NC2021-35 (4/20)

2020 Prior Authorization and

Specialty RX Management Guidelines

This form contains information regarding Nippon Life Benefits’ Prior Authorization program, which

includes drugs that have dispensing limitations, dose limitations, and prior authorization requirements

including the Prior Authorization Process on Formulary Drugs with Clinically Effective Alternatives as

well as the Specialty Drug Management program.

The following drugs have a Dispensing Limitation (quantity limit per 30 days unless otherwise specified) and

please note that the quantity limit may include other prescript ion drugs if they treat the same condit ion:

Quantity Limits

Prescription Drug

Albenza (336 tabs per 365

days)

Imitrex Injection (12 ea) Sonata 5/10 mg (30)

Alsuma Injection (12 ea) Imitrex Inj Vial (12vl) Sprix (5 bottles per 25 days)

Ambien 5/10 (30) Imitrex 5mg Nasal Spray (24);

Imitrex 20mg Nasal Spray (12 ea)

Stadol Nasal Spray (5 ml)

Ambien CR (30) Intermezzo (30) Stayxn (6)

Amerge 1mg & 2.5 mg Tab (12) Levitra 2.5/5/10/20 mg (6) Stendra (6)

Arymo** Levorphanol** Sumavel Dosepro 4mg (18ea),

Sumavel Dosepro 6mg (12ea)

Axert 6.5mg & 12.5 mg Tab (12) Lidocaine (Emla (30 gm), Lidocaine

2% gel (30 gm), Lidocaine 4% gel

(30gm), Lidocaine 5% oint (50gm),

Lidocaine 4% soln (50ml), Pliaglis

7-7% cream (30gm), Synera 70-

70mg patch(2))

Tamiflu 75mg Cap (14 tabs),

Tamiflu 45mg (14 tabs), Tamiflu

30mg (28 tabs), Tamiflu 30mg/5ml

Oral Susp, (180ml), (1 fill of either

Relenza or Tamiflu every 90 days)

Belbuca** Lunesta 1/2/3 mg (30) Tapentadol**

Biltricide (24 tab per 365 days) Maxalt/Maxalt MLT 5mg & 10mg Tab

(18)

Targiniq ER**

Butrans** Meperidine** Toradol 10 mg (20)

Caverject (6) Methadone** Tramadol**

Cialis 10/20 mg (6),

Cialis 2.5/5mg (30)

Methadose** Treximet 10-60mg, 85-500mg Tab

(9)

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Codeine** Migranal Nasal Spray – (1 x8ml) Troxyca ER**

Conzip** Monurol (1) Vantrella**

Diflucan 150mg (2) Morphabond** Viagra 25/50/100 mg (6)

Dolophine** Morphine** Xtampza ER**

Edex (6) Muse (6) Zohydro**

Edluar (30) Nucynta** Zohydro ER**

Embeda** OxyContin**

Zomig Nasal Spray (12 ea)

Emverm (12 tabs per 365 days) Oxycodone** Zomig/Zomig ZMT 2.5mg & 5mg

(12)

Exalgo** Oxymorphone**

Frova 2.5 mg Tab (18) Pentazocine/naloxone**

Hydromorphone** Relenza cap(40) (1 fill of either

Releza or Tamiflu every 90 days)

Hysingla ER** Relpaz 20mg & 40 mg Tab (12)

Imitrex 25mg, 50mg, 100mg

Tab (12)

Rozerem (30)

**Opioids

- Plans implementing morphine milligram equivalent (MME) based quantity limits on opioids are providing

coverage for an initial amount of 90 MME or less per day.

- This program requires a post limit review to provide coverage for additional quantities of the prescribed

opioids of 200 MME or less per day.

- Neither initial quantities nor post limit quantities will be set up for patients with cancer, a terminal condition,

or pain being managed through hospice or palliative care.

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Dos e Opt i m i z a t i o n

A cost-savings program that identifies medications where a different dosage or quantity would be more efficient. The

pharmacy works with the physician to recommend such options. Dose optimization Quantity Limit – 30 tablets.

Drug Dose (mg) Drug Dose (mg)

Abilify 5/10/15 Movantik 12.5

Actos 15 Namenda XR 7

Adalat CC 30 Nesina 6.25/12.5

Altoprev 20 Niaspan 500

Amaryl 1 Norvasc 2.5/5

Aplenzin 174 Oleptro 150

Arava 10 Onglyza 2.5

Aricept 5 Oseni 12.5/15

Aricept ODT 5 Paxil 10/20

Avapro 75/150 Paxil CR 12.5

Azilect 0.5 Pexeva 10/20

Azor 5-20 Plendil 2.5/5

Benicar 5/20 Pravachol 10/20/40

Benicar HCT 20-12.5 Prestalia 3.5/2.5

Bevyxxa 40 Prestalia 7/5

Bystolic 2.5/5/10 Prinivil 5/10/20

Caduet 2.5-10, 2.5-20, 2.5-

40, 5-10, 5-20, 5-

40

Pristiq 25/50

Cardura 1/2/4 Procardia XL 30

Cardura XL 4 Provera 2.5/5

Celexa 10/20 Rapaflo 4

Coreg Cr 10/20/40 Razadyne ER 8

Corgard 20/40 Remeron 7.5/15

Crestor 5/10/20 Remeron Rapid Disolve 15

Depakote ER 250 Requip XL 2/4/6

Detrol LA 2 Rexulti 0.25/0.5/1/2

Desvenlafaxine ER 50 mg Savaysa 15/30

Dexilant 30 Seroquel XR 50/150/200

Diflucan 100 Silenor 3

Diovan HCT 80-12.5 / 160-12.5 Steglatro 5

Ditropan XL 5 Sular 8.5/17/20

Edarbi 40 Symbyax 3/25 – 6/25

Effexor XR 37.5/75 Tekturna 150

Enablex 7.5 Tekturna HCT 150-12.5

Exforge 5-160 Toprol XL 25/50/100

Exforge HCT 5-160-12.5 Toviaz 4

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Ezallor Sprinkle 5/10/20 Tribenzor 20.5-12.5

Farxiga 5 Trintellix 5/10

Fetzima 20/40 Twynsta 40-5

Fosamax 5 Vaseretic 5-12.5

Inderal LA 60/80 venlafaxine HCI ER 37.5/75

Ingrezza 40 Verelan PM 100

Intuniv 1/2 Verelan SR 120/180

Invega 1.5/3 Vesicare 5

Invokana 100 Viibryd 10/20

Januvia 25/50 Vivlodex 5

Kerlone 10 Vraylar 1.5/3

Khedezla ER 50 Xadago 50

Latuda 20/40/60 Xigduo XR 5/500

Levaquin 250 Zaroxlyn 2.5/5

Lexapro 5/10 Zebeta 5

Linzess 145 Zestoretic 10-12.5

Lipitor 10/20/40 Zestril 5/10/20

Livalo 1 / 2 Zocor 5/10/20

Lotrel 2.5-10, 5-10, 5-20 Zoloft 25/50

Lozol 1.25 Zypitamag 1/2

Luvox 25/50 Zyprexa 2.5/5/7.5

Micardis HCT 40-12.5 Zyprexa Zydis 5/10

Micardis 20/40 mg

Mirapex ER 0.375/

0.75/1.5/2.25

Mobic 7.5

Pri o r Aut h o r i z a t i o n Dru g s Your physician will have to provide additional information to indicate medical necessity to CVS Caremark for the following

drugs to be filled:

Acne Agents: Topical tretinoins (Atralin, Avita, Retin-A, Retin-A Micro, Tretin-X, Tretinoin) and Differin for ages 35 and older and all ages for Fabior and Tazorac.

Anabolic Steroids: Anadrol-50, Oxandrin

Antifungals: Ciclodan, ciclopirox topical solutions, CNL8, Jublia, Kerydin, Lamisil/terabinafine, Onmel/itraconazole, Pedipirox,

Penlac/ciclopirox Sporanox/itraconazole, terbinafine, Terbinex

Anti-viral: Sitavig

Compounds: All Compounds*

Dental products: Arestin

Dermatological: Amcinonide Ointment, Ala Scalp, Bryhali, Capex, Clobex lotion, Clobex Shampoo, Cloderm, Cordran, Cutivate, Cyclocort, Derma-Smooth, Dermatop Ointment, Desonate, Desowen Cream, Diprolene Augmented Ointment, Diprolene AF Augmented Cream, Elocon, Halobetasol Aerosol Foam, Halog, Impoyz, Kenalog Aerosol Spray, Lexette, Locoid, Luxiq Aerosol Foam, Micort-HC, Olux Aerosol Foam, Pandel Cream, Santyl, Sernivo Spray, Solaraze, Synalar, Temovate, Texacort, Topicort, Tridesilon, Trianex, Ultravate, Vanos, Verdeso, Westcort Ointment Dermatological Medical Products

Eczema: Eucrisa

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Infant Formulas: New Jersey Only

Erectile Dysfunction: Caverject, Edex, Lavitra, Muse, Stayxn, through age 49

GI Motility: Lotronex

Narcolepsy: armodafanil, Provigil, Xyrem

Narcotic Analgesics: Abtral, Actiq, Fentora, Onsolis, Subsys

Pain Management: Duexis, Vimovo

Saliva Substitutes

Testosterones: Enanthate injection, Cypionate injection, topical gel, topical cream, topical ointment, topical

solution, transdermal patch, nasal gel, mucoadhesive buccal system, propionate implant pellets, powder/crystals

for compounding ( Androderm, Axiron, Fortesta, Striant, Testosterone Ointment, Testosterone Cream,

Methyltestosterone, Oral Fluoxymesterone, Testopel)

Topical Analgesics: Pain Patches *A compound medication is one that is made by combining, mixing or altering ingredients, in response to a prescription, to create a customized medication that is not otherwise commercially available.

Pri o r A uthor i z a t i o n Pro c ess

For the medications above that indicate a prior authorization is required, please follow the process below.

1. Bring your prescription to a pharmacist.

2. If drugs require prior authorization, the pharmacist will receive a message stating that the physician must call

CVS Caremark at 800-294-5979.

3. Your pharmacist should advise you as well as your physician of the Prior Authorization process and number to call.

4. This means that your physician will have to call the number or FAX a letter of medical necessity to CVS Caremark.

Physician prior authorization number is 800-294-5979. Physician prior authorization FAX number is 888-836-0730.

5. CVS Caremark will evaluate the information received based on internally developed clinical criteria. The decision

will be an approval, denial, or review for more information.

App r ova l

After a claim is approved, an override is applied so that the claim will process electronically at the pharmacy and a

letter will be sent to you and your physician indicating the approval and the time period of the approval.

Den i a l

If the medication is denied, then a letter is sent to both you and your physician. The denial letter will outline

directions on how to appeal the decision.

Mis s i n g I n f o r m a t i o n

If more information is required, the physician’s office will be contacted. Once the physician’s office provides

CVS Caremark with the required information then a review will be completed within 24 – 48 hours.

Additional drugs may be added to the Prior Authorization or Quantity Limit list throughout the year. Your specific benefit

design may not cover certain drugs, even though they appear on this list. This document is a summary reference and may

not necessarily reflect all coverage and exclusions of the plan benefit system.

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Prior Authorization Process on Formulary Drugs and Supplies

with Clinically Effective Alternatives

The following drugs and supplies are included:

Supply Name Supply Usage Available Alternatives

All insulin needles that are not BD brand needles (Examples include, but are not limited to: Novo Nordisk Needles, Owen Mumford Needles, Perrigo Needles, Ultimed Needles

Diabetes Supplies, Needles BD Ultrafine Needles

All insulin syringes that are not BD brand syringes (Examples include, but are not limited to: Allison Medical Insulin Syringes, Techlite Insulin Syringes, Trividia Insulin Syringes, Ultimed Insulin Syringes, Vanishpoint Insulin Syringes

Diabetes Supplies, Syringes BD Ultrafine Insulin Syringes

All strips and kits that are not Accu-Chek brand strips and kits (Examples include, but are not limited to: (Breeze 2 Strips and Kits, Contour Next Strips and Kits, Contour Strips and Kits, Freestyle Strips and Kits, OneTouch Ultra Strips and Kits, OneTouch Verio Strips and Kits

Diabetes Supplies, Strips and Kits Accu-Check Aviva Plus Strips and Kits, Accu-Check Compact Plus Strips and Kits, Accu-Check Smartivew Strips and Kits

Elite Continuous Glucose Monitoring System, Freestyle Libre Continuous Glucose Monitoring System, Guardian Connect Continuous Glucose Monitoring System

Diabetes Supplies Dexcom Continuous Glucose Monitoring System

Drug Name Medication Usage Available Alternatives

Abilify Depression aripiprazole, clozapine, olanzapine,quetiapine, quetiapine ext-rel, risperidone, ziprasidone, Latuda, Vraylar

Acanya Topical Derm Acne adapalene, benzoyl peroxide, clindamycin gel, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, Epiduo, Tazorac

Aciphex/Aciphex Sprinkle Gastrointestinal Agents esomeprazole, lansoprazole, omeprazole, pantoprazole, Dexilant

Acticlate Anti-Infective doxycycline hyclate, minocycline, tetracycline

Actemra Rheumatoid Arthritis Enbrel, Humira, Rinvoq, Xelijanz, Xelijanz XR

Actos Diabetes pioglitazone

acyclovir cream 5% Antiviral acyclovir capsule, acyclovir tablet, valacyclovir

Alcortin A Dermatology desonide, hydrocortisone

Alevicyn Gel, Alevicyn SG, Alevicyn solution Dermatology desonide, hydrocortisone

Alprolix Hemophilia IX Consult doctor

Alrex Ophthalmic azelastine, cromolyn sodium, olopatadine, Lastacaft, Pazeo

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Altoprev Cardiovascular antilipemics atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Alvesco Asthma Arnuity Ellipta, Flovent Diskus, Flovent HFA, Pulmicort Flexhaler, Qvar Redihaler

Amrix Musculoskeletal cyclobenzaprine (except cyclobenzaprine tablet 7.5mg)

Androgel 1% Testosterone Relacement testosterone gel 2%, testosterone solution, Androderm

Apexicon E Dermatology desoximetasone, fluocinonide (except fluocinonide cream 0.1%) Apidra Diabetes Fiasp, Novolog

Arthrotec Anti-inflammatory celecoxib, diclofenac sodium,

ibuprofen, meloxicam or naproxen

(except naproxen CR or naproxen

suspension) WITH esomeprazole,

lansoprazole, omeprazole,

pantoprazole or Dexilant

Asacol HD Inflammatory bowel disease balsalazide, mesalamine del-rel

cap, sulfasalazine, sulfasalazine

del-rel, Apriso, Pentasa

Asmanex/Asmanex HFA Asthma Arnuity Ellipta, Flovent Diskus,

Flovent HFA, Pulmicort Flexhaler,

Qvar Redihaler

Atacand High blood pressure candesartan, eprosartan, irbesartan,

losartan, olmesartan, telmisartan,

valsartan,

Atacand HCT High blood pressure candesartan-hydrochlorothiazide,

irbesartan-hydrochlorothiazide,

losartan-hydrochlorothiazide,

olmesartan-hydrochlorothiazide,

telmisartan-hydrochlorothiazide,

valsartan-hydrochlorothiazide

Atopaderm Dermatology desonide, hydrocortisone

Avenova Ophthalmic Consult doctor

Avonex Multiple Sclerosis glatiramer, Aubagio, Betaseron,

Copaxone 40 MG, Gilenya, Mayzent,

Rebif, Tecfidera, Tysabri

Baraclude Tab Anti-infectives, Antivirals, Hepatitis B entecavir, lamivudine, Vemlidy

Beau Rx Dermalogy Consult doctor

Beconase AQ Allergies flunisolide spray, fluticasone spray,

mometasone spray, Dymista

Benicar/Benicar HCT High Blood Pressure candesartan, candesartan-

hydrochlorothiazide, eprosartan,

irbesartan, irbesartan-

hydrochlorothiazide, losartan,

losartan-hydrochlorothiazide,

olmesartan, olmesartan-

hydrochlorothiazide, telmisartan,

telmisartan-hydrochlorothiazide,

valsartan, valsartan—

hydrochlorothiazide Berninert Hematologic Firazyr, Ruconest

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Bensal HP Dermatology/Misc. Skin Conditions desonide, hydrocortisone

Benzaclin Topical Derm Acne adapalene, benzoyl peroxide,

clindamycin gel, clindamycin

solution, clindamycin-benzoyl

peroxide, erythromycin solution,

erythromycin-benzoyl peroxide,

tretinoin, Epiduo, Tazorac

benzonatate (NDC 69336012615, 69499032915 only)

Respiratory Cough benzonatate (except NDC

69336012615, 69499032915)

Berinert Hematologic Firazry, Ruconest

Betapace Tab/Betapace AF Tab Ventricula Arrhythmias sotalol

Beyaz Contraceptive ethinyl estradiol-drospirenone,

ethinyl estradiol-drospirenone-

levomefolate, ethinyl estradiol-

norethindrone acetate, ethinyl

estradiol-norethindrone acetate-

iron

butalbital-acetaminophen (NDC 69499034230 only)

Pain diclofenac sodium,ibuprofen, naproxen (except naproxen CR or suspension)

butalbital-acetaminophen-caffeine capsule Pain diclofenac sodium, ibuprofen, naproxen (except naproxen CR or suspension)

Butrans Pain buprenorphine transdermal, Belbuca

Bydureon Diabetes Ozempic, Trulicity, Victoza

Byetta Diabetes (injectable) Ozempic,Trulicity, Victoza

Cafergot Migraines eletriptan, ergotamine-caffeine, naratriptan, rizatriptan, sumatriptan, zolmitriptan, Onzetra Xsail, Zembrace Symtouch, Zomig Nasal Spray

calcipotrien cre 0.005% Topical Dermatology calcipotriene ointment, calcipotriene solution

calcitriol oin 3mcg/gm Topical Dermatology calcipotriene ointment, calcipotriene solution

Cambia Migraine NSAID diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Carac Dermatology fluorouracil cream 5%, fluorouracil soln, imiquimod, Picato, Tolac, Zyclara

Carafate Gastrointestinal sucralfate

carbinoxamine Tab Antihistamine levocetirizine

Cardizem/ Cardizem CD High Blood Pressure diltiazem ext-rel (except generic of Cardizem LA)

Cardizem LA (and its generics) High Blood Pressure diltiazem ext-rel (except generic of Cardizem LA)

Carnitor/Carnitor SF Carnitine Deficiency Agents levocarnitine

chlordiazepoxide/clidinium capsule 5-2.5mg (NDC 42494040901 only)

Gastrointestinal dicyclomine

Chlorzoxazone 250 mg (NDC 44672086046, 69499033060 only)

Muscle Relaxer cyclobenzaprine (except cyclobenzaprine table 7.5mg)

Cialis Erectile Dysfunction silendafil, tadalafil

Cicatrace Dermatology Consult doctor

Cimzia Crohn’s Disease Cosentyx, Enbrel, Humira, Otezla, Rinvoq, Skyrizi, Stelara Subcutaneous, Tremfya, Xelijanz, Xelijanz XR

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clobetasol spray Dermatology clobetasol foam

Clobex Spray Dermatology clobetasol foam

Colazal Gastrointestinal/Inflammatory Bowel Disease balsalazide

Colcrys Gout colchincine tablet

Combivent Respimat COPD ipratropium-albuterol inhalation solution, Anora Ellipta, Bevespi Aerosphere, Stiolto Respimat

Contrave Anti-Obesity Oral Belviq, Belviq XR, Saxenda

Cordran Oin 0.05% Topical Dermatology hydrocortisone butyrate, mometasone, triamcinolone

Coumadin Hematologic warfarin

Crestor Cardiovascular Antilipemics atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

cyclobenzaprine tab 7.5mg Musculoskeletal agents cyclobenzaprine (except cyclobenzaprine 7.5mg)

Cymbalta Depression desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule

Delzicol Inflammatory bowel disease balsalazide, mesalamine del-rel cap, sulfasalazine, sulfasalazine del-rel, Apriso, Pentasa

Detrol LA Overactive bladder darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel,

trospium, trospium ext-rel, Myrbetriq,

Toviaz dexchlorpheniramine syrup Allergies levocetirizine

Dexpak Pain and Inflammation dexamethasone, hydrocortisone, methylprednisolone, prednisone solution, prednisone

diclofenac sodium gel 1% (NDC 69499031866 only)

NSAID diclofenac sodium, diclofenac sodium gel 1% (except NDC 69499031866), diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Diclofex DC Mis (NDC 51021037201 only) Analgesics/NSAID diclofenac sodium, diclofenac sodium gel 1% (except NDC 69499031866), diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Diclosaicin Mis Analgesics/NSAID diclofenac sodium, diclofenac sodium gel 1% (except NDC 69499031866), diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

diflorasone cre 0.05% Topical dermatology desoximetasone, fluocinonide (except fluocinonide cream 0.1%)

diflorasone oin 0.05% Topical dermatology desoximetasone, fluocinonide (except fluocinonide cream 0.1%)

dihydroergotamine mesylate nasal spray Migraines eletriptan, ergotamine-caffeine, naratriptan, rizatriptan, sumatriptan, zolmitriptan, Onzetra Xsail, Zembrace Symtouch, Zomig Nasal Spray

Diovan High Blood Pressure candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, valsartan

Diovan HCT High blood pressure candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, olmesartan-hydrochlorothiazide, telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide

Doryx/Doryx MPC Anti-Infectives, Antibacterials doxycycline hyclate, minocycline, tetracycline

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doxepin hydrochloride cream 5% Moderate pruritis desonide, hydrocortisone, pimecrolimus, tacrolimus, Eucrisa

Dulera Asthma Advair Diskus, Advair HFA, Breo Ellipta, Symbicort

Dutoprol High Blood Pressure metoprolol succinate ext-rel with hydrochlorothiazide

Dyrenium Cap Edema Amiloride, triamterene

Edarbi High blood pressure candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, valsartan

Edarbyclor High blood pressure candesartan-hydrochlorothiazide,

irbesartan-hydrochlorothiazide,

losartan-hydrochlorothiazide,

olmesartan-hydrochlorothiazide,

telmisartan-hydrochlorothiazide,

valsartan-hydrochlorothiazide E.E.S. Granules Infections erythromycins

Effexor XR Antidepressent desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule

Elelyso Type 1 Gaucher Disease Cerdelga, Cerezyme

Eloctate Hemophilia VIII Adynovate, Jivi, Kogenate FS, Kovaltry, Novoeight, Nuwiq

Enablex Overactive Bladder darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, Myrbetriq, Toviaz

Enteragam Gastrointestinal alosetron, Viberzi, Xifaxan 550mg

Entyvio Ulcerative Colitis or Crohn’s Disease Humira, Xeljanz, Xeljanz XR

Epiceram Dermatologic desonide, hydrocortisone

Epogen Anemia Aranesp, Retacrit

Eryped Infections erythromycins

Euflexxa Osteoarthritis Durolane, Gel-One, Gelsyn-3, Supartz FX, Visco-3

Evekeo ADHD amphetamine–dextroamphetamine mixed salts, methylphenidate

Evzio Opiod Reversal Agents naloxone injection, Narcan Nasal Spray

Exforge High Blood Pressure amlodipine-olmesartan, amlodipine-telmisartan, amlopdipine-valsartan

Exforge HCT High Blood Pressure amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine-hydrochlorothiazide

Extavia Multiple Sclerosis glatiramer, Aubagio, Betaseron, Copaxone 40 MG, Gilenya, Mayzent, Rebif, Tecfidera, Tysabri

Fanapt Antipsychotics aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, Latuda, Vraylar

fenofibrate tab 120mg Cardiovascular fenofibrate (except 120mg tablet), fenofibric acid del-rel

Fenoglide Tab 120mg Cardiovascular fenofibrate (except 120mg tablet), fenofibric acid del-rel

fenoprofen capsule Nonsteroidal, anti-infammatory (NSAID) diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Fexmid Tab Musculoskeletal cyclobenzaprine (except cyclobenzaprine tablet 7.5mg)

Finacea Gel Rosacea azelaic acid gel, metronidazole, Finacea Foam, Soolantra

Fioricet Capsule Pain diclofenac sodium, ibuprofen, naproxen (except naproxen CR or suspension)

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Flarex Opthalmic dexamethasone, loteprednol, prednisolone acetate 1%, Durezol, FML Forte, FML S.O.P., Maxidex, Pred Mild

fluocinonide cream 0.1% Topical steroid clobetasol cream

fluorouracil cream 0.5% Dermatology fluorouracil cream 5%, fluorouracil soln, imiquimod, Picato, Tolak, Zyclara

flurandrenolide ointment Dermatology hydrocortisone butyrate, mometasone, triamcinolone FML Liquifilm Anti-inflammatory dexamethasone, loteprednol, prednisolone

acetate 1%, Durezol, FML Forte, FML S.O.P., Maxidex, Pred Mild

Follistim AQ Infertility Gonal-F

Fortamet Diabetes (oral medication) metformin, metformin ext-rel (except generic Fortamet or Glumetza)

Fortesta Testosterone Relacement testosterone gel 2%, testosterone solution, Androderm

Fosrenol Kidney Disease calcium acetate, sevelamer carbonate, Phoslyra, Velphoro

Fulphila Hematologic Neulesta, Udenyca

Glycopyrrolate Tab 1.5mg Anticholinergic dicyclomine

Gleevec Cancer imatinib mesylate, Bosulif, Sprycel

Glumetza Diabetes (oral medication) metformin, metformin ext-rel (except generic Fortamet or Glumetza)

Granix Hematologic Nivestym

Helixate FS Hematologic Adynovate, Jivi, Kogenate FS, Kovaltry, Novoeight, Nuwiq

Horizant Restless Leg Syndrome gabapentin, Gralise

Humalog Diabetes (insulin) Fiasp, Novolog

Humalog Mix 50/50 Diabetes (insulin) Novalog Mix 70/30

Humalog Mix 75/25 Diabetes (insulin) Novalog Mix 70/30

Humulin 70/30 Diabetes (insulin) Novolin 70/30

Humulin N Diabetes (insulin) Novolin N

Humulin R Diabetes (insulin) Novolin R

NOTE: Humulin R U-500 concentrate will not be subject to review.

Hyalgan Osteoarthritis Durolane, Gel-one, Gelsyn-3, Supartz FX, Visco-3

Hysingla ER Pain fentanyl transdermal, hydromorphone ext-rel, methadone, morphine ext-rel, Embeda, Nucynta ER, Xtampza ER

Inflammacin Mis 75-0.025 Analgesics/NSAID diclofenac sodium, diclofenac sodium gel 1% (except NDC 69499031866), diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Indocin Suppository, Indocin Suspension Analgesics/NSAIDS diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Intermezzo Hypnotics eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, Belsomra, Silenor

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Intuniv Attention deficit hyperactivity amphetamine-dextroamphetamine mixed salts ext-rel, atomoxetine, guanfacine ext-rel, methylphenidate ext-rel, Mydayis, Vyvanse

Invokamet/Invokamet XR Diabetes Synjardy, Synjardy XR, Xigduo XR

Invokana Diabetes Farxiga, Jardiance

Jalyn Prostate condition dutasteride-tamsulosin; dutasteride or finasteride with alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin

Jentadueto/Jentadueto XR Diabetes Janumet, Janumet XR

Kamdoy Dermatologic desonide, hydrocortisone

Kazano Diabetes Janumet, Janumet XR,

ketoconazole aerosol foam 2% Dermatology ketoconazole shampoo 2%, selenium sulfide lotion 2.5%

Ketodan Dermatology ketoconazole shampoo 2%, selenium sulfide lotion 2.5%

ketoprofen Cap 200mg ER Pain and Inflammation diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Kineret Rheumatoid Arthritis Enbrel, Humira, Rinvoq, Xelijanz, Xelijanz XR

Kombiglyze XR Diabetes Janumet, Janumet XR

lactulose pak 10gm Constipation lactulose solution

Lamictal/Lamictal ODT/Lamictal XR Anticonvulsants carbamazepine, carbamazepine ext–rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext. rel, levetiracetam, levetiracelam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, Fycompa, Oxtellar XR, Trokendi XR, Vimpat

Lanoxin Tab (125 mcg and 250 mcg only) Heart failure digoxin

lanthanum carbonate Kidney Disease calcium acetate, sevelamer carbonate, Phoslyra, Velphoro

Lantus Diabetes Basaglar, Levemir

Lazanda Pain fentanyl transdermal lozenge, Subsys

Lescol XL Cardiovascular antilipemics atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

levorphanol Pain fentanyl transdermal, hydromorphone ext-rel, methadone, morphine ext-rel., Embeda, Nucynta ER, Xtampza ER

Lexapro Depression citalopram, escitalopram, fluoxetine, paroxetine HCI, paroxetine HCI ext-rel, sertraline, Trintellix, Viibryd

Lialda Inflammatory Bowel Disease balsalazide, mesalamine del-rel cap, sulfasalazine, sulfasalazine del-rel, Apriso, Pentasa

Lidocaine-Tetracaine Cream Topical/Dermatology lidocaine/prilocaine

Lidotrex Gel 2% Topical/Dermatology lidocaine/prilocaine

Lipitor Cardiovascular antilipemics atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

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Livalo Cardiovascular antilipemics atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Lo Loestrin Fe Contraceptive ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol-norgestimate

Lotemax/Lotemax SM Ophthalmic dexamethasone, loteprednol, prednisolone acetate 1%, Durezol, FML Forte, FML S.O.P., Maxidex, Pred Mild

Lunesta Hypnotics eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, Belsomra, Silenor

Macrodantin Urinary Tract Infection nitrofurantoin

Matzim LA High blood pressure diltiazem ext-rel (except generic of Cardizem LA)

Mavyret Hepatitis C Epclusa, Harvoni, Vosevi

Miacalcin Inj Postmenopausal osteoporosis alendronate, calcitonin salmon, ibandronate, risedronate, Forteo, Prolia, Tymlos

Miacalcin Nasal Spray Postmenopausal osteoporosis calcitonin-salmon

Migergot Migraines eletriptan, ergotamine-caffeine, naratriptan, rizatriptan, sumatriptan, zolmitriptan, Onzetra Xsail, Zembrace Symtouch, Zomig Nasal Spray

Millipred Pain and Inflammation dexamethasone, hydrocortisone, methylprednisolone, prednisone solution, prednisone

Minastrin 24 FE Contraceptive ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron

Minivelle Estrogen replacement estradiol, Divigel, Evamist

Minocin Anti-infectives/Antibacterials/Tetracyclines doxycycline hyclate, minocycline, tetracycline

Monovisc Osteoarthritis Durolane, Gel-one, Gelsyn-3, Supartz FX, Visco-3

MoviPrep Laxative Peg 3350-electrolytes, Suprep

mupirocin cream Dermatology antibiotics gentamicin, mupirocin ointment

Naprelan Pain and inflammation diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

naproxen sodium CR tabs Pain and inflammation diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

naproxen suspension 125/5ml Pain and inflammation Ibuprofen

Natazia Contraceptive ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate

Natesto Testosterone replacement testosterone gel 2%, testosterone solution, Androderm

Nesina Diabetes Januvia

Neupogen Hematologic Nivestym

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Nexium Gastrointestinal Agents esomeprazole, lansoprazole, omeprazole, pantoprazole, Dexilant

Nilandron Cancer abiraterone, bicalutamide, Xtandi, Yonsa

Norditropin Growth Hormone Genotropin, Humatrope

Noritate Dermatology azelaic aicd gel, metronidazole, Finacea Foam, Soolantra

Norvasc High blood pressure amlodipine

Novacort Dermatology desonide, hydrocortisone

NuDiclo SoluPak Analgesics/NSAID diclofenac sodium, diclofenac sodium gel 1% (except NDC 69499031866), diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

NuDiclo TabPak Analgesics/NSAID diclofenac sodium, diclofenac sodium gel 1% (except NDC 69499031866), diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Nutropin AQ Growth hormones Genotropin, Humatrope

Nuvigil Sleep apnea, Narcolepsy armodafinil, Sunosi

Oleptro Depression trazodone

Olux-E Dermatology clobetasol foam

omeprazole sodium bicarbonate (generic Zegerid)

Gastrointestinal agents esomeprazole, lansoprazole, omeprazole, pantoprazole, Dexilant

Omnaris Allergies flunisolide spray, fluticasone spray,

mometasone spray, Dymista

Omnitrope Growth hormones Genotropin, Humatrope

Onexton Topical Derm Acne adapalene, benzoyl peroxide, clindamycin gel, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, Epiduo, Tazorac

Onfi Anticonvulsant clobazam, lamotrigine, topiramate, Trokendi XR

Onglyza Diabetes Januvia

Orencia Clickjet, Orencia Intravenous, Orencia Subcutaneous

Rheumatoid Arthritis Cosentyx, Enbrel, Humira, Otezla, Rinvoq, Stelara Subcutaneous, Xelijanz, Xelijanz XR

OrthoTricyclen Lo Contraceptive ethinyl estradiol-norgestimate

Orthovisc Osteoarthritis Durolane, Gel-One, Gelsyn-3, Supartz FX, Visco-3

Oseni Diabetes Janumet, Janumet XR,

Osmoprep Laxative peg 3350-electrolytes, Suprep

Oxycontin Pain fentanyl transdermal, hydromorphone ext-rel, methadone, morphine ext-rel, Embeda, Nucynta ER, Xtampza ER

Oxytrol Overactive bladder darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, Myrbetriq, Toviaz

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Pennsaid Pain and inflammation diclofenac sodium, diclofenac sodium

solution, diclofenac sodium 1% gel,

ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Percocet Pain hydrocodone-acetaminophen,

hydromorphone, morphine,

oxycodone-acetaminophen, Nucynta

Plavix Hematologic clopidogrel, prasugrel, Brilinta

Plegridy Multiple Sclerosis glatiramer, Aubagio, Betaseron, Copaxone 40 MG, Gilenya, Mayzent, Rebif, Tecfidera, Tysabri

Polytoza Dermatology Consult doctor

Pradaxa Hemotologic warfarin, Eliquis, Xarelto

Praluent Lipid Disorders – PCSK9 Inhibitors Repatha

Pred Forte Ophthalmic/Anti-inflammatories/Steroidal dexamethasone, loteprednol, prednisolone acetate 1%, Durezol, FML Forte, FML S.O.P., Maxidex, Pred Mild

Prevacid Gastrointestinal agents esomeprazole, lansoprazole, omeprazole, pantoprazole, Dexilant

Prevident Dental Consult doctor

Primlev Pain hydrocodone-acetaminophen, hydromorphone, morphine, oxycodone-acetaminophen, Nucynta

Pristiq Depression desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule

Proair HFA/Proair Respiclick Asthma albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol

Procrit Anemia Aranesp, Retacrit

Protonix Gastrointestinal agents esomeprazole, lansoprazole, omeprazole, pantoprazole, Dexilant

Proventil HFA Asthma albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol

Prozac Depression citalopram, escitalopram, fluoxetine, paroxetine HCI, paroxetine HCI ext-rel, sertraline, Trintellix, Viibryd

Psorcon Cre 0.05% Topical Dermatology desoximetasone, fluocinonide (except fluocinonide creat 0.1%)

Qnasl Allergies flunisolide spray, fluticasone spray, mometasone spray, Dymista

Qsymia Anti-Obesity Belviq, Belviq XR, Saxenda

Qtern Diabetes Glyxambi

Rapaflo Benign Prostatic hyperplasia alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin

Rayos Pain and inflammation dexamethasone, hydrocortisone, methylprednisolone solution, prednisone solution, prednisone Recedo Scar Treatment Consult doctor

Rimso-50 Interstitial cystitis Consult doctor

Riomet Diabetes (oral medication) metformin, metformin ext-rel (except generic Fortamet or Glumetza)

Rozerem Hypnotics eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, Belsomra, Silenor

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Ryclora Allergies levocetirizine

Sabril Anticonvulsant vigabatrin

Saizen Growth hormones Genotropin, Humatrope

Scarsilk Dermatology Consult doctor

Seroquel XR Antipsychotic aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, Latuda, Vraylar

Sil-K Pad Scar Treatment Consult doctor

Silivex Dermatology Consult doctor

Siltrex Dermatology Consult doctor

Simponi Rheumatoid Arthritis Cosentyx, Enbrel, Humira, Otezla, Rinvoq, Stelara subcutaneous, Xelijanz, Xelijanz XR

Singular Asthma montelukast, zafirlukast, zileuton ext-rel

Sorilux Antipsoriatics calcipotriene ointment, calcipotriene solution

Sprix Pain diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or suspension)

Stendra Erectile Dysfunction sildenafil, tadalafil

Suboxone Opioid Dependency buprenorphine-naloxone sublingual, Zubsolv

Synerderm Emulsion Dermatology desonide, hydrocortisone

Synvisc/Synvisc One Osteoarthritis Durolane, Gel-One, Gelsyn-3, Supartz FX, Visco-3

Taltz Plaque Psoriasis Cosentyx, Enbrel, Humira, Otezla, Skyrizi, Stelara Subcutaneous, Xelijanz, Xelijanz XR

Targadox Anti-infective doxycycline hyclate, minocycline, tetracycline

Tasigna Cancer imatinib mesylate, Bosulif, Sprycel

Taytulla Contraceptive ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron

Testim Testosterone Replacement testosterone gel 2%, testosterone solution, Androderm

testosterone gel 1% Testosterone Replacement testosterone gel 2%, testosterone solution, Androderm

Timoptic Ocudose Ophthalmic timolol maleate solution, Betimol, Betoptic S

Tirosint Thyroid Agents levothyroxine, Synthroid

Tobi / Tobi Podhaler Cystic Fibrosis tobramycin inhalation solution, Bethkis

Toprol XL High blood pressure atenolol, carvedilol, carvedilol

phosphate ext-rel, metoprolol succinate

ext-rel, metoprolol tartrate, nadolol,

pindolol, propranolol, propranolol ext-rel,

Bystolic

Toujeo Diabetes Tresiba

Tradjenta Diabetes Januvia

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Transderm-Scop Antiemetic meclizine, scopolamine transdermal

Tricor Cardiovascular fenofibrate (except fenofibrate tablet 120mg) fenofibric acid del-rel

Tudorza Chronic obstructive pulmonary disease (COPD)

Incruse Ellipta, Spiriva

Uroxatral Benign Prostatic hyperplasia alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin

Valcyte Anti-Infective, Antivirals valganciclovir

Valtrex Anti-infective, Antivirals acyclovir capsule, acyclovir tablet, valacyclovir

Vanatol LQ/Vanatol S Pain diclofenac sodium, ibuprofen, naproxen (except naproxen CR or suspension)

Vanoxide-HC Acne vulgaris adapalene, benzoyl peroxide, clindamycin gel, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, Epiduo, Tazorac

Vectical Oin 3mcg/gm Topical Dermatology calcipotriene ointment, calcipotriene solution

Veltin Topical Derm Acne adapalene, benzoyl peroxide, clindamycin gel, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, Epiduo, Tazorac

venlafaxine ext-rel tablet (except 225 mg) Depression desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule,

Ventolin HFA Asthma albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol

Veregen Dermatology imiquimod

Viagra Erectile Dysfunction sildenafil, tadalafil

Viekira Pak Hepatitis Epclusa, Harvoni

Vivelle-Dot Estrogen replacement estradiol, Divigel, Evamist

Vogelxo Testosterone replacement testosterone gel 2%, testosterone solution, Androderm

Xanax, Xanax XR Anxiety alprazolam, clonazepam, diazepam, lorazepam, oxazepam

Xenazine Huntington’s Disease Agents tetrabenazine, Austedo

Xolegel Topical Dermatology ciclopirox, ketoconazole

Xopenex HFA Asthma albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol

Yaz Contraceptive ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron

Zarxio Hematologic Nivestym

Zemaira Pulmonary Enzyme Deficiency Prolastin-C

Zegerid Gastrointestinal Agents esomeprazole, lansoprazole, omeprazole, pantoprazole, Dexilant

Zepatier Anti-infectives, Antivirals Epclusa, Harvoni

Zetia High Cholesterol ezetimibe

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Zetonna Allergies flunisolide spray, fluticasone spray,

mometasone spray, Dymista

Ziana Topical Derm Acne adapalene, benzoyl peroxide,

clindamycin gel, clindamycin

solution, clindamycin-benzoyl

peroxide, erythromycin solution,

erythromycin-benzoyl peroxide, tretinoin, Epiduo, Tazorac

Zohydro ER Pain fentanyl transdermal,

hydromorphone ext-rel,

methadone, morphine ext-rel,

Embeda, Nucynta ER, Xtampza ER

Zolpimist Sleep disorders eszopiclone, ramelteon, zolpidem

ext.-rel., zolpidem sublingual, Belsomra, Silenor

Zonegran Epilepsy carbamazepine, carbamazepine

ext–rel, divalproex sodium, divalproex sodium ext-rel,

gabapentin, lamotrigine,

lamotrigine ext. rel, levetiracetam,

levetiracelam ext-rel,

oxcarbazepine, phenobarbital,

phenytoin, phenytoin sodium extended, primidone, tiagabine,

topiramate, valproic acid,

zonisamide, Fycompa, Oxtellar

XR, Trokendi XR, Vimpat

Zontivity Hematologic Consult doctor

Zorvolex Pain diclofenac sodium, ibuprofen, meloxicam, naproxen (except

naproxen CR or suspension)

Zuplenz Antiemetic granisetron, ondansetron, Sancuso

Zylet Ophthalmic neomycin-polymyxin B-bacitracin-

hyrocortisone, neomycin-polymyxin

B-dexamethasone, tobramycin-dexamethasone, Tobradex

Ointment, Tobradex St

Zytiga Prostate cancer abiraterone, bicalutamide, Xtandi, Yonsa

*Lowercase alternative drugs indicate generic. Initial capitalized drugs indicate brand

Prior Authorizat ion Process on Formulary Drugs and supp l ies with Clinically Effect ive Alternatives

Aut h o r i z a t i o n P r o c e s

1. Upon receipt of a prescription for one of the above listed drugs or supplies, the pharmacist will be provided a list of

available alternatives.

2. The pharmacist will call your physician to discuss changing the prescription to an alternative.

3. If there is a medical reason that you cannot take an available alternative, your physician must call CVS Caremark at

855-240-0536.

4. CVS Caremark will evaluate the information received based on clinical criteria.

App r o v a l

After approval is received, the claim will process electronically at the pharmacy and a letter will be sent to you and your

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physician indicating the approval and the time period for the approval.

Den i a l

If denied, a letter is sent to both you and your physician. The denial letter will outline directions on how to appeal the decision.

Specialty Guideline Management

Specialty Guideline Management is a program that supports safe, clinically appropriate and cost-effective use of specialty

medications. The following specialty medications require prior authorization.

Specialty Drug Class Drug Names

Acromegaly octreotide (Sandostatin), Sandostatin LAR Depot, Signifor LAR Somatuline Depot, Somavert

Allergic Asthma Cinquair, Fasenra, Nucala, Xolair

Alpha-1 Antitrypsin (AAT) Deficiency Aralast NP, Glassia, Prolastin-C Zemaira

Amyloidosis Onpattro, Tegsedi, Vyndamax, Vyndaqel

Anemia Aranesp, Epogen, Mircera, Procrit, Retacrit

Atopic Dermatitis Dupixent

Bone Disorders Strensiq

Botulinum Toxins Botox, Dysport, Myobloc, Xeomin

Cardiac Disorders Tikosyn

Central Precocious Puberty (CPP) leuprolid, Lupron Depot-PED, Supprelin LA

Cryopyrin-Associated Periodic Syndromes (CAPS) Arcalyst, Ilaris, Kineret

Cushing’s Syndrome Korlym, Signifor

Cystic Fibrosis (CF) Bethkis, Cayston, Kalydeco, Kitabis Pak, Orkambi, Pulmozyme, TOBI Podhaler, Symdeko, tobramycin inhalation solution (TOBI), Trikafta

Electrolyte Disorders Keveyis, Samsca Gastrointestinal Disorders - Other Cholbam, Gattex, Ocaliva, Zorbtive

Gout Krystexxa

Growth Hormone (GH) and Related Disorders Genotropin, Humatrope, Increlex, Norditopin, Nutropin/Nutropin AQ, Omnitrope, Saizen, Zomacton

Hematopoietics Mozobil, Neumega

Hemophagocytic Lymphohistiocytosis Gamifant

Hemophilia and Related Bleeding Disorders Advate, Adynovate, Afstyla, Alphanate, AlphaNine SD, Alproloix, Bebulin VH, BeneFIX, Coagadex, Eloctate, Feiba NF, Helixate FS, Hemlibra,Hemofil M, Humate-P, I d e l v i o n , I x i n i t y , J i v i , Koate-DVI, Kogenate FS, Kovaltry, Monoclate-P, Mononine, Novoeight, NovoSeven, Nuwiq, Obizur, Profilnine SD, Recombinate, Rixubis, Stimate Nasal Spray, Vonvendi, Wilate, Xyntha

Hepatitis C Daklinza, Epclusa, Harvoni, Mavyret, Olysio, Pegasys, Ribavirin (ribavirin capsules/tablets), Copegus, Moderiba, Rebetol, Ribasphere, Ribasphere Ribatab, Sovaldi, Technivie, Viekira Pak, Viekira XR, Vosevi, Zepatier

Hereditary Angioedema (HAE) Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro Hormonal Therapies Aveed, Eligard, Firmagon, leuprolide, Lupaneta Pack, Lupron

Depot, Natpara, Trelstar, Triptodur, Vantas, Zoladez

Human Immunodeficiency Virus (HIV) Egrifta, Serostim

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Immune Deficiencies and related disorders Cutaquig, Panzyga

Immune Therapies Asceniv, Bivigam, Carimune NF, Cuvitru, GamaSTAN S/D, Gammagard, Gammaked, Gammaplex, Gamunex, Hizentra, HyQvia, Octagam, Privigen, Xembify

Immune (Idiopathic) Thrombocytopenia (ITP Nplate, Promacta, Tavalisse

Infectious Disease Actimmune

Infertility Bravelle, Cetrotide, chorionic gonadotropin (Novarel, Ovidrel, Pregnyl), Follistim AQ, ganirelix acetate, Gonal-F, leuprolide, Menopur, Repronex

Inflammatory Bowel Disease (IBD) Cimzia, Entyvio, Humira, Inflectra, Remicade, Renflexis, Simponi, Stelara, Tysabri

Iron Overload deferoxamine (Desferal), Exjade, Ferriprox, Jadenu

Lambert-Eaton myasthenic syndrome Firdapse

Lipid Disorders Juxtapid, Kynamro,Repatha

Lipodystrophy Myalept

Lysosomal Storage Disorders (LSD) and Related Disorders

Adagen, Aldurazyme, Cerdelga, Cerezyme, Cystagon, Cystaran, Elaprase, Elelyso, Fabrazyme, Galafold, Kanuma, Lumizyme, Mepsevii, Naglazyme, Nityr, Orfadin, Procysbi, Vimzim, VPRIV, Zavesca

Mental Health Spravato, Zulresso

Movement Disorders Apokyn, Austedo, Inbrija, Ingrezza, Northera, Nuplazid, Radicava, Soliris, Xenazine

Multiple Sclerosis (MS) Ampyra, Aubagio, Avonex, Betaseron, Copaxone, Extavia, Gilenya, Glatopa, Lemtrada, Mavenclad, Mayzent, mitoxantrone, Ocrevus, Plegridy, Rebif, Tecfidera, Tysabri

Muscular Dystrophy Emflamza, Exondys 51

Neutropenia Fulphila, Granix, Leukine, Neulasta, Neupogen, Nivestyn, Udenyca, Zarxio

Ocular Disorders Beovu, Oxervate

Oncology Adcetris, Afinitor, Alecensa. Aliqopa, Alunbrig, Arzerra, Asparlas, Avastin, azacitidine (Vidaza), Balversa, Bavencio, Beleodaq, Bendeka, Blincyto, Bosulif, capecitabine (Xeloda), Braftovi, Caprelsa, Cabometyx, Calquence, Cometriq, Copiktra, Cotellic Cyramza, Darzalex, Daurismo, decitabine (Dacogen), Elzonris, Empliciti, Erbitux, Erivedge, Erleada, Erwinaze, Farydak, Folotyn, Fusilev, Gazyva, Gilotrif, Gleevec, Halaven, Herceptin, Hycamtin Capsules, Ibrance, Iclusig, Idhifa, Imbruvica, Imfinzi, Imlygic, Inlyta, Inrebic, Intron-A, Iressa, Istodax, Ixempra, Jakafi, Jevtana, Kadcyla, Kanjinti, Keytruda, Khapzory, Kisquali, Kyprolis, Lartruvo, Lenvima, Libatyo, Lonsurf, Lorbrena, Lumoxiti, Lynparza, Mekinist, Mektovi, mitroxantrone, Mvasi, Mylotarg, Nerlynx, Nexavar, Ninlaro, Nubeqa, Odomzo, Ogivri, Oncaspar, Opdivo, Perjeta, Piqray, Polivy, Pomalyst, Portrazza, Poteligeo, Proleukin, Revlimid, Rituxin, Rituxin Hycela, Rozlytrek, Rubraca, Rydapt, Sprycel, Stivarga, Sutent, Sylatron, Sylvant, Synribo, Tafinlar, Tagrisso, Talzenna, Tarceva, Targretin, Tasigna, Tecentriq, temozolomide (Temodar), Thalomid, Tibsovo, Torisel, Treanda,Truxima, Turalio, Tykerb, Valchlor, Vectibix, Velcade, Venclexta, Verzenio, Vitrakvi, Vizimpro, Votrient, Xalkori, Xermelo, Xospata, Xgeva, Xtandi, Yervoy, Yonsa, Zaltrap, Zejula, Zelboraf, zoledronic acid (Zometa), Zolinza, Zydelig, Zykadia, Zytiga

Osteoarthritis (OA) Euflexxa, Gel-One, Gelsyn-3, Genvisc-850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz, Synvisc/Synvisc One, Triluron, Visco-3

Osteoporosis Evenity, Forteo, Prolia, Tymlos, zoledronic acid (Reclast)

Paroxysmal Nocturnal Hemoglobinuria (PNH) Soliris

Phenylketonuria (PKU) Kuvan, Palynziq, Ultomiris

Pre-term Birth Makena

Psoriasis Cosentyx, Enbrel, Humira, Ilumya, Inflectra, Otezla, Otrexup, Rasuvo, Remicade, Renflexis, Siliq, Skyrizi, Stelara, Taltz, Tremfya

20

NC2021-35 (4/20)

Pulmonary Arterial Hypertension (PAH) Adcirca, Adempas, Alyq, epoprostenol (Flolan), Letairis, Opsumit, Orenitram, Remoudlin, sildenafil (Revatio), Tracleer, Tyvaso, Uptravi, Veletri, Ventavis

Pulmonary Disorders - Other Esbriet, Ofev

Rare Disorders Ruzurgi

Renal Disorders Jynarque, Parsabiv, Sensipar

Respiratory Syncytial Virus (RSV) Synagis

Retinal Disorders Avastin, Eylea, Lucentis,

Rheumatoid Arthritis (RA) Actemra, Cimzia, Enbrel, Humira, Inflectra, Kevzara, Kineret, Olumaiant, Orencia, Otrexup, Rasuvo, Remicade, Renflexis, Rinvoq, Rituxan, Simponi, Simponi Aria, Xelijanz, Xelijanz XR

Seizure Disorders Acthar, Epilodex, Sabril

Sickle Cell Disease Endari

Sleep Disorders Hetlioz, Wakik

Systemic Lupus Erythamatosus Benlysta

Thrombocytopenia Cablivi

Urea Cycle Disorders Buphenyl, Carbaglu, Ravicti

21