Coverage Authorization List

Brand Name	Generic Name	Effective Date	Requirements	Class
Absorica	isotretinoin	01/01/2018	Requires Prior Approval	Isotretinoins
Abstral	fentanyl citrate sublingual tablet	01/01/2017	Requires Prior Approval Subject to Quantity Limits	Oral/Intranasal Fentanyl Products
Acanya	clindamycin phosphate/benzoyl peroxide gel	09/01/2017	Requires Prior Approval Requires Step Therapy	Topical Acne Products
Accuneb	albuterol sulfate nebulization solution	01/01/2017	Subject to Quantity Limits	Short-Acting Beta Agonists - Oral Inh
Acetaminophen/Caffeine/Dihydrocodeine	acetaminophen/caffeine/dihydrocodeine	09/01/2017	Requires Prior Approval Requires Step Therapy Subject to Quantity Limits	Opioid Analgesics
Aclovate (Brand Only)	alclometasone dipropionate	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Topical Skin Product
Actemra	tocilizumab	01/01/2018	Requires Excluded Exception Approval	Autoimmune
Acthar	repository corticotropic injection	01/01/2018	Requires Prior Approval	Corticosteroid
Acticlate	doxycycline hyclate	05/01/2018	Requires Prior Approval Requires Step Therapy	Antibiotic
Actimmune	interferon gamma-1b	01/01/2018	Requires Prior Approval	Interferon
Actiq	fentanyl citrate oral transmucosal lozenge	01/01/2017	Requires Prior Approval Subject to Quantity Limits	Oral/Intranasal Fentanyl Products
Aczone	dapsone topical gel	09/01/2017	Requires Prior Approval Requires Step Therapy	Topical Acne Products
Adagen	pegademase bovine injection	01/01/2018	Requires Prior Approval	Enzyme
Adcetris	brentuximab vedotin	01/01/2018	Requires Prior Approval	Oncology
Adcirca	tadalafil	01/01/2018	Requires Excluded Exception Approval	Pulmonary arterial hypertension
Adderall	amphetamine-dextroamphetamine tablet	01/01/2017	Requires Prior Approval Subject to Quantity Limits	ADHD-Narcolepsy Agents
Adempas	riociguat	01/01/2018	Requires Prior Approval	Pulmonary Arterial Hypertension
Advair	fluticasone propionate and salmeterol xinafoate aerosol and aerosol powder	01/01/2017	Subject to Quantity Limits	Corticosteroid
Advate	antihemophilic factor VIII	10/01/2017	Requires Prior Approval	Hemophilia
Adynovate	antihemophilic factor VIII	01/01/2017	Requires Excluded Exception Approval	Hemophilia
Adzenys XR-ODT	amphetamine extended-release	01/01/2018	Requires Prior Approval Subject to Quantity Limits	ADHD-Narcolepsy Agents
Aerospan	flunisolide	01/01/2019	Subject to Quantity Limits	Corticosteroid
Afinitor	everolimus	01/01/2018	Requires Prior Approval	Oncology
Afstyla	antihemophilic factor VIII	10/01/2017	Requires Prior Approval	Hemophilia
Aimovig	erenumab-aooe	01/01/2019	Requires Prior Approval Requires Step Therapy	CGRP Receptor Antagonists
Airduo Respiclick	fluticasone propionate/salmeterol	01/01/2018	Requires Excluded Exception Approval	Long-Acting Beta Agonists (LABA)
Ajovy	fremanezumab-vfrm	01/01/2019	Requires Prior Approval Requires Step Therapy	CGRP Receptor Antagonists
Akne-Mycin	erythromycin ointment	09/01/2017	Requires Prior Approval Requires Step Therapy	Topical Acne Products
Akynzeo	netupitant and palonosetron capsules	01/01/2017	Requires Prior Approval Subject to Quantity Limits	Antiemetics
Ala-Scalp (Brand Only)	hydrocortisone	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Topical Skin Product
Albenza	albendazole	01/01/2017	Requires Prior Approval Subject to Quantity Limits	Anthelmintic
Aldurazyme	laronidase	01/01/2018	Requires Prior Approval	Lysosomal Storage Disorders
Alecensa	alectinib	01/01/2018	Requires Prior Approval	Oncology
Aliqopa	copanlisib	01/01/2018	Requires Excluded Exception Approval	Oncology
Aloxi	palonosetrom hcl solution	01/01/2017	Requires Prior Approval Subject to Quantity Limits	Antiemetics
Alphanate	antihemophilic factor VIII	10/01/2017	Requires Prior Approval	Hemophilia
Alphanine SD	coagulation factor IX [human]	01/01/2017	Requires Prior Approval	Hemophilia
Alprolix	coagulation factor IX [recombinant], Fc fusion protein	01/01/2017	Requires Prior Approval	Hemophilia
Altreno	tretinoin	01/01/2019	Requires Prior Approval	Retinoids
Alunbrig	brigatinib	01/01/2018	Requires Excluded Exception Approval	Oncology
Alvesco	ciclesonide	01/01/2019	Subject to Quantity Limits	Corticosteroid
Ambien	zolpidem tartrate	01/01/2017	Requires Prior Approval Subject to Quantity Limits	Sedative-Hypnotics
Amerge	naratriptan	01/01/2017	Requires Prior Approval Subject to Quantity Limits	Antimigraine
Amnesteem	isotretinoin	01/01/2018	Requires Prior Approval	Isotretinoins
Ampyra	dalfampridine	01/01/2018	Requires Prior Approval	Multiple Sclerosis
Anadrol-50	oxymetholone tablets	01/01/2017	Requires Prior Approval	Anabolic Steroids
Androderm	testosterone transdermal patch	01/01/2018	Requires Prior Approval	Testosterone Products
Androgel	testosterone topical gel	01/01/2018	Requires Prior Approval	Testosterone Products
Android	methyltestosterone capsules	01/01/2018	Requires Prior Approval	Testosterone Products
Androxy	fluoxymesterone, oral tablet	01/01/2018	Requires Prior Approval	Testosterone Products