Medications Requiring Prior Authorization

The medications listed on this page may require prior authorization.  See bottom of page for contact information.

Use the links below for easy access to categories of Prior Authorization medications.

Angiotensin II Receptor Antagonists

• Atacand® (candesartan)

• Atacand HCT® (candesartan/HCTZ)

• Avalide® (irbesartan/HCTZ)

• Avapro® (irbesartan)

• Benicar® (olmesartan)

• Benicar HCT® (olmesartan/HCTZ)

• Cozaar® (losartan)

• Diovan® (valsartan)

• Diovan HCT® (valsartan/HCTZ)

• Hyzaar® (losartan/HCTZ)

• Micardis® (telmisartan)

• Micardis HCT® (telmisartan/HCTZ)

• Teveten® (eprosartan)

• Teveten HCT® (eprosartan/HCTZ)

Anti-Depressive Therapy

• Bupropion

• Bupropion SR

• Bupropion XL 300mg

• Lexapro® (escitalopram oxalate)

• Wellbutrin® XL 150mg

Anti-Influenza Agents

• Relenza® (zanamivir)

• Tamiflu® Capsules/Suspensions (osteltamivir)

Antineoplastic Therapy

• Iressa® (gefitinib) 

COX-II Inhibitors

• Celebrex® (celecoxib)

CNS Stimulants(Prior authorization required for age 21 and older)

• Adderall®, Adderall XR® (amphetamine/dextroamphetamine combination)

• Desoxyn® (methamphetamine)

• Dexedrine®, Dexedrine Spansules®, Dextrostat® (dextroamphetamine)

• Focalin®(dexmethylphenidate)

• Ritalin®, Ritalin SR®, Ritalin LA®, Metadate CD®, Concerta®, Methylin ER® (methylphenidate)

• Strattera® (atomoxetine)

Erythroid Stimulants

• Aranesp® (darbepoetin)

• Procrit® /Epogen® (erythropoietin)

Growth Hormones

• Genotropin® (somatropin)

• Geref® (somatropin)

• Humatrope® (somatropin)

• Norditropin® (somatropin)

• Nutropin® (somatropin)

• Protropin® (somatropin)

• Saizen® (somatropin)

• Serostim® (somatropin)

• Somavert® (somatropin)

Impotency Agents (Prior authorization approved only if you have had radical retropubic prostatectomy surgery, otherwise these medication are not covered)

• Caverject® , Edex® Injection (alprostadil)

• Cialis® (tadalafil)

• Levitra® (vardenafil)

• MUSE® (alprostadil)

• Viagra® (sildenafil)

• Yohimbine HCL, both generic and brand-name

Leukotriene Inhibitors

• Accolate® (zafirlukast)

• Singulair® (montelukast)

• Zyflo® (zileuton)

• Zyflo® CR (zileuton)

Myeloid Stimulants

• Leukine® (sargramostim)

• Neulasta® (pegfilgrastim)

• Neumega® (oprelvekin)

• Neupogen® (filgrastim)

Osteoporosis Therapy

• Actonel® (risedronate sodium) All products except 30 mg requires a prior authorization effective 03/01/2008

• Boniva® 150 mg (ibandronate)

• Forteo® Injection (teriparatide, RDNA origin injection)
   

Pain Therapy

• Stadol® Nasal Spray (butorphanol)

Proton Pump Inhibitors

• Aciphex® (rabeprazole)

• Prevacid® (lansoprazole)

• Prilosec® 40mg (omeprazole)

• Protonix® (pantoprazole sodium)

• Zegerid® (omeprazole/sodium bicarbonate)

Sedative-Hypnotics (Prior authorization required effective 04/01/08)

• Lunesta® (eszopiclone)

• Rozerem® (ramelteom)

• Sonata® (zaleplon)
   

Topical Retinoids (Prior authorization required for age 23 and older)

• Differin® (adapalene) all dosage forms

• Retin®-A (tretinoin) all dosage forms

• Tazorac® (tazarotene) all dosage forms

To request prior authorization for these medications, please have your physician contact Medco Health.  The phone number is 1-800-753-2851, Monday through Friday (7AM-8PM CST).