Serve You Rx Prior Authorization Information and Drug List
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Serve You Rx Prior BRAND GENERIC Actiq fentanyl Authorization Information Adakveo crizanlizumab-tmca Adasuve loxapine and Drug List Adcirca tadalafil Addyi flibanserin Adempas riociguat What follows is a listing of drugs that may be Adipex-P phentermine subject to Prior Authorization on an outpatient Aemcolo rifamycin prescription drug benefit plan administered by Afrezza insulin Aimovig erenumab-aooe Serve You Rx. To confirm if a drug listed here is Ajovy fremanezumab-vfrm subject to Prior Authorization, please call 800-759- Albenza albendazole 3203. Alkindi Sprinkle hydrocortisone Amondys 45 casimersen Ampyra dalfampridine Prior Authorization is a restriction that applies to Androderm testosterone transdermal certain medications. Prior Authorizations may be Androgel testosterone topical gel required at therapy initiation as well as periodically Aplenzin bupropion Apokyn apomorphine thereafter as a means to confirm the ongoing Aralast NP alpha-1-proteinase inhibitor necessity and appropriateness of prescription drug Aranesp darbepoetin alfa use. Arikayce amikacin liposome Arymo ER morphine sulfate Asceniv immune globulin At the time of therapy initiation, Prior Authorization Aubagio teriflunomide requires the prescriber to submit supporting clinical Austedo deutetrabenazine Aveed testosterone injection documentation to Serve You Rx confirming the Avodart dutasteride intended use is appropriate and non-experimental. Avonex interferon beta-1a Under the reauthorization process, such as for a Avsola infliximab Prior Authorization that has expired, the prescriber Axiron testosterone topical solution Bafiertam monomethyl fumarate must generally demonstrate clinical improvement Banzel rufinamide and provide other documentation as necessary to Belbuca buprenorphine support continued therapy. Other plan-specific Benlysta belimumab Berinert C1-esterase inhibitor exclusions and exceptions may apply. Betaseron interferon beta-1b Bethkis tobramycin Providers can submit Prior Authorization requests Bivigam immune globulin to Serve You Rx via the following methods: Bonjesta doxylamine/pyridoxine Botox botulinum toxin type A • Email: [email protected] Brineura cerliponase alpha • Fax: 800-480-4840 Bronchitol mannitol • Phone: 800-759-3203 buprenorphine patch buprenorphine Butrans buprenorphine Bynfezia pen octreotide For additional information about Prior Authorization, Cablivi caplacizumab-yhdp including plan-specific appeals information, please Carimune NF immune globulin Cayston aztreonam call Serve You Rx Member and Provider Services Cequa cyclosporine at 800-759-3203. Cerdelga eligulstate tartrate Cholbam cholic acid Though not listed here, the majority of oncology Cimzia certolizumab Cinqair reslizumab drugs also require Prior Authorization. Listings are Cinryze C1-esterase inhibitor subject to change. Clovique trientine Consensi amlodipine/celecoxib Contrave naltrexone/bupropion BRAND GENERIC Conzip tramadol ER Absorica isotretinoin Copaxone glatiramer acetate Absorica LD isotretinoin Corlanor ivabradine Abstral fentanyl Cosela trilaciclib Actemra tocilizumab Cosentyx secukinumab Acthar Gel corticotropin Crysvita burosumab Acticlate doxycycline Cuprimine penicillamine Actimmune interferon gamma-1b Cuvitru immune globulin Serve You Rx Prior Authorization Information and Drug List BRAND GENERIC BRAND GENERIC Cystadrops cysteamine Gel-One cross-linked hyaluronate Cystaran cysteamine Gelsyn-3 sodium hyaluronate Cytogam cytomegalovirus immune globulin Genotropin somatropin Daklinza daclatasvir Genvisc 850 sodium hyaluronate Daliresp roflumilast Gilenya fingolimod Daraprim pyrimethamine Gimoti metoclopramide deferasirox deferasirox Givlaari givosiran Depo-testosterone testosterone injection Glassia alpha-1-proteinase inhibitor Diacomit stiripentol Glatopa glatiramer Diclegis doxylamine/pyridoxine Glumetza metformin Dojolvi triheptanoin Gocovri amantadine Dolophine methadone Gonal-F follitropin Doptelet avatrombopag Gralise gabapentin Doryx doxycycline Granix tbo-filgrastim Duexis ibuprofen/famotidine Haegarda C1-esterase inhibitor Duopa carbidopa/levodopa Harvoni ledipasvir/sofosbuvir Dupixent dupilumab Hemady dexamethasone Duragesic fentanyl Hemlibra emicizumab-kxwh Durlaza aspirin Hetlioz tasimelteon Durolane hyaluronic acid Hetlioz LQ tasimelteon Dysport abobotulinumtoxin A Hizentra immune globulin Egrifta tesamorelin Horizant gabapentin enacarbil Embeda morphine/naltrexone Humatrope somatropin Emflaza deflazacort Humira adalimumab Emgality galcanezumab-gnlm Hyalgan sodium hyaluronate Enbrel etanercept hydrocodone ER hydrocodone Endari glutamine hydromorphone ER hydromorphone Enspryng satralizumab-mwge Hymovis viscoelastic hyaluronan Entyvio vedolizumab Hyqvia immune globulin Epclusa sofosbuvir/velpatasvir Hysingla ER hydrocodone Epidiolex cannabidiol Ilaris canakinumab Epogen epoetin alfa Ilumya tildrakizumab-asmn Esbriet pirfenidone Imcivree setmelanotide Euflexxa sodium hyaluronate Immune Globulin immune globulin Evenity romosozumab-aqqg (IGG) Evkeeza evinacumab-dgnb Inbrija levodopa Evrysdi risdiplam Increlex mecasermin Exalgo hydromorphone Inflectra infliximab Exjade deferasirox Ingrezza valbenazine Exondys 51 eteplirsen Isturisa osilodrostat Extavia interferon beta-1b Jadenu deferasirox Eysuvis loteprednol etabonate Jatenzo testosterone Fabrazyme agalsidase beta Jublia efinaconazole Fasenra benralizumab Juxtapid lomitapide Fensolvi leuprolide Jynarque tolvaptan fentanyl patch fentanyl Kadian morphine sulfate Fentora fentanyl Kalbitor ecallantide Ferriprox deferiprone Kalydeco ivacaftor finasteride finasteride Kanuma sebelipase alpha Firazyr icatibant Kerydin tavaborole Firdapse amifampridine Kesimpta ofatumumab Flebogamma immune globulin Keveyis dichlorphenamide Flolan epoprostenol Kevzara sarilumab flurazepam flurazepam Khapzory levoleucovorin Follistim AQ follitropin Kineret anakinra Forteo teriparatide Kitabis tobramycin Fortesta testosterone topical gel Korlym mifepristone Fulphila pegfilgrastim-jmdb Krystexxa pegloticase Galafold migalastat Kuvan sapropterin GamaSTAN S/D immune globulin Kynmobi apomorphine Gamifant emapalumab-lzsg Lazanda fentanyl Gammagard Liquid immune globulin Lemtrada alemtuzumab Gammagard S/D immune globulin Letairis ambrisentan Gammaked immune globulin Leukine sargramostim, GM-CSF Gammaplex immune globulin Lotronex alosetron Gamunex immune globulin Lupaneta leuprolide/norethindrone 2 Serve You Rx Prior Authorization Information and Drug List BRAND GENERIC BRAND GENERIC Lupkynis voclosporin oxycodone ER oxycodone Lupron Depot leuprolide Oxycontin oxycodone Lupron Depot-Ped leuprolide oxymorphone ER oxymorphone Luxturna voretigene neparvovec-rzyl Palynziq pegvaliase-pqpz Makena hydroxyprogesterone caproate Panzyga immune globulin Mavenclad cladribine Pegasys peginterferon alfa-2a Mavyret glecaprevir/pibrentasvir Pennsaid diclofenac solution Mayzent siponimod Phexxi lactic acid/citric acid/potassium Mepsevii vestronidase alfa bitartrate methadone methadone Pliaglis lidocaine/tetracaine methyltestosterone methyltestosterone Plegridy peginterferon beta-1A Miacalcin injection calcitonin Ponvory ponesimod Monovisc cross-linked hyaluronate Praluent alirocumab Morphabond ER morphine sulfate Prevymis letermovir morphine sulfate ER morphine sulfate Privigen immune globulin Mozobil plerixafor Procrit epoetin alfa MS Contin morphine sulfate Procysbi cysteamine bitartrate Mulpleta lusutrombopag Prolastin-C alpha-1-proteinase inhibitor Mycapssa octreotide Prolia denosumab Myobloc botulinum toxin type B Promacta eltrombopag Natesto testosterone nasal gel Proscar finasteride Natpara parathyroid hormone Pulmozyme dornase alfa Neulasta pegfilgrastim, G-CSF Qsymia phentermine/topiramate Neumega oprelvekin Radicava edaravone Neupogen filgrastim Rasuvo methotrexate Nexletol bempedoic acid Rayos prednisone Nexlizet bempedoic acid/ezetimibe Rebetol ribavirin Nityr nitisinone Rebif interferon beta-1a Nivestym filgrastim-aafi Reblozyl luspatercept-aamt Norditropin somatropin RediTrex methotrexate Northera droxidopa Remicade infliximab Noxafil posaconazole Remodulin treprostinil Nplate romiplostim Renflexis infliximab Nucala mepolizumab Repatha evolocumab Nucynta ER tapentadol Restasis cyclosporine Nuedextra dextromethorphan HBr/quinidine Retacrit epoetin alfa-epbx Nulibry fosdenopterin Revatio sildenafil Nuplazid pimavanserin Revcovi elapegademase-lvlr Nurtec ODT rimegepant sulfate Reyvow lasmiditan succinate Nutropin AQ somatropin Rhofade oxymetazoline Nuzyra omadacycline Ribasphere ribavirin Nyvepria pegfilgrastim-apgf Ribavirin ribavirin Ocaliva obeticholic acid Rilutek riluzole Ocrevus ocrelizumab Rinvoq upadacitinib Octagam immune globulin Ruconest C1-esterase inhibitor Ofev nintedanib Ruzurgi amifampridine Olumiant baricitinib Sabril vigabatrin omeprazole/bicarbonate omeprazole/bicarbonate Saizen somatropin Omnitrope somatropin Samsca tolvaptan Onfi clobazam Sandostatin octreotide Onpattro patisiran Saxenda liraglutide Opana ER oxymorphone Sensipar cinacalcet Opsumit macitentan Serostim somatropin Orencia abatacept Signifor pasireotide Orenitram treprostinil Siklos hydroxyurea Orfadin nitisinone Siliq brodalumab Oriahnn elagolix/estradiol/norethindrone Simponi golimumab Orilissa elagolix Skyrizi risankizumab-rzaa Orkambi lumacaftor/ivacaftor Soliris eculizumab Orladeyo berotralstat Somatuline Depot lanreotide Orthovisc high MW hyaluronan Somavert pegvisomant Osmolex ER amantadine Somryst digital therapeutic Otezla apremilast Sovaldi sofosbuvir Otrexup methotrexate Sporanox itraconazole Oxervate cenegermin-bkbj