PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION

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Transcription:

Abstral fentanyl citrate oral tablet Controlled Dangerous substance Actemra tocilizumab Monoclonal antibody Acthar corticotropin Hormone Actimmune interferon gamma 1b Interferon Actiq fentanyl citrate OTFC Controlled Dangerous substance Adcirca tadalafil Pulmonary Vasodilator Advocate Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Ampyra dalfampridine Multiple Sclerosis Agent Androderm testosterone Topical Testosterone Drug Androgel testosterone Topical Testosterone Drug Aranesp darbepoetin alfa Red Blood Cell Progenitor Atralin tretinoin Anti Acne Avinza morphine sulfate ER Controlled Dangerous substance Avita tretinoin Anti Acne Axiron testosterone Topical Testosterone Drug Benlysta Belimumab Lupus Berinert C1 esterase inhibitor Hereditary Angioedema Boniva Syringe ibandronate Osteoporosis/Bones Botox onabotulinumtoxina Specialty Drug Bydureon exenatide ER Incretin Mimetic Agent Byetta exenatide Incretin Mimetic Agent Carimune NF immune globulin-intravenous Intravenous Immune Globulin Cimzia certolizumab pegol Anti Tumor Necrosis Factor Drug Cinryze C1 esterase inhibitor Hereditary Angioedema Dysport onabotulinumtoxina Specialty Drug Embeda morphine sulfate/naltrexone ER Controlled Dangerous substance Enbrel etanercept Anti Tumor Necrosis Factor Drug Euflexxa sodium hyaluronate Hyaluronic Acid Derivatives For Joint Injection Epogen epoetin alfa Red Blood Cell Progenitor Exalgo hydromorphone ER Controlled Dangerous substance Fast Take Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Fentora fentanyl buccal tablet Controlled Dangerous Substances Firazyr icatibant Hereditary Angioedema

Flolan epoprostenol sodium Pulmonary Vasodilator Flebogamma immune globulin-intravenous Intravenous Immune Globulin Forteo teriparatide Osteoporosis/Bones Fortesta testosterone Topical Testosterone Drug FreeStyle Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Gamimune N immune globulin-intravenous Intravenous Immune Globulin Gammagard S/D immune globulin-intravenous Intravenous Immune Globulin Gammaked immune globulin-intravenous Intravenous Immune Globulin Gammaplex immune globulin-intravenous Intravenous Immune Globulin Gammar-P IV immune globulin-intravenous Intravenous Immune Globulin Gamunex immune globulin-intravenous Intravenous Immune Globulin Gamunex-C immune globulinintravenous/subcutaneous Genotropin somatropin Growth Hormone Intravenous/Subcutaneous Immune Globulin Gilenya fingolimod Multiple Sclerosis Agent Glucose Test Strip Blood Glucose Test Strips Blood Glucose Test Strips Hizentra immune globulin-subcutaneous Subcutaneous Immune Globulin Humatrope somatropin Growth Hormone Humira adalimumab Monoclonal Antibody Hyalgan sodium hyaluronate Hyaluronic Acid Derivative For Joint Injection Incivek Hep C Protease Inihibitors Hepatitis C Increlex mecasermin Growth Hormone Infergen interferon alfacon-1 Interferon Intron A interferon alfa-2b Interferon Iveegam EN immune globulin-intravenous Intravenous Immune Globulin IVIG or IGIV immune globulin-intravenous Intravenous Immune Globulin Kadian morphine sulfate ER Controlled Dangerous substance

Kalbitor ecallantide Hereditary Angioedema Kalydeco ivacaftor Cystic Fibrosis Krystexxa Pegloticase Gout Lazanda Nasal Spray Fentanyl citrate Controlled Dangerous substance Letairis ambrisentan Pulmonary Vasodilator Liberty Test Strip Blood Glucose Test Strips Blood Glucose Test Strips Lidoderm lidocaine Topical Anesthetic Lovaza omega-3-acid ethyl esters Omega-3 Fatty Acid Lumigan bimatoprost Anti Glaucoma Makena hydroxyprogesterone Hormone MS Contin morphine sulfate ER Controlled Dangerous substance Myobloc rimabotulinumtoxinb Specialty Drug Norditropin somatropin Growth Hormone Nucynta tapentadol Controlled Dangerous substance Nutropin somatropin Growth Hormone Nutropin AQ somatropin Growth Hormone Nuvigil armodafinil CNS Stimulant Octagam immune globulin-intravenous Intravenous Immune Globulin Omnitrope somatropin Growth Hormone Omontys peginesatide Red Blood Cell Progenitor One Touch Test Strips Blood Glucose Test Strips Blood Glucose Test Strips One Touch Ultra Test Blood Glucose Test Strips Blood Glucose Test Strips Strips Onsolis fentanyl soluble film Controlled Dangerous Substances Opana ER oxymorphone ER Controlled Dangerous substance Oramorph SR morphine sulfate SR Controlled Dangerous substance Orencia abatacept Selective Co-Stimulation Modulator For RA Orthovisc high molecular weight hyaluronan Hyaluronic Acid Derivative For Joint Injection Oxycontin- quantities greater than 90 per month oxycodone extended release Controlled Dangerous Substances Panglobulin NF immune globulin-intravenous Intravenous Immune Globulin Pegasys peginterferon alfa-2a Interferon Peg-Intron peginterferon alfa-2b Interferon Precision SOF-TACT Test Blood Glucose Test Strips Blood Glucose Test Strips Strips Precision Xtra Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Polygam S/D immune globulin-intravenous Intravenous Immune Globulin

Privigen immune globulin-intravenous Intravenous Immune Globulin Prestige Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Procrit epoetin alfa Red Blood Cell Progenitor Prodigy Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Prolia denosumab Osteoporosis/Bones Provenge sipuleucel-t Oncology Provigil modafinil CNS Stimulant Qutenza capsaicin Topical Anesthetic Reclast zoledronic acid Osteoporosis/Bones Relion Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Remicade infliximab Monoclonal Antibody Remodulin treprostinil sodium Pulmonary Vasodilator Retin-A tretinoin Anti Acne Retin-A Micro tretinoin Anti Acne Revatio sildenafil citrate Pulmonary Vasodilator Rituxan rituximab Monoclonal Antibody Roferon-A interferon alpha-2a Interferon Sabril vigabatrin Anticonvulsant Saizen somatropin Growth Hormone Seroquel quetiapine Anti Psychotic Serostim somatropin Growth Hormone Simponi golimumab Anti Tumor Necrosis Factor Drug Stelara ustekinumab Anti Tumor Necrosis Factor Drug Striant testosterone Topical Testosterone Drug Subsys fentanyl sublingual spray Controlled Dangerous substance Suboxone SL Film buprenorphine and naloxone Controlled Dangerous substance Suboxone SL Tablets buprenorphine and naloxone Controlled Dangerous substance Supartz sodium hyaluronate Hyaluronic Acid Derivatives For Joint Injection SureStep Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Symlin pramlintide Amylin Analogue Synagis palivizumab Monoclonal Antibody Synvisc hylan GF 20 Hyaluronic Acid Derivatives For Joint Injection Synvisc-One hylan GF 20 Hyaluronic Acid Derivatives For Joint Injection Testim testosterone Topical Testosterone Drug Tev-Tropin somatropin Growth Hormone

Tracleer bosentan Pulmonary vasodilator Travatan Z travoprost Anti Glaucoma tretinoin tretinoin Anti Acne Tretin-X tretinoin Anti Acne TrueTest Test Strips Blood Glucose Test Strips Blood Glucose Test Strips TrueTrack Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Tyvaso treprostinil Pulmonary Vasodilator Tysabri natalizumab Monoclonal Antibody Vascepa icosapent ethyl Omega-3 Fatty Acid Veletri epoprostenol sodium Pulmonary Vasodilator Veltin tretinoin/clindamycin Anti Acne Ventavis iloprost Pulmonary Vasodilator Victoza liraglutide Incretin Mimetic Agent Victrelis Hep C Protease Inihibitors Hepatitis C Vivaglobin immune globulin-subcutaneous Subcutaneous Immune Globulin Xalatan latanoprost Anti Glaucoma WaveSense Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Xeomin incobotulinumtoxina Specialty Drug Xgeva denosumab Oncology/Bones Xiaflex collagenase clostridium Cord Injection Xolair omalizumab Monoclonal antibody Ziana tretinoin/clindamycin Anti Acne Zometa zoledronic acid Oncology/Bones Zorbtive somatropin Growth Hormone

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