Coverage Authorization List

Brand Name	Generic Name	Effective Date	Requirements	Class
Dermatop (Brand Only)	prednicarbate	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Descovy	emtricitabine/tenofovir	01/01/2018	Subject to Quantity Limits	HIV
Desferal	deferoxamine	01/01/2017	Requires Prior Approval	Iron Overload
Desonate (Brand Only)	desonide	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Desowen (Brand Only)	desonide	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Desoxyn	methamphetamine tablets	01/01/2017	Requires Prior Approval Subject to Quantity Limits	ADHD-Narcolepsy Agents
Dexedrine	dextroamphetamine extended-release	01/01/2017	Requires Prior Approval Subject to Quantity Limits	ADHD-Narcolepsy Agents
Diacomit	stiripentol	01/01/2019	Requires Excluded Exception Approval	Seizure Disorders
Diethylpropion	diethylpropion	01/01/2017	Requires Prior Approval	Antiobesity
Differin	adapalene	01/01/2017	Requires Prior Approval	Retinoids
Dilaudid	hydromorphone	03/01/2018	Requires Prior Approval Requires Step Therapy Subject to Quantity Limits	Opioid Analgesics
Diprolene (Brand Only)	betamethasone dipropionate	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Dolophine	methadone hydrochloride tablets	03/01/2018	Requires Prior Approval Requires Step Therapy Subject to Quantity Limits	Opioid Analgesics
Doptelet	avatrombopag	01/01/2019	Requires Excluded Exception Approval	Idiopathic Thrombocytopenic Purpura (ITP)
Doral	quazepam, estazolam	01/01/2017	Subject to Quantity Limits	Sedative-Hypnotics
Dovato	dolutegravir and lamivudine	06/03/2019	Subject to Quantity Limits	HIV
Duac	clindamycin phosphate/benzoyl peroxide gel	09/01/2017	Requires Prior Approval Requires Step Therapy	Topical Acne Products
Duaklir	aclidinium/formoterol	06/03/2019	Subject to Quantity Limits	Long-Acting Beta Agonists (LABA)
Dulera	formoterol; mometasone	01/01/2017	Requires Excluded Exception Approval	Long-Acting Beta Agonists (LABA)
Duopa	carbidopa / levodopa	01/01/2020	Requires Prior Approval	Parkinson's Disease
Dupixent	dupilumab	01/01/2018	Requires Prior Approval	Eczema
Duragesic	fentanyl transdermal system	03/01/2018	Requires Prior Approval Requires Step Therapy Subject to Quantity Limits	Opioid Analgesics - Extended-Release
Durolane	hyaluronic acid	01/01/2019	Requires Prior Approval	Osteoarthritis
Dyanavel XR	amphetamine extended release	01/01/2017	Requires Prior Approval Subject to Quantity Limits	ADHD-Narcolepsy Agents
Dysport	AbobotulinumtoxinA	01/01/2017	Requires Prior Approval	Botulinum Toxins
Edluar	zolpidem sublingual tablet	01/01/2017	Requires Prior Approval Requires Step Therapy	Sedative-Hypnotics
Edurant	rilpivirine	01/01/2017	Subject to Quantity Limits	HIV
Egaten	triclabendazole	08/01/2019	Requires Prior Approval Subject to Quantity Limits	Anthelmintic
Egrifta	tesamorelin injection	01/01/2017	Requires Prior Approval	HIV
Elaprase	Idursulfase	01/01/2017	Requires Prior Approval	Lysosomal Storage Disorders
Elelyso	Taliglucerase Alfa	01/01/2018	Requires Prior Approval Subject to Quantity Limits	Lysosomal Storage Disorders
Elidel	Calcineurin Inhibitor	10/01/2017	Requires Prior Approval	Chelating Agent
Eligard	Leuprolide	01/01/2017	Requires Prior Approval	Hormonal Therapies
Elocon (Brand Only)	mometasone	01/01/2019	Requires Prior Approval Subject to Quantity Limits	Corticosteroid
Eloctate	antihemophilic factor VIII	01/01/2017	Requires Excluded Exception Approval	Hemophilia
Eloxatin	oxaliplatin	12/01/2020	Requires Prior Approval	Oncology
Elzonris	tagraxofusp-erzs	01/01/2019	Requires Excluded Exception Approval	Oncology
Embeda	morphine sulfate and naltrexone hydrochloride extended-release	03/01/2018	Requires Excluded Exception Approval	Opioid Analgesics - Extended-Release
Emend	aprepitant, fosaprepitant dimeglumine	01/01/2017	Requires Prior Approval Subject to Quantity Limits	Antiemetics
Emflaza	deflazazort	01/01/2018	Requires Excluded Exception Approval	Corticosteroid
Emgality	galcanezumab-gnlm	01/01/2019	Requires Prior Approval Requires Step Therapy	CGRP Receptor Antagonists
EMLA	Lidocaine; Prilocaine	01/01/2017	Requires Prior Approval Subject to Quantity Limits	Topical Anesthetics - Lidocaine Containing
Empliciti	Elotuzumab	01/01/2017	Requires Prior Approval	Oncology
Emtriva	emtricitabine	01/01/2018	Subject to Quantity Limits	HIV
Emverm	mebendazole	10/01/2017	Requires Prior Approval Subject to Quantity Limits	Anthelmintic
Enbrel	etanercept injection	01/01/2018	Requires Prior Approval	Autoimmune
Endari	l-glutamine oral powder	01/01/2018	Requires Prior Approval	Blood Product Derivative
Endometrin	progesterone, vaginal	01/01/2017	Requires Prior Approval	Fertility Products - Non-Specialty
Enhertu	fam-trastuzumab deruxtecan	03/07/2020	Requires Prior Approval	Oncology
Entresto	sacubitril-valsartan tablets	01/01/2017	Requires Prior Approval	Heart Failure