Coverage Authorization List

Brand Namesort descending 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