Coverage Authorization List

Brand Namesort descending Generic Name Effective Date Requirements Class
Clindagel clindamycin phosphate gel 09/01/2017
  • Requires Prior Approval
  • Requires Step Therapy
Topical Acne Products
Clobex (Brand Only) clobetasol propionate 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Corticosteroid
Clodan (Brand Only) clobetasol propionate 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Corticosteroid
Cloderm (Brand Only) clocortolone pivalate 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Corticosteroid
Clomid clomiphene citrate 01/01/2019
  • Requires Prior Approval
Fertility Products - Non-Specialty
Coagadex coagulation Factor X 01/01/2018
  • Requires Prior Approval
Blood Product Derivative
Codeine codeine sulfate 03/01/2018
  • Requires Prior Approval
  • Requires Step Therapy
  • Subject to Quantity Limits
Opioid Analgesics
Combivir lamivudine/zidovudine 01/01/2018
  • Subject to Quantity Limits
HIV
Combunox (ibuprofen and oxycodone) ibuprofen and oxycodone hydrochloride 11/01/2020
  • Requires Prior Approval
Opioid Analgesics
Cometriq cabozantinib 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Oncology
Complera emtricitabine/rilpivirine/tenofovir 01/01/2018
  • Subject to Quantity Limits
HIV
Compounded Products 01/01/2017
  • Requires Prior Approval
Compounded Products
Concerta methylphenidate extended-release tablets 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
ADHD-Narcolepsy Agents
Contrave naltrexone Hcl/buproprion Hcl ER tablets 01/01/2017
  • Requires Prior Approval
Antiobesity
Conzip tramadol hydrochloride extended-release 03/01/2018
  • Requires Prior Approval
  • Requires Step Therapy
  • Subject to Quantity Limits
Opioid Analgesics - Extended-Release
Copaxone glatiramer 01/01/2018
  • Requires Prior Approval
Multiple Sclerosis
Copegus ribavirin 01/01/2017
  • Requires Prior Approval
Hepatitis
Copiktra duvelisib 01/01/2019
  • Requires Prior Approval
Oncology
Cordan Pacerone, Cordarone, Cordarone IV, Nexterone 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Corticosteroid
Cordran (Brand Only) flurandrenolide except tape 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Corticosteroid
Corlanor ivabradine tablets 01/01/2017
  • Requires Prior Approval
Misc CV Agents
Cormax (Brand Only) clobetasol propionate 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Corticosteroid
Cosentyx secukinumab 01/01/2018
  • Requires Prior Approval
  • Requires Step Therapy
Autoimmune
Cotellic cobimetinib 01/01/2018
  • Requires Prior Approval
Oncology
Cotempla XR-ODT methylphenidate extended-release 01/01/2018
  • Requires Excluded Exception Approval
ADHD-Narcolepsy Agents
Crinone progesterone, vaginal 01/01/2017
  • Requires Prior Approval
Fertility Products - Non-Specialty
Crixivan indinavir 01/01/2018
  • Subject to Quantity Limits
HIV
Crysvita burosumab-twza 01/01/2019
  • Requires Prior Approval
Autoimmune
Cuprimine penicillamine 10/01/2017
  • Requires Prior Approval
  • Requires Step Therapy
Chelating Agent
Cutaquig immune globulin 01/01/2019
  • Requires Excluded Exception Approval
IVIG
Cutivate (Brand Only) fluticasone propionate 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Corticosteroid
Cuvitru immune globulin 01/01/2017
  • Requires Excluded Exception Approval
IVIG
Cylocort amcinonide 01/01/2019
  • Requires Excluded Exception Approval
  • Subject to Quantity Limits
Topical Corticosteroids
Cyramza ramucirumab 01/01/2018
  • Requires Prior Approval
Oncology
Cystadrops cysteamine hydrochloride 11/01/2020
  • Requires Prior Approval
Anticystine Agent
Cystagon cysteamine bitartrate 01/01/2018
  • Requires Prior Approval
Anticystine Agent
Cystaran cysteamine 01/01/2018
  • Requires Prior Approval
Anticystine Agent
Dacogen Decitabine 01/01/2017
  • Requires Prior Approval
Oncology
Daklinza daclatasvir 01/01/2018
  • Requires Excluded Exception Approval
Hepatitis
Daraprim pyrimethamine tablets 01/01/2017
  • Requires Prior Approval
Antiparasitic
Darzalex daratumumab 01/01/2017
  • Requires Prior Approval
Oncology
Darzalex Faspro Daratumumab 08/01/2020
  • Requires Prior Approval
Oncology
Daurismo glasdegib 01/01/2019
  • Requires Prior Approval
Oncology
Daytrana methylphenidate transdermal system 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
ADHD-Narcolepsy Agents
Dayvigo lemborexant 01/01/2018
  • Requires Prior Approval
  • Requires Step Therapy
Sedative-Hypnotics
Delatestryl testosterone enanthate injection 01/01/2018
  • Requires Prior Approval
Testosterone Products
Delstrigo doravirine/lamivudine/tenofovir 01/01/2019
  • Subject to Quantity Limits
HIV
Demerol meperidine hydrochloride 03/01/2018
  • Requires Prior Approval
  • Requires Step Therapy
  • Subject to Quantity Limits
Opioid Analgesics
Depo-Testosterone testosterone cypionate injection 01/01/2018
  • Requires Prior Approval
Testosterone Products
Derma-Smoothe (Brand Only) fluocinolone 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Corticosteroid