Coverage Authorization List

Brand Namesort descending 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
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