Standard Prior Authorization Medication List July, 2017

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Standard Prior Authorization Medication List July, 2017 Drug Class or Disease Medication Name(s) Acne - oral Absorica® (isotretinoin) Acne - oral antibiotics Doryx®, Adoxa®, Monodox®, Solodyn®, Acticlate®, Oracea® Acanya® (clindamycin/benzoyl peroxide) 1.2%-2.5% gel, Atralin® (tretinoin) 0.05% gel, cream, Onexton® Acne - topical (clindamycin/benzoyl peroxide), Avar LS® (sulfacetamide/sulfur), Clindagel® (clindamycin) gel 1%, Ziana® (clindamycin/tretinoin), Retin-A MicroGel® (tretinoin) Carac® (fluorouracil) cream 5%, Zyclara® (imiquimod) 2.5% & Actinic keratosis 3.75% cream, Picato® (ingenol mebutate) gel Allergic Reaction Auvi-Q®, EPIPEN-JR® (epinephrine ) Anabolic androgens Testosterone Analgesia – topical Lido-K® (lidocaine) 3% lotion Antibiotic - topical Nuvessa® Gel 1.3% Anticonvulsant Trokendi ®XR Antidiabetic medications Glumetza® (metformin ER), Ertaczo® 2% cream (sertaconazole), Xolegel® 2% Gel Antifungal - topical (ketoconazole) Antifungal – oral Oravig® (miconazole) buccal tab Antihypertensive Epaned® (enalapril) soln Zovirax® 5% cream (acyclovir), Denavir® 1% cream Antiviral - topical (penciclovir); Xerese® (acyclovir-hydrocortisone) cream 5-1% Vimovo® (naproxen-esomeprazole), Duexis® (ibuprofen- Combination medications famotidine), Treximet® (sumatriptan-naproxen) Clobex® (clobetasol) spray 0.05%, Trianex® (triamcinolone) Corticosteroids - topical oint., Verdeso® (desonide) 0.05% foam, Locoid® (hydrocortisone) 0.1% cream, lotion, oint. Enterocolitis Donnatal® (phenobarbital/atropine/scopolamine) External warts (condylomata acuminate) due Condylox (podofilox) Gel 0.5% to HPV infection Gamma-aminobutyric acid (GABA) agonists Horizant® (gabapentin enacarbil) Gastrointestinal conditions Carafate® (sucralfate) suspension Glaucoma Istalol® (timolol) ophth soln 0.5% Musculoskelatal pain Lorzone® (chlorzoxazone); Amrix® (cyclobenzaprine) Neuropathic pain Lidoderm® (lidocaine) patch; Gralise® (gabapentin) oral Non-steroidal anti-inflammatory meds (oral) Zipsor® (diclofenac), Zorvolex® (diclofenac) Non-steroidal anti-inflammatory meds Pennsaid® (diclofenac) (topical) Ocular inflammation Restasis® (cyclosporine), Xiidra® (lifitegrast) Jublia® (efinaconazole) solution, Kerydin® solution 5% Onychomycosis (toenail fungus) (tavaborole) Oral antibiotic Vancomycin capsules Pain management/opiates Fentora®, Abstral®, Lazanda®, Actiq®, Subsys®, Embeda® Enstilar (calcipotriene-betamethasone) foam, Taclonex® Psoriasis – topical Suspension Specialty Medications IPM defined list PROP R IETARY P a g e 1 | 2 Drug Class or Disease Medication Name(s) Topical Medications (misc.) Eucrisa® (crisaborole); Sklice® (ivermectin) PROP R IETARY P a g e 2 | 2 .

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