Coverage Authorization List

Brand Name	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