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 |
|
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 |
|
Antiobesity |
Differin |
adapalene
|
01/01/2017 |
|
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 |
|
Parkinson's Disease |
Dupixent |
dupilumab
|
01/01/2018 |
|
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 |
|
Osteoarthritis |
Dyanavel XR |
amphetamine extended release
|
01/01/2017 |
- Requires Prior Approval
- Subject to Quantity Limits
|
ADHD-Narcolepsy Agents |
Dysport |
AbobotulinumtoxinA
|
01/01/2017 |
|
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 |
|
HIV |
Elaprase |
Idursulfase
|
01/01/2017 |
|
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 |
|
Chelating Agent |
Eligard |
Leuprolide
|
01/01/2017 |
|
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 |
|
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 |
|
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 |
|
Autoimmune |
Endari |
l-glutamine oral powder
|
01/01/2018 |
|
Blood Product Derivative |
Endometrin |
progesterone, vaginal
|
01/01/2017 |
|
Fertility Products - Non-Specialty |
Enhertu |
fam-trastuzumab deruxtecan
|
03/07/2020 |
|
Oncology |
Entresto |
sacubitril-valsartan tablets
|
01/01/2017 |
|
Heart Failure |