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1 Prior Authorization PricewaterhouseCoopers The following medications may require prior authorization prior to dispensing at a participating retail pharmacy or through the Express Scripts Pharmacy home delivery. This drug list is subject to change. For more information, please contact Express Scripts PricewaterhouseCoopers The following medications may require prior authorization prior to dispensing at a participating retail pharmacy or through the Express Scripts Pharmacy home delivery. This drug list is subject to change. For more information, please contact Express Scripts Member Services at Drug Name Abstral Actemra Acthar Gel Acticlate Actiq Adcirca Adderall Adderall XR Adempas Adipex-P Adoxa Adzenys XR-ODT Alodox Ampyra Androderm AndroGel Aptensio XR Aralast NP Aranesp Arcalyst Atralin Aveed Avidoxy Avita Avonex Axiron Belviq Belviq XR Therapeutic Category
2 Berinert Betaseron Bivigam Boniva IV Bontril PDM Botox BRAVELLE Carimune NF CETROTIDE Chenodal Cholbam CHORIONIC GONADOTROPIN Cimzia Cinqair Cinryze CLOMIPHENE CITRATE Concerta Contrave Copaxone Copegus Cosentyx CRINONE Cuvitru Daklinza Daliresp Daytrana Depo - Testosterone Desoxyn Dexedrine Didrex Doryx Doxycycline 40mg Capsule Dyanavel XR Dynacin Egrifta Eligard Emflaza Enbrel ENDOMETRIN Entyvio Epclusa Epogen Esbriet Euflexxa Evekeo Asthma Specialty Asthma/COPD Duchenne Muscular Dystrophy
3 Exondys 51 Extavia Eylea Fabior Fentora Firazyr FIRST-PROGESTERONE Flebogamma DIF Flolan Focalin Focalin XR FOLLISTIM AQ Forteo Fortesta Gammagard Liquid Gammagard Liquid Gammagard S/D Gammaked Gammaked Gammaplex Gamunex Gamunex-C Gamunex-C GANIRELIX ACETATE Gel-One Gelsyn-3 Genotropin GenVisc 850 Glassia Glatopa GONAL-F Granix Grastek Harvoni Hetlioz Hizentra Humatrope Humira Hyalgan Hymovis HyQvia Ilaris Increlex Inflectra Intuniv Duchenne Muscular Dystrophy Eye Conditions Allergies Sleep Disorder
4 Kalbitor Kalydeco Kapvay Keveyis Kineret Korlym Krystexxa Kuvan Lazanda Lemtrada Letairis Lidoderm Lomaira Lovaza Lucentis Lupaneta Lupron Depot Lupron Depot-PED Macugen Makena MENOPUR Metadate CD Metadate ER Methylin Minocin Mircera Moderiba Mondodox Monovisc Morgidox Myalept Myobloc Natesto Natpara Neulasta Neupogen Norditropin Northera NOVAREL Nplate Nucala Nutropin Nutropin AQ Nuvigil Ocaliva Gout Pain High Blood Cholesterol Eye Conditions Eye Conditions Hormone supplementation Asthma Specialty Narcolepsy
5 Octagam Ofev Olysio Omnitrope Onsolis Opsumit Oracea Oralair Orencia Orenitram Orkambi Orthovisc Otezla OVIDREL Pegasys PEG-Intron Plegridy PREGNYL Privigen Procentra Procrit Prolastin - C Prolia Promacta Provigil Qsymia QuilliChew ER Quillivant XR Ragwitek Rebetol Rebif Reclast Regimex Remicade Remodulin REPRONEX Retin-A Retin-A Micro Revatio Ribasphere Ritalin Ritalin LA Ritalin SR Rituxan Ruconest Allergies Narcolepsy Allergies
6 Saizen Samsca Saxenda Selzentry SEROPHENE Serostim Signifor Signifor LAR Simponi Solaraze Solodyn Sovaldi Spinraza Stelara Strattera Striant Subsys Supartz Supartz FX Suprenza Synagis Synvisc Synvisc-One Taltz Taradox Tazorac Technivie Testim Testopel testosterone enanthate Tracleer Tretin-X Tysabri Tyvaso Uptravi Vascepa Veletri Veltin Ventavis Vibramycin Viekira Vogelxo Vyvanse Xeljanz Xenazine HIV High Blood Cholesterol
7 Xenical Xeomin Xolair Zarxio Zemaira Zenzedi Zepatier Ziana Zinbryta Zomacton Zorbtive Zovirax Asthma Specialty
METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE ALPHA-1 PROTEINASE INHIBITORS ARANESP BLOOD CELL DEFICIENCY ARANESP ARCALYST
PRIOR AUTHORIZATION LIST (SUBJECT TO CHANGE) MEDICATION THERAPEUTIC CATEGORY MODULE ACTEMRA INFLAMMATORY CONDITIONS ACTEMRA ADCIRCA PULMONARY HYPERTENSION PDE-5 INHIBITORS FOR PAH ADDYI SEXUAL DISORDERS
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DRUGS REQUIRING PRIOR AUTHORIZATION Medication Abstral Actemra Acthar Gel Actiq* Adcirca Adderall Adderall XR Addyi Adempas Adipex* Adzenys XR-ODT Afinitor Afinitor Alecensa Alecensa Ampyra Androderm AndroGel
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Abstral fentanyl citrate oral tablet Controlled Dangerous substance Actemra tocilizumab Monoclonal antibody Acthar corticotropin Hormone Actimmune interferon gamma 1b Interferon Actiq fentanyl citrate
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