Prior Authorization List

Transcription

1 Certain medications require prior authorization, which means approval is needed before the prescription can be filled. If approval is not received, the drug may not be covered. The following prescription drugs require PRIOR AUTHORIZATION: Prior Authorization List Angioedema Blood Cancer Trade Name: BERINERT, CINRYZE, FIRAZYR Blood Cell Stimulation Trade Name: ARANESP ALBUMIN FREE, EPOGEN, MOZOBIL, OMONTYS, PROCRIT Antineoplastic Trade Name: ACTIMMUNE, AFINITOR, CAPRELSA, ERIVEDGE, HYCAMTIN, INLYTA, JAKAFI, NEXAVAR, REVLIMID, SPRYCEL, SUTENT, TARCEVA, TASIGNA, TYKERB, VANDETANIB, VOTRIENT, XALKORI, ZELBORAF, ZOLINZA, ZYTIGA Cardiovascular / Heart Anti-anginal Agents Trade Name: NITROMIST Antihypertensive Combinations / Miscellaneous Trade Name: AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM, AZOR, CADUET, EXFORGE, EXFORGE HCT, NEXICLON XR, TRIBENZOR, TWYNSTA Central Nervous System Trade Name: CUVPOSA, MODAFINIL, NUVIGIL, PROVIGIL, XYREM Cryopyrin Associated Periodic Syndromes Trade Name: ARCALYST Cushing's Syndrome Cystic Fibrosis Dermatology Trade Name: KORLYM Trade Name: KALYDECO Psoriasis Products Trade Name: SORILUX, TACLONEX SCALP Topical / Oral Acne Products Trade Name: MINOCYCLINE HCL ER, SOLODYN, TRETIN-X, ZIANA Topical / Oral Steroids Endocrine Eye PKU Trade Name: DESOWEN LOTION/CETAPHIL CREAM, HALONATE, ULTRAVATE PAC Trade Name: KUVAN Antiinfectives Trade Name: ZYMAXID Growth Hormone / Factors Hepatitis B Hepatitis C HIV Trade Name: GENOTROPIN, HUMATROPE, INCRELEX, NUTROPIN, NUTROPIN AQ, OMNITROPE, SAIZEN, SEROSTIM, SOMAVERT, TEV-TROPIN, ZORBTIVE Trade Name: BARACLUDE, EPIVIR HBV, HEPSERA, TYZEKA Trade Name: COPEGUS, INCIVEK, INFERGEN, PEG-INTRON, PEGASYS, RIBASPHERE, RIBAVIRIN, SYLATRON, VICTRELIS Trade Name: EGRIFTA Huntington's Chorea Hyperammonemia Trade Name: XENAZINE Trade Name: CARBAGLU Idiopathic Thrombocytopenia Trade Name: PROMACTA Inborn Errors of Metabolism Infantile Spasms Infections Antibiotics Trade Name: ORFADIN, ZAVESCA Trade Name: SABRIL Trade Name: MOXATAG, ZYVOX Antifungal Drugs (oral) Trade Name: LAMISIL Antiviral Drugs Malaria Trade Name: XERESE Trade Name: QUALAQUIN Inflammatory Bowel Intranasal Trade Name: CIMZIA, HUMIRA PEN, MESALAMINE, ROWASA Steroids / Antihistamines / Miscellaneous Men's Health Trade Name: DYMISTA BPH Agents (prostate) Mental Health Trade Name: JALYN Antidepressants Trade Name: PRISTIQ Antipsychosis Trade Name: INVEGA 1 (Rev. 04/01/13)

2 Certain medications require prior authorization, which means approval is needed before the prescription can be filled. If approval is not received, the drug may not be covered. The following prescription drugs require PRIOR AUTHORIZATION: Prior Authorization List Multiple Sclerosis Trade Name: ACTHAR HP, AMPYRA, EXTAVIA, GILENYA Osteoporosis Trade Name: FORTEO Pain / Inflammation Muscle Relaxants NSAIDs Trade Name: AMRIX, CARISOPRODOL, CYCLOBENZAPRINE COMFORT PAC, FEXMID, LORZONE, SOMA Trade Name: SPRIX Pain Relievers Narcotic Trade Name: ABSTRAL, ACTIQ, FENTANYL CITRATE ORAL TRANSMUCOSAL, FENTORA, LAZANDA, ONSOLIS, SUBSYS Post-Herpetic Neuralgia Trade Name: GRALISE Pseudobulbar Affect Trade Name: NUEDEXTA Pulmonary Arterial Hypertension Trade Name: ADCIRCA, LETAIRIS, REVATIO, TRACLEER, TYVASO STARTER Rheumatoid Arthritis Trade Name: ENBREL, HUMIRA, KINERET, ORENCIA, SIMPONI Weight Management Anorexiants Trade Name: SUPRENZA, XENICAL Women's Health Fertility Drugs Trade Name: BRAVELLE, CETROTIDE, CHORIONIC GONADOTROPIN, ENDOMETRIN, FOLLISTIM AQ, GANIRELIX ACETATE, GONAL-F, LEUPROLIDE ACETATE, MENOPUR, NOVAREL, OVIDREL, PREGNYL W/DILUENT BENZYL ALCOHOL/ NACL, REPRONEX 2 (Rev. 04/01/13)

3 Alzheimer's ARICEPT 23MG Required Prerequisite Drug(s): Aricept 10mg Asthma Inhaled Beta Agonists/ Inhaled Respiratory Drugs DALIRESP Required Prerequisite Drug(s): Inhaled corticosteroid or long acting beta agonist Attention Deficit Disorder ADDERALL XR, CONCERTA, DAYTRANA, FOCALIN XR, METADATE CD, METHLPHENIDATE HCL ER, RITALIN LA, STRATTERA, VYVANSE Required Prerequisite Drug(s): TWO of the following: Amphetamine/Dextroamphetamine ER (Adderall XR), Methylphenidate LA (Ritalin LA), Methylphenidate CD (Metadate CD), Methylphenidate SR (Ritalin SR) INTUNIV, KAPVAY Required Prerequisite Drug(s): Any long acting stimulant Blood Blood Cell Stimulation ARANESP Required Prerequisite Drug(s): Epogen or Procrit Cardiovascular / Heart Angiotensin II Receptor Blockers ATACAND, BENICAR, COZAAR, EDARBI, EDARBYCLOR, MICARDIS, TEVETEN Required Prerequisite Drug(s): Losartan, Diovan or Avapro Antihyperlipidemics LIVALO Required Prerequisite Drug(s): atorvastatin, lovastatin (GT), pravastatin (GT), or simvastatin (GT) AND Crestor ADVICOR, ALTOPREV, CRESTOR (5mg,10mg,20mg only), LESCOL, LESCOL XL, LIPITOR, MEVACOR, PRAVACHOL, SIMCOR, ZOCOR Required Prerequisite Drug(s): atorvastatin, lovastatin (GT), pravastatin (GT), or simvastatin (GT) VYTORIN Required Prerequisite Drug(s): simvastatin (GT) and Crestor Antihypertensive Combinations / Miscellaneous AMTURNIDE, TEKAMLO, TEKTURNA, TEKTURNA HCT Required Prerequisite Drug(s): ACE inhibitor or ARB and one other antihypertensive medication ATACAND HCT, BENICAR HCT, HYZAAR, MICARDIS HCT, TEVETEN HCT Required Prerequisite Drug(s): Losartan/HCTZ, Diovan HCT or Avalide Beta Blockers (high blood pressure) BYSTOLIC Required Prerequisite Drug(s): Two of the following beta blockers: Atenolol, Propranolol, Bisoprolol, Carvedilol, Pindolol, Timolol, Nadolol, Betaxolol, Metoprolol, Labetalol, Acebutolol COREG CR Required Prerequisite Drug(s): carvedilol Dermatology Psoriasis Products TACLONEX Required Prerequisite Drug(s): One of the following high potency generic topical steroids if written by dermatologist; and two of the following high potency steroids if written by another specialty: amcinonide, augmented betamethasone, betamethasone, clobetasol, desoximetasone, diflor Topical / Oral Acne Products ACZONE Required Prerequisite Drug(s): benzoyl peroxide and a topical retinoid CLEOCIN-T, CLINDAGEL, EVOCLIN Required Prerequisite Drug(s): topical clindamycin and tretinoin DIFFERIN LOTION Required Prerequisite Drug(s): Differin Cream/Gel and a topical retinoid ORACEA Required Prerequisite Drug(s): doxycycline and minocycline ZACLIR CLEANSING Required Prerequisite Drug(s): benzoyl peroxide and tretinoin Topical / Oral Steroids CLODERM, CORDRAN, DESONATE, HALOG, KENALOG SPRAY, LOCOID LIPOCREAM, LUXIQ, OLUX, OLUX-E, PANDEL, TRIANEX, VERDESO topical steroids: aclometasone, amcinonide, betamethasone, clobetasol, desonide, desoximetasone, diflorasone, fluocinolone, fluocinonide-e, fluticasone, halobetasol, hydrocortisone 2.5%, hydrocortisone valerate, hydrocortisone VANOS topical steroids: aclometasone, amcinonide, betamethasone, clobetasol, desonide, desoximetasone, diflorasone, fluocinolone, fluocinonide-e, fluticasone, halobetasol, hydrocortisone 2.5%, hydrocortisone valerate, hydrocortisone Topical Antibiotics ALTABAX, BACTROBAN Required Prerequisite Drug(s): topical mupirocin METROGEL, NORITATE Required Prerequisite Drug(s): topical metronidazole Topical Antifungals ERTACZO, EXTINA, LOPROX, MENTAX, NAFTIN, NIZORAL, OXISTAT, XOLEGEL topicals: ciclopirox, econazole, ketoconazole, nystatin Diabetes KOMBIGLYZE XR, ONGLYZA Required Prerequisite Drug(s): Januvia, Janumet or Tradjenta 3 (Rev. 04/01/13)

4 Eye Glaucoma LUMIGAN Required Prerequisite Drug(s): latanoprost TRAVATAN Z, XALATAN, ZIOPTAN Required Prerequisite Drug(s): latanoprost and Lumigan Fibromyalgia CYMBALTA Required Prerequisite Drug(s): Approved when given for a diagnosis of diabetic peripheral neuropathy or fibromyalgia Gout ULORIC Required Prerequisite Drug(s): allopurinol Growth Hormone GENOTROPIN, HUMATROPE, NUTROPIN, NUTROPIN AQ, SAIZEN, TEV-TROPIN Required Prerequisite Drug(s): omnitrope Hepatitis C PEG-INTRON Required Prerequisite Drug(s): Pegasys Immune System AZASAN Required Prerequisite Drug(s): azathioprine MYFORTIC Required Prerequisite Drug(s): mycophenolate Infections Antibiotics Intranasal DIFICID Required Prerequisite Drug(s): vancomycin or vancocin - bypassed for infectious disease DORYX Required Prerequisite Drug(s): doxycycline and minocycline Steroids / Antihistamines / Miscellaneous BECONASE AQ, FLONASE, NASACORT AQ, QNASL, RHINOCORT AQUA, VERAMYST Required Prerequisite Drug(s): flunisolide or fluticasone and Nasonex and Omnaris OMNARIS, ZETONNA Required Prerequisite Drug(s): flunisolide or fluticasone and Nasonex ASTELIN, ASTEPRO, PATANASE Required Prerequisite Drug(s): azelastine Men's Health BPH Agents AVODART Required Prerequisite Drug(s): finasteride FLOMAX, RAPAFLO, UROXATRAL Required Prerequisite Drug(s): tamsulosin Mental Health Antidepressants APLENZIN, CELEXA, EFFEXOR XR, EMSAM, FORFIVO XL, LEXAPRO, LUVOX CR, OLEPTRO, PAXIL, PAXIL CR, PEXEVA, PROZAC, PROZAC WEEKLY, SARAFEM, VIIBRYD, WELLBUTRIN, WELLBUTRIN SR, WELLBUTRIN XL, ZOLOFT Required Prerequisite Drug(s): Two of the following: mirtazapine (GT), citalopram (GT), fluoxetine (GT), paroxetine (GT), sertraline, venlafaxine or bupropion (GT) (Trial of one if prescribed by a psychiatrist) Antipsychosis FANAPT, LATUDA, SAPHRIS Required Prerequisite Drug(s): Two of the following: Invega, risperidone Seroquel XR, olanzapine, Abilify, Geodon ABILIFY, ABILIFY DISCMELT, SEROQUEL XR Required Prerequisite Drug(s): For Diagnosis of depression (bypass for psychiatrist): Two different antidepressants and a trial of one proven augmentation therapy (lithium, buspirone, thyroid, bupropion) in combin Migraine Migraine TREXIMET Required Prerequisite Drug(s): Imitrex 100mg and one of the following: Axert, Relpax, Frova, Amerge, Maxalt, Maxalt MLT, Zomig (Only trial of Imitrex 100mg when prescribed by neurologist) Sedatives / Hypnotics / Anxiety AMBIEN, AMBIEN CR, EDLUAR, INTERMEZZO, LUNESTA, ROZEREM, SILENOR, SONATA, ZOLPIMIST Required Prerequisite Drug(s): zolpidem CAMBIA Required Prerequisite Drug(s): Perscribed by Neurologist AMERGE, MAXALT, MAXALT-MLT Required Prerequisite Drug(s): Sumatriptan ALSUMA, AXERT, FROVA, IMITREX, RELPAX, SUMAVEL DOSEPRO, ZOMIG, ZOMIG ZMT Required Prerequisite Drug(s): Sumatriptan and Maxalt or Maxalt MLT Osteoporosis ACTONEL, ATELVIA BINOSTO BONIVA, FOSAMAX FOSAMAX PLUS D Pain / Inflammation Muscle Relaxants SKELAXIN muscle relaxants: carisoprodol, baclofen, tizanidine, methocarbamol, orphenadrine, cyclobenzaprine 4 (Rev. 04/01/13)

5 NSAIDs ANAPROX, ANAPROX DS, ARTHROTEC 75, CATAFLAM, CELEBREX, DAYPRO, DUEXIS, FELDENE, FLECTOR, INDOCIN, MOBIC, NALFON, NAPRELAN, NAPROSYN, PENNSAID, PONSTEL, VIMOVO, VOLTAREN- XR, ZIPSOR Required Prerequisite Drug(s): THREE different generic NSAIDs (Examples: diclofenac, ibuprofen, indomethacin, ketoprofen, meloxicam, nabumetone, naproxen sodium, piroxicam, salsalate, sulindac) one of which must be meloxicam Pain Relievers NEXIUM, ZEGERID Required Prerequisite Drug(s): omeprazole 40mg (GT) ACIPHEX, PREVACID, PRILOSEC, PROTONIX Required Prerequisite Drug(s): omeprazole 40mg (GT) and lansoprazole (GT) Women's Health Fertility Drugs FOLLISTIM Required Prerequisite Drug(s): Gonal-F Narcotic BUTRANS, DURAGESIC, EXALGO, FENTANYL, OXYCONTIN Required Prerequisite Drug(s): morphine ER, oramorph SR, Avinza or Kadian (unless prescribed by Oncologists, Hematologist, Palliative Care or Pain Specialist) Parkinson's Disease MIRAPEX ER Required Prerequisite Drug(s): pramipexole REQUIP XL Required Prerequisite Drug(s): ropinirole ZELAPAR Required Prerequisite Drug(s): Trial of one other Parkinson s disease medication (such as carbidopa/levodopa,ropinirole, selegiline, Mirapex) Pulmonary Arterial Hypertension REVATIO Required Prerequisite Drug(s): Adcirca Restless Leg Syndrome HORIZANT Required Prerequisite Drug(s): ropinirole or pramipexole AND Gabapentin Seizure / Pain LAMICTAL ODT, LAMICTAL XR Required Prerequisite Drug(s): lamotrigine Stomach / Intestinal Antiemetics (for nausea) ANZEMET, ZOFRAN, ZUPLENZ Required Prerequisite Drug(s): ondansetron SANCUSO Required Prerequisite Drug(s): ondansetron and granisetron Antispasmodic Drugs DETROL, DETROL LA, DITROPAN XL, ENABLEX, GELNIQUE, MYRBETRIQ, OXYTROL, TOVIAZ Required Prerequisite Drug(s): oxybutynin or oxybutynin ER and Vesicare Ulcer / Heartburn DEXILANT Required Prerequisite Drug(s): omeprazole (GT) or lansoprazole (GT) METOZOLV ODT Required Prerequisite Drug(s): metoclopramide 5 (Rev. 04/01/13)