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 Apidra (effective 1/1/14) insulin glulisine [rdna origin] Human Insulin Analog Aranesp darbepoetin alfa Red Blood Cell Progenitor Atralin tretinoin Anti Acne 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 Enbrel etanercept Anti Tumor Necrosis Factor Drug Euflexxa sodium hyaluronate Hyaluronic Acid Derivatives For Joint Injection Epogen epoetin alfa Red Blood Cell Progenitor 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 Liquid 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 Intravenous/Subcutaneous Immune Globulin Gattex teduglitide [rdna origin] Short Bowel Syndrome Gel-One sodium hyaluronate Hyaluronic Acid Derivatives For Joint Injection Genotropin somatropin Growth Hormone Gilenya fingolimod Multiple Sclerosis Agent Glucose Test Strip Blood Glucose Test Strips Blood Glucose Test Strips Hizentra immune globulin-subcutaneous Subcutaneous Immune Globulin Humalog (effective 1/1/14) insulin lispro [rdna origin] Human Insulin Analog Humatrope somatropin Growth Hormone Humira adalimumab Monoclonal Antibody Humulin (effective 1/1/14) Insulin human [rdna origin] Human Insulin Hyalgan sodium hyaluronate Hyaluronic Acid Derivative For Joint Injection Incivek telaprevir Hepatitis C Protease Inihibitors Increlex mecasermin Growth Hormone Iveegam EN immune globulin-intravenous Intravenous Immune Globulin IVIG or IGIV immune globulin-intravenous Intravenous Immune Globulin Juxtapid lomitapide Homozygous Familial Hypercholesterolemia Agent Kalbitor ecallantide Hereditary Angioedema Kalydeco ivacaftor Cystic Fibrosis Korlym mifepristone Endocrine/Cushing s disease Krystexxa pegloticase Gout Lazanda Nasal Spray fentanyl citrate Controlled Dangerous substance Kuvan sapropterin Phenylketonuria Kynamro mipomersen Homozygous Familial Hypercholesterolemia Agent 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 Myobloc rimabotulinumtoxinb Specialty Drug Norditropin somatropin Growth Hormone 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 Strips Blood Glucose Test Strips Blood Glucose Test Strips Onsolis fentanyl soluble film Controlled Dangerous Substances 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 Strips Blood Glucose Test Strips Blood Glucose Test 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 Rescula unoprostone Anti Glaucoma

Retin-A tretinoin Anti Acne Retin-A Micro tretinoin Anti Acne Revatio sildenafil citrate Pulmonary Vasodilator Rituxan rituximab Monoclonal Antibody Sabril vigabatrin Anticonvulsant Saizen somatropin Growth Hormone Seroquel quetiapine Anti Psychotic Serostim somatropin Growth Hormone Signifor pasireotide Somatostatin/Cushing s disease 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 Tecfidera dimethyl fumarate Multiple Sclerosis Agent Testim testosterone Topical Testosterone Drug Tev-Tropin somatropin Growth Hormone Tracleer bosentan Pulmonary vasodilator Travatan Z travoprost Anti Glaucoma Travoprost 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 boceprevir Hepatitis C Protease Inhibitor Vivaglobin immune globulin-subcutaneous Subcutaneous Immune Globulin Xalatan latanoprost Anti Glaucoma Xeljanz tofacitinib Janus Kinase Inhibitor WaveSense Test Strips Blood Glucose Test Strips Blood Glucose Test Strips Xeomin incobotulinumtoxina Specialty Drug Xenazine tetrabenazine Huntington s Chorea Xgeva denosumab Oncology/Bones Xiaflex collagenase clostridium Cord Injection Xolair omalizumab Monoclonal antibody Ziana tretinoin/clindamycin Anti Acne Zioptan tafluprost Anti Glaucoma Zometa zoledronic acid Oncology/Bones Zorbtive somatropin Growth Hormone Zubsolv SL Tablets buprenorphine and naloxone Controlled Dangerous substance