| |
Prior Authorization |
Quantity Limits |
Specialty Medication |
| Allergic Reactions –
Emergency |
|
|
|
|
Epipen (epinephrine auto injector) |
|
QL |
|
| |
|
|
|
| Angiotensin II Receptor Antagonists |
|
|
|
|
Atacand® (candesartan) |
PA |
|
|
|
Atacand HCT® (candesartan/HCTZ) |
PA |
|
|
|
Avalide® (irbesartan/HCTZ) |
PA |
|
|
|
Avapro® (irbesartan) |
PA |
|
|
|
Benicar® (olmesartan) |
PA |
|
|
|
Benicar HCT® (olmesartan/HCTZ) |
PA |
|
|
|
Cozaar® (losartan) |
PA |
|
|
|
Diovan® (valsartan) |
PA |
|
|
|
Diovan HCT® (valsartan/HCTZ) |
PA |
|
|
|
Hyzaar® (losartan/HCTZ) |
PA |
|
|
|
Micardis® (telmisartan) |
PA |
|
|
|
Micardis HCT® (telmisartan/HCTZ) |
PA |
|
|
|
Teveten® (eprosartan) |
PA |
|
|
|
Teveten HCT® (eprosartan/HCTZ) |
PA |
|
|
| |
|
|
|
| Anti-Depressive Therapies |
|
|
|
|
Lexapro® (escitalopram oxalate) |
PA |
|
|
| |
|
|
|
| Anti-Influenza Therapies |
|
|
|
|
Relenza® (zanamivir) |
|
QL |
|
|
Tamiflu® Capsules/Suspensions (osteltamivir)
|
|
QL |
|
| |
|
|
|
| Anti-Nausea Therapies |
|
|
|
|
Anzemet® (dolasetron) |
|
QL |
|
|
Emend® (aprepitant) |
|
QL |
|
|
Kytril® (granisetron HCL) |
|
QL |
|
|
Zofran® (odansetron) |
|
QL |
|
| |
|
|
|
| Antineoplastic Therapies
|
|
|
|
|
Iressa® (gefitinib) |
PA |
QL |
|
| |
|
|
|
| Asthma Inhalers
|
|
|
|
|
Intal® (cromolyn sodium aerosol) |
|
QL |
|
|
Tilade® (nedocromil sodium aerosol) |
|
QL |
|
| |
|
|
|
| COX-II Inhibitors
|
|
|
|
|
Celebrex® (celecoxib) |
PA |
|
|
| |
|
|
|
CNS Stimulants
(PA required for age 21 and older) |
|
|
|
|
Adderall® (amphetamine/dextroamphetamine)
|
PA |
|
|
|
Adderall XR® (amphetamine/dextroamphetamine) |
PA |
|
|
|
Concerta® (methylphenidate extended-release
tablets) |
PA |
|
|
|
Desoxyn® (methamphetamine) |
PA |
|
|
|
Dexedrine® (dextroamphetamine) |
PA |
|
|
|
Dexedrine Spansules® (dextroamphetamine) |
PA |
|
|
|
Dextrostat® (dextroamphetamine) |
PA |
|
|
|
Focalin®(dexmethylphenidate) |
PA |
|
|
|
Metadate CD® (methylphenidate hcl) |
PA |
|
|
|
Methylin ER® (methylphenidate) |
PA |
|
|
|
Ritalin® (methylphenidate) |
PA |
|
|
|
Ritalin SR® (methylphenidate hcl) |
PA |
|
|
|
Ritalin LA® (methylphenidate hcl) |
PA |
|
|
|
Strattera® (atomoxetine) |
PA |
|
|
| |
|
|
|
| Erythroid Stimulants
|
|
|
|
|
Aranesp® (darbepoetin) |
PA |
|
|
|
Procrit® /Epogen® (erythropoietin) |
PA |
|
|
| |
|
|
|
| Estrogen Therapies (Topical) |
|
|
|
|
Alora® (estradiol transdermal) |
|
QL |
|
|
Climara® (estradiol transdermal) |
|
QL |
|
|
CombiPatch® (estradiol, norethindrone acetate
transdermal) |
|
QL |
|
|
Esclim® (estradiol transdermal) |
|
QL |
|
|
Estrasorb® (estradiol transdermal) |
|
QL |
|
|
Estraderm® (estradiol transdermal) |
|
QL |
|
|
Generic estrogen patches |
|
QL |
|
|
Vivelle Dot® (estradiol transdermal) |
|
QL |
|
| |
|
|
|
| Growth Hormone Therapies
|
|
|
|
|
Genotropin® (somatropin) |
PA |
|
SM |
|
Geref® (somatropin) |
PA |
|
|
|
Humatrope® (somatropin) |
PA |
|
SM |
|
Norditropin® (somatropin) |
PA |
|
SM |
|
Nutropin® (somatropin) |
PA |
|
SM |
|
Omnitrope® (somatropin) |
PA |
|
SM |
|
Protropin® (somatropin) |
PA |
|
SM |
|
Saizen® (somatropin) |
PA |
|
SM |
|
Serostim® (somatropin) |
PA |
|
SM |
|
Somavert® (somatropin) |
PA |
|
SM |
|
Zorbitive® (somatropin) |
PA |
|
SM |
| |
|
|
|
Impotency
Agents
(Prior authorization is approved for use following radical retropubic prostatectomy surgery, otherwise, these medication are not
covered) |
|
Caverject® Injection (alprostadil) |
PA |
QL |
|
|
Cialis® (tadalafil) |
PA |
QL |
|
|
Edex® Injection (alprostadil) |
PA |
QL |
|
|
Levitra® (vardenafil) |
PA |
QL |
|
|
MUSE® (alprostadil) |
PA |
QL |
|
|
Viagra® (sildenafil) |
PA |
QL |
|
|
Yohimbine® HCL, both generic and brand-name |
PA |
QL |
|
| |
|
|
|
| Insulin and Supplies |
|
|
|
|
Cartridges |
|
QL |
|
|
Needles |
|
QL |
|
|
Pens |
|
QL |
|
|
Syringes |
|
QL |
|
|
Pre-Filled Syringes |
|
QL |
|
|
Diabetic Supplies (over-the-counter) |
|
QL |
|
| |
|
|
|
| Leukotriene Inhibitors
|
|
|
|
|
Accolate® (zafirlukast) |
PA |
|
|
|
Singulair® (montelukast) |
PA |
|
|
|
Zyflo® (zileuton) |
PA |
|
|
|
Zyflo® CR (zileuton) |
PA |
|
|
| |
|
|
|
Migraine Therapies – Triptans
(Prior authorization is required effective 07/01/09) |
|
Amerge® (naratriptan) |
PA |
QL |
|
|
Axert® (almotriptan malate) |
PA |
QL |
|
|
Frova® (frovatriptan succinate) |
PA |
QL |
|
|
Imitrex® (sumatriptan succinate) |
|
QL |
|
|
Maxalt® (rizatriptan benzoate) |
PA |
QL |
|
|
Maxalt-MLT® (rizatriptan benzoate) |
PA |
QL |
|
|
Migranal® Nasal Spray (dihydroergotamine mesylate) |
|
QL |
|
|
Relpax® (eletriptan hydrobromide) |
PA |
QL |
|
|
Stadol® Nasal Spray (butorphanol tartrate) |
|
QL |
|
|
Treximet® (sumatriptan and naproxen) |
PA |
QL |
|
|
Zomig® (zolmitriptan) |
PA |
QL |
|
|
Zomig-ZMT® (zolmitriptan) |
PA |
QL |
|
| |
|
|
|
| Miscellaneous Devices
|
|
|
|
|
Inhaler spacers (Limited to two per calendar year) |
|
QL |
|
| |
|
|
|
| Multiple Sclerosis Therapies
|
|
|
|
|
Avonex® (interferon beta-1a) |
|
QL |
SM |
|
Betaseron® (interferon beta-1b) |
|
QL |
SM |
|
Copaxone® (glatiramer acetate) |
|
QL |
SM |
|
Rebif® (interferon beta-1a) |
|
QL |
SM |
| |
|
|
|
| Myeloid Stimulants
|
|
|
|
|
Leukine® (sargramostim) |
PA |
|
SM |
|
Neulasta® (pegfilgrastim) |
PA |
|
SM |
|
Neumega® (oprelvekin) |
PA |
|
SM |
|
Neupogen® (filgrastim) |
PA |
|
SM |
|
Nplate® (romiplostim) |
PA |
|
SM |
| |
|
|
|
| Nasal Sprays |
|
|
|
|
Beconase® (AQ) (beclomethasone dipropionate) |
|
QL |
|
|
Flonase® (fluticasone propionate) |
|
QL |
|
|
Nasacort® (AQ) (triamcinolone acetonide) |
|
QL |
|
|
Nasarel® (flunisolide) |
|
QL |
|
|
Nasonex Rhinocort® (AQ) (mometasone furoate) |
|
QL |
|
|
Veramyst® (fluticasone furoate) |
|
QL |
|
| |
|
|
|
| Ophthalmic Therapies |
|
|
|
|
Restasis® (cyclosporine) |
|
QL |
|
| |
|
|
|
| Osteoporosis Therapies |
|
|
|
|
Actonel® (risedronate sodium)
All products except
30 mg. |
PA |
QL |
|
|
Boniva® (ibandronate sodium) |
|
QL |
|
|
Forteo® (teriparatide, RDNA origin) |
PA |
QL |
|
|
Fosamax® (alendronate sodium)
All products |
|
QL |
|
| |
|
|
|
| Proton Pump Inhibitors |
|
|
|
|
Aciphex® (rabeprazole) |
PA |
|
|
|
Kapidex® (dexiansoprazole) |
PA |
|
|
|
Prevacid® (lansoprazole) |
PA |
|
|
|
Prilosec® Suspension packets (omeprazole
magnesium) |
PA |
|
|
|
Zegerid® (omeprazole/sodium bicarbonate) |
PA |
|
|
| |
|
|
|
| Rheumatoid Arthritis Therapies
|
|
|
|
|
Arava® (leflunomide) |
|
QL |
|
|
Enbrel® (etanercept) |
|
QL |
SM |
|
Humira® (adalimumab) |
|
QL |
SM |
|
Kineret® (anakinra) |
|
QL |
SM |
| |
|
|
|
| Sedative-Hypnotic Therapies
|
|
|
|
|
Ambien® (zolpidem tartrate) |
|
QL |
|
|
Ambien® CR (zolpidem tartrate) |
|
QL |
|
|
Butisol® (butabarbital sodium) |
|
QL |
|
|
chloral hydrate |
|
QL |
|
|
Dalmane® (flurazepam hydrochloride) |
|
QL |
|
|
Doral® (quazepam) |
|
QL |
|
|
Halcion® (triazolam) |
|
QL |
|
|
Lunesta® (eszopiclone) |
PA |
QL |
|
|
Prosom® (estazolam) |
|
QL |
|
|
Restoril® (temazepam) |
|
QL |
|
|
Rozerem® (ramelteom) |
PA |
QL |
|
|
Sonata® (zaleplon) |
|
QL |
|
|
|
|
|
|
| Therapeutic Patches
|
|
|
|
|
Androderm® (testosterone transdermal) |
|
QL |
|
|
Androgel® (testosterone gel) |
|
QL |
|
|
Catapres TTS® (clonidine transdermal) |
|
QL |
|
|
Daytrana® (methylphenidate transdermal) |
|
QL |
|
|
Emsam® (selegiline transdermal) |
|
QL |
|
|
fentanyl transdermal |
|
QL |
|
|
Lidoderm® (lidocaine transdermal) |
|
QL |
|
|
nitroglycerin transdermal |
|
QL |
|
|
Ortho-Evra® (norelgestromin/ethinyl estradiol trandsermal) |
|
QL |
|
|
Oxytrol® (oxybutynin transdermal) |
|
QL |
|
|
Striant® (testosterone mucoadhesive system) |
|
QL |
|
|
Testim Gel® (testosterone gel) |
|
QL |
|
|
Transderm-Scope® (scopolamine transdermal) |
|
QL |
|
| |
|
|
|
Topical Retinoid Therapies
(Prior authorization required for age 23 and older) |
|
Differin® (adapalene) All dosage forms |
PA |
|
|
|
Retin-A® (tretinoin) All dosage forms |
PA |
|
|
|
Tazorac® (tazarotene) All dosage forms |
PA |
|
|
