Coverage Authorization List

Brand Namesort descending Generic Name Effective Date Requirements Class
Fulphila pegfilgrastim-jmdp 01/01/2019
  • Requires Excluded Exception Approval
  • Subject to Quantity Limits
Neutropenia
Fusilev Levoleucovorin 01/01/2017
  • Requires Prior Approval
Oncology
Fuzeon enfuvirtide 01/01/2018
  • Subject to Quantity Limits
HIV
Galafold migalastat 01/01/2019
  • Requires Prior Approval
Lysosomal Storage Disorders
GamaSTAN S/D immune globulin (Human) 01/01/2019
  • Requires Excluded Exception Approval
IVIG
Gamifant emapalumab-Izsg 04/01/2019
  • Requires Prior Approval
Blood Disorders
Gammaguard Immune globulin 01/01/2017
  • Requires Prior Approval
IVIG
Gammaked immune globulin injection (Human) 01/01/2017
  • Requires Prior Approval
IVIG
Gammunex-C Immune globulin 01/01/2017
  • Requires Prior Approval
IVIG
Ganirelix acetate ganirelix acetate 01/01/2017
  • Requires Prior Approval
Fertility Products - Specialty
Gattex Teduglutide 01/01/2017
  • Requires Prior Approval
GI Disorders
Gazyva Obinutuzumab 01/01/2017
  • Requires Prior Approval
Oncology
Gel-One hyaluronate 01/01/2017
  • Requires Prior Approval
Osteoarthritis
Gelsyn-3 hyaluronate 01/01/2017
  • Requires Prior Approval
Osteoarthritis
Gemzar gemcitabine 12/01/2020
  • Requires Prior Approval
Oncology
Genotropin somatropin 01/01/2017
  • Requires Excluded Exception Approval
Growth Hormone and Related Disorders
Genvisc 850 hyaluronate 01/01/2017
  • Requires Prior Approval
Osteoarthritis
Genvoya elvitegravir/cobicistat/emtricitabine/tenofovir 01/01/2018
  • Subject to Quantity Limits
HIV
Gilenya fingolimod capsules 01/01/2018
  • Requires Prior Approval
Multiple Sclerosis
Gilotrif afatinib 01/01/2018
  • Requires Prior Approval
Oncology
Glassia Alpha-1-proteinase Inhibitor 01/01/2017
  • Requires Prior Approval
Alpha-1 Antitrypsin Deficiency
Glatopa glatiramer acetate injection 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Multiple Sclerosis
Gleevec imatinib mesylate 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Oncology
Glumetza metformin ER 08/01/2017
  • Requires Prior Approval
Diabetes
Gonal-F follitropin alfa 01/01/2017
  • Requires Prior Approval
Fertility Products - Specialty
Granix Tbo-Filgrastim 01/01/2017
  • Requires Prior Approval
Neutropenia
Grastek timothy grass pollen allergen extract sublingual [SL] tablets 01/01/2017
  • Requires Prior Approval
Sublingual Immunotherapy Products
H.P. Acthar Gel repository corticotropin injection 08/01/2017
  • Requires Prior Approval
Seizure Disorders
Haegarda C1 Esterase Inhibitor 01/01/2018
  • Requires Prior Approval
Hereditary Angioedema
Halaven Eribulin 01/01/2017
  • Requires Prior Approval
Oncology
Halcion Triazolam 01/01/2017
  • Subject to Quantity Limits
Sedative-Hypnotics
Halog (Brand Only) halcinonide 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Corticosteroid
Harvoni sofosbuvir/ledipasvir tablets 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Hepatitis C
Helixate FS Antihemophilic factor VIII 01/01/2017
  • Requires Excluded Exception Approval
Hemophilia
Hemlibra emicizumab-kxwh 01/01/2018
  • Requires Excluded Exception Approval
Hemophilia
Hemofil M Antihemophilic factor VIII 01/01/2017
  • Requires Prior Approval
Hemophilia
Herceptin Trastuzumab 01/01/2017
  • Requires Prior Approval
Oncology
Herceptin Hylecta Trastuzumab and hyaluronidase-oysk 01/01/2017
  • Requires Prior Approval
Oncology
Heruzuma trastuzumab-pkrb 07/01/2020
  • Requires Prior Approval
Oncology
Hetlioz tasimelteon capsules 01/01/2018
  • Requires Prior Approval
Sleep Disorders
Hizentra immune globulin subcutaneous 01/01/2017
  • Requires Prior Approval
IVIG
Humate-P Antihemophilic Factor VIII 10/01/2017
  • Requires Prior Approval
Hemophilia
Humatrope somatropin injection 01/01/2017
  • Requires Prior Approval
Growth Hormone and Related Disorders
Humira adalimumab injection 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
IBS/RA/Psoriasis
Hyalgan Sodium Hyaluronate 01/01/2017
  • Requires Excluded Exception Approval
Osteoarthritis
Hyaluronates 01/01/2020
  • Requires Prior Approval
Osteoarthritis
Hycamtin Topotecan 01/01/2017
  • Requires Prior Approval
Oncology
Hymovis Sodium Hyaluronate 01/01/2017
  • Requires Excluded Exception Approval
Osteoarthritis
HyQvia immune globulin subcutaneous 01/01/2018
  • Requires Prior Approval
IVIG
Hysingla hydrocodone bitartrate extended-release tablets 03/01/2017
  • Requires Prior Approval
  • Requires Step Therapy
  • Subject to Quantity Limits
Opioid Analgesics - Extended-Release