Table of Contents

90 Day Generic Med List (eff. 5-18-14)

Prior Authorization Med List

Interim Prior Authorization List

Maximum Units Med List

Preferred Drug List (eff. 3-15-15)​

General Medication Prior Authorization Form

General Medication Prior Authorization Fill-in

Information About Your Prescription Drug Benefits and Prior Authorization - Pamphlet

Prior Authorization Medication Categories

• Analgesics, non-opioid
• Analgesics, opioid & reversal agents
  
• Antipsychotics
• Biologics
• Cystic Fibrosis
• Gastrointestinal
• Genitourinary
• Growth Hormones
• Hemophilia
• Hormones
• Infectious disease
• Lipotropics
• Metabolic
• Opioid dependence
• Pulmonary Arterial Hypertension (PAH)
• Respiratory (Asthma, COPD, Allergy)
• Skeletal muscle relaxants
• Other, including retired criteria

Navigation Tips:
1. Use the table of contents above to jump to the desired medication category, or
2. Use “CTRL-F” to open a search box into which you can type your search term, or
3. Scroll through the list below to find the desired medication.
4. Clicking on the [PDL] link in the medication category header will open a new window with the current Preferred Drug List to allow you to readily search for preferred products within the category.
5. Clicking on the [TOP] link in the medication category header will bring you back to the Table of Contents at the top of this page. 

Prior Authorization Medication Categories

​Medication
​ANALGESICS, NON-OPIOID [PDL] [TOP]	​Criteria	​Form(s)
Lidoderm (lidocaine) patch	​PDF Effective thru 10/2/16	​​Form
Lidoderm (lidocaine) patch	​PDF Effective 10/3/16	​​Form
​Lyrica (pregabalin)	PDF​	​Form
​​Vimovo	​PDF	​​Form
​	​	​
​ANALGESICS, OPIOID & REVERSAL AGENTS [PDL] [TOP]	​Criteria	​Form(s)
​Additional Information for Prescribing Opioids	​	​
​Extended Release Opioids (generic morphine SR and generic fentanyl patch do not require PA)	​PDF Effective thru 10/2/16	Form
Extended Release Opioids (generic morphine ER, generic fentanyl patch, & Butrans patch do not require PA)	​PDF Effective 10/3/16	Form
​Actiq (fentanyl)	​PDF	​Form
​Fentora	​PDF	​​Form
​Hydromorphone	​PDF	​​​Form
​Onsolis (fentanyl) – to be retired	​PDF	​​Form
​Oxycodone, immediate release	​PDF	​​Form
​Rybix ODT	​​PDF	​​Form
​Stadol (LTC, Onc, Hospice override)	​PDF	​​Form
Subsys	​PDF	​Form Fill-in
Narcan Nasal Spray: Naloxone Opioid Overdose Treatment	​PDF	​​Form
​Evzio: Naloxone Opioid Overdose Treatment	​PDF	​Form
​	​	​
ANTIPSYCHOTICS [PDL] [TOP]	​Criteria	​Form(s)
Atypical Antipsychotic Therapeutic Duplication	​PDF	​Form
Atypical Antipsychotic – Exceed Quantity Limit (QL)	​	​Form
Atypical Antipsychotic – Child Less than 5 years old	​	​Form
	​	​​
BIOLOGICS [PDL] [TOP]	​Criteria	​Form(s)
​Cosentyx	PDF​	​Form
​Lemtrada	​PDF	​Form
Stelara [CAM]	​PDF	​​Form
​Synagis, 2015-2016	​PDF	Form​​
Synagis, 2014-2015	​PDF	​Form
​Synagis, 2016-2017	PDF​	​
​	​	​​
CYSTIC FIBROSIS ​[PDL] [TOP]	​Criteria	​Form(s)
Kalydeco	​PDF Effective thru 10/2/16	​​Form
Kalydeco	​PDF Effective 10/3/16	​​Form
​Orkambi	​PDF	​Form
TOBI Podhaler	PDF​	​​Form
	​	​
GASTROINTESTINAL [PDL] [TOP]	​Criteria	​Form(s)
Amitiza and Linzess	​PDF	​​Form
​Marinol	​PDF	​​Form
​Diclegis	​PDF	​​​Form
H. pylori kits	​PDF	​​Form
​Movantik	​PDF	​Form
​Proton Pump Inhibitors	​PDF	​Form
​Relistor (methylnaltrexone)	​PDF	​​Form
​Transderm Scop (scopolamine patch)	​PDF	​​Form
​	​	​
GENITOURINARY [PDL] [TOP]	​Criteria	​Form(s)
Botulinum Toxin Products (JCode only)	​PDF Effective thru 10/2/16	Form​ Service Auth
Botulinum Toxin Products (JCode only)	​PDF Effective 10/3/16	Form​ Service Auth
Cialis	​PDF	​​Form
	​
GROWTH HORMONES [PDL] [TOP]	​Criteria	​Form(s)
​Human Growth Hormone		​Form​​​
​Human Growth Hormone	PDF Effective 10/3/16	​Form​​​
Serostim	​PDF Effective thru 10/2/16	​​Form
Serostim	​PDF Effective 10/3/16	​​Form
​	​	​
HEMOPHILIA [PDL] [TOP]	​Criteria	​Form(s)
​Hemophilia / Clotting Factor	​	​Form
​	​	​
HORMONES [TOP]	​Criteria	​Form(s)
​Egrifta	​PDF	​​Form
​​H.P. Acthar Gel	​PDF Effective thru 10/2/16	​​Form
​​H.P. Acthar Gel	​PDF Effective 10/3/16	​​Form
​​Human Chorionic Gonadotropin (HCG)	​PDF	​​Form
Makena	PDF	​​​Form
​	​	​
INFECTIOUS DISEASE [PDL] [TOP]	​Criteria	​Form(s)
Bactroban cream	​PDF	​​Form
​Direct Acting Antivirals for Hepatitis C Genotype 1	​PDF​ Effective 7/1/16	Form​
​Direct Acting Antivirals for Hepatitis C Genotype 2, 3, 5, & 6	​PDF Effective 7/1/16	Form​
​Direct Acting Antivirals for Hepatitis C Genotype 4	PDF​ Effective 7/1/16	Form​
​Nizoral (ketoconazole oral)	​PDF	​​​Form
Noxafil (posaconazole)	​PDF	​​Form
Quinine	​PDF	​​Form
Vancocin (vancomycin)	​​PDF	​​Form
Xifaxan (rifaximin)	​PDF Effective thru 10/2/16	​​Form
Xifaxan (rifaximin)	​PDF Effective 10/3/16	​​Form
​​Zyvox (linezolid)	​PDF	​Form
​	​	​
LIPOTROPICS [PDL] [TOP]	​Criteria	​Form(s)
Juxtapid and Kynamro	​PDF	​​Form
​Lovaza – to be retired	​PDF	​​Form
​PCSK9 Inhibitors (Praluent and Repatha)	​PDF	​Form
​Statins (HMG CoA Reductase Inhibitors)	​PDF	​​​Form
Vascepa and Lovaza	​PDF	​​Form
​	​	​
METABOLIC [PDL] [TOP]	​Criteria	​Form(s)
Bone Resorption Inhibitors	​PDF	​​Form
​Ergocalciferol (Vitamin D; 50,000 unit)	​PDF, PDF	​​Form
Invokana	​PDF	​​​Form
Korlym	​PDF	​​Form
Leuprolide	​PDF	​​Form
​Extended-Release Metformin (Glumetza and Fortamet ER)	​PDF	​Form
		​
OPIOID DEPENDENCE [PDL] [TOP]	​Criteria	​Form(s)
Suboxone and Subutex	​PDF	​Form Fill-in
	​	​​
PULMONARY ARTERIAL HYPERTENSION [PDL] [TOP]	​Criteria	​Form(s)
Adcirca	​PDF	​​Form
​Revatio	​PDF	​​Form
	​	​​
RESPIRATORY [PDL] [TOP]	​Criteria	​Form(s)
Daliresp [COPD]	​PDF	​​Form
Long-acting Beta Agonist [BRONCHODILATORS]	​PDF	​​Form
Second Generation Non-Sedating Antihistamines	​PDF	​​​Form
​	​	​
SKELETAL MUSCLE RELAXANTS [PDL] [TOP]	​Criteria	​Form(s)
Amrix	​PDF	​​Form
Fexmid	​PDF	​​Form
Soma	​PDF	​​​Form
Zanaflex	​PDF	​​Form
​	​	​
OTHER, INCLUDING RECENTLY RETIRED CRITERIA [PDL] [TOP]	​Criteria	​Form(s)
​New Prescription Medications	PDF​	​​Form
Maximum Units (QL)	​PDF​	​​Form
Brand Name Multisource Medications	​PDF	​​​Form
Botulinum Toxin Products (JCode only)	​PDF	Form​ Service Auth
​Onfi [ANTICONV]	​PDF	​​Form
​Vecamyl (HTN)	​PDF	​​Form
​Berinert (HAE)	​PDF	​​Form
​Cinryze (HAE)	​PDF	​​Form
​Firazyr (HAE)	​PDF	​​Form
​Ampyra [MS]	​PDF	​​Form
​Celebrex [NSAID]	​PDF	​​Form
​Imbruvica (ONC)	​PDF	​​Form
​Panretin (ONC)	​PDF	​​Form
​Zydelig (ONC)	​PDF	​​Form
​Tecfidera (dimethyl fumarate)	​PDF	​Form
​Belsomra	​PDF	​Form
​	​	​
​Onsolis (fentanyl) – to be retired	​PDF	​
​Vitamin E (retired)	PDF​	​
​Calcium (retired)	​PDF	​
​Magnesium (retired)	​PDF	​
​Victrelis (retired)	​PDF	​
Folic acid 1mg (retired)	​PDF	​
Eliquis (retired)	​PDF
​Pradaxa (retired)	​PDF	​
​Xarelto (retired)	​​PDF	​
​Direct Acting Antivirals for Hepatitis C (retired) – Effective through 1/15/2015	PDF Update​	​
​Direct Acting Antivirals for Hepatitis C Genotype 1 (retired) – Effective through 6/30/2015	​PDF Effective thru 6/30/15	​
​Direct Acting Antivirals for Hepatitis C Genotype 1 (retired) - Effective through 6/30/2016	​PDF Effective thru 6/30/16	​
​Direct Acting Antivirals for Hepatitis C Genotypes 2, 3, 4 (retired) – Effective through 6/30/2016	​PDF Effective thru 6/30/16	​
​Extended Release Opioids (Historical) (generic morphine SR and generic fentanyl patch do not require PA)	​PDF	​Form Fill-in
​	​	​