DRUGS REQUIRING PRIOR AUTHORIZATION

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Transcription:

DRUGS REQUIRING PRIOR AUTHORIZATION Medication Abstral Actemra Acthar Gel Actiq* Adcirca Adderall Adderall XR Addyi Adempas Adipex* Adzenys XR-ODT Afinitor Afinitor Alecensa Alecensa Ampyra Androderm AndroGel Aptensio XR Aralast NP Aranesp Arcalyst Atralin* Aveed Avita* Avonex Axiron Belviq Berinert Betaseron Bivigam Bontril* Bosulif Bosulif Botox Bunavail Bydureon Byetta Therapeutic Category

Cabometyx Caprelsa Carimune Caverject Chenodal Cholbam Cialis Cimzia Cinqair Cinryze Cometriq Concerta Contrave Copaxone Cosentyx Cotellic Daklinza Daliresp Daraprim Daytrana Delatestryl* Depo - Testosterone* Desoxyn Dexedrine Didrex* Dyanavel XR Dysport Edex Injection Egrifta Enbrel Entyvio Epclusa Epogen Erbitux Erivedge Esbriet Euflexxa Evekeo Exondys 51 Extavia Eylea Fabior Farydak Fentora Firazyr Asthma Specialty Asthma/COPD Toxoplasmosis Respiratory Miscellaneous Duchenne Muscular Dystrophy

Flebogamma Flolan* Focalin Focalin XR Forteo Fortesta* Gammagard Liquid Gammagard S/D Gammaked Gamunex Gamunex-C Gel-One Gelsyn-3 Genotropin Gilotrif Gilotrif Glassia Gleevec Gleevec* Granix Grastek Harvoni Herceptin Hetlioz Humatrope Humira Hyalgan Hymovis Hyqvia Ibrance Ibrance Iclusig Iclusig Ilaris Imbruvica Impulse Increlex Inlyta Intuniv * Iressa Iveegam EN Jakafi Juxtapid Kadcyla Kalbitor Bone Conditions Allergies Sleep Disorder

Kalydeco Kapvay* Keveyis Kineret Korlym Krystexxa Kuvan Kynamro Lazanda Lemtrada Lenvima Letairis Levitra Lidoderm* Lonsurf Lovaza* Lucentis Lumigan* Lynparza Lynparza Macugen Makena Mekinist Mekinist Metadate CD Metadate ER Methylin Mircera Monovisc Muse Myalept Myobloc Natesto Natpara Neulasta Neupogen Nexavar Ninlaro Norditropin Northera Nplate Nucala Nuedexta Nutropin Nutropin AQ Respiratory Miscellaneous Endocrine disorder Gout Pain Hormone supplementation Asthma Specialty Mood Stabilizer

Nuvigil* Ocaliva Octagam Odomzo Ofev Olysio Omnitrope Onsolis Opsumit Oralair Orencia Orenitram Orkambi Orthovisc Otezla Pegasys PEG-Intron Perjeta Plegridy Polygam Praluent Procentra Procrit Prolastin Prolastin - C Promacta Provigil* Qsymia QuilliChew ER Quillivant XR Ragwitek Rebif Regimex Remicade Remodulin Repatha Restasis Retin-A Micro* Retin-A* Revatio* Revlimid Ritalin Ritalin LA Ritalin SR Rituxan Narcolepsy Respiratory Miscellaneous Allergies Respiratory Miscellaneous Narcolepsy Allergies

Ruconest Saizen Samsca Saxenda Selzentry Sensipar Serostim Signifor Signifor LAR Simponi Sivextro Solaraze* Sovaldi Spansules Sprycel Sprycel Staxyn Stelara Stendra Stivarga Stivarga Strattera Striant Suboxone* Subsys Supartz Suprenza Sutent Symlin Synvisc Synvisc-One Tafinlar Tafinlar Tagrisso Tagrisso Taltz Tanzeum Tarceva Tarceva Tasigna Tasigna Tazorac Technivie Temodar* Testim* Endocrine disorder HIV Chronic Kidney Disease Endocrine disorder Endocrine disorder

Testopel Tev-Tropin Thalomid Tracleer Travatan/Z Tretin X Trulicity Tykerb Tykerb Tysabri Tyvaso Uptravi Vascepa Vectibix Veletri Veltin* Venclexta Venclexta Ventavis Viagra Victoza Viekira Vogelxo* Votrient Vyvanse Xalatan* Xalkori Xalkori Xenazine* Xenical Xeomin Xiidra Xolair Xtandi Xyrem Zarxio Zelboraf Zelboraf Zemaira Zenzedi Ziana* Zinbryta Zioptan Zomacton Zorbtive Asthma Specialty Narcolepsy

Zovirax Zubsolv Zydelig Zykadia Zykadia Zytiga Zytiga Zyvox* * Indicates generics available, generics require a PA same as brand List as of 11.30.16, lists subject to change

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