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A Abatacept (ORENCIA) Updated: September 18, 2020 Prior Authorization Drugs (NEW ADDITIONS HIGHLIGHTED) A Abatacept (ORENCIA) Abemaciclib (VERZENIO) Abiraterone Acetate (ZYTIGA) AbobotulinumtoxinA (DYSPORT) Abraxane (ABRAXANE) Acalabrutinib (CALQUENCE) Actemra (ACTEMRA) Adalimumab (HADLIMA) Adalimumab (HUMIRA) Adcetris (ADCETRIS) Adcirca (ADCIRCA) Adempas (ADEMPAS) Afatinib (GIOTRIF) Afinitor (AFINITOR) Aflibercept (EYLEA) Aflibercept (ZALTRAP) Afstyla (AFSTYLA) Agalsidase Alfa (REPLAGAL) Agalsidase Beta (FABRAZYM) Aimovig (AIMOVIG) Ajovy (FREMANEZUMAB) Aldesleukin (PROLEUKIN) Aldurazyme (ALDURAZYME) Alecensaro (ALECENSARO) Alectinib (ALECENSARO) Alefacept (AMEVIVE) Alemtuzumab (MABCAMPATH) Alemtuzumab (LEMTRADA) Alglucosidase Alfa (MYOZYME) Alimta (ALIMTA) Alirocumab (PRALUENT) Alpha-1-Proteinase Inhibitor (PROLASTIN - C) Alpha-1-Proteinase Inhibitor (ZEMAIRA) Alpelisib (PIQRAY) Alunbrig (ALUNBRIG) Ambrisentan (VOLIBRIS) Ambrisentan (Generic Formulations) Amevive (AMEVIVE) Amifampridine Phosphate (FIRDAPSE) Amifampridine Phosphate (RUZURGI) Anakinra (KINERET) Apalutamide (ERLEADA) Apomorphine (KYNMOBI) Apremilast (OTEZLA) Arsenic Trioxide (TRISENOX) Arsenic Trioxide (Generic Formulations) Arzerra (ARZERRA) Asfotase Alfa (STRENSIQ) Asparaginase (ERWINASE) Asunaprevir (SUNVEPRA) Page 1 of 16 Updated: September 18, 2020 Atezolizumab (TECENTRIQ) Atriance (ATRIANCE) Aubagio (AUBAGIO) Avastin (AVASTIN) Avelumab (BAVENCIO) Avonex (AVONEX) Avsola (INFLIXIMAB) Axicabtagene Ciloleucel (YESCARTA) Axitinib (INLYTA) Azacitidine (VIDAZA) Azacitidine (Generic Formulations) Aztreonam (CAYSTON) B Bacillus Calmette-Guerin (BCG) Substrain Connaught (IMMUCYST) Balversa (BALVERSA) Baricitinib (OLUMIANT) Bavencio (BAVENCIO) Belimumab (BENLYSTA) Belkyra (BELKYRA) Bendamustine Hydrochloride (TREANDA) Benlysta (BENLYSTA) Berinert (BERINERT) Benralizumab (FASENRA) Beovu (BROLUCIZUMAB) Besponsa (BESPONSA) Betaseron (BETASERON) Bevacizumab (AVASTIN) Bevacizumab (MVASI) Bevacizumab (ZIRABEV) Bicnu (BICNU) Bleomycin (Generic Formulations) Blinatumomab (BLINCYTO) Blincyto (BLINCYTO) Boceprevir (VICTRELIS) Boceprevir (VICTRELIS TRIPLE) Bortezomib (VELCADE) Bortezomib (Generic Formulations) Bosentan (TRACLEER) Bosentan (Generic Formulations) Bosulif (BOSULIF) Bosutinib (BOSULIF) Botox (BOTOX) Brentuximab Vedotin (ADCETRIS) Brenzys (BRENZYS) Brigatinib (ALUNBRIG) Brineura (BRINEURA) Brodalumab (SILIQ) Brolucizumab (BEOVU) Burosumab (CRYSVITA) C C1 Esterase Inhibitor (Human) (BERINERT) Page 2 of 16 Updated: September 18, 2020 C1 Esterase Inhibitor (Human) (CINRYZE) C1 Esterase Inhibitor (Human) (HAEGARDA) Cabazitaxel (JEVTANA) Cabazitaxel (Generic Formulations) Cabenuva (CABOTEGRAVIR/RILPIVIRINE) Cablivi (CAPLACIZUMAB) Cabotegravir (VOCABRIA) Cabotegravir/Rilpivirine (CABENUVA) Cabometyx (CABOMETYX) Cabozantinib (CABOMETYX) Caelyx (CAELYX) Calcifediol (RAYALDEE) Calquence (CALQUENCE) Camptosar (CAMPTOSAR) Canakinumaab (ILARIS) Cannabidiol (SATIVEX) Capecitabine (XELODA) Capecitabine (Generic Formulations) Caplacizumab (CABLIVI) Caprelsa (CAPRELSA) Carbaglu (CARBAGLU) Carfilzomib (KYPROLIS) Carglumic Acid (CARBAGLU) Carmustine (BICNU) Caripul (CARIPUL) Catumaxomab (REMOVAB) Cayston (CAYSTON) Cedazuridine/Decitabine (INQOVI) Cemiplimab (LIBTAYO) Cenegermin (OXERVATE) Cerdelga (CERDELGA) Cerezyme (CEREZYME) Ceritinib (ZYKADIA) Cerliponase Alfa (BRINEURA) Certican (CERTICAN) Certolizumab Pegol (CIMZIA) Cetuximab (ERBITUX) Cimzia (CIMZIA) Cinacalet (SENSIPAR) Cinacalet (Generic Formulations) Cinqair (CINQAIR) Cinryze (CINRYZE) Cladribine (MAVENCLAD) Clofarabine (CLOLAR) Clolar (CLOLAR) Cobimetinib (COTELLIC) Copaxone (COPAXONE) Cosentyx (COSENTYX) Cotellic (COTELLIC) Crizotinib (XALKORI) Crysvita (CRYSVITA) Cubicin (CUBICIN) Cutaquig (CUTAQUIG) Page 3 of 16 Updated: September 18, 2020 Cuvposa (CUVPOSA) Cyramza (CYRAMZA) Cystadrops (CYSTADROPS) Cysteamine (CYSTADROPS) Cysteamine (PROCYSBI) D Dabrafenib (TAFINLAR) Daclatasvir (DAKLINZA) Daclizumab Beta (ZINBRYTA) Dacogen (DACOGEN) Dacomitinib (VIZIMPRO) Daklinza (DAKLINZA) Daptomycin (CUBICIN) Daratumumab (DARZALEX) Darolutamide (NUBEQA) Darzalex (DARZALEX) Dasatinab (SPRYCEL) Dasatinab (Generic Formulations) Daurismo (GLASDEGIB) Decitabine (DACOGEN) Decitabine (DEMYLOCAN) Deferasirox (EXJADE) Deferasirox (JADENU) Deferasirox (Generic Formulations) Deferiprone (FERRIPROX) Defibrotide (DEFITELIO) Defitelio (DEFITELIO) Demylocan (DEMYLOCAN) Deoxycholic Acid (BELKYRA) Dimethyl Fumarate (TECFEDERA) Dinutuximab (UNITUXIN) Docataxel (TAXOTERE) Docataxel (Generic Formulations) Dornase Alfa (PULMOZYME) Doxorubicin (CAELYX) Doxorubicin (MYOCET) Doxorubicin (Generic Formulations) Dupilumab (DUPIXENT) Dupixent (DUPIXENT) Durvalumab (IMFINZI) Dysport Therapeutic (DYSPORT) E Eculizumab (SOLIRIS) Edaravone (RADICAVA) Egrifta (EGRIFTA) Elaprase (ELAPRASE) Elbasvir (ZEPATIER) Elelyso (ELELYSO) Eliglustat (CERDELGA) Elosulfase Alfa (VIMIZIM) Elotuzumab (EMPLICITI) Page 4 of 16 Updated: September 18, 2020 Eloxatin (ELOXATIN) Eltrombopag (REVOLADE) Emgality (EMGALITY) Emicizumab (HEMLIBRA) Empliciti (EMPLICITI) Enasidenib (IDHIFA) Enbrel (ENBREL) Enspryng (SATRALIZUMAB) Entrectinib (ROZLYTREK) Entyvio (ENTYVIO) Enzalutamide (XTANDI) Epclusa (EPCULSA) Epoprostenol (CARIPUL) Epoprostenol (FLOLAN) Epoprostenol (Generic Formulations) Erbitux (ERBITUX) Erdafitinib (BALVERSA) Erelzi (ERELZI) Erenumab (AIMOVIG) Erivedge (ERIVEDGE) Erleada (ERLEADA) Erlotinib (TARCEVA) Erlotinib (Generic Formulations) Erwinase (ERWINASE) Esbriet (ESBRIET) Esketamine (SPRAVATO) Etanercept (BRENZYS) Etanercept (ENBREL) Etanercept (ERELZI) Evenity (EVENITY) Everolimus (AFINITOR) Everolimus (CERTICAN) Everolimus (Generic Formulations) Evolocumab (REPATHA) Exjade (EXJADE) Extavia (EXTAVIA) Eylea (EYLEA) F Fabrazyme (FABRAZYME) Fampridine (FAMPYRA) Fampridine (Generic Formulations) Fampyra (FAMPYRA) Fasenra (FASENRA) Fasturtec (FASTURTEC) Fedratinib (INREBIC) Ferona (FERONA) Ferriprox (FERRIPROX) Filgrastim (NEUPOGEN) Filgrastim (GRASTOFIL) Filgrastim (NIVESTYM) Fingolimod (GILENYA) Page 5 of 16 Updated: September 18, 2020 Fingolimod (Generic Formulations) Firazyr (FIRAZYR) Firdapse (AMIFAMPRIDINE PHOSPHATE) Flebogamma (FLEBOGAMMA) Flolan (FLOLAN) Fludara (FLUDARA) Fludarabine (FLUDARA) Fludarabine (Generic Formulations) Fluocinolone Acetonide (ILUVIEN) Folotyn (FOLOTYN) Fremanezumab (AJOVY) Fulphila (FULPHILA) G Galafold (GALAFOLD) Galexos (GALEXOS) Galsulfase (NAGLAZYME) Gazyva (GAZYVA) Gefitinib (IRESSA) Gefitinib (Generic Formulations) Galcanezumab (EMGALITY) Gemcitabine (GEMZAR) Gemcitabine (Generic Formulations) Gemtuzumab Ozogamicin (MYLOTARG) Gemzar (GEMZAR) Genotropin (GENOTROPIN) Gilenya (GILENYA) Giotrif (GIOTRIF) Gilteritinib (XOSPATA) Glasdegib (DAURISMO) Glatect (GLATECT) Glatiramer Acetate (COPAXONE) Glatiramer Acetate (GLATECT) Glatiramer Acetate (Generic Formulations) Glecaprevir (MAVIRET) Glycerol Phenylbutyrate (RAVICTI) Glycopyrrolate (CUVPOSA) Gleevec (GLEEVEC) Grastofil (GRASTOFIL) Grazoprevir (ZEPATIER) Golimumab (SIMPONI) Guselkumab (TREMFYA) H Hadlima (HADLIMA) Haegarda (HAEGARDA) Harvoni (HARVONI) Hemlibra (HEMLIBRA) Herceptin (HERCEPTIN) Herzuma (HERZUMA) Hizentra (HIZENTRA) Holkira (HOLKIRA) Humatrope (HUMATROPE) Page 6 of 16 Updated: September 18, 2020 Humira (HUMIRA) Hycamtin (HYCAMTIN) I Ibavyr (IBAVYR) Ibrance (IBRANCE) Ibrutinib (IMBRUVICA) Icatibant (FIRAZYR) Icosapent Ethyl (VASCEPA) Iclusig (ICLUSIG) Idelalisib (ZYDELIG) Idhifa (IDHIFA) Idursulfate (ELAPRASE) Ilaris (ILARIS) Iluvien (ILUVIEN) Imatinib (GLEEVEC) Imatinib (Generic Formulations) Imbruvica (IMBRUVICA) Imfinzi (IMFINZI) Imiglucerase (CEREZYME) Immucyst (IMMUCYST) Immune Globulin (FLEBOGAMMA) Immune Globulin (HIZENTRA) Immune Globulin (XEMBIFY) Immunoglobin G (CUTAQUIG) IncobotulinumtoxinA (XEOMIN) Inflectra (INFLECTRA) Infliximab (INFLECTRA) Infliximab (REMICADE) Infliximab (RENFLEXIS) Infliximab (AVSOLA) Inlyta (INLYTA) Inotersen (TEGSEDI) Inotuzumab Ozogamicin (BESPONSA) Inqovi (CEDAZURIDINE/DECITABINE) Inrebic (FEDRATINIB) Interferon Alfa-2B (INTRON A) Interferon Alpha-2A (ROFERON-A) Interferon Alpha-N1 (WELLFERON) Interferon Beta-1A (AVONEX) Interferon Beta-1A (REFIB) Interferon Beta-1B (BETASERON) Interferon Beta-1B (EXTAVIA) Interferon Beta-1B (FERONA) Intron A (INTRON A) Ipilimumab (YERVOY) Iressa (IRESSA) Irinotecan (CAMPTOSAR) Irinotecan (ONIVYDE) Irinotecan (Generic Formulations) Isatuximab (SARCLISA) Istodax (ISTODAX) Ivacaftor (KALYDECO) Page 7 of 16 Updated: September 18, 2020 Ivacaftor (ORKAMBI) Ivacaftor (SYMDEKO) Ixazomib (NINLARO) Ixekizumab (TALTZ) J Jadenu (DEFERASIROX) Jakavi (JAKAVI) Jetrea (JETREA) Jevtana (JEVTANA) Jinarc (JINARC) Juxtapid (JUXTAPID) K Kadcyla (KADCYLA) Kalydeco (KALYDECO) Kanjinti (KANJINTI) Kanuma (KANUMA) Kepivance (KEPIVANCE) Kevzara (KEVZARA) Keytruda (KEYTRUDA) Kineret (KINERET) Kisqali (KISQALI) Kuvan (KUVAN) Kymriah (KYMRIAH) Kynmobi (APOMORPHINE) Kyprolis (KYPROLIS) L Lanadelumab (TAKHZYRO) Lanreotide (SOMATULINE AUTOGEL) Lapatinib (TYKERB) Lapelga (LAPELGA) Laronidase (ALDURAZYME) Larotrectinib (VITRAKVI) Lartruvo (LARTRUVO) Ledipasvir (HARVONI) Lemtrada (LEMTRADA) Lenalidomide (REVLIMID) Lenvatinib (LENVIMA) Lenvima (LENVIMA) Letermovir (PREVYMIS) Leukine (LEUKINE) Levofloxacin (QUINSAIR) Libtayo (LIBTAYO) Lokelma (LOKELMA) Lomitapide (JUXTAPID) Lonoctocog Alfa (AFSTYLA) Lonsurf (LONSURF) Lorbrena (LORBRENA) Lorlatinib (LORBRENA) Lucentis (LUCENTIS) Lumacaftor (ORKAMBI) Page 8 of 16 Updated: September 18, 2020 Lynparza (LYNPARZA) M Mabcampath (MABCAMPATH) Macitentan (OPSUMIT) Matulane (MATULANE) Mavenclad (MAVENCLAD) Maviret (MAVIRET)
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