Prior Authorization for Drugs Covered Under the Medical Benefit 

Prior authorization is required for the following drugs 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. The drugs listed below are covered under the medical benefit as they are typically administered in an office, home, or outpatient setting. Click on the drug name below to view the specific prior authorization guidelines. You can also download a pdf version of the Medical Prior Authorization List which lists those drugs requiring prior authorization that are covered under the medical benefit.

Unless otherwise stated, please call the Pharmacy Management Department at 330-996-8805 to initiate the prior authorization process for these items.

Prior Authorization List for Drugs Covered Under the Medical Benefit - Commercial (updated August 2016)
Prior Authorization List for Drugs Covered Under the Medical Benefit - Medicare (updated June 2016)
Prior Authorization Request Form for Drugs Covered Under the Medical Benefit

 

Drugs covered under the medical benefit:

ABILIFY MAINTENA (aripirazole)
ACTEMRA SQ (tocilizumab)
ACTEMRA IV (tocilizumab)
ACTHAR GEL (corticotropin)
ADAGEN (pegademase)
ALDURAZYME (laronidase)
ARALAST (alpha proteinase inhibitor)
ARCALYST (rilonacept)
ARISTADA (aripiprazole)
ARZERRA (ofatumumab)
AVONEX (interferon beta-1a)
BAVENCIO (avelumab) 
BELEODAQ (belinostat)
BENLYSTA (belimumab)
BIVIGAM (immune globulin)
BLINCYTO (blinatumomab)
BONIVAIV (ibandronate) 
BOTOX (onabotulinumtoxina)
CARIMUNE (immune gobulin)
CAYSTON (aztreonam inhaled)
CEREZYME (imiglucerase)
CIMZIA (certolizumab pegol)
CINQAIR (reslizumab)
CINRYZE (C1 inhibitor, human)
Cuvitru
CYRAMZA (ramucirumab)
Darzalex (daratumumab)
DYSPORT (abobotulinumtoxina)
ELAPRASE (idursulfase)
ELELYSO (taliglucerase)
EMPLICITI (elotuzumab)
ENTYVIO (vedolizumab)
ERBITUX (cetuximab)
EXONDYS 51 (ETEPLIRSEN)
FABRAZYME (agalsidase)
FLEBOGAMMA (immune gobulin)
FLOLAN (epoprostenol)
GAMASTAN (immune gobulin)
GAMMAGARD (immune gobulin)
GAMMAKED (immune globulin)
GAMMAPLEX (immune globulin)
GAMUNEX-C (immune globulin)
GAZYVA (obinutuzumab)
GLASSIA (proteinase inhibitor)
GRANIX (TBO-filgrastim)
HALAVEN (eribulin mesylate)
HERCEPTIN (trastuzumab)
HIZENTRA (immune globulin, sq)
HYQVIA (immune globulin)
ILARIS (canakinumab)
IMLYGIC (talimogene)
INFLECTRA (infliximab-dyyb)
INVEGA SUSTENNA (paliperidone palmitate)
INVEGA TRINZA (paliperidone palmitate)
KADCYCLA (trastuzumab emtansine)
KANUMA (sebelipase)
KEYTRUDA (pembrolizumab)
KRYSTEXXA (pegloticase)
KYPROLIS (carfilzomab)
LEMTRADA (alemtuzumab)
LEUKINE (sargramostim)
LUMIZYME (alglucosidase)
LUPRON DEPOT (leuprolide acetate)
MARQIBO (vincristine sulfate liposome injection)
MOZOBIL (plerixafor)
MYOBLOC (rimabotulinumtoxinb)
NAGLAZYME (galsulfase)
N-PLATE (romiplostim)
NUCLALA (mepolizumab)
NULOJIX (belatacept)
OCREVUS (ocrelizumab)
OCTOGAM (immune globulin)
OFIRMEV (acetaminophen)
ONIVYDE (irinotecan)
OPDIVO (nivolumab)
ORENCIA IV (abatacept/maltose)
PERJETA (pertuzumab)
PORTRAZZA (necitumumab)
PRIVIGEN (immune globulin)
PROLASTIN (alpha proteinase inhibitor)
PROLIA (denosumab)
PROVENGE (sipuleucel-T)
QUTENZA (capsaicin 8% patch)
RECLAST (zoledronic acid)
REMICADE (infliximab)
RISPERDAL CONSTA (risperidone)
RITUXAN (rituximab)
SIGNIFOR LAR (pasireotide pamoate)
SIMPONI ARIA (golimumab)
SOLIRIS (eculizumab)
SPINRAZA (nusinersen)
STELARA (ustekinumab)
SUPPRELIN LA (histrelin acetate)
SYLVANT (siltuximab)
SYNAGIS (palivizumab)
SYNRIBO (omacetaxine mepesuccinate)
Tecentriq (atezolizumab)
TEFLARO (ceftaroline fosamil)
TEMODAR oral (temozolomide)
TESTOPEL (testosterone pellets, implant)
TYSABRI (natalizumab)
Tyvaso
VECTIBIX (panitumumab)
VENTAVIS (iloprost)
VORAXAZE (glucarpidase)
VPRIV (velaglucerase)
XEOMIN (incobotulinumtoxina)
XGEVA (denosumab)
XIAFLEX (collagenase clostridium histolyticum)
XOFIGO (radium Ra 223 dichloride)
XOLAIR (omalizumab)
YERVOY (ipilimumab)
YONDELIS (trabectedin)
ZALTRAP (ziv-aflibercept)
ZEMAIRA (alpha proteinase inhibitor)
ZOLADEX (goserelin acetate implant)
ZYPREXA RELPREVV (olanzapine pamoate)

Last Updated: 05/2017