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 ACTIQ BELBUCA buprenorphine diclofenac sodium DUEXIS EMBEDA BUTRANS DOLOPHINE HCL DURAGESIC fentanyl fentanyl citrate FIORINAL WITH CODEINE #3 hydrocodone-ibuprofen LAZANDA lortab morphine sulfate er nalocet oxymorphone hcl er SPRIX HYSINGLA ER levorphanol tartrate methadone hcl MS CONTIN OXYCONTIN PENNSAID SUBSYS tramadol hcl er tramadol hcl-acetaminophen ULTRACET VIMOVO
ANESTHETICS ANTIBACTERIALS ANTICONVULSANTS ANTIEMETICS ANTIFUNGALS ANTIGOUT AGENTS ANTINEOPLASTICS XTAMPZA ER XIFAXAN ONFI vigabatrin BONJESTA DICLEGIS MARINOL ciclopirox SPORANOX KRYSTEXXA ALUNBRIG bexarotene CALQUENCE COTELLIC ELITEK FARYDAK GILOTRIF ICLUSIG IMBRUVICA KISQALI LONSURF NINLARO PROVENGE RUBRACA TARCEVA TEMODAR THALOMID SABRIL CESAMET dronabinol SYNDROS itraconazole BELEODAQ bortezomib capecitabine decitabine ERLEADA FOLOTYN HERCEPTIN imatinib mesylate JAKAFI KISQALI FEMARA CO-PACK MYLOTARG PORTRAZZA REVLIMID RYDAPT TARGRETIN temozolomide VERZENIO
ANTINEOPLASTICS -- Continued VOTRIENT ZEJULA XALKORI ZOLINZA ANTIPARASITICS ANTIPARKINSON AGENTS ANTIPSYCHOTICS ANTIVIRALS ZYKADIA ALBENZA quinine sulfate APOKYN OSMOLEX ER ADASUVE DAKLINZA MAVYRET PEGINTRON REDIPEN SELZENTRY TROGARZO VIEKIRA XR DARAPRIM DUOPA NUPLAZID EPCLUSA PEGASYS PROCLICK PREVYMIS TECHNIVIE VIEKIRA PAK BLOOD GLUCOSE REGULATORS AFREZZA GLUMETZA BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS MIRCERA chlorpropamide metformin hcl er 500 (generic for glumetza er) MOZOBIL CARDIOVASCULAR AGENTS PROCRIT CORLANOR JUXTAPID KYNAMRO PRALUENT PEN REPATHA PUSHTRONEX REPATHA SYRINGE VYTORIN ezetimibe-simvastatin KEVEYIS NORTHERA PRALUENT SYRINGE REPATHA SURECLICK simvastatin ZOCOR
CENTRAL NERVOUS SYSTEM AGENTS ADDERALL ADZENYS XR-ODT AUBAGIO AVONEX BETASERON ADZENYS ER AMPYRA AUSTEDO AVONEX PEN COPAXONE DERMATOLOGICAL AGENTS COTEMPLA XR-ODT DEXEDRINE dextroamphetamine sulfate dextroamphetamine-amphet er DYANAVEL XR FOCALIN glatiramer acetate HORIZANT metadate er METHYLIN methylphenidate hcl cd NUEDEXTA PLEGRIDY procentra QUILLIVANT XR REBIF riluzole RITALIN LA tetrabenazine VYVANSE zenzedi ZINBRYTA adapalene COSENTYX PEN DUPIXENT STELARA DESOXYN dexmethylphenidate hcl dextroamphetamine sulfate er dextroamphetamine-amphetamine EXTAVIA GILENYA glatopa INGREZZA methamphetamine hcl methylphenidate hcl methylphenidate la OCREVUS PLEGRIDY PEN QUILLICHEW ER RADICAVA REBIF REBIDOSE RITALIN TECFIDERA TYSABRI ZENZEDI ZENZEDI claravis DIFFERIN RETIN-A MICRO PUMP TALTZ SYRINGE (3 PACK)
ENZYME REPLACEMENT/MODIFIERS MEPSEVII GASTROINTESTINAL AGENTS alosetron hcl LOTRONEX RELISTOR XENICAL miglustat CHOLBAM OCALIVA VIBERZI XERMELO GENITOURINARY AGENTS CUPRIMINE HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL) EMFLAZA KORLYM HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) GENOTROPIN H.P. ACTHAR NOVAREL HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) ANADROL-50 ANDROGEL hydroxyprogesterone caproate methyltestosterone oxandrolone testosterone HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) SENSIPAR MAKENA OXANDRIN TESTONE CIK testosterone cypionate HORMONAL AGENTS, SUPPRESSANT (PITUITARY) EGRIFTA FIRMAGON LUPRON DEPOT SIGNIFOR SOMATULINE DEPOT TRELSTAR ELIGARD LUPANETA PACK SANDOSTATIN SIGNIFOR LAR SUPPRELIN LA TRIPTODUR IMMUNOLOGICAL AGENTS VANTAS BERINERT GAMMAPLEX ILARIS CUVITRU HUMIRA PEN KEVZARA
IMMUNOLOGICAL AGENTS -- Continued ORENCIA OTREXUP OTEZLA RASUVO SYNAGIS METABOLIC BONE DISEASE AGENTS FORTEO PROLIA MISCELLANEOUS THERAPEUTIC AGENTS ADDYI AIMOVIG AUTOINJECTOR (2 PACK) CETROTIDE hydrocodone-chlorpheniramne er NUCALA REZIRA TUSSICAPS XURIDEN NATPARA XGEVA adipex-p benzphetamine hcl CONTRAVE hydrocodone-homatropine mbr ODACTRA supartz fx tussigon OPHTHALMIC AGENTS CYCLOSPORINE IN KLARITY LUXTURNA XIIDRA CYSTARAN RESTASIS MULTIDOSE RESPIRATORY TRACT/PULMONARY AGENTS ADEMPAS AUVI-Q DALIRESP OPSUMIT ORKAMBI sildenafil TRACLEER TYVASO INSTITUTIONAL START KIT ARALAST NP CAYSTON GRASTEK ORENITRAM ER REVATIO SYMDEKO TYVASO UPTRAVI SKELETAL MUSCLE RELAXANTS VENTAVIS BOTOX SLEEP DISORDER AGENTS armodafinil HETLIOZ flurazepam hcl modafinil
SLEEP DISORDER AGENTS -- Continued NUVIGIL XYREM THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES ENDARI JADENU EXJADE trientine hcl
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)