Drug Prior Authorization List - ConnectiCare · Alkeran Generic Oncology Alocril Ophthalmic...

DRUG PRIOR AUTHORIZATION LIST

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Drug Prior Authorization List | 02 2021

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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. 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. 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

Absorica LD Absorica LD

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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Acticlate* Acne Meds Oral

Actimmune Actimmune

Actiq (fentanyl lozenge) Fentanyls

ActoplusMet XR* (Use metformin first) Diabetic Oral

Acuvail Ophthalmic NSAIDs

Acyclovir cream/ointment Acyclovir Topical PA

AdakveoM Adakveo

AdcetrisM Adcetris

Adcirca Adcirca

Adempas* Adempas

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/Digihaler 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


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Alecensa Oncology

Alferon Alferon

AlimtaM Alimta

Aliskiren ACE/ARB Step

Aliqopa Aliqopa

Alkeran Generic Oncology

Alkindi Sprinkle Alkindi PA CCI

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

Amitiza Amitiza-Motegrity

amlodipine/olmesartan amlodipine/valsartan

ACE/ARB Step

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


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Android Testosterone

Anzemet (Use ondansetron first) 5HT3 Receptor Antagonists

Apidra Insulins

Aplenzin (Use generic bupropion hcl)

Aplenzin-Forfivo

Apokyn Apokyn

Apriso ER Ulcerative colitis ST

Aptensio XR ADHD

Aptiom Aptiom

AralastM Alpha-1 Proteinase Inhibitors

Arazlo Arazlo

ArcalystM Arcalyst

Aricept 23 (PA < 50 years old only)

Cholinesterase Inhibitors

Aricept ODT (PA < 50 years old only)


Arikayce Arikayce

Armonair Respiclick Steroid Inhalers PA CCI

Arthrotec NSAIDs

Arymo ER Freedom LA

Narcotics/Morphines

ArzerraM Arzerra

Asacol/HD Ulcerative colitis ST

Asceniv Intravenous Immune

Globulins (immune globulin)

Ascensia Test Strips (Use Freestyle) Diabetic Test Strips

Asparlas Asparlas

Aubagio MS

Auryxia Auryxia PA CCI

Austedo VMAT2 Inhibitors

Auvi Q Auvi Q/Symjepi

Avar Cleanser Topical Acne


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Avar 9.5-5% Cleansing pads Avar-E LS Cream Avar LS Cleaner

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

Avsola Infliximab Injectable

Axiron Testosterone

Ayvakit Ayvakit

Azedra Azedra

Azelex 20% Cream Topical Acne

Azopt Glaucoma Combinations

Bactroban Topical Antibiotics

Bafiertam Bafiertam PA

Balcoltra@ FREEDOM Contraceptives

Balversa Balversa

Barhemsys Barhemsys

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


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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 PA CCI

Blenrep Blenrep

Blincyto Blincyto

Blood Clotting Factors (All) M

Clotting Disorder Therapy

Boniva Injection Boniva Injection

Bosulif Bosulif

Botox Neurotoxins

Braftovi Braftovi

Bravelle Fertility

Breztri Aerosphere Breztri Aerosphere PA

Brineura Brineura

Briviact Briviact PA CCI

Brukinsa Brukinsa

Bryhali Topical Steroids

Bunavail@ Freedom Zubsolv-Bunavail

Buphenyl

Sodium phenylbutyrate

Buprenorphine/Naloxone tabs

(Use Suboxone Film) Buprenorphine/Naloxone


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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

candesartan candesartan/HCT

ACE/ARB Step

Caplyta Caplyta

Caprelsa Oncology

Carbinoxamine Carbinoxamine

Cardizem LA@ Freedom Calcium Channel

Blockers

Carvedilol ER Carvedilol ER

Cayston Cayston

Centany 2% Ointment Topical Antibiotics

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)


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Cinacalcet Cinacalcet (Sensipar ) PA CCI

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

Coagadex Clotting Disorder Therapy

Coartem Antimalarials

Cometriq Cometriq

Compounded Medications

Consensi Consensi

Contraceptives@ Freedom Contraceptives

Copiktra Copiktra

Cordran Topical Steroids

Coremino Acne Oral

Corifact Clotting Disorder Therapy

Corlanor Corlanor

Cosentyx Cosentyx


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Cotellic Cotellic

Cotempla XR-ODT ADHD

CrysvitaM Crysvita

Cuprimine Penicillamine

Cuvitru IVIG SQ

Cuvposa Cuvposa

Cyramza Cyramza

Cystadrops Cystadrops-Cystaran PA CCI

Cystaran Cystadrops-Cystaran PA CCI

CytogamM Cytogam (cytomegalovirus immune globulin, human)

DacogenM Dacogen

Daklinza Hepatitis C

Danyelza Danyelza

Darifenacin er Overactive Bladder

Darzalex/Faspro Darzalex

Daunorubicin Generic Oncology

Daurismo Daurismo

Daxbia Daxbia

Dayvigo Dayvigo

Delzicol Mesalamines

Depen Penicillamine

Desonide 0.05% lotion/gel Topical Steroids

Desoximetasone 0.05% gel, cream Desoximetasone 0.25% spray, ointment

Topical Steroids

Desvenlafaxine ER tablet Antidepressants

Dexilant (Use OTC’s 1st) Proton Pump Inhibitors

DexPak Dexamethasone Packs

Dextenza Intravitreal Injections/Implants

Dexycu Intravitreal Injections/Implants


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Diacomit Diacomit

Dihydroergotamine nasal spray

Dihydroergotamine spray PA

CCI

Dificid Dificid

Diflorasone 0.05% ointment, 0.05% cream

Topical Steroids

Dimethyl fumarate Tecfidera

Dipentum Ulcerative colitis ST

Dojolvi Dojolvi

Doptelet Doptelet

Doral (quazepam) Sedative Hypnotics ST

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

Dronabinol Dronabinol PA CCI

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

Durysta Intravitreal Injections-Implants

Duzallo Zurampic--Duzallo

Dyanavel XR ADHD

Dymista Dymista


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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

Enspryng Enspryng PA

Enstilar Psoriasis Topicals

EntyvioM Entyvio

Epaned Qbrelis-Epaned

Epclusa Hepatitis C

Epidiolex Epidiolex

Epiduo Forte Acne Topicals

Eprosartan ACE/ARB Step


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Equetro ER Equetro

ErbituxM Erbitux

Erivedge Erivedge

Erleada Erleada

Erwinaze Erwinaze

Esbriet Esbriet

Esperoct Clotting Disorder Therapy

Eucrisa Eucrisa

EuflexxaM Hyaluronic Acid Derivatives

Evekeo Evekeo

Evekeo-ODT Evekeo-ODT

EvenityM Evenity

Evomela Generic Oncology

Evrysdi Evrysdi PA

Exelon capsules (rivastigmine)

(PA for <50 years old only)


Exjade PA To Indication

Exondys 51 Eteplirsen (Exondys 51)

Extavia MS

Eylea Intravitreal Injections/Implants

Eysuvis Eysuvis PA CCI

FabrazymeM Fabrazyme

Fanapt* Atypicals

Farxiga* Diabetic Oral

Farydak Farydak

FasenraM Fasenra

Febuxostat Febuxostat

Fenofibrate 50mg, 160mg Fenofibrates

Fenoglide Fenofibrates

Fensolvi Fensolvi


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Fentora Fentanyls

Fetroja Fetroja

Fetzima* Antidepressants

Fexmid Amrix-Fexmid

Fiasp Insulins

Fibricor Fenofibrate step

Finacea Rosacea Topicals

Fintepla Fintepla

FirazyrM Firazyr

Firdapse Firdapse - Ruzurgi

Flarex Ophthalmic Steroids

Flector Patch Flector

Flolan/epoprostenolM PAH

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

Fluvoxamine Er capsule Antidepressants

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


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Fortesta Testosterone

Fosrenol (lanthanum) Phosphate Binders ST

Fulphila

Colony Stimulating Factors: Fulphila™ (pegfilgrastim-jmdb)

Fuzeon Fuzeon

Galafold Galafold

GamifantM Gamifant

Ganirelix Fertility

Gattex GLP-2 Analogs

Gavreto Gavreto PA

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

Gimoti Gimoti

GivlaariM Givlaari

Glassia Alpha-1 Proteinase Inhibitors

Gleevec (imatinib) Oncology

Gloperba Gloperba

Glucagen Hypokit Glucagon products PA

Glucagon emergency kit (ndc 63323-0582-82)

Glucagon products PA

Glumetza Diabetic Oral

Glycopyrrolate 1.5mg tab Glycopyrrolate

Gocovri Gocovri

Gonal-F Fertility


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Gralise Gralise

Granix Granix

Grastek Grastek

Gvoke pre-filled syringes Glucagon products PA

Haegarda Takhzyro and Haegarda

HalavenM Halaven

Halcinonide 0.1% ointment, 0.1% cream

Topical Steroids

Halobetasol 0.05% lotion Topical Steroids

Harvoni Hepatitis C

Hemady Hemady

Hemlibra Clotting Disorder Therapy

Herceptin Hylecta Herceptin Hylecta

HerceptinM Herceptin

Herzuma Trastuzumab Injection

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


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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

Incruse Ellipta@ Long-acting muscarinic

antagonists

Infertility Medications (All)

Gonadotropins

Inflectra Infliximab Injectables

Ingrezza VMAT2 Inhibitors

Injectable Drugs – All (excluding insulin)

Inlyta Inlyta

Inqovi Inqovi PA

Inrebic Inrebic

Intron-A Intron-A

Inveltys Ophthalmic Steroids

Iressa Oncology

IstodaxM Istodax

Isturisa Isturisa


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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

Jatenzo Jatenzo

Jelmyto Jelmyto

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

Kanjinti Herceptin/Ogivri/Herzuma/Ont

ruzant /Kanjinti

KanumaM Kanuma

Katerzia Katerzia

Kazano* Diabetic Oral

Kerydin Antifungal Agents

Kesimpta Kesimpta

Ketoprofen Ketoprofen

Keveyis PA To Indication

Kevzara Kevzara

KeytrudaM Keytruda

KhapzoryM Khapzory


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Kineret Kineret

Kisqali Kisqali

Kombiglyze XR* Diabetic Oral

Korlym PA To Indication

Koselugo Koselugo

Kovaltry Clotting Disorder Therapy

KrystexxaM Krystexxa

Kuvan Kuvan

KymriahM Kymriah

Kynamro Kynamro

Kynmobi Kynmobi

KyprolisM Kyprolis

Kytril (granisetron) (Use generic Zofran first)

5HT3 Receptor Antagonists

Lac-Hydrin@ Freedom Lac-Hydrin

Lactulose Packets Lactulose

Lampit Lampit PA

Lartruvo Lartruvo

Lastacaft Ophthalmic Anti-Allergy

Latuda* Atypicals

Lazanda Fentanyls

LemtradaM Lemtrada

Lenvima Oncology

Letairis Letairis

Leucovorin Generic Oncology

LeukineM Leukine

Lexette Topical Steroids

Lialda Ulcerative Colitis ST

Libtayo Libtayo

Lidtopic Max Lidocaines


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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


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

Lynparza Oncology

Lyrica/Lyrica CR* Lyrica

Lyumjev Insulins PA CCI

Macugen Intravitreal Injections/Implants

Marqibo Marqibo

Matulane Matulane

Matzim LA@ Freedom Calcium Channel

Blockers


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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

Metformin ER Diabetic Oral

Metoprolol ER-HCTZ Metoprolol HCTZ

Metyrosine Metyrosine

Minolira ER Acne Orals

Mirvaso Rosacea Topicals

Monjuvi Monjuvi

Mononine Clotting Disorder Therapy

Monovisc Hyaluronic Acid Derivatives

Morphabond ER Freedom LA

Narcotics/Morphines

Motegrity Amitiza-Motegrity

MozobilM Mozobil

Mulpleta Mulpleta

Mupirocin Topical Antibiotics

Mvasi Avastin/Mvasi

Myalept PA to Indication

Mycapssa Mycapssa

MylotargM Mylotarg

MyoblocM Neurotoxins


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Myrbetriq* Overactive Bladder

Mytesi Mytesi

NaglazymeM Naglazyme

Namenda/Namzaric (PA < 50 years old only)


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

Nexletol Nexletol

Nexlizet Nexletol_Nexlizet

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)

Nocdurna Noctiva-Nocdurna

Noctiva Noctiva-Nocdurna

Norditropin Growth Hormone


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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

Nurtec ODT Nurtec ODT

Nutropin/AQ Growth Hormone

Nuvigil (armodafanil) Nuvigil

Nuwiq Clotting Disorder Therapy

Nuzyra Nuzyra

Nymalize PA To Indication

Nyvepria Nyvepria

Obizur Clotting Disorder Therapy

Ocaliva PA To Indication

OcrevusM Ocrevus

Odactra Odactra

Odomzo Oncology

Ofev Ofev

Ogivri Trastuzumab Injection

Oleptro Oleptro

Olmesartan olmesartan/HCT

ACE/ARB Step


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Olumiant Olumiant

Olux/Olux-E (Use generic clobetasol first)

Topical Steroids

Olysio Hepatitis C

Omeprazole-bicarbonate PPI

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

Ongentys Ongentys PA

Onglyza* Diabetic Oral

Onmel Onmel

OnpattroM Onpattro

Ontruzant Trastuzumab Injection

Onureg Onureg

Onzetra Xsail Sumatriptans

Opana ER (crush resistant

formulation) @ (Generic Opana ER does not require PA)

Freedom Long Acting Narcotics

Opdivo Opdivo

Opsumit* Opsumit

Oracea (Doxycycline

Rosacea) * Oracea

Oralair Oralair

Oravig Oravig

Orencia/Orencia SQM Orencia

Orenitram Orenitram

Orfadin PA To Indication

Orgovyx Orgovyx PA CCI

Oriahnn Oriahnn

Orilissa Orilissa


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Orkambi Orkambi

Orladeyo Orladeyo PA CCI

OrthoviscM Hyaluronic Acid Derivatives

Ortikos Ortikos

Oseni* Oseni

Osmolex ER Osmolex ER

Otezla Otezla

Otrexup Methotrexates

Ovace Plus Foam Ovace

Oxandrin Oxandrin

Oxaydo Oxycodones

Oxbryta Oxbryta

Oxervate Oxervate

Oxiconazole Cream Oxiconazole cream PA CCI

Oxlumo Oxlumo

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

Panretin Panretin

Panzyga IVIG

Paricalcitol Vitamin D2 Analogs

ParsabivM Parsabiv


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Patanase (olopatadine) (Use Astelin first) Freedom Nasal

Sprays/Patanase

Paxil 10mg/5ml suspension

Antidepressants

Pazeo Ophthalmic Anti-Allergy

Pegasys Pegasys-PegIntron

Peg-Intron Pegasys-PegIntron

Penicillamine Penicillamine

Pennsaid 2% Pennsaid

Pentasa Ulcerative colitis ST

PerjetaM Perjeta

Pertzye Pancreatic Enzymes

Pexeva* (Use generics first) Antidepressants

Phenoxybenzamine Phenoxybenzamine

Phesgo Perjeta and Phesgo

Piqray Piqray

Plegridy MS

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


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Pretomanid Pretomanid

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

Protonix suspension Protonix suspension

ProvengeM Provenge

Proventil HFA@ Short Acting Bronchodilators

Provigil (modafinil) Provigil

Prozac Weekly** (Use generics first) Antidepressants

Prudoxin Cream Doxepin Cream

Psorcon Topical Steroids

Pyrimethamine Pyrimethamine

Qbrelis Qbrelis-Epaned

Qbrexza Qbrexza

Qdolo Qdolo PA CCI

Qinlock Qinlock

Qmiiz ODT NSAID’s

Qnasl* Freedom Nasal Sprays/Nasal

Steroids


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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

Riabni Infliximab Injectable

Rebif MS

Rebinyn Clotting Disorder Therapy

ReblozylM Reblozyl

Regranex Regranex

Relafen DS NSAID

Relistor Relistor

RelizorbM Relizorb

Relpax* (Use generic triptan first)

Relpax

RemicadeM Infliximab Injectables

RemodulinM PAH Meds

Renagel Phosphate Binders ST

Renflexis Infliximab Injectables

Renvela (sevelamer) Phosphate Binders ST

Repatha Repatha


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Retisert Intravitreal Injections/Implants

Revatio (sildenafil) Revatio

RevcoviM Revcovi

Revlimid Oncology

Rexulti* Rexulti

Reyvow Reyvow

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

Rukobia Rukobia

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

Saphris* Atypicals

Sarclisa Sarclisa

Savaysa Anticoagulants


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Scalacort DK 2% kit Topical Steroids

Secuado Secuado

Seebri Neohaler@ Long-acting muscarinic

antagonists

Semglee Semglee

Sensipar J0604 NOT COVERED

Sernivo Topical Steroids

Sevelamer HCL Phosphate Binders ST

Sevenfact Clotting Disorder Therapy

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

Sirturo Sirturo

Sitavig Sitavig

Sivextro Sivextro

Skyrizi Skyrizi

Solifenacin Overactive Bladder

Soliqua Soliqua

SolirisM Soliris

Solodyn (minocycline extended release)

Solodyn (minocycline

extended release) PA CCI

Solosec Solosec

Somavert Somavert

Soolantra Rosacea Topicals


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Sorilux Foam Psoriasis Topicals

Sovaldi Hepatitis C

Spinraza Spinraza

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


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Syndros Syndros

Synjardy/XR** Diabetic Oral

Synojoynt Hyaluronic Acids

Synribo Oncology

Synvisc/Synvisc-OneM Hyaluronic Acid Derivatives

Tafinlar Oncology

Tagrisso Tagrisso

TakhzyroM Takhzyro and Haegarda

Taltz Taltz

Talzenna Talzenna

TaperDex Dexamethasone Packs

Tarceva Oncology

Targadox Acne Meds Oral

Targretin Targretin

Targretin Gel Targretin Gel

Tasigna Oncology

Tavalisse Tavalisse

Tazverik Tazverik

Tecartus Tecartus

Tecentriq Tecentriq

Tecfidera MS

Technivie Hepatitis C

TegsediM Tegsedi

Tekturna (Use generic ACE or ARB first)

ACE/ARB Step

telmisartan telmisartan/HCT telmisartan/amlodipine,

ACE/ARB Step

Temodar (temozolomide) Oncology

TepadinaM Tepadina

Tepezza Tepezza


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Testim (testosterone transdermal gel)

Testosterone

Testosterone (All) Testosterone

TevTropin Growth Hormone

Thalomid Oncology

Thyquidity Tirosint-SOL

Thyrogen Thyrogen

Tibsovo Tibsovo

Tiglutik Tiglutik

Timoptic Ocudose Glaucoma Combinations

Tirosint-SOL Tirosint-SOL

Tivorbex NSAIDs

TOBI Podhaler Tobramycin PA

Tobramycin ampule Tobramycin PA

Tolsura Tolsura

ToriselM Torisel

Tosymra Tosymra

Toviaz* Overactive Bladder

Tracleer Tracleer

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

Tretinoin oral capsule Tretinoin PA CCI

Tretten Clotting Disorder Therapy

Treximet Sumatriptan_Naproxen

(Treximet)


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Triamcinolone 0.05% ointment

Topical Steroids

Trientine Trientine

Triglide Fenofibrate step

Trikafta Trikafta

Triluron Hyaluronic Acids

Trintellix* Formerly Brintellix Antidepressants

TriVisc Hyaluronic Acid Derivatives

Trodelvy Trodelvy

TrogarzoM Trogarzo

Trokendi XR Qudexy--Trokendi

Trospium ER capsule Trospium IR tablet

Overactive Bladder

Troxyca ER Oxycodones

Trulicity Non-Preferred GLP1 PA

Truxima Truxima

Tudorza Tudorza

Turalio Turalio

Tuzistra XR Cough Meds

Twirla Freedom Contraceptives

Tykerb Tykerb

Tysabri MS/Tysabri

Tyvaso PAH Meds

Ubrelvy Ubrelvy

Uceris rectal foam Uceris Rectal Foam

Udenyca Colony Stimulating Factors:

Udenyca (Pegfilgrastim-cbqv)

Uloric Febuxostat

UltomorisM Ultomoris

UnituxinM Unituxin

Uplizna Uplizna


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Upneeq Upneeq PA

Uptravi Uptravi

Utibron Neohaler@


agonist PA CCI

Utopic 41% Cream Utopic 41% Cream

Valchlor Valchlor

Valtoco Valtoco

Vanos Topical Steroids

VantasM Vantas

Vascepa Omega 3’s

VectibixM Vectibix

VelcadeM Velcade

Velphoro Phosphate Binders ST

Veltassa Veltassa

Veltin 1.2%-0.025% gel Acne Topical

Vemlidy Vemlidy PA CCI

Venclexta Oncology

Venlafaxine hcl er tablets Antidepressants

VentavisM PAH Meds

Ventolin HFA@ Short Acting Bronchodilators

Verdeso Topical Steroids

Verzenio Oncology

Vesicare* Overactive Bladder

Victoza* (Use metformin first) Preferred GLP1 ST

VidazaM Oncology

Viekira Pak Hepatitis C

Viibryd* Antidepressants

Viltepso Viltepso

VimizimM Vimizim

Vimovo NSAID Combinations


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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

Vyepti Vyepti

Vyndaqel Vyndaqel

Vyondys 53 Vyondys 53

Vyxeos Vyxeos

Vyzulta Ophthalmics Glaucoma PA

Wakix Wakix

Wilate Clotting Disorder Therapy

Xadagp Xadago

Xalkori Oncology

Xartemis XR Oxycodones

Xatmep Methotrexates

Xcopri Xcopri

Xeljanz/XR Xeljanz


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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

Xyrem Xyrem

Xywav Xywav PA

YervoyM Vervoy

YescartaM Yescarta

Yondelis Oncology

Yonsa Yonsa


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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 Zejula

Zelboraf Zelboraf

Zelnorm Zelnorm PA

ZemairaM Alpha-1 Proteinase Inhibitors

Zembrace SymTouch Sumatriptans

Zenzedi ADHD meds

Zepatier Hepatitis C

Zeposia Zeposia

Zepzelca Zepzelca

Zetonna* Freedom Nasal Sprays/Nasal

Steroids

ZevalinM Zevalin

ZiextenzoM Colony Stimulating Factors:

Ziextenzo

ZilrettaM Zilretta

Zilxi Minocycline topical foam PA

CCI

Zinbryta MS

ZinplavaM Zinplava

Zioptan Ophthalmic Glaucoma PA

Zipsor (Use diclofenac tablets)

NSAIDs

Zohydro ER Long Acting Hydrocodones

ZolgensmaM Zolgensma

Zolinza Zolinza

Zolpimist (Use generic zolpidem tablets)

Zolpidem


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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 (zileuton) CR (Use Singulair first) Zyflor CR

Zykadia Oncology

Zypitamag Statin Step

Zytiga Oncology

Drug Prior Authorization List - ConnectiCare · Alkeran Generic Oncology Alocril Ophthalmic...

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