Coverage Authorization List

Brand Name	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