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 SQ (tocilizumab)
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 (insulin regular, human, inhaled)
ALECENSA (alectinib) 
Aliskiren PA
ALUNBRIG (brigatinib)
Ambrisentan PA 
Ampyra PA
Androderm (Testosterone)
Androgel (Testosterone) Antipsoriatic Agents 
APOKYN (apomorphone)
APTENSIO XR (methylphenidate hcl)
Aptiom PA 
Aranesp (darbepoetin)
Arava PA 
Arcalyst PA 
ARISTADA 
ARZERRA (ofatumumab)
AUBAGIO (TERIFLUNOMIDE)
AUSTEDO (deutetrabenazine)
AVIDOXY (doxycycline monohydrate)
Axiron (Testosterone)
BENLYSTA (belimumab)
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)
COTEMPLA XR-ODT (methylphenidate hcl)
CRINONE (progesterone micronized)
Cuprimine (Penicillamine)
Cuvitru (Immun glob G(IGG)/Pro/Iga 0-50)
Cystaran PA 
DAKLINZA (daclatasvir)
Daliresp PA
Daraprim (pyrimethamine)
DHE PA
DEFERASIROX
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) 
Dificid PA 
DORYX (doxycycline hyclate)
DORYX MPC (doxycycline hyclate)
Doxycycline Monohydrate PA
Doxycycline Hyclate PA 
Duexis PA
DUPIXENT (dupilumab)
Durlaza (Aspirin ER) 
Effient 
Embeda PA
EMFLAZA (deflazacort)
ENBREL (etanercept)
ENDOMETRIN (progesterone micronized)
Endothelin Receptor Antagonists
Epculsa (SOFOSBUVIR-VELPATASVIR)
Epogin (Epoetin alfa) 
Erivedge PA 
Erythropoiesis Stimulating Agents (epoetin) 
ESBRIET (pirfenidone) 
Evekeo (amphetamine) 
EXJADE 
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 (ledipasvir/sofosbuvir)
HAEGARDA (c1 esterase inhibitor, human)
Hemangeol PA 
Hizentra (immune globin)
Humatrope (Somatropin)
HUMIRA (adalimumab) 
Hydromorphone PA
HYQVIA
HYQVIA IG Component (IGG/hyaluronidase, recombinant) 
IBRANCE (palbociclib) 
ICLUSIG (ponatinib) 
IDHIFA (enasidenib)
IMBRUVICA (ibrutinib)
INGREZZA (valbenazine)
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 (ivacaftor)
Kerydin (tavaborole)
KEVEYIS (dichlorphenamide)
KEVZARA (sarilumab)
Kineret PA
KISQUALI (ribociclib)
Korlym PA 
Kuvan PA 
Kynamro PA
Latuda (Lurasidone)
Lazanda PA 
Lenvima PA 
LEVITRA (vardenafil)
Levocetirizine PA 
Leukine PA 
Leuprolide Acetate PA 
Linzess 
Long-Acting Beta Agonist Inhalers PA 
Lonsurf (trifluridine) 
Lumigan PA 
Lumizyme 
Lynparza
MAVYRET (glecaprevir/pibrentasvir)
MEKINIST (trametinib) 
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 (metreleptin)
MYDAYIS (dextroamphetamine/amphetamine)  
MS Agents 
Namzaric PA
Natesto (Testosterone)
Natpara PA
NERLYNX (neratinib)
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 (armodafinil)

Ocaliva (obeticholic)
Odomzo (sonidegib)
OFEV (momtedamob)
Oforta
OLYSIO (simeprevir)
Omnitrope (Somatropin)
Onfi PA
ORACEA (doxycycline monohydrate) 
ORENCIA (abatacept)
ORENITRAM (treprostinil)
ORFADIN (NITISINONE)
ORFADIN (nitisinone)
ORKAMBI (lumacaftor-Ivacaftor)
OTEZLA (Apremilast)
Oxtrella PA 
Oxycodone PA 
Oxymorphone PA 
Pegasys-Pegintron (eginterferon) PA 
PDE5 Inhibitors for PAH
Pegfilgrastim PA 
Plegridy PA 
POMALYST (pomalidomide) 
Potiga PA and ST 
PRALUENT (alirocumab) 
PROCENTRA (dextroamphetamine sulfate) 
Procrit (epoetin alfa)
Procysbi PA 
Promacta PA 
PROVIGIL (modafinil)
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 (evolocumab)
Relenza-Tamiflu PA
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 
RUBRACA (rucaparib)
RYDAPT (midostaurin)
Saizen (Somatropin)
Samsca PA 
Sandostatin PA 
Savaysa 
Savella PA 
SELZENTRY (maraviroc)
Serostim (Somatropin)
SGLT2 Inhibitors 
Signifor PA
SILIQ (brodalumab)
Simponi PA 
SIRTURO (bedaquiline) 
Sitavig PA 
SOLODYN (minocycline hcl) 
Somatropin PA 
Somavert PA 
SOVALDI (sofosbuvir) 
Spritam (levetiracetam) 
Sprycel PA 
STAXYN (vardenafil)
STELARA (ustekinumab) 
STENDRA (avanafil)
STIVARGA (regorafenib) 
STRATTERA (atomoxetine hcl) 
STRENSIQ (asfotase alfa) 
Striant (Testosterone)
Suboxone 
Suboxone Subsolv
Subsys PA 
Subutex (Buprenorphine)
SUTENT (sunitinib) 
Sylatron PA 
Symbicort PA 
Symlin PA 
Synagis PA
Synarel PA 
Synribo PA 
TAFINLAR (dabrefenib)
Tagrisso (osimertinib) 
Taltz (Ixekizumab) Specialty PA and QL
TARCEVA (erlotinib) 
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 
TREMFYA (guselkumab)
Treximet PA 
Tretinoin PA 
Triptans
Tykerb PA
TYMLOS (abaloparatide)
TYVASO (treprostinil)
Tyzeka PA
Utibron Neohaler (indacaterol - glylcopyrrolate)
UPTRAVI (selexipag) 
Vandetanib 
Vecamyl PA 
VELTASSA (patiromer) 
Venclexta (Venetoclax) Specialty w/PA 
VENTAVIS (iloprost) 
VIAGRA (sildenafil)
VIBERZI (eluxadoline) 
Viekira (ombitasvir/paritaprevir/ritonavir/dabuvir)
Vimovo PA 
Vogelxo (Testosterone)
VOSEVI (sofosbuvir/velpatasvir/voxilaprevir)
Votrient PA 
VYVANSE (lisdexamfetamine)
Xalkori PA 
Xeljanz PA 
Xenazine PA and QL
XERMELO (telotristat)
XIFAXAN (rifaximin) 
Xopenex PA 
Xtandi 
XYREM (sodium oxybate)
ZARXIO (filgrastim/sndz) 
Zavesca PA
ZEJULA (niraparib)
Zelboraf PA 
ZEPATIER (elbasvir-grazoprevir) 
Zinbryta (daclizumab)
Zipsor PA 
Zomacton (Somatropin)
Zorptive (Somatropin)
Zuplenz PA 
ZYDELIG (idelalisib) 
ZYKADIA (ceritinib) 
ZYPREXA RELPREVV (olanzapine) 
ZYTIGA (abiraterone) 
Zyvox PA
Lomaira (Phentermine HCL)
Phentermine hcl (Phentermine hcl)
Qsymia (Phentermine/Topiramate)
Last Updated:  09/2017