Coverage Authorization List

Brand Namesort ascending Generic Name Effective Date Requirements Class
Zytiga Abiraterone 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Oncology
Zykadia

ceritinib

01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Oncology
Zydelig

Idelalisib

01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Oncology
Zuplenz ondansetron 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
Antiemetics
Zulresso brexanolone 07/01/2019
  • Requires Prior Approval
Mental Health
Ztlido lidocaine topical system 01/01/2019
  • Requires Prior Approval
Topical Anesthetics - Lidocaine Containing
Zorvolex Diclofenac 01/01/2017
  • Requires Step Therapy
COX-2/NSAIDs
Zorbtive somatropin injection 01/01/2017
  • Requires Prior Approval
GI Disorders
Zonalon doxepin 10/01/2017
  • Requires Prior Approval
  • Requires Step Therapy
Topical Skin Product
Zomig zolmitriptan 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
Zometa zoledronic acid 01/01/2017
  • Requires Prior Approval
Oncology
Zomacton somatropin 01/01/2017
  • Requires Excluded Exception Approval
Growth Hormone and Related Disorders
Zolpimist zolpidem 01/01/2018
  • Requires Prior Approval
  • Requires Step Therapy
Sedative-Hypnotics
Zolinza Vorinostat 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Oncology
Zoladex Goserelin 01/01/2018
  • Requires Prior Approval
Hormonal Therapies
Zohydro ER hydrocodone bitartrate extended-release capsules 03/01/2018
  • Requires Prior Approval
  • Requires Step Therapy
  • Subject to Quantity Limits
Opioid Analgesics - Extended-Release
Zofran ondansetron 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
Antiemetics
Zirabev bevacizumab-bvzr 01/01/2018
  • Requires Prior Approval
Oncology
Zipsor Diclofenac 01/01/2017
  • Requires Step Therapy
COX-2/NSAIDs
Zioptan tafluprost 01/01/2017
  • Requires Step Therapy
Glaucoma
Zinbryta daclizumab 01/01/2018
  • Requires Excluded Exception Approval
Multiple Sclerosis
Ziextenzo Pegfilgrastim-bmez 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Neutropenia
Ziana clindamycin phosphate/tretinoin gel 01/01/2017
  • Requires Prior Approval
Retinoids
Ziagen abacavir 01/01/2018
  • Subject to Quantity Limits
HIV
Zerit stavudine 01/01/2018
  • Subject to Quantity Limits
HIV
Zepatier elbasvir and grazoprevir 01/01/2018
  • Requires Excluded Exception Approval
Hepatitis C
Zenzedi dextroamphetamine tablets 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
ADHD-Narcolepsy Agents
Zenatane Isotretinoin 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
Isotretinoins
Zembrace Symtouch sumatriptan 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
Zemaira Alpha-1-proteinase Inhibitor 01/01/2017
  • Requires Prior Approval
Alpha-1 Antitrypsin Deficiency
Zelboraf vemurafenib tablets 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Oncology
Zejula niraparib 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Oncology
Zegerid omeprazole/sodium bicarbonate 03/20/2019
  • Requires Prior Approval
Proton Pump Inhibitors
Zavesca Miglustat 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Lysosomal Storage Disorders
Zarxio filgrastim-sndz injection 01/01/2017
  • Requires Prior Approval
Neutropenia
Zaltrap Ziv-Aflibercept 01/01/2017
  • Requires Prior Approval
Oncology
Zaclir benzoyl peroxide 09/01/2017
  • Requires Prior Approval
  • Requires Step Therapy
Topical Acne Products
Yonsa abiraterone 01/01/2019
  • Requires Excluded Exception Approval
Oncology
Yervoy ipilimumab 01/01/2017
  • Requires Prior Approval
Oncology
Xyrem sodium oxybate oral solution 10/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
Narcolepsy (Other)
Xyosted testosterone enanthate 01/01/2019
  • Requires Excluded Exception Approval
Testosterone Products
Xyntha Antihemophilic factor VIII 10/01/2017
  • Requires Prior Approval
Hemophilia
Xylocaine lidocaine 4% solution 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Topical Anesthetics - Lidocaine Containing
Xtandi enzalutamide 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Oncology
Xtampza ER oxycodone extended-release capsules 03/01/2018
  • Requires Prior Approval
  • Requires Step Therapy
  • Subject to Quantity Limits
Opioid Analgesics - Extended-Release
Xpovio selinexor 08/01/2019
  • Requires Excluded Exception Approval
Oncology
Xospata gilteritinib 01/01/2019
  • Requires Excluded Exception Approval
Oncology
Xopenex Levalbuterol 01/01/2017
  • Subject to Quantity Limits
Short-Acting Beta Agonists - Oral Inh
Xolair omalizumab injection for subcutaneous [SC] use 01/01/2017
  • Requires Prior Approval
Allergic Asthma
Xofluza baloxavir 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Influenza