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2019 Prior Authorization Criteria

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2019 Prior Authorization Criteria 2019 PRIOR AUTHORIZATION CRITERIA TABLE OF CONTENTS abiraterone 250 mg tablet ......................................................................................................... 227 ABRAXANE .............................................................................................................................. 130 ACTIMMUNE .............................................................................................................................. 16 ADASUVE ................................................................................................................................... 27 ADCIRCA .................................................................................................................................. 207 ADEMPAS ................................................................................................................................ 209 AFINITOR ................................................................................................................................. 227 AFINITOR DISPERZ ................................................................................................................. 227 AIMOVIG ..................................................................................................................................... 17 ALECENSA ............................................................................................................................... 227 ALIMTA ..................................................................................................................................... 130 ALIQOPA .................................................................................................................................. 130 ALUNBRIG ................................................................................................................................ 227 ambrisentan tablet .................................................................................................................... 213 AMITIZA ...................................................................................................................................... 20 amitriptyline tablet ..................................................................................................................... 120 AMOXAPINE ............................................................................................................................. 120 AMPYRA ..................................................................................................................................... 78 ANADROL-50 ............................................................................................................................. 23 ANDRODERM ............................................................................................................................ 26 ANDROGEL 1.62% ..................................................................................................................... 26 ANDROXY .................................................................................................................................. 25 APOKYN ..................................................................................................................................... 29 Updated 11/2019 VALUE 2019 1 ARCALYST ................................................................................................................................. 30 aripiprazole ODT ......................................................................................................................... 27 aripiprazole solution, tablet ......................................................................................................... 27 ARISTADA .................................................................................................................................. 27 ARISTADA INITIO ...................................................................................................................... 27 armodafinil tablet ......................................................................................................................... 31 ARZERRA ................................................................................................................................. 130 AUBAGIO .................................................................................................................................. 152 AVASTIN ................................................................................................................................... 130 AVONEX ................................................................................................................................... 153 AVONEX PREFILLED KIT ........................................................................................................ 153 BALVERSA ............................................................................................................................... 227 BAVENCIO ............................................................................................................................... 174 BELEODAQ .............................................................................................................................. 130 BENLYSTA ................................................................................................................................. 34 benztropine tablet ..................................................................................................................... 118 BESPONSA .............................................................................................................................. 130 BETASERON ............................................................................................................................ 154 bexarotene capsule ................................................................................................................... 227 BLINCYTO ................................................................................................................................ 130 bosentan tablet ......................................................................................................................... 211 BOSULIF ................................................................................................................................... 227 BRAFTOVI ................................................................................................................................ 227 CABOMETYX ........................................................................................................................... 227 CALQUENCE ............................................................................................................................ 227 CAPRELSA ............................................................................................................................... 227 Updated 11/2019 VALUE 2019 2 CARBAGLU ................................................................................................................................ 67 CEREZYME .............................................................................................................................. 101 CHENODAL ................................................................................................................................ 68 CHLORPROMAZINE injection .................................................................................................... 27 chlorpromazine tablet .................................................................................................................. 27 CHORIONIC GONADOTROPIN ................................................................................................. 69 cinacalcet tablet .......................................................................................................................... 70 CINRYZE .................................................................................................................................. 110 CLEMASTINE tablet ................................................................................................................. 118 clobazam suspension, tablet ....................................................................................................... 44 clomipramine capsule ............................................................................................................... 120 clonazepam ODT ........................................................................................................................ 36 clonazepam tablet ....................................................................................................................... 36 clorazepate tablet ........................................................................................................................ 38 clozapine ODT 12.5 mg, 25 mg, 100 mg .................................................................................... 27 clozapine tablet ........................................................................................................................... 27 COMETRIQ ............................................................................................................................... 227 COPAXONE .............................................................................................................................. 156 COPIKTRA ...............................................................................................................................
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