Coverage Authorization List

Brand Namesort descending 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