Coverage Authorization List

Brand Name	Generic Name	Effective Date	Requirements	Class
Cutivate (Brand Only)	fluticasone propionate	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Nolix (Brand Only)	flurandrenolide	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Elocon (Brand Only)	mometasone	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Alvesco	ciclesonide	01/01/2019	Subject to Quantity Limits	Corticosteroid
Halog (Brand Only)	halcinonide	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Locoid (Brand Only)	hydrocortisone butyrate	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Acthar	repository corticotropic injection	01/01/2018	Requires Prior Approval	Corticosteroid
Westcort (Brand Only)	hydrocortisone valerate	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Sernivo (Brand Only)	betamethasone dipropionate spray	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Apexicon E (Brand Only)	diflorasone diacetate	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Advair	fluticasone propionate and salmeterol xinafoate aerosol and aerosol powder	01/01/2017	Subject to Quantity Limits	Corticosteroid
Lokara (Brand Only)	desonide	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Armonair Respiclick	fluticasone propionate	01/01/2019	Subject to Quantity Limits	Corticosteroid
Clobex (Brand Only)	clobetasol propionate	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Impoyz (Brand Only)	clobestasol	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Cordan	Pacerone, Cordarone, Cordarone IV, Nexterone	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Derma-Smoothe (Brand Only)	fluocinolone	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Temovate (Brand Only)	clobetasol propionate	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Arnuity Ellipta	fluticasone furoate	01/01/2019	Subject to Quantity Limits	Corticosteroid
Ultravate (Brand Only)	halobetasol	03/07/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Clodan (Brand Only)	clobetasol propionate	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Dermatop (Brand Only)	prednicarbate	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Asmanex	mometasone furoate	01/01/2019	Subject to Quantity Limits	Corticosteroid
Texacort (Brand Only)	hydrocortisone	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Cloderm (Brand Only)	clocortolone pivalate	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Luxiq (Brand Only)	betamethasone valerate	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Desonate (Brand Only)	desonide	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Vanos (Brand Only)	fluocinonide	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Psorcon (Brand Only)	diflorasone	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Breo Ellipta	Fluticasone; Vilanterol	01/01/2017	Subject to Quantity Limits	Corticosteroid
Desowen (Brand Only)	desonide	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Aerospan	flunisolide	01/01/2019	Subject to Quantity Limits	Corticosteroid
Olux (Brand Only)	clobetasol propionate	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Pulmicort	budesonide	01/01/2019	Subject to Quantity Limits	Corticosteroid
Kenalog (Brand Only)	triamcinolone acetonide	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Micort HC (Brand Only)	hydrocortisone acetate	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Synalar (Brand Only)	fluocinolone acetonide	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Bryhali (Brand Only)	halobetasol lotion	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Flovent	fluticasone propionate	01/01/2019	Subject to Quantity Limits	Corticosteroid
Topicort (Brand Only)	desoximetasone	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Cordran (Brand Only)	flurandrenolide except tape	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Qvar	beclomethasone	01/01/2019	Subject to Quantity Limits	Corticosteroid
Diprolene (Brand Only)	betamethasone dipropionate	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Trianex (Brand Only)	triamcinolone acetonide	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Verdeso (Brand Only)	desonide	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Cormax (Brand Only)	clobetasol propionate	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Tridesilon (Brand Only)	desonide	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Emflaza	deflazazort	01/01/2018	Requires Excluded Exception Approval	Corticosteroid
Lexette (Brand Only)	halobetasol foam	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Pandel (Brand Only)	hydrocortisone probutate	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid