METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE ALPHA-1 PROTEINASE INHIBITORS ARANESP BLOOD CELL DEFICIENCY ARANESP ARCALYST
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1 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 ADDYI ADEMPAS PULMONARY HYPERTENSION ADEMPAS ADIPEX WEIGHT LOSS WEIGHT LOSS DRUGS ADIPEX-P WEIGHT LOSS WEIGHT LOSS DRUGS AIMOVIG MIGRAINE HEADACHES AIMOVIG AMPYRA MULTIPLE SCLEROSIS AMPYRA ANDRODERM ENDOCRINE DISORDERS TOPICAL TESTOSTERONE ANDROGEL ENDOCRINE DISORDERS TOPICAL TESTOSTERONE ARALAST NP ARANESP BLOOD CELL DEFICIENCY ARANESP ARCALYST ARCALYST ATRALIN SKIN CONDITIONS TOPICAL TRETINOIN AUSTEDO MENTAL/NEUROLOGICAL DISORDERS AUSTEDO AVEED ENDOCRINE DISORDERS INJECTABLE TESTOSTERONE AVITA SKIN CONDITIONS TOPICAL TRETINOIN AVONEX MULTIPLE SCLEROSIS AVONEX AXIRON ENDOCRINE DISORDERS TOPICAL TESTOSTERONE BELVIQ WEIGHT LOSS WEIGHT LOSS DRUGS BELVIQ XR WEIGHT LOSS WEIGHT LOSS DRUGS BENLYSTA SC SLE AGENTS BENLYSTA SC BENZPHETAMINE WEIGHT LOSS WEIGHT LOSS DRUGS BERINERT CINRYZE, BERINERT BETASERON MULTIPLE SCLEROSIS BETASERON, EXTAVIA BONTRIL WEIGHT LOSS WEIGHT LOSS DRUGS BONTRIL PDM WEIGHT LOSS WEIGHT LOSS DRUGS BONTRIL SLOW-RELEASE WEIGHT LOSS WEIGHT LOSS DRUGS BOTOX MENTAL/NEUROLOGICAL DISORDERS BOTOX BYDUREON DIABETES GLP-1 AGONISTS BYETTA DIABETES GLP-1 AGONISTS CAVERJECT SEXUAL DISORDERS ALPROSTADIL PRODUCTS CAVERJECT IMPULSE SEXUAL DISORDERS ALPROSTADIL PRODUCTS CHENODAL CHENODAL CHOLBAM CHOLBAM CIALIS SEXUAL DISORDERS CIALIS CIMZIA INFLAMMATORY CONDITIONS CIMZIA CINQAIR ASTHMA SPECIALTY CINQAIR CINRYZE HEREDITARY ANGIOEDEMA CINRYZE, BERINERT CLINDAMYCIN/TRETINOIN GEL SKIN CONDITIONS TOPICAL TRETINOIN CONTRAVE WEIGHT LOSS WEIGHT LOSS DRUGS
2 COPAXONE MULTIPLE SCLEROSIS COPAXONE COSENTYX INFLAMMATORY CONDITIONS COSENTYX CRYSVITA BONE CONDITIONS CRYSVITA DALIRESP ASTHMA/COPD DALIRESP DELATESTRYL ENDOCRINE DISORDERS INJECTABLE TESTOSTERONE DEPO-TESTOSTERONE ENDOCRINE DISORDERS INJECTABLE TESTOSTERONE DIDREX WEIGHT LOSS WEIGHT LOSS DRUGS DIETHYLPROPION WEIGHT LOSS WEIGHT LOSS DRUGS DOPTELET BLOOD CELL DEFICIENCY DOPTELET DUPIXENT SKIN CONDITIONS DUPIXENT DUROLANE OSTEOARTHRITIS HYALURONIC ACID DERIVATIVES DYSPORT MENTAL/NEUROLOGICAL DISORDERS DYSPORT EDEX SEXUAL DISORDERS ALPROSTADIL PRODUCTS EGRIFTA ENDOCRINE DISORDERS EGRIFTA EMFLAZA DUCHENNE MUSCULAR DYSTROPHY EMFLAZA ENBREL INFLAMMATORY CONDITIONS ENBREL ENDARI SICKLE CELL DISEASE ENDARI ENTYVIO INFLAMMATORY CONDITIONS ENTYVIO EPOGEN BLOOD CELL DEFICIENCY EPOGEN, PROCRIT ESBRIET RESPIRATORY CONDITIONS ESBRIET EUFLEXXA OSTEOARTHRITIS HYALURONIC ACID DERIVATIVES EXTAVIA MULTIPLE SCLEROSIS BETASERON, EXTAVIA EYLEA EYE CONDITIONS MACULAR DEGENERATION FABIOR SKIN CONDITIONS TOPICAL TAZAROTENE PRODUCTS FASENRA ASTHMA SPECIALTY FASENRA FIRAZYR FIRAZYR FIRST-TESTOSTERONE ENDOCRINE DISORDERS TOPICAL TESTOSTERONE FIRST-TESTOSTERONE MC ENDOCRINE DISORDERS TOPICAL TESTOSTERONE FLOLAN PULMONARY HYPERTENSION FLOLAN, VELETRI, REMODULIN FORTEO BONE CONDITIONS FORTEO FORTESTA ENDOCRINE DISORDERS TOPICAL TESTOSTERONE FULPHILA BLOOD CELL DEFICIENCY PEGFILGASTRIM GEL-ONE OSTEOARTHRITIS HYALURONIC ACID DERIVATIVES GELSYN-3 OSTEOARTHRITIS HYALURONIC ACID DERIVATIVES GENOTROPIN GROWTH DEFICIENCY GROWTH HORMONES GENVISC 850 OSTEOARTHRITIS HYALURONIC ACID DERIVATIVES GLASSIA GOCOVRI MENTAL/NEUROLOGICAL DISORDERS GOCOVRI GRANIX BLOOD CELL DEFICIENCY GRANIX GRASTEK ALLERGIES GRASTEK, ORALAIR HAEGARDA HEREDITARY ANGIOEDEMA HAEGARDA
3 HEMLIBRA HEMOPHILIA HEMLIBRA HETLIOZ SLEEP DISORDERS HETLIOZ HUMATROPE ENDOCRINE DISORDERS GROWTH HORMONES HUMIRA INFLAMMATORY CONDITIONS HUMIRA HYALGAN OSTEOARTHRITIS HYALURONIC ACID DERIVATIVES HYMOVIS OSTEOARTHRITIS HYALURONIC ACID DERIVATIVES ILARIS ILARIS ILUMYA INFLAMMATORY CONDITIONS ILUMYA INCRELEX ENDOCRINE DISORDERS INCRELEX INFLECTRA INFLAMMATORY CONDITIONS INFLECTRA/REMICADE/REFLEXIS INGREZZA MENTAL/NEUROLOGICAL DISORDERS INGREZZA IONAMIN WEIGHT LOSS WEIGHT LOSS DRUGS JYNARQUE KIDNEY DISEASE JYNARQUE KALBITOR KALBITOR KEVEYIS KEVEYIS KEVZARA INFLAMMATORY CONDITIONS KEVZARA KINERET INFLAMMATORY CONDITIONS KINERET KORLYM ENDOCRINE DISORDERS KORLYM KRYSTEXXA GOUT KRYSTEXXA KUVAN KUVAN LATANOPROST GLAUCOMA OPHTHALMIC PROSTAGLANDIN LEMTRADA MULTIPLE SCLEROSIS LEMTRADA LETAIRIS PULMONARY HYPERTENSION LETAIRIS, TRACLEER, OPSUMIT LEVITRA SEXUAL DISORDERS LEVITRA/STAXYN LIDOCAINE PATCH/LIDODERM PAIN - NARCOTIC LIDODERM LOVAZA HIGH BLOOD CHOLESTEROL LOVAZA, VASCEPA LUCENTIS EYE CONDITIONS MACULAR DEGENERATION LUMIGAN EYE CONDITIONS OPHTHALMIC PROSTAGLANDIN MACUGEN EYE CONDITIONS MACULAR DEGENERATION MAKENA HORMONAL SUPPLEMENTATION MAKENA MIRCERA BLOOD CELL DEFICIENCY MIRCERA MIRVASO TOPICAL GEL SKIN CONDITIONS MIRVASO, RHOFADE MONOVISC OSTEOARTHRITIS HYALURONIC ACID DERIVATIVES MULPLETA BLOOD CELL DEFICIENCY MULPLETA MUSE SEXUAL DISORDERS ALPROSTADIL PRODUCTS MYALEPT ENDOCRINE DISORDERS MYALEPT MYOBLOC NEUROMUSCULAR CONDITIONS/COSMETIC MYOBLOC NATPARA ENDOCRINE DISORDERS NATPARA NEULASTA BLOOD CELL DEFICIENCY PEGFILGASTRIM NEUPOGEN BLOOD CELL DEFICIENCY NEUPOGEN
4 NORDITROPIN GROWTH DEFICIENCY GROWTH HORMONES NORTHERA MENTAL/NEUROLOGICAL DISORDERS NORTHERA NPLATE BLOOD CELL DEFICIENCY NPLATE NUCALA ASTHMA SPECIALTY NUCALA NUTROPIN GROWTH DEFICIENCY GROWTH HORMONES NUTROPIN AQ GROWTH DEFICIENCY GROWTH HORMONES NUTROPIN AQ NUSPIN GROWTH DEFICIENCY GROWTH HORMONES NUVIGIL NARCOLEPSY NUVIGIL, PROVIGIL OCALIVA OCALIVA OCREVUS MULTIPLE SCLEROSIS OCREVUS ODACTRA ALLERGIES ODACTRA OFEV RESPIRATORY CONDITIONS OFEV OLUMIANT INFLAMMATORY CONDITIONS OLUMIANT OMNITROPE ENDOCRINE DISORDERS GROWTH HORMONES ONPATTRO MENTAL/NEUROLOGICAL DISORDERS ONPATTRO OPSUMIT PULMONARY HYPERTENSION LETAIRIS, TRACLEER, OPSUMIT ORALAIR ALLERGIES GRASTEK, ORALAIR ORENCIA INFLAMMATORY CONDITIONS ORENCIA ORENITRAM PULMONARY HYPERTENSION ORENITRAM ORTHOVISC OSTEOARTHRITIS HYALURONIC ACID DERIVATIVES OTEZLA INFLAMMATORY CONDITIONS OTEZLA PALYNZIQ PALYNZIQ PHENDIMETRAZINE WEIGHT LOSS WEIGHT LOSS DRUGS PHENTERMINE WEIGHT LOSS WEIGHT LOSS DRUGS PLEGRIDY MULTIPLE SCLEROSIS PLEGRIDY PROCRIT BLOOD CELL DEFICIENCY EPOGEN, PROCRIT PROLASTIN PROLASTIN C PROMACTA BLOOD CELL DEFICIENCY PROMACTA PROVIGIL NARCOLEPSY NUVIGIL, PROVIGIL QSYMIA WEIGHT LOSS WEIGHT LOSS DRUGS RAGWITEK ALLERGIES RAGWITEK REBIF MULTIPLE SCLEROSIS REBIF REGIMEX WEIGHT LOSS WEIGHT LOSS DRUGS REMICADE INFLAMMATORY CONDITIONS INFLECTRA/REMICADE/REFLEXIS REMODULIN PULMONARY HYPERTENSION FLOLAN, VELETRI, REMODULIN RENFLEXIS INFLAMMATORY CONDITIONS INFLECTRA/REMICADE/REFLEXIS RESCULA EYE CONDITIONS OPHTHALMIC PROSTAGLANDIN RESTASIS EYE CONDITIONS RESTASIS RETACRIT BLOOD CELL DEFICIENCY EPOGEN, PROCRIT RETIN-A SKIN CONDITIONS TOPICAL TRETINOIN RETIN-A MICRO SKIN CONDITIONS TOPICAL TRETINOIN REVATIO PULMONARY HYPERTENSION PDE-5 INHIBITORS FOR PAH RHOFADE CREAM SKIN CONDITIONS MIRVASO, RHOFADE RITUXAN INFLAMMATORY CONDITIONS RITUXAN
5 RUCONEST HEREDITARY ANGIOEDEMA RUCONEST SAIZEN ENDOCRINE DISORDERS GROWTH HORMONES SAMSCA ENDOCRINE DISORDERS SAMSCA SAXENDA WEIGHT LOSS WEIGHT LOSS DRUGS SEROSTIM ENDOCRINE DISORDERS GROWTH HORMONES SIGNIFOR ENDOCRINE DISORDERS SIGNIFOR SILIQ INFLAMMATORY CONDITIONS SILIQ SIMPONI INFLAMMATORY CONDITIONS SIMPONI SIMPONI ARIA INFLAMMATORY CONDITIONS SIMPONI SOLARAZE SKIN CONDITIONS SOLARAZE SOLIRIS BLOOD DISORDERS SOLIRIS STAXYN SEXUAL DISORDERS LEVITRA/STAXYN STELARA INFLAMMATORY CONDITIONS STELARA STENDRA SEXUAL DISORDERS STENDRA STRIANT ENDOCRINE DISORDERS TOPICAL TESTOSTERONE SUPARTX FX OSTEOARTHRITIS HYALURONIC ACID DERIVATIVES SUPARTZ OSTEOARTHRITIS HYALURONIC ACID DERIVATIVES SUPRENZA WEIGHT LOSS WEIGHT LOSS DRUGS SYMLIN DIABETES SYMLIN SYNVISC OSTEOARTHRITIS HYALURONIC ACID DERIVATIVES SYNVISC-ONE OSTEOARTHRITIS HYALURONIC ACID DERIVATIVES TAKHZYRO HEREDITARY ANGIOEDEMA TAKHZYRO TALTZ INFLAMMATORY CONDITIONS TALTZ TANZEUM DIABETES GLP-1 AGONISTS TAVALISSE BLOOD CELL DEFICIENCY TAVALISSE TAZAROTENE SKIN CONDITIONS TOPICAL TAZAROTENE PRODUCTS TAZORAC SKIN CONDITIONS TOPICAL TAZAROTENE PRODUCTS TENUATE WEIGHT LOSS WEIGHT LOSS DRUGS TESTIM ENDOCRINE DISORDERS TOPICAL TESTOSTERONE TESTOPEL ENDOCRINE DISORDERS INJECTABLE TESTOSTERONE TESTOSTERONE CYPIONATE ENDOCRINE DISORDERS INJECTABLE TESTOSTERONE TESTOSTERONE ENANTHATE ENDOCRINE DISORDERS INJECTABLE TESTOSTERONE TEV-TROPIN GROWTH HORMONES TRACLEER PULMONARY HYPERTENSION LETAIRIS, TRACLEER, OPSUMIT TRAVATAN EYE CONDITIONS OPHTHALMIC PROSTAGLANDIN TRAVATAN Z EYE CONDITIONS OPHTHALMIC PROSTAGLANDIN TREMFYA INFLAMMATORY CONDITIONS TREMFYA TRETIN X SKIN CONDITIONS TOPICAL TRETINOIN TRETINOIN TOPICAL PRODUCTS SKIN CONDITIONS TOPICAL TRETINOIN TRULICITY DIABETES GLP-1 AGONISTS TYMLOS BONE CONDITIONS TYMLOS TYSABRI MULTIPLE SCLEROSIS TYSABRI TYVASO PULMONARY HYPERTENSION TYVASO, VENTAVIS
6 UPTRAVI PULMONARY HYPERTENSION UPTRAVI VASCEPA HIGH BLOOD CHOLESTEROL LOVAZA, VASCEPA VELETRI PULMONARY HYPERTENSION FLOLAN, VELETRI, REMODULIN VELTIN SKIN CONDITIONS TOPICAL TRETINOIN VENTAVIS PULMONARY HYPERTENSION TYVASO, VENTAVIS VIAGRA SEXUAL DISORDERS VIAGRA VICTOZA DIABETES GLP-1 AGONISTS XALATAN EYE CONDITIONS OPHTHALMIC PROSTAGLANDIN XELJANZ INFLAMMATORY CONDITIONS XELJANZ XENAZINE MENTAL/NEUROLOGICAL DISORDERS XENAZINE XENICAL WEIGHT LOSS WEIGHT LOSS DRUGS XEOMIN MENTAL/NEUROLOGICAL DISORDERS XEOMIN XERMELO GASTROINTESTINAL XERMELO XIIDRA EYE CONDITIONS XIIDRA XOLAIR ASTHMA SPECIALTY XOLAIR ZARXIO BLOOD CELL DEFICIENCY ZARXIO ZEMAIRA ZIANA SKIN CONDITIONS TOPICAL TRETINOIN ZINBRYTA MULTIPLE SCLEROSIS ZINBRYTA ZIOPTAN EYE CONDITIONS OPHTHALMIC PROSTAGLANDIN ZOMACTON ENDOCRINE DISORDERS GROWTH HORMONES ZORBTIVE ENDOCRINE DISORDERS GROWTH HORMONES ZOVIRAX SKIN CONDITIONS ZOVIRAX
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