PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
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1 Abstral fentanyl citrate oral tablet Controlled Dangerous substance Actemra tocilizumab Monoclonal antibody Acthar corticotropin Hormone Actimmune interferon gamma 1b Interferon Actiq fentanyl citrate OTFC Controlled Dangerous substance Adcirca tadalafil Pulmonary Vasodilator Advocate Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Ampyra dalfampridine Multiple Sclerosis Agent Androderm testosterone Topical Testosterone Drug Androgel testosterone Topical Testosterone Drug Apidra (effective 1/1/14) insulin glulisine [rdna origin] Human Insulin Analog Aranesp darbepoetin alfa Red Blood Cell Progenitor Atralin tretinoin Anti Acne Avita tretinoin Anti Acne Axiron testosterone Topical Testosterone Drug Benlysta Belimumab Lupus Berinert C1 esterase inhibitor Hereditary Angioedema Boniva Syringe ibandronate Osteoporosis/Bones Botox onabotulinumtoxina Specialty Drug Bydureon exenatide ER Incretin Mimetic Agent Byetta exenatide Incretin Mimetic Agent Carimune NF immune globulin-intravenous Intravenous Immune Globulin Cimzia certolizumab pegol Anti Tumor Necrosis Factor Drug Cinryze C1 esterase inhibitor Hereditary Angioedema Dysport onabotulinumtoxina Specialty Drug Enbrel etanercept Anti Tumor Necrosis Factor Drug Euflexxa sodium hyaluronate Hyaluronic Acid Derivatives For Joint Injection Epogen epoetin alfa Red Blood Cell Progenitor Fast Take Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Fentora fentanyl buccal tablet Controlled Dangerous Substances Firazyr icatibant Hereditary Angioedema Flolan epoprostenol sodium Pulmonary Vasodilator Flebogamma immune globulin-intravenous Intravenous Immune Globulin Forteo teriparatide Osteoporosis/Bones Fortesta testosterone Topical Testosterone Drug FreeStyle Test Strips Blood Glucose Test Strips Blood Glucose Test Strips
2 Gamimune N immune globulin-intravenous Intravenous Immune Globulin Gammagard Liquid immune globulin-intravenous Intravenous Immune Globulin Gammagard S/D immune globulin-intravenous Intravenous Immune Globulin Gammaked immune globulin-intravenous Intravenous Immune Globulin Gammaplex immune globulin-intravenous Intravenous Immune Globulin Gammar-P IV immune globulin-intravenous Intravenous Immune Globulin Gamunex immune globulin-intravenous Intravenous Immune Globulin Gamunex-C immune globulinintravenous/subcutaneous Intravenous/Subcutaneous Immune Globulin Gattex teduglitide [rdna origin] Short Bowel Syndrome Gel-One sodium hyaluronate Hyaluronic Acid Derivatives For Joint Injection Genotropin somatropin Growth Hormone Gilenya fingolimod Multiple Sclerosis Agent Glucose Test Strip Blood Glucose Test Strips Blood Glucose Test Strips Hizentra immune globulin-subcutaneous Subcutaneous Immune Globulin Humalog (effective 1/1/14) insulin lispro [rdna origin] Human Insulin Analog Humatrope somatropin Growth Hormone Humira adalimumab Monoclonal Antibody Humulin (effective 1/1/14) Insulin human [rdna origin] Human Insulin Hyalgan sodium hyaluronate Hyaluronic Acid Derivative For Joint Injection Incivek telaprevir Hepatitis C Protease Inihibitors Increlex mecasermin Growth Hormone Iveegam EN immune globulin-intravenous Intravenous Immune Globulin IVIG or IGIV immune globulin-intravenous Intravenous Immune Globulin Juxtapid lomitapide Homozygous Familial Hypercholesterolemia Agent Kalbitor ecallantide Hereditary Angioedema Kalydeco ivacaftor Cystic Fibrosis Korlym mifepristone Endocrine/Cushing s disease Krystexxa pegloticase Gout Lazanda Nasal Spray fentanyl citrate Controlled Dangerous substance Kuvan sapropterin Phenylketonuria Kynamro mipomersen Homozygous Familial Hypercholesterolemia Agent Letairis ambrisentan Pulmonary Vasodilator Liberty Test Strip Blood Glucose Test Strips Blood Glucose Test Strips Lidoderm lidocaine Topical Anesthetic Lovaza omega-3-acid ethyl esters Omega-3 Fatty Acid
3 Lumigan bimatoprost Anti Glaucoma Makena hydroxyprogesterone Hormone Myobloc rimabotulinumtoxinb Specialty Drug Norditropin somatropin Growth Hormone Nutropin somatropin Growth Hormone Nutropin AQ somatropin Growth Hormone Nuvigil armodafinil CNS Stimulant Octagam immune globulin-intravenous Intravenous Immune Globulin Omnitrope somatropin Growth Hormone Omontys peginesatide Red Blood Cell Progenitor One Touch Test Strips Blood Glucose Test Strips Blood Glucose Test Strips One Touch Ultra Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Onsolis fentanyl soluble film Controlled Dangerous Substances Orencia abatacept Selective Co-Stimulation Modulator For RA Orthovisc high molecular weight hyaluronan Hyaluronic Acid Derivative For Joint Injection Oxycontin- quantities greater than 90 per month oxycodone extended release Controlled Dangerous Substances Panglobulin NF immune globulin-intravenous Intravenous Immune Globulin Pegasys peginterferon alfa-2a Interferon Peg-Intron peginterferon alfa-2b Interferon Precision SOF-TACT Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Precision Xtra Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Polygam S/D immune globulin-intravenous Intravenous Immune Globulin Privigen immune globulin-intravenous Intravenous Immune Globulin Prestige Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Procrit epoetin alfa Red Blood Cell Progenitor Prodigy Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Prolia denosumab Osteoporosis/Bones Provenge sipuleucel-t Oncology Provigil modafinil CNS Stimulant Qutenza capsaicin Topical Anesthetic Reclast zoledronic acid Osteoporosis/Bones Relion Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Remicade infliximab Monoclonal Antibody Remodulin treprostinil sodium Pulmonary Vasodilator Rescula unoprostone Anti Glaucoma
4 Retin-A tretinoin Anti Acne Retin-A Micro tretinoin Anti Acne Revatio sildenafil citrate Pulmonary Vasodilator Rituxan rituximab Monoclonal Antibody Sabril vigabatrin Anticonvulsant Saizen somatropin Growth Hormone Seroquel quetiapine Anti Psychotic Serostim somatropin Growth Hormone Signifor pasireotide Somatostatin/Cushing s disease Simponi golimumab Anti Tumor Necrosis Factor Drug Stelara ustekinumab Anti Tumor Necrosis Factor Drug Striant testosterone Topical Testosterone Drug Subsys fentanyl sublingual spray Controlled Dangerous substance Suboxone SL Film buprenorphine and naloxone Controlled Dangerous substance Suboxone SL Tablets buprenorphine and naloxone Controlled Dangerous substance Supartz sodium hyaluronate Hyaluronic Acid Derivatives For Joint Injection SureStep Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Symlin pramlintide Amylin Analogue Synagis palivizumab Monoclonal Antibody Synvisc hylan GF 20 Hyaluronic Acid Derivatives For Joint Injection Synvisc-One hylan GF 20 Hyaluronic Acid Derivatives For Joint Injection Tecfidera dimethyl fumarate Multiple Sclerosis Agent Testim testosterone Topical Testosterone Drug Tev-Tropin somatropin Growth Hormone Tracleer bosentan Pulmonary vasodilator Travatan Z travoprost Anti Glaucoma Travoprost travoprost Anti Glaucoma tretinoin tretinoin Anti Acne Tretin-X tretinoin Anti Acne TrueTest Test Strips Blood Glucose Test Strips Blood Glucose Test Strips TrueTrack Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Tyvaso treprostinil Pulmonary Vasodilator Tysabri natalizumab Monoclonal Antibody Vascepa icosapent ethyl Omega-3 Fatty Acid Veletri epoprostenol sodium Pulmonary Vasodilator Veltin tretinoin/clindamycin Anti Acne
5 Ventavis iloprost Pulmonary Vasodilator Victoza liraglutide Incretin Mimetic Agent Victrelis boceprevir Hepatitis C Protease Inhibitor Vivaglobin immune globulin-subcutaneous Subcutaneous Immune Globulin Xalatan latanoprost Anti Glaucoma Xeljanz tofacitinib Janus Kinase Inhibitor WaveSense Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Xeomin incobotulinumtoxina Specialty Drug Xenazine tetrabenazine Huntington s Chorea Xgeva denosumab Oncology/Bones Xiaflex collagenase clostridium Cord Injection Xolair omalizumab Monoclonal antibody Ziana tretinoin/clindamycin Anti Acne Zioptan tafluprost Anti Glaucoma Zometa zoledronic acid Oncology/Bones Zorbtive somatropin Growth Hormone Zubsolv SL Tablets buprenorphine and naloxone Controlled Dangerous substance
PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Abstral fentanyl citrate oral tablet Controlled Dangerous substance Actemra tocilizumab Monoclonal antibody Acthar corticotropin Hormone Actimmune interferon gamma 1b Interferon Actiq fentanyl citrate
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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Drug Name. J0129 Injection, abatacept (Orencia ), 10 mg Effective 01/01/2014. J0178 Injection, aflibercept (Eylea ), 1 mg Effective 04/01/2015
J0129 Injection, abatacept (Orencia ), 10 J0178 Injection, aflibercept (Eylea ), 1 J0256 J0257 J0585 J0586 J0587 J0588 J0597 J0641 J0717 J0800 Injection, alpha 1-proteinase inhibitor, human (Aralast NP,
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Provider Administered Drug Program (PADP) and Physician Administered Drug VPSS List Code Drug Name Effective and/or Term Date J0129 Injection, abatacept (Orencia ), 10 mg J0178 Injection, aflibercept (Eylea
RAHF PFM ALPHANINE SD COAGULATION FACTOR IX J7193 COAGULATION FACTOR IX (RFIXFC)
INFECTIOUS DISEASE ACTIMMUNE INTERFERON GAMMA 1B J9216 ADVATE RAHF PFM ONCOLOGY ORAL AFINITOR EVEROLIMUS J7527 INFECTIOUS DISEASE ALFERON N INTERFERON ALFA N3 J9215 ALPHANATE VWF J7186 ALPHANINE SD J7193
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DRUGS REQUIRING PRIOR AUTHORIZATION
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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PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Abstral fentanyl citrate oral tablet Controlled Dangerous Substance Accu-Chek Test Strips blood glucose test strips Blood Glucose Test Strips Actemra tocilizumab Monoclonal Antibody Acthar corticotropin
Descriptor Brand Name. Alprostadil, Caverject, Edex, Prostin VR Pediatric. Calcimar, Miacalcin
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Abraxane J9264 Provider ONCOLOGY None NO Actemra J3262 Provider ARTHRITIS PA - all YES Acthar HP Gel J0800 Prov/Self Med/Pharm ENDOCRINE/METABOLIC PA - all YES Adagen J2504 Provider ENZYME DISORDERS None
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Abstral Actemra Adcirca Adempas Afinitor Afinitor- Disperz Alecensa Alunbrig Amitiza Amitriptyline Ampyra Anadrol-50 Androgel Androderm Aralast NP Aranesp Arcalyst Armodafinil Aubagio Avonex Bavencio Beleodaq
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PA Category Name Code(s) Additional Notes ABA. Applied Behavioral Analysis stage 3*
ABA BEHAVIORAL HEALTH CHEMICAL DEPENDENCY Applied Behavioral Analysis stage 3* Neuropsychological Testing Chemical Dependency/Substance Abuse* (MA Only) 0373T H2020 96116 96112 96113 96121 96130 96131
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PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
ABSTRAL fentanyl citrate oral tablet ACCU-CHEK TEST STRIPS blood glucose test strips Blood Glucose Test Strips ACTEMRA tocilizumab Monoclonal Antibody ACTHAR corticotropin Hormone ACTIMMUNE interferon
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J0586 ABOBOTULINUMTOXINA Dysport X X X the medication is being used to treat J0178 AFLIBERCEPT Eylea X X X X X of Neovascular (Wet) -Related Macular Degeneration of Macular Edema following either central
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Prior_Authorization_Group_Description 5HT3 ANTI-NAUSEA AGENT BVD DETERMINATION ALDARA Drug_Name GRANISETRON HCL ONDANSETRON HCL ONDANSETRON ODT ALDARA ARANESP BYETTA CERTOLIZUMAB PEGOL CHANTIX CHOLINESTERASE