Prior Authorization Guidelines

Prior Authorization is required for the following medications because they may have limited conditions for which they are prescribed; special monitoring or dispensing requirements; or an extremely high cost. Guidelines for approving coverage for prior authorization drugs are developed and approved by a panel of practicing physicians and pharmacists. Click on the drug name to view the specific prior authorization guidelines.

Commercial Guidelines:

ABILIFY Maintena (aripiprazole) 
Actemra PA
Acthar PA  
ACTIMMUNE (interferon gamma) 
Adapalene PA 
Adapalene/Benzoyl Peroxide PA 
Adcirca (Tadalafil) PA
ADDERALL (dextroamphetamine/amphetamine) 
ADDERALL XR (dextroamphetamine/amphetamine) 
Adempas PA 
ADOXA (doxycycline monohydrate) 
ADZENYS XR-ODT (dextroamphetaman/amphetamine base)
AFINITOR (everolimus) 
Afrezza (Inhaled Insulin) 
ALECENSA (alectinib) 
Aliskiren PA 
Ambrisentan PA 
Ampyra PA
Androderm (Testosterone)
Androgel (Testosterone)
APTENSIO XR (methylphenidate) 
Antipsoriatic Agents 
Apokyn PA 
Aptiom PA 
Aranesp (darbepoetin)
Arava PA 
Arcalyst PA 
ARISTADA 
ARZERRA (ofatumumab)
AUBAGIO (TERIFLUNOMIDE)
AVIDOXY (doxycycline monohydrate)
Axiron (Testosterone)
Bosentan PA 
Bosulif PA
Bunavail (Buprenorphine/Naloxone)
CABOMETYX (cabozantinib s-malate)
Cambia PA
Caprelsa PA
CARBAGLU (carglumic)
Caverject-Edex PA 
Cayston PA 
Celebrex (all strengths except 400mg) PA 
CERDELGA (eliglustat) 
CESAMET (nabilone) 
Cetirizine PA 
Cholbam PA
CIALIS (tadalafil)
CIMZIA (certolizumab) 
Clindamycin/Tretinoin PA 
Crinone Prochieve Endometrin 
COMETRIQ (cabozantinib s-malate)
CONCERTA (methylphenidate hcl) 
COSENTYX (secukinumab) 
COTELLIC (cobimetinib)
Crinone Prochieve (Progesterone Micronized)
Cuprimine (Penicillamine)
Cuvitru (Immun glob G(IGG)/Pro/Iga 0-50)
Cystaran PA 
DAKLINZA (daclatasvir)
Daliresp PA
Daraprim (pyrimethamine)
DHE PA
Delatestryl (Testosterone Enanthate)
Depen (Penicillamine)
Depo-Testosterone (Testosterone Cypionate)
Descovy (emtricitabin_etenofovir alafenamide) SPECIALTY 
Desloratadine PA 
Desloratadine/PSE PA 
DESOXYN (methamphetamine hcl)
DEXEDRINE (dextroamphetamine sulfate) 
Dexlansoproazole PA 
Dificid PA 
DORYX (doxycycline hyclate)
DORYX MPC (doxycycline hyclate)
Doxycycline Monohydrate PA
Doxycycline Hyclate PA 
Duexis PA 
Durlaza (Aspirin ER) 
Effient 
Embeda PA 
Enbrel PA
Endometrin (Progesterone Micronized)
Endothelin Receptor Antagonists
Epculsa (SOFOSBUVIR-VELPATASVIR)
Epogin (Epoetin alfa) 
Erivedge PA 
Erythropoiesis Stimulating Agents (epoetin) 
Esbriet PA 
Esomeprazole Magnesium PA 
Esomeprazole Strontium PA 
Exemestane PA 
EXJADE 
Evekeo (amphetamine) 
EVISTA (raloxifene) (Marketplace only) 
Farxiga PA 
FARYDAK (panobinostat) 
Fentanyl Transmucosal PA 
Fetzima PA 
Filgrastim PA
Firazyr 
FOCALIN (dexmethylphenidate hcl) 
FOCALIN XR (dexmethylphenidate hcl er) 
FORTEO (teriparatide)
Fortesta (Testosterone)
Fulyzaq Mytesi (Crofelemer)
FUZEON (enfuvirtide) 
Fycompa PA 
Gattex PA
Genotropin (Somatropin)
GILENYA (FINGOLIMOD)
Gilotrif PA 
Gleevec PA 
GLP-1 Analogs PA (Byetta, Bydureon, Tanzeum, Trulicity, Victoza) Glyxambi PA
Gosereline Acetate PA 
GRANIX (tbo-filgrastim)
GROWTH HORMONE
Harvoni PA 
Hemangeol PA 
Hizentra (immune globin)
Humatrope (Somatropin)
Humira PA 
Hydromorphone PA
HYQVIA
HYQVIA IG Component (IGG/hyaluronidase, recombinant) 
IBRANCE (palbociclib) 
ICLUSIG (ponatinib) 
IMBRUVICA (ibrutinib) 
Inlyta PA 
Inspra PA 
Interferon Alfa for Hepatitis 
Intron A PA 
INVEGA SUSTENNA (paliperidone palmitate) 
INVEGA TRINZA (paliperidone palmitate) 
Invokana PA 
Invokamet PA
Iressa PA 
Iressa Tarceva 
Isotretinoin PA 
JADENU (deferasirox) 
Jakafi 
Jardiance PA 
Jevtana 
Juxtapid (lomitapide)
Kalydeco PA
Kerydin (tavaborole)
KEVEYIS (dichlorphenamide) 
Kineret PA 
Korlym PA 
Kuvan PA 
Kynamro PA
Lansoprazole PA
Latuda (Lurasidone)
Lazanda PA 
Lenvima PA 
LEVITRA (vardenafil)
Levocetirizine PA 
Leukine PA 
Leuprolide Acetate PA 
Linzess 
Long-Acting Beta Agonist Inhalers PA 
Long-Acting Muscarinic Antagonists Inhalers PA 
Lonsurf (trifluridine) 
Lumigan PA 
Lumizyme 
Lynparza 
Macitentan PA 
Mekinist PA 
METADATE CD (methylphenidate hcl) 
METADATE ER (methylphenidate hcl)
Mircera (Methoxy pegepoetin beta)
METHYLIN (methylphenidate hcl) 
Minocycline HCL PA 
MONDOXYNE NL (doxycycline monohydrate)
MONODOX (doxycycline monohydrate)
Morphine Sulfate PA
Mozobil PA
Myalept PA
MS Agents 
Namzaric PA
Natesto (Testosterone)
Natpara PA 
NEUPOGEN (filgrastim)
NEULASTA (pegfilgrastim)
Nexavar PA 
NINLARO (ixazomib) 
NORTHERA (droxidopa)
NOXAFIL (posaconazole) 
Nuedexta PA 
Nuplazid (Pimavanserin) Specialty w/PA & QL
Nutropin/ Nutropin AQ/ Nutropin AQ Nuspin (Somatropin)
Nuvigil
Ocaliva (obeticholic)
Odomzo (sonidegib)
Omnitrope (Somatropin)
ORFADIN (nitisinone)
Ofev PA

Oforta 
OLYSIO (simeprevir) 
Omeprazole PA 
Omeprazole Magnesium PA 
Omeprazole/Sodium Bicarbonate PA 
Onfi PA 
ORACEA (doxycycline monohydrate) 
Orencia (abatecept) SQ
ORFADIN (NITISINONE)
ORKAMBI (lumacaftor-Ivacaftor)
OTEZLA (Apremilast)
Oxtrella PA 
Oxycodone PA 
Oxymorphone PA 
Patoprazole Sodium PA 
Pegasys-Pegintron (eginterferon) PA 
PDE5 Inhibitors for PAH
Rabeprazole Sodium PA 
Pegfilgrastim PA 
Plegridy PA 
POMALYST (pomalidomide) 
Potiga PA and ST 
Praluent PA 
PROCENTRA (dextroamphetamine sulfate) 
Procrit (epoetin alfa)
Procysbi PA 
Progesterone Micronized PA 
Promacta PA 
Provigil 
Purixan 
QUDEXY XR (topiramate) 
QUILLICHEW ER (methylphenidate hcl)
QUILLIVANT XR (methylphenidate hcl) 
Ranexa PA 
RASUVO (methotrexate SQ) 
Ravicti PA
RAYALDEE (calcifediol)
Rayos PA 
RELISTOR (methylnatrexone)
Repatha PA 
Relenza-Tamiflu PA
Repatha (evolocumab) 
Revatio (Sildenafil Citrate) PA
Revlimid PA
Rexulti (Brexpiprazole) 
Rilutek PA 
RISPERDAL CONSTA (risperidone) 
RITALIN (methylphenidate hcl) 
RITALIN LA (methylphenidate hcl) 
RITALIN SR (methylphenidate hcl)
Rosiglitazone PA 
Saizen (Somatropin)
Samsca PA 
Sandostatin PA 
Savaysa 
Savella PA 
SELZENTRY (maraviroc)
Serostim (Somatropin)
SGLT2 Inhibitors 
Signifor PA 
Simponi PA 
Sirturo PA 
Sitavig PA 
SOLODYN (minocycline hcl) 
Somatropin PA 
Somavert PA 
Sovaldi 
Spritam (levetiracetam) 
Sprycel PA 
STAXYN (vardenafil)
STELARA (ustekinumab) 
STENDRA (avanafil)
Stivarga PA 
STRATTERA (atomoxetine hcl) 
STRENSIQ (asfotase alfa) 
Striant (Testosterone)
Suboxone 
Suboxone Subsolv
Subsys PA 
Subutex (Buprenorphine)
Sutent PA 
Sylatron PA 
Symbicort PA 
Symlin PA 
Synagis PA
Synarel PA 
Synribo PA 
Taflinar (Dabrafenib) PA 
Tagrisso (osimertinib) 
Taltz (Ixekizumab) Specialty PA and QL
Tarceva PA 
TARGADOX (doxycycline hyclate)
TARGRETIN (bexarotene) 
Tasigna (nilotinib) 
Tazarotene PA 
Tecfidera 
TECHNIVIE (ombitasvir-paritaprevir-ritonavir)
Testim (Testosterone)
Testopel (Testosterone)
Testred Android Methitest (Methyltestosterone)
Tev-Tropin (Somatropin)
Thalomid PA 
TOPICAL RETINOIDS 
Treprostinil PA 
Treximet PA 
Tretinoin PA 
Triptans 
Trokendi PA 
Tykerb PA 
Tyzeka PA
Utibron Neohaler (indacaterol - glylcopyrrolate)
UPTRAVI (selexipag) 
Vandetanib 
Vecamyl PA 
VELTASSA (patiromer) 
Venclexta (Venetoclax) Specialty w/PA 
Ventavis PA 
VIAGRA (sildenafil)
VIBERZI (eluxadoline) 
Viekira (ombitasvir/paritaprevir/ritonavir/dabuvir)
Vimovo PA 
Vogelxo (Testosterone)
Votrient PA 
VYVANSE (lisdexamfetamine)
Xalkori PA 
Xeljanz PA 
Xenazine PA and QL 
XIFAXAN (rifaximin) 
Xopenex PA 
Xtandi 
Xyrem PA 
ZARXIO (filgrastim/sndz) 
Zavesca PA 
Zelboraf PA 
ZEPATIER (elbasvir-grazoprevir) 
Zinbryta (daclizumab)
Zipsor PA 
Zomacton (Somatropin)
Zorptive (Somatropin)
Zuplenz PA 
ZYDELIG (idelalisib) 
ZYKADIA (ceritinib) 
ZYPREXA RELPREVV (olanzapine) 
Zytiga PA
Zyvox PA
Lomaira (Phentermine HCL)
Phentermine hcl (Phentermine hcl)
Qsymia (Phentermine/Topiramate)
Last Updated:  02/2017