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Drug Therapy Guidelines

Our prescription drug and medical injectable policies promote safe and effective use by helping physicians select the drug product(s) considered most beneficial to their patients. In order to ensure thorough consideration of both quality-of-care and economic issues, some drugs require prior authorization to be covered under a member's prescription drug or medical benefit. We work with a committee of local physicians and pharmacists to identify medications that should require prior authorization and to develop the medical criteria used to determine when coverage for these agents is appropriate.

Prior authorization is required for injectable medications, including self-administered injectable medications except insulin, glucagon, self-administered epinephrine and injectable chemotherapeutic agents when not available in a physician's office. The following is a complete list of medications requiring prior authorization and their committee-approved criteria.

A B C D E F G H I J K L M N O P Q R S T U V W

   A

  • pdf icon Abbreviated Criteria Abbreviated Criteria: Austedo, Carbaglu, Dificid, Doptelet, Gralise, Hetlioz, Jetrea, Kanuma, Keveyis, Nuedexta, Nuplazid, Strensiq, Sylvant, Syprine, Xatmep, Xenazine, Xuriden
  • pdf icon Abiraterone Abiraterone acetate (Zytiga™, Yonsa®)
  • pdf icon Actemra Actemra® (tocilizumab)
  • pdf icon Actimmune Actimmune® (interferon gamma 1b)
  • pdf icon Adcetris Adcetris™ (brentuximab vedotin)
  • pdf icon Addyi AddyiTM (flibanserin)
  • pdf icon Afinitor Afinitor® (everolimus)
  • pdf icon Afrezza Afrezza® (insulin human)
  • pdf icon Aimovig Aimovig™ (erenumab-aooe)
  • pdf icon Alecensa Alecensa® (alectinib)
  • pdf icon Alimta Alimta® (pemetrexed)
  • pdf icon Aliqopa Aliqopa™ (copanlisib)
  • pdf icon Alunbrig AlunbrigTM (brigatinib)
  • pdf icon Amantadine ER Amantadine ER (Gocovri®, Osmolex ERTM)
  • pdf icon Ampyra Ampyra® (dalfampridine)
  • pdf icon Antiemetic Agents Antiemetic Agents: Zofran®/ODT® (ondansetron/ondansetron ODT/ondansetron oral solution), Zuplenz® (ondansetron oral film), Kytril® (granisetron), granisetron, Sancuso® (granisetron topical), Anzemet® (dolasetron), Emend® (aprepitant), Akynzeo® (netupitant/palonosetron), Varubi® (rolapitant)
  • pdf icon Antifungal Agents Antifungal Agents: Lamisil® (terbinafine), Sporanox® (itraconazole), Vfend® (voriconazole), Noxafil® (posaconazole), Cresemba® (isavuconazonium)
  • pdf icon Antinarcoleptic Agents armodafinil, modafinil, Nuvigil®, Provigil®
  • pdf icon Appetite Suppressants Appetite Suppressants (Anorexiants) & Weight Loss Agents: Adipex®, phentermine, Bontril®, phendimetrazine, Didrex®, benzphetamine, Suprenza®, diethylpropion, Xenical®, Qsymia®, Belviq®, Belviq XR®, Contrave®, Saxenda®
  • pdf icon Arcalyst Arcalyst® (rilonacept)
  • pdf icon Arzerra Arzerra® (ofatumumab)
  • pdf icon Aubagio Aubagio® (teriflunomide)
  • pdf icon Avastin Avastin® (bevacizumab)

B, C, D

E, F, G


  • pdf icon Egrifta Egrifta® (tesamorelin)
  • pdf icon Emflaza EmflazaTM (deflazacort)
  • pdf icon Empliciti EmplicitiTM (elotuzumab)
  • pdf icon Enbrel Enbrel® (etanercept)
  • pdf icon Endari EndariTM (L-glutamine)
  • pdf icon Entyvio Entyvio® (vedolizumab)
  • pdf icon Epaned Epaned® (enalapril powder for oral solution)
  • pdf icon Epclusa EpclusaTM (sofosbuvir and velpatasvir)
  • pdf icon Erbitux Erbitux® (cetuximab)
  • pdf icon Erectile Dysfunction (ED) Agents Erectile Dysfunction (ED) Agents: Cialis® (tadalafil), Levitra® (vardenafil), Viagra® (sildenafil), Caverject® (alprostadil), Edex® (alprostadil), Muse® (alprostadil), Staxyn® (vardenafil), Stendra™ (avanafil)
  • pdf icon Erivedge Erivedge® (vismodegib)
  • pdf icon Erleada Erleada™ (apalutamide)
  • pdf icon Esbriet Esbriet® (pirfenidone)
  • pdf icon Exondys 51 Exondys 51™ (eteplirsen)
  • pdf icon Eylea Eylea™ (aflibercept)
  • pdf icon Farydak Farydak® (panobinostat)
  • pdf icon Fasenra FasenraTM (benralizumab)
  • pdf icon Ferriprox Ferriprox® (deferiprone)
  • pdf icon Forteo Forteo® (teriparatide)
  • pdf icon Gattex Gattex® (teduglutide [rDNA origin])
  • pdf icon Gaucher’s Disease Agents Gaucher’s Disease Agents: Cerdelga® (eliglustat), Cerezyme® (imiglucerase), Elelyso® (taliglucerase alfa), Vpriv (velaglucerase alfa), Zavesca® (miglustat)
  • pdf icon Gazyva Gazyva® (obinutuzumab)
  • pdf icon Gilenya GilenyaTM (fingolimod)
  • pdf icon Gilotrif Gilotrif® (afatinib)
  • pdf icon Gleevec Gleevec® imatinib
  • pdf icon Gonadotropin-Releasing Hormone Agonists Gonadotropin-Releasing Hormone Agonists- Eligard®, Lupron®, Lupron-Depot®, Lupron Depot-Ped®, Lupaneta® (leuprolide, norethindrone pack), Triptodur™ (triptorelin), Trelstar® (triptorelin, including Depot and LA), Synarel ®(nafarelin acetate)
  • pdf icon Grastek Grastek® (Timothy Grass Pollen Allergen Extract)
  • pdf icon Growth Stimulating Drugs Growth Stimulating Drugs: Norditropin®, Genotropin®, Humatrope®, Omnitrope®, Nutropin®, Saizen®, Serostim®, ZomactonTM, Zorbtive® (somatropin, recombinant growth hormone)

   H

 

  • pdf icon H.P. Acthar Gel H.P. Acthar® Gel (repository corticotropin)
  • pdf icon Halaven Halaven™ (eribulin mesylate)
  • pdf icon Harvoni Harvoni® (ledipasvir and sofosbuvir)
  • pdf icon Hemlibra Hemlibra® (emicizumab-kxwh)
  • pdf icon Hepatitis C Antivirals Pegasys®, Peg-Intron®, ribavirin, ribasphere, ribapak, Copegus®, Rebetol®, Infergen®, Intron-A®
  • pdf icon Herceptin Herceptin® (trastuzumab)
  • pdf icon Hereditary Angioedema (HAE) Agents Hereditary Angioedema (HAE) Agents: Berinert® (C1 esterase inhibitor [human]), Cinryze® (C1 esterase inhibitor [human]), Haegarda® (C1 esterase inhibitor [human]) Kalbitor® (ecallantide), Firazyr® (icatibant), Ruconest® (C1 esterase inhibitor [recombinant])
  • pdf icon Horizant Horizant® (gabapentin enacarbil ER)
  • pdf icon Humira Humira® (adalimumab)

I, J

 

  • pdf icon Ibrance Ibrance® (palbociclib)
  • pdf icon Iclusig Iclusig® (ponatinib)
  • pdf icon Idhifa Idhifa® (enasidenib)
  • pdf icon Ilaris Ilaris® (canakinumab)
  • pdf icon Ilumya Ilumya™ (tildrakizumab-asmn)
  • pdf icon Imbruvica Imbruvica® (ibrutinib)
  • pdf icon Imfinzi Imfinzi (durvalumab)
  • pdf icon Imlygic ImlygicTM (talimogene laherparepvec)
  • pdf icon Immune Globulin Intravenous: Carimune® NF, Flebogamma®, Flebogamma® DIF, Gammagard®, Gammagard® S/D, Gammaplex®, Gamunex®, Gamunex-C®, Octagam®, Gammaked® and BIVIGam®, Privigen® Subcutaneous: Hizentra®, Gamunex-C®, Gammaked®, Gammagard®, HyQvia®, Cuvitru™
  • pdf icon Impoyz Impoyz™ (clobetasol propionate)
  • pdf icon Increlex Increlex® (mecasermin)
  • pdf icon Incretin Mimetics Incretin Mimetics – AdlyxinTM (lixisenatide) Bydureon® (exenatide), Bydureon®BCiseTM (exenatide extended-release) Byetta® (exenatide), Ozempic® (semaglutide), TanzeumTM (albiglutide), TrulicityTM (dulaglutide), Victoza® (liraglutide)
  • pdf icon Incretin Mimetics/Insulin Combinations Incretin Mimetics/Insulin Combinations – SoliquaTM (insulin glargine/lixisenatide), Xultophy® (insulin degludec/liraglutide)
  • pdf icon Infliximab Infliximab (Remicade®, Inflectra®/infliximab-dyyb, RenflexisTM/infliximab-abda)
  • pdf icon Ingrezza Ingrezza™ (valbenazine)
  • pdf icon Injectable Fertility Medications Injectable Fertility Medications: Bravelle®, Cetrotide®, Follistim AQ®, Ganirelix®, Gonal-F®, human chorionic gonadotropin, leuprolide, Menopur®, Novarel®, Ovidrel®, Pregnyl®, progesterone in oil
  • pdf icon Inlyta Inlyta® (axitinib)
  • pdf icon Intravenous (IV) Bisphosphonates Intravenous (IV) Bisphosphonates: Reclast®, Zometa®, zoledronic acid, Boniva®
  • pdf icon Iressa Iressa® (gefitinib)
  • pdf icon Istodax Istodax® (romidepsin)
  • pdf icon Jakafi Jakafi® (ruxolitinib)
  • pdf icon Jevtana Jevtana® (cabazitaxel)
  • pdf icon Juxtapid Juxtapid™ (lomitapide)
  • pdf icon Jynarque Jynarque™ (tolvaptan)

K, L


  • pdf icon Kadcyla Kadcyla® (ado-trastuzumab emtansine)
  • pdf icon Kalydeco Kalydeco® (ivacaftor)
  • pdf icon Kevzara Kevzara® (sarilumab)
  • pdf icon Keytruda Keytruda® (pembrolizumab)
  • pdf icon Kineret Kineret® (anakinra)
  • pdf icon Kisqali Kisqali ® (ribociclib), Kisqali®Femara® Co-Pack (ribociclib; letrozole)
  • pdf icon Korlym KorlymTM (mifepristone)
  • pdf icon Krystexxa KrystexxaTM (pegloticase)
  • pdf icon Kuvan Kuvan® (sapropterin dihydrochloride)
  • pdf icon Kymriah Kymriah® (tisagenlecleucel)
  • pdf icon Kynamro Kynamro™ (mipomersen sodium)
  • pdf icon Kyprolis Kyprolis™ (carfilzomib injection)
  • pdf icon Lartruvo Lartruvo™ (olaratumab)
  • pdf icon Lemtrada Lemtrada® (alemtuzumab)
  • pdf icon Lenvima Lenvima® (lenvatinib)
  • pdf icon Lonsurf Lonsurf® (trifluridine and tipiracil)
  • pdf icon Lucentis Lucentis® (ranibizumab)
  • pdf icon Lutathera Lutathera ® (lutetium Lu 177 dotatate)
  • pdf icon Luxturna Luxturna® (voretigene neparvovec-rzyl)
  • pdf icon Lynparza Lynparza® (olaparib)
  • pdf icon Lyrica CR Lyrica CR® (pregabalin ER)

M, N, O

  • pdf icon Macugen Macugen® (pegaptanib)
  • pdf icon Makena Makena®, hydroxyprogesterone caproate injection
  • pdf icon Marqibo Marqibo™ (vincristine liposomal)
  • pdf icon Mavyret Mavyret® (glecaprevir and pibrentasvir)
  • pdf icon Medical Benefit Reference Guide
  • pdf icon Mekinist Mekinist™ (trametinib)
  • pdf icon Mepsevii MepseviiTM (vestronidase alfa-vjbk)
  • pdf icon Movantik Movantik® (naloxegol oxalate)
  • pdf icon Mozobil Mozobil™ (plerixafor)
  • pdf icon MS Agents Multiple Sclerosis (MS) Self-Injectable Agents: Avonex®, Betaseron®, Copaxone®, Extavia®, glatopa™, Plegridy™, Rebif®
  • pdf icon Myalept MyaleptTM (metreleptin)
  • pdf icon Mylotarg MylotargTM (gemtuzumab ozogamicin)
  • pdf icon Natpara Natpara® (parathyroid hormone)
  • pdf icon Nerlynx Nerlynx™ (neratinib)
  • pdf icon Nexavar Nexavar® (sorafenib)
  • pdf icon Ninlaro Ninlaro® (ixazomib)
  • pdf icon Noctiva Noctiva (desmopressin acetate)
  • pdf icon Northera Northera® (droxidopa)
  • pdf icon Nplate Nplate® (romiplostim)
  • pdf icon Nucala Nucala® (mepolizumab)
  • pdf icon Nutritional Supplements Nutritional Supplements, Enteral Formulas
  • pdf icon Ocaliva Ocaliva® (obeticholic acid)
  • pdf icon Ocrevus OcrevusTM (ocrelizumab)
  • pdf icon Odactra OdactraTM (House Dust Mite [Dermatophagoides farinae and Dermatophagoides pteronyssinus] Allergen Extract)
  • pdf icon Odomzo Odomzo® (sonidegib)
  • pdf icon Ofev Ofev® (nintedanib)
  • pdf icon Olysio OlysioTM (simeprevir)
  • pdf icon Opdivo Opdivo® (nivolumab)
  • pdf icon Opioid Management Opioid Management
  • pdf icon Oralair Oralair® (Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass Mixed Pollens Allergen Extract)
  • pdf icon Orencia Orencia® (abatacept)
  • pdf icon Orkambi Orkambi® (lumacaftor/ivacaftor)
  • pdf icon Otezla Otezla® (apremilast)

P, Q

  • pdf icon Palynziq Palynziq (pegvaliase-pqpz)
  • pdf icon PCSK9 Inhibitors PCSK9 Inhibitors: Praluent™, Repatha™
  • pdf icon Penicillamine Therapy Penicillamine Therapy – Cuprimine®, Depen®
  • pdf icon Perjeta Perjeta™ (pertuzumab)
  • pdf icon Pomalyst Pomalyst® (pomalidomide)
  • pdf icon Portrazza Portrazza® (necitumumab)
  • pdf icon Preferred Drug Step Therapy Angiotensin Receptor Blockers (ARBs); Antipsychotics, 2nd generation; BPH (alpha-antagonists); Beta Agonist Inhalers; Calcipotriene Agents; CNS Stimulants; Constipation Agents; Desvenlafaxine; DPP-4 Inhibitors; Duexis; Epinephrine Products; Extended-Release Antibiotics; Fenofibrates; Inhaled Combinations; Inhaled Corticosteroids; Insulin; Insulin, Basal; Intranasal Steroids; Metformin ER Products; Osteoporosis Agents; Pancreatic Enzymes; Prexxartan, Prostaglandin Analogs; Proton Pump Inhibitors (PPIs); Rayos (prednisone delayed-release); Renin Inhibitors; Rhopressa; Selective Serotonin Reuptake Inhibitors (SSRIs); SGLT-2 Inhibitors; Statins; Test Strips for Blood Glucose; Testosterone Replacements; Topical Dermatologics; Topical Non-Steroidal Anti-Inflammatory Drugs; Urinary Agents; Verzacloz; Vimovo; Vivlodex
  • pdf icon Prevymis PrevymisTM (letermovir)
  • pdf icon Procysbi Procysbi® (cysteamine bitartrate delayed release capsules)
  • pdf icon Promacta Promacta® (eltrombopag)
  • pdf icon Provenge Provenge® (sipuleucel-T)
  • pdf icon Pulmonary Arterial Hypertension (PAH) Agents Pulmonary Arterial Hypertension (PAH) Agents: Revatio™ (sildenafil), Ventavis® (iloprost), Tracleer® (bosentan), Letairis™ (ambrisentan), Adcirca® (tadalafil), Tyvaso® (treprostinil), Remodulin® (treprostinil), Flolan®/Veletri® (epoprostenol), Adempas® (riociguat), Opsumit® (macitentan), Orenitram® (treprostinil), Uptravi® (selexipag)
  • pdf icon Qbrelis Qbrelis™ (lisinopril oral solution)
  • pdf icon Qutenza Qutenza® (8% capsaicin patch)

R, S

  • pdf icon Radicava Radicava® (edaravone)
  • pdf icon Ragwitek Ragwitek® (Short Ragweed Pollen Allergen Extract)
  • pdf icon RANKL Inhibitors RANKL Inhibitors: Prolia®, Xgeva® (denosumab)
  • pdf icon Ravicti Ravicti™ (glycerol phenylbutyrate)
  • pdf icon Relistor Relistor® (methylnaltrexone bromide)
  • pdf icon Revlimid Revlimid® (lenalidomide)
  • pdf icon Rituxan Rituxan® (rituximab)
  • pdf icon Rubraca Rubraca® (rucaparib)
  • pdf icon Rydapt Rydapt® (midostaurin)
  • pdf icon Samsca Samsca® (tolvaptan)
  • pdf icon Sedative Hypnotics Sedative Hypnotics: zolpidem, Ambien®, zolpidem CR, Ambien CR1®, zaleplon, Sonata®, Lunesta®, eszopiclone, Rozerem®, Edluar™, Zolpimist™, Silenor®, Intermezzo®/zolpidem SL, Belsomra®
  • pdf icon Signifor Signifor®, Signifor® LAR (pasireotide)
  • pdf icon Siliq Siliq (brodalumab)
  • pdf icon Simponi Simponi®, Simponi Aria® (golimumab)
  • pdf icon Solaraze Solaraze®, diclofenac 3% gel
  • pdf icon Soliris Soliris™ (eculizumab)
  • pdf icon Somavert Somavert® (pegvisomant)
  • pdf icon Sovaldi Sovaldi (sofosbuvir)
  • pdf icon Spinraza Spinraza™ (nusinersen)
  • pdf icon Sprycel Sprycel® (dasatinib)
  • pdf icon Stelara Stelara® (ustekinumab)
  • pdf icon Stivarga Stivarga® (regorafenib)
  • pdf icon Sutent Sutent® (sunitinib)
  • pdf icon Sylatron Sylatron™ (peginterferon alfa-2b)
  • pdf icon Symdeko Symdeko™ (tezacaftor/ivacaftor)
  • pdf icon Symlin Symlin® (pramlintide acetate)
  • pdf icon Symproic Symproic® (naldemedine)
  • pdf icon Synagis Synagis® (palivizumab injection)
  • pdf icon Synribo Synribo® (omacetaxine mepesuccinate)

T, U, V

  • pdf icon Tafinlar Tafinlar® (dabrafenib)
  • pdf icon Tagrisso TagrissoTM (osimertinib)
  • pdf icon Taltz Taltz® (ixekizumab)
  • pdf icon Tarceva Tarceva® (erlotinib)
  • pdf icon Targretin Targretin®/bexarotene capsules, Targretin® gel
  • pdf icon Tasigna Tasigna® (nilotinib)
  • pdf icon Tavalisse Trogarzo™ (ibalizumab-uiyk)
  • pdf icon Tecentriq Tecentriq® (atezolizumab)
  • pdf icon Tecfidera Tecfidera® (dimethyl fumarate)
  • pdf icon Technivie TechnivieTM (ombitasvir, paritaprevir, ritonavir)
  • pdf icon Temodar Temodar®, temozolomide
  • pdf icon Topical Immunomodulators Elidel® (pimecrolimus cream), Eucrisa® (crisaborole ointment), Protopic®, tacrolimus ointment
  • pdf icon Torisel Torisel® (temsirolimus)
  • pdf icon Transmucosal Immediate Release Fentanyl Abstral® (sublingual tablet), Actiq® (oral transmucosal lozenge), fentanyl powder, Fentora® (buccal tablet), Lazanda® (nasal spray), Onsolis® (buccal soluble film), Subsys® (sublingual spray) (buccal soluble film), Subsys® (sublingual spray)
  • pdf icon Tremfya TremfyaTM (guselkumab)
  • pdf icon Triptans Triptans: almotriptan, Alsuma®, Amerge®, Axert®, Frova®, Imitrex® and sumatriptan tablets/nasal spray/injection, Maxalt/MLT®, naratriptan, OnzetraTM XsailTM, Relpax® and eletriptan tablets, rizatriptan/ODT, Sumavel®, Treximet®, ZembraceTM SymTouchTM, zolmitriptan/ODT tablets, Zomig/ZMT® tablets/nasal spray
  • pdf icon Trogarzo Trogarzo™ (ibalizumab-uiyk)
  • pdf icon Tykerb Tykerb® (lapatinib)
  • pdf icon Tymlos Tymlos® (abaloparatide)
  • pdf icon Tysabri Tysabri® (natalizumab)
  • pdf icon Uloric Uloric® (febuxostat)
  • pdf icon Unituxin UnituxinTM (dinutuximab)
  • pdf icon Valchlor Valchlor® (mechlorethamine gel)
  • pdf icon Vectibix Vectibix® (panitumumab)
  • pdf icon Venclexta Venclexta® (venetoclax)
  • pdf icon Verzenio Verzenio™ (abemaciclib)
  • pdf icon Vidaza Vidaza® (azacitidine)
  • pdf icon Viekira Viekira PakTM (ombitasvir, paritaprevir, and ritonavir tablets; dasabuvir tablets), Viekira XRTM (dasabuvir, ombitasvir, paritaprevir, and ritonavir) extendedrelease tablets
  • pdf icon Vimizim Vimizim (elosulfase alfa)
  • pdf icon Vosevi Vosevi™ (sofosbuvir, velpatasvir, and voxilaprevir)
  • pdf icon Votrient Votrient™ (pazopanib)
  • pdf icon Vyxeos Vyxeos™ (daunorubicin and cytarabine) liposome for injection

X, Y, Z

  • pdf icon Xalkori Xalkori® (crizotinib)
  • pdf icon Xeljanz Xeljanz®, Xeljanz® XR (tofacitinib)
  • pdf icon Xepi XepiTM (oxenoxacin)
  • pdf icon Xermelo XermeloTM (telotristat ethyl)
  • pdf icon Xhance Xhance® (fluticasone propionate)
  • pdf icon Xifaxan Xifaxan® (rifaximin)
  • pdf icon Xolair Xolair® (omalizumab)
  • pdf icon Xtandi Xtandi® (enzalutamide)
  • pdf icon Xyrem Xyrem® (sodium oxybate oral solution)
  • pdf icon Yervoy YervoyTM (ipilimumab)
  • pdf icon Yescarta Yescarta® (axicabtagene ciloleucel)
  • pdf icon Yondelis Yondelis® (trabectedin)
  • pdf icon Zaltrap Zaltrap® (ziv-aflibercept)
  • pdf icon Zelboraf ZelborafTM (vemurafenib)
  • pdf icon Zejula Zejula (niraparib)
  • pdf icon Zepatier Zepatier® (elbasvir and grazoprevir tablets)
  • pdf icon Zinplava Zinplava™ (bezlotoxumab)
  • pdf icon Zolinza Zolinza® (vorinostat)
  • pdf icon Zurampic Zurampic® (lesinurad)
  • pdf icon Zydelig Zydelig® (idelalisib)
  • pdf icon Zykadia Zykadia® (ceritinib)