Coverage Authorization List

Brand Name Generic Name Effective Date Requirements Classsort descending
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