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Drugs That Require Prior Authorization

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Drugs That Require Prior Authorization 2017 Drugs Requiring Prior Authorization List 12/1/17 Edition Status Definition PA required Prior Authorization is required. Please submit a Pharmacy Prior Authorization Request Form. Non-Preferred Use another agent similar to requested agent. Specific indication might be required also. Step Therapy An adequate trial of another preferred agent(s) is required before approval. Specialty Requires Prior Authorization. Refer to Specialty Pharmacy Medication Policies on CareSource.com Note: A drug is available generically if its listing includes both a generic and a brand name. Drug Status Special Instructions 8-Mop 10 mg Capsule PA required Required Diagnosis= Cutaneous T-Cell Lymphoma (CTCL) OR Psoriasis With A 30 Day Trial Of Calcipotriene Abelcet 5 mg/mL Vial Medical Benefit Bill Through Medical Benefit ABSORICA 10 mg CAPSULE Non-Preferred Requires trials of 30 days total of each group below either at the same time, separately, or overlapping Topicals: benzoyl peroxide 5% or 10%; benzoyl peroxide 4% or 8% liquid (Panoxyl), erythromycin/benzoyl (Benzamycin), sulfacetamide (Klaron), clindamycin topical (Cleocin T), erythromycin topical, tretinoin cream or gel or adapalene 0.1% gel or cream [or previously approved for a similar non-preferrerd topical agent] AND Orals: minocycline, doxycycline, tetracycline, or erythromycin ABSORICA 20 mg CAPSULE Non-Preferred Requires trials of 30 days total of each group below either at the same time, separately, or overlapping Topicals: benzoyl peroxide 5% or 10%; benzoyl peroxide 4% or 8% liquid (Panoxyl), erythromycin/benzoyl (Benzamycin), sulfacetamide (Klaron), clindamycin topical (Cleocin T), erythromycin topical, tretinoin cream or gel or adapalene 0.1% gel or cream [or previously approved for a similar non-preferrerd topical agent] AND Orals: minocycline, doxycycline, tetracycline, or erythromycin ABSORICA 30 mg CAPSULE Non-Preferred Requires trials of 30 days total of each group below either at the same time, separately, or overlapping Topicals: benzoyl peroxide 5% or 10%; benzoyl peroxide 4% or 8% liquid (Panoxyl), erythromycin/benzoyl (Benzamycin), sulfacetamide (Klaron), clindamycin topical (Cleocin T), erythromycin topical, tretinoin cream or gel or adapalene 0.1% gel or cream [or previously approved for a similar non-preferrerd topical agent] AND Orals: minocycline, doxycycline, tetracycline, or erythromycin 1 Drug Status Special Instructions ABSORICA 40 mg CAPSULE Non-Preferred Requires trials of 30 days total of each group below either at the same time, separately, or overlapping Topicals: benzoyl peroxide 5% or 10%; benzoyl peroxide 4% or 8% liquid (Panoxyl), erythromycin/benzoyl (Benzamycin), sulfacetamide (Klaron), clindamycin topical (Cleocin T), erythromycin topical, tretinoin cream or gel or adapalene 0.1% gel or cream [or previously approved for a similar non-preferrerd topical agent] AND Orals: minocycline, doxycycline, tetracycline, or erythromycin ABSTRAL 100 mcg TABLET PA required Required diagnosis = breakthrough pain in adults with cancer who are receiving and are tolerant to opioid therapy SUBLINGAL ABSTRAL 200 mcg TABLET PA required Required diagnosis = breakthrough pain in adults with cancer who are receiving and are tolerant to opioid therapy SUBLINGAL ABSTRAL 300 mcg TABLET PA required Required diagnosis = breakthrough pain in adults with cancer who are receiving and are tolerant to opioid therapy SUBLINGAL ABSTRAL 400 mcg TABLET PA required Required diagnosis = breakthrough pain in adults with cancer who are receiving and are tolerant to opioid therapy SUBLINGAL ABSTRAL 600 mcg TABLET PA required Required diagnosis = breakthrough pain in adults with cancer who are receiving and are tolerant to opioid therapy SUBLINGAL ABSTRAL 800 mcg TABLET PA required Required diagnosis = breakthrough pain in adults with cancer who are receiving and are tolerant to opioid therapy SUBLINGAL ACANYA GEL PUMP 2.5%-1.2% Non-Preferred Formulary Agents: BENZOYL PEROXIDE 2.5% GEL AND CLINDAMYCIN, CLINDAMAX (CLEOCIN-T) 1% GEL separately used together Acebutolol 200 mg Capsule Non-Preferred Formulary Agent(s): Any Formulary Beta-Blockers (Atenolol, Bisoprolol, Carvedilol, Labetalol, Metoprolol Succinate Or Tartrate, Nadolol, Propranolol) Acebutolol 400 mg Capsule Non-Preferred Formulary Agent(s): Any Formulary Beta-Blockers (Atenolol, Bisoprolol, Carvedilol, Labetalol, Metoprolol Succinate Or Tartrate, Nadolol, Propranolol) ACETAMINOPHEN- Non-Preferred Formulary Agents: Butalbital-Acetaminophen 50-325MG tablet (Phrenilin, Marten tabs), Butalbital-Acetaminophen- ISOMETHEPTENE-CAFFEINE Caffeine (Esgic-Plus) 50-500-40MG tablet, Butalbital-Aceteminophen-Caffeine (Fioricet) 50-325-40MG tablet (PRODRIN) TAB 325-65-20 MG ACETAMINOPHEN- Non-Preferred Formulary Agents: Butalbital-Acetaminophen 50-325MG tablet (Phrenilin, Marten tabs), Butalbital-Acetaminophen- ISOMETHEPTENE-CAFFEINE Caffeine (Esgic-Plus) 50-500-40MG tablet, Butalbital-Aceteminophen-Caffeine (Fioricet) 50-325-40MG tablet (PRODRIN) TAB 500-130-20 MG ACCU-CHEK TEST STRIPS/METER Non-Preferred Formulary Agents: FreeStyle or Precision products ACETAMINOPHEN-CAFFEINE- Non-Preferred Formulary Agent: Butalbital-Aceteminophen-Caffeine-Codeine (FIORICET-COD) 30-50-325-40 capsule DIHYDROCODEINE (PANLOR/PANLOR SS) 712.8-60-32 mg TABLET ACETYLCYSTEINE 10% Solution Non-Preferred Required Diagnosis: acetaminophen overdose OR *as mucolytic for diagnoses such as: chronic emphysema, chronic asthmatic bronchitis, emphyseam with bronchits, pneumonia, bronchitis, pulmonary complications of cystic fibrosis 2 Drug Status Special Instructions ACETYLCYSTEINE 20% Solution Non-Preferred Required Diagnosis: acetaminophen overdose OR *as mucolytic for diagnoses such as: chronic emphysema, chronic asthmatic bronchitis, emphyseam with bronchits, pneumonia, bronchitis, pulmonary complications of cystic fibrosis ACID JELLY Non-Preferred Formulary Agents: ALIGN, FLORAJEN, FLORA-Q, RESTORA, RISAQUAD, REZYST, or DIFF-STAT (oral probiotics) ACIPHEX 10 mg SPRINKLE CAPS Non-Preferred Formulary Agent: RABEPRAZOLE (ACIPHEX EC) 20 MG TABLET ACIPHEX 5 mg SPRINKLE CAPS Non-Preferred Formulary Agent: RABEPRAZOLE (ACIPHEX EC) 20 MG TABLET ACITRETIN (SORIATANE) 10 mg Non-Preferred Formulary Agent: calcipotriene (Dovonex) or previous approval of Enbrel, Humira, or Stelara CAPSULE ACITRETIN (SORIATANE) 17.5 mg Non-Preferred Formulary Agent: calcipotriene (Dovonex) or previous approval of Enbrel, Humira, or Stelara CAPSULE ACITRETIN (SORIATANE) 25 mg Non-Preferred Formulary Agent: calcipotriene (Dovonex) or previous approval of Enbrel, Humira, or Stelara CAPSULE ACLARO, ACLARO PD 4% Excluded benefit EMULSION ACTEMRA 200/10 mL Medical Benefit Please see the state specific Pharmacy Policy Statement titled Actemra by clicking your state under Pharmacy Policies at https://www.caresource.com/providers/policies/ ACTEMRA 400/20 mL Medical Benefit Please see the state specific Pharmacy Policy Statement titled Actemra by clicking your state under Pharmacy Policies at https://www.caresource.com/providers/policies/ ACTEMRA 162 mg/0.9 mL Medical Benefit Please see the state specific Pharmacy Policy Statement titled Actemra by clicking your state under Pharmacy Policies at https://www.caresource.com/providers/policies/ ACTEMRA 80 mg/4 mL Medical Benefit Please see the state specific Pharmacy Policy Statement titled Actemra by clicking your state under Pharmacy Policies at https://www.caresource.com/providers/policies/ ACTHAR HP Specialty Specialty; follow policy on CareSource.com. Acticlate 75 mg Tablet Non-Preferred Formulary Agent(s): Doxycycline Hyclate Capsule (50 mg Or 100 mg), Doxycycline Hyclate Tablet (20 mg Or 100 mg), Doxycycline Monohydrate Capsule (50 mg Or 100mg) Or Doxycycline Monohydrate (Adoxa) 75 mg Tablet Acticlate 150 mg Tablet Non-Preferred Formulary Agent(s): Doxycycline Hyclate Capsule (50 mg Or 100 mg), Doxycycline Hyclate Tablet (20 mg Or 100 mg), Doxycycline Monohydrate Capsule (50 mg Or 100mg) Or Doxycycline Monohydrate (Adoxa) 75 mg Tablet ACTIMMUNE 2 MILLION UNIT VIAL PA required Required diagnosis = chronic granulomatous disease or malignant osteoporosis Active OB Non-Preferred Formulary Agent(s): Any Formulary Prenatal Vitamin ACTONEL 150 mg TABLET Non-Preferred Formulary Agent: alendronate ACTONEL 30 mg TABLET Non-Preferred Formulary Agent: alendronate ACTONEL 35 mg TABLET Non-Preferred Formulary Agent: alendronate ACTONEL 5 mg TABLET Non-Preferred Formulary Agent: alendronate 3 Drug Status Special Instructions ACTONEL WITH CALCIUM TABLET Non-Preferred Formulary Agent: alendronate then Actonel and OTC calcium 500 mg tablet 35 mg/500 mg ACTOPLUS MET XR 15-1,000MG Step Therapy Formulary agents: Metformin IR or ER (Glucophage or Glucophage ER) TABLET ACTOPLUS MET XR 30-1,000MG Step Therapy Formulary agents: Metformin IR or ER (Glucophage or Glucophage ER) TABLET ACUVAIL 0.45% OPHTH SOLUTION Non-Preferred Formulary Agent: ketorolac (ACULAR) 0.5% EYE DROPS ACYCLOVIR (ZOVIRAX) 5% Step Therapy Required Diagnosis= Acute Outbreak Of Genital Herpes Simplex OR Cold Sores/Oral Herpes Simplex OINTMENT With A Trial Of Abreva Aczone 5% Gel Non-Preferred Formulary Agent(s): Adapalene 0.1% Gel Or Cream, Benzoyl Peroxide 5% Or 10%, Benzoyl Peroxide 4% Or 8% Liquid (Panoxyl), Clindamycin Topical (Cleocin T), Erythromycin Topical, Erythromycin/Benzoyl (Benzamycin), Sulfacetamide (Klaron), Or Tretinoin Cream Or Gel Aczone 7.5% Gel With Pump Non-Preferred Formulary Agent(s): Adapalene 0.1% Gel Or Cream, Benzoyl Peroxide 5% Or 10%, Benzoyl Peroxide 4% Or 8% Liquid (Panoxyl),
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