Abraxane |
paclitaxel, albumin-bound
|
07/01/2019 |
|
Oncology |
Absorica |
isotretinoin
|
01/01/2018 |
|
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/Benzhydrocodone |
acetaminophen/benzhydrocodone
|
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 |
|
Corticosteroid |
Acticlate |
doxycycline hyclate
|
05/01/2018 |
- Requires Prior Approval
- Requires Step Therapy
|
Antibiotic |
Actimmune |
interferon gamma-1b
|
01/01/2018 |
|
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 |
|
Enzyme |
Adakveo |
crizanlizumab-tmca
|
02/02/2020 |
|
Hematopoietics |
Adcetris |
brentuximab vedotin
|
01/01/2018 |
|
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 |
|
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 |
|
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 |
|
Oncology |
Afinitor Disperz |
everolimus
|
10/01/2020 |
|
Oncology |
Afstyla |
antihemophilic factor VIII
|
10/01/2017 |
|
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 |
|
Lysosomal Storage Disorders |
Alecensa |
alectinib
|
01/01/2018 |
|
Oncology |
Alimta |
pemetrexed
|
12/01/2020 |
|
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 |
|
Hemophilia |
Alphanine SD |
coagulation factor IX [human]
|
01/01/2017 |
|
Hemophilia |
Alprolix |
coagulation factor IX [recombinant], Fc fusion protein
|
01/01/2017 |
|
Hemophilia |
Altreno |
tretinoin
|
01/01/2019 |
|
Retinoids |
Alunbrig |
brigatinib
|
01/01/2018 |
- Requires Excluded Exception Approval
|
Oncology |
Alvesco |
ciclesonide
|
01/01/2019 |
- Subject to Quantity Limits
|
Corticosteroid |
Alyq |
tadalafil
|
10/01/2020 |
|
Pulmonary arterial hypertension |
Ambien |
zolpidem tartrate
|
01/01/2017 |
- Requires Prior Approval
- Subject to Quantity Limits
|
Sedative-Hypnotics |
Ambien CR |
flurazepam
|
01/01/2017 |
- Subject to Quantity Limits
|
Sedative-Hypnotics |
Amerge |
naratriptan
|
01/01/2017 |
- Requires Prior Approval
- Subject to Quantity Limits
|
Antimigraine |
Amnesteem |
isotretinoin
|
01/01/2018 |
|
Isotretinoins |