Medical Necessity Criteria - Non-Covered Drugs Prior Authorization Form Page 4
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4DRUGS REQUIRING PRIOR
Formulary Options
DRUGS REQUIRING PRIOR
Formulary Options
DRUGS REQUIRING PRIOR
Formulary Options
AUTHORIZATION FOR
AUTHORIZATION FOR
AUTHORIZATION FOR MEDICAL
MEDICAL NECESSITY
MEDICAL NECESSITY
NECESSITY
ANDRODERM, AXIRON
KAZANO
JANUMET, JANUMET XR, JENTADUETO
ONGLYZA
JANUVIA, TRADJENTA
testosterone gel 1% 5
candesartan, eprosartan,
irbesartan, losartan, telmisartan,
KOMBIGLYZE XR
JANUMET, JANUMET XR, JENTADUETO
ORTHOVISC
GEL-ONE, HYALGAN, SUPARTZ
TEVETEN
valsartan, BENICAR
candesartan-hydrochlorothiazide,
irbesartan-hydrochlorothiazide,
losartan-hydrochlorothiazide,
azelastine, cromolyn sodium, PATADAY,
LASTACAFT
OSENI
JANUMET, JANUMET XR, JENTADUETO
TEVETEN HCT
PATANOL
telmisartan-hydrochlorothiazide,
valsartan-hydrochlorothiazide,
BENICAR HCT
atorvastatin, fluvastatin, lovastatin,
oxybutynin ext-rel, tolterodine, tolterodine
HUMATROPE PA SP SI,
pravastatin, simvastatin, CRESTOR,
LESCOL XL
OXYTROL
TEV-TROPIN
ext-rel, trospium, trospium ext-rel,
NORDITROPIN PA SP SI
SIMCOR, VYTORIN
GELNIQUE, MYRBETRIQ, VESICARE
oxybutynin ext-rel, tolterodine,
diclofenac sodium, diclofenac sodium
tolterodine ext-rel, trospium,
solution, meloxicam, naproxen, VOLTAREN
LEVITRA
CIALIS
PENNSAID
TOVIAZ
trospium ext-rel, GELNIQUE,
GEL
MYRBETRIQ, VESICARE
atorvastatin, fluvastatin, lovastatin,
pravastatin, simvastatin, CRESTOR,
fenofibrate, fenofibric acid
LIPITOR
PLAVIX
clopidogrel, BRILINTA, EFFIENT
TRICOR
SIMCOR, VYTORIN
atorvastatin, fluvastatin, lovastatin,
AUBAGIO PA SP, BETASERON PA SP SI,
COPAXONE PA SP SI, GILENYA PA SP,
SPIRIVA
LIPTRUZET
pravastatin, simvastatin, CRESTOR,
PLEGRIDY
TUDORZA
SIMCOR, VYTORIN
REBIF PA SP SI, TECFIDERA PA SP
atorvastatin, fluvastatin, lovastatin,
ansoprazole, omeprazole,
pravastatin, simvastatin, CRESTOR,
omeprazole-sodium bicarbonate capsule,
valganciclovir
LIVALO
PREVACID
VALCYTE
pantoprazole, DEXILANT, NEXIUM
SIMCOR, VYTORIN
ansoprazole, omeprazole,
latanoprost, travoprost, TRAVATAN Z,
LUMIGAN
PROTONIX
omeprazole-sodium bicarbonate capsule,
VALTREX
acyclovir, valacyclovir
ZIOPTAN
pantoprazole, DEXILANT, NEXIUM
eszopiclone, zolpidem, zolpidem ext-rel,
PROAIR HFA
LUNESTA
PROVENTIL HFA
PROAIR HFA
VENTOLIN HFA
SILENOR
flunisolide spray, triamcinolone
diltiazem ext-rel (except generic of Cardizem
flunisolide spray, triamcinolone spray,
Matzim LA
QNASL
VERAMYST
LA)
NASONEX
spray, NASONEX
CIALIS
MONOVISC
GEL-ONE, HYALGAN, SUPARTZ
QSYMIA
BELVIQ, CONTRAVE, SAXENDA SI
VIAGRA
celecoxib, diclofenac sodium, meloxicam,
dexamethasone, methylprednisolone,
HARVONI
NAPRELAN
RAYOS
VIEKIRA PAK
naproxen
prednisone
celecoxib; diclofenac sodium,
RELISTOR
NATESTO
ANDRODERM, AXIRON
MOVANTIK
meloxicam or naproxen WITH
lansoprazole, omeprazole,
NESINA
JANUVIA, TRADJENTA
VIMOVO
omeprazole-sodium bicarbonate
flunisolide spray, triamcinolone spray,
RHINOCORT AQUA
capsule, pantoprazole, DEXILANT
NASONEX
metronidazole, sulfacetamide-sulfur,
NORITATE
or NEXIUM
FINACEA, SOOLANTRA
ANDRODERM, AXIRON
NORVASC
RIOMET
VOGELXO
amlodipine
metformin, metformin ext-rel
eszopiclone, zolpidem, zolpidem ext-rel,
PROAIR HFA
OLEPTRO
ROZEREM
XOPENEX HFA
trazodone
SILENOR
flunisolide spray, triamcinolone
OLUX-E
clobetasol foam
SAIZEN
HUMATROPE PA SP SI, NORDITROPIN
ZETONNA
spray, NASONEX
flunisolide spray, triamcinolone spray,
OMNARIS
SYMBICORT
buprenorphine-naloxone
ADVAIR, DULERA
NASONEX
sublingual tablet, SUBOXONE
ZUBSOLV
FILM
OMNITROPE
HUMATROPE I, NORDITROPIN
TESTIM
ANDRODERM, AXIRON
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