Prior Authorization Guidelines and Statistics
Adalimumab (Humira) Humira Biosimilars
Age Limit Override for Codeine, Tramadol, Hydrocodone
Amantadine ER (Gocovri, Osmolex)
Amifampridine (Firdapse, Ruzurgi)
Anti-inhibitor Coagulation Complex (Feiba)
Antithrombin III (ATryn, Thrombate III)
Antithymocyte globulin (Atgam, Thymoglobulin)
Aripiprazole for oral use (Abilify)
Aripiprazole Inj (Abilify Maintena, Aristada)
Avalglucosidase alfa-ngpt (Nexviazyme)
Belantamab mafodotin (Blenrep)
Bempedoic acid, bempedoic acid/ezetimibe (Nexletol, Nexlizet)
Bendamustine (Belrapzo, Bendeka, Treanda)
Betibeglogene autotemcel (Zynteglo)
Bevacizumab (Avastin, Alymsys, Mvasi, Vegzelma, Zirabev)
Bexarotene (Targretin Capsules, Gel)
Brexucabtagene autoleucel (Tecartus)
Buprenorphine implant/injection (Probuphine, Sublocade)
Buprenorphine injection (Brixadi)
Buprenorphine-naloxone (Bunavail, Suboxone, Zubsolv)
Cabozantinib (Cometriq, Cabometyx)
Carbidopa-levodopa ER capsules (Rytary)
Ciltacabtagene Autoleucel (Carvykti)
Collagenase clostridium (Xiaflex)
Corticosteroid for Ophthalmic Injection (Iluvien, Ozurdex, Retisert, Xipere, Yutik)
Corticotropin (HP Acthar, Purified Cortropin Gel)
Cyclosporine ophthalmic emulsion (Verkazia)
Cysteamine (Cystagon, Procysbi)
Dasabuvir-Ombitasvir-Paritaprevir-Ritonavir (Viekira XR, Pak)
Daunorubicin-cytarabine (Vyxeos)
Decitabine-Cedazuridine (Inqovi)
Desmopressin (DDAVP, Stimate, Noctiva)
Dextromethorphan/bupropion (Auvelity)
Diazepam nasal spray (Valtoco)
Dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity), monomethyl fumarate (Bafiertam)
Efgartigimod alfa-fcab (Vyvgart)
Elagolix (Orilissa), elagolix-estradiol-norethindrone (Oriahnn)
Elbasvir-Grazoprevir (Zepatier)
Elexacaftor-ivacaftor-tezacaftor (Trikafta)
Elivaldogene autotemcel (Skysona)
Enfortumab Vedotin-ejfv (Padcev)
Epoetin alfa (Epogen, Procrit), Epoetin alfa-epbx (Retacrit)
Epoprostenol (Flolan, Veletri)
EPSDT Benefit for Pediatric Members
Erwinia Asparaginase (Erwinaze, Rylaze)
Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest)
Factor VIIa, recombinant (NovoSeven RT, SevenFact)
Factor XIII A-subunit, Recombinant (Tretten)
Factor VIII-von Willebrand (Alphanate, Humate-P, Wilate)
Factor IX Complex, Human (Bebulin, Profilnine)
Fam-trastuzumab deruxtecan-nxki (Enhertu)
Fibrinogen concentrate (human) (Fibryga, RiaSTAP)
Filgrastim (Tbo-, -sndz, -aafi, -ayow) (Neupogen, Zarxio, Granix, Nivestym, Releuko)
Fingolimod (Gilenya, Tascenso ODT)
Latanaprostene bunod (Vyzulta)
Ledipasvir-Sofosbuvir (Harvoni)
Leuprolide acetate (Lupron, Lupron Depot, Eligard, Lupaneta Pack, Fensolvi, Camcevi)
Levoleucovorin (Fusilev, Khapzory)
Lidocaine transdermal (Lidodermn, ZTlido)
Lisocabtagene maraleucel (Breyanzi)
Loteprednol etabonate (Eysuvis)
Medical Necessity for Drug not on PDL
Melphalan flufenamide (Pepaxto)
Metformin ER (Fortamet, Glumetza)
Methotrexate (Otrexup, Rasuvo, Reditrex, Xatmep)
Methoxy Polyethylene Glycol-epoetin Beta (Mircera)
Methylnaltrexone bromide (Relistor)
Methylphenidate ER (Aptensio XR, Cotempla XR-0DT)
Metronidazole Vaginal Gel (Nuvessa)
Minocycline ER (Solodyn) and Microspheres (Arestin)
Mitomycin for Pyelocalyceal Solution (Jelmyto)
Paclitaxel Protein-Bound (Abraxane)
Paliperidone for Injection (Invega Hayfera, Invega Sustenna, Invega Trinza)
Pasireotide (Signifor, Signifor LAR)
Peanut Allergen Powder (Palforzia)
Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas)
Pegcetacoplan (Empaveli, APL-2)
Pegfilgrastim (Neulasta and biosimilars)
Peginterferon alfa-2a, b (Pegasys Peg-intron)
Peginterferon beta-1a (Plegridy)
Pertuzumab/trastuzumab/hyaluronidase-zzxf (Phesgo)
Phendimetrazine (Bontril SR, Bontril PDM)
Phentermine (Apidex-P, Lomaira)
Phentermine-topiramate (Qsymia)
Polatuzumab vedotin-piiq (Polivy)
Ranibizumab (Lucentis, Susvimo), Lucentis Biosimilars
Relugolix (Orgovyx), elagolix-estradiol-norethindrone (Myfembree)
Ribavirin (Rebetol, Ribasphere)
Ribociclib (Kisqali, Kiswala Femara)
Rifabutin (Mycobutin), Rifabutin, Omeprazole, Amoxicillin (Talicia)
Risperidone for Injection (Risperdal Consta)
Rituximab (Rituxan, Riabni, Ruxience, Truxima, Rituxan Hycela)
Sacituzumab govitecan-hziy (Trodelvy)
Short ragweed pollen allergen extract (Ragwitek)
Sirolimus protein-bound particles (Fyarro), topical gel (Hyftor)
Sodium-glucose co-transporter 2 (SGLT) inhibitors
Sodium oxybate (Xyrem) and Calcium Magnesium Potassium Sodium Oxybate (Xywav)
Sodium phenylbutyrate (Buphenyl, Pheburane)
Sofosbuvir-Velpatasvir (Epclusa)
Sofosbuvir-Velpatasvir-Voxilaprevir (Vosevi)
Somatropin (human growth hormone)
Tadalafil (Adcirca, Alyq, Tadliq)
Tafamidis (Vyndaqel, Vyndamax)
Tafenoquine (Arakoda, Krintafel)
Talimogene laherparepvec (Imlygic)
Tasimelteon (Hetlioz, Hetlioz HQ)
Tezacaftor-ivacaftor (Symdeko)
Timothy grass pollen (Grastek)
Tisotumab vedotin-tftv (Tivdak)
Tobramycin (Kitabis Pak, TOBI, TOBI Podhaler)
Tofacitinib (Xeljanz, Xeljanz XR)
Trastuzumab, Biosimilars, Trastuzumab-Hyaluronidase
Treprostinil (Orenitram, Remodulin, Tyvaso)
Triamcinolone ER Injection (Zilretta)
Trifluridine-tipiracil (Lonsurf)