Prior Authorization Drug List This is a list of drugs that require Prior Authorization before coverage is provided. If you are prescribed a medication that requires Prior Authorization, your physician will need to contact PreferredOne at the number provided on your ID card to request a prior authorization review. PreferredOne will review the request to determine if the medication use is consistent with your benefit coverage and will notify you and your physician of the coverage determination. Without prior authorization approval, these drugs may not be covered by your pharmacy benefit. This list is subject to change throughout the year. The presence of a drug on this list does not guarantee coverage and not all drugs included on this list may be covered by your pharmacy benefit plan. Coverage of medications is determined your benefit plan. Your plan may require prior authorization for additional medications not included on this list. Drug Class ANALGESICS ABSTRAL acetaminophen-codeine ARYMO ER aspirin-caffeine-dihydrocodein buprenorphine butalb-caff-acetaminoph-codein butorphanol tartrate carisoprodol compound-codeine codeine sulfate DEMEROL DOLOPHINE HCL EMBEDA EXALGO fentanyl citrate acetamin-caff-dihydrocodeine ACTIQ ascomp with codeine BELBUCA butalb-acetaminoph-caff-codein butalbital compound-codeine BUTRANS carisoprodol-aspirin-codeine CONZIP DILAUDID DURAGESIC endocet fentanyl FENTORA FIORICET WITH CODEINE FIORINAL WITH CODEINE #3 HYCET hydrocodone-ibuprofen hydromorphone hcl ibudone hydrocodone-acetaminophen hydromorphone er HYSINGLA ER KADIAN
ANALGESICS -- Continued LAZANDA lorcet hd lortab methadone hcl morphine sulfate er NORCO NUCYNTA ER lorcet lorcet plus meperidine hcl morphine sulfate MS CONTIN NUCYNTA OPANA OPANA ER oxycodone hcl oxycodone hcl-aspirin oxycodone-acetaminophen oxymorphone hcl pentazocine-naloxone hcl primlev ROXICODONE SUBSYS tramadol hcl tramadol hcl-acetaminophen TYLENOL-CODEINE NO.3 OXAYDO oxycodone hcl er oxycodone hcl-ibuprofen OXYCONTIN oxymorphone hcl er PERCOCET REPREXAIN ROXYBOND SYNALGOS-DC tramadol hcl er TREZIX TYLENOL-CODEINE NO.4 ULTRACET ULTRAM verdrocet vicodin vicodin es vicodin hp XODOL 10-300 XODOL 5-300 ANTIBACTERIALS ANTICONVULSANTS XODOL 7.5-300 xylon 10 ZOHYDRO ER ARIKAYCE clobazam ONFI vigabatrin XTAMPZA ER ZAMICET XIFAXAN EPIDIOLEX SABRIL vigadrone
ANTIEMETICS ANTIFUNGALS ANTIMIGRAINE AGENTS ANTINEOPLASTICS dronabinol SYNDROS itraconazole SPORANOX AIMOVIG AUTOINJECTOR AJOVY AFINITOR ALECENSA bexarotene BRAFTOVI CALQUENCE CAPRELSA COPIKTRA ERIVEDGE FARYDAK GLEEVEC ICLUSIG imatinib mesylate INLYTA JAKAFI KISQALI FEMARA CO-PACK LONSURF LYNPARZA MEKTOVI NEXAVAR ODOMZO REVLIMID RUBRACA SPRYCEL SUTENT SYNRIBO MARINOL ONMEL AIMOVIG AUTOINJECTOR (2 PACK) EMGALITY AFINITOR DISPERZ ALUNBRIG BOSULIF CABOMETYX capecitabine COMETRIQ COTELLIC ERLEADA GILOTRIF IBRANCE IDHIFA IMBRUVICA IRESSA KISQALI LENVIMA LORBRENA MEKINIST NERLYNX NINLARO POMALYST RITUXAN HYCELA RYDAPT STIVARGA SYLATRON TAFINLAR
ANTINEOPLASTICS -- Continued TAGRISSO TARCEVA TEMODAR THALOMID TYKERB VELCADE VENCLEXTA STARTING PACK VIZIMPRO XALKORI XTANDI ZEJULA ZOLINZA ZYKADIA TALZENNA TASIGNA temozolomide TIBSOVO VALCHLOR VENCLEXTA VERZENIO VOTRIENT XELODA YONSA ZELBORAF ZYDELIG ZYTIGA ANTIPARASITICS ANTIPARKINSON AGENTS ANTIPSYCHOTICS ANTIVIRALS albendazole DARAPRIM quinine sulfate APOKYN ADASUVE DAKLINZA HARVONI MAVYRET PEGASYS PEGINTRON PREVYMIS SOVALDI VIEKIRA PAK VOSEVI ALBENZA QUALAQUIN DUOPA NUPLAZID EPCLUSA INTRON A OLYSIO PEGASYS PROCLICK PEGINTRON REDIPEN SELZENTRY TECHNIVIE VIEKIRA XR ZEPATIER
BLOOD GLUCOSE REGULATORS Drug Class BLOOD GLUCOSE REGULATORS -- Continued AFREZZA chlorpropamide SYMLINPEN 120 SYMLINPEN 60 BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS ARANESP FULPHILA LEUKINE MOZOBIL NEULASTA NIVESTYM PROCRIT RETACRIT EPOGEN GRANIX MIRCERA MULPLETA NEUPOGEN NPLATE PROMACTA TAVALISSE CARDIOVASCULAR AGENTS ZARXIO CORLANOR KEVEYIS NORTHERA PRALUENT SYRINGE REPATHA SURECLICK simvastatin JUXTAPID KYNAMRO PRALUENT PEN REPATHA PUSHTRONEX REPATHA SYRINGE ZOCOR CENTRAL NERVOUS SYSTEM AGENTS ADDERALL ADZENYS ER amphetamine sulfate APTENSIO XR AUSTEDO AVONEX PEN CONCERTA COTEMPLA XR-ODT DAYTRANA DEXEDRINE dexmethylphenidate hcl er dextroamphetamine sulfate er dextroamphetamine-amphetamine ADDERALL XR ADZENYS XR-ODT AMPYRA AUBAGIO AVONEX BETASERON COPAXONE dalfampridine er DESOXYN dexmethylphenidate hcl dextroamphetamine sulfate dextroamphetamine-amphet er DYANAVEL XR
CENTRAL NERVOUS SYSTEM AGENTS -- Continued EVEKEO FOCALIN GILENYA glatopa INGREZZA metadate er METHYLIN methylphenidate er (la) methylphenidate hcl cd methylphenidate la NUEDEXTA PLEGRIDY PEN QUILLICHEW ER REBIF RILUTEK RITALIN TECFIDERA TIGLUTIK XENAZINE zenzedi ZINBRYTA EXTAVIA FOCALIN XR glatiramer acetate HORIZANT METADATE CD methamphetamine hcl methylphenidate er methylphenidate hcl methylphenidate hcl er (cd) MYDAYIS PLEGRIDY procentra QUILLIVANT XR REBIF REBIDOSE riluzole RITALIN LA tetrabenazine VYVANSE ZENZEDI ZENZEDI DERMATOLOGICAL AGENTS ABSORICA amnesteem AVITA COSENTYX (2 SYRINGES) COSENTYX PEN (2 PENS) DUPIXENT myorisan RETIN-A RETIN-A MICRO PUMP TALTZ AUTOINJECTOR TALTZ AUTOINJECTOR (3 PACK) adapalene ATRALIN claravis COSENTYX PEN COSENTYX SYRINGE isotretinoin REGRANEX RETIN-A MICRO STELARA TALTZ AUTOINJECTOR (2 PACK) TALTZ SYRINGE
DERMATOLOGICAL AGENTS -- Continued tretinoin zenatane ENZYME REPLACEMENT/MODIFIERS TALTZ SYRINGE (2 PACK) TREMFYA BRINEURA GALAFOLD miglustat ORFADIN PROCYSBI STRENSIQ TALTZ SYRINGE (3 PACK) TRETIN-X tretinoin microsphere CERDELGA KUVAN NITYR PALYNZIQ RAVICTI ZAVESCA GASTROINTESTINAL AGENTS GENITOURINARY AGENTS alosetron hcl GATTEX OCALIVA VIBERZI XERMELO CUPRIMINE CHOLBAM LOTRONEX RELISTOR XENICAL HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL) EMFLAZA KORLYM HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) chorionic gonadotropin HUMATROPE GENOTROPIN INCRELEX NORDITROPIN FLEXPRO NUTROPIN AQ OMNITROPE SAIZEN SEROSTIM NOVAREL NUTROPIN AQ NUSPIN PREGNYL SAIZEN-SAIZENPREP ZOMACTON ZORBTIVE HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) ANADROL-50 ANDRODERM ANDROGEL AVEED androxy AXIRON
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) -- Continued DEPO-TESTOSTERONE FORTESTA hydroxyprogesterone caproate METHITEST NATESTO oxandrolone testosterone testosterone enanthate XYOSTED HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) SENSIPAR MAKENA methyltestosterone OXANDRIN TESTIM testosterone cypionate VOGELXO HORMONAL AGENTS, SUPPRESSANT (PITUITARY) EGRIFTA FIRMAGON LUPANETA PACK LUPRON DEPOT-PED SANDOSTATIN SIGNIFOR SOMATULINE DEPOT SUPPRELIN LA TRIPTODUR ELIGARD leuprolide acetate LUPRON DEPOT octreotide acetate SANDOSTATIN LAR DEPOT SIGNIFOR LAR SOMAVERT TRELSTAR VANTAS IMMUNOLOGICAL AGENTS ACTEMRA BENLYSTA CUVITRU ENBREL MINI FIRAZYR GAMASTAN S-D GAMMAKED HAEGARDA HUMIRA HUMIRA PEN HUMIRA PEN PSORIASIS-UVEITIS ILARIS KALBITOR ARCALYST CIMZIA ENBREL ENBREL SURECLICK GAMASTAN GAMMAGARD LIQUID GAMUNEX-C HIZENTRA HUMIRA PEDIATRIC CROHN'S HUMIRA PEN CROHN-UC-HS STARTER HYQVIA ILUMYA KEVZARA
IMMUNOLOGICAL AGENTS -- Continued METABOLIC BONE DISEASE AGENTS KINERET ORENCIA OTEZLA RASUVO SIMPONI ARIA SYNAGIS VARIZIG XELJANZ XR FORTEO PROLIA OLUMIANT ORENCIA CLICKJECT OTREXUP SIMPONI STELARA TAKHZYRO XELJANZ ZORTRESS NATPARA TYMLOS XGEVA MISCELLANEOUS THERAPEUTIC AGENTS ADDYI BELVIQ benzphetamine hcl CETROTIDE diethylpropion hcl er EUFLEXXA GANIRELIX ACETATE adipex-p BELVIQ XR BRAVELLE diethylpropion hcl DUROLANE FOLLISTIM AQ gel-one GELSYN-3 genvisc 850 GONAL-F GONAL-F RFF REDI-JECT hydrocod-cpm-pseudoephedrine hydrocodone-homatropine mbr HYMOVIS MENOPUR MYALEPT NUCALA ORILISSA phendimetrazine tartrate phentermine hcl promethazine-codeine REGIMEX GONAL-F RFF HYALGAN hydrocodone-chlorpheniramne er hydromet lomaira MONOVISC MYOBLOC ODACTRA ORTHOVISC phendimetrazine tartrate er promethazine vc-codeine promethazine-phenyleph-codeine REZIRA
MISCELLANEOUS THERAPEUTIC AGENTS -- Continued SAXENDA SYNVISC TEGSEDI trivisc TUSSIONEX visco-3 XIAFLEX supartz fx SYNVISC-ONE THYROGEN tussigon TUZISTRA XR VITUZ XURIDEN OPHTHALMIC AGENTS ZUTRIPRO CYSTARAN RESTASIS XIIDRA LUXTURNA RESTASIS MULTIDOSE RESPIRATORY TRACT/PULMONARY AGENTS ADCIRCA CAYSTON ESBRIET GRASTEK LETAIRIS OPSUMIT ORENITRAM ER PULMOZYME REMODULIN sildenafil tadalafil 20 mg tablet (generic for adcirca) TYVASO TYVASO REFILL KIT UPTRAVI ADEMPAS DALIRESP FASENRA KALYDECO OFEV ORALAIR ORKAMBI RAGWITEK REVATIO SYMDEKO TRACLEER TYVASO INSTITUTIONAL START KIT TYVASO STARTER KIT VENTAVIS XOLAIR SKELETAL MUSCLE RELAXANTS BOTOX DYSPORT SLEEP DISORDER AGENTS XEOMIN armodafinil HETLIOZ flurazepam hcl modafinil
SLEEP DISORDER AGENTS -- Continued NUVIGIL THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES EXJADE JADENU PROVIGIL FERRIPROX JADENU SPRINKLE
PreferredOne Insurance Company Nondiscrimination Notice PreferredOne Insurance Company ( PIC ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PIC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PIC: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact a Grievance Specialist. If you believe that PIC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Grievance Specialist PreferredOne Insurance Company PO Box 59212 Minneapolis, MN 55459-0212 Phone: 1.800.940.5049 (TTY: 763.847.4013) Fax: 763.847.4010 Email: customerservice@preferredone.com You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a Grievance Specialist is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. NDR PIC LV (1/18)
PreferredOne Community Health Plan Nondiscrimination Notice PreferredOne Community Health Plan ( PCHP ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PCHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PCHP: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact a Grievance Specialist. If you believe that PCHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Grievance Specialist PreferredOne Community Health Plan PO Box 59052 Minneapolis, MN 55459-0052 Phone: 1.800.940.5049 (TTY: 763.847.4013) Fax: 763.847.4010 customerservice@preferredone.com You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a Grievance Specialist is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. NDR PCHP LV (1/18)