PRESCRIPTION DRUGS REQUIRING PRE-AUTHORIZATION List 1 ACNE THERAPY If covered person over 30 years of age approval by Liberty Health required RETIN A CR 0.01% 00897329 RETIN A CR 0.025% 00897310 RETIN A CR 0.05% 00443794 RETIN A CR 0.1% 00870021 RETIN A GEL 0.01% 00870013 RETIN A GEL 0.025% 00443816 RETIN_A CR 0.05% 00532665 RETIN_A CR 0.1% 00577278 RETIN_A GEL 0.01% 00577251 RETIN_A GEL 0.025% 00532673 RETIN A GEL 0.1% 02243914 RETISOL A CR 0.01% 02008688 RETISOL A CR 0.025% 02008696 RETISOL A CR 0.05% 02008718 RETISOL A CR FORTE 0.1% 02008726 STIEVA-A CR 0.01% 00657204 STIEVA-A CR 0.025% 00578576 STIEVA-A CR 0.05% 00518182 STIEVA-A FORTE CR 0.1% 00662348 STIEVA-A GEL 0.01% 00587958 STIEVA-A GEL 0.025% 00587966 STIEVA-A GEL 0.05% 00641863 STIEVA-A SOLN 0.025% 00578568 STIEVA-A SOLN 0.05% 00518174 STIEVAMYCIN FORTE GEL 01945262 STIEVAMYCIN GEL 01905112 STIEVAMYCIN MILD GEL 02015994 VIT A ACID CR 0.01% 01926497 VIT A ACID CR 0.025% 01926500 VIT A ACID CR 0.05% 01926519 VIT A ACID CR 0.1% 01926527 VIT A ACID GEL 0.025% 01926470 VIT A ACID GEL 0.05% 01926489 VIT A ACID GEL MILD 0.01% 01926462 VIT-A ACID CR 0.01% 00805505 VIT-A ACID CR 0.025% 00805513 VIT-A ACID CR 0.05% 00493333 VIT-A ACID CR 0.1% 00673110 VIT-A ACID GEL 0.025% 00673102 VIT-A ACID GEL 0.05% 00419001 1
ACNE THERAPY Cont d. If covered person over 30 years of age approval by Liberty Health required VIT-A ACID GEL MILD 0.01% 00590797 VITINOIN CR 0.025% 02125293 VITINOIN CR 0.05% 02125307 VITINOIN CR 0.1% 02125315 VITINOIN GEL 0.025% 02069598 AMYOTROPHIC LATERAL SCLEROSIS RILUTEK TAB 50MG 02242763 ATOPIC DERMATITIS PROTOPIC OINT 0.1% 02244148 PROTOPIC OINT 0.03% 02244149 BOTOX BOTOX INJECTION 01981501 CROHN S DISEASE REMICADE INJ IV 100MG/VL 02244016 COX-2 CELEBREX CAP 100MG 02233941 CELEBREX CAP 200MG 02239942 VIOXX SUSP 12.5MG/5ML 02241109 VIOXX TAB 12.5MG 02241107 VIOXX TAB 25MG 02241108 MOBICOX TAB 7.5MG 02242785 MOBICOX TAB 15MG 02242786 CYCLOSPORINE NEORAL CAP 10MG 02237671 NEORAL CAP 25MG 02150689 NEORAL CAP 50MG 02150662 NEORAL CAP 100MG 00950815 NEORAL CAP 100MG 02150670 NEORAL LIQ 02150697 NEORAL LIQ 100MG/ML 00950823 NEORAL_CAP 10MG 00950792 NEORAL_CAP 25MG 00950793 NEORAL_CAP 50MG 00950807 2
CYCLOSPORINE Cont. SANDIMMUNE AMP 50MG 00593257 SANDIMMUNE CAP 25MG 00755591 SANDIMMUNE CAP 50MG 01907182 SANDIMMUNE CAP 100MG 00755605 SANDIMMUNE LIQ 100MG/ML 00950556 SANDIMMUNE ORL SOLN 100MG 00593249 SANDIMMUNE_CAP 25MG 00950513 SANDIMMUNE_CAP 50MG 00950521 SANDIMMUNE_CAP 100MG 00950548 CYSTIC FIBROSIS COTAZYM CAP 300MG 00263818 COTAZYM CAP 65B 00456233 COTAZYM ECS 4 CAP 02181215 COTAZYM ECS 8 CAP 00502790 COTAZYM ECS 20 CAP 00821373 COTAZYM PDR 00405647 COTAZYM_ECS CAP 4 00848514 COTAZYM_ECS CAP 12 00838861 CREON 5 CAP 02239007 CREON 8 CAP 01985191 CREON 10 CAP 02200104 CREON 20 CAP 02239008 CREON 25 CAP 01985205 PANCREASE CAP 00591548 PANCREASE CAP MT 4 00789445 PANCREASE MT 10 CAP 00789437 PANCREASE MT 16 CAP 00789429 PANCREASE EC SR CAP 02242374 VIOKASE PDR 02230020 VIOKASE PDR (114G) 02043750 VIOKASE TAB 02230019 VIOKASE_PDR 00651672 VIOKASE_PDR (114GM) 01910493 VIOKASE_TAB 325MG 00651680 VIOKASE_TAB 325MG 01910507 VIOKASE TAB 16 02241933 VIOKASE TAB 325MG 02043742 3
CHRONIC HEPATITIS C PEG- INTRON INJ 50MCG/0.5ML 02242966 PEG-INTRON INJ 80MCG/0.5ML 02242967 PEG-INTRON INJ 120MCG/0.5ML 02242968 PEG-INTRON INJ 150MCG/0.5ML 02242969 RENAL DISEASE RENAGEL CAP 403MG 02241701 RENAGEL TAB 400MG 02244309 RENAGEL TAB 800MG 02244310 RHEUMATOID ARTHRITIS ENBREL INJ 25MG/VIAL 2242903 REMICADE INJ IV 100MG/VL 02244016 KINERET 02245913 TESTOSTERONE REPLACEMENT THERAPY ANDROGEL 25MG PER 2.5G GEL 02245345 ANDROGEL 50MG PER 5.0G GEL 02245346 ANDRODERM 12.2MG PATCH 02239653 ANDRODERM 24.3 MG PATCH 02245972 CHRONIC MYELOID LEUKEMIA GLEEVEC 02244725 PULMONARY ARTERIAL HYPERTENSION TRACLEER 62.5MG 02244981 TRACLEER 125MG 02244982 FLOLAN 0.5MG/VIAL 02230845 FLOLAN 1.5MG/VIAL 02230848 INJECTIBLE IRON PRODUCTS INFUFER 02221780 DEXIRON 02205963 4
MELANOMA MELACINE INJ 02241211 KIDNEY TRANSPLANT THERAPY RAPAMUNE ORAL SOLN 1MG/ML 02243237 ANTIBIOTICS ZYVOXAM TAB 600MG 02243684 AGE RELATED MACULAR DEGENERATION VISUDYNE INJ 15MG 02242367 VARICOSE VEIN/SCLEROSING AGENTS DEXTROJECT INJ 25% 00623563 ETHANOLAMINE OLEATE INJ 01955195 ETHANOLAMINE_OLEATE AMP 01923722 SALIJECT 00522538 SALIJECT INJ 570MG/ML 00623571 SCLERODEX INJ 00394785 SCLERODEX INJ 25% 00457108 SCLERODEX IV INJ 02020939 SCLERODINE INJ 3% 00336688 SCLERODINE INJ 60MG/ML 00592722 TROMBOJECT INJ 1% 00511234 TROMBOJECT INJ 3% 00511226 TROMBOVAR THERAPEX SOLN 1% 00363332 TROMBOVAR THERAPEX SOLN 3% 00363340 ANTI-EPILEPTIC DRUGS TRILEPTAL 150MG TABLETS 02242067 TRILEPTAL 300MG TABLETS 02242068 TRILEPTAL 600MG TABLETS 02242069 TRILEPTAL 600MG/ML ORAL SUSPENSION 02244673 5
ANTI-ANEMIC DRUGS (ANEMIA ASSOCIATED WITH CHRONIC KIDNEY DISEASE) LIBERTY HEALTH ARANESP PF SYRINGE 10MCG - 0.4ML 02246354 ARANESP PF SYRINGE 20MCG - 0.5ML 02246355 ARANESP PF SYRINGE 30MCG 0.3ML, 02246357 40MCG 0.4ML, 50MCG 0.5ML ARANESP PF SYRINGE 60MGC 0.3ML, 02246358 80MCG 0.4ML, 100MCG 0.5ML ARANESP PF SYRINGE 150MCG 0.3ML 02246360 CHRONIC LYMPHOCYTIC LEUKEMIA FLUDARA 10MG TABLET 02246226 ANTI-OBESITY XENICAL CAP 120MG 02240325 MERIDIA CAP 10MG 02243163 MERIDIA CAP 15MG 02243164 For Xenical and Meridia, the patient s physician must complete the Weight Loss Drug Therapy Authorization Form. ********************* 6
List 2 LIBERTY HEALTH ANTI NEOPLASTIC THERAPY FLUDARA INJ 50MG 01989537 CANCER DRUGS INTRON A 3M IU PDR 02223384 INTRON A 3M IU-0.5ML VIAL 02238674 INTRON A 5M IU PDR 02223392 INTRON A 5M IU-0.5ML VIAL 02238675 INTRON A 5M IU/ML 02223414 INTRON A 10M IU PDR 02223406 INTRON A 10M IU-1ML VIAL 09853995 INTRON A 18M IU M-DOSE PEN KIT 02240693 INTRON A 18M IU-3ML VIAL 09854045 INTRON A 18M IU-KIT 02231651 INTRON A 25M IU-2.5ML VIAL 09854053 INTRON A 30M IU M-DOSE PEN KIT 02240694 INTRON A 60M IU M-DOSE PEN KIT 02240695 INTRON-A 3M IU 00705896 INTRON-A 5M IU 00705918 INTRON-A 10M IU 00705926 INTRON-A 10M IU 00889067 ROFERON A PDR 3M IU 01911988 ROFERON A PDR 9M IU 01911996 ROFERON A PDR 18M IU 01912003 ROFERON A SOLN INJ 3M IU 02217015 ROFERON A SOLN INJ 4.5M IU 02217023 ROFERON A SOLN INJ 6M IU 02217031 ROFERON A SOLN INJ 9M IU 02217058 ROFERON A SOLN INJ 18M IU 02217066 ROFERON-A INJ 36M IU 00891002 ROFERON-A PDR 18M IU 00812471 ROFERON-A SOLN INJ 3M IU 00812501 ROFERON-A SOLN INJ 9M IU 02019914 ROFERON-A SOLN INJ 18M IU 00812498 STEROIDS DUE TO GROWTH HORMONE FAILURE NUTROPIN AQ INJ 10MG 02229722 NUTROPIN PDR 5MG 02216183 NUTROPIN PDR 10MG 02216191 PROTROPIN INJ 5MG 02204584 PROTROPIN INJ 10MG 02204576 PROTROPIN_INJ 5MG 01959263 PROTROPIN_INJ 10MG 01916742 SAIZEN PDR 5MG/VIAL 02237971 SAIZEN PDR 10 IU (3.3MG VIAL) 02215136 7
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