National Preferred Formulary Prior Approval List As of: 04/01/2019
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- Cora Long
- 5 years ago
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1 National Preferred Formulary Prior Approval List As of: 04/01/2019 Helpful Tip: To search for a specific drug, use the find feature (Ctrl + F) KYMRIAH (CAR-T) ADOPTIVE IMMUNOTHERAPY CUSTOM LUXTURNA (gene therapy) ADOPTIVE IMMUNOTHERAPY CUSTOM YESCARTA ADOPTIVE IMMUNOTHERAPY CUSTOM ACTHAR H.P. ADRENAL HORMONES HORMONES EMFLAZA ADRENAL HORMONES HORMONES TEMODAR ALKYLATING AGENTS ANTINEOPLASTICS TEMOZOLOMIDE ALKYLATING AGENTS ANTINEOPLASTICS ALL ANALGESIC OPIOIDS ANALGESIC HIGH DOSE OPIOID IMMEDIATE RELEASE AND/OR LONG ACTING OPIOID ANALGESIC CUSTOM IN OPIOID NAÏVE PERSON ADIPEX-P (phentermine hydrochloride) ANOREXIANTS ANTI-OBESITY DRUGS BELVIQ (lorcaserin hydrochloride) ANOREXIANTS ANTI-OBESITY DRUGS BELVIQ XR (lorcaserin hydrochloride) ANOREXIANTS ANTI-OBESITY DRUGS BENZPHETAMINE HCL ANOREXIANTS ANTI-OBESITY DRUGS BONTRIL PDM (benzphetamine hydrochloride) ANOREXIANTS ANTI-OBESITY DRUGS BONTRIL SLOW-RELEASE ANOREXIANTS ANTI-OBESITY DRUGS CONTRAVE ER (naltrexone HCl/buproprion HCl ER) ANOREXIANTS ANTI-OBESITY DRUGS DIDREX (benzphetamine hydrochloride) ANOREXIANTS ANTI-OBESITY DRUGS DIETHYLPROPION HCL ANOREXIANTS ANTI-OBESITY DRUGS DIETHYLPROPION HCL ER ANOREXIANTS ANTI-OBESITY DRUGS LOMAIRA (phentermine hydrochloride) ANOREXIANTS ANTI-OBESITY DRUGS PHENDIMETRAZINE TARTRATE ANOREXIANTS ANTI-OBESITY DRUGS PHENTERMINE HCL ANOREXIANTS ANTI-OBESITY DRUGS QSYMIA (phentermine and topiramate) ANOREXIANTS ANTI-OBESITY DRUGS REGIMEX (benzphetamine) ANOREXIANTS ANTI-OBESITY DRUGS SAXENDA (liraglutide) ANOREXIANTS ANTI-OBESITY DRUGS SUPRENZA ODT (phentermine hydrochloride) ANOREXIANTS ANTI-OBESITY DRUGS XENICAL (orlistat) ANOREXIANTS ANTI-OBESITY DRUGS ERLEADA ANTIANDROGENS ANTINEOPLASTICS XTANDI ANTIANDROGENS ANTINEOPLASTICS ZYTIGA ANTIANDROGENS ANTINEOPLASTICS ARIKAYCE ANTIBIOTIC INHALED ANTIBIOTICS DARAPRIM ANTIMALARIALS ANTIINFECTIVES/MISCELLANEOUS COSENTYX 150MG ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS COSENTYX 300MG ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS ILUMYA ANTIPSORIATIC / ANTISEBORRHEIC IMMUNOSUPPRESSANTS SILIQ ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS STELARA ANTIPSORIATIC / ANTISEBORRHEIC IMMUNOSUPPRESSANTS TALTZ AUTOINJECTOR ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS TALTZ AUTOINJECTOR (2 PACK) ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS TALTZ AUTOINJECTOR (3 PACK) ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS TALTZ SYRINGE ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS TALTZ SYRINGE (2 PACK) ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS TALTZ SYRINGE (3 PACK) ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS TREMFYA ANTIPSORIATIC / ANTISEBORRHEIC SKIN PREPS WAYLIVRA ANTISENSE DRUG CHYLOMICRONEMIA Syndrome ZUPLENZ ANTIVERTIGO & ANTIEMETIC AGENTS GASTROINTESTINAL BRAFTORI (ENCORAFENIB) BRAF INHIBITOR ONCOLOGY AIMOVIG CALCITONIN GENE-RELATED RECEPTOR (CGRP) ANTAGONISTS MIGRAINE AJOVY CALCITONIN GENE-RELATED RECEPTOR (CGRP) ANTAGONISTS MIGRAINE EMGALITY CALCITONIN GENE-RELATED RECEPTOR (CGRP) ANTAGONISTS MIGRAINE EPIDIOLEX CANNABINOID ANTI-CONVULSANT CANNABINOID ANTI-CONVULSANT KEVEYIS CARBONIC ANHYDRASE INHIBITOR MISCELLANEOUS LUCEMYRA CENTRAL ALPHA-2 ADRENERGIC AGONIST OPIOID WITHDRAWAL ULTOMIRIS COMPLEMENT INHIBITOR PAROXYSMAL NOCTURNAL HEMOGLOBINURIA NOCDURNA DESMOPRESSIN DESMOPRESSIN THERAPY RESPECTIVELY CEREZYME ENZYME CUSTOM ARANESP ERYTHROID STIMULANTS COLONY STIMULATING FACTORS EPOGEN ERYTHROID STIMULANTS COLONY STIMULATING FACTORS PROCRIT ERYTHROID STIMULANTS COLONY STIMULATING FACTORS ORILISSA GNRH RECEPTOR ANTAGONIST PAIN DUE TO ENDOMETRIOSIS ELIGARD GONADOTROPIN-RELEASING HORMONE ANALOGS ANTINEOPLASTICS FIRMAGON GONADOTROPIN-RELEASING HORMONE ANALOGS ANTINEOPLASTICS TRELSTAR GONADOTROPIN-RELEASING HORMONE ANALOGS ANTINEOPLASTICS GENOTROPIN GROWTH HORMONES HORMONES HUMATROPE GROWTH HORMONES HORMONES NORDITROPIN GROWTH HORMONES HORMONES NORDITROPIN FLEXPRO GROWTH HORMONES HORMONES NORDITROPIN NORDIFLEX GROWTH HORMONES HORMONES NUTROPIN GROWTH HORMONES HORMONES NUTROPIN AQ GROWTH HORMONES HORMONES NUTROPIN AQ NUSPIN GROWTH HORMONES HORMONES OMNITROPE GROWTH HORMONES HORMONES SAIZEN GROWTH HORMONES HORMONES SAIZENPREP GROWTH HORMONES HORMONES SEROSTIM GROWTH HORMONES HORMONES ZOMACTON GROWTH HORMONES HORMONES
2 ZORBTIVE GROWTH HORMONES HORMONES HEMLIBRA HEMOPHILIA HEMOPHILIA AGENT DUROLANE HYALURONIC ACID DERIVATIVES HYALURONIC ACID DERIVATIVES EUFLEXXA HYALURONIC ACID DERIVATIVES HYALURONIC ACID DERIVATIVES GEL-ONE HYALURONIC ACID DERIVATIVES HYALURONIC ACID DERIVATIVES GELSYN-3 HYALURONIC ACID DERIVATIVES HYALURONIC ACID DERIVATIVES GENVISC-850 HYALURONIC ACID DERIVATIVES HYALURONIC ACID DERIVATIVES HYALGAN HYALURONIC ACID DERIVATIVES HYALURONIC ACID DERIVATIVES HYMOVIS HYALURONIC ACID DERIVATIVES HYALURONIC ACID DERIVATIVES MONOVISC HYALURONIC ACID DERIVATIVES HYALURONIC ACID DERIVATIVES ORTHOVISC HYALURONIC ACID DERIVATIVES HYALURONIC ACID DERIVATIVES SUPARTZ/SUPARTZ FX HYALURONIC ACID DERIVATIVES HYALURONIC ACID DERIVATIVES SYNOJOYNT HYALURONIC ACID DERIVATIVES HYALURONIC ACID DERIVATIVES SYNVISC HYALURONIC ACID DERIVATIVES HYALURONIC ACID DERIVATIVES SYNVISC-ONE HYALURONIC ACID DERIVATIVES HYALURONIC ACID DERIVATIVES TRIVISC HYALURONIC ACID DERIVATIVES HYALURONIC ACID DERIVATIVES VISCO-3 HYALURONIC ACID DERIVATIVES HYALURONIC ACID DERIVATIVES HETLIOZ HYPNOTIC AGENTS SEDATIVE/HYPNOTICS FASENRA IMMUNOLOGICAL AGENT ANTIASTHMATICS AVONEX ADMINISTRATION PACK INTERFERONS CNS DRUGS AVONEX PEN INTERFERONS CNS DRUGS BETASERON INTERFERONS CNS DRUGS EXTAVIA INTERFERONS CNS DRUGS PEGASYS INTERFERONS ANTIVIRALS PEGASYS PROCLICK INTERFERONS ANTIVIRALS PEG-INTRON INTERFERONS ANTIVIRALS PEG-INTRON REDIPEN INTERFERONS ANTIVIRALS PLEGRIDY INTERFERONS CNS DRUGS REBIF INTERFERONS CNS DRUGS REBIF REBIDOSE INTERFERONS CNS DRUGS EXJADE (DEFERASIROX) IRON CHELATORS CHELATING AGENTS FERRIPROX (DEFERIPRONE) IRON CHELATORS CHELATING AGENTS JADENU (DEFERASIROX) IRON CHELATORS CHELATING AGENTS MEKTOVI (BINIMETINIB) KINASE INHIBITOR ONCOLOGY INBRIJA LEVODOPA PARKINSON'S DISEASE JUXTAPID LIPID/CHOLESTEROL LOWERING AGENTS CARDIOVASCULAR PRALUENT PEN LIPID/CHOLESTEROL LOWERING AGENTS CUSTOM PRALUENT SYRINGE LIPID/CHOLESTEROL LOWERING AGENTS CUSTOM REPATHA PUSHTRONEX LIPID/CHOLESTEROL LOWERING AGENTS CUSTOM REPATHA SURECLICK LIPID/CHOLESTEROL LOWERING AGENTS CUSTOM REPATHA SYRINGE LIPID/CHOLESTEROL LOWERING AGENTS CUSTOM ADAGEN MISCELLANEOUS ENZYME REPLACEMENT THERAPY BERINERT MISCELLANEOUS HEREDITARY ANGIOEDEMA CHEMET (SUCCIMER) MISCELLANEOUS CHELATING AGENTS CINRYZE MISCELLANEOUS HEREDITARY ANGIOEDEMA DAMOCTOCOG ALFA PEGOL MISCELLANEOUS HEMOPHILIA AGENT FIRAZYR MISCELLANEOUS HEREDITARY ANGIOEDEMA GALAFOLD MISCELLANEOUS FABRY DISEASE HAEGARDA MISCELLANEOUS HEREDITARY ANGIOEDEMA KALBITOR MISCELLANEOUS HEREDITARY ANGIOEDEMA MULPLETA MISCELLANEOUS THROMBOCYTOPENIA NUPLAZID MISCELLANEOUS PARKINSON'S DISEASE ONPATTRO MISCELLANEOUS AMYLOIDOSIS OXERVATE MISCELLANEOUS OPTHALMOLOGY POTELIGEI MISCELLANEOUS ONCOLOGY QBREXZA MISCELLANEOUS MISCELLANEOUS REVCOVI MISCELLANEOUS ENZYME REPLACEMENT THERAPY RUCONEST MISCELLANEOUS HEREDITARY ANGIOEDEMA SPRAVATO MISCELLANEOUS MENTAL HEALTH STRENSIQ MISCELLANEOUS ENZYME REPLACEMENT THERAPY TAKHZYRO MISCELLANEOUS HEREDITARY ANGIOEDEMA TEGSEDI MISCELLANEOUS AMYLOIDOSIS ARALAST MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS ARALAST NP MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS CRYSVITA MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS DIACOMIT MISCELLANEOUS AGENTS ANTI-EPILEPTIC GAMIFANT MISCELLANEOUS AGENTS HEMOPHAGOCYTIC LYMPHOHISTOCYTOSIS GLASSIA MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS PROLASTIN MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS PROLASTIN C MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS RECLAST MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS SOLIRIS MISCELLANEOUS AGENTS CUSTOM ZEMAIRA MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS ZENAPAX MISCELLANEOUS AGENTS IMMUNOSUPPRESSANTS ZOLEDRONIC ACID MISCELLANEOUS AGENTS UNCLASSIFIED DRUG PRODUCTS COPIKTRA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS DAURISMO MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS LIBTAYO MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS LORBRENA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS LUMOXITI MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS POMALYST MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TALZENNA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TARGRETIN MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS VITRAKVI MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS VIZIMPRO MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS XOSPATA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS
3 CALQUENCE MISCELLANEOUS ANTIINFECTIVES ANTINEOPLASTICS LINEZOLID MISCELLANEOUS ANTIINFECTIVES ANTIBIOTICS SIVEXTRO MISCELLANEOUS ANTIINFECTIVES ANTIBIOTICS ZYVOX MISCELLANEOUS ANTIINFECTIVES ANTIBIOTICS AFINITOR MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS AFINITOR DISPERZ MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ALECENSA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ALUNBRIG MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS BOSULIF MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS CABOMETYX MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS CAPRELSA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS COMETRIQ MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS COTELLIC MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ERBITUX MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ERIVEDGE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS FARYDAK MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS GILOTRIF MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS GLEEVEC MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS HERCEPTIN MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS HERCEPTIN HYLECTA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS IBRANCE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ICLUSIG MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS IMATINIB MESYLATE MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS IMBRUVICA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS INLYTA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS IRESSA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS JAKAFI MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS KADCYLA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS KISQALI MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS KISQALI FEMARA CO-PACK MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS LENVIMA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS LONSURF MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS LYNPARZA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS MEKINIST MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS NINLARO MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ODOMZO MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS PERJETA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS REVLIMID MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS RITUXAN MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS RUBRACA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS RYDAPT MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS SPRYCEL MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS STIVARGA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS SUTENT MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TAFINLAR MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TAGRISSO MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TASIGNA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS THALOMID MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTIBIOTICS TIBSOVO MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS TYKERB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS VANDETANIB MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS VECTIBIX MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS VENCLEXTA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS VENCLEXTA STARTING PACK MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS VOTRIENT MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS XALKORI MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS XERMELO MISCELLANEOUS ANTINEOPLASTIC DRUGS GASTROINTESTINAL YERVOY MISCELLANEOUS ANTINEOPLASTIC DRUGS CUSTOM ZEJULA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ZELBORAF MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ZYDELIG MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS ZYKADIA MISCELLANEOUS ANTINEOPLASTIC DRUGS ANTINEOPLASTICS DAKLINZA MISCELLANEOUS ANTIVIRALS ANTIVIRALS EPCLUSA MISCELLANEOUS ANTIVIRALS ANTIVIRALS HARVONI MISCELLANEOUS ANTIVIRALS ANTIVIRALS MAVYRET MISCELLANEOUS ANTIVIRALS ANTIVIRALS OLYSIO MISCELLANEOUS ANTIVIRALS ANTIVIRALS SOVALDI MISCELLANEOUS ANTIVIRALS ANTIVIRALS TECHNIVIE MISCELLANEOUS ANTIVIRALS ANTIVIRALS VIEKIRA PAK MISCELLANEOUS ANTIVIRALS ANTIVIRALS VIEKIRA XR MISCELLANEOUS ANTIVIRALS ANTIVIRALS VOSEVI MISCELLANEOUS ANTIVIRALS ANTIVIRALS ZEPATIER MISCELLANEOUS ANTIVIRALS ANTIVIRALS ENTRESTO MISCELLANEOUS CARDIOVASCULAR AGENTS CARDIOVASCULAR DUPIXENT MISCELLANEOUS DERMATOLOGICALS SKIN PREPS CIMZIA MISCELLANEOUS GASTROINTESTINAL AGENTS GASTROINTESTINAL ENTYVIO MISCELLANEOUS GASTROINTESTINAL AGENTS GASTROINTESTINAL INFLECTRA MISCELLANEOUS GASTROINTESTINAL AGENTS GASTROINTESTINAL OCALIVA MISCELLANEOUS GASTROINTESTINAL AGENTS GASTROINTESTINAL REMICADE MISCELLANEOUS GASTROINTESTINAL AGENTS GASTROINTESTINAL RENFLEXIS MISCELLANEOUS GASTROINTESTINAL AGENTS GASTROINTESTINAL AMPYRA MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS AUBAGIO MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS AVONEX MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS COPAXONE MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS EXONDYS 51 MISCELLANEOUS NEUROLOGICAL THERAPY UNCLASSIFIED DRUG PRODUCTS
4 GILENYA MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS GLATIRAMER (GENERIC) MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS GLATOPA MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS GOCOVRI MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS MAYZENT MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS MAVENCLAD MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS OCREVUS MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS OSMOLEX (AMANTADINE EXTENDED RELEASE) MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS SPINRAZA MISCELLANEOUS NEUROLOGICAL THERAPY UNCLASSIFIED DRUG PRODUCTS TECFIDERA MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS TYSABRI MISCELLANEOUS NEUROLOGICAL THERAPY UNCLASSIFIED DRUG PRODUCTS ZINBRYTA MISCELLANEOUS NEUROLOGICAL THERAPY CNS DRUGS ASPARLAS MISCELLANEOUS ONCOLOGY ANTINEOPLASTICS ELZONRIS MISCELLANEOUS ONCOLOGY ANTINEOPLASTICS EYLEA MISCELLANEOUS OPHTHALMOLOGICS EENT PREPS LUCENTIS MISCELLANEOUS OPHTHALMOLOGICS EENT PREPS MACUGEN MISCELLANEOUS OPHTHALMOLOGICS EENT PREPS ADDYI MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTS PSYCHOTHERAPEUTIC DRUGS ARMODAFINIL MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTS PSYCHOTHERAPEUTIC DRUGS MODAFINIL MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTS PSYCHOTHERAPEUTIC DRUGS NUVIGIL MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTS PSYCHOTHERAPEUTIC DRUGS PROVIGIL MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTS PSYCHOTHERAPEUTIC DRUGS VYVANSE MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTS PSYCHOTHERAPEUTIC DRUGS ADCIRCA MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR ADEMPAS MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR CINQAIR MISCELLANEOUS PULMONARY AGENTS ANTIASTHMATICS DUONEB MISCELLANEOUS PULMONARY AGENTS ANTIASTHMATICS ESBRIET MISCELLANEOUS PULMONARY AGENTS UNCLASSIFIED DRUG PRODUCTS IPRATROPIUM-ALBUTEROL MISCELLANEOUS PULMONARY AGENTS ANTIASTHMATICS KALYDECO MISCELLANEOUS PULMONARY AGENTS UNCLASSIFIED DRUG PRODUCTS LETAIRIS MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR NUCALA MISCELLANEOUS PULMONARY AGENTS ANTIASTHMATICS OFEV MISCELLANEOUS PULMONARY AGENTS UNCLASSIFIED DRUG PRODUCTS OPSUMIT MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR ORKAMBI MISCELLANEOUS PULMONARY AGENTS UNCLASSIFIED DRUG PRODUCTS REVATIO MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR SILDENAFIL CITRATE MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR SYMDEKO MISCELLANEOUS PULMONARY AGENTS UNCLASSIFIED DRUG PRODUCTS TRACLEER MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR TYVASO MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR VENTAVIS MISCELLANEOUS PULMONARY AGENTS CARDIOVASCULAR XOLAIR MISCELLANEOUS PULMONARY AGENTS ANTIASTHMATICS ACTEMRA MISCELLANEOUS RHEUMATOLOGICAL AGENTS IMMUNOSUPPRESSANTS ENBREL MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS HUMIRA MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS HUMIRA PEDIATRIC MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS KEVZARA MISCELLANEOUS RHEUMATOLOGICAL AGENTS IMMUNOSUPPRESSANTS KINERET MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS OLUMINANT (baricitinib) MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS ORENCIA MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS ORENCIA CLICKJECT MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS OTEZLA MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS SIMPONI MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS SIMPONI ARIA MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS XELJANZ MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS XELJANZ XR MISCELLANEOUS RHEUMATOLOGICAL AGENTS ANTIARTHRITICS STENDRA MISCELLANEOUS UROLOGICALS UNCLASSIFIED DRUG PRODUCTS BENLYSTA MONOCLONAL ANTIBODY INFLAMMATORY CONDITION GRANIX MYELOID STIMULANTS COLONY STIMULATING FACTORS NEULASTA MYELOID STIMULANTS COLONY STIMULATING FACTORS NEUPOGEN MYELOID STIMULANTS COLONY STIMULATING FACTORS NIVESTYM MYELOID STIMULANTS COLONY STIMULATING FACTORS ZARXIO MYELOID STIMULANTS COLONY STIMULATING FACTORS APOKYN N/A CUSTOM CERDELGA N/A CUSTOM CEREZYME N/A CUSTOM CYRAMZA N/A CUSTOM DARZALEX N/A CUSTOM EMPLICITI N/A CUSTOM FABRAZYME N/A CUSTOM GAZYVA N/A CUSTOM IMLYGIC N/A CUSTOM JEVTANA N/A CUSTOM KEYTRUDA N/A CUSTOM KYPOLIS N/A CUSTOM MEDICAL FOODS N/A CUSTOM ONIVYDE N/A CUSTOM OPDIVO N/A CUSTOM PORTRAZZA N/A CUSTOM PROLEUKIN N/A CUSTOM PROVENGE N/A CUSTOM SEROQUEL N/A CUSTOM SYNAREL N/A CUSTOM TECENTRIQ N/A CUSTOM VIDAZA N/A CUSTOM VIMIZIM N/A CUSTOM
5 VPRIV N/A CUSTOM YONDELIS N/A CUSTOM ZOLINZA N/A CUSTOM KETOROLAC TROMETHAMINE NSAIDS ANALGESICS BONIVA OSTEOPOROSIS THERAPY UNCLASSIFIED DRUG PRODUCTS FORTEO OSTEOPOROSIS THERAPY UNCLASSIFIED DRUG PRODUCTS IBANDRONATE SODIUM OSTEOPOROSIS THERAPY UNCLASSIFIED DRUG PRODUCTS PROLIA OSTEOPOROSIS THERAPY UNCLASSIFIED DRUG PRODUCTS TYMLOS OSTEOPOROSIS THERAPY HORMONES LANSOPRAZOL-AMOXICIL-CLARITHRO OTHER ULCER THERAPY GASTROINTESTINAL PREVPAC OTHER ULCER THERAPY GASTROINTESTINAL FULPHILA (PEGFILGRASTIM-JMDB) PEGFILGRASTIM PRODUCTS COLONY STIMULATING FACTORS NIVESTYM PEGFILGRASTIM PRODUCTS COLONY STIMULATING FACTORS UDENYCA PEGFILGRASTIM PRODUCTS COLONY STIMULATING FACTORS CUPRIMINE (PENICILLAMINE) PENICILLAMINE PRODUCTS CHELATING AGENTS DEPEN (PENICILLAMINE) PENICILLAMINE PRODUCTS CHELATING AGENTS PALYNZIQ PHENYLALANINE AMMONIA LYASE ENZYME PHENYLKETONURIA FIRDAPSE POTASSIUM CHANNEL BLOCKER MISCELLANEOUS DRUG FOR LEMS NEXIUM RX PROTON PUMP INHIBITORS GASTROINTESTINAL AZEDRA RADIOPHARMACEUTICAL ANTINEOPLASTICS LUTATHERA RADIOPHARMACEUTICAL CUSTOM JYNARQUE SELECTIVE VASOPRESSIN V2-RECEPTOR ANTAGONIST TOLVAPTAN PRODUCTS SAMSCA SELECTIVE VASOPRESSIN V2-RECEPTOR ANTAGONIST TOLVAPTAN PRODUCTS SANDOSTATIN LAR SOMATOSTATIN ANALOGS SOMATOSTATIN ANALOGS SIGNIFOR LAR SOMATOSTATIN ANALOGS SOMATOSTATIN ANALOGS SOMATULINE DEPOT SOMATOSTATIN ANALOGS SOMATOSTATIN ANALOGS ATRALIN THERAPY FOR ACNE SKIN PREPS AVITA THERAPY FOR ACNE SKIN PREPS CLINDAMYCIN PHOS-TRETINOIN THERAPY FOR ACNE SKIN PREPS MIRVASO THERAPY FOR ACNE SKIN PREPS RETIN-A THERAPY FOR ACNE SKIN PREPS RETIN-A MICRO THERAPY FOR ACNE SKIN PREPS RETIN-A MICRO PUMP THERAPY FOR ACNE SKIN PREPS RHOFADE THERAPY FOR ACNE SKIN PREPS TRETINOIN THERAPY FOR ACNE SKIN PREPS TRETINOIN MICROSPHERE THERAPY FOR ACNE SKIN PREPS TRETIN-X THERAPY FOR ACNE SKIN PREPS VELTIN THERAPY FOR ACNE SKIN PREPS ZIANA THERAPY FOR ACNE SKIN PREPS DOPTELET THROMBOPOEITIN RECEPTOR AGONIST THROMBOCYTOPENIA NPLATE THROMBOPOEITIN RECEPTOR AGONIST THROMBOCYTOPENIA PROMACTA THROMBOPOEITIN RECEPTOR AGONIST THROMBOCYTOPENIA TAVALISSE TYROSINE KINASE INHIBITOR THROMBOCYTOPENIA BIVIGAM VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS BOTOX VACCINES & MISCELLANEOUS IMMUNOLOGICALS AUTONOMIC DRUGS CARIMUNE NF NANOFILTERED VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS CUVITRU VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS DYSPORT VACCINES & MISCELLANEOUS IMMUNOLOGICALS AUTONOMIC DRUGS FLEBOGAMMA VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS FLEBOGAMMA DIF VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS GAMMAGARD LIQUID VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS GAMMAGARD S-D VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS GAMMAKED VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS GAMMAPLEX VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS GAMUNEX VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS GAMUNEX-C VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS HIZENTRA VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS HYQVIA VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS MYOBLOC VACCINES & MISCELLANEOUS IMMUNOLOGICALS AUTONOMIC DRUGS OCTAGAM VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS PRIVIGEN VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS VIVAGLOBIN VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIOLOGICALS XEOMIN VACCINES & MISCELLANEOUS IMMUNOLOGICALS AUTONOMIC DRUGS EPOPROSTENOL SODIUM VASODILATORS CARDIOVASCULAR FLOLAN VASODILATORS CARDIOVASCULAR ORENITRAM ER VASODILATORS CARDIOVASCULAR REMODULIN VASODILATORS CARDIOVASCULAR UPTRAVI VASODILATORS CARDIOVASCULAR VELETRI VASODILATORS CARDIOVASCULAR
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National Preferred Formulary Prior Approval List As of: 1/17/2019
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Medical Coverage Policy Prior Authorization of Drugs sa EFFECTIVE DATE: 06 01 2018 POLICY LAST UPDATED: 11 20 2018 OVERVIEW This policy documents drugs that are covered under the member s Commercial medical
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Prior Authorization Your health plan participates in a Prior Authorization (PA) program for specific prescription drugs. This means that Caremark must review certain information provided by your doctor
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PROVIDER MEMO To: From: Date: Subject: Santa Clara Family Health Plan Providers Utilization Management December 27, 2018 2019 Dear Providers, Santa Clara Family Health Plan (SCFHP) has made some changes
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90284 or J1559 90378 J0129 MEDICATIONAUTHORIZATIONWORKFLOWFORDRUGSTHATREQUIREPRIOR-AUTHORIZATION (06/9/17) BASEDONLOCATIONWHEREDRUGWILLBEADMINISTERED J-code Medication Drug Name Immune globulin (SCIg),
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