Coverage Authorization List

Brand Namesort descending Generic Name Effective Date Requirements Class
Entyvio Vedolizumab 01/01/2018
  • Requires Excluded Exception Approval
IBS
Epanova omega-3-carboxylic acids 01/01/2019
  • Requires Prior Approval
Omega-3 Fatty Acids
Epclusa Sofosbuvir 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Hepatitis C
Epidiolex cannabidiol 01/01/2019
  • Requires Prior Approval
Seizure Disorders
Epiduo/Epiduo Forte adapalene/benzoyl peroxide gel 09/01/2017
  • Requires Prior Approval
  • Requires Step Therapy
Topical Acne Products
Epivir lamivudine 01/01/2018
  • Subject to Quantity Limits
HIV
Epogen Epoetin Alfa 01/01/2017
  • Requires Prior Approval
Anemia
Epzicom abacavir/lamivudine 01/01/2018
  • Subject to Quantity Limits
HIV
Erbitux Cetuximab 01/01/2017
  • Requires Prior Approval
Oncology
Erivedge vismodegib capsules 01/01/2018
  • Requires Prior Approval
Oncology
Erleada apalutamide 01/01/2019
  • Requires Prior Approval
Oncology
Erwinaze L-asparaginase 01/01/2017
  • Requires Prior Approval
Oncology
Erygel erythromycin topical gel 09/01/2017
  • Requires Prior Approval
  • Requires Step Therapy
Topical Acne Products
Esbriet pirfenidone capsules 01/01/2018
  • Requires Prior Approval
Idiopathic Pulmonary Fibrosis
Eucrisa crisaborole 01/01/2019
  • Requires Prior Approval
  • Requires Step Therapy
Phosphodiesterase-4 Enzyme Inhibitor
Euflexxa sodium hyaluronate 01/01/2018
  • Requires Excluded Exception Approval
Osteoarthritis
Evekeo amphetamine sulfate tablets 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
ADHD-Narcolepsy Agents
Evenity romosozumab-aqqg 01/01/2018
  • Requires Prior Approval
Bone Disorders - Other
Evoclin clindamycin phosphate gel 09/01/2017
  • Requires Prior Approval
  • Requires Step Therapy
Topical Acne Products
Evotaz atazanavir/cobicistat 01/01/2018
  • Subject to Quantity Limits
HIV
Exalgo hydromorphone hcl extended release tablets 03/01/2017
  • Requires Prior Approval
  • Requires Step Therapy
  • Subject to Quantity Limits
Opioid Analgesics - Extended-Release
Exjade deferasirox 01/01/2017
  • Requires Prior Approval
Iron Overload
Exondys 51 eteplirsen 01/01/2018
  • Requires Prior Approval
Duchenne muscular dystrophy
Extavia interferon beta-1b 01/01/2018
  • Requires Excluded Exception Approval
Multiple Sclerosis
Eylea Aflibercept 01/01/2017
  • Requires Prior Approval
Retinal Disorders
Fabior tazarotene foam 01/01/2017
  • Requires Prior Approval
  • Requires Step Therapy
Retinoids
Fabrazyme Agalsidase Beta 01/01/2017
  • Requires Prior Approval
Lysosomal Storage Disorders
Fanapt iloperidone 10/01/2017
  • Requires Prior Approval
Atypical Antipsychotics
Farydak panobinostat 01/01/2017
  • Requires Excluded Exception Approval
Oncology
Fasenra benralizumab 01/01/2018
  • Requires Excluded Exception Approval
Asthma
Faslodex fulvestrant 01/01/2020
  • Requires Prior Approval
Oncology
Feiba Antihemophilic Factor VIII 01/01/2017
  • Requires Prior Approval
Hemophilia
Fensolvi leuprolide 09/01/2020
  • Requires Prior Approval
Hormonal Therapies
Fentora fentanyl buccal tablets 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
Oral/Intranasal Fentanyl Products
Ferriprox deferiprone 01/01/2017
  • Requires Excluded Exception Approval
Iron Overload
Finacea azelaic acid 10/01/2017
  • Requires Prior Approval
Rosacea
Firazyr icatibant for subcutaneous [SC] injection 01/01/2017
  • Requires Prior Approval
Hereditary Angioedema
Firdapse amifampridine 01/01/2019
  • Requires Excluded Exception Approval
Seizure Disorders
Firmagon Degarelix 01/01/2017
  • Requires Prior Approval
Hormonal Therapies
Flolan epoprostenol 01/01/2019
  • Requires Prior Approval
Pulmonary Arterial Hypertension
Flovent fluticasone propionate 01/01/2019
  • Subject to Quantity Limits
Corticosteroid
Focalin dexmethylphenidate immediate release tablets 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
ADHD-Narcolepsy Agents
Follistim AQ follitropin beta 01/01/2017
  • Requires Excluded Exception Approval
Fertility Products - Specialty
Folotyn Pralatrexate 01/01/2017
  • Requires Prior Approval
Oncology
Foradil Formoterol 01/01/2017
  • Subject to Quantity Limits
Long-Acting Beta Agonists (LABA)
Fortamet metformin ER 08/01/2017
  • Requires Prior Approval
Diabetes
Forteo teriparatide injection 01/01/2018
  • Requires Prior Approval
Osteoporosis
Fortesta testosterone topical gel 01/01/2018
  • Requires Excluded Exception Approval
Testosterone Products
Fosamax + D alendronate/cholecalciferol 01/01/2017
  • Requires Step Therapy
Bisphosphanates
Frova frovatriptan 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
Antimigraine