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Prior Authorization Drug List

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Prior Authorization Drug List Commercial PAR List 2021 Policy TITLE Number DRUGS REQUIRING PRIOR AUTHORIZATION acalabrutinib (CALQUENCE) PAR-427 acalabrutinib (CALQUENCE) ACTERMA PAR-287 ACTEMRA (tocilizumab) ADEMPAS® (riociguat) PAR-409 ADEMPAS® (riociguat) ADRENACLICK/SYMJEPI PAR-384 ADRENACLICK ADRENACLICK/SYMJEPI PAR-384 SYMJEPI ADUHELM (adacanumab) PAR-588 ADUHELM (adacanumab) AFINITOR (everolimus) PAR-361 AFINITOR (everolimus) AIMOVIG PAR-445 AIMOVIG Aldesleukin (PROLEUKIN) PAR-209_A aldesleukin (PROLEUKIN) ALECENSA (alectinib) PAR-360 ALECENSA (alectinib) ALINIA (nitazoxanide) PAR-429 ALINIA (nitazoxanide) Anticholinergic Beta Agonist Combo Inhalers PAR-458 BEVESPI AEROSPHERE Anticholinergic Beta Agonist Combo Inhalers PAR-458 DUAKLIR PRESSAIR Anticholinergic Beta Agonist Combo Inhalers PAR-458 UTIBRON NEOHALER ANTICHOLINERGIC INHALERS PAR-459 SEEBRI NEOHALER ANTICHOLINERGIC INHALERS PAR-459 TUDORZA PRESSAIR ANTICOAGULANTS PAR-389 BEVYXXA ANTICOAGULANTS PAR-389 PRADAXA ANTICOAGULANTS PAR-389 SAVAYSA ANTIMALARIAL AGENTS PAR-262_A ARAKODA (tafenoquine) ANTIMALARIAL AGENTS PAR-262_A ARALEN (chloroquine) ANTIMALARIAL AGENTS PAR-262_A atovaquone/ proguanil ANTIMALARIAL AGENTS PAR-262_A chloroquine ANTIMALARIAL AGENTS PAR-262_A COARTEM (artemether/lumefantrine) ANTIMALARIAL AGENTS PAR-262_A DARAPRIM (pyrimethamine) ANTIMALARIAL AGENTS PAR-262_A KRINTAFEL (tafenoquine) ANTIMALARIAL AGENTS PAR-262_A MALARONE (atovaquone/proguanil) ANTIMALARIAL AGENTS PAR-262_A mefloquine ANTIMALARIAL AGENTS PAR-262_A primaquine ARCALYST,iLARIS PAR-278_A ARCALYST (rilonacept) ARCALYST,iLARIS PAR-278_A iLARIS (canakinumab) AUVI-Q 0.1MG, 0.15MG, 0.3MG PAR-495 AUVI-Q AYVAKIT (avapritinib) PAR-505 AYVAKIT (avapritinib) BALVERSA (erdafitinib) PAR-484 BALVERSA (erdafitinib) BASAL INSULINS (Commercial) PAR-385 LANTUS Updated: 9/2021 Commercial PAR List 2021 Policy TITLE Number DRUGS REQUIRING PRIOR AUTHORIZATION BASAL INSULINS (Commercial) PAR-385 TOUJEO benralizumab (FASENRA) PAR-426 benralizumab (FASENRA) BOSULIF (bosutinib) PAR-362 BOSULIF (bosutinib) BOTOX, DYSPORT, xeomin PAR-273_D BOTOX (botulinum toxin type a) BOTOX, DYSPORT, xeomin PAR-273_D DYSPORT (abobotulinumtoxina) BOTOX, DYSPORT, xeomin PAR-273_D XEOMIN (incobotulinumtoxin a) BRAF MUTATIONS IN MALGINANT MELANOMA PAR-299 COTELLIC (cobietinib) BRAF MUTATIONS IN MALGINANT MELANOMA PAR-299 MEKINIST (trametinib) BRAF MUTATIONS IN MALGINANT MELANOMA PAR-299 TAFINLAR (dabrafenib) BRAF MUTATIONS IN MALGINANT MELANOMA PAR-299 ZELBORAF (vemurafenib) BRAFTOVI PAR-452 BRAFTOVI brigatinib (ALUNBRIG) PAR-397 ALUNBRIG (brigatinib) BRUKINSA (zanubrutinib) PAR-503 BRUKINSA (zanubrutinib) BYETTA/BYDUREON PAR-392 BYDUREON BYETTA/BYDUREON PAR-392 BYETTA BYLVAY (odevixibat) PAR-591 BYLVAY (odevixibat) C1 Inhibitor (CINRYZE) PAR-282_A CINRYZE (esterase inhibitor) C1 INHIBITOR (human) (HAEGARDA) PAR-412 HAEGARDA CABLIVI (caplacizumab) PAR-478 CABLIVI (caplacizumab) CABOMETYX (cabozantinib) PAR-380 CABOMETYX (cabozantinib) CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAGONISTS PAR-463 AJOVY CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAGONISTS PAR-463 EMGALITY CIALIS PAR-301 CIALIS (tadalafil) CIMZIA PAR-277 CIMZIA (certolizumab pegol) CINQAIR (reslizumab) PAR-358 CINQAIR (reslizumab) Compounded Products PAR-334 Compounds Non-preferred Continuous Glucose Monitor (CGM) and associated CONTINUOUS GLUCOSE MONITOR (CGM)- MNPA PAR-477 supplies (Guardian, Enlite, Real-Time, Minimed, Eversense) CONTRACEPTIVES MEDICAL EXCEPTION PAR-272 Contraceptives (oral,transdermal and vaginal) and LUNELLE COPAXONE PAR-441 COPAXONE COPIKTRA (duvelisib) PAR-466 COPIKTRA (duvelisib) CORTICOSTEROID INHALERS (Commercial only) PAR-387 AEROSPAN CORTICOSTEROID INHALERS (Commercial only) PAR-387 ALVESCO CORTICOSTEROID INHALERS (Commercial only) PAR-387 PULMICORT COSENTYX PAR-338 COSENTYX (secukinumab) Updated: 9/2021 Commercial PAR List 2021 Policy TITLE Number DRUGS REQUIRING PRIOR AUTHORIZATION CRYSVITA PAR-437 CRYSVITA DAKLINZA PAR-348 DAKLINZA (daclatasvir) DAURISMO (glasdegib) PAR-473 DAURISMO (glasdegib) DESOXYN PAR-381 DESOXYN (methamphetamine) DESOXYN PAR-381 methamphetamine deutetrabenazine (Austedo) PAR-395 AUSTEDO (deutetrabenazine) DIABETIC TEST STRIPS (Commercial only) PAR-386 DIABETIC TEST STRIPS (other than ONE TOUCH) diclofenac 3% gel PAR-399 diclofenac 3% gel DIFICID PAR-297 DIFICID( fidaxomicin) DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS PAR-316 alogliptin DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS PAR-316 JUVISYNC (sitagliptin/simvastatin) DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS PAR-316 KAZANO (alogliptin-metformin) DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS PAR-316 KOMBIGLYZE (saxagliptin-metformin) DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS PAR-316 NESINA (alogliptin) DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS PAR-316 ONGLYZA (saxagliptin) DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS PAR-316 OSENI (alogliptin-pioglitazone) DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS PAR-316 saxagliptin DOPTELET (avatrombopag) PAR-481 DOPTELET (avatrombopag) doxepin Topical PAR-433 doxepin topical doxepin Topical PAR-433 prudoxin doxepin Topical PAR-433 zonalon DUPIXENT (dupilumab) PAR-416 DUPIXENT (dupilumab) EGFR MUTATIONS PAR-319 GILOTRIF (afatinib dimaleate) EGFR MUTATIONS PAR-319 TAGRISSO (osimertinib) EGRIFTA PAR-293 EGRIFTA (tesamorelin acetate [rDNA origin]) ELZONRIS (tagraxofusp-erza) PAR-479 ELZONRIS (tagraxofusp-erza) EMFLAZA (deflazacort tablets and oral susp) PAR-394 EMFLAZA (deflazacort tablets and oral susp) EMPAVELI (pegcetacoplan) PAR-590 EMPAVELI (pegcetacoplan) Endari (glutamine) PAR-424 Endari (glutamine) ENSPRYNG (satralizumab-mwge) PAR-540 ENSPRYNG (satralizumab-mwge) ENTYVIO PAR-442 ENTYVIO EPCLUSA PAR-379 EPCLUSA (sofosbuvir-velpatasvir) EPIDIOLEX (cannabidiol) PAR-465 EPIDIOLEX (cannabidiol) Epoetin alfa (EPOGEN, PROCRIT) Darbepoetin alfa (ARANESP) PAR-231_E ARANESP (darbepoetin alfa) Epoetin alfa (EPOGEN, PROCRIT) Darbepoetin alfa (ARANESP) PAR-231_E EPOGEN (epoetin alfa) Updated: 9/2021 Commercial PAR List 2021 Policy TITLE Number DRUGS REQUIRING PRIOR AUTHORIZATION Epoetin alfa (EPOGEN, PROCRIT) Darbepoetin alfa (ARANESP) PAR-231_E PROCRIT (epoetin alfa) ERLEADA (apalutamide) PAR-430 ERLEADA (apalutamide) etanercept (ENBREL) PAR-250 ENBREL (etanercept) EVEKEO (amphetamine sulfate) PAR-340 EVEKEO (amphetamine sulfate) EVRYSDI (risdiplam) PAR-543 EVRYSDI (risdiplam) EVZIO (naloxone) PAR-383 EVZIO (naloxone) EXCLUDED/NON-FORMULARY DRUGS PAR-337 EXCLUDED/NON-FORMULARY DRUGS EXONDYS 51 PAR-391 EXTONDY 51 (antisense oligonucleotide) FAMILIAL HYPERCHOLESTEROLEMIA PAR-314 JUXTAPID (lomitapide) FAMILIAL HYPERCHOLESTEROLEMIA PAR-314 KYNAMRO (mipomersen) FINTEPLA (fenfluramine) PAR-539 FINTEPLA (fenfluramine) FIRAZYR (icatibant) PAR-434 FIRAZYR (icatibant) FIRDAPSE (amifampridine) PAR-476 FIRDAPSE (amifampridine) FLECTOR (diclofenac) PATCH PAR-354 FLECTOR PATCH (diclofenac) GALAFOLD PAR-454 GALAFOLD (migalastat) GATTEX (teduglutide) PAR-432 GATTEX (teduglutide) GLEEVEC (imatinib) PAR-363 GLEEVEC (imatinib) GLEEVEC (imatinib) PAR-363 imatinib GROWTH HORMONES PAR-233_H GENOTROPIN (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H HUMATROPE (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H NORDITROPIN (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H NORDITROPIN NORDIFLEX and FLEXPRO(somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H NUTROPIN (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H NUTROPIN AQ (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H NUTROPIN AQ NUSPIN (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H OMNITROPE (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H SAIZEN (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H SEROSTIM (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H ZOMACTON (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H ZORBTIVE (somatropin [rDNA origin]) H.P. ACTHAR GEL (corticotrophin) PAR-310 ACTHAR HP (corticotrophin) H2 Blocker Medical Exception PAR-497 rantidine 15mg/ml solution HARVONI (ledipasvir-sofosbuvir) PAR-335 HARVONI (ledipasvir-sofosbuvir) HEMATOPOIETIC GROWTH FACTOR(PROMACTA,NPLATE) PAR-283_A NPLATE (romiplostim) HEMATOPOIETIC GROWTH FACTOR(PROMACTA,NPLATE) PAR-283_A PROMACTA (eltrombopag olamine) Updated: 9/2021 Commercial PAR List 2021 Policy TITLE Number DRUGS REQUIRING PRIOR AUTHORIZATION HUMIRA PAR-275 HUMIRA (adalimumab) ICLUSIG (ponatinib) PAR-364 ICLUSIG (ponatinib) IDHIFA® (enasidenib) PAR-419 IDHIFA® (enasidenib) IDIOPATHIC PULMONARY FIBROSIS PAR-336 ESBRIET (pirfenidone) IDIOPATHIC PULMONARY FIBROSIS PAR-336 OFEV (nintedanib) ILUMYA PAR-456 ILUMYA (tildrakizumab-asmn) IMITREX (sumatriptan)SPRAY PAR-307 IMITREX 5 mg NASAL SPRAY (sumatriptan) IMITREX (sumatriptan)SPRAY PAR-307 sumatriptan 5 mg nasal spray IMPAVIDO (miltefosine) PAR-571 IMPAVIDO (miltefosine) INFLAMATORY BOWEL DISEASE PAR-388 ASACOL HD INFLAMATORY BOWEL DISEASE PAR-388 DELZICOL INFLAMATORY BOWEL DISEASE PAR-388 GIAZO (balsalazide disodium) INSULIN PAR-317 ADMELOG INSULIN PAR-317 HUMULIN except Humulin R U-500 (insulin isophene & regular) INSULIN PAR-317 insulin lispro INSULIN PAR-317 AFREZZA INSULIN PAR-317 APIDRA (insulin glulisine) INSULIN PAR-317 HUMALOG (insulin lispro) INTERMEZZO PAR-312 INTERMEZZO (zolpidem tartrate) INTRAROSA/OSPHENA PAR-439 INTRAROSA (prasterone) INTRAROSA/OSPHENA PAR-439 OSPHENA (ospemifene) IRESSA (gefitinib) PAR-366 IRESSA (gefitinib) ISTURISA (osilodrostat) PAR-509 ISTURISA (osilodrostat) Itraconazole (SPORANOX Capsules and Solution, ONMEL, tolsura) PAR-216_F itraconazole (caps and solution), SPORANOX, tolsura Itraconazole (SPORANOX Capsules and Solution, ONMEL,
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