Coverage Authorization List

Brand Name Generic Namesort descending 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