Prior Authorization Program Information (Effective April 1st, 2018)
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1 Prior Authorization Program Information (Effective April 1st, 2018) Prior Authorization Certain drugs require prior authorization to help promote safe, quality and affordable pharmacy care. Your doctor will need to submit a prior authorization request to Prime Therapeutics, which must be approved before you can continue to receive coverage for these drugs. The Prior Authorization form that your physician will need to complete to request an approval can be found on the MyPrime website (located on the same page where this form is found). Coverage Considerations: Your prescription drug benefit plan may not cover certain products or drug categories, regardless of their appearance in this document. Please consult your benefit plan materials for details about your particular benefit. Brand names are the property of their respective owners. Unless otherwise noted Prior Authorization Programs will apply to both brand and generic equivalents Product Classification Prior Authorization Program Name Drugs Included in Program ALLERGIES Oral Immunotherapies Grastek, Oralair, Ragwitek AMYOTROPHIC LATERAL SCLEROSIS Radicava Radicava ANAPHYLAXIS Epinephrine Auvi-Q, Adrenaclick, authorized generics of Adrenaclick Anadrol-50, Androderm, AndroGel, Android, Androxy, Aveed, Axiron, Bio-T- Gel, danazol, Delatestryl, Depo-Testosterone, First-Testosterone, First- Testosterone MC, Fortesta, Methitest, Natesto, methyltestosterone, Oxandrin, Striant, Testim, Testopel, Testred, testosterone gel, Vogelxo ANDROGENS / ANABOLIC STEROIDS Androgens Anabolic Steroids (with quantity limit) Preferred Product: Androgel 1.62% ANTIINFLAMMATORY Rayos Rayos PRIME THERAPEUTICS LLC 04/18 Page 1 of 6
2 Actemra, Enbrel, Cimzia, Cosentyx, Entyvio, Humira, Inflectra, Kevzara, Kineret, Orencia, Orencia Clickject autoinjector, Remicade, Renflexis, Siliq, Simponi, Simponi ARIA, Stelara, Stelara IV soln, Taltz, Tremfya, Xeljanz, Xeljanz XR ARTHRITIS / PAIN Biologic Immunomodulators Preferred Products: Cosentyx, Enbrel, Humira, Simponi, Stelara ARTHRITIS / PAIN Otezla Otezla, Otezla starter pack ASTHMA Injectable Asthma Agents Fasenra, Nucala, Cinqair ASTHMA Xolair Xolair AUTOIMMUNE DISORDERS Interleukin (IL)-1 Inhibitor Arcalyst, Ilaris BLOOD MODIFYING DRUGS Erythropoietins Aranesp, Epogen, Mircera, Procrit Forteo, Tymlos Parathyroid Hormone Analog BLOOD MODIFYING DRUGS Osteoporosis Preferred Product: Tymlos CANCER / ONCOLOGY Self Administered Oncology Afinitor, Afinitor Disperz, Alecensa, Alunbrig, Bosulif, Cabometyx, Calquence, Caprelsa, Cometriq, Cotellic, Erivedge, Erleada, Farydak, Gilotrif, Gleevec, Hexalen, Hycamtin, Ibrance, Iclusig, Idhifa, Imbruvica, Inlyta, Iressa, Jakafi, Kisqali, Kisqali 200 Pak Femara, Lenvima, Lonsurf, Lynparza, Lysodren, Matulane, Mekinist, Nerlynx, Nexavar, Ninlaro, Odomzo, Pomalyst, Revlimid, Rubraca, Rydapt, Sprycel, Stivarga, Sutent, Sylatron, Synribo, Taflinar, Tagrisso, Tarceva, Targretin, Tasigna, Temodar, Thalomid, Tretinoin (oral), Tykerb, Venclexta, Votrient, Xalkori, Xeloda, Xtandi, Zejula, Zelboraf, Zolinza, Zydelig, Zykadia, Zytiga CARDIOVASCULAR Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker Corlanor CARDIOVASCULAR PCSK9 Praluent, Repatha CUSHING'S DISEASE Signifor Signifor, Signifor LAR CYSTIC FIBROSIS Kalydeco Orkambi Kalydeco, Orkambi PRIME THERAPEUTICS LLC 04/18 Page 2 of 6
3 Prior Authorization applies to only brand products and generics as listed below: Doxycycline Products: Acticlate, Adoxa, Doryx, Doryx generic equivalent, Doxycycline, Monodox, Oracea, Oraxyl, Targadox, Vibramycin Minocycline Products: Dynacin, Minocin, Solodyn, Solodyn generic equivalent DERMATOLOGY Doxycycline/Minocycline DERMATOLOGY Injectable Atopic Dermatitis Agents Dupixent DIABETES Afrezza Afrezza Admelog, Apidra, Humalog, Humalog Junior Kwikpen, Humalog Kwikpen U500, Humalog Mix 75/25, Humalog Mix 50/50, Humulin R U-100, Humulin R U-500, Humulin R U-500 kwikpen, Humulin N, Humulin 70/30 DIABETES Insulin Agents Preferred Products (not subject to PA): Fiasp, Novolin, Novolog DIABETES Korlym Korlym ENDOCRINOLOGY H.P. Acthar Gel H.P. Acthar Gel FAT STORAGE DISORDERS Myalept Myalept GASTROINTESTINAL Amitiza/ Linzess Amitiza, Linzess, Trulance GASTROINTESTINAL Gattex Gattex GASTROINTESTINAL Somatostatin Analogs Sandostatin, Sandostatin LAR, Somatuline Depot, Somavert GASTROINTESTINAL Endari Endari Genotropin, Humatrope, Norditropin Flexpro, Norditropin NordiFlex, Omnitrope, Saizen, Saizen Click.Easy, Serostim, Tev-Tropin, Zomacton, Zorbtive GROWTH HORMONE Growth Hormone Preferred Product: Omnitrope PRIME THERAPEUTICS LLC 04/18 Page 3 of 6
4 Daklinza, Epclusa, Harvoni, Incivek, Mavyret, Olysio, Pegasys, Pegasys Proclick, PegIntron, Sovaldi, Technivie, Victrelis,Viekira Pak, Viekira XR, Vosevi, Zepatier HEPATITIS B & HEPATITIS C Hepatitis B/Hepatitis C Agents Preferred Products: Epclusa, Harvoni, Mavyret, Sovaldi, and Vosevi HEREDITARY BLOOD VESSEL SWELLING Hereditary Angioedema (HAE) Berinert, Cinryze, Firazyr, Kalbitor, and Ruconest HIGH BLOOD AMMONIA LEVELS Urea Cycle Disorders Buphenyl, Ravicti HIV LIPODYSTORPHY Egrifta Egrifta HUNTINGTON S CHOREA VMAT-2 Inhibitors Austedo, Ingrezza, Xenazine, tetrabenazine HYPERTENSION (HIGH BLOOD PRESSURE)/HYPOTENSION (LOW BLOOD PRESSURE) Northera Northera HYPERTENSION (HIGH BLOOD PRESSURE)/HYPOTENSION (LOW Adcirca, Adempas, Letairis, Opsumit, Oralair, Orenitram, Revatio, Tracleer, BLOOD PRESSURE) Oral Pulmonary Hypertension Agents Tyvaso, Uptravi, Ventavis LUPUS Benlysta Benlysta METABOLIC DISORDERS Kuvan Kuvan Addyi Addyi Botulinum toxin Botox, Dysport, Myobloc, Xeomin Carbaglu Carbaglu Compound Medications: Custom made medications produced in a pharmacy containing the following bulk powder ingredients Diclofenac_Gel_Fluorouracil_Cream_ Imiquimod_Cream_Ingenol Compound Medications containing the following bulk powders: Baclofen, Clonidine, Coenzyme Q10, Cyclobenzaprine, Diclofenac, Flurbiprofen, Fluticasone propionate, Gabapentin, Ketamine, Ketoprofen, Ketorolac, Lansoprazole, Levocetirizine, Loperamide, Meloxicam, Mometasone, Nabumetone, Omeprazole, Pentoxifylline, Sumatriptan, Tamoxifen, Testosterone, Testosterone propionate, Testosterone micronized, Tramadol, Vancomycin Solaraze, Carac, Efudex, Fluoroplex, Tolak, Aldara, Zyclara, Picato PRIME THERAPEUTICS LLC 04/18 Page 4 of 6
5 Emflaza Emflaza Bivigam, Carimune NF, Cuvitru, Flebogamma, Flebogamma DIF, GamaSTAN S/D, Gammagard S/D, Gammagard S/D (IgA less than 1 mcg/ml), Gammagard Liquid, Gammaked Liquid, Gammaplex Liquid, Gamunex-C, Hizentra, Hyqvia, Octagam, Privigen Immune Globulins Keveyis Keveyis Neprilysin Inhibitor Entresto Ocaliva Ocaliva Ophthalmic Immunomodulators Restasis, Restasis multidose, Xiidra Opioid Antidote Evzio Selective Serotonin Inverse Agonist (SSIA) Nuplazid Strensiq Strensiq Substrate Reduction Therapy Cerdelga, Zavesca Thrombopoietin Receptor Agonists Nplate, Promacta URAT1 Inhibitor Zurampic, Duzallo Weight Loss Agents Adipex-P, Belviq, Belviq XR, Bontril PDF, Bontril Slow Release, Contrave, Didrex, Diethylpropion, Lomaira, Phentermine, Qsymia, Regimex, Saxenda, Suprenza, Xenical Xermelo Xermelo Bonjesta / Diclegis Bonjesta, Diclegis Opioids ER Arymo ER, Avinza, Belbuca, Butrans, Conzip, Duragesic, Embeda, Exalgo, Fentanyl transdermal patch, Hysingla ER, Kadian, Morphabond ER, MS Contin, Nucynta ER, Opana ER, Opana ER crush-resistant, Oramorph SR, Oxycontin, Ryzolt, Tramadol SR Biphasic, Ultram ER, Xartemis XR, Xtampza ER, Zohydro ER, Zohydro ER Abuse Deterrent Topical Doxepin Doxepin, Prudoxin, Zonalon Lyrica CR Lyrica CR MULTIPLE SCLEROSIS Ampyra (with quantity limit) Ampyra PRIME THERAPEUTICS LLC 04/18 Page 5 of 6
6 MULTIPLE SCLEROSIS IV Multiple Sclerosis Lemtrada, Ocrevus, Tysabri Aubagio, Avonex, Betaseron, Copaxone, Extavia, Gilenya, Glatopa,Plegridy, Rebif, Tecfidera, Zinbryta Preferred Products: Aubagio, Avonex, Betaseron, Copaxone, Gilenya, MULTIPLE SCLEROSIS Multiple Sclerosis Glatopa, Rebif, Plegridy, and Tecfidera Transmucosal Immediate Release PAIN MANAGEMENT Fentanyl (TIRF) Abstral, Actiq, Fentora, Lazanda, Subsys PAIN MANAGEMENT Topical Lidocaine Lidoderm 5%, Lidocaine 5% RESPIRATORY Airduo Airduo RESPIRATORY Idiopathic Pulmonary Fibrosis (IPF) Esbriet, Ofev RESPIRATORY Synagis Synagis Homozygous Familial SEVERE HIGH CHOLESTEROL Hypercholesterolemia Agents (HoFH) Juxtapid, Kynamro SLEEP DISORDERS Circadian Rhythm Disorder Hetlioz SLEEP DISORDERS Xyrem Xyrem THYROID / PARATHYROID Natpara Natpara THYROID / PARATHYROID Sensipar Sensipar WOMEN S HEALTH Prolia Prolia ANTIVIRAL Gocovri Gocovri PRIME THERAPEUTICS LLC 04/18 Page 6 of 6
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