Coverage Authorization List

Brand Name	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