Prior Authorization Drug List
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1 Prior Authorization Drug List Drug Class 5-HT3 RECEPTOR ANTAGONISTS AKYNZEO ADRENALS EMFLAZA ADRENOCORTICAL INSUFFICIENCY H.P. ACTHAR ALPHA AND BETA ADRENERGIC AGONIST(RESPR) ADRENACLICK EPIPEN AUVI-Q EPIPEN 2-PAK EPIPEN JR 2-PAK ALPHA- AND BETA-ADRENERGIC AGONISTS NORTHERA AMINOGLYCOSIDES BETHKIS TOBI tobramycin KITABIS PAK TOBI PODHALER AMMONIA DETOXICANTS RAVICTI ANDROGENS ANDRODERM ANDROID AVEED DELATESTRYL METHITEST oxandrolone ANDROGEL ANDROXY AXIRON FORTESTA OXANDRIN STRIANT Pg 1_Prior Authorization_Magellan Health_12/2017
2 Drug Class ANDROGENS -- Continued testosterone TESTRED testosterone enanthate VOGELXO ANGIOTENSIN II RECEPTOR ANTAGONISTS ENTRESTO ANTHELMINTICS ALBENZA EMVERM STROMECTOL BILTRICIDE ivermectin ANTI-INFLAMMATORY AGENTS (GI DRUGS) ASACOL HD LOTRONEX ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) ACANYA BENZAMYCIN VELTIN ANTICONVULSANTS, MISCELLANEOUS BRIVIACT LYRICA SABRIL DELZICOL mesalamine BENZACLIN DUAC ZIANA FELBATOL POTIGA vigabatrin ANTIDIABETIC AGENTS, MISCELLANEOUS ANTIDIARRHEA AGENTS KORLYM XERMELO ANTIEMETICS, MISCELLANEOUS CESAMET MARINOL DICLEGIS SYNDROS Pg 2_Prior Authorization_Magellan Health_12/2017
3 VARUBI Drug Class ANTIESTROGENS ANTIFIBROTIC AGENTS ESBRIET OFEV ANTILIPEMIC AGENTS, MISCELLANEOUS JUXTAPID KYNAMRO ANTIMALARIALS atovaquone-proguanil hcl QUALAQUIN MALARONE quinine sulfate ANTIMUSCARINICS/ANTISPASMODICS SEEBRI NEOHALER ANTIPROTOZOALS, MISCELLANEOUS ALINIA TUDORZA PRESSAIR atovaquone ANTIPRURITICS AND LOCAL ANESTHETICS LIDORX ANTITOXINS AND IMMUNE GLOBULINS GAMASTAN S-D GAMUNEX-C HYQVIA GAMMAKED HIZENTRA HYQVIA IG COMPONENT ANTITUBERCULOSIS AGENTS SIRTURO ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) DENAVIR XERESE ZOVIRAX ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC HETLIOZ ATYPICAL ANTIPSYCHOTICS ABILIFY MAINTENA INVEGA SUSTENNA ARISTADA INVEGA TRINZA Pg 3_Prior Authorization_Magellan Health_12/2017
4 Drug Class ATYPICAL ANTIPSYCHOTICS -- Continued NUPLAZID RISPERDAL CONSTA REXULTI VRAYLAR AZOLES ZYPREXA RELPREVV CRESEMBA ONMEL AZOLES (SKIN AND MUCOUS MEMBRANE) JUBLIA LUZU BENZODIAZEPINES (ANTICONVULSANTS) ONFI BIGUANIDES alogliptin-metformin KAZANO XIGDUO XR AVANDAMET KOMBIGLYZE XR BONE RESORPTION INHIBITORS XGEVA CENTRAL NERVOUS SYSTEM AGENTS, MISC. ADDYI INGREZZA tetrabenazine AUSTEDO NUEDEXTA XENAZINE XYREM CLASS III ANTIARRHYTHMICS MULTAQ COMPLEMENT INHIBITORS FIRAZYR KALBITOR CYSTIC FIBROSIS (CFTR) CORRECTORS ORKAMBI CYSTIC FIBROSIS (CFTR) POTENTIATORS Pg 4_Prior Authorization_Magellan Health_12/2017
5 KALYDECO Drug Class DIGESTANTS PERTZYE VIOKACE ULTRESA DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS alogliptin GLYXAMBI ONGLYZA DIRECT FACTOR XA INHIBITORS ELIQUIS DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ACTEMRA ENBREL MINI KEVZARA ORENCIA OTEZLA RASUVO STELARA XELJANZ alogliptin-pioglitazone NESINA OSENI SAVAYSA ENBREL ENBREL SURECLICK KINERET ORENCIA CLICKJECT OTREXUP SIMPONI XATMEP XELJANZ XR DOPAMINE PRECURSORS DUOPA EENT ANTI-INFLAMMATORY AGENTS, MISC. RESTASIS RESTASIS MULTIDOSE XIIDRA EENT DRUGS, MISCELLANEOUS CYSTARAN JETREA LUCENTIS ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS Pg 5_Prior Authorization_Magellan Health_12/2017
6 CYCLOSET Drug Class GI DRUGS, MISCELLANEOUS CHOLBAM GATTEX CIMZIA HUMIRA HUMIRA PEDIATRIC CROHN'S HUMIRA PEN CROHN-UC-HS STARTER MOVANTIK RELISTOR HUMIRA PEN HUMIRA PEN PSORIASIS-UVEITIS OCALIVA TRULANCE VIBERZI GONADOTROPIN-RELEASING HORMONE ANTAGNTS FIRMAGON GONADOTROPINS ELIGARD LUPRON DEPOT LUPRON DEPOT-PED SYNAREL ZOLADEX leuprolide acetate LUPRON DEPOT (LUPANETA) NOVAREL TRELSTAR HCV POLYMERASE INHIBITORS EPCLUSA HARVONI SOVALDI HCV PROTEASE INHIBITORS OLYSIO ZEPATIER HCV REPLICATION COMPLEX INHIBITORS DAKLINZA HEMATOPOIETIC AGENTS ARANESP GRANIX MIRCERA NEULASTA NPLATE EPOGEN LEUKINE MOZOBIL NEUPOGEN PROCRIT Pg 6_Prior Authorization_Magellan Health_12/2017
7 Drug Class HEMATOPOIETIC AGENTS -- Continued ZARXIO HISTAMINE H2-ANTAGONISTS DUEXIS HIV PROTEASE INHIBITORS TECHNIVIE VIEKIRA PAK VIEKIRA XR HMG-COA REDUCTASE INHIBITORS simvastatin ZOCOR HYPOTENSIVE AGENTS, MISCELLANEOUS VECAMYL IMMUNOMODULATORY AGENTS AUBAGIO AVONEX PEN COPAXONE GILENYA POMALYST REBIF REBIDOSE TECFIDERA AVONEX BETASERON EXTAVIA GLATOPA REBIF REVLIMID THALOMID ZINBRYTA IMMUNOSUPPRESSIVE AGENTS ASTAGRAF XL cyclophosphamide PURIXAN BENLYSTA ENVARSUS XR ZORTRESS INCRETIN MIMETICS ADLYXIN SOLIQUA TANZEUM XULTOPHY Pg 7_Prior Authorization_Magellan Health_12/2017
8 Drug Class INSULINS BASAGLAR KWIKPEN U-100 INTERFERONS LEPTINS INTRON A PEGASYS PROCLICK PEGINTRON REDIPEN MYALEPT PEGASYS PEGINTRON SYLATRON MONOAMINE OXIDASE B INHIBITORS XADAGO MONOBACTAMS MUCOLYTIC AGENTS CAYSTON PULMOZYME NITRATES AND NITRITES GONITRO NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST APOKYN NUCLEOSIDES AND NUCLEOTIDES BARACLUDE HEPSERA REBETOL RIBASPHERE RIBAPAK ribavirin TYZEKA COPEGUS MODERIBA RIBASPHERE RIBATAB SITAVIG VEMLIDY OPIATE AGONISTS ABSTRAL ARYMO ER DOLOPHINE HCL ACTIQ CONZIP DURAGESIC Pg 8_Prior Authorization_Magellan Health_12/2017
9 Drug Class OPIATE AGONISTS -- Continued EMBEDA fentanyl FENTORA HYSINGLA ER LAZANDA EXALGO fentanyl citrate hydromorphone er KADIAN methadone hcl METHADONE INTENSOL MORPHABOND ER morphine sulfate er NUCYNTA ER OXYCONTIN SUBSYS ULTRAM ER METHADOSE morphine sulfate MS CONTIN oxycodone hcl er oxymorphone hcl er tramadol hcl er XTAMPZA ER OPIATE ANTAGONISTS ZOHYDRO ER EVZIO VIVITROL OPIATE PARTIAL AGONISTS BELBUCA buprenorphine buprenorphine-naloxone SUBOXONE ORALLY INHALED PREPARATIONS (STEROIDS) ALVESCO ASMANEX BUNAVAIL buprenorphine hcl BUTRANS ZUBSOLV ARMONAIR RESPICLICK ASMANEX HFA OTHER MACROLIDES DIFICID OTHER MISCELLANEOUS THERAPEUTIC AGENTS AMPYRA BOTOX CERDELGA ARCALYST BOTOX COSMETIC DYSPORT Pg 9_Prior Authorization_Magellan Health_12/2017
10 Drug Class OTHER MISCELLANEOUS THERAPEUTIC AGENTS -- Continued ILARIS KEVEYIS KUVAN ORALAIR RAGWITEK XEOMIN OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS CAMBIA MYOBLOC ORFADIN SENSIPAR ZAVESCA VIVLODEX ZORVOLEX OXABOROLES OXAZOLIDINONES PARATHYROID PCSK9 INHIBITORS KERYDIN SIVEXTRO FORTEO TYMLOS PRALUENT PEN REPATHA PUSHTRONEX REPATHA SYRINGE ZYVOX NATPARA PRALUENT SYRINGE REPATHA SURECLICK PHOSPHODIESTERASE TYPE 4 INHIBITORS DALIRESP PITUITARY GENOTROPIN NORDITROPIN FLEXPRO NUTROPIN AQ NUSPIN SAIZEN SEROSTIM HUMATROPE NUTROPIN AQ OMNITROPE SAIZEN-SAIZENPREP ZOMACTON Pg 10_Prior Authorization_Magellan Health_12/2017
11 ZORBTIVE Drug Class PLATELET-AGGREGATION INHIBITORS ZONTIVITY POTASSIUM-REMOVING AGENTS VELTASSA PROGESTINS QUINOLONES MAKENA FACTIVE RESPIRATORY TRACT AGENTS, MISCELLANEOUS XOLAIR RIFAMYCINS XIFAXAN SELECT.BETA-2-ADRENERGIC AGONIST(RESPIR) AIRDUO RESPICLICK levalbuterol tartrate hfa DULERA PROVENTIL HFA XOPENEX HFA SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ABSORICA CLARAVIS COSENTYX PEN COSENTYX SYRINGE FINACEA RHOFADE TALTZ AUTOINJECTOR TALTZ AUTOINJECTOR (3 PACK) TALTZ SYRINGE (2 PACK) TARGRETIN AMNESTEEM COSENTYX (2 SYRINGES) COSENTYX PEN (2 PENS) DUPIXENT MYORISAN SILIQ TALTZ AUTOINJECTOR (2 PACK) TALTZ SYRINGE TALTZ SYRINGE (3 PACK) VALCHLOR Pg 11_Prior Authorization_Magellan Health_12/2017
12 ZENATANE Drug Class SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB SOMATOSTATIN AGONISTS octreotide acetate SIGNIFOR SANDOSTATIN SIGNIFOR LAR SOMATULINE DEPOT SOMATOTROPIN AGONISTS EGRIFTA INCRELEX THIAZOLIDINEDIONES URICOSURIC AGENTS Unclassified AVANDIA ZURAMPIC AFINITOR ALECENSA bexarotene CABOMETYX COMETRIQ ERIVEDGE FARYDAK FERRIPROX GLEEVEC HYCAMTIN IBRANCE IMBRUVICA IRESSA JADENU SPRINKLE KISQALI LENVIMA LYNPARZA AFINITOR DISPERZ ALUNBRIG BOSULIF CAPRELSA COTELLIC EXJADE FASLODEX GILOTRIF HEXALEN HYQVIA HY COMPONENT ICLUSIG INLYTA JADENU JAKAFI KISQALI FEMARA CO-PACK LONSURF MAVYRET Pg 12_Prior Authorization_Magellan Health_12/2017
13 Drug Class Unclassified -- Continued MEKINIST nilutamide ODOMZO RYDAPT STIVARGA SUTENT SYPRINE TAGRISSO TARGRETIN TEMODAR TYKERB VENCLEXTA VOSEVI XALKORI XTANDI ZELBORAF ZYDELIG NEXAVAR NINLARO RUBRACA SPRYCEL STRENSIQ SYNRIBO TAFINLAR TARCEVA TASIGNA temozolomide VELCADE VENCLEXTA STARTING PACK VOTRIENT XELODA ZEJULA ZOLINZA ZYKADIA ZYTIGA VASOCONSTRICTORS ADRENALIN CHLORIDE VASODILATING AGENTS (RESPIRATORY TRACT) ADCIRCA LETAIRIS ORENITRAM ER sildenafil TYVASO TYVASO REFILL KIT ADEMPAS OPSUMIT REVATIO TRACLEER TYVASO INSTITUTIONAL START KIT TYVASO STARTER KIT Pg 13_Prior Authorization_Magellan Health_12/2017
14 UPTRAVI Drug Class VASOPRESSIN ANTAGONISTS SAMSCA VITAMIN D ZEMPLAR WAKEFULNESS-PROMOTING AGENTS armodafinil NUVIGIL modafinil PROVIGIL Pg 14_Prior Authorization_Magellan Health_12/2017
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AAT DEFICIENCY Aralast NP intravenous recon soln 1,000 Prolastin-C intravenous recon soln mg Zemaira Glassia Other Diagnosis of severe congenital A1-PI deficiency who have clinically evident emphysema,
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AAT DEFICIENCY. Products Affected Aralast Np INJ 1000MG, 500MG Glassia Prolastin-c INJ 1000MG Zemaira
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