Medical Necessity Criteria - Non-Covered Drugs Prior Authorization Form Page 3
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4DRUGS REQUIRING PRIOR
Formulary Options
DRUGS REQUIRING
Formulary Options
DRUGS REQUIRING
Formulary Options
AUTHORIZATION FOR
PRIOR AUTHORIZATION
PRIOR AUTHORIZATION
MEDICAL NECESSITY
FOR MEDICAL
FOR MEDICAL NECESSITY
NECESSITY
fluorouracil cream 5%, fluorouracil
ONETOUCH ULTRA STRIPS AND KITS
aripiprazole, clozapine, olanzapine, quetiapine,
ABILIFY
BREEZE 2 STRIPS AND KITS 4
3, ONETOUCH VERIO STRIPS AND KITS
fluorouracil cream 0.5%
soln, imiquimod, PICATO,
risperidone, ziprasidone, LATUDA, SEROQUEL XR
3
ZYCLARA
ONETOUCH ULTRA STRIPS AND KITS 3,
ACCU-CHEK STRIPS AND KITS 4
BYDUREON
TRULICITY SI, VICTOZA SI
FORTAMET
metformin, metformin ext-rel
ONETOUCH VERIO STRIPS AND KITS 3
ACTOS
BYETTA
TRULICITY SI, VICTOZA SI
FORTESTA
ANDRODERM, AXIRON
pioglitazone
CARAC
amphetamine-dextroamphetaminemixed salts,
CARDIZEM CARDIZEM
amphetamine-dextroamphetaminemixed salts ext-rel,
calcium acetate, PHOSLYRA,
diltiazem ext-rel (except generic of
guanfacine ext-rel, methylphenidate, methylphenidate
CD CARDIZEM LA
ADDERALL XR
FOSRENOL
RENVELA, VELPHORO
Cardizem LA)
ext-rel, DAYTRANA, QUILLIVANT XR, STRATTERA,
(includes generic
Cardizem LA)
VYVANSE
ONETOUCH ULTRA STRIPS
FREESTYLE STRIPS AND KITS
AND KITS 3, ONETOUCH VERIO
ADRENACLICK
AUVI-Q , EPIPEN , EPIPEN JR
clobetasol spray
clobetasol foam
4
STRIPS AND KITS 3
atorvastatin, fluvastatin, lovastatin, pravastatin,
HUMATROPE PA SP SI,
ADVICOR
CLOBEX SPRAY
GENOTROPIN
clobetasol foam
NORDITROPIN PA SP SI
simvastatin, CRESTOR, SIMCOR, VYTORIN
ONETOUCH ULTRA STRIPS AND KITS
CONTOUR NEXT STRIPS AND
ASMANEX, FLOVENT, PULMICORT FLEXHALER,
AEROSPAN
3, ONETOUCH VERIO STRIPS AND KITS
GLUMETZA
metformin, metformin ext-rel
QVAR
KITS 4
3
ONETOUCH ULTRA STRIPS AND KITS
atorvastatin, fluvastatin, lovastatin, pravastatin,
ALTOPREV
CONTOUR STRIPS AND KITS 4
3, ONETOUCH VERIO STRIPS AND KITS
HECORIA
tacrolimus
simvastatin, CRESTOR, SIMCOR, VYTORIN
3
ASMANEX, FLOVENT, PULMICORT FLEXHALER,
duloxetine, venlafaxine, venlafaxine ext-rel,
ALVESCO
CYMBALTA
HUMALOG
NOVOLOG
QVAR
KHEDEZLA, PRISTIQ
balsalazide, budesonide capsule,
AMITIZA
LINZESS
DELZICOL
sulfasalazine, sulfasalazine delayed-rel,
HUMALOG MIX 50/50
NOVOLOG MIX 70/30
APRISO, LIALDA, PENTASA, UCERIS
oxybutynin ext-rel, tolterodine, tolterodine
AMRIX
DETROL LA
HUMALOG MIX 75/25
NOVOLOG MIX 70/30
cyclobenzaprine
ext-rel, trospium, trospium ext-rel,
GELNIQUE, MYRBETRIQ, VESICARE
candesartan, eprosartan, irbesartan,
ANDROGEL
ANDRODERM, AXIRON
DIOVAN
HUMULIN 70/30 2
NOVOLIN 70/30
losartan, telmisartan, valsartan, BENICAR
candesartan-hydrochlorothiazide,
irbesartan-hydrochlorothiazide,
losartan-hydrochlorothiazide,
APEXICON E
desoximetasone, fluocinonide
DIOVAN HCT
HUMULIN N 2
NOVOLIN N
telmisartan-hydrochlorothiazide,
valsartan-hydrochlorothiazide, BENICAR
HCT
celecoxib; diclofenac sodium, meloxicam
or naproxen WITH lansoprazole,
APIDRA
DUEXIS
omeprazole, omeprazole-sodium
HUMULIN R 2
NOVOLOG
NOVOLIN R
bicarbonate capsule, pantoprazole,
DEXILANT or NEXIUM
celecoxib; diclofenac sodium, meloxicam or naproxen
flunisolide spray, triamcinolone spray
WITH lansoprazole, omeprazole, omeprazole-sodium
ARTHROTEC
DYMISTA
or NASONEX WITH azelastine spray
INCRUSE ELLIPTA
SPIRIVA
bicarbonate capsule, pantoprazole, DEXILANT or
or olopatadine spray
NEXIUM
balsalazide, budesonide capsule, sulfasalazine,
candesartan, eprosartan, irbesartan,
eszopiclone, zolpidem, zolpidem
sulfasalazine delayed-rel, APRISO, LIALDA,
ASACOL HD
EDARBI
INTERMEZZO
losartan, telmisartan, valsartan, BENICAR
ext-rel, SILENOR
PENTASA, UCERIS
candesartan, eprosartan, irbesartan, losartan,
amphetamine-dextroamphetamin
ATACAND
candesartan-hydrochlorothiazide,
telmisartan, valsartan, BENICAR
mixed salts,
irbesartan-hydrochlorothiazide,
amphetamine-dextroamphetamine
candesartan-hydrochlorothiazide,
losartan-hydrochlorothiazide,
mixed salts ext-rel, guanfacine ext-re
EDARBYCLOR
INTUNIV
irbesartan-hydrochlorothiazide,
telmisartan-hydrochlorothiazide,
methylphenidate, methylphenidate
ATACAND HCT
losartan-hydrochlorothiazide,
valsartan-hydrochlorothiazide, BENICAR
ext-rel, DAYTRANA, QUILLIVANT
telmisartan-hydrochlorothiazide,
HCT
XR, STRATTERA, VYVANSE
valsartan-hydrochlorothiazide, BENICAR HCT
EUFLEXXA
GEL-ONE, HYALGAN, SUPARTZ
INVOKAMET
XIGDUO XR
AUBAGIO , BETASERON, COPAXONE , GILENYA,
AVONEX
amlodipine-telmisartan,
REBIF, TECFIDERA
INVOKANA
FARXIGA, JARDIANCE
EXFORGE
amlodipine-valsartan, AZOR
finasteride or AVODART
Amlodipine-valsartan-hydrochlorothiazide,
EXFORGE HCT
TRIBENZOR
WITH alfuzosin ext-rel,
JALYN
BECONASE AQ
flunisolide spray, triamcinolone spray, NASONEX
AUBAGIO, BETASERON, COPAXONE,
doxazosin, tamsulosin,
EXTAVIA
GILENYA, REBIF
terazosin or RAPAFLO
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