Coverage Authorization List

Brand Name	Generic Name	Effective Date	Requirements	Class
Benzaclin	clindamycin phosphate/benzoyl peroxide gel	09/01/2017	Requires Prior Approval Requires Step Therapy	Topical Acne Products
Benziq	benzoyl peroxide	09/01/2017	Requires Prior Approval Requires Step Therapy	Topical Acne Products
Berinert	C1 esterase inhibitor [human] for IV	01/01/2017	Requires Prior Approval	Hereditary Angioedema
Besponsa	inotuzumab ozogamicin	01/01/2018	Requires Prior Approval	Oncology
Betaseron	interferon beta-1b for subcutaneous [SC] injection	01/01/2018	Requires Prior Approval	Multiple Sclerosis
Bethkis	tobramycin (oral inhalation) nebulization solution	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Cystic Fibrosis
Bevespi Aerosphere	Glycopyrrolate; Formoterol	01/01/2017	Subject to Quantity Limits	Long-Acting Beta Agonists (LABA)
Biktarvy	bictegravir/emtricitabine/tenofovir/disoproxil	01/01/2019	Subject to Quantity Limits	HIV
Biltricide	praziquantel	10/01/2017	Requires Prior Approval Subject to Quantity Limits	Anthelmintic
Binosto	alendronate effervescent tablets	01/01/2017	Requires Step Therapy	Bisphosphanates
Blincyto	Blinatumomab	01/01/2017	Requires Prior Approval	Oncology
Bonsity	teriparatide injection	01/01/2018	Requires Prior Approval	Osteoporosis
Bontril	phendimetrazine	01/01/2017	Requires Prior Approval	Antiobesity
Bosulif	bosutinib tablets	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Oncology
Botox	onabotulinumtoxin A	01/01/2017	Requires Prior Approval	Botulinum Toxins
Braftovi	encorafenib	01/01/2019	Requires Prior Approval	Oncology
Bravelle	urofollitropin	01/01/2017	Requires Excluded Exception Approval	Fertility Products - Specialty
Breo Ellipta	Fluticasone; Vilanterol	01/01/2017	Subject to Quantity Limits	Corticosteroid
Breztri Aerosphere	budesonide, glycopyrrolate, and formoterol fumarate	09/01/2020	Requires Prior Approval	Long-Acting Beta Agonists (LABA)
Brovana	Arformoterol	01/01/2017	Subject to Quantity Limits	Long-Acting Beta Agonists (LABA)
Brukinsa	zanubrutinib	02/02/2020	Requires Prior Approval Subject to Quantity Limits	Oncology
Bryhali (Brand Only)	halobetasol lotion	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Buphenyl	sodium phenylbutyrate	01/01/2017	Requires Prior Approval	Urea Cycle Disorders
Butalbital Products	butalbital, acetaminophen, aspirin, caffeine, codeine	04/01/2019	Subject to Quantity Limits	Antimigraine
Butrans	buprenorphine transdermal system	03/01/2018	Requires Prior Approval Requires Step Therapy Subject to Quantity Limits	Opioid Analgesics
Bynfezia pen	octreotide acetate	10/01/2020	Requires Prior Approval	Acromegaly
Cablivi	caplacizumab-yhdp	06/03/2019	Requires Prior Approval	Blood Disorders
Cabometyx	cabozantinib	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Oncology
Calquence	acalabrutinib	01/01/2019	Requires Prior Approval	Oncology
Cambia	diclofenac potassium powder for oral solution	01/01/2017	Requires Step Therapy	COX-2/NSAIDs
Caplyta	lumateperone	03/18/2020	Requires Prior Approval	Atypical Antipsychotics
Caprelsa	vandetanib	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Oncology
Carbaglu	carglumic acid	01/01/2018	Requires Prior Approval	Urea Cycle Disorders
Cayston	aztreonam	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Cystic Fibrosis
Cequa	Cyclosporine	01/01/2019	Requires Prior Approval	Ophthalmic Immunomodulators
Cerdelga	eliglustat	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Enzyme Inhibitor
Cerezyme	imiglucerase	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Lysosomal Storage Disorders
Cesamet	nabilone	01/01/2017	Requires Prior Approval Subject to Quantity Limits	Antiemetics
Cetrotide	cetrorelix acetate	01/01/2018	Requires Prior Approval	Fertility Products - Specialty
Chenodal	chenodiol	01/01/2019	Requires Prior Approval	Genitourinary Agents
Cholbam	cholic acid	01/01/2018	Requires Prior Approval	GI Disorders
Cialis 2.5 and 5 mg	tadalafil	01/01/2017	Requires Prior Approval Requires Step Therapy	BPH
Ciclodan Kit	ciclopirox topical solution 8% moisturize	10/01/2017	Requires Prior Approval Requires Step Therapy	Topical Antifungals
Cimduo	lamivudine/tenofovir	01/01/2019	Subject to Quantity Limits	HIV
Cimzia	certolizumab pegol	01/01/2018	Requires Prior Approval Requires Step Therapy	Autoimmune
Cinqair	reslizumab	01/01/2018	Requires Excluded Exception Approval	Asthma
Cinryze	C1 esterase inhibitor	02/13/2019	Requires Prior Approval	Hereditary Angioedema
Cinvanti	aprepitant	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Antiemetics
Claravis	isotretinoin	01/01/2017	Requires Prior Approval	Isotretinoins
Cleocin-T	clindamycin phosphate gel	09/01/2017	Requires Prior Approval Requires Step Therapy	Topical Acne Products