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 Ampyra dalfampridine Androderm testosterone transdermal Prior Authorization is a restriction that applies to Androgel testosterone topical gel certain medications. Prior Authorizations may be Android methyltestosterone required at therapy initiation as well as periodically Androxy fluoxymesterone Aplenzin bupropion thereafter as a means to confirm the ongoing Apokyn apomorphine necessity and appropriateness of prescription drug Aralast NP alpha-1-proteinase inhibitor use. Aranesp darbepoetin alfa Arymo ER morphine sulfate Asceniv immune globulin At the time of therapy initiation, Prior Authorization Ativan lorazepam requires the prescriber to submit supporting clinical Aubagio teriflunomide Austedo deutetrabenazine documentation to Serve You Rx confirming the Aveed testosterone injection intended use is appropriate and non-experimental. Avodart dutasteride Under the reauthorization process, such as for a Avonex interferon beta-1a Prior Authorization that has expired, the prescriber Avsola infliximab Axiron testosterone topical solution must generally demonstrate clinical improvement Bafiertam monomethyl fumarate and provide other documentation as necessary to Banzel rufinamide support continued therapy. Other plan-specific Belbuca buprenorphine Belviq lorcaserin exclusions and exceptions may apply. Benlysta belimumab Berinert C1-esterase inhibitor Providers can submit Prior Authorization requests Betaseron interferon beta-1b to Serve You Rx via the following methods: Bivigam immune globulin Bonjesta doxylamine/pyridoxine • Email: [email protected] Botox botulinum toxin type A • Fax: 800-480-4840 Bravelle urofollitropin • Phone: 800-759-3203 Brineura cerliponase alpha buprenorphine patch buprenorphine Butrans buprenorphine For additional information about Prior Authorization, Bynfezia pen octreotide including plan-specific appeals information, please Cablivi caplacizumab-yhdp Carimune NF immune globulin call Serve You Rx Member and Provider Services Cayston aztreonam at 800-759-3203. Cequa cyclosporine Cerdelga eligulstate tartrate Though not listed here, the majority of oncology Cholbam cholic acid Cimzia certolizumab drugs also require Prior Authorization. Listings are Cinqair reslizumab subject to change. Cinryze C1-esterase inhibitor Clovique trientine Consensi amlodipine/celecoxib BRAND GENERIC Contrave naltrexone/bupropion Absorica isotretinoin Conzip tramadol ER Absorica LD isotretinoin Copaxone glatiramer acetate Abstral fentanyl Copegus ribavirin Actemra tocilizumab Corlanor ivabradine Acthar Gel corticotropin Cosentyx secukinumab Acticlate doxycycline Crysvita burosumab Actimmune interferon gamma-1b Cuprimine penicillamine Serve You Rx Prior Authorization Information and Drug List
BRAND GENERIC BRAND GENERIC Cuvitru immune globulin Gamunex immune globulin 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 Dayvigo lemborexant Givlaari givosiran deferasirox deferasirox Glassia alpha-1-proteinase inhibitor Depo-testosterone testosterone injection Glatopa glatiramer Diacomit stiripentol Glumetza metformin Diclegis doxylamine/pyridoxine Gocovri amantadine Didrex benzphetamine Gonal-F follitropin Dojolvi triheptanoin Gralise gabapentin Dolophine methadone Granix tbo-filgrastim Doptelet avatrombopag Haegarda C1-esterase inhibitor Doryx doxycycline Harvoni ledipasvir/sofosbuvir Duexis ibuprofen/famotidine Hemady dexamethasone Duopa carbidopa/levodopa Hemlibra emicizumab-kxwh Dupixent dupilumab Hetlioz tasimelteon Duragesic fentanyl Hizentra immune globulin Durlaza aspirin Horizant gabapentin enacarbil Durolane hyaluronic acid Humatrope somatropin Dysport abobotulinumtoxin A Humira adalimumab Egrifta tesamorelin Hyalgan sodium hyaluronate Embeda morphine/naltrexone hydromorphone ER hydromorphone Emflaza deflazacort Hymovis viscoelastic hyaluronan Emgality galcanezumab-gnlm Hyqvia immune globulin Enbrel etanercept Hysingla ER hydrocodone Endari glutamine Ilaris canakinumab Enspryng satralizumab-mwge Ilumya tildrakizumab-asmn Entyvio vedolizumab Immune Globulin immune globulin Epclusa sofosbuvir/velpatasvir (IGG) Epidiolex cannabidiol Inbrija levodopa Epogen epoetin alfa Increlex mecasermin Esbriet pirfenidone Inflectra infliximab Euflexxa sodium hyaluronate Ingrezza valbenazine Evenity romosozumab-aqqg Isturisa osilodrostat Evrysdi risdiplam Jadenu deferasirox Exalgo hydromorphone Jatenzo testosterone Exjade deferasirox Jublia efinaconazole Exondys 51 eteplirsen Juxtapid lomitapide Extavia interferon beta-1b Jynarque tolvaptan Fabrazyme agalsidase beta Kadian morphine sulfate Fasenra benralizumab Kalbitor ecallantide Fensolvi leuprolide Kalydeco ivacaftor fentanyl patch fentanyl Kanuma sebelipase alpha Fentora fentanyl Kerydin tavaborole Ferriprox deferiprone Kesimpta ofatumumab finasteride finasteride Keveyis dichlorphenamide Firazyr icatibant Kevzara sarilumab Firdapse amifampridine Khapzory levoleucovorin Flebogamma immune globulin Kineret anakinra Flolan epoprostenol Kitabis tobramycin flurazepam flurazepam Korlym mifepristone Follistim AQ follitropin Krystexxa pegloticase Forteo teriparatide Kuvan sapropterin Fortesta testosterone topical gel Kynmobi apomorphine Fulphila pegfilgrastim-jmdb Lazanda fentanyl Galafold migalastat Lemtrada alemtuzumab GamaSTAN S/D immune globulin Letairis ambrisentan Gamifant emapalumab-lzsg Leukine sargramostim, GM-CSF Gammagard Liquid immune globulin Lotronex alosetron Gammagard S/D immune globulin Lupaneta leuprolide/norethindrone Gammaked immune globulin Lupron Depot-Ped leuprolide Gammaplex immune globulin Lupron Depot leuprolide
2 Serve You Rx Prior Authorization Information and Drug List
BRAND GENERIC BRAND GENERIC Luxturna voretigene neparvovec-rzyl Palynziq pegvaliase-pqpz Makena hydroxyprogesterone caproate Panzyga immune globulin Mavenclad cladribine Peg Intron peginterferon alfa-2b Mavyret glecaprevir/pibrentasvir Pegasys peginterferon alfa-2a Mayzent siponimod Pennsaid diclofenac solution Mepsevii vestronidase alfa Plegridy peginterferon beta-1A methadone methadone Praluent alirocumab methyltestosterone methyltestosterone Privigen immune globulin Miacalcin injection calcitonin Procrit epoetin alfa Monovisc cross-linked hyaluronate Procysbi cysteamine bitartrate Morphabond morphine sulfate Prolastin-C alpha-1-proteinase inhibitor morphine sulfate ER morphine sulfate Prolia denosumab Mozobil plerixafor Promacta eltrombopag MS Contin morphine sulfate Proscar finasteride Mulpleta lusutrombopag Pulmozyme dornase alfa Mycapssa octreotide Qsymia phentermine/topiramate Myobloc botulinum toxin type B Radicava edaravone Natesto testosterone nasal gel Rasuvo methotrexate Natpara parathyroid hormone Rayos prednisone Neulasta pegfilgrastim, G-CSF Rebetol ribavirin Neumega oprelvekin Rebif interferon beta-1a Neupogen filgrastim Reblozyl luspatercept-aamt Nexletol bempedoic acid Remicade infliximab Nexlizet bempedoic acid/ezetimibe Remodulin treprostinil Nityr nitisinone Renflexis infliximab Nivestym filgrastim-aafi Repatha evolocumab Norditropin somatropin Restasis cyclosporine Northera droxidopa Retacrit epoetin alfa-epbx Nplate romiplostim Revatio sildenafil Nucala mepolizumab Revcovi elapegademase-lvlr Nucynta ER tapentadol Reyvow lasmiditan succinate Nuedextra dextromethorphan HBr/quinidine Rhofade oxymetazoline Nuplazid pimavanserin Ribasphere ribavirin Nurtec ODT rimegepant sulfate Ribavirin ribavirin Nutropin AQ somatropin Rilutek riluzole Nuzyra omadacycline Rinvoq upadacitinib Ocaliva obeticholic acid Ruconest C1-esterase inhibitor Ocrevus ocrelizumab Ruzurgi amifampridine Octagam immune globulin Sabril vigabatrin Ofev nintedanib Saizen somatropin Olumiant baricitinib Samsca tolvaptan Omeppi omeprazole/bicarbonate Sandostatin octreotide omeprazole/bicarbonate omeprazole/bicarbonate Saxenda liraglutide Omnitrope somatropin Sensipar cinacalcet Onfi clobazam Serostim somatropin Ongentys opicapone Signifor pasireotide Onmel itraconazole Siklos hydroxyurea Onpattro patisiran Siliq brodalumab Onsolis fentanyl Simponi golimumab Opana ER oxymorphone Skyrizi risankizumab-rzaa Opsumit macitentan Soliris eculizumab Orencia abatacept Somatuline Depot lanreotide Orenitram treprostinil Somavert pegvisomant Orfadin nitisinone Sovaldi sofosbuvir Oriahnn elagolix/estradiol/norethindrone Sporanox itraconazole Orilissa elagolix Spravato esketamine Orkambi lumacaftor/ivacaftor Sprix ketorolac Orthovisc high MW hyaluronan Stelara ustekinumab Osmolex ER amantadine Strensiq asfotase alfa Otezla apremilast Striant testosterone buccal Otrexup methotrexate Subsys fentanyl Oxandrin oxandrolone Sunosi solriamfetol Oxervate cenegermin-bkbj Supartz sodium hyaluronate oxycodone ER oxycodone Supprelin LA histrelin Oxycontin oxycodone Symdeko tezacaftor/ivacaftor, ivacaftor oxymorphone ER oxymorphone Symlin pramlintide
3 Serve You Rx Prior Authorization Information and Drug List
BRAND GENERIC BRAND GENERIC Sympazan clobazam Xtampza ER oxycodone Synagis palivizumab Xuriden uridine triacetate Syndros dronabinol Xyosted testosterone injection Synvisc hylan G-F 20 Xyrem sodium oxybate Synvisc-One hylan G-F 20 Xywav sodium oxybate Syprine trientine Zarxio filgrastim-sndz Takhzyro lanadelumab-flyo Zavesca miglustat Taltz ixekizumab Zegerid omeprazole/sodium bicarbonate Tasmar tolcapone Zelapar selegiline Tavalisse fostamatinib Zelnorm tegaserod Tecfidera dimethyl fumarate Zemaira alpha-1-proteinase inhibitor Tegsedi inotersen Zepatier elbasvir/grazoprevir Teriparatide teriparatide Zeposia ozanimod Testim testosterone topical gel Ziextenzo pegfilgrastim-bmez testosterone testosterone injection Zohydro ER hydrocodone cypionate Zolgensma onasemnogene abeparvovec-xioi testosterone testosterone injection Zomacton somatropin enanthate Zorbtive somatropin testosterone pellets testosterone Zortress everolimus Testred methyltestosterone ZTlido lidocaine Tev-Tropin somatropin Zulresso brexanolone Tiglutik riluzole Tobi Nebulizer tobramycin Tobi Podhaler tobramycin Tolsura itraconazole Tracleer bosentan Tremfya guselkumab Trikafta elexacaftor/tezacaftor/ivacaftor Triluron sodium hyaluronate Triptodur triptorelin TriVisc sodium hyaluronate Tymlos abaloparatide Tysabri natalizumab Tyvaso treprostinil Ubrelvy ubrogepant Udenyca pegfilgrastim-cbqv Ultomiris ravulizumab-cwvz Uplizna inebilizumab-cdon Uptravi selexipag Veletri epoprostenol Ventavis iloprost Viberzi eluxadoline Viekira Pak dasabuvir/ombitasvir/paritaprevir/ritonavir Viltepso viltolarsen Vimizim elosulfase alfa Vimovo naproxen/esomeprazole Visco-3 sodium hyaluronate Vivlodex meloxicam Vogelxo testosterone topical gel Vosevi sofosbuvir/velpatasvir/voxilaprevir Vumerity diroximel fumarate Vyepti eptinezumab-jjmr Vyleesi bremelanotide Vyndaqel tafamidis meglumine Vyondys 53 golodirsen Wakix pitolisant Wellbutrin XL bupropion Xeljanz/XR tofacitinib Xenical orlistat Xeomin incobotulinumtoxina Xermelo telotrista Xgeva denosumab ServeYouRx.com Xiaflex collagenase clostridium histolyticum Xifaxan rifaximin Xiidra lifitegrast ©2021 Serve You Rx Xolair omalizumab 190080CL(1120)
4