (Oral)
ANADROL-50 (oxymetholone) None
ANDROID (methyltestosterone) None
ANDROXY (fuoxymesterone) None
METHITEST (methyltestosterone) None
16
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)
Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)
Antidiabetic Agents
Antiemetics
Antiemetics
Antiemetics
Antiemetics
Irritable Bowel Syndrome
Allergen Extracts
Allergen Extracts
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday
OXANDRIN (oxandrolone) 10 mg 2 tabsday
TESTRED (methyltestosterone) None
Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)
DELATESTRYL (testosterone None enanthate)
TESTOPEL (testosterone pellet) None
testosterone cypionate None
Androgens ANDRODERM (testosterone) None Testosterone (Topical)
NATESTO (testosterone nasal) None
STRIANT (testosterone) None
testosterone gel 162 None
Antidiabetic Agents AFREZZA (insulin regular) None
SYMLINPEN (pramlintide) None
Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday
CESAMET (nabilone) 20 capsfll or 3 max days supply
DICLEGIS (doxylamine-pyridoxine) 4 tabsday
MARINOL (dronabinol) 2 capsday
SYNDROS (dronabinol) 120 mL30 days
Irritable Bowel LOTRONEX (alosetron) None Syndrome
VIBERZI (eluxadoline) 2 tabsday
Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday
ODACTRA (house dust mite) 1 tabday
ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR
17
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Methotrexate Auto-Injectors
Miscellaneous
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)
Immunizations VARIZIG (varicella-zoster immune None globulin)
Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None
Calcium Modifer cinacalcet None
Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors
RASUVO (methotrexate) 4 auto-injectors28 days
Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None
Oncology Miscellaneous PROVENGE (sipuleucel-T) None
Ophthalmology Miscellaneous RESTASIS (cyclosporine) None
XIIDRA (liftegrast) None
Respiratory AsthmaCOPD DALIRESP (rofumilast) None
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Premium specialty prior authorization list
These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None
18
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT morphine supp 10 mg 4 suppsday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 suppsday 2 flls60 days for treatment experienced
morphine supp 20 mg 2 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 suppsday 2 flls60 days for treatment experienced
morphine supp 30 mg 1 suppday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 suppsday 2 flls60 days for treatment experienced
morphine supp 5 mg 9 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 suppsday 2 flls60 days for treatment experienced
morphine tab 15 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
morphine tab 30 mg
morphine sulfate ER cap
MS CONTIN (morphine ext-release)
1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced 2 capsday
3 tabsday
NALOCET (oxycodone acetaminophen)
13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
OPANA (oxymorphone) tab 10 mg 1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced
8
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OPANA (oxymorphone) tab 5 mg 3 tabsday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
OXAYDO (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
OXAYDO (oxycodone) tab 75 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
oxycodoneaspirin tab 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneibuprofen tab 5-400 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
oxycodone cap 5 mg 6 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
oxycodone conc 20 mgmL 16 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 mLday 2 flls60 days for treatment experienced
oxycodone sol 5 mg5 mL 326 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodone tab 10 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
9
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
OXYCONTIN (oxycodone ext-release) 4 tabsday
oxymorphone ER 4 tabsday
pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
10
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
11
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap
11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced
TREZIX (acetaminophencaffeine dihydrocodeine) cap
12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 3
10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 4
5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
ULTRACET (tramadol acetaminophen) tab 375-325 mg
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
ULTRAM (tramadol) tab 50 mg
ULTRAM ER (tramadol ext-release)
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday
VERDROCET (hydrocodone acetaminophen) tab 25-325 mg
12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
12
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Anticonvulsants
Anticonvulsants
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12
tabsday 2 flls60 days for treatment experienced
VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9
tabsday 2 flls60 days for treatment experienced
VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135
mLday 2 flls60 days for treatment experienced
Anticonvulsants BANZEL (rufnamide) None
clobazam None
HORIZANT (gabapentin enacarbil) 2 tabsday
Antipsychotics ADASUVE (loxapine) None
Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)
CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)
13
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days
HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days
M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
promethazinephenylephrine codeine promethazinecodeine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
REZIRA (pseudoephedrine hydrocodone)
240 mLfll 2 flls60 days
14
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Antitussives (PA age lt18)
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Migraine
Migraine
Migraine
Parkinsonrsquos
Stimulants
Stimulants
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days
TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)
Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days
AIMOVIG (erenumab) 140 mgmL 1 syringe30 days
EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days
EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg
Miscellaneous NUEDEXTA (dextromethorphan None quinidine)
Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None
NUPLAZID (pimavanserin) None
Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday
Stimulants armodafnil 1 tabday
armodafnil 50 mg 2 tabsday
modafnil 1 tabday
15
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None
BELVIQ XR (lorcaserin) None
BONTRIL (phendimetrazine) None
CONTRAVE (naltrexone-bupropion) None
DIDREX (benzphetamine) None
LOMAIRA (phentermine) None
phentermine None
QSYMIA (phenterminetopiramate) None
REGIMEX (benzphetamine) None
SAXENDA (liraglutide) None
SUPRENZA (phentermine) None
TENUATE (diethylpropion) None
XENICAL (orlistat) None
Dermatology Acne (Oral) ABSORICA (isotretinoin) None
AMNESTEEM (isotretinoin) None
CLARAVIS (isotretinoin) None
MYORISAN (isotretinoin) None
ZENATANE (isotretinoin) None
Acne (PA age gt25 adapalene None only)
ATRALIN (tretinoin) None
AVITA (tretinoin) None
PLIXDA (adapalene) None
RETIN-A (tretinoin) None
tretinoin microsphere gel None
TRETIN-X (tretinoin) None
Endocrinology amp Metabolism Androgens Testosterone (Oral)
ANADROL-50 (oxymetholone) None
ANDROID (methyltestosterone) None
ANDROXY (fuoxymesterone) None
METHITEST (methyltestosterone) None
16
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)
Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)
Antidiabetic Agents
Antiemetics
Antiemetics
Antiemetics
Antiemetics
Irritable Bowel Syndrome
Allergen Extracts
Allergen Extracts
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday
OXANDRIN (oxandrolone) 10 mg 2 tabsday
TESTRED (methyltestosterone) None
Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)
DELATESTRYL (testosterone None enanthate)
TESTOPEL (testosterone pellet) None
testosterone cypionate None
Androgens ANDRODERM (testosterone) None Testosterone (Topical)
NATESTO (testosterone nasal) None
STRIANT (testosterone) None
testosterone gel 162 None
Antidiabetic Agents AFREZZA (insulin regular) None
SYMLINPEN (pramlintide) None
Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday
CESAMET (nabilone) 20 capsfll or 3 max days supply
DICLEGIS (doxylamine-pyridoxine) 4 tabsday
MARINOL (dronabinol) 2 capsday
SYNDROS (dronabinol) 120 mL30 days
Irritable Bowel LOTRONEX (alosetron) None Syndrome
VIBERZI (eluxadoline) 2 tabsday
Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday
ODACTRA (house dust mite) 1 tabday
ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR
17
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Methotrexate Auto-Injectors
Miscellaneous
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)
Immunizations VARIZIG (varicella-zoster immune None globulin)
Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None
Calcium Modifer cinacalcet None
Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors
RASUVO (methotrexate) 4 auto-injectors28 days
Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None
Oncology Miscellaneous PROVENGE (sipuleucel-T) None
Ophthalmology Miscellaneous RESTASIS (cyclosporine) None
XIIDRA (liftegrast) None
Respiratory AsthmaCOPD DALIRESP (rofumilast) None
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Premium specialty prior authorization list
These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None
18
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OPANA (oxymorphone) tab 5 mg 3 tabsday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
OXAYDO (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
OXAYDO (oxycodone) tab 75 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
oxycodoneaspirin tab 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneibuprofen tab 5-400 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
oxycodone cap 5 mg 6 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
oxycodone conc 20 mgmL 16 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 mLday 2 flls60 days for treatment experienced
oxycodone sol 5 mg5 mL 326 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodone tab 10 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
9
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
OXYCONTIN (oxycodone ext-release) 4 tabsday
oxymorphone ER 4 tabsday
pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
10
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
11
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap
11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced
TREZIX (acetaminophencaffeine dihydrocodeine) cap
12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 3
10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 4
5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
ULTRACET (tramadol acetaminophen) tab 375-325 mg
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
ULTRAM (tramadol) tab 50 mg
ULTRAM ER (tramadol ext-release)
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday
VERDROCET (hydrocodone acetaminophen) tab 25-325 mg
12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
12
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Anticonvulsants
Anticonvulsants
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12
tabsday 2 flls60 days for treatment experienced
VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9
tabsday 2 flls60 days for treatment experienced
VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135
mLday 2 flls60 days for treatment experienced
Anticonvulsants BANZEL (rufnamide) None
clobazam None
HORIZANT (gabapentin enacarbil) 2 tabsday
Antipsychotics ADASUVE (loxapine) None
Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)
CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)
13
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days
HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days
M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
promethazinephenylephrine codeine promethazinecodeine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
REZIRA (pseudoephedrine hydrocodone)
240 mLfll 2 flls60 days
14
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Antitussives (PA age lt18)
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Migraine
Migraine
Migraine
Parkinsonrsquos
Stimulants
Stimulants
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days
TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)
Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days
AIMOVIG (erenumab) 140 mgmL 1 syringe30 days
EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days
EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg
Miscellaneous NUEDEXTA (dextromethorphan None quinidine)
Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None
NUPLAZID (pimavanserin) None
Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday
Stimulants armodafnil 1 tabday
armodafnil 50 mg 2 tabsday
modafnil 1 tabday
15
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None
BELVIQ XR (lorcaserin) None
BONTRIL (phendimetrazine) None
CONTRAVE (naltrexone-bupropion) None
DIDREX (benzphetamine) None
LOMAIRA (phentermine) None
phentermine None
QSYMIA (phenterminetopiramate) None
REGIMEX (benzphetamine) None
SAXENDA (liraglutide) None
SUPRENZA (phentermine) None
TENUATE (diethylpropion) None
XENICAL (orlistat) None
Dermatology Acne (Oral) ABSORICA (isotretinoin) None
AMNESTEEM (isotretinoin) None
CLARAVIS (isotretinoin) None
MYORISAN (isotretinoin) None
ZENATANE (isotretinoin) None
Acne (PA age gt25 adapalene None only)
ATRALIN (tretinoin) None
AVITA (tretinoin) None
PLIXDA (adapalene) None
RETIN-A (tretinoin) None
tretinoin microsphere gel None
TRETIN-X (tretinoin) None
Endocrinology amp Metabolism Androgens Testosterone (Oral)
ANADROL-50 (oxymetholone) None
ANDROID (methyltestosterone) None
ANDROXY (fuoxymesterone) None
METHITEST (methyltestosterone) None
16
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)
Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)
Antidiabetic Agents
Antiemetics
Antiemetics
Antiemetics
Antiemetics
Irritable Bowel Syndrome
Allergen Extracts
Allergen Extracts
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday
OXANDRIN (oxandrolone) 10 mg 2 tabsday
TESTRED (methyltestosterone) None
Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)
DELATESTRYL (testosterone None enanthate)
TESTOPEL (testosterone pellet) None
testosterone cypionate None
Androgens ANDRODERM (testosterone) None Testosterone (Topical)
NATESTO (testosterone nasal) None
STRIANT (testosterone) None
testosterone gel 162 None
Antidiabetic Agents AFREZZA (insulin regular) None
SYMLINPEN (pramlintide) None
Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday
CESAMET (nabilone) 20 capsfll or 3 max days supply
DICLEGIS (doxylamine-pyridoxine) 4 tabsday
MARINOL (dronabinol) 2 capsday
SYNDROS (dronabinol) 120 mL30 days
Irritable Bowel LOTRONEX (alosetron) None Syndrome
VIBERZI (eluxadoline) 2 tabsday
Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday
ODACTRA (house dust mite) 1 tabday
ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR
17
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Methotrexate Auto-Injectors
Miscellaneous
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)
Immunizations VARIZIG (varicella-zoster immune None globulin)
Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None
Calcium Modifer cinacalcet None
Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors
RASUVO (methotrexate) 4 auto-injectors28 days
Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None
Oncology Miscellaneous PROVENGE (sipuleucel-T) None
Ophthalmology Miscellaneous RESTASIS (cyclosporine) None
XIIDRA (liftegrast) None
Respiratory AsthmaCOPD DALIRESP (rofumilast) None
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Premium specialty prior authorization list
These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None
18
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
OXYCONTIN (oxycodone ext-release) 4 tabsday
oxymorphone ER 4 tabsday
pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced
10
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
11
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap
11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced
TREZIX (acetaminophencaffeine dihydrocodeine) cap
12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 3
10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 4
5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
ULTRACET (tramadol acetaminophen) tab 375-325 mg
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
ULTRAM (tramadol) tab 50 mg
ULTRAM ER (tramadol ext-release)
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday
VERDROCET (hydrocodone acetaminophen) tab 25-325 mg
12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
12
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Anticonvulsants
Anticonvulsants
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12
tabsday 2 flls60 days for treatment experienced
VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9
tabsday 2 flls60 days for treatment experienced
VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135
mLday 2 flls60 days for treatment experienced
Anticonvulsants BANZEL (rufnamide) None
clobazam None
HORIZANT (gabapentin enacarbil) 2 tabsday
Antipsychotics ADASUVE (loxapine) None
Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)
CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)
13
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days
HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days
M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
promethazinephenylephrine codeine promethazinecodeine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
REZIRA (pseudoephedrine hydrocodone)
240 mLfll 2 flls60 days
14
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Antitussives (PA age lt18)
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Migraine
Migraine
Migraine
Parkinsonrsquos
Stimulants
Stimulants
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days
TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)
Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days
AIMOVIG (erenumab) 140 mgmL 1 syringe30 days
EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days
EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg
Miscellaneous NUEDEXTA (dextromethorphan None quinidine)
Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None
NUPLAZID (pimavanserin) None
Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday
Stimulants armodafnil 1 tabday
armodafnil 50 mg 2 tabsday
modafnil 1 tabday
15
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None
BELVIQ XR (lorcaserin) None
BONTRIL (phendimetrazine) None
CONTRAVE (naltrexone-bupropion) None
DIDREX (benzphetamine) None
LOMAIRA (phentermine) None
phentermine None
QSYMIA (phenterminetopiramate) None
REGIMEX (benzphetamine) None
SAXENDA (liraglutide) None
SUPRENZA (phentermine) None
TENUATE (diethylpropion) None
XENICAL (orlistat) None
Dermatology Acne (Oral) ABSORICA (isotretinoin) None
AMNESTEEM (isotretinoin) None
CLARAVIS (isotretinoin) None
MYORISAN (isotretinoin) None
ZENATANE (isotretinoin) None
Acne (PA age gt25 adapalene None only)
ATRALIN (tretinoin) None
AVITA (tretinoin) None
PLIXDA (adapalene) None
RETIN-A (tretinoin) None
tretinoin microsphere gel None
TRETIN-X (tretinoin) None
Endocrinology amp Metabolism Androgens Testosterone (Oral)
ANADROL-50 (oxymetholone) None
ANDROID (methyltestosterone) None
ANDROXY (fuoxymesterone) None
METHITEST (methyltestosterone) None
16
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)
Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)
Antidiabetic Agents
Antiemetics
Antiemetics
Antiemetics
Antiemetics
Irritable Bowel Syndrome
Allergen Extracts
Allergen Extracts
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday
OXANDRIN (oxandrolone) 10 mg 2 tabsday
TESTRED (methyltestosterone) None
Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)
DELATESTRYL (testosterone None enanthate)
TESTOPEL (testosterone pellet) None
testosterone cypionate None
Androgens ANDRODERM (testosterone) None Testosterone (Topical)
NATESTO (testosterone nasal) None
STRIANT (testosterone) None
testosterone gel 162 None
Antidiabetic Agents AFREZZA (insulin regular) None
SYMLINPEN (pramlintide) None
Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday
CESAMET (nabilone) 20 capsfll or 3 max days supply
DICLEGIS (doxylamine-pyridoxine) 4 tabsday
MARINOL (dronabinol) 2 capsday
SYNDROS (dronabinol) 120 mL30 days
Irritable Bowel LOTRONEX (alosetron) None Syndrome
VIBERZI (eluxadoline) 2 tabsday
Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday
ODACTRA (house dust mite) 1 tabday
ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR
17
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Methotrexate Auto-Injectors
Miscellaneous
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)
Immunizations VARIZIG (varicella-zoster immune None globulin)
Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None
Calcium Modifer cinacalcet None
Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors
RASUVO (methotrexate) 4 auto-injectors28 days
Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None
Oncology Miscellaneous PROVENGE (sipuleucel-T) None
Ophthalmology Miscellaneous RESTASIS (cyclosporine) None
XIIDRA (liftegrast) None
Respiratory AsthmaCOPD DALIRESP (rofumilast) None
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Premium specialty prior authorization list
These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None
18
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced
REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced
11
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap
11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced
TREZIX (acetaminophencaffeine dihydrocodeine) cap
12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 3
10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 4
5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
ULTRACET (tramadol acetaminophen) tab 375-325 mg
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
ULTRAM (tramadol) tab 50 mg
ULTRAM ER (tramadol ext-release)
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday
VERDROCET (hydrocodone acetaminophen) tab 25-325 mg
12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
12
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Anticonvulsants
Anticonvulsants
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12
tabsday 2 flls60 days for treatment experienced
VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9
tabsday 2 flls60 days for treatment experienced
VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135
mLday 2 flls60 days for treatment experienced
Anticonvulsants BANZEL (rufnamide) None
clobazam None
HORIZANT (gabapentin enacarbil) 2 tabsday
Antipsychotics ADASUVE (loxapine) None
Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)
CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)
13
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days
HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days
M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
promethazinephenylephrine codeine promethazinecodeine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
REZIRA (pseudoephedrine hydrocodone)
240 mLfll 2 flls60 days
14
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Antitussives (PA age lt18)
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Migraine
Migraine
Migraine
Parkinsonrsquos
Stimulants
Stimulants
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days
TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)
Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days
AIMOVIG (erenumab) 140 mgmL 1 syringe30 days
EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days
EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg
Miscellaneous NUEDEXTA (dextromethorphan None quinidine)
Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None
NUPLAZID (pimavanserin) None
Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday
Stimulants armodafnil 1 tabday
armodafnil 50 mg 2 tabsday
modafnil 1 tabday
15
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None
BELVIQ XR (lorcaserin) None
BONTRIL (phendimetrazine) None
CONTRAVE (naltrexone-bupropion) None
DIDREX (benzphetamine) None
LOMAIRA (phentermine) None
phentermine None
QSYMIA (phenterminetopiramate) None
REGIMEX (benzphetamine) None
SAXENDA (liraglutide) None
SUPRENZA (phentermine) None
TENUATE (diethylpropion) None
XENICAL (orlistat) None
Dermatology Acne (Oral) ABSORICA (isotretinoin) None
AMNESTEEM (isotretinoin) None
CLARAVIS (isotretinoin) None
MYORISAN (isotretinoin) None
ZENATANE (isotretinoin) None
Acne (PA age gt25 adapalene None only)
ATRALIN (tretinoin) None
AVITA (tretinoin) None
PLIXDA (adapalene) None
RETIN-A (tretinoin) None
tretinoin microsphere gel None
TRETIN-X (tretinoin) None
Endocrinology amp Metabolism Androgens Testosterone (Oral)
ANADROL-50 (oxymetholone) None
ANDROID (methyltestosterone) None
ANDROXY (fuoxymesterone) None
METHITEST (methyltestosterone) None
16
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)
Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)
Antidiabetic Agents
Antiemetics
Antiemetics
Antiemetics
Antiemetics
Irritable Bowel Syndrome
Allergen Extracts
Allergen Extracts
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday
OXANDRIN (oxandrolone) 10 mg 2 tabsday
TESTRED (methyltestosterone) None
Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)
DELATESTRYL (testosterone None enanthate)
TESTOPEL (testosterone pellet) None
testosterone cypionate None
Androgens ANDRODERM (testosterone) None Testosterone (Topical)
NATESTO (testosterone nasal) None
STRIANT (testosterone) None
testosterone gel 162 None
Antidiabetic Agents AFREZZA (insulin regular) None
SYMLINPEN (pramlintide) None
Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday
CESAMET (nabilone) 20 capsfll or 3 max days supply
DICLEGIS (doxylamine-pyridoxine) 4 tabsday
MARINOL (dronabinol) 2 capsday
SYNDROS (dronabinol) 120 mL30 days
Irritable Bowel LOTRONEX (alosetron) None Syndrome
VIBERZI (eluxadoline) 2 tabsday
Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday
ODACTRA (house dust mite) 1 tabday
ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR
17
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Methotrexate Auto-Injectors
Miscellaneous
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)
Immunizations VARIZIG (varicella-zoster immune None globulin)
Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None
Calcium Modifer cinacalcet None
Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors
RASUVO (methotrexate) 4 auto-injectors28 days
Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None
Oncology Miscellaneous PROVENGE (sipuleucel-T) None
Ophthalmology Miscellaneous RESTASIS (cyclosporine) None
XIIDRA (liftegrast) None
Respiratory AsthmaCOPD DALIRESP (rofumilast) None
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Premium specialty prior authorization list
These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None
18
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and
older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced
SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap
11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced
TREZIX (acetaminophencaffeine dihydrocodeine) cap
12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 3
10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
TYLENOL (acetaminophen)codeine 4
5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced
ULTRACET (tramadol acetaminophen) tab 375-325 mg
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced
ULTRAM (tramadol) tab 50 mg
ULTRAM ER (tramadol ext-release)
8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday
VERDROCET (hydrocodone acetaminophen) tab 25-325 mg
12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
12
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Anticonvulsants
Anticonvulsants
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12
tabsday 2 flls60 days for treatment experienced
VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9
tabsday 2 flls60 days for treatment experienced
VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135
mLday 2 flls60 days for treatment experienced
Anticonvulsants BANZEL (rufnamide) None
clobazam None
HORIZANT (gabapentin enacarbil) 2 tabsday
Antipsychotics ADASUVE (loxapine) None
Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)
CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)
13
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days
HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days
M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
promethazinephenylephrine codeine promethazinecodeine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
REZIRA (pseudoephedrine hydrocodone)
240 mLfll 2 flls60 days
14
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Antitussives (PA age lt18)
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Migraine
Migraine
Migraine
Parkinsonrsquos
Stimulants
Stimulants
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days
TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)
Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days
AIMOVIG (erenumab) 140 mgmL 1 syringe30 days
EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days
EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg
Miscellaneous NUEDEXTA (dextromethorphan None quinidine)
Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None
NUPLAZID (pimavanserin) None
Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday
Stimulants armodafnil 1 tabday
armodafnil 50 mg 2 tabsday
modafnil 1 tabday
15
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None
BELVIQ XR (lorcaserin) None
BONTRIL (phendimetrazine) None
CONTRAVE (naltrexone-bupropion) None
DIDREX (benzphetamine) None
LOMAIRA (phentermine) None
phentermine None
QSYMIA (phenterminetopiramate) None
REGIMEX (benzphetamine) None
SAXENDA (liraglutide) None
SUPRENZA (phentermine) None
TENUATE (diethylpropion) None
XENICAL (orlistat) None
Dermatology Acne (Oral) ABSORICA (isotretinoin) None
AMNESTEEM (isotretinoin) None
CLARAVIS (isotretinoin) None
MYORISAN (isotretinoin) None
ZENATANE (isotretinoin) None
Acne (PA age gt25 adapalene None only)
ATRALIN (tretinoin) None
AVITA (tretinoin) None
PLIXDA (adapalene) None
RETIN-A (tretinoin) None
tretinoin microsphere gel None
TRETIN-X (tretinoin) None
Endocrinology amp Metabolism Androgens Testosterone (Oral)
ANADROL-50 (oxymetholone) None
ANDROID (methyltestosterone) None
ANDROXY (fuoxymesterone) None
METHITEST (methyltestosterone) None
16
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)
Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)
Antidiabetic Agents
Antiemetics
Antiemetics
Antiemetics
Antiemetics
Irritable Bowel Syndrome
Allergen Extracts
Allergen Extracts
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday
OXANDRIN (oxandrolone) 10 mg 2 tabsday
TESTRED (methyltestosterone) None
Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)
DELATESTRYL (testosterone None enanthate)
TESTOPEL (testosterone pellet) None
testosterone cypionate None
Androgens ANDRODERM (testosterone) None Testosterone (Topical)
NATESTO (testosterone nasal) None
STRIANT (testosterone) None
testosterone gel 162 None
Antidiabetic Agents AFREZZA (insulin regular) None
SYMLINPEN (pramlintide) None
Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday
CESAMET (nabilone) 20 capsfll or 3 max days supply
DICLEGIS (doxylamine-pyridoxine) 4 tabsday
MARINOL (dronabinol) 2 capsday
SYNDROS (dronabinol) 120 mL30 days
Irritable Bowel LOTRONEX (alosetron) None Syndrome
VIBERZI (eluxadoline) 2 tabsday
Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday
ODACTRA (house dust mite) 1 tabday
ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR
17
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Methotrexate Auto-Injectors
Miscellaneous
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)
Immunizations VARIZIG (varicella-zoster immune None globulin)
Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None
Calcium Modifer cinacalcet None
Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors
RASUVO (methotrexate) 4 auto-injectors28 days
Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None
Oncology Miscellaneous PROVENGE (sipuleucel-T) None
Ophthalmology Miscellaneous RESTASIS (cyclosporine) None
XIIDRA (liftegrast) None
Respiratory AsthmaCOPD DALIRESP (rofumilast) None
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Premium specialty prior authorization list
These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None
18
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Analgesics (opioid)
Anticonvulsants
Anticonvulsants
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced
VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12
tabsday 2 flls60 days for treatment experienced
VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9
tabsday 2 flls60 days for treatment experienced
VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)
2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced
ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135
mLday 2 flls60 days for treatment experienced
Anticonvulsants BANZEL (rufnamide) None
clobazam None
HORIZANT (gabapentin enacarbil) 2 tabsday
Antipsychotics ADASUVE (loxapine) None
Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)
CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days
CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)
13
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days
HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days
M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
promethazinephenylephrine codeine promethazinecodeine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
REZIRA (pseudoephedrine hydrocodone)
240 mLfll 2 flls60 days
14
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Antitussives (PA age lt18)
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Migraine
Migraine
Migraine
Parkinsonrsquos
Stimulants
Stimulants
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days
TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)
Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days
AIMOVIG (erenumab) 140 mgmL 1 syringe30 days
EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days
EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg
Miscellaneous NUEDEXTA (dextromethorphan None quinidine)
Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None
NUPLAZID (pimavanserin) None
Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday
Stimulants armodafnil 1 tabday
armodafnil 50 mg 2 tabsday
modafnil 1 tabday
15
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None
BELVIQ XR (lorcaserin) None
BONTRIL (phendimetrazine) None
CONTRAVE (naltrexone-bupropion) None
DIDREX (benzphetamine) None
LOMAIRA (phentermine) None
phentermine None
QSYMIA (phenterminetopiramate) None
REGIMEX (benzphetamine) None
SAXENDA (liraglutide) None
SUPRENZA (phentermine) None
TENUATE (diethylpropion) None
XENICAL (orlistat) None
Dermatology Acne (Oral) ABSORICA (isotretinoin) None
AMNESTEEM (isotretinoin) None
CLARAVIS (isotretinoin) None
MYORISAN (isotretinoin) None
ZENATANE (isotretinoin) None
Acne (PA age gt25 adapalene None only)
ATRALIN (tretinoin) None
AVITA (tretinoin) None
PLIXDA (adapalene) None
RETIN-A (tretinoin) None
tretinoin microsphere gel None
TRETIN-X (tretinoin) None
Endocrinology amp Metabolism Androgens Testosterone (Oral)
ANADROL-50 (oxymetholone) None
ANDROID (methyltestosterone) None
ANDROXY (fuoxymesterone) None
METHITEST (methyltestosterone) None
16
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)
Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)
Antidiabetic Agents
Antiemetics
Antiemetics
Antiemetics
Antiemetics
Irritable Bowel Syndrome
Allergen Extracts
Allergen Extracts
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday
OXANDRIN (oxandrolone) 10 mg 2 tabsday
TESTRED (methyltestosterone) None
Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)
DELATESTRYL (testosterone None enanthate)
TESTOPEL (testosterone pellet) None
testosterone cypionate None
Androgens ANDRODERM (testosterone) None Testosterone (Topical)
NATESTO (testosterone nasal) None
STRIANT (testosterone) None
testosterone gel 162 None
Antidiabetic Agents AFREZZA (insulin regular) None
SYMLINPEN (pramlintide) None
Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday
CESAMET (nabilone) 20 capsfll or 3 max days supply
DICLEGIS (doxylamine-pyridoxine) 4 tabsday
MARINOL (dronabinol) 2 capsday
SYNDROS (dronabinol) 120 mL30 days
Irritable Bowel LOTRONEX (alosetron) None Syndrome
VIBERZI (eluxadoline) 2 tabsday
Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday
ODACTRA (house dust mite) 1 tabday
ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR
17
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Methotrexate Auto-Injectors
Miscellaneous
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)
Immunizations VARIZIG (varicella-zoster immune None globulin)
Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None
Calcium Modifer cinacalcet None
Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors
RASUVO (methotrexate) 4 auto-injectors28 days
Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None
Oncology Miscellaneous PROVENGE (sipuleucel-T) None
Ophthalmology Miscellaneous RESTASIS (cyclosporine) None
XIIDRA (liftegrast) None
Respiratory AsthmaCOPD DALIRESP (rofumilast) None
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Premium specialty prior authorization list
These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None
18
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days
HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days
M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
promethazinephenylephrine codeine promethazinecodeine
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
240 mLfll 2 flls60 days
REZIRA (pseudoephedrine hydrocodone)
240 mLfll 2 flls60 days
14
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Antitussives (PA age lt18)
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Migraine
Migraine
Migraine
Parkinsonrsquos
Stimulants
Stimulants
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days
TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)
Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days
AIMOVIG (erenumab) 140 mgmL 1 syringe30 days
EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days
EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg
Miscellaneous NUEDEXTA (dextromethorphan None quinidine)
Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None
NUPLAZID (pimavanserin) None
Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday
Stimulants armodafnil 1 tabday
armodafnil 50 mg 2 tabsday
modafnil 1 tabday
15
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None
BELVIQ XR (lorcaserin) None
BONTRIL (phendimetrazine) None
CONTRAVE (naltrexone-bupropion) None
DIDREX (benzphetamine) None
LOMAIRA (phentermine) None
phentermine None
QSYMIA (phenterminetopiramate) None
REGIMEX (benzphetamine) None
SAXENDA (liraglutide) None
SUPRENZA (phentermine) None
TENUATE (diethylpropion) None
XENICAL (orlistat) None
Dermatology Acne (Oral) ABSORICA (isotretinoin) None
AMNESTEEM (isotretinoin) None
CLARAVIS (isotretinoin) None
MYORISAN (isotretinoin) None
ZENATANE (isotretinoin) None
Acne (PA age gt25 adapalene None only)
ATRALIN (tretinoin) None
AVITA (tretinoin) None
PLIXDA (adapalene) None
RETIN-A (tretinoin) None
tretinoin microsphere gel None
TRETIN-X (tretinoin) None
Endocrinology amp Metabolism Androgens Testosterone (Oral)
ANADROL-50 (oxymetholone) None
ANDROID (methyltestosterone) None
ANDROXY (fuoxymesterone) None
METHITEST (methyltestosterone) None
16
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)
Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)
Antidiabetic Agents
Antiemetics
Antiemetics
Antiemetics
Antiemetics
Irritable Bowel Syndrome
Allergen Extracts
Allergen Extracts
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday
OXANDRIN (oxandrolone) 10 mg 2 tabsday
TESTRED (methyltestosterone) None
Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)
DELATESTRYL (testosterone None enanthate)
TESTOPEL (testosterone pellet) None
testosterone cypionate None
Androgens ANDRODERM (testosterone) None Testosterone (Topical)
NATESTO (testosterone nasal) None
STRIANT (testosterone) None
testosterone gel 162 None
Antidiabetic Agents AFREZZA (insulin regular) None
SYMLINPEN (pramlintide) None
Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday
CESAMET (nabilone) 20 capsfll or 3 max days supply
DICLEGIS (doxylamine-pyridoxine) 4 tabsday
MARINOL (dronabinol) 2 capsday
SYNDROS (dronabinol) 120 mL30 days
Irritable Bowel LOTRONEX (alosetron) None Syndrome
VIBERZI (eluxadoline) 2 tabsday
Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday
ODACTRA (house dust mite) 1 tabday
ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR
17
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Methotrexate Auto-Injectors
Miscellaneous
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)
Immunizations VARIZIG (varicella-zoster immune None globulin)
Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None
Calcium Modifer cinacalcet None
Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors
RASUVO (methotrexate) 4 auto-injectors28 days
Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None
Oncology Miscellaneous PROVENGE (sipuleucel-T) None
Ophthalmology Miscellaneous RESTASIS (cyclosporine) None
XIIDRA (liftegrast) None
Respiratory AsthmaCOPD DALIRESP (rofumilast) None
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Premium specialty prior authorization list
These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None
18
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Antitussives (PA age lt18)
Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)
Migraine
Migraine
Migraine
Parkinsonrsquos
Stimulants
Stimulants
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days
TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)
Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days
AIMOVIG (erenumab) 140 mgmL 1 syringe30 days
EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days
EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg
Miscellaneous NUEDEXTA (dextromethorphan None quinidine)
Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None
NUPLAZID (pimavanserin) None
Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday
Stimulants armodafnil 1 tabday
armodafnil 50 mg 2 tabsday
modafnil 1 tabday
15
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None
BELVIQ XR (lorcaserin) None
BONTRIL (phendimetrazine) None
CONTRAVE (naltrexone-bupropion) None
DIDREX (benzphetamine) None
LOMAIRA (phentermine) None
phentermine None
QSYMIA (phenterminetopiramate) None
REGIMEX (benzphetamine) None
SAXENDA (liraglutide) None
SUPRENZA (phentermine) None
TENUATE (diethylpropion) None
XENICAL (orlistat) None
Dermatology Acne (Oral) ABSORICA (isotretinoin) None
AMNESTEEM (isotretinoin) None
CLARAVIS (isotretinoin) None
MYORISAN (isotretinoin) None
ZENATANE (isotretinoin) None
Acne (PA age gt25 adapalene None only)
ATRALIN (tretinoin) None
AVITA (tretinoin) None
PLIXDA (adapalene) None
RETIN-A (tretinoin) None
tretinoin microsphere gel None
TRETIN-X (tretinoin) None
Endocrinology amp Metabolism Androgens Testosterone (Oral)
ANADROL-50 (oxymetholone) None
ANDROID (methyltestosterone) None
ANDROXY (fuoxymesterone) None
METHITEST (methyltestosterone) None
16
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)
Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)
Antidiabetic Agents
Antiemetics
Antiemetics
Antiemetics
Antiemetics
Irritable Bowel Syndrome
Allergen Extracts
Allergen Extracts
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday
OXANDRIN (oxandrolone) 10 mg 2 tabsday
TESTRED (methyltestosterone) None
Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)
DELATESTRYL (testosterone None enanthate)
TESTOPEL (testosterone pellet) None
testosterone cypionate None
Androgens ANDRODERM (testosterone) None Testosterone (Topical)
NATESTO (testosterone nasal) None
STRIANT (testosterone) None
testosterone gel 162 None
Antidiabetic Agents AFREZZA (insulin regular) None
SYMLINPEN (pramlintide) None
Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday
CESAMET (nabilone) 20 capsfll or 3 max days supply
DICLEGIS (doxylamine-pyridoxine) 4 tabsday
MARINOL (dronabinol) 2 capsday
SYNDROS (dronabinol) 120 mL30 days
Irritable Bowel LOTRONEX (alosetron) None Syndrome
VIBERZI (eluxadoline) 2 tabsday
Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday
ODACTRA (house dust mite) 1 tabday
ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR
17
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Methotrexate Auto-Injectors
Miscellaneous
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)
Immunizations VARIZIG (varicella-zoster immune None globulin)
Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None
Calcium Modifer cinacalcet None
Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors
RASUVO (methotrexate) 4 auto-injectors28 days
Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None
Oncology Miscellaneous PROVENGE (sipuleucel-T) None
Ophthalmology Miscellaneous RESTASIS (cyclosporine) None
XIIDRA (liftegrast) None
Respiratory AsthmaCOPD DALIRESP (rofumilast) None
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Premium specialty prior authorization list
These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None
18
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Weight Loss
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (Oral)
Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None
BELVIQ XR (lorcaserin) None
BONTRIL (phendimetrazine) None
CONTRAVE (naltrexone-bupropion) None
DIDREX (benzphetamine) None
LOMAIRA (phentermine) None
phentermine None
QSYMIA (phenterminetopiramate) None
REGIMEX (benzphetamine) None
SAXENDA (liraglutide) None
SUPRENZA (phentermine) None
TENUATE (diethylpropion) None
XENICAL (orlistat) None
Dermatology Acne (Oral) ABSORICA (isotretinoin) None
AMNESTEEM (isotretinoin) None
CLARAVIS (isotretinoin) None
MYORISAN (isotretinoin) None
ZENATANE (isotretinoin) None
Acne (PA age gt25 adapalene None only)
ATRALIN (tretinoin) None
AVITA (tretinoin) None
PLIXDA (adapalene) None
RETIN-A (tretinoin) None
tretinoin microsphere gel None
TRETIN-X (tretinoin) None
Endocrinology amp Metabolism Androgens Testosterone (Oral)
ANADROL-50 (oxymetholone) None
ANDROID (methyltestosterone) None
ANDROXY (fuoxymesterone) None
METHITEST (methyltestosterone) None
16
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)
Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)
Antidiabetic Agents
Antiemetics
Antiemetics
Antiemetics
Antiemetics
Irritable Bowel Syndrome
Allergen Extracts
Allergen Extracts
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday
OXANDRIN (oxandrolone) 10 mg 2 tabsday
TESTRED (methyltestosterone) None
Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)
DELATESTRYL (testosterone None enanthate)
TESTOPEL (testosterone pellet) None
testosterone cypionate None
Androgens ANDRODERM (testosterone) None Testosterone (Topical)
NATESTO (testosterone nasal) None
STRIANT (testosterone) None
testosterone gel 162 None
Antidiabetic Agents AFREZZA (insulin regular) None
SYMLINPEN (pramlintide) None
Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday
CESAMET (nabilone) 20 capsfll or 3 max days supply
DICLEGIS (doxylamine-pyridoxine) 4 tabsday
MARINOL (dronabinol) 2 capsday
SYNDROS (dronabinol) 120 mL30 days
Irritable Bowel LOTRONEX (alosetron) None Syndrome
VIBERZI (eluxadoline) 2 tabsday
Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday
ODACTRA (house dust mite) 1 tabday
ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR
17
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Methotrexate Auto-Injectors
Miscellaneous
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)
Immunizations VARIZIG (varicella-zoster immune None globulin)
Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None
Calcium Modifer cinacalcet None
Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors
RASUVO (methotrexate) 4 auto-injectors28 days
Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None
Oncology Miscellaneous PROVENGE (sipuleucel-T) None
Ophthalmology Miscellaneous RESTASIS (cyclosporine) None
XIIDRA (liftegrast) None
Respiratory AsthmaCOPD DALIRESP (rofumilast) None
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Premium specialty prior authorization list
These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None
18
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)
Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)
Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)
Antidiabetic Agents
Antiemetics
Antiemetics
Antiemetics
Antiemetics
Irritable Bowel Syndrome
Allergen Extracts
Allergen Extracts
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday
OXANDRIN (oxandrolone) 10 mg 2 tabsday
TESTRED (methyltestosterone) None
Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)
DELATESTRYL (testosterone None enanthate)
TESTOPEL (testosterone pellet) None
testosterone cypionate None
Androgens ANDRODERM (testosterone) None Testosterone (Topical)
NATESTO (testosterone nasal) None
STRIANT (testosterone) None
testosterone gel 162 None
Antidiabetic Agents AFREZZA (insulin regular) None
SYMLINPEN (pramlintide) None
Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday
CESAMET (nabilone) 20 capsfll or 3 max days supply
DICLEGIS (doxylamine-pyridoxine) 4 tabsday
MARINOL (dronabinol) 2 capsday
SYNDROS (dronabinol) 120 mL30 days
Irritable Bowel LOTRONEX (alosetron) None Syndrome
VIBERZI (eluxadoline) 2 tabsday
Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday
ODACTRA (house dust mite) 1 tabday
ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR
17
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Methotrexate Auto-Injectors
Miscellaneous
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)
Immunizations VARIZIG (varicella-zoster immune None globulin)
Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None
Calcium Modifer cinacalcet None
Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors
RASUVO (methotrexate) 4 auto-injectors28 days
Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None
Oncology Miscellaneous PROVENGE (sipuleucel-T) None
Ophthalmology Miscellaneous RESTASIS (cyclosporine) None
XIIDRA (liftegrast) None
Respiratory AsthmaCOPD DALIRESP (rofumilast) None
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Premium specialty prior authorization list
These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None
18
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Allergen Extracts
Methotrexate Auto-Injectors
Miscellaneous
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)
Immunizations VARIZIG (varicella-zoster immune None globulin)
Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None
Calcium Modifer cinacalcet None
Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors
RASUVO (methotrexate) 4 auto-injectors28 days
Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None
Oncology Miscellaneous PROVENGE (sipuleucel-T) None
Ophthalmology Miscellaneous RESTASIS (cyclosporine) None
XIIDRA (liftegrast) None
Respiratory AsthmaCOPD DALIRESP (rofumilast) None
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Premium specialty prior authorization list
These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None
18
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Antilipemic
Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Antithrombotic Agents von Willebrand Factor-Directed Antibody
CABLIVI (caplacizumab-yhdp) 1 kit per day
Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday
KYNAMRO (mipomersen) 4 syringes28 days
Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension
ALYQ (tadalafl) 2 tabsday
ambrisentan 1 tabday
FLOLAN (epoprostenol) None
OPSUMIT (macitentan) 1 tabday
ORENITRAM (treprostinil diolamine) None
REVATIO (sildenafl) Soln None
REVATIO (sildenafl) Susp 2 bottles30 days
REVATIO (sildenafl) Tabs 3 tabsday
tadalafl 2 tabsday
TRACLEER (bosentan) Tabs 2 tabsday
TRACLEER (bosentan) Tabs for Susp 4 tabsday
treprostinil None
TYVASO (treprostinil) 1 ampuleday
UPTRAVI (selexipag) 2 tabsday
UPTRAVI (selexipag) Pack 2 packsyear
VELETRI (epoprostenol) None
VENTAVIS (iloprost) 9 ampulesday
19
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Transthyretin Stabilizers
Anticonvulsants
Anticonvulsants
Miscellaneous
Miscellaneous
Muscular Dystrophy
Musculoskeletal Agents
Neurological Agents
Neurotoxins
Neurotoxins
Neurotoxins
Neurotoxins
Parkinsonrsquos
Sleep Disorder
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday
VYNDAQEL (tafamidis meglumine) 4 capsday
Vasopressors NORTHERA (droxidopa) None
Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None
EPIDIOLEX (cannabidiol) soln None
vigabatrin tabs None
Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)
Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days
Miscellaneous RADICAVA (edaravone) Soln None
RILUTEK (riluzole) 2 tabsday
TIGLUTIK (riluzole susp) 20 mLday
Muscular Dystrophy EMFLAZA (defazacort) None
EXONDYS 51 (eteplirsen) None
Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents
RUZURGI (amifanpridine) None
Neurological Agents ONPATTRO (patisiran sodium) None
TEGSEDI (inotersen) None
Neurotoxins BOTOX (onabotulinumtoxinA) None
BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None
MYOBLOC (rimabotulinumtoxinB) None
XEOMIN (incobotulinumtoxinA) None
Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days
INBRIJA (levodopa) None
Sleep Disorder HETLIOZ (tasimelteon) 1 capday
SUNOSI (solriamfetol) 1 capday
Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None
Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days
Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday
Endocrinology amp Metabolism
20
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Gonadotropins
Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT
Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear
FIRMAGON (degarelix) 80 mg 1 vial28 days
LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None
LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None
ORILISSA (elagolix) 150 mg 1 tabday
ORILISSA (elagolix) 200 mg 2 tabday
SUPPRELIN LA (histrelin acetate) 1 kit365 days
TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days
VANTAS (histrelin) 1 implantyear
Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy
EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day
NORDITROPIN (somatropin) None
NUTROPIN (somatropin) None
NUTROPIN AQ (somatropin) None
OMNITROPE (somatropin) None
21
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Growth Hormones and Related TherapyGrowth Hormones and Related Therapy
Growth Hormones and Related Therapy (Acromegaly)
Hormone Modifers
Miscellaneous
Osteoporosis
Osteoporosis
Osteoporosis
Somatostatins
Somatostatins
Somatostatins
Somatostatins
Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor
Cystine-depleting Agents
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None
ZORBTIVE (somatropin) None
Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)
SOMAVERT (pegvisomant) None
Hormone Modifers MYALEPT (metreleptin) None
NATPARA (parathyroid hormone) 2 cartridges28 days
Miscellaneous ACTHAR (corticotropin) None
KORLYM (mifepristone) 4 tabsday
Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days
FORTEO (teriparatide) None
PROLIA (denosumab) 2 syringesyear
TYMLOS (abaloparatide) Sopn None
Somatostatins octreotide inj None
SANDOSTATIN LAR (octreotide) None
SIGNIFOR (pasireotide) 2 ampulesday
SIGNIFOR LAR (pasireotide) 1 vial28 days
SOMATULINE DEPOT (lanreotide) None
Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)
GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)
Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents
PROCYSBI (cysteamine bitartrate) None
Enzyme Replacement ALDURAZYME (laronidase) None
BRINEURA (cerliponase) Soln None
CERDELGA (eliglustat) None
CEREZYME (imiglucerase) None
ELAPRASE (idursulfase) None
ELELYSO (taliglucerase) None
FABRAZYME (agalsidase beta) None 22
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Enzyme Replacement
Metabolic Agents
Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
Hematopoietic Agents
THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days
KANUMA (sebelipase alfa) None
LUMIZYME (alglucosidase alfa) None
MEPSEVII (vestronidase alfa) None
NAGLAZYME (galsulfase) None
RAVICTI (glycerol phenylbutyrate) None
STRENSIQ (asfotase alfa) None
VIMIZIM (elosulfase) None
VPRIV (velaglucerase) None
XURIDEN (uridine triacetate) 4 packetsday
ZAVESCA (miglustat) None
Enzyme Gout KRYSTEXXA (pegloticase) None
Metabolic Agents NITYR (nitisinone) None
ORFADIN (nitisinone) None
Phenylketonuria KUVAN (sapropterin) None Treatment Agents
PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL
Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None
Diarrhea XERMELO (telotristat ethyl) 3 tabsday
Hepatic Agents OCALIVA (obeticholic acid) 1 tabday
Short Bowel Syndrome GATTEX (teduglutide) None
Immunology Hematopoietic Agents DOPTELET (avatrombopag) None
LEUKINE (sargramostim) None
MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant
MULPLETA (lusutrombopag) None
NEULASTA (pegflgrastim) None
NIVESTYM (flgrastim-aaf) None
NPLATE (romiplostim) None
PROMACTA (eltrombopag) None
RETACRIT (epoetin alfa-epbx) None
SOLIRIS (eculizumab) None
TAVALISSE (fostamatinib) None
23
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Hematopoietic Agents
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hemostatic Agent
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Hepatitis C Agents
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
Immune Globulins
ZARXIO (flgrastim) None
Hemostatic Agent BERINERT (c1 esterase) None
CINRYZE (c1 esterase) None
FIRAZYR (icatibant) Soln None
HAEGARDA (c1 esterase) None
KALBITOR (ecallantide) Soln None
RUCONEST (c1 esterase) Solr None
TAKHZYRO (lanadelumab-fyo) None
Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday
HARVONI (ledipasvir-sofosbuvir) 1 tabday
MAVYRET (glecaprevir-pibrentasvir) 3 tabsday
OLYSIO (simeprevir) 1 capday
PEGASYS (peginterferon alfa-2a) None
PEG-INTRON (peginterferon alfa-2b) None
SOVALDI (sofosbuvir) 1 tabday
TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday
ZEPATIER (elbasvir-grazoprevir) 1 tabday
Immune Globulins BIVIGAM (immune globulin) None
CARIMUNE (immune globulin) None
CUVITRU (immune globulin) None
CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None
FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None
GAMMAGARD (immune globulin) None
GAMMAKED (immune globulin) None
GAMMAPLEX (immune globulin) None
GAMUNEX (immune globulin) None
GAMUNEX-C (immune globulin) None
HIZENTRA (immune globulin) None
HYQVIA (hyaluron immune globulin) None
OCTAGAM (immune globulin) None
PRIVIGEN (immune globulin) None
24
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Immunomodulators
Interleukins
Miscellaneous
Miscellaneous
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Immunomodulators ACTEMRA (tocilizumab) Sosy None
CIMZIA (certolizumab) None
ENBREL (etanercept) None
ENTYVIO (vedolizumab) None
HUMIRA (adalimumab) None
INFLECTRA (infiximab) None
KEVZARA (sarilumab) None
KINERET (anakinra) None
ORENCIA (abatacept) None
OTEZLA (apremilast) None
RENFLEXIS (infiximab) None
SILIQ (brodalumab) Sosy None
SIMPONI (golimumab) None
SIMPONI ARIA (golimumab) None
SKYRIZI (risankizumab-rzaa) None
STELARA (ustekinumab) None
TALTZ (ixekizumab) None
TREMFYA (guselkumab) None
XELJANZ (tofacitinib) None
XELJANZ XR (tofacitinib) None
Interleukins ARCALYST (rilonacept) None
ILARIS (canakinumab) 2 vials4 weeks
Miscellaneous ACTIMMUNE (interferon gamma-1b) None
BENLYSTA (belimumab) None
CRYSVITA (burosumab-twza) None
Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday
AUBAGIO (terifunomide) 1 tabday
AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days
BETASERON (interferon beta-1b) 1 package28 days
COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday
GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None
MAVENCLAD (cladribine) None
MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg
25
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Transplant
Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents
Musculoskeletal Agents
Toxicology
Toxicology
Toxicology
Toxicology
Toxicology
Viscosupplements
Viscosupplements
Viscosupplements
MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None
OCREVUS (ocrelizumab) Soln 40 mL365 days
REBIF (interferon beta-1a) 12 syringes28 days
REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday
TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days
Transplant NULOJIX (belatacept) None
ZORTRESS (everolimus) None
Miscellaneous Amino Acid ENDARI (glutamine) None
Collagenase XIAFLEX (collagenase clostridium None histolyticum)
Diagnostic THYROGEN (thyrotropin alfa) None
Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents
INGREZZA (valbenazine tosylate) 2 capsday
INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None
Musculoskeletal SPINRAZA (nusinersen) Soln None Agents
ZOLGENSMA (onasemnogene) None
Toxicology CUPRIMINE (penicillamine) None
EXJADE (deferasirox) None
FERRIPROX (deferiprone) None
JADENU (deferasirox) None
JADENU SPRINKLE (deferasirox) None
SYPRINE (trientine) None
Viscosupplements DUROLANE (sodium hyaluronate) None
EUFLEXXA (sodium hyaluronate) None
GELSYN-3 (sodium hyaluronate) None
HYALGAN (sodium hyaluronate) None
26
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Viscosupplements
Viscosupplements
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Fertility Agents
Hormone Replacement
Antifolate
Antimicrotubular
CAR-T Therapy
Interferons
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
Miscellaneous
Miscellaneous
Miscellaneous
Miscellaneous
HYMOVIS (sodium hyaluronate) None
VISCO-3 (sodium hyaluronate) None
Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None
FOLLISTIM AQ (follitropin beta) None
ganirelix acetate None
MENOPUR (menotropins) None
NOVAREL (chorionic gonadotropin) None
OVIDREL (chorionic gonadotropin) None
PREGNYL (chorionic gonadotropin) None
REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None
MAKENA (hydroxyprogesterone None caproate)
Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None
TREANDA (bendamustine) None
Antifolate FOLOTYN (pralatrexate) Soln None
TECENTRIQ (atezolizumab) Soln None
Antimicrotubular HALAVEN (eribulin) None
JEVTANA (cabazitaxel) None
CAR-T Therapy KYMRIAH (tisagenlecleucel) None
YESCARTA (axicabtagene ciloleucel) None
Interferons INTRON A (interferon alfa-2b) None
SYLATRON (peginterferon alfa-2b) None
Interleukins ELZONRIS (tagraxofusp-erzs) None
Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors
KYPROLIS (carflzomib) None
PORTRAZZA (necitumumab) Soln None
VELCADE (bortezomib) None
ZALTRAP (ziv-afibercept) None
Miscellaneous BELEODAQ (belinostat) None
DACOGEN (decitabine) None
ISTODAX (romidepsin) None
SYNRIBO (omacetaxine) None
VYXEOS (daunorubicin-cytarabine) None
Monoclonal Antibody ADCETRIS (brentuximab) None
27
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Monoclonal Antibody
Antiandrogen
Antiandrogen
Antiandrogen
ARZERRA (ofatumumab) None
AVASTIN (bevacizumab) None
BAVENCIO (avelumab) Soln None
BESPONSA (inotuzumab) None
BLINCYTO (blinatumomab) None
CYRAMZA (ramucirumab) None
DARZALEX (daratumumab) Soln None
EMPLICITI (elotuzumab) Solr None
ERBITUX (cetuximab) Soln None
GAZYVA (obinutuzumab) None
HERCEPTIN (trastuzumab) None
HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None
KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None
KEYTRUDA (pembrolizumab) None
LARTRUVO (olaratumab) None
LIBTAYO (cemiplimab-rwlc) None
LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None
MYLOTARG (gemtuzumab) None
OPDIVO (nivolumab) None
PERJETA (pertuzumab) None
POLIVY (polatuzumab vedotin-piiq None
POTELIGEO (mogamulizumab-kpkc) None
RITUXAN (rituximab) None
RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None
UNITUXIN (dinutuximab) None
XGEVA (denosumab) None
YERVOY (ipilimumab) None
Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None
Antiandrogen ERLEADA (apalutamide) None
XTANDI (enzalutamide ) None
YONSA (abiraterone) None
ZYTIGA (abiraterone) None
Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors
28
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
AFINITOR DISPERZ (everolimus) None
ALECENSA (alectinib) 8 capsday
ALUNBRIG (brigatinib) 30 mg 4 tabsday
ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear
BALVERSA (erdaftinib) None
BOSULIF (bosutinib) None
BRAFTOVI (encorafenib) None
CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None
CAPRELSA (vandetanib) None
CAPRELSA (vandetanib) 100 mg 2 tabsday
COMETRIQ (carbozantinib) None
COTELLIC (cobimetnib) None
ERIVEDGE (vismodegib) None
FARYDAK (panobinostat) None
GILOTRIF (afatinib) 1 tabday
GLEEVEC (imatinib) None
IBRANCE (palbociclib) None
ICLUSIG (ponatinib) 15 mg 2 tabday
ICLUSIG (ponatinib) 45 mg None
IDHIFA (enasidenib) None
IMBRUVICA (ibrutinib) None
29
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors
Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors
INLYTA (axitinib) None
IRESSA (geftinib) None
JAKAFI (ruxolitinib) None
JAKAFI (ruxolitinib) 10 mg 2 tabsday
LENVIMA (lenvatinib) None
LYNPARZA (olaparib) None
MEKINIST (trametinib) None
MEKTOVI (binimetinib) None
NERLYNX (neratinib) 6 tabsday
NEXAVAR (sorafenib) None
NINLARO (ixazomib) None
ODOMZO (sonidegib) None
RYDAPT (midostaurin) None
SPRYCEL (dasatinib) None
STIVARGA (regorafenib) None
SUTENT (sunitinib) None
TAFINLAR (dabrafenib) None
TAGRISSO (osimertinib) 1 tabday
TAGRISSO (osimertinib) 40 mg None
TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday
TASIGNA (nilotinib) None
30
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Target Inhibitors TIBSOVO (ivosidenib) None
Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None
Miscellaneous KISQALI (ribociclib) None
Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack
Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg
Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg
Miscellaneous RUBRACA (rucaparib camsylate) None
Miscellaneous XELODA (capecitabine) None
Miscellaneous ZOLINZA (vorinostat) None
Skin Cancer TARGRETIN GEL (bexarotene) None
Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None
neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None
31
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
OPTUMreg
AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days
AsthmaCOPD FASENRA (benralizumab) None
AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days
AsthmaCOPD XOLAIR (omalizumab) None
Cystic fbrosis CAYSTON (aztreonam) None
Cystic fbrosis KALYDECO (ivacaftor) None
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday
Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets
Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None
Pulmonary Fibrosis OFEV (nintedanib) None
Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents
PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Rvs13 313201713 113 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713
Rvs13 313201713 213 19199-shy‐3-shy‐201713