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(PA) Cross Reference Prior Authorization Drug Criteria Cross Reference PA Drug Name Generic Name PA Summary Name Epaned enalapril ACE Inhibitors and Combinations Perindopril perindopril ACE Inhibitors and Combinations Prestalia perindopril/amlodipine ACE Inhibitors and Combinations Qbrelis lisinopril ACE Inhibitors and Combinations Trandolapril/Verapamil ER by Greenstone trandolapril/verapamil ER ACE Inhibitors and Combinations Absorica/LD, Amnesteem, Claravis, isotretinoin Acne Agents, Oral Isotretinoin, Myorisan, Zenatane Acanya clindamycin/benzoyl peroxide Acne and Rosacea Agents, Topical Aczone dapsone Acne and Rosacea Agents, Topical Aklief trifarotene Acne and Rosacea Agents, Topical Altreno, Avita, Tretinoin, Retin-A Micro tretinoin Acne and Rosacea Agents, Topical Amzeeq, Zilxi minocycline Acne and Rosacea Agents, Topical Arazlo, Fabior, Tazorac tazarotene Acne and Rosacea Agents, Topical Azelex, Finacea azelaic acid Acne and Rosacea Agents, Topical Clindamycin, Clindacin, Evoclin clindamycin Acne and Rosacea Agents, Topical Clindamycin 1%/Benzoyl Peroxide 5%, clindamycin/benzoyl peroxide Acne and Rosacea Agents, Topical Neuac, Onexton Differin, Adapalene adapalene Acne and Rosacea Agents, Topical Adapalene/Benzoyl Peroxide, Epidue Forte adapalene/benzoyl peroxide Acne and Rosacea Agents, Topical Ery Pad, erythromycin pad erythromycin Acne and Rosacea Agents, Topical Erythromycin/Benzoyl Peroxide erythromycin/benzoyl peroxide Acne and Rosacea Agents, Topical Metrogel, Metronidazole, Noritate, Rosadan metronidazole Acne and Rosacea Agents, Topical Soolantra ivermectin Acne and Rosacea Agents, Topical Ziana tretinoin/clindamycin Acne and Rosacea Agents, Topical BP 10-1%, Sulfacetamide Sodium/Sulfur, sodium sulfacetamide/sulfur Acne and Rosacea Agents, Topical Sumaxin Sulfacetamide sodium sulfacetamide sodium Acne and Rosacea Agents, Topical Tekturna aliskiren Aliskiren and Combinations Tekturna HCT aliskiren/HCTZ Aliskiren and Combinations Donepezil 23 mg donepezil Alzheimer's Agents Memantine oral solution memantine Alzheimer's Agents Memantine ER, Namenda XR Titration Pak memantine extended-release Alzheimer's Agents Namzaric, Titration Pak memantine/donepezil Alzheimer's Agents Tiglutik riluzole Amyotrophic Lateral Sclerosis Agents Arymo ER, Kadian, Morphabond ER, morphine ER Analgesics, Narcotics Long Morphine ER capsules Belbuca buprenorphine Analgesics, Narcotics Long Fentanyl Patch 37.5, 62.5, 87.5 mcg/hour fentanyl Analgesics, Narcotics Long Hydromorphone ER hydromorphone ER Analgesics, Narcotics Long Hysingla ER, Zohydro ER hydrocodone ER Analgesics, Narcotics Long Levorphanol levorphanol Analgesics, Narcotics Long Nucynta ER tapentadol ER Analgesics, Narcotics Long OxyContin, Xtampza ER oxycodone ER Analgesics, Narcotics Long Oxymorphone ER oxymorphone ER Analgesics, Narcotics Long Acetaminophen/Caffeine/Dihydrocodeine acetaminophen/caffeine/dihydrocodeine Analgesics, Narcotics Short Benzhydrocodone/Acetaminophen benzhydrocodone/acetaminophen Analgesics, Narcotics Short Butalbital/Acetaminophen/Caffeine/Codeine butalbital/acetaminophen/caffeine/codeine Analgesics, Narcotics Short Butalbital/Aspirin/Caffeine/Codeine butalbital/aspirin/caffeine/codeine Analgesics, Narcotics Short Butorphanol Nasal Spray QLL butorphanol Analgesics, Narcotics Short Codeine codeine Analgesics, Narcotics Short Dilaudid Oral Liquid, Hydromorphone Rectal hydromorphone Analgesics, Narcotics Short Suppository Hydrocodone/Ibuprofen, Ibudone hydrocodone/ibuprofen Analgesics, Narcotics Short Meperidine meperidine Analgesics, Narcotics Short Morphine Rectal Suppository morphine Analgesics, Narcotics Short Nalocet, Primlev oxycodone/acetaminophen Analgesics, Narcotics Short Nucynta tapentadol Analgesics, Narcotics Short Oxaydo, Oxycodone QLL, Oxycodone oxycodone Analgesics, Narcotics Short Concentrate Oral Solution Oxycodone/Aspirin oxycodone/aspirin Analgesics, Narcotics Short Oxycodone/Ibuprofen oxycodone/ibuprofen Analgesics, Narcotics Short Oxymorphone oxymorphone Analgesics, Narcotics Short Diflunisal diflunisal Analgesics, Salicylates Salsalate salsalate Analgesics, Salicylates Testosterone Injection testosterone cypionate Androgenic Agents, Injectable Testosterone Injection, Xyosted testosterone enanthate Androgenic Agents, Injectable Anadrol-50 oxymetholone Androgenic Agents, Oral Danazol danazol Androgenic Agents, Oral Jatenzo testosterone undecanoate Androgenic Agents, Oral Methitest, Methyltestosterone methyltestosterone Androgenic Agents, Oral Oxandrolone oxandrolone Androgenic Agents, Oral Androderm, Striant, Testosterone testosterone Androgenic Agents, Topical Trandermal Candesartan candesartan Angiotensin Receptor Blockers and Combinations Edarbi azilsartan Angiotensin Receptor Blockers and Combinations Eprosartan eprosartan Angiotensin Receptor Blockers and Combinations Micardis, Telmisartan telmisartan Angiotensin Receptor Blockers and Combinations Amlodipine/Valsartan amlodipine/valsartan Angiotensin Receptor Blockers and Combinations Amlodipine/Valsartan/HCTZ amlodipine/valsartan/HCTZ Angiotensin Receptor Blockers and Combinations Amlodipine/olmesartan amlodipine/olmesartan Angiotensin Receptor Blockers and Combinations Entresto sacubitril/valsartan Angiotensin Receptor Blockers and Combinations Tribenzor olmesartan/amlodipine/HCTZ Angiotensin Receptor Blockers and Combinations Candesartan/HCTZ candesartan/HCTZ Angiotensin Receptor Blockers and Combinations Edarbyclor azilsartan/HCTZ Angiotensin Receptor Blockers and Combinations Micardis, Telmisartan/HCTZ telmisartan/HCTZ Angiotensin Receptor Blockers and Combinations Telmisartan/Amlodipine, Twynsta telmisartan/amlodipine Angiotensin Receptor Blockers and Combinations Albendazole albendazole Anthelmintics Emverm mebendazole Anthelmintics Stromectol ivermectin Anthelmintics Oralair mixed grass pollen allergen extract Antiallergens, Oral peanut [Arachis hypogaea] allergen powder- Palforzia Antiallergens, Oral dnfp Multaq dronedarone Antiarrhythmics, Oral Dificid fidaxomicin Antibiotics, GI Paromomycin paromomycin Antibiotics, GI Xifaxan rifamixin Antibiotics, GI Tobi Podhaler, Tobramycin Nebulized tobramycin Antibiotics, Inhaled Mupirocin Cream mupirocin Antibiotics, Topical Neo-Synalar neomycin/fluocinolone Antibiotics, Topical Neo-Synalar Kit neomycin/fluocinolone/emollient cream Antibiotics, Topical Xepi ozenoxacin Antibiotics, Topical Cleocin Ovules, Clindamycin Vaginal Cream clindamycin Antibiotics, Vaginal (7-day) Solosec secnidazole Antibiotics, Vaginal Chlordiazepoxide/Clidinium chlordiazepoxide/clidinium Anticholinergics-Antispasmodics Cuvposa, Glycate, Glycopyrrolate Injection glycopyrrolate Anticholinergics-Antispasmodics Methscopolamine methscopolamine Anticholinergics-Antispasmodics Proprantheline proprantheline Anticholinergics-Antispasmodics Bevyxxa betrixaban Anticoagulants Savaysa edoxaban Anticoagulants Fondaparinux fondaparinux Anticoagulants Fragmin Syringes dalteparin Anticoagulants Aptiom eslicarbazepine Anticonvulsants Banzel rufinamide Anticonvulsants Briviact brivaracetam Anticonvulsants Clobazam oral suspension, Sympazan clobazam Anticonvulsants Diazepam Rectal, Valtoco Nasal Spray diazepam Anticonvulsants Diacomit stiripentol Anticonvulsants Epidiolex cannabidiol Anticonvulsants Equetro carbamazepine extended-release Anticonvulsants Felbamate felbamate Anticonvulsants Fintepla fenfluramine Anticonvulsants Fycompa perampanel Anticonvulsants Gabitril, Tiagabine tiagabine Anticonvulsants Lamictal Kits/ODT, Lamotrigine ER/ODT/kits lamotrigine Anticonvulsants Levetiracetam ER levetiracetam extended-release Anticonvulsants Lyrica CR pregabalin extended-release Anticonvulsants Nayzilam midazolam Anticonvulsants Oxtellar XR oxcarbazepine Anticonvulsants Qudexy XR, Topiramate ER, Trokendi XR topiramate extended-release Anticonvulsants Sabril vigabatrin Anticonvulsants Stavzor, Valproic Acid Capsules valproic acid Anticonvulsants Vimpat Injection lacosamide Anticonvulsants Xcopri cenobamate Anticonvulsants Brisdelle, Paxil Suspension, Pexeva paroxetine Antidepressants Escitalopram Oral Solution escitalopram Antidepressants Fluoxetine 10 mg, 20 mg Tablets fluoxetine Antidepressants Fluoxetine 90 mg Delayed-Release fluoxetine DR Antidepressants Fluoxetine [PMDD], Sarafem fluoxetine [PMDD] Antidepressants Fluvoxamine ER fluvoxamine extended-release Antidepressants Paroxetine ER paroxetine extended-release Antidepressants Desvenlafaxine ER desvenlafaxine extended-release Antidepressants Drizalma, Duloxetine 40 mg duloxetine Antidepressants Fetzima levomilnacipran Antidepressants Savella milnacipran Antidepressants Trintellix (previously Brintellix) vortioxetine Antidepressants Venlafaxine ER Tablets venlafaxine extended-release Antidepressants Nefazodone nefazodone Antidepressants Trazodone 300 mg trazodone Antidepressants Viibryd viladazone Antidepressants Emsam selegiline Antidepressants Marplan isocarboxazid Antidepressants Phenylzine phenylzine Antidepressants Tranylcypromine tranylcypromine Antidepressants Imipramine Capsules imipramine pamoate Antidepressants Protriptyline protriptyline Antidepressants Trimipramine trimipramine Antidepressants Aplenzin, Forfivo XL bupropion extended-release Antidepressants Maprotiline maprotiline Antidepressants Spravato esketamine Antidepressants Alogliptin 6.25, 12.5mg, Nesina 25mg alogliptin Antidiabetic Agents Alogliptin/Metformin alogliptin/metformin Antidiabetic Agents Alogliptin/Pioglitazone alogliptin/pioglitazone Antidiabetic Agents Janumet XR sitagliptin/metformin ER Antidiabetic Agents Jentadueto XR linagliptin/metformin ER
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