Rx Prior Authorization

View prior authorization information for plans in California, Georgia, or New York.
 
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 patients enrolled in a Colorado health plan: The Colorado Prescription Drug Prior Authorization Request form may now be used to submit prior authorization requests for members enrolled in a Colorado health plan. You may also choose to continue to use the drug specific forms which are provided below along with the drug specific criteria. Requests for prior authorization may also be submitted by phone by calling 866-310-3666 or through our secure electronic portal located at https://express-scripts.covermymeds.com/. To learn more about required Colorado timelines for decisions regarding prior authorization requests, please click here.
 
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 (aripiprazole)

Abstral (fentanyl citrate)

 
AcipHex (rabeprazole sodium)

Actemra (tocilizumab)

Actiq (fentanyl citrate)

Actos (pioglitazone hcl)
Adalat CC (nifedipine er)

Adcirca (tadalafil)

Adderall (amphetamine salt combo)

Adipex-P (phentermine hcl)

Adoxa (doxycycline monohydrate)



Advair (fluticasone/salmeterol)
Advicor (niacin/lovastatin)

Afinitor (everolimus)

Alamast (pemirolast potassium)

Aldara (imiquimod)
Allegra (fexofenadine hcl)

Allegra-D (fexofenadine/pseudoephedrine)

Alocril (nedocromil sodium)

Alodox (doxycycline/eyelid clns no.2&3)

Alomide (lodoxamide tromethamine)

Alsuma (sumatriptan succinate)

Altoprev (lovastatin)


Alvesco (ciclesonide)
Ambien CR (zolpidem tartrate er)

Amerge (naratriptan hcl)
Amevive (alefacept)

Amnesteem (isotretinoin)

Amphetamine Salt Combination (Generic Adderall XR)

Ampyra (dalfampridine)

Androderm (testosterone)

Androgel (testosterone)

Anzemet (dolasetron mesylate)
Antipsychotic Medications

Apidra (insulin glulisine)

Aplenzin (bupropion hbr)

Aranesp (darbepoetin alfa in polysorbat)

Arestin (minocycline hcl microspheres)

Arixtra (fondaparinux sodium)

Arthrotec (diclofenac sodium-misoprostol)

Asmanex (mometasone furoate)
Atacand (candesartan cilexetil)

Atacand HCT (candesartan-hydrochlorothiazid)

Atralin (tretinoin)

Atrovent Nasal Spray (ipratropium bromide)
Atrovent oral inhaler (ipratropium bromide)
Atrovent Soln for inhalation (ipratropium bromide)
Avalide (irbesartan/hydrochlorothiazide)

Avandamet (rosiglitazone/metformin hcl)

Avandaryl (rosiglitazone/glimepiride)

Avandia (rosiglitazone maleate)

Avapro (irbesartan)

Avastin (bevacizumab)

Avelox (moxifloxacin hcl)
Avidoxy (doxycycline monohydrate)

Avinza (morphine sulfate er)
Avita (tretinoin)

Avodart (dutasteride)

Axert (almotriptan malate)
Axiron (testosterone)

Azelastine Hydrochloride (azelastine hcl)
Azelex (azelaic acid)

Azor (amlodipine bes/olmesartan med)

Beleodaq (belinostat)

Benicar (olmesartan medoxomil)

Benicar HCT (olmesartan/hudrochlorothiazide)

Benlysta (belimumab)

BenzaClin (clindamycin phos/benzoyl perox)

Benzoyl Peroxide Products (benzoyl peroxide )

Bepreve (bepotastine besilate)

Betaseron (interferon beta-1b)
Only applies to commercial

Birth Control/Contraceptives

Bontril SR (phendimetrazine tartrate)

Botox (onabotulinumtoxina)

Bravelle (urofollitropin)

Brovana Solution (arformoterol tartrate)

Bunavail (buprenorphine with naloxone)

Buphenyl (sodium phenylbutyrate)

Buprenorphine with naloxone (generic Suboxone)

Bydureon (exenatide microspheres)

Byetta (exenatide)

Caprelsa (vandetanib)

Caduet (amlodipine-atorvastatin)

Capital w/codeine (acetaminophen with codeine)
Cardene (nicardipine in dextrose,iso-os)

Cardene S.R. (nicardipine hcl)

Cardizem CD 360mg (diltiazem hcl)

Cardizem LA (diltiazem hcl)

Carimune NF (immune globulin, gamma)

Caverject (alprostadil)

Celebrex (celecoxib)

Celexa (citalopram hbr)

Ceredase (alglucerase)

Cerezyme (imiglucerase)

Cetrotide (cetrorelix acetate)

Chantix (varenicline tartrate)

Cialis (tadalafil)

Cimzia Kit (certolizumab pegol)

Ciprofloxacin (Cipro Tablets)
Claravis (isotretinoin)

Clarinex (desloratadine)

Clarinex D (desloratadine)

Clomiphene Citrate (clomiphene citrate)

Clozaril (clozapine)

Cocet (acetaminophen with codeine)
Cocet Plus (acetaminophen with codeine)
Colcrys (colchicine)
Combivent (ipratropium/albuterol sulfate)
Combunox (ibuprofen/oxycodone hcl)
Concerta (methylphenidate er)
Copaxone (glatiramer acetate)

Cosentyx (secukinumab)

Covera H.S. (verapamil hcl)

Cozaar (losartan potassium)

Crestor (rosuvastatin calcium)

Crinone 4% (progesterone,micronized)

Crinone 8% (progesterone,micronized)

Cymbalta (duloxetine hcl)

Daytrana (methylphenidate)

Depo-Provera (medroxyprogesterone acetate)

Desoxyn (methamphetamine hcl)

Dexedrine (dextroamphetamine sulfate er)

Dexilant (dexlansoprazole)

Diabetic Test Strips

Didrex (benzphetamine hcl)

Diethylpropion (diethylpropion hcl)

Differin (adapalene)

Dilacor XR (diltia xt)

Diovan (valsartan)

Diovan HCT (valsartan-hydrochlorothiazide)

Doryx (doxycycline hyclate)

Dose Optimization

Doxycycline (doxycycline monohydrate)

Duexis (ibuprofen/famotidine)

Dulera (mometasone/formoterol)
Duragesic (fentanyl)
Dynacin (minocycline hcl)

Dynacirc C.R. (isradipine)

Dysport (abobotulinumtoxina)

Edarbi (azilsartan medoxomil)

Edex (alprostadil)

Edluar (zolpidem tartrate)

Effexor XR (venlafaxine hcl er)

Effient (prasugrel hcl)

Egrifta (tesamorelin acetate)

Elelyso (taliglucerase alfa)

Elestat (epinastine hcl)

Elidel (pimecrolimus)

Eligard (leuprolide acetate)

Emadine (emedastine difumarate)

Embeda (morphine sulfate/naltrexone)

Emcyt (estramustine phosphate sodium)

Enablex (darifenacin hydrobromide)

Enbrel (etanercept)

Endometrin (progesterone,micronized)

Enteral Nutrition
Epinastine (epinastine hcl)
Epogen (epoetin alfa)

Erbitux (cetuximab)

Erivedge (vismodegib)

Euflexxa (hyaluronate sodium)

Exalgo (hydromorphone er)

Exforge (amlodipine/valsartan)

Exforge HCT (amlodipine/valsartan/hcthiazid)

Extavia (interferon beta-1b)
Only applies to commercial

Fanapt (iloperidone)

FazaClo (clozapine)

Fentanyl - Oral (fentanyl)

Fentanyl - Transdermal (fentanyl)
Fentora (fentanyl citrate)

Fioricet (butalbital/apap/caffeine)
Firmagon (degarelix acetate)

Flebogamma (immune globulin, gamma)

Flector (diclofenac epolamine)

Flolan (epoprostenol sodium (glycine))

Flomax (tamsulosin hcl)

Flonase (fluticasone propionate)

Flovent (fluticasone propionate)
Flunisolide (flunisolide)

Fluoxetine (fluoxetine hcl)

Fluvoxamine (fluvoxamine maleate)

Focalin (dexmethylphenidate hcl)

Focalin/XR (dexmethylphenidate hcl)

Follistim AQ (follitropin beta,recomb)

Forteo (teriparatide)

Fortesta (testosterone)

Fragmin (dalteparin sodium,porcine)

Frova (frovatriptan succinate)
Gamastan (immune globulin, gamma)

Gammagard (immune globulin, gamma)

Gammaked (immune glob,gam caprylate(igg))

Gammaplex (immune globulin,gamma(igg))

Gamunex (immune glob,gam caprylate(igg))

Ganirelix (ganirelix acetate)

Gelnique (oxybutynin)

Genotropin (somatropin)

Geodon (ziprasidone mesylate)

Gilenya (fingolimod hcl)

Gleevec (imatinib mesylate)

Gonal-F (follitropin alfa, recomb)

Granisetron (granisetron hcl)
Granisol (granisetron hcl)
Halaven (eribulin mesylate)

Haldol (haloperidol)

Herceptin (trastuzumab)

Hizentra (immune globulin,gamma(igg))

HP Acthar (corticotropin)

Humatrope (somatropin)

Humira (adalimumab)

Hyalgan (hyaluronate sodium)

Hycet (hydrocodone w/acetaminophen)
Hydrocodone -acetaminophen (hydrocodone/acetaminophen)
Hyzaar (losartan-hydrochlorothiazide)

Imitrex Injection (sumatriptan succinate)
Imitrex Nasal Inhaler (sumatriptan succinate)
Imitrex Tablet (sumatriptan succinate)
Immune Globulin

Incivek (telaprevir)

Increlex (mecasermin)

Indocin (indomethacin)

Inlyta (axitinib)

Innohep (tinzaparin sodium,porcine)

Intron-A (interferon alfa-2b,recomb)

Intuniv (guanfacine hcl)

Invega (paliperidone)

Jakafi (ruxolitinib phosphate)

Kadian (morphine sulfate)
Kalydeco (ivacaftor)

Kapvay (clonidine hcl)

Kineret (anakinra)

Kuvan (sapropterin dihydrochloride)

Kytril (granisetron hcl)
Lansoprazole (lansoprazole)

Lastacaft (alcaftadine)

Latuda (lurasidone hcl)

Lazanda (fentanyl citrate)

Lescol (fluvastatin sodium)


Leukine (sargramostim)

Leuprolide Acetate (leuprolide acetate)



Levaquin (levofloxacin hemihydrate)
Levitra (vardenafil hcl)

Lexapro (escitalopram oxalate)

Lipitor (atorvastatin calcium)


Livalo (pitavastatin calcium)


Lorcet (hydrocodone/acetaminophen)
Lorcet HD (hydrocodone/acetaminophen)
Lorcet Plus (hydrocodone w/acetaminophen)
Lortab (hydrocodone/acetaminophen)
Lovastatin (lovastatin)

Lovenox (enoxaparin sodium)

Loxapine/Loxitane (loxapine succinate)

Lucentis (ranibizumab)

Lumizyme (alglucosidase alfa)

Lunesta (eszopiclone)

Lupron (leuprolide acetate)



Lupron Depot (leuprolide acetate)



Lupron Depot - PED (leuprolide acetate)

Luveris (lutropin alfa)

Luvox (fluvoxamine maleate)

Lyrica (pregabalin)

Macugen (pegaptanib sodium)

Makena (hydroxyprogesterone caproate)

Maxalt (rizatriptan)
Maxidone 10- 750mg tab (hydrocodone/acetaminophen)
Medroxyprogesterone acetate Injectable (medroxyprogesterone acetate)

Menopur (menotropins)

Metabolic Infant Formula
Metadate (methylphenidate hcl)

Methylin (methylphenidate hcl)

Mevacor (lovastatin)

Micardis (telmisartan)

Micardis HCT (telmisartan-hydrochlorothiazid)

Minocin (minocycline hcl)



Minocycline HCl, ER (minocycline hcl)



Moban (molindone hcl)

Monodox (doxycycline monohydrate)

Morgidox (doxycycline/skin cleanser #19)



Morphine Sulfate (morphine sulfate)
MS Contin (morphine sulfate er)
MSB Medications

Muse (alprostadil)

Myobloc (rimabotulinumtoxinb)

Myozyme (alglucosidase alfa)

Nalfon (fenoprofen calcium)

Narcotic Analgesics Combination Products
Nasacort AQ (triamcinolone acetonide)

Nasonex (mometasone furoate)
Navane (thiothixene)

Neulasta (pegfilgrastim)

Neumega (oprelvekin)

Neupogen (filgrastim)

Nexavar (sorafenib tosylate)

Nexium (esomeprazole strontium)

Nicotrol Inhaler (nicotine)

Nicotrol Nasal Spray (nicotine)

3. Non Formulary Medications

4. CT Step Therapy Mandate
5. HIX Non Formulary Medications

Norco (hydrocodone w/acetaminophen)
Norditropin (somatropin)

Noroxin (norfloxacin)
Norvasc (amlodipine besylate)

Novarel (chorionic gonadotropin, human)

Nucynta (tapentadol hcl)
NuOx (benzoyl peroxide/sulfur)

Nutridox (doxycycline/omega-3 #1/eye msk)

Nutropin (somatropin)

Nutropin, AQ (somatropin)

Nuvigil (armodafinil)

Octagam (immune globulin,g(igg)/maltose)

Omeprazole (omeprazole)

Omeprazole/Sodium Bicarbonate (omeprazole)

Omnaris (ciclesonide)

Omnitrope (somatropin)

Omontys (peginesatide)

Ondansetron (ondansetron hcl)
Onglyza (saxagliptin hcl)


Onsolis (fentanyl citrate)

Opana (oxymorphone hcl)
Opana/ER (oxymorphone hcl)
Optivar (azelastine hcl)

Oramorph SR (morphine sulfate er)
Orap (pimozide)

Oraxyl (doxycycline hyclate)

Orencia (abatacept)

Orthovisc (hyaluronate sodium)

Ovidrel (choriogonadotropin alfa)

Oxandrin (oxandrolone)

Oxycodone (oxycodone hcl)


Oxycontin (oxycodone hcl)
Oxymorphone (oxymorphone hcl)
Oxytrol (oxybutynin)

Panlor DC caps (dhcodeine bt/acetaminophn/caff)
Panlor SS tabs (dhcodeine bt/acetaminophn/caff)
Pantoprazole (pantoprazole sodium)

Pataday (olopatadine hcl)

Patanol (olopatadine hcl)

Paxil (paroxetine hcl)

Paxil CR (paroxetine hcl)

Peg-Intron (peginterferon alfa-2b)

Pegasys (peginterferon alfa-2a)

Pennsaid (diclofenac sodium)

Percocet (endocet)
Perforomist (formoterol fumarate)
Periostat (doxycycline hyclate)

Pexeva (paroxetine mesylate)

Plan B (levonorgestrel)

Pravachol (pravastatin sodium)

Pravastatin (pravastatin sodium)

Pregnyl (chorionic gonadotropin, human)

Prevacid (lansoprazole)

Prilosec (omeprazole)

Pristiq (desvenlafaxine succinate)

Privigen (immune globulin,gamma(igg))

Procardia XL (nifedipine er)

ProCentra (dextroamphetamine)
Prochieve 4% (progesterone,micronized)

Prochieve 8% (progesterone,micronized)

Procrit (epoetin alfa)

Prolia (denosumab)

Proscar (finasteride)

Protonix (pantoprazole sodium)

Protopic (tacrolimus)

Provenge (sipuleucel-t/lactated ringers)

Provigil (modafinil)

Prozac (fluoxetine hcl)

Pulmicort Respules (suspension) (budesonide)
Pulmicort Turbuhaler (inhaler) (budesonide)
Pulmozyme (dornase alfa)

Qnasl (beclomethasone dipropionate)

Qualaquin (quinine sulfate)

Quantity Supply
Quinine (quinine sulfate)

Quillivant XR (methylphenidate)
Qvar (beclomethasone dipropionate)
Rebif (interferon beta-1a/albumin)
Only applies to closed commercial

Relpax (eletriptan hbr)
Remicade (infliximab)

Remodulin (treprostinil sodium)

Renova (tretinoin/emollient base)

Reprexain (hydrocodone/ibuprofen)
Repronex (menotropins)

Retin-A (avita)

Revatio (sildenafil citrate)

Revlimid (lenalidomide)

Rhinocort Aqua (budesonide)

Risperdal (risperidone)

Ritalin (methylphenidate hcl)

Rituxan (rituximab)

Roxicet (oxycodone hcl/acetaminophen)
Rozerem (ramelteon)

Rybix ODT (tramadol hcl)
Ryzolt (tramadol hcl er)
Saizen (somatropin)

Sanctura (trospium chloride)

Sanctura XR (trospium chloride)

Saphris (asenapine maleate)

Sarafem (fluoxetine hcl)

Semprex-D (pseudoephedrine hcl/acrivas)

Seroquel (quetiapine fumarate)

Seroquel XR (quetiapine fumarate)

Serostim (somatropin)

Silenor (doxepin hcl)

Simponi (golimumab)

Simvastatin (simvastatin)


Sodium sulfacetamide/sulfur (sulfacetamide sod/sulfur/urea)

Solodyn (minocycline hcl)



Sonata (zaleplon)

Sotret (isotretinoin)

Spiriva (tiotropium bromide)
Sporanox (itraconazole)

Sprycel (dasatinib)

Staxyn (vardenafil hcl)

Stelara (ustekinumab)

Stendra (avanafil)

Strattera (atomoxetine hcl)

Striant (testosterone)

Suboxone (buprenorphine hcl/naloxone hcl)

Subsys (fentanyl)

Subutex (buprenorphine hydrochloride)

Sular (nisoldipine)

Sumatriptan (sumatriptan succinate)
Sumavel DosePro (sumatriptan succinate)

Suprenza ODT (phentermine hcl)

Supartz (hyaluronate sodium)

Supprelin LA (histrelin acetate)

Sutent (sunitinib malate)

Symbicort Inhaler (budesonide/formoterol fumarate)
Synagis (palivizumab)

Synarel (nafarelin acetate)

Synvisc (hylan g-f 20)

Synvisc-One (hylan g-f 20)

Tamiflu (oseltamivir phosphate)

Tarceva (erlotinib hcl)

Targretin (bexarotene)

Tasigna (nilotinib hcl)

Tekamlo (aliskiren/amlodipine besylate)

Tekturna (aliskiren hemifumarate)

Tekturna HTC (aliskiren hemifumarate)

Temodar (temozolomide)

Testim (testosterone)

Tetracycline HCl (tetracycline hcl)

Tev-Tropin (somatropin)

Thalomid (thalidomide)

Tiazac (diltiazem er)

Trelstar Depot or LA (triptorelin pamoate)

Tretin-X (tretinoin)

Treximet (sumatriptan succ/naproxen sod)
Twynsta (telmisartan-amlodipine)

Tykerb (lapatinib ditosylate)

Tylenol w/Cod (acetaminophen with codeine)
Tylox (oxycodone w/acetaminophen)
Tyvaso (treprostinil/nebulizer/accesor)

Uloric (febuxostat)

Ultracet (tramadol hcl-acetaminophen)
Ultram (tramadol hcl)
Valturna (aliskiren/valsartan)

Vantas Implant (histrelin acetate)

Vectibix (panitumumab)

Veletri (epoprostenol sodium (arginine))

Veltin (clindamycin/tretinoin)

Venlafaxine ER (venlafaxine hcl)

Ventavis (iloprost tromethamine)

Veramyst (fluticasone furoate)
Verelan PM (verapamil er pm)

Vfend (voriconazole)

Viagra (sildenafil citrate)

Vibramycin (doxycycline calcium)

Vicodin (hydrocodone w/acetaminophen)
Vicoprofen (hydrocodone bit-ibuprofen)
Victoza (liraglutide)

Victrelis (boceprevir)

Viibryd (vilazodone hydrochloride)

Vivaglobin (immune globuline, gamma)

Vivitrol (naltrexone microspheres)

Votrient (pazopanib hcl)

VPRIV (velaglucerase alfa)

Vytorin (ezetimibe/simvastatin)

Vyvanse (lisdexamfetamine dimesylate)

Wellbutrin XL (budeprion xl)

Xalkori (crizotinib)

Xiaflex (collagenase clostridium hist.)

Xeloda (capecitabine)

Xenazine (tetrabenazine)

Xenical (orlistat)

Xeomin (incobotulinumtoxina)

Xgeva (denosumab)

Xifaxan (rifaximin)

Xodol (hydrocodone w/acetaminophen)
Xolair (omalizumab)

Xyzal (levocetirizine dihydrochloride)

Yervoy (ipilimumab)

Zamicet (hydrocodone bit/acetaminophen)
Zavesca (miglustat)

Cerdelga (eliglustat)

Zetia (ezetimibe)

Zegerid (omeprazole/sodium bicarbonate)

Zelboraf (vemurafenib)

Zerlor (dhcodeine bt/acetaminophn/caff)
Ziana Gel (clindamycin/tretinoin)

Zithromax (azithromycin)
Zmax (azithromycin)
Zocor (simvastatin)

Zofran (ondansetron hcl)
Zoladex (goserelin acetate)

Zolinza (vorinostat)

Zoloft (sertraline hcl)

Zolpimist (zolpidem tartrate)

Zomig (zolmitriptan)
Zomig nasal spray (zolmitriptan)

Zorbtive (somatropin)

Zuplenz (ondansetron)
Zyban (buproban)

Zydone (hydrocodone/acetaminophen)
Zyprexa (olanzapine)

Zytiga (abiraterone acetate)

Zyvox (linezolid)

Myorisan (isotretinoin)

Beyaz (drospir/eth estra/levomefol ca)

Safyral (drospir/eth estra/levomefol ca)

Ovcon (norethindrone-ethinyl estrad)

Ortho Tri-Cyclen Lo (norgestimate-ethinyl estradiol)

Norinyl (necon)

Natazia (estradiol valerate/dienogest)

Loestrin Fe (microgestin fe)

Lo Loestrin Fe (norethindrone-e.estradiol-iron)

Generess Fe (noreth-ethinyl estradiol/iron)

Zetonna (ciclesonide)

Korlym (mifepristone)

Magnacet (oxycodone hcl/acetaminophen)

Primlev (oxycodone hcl/acetaminophen)

Xolox (oxycodone hcl/acetaminophen)

Januvia (sitagliptin phosphate)

Tradjenta (linagliptin)

Avonex (inerferon beta-1A)
Only applies to closed commercial

Bosulif (bosutinib)

Xtandi (enzalutamide)

Relenza (zanamivir)
Aubagio (teriflunomide)

Stivarga (regorafenib)

Bontril PDM (phendimetrazine tartrate)

Dymista (azelastine/fluticasone)

Isotretinoin (isotretinoin)
Nulojix (belatacept)

Femara (letrozole)

Berinert (c1 esterase inhibitor)

Cinryze (c1 esterase inhibitor)

Firazyr (icatibant acetate)

Kalibitor (ecallantide)

Picato (ingenol mebutate)

Solaraze (diclofenac sodium)

Soliris (eculizumab)

Sylvant (siltuximab)

Xeljanz (tofacitinib citrate)

Adcetris (brentuximab vedotin)

Eylea (aflibercept)

Buproban (bupropion hcl)

Bupropion SR (bupropion hcl)

Jetrea (ocriplasmin/pf)

Pomalyst (pomalidomide)

Kyprolis (carfilzomib)

Perjeta (pertuzumab)

Zaltrap (ziv-aflibercept)

Zyclara (imiquimod)

Nesina (alogliptin benzoate)

Diltiazem ER (diltiazem hcl)

Wellbutrin SR (budeprion sr)

Eliphos (calcium acetate)

PhosLo (calcium acetate)

Phoslyra (calcium acetate)

Fosrenol (lanthanum carbonate)

RenaGel (sevelamer hcl)

Tecfidera (dimethyl fumarate)

Mekenist (trametinib dimethyl sulfoxide)

Arimidex (anastrozole)

Fulyzaq (crofelemer)
Gattex (teduglutide)

Juxtapid (lomitapide mesylate)

Kynamro (mipomersen sodium)

Ravicti (glycerol phenylbutyrate)

Niacin ER (niacin)

Zenzedi (dextroamphetamine sulfate)

Invokana (canagliflozin)

Oseni (alogliptin benz/pioglitazone)

Kombiglyze XR (saxagliptin hcl/metformin hcl)

Kazano (alogliptin benz/metformin hcl)

Jentadueto (linagliptin/metformin hcl)

Juvisync (sitagliptin/simvastatin)

Janumet (sitagliptin phos/metformin hcl)

Janumet XR (sitagliptin phos/metformin hcl)

Gilotrif (afatinib dimaleate)

Liptruzet (ezetimibe/atorvastatin calcium)

Migranal (dihydroergotamine mesylate)

Zubsolv (buprenorphine hcl/naloxone hcl)

Bivigam (immune globulin, gamma(IGG))

Octagam (immune globulin,g(igg)/maltose)

Olysio (simeprevir sodium)

Sovaldi (sofosbuvir)

Granix (tbo-filgrastim)

Diclegis (doxylamine/pyridoxine hcl)

Procysbi (cysteamine bitartrate)

1. Health Care Reform Formulary Exception Criteria
Lomedia (noreth a-et estra/fe fumarate)

Versacloz (clozapine)

Khedezla (desvenlafaxine)

Osphena (ospemifene)

Aromasin (exemestane)

Farxiga (dapagliflozin)

2. Quantity Limit
Reclast (zoledronic acid)

Mozobil (plerixafor)

Lovaza (omega-3 acid ethyl esters)

Vascepa (icosapent ethyl)

Niaspan ER (niacin)

Zohydro ER (hydrocodone bitartrate)

Velphoro (sucroferric oxyhydroxide)

Ilaris (canakinumab/pf)

Tadalafil (Cialis (Tadalafil))

Gazyva (obinutuzumab)

Zykadia (ceritinib)

Grastek (grass pollen-timothy, std)

Oralair (gr pol-orc/sw ver/rye/kent/tim)

Kadcyla (ado-trastuzumab emtansine)

Auvi – Q (epinephrine)

Ragwitek (weed pollen-short ragweed)

Hetlioz (tasimelteon)

Xyrem (sodium oxybate)

Entyvio (vedolizumab)

Purixan (mercaptopurine)

Brintellix (vortioxetine hydrobromide)

Afrezza (insulin human) inhalation

Esomeprazole Strontium (esomeprazole strontium)

Cyramza (ramucirumab)

Prialt (ziconotide acetate)

Testopel (testosterone)

Promacta (eltrombopag olamine)

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)

Tanzeum (albiglutide)

Trulicity (dulaglutide)

Invokamet (canagliflozin and metformin)

Jardiance (empagliflozin)

Cordarone (amiodarone)
Alprolix (recombinant coagulation Factor IX, Fc Fusion protein [rFIXFc])

Evzio (naloxone injection)

Otezla (apremilast)

Ruconest (C1 esterase inhibitor [recombinant])

Zydelig (idelalisib)

Viekira (paritaprevir/ritonavir-ombitasvir + dasabuvir)

Arzerra (ofatumumab)

Alimta (pemetrexed disodium)

Aloxi (palonosetron)

Erwinaze (asparaginase Erwinia chrysanthemi)

Oncaspar (pegaspargase)

Taxotere (docetaxel)

Velcade (bortezomib)

Zometa (zoledronic acid)

Eloctate [recombinant antihemophilic factor, Fc fusion protein (rFVIIIFc)]

Denavir (penciclovir)

LidoVir (acyclovir and lidocaine)

Sitavig (acyclovir buccal tablet)

Xerese (acyclovir and hydrocortisone)

Beconase AQ (beclomethasone)

Nasonex (mometasone)

Veramyst (fluticasone)

Antihemophilic and Clotting Factors

Iclusig (ponatinib oral tablets)

Xigduo XR (dapagliflozin/metformin extended-release)

Actimmune (interferon gamma-1b)

Aldurazyme (laronidase)

Apokyn (apomorphine)

Elaprase (idursulfase)

Iluvien (fluocinolone acetonide intravitreal implant)

Ozurdex (dexamethasone intravitreal implant)

Avage (tazarotene)

Fabior (tazarotene)

Tazorac (tazarotene)

Imbruvica (ibrutinib)

Cometriq (cabozantinib)

Lynparza (olaparib)

Gel-One (Cross-linked Hyaluronate)

Monovisc (hyaluronan)

Farydak (panobinostat)

Gleostine (lomustine)

Ibrance (palbociclib)

Lenvima (lenvatinib)

Plegridy (interferon beta-1a)

Aralast NP (alpha-1 proteinase inhibitor)

Glassia (alpha-1 proteinase inhibitor)

Prolastin-C (alpha-1 proteinase inhibitor)

Zemaira (alpha-1 proteinase inhibitor)

Dihydroergotamine Mesylate (DHE) Injection

Krystexxa (pegloticase)

Tysabri (natalizumab)

Actimmune (interferon gamma-1b)
Enteral Nutrition
Hycamtin (topotecan)

Nilandron (nilutamide)
Tivorbex (indomethacin)

Refissa (tretinoin)

Arcalyst (rilonacept)

Corlanor (ivabradine)

Cresemba (isavuconazonium)

Keytruda (pembrolizumab)

Lemtrada (alemtuzumab)

Nplate (romiplostim)

Orkambi (ivacaftor/lumacaftor)

Antihemophilic and Clotting Factors

Blincyto (blinatumomab)

Emend (fosaprepitant) injectable

Mitigare (colchicine)

Neutroval (tbo-filgrastim)
Opdivo (nivolumab)

Sandostatin (octreotide acetate)

Sandostatin LAR Depot (octreotide acetate)

Zarxio (filgrastim-sndz)

Zomacton (somatropin)