Coverage Authorization List

Brand Name	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