Prior authorization — Premium - OptumRx · 2020. 8. 17. · Utilization management updates -...

Utilization management updates - January 1, 2020

Prior authorization — Premium

There are some medications that have to be authorized by a doctor before a patient 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:

• U.S. Food and Drug Administration (FDA) approved uses

• Medication instruction labels

• Accepted or published clinical recommendations

Getting a short-term supply

If a patient must take a medication that requires prior authorization right away, there are two options that may work for them. First, the patient should ask their doctor if a sample is available. Or, check with their pharmacy to request a short-term supply of 5 days or less. Keep in mind, they will be responsible for the full cost at that time. If the prior authorization request is approved, then their pharmacist can fll the rest of their prescription.

Requesting a prior authorization The patient, the pharmacist or their doctor can start the prior authorization process by contacting us. We will work with your patient's doctor to get the information needed for the review. Once we receive a fnished prior authorization form from their doctor, we will conduct a review within a few days and send them and their 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)ADHD Agents (PA age 19+ only)

Premium non-specialty prior authorization list

These medications may require prior authorization based on the patient's beneft plan.

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

Cardiology Antilipemic omega-3 fatty acid None

PRALUENT (alirocumab) 2 syringes/28 days

REPATHA (evolocumab) 3 syringes/28 days

REPATHA PUSH (evolocumab) 1 cartridge/28 days

VASCEPA (icosapent ethyl) None

Heart Failure CORLANOR (ivabradine) 2 tabs/day

CORLANOR (ivabradine) Soln 15 mL/day

Central Nervous System ADHD Agents (PA age ADHANSIA XR (methylphenidate) 4 caps/day 19+ only) 25 mg

ADHANSIA XR (methylphenidate) 1 cap/day

ADZENYS ER (amphetamine) 15 mL/day

ADZENYS XR-ODT (amphetamine) 1 tab/day

amphetamine 6 tabs/day

amphetamine/detroamphetamine 2 tabs/day 30 mg tab amphetamine/detroamphetamine 3 tabs/day

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 amphetamine/detroamphetamine ER

APTENSIO XR (methylphenidate)

COTEMPLA XR-ODT (methylphenidate) 8.6 mg COTEMPLA XR-ODT (methylphenidate) 17.3 mg COTEMPLA XR-ODT (methylphenidate) 25.9 mg DAYTRANA (methylphenidate transdermal) DESOXYN (methamphetamine)

1 cap/day

1 cap/day

6 tabs/day

3 tabs/day

2 tabs/day

1 patch/day

5 tabs/day

DEXEDRINE (dextroamphetamine) 10 mg DEXEDRINE (dextroamphetamine) 5 mg DEXEDRINE (dextroamphetamine) 15 mg dexmethylphenidate

6 caps/day

3 caps/day

4 caps/day

2 tabs/day

DYANAVEL XR (amphetamine) 8 mL/day

EVEKEO ODT (amphetamine) 5 mg, 10 mg EVEKEO ODT (amphetamine) 15 mg20 mg FOCALIN XR (dexmethylphenidate)

3 tabs/day

, 2 tabs/day

1 cap/day

FOCALIN XR (dexmethylphenidate) 20 mg JORNAY PM (methylphenidate)

2 caps/day

1 cap/day

METADATE CD (methylphenidate) 1 cap/day

METADATE ER (methylphenidate) 20 mg METHYLIN (methylphenidate)

METHYLIN (methylphenidate) Soln 10 mg/5 mL METHYLIN (methylphenidate) Soln 5 mg/5 mL

3 tabs/day

3 tabs/day

30 mL/day

60 mL/day

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)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 CHEW TAB (methylphenidate)

3 tabs/day

METHYLIN CHEW TAB (methylphenidate) 10 mg

6 tabs/day

METHYLIN ER (methylphenidate) 20 mg methylphenidate

METHYLPHENIDATE ER (methylphenidate) 10 mg methylphenidate ER tab osmotic release 36 mg

3 tabs/day

3 tabs/day

2 tabs/day

2 tabs/day

methylphenidate ER tab osmotic release MYDAYIS (amphetamine/ dextroamphetamine) PROCENTRA (dextroamphetamine) Sol

1 tab/day

1 cap/day

60 mL/day

QUILLICHEW ER (methylphenidate) 30 mg

2 tabs/day

QUILLICHEW ER (methylphenidate) 1 tab/day

QUILLIVANT XR (methylphenidate) 12 mL/day

RELEXXII (methylphenidate) 72 mg 1 tab/day

RITALIN LA (methylphenidate) 1 cap/day

RITALIN SR (methylphenidate) 20 mg

VYVANSE (lisdexamfetamine)

VYVANSE CHEW TAB (lisdexamfetamine) ZENZEDI (dextroamphetamine) 30 mg

3 tabs/day

1 cap/day

1 tab/day

2 tabs/day

ZENZEDI (dextroamphetamine) 3 tabs/day

ZENZEDI (dextroamphetamine) 6 tabs/day 10 mg

Analgesics (non-opioid) QUTENZA (capsaicin) 4 patches/3 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) acetaminophen/codeine soln 136 mL/day, 7 day supply (age 20

120-12 mg/5 mL and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 166.5 mL/day, 2 flls/60 days for treatment experienced

acetaminophen/codeine tab 300-15 13 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 13 tabs/day, 2 flls/60 days for treatment experienced

ACTIQ (fentanyl citrate) 4 lozenges/day

AVINZA (morphine ext-release) 1 cap/day

AVINZA (morphine ext-release) 2 caps/day 120 mg BELBUCA (buprenorphine) flm 2 flms/day

butorphanol nasal spray 10 mg/mL 1 bottle/fll, 2 flls/60 days

BUTRANS (buprenorphine) 4 patches/28 days

codeine tab 15 mg 21 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 40 tabs/day, 2 flls/60 days for treatment experienced



DEMEROL (meperidine) tab 100 mg 4 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 9 tabs/day, 2 flls/60 days for treatment experienced

DEMEROL (meperidine) tab 50 mg 9 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 18 tabs/day, 2 flls/60 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 12.25 mL/day, 7 day supply (age 20 1 mg/mL and older), 3 day supply (age less

than 20), 2 flls/60 days for treatment naive; 22.5 mL/day, 2 flls/60 days for treatment experienced

DILAUDID (hydromorphone) 6 tabs/day, 7 day supply (age 20 and tab 2 mg older), 3 day supply (age less than 20),

2 flls/60 days for treatment naïve; 11 tabs/day, 2 flls/60 days for treatment experienced

DILAUDID (hydromorphone) 3 tabs/day, 7 day supply, 2 flls/60 tab 4 mg days for treatment naïve; 5 tabs/day, 2

flls/60 days for treatment experienced DILAUDID (hydromorphone) tab 8 mg 1 tab/day, 7 day supply (age 20 and

older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 2 tabs/day, 2 flls/60 days for treatment experienced

EMBEDA (morphine/naltrexone) 2 caps/day

EXALGO (hydromorphone) 2 tabs/day

fentanyl transdermal patch 15 patches/30 days

fentanyl transdermal patch 75 mcg/ 30 patches/30 days hr, 100 mcg/hr HYCET (hydrocodone/ 98 mL/day, 7 day supply (age 20 and acetaminophen) sol 7.5-325 mg/ older), 3 day supply (age less than 20), 15 mL 2 flls/60 days for treatment naive; 180

mL/day, 2 flls/60 days for treatment experienced

hydrocodone/acetaminophen tab 4 tabs/day, 7 day supply (age 20 and 10-325 mg older), 3 day supply (age less than 20),


hydrocodone/acetaminophen tab 9 tabs/day, 7 day supply (age 20 and 5-325 mg older), 3 day supply (age less than 20),


hydrocodone/acetaminophen tab 6 tabs/day, 7 day supply (age 20 and 7.5-325 mg older), 3 day supply (age less than 20),


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 supps/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 7 supps/day, 2 flls/60 days for treatment experienced 1 tab/day

levorphanol tab 2 mg 3 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 6 tabs/day, 2 flls/60 days for treatment experienced

LORTAB (hydrocodone/ acetaminophen) elx 10-300 mg/ 15 mL

73.5 mL/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 135 mL/day, 2 flls/60 days for treatment experienced

meperidine/promethazine cap 50-25 mg

9 caps/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 18 caps/day, 2 flls/60 days for treatment experienced

mepridine sol 50 mg/5 mL

MORPHABOND ER (morphine ext-release)

49 mL/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 90 mL/day, 2 flls/60 days for treatment experienced 2 tabs/day

morphine sol 10 mg/5 mL 24.5 mL/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 45 mL/day, 2 flls/60 days for treatment experienced

morphine sol 20 mg/5 mL 12.25 mL/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 22.5 mL/day, 2 flls/60 days for treatment experienced

morphine sol 20 mg/mL 2.4 mL/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 4.5 mL/day, 2 flls/60 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 supps/day, 7 day supply (age 20 and

older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 9 supps/day, 2 flls/60 days for treatment experienced

morphine supp 20 mg 2 supps/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 4 supps/day, 2 flls/60 days for treatment experienced

morphine supp 30 mg 1 supp/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 3 supps/day, 2 flls/60 days for treatment experienced

morphine supp 5 mg 9 supps/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 18 supps/day, 2 flls/60 days for treatment experienced

morphine tab 15 mg 3 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 6 tabs/day, 2 flls/60 days for treatment experienced

morphine tab 30 mg

morphine sulfate ER cap

MS CONTIN (morphine ext-rele

1 tab/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 3 tabs/day, 2 flls/60 days for treatment experienced 2 caps/day

ase) 3 tabs/day

NALOCET (oxycodone/ acetaminophen)

13 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 13 tabs/day, 2 flls/60 days for treatment experienced

OPANA (oxymorphone) tab 10 mg 1 tab/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 3 tabs/day, 2 flls/60 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 tabs/day, 7 day supply (age 20 and


OXAYDO (oxycodone) tab 5 mg 6 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 12 tabs/day, 2 flls/60 days for treatment experienced

OXAYDO (oxycodone) tab 7.5 mg 4 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 8 tabs/day, 2 flls/60 days for treatment experienced

oxycodone/aspirin tab 6 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 12 tabs/day, 2 flls/60 days for treatment experienced

oxycodone/ibuprofen tab 5-400 mg 6 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 8 tabs/day, 2 flls/60 days for treatment experienced

oxycodone cap 5 mg 6 caps/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 12 caps/day, 2 flls/60 days for treatment experienced

oxycodone conc 20 mg/mL 1.6 mL/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 3 mL/day, 2 flls/60 days for treatment experienced

oxycodone sol 5 mg/5 mL 32.6 mL/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 60 mL/day, 2 flls/60 days for treatment experienced

oxycodone tab 10 mg 3 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 6 tabs/day, 2 flls/60 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 tab/day, 7 day supply (age 20 and


oxycodone/acetaminophen sol 32.6 mL/day, 7 day supply (age 20 and 5-325 mg/5 mL older), 3 day supply (age less than 20),

2 flls/60 days for treatment naïve; 60 mL/day, 2 flls/60 days for treatment experienced

oxycodone/acetaminophen tab 3 tabs/day, 7 day supply (age 20 and 10-325 mg older), 3 day supply (age less than 20),


oxycodone/acetaminophen tab 12 tabs/day, 7 day supply (age 20 and 2.5-325 mg older), 3 day supply (age less than 20),


oxycodone/acetaminophen tab 6 tabs/day, 7 day supply (age 20 and 5-325 mg older), 3 day supply (age less than 20),


oxycodone/acetaminophen tab 4 tabs/day, 7 day supply (age 20 and 7.5-325 mg older), 3 day supply (age less than 20),


OXYCONTIN (oxycodone ext-release) 4 tabs/day

oxymorphone ER 4 tabs/day

pentazocine/naloxone tab 50-0.5 mg 5 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 10 tabs/day, 2 flls/60 days for treatment experienced

PRIMLEV (oxycodone/ 3 tabs/day, 7 day supply (age 20 and acetaminophen) tab 10-300 mg older), 3 day supply (age less than 20),


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 tabs/day, 7 day supply (age 20 and acetaminophen) tab 5-300 mg older), 3 day supply (age less than 20),


PRIMLEV (oxycodone/ 4 tabs/day, 7 day supply (age 20 and acetaminophen) tab 7.5-300 mg older), 3 day supply (age less than 20),


REPREXAIN (hydrocodone/ibuprofen) 4 tabs/day, 7 day supply (age 20 and tab 10-200 mg older), 3 day supply (age less than 20),


REPREXAIN (hydrocodone/ibuprofen) 9 tabs/day, 7 day supply (age 20 and tab 5-200 mg older), 3 day supply (age less than 20),


ROXICODONE (oxycodone) tab 15 2 tabs/day, 7 day supply, (age 20 and mg older), 3 day supply (age less than 20)


ROXICODONE (oxycodone) tab 30 1 tab/day, 7 day supply (age 20 and mg older), 3 day supply (age less than 20),


ROXICODONE (oxycodone) tab 5 mg 6 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 12 tabs/day, 2 flls/60 days for treatment experienced

ROXYBOND (oxycodone) tab 5 mg 6 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 12 tabs/day, 2 flls/60 days for treatment experienced

ROXYBOND (oxycodone) tab 15 mg 2 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 4 tabs/day, 2 flls/60 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 tab/day, 7 day supply (age 20 and


SYNALGOS-DC (aspirin/caffeine/ dihydrocodeine) cap


TREZIX (acetaminophen/caffeine/ dihydrocodeine) cap


TYLENOL (acetaminophen)/codeine #3


TYLENOL (acetaminophen)/codeine #4


ULTRACET (tramadol/ acetaminophen) tab 37.5-325 mg


ULTRAM (tramadol) tab 50 mg

ULTRAM ER (tramadol ext-release)

8 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 flls/60 days for treatment naïve; 8 tabs/day, 2 flls/60 days for treatment experienced 1 tab/day

VERDROCET (hydrocodone/ acetaminophen) tab 2.5-325 mg


12

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Anticonvulsants

Anticonvulsants

Antitussives (PA age

Antitussives (PA age

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 >25 only)Acne (PA age >25 only)Acne (PA age >25 only)Acne (PA age >25 only)Acne (PA age >25 only)Acne (PA age >25 only)

Androgens, Testosterone (Oral)Androgens, Testosterone (Oral)Androgens, Testosterone (Oral)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss

Dermatology Acne (Oral)

Acne (PA age >25 only)

BELVIQ (lorcaserin)

BELVIQ XR (lorcaserin)

BONTRIL (phendimetrazine)

CONTRAVE (naltrexone-bupropion)

DIDREX (benzphetamine)

LOMAIRA (phentermine)

phentermine

QSYMIA (phentermine/topiramate)

REGIMEX (benzphetamine)

SAXENDA (liraglutide)

SUPRENZA (phentermine)

TENUATE (diethylpropion)

XENICAL (orlistat)

ABSORICA (isotretinoin)

AMNESTEEM (isotretinoin)

CLARAVIS (isotretinoin)

MYORISAN (isotretinoin)

ZENATANE (isotretinoin)

adapalene

ATRALIN (tretinoin)

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None

AVITA (tretinoin) None

PLIXDA (adapalene) None

RETIN-A (tretinoin) None

tretinoin microsphere gel None

TRETIN-X (tretinoin) None

Endocrinology & Metabolism Androgens, Testosterone (Oral)

ANADROL-50 (oxymetholone)

ANDROID (methyltestosterone)

None

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) 2.5 mg 8 tabs/day

OXANDRIN (oxandrolone) 10 mg 2 tabs/day

TESTRED (methyltestosterone) None

Androgens, Testosterone (Injectable)

AVEED (testosterone undecanoate)

DELATESTRYL (testosterone enanthate)

None

None

TESTOPEL (testosterone pellet) None

testosterone cypionate None

Androgens, Testosterone (Topical)

ANDRODERM (testosterone)

NATESTO (testosterone nasal)

None

None

STRIANT (testosterone) None

testosterone gel 1.62% None

Antidiabetic Agents

Gastroenterology Antiemetics

Irritable Bowel Syndrome

AFREZZA (insulin regular)

SYMLINPEN (pramlintide)

BONJESTA (doxylamine-pyridoxine)

CESAMET (nabilone)

DICLEGIS (doxylamine-pyridoxine)

MARINOL (dronabinol)

SYNDROS (dronabinol)

LOTRONEX (alosetron)

VIBERZI (eluxadoline)

None

None

2 tabs/day

20 caps/fll or 3 max days supply

4 tabs/day

2 caps/day

120 mL/30 days

None

2 tabs/day

Immunology Allergen Extracts GRASTEK (timothy grass pollen)

ODACTRA (house dust mite)

ORALAIR (mixed grass pollens allergen) 300 IR

1 tab/day

1 tab/day

1 tab/day

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 kit/year grass pollens allergen) Kit ORALAIR ADULT STARTER PACK (mixed grass pollens allergen)

1 pack/year

ORALAIR CHILDREN/ADOLESCENTS 2 packs/year (mixed grass pollens allergen) Starter Pack ORALAIR CHILDREN/ADOLESCENTS 2 kits/year (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tab/day 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-injectors/28 days Injectors

RASUVO (methotrexate) 4 auto-injectors/28 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 Asthma/COPD 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 the patient's beneft plan. For more information, the patient should contact customer service at the phone number on their ID card.


Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

Antiretrovirals, HIV SELZENTRY (maraviroc) None

18

Antiretrovirals, HIV

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 Hypertension


Antithrombotic Agents von Willebrand Factor-Directed Antibody Cardiology Antilipemic

Pulmonary Arterial Hypertension

TROGARZO (ibalizumab-uiyk)

CABLIVI (caplacizumab-yhdp)

JUXTAPID (lomitapide)

KYNAMRO (mipomersen)

ADEMPAS (riociguat)

ALYQ (tadalafl)

None

1 kit per day

1 tab/day

4 syringes/28 days

3 tabs/day

2 tabs/day

ambrisentan 1 tab/day

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tab/day

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles/30 days

REVATIO (sildenafl) Tabs 3 tabs/day

tadalafl 2 tabs/day

TRACLEER (bosentan) Tabs 2 tabs/day

TRACLEER (bosentan) Tabs for Susp 4 tabs/day

treprostinil None

TYVASO (treprostinil) 1 ampule/day

UPTRAVI (selexipag) 2 tabs/day

UPTRAVI (selexipag) Pack 2 packs/year

VELETRI (epoprostenol) None

19

Pulmonary Arterial Hypertension

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinson’s

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VENTAVIS (iloprost) 9 ampules/day

Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 cap/day

VYNDAQEL (tafamidis meglumine) 4 caps/day

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 tabs/day

TIGLUTIK (riluzole susp) 20 mL/day

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

Parkinson’s APOKYN (apomorphine) 30 cartridges/30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 cap/day

SUNOSI (solriamfetol) 1 cap/day

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes/28 days

Electrolyte & Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabs/day

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 Therapy


Endocrinology & Metabolism Gonadotropins ELIGARD (leuprolide) 22.5 mg 1 injection/84 days

(3-month) ELIGARD (leuprolide) 30 mg 1 injection/112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection/168 days (6-month) ELIGARD (leuprolide) 7.5 mg 1 injection/28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vials/year

FIRMAGON (degarelix) 80 mg 1 vial/28 days

LUPANETA PACK (leuprolide) 11.25 1 pack/84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack/28 days 3.75 mg (1 mon) LUPRON (leuprolide) 1 mg/0.2 mL None

LUPRON DEPOT (leuprolide) 3.75 mg None & 7.5 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tab/day

ORILISSA (elagolix) 200 mg 2 tab/day

SUPPRELIN LA (histrelin acetate) 1 kit/365 days

TRELSTAR (triptorelin) 22.5 mg 1 injection/168 days (6-month) TRELSTAR DEPOT (triptorelin) 3.75 1 injection/28 days mg (1-month) TRELSTAR LA (triptorelin) 11.25 mg 1 injection/84 days (3-month) TRIPTODUR (triptorelin) 1 injection/84 days

VANTAS (histrelin) 1 implant/year

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

21

Growth Hormones and Related TherapyGrowth 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

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OMNITROPE (somatropin) None

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 cartridges/28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabs/day

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (2.34 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringes/year

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampules/day

SIGNIFOR LAR (pasireotide) 1 vial/28 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 bottles/28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

22

Enzyme Replacement

Enzyme Replacement

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








THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None

GALAFOLD (migalastat hcl) cap 14 caps/28 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 packets/day

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 syringe/day 10 mg/0.5 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes/28 days 2.5 mg/0.5 mL PALYNZIQ (pegvaliase-pqpz) 2 syringes/day 20 mg/mL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabs/day

Hepatic Agents OCALIVA (obeticholic acid) 1 tab/day

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 (8.4 mL)/transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

23




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

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

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 tab/day dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tab/day

HARVONI (ledipasvir-sofosbuvir) 1 tab/day

MAVYRET (glecaprevir-pibrentasvir) 3 tabs/day

OLYSIO (simeprevir) 1 cap/day

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tab/day

TECHNIVIE (ombitasvir-paritaprevir- 2 tabs/day ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabs/day paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabs/day paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tab/day

ZEPATIER (elbasvir-grazoprevir) 1 tab/day

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

24

Immune Globulins

Immune Globulins

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

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

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 vials/4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabs/day

AUBAGIO (terifunomide) 1 tab/day

AVONEX (interferon beta-1a) 1 kit (4 syringes)/28 days

BETASERON (interferon beta-1b) 1 package/28 days

COPAXONE (glatiramer) SOSY 20 mg/ml COPAXONE (glatiramer) SOSY 40 mg/ml GILENYA (fngolimod)

30 syringes/30 days

12 syringes/28 days

1 cap/day

GLATOPA (glatiramer) SOSY 20 mg/ ml LEMTRADA (alemtuzumab)

MAVENCLAD (cladribine)

MAYZENT (siponimod fumarate) 0.25 mg

30 syringes/30 days

None

None

4 tabs/day

25

Multiple Sclerosis

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

MAYZENT (siponimod fumarate) 2 mg MAYZENT (siponimod fumarate) starter pack NOVANTRONE (mitoxantrone)

OCREVUS (ocrelizumab) Soln

1 tab/day

2 starter packs (24 tabs)/365 days

None

40 mL/365 days

REBIF (interferon beta-1a)

REBIF (interferon beta-1a) Starter Pack TECFIDERA (dimethyl fumarate)

TECFIDERA (dimethyl fumarate) Starter Pack

12 syringes/28 days

1 starter pack/year

2 caps/day

1 starter pack/year

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 tabs/day Agents

INGREZZA (valbenazine tosylate) 2 caps/day

INGREZZA (valbenazine tosylate) 80 1 cap/day 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

26

Viscosupplements

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

HYALGAN (sodium hyaluronate) None

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics & 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

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

Monoclonal Antibody ADCETRIS (brentuximab) None

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

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 Inhibitors

Kinase and Molecular AFINITOR (everolimus) 1 tab/day Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 caps/day

ALUNBRIG (brigatinib) 30 mg 4 tabs/day

ALUNBRIG (brigatinib) 90 mg, 1 tab/day 180 mg ALUNBRIG (brigatinib) Pack 1 pack/year

BALVERSA (erdaftinib) None

BOSULIF (bosutinib)

BRAFTOVI (encorafenib)

CABOMETYX (cabozantinib s-malate)CALQUENCE (acalabrutinib)

None

None

None

None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabs/day

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tab/day

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tab/day

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) 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 InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

IMBRUVICA (ibrutinib) None

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabs/day

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabs/day

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 tab/day

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg, None 150 mg TARCEVA (erlotinib) 25 mg 3 tabs/day

30

Kinase and Molecular TASIGNA (nilotinib) None Target Inhibitors 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 15-6.14 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-8.19 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)

31

Respiratory Asthma/COPD CINQAIR (reslizumab) Soln None

Asthma/COPD DUPIXENT (dupilumab) Sosy 4 syringes/28 days

Asthma/COPD FASENRA (benralizumab) None

Asthma/COPD NUCALA (mepolizumab) 3 vials/28 days

Asthma/COPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabs/day

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packets/day packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabs/day 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.

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ADHANSIA XR methylphenidate: ADHANSIA XR methylphenidate_2: ADZENYS ER amphetamine: ADZENYS XRODT amphetamine: amphetamine: amphetaminedetroamphetamine: APTENSIO XR methylphenidate: 1 capday: COTEMPLA XRODT: 6 tabsday: DEXEDRINE dextroamphetamine: 6 capsday: DEXEDRINE dextroamphetamine_2: 3 capsday: DEXEDRINE dextroamphetamine: 4 capsday: dexmethylphenidate: 2 tabsday: DYANAVEL XR amphetamine: 8 mLday: EVEKEO ODT amphetamine 5 mg: 3 tabsday: EVEKEO ODT amphetamine 15 mg: 2 tabsday_2: FOCALIN XR dexmethylphenidate: 1 capday_2: FOCALIN XR dexmethylphenidate_2: 2 capsday: JORNAY PM methylphenidate: 1 capday_3: METADATE CD methylphenidate: 1 capday_4: METADATE ER methylphenidate: 3 tabsday_2: METHYLIN methylphenidate: 3 tabsday_3: METHYLIN methylphenidate Soln: 30 mLday: methylphenidate: 3 tabsday_4: METHYLPHENIDATE ER: 2 tabsday_3: MYDAYIS amphetamine: 1 capday_5: QUILLICHEW ER methylphenidate: 2 tabsday_4: QUILLICHEW ER methylphenidate_2: 1 tabday: QUILLIVANT XR methylphenidate: 12 mLday: RELEXXII methylphenidate 72 mg: 1 tabday_2: RITALIN LA methylphenidate: 1 capday_6: RITALIN SR methylphenidate 20 mg: 3 tabsday_5: VYVANSE lisdexamfetamine: 1 capday_7: VYVANSE CHEW TAB: 1 tabday_3: ZENZEDI dextroamphetamine: 3 tabsday_6: ZENZEDI dextroamphetamine_2: 6 tabsday_2: CODAR AR chlorpheniramine: 240 mLfill 2 fills60 days: CODITUSSIN guaifenesincodeine: 240 mLfill 2 fills60 days_2: CODITUSSIN AC guaifenesin: 240 mLfill 2 fills60 days_3: HISTEXAC phenylephrine: 240 mLfill 2 fills60 days_4: HYDROMET hydrocodone: 240 mLfill 2 fills60 days_5: MCLEAR WC guaifenesincodeine: 240 mLfill 2 fills60 days_6: MEND MAX D pseudoephedrine: 240 mLfill 2 fills60 days_7: OBREDON hydrocodone: 240 mLfill 2 fills60 days_8: promethazinephenylephrine: 240 mLfill 2 fills60 days_9: pseudoephedrinechlorpheniramine: 240 mLfill 2 fills60 days_10: REZIRA pseudoephedrine: 240 mLfill 2 fills60 days_11: TUSNEL C pseudoephedrine w cod: 240 mLfill 2 fills60 days_12: TUSSICAPS hydrocodone: 2 capsday 7 day supply 2 fills60 days: adapalene: ATRALIN tretinoin: AVITA tretinoin: PLIXDA adapalene: RETINA tretinoin: tretinoin microsphere gel: ANADROL50 oxymetholone: ANDROID methyltestosterone: ANDROXY fluoxymesterone: METHITEST methyltestosterone: OXANDRIN oxandrolone 10 mg: 2 tabsday_5: TESTRED methyltestosterone: None: Androgens: AVEED testosterone undecanoate: None_2: DELATESTRYL testosterone: None_3: TESTOPEL testosterone pellet: None_4: testosterone cypionate: None_5: Androgens_2: ANDRODERM testosterone: None_6: NATESTO testosterone nasal: None_7: STRIANT testosterone: None_8: testosterone gel 162: None_9: Antidiabetic Agents: AFREZZA insulin regular: None_10: VIBERZI eluxadoline: 2 tabsday_6: ORALAIR CHILDRENADOLESCENTS: 2 kitsyear: RASUVO methotrexate: 4 autoinjectors28 days: Movement Disorder: OSMOLEX ER amantadine: None_11: Wound Care: REGRANEX becaplermin: None_12: ALYQ tadalafil: 2 tabsday_7: ambrisentan: 1 tabday_4: FLOLAN epoprostenol: None_13: OPSUMIT macitentan: 1 tabday_5: ORENITRAM treprostinil diolamine: None_14: REVATIO sildenafil Soln: None_15: REVATIO sildenafil Susp: 2 bottles30 days: REVATIO sildenafil Tabs: 3 tabsday_7: tadalafil: 2 tabsday_8: TRACLEER bosentan Tabs: 2 tabsday_9: TRACLEER bosentan Tabs for Susp: 4 tabsday: treprostinil: None_16: TYVASO treprostinil: 1 ampuleday: UPTRAVI selexipag: 2 tabsday_10: UPTRAVI selexipag Pack: 2 packsyear: VELETRI epoprostenol: None_17: Transthyretin Stabilizers VYNDAMAX tafamidis: 1 capday_8: RUZURGI amifanpridine: None_18: Neurological Agents: ONPATTRO patisiran sodium: None_19: EGRIFTA tesamorelin 1 mg: EGRIFTA tesamorelin 2 mg: NORDITROPIN somatropin: NUTROPIN somatropin: NUTROPIN AQ somatropin: SEROSTIM somatropin: None_20: ZORBTIVE somatropin: None_21: Growth Hormones: INCRELEX mecasermin: None_22: SOMAVERT pegvisomant: None_23: Hormone Modifiers: MYALEPT metreleptin: None_24: PROCYSBI cysteamine bitartrate: None_25: Enzyme Replacement: ALDURAZYME laronidase: None_26: Phenylketonuria: KUVAN sapropterin: None_27: PALYNZIQ pegvaliasepqpz: 1 syringeday: SOLIRIS eculizumab: None_28: OCTAGAM immune globulin: None_29: COPAXONE glatiramer SOSY 40: 12 syringes28 days: GILENYA fingolimod: 1 capday_9: LEMTRADA alemtuzumab: None_30: MAYZENT siponimod fumarate: 1 tabday_6: MAYZENT siponimod fumarate_2: 2 starter packs 24 tabs365 days: TECFIDERA dimethyl fumarate: 2 capsday_2: INGREZZA valbenazine tosylate: 2 capsday_3: INGREZZA valbenazine tosylate 80: 1 capday_10: INGREZZA valbenazine tosylate_2: 56 caps 2 packs per 365 days: XENAZINE tetrabenazine: None_31: Musculoskeletal: SPINRAZA nusinersen Soln: None_32: ZOLGENSMA onasemnogene: None_33: Toxicology: CUPRIMINE penicillamine: None_34: HYALGAN sodium hyaluronate: None_35: KYPROLIS carfilzomib: None_36: PORTRAZZA necitumumab Soln: None_37: VELCADE bortezomib: None_38: ZALTRAP zivaflibercept: None_39: Miscellaneous: BELEODAQ belinostat: None_40: Monoclonal Antibody: ADCETRIS brentuximab: None_41: Kinase and Molecular: AFINITOR everolimus: 1 tabday_7: AFINITOR DISPERZ everolimus: None_42: ALECENSA alectinib: 8 capsday: ALUNBRIG brigatinib 30 mg: 4 tabsday_2: ALUNBRIG brigatinib 90 mg: 1 tabday_8: BALVERSA erdafitinib: None_43: BOSULIF bosutinib: None_44: BRAFTOVI encorafenib: None_45: CABOMETYX cabozantinib: None_46: CAPRELSA vandetanib: None_47: CAPRELSA vandetanib 100 mg: 2 tabsday_11: COMETRIQ carbozantinib: None_48: COTELLIC cobimetnib: None_49: ERIVEDGE vismodegib: None_50: FARYDAK panobinostat: None_51: GILOTRIF afatinib: 1 tabday_9: GLEEVEC imatinib: None_52: IBRANCE palbociclib: None_53: ICLUSIG ponatinib 15 mg: 2 tabday: ICLUSIG ponatinib 45 mg: None_54: IDHIFA enasidenib: None_55: 29: IMBRUVICA ibrutinib: None_56: INLYTA axitinib: None_57: IRESSA gefitinib: None_58: JAKAFI ruxolitinib: None_59: JAKAFI ruxolitinib 10 mg: 2 tabsday_12: LENVIMA lenvatinib: None_60: LYNPARZA olaparib: None_61: MEKINIST trametinib: None_62: MEKTOVI binimetinib: None_63: NERLYNX neratinib: 6 tabsday_3: NEXAVAR sorafenib: None_64: NINLARO ixazomib: None_65: ODOMZO sonidegib: None_66: RYDAPT midostaurin: None_67: SPRYCEL dasatinib: None_68: STIVARGA regorafenib: None_69: SUTENT sunitinib: None_70: TAFINLAR dabrafenib: None_71: TAGRISSO osimertinib: 1 tabday_10: TAGRISSO osimertinib 40 mg: None_72: TARCEVA erlotinib 100 mg: None_73: TARCEVA erlotinib 25 mg: TASIGNA nilotinib: None_74: TIBSOVO ivosidenib: None_75: TYKERB lapatinib: None_76: VENCLEXTA venetoclax: None_77: VERZENIO abemaciclib: None_78: VOTRIENT pazopanib: None_79: XALKORI crizotinib: None_80: ZEJULA niraparib tosylate: None_81: ZELBORAF vemurafenib: None_82: ZYDELIG idelalisib: None_83: ZYKADIA ceritinib: None_84: REVLIMID lenalidomide: None_85: THALOMID thalidomide: None_86:

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