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)
ACTIMMUNE (interferon gamma) 
Adapalene PA 
Adapalene/Benzoyl Peroxide PA 
Adcirca (Tadalafil) PA
ADDERALL (dextroamphetamine-amphetamine) 
ADDERALL XR (dextroamphetamine-amphetamine)
ADEMPAS (riociguat)
ADOXA (doxycycline monohydrate) 
ADZENYS ER (amphetamine)
ADZENYS XR-ODT (dextroamphetamine/amphetamine base)
AFINITOR (everolimus) 
AFREZZA (insulin regular, human, inhaled)
ALECENSA (alectinib) 
Aliskiren PA
ALUNBRIG (brigatinib)
Ambrisentan PA 
Ampyra PA
ANDRODERM (testosterone)
ANDROGEL (testosterone)
ANDROID (methyltestosterone)
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 (bosutinib)
BRISDELLE (paroxetine)
Bunavail (Buprenorphine/Naloxone)
CABOMETYX (cabozantinib s-malate)
CALQUENCE (acalabrutinib)
Cambia PA
Caprelsa PA
Caverject-Edex PA 
Cayston PA 
CELEBREX (celecoxib) - effective June 1, 2018
CERDELGA (eliglustat) 
CESAMET (nabilone) 
Cetirizine PA 
Cholbam PA
CIALIS (tadalafil)
CIMZIA (certolizumab)
CLENPIQ (sod picosulf/magox/citric ac) 
Clindamycin/Tretinoin PA 
Crinone Prochieve Endometrin
COLYTE (peg3350/sod sulf, bicarb, cl/kcl) 
COMETRIQ (cabozantinib s-malate)
CONCERTA (methylphenidate hcl)
COREMINO (minocycline 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)
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)
DYNAVEL XR (amphetamine)
Effient 
Embeda PA
EMFLAZA (deflazacort)
ENBREL (etanercept)
ENDOMETRIN (progesterone micronized)
EPCLUSA (sofobuvir-velpatasvir)
EPOGEN (epoetin alpha) 
Erivedge PA
ERLEADA (apalutamide)
ESBRIET (pirfenidone) 
Evekeo (amphetamine)
EVISTA (raloxifene)
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)
Fycompa PA 
Gattex PA
GAVILYTE-C (peg3350/sod sulf, bicarb, cl/kcl)
GAVILYTE-G (peg3350/sod sulf, bicarb, cl/kcl)
GAVILYTE-H AND BISACODYL (bisac/nacl/nahco3/kcl/peg3350)
GAVILYTE-N (nacl/nahco3/kcl/peg)
Genotropin (Somatropin)
GILENYA (FINGOLIMOD)
GILOTRIF (afatinib)
Gleevec PA 
GLP-1 Analogs PA (Byetta, Bydureon, Tanzeum, Trulicity, Victoza)
Glyxambi PA

GOCOVRI (amantadine)
GOLYTELY (peg3350/sod sulf, bicarb, cl/kcl)
Gosereline Acetate PA 
GRANIX (tbo-filgrastim)
GROWTH HORMONE
HALFLYTELY-BISACODYL(bisac/nacl/nahco3/kcl/peg3350)
HARVONI (ledipasvir-sofosbuvir)
HAEGARDA (c1 esterase inhibitor, human)
Hemangeol PA 
Hizentra (immune globin)
HP ACTHAR (repository corticotropin injection)
Humatrope (Somatropin)
HUMIRA (adalimumab) 
Hydromorphone PA
HYQVIA
HYQVIA IG Component (IGG/hyaluronidase, recombinant) 
IBRANCE (palbociclib) 
ICLUSIG (ponatinib) 
IDHIFA (enasidenib)
IMBRUVICA (ibrutinib)
IMPAVIDO (miltefosine)
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
KISQALI (ribociclib)
Korlym PA 
Kuvan PA 
Kynamro PA
Latuda (Lurasidone)
Lazanda PA
LETAIRIS (ambrisentan) 
Lenvima PA 
LEVITRA (vardenafil)
Levocetirizine PA 
Leukine PA 
Leuprolide Acetate PA 
Linzess 
Long-Acting Beta Agonist Inhalers PA 
Lonsurf (trifluridine) 
Lumigan PA 
Lumizyme 
LYNPARZA (olaparib)
MAVYRET (glecaprevir-pibrentasvir)
MEKINIST (trametinib) 
METADATE CD (methylphenidate hcl) 
METADATE ER (methylphenidate hcl)
MIRCERA (methoxy peg-epoetin beta)
METHITEST (methyltestosterone)
METHYLIN (methylphenidate hcl)
Minocycline HCL PA 
MONDOXYNE NL (doxycycline monohydrate)
MONODOX (doxycycline monohydrate)
Morphine Sulfate PA
MOVIPREP (peg3350/sod sul/nacl/asb/c/kcl)
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 
NULYTELY (nacl/nahco3/kcl/peg)
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
OPIOID CUMULATIVE DOSING OVERRIDE
OPSUMIT (macitentan)
ORACEA (doxycycline monohydrate) 
ORENCIA (abatacept)
ORENITRAM (treprostinil)
ORFADIN (NITISINONE)
ORFADIN (nitisinone)
ORKAMBI (lumacaftor-Ivacaftor)
OSMOPREP (naphos m-b m-h/naphos, di-ba)
OTEZLA (Apremilast)
Oxtrella PA 
Oxycodone PA 
Oxymorphone PA 
PDE5 Inhibitors for PAH
PEG-3350 AND ELECTROLYTES (peg3350/sod sulf, bicarb, cl/kcl
PEG 3350-ELECTROLYTE (nacl/nahco3/kcl/peg)
PEG-PREP (bisac/nacl/nahco3/kcl/peg3350)
PEGASYS (peginterferon alfa-2a)
PEGASYS PROCLICK (peginterferon alfa-2a)
PEGINTRON (peginterferon alfa-2b)
Pegfilgrastim PA 
Plegridy PA 
POMALYST (pomalidomide) 
Potiga PA and ST 
PRALUENT (alirocumab)
PREPOPIK (sod picosulf/magox/citric ac)
PREVYMIS (letermovir) 
PROCENTRA (dextroamphetamine sulfate) 
PROCRIT (epoetin alpha)
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
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 
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)
SUCLEAR (peg3350-bowel 2)
SUPREP (sod/k/mag sulfate)
SUTENT (sunitinib) 
Sylatron PA 
Symbicort PA
SYMDEKO (tezacaftor-ivacaftor) 
Symlin PA 
Synagis PA
Synarel PA 
Synribo PA 
TAFINLAR (dabrefenib)
Tagrisso (osimertinib)
TALTZ (ixekizumab)
TARCEVA (erlotinib) 
TARGADOX (doxycycline hyclate)
TARGRETIN (bexarotene) 
Tasigna (nilotinib) 
Tazarotene PA 
Tecfidera 
TECHNIVIE (ombitasvir-paritaprevir-ritonavir)
TESTIM (testosterone)
Testopel (Testosterone)
TESTRED (methyltestosterone)
Tev-Tropin (Somatropin)
Thalomid PA 
TOPICAL RETINOIDS
TRACLEER (bosentan) 
TREMFYA (guselkumab)
Treximet PA 
Tretinoin PA
TRILYTE PACKETS (nacl/nahco3/kcl/peg)
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)
VERZENIO (abemaciclib)
VIAGRA (sildenafil)
VIBERZI (eluxadoline) 
VIEKIRA (ombitasvir-paritaprevir-ritonavir-dasabuvir)
Vimovo PA 
VOGELXO (testosterone)
VOSEVI (sofosbuvir/velpatasvir/voxilaprevir)
Votrient PA 
VYVANSE (lisdexamfetamine)
Xalkori PA
XELJANZ (tofacitinib)
Xenazine PA and QL
XERMELO (telotristat)
XIFAXAN (rifaximin)
Xopenex PA 
Xtandi 
XYREM (sodium oxybate)
ZARXIO (filgrastim/sndz) 
Zavesca PA
ZEJULA (niraparib)
ZELBORAF (vemurafenib) 
ZEPATIER (elbasvir-grazoprevir) 
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:  06/2018