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In an effort to promote the appropriate use of certain drugs and to help better manage the cost of expensive
drugs, the ConnectiCare Pharmacy & Therapeutics Committee has developed a list of prescription drugs that
require prior authorization. Prior authorization requests must be faxed to ConnectiCare’s Pharmacy Services
department at 860-674-2851 or toll-free at 800-249-1367 by the prescribing physician’s office. POS members
receiving out-of-network care are responsible for initiating this process. When submitting a request for Prior
Authorization, please use a Prior Authorization form which can be obtained from ConnectiCare.com or by calling
ConnectiCare at 800-251-7722. If the prescribed drug is approved, the prescription will be filled as usual at a
participating pharmacy or administered by a provider (where appropriate).
Note: Self-administered medications (i.e. interferons), even those not on this list, may not be dispensed for self-
administration and billed through the medical benefit by a provider. They must be dispensed through a
participating pharmacy.
(*) prior authorization is not required within the first 90 days of membership with ConnectiCare. (M) physician-administered drug, usually billed under the medical benefit. (@) Prior Authorization required for members of ConnectiCare Exchange Plans and ConnectiCare SOLO Plans only
To find a drug, click on a letter and browse the table alphabetically.
A • B • C • D • E • F • G • H • I • J • K • L • M • N • O • P • Q • R • S • T • U • V • W • X • Y • Z
Or, click this Search button and enter the name of the drug in the pop-up task pane.*
Medication Comments Policy Name
OPIOIDS
LONG & SHORT ACTING PRODUCTS
(ALL) *See formulary
Long Acting Opioids, Short Acting Opioids
Abilify MyCite Atypicals
Absorica Absorica
Abstral Fentanyls
Acanya Gel pump Topical Acne
Accu-Chek Test Strips@ Use Freestyle Diabetic Test Strips
Aciphex (Use OTC PPI first) Proton Pump Inhibitors
Acitretin Acitretin
Actemra Actemra
Acthar Gel Acthar
* Please note: If the Search button does not work in the browser you are using, use the search feature within your web browser.
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Medication Comments Policy Name
Acticlate* Acne Meds Oral
Actimmune Actimmune
Actiq (fentanyl lozenge) Fentanyls
ActoplusMet XR* (Use metformin first) Diabetic Oral
Acuvail Ophthalmic NSAIDs
AdakveoM Adakveo
AdcetrisM Adcetris
Adcirca PAH Meds
Adempas* PAH Meds
Adhansia XR ADHD PA CCI
Adlyxin Non-Preferred GLP1 PA
Admelog Insulins
Adoxa* (Use generics first) Acne Meds Oral
Adynovate Clotting Disorder Therapy
Adzenys ADHD
Aemcolo Aemcolo
Afinitor Oncology
Afrezza Afrezza
Afstyla Clotting Disorder Therapy
Aimovig Aimovig
Airduo Respiclick Steroid - Beta Agonist Combo
Inhalers
Ajovy Ajovy
AjovyM Ajovy (fremanezumab)
Aklief Aklief
Akynzeo 5HT3 Receptor Antagonists
Akynzeo Medical Policy
Albuterol HFA Short Acting Bronchodilators
Alcortin A Alcortin-Alaquin
AldurazymeM Aldurazyme
Alecensa Oncology
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Medication Comments Policy Name
Alferon Alferon
AlimtaM Alimta
Aliqopa Aliqopa
Alkeran Generic Oncology
Alocril Ophthalmic Anti-Allergy
Alomide Ophthalmic Anti-Allergy
AloQuin Alcortin-Alaquin
Alprolix Clotting Disorder Therapy
Alrex Ophthalmic Anti-Allergy
Alsuma Sumatriptans
Altabax Topical Antibiotics
Altoprev* (Use simva-, prava-, lovastatin first)
Statin Step
Altreno Topical Acne
Alunbrig Alunbrig
Alvesco@ Steroid Inhalers PA CCI
Amcinonide 0.1% cream, lotion, ointment
Topical steroids
Ampyra Ampyra
Amrix (cyclobenzaprine ER)
(Use older generics first)
Amrix-Fexmid
Amzeeq Amzeeq
Anastia Lotion Lidocaines
Androderm Testosterone
Androgel *preferred product for commercial and exchange
Testosterone
Android Testosterone
Anzemet (Use ondansetron first) 5HT3 Receptor Antagonists
Apidra Insulins
Aplenzin (Use generic bupropion hcl)
Aplenzin-Forfivo
Apokyn Apokyn
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Medication Comments Policy Name
Aptensio XR ADHD
Aptiom Aptiom
AralastM Alpha-1 Proteinase Inhibitors
ArcalystM Arcalyst
Aricept 23 (PA < 50 years old only)
Cholinesterase Inhibitors
Aricept ODT (PA < 50 years old only)
Cholinesterase Inhibitors
Arikayce Arikayce
Armonair Respiclick Steroid Inhalers PA CCI
Arthrotec NSAIDs
Arymo ER Freedom LA
Narcotics/Morphines
ArzerraM Arzerra
Asacol/HD@ Mesalamines
Ascensia Test Strips (Use Freestyle) Diabetic Test Strips
Asceniv Intravenous Immune
Globulins (immune globulin)
Asparlas Asparlas
Aubagio MS
Austedo VMAT2 Inhibitors
Auvi Q Auvi Q/Symjepi
Avar Cleanser Avar 9.5-5% Cleansing pads Avar-E LS Cream Avar LS Cleaner
Topical Acne
Avar/Avar Plus Acne Meds Topical
AvastinM (PA not required for use in the eye)
Avastin
Aveed injection Aveed
Avidoxy DK (Use generic first) Acne Meds Oral
Avonex MS
Axiron Testosterone
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Medication Comments Policy Name
Ayvakit Ayvakit
Azedra Azedra
Azelex 20% Cream Topical Acne
Azopt Glaucoma Combinations
Bactroban Topical Antibiotics
Balcoltra@ FREEDOM Contraceptives
Balversa Balversa
Bavencio Bavencio
Baxdela Baxdela
BaxdelaM Baxdela (delafloxacin)
Bebulin Clotting Disorder Therapy
Beconase AQ* Freedom Nasal Sprays/Nasal
Steroids
Belbuca Belbuca
Beleodaq Beleodaq
Belsomra Belsomra
BendekaM Treanda/Bendeka
BeneFIX Clotting Disorder Therapy
BenlystaM Benlysta
BenzEFoam Ultra Acne Topical
Benznidazole Benznidazole
BeovuM Intravitreal Injections/Implants
Bepreve Ophthalmic Anti-Allergy
BerinertM Berinert
Besponsa Besponsa
Betamethasone Valerate 0.12% Foam
Topical Steroids
Betaseron MS
Betoptic S Glaucoma Combinations
Bevespi Aerosphere@
Long-acting muscarinic antagonist/long-acting beta-
agonist CCI Exchange
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Medication Comments Policy Name
Blincyto Blincyto
Blood Clotting Factors (All) M
Clotting Disorder Therapy
Boniva Injection Boniva Injection
Bosulif Bosulif
Botox Neurotoxins
Braftovi Braftovi
Bravelle Fertility
Brineura Brineura
Brukinsa Brukinsa
Bryhali Topical Steroids
Bunavail@ Freedom Zubsolv-Bunavail
Buphenyl
Sodium phenylbutyrate
Buprenorphine/Naloxone tabs
(Use Suboxone Film) Buprenorphine/Naloxone
Bydureon* Preferred GLP1 ST
Byetta* (Use metformin first) Preferred GLP1 ST
Byvalson Freedom Beta Blockers
CabliviM Cablivi
Cabometyx Oncology
Calquence Oncology
Cambia Cambia
CampathM Campath
Caplyta Caplyta
Caprelsa Oncology
Carbinoxamine Carbinoxamine
Cardizem LA@ Freedom Calcium Channel
Blockers
Carvedilol ER Carvedilol ER
Cayston Cayston
Centany 2% Ointment Topical Antibiotics
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Medication Comments Policy Name
Centany AT 2% Ointment kit
Centany
Cequa Cequa
CerdelgaM Cerdelga
CerezymeM Cerezyme
Cesamet Cesamet
Cetrotide
Chenodal Chenodal
Chloroquine Antimalarials
Cholbam PA to Indication
Chorionic Gonadotrophins Fertility
Cimzia Cimzia
CimziaM Cimzia (certolizumab)
CinqairM Cinqair
CinryzeM Cinryze
CinvantiM Cinvanti
Cladribine Generic Oncology
Clarinex/Clarinex D (desloratadine)
(Use Allegra, Zyrtec, and Claritin OTC first—covered)
Antihistamines
Clenpiq Bowel Preparations
Clindagel 1% gel Topical Acne
Clobazam Clobazam
Clobetasol Topical Steroids
Clobex Lotion (Use generic clobetasol first)
Topical Steroids
Clocortolone 0.1% Cream Topical Steroids
Clodan Topical Steroids
Cloderm Topical Steroids
ClolarM Clolar
Clotting Disorder Therapy Clotting Disorder Therapy
CNL Nail Kit Antifungal Agents
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Medication Comments Policy Name
Coagadex Clotting Disorder Therapy
Coartem Antimalarials
Cometriq Cometriq
Compounded Medications
Contraceptives@ Freedom Contraceptives
Copiktra Copiktra
Cordran Topical Steroids
Coremino Acne Oral
Corifact Clotting Disorder Therapy
Corlanor Corlanor
Cosentyx Cosentyx
Cotellic Oncology
Cotempla XR-ODT ADHD
CrysvitaM Crysvita
Cuprimine Penicillamine
Cuvitru IVIG SQ
Cuvposa Cuvposa
Cyramza Cyramza
CytogamM Cytogam (cytomegalovirus immune globulin, human)
DacogenM Dacogen
Daklinza Hepatitis C
Daraprim Daraprim
Darzalex Darzalex
Daunorubicin Generic Oncology
Daurismo Daurismo
Daxbia Daxbia
Delzicol@ Mesalamines
Demser Demser
Depen Penicillamine
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Medication Comments Policy Name
Desonide 0.05% lotion Topical Steroids
Desoximetasone 0.05% gel, cream Desoximetasone 0.25% spray, ointment
Topical Steroids
Desvenlafaxne Fumarate* Antidepressants
Dexilant (Use OTC’s 1st) Proton Pump Inhibitors
DexPak Dexamethasone Packs
Dextenza Intravitreal Injections/Implants
Dexycu Intravitreal Injections/Implants
Diacomit Diacomit
Dificid Dificid
Diflorasone 0.05% ointment, 0.05% cream
Topical Steroids
Dipentum@ Mesalamines
Doptelet Doptelet
Doryx/MPC* (Use generics first) Acne Meds Oral
Dovonex Psoriasis Topicals
Doxepin Cream Doxepin Cream
Doxepin Tablets Silenor
doxercalciferol Vitamin D2 Analogs
D-penamine Penicillamine
Drizalma Sprinkle Drizalma Sprinkle
Duaklir Pressair Duaklir Pressair
Duetact* (Use metformin first) Diabetic Oral
Duexis NSAID Combinations
Duobrii Psoriasis Topicals
Dupixent Dupixent
Durezol Ophthalmic Steroids
Durlaza Aspirins
Durolane Hyaluronic Acids
Duzallo Zurampic--Duzallo
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Medication Comments Policy Name
Dyanavel XR ADHD
Dymista Dymista
Dysport Neurotoxins
Ecoza Ecoza-Luzu
Edarbi/Edarbyclor* ACE/ARB Step
Edluar* (Use zolpidem generic tablets)
Zolpidem
Egrifta Egrifta
ElapraseM Elaprase
ElelysoM Elelyso
Eletriptan Relpax
Elliots B Elliots B
EloxatinM Eloxatin
Elzonris Elzonris
Emadine Ophthalmic Anti-Allergy
Embeda @ Freedom Long Acting
Narcotics
Emflaza Emflaza
Emgality Emgality
Empliciti Empliciti
Emsam Emsam
Enbrel Enbrel
Endari Endari
Endometrin Fertility
Enstilar Psoriasis Topicals
EntyvioM Entyvio
Epaned Qbrelis-Epaned
Epclusa Hepatitis C
Epidiolex Epidiolex
Epiduo Forte Acne Topicals
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Medication Comments Policy Name
Equetro ER Equetro
ErbituxM Erbitux
Erivedge Erivedge
Erleada Erleada
Erwinaze Erwinaze
Esbriet Esbriet
Eucrisa Eucrisa
EuflexxaM Hyaluronic Acid Derivatives
Evekeo Evekeo
Evekeo-ODT Evekeo-ODT
EvenityM Evenity
Evomela Generic Oncology
Exelon capsules (rivastigmine)
(PA for <50 years old only)
Cholinesterase Inhibitors
Exjade PA To Indication
Exondys 51 Eteplirsen (Exondys 51)
Extavia MS
Eylea Intravitreal Injections/Implants
FabrazymeM Fabrazyme
Fanapt* Atypicals
Farxiga* Diabetic Oral
Farydak Farydak
FasenraM Fasenra
Febuxostat Febuxostat
Fenofibrate 50mg, 160mg Fenofibrates
Fenoglide Fenofibrates
Fentora Fentanyls
Fetzima* Antidepressants
Fexmid Amrix-Fexmid
Fiasp Insulins
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Medication Comments Policy Name
Fibricor Fenofibrate step
Finacea Rosacea Topicals
FirazyrM Firazyr
Firdapse Firdapse - Ruzurgi
Flarex Ophthalmic Steroids
Flector Patch Flector
Flolan/epoprostenolM PAH Meds
Flolipid Statin Step
Flowtuss Cough Meds
Fluocinonide 0.1% cream Topical Steroids
Fluoxetine 60mg Antidepressants
Flurandrenolide 0.05% cream, ointment, lotion
Topical Steroids
Fluticasone Propionate 0.05% lotion
Topical Steroids
Fluticasone-Salmeterol inhaler
Steroid - Beta Agonist Combo
Inhalers
FML Forte Ophthalmic Steroids
FML S.O.P. Ophthalmic Steroids
Focalin XR ADHD
Follistim AQ Fertility
Folotyn Folotyn
Forfivo XL Aplenzin-Forfivo
Fortamet (Use generic metformin first)
Diabetic Oral
Fortesta Testosterone
Fulphila
Colony Stimulating Factors: Fulphila™ (pegfilgrastim-jmdb)
Fuzeon Fuzeon
Galafold Galafold
GamifantM Gamifant
Ganirelix Fertility
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Medication Comments Policy Name
Gattex GLP-2 Analogs
Gazyva Gazyva
Gelnique* Overactive Bladder
Gel-OneM Hyaluronic Acid Derivatives
Gelsyn-3 Hyaluronic Acid Derivatives
Genotropin Growth Hormone
Genvisc 850 Hyaluronic Acid Derivatives
Gilenya MS
Gilotrif Oncology
GivlaariM Givlaari
Glassia Alpha-1 Proteinase Inhibitors
Gleevec (imatinib) Oncology
Gloperba Gloperba
Glumetza Diabetic Oral
Glycopyrrolate 1.5mg tab Glycopyrrolate
Gocovri Gocovri
Gonal-F Fertility
Gralise Gralise
Granix Granix
Grastek Grastek
Haegarda Takhzyro and Haegarda
HalavenM Halaven
Halcinonide 0.1% ointment, 0.1% cream
Topical Steroids
Halobetasol 0.05% lotion Topical Steroids
Harvoni Hepatitis C
Hemlibra Clotting Disorder Therapy
Herceptin Hylecta Herceptin Hylecta
HerceptinM Herceptin
Herzuma Trastuzumab Injection
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Medication Comments Policy Name
Hetlioz PA To Indication
HizentraM IVIG- Subcutaneous
Horizant Horizant
Humate – P Clotting Disorder Therapy
Humatrope Growth Hormone
Humira Humira
HyalganM Hyaluronic Acid Derivatives
Hycamtin Generic Oncology
Hycamtin Capsules Hycamtin
Hycofenix Cough Meds
Hydrocortisone butyrate 0.1% lotion
Topical Steroids
Hymovis Hyaluronic Acid Derivatives
Hyqvia IVIG SQ
Hysingla ER Long Acting Hydrocodones
Ibrance Oncology
Iclusig Oncology
Idamycin/Idarubicin Generic Oncology
Idelvion Clotting Disorder Therapy
Idhifa Oncology
IlarisM Ilaris
Ilumya Ilumya
Iluvien Intravitreal Injections/Implants
Imbruvica Oncology
Imfinzi Imfinzi
Imlygic Imlygic
Impavido PA to Indication
Impoyz Topical Steroids
Inbrija Inbrija
Increlex Increlex
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Medication Comments Policy Name
Incruse Ellipta@ Long-acting muscarinic
antagonists
Infertility Medications (All)
Gonadotropins
Inflectra Infliximab Injectables
Ingrezza VMAT2 Inhibitors
Injectable Drugs – All (excluding insulin)
Inlyta Inlyta
Inrebic Inrebic
Intron-A Intron-A
Inveltys Ophthalmic Steroids
Iressa Oncology
IstodaxM Istodax
IV Immune Globulin (IVIG)
M
Intravenous Immune Globulins (immune globulin)
Ivermectin topical cream Rosacea Topicals
IxempraM Ixempra
Ixifi Infliximab
Jadenu PA To Indication
Jakafi Jakafi
Jetrea Intravitreal Injections/Implants
JevtanaM Jevtana
Jivi Clotting Disorder Therapy
Jornay PM ADHD
Jublia Antifungal Agents
Juxtapid Juxtapid
Jynarque Jynarque
KadcylaM Kadcyla
KalbitorM Kalbitor
Kalydeco Kalydeco
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Medication Comments Policy Name
Kanjinti Herceptin/Ogivri/Herzuma/Ont
ruzant /Kanjinti
KanumaM Kanuma
Katerzia Katerzia
Kazano* Diabetic Oral
Kerydin Antifungal Agents
Ketoprofen Ketoprofen
Keveyis PA To Indication
Kevzara Kevzara
KeytrudaM Keytruda
KhapzoryM Khapzory
Khedezla* Antidepressants
Kineret Kineret
Kisqali Kisqali
Kombiglyze XR* Diabetic Oral
Korlym PA To Indication
Kovaltry Clotting Disorder Therapy
KrystexxaM Krystexxa
Kuvan Kuvan
KymriahM Kymriah
Kynamro Kynamro
KyprolisM Kyprolis
Kytril (granisetron) (Use generic Zofran first)
5HT3 Receptor Antagonists
Lac-Hydrin@ Freedom Lac-Hydrin
Lactulose Packets Lactulose
Lartruvo Lartruvo
Lastacaft Ophthalmic Anti-Allergy
Latuda* Atypicals
Lazanda Fentanyls
LemtradaM Lemtrada
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Medication Comments Policy Name
Lenvima Oncology
Letairis PAH Meds
Leucovorin Generic Oncology
LeukineM Leukine
Lexette Topical Steroids
Lialda@ Freedom Mesalamines
Libtayo Libtayo
Lidtopic Max Lidocaines
Livalo* Statin Step
Livixil Lidocaines
Lofibra Fenofibrate step
Lokelma Lokelma
Long-acting muscarinic antagonist
Long-acting muscarinic
antagonist
Long-acting muscarinic antagonist/long-acting beta-agonist
Long-acting muscarinic antagonist/long-acting beta-
agonist
Lonsurf Lonsurf
Lorbrena Lorbrena
Lotemax Ophthalmic Drops Gel
Ophthalmic Steroids
Lotemax Ophthalmic Ointment
Ophthalmic Steroids
Lotemax SM Ophthalmic Steroids
Lovaza (Omega 3 acid ethyl esters)
Omega 3’s
Lucemyra Lucemyra
Lucentis Intravitreal Injections/Implants
LumizymeM Lumizyme
LumoxitiM Lumoxiti
LutatheraM Lutathera
LuxturnaM Luxturna
Luzu Ecoza-Luzu
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Medication Comments Policy Name
Lynparza Oncology
Lyrica/Lyrica CR* Lyrica
Macugen Intravitreal Injections/Implants
Marqibo Marqibo
Matulane Matulane
Matzim LA@ Freedom Calcium Channel
Blockers
Mavenclad Mavenclad
Mavyret Hepatitis C
Maxidex Ophthalmic Steroids
Mayzent Mayzent
Mefloquine Antimalarials
Mekinist Oncology
Mektovi Mektovi
Melphalan Generic Oncology
Menopur Fertility
Mepron (atovaquone) Mepron
MepseviiM Mepsevii Medical Policy
Mesalamine 800mg DR@ Mesalamines
Metformin ER Diabetic Oral
Metoprolol ER-HCTZ Metoprolol HCTZ
Minocycline ER Minocycline extended release
Minolira ER Acne Orals
Mirvaso Rosacea Topicals
Mononine Clotting Disorder Therapy
Monovisc Hyaluronic Acid Derivatives
Morphabond ER Freedom LA
Narcotics/Morphines
Motegrity Trulance-Motegrity
MozobilM Mozobil
Mulpleta Mulpleta
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Medication Comments Policy Name
Mupirocin Topical Antibiotics
Mvasi Avastin/Mvasi
Myalept PA to Indication
MylotargM Mylotarg
MyoblocM Neurotoxins
Myrbetriq* Overactive Bladder
Mytesi Mytesi
NaglazymeM Naglazyme
Namenda/Namzaric (PA < 50 years old only)
Cholinesterase Inhibitors
Nasacort Freedom Nasal Inhalers
Natesto Testosterone
Natpara Natpara
Nayzilam Nayzilam
Nerlynx Oncology
Nesina* (Use metformin and Sitagliptin or Linagliptin first)
Diabetic Oral
Neulasta Neulasta
Neupogen Neupogen
Nevanac Ophthalmic NSAIDs
Nexavar Oncology
Nexium Rx Proton Pump Inhibitors
Nilandron Oncology
Nilutamide Nilutamide
Nimodipine PA To Indication
Ninlaro Oncology
Nipent Generic Oncology
Nitisinone Nitisinone
Nityr PA To Indication
Nivestym Colony Stimulating Factors: Nivestym™ (filgrastim-aafi)
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Medication Comments Policy Name
Nocdurna Noctiva-Nocdurna
Noctiva Noctiva-Nocdurna
Norditropin Growth Hormone
Noritate Rosacea Topicals
Northera Northera
Nourianz Nourianz
Novarel Fertility
Novolin/Novolog Insulins
NovosevenM Novoseven
NplateM Nplate
Nubeqa Nubeqa
NucalaM Nucala
Nuedexta Nuedexta
NulojixM Nulojix
Numbonex Lidocaines
Nuplazid Nuplazid
Nutropin/AQ Growth Hormone
Nuvigil (armodafanil) Nuvigil
Nuwiq Clotting Disorder Therapy
Nuzyra Nuzyra
Nymalize PA To Indication
Obizur Clotting Disorder Therapy
Ocaliva PA To Indication
OcrevusM Ocrevus
Odactra Odactra
Odomzo Oncology
Ofev Ofev
Ogivri Trastuzumab Injection
Oleptro Oleptro
Olumiant Olumiant
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Medication Comments Policy Name
Olux/Olux-E (Use generic clobetasol first)
Topical Steroids
Olysio Hepatitis C
Omnaris* (Use fluticasone or Nasonex)
Freedom Nasal Sprays/Nasal Steroids
Omnitrope Growth Hormone
One Touch Test Strips (Use Freestyle) Diabetic Test Strips
Onexton Acne Meds Topical
Onfi Clobazam
Onglyza* Diabetic Oral
Onmel Onmel
OnpattroM Onpattro
Ontruzant
Onzetra Xsail Sumatriptans
Opana ER (crush resistant
formulation) @ (Generic Opana ER does not require PA)
Freedom Long Acting Narcotics
Opdivo Opdivo
Opsumit* PAH Meds
Oracea (Doxycycline
Rosacea) * Oracea
Oralair Oralair
Oravig Oravig
Orencia/Orencia SQM Orencia
Orenitram PAH Meds
Orfadin PA To Indication
Orilissa Orilissa
Orkambi Orkambi
OrthoviscM Hyaluronic Acid Derivatives
Oseni* Oseni
Osmolex ER Osmolex ER
Otezla Otezla
Otrexup Methotrexates
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Medication Comments Policy Name
Ovace Plus Foam Ovace
Oxandrin Oxandrin
Oxaydo Oxycodones
Oxbryta Oxbryta
Oxervate Oxervate
Oxtellar XR Oxtellar XR
Oxycodone AG (Oxycontin Authorized Generic)
Oxycodones
Oxycontin (brand name) @
Freedom Long Acting
Narcotics
Oxytrol* Overactive Bladder
Ozempic Preferred GLP1 ST
Ozurdex Intravitreal Injections/Implants
Palforzia Palforzia
Palynziq Palynziq
Pancreaze Pancreatic Enzymes
Panzyga IVIG
Paricalcitol Vitamin D2 Analogs
ParsabivM Parsabiv
Patanase (olopatadine) (Use Astelin first) Freedom Nasal
Sprays/Patanase
Pazeo Ophthalmic Anti-Allergy
Pegasys Pegasys-PegIntron
Peg-Intron Pegasys-PegIntron
Penicillamine Penicillamine
Pennsaid 2% Pennsaid
PerjetaM Perjeta
Pertzye Pancreatic Enzymes
Pexeva* (Use generics first) Antidepressants
Piqray Piqray
Plegridy MS
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Medication Comments Policy Name
Plenvu Bowel Preparations
Plexion 9.8-4.8% Cleanser Plexion 9.8-4.8% Cleanser
Polivy Polivy
Pomalyst Oncology
PortrazzaM Oncology
Posaconazole Noxafil (posaconazole)
PoteligeoM Poteligeo
Pradaxa Anticoagulants
Praluent Praluent
Pred Mild Ophthalmic Steroids
Pregnyl Fertility
Prepopik Bowel Preparations
Prestalia Prestalia
Prevacid Rx Proton Pump Inhibitors
Prevymis Prevymis
PrialtM Prialt
Prilosec Rx (Use Prilosec OTC) Proton Pump Inhibitors
ProAir Digihaler Short Acting Bronchodilators
ProbuphineM Probuphine/Buprenorphine
Procysbi Procysbi
Profilnine SD Clotting Disorder Therapy
Prolastin/Prolastin-C Alpha-1 Proteinase Inhibitors
Prolensa Ophthalmic NSAIDs
ProleukinM Proleukin
Prolia/Xgeva Prolia/Xgeva
Promacta Promacta
Protonix Proton Pump Inhibitors
ProvengeM Provenge
Proventil HFA@ Short Acting Bronchodilators
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Medication Comments Policy Name
Provigil (modafinil) Provigil
Prozac Weekly** (Use generics first) Antidepressants
Prudoxin Cream Doxepin Cream
Psorcon Topical Steroids
Qbrelis Qbrelis-Epaned
Qbrexza Qbrexza
Qmiiz ODT NSAID’s
Qnasl* Freedom Nasal Sprays/Nasal
Steroids
Qtern Diabetic Oral
Qualaquin Qualaquin
Qudexy XR Qudexy--Trokendi
Quillichew ER ADHD
Quillivant ADHD
Qutenza Qutenza
RadicavaM Radicava
Ragwitek Ragwitek
Rapaflo* BPH_Silodosin
Rasuvo Methotrexates
Ravicti Ravicti
Rayaldee Rayaldee
Rayos Rayos
Razadyne Cholinesterase Inhibitors
Rebif MS
Rebinyn Clotting Disorder Therapy
ReblozylM Reblozyl
Regranex Regranex
Relafen DS NSAID
Relistor Relistor
RelizorbM Relizorb
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Medication Comments Policy Name
Relpax* (Use generic triptan first)
Relpax
RemicadeM Infliximab Injectables
RemodulinM PAH Meds
Renflexis Infliximab Injectables
Repatha Repatha
Retisert Intravitreal Injections/Implants
Revatio (sildenafil) PAH Meds
RevcoviM Revcovi
Revlimid Oncology
Rexulti* Rexulti
Rhofade Rosacea Topicals
Rhopressa Rhopressa - Rocklatan
RiaSTAPM RiaSTAP
Rinvoq Rinvoq
Riomet Diabetic Oral Medications
Rituxan/Rituxan HycelaM Rituxan
Rixubis Clotting Disorder Therapy
Rocklatan Rhopressa - Rocklatan
Rosula Acne Meds Topical
Roxybond Oxycodones
Rozlytrek Rozlytrek
Rubraca Oncology
RuconestM Ruconest
Ruzurgi Firdapse - Ruzurgi
Rybelsus Preferred GLP1 ST
Rydapt Rydapt
Ryvent Antihistamines
Saizen Growth Hormone
Sanctura (trospium) * Overactive Bladder Meds
Sancuso (Use ondansetron first) 5HT3 Receptor Antagonists
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Page 26 of 34
Medication Comments Policy Name
Saphris* Atypicals
Savaysa Anticoagulants
Secuado Secuado
Seebri Neohaler@ Long-acting muscarinic
antagonists
Sensipar J0604 NOT COVERED
Sernivo Topical Steroids
Seysara Acne oral
Signifor/LARM Pasireotide (Signifor LAR)
Siklos Siklos
Silenor Silenor
Siliq Siliq
Silodosin BPH_Silodosin
Simbrinza Glaucoma Combinations
Simponi Simponi
Simponi ARIAM Simponi ARIA
Simvastatin Suspension Simvastatin Suspension
Sitavig Sitavig
Sivextro Sivextro
Skyrizi Skyrizi
Soliqua Soliqua
SolirisM Soliris
Solodyn Solodyn
Solodyn ER Minocycline extended release
Solosec Solosec
Somavert Somavert
Soolantra Rosacea Topicals
Sorilux Foam Psoriasis Topicals
Sovaldi Hepatitis C
Spinraza Spinraza
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Medication Comments Policy Name
Spiriva@ Freedom Inhalers
Spravato Spravato
Sprix Nasal spray Sprix
Sprycel Oncology
Steglatro Diabetic Oral
Steglujan Diabetic Oral
Stegluromet Diabetic Oral
Stelara syringes/vials Stelara
Stivarga Oncology
Strensiq PA To Indication
Striant Testosterone
Subsys Fentanyls
Sucraid Sucraid
Sumavel Dosepro Sumavel Dosepro
Sunosi Sunosi
Supartz/FXM Hyaluronic Acid Derivatives
Supprelin LAM Supprelin LA
Sustol 5HT3 Receptor Antagonists
Sutent Oncology
Sylatron Sylatron
SylvantM Sylvant
Symdeko Symdeko
Symjepi Auvi-Q/Symjepi
SymlinPen* SymlinPen
Sympazan Sympazan
Synagis M Synagis
Synarel Synarel
Syndros Syndros
Synjardy/XR** Diabetic Oral
Synojoynt Hyaluronic Acids
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Medication Comments Policy Name
Synribo Oncology
Synvisc/Synvisc-OneM Hyaluronic Acid Derivatives
Tafinlar Oncology
Targretin Targretin
Targretin Gel Targretin Gel
Tagrisso Tagrisso
TakhzyroM Takhzyro and Haegarda
Taltz Taltz
Talzenna Talzenna
TaperDex Dexamethasone Packs
Tarceva Oncology
Targadox Acne Meds Oral
Tasigna Oncology
Tavalisse Tavalisse
Tazverik Tazverik
Tecentriq Tecentriq
Tecfidera MS
Technivie Hepatitis C
TegsediM Tegsedi
Tekturna (Use generic ACE or ARB first)
ACE/ARB Step
Temodar (temozolomide) Oncology
TepadinaM Tepadina
Testim (testosterone transdermal gel)
Testosterone
Testosterone (All) Testosterone
TevTropin Growth Hormone
Thalomid Oncology
Thyrogen Thyrogen
Tibsovo Tibsovo
Tiglutik Tiglutik
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Page 29 of 34
Medication Comments Policy Name
Timoptic Ocudose Glaucoma Combinations
Tirosint-SOL Tirosint-SOL
Tivorbex NSAIDs
Tolsura Tolsura
ToriselM Torisel
Tosymra Tosymra
Toviaz* Overactive Bladder
Tracleer PAH Meds
Tramadol Biphasic Tramadol Biphasic
Tranzarel Lidocaines
Travatan/Travatan Z Ophthalmic Preparations
TreandaM Treanda/Bendeka
Trelegy Ellipta Trelegy Ellipta
Trelstar PA To Indication
Tremfya Tremfya
Tretin-X Cream (Use tretinoin first) Tretin-X
Tretten Clotting Disorder Therapy
Treximet Sumatriptan_Naproxen
(Treximet)
Triamcinolone 0.05% ointment
Topical Steroids
Trientine Trientine
Triglide Fenofibrate step
Trikafta Trikafta
Triluron Hyaluronic Acids
Trintellix* Formerly Brintellix Trintellix
TriVisc Hyaluronic Acid Derivatives
TrogarzoM Trogarzo
Trokendi XR Qudexy--Trokendi
Troxyca ER Oxycodones
Trulance Trulance-Motegrity
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Medication Comments Policy Name
Trulicity Non-Preferred GLP1 PA
Truxima Truxima
Tudorza Tudorza
Turalio Turalio
Tuzistra XR Cough Meds
Tykerb Tykerb
Tysabri MS/Tysabri
Tyvaso PAH Meds
Udenyca Colony Stimulating Factors:
Udenyca (Pegfilgrastim-cbqv)
Uloric Febuxostat
UltomorisM Ultomoris
UnituxinM Unituxin
Uptravi PAH Meds
Utibron Neohaler@
Long-acting muscarinic antagonist/long-acting beta-
agonist CCI Exchange
Utopic 41% Cream Utopic 41% Cream
Valchlor Valchlor
Valtoco Valtoco
Vanos Topical Steroids
VantasM Vantas
Vascepa Omega 3’s
VectibixM Vectibix
VelcadeM Velcade
Velphoro PA To Indication
Veltassa Veltassa
Veltin 1.2%-0.025% gel Acne Topical
Venclexta Oncology
VentavisM PAH Meds
Ventolin HFA@ Short Acting Bronchodilators
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Medication Comments Policy Name
Verdeso Topical Steroids
Verzenio Oncology
Vesicare* Overactive Bladder
Victoza* (Use metformin first) Preferred GLP1 ST
VidazaM Oncology
Viekira Pak Hepatitis C
Viibryd* Antidepressants
VimizimM Vimizim
Vimovo NSAID Combinations
Vinblastine Generic Oncology
Viokace Pancreatic Enzymes
Visco-3 Hyaluronic Acid Derivatives
Vistogard PA to Indication
Vitrakvi Vitrakvi
Vituz Cough Meds
Vivlodex NSAIDs
Vizimpro Vizimpro
Vogelxo Testosterone
Vonvendi Clotting Disorder Therapy
Voraxaze Voraxaze
Vosevi Hepatitis C
Votrient Oncology
VprivM Vpriv
Vraylar Atypicals
Vumerity Vumerity
Vusion Vusion
Vyndaqel Vyndaqel
Vyxeos Vyxeos
Vyzulta Ophthalmics Glaucoma PA
Wakix Wakix
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Medication Comments Policy Name
Wilate Clotting Disorder Therapy
Xadagp Xadago
Xalkori Oncology
Xartemis XR Oxycodones
Xatmep Methotrexates
Xeljanz/XR Xeljanz
Xeloda (capecitabine) Oncology
Xelpros Ophthalmics Glaucoma PA
Xembify IVIG- Subcutaneous
Xenazine tetrabenazine
Xenleta Xenleta
XeominM Neurotoxins
Xepi Topical Antibiotics
Xerese Xerese
Xermelo Xermelo
Xhance Nasal Sprays/Freedom Nasal
Sprays
XiaflexM Xiaflex
Xifaxan Xifaxan
Xigduo XR* Diabetic Oral Step
XofigoM Xofigo
Xolair Xolair
Xopenex HFA@ Short Acting Bronchodilators
Xospata Xospata
Xpovio Xpovio
Xtampza ER Oxycodones
Xtandi Xtandi
Xuriden PA To Indication
Xyntha Clotting Disorder Therapy
Xyosted Testosterones
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Medication Comments Policy Name
Xyrem Xyrem
YervoyM Vervoy
YescartaM Yescarta
Yondelis Oncology
Yonsa Yonsa
Yosprala Aspirins
ZaltrapM Zaltrap
Zarxio Zarxio
Zavesca Zavesca
Zegerid Rx (PA for > 15 y/o) (Use OTC or OTC Prevacid/Prilosec)
Proton Pump Inhibitors
Zejula Oncology
Zelboraf Oncology
ZemairaM Alpha-1 Proteinase Inhibitors
Zembrace SymTouch Sumatriptans
Zenzedi ADHD meds
Zepatier Hepatitis C
Zetonna* Freedom Nasal Sprays/Nasal
Steroids
ZevalinM Zevalin
ZiextenzoM Colony Stimulating Factors:
Ziextenzo
ZilrettaM Zilretta
Zinbryta MS
ZinplavaM Zinplava
Zioptan Ophthalmic Glaucoma PA
Zipsor (Use diclofenac tablets)
NSAIDs
Zohydro ER Long Acting Hydrocodones
ZolgensmaM Zolgensma
Zolinza Zolinza
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Page 34 of 34
Medication Comments Policy Name
Zolpimist (Use generic zolpidem tablets)
Zolpidem
Zonalon Cream Doxepin Cream
Zontivity Zontivity
Zortress Zortress
Zorvolex NSAIDs
ZTLido Lidocaines
Zubsolv@ Freedom Zubsolv-Bunavail
ZulressoM Zulresso
Zuplenz 5HT3 Receptor Antagonists
Zurampic Zurampic--Duzallo
Zydelig Oncology
Zyflo CR (Use Singulair first) Zyflor CR
Zykadia Oncology
Zypitamag Statin Step
Zytiga Oncology
