Select Prior Authorization Some medications must be authorized for coverage because they re only approved or effective in treating specific illnesses, they cost more or they may be prescribed for conditions for which safety and effectiveness have not been well established. Reviewing Medications Our review committee of independent doctors and pharmacists meets regularly to review medications and consider how they should be covered by pharmacy benefit plans. They also recommend prior authorization guidelines. Safe and Effective When making recommendations, the review committee focuses on proven medication safety, effectiveness and cost. The committee considers: U.S. Food and Drug Administration (FDA) approved indications Manufacturer s package labeling instructions Well-accepted and/or published clinical recommendations Getting a Short-Term Supply If you must start taking a medication that requires prior authorization right away, two options may be available to you. First, ask your doctor if a sample is available. If not, check with your pharmacy to request a short-term supply of five days or less keep in mind you will be responsible for the full cost at that time. If the prior authorization request is approved, then your pharmacist can dispense the rest of your prescription. Requesting a Prior Authorization You, your pharmacist or your doctor can start the prior authorization review process by contacting our prior authorization department. A pharmacy technician then works with your doctor to get the information needed for the review. Once we receive a completed prior authorization form from your doctor, we conduct a clinical review within two business days. We then send you and your doctor a letter regarding the prior authorization decision.
Select Prior Authorization Select Non-Specialty Prior Authorization List Products on these pages may require prior authorization as determined by your specific benefit plan design. For more information, contact customer service at the number on the back of your benefit plan ID card. THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Anti-infectives Antibiotics XIFAXAN (rifaximin) Antifungals CICLODAN KIT (ciclopirox) CICLOPIROX KIT (ciclopirox) CNL8 NAIL KIT (ciclopirox) JUBLIA (efinaconazole) KERYDIN (tavaborole) ONMEL (itraconazole) PEDIPIROX-4 NAIL KIT (ciclopirox) SPORANOX (itraconazole) Soln SPORANOX (itraconazole) Antimalarial QUALAQUIN (quinine) Antiprotozoal DARAPRIM (pyrimethamine) Cardiology Antilipemic VYTORIN 10-80 MG (simvastatin/ezetimibe) ZOCOR 80 mg (simvastatin) Heart Failure CORLANOR (ivabradine) Central Nervous System ADHD Agents (PA age 19+ only) ENTRESTO (sacubitril/valsartan) ADDERALL (amphetamine/ dextroamphetamine) ADDERALL XR (amphetamine/ dextroamphetamine mixed salts) ADZENYS XR-ODT (amphetamine) APTENSIO XR (methylphenidate) CONCERTA (methylphenidate) 36 mg CONCERTA (methylphenidate) DAYTRANA (methylphenidate transdermal) DESOXYN (methamphetamine) DEXEDRINE (dextroamphetamine) 5 mg DEXEDRINE (dextroamphetamine) 15 mg DEXEDRINE (dextroamphetamine) 10 mg 1 patch/day 5 tabs/day 3 caps/day 4 caps/day 6 caps/day OptumRx optumrx.com
DYANAVEL XR (amphetamine) EVEKEO (amphetamine) FOCALIN (dexmethylphenidate) FOCALIN XR (dexmethylphenidate) 20 mg FOCALIN XR (dexmethylphenidate) METADATE CD (methylphenidate) METADATE ER (methylphenidate) 20 mg METHYLIN (methylphenidate) METHYLIN (methylphenidate) Soln 10 mg/5 ml METHYLIN (methylphenidate) Soln 5 mg/5 ml METHYLIN CHEW TAB (methylphenidate) METHYLIN CHEW TAB (methylphenidate) 10 mg METHYLIN ER (methylphenidate) 20 mg METHYLPHENIDATE ER (methylphenidate) 10 mg PROCENTRA (dextroamphetamine) Sol QUILLICHEW ER (methylphenidate) 30 mg QUILLICHEW ER (methylphenidate) QUILLIVANT XR (methylphenidate) RITALIN (methylphenidate) RITALIN LA (methylphenidate) RITALIN SR (methylphenidate) 20 mg VYVANSE (lisdexamfetamine) ZENZEDI (dextroamphetamine) 10 mg ZENZEDI (dextroamphetamine) ZENZEDI (dextroamphetamine) 30 mg 8 ml/day 6 tabs/day 2 caps/day 30 ml/day 60 ml/day 6 tabs/day 60 ml/day 12 ml/day 6 tabs/day Analgesics (non-opioid) PENNSAID (diclofenac) QUTENZA (capsaicin) SPRIX (ketorolac) VIMOVO (naproxen/esomeprazole) 4 patches/3 months 5 bottles or 5 days supply/30 days Analgesics (opioid) ABSTRAL (fentanyl citrate) 4 tabs/day ACTIQ (fentanyl citrate) BELBUCA (buprenorphine) film BUNAVAIL (buprenorphrine/naloxone) 2.1-0.3 mg BUNAVAIL (buprenorphrine/naloxone) 6.3-1 mg 4 lozenges/day 2 films/day 6 films/day 2 films/day 3
Select Prior Authorization BUNAVAIL (buprenorphrine/naloxone) 4.2-0.7 mg BUTRANS (buprenorphine) CONZIP (tramadol SR) FENTORA (fentanyl citrate) LAZANDA (fentanyl citrate) SUBOXONE (buprenorphrine/naloxone) 8-2 mg SUBOXONE (buprenorphrine/naloxone) 12-3 mg SUBOXONE (buprenorphrine/naloxone) 4-1 mg SUBOXONE (buprenorphrine/naloxone) 2-0.5 mg SUBSYS (fentanyl) SUBUTEX (buprenorphrine) 8 mg SUBUTEX (buprenorphrine) 2 mg ZUBSOLV (buprenorphine/naloxone) SL Tab 5.7-1.4 MG ZUBSOLV (buprenorphine/naloxone) SL Tab 8.6/2.1 MG ZUBSOLV (buprenorphine/naloxone) SL Tab 11.4/2.9 MG ZUBSOLV (buprenorphine/naloxone) SL Tab 2.9/0.71 MG ZUBSOLV (buprenorphine/naloxone) SL Tab 1.4-0.36 MG 3 films/day 4 patches/28 days 4 tabs/day 1 bottle/day 3 tabs or films/day 2 films/day 6 films/day 12 tabs or films/day 16 sprays/day 1 6 tabs/day 1 Anticonvulsants HORIZANT (gabapentin enacarbil) ONFI (clobazam) Antipsychotics ADASUVE (loxapine) Hypoactive Sexual Desire Disorder ADDYI (flibanserin) Miscellaneous RILUTEK (riluzole) Parkinson s DUOPA (carbidopa-levodopa) Susp NUPLAZID (pimavanserin) Sedative Hypnotics FLURAZEPAM (flurazepam) Stimulants NUVIGIL (armodafinil) NUVIGIL (armodafinil) 50 mg PROVIGIL (modafinil) Weight Loss ADIPEX-P (phentermine) BELVIQ (lorcaserin) OptumRx optumrx.com
Dermatology BONTRIL (phendimetrazine) CONTRAVE (naltrexone-bupropion) DIDREX (benzphetamine) QSYMIA (phentermine/topiramate) SAXENDA (liraglutide) SUPRENZA (phentermine) TENUATE (diethylpropion) XENICAL (orlistat) Acne (Oral) ABSORICA (isotretinoin) AMNESTEEM (isotretinoin) CLAVARIS (isotretinoin) MYORISAN (isotretinoin) ZENATANE (isotretinoin) Acne (PA age >25 only) ATRALIN (tretinoin) Miscellaneous Endocrinology & Metabolism AVITA (tretinoin) DIFFERIN (adapalene) RETIN-A (tretinoin) RETIN-A MICRO (tretinoin) TRETIN-X (tretinoin) ENSTILAR (calcipotriene-betamethasone dipropionate) Androgens, Testosterone (Oral) ANADROL-50 (oxymetholone) ANDROID (methyltestosterone) ANDROXY (fluoxymesterone) METHITEST (methyltestosterone) OXANDRIN (oxandrolone) 10 mg OXANDRIN (oxandrolone) 2.5 mg TESTRED (methyltestosterone) 420 g/28 days 8 tabs/day Androgens, Testosterone ANDRODERM (testosterone) (Topical) ANDROGEL (testosterone) AXIRON (testosterone) FORTESTA (testosterone) NATESTO (testosterone nasal) STRIANT (testosterone) TESTIM (testosterone) VOGELXO (testosterone) 5
Select Prior Authorization Androgens, Testosterone AVEED (testosterone undecanoate) (Injectable) DELATESTRYL (testosterone enanthate) Endocrinology & Metabolism DEPO-TESTOSTERONE (testosterone cypionate) TESTOPEL (testosterone pellet) Antidiabetic Agents AFREZZA (insulin regular) Antidiabetic Agents (PA age > 65 only) Gastroenterology GLUMETZA (metformin) SYMLIN (pramlintide) CHLORPROPAMIDE (chlorpropamide) Antiemetics CESAMET (nabilone) 20 tabs/fill or 3 max days DICLEGIS (doxylamine-pyridoxine) MARINOL (dronabinol) 4 tabs/day 2 caps/day Irritable Bowel Syndrome LOTRONEX (alosetron) VIBERZI (eluxadoline) Opioid-induced Constipation RELISTOR (methylnaltrexone) 1 syringe/day. Immunology RELISTOR (methylnaltrexone) Kit 1 vial/day Allergen Extracts GRASTEK (timothy grass pollen) Immunizations Miscellaneous ORALAIR (mixed grass pollens allergen) 300 IR ORALAIR ADULT SAMPLE KIT (mixed grass pollens allergen) Kit 1 kit/year ORALAIR CHILDREN/ADOLESCENTS (mixed grass pollens allergen) Starter Pack 2 packs/year ORALAIR CHILDREN/ADOLESCENTS (mixed grass pollens allergen) Sample Kit 2 kits/year RAGWITEK (short ragweed pollen allergen) VARIZIG (varicella-zoster immune globulin) Calcium Modifier SENSIPAR (cinacalcet) Methotrexate Auto-Injectors OTREXUP (methotrexate) 4 auto-injectors/28 days RASUVO (methotrexate) Wound Care REGRANEX (becaplermin) Oncology Miscellaneous PROVENGE (sipuleucel-t) 4 auto-injectors/28 days OptumRx optumrx.com
Topical TARGRETIN (bexarotene) Gel Ophthalmology Miscellaneous RESTASIS (cyclosporine) Respiratory XIIDRA (lifitegrast) Asthma/COPD DALIRESP (roflumilast) PLEASE NOTE: This drug list is subject to periodic updates and may not be all inclusive. Drugs affected include both brand and generic where applicable and includes all dosage formulations unless otherwise specifically notated. If a new drug is approved and falls into one of the targeted PA categories, the new drug may automatically be added to this list. Quantity limits may also apply. Select Specialty Prior Authorization List Products on these pages may require prior authorization as determined by your specific benefit plan design. For more information, contact customer service at the number on the back of your benefit plan ID card. THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Anti-infectives Antiretrovirals, HIV SELZENTRY (maraviroc) Cardiology Antilipemic JUXTAPID (lomitapide) KYNAMRO (mipomersen) PRALUENT (alirocumab) REPATHA (evolocumab) REPATHA PUSH (evolocumab) 4 syringes/28 days 2 syringes/28 days 3 syringes/28 days 1 cartridge/28 days Pulmonary Arterial Hypertension ADCIRCA (tadalafil) ADEMPAS (riociguat) FLOLAN (epoprostenol) LETAIRIS (ambrisentan) OPSUMIT (macitentan) ORENITRAM (treprostinil diolamine) REMODULIN (treprostinil) REVATIO (sildenafil) Soln REVATIO (sildenafil) Susp REVATIO (sildenafil) Tabs TRACLEER (bosentan) TYVASO (treprostinil) UPTRAVI (selexipag) UPTRAVI (selexipag) Pack VELETRI (epoprostenol) 90 tabs/30 days 2 bottles/30 days 1 ampule/day 2 packs/year 7
Select Prior Authorization VENTAVIS (iloprost) Vasopressors NORTHERA (droxidopa) Central Nervous System Anticonvulsants SABRIL (vigabatrin) pack Depressant SABRIL (vigabatrin) Tabs XYREM (sodium oxybate) 9 ampules/day Muscular Dystrophy EXONDYS 51 (eteplirsen) Neurotoxins BOTOX (onabotulinumtoxina) DYSPORT (abobotulinumtoxina) MYOBLOC (rimabotulinumtoxinb) XEOMIN (incobotulinumtoxina) 3 bottles (540 ml)/30 days Opiate Antagonist VIVITROL (naltrexone) Parkinson's APOKYN (apomorphine) 20 cartridges/30 days Sleep Disorder HETLIOZ (tasimelteon) Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel Electrolyte & Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabs/day Endocrinology & Metabolism Gonadotropins ELIGARD (leuprolide) 22.5 mg (3-month) 1 injection/84 days ELIGARD (leuprolide) 30 mg (4-month) ELIGARD (leuprolide) 45 mg (6-month) ELIGARD (leuprolide) 7.5 mg (1-month) FIRMAGON (degarelix) 120 mg FIRMAGON (degarelix) 80 mg LUPANETA PACK (leuprolide) 11.25 mg (3 mon) LUPANETA PACK (leuprolide) 3.75 mg (1 mon) LUPRON (leuprolide) 1 mg/0.2 ml LUPRON DEPOT (leuprolide) 3.75 mg & 7.5 mg (1-month) LUPRON DEPOT-PED (leuprolide) SUPPRELIN LA (histrelin acetate) 1 injection/112 days 1 injection/168 days 1 injection/28 days 2 vials/year 1 vial/28 days 1 pack/84 days 1 pack/28 days 1 kit/365 days TRELSTAR (triptorelin) 22.5 mg (6-month) 1 injection/168 days TRELSTAR DEPOT (triptorelin) 3.75 mg (1-month) TRELSTAR LA (triptorelin) 11.25 mg (3-month) 1 injection/28 days 1 injection/84 days OptumRx optumrx.com
Growth Hormones and Related Therapy VANTAS (histrelin) EGRIFTA (tesamorelin) 1 mg EGRIFTA (tesamorelin) 2 mg GENOTROPIN (somatropin) HUMATROPE (somatropin) NORDITROPIN (somatropin) NUTROPIN (somatropin) NUTROPIN AQ (somatropin) OMNITROPE (somatropin) SAIZEN (somatropin) SEROSTIM (somatropin) TEV-TROPIN (somatropin) ZOMACTON (somatropin) ZORBTIVE (somatropin) 1 implant/year 2 vials (1 mg each)/day 1 vial (2 mg each)/day Growth Hormones and Related INCRELEX (mecasermin) Therapy (Acromegaly) SOMAVERT (pegvisomant) Hormone Modifiers MYALEPT (metreleptin) NATPARA (parathyroid hormone) Miscellaneous H.P. ACTHAR (corticotropin) KORLYM (mifepristone) 2 cartridges/28 days 4 tabs/day Osteoporosis FORTEO (teriparatide) PROLIA (denosumab) Somatostatins SANDOSTATIN (octreotide) Enzyme-Related SANDOSTATIN LAR (octreotide) SIGNIFOR (pasireotide) SIGNIFOR LAR (pasireotide) SOMATULINE DEPOT (lanreotide) 2 syringes/year 2 ampules/day 1 vial/28 days Alpha-1 proteinase inhibitor ARALAST (alpha-1 proteinase inhibitor) GLASSIA (alpha-1 proteinase inhibitor) PROLASTIN (alpha-1 proteinase inhibitor) ZEMAIRA (alpha-1 proteinase inhibitor) Cystine-depleting Agents CYSTARAN (cysteamine) 4 bottles/28 days PROCYSBI (cysteamine bitartrate) Enzyme Replacement ALDURAZYME (laronidase) CERDELGA (eliglustat) CEREZYME (imiglucerase) ELAPRASE (idursulfase) 9
Select Prior Authorization ELELYSO (taliglucerase) FABRAZYME (agalsidase beta) KANUMA (sebelipase alfa) Soln LUMIZYME (alglucosidase alfa) MYOZYME (alglucosidase alfa) NAGLAZYME (galsulfase) RAVICTI (glycerol phenylbutyrate) STRENSIQ (asfotase alfa) VIMIZIM (elosulfase) VPRIV (velaglucerase) XURIDEN (uridine triacetate) ZAVESCA (miglustat) 4 packets/day Enzyme, Gout KRYSTEXXA (pegloticase) Phenylketonuria Treatment Agents Gastroenterology KUVAN (sapropterin) Bile Acid Agents CHOLBAM (cholic acid) Hepatic Agents OCALIVA (obeticholic acid) Short Bowel Syndrome GATTEX (teduglutide) Immunology Hematopoietic Agents ARANESP (darbepoetin alfa) EPOGEN (epoetin alfa) GRANIX (tbo-filgrastim) LEUKINE (sargramostim) MIRCERA (methoxy polyethylene glycol-epoetin) MOZOBIL (plerixafor) NEULASTA (pegfilgrastim) NEUMEGA (oprelvekin) NEUPOGEN (filgrastim) NPLATE (romiplostim) PROCRIT (epoetin alfa) PROMACTA (eltrombopag) SOLIRIS (eculizumab) ZARXIO (filgrastim) 8 vials (9.6 ml) per transplant Hemostatic Agent BERINERT (c1 esterase) CINRYZE (c1 esterase) FIRAZYR (icatibant) Soln OptumRx optumrx.com
KALBITOR (ecallantide) Soln RUCONEST (c1 esterase) Solr Hepatic Agents OCALIVA (obeticholic acid) Hepatitis C Agents DAKLINZA (daclatasvir dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) HARVONI (ledipasvir-sofosbuvir) OLYSIO (simeprevir) PEGASYS (peginterferon alfa-2a) PEG-INTRON (peginterferon alfa-2b) SOVALDI (sofosbuvir) TECHNIVIE (ombitasvir-paritaprevirritonavir) VIEKIRA PAK (dasabuvir-ombitasvirparitaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvirparitaprevir-ritonavir) ZEPATIER (elbasvir-grazoprevir) 4 tabs/day Immune Globulins BIVIGAM (immune globulin) CARIMUNE (immune globulin) CYTOGAM (cytomegalovirus immune globulin) FLEBOGAMMA (immune globulin) FLEBOGAMMA DIF (immune globulin) GAMASTAN (immune globulin) GAMMAGARD (immune globulin) GAMMAKED (immune globulin) GAMMAPLEX (immune globulin) GAMUNEX (immune globulin) GAMUNEX-C (immune globulin) HIZENTRA (immune globulin) HYQVIA (hyaluron immune globulin) OCTAGAM (immune globulin) PRIVIGEN (immune globulin) Immunomodulators ACTEMRA (tocilizumab) Sosy CIMZIA (certolizumab) COSENTYX (secukinumab) ENBREL (etanercept) ENTYVIO (vedolizumab) HUMIRA (adalimumab) 11
Select Prior Authorization KINERET (anakinra) ORENCIA (abatacept) OTEZLA (apremilast) REMICADE (infliximab) SIMPONI (golimumab) SIMPONI ARIA (golimumab) STELARA (ustekinumab) TALTZ (ixekizumab) XELJANZ (tofacitinib) XELJANZ XR (tofacitinib) Interleukins ARCALYST (rilonacept) ILARIS (canakinumab) Miscellaneous BENLYSTA (belimumab) 2 vials/4 weeks Multiple Sclerosis AMPYRA (dalfampridine) AUBAGIO (teriflunomide) AVONEX (interferon beta-1a) BETASERON (interferon beta-1b) COPAXONE (glatiramer) SOSY 20 mg/ml COPAXONE (glatiramer) SOSY 40 mg/ml EXTAVIA (interferon beta-1b) GILENYA (fingolimod) GLATOPA (glatiramer) SOSY 20 mg/ml LEMTRADA (alemtuzumab) NOVANTRONE (mitoxantrone) PLEGRIDY (peginterferon beta) PLEGRIDY (peginterferon beta) Starter Pack REBIF (interferon beta-1a) REBIF (interferon beta-1a) Starter Pack TECFIDERA (dimethyl fumarate) TECFIDERA (dimethyl fumarate) Starter Pack TYSABRI (natalizumab) ZINBRYTA (daclizumab) 1 kit (4 syringes)/28 days 1 package/28 days 1 kit/30 days 1 kit/30 days 1 package/28 days 1 kit/30 days 2 PENS/SYR PER 28 DAYS. 1 starter pack/30 days 12 syringes/28 days 1 starter pack/year 2 caps/day 1 starter pack/year 1 injection /28 days Transplant NULOJIX (belatacept) Miscellaneous Collagenase ZORTRESS (everolimus) XIAFLEX (collagenase clostridium histolyticum) OptumRx optumrx.com
Diagnostic THYROGEN (thyrotropin alfa) Movement Disorder Agents XENAZINE (tetrabenazine) Toxicology CUPRIMINE (penicillamine) EXJADE (deferasirox) FERRIPROX (deferiprone) Soln FERRIPROX (deferiprone) Tabs JADENU (deferasirox) SYPRINE (trientine) Viscosupplements EUFLEXXA (sodium hyaluronate) Obstetrics & Gynecology GEL-ONE (sodium hyaluronate) GELSYN-3 (sodium hyaluronate) HYALGAN (sodium hyaluronate) HYMOVIS (sodium hyaluronate) MONOVISC (hyaluronan) ORTHOVISC (sodium hyaluronate) SUPARTZ (sodium hyaluronate) SYNVISC (sodium hyaluronate) SYNVISC-ONE (sodium hyaluronate) Fertility Agents BRAVELLE (urofollitropin) CETROTIDE (cetrorelix) Chorionic gonadotropin (chorionic gonadotropin) FOLLISTIM AQ (follitropin beta) Ganirelix acetate (ganirelix) GONAL-F (follitropin alfa) 450 IU GONAL-F RFF (follitropin alfa) Pens 300 IU GONAL-F RFF REDIINJECT (follitropin alfa) Soln 900 IU MENOPUR (menotropins) NOVAREL (chorionic gonadotropin) PREGNYL (chorionic gonadotropin) REPRONEX (menotropins) Hormone Replacement MAKENA (hydroxyprogesterone caproate) Oncology (Injectable) Antifolate FOLOTYN (pralatrexate) Soln TECENTRIQ (atezolizumab) Soln Antimicrotubular HALAVEN (eribulin) JEVTANA (cabazitaxel) 13
Select Prior Authorization Interferons INTRON A (interferon alfa-2b) SYLATRON (peginterferon alfa-2b) Kinase and Molecular Target KYPROLIS (carfilzomib) Inhibitors PORTRAZZA (necitumumab) Soln 2 vials/21 days VELCADE (bortezomib) ZALTRAP (ziv-aflibercept) Miscellaneous BELEODAQ (belinostat) DACOGEN (decitabine) ISTODAX (romidepsin) SYNRIBO (omacetaxine) Monoclonal Antibody ADCETRIS (brentuximab) ARZERRA (ofatumumab) BLINCYTO (blinatumomab) CYRAMZA (ramucirumab) DARZALEX (daratumumab) Soln EMPLICITI (elotuzumab) Solr ERBITUX (cetuximab) Soln GAZYVA (obinutuzumab) HERCEPTIN (trastuzumab) KADCYLA (ado-trastuzumab emtansine) KEYTRUDA (pembrolizumab) Soln KEYTRUDA (pembrolizumab) Solr OPDIVO (nivolumab) PERJETA (pertuzumab) RITUXAN (rituximab) SYLVANT (siltuximab) XGEVA (denosumab) YERVOY (ipilimumab) Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) Antiandrogen XTANDI (enzalutamide ) ZYTIGA (abiraterone) Kinase and Molecular Target AFINITOR (everolimus) Inhibitors AFINITOR DISPERZ (everolimus) ALECENSA (alectinib) 8 caps/day BOSULIF (bosutinib) CAPRELSA (vandetanib) 100 mg CAPRELSA (vandetanib) 300 mg COMETRIQ (carbozantinib) OptumRx optumrx.com
Miscellaneous COTELLIC (cobimetnib) ERIVEDGE (vismodegib) FARYDAK (panobinostat) GILOTRIF (afatinib) GLEEVEC (imatinib) IBRANCE (palbociclib) ICLUSIG (ponatinib) 15 mg ICLUSIG (ponatinib) 45 mg IMBRUVICA (ibrutinib) INLYTA (axitinib) IRESSA (gefitinib) JAKAFI (ruxolitinib) JAKAFI (ruxolitinib) 10 mg LENVIMA (lenvatinib) LYNPARZA (olaparib) MEKINIST (trametinib) NEXAVAR (sorafenib) NINLARO (ixazomib) ODOMZO (sonidegib) SPRYCEL (dasatinib) STIVARGA (regorafenib) SUTENT (sunitinib) TAFINLAR (dabrafenib) TAGRISSO (osimertinib) TARCEVA (erlotinib) 100 mg, 150 mg TARCEVA (erlotinib) 25 mg TASIGNA (nilotinib) TYKERB (lapatinib) VENCLEXTA (venetoclax) VOTRIENT (pazopanib) XALKORI (crizotinib) ZELBORAF (vemurafenib) ZYDELIG (idelalisib) ZYKADIA (ceritinib) LONSURF (trifluridine-tipiracil) 15-6.14 MG LONSURF (trifluridine-tipiracil) 20-8.19 MG TARGRETIN (bexarotene) caps 63 tabs/28 days 6 caps/ 21 days 3 caps/28 days 100 tabs/28 days 80 tabs/28 days 15
XELODA (capecitabine) ZOLINZA (vorinostat) Thalidomide-related Agents POMALYST (pomalidomide) Respiratory REVLIMID (lenalidomide) THALOMID (thalidomide) Asthma/COPD CINQAIR (reslizumab) Soln NUCALA (mepolizumab) XOLAIR (omalizumab) 1 vial/28 days Cystic fibrosis CAYSTON (aztreonam) KALYDECO (ivacaftor) KALYDECO (ivacaftor) Packs ORKAMBI (lumacaftor-ivacaftor) PULMOZYME (dornase alfa) 4 tabs/day Pulmonary Fibrosis ESBRIET (pirfenidone) Respiratory Syncytial Virus Agents OFEV (nintedanib) SYNAGIS (palivizumab) PLEASE NOTE: This drug list is subject to periodic updates and may not be all inclusive. Drugs affected include both brand and generic where applicable and includes all dosage formulations unless otherwise specifically notated. If a new drug is approved and falls into one of the targeted PA categories, the new drug may automatically be added to this list. Quantity limits may also apply. optumrx.com OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum company a leading provider of integrated health services. Learn more at optum.com. All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. 2016 OptumRx, Inc. ORX0800A-CTRX_160930 55526A-092016