Drug Therapy Guidelines

Our prescription drug and medical injectable policies promote safe and effective use by helping physicians select the drug product(s) considered most beneficial to their patients. In order to ensure thorough consideration of both quality-of-care and economic issues, some drugs require prior authorization to be covered under a member's prescription drug or medical benefit. We work with a committee of local physicians and pharmacists to identify medications that should require prior authorization and to develop the medical criteria used to determine when coverage for these agents is appropriate.

Prior authorization is required for injectable medications, including self-administered injectable medications except insulin, glucagon, self-administered epinephrine and injectable chemotherapeutic agents when not available in a physician's office. The following is a complete list of medications requiring prior authorization and their committee-approved criteria.

Abbreviated Criteria
Abbreviated Criteria: Austedo, Carbaglu, Chenodal, Cholbam, Dificid, Gralise, Hetlioz, Jetrea, Kanuma, Keveyis, Nuedexta, Nuplazid, Rayos, Strensiq, Sylvant, Syprine, Trelstar, Versacloz, Xatmep, Xenazine, Xuriden, Zontivity
Actemra
Actemra® (tocilizumab)
Actimmune
Actimmune® (interferon gamma 1b)
Adcetris™
Adcetris™ (brentuximab vedotin)
Addyi
Addyi TM (flibanserin)
Afinitor
Afinitor® (everolimus)
Afrezza
Afrezza® (insulin human)
Alecensa
Alecensa® (alectinib)
Alimta
Alimta® (pemetrexed)
Alunbrig
Alunbrig TM(brigatinib)
Ampyra
Ampyra® (dalfampridine)
Antiemetic Agents
Antiemetic Agents: Zofran®/ODT® (ondansetron/ondansetron ODT/ondansetron oral solution), Zuplenz® (ondansetron oral film), Kytril® (granisetron), granisetron, Sancuso® (granisetron topical), Anzemet® (dolasetron), Emend® (aprepitant), GranisolTM (granisetron) oral solution, Akynzeo® (netupitant/palonosetron), Varubi® (rolapitant)
Antifungal Agents
Antifungal Agents: Lamisil® (terbinafine), Sporanox® (itraconazole), Vfend® (voriconazole), Noxafil® (posaconazole), Cresemba® (isavuconazonium)
Anti-Influenza Agents
Anti-Influenza Agents: Relenza® (zanamivir), Tamiflu® (oseltamivir)
Antinarcoleptic Agents
Antinarcoleptic Agents: Provigil®, modafinil, Nuvigil®, armodafinil
Appetite Suppressants
Appetite Suppressants: Adipex®, phentermine, Bontril®, phendimetrazine, Didrex®, benzphetamine, Suprenza®, Tenuate®, diethylpropion, Xenical®, Qsymia®, Belviq®, Belviq XR®, Contrave®, Saxenda®
Arcalyst
Arcalyst® (rilonacept)
Arzerra
Arzerra® (ofatumumab)
Aubagio
Aubagio® (teriflunomide)
Avastin
Avastin® (bevacizumab)
Ibrance
Ibrance® (palbociclib)
Iclusig
Iclusig® (ponatinib)
Ilaris
Ilaris® (canakinumab)
Imbruvica
Imbruvica® (ibrutinib)
Imfinzi
ImfinziTM (durvalumab)
Imlygic
ImlygicTM (talimogene laherparepvec)
Immune Globulin
Intravenous: Carimune® NF, Flebogamma®, Flebogamma® DIF, Gammagard®, Gammagard® S/D, Gammaplex®, Gamunex®, Gamunex-C®, Octagam®, Gammaked® and BIVIGam®, Privigen® Subcutaneous: Hizentra®, Gamunex-C®, Gammaked®, Gammagard®, HyQvia®, Cuvitru™
Increlex
Increlex® (mecasermin)
Incretin Mimetics
Incretin Mimetics – Bydureon® (exenatide), Byetta® (exenatide), TanzeumTM (albiglutide), TrulicityTM (dulaglutide), Victoza® (liraglutide)
Incretin Mimetics/Insulin Combinations
Incretin Mimetics/Insulin Combinations – SoliquaTM (insulin glargine/lixisenatide), Xultophy® (insulin degludec/liraglutide)
Infliximab
Infliximab (Remicade®, Inflectra®/infliximab-dyyb, RenflexisTM/infliximab-abda)
Ingrezza
Ingrezza™ (valbenazine)
Injectable Fertility Medications
Injectable Fertility Medications: Bravelle®, Cetrotide®, Follistim AQ®, Ganirelix®, Gonal-F®, human chorionic gonadotropin, leuprolide, Menopur®, Novarel®, Ovidrel®, Pregnyl®, progesterone in oil
Inlyta
Inlyta® (axitinib)
Intravenous (IV) Bisphosphonates
Intravenous (IV) Bisphosphonates: Reclast®, Zometa®, zoledronic acid, Boniva®
Iressa
Iressa® (gefitinib)
Istodax
Istodax® (romidepsin)
Jakafi
Jakafi® (ruxolitinib)
Jevtana
Jevtana® (cabazitaxel)
Juxtapid
Juxtapid™ (lomitapide)
PCSK9 Inhibitors
PCSK9 Inhibitors: PraluentTM, RepathaTM
Penicillamine Therapy
Penicillamine Therapy - Cuprimine®, Depen®
Perjeta
PerjetaTM (pertuzumab)
Pomalyst
Pomalyst® (pomalidomide)
Portrazza
Portrazza® (necitumumab)
Preferred Drug Step Therapy
Acne/Rosacea Therapy; Angiotensin Receptor Blockers (ARBs); Antipsychotics, 2nd generation; BPH (alpha-antagonists); Beta Agonist Inhalers; Calcipotriene Agents; CNS Stimulants; Constipation Agents; Desvenlafaxine; DPP-4 Inhibitors; Duexis; Epinephrine Products; Extended-Release Antibiotics; Fenofibrates; Inhaled Combinations; Inhaled Corticosteroids; Insulin; Insulin- Basal; Intranasal Steroids; Metformin ER Products; Opioids (Long-Acting); Osteoporosis Agents; Pancreatic Enzymes; Prostaglandin Analogs; Proton Pump Inhibitors (PPIs); Renin Inhibitors; Selective Serotonin Reuptake Inhibitors (SSRIs); SGLT-2 Inhibitors; Statins; Test Strips for Blood Glucose; Testosterone Replacements; Topical NSAIDs; Urinary Agents; Vimovo; Vivlodex
Procysbi
Procysbi® (cysteamine bitartrate delayed release capsules)
Promacta
Promacta® (eltrombopag)
Provenge
Provenge® (sipuleucel-T)
Pulmonary Arterial Hypertension (PAH) Agents
Pulmonary Arterial Hypertension (PAH) Agents: Revatio™ (sildenafil), Ventavis® (iloprost), Tracleer® (bosentan), Letairis™ (ambrisentan), Adcirca® (tadalafil), Tyvaso® (treprostinil), Remodulin® (treprostinil), Flolan®/Veletri® (epoprostenol), Adempas® (riociguat), Opsumit® (macitentan), Orenitram® (treprostinil), Uptravi® (selexipag)
Qbrelis
Qbrelis™ (lisinopril oral solution)
Qutenza
Qutenza® (8% capsaicin patch)
Tafinlar
Tafinlar® (dabrafenib)
Tagrisso
TagrissoTM (osimertinib)
Taltz
Taltz® (ixekizumab)
Tarceva
Tarceva® (erlotinib)
Targretin
Targretin®/bexarotene capsules, Targretin® gel
Tasigna
Tasigna® (nilotinib)
Tecentriq
Tecentriq® (atezolizumab)
Tecfidera
Tecfidera® (dimethyl fumarate)
Technivie
TechnivieTM (ombitasvir, paritaprevir, ritonavir)
Temodar
Temodar® (temozolomide)
Topical Immunomodulators
Elidel® (pimecrolimus cream), Eucrisa® (crisaborole ointment), Protopic®, tacrolimus ointment
Torisel
Torisel® (temsirolimus)
Transmucosal Immediate Release Fentanyl
Abstral® (sublingual tablet), Actiq® (oral transmucosal lozenge), fentanyl powder, Fentora® (buccal tablet), Lazanda® (nasal spray), Onsolis® (buccal soluble film), Subsys® (sublingual spray) (buccal soluble film), Subsys® (sublingual spray)
Triptans
almotriptan, Alsuma®, Amerge®, Axert®, Frova®, Imitrex® and sumatriptan tablets/nasal spray/injection, Maxalt/MLT®, naratriptan, OnzetraTM XsailTM, Relpax® and eletriptan tablets, rizatriptan/ODT, Sumavel®, Treximet®, ZembraceTM SymTouchTM, zolmitriptan/ODT tablets, Zomig/ZMT® tablets/nasal spray
Tykerb
Tykerb® (lapatinib)
Tymlos
Tymlos® (abaloparatide)
Tysabri
Tysabri® (natalizumab)
Uloric
Uloric® (febuxostat)
Unituxin
UnituxinTM (dinutuximab)
Valchlor
Valchlor® (mechlorethamine gel)
Vectibix
Vectibix® (panitumumab)
Venclexta
Venclexta® (venetoclax)
Vidaza
Vidaza® (azacitidine)
Viekira
Viekira PakTM (ombitasvir, paritaprevir, and ritonavir tablets; dasabuvir tablets)
Vimizim
VimizimTM (elosulfase alfa)
Votrient
Votrient™ (pazopanib)