Coverage Authorization List

Brand Name Generic Name Effective Date Requirements Class
1% sodium hyaluronate

1% sodium hyaluronate 

  • Requires Prior Approval
Osteoarthritis
5 HT1 Agonist Limit Policy 2 H 06 2018 2
  • Requires Excluded Exception Approval
Antimigraine
5 HT1 Agonist Limit Policy 2 H 06 2020
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
5 HT1 Agonist Limit Policy 2 H 06 2020
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
5 HT1 Agonist Limit Policy 2 H 06 2020
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
5 HT1 Agonist Limit Policy 2 H 06 2020
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
5 HT1 Agonist Limit Policy 2 H 06 2020
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
5 HT1 Agonist Limit Policy 2 H 06 2020
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
5 HT1 Agonist Limit Policy 2 H 06 2020
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
5 HT1 Agonist Limit Policy 2 H 06 2020
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
5 HT1 Agonist Limit Policy 2 H 06 2020
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
5 HT1 Agonist Limit Policy 2 H 06 2020
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
5 HT1 Agonist Limit Policy 2 H 06 2020
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
5 HT1 Agonist Limit Policy 2 H 06 2020
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
5 HT1 Agonist Post Limit PA Policy 1 J 903 J 06 2020a
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
5 HT1 Agonist Post Limit PA Policy 1 J 903 J 06 2020a
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
5 HT1 Agonist Post Limit PA Policy 1 J 903 J 06 2020a
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
5 HT1 Agonist Post Limit PA Policy 1 J 903 J 06 2020a
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
5 HT1 Agonist Post Limit PA Policy 1 J 903 J 06 2020a
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
5 HT1 Agonist Post Limit PA Policy 1 J 903 J 06 2020a
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine