Coverage Authorization List

Brand Name	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