Prior Authorization List

ACCRETROPIN (somatropin) FOCALIN (methylphenidate) PRO-FAST HS (phentermine) ACCUTANE (isotretinoin) FOLLISTIM (follitropin beta) PRO-FAST SA (phentermine) ACTIMMUNE (interferon gamma 1b) FORTAMET (metformin hydrochloride) PRO-FAST SR (phentermine) ACTIQ (fentanyl citrate) FORTEO(teriparatide(rDNA origin) injection) PROMACTA (eltrombopag) ADAPALENE GALANTAMINE PROVIGIL (modafinil) ADCIRCA (tadalafil) GANIRELIX ACETATE RAZADYNE (galantamine) ADDERALL (amphetamine and GENOTROPIN (somatropin) REBETOL (ribavirin) dextroamphetamine mixed salts) GILENYA (fingolimod) REGRANEX (becaplermin) ADDERALL XR (amphetamine and GLEEVEC (imatinib mesylate) REPRONEX (menotropin) dextroamphetamine mixed salts) GONAL-F (follitropin alfa) RETIN-A (tretinoin topical) ADIPEX-P (phentermine) HCG RETIN-A MICRO (tretinoin topical) AFINITOR (everolimus) HUMATROPE (somatropin) REVATIO (sildenafil citrate) AMNESTEEM (isotretinoin) HUMIRA (adalimumab) REVLIMID (lenalidomide) AMPHETAMINE SALT COMBO HYCAMTIN ORAL (topotecan RIBASPHERE(ribavirin) AMPYRA (dalfampridine) hydrochloride) RIBAVIRIN ANDRODERM (testosterone topicals) INCRELEX (mecasermin) RITALIN PRODUCTS (methylphenidate) ANDROGEL (testosterone topicals) INFERGEN (interferon alfacon-1) RIVASTIGMINE ARANESP (darbepoetin alfa) INTRON A (interferon alfa-2b) SABRIL (vigabatrin) ARCALYST (rilonacept) INTUNIV (guanfacine) SAIZEN (somatropin) ARICEPT(donepezil) IONAMIN (phentermine) SAMSCA (tolvaptan) ATRALIN (tretinoin topical) IRESSA (gefitinib) SANCUSO (granisetron) AVITA (tretinoin topical) KUVAN (sapropterin hydrochloride) SELZENTRY (maraviroc) BENZPHETAMINE PRODUCTS LETAIRIS (ambrisentan) SEROPHENE (clomiphene) BONTRIL PDM (phentermine) LEUKINE (sargramostim) SEROSTIM (somatropin) BONTRIL SR (phentermine) LOTRONEX (alosetron HCL) SIMPONI (golimumab) BRAVELLE (urofollitropin) LOVAZA (omega-3-acid ethyl esters) SOTRET (isotretinoin) BYETTA (exenatide) LUVERIS (lutropin alfa) SPRYCEL (dasatinib) CETROTIDE (cetrorelix acetate) MEMANTINE STRATTERA (atomoxetine) CHENODAL MENOPUR (menotropin) STRIANT (testosterone topicals) CHORIONIC GONADOTROPIN METADATE PRODUCTS (methylphenidate) SUTENT (sunitinib malate) CIMZIA (certolizumab pegol) METHYLIN PRODUCTS (methylphenidate) TACRINE CLARAVIS (isotretinoin) METHYLPHENIDATE TARCEVA (erlotinib) CLOMID (clomiphene) MILOPHENE (clomiphene) TASIGNA (nilotinib) CLOMIPHENE CITRATE NAMENDA (memantine) TAZORAC (tazarotene) COGNEX(tacrine) NEULASTA (pegfilgrastim) TEMODAR (temozolomide) CONCERTA (methylphenidate) NEUMEGA (oprelvekin) TESTIM (testosterone topicals) COPEGUS (ribavirin) NEUPOGEN (filgrastim) TESTOSTERONE CYPIONATE CRINONE (progesterone) NEXAVAR (sorafenib) TESTOSTERONE ENANTHATE DAYTRANA (methylphenidate) NORDITROPIN (somatropin) TESTOSTERONE POWDER DELATESTRYL (testosterone enanthate) NOVAREL (chorionic gonadotropin) TEV-TROPIN (somatropin) DEPO-TESTOSTERONE NUTROPIN (somatropin) THALOMID (thalidomide) DESOXYN (methamphetamine hydrochloride) NUTROPIN AQ (somatropin) TRACLEER (bosentan) DEXEDRINE (dextroamphetamine) NUTROPIN DEPOT (somatropin) TRETIN - X (tretinoin topical) DEXTROAMPHETAMINE SULFATE NUVIGIL (armodafinil) TYKERB (lapatinib) DEXTROSTAT (dextroamphetamine) OBY-TRIM (phentermine) ULORIC (febuxostat) DIDREX (phentermine) OFORTA (fludarabin phosphate) VELTIN(tretinoin topical) DIETHYLPROPION PRODUCTS OMNITROPE (somatropin) VEPESID (etoposide) DIFFERIN (adapalene) ONSOLIS (fentanyl citrate) VICTOZA (liraglutide (rDNA origin)) DONEPEZIL ORFADIN (nitisinone) VIMOVO (naproxen/esomeprazole EFFIENT(prasugrel) OVIDREL (choriogonadotropin alfa) magnesium) ENBREL (etanercept) PEGASYS (peginterferon alfa-2a) VOTRIENT (pazopanib) ENDOMETRIN (progesterone) PEG INTRON (peginterferon alfa-2b) VYNANSE(lisdexamfetamine dimesylate) EPIDUO (adapalene and benzoyl peroxide) PHENDIMETRAZINE PRODUCTS XELODA (capecitabine) EPOGEN (epoetin alfa) PHENTERMINE PRODUCTS XENAZINE (tetrabenazine) ETOPOSIDE PHENTRIDE (phentermine) XENICAL (orlistat) EXELON(rivastigmine) PREGNYL (chorionic gonadotropin) XYREM (sodium oxybate) EXJADE (deferasirox) PROCENTRA (dextroamphetamine sulfate) ZIANA (tretinoin topical) FENTANYL CITRATE TRANSMUCOSAL PROCHIEVE (progesterone) ZOLINZA (vorinostat) FENTORA (fentanyl citrate) PROCRIT (epoetin alfa ZORBTIVE (somatropin)

Members covered under the Advantage Formulary will also require a prior authorization for the following drug categories: antihistamines, bisphosphosphonates, non-steroids anti-inflammatory drugs, cholesterol medications, hypnotics, migraine drugs, nasal steroids, proton pump inhibitors, urinary antispasmodics.

Prior authorizations may also be required for brand name drugs where there is an FDA approved generic equivalent drug available.

Independent licensee of the Blue Cross and Blue Shield Association Revised: 12.15.2010