Coverage Authorization List

Brand Namesort descending Generic Name Effective Date Requirements Class
Ampyra dalfampridine 01/01/2018
  • Requires Prior Approval
Multiple Sclerosis
Anadrol-50 oxymetholone tablets 01/01/2017
  • Requires Prior Approval
Anabolic Steroids
Androderm testosterone transdermal patch 01/01/2018
  • Requires Prior Approval
Testosterone Products
Androgel testosterone topical gel 01/01/2018
  • Requires Prior Approval
Testosterone Products
Android methyltestosterone capsules 01/01/2018
  • Requires Prior Approval
Testosterone Products
Androxy fluoxymesterone, oral tablet 01/01/2018
  • Requires Prior Approval
Testosterone Products
Anoro Ellipta umeclidinium/vilanterol 01/01/2018
  • Subject to Quantity Limits
Long-Acting Beta Agonists (LABA)
Anzemet dolasetron 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
Antiemetics
Apexicon E (Brand Only) diflorasone diacetate 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Corticosteroid
Apokyn apomorphine 01/01/2018
  • Requires Prior Approval
Movement Disorders
Aptensio XR methylphenidate extended-release 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
ADHD-Narcolepsy Agents
Aptivus tipranavir 01/01/2018
  • Subject to Quantity Limits
HIV
Aralast NP alpha1-proteinase inhibitor 01/01/2018
  • Requires Prior Approval
Alpha-1 Antitrypsin Deficiency
Aranesp darbepoetin alfa 01/01/2018
  • Requires Prior Approval
Anemia
Arcalyst rilonacept 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Cryopyrin Associated Periodic Synd (CAPS)
Arcapta indacaterol capsule 01/01/2017
  • Subject to Quantity Limits
Long-Acting Beta Agonists (LABA)
Armonair Respiclick fluticasone propionate 01/01/2019
  • Subject to Quantity Limits
Corticosteroid
Arnuity Ellipta fluticasone furoate 01/01/2019
  • Subject to Quantity Limits
Corticosteroid
Arymo ER morphine sulfate extended-release tablets 03/01/2018
  • Requires Excluded Exception Approval
Opioid Analgesics - Extended-Release
Arzerra ofatumumab 01/01/2018
  • Requires Prior Approval
Oncology
Asmanex mometasone furoate 01/01/2019
  • Subject to Quantity Limits
Corticosteroid
Asparlas calaspargase pegol - mknl 02/01/2019
  • Requires Excluded Exception Approval
Oncology
Aspirin/Caffeine/Dihydrocodeine aspirin/caffeine/dihydrocodeine 09/01/2017
  • Requires Prior Approval
  • Requires Step Therapy
  • Subject to Quantity Limits
Opioid Analgesics
Atralin tretinoin 10/01/2017
  • Requires Prior Approval
Retinoids
Atripla efavirenz/emtricitabine/tenofovir 01/01/2018
  • Subject to Quantity Limits
HIV
Aubagio teriflunomide 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Multiple Sclerosis
Austedo deutetrabenazine 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Movement Disorders
Avar sulfacetamide sodium-sulfur 09/01/2017
  • Requires Prior Approval
  • Requires Step Therapy
Topical Acne Products
Avastin bevacizumab 01/01/2018
  • Requires Prior Approval
Oncology
Aveed testosterone undecanoate injection 01/01/2018
  • Requires Prior Approval
Hormonal Therapies
Avinza morphine extended-release capsules 03/01/2018
  • Requires Prior Approval
  • Requires Step Therapy
  • Subject to Quantity Limits
Opioid Analgesics - Extended-Release
Avita tretinoin 10/01/2017
  • Requires Prior Approval
Retinoids
Avonex interferon beta-1a 01/01/2018
  • Requires Prior Approval
Multiple Sclerosis
Avsola infliximab 03/20/2020
  • Requires Excluded Exception Approval
Autoimmune
Axert almotriptan 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine
Axiron testosterone topical solution 01/01/2018
  • Requires Prior Approval
Testosterone Products
Ayvakit avapritinib 03/07/2020
  • Requires Prior Approval
Oncology
Azelex azelaic acid cream 09/01/2017
  • Requires Prior Approval
  • Requires Step Therapy
Topical Acne Products
Bafiertam monomethyl fumarate 07/01/2020
  • Requires Prior Approval
Multiple Sclerosis
Balversa erdafitinib 07/01/2019
  • Requires Prior Approval
Oncology
Bavencio avelumab 01/01/2018
  • Requires Prior Approval
Oncology
Bebulin factor IX complex [human] 01/01/2017
  • Requires Prior Approval
Hemophilia
Belbuca buprenorphine buccal film 03/01/2018
  • Requires Prior Approval
  • Requires Step Therapy
  • Subject to Quantity Limits
Opioid Analgesics
Beleodaq belinostat solution reconstituted 01/01/2017
  • Requires Prior Approval
Oncology
Belrapzo Bendamustine 01/01/2017
  • Requires Prior Approval
Oncology
Belsomra suvorexant 01/01/2018
  • Requires Prior Approval
  • Requires Step Therapy
Sedative-Hypnotics
Bendeka bendamustine 01/01/2018
  • Requires Prior Approval
Oncology
Benefix coagulation factor IX [recombinant] 01/01/2017
  • Requires Prior Approval
Hemophilia
Benlysta belimumab solution reconstituted 01/01/2017
  • Requires Prior Approval
Systemic Lupus Erythematosus
Benzac benzoyl peroxide gel 09/01/2017
  • Requires Prior Approval
  • Requires Step Therapy
Topical Acne Products