Coverage Authorization List

Brand Namesort descending Generic Name Effective Date Requirements Class
Keveyis dichlorphenamide 01/01/2019
  • Requires Prior Approval
Electrolyte Disorders
Kevzara sarilumab 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Rheumatoid Arthritis
Keytruda Pembrolizumab 01/01/2017
  • Requires Prior Approval
Oncology
Khapzory Levoleucovorin 01/01/2017
  • Requires Prior Approval
Oncology
Kineret anakinra 01/01/2018
  • Requires Excluded Exception Approval
Rheumatoid Arthritis
Kisqali ribociclib 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Oncology
Kisqali-Femara ribociclib-letrozole 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Oncology
Kitabis Pak tobramycin inhalation 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Cystic Fibrosis
Klaron sodium sulfacetamide lotion 09/01/2017
  • Requires Prior Approval
  • Requires Step Therapy
Topical Acne Products
Klofensaid II diclofenac sodium topical solution 1.5% 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
COX-2/NSAIDs
Koate-DVI Antihemophilic factor VIII 01/01/2017
  • Requires Prior Approval
Hemophilia
Kogenate FS Antihemophilic factor VIII 10/01/2017
  • Requires Prior Approval
Hemophilia
Korlym mifepristone 01/01/2017
  • Requires Prior Approval
Cushing's Syndrome
Kovaltry Antihemophilic factor VIII 10/01/2017
  • Requires Prior Approval
Hemophilia
Krystexxa Pegloticase 01/01/2017
  • Requires Prior Approval
Gout
Kuvan sapropterin dihydrochloride 01/01/2017
  • Requires Prior Approval
Phenylketonuria (PKU)
Kynamro mipomersen sodium injection 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Lipid Disorders
Kynmobi apomorphine hydrochloride 08/01/2020
  • Requires Prior Approval
Movement Disorders
Kyprolis Carfilzomib 01/01/2017
  • Requires Prior Approval
Oncology
Lartruvo olaratumab 01/01/2018
  • Requires Prior Approval
Oncology
Latuda lurasidone 10/01/2019
  • Requires Prior Approval
Atypical Antipsychotics
Lazanda fentanyl nasal spray 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
Oral/Intranasal Fentanyl Products
Lemtrada alemtuzumab 01/01/2018
  • Requires Prior Approval
Multiple Sclerosis
Lenvima Lenvatinib 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Oncology
Letairis ambrisentan tablets 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Pulmonary Arterial Hypertension
Leukine sargramostim 01/01/2017
  • Requires Prior Approval
Neutropenia
Levorphanol levorphanol tartrate 03/01/2018
  • Requires Prior Approval
  • Requires Step Therapy
  • Subject to Quantity Limits
Opioid Analgesics
Lexette (Brand Only) halobetasol foam 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Corticosteroid
Lexiva fosamprenavir 01/01/2018
  • Subject to Quantity Limits
HIV
Libtayo cemiplimab-rwlc 01/01/2019
  • Requires Excluded Exception Approval
Oncology
Lidocaine 5% Ointment Lidocaine 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
Topical Anesthetics - Lidocaine Containing
Lidocaine Gel - 2% and 4% Lidocaine 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
Topical Anesthetics - Lidocaine Containing
Lidocaine HCL 4% Solution Lidocaine 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
Topical Anesthetics - Lidocaine Containing
Lidoderm lidocaine patch 5% 10/01/2017
  • Requires Prior Approval
Topical Anesthetics - Lidocaine Containing
Locoid (Brand Only) hydrocortisone butyrate 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Corticosteroid
Lokara (Brand Only) desonide 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Corticosteroid
Lonsurf Trifluridine; Tipiracil 01/01/2017
  • Requires Prior Approval
Oncology
Lorbrena lorlatinib 01/01/2019
  • Requires Excluded Exception Approval
Oncology
Lovaza omega-3-acid ethyl esters capsules 01/01/2017
  • Requires Prior Approval
Omega-3 Fatty Acids
Lucentis Ranibizumab 01/01/2017
  • Requires Prior Approval
Retinal Disorders
Lumizyme Alglucosidase alfa 01/01/2017
  • Requires Prior Approval
Lysosomal Storage Disorders
Lumoxiti moxetumomab pasudotox-tdfk 01/01/2019
  • Requires Excluded Exception Approval
Oncology
Lunesta eszopiclone 01/01/2017
  • Requires Prior Approval
  • Subject to Quantity Limits
Sedative-Hypnotics
Lupaneta Leuprolide; Norethindrone 01/01/2017
  • Requires Prior Approval
Hormonal Therapies
Lupron leuprolide 01/01/2017
  • Requires Prior Approval
Fertility Products - Specialty
Lupron Depot PED leuprolide acetate for depot suspension 01/01/2018
  • Requires Prior Approval
Hormonal Therapies
Lutathera lutetium Lu 117 dotatate 01/01/2017
  • Requires Prior Approval
Oncology
Luxiq (Brand Only) betamethasone valerate 01/01/2019
  • Requires Prior Approval
  • Subject to Quantity Limits
Corticosteroid
Lynparza Olaparib 01/01/2018
  • Requires Prior Approval
  • Subject to Quantity Limits
Oncology
Makena hydroxyprogesterone caproate injection 01/01/2018
  • Requires Prior Approval
Progestin