Rx Prior Authorization

Drugs that Require Prior Authorization
 
Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. This approval process is called prior authorization.
 
Drug list/Formulary inclusion does not infer a drug is a covered benefit. Please check your schedule of benefits for coverage information.  
 
Attention Prescribing Providers with members who are enrolled in an Anthem California plan: The California Prescription Drug Prior Authorization Request must be used for all members enrolled in a California plan, regardless of residence. We will be unable to review your request for authorization if it is not submitted on the California Prescription Drug Prior Authorization Request form. The drug specific criteria and forms below are for informational purposes only to assist you in completing the California Prescription Drug Prior Authorization Request form if they are helpful to you. Please fill out the California Prescription Drug Prior Authorization Request form and fax it to (877) 327-8009.
 
Select an authorization document link below to review more information about a specific prior authorization. 
 
Pharmacy Prior Auth Criteria
Drug Name
Quantity Limit
Prior Authorization
Dosage Limit
ABC Multi Source Brand

Abilify

Abstral

 
AcipHex

Actemra

Actiq

Actos
Adalat CC

Adcirca

Adderall

Adipex-P

Adoxa



Advair
Advicor

Aerobid
Aerobid-M
Afinitor

Alamast

Ala-Tet

Aldara
Allegra

Allegra-D

Alocril

Alodox

Alomide

Alsuma

Altoprev


Alvesco
Ambien CR

Amerge
Amevive

Amnesteem

Amphetamine Salt Combination(Generic Adderall XR)

Ampyra

Androderm

Androgel

Anexsia
Anzemet
Apidra

Aplenzin

Aranesp

Arestin

Arixtra

Arthrotec

Asmanex
Atacand

Atacand HCT

Atralin

Atrovent Nasal Spray
Atrovent oral inhaler
Atrovent Soln for inhalation
Avalide

Avandamet

Avandaryl

Avandia

Avapro

Avastin

Avelox
Avidoxy

Avinza
Avita

Avodart

Axert

Axiron

Azelastine Hydrochloride
Azelex

Azmacort
Azor

Balacet
Beconase A.Q.

Benicar

Benicar HCT

Benlysta

BenzaClin

Benzoyl Peroxide Products

Bepreve

Betaseron
Only applies to commercial

Betaseron
Only applies to closed commercial

Birth Control/Contraceptives

Boniva

Bontril SR

Botox

Bravelle

Brovana Solution

Buphenyl

Bydureon

Byetta

Caprelsa

Caduet

Capital w/codeine
Cardene

Cardene S.R.

Cardizem CD 360mg

Cardizem LA

Carimune NF

Caverject

Celebrex

Celexa

Ceredase

Cerezyme

Cetrotide

Chantix

Cialis

Cimzia Kit

Ciprofloxacin (Cipro Tablets)
Claravis

Clarinex

Clarinex D

Clomiphene Citrate

Clozaril

Cocet
Cocet Plus
Colcrys
Combivent
Combunox
Concerta
Copaxone

Covera H.S.

Cozaar

Crestor

Crinone 4%

Crinone 8%

Cymbalta

Darvocet
Daytrana

Declomycin

Depo-Provera

Desoxyn

Dexedrine

Dexilant

Dextrostat

Diabetic Test Strips

Didrex

Diethylpropion

Differin

Dilacor XR

Diovan

Diovan HCT

Doryx

Dose Optimization

Doxycycline

Doxy-Lemmon

Duexis

Dulera
Duragesic
Dynacin

Dynacirc C.R.

Dysport

Edarbi

Edex

Edluar

Effexor XR

Effient

Egrifta

Elelyso

Elestat

Elidel

Eligard

Emadine

Embeda
Emcyt

Enablex

Enbrel

Endometrin

Enteral Nutrition
Epinastine
Epogen

Erbitux

Erivedge

Euflexxa

Exalgo

Exforge

Exforge HCT

Extavia
Only applies to commercial

Extavia
Only applies to closed commercial

Fanapt

FazaClo

Fentanyl - Oral

Fentanyl - Transdermal
Fentora

Fioricet
Firmagon

Flebogamma

Flector

Flolan

Flomax

Flonase

Flovent
Flunisolide

Fluoxetine

Fluvoxamine

Focalin

Focalin/XR

Follistim AQ

Forteo

Fortesta

Fragmin

Frova

Gamastan

Gammagard

Gammaked

Gammaplex

Gamunex

Ganirelix

Gelnique

Genotropin

Geodon

Gilenya

Gleevec

Gonal-F

Granisetron
Granisol
Halaven

Haldol

Herceptin

Hizentra

HP Acthar

Humatrope

Humira

Hyalgan

Hycet
Hydrocodone -acetaminophen
Hyzaar

Imitrex Injection
Imitrex Nasal Inhaler
Imitrex Tablet
Immune Globulin

Incivek

Increlex

Indocin

Inlyta

Innohep

Intron-A

Intuniv

Invega

Jakafi

Kadian
Kalydeco

Kapvay

Kineret

Kuvan

Kytril
Lansoprazole

Lastacaft

Latuda

Lazanda

Lescol


Leukine

Leuprolide Acetate



Levaquin
Levitra

Lexapro

Lipitor


Livalo


Lorcet
Lorcet HD
Lorcet Plus
Lortab
Lovastatin

Lovenox

Loxapine/Loxitane

Lucentis

Lumizyme

Lunesta

Lupron



Lupron Depot



Lupron Depot - PED

Luveris

Luvox

Lyrica

Macugen

Makena

Maxalt
Maxidone 10- 750mg tab
Medroxyprogesterone acetate Injectable

Mellaril

Menopur

Metabolic Infant Formula
Metadate

Methylin

Mevacor

Micardis

Micardis HCT

Minocin



Minocycline HCl, ER



Moban

Monodox

Morgidox



Morphine Sulfate
MS Contin
MSB Medications

Muse

Myobloc

Myozyme

Nalfon

Narcotic Analgesics Combination Products
Nasacort AQ

Nasonex
Navane

Neulasta

Neumega

Neupogen

Nexavar

Nexium

Nicotrol Inhaler

Nicotrol Nasal Spray

Non Formulary Medications

Norco
Norditropin

Noroxin
Norvasc

Novarel

Nucynta
NuOx

Nutridox

Nutropin

Nutropin, AQ

Nuvigil

Octagam

Omeprazole

Omeprazole/Sodium Bicarbonate
Omnaris

Omnitrope

Omontys

Ondansetron
Onglyza


Onsolis

Opana
Opana/ER
Optivar

Oramorph SR
Orap

Oraxyl

Orencia

Orthovisc

Ovidrel

Oxandrin

Oxycodone


Oxycontin
Oxymorphone
Oxytrol

Panlor DC caps
Panlor SS tabs
Pantoprazole

Pataday

Patanol

Paxil

Paxil CR

Peg-Intron

Pegasys

Pennsaid

Percocet
Perforomist
Periostat

Pexeva

Plan B

Plendil

Pravachol

Pravastatin

Pregnyl

Prevacid

Prilosec

Pristiq

Privigen

Procardia XL

Prochieve 4%

Prochieve 8%

Procrit

Prolia

Prolixin/Permitil

Propoxyphene(Darvon and Darvocet)

Proscar

Protonix

Protopic

Provenge

Provigil

Prozac

Pulmicort Respules (suspension)
Pulmicort Turbuhaler (inhaler)
Pulmozyme

Qnasl

Qualaquin

Quantity Supply
Quinine

Qvar
Rebif
Only applies to closed commercial

Relpax

Remicade

Remodulin

Renova

Reprexain
Repronex

Retin-A

Revatio

Revlimid

Rhinocort Aqua

Risperdal

Ritalin

Rituxan

Roferon-A

Roxicet
Rozerem

Rybix ODT
Ryzolt
Saizen

Sanctura

Sanctura XR

Saphris

Sarafem

Semprex-D

Seroquel

Seroquel XR

Serostim

Silenor

Simponi

Simvastatin


Sodium sulfacetamide/sulfur

Solodyn



Sonata

Sotret

Spiriva
Sporanox

Sprycel

Stadol N.S.
Staxyn

Stelara

Stelazine

Stendra

Strattera

Striant

Suboxone

Subsys

Subutex

Sular

Sumatriptan
Sumavel DosePro

Suprenza ODT

Supartz

Supprelin LA

Sutent

Symbicort Inhaler
Synagis

Synarel

Synvisc

Synvisc-One

Tamiflu

Tarceva

Targretin

Tasigna

Tekamlo

Tekturna

Tekturna HTC

Temodar

Testim

Tetracycline HCl

Tev-Tropin

Thalomid

Thorazine (excludes suppositoriesand injectables)

Tiazac

Toradol
Trelstar Depot or LA

Tretin-X

Treximet

Trilafon

Twynsta

Tykerb

Tylenol w/Cod
Tylox
Tyvaso

Uloric

Ultracet
Ultram
Valturna

Vantas Implant

Vectibix

Veletri

Veltin

Venlafaxine ER

Ventavis

Veramyst
Verelan PM

Vfend

Viagra

Vibramycin

Vicodin
Vicoprofen
Victoza

Victrelis

Viibryd

Vivaglobin

Vivitrol

Vopac
Votrient

VPRIV

Vytorin

Vyvanse

Wellbutrin XL

Xalkori

Xiaflex

Xeloda

Xenazine

Xenical

Xeomin

Xgeva

Xifaxan

Xodol
Xolair

Xyzal

Yervoy

Zamicet
Zavesca

Zetia

Zegerid

Zelboraf

Zerlor
Ziana Gel

Zithromax
Zmax
Zocor

Zofran
Zoladex

Zolinza

Zoloft

Zolpimist

Zomig

Zomig nasal spray

Zorbtive

Zuplenz
Zyban

Zydone
Zyprexa

Zytiga

Zyvox

Myorisan

Beyaz

Safyral

Ovcon

Ortho Tri-Cyclen Lo

Norinyl

Natazia

Loestrin Fe

Lo Loestrin Fe

Generess Fe

Zetonna

Korlym

Magnacet

Primlev

Xolox

Januvia

Tradjenta

Avonex
Only applies to closed commercial

Bosulif

Xtandi

Relenza
Aubagio

Stivarga

Bontril PDM

Dymista

Isotretinoin
Nulojix

Femara

Berinert

Cinryze

Firazyr

Kalibitor

Picato

Solaraze

Soliris

Xeljanz

Adcetris

Eylea

Neutroval

Buproban

Bupropion SR

Jetrea

Pomalyst

Kyprolis

Perjeta

Zaltrap

Zyclara

Nesina

Diltiazem ER

Wellbutrin SR

Eliphos

PhosLo

Phoslyra

Fosrenol

RenaGel

Tecfidera

Menekist
Arimidex

Fulyzaq
Gattex

Juxtapid

Kynamro

Ravicti

Niacin ER

Zenzedi

Invokana

Oseni

Kombiglyze XR

Kazano

Jentadueto

Juvisync

Janumet

Janumet XR

Gilotrif

Liptruzet

Migranal

Zubsolv

Bivigam

Octagam

Olysio

Sovaldi

Granix

Diclegis

Procysbi

1. Health Care Reform Formulary Exception Criteria
Lomedia

Versacloz

Khedezla

Osphena

Aromasin

Fargixa

2. Quantity Limit
Reclast

Mozobil

Lovaza

Vascepa

Niaspan ER

Zohydro ER

Velphoro

Ilaris

Tadalafil

Gazyva

Zykadia

Grastek

Oralair

Arzerra

Kadcyla

Auvi – Q

Ragwitek

Hetlioz

Xyrem

Entyvio

Purixan

Brintellix

Arzerra

Esomeprazole Strontium

Cyramza

Prialt

Testopel

Promacta

Harvoni (ledipasvir / sofosbuvier)

Ofev (nintedanib)

Esbriet (pirfenidone)
Detrol (tolterodine tartrate)

Ditropan (oxybutynin chloride)

Sivextro (tedizolid phosphate)

Vimovo (naproxen/esomeprazole mag)

Xartemis (oxycodone hcl/acetaminophen)

Zipsor (diclofenac potassium)

Zovirax (acyclovir)