PDF Medications Requiring Prior Authorization for Medical Necessity
April 2023
Medications Requiring Prior Authorization for Medical Necessity for Standard Option, High Option and High Deductible Health Plan (HDHP) Members Chart
Below is a list of medicines by drug class that will not be covered without a prior authorization for medical necessity. If you continue using one of these drugs without prior approval for medical necessity, you may be required to pay the full cost.
If you are currently using one of the drugs requiring prior authorization for medical necessity, ask your doctor to choose one of the generic or brand formulary options listed below.
Category Drug Class
Acromegaly
Allergies Antihistamines
Allergies Nasal Steroids / Combinations
Anti-infectives, Antibacterials Erythromycins / Macrolides Anti-infectives, Antibacterials Tetracyclines
Anti-infectives, Antibacterials Miscellaneous Anti-infectives, Antifungals
Drugs Requiring Prior Authorization for Medical Necessity 1
SANDOSTATIN LAR SIGNIFOR LAR SOMAVERT
dexchlorpheniramine Diphen Elixir RyClora CARBINOXAMINE TABLET 6 MG
BECONASE AQ OMNARIS QNASL ZETONNA
E.E.S. GRANULES ERYPED
doxycycline hyclate delayed-rel tablet doxycycline hyclate tablet 50 mg doxycycline hyclate tablet 75 mg doxycycline hyclate tablet 150 mg doxycycline monohydrate capsule 75 mg doxycycline monohydrate capsule 150 mg minocycline ext-rel CoreMino Mondoxyne NL capsule 75 mg Targadox ACTICLATE DORYX DORYX MPC
nitrofurantoin (NDC* 16571074024 only) MACRODANTIN
flucytosine capsule 500 mg
posaconazole delayed-rel tablet NOXAFIL
CRESEMBA
tavaborole
COMPLERA STRIBILD
Formulary Options (May Require Prior Authorization)
SOMATULINE DEPOT levocetirizine
azelastine-fluticasone, flunisolide, fluticasone, mometasone
erythromycins doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
nitrofurantoin (except NDC* 16571074024) fluconazole fluconazole, itraconazole itraconazole terbinafine tablet efavirenz-emtricitabine-tenofovir disoproxil fumarate, efavirenz-lamivudine-tenofovir disoproxil fumarate, BIKTARVY, DOVATO, GENVOYA, ODEFSEY, SYMTUZA
Category Drug Class
Anti-infectives, Antiretroviral Agents Combination Agents
Anti-infectives, Antiretroviral Agents Protease Inhibitors Anti-infectives, Antivirals Cytomegalovirus Anti-infectives, Antivirals Hepatitis B Anti-infectives, Antivirals Hepatitis C
Anti-infectives, Antivirals Herpes Anti-infectives Miscellaneous Antiobesity Antiseizure Agents
Anxiety Benzodiazepines Asthma Beta Agonists, Short-Acting
Asthma Leukotriene Modulators
Drugs Requiring Prior Authorization for Medical Necessity 1
TRUVADA
Formulary Options (May Require Prior Authorization)
abacavir-lamivudine, emtricitabine-tenofovir disoproxil fumarate, lamivudine-zidovudine, CIMDUO, DESCOVY
APTIVUS LEXIVA VIRACEPT VALCYTE
BARACLUDE TABLET EPIVIR HBV HEPSERA MAVYRET
VIEKIRA PAK ZEPATIER acyclovir cream VALTREX
DARAPRIM
CONTRAVE XENICAL topiramate ext-rel capsule (generics for QUDEXY XR only)
BANZEL SUSPENSION ONFI SABRIL ZONEGRAN
ATIVAN XANAX XANAX XR albuterol sulfate CFC-free aerosol
(NDC* 66993001968 only) PROAIR HFA PROAIR RESPICLICK PROVENTIL HFA VENTOLIN HFA XOPENEX HFA zileuton ext-rel SINGULAIR
Talk to your doctor atazanavir, lopinavir-ritonavir, EVOTAZ, PREZCOBIX, PREZISTA
valganciclovir
entecavir, lamivudine, tenofovir disoproxil fumarate, BARACLUDE SOLUTION, VEMLIDY
EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI
2
EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)
acyclovir capsule, acyclovir tablet, valacyclovir
pyrimethamine
QSYMIA, SAXENDA, WEGOVY
carbamazepine, carbamazepine ext-rel, clobazam, divalproex sodium, divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine, lamotrigine extrel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, rufinamide, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, XCOPRI clobazam, lamotrigine, rufinamide, topiramate, TROKENDI XR
vigabatrin carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine, lamotrigine extrel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, XCOPRI alprazolam, clonazepam, diazepam, lorazepam, oxazepam
albuterol sulfate CFC-free aerosol (except NDC* 66993001968), levalbuterol tartrate CFC-free aerosol
montelukast, zafirlukast
Category Drug Class
Drugs Requiring Prior Authorization for Medical Necessity 1
Asthma Steroid Inhalants
ALVESCO ASMANEX ASMANEX HFA
Asthma or Chronic Obstructive
DULERA
Pulmonary Disease (COPD)
Steroid / Beta Agonist Combinations
Attention Deficit Hyperactivity Disorder
ADDERALL EVEKEO
ADDERALL XR ADZENYS XR-ODT APTENSIO XR CONCERTA DAYTRANA FOCALIN XR
INTUNIV
Autoimmune Agents Physician-Administered Agents
Autoimmune Agents Self-Administered Agents Ankylosing Spondylitis
Autoimmune Agents Self-Administered Agents Crohn's Disease Autoimmune Agents Self-Administered Agents Psoriasis Autoimmune Agents Self-Administered Agents Psoriatic Arthritis
Autoimmune Agents Self-Administered Agents Rheumatoid Arthritis
Autoimmune Agents Self-Administered Agents Ulcerative Colitis
ACTEMRA INTRAVENOUS ORENCIA INTRAVENOUS
AVSOLA CIMZIA LYOPHILIZED POWDER INFLECTRA RENFLEXIS
ENTYVIO (For Crohn's Disease Only)
ILUMYA
CIMZIA PREFILLED SYRINGE SIMPONI TALTZ XELJANZ XELJANZ XR
CIMZIA PREFILLED SYRINGE
CIMZIA PREFILLED SYRINGE COSENTYX ENBREL
CIMZIA PREFILLED SYRINGE ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS SIMPONI STELARA SUBCUTANEOUS TALTZ TREMFYA XELJANZ XELJANZ XR
ACTEMRA ACTPEN ACTEMRA SUBCUTANEOUS CIMZIA PREFILLED SYRINGE KINERET SIMPONI
SIMPONI
Formulary Options (May Require Prior Authorization)
ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR REDIHALER ADVAIR DISKUS, ADVAIR HFA**, BREO ELLIPTA**, SYMBICORT
amphetamine-dextroamphetamine mixed salts, methylphenidate amphetamine-dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext-rel, methylphenidate ext-rel, MYDAYIS, VYVANSE
amphetamine-dextroamphetamine mixed salts ext-rel, atomoxetine, dexmethylphenidate ext-rel, guanfacine ext-rel, methylphenidate ext-rel, MYDAYIS, VYVANSE REMICADE, SIMPONI ARIA REMICADE, SIMPONI ARIA, SKYRIZI INTRAVENOUS, STELARA INTRAVENOUS
REMICADE, SKYRIZI INTRAVENOUS, STELARA INTRAVENOUS REMICADE COSENTYX, ENBREL, HUMIRA, RINVOQ
HUMIRA, SKYRIZI SUBCUTANEOUS, STELARA SUBCUTANEOUS
HUMIRA, OTEZLA, SKYRIZI SUBCUTANEOUS, STELARA SUBCUTANEOUS, TALTZ, TREMFYA
COSENTYX, ENBREL, HUMIRA, OTEZLA, RINVOQ, SKYRIZI SUBCUTANEOUS
ENBREL, HUMIRA, KEVZARA, ORENCIA CLICKJECT, ORENCIA SUBCUTANEOUS, RINVOQ, XELJANZ, XELJANZ XR
HUMIRA, RINVOQ, STELARA SUBCUTANEOUS, XELJANZ, XELJANZ XR
Category Drug Class
Autoimmune Agents Self-Administered Agents All Other Conditions
Cancer Biosimilars
Cancer Chronic Myelogenous Leukemia Kinase Inhibitors
Cancer Follicular Lymphoma PI3K Inhibitors
Cancer Monoclonal Antibodies
Cancer Multiple Myeloma Proteasome Inhibitors
Cancer Prostate Antiandrogens
Cancer Prostate Luteinizing Hormone-Releasing Hormone (LHRH) Agonists
Cardiovascular Antiarrhythmics
Cardiovascular Antilipemics Cholesterol Absorption Inhibitors
Cardiovascular Antilipemics Fibrates
Cardiovascular Antilipemics HMG-CoA Reductase Inhibitors (HMGs or Statins) / Combinations 3
Cardiovascular Antilipemics Niacins
Drugs Requiring Prior Authorization for Medical Necessity 1
ACTEMRA ACTPEN ACTEMRA SUBCUTANEOUS KINERET ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS
RIABNI TRUXIMA
GLEEVEC TASIGNA
ALIQOPA
ZYDELIG
AVASTIN
HERCEPTIN HERCEPTIN HYLECTA
RITUXAN
BORTEZOMIB KYPROLIS
NILANDRON ZYTIGA
LUPRON DEPOT TRELSTAR MIXJECT ZOLADEX
BETAPACE BETAPACE AF
NORPACE
ZETIA
fenofibrate capsule 30 mg fenofibrate capsule 50 mg fenofibrate capsule 90 mg fenofibrate capsule 130 mg fenofibrate tablet 40 mg fenofibrate tablet 120 mg FENOGLIDE TABLET 120 MG TRICOR
ALTOPREV CRESTOR LESCOL XL LIPITOR LIVALO
niacin tablet 500 mg Niacor
Formulary Options (May Require Prior Authorization)
ENBREL, HUMIRA
RUXIENCE imatinib mesylate, BOSULIF, SPRYCEL
Talk to your doctor COPIKTRA ZIRABEV KANJINTI, TRAZIMERA RUXIENCE NINLARO, VELCADE
abiraterone, bicalutamide, ERLEADA, XTANDI, YONSA
ELIGARD, FIRMAGON
sotalol disopyramide ezetimibe
fenofibrate (except fenofibrate capsule 30 mg, 50 mg, 90 mg, 130 mg; fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed-rel
atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
niacin ext-rel
Category Drug Class
Cardiovascular Antilipemics Omega-3 Fatty Acids
Cardiovascular Antilipemics PCSK9 Inhibitors
Cardiovascular Digitalis Glycosides
Cardiovascular Diuretics
Cardiovascular Nitrates
Cardiovascular Pulmonary Arterial Hypertension Endothelin Receptor Antagonists
Cardiovascular Pulmonary Arterial Hypertension Phosphodiesterase Inhibitors
Cardiovascular Pulmonary Arterial Hypertension Prostaglandin Vasodilators
Carnitine Deficiency
Central Precocious Puberty
Chronic Obstructive Pulmonary Disease (COPD) Anticholinergics
Chronic Obstructive Pulmonary Disease (COPD) Anticholinergic / Beta Agonist Combinations Long Acting
Contraceptives Oral
Contraceptives Progestin Intrauterine Devices
Contraceptives Vaginal
Cystic Fibrosis Inhaled Antibiotics
Drugs Requiring Prior Authorization for Medical Necessity 1
icosapent ethyl
Formulary Options (May Require Prior Authorization)
omega-3 acid ethyl esters, VASCEPA
REPATHA
PRALUENT
LANOXIN TABLET (125 MCG and 250 MCG only) DYRENIUM
isosorbide dinitrate 40 mg
LETAIRIS TRACLEER
ADCIRCA REVATIO
REMODULIN
digoxin amiloride, triamterene isosorbide dinitrate (except isosorbide dinitrate 40 mg), isosorbide mononitrate ambrisentan, bosentan, OPSUMIT sildenafil, tadalafil treprostinil
CARNITOR CARNITOR SF LUPRON DEPOT-PED INCRUSE ELLIPTA TUDORZA
BEVESPI AEROSPHERE
levocarnitine SUPPRELIN LA, TRIPTODUR SPIRIVA
ANORO ELLIPTA, STIOLTO RESPIMAT
BALCOLTRA BEYAZ MINASTRIN 24 FE NATAZIA SEASONIQUE TAYTULLA YASMIN YAZ
LILETTA
NUVARING
TOBI TOBI PODHALER
ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate, LO LOESTRIN FE
KYLEENA, MIRENA, SKYLA
ethinyl estradiol-etonogestrel, ANNOVERA
tobramycin inhalation solution, BETHKIS
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