Commercial 3-Tier Prior Authorization List The following prescription drugs require Prior Authorization

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1 Commercial 3-Tier Prior Authorization List The following prescription drugs require Prior Authorization Certain medications require prior authorization, which means approval is needed before the prescription can be filled. If approval is not received, the drug may not be covered. ABSORICA ABSTRAL ACANYA ACIPHEX SPRINKLE ACTEMRA ACTICLATE ACTIMMUNE ACTIQ ADCIRCA ADDYI ADEMPAS ADZENYS ER ADZENYS XR-ODT AFINITOR AIMOVIG AUTOINJECTOR ALECENSA ALUNBRIG amlodipine-valsartan amlodipine-valsartan-hctz AMPYRA AMRIX ANDRODERM ANDROGEL ANDROID ANDROXY ANODYNE LPT APTIOM ARCALYST ARIKAYCE ARYMO ER ASTAGRAF XL AUSTEDO AUVI-Q AVINZA AXIRON BELBUCA BELVIQ BELVIQ XR BENLYSTA PAGE 1 BERINERT bexarotene BONJESTA BOSULIF BRAFTOVI BRAVELLE BRISDELLE BRIVIACT budesonide er buprenorphine patch BUTRANS CABOMETYX CALQUENCE CAPRELSA CARAC CARBAGLU carbinoxamine maleate carisoprodol 250mg CENTANY AT CERDELGA CETROTIDE chlorzoxazone 250mg CHOLBAM chorionic gonadotropin CIMZIA CINRYZE CLINDACIN ETZ CLINDACIN PAC clindamycin phos-benzoyl perox clindamycin phos-tretinoin CLODAN COMETRIQ COMFORT PAC-CYCLOBENZAPRINE COMFORT PAC-MELOXICAM COMFORT PAC-NAPROXEN COMFORT PAC-TIZANIDINE CONTRAVE CONZIP COPEGUS COPIKTRA COSENTYX

2 COTELLIC COTEMPLA XR-ODT CUPRIMINE CUVPOSA cyclobenzaprine hcl 7.5mg cyproheptadine syrup CYSTARAN DAKLINZA dalfampridine er DERMACINRX CINLONE-I CPI DERMACINRX CLORHEXACIN DERMACINRX EMPRICAINE DERMACINRX LEXITRAL DERMACINRX PRIZOPAK DERMACINRX SILAPAK DERMACINRX SILAZONE DERMACINRX SURGICAL PHARMAPAK DERMACINRX THERAZOLE PAK DERMAZONE dexamethasone therapy pack DICLEGIS DICLO GEL DICLO GEL-XRYLIX SHEET diclofenac sodium 3% DICLOPR DICLOTRAL DICLOZOR DITHOL DOLOTRANZ DOPTELET doxycycline hyclate tab DUEXIS DUPIXENT DURAGESIC DUZALLO DYANAVEL XR DYMISTA EGRIFTA ELLZIA PAK EMBEDA EMFLAZA EMGALITY EMVERM ENBREL ENBREL MINI ENBREL SURECLICK ENDARI ENDOMETRIN ENSTILAR ENVARSUS XR EPANDED SOLUTION EPCLUSA EPIDIOLEX ERIVEDGE ERLEADA ESBRIET ESOMEP-EZS esomeprazole strontium EXALGO EXTAVIA ENTERAL FORMULA REQUIRES PRIOR AUTHORIZATION. FABIOR FARYDAK fenoprofen calcium FENORTHO fentanyl patch fentanyl citrate FENTORA FEXMID FIRAZYR FLECTOR FLEXIPAK fluorouracil 0.5% cream FOLLISTIM AQ FORTEO FORTESTA FULYZAQ PAGE 2

3 GALAFOLD ganirelix acetate GATTEX GENOTROPIN GIAZO GILOTRIF GLYCATE glycopyrrolate 1.5mg GOCOVRI GONITRO GRALISE GRANIX GONAL-F H.P. ACTHAR HAEGARDA HARVONI HETLIOZ HORIZANT HUMATROPE HYCAMTIN hydrocodone-guaifenesin hydromorphone er HYSINGLA ER HUMIRA IBRANCE ICLUSIG IDHIFA IMBRUVICA IMPAVIDO INCRELEX INFLAMMACIN INGREZZA INLYTA IRESSA JAKAFI JUBLIA JUXTAPID JYNARQUE KADIAN KALYDECO KERYDIN KEVEYIS KEVZARA KINERET KISQALI KISQALI FEMARA CO-PACK KORLYM KRISTALOSE KUVAN KYNAMRO lactulose packet LAMISIL GRANULES LAZANDA LENVIMA LETAIRIS leuprolide acetate levorphanol tartrate LEXIXRYL LIDO-PRILO CAINE PACK LIDOPAC LIDOPRIL LIDOPRIL XR LIDOTRANS 5 PAK LIPROZONEPAK LONSURF LOPROX LORBRENA LORZONE LYNPARZA LYRICA CR MAVYRET MEDOLOR PAK MEKINIST MEKTOVI MENOPUR mesalamine kit methadone hcl METHADONE INTENSOL METHADOSE METHITEST methyltestosterone miglustat PAGE 3

4 minocycline hcl er tab MINOLIRA ER MODERIBA MORGIDOX MORPHABOND ER morphine sulfate er MOXATAG MOZOBIL MS CONTIN MULPLETA MYALEPT MYTESI NALFON NAMZARIC NATESTO NATPARA NERLYNX NEUPOGEN NEUPRO NEURCAINE NEXAVAR NINLARO nitroglycerin spray NITROMIST NITYR NIVESTYM NORDITROPIN FLEXPRO NORTHERA nortriptyline dose cup NOVAREL NUCYNTA ER NUDICLO NUDROXIPAK NUDROXIPAK DSDR-50 NUDROXIPAK DSDR-75 NUDROXIPAK E-400 NUDROXIPAK I-800 NUDROXIPAK N-500 NUEDEXTA NUPLAZID NUTRESTORE PAGE 4 NUTRIARX NUTROPIN AQ OCALIVA ODOMZO OFEV OLUMIANT OLYSIO OMECLAMOX-PAK OMNITROPE ONEXTON ONMEL OPSUMIT ORAVIG ORENCIA ORENITRAM ER ORFADIN ORILISSA ORKAMBI OSMOLEX ER OTEZLA OTREXUP OVIDREL OXTELLAR XR oxycodone hcl er OXYCONTIN oxymorphone hcl er PAINGO KFT PALYNZIQ paroxetine mesylate 7.5mg PEDIADERM HC PEGASYS PEGASYS PROCLICK PEGINTRON PEGINTRON REDIPEN PENNSAID POMALYST PRALUENT PREGNYL PREVIDOLRX PLUS ANALGESIC PAK PRILOLID PROCYSBI

5 PROFENO PROMACTA PURIXAN QBRELIS QSYMIA QUALAQUIN QUDEXY XR QUILLICHEW ER QUILLIVANT XR quinine sulfate RASUVO RAVICTI RAYOS REBETOL RELADOR PAK REPATHA REVATIO REVLIMID RIBASPHERE RIBASPHERE RIBAPAK RIBATAB ribavirin ROSADAN ROWASA RUBRACA RUCONEST RYDAPT RYTARY RYVENT SABRIL SAIZEN SANADERMRX SAXENDA SEROSTIM SIGNIFOR SIKLOS SILALITE PAK SILAZONE-II sildenafil 20mg SILIQ SIMPONI SITAVIG SIVEXTRO SOLARAZE SOLODYN SOLTAMOX SOLUPAK SOMA SOMAVERT SORILUX SOTYLIZE SOVALDI SPRITAM SPRIX SPRYCEL STELARA STIVARGA STRENSIQ STRIANT SUBSYS SUCRAID SUPRENZA ODT SUTENT SYLATRON SYMDEKO SYNALAR TS SYNDROS SYPRINE TACLONEX SUSP tadalafil 20mg TAFINLAR TAGRISSO TAKHZYRO TALZENNA TAPERDEX TARCEVA TARGRETIN TASIGNA TAVALISSE TECHNIVIE TEGSEDI TESTIM PAGE 5

6 testosterone - topical tetrabenazine TIBSOVO TICALAST TICANASE TICASPRAY TIVORBEX topiramate er caps TRACLEER tramadol er caps tramadol hcl er TREMFYA TRETIN-X tretinoin 0.05% cream TRI-SILA trientine hcl TRIXYLITRAL TROKENDI XR TYKERB TYMLOS TALTZ TYVASO UCERIS ULTRAM ER ULTRAVATE X UPTRAVI VACUSTIM BLACK VACUSTIM SILVER VALCHLOR VELTIN VENCLEXTA VERZENIO VIEKIRA PAK VIEKIRA XR vigabatrin VIMOVO VIVLODEX VIZIMPRO VOGELXO PAGE 6 VOSEVI VOTRIENT WHYTEDERM TRILASIL PAK XALKORI XARTEMIS XR XATMEP XELITRAL XELJANZ XELJANZ XR XENAFLAMM XENICAL XERESE XERMELO XHANCE XIMINO XRYLIX XTAMPZA ER XTANDI XURIDEN XYOSTED XYREM YONSA ZAVESCA ZEJULA ZELAPAR ZELBORAF ZEPATIER ZEYOCAINE ZIANA ZIPSOR ZODEX ZOHYDRO ER ZOLINZA ZOMACTON ZONTIVITY ZORBTIVE ZORVOLEX ZURAMPIC ZYDELIG ZYKADIA ZYTIGA

7 Commercial 3-Tier Step Therapy List The following prescription drugs require Step Therapy Step Therapy requires that members try certain First Line options before other medications will be considered medically necessary for treatment of a specific condition. Step therapy requirements may apply to both brand and generics. Typically, First Line medications are classified as generics, but there are instances where brand name medications may be preferred. ACZONE ADAPALENE SOLUTION ADAPALENE 0.1% LOTION AEROSPAN AIRDUO RESPICLICK AKTIPAK ALOGLIPTIN BENZOATE ALVESCO AMITIZA ANZEMET APLENZIN APTENSIO XR ATRIPLA AUBAGIO AZASAN BELSOMRA BETASERON BRYHALI BUPROPION XL 450 MG CAMBIA CIALIS CIMZIA CLEOCIN T CLINDAGEL CLINDAMYCIN PHOSPHATE 1% GEL CLOCORTOLONE PIVALATE 0.1 % CREAM(G) CLODERM CORDRAN COSENTYX DAKLINZA DALIRESP DAYTRANA DESONATE DEXILANT DIFFERIN DIFICID DORYX DOXYCYCLINE MONOHYDRATE 40 MG ECOZA EDARBI EDARBYCLOR EDLUAR EMSAM ENTRESTO ERTACZO EUCRISA EVOCLIN EXTINA FANAPT FOLLISTIM AQ FORFIVO XL FORTAMET GELNIQUE GENOTROPIN GLATOPA 20 MG/ML GLEEVEC GLUMETZA HALOG HUMATROPE HYDROCORTISONE BUTYRATE 0.1 LOTION IMPOYZ INTERMEZZO KADIAN KAZANO KENALOG SPRAY KEVZARA KHEDEZLA KINERET KOMBIGLYZE XR LATUDA LEVITRA LEXETTE LIVALO LOCOID LOCOID LIPOCREAM PAGE 1

8 LONHALA MAGNAIR REFILL LONHALA MAGNAIR STARTER LUZU MENTAX MORPHINE SULFATE MYDAYIS NAMENDA XR NESINA NEXIUM NORDITROPIN FLEXPRO NORITATE NUTROPIN AQ OLEPTRO ER OLYSIO OMEPRAZOLE-SODIUM BICARBONATE ONGLYZA ONZETRA ORACEA ORENCIA OSENI OSPHENA OXYTROL PANDEL PEXEVA PLIXDA PRADAXA PULMICORT FLEXHALER QBREXZA RAPAFLO REXULTI RHOPRESSA ROZEREM SAIZEN SANCUSO SAPHRIS SAVAYSA SAVELLA SERNIVO PAGE 2 SILENOR SILIQ SIMPONI SOOLANTRA STAXYN STENDRA SUMAVEL DOSEPRO SYMPAZAN SYMPROIC TECHNIVIE TRELEGY ELLIPTA TREMFYA TRULANCE TUSSIONEX TUZISTRA XR TALTZ TEST STRIPS (OTHER THAN ABBOTT AND ONE TOUCH) ULORIC ULTRAVATE LOTION VANOS VELTASSA VENLAFAXINE ER TAB VERDESO VIEKIRA PAK VIEKIRA XR VRAYLAR VYZULTA XADAGO XELPROS XOLEGEL YUPELRI ZEGERID ZEMBRACE SYMTOUCH ZEPATIER ZINBRYTA ZIOPTAN ZOLPIMIST ZOMIG ZUPLENZ

9 ZYPITAMAG ALOGLIPTIN BENZOATE/METFORMIN HCL ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL METFORMIN ER 500MG & 1000MG TAB (GENERIC VERSION OF GLUMETZA & FORTAMET) Please submit completed PA and Step Therapy forms to: Pharmacy Help Desk Mail to: 165 Court Street, Rochester, NY Fax: 1 (800) Phone: 1 (800) PAGE 3