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Updated: May 20, 2021 Prior Authorization Drugs (NEW ADDITIONS HIGHLIGHTED)

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Updated: May 20, 2021 Prior Authorization Drugs (NEW ADDITIONS HIGHLIGHTED) Updated: May 20, 2021 Prior Authorization Drugs (NEW ADDITIONS HIGHLIGHTED) A Abatacept (ORENCIA) Abemaciclib (VERZENIO) Abiraterone Acetate (ZYTIGA) Abiraterone Acetate (+ GENERIC FORMULATIONS) AbobotulinumtoxinA (DYSPORT) Abraxane (ABRAXANE) Acalabrutinib (CALQUENCE) Actemra (ACTEMRA) Adalimumab (AMGEVITA) Adalimumab (HADLIMA) Adalimumab (HULIO) Adalimumab (HUMIRA) Adalimumab (HYRIMOZ) Adalimumab (IDACIO) Adcetris (ADCETRIS) Adcirca (ADCIRCA) Adempas (ADEMPAS) Afatinib (GIOTRIF) Afinitor (AFINITOR) Aflibercept (EYLEA) Aflibercept (ZALTRAP) Afstyla (AFSTYLA) Agalsidase Alfa (REPLAGAL) Agalsidase Beta (FABRAZYM) Aimovig (AIMOVIG) Ajovy (FREMANEZUMAB) Aldesleukin (PROLEUKIN) Aldurazyme (ALDURAZYME) Alecensaro (ALECENSARO) Alectinib (ALECENSARO) Alefacept (AMEVIVE) Alemtuzumab (MABCAMPATH) Alemtuzumab (LEMTRADA) Alglucosidase Alfa (MYOZYME) Alimta (ALIMTA) Alirocumab (PRALUENT) Alpha-1-Proteinase Inhibitor (PROLASTIN - C) Alpha-1-Proteinase Inhibitor (ZEMAIRA) Alpelisib (PIQRAY) Alunbrig (ALUNBRIG) Ambrisentan (VOLIBRIS) Ambrisentan (Generic Formulations) Amevive (AMEVIVE) Amgevita (ADALIMUMAB) Amifampridine Phosphate (FIRDAPSE) Amifampridine Phosphate (RUZURGI) Anakinra (KINERET) Apalutamide (ERLEADA) Apomorphine (KYNMOBI) Apremilast (OTEZLA) Page 1 of 17 Updated: May 20, 2021 Arsenic Trioxide (TRISENOX) Arsenic Trioxide (Generic Formulations) Arzerra (ARZERRA) Asfotase Alfa (STRENSIQ) Asparaginase (ERWINASE) Asunaprevir (SUNVEPRA) Atezolizumab (TECENTRIQ) Atriance (ATRIANCE) Aubagio (AUBAGIO) Avastin (AVASTIN) Avelumab (BAVENCIO) Avonex (AVONEX) Avsola (INFLIXIMAB) Axicabtagene Ciloleucel (YESCARTA) Axitinib (INLYTA) Azacitidine (ONUREG) Azacitidine (VIDAZA) Azacitidine (Generic Formulations) Aztreonam (CAYSTON) B Bacillus Calmette-Guerin (BCG) Substrain Connaught (IMMUCYST) Bacillus Calmette-Guerin (BCG) – Strain Russian BCG-I (VERITY-BCG) Balversa (BALVERSA) Baricitinib (OLUMIANT) Bavencio (BAVENCIO) Belimumab (BENLYSTA) Belkyra (BELKYRA) Bendamustine Hydrochloride (TREANDA) Bendamustine Hydrochloride (+ GENERIC FORMULATIONS) Benlysta (BENLYSTA) Berinert (BERINERT) Benralizumab (FASENRA) Beovu (BROLUCIZUMAB) Besponsa (BESPONSA) Betaseron (BETASERON) Bevacizumab (AVASTIN) Bevacizumab (MVASI) Bevacizumab (ZIRABEV) Binimetinib (MEKTOVI) Bicnu (BICNU) Bleomycin (Generic Formulations) Blinatumomab (BLINCYTO) Blincyto (BLINCYTO) Boceprevir (VICTRELIS) Boceprevir (VICTRELIS TRIPLE) Bortezomib (VELCADE) Bortezomib (Generic Formulations) Bosentan (TRACLEER) Bosentan (Generic Formulations) Bosulif (BOSULIF) Bosutinib (BOSULIF) Botox (BOTOX) Page 2 of 17 Updated: May 20, 2021 Braftovi (ENCORAFENIB) Brentuximab Vedotin (ADCETRIS) Brenzys (BRENZYS) Brigatinib (ALUNBRIG) Brineura (BRINEURA) Brodalumab (SILIQ) Brolucizumab (BEOVU) Brukinsa (ZANUBRUTINIB) Burosumab (CRYSVITA) C C1 Esterase Inhibitor (Human) (BERINERT) C1 Esterase Inhibitor (Human) (CINRYZE) C1 Esterase Inhibitor (Human) (HAEGARDA) Cabazitaxel (JEVTANA) Cabazitaxel (Generic Formulations) Cabenuva (CABOTEGRAVIR/RILPIVIRINE) Cablivi (CAPLACIZUMAB) Cabotegravir (VOCABRIA) Cabotegravir/Rilpivirine (CABENUVA) Cabometyx (CABOMETYX) Cabozantinib (CABOMETYX) Caelyx (CAELYX) Calcifediol (RAYALDEE) Calquence (CALQUENCE) Camptosar (CAMPTOSAR) Canakinumaab (ILARIS) Cannabidiol (SATIVEX) Capecitabine (XELODA) Caplacizumab (CABLIVI) Caprelsa (CAPRELSA) Carbaglu (CARBAGLU) Carfilzomib (KYPROLIS) Carglumic Acid (CARBAGLU) Carmustine (BICNU) Caripul (CARIPUL) Cayston (CAYSTON) Cedazuridine/Decitabine (INQOVI) Cemiplimab (LIBTAYO) Cenegermin (OXERVATE) Cerdelga (CERDELGA) Cerezyme (CEREZYME) Ceritinib (ZYKADIA) Cerliponase Alfa (BRINEURA) Certican (CERTICAN) Certolizumab Pegol (CIMZIA) Cetuximab (ERBITUX) Cimzia (CIMZIA) Cinacalet (SENSIPAR) Cinacalet (Generic Formulations) Cinqair (CINQAIR) Cinryze (CINRYZE) Page 3 of 17 Updated: May 20, 2021 Cladribine (MAVENCLAD) Clofarabine (CLOLAR) Clolar (CLOLAR) Cobimetinib (COTELLIC) Copaxone (COPAXONE) Cosentyx (COSENTYX) Cotellic (COTELLIC) Crizotinib (XALKORI) Crysvita (CRYSVITA) Cubicin (CUBICIN) Cutaquig (CUTAQUIG) Cuvposa (CUVPOSA) Cyramza (CYRAMZA) Cystadrops (CYSTADROPS) Cysteamine (CYSTADROPS) Cysteamine (PROCYSBI) Cytarabine/Daunorubicin (VYXEOS) D Dabrafenib (TAFINLAR) Daclatasvir (DAKLINZA) Dacogen (DACOGEN) Dacomitinib (VIZIMPRO) Daklinza (DAKLINZA) Daptomycin (CUBICIN) Daratumumab (DARZALEX) Darolutamide (NUBEQA) Darzalex (DARZALEX) Dasatinab (SPRYCEL) Dasatinab (Generic Formulations) Daurismo (GLASDEGIB) Decitabine (DACOGEN) Decitabine (DEMYLOCAN) Deferasirox (EXJADE) Deferasirox (JADENU) Deferasirox (Generic Formulations) Deferiprone (FERRIPROX) Defibrotide (DEFITELIO) Defitelio (DEFITELIO) Demylocan (DEMYLOCAN) Deoxycholic Acid (BELKYRA) Dimethyl Fumarate (TECFEDERA) Dinutuximab (UNITUXIN) Docataxel (TAXOTERE) Docataxel (Generic Formulations) Dojolvi (TRIHEPTANOIN) Dornase Alfa (PULMOZYME) Doxorubicin (CAELYX) Doxorubicin (MYOCET) Doxorubicin (Generic Formulations) Dupilumab (DUPIXENT) Dupixent (DUPIXENT) Durvalumab (IMFINZI) Page 4 of 17 Updated: May 20, 2021 Dysport Therapeutic (DYSPORT) E Eculizumab (SOLIRIS) Edaravone (RADICAVA) Egrifta (EGRIFTA) Elaprase (ELAPRASE) Elbasvir (ZEPATIER) Elelyso (ELELYSO) Eliglustat (CERDELGA) Elosulfase Alfa (VIMIZIM) Elotuzumab (EMPLICITI) Eloxatin (ELOXATIN) Eltrombopag (REVOLADE) Emgality (EMGALITY) Emicizumab (HEMLIBRA) Empliciti (EMPLICITI) Enasidenib (IDHIFA) Encorafenib (BRAFTOVI) Enbrel (ENBREL) Enhurtu (TRASTUZUMAB DERUXTECAN) Enspryng (SATRALIZUMAB) Entrectinib (ROZLYTREK) Entyvio (ENTYVIO) Enzalutamide (XTANDI) Epclusa (EPCULSA) Epoprostenol (CARIPUL) Epoprostenol (FLOLAN) Epoprostenol (Generic Formulations) Eptinezumab (VYEPTI) Erbitux (ERBITUX) Erdafitinib (BALVERSA) Erelzi (ERELZI) Erenumab (AIMOVIG) Erivedge (ERIVEDGE) Erleada (ERLEADA) Erlotinib (TARCEVA) Erlotinib (Generic Formulations) Erwinase (ERWINASE) Esbriet (ESBRIET) Esketamine (SPRAVATO) Etanercept (BRENZYS) Etanercept (ENBREL) Etanercept (ERELZI) Evenity (EVENITY) Everolimus (AFINITOR) Everolimus (CERTICAN) Everolimus (Generic Formulations) Evolocumab (REPATHA) Evrysdi (RISDIPLAM) Exjade (EXJADE) Extavia (EXTAVIA) Eylea (EYLEA) Page 5 of 17 Updated: May 20, 2021 F Fabrazyme (FABRAZYME) Fampridine (FAMPYRA) Fampridine (Generic Formulations) Fampyra (FAMPYRA) Fasenra (FASENRA) Fasturtec (FASTURTEC) Fedratinib (INREBIC) Ferona (FERONA) Ferriprox (FERRIPROX) Filgrastim (NEUPOGEN) Filgrastim (GRASTOFIL) Filgrastim (NIVESTYM) Fingolimod (GILENYA) Fingolimod (Generic Formulations) Firazyr (FIRAZYR) Firdapse (AMIFAMPRIDINE PHOSPHATE) Flebogamma (FLEBOGAMMA) Flolan (FLOLAN) Fludara (FLUDARA) Fludarabine (FLUDARA) Fludarabine (Generic Formulations) Fluocinolone Acetonide (ILUVIEN) Folotyn (FOLOTYN) Fostamatinib (TAVALISSSE) Fremanezumab (AJOVY) Fulphila (FULPHILA) G Galafold (GALAFOLD) Galexos (GALEXOS) Galsulfase (NAGLAZYME) Gazyva (GAZYVA) Gefitinib (IRESSA) Gefitinib (Generic Formulations) Galcanezumab (EMGALITY) Gemcitabine (GEMZAR) Gemcitabine (Generic Formulations) Gemtuzumab Ozogamicin (MYLOTARG) Gemzar (GEMZAR) Genotropin (GENOTROPIN) Gilenya (GILENYA) Giotrif (GIOTRIF) Gilteritinib (XOSPATA) Givlaari (GIVOSIRAN) Givosiran (GIVLAARI) Glasdegib (DAURISMO) Glatect (GLATECT) Glatiramer Acetate (COPAXONE) Glatiramer Acetate (GLATECT) Glatiramer Acetate (+Generic Formulations) Page 6 of 17 Updated: May 20, 2021 Glecaprevir (MAVIRET) Glycerol Phenylbutyrate (RAVICTI) Glycopyrrolate (CUVPOSA) Gleevec (GLEEVEC) Grastofil (GRASTOFIL) Grazoprevir (ZEPATIER) Golimumab (SIMPONI) Guselkumab (TREMFYA) H Hadlima (HADLIMA) Haegarda (HAEGARDA) Harvoni (HARVONI) Hemlibra (HEMLIBRA) Herceptin (HERCEPTIN) Herzuma (HERZUMA) Hizentra (HIZENTRA) Holkira (HOLKIRA) Humatrope (HUMATROPE) Hulio (ADALIMUMAB) Humira (HUMIRA) Hycamtin (HYCAMTIN) Hyrimoz (ADALIMUMAB) I Ibavyr (IBAVYR) Ibrance (IBRANCE) Ibrutinib (IMBRUVICA) Icatibant (FIRAZYR) Icosapent Ethyl (VASCEPA) Iclusig (ICLUSIG) Idacio (ADALIMUMAB) Idelalisib (ZYDELIG) Idhifa (IDHIFA) Idursulfate (ELAPRASE) Ilaris (ILARIS) Iluvien (ILUVIEN) Imatinib (GLEEVEC) Imatinib (Generic Formulations) Imbruvica (IMBRUVICA) Imfinzi (IMFINZI) Imiglucerase (CEREZYME) Immucyst (IMMUCYST) Immune Globulin (FLEBOGAMMA) Immune Globulin (HIZENTRA) Immune Globulin (XEMBIFY) Immunoglobin G (CUTAQUIG) IncobotulinumtoxinA (XEOMIN) Increlex (MECASERMIN) Inflectra (INFLECTRA) Infliximab (INFLECTRA) Infliximab (OMVYENCE) Page 7 of 17 Updated: May 20, 2021 Infliximab (REMICADE) Infliximab (RENFLEXIS) Infliximab (REMSIMA SC) Infliximab (AVSOLA) Inlyta (INLYTA) Inotersen (TEGSEDI) Inotuzumab Ozogamicin (BESPONSA) Inqovi (CEDAZURIDINE/DECITABINE) Inrebic (FEDRATINIB) Interferon Alfa-2B (INTRON A) Interferon Alpha-2A (ROFERON-A) Interferon Alpha-N1 (WELLFERON) Interferon Beta-1A (AVONEX) Interferon Beta-1A (REFIB) Interferon Beta-1B (BETASERON) Interferon Beta-1B (EXTAVIA) Interferon Beta-1B (FERONA) Intron A (INTRON A) Ipilimumab (YERVOY) Iressa (IRESSA) Irinotecan (CAMPTOSAR) Irinotecan (ONIVYDE) Irinotecan (Generic Formulations) Isatuximab (SARCLISA) Istodax (ISTODAX) Ivacaftor (KALYDECO) Ivacaftor (ORKAMBI) Ivacaftor (SYMDEKO) Ixazomib (NINLARO) Ixekizumab (TALTZ) J Jadenu (DEFERASIROX) Jakavi (JAKAVI) Jetrea (JETREA) Jevtana (JEVTANA) Jinarc (JINARC) Juxtapid (JUXTAPID) K Kadcyla (KADCYLA) Kalydeco (KALYDECO) Kanjinti (KANJINTI) Kanuma (KANUMA) Kepivance (KEPIVANCE) Kesimpta (OFATUMUMAB) Kevzara (KEVZARA) Keytruda (KEYTRUDA) Kineret (KINERET) Kisqali (KISQALI) Kuvan (KUVAN) Kymriah (KYMRIAH) Kynmobi (APOMORPHINE) Page 8 of 17 Updated: May 20, 2021 Kyprolis (KYPROLIS) L Lanadelumab (TAKHZYRO) Lanreotide (SOMATULINE
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