2020 Prior Authorization Criteria

2020 PRIOR AUTHORIZATION CRITERIA TABLE OF CONTENTS abiraterone tablet ...................................................................................................................... 217 ABRAXANE .............................................................................................................................. 131 ACTIMMUNE .............................................................................................................................. 14 ADASUVE ................................................................................................................................... 27 ADEMPAS ................................................................................................................................ 197 AFINITOR ................................................................................................................................. 217 AFINITOR DISPERZ ................................................................................................................. 217 AIMOVIG ..................................................................................................................................... 15 ALECENSA ............................................................................................................................... 217 ALIMTA ..................................................................................................................................... 131 ALIQOPA .................................................................................................................................. 131 alosetron tablet ........................................................................................................................... 17 ALUNBRIG ................................................................................................................................ 217 ambrisentan tablet .................................................................................................................... 199 AMITIZA ...................................................................................................................................... 19 ANADROL-50 ............................................................................................................................. 22 ANDRODERM ............................................................................................................................ 25 APOKYN ..................................................................................................................................... 29 ARCALYST ................................................................................................................................. 30 armodafinil tablet ......................................................................................................................... 31 ARRANON ................................................................................................................................ 131 ARZERRA ................................................................................................................................. 131 AUBAGIO .................................................................................................................................. 152 Updated 10/2019 VALUE PLUS 2020 1 AVASTIN ................................................................................................................................... 131 AVONEX ................................................................................................................................... 153 AVONEX PREFILLED KIT ........................................................................................................ 153 BALVERSA ............................................................................................................................... 217 BAVENCIO ............................................................................................................................... 172 BELEODAQ .............................................................................................................................. 131 BENLYSTA ................................................................................................................................. 34 benztropine tablet ..................................................................................................................... 122 BESPONSA .............................................................................................................................. 131 BETASERON ............................................................................................................................ 154 bexarotene capsule ................................................................................................................... 217 BLINCYTO ................................................................................................................................ 131 bosentan tablet ......................................................................................................................... 200 BOSULIF ................................................................................................................................... 217 BRAFTOVI 75 mg capsule ........................................................................................................ 217 CABOMETYX ........................................................................................................................... 217 CALQUENCE ............................................................................................................................ 217 CAPRELSA ............................................................................................................................... 217 CARBAGLU ................................................................................................................................ 75 CEREZYME .............................................................................................................................. 105 CHENODAL ................................................................................................................................ 76 CHLORPROMAZINE injection .................................................................................................... 27 chlorpromazine tablet .................................................................................................................. 27 CHORIONIC GONADOTROPIN ................................................................................................. 77 cinacalcet tablet .......................................................................................................................... 78 CINRYZE .................................................................................................................................. 114 Updated 10/2019 VALUE PLUS 2020 2 CLEMASTINE tablet ................................................................................................................. 122 clobazam suspension, tablet ....................................................................................................... 36 clorazepate tablet ........................................................................................................................ 39 COMETRIQ ............................................................................................................................... 217 COPAXONE .............................................................................................................................. 156 COPIKTRA ................................................................................................................................ 217 CORLANOR ................................................................................................................................ 81 COSENTYX ................................................................................................................................ 46 COTELLIC ................................................................................................................................ 217 CRESEMBA ................................................................................................................................ 82 CRYSVITA .................................................................................................................................. 83 cyclobenzaprine 5 mg, 10 mg tablet ......................................................................................... 123 CYRAMZA ................................................................................................................................ 131 CYSTAGON ................................................................................................................................ 86 CYSTARAN ................................................................................................................................ 85 DAKLINZA .................................................................................................................................. 87 dalfampridine ER tablet ............................................................................................................... 88 DALIRESP .................................................................................................................................. 89 danazol capsule .........................................................................................................................

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