Coverage Authorization List

Brand Name	Generic Name	Effective Date	Requirements	Class
Compounded Products		01/01/2017	Requires Prior Approval	Compounded Products
Hyaluronates		01/01/2020	Requires Prior Approval	Osteoarthritis
Tasigna	nilotinib	01/01/2018	Requires Excluded Exception Approval	Oncology
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
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
Adempas	riociguat	01/01/2018	Requires Prior Approval	Pulmonary Arterial Hypertension
Akynzeo	netupitant and palonosetron capsules	01/01/2017	Requires Prior Approval Subject to Quantity Limits	Antiemetics
Emend	aprepitant, fosaprepitant dimeglumine	01/01/2017	Requires Prior Approval Subject to Quantity Limits	Antiemetics
Aldurazyme	laronidase	01/01/2018	Requires Prior Approval	Lysosomal Storage Disorders
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
Alunbrig	brigatinib	01/01/2018	Requires Excluded Exception Approval	Oncology
Anadrol-50	oxymetholone tablets	01/01/2017	Requires Prior Approval	Anabolic Steroids
Oxandrin	Oxandrolone	01/01/2017	Requires Prior Approval	Anabolic Steroids
Apokyn	apomorphine	01/01/2018	Requires Prior Approval	Movement Disorders
Aranesp	darbepoetin alfa	01/01/2018	Requires Prior Approval	Anemia
Arzerra	ofatumumab	01/01/2018	Requires Prior Approval	Oncology
Avastin	bevacizumab	01/01/2018	Requires Prior Approval	Oncology
Aveed	testosterone undecanoate injection	01/01/2018	Requires Prior Approval	Hormonal Therapies
Vidaza	azacitidine	01/01/2017	Requires Prior Approval	Oncology
Bavencio	avelumab	01/01/2018	Requires Prior Approval	Oncology
Beleodaq	belinostat solution reconstituted	01/01/2017	Requires Prior Approval	Oncology
Benlysta	belimumab solution reconstituted	01/01/2017	Requires Prior Approval	Systemic Lupus Erythematosus
Berinert	C1 esterase inhibitor [human] for IV	01/01/2017	Requires Prior Approval	Hereditary Angioedema
Besponsa	inotuzumab ozogamicin	01/01/2018	Requires Prior Approval	Oncology
Extavia	interferon beta-1b	01/01/2018	Requires Excluded Exception Approval	Multiple Sclerosis
Blincyto	Blinatumomab	01/01/2017	Requires Prior Approval	Oncology
Bosulif	bosutinib tablets	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Oncology
Botox	onabotulinumtoxin A	01/01/2017	Requires Prior Approval	Botulinum Toxins
Buphenyl	sodium phenylbutyrate	01/01/2017	Requires Prior Approval	Urea Cycle Disorders
Cabometyx	cabozantinib	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Oncology
Calquence	acalabrutinib	01/01/2019	Requires Prior Approval	Oncology
Carbaglu	carglumic acid	01/01/2018	Requires Prior Approval	Urea Cycle Disorders
Cayston	aztreonam	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Cystic Fibrosis
Cerdelga	eliglustat	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Enzyme Inhibitor
Cerezyme	imiglucerase	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Lysosomal Storage Disorders
Cetrotide	cetrorelix acetate	01/01/2018	Requires Prior Approval	Fertility Products - Specialty
Cholbam	cholic acid	01/01/2018	Requires Prior Approval	GI Disorders
Cinqair	reslizumab	01/01/2018	Requires Excluded Exception Approval	Asthma
Claravis	isotretinoin	01/01/2017	Requires Prior Approval	Isotretinoins
Coagadex	coagulation Factor X	01/01/2018	Requires Prior Approval	Blood Product Derivative
Cometriq	cabozantinib	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Oncology
Contrave	naltrexone Hcl/buproprion Hcl ER tablets	01/01/2017	Requires Prior Approval	Antiobesity
Glatopa	glatiramer acetate injection	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Multiple Sclerosis
Cotellic	cobimetinib	01/01/2018	Requires Prior Approval	Oncology
Syprine	trientine	10/01/2017	Requires Prior Approval Requires Step Therapy	Chelating Agent